Clinical Deductions

Pierre Aristide André Brouillet
A Clinical Lesson at the Salpêtrière
290 x 430 cm
Descartes University, Paris
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Here we see Jean-Martin Charcot, a leading figure in the modern field of neurology, performing a demonstration with a “hysterical” patient for the benefit of the gathered students and onlookers. The scene is set in the Salpêtrière Hospital, an asylum for patients with neurological disorders where Charcot played an active role. Charcot was one of the first to realize the important connection between clinical information (what the patient says and what the neurologist sees on examination) and pathology (looking at brain tissue under the microscope). Charcot used this realization to better understand diseases such as multiple sclerosis and Parkinson’s Disease. He also did important work in comprehending the medical condition of “hysteria,” now referred to as conversion disorder, where neurological symptoms are present without a medical explanation.

Jean-Martin Charcot, a piece in the Neurology, Illustrated gallery at Tufts Medical Center in Boston, MA.Jean-Martin Charcot was a pioneer in the field of neurology, whose work was profoundly influential on the emerging field of psychiatry. Charcot (1825-1893) identified and described several disorders, including multiple sclerosis, but today is most well-known for his work on hysteria. The term “hysteria” comes from the Greek word for uterus, and was used to refer to the symptoms present in women who were suffering from a “wandering womb.” Hysteria was a common diagnosis for women during the early modern period. In Shakespeare’s play King Lear, Lear is so upset by his daughters’ betrayal he says he suffers from “hysterica passio,” the excessive emotions usually only suffered by women. Charcot was the first to take a more modern, scientific approach to hysteria, associating the symptoms with certain psychological disorders, and began using hypnosis as a form of treatment. Hysteria is now considered an archaic and historic term.

After finishing medical school, Charcot interned at the Salpêtrière Hospital in Paris, a building constructed under King Louis XIII and originally used to store gunpowder. Charcot played an important role in later converting the building into a leading center for neurology, with a pathology lab and other state-of-the-art features. In 1862, there were around 5,000 patients at the Salpêtrière, 3,000 of whom were suffering from neurological disorders. The Salpêtrière was a place of asylum for these individuals, but also offered excellent opportunities for Charcot to observe patients, conduct studies, and teach.

The Circular Arc by Paul Richer, a piece in the Neurology, Illustrated gallery at Tufts Medical Center in Boston, MA.Charcot believed in the power of art as an important tool in the field of medicine. In his classes, he utilized drawings and photos to illustrate important concepts. In this painting by Pierre Aristide André Brouillet, titled A Clinical Lesson at the Salpêtrière, we see Charcot with a hysterical young woman before a group of students at the hospital. Along the back wall, we find a charcoal drawing by Paul Richer of a woman in a similar hysterical pose, based on the photographs that had been taken of patients at the Salpêtrière. Brouillet, who was a pupil of the great French painter Jean-Léon Gérôme, was skilled at executing group scenes such as this, where the figures have been arranged in a manner that captures our attention. Slightly to the right of center, Charcot and his patient, Marie Wittman, are the focus of the scene. Many reproductions of this painting were made in print form; Sigmund Freud owned a small lithograph after the painting, which he displayed over his analytical couch in London.

Slightly to the right of center, Charcot and his patient, Marie Wittman, are the focus of the scene. Many people in the painting have been identified. Some are neurologists of renown who are still recognized today as medical pioneers. Joseph Babinski is holding the patient. Immediately behind Charcot’s right elbow is the medical artist, Paul Richer. Also pictured are George Gilles de la Tourette (Tourette Syndrome), Pierre Marie (acromegaly, Marie-Foix-Alajouanine syndrome, and Charcot-Marie-Tooth disease), Edouard Brissaud (tuberous sclerosis), Henri Parinaud (Parinaud syndrome and cat scratch disease), and Charcot’s son, Jean-Baptiste. Jean-Baptiste became a polar explorer who discovered and then named an Antarctic island after his father. Although an island, it was attached to adjacent land by the massive Wilkins Ice Shelf. Global warming is thought to be responsible for the retreat of the ice until it collapsed in 2009 leaving Charcot Island surrounded by water for the first time since its discovery.

A conversion disorder, from which the woman in the painting is suffering, is diagnosed when patients show neurological symptoms that are not consistent with a known neurological disease. Conversion disorders, formerly known as hysteria, have been described in patients of all sexes and ages but it is rare in children and more common in women. It can appear as weakness, sensory symptoms, speech disturbances, abnormal movements, or attacks that look like seizures but which are non-epileptic. It should not be confused with malingering whereby patients misrepresent and consciously deceive health care workers with simulated symptoms of other diseases. Evaluation of a patient with a conversion disorder must be detailed and complete so as not to miss an underlying neurological disorder. Indeed, some patients with non-epileptic seizures have co-existing electrical (epileptic) seizures. In most patients, laboratory and radiological tests are normal. There is a strong association with pre-existing mood disorders like anxiety and depression. Treatment starts with reassuring patients that there is not another underlying neurological condition, avoiding neurological medications (like antiepileptic drugs), stress reduction, and psychological treatments like counseling and, sometimes, medication.