History of Neurology
Armand Trousseau (1801–1867), a neurologist before neurology
O. Walusinski
20,ruedeChartres,28160Brou,France
InFrance,Jean-MartinCharcot(1825–1893)isconsideredone oftheoriginatorsofneurologyasaspeciality.Diseasesofthe nervoussystemhavealwaysexistedandwellbeforeCharcot, physicians had noted some of their symptoms. One such physician was Armand Trousseau (1801–1867), among the mostfamouscliniciansinmid-nineteenthcenturyParis.After somebiographicaldetails,wewillreviewhislessonsthatdealt withnervoussystempathologies.
1. Medical studies: Pierre Bretonneau’s influence as his teacher
Armand Trousseau (Fig. 1) was born on 14 October 1801 (23 Vende´miaire an X according to the French revolutionary calendar) inTours,thesonofateacher,NicolasTrousseau (1763–1812), from Berry in central France.His mother was info article
Articlehistory:
Received9November2019 Receivedinrevisedform 11December2019
Accepted11December2019 Availableonline7January2020
Keywords:
ArmandTrousseau DuchennedeBoulogne Historyofneurology Apoplexia
Epilepsy Chorea
Parkinson’sdisease Tourette’ssyndrome Facialpalsy
Tabes Aphasia
abstract
ArmandTrousseauistheemblematicfigureoftheprominentmid-19thcenturyclinician, owingtothequalityofhisteachingandtheinfluenceofFrenchmedicine,whichduringhis timebroughtstudentsfromaroundtheworldtoParis.AstudentofPierreBretonneau(1778–
1862), thefamous physicianfromthe western Frenchcityof Tours,Trousseaucarried forwardBretonneau’sclinicaldescriptionofinfectiousdiseases,developingthenotionof theircontagionandpavingthewaytowardthediscoveryoftheirmicrobialaetiologyby LouisPasteur(1822–1895)attheendofthecentury.Histeachings,LesLec¸onscliniquesde l’Hoˆtel-Dieu,transcribedbyhisstudents,playedaroleintrainingyoungphysiciansforhalfa century.Inthiswork,Trousseaucoveredseveralneurologicaldiseasessuchasapoplexy, epilepsy,chorea,Parkinson’sdisease,andamyotrophiclateralsclerosis.Therich,Balzac- likedetailofhisclinicalpictureswouldbeunthinkabletoday.Whilehecannotbecredited withanyseminaldescriptionsinparticular,someofhisobservationscontainsignificant nuggets,suchasacaseofGillesdelaTourettesyndrome,twentyyearsbeforetheseminal publication. After a biographical account, we will present the main lessons given by Trousseauonneurologicalsubjects.OneofTrousseau’slittle-knowncontributionsisto haveinvitedGuillaumeDuchennedeBoulogne(1806–1875)tohisdepartmentattheHoˆtel- Dieuhospital,settingDuchenneonthepathtobecomingapioneerofParisianneurology.
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Marie-ArmandeCle´rant(1769–1845)[1],whowaswidowedin 1812.Withtwochildrenfromapreviousmarriage,shefound herself ina particularlydifficult financial situation. Oneof these two children, the future general Maxime Jacquemin (1795–1863), would help Trousseau financially during his medicalstudies. Hismother obtained ascholarship forhis secondary education,first at aboarding school inOrle´ans, then in Lyon, where he was a classmate of the future republican historian, Edgar Quinet (1803–1875). Following theseinitialstudies,Trousseauworkedasaprivatetutorin Blois,theninToursbeforebeingnamedtoapositionteaching rhetoric at the age of twenty, at a middle school in Chateauroux,inkeepingwithhisfather’swishes[2].
His fate changed course in 1821, when he met Pierre Bretonneau (1778–1862), chief physician at the hospital in Tours. After a brief conversation, Bretonneau urged him:
‘‘Becomeaphysician!’’ Leavinghis teachingcareerbehind, TrousseauheadedtothemedicalschoolinParis[2].In1822, theAbbotDenisFrayssinous(1765–1841),designated‘‘Grand- Maıˆtre de l’Universite´’’ by the KingLouis XVIII, would order thetemporaryclosureofthisschool.Availinghimselfofthe university monopoly created by Napoleon, he enabled the Catholic hierarchy and the Bourbon monarchy to reclaim poweroverteachingbyappointingprofessorsloyaltothese groups[3].OnceagainTrousseau’sfatetookanunexpected turn.Dislikingthiskindofclericalism,hepreferredtoreturnto
Tours,whereon17January1823,heenrolledasanexterne(a non-residentmedicalstudent),becomingasurgeryresidentin 1824 [4]. During his two years in Tours, he studied with Bretonneauwhobecameakindoffatherfigureaswellasa faithfulfriend.Trousseauwashisbrilliantsuccessorforthe studyofboth‘‘dothie´nente´rite’’(typhoidfever)anddiphtheria.
ReturningtoParisin1825tocompletehisstudies(butnot asaresident)intheParishospitals,Trousseauattendedthe hospitallessonsofJosephRe´camier(1774–1852),HenriHusson (1772–1853), Franc¸ois Broussais (1772–1838), and Franc¸ois Magendie(1783–1855),ashewrotetoBretonneau:‘‘I’mnow intouchwithMr.Magendieandhavearrangedtobeadmitted tohisexperimentalphysiologylessons[...].Hedoesroundsat Hoˆtel-DieuandIamabletowatchhimadministermorphine, hydrocyanic acid,and allthese newmedicines [...]. Ihave ampletimetolearnhowtouseLaennec’scylinder[stetho- scope],sinceonly5or6ofusareparticipatingintheseclinical lessons’’ [5]. It was his friend, also a faithful student of Bretonneau, Alfred Velpeau (1795–1867), who presented TrousseautoAntoine-AthanaseRoyer-Collard(1768–1825),a physicianattheCharentonasylum.InOctober1825,amonth beforehisdeath,thelattergaveTrousseauaresidentposition, includingfood,board,andremuneration.Duringthisperiodin Charenton, Trousseau regularly spent time at the nearby Maisons-Alfort veterinary school, where ‘‘he familiarised himselfwithusingamicroscope’’andcontinuedhisstudies ofexperimentalphysiologyhehadbegunwithMagendie[2].
Forawhile,heconsideredpassingtheveterinaryexamina- tion, followed by ‘‘an apprenticeship with some little blacksmithintheFaubourgSaint-Antoine’’inordertolearn
‘‘those difficult operations of forging and horse-shoeing’’
which caused him apprehension [5]. He did not end up realisingthisplan.
Disappointed with Bretonneau’s unfulfilled promises to pass along manuscripts on diphtheria and typhoid fever whichhewasveryinterestedin,Trousseautooktheinitiative in 1826 of writing an article for the Archives ge´ne´rales de Me´decineentitled‘‘Delamaladiea` laquelleM.Bretonneauadonne´
lenomdedothie´nente´rie’’(OnthediseasethatMr.Bretonneau has named ‘‘dothie´nente´rie’’ [typhoid fever]) [6]. Trousseau showedthesimilaritieswithwhatPhilippePinel(1745–1826) hadcalledadynamicfever[7].Bretonneau’streatise,Traite´ de ladothie´nente´rite,wouldnotbepublisheduntil1922,byLouis Dubreuil-Chambardel(1879–1927).
JoiningforceswithVelpeau,Trousseauobtained permis- sionfromBretonneautopublishDesinflammationsspe´ciales dutissumuqueuxetenparticulierdeladiphte´rite,ouinflam- mation pelliculaireconnuesousle nomdecroup, d’angine maligne,d’anginegangre´neuse(Specialcasesofinflammation ofthemucoustissue,particularlydiphtheritis,orthepellicular inflammation knownascroup,malignantangina,and gan- grenous angina) [8]. Only in 1855 did Bretonneau accept Trousseau’ssuggestiontousetheterm‘‘diphtheria’’inplace of‘‘diphtheritis’’.
2. Thesis, agre´gation, and university career
On19August1825,withajurypresidedbyJosephRe´camier (1774–1852), Trousseau defended his thesis: Des lividite´s Fig.1–PhotographyfromA.TrousseaubyFe´lixNadar
(1861).FrontispieceofthebookCliniqueme´dicaledel’Hoˆtel- Dieu(Privatecollectionoftheauthor).
cadave´riquesducanaldigestif(Livormortisofthedigestivecanal) [9].AsheconfessedtoBretonneau:‘‘Istarteditthedaybefore yesterdayinthemorningandfinisheditlastnight.Imadea potpourri de resorption, marsh fever, dothie´nente´rite, and suggilationswhichaltogethermadefor15printedpages.Iwas brief,firstlybecauseIdidn’thavemuchtimeand secondly becauseprintingcostsareveryhighandIdon’thavemuch money.Mybrothercoveredallmycosts’’[5].Hewasreferring tohishalf-brother,MaximeJacquemin.
In1826,Trousseaupassedtheagre´gationexamtoenterthe pathtowardprofessorship:‘‘HereisthethesissubjectthatI drewthisevening:anmembranoemucosoegastro-intestina- lis inflammtio,certis signis, tumin vivo,tum incadaverer diagnoscitur’’[5].TheresponsewastobewritteninLatin.He was second-to-last among those who passed the exam, rankingbelow AdolphePiorry(1794–1879), Franc¸oisMartin- Solon (1794–1856), Melchior Gibert (1797–1866), Antoine- Laurent-Jesse´ Bayle(1799–1858),andJean-BaptisteBouillaud (1796–1881). Hegave hisfirst lessonon 24 November1827, attendedby Jean-E´tienne Esquirol(1772–1840) andE´tienne- JeanGeorget(1795–1828),butbyfewstudents.
In1828,anepidemicofdiphtheriabrokeoutinSologne,to theeastofTours.BretonneausentTrousseautotheregion, who quickly realised that the cauterisation of the throat recommended by his teacher was ineffective. He tried tracheotomy,atechniqueinventedbyLorenzHeister(1638–
1758)in 1739 [10], whereby he fashioneda cannulawith a leadbullet andincisedthetracheawithapocketknife.The successof this test led tohis performing severalhundred tracheotomiesduringhiscareer and broadly disseminating thismethod[2].ThefollowingyearPierre-Charles-Alexandre Louis(1787–1872)andNicolasChervin(1783–1843)senthimto Gibraltartostudytheyellowfeverepidemic.Hecamedown withthediseasehimself,struggledtorecover,andwasunable tocompletehismission.
In1830,hebecameaphysicianoftheCentralOfficeofthe Paris hospitals and stepped infor Re´camierat Hoˆtel-Dieu.
HemarriedGenevie`veCailloton21October1830.Thecouple wouldhavetwochildren.CholerabrokeoutinParisin1832 andTrousseauwasoneofthefirstvictims:‘‘Iwaslucky,and mycholeracouldhardlybecalledbythisnamewereitnotfor thefaintingspellsthatmademequitemiserable’’[5].
Trousseau did not succeed in his bid for the Chair of Physiologyin1833.From1835to1839heworkedat Necker hospital,thenatSaint-Antoinefrom1839to1852(Fig.2).In 1837,heonceagainfailedtoobtainachair,thistimetheChair ofHygiene.Thethesishedefendedwasentitled:Desprincipaux alimentsenvisage´ssouslepointdevuedeleurdigestibilite´ etdeleur puissance nutritive (Primary foodstuffs considered in terms ofdigestibilityandnutritivepower).Finally,in1839,hewas appointed to the Chair of Therapeutic Treatments after defendingathesisentitledDel’influencedel’habitudesurl’action des me´dicaments (The influence of habit on the action of medicines)andaftergivinganorallessononthetherapeutic usesofopium.Anindicationofhistemperament,Professor Trousseaubecamethestudentofhis1844externeandfuture successor,AdolpheGubler(1821–1879),togainthebotanical knowledge he lacked: ‘‘My friend, I’d like you to give me lessonsinnaturalhistoryandchemistry’’[11].Inhisteachings on treatments, Trousseau championed the use of iron for
chlorosis,quinquinaforfever,andmostoftendisapprovedof bloodletting. In 1843, he published his first studies on thoracentesisincasesofpleurisy[12].
WhenAuguste-Franc¸oisChomel(1788–1858),physicianto King Louis-Philippe and a ‘‘faithful friend of a banished dynasty’’, refused to‘‘swear an allegiancethat injured his conscience’’ [13], which isto saythat herefused toswear allegiancetoEmperorNapoleonIII,Trousseaureplacedhimin 1852,intheMedicalClinicatHoˆtel-Dieu.Histeachinginthis capacity ensured his renown and he became the most consultedclinicianinParis[14].
Trousseau had a brief political career. After the 1848 Revolutionandthefallofthe‘‘JulyMonarchy’’,hewaselected on23April1848asdeputyoftheEure-et-Loirdepartmentfor theconstituentassembly,alongwithsomethirtyrepublican physicians,includingEuge`neDezeimeris(1799–1851),Ulysse Tre´lat(1795–1879),LouisLausse´dat(1809–1878),andBenjamin Buchez (1796–1865). He voted in favour of banishing the Orle´ans familyand rejectedthe prosecutionofLouis Blanc (1811–1882). ‘‘Withhisstrong,clear voice andhisgiftsasa professor,MrTrousseauisaneloquentspeakerandmaythus findsuccessinthe NationalAssembly’’[14].When General Euge`ne Cavaignac (1802–1857) lost the election to become president under the 2nd Republic, on 04 November 1848, Trousseaulosthisownre-electioncampaign.Thismarkedthe endofTrousseau’spoliticalcareer[15].
In1856,hewaselectedamemberoftheFrenchAcademyof Medicine.ButinalettertoBretonneaudescribingthepositive resultsoftracheotomyincasesofdiphtheria,hehadthisto say: ‘‘I so distrust this institution thatI’m tempted tosay nothingtothematall.Itis,however,mydutytoshinelighton thetruth,soImaythrowthemthisboneandwatchthemfight over it publicly, inorder that you getthe recognitionyou deserve’’[5].
Adolphe Bloch was hisexternein1864.He paintedthis portraitofTrousseau:‘‘Tallandslim,heheldhisheadhigh.
Hisfeatureswerehandsome:ahighforehead,aslightlylong Fig.2–Trousseauandhisstudentsin1865(BIUsante´, Paris.Publicdomain).
nose,thinlips,andaproudchin.Hedidnotwearabeardbut had medium-lengthsideburns,grey in1862,and which he often stroked with his fingers as he spoke’’. As an aside, headded:‘‘IamunawarewhetherthebustattheAcademyof Medicine was modelled afterTrousseau himself,but I can affirmthatitinnowayresemblestheoriginal’’[16](Fig.3).
JulesAuguste Be´clard (1818–1887) described Trousseauthis way:‘‘Withararedegreeofgoodsense,anardentimagination, determinationcombinedwithflexibility,clarityandaccuracy, hehadallthecharacteristics,goodandsometimesbad,ofan inventiveandimpulsivemind’’[13].
3. A few of his publications
Once he had defended his thesis, Trousseau put out publicationafterpublication.In1826,hepreparedathesaurus forthemonumental,nine-volumesurgicaltreatise,Traite´ des maladieschirurgicales et desope´rations qui leur conviennent by AlexisBoyer(1757–1833),publishedbetween1814and1826.In 1828,hecollaboratedwithUrbainLeblanc(1796–1871)onthe DictionnairedeMe´decineetChirurgieVe´te´rinairesofJosephHurtel d’Arboval (1777–1839) [17], who valued the comparative anatomy knowledge Trousseau had acquired at the Mai- sons-Alfortveterinaryschool.Thiswaswhenhewasteaching comparative anatomical pathology outside the medical school.Duringoneofhisopenlessons,hemadethemistake oflikeninghumantuberculosistoglandersinthehorse.This regrettableconfusionwasnotcorrecteduntil1837,byPierre Rayer [18]. In his correspondence with Bretonneau, he
indicatedthathehadwrittenatreatiseonmedical-surgical pathology, initially with Fre´de´ric Blandin (1798–1849), then with Jean-Nicolas Marjolin (1780–1850), to be published in 1828.Theworkwasnever releasedandthereasonforthis remainsunknown[5].
In 1833,Trousseau founded theJournal desconnaissances me´dico-chirurgicales with Henry Gouraud (1807–1874) and Jacques Lebaudy (1804–?), also Bretonneau’s disciples. In 1836,hepublishedthefirsteditionofatreatiseonmedical treatmentsandmaterials,Traite´ dethe´rapeutiqueetdematie`re me´dicale,writtenwithClaudePidoux(1808–1882)andcorrected byBretonneau.Thenin1837,hereleasedhispracticaltreatise ontuberculouslaryngitis,Traite´ pratiquedelaphtisielarynge´e.In 1851, with the help of Pierre-Oscar Reveil (1821–1865), he addedatreatiseonprescribingformulationsforpharmacists, Traite´ de l’art de formuler, to his lessons on therapeutic treatments[19].InalettertoBretonneau,dated30December 1843, he wrote that he had personally performed 133 tracheotomiestosavechildrenfromdiphtheria[20].
Trousseau’s lessons had a large following. His easy eloquenceandgiftsofexpressionmadeastrongimpacton hisstudents’imaginationsandmemories:‘‘Coughingincroup ishoarse,muffled, anddry,producingasoundcomparable to the far-off barking of a young dog’’; or, inreference to Addison’sdisease:‘‘Herfacetookonaswarthy,smokytintlike theskinofamulatto’’.HisclinicallessonsatHoˆtel-Dieuwere publishedstartingin1861andwerereprintedseveraltimes, with thefinal eleventhedition released in1913.An Italian version was published in 1865, followed by English and Germanversions in1868.Severalgenerationsofphysicians studied these lessons: ‘‘His speech was like a bouquet of flowers, and these transcriptions are simply the dried-out remains’’ [16]. In reality, Trousseau did not transcribe his lessonshimself.Theywerecollatedbyseveralofhisstudents insuccession:Le´onBlondeau(1824–1889),VictorDumontpal- lier(1826–1899),andMichelPeter(1824–1893).Petercontinued to organise the editions published after his death. His favourite student and true successor, in terms of the excellence ofthe clinical lessons he would later give, was CharlesLase`gue(1816–1883)[21].
Trousseau befriendedGuillaume-BenjaminDuchennede Boulogne(1806–1875)andwasthefirsttoinvitehimtoworkat Hoˆtel-Dieu. He brought his work to a broader readership, notably that on progressive locomotor ataxia [22]: ‘‘The department where hewas mostoften present was that of TrousseauatHoˆtel-Dieu’’[23].Blochcrossedpathswithhim there:‘‘Alittleoldman,dressedinablackfrockcoatanda whitetie,hewaspaleandthinand,liketheMaster,worelittle whitesideburns.Hewasrespectfulandsaidlittle.Afaithful assistant,hewasnoneotherthanDucheˆnedeBoulogne’’[16].
Not the least of Trousseau’s contributions was to have realised,beforeCharcot,thegreatsignificanceofDuchenne’s workinclarifyingthediseasesofthenervousandmuscular systems.
4. Lucidity
Trousseau gave up his Chair of Clinical Medicine in 1864 but maintained the Chair of Therapeutic Treatments and Fig.3–MarblebustofA.Trousseau(AcademyofMedicine,
Paris.Photographedbytheauthor).
continuedtoteachfortwomoreyears,untilhisretirementin June1866.Hisretirementwasbrief;inthewordsofhisstudent Peter:‘‘Onthis1January1867,whenIwenttoextendmybest wishestohimforthenewyear,Trousseautoldmewithsad resignation:‘I’mdonefor.Phlebitiscameonlastnight,leaving nodoubtastothenatureofmyailment.’Trousseauwasright:
he was the one who had discovered the links between phlebitis and stomach cancer, and now he was observing thisconnectioninhisownbody,therealityofhisdiscovery.
Fromthenon,hislifewasnothingbutdrawn-outtorture.The physicalsufferingdepletedhisforceswithoutdisturbinghis serenity;hespokeofhisdiseaselikeascholar,andsupported itlikeastoic’’[24].TheGoncourts’journalstarted1883withan accountbyDieulafoyexplaininghowTrousseauhadshowed himhislegandspokenofhisstomachcancer:‘‘Iwashoping forperforationor haemorrhage,butno; this willlastsome time’’[25]. Trousseaudiedon 23June1867 (Fig.4).Hewas buriedatPe`reLachaiseCemeteryinParis[26].
5. Neurological diseases taught by Trousseau
Trousseau’slessonsweredeliveredintheclassicalformused bymostofthemedicalschoolprofessors.Aclinicalcasethat studentswereabletoobserveandexamineinawardofthe Hoˆtel-Dieudepartmentwasusedasanexampleon which Trousseauelaborated,asifhewerethinkingaloud,inorderto makeadiagnosisbyeliminatingvariouspossibilitiesarising from theclinical examination,which he described, along withothercasesfromhislongandrichexperience.Wewill now review some of the lessons that cover the nervous system[27].
6. Cerebral haemorrhage and apoplexy
A patient hospitalised for ‘‘pulmonary catarrh’’ suddenly developedhemiplegia.Theparalysis,forwhichtherewereno premonitorysigns,predominatedintheface,wasslightinthe
upperlimb,andbarelynoticeableintheleg:‘‘Themanfelthis tongue was notworking properly, and that hestammered whenheattemptedtospeak.Hisintelligencewasinnoway affected’’. Trousseauclearlypresentedthedifferential diag- nosisbetweencentralandperipheralfacialpalsywithoutever citing the name of Charles Bell(1774–1842). Henoted that the use of ‘‘apoplexy’’ made it necessary to differentiate betweencerebral softeningand cerebralhaemorrhage. Sof- teningwasdueto‘‘bloodcongestion’’orembolism.Hegave multipleexamplestoshowthevarietyofforms,fromslight, regressive paralysisto coma, a sign of eminent death. He creditedRe´camierwiththeclinicalelementsfordistinguish- ing haemorrhagefromsoftening:‘‘Completeabsolutepara- lysisononesideofthebodywhilethepatient’sintelligence and sensitivity remain intact; in this case there is brain softening. When, on the contrary, this absolute loss of movementislinkedtothelossofsensitivityandintelligence, especially when the individual suddenly falls into a deep coma,significanthaemorrhagehasoccurred’’.Buthewasalso
‘‘temptedtoacceptthepreliminarysofteningthatRochoux [28] seesas theorganic condition;that is,the pathological work necessarily preceding any cerebral haemorrhage’’.
Trousseauregrettedthattheexpression‘‘cerebralcongestion’’
wasoftenusedabusively:‘‘Ihavetroublebelievinginapoplexy inthirty-five-year-oldpatients,especiallywhenitrecursevery two months. What comes immediately to my mind is epilepsy’’[27].Inthesecases,Trousseauspokeof‘‘epileptic vertigo’’.Henevermentionedarrhythmia.Whatwenowcalla
‘‘transientischaemicattack’’wasstillunknownorconsidered aformofepilepsy.Butheaccuratelydescribedcarotidartery atheroma:‘‘Astodamagetothearteries,characterisedbythe presence ofyellowish, cartilaginous plaqueencrusted with calciumsalts,itdoesnotappeartobeanessentialcondition of cerebral haemorrhage’’ [27]. For him, the presence of atheromatousplaquesdidnotexplaincerebralhaemorrhage.
Heseemedunawareofembolicstrokeanddidnotclearlyrefer torupture ofthearterialwall,duetohyperpressure inthe vessel,asanaetiologyofhaemorrhage.
7. On epilepsy
Trousseaudescribedthe‘‘grandmal’’seizureatlengthandin detail, highlighting the frequency of nocturnal seizures.
Tonguebitingwasenoughtoconfirmthediagnosis,butany involuntary loss of urine was considered a sure sign of epilepsy.Trousseauadmittedthathedidnotknowthecause giventheusuallackofamacroscopicallyvisiblelesionduring autopsy.Hedescribedtheclinicalpictureof‘‘statusepilepti- cus’’,whichfrequentlyprecedesdeath.Itisunclearwhether Trousseauwasdescribinganabsenceseizureorcataplexyora generalizedatonicseizureinthiscase:‘‘Achildwasbroughtto mewhohadthissingularformofepilepsy.Iwastoldhehad attacksfour,five,evensixtimesperhour;ashisparentswere tellingmewhattheyhadobserved, thelittlepatientfellto the groundbefore me.Hesuddenly slipped fromthechair wherehewassittingandrolledontothecarpet.Iexamined himattentivelyandsawnothingthatresembledaconvulsion [...].Thisformofepilepsyconsistsinsimple dizzinessand doesnotseemtohavesequelae,notanyimmediatesequelae Fig.4–A.Trousseauonhisdeathbed,asdrawnbyhis
studentGeorgesDieulafoy(1839–1911)(Bibliothe`que nationaledeFrance,Publicdomain).
at least; the individual, when he gets up, appears a bit surprised, then continues the interrupted conversation, as if nothing were wrong’’ [27]. He did not mention the comparabledescriptionsbyFranc¸ois Poupart(1661–1709)in 1705 [29], the‘‘petits acce`s’’of SamuelTissot (1728–1797) in 1770 [30], the ‘‘petitmal’’ ofEsquirolin 1815 [31], or Louis- Florentin Calmeil (1798–1895), the first to use the term
‘‘absence’’in1824[32].
Trousseau recognised in his patient a case of gelastic epilepsy:‘‘Duringtheshorttimehewasinmyoffice,hewas overcomebyanattackcharacterisedbyafitoflaughter.The attack lasted a few seconds, then the patient returned immediatelytohissensesandseemedverysurprisedwhen Iaskedhimwhyhehadlaughedinthisway.Hewastotally unawareofwhathehadjustdone’’.Thischildalsohad‘‘grand malseizures’’[27].Trousseau’sdiscussiondoesnotaddress anyparticularlesionbecausetherewasnoautopsy.
Buthistextdoesnotlackforerrors.Forexample,inhis descriptions of ‘‘epileptic auras’’ he brings in angina. The intellectualdisordersthathepresentsasepilepticinnature areoftentransientacutehallucinations thatarecurrently not linked to epilepsy and are instead considered brief psychotic disorders or transient dissociative episodes.
Incidentally,Trousseaumentionedthecaseof‘‘LaMarquise deDampierre’’(1799–1884)[33]withoutnamingher:‘‘Eve- ryonehereasheardofasocietyladywho,whenoutinthe world—atthetheatre,atchurch,orwhiletakingawalk— wouldsuddenlyutterthemostseriousinsults,orthemost obscenewords,ofwhichshewassupposedlyunaware.She was a respectable woman in every way and of great intelligence’’[27].Hesawthisasacaseofthesuddenand irresistibleimpulsesthatepilepticsexperience:‘‘Thesociety lady I spoke of just now, and who, under the control of singular, irresistible influences would utter the strangest words,ofwhichshewassupposedlyunaware,wouldexpress outloudduring herattackwittyandinsightfulideasthat, according to convention, were usually kept silent. Even thoughinthiscasetheimpulsewasirresistible,theveracity oftheresponseorstatementcouldmakeitseem,tothose unaccustomed to the phenomena of epilepsy, that these words were intentionally uttered’’ [27]. He recounted the observationreported by Jean-Gaspard Itard(1775–1838) in 1825[34]andthatGeorgesGillesdelaTourette(1857–1904) woulduseasthefirstexampleoftheeponymoussyndromein hisseminaldescriptionin1885[35].
8. Epileptoid neuralgia
Underthename‘‘epileptoidneuralgia’’,Trousseaudescribed trigeminalneuralgia, knownthereafteras ‘‘ticdouloureux de Trousseau’’, whichhetreatedwithmorphine.Healsoasked AugusteNe´laton(1807–1873)totrytocutthenerve,butthere wasnolastingbenefit,nomorethanfortheelectricshocks performedbyDuchennedeBoulogne.Healsorecognised‘‘tic douloureux’’,whichisneuralgia‘‘accompaniedbyconvulsive movements’’ with possible blepharospasm or hemifacial spasm which,forhim, was ‘‘atypeof choreaor danse de Saint-Guy[StVitus’dance]’’forwhichhedidnotmentiona treatment[27].
9. Tetany
Thefirstdescriptionoftetany,underthename‘‘intermittent tetanus’’,isprobablythatofJean-BaptisteDance(1797–1832) in1831,inthecontextoffeverinfourpatients[36].Trousseau firstidentifiedcasesoftetany inmotherswhohadrecently givenbirthandwerebreast-feeding.Henamedthecondition
‘‘rheumatic contraction of nursing mothers’’. Then he observed it during the 1854 cholera epidemic, and other diarrhoealconditionssuchastyphoidfever.Hereishowhe describedthecrisis:‘‘Thethumbisenergeticallyforcedinto adduction, the fingers areheldtightly againstoneanother and half-flex over the thumb,with flexion ordinarily only occurringinthemetacarpophalangialjoint;thehand,withits palmhollowingoutbythecomingtogetheroftheexternaland internaledges,takesontheformofacone,orifyouprefer,the formtheobstetrician’shandwhenheintroducesitintothe vagina’’.Thisdescriptionhasbecome‘‘Trousseau’ssign’’,also referredtoasthe‘‘obstetrician’shand’’[27].Heobservedhis casesforuptothreedays.Achancediscovery,histreatment consistedinplacingatourniquetattherootofthelimbuntil arterial circulation was stopped and the contraction was released by ischaemia. His discussion as to the origin of thesecontractionswasquitegeneral,anditisstrangethathe viewedthis symptomasarheumaticcomplication,despite the diarrhoeaandtuberculosis heobserved‘‘in debilitating conditions’’. Aside from a tourniquet, he recommended bloodlettingand,asalastresort,theinhalationofchloroform.
10. Chorea
E´tienne-Michel Bouteille (1732–1816), from Manosque in Southern France,was the first to have performed a study distinguishingbetweenthedifferenttypesofchoreaor‘‘danse deSaint-Guy’’(StVitus’dance)in1810[37].Trousseauusedthe term ‘‘dancedeSaint-Guy’’torefertothe choreaofThomas Sydenham(1624–1689)[38]:‘‘Thisnameseemsbetterthanany other, preferable to that of chorea, which, in its generic meaning, encompasses many things and specifies none, whereas‘‘danse deSaint-Guy’’appliestoonlyonethingand allofit,whichmakeslogicalsense’’[27].Duringthisperiod,it istruethatalmostallabnormalmovementswereclassified underthenameofchorea.However,the‘‘dancedeSaint-Guy’’,a namegivenbyParacelsus(TheophrastusPhilippusAureolus BombastusvonHohenheim,1493–1541)foradisease,infact, known for centuries before him, lacks the specificity that Trousseauascribestoit,asitalsoreferstoanepidemicof freneticdancesordancingplague(maniesdansantes)thatare psychogenicinorigin.HecreditedJacques-PierreBotrel(1819–
?)withhavingbeenthefirsttorecognisethephenomenolo- gicallinkbetweenacuterheumatoidarthritisandthe‘‘dansede Saint-Guy’’;thiswasinadissertationawardedaprizebythe medicalschoolin1849 andwhichbecamethethesisBotrel defendedon25May1850[39].However,itisusuallyGermain Se´e(1818–1896)whoiscreditedwiththislink.Se´epresenteda dissertation shortly after Botrel tothe French Academy of Medicine, on 11 December 1849: De la chore´e, rapports du rhumatismeetdesmaladiesducœuraveclesaffectionsnerveuseset
convulsives(Onchorea:linksofrheumatismandheartdisease withnervousandconvulsiveconditions)[40].Aremarkthat Trousseau added was that scarlet fever may also lead to rheumatism,carditis,andchorea.Henotedthattheappea- rance of abnormal movements is preceded by changes in
‘‘intellectualfunctions’’, whichhelisted asmorosity, anxiety, agitation, attentional deficit, and memory loss. Most often generalised,choreamayinsomecasesaffectonlyonesideof thebodyandmaytransformintotemporaryparalysis,but,in all cases, the patientcannot voluntarily control the motor agitation.HealsonotedthatLouisVictorMarce´ (1826–1864) hadadvanced thepossibilityofsimultaneoushallucinatory episodesduringchoreic movements, which had previously beendescribedbyBouteille.Trousseaurecognisedthathehad notfound evidence ofbrain lesionsduring autopsies once thediseasehadrunitscourse.Hedidnotconsidercoldbaths tobebeneficialinanywaybutdidrecommendedgymnastic movements whereby the patient had to adjust choreic movementtotherhythmofametronome.Herecommended strychninein progressivedoses andsometimes hashish or chloroform,and,asalastresort,astraightjacket!
Inhisnextlesson,Trousseaucoveredothertypesofchorea.
Hisdescriptionofchoreafestinanssuggestsapossiblecaseof corticobasaldegenerationorprogressivesupranuclearpalsy:
‘‘Hisbodywasstiff,bentforward,histwoarmsextendedalong histrunkandthighs.Hestaredfixedlyandranrapidlyonthe tipsofhistoes,takingverysmallsteps,likeamanwhowas playingsomesortofgame’’.Heexplicitlydifferentiatedthis choreafestinansfromparalysisagitans.Describingdifferent ticphenomenology,hegavethisexample:‘‘AyoungEnglish- manwassenttomefromDieppe.Histicconsistedinviolent convulsivemovementsoftheheadandrightshoulder[...].
Theseticsareinsomecasesaccompaniedbyacry,thevoice burstingforth more or less loudly, which is characteristic.
Whileonthissubject,IshallmentionthestorythatIhave recountedseveraltimes,ofoneofmyoldclassmates,whomI oncerecognised,aftertwentyyearsofnotseeinghim,whilehe waswalkingbehindme,bythebark-likenoisethatIhadheard himmakewhenwewerestudentstogether.Thiscry,thisyelp, this burst of voice, a veritable laryngeal or diaphragmatic chorea,mayconstitutetheentiretic.Inafewcases,itisnot only a bursting forth of the voice, a singularcry; it is an irresistible tendency to always repeat the same word, the same exclamation; and the individual may even reiterate wordsaloudthatitwouldbebettertoholdback.Thesetics arequiteoftenhereditary’’[27].Trousseauprovidedinthis 1862 lessona completedescription ofGilles delaTourette syndrome,morethantwentyyearsbeforetheseminalarticle.
GeorgesGilles de laTourette (1857–1904) criticised himfor consideringthispatientchoreic.
Trousseau went on to mention ‘‘writer’s chorea’’ or
‘‘writer’s cramp’’, which Duchenne de Boulogne called a
‘‘functionalspasm’’.Hegaveexamplesofdifferenttypesof dystoniaasDuchennehadreportedthem.
11. Shaking and ‘‘paralysis agitans’’
Trousseautaughtthedifferencebetweenactiveshakingand shaking at rest. Forthe first:‘‘This shaking is never more
pronouncedthan whenthe affected individualsattemptto perform voluntarymovement,or whenthey aresubjectto mentaltensionthatisoutoftheordinary,toamoralemotion.
Restandmentalcalmdiminishtheviolence’’.Forshakingat rest, Trousseau did not neglect to mention the initial asymmetry, the slowness and the decrement in speed of movement,withoutrealparalysis:‘‘Somethingverystrange happenedtoourpatient.Iaskedhimtocloseandopenhis righthandasquicklyashecould.Hismovementswereatfirst rapid,butnotaquarterofaminutehadgonebybeforethey slowed,thenbecameimpossible’’[27].Hedidnotfailtonotice his patient’s difficulty with writing, his stiffness, and the slownessofhisgestures:‘‘Hestoodandwalkedwithhisbody bent forward, hisarmon the affected sidehalf-flexed and strongly held to his body. His centre of gravity was thus displaced,andhehadtorunafterhimself,sotospeak;hethus trottedandhopped.’’Hedescribedakathisia:‘‘Itisimpossible forcertainpatientstoremainsittingforanyextendedperiod oftime.’’Astotheprogression:‘‘Intelligence,initiallyintact, ends up weakening, memory is lost, and the patient’s entourage soon realise that the patient haslost his usual mental clarity; senility arrives at an early age’’. Later, he added:‘‘Paralysisagitansisaninexorablediseasethatalways leadstodeath’’[27].
ReferringtothepublicationofCharcotandAlfredVulpian (1826–1887) in 1861 [41], Trousseau distinguished between Parkinson’s disease and multiple sclerosis, providing the progressive clinicaldescriptionand thecorresponding ana- tomopathologicalresultsforthelatter.
Hemadethe curiouscomparison betweenthemuscular stiffnessof‘‘paralysisagitans’’andwhathecalled‘‘thelossof muscularincitability’’.Hedescribedaskingaeighteen-year- old woman to walkfor him:‘‘She arosewith purpose and confidence, withoutwavering, tookten,fifteen,twenty-five steps,thenshebegantofeelweak,andifshecouldnotfinda seat,shehadtositdownonthefloor.Aftersuchaminoreffort, shewasdepleted.Shehadexhaustedthedoseofincitability allottedtothemuscularnervoussystem.Afewminutesofrest wereenoughforhertoregaintheaptitudeshehadlost’’[27].
Was this a case of ‘‘myasthenia gravis pseudoparalytica’’ as described by Samuel Wilks in 1877 [42], which was then renamedsimply‘‘myasthenia’’byFriedrichJolly(1844–1904)in 1884[43]?
12. Facial palsy
WhileTrousseaudidnotciteCharlesBell(1774–1842)during hislessononcerebralhaemorrhage,hedevotedanentireclass onBell’speripheralfacialpalsy.Takingtwocasesobservedat Hoˆtel-Dieuasanexample,hedescribedwhathecalled‘‘facial hemiplegia’’.Hefocusedonpossiblecauses:‘‘coldaction’’and
‘‘moralemotion’’.Amongtheacuteforms,hecitedfacialpalsy in new-borns after forceps were applied, after fracture of thepetrouspartofthetemporalbone,andfollowingparotid surgery. Tracing the anatomical path of the seventh pair, Trousseauexplainedthatanyprogressivecompressionofthe nervetrunkalongthispathmightcauseperipheralfacialpalsy withslow onset,forexample‘‘necrosis orcavityformation withsuppurationinthispartofthetemporalbone’’causedby
tuberculosis, frequentat that time, or bythe extensionof chronicotitisleadingto‘‘perforationoftheduramater,and thenoneseestheseabscessesatthebaseoftheskull,these purulentsuffusionsofthe arachnoid’’[27]. Drawingonthe assertions of Euge`ne Cazalis (1808–1883), one of Charcot’s teachers,heinsisted onthe distinctionbetweenperipheral andcentralformsofpalsy.Speakingofcentralpalsy:‘‘Ihave never seen the orbicularis oculi completely paralysed. The eye can always close,whereas in Bell’spalsy, paralysisof theorbicularisoculiisalwayspresent,andcompleteclosure oftheeyeisimpossible’’[27].Hedidnotfailtomention‘‘the disturbance to the sense of taste, proof that the chorda tympani is a sensitive nerve, or perhaps taste is modified becausethisfinenervousfibregovernssalivarysecretionas demonstratedbyClaudeBernard’’(1813–1878)[27].Trousseau didnotforgettonotethatrecoverymaycomewithapersistent contractionormaynotcomeatall.
13. Labio-glosso-laryngeal paralysis
It israre fora professorof clinicalmedicine to publisha lessoninwhichheadmitshavingmadeamisdiagnosis.This is nonetheless what Trousseau did in recognising that Duchenne deBoulogne haddescribed an accurateclinical pictureforaconditionhehimselfhadseen,withoutrealising it was a unique entity [44]. The clinical picture included difficultieswithspeech,swallowingfoodorsaliva,paralysis ofthelips,tongue,orsoftpalate,whereasintelligencewas unaffected.Trousseauregrettednotexaminingthenervous tissueunderthemicroscopeforthefirstcasesheencounte- red,butsince then,hehadnotedatrophyinthedamaged nerveroots.Andheskilfullyanalysedtherapidandalways fatalprogression‘‘bydamagetothemusclesofrespiration’’, preceded by progressive paralysis in the limbs. He also explainedaphonia:‘‘Thelackoftensionintheglottisexplains theweaknessofthevoice;moreover,thelesioninthespinal nervemeansthatthereisnovoluntaryprolongedexpiration tosupportthevoice’’[27].Trousseauconfirmedtheobserva- tionofMauriceKrishaber(1836–1883)findingdissociationof laryngeal sensitivity with persistence oftouch sensitivity, but loss of ‘‘reflex sensitivity’’ which he interpreted as a precursorsignofthedisease[45].‘‘Severalcross-sectionsof themedullaandponswereexaminedunderthemicroscope, demonstrating that the fundamental anatomical lesion ofthisparalysisis locatedin thenucleiwherethe bulbar nervesoriginate.This discoveryisdue tothe anatomopa- thologicalresearchofMr.Charcotwho,inaddition,attemp- ted to establish that the anatomical lesion consists in primitiveatrophyofthecells’’[27].Trousseauwasreferring to articles by Charcot [46] and Duchenne de Boulogne published in 1870 [47]. He never relates having seen fasciculationinthetongue.
14. Progressive muscular atrophy
Trousseau’s lessonislike aprogressreportonthegrowing knowledgeaboutprogressivemuscularatrophyleadingupto Charcot’ssummaryofanteriorhornlesions(atrophyoflarge
motorcells)andsclerosisintheanterolateralsystemofthe spinalcordduringhislessonon16July1870,thesamedaythe Franco-PrussianWarwasdeclared,interruptinghisresearch.
Hewouldonlyreturntohisworkin1874,drawingupthebirth certificateofamyotrophiclateralsclerosis[48].
Trousseaugaveacompletedescriptionofthegradualand asymmetricprogressionofmuscularatrophy,accompanied bythecharacteristicfasciculation.Hedidnotfailtocitethe initialdissertation ofFranc¸ois-AmilcarAran(1817–1861)in 1850[49],andthatofJeanCruveilhier(1791–1874)in1853[50].
However,hehesitatedinhisinterpretation,beginningwith this statement: ‘‘The morbid process that characterises it occursinthemuscularsystem,inthestructureoftheaffected muscles’’;thenlateradding,‘‘thelackofperipheralnervous influxseemstoresultfrommusculardegeneration’’[27].He dealtatlengthwiththeaffectedmusclesandtheonsetofthe disturbances beforedeploringthe progression,most often rapidandleadingtodeathwithintwoyears.Discussingthe roleofheredity,hereferredtothepresentationbyEdward Meryon (1807–1880)in London in1851 on a family where only ‘‘the three boys hadmuscular atrophy’’, adding that Duchennehadreportedsimilarcases[51,52].Ofcourse,he confusedhisconditionwith‘‘fattydegenerationofvoluntary muscles’’: Duchenne muscular dystrophy or Meryon’s disease.
Trousseau described the clinical symptoms, borrowing heavily fromDuchenne de Boulogne,but didnot correctly interpretthepathophysiology,whereasCharcotputforward thepathophysiologyandanatomopathology [53], explaining the clinical aspects.Itwas indeedCharcotthat unifiedthe spinal damage and muscular atrophy on one hand, and thebulbardamageandglosso-labio-laryngealparalysisonthe other. He thus named this pathology ‘‘amyotrophic lateral sclerosis’’,employingananatomopathologicalratherthana clinicalterm,ashehaddonepreviouslyformultiplesclerosis (‘‘scleroseenplaques’’).
15. Progressive locomotor ataxia
TrousseaubeganhislessonwiththishomagetoDuchennede Boulogne: ‘‘To him we owe our being able to recognise a diseasethatwaspreviouslyunidentifiableamongamultitude of different diseases’’[54]. He didnot cite Moritz Heinrich Romberg (1795–1873) for his truly novel contribution [55], whichwasmoresignificantthanDuchenne’sarticles.Charcot and Vulpian noted in 1862: ‘‘By professing Duchenne’s ideas with his own uncontested authority, Mr Trousseau contributed to their being accepted by a large number of clinicians’’[56].
Trousseaugavethisclinicalpictureofataxia:‘‘Theycannot takeastep;theythrowtheirlegsforward,backward,tothe side,ingreatdisorder.Iftheyaretoldtoclosetheireyes,the disorder is without bounds and the movements are so extravagant that it is impossible to describe’’. He insisted onthepreservationofmuscularforce,whereas‘‘thedifficulty of movement coordination iseven greater whenthey lack the sense ofsight tocorrect disorderlymotion’’ [27]. Then Trousseau explained thesearing pain,often accompanying theonsetofataxia,theurinaryincontinence,andthedigestive
pain. He did not fail to mention Bell’s research on ‘‘the muscularsense’’[57]in1826,andparalysisofthe‘‘feelingof muscularactivity’’describedbyOctaveLandry(1826–1865)[58]
in 1855; that is, proprioception and its disturbances [59].
Trousseau did not contest the reality of this sense, but ratheritsname,preferringtheterm‘‘deepsensitivity’’.Citing AlexandreAxenfeld(1825–1876)[60]whileomitting Charcot and Vulpianand theirlinkingofincoordination todamage in the posterior tracts of the spine, Trousseau revealed, despitehimself,hismisunderstandingofataxia.Forexample, inhislongdiscussionofthepathologicalanatomy,hesaid:‘‘In this disease essentiallycharacterised by movement distur- bances, and in which sensitivity plays only a relatively secondaryrole,asitmaybemoreorlesscompletelyabsent, wemightexpecttofindlesions, notintheposteriortracts, butratherintheanteriortracts.Infact,thereverseistrue’’.
Heproposed,withoutcertainty,that‘‘theposteriortractsof thespine[were]thecentreofvoluntarymovementcoordina- tion’’[27].
At the end of his presentation, he briefly mentioned cerebellarataxia: ‘‘This is an opportunity torecognise the priorityowedtoMrBouillaud(1796–1881)intheexperimental andclinicalstudyofcerebellarlesions’’[61]. Butnothingin this lesson helps the student distinguish the cerebellaror proprioceptiveoriginofataxia.
For treatment, Trousseau objected to bloodletting butrecommendedfloggingtoreducepain,cutaneousfaradi- sation, belladonna, and turpentine. However, none of his patientsimprovedwiththe silvernitrate treatmentrecom- mendedbyCharcotandVulpian,whowerefollowingthelead ofKarlAugustWunderlichfromLeipzig(1815–1877)[62].
16. Aphasia
A student of Pierre Marie (1853–1940), Franc¸ois Moutier (1881–1961)showedinthis1908thesis‘‘how,andwhether itwashisintentor not,Brocafell undertheinfluence of Gallbyfollowing Bouillaud:both were localisers,thefirst with a singularly superficial faculty of observation, the secondemployingauthenticscience’’[63].In1820,Jacques Lordat(1773–1870),usedtheterm‘‘alalia’’forlossofspeech [64], thendescribedhisown caseinoneofhis lessonsin 1843[65].
AsforTrousseau,hestartedhislessonbynoting:‘‘In1861, Brocathoughttousethenameofaphemia,butasinGreekthis means ‘infamy’, the term is clearly inappropriate. Mr.
Crysaphis,a highlydistinguishedGreekscholar withGreek origins,thoughttheword‘aphasia’preferable,derivingitfrom the ‘a’, meaning ‘not’ or ‘without’, and ‘speech’’’. The physicianhereferstoisNicolasChrysaphis(1830–1896), to whomGastonVariotpaidhomageintheJournaldecliniqueetde the´rapeutique infantiles, on 3 December 1896: ‘‘A singular physicianwellknownintheParishospitals.We wouldsee himregularlyinthewardsofHoˆpitalLaennecwherehespent his mornings meticulously scrutinising incoming patients sufferingfromnervousconditions.Hiseruditioninmattersof neuropathywasimmense[...].ItistoCrysaphis(sic)thatwe owethe termofaphasia...’’[27,66]. Thismisspelled family namewascopiedhundredsoftimeswhentheoriginofthe
word‘‘aphasie’’wasrelated,suchthatcreditwasnotactually accordedtoChrysaphis1. Trousseau,adoptingtheproposal, had it validated by Rene´ Briau (1810–1886), the learned librarianoftheFrenchAcademyofMedicine[67]andbythe lexicographerE´mileLittre´ (1801–1881).Sowhile‘‘aphasia’’is attributedtoTrousseau,thisissomewhatfallacious.
Among the clinical cases Trousseau depicted for his studentswasthatofLe´onRostan(1790–1866),whodescribed cerebral infarct in 1820 [68] and fell victim to temporary aphasia, as had Lordat. After a long list of observations, Trousseaurelatedthediscussionsfollowingthepublications ofBouillaud,MarcDax(1770–1837),GustaveDax(1815–1893), Pierre-Louis Gratiolet (1815–1865), Ernest Auburtin (1825–
1895), and Paul Broca (1824–1880). He covered the case of Leborgne indetail. This patient, whowould only utterhis famous‘‘Tan’’,diedon17April1861.Theexaminationofhis brainledBrocatolocaliselanguageinthethirdfrontalgyrusof thelefthemisphere.Trousseauadded:‘‘Thiswasasingular ideaofDaxandBroca.Inanorganasperfectlysymmetricalas the brain, tosay that oneside serves one functionto the exclusion ofthe other,seemstogoagainstphysiology and goodsense.Buthoweverunusualanideamaybe,whenthe factsareinsupportofit,wisdomdictatesweacceptthefacts and theidea’’[27].Trousseaudid,however,contestBroca’s conclusions: ‘‘Of the 32 facts that I gathered and that are knowntoBroca,14conformtohisdoctrineand18contradict it’’. He gave this summation of his concept of aphasia:
‘‘Aphasia is the loss ofa faculty, that of expressing one’s thoughtsthroughspeech,andinmostcasesthroughwriting and gesture’’. Intelligence, and particularly memory, were consistentlydamaged.‘‘Thecerebrallocationofthisfaculty appearstobetheposteriorpartofthethirdfrontalgyrusof thelefthemisphere.Butvariouslesionsofthisportionofthe thirdgyrusmayleadtoaphasia,andInotethistobethecase notonlyforlesionsintheneighbouring,deeperparts,suchas theReilinsulaandthestriatum,butalsofordamagetothe middleandposteriorlobesofthebrain’’[27].Heconcluded bymentioningthearticleofAdrienProust(1834–1903)which heldthatsomecasesofaphasiawereinfact‘‘verbalamnesia’’, distinct from other forms such as ‘‘mechanical alalia’’, a conceptwhichhadclearlywonhimover[69].
Trousseaureportedonthecaseofavictimofadualwho survivedseveralmonthsafterabitemporalgunshotwound, madebyabulletthatenteredonetempleandexitedtheother.
1BornonCorfu(IonianIslands)on01July1830,NicolasChry- saphisdefendedhisthesisforhisdoctorateinmedicineon15May 1891inParis,atage61,whichdistinguishedhimasaveteranat themedicalschool.Thesubject:Delacurabilite´ delare´troversion ute´rineparre´ductionetcontentionme´caniquesansope´rationsanglante (Paris,1891no197)(Onthecurabilityoftheretroverteduterusby reductionandmechanicalsupportwithoutinvasivesurgery).Pro- fessorLeDentupresidedoverthejury,whichincludedProfessor FarabeufandAssociateProfessorsBrunandPoirier.Chrysaphis drewfromnineobservations,includedonecomplicatedbyinvag- ination.Thetreatmentinvolvedaballfilledwithairortheplace- mentofaring,withtheriskofavaginalfold,observedinthreeof thecases.Butoverall,thetreatmentwasbeneficial.Chrysaphis figuresonthelistoffoundingmembersoftheSocie´te´ me´dicale Helle´niquedeParis,establishedon13December1856.Hewasthus already in Parisand probably already enrolled inthe medical school.
The patient’s behaviour is described simply, without the characteristicsoffrontaldisinhibition,recallingthecaseof PhineasGage:‘‘Heamusedtheresidentswithhisgaiety,his witty conversation. He spent all his free time acting out comediesandvaudevilles’’[27].
Trousseau covered other neurological pathologies, but without originality and sometimes in a confused manner, as in the case of tuberculous meningitis, neuralgia, and
‘‘cerebralrheumatism’’,forwhichtheclinicalpictureevokes acutementalconfusionduringsevereinfections.Followingon from his work with his mentor, Bretonneau, he became interestedinparalysisincasesofdiphtheriaandlecturedon softpalateparalysis,amongothertopics.
17. Conclusion
According toLase`gue: ‘‘Only those who lived closeto Mr.
Trousseaucan trulyappreciate him,whereastoappreciate other,equally renowned physicians,reading their books is betterthanwatchingtheminpracticewouldhavebeen’’[70].
However,it mustbesaid thatTrousseaudidnotmakethe dialectal leap that Claude Bernard did in 1865, with the publicationofIntroductiona` l’e´tudedelame´decineexpe´ri- mentale (An Introduction to the Study of Experimental Medicine).Trousseau’s disdainforchemistryand biological physiologybearswitnesstohisreactionaryappreciationofthe progressmadebyhiscontemporaries:‘‘Althoughchemistryis onlyofverylimitedservicetomedicineinthestrictsense, althoughgenerallythemosteminentfiguresinthechemical sciences were poor physicians, in the same way real practitionersfrom all erashave been poorchemists, I still hold thatphysiciansshouldhave moreextensivechemical knowledge, if only to underscore the vain pretension of chemistswhothinktheyknowandcanexplainthelawsoflife andmedicaltreatment,justbecausetheyknowafewofthe reactionsthatcanbecarriedoutinlimitedconditions[...].Far be it from me to condemn the accessory sciences and chemistry in particular; I only condemn the exaggeration and pretension of these sciences, their awkward and impertinentinterferenceinourart[...].Letthemkeeptheir opinionthattheycansubordinate,inamoreorlessdistant future,thelawsoflifetothoseofthebeaker,butuntilanew orderdictatesotherwise,Iaskthemtobemodestandnotto impose their hopes as proven truths. I readily admit my ignoranceasachemist,butonlyonconditionthattheyadmit theirs as physiologists and physicians’’ [27]. It should be rememberedthatClaudeBernardemployedtheconceptofan internalenvironmentanditsequilibriuminhislessonsatthe Colle`gedeFranceon09and16December1857[71],several yearsbeforeTrousseau’swords(Fig.5).
Thewell-knownideathatthegeniussomelackinmaking discoveries,theymake up forinpracticalapplication,may thusbeusedwithrespecttoTrousseau.This‘‘Chateaubriandof medicine’’ [72]was skilled insharing hisknowledge and an astuteclinician,eventhoughhewasn’toneofthediscoversin neurology,unlikeinthefieldofinfectiousdiseases,wherehe madeimportantcontributions.Hisownawarenessofthisfact perhapsexplainstheadmirationandsincerefriendshipthat he showed to the perspicacious and curious Guillaume
Duchenne de Boulogne,the true discovererbefore Charcot andVulpian.
Funding
Thisresearchdidnotreceiveanyspecificgrantsfromfunding agencies,inthepublic,commercial,ornot-for-profitsectors.
Disclosure of interest
Theauthordeclaresthathehasnocompetinginterest.
Acknowledgements
TheauthorwouldliketothankDrHubertDe´chyandProfessor JacquesPoirierfortheircriticalreviewofthemanuscript,and AnnaFitzgeraldforhertranslation.
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