Alfred Vulpian and Jean-Martin Charcot in each other's shadow? From Castor and Pollux at La Salpêtrière to neurology forever

While Alfred Vulpian (1826-1887) is not completely forgotten, he cannot match the uninterrupted celebrity which Jean-Martin Charcot (1825-1893) still enjoys today. After becoming interne (residents) at the same institute in 1848, both were involved in shaping the cradle of what would become modern neurology. Both started work as chiefs at a La Salpêtrière service on January 1, 1862, making common rounds and studies, with several common publications. While their friendship remained 'for life', as stated by Charcot at Vulpian's funeral, their career paths differed. Vulpian progressed quicker and higher, being appointed full professor and elected at the Académie Nationale de Médecine and the Académie des Sciences several years before Charcot, as well as becoming dean of the Paris Faculty of Medicine. These positions also enabled him to support his friend Charcot in getting appointed full clinical professor and becoming the first holder of the chair of Clinique des Maladies du Système Nerveux in 1882. Before studying medicine, Vulpian had worked in physiology with Pierre Flourens, and his career always remained balanced between physiology and neurology, with remarkable papers. He introduced Charcot to optic microscopy during their La Salpêtrière years, indirectly helping him to become his successor to the chair of pathological anatomy in 1872. While Vulpian succeeded so well in local medical affairs, Charcot spent his time building up a huge clinical service and a teaching 'school' at La Salpêtrière, which he never left for over 31 years until his death. This 'school' progressively became synonymous with clinical neurology itself and perpetuated the master's memory for decades. Vulpian never had such support, although Jules Déjerine was his pupil and Joseph Babinski was his interne before becoming Charcot's chef de clinique (chief of staff) in 1885. This unusual switch in Parisian medicine contributed to Charcot's unaltered celebrity over more than a century, while Vulpian was progressively relegated to the studies of historians. However, Vulpian and Charcot remain inseparable in the memory of a lifelong friendship which gave birth to neurology.     

Visual art in the neurologic career of Jean-Martin Charcot

Jean-Martin Charcot, the world's first chaired professor of neurology, incorporated visual art into his daily practice of neurology. Art served as scientific documentation and was a pivotal tool in the development and dissemination of Charcot's clinicoanatomic method. Although Charcot drew extensively in clinical and laboratory studies, very few of these visual documents have ever been published or are currently available for public study. Charcot was central to the incorporation of medical photographs into the study of neurologic disease and relied heavily on visual material in his capacity as an international teacher. Art also misguided Charcot's career when he relied heavily on artwork in his attempt to convince critics that disorders seen at the Salpêtrière Hospital, Paris, France, were independent of his suggestive influence.     

Early american professorships in neurology

American universities recognized and institutionalized the emerging importance of neuroscience in medicine by establishing neurological professorships as early as the 1860s. Nearly 20 years before Charcot assumed his celebrated chaired professorship for Diseases of the Nervous System in France, Harvard University created a professorship of Physiology and Pathology of the Nervous System (1864), naming Brown-Séquard as its recipient. In 1867, the new Bellevue Hospital Medical School established a combined neurology/psychiatry chair with William A. Hammond as professor, and the University of Pennsylvania created a clinical professorship devoted specifically to neurology in 1875, naming Horatio C. Wood. Although modest in their university power base and their clinical research/laboratory programs, these American posts were internationally unique for their time and solidly entrenched neurology as a specific division in early US medical education.     

Charcot and art: from a hobby to science

Jean-Martin Charcot not only was one of the founders of modern neurology, but he displayed an exceptionally developed visual perception and memory, with special artistic gifts, which he used first as a hobby and subsequently as a tool in his profession. Previously unpublished drawings emphasize Charcot's talents in caricature, including autoderision. One of the best achievements of Charcot in correlating the clinic with art includes his thorough study of artistic representations of "possessed states", which allowed him to refine his work on hysteria. The artist and the scientist are two unique facets of Charcot, whose permanent coexistence help to understand his legacy.     

Babinski's clinical differentiation of organic paralysis from hysterical paralysis: effect on US neurology

BACKGROUND: The formalized neurological examination developed near the end of the 19th century, and clinicians searched for signs to differentiate weakness due to structural lesions of the central nervous system (organic paralysis) from weakness caused by hysteria. Joseph F. F. Babinski worked in the shadow of his mentor, Jean M. Charcot, until 1893, but then developed independent studies to examine patients with both types of weakness. OBJECTIVES: To elucidate the role of Babinski in differentiating organic paralysis from hysterical paralysis and to describe his influence on 2 US neurologists, Charles Gilbert Chaddock and Charles Franklin Hoover. DESIGN: Primary and secondary sources were studied to outline the discoveries of Babinski and to determine his influence on US neurology. RESULTS: Babinski described toe extension in cases of organic paralysis and specifically stated that this sign did not occur in cases of hysterical paralysis. Chaddock and Hoover were influenced by the work of Babinski and disseminated his discoveries to US neurologists, each developing additional techniques to differentiate the 2 forms of paralysis. Each considered his technique superior to the Babinski toe sign. CONCLUSIONS: Although Babinski was only modestly appreciated by his contemporary peers of French neurology, his influence on US neurology was substantial. The Babinski, Chaddock, and Hoover signs that demonstrate whether structurally related upper motor neuron weakness exists continue to be useful maneuvers in separating these forms of paralysis from psychogenic weakness.     

Charcot at the Salpêtrière: ambulatory automatisms

Jean-Martin Charcot, as professor of neurology at the Salpêtrière Hospital in Paris, delivered a series of dialogue case presentations on general neurology in 1887-1889. These cases, never before translated into English, provide a first-hand view of Charcot's renowned teaching method and his opinions on many neurologic topics. One patient with bizarre ambulatory spells probably representing absence status was recognized by Charcot as an epileptic. This otherwise healthy young man, without a history of generalized epilepsy or hysteria, experienced multiple spells during which he suddenly became unaware of his surroundings, rambled throughout Paris and its outskirts, and had complex interactions with other people. As Charcot unraveled the diagnostic mystery, he traced the patient's wanderings and analyzed the differential diagnosis, treatment, and pathophysiology of these intermittent spells.     

Alix Joffroy (1844-1908), titulaire de la chaire des maladies mentales et de l'encéphale de 1893 à 1908, vu par Jean-Martin Charcot

The title of chair for the mental illness clinic was created in 1879. Benjamin Ball was the first chair holder. The other chair holders are well known: Gilbert Ballet, Ernest Dupré, Henri Claude, Laignel-Lavastine, Lévy-Valensi, Delay, Pichot… and Alix Joffroy (1844-1908)? This name does not sound familiar as do the names of Baillarger, Morel, Magnan, Seglas, Falret, Voisin and so many others. He had three masters who deeply marked his career: Vulpian, Duchenne of Boulogne and Charcot. Intern in 1868, doctor in 1879, obtaining an advanced training degree in 1880, he succeeded Benjamin Ball as chair for the mental illness clinic in 1893. Pioneer in his research in neuropathology on progressive muscular atrophy, infantile paralysis and glosso-labio-pharyngeal paralysis, Joffroy demonstrated that the common and fundamental character of these diseases is the lesion of the nerve cells of the moto-neuron. In his work on Basedow's disease, he defended the thyroid's role in this disease against the bulb's partisans. Joffroy was the first to establish the existence of generalized amyotrophy in primitive neuritis without spinal lesions and was the first to shed light on the chronic process of an ischemic nature as a cause of neuritis. He reoriented himself gradually to the study of mental pathology with a strong interest in all the mental disorders with organic components. As an experienced experimenter, he undertook many works on the toxicity of alcohol proving the disastrous consequences that it has on the nervous system. His results contributed to the development of mental hygiene. If hysteria, hallucinations and fugue were the subject of his studies, nevertheless he also undertook many works on General Paralysis resulting in a posthumous publication with R. Mignot. Opposed to A. Fournier, Joffroy stated that General Paralysis is often of syphilitic origin and never of syphilitic nature. Joffroy held the title of chair for the mental illness clinic for 15 years and yet he remains a forgotten pioneer of psychiatry. In this present article, we will try to explain this collective amnesia following Alix Joffroy's career via the report Charcot submitted on him while he was competing with Gilbert Ballet and Valentin Magnan for the succession of Benjamin Ball as chair.     

Jean-Martin Charcot at the birth of Russian neurology

Russian neurology was virtually nonexistent in the middle of the 19th century which made a traineeship abroad an absolute necessity. Charcot and his school did not just offer professional training, but created the best minds, which would determine the direction of neurology and psychiatry in Russia for many decades. After returning home, young Russian doctors not only implemented everything they had learned in Western Europe, but proceeded to make their own original contributions. The most talented pupils of Charcot, including such prominent names as Kozhevnikov, Korsakov, Minor, Bekhterev and Darkshevich, became the founders of neurological schools in Russia. They laid the basis for the further development of neurology and psychiatry. Remarkably, though trained by the same teachers, each of these future 'founding fathers' of these neurological and psychiatric schools followed his own individual path which resulted in an undeniable diversity in Russian neurology and psychiatry during the period of their formation.     

Neurologie et psychiatrie. Des relations historiques complexes

In France, in the 19th century, French neurologists emerged as specialists among general medicine practitioners with no direct relationship to alienists. La Pitié-Salpêtrière was the Mecca of neurology and the Sainte-Anne Hospital Center that of psychiatry. The chair occupied by Charcot was above all neurologically unambiguous, unrelated to alienists. In the 20th century, the creation of a Certificate of Higher Studies (CES) in neuropsychiatry was decreed in 1949. In 1968, in accordance with the work of Henri Ey, it was proposed that neuropsychiatry be divided into two distinct CESs: neurology and psychiatry. This governmental decision was taken in a very particular context, that of the social upheaval and demonstrations of May 1968, which culminated in numerous demands and various reforms. The evolution of these two fields in France took a different path from that of Germany and the countries under its influence. In America, which is a mixture of cultures, there has been a development that could be considered to be a hybrid progression that was alternately in step with the French and at times more linked to Germany. We evoke the particular case of Jean Lhermitte. In recent years, many psychiatrists and neurologists, of all generations, have expressed the desire for a new reconciliation of these two specialties.     

Neuropathology in Pitié-Salpêtrière hospital: Past,present and prospect

Pitié and La Salpêtrière, both founded in the17th century, were for long two distinct hospitals until they merged in 1964. The name La Salpêtrière is inherited from the initial purpose of the buildings designed to produce saltpeter for gun powder. But the place was soon transformed into an asylum to shelter the poor and the insane. From the care of this underprivileged population, alienists such as Pinel have paved the way for modern medicine for the mentally ill at the time of the French Revolution. In the second half of the 19th century, Jean-Martin Charcot and his students laid the foundations of modern neurology from the observation of the large population hosted in La Salpêtrière, mostly women with severe chronic diseases. Charcot led clinicopathological studies in almost all the fields of nervous system disorders. His successors (including Raymond, Dejerine, Pierre Marie) maintained the same close relationship between clinical neurology and neuropathology. In parallel with the development of neurosurgery at Pitié hospital, neuropathology first spread through small laboratories attached to clinical departments. The merger of the two hospitals in the early '60s coincided with the creation of a large university hospital in which the care and study of diseases of the nervous system were preponderant. An independent laboratory of neuropathology was created, led by Raymond Escourolle. This period was on the eve of important developments in neuroscience around the world. Today, the Pitié-Salpêtrière neuropathology laboratory still plays a central role between neurology and neurosurgery clinics and major research institutes such as the Brain Institute, callled Institut du Cerveau et de la Moelle (ICM), and the Institute of Myology.     

The impossible succession of Charcot - the quest for a suitable heir

With the death of Jean-Martin Charcot (1825-1893) in 1893 came the impossible task of finding a suitable successor. The clinical chair for nervous system diseases was temporarily entrusted to édouard Brissaud (1852-1909). There were a number of potential successors, but only three were officially declared: Brissaud, Jules Déjerine (1849-1917) and Fulgence Raymond (1844-1910). In the final vote, Raymond was appointed as Charcot's successor. Although this succession would prove too great a challenge for him, Raymond's work in neurology, which is often unrecognised, made him one of the most important French neurologists of the early 20th century.     

The Salpêtrière in the wake of Charcot's death

After Charcot died in 1893, the students of his immediate circle did not fare well academically in the French medical system. Fatigue and bitterness toward the authoritarian Charcot may have contributed to the change in the scientific and social ambience of the Salpêtrière of Paris in the generation after Charcot died. Clearly, however, the faculty were not invested in energetically overturning the system that Charcot had established, and their choice of Fulgence Raymond as Charcot's successor was an effective means of permitting a passive waning in the Salpêtrière's magnetic influence in world neurology.     

François-Amilcar Aran (1817–1861) and the recognition of spinal muscular atrophy

Jean-Martin Charcot coined the term Duchenne-Aran atrophy. The inversion of names compared to standard practice shows the respect Charcot had for Guillaume Duchenne de Boulogne, who had encouraged him to study nervous disease. Using innovative localised electrification, Duchenne identified various types of muscular atrophy which he distinguished from paralysis. But it was François-Amilcar Aran who, published the observations that he had compiled and studied with Duchenne's help first in 1848 and again in 1850. The result was the seminal articles that led to the eponym “Aran-Duchenne hand”. Focusing on the second half of the nineteenth century in Paris, this article will explore how knowledge evolved around the nosography of different types of muscular atrophy, starting with Duchenne and Aran and then with Charcot and his students, notably Albert Gombault, Joseph Babiński, Fulgence Raymond, and Jean-Baptiste Charcot. This historical overview is accompanied by a biographical account aimed at rescuing Aran from the sea of oblivion and covering the other subjects he wrote about, especially in neurology: including cerebral hydatid disease, skull base fractures and “cancer of the dura mater”.     

Charcot and the myth of misogyny.

OBJECTIVE: To evaluate Jean-Martin Charcot's attitudes toward women and evaluate contemporary and modern accusations of misogyny. BACKGROUND: During the last quarter of the nineteenth century, issues of women's health and feminism became increasingly a medical and political priority. Early neurologists, and specifically Charcot, have been criticized for retarding the advancement of women, but the issue has never been studied in detail. METHODS: Review of original documents from the Bibliothèque Charcot, archives of the Sorrel-Dejerine and Leguay families, and materials from the Académie de Médecine, Paris. RESULTS: Several lines of evidence demonstrate that Charcot, although highly authoritarian and patronizing toward patients and colleagues in general, fostered the concepts of advancing women in the medical profession and eliminating former gender biases in neurologic disorders. The first woman extern in Paris, Blanche Edwards, worked directly under Charcot, and he later became her thesis advisor. When women lobbied for entrance rights to the intern competition, Charcot was one of the few professors to sign the original petition of support. Charcot worked extensively with hysteria and female patients, although he energetically rejected the idea that the disorder was restricted to women. He categorically deplored ovariectomy as a treatment for women with hysteria. His most important scientific contribution in the study of hysteria was his identification of the disorder in men. CONCLUSIONS: Although overtly apolitical throughout his life and certainly not a feminist in the modern definition of the term, Charcot worked to incorporate women professionally into neurology, advanced areas of women's health through his long-term commitment to work in a largely women's hospital (the Salpêtrière), and dispelled the prejudice that hysteria was a woman's malady.     

Allbutt of Leeds and Duchenne de Boulogne: Newly discovered insights on Duchenne by a British neuropsychiatrist

It is well-established that Guillaume-Benjamin-Amand Duchenne de Boulogne (1806–1875), and Jean-Martin Charcot (1825–1893) were the founding fathers of Parisian and French neurology during the second half of the 19th century, although much more is known about Charcot than about his “master” Duchenne. In Britain, Thomas Clifford Allbutt (1836–1925) was Leeds’ most distinguished physician of the 19th century, eventually becoming Regius Professor of Physic at Cambridge. Allbutt's 1860–1861 year of postgraduate study in Paris and his friendship with Duchenne profoundly influenced his own contributions to nervous system and mental diseases, partly in collaboration with his colleague James Crichton-Browne (1840–1938) at the nearby West Riding Lunatic Asylum in Wakefield, Yorkshire. The present report briefly recalls the careers of Duchenne and Allbutt, and also presents a unique account by Allbutt of Duchenne in action at the height of his powers, investigating and defining the previously uncharted field of neuromuscular diseases with the aid of his localized electrization techniques. This account is discussed in relation to: Duchenne's personality and pioneering neurological achievements; the origins of French neurology; and the development of Anglo–French neurological relationships during the 19th century. Interestingly, both Duchenne and Crichton-Browne separately made important and much-appreciated contributions to the third major book by Charles Darwin (1809–1882), The Expression of the Emotions in Man and Animals, published in 1872.     

Aphasia: debates]

Quarrels over aphasia are no recent phenomena and have not always been explicit. Lordat and Gall can be cited in this respect as well as Dax and Bouillaud. Reference is also made to Broca-Dax and Trousseau-Lordat. The creation of the Chair in honour of Charcot, which contributed so greatly (thanks to Charcot himself, the others Masters and their students) to the birth of neurology, then to that of the neurological sciences and eventually to that of the neurocognitive sciences. Next, the most explicit of quarrels on aphasia is dealt with, namely that in which, during three meetings of the French Society of Neurology in 1908, Joseph Jules Dejerine and Pierre Marie crossed swords. Their duel in the Bois de Boulogne in 1893 having fortunately been cancelled, it was in 1908 merely a battle of words. Fulgence Raymond was soon to retire. Dejerine and Pierre Marie each put forward their proposal to the Society for a discussion program and Dejerine's was accepted following a vote. The meeting on 11th June, in accordance with the program proposed by Dejerine, was largely restricted to clinical facts. Fulgence Raymond was not present. Dejerine always spoke first, but some of the replies from Pierre Marie received a degree of approval from the audience. It was during this meeting that Achille Souques, the future founder of the history of neurology, cleverly defended the ideas of Pierre Marie. A little later, Dejerine went on the defensive and agreed to a change in the program along the lines suggested by Pierre Marie: he then presented his ideas on the manifest clinical difference between Broca's aphasia and that of Wernicke. After Souques, Edouard Brissaud also came to the rescue of Pierre Marie by mentioning the Leborgne case published by Broca in the spring 1861. Matters were unresolved and André-Thomas, the future founder of neuropaediatrics, produced a highly intelligent deference of his Master Dejerine. Gilbert Ballet and Ernest Dupré also came down largely on his side. The meeting of 9th July (27th anniversary of the Charcot Chair) was dedicated to cerebral anatomy and the "quadrilateral". The subject of Dejerine's questionnaire was again raised. Accompanied by Georges Guillain, Fulgence Raymond was present on this occasion (but refrained from speaking). This time the star was Augusta Dejerine Klumpke, born on a Spanish sand dune now known as San Francisco, U.S.A. Mrs Dejerine contested the "lenticular zone" and gave it a quite different dimension by proving that its anterodorsal part included associative axons originating in or projecting to Broca's area, the remainder of the "Pierre Marie quadrilateral" being called into question. Brissaud was impressed by the performance of Madame Dejerine, and Pierre Marie found himself in an awkward position. His student Fran?ois Moutier, present at his request, discussed his own clinical cases and then, on the subject of "Lelong's" brain' (autumn 1861), let it be known that Broca had scratched it with his finger nails while removing the meninges. André-Thomas and Georges Guillain took part in the discussion. At the last meeting, on 23rd July, Brissaud was absent. Fulgence Raymond was again present but remained silent. The only subject on the agenda was "physiological pathology", but several points that had not been resolved on the 9th July were brought up again. On this occasion, Pierre Marie opened the debate and adopted a very cautious approach. However, his patience eventually ran out and he replied sharply to the comments of Dejerine on "images of language" and those of Dupré on "mental representations". Metaphorically speaking, it might be said that the gold medal was not awarded, Augusta Dejerine Klumpke took the silver, Dupré and André-Thomas shared the bronze, and Souques and Moutier each deserved a special mention. It might also be suggested that in 1908 the Society sketched out to a large extent the programme for research on aphasia for the century to come. (ABSTRACT TRUNCATE     

Marguerite Bottard (1822-1906), nurse under Jean-Martin Charcot, portrayed by G. Gilles de la Tourette

Hospitals in Paris underwent considerable change at the end of the 19th century. As they moved from providing accommodation to care, their mission shifted from helping to healing. The glorification of scientific progress, as opposed to religious obscurantism, affected all of French 'Republican' society, in particular a significant part of the medical profession, led by figures such as D.M. Bourneville, former interne (house officer) under J.M. Charcot and also his publisher. Bourneville helped bring about the creation of nursing schools and the gradual replacement of religious orders by educated secular nurses. Marguerite Bottard, Charcot's chief nurse made famous by A. Brouillet's painting 'Une le?on clinique à La Salpêtrière', would be glorified and decorated as a model for this movement. A letter by G. Gilles de la Tourette to Charcot's successor F. Raymond, never before published, illustrates this progressive current of thought and revisits the struggle to secularise hospitals under the Third Republic in France. At the same time, it renews interest in the exemplary career of a nurse whose name was recently given to a building at La Salpêtrière Hospital.     

Charcot and Babinski: beyond a simple teacher-student relationship

Jean-Martin Charcot (1825-1893) is now considered to be the father of clinical neurology in France. He trained a generation of eminent neurologists, among them Joseph Babinski, with whom he had a special relationship. Babinski was undoubtedly Charcot's favorite pupil and they enjoyed an excellent collaboration at la Salpétrière. Even though both men felt tremendous respect for each other, it is sad that this relationship may, in one instance, have been detrimental to Babinski. This is probably the reason why Bouchard denied him full professorship, a decision with eventual consequences for both men. In spite of this, the neurologist of Polish origin held his master in tremendous admiration, even as he pursued Charcot's research on hysteria after his death. Even though Babinski eventually contradicted his master on many fundamental issues, it did not affect his devotion to him. The relationship between the two men can be considered as more than a simple relationship between a teacher and his pupil and may be compared to a father-son relationship, which is a reminder of the original model of Hippocratic teaching.