History of Neurology
Adolphe Gubler (1821–1879) or Parisian neurology outside La Salpeˆtrie`re in the age of Jean-Martin Charcot
O. Walusinski
20,ruedeChartres,28160Brou,France
The eponymous Millard-Gubler syndrome is familiar to neurologists[1].In1856,AugusteMillard(1830–1915),who wasstillaninterneoramedicalstudentlivingandworkingin theParishospitals,wroteareportonthepresentationthat his colleague Hippolyte Se´nac (1830–1892) gave to the members oftheSocie´te´ Anatomique. Drawing on thecases reportedinthe1851thesisofPierre-HenriJosias(1825–1895) [2], Se´nac gave a complete clinical picture of crossed hemiplegia. Apparently unaware of this work, Adolphe Gubler(1821–1879)alsodefinedin1856‘‘crossedparalysis, this singular variety of hemiplegia in which the face is paralysedononeside,whilethelimbsareparalysedonthe oppositeside’’[3].Inthisfirstpublication,Gublerdeduced
‘‘probabledamageofthepons’’because‘‘thefacialnerves thatproject totheponsare alreadycrossed,whereasthe tracts that project to the limbs are not yet crossed’’. He provided otherclinicalandanatomopathological evidence for this localization in asecond publication in 1859 [4,5].
Gubler officially accepted sharing credit for this first description withMillardinaletter senttothejournal,as demandedbyMillard![6].
FollowingabriefbiographyofGubler,wewillshowhowhe usedhisobservationalskillsasanexpertcliniciantostudythe many facets of neurology, resulting in a wide range of publications, especially as evidenced by the theses of his students.
info article
Articlehistory:
Received26January2018 Receivedinrevisedform 18June2018
Accepted3July2018
Availableonline26March2019
Keywords:
Crossedhemiplegia AdolpheGubler
Millard-Gublersyndrome Migraine
Aphasia
Acuterheumaticfever Octavelandry
abstract
AdolpheGubler(1821–1879)isatypicalexampleofa19thcenturyhospitalphysicianinParis.
HeadofamedicalunitatBeaujonhospitalin1855,hewasnominatedtothetreatmentand pharmacognosiaChairin1868.Hetrainedmanystudentswhobecamehisdisciplesand remainedveryclosetohim.Gublerpublishedprolificallyinallareasofmedicine.Hismost well-knownworkisclearlyhiscontributiontothestudyofvascularaccidentsaffectingthe brain stem, which Auguste Millard worked on simultaneously; hence the eponymous Millard-Gublersyndrome,anexampleofcrossedhemiplegia.Followingabriefbiography, wewillpresentGubler’smainpublicationsintheareaofneurology:onmigraine,neuro- logicaldamageduringacuterheumaticfever,aphasia,andtheautonomicnervoussystem.
MuchofthisworkwascarriedoutthroughstudentthesesthatGublerdirected.Thefameof hiscontemporaryJean-MartinCharcot(1825–1893)eclipsedthatofGubler,eventhoughthe latterwaswellknownandrespected amongParisianprofessors. By tyingtogetherthe diversethreadsofhiswork,wehopetorenewinterestinthis19thcenturyneurologist.
#2019ElsevierMassonSAS.Allrightsreserved.
E-mailaddress:walusinski@baillement.com.
Availableonlineat
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https://doi.org/10.1016/j.neurol.2018.07.010
0035-3787/#2019ElsevierMassonSAS.Allrightsreserved.
1. A biography
Adolphe (Nicolas, Marie) Goblet, who went by the name AdolpheGubler,wasbornon5April1821inMetzinNortheast France.Hisfatherhaddiedbeforehisbirth,andhismother,
unabletoprovideforhisupbringing,senttheyoungAdolphe tohersisterinRocroyinNorthernFrance.ThereGublerwasa brilliant student throughout his primary and secondary studies, withaparticularlikingforclassicaltextswhich he readfluently inbothLatinandGreek.Buthistruepassion, fromchildhood,wasthestudyofplantswhichhecollected duringwalksthroughthecountrysidewithhisuncle,whohad beenamilitarypharmacist.Proudofhisherbariumwhichhe had patiently classified, he went so far as to attempt the beginnings of a new classification system! Once he had obtained both the scientificandliterary baccalaureates, he enrolledattheFaculte´ deMe´decineinParis,‘‘fullofenthusiasm but withmeagerfunds’’ [7].In1844,Gublerwasanexterne,
‘‘non-residentialstudent’’,andworkedunderArmandTrous- seau(1801–1867), whoadmiredhisbotanicalknowledge.To assist Gubler financially, Trousseau helped him obtain a position to accompany a rich young ‘‘melancholic’’ on a voyagetoSwitzerlandandItaly,withtheaimofimprovingthe patient’smood.OnenightinMilan,Gubler’scharge,overcome with hallucinations and delusions of persecution, shot at Gublerthentriedtostabhim.Thebulletthatlodgedinhis thoraxwasnotremoved.Later,‘‘he quiteoftendescribeda paininhissideandwouldsay:‘Icanfeelmybullet’’’.Hisface, neck,andchestwerelacerated,leavingscarswhichhealways triedtocoverby wearinghishairlong and withsideburns (Figs.1and2)[7].Thisseriousaccidentdidnotpreventhim frompassinghisfirstattemptatthe1845competitiveexamto becomeaninterne,‘‘full-timeresident’’,intheParishospitals.
In 1849, Gubler defended his thesis: Des glandes de Me´ry (vulgairementglandesdeCooper)etdeleursmaladieschezl’homme (Me´ryglands(commonlyknownasCooperglands)andtheir diseasesinman)(Fig.3).HethenservedunderJean-Baptiste Bouillaud (1796–1881)aschefdeclinique(orchiefinterne)and soon thereafter passed hisfirst attemptat the competitive examtobecomeahospitalphysician[8].Advancingswiftly, Gublerwentontoentertheuniversityphaseofhiscareerby passingtheagre´gationexamin1853:‘‘Amonghisfirstworks, Fig.1–AdolpheGubler.InDr.A.Corlieu,Centenairedela
Faculte´ deMe´decine1794–1894.Alcanetal.,1895.(Private collectionoftheauthor).
Fig.2–AdolpheGublersurroundedbyhisstudentsatBeaujonhospitalin1877.(Privatecollectionoftheauthor).
oneofthemostimportantwas undoubtedlyhisagre´gation thesisoncirrhosis,athesisstillconsideredclassicalinthatit containsthemostexactdescriptionoftheanatomicallesions causedbythisdisease,aswellasthemostrationalexplana- tionofthemetamorphosesthatthecirrhoticliverundergoes’’
(Fig.4)[7,9].
On 28 July 1856, Gubler married Jeanne-He´le`ne David d’Angers(1836–1926),thedaughterofthesculptorPierre-Jean Davidd’Angers(1788–1856);theywouldhave onedaughter.
GublerspentmostofhishospitalcareeratBeaujonHospital, wherehetaughtcoursesinmedicalpathology.Afterreplacing Gabriel Andral(1797–1876), who heldthe Chairof General PathologyandTreatment,in1858and1859,Gublersucceeded GermainSe´e(1818–1896)in1868,thereafterholdingtheChair ofTreatmentandPharmacognosiaattheFaculte´ deMe´decine.
‘‘Gubler was a man of learned societies; he assiduously attendedsessions andcontributed thefruitofhislabours’’
[10].Gublerwasvice-presidentoftheSocie´te´ deBiologiein1852, afterservingasoneofthesociety’sfoundingmembersin1848.
Hewasalsovice-presidentoftheSocie´te´ deBotaniquefrom1862 to1866.‘‘Oncehehadfoundedhistheories,hecherishedthem asonedoeschildren.Hedefendedthemfervently,andalmost alwayswithsuccess’’.In1865,hewaselectedamemberofthe Acade´miedeMe´decineinthe‘‘treatmentandmedicalnatural history’’section.GublerfoundedtheJournaldeThe´rapeutiquein 1874, published by Georges Masson (1839–1900), which
remainedinprintafterGubler’sdeathuntil1883[6].Andon 11September1865,hewasawardedtheChevalierdelaLe´gion d’honneurmedal[11].
‘‘The memoryof his difficulties as a young man made Gubler particularlycompassionate towardstrugglingyoung students,andwenowknow,fromatleastsomeofthosewho haven’tforgotten,thathehelpedmorethanonestudentavoid the deprivations hehimself hadsuffered’’ [6]. Every Friday evening,Gublerandhisfriendsgatheredforurbanediners.His closest and most faithful friend was Alexandre Bonnefin (1832–1911);amongsttheotherswereHermannPidoux(1808–
1882),JulesCloquet(1790–1883),andHenriBouley(1814–1885).
In 1874,Gubler boughtCloquet’sproperty in theLamalgue district of Toulon (Southeast France), where a hotel now stands,onrueGubler.On20April1879,GublerdiedinToulon ofstomachcancer,atage58[7,8,12].
The mostsignificant of Gubler’s manyand variednon- neurological contributions include his description of liver damage in syphilitic new-borns, the ‘‘signe dela pommette’’
(during pneumonia,cheekbone rednessisindicative ofthe sideofpulmonarydamage),isolationofherpesesophagitis, introductionofthetherapeuticuseofjaborandi,rationaliza- tion oftheuseofpotassiumbromide,refutationofhomeo- pathy [13], definition of physiochemical acid conditions favouring the spread of oral thrush, and research on proteinuriawhichheconsideredtobeasymptomandnota disease.‘‘Hewasoneofthefirsttousemicroscopesforclinical work’’, which led him to describe, among other things,
‘‘epithelial cell casts, granular casts, and hyaline casts in urine’’[7,8]. Gublerbegan topresideoverthejuriesforhis doctoral studentsin 1869.Their thesissubjectscovered all aspectsofmedicine.
2. Error of an interne who went on to fame:
Octave Landry
OctaveLandry(1826–1865), whopassed theinternatcompe- titiveexaminationin1849,workedasaninterneunderGubler in1853[14].Thepreviousyear,hehadpublishedanarticle entitled ‘‘Recherches physiologiques et pathologiques sur les sensations tactiles’’ (Physiological and pathological research on tactilesensations).Init,hewrote: ‘‘Temperaturesensa- tionsaredistinctfromandindependentoftouchandpain’’
[15].In1855,hewasthefirsttodeveloptheconceptof‘‘the sensation of muscular action’’—that is, the concept of proprioception and stereognosis, based on observations gatheredin thedepartments ofGublerat BeaujonHospital and Claude-StanislasSandras(1802–1856) attheHoˆtelDieu Hospital[16].
Ofnoteamongthequestionsposedbythejury,listedinthe back ofLandry’sthesis,isapathologicalanatomyquestion concerning:‘‘Apoplexyoftheponsandthespinalcord’’[17].
ThereisnowayofknowingLandry’sresponseonthedayof hisdefence,butinhisTraite´ completdesparalysiespublishedin 1859,hecontestedthetheoryproposedbyhisthesisdirector, Gubler, in1853: ‘‘Mr. Gubler’s position, perfectly plausible, assumesscientificbackingforahighlycontestableassertion:
the decussation of nerve roots themselves’’. Landry was wrong;hiserrorlayinconsideringtheponstobespecificallya Fig.3–CoverofAdolpheGubler’sthesis,defendedin1849.
(Privatecollectionoftheauthor).
centreofmotionandsensationandinbeingunawareofthe existenceofacorticobulbartract:‘‘Asameansoftransmis- sion,themesencephalonextendsitsinfluencethroughoutthe body; but, as a motor and sensory centre, its influence is limitedtotheorganstowhichitprojectsnerves[...].Wenow understandwhydamagetotheponsalwaysresultsincrossed hemiplegiain thelimbs and trunk,whereas forthe faceit sometimes leads to crossed hemiplegia, sometimes to ipsilateral weakness or hemiplegia’’. Gubler, on the other hand,hadthepresciencetoassert:‘‘Theoriginatingfibresof facialnervescrossatcertainpointsalongtheirpathand,for example,thenervethatemergesontheleftsideofthepons originates on the right sideof the encephalon, or at least derivesitsmotorfunctionthere’’(Figs.5and6).Inneitherof thesetwopublicationsdidGublerrefertoparalysisofocular motion.
AsnotedbyFe´lix Fe´re´ol(1825–1891)[18], thecredit‘‘for havingstudiedand interpretedoculardeviation’’ —thatis,
paralysisofthe lateralityofvision associated withcrossed hemiplegia—shouldbeattributedtoAchilleLouisFovilleor Defoville(1831–1887)(Fig.7).Fovillehadnoted:‘‘Thedecussa- tion of the roots of the facial nerve has been established beyonddoubtbyMr.VulpianandMr.Philipeauxthroughtheir importantworkontheoriginsofthecranialnerves’’[19].Jean- MariePhilipeaux(1809–1892)wasanassistanttotheholderof the ChairofComparative PhysiologyPierreFlourens(1794–
1867)at theMuse´umd’HistoireNaturelleinParis.WithAlfred Vulpian(1826–1887),hehadindeedpublished,in1853:‘‘Essai surl’originedeplusieurspairesdesnerfscraˆniens’’(Essayonthe origin of several pairs of cranial nerves), which was the commercialeditionofVulpian’sthesis[20].Inhis26July1864 lesson, Vulpian gave an accurate report of semiology and anatomopathology of facial paralysis by localization of an ischaemicaccidentinthepons[21].Fe´re´olwouldbethefirstto give theanatomoclinical demonstrationofthe connections betweenthenucleiofthethirdandsixthcranialnerves,which Fig.4–AdolpheGubler’sagre´gationthesisdedicatedtoPierre-OscarRe´veil(1821–1885).(Privatecollectionoftheauthor).
Fovillehadonlysuspected[22].Fe´re´ol’sstudentGastonGraux (1848–1825)wouldmakethisthesubjectofhisthesisin1878 (Fig. 6) [23]. The anatomical and experimental research of GrauxwouldbeconfirmedbyJean-BaptisteVincentLaborde (1830–1903)andMathiasDuval(1844–1907)in1880[24].
Gublerdirectedandpresidedoverthethesesofthreeofhis studentswhohadstudiedcrossedparalysis.In1847,Victor Fontorbe (1850–1901) described an aneurysm in the right vertebralarterycompressingtheponswhichinturncaused left hemianaesthesia with right facial paralysis, but the associationwithmiddlecerebralarterythrombosismayhave also explained the left hemiplegia [25]. In 1876, Victor Schoepfer(1851–?) reported acase ofcomplete hemiplegia with anaesthesia, remarkable due to the appearance of hemiataxiaduringregressionofthemotordeficitindicating damagetothemiddlecerebellarpeduncleatthebaseofthe pons[26].In1877,Le´onFeuillet(1852–?)soughtto‘‘establish thathemianaesthesiaoriginatinginthemesencephaloncould
be real,complete, and comparablein intensity tocases of cerebralhemianaesthesia’’associatedwithcrossedhemiple- giaasdescribedbyGubler.
3. Je´re´mie Girard and ‘‘cerebral rheumatism’’
Bouillauddescribed‘‘rheumaticendocarditis’’,thatis,heart damageduringacuterheumaticfever,in1840[27].Germain Se´e(1818–1896)wrotein1850:‘‘Rheumatismfrequentlyaffects thenervoussystem,resemblinginitscharacteristicsneuroses or simulating phenomena, either isolated or grouped, of Fig.5–Me´moiresurlesparalysiesalternes(Dissertationon
crossedparalysis),AdolpheGubler1859.(Privatecollection oftheauthor).
Fig.6–PlateillustratingthethesisofGastonGraux(1848–
1925)in1878.Contributiona` l’e´tudedeslocalisations ce´re´brales(me´sence´phale):delaparalysiedumoteuroculaire externeavecde´viationconjuge´e(paralysiecentraleparle´sion dunoyaudela6epaire)(Contributiontothestudyof cerebrallocalizations(mesencephalon):externalocular motorparalysiswithconjugaldeviation(centralparalysis bydamagetothenucleusofthesixthcranialnerve)).
(Privatecollectionoftheauthor).
diseasesoftheencephalon,thespinalcord,ortheirenvelopes [28].TheexamplegivenbySe´e,whichhisstudentJacques- PierreBotrel(1819–?)revisitedinhisthesis[29],wasthechorea theyhadbeenthefirsttoassociatewithacuterheumaticfever:
‘‘Choreaisthe resultofrheumaticdiathesisand resultsin plastic inflammation of the heart membranes, meninges, pleura,andperitoneumwithorwithoutrheumaticfever’’.
PayinghomagetohismentorBouillaud,Gublerextended the scope of this type of pathology in 1857: ‘‘Ingenious observershaveshownusthatrheumatismattacksbyturns the various serous membranes as well as the articular capsules, and it affects the various viscera involved’’ [30].
Gubler’sin-depthhistoricalresearchledhimtoconcludethat
‘‘thephenomenaremainthesame;onlytheinterpretations havevaried,dependingonthephysician’spointofview,and on the state ofscience in the country and period of each physician’’; he then proposed various observations to demonstrate that in addition to chorea, other types of neurologicaldamage wereassociatedwithacuterheumatic fever.Forhim,‘‘unece´phalalgiedeformegravitive’’(thatis,a serious, severe headache that worsens when the head is movedforwardorback)couldinauguratethefever.Momen- tarydeliriumormeningoencephalitismayalsobelinkedto rheumatism:‘‘Asacause,rheumatismoftenimpactstheheart duringgeneralizedacuterheumaticfever,andendocarditisis the rule. Consequently, why not recognize that cerebral accidents,muchmoreexceptionalinfact,occurinthesame way?’’He nonethelessrefutedthe existence of‘‘rheumatic apoplexy’’.Hispathophysiologicalexplanationishypotheti- cal:‘‘Thecausalactionofrheumatismappearstoinvolvethe
serovascularenvelopeoftheencephalon,thislatterordinarily becoming the pointofinflammation,but consecutivelythe corticalsubstanceparticipatesintheinflammation’’[30].His studentJe´re´mieGirard(1835–?),confrontedwithcasesofrapid death and unable to find macroscopic traces of cerebral lesions, provided aprescient and clear-sightedexplanation thatisalsoelegantlyphrased:‘‘Wehavenoshameadmitting thatwhenthescalpelfailsinthesearchforlesionsinanillness clearlyobserved,theorganicdamage,invisibletooureye,is entirelyinteriorandinthiswaymolecular’’[31].BenjaminBall (1833–1893) was inspired by the writings ofGubler and by Girard’sthesisforhisownagre´gationthesisdefendedon14 March1866:Durhumatismevisce´ral[32].
4. Ulysse Bailly and paralysis in various diseases
AlfredMaingault(1823–1884)defendedhisthesison11August 1854 entitledLaparalysieduvoiledupalaisa` lasuited’angine (Paralysisofthesoftpalatefollowingangin[33],withAchille- PierreRequin(1803–1854)presidingoverthejury.Maingault identifieddiphtheria,describedbyPierreBretonneauin1826 [34],asthecauseofparalysis.Inspiredbythis,Gublercollected over several years cases of acute illness accompanied by paralysis,eitherintheacutephaseorduringconvalescence.
This explains his statementthat ‘‘I engagedDr. Landryto carefullygatherandpromptlypublishsuchcasesofascending paralysis,whichhehadstudiedespecially,butalsotoprovide important evidence supporting my proposition’’; said pro- positionbeingthat‘‘generalizedparalysismayfollowonfrom aseriesofacuteillnesses,notonlythosethatarevirulentor septicsuchascholera,dysentery,typhoidfever,anderuptive fevers,butalsothosethatareclearlyinflammatory,suchas tonsillar angina, herpetic tonsillitis, and pneumonia’’ [35].
Gubler surveyed all of these pathologies using numerous clinicalcases.Eruptivefever(measles,scarletfever,smallpox, erysipelas) and typhoidfever maybefollowedby ‘‘general paralysis’’, ‘‘general anaesthesia’’, or convulsions, but the cause,accordingtoGubler,couldnotbeassessedduringthe anatomopathologicalexam.‘‘Encephalitismaybethesiteof prolonged functional disturbance,even when what canbe calledthemolecularmodificationsofthesubstancecannotbe detectedbycurrentmeansofinvestigation,whichmeansthat paralysis can exist without noticeable (detectable) cerebral lesion.Hesometimesobservedabnormalmovements,suchas
‘‘astrangeplayofsudden,disorderly,choreoid,contractions throughout much ofthe body’’,for whichhe mentioneda possible cerebellar cause, with reference to recent experi- mentsbyFlourensontheroleofthecerebelluminmovement control.Gublersoughttoavoidanover-simplificationpopular inhisday,whichinvolveddiagnosingdiphtheriaassoonas paralysisappearedduringfever.
On11January1872,Gublerpresidedoverthejuryforthe thesisofhisexterneUlysseBailly(1846–1909)[36].Baillyadded several observations in order tosupport the theory ofhis teacherbut,morespecifically,hereportedontheanatomopa- thologicaldiscoveriespublishedbyJean-MartinCharcot(1825–
1893)andVulpianin1863[37]—peripheralnervedamagein theabsenceofmusculardamageduringdiphtheria—asan Fig.7–«Uncasd’he´miple´giealternecomplique´ destrabisme
internebilate´raletdeglossople´gie»(Acaseofcrossed hemiplegiacomplicatedbybilateralinternalstrabismus andglossoplegia),AchilleSouques,NouvelleIconographie deLaSalpeˆtrie`re1891;4:358-361.(Privatecollectionofthe author).
argument for the theory defended by Gubler. Thistype of neurological pathology would not be explained until the discoveriesofLouisPasteur(1822–1895), thenthenotion of bacterialtoxins,followedbytheemergenceofimmunology.
WeshouldcreditGublerwithhelpingtolistandidentify thistypeofpathology,butalsowithallowingLandrytoisolate
‘‘acuteascendingparalysis’’[38],beforesuchpathologieswere re-evaluatedin1879byJulesDejerine(1849–1917)inhisthesis [39],andin1916byGeorgesGuillain(1876–1961)andAlexandre Barre´ (1880–1967),under the eponymousname stillin use today,Guillain-Barre´ syndrome[40].
5. Arthur Bordier (1841–1910) and migraine
In 1873,Ame´de´e Dechambre (1812–1886)asked Gublerand ArthurBordier(1841–1910),hisinterne,towritethemigraine entryinthe DictionnaireEncyclope´diquedesSciencesMe´dicales.
Afteradescriptionofmigrainethatmighteasilybefoundina publicationtodaywithnoneedforrevision,Gublerrecalled thatPierre-AdolphePiorry(1794–1879)[41]had‘‘insistedona particularformofthecondition(irisalgicmigraine)inwhich opticaldisturbanceisparticularlyintense;acloudseemsto appearinthecentreofthe imagerubbedoffontheretina, followed by the appearance of luminous arcs around a darkenedpoint,andonthispointtherearezigzagginglines offirethatproducecontinualscintillation’’.Theaccuracyof thisdescriptionisinfactbasedonself-observationbyPiorry [42].Gublerdidnotomitanyoftheclinicalaspects,neither susceptibilitytoodours,norvomiting,northereliefbroughtby sleep,nor factorsfavouringthedisturbance,northefavou- rableprognosis,etc.Hesurveyedthediversepathophysiolo- gicalopinionsofferedatthattime,andproposed,presciently, that: ‘‘Trigeminal involvement seems incontestable.’’ For Gubler,reliefcouldmostoftenbeobtainedfromopium,rest, anddarkness.Andheconcludedthatthephysician‘‘cantake heartinthefactofatleastprovidingsomerelief,evenifheis notalwaysabletocure’’.
6. Arthur Bordier and ‘‘vasomotor nerves’’
In1868,thethesisofBordier,dedicatedtoGublerbutpresided overbyAlexandreAxenfeld(1825–1876),reviewedknowledge about the physiological role of the ‘‘ganglionic nervous system’’, that is, the autonomic nervous system, by its sympatheticcomponent, as it was understood at the time following the work ofClaude Bernard (1813–1878). Bordier referencedthe strangetheory ofGubler: ‘‘The sympathetic nervoussystemisasortofcondenserthatreceivestheenergy givenoffbyrespiratorycombustionandtransmitsittocentres ofinnervation.Whenitactsinthismanner,thevesselsare contractedandthereislittleheat.Ontheotherhand,whenit stops drawing the energy for chemical actions from the vessels,calorificationintensifiesandthecapillariesrelease’’
[43]. Bordiercited,asanexampleoftheganglionicnervous system, cheekboneredness duringpneumonia,a sign des- cribedbyGubler[44].AttheendofBordierlengthythesis,he attempted tolist the medications modulating sympathetic action,suchasopium,belladonna,ryeergot;healsonotedthe
indications, referring each time to examples from the teachingsofGubler[45].
7. Alcide Rontin (1844–1903) and aphasia
Afterworking under Gubler as a temporaryinterne, Alcide Rontin(1844–1903)defendedtheopinionofGublerinhis1873 thesis, which was based in part on the theories of Pierre Gratiolet(1815–1865)andonTrousseau’slessons.Headmitted that ‘‘whenI wasaninterneIborrowedfromhim[Gubler]
someofmymostcuriousclinicalthinking’’[46].Thenhenoted straightawaythataphasiawasasymptomandnotadisease:
‘‘We will adopt the opinion of Bouillaud, who places the coordinatingcentreofthought,thelegislativepowerofspeech intheanteriorlobesofthebrain’’.
After analysing the writings of Paul Broca (1824–1880) [47,48] and Adrien Proust (1834–1903) [49], and essentially rejectingthem,RotinputforwardtheopinionofGubler:‘‘Ifthe damageinaphasiaisalmostalwayslocatedontheleft,thisis becauseofasortofpathologicalselectionofwhichwepresent numerousclinicalexamples.Whoisunawareofthefactthat ninetimesoutoftenintercostalneuralgiaaffectstheleftside?
Anddoesn’trheumatism,asestablishedbyBouillaud,affect almost exclusively the left part of the heart? He localized
‘‘intelligenceandmemoryintheanteriorlobes’’.Accordingto Gubler,speechalsodependedonthe‘‘medullaoblongata’’,the locationofthe‘‘systemofexecution’’.ForGublerandRontin, aphasia‘‘islinkedtoalesioneitherintheanteriorlobesorin transmission fibres or in the system of execution’’, and amnesia‘‘isoneofitsforms’’.Asfortheaetiology,‘‘allofthe causesthatdisturbencephaliccirculationanddamagebrain substance at one or several of its points, may produce aphasia’’. Gubler’s thinking on aphasia was not carried forwardbyanyone.Hisanatomopathologicalbasesarepoorly established, as Rontin’s reading indicates. The distinction betweenthoughtandlanguageisclearandvariesaccordingto theexamplesused.Finally,Gubler’sabsencefromthesessions oftheSocie´te´ d’Anthropologie,wheretheproductivediscussions between Gratiolet, Ernest Auburtin (1825–1893, Bouillaud’s son-in-law),andBrocatookplace,meantthatGubler’s‘‘most curious’’ ideas based on approximative physiology were excludedstraightaway[50].
8. Lucien de Valicourt (1853–1920) and hemiplegia observed during pleurisy
The pathophysiology of thrombosis and embolism was a frequently debated subject at the beginning of the 19th century. The first thesis mentioning inflammation and intracardiacbloodstasis asfactors favouringtheformation ofaclotwasdefendedbyCharlemagneLegroux(1798–1861)in 1827 [51]. During a discussionat the LaSocie´te´ me´dicale des Hoˆpitaux,Gublerspokeof‘‘erraticblockages’’in1857toreferto amigratingorembolicclot[52].Thisideawasrevisitedbyhis studentLuciendeValicourtdeSe´ranvilliers(1853–1920)[53];
GublerpresidedoverthejuryforValicourtdeSe´ranvilliers’s thesison8November1875.Gubler’sstudentincludedafew hemiplegia observationsduringinfectious pleurisy.He pro-
posedanembolicmechanismcausingmiddlecerebralartery thrombosis starting with pulmonary vein thrombosis compressedbysignificantpleuraleffusionand/orneighbour- ingpleural inflammation.He suspected,andrightlyso,the causetobeamodificationofbloodcoagulabilityarisingfrom the inflammatory condition, favouring clot formation, and callingtomindthethesisofLegroux.Healsosuggestedthat Gublerwouldhavereferredto‘‘erraticblockages’’beforethe workofRudolphVirchowpublishedin1856[54]:‘‘Itwasonly thereafter that Virchow, according to the Germans, gave science a new doctrine, a theory resting mainly on his bibliographic and experimental research’’. In fact, it is impossibletoestablishanysortofanterioritybasedonany specificpublicationbyGubler.
9. Homage paid by Charcot
When Charcot gavehislessons on Parkinson’sdisease, he insistedonthedifferentialdiagnosisbetweenshakingatrest and shakinginaction.He recognizedthatonlyGublerhad accuratelyinterpretedthephenomenon,asearlyas1860:‘‘The shaking does not consist in a succession of contrary movementsoutsideofwilfulcontrol,butratherasalternating contractionandreleaseofthemusclesthatareinvolved’’[55].
10. Posterity and fame
In1878,Le´onGinain(1825–1898)wasthearchitectinchargeof enlarging, on the rue Hautefeuille side, the old Faculte´ de Me´decineinParis,whichhadbeenbuiltfrom1774to1786under the directionof JacquesGondouin de Folleville (1737–1818) [56].Tohonourthesolemnityofthecentralstairwayandthe mainhallleadingtothelecturehalls,Ginainhadabustofa formerprofessorplacedoneachofthepilasters[57].Nextto the busts of Gabriel Andral (1797–1876) or Jean-Baptiste Bouillaud(1796–1881),forexample,thebustofAdolpheGubler (Fig.8)atteststotheesteemhiscolleagueshadforhimand theirposthumousacknowledgementofhiswork,whichthey wishedtocommemoratelastinglyin1900.Foroveracentury, thousands of students have passed by without noticing, illustrating the precept of Alexandre Vialatte (1901–1971):
‘‘Statuesmerelypointtowardforgetting;oneisneverdeader than when rendered in bronze’’. It must be realized that, despite Gubler’s numerous works, only the eponymous Millard-Gubler syndromecommemorateshim, and does so almostexclusivelyamongneurologists.
CharcottaughtanatomopathologyattheFaculte´ deMe´dicine from1872to1882.Mostofhisteachingwasconductedatthe La Salpeˆtrie`re Hospital which undoubtedly explains the absenceofabustatthemedicalschool.Hislegitimateglory and international renown result from his isolation and descriptionofneurologicaldiseasessuchasmultiplesclerosis, Parkinson’sdisease,and amyotrophic lateral sclerosis.The publicationsGubler left uscannotrival Charcot’s.Butas a goodinstructor,Gublerformedseveralgenerationsofpracti- tionersoffamilymedicine,coveringalmostallmedicalfields.
Thisis thehighly honourable mission ofamedical school professor,andGublerfulfilleditperfectly.
Disclosure of interest
Theauthordeclaresthathehasnocompetinginterest.
Acknowledgements
AllofmythankstoJacquesPoirierforhiscriticalanderudite readingandforhissuggestions.
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