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The vast literature of aphasia is rich in improbabilities and guesses from false premises. Two pioneers have become eponyms (Broca and Wernicke), and many are famous, such as Gall, Bouillaud, Trousseau and Pierre Marie in France, Liepmann in Germany, and Hughlings Jackson and Bastian in England. Larrey too deserves fame, but was only cited by his contemporaries, Gall and Osborne.
The nosography of aphasia1,2,3 started with dramatic single case reports, centuries before Broca's watershed paper in 1861 on the site of aphasia in the left second and third frontal gyri. Some of the early accounts were by great writers, among them Samuel Johnson (of himself)4 and Goethe (probably of his maternal grandfather)1; and the Swedish botanist and physician Linnaeus wrote of the condition in a fellow academic at Uppsala5. Pinel, the Paris liberator of psychiatric patients, gave a classic description in 1809 of a notary who could not speak, read or write after a stroke1.
But the writings of Larrey contain no fewer than twelve cases of aphasia, two with illustrations. This military surgeon started his long career in the navy of the Bourbons in 1787, and recorded his experiences in twenty-six bloody Napoleonic campaigns, and their aftermath, in two multi-volume oeuvres—the chronological Mémoires de Chirurgie Militaire et Campagnes6 up to 1814 and Relation Médicale de Campagnes... de 1815 à 18407, and the more didactic Clinique Chirurgicale dans les Camps et Hôpitaux Militaires8.
Larrey's prize aphasic was Louis Manez (case 1, Table 1), a corporal in Napoleon's horse guards who was struck at long range by a British musket ball in the left eyebrow at Waterloo on 18 June 1815. He lost consciousness and lay on the battlefield for two nights. He was then tended by a citizen of Brussels for some months while his right hemiplegia improved. He became mobile, and at the end of 1815 came under the care of Larrey at the Guards Hospital in Paris. Despite a discharging wound with half the projectile still impacted, he improved to the extent that he returned to duty in the (now royal) foot guards, and was promoted to sergeant instructor. He compensated for his inability to name his pupil soldiers, or the parts of the weapons, by reading from lists and instruction booklets. He died of pulmonary tuberculosis 12 years after Waterloo. The skull vault had multiple small depressed fractures deep to the bullet remnant, overlying the lateral surface of the frontal lobe and the course of the left middle cerebral artery. Larrey deposited the skull vault specimen (Figure 1) in the museum of the Paris Jardin des Plantes, and described this man in several sections of his books6,7,8, as did F J Gall in 18199 and J Osborne10 in 1834 in Dublin (where Larrey had pontificated on his 1826 tour of Great Britain and Ireland).
Five others of his aphasia cases were battle casualties: one, a sailor (case 6), had been wounded and captured by the British in the West Indies, and had been trephined in England while a prisoner of war8 (Figure 2). Larrey himself taught conservative management of head injuries, except when bone splinters or other matter had penetrated the brain through the meninges.
Three had been injured by a penetrating fencing foil— via the left orbit (case 3), via the right orbit through to the left Sylvian fissure (case 4), and via the left temple (case 5).
One had suffered a bad road traffic accident (case 9). Larrey also recorded aphasia in a survivor of coal gas poisoning (case 10) and lastly, after an atypical stroke (case 12).
All had difficulties with proper names and with naming objects; in case 3 the otherwise intelligent man kept calling Larrey ‘monsieur chose’8,9. In two there was also dyscalculia (cases 1 and 7); however, two other aphasics (cases 4 and 5) were good at cards. In case 8 the severely aphasic patient could only utter expletives9, anticipating Hughlings Jackson's description of the distinction between ‘propositional’ and ‘emotional’ speech.
The moribund soldier (case 2)6 indicated ‘yes’ and ‘no’ by uttering ‘baba’ and ‘lala’, respectively; and the stroke survivor (case 12)8 is described as using periphrasie: later terms would be jargon and paraphasia.
While Larrey was struck by the preservation of understanding in the majority, he also stressed there could be general intellectual impairment with aphasia—e.g. in cases with fits (cases 7 and 11), and with multiple injuries (11), or after the coal gas poisoning (10).
Larrey made no attempt to discuss the anatomy of aphasia, let alone the physiology of speech, beyond citing Gall's belief9 in the localization of the memory for words in the brain behind and above the two orbits, or in Larrey's words8 ‘... lésion partielle des circonvolutions latérales de la surface antérieure des lobes cérébraux’. And, in turn, Gall quoted Larrey's cases in support of his own thesis9.
Larrey was sufficiently intrigued by aphasia to revisit his road traffic accident patient (case 9) in Berlin in 1813, after his return from the catastrophic Russian campaign of 1812 in which he himself had nearly perished from typhus. And, rather ghoulishly, he had the pickled head of the soldier with jargon aphasia (case 2) sent from Vienna to Paris for study, but did not record any findings7. And it must have been his interest in aphasia that made him include the cases of coal gas poisoning (case 10) and of stroke (case 12) in his mainly surgical texts.
Larrey consulted Gall about at least three of his patients, who were duly included in Gall's monumental Anatomie et Physiologie du Système Nerveux en Général et du Cerveau en Particulier of 18199. Gall was highly regarded in medical Paris of the first half of the century, and his theories persisted well beyond. Gall's belief in a frontal memory store for words stemmed originally from an impression that his schoolmates with prominent eyes had better verbal memory than the others. Might the apparent proptosis reflect a larger frontal brain? This gave rise to the fantasies of phrenology but also to Gall's half-truth of cerebral localization in general and localization of speech in the front of the brain.
Bouillaud11, one of the leaders of Paris medicine at its apogee and another faithful disciple of Gall, stressed a bifrontal location of speech in 1825, but also extended the range of defects in aphasia beyond Gall's amnesia for words. Bouillaud's ‘gospel’ was still defended in the early 1860s by his son-in-law Auburtin—that is, at the time of Paul Broca's papers on lesions of the left second and third frontal convolutions, papers which had coincided with Gustave Dax's publication of his father's (Marc Dax) presentation of 1836 to the Congrès Méridional at Montpellier entitled Lésions de la moitié gauche de l'encéphale coincidant avec l'oubli des signes de la parole12.
The cholera epidemic of 1835 in the Midi had taken Larrey also to Montpellier where one of his books had been published. But there is no mention of Dax in his last book of 1841 which reverts to his own aphasia cases and the preservation of the Manez skull specimen7.
The improbable notion of a lateralization of speech in a seemingly symmetrical brain took some years to be accepted. It is ironic that Broca was right despite the faulty description of the cerebral lesions in his two cases, criticized as early as 1868 by Maudsley13 and finally by Pierre Marie in 190614.
Larrey's contributions to medicine are described beautifully by J H Dible in Napoleon's Surgeon15, alongside extensive quotations from Larrey's Campagnes. he was a great surgeon who designed new instruments16 and organized the early (forward) treatment of battle casualties, after triage which is modern and humanitarian, disregarding rank and nationality. He defined indications for trephining, and for amputations, by better surgical techniques; he was also a pioneer of ambulance design for evacuation of the wounded. Figure 3 shows him in middle life.
His experience of epidemic ophthalmia (probably trachoma15) and plague in Bonaparte's Egyptian and Syrian campaigns of 1797-17986, and of a cholera epidemic in the Midi in 18357, made him a practitioner of public health in the days before bacteriology. He also contributed to the anthropological studies of 1797-1798 in the Near East7. Sömmerring's elaboration of the discoveries of Galvani and Volta encouraged Larrey to experiment with nerve and muscle stimulation in amputated limbs, and to toy with the concept of long-distance electrical télégraphie8. After Waterloo he participated in the foundation of the Paris academies of science and of medicine; and he cared for the veterans and for civilians, with a period of acute casualty work during the July revolution of 1830. He had been appalled by French prison conditions as a young man under the ancien régime, and more than 40 years later helped in getting the branding of prisoners abolished7.
Under the reign of Louis-Philippe, Larrey was surgeon-in-chief at Les Invalides (1832-1839); despite this, his wish to be interred there was vetoed by Marshal Soult, the ‘vicar of Bray’ of French politics. Larrey had clashed with him in 1813 when some young conscripts in Napoleon's penultimate campaign in Saxony were charged with self-inflicting wounds; he had got Napoleon to block Soult's order to have one in four of them shot15.
Napoleon, more a practitioner of man's inhumanity to man than a philanthropist, described Larrey in his will as the most virtuous man he had known, and left him 100 000 francs. His estate was insufficient to pay even half in Larrey's lifetime, but Napoleon III gave the balance to Larrey's son Hippolyte who had in turn become surgeon-in-chief to the army of the Second Empire15.
Larrey's contributions went far beyond the military surgery for which he is renowned. One of the least known is his work as an early limner of aphasia.