Charcot Revisited: Title and subTitle BreakThe Case of Bruegel’s Chorea

Chorea has a dual reference to medicine and to art through the Greek etymology of the word, meaning dance. For the neurologist of the 21st century, chorea belongs to the vast category of movement disorders. As stated by Osler¹ in the introduction to his famous monograph On Chorea and Choreiform Affections, the long medical history of chorea is filled with much folklore and misinformation. It is the alchemist and physician Paracelsus who first coined the term Chorea Sancti Viti at the beginning of the 16th century. He was describing the dancing mania, a peculiar choreiform disease that reached epidemic proportions in medieval central Europe. The majority of those diagnosed as having dancing mania or chorea major were likely affected by a form of mass hysteria. In 1686, Sydenham used the same term Chorea Sancti Viti for an affection of a totally different nature, sometimes named childhood chorea or chorea minor, which today is known as Sydenham chorea. In 1872, Huntington described yet another progressive form of hereditary choreic disease, which soon was referred to as Huntington chorea. Since Osler’s masterly synthesis, it has been universally accepted that Sydenham and Huntington choreas are clearly delineated distinct disorders, whereas chorea major as well as the various forms of dancing mania or St Vitus’ dance belong to hysteria.

Several recent historical overviews of chorea and dancing mania mention Pieter Bruegel (ca 1525/1530-1569) as a contributor to the iconography of St Vitus’ dance.^{2 - 5} Charcot must be credited with the first presentation of a picture by Bruegel on this subject.^{6 - 7} However, what is shown in all these studies is not a picture by Bruegel himself but a 17th-century engraving by Hondius (right part of Figure 1) or a 19th century woodcut by Huyot (Figure 2), both inspired by a composition by Bruegel. Curiously, Bruegel’s original work is rarely displayed and discussed in the medical literature.^{10 - 11}

Bruegel’s interest in the realistic rendering of human misery and medical conditions is acknowledged by several well-known works depicting disabled or blind people or lepers. The art history literature dedicated to Bruegel does not indicate chorea or St Vitus’ dance as a subject of any of his works. However, a pilgrimage of epileptics is repeatedly mentioned.^{12 - 21} The basis for this reference to epilepsy is not stated. The history of the medical understanding of epilepsy certainly is no less confused than that of chorea.^{22 - 23} Moreover, it is often difficult to draw a distinct line between epilepsy, chorea, and hysterical disorders, as patients with dancing mania showed certain similarities to epileptics when their limbs jerked and they collapsed snorting, unconscious, and frothing.^{22 ,24} In Bruegel’s time, epilepsy was often referred to as the falling sickness. Actually, this term, used since late antiquity, encompassed all kinds of morbid conditions characterized by a sudden fall by the victim.²² In Charcot’s era, epilepsy belonged to the group of neuroses that included hysteria and chorea because no organic lesion could be delineated for these distinct clinical disorders.²⁵

This study examines Charcot’s allusions to Bruegel’s picture and explores the compositions considered to have originated with Bruegel in the context of chorea, epilepsy, and hysteria.

The first mention of Bruegel in Charcot’s work is to be found in an appendix to Leçons sur les maladies du système nerveux, collected and edited by Bourneville.⁶ This appendix contains a second and shorter part dedicated to a sketch by Rubens, which will not be discussed here. The appendix reads as follows (author’s translation from French, original in italics):

Representation From Life of St Vitus’ Dance (Chorea Germanorum), by P. Breughel

In one of his latest lectures at the Salpêtrière, M. Charcot showed his audience the copy of a drawing from the 16th century, evidently drawn from life, which depicts an episode of one of those dancing processions (Springprocessionen), which, at that time, took place yearly in Echternach, a small town located between Trier and Luxembourg, around the tomb of Saint Willibrod. It is known that these processions have been quite rightly considered as an expression and one of the last vestiges of the famous Saint Vitus’ Dance (Chorea Germanorum) which, repeatedly, prevailed as a pandemic in the Rhine provinces, in the course of the 14th and 15th centuries.

The drawing in question (Figure 2) allows us, so to speak, to witness an instance of St Vitus’ Dance, in a somewhat attenuated form. It is easy at first sight to recognize that hysteria and hystero-epilepsy played a predominant role there, as they most certainly did in the epidemics proper. It is a simple sketch, but as can be seen, a very instructive one for the physician. It is by the hand of P. Breughel who was sometimes known as the painter of the peasants, because he especially sought to represent popular scenes, or else as Wieusen Breughel, Breughel the droll. The original belongs to the gallery of the archduke Albert in Vienna. A reproduction of it can be found in the interesting work of M. P. Lacroix.⁸

A series of women dancing in single file, each lifted by two men and preceded by bagpipes players blowing into their instruments with all their might, head for a chapel, which can be seen in the distance, and where doubtless the remains of the saint are laid. These are common people, as shown by their clothing which resembles that of the peasants who appear in paintings by Teniers and Brauwer.

The order of the procession is disrupted at various points. Indeed, several of the pilgrims, racked by attacks whose character is unmistakable, gesticulate, writhe and struggle in the grip of their companions. These latter figures, and this is perhaps their principal function, make every effort to restrain the victims and prevent them from falling to the ground. The scene is, as can be seen, extremely animated. It must have been extremely noisy too, as some of the possessed women seem to be screaming at the top of their voices.

In the middle distance is a brook where devoted attendants draw water with bowls. The water which runs there might be endowed with curative properties. In any case, it could be used to quench the thirst from which the principal actors certainly suffered. Some episodes, which the artist has discreetly relegated to the less prominent parts of his picture, obviously affirm that lubricity was not always, far from it, banished from these gatherings.^{6 (pp455-457)}

(Sometime in 1559, the artist changed the spelling of his name from Brueghel to Bruegel, the spelling that he consistently used thereafter when signing his works and that is usually used today. His elder son Pieter spelled his name Brueghel until 1616 and Breughel thereafter. Charcot consistently uses the spelling Breughel. Concerning his first name, Pieter is the original Flemish name and Pierre the French translation, used by Charcot.)

Seven years later, Charcot returned to this picture in his book Les démoniaques dans l’art,⁷ a copiously illustrated essay that he presented to the Academy of Sciences. As a member of this branch of the Institut, he was then at the pinnacle of French scientific recognition.²⁵ The book was published in collaboration with Paul Richer, probably Charcot’s favorite disciple, a talented artist and physician. In the preface, the authors set out the subject of their study. The central idea is that at a time when hysteria was considered not a disease but a perversion of the soul due to the presence of the devil and his doings, the disorder inspired masterpieces, and artists sometimes anticipated scientific observations. As claimed by the authors, they looked for the most diverse artworks relating to convulsionary possession and, in this undertaking, pursued every possible lead: trips, museums, private collections, photographs, casts, etc. However, as they modestly added, they were certainly far from having exhausted all the potential sources.⁷

In their presentation of Bruegel’s work (Figure 2), the documentary character of the scene is expressly asserted (author’s translation from French): “Chance would have it that a master draughtsman and painter, Pierre Breughel, witnessed one of those singular pilgrimages, which was heading to the church of St Willibrod, in Epternach [sic], near Luxembourg.”^{7 (p34)}

However, no new argument is brought forward to support this affirmation. The authors repeat the earlier description almost verbatim and do not expand on the former analysis of Bruegel’s drawing. The principal novelty of this presentation is the mention of Hondius’ engravings (Figure 1).

We know a sketch by Pierre Breughel depicting a group scene and several engravings by Hondius relating to the same subject and based on more carefully executed drawings by the Flemish master. . . .

The engravings by Hondius that we have found in the Printroom are carefully drawn and well finished. They are of rather large dimensions and bear, in addition to the signature of the engraver, the mark of the painter: “P. Breughel, inv.” The scene depicted is exactly the same as that of the sketch, which is divided in three parts. Indeed there are three engravings by Hondius; one with the two bagpiper players, the two others with the pilgrims, divided into two very distinct groups on the right and left of the picture.

Each figure in the original sketch is recognizable. Except for details of clothing, their general bearing is only minimally changed. In particular, the rendering of the faces shows the meticulous care and the naturalistic concern, which distinguishes the Flemish master.^{7 (pp34-38)}

Charcot’s first presentation is illustrated by what he states is a simple sketch from the hand of Bruegel. What is actually shown is a small 19th-century woodcut, with the name Huyot printed in upper-case characters in the bottom left-hand corner (Figure 2). Charcot indicates that the original is in Vienna, Austria. Today, besides the drawing kept in the Albertina in Vienna, 2 other copies with the same subject have been identified, one in the Rijksmuseum, Amsterdam, the Netherlands, and the other in the Staatliche Museen, Berlin, Germany.²⁰ The 3 known copies are remarkably similar drawings in pen and brown ink heightened with white on tinted paper and of a relatively large size (Figure 3).

The composition is highly structured in 3 carefully articulated planes. A large sinuous movement leads the viewer’s gaze from the procession in the foreground to the church in the distance. Spatial depth is increased by the contrast between the strongly delineated figures and the barely sketched bucolic landscape. Four groups of 2 sturdy men, each sustaining a tall recalcitrant woman, stomp to the rhythm of a pair of bagpipers puffing away in the center of the foreground. The dynamic movement given by the musicians appears vigorously opposed by the left-hand figures rendered in complex poses. In the middle distance runs a stream. Another group of figures is crossing a bridge. Somewhat further on, 2 women are sitting apparently exhausted, while a crippled figure wobbles forward on crutches. On the near bank, 2 servants are seen bringing bowls. Against this animation, a country village with farmsteads and a church amid a grove of trees provide a quiet background, faintly outlined with rapid pen strokes.

The Vienna and Amsterdam versions of the drawing are almost identical. Only very few minor details are different. For instance, the second small seated figure in the Vienna drawing is missing in the Amsterdam version. These drawings are respectively known as “Die Epileptikerinnen von Meulebeeck” and “Pelgrimage naar Meulebeke.” Both carry an explanatory caption, elegantly lettered. Similar inscriptions, set in a bar across the bottom and sometimes marked off by a border as in the Amsterdam replica, are regularly found in Bruegel’s drawings and engravings. The caption is in old Dutch. The text is a guide to the interpretation of Bruegel’s original composition. It reads (author’s translation): “Those are the pilgrims who on St John’s day, outside Brussels in Molenbeek, must dance, and when they have danced or jumped over a bridge, then they are cured for a whole year of St John’s sickness.”

A name and a date are added, “bruegel 1564” on the Vienna copy, “H brueghel 1569,” written in a different ink over an earlier signature, on the Amsterdam one.^{16 ,20} The Berlin composition is somewhat different, particularly in the treatment of the background. Only a fragment of inscription is to be seen bearing the word “pilgrims.”

Engravings are an important part of Bruegel’s work.^{12 ,18} Drawings made by his pen were regularly passed to contemporary engravers. Hieronymus Cock of Antwerp, one of the foremost publishers of prints in the Netherlands at Bruegel’s time, issued high-quality engravings based on dozens of Bruegel’s works.¹⁵ Of the image studied by Charcot, no 16th-century etching, engraving, or woodcut is known. However, as introduced in Les démoniaques dans l’art,⁷ engravings from this picture were produced in the 17th century (Figure 1). Bruegel’s drawing has been transferred to copper plate by the hand of a skilled engraver, Hendrick Hondius, and became a set of 3 engravings. They are known as “Pilgrimage of the Epileptics to the Church at Molenbeek.”^{12 ,18 - 19} The grouping of the figures lent itself perfectly to this splitting. Of course, in the engraving process, the picture itself has been reversed. The central part showing the 2 bagpipe players is accompanied by a text in old Dutch, reading (author’s translation):

Representation

How the pilgrims, on St John’s day, must dance to Molenbeek outside Brussels. And when they have danced over the bridge, or have been forced to do so, then they seemed to be cured for a year of the falling sickness. Ahead go the musicians or bagpipers, then follow the pilgrims held by strong servants, reluctantly against their will (as shown in the following second and third figures), sometimes shouting and vociferating; but when they come near the bridge, then they turn around, using great resistance; however, they are promptly overcome and carried and lifted over the bridge; once crossed, they sit down on the ground, as if exhausted: and then come the servants of the place quenching their thirst and giving them something warm: and so is the work accomplished.

Nicely depicted by the excellent and skillful painter Pieter Breugel [sic]. Engraved and published by Henricus Hondius’ house, in The Hague, 1642.

The subject of these engravings appears to have been very popular, as shown by the identification of 4 different editions.¹⁹ Hondius’ engravings from Bruegel’s picture have been located and catalogued in several departments of prints in Europe, including those in Amsterdam, Brussels, Paris, and Vienna.¹⁹ The engraved images are identical in all the versions, whereas numbers, letters, and inscriptions in the margins differ somewhat from one edition to another. In 1 of the editions, a supplementary line is added to the explanatory text, with a reference to 2 verses from the Revelation of St John: “NOTA: Apocal, cap. 13. vers. 14. ende cap. 19. vers. 20.”

The caption on Bruegel’s drawing (Figure 3) leaves no doubt concerning the nature and location of the pilgrimage as well as the saint invoked, which are completely different from what Charcot specified. There is no trace of Echternach or Luxembourg, no mention of chorea, and no allusion to St Vitus or St Willibrod. Although he was known to be an avid admirer of Flemish art and a reader of several foreign languages, Charcot apparently did not consult the original documents. The origin of this misinterpretation can be found in the other source indicated by Charcot himself, a book by Lacroix.⁸ Paul Lacroix, also known as the bibliophile Jacob, was curator of the Imperial Library of the Arsenal in Paris, France, and a prolific author himself. Besides novels, drama, and poetry, he wrote several voluminous and popular books on mores, arts, and life in the Middle Ages and the Renaissance. These works were widely circulated and several, including the book in question, were translated into English.⁹ Although not clearly stated, the picture shown by Charcot (Figure 2) without doubt is borrowed from Lacroix’s book,⁸ where it can be found in the chapter dedicated to pilgrimages, with the following caption (English translation^{9 (p392)}): “Sufferers from St Vitus’ Dance going on a pilgrimage to the church of St Willibrod, Epternach, near Luxemburg. After a drawing by P. Breughel (Sixteenth Century), in the gallery of Archduke Albert, at Vienna.”

What Charcot said about Bruegel’s drawing is simply copied from this caption, even the misspelling “Epternach” instead of “Echternach.” It must be concluded that neither Lacroix nor Charcot bothered to look at the Vienna drawing, and both were thus unaware of the very clear explanation given in its caption.

Hondius’ engravings (Figure 1), discovered somewhat later by Charcot, should have helped him to rectify his comments, thanks to the quite explicit text that confirms the indications found on the drawing. The Département des Estampes of the Bibliothèque Nationale de France in Paris owns 1 series of the 3 engravings by Hondius. These French prints are marked with a stamp affixed with the year 1833, but there is cause to believe that they entered this collection before the 18th century. Unfortunately, the central sheet of Hondius’ triptych in Paris has been trimmed, leaving the proof without margins or text! This may explain why Charcot remained unaware of the exact meaning of Bruegel’s drawing. Had he had the curiosity to go to Vienna and examine the drawing, he would have had a chance to see the complete set of Hondius’ engravings, also kept in the Albertina.

Charcot is known to have traveled extensively, and he visited most European capitals for medical and scientific purposes but also for what we would today call tourism. However, after the Franco-Prussian war of 1870 and the alliance of Germany with Austro-Hungary, Charcot declined visits to eastern neighboring countries for many years. His only known visit to Vienna was a 1-night stop on his return trip from Russia in 1891, long after his first interest in Bruegel’s drawing.²⁵

Today, Molenbeek-Saint-Jean, 1 of Brussels’ 19 communes, is a mixed neighborhood featuring a large immigrant population living in run-down urban areas. In Bruegel’s time, it was a suburban Flemish village with long and lively traditions, reported in great detail by Wauters in his monumental history of Brussels and its outskirts.²⁶ The church had been founded by St Gertrude, who bequeathed some land for the building of a temple in honor of God and St John the Baptist. A nearby well was dedicated to St Gertrude. Its water was considered to be endowed with supernatural properties, and it soon attracted pilgrims. The earth of the churchyard also was considered miraculous, and people piously collected the soil. In 1399, while a contagious illness was ravaging the country, several miracles made the church of Molenbeek famous. St John announced to a child fallen in lethargy that those who would go thrice around the church on their knees would be protected against the disease forever. From then on, crowds of pilgrims began to gather to celebrate with great pomp the name day of St John the Baptist. Those pilgrimages culminated in the 16th century when thousands attended holy day processions sometimes followed by mystery plays or allegorical comedies relating the principal episodes of the patron saint’s life. In 1548, 1 of these celebrations was marked by the collapse of scaffolding, and several spectators suffered from severe contusions.

In 1563, Bruegel moved from Antwerp to Brussels and married Mayken, the daughter of the painter Pieter Coecke van Aelst. This marked a turning point in Bruegel’s activity with an intensification in the production of paintings. From this period date the series of the Labors of the Months and peasant dances and festivities. An often-told anecdote relates that Bruegel and his friend Franckert used to attend country celebrations, weddings, fairs, and church festivals, by passing themselves off as distant relatives or fellow countrymen, to observe and record the labors and customs of the peasants, their pleasures and recreations. This might have been the case in this instance. It is likely that Bruegel attended the yearly pilgrimage to the church of Molenbeek, situated just outside the city walls, only 3 km northwest of downtown Brussels where he lived at 132 Rue Haute. What he drew is a kind of graphic reportage of the custom and practice associated with St John’s feast.

In view of its elaborate composition, it is unlikely that the drawing of The Epileptic Women of Molenbeek was sketched on the spot. Rather, it must have been carefully executed later on. The authorship of the drawing has been disputed for the last century.^{12 - 14 ,16 - 18 ,20} The similarity of the drawings kept in Vienna and Amsterdam suggests that there is some relationship between the 2. Today, most experts as well as both museums consider these drawings faithful copies of an earlier lost work by Pieter Bruegel the Elder. No certain attribution has been accepted, but the names of his sons, Pieter and Jan, have been proposed.^{16 - 18} For the specimen kept in Berlin, which is stylistically different from the 2 others, David Vinckeboons has been suggested as the draughtsman.²⁰

The practice of copying artworks was very common in the 16th century. Bruegel’s strong reputation explains the number of copies—drawings, engravings, and paintings—of his works, and his sons made this a real business activity.²⁷ Many of Bruegel’s famous paintings were kept in private collections. When the original pictures were unavailable, faithful copies met the demand for appreciated subjects. Several paintings by Pieter Bruegel the Elder, which are recorded by official documents of the time but have disappeared, are known only by copies made by Pieter Breughel the Younger. It is not unreasonable to speculate that the representation of the popular pilgrimage to Molenbeek—in a drawing or maybe a lost painting—appealed to the faithful who asked for copies as a memento.

The inventory of Bruegel’s work does not mention paintings depicting The Epileptic Women of Molenbeek. However, at least 1 painting on this subject has been traced. Painted on a wood panel, it seems to be a fragment of a larger composition (Figure 4).¹⁴ It has been on exhibit in the United Kingdom at least 4 times between 1945 and 1960 and was sold in London to a Belgian collector in the 1960s. It has been submitted to a chemical and radiological analysis by the Royal Institute for the Study and Conservation of Belgium’s Artistic Heritage in Brussels and has been the subject of a scholarly essay by an art historian.¹⁴ The conclusions concerning its authenticity—original painting by Bruegel the Elder or 16th-century copy—remain uncertain. Since this study, the painting has disappeared from view and the present owner is unknown.

Even if the works that survive (drawings and painting) are not originals by Pieter Bruegel the Elder himself, they are important historical documents that show Bruegel’s account of a yearly religious event related to St John’s disease.

If the nosography of chorea, hysteria, and epilepsy is complicated, the associations of saints with these various conditions is no less complex. The Middle Ages saw a virtual explosion of cults devoted to all kinds of saints. Their popularity varied according to subtle medical, sociological, religious, linguistic, and geographic criteria.

St John is often cited beside St Vitus as a patron saint of the dancing mania.^{10 - 11 ,22 ,24 ,28} Several shrines dedicated to St Vitus, in Germany, Alsace, and Luxembourg, were visited by patients struck with this dancing disease.^{10 ,24 ,28} However, the most famous dancing procession related to St Vitus’ chorea took place and still takes place in Echternach in Luxembourg, where pilgrims began to gather at the grave of St Willibrord as early as the 11th century.^{28 - 29}

The first descriptions of dancing mania related this disease either to St John or to St Vitus. However, after an outbreak of the dancing plague in Strasbourg in 1418, St Vitus became the specific saint of this neurosis, whereas St John was relegated to epilepsy, which was also called the falling sickness. During the Renaissance, 2 saints were associated with the falling sickness, St John and St Valentine. St John seems to have been more popular in France, where le mal St Jean was a common expression, whereas the worship of St Valentine seems to have originated and predominated in Germany.²² Why exactly St John was brought into this connection is as little known as whether the name related to St John the Baptist or St John the Evangelist.^{22 ,30}

As must be concluded by the captions on Bruegel’s drawing and Hondius’ engraving, in 16th- and 17th-century Brussels, St John’s disease explicitly referred to the falling sickness. These pictures provide some clues about which John was associated with this disease. Indeed, the church of Molenbeek where the pilgrimage depicted by Bruegel took place was consecrated to St John the Baptist. The time of the year suggested by the clothing of the pilgrims similarly points to the Baptist, whose name day is June 24, whereas St John the Evangelist’s day is at the winter solstice, on December 27. The only link to the Evangelist is to be found in one set of Hondius’ engravings, by the reference to 2 verses of the Revelation of St John, also known as the Apocalypse. Both verses mention the beast, a figure of the evil one or the devil, evoking the popular belief that the falling sickness was the expression of a demoniac possession.

In his preface to Les démoniaques dans l’art, Charcot made a plea that unknown collaborators would take interest in his studies, and he hoped that his publication would provoke new discoveries. He concluded by declaring that he had no other wish than to supply comprehensive information to the reader and to put in the reader’s hands all pertinent documents.⁷ At the end of the present research, this modest statement helps to mitigate a first reaction of disappointment at Charcot’s casualness: in his analysis of Bruegel’s drawing, by relying only on secondary sources, he has not been as rigorous as might have been expected from the father of neurology.

This case exemplifies one of Charcot’s personality traits, already underlined by his biographers, that is, his extremely vivid imagination that sometimes prevented him from objective and rigorous analysis.²⁵ In clinical settings, there are several instances in the Leçons du Mardi² where Charcot summarized the case of the patient to fit his ideas rather than the patient’s actual words. More than once, Charcot relied on preconceptions at the expense of objectivity, and his vision was obscured by the tenets of his time. Similarly, in this case, Charcot took up Lacroix’s material without verification. Recognizing there a characteristic depiction of St Vitus’ dance, Charcot assimilated it with the dancing procession of Echternach in Luxembourg, which was still very popular in his time, as it is today. Even in the small details of his analysis, Charcot’s interpretation is problematic, and the obscenity that he sees in some parts of the drawing is certainly questionable. The behavior of the attendants instead seems to reveal deep sympathy for the possessed women.¹⁰

On the other hand, while Charcot ignored the precise details of Bruegel’s drawing, his global interpretation is correct. His sharpened clinical eye, coupled with his artistic sensibility, immediately led him to see there a typical manifestation of hysteria, which was becoming central to his preoccupations at the time of his presentation of Bruegel’s picture. Beyond any specific diagnosis, Bruegel’s composition remains universal, giving a unique and compelling picture of human suffering and of the plight of devoted caregivers.^{10 ,18}

Correspondence: Geneviève Aubert, MD, PhD, Department of Neurology (1932), Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Ave Hippocrate 10, B-1200 Brussels, Belgium (aubert@nops.ucl.ac.be).

Accepted for Publication: June 25, 2004.

Acknowledgement: I thank the many friends and colleagues who helped me in locating material and who carefully read and commented on this study.