Jean-Martin Charcot's lessons on Parkinson's disease

Abstract

James Parkinson's 1817 seminal article was unknown in France until 1861, when Jean-Martin Charcot and his friend Alfred Vulpian published the first clinical description in French of paralysis agitans . The pedagogical aims of this work are evident in its organization. The first chapter, “Symptoms, progression, prognosis” is a detailed discussion of shaking, “the feeling of muscular rigidity”, “irresistible propulsion” and slowness of speech despite “very clear and accurate comprehension”. However, “later on, generally the psychic faculties decline significantly”. The prognosis “is very sad” due to “weakening and, above all, loss of mobility resulting from paralysis, as well as deterioration of the memory and intelligence (which) demonstrates that damage caused by the disease is increasingly profound”. In 1868, Desire-Magloire Bourneville (1840–1909) transcribed, in the Gazette des Hopitaux civils et militaires, Charcot's lesson on the differential diagnoses of paralysis agitans and multiple sclerosis , later republished in Charcot's lessons book in 1872. From his earliest days at La Salpetriere and throughout his career, Charcot delegated some of his work to successive internes and his favorite students. Their theses, whether or not he was part of the defence jury, always gave an overview of the Master's research, who used that practice to disseminate his own discoveries. For example, Leopold Ordenstein (1835–1902) defended his thesis, “Sur la paralysie agitante et la sclerose en plaques generalisee”, on 17 December 1867. As Charcot himself recalled, “If I am not mistaken, I indicated the delineation between these two conditions for the first time, as noted in the thesis of Mr. Ordenstein”. Albert Boucher (1852–?) defended his own thesis, entitled “Parkinson's disease (paralysis agitans), in particular its mild form”, on 28 February 1877. Through this work, Charcot wanted to make non-shaking forms more widely known: Boucher insisted on “rigidity” and on Charcot's intelligent addition of this clinical sign that Parkinson had overlooked. For Charcot, by the beginning of the 1880s, the clinical signs for diagnosing Parkinson's disease, its various presentations and different patterns of progression were considered established. However, the causes of the disease remained unknown. The results of pathological–anatomical examinations were contradictory, and none of them were convincing. Charcot asked two of his externes (medical students), Paul-Desire Leroux (1851–?) in 1880, then Gaston Lhirondel (1855–?) three years later, to compile observations from the Clinic of Nervous Diseases to demonstrate the role of heredity . As Sigmund Freud (1856–1939) wrote in a posthumous homage: “It will undoubtedly soon be necessary to review and correct the aetiological 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 aetiological role of heredity that no place remained for other neuropathic aetiologies”. During the 31 January 1888 lesson, Charcot presented a portrait of the patient referred to as “Bachere, aged 31“, which was his own drawing of the inexpressive facies of Bachere to emphasize to his audience the characteristic hypomimia and to show how to distinguish contractions of paralysis agitans from those of hemiplegia . However, there is no doubt that Paul Richer (1849–1933) was the interne who did the most to help Charcot develop the visual teaching materials that enriched his lessons and publications. As part of the work completed in December 1888 for La Nouvelle Iconographie de La Salpetriere, Richer made his own drawings of Bachere to illustrate “what could be called the artistic side of Parkinson's disease”. He emphasized the facial expression, which he wanted to depict as accurately as possible: “The raised eyebrows and the exclusively transversal wrinkles make the expression one of surprise […] Between this forehead, expressive or wrinkled transversely and vertically, and the rest of the impassive face, we have the fixed and immobile eyes that are wide open, with a near absence of blinking; these are the fundamental elements of this strange and striking mask”. The master also gave Richer the idea to make a statue of a patient affected with the disease ( Fig. 1 ). Charcot died on 16 August 1893 and never saw the statue, which Richer did not finish until 1895. It was Charcot's successor, Fulgence Raymond (1844–1910), who used the statue for his lessons. Richer was able to render with amazing precision how “the brachioradialis [long supinator] of the forearm protrudes in a characteristic way. In the normal state, this muscle is never observed to contract for simple elbow flexion . Its rope-like, visual protrusion is almost important enough to be pathognomonic”. This historical overview of Charcot's isolation of Parkinson's disease not only demonstrates his clinical skills, but also shows the many ways in which he excelled as a teacher.