The tic douloureux of Alexis Pujol (1739–1804)

Elsevier

Available online 20 September 2022

Revue NeurologiqueAbstract

In 1787, Alexis Pujol (1739–1804) wrote the first monograph exclusively on trigeminal neuralgia which he called “tic douloureux”, or painful tic. Although it was not a seminal description, his monograph was a valuable clinical summary that helped his contemporaries make an exact diagnosis, even though it did not offer proven treatments. Unlike most in his day, Pujol adhered to the theory of electricity, seeing it as the vector of information transmission by the nerve. This made him a precursor and put him in a position to propose a novel pathophysiological theory of pain, not yet qualified as neuralgic. His thinking illustrates that, at the dawn of the nineteenth century, a provincial physician working alone was able to make his contribution to building medical knowledge, particularly in the field of neurology. After a brief biography of Pujol, this article will cite from his book to show the relevance of his clinical observations, which are still valuable today. Without omitting the inspiration, he took from his predecessors, this article also mentions the work of those who followed in his footsteps.

Section snippetsWho was Alexis Pujol?

The son of a lawyer in Toulouse, Alexis Pujol was born on 10 October 1739 in Le Poujol-sur-Orb, not far from Béziers in southern France. After abandoning his initial plan to become a priest, he studied medicine in Toulouse where he received his “doctor's hat”, meaning his doctorate, on 23 June 1762 [3]. He then left to perfect his skills under the famous masters at the University of Montpellier. Practising initially in Bédarieux, west of Montpellier, he moved to Castres at the request of a

Description of tic douloureux

Confronted with several cases of “tic douloureux.. this singular affection”, Pujol searched in vain for works that could familiarise him with this pathology and its possible treatments. “I finally undertook to compile my own observations.” From the beginning of his work, published in 1787 (Fig. 1), Pujol took into account recent advances in the physiology of nerves. Nerves were thought to carry “the electric fluid”, which had come to replace “the animal spirits”. Abbot Jean-Antoine Nollet

Pathophysiological explanation of tic douloureux

Pujol then discussed “the theory of tic douloureux”. He saw a similarity with cramps, notably the horrible cramping in cholera, and borrowed an expression coined by the Scottish Duncan Liddel (1561–1613): “An illegitimate, bastard kind of convulsion” [10]. Pujol believed in the existence of cramps without muscular contraction. For him, the intensity of the pain and the fact that the face has numerous muscles validated the link he saw between tic douloureux and cramps. He noted regretfully, “As

Similarity between raptus caninus and tic douloureux

Johann Conrad Amman (1669–1724), a Dutch physician originally from Schaffhausen in Switzerland, compiled in 1722 the writings of de Cælius Aurelianus, a Roman physician living in the fifth century [14] who coined the neologism, “De canino raptu, quem Græci κυνικον σπασμον” [15], what the Greeks called “cynic spasm” [16]. This pathology is currently known to be a focal dystonia called oromandibular dystonia. For Pujol, “it is more than likely that this spasmodic & idiopathic disease of the face

Treatment of tic douloureux

Pujol recommended treating patients with opium preparations at increasing doses until beneficial somnolence was attained. In addition, “a linen folded in four and soaked in henbane & poppyhead should be applied to the place from which these shooting pains originate, or cotton soaked in Sydenham's tincture”; the dressing was left in place for several hours. By the general route, drinking abundant quantities of donkey, mare, or goat milk, along with chicory, hemlock, or white henbane, increased

Why did Pujol use the term “tic”?

The hippiatrist Carlo Ruyni (1456–1530) of Bologna in Italy was the first to use the word “tic” in a posthumous work on veterinary medicine published in Venice in 1598 [18]. Ruyni employed this term in the section Spasmo delto tico mortale to distinguish between contractions secondary to tetanus and dystonic spasms observed in some horses: “Et en differenza del ticco secco, il quale a più tosto vitio che male”; that is, unlike in tetanus, the dry (isolated) tic was brief and not fatal. In

Pujol's predecessors

Descriptions of pain in the face compatible with the diagnosis of facial neuralgia are reportedly found in the writings of Avicenna (980–1036) and of Persian authors [22]. The numerous and inaccurate descriptions of various types of head pain written in past centuries were undoubtedly referring to cases of trigeminal neuralgia poorly differentiated from migraines, tumours, dystonia (cynic spasm), or contracture as sequelae in Bell's palsy.

It was probably the disciples of Johanes Laurentius

Following Pujol's book

Once Pujol's book was published, Thouret, who had proof-read the material, presented a long paper to the Royal Society of Medicine in 1787 [32]. In his discussion of fourteen personal cases, he added the notion of a “trigger area” that, when touched lightly, caused the painful attack. His long presentation was a panegyrical review of all Pujol's arguments.

The first thesis on tic douloureux was defended in Paris in 1803 (year XI according to the French revolutionary calendar) by Jean Philippe

In conclusion

The book that Pujol wrote on trigeminal neuralgia, while not a seminal description, is a valuable clinical summary that helped his contemporaries make an exact diagnosis, even though it did not offer a proven treatment. Pujol adhered to the theory of electricity, seeing it as the vector in nerves for transmitting information. This put him in a position to propose a novel pathophysiological theory of pain, not yet qualified as neuralgic. His thinking illustrates that, at the dawn of the

Statement of ethics

This work required no approval from an institutional review board and was prepared in accordance with the ethical guidelines of the journal La Revue Neurologique.

Disclosure of interest

The author declares that he has no competing interest.

Funding sources

No funding was obtained for this work.

Acknowledgements

Many thanks to Hubert Déchy, and Jacques Poirier and their attentive readings and suggestions and to Anna Fitzgerald for her translation.

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