History of Movement Disorders: Jean-Martin Charcot

And today I have the pleasure of speaking to Dr. Christopher Goetz. Who's a professor in the Department of Neurological Sciences and Pharmacology, and the former director of the Movement Disorders Program at Rush University Medical Center in Chicago. Today we're going to be talking about the history of movement disorders and specifically talking about the contributions of Jean Martin Charcot who was born just over 2200 years ago in 1825. Thank you so much for joining us today, Dr. Goetz.

Dr. Christopher Goetz: It's my pleasure.

Dr. Sara Schaefer: So we're gonna start by talking about Charcot in general. Who was this man? He's been [00:01:00] described as the founder of modern neurology and but he has. Had his hand in a lot of medicine across disciplines and certainly is one of the most eponymous people in medicine with many eponyms to his name.

Tell us about him and his influence on medicine in general and neurology specifically.

Dr. Christopher Goetz: In the 19th century, the French School of Medicine was really the premier place to study in a hospital, and Charcot was trained as a medical physician psychiatry and neurology are completely separate in France, historically in the 19th century. So his development of neural clinical neurology came out of medicine.

It did not come out of psychiatry. It did not come really out of pathology. It came out of clinical medicine. And historically, what is distinctive about the French medical system is that during the 19th century. This [00:02:00] idea of developing specialty services became the icon of the Paris medical system and various high level professors who were perhaps a pulmonologist, would take the patients from the public health system and develop a pulmonology service. And the hepatology professor would take from all of the public hospitals the best and most interesting liver patients. And so this happened across all of the Paris medical system to develop this idea of medical specialization.

The result of this was that the Salpêtrière where Charcot was working was really depleted of most of what other doctors would consider interesting and what was left were more chronic, non-curable patients, mostly falling into arthritic conditions and what turned out to be [00:03:00] neurodegenerative conditions and Charcot was both the beneficiary but also the victim of this because he was really left with these patients.

But it was his idea to categorize them, to look at them in detail and out of this. Developed the field of clinical neurology because most of these patients were either arthritic and often both or neurologic, and that's where he became the premier clinical specialist in neurologic disorders. He was also a very conscious person of publicity, because of his kind of magnetic personality and his teaching method. He drew upon people to come to his classes and he'd had show and tell lectures where the patients were brought within the amphitheater and shown right in front of the students so that you really couldn't help that be mesmerized by [00:04:00] what he was showing. And because he had so many patients that the Salpêtrière housed 5,000 patients during his career.

So he had a lot of patients to choose from, and he would develop a unit with resting tremor, a unit with action tremor, the various neurologic signs. He had enough patients that he could study them longitudinally because nobody left the Salpêtrière. It was a hospice basically. and people who registered there they live there forever.

Dr. Sara Schaefer: So you mentioned him as an educator, which of course is one of the things that draws me to him. And of, many people that I interview for residency in neurology can recall the time that a patient was brought into their medical school, pre clerkship curriculum, a patient with tremor who had deep brain stimulation and they watched the clinician turn that DBS on or off and it sparked their [00:05:00] interest in neurology. Obviously this is a longstanding and very powerful way to to educate and inspire medical trainees. And you also mentioned, you said that he draws people, but he also draws, right? He draws and he photographs and as movement disorders, neurologists we're very interested in the video and the patient video.

And I have to imagine that Charcot would be one of the people videotaping folks if he had that technology way back 200 years ago. But can you talk a little bit about that? About how he has influenced, the use of those visuals in, in teaching and learning about neurological disorders?

Dr. Christopher Goetz: Charcot was very much a visual physician and he relied on his eye to make the diagnosis and to follow patients. And there's in fact a very nice quote, and if I may take the second just to find it here, he dealing specifically with patients and [00:06:00] how important it is to be able to see and he is working on

Dr. Sara Schaefer: I think I have the quote actually. Is it, "If the clinician, as observer wishes to see things as they really are, he must make a tabula rasa of his mind, so a blank slate of his mind, and proceed without any preconceived notions whatsoever"?

Dr. Christopher Goetz: That's a nice quote, but that has more to do with objectivity and not carrying an internal prejudice, which is part of his credo. But let me read you another quote, and he's talking to his students, "Let someone say that a doctor is strong in physiology or anatomy, that the doctor is highly intelligent. These are not real compliments, but if you say there is one with a keen eye, who knows how to see, that is perhaps the greatest compliment you can give". And what is important here in terms of our discussion is that Charcot's [00:07:00] lectures were transcribed. So for the years of 1887 and 88 and then 88 and 89, the academic year, there were students who sat in the front row of the auditorium and actually transcribed the doctor patient interviews.

So we have Charcot, unlike most famous neurologists and teachers, we have actually his word. And yes, they're edited and probably not exactly what he said. And, just as a podcast can be edited. Nonetheless, we have Charcot saying things that to me, resonate still. And I use them as teaching tools, but I also use them as a breath of oxygen on a day where I'm discouraged.

So, h e does remain as a teacher. Vibrant, because of the quality and the content, but also because of the humanity of his words.

Dr. Sara Schaefer: And you mentioned, really seeing [00:08:00] and being a keen observer, which I think resonates a lot with movement disorders neurologists who value so much the observational aspect of our lives.

I think, Charcot might have been a movement disorder specialist if he were alive today.

Dr. Christopher Goetz: Well, he made many contributions in movement disorders. And again, if we can just use some quotes certainly Parkinson, James Parkinson's, precedes him. That's 1817. And Charcot was in the 1860s, seventies, eighties in terms of his teaching. But Charcot was the first to recognize bradykinesia.

Bradykinesia, of course, is the hallmark of Parkinson's. It's not tremor, it's not postural reflex instability, it's not rigidity. It's bradykinesia as the core, and then other ancillary findings. But he was able to separate this and he said to his students, again, with the patient in front of him, [00:09:00] "There's more slowness than actual weakness of motor function. In spite of tremor, the patient is still able to execute most motor actions, but he does them with extreme slowness between the thought and action. There's a considerable time lapse. One might think that the needed neural activity can only be unleashed with considerable effort so that the tiniest of movements will provoke excessive fatigue."

It's a lovely description of the hallmark of Parkinson's disease. Only defined by Charcot.

Dr. Sara Schaefer: And even the name was changed with his influence. Correct. It was paralysis agitans, or shaking palsy, which doesn't encompass, as you said, all that we know about how Parkinson's Disease can present. And wasn't he part of the reason that it was renamed after James Parkinson?

Dr. Christopher Goetz: He introduced the term and asked people to call [00:10:00] it henceforth Parkinson's disease, to honor Parkinson's, but also to emphasize that you do not have to have paralysis. In fact, you don't have paralysis. There's no weakness per se, from a dramatic finding, nor does there necessarily have to be tremor.

And he did define, you were mentioning earlier, progressive supranuclear palsy, which was not known until much later. But he did recognize that there were alternative variants of Parkinsonism that were not really typical, or atypical Parkinsonism. And he showed patients who had impaired vertical gaze.

He showed patients who had the frontalis activation and the procerus sign. These were recognized but not named specifically because the anatomy of progressive supranuclear palsy was not recognized. But the idea of taking a clinical finding and equating it with an anatomical [00:11:00] correlate. That's the gift, the main gift of Charcot that every student should remember is that trying to work with that correlation between clinical disease and anatomical lesions with precision. And that's the archetype is of course amyotrophic lateral sclerosis, which is not a movement disorder, but nonetheless it's a motor disorder and naming it by the anatomy as well as the clinical. Amyotrophic, clinical. Lateral sclerosis, anatomic.

So having that sense of the anatomy and the clinical rolled into a single term is the gift of Charcot.

Dr. Sara Schaefer: And I suppose that stems from him coming from medicine as opposed to psychiatry as his underpinning of understanding neurological disease.

Dr. Christopher Goetz: It is. It is. He was a person who looked at the anatomy because the patients lived at the Salpêtrière, every [00:12:00] patient belonged to him because when they died their brain belonged to the state.

He developed an autopsy laboratory to begin to look at each and every patient in terms of spinal cord, brain, the brainstem was not studied in great detail. That was a later development with his students, but he began that discipline of saying, I have a series of patients with these signs. Let me look at these lesions.

And to say, yes, this lesion correlates back to the clinical sign, and even this clinical sign should predict when this patient finally dies, that there will be a lesion in that spinal cord.

There will be a lesion in the left cortex. And to be able to predict that correlation, that's the clinical anatomic method that is really the Charcot legacy.

Dr. Sara Schaefer: And further, not only describing these with [00:13:00] excellent, precise language, but also drawing the things that he saw, like the procerus signs so that we can look at that now and say, that looks like a patient in my clinic with PSP.

Dr. Christopher Goetz: Is true because he was a sketcher. He was not a great artist, but with the kind of reductionist approach of just a few lines, he could capture the essential features of the neurologic disorder. So, within the transcripts of his writing are his own pictures of his patients, and this is a rich archive, a visual archive.

You had mentioned photography. And indeed he engaged professional artists and sculptors and photographers to capture the various deformities. And he even used time lapse photography to catch the movement of movement disorders. It is interesting that he did not use cinematography.

Cinematography in France had been [00:14:00] scandalized actually, because after the Lumiere brothers had developed cinematography, it was abused and used in circuses and country fairs to show people with deformities and it was pejoratively looked upon in the medical profession. So only really the students of Charcot who visited Paris, they took the Lumiere camera back to their own countries that the archetypal example is Marinesco who returned to Romania and filmed his patients exactly the way Charcot did of these long lines, of a single diagnosis so you could see the nuances of disease, but Charcot did not do that. There's no cinematography in the Charcot record. Very important to appreciate, but I agree that he would've loved video.

Dr. Sara Schaefer: Well, you keep mentioning his students and himself as an educator. And he does have a number of very notable [00:15:00] students and quite an influence down the line. Do you wanna talk about a couple of the people that you think are particularly notable, that trained under Charcot?

Dr. Christopher Goetz: Well, I think that what is important to know is that the Charcot classroom became part of the grand tour that doctors of a certain social class were sent to Europe to tour and to go to London and see Hughlings Jackson, to go to Paris and to sit in the Charcot classroom. Then to go to Prussia and to visit Berlin and to the various centers of the world.

It was a kind of medical pilgrimage and it had a program and Charcot was at the top of that program. So American doctors went and visited. And there's very nice writings by S. Weir Mitchell and various Americans who went. But within France, Babinski trained with Charcot, [00:16:00] Pierre Marie. All the people of the next generation except, Dejerine, and Madam Dejerine did not train. They were not part of the Charcot school. Dejerine worked with Vulpian who was close to Charcot, but still, Dejerine was absolutely not part of the Charcot student era, and yet he was named to the Charcot chair in the aftermath of Charcot's death. Not immediately, but eventually he became the Charcot chair recipient.

So even Sigmund Freud spent a certain amount of time with Charcot brief, but he came to study the pathology because Charcot was in fact studying the brains of patients with various neurologic disorders. He became interested in psychiatry because of the behaviors that he saw neurologically, but he didn't study psychiatry.

He came as a neurologist, to study under Charcot as a neurologist.[00:17:00] 

Dr. Sara Schaefer: And Tourette as well, was a student of his. And

Dr. Christopher Goetz: He was, Tourette was probably not a particularly astute neurologist, at least to my reading. But he was a student and he was a dedicated student to Charcot. Charcot had the habit from my reading of letting younger people take the first step with a diagnosis and be the first author and he tested the waters, and if it was successful, then he took over.

But he let young people actually be the first authors of new ideas. And all that's written in that original article about tic disorder by Tourette is really all from Charcot. It's very clear that those are all the case histories are all from the senior colleagues that would only have referred to Charcot. Tourette was really the recipient of that fruit. Right.

Dr. Sara Schaefer: So can we talk a little bit about Charcot's contribution to the [00:18:00] concepts of hysteria and maybe even functional neurological disorders and how the way that he thought of it may have influenced future ways that we think about these diseases?

Dr. Christopher Goetz: Well, I think, I think much of what's been dealt with in terms of hysteria. Hysteria has changed its kind of concept. And during the 19th century, hysteria was a neurologic disorder and Charcot tried to understand it and felt that it was not a lesion in the structural sense, but a dynamic or functional lesion in the sense of a transient change in the same anatomy.

So that there was an anatomical basis to hysteria and many of the current studies of functional movement disorders look at functional MR. And see alterations in the areas that are seen [00:19:00] with structural lesions that are static. But these were more transient, functional and amenable to various therapies different from neurologic.

He lost a lot of credibility. I think a certain amount of that loss of credibility was somewhat imposed. And this just has to do with the history of the way the Salpêtrière was set up. But I think that he was not a psychiatrist. He was never a psychiatrist. He didn't in any way have to do with the psychiatric wing of the Salpêtrière.

His service was a neurologic service, but there were hysterics on that neurologic service.

Dr. Sara Schaefer: Yeah. Per my reading, he also was a big proponent in not ascribing the diagnosis of hysteria exclusively to women, to saying that men can also be affected by these types of disorders and relating it to [00:20:00] traumatic history as well as, like you said, relating it to neurological determinism or an underlying neurological issue as opposed to a primarily psychiatric issue.

Though I know his opinions have also changed over the course of his career and there obviously is a lot of controversy about how all of this was dealt with back in the 1800s in general, right?

Dr. Christopher Goetz: You're absolutely right that Charcot is perhaps not known, but he was the person who emphasized that hysteria was not a female disease. And part of this is just the location of the Salpêtrière . The Salpêtrière , if you visit it is directly behind the major train station of what is now the Gare d'Austerlitz.

But at the time was the Gare d'Orléans, but it was the train station and all the train employees who had any kind of seemingly neurologic problem [00:21:00] were referred to Charcot. So he saw a very large number of railway, and the railway was the height of industry, the height of the newest way and the fastest, the most industrial way of transportation was in the railway industry.

So he saw these men who were under enormous stress in this field of the railway. And he was quite emphatic that the trauma that they endure can lead to, even though they heal neurologically, they are left with hysterical manifestations. He had the premise that being able to be hypnotized and being hysteric we're linked mechanistically. And so that ability to hypnotize and to show how these patients could change their neurologic function [00:22:00] depending on the level of their hypnotic trance was part of his premise of the vocality of the neurologic basis of the hysterical findings. But he saw this, as he said, as well in men, as in women.

And so to get away from that idea of ovarian disease or uterine disease, that this was a neurologic disease, a brain disease, and needed to be respected, needed to be studied, and needed to be treated. But that's somewhat localized too because he worked behind the train station.

Dr. Sara Schaefer: Opportunity knocks. 

Dr. Christopher Goetz: I know. I very much and he was very conscious of that and recognized that. Yeah.

Dr. Sara Schaefer: In closing, can you tell me what you think? You've talked a little bit about obviously his contributions, his legacy. What do you think, modern audiences should take away from Charcot and our discussion today?

Dr. Christopher Goetz: [00:23:00] Well, I think certainly you want to remember always that the idea that neurologists pride themselves on of the lesion and the clinical sign. That is a Charcotian concept that comes directly from Charcot to look for the lesion. Look for the single lesion, but to be willing to accept the multiple lesion.

That is a Charcotism. And if we hold it because Charcot taught it to us. Not to let anybody forget that. I'll tell you that what moves me the most is a quote by Charcot dealing with, and not specifically a movement disorder, but dealing with the challenge of a neurologic patient whom he can't cure.

And I think all of us are sensitive to the fact that we see patients whom we cannot cure. We can help them, we can comfort them. But we cannot cure them. And how does [00:24:00] the modern doctor face that reality? For me at least, I feel with this quote that I will share with you to end that I have Charcot at my shoulder.

I have him there with me as I think through what might be discouragement, but in fact turns into hope. So he has seen a patient, and in the case that I cite here, it's a patient with bulbar amyotrophic lateral sclerosis, a devastating illness. And the patient's examined, the patient's discussed, right in front of the audience. And then he dismisses the patient and tells them that the intern will be out in a few minutes to give him the next step of how he will feel better, and then he turns to his audience and he says, "Naturally, I did not speak about prognosis in front of the poor patient who has just left the room. The prognosis is abominable. It's sad to say, but for the [00:25:00] physician whether it's sad or not is hardly the issue. Truth is the issue. Let the patient live in illusion to the end. It's good, it's humane, but the doctor, what is his role? Indeed our duty is otherwise. Let us keep searching in spite of everything, let us always be searching as it is the best way to find. And perhaps thanks to our efforts today, tomorrow's verdict will not be that of today".

And I'll tell you, I have thought through that on many a day where I've had hard time with patients or I'm about to see a difficult patient that hope that gives me. Yes, it's my job to comfort the patient. I need to be honest we've evolved in kind of in how we deal with patients and the honesty with it.

But the concept is not that. The concept is how do we deal with it as doctors? What's our responsibility? Do we [00:26:00] delude ourselves? No, we keep searching and that's why we're academic physicians, or we are physicians who are treating patients and always keeping our eyes open for the next opportunity to help a patient.

It is only by keeping and looking and not having a preconception, that we will probably learn something that will make that next prognosis better. That to me, that touches, and I've been in this business a long time. I have used that on a many a week basis. So I leave that with all my colleagues because I think that is a good legacy.

And those are the words of Charcot said before an audience of students and colleagues and visitors. It touches me when I read those words. So I keep it close in mind. I thank you for your interest and hopefully the Movement Disorder Society membership's interest in a colleague who vibrates still and as, yes, it's 200 years, but his legacy still lives [00:27:00] on.

Dr. Sara Schaefer: Absolutely. Thank you for sharing all of this information with us about him and his wonderful quotes that were able to be documented in perpetuity, which is wonderful for us 200 years later. And obviously he had a lot of lessons to teach and still does.

Dr. Christopher Goetz: That's right. That's right. Thank you for your interest.