Authors: Steven Levingston
Charcot’s climb to the pinnacle of the medical world had been gradual and far from certain. He was a man of contradictions, a bookish, restrained figure of subtle movements and precise language. He had an artist’s soul, a sympathy for the suffering, and an eye for detail. His father created beauty with his hands as a working-class artisan, a highly regarded designer and decorator of coaches. Charcot, too, was an artist: His sketchbook showed considerable talent. In his youth, he had to choose between two passions, two paths: one led to a life in art, the other to medicine. He was a bright young man from a modest background, aching with ambition. In the Paris of the 1840s, the medical profession made room for men of his circumstances. So he chose the healing arts for their promise of wealth and prestige.
His gift of observation followed him into medicine. It went with him into the classroom, the clinic, the wards. He was an innovator and sought to see beyond what men of medicine had become accustomed to seeing. His former student Sigmund Freud wrote that Charcot
“described how wonderful it was suddenly to see new things—new diseases—although they were probably as old as the human race.”
Shyness, however, nearly crushed him, particularly in his youth. It was the weight in his shoes, the clamp on his tongue. At the University of Paris Medical School in the 1840s, he had to compete for honors by written and oral exam and, on his first application for a coveted internship, was passed over, although his work was rated as
above average. He threw himself into arduous studies and grotesque lab work—anything, as long as he could prove himself without speaking. In the dissection room he got his first exposure to the study of anatomy—at which he would later excel. An American student in Paris described a typical dissection:
“Here, the assiduous student may be seen, with his soiled blouse, and his head bedecked with a fantastic cap. In one hand he holds a scalpel, in the other a treatise on anatomy. He carries in his mouth a cigar, whose intoxicating fumes, so hurtful on most occasions, render him insensible to the smell of twenty bodies, decomposing, putrefying around him.”
As a student Charcot showed a fondness for bizarre images and strange behavior, the kind of phantasmagoria that would come to life for him later in the Salpêtrière’s hysteria ward. He smoked hashish experimentally and while high took to his sketch pad. As a fellow student described it,
“The entire page was covered with drawings: prodigious dragons, grimacing monsters, incoherent personages who were superimposed on each other and who were intertwined in a fabulous whirlpool bringing to mind the apocalyptic conceptions of Van Bos[c]h and Jacques Callot.”
In his early years, Charcot was more at ease in the stench of the dissection room than before an audience delivering his findings. His shaky verbal skills still plagued him, and he failed in his first try to win an associate professorship in 1857. But with an indomitable will he overcame this weakness, winning the post three years later. He was no rising star in the Paris medical world, however. He published fairly widely and was considered erudite. But destined for greatness? His career until the age of thirty-seven did not suggest it. Then things changed. In 1862 he was appointed head of medical services of the Salpêtrière Hospital, near quai d’Austerlitz in the thirteenth arrondissement.
The Salpêtrière, once a small arsenal, had been transformed into a vast hospital, home to nearly five thousand live-in patients, mostly women—a third of them insane and the rest so ill they couldn’t function in society. Behind its walls were dozens of structures, narrow lanes, stone walkways, gardens and squares, and an enormous domed church. It was a world of its own, known as the city of incurable women. Charcot’s was largely an administrative job that others before him accepted in hopes of moving on to a more modern and prestigious
institution with a better address. But Charcot had other ideas. It was this
“grand asylum of human misery,” as he called it, that set him on his journey probing the mysteries of the nervous system.
When Charcot took over, conditions were grim for the institution’s destitute and disturbed women. A report in 1863 detailing the previous year at the hospital recorded two hundred and fifty-four deaths from
“causes presumed to be due to insanity.” Among the reasons cited were masturbation, debauchery, erotomania, rape, blows and wounds, alcoholism, joy, love, and nostalgia. But there were glimmers of hope, too. The report contained the news that during the year a garden was planted in a courtyard and a piano was purchased. Of the women who were able, many were put to work to burn off the boredom and aid the economy of the institution. Their chief task was sewing in small workshops: making bonnets and blouses, mending sheets, and stitching lace.
Jules Claretie, who later portrayed the Salpêtrière atmosphere in his novel
Les Amours d’un Interne
, explained in a journal article:
“Behind those walls, a particular population lives, swarms, and drags itself around: old people, poor women, cripples and convalescents awaiting death on a bench, lunatics howling their fury or weeping their sorrow in the insanity ward or the solitude of the cells. The thick gray walls of this
città dolorosa
seem to retain, in their solemn dilapidation, the majestic qualities of Paris under the reign of Louis the Fourteenth, forgotten by the age of electric tramways. It is the Versailles of pain.”
Charcot designated himself the curator of what he called this
“museum of living pathology.” Until then he had demonstrated little interest in the pathology of the nervous system. Now in the face of it he found his calling. In eight years he produced a flurry of groundbreaking studies, paving the way for the creation of a new, separate discipline called neurology. His achievements in such a short span were extraordinary for a man who took on the study of the nervous system only after his appointment in 1862.
“While unquestionably he was considered by his contemporaries as a very well-trained worker in his field, no one would at that time have predicted that, a few years later, he would become one of the founders of neurology,” wrote Georges Guillain, a neurologist at the Salpêtrière who would succeed Charcot as the professor of clinical diseases of the nervous system.
Some of his achievements still stand. Before Charcot no one had observed order in the chaos of the degenerating nerve cells that control muscles. He identified lesions on the spinal cord that correlated to various symptoms, including muscle contractures, atrophy, and flaccidity. Perhaps the disease was as old as the human race but on the basis of his observations Charcot named it “amyotrophic lateral sclerosis”—known in France as
maladie de Charcot.
For Americans nearly seventy years later, Lou Gehrig became the poster boy of courage in the face of the ailment, which then became known as Lou Gehrig’s disease.
Charcot also turned his eye on a scourge that raged unabated until the discovery of penicillin in the early twentieth century. Syphilis caused a torturous slow degeneration in the nerves that send sensory information to the brain. Charcot discovered the role played by damage to the spinal cord.
In another seminal insight, he detected that tremors thought to be associated with Parkinson’s disease were actually something else. His eye was sharper than anybody else’s and his minute clinical observations revealed a distinction: Certain tremors indicated a separate ailment entirely, something no one had ever identified before, which he called multiple sclerosis.
His curiosity drove him. He wrote on a range of neurological topics, among them aphasia, epilepsy, hysteria, intracranial hemorrhage and stroke, meningitis, migraine, neuropathy, sleep disorders, tics. Somber and meditative, and obsessed with personal glory, he set the standard for modern practices in neurological science. Brain, spinal cord, nerve, and muscle diseases—he built the foundation on which they were defined. He became the uncompromising, sometimes dictatorial, father of modern neurology.
By 1870 Charcot had turned in a new direction, again partly by happenstance. This shift came as a result of a long-needed remodeling at the Salpêtrière. The building housing epileptics, hysterics, and psychotics had become so dilapidated that the patients had to move to new quarters. The epileptics and hysterics went together into a new ward, and the psychotics were placed elsewhere. The hysterics became Charcot’s responsibility. He’d had only a passing interest in hysteria, but now he was drawn to the enigmatic behavior of his new patients. With hysteria Charcot moved away from the study of disease
with purely organic roots into a realm where anatomical origins were impossible to observe. When studying spinal cord disturbances in his earlier work, he could rely on visible lesions found during autopsies to aid his analysis. With his hysterical patients he was on less firm ground because no physical evidence was discernible in their postmortems. He had only symptoms and behavior to guide his research.
Charcot approached hysteria in the same manner with which he’d tackled previous medical questions: He concentrated on the observable. By its nature, however, this question was among the trickiest he had encountered. Hysterics were known to dissimulate even in the throes of an attack; they also were great imitators.
Working with an intern named Paul Richer, a gifted medical artist, Charcot established the patterns of a hysterical attack. He laid out the recurring phases of what he called an attack of
grande hystérie.
It began with palpitations, pain in the ovaries, uncontrollable coughing or yawning, loss of consciousness, then erupted into muscular contractions similar to what an epileptic experiences. The attack progressed into spectacular contortions on an acrobatic scale that Charcot dubbed “clownism.” A patient lying in bed would shoot up into a sitting position then fall back again and repeat the action over and over in what was called “salutations.” In another variety, the patient would arch her back so dramatically that her body would rise up and form a semicircle, an
arc-en-cercle
, with only the head and feet touching the bed. The attack then passed into a theatrical phase where the woman expressed a range of emotions. During these
attitudes passionnelles
, Charcot heard love, hate, fear, and anger and saw acts of bold sensuality. Sometimes the young women launched into diatribes or imaginary conversations. The attacks climaxed in a delirium that could last hours or days.
Charcot relied on a handful of women hysterics to develop his concepts. Among them was a young woman named Augustine who was admitted to the Salpêtrière on October 21, 1875, when she was fifteen years old. She was prone to spasms, convulsions, and loss of consciousness. Hospital records showed she had a stunning 2,239 attacks in a single year. Some were sexually charged. During one episode, Charcot noted that her breathing was noisy and rapid. Suddenly she screamed and wriggled her body as if struggling to escape someone’s
grasp. She then threw her arms out in the shape of the crucifix, saying,
“What do you want? Nothing. Nothing.” Then she smiled and declared, “Well done!” She looked to the side and lifted herself up and kissed the air. “No no, I don’t want him!” Then she kissed the air again. She smiled and opened her legs. “You’re starting over again. This isn’t it. This isn’t it.” Her face then took on an expression of regret, and she began to cry. Charcot ended the notation in his records with the words “Abundant vaginal secretion.”
In the mid-1870s, Charcot became intrigued by the work of a French doctor named Victor Burq who had worked with hysterics for twenty-five years. Burq had discovered a way to relieve numbness in the limbs of such patients. He found that if he placed certain metals on the skin he was able in some cases to revive sensation. He had his patients wear bracelets of gold, copper, or iron. The key to the treatment, known as metallotherapy, was discovering the right metal for each patient. If the metal was chosen correctly, Burq reported that sensation returned in stages. First came a tingling, then a feeling of heat and weight, and finally of pins and needles. Sometimes, in this way, Burq said he was able to relieve cases of complete paralysis.
In 1876 the Society of Biology agreed at Burq’s request to look into metallotherapy for possible scientific validation. It chose Charcot as president of a commission of inquiry. Burq’s treatments were replicated at the Salpêtrière. One phenomenon in particular grabbed investigators. They observed that when sensation was returned to one limb by use of metals it simultaneously was lost in another. Magnets, in particular, were found to stimulate a transfer of anesthesia from one leg to the other. Overall, investigators found that repeated use of magnets had an ameliorative effect on the body. Charcot and the commission gave metallotherapy a stamp of approval.
Over the next few years Charcot introduced metallotherapy into his own work with hysterics at the Salpêtrière. Around this time he was drawn to the work of the British surgeon James Braid, who some years earlier had experimented with a phenomenon he called “neurohypnotism.” He put subjects into a trancelike sleep by having them lock their gaze on an object, such as the top of a wine bottle or a sugar bowl. He recorded the changes in pulse, respiration, and muscular
activity in these somnambulists. Over time the term that described the phenomenon of induced sleep would lose its prefix, and it became simply “hypnotism.”
Braid’s work fascinated Charcot. With metallotherapy and now hypnotism he saw an opportunity to move from merely observing and describing symptoms to experimenting on patients. In 1878 Charcot described his own use of hypnosis for the first time, though he didn’t mention the word. His report focused on two young hysterical women at the Salpêtrière. Like Braid’s subjects, Charcot’s women fixed their gaze on an object, in this case a bright light.
It was at this time that Charcot began to believe in a link between hysteria and hypnotism, and he set about formulating what he thought were the stages of a hysterical attack under hypnosis. Hysterics put into a hypnotic state experienced a sequence of symptoms that Charcot identified as lethargy, catalepsy, and somnambulism. A woman who passed through these three stages in strict obedience to Charcot’s classification was said to have suffered an attack of
grand hypnotisme
, or major hypnotism. Charcot asserted that a woman experiencing such an attack had physical reactions that were impossible to simulate. He was able to assert then that his work with hypnotism was grounded in the science of physiology. He had also discerned a smaller-scale reaction that he dubbed
petit hypnotisme
, or minor hypnotism. This attack had a psychological component and lacked the clear physiological markers Charcot required. It was therefore harder to pin down and of less interest to him.