Jean-Martin Charcot

Born 1825-11-29
Died 1893-08-16

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French neurologist, born November 29, 1825 Paris; died August 16, 1893, Lac des Settons, Nièvre.

Biography of Jean-Martin Charcot

Charcot was one of a select group of physicians who made the Salpêtrière hospital in Paris a world medical centre, founding the famous neurological clinique there. He is considered the founder of modern neurology, and is remembered as the first professor of neurology. His name is associated with at least 15 medical eponyms, of which the most known is Charcot-Marie-Tooth disease. Another is amyotrophic lateral sclerosis, in America particularly known as Lou Gehrig’s disease.

Jean Martin Charcot was born in Paris in 1825, the son and grandson of a coach-builder. The family originally came from Champagne. In childhood he manifested a taciturn personality which persisted throughout his life, and while still a boy demonstrated an early interest in medicine, but was no less interested in drawing and painting which taught him the importance of making careful observations - from which he was later to benefit greatly, both as a teacher and a scientist.

Charcot at an early age decided upon a career in medicine. He qualified in 1853, at the age of 23, and gained a junior post at the Salpêtrière. He became interne des hôpitaux in 1848 and was appointed chef de clinique in 1853, after defending an outstanding doctoral thesis on gout and chronic rheumatism (arthritis nodosa), in which he differentiated gout from other forms of chronic rheumatism He became médecin des hôpitaux de Paris (Bureau Central des hôpitaux de Paris) in 1856.

No gunpowder plot, just nerves
In 1862, at the age of 37 years Charcot was appointed senior physician at the Salpêtrière. This famous hospital on the left bank of the Seine is frequently mentioned in the history of great physicians. Among Charcot's predecessors here were Léon Jean Baptiste Cruveilhier (1791-1874) and Ernest-Charles Lasègue (1816-1883), but it was under the carismatic leadership of Charcot that classic French neurology was founded.

The name Salpêtrière dates back to the time when the building was the arsenal and gunpowder store of Louis XIII. Now it was a hospice for more than 5000 indigent patients. Charcot life's work revolved around the diagnosis and classification of these patients, and he gave definitive descriptions of numerous disorders, correlating their clinical and pathological findings. From 1862 he was active in the women’s clinic at the Salpêtrière. Between 1866 and 1878 he gave regular annual lectures on chronic diseases, diseases of old age and, in particular, on diseases of the nervous system.

Charcot became professeur agrégé in 1860.

War and peace
Charcots work was temporarily interrupted during the Franco-Prussian war of 1870-1871. He was forced to send his family to England and, in 1871, following the war and the strife engendered by the Commune of Paris, occupied himself with epidemics of typhoid and smallpox.

Thereafter his interest moved to hysteria and he advanced the revolutionary concept that affected persons had diseases of the brain which were functional rather than structural; in this respect he is regarded as a founder of the science of psycopathology.

Charcot's career prospered and he was made professor of pathological anatomy at the Faculty of Medicine at the University of Paris in 1872, and in 1882 was appointed to the first chair of neurology, established especially for him, as professor of diseases of the nervous system. This year, at the Salpêtrière, he opened what was to become the greatest neurological clinic of his time in Europe.

During this period Charcot published a series of memoirs that attracted wide attention among neurologists. He also practiced extensively the clinical-anatomical method that correlated the symptoms observed in the sick patient and the lesions discovered at the time of autopsy. Through these he proved that the cells of the dorsal horn of the spinal cord possesses certain trophic properties and then analyzed the lesions found in theses cells as a result of infantile paralysis. In collaboration with Charles-Joseph Bouchard (1837-1915) he studied the secondary degeneration of the spinal cord.

Farewell to hysteria
Jean-Martin Charcot vigorously supported and defended the theory of cerebral localizations in man; several of his outstanding courses dealt with this theory and its application to Jacksonian epilepsy (John Hughlings Jackson, 1835-1911), aphasia, and Beard’s neurasthenia (George Miller Beard, 1839-1883). In 1872 he initiated work on hysteria and hysterical hemianesthesia, and on the link between traumatism and local hysteria. Indeed, Charcot must be considered as one of the first to demonstrate the clear and fruitful relationship between psychology and physiology.

Charcot, thought he had discovered a new disease he called "hystero-epilepsy," a disorder of mind and brain combining features of hysteria and epilepsy. The patients displayed a variety of symptoms, including convulsions, contortions, fainting, and transient impairment of consciousness.

Joseph Babinski, his student, however, decided that Charcot had invented rather than discovered hystero-epilepsy. The patients had come to the hospital with vague complaints of distress and demoralization. Charcot had persuaded them that they were victims of hystero-epilepsy and should join the others under his care. Charcot's interest in their problems, the encouragement of attendants, and the example of others on the same ward prompted patients to accept Charcot's view of them and eventually to display the expected symptoms. These symptoms resembled epilepsy, Babinski believed, because of a municipal decision to house epileptic and hysterical patients together (both having "episodic" conditions). The hysterical patients, already vulnerable to suggestion and persuasion, were continually subjected to life on the ward and to Charcot's neuropsychiatric examinations. They began to imitate the epileptic attacks they repeatedly witnessed.

Babinski eventually won the argument. In fact, he persuaded Charcot that doctors can induce a variety of physical and mental disorders, especially in young, inexperienced, emotionally troubled women. There was no "hystero-epilepsy." These patients were afflicted not by a disease but by an idea. With this understanding, Charcot and Babinski devised a two-stage treatment consisting of isolation and counter suggestion.

First, "hystero-epileptic" patients were transferred to the general wards of the hospital and kept apart from one another. Thus they were separated from everyone else who was behaving in the same way and also from staff members who had been induced by sympathy or investigatory zeal to show great interest in the symptoms. The success of this first step was remarkable. Babinski and Charcot were reminded of the rare but impressive epidemic of fainting, convulsions, and wild screaming in convents and boarding schools that ended when the group of afflicted persons was broken up and scattered.

The second step, countersuggestion, was designed to give the patients a view of themselves that would persuade them to abandon their symptoms. Dramatic countersuggestions, such as electrical stimulation of "paralyzed" muscles, proved to be unreliable. The most effective technique was simply ignoring the hysterical behavior and concentrating on the present circumstances of these patients. They were suffering from many forms of stress, including sexual feelings and traumas, economic fears, religious conflicts, and a conviction (perhaps correct) that they were being exploited or neglected by their families. In some cases their distress had been provoked by a mental or physical illness. The hysterical symptoms obscured the underlying emotional conflicts and traumas. How trivial a sexual fear seemed to a patient in whom convulsive attacks produced paralysis and temporary blindness every day!

Staff members expressed their withdrawal of interest in hysterical behavior subtly, in such words as, "You're in recovery now and we will give you some physiotherapy, but let us concentrate on the home situation that may have brought this on." These face-saving countersuggestions reduced a patient's need to go on producing hysteroepileptic symptoms in order to certify that her problems were real. The symptoms then gradually withered from lack of nourishing attention. Patients began to take a more coherent and disciplined approach to their problems and found a resolution more appropriate than hysterical displays.

Charcot removed his patients from the special wards when he realised what he had been inventing.

The great teacher
It was perhaps his incomparable qualities as teacher, writer and organizer that contributed most to the great reputation of this gifted clinician. As a teacher he was not afraid of employing theatrical techniques during his lecture-demonstrations on a floodlit stage in the amphitheatre of the Salpêtrière. As a lecturer he spoke rather slowly and articulated, often staying quiet for several minutes while observing the patient being demonstrated to the auditorium. The discussion of the neurologal status progressed during minutious observations of the patient's physical signs. On tuesday mornings he held his famous clinical demonstrations, and, on fridays, his well prepared and repeated lectures connected to clinical cases.

Charcot's experiments in hypnosis and his clinical demonstrations were open to the lay public, attracting the famous, the fashionable, and the aristocratic. At this stage of his career he was known as the "Caesar of the Salpêtrière". Among his students were Pierre Marie, Joseph Jules Babinski, Wladimir Michailowich Bekhterev, Desiré-Magloire Bourneville, and George Albert Edouard Brutus Gilles de la Tourette. In 1885 one of his students was Sigmund Freud, and it was Charcot's employment of hypnosis in an attempt to discover an organic basis for hysteria that stimulated Freud's interest in the psychological origins of neurosis.

Axel Munthe on Jean-Martin Charcot
In his book on San Michele Axel Munthe describes daily life and the athmosphere at La Salpêtrière. In it, Munthe is highly critical of Charcot's theories of hypnotism and his treatment of conditons of hysteric conversions. Munthe declares Charcot's famous "Leçons du Mardi" at the Salpêtrière as a confused mixture of truth and fraud". He considered the hysteric female patients to be "pure impostors knowing what was expected of them and delighted to demonstrate their skills to the public".

Munthe also describes Charcot as a person: "Short, with the chest of an athlet and the neck of a bull, he was an impressing appearance. A pale, smoothly shaved face, a low forehead, cold, piercing eyes, aquiline nose, sensitive lips: the mask of a Roman Caesar. Charcot was also a rather charismatic character, but Munthe believed him to be callous and indifferent to the sufferings of his patients. Both his appearance and his personality, however, must have been inspiring confidence in his patients, as he had an enormous practice.

During his visit at the Salpêtrière Munthe happened to interfere in the treatment of one of Charcot's favourite patients, causing his fall from grace and eventually being fired from his position.

Subsequent readers may accept parts of Munthe's critisism of the methods of treatment at the Salpêtrière. This does not, however, diminish Charcot's importance as a clinician. It is worth reminding that he was able to distinguish between conditions of neurological disease, although methods for testing muscular reflexes were still not available.

A hard working artist with no dog clinic
Charcot was very hard-working: "he worked uninterruptedly all day, and the lamp on the desk in his large library was still to be seen burning at two o'clock in the night. His only leisurely pleasure was music, Ludvig van Beethoven being his favourite composer. On his Thursday evenings, which were devoted entirely to music, nobody was allowed to utter a single word on medicine."

Charcot was also a talented artist and a great lover of animals, always avoiding experiments on animals. He had inscribed on his door: "Vous ne trouverez pas une clinique des chiens chez moi" (you find no dog clinic with me). Every morning when he stepped out of his landauer in the inner yard of the Salpêtrière, he took a piece of bread from his pocket and and gave it to his two Rosinantes. He interrupted all conversations on hunting, and his antipathy against Englishmen was probably caused by his disgust of fox hunting.

Later years
Charcot was disturbed by the idea of disease running in families and when speaking of such conditions he would repeat the quotation "What have we done, Oh Zeus, to deserve this destiny? Our fathers were wanting but we, what have we done?"

The famous Charcot had preferred to see his favourite pupil, Joseph Babinsky, succeed him in the chair of neurology. Babinsky, however, was outmaneuvered through academic intrigue, and the chair thus was given to Fulgence Raymond (1844-1910), a somewhat distinguished neurologist, also of eponymic fame, but a man of much lesser format than Babinski.

From 1890 Charcot's health began to deteriorate. He had several attacks of angina and died suddenly from pulmonary oedema in 1893, during a journey in the Morvan, at the age of 68 years. His funeral service was held in the Chapel of the Salpêtrière and he was buried at the Montmartre churchyard. Beside him rests his son, Jean Baptiste, also a physician, and a well known scientific traveller.

Charcot's tremendous influence as a founder of neurology was recognised after his death by the erection of his bronze statue at the Salpêtrière. Regrettably it was destroyed in 1942 during the Nazi occupation of Paris.

Charcot was an officer of the Légion d’Honneur, vice president of the Société de biologie from 1860, honorary member of the Société anatomique (of which he became president in 1872) from 1882, member of the Académie de médecine from 1872, member of the Académie des sciences (elected with 46 against 12 votes) from November 12, 1883. He was created doctor of honour at the University of Würzburg in 1882 on the occasion of its 300th anniversary. He left a very great number of publications.

Just work, dear maid
In his immensely productive period between 1862 and 1870 Charcot gave a series of masterly clinical descriptions. He elucidated the adult progressive neuromuscular atrophy described by Guillaume Benjamin Amand Duchenne de Boulogne (1806-1875) in 1849 and François-Amilcar Aran (1817-1861) in 1850, demonstrating that the disease could also attack the lateral strings of the spinal marrow. In the same period he described a severe complication in with tabes dorsalis, known as Charcot's joints. He gave clinical-anatomical description of multiple sclerosis unequelled to his day. Charcot's triade classically comprises nystagmys, intention tremor and scandering speech. Among his other important contributions were clinical-pathological localisations of lesions to the spinal marrow.

Charcot recognised disseminated sclerosis as a distinct disease and was the first to diagose it on a living patient - previously it had been confused with Parkinsonism. Being a pragmatic, Charcot employed a housemaid with disseminated sclerosis in order to facilitate continuous close scrutiny. He noticed that her tremor was intentional and not static, and kept her employed until she had to be admitted to the the Salpêtrière, where his clinical diagnosis of disseminated sclerosis was confirmed at autopsy.

Charcot localised the motor centres of the cerebral cortex, he was the first to describe syphillitic and amyotrphic lateral sclerosis, and with Vulpian, first described ankle clonus. He is credited introducing geriatics as a separate educational specialty and in 1859 was among the first to recognise intermittent claudication. Besides having made excellent descriptions of neurological diseases, Charcot also made valuable contributions to the understanding of the pathology of the liver, kidneys and the organs of the chest, as well as the nature of tuberculosis and rheumatism. He is also famous for the investigations into the V. B. Burq’s (1823-1884) metaloscopy and metalltotherapy.

Charcot was one of the «grandes gloires» of the French nation, elevating its scientific medicine to a level it had not seen for one or two decades. In his capacity as pioneering representative of moderne nervous pathology, he gave numerous important contributions to medical science.

Charcot was a formidable writer, the author of many articles and books. He founded the journal Archives de neurologie, which he edited until his death.

"Vous ne trouveres pas une clinique des chiens chez moi".
"You find no dog clinic with me".

"Six mois, un an après début, tous les symptômes se son accumulés et plus ou moins fortement accentués. La mort arrive au bout de deux ou trois ans en moyenne par le fait des symptômes bulbaires." Charcot in his lecture summarizing his observations
concerning the disease which he called
amyotrophic lateral sclerosis; May 18, 1874.

«Clinical medicine is made up of anomalies, while nosography is the description of phenomena that occur regularly. What we look for in the clinics is almost always exceptional; what we study in nosography is the rule. It is well to know that, in the practice of medicine, a nosographer is not always a clinician.»

«To learn how to treat a disease, one must learn how to recognize it. The diagnosis is the best trump in the scheme of treatment.»

«Disease is very old, and nothing about it has changed. It is we who change, as we learn to recognize what was formerly imperceptible.» De l’expectation en médecine.

«Why do we have to go over the same set of symptoms twenty times before we understand them? Why does the first statement of a new fact always leave us cold? Because our minds have to take in something which deranges our original set of ideas, but we are all like that in this miserable world.»

«It is the mind which is really alive and sees things, yet it hardly sees anything without preliminary instruction.»

«If the clinician, as observer wishes to see things as they really are, he must make a tabula rasa of his mind and procees without any preconceived notions whatever.»

«In the last analysis, we see only what we are ready to see, what we have been taught to see. We eliminate and ignore everything that is not a part of our prejudices.»

«How is that, one fine morning, Duchenne discovered a disease which probably existed in the time of Hoppocrates?»

«In dealing with a nervous patient, you should regard the malady before you merely as an episode. Thus, in a case of chorea, it is only necessary to inquire how long it has existed. The condition of the patient is only an accident in the history of the disease, just as each of us is only an accident in the history of humanity. De l’expectation en médecine

«Common-place scepticism, which is so readily opposed to all progress of the human mind, is a convenient pillow for lazy heads; but in this epoch there is no longer time to go to sleep.»
Lecons cliniques sur les maladies des vieillards et les maladies chroniques.
Introduction, Sect. 5.

«Symptoms then, are in reality nothing but the cry from suffering organs.»
Leçons cliniques sur les maladies des vieillards et les maladies chroniques.
Introduction, Sect. 1.

«In medicine . . . one never sees even the most stoic intellects limit themselves to stating the facts without looking for a way to relate them by some sort of theory: from the outset, one sees minds occupied more with the subjective relationships of things than with their reality itself; the empirical results of observation, scarcely acquired, are brought together, tested one against the other, to evolve thories or systems. There, one must recognize, is a necessity of the human mind.»
Leçons cliniques sur les maladies des vieillards et les maladies chroniques.
Introduction.

«There is, in any well executed description of disease, a remarkable power of transmission. If made at the right time, it will penetrate even the least prepared minds. What had hitherto remained in the womb of nothingness has begun to live. A description of a hitherto unknown species of disease is an event, a very great event, in pathology.»
Quoted by F. H. Garrison in Bulletin of New York Academy of Medicine, 1928; 4: 1000.

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