126 hysterical years - the contribution of Charcot

Histeria 126 anos – a contribuição de Charcot

Abstracts

The authors summarise the concepts of hysteria, emphasizing the seminal contribution of Charcot to its study.

hysteria; conversion; functional disorders

Os autores fazem um resumo sobre os conceitos de histeria, enfatizando a grande contribuição de Charcot ao estudo da histeria.

histeria; conversão; distúrbios funcionais

In its most recent edition, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) defined a group of conditions as functional disorders. This group comprises disorders that have at least one symptom affecting either voluntary or sensory function, or can lead to transient loss of consciousness that is not explained by an organic disorder¹. Usually symptoms are not due to a general medical condition, nor are they a direct effect of a substance. Additionally, they are not considered to be a culturally sanctioned behavior or experience. One or more diagnostic features should be present as to provide evidence of internal inconsistency, or incongruity with a recognized neurological or medical disorder. The functional symptom should either cause a clinically significant distress or impairment in social, occupational, or other important areas of functioning, or it may warrant medical evaluation¹.

Patients can present with a wide range of pseudo-neurological signs that can be divided in three different groups: pseudo-localizing symptoms (weakness, sensory loss, visual deficits, and pain), psychogenic movement disorders, and non-epileptic seizures; all classified as functional disorders^1,2. Further classification of functional disorders according to psychiatric evaluation also varies and includes somatoform disorders, somatization disorders, conversion, and dissociative disorders. Hysteria is a classical term that encompasses all of these psychopathological states^2,3,4. The aim of this historical review is to analyze the contribution of Professor Jean-Martin Charcot, the father of clinical Neurology, to the study of hysteria 126 years ago (summarised in the Table).

Table
Historical summary of researchers and different concepts regarding the origins of hysteria, from ancient times until the post-Charcot period.

Time period	Researcher(s)	Concept/contribution	Rationale
Ancient/ classical times (Egypt, Greece and Rome)	Hippocrates	Frustrated uterus	Lack of sexual intercourse
			Toxic effects of the Wandering Womb
18th and 19th centuries, prior to Charcot	Ferriar	Hysterical conversion	Sexual frustration
	Briquet	Treatise on hysteria	Different clinical presentations of hysterical symptoms, ruled out the gynecological origin
	Laségue	Hysterical anesthesia, ataxia, cataplexy, cough
Charcot’s Salpêtrière’s years	Charcot	Hysteria as a neurological disease	Dynamic, functional lesion
	Charcot and Richer	Four stages of the hysterical attack (grande hystérie): (1) Epileptoid; (2) Clownism; (3) emotional gestures (“attitudes passionnelles”); (4) final delirium.
	Charcot	C’est toujours la chose sexuelle	Lack of sexual intercourse
	Charcot	Male hysteria	Traumatic shock
	Charcot	Hypnotism
Post-Charcot period	Babinski	Pithiatism	Psychic state prone to suggestion
	Janet	Subconscious	Subconscious fixed ideas
	Freud	Conversion hysteria
	Freud	Therapeutical catharsis
	Vincent	Torpillage
	Yelland	Shell shock	Traumatic (war) shock

HYSTERIA IN ANCIENT TIMES

The term hysteria was used in ancient times in texts of the Egyptians, Greeks, and Romans to describe a group of disorders that affected women, in whom symptoms were believed to be the result of “suffocation of the mother”^3,5. The premise was that if the patient had no frequent sexual intercourse, the uterus would be “frustrated” by lack of proper use, leave its anatomical position and move around the body causing the symptoms; an allegory that often mentioned as either the “wandering womb”, or as “the wicked womb”^3,5. Hippocrates himself described hysteria as occurring in either widows or virgins, resulting from the neurotoxic effects of the “frustrated uterus”^3,5.

HYSTERIA BEFORE CHARCOT

Several researchers including Charles Lepois, Thomas Willis, Thomas Sydenham, and Pierre Pomme had great interest in the study of hysteria⁵.

In the 1770s Ferriar, an English doctor, introduced the term hysterical conversion. During the eighteenth and nineteenth centuries hysteria and epilepsy were considered correlate diseases and the relationship between hysteria and sexuality, namely sexual frustration, were linked⁵. Hysteria could also be addressed by other names, such as hysteria libidinosa and furor uterinus. In 1859 Briquet, a French physician, published his book on the subject entitled “Treatise on hysteria”. During a period of 10 years Briquet studied 430 cases of hysterical patients with different conversion symptoms, such as spasms, anesthesias, hyperesthesias, paralysis, and convulsions⁵. After Briquet’s seminal study, the galenic-hippocratic uterine theory was changed, emphasizing the role of the brain, and hysteria was named “Briquet's disease”. Another important contribution to the studies of hysteria came from Charles Lasègue, who published several studies about hysterical cough, hysterical anesthesia, catalepsy and hysterical ataxia⁵.

CHARCOT’S CONTRIBUTION TO HYSTERIA

Professor Charcot started his activities at the Salpêtrière hospital in 1862 and in 1882 a new discipline, the study of Diseases of the Nervous System was created for him. From that time onwards, until his death in 1893, Charcot reigned as the most celebrated neurologist of the XIX century³. He was unanimously regarded as the founder of Neurology and the Parisian Salpêtrière Hospital was aptly considered as the Mecca of World Neurology. During his time, Charcot’s contributions to Neurology were enormous, including the description of several neurological diseases, such as amyotrophic lateral sclerosis (later known as Charcot’s disease), multiple sclerosis (“sclérose en plaques”), Charcot-Marie-Tooth’s disease (hereditary sensory and motor neuropathy), the clinical description of Parkinson’s disease, Tourette’s syndrome (“Maladie des tics”), tabetic arthropathy (Charcot’s joints), the pathogenesis of intracerebral hemorrhage (the microaneurysms of Charcot-Bouchard), and studies of cerebral localization, among myriad others^3,6.

By the end of his academic career, Charcot was also interested in hysteria (hysteroepilepsia) and hypnosis. In the late 1870s Charcot and the Salpêtrière’s School of Neurology defined hysteria as a neurological disease, with a non-visible “dynamic or functional lesion”^3,6.

The very famous anatomo-clinical method had failed in demonstrating any neuropathological lesion. Charcot and his disciple Paul Richer defined that a hysteria attack (“grande hystérie”) was composed of four stages: (1) Epileptoid; (2) Contortions and acrobatic postures (Clownism); (3) Emotional gestures (“attitudes passionnelles”); and (4) final delirium³. Most of the patients studied were women and Charcot also associated hysteria to sexual intercourse, or lack thereof, even coining a very famous statement about hysteria: “c’est toujours la chose sexuelle”⁷. After that statement, hysteria went on to become a remarkable and even trendy, fashionable disease, and Charcot's patients, including several women, some of which, such as Justine Etchevery, Rosalie Leroux, Augustine, and, particularly, Blanche Wittman (Figure), would become known worldwide³.

Figure
“A clinical lesson at the Salpêtrière”, the original painting exhibited at the Musée de l’Histoire de la Médicine. Picture taken by one of the authors − Francisco M. B. Germiniani − at the Museum, on 18^th May 2012.

Charcot used hypnotism as an experimental technique to treat hysterical patients and this approach became very popular with the general public. However, in academic circles hypnosis was considered a non-scientific treatment and Charcot became the target of heavy criticism. Another contribution of Charcot was the definition of traumatic male hysteria. Finally, in 1893 Charcot stated that the Salpêtrière’s concept of hysteria had become obsolete and that it needed to undergo a profound revision, but a few months later he died suddenly³.

HYSTERIA AFTER CHARCOT

After Charcot’s death in 1893, the continuing investigation of hysteria had other protagonists. In the group of Professor Charcot’s disciples, Georges Gilles de la Tourette, Paul Richer, Paul Sollier and Charles Ferè published studies in accordance to the Salpêtrière’s master; however, another branch of Charcot’s disciples, such as Pierre Janet, Sigmund Freud and Joseph Babinski, developed other hypotheses that would clash with their mentor’s vision⁵. Babinski defined hysteria as a psychic state that would give the patient the ability of “auto-suggestion”, so that the patient would be able “to be persuaded” and therefore was prone to “healing” by suggestion⁸. Babinski created the term “Pithiatism” and also published a study about hypnotism and hysteria⁸. Janet created the concept of “subconscious fixed ideas” as an underlying mechanism for hysteria, while Freud’s contributions included discussing the concept of conversion hysteria and describing the first historical case of therapeutic catharsis in a famous patient, a Jewish woman named Bertha Pappenheim, a.k.a. “Ana O”³. During the first world war, across the pond, male patients would also be diagnosed with hysteria: in France, Clovis Vincent had a pivotal role with his studies and the development of the “torpillage” method of treatment, whereas in the UK, Lewis Yealland contributed by studying 196 soldiers with functional motor and sensory symptoms, functional seizures and somatoform disorders resulting from witnessing explosions (“shell shock”)^3,9.

HYSTERIA IN THE XX CENTURY

During most of the XX century the interest in the study of hysteria suffered a progressive decline, but by the end of the XX century and the beginning of XXI century a new interest reklinded¹⁰. Psychogenic movement disorders and nonepileptic seizures, now defined as functional disorders, represent an important group of diseases evaluated in neurological services worldwide, with expressive prevalence^4,5,7.

In conclusion, the study of hysteria was one of the great contributions of Professor Charcot to Neurology, and although his concepts concerning it were openly criticized at the time, nowadays a new interest in the study of this still somewhat unknown condition and its intersection with neuropsychiatry has resurfaced.

References

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  Goetz CG. Charcot and psychogenic movement disorders. In: Hallet M, Fahn S, Jankovic J, Lang AE, Cloninger CR, Yudofsky SC (Eds). Psychogenic movement disorders. Lippincott Williams & Wilkins, Philadelphia, USA, 2006:3-13.
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  Bogousslavsky J. Hysteria after Charcot: back to the future. Front Neurol Neurosci 2013;29:137-161.
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  Munhoz RP, Zavala JA, Becker N, Teive HA. Cross-cultural influences on psychogenic movement disorders − a comparative review with a Brazilian series of 83 cases. Clin Neurol Neurosurg 2011;113:115-118
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  Philippon J, Poirier J. Pithiatism versus hysteria. In: Philippon J, Poirier J (Eds). Joseph Babinski, Oxford University Press, Oxford, UK, 2009:297-319.
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  Linden SC, Jones E, Lees AJ. Shell shock at Quenn Square: Lewis Yealland 100 years on. Brain 2013;136:1976-1988.
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  Critchley EMR, Cantor HE. Charcot’s hysteria renaissant. Br Med J 1984;289: 1785-1788.

Publication Dates

• Publication in this collection
  Aug 2014

History

• Received
  17 Feb 2014
• Reviewed
  05 Apr 2014
• Accepted
  25 Apr 2014