Keywords:
History of Medicine - Hysteria - Salpêtrière
Palabras clave:
Historia de la Medicina - Histeria - Salpêtrière
Jean-Martin Charcot (1825–1893) is widely considered the father of modern Neurology. While working as Chief of Service at La Salpêtrière (1862–1893), he became increasingly interested in hysteria. His concepts on this enigmatic condition have evolved significantly over the last 20 years of his career, which explains why they can sometimes appear contradictory[1]. Charcot had initially regarded hysteria as an organic disease, seeking a cerebral localization through autopsy and anatomopathological exam. His failure led him to consider hysteria as the consequence of a “dynamic lesion” (“lésion fonctionnelle” or “lésion dynamique”) of the nervous system; such explanation accounted for the lack of detectable morphological lesions in the brain of hysterical patients[2]. Furthermore, he vehemently rejected the equation between hysteria and simulation. Charcot became increasingly convinced of the importance of psychological factors in the genesis of hysteria only shortly before his death[3]; this idea would have been further developed by his pupil Pierre Janet (1859–1947). In Charcot's latest works, the original conception of a “dynamic lesion” coexists alongside the new psychological conception, sometimes in a rather contradictory way.
The “Leçons du Mardi à la Salpêtrière” (Tuesday lessons) are transcriptions of impromptu clinical presentations held by Charcot between 1887 and 1889. They incorporate the dialogues between Charcot and his patients, reflecting the spontaneity of real-life interactions[4]. Hand transcriptions of the lessons were made by his students, Edouard-Emmery Blin (1863–1930), Jean-Baptiste Charcot (1867–1936), and Henri Colin (1860–1930); they underwent thorough editing and revision before print publication between 1889 and 1892[5],[6].
References to a “dynamic lesion” — a term still deeply rooted in an organic view of hysteria — recur frequently in the Tuesday lessons (see for instance lessons of January 17th, April 10th and 17th, November 6th, December 4th and 18th, 1888; and March 5th, 1889)[5],[6]. In his Tuesday lesson on February 21st, 1888, Jean-Martin Charcot described a 14-year-old boy with chest pain, dyspnea, and the beginning of opisthotonos. According to the typescript, on this occasion — after having emphasized that hysteria was totally distinct from simulation in children — Charcot stated: “Hysteria must be taken for what it is: a psychic disease par excellence” (“Il faut prendre cette affection pour ce qu'elle est, c'est à dire pour une maladie psychique par excellence”) (manuscript, page 205)[7]. Such statement has been widely quoted in the literature[8],[9],[10],[11],[12],[13],[14] as the most concise and vivid expression of Charcot's late psychic conception of hysteria.
Intriguingly, this statement was reported differently in the printed edition, where it reads as: “It is definitely the case to present hysteria as a disease which for three quarters is psychic” (“C'est le cas, ou jamais, de vous présenter l'hystérie comme une maladie aux trois quarts psychique”) (page 138)[6]. Compared to the original handmade transcription, the statement sounds awkward and is definitely ambiguous: how else to consider the remaining quarter of non-psychic cases of hysteria? By weakening the emphasis on the psychological nature of hysteria, the different wording implicitly retrieves Charcot's former conception of a “dynamic lesion”. The shift in meaning underlying the different wording is extremely relevant and, probably, Charcot himself had been made aware of this by the editors, and had agreed upon it. After over 20 years spent studying this condition, Charcot was probably not confident enough in making too assertive conclusions on the psychological mechanisms underlying hysteria.
