visual art in charcot

Visual Art in the Neurologic Careerof Jean-Martin CharcotChristopher G. Goetz, MD

\s=b\Jean-Martin Charcot, the world's firstchaired professor of neurology, incorpo-rated visual art into his daily practice ofneurology. Art served as scientific docu-mentation and was a pivotal tool in the de-velopment and dissemination of Charcot'sclinicoanatomic method. Although Char-cot drew extensively in clinical and labo-ratory studies, very few of these visualdocuments have ever been published orare currently available for public study.Charcot was central to the incorporationof medical photographs into the study ofneurologic disease and relied heavily onvisual material in his capacity as an inter-national teacher. Art also misguided Char-cot's career when he relied heavily on art-work in his attempt to convince critics thatdisorders seen at the Salp\l=e^\tri\l=e`\reHospital,Paris, France, were independent of hissuggestive influence.

(Arch Neurol. 1991;48:421-425)

Asa physician at the Salpêtrière ** Hospital, Paris, France, and theworld's first chaired professor of neu¬

rology, Jean-Martin Charcot consid¬ered art and science to be pivotallycomplementary in his effort to de¬scribe and categorize neurologic dis¬ease. Science nourished art as Charcotused his own patients as models in hisneurologic sketches and photographs;art nourished neurology as Charcotused art objects from past ages to con¬vince critics that certain of the disor¬ders he sometimes described were nei¬ther new nor of his own creation.

Charcot's incorporation of art intoneurology guided and misguided hisindividual career and established a vi¬sual tradition in neurologic study thatpersists today, although in new tech¬nologic forms.

ART AS SCIENTIFIC DOCUMENTATION

Charcot's dual devotion to art andscience was reportedly lifelong, and hehad wrestled between medicine andart as careers.1 Charcot finally chosemedicine and enrolled in the nationalmedical school in Paris in 1842. Thereis almost no documentation of his stu¬dent years, and his first known medicaldrawings date from when Charcotcame to the Salpêtrière as a juniorfaculty member. Almost none of Char¬cot's clinical drawings have ever beenpublished, and they are not availablefor public viewing.

After arriving at the Salpêtrière,Charcot's first task was to examine andcategorize the thousands of patientshaphazardly housed together through¬out the walled hospital village of theSalpêtrière. With his colleague, Vulpi-an, Charcot gathered a massive clini¬cal database of neurologic and geriat¬ric diseases. This material became thecore of Charcot's clinicoanatomicmethod, the hallmark of his Salpêt¬rière school.2

The two-step clinicoanatomicmethod involved artistic documenta¬tion in both phases. The first stepfocused on clinical description of neu¬

rologic disease, and Charcot's patientdrawings documented the static defor¬mities of chronic cases as well as evolv¬ing signs of acute illnesses. Whereasthe notes accompanying the drawings

were often long-winded, the drawingsrapidly communicated a patient'schanging neurologic state (Fig 1). Us¬ing art, Charcot documented unusualcases of dramatic amputees, pock¬marked victims, and contracted hémi¬plégies as well as more typical cases ofvascular and neurodegenerative dis¬eases (Fig 2).

The second step of the clinicoana¬tomic method, which focused on ana¬tomic and microscopic analyses, oc¬curred after the patient died. Here,too, Charcot used his artistic skills andlater engaged professional artists. Hetraced lesions throughout the neuraxisand documented vascular anomalies indetail (Fig 3). His early drawings were

among the first to document the mi¬croscopic changes of multiple sclerosisand the spinal changes of amyotrophiclateral sclerosis (Fig 4).

Charcot's self-appointed charge wasto be an objective observer, articulateand clear, independent of preconceivedprejudice or expectation.3 His personalartistic preferences focused primarilyon the Dutch masters, whose realismrevealed the world with simplicity andunadorned clarity.4 His own personalartistic style reflected his scientificapproach to clinical neurology. Hismost distinguishing clinical charac¬teristic was a keen ability to see theessential features of diseases, cullingthem from among the confusion of de¬tail. He likewise sketched with an

economy of line that permitted view¬ers to grasp essential features at a

glance. Whereas his artworks showedlittle artistic refinement, they were ef¬fective documents of immediate visualimpact. He drew patients wherever he

Accepted for publication September 13, 1990.From the Department of Neurological Sciences,

Rush-Presbyterian-St Luke's Medical Center,Chicago, Ill.

Reprints not available.

at Kings College London, on January 24, 2011 www.archneurol.comDownloaded from

http://www.archneurol.com

Fig 1.—A drawing from a series of sketches in the hospital record of a patient with a cerebrovas¬cular accident, stressing here the head and eye deviation with prominence of the stemocleido-mastoid muscle (original drawing in Bibliothèque Charcot, Salpêtrière Hospital, Paris, France).

Fig 2.—Patient with decerebrate rigidity (original drawing in Bibliothèque Charcot, SalpêtrièreHospital, Paris, France).

saw them, and even when he was onvacation or on foreign travel, neuro¬

logic disease did not escape his eyes.For example, he sketched a North Af¬rican with Parkinson's disease, cap¬turing in his hasty strokes the handposture, body attitude, joint deformi¬ties, and masked facies typical of thedisease (Fig 5).

CHARCOT AND PHOTOGRAPHY

Charcot's artistic interests were un¬

doubtedly at the core of his immediateappreciation of the new art of photog¬raphy. Under his direction, a photo¬graphic service at the Salpêtrière wasestablished 'by Londe,5 and patientswere regularly photographed as part

of their neurologic evaluation.Whereas those with static findingswere photographed only once or twiceat different angles, the photographersbecame increasingly adept at docu¬menting dynamic disorders with se¬

quential and time-lapse photographymethods (Fig 6). Charcot even spoke ofhimself in photographic terms: "I onlyobserve, nothing more," and "I am a

photographer."6The Salpêtrière photographs were

printed on positive silver plates, andseveral thousands of them were gen¬erated during Charcot's career. Someof these and many more from theperiod after Charcot's death are todayhoused in the Countway Medical Li-

brary, Boston, Mass. Such pictorialdocuments formed the foundation oftwo of Charcot's major neurologic en¬

terprises, the Iconographie Photo¬graphique and the Nouvelle Iconogra¬phie de la Salpêtrière. The former wasa limited edition of hand-pasted pho¬tographs documenting the various dis¬orders, primarily epilepsy and hyste¬ria, seen in the Charcot service. Thelatter replaced this set with a largercirculation journal with neurologic ar¬ticles based specifically on photo¬graphic or artistic documentation. Inthe introduction of the first volume ofthe Nouvelle Iconographie de la Sal¬pêtrière, the editors wrote:

When a patient demonstrates signs of par¬ticular interest—various atrophies, con¬

tractures, special postures or deformities-he is immediately drawn or photographed.With the aid of this immediate record, weare able to freeze the abnormality, to de¬compose the various abnormal movementsone by one, and thereby capture the disor¬der with precision. These vignettes fromthe Salpêtrière complement the clinical ex¬amination to form a collection of greatsignificance.7Contemporary journals based on pho¬tography or videotape (eg, MovementDisorders) are modern descendants ofthis Charcot tradition.

ART AND TEACHING

The incorporation of an artistic ef¬fort in the Charcot service had impor¬tant consequences not directly linkedto scientific documentation. Visualmaterial, by nature, extends beyondlanguage barriers and bypasses tech¬nical medical terminology. It can at¬tract attention and provoke inquirythat might be passed over in a dry ac¬count of written neurologic descrip¬tion. When Charcot started his facultycareer, he was acutely aware that theSalpêtrière was considered far fromcentral Paris and that it carried thestigma of an academic wasteland, "anexile in a lost land where the patholo-gists and clinician had very little tosee."8 To attract students, Charcotcompiled a series of rehearsed-to-per-fection lessons on selected medical top¬ics. He incorporated all his resourcesin these efforts, and each year theirappeal grew wider. His drawings,charts, and theoretical constructswere presented in multicolored spec¬tacle. Fifteen years before the betterknown aphasia diagrams of Lichteimwere created, Charcot presented hisaudience with an elaborate series ofdrawings involving a bell as the cen¬tral theme (Fig 7). Charcot was amongthe first teachers to use slide projec-



Fig 3.—Charcot's autopsy diagram of an aneurysm, drawn in red and black, and accompanyingclinical notes and medical drawings of the patient (original drawing in Bibliothèque Charcot, Sal¬pêtrière Hospital, Paris, France).

Fig 4.—

Denuded axons and maintained neu¬rons in multiple sclerosis. Drawn by Charcotand published in his Oeuvres Complètes.

Fig 6.—Londe5 photographing a patient in her room at the Salpêtrière Hospital, Paris, France. Thephotographic service was a regular part of the neurologic evaluation and research effort underCharcot's direction (from La Nature, No. 536; Paris, France: Bureaux du Progrès Médical; 1892.

Fig 5.—A drawing by Charcot of a Moroccanwith Parkinson's disease (1889). "I have seen

such patients everywhere, in Rome, Amster¬dam, Spain, always the same picture."3

tors in his classroom. He brought stat¬ues, photographs, and patients them¬selves as visual documents. He alsowas an excellent mime and recreatedclinical syndromes for his audience,including gait abnormalities, parkin¬sonism, tic disorders, and varioustypes of weakness.2

Charcot's reputation of magneticpresentations extended beyond the

Paris medical system to the foreignmedical world and to nonmedicai Parissociety. Especially in the 1880s and inhis last years, Charcot's classroom wasa mélange of doctors from eastern andwestern Europe and the Americas, aswell as Parisian artists, journalists,politicians, and social commentators.For many of these people, whose fa¬miliarity with French or with medi-

cine was weak, the visual material was

undoubtedly pivotal to effective com¬munication. As the American AlanStarr recalled when he first saw Char¬cot in a classroom:But grant that it was theatrical; it left on

the mind of the student a series of mentalpictures of patients and of lessons which noamount of private study could possibly pro¬duce. It taught man so that they could notfail to remember; and what higher resultcan a teacher wish?9

Clearly Charcot was not the first orthe only investigator to use medical il¬lustration and visual arts as a meansof medical documentation. His con-



Fig 7.—Diagram of a bell used by Charcot inhis presentations on aphasia. IC indicatescenter for ideas; CAC, auditory center; CVC,visual center; CAM, auditory center for words;CVM, visual center for words; CPM, phoneticcenter for words; and CGM, graphic center forwords."

Fig 8.—Cover from Charcot's and Richer'sDemonios in Art, showing one of the drawingsused by the authors to support their thesis thathysterical epileptic fits were not a new disordernor were they behaviors found only, or pre¬dominantly, at the Salpêtrière Hospital, Paris,France.

Fig 9.—A clinical lesson at the Salpêtrière Hospital, Paris, France, by Brouillet, prepared for the1887 Paris Salon and showing Charcot, Babinski, Marie, Tourette, and other physicians, as wellas artists, social commentators, and government officials in attendance.

Fig 10.—Charcot and his patients. This picturewas on the cover of the Paris tabloid Revue Il¬lustrée and shows the extent to which Charcotbecame a popularized figure in nonmedicai so¬

ciety (from Countway Medical Library, HarvardUniversity, Boston, Mass).

temporaries Gowers and HughlingsJackson included their own medicaldrawings in their text. Charcot, how¬ever, used visual arts in every aspect ofhis daily work effort. Art at the Sal¬pêtrière was inseparable from the sci¬entific effort and was as much the em¬bodiment of the clinicoanatomicmethod as any other neurologic activ¬ity under Charcot's direction.

ART AS SCIENTIFIC JUSTIFICATION

In the sphere of organic neurology,Charcot's clinicoanatomic method metwith repeated successes and estab¬lished him and his school as the inter¬national pillars of clinical neurology.In the 1870s and thereafter, however,he increasingly devoted his attentionto hysteria, a topic that had haunted

and befuddled physicians beforehim.10·" In working with hysteria andattempting to apply the clinicoana¬tomic method to a condition with anelusive lesion, Charcot drifted in theeyes of his contemporaries. Visitingphysicians did not recognize the spellshe demonstrated in the amphitheaterof the Salpêtrière, and, because thespells were too dramatic to be missedif they actually existed elsewhere, crit¬ics contended that they must befeigned or created by Charcot's own

powerful suggestion. Charcot was

keenly aware that hysteroepilepsy be¬came derisively known as the Salpêt¬rière illness.6

To address this criticism and rescuehis compromised scientific reputation,Charcot called on art in a way he hadnever previously used it. While lectur¬ing to his students that hysteria "musthenceforth become a householdword,"12 he looked to art to demon¬strate that the behaviors he saw were

independent of him. He went outsidethe Salpêtrière, beyond medicine, andindeed out of the time constraints ofhis own era to j ustify his stand that thesigns of hysteria were implicit to thedisease and not to the observer. At atime when he relegated much of hispublication material to students, heembarked on two major works on neu¬

rologic disease in art, The Disease andDeformed in Art and The Demonios inArt, both largely focusing on hysteria(Fig 8). These works were pointedly



aimed at repudiating suspicions of ma¬

nipulation of falsification of clinicalmedicine.

In them, Charcot demonstrated thatbehaviors similar to those seen at theSalpêtrière could be found in medievaland mannerist paintings and otherartworks depicting demonic posses¬sion or spiritual ecstacy. Charcot, how¬ever, did not succeed in accomplishinghis goal, and he did not convince scien¬tific skeptics that his personality wasnot intimately connected to the behav¬iors seen at the Salpêtrière.13 In fact,Charcot's mere reliance on religiousart that was doubtfully conceived orexecuted with objectivity as its guidingforce and the glaring lack of historicalor genre painting to support his thesissuggest a certain intellectual despera¬tion in a man otherwise so perceptu¬ally acute. In the end, Charcot appar¬ently recognized that his efforts hadfailed. The last night he worked onscientific material before he died, hereportedly told Guiñón14: "Our concep¬tion of hysteria has become obsolete. Atotal revamping of this area of neuro¬

logic disease is required."ART AS SOCIAL VEHICLE

In spite of his failure to justify sci¬entific credibility through art, Char¬cot's artistic projects were of signifi¬cant personal and social benefit. Withthem, he effectively presented himselfas a multitalented and culturally so¬

phisticated man. The importance of

this dimension to his career should notbe underestimated, for Charcot camefrom very humble origins. If a certainunderlying cultural insecurity existed,his extensive literary references to po¬etry and Shakespeare and his artisticallusions that spanned the centuries ofwestern culture obviously helpedCharcot to present himself as a man ofRenaissance dimension.215 He alsoposed as the focal point for an im¬mense group portrait by Brouillet, "AClinical Lesson at the Salpêtrière"(Fig 9), a painting that became part ofthe celebrated 1887 Paris Salon, thefocal point of artistic Paris at thetime.16 His name was known to thepublic, and he was even pictured on thecover of a popular street tabloid sur¬rounded by his patients (Fig 10). Thesedocuments demonstrate that by theclose of his career, Charcot, the Sal¬pêtrière, and neurology had enteredinto the current social consciousness ofthe time. In these ways, art servedCharcot directly to broaden his imageand to solidify him as a cultural as wellas a scientific figure of French societyin the glittering close of the 19th cen¬

tury. Without this dimension and theclose political ties that Charcot culti¬vated with Gambetta and other gov¬ernmental figures of the third FrenchRepublic, one could question whetherthe original chair of neurologic dis¬eases would ever have been establishedas early as 1882, and specifically inParis at the Salpêtrière.

CHARCOT'S NEUROLOGIC ARTISTICLEGACY

In 1893, when Charcot died, the Sal¬pêtrière service included artists, sculp¬tors, photographers, and a team ofyoung neurologists well versed in vi¬sual documentation. Thereafter, thephotographic wing actively continuedfor several generations, and the Nou¬velle Iconographie de la Salpêtrièrewas published until 1929. In the 1950s,however, the Charcot Museum, withits extensive documentation of the Sal¬pêtrière visual effort, was dissolvedand the collection was lost or

dispersed.2 A pivotal investment in vi¬sual medical documentation is no

longer specifically linked to the Salpêt¬rière, nor has it been for the past 70years, and more recent internationalgenerations have developed innovativeapplications of scanning devices, vid¬eotaping, and other technologies thatcontinue Charcot's tradition of visualneurologic documentation. These tech¬niques are pivotal to the continued ap¬plication of the clinicoanatomic neu¬

rologic method and to the refinementof modern neurologic nosology. As thecentenary of Charcot's death ap¬proaches and the neurologic world in¬vests increasingly in reexamining hiswritten legacy, the "visual Charcot"deserves emphasis because it coalescesneurologist, teacher, social figure, andprivate citizen without needed gram¬matical translation or language study.

References

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3. Charcot JM. Le\l=c;\onsdu Mardi, 1887-88. Paris,France: Bureaux du Progr\l=e`\sM\l=e'\dical;January 31,1888.

4. Meige H. Charcot\p=m-\artiste.Nouv IconogrSalpetriere. 1898;2:489-516.

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1888.7. Richer P, Tourette G, Londe A. Advertisse-ment. Nouv Iconogr Salp\l=e^\tri\l=e`\re.1888;1:i-ii.

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10. Trillat E. Histoire de l'hyst\l=e'\rie.Paris,France: Seghers; 1986.

11. Laseque C. Etudes m\l=e'\dicales.Paris, France:Asselin; 1884.

12. Charcot JM. Le\l=c;\onsdu Mardi, 1887-88.Paris, France: Bureaux du Progr\l=e`\sM\l=e'\dical;Octo-

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Convulsive Disorders. London, England:Churchill; 1881.

14. Guinon G. Charcot intime. Paris Med.1925;26:511-526.

15. Goetz CG. Shakespeare in Charcot's neuro-

logic teaching. Arch Neurol. 1988;45:920-921.16. Signoret JL. Une le\l=c;\onclinique \l=a`\la Salp\l=e^\t-

ri\l=e`\re(1887) par Andr\l=e'\Brouillet. Rev Neurol(Paris). 1983;139:687-701.

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