History of Neurology
Jean-Martin Charcot and Parkinson’s disease:
Teaching and teaching materials
O. Walusinski *
CabinetPrive´,20ruedeChartres,28160Brou,France
In 1817, James Parkinson (1755–1824) wrote the first clear medicaldescriptionofthediseasethatnowbearshisname.In the years that followed, a few cases were reported, with varyingdegreesofaccuracy,inGreatBritainandGermany[1].
InFrance,GermainSe´e(1818–1896)in1850[2]andArmand Trousseau (1801–1867) in 1859 [3] referred to ‘paralysis agitans’,thenamegivenbyParkinsontooneofthedifferential diagnosesforchorea.However,thepathologydidnotbecome adiscreteentityuntiltheworkofCharcotandhisstudentsin the second half of the 19th century. The hagiographic hyperbole of Victor Cornil (1837–1908) in referring to the
diseasesdescribedbyCharcotgivesasenseofhowthelatter wasviewedbyhiscontemporaries:‘‘Youhavesoprofoundly reexaminedthestudyofthesediseasesthatoneistemptedto believeyouwerethefirsttodescribethem’’[4].
Inthisreport,abriefreviewofCharcot’srisetotheposition ofprofessor,andhisachievementsinthisrole,isfollowedbya descriptionofhowhetaughteachofthecardinalsignsofthe disease—tremor,hypertoniaandbradykinesia—thathehel- pedtoestablishasanindividualentity.Charcotprovidedhis studentswithnumeroussuggestionsforresearchtopics,and the theses in which they developed these topics were an info article
Articlehistory:
Received10July2017 Receivedinrevisedform 15August2017
Accepted22August2017 Availableonline10April2018 Keywords:
Historyofneurology Jean-MartinCharcot Parkinson’sdisease LaSalpeˆtrie`reschool AlfredVulpian Charcot’spupils PaulRicher AlbertLonde
abstract
JamesParkinson’s1817seminalarticlewasnotwellknowninFranceuntil1861,when Jean-MartinCharcotand hisfriend, AlfredVulpian, publisheda detaileddescriptionin French ofparalysis agitans. Their articleprovided clinicalinformation to help French physiciansmakeanaccuratediagnosisbyconsideringgait,shakingandrigidityaswell asmaskedfacies.AsCharcotalwayshadastrongdesiretoteach,thisarticledescribeshis lessonsonParkinson’sdiseasefrom1868to1888,andalsoexaminestheteachingapproach heusedtopassonhislatestfindingstohisstudentsandcolleagues.Charcotalsousedhis roleasthesisadvisortodisseminateParkinson’swork,andsevenofthethesesheoversaw, whichuntilnowhavebeenoverlooked,revealanotherfacetofhisteacher–studentrela- tionship.ThesedissertationsprovidedCharcotwithanopportunitytohighlightwhathehad alreadyidentified concerning whatistoday referredto as‘Parkinson-plus syndromes’.
Finally,thisreportconcludeswithanhistoricalsurveyoftheteachingmaterialsthatPaul RicherandAlbertLondedevelopedfortheMasteratLaSalpeˆtrie`retoprovidehimwith visualdocumentation.
#2018ElsevierMassonSAS.Allrightsreserved.
*Correspondenceto:CabinetPrive´,20ruedeChartres,28160Brou,France.
E-mailaddress:[email protected].
Availableonlineat
ScienceDirect
www.sciencedirect.com
https://doi.org/10.1016/j.neurol.2017.08.005
0035-3787/#2018ElsevierMassonSAS.Allrightsreserved.
additional means ofdissemination for the Master (Box1).
Severalofthesehavebeenselectedasexamplesthat,while mostlyforgottentoday,focusonatypicalformsofthedisease.
Finally, the visual aids that complemented Charcot’s tea- chings,forwhichheowedPaulRicher(1849–1933)andAlbert Londe (1858–1917) for their skill and innovations, are also presentedhere.
1. Charcot, his teaching and La Salpeˆtrie`re Hospital
Jean-MartinCharcotenteredLaSalpeˆtrie`reforthefirsttimein 1852.Thehospital wasatthattimearesthomeforelderly women calledtheHospice delaVieillesse-Femme.Charcot wastocompletehisfourthyearthereasaninterne(medical studentlivingandworkinginahospital)underEuge`neCazalis (1808–1882), an obscure physician whom Charcot never referred to during his long career. Responsible for several hundredelderlyandinfirmwomen,Charcotbroughttogether theobservationsofchronicrheumatismandgoutthatwould eventually form the material necessary for writing his inauguralthesis,defendedon13March1853.Hewentonto becomechefdeclinique(seniorinterne)for2yearsatHoˆpital La Charite´ in the department of Pierre-Adolphe Piorry (1794–1879). In 1856, Charcot became a physician at the Central Office of the Paris hospital system. After failing theagre´gationexam(tobecomeanassociateprofessor)in1857, hesucceeded3yearslaterin1860.Hewasappointedhospital physicianat LaSalpeˆtrie`re in1862at thesametime ashis friend,AlfredVulpian(1826–1887), wasassignedtoanother, smaller department. Charcot explained the advantages of beingaphysicianatLaSalpeˆtrie`rethisway:‘‘Herewehave benefitsonedoesnotfindinmostordinaryhospitals,inthat theconditionsarerightforfruitfulstudyofdiseaseswithslow progression’’[5].In1866,Charcottransformedanoldkitchen atthehospitalintoaplaceofstudyandteaching.Thiswasthe firststeptowarddevelopingtheresearch/teachingcenterthat LaSalpeˆtrie`rewouldeventuallybecome.
That same year, Charcot inaugurated ‘des cours libres’, classesoutsideoftheuniversityprogram,whichheheldinhis Box1.Charcot-inspiredthesesonParkinson’sdisease
Jean-MartinCharcotwasajurymemberforthefollowing theses.Le´opoldOrdenstein(born23July1835inOffstein, GrandDuchyofHesse),‘Surlaparalysieagitanteetla scle´roseenplaques(Onparalysisagitansandmultiple sclerosis)’,1867;No.234
Jury: Be´hier, president; Gosselin, professor; Charcot, Raynaud,associateprofessors
Fulgence Raymond (born 29 September 1844 in Saint-Christophe, French administrative department:
IndreetLoire),‘Etudeanatomique,physiologiqueetcli- nique surl’he´michore´e,l’he´mianesthe´sie, et les trem- blements symptomatiques (Anatomical, physiological andclinicalstudyofhemichorea,hemianaesthesiaand symptomatic shaking)’ [but no specific discussion on parkinsonianshaking],1876;No.157
Jury:Charcot,president;Chauffard,professor;Bouchard, Anger,associateprofessors
AlbertBoucher[born9December1852inMetz,trainee militaryphysician(aide-major)attheVal-de-Graˆcemili- tary hospital], ‘De la maladie de Parkinson (paralysie agitante)etenparticulierdelaformefruste[Parkinson’s disease(paralysisagitans),inparticularitsmildform]’, 1877;No.75
Jury:Charcot,president;Gavarret,professor;Bouchardat, Damaschino,associateprofessors
Paul-De´sire´ Leroux (born 22 June 1880 in Cre´ances, Frenchadministrativedepartment:Manche),‘Contribu- tiona` l’e´tudedescausesdelaparalysieagitante(Contri- butiontothestudyofcausesofparalysisagitans)’,1880;
No.267
Jury:Charcot, president;Panas,professor; Lancereaux, Fernet,associateprofessors
Gaston Lhirondel (born 22 July 1855 in Saint-Julien le Faucon, French administrative department: Calvados),
‘Ante´ce´dentsetcausesdelamaladiedeParkinson(Ante- cedentsandcausesofParkinson’sdisease)’,1883;No.236 Jury: Charcot, president; Proust, professor; Landouzy, Rendu,associateprofessors
PaulBlocq(born4January1860inToul,Frenchadminis- trativedepartment:MeurtheetMoselle),‘Descontractu- res(Contractions)’,1888;No.128
Jury:Charcot, president;Fournier, professor; Brissaud, Chauffard,associateprofessors
AdolpheDutil(born18February1862inVillefranchedu Queyran, French administrative department: Lot et Garonne),‘Contributiona` l’e´tudecliniquedestremble- mentshyste´riques(Contributiontotheclinicalstudyof hystericalshaking)’,1891;No.159
Jury:Charcot,president;Brouardel,professor;Chauffard, Ballet,associateprofessors
Euge`neBe´chet(born30July1862inAvranches,French administrative department: Manche), ‘Contribution a`
l’e´tudecliniquedesformesdelamaladiedeParkinson (ContributiontotheclinicalstudyofformsofParkinson’s disease)’,1892;No.351
Jury:Charcot,president;Proust,professor;Ballet,Poirier, associateprofessors.
Inaddition,thisimportantthesisforwhichCharcotwas notajurymember:
Paul de Saint-Le´ger(born 27 March 1855 in Cherveix, Frenchadministrativedepartment:Dordogne),‘Paralysie agitante(MaladiedeParkinson),e´tudeclinique[Paralysis agitans(Parkinson’sdisease), clinicalstudy]’,1879;No.
121
Jury: Lase`gue, president; Peter, professor; Debove, Legroux,associateprofessors.
owndepartment(Fig.1).Hegaveadozenoftheseclassesper year,andhisteachingsoongainedareputationforexcellence and attracted large numbers of students, especially from outside of France. In 1872, he was elected to the medical school’sPathologicalAnatomyChair,whichheoccupiedfor10 years as a professor. In 1880, the hospital administration grantedCharcot’srequestforawardinwhichwomenandmen couldbeadmittedforshortstays.InJune1881,Charcotwasalso grantedanoutpatientservice,whichtransformedrecruitment forhisdepartment.Finally,aChairofNervousSystemDiseases wascreatedforhimin1882atthemedicalschool[6].
Inadditiontohisteachingsasamedicalschoolprofessor, Charcot set up weekly classes at La Salpeˆtrie`re. These
‘Tuesday lectures’, combining impromptu interviews and examinations, were a major teaching tool in Charcot’s pedagogical repertoire. They were clinical show-and-tell exercises,oftenwithcontrastingcasesshownsidebyside.
Thismade them pivotal foreducating peersand students.
These‘‘unpretentiouslectures’’,asCharcotcalledthem,were initiatedon17November1882.InthewordsofPierreMarie (1853–1940), who recalled the Master at the centennial celebration ofhisbirth in 1925,these lectureswereaimed at‘‘introducingstudentstopracticalanddiagnosticdifficulties which one often encounters, particularly with nervous pathologies[...]Charcot’steachingwasbipartite:inaddition tohisofficiallessons,whichtookplaceonFriday,therewas the teaching he dispensed daily to the students in his
department [...] This daily teaching was precious for his immediateentourage.MorningsessionswiththeMasterwere a key element of his students’ training. As for his official teaching,howtodescribehisadmirableTuesdaylessons?For onething,theytookplaceinthesamefacilitiesthathoused theoutpatientservices.Someofthepatientswhohadcome for a consultation were examined by Charcot one after another. He questioned them himself [...] Though his questions were precise, hewas nonetheless charming and affable,drawingresponsesoutofhispatientswithakindof Socratic method. A diagnosis gradually became clear, accompanied by Charcot’s remarks based on his long experience[...]AsfortheFridaylessons,Charcotgavethem withagreatdealofstyle,andfewlessonscomparedinterms of the careand time that wentinto theirpreparation. For Charcot,theweeklyuniversityclassesinthelecturehallwere themajoreventinhislife,whatmatteredmorethananything.
Theweekdaysled uptothem, withspecialpreparationon Fridaymorningatthehospital.Eachlecturecontinuedtobea topicofdiscussionwellintotheevening’’[7].
Joseph Babin´ski (1857–1932) recalled the way in which Charcotcultivatedresearchideasinthemindsofhisstudents.
During the Tuesday lessons, ‘‘the Master often introduced novelideas,presentednewanglesandsketchedoutresearch areas thathefelt werenotyet readytobeincludedinhis Fridayuniversityclassesbut thatcouldnonethelesshavea positiveinfluence onhisaudience, particularlythoseinter- Fig.1–Jean-MartinCharcotteaching,drawingbyPaulRicherdonearound1882.#E´coledesBeaux-ArtsdeParis,withkind permission.
ested in exploring new realms in the intriguing field of neuropathology’’. Babin´ski went on to add: ‘‘It was not a matterof finished science,but science in the making’’[8].
According to C. Goetz, ‘‘These latter presentations were especiallyimportant forestablishing theevolving nosology or classification system of clinical neurology that has remainedlargelyunalteredintothetwenty-firstcentury’’[9].
Inone1872lesson,Charcotgavehisownexplanationofhis teachingphilosophy:‘‘Youarewellaware,sirs,ofthevalueof thesesymptomatologiespresentedwithgreateloquence,far fromthebedsideofthepatient.Rarelycantheydomorethan giverisetoflat,two-dimensionalimagesthatgenerallyleave theaudiencewithavague,transientimpression.Toavoidthe shortcomingIhavejustdescribed,Iwillproceedbeforeyou withthemethodicalexaminationofapatientwhopresentsall of the symptoms, perfectly developed, of cerebrospinal multiple sclerosis.’’ He used the same approach for his teachingsonParkinson’sdisease[10].
2. Dissemination through writing
Most of Charcot’s lessons were initially published in the journalGazettedesHoˆpitauxCivilsetMilitaires.De´sire´-Magloire Bourneville(1840–1909),whohadbeeninvolvedwithmedical journalssince1861,becameCharcot’sinternein1868.Hewas alsoatthattimeeditor-in-chiefofLeMouvementMe´dical,which ledhimtopublishtheMaster’slessonsinhisjournal.Hethen leftthisposition(forunknownreasons)andwentonin1873to found, with Charcot’s support,one ofthe mostinfluential medicaljournalsofthelast30yearsofthe19thcentury,Le Progre`s Me´dical. From that point onwards, all of the La Salpeˆtrie`relessonswouldbepublishedinthisjournal.They werealsocompiledintobookspublishedinseveraleditions beforetheirinclusioninCharcot’sOeuvrescomple`tes[11].
3. First publication on paralysis agitans
Inthe29November1861issueofLaGazettehebdomadairede Me´decine et de Chirurgie, Charcot and Vulpian published a collaborativearticleentitled‘Delaparalysieagitante’[12].This articleisanexampleofalessongivenaspartofthe‘‘open classes’’atLaSalpeˆtrie`re;Charcothopeditspublicationwould helpitreachawiderreadership.CharcotandVulpiantookas theirstartingpointJamesParkinson’s‘EssayontheShaking Palsy’: a ‘‘remarkable treatise on paralysis agitans [...]
Paralysisagitansiswithoutcontestadiseasethatisgenerally notwellknown;careful,detailedobservationsaredifficultto find.’’ Charcot and Vulpian also put forward the recent publicationbyViennesephysicianJohannRittervonOppolzer (1808–1871)[13].Theirpurposewasthus‘‘tousetheexisting materialtosketchoutashorthistoryofparalysisagitans[...]
andtoaddseveralcaseswhich[theyhad]beenobservingfor sometime’’.Thepedagogicalaimsoftheworkareevidentin itsorganization.Thefirstchapter—‘Symptoms,progression, prognosis’—isadetaileddiscussionofshaking,of‘‘thefeeling of muscular rigidity’’, of ‘‘irresistible propulsion’’ and of slownessofspeechdespite‘‘veryclearandaccuratecompre- hension’’, although ‘‘lateron, the psychic faculties tendto
decline significantly’’. The prognosis ‘‘is very sad’’ due to
‘‘weakening and,above all,loss ofmobility resulting from paralysis, as well as deterioration of the memory and intelligence [which] demonstrates that damage caused by the diseaseisincreasingly profound[...]Therapeutictreat- mentisalmostpowerlesstostopthedisease’sprogression’’.
Thesecond chaptercovers etiology,treatment,autopsy, nosographyanddiagnosis.‘‘Givenwhatcanrightlybecalled therudimentarystateoftheetiologyandautopsyofparalysis agitans today,it is almostexclusively the symptomatology thatmustpredominateineffortstocharacterizethisdisease.’’
ForCharcotandVulpian,coldweather,humidityandacute statesoffearcouldbringonthesymptoms:‘‘Itisnaturalto assumethatthisphenomenon[shaking]beginsinarelatively limited space ofthe centralnervous system, including the medullaoblongata,theponsandpossiblypartoftheupper regions of the spinalcord.’’ To describethe rigidity ofthe patients, they were clear-sighted in their discussion of abnormal‘‘innervationofstability’’and‘‘astabilityneurosis’’
involving ‘‘muscle tone’’, a term coined by Ernst Blasius (1802–1875)in1851[14].
4. Teachings on tremor
Charcotbeganalessonin1868,transcribedbyBourneville,as follows:‘‘Thoseofyouwho,thismorning,visitedourwards were perhaps surprised to find a considerable number of women in whom shaking appears to be the predominant symptom,oratleastthemostobvioussymptomofthedisease theysufferfrom.Ipurposelybroughttogetherthesepatients, whohavespecific,similarsymptoms’’[15].Asanexperienced teacher,Charcotoftenpresentedcasesofdifferentpatholo- giessidebysidetohighlightthesemiologicalelementsthat distinguishedshakingineachcase:‘‘Someof[thepatients]
only shake when they are performing a global movement usingtheirlimbs,suchasliftingaglasstotheirlipstodrink,or attemptingtorisefromtheirchairtowalk[...]Ontheother hand,whentheyarerestingandunaffectedbyanyemotion, these same women,whether sitting or lyingdown, appear mostnaturalintheir posture;noneoftheir bodyparts are agitated,suchthatifonlyobservedintheseconditions,they donotappeartohavethediseasetheyaresufferingfrom.On the contrary,inthe secondseriesofcases,theirshakingis continuous andpermanent, causingceaselessshaking,and whileintentionalmovementsmayexaggeratethiscondition, therestingstatedoesnoteliminateit.’’
ThemainpurposeofthelessonforCharcotwastohighlight theimportance oftheclinicaldistinctionbetweenparalysis agitansandmultiple sclerosis,asthey‘‘haduntilnowbeen included in one category, despite their being perfectly independentinallways’’.Asfortheshaking,Charcotnoted that‘‘itisalmostuniversallymisunderstoodinourtimes’’.He citedonlyAdolpheGubler(1821–1879),whoworkedatHoˆpital Beaujon,foraccuratelyinterpretingthisphenomenonin1860:
‘‘Shakingconsistsnotinasuccessionofopposingmovements beyondvoluntarycontrol,butratherinalternatingcontrac- tionsandrelaxationsofthemusclesinvolved’’[16].
CharcotdevotedmostofhisFridaylessonon16November 1876 ‘‘to shaking in Parkinson’s disease’’, reviewing the
differential diagnostic information in relation to multiple sclerosis.Itgoeswithoutsayingthatmostofhisaudiencehad notheardthe1868lessonand,likeallgoodteachers,Charcot had updated his material. Specifically, he noted that the movements ofthehead wereatransmissionofthe body’s shakingand,thus,didnotoriginateinthehead.Anotherpoint raisedduringthislessonwasthecharacteristichandwriting, whichwasnotonlyaffectedbyshakingbut‘‘oftendiminish- ing in size’’. During this lesson, he proposed abandoning the term ‘paralysie agitante’ in favor of the eponymous
‘Parkinson’sdisease’[17].Charcot’s aimwas tohelpphysi- ciansabandontheideaofparalysiswhileclarifyingtheclinical picture he wished to impart. Thus, from 1880 onwards in France, Parkinson’s disease was the name used by all physicianswhereas,inGreatBritainforexample,thisepony- mousnamewasnotuseduntilthemiddleofthe20thcentury.A transcriptionofalessononParkinson’sdiseasewasthefirst articleonthispathologypublishedinLeProgre`sMe´dical.
During his lesson on Tuesday, 22 May 1888, Charcot explained his own pedagogical method for teaching the differentialdiagnosisasregardsshaking;inthesamelesson, hepresentedhisstudentswithacaseofshakinginactionand anotherinarestingstate:‘‘Nowisthetimetousethemethod ofcontrasts.Toimpressuponyourmindsthecharacteristics ofshakingduetomercurypoisoning,Iwillpresentasubject whohasjustnowcometotheoutpatientservicesandwho offers a fine example of paralysis agitans or Parkinson’s disease’’[18]. Charcot drewsomesketches ofthe different patternsofshaking(Fig.2).
DuringalessoninMarch1885,Charcotanalyzed,beforehis students,recordingsbasedon ‘‘thegraphicmethod’’,using
‘‘the rotating drum invented by Mr. Marey’’ (Etienne-Jules Marey,1830–1904) todistinguish betweencasesofmultiple sclerosisandParkinson’sdisease.‘‘Youalreadyknowthatone cannotjudge the rapidityofthe rhythmic oscillations that constituteatremorwithonlytheinformationgleanedfrom theeye.Tosurmountthisdifficulty,thegraphicalmethodis notoverlytechnical.Wearenotignorantofthefactthatthe data provided by such measurement techniques are of considerable clinical importance.’’ He then presented the graphs:‘‘ShakinginParkinson’sdiseaseinvolvesrhythmical oscillations,buttheirscopeislimitedasistheirduration[...]
Thisshakingiscontinuous,anditisimportanttonotethatit occurs outside of all voluntary movement [...] Shaking in multiple sclerosis and Parkinson’s disease involves slow oscillations,fourorfivepersecondonaverage’’(Fig.2).These graphics allowed him to clearly distinguish the role of movementintheaggravationofshakinginmercurypoisoning and in multiple sclerosis. He continued the lesson by mentioningother typesofshaking, inhysteria,alcoholism, general paralysis and Graves’ disease. Londesubsequently perfected the recording of oscillations and their visual representation(seebelow)[19].
5. Rigidity and slowness
Inan1872lesson,Charcotstartedbynotingthat‘‘paralysis agitansstrikessubjectsalready advancedinage, especially thoseolderthan40or50[...]buttoconsideritasadiseaseof
senility wouldbetogotoofar’’.Hewentontoinsist:‘‘We wish to highlight an aspect that appears to have escaped Parkinson’snoticeaswellasthatofmostoftheauthorsthat followedhim:rigidity,whichatacertainphaseofthedisease affects the muscles of the limbs, the trunk and, most frequently,themusclesoftheneck.’’Hecompletedtheclinical picture with a description ofposture during walking: ‘‘The patientisbentforward;heappearsforcedintoadoptingarapid step,anditisonlywithgreatdifficultythatheisabletostop, having nochoice buttoracealongafter his forward-bound centreofgravity.Aparticularpostureofthebodyandthelimbs, afrozengaze,andfacialtraitsthatareimmobilearethemost significantsymptomsofthedisease’’[20].Heneverusedthe term ‘bradykinesia’, although hedid mention ‘‘difficulty in movement’’,andlaterstated:‘‘Movementisslowedratherthan hindered by real motor weakening [...] It seems that the nervousinfluxcanbeinitiatedonlyafterexceptionalefforts.’’
During the Tuesday lesson on 31 January 1888,Charcot interrogateda52-year-oldmasonunabletocontinuehiswork duetoshaking.Charcotproceededwithhishabitualmethod of comparison: standing next to the mason was another patientfromthedepartment‘‘withtheoppositeformofthe disease,rigiditywithoutshaking.Lookatthem,bothofthem.
Theyrepresentthetwoextremesofthesamedisease.Oneof themhaswhatthesecondlacks,i.e.rigidjoints,characteristic physiognomy,fixedgaze,theappearanceofawoodenfigure, rigid facial muscles which cause raised eyebrows and squinting eyes, giving him an expression both sad and surprised’’(Fig.3)[18].Charcotthenaddedthefollowingto highlightthegaitpeculiarities:‘‘Iwishtostopusingtheterm
‘paralysis’,aspatientsareawareoftheirstate;theydon’twish to be paralyzed and,in fact,they are notparalyzed. They almostalwayshavesuchasingularphysiognomythattheyare takenformorons,forindividualswhosebrainisdamaged.The truthisthatintellectualphenomenaareabsolutelyintact,and theirbrainsareperfectlyhealthy’’[18].Thelessonwentonthis way, rather like ananimated conversationorchestrated by Charcot for his students. He recalled voyages to Rome, AmsterdamandSpainduringwhichhediagnosedthisdisease withgreat simplicity:‘‘You canrecognize [patients]froma distance;noneedtoquestionthem’’[18].
During the Tuesday lesson on 12 June 1888, Charcot explained how to distinguish contraction in Parkinson’s diseasefromthatofhemiplegia,notingtheexaggerationof reflexes in the latter; however, ‘‘the muscular rigidity in paralysis agitans remains a problem from a physiological perspective’’[18].Toillustratethisrigidity,hediscussedgait, contradicting his lesson of 1872: ‘‘Parkinson spoke of the rigidity and stiffnesswhich makes patientslook like auto- matons,like‘apieceofmachinery’hesaid,speakingoftheir appearance.’’Inagesturecharacteristicofhislessons,Charcot underscoredtheimportanceofhisresearchforconfirmingthe diagnosis,althoughasecondaryreasonforthismayhavebeen toencouragestudentstoseekoutcauses:‘‘Itispreciselyour ignoranceinthisareathatIwishtohighlightforyou,ifonlyto incite you to pursue your ownresearch. I also draw your attentiontotheabsenceofreflexesintherigidityofparalysis agitanspatientsincontrasttowhatweseeinwhatisproperly spasmodiccontractionor,ifyouprefer,spinalcontraction’’
[18].
Charcotalsousedhisowndrawingsasvisualaidsforhis teachings (Fig. 4).This allowed himto show characteristic facialexpressions,asinthefollowinglesson:‘‘Whatstrikesus immediately is the immobility of the head and the facial features[...]Thewrinkledforeheadandtheraisedeyebrows duetotheexaggeratedactionofthecorrespondingmuscles are among the most common features and the most characteristicfacialtraitsinparalysisagitans.’’
CharcothadestablishedallclinicalaspectsofParkinson’s diseaseby1872,includingslowedspeech,salivaatthecorners ofthemouthandlimbrigidity(‘‘jointsseeminglyweldedand
theforward-flexedposture’’).Healsodidnotfailtopointout theinitiallyinsidiousonsetthatcouldsometimesleadtoits suddenmanifestationandthegradualprogression.Hegavea detaileddescriptionofthechronicperiod:‘‘Facialmusclesare immobile;eventhegazehasremarkablefixedness,andthe facial featuresaremarkedby apermanentsadness, some- times a daze’’ [15]. Charcot paid particular attention to deformations of the hands, providing specific information on thedifferential diagnosisbetweenparalysisagitansand
‘‘chronicrheumatoidarthritisofthejoints’’.Onceagain,he usedhisowndrawingsofdeformedhandsasvisualaidsfor Fig.2–SchematicdiagramsbyCharcotofdifferentshakingfrequenciesaccordingtotheiretiology.Lec¸onsduMardia` La Salpeˆtrie`re,1887(page417).Privatecollectionoftheauthor.
theselessons(Fig.5).‘‘Noticethatthehandsandthefingers shakeindividually,butwhatyoushouldimpressuponyour minds is the very specific appearance of the hand. The phalangesareextendedoneuponthenext,butthefingersare flexedtowardthemetacarpus.Thethumbisadductedandthe padrestsontheindexfingerinapositionrecallingthatofa handholdingapen,andthemovementsinthesevariousparts ofthehandsometimesbringtomindtheactofrollingaballof paperorbread’’[19].
Finally,toavoidanyanachronism,itshouldbenotedthat theclassicsigndubbed‘cogwheeling’wasproposedlater,in 1901,bytheItalianneurologistCamilloNegro(1861–1927).
6. Theses by Charcot’s students: another means of disseminating knowledge
FromhisearliestdaysatLa Salpeˆtrie`reandthroughouthis career, Charcot delegated some of his work to successive internesandhisfavoritestudents.Whetherornothewaspart ofthedefencejury,theirthesesalwaysgaveanoverviewof Charcot’s research. Some of them are worthy of critical attention because they describecasesthat today mightbe classifiedamongtheParkinson-plussyndromes;inaddition andthankstoBourneville,someofthesewerepublishedin commercial editions.Inthecommentaries below,Charcot’s students provide some insight into the teacher–student partnershipandtheaimsofthesecollaborations.
PierreMarie:‘‘Itmostoftenhappenedthathespecifically asked oneofhisstudentstocarry out astudy, toconduct bibliographicresearchonasubject.Heremainedinterestedin how the work was progressing and was unstinting in his advice to the student chosen for the task. This sort of collaboration with the Master was notonly a sought-after honour,but alsoavaluablelesson[...]Themanystrengths Fig.3–DrawingbyCharcotofgait.Lec¸onsduMardia` LaSalpeˆtrie`re,1887(page440).Privatecollectionoftheauthor.
Fig.4–DrawingbyCharcotofthenon-expressivefaciesof theParkinson’spatientBache`re.Lec¸onsduMardia` La Salpeˆtrie`re,1887(page437).Privatecollectionoftheauthor.
andskillsthatCharcotbroughttothesecollaborationsenabled himtofoundandmaintainaschool.Fewinhispositionhad thesavvytoattractsuchahostofstudents’’[7].
PaulPeugniez(1859–1943):‘‘Fromascientificviewpoint,he allowedhisstudentstoenjoyallofthebenefitsoftheirwork and also let them work in complete liberty, offering his assistanceonly tohelpthem gather thefruits ofa shared effort’’[21].
Indeed,thetheseswrittenbyCharcot’sstudents,whomthe Masterguidedandencouraged,areofhistoricalinteresttoday and this, in a sense, has fulfilled Charcot’s hope that the researchanddiscoveriesatLaSalpeˆtrie`rewouldhaveawider sphereofinfluence.Whatfollowsarethreeexamplesofthis.
6.1. ThesisofLe´opoldOrdenstein
ThethesisofLe´opoldOrdenstein(1835–1902),defendedon17 December1867,wastheveryfirstthesisonparalysisagitans preparedinParis [22].Itwasdedicated‘‘tomydearMaster, ProfessorCharcot,towhomIpaythehomageofmyprofound andaffectionategratitude’’.Ordenstein’sthesispresentsthe stateofknowledgeasCharcotwishedittobepresentedtoall physicians.Thethesisreproduceswordforwordtheoutline andlargesectionsoftheinitialarticlepublishedbyCharcot andVulpianin1861.Hefocusedinhisdescriptiononshaking asrhythmicoscillationsor‘‘shakingparalysis’’—or,forhim,
‘‘Schu¨ttellœhmung’’. Theinitialunilaterality isalsonoted, as wellasthediffusechronicpainstate.Gaitwasdescribedas having‘‘ajerkingandprecipitousappearance’’markedbyan
‘‘irresistible forward-leaning propulsion or a tendency to movebackward’’,withdeformationofthetrunk.Ordenstein’s
textincludedtheterm‘Parkinson’sdisease’,mostlikelyasa suggestionfromtheMaster,whohimselfdidnotusetheterm until1876.WhereasCharcotfocusedonclinicalaspectsinhis lessons,OrdensteinnotedinhisthesisthatCharcotprescribed hyoscyamine granules, which significantly alleviated his patients’shaking[23].
Charcotneverfailedtorefertohisstudentsandespecially theirthesesduringhislessons,whichcanbetakenasproofof his involvement intheir work. During his 1868 lesson,for example,hemadethefollowingremark:‘‘IfIamnotmistaken, Iindicatedthedelineationbetweenthesetwoconditionsfor thefirsttime,asnotedinthethesisofMr.Ordenstein.’’Even today,thisthesisremainsasignificanteventinthehistoryof neurology, asLucien Denombre´ (1839–?)pointedout inhis ownthesisin1880.ItwasonlyafterOrdenstein’sthesisin1867 that ‘‘Parkinson’s disease was definitively considered as a distinctmorbidentity’’[24].
6.2. AlbertBoucher
Albert Boucher (1852–?) defended his thesis, dedicated to Bourneville, on28February 1877[25].He beganhistextby recallingthecircumstancesthatgaverisetohisstudy.After listeningtooneofCharcot’slessons,hedecidedtofocuson cases of paralysis agitans that ‘‘while having most of the general characteristicsofthisdisease,standapartduetoa totallackofagitation[...]Whileourstudyislimitedtoafew observationsonly,thismaynotbeindicativeoftheirrarity, butrathertheignoranceofphysiciansastotheirexistence’’.It isclearthatCharcotwantedtomakenon-shakingformsmore widely knownandaccomplished this byhavingoneofhis Fig.5–DrawingbyCharcotofthehandofParkinson’spatientFranc¸oise-AugusteBerlin,formerservant,age59years.# Bibliothe`queCharcot,Bibliothe`queUniversitairePierreetMarieCurie(BUPMC),withkindpermission.
students write the relevant thesis. Boucher compiled six highly detailed observations of cases without shaking. He insistedonincluding‘‘rigidity[...]Charcot’sintelligentaddition ofthisclinicalsignthatParkinsonhadoverlooked’’.Healso includedtheresults ofdynamometric examinations,carried out by Bourneville, indicating a loss of muscle strength,
‘‘whereasuntilnowithasbeengenerallythoughtthatthere was no weakening’’. Boucher also remarked that Charcot emphasized a symptom that he (Boucher) was the first to describe:‘‘Thereisoftenasensationofexcessiveheatthatis feltespeciallyintheepigastricregionandintheback.’’Asnoted byCharcot,body temperaturewas not affected.Would this today be considered a type of autonomic dysfunction?
Boucher’sworkprovidesyetanotheropportunityforhighlight- ingCharcot’srelationshipwithhisstudents.In1885,Boucher, whowentontobecomeamilitaryphysician,publishedinLe Progre`sMe´dicalaclinicalcasewhichheattributedtoprolonged exposuretocolddampconditions.Hemadementionseveral timesofhisteacher:‘‘DespitetheattentionCharcot’sworkhas garnered,therearestillfewobservationsofparalysisagitans.’’
6.3. PaulOscarBlocq
Paul OscarBlocq(1860–1896),Charcot’s internein1887,was oneofmanybrilliantstudentswhodiedprematurelyandso wereunabletorealizethepotentialoftheirinitialcontribu- tions.On24February1888,withCharcotpresidingoverthe jury,Blocqdefendedhisthesisentitled‘Descontractures’[26].
ThereinhediscussedmusclerigidityinParkinson’spatients andsuggestedtheyweresufferingfrom‘‘apseudo-contrac- tion’’. He listed a series of observations in which rigidity precededthepresenceofshaking,orgrewworsewithoutthe presenceofanyshaking.Havingdiscoverednolesionsduring the pathological–anatomical examination of the central nervoussystem,Blocqsuggestedthat‘‘parkinsonianrigidity depended on damage to muscular fibres’’, establishing a parallelwithThomsendisease.Inotherwords,hepresented Parkinson’sdiseaseasamyopathiccondition.Thefactthat Charcotoversawthisthesisraisesthepossibilitythatheused Blocq’sworktoadvanceahypothesisthathehimselfnever explicitlyformulated.
ItwasBlocq’s1893publication,however,thatisnotewor- thyfromanhistoricalperspective.AlongwiththeRomanian student Georges Marinesco (1864–1938), who attended Charcot’s lessons and would eventually become famous himself,Blocqpublished(3monthsbeforeCharcot’sdeath) acaseof‘‘hemiplegicparkinsonianshaking’’[27]secondaryto a tuberculoma that unilaterally destroyed ‘‘Sœmmerring’s substance’’1,nowknownasthe‘substantianigra’[28].Blocq and Marinesco pointed out the probable coincidence of tuberculosisandParkinson’sdisease,basingtheirconclusion onanunpublishedobservationofasimilarcasepreparedby Charcot. Edouard Brissaud (1852–1909), referring again to thesepreciselesionaldata,hadtheperspicacitytopropose,in 1894,thepathophysiologicalhypothesisofdysfunctioninthe
‘black substance’(his term forthe substantia nigra)asthe explanationforParkinsonsymptoms[29].
7. Charcot’s teaching on atypical forms and their significance today
Euge`ne Be´chet (1862–1939), a former interne at the insane asylumsintheareaaroundParis,defendedhisthesison28 July 1892 before a jury that Charcot presided over. He dedicatedhisthesistoCharcot:‘‘Allofthedatacollectedin hisdepartmentandtherelatedcommentariesarebasedon thetrainingIreceivedthere.’’Afteralongdiscussionofallthe signsandsymptomsofParkinson’sdisease,Be´chetundertook to establish a list of atypical forms based on personal observations or found in the literature, including: atypical formsduetotheabsenceofshakingorrigidity;atypicalforms duetothelocationofsymptoms;andatypicalformsdueto additionaldisturbances(mostnotably,hisaccuratedescrip- tionofdepressionandhallucinationsfollowingdementia;he alsoincludedurologicalandocularproblems).Be´chetremai- ned‘‘exclusivelyintheclinicaldomain[...]inpartbecause [he]wasawarethatPaulBlocqwascarryingoutpathological–
anatomicalresearchinthisarea’’[30].Thedetailedobserva- tions included one that Blocq and Marinesco took up the following year in1893. Be´chet alsomentioned that it was Jean-BaptisteCharcot(1867–1936),theMaster’sson,whohad passedthisobservationontohim.
In additiontohemiplegic forms,Be´chet presentedthree observations ofstiffnessinthetrunk and extensiontothe limbs.Oneinvolveda52-year-oldmanwho‘‘hadundergone treatmentinthevibratorychairatLaSalpeˆtrie`reforseveral weeks’’; Charcot had tasked Georges Gilles de la Tourette (1857–1904)withtestingthistreatment[31].‘‘Butwhatismost markedinthispatientisanunusualappearance,aspecialway ofholdinghimselfthatisnotablydifferentthanthatusually observedduringparalysisagitans.Itseemedthusappropriate toplacethiscasewiththosegroupedtogetherbyCharcotand referredtoasextensioncases.’’Healsoincludedthecaseofa patientexaminedbyCharcotduringhisTuesdaylessonon12 June1888.Thepatientwasamanreferredtoas‘‘Bache`re,aged 31’’,withonsetatage26.Charcothighlightedforhisaudience the characteristichypomimia (Figs. 3and 4):‘‘Lookhowhe stands.Ipresenthiminprofilesoyoucanseetheinclinationof theheadandtrunk,welldescribedbyParkinson.Allofthisis typical.Whatisatypical,however,isthatBache`re’sforearms andlegsareextended,makingtheextremitieslikerigidbars whereas,intheordinarycase,thesamebodypartsarepartly flexed.OnecansaythenthatinthetypicalcaseofParkinson’s disease, flexion is the predominant feature, whereashere, extension predominates and accounts for this unusual presentation.Thedifferenceisevenmoreevidentwhenthe patientswalk.’’Charcotalsogaveanin-depthdescriptionof thepatient’sforeheadwrinkles,whilenotingthat‘‘thefixed gazeisalsoduetoarigiditywhichisequallypronouncedinall ofthemusclesoftheeye’’.Charcotfinishedhislessonwith this pronouncement: ‘‘We have arranged for admission at HoˆpitalBiceˆtre,incurablestatus’’[18].Thepublishedlesson includedadrawingofBache`re’sfacethatCharcothimselfhad sketched (Fig. 4). Charcot enjoyed drawing and sometimes evenillustratedhislessonswhiletheywereunderway.
During his internat (internship) under Charcot, Adolphe Dutil (1862–1929) published, in 1889, an observationof a
1 SamuelThomasvonSœmmerring(1755–1830)wasaGerman physicianandanatomist.
50-year-oldwoman,PaulineDro—,whomCharcothadusedin his 19 July 1889 lesson as an example of ‘‘hemiplegic Parkinson’sdisease’’:‘‘Theupperlimbpresentsthecharacte- risticflexionandshaking,whereastheheadandthetrunkare strongly thrown back rather than inclining forward, as is usuallythecase’’[32].Dutilalsoaddedthathereyesdidnot move.
Thus, once the archetype of Parkinson’s disease was established, Charcot, along with his students Be´chet and Dutil, could then identify variants with atypical features compared with the classic descriptions, calling them
‘Parkinson’s disease with extended posture or with hemi- plegia’.Thesecasesareofhistoricalinterestbecausetheyare now recognized as ‘Parkinson-plus syndromes’. Bache`re (Figs. 3–7)would perhaps todaybe considered anexample of progressive supranuclear palsy (Steele–Richardson–Ols- zewski syndrome)2, whereas the case of the woman with asymmetrical rigidity of the extremities is perhaps more evocativeofcorticobasaldegeneration(Fig.9)[1].
8. Teaching pathological anatomy: in search of an etiology
In his 1868 lesson, Charcot moved rapidly through the disease’s pathophysiology: ‘‘Adiscussion would be prema- ture.’’Charcottaskedhisinternefortheyear1869,AlixJoffroy (1844–1903), with the department’s first publication on the pathological–anatomical research conducted there. After threeautopsiesofpatientswhomCharcothaddiagnosedas suffering from paralysisagitans, Joffroy, who ‘‘did notsee lesions of the medulla oblongata or pons as having the importance accorded byforeignspecialists’’, arrivedat the followingconclusion:‘‘Weareinclinedtoadopttheopinion thattheanatomicallocationofparalysisagitansisexclusively inthespinalcord,andthusabsentfromthemedullaoblongata andthepons’’[33].Theuseof‘‘weareinclined’’isatelling exampleofthedeferenceofCharcot’sstudentswithregardto theMaster.ItwouldhavebeenwrongforJoffroytosay‘‘Iam inclined’’ as Charcot was the mastermind behind such projectsandthebasicthinkingwashis.
Inhis22May1888 lesson,Charcotonlytouchedonthe causeofshakinginthedisease:‘‘Thissubjectisshroudedin obscurityandnewstudiesarecalledfor.’’Infact,theclinical casespresentedintheselivelylessonsdonotappeartohave benefittedfromfollow-ups throughtothepatients’ deaths.
Also,Charcotmadenomentionofautopsiesand,asforother casespublishedinFranceandinothercountries,theresultsof pathological–anatomical examinations were contradictory andnotconvincingtohim.
Tenyearsaftertheveryfirstlessonatthebeginningofthe 1880s,theclinical signsfordiagnosingParkinson’sdisease,
their various presentations and their different patterns of progressionwereconsideredestablished.However,thecauses ofthediseaseremainedunknown.Charcottaskedtwoofhis externes,Paul-De´sire´ Lerouxin1880andthenGastonLhirondel 3 years later, to compile observations from the Clinic of NervousDiseasestodemonstratethe roleofheredity. This period was important for the development of Charcot’s etiological concepts at a time when the Chair of Nervous System Diseaseshad justrecentlybeen created forhim.A clinician through and through, Charcot gave priority to rigorous empirical observations and made his skepticism withregardtotheoryanelementofhisteaching:‘‘Iamnotin the habitofproposing thingsthatcannotbedemonstrated experimentally. As you know, my principle is to pay no attentiontotheoryandtosetasideprejudices.Toseeclearly, onemusttakethingsastheyare[...]Inthisway,Iamnothing morethanaphotographer’’[18].
As shaking was an additional behavior rather than a functional deficit, there was no precise anatomicalcorres- pondence.Thus,theanatomical–clinicalmethod,whichhad Fig.6–EtchingbyPaulRicher:Untypedeparalysieagitante (Atypeofparalysisagitans),publishedforthefirsttimein PauldeSaint-Le´ger’sthesisin1879.Privatecollectionof theauthor.
2 Steele–Richardson–Olszewskisyndromeisaprogressiveneu- rologicaldisordercharacterizedbysupranuclearophthalmople- gia, especially paralysis of vertical gaze, retraction of eyelids, pseudobulbar palsy, dysarthria, dystonic rigidity of the neck andtrunk,anddementia.Onset isusuallyinthesixthdecade oflife.Richardsonfirstrecognizedtheconditionin1955inhis privatepracticeand beganlooking forotherpatients,and the eponymousteambeganworkingtogetherin1959.
ledCharcottosomanydiscoveries,revealeditslimitationsnot onlyforParkinson’sdisease,butalsoepilepsyandhysteria.
The time was ripe for an epistemological reassessment, especiallyasthePasteurianrevolutionhadbeenconsecrated at the International Medical Congress in August 1881 in London,aneventat which bothPasteurandCharcot were lauded[6]. Later,Charles Fe´re´ (1852–1907),interne andthen personal secretary to Charcot, compiled data to officially establish‘‘theneuropathicfamily’’inhisfamous1884article.
ConvincedbyFe´re´’sconcept,Charcotwoulddefenduntilhis deaththepredominanceofheredityinthe originofneuro- logical diseases, therebyaligning himself with the leading hypothesis at the time [34]. His ideas are evident in the writingsofFe´re´:‘‘Nervoussystemdiseases,whethermanifest inpsychic,sensoryormotordisturbances,havemanypoints ofcorrespondenceandcontactbetweenthemselves.Although in recent years both clinical and pathological–anatomical studies havemultiplied the types,they stillconstitute one familyindissolublylinkedbythelawsofheredity’’[35].
Paul-De´sire´ Leroux (1851–?) defended his thesis, with Charcot presiding over the jury, on 22 June 1880 [36]. He concluded his introduction with an homage ‘‘to Professor Charcotforhisguidanceandtheencouragementhegaveme’’.
Basedoneight patientshehadpersonallyinterrogatedand examined, Leroux made the following remark: ‘‘Exterior
causes,moralemotions, humidcoldweatherand irritation of peripheral nerves are causes that merely activate the potential for illness, inducing flare-up of the underlying disease.Heredityisarealcauseofparalysisagitans,perhaps theonlyrealcause.’’
Gaston Lhirondel (1855–?) defended his thesis, with Charcot presiding over the jury, on 18 May 1883 [37]. He beganthus:‘‘Theideasforthisstudydidnotoriginatewithus.
Twoyearsago,ProfessorCharcotgaveustheassignmentof delvingintothehereditaryantecedentsofseveraloutpatients withParkinson’sdisease[...]Wearegratefultooureminent teacher, Professor Charcot, whoassisted and guideduson severaloccasions.Itwashislessonsthatpromptedustotake up the study of Parkinson’s disease, and the patients we studied were either his outpatients or patients in his department.’’ Later in his text, Lhirondel’s statements are surprising:‘‘Wefoundnothingofwhatwewerelookingfor.By contrast,wedidfindwhatwewerenotyetlookingfor;thatis, traces of arthritic diathesis.’’ Thepresentation of casesin Lhirondel’s thesis strikes the modern reader as extremely confused. The association of chronic, mostly rheumatoid, pathologies,or‘diatheses’(astheywerecalledatthetime), withParkinson’sdiseaseasanetiologicalfactorandproofof familytransmissionstandsout,especiallyasthepossibilityof coincidenceisneverraised.
Fig.7–PhysiognomyofaParkinson’spatient,drawnbyPaulRicheron22June1888.NouvelleIconographiedeLaSalpeˆtrie`re, 1888;1:213–216(platesXLIIIandXLIV).Privatecollectionoftheauthor.
SigmundFreud(1856–1939),intheposthumoushomagehe wrotewhenCharcotdied,mayhaveofferedthemosttelling commentary on the epistemological impasse at which the Masterfoundhimself:‘‘Itwillundoubtedlysoonbenecessary to review and correct the etiological theories defended by Charcot in his doctrine of the neuropathic family and on which he founded his global understanding of nervous diseases. Charcot so overestimated the etiological role of heredity that no place remained for other neuropathic etiologies’’[38].ThisconceptoffamilialdiseaseinCharcot’s day was more related to a deterministic philosophy (‘‘one cannotchoosetobecomeanhystericoraneurasthenic’’)than toourpresent-daynotionofgenetics.Indeed,Charcotnever presented, in any of his lessons, a family of Parkinson’s sufferers,andanyextrapolationofCharcot’sideasonheredity asprecursors ofthecurrent knowledgewould beanachro- nistic[34].
9. Paul Richer: artistic talent in the service of Charcot’s teaching
For Achilles Souques (1860–1944) and Henry Meige (1866–1940),‘‘Charcothasanexcellentmindforthesynthesis ofideasaswellasafinesenseofschematization.Hehasa broadview;heaimstobeclearandconcise.Thisexplainshis useofdrawingsandothervisualaids;byengagingtheeyesof hisaudience,hecankeepexplanationtoaminimum’’[39].To develophisuseofdrawings,Charcotturnedtohistalented internefortheyear1878,PaulRicher(1849–1933).Thereisno doubtthatRicherdidthemosttohelpCharcotdevelopthe visual teaching materials that enriched his lessons and publications.Richerwentwellbeyondthemasterlyillustra- tionofhystericalepisodesinhisthesis,defendedon9April 1879. He made striking drawings of parkinsonian physio- gnomyduringhisinternatin1878 andagainasheadofthe laboratoryoftheClinicofNervousSystemDiseases(from1882 to1895). Forthe first issueofLaNouvelle Iconographiede La Salpeˆtrie`re,publishedinJanuary1888,Richerdrew‘‘atypical case,particularlyappropriatefordemonstration;sheremai- ned fora long timein Charcot’s department at Hoˆpital La Salpeˆtrie`re,andtheeminentprofessorpresentedhermany times to his students during his clinical lessons. Her observationwas publishedin extensointhe first volumeof Charcot’scompleteworks’’[40].Anetchingofthepatientwas also used toillustrate Paul de Saint-Le´ger’sthesis in 1879 (Fig.6).
WhileCharcot had made hisowndrawings of Bache`re, Richer added further drawings of the patient to illustrate
‘‘whatcouldbecalledtheartisticsideofParkinson’sdisease’’.
He emphasized the facialexpression, which hewanted to render as accurately as possible: ‘‘Between this forehead, expressiveor wrinkled transversely andvertically, andthe restoftheimpassiveface,wehavethefixedandimmobile eyesthatarewideopen,withanearabsenceofblinking;these arethe fundamental elements ofthis strange and striking mask’’[40].Incomparison,hisportraitofBache`reisclearly moreaccomplishedthanCharcot’sdrawing(Fig.7).
Charcot also gave Richer the idea to make a sculpture modeledafterGell—,aged58,apatientadmittedon12July
1892totheRayerward.Twoyearsafteranemotionalshock, herrighthandbegantoshakeduringrest.Theshakingspread totheentireupperlimbandeventuallythelowerrightlimbas well;theentirerightsideofherbodywasthusaffected.She also suffered fromdiffuse painthat graduallyincreasedin intensity; theoverallresultwas reducedmovement.Richer andhisstudentMeigepresentedthisobservationindetailin LaNouvelleIconographiedeLaSalpeˆtrie`re in1895[41].Charcot died on16August1893andwould neverseethesculpture, whichRicherdidnotfinishuntil1895.Instead,itwasleftto Charcot’ssuccessor,FulgenceRaymond(1844–1910),touseit forhislessons [42]. Richer wasable torender‘‘thegeneral emaciationandcutaneousfolds’’withamazingprecision.In fact, the skin is depicted so realistically that the entire subcutaneousvenousnetworkisdistinctlyvisible,including even the hypogastric hernia secondary to the patient’s 11 pregnancies.Richernotedthefollowing:‘‘Thebrachioradialis [longsupinator]oftheforearmprotrudesinacharacteristic way. In thenormalstate, thismuscle isneverobservedto contractforsimpleelbowflexion.Itsrope-like,visualprotru- sionisalmostimportantenoughtobepathognomonic’’(Fig.8) [43].Asanartistinhisownright, Charcotwasable totake advantageofRicher’stalentstoenrichhislessons:‘‘Whereas thelearnedmanaddressestheintelligenceofhisaudience, the artistdoesnothesitatetocapturetheeyeandcreatea lastingimage’’[21].
ThefirstphotographstakenatLaSalpeˆtrie`re,aftertheend oftheFranco-PrussianWar,weretheworkofBournevilleand
Fig.8–SculptureofLaParkinsonienne,byPaulRicher,1895.
Privatecollectionoftheauthor.
PaulRegnard(1850–1927).Thehospital’sphotographicdepart- mentwasofficiallycreatedin1878.Afterthesetwooriginators leftLaSalpeˆtrie`re,Charcottemporarilyassignedthedepart- menttoLoreau,whowasinchargeofanatomicalwaxmodels atthehospital.HewaseventuallyreplacedbyAlbertLondein 1882,ayoungphotographerwhopioneeredanewtechnology using gelatin silver bromide, and also invented a rapid mechanical shutter and a sequential photo technique: ‘‘In his clinic, Professor Charcot has numerous patients; they sufferfromparalysis,hysteria,epilepsy,chorea,etc.,andthey representachallengeforthephotographer,whomustcapture shakingandattackssoastoallowexaminationandanalysis’’
[44]. Londetransformed whatbeganas asimple studiofor takingpicturesintoaresearchlaboratorytodevelopphoto- graphictechniquesforthepurposesofscience.Thephoto- graphsofParkinson’spatientsthatLondetookwereusedto illustrate Dutil’s article in La Nouvelle Iconographie de La Salpeˆtrie`re in 1889,and Be´chet’s 1892 article as wellas his thesis(Fig.9)[30,32,45].
Infact,Londe’sinventions extendedwellbeyondphoto- graphs.Toovercomethedifficultiesofrecordingtheshaking ofpatientsusingMarey’sgraphicmethod,Londedevelopeda methodusingdotsoflight:‘‘Onthelimbforwhichoscillations
aretoberecorded,wefirmlyattachasmall 3/4-voltelectric lamp(Edisonbulb).Thislampshouldbeassmallaspossibleso that itslightisperceptibly punctiform.Then thesubjectis positionedfacingthephotographicobjectivebehindwhichthe cylinderofaFoucaultregulatorisinmotion.Itiscoveredwith asheetofsensitivepaperoraplatethatglidesovertherollers with uniform motion in the transversal direction.’’ The movementsofthepointoflightwererecordedasathintrace onthephotographicpaper.Dutilexplainedthistechnologyin his thesisand addedthatLonde ‘‘wasgenerousenoughto advise uswiththe skills andknowledge heisknownfor’’.
Unfortunately, no such traces of Parkinson’s disease were reproduced,andthereisnorecordofhoworifCharcotever madepedagogicaluseofthistechnology[46].
10. The power of Charcot’s teaching
This historical overview of how Charcot helped to isolate Parkinson’sdiseasenotonlyshowshisclinicalskills,butalso demonstrates the many ways in which he excelled as a teacher,asrecalledbyPierreJanet(1859–1947),oneofhislast students: ‘‘Asidefromthe valueofhisdiscoveries,Charcot Fig.9–PhotographstakenbyAlbertLonde.NouvelleIconographiedeLaSalpeˆtrie`re,1889(platesXXVIIIandXXIX).Private collectionoftheauthor.
wasknownasoneofthemostremarkableprofessorstohave taughtatthemedicalschool.Theclarityofhislessonsand theirpertinencehaveremainedlegendary.Notonlywerethey rigorouslyconstructed;theywereaslivelyasperformances.
Charcothadapassionforteachingandpreparedhisclasses withmeticulouscare’’[47].
This portrait of Charcot, the teacher, gives us the opportunity to highlight the importance of his lectures in themodernizationoftheFaculte´ deMe´decineandthecreation ofnew chairs, leadingto arange of medicalspecialties in Franceattheendofthe19thcentury.
Disclosure of interest
Theauthordeclaresthathehasnocompetinginterest..
Acknowledgements
My sincere thanks to Jacques Poirier for his insightful suggestions,andtotheanonymousreviewersfortheircritical readingandtheirthoughtful,pertinentcomments.
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