Napoleon of the Neuroses

The founder of modern neurology, Charcot became a resident doctor at the Salpêtrière, a Parisian hospice for indigent patients, in 1862 and founded its neurology clinic in 1882, becoming the first professor of neurology in the same year. Among the diseases he described that still belong to the diagnoses used by contemporary neurologists were multiple sclerosis, ALS (initially dubbed Charcot’s disease, only later Lou Gehrig’s disease), Charcot-Marie-Tooth disease (a hereditary neuropathy of the feet and legs currently thought to be associated with changes in the myelin gene PMP-22), and Charcot joint (a progressive degeneration of the foot joints due to peripheral neuropathy that was associated with syphilis in Charcot’s day, diabetes in our own). He was involved in the elucidation of two neurological disorders, Parkinson’s disease and Tourette’s syndrome, that he proposed be named after his students, demonstrated the importance of the small arteries in cerebral hemorrhage, and made important discoveries concerning the related mechanisms of peripheral arterial disease such as intermittent claudication. Additional discoveries outside of the realm of neurology included Charcot's triad, the combination of fever, jaundice and upper abdominal pain associated with infection of the common bile duct; and Charcot-Leyden crystals, the needle-shaped phosphate crystals still considered a characteristic pathological finding in asthma. As Joseph Babinski, after whom the famous plantar reflex was named, put it, “to take away from neurology all the discoveries made by Charcot would be to render it unrecognizable.”

Charcot was clearly one of the virtuoso practitioners of nineteenth-century positivist empiricism. Prior to becoming a professor of neurology, he had served as a professor of anatomical pathology, deploying the clinical-anatomical method developed by the seventeenth-century Italian pathologist Giovanni Morgagni and refined by the French clinician Rene Laennec to correlate the clinical symptoms observed in patients with anatomic lesions discovered at the time of autopsy. He was among the founders of the field of neuroanatomy that remains centrally important to brain science today. For all its fruitfulness, however, Charcot’s method required no major technological innovation: the methods of gross anatomical pathology he employed in the elucidation of neurological disorders had already been developed by the eighteenth century, and Virchow had created the field of microscopic pathology earlier in the nineteenth. Even Charcot’s interest in photography was adopted from his mentor, Guillaume Duchenne. Indeed, it was where Charcot introduced new methods, experimenting with paramedical technologies of his day such as electromagnetism, that he caused the greatest damage to his reputation.

Known to the fashionable crowds who gathered to see his Tuesday lectures as the “Napoleon of the Neuroses,” Charcot has sometimes been credited as the founder of psychopathology. His primary contribution to the field was his revival of the diagnosis of hysteria, which he regarded not as a form of malingering, as it had come to be regarded, but as a hereditary neurological disorder, focusing on symptoms such as motor paralysis, sensory loss, convulsions and amnesia. Many contemporary neurologists show a similar interest in rescuing conversion and catatonia as movement disorders. Charcot constructed maps of what he termed "hysterogenic zones" that are strikingly similar to contemporary diagrams of fibromyalgia points. He was never able to associate hysteria with any anatomical lesion, acknowledging that it could not be accounted for within the parameters of the anatomico-clinico method and was what would nowadays be termed a “functional disorder.” Still, he performed careful clinical experiments that demonstrated the physiological differences between hysteria (the muscular contractures of which he observed to be smooth), and malingering (in which such contractures were accompanied by muscle fatigue and progressively labored breathing). As Freud famously put it, Charcot threw “the whole weight of his authority on the side of the genuineness and objectivity of hysterical phenomena," defending the hysteric against charges that she was no more than a fake. The great American psychologist William James concurred, observing that "amongst all the many victims of medical ignorance clad in authority, the poor hysteric has hitherto fared the worst; and her gradual rehabilitation and rescue will count among the philanthropic conquests of our generation." More recently, the feminist psychiatrist Judith Herman has pointed to the paternalistic nature of this rescue attempt, observing that feminists a generation later would come to criticize Charcot for his "vivisection of women under the pretext of studying a disease" -- a charge weighted with some irony, since Charcot, a lover of animals, had banned all experiments that used vivisection at the Salpetriere.

Although he gave the “nomadic uterus” and its fixation by what seem now like barbaric methods such as the uterine compression belt a central role in the treatment of hysteria, Charcot was famous for his insistence that hysteria was by no means specific to the female sex. Regarding male hysteria as underdiagnosed, he maintained that it was "not at all rare," occurring in men of all ages and social classes, even in those “without an effeminate exterior,” and relating it to traumas including railroad accidents and industrial work injuries. He saw the clinical presentation of male hysteria as similar to (although "less dynamic" than) the female version, with more static symptoms such as tunnel vision, hemianesthesia, and muscular contractures. "Little by little," he told his students, "you will acquire the habit of speaking of hysteria in men without thinking in any way of the uterus." Charcot thus did a great deal to establish a diagnosis that was to become extremely important with the appearance of shell shock during World War I, becoming the object of study of psychologists as diverse as William Rivers and Freud (and ultimately featuring in Walter Benjamin’s diagnosis of shock and the literature of modernity in poets such as Baudelaire).

While the neurologist Christopher Goetz has proposed that Charcot “faltered...in attempting to impose on hysteria the clinico-anatomic strategy he had used previously with success," it would perhaps be more accurate to say that he was forced in the case of hysteria to depart from this method, with scandalous results. Goetz suggests that Charcot's work on hysteria can be divided into two phases, a descriptive phase prior to 1877 in which he was concerned to categorize the symptoms and isolate the patterns and phases of hysteria, and an etiological phase after 1877, in which he began his experiments in the auditorium in search of a cause. In the first phase, he worked with the graphic illustrator Paul Richer, seated at the table in Brouillet's iconic 1887 painting "A Clinical Lesson at the Salpêtrière" (a lithograph of which Freud kept in his study throughout his career) and later professor of artistic anatomy at the Ecole des Beaux-Arts, using medical illustration as a means of delineating the clinical features of the diagnosis. Later, he amplified this project by making additional use of photography under the direction of Albert Londe, the medical photographer of the Salpêtrière who later became an expert in x-ray photography. In the second phase, Charcot developed the hypnotic experiments that he conducted in the amphitheatre before an admiring public, noting, for example, that hysterical contractures could be removed if a patient passed into a lethargic state and made to persist if she became cataleptic.

At the Salpêtrière, Charcot thus discovered the existence of a “new disorder” that was not to be named after him, but which he termed “hystero-epilepsy." An account of the phases of the hystero-epileptic attack is found in his 1887 treatise authored with Richer, Les Démoniaques dans l’art. In this description, the attack began with a prodrome that often appeared several days in advance, in which the patient became taciturn and melancholic or suffered from over-excitement, often vomiting or losing her appetite. This phase was sometimes accompanied by visual hallucinations (such as visions of animals), cramps or trembling limbs and a jerking body along with vertigo. Just prior to attack, there was an hysterical aura, followed by loss of consciousness as the attack proper began. The initial epileptoid phase mimicked a seizure and could, Charcot noted, easily "be mistaken” for one, lasting 1-3 mins. and consisting of three phases. The tonic phase was described as starting with a momentary arrest of inspiration and pallor, followed by flushing and facial distortion, including protrusion of the tongue. It ended with a tetanous immobilization that frequently involved extension of the trunk and limbs, followed by the clonic phase, a large generalized seizure accompanied by grimacing. This was followed by the phase of resolution, in which the eyes were closed and the muscles completely relaxed. These phases lasted about a minute each, the resolution phase 2-3 minutes.

The second phase of the attack was described as the “period of clownism.” After a moment of calm, it was characterized by contorsions and “grand movements,” phenomena that Charcot saw as linked by “an exaggerated discharge of muscular force.” It was in this phase that the famous arc-en-cercle, or arching of the back, took place. At this point, the patient was capable of displaying “a suppleness and agility, a muscular strength that may astonish the spectator.” With delicate discernment of gender differences, Charcot noted that women might significantly exceed the physical strength expected of their age and sex, whereas “in men, this period sometimes achieves a degree of violence that exceeds anything one can imagine.” It was also this phase that Charcot linked to the demoniacal possession of religious ecstasy examined in Les Demoniaques dans l'art. The third phase was described as a phase of "plastic poses" or what he termed "passionate attitudes," lasting from 5-15 minutes, in which the patient displayed happy, sad or frightened affect, often speaking or shouting. In the terminal phase, similar to the epileptic's post-ictal state, the patient at least partly regained consciousness, although she might remain delirious for periods of up to an hour.

As Goetz points out, Charcot never liked the term "hystero-epilepsy," with its implication that hysteria could be classified as a form of epilepsy. Although he noted that the hystero-epileptic attack resembled true epilepsy, and also that the latter sometimes occurred in conjunction with hysteria, he regarded the two disorders as distinct. "We are dealing always and exclusively with hysteria," he declared, "but hysteria taking on the appearance of epilepsy" (italics mine). Hystero-epilepsy was not a separate diagnosis, but one of many possible manifestations of hysteria. "It is likely that hysteria in the guise of epilepsy is only an exaggerated form," he insisted, "the highest development of this tonic variety of ordinary hysteria."

While Goetz defends Charcot's early descriptive work, Georges Didi-Huberman has observed that there was far more than description at stake in Charcot's classification of the phases of the hysteroepileptic attack. "Charcot's 'genius,'" Didi-Huberman proposes, was "not simply to arrive at a description...but to calibrate it into a general type that can be called 'the great hysterical attack.'" He argues that Charcot imposed on hysteria a form and regularity required by the epistemological dictates of rationalist positivism, the goal of which was the production of an hysterical "type." "Charcot domesticated the most Baroque theatricality," argues Didi-Huberman, "he achieved the coup de force, and I mean force, of making theatricality into not only a clinical, but a classical tableau...Charcot was a kind of entrepreneur and sponsor of the narrative and iconic type required by the principles of his concept of hysteria and his epistemological objectives…constraining the real to resemble the rational." For Didi-Huberman, Charcot’s efforts to provide a medical account of hysteria are thus both a domestication and the imposition of a particular genre, namely that of the classical tableau, a forerunner of photography in which actors were arranged in poses in order to reenact scenes from famous paintings. First enacting a “dramaturgical cutting of … symptoms into acts, scenes, and tableaux," Charcot's rationalism thus required an additional reduction of the theatrical and dynamic to the painterly and static. As an art historian, he emphasizes the graphic dimensions of Charcot's project, observing that Charcot's method was "primarily visual" and pointing out the role that the illustrator Paul Richer played in the production of the regular forms of the classic hystero-epileptic attack, sketching eighty-six poses that were later whittled down to nine and organizing them into a chart that offered a schematic overview of the onset and development of the attack. For Didi-Huberman, this chart became the "figurative standard" for Charcot's conception of hystero-epilepsy. Once the standard had been established, it remained only to fit the patient into it. Didi-Huberman thus characterizes Charcot's most famous patient, Augustine, who became the photographic model for most of the series of photographs published in the first Iconographie photographique de la Salpêtrière, as the “’most classical’ example of the model,” since the temporal progression of her attacks conformed almost perfectly to the clearly delineated phases of Richer's illustrations. Placed by the camera into the static poses of the tableau, Augustine thus met the demands of Charcot's typology. She was Charcot's "masterpiece," "the star model for a whole concept of hysteria."

In Les Demoniaques dans l’art, Charcot boasts that he has “been able to give the great hysterical attack a methodical description and to subdivide it into numerous phases and periods that have been neatly characterized. Where authors have only seen disorder and confusion, we have shown the existence of an immutable and fixed rule around a type that represents the hysterical attack in its entire and complete development, and we have grouped the varieties resulting from the predominance or attenuation of one of the several periods that compose it.” Emphasizing the precision of his delineation of the phases of hysteroepilepsy, Charcot boasts of the methodical and organized character of his description, which has led to the discernment of the fixed and immutable rules of the natural world in place of meaningless disorder and confusion. The effect is to produce a typology held to be entire and complete and into which varieties and subtypes of the disorder may be classified based on the predominance of one or another of the key phases. While the description is thus timeless and totalizing, Charcot notes proudly that it “will be as succinct as possible,” observing that “for clarity and ease, we will introduce a number of figures that illustrate [our] special work on the question.” As Didi-Huberman observes, Richer's figures thus occupy a crucial position in the construction of the typology, allowing it to attain an ease and concision not attainable by words alone. The figures accompany and, in the layout of the text, even precede the verbal description, anticipating and in a sense ultimately short-circuiting it.

In the end, it was hysterico-epilepsy that led the Napoleon of the Neuroses to his Waterloo. Charcot's favorite pupil, Joseph Babinski, depicted by his side holding up the hysterical patient in Brouillet's painting and an important neurologist in his own right whose discoveries included the Babinski sign, the infantile plantar reflex whose reappearance in adults is considered an indication of corticospinal damage -- proposed that hystero-epilepsy was in fact an invention, an effect of clinical suggestion. The hysterical women at the Salpêtrière were prone to epileptic attacks not because epilepsy belonged inherently to the disorder, but because of a purely contingent municipal decision to house epileptic and hysterical patients together. Before Charcot arrived at the Salpêtrière, the Sainte Laure building, where the female patients had been housed, was declared so dilapidated that it had to be vacated. Psychotic and non-psychotic patients were separated, with epileptics and hysterical patients placed together since they were both classed as episodic neurotics. As Pierre Marie described it, "the young hysterics became susceptible to powerful impressions and because of their tendencies to mimic, which is so characteristic of their neurosis, they duplicated in their hysterical fits every phase of a genuine epileptic seizure. The tonic phase, the clonic phase, then a phase of hallucination, sometimes terrifying to behold, but more often agreeable and pleasant, to which they added their bizarre postures." As the feminist psychiatrist Judith Herman proposes, “the hysterical patients, already vulnerable to suggestion and persuasion, were continually subjected to life on the ward and to Charcot’s neuropsychiatric examinations. They began to imitate the epileptic attacks they repeatedly witnessed.”

Ultimately, Charcot accepted Babinski's critique, the two collaborating to devise a treatment that combined counter-suggestion, with the staff withdrawing all interest in the hysteric's epileptic symptoms, and isolation, sending the hysteric back to the general ward away from the epileptics. The results of this treatment in terms of the resolution of epileptic symptoms were said to be impressive. Still, the damage had been done: the showmanship of Charcot’s Tuesday lectures was vilified in Axel Munthe’s scathing attack on his time at the Salpêtrière, and the great neurologist's reputation with Parisian society never fully recovered. In the end, Charcot is said to have regretted his work on hystero-epilepsy. A few days before his death, he was reported to have conceded that "our conception of hysteria has become obsolete. A total revamping of this area of neurologic disease is required." Apparently, he particularly regretted his role in the popularization of hypnotism and his interest in paramedical technologies such as magnets, electricity and metals.

This version of Charcot's career is reiterated in influential histories of psychiatry and psychoanalysis such as Henri Ellenberger’s The Discovery of the Unconscious. The basic elements of Babinski’s and Munthe’s critique are also adopted in Didi-Huberman’s Invention of Hysteria. (see also Baer) Indeed, it is common among the media theorists who have focused on the visual regimes governing Charcot’s conception of hysteria to assume that he “invented” a disorder that no longer exists. Friedrich Kittler, for example, observes that "the 'great hysterical arc' can no longer be found in the lecture halls of today's medical schools," arguing that Charcot’s hystero-epilepsy should be understood as an effect of filmic technologies that "disappears from nosology of the world shortly after its storage on film.”

By comparison, psychiatrists continue to believe that what Charcot termed hysteria continues to exist. Guillain, a biographer of Charcot who served as a psychiatrist at the Salpêtrière in the 1960's, compared the percentage of cases diagnosed as hysteria by Charcot with those he himself later diagnosed at the same institution, finding that "the patients have not changed since Charcot's times, but the terminology applied to them has." While one well-known study has shown that the misdiagnosis of conversion disorder has decreased since the dramatic advances in neurology's use of diagnostic imaging (with 50% of cases initially diagnosed as conversion in 1965 later found to have neurological disease, whereas misdiagnosis is now thought to constitute between 4 and 10% of cases), it is still estimated to constitute 1-4% of diagnoses in Western hospitals. "The symptoms themselves have never changed," Patrik Veilleumier, a neurologist at the University of Geneva, states in The New York Times; "they are still common in practice." "People who say [hysteria] has vanished need to come and work in some tertiary hospitals where they will see plenty of patients," concurs Kasia Kozlowkska, author of a 2005 review of conversion disorder in the Harvard Review of Psychiatry.

Neither the media historians nor the psychiatrists appear entirely correct. While hysteria was not the invention of Charcot’s nineteenth-century positivism and it did not disappear with decline of filmic technologies for the recording of clinical presentations, hysteria has been changed by its contemporary incarnation as conversion disorder. In what follows, I will attempt to examine the evolution in the visual economies of hysteria that has occurred between Charcot and the present day.

In the DSM-III in 1980, psychogenic conversion was definitively stripped of all association with the uterus when "hysterical neurosis, conversion type," was renamed "conversion disorder," now defined as the production of quasi-neurologic symptoms such as blindness, paralysis and seizure. In the New York Times, William E. Narrow, associate director of the research division of the American Psychiatric Association, remarked that "hysteria, to me, has always been a pejorative term, because of its association with women. I think the fact we got rid of that word is a good thing." He could, perhaps, have been more precise, since the word he presumably meant to 'get rid of' was the uterus, never more than a metonymy for woman as such, and really more the etiological misattribution of a symptom to an unsubstantiated underlying anatomical defect. Ultimately, the new nomenclature was the culmination of Charcot's insistence that his students "should acquire the habit of speaking of hysteria ... without thinking in any way of the uterus." Indeed, the contemporary criteria for conversion disorder enumerated in DSM-IV bear such remarkable similarities to Charcot's view that one might argue that they constitute a re-neurologization of hysteria, the ultimate effect of which is the elision of any psychoanalytic explanation of hysterical symptoms on the level of unconscious desire.

The most basic criteria for the diagnosis of conversion disorder is the presence of "one or more symptoms or deficits affecting voluntary motor or sensory functioning that suggest a neurological or other general medical condition." As with many diagnoses in the DSM, conversion disorder requires that the symptom not be "fully" (the term is generally "better") explained 'by a general medical condition or as the direct effects of a substance,' thus acknowledging that conversion, while it suggests a neurological condition, lacks an organic lesion and thus eludes the clinico-anatomic method still encapsulated in the neurologist's demand to "localize the lesion." Considerable care is nonetheless taken to differentiate conversion from two DSM diagnoses characterized by the voluntary production of somatic symptoms, namely malingering (in which both the production and the motivation of symptoms are voluntary) and, more subtly, factitious disorder (in which the production of the symptoms may be voluntary, but their motivation remains obscure to the patient and occurs on the level of primary gain). Medical science thus remains torn between continuing to defend the hysteric's honor against charges of faking and the more troubling realization that conversion continues, whatever the patient's intention may be, to present the false appearance of a neurological disorder. Conversion has still not been rid of its dangerous capacity for representation-as-dissimulation and, worse still, for making a fool of the physician.

The second major criterion, which falls short of offering an etiological account of conversion, is the judgment that psychological factors are present since 'the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.' Charcot's patient Augustine, who maintained, like many other female hysterics in the Salpêtrière, that she had been raped (in her case by her employer at razor point at the age of 13), would fit both criteria, since her seizures were both manifestly neurological in appearance and had a psychological stressor as their immediate precipitant: "A few days [after the rape and the subsequent onset of bleeding, mistaken for her first menses], [she] was lying in her room and became frightened when she saw the green eyes of a cat looking at her; when she cried out, her mother arrived to find her utterly terrified and bleeding from her nose. Then the attacks broke out..." The basic phenomena that interested Charcot (motor contractures, opthalmological symptoms, and the notorious hystero-epilepsy) remain largely unchanged in the four subtypes of conversion disorder, 'with motor symptom or deficit,' 'with sensory symptom or deficit,' 'with seizures or convulsions' (with which Augustine would presumably have been diagnosed) and 'with mixed presentation.' Perhaps the major departure is the stipulation that the symptom cannot be explained 'as a culturally sanctioned behavior or experience,' a common gesture in the DSM that in this case serves to exclude the intimate association between hysteria and female religious experience that interested Charcot so much.

Interestingly, the misdiagnosis of conversion disorder is thought to have decreased since the dramatic advances in neurology's use of diagnostic imaging tools: in 1965, 50% of cases initially diagnosed as conversion were later found to have neurological disease, whereas misdiagnosis is now thought to constitute between 4 and 10% of cases. It is estimated to constitute 1-4% of diagnoses in Western hospitals. Goetz observes that Guillain, a biographer of Charcot who served as a psychiatrist at the Salpêtrière in the 1960's, compared the percentage of cases diagnosed as hysteria by Charcot with those "he himself diagnosed at the same institution over a comparable period in our century," finding that "the patients have not changed since Charcot's times, but the terminology applied to them has." "The symptoms themselves have never changed," Patrik Veilleumier, a neurologist at the University of Geneva, is quoted as stating in the New York Times. "They are still common in practice." "People who say [hysteria] has vanished need to come and work in some tertiary hospitals where they will see plenty of patients," concurs Kasia Kozlowkska, the author of a 2005 review of conversion disorder in the Harvard Review of Psychiatry.