Historical figure: Dr Joseph Babinski (1857-1932).
Each time a patient is examined somewhere, one looks for Babinski's sign. It is recorded in medical files all over the world, but because the history of medicine is only minimally taught, Babinski remains virtually unknown. At times he is thought to be Russian, some write his name with a Y; the reflex he discovered is sometimes abbreviated as 'Bab' or, less frequently, as BBK.
The essence of Babinski's success was in creating an original approach to the evaluation of the patient, based on a meticulous clinical exam, looking for those abnormal reflexes or 'signs' which he described, often in the face of considerable criticism.
Joseph Babinski: His Life
A Student of Polish Descent
Poland was partitioned in 1795 (and again in 1815) between split Prussia, Austria and Russia. As a result, many families, including the Babinskis, chose to emigrate from Poland, notably to France. Aleksander Babinski, an engineer married in Poland to Henryeta Weren, took voluntary exile in 1848; the couple settled in Paris and had two sons: the elder, Henri, was born in 1855 and Joseph Francois Felix was born on the 17 November 1857, at 5 o'clock in the morning in Paris' XIth district.
During his youth, Joseph Babinski lived through both the Franco-Prussian War between July 1870 to January 1871, and the Paris Commune uprising, with its sad end in May 1871. Following this, Babinski undertook his study at the Faculty of Medicine of Paris in 1875.
Internship and Clinical Residency
In the 'Internat' examination for the year 1879, Babinski came fourth out of the 50 who passed the exam. He published 12 articles between 1882 and 1884; while the subject he wrote about is most often histological, eight of them do have a neurological theme. Babinski is credited with the first basic description of the neuromuscular spindle, as presented in a report to the Academy of Sciences on the 7 January 1884. The subject of his 1885 thesis was: Etude anatomique et clinique sur la sclerose en plaques (Anatomical and clinical study of multiple sclerosis). See the Annex on page 20 for a discussion of this work.
At the Salpetriere Hospital for Elderly Women, Babinski stood little chance of becoming Clinical Assistant to Jean-Martin Charcot, the appointed Professor in the Chair for diseases of the nervous system, or to succeed Pierre Marie, as he had not carried out an internship with him; but the putative candidate renounced the role, and so it happened.
This was the turning point and a defining moment of his career. It would lead him to work side-by-side with one of the most exceptional teachers and researchers of the period and his collaboration with Jean-Martin Charcot continued until 1893. He also became a regular guest at the dinner parties in Charcot's mansion at Boulevard Saint-Germain, Paris.
Later he became Chief of the Department of Medicine in 1894 at Aubervilliers Hospital; in 1896, he transferred to Old Pitie hospital, adjacent to the Jardin des Plantes (the Paris Botanical Gardens) where the Great Mosque of Paris now stands.
Failure at the 'Agregation'
The French 'Agregation' is a national competitive examination which opens the door to a university career--the royal road to becoming a full professor in an established chair. The jury is made up of people having connections to the President of the jury. At the end of 1891, when Charcot's former student, Bouchard was nominated to be President of the jury for the following year, Charcot must immediately have realized the political danger for his protege Babinski. Charcot had been strongly criticized by Bouchard and, consequently, despite his obvious merit, Babinski was passed over in favour of those who had closer connections to the President.
Babinski set out to identify as many traits as possible that were specific to organic diseases. In two lectures, given at the Paris Medical Society on 11 November 1892 and 5 May 1893 respectively, he stated: 'in hysterical paralysis and contractures, tendinous reflexes are unaffected and their excess is not seen in hysteria'. He submitted these facts to his master, Charcot and disturbed him. If Charcot had not died a few months later, he probably would have changed his mind about reflexes, so convincing was Babinski.
On the Cutaneous Plantar Reflex in Certain Organic Diseases
On 22 February 1896, he submitted his article Sur le reflexe cutane plantaire dans certaines affections organiques du systeme nerveux central (On the cutaneous plantar reflex in certain organic affections of the central nervous system) to the Society of Biology (1) in which he first described the reflex we now call the Babinski sign. Following this submission, Babinski gave a lecture to the International Congress in Brussels in 1897 and, according to J van Gijn, (2) with this his international recognition began. The Belgian neurologist A van Gehuchten insisted that the pyramidal tract was responsible for the phenomenon and, in an exchange of letters, this eminent neurologist recognized Babinski's paternity of the sign. (3)
On 27 July 1898, in the Semaine Medicale, Joseph Babinski discussed the plantar reflex: both in the case of central nervous system anomalies and in the healthy newborn infant during his first year, following a moving sensory stimulus, applied to the lateral plantar surface of the foot, there would be a slow extension of the big toe. He gave examples of pathological reflexes in patients suffering from hemiplegia or paraplegia. In contrast the abnormal reflex was never present in hysteria and in afflictions of the peripheral nerves or muscle. (4)
Although a few critical comments regarding these findings were made by neurologists in France and Germany, many very quickly began to look for other similar signs. It is now widely accepted that the inversion of the normal cutaneous plantar reflex (i.e. the Babinski sign) is indicative of corticospinal or pyramidal tract dysfunction in the adult. The phenomenon can be reproduced experimentally in the great apes by destruction of this tract, as proved by John F Fulton and Allen D Keller much later. (5)
Major Advances in the Clinical Examination of Patients
Complementary to this fundamental contribution, on 2 July 1903 in a lecture before the French Society of Neurology, Babinski discussed the reflex movement of the other toes 'spreading out like a fan' (according to Dupre) following extension of the big toe in the case of a syndrome affecting the pyramidal tract. This presentation was illustrated by a fine photograph showing the shadow of the spread-out toes on the opposite leg. (6)
In his discussion of other signs of nervous system disease, Babinski gave a detailed account of the best positions for testing the ankle jerk, insisting particularly on having the patient kneeling. He also discussed the phenomena of areflexia and reflex inversion and stressed the disappearance of the Achilles tendon reflex in cases of sciatica (1896) and in tabes dorsalis (1898). He also noted that percussion of a muscle will cause an idiomotor reflex which was abolished in case of myopathy. This allowed him to differentiate such cases from neuritis (1911). Together with A Charpentier he gave a description of 'polykinetic reflexes'.
Among his main achievement stands the analysis of symptoms pointing to afflictions of the cerebellum. Up until that time, the disturbances of balance caused by cerebellar disorders were confused with locomotor ataxia. By intensively and repeatedly examining a single patient (Henri Mouninou) from 1899-onwards, Babinski was able to deduce the role that the cerebellum played in regulating coordination. When this function was deficient, he described the condition as asynergy (1899). He also explained difficulties in performing rapid alternating movements, which he termed adiadochokinesia (1902). He completed this exceptional case study in 1913, presenting a synthesis of the signs of cerebellar pathology at the London Congress (to a standing ovation). At this meeting he noted that cerebellar pathology was associated with hypermetria and ataxia, which are not aggravated by eye closure, contrary to that which was found in tabes dorsalis.
In 1913, together with GA Weil, he described the 'star pattern' walk of a patient suffering from impairment of the vestibular system. With eyes closed the patient would go forward and then back several times tracing a star pattern on the ground.
Another of his works, read on 6 April 1905 to the French Society of Neurology, differentiates hemifacial spasm and facial tic. In hemifacial spasm there is a paradoxical synergy in which the eyebrow is raised concomitant with contraction of the jaw--as opposed to the eyebrow furled. Always keen on differentiating the organic from the hysterical, he pointed to discrete, but precious symptoms in the case of hemiplegia. He noted that in hemiplegia there is a deficient contraction of the muscle platysma (1897), exaggerated flexion of the forearm on the arm, an inversion of the habitual swinging of the arms while walking and combined flexion of the thigh and trunk.
Babinski completed G Anton's work on corporal representation and its disturbances. These are independent of intellectual impairment and are present due to affections of the minor hemisphere. In Babinski-Anton Syndrome (11 June 1914) there is anosognosia (hemiplegia is not perceived) or anosodiaphoria (the patient is indifferent to the deficit).
Such are the principal contributions of Babinski to semiology, but he also did pioneering work in relating the Argyll-Robertson pupillary sign to neurosyphilis. This was proven by demonstrating the lymphocytosis reaction into the cerebrospinal fluid. (7) An aortic aneurysm can be present, now known as Babinski-Vaquez syndrome. Several other syndromes bear his name: Babinski-Frohlich or adiposo-genital syndrome; Babinski-Nageotte or hemibulbus syndrome, etc. Others can be found in the Bibliography of 288 scientific publications.
Hysteria and Pithiatism
Starting with a lecture to the French Society of Neurology on 7 November 1901, Babinski wrote a great deal on hysteria. In the conclusion he proposed a new term, 'pithiatism', which refers to the effects of persuasion, to replace 'hysteria', a term which had long since lost its original meaning as determined by etymology.
These concepts of hysteria and hypnosis were further developed in the lecture of 28 June 1906. He paid tribute to his master Charcot for having proved that these pathological phenomena also were common in men, in children before puberty and even in the elderly after sexuality has long run its course. He gave an overview of all the diverse symptoms linked to hysteria. On the other hand, he felt that vasomotor pathology (e.g. a disturbance of circulation and body temperature), which was thought at the time to be hysterical in origin, was not related to hysteria, but rather to a reflex disturbance of the sympathetic nervous system.
Progress in Neurosurgery
Concerning cerebral tumours, Babinski put great emphasis on the effects on the papilloedema; the side where the papilloedema is predominant can indicate where the surgeon should apply himself. In 1909 he published an article with T de Martel, about trepanation for a brain tumour (one case with marked improvement) and, in 1910, he wrote a follow-up article on 'decompressive craniotomy' which was then the only means available, but subject to strict protocol.
He explained his reasoning on the localization of medullar compression in a lecture before the Academy of Medicine in 1911: 'Local effects of anaesthesia allow one usually to determine the upper limit of the zone of spinal compression. The lower limit of the compression zone can generally be determined by the limit of the zone of the defence reflexes, flexion of foot, leg or thigh by cutaneous stimulation.' Locating the problem so precisely made surgical intervention possible. As early as 1911 in France, P Lecene performed the first operation to relieve compression of the spinal cord for a patient of Joseph Babinski who had a meningioma.
[FIGURE 1 OMITTED]
His students, the neurologists C Vincent (1879-1947) and T de Martel (1875-1940), both went abroad to train in surgical techniques to alleviate and cure disorders of the nervous system. They introduced these techniques in France. When one friend asked Joseph Babinski in 1932 how he thought his achievement would be judged by posterity, he replied: 'The sign is not really my greatest achievement. It is the way I've shown to de Martel and Vincent'.
Hospital Consultancy and Private Practice
Construction of the new Pitie hospital next to La Salpetriere started in February 1905. In November 1911 all patients were transferred. For his new department Babinski had added several rooms necessary for a complete exam, such as a dark room for exploration of the visual system and a room for testing the vestibular system.
[FIGURE 2 OMITTED]
He ran his private practice during afternoons in his apartment on the third floor at 170 Bis Boulevard Haussmann, where he lived with his parents. After they had died, his brother Henri moved in and lived with him until his death in 1931. He took charge of running the household; managing it so well that he became an expert cook and gourmet, and even wrote a culinary masterpiece, Gastronomie Pratique, which is still greatly prized by chefs.
[FIGURE 3 OMITTED]
In private practice Joseph Babinski was as meticulous as in the hospital, guided by a sincere devotion to his patients. His thinking greatly benefited from his diligence in attending and participating in scientific meetings. On 8 June 1899 he was among the founders of the French Society of Neurology, to which he would present most of his discoveries. Finally, on 3 February 1914 he achieved official recognition by being elected to the Academy of Medicine. On 29 October 1932 he died and was buried in the Polish part of the cemetery in Montmorency. (8)
Although posterity has clearly retained Babinski's name, as it comes up every time a patient is presented on hospital rounds, many of his contributions are now underappreciated even though his discoveries still remain at the heart of good neurological and medical practice. We should not forget Babinski's important warning to future physicians that 'Errors in diagnosis stem far less frequently from faulty interpretation of symptoms than from imperfect observation'.
Joseph Babinski's Thesis: Anatomical and clinical study of multiple sclerosis--1885
1. The fact that secondary degeneration is usually absent in multiple sclerosis does not constitute an exception to Waller's law. This apparent anomaly is due to the fact that axons are usually conserved intact in the plaques. When they are not completely unaffected there develop, as is the case in other destructive diseases of the central nervous system, secondary degenerations whose intensity is related to the number of axons afflicted.
2. Destruction of the myelin sheath in multiple sclerosis is not dependent on any mechanical phenomenon caused by the nerve fibres being compressed by the newly formed conjunctive tissue. On the contrary, it is dependent on vital phenomena, i.e. mainly the nourishing function of the neuroglia and the lymphatic cells.
3. The nature of the degeneration of nerve fibres is analogous to the degeneration observed in the central part of a sectioned nerve fibre, close to the point of section, a great number of naked axons, the intensity of alteration to the vascular lining, the often complete absence of myelin in the centre of the plaque--these constitute, from the histological point of view, the essential characteristics of multiple sclerosis.
JOSEPH BABINSKI; JEAN-MARTIN CHARCOT; PLANTAR REFLEX; HYSTERIA; HISTORY OF MULTIPLE SCLEROSIS
Received: 29 July 2008
Accepted: 19 March 2009
(1.) Babinski J. Sur le reflexe cutane plantaire dans certaines affections organiques du systeme nerveux central. Comptes rendus et Memoires de la Societe de Biologie 1896; 48: 207-208.
(2.) van Gijn J. The Babinski Sign : A Centenary. Utrecht: University of Utrecht, 1996.
(3.) van Gehuchten A. Le phenomene des orteils. J de Neurol 1898; 3: 153-155, 284-286.
(4.) Babinski J. Du phenomene des orteils et de sa valeur semiologique. Sem Med 1898; 18: 321-322.
(5.) Fulton JF, Keller AD. The evolution of cortical dominance. In: The Sign of Babinski: A Study of the Evolution of Cortical Dominance in Primates. (Thomas CC, ed) : Springfield-Baltimore 1932; pp120-139.
(6.) Babinski J. De l'abduction des orteils (signe de l'evantail). Rev Neurol 1903; 11: 1205-1206.
(7.) Dechy A. Le signe d'Argyll-Robertson et la cytologie du liquide cephalo-rachidien. Medical thesis, Paris, 1902 (grandfather of the author).
(8.) Philippon J, Poirier J. Joseph Babinski, a Biography. New York: Oxford University Press, Inc. 2009.
Boulevard du Roi, Versailles, France
Address for Correspondence
Dr Hubert Dechy, 39 Boulevard du Roi 78000, Versailles, France
Tel: +33 (0)1 39 53 20 64
Fax: +33 (0)1 39 51 92 44
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|Publication:||The International MS Journal|
|Article Type:||Brief biography|
|Date:||Mar 1, 2010|
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