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The Legacy of Jean-Martin Charcot

2000; American Medical Association; Volume: 124; Issue: 1 Linguagem: Inglês

10.5858/2000-124-0010-tlojmc

1543-2165

Venita Jay,

Historical and Scientific Studies

It has been said of Jean-Martin Charcot that he entered neurology in its infancy and left it at its coming of age, largely nourished by his own contributions. Dubbed the "Caesar of Salpêtrière," Charcot's life story is inseparable from the story of the Salpêtrière and the greatest century of Parisian medicine.Charcot (1825–1893) was born in Paris on November 29, 1825, to a carriage builder of modest means. He and his 3 brothers went to school with the understanding that the one with the best grades would pursue a learned profession. The winner was Jean-Martin, who chose the path of medicine. As a youth, Charcot was introspective and liked to read and draw. He also developed a keen sense of observation. These childhood traits would persist in later life, empowering Charcot as an astute clinician and effective teacher.In 1848, at the age of 23 years, Charcot successfully completed competitive examinations for a hospital internship and became an intern at the Hôpitaux de Paris at the Salpêtrière. He was fortunate to have Pierre Rayer, the dean of the faculty of medicine and physician to Emperor Napoleon III, as his mentor and teacher.In 1853, Charcot successfully defended his doctoral thesis, presenting original work to differentiate the symptoms of gout from chronic rheumatism. Shortly afterwards, he became chief of clinic in the faculty of medicine and set up a small private practice. Charcot was appointed "physician to the hospitals of Paris" in 1856, and in 1860, he secured the title of Professeur agrégé.The turning point in Parisian medicine and in Charcot's medical career came when he was appointed to the Salpêtrière as physician in 1862. He would spend the rest of his professional life at this great institution. The Salpêtrière (derived from saltpeter, the principal ingredient of gunpowder) was constructed as Louis XIII's gunpowder arsenal on the Left Bank of the Seine in the 16th century. In 1656, it was amalgamated with other hospitals as an asylum for beggars, prostitutes, the aged, feeble, and the insane, with the Salpêtrière designated primarily for women and prostitutes. With the construction of new buildings in 1680, the Salpêtrière became the largest asylum in Europe. In the 18th century, it was transformed into a hospital with an officially appointed medical staff.When Charcot walked into Salpêtrière, it was a great asylum of human misery but a source of case material that was unique in the history of neurology. With some 5000 inhabitants, of whom nearly 3000 suffered from neurologic disease or epilepsy, Salpêtrière was a veritable gold mine of untapped clinical material for neurologic and psychiatric studies. Charcot's first step was to set up a pathology laboratory in a dimly lit room. He reorganized the clinical service, introducing ophthalmoscopy, photography, and microscopy.Charcot's interest in neurology was probably inspired by Duchenne, for whom he had the highest regard. Charcot invoked the assistance of his colleague Alfred Vulpian to bring order out of the chaos at Salpêtrière. Together, they surveyed patients systematically, classifying their neurologic disorders and cataloging them into distinct types.In July 1881, the French Parliament established a sum of 200 000 francs for the establishment of a new clinical chair in diseases of the nervous system, designed specifically for Charcot. Neurology as a specialty was formally initiated in 1882, when Charcot took up the position, establishing Salpêtrière as a premier institution dedicated to the treatment of diseases of the nervous system. Charcot had all the prerequisites of an excellent chief—he was a clinician of extraordinary ability who was passionately devoted to teaching and dedicated to research.In his teaching sessions, Charcot would mimic the clinical signs of certain diseases—the asymmetry of the face in facial paralysis, the rigidity of Parkinson disease, and various types of tics, spasms, postures, and gaits. The lectures were carefully prepared and the delivery was dramatic. Charcot, with a bearing reminiscent of Napoleon, would stand beside a patient in a 600-seat amphitheater filled to capacity, with floodlights on the stage, and demonstrate each clinical sign to the spellbound audience, including many international visitors. He stressed the paramount importance of observation, exemplified in the "mysterious silence of Charcot"—where he would subject his patients to a slow, systematic scrutiny for several minutes without saying a word. Charcot devised the "anatomoclinical" method of teaching and the concept of localization, leading his students from 1 salient point of the case to another, using colored chalk drawings to illustrate the lesion. Art and illustration became a pivotal tool in stressing his anatomoclinical method—the artist in Charcot rapidly communicated a patient's changing neurologic state with sketches and drawings. The art of photography, introduced to him by Duchenne, was also extensively used by Charcot to capture changes in a patient's neurologic status.Charcot's earlier studies had focused on a variety of topics such as gout, rheumatism, goiter, claudication, decubitus ulcers, pulmonary disease, and diseases of the aged. His description of "Charcot-Leyden crystals" came early in his career in 2 reports published in 1853 and 1860. But Charcot's greatest legacy was to the discipline of neurology, with an exhaustive list of contributions, some of which are enumerated below. Examples of his acclaimed work include pathology of poliomyelitis, clinical diagnosis of multiple sclerosis during life, vascular pathology in the brain in hypertension, establishment of amyotrophic lateral sclerosis as a distinct entity, work on localization of function in the brain and spinal cord, the basis of hysteria, tabes dorsalis and tabetic arthropathy (Charcot joints), bulbar paralysis, neuroses, peroneal muscular atrophy (Charcot-Marie-Tooth disease), as well as excursions into hypnotism. Charcot and his pupil, Charles Bouchard, put forth the hypothesis that apoplectic hemorrhages were due to "miliary aneurysms," minute dilatations on cerebral vessels.Charcot became a legend in his own lifetime and was elected to several major medical and neurologic societies in Europe and accorded many honors. He loved music and painting and read Shakespeare as well as Greek and Latin classics. He died unexpectedly of a coronary thrombosis in 1893.Before Charcot, there had been no attempt at a systematic classification of neurologic diseases. Few men left such an enduring and lasting impression on medicine and neurology.