Jean-Martin Charcot´s medical instruments: Electrotherapeutic devices in La Leçon Clinique à la Salpêtrière

  • Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
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In the famous painting La Leçon Clinique à la Salpêtrière (A Clinical Lesson at the Salpêtrière) by André Brouillet (1857–1914), the neurologist Jean-Martin Charcot (1825–1893) is shown delivering a clinical lecture in front of a large audience. A hysterical patient, Marie Wittman (known as “Blanche”; 1859–1912) is leaning against Charcot’s pupil, Joseph Babinski (1857–1932). Lying on the table close to Charcot are some medical instruments, traditionally identified as a Duchenne electrotherapy apparatus and a reflex hammer. A closer look at these objects reveals that they should be identified instead as a Du Bois-Reymond apparatus with a Grenet cell (bichromate cell) battery and its electrodes. These objects reflect the widespread practice of electrotherapeutic faradization at the Salpêtrière. Furthermore, they allow us to understand the moment depicted in the painting: contrary to what is sometimes claimed, Blanche has not been represented during a hysterical attack, but during a moment of hypnotically induced lethargy.

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Epilepsy surgery developed following the clinical and experimental demonstration of the existence of the primary motor cortex in animals and humans. The first epilepsy surgery procedures were mainly performed to treat focal motor (Jacksonian) epilepsy, as the seizure semiology precisely pointed to the contralateral motor cortex (epileptogenic zone), guiding the surgical removal of the visible lesion found in that region. However, mainly in the absence of any visible alteration of brain tissue, the removal of the portion of the cortex supposed to be responsible for the seizures carried the risk of injuring healthy areas of the brain, often resulting in permanent neurological deficits. In 1891, the prominent Italian neurologist Camillo Negro (1861–1927) described a new technique to treat focal epilepsy using galvanic electrical stimulation of the motor cortex to induce selective cortical destruction. The procedure of “cortical electrolysis”, initially performed by prof. Antonio Carle (1854–1927), chief surgeon at the Mauriziano Hospital of Turin, aimed at avoiding the risk of hemorrhage and neurological deficits due to the resective surgical procedures, without compromising asepsis. Camillo Negro deserves to be credited as the first to have envisioned a non-resective surgical approach to the treatment of epilepsy, which in its conceptual basis appears nowadays as extraordinarily modern and pioneering. Recent neurosurgical procedures, such as stereoelectroencephalography-guided radiofrequency thermocoagulation and MRI-guided laser-induced interstitial thermal ablation, although based on different technologies, share the same rationale, using minimally invasive epilepsy surgery to reduce tissue disruption and thus morbidity.
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In June 1870, Jean-Martin Charcot (1825-1893) delivered his first lecture on hysteria, a lesson on hysterical contractures, at the Salpêtrière in Paris, France.2 His lecture emphasized a scientific approach to hysteria and focused on not only the physical features but also the psychological aspects. Thus, he expressed doubt about reports of miraculous religious cures and likened them to the sudden recovery of hysterical patients. Charcot was influenced by the work of Pierre Briquet (1776-1881),3,4 who in 1859, based on clinical assessments, published a systematic epidemiologic study describing 430 cases of hysteria seen over a 10-year period. Briquet considered “hysteria as the product of suffering of the part of the brain destined to receive affective impressions and feelings,”4(p60)suggested a role for heredity, proposed a predisposing temperament, and identified male cases but noted that they were far less common than female cases. The previous July, Charcot attended the British Medical Society meeting in Leeds, England, where Russell Reynolds delivered a paper that had intrigued him, “Paralysis, and other disorders of motion and sensation, dependent on idea.”5 Reynolds wrote “that some of the most serious disorders of the nervous system, such as paralysis, spasm, pain, and otherwise altered sensations, may depend upon a morbid condition of emotion, of idea and emotion, or of idea alone . . . they sometimes associate themselves with distinct and definite diseases of the nervous centres, so that it becomes very important to know how much a given case is due to an organic lesion, and how much to morbid ideation.”5(p483)
Jean-Martin Charcot (1825-1893) rightly is considered the father of both modern neurology and psychiatry in France and much beyond. While he never was interested in mental disease and what was called 'alienism' at the time, his career at La Salpêtrière Hospital over 30 years was mainly marked by the development of a huge group of students which focused on the study and management of hysteria. When Charcot took office at the beginning of 1862, hysteria was a 'no-man's land', medically speaking, since neither the alienists nor the internists had much interest in this condition. At La Salpêtrière, these chronic patients were largely left to themselves before Désiré Bourneville, one of Charcot's first students, convinced his chief to care for them. Subsequently, the studies of Charcot with Paul Richer, Joseph Babinski, Georges Gilles de la Tourette, Paul Sollier, Pierre Janet, and many others allowed the condition to be addressed in detail. During his stay with Charcot in 1885-1866, Sigmund Freud, a young neuropathologist at the time, became fascinated by hysteria, an interest which probably was the main start of his interest in psychology. Charcot emphasized the concept of mental factors in hysteria, along with that of a 'dynamic' lesion, which accounted for the lack of neuropathological findings in the patients. While his ideas on hysteria and hypnotism were criticized after his death even by former pupils, such as Babinski, recent findings from functional studies using magnetic resonance imaging show how accurate and often visionary Charcot's thinking was in this field. © 2014 S. Karger AG, Basel.
This historical review presents the advances made mostly during the last 200 years on the description, concepts, theories, and (more specifically) cure of patients suffering from hysteria, a still obscure entity. The denomination of the syndrome has changed over time, from hysteria (reinvestigated by Paul Briquet and Jean-Martin Charcot) to pithiatism (Joseph Babinski), then to conversion neurosis (Sigmund Freud), and today functional neurological disorders according to the 2013 American Neurological Association DSM-5 classification. The treatment was renewed in the second half of the 19th century in Paris by Paul Briquet and then by Jean-Martin Charcot. Hysterical women, who represented the great majority of cases, were cured by physical therapy (notably physio-, hydro-, and electrotherapy, and in some cases ovary compression) and 'moral' therapies (general, causal therapy, rest, isolation, hypnosis, and suggestion). At the turn of the 19th and 20th centuries, psychotherapy, psychoanalysis, and persuasion were established respectively by Pierre Janet, Sigmund Freud, and Joseph Babinski. During World War I, military forces faced a large number of posttrauma neurosis cases among soldiers (named the 'Babinski-Froment war neurosis' and Myers 'shell shock', in the French and English literature, respectively). This led to the use of more brutal therapies in military hospitals, combining electrical shock and persuasion, particularly in France with Clovis Vincent and Gustave Roussy, but also in Great Britain and Germany. After World War I, this method was abandoned and there was a marked decrease in interest in hysteria for a long period of time. Today, the current treatment comprises (if possible intensive) physiotherapy, together with psychotherapy, and in some cases psychoanalysis. Antidepressants and anxiolytics may be required, and more recently cognitive and behavioral therapy. Repetitive transcranial magnetic stimulation is a new technique under investigation which may be promising in patients presenting with motor conversion syndrome (motor deficit or movement disorder). Functional neurological disorders remain a difficult problem to manage with frequent failures and chronic handicapping evolution. This emphasizes the need for therapeutic innovations in the future. © 2014 S. Karger AG, Basel.
In this chapter, excerpts from famous or little-known works of French literature are used to illustrate how eighteenth- and nineteenth-century physicians tried to treat neuropsychiatric illnesses. Although the causes were unknown to them, they did not hesitate to inflict suffering on their patients, who were often in an appalling condition to begin with. Novelists such as Gustave Flaubert, Alphonse Daudet, the Goncourt brothers, Georges Siménon, and Céline applied their writing talents to describing the use of leeches, bloodletting, vibratory treatments, suspension of the body, multiple painful injections, and brutal electrotherapy. These writers reveal how physicians used their imaginations not only boundlessly but also without pity, to treat their patients. Each literary work is presented with the medical justifications of the time, for example, the explanations of Cruveilhier, Charcot, Brown-Sequard, Sollier, Vincent, and Roussy.
In 1886 Sigmund Freud returned from Paris with the lessons taught to him by Jean-Martin Char cot. In 1889 Freud returned from Paris with an image ofCharcot teaching. This essay analyzes three images—or three different versions of that one image: the original painting of 1887 by André Brouillet, the 1888 reproduction of it as a lithograph by Eugène Pirodon, and a photographic “installation shot” of one copy ofthat lithograph by Nick Bagguley as it appears on a postcard of the Freud Museum. “The picture over the couch” in Freud's consulting room is examined both for the demonstration it depicts and for what it cannot show, that is, the scene of analysis which took place beneath it. Seeing how the image functions for Brouillet in Paris and for Freud in Vienna, the question arises how it functions f or us—those called by Freud and psychoanalysis—in London. In giving us an image of what we want but can never see of Freud, the picture may at least in fantasy be seen as the primal scene of psychoanalysis.
The interactions between developing neurology and psychiatry in Paris are of interest, in a city which was the main center for studies on the nervous system and its disorders during the nineteenth century. Contrary to a common view, and in spite of an established tradition for mental diseases, emerging neurology had a much stronger influence on psychiatry ('alienism') than the reverse. This was largely due to the school built up by Jean-Martin Charcot, which was organized around the study and management of hysteria. Although Charcot himself always claimed his disinterest in mental medicine, he stimulated the development of an original scientific approach to nervous system conditions, along with a structured academic teaching, while alienism paradoxically remained stuck in organicism, after Antoine Bayle's report in 1822 of 'arachnitis' as the substratum of general paresis of the insane. Contrary to alienism, the young neurological school was able of self-criticism, and progressively underscored mental factors in hysteria. This led to the paradox that neurologists were active in a disease with a recognized lack of organic lesion, while alienists were postulating brain lesions in all mental disorders. The neurological activity thus indirectly and involuntarily led to the first developments of psychodynamic concepts in mental diseases. The academic evolution led to the launch of a faculty chair of mental and brain diseases in 1875, which was taken over for nearly half a century by direct pupils of Charcot: Benjamin Ball, Alix Joffroy, and Gilbert Ballet held the position until 1916, supporting the development of modern psychiatry in general hospitals, while alienism progressively disappeared at the turn of the century.
Following the simultaneous description of muscle stretch reflexes by Heinrich Erb and Carl Westphal in 1875, neurologists used direct finger taps or chest percussion hammers to elicit these phenomena. Because of inadequacies of chest percussion hammers for eliciting muscle stretch reflexes, a variety of hammers were developed specifically for this purpose. In 1888, J. Madison Taylor, working for S. Weir Mitchell at the Philadelphia Orthopedic Hospital, designed the first such "reflex hammer." Taylor's hammer had a triangular rubber head and a short, flattened metal handle. Krauss (1894), Berliner (1910), Troemner (1910), Babinski (1912), and Wintle (1925) also designed popular reflex hammers. Many of these hammers and several others are still in use.
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