The Sign of Babinski

For every student of medicine, the name Babinski immediately invokes the image of an upgoing toe. But the contributions of Joseph François Félix Babinski to neurology and neurosurgery were indeed more far-reaching—his legacy marked an exemplary chapter in Parisian medicine.Babinski was Jean Martin Charcot's favorite pupil. While the turbulent political scene of the mid-19th century did not affect Charcot, who was busy establishing the world's leading center of neurology in Paris, Babinski's parents were violently uprooted from their native Poland when an uprising against the Russian domination failed. Babinski's parents eventually settled in Paris, where they had 2 sons, Henri and Joseph. The brothers would remain inseparable to the end.Joseph Babinski (1857–1932) was brought up in modest circumstances in Paris. He studied medicine and graduated from the University of Paris in 1885. Prior to graduation, he was appointed an intern at the Hôpitaux de Paris in 1879. Working under the famous neurologist Edme Vulpian aroused Babinski's interest in neurology. He served as chef de clinique to Charcot at the Salpêtrière. Babinski obtained his doctorate with a meticulous thesis on the topography of lesions and their correlation with symptomatology in multiple sclerosis.When Babinski appeared for the highly competitive examination of Professeur agrégé, he was not deemed successful due to an unfortunate and regrettable estrangement between Charles Bouchard, who conducted the examinations, and Charcot. Bouchard passed one of his own students and eliminated Babinski, who was Charcot's pupil. Thus Babinski, who was viewed by many as Charcot's successor, could not take up an academic appointment at the university. Instead, he served as head of the neurological clinic of the Pitié hospital in Paris from 1890 to 1927. In one sense, being spared the burden of academia and hours of systematic teaching allowed Babinski to become one of Paris' exemplary clinicians who could devote time to his 2 passions: clinical neurology and research.Before he devoted his life to neurology, Babinski excelled in general medicine. He made several noteworthy contributions in medicine, including work on typhoid fever, aortic aneurysm, hysteria, pupillary abnormalities in neurosyphilis, and vertigo. He stressed the role of suggestion in the production of hysterical symptoms. In 1900, a year before Alfred Fröhlich, Babinski provided an accurate clinical account of the adiposogenital syndrome and its relationship to the hypophyseal-hypothalamic dysfunction.Babinski also was drawn to microscopic examination of tissues. His pathologic studies encompassed neurogenic and myopathic muscle disease, transverse myelitis, and multiple sclerosis. He recognized the relative axonal sparing in multiple sclerosis and collaborated with Jean Nageotte on medullary lesions (Babinski-Nageotte syndrome). In 1913, he published a classic paper on cerebellar disease. Babinski introduced the concepts and terminology of asynergy and adiadochokinesis. In 1914, he described anosognosia (Babinski-Anton syndrome).Several of Babinski's publications dealt with neurosurgical topics. He localized spinal tumors for surgical extirpation. Babinski suggested a role for surgical decompression in the setting of increased intracranial pressure and described relief of papilledema with surgical decompression. Many of his writings focused on brain tumors, including a report of an intracranial meningioma successfully treated by surgical extirpation.Babinski played a key role in the evolution of French neurosurgery as a separate discipline. He encouraged his pupils, Thierry De Martel and Clovis Vincent, to pursue careers in neurosurgery. Both De Martel and Vincent emerged as pioneers of modern neurosurgery in France.Although his teaching demonstrations did not have the theatrical quality of his mentor Charcot, Babinski was an outstanding teacher. His written communications were brief and to the point; his most famous communication on the plantar reflex was only 28 lines long. In 1900, along with other celebrated clinicians such as Edouard Brissaud, Pierre Marie, and Joseph Dejerine, Babinski established the Society of Neurology in Paris and served on the editorial board of Revue Neurologique. He authored many scientific works and established a bibliography of some 288 titles. He also served on the editorial board of Neurologia Polska and maintained close links with Polish universities.Babinski was a meticulous clinician. He examined patients himself, scrutinizing every detail, repeating every maneuver, and comparing the results between different patients. He was tireless and patient, doubting what he observed until his methodical assessment and perseverance proved him right. Babinski's objective was to establish clinical signs that allowed for authentication of organic conditions and aided in disease localization.Turning now to that famous reflex, Babinski's seminal paper on the subject was presented in 1896. As medical historians would recount, observant Renaissance artists some 4 centuries before Babinski had illustrated the upgoing toe in infants. However, Babinski established the tremendous clinical significance of the reflex.Having dealt with many of Charcot's hysterical patients, Babinski was determined to find a reliable method of distinguishing true neurological affliction and organic disease from hysterical symptomatology. His 1896 communication on the plantar response was only 28 lines long, but it defined this response and its relationship to organic lesions of the nervous system and spastic paresis of central origin. Babinski's continued research on the plantar response showed that the extensor response was absent in hysteria, and that it was present in infancy and transiently appeared in epilepsy and strychnine poisoning. Two years later, Babinski gave a full account of the diagnostic significance of the toe phenomenon as an indication of pyramidal dysfunction. It was in a subsequent communication in 1903 that Babinski described the associated fanning of the outer toes (signe de l’éventail).While his name is immortalized in that famous cutaneous plantar reflex, Babinski did not regard that as his most significant medical contribution. He regarded having “pointed the way to Martel and Vincent,” pioneer figures in French neurosurgery, as a particularly significant achievement.Babinski was close to his brother, Henri, who died in 1931. Joseph Babinski, who suffered from parkinsonism, did not survive long after Henri's death, and he passed away October 30, 1932.

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