Gunpowder, madness, and hysteria: the birth of neurology in France Vignettes of five great neurologists who made history at the Salpêtrière Hospital in Paris: Jean-Martin Charcot (1825-1893), Pierre Marie (1853- 1940), Joseph Babinski (1857-1932), Jean Lhermitte (1877-1959), Paul Castaigne (1916-1988)

Christian RÉGNIER, MD
Praticien Attaché Consultant de l’Hôtel-Dieu de Paris
Société Internationale d’Histoire de la Médecine
9 rue Bachaumont
75002 Paris, FRANCE

C. Régnier, France

The early history of the Salpêtrière in Paris was turbulent. Now a major teaching hospital beside the River Seine, it was founded by Louis XIV as the Hospice de la Salpêtrière in the mid-17th century, on the site of a gunpowder factory (whence its name—from saltpeter). By the time of the French Revolution, the Salpêtrière had 10 000 inmates—thementally disabled, criminally insane, epileptics—as well as paupers and hundreds of prostitutes cleared off the streets of Paris. In September 1792 the revolutionary mob stormed the Salpêtrière, ravished hundreds of girls and women, and slit the throats of 35 among them. For the next two years, in the words of one historian, the doors of the hospital remained open as the Salpêtrière became the largest brothel in Europe. Philippe Pinel initiated humanitarian reforms in the treatment of mental illness in the 1800s, literally unchaining the inmates, and by the close of the century the Salpêtrière was famous worldwide as a psychiatric center and Jean-Martin Charcot and his students had laid the foundations of modern neurology. Using all the scientific resources of his time— laboratory analyses, photographs, electrostimulation, drawings, casts, histological sections—Charcot meticulously described the symptoms observed, sought the corresponding anatomical and histological lesions, and analyzed causes and mechanisms. He attracted hordes of students from France and Europe who were to achieve international renown, such as Sigmund Freud, Eugen Bleuler, Alfred Binet, Georges Gilles de la Tourette, and many others. Charcot also blazed the trail for illustrious followers who in his wake established the fame and reputation of French neurology, such as Joseph Babinski, Pierre Marie, Jean Lhermitte, and Paul Castaigne, and of which the presentday Pitié-Salpêtrière is the worthy successor.

Medicographia. 2010;32:310-318 (see French abstract on page 318)

Blanche Wittmann, the “queen of hysterics” at the Salpêtrière, has found posthumous fame of a sort through her depiction in a painting by Pierre-André Brouillet. Une Leçon Clinique du Professeur Charcot à la Salpêtrière [A Clinical Lesson at the Salpêtrière Hospital by Professor Charcot] (1887) shows the neurologist Jean-Martin Charcot (1825-1893) at one of his famous Tuesday demonstrations about to apply an electrode to the swooning Blanche. Among those in attendance were future luminaries in neurology—Gilles de la Tourette, Paul Richer, Pierre Marie, Gilbert Ballet, Maurice Debove, Alfred-Joseph Naquet, Désiré-Magloire Bourneville, Joseph Babinski, Henri Parinaud—as well as other notables, including Théodule Ribot (the director of the Revue Philosophique), Jules Claretie (novelist, playwright, and administrator of the Comédie-Française), Paul Arène (poet, writer, and friend of Alphonse Daudet), and Philippe Burty (art critic and inspector of the French National College of Art and Architecture). Brouillet’s painting symbolizes a certain supremacy of French neurology and was reproduced in a Scientific American supplement in 1887 in the form of an engraving, together with the names of all those present.1-5

View of Salpêtrière Hospital, with the River Seine in the foreground. Lithography by Perelle; 1680.

© Leonard de Selva/CORBIS.

The Hospice de la Salpêtrière, the temple of neurology

The emergence of neurology at the Salpêtrière was part of a long history in which Charcot and his students were at one and the same time pioneers and heirs. In 1862, when Charcot started work there, this immense 32-hectare hospital housed some 5000 women suffering from a whole range of ills, which offered vast scope for anatomical and clinical observation in all medical specialties, notably neurology. Yet the staff at the Salpêtrière were hardly numerous: seven doctors, one surgeon, eight interns, fourteen externs, and a pharmacist and his eight interns. From 1804 to 1861, the annual mortality rate was 17.51%, slightly below the average for the public hospitals of Paris.6,7

Between 1823 and 1860, the Salpêtrière was called the Hospice de la Vieillesse-Femmes, a name that masked its psychiatric vocation: it was both an asylum for the insane and a hospice for women young and old deemed “incurable.”While the asylum had acquired a certain prestige since Philippe Pinel’s early 19th-century invention of “moral treatment,” the hospice had been neglected. The women of the Salpêtrière were divided into four large sections: former staff members, women in their seventies, those in their eighties, and those treated in the infirmary (400 beds). Each woman was allowed and had a straw mattress, but the regulations were still very strict.6,8,9,10

In 1852-1853, Charcot completed his internship at the Salpêtrière, after which he compared the hospital to a living museum of pathology with considerable resources, adding that he was determined to return and to stay, unlike many of his contemporaries who moved on to more prestigious institutions.7,11

Entrance to the 17th- and 18th-century buildings of the Salpêtrière
with dome of the Saint-Louis church.

© Vaughan.

Entrance Philippe Pinel (1745-1826) releasing the lunatics from their chains at the Salpêtrière Hospital in 1795.

Color lithography after a painting by Tony Robert-
Fleury. © Bibliothèque des Arts Décoratifs, Paris/Archives Charmet/Bridgeman Giraudon.

Jean-Martin Charcot (1825-1893)

_ Charcot and neurology: a prepared mind
Charcot’s arrival at the Salpêtrière coincided with the emergence of neurology as a medical specialty. “Neurology” was coined in 1664 by the great English neuroanatomist Thomas Willis. The first work exclusively devoted to neurology was the three-volume A Manual of the Nervous Diseases of Man published in Berlin between 1840 and 1846 by Moritz Heinrich Romberg. Charcot was an acute observer of clinical signs and excelled in performing autopsies. His methodology was based solely on observation of facts. He didn’t hypothesize and was little interested in experimentation.7,12

While still an intern and a member of the Biology Society, Charcot studied a 20-year-old epileptic woman with partial atrophy of the left hemisphere. He later attributed the patient’s clinical manifestations with the brain lesions he had observed when conducting an autopsy. This type of so-called localizationist observation was quite common in the mid-19th century. Charcot considered the brain an assembly of regions— modules of sorts—that functioned autonomously. Each zone controlled a very precise nervous function. He started by studying motor cortex areas and used his findings to hypothesize on aphasia, poliomyelitis, and cerebral hemorrhages. Charcot soon admitted that the localizationist theory was too restrictive to explain certain cognitive phenomena, notably hysteria.3,13,14

After joining the Salpêtrière in 1862, Charcot worked with his friend the anatomist and physiologist Alfred Vulpian (1826- 1887). Vulpian ran a small department of general medicine at the Salpêtrière and helped Charcot perfect his techniques of microscopy and the preparation and staining of cells, which were essential for deepening histological understanding of nerves and brain structures. The two men had various affinities, as Vulpian recalled in his oration at Charcot’s funeral in 1887: “We were soon brought together by a perfect sharing of feelings, ideas, leanings, and even existential difficulties; and this was lifelong.” Vulpian was one of the first to enunciate the principle of the degeneration and regeneration of nerves and to explain the action of strychnine, nicotine, and anesthetics on the nervous system.2,7,13,15,16

Charcot read both German and English and was familiar with Charles Bell’s Exposition of the Natural System of the Nerves of the Human Body (1824), Romberg’s Lehrbuch der Nerven- Krankheiten des Menschen [Textbook of Nervous Diseases in Humans] (1853), as well as Rudolf Virchow’s 1858 work Die Cellularpathologie in ihrer Begründung auf physiologische und pathologische Gewebelehre [Cell Pathology Founded on Physiological and Pathological Findings in Tissues]. Through a combination of theoretical knowledge and mastery of tissue preparation, Charcot possessed a solid grounding in pathology, and in 1872 was appointed Professor of Pathology at the Paris Faculty of Medicine.14,16,17

_ The Salpêtrière School of Neurology and its director
Unlike most French hospital physicians at the time, Charcot did not attend his patients in the wards, but rather had them brought to his consulting room. The patient was undressed, while the intern read the latest findings. Charcot listened, drumming his fingers on the table. Meanwhile, the assistants would stand close together, waiting for a word from the master. Charcot would tell the patient to perform a movement and to speak. He asked his assistants to test the patient’s reflexes. Silence again. Another patient was brought in and examined as before. And a third, still without an utterance from Charcot, who would then compare the patients. He noted everything and sketched what he observed, a skill he’d cultivated since childhood.7,11

The confines of the consulting room contrasted sharply with the breadth of his ambition for the Salpêtrière. Charcot set up a pathology laboratory, an outpatient department, a room for ophthalmology, a psychology laboratory, workshops for drawings and casts, a biology laboratory, and a museum. Charcot had an amphitheater built in which the first electrical equipment for the projection of photographic plates to illustrate lectures given to students was installed. Charcot also called upon his “master” Guillaume-Benjamin-Amand Duchenne, who had overseen Charcot as an intern, to set up an electrotherapy laboratory and a photography workshop.2,4,7 Duchenne’s Mécanisme de la Physionomie Humaine [Mechanism of Human Physiognomy] was the first text on the neurophysiology of emotion and a landmark in clinical medical photography, but he is best remembered for his pioneering work on myopathies, including what are now called Duchenne muscular dystrophy, Duchenne-Aran spinal muscular atrophy, and Duchenne-Erb paralysis.

Jean Martin-Charcot (1825-1893).

Photo by Paul Nadar, Paris; albumen print, Paris, Musée
d’Orsay. © RMN (Musée d’Orsay)/Hervé Lewandowski.

A Clinical Lesson with Doctor Charcot at the Salpêtrière.

Painting by André Brouillet, 1887. Lyon, Hôpital Neurologique. © akg-images/Erich Lessing.

_ Multiple sclerosis and Parkinson’s disease
By observing and classifying the Salpêtrière’s “palsied” elderly women, Charcot and his students provided neurological descriptions and clinical definitions of multiple sclerosis and of Parkinson’s disease and were able to differentiate the intention tremor of multiple sclerosis from the resting tremor of Parkinson’s disease.7

In an 1861 article entitled De la Paralysie Agitante, Vulpian and Charcot differentiated “paralysis agitans” or “tremor paralyticus” from other forms of tremor and called it Parkinson’s disease. James Parkinson had, in 1817, published An Essay on the Shaking Palsy, of which Charcot said, “It is a work which, while exiguous, contains a large number of excellent things.” In his autopsies of patients with Parkinson’s disease, Charcot found no “apparent” histological lesion of the nerve tissue.4,11,18,19

Between 1860 and 1866, Charcot and Vulpian studied the anatomical and clinical forms of multiple sclerosis and defined what has since become known as Charcot’s neurological triad, which although not pathognomonic of multiple sclerosis is associated with it, to wit: nystagmus, an involuntary eye movement; intention tremor of the arms; and staccato speech. They also described the histological characteristics of multiple sclerosis: a thinning or loss of the myelin sheaths and a build-up of scar-like plaque around axons.18,19

On January 25, 1865, Charcot gave a lecture at the Société Médicale des Hôpitaux de Paris on a case of primary sclerosis of the lateral columns of the spinal cord in a hysterical woman admitted in September 1856, who died in January 1862. He detailed the history, the clinical observation, and the disease course, reviewed the medical literature, read his autopsy report, reported his histological findings, and concluded: “I am inclined to believe that there is a distinct anatom- ical and pathological entity which will become less and less rare as careful autopsies grow in number.”18,19 Charcot’s merit was that he clarified the hazy nosology of “chronic myelitis” by distinguishing multiple sclerosis from the progressive locomotor ataxia, or tabes dorsalis (linked to sclerosis of the dorsal columns), described by Duchenne. In all, Charcot conducted 34 anatomical and histological observations of multiple sclerosis and published his findings in 1868, the year in which he started classes on the disease.

“Hysterical yawnings.” Three photos in a series showing a hysterical woman screaming.

From: Nouvelles Iconographies de la Salpêtrière – Clinique des Maladies du Système Nerveux. Volume 3, Plate XVII. Published by LeCrosnier et Babe, Paris, 1890. © Wellcome Library, London.

Between 1867 and 1878, Charcot continued his work on neuropathology in a quest to disentangle the etiologies of tremors in the elderly: cerebellar tremor, Huntington’s chorea, posthemiplegic chorea, hysterical chorea, athetosis, and spasms. In 1870, Charcot gathered the mentally disturbed, epileptics, and hysterics together in a new department of “simple epileptics.” In the second half of the 19th century, the greatest confusion shrouded understanding of those subject to seizures. Charcot sought to differentiate hysterics from epileptics using anatomical and clinical rules. Thus it was that he entered the world of hysteria, never to leave it until his death.1,3,7,17 Drawing on his own work and on the findings of Duchenne, whom he referred to as “mon maître,” and of the anatomist Jean Cruveilhier, Charcot established the anatomical and clinical characteristics of amyotrophic lateral sclerosis (also known in English-speaking countries as Lou Gehrig’s disease, after the New York Yankees baseball player), a motor neuron disorder which in France is still sometimes called Charcot’s disease:

This disease starts with muscle weakness which progressively spreads to all four limbs, and soon gives way to stiffness or more or less pronounced permanent contraction which is more marked in the lower than upper limbs.

For several years, Charcot organized courses in neurology on Tuesdays, where observations on nervous diseases made at the hospital were reported before an audience of attendant students as well as French and foreign physicians.2,7,10,20

His career ended in honor: the Chair in Diseases of the Nervous System was created in 1882 for Charcot, the crowning achievement to a lifetime’s work.

In 1900, seven years after his death, the Salpêtrière was divided into three parts: the back housed madwomen, the more agitated among them isolated in individual “chalets”; a large Louis XIII building for elderly women with common rooms 60 meters in length abutted the main thoroughfare (the boulevard de l’Hôpital); and between the two was Charcot’s domain, with its laboratories, maintenance department, museum, and amphitheater.9,21,22 Many more changes have occurred over the intervening years, but today’s modern Pitié- Salpêtrière Hospital is a living testament to the best of French neurology, thanks to the pioneering vision of Jean-Martin Charcot.

Pierre Marie (1853-1940)

Pierre Marie, one of Charcot’s most outstanding students, first studied law to comply with his father’s wishes, but then entered medical school, qualifying in 1878. He received his medical doctorate in 1883 with a dissertation on Basedow’s disease (also known as Graves’ disease), in which he described tremors of the outstretched arms and fingers, which he had studied while a medical student.

The same year, while the neurologist Howard Henry Tooth (1856-1925) was conducting similar studies in England, Charcot worked with Pierre Marie on what is now known as Charcot-Marie-Tooth disease. This motor neuron disease is one of the most common inherited (usually autosomal dominant) neurological disorders and is characterized by demyelinization of the peripheral nerves.7,16,23 Marie was one of the first to study and describe acromegaly and, through his work on this pituitary gland disorder, made a major contribution to the nascent discipline of endocrinology. He published extensively on aphasia, rejecting the views of Pierre Paul Broca (1824-1880) and Karl Wernicke (1848- 1905) on the localization of the speech cen- ter, notably in a paper entitled, The third left frontal convolution has no special role in the function of language. Marie’s studies in neurology also concerned spinal cord diseases, spinocerebellar ataxia, pulmonary hypertrophic osteoarthropathy, cerebellar heredotaxia, cleidocranial dysostosis, and rhizomelic spondylosis, and he distinguished rheumatology from neurology, with which it had long been conflated.

Pierre Marie (1853-1940).

Photo by Eugène Pirou, Paris. © Wellcome Library, London.

In 1897, Marie founded a school of neurology at the Hospice de Bicêtre, which soon acquired a worldwide reputation and over the years produced many distinguished pupils guided by his rigorous approach to the practice and study of neurology. Ten years later, Marie was appointed to the Chair of Pathological Anatomy at the Salpêtrière Neurological Clinic. He established a museum and laboratories and modernized the teaching of the subject together with his successor Gustave Roussy, with whom he wrote Les Psychonévroses de Guerre, an early work on what we would now call posttraumatic stress disorder.

“New suspensory treatment for nervous ataxia” at the Salpêtrière Hospital.

© Bettmann/ CORBIS.

PierreMarie cofounded the Revue Neurologique with Édouard Brissaud, served as the first General Secretary of the Société Française de Neurologie, and from1911 was amember of the Académie de Médecine. Towards the end of the Great War, during which he studied and treated the traumatic brain injuries of the wounded, Marie was appointed to the chair that had been created for Charcot. This was a position he held until 1925, when he resigned at the age of seventy-two.

Joseph Babinski (1857-1932)

Charcot’s favorite student was Joseph Babinski, the son of a Polish engineer who fled to Paris in 1848 to escape Russian terror after an insurrection in Warsaw. From the turn of the century, Babinski lived with his elder brother Henri, a mining engineer and famous gastronome, whose book Gastronome Pratique [Practical Gastronomy] ran to over one thousand pages by the time of its 1928 edition.

Babinski’s motto of “observation is the highest principle” served him well throughout his rich and varied medical career, which ranged from a treatise on typhoid fever in 1882 and an 1885 thesis on multiple sclerosis to a study of hysteria in 1930. Babinski cofounded the Société de Neurologie de Paris [Neurological Society of Paris] and made major contributions to the development of psychiatry and neuropsychology in France. In 1903, he described his conclusions following years of studying fanning of the toes, the abnormal response to plantar stimulation that signals upper motor neuron damage to the thoracic or lumbar region or brain disease, which is now termed Babinski’s sign.

Joseph Babinski (1857-1932).

Photo by Eugène Pirou, Paris. © Wellcome Library, London.

Babinski foresaw the rise of neurology in France and later said of two of his favorite students—Thierry de Martel and Clovis Vincent—“I showed them the way to found French neurosurgery.” Another of his famous pupils was Egas Moniz, the Portuguese neurologist who developed cerebral angiology and introduced prefrontal lobotomy, for which he won the 1949 Nobel Prize in Medicine. Controversial from its inception, this psychosurgical procedure was used widely in the 1940s and 1950s to treat various psychiatric disorders, but has since fallen into disfavor and is now rarely performed.

Whereas Charcot had relied mainly on medical history taking and observation, Babinski broke with the tradition of his former mentor and developed and emphasized the importance of bedside neurological examination, paving the way for mod- ern neurology. The Lancet concluded Joseph Babinski’s obituary with the following words: “None of Charcot’s pupils is surer to be remembered for his achievements in the field of neurology.”

Babinski’s sign.

Drawing by Dr
K. Wagner, for Lévy-Valensi’s Diagnostic Neurologique. Paris, 1921.

Jean Lhermitte (1877-1959)

Jean Lhermitte was the son of the French realist painter Léon Augustin Lhermitte, of one of whose works Vincent van Gogh wrote: “…for years I have not seen anything as beautiful as this scene by Lhermitte.” Lhermitte “fils” graduated in medicine in 1907 and specialized in neurology. During the Great War, he studied spinal injuries, and is above all known for Lhermitte’s sign (strictly speaking a symptom, since it is experienced and reported by the patient): an electrical sensation that runs down the spine and into the limbs, which is generated by bending the neck backward or forward. Lhermitte’s sign is most frequently seen in multiple sclerosis, but can also be caused by other conditions, including Behçet’s disease (a form of vasculitis), compression of the spinal cord in the neck, radiation myelopathy, and vitamin B12 deficiency.

Jean Lhermitte (1877-1959).

© Bibliothèque Inter-Universitaire de Médecine (BIUM), Paris.

A variety of eponyms bear witness to the scope of Lhermitte’s work as a clinical neurologist, including Lhermitte-Cornil-Quesnel syndrome (progressive pyramido-pallidal degeneration), Lhermitte-McAlpine syndrome (combined pyramidal and extrapyramidal tract syndrome in the middle-aged and elderly), Lhermitte-Trelles syndrome (lymphoblastic infiltrations of the peripheral nervous system associated with paresis and amyotrophy), and Lhermitte-Lévy syndrome (slowly progressive poststroke paralysis). In 1922, he published a work entitled L’Encéphalite Léthargique, which describes encephalitis lethargica or von Economo disease, an epidemic of which killed hundreds of thousands around the world and left many more in a state of living death—catatonic, speechless, and motionless—between 1915 and 1926. Theories as to its etiology are not lacking, and recent research suggests that an immune reaction may be involved, but its cause remains unclear.

Lhermitte took intense interest in neuropsychiatry and explored the common ground between alleged religious manifestations and medicine, conducting studies on demoniacal possession and stigmatization. In neuropsychology, he made contributions to the understanding of phantom limbs, visual hallucinations (such as the unreal, abnormal phenomena of Lhermitte’s peduncular hallucinosis), spatial thinking, constructive apraxia, and disorders of consciousness.

Paul Castaigne (1916-1988)

Paul Castaigne became an “intern” (house physician) just as WorldWar II broke out and saw active duty at the front with the Army Medical Corps. Back at the hospital he entered the French Resistance alongside Jacques Chaban-Delmas, starting a lifelong friendship. He embarked on a brilliant hospital career becoming, in the 1960s, Dean of the Medical School, when the Salpêtrière merged with its neighbor La Pitié hospital, creating the new Pitié-Salpêtrière Faculty of Medicine. As Dean of the Medical School, Castaigne oversaw the development of a multidisciplinary university hospital where bench-to-bedside research covered many fields, while staying true to the Salpêtrière’s historical vocation of neurology, epitomized today by the work done at the Federative Institute of Neuroscience Research.

Paul Castaigne (1916-1988).

Private collection. Photo courtesy of Dr Micheline Castaigne.

In 1951, he became a household name for generations of French medical students and doctors as one of the founding fathers, then director, of a new medical journal destined for general practitioners, La Revue du Praticien. La Revue, started by Dr André Roux-Dessarps–Baillière, gained instant fame and endures to this very day. When Castaigne retired in 1985 after a quarter of a century as its longest holder, Charcot’s chair at the Salpêtrière was abolished in university reforms over one hundred years after its creation. And with Castaigne went the last direct link to Charcot. In 1891, Charcot examined 12-year-old Elisabeth H., who suffered from a particular type of progressive muscular atrophy, which later became known as Charcot-Marie-Tooth disease. Four years later, Elisabeth entered the Salpêtrière and long afterwards, shortly before her death, she was examined by Paul Castaigne, newly appointed to the chair created for the man who started it all, Jean-Martin Charcot.

The Pitié-Salpêtrière Hospital today.

© Yoan Valat/epa/CORBIS.


Jean-Martin Charcot and his illustrious aforementioned followers at the Pitié-Salpêtrière Hospital: Joseph Babinski, Pierre Marie, Jean Lhermitte, and Paul Castaigne—but there were many others—were the trailblazers of French neurology. They all assisted the present-day Pitié-Salpêtrière Hospital in gaining the top international reputation it enjoys today as one of the world’s leading centers of neurology and neuroscience.

It is perhaps fitting to leave the last word on Jean-Martin Charcot to his students. A decade after hismentor’s death, Charles- Joseph Bouchard (he of the Charcot-Bouchard aneurysm) wrote:

It was Charcot who shaped our intellects; it was he who opened the gates to scientific work, it was he who took my hand and led me to the highest academic position I could reach. Confronted with his memory, I shall always feel the deepest gratitude.

And the young Sigmund Freud, who attended some of Charcot’s Tuesday neurology classes, wrote in a letter to his fiancée Martha Bernays, later his wife and the mother of their six children, how he would leave Charcot’s courses full of new ideas, his mind abuzz as after a good evening at the theater. “Will the seed produce fruit?”, Freud wondered. “I know not, but this I do know: no other man has ever had as much influence on me.” _

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