Gaëtan Gatian de Clérambault (1872–1934) submitted his thesis for his medical degree in 1899. This thesis testifies for the visionary nature of its author in the field of psychiatry. In our study, we present the very rare work entitled “Contribution to the study of the othematoma. Pathogenesis, pathological anatomy and treatment”. We then analyze this work before attempting to understand the choice of this thesis topic, which may seem strange for a psychiatrist. We put forward three hypotheses. The study of Clérambault's thesis hardly unveils the mystery of this great psychiatrist who committed suicide in 1934, thus putting an end to a brilliant career.

Gaëtan Gatian de Clérambault (1872–1934) a soumis sa thèse pour son diplôme de médecine en 1899. Cette thèse dénote du caractère visionnaire de son auteur dans le domaine de la psychiatrie. Dans notre étude, nous faisons une présentation du très rare ouvrage intitulé Contribution à l’étude de l’othématome. Pathogenèse, anatomie pathologique et traitement. Ensuite, nous analysons ces travaux avant de tenter de comprendre le choix de ce sujet de thèse qui peut paraître étrange pour un psychiatre. Nous émettons trois hypothèses. L’étude de la thèse de Clérambault dévoile à peine le mystère de ce grand psychiatre qui se suicida en 1934, mettant ainsi fin à une brillante carrière.

# Introduction

Gaëtan Gatian de Clérambault (1872–1934) began his externship in 1892 and completed it in 1898, with a break for his military service in 1893–1894. In 1898, at the end of the competitive examination, he passed in 6th position out of eight, Joseph Capgras (1873–1950) being the valedictorian. It is during his internship at the “Asiles des Aliénés de Seine” that he got to know the world of mental pathology. He followed, among others, the courses of Jules Voisin (1844–1920), Jules Dejerine (1849–1917) and Philippe Chaslin (1857–1923), a doctor in Bicêtre. Clérambault defended his medical thesis on October 25, 1899, at the Faculty of Medicine in Paris. At the time, he was an intern in the department of Dr Guillaume Boudrié at the Perray Vaucluse asylum. His thesis entitled “Contribution to the study of the othematoma. Pathogenesis, pathological anatomy and treatment” was dedicated to his promoter, Pr Carl Potain (1825–1901), then a doctor at the Charité hospital, a member of the Institute. It was printed by Vigoté Frères, the publishers and is 76 pages long (Fig. 1
                     ). This thesis by the last great expert in classical French psychiatry and the only avowed master of Jacques Lacan (1901–1981) is extremely rare and only ten copies have been published. We only know of two copies in the world, one at Sainte-Anne in Paris, the other one at the library in the former Faculty of Medicine in Paris.

In addition, we were lucky enough to acquire the copy that belonged to Dr. Marchand (a French alienist), dedicated by Clérambault to “La revue de Psychiatrie” (Fig. 1). At the end of this article, we propose to present this thesis, to make an analysis of the theories of the time at the origin of the othematoma, and finally to reveal what motivated Clérambault to choose such a subject for his thesis. Indeed, nowadays, Clérambault is mainly known for two phenomena that he described, i.e., erotomania and mental automatism. In addition, we know his passion for fabrics and drapes, but he is also famous for the rigor of his clinical descriptions.

# Presentation of Clérambault's thesis

From a review of the literature on othematoma, Clérambault gathers clinical observations, among others, from the surgical files of Dr. Picqué, a hospital surgeon and chief physician at the surgical department of Saint Anne Hospital. Mr. Macé, the micrographer, examined the histological sections. Dr. Farnarier, an intern at the “Asiles des Aliénés de la Seine”, wrote the three observations of othematoma published at the end of the thesis. Dr. Küss (1815–1871), a hospital extern, attached to the laboratory of Pr Mathias Duval (1844–1907), helped Clérambault in the examination of histological preparations. Finally, Clérambault showed his admiration for Pr Tillaux (1834–1904), Rendu and Mathias Duval. Clérambault's anatomo-pathological study relates to a single case of othematoma, specifying that “he hadn’t the time to examine all the cases of othematoma in the establishments for the insane located in Paris or near Paris”. At the end of his study, Clérambault presents for the first time the four theories put forward on pathogenesis and on the exact location of othematoma. His hypothesis is that a purely traumatic etiology of these lesions is unlikely, and that this theory is based on rough estimates. Only anatomo-pathology can draw this discussion to a close, by showing how certain alterations in the pinna predispose to othematoma.

## Etiology

Cases of othematoma can occur in healthy subjects (not insane) following repeated shocks or pulling, as in boxers or football players. Clérambault believes that it is in alienation, especially in forms where nutrition is deeply perturbed (with cachexia), that othematoma are most often encountered. According to him, general paralysis alone accounts for about half the cases. This is followed by melancholy, then epilepsy and mania. These patients are not more exposed to trauma. On the other hand, such patients display organic alterations conducive to othematoma. However, the nature of these alterations which predispose to othematoma still eludes Dr. Clérambault. Achille Foville (1831–1887), a French alienist, is inclined to favour congestion, under the dependence of the sympathetic. Others lean towards trophic disorders, either in the vessel walls, or in the constituent layers of the pinna. Rudolf Virchow (1821–1902), Meyer and Robertson speak of cartilage alterations. Finally, vessel atheroma was observed in several cases.

Drs Marcé, Foville, and Henri Dagonet (1823–1902) believe in the predominant importance of subjective causes and consider the appearance of othematoma in the insane as “the hallmark of serious forms” and as the forerunner cachexia. However, some alienists just blame trauma.

## Seat of othematom

Clérambault subsequently talks to us about the seat of othematoma. He reviews four theories: that of Feltz and Mabille who favour an effusion at the level of the cellular tissue, following the rupture of an arteriole; and the spilled blood appears to encyst in the fibrous membrane, which transforms into cartilage. Foville's theory was that the effusion would take place in a pocket suddenly formed by detachment of the perichondrium, between the latter and the cartilage. Foville relies on an autopsy performed by Dr. Cossy. Virchow admits, like Foville, that the hematoma is produced by a detachment of the perichondrium, but he adds to Foville's data that this detachment occurs as a result of prior alterations in the cartilage which reduce its resistance. Finally, Clérambault evokes Robertson's theory. According to the latter, degenerative lesions of the cartilage of the ear pave the way for haemorrhaging, which originates from the newly formed vessels in the wall of an intra-cartilaginous cavity. As newly formed vessels are particularly susceptible to degeneration, they are also more capable of rupturing under the influence of mild violence or even spontaneously. Clérambault believes that “each of these four theories presents a priori chances of likelihood, perhaps each of them is true, for a category of cases” 
                        [1].

According to him, it would be necessary to investigate whether cellular proliferations really precede the hematoma, what vascularization the deep layer of the perichondrium, presents in the absence of any effusion, and whether the cartilage, before the hematoma, presents an abnormal vascularization. This is why Clérambault presents the anatomo-pathology from the case of Mrs. L, aged 56, who was admitted on October 21, 1893, and whose examination of the tumours took place in 1899. There was no autopsy, but samples were taken from the auricle. At the level of the right ear, Dr. Macé specifies: “the pinna cartilage passing to the hyaline form accomplishes a regressive process”; In addition, “external violence, often minimal, which marked the beginning of the othematoma, cannot on its own be accused of having caused this regression” [2]. At the level of the left ear: Mr. Macé notes a bone transformation of a reticulated cartilage. However, this transformation did not occur directly. The reticulated cartilage, under the influence of the hematoma, has returned to the hyaline form, which results in the bone form.

# Discussion

Othematoma is a hematoma of the pinna of the ear. At the time, this hematoma was known to be a fairly common phenomenon among the insane. As for the origin of this lesion, there were two schools of thought. Some thought that the hematoma produced neuroparalytic hyperemia of the ears (paralysis of the vessels of the vascular nerves of the external ear which follow the path of the trigeminal) and that in general it could not be observed in healthy subjects (except in boxers or wrestlers). The insane with paralytic dementia would have presented deep vasomotor disorders of the nervous centres, resulting in edema and ecchymoses. A slight trauma could then have sufficed in these patients, whose vascular walls were often in a cachectic state (nutritional disorders) to produce an extravasation of blood. Other authors thought that the origin of othematoma is exclusively of traumatic origin. Clérambault argues that othematoma has “subjective” causes, specific to the insane, rather than traumatic causes. He thus opposes his “venerable master”, Dr. Valentin Magnan (1835–1916), responsible for admissions at Sainte-Anne, who defended the opposite thesis in Les Hématomes du pavillon de l’oreille (1868). Indeed, Valentin Magnan reports that in 1859, at the Antiquaille hospice in Lyon, an “epidemic” of othematoma stopped after the dismissal of three violent nurses; so that it links othematoma to a trauma [10]. Magnan, just like Gudden, Lunier, Paul Broca (1824–1880), explain the othematoma of the insane by an over prolonged pressure of the ear or by over repeated frictions. Mr. Bouteille d’Armentières, alienist, brought together in 1880, all the arguments in favour of this traumatic hypothesis by more or less voluntary friction in these insane patients. Mr. Bouteille, explained that at the Armentières asylum, of which he was the doctor-director, the supervisors pulled the left ear of the insane, within easy reach of right-handers, explaining the greater frequency of this lesion on the left ear. This phenomenon is rarer among insane women who often wore caps that covered their ears. Clérambault, then an intern at Baudrie, had also made this observation. In addition, Joseph Rogues de Fursac (1872–1941), was also cautious, and he indicated that proper supervision (in well-organized asylums) reduces the frequency of the othematoma in considerable proportions [4]. However, Koeppe had noted analogous facts on the cartilages of the nose called a rhinhematoma [9]. Richard von Krafft-Ebing (1840–1902), a German-Austrian psychiatrist, specified that with an othematoma in a healthy subject, it was necessary to examine, if in reality, the latter did not present a defect [12].

## Why this thesis subject?

Three main hypotheses seem plausible. The first is that Clérambault, a worthy clinician, was perhaps researching, as Joseph Babinski (1857–1932) had observed with the cutaneous-plantar reflex in his time, an objective and hardly debatable sign specific to insanity, which would have been a real challenge. On Page 7 of his thesis, Clérambault explicitly indicates that he ran out of time and that he would continue his studies on this subject, “expecting to publish, under the direction of his master M. Picqué and with the assistance of M. Macé, precise data on the various points which he neglected”. However, between 1902 and 1934 (the date of his death by suicide), Clérambault would publish 139 articles [8] and he never spoke about othematoma.

The second hypothesis is that this thesis subject echoed Clérembault's own biography. This subject of othematoma reminds us of that of the thesis of Dr Alice Sollier (1861–1942) on dentition in the retarded [11]. After opting for dentistry like her father, she ended up turning to nervous and mental illnesses, hence the subject of her thesis. Paul Sollier (1861–1933), her husband, one of the best students of Jean–Martin Charcot (1825–1893) remained in the shadows and owes his posterity to the fact of having treated in his clinic, with his wife, Alice Sollier, the neurasthenia of Marcel Proust (1871–1922). An oral tradition indicates that Clérambault had told Dr. Marc Trénel (1886–1932), his colleague, that he had chosen this thesis subject because of the deafness of an ancestor, an engraver in his own right who was deaf as well as the engraver's mother. Dr. Marc Trenel was a psychiatrist and head of department at the Maison Blanche asylum, of which Lacan was the student and the friend with whom he learned about language disorders.

The third hypothesis is based on Clérembault's well-known and well-documented passion for fabrics and drapes. We will find later in his career this concern for folds in the interest of Clérambault for the art of drapery and fabrics among Moroccan and Algerian women [3]. This idea of the eroticism of silk in women comes from Dr Dubuisson (1847–1908) who had written a book on thieves in department stores [6] and with whom he had been an intern at Sainte-Anne Hospital. Furthermore, embryology, at its peak at this time, is a science of folds and how to hold them together, formed from three layers–the endoderm, ectoderm and mesoderm [5]. It is possible that this passion for tissues is already perceptible in this thesis, even if it is a question here of cellular tissues, perichondrium, fibrous membranes, etc. Subsequently Clérambault would never take up the subject of othematoma in his writings. Did he understand that he was on the wrong track by associating othematoma, vascularization of cellular tissues and insanity?

# Conclusion

We recall Clérambault's keen sense of observation, mirrored by the qualifications he obtained at the special infirmary of the Paris Police Prefecture [7]. At this one-of-a-kind observation post, he specified the clinical manifestations of several morbid entities: acute drunkenness, epilepsy with psychiatric expression, passionate delusions and especially erotomania. He teaches there and his lectures attract the Parisian socialite public, fascinated by the presentations of the sick.

Reading his thesis, there may be a certain disappointment for the contemporary reader not to find the clarity and clinical precision of this great expert in psychiatry, who subsequently seems to lose himself in unsuccessful hypotheses. Nevertheless, the impasses of research are also part of the history of medicine and remind us of the relativity of our theoretical assumptions.

The study of Clérambault's thesis only slightly unveils the mystery of this great psychiatrist who committed suicide in 1934, so ending a brilliant career.

# Disclosure of interest

The authors declare that they have no competing interest.