Dreams: Charcot's Last Words on Hysteria

Abstract

Jean-Martin Charcot (1825–1893), the leading neurologist of his time, is best remembered for his studies on hysteria presented in clinical lectures at the Paris Salpêtrière hospital. Developing the concept of traumatic male hysteria after accidents in which patients suffered slight physical damage led him to advance a psychological explanation for hysteria. Traumatic hysteria is the context for a close reading of Charcot's "last words" based upon a final unpublished lesson in 1893. This case history concerns a seventeen-year-old Parisian artisan whose various signs of hysteria developed following a dream in which he imagined himself the victim of a violent assault. Charcot identifies the dream/nightmare as the "original" feature determining traumatic hysteria. The dream sets in motion an overwhelming consciousness followed by a susceptibility to "autosuggestion" producing somatic signs of hysteria. Charcot's final lesson on dreams thus culminates his study of the psychological basis of traumatic hysteria.

On May 9, 1893, neurologist Jean-Martin Charcot readied his notes for one of his internationally famous Tuesday clinical lessons at the Salpêtrière hospital in Paris. A little over three months later, on August 16, he died suddenly while on a summer holiday. Detailed accounts of Charcot's final days and hours by his traveling companions, two of whom were medical colleagues, make no mention of any passing reflections on his ongoing work on hysteria amid Charcot's various musings.¹ Nor did the physician's two published clinical case lessons on hysteria earlier in 1893 suggest significant revisions in his understanding of the ailment to which he had devoted increasing attention as his career advanced and on which he had become the world's leading authority.² In this article, I conclude, based upon an unpublished lesson of May 9 on dreams, that Charcot here articulated his fullest argument for the psychological roots of hysteria.

Since the mid-1880s, Charcot's published case histories on male hysteria had alluded to psychic mechanisms underlying hysteria. But, le patron, as he was respectfully and affectionately known by students, said little about how such mechanisms acted. As he had done throughout his career, the neurologist focused his attention on detailed descriptions of the physical signs or "stigmata" in patients' case histories. Yet, a year prior to his death, Charcot declared that hysteria was "in large measure a mental disease," a "way of thinking" (une pensée) he had many times confirmed in his teaching lessons.³

The goal of this essay is to flesh out Charcot's pensée beyond what he ever published. He did however leave a final case history lesson in manuscript. This document provides clinical detail on Charcot's end-of-career interest in the psychological basis of hysteria, an interest noted briefly in the outpouring of eulogies in 1893. Not surprisingly, Charcot's colleagues celebrated their mentor's achievements in neuropathology, as witnessed by the numerous disease eponyms associated with his name. Until well beyond the mid-twentieth century, scholarship on Charcot tended to be the preserve of neurologists interested in the history of their specialized discipline.

Two main trends transformed and broadened the subsequent historiography of Charcot scholarship: first, the novel perspective of dynamic psychiatry and, second, the engagement with cultural history. Historians with a formation in psychiatry, especially in Freudian psychoanalysis, followed the pioneering example set by Henri Ellenberger's The Discovery of the Unconscious (1970). Ellenberger situated Charcot's work on hysteria in the broader context of the history of psychology. However, his magisterial survey tended to view Charcot (along with other nineteenth-century and earlier figures) as essentially precursors to Freud and Janet, among the turn-of-the-century founders of dynamic psychiatry. Subsequent historians of psychoanalysis framed Charcot's work on hysteria in this perspective while greatly expanding scholarly interest in the subject.

A more recent approach drew upon university academicians' work in cultural and social history. Inspired by prominent philosophers like Michel Foucault and Ian Hacking, who drew attention to the novel epistemology of Charcot's hysteria project, several historians published important monographs.⁴ Jan Goldstein, in Console and Classify: The French Psychiatric Profession in the Nineteenth Century (1987), showed the political and social significance of Charcot's cultural construction of the hysteria diagnosis. Mark Micale, in Hysterical Men: The Hidden History of Male Nervous Illness (2008), focused on Charcot's turn toward case histories of traumatic hysteria in males during the 1880s and thus provided the context for the final case history that is the subject of this article.

Hysteria: A Sosie and a Sphinx

Psychological issues had not been conspicuous in Charcot's approach to hysteria prior to the 1880s.⁵ His reputation had been built on clinical demonstrations of striking physical motor and sensory deficits, such as paralyses and anesthesias, in hysterical patients, not on their psychological or mental component.⁶ After Charcot's death, his former student, Pierre Janet, himself a leading psychologist, sought to correct this impression in a substantial eulogy dealing with the significance of his mentor as "psychologist."⁷ But a more widely held opinion charging neglect of psychological aspects came from an American colleague who recognized Charcot's stature as the "great apostle of hysteria," a disorder otherwise "perfectly described" by his Salpêtrière school: "There is one feature," George Preston of Baltimore noted, "which has hardly received its due attention, and which is certainly one of the most important elements which go to make up the complex neurosis—namely the mental condition in hysteria."⁸

Although Charcot's investigations embraced the full range of nervous pathology, hysteria consistently posed a challenging diagnostic puzzle for him and other neuropathologists.⁹ How was one to differentiate manifestations of hysteria, from clinically similar organic diseases? Charcot considered hysteria, a functional or "dynamic" disorder lacking a known pathological anatomical location. But hysteria could masquerade clinically, as it were, in the guise of many and various known organic diseases of the nervous system. Charcot termed this property neuromimesis, or mimicking.¹⁰ Included were epilepsy, chorea, multiple sclerosis, amyotrophic lateral sclerosis, tabes dorsalis and isolated paralyses and anesthesias, all of which were quite well known to Charcot, who had been a major contributor to their clinical and pathological understanding.¹¹ Concluding his Tuesday lessons in June 1889, Charcot insisted that the neuropathologist must "never forget" that every known organic nervous disease had its hysterical counterpart, a double, or sosie.¹²

If Charcot's initial concern with hysteria began as a diagnostic challenge to distinguish or exclude that ailment from cases of epilepsy and other neurological disorders, his clinical research interest gradually came to focus on hysteria itself. The third volume of Charcot's published clinical lectures, dating from the 1880s, devoted more than half of its subjects (fifteen of twenty-six lessons, including the last eleven) to hysteria plus an appendix with numerous case histories of novel expressions of what he sometimes called the "great neurosis," such as hysterical muscular atrophy and hysterical mutism.¹³

Charcot called for an extension of the study of hysteria in a public lecture in March 1882 inaugurating the professorship created expressly for him in diseases of the nervous system. Here he likened hysteria to a "sphinx" in its defiance of anatomical localization; hysteria also seemed to resist objective clinical measurement. Addressing this issue, Charcot demonstrated a recording apparatus for detecting altered respiratory and motor tracings in hysterical patients. Such results enabled the diagnosis of hysterical deficits as legitimate and distinct from patient simulation.¹⁴

Trauma and Male Hysteria

The 1880 opening at the Salpêtrière of an outpatient clinic (polyclinic) and an inpatient ward of sixty beds for nervous diseases permitted the admission of male patients to the more than two-centuries-old women's hospice for the first time. These innovations, due to Charcot's initiative, permitted the study of male hysteria, which would become the focus of the final decade of his career.

In the spring of 1885, Charcot presented two lengthy lessons on a series of patients published under the title "Six Cases of Hysteria in Men." Although he had broached the subject earlier in the decade, male patients for instruction had never before been so plentiful: "We possess in the clinical service at the moment a truly remarkable collection of patients which I can show and study with you."¹⁵

Charcot's enthusiasm over the arrival, "by chance,"¹⁶ at the Salpêtrière of six male hysterics was somewhat disingenuous, given the fact that his clinic had already acquired a reputation for receiving such patients from other Paris hospitals and provincial institutions. Ranging in age from sixteen to forty-four years, the six patients demonstrated the clinical reality and suggested the frequency of male hysteria, a diagnosis still missed by excellent clinicians or doubted by others due to a widely held "prejudice" that hysteria was confined to females or to effeminate males. On the contrary, Charcot's subjects were "vigorous artisans, solidly built."¹⁷ Male hysteria in fact, he stated, was "not very rare." Except for nuances, such as a greater tendency to be accompanied by a melancholy mood alteration, hysteria in the male, Charcot asserted, closely resembled its better-known female counterpart.¹⁸ Deficits in the male also tended to be more obdurate. Trauma, often the result of workplace accidents, more common in men than in women, formed part of the typical male hysteric's case history.¹⁹

Charcot's six male hysterics all became ill following accidents or violence in which they had escaped serious physical injury. Thus "Rig," "a big man, strong and well-developed," forty-six years old, a former cooper, narrowly escaped being crushed by a falling barrel while working in a wine cellar.²⁰ He emerged with a slight wound of the finger. But Charcot identified the life-threatening "horror [terreur] experienced by the worker at the moment of the accident" as the critical factor.²¹ A few minutes after his fright, Rig briefly lost consciousness and suffered severe leg weakness such that he had to be carried home. Unable to work for two days, he had terrifying nightmares recalling the scene with the barrel. Ten days later he had the first of a series of convulsive attacks of "hystero-epilepsy," the phases of involuntary movements and unconscious hallucinations familiar from cases of female hysteria. These continued periodically during the following three years, accompanied by extensive patches of anesthesia, retraction of the visual field, and nightmares.

Charcot summed up Rig's "perfectly typical" case,²² generalizing that male hysteria resulted from "'shock' with or without injury, but where emotion plays a great role."²³ He noted that the five further patients conformed to a similar pattern of emotional trauma.²⁴ Providing evidence that "hysteria, even grave hysteria, is not so rare a disease in the male, at least among us in France,"²⁵ Charcot remarked that the ailment was starting to be seen "rather frequently" in ordinary practice.

Statistics published in 1885 by Charcot's assistants revealed hysteria to be the leading diagnosis in patients seen at the Salpêtrière outpatient clinic. Ninety-six cases over six months argued for a greater prevalence of the ailment over organic nervous disease. (There were sixty-six cases of stroke and sixty-five of epilepsy during the same period.)²⁶

According to a second tally of patients at the outpatient clinic in 1891, hysteria remained the leading nervous condition. There was in fact an increase of nearly 70 percent compared with the 1885 total. The impressive annualized total of 325 new cases of hysteria was, in the words of Charcot's chief assistant, "un joli chiffre," a reflection of the unrivalled reputation of the service under his mentor's leadership.²⁷

In 1889 Charcot estimated that the total number of inpatients with hysteria or hystero-epilepsy had remained constant at nearly two hundred women during his thirty-year tenure at the hospice.²⁸ What had changed beginning in the mid-1880s was the increasing diagnosis of men with traumatic hysteria at the newly established Salpêtrière nervous disease clinic and outpatient consultation.

Charcot expressed pride in his school's (l'école française) legitimation of the diagnosis of traumatic hysteria. He believed their work had "profoundly transformed neuropathology," benefiting both patients and physicians, by bringing to light a new disease entity.²⁹ In just a few years, due in large measure to the "tenacious" efforts of the Salpêtrière school, recognition of traumatic hysteria had "penetrated bit by bit" into the practice of medicine and surgery.³⁰

But Charcot did not represent the work on traumatic hysteria as a new discovery. Rather, he said that he had laboriously come to recognize what had always been present. "Certainly, one sees only that which one has learned to see; those cases [male traumatic hysteria] remained unknown to me, like everyone else, three years ago. Yet they existed, for it is not at all likely that we are dealing with a new disease."³¹

Charcot's Last Tuesday Lesson

The lesson dated May 9, 1893 (a Tuesday), survives only in manuscript among Charcot's unpublished papers in the library bearing his name.³² It deals with a single case history of hysteria in which the patient's dreams were accorded a decisive role in causing various somatic manifestations. Why this lesson did not follow the customary route to publication in one of the medical journals in which Charcot's lessons typically first appeared in print remains unclear.³³ Nor did it find its way posthumously into the neurologist's volumes of so-called Oeuvres complètes.³⁴ Given that the date of the May 9 lesson fell toward the conclusion of Charcot's teaching for 1892–93 and came only a few months before his sudden death, that lesson likely represents his final formal statement on hysteria.

Charcot of course would not have realized the critical timing of the May 9 lesson.³⁵ Although he did not provide a synthesis, he described in forceful language with rich detail a case history in which he concluded that dreams played a causal role in hysteria. While there were continuities with Charcot's earlier teaching, the lesson on dreams constituted his strongest claim for a psychological interpretation of hysteria.³⁶

Charcot's Sources on Dreams

Notions about dreams have a venerable pedigree in medicine going back to ancient incubation healing in the Temples of Asclepius and prophetic dreams discussed in the Hippocratic corpus.³⁷ In the mid-eighteenth century, the article "Rêve (Médecine)" in the Encyclopédie of Diderot and D'Alembert remained thoroughly Hippocratic. Dreams provided clues for diagnosis and prognosis. Those who dreamed of fire had too much yellow bile, and similar analogies were associated with the other bodily humors. Dreaming of an agitated sea foretold trouble in the gut; if a patient dreamed of falling from a height, vertigo, epilepsy, or apoplexy threatened.³⁸

Notable early modern medical authors—Ambroise Paré, Thomas Sydenham, and Philippe Pinel—considered dreams relevant to understanding mental illness. The view that the mental state of a dreaming person could be likened to hallucinations in the insane or, alternatively, dreams might stimulate creative reveries in the artist.³⁹ Charcot's reputation for preparing his lessons in depth was illustrated in his lesson on dreams.⁴⁰ In notes accompanying the lesson, Charcot made extensive references to contemporary scientific literature. He cited numerous articles and reviews of scholarly work in the French literature as well as German and Italian sources. His marks in blue pencil show that Charcot read articles on "rêve," "sommeil," and "hypnose" in French medical encyclopedia. He took notes on the article "rêve," by his Paris colleague Mathias Duval, in the Nouveau dictionnaire de médecine et de chirurgie (1882): while most dreams were quickly forgotten, "only painful [pénible] dreams persisted," a comment which Charcot confirmed in his own patients. He showed particular interest in nightmares. Analogies between disturbed dreaming and mental illness as formulated by French alienist Moreau de Tours's phrase, "to dream in a waking state is madness" (cited in Duval's article), were conspicuous in the literature.⁴¹ Another encyclopedia article, "songe," also quoted Moreau: "Between the state of madness and the state of dreaming, there is an absolute psychological identity."⁴²

Charcot, as was his custom in the Tuesday lectures, cited popular literature. Thus he noted a passage on dreams in Don Quixote, several lines from Shakespeare's plays, and Le Pays des Rêves (1831), by French romantic author Charles Nodier. Diverse and eclectic, Charcot's reading in the dream literature served as background to his more focused clinical study of dreams in hysteria.⁴³

The Salpêtrière Team on Dreams and Hysteria

Charcot's copious notes for his lesson of May 9, 1893, provide a paper trail of his immediate sources for claiming an important role for dreams in hysteria. These notes consist for the most part of passages from publications by former students who remained his close collaborators. Four colleagues who lent support to Charcot's notion that dreams could, as he put it, "determine" the "somatic phenomena" of hysteria were Désiré Magloire Bourneville, Charles Féré, Gilles de la Tourette, and Pierre Janet.⁴⁴ He referred to published work by each. Collectively they displayed the chief of the Salpêtrière in reciprocal interaction with his youthful team.

Désiré Magloire Bourneville (1840–1909) had initially introduced Charcot to the investigation of hysteria. Although fifteen years Charcot's junior and former intern, Bourneville's clinical experience with hysteria predated his mentor's.⁴⁵ Bourneville had studied the case histories of a group of hysterical women patients before they were admitted for the first time to Charcot's service in 1870. Bourneville subsequently promoted the hysteria project, including publication of Charcot's lectures in Le Progrès Médical, a weekly journal he founded and edited beginning in 1872.

In 1893 Charcot again invoked Bourneville's precedent. His notes for the May 9 lesson cited Bourneville's account of the "sleep of hysterics" published more than a decade earlier.⁴⁶ Based on his questioning of parents of young female patients on Charcot's service, Bourneville divided their dreams into three types: "painful or nightmares," "pleasurable," and "indifferent." He dismissed the indifferent as simply reflecting trivial daytime incidents. But he asserted that nightmares and pleasant dreams recalled the most significant emotionally charged memories from the patient's life history. Most important were nightmares, whose varieties Charcot copied into his notes: "quarrels, gun shots, drownings, resisting men who seek to rape them etc."⁴⁷ The dreaming patients "wake with a start, frightened, all in a sweat, and for a few moments, the frightful scenes continue to unfold before them, although they have their eyes open."⁴⁸

Bourneville proposed a "strong analogy" between the dreams of hysterics and the delirium phase of the hysterical attack. He stopped short of attributing a causal role to dreams, but Charcot nevertheless credited Bourneville's account with being the first to consider psychological phenomena in different types of dreams in the context of hysteria.

Charles Féré (1852–1907), who had been Charcot's intern in 1881 and subsequently his personal secretary, contributed a single case history to his mentor's dossier on dreams. In 1886 Féré published the case of a fourteen-year-old girl brought to the Salpêtrière clinic with weakness of both legs, leading to flaccid paralysis.⁴⁹ According to Féré, the hysteria of Eugénie P. was the result of a recurrent nightmare in which she was "pursued on the place de l'Odéon by men who sought to kill her." He concluded that the cumulative trauma of the dream over several weeks produced "exhaustion of motor centres" as the girl dreamed of flight from her assailants. "The main goal of this paper," Féré stated, "is to draw attention to the influence of dreams in the development of certain psychical disorders. Our cases tend to show that dreaming, especially repeated dreaming, must not be considered an indifferent phenomenon; rather it often constitutes the opening scene of a morbid drama, and as such deserves the attention of the physician."⁵⁰ Charcot credited Féré's case history with showing the "efficacy of dreams in producing permanent somatic disorders."⁵¹

Charcot copied extensive notes from Georges Gilles de la Tourette's Traité clinique et thérapeutique de l'hystérie (1891). Another member of Charcot's inner circle, Gilles de la Tourette (1857–1904) had served as Charcot's intern in 1884, then as chef de clinique, and finally as personal secretary. Gilles and Charcot exchanged gracious compliments in prefaces to the Traité, Gilles declaring that his work was based on the teachings of the leader of the Salpêtrière school, while Charcot assured the young author that he was "one of the best" of his pupils. But the patron forcefully asserted his intellectual priority: "Reading the work of M. Gilles de la Tourette before it was published, I was surprised to find several times my very own ideas that I think I had never made public, that, in any case, had remained unpublished."⁵²

Gilles acknowledged Charcot's inspiration in his chapter "De l'état mental des hystériques," which dealt at length with dreams.⁵³ Several points would reoccur in Charcot's lesson two years later. Gilles claimed that dreams of "long ago memories" (souvenirs anciens) resurfaced during the attitudes passionelles phase of the hysterical attack. Hysterics displayed lingering sadness, seemingly without cause, because they had forgotten the content of dreams still acting on the brain.⁵⁴ Dreams could produce (déterminer) somatic disorders, such as the paralysis observed by Féré. They could be considered "nocturnal hallucinations," exerting enormous influence on the daily lives of hysterics, affecting their psychological and physiological states. According to Gilles, dreams consisted of "lived experiences grossly exaggerated," a phrase Charcot copied in his notes.⁵⁵

Charcot's notes contained brief summaries of two case histories by Pierre Janet (1859–1947), the youngest among his protégés cited and the only one not to have served as his intern.⁵⁶ "Janet has seen," Charcot noted, "an hysterical girl who was learning to play the piano with passion." One morning they found her with fingers stiff, contracted in extension, and numb. She did not remember her dreams. But under hypnosis, she recalled "dreaming all night long that she had been forcefully playing the piano in a frenzy." In the second case, Janet's patient displayed various hysterical stigmata (pain, rigidity of the muscles of the back, hypersensitivity) that corresponded to a dream of moving house. Again, the female patient's memory of the forgotten dream had to be elicited by hypnosis.⁵⁷

The intellectual relationship between Charcot and Janet was less hierarchical than the customary teacher to pupil. Charcot, in many respects, remained the unquestioned patron—he welcomed Janet to the Salpêtrière team, entrusted him with running a new laboratory of experimental psychology, and accorded him time for lectures. But Janet may have been the maître à penser when it came to raising Charcot's appreciation of the psychological nature of hysteria.⁵⁸

From the mid-1880s Janet established a reputation as one of the leading French contributors to new themes in medical psychology such as amnesia, double personality, hypnotism, and somnambulism. He mentioned the importance of dreams in such conditions and in a review article titled "Recent Definitions of Hysteria" published in June 1893 in Charcot's Archives de neurologie. Janet's article noted that hysteria could result from fixed ideas or mental "representations." "The patient," he wrote, "dreams of his accident, thinking about it unceasingly, obsessively … these ideas have the greatest significance and determine not only the hysterical ailment in a general way but also the specific form it assumes."⁵⁹ Janet's formulation that dreams could determine the specific form of hysteria was identical to that adopted by Charcot at almost the same time. (Janet's article was dated the month after Charcot's lesson.)

Janet added that Charcot's conception of hysteria needed to be generalized "a little more," beyond the instance of traumatic cases.⁶⁰ He suggested a recent definition by Moebius, a German neuropsychiatrist, which encompassed all forms of hysteria: "One can consider as manifestations of hysteria all dysfunctional [maladives] modifications of the body which are caused by representations." Charcot too would quote approvingly Moebius's definition of hysteria in his lesson of May 9.⁶¹

Janet believed Charcot had established a psychological mechanism for traumatic hysteria. He praised his mentor's experimental reproduction of hysterical signs on patients by means of suggestion and hypnosis, further demonstrating an underlying psychological basis.⁶²

Sigmund Freud, like Janet, had high praise for Charcot's work on traumatic hysteria, crediting those studies as "the first to explain hysteria" by revealing underlying psychological mechanism.⁶³ Charcot had "succeeded … in proving that these paralyses were the result of ideas which had dominated the patient's brain." In an admiring eulogy written the month of Charcot's demise, Freud praised the "incomparably fine piece of clinical research" based upon the initial cases of traumatic male hysterical patients he had witnessed during a study visit of several months under Charcot eight years earlier. Since then, Freud noted, the psychological interpretation had been taken up by "his [Charcot's] own pupil, Pierre Janet" as well as others.

But Freud too, again like Janet, had reservations about Charcot's exclusively clinical approach. "He treated hysteria as just another topic in neuropathology."⁶⁴ In retrospect, Freud deemed Charcot's "exclusively nosographical approach" to classifications of hysteria and hypnosis "not suitable for a purely psychological subject."⁶⁵

Charcot's Conception of Hysteria: Physiological and Psychological

Charcot's conception of hysteria remained in tension between a career-long commitment to clinical medicine and pathological anatomy and a relatively recent recourse to psychological explanations. Referring to the brain's cerebral cortex as the central location for psychic or psychophysiological phenomena, he reconciled the dichotomy between conceptions he believed complementary. At times, he sounded a strictly reductionist note: "What I call psychology, is the rational physiology of the cerebral cortex."⁶⁶ But he modified this "phrase in characterizing a case of hysterical traumatic paralysis as "physiological or, better yet, psychological, they're really one and the same."⁶⁷

Charcot hesitated over adopting an exclusively neurological explanation, even though he acknowledged that current clinical evidence inclined in that direction. In a Tuesday lesson on February 21, 1888, he characterized "hysteria as a disease aux trois quarts psychiques."⁶⁸ A month later in another Tuesday lesson, Charcot similarly hedged, stating that hysteria should be considered "pour une bonne part" as a psychical disorder.⁶⁹ In his preface to Janet's Etat mentale des hystériques (November 1892), Charcot again wrote that hysteria was "en grande partie une maladie mentale."⁷⁰ But in his preface to an M.D. thesis (1890) Charcot confidently predicted that the tension between psychological and neurological conceptions would ultimately find an anatomical resolution: "I venture to hope that some day the anatomo-clinical method will count yet another success in revealing at last the primordial cause [of hysteria], the anatomical cause, which is known presently by so many material effects."⁷¹

Charcot on Dreams: Before 1893

The significance of dreams for Charcot's hysteria project has been largely overlooked by historians.⁷² Charcot often mentioned patients' dreams in his case histories of traumatic hysteria. Rig, the first of the six men presented in the spring of 1885, suffered frightful dreams, repeating the traumatic scene in which he screamed that he was about to be crushed by a falling wine barrel.⁷³ In a lesson in 1886, Charcot described a case of hysterical paralysis in a young man, "Le Log," who suffered a recurrent terrifying dream of being run over by a horse-drawn van, when in reality he had been knocked to the ground but unharmed by hoofs or wheels.⁷⁴

Charcot frequently associated dreams with hysteria in his Tuesday lessons at the end of the 1880s.⁷⁵ On February 5, 1889, for example, he included rêves as a subject heading in a table summarizing the histories of four typical cases of traumatic hysteria.⁷⁶ Dreams, often nightmares of frightening animals, were noted in all four instances following the trauma and persisting during the ensuing case history. At times Charcot elaborated on the nature of the dream and considered it significant. A lesson on January 29, 1889, presented a thirty-one-year-old baker who, after nearly drowning, suffered from hysterical anesthesia, left-sided weakness, and visual field restriction. "The nightly dreams with which this patient is tormented deserve special mention," Charcot declared. They consisted of scenes from a funeral in which the patient saw the passing cortege and coffin carrying his aunt, whose death he had witnessed; strange animals followed.⁷⁷

These and other examples indicate that Charcot paid attention to dreams when taking the patient's history. But his consideration of the dreams' content tended to be routine and cursory, its relationship to the traumatic event at times not clear,⁷⁸ and its connection with the hysterical signs problematic. The brief accounts (rarely more than a paragraph in the case history) left dreams with little if any etiological significance. At most, he seemed to regard dreams as frequent but incidental accompaniments of hysteria.⁷⁹

The Case History of Siméon Penhouet

Siméon Penhouet was the young patient whom Charcot chose for his Tuesday lesson on May 9, 1893. Among the myriad case histories the neurologist published, Penhouet's would be one of the most meticulously narrated and theorized. A folder bore a manuscript title, "Efficacy of Dreams in Producing Somatic Phenomena,"⁸⁰ along with the date and didactic intention, "May 9 1893, Lesson."

Penhouet, a seventeen-year-old cabinet maker (ébéniste), had been born in Nantes but lived in Paris since childhood. He was employed in the working-class district of the Faubourg Saint Antoine, famous as a center for woodworking crafts. Charcot characterized his patient as fitting the description of a certain type of skilled Parisian worker: "half artist with all the qualities and a few of the defects."⁸¹ Penhouet lived with his widowed mother under straitened circumstances in a one-room sixth-floor flat under the roof at 12 place de la Bastille.

The young man had been admitted to the Salpêtrière a week earlier, on May 2, with the diagnosis of hysteria. "A fine example," Charcot remarked, but one that he conceded had become rather commonplace (vulgaire) given the Salpêtrière's numerous published contributions to the subject over the past eight years.⁸² This particular case, however, presented "certain original features well worth taking seriously," namely, that "dreams, yes dreams, have the power to produce directly" all the somatic signs of hysteria.⁸³ It was important to recognize, Charcot declared, that "certain paralyses and certain pains … originate in ideas coming from dreams."⁸⁴

The history of the patient's malady began toward the end of March when the young man, described as intelligent and highly impressionable, fond of reading novels and an avid spectator of the popular theater, had fallen ill with fever.⁸⁵ He took to bed where, on the evening of "Good Friday" (March 31), he began reading a "frightful" novel, Le martyre d'un père (The martyrdom of a father), the story of a father who sacrifices himself in place of his son, the true criminal.⁸⁶ The lad read deep into the night, kept awake by a "violent headache."

Sometime around midnight or one o'clock in the morning, Siméon experienced a "morbid and terrible" dream, which he would subsequently dictate in graphic detail to the Salpêtrière physicians.⁸⁷ The dream began with two thieves creeping through an exposed window (an easy access the young man had worried about given the vulnerability of his top-floor dwelling). Siméon noticed the appearance of the strangers, whom he did not recognize, and their filthy, torn clothes.

One of the men gestures and on tip-toe heads toward Siméon's mother, while the other creeps toward his bedside. The dreamer then sees only the approaching man, who comes nearer and nearer and finally springs upon his victim planting his knee under the edge of his ribs.⁸⁸ Seizing the lad by the throat, the thief, now termed a murderer (assassin), directs a dagger toward his heart. At that instant, as the dagger nears amid the dreamer's helpless struggles to defend himself, the nightmare ends. He opens his eyes, awakens with a scream, and immediately loses consciousness, to be revived a short time later by his mother.

When Siméon returned to his job at the end of the following week, the trembling and weakness of his hands prevented him from performing the delicate movements needed for woodworking. He gave up and went home, where, on the morning of April 8, he suffered another attack—with a headache, buzzing in the ears, and a cramping sensation in the stomach that rose into his throat threatening suffocation. At that moment, "he saw once more the scene of the [attempted] murder, the assassin pouncing upon him and seizing him by the throat."⁸⁹ As in the dream, the attack ended with a brief loss of consciousness.

Siméon experienced a total of five such attacks, the most recent of which had occurred in the hospital on the day before the Tuesday lesson. On each occasion the dream scene reappeared. The summary of the patient's clinical state at the lesson on May 9 included trembling of the right hand and arm, diminished strength on that side, patches of anesthesia, disorders of taste, smell, and vision, in addition to the recurrent dream with loss of consciousness.

Charcot's ready diagnosis was traumatic hysteria. But what made the case exceptional—in his phrase, imparted "certain original features"—was the role of the dream, that "interesting event" evolving over a five-week period between March and May 1893. Charcot was convinced that the dream determined the various manifestations of hysteria. Not merely a trigger or agent provocateur, the dream also acted at a deeper level of causality. It determined "the form and localisation" of the hysterical phenomena.⁹⁰

Charcot identified the patient's right-sided weakness and fatigue with Penhouet's struggle to resist his attacker, presumably using mainly his right arm. Being choked in the dream accounted for an area of insensitivity localized to the neck. Marked bodily trembling arose, Charcot explained, from the emotion of terror felt by Penhouet in his dream. Patients suffering from the various emotions associated with traumatic hysteria frequently displayed trembling. More generally, hysterical paralyses, anesthesias, contractures, neuralgias, and so on did not follow the known anatomical pathways of nervous system distribution. Rather, they were displayed in conformity with popular notions of the divisions and function of limbs, in segments (en gigot, or "sleeve" paralysis). All forms of hysteria could result from the specific content of dreams.

The case history of Siméon Penhouet conveyed ample evidence of the young man's emotional distress. Even before the crucial nightmare, he had felt vulnerable to invasion of his home, an apprehension augmented by his reading of the "horrific novel." A detail in the dream added to its harrowing impact: Siméon thought that he might have recognized the assailants, but he couldn't make out their faces, unsure whether they were concealed or only blurred. Were the enemies in the dream wholly imaginary?

Dreams and Le Moi

The emotional impact of such a dream could be perceived as a life-threatening cause of traumatic hysteria in much the same manner as accidents had been shown to be. Charcot appreciated the granular sensory quality of Siméon's dream: its "color, one might say, had never passed from his mind," and which the patient reexperienced in his subsequent daytime hysterical attacks. The dream "reappeared a bit after the aura in all its vividness and with every appearance of objective reality."⁹¹ "A dream," Charcot declared, "contains an intense mental representation, whether visual or auditory, which develops sheltered from all analysis by the conscious mind [moi]. In hysterics it can provide the material for autosuggestion to bring to objective reality."⁹²

Charcot integrated the concept of dreams as etiological agents with the general model, he had put forward earlier, of hysteria "dependent on idea." Citing the case of a young mother who developed a hysterical paralysis of the hand after angrily slapping her seven-year-old son, Charcot explained that mother's intense anger constituted an emotional shock, her own trauma, leaving her in a mental state "comparable to hypnotic sleep." In this condition, an idea (of paralysis) is implanted and established free of any control by the consciousness (le moi). Unconscious ideas, like foreign bodies or parasites, "acquire extreme intensity, a power almost without limits, as often takes place in our dreams."⁹³

In the May lesson, Charcot invoked Moebius's (and Janet's) conception of hysteria—all somatic phenomena that result from the representation of an idea—as applicable to dreams as causal agents. Penhouet's dream constituted just such a "representation with remarkable power."

Charcot considered the Penhouet case special but scarcely unique. Unlike the young man's vivid detailed waking memory of his nightmare, pathogenic dreams "are sometimes completely forgotten": "The dream may have left or not have left a memory. One knows that the sleep was agitated. But how to know about the dream? On several occasions hypnosis has permitted us to recognize that a dream forgotten by the consciousness has been registered by the unconscious where it can be recovered."⁹⁴ In either case, pathological signs arose automatically, produced by an unconscious process of suggestion beyond the patient's control.

In his May 9 lesson Charcot repeated supporting evidence from a memorable earlier case history, that of Lelog, a young delivery man described as "dreaming" his hysteria following a terrifying near-miss vehicle accident. In his dream (and subsequent attacks in a waking state) Lelog screamed for the approaching driver to stop before crushing him. In reality, he had narrowly escaped serious injury. But in his dream he experienced being run over by the horse and van, leaving him with corresponding hysterical deficits.

Charcot explained that such patients suffered an abnormal state of mind, a disunity in which the unconscious mind escaped from its normal subordination to the moi, "that large collection of personal ideas long accumulated and organised which constitute the conscience."⁹⁵ The psychological state of hysterics resembled that of a hypnotized patient in a somnambulistic trance. Lacking critical restraint normally exercised by the moi, somnambulists (and hysterics) processed ideas at an unconscious level with greater intensity and diminished inhibition.

According to contemporary psychological theory, visualizing or even imagining a voluntary movement—moving the hand, for example—already constituted the normal first step in the corresponding motor action.⁹⁶ Conversely, imagining that her hand could not move (the result of anger acting as an emotional shock) could lead to a hysterical paralysis. After a period of unconsciousness immediately following the perceived trauma (the "incubation" or "méditation" time), during which conscious control was overwhelmed, autosuggestion (again the analogy with hypnotic suggestion) produced the hysterical "accidents."

Charcot's last words on hysteria elevated dreams to a significant etiological role. Although he cited earlier references, especially to his own work and that of his junior colleagues, the Penhouet case history considered dreams in neuropathology in unprecedented depth. It articulated how dreams might operate on a vulnerable unconscious by autosuggestion to produce the stigmata of hysteria.

The Penhouet case also demonstrated how a purely psychological phenomenon—the dream—could bring about substantial somatic changes. More subtlety than accidents or other forms of physical or chemical trauma, dreams revealed the psychological basis of hysteria. "Cherchez le rêve," Charcot exhorted, in specifying the source of the objective clinical findings in the Penhouet case.⁹⁷ He urged further research: "The study of dreams (in psychology) and especially in neuropathology deserves the attention of researchers who, it seems to me, have not taken this subject sufficiently seriously." Much writing, he said, had yielded few practical results.⁹⁸ "And yet," Charcot again quoted Shakespeare, "we are such stuff as dreams are made on"—underlined the intrinsic human importance of the subject.⁹⁹

There were definite limitations to Charcot's conception of the significance of dreams in medical psychology. Dreams did not assume the central symbolic importance they would later hold for psychoanalysis. Although Charcot believed "dreams ought to be seen as playing a very great role," that role was limited for him to the "history of hysteria."¹⁰⁰ Charcot's recommendation for ongoing treatment was essentially psychological, consisting in acting to counter harmful ideas and influences. The young man needed to be removed from the city to a retreat where he would benefit from "isolation." Hypnosis might also prove beneficial.¹⁰¹

Conclusion: Charcot and the Turn toward Psychology

If the lesson on dreams turned out to be Charcot's last words on hysteria, this was not anticipated. The professor, still several years from retirement, looked forward, as he told his secretary, Georges Guinon, to returning the following academic year to continue work on hysteria and perhaps make significant revisions.¹⁰²

What further work would have looked like is uncertain. But Charcot's repeated insistence on psychological causes and mechanisms in the dream lesson already marked a significant evolution in his decade-long investigation of traumatic hysteria. With dreams as causes, Charcot clearly moved beyond his earlier somatic description of hysteria. A close colleague summed up Charcot's interrupted project in a eulogy: "When death took him by surprise, he was engaged in constructing the theory of the psychical origin of all hysterical symptoms."¹⁰³ Charcot, had he lived, might well have pursued this work on psychology broached in his last lesson. The issues Charcot raised around the role of dreams in traumatic hysteria bridged what for him were increasingly fluid borders between physiology and psychology.

Charcot exhibited a growing interest in psychology during the final years of his career. In addition to his own interests, he encouraged privately and praised publicly work on amnesia by Pierre Janet and Alfred Binet, two youthful medical psychologists at the Salpêtrière.¹⁰⁴ I suggest that the final stance displayed in his unpublished May 1893 manuscript by the dominant medical figure in France fits within a broader context of a turn toward psychological modes of thinking across diverse disciplines at the fin de siècle. Hysteria, dreams, amnesia, fugue, symbolism, sexuality, unconscious behavior, and multiple personality were all subjects of active psychological study at the time. Disciplines as diverse as medicine, philosophy, sociology, the visual arts, and creative writing all took part in the turn toward psychology.¹⁰⁵

A striking illustration of the pervasiveness of psychology is evident in Marcel Proust's immense novel, A la recherche du Temps Perdu (In Search of Lost Time), published during the second decade of the new century. The work is a vast multivolume immersion in upper-class French society, and Proust's dominant theme of unconscious memory was permeated by psychological considerations; the contemporary Petit Larousse dictionary even defined him as a "psychologue original."¹⁰⁶ Proust made an earlier brief foray into psychopathology in "Sur la lecture" (On reading, 1906). In discussing the treatment of writers suffering from nervous apathy or neurasthenia, Proust uses the term "psychotherapist" and refers to Ribot's "beautiful book on Diseases of the Will (Maladies de la Volonté)."¹⁰⁷

Théodule Ribot, a philosopher by vocation and the founding figure of academic psychology in France, had numerous links with Charcot and the Salpêtrière school.¹⁰⁸ Ribot's prolific popular writings went through numerous editions, attracting a readership as seemingly diverse as Charcot and Proust.¹⁰⁹ Such appeal, accessibility, and pertinence to an audience ranging from neurologist to novelist testified to the fluidity of the border lines of psychology at the fin de siècle.