History of Neurology
Jean-Louis Brachet (1789–1858). A forgotten contributor to early 19th century neurology
Jean-Louis Brachet (1789–1858). Ses contributions me´connues a` la neurologie au de´but du XIX
esie`cle
O. Walusinski
20,ruedeChartres,28160Brou,France
info article
Articlehistory:
Received7March2015 Receivedinrevisedform 15April2015
Accepted19April2015
Availableonline28August2015
Keywords:
Historyofneurology Brachet
Vegetativenervoussystem Meningoencephalitis Epilepsia
Hydrocephalus Hysteria
Motscle´s:
Histoiredelaneurologie Brachet
Syste`menerveuxve´ge´tatif Me´nigoence´phalite E´pilepsie
Hydroce´phalie Hyste´rie
abstract
SpecialistsofthehistoryofhysteriaknowthenameofJean-LouisBrachet(1789–1858),but fewrealisetheinfluenceofthisphysicianandsurgeonfromLyon,acityinthesoutheastern partofFrance.Notonlyaclinician,hewasalsoaneurophysiologyresearcherintheearly 19thcentury.Alongwithhisdescriptionsofmeningoencephalitis,includinghydrocephalus andmeningoencephalitis,heelucidatedthefunctioningofthevegetativenervoussystem anddescribeditsactivityduringemotionalstates.Healsohelpeddescribethedifferent formsofepilepsyandsoughttounderstandtheiraetiologies,workingatthesametimeas the better-known Louis-Florentin Calmeil (1798–1895). We present a biography of this forgotten physician, a prolific writer,keen clinicalobserver and staunch devotee of a rigorousscientificapproach.
#2015ElsevierMassonSAS.Allrightsreserved.
re´ sume´
SilenomdeJean-LouisBrachet(1789–1858)restefamiliera` ceuxquis’inte´ressenta` l’histoire del’hyste´rie,ilsme´connaissentl’activite´ deceme´decinetchirurgienlyonnaisqui,aude´but duXIXesie`cle,saiteˆtrea` lafoisunme´decinclinicienetunchercheurenneuro-physiologie.A`
coˆte´ de sadescription desme´ningo-ence´phalites, notammenttuberculeuses, ilmeten e´videncelefonctionnementdusyste`menerveuxve´ge´tatifetde´critsonactivite´ lorsdes e´motions.Ilparticipea` ladescriptiondesdiffe´rentesformesd’e´pilepsiesetrechercheleurs e´tiologies, en contemporain du plus ce´le`bre Louis-FlorentinCalmeil (1798–1895). Nous pre´sentonsiciunebiographiedeceme´decinme´connu,e´crivainprolifique,doue´ d’untalent d’observationcliniqueace´re´,cheville´ a` unefoiscientifiquerigoureuse.
#2015ElsevierMassonSAS.Tousdroitsre´serve´s.
E-mailaddress:walusinski@baillement.com.
Availableonlineat
ScienceDirect
www.sciencedirect.com
http://dx.doi.org/10.1016/j.neurol.2015.04.012
0035-3787/#2015ElsevierMassonSAS.Allrightsreserved.
Jean-LouisBrachet(1789–1858)isoneofthoseobscurefigures whoseworkintheearly19thcenturypavedthewayforthe experimentalsciences,the clinicalanatomicalmethod,and psychology,whichwould respectivelyblossomwithClaude Bernard (1813–1878), Alfred Vulpian (1826–1887), and Jean- Martin Charcot (1825–1893) followedby Pierre Janet(1859–
1947). After a biographical sketch and a brief look at his numerouspublicationsinallfieldsofmedicine,wewillmainly focus onhisresearch intothe physiologyofthe vegetative nervous system, hydrocephalus and meningoencephalitis, epilepsyandmostimportantlyhisworkonhysteria.
1. A life devoted to medicine
Jean-LouisBrachetwasbornon21April1789inGivors,near Lyon,acityinthesoutheasternpartofFrance(Fig.1).Hewasa giftedstudentandpursuedhissecondaryeducationunder‘‘an adept ecclesiast left over from one of these educated communities that, before the French revolution, dedicated themselves to educating the youth’’, according to his biographerFranc¸ois-AristePotton(1810–1869),alsofromLyon [1]. PottonaddsthatBrachet’stutor ‘‘developedinhimthe spiritofobservation thatwould be themain source ofhis success’’.Fromtheagesof17to21,hetrainedasasurgeonat Hoˆtel-DieudeLyon,thenwenttoParistodefendhisdoctoral thesis. His fellow students in the capital included Claude Franc¸ois Lallemand(1790–1854), Jacques Lisfranc de Saint- Martin (1790–1847) and Franc¸ois Magendie (1783–1855). He beganhisinternshipin 1810,alongwithHippolyteCloquet (1787–1840),thefamousauthorofan1821treatiseonodours.
BrachetworkedunderAugustinLandre´-Beauvais(1772–1840), Jean-NicolasCorvisart(1755–1821)andGuillaumeDupuytren (1777–1835), building on the surgical education he had receivedinLyon.Histhesis,defendedon4March1813,was already focused on physiology, specifically the cause of dilatorymovementintheheart[2].
Ataroundthistime,atyphusepidemicbrokeoutinParis.
Brachetwasrelentlessincaringforthevictims:‘‘Whilethis obscurecitizensilentlyconsumedthestrengthofhisyouthto performhissadduties,externaleventscontinuedtheirmarch:
on 31 March 1814, the enemy entered the capital, Paris surrenderedtotheRussians,andLyonwasabandonedtothe Austrians’’[1].AftertheEmperorabdicatedinApril1814,itfell toDupuytrentoselectthe surgeonwhowould accompany NapoleonintoexileontheislandofElba.Brachetwaschosen as‘‘thebestsubjectofhistime[...].Asheisextremelylearned, andhasmanyfaculties,IthinkthatHisMajestywillfindhis conversation agreeable’’, noted the dean of the Faculte´ de Me´decine,Jean-JacquesLerouxdesTilliets(1749–1832).Brachet journeyedtoFontainebleautojoinNapoleon,butoncethere, hewasstruckwithtyphushimself,themanwho‘‘uptothat pointhadbravedeverythingwithimpunity[...].Hisvigorous constitutionfoughtback,triumphingovertheviolenceofhis ills,andhemiraculouslyreturnedfromthethresholdofhis own grave’’ [1]. After a period of convalescence with his parents, he began practising as a surgeon in Lyon and
‘‘returned with joy to his favourite pursuits: experimental researchandpathologicalanatomy’’.Inadditiontoworkingas aprisondoctor,hebecameanassistantsurgeonatHoˆtel-Dieu
deLyonin1813,goingontobecomeahousesurgeonin1818 andProfessorattheE´coledeMe´decinedeLyonfrom1842to 1858.On5April1825,hebecameacorrespondingmemberof theAcade´miedeMe´decine.
‘‘Brachet thoughtonly ofmedicine andits application’’.
Keepingfarfrompubliclifetodevoteasmuchtimeaspossible to his professional activities, ‘‘he practiced medicine as a serious art, which inspired confidence. [...] He made no distinctionbetweendayandnight,makinghimselfavailable tohispatientsatalltimes.Heonlylefthisofficetoseethesick, andreturnedtoawaittheirarrival;inthemeantime,research providedaformofrelaxation.[...]Hischaracterandabilities were well portrayed by his appearance: his calm, regular physiognomywasmarkedbyfinesseratherthandistinction, andhisdeportmentandattirewereinperfectharmonywith hishabits’’(Fig.1).‘‘Ashisspeechwasparalysedbyshyness, hewasfarmoreateasewithpatientsthanattheprofessor’s rostrum’’[1].
Brachetleftusabodyofpublicationsonanimpressively abundantandvariednumberoftopics.Asayoungsurgeon,he wasinterestedinwoundsuturesandthetreatmentofanal fissuresandingrownnails[3].Hemodifiedtheshapeofthe cannula that histeacher Dupuytren usedto drain tearsin cases of lacrimal fistulas [4]. He designed an extension- rotationdeviceforrepositioningfemoralneckfractures[5].In 1829hedescribedaconditionlaternamedcarbonmonoxide poisoning,ofallthepossiblecausesofasthenia,notingthat themaladywasnotdueto‘‘alackofair’’butratherto‘‘the introductionofavenomousprincipleintheconstitution’’[6].
As aphysiologist,hewrote abooklet onthe rarefaction of oxygenathighaltitudesintheAlps,whichheknewwell;he wasattemptingtoexplaindyspnoeainmountaindwellers[7].
Asanobstetrician,hestudied‘‘thediseasesoftheplacenta andtheirinfluenceonthelifeofthefoetus’’[8],thevascular
Fig.1–Jean-LouisBrachet(1789–1858).
connectionsintheplacentafortwinpregnancies[9],uterine prolapse[10], andothertopics.In1820,inadissertationon Werlhof’sdisease(autoimmunethrombocytopenicpurpura), hedescribedthis mortalsyndromeinvolving purpuricrash andbleeding,andimplicatedscurvyormeaslesasthecause [11].AsadiscipleofCorvisartandPhilippePinel(1745–1826) andastrongadvocateofreason,hearguedagainstusingthe conceptofinflammationtoexplainalldiseases.Forexample, hecriticisedthe doctrineofFranc¸ois Broussais(1772–1838), whofocusedonstomachinflammation:‘‘This exalteddoc- trinehaswanderedfromthedifficultpathofexperienceand observation, and forms the basisof a veritable sect’’ [12].
Brachetwroteabasichumanphysiologybook,publishedin two editions (1835 and 1855), for physicians in training.
Students appreciated the work in both its original French version and its German translation. Brachet notes in the introduction:‘‘Thestudyofanatomyisthebasisofphysiology.
[...]Itwouldbeanerrortobelievethatthesimpleinspectionof formandstructuresufficedtorevealfunction.Allthefoldsin thebrainhavebeensmoothedinvain;theyyieldnothingto thisinvestigation,notraceofthesublimeactsthattakeplace during life’’ [13]. In 1847, as an epidemiologist, Brachet confirmedthe needtoquarantinesick patientsinorder to wipeoutepidemicsoftheplague[14].
Hispracticaltreatiseonleadcolicwaspublishedinseveral editions from1824 to 1850. Aftera long history ofthe ills sufferedbyworkersincontactwithlead,Brachetattributeda pathophysiology to saturnism involving the ‘‘ganglionated nervous system’’. As a sanitarian, Brachet recommended replacing ceruse with zinc white to reduce the toxicity of paints[15].
Brachet practised medicine inLyon for 40 years, during whichtimehisloveofmedicineledhimtoacquiresome18,000 books,alibraryhemadeconstantlyavailabletohiscolleagues [1].Pottongoesontonote:‘‘ItwouldbeeasytoaccuseBrachetof having precipitated the decay of his robust temperament throughsleeplessnights,poorhygieneandimmoderateuseof opium,whichhetooktoalleviatetheacutepainsreminding himhehadaseriousdigestivedisorder’’[1].In1828,Brachet wrote a book on opium usage in which he recommended prescribing high doses [16]. Likely suffering from stomach cancer,BrachetdiedinLyonon10April1858.Inhiswill,he stipulatedthathishomeshouldbecomearetirementcentrefor oldphysiciansanddonatedhismonumentallibrarytotheE´cole deMe´decineetdePharmaciedeLyon[17].
2. ‘‘Ganglionic’’ or vegetative nervous system
Trained by master physicianswho chose observation and experimentationoverphilosophy—Corvisart,Ce´sarLegallois (1770–1814)andXavierBichat(1771–1802)—Brachetembraced the same precepts and only accepted facts confirmed by experience.Legallois,BrachetandhiscontemporaryFranc¸ois Magendie(1783–1855)canbeconsideredamongthepioneers of modern experimental physiology. Published in 1812, Legallois’sbookonexperimentsconcerningthe‘‘lifeprinci- ple’’andexploringthemovementsoftheheartandthemain locationofthisprinciple,servedasinspirationforBrachet’s thesis,defendedtheyearClaudeBernardwasborn[2,18].
Brachet’scolleagueandfriendPierre-AntoineProst(1770–
1832),analienistinParis,whowouldbesucceededasheadof the Montmartre asylum by the famous physicians Esprit Blanche(1796–1852)andEmileBlanche(1828–1893),afather andson,wroteabookontheprogressmadeinunderstanding pathologicalanatomy.AlongwithBrachet,Prostcarriedout numerousexperimentsinvolvingvivisection,writingthathe was ‘‘struck by the many lacunae in this science (i.e.
physiology),andbythegratuitousexplanationsthatdidnot appear to reston anyfacts’’ [19]. For Brachet,pathological anatomyandphysiology,‘‘bysupportingeachother[...]will advance with ever more positive results’’; Brachet also mentions athird source‘‘perhaps toooften overlookedup tillnow:comparativeanatomy’’[20].
The individualization of the vegetative nervous system maybecreditedtotheworkofseveralimportantscientists fromthe 16th,17thand 18thcenturies,towhich Brachet’s contributionwouldbeaddedintheearly19thcentury.In1563, Bartolomeo Eustachio (1510/13–1574) described the sympa- theticnerveasthecontinuationofthesixthpairofcranial nervesanddifferentiateditfromthevagusnerve[21].Thomas Willis(1621–1675)wasthefirsttodistinguishvoluntarymotor activity (cerebrum) from automatic activities which he believed were governed by the cerebellum, where he also situatedthedescentofthevagusnerveand theintercostal nerves(sympathetic)[22].In1710,Franc¸oisPourfourduPetit (1664–1741)severedthesuperiorcervicalganglioninadogand observedatriadofeffects: miosis,ptosisandenopthalmos [23]. But it was in 1732 that the DanishJacobus Benignus Winslow(1669–1760)correctlyindividualisedtheanatomyof thefacialnerveas‘‘thesmallsympathetic’’,thevagusnerveas the‘‘mediumsympathetic’’andtheganglionatedsympathetic trunk as ‘‘thelarge sympathetic’’ [24]. The Scottish Robert Whytt(1714–1766)explainedtheresultsofhisexperimentsby thenotionof‘‘sympathy’’,whichmovesthroughthenervous systemandwhichBrachetdescribedasfollows:‘‘Anyactor phenomenoninanorganoranypartofthebody,duringwhich thecausedeterminingithasactedonanorganorpartmoreor less at a distance, without there being any known direct relationbetweenthetwoparts’’[20,25].In1771,theScotsman James Johnstone (1730–1802), continuing the thought of Giovanni-MariaLancisi(Italian,1654–1720),conceivedofthe ganglionicsystemasamodulatorofvolition[26,27].In1800, Bichatdistinguishedbetweenthe‘‘animalisticlife’’—perceiv- ing,moving,learning,whichhesituatedinthebrain—andthe
‘‘organic’’ or ‘‘vegetative life’’, similar to that of plants—
breathinganddigesting,independentofthewillwhosecentre hesituatedintheepigastrium.Basedontheseideas,Bichat coinedtheterm‘‘vegetativenervoussystem’’[28,29].
FollowinginBichat’sfootsteps,in1823Brachetpublisheda dissertation on the ganglionic nervous system, releasedin bookformin1830andexpandedinasecondeditionin1837.
‘‘In animals as in plants, absorption, capillary circulation, nutrition, secretions and exhalations function under the influence of the ganglionic nervous system’’ — which the EnglishmanJohnNewportLangley(1852–1925)wouldtermthe autonomicnervoussystemin1921[20,30].
‘‘Anatomists have patiently and tenaciously overcome difficulties, and the sympatheticnervous system has been pursuedtothefarthestreaches,onthearteriesitaccompanies
in the form of a plexus, many branches of which have a gangliformappearance,regeneratethenerve,andprolongthe trunk’’. Brachet goes on with emphasis: ‘‘We should not exaggerate the superiority of the cerebral system, as the ganglionicsystemanditsfunctionsseemtoworkonlyforthe cerebralsystem, whichinturn seemstoworkonlyforthe ganglionicsystemanditdependencies.[...]Eachistheother’s slave, or rather they are united and combined to form a harmonicwhole’’[20](Fig.2).
Thealcoholiccomaisoneofthemanycasesexaminedby Brachet.Brachetnoted thatconsciousness hasbeen putto sleep,buttheheartbeatsnormally.Hededucedthatthebrain isnotindispensableforcardiacactivity.Inmanyanimals,he removedthebrainwithoutcausingthehearttostopbeating.
Thenhedestroyedthemedullaoblongata;breathingstopped immediatelyanddeathensued.Heconcludedthatrespiratory control was located in the medulla, which Legallois had already demonstrated, but Brachet noted that automatic cardiacfunction,whosemechanismhedidnotfullyunders-
tand,continuesafterbreathingstops,showingvariationsin rhythmandfrequency[20].
Pursuing his vivisection experiments, Brachet described thephysiologyofthe‘‘ganglionicsystem’’,withtransmission bythevagusnerve(oreighthpairintheparlanceofthetime) to the eye, stomach, intestines, organsofmicturition, and organsof‘‘generation’’.Achapterofhisbookisdevotedto
‘‘sympathies’’.Inoneexperiment,Brachet‘‘tickled’’theback of a dog’s throat that had just eaten, thereby triggering vomiting.Rathercruelly, heseveredthe oesophagusinthe upperpartofthethoraxandstimulatedthedog’sthroatagain.
Thestomachcontractionsandvomitingmovementspersis- ted,whichforhimdemonstratedthatitwas‘‘bysympathy’’, i.e.bymediationoftheganglionicnervoussystem,thatthe vomitinghadoccurred,ratherthan‘‘bycontinuityofdigestive membranes’’.Brachetconcludedthattheganglionicnervous systemgovernedvitalunconsciousfunctions,andunlikethe
‘‘relational’’ or somatic nervous system, it didnot need a single centre of action. Rather, it was situated diffusely throughouttheorganismandgovernedreciprocalorsympa- thetic influences, such as those ofthe brainand stomach (headacheandvomiting)andthoseofthebrainandheartin emotional states:‘‘Inamanovercome withfury,theentire constitutionmanifeststheviolentstate[...]speechismore rapid,expressionsdonotarrivewiththesamespeedasideas, and they give the impression of stammering. [...] the contractionsoftheheartquickenandacceleratecirculation.
[...]colourinthefaceintensifies,theeyesbecomebloodshot andlustrous’’[20].Brachetwasalsointerestedin‘‘passions’’, which is to say psychology. For example, he considered intellectual exaltation ‘‘to depend on the central nervous system’’ and the accompanying physical phenomena ‘‘to depend on theganglionic system,which isonly influenced secondarilybythebrain;thatis,inacommunicated,reflected way’’[20].Brachetshowedthatforjoyor‘‘sadpassions’’,the physiological mechanisms were comparable. The origin of emotionswasthusnottheepigastriumassuggestedbyPinel andBroussaisbasedonBichatbutwasinthebrain,‘‘theseatof passionsandtheimagination’’[31–33].Brachetappliedthisdata tohistheoryofhypochondriaandhysteria.Hisdescriptions anticipatedthetheoriesofWilliamJames(1842–1910)andCarl Lange(1834–1900)in1884,namelythatemotionsareperceived followingbodilymodifications,aswellasthetheoriesofWalter Cannon (1871–1945) and Philipp Bard (1898–1977) in 1929, wherebyacognitiveperceptionofthebodilystateisdetermined byhypothalamus-basedphysiologicalactivation[34].
Brachetboldly statedthat hehad given‘‘anewphysio- gnomytothestudyofphysiology’’.Hecontinuedtodevelop hisconceptsofthetwonervoussystemswiththeirembedded functionsinordertoexplainanumberofpathologicalfacts andtherapeuticmodesofactionsuch,astheplaceboeffect:
‘‘The physician whoknowshowtoinspire confidence and persuadehispatientmayowegreatersuccesstothisapproach thantotheremediesheprescribes.Mostoften,apotionwill only be an additional means of controlling his patient’s imagination, or ofpractisingmoralmedicine bythe use of remedies [...]. All ofthese arguments can onlyact on the brain’’[20,33,35].
However,hewasunawareofthehypothesis bywhicha modeotherthanthenervoussystemcausedthe‘‘sympathies’’.
Fig.2–Experimentalresearchonthefunctionsofthe ganglionicnervoussystem1837.
His friend Prost,on the other hand, suggested in 1806 the existenceoftwocommunicationmechanismsbetweenthese
‘‘sympathies’’:‘‘Twosystemsaffecttheattributionofroles;the first,theredbloodsystemsendsaliqueurthroughthebodythat containsprinciples whosecharactervariesaccording tothe mannerinwhicheachfunctionisexecuted;thesecondsystem includesallthenerves’’[36].WhereasJosephLieutaud(1703–
1780)haddescribedthepituitaryglandanditsportalvascular networkin1742,Prost,withgreatforesightofendocrinology, wasapparentlyinspiredbyThe´ophiledeBordeu(1722–1776), who in 1751 suggested that the ‘‘humour’’ of one organ influencedothers[37–39].We alsoshouldnotethatasearly as1810HenriDutrochet(1776–1847)conceivedofahumoral mechanism regulating circadian rhythms, referring to it as
‘‘synergiesorhabitsoffrequency’’[40].ItisclearthatBrachet’s contemporariesdidnotperceivethenoveltyofhisconcepts.
Henri MilneEdwards (1800–1885)concluded his assessment withthesewords:‘‘Thisdissertationisnothingbutacollection ofvaguearguments,hypotheticalexplanationsandcommon truthsthateveryoneknowsbutthatnoonetakesthetroubleto writedown’’[41].
SubsequentlytothecontributionofBrachetandtheother eminent researchers mentioned above, new findings and concepts on the sympathetic nervous system would be providedlaterinthe19thcenturybyClaudeBernardandby Charles-EdouardBrown-Se´quard(1817–1894)[42].
3. Hydrocephalus and meningoencephalitis
‘‘The negligence with which we have treated childhood diseasesissufficientexplanationforwhyacutehydrocepha- lus has remained unidentified for so long’’ [9]. Whytt is classicallyattributedwiththefirstdescriptionofthisclinical picture,in1768,whichincludeddilationofcerebralventricles, notably of the foramina of Monro, with brain swelling or hydrops,causedbymeningoencephalitis,mostoftentuber- culousmeningitis[43].Itshouldbenotedthat,atthetime,only hydrocephaluswasrecognized,butmeningoencephalitiswas notproperlyappreciated.However,theScotsmanJohnPaisley (1685?–1740)iscreditedwiththe firstclinicaldescriptionin 1733 [44]. Franc¸ois Boissier de la Croix de Sauvages, also knownasFranc¸oisBoissierdeSauvagesorshortlyasSauvages (1706–1767)and the Scottish WilliamCullen(1710–1790), in theirrenownedpioneeringnosologicalworkondiseasesofthe nervoussystempublishedin1763 andin1787respectively, identifiedthisformofmeningoencephalitisas‘‘hydrocepha- lusinterior’’,includingitamongthe‘‘partialhydrops’’[45,46].
At the time, this condition was also known as a type of apoplexiahydrocephalica[45,46]. We shouldrecallthatthe notionofaliquidcirculatingaroundthenervoussystemwas documentedby DomenicoCotugno (1736–1822)in1768,but wasonlydemonstratedbyMagendiein1825,afterBrachet’s 1818‘‘Essai’’,publishedwhenhewasstillayoungphysician andaddressingahotlydebatedsubject[47–49](Fig.3).
BrachetdrewonthedissertationofLouisOdier(Geneva, 1748–1817)andthebookofEnglishmanJohnFothergill(1712–
1780),knownforhavingindividualisedthe‘‘painfulticofthe face’’inmigrainein1776andpartoftheclinicalsymptoms,as distinctfromthoseofbraincompressionbyboneindentation.
Fothergill, insisting on the condition’s verminous origin, mixedbraintumourswithcasesof‘‘hydrocephalus’’,notably ventricular hydatidosis (1771) [50,51]. Brachet referred to JosephLieutaud (1703–1780)indescribing‘‘drowsiness’’,i.e.
progressive slipping into coma [52]. In his 1802 thesis, L.P. Collinetattributed novel importance to the associated fever,a‘‘remittentmalignantbrainfever’’,andhewasthefirst todescribeit as‘‘contagious’’[53].Thehighlydetailed1814 thesisofIsidoreBricheteau(1789–1861)andthedissertationof Jean-Franc¸oisCoindet,(Swiss,1774–1834)wereanimportant source of inspiration for Brachet, especially the clinical descriptionsand thecasesdetailed[54,55].ForBrachet,the symptomswere‘‘cephalgiaintheforehead,thesinciput,or crossingfromoneparietallobetotheother,worsenedbynoise and light, causing cries of pain [...]. The patient becomes torpid,onlyleaveshisbedwithdifficulty,holdinghisheadon thepillow;theverticalpositionusuallycausesvomitingthat exhausts his strength’’. Gradually the sick child ‘‘drowses Fig.3–Essayonhydrocephalusandacutedropsyofthe cerebralventricles1818.
withoutsleeping’’,thengrowsagitatedandvomits;‘‘hiseyes areconvulsively agitated and superiorstrabismus results’’.
Paralysis, convulsions and lethargy with dilated pupils followed;‘‘lightnolongerproducessensationorconvulsive oscillation’’. Before death, ‘‘strabismus, trismus and facial featurespullingtoonesideindicatetheroleofthemusclesof thedifferentheadregions.Everything suggeststhatalarge quantityofserosityisamassedinsidethebrain’’.Bricheteau repeatedlynotesthesalvosofyawningatthisstage,asignof intracranialhypertension[54].Attheautopsy,Brachetfound thatthearachnoidwasopaqueandthickened,withatsome pointstherednessofinflammation.Henotedthepresenceof pusinsomeplacesandverydilatedventriclescontainingclear orturbidliquid,‘‘withaturgescenceofblood’’inthevessels, and ‘‘choroid plexuses dotted with glandulous bodies’’.
Brachet remarked on the high number of familial cases, which like most of his contemporaries he attributed to
heredity, not contagion. He distinguished between acute forms,andsubacuteorchronicformsaccompaniedbyfever andcachexiaorworseningofthepatient’sgeneralcondition.
Theaetiologyremainedamysteryforhim,asthesymptoms wereoftensecondarytoanotherdiseasesuchasscarletfever ormeasles,ortotrauma;inthiscase,hisdescriptionscallto mindthe‘‘shakenbabysyndrome’’.Hisobservationsseemto confuseinfectiousformsofmeningoencephalitiswithintra- cranial hypertensionduetotumours. Brachetmentionsthe opinionformulatedbyRene´ Laennec(1781–1826),whothought thatthe‘‘diseaseisnotessentiallyproducedbytheaccumula- tion of serosity in the ventricles’’ but is linked to the
‘‘developmentoftuberclesinthecerebralmatteritself.This is entirely incurable, and is no way an idiopathic hydro- cephalus’’(Fig.4).
WhileBrachet’s‘‘essay’’helpedidentifyvariousformsof meningoencephalitis, mostly tuberculous meningitis, it Fig.4–Analyticalessayonacutedropsyofthecerebralventriclesinchildren.IsidoreBricheteau1814.
should be noted that the ‘‘Hydrocephalus’’ entry in the dictionaryofmedicalsciencesbyJean-GaspardItard (1774–
1838)isbriefer,clearerandmoreinstructive[56].
4. Convulsions in children
‘‘Convulsions belong especially to childhood; the slightest condition in children can include these disordered move- ments, moreoften frightening than dangerous;they chose their victims at all levels of society, both in golden per- ambulatorsandthatchedhuts’’,Brachetsaidinhis1824book onepilepsy[57].Hewasawardedaprizeforthisworkbythe Cercle Me´dicale de Paris. Brachet starts with an in-depth historyofepilepsyfromthetimeofHippocrates,butheonly recognisesthe workofSamuelTissot (1728–1797) andJean Baptiste The´odore Baumes (1756–1828) as source material [58,59]. ‘‘By convulsions,I refer to anyviolent, alternating, involuntaryandshort-livedmovement,involvingavariable numberofmusclesundervoluntarycontrol,withorwithout loss of consciousness’’. Brachet acknowledges ‘‘the key distinctionseparating idiopathicconvulsions fromsympto- maticconvulsions’’,butleavesthereaderindoubtastowhat heseesasthedifference,ifanyexists,betweenconvulsions andepilepsy.Brachetdescribestheattack:‘‘Thechildcries out;hisfacegrows animatedandreddens;hiseyesglisten haggardly;helosesconsciousness,stiffens,thenflailsabout withavarietyofviolentmovements’’(Fig.5).Afternotingthe possibilityofinjury,Brachetdistinguishesconvulsionsfrom tetanus,choreaandrabies.Usuallytheattackspontaneously stops,but‘‘convulsionsdonotalwayshavesuchafortunate ending.Toooftenthephysicianmustlamenttheinsufficiency ofhis art, and parentsthe loss oftheir beloved child, the darlingandhopeofthefamily’’—afterseveralhoursordays ofsuffering.Buthecautionsagainstimmediatelyacquiescing to death. Brachet distinguishes clearly between partial convulsions,whichheconsiderslessseriousthangeneralised convulsionswithoutprovidingmoreinformation.Thelonglist of causes indicates physicians’ ignorance: heredity, fever, cold,worms,tootheruption,pollutedairincities,asphyxia, headwounds,anger,masturbation,excessivelytightswaddl- ingclothes,andsoon.Brachetcriticisesaviewwidelyheldby hiscontemporarieswhereby illnesses werelookedupon as
‘‘beneficialeffortsbyNature[...]andconsequently,convul- sionsaregood’’.Undoubtedlythefirsttodoso,helinksthe convulsionsofchildrentopathologicalbrainactivityrather thanasimplemuscularphenomenon:‘‘Theprimarycauseof convulsionsisbrainirritation.Toexplainhowthishappens, wemuststartbyexplaininghowthebrainactsonthemuscles tomakethemcontract.Allthatphysiologyteachesusisthat thenervesarethemeansoftransmission.Anythingassumed beyondthisismerehypothesis,andoffersnothingsolid’’.His concernsarewellfounded:‘‘Willconvulsionstellustheseat and precise degree of damage, based on whether a given muscle convulsed and not another?’’ Also: ‘‘The infinitely varied pathological lesions found in the brain following convulsions teach us two things: first, that they were the causeofthesemovements;second,thattheconvulsionsdo nothavea singlemode ofdamage’’.And hisconclusionis sound:‘‘Convulsionsneverexistpriortothebrainaffection;
they are always subsequent to it.’’ The recommended treatmentsrangefromsprayingtheheadwithcoldwaterto the ingestion ofzinc oxide,henbanes andnumerous other plants,ether,opium,ammoniumhydroxide,andquinquina;
‘‘vesicantswerealsoappliedtothelimbs,theneckandeven thetopofthehead.[...]Theremedywouldbeworsethanthe maladyif,ratherthancalmandpeacefulsleep,narcotismand braincongestionweretriggered’’—thenapurgativewouldbe necessary![57].
ApartfromBrachet,importantcontributionstothefieldof epilepsy weremadeinthe19thcenturybyseveralauthors.
Jacques-GillesMaisonneuve describesepilepsy inadults,in 1803 [60]. The year Brachet’s book was published, Louis- FlorentinCalmeil(1798–1895)defendedhisthesis,distinguish- ingclearlyagrandmalseizurefromanepilepticabsence.He inventedtheterm‘‘e´tatdemal’’forsevereprolongedattacks [61].AsforLouisFranc¸oisBravais(1801–1843),hedefendedhis Fig.5–Memoirontheseizures’causesinchildren.1824.
thesison31May1827,threeyearsafterBrachet’spublication.
Bravaisincludesobservationsofepilepsylimitedtothearm andface,withpost-criticalparesisthatheterms‘‘hemiplegic epilepsy’’[62].InhisTuesdayLessonon15November1887, Jean-MartinCharcot(1825–1893)stated:‘‘Thisphenomenonof partial epilepsy was described and distinguished from ordinaryepilepsybyBravais,whodidhisinternshipinthis hospital.Thatwasbackin1827or1828.Butmorerecently,an Englishscholar, Mr.JacksonofLondon,tookup thesubject againandhandleditinsuchaparticularwaythatIsometimes call this condition Jacksonian epilepsy, and the name persists.Thisisjustified,Idon’tregretit.Imaybewronging Bravaisalittle,butMr.Jackson’sstudyissoimportantthathe truly deserves having his name associatedwith this dis- covery.IftheFrenchandEnglishnamescouldbemergedinto Bravais-Jacksonianepilepsy,thiswoulddojustice toboth, although it would be a little longer’’ [63]. The multiple publicationsofJohnHughlingsJackson(1835–1911)onthis formofepilepsyspannedadecadestartingin1863[64–66].
The´odoreHerpin(1799–1865)describedmyoclonicepilepsyin 1867[67,68].ItshouldalsobenotedthatwhenBrachetwrote his book, adult epileptics were locked in asylums with lunatics. Etienne Esquirol (1772–1840) suggested they be separatedin1838:‘‘Theymustnotbehousedpell-mellwith lunatics, as is the current practice in all hospices where epilepticsandlunaticsarekept’’[69].Undoubtedly,allthe researcherslistedaboveincludingBrachetshouldbecredited fortheircontributiontothefieldofepilepsy.Itmustbeadded that throughoutthe19th century,epilepsy was studied in asylumsby alienists. Unfortunately,Owsei Temkin (1902–
2002), in his‘‘reference’’ work on the history of epilepsy, totallyignoresBrachet[66].
5. Hysteria
TheconceptualrigorandevercriticalpositionthatBrachet adoptedinstudyandresearchonhisbroadrangeofsubjects easilyexplainswhyhedevelopedapurelycerebraltheoryof hysteriaforthe1845PrixCivrieuxawardedbytheAcade´mie RoyaledeMe´decine.Hehadalreadydefendedthisconceptin 1832inhisstudyofhypochondria:‘‘Abizarrecontamination ofthesensationofthecerebralnervoussystem,ofseveralacts oforganiclifeandofthefunctionsoftheorganofintelligence, relative to the perception of these phenomena and the judgment ofthis organitself’’[70]. Brachet’sworkowesits noveltytothefactthathesolelyusedclinicalcaseshehad personallyhandled,andtohisplacingofhysteriainitssocial andculturalcontext.Herecognisedmasculinehysteriabut onlyineffeminatemen,asdidEtienneGeorget(1772–1840), withwhomBrachetsharedtheviewthatwomenhadmore fragilenervoussystems:‘‘Thereal worlddoesn’tsuffice for [thehysteric];sheneedsanimaginaryworldthathermind delightsinembellishing’’;but‘‘hysteriadoesnotdamagethe intellectual faculties in any way’’ [71,72]. For Brachet, a precursor to Pierre Briquet (1796–1881) and Charcot, the hysteric expressed an immoral and socially inappropriate behaviourwithoutanysexualdeficiency.Heoutlinedatheory ofthegender-specificbrain,wherebyeachsexhasitsownway ofreactingdynamicallytoemotionsandpsychicaggressions,
thebasisfortheideathatwomenhavespecificbehavioural reactions. The novelistGustave Flaubert (1821–1880) would completelyassimilatethisinhischaracterofMadameBovary [73–75].Brachetproposed,likeEsquirolandlaterPaulSollier (1861–1933), a ‘‘moral’’ treatment of hysteria, during a hospitalisationthatremovedthepatientfromhertraumatic environment and included repeated one-on-one interviews withthe physician,sothat hercomplaintscould beheard.
Hydrotherapyand‘‘anti-spasmodics’’[76,77]werealsoused.
HysteriaisathemethatBrachethadcontinuallystudiedsince 1828, withhistreatise onasthenia, followedbya workon hypochondriain1832andhishysteriatreatisein1847.Brachet ultimatelysharedthe1845PrixCivrieuxwithHectorLandouzy (1812–1864)whodefendedaneuro-uterinetheory,whichtheir contemporariesweremuchmorereceptiveto.Itisunfortu- natethatthisprize,recognisingtwoauthorswithopposing views,andCharcot’stendencytorefermainlytoBriquetled theinnovativeconceptsadvancedbyBrachetasearlyas1832 tobeovershadowed[6,78–80].
6. Conclusion
Potton had a perfect understanding of Jean-Louis Brachet:
‘‘Whileheisnot rankedamong themostexceptional men whom Nature endowssorarely,one cannotdenythatshe granted him highly felicitous gifts, which he developed through tenacious study’’. We share his analysis: The noteworthy pointsand characteristicsthatstandout inhis wide-rangingpublicationsare:
ademonstratedfaiththatsciencewouldrewardwhoever tookthepainstofollowandstudyitsprinciples;
strong powers of observation and comparison which allowed him to combine isolated facts and to establish rulessanctionedbyhispracticalexperienceasaphysician;
experimental demonstration applied on a large scale to physiologyandpathology;
theenergytostudyaseriesofproblems,evenifthesolution remainedbeyondreach,inthediversebranchesoftheartof healing[1].
Twoexplanations canbe advancedas towhy Brachet’s workhasremainedmoreorlessforgottentothisday.Byusing experimentation to confirm facts, and thus abandoning philosophical reasoning, Brachet developed a materialism viewedwithdisdain,andoftenhostility,byhiscontemporar- ies.Healsoremainedinhisnativeregionanddidnotseekout aprestigiousprofessorshipattheFaculte´ deMe´decineinParis, which,inacountryascentralisedasFrance,constitutesan irremediablebarriertorecognitionamongone’speersandto immediateandfuturerenown.Myhopeisthatthisarticlewill give his innovative ideas the exposure they should have receivedfromthestart.
Disclosure of interest
The author declares that he has no conflicts of interest concerningthisarticle.
Acknowledgements
Mysincere thankstoProfessorsJacquesPoirier,Emmanuel Broussolleandthereviewersfortheircriticalandconstructive readings.
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