The death of a recognized national leader
immediately evokes interest and discussion with
regard to his successor. Similar situations
often occur in academic life. The sudden death
of Jean-Martin
Charcot August 1893 made it necessary for
the Faculty of Medicine in Paris to seek a
replacement for the professorship at the
Salpêtrière. The imediate successor
of Charcot, Fulgence
Raymond, is not generally known to
neurologists nowadays and one might wonder why
he was selected at all. In retrospect it is
possible to see some of the difficulties of
replacing Charcot. A review of the candidates
for his chair allows us to gain perspective into
the state of French neurology at the time and to
recall some prominent neurologists in Paris who
vied for the position.
Charcot's death was a loss not only for
French neurology but for the entire medical
world. Charcot had been known internationally as
superior clinical investigator and teacher. His
contributions to the classification of
neurologic disease, and to neuropathology and
neuronatomy, were well known also. In his later
years he had devoted hmself to investigations
and treatment of psychoneurosis and hysteria;
his work on these problems had aroused intense
controversy. Ultimately, many of his students
elaborated or developed theories related to
these illnesses. Charcot trained many excellent
neurologists whose contributions, though perhaps
not as lustrous as those of their mentor, remain
part of our heritage in clinical neurology.
In the early 1860s, when he was named
physician at the Salpêtrière,
Charcot assumed responsibility for more than 5
000 women patients. Many were merely elderly and
infirm. Others had primary neurologic illness
and several hundred had psychiatric
disease.
In the years which followed, in the physical
setting of the former arsenal and prison.
Charcot and his staff began a laborious triage
of this diverse population and created what
today we would call a neurologic institute.
Charcot added laboratory facilities, a medical
photographic unit, a unit for
electrotherapy, an ophthalmology service, and an
outpatient clinic. Together with Pierre Janet,
he began what may be considered one of the first
medical psychology units.
In 1882 the French government created a
professorship at the Salpêtrière in
diseases of the nervous system; Charcot was
appointed to the chair.
He was described by some as aloof, remote,
and tending to view his patients as a captive
group capable of serving his interests in
clinical investigation. Freud, who spent several
months at the Salpêtrière in 1885
and 1886, gave a more sympathetic descripion of
Charcot. Freud had come to Paris to do
neuropathological research on degenerative
changes in the motor system and to attend
lectures at hospitals. Lacking laboratory
facilities and fascinated by the clinical skills
of Charcot, he was led into his life's work in
psychologic disease.
The candidates for Charcot's chair were a
small but outstanding group of French physicians
(see accompanying table). The term physician is
more appropriate than neurologist, since at that
time the employment category of "neurologist"
did not exist in the system of examinations for
professorial tenure. Those French physicianswho
turned to neurology entered it after long
training in general medicine and after passing
the necessary competitive examinations.
The names in the table represent the
survivors of the highly selective and
competitive centralized system of examinations
(agrégations) directed by the French
government. Other tenured professors in medicine
were included in the Faculty of Medicine in
Paris at that time, but I have omitted them
because of their lack of interest in neurology
at the time of Charcot's death. It can be seen
that later successors to Charcot, after Raymond,
were Jules Dejerine
and Pierre Marie.
According to custom, the faculty elected the
successor and approval was then given by the
French government. There is no precise way to
determine what factors were involved in the
election of 1893-1894. We can no more be certain
about the events of the appointment of Raymond
than we can about possible intramural intrigues
underlying the selection of professors at any
university.
I have attenipted to review the work and
qualifications of other candidates and some of
the realities that may have been involved in
their sclection or rejection. Information
available about the lives of each of these men
is far from complete and is probably biased,
since most of the biographical sketches or
biographies have been written by former students
or interns and hence for the most part are
favorable. A review nevertheless, offers
information on the life, work, and personality
of the candidates, about their activities in the
medical world, and about the social setting of
the time.
Joseph Babinski,
the "preferred pupil" of Charcot," is linked
with the tradition of the
Salpêtrière. Wartenberg,who wrote
the biographie sketch of Babinski in The
Founders of Neurology, states that Babinski
would have succeeded to Charcot's chair had he
passed the agrégation examination. This
perhaps represents bias, since Wartenberg was a
pupil of Babinski in the I920s. The fallure of
Babinski to succeed in the agrégation
competition made it impossible for him to secure
a tenured professorial position and eliminated
him from any possibility of succeeding
Charcot.
Pierre Marie had secured his
agrégation. appointment four years before
the death of Charcot and was probably too young
to succeed his former teacher. Nevertheless, he
is famous as an excellent clinical neurologist.
Marie described progressive muscular dystrophy
and was the first to use the terms acromegaly
and hypertrophie pulmonary osteoarthropathy.
He also classified hereditary cerebellar
ataxia as a variant of Friedreich's
ataxia. Roussy, one of his biographers,
states that Marie had many of the
characteristics of Charcot and depicts him as
authoritative, uncompromising and proud,
enjoying the development of new ideas but also
imposing them on others. An example of his
contentiousness was his attack on Paul Broca
entitled The Third Left Frontal Convolution Has
No Specific Role in the Function of Language.
Marie succeeded to the professorship at the
Salpêtrière after the death of
Dejerine in 1917. By that time he was in his 60s
and his most productive years had passed.
Louis Landouzy merits consideration. A
contemporary of Raymond, he achieved his
agrégation appointment in the same year.
Landouzy had written hiss medical thesis on
Contributions to the Study of Convulsions and
Paralyses Related to Frontal Parietal
Meningoencephalitis. In his thesis he focused on
seizures resulting from tuberculous meningitis.
His interest in tuberculosis eventually led hini
to specialize in that disease. At the
tînie of Charcot's death, Landouzy had
been
concerned with the diverse and social
aspects of tuberculosis. Despite advances in
bacteriology made during this period, specific
therapy was 50 years in the future. In Paris in
the 1890s about 2000 babies died each year of
tuberculosis. Landouzy had been awarded the
professorship of materia medica and therapeutics
at the Laennec Hospital. Ultimately he became
dean of the Faculty of Medicine. The direction
of Landouzy's medical career and his appointment
in I893 would have lessened his potential for
consideration as a successor of Charcot.
Another strong and forceful personality was
Jules Dejerine, who
came to Paris in 1871 from modest surroundings
in Geneva and achieved success by hard work.
Although he is reported to have said: "In Paris
you always can advance yourself by work and
enthusiasm. You don't need any strings. You are
the product of your work," he was realistic
about the facts of academic life and the need
for favors and support. In 1886 he competed for
the agrégation.. Not of the school of
Charcot, he learned that Charcot was disinclined
to favor him in this competition. A
confrontation ensued and Dejerine was able to
convince Charcot that he merited consideration
and approval. E. Gauckler, a biographer of
Dejerine, states that after the death of Charcot
many members of the faculty assured Dejerine of
their support for Charcot's chair, and that his
failure to secure immediate succession
embittered him. Gauckler holds that on the
strenoth of Déjérine's
publications he should have been the immediate
successor in 1894 and should not have been
compelled to wait until the death of Raymond
some 17 years later. Dejerine's incisive and
sarcastic style often produced exciting debates
at the Society of Neurology. There is a record
of at least one polemic in the medical
literature in which he disagreed with Marie
about a paper the latter had written. Dejerine
claimed his scientific honor and good faith had
been questioned and he demanded a retraction or
a duel. It remained for Edouard
Brissaud to resolve the disagreement.
Brissaud and Raymond provide an interesting
contrast because of tlicir backgrounds and life
styles. Brissaud, several years younger than
Raymond, had been brought up in a highly
educated family which stressed education and
cultivated the arts. Rayniond was the son of a
farmer. A medical heritage had long existed ni
Brissaud's faily and lacking in Raymond's. Upon
Charcot's death Brissaud served as acting chief
of the unit until Raymond was appointed.
Brissaud had been stimulated by Charcot, and
had donc his early work in neurology and
neuropathology . In 1894 he concluded that
Parkinson's disease was due to some anatomic
disorganization in the subthalamic or peduncular
area and he disagreed with the hypothesis that
Parkinson's disease reflected muscular disease
or psychoneurosis. He reached his decision as a
result of neuropathologic findings in a patient
who had a tuberculoma of the substantia nigra
and had had a Parkinsonian tremor .
Brissaud's interests extended beyond
neurology. Drawn to psychiatry, he achieved a
high reputation in legal medicine and became
skilled in coping with problems secondary to
occupational injury. Brissaud and Marie
founded the Revue Neuroologique. In addition
to writing a textbook of neuroanatomy, he
illustrated the volume himself. His biographers
describe him as intelligent, outspoken, and
fiercely honest. Although a member of the
faculty of medicine he did not hesitate to
criticize it. He enjoyed popularity among his
students as a teacher and heightened their
enthusiasm by not wearing the top hat which at
that period was a symbol of professorial
authority.
Brissaud did not shrink from supporting or
lending his prestige to groups whose activities
he considered worthwhile. Concerned about the
growing separation of neurology and psychiatry,
he worked to bring these two groups together and
in 1893 was able to transform the Congress of
Alienists into the Congress of Alienists and
Neurologists. Brissaud also supported the
private School of Psychology in Paris. Its
driving force was E. Bérillon, who
described Brissaud as a rarity in their time, a
professor in fact as well as title.
Bérillon had personal reasons for the
accolade. For 20years he had pursued a vigorous
campaign against the agrégation system.
In 1910 Bérillon, because of alleged
remarks against the agrégation jury and
its president, was eliminated as candidate after
the competition had commenced. Brissaud, a
product of this competition, supported the
school of psychology and its activities despite
these attacks by its leader.
An additional dimension of Brissaud is made
clear in his address at the opening of the
School of Psychology in Paris in 1908. His theme
on that occasion dealt with political tyranny
and repression, his discourse being devoted to
the uprisings and suppressions which were then
taking place in Turkey. Described as a
"neurologist's neurologit" he appears to have
possessed much of the strength and force and
many of the widespread interests of Charcot.
More than any other candidate, he participated
in social actions.
Raymond, in contrast, was born in a small
town. His parents had simple ambitions and hoped
that their son would live out his life on the
farm as his father had done. Raymond's initial
schooling was in his village. When he showed
ability as a scholar, his family allowed him,
their only child, to enter the
veterinary school at Alfort. He then
procceded to join the army rather than practice
in his community. Later, by competitive
examination, he qualified as chief of anatomy
and physiology at the veterinary school where he
had trained.
By the time he was 23 he was married. He was
slightly older than applicants for medical
school nowadays and much older than most
candidates of that time. Disenchanted with
veterinary medicine, he decided to apply to
medical school. Lacking the necessary premedical
qualifications, he proceeded to study Latin,
Greck, mathematics, and philosophy. By the time
he entered the faculty of medicine he had a
wife, a child, little money, and no connections.
His biographers comment on his amiability and
prodigious memory as favorably impressing his
teachers . During his days as an extern, along
with other physicians in Paris, he lived through
the bombardments during the days of the Paris
Commune. His wife dying soon afterward, he sent
his infant daughter to be brought up by his
in-laws. He then competed successfully for the
internship and, despite the crises in his
personal life, achieved a brilliant academic
record. In 10 years he was able to switch from
veterinarian to professor agrégé
at the Faculty of Medicine.
Raymond's medical writings number in the
hundreds and range from works of general
medicine to publications which touch on every
aspect of neurology. Several of Rayrnond's
papers show that there are probably few new
neurologic diseases and that many of the
clinical entities described during the 20th
century had been observed 100 years earlier. One
of his early major contributions was the
demonstration that tabes and general paresis are
clinical varleties of luetic origin rather than
separate entities. He became interested in
hereditary and familial disease and spoke on the
subject in 1908 when he was awarded an honorary
degree at Oxford.
One of his most interesting papers from the
standpoint of medical history reviews the
organization of medical schools in Russia in the
19th century, as an introduction to a study of
diseases of the nervous system in that country.
The interesting and valuable document deals with
the system of medical education that existed in
Russia in the late 1800s and with the state of
neurologic research there.
Whether Raymond had been invited to visit
Russia for purposes of an external review or
whether his visit was in part a diplornatic
cultural exchange is not known; however, during
the era which followed the Franco-Prussian War
Russia was one of France's few allies.
Raymond was well aware of pseudotumor
cerebri and the need to make a precise diagnosis
in view of the benign course, yet the fact that
many of the patients became blind led him to
advise surgical decompression when
necessary.
In some of his papers we see the antecedents
of the Guillain-Barré syndrome, described
during World War 1 by G. Guillain, J.-A.
Barré, and A. Strohl. Raymond was aware
that ascending paralysis could occur after an
infectious illness or in the setting of some
focal abdominal lesion such as
appendicitis.
He made no primary claim to priority in
describing the remote effects of carcinoma on
the nervous system. He knew the work of
Auché,who had described patients who, had
gastrointestinal, ovarian, and uterine neoplasms
and who developed neuropathies which could not
be explained either by cachexia or by neoplastic
infiltration of nerves or plexuses.
To inherit the position of professor of
nervous diseases at the Salpêtrière
was to assume the task of diagnosing and
treating a large number of patients who had
emotional disorders. Like his predecessor,
Raymond continued to support the work of Janet;
together they published works on hysteria,
obsessions, and fixed ideations. His position as
an editor of Epilepsia when it was first
published is an indication of his reputation in
neurology .
In contrast to some of the other
neurologists previously described, Raymond was a
friendly man, inclined to compromise rather than
argue. His early background may have made him
modest and conciliatory rather than aggressive.
Raymond had few if any enemies. In his teaching
he seemed ill at ease and under great tension.
He was unable to categorize and systematize
diseases as forcefully as Charcot. A biographer
describes him as so impartial in the
presentation of clinical data and theoretical
considerations that many in his audience had
difficulty understanding his conclusions .
His life was one of unending work, devoted
almost exclusively to medical teaching and to
the care of patients; this contrasts with the
diverse activities of Brissaud. In the last year
of his life, despite failing health, he
continued to fulfill his academic obligations
and served on the jury of the stormy
agrégation competition of 1910.
Raymond appears to have been the most benign
and least controversial of the candidates
available to succeed Charcot. It is possible
that the faculty was interested in a tractable
and unassertive figure after the death of
Charcot. Although his appointment may have been
based solely on seniority, Raymond stated that
Charcot had indicated that he hoped Raymond
would succeed him. The faculty may have wanted
to lessen the dynamic, productive ferment
instituted by Charcot which, in comparison, may
have made the rest of the medical school appear
unproductive. They may have wanted a less
charismatic successor. Beside the other
candidates Raymond appears less aggressive and
imaginative. In recent times hîs image has
become even fainter. The bioaphic sketch which
appeared in the first edition of The Founders of
Neurology in 1953 was omitted from the edition
of 1970.
It is doubtful that any of the possible
candidates would have maintained Charcot's
powerfuI energetic leadership. His immediate
successor was destined to be dwarfed by the
brilliance of his predecessor. Guillain is
correct in stating that Raymond nevertheless
merits recognition as one of the foremost
clinical neurologists of his time.
Whether or not we shall ever possess all the
facts related to the appointment of Raymond, a
review of the potential successors of Charcot
gives us a glimpse into 19th century French
neurology and into the academic and personal
qualities of outstanding French neurologists of
this period.
