Since the modern concept of hysteria was cut from the cloth of malingering, and since the physician most responsible for establishing “hysteria” as a medically legitimate illness was Charcot, I shall start with an examination of his work; and I shall then trace the development of the concept of hysteria to the present time.
Jean-Martin Charcot (1825–1893) was a neurologist and neuropathologist. In other words, he was a physician who specialized in diseases of the nervous system. Exactly what did this mean at that time? It is important that we understand what a physician like Charcot did, how he practiced, and how his work differed from that of his counterparts today.
One hundred years ago, physicians possessed practically no effective therapeutic methods with which to help their patients. This was especially true for the neurologist, who dealt almost entirely with what were then incurable diseases. Charcot, moreover, was not just a physician in private practice. He was also a professor of pathological anatomy at the Sorbonne, and, as such, his duties were educational and scientific; in addition he was a physician in charge of the care of patients at the Salpêtrière. In short, there was nothing therapeutic, in the contemporary medical sense of this word, about much of his work. Most of Charcot’s hospitalized patients, whether those with or without organic neurological diseases—and, as we shall see, it was often extremely difficult to make this distinction at that time—were hospitalized not so much because they were sick as because they were poor, unwanted, or disturbing to others. From an economic, social, and political point of view, these patients were similar to those who today are committed to mental hospitals with psychiatric diagnoses of “major” mental disorders.1 The families of these patients either could not care for their disabled relative because they were too poor to do so and it was cheaper to have the patient hospitalized, or, if they could, they did not want to do so because the patient was too offensive or troublesome. Overwhelmingly, then, Charcot’s hospital patients came from the lower classes and thus stood socially far beneath their physician. What was Charcot’s personal attitude toward his patients? We can infer the answer to this question from Freud’s obituary of his great teacher:
Having at his disposal a considerable number of patients afflicted with chronic nervous disease he was enabled to take full advantage of his peculiar talent. He was not much given to cogitation, was not of the reflective type, but he had an artistically gifted temperament—as he said himself, he was a visuel, a seer. He himself told us the following about his method of working. He was accustomed to look again and again at things that were incomprehensible to him, to deepen his impression of them day by day until suddenly understanding of them dawned on him. Before his mind’s eye, order then came into the chaos apparently presented by the constant repetition of the same symptoms; the new clinical pictures which were characterized by the constant combination of certain syndromes took shape; the complete and extreme cases, the “types,” were then distinguishable with the aid of a specific kind of schematic arrangement, and with these as a starting point the eye could follow down the long line of the less significant cases, the formes frustes, showing some one or other peculiar feature of the type and fading into the indefinite. He called this kind of mental work, in which he had no equal, “practising nosography” and he was proud of it.2
Charcot’s own term for this work—”practising nosography”—is indeed an apt expression to describe his charting of human misery and cataloguing it in the language of medicine. It is obvious that what Charcot here describes was of no more help to his unknown patients than is a biologist’s description of unknown bacteria to the microbes; indeed, depending on the subsequent uses to which such information is put, the objects catalogued may be as easily harmed as helped.
Freud then continues:
But to his pupils, who made the rounds with him through the wards of the Salpêtrière—the museum of clinical facts for the greater part named and defined by him—he seemed a very Cuvier, as we see him in the statue in front of the Jardin des Plantes, surrounded by the various types of animal life which he had understood and described; or else he reminded them of the myth of Adam, who must have experienced in its most perfect form that intellectual delight so highly praised by Charcot, when the Lord led before him the creatures of Paradise to be named and grouped.3
To Charcot and Freud, these patients are mere objects or things to be classified and manipulated. It is an utterly dehumanized view of the sick person. But then, we might recall that even today physicians often speak of “cases” and “clinical material” rather than of persons, thus betraying the same bias.
Charcot’s sole clinical interest was thus to identify, describe, and classify neurological diseases—diseases of the nervous system. He therefore had to establish which phenomena constituted such diseases, and which did not. As the geologist must differentiate gold from copper, and both from other metals which glitter, so the neurologist-nosographer must differentiate multiple sclerosis, tabes, and hysteria. How does he do this?
In Charcot’s days the most important tool, besides the clinical examination, was the post-mortem study of the brain. Freud provided us with an interesting glimpse of how Charcot carried out his taxonomic work:
During his student days chance brought him into contact with a charwoman who suffered from a peculiar form of tremor and could not get work because of her awkwardness. Charcot recognized her condition to be “choreiform paralysis,” already described by Duchenne, of the origin of which, however, nothing was known. In spite of her costing him a small fortune in broken plates and platters, Charcot kept her for years in his service and, when at last she died, could prove in the autopsy that “choreiform paralysis” was the clinical expression of multiple cerebro-spinal sclerosis.4
Guillain’s biography of Charcot furnishes considerable additional information consistent with the picture sketched so far.5 For example, we learn that Charcot moved in the highest social circles. He was a friend of Premier Gambetta and also of the Grand Duke Nicholas of Russia. He is said to have paved the way for the Franco-Russian Alliance. By all accounts, he aspired to the role of aristocratic autocrat. It requires no great feat of the imagination to infer what sort of personal relationship must have prevailed between him and his destitute and near-illiterate patients.
A firsthand account, although perhaps somewhat embellished, of the human side of Charcot’s work may be obtained from Axel Munthe’s beautiful autobiography, The Story of San Michèle* Of particular interest is Munthe’s story of a young peasant girl who took refuge in hysterical symptoms to escape the drudgery of her home life. Munthe felt the “treatment” she was receiving at the Saltpêtrière was making her a lifelong invalid, and that Charcot was, in a way, keeping her imprisoned. He tried to “rescue” the girl, took her to his apartment, and hoped to convince her to return home. It appears from Munthe’s story, however, that the young woman preferred the social role of hysterical patient at the Salpêtrièrè to that of peasant girl in her village. Evidently, life in the hospital was more exciting and rewarding than her “normal” existence—a contingency Munthe seriously underestimated. What emerges from this account, too, is that the Salpêtrière, under Charcot, was a special type of social institution. In addition to its similarities to present day state mental hospitals, its function could also be compared to armies and religious organizations. In other words, the Salpêtrière provided its inmates with certain comforts and gratifications lacking in their ordinary social environment. Charcot and the other physicians who worked there functioned as rulers vis-à-vis their subjects. Instead of intimacy and trust, their relationship to each other was based on fear, awe, and deception.
As Charcot’s knowledge of neuropathology increased and as his prestige grew, his interest shifted from neurological disorders to disorders which simulated such conditions. Such patients were then classified either hysterics or malingerers, depending on the observer’s point of view. Those labeled “hysterics” were declared relatively more respectable and fit objects for serious study. They were regarded as suffering from an illness, rather than as trying to fool the physician or exhibiting willful misbehavior. This is the most fundamental connection, although by no means the only one, between the notions of hysteria and malingering. Freud’s account of Charcot’s work is again illuminating:
He explained that the theory of organic nervous diseases was for the present fairly complete, and he began to turn his attention almost exclusively to hysteria, thus suddenly focusing general attention to this subject. This most enigmatic of all nervous diseases—no workable point of view having yet been found from which physicians could regard it—had just at this time come very much into discredit, and this ill-repute related not only to the patients but was extended to the physicians who treated this neurosis. The general opinion was that anything may happen in hysteria; hysterics found no credit whatsoever. First of all Charcot’s work restored dignity to the subject; gradually the sneering attitude, which the hysteric could reckon on meeting when she told her story, was given up; she was no longer a malingerer, since Charcot had thrown the whole weight of his authority on the side of the reality and objectivity of hysterical phenomena.7
This passage reveals how the study of hysteria was prejudged by the importance of its investigator, Charcot. Certain crucial issues were, therefore, obscured and must now be reexamined. Even the simple statement that Charcot turned his attention to “hysteria” rests on the tacit assumption that this was the patient’s trouble. It was decided by fiat that, in contrast to organic neurological disease, these people had “functional nervous illnesses.” And most of these “illneses” were then named “hysteria.” Freud’s interesting comment should now be recalled: hysterics were no longer diagnosed as malingerers because of Charcot’s authority. Freud offered no evidence or reason for preferring the category of hysteria to that of malingering. Instead, he appealed to ethical considerations, although without explicitly saying so:
Charcot had repeated on a small scale the act of liberation commemorated in the picture of Pinel which adorned the lecture hall of the Salpêtrière. Now that the blind fear of being fooled by the poor patient which had stood in the way of a serious study of the neurosis was overcome, the question arose which mode of procedure would most speedily lead to the solution of the problem.8
This situation is historically significant on two counts: first, because it marks the beginning of the modern study of so-called mental illnesses; second, because it contains what I regard as the major logical and procedural error in the evolution of modern psychiatry.
Freud compared Charcot’s work to Pinel’s. But, as I see it, Pinel’s liberation of the mental patient from the dungeon was not a psychiatric achievement at all. It was a moral achievement. He claimed that the sufferers who had been placed in his charge were human beings, and as such entitled to the rights and dignities which, in principle at least, motivated the French Revolution. Pinel did not advocate that the patient should be better treated because he was sick. Indeed, the social role of the sick person was not an enviable one at that time. Hence, an appeal for better treatment on this ground would not have been effective.
Pinel’s liberation of the mental patient should thus be viewed as social reform rather than as innovation in medical treatment. This is an important distinction. For instance, during the Second World War the removal of venereal infection from the classification of disciplinary offenses among military personnel was an act of social reform. The discovery of penicillin, while bearing on the same problem—namely, the control of venereal disease—was a scientific discovery.
What were the effects of Charcot’s insistence that hysterics were ill and not malingering? Although this diagnosis did not alter the hysteric’s disability, it did make it easier for him to be “ill.” Like a little knowledge, this type of assistance can be dangerous. It makes it easier for both sufferer and helper to stabilize the situation and rest content with what is still a very unsatisfactory state of affairs. A comparison of Charcot with another famous French physician, Guillotin, may be illuminating in this connection.
Guillotin’s highly questionable contribution to human welfare consisted of the reinvention and advocacy of the guillotine. This resulted in a relatively painless and, therefore, less cruel form of execution than those previously in vogue. In our day, the guillotine and the rope have been succeeded in America by the gas chamber and electric chair. Clearly, Guillotin’s work is humane or inhuman, depending on which side of the issue we examine. From the point of view of making execution less painful for the executed, it was humane. Since it also made things easier for the executioner and his employers, it was inhuman. What Charcot did was similar. To put it succinctly, Guillotin made it easier for the condemned to die, and Charcot made it easier for the sufferer, then commonly called a malingerer, to be sick. It may be argued that when dealing with the hopeless and the helpless, these are real accomplishments. Still, I would maintain that Guillotin’s and Charcot’s interventions were not acts of liberation, but were rather processes of narcotization or tranquilization.
In short, Charcot and Guillotin made it easier for people—particularly for the socially downtrodden—to be ill and to die. Neither made it easier for people to be well and to live. They used their medical knowledge and prestige to help society shape itself into an image it found pleasing. Efficient and painless execution fitted well into the self-image of Guillotin’s society. Similarly, late-nineteenth-century European society was ready to view almost any disability—and particularly one, such as hysteria, that looked so much like a disorder of the body—as illness. Charcot, Kraepelin, Breuer, Freud, and many others lent their authority to the propagation of this socially self-enhancing image of what was then “hysteria,” and what in our day has become the problem of “mental illness.” The weight of authority of contemporary medical and psychiatric opinion continues, of course, to support and to expand this image.
The foregoing events have had far-reaching consequences in shaping contemporary consciousness and practices with respect to the so-called mentally ill. It might seem, at first glance, that to advocate, and indeed to insist, that an unhappy or troubled person is sick—and that he is sick in exactly the same sense and way in which a person suffering from cancer is sick—is humane and well-intentioned, as it aims to bestow upon such a person the dignity of suffering from a genuine illness over which he has no control. However, there is a hidden weight attached to this tactic which pulls the suffering person back into the same sort of disrepute from which this semantic and social reclassification was intended to rescue him. Indeed, labeling individuals displaying or disabled by problems in living as “mentally ill” has only impeded and retarded the recognition of the essentially moral and political nature of the phenomena to which psychiatrists address themselves.
Another error in decreeing that some malingerers be called hysterics was that it led to obscuring the similarities and differences between organic neurological disease and phenomena that only resembled them. In analyzing hysteria, we have a choice between emphasizing the similarities or the differences between it and neurological illness. Actually, both are readily apparent. The similarities between hysteria and bodily illness lie chiefly in the patient’s complaints, his clinical appearance, and the fact that he is disabled. The differences between them lie in the empirical findings on physical, laboratory, and post-mortem examination. Moreover, these similarities and differences do not really stand in opposition to one another: there is no reason to believe that every person who complains of being ill or who looks ill or who is disabled—or who manifests all three of these features—must also have a physicochemical disorder of his body! This does not deny the possibility that there may be a connection between such complaints and bodily diseases. The nature of this connection, however, is empirical, not logical. Once this is clear, it becomes a matter of scientific and social choice whether we prefer to emphasize the similarities—and place hysteria in the category of illness; or whether we prefer to emphasize the differences—and place it in the category of nonillness.
The aim of my analysis of the problem of hysteria up to here has been to make explicit the values which influenced members of the psychiatric profession in the late nineteenth century. I dwelled on Charcot’s attitude toward patients to show, first that he never considered himself to be the patient’s agent, and second, that his principal goal was to identify accurately specific diseases. As a result, Charcot tended to define all of the phenomena he studied as neurological disorders. If this accomplished nothing else, it at least justified the attention he paid to these phenomena and the pronouncements he made about them. In this respect, Charcot and his group stood in the same sort of relationship to hysteria as the contemporary physicist stands to nuclear war. The fact that atomic energy is used in warfare does not make international conflicts problems in physics; likewise, the fact that the brain is used in human behavior does not make moral and personal conflicts problems in medicine.
The point is that the prestige of the scientist—whether of a Charcot or of an Einstein—can be used to lend power to its possessor. He then may be able to achieve social goals that he could not otherwise attain. Once a scientist becomes so engaged, however, he has a powerful incentive to claim that his opinions and recommendations rest on the same grounds as his reputation! In Charcot’s case, this meant that he had to base his case about hysteria on the premise that it was an organic neurological illness. Otherwise, if hysteria and hypnosis were problems in human relations and psychology, why should anyone have taken Charcot’s opinions as authoritative? He had no special qualifications or competence in these areas. Hence, had he openly acknowledged that he was speaking about such nonmedical matters, he might have encountered serious opposition.
These historical developments lie at the root of a double standard in psychiatry that still persists. I refer to the dual orientation of physicians and psychiatrists to certain occurrences which they encounter in their practices. Charcot’s informal, off-the-record comment about hysteria illustrates this phenomenon:
Some years later, at one of Charcot’s evening receptions, I happened to be standing near the great teacher at a moment when he appeared to be telling Brouardel a very interesting story about something that had happened during his day’s work. I hardly heard the beginning, but gradually my attention was seized by what he was talking of: a young married couple from a distant country in the East—the woman a severe sufferer, the man either impotent or exceedingly awkward. “Tachez donc” I heard Charcot repeating, “je vous assure, vous y arriverez.” Brouardel, who spoke less loudly, must have expressed his astonishment that symptoms like the wife’s could have been produced by such circumstances. For Charcot suddenly broke out with great animation, “Mais, dans des cas pareils c’est toujours la chose genitale, toujours … toujours”; and he crossed his arms over his stomach, hugging himself and jumping up and down on his toes several times in his own characteristically lively way. I know that for a moment I was almost paralyzed with amazement and said to myself: “Well, but if he knows that, why does he never say so?” But the impression was soon forgotten; brain anatomy and the experimental induction of hysterical paralyses absorbed all available interest.9
Why was Charcot so insistent? With whom was he arguing? With himself! Charcot must have known that he was deceiving himself when he believed that hysteria was a disease of the nervous system. Herein lies the double standard. The organic viewpoint is dictated by social expediency insofar as the rules of the game of medicine are defined so that adherence to this position will be rewarded. Adherence to the psychological viewpoint is required by the physician’s loyalty to the truth and his identification or empathy with the patient. This dichotomy is reflected in the two basic contemporary psychiatric methods, namely, the physicochemical and the psychosocial. In the days of Charcot and Freud, however, only the former was recognized as belonging to science and medicine. Interest in the latter was synonymous with charlatanry and quackery.
Adherence to the organic or physicochemical viewpoint was, and continues to be, dictated also by the’ difficulty in many cases of differentiating hysteria from, say, multiple sclerosis or brain tumor (especially in their early stages). Conversely, patients with neurological illnesses may also exhibit so-called hysterical behavior or may show signs of other types of mental illness. This problem of the so-called differential diagnosis between “organic” and “psychological” illness has constituted one of the major stumbling blocks in the way of a systematic theory of personal conduct free of brain-mythological components.
Although the problem of malingering will be examined in detail in the next chapter, it is necessary here to say a few words concerning Charcot’s view of the relationship between hysteria and malingering. In one of his lectures he said:
This brings me to say a few words about malingering. It is found in every phase of hysteria and one is surprised at times to admire the ruse, the sagacity, and the unyielding tenacity that especially the women, who are under the influence of a severe neurosis, display in order to deceive … especially when the victim of the deceit happens to be a physician.10
Already, during Charcot’s lifetime and at the height of his fame, it was suggested, particularly by Bernheim, that the phenomena of hysteria were due to suggestion. It was also intimated that Charcot’s demonstrations of hysteria were faked, a charge that has since been fully substantiated. Clearly, Charcot’s cheating, or his willingness to be duped—whichever it was seems impossible to ascertain now—is a delicate subject. It was called “the slight failing of Charcot” by Pierre Marie. Guillain, more interested in the neurological than in the psychiatric contributions of his hero, minimized Charcot’s involvement in and responsibility for faking experiments and demonstrations on hypnotism and hysteria. But he was forced to concede that “Charcot obviously made a mistake in not checking his experiments…. Charcot personally never hypnotized a single patient, never checked his experiments and, as a result, was not aware of their inadequacies or of the reasons of their eventual errors.”11
To speak of “inadequacies” and “errors” here is to indulge in euphemisms. What Guillain described, and what others have previously intimated, was that Charcot’s assistants had coached the patients on how to act the role of the hypnotized or hysterical person. Guillain himself tested this hypothesis with the following results:
In 1899, about six years after Charcot’s death, I saw as a young intern at the Salpêtrière the old patients of Charcot who were still hospitalized. Many of the women, who were excellent comedians, when they were offered a slight pecuniary remuneration imitated perfectly the major hysteric crises of former times.12
Troubled by these facts, Guillain asked himself how this chicanery could come about and how it could have been perpetuated? All of the physicians, Guillain hastened to assure us, “possessed high moral integrity.”13 He then suggested the following explanation:
It seems to me impossible that some of them did not question the unlikelihood of certain contingencies. Why did they not put Charcot on his guard? The only explanation that I can think of, with all the reservation that it carries, is that they did not dare alert Charcot, fearing the violent reactions of the master, who was called the “Caesar of the Salpêtrière.”14
We must conclude that Charcot’s orientation to the problem of hysteria was neither organic nor psychological. He recognized and clearly stated that problems in human relationships may be expressed in hysterical symptoms. The point is that he maintained the medical view in public, for official purposes, as it were, and espoused the psychological view only in private, where such opinions were safe.
My criticism of Charcot rests not so much on his adherence to a conventional medical model of illness for his interpretation of hysteria as on his covert use of scientific prestige to gain certain social ends. What were these ends? They were the acceptance of the phenomena of hypnotism and hysteria by the medical profession in general, and particularly by the French Academy of Sciences. But at what cost was this acceptance won? This question is rarely raised. As a rule, only the conquest over the resistance of the medical profession is celebrated. Zilboorg describes Charcot’s victory over the French Academy as follows:
These were the ideas which Charcot presented to Académie des Sciences on February 13, 1882, in a paper on the diverse nervous states determined by the hypnotization of hysterics. One must not forget that the Académie had already condemned all research on animal magnetism three times and that it was a veritable tour de force to make the Académie accept a long description of absolutely analogous phenomena. They believed, and Charcot himself believed, that this study was far removed from animal magnetism and was a definite condemnation of it. That is why the Académie did not revolt and why they accepted with interest a study which brought to a conclusion the interminable controversy over magnetism, about which the members of the Académie could not fail to have some remorse. And remorse they well might have, for, from the standpoint of the actual facts observed, Charcot did nothing more than what Georget had asked the Académie to do fifty-six years previously. Whether one called the phenomenon animal magnetism, mesmerism, or hypnotism, it stood the test of time. The scientific integrity of the Académie did not. Like a government reluctant, indecisive, and uncertain of itself, it did nothing whenever it was safe to do nothing and yielded only when the pressure of events forced it to act and the change of formulatory cloak secured its face-saving complacency.15
I believe that this “change of formulatory cloak,” which secured the admittance of hysteria into the French Academy, constitutes a historical paradigm. Like the influence of an early but significant parental attitude on the life of the individual, it continues to exert a malignant effect on the life of psychiatry.
Such “pathogenic” historical events may be counteracted in one of two ways. The first is by reaction-formation—that is, by an overcompensation against the original influence. Thus, to correct the early organic bias the significance of psychogenic factors in so-called mental illness is exaggerated. Enormous efforts have been expended in modern psychiatry, psychoanalysis, and psychosomatic medicine to create the impression that “mental illness is like any other illness.”
The second way to remedy such a “trauma” is exemplified by the psychoanalytic method itself. By helping the person become explicitly aware of the events that have influenced his life in the past, the persistent effects of these events on his future can be mitigated and indeed radically modified. In my epistemological analysis of the problem of mental illness, I have relied in part on the same method and premise—namely, that by becoming explicitly aware of the historical origins and philosophical foundations of current psychiatric ideas and practices, we may be in a better position to modify them than we would be without such self-scrutiny.