It UC-NRLF B E T3fi 71D r«#v. :wl»,:r>,V/7. e-- mi^ T0\j\-^h >r LECTURES ^" ,_y^ ON / / THE DISEASES OF THE NERVOUS SYSTEM DELIVERED AT LA SALPllTRIfiRE BY J. M. CHAECOT, PROFEBSOR TO THE FACULTY OF MEDICINE OF PARIS ; PHYSICIAN TO LA SALPETRlf RE ; MEMUEROP THE ACADEMY OF MEDICINE, AND OF THE CLINICAL SOCIETY OF LONDON ; PRB3IDENT OF THB ANATOMICAL SOCIETY, AND EX-VICE-PRESIDENT OF THE BIOLOGICAL SOCIETY OF PAKI8. ETC. TRANSLATED FROM THE SECOND EDITION BY GEORGE SIGERSON, M.D., M.Cii., LICENTIATE OF THE KING AND QUEEN'S COLLEGE OF PHYSICIANS; LECTURER ON BIOLOGY AS'D KX-DEAN OF THE FACULTY OF SCIENCE, CATHOLIC UNIVERSITY OF IRELAND ; FELLOW OF THE LINNEAN SOCIETY OF LONDON ; MEMBER OF THE SCIENTIFIC SOCIETY OF BELGIUM, AND OF THE RoYAL IRISH ACADEMY, ETC. WITH ILLUSTRATIONS. PHILADELPHIA: HENEY O.LEA. 1879. Philadelphia: collins, printer. TEANSLATOR^S PREFACE. Although but recently published in Paris, the Lec- tures of Professor Charcot on Diseases of the Nervous System have already taken a place amongst the classic works of medical literature, and been translated into several Continental languages. When preparing for the following version, it was judged best to await the appearance of the second French edition ; thus the reader, in exchange for some delay, has been enabled to obtain the work in its most correct form, enlarged by about one-sixth. It was found inconvenient to repro- duce the ten plates appended to the French volume. It is proper to mention that these lectures were reported and edited in French by Dr. Bourne ville, editor of 'Le Progres Medical,' whose name or initial will be found attached to several notes. G. S. Dublin. ivi37i.e95 CONTENTS PAET I. DISORDERS OF NUTRITION CONSEQUENT ON LESIONS OF THE BRAIN AND SPINAL CORD. LECTURE I. DISORDERS OF NUTRITION CONSEQUENT ON LESIONS OF THE NERVES. PAG SoMMARY. — Preliminary observations. Object of these lectures : they shall be devoted to those diseases of the nervous system, and of the spinal cord especially, which are most usually met with in the Salpfitriore Hospital. Nutritive disorders consequent on lesions of the cerebro- spinal axis and of the nerves. These morbid alterations may affect the skin, the connective tissue, the muscles, the articulations, the viscera. Their importance in relation to diagnosis and prognosis. Nutritive de- rangements consequent on lesions of the peripheral nerves. Slight in- fluence (in the normal state) of the nervous system upon nutritive action. Passive lesions of the nerves and spinal cord do not directly produce disorders of nutrition in the peripheral parts. Demonstrative experiments. Influence of the irritation and inflammation of nerves or of nervous centres on the production of nutritive disturbances. Nutri- tive disorders consequent on traumatic lesion of nerves, considered specially. Tliey arise not from complete but from imperfect sections or from contusions, etc., of the nerve. Cutaneous eruptions : erythema, zona traumatica, pemphigus, "glossy skin." Muscular lesions, atrophy. Articular lesions. Lesions of the osseous system : periostitis, necrosis. Disorders of nutrition consequent on non-traumatic lesions of the nerves ; their analogy with those which result from traumatic lesions. Nutri- tive disorders affecting the eyes in cases of compression of the trifacial by tumour. Inflammation of the spinal nerves, consequent on verte- bral cancer, on spinal pachymeningitis, on asphyxia by charcoal fumes, «tc. Cutaneous eruptions (zona, pemphigus, etc.), muscular atrophy, and articular affections, which, in such cases, are developed in conse- quence of the neuritis. Anaesthetic lepra, leprous perineuritis, lepra mutilans VI CONTENTS. LECTURE II. NUTRITIVE DISORDERS CONSECUTIVE ON NERVE LESIONS (CONTINUED). AFFECTIONS OF THE MUSCLES. NUTRITIVE DISORDERS CONSECU- TIVE ON LESIONS OF THE SPINAL CORD. PAQB Summary. — Anatomical and functional modifications occurring in muscles under the intlnenceof lesions of the nerves supplying them. Importance of electrization as a means of diagnosis and prognosis. Researches of Dr. Dnchenne (de Boulogne). Experiments: Long persistence of the electrical contractility and of normal nutrition of muscles, after the section or excision of motor or mixed nerves in the case of animals. Pathological cases : Dimimition or speedy abolition of the electrical contractility, followed by rapid atrophy of the muscles in cases of rheu- matic paralysis of the facial nerve, and of irritative lesions of mixed nerves, v^hether of traumatic or spontaneous origin. Causes of appar- ent contradiction between the results of experiment and the facts of pathology. Application of the researches of M. Brown-Sequard : Irri- tative nerve-lesions alone determine the speedy abolition of electrical contractility, followed by rapid atrophy of the muscles. Experiments of MM. Erb, Ziemssen, 0. Weiss. Contusion and ligation of nerves are irritative lesions. Diflfereuce of the results obtained in the exploration of muscles when faradization and galvanization are employed. The results of these new researches are comparable with the facts of human pathology; they do not weaken the proposition of M. Brown-Sequard. Trophic disorders consecutive on lesions of the spinal cord. Considered with regard to their influence on the nutrition of the muscles, these lesions constitute two well-defined groups. First group: lesions of the cord having no direct influence on muscular nutrition : a, lesions in circumscribed spots aflFecting the gray sub- stance to but a slight extent vertically, e.g., partial myeliiis, tumours, Pott's disease ; 6, extensive fasciculated lesions of the posterior white or the antero-lateral columns, without the gray matter participating ; e. 5f., primitive or secondary sclerosis of the posterior, antero-lateral columns, etc. Second group : Lesions of the spinal cord which influence, more or less rapidly, the nutrition of the muscles: a, fasciculated or circumscribed lesions which affect the anterior cornua of the gray matter to a certain extent, in height ; central myelitis, hsematomyelia, etc. ; b, irritative lesions of the large nerve-cells of the anterior cornua with or without participation on the part of the white fasciculi : infantile spinal paral- ysis, spinal paralysis of adults, general spinal paralysis (Duchenne de Boulogne), progressive muscular atrophy, etc. Predominant influence of lesions of the gray matter in the production of trophical troubles of the muscles. These facts can be interpreted by m'^ans of Brown-Se- quard's proposition ,,,,,,,.., 22 CONTENTS. Vll LECTURE III. DISORDERS OF NUTRITION CONSECUTIVE ON LESIONS OF THE SFINAL CORD AND BRAIN. • PAGB Summary. — Cutaneous affections in sclerosis of the posterior columns: papular or lichenoid eruptions, urticaria, zona, pustular eruptions ; their relations with the fulgurant pains; the former appear to arise from the same organic cause as the latter. Eschars of rapid development (acute bed-sores) in diseases of the brain and spinal cord. Mode of evolution of this skin affection : erythema, bullae, mortification of the derma, accidents consecutive on the forma- tion of eschars : a, putrid infection, purulent infection, gangrenous em- boli ; b, simple purulent ascending meningitis, ichorous ascending meningitis. Acute bed-sore in apoplexy symptomatic of circumscribed cerebral lesions. It appears principally in the gluteal region of paral- yzed extremities; its importance in prognosis. Acute bed-sore in dis- eases of the spinal cord ; it generally occupies the sacral region. Arthropathies depending on a lesion of the brain or spinal cord. A. Acute or subacute forms ; they appear in cases of traumatic lesion of the spinal cord ; in myelitis occasioned by compression (tumours. Pott's disease), in primary myelitis, in recent hemiplegia, connected with cerebral J-oftening. These arthropathies occupy the joints of paralyzeii limbs. B. Chronic forms; they seem to depend, like amyotrophies of spinal origin, on a lesion of the anterior cornua of the gray axis ; ob- served in posterior sclerosis (locomotor ataxia) and in certain cases of progressive muscular atrophy 51 LECTURE IV. NUTRITIVE DISORDERS CONSECUTIVE ON LESIONS OF THE BRAIN AND SPINAL CORD. (conclusion.) AFFECTIONS OF THE VISCERA. THEORETICAL OBSERVATIONS. Sdmmary. — ViscerU hypersemia and ecchymoses consecutive on experi- mental lesions of different portions of the encephalon, and on intra- encephalic hemorrhage. Experiments of Schiff and Brown-Sequard : personal observations. These lesions seem to depend on vaso-motor paralysis : they should form a separate category. Opinion of Schroe- der van der Kolk, relative to the relations alleged to exist between cer- tain lesions of the encephalon and different forms of pneumonia, and pulmonary tuberculization. Hemorrhage of the supra-renal capsules in myelitis. Nephritis and cystitis consecutive on irritative spinal affec- tions of sudden invasion, whether traumatic or spontaneous. Rapid alteration of the urine under these circumstances ; often remarked con- temporaneously with the development of eschars in the sacral region; its connection with lesions of the urinary passages which are due to direct influence of the nervous system. viii CONTENTS. PAGE Theory of the production of nutritive disorders consecutive on lesions of the nervous system. Insufficiency of our present knowledge, with re- spect to this question. Paralysis of the vaso-motor nerves : consecu- tive hypersemia ; trophic disorders not produced. Exceptions to the rule. Irritation of the vaso-motor nerves : the consequent ischsemia seems to have no marked influence on local nutrition. Dilator and secretor nerves : researches of Ludwig and Claude Bernard ; analogies between these two orders of nerves. Theoretical application of trophic nerves, Samuel's hypothesis. Exposition. Criticisms. Conclusion . . 84 PAET II. PARALYSIS AGITANS AND DISSEMINATED SCLEROSIS. LECTURE V. ON PARALYSIS AGITANS. Summary. — Of tremor in general. Its varieties. Intermittent tremor. Continuous tremor. Influence of sleep, rest, and voluntary motion. Distinction established by Van Swieten. Opinion of M. Gubler. Tre- mor, according to Galen. Paralysis agitans, and disseminated sclerosis, independent diseases. Parkinson's researches. French works : MM. See, Trousseau, Charcot, and Vulpian. Paralysis agitans admitted to the right of domicile in classic treatises. Fundamental characters of paralysis agitans. A disease of adult life. Its symptoms. Modifications observed in the gait. Tendency to propul- sion and retropulsion Invasion ; its modes, slow or abrupt. Period of stationary intensity. Head and neck not affected by tremor. Altera- tions of speech. Rigidity of the muscles. Attitude of the body and limbs. Deformation of the hands and feet. Delay in the execution of movements. Perversions of sensibility. Cramps ; general sensation of tension and fatigue : need of frequent change of position. Habitual feeling of excessive heat. Temperature in paralysis agitans. Influence of the kind of convulsions — static or dynamic. Terminal period. Confinement to bed. Disorders of nutrition. Enfeeble- ment of the intellect. Sacral eschars. Terminal complaints : they differ from those of disseminated sclerosis. Duration of paralysis agi- tans. Necroscopical results. Inconstant lesions in paralysis agitans ; fixed le- sions in disseminated sclerosis. Lesions of the pons Varolii and of the medulla oblongata (Parkinson, Oppolzer). Pathological physiology. Etiology. External causes ; violent moral emotions ; influence of damp cold, when much prolonged ; irritation of certain peripheral nerves. Predisposing causes. Influence of age. Paralysis agitans appears at a more advanced period of life than disseminated sclerosis. Sex. Heredi- tary predisposition. Influence of race . 105 CONTENTS. IX LECTURE YI. DISSEMINATED SCLEROSIS. PATHOLOGICAL ANATOMY. PAQB Summary. — History of disseminated sclerosis ; French period ; German period ; New French investigations ; Macroscopic morbid anatomy ; ex- ternal aspect of the patches of sc'erosis ; the'r distribution in brain, cerebellum, protuberantia, bulbus rachidicus, and spinal cord. Patches of sclerosis on the nerve". Spinal, cephalic or bulbar, and cerebro- spinal forms. Characters of the sclerosed patches ; their colour ; con- sistence, etc. Microscopic anatomy ; sketch of the normal histology of the ppinal cord ; Nerve-tubes ; Neuroglia, its distribution ; Cortical layer of the recticu- lum. Characters of the neuroglia, influence of chromic acid. Arterial capillaries. Histological characters of the sclerosed patches ; transverse se-tions ; peripheral zone ; transition zone ; central region. Longitudi- nal sections. Alterations of the bloodvessels. Examination of the sclerosed patches in the fresh state. Histological lesions consecutive on section of tbe nerves. Fatty granulations in sections of the sclerosed patches observed in the fresh state. Modifications of the nerve-cells. Mode of succession of the lesions 128 LECTURE VII. DISSEMINATED SCLEROSIS. ITS SYMPTOMATOLOGY. Summary. — Different aspects of disseminated sclerosis, considered from a clinical point of view. Causes of error in diagnosis. Clinical examination of a case of disseminated sclerosis. Tremor: modi- fications caused thereby, in the handwriting ; characters which dis- tinguish it from the tremor of paralysis agitans, chorea, general paral- ysis, and the motor incoordination of ataxia Cephalic symptoms. Disorders of vision : diplopia, amb'yopia, nystag- mus. Irapedt d utterance. Vertigo. State of the inferior extremities. Paresis. Remissions. Absence of dis- orders of sensibility. Commixture of rare sj mptoms ; tabetic ph nom- ena ; muscular atrophy. Permanent contracture. Spinal epilepsy . 149 LECTURE VIII. APOPLECTIFORM SEIZURES IN DISSEMINATED SCLEROSIS. PERIODS AND FORMS. PATHOLOGICAL PHYSIOLOGY. ETIOLOGY. TREATMENT. Summary. — Apoplectiform seizures. Their frequency in dissrainated scle- rosis. General considerations on apoplectiform attacks in general paral- ysis, and in ca^es of circumscribed cerebral lesions of old standing (hemorrhage and ramoUissement). Pathogeny of apoplectiform seizures; insufl9ciency cf the congestion theory. Symptoms: state of the pulse; elevation of the central temperature. Apoplectiform seizures in old cases of hemiplegia. Import mce of temperature in diagnosis. CONTENTS. PAGE Periods in disseminatefi sclerosis. First, second, and third periods. Symp- toms of bulbar paralysis. Forms and duration of disseminated sclerosis. Pathological physiology : relations between symptoms and lesions. Etiology. Influence of sex and age. Hereditary predisposition. Previ- ous nervous affections. Occasional causes : prolonged action of moist cold ; traumatism ; moral causes. Prognosis. Treatment . 167 PAKT III. HYSTERIA. HYSTERO-EPILEPSY. LECTURE IX. HYSTERICAL ISCHURIA. Summary. — Introduction. Hysterical ischuria. Differences which divide it from oliguria. General considerations. Supplementary vomiting. Historical sketch. Causes which have thrown doubt on the existence of hysterical ischuria. Distinction between calculous ischuria and hysterical ischuria. Case. Hysterical paralysis and contracture. Complete hemiansesthesia. Ilemiopia and achromatopsia. Ovarian hypera?sthesia. Retention of urine. Tympanites. Convulsive seizures; trismus. Manifestation of hysterical ischuria. Precautions taken to guard against error. Com- plete anuria. Ursemic vomiting. Relation of the quantity of urine excreted to the vomited matter. Chemical analysis of vomited matter, urine, and blood. Suspension of phenomena. Reappearance of hysterical ischuria. New results of chemical analyses. Serious nature of common anuria and of experimental anuria. Limit of the duration of accidents compatible with life. Influence of the evacuation of even a minute quantity of urine. Rapid appearance of symptoms in calculous ischuria ; their tardiness in hysterical is( huria. Innocuousness of symptoms in direct ratio with the quantity of urine secreted Resistance to inanition in hysteria. Mechanism of hysterical ischuria. Imperfect supply of information in relation to this subject 185 LECTURE X. HYSTERICAL HEMIANESTHESIA. BuMMABT. — Hemiansesthesia and ovarian hyperaesthesia in hysteria. Fre- quent association of these two symptoms. Frtquency of hemianses- thesia in hysterical patients ; its varieties, complete or incomplete. Characters of hysterical hemiansesthesia, ischsemia and the " Convul- sionuaires." Lesions of special sen ea. Achromatopsia. Re'atious CONTENTS. XI between hemiansesthesia, ovarian hypersesthesia, paresis, and contrac- ture. Variation of symptoms in hysteria. Diagnostic value of hysteri- cal hemiansesthesia ; necessary restrictions. Hemiansesthesia depending on certain encephalic lesions. Its analogies with hysterical hemiansesthesia. Cases in which encephalic hemian- sesthesia resembles hysterical hemiansesthesia. Seat of the enceplialic lesions capab'e of producing hemiansesthesia. Functions of the optic thalamus ; British theory ; French theory. Criticism. German nomen- clature of different parts of the eucephalon. Its advantages as regards the circumscription of lesions. Cases of hemiansesthesia recorded by Turck ; special seat of the encephalic lesions in these cases. Observa- tion of M. Magnan. Alteration of special senses 202 LECTURE XI. OVARIAN HYPERESTHESIA. Summary. — Local hysteria of British authors. Ovarian pain ; its frequency. Historical remarks. Opinion of M. Briquet. Characters of ovarian hypersesthesia. Its exact position. Aura hysterica : first node ; globus hystericus, or second node ; cephalic phenomena, or third node. The starting-point of the first node in the ovary. Lesions of the ovary. Desiderata. . Relations between ovarian hypersesthesia and the other accidents of local hysteria. Ovarian compression. Its influence on the attacks. Modus operandi. Ovarian compression as a means of arresting or preventing hysterical convulsions known in former times. Its application in hysterical epidemics. Epidemic of St. Medard — the remedy termed "seoours." Analogies which exist between the arrest of hysterical convulsions by compression of the ovary, and the arrest of the aura epileptica by liga- ture of a limb. Conclusion from a therapeutical point of view. Clinical observations . 216 LECTURE XII. HYSTERICAL CONTRACTURE. Summary. — Forms of hysterical contracture. Description of the hemiplegic form ; analogies and differences between hysterical contracture and that resulting from a circumscribed lesion of the brain. Example of the paraplegic form of hysterical contracture. Prognosis. — Sudden recovery in some cases. Scientific explanation of certain reputedly miraculous events. Incurability of contracture in a certain number of hysterical patients. Examples. Anatomical lesions. Sclerosis of the lateral columns. Varieties of contracture. Hysterical club-foot 234 Xll CONTENTS. LECTURE XIII. HYSTERO-EPILEPSY. PAQB Summary. — Hystero-epilepsy. Meaning of this term. Opinions of authors. Epileptiform hysteria ; hysteria with mixed crises. Varieties of hystero- epilepsy; hystero-epilepsy with distinct crises; hystero-epilepsy with combined crises, or attaques-acces (seizure fits). Differences and anal- ogies between epilepsy and hystero-epilepsy. Diagnostic signs supplied by examination of central temperature in hystero-epileptic acme, and in epileptic acme. Epileptic acme ; its phases. Clinical characters of hysteria, epileptic acme. Gravity of certain exceptional cases of hys- tero-epilepsy. Case recorded by Wunderlich 247 APi»ENDIX. Case of paralysis agitaus 261 LECTURES DISEASES OF THE NERVOUS SYSTEM. PAET FIRST. DISORDERS OF NUTRITION CONSEQUENT ON LESIONS OF THE BRAIN AND SPINAL CORD. LECTURE T. DISORDERS OF NUTRITION CONSEQUENT ON LESIONS OF THE NERVES. Summary, — Preliminary observations. Object of tbese lectures: tliey shall be devoted to those diseases of the nervous system, and of the spinal cord, especially, which are most usually met with in the Salp6triiire Hospital. Nutritive disorders consequent on lesions of the cerebro-spinal axis and of the nerves. These morbid alterations may affect the skin, the connective tissue, the muscles, the articulations, the viscera. Their importance in rela- tion to diagnosis and prognosis. Nutritive derangements consequent on lesions of the peripheral nerves. Slight influence (in the normal state) of the nervous system upon nutritive action. Passive lesions of the nerves and spinal cord do not directly produce disorders of nutrition in the peri- pheral parts. Demonstrative experiments. Influence of the irritation and inflammation of nerves or of nervous centres on the production of nutritive disturbances. Nutritive disorders consequent on traumatic lesions of nerves, considered specially. They arise not from complete but from imperfect sec- tions or from contusions, etc., of the nerve. Cutaneous eruptions: erythema, zona traumatica, pemphigus, "glossy skin." Muscular lesions, atrophy. Articular lesions. Lesions of the osseous system : periostitis, necrosis. Dis- orders of nutrition consequent on non-traumatic lesions of the nerves ; their analogy with those which result from traumatic lesions. Nutritive disorders aff'ectiug the eyes in cases of compression of the trifacial by tumour. Inflam- mation of the spinal nerves, consequent on vertebral cancer, on spinal pachy- meningitis, on asphyxia by charcoal fumes, etc. Cutaneous eruptions (zona pemphigus, etc.), muscular atrophy, and articular afi"ections, which, in such cases, are developed in consequence of the neuritis. Anaesthetic lepra, leprous perineuritis, lepra mutilans. Gentlemen: Never withoat emotion, yet never without ^reat gratification, do I inaugurate, each session, the series of lectures 1 Z PRELIMINARY OBSERVATIONS. which you have assembled to hear. On such occasions, indeed, I never fail to discover the friendly faces of former students, some of whom have attained professorial rank, and some of whom have already signalized their career by brilliant researches. Their pre- sence affords me a great satisfaction, and I gladly seize the occasion to testify my gratitude. It seems to me that the unusual number of those who have assembled here to-day is a convincing proof of the correctness of my belief when, five years ago, I ventured to maintain that this vast emporium of human suffering might one day become a seat of theoretical and clinical instruction, of uncontested utility.^ It is true, gentlemen, that the field of observation before us does not embrace the entire of pathology. But, taken for what it is, who shall complain of its extent, or say that it is not vast? On the one hand, it offers for our study the ailments of the aged, which call for a share of our attention. On the other hand, amongst chronic diseases, it exhibits, under conditions peculiarly favour- able to research, and gathered together in numerous array, those diseases of the nervous and of the locomotor systems which are so common, and consequently so interesting to the physician — dis- eases the pathology of which has begun, within the last twenty years, to emerge from the deep darkness which had previously covered it. As for myself, gentlemen, I have never doubted that the Hos- pital of La Salpetri^re was destined to become, both for the dis- eases of old age and for many chronic disorders, an incomparable centre of instruction. All that was required to realize this idea was that certain modifications should be made in the internal arrangement of this institution, and I am happy to inform you that circumstances, at present, seem wholly favourable to our views. The authorities have already, without any solicitation, placed under our care wards containing nearly one hundred and fifty beds, where we may study all the forms of epilepsy and of the graver hysterical affections. The Director of the Assistance Puhlique has also formed the project of opening in. this hospital a dispensar}^ specially destined for patients suffering from chronic ailments, and a ward to which a certain number of them should be admitted, tem- porarily, to undergo treatment. When all these elements of study shall have been classed and organized with a view to scientific investigation and clinical in- struction, I have no hesitation in saying that we shall possess at Paris an institution which, of its kind, can scarcely have a rival.'' I hope to have soon the happiness of seeing this plan realized in all ' This lecture was delivered in May, 1870. 2 This project has, unfortunately, not yet been made a reality (September, 1874). DISORDERS OF NUTRITION. 3 its details. But if unforeseen circumstances should call me else- where, it would still yield me a deep gratification to see my suc- cessors crowning the edifice whose first foundations only I had been allowed to build. Gentlemen, your time is valuable, and T do not desire that this preamble should extend too far. It is time to come to the special subject of these lectures. I purpose, then, to devote this session to the study of those diseases of the nervous system, and espe- cially of the spinal cord, which are most usually met with in this hospital. As I feel it would be objectionable to plunge at once into technical details, it seems to me suitable to invite your atten- tion to a question of general interest, and one which we shall encounter at every step in the course of our studies. Lesions of the cerebrospinal axis frequently react upon different portions of the body, and produce there, by means of the nerves, various disorders of nutrition. These secondary affections consti- tute one of the most interesting pathological groups, and I shall therefore devote several sittings to trace out for you the principal features of their history. The consecutive lesions in question may affect most of the tissues and may occupy the most diverse regions of the body; thus, we may find them in the skin, the connective tissue, the articulations, the bones, and even the viscera. They generally present, at least at the beginning, the characteristics of inflammatory action. Fre- quently they play in the drama of disease but an accessory part, being simply added on to the usual symptoms, hypersesthesia, anuesthesia, hyperkinesis, akinesis, motor incoordination, etc. But were it only for the interest they have, when considered from the standpoint of pathological physiology, they should not be neg- lected. Occasionally, however, these lesions assume an unmistakable im- portance in the eyes of the clinical observer, either because of the serious ailments which they cause, or because of their value as regards diagnosis or prognosis. Allow me to offer some examples in support of this assertion. Last year I pointed out to you, and I shall return to this symp- tom again, that the sacral eschar which is developed in the course of apoplexy from cerebral hemorrhage or from softening of the brain allows us to lay down a prognosis of almost absolute cer- tainty. The sacral eschars, the affections of the kidneys and of the bladder, which are produced with such rapidity in certain acute dis- eases and in the exacerbations of some chronic diseases of the spinal cord, are often the immediate cause of death. An arthropathy, arising in the course of locomotor ataxia, may 4 DISOKDERS OF NUTRITION. deprive the patient of all future use of a limb which might other- wise have served him long. Finally, these consecutive lesions of nutrition sometimes deceive thephysician, who may mistake them for the disease itself. Such, for instance, are certain forms of progressive muscular atrophy which were formerly regarded as primary affections of the muscles themselves, and whose origin really lies in certain morbid altera- tions which have taken place in the gray matter of the spinal cord. It would, I believe, be superfluous to multiply examples, for these observations should now suffice to indicate the interest which belongs to the study of such lesions of nutrition. The power of producing, under certain morbid conditions, lesions, of nutrition, in the peripheral parts of the body or in the viscera, is not an attribute of the brain and spinal cord alone. These centres share the privilege with the nerves which radiate from them. And it is to be observed that the consecutive affections produced by protopathic lesions developed in the most widely different regions of the nervous system present most remarkable analogies, in spite of some specific differences. Hence when the physician's attention has been called to such affbctions it is often a question of extreme difficulty to determine what portion of the nervous system was originally affected, and what is the true cause of the trophical lesion. This consideration has induced me to limit our study to the lesions which are assignable to cerebral or spinal cauvses alone. These shall be, if you will, our objective point; but it seems useful to draw out, in parallel lines, the history of those trophical troubles which appear in consequence of lesions of the peripheral nerves. Is it not, indeed, one of the greatest advantages of the compara- tive method that it creates light by contrasts? In order to bound our field of study, we shall, however, only take into consideration those nutritive disorders which appear in the peripheral domain of the svffering nerve. The trophical changes which take place in consequence of reflex action, in a region more or less remote, and within the domain of nerves which have undergone no primitive lesions, constitute undoubtedly an interesting subject, but one which deserves to be treated specially. II. In hearing me speak, gentlemen, of the nutritive disorders which arise under the influence of lesions of the nervous centres or of the nerves, most of you, I am sure, have been immediately reminded of the corresponding problem which is debated in normal phy- siology. There is nothing belter estallished in pathology (as I hope to demon- INFLUEN-CE OF NERVE-SECTION. 5 strate) than the existence of irophical troubles conseqjient on lesions of the nervous centres or of the nerves. Nevertheless, you are aware that the most advanced physiology teaches that, in the normal state, the nutrition of different parts of the body does not essentially depend upon the influence of the nervous system. These statements appear contradictory, but the opposition is only in appearance and not in reality. This I shall endeavour to prove, and with that object I have to ask your permission to make a short incursion into the domain of experimental physiology. You are aware that in order to show that the chemical acts of molecular renovation, which constitute nutrition, are not imme- diately dependent on the action of the nervous system, many kinds of arguments are adduced : — 1. The most complex acts of nutritive life take place in certain organisms without the intervention of a nervous system. Plants, for instance, and some of the lowest animals, such as certain pro- tozoa, though unprovided with nervous systems, manifest great vital activity. Does not the embryo, it is also asked, perform all the acts of organic life, at a period when it as yet possesses no nervous element whatever? 2. They base another argument on the fact that certain tissues, even in the superior animals, are totally devoid of nerves and ves- sels. As instances, they refer to the epithelial layer and to carti- lage, which if placed under pathological conditions will become seats of cell-proliferation — a plain proof that nutrition can take place there in a very energetic manner.^ ' . . . "The whole organic life of aniraals, i. e., ever> thing which goes on in them without the intervention of any sensation, or other mental act, may go on without the intervention of the nervous system and stands in no relation of de- pendence to any change in nervous matter; just as the corresponding functions of circulation, nutrition, secretion, absorption, go on in equal perfection in the lowest class of animals where no nerves are detected, and in the whole vegetable kingdom, where there is no plausible reason for supposing that nerves exist ; . . . the nervous system lives and grows within an animal as a parasitic plant does in a vegetable." — 'British and Foreign Med.-Chir. Review,' vol. iii, 1837, pp. 9, 10; and Carpenter, 'Principles of Human Physiology,' Philadelphia, 1855, p. 59. The following is a succinct analysis of an essay in which M. Charles Robin has quite recently expounded the prevalent ideas of the present day in reference to the far from prominent role which the nervous system plays in the work of nutrition : "Those chemical acts which, in a living organism, constitute molecular renovation, otherwise called nutrition, are not under the direct influence of the nerves. There can be no question here of an influence of nerves over tissues, comparable to that of electricity upon chemical action. There exist no nerves which extend over the extra-vascular anatomical elements, such as tlie epithe- lium, like those nerve-tubes which proceed and are .applied to the muscular fibrils. The cause of the movement of nutrition lies in the anatomical elements themselves. In plants, where no nervous system is found, we see the tissues sud- denly swell, the cells increase and multiply. In the embryo, cells are formed, and increase and multiply before the appearance of any peripheral nerve-element. Nutrition is, therefore, a general property of anatomical elements, be they animal or vegetable. Secretion itself is a property inherent in anatomical elements, as 6 • INFLUENCE OF NERVE-SECTION. 8. Finally, arguments bearing more directly on the subject are drawn from the arsenal of experimental physiology. You know- that, after section of the nerves supplying them, and even when the spinal cord has been destroyed, the peripheral parts of the body, such as the muscles or the bones of a limb, will continue to live and be nourished for a considerable time, almost as efficiently as though they were under normal conditions. In such cases, lesions of nutrition do not make their appearance until a comparatively long period has elapsed. Even then they are almost always purely passive^ and seem, in reality, due to the state of inaction to which the parts are condemned in consequence of the suppression of ner- vous influence. This belief is supported by the fact that lesions displaying similar characteristics, present themselves when limbs, are kept in a state of immobility, though the nervous system be not directly implicated. Such passive lesions, which we shall meet with in different paralytic affections, have nothing in common with the special trophical lesions which engage our attention. Gene- rally they can be distinguished from them, objeciively, by certain particular signs. The special lesions are almost always characterized, at some period of their evolution, at least, by evidence of phlegmasic irri- tation. From the commencement they usually take on the appear- ance of inflammation ; and they may, as we shall see, issue in ulcer- ation, gangrene, and necrosis. There is, besides, one characteristic common to most of them, and that is the great rapidity of their development, after the lesion of nerves or nervous centres which provokes their manifestation. Sometimes they make their appear- ance with incredible quickness. Thus we frequently see eschars visible on the sacrum, the second or third day after the accident, in certain cases of fracture of the backbone, with compression and irritation of the spinal cord. It may therefore be laid down as a general rule that there is a striking distinction between passive lesions, resulting from func- tional inaction alone, and trophic disorders which follow on certain lesions of the nervous centres. The former are slow of production, and usually manifest no symptom of inflammation ; the latter often suddenly break out and generally present, at least at the commence- ment, more or less notable signs of phlegmasic irritation. De Blainville and A. Comte have observed. In the lower animals, and in the case of animal grafts, it is evident that the nutrition of tissues is independent of the nervous system." "Disorders of secretion and of absorption, induration, soften- ings, hypertrophies, and other alterations oonsecutive on nerve-lesions, are a con- sequence of perturbations of the circulation through the medium of the preceding (vaso-motor) nerves, directly affected by reflex action, and are not a consequence of the action of nerves which should, like electricity, have an influence over the molecular or chemical acts of assimilation and dis-assimilation in a zone of a certain extent beyond their surface." — 'Journal de I'Anatomie,' etc., 1867, pp. 276-300. INFLUENCE OF NE RVE- SECTION. ' 7 Allow me, gentlemen, to remind you, briefly, of some of the ex- periments to which I have just alluded, and which tend to demon- strate that the nerves and spinal cord have no direct immediate influence upon the nutrition of peripheral parts. 1. One of the first of these relates to the section of the ischiatic nerve in mammalia. Schroeder van der Kolk, who was one of the earliest to make the experiment, attributed the disorders of nutri- tion which followed, with some rapidity in such cases, in the cor- responding member, to the abolition of the action of the nervous system in consequence of the section. M. Brown-S^quard repeated the experiment, in 1849, on guinea-pigs and rabbits, and succeeded in showing that the trophical troubles which follow in the course of a few days, and which consist of tumefaction of the extremity of the member, ulceration of the toes, loss of the nails, only make their appearance because the animal is no longer able to preserve the limb, now devoid of movement and sensation in consequence of the section of the ischiatic, from the action of external influences, such as contact with the hard rough ground over which it is dragged. When the animal experimented on was placed under proper conditions, confined in a box, for instance, the bottom of which was covered with a thick layer of bran, there was no modi- fication of nutrition to be remarked in the paralyzed member, ex- cept a more or less perceptible atrophy which, however, only made its appearance slowly in the course of time.^ This atrophy, which follows the section of the ischiatic nerve, evidently results from the functional inaction to which the para- lyzed limb is condemned. It aff'ects not only the muscles, but also the bones and the skin, as J. Eeid has already remarked. It will not be produced, even when the section has been complete, if, fol- lowing the example of the physiologist quoted, you take care to pass a galvanic current daily through the muscles of the paralyzed member. 2. The complete section of the trifacial nerve, made within the cranium, presents results perfectly in keeping with those produced by section of the ischiatic. You are aware that the lesions of the eye which are found in animals subjected to this operation, and which were formerly considered by some physiologists as the con- sequence of the abolition of the nutritive influence of the trifacial, have, since the experiments of Snellen in 1857 and those of Biittner in 1862, been recognized as resulting from the consecutive anaes- 1 Brown-Pequard, " Sur les alterations patliologiques qui suivent la section du nerf sciatique," ' Comtes-rendus des Seances de la Societe de Bi()lop;ie,' t. i, 1849; and 'Experimental Researches applied to Piiysiology and Patliolosjy,' New York, 1863, p. 6. After the section of a mixed nerve the atrophy of the muscles does not gene- rally hegin to show itself, in man and mammalia, hy a slight emaciation, until the end of about a month. At the close of the second month it is more marked ; it is very evident at the end of three months. — Magnin, Thbse de Paris, 18G(J, p. 19. 8 • SECTION OF SPINAL CORD. thesia which exposes the parts deprived of sensation to all kinds of traumatic causes. If the eye be protected after the section of the nerve, either by Snellen's method of tying the still sensitive ear of the same side in front of it, or by Biittner's plan of covering it with a piece of thick leather, the trophical troubles will not make their appearance in the cornea. A certain amount of neuro-paralytic hypersemia in the iris and conjunctiva is, in short, the only phe- nomenon observable, after section of the trifacial, when the eye has been properly protected.^ 3. With respect to the spinal cord it seems demonstrated that a complete transverse section, or even its destruction for a certain length, when resulting in no considerable inflammation of the organ, is not immediately followed by troubles of nutrition in the para- lyzed members. M. Brown-Sequard has shown that the ulcerations which appear, rather quickly, in the vicinity of the genital organs of mammalia and birds, after complete transverse section of the cord, are not direct consequences of the absence of nervous influx. They are produced by the prolonged pressure, and the contact of fecal matters and decomposed urine, to which these parts are ex- posed. The hinder limbs of a young cat, which survived for nearly three months the complete destruction of the lumbar region of the spinal cord, were seen to develop in a normal manner. The func- tions of organic life seemed to proceed there in due accordance with physiological order; the secretion of claws and hair went on as in a healthy and uninjured animal.^ According to Valentin, when the posterior portion of the spinal cord has been destroyed, in mammalia and frogs, you will find the electrical contractility of the muscles of the hind members persist until death supervenes, that is to say, for several weeks or even several months after the operation.^ To sum up: in those animals whose spinal cords have been com- pletely divided transversely, or extirpated in part, ulcerations and even eschars may form, principally in those regions subject to pressure ; but it is always possible to attribute these lesions to the anaesthesia and paralysis, in consequence of which the animal lies constantly in contact with its excrements or unwittingly wounds itself, when dragging about its paralyzed members. As to the atrophy which supervenes, in the long run, in the paralyzed limbs after this operation, it arises solely, as in the case of the section of the ischiatic nerve, from the functional inertia to which they are condemned. ' See the experiments of M. Schiflf relating to this subject in the thesis of M. Hauser, entitled 'Nouvelles recherches relatives ^ riufluence du systeme nerveux sur la nutrition,' Paris, 1858. 2 Brown-Sgquard, loc. cit., pp. 14, 15, 16. 3 Valentin, ' Versuch einer riiysiologiscben Pathologie der Nerveu,' 2 Abth., p. 3, Leipzig, 1864. INFLUITNCE OF VASO-MOTORS. 9 It follows from all these facts, which experimental physiology offers, that the abolition of the action of the nervous system, whether determined by complete section of the peripheral nerves or by destruction of a portion of the spinal cord, produces no other nutritive disturbance in the anatomical elements of the paralyzed members than what would be caused in the same elements by the influence of functional inertia, or prolonged inaction alone. The discovery of the vaso-motor nerves and of the effects which follow .the paralysis of these nerves was not destined to modify this formula, in any essential manner. It is in fact demonstrated at present, that neuro-paralytic hyperaemia, however far it may go, is never of itself alone sufficient to cause an alteration in the nutri- tion of tissues. Undoubtedly, this hyperasmia, as M. Schiff' has pointed out, creates a certain predisposition to inflammatory action, which may supervene either spontaneously (to all appearance, at least) in the diseased animal or in consequence of irritative causes which would be comparatively trifling in a healthy organism. But lesions of nutrition of neuro-paralytic origin are nowise comparable to the trophical troubles which form the special object of our study, — they constitute a class apart. The latter, as we shall frequently have occasion to observe, may develop and accomplish, their evo- lution without being preceded or accompanied by any of the phe- nomena v;hich betray the paralytic state, or the contrary condition, of the vaso-motor nerves. At present we shall dwell no longer upon this subject, which we shall have an opportunity of referring to hereafter. III. If lesions, whose consequence is the abolition or suspension of the action of the nervous system, are impotent to produce in dis- tant parts other nutritive disturbances than those attributable to prolonged inaction, it is not thus as regards lesions which determine either in the nerves or nervous centres an exaltation of their properties j an irritation, or an inflammation. That, gentlemen, is a proposition of capital importance: it con- trols, in fact, the question which engages our attention. Although long since discovered by M. BrownS^quard the principle upon which it reposes is still, if I do not mistake, too frequently over- looked both by physiologists and by pathologists.^ We shall find, in due time and place, that human pathology presents many facts and decisive arguments in support of this proposition. On the other hand, we shall have less frequently to quote the results of experiments on animals. The especial reason of this paucity lies, 1 "Note sur quelques cas d'affection de la peau, dependent d'nne influence du syst^rae nerveux," par J. M. Charcot, suivies de " Remarques sur la mode d'influ- ence du sjstfeme nerveux sur la nutrition," par le docteur Browu-Sequard, 'Jour- nal de Physiologie,' t. ii, No. 5, p. 108, 1859. 10 INFLUENCE OF NERVE-IKRITATION. undoubtedly, In the fact that the nervous tissue of animals seems much better able than that of man to resist the influence of the diverse causes of irritation and inflammation. All experimenters are aware that even the most serious traumatic lesions of the spinal cord or of the peripheral nerves do not readily produce, in the case of most animals, a myelitis or a neuritis, having some duration, which could be considered comparable with those developed so quickly in man, after the very slightest lesions. The experiments which go to show that irritative lesions of the nerve-tissues are capable of determining various trophical troubles in the parts they supply, are, as we have said, few in number. They relate almost exclusively to the fifth pair. The following is an abridged account of an experiment of Samuel: In the case of a rabbit, two needles are applied to the Casserian ganglion and an inductive current produced ; immediately ensue a more or less marked contraction of the pupil, and at the same time a slight injection of the vessels of the conjunctiva. The lachrymal secretion is greatly increased. The sensibility of the eyelids, con- junctiva, and cornea is augmented. After the operation, the con- traction of the pupil persists, though not to the same extent, and the hyperaesthesia is still further increased. Inflammatory action generally sets in at the end of twenty -four hours; it increases in intensity during the second and third days and then gradually diminishes. All the stages of ophthalmia may be observed, from the slightest conjunctivitis to the most intense blennorrhoea. The exaltation of the sensibility still proceeds, and the hypersesthesia may rise to such a degree that, at the slightest touch of the eye, the animal is seized with general convulsions. On the cornea a general opacity develops, and we find, besides, sometimes little ex- ulcerations, sometimes a solitary oval-shaped ulcer occupying the middle portion of this membrane. In one case a small purulent collection formed in the anterior chamber. Hypersemia excepted, no pathological alteration of the iris, neither adhesions nor changes of colour, are ever observed. In every instance, hypersesthesia of the ophthalmic branches of the fifth pair is specifically remarked. Hence it is plain that we cannot here, as in the experiments of Snellen and Biittner, invoke the aid of anaesthesia in order to explain the trophical troubles supervening in an imperfectly protected eye.^ After an unsuccessful attempt to divide the trifacial in a rabbit, Meissner observed certain remarkable lesions of nutrition to ensue in the eye, which had preserved its sensibility. The author care- fully points out that these lesions were produced without having been preceded by any sign of neuro-paralytic hypero&mia. A post-mortem examination revealed that the (internal) median part of the trifacial ' Samuel, ' Die Trophisohen Nerven,' Leipzig, 1860, p. 61. INFLUENCE OF NERVE- IRRITATION. 11 alone had been wounded by the instrument (a neurotome).^ Schiff also cites four cases, in support of Meissner's observation, of partial lesions of the trifacial in the cranium, which were followed by in- flammation of the eye, although its sensibility persisted.^ In Samuel's experiment trophical troubles arose in the eye, in consequence of faradaic irritation of the fifth pair. May we not infer that, in the experiments of Meissner and Schiff, the lesions of the eye were caused by phlegmasic irritation developed in the nerve in consequence of the imperfect section ? In support of this opinion, I would remind you that incomplete sections, in man, are much more likely than complete sections to give rise to irritative action. This fact has long been familiar to surgeons. We may suppose that it holds good, at least to some extent, in the case of animals as well as of man.^ Let me place, side by side, with these facts several observations recorded in reference to the human organism, to which I shall afterwards recur. They relate also to the trifacial nerve. Like the preceding experiments, they show that irritative lesions of this nerve, spontaneously developed, may also, without being followed by anaesthesia, give rise to very striking nutritive disorders in the eye. A woman, aged 57, whose case has been noted by Bock,^ expe- rienced, for about a year, violent pains in the right side of the face. Though intermittent at first, they became afterwards almost con- tinuous. The sensibility of the face never completely disappeared; slight pressure was, indeed, scarcely felt, but if the pressure was increased, it brought on acute pains. The conjunctiva of the right eye was injected. The cornea, slightly opaque all over, presented a hypertrophic ulceration in its lower part, of ab.)Ut two lines in length. Afterwards, the ulceration increased in depth, and the opacity of the cornea was augmented. Perforation at last ensued, ^ G. Meissner, " Ueber die nach der Durchschneidung der Trigeminus am Auge der Kaninchens Eintretende P>nal)rnngstarung," ' Henle und Pfeufer's Ztsch.' (3), xxix, 96-104. ' Centralblatt,' 18(37, p. 265. « Gazette Hebdomadaire,' 1866, p. 634. 2 Scbiff, 'Henle's Zeitscli.' (3), xxix, 217-229. 'Centralblatt,' 1867, p. 655. 'Gazette Hebdom.,' 1867, p. 634. 3 This is not the interpretation which Meissner proposed for his experitnent. He supposes that the innermost fibrils of the trifacial, which had alone been cut, in the case quoted, have a special action on the nutrition of the eye. He bases his opinion on this that, in three other cases where the trifacial had undergone incomplete section, but where the innermost nerve fibrils bad been respected, no trophical troubles in the eye ensued, altliouoli this organ which had lost its sensibility was not protected from external agencies. VVe think that incomplete sections need to be repeated a considerable number of times before it is possible to pronounce a definite judgn)ent on the interpretation proposed by Meissner. * Bock, ' Ugeskrift for Lseger,' 1842, vii, p. 431. Extract in ' Hannover's Jahres- bericht,' 'Muller's Archiv,' 1844, p.'47, and Scbiff's ' Untersuchungen zur Pliysio- logie des Nervenssystems mit Beriicksiclitigung der Pathologie,' Frankfurt am Main, 1855, pp. 63, 64. 12 INFLUENCE OF NE RVE- IRRITATION. and, under the influence of pressure, issue was given to a puriform liquid. Death took place unexpectedly. On a post-mortem ex- amination the Casserian ganglion of the right side was found to be of considerable volume and very hard. The three branches of the right trifacial were likewise found much thickened up to the point of their emergence from the bone. The following case is taken from a memoir by Friedreich.^ A man, aged 60, was suddenly smitten by hemiplegia on the right side, with loss of sensibility on the same side. Some weeks before this attack he had felt slight lancinating pains in the left side of the face and in the globe of the left eye. These pains increased rapidly and to a high degree after the apoplectic attack. At the same time the conjunctiva of the left eye became injected, and there was an increase of the lachrymal secretion : later on, the conjunctiva was coated by a pseudo-membranous puriform exuda- tion. The left pupil, though very much contracted, was still sensi- tive to the action of light. Sensibility remained normal over the whole of the left side of the face. At the autopsy there was found at the surface of the middle peduncle of the cerebellum a collection of little sarcomatous tumours, which, taken altogether, were about the size of a filbert ; the adjacent brain-substance, especially next the cerebellum, was softened and very much injected. The left trifacial nerve, at its emergence from the base of the encephalon, was red, slightly softened, and flattened by the tumour. It would be easy to quote a considerable number of cases analo- gous to those we have cited, but these will suffice for the object we ' Friedreich, ' Beitriige zur Lehre von den Geschwiilsten, innerhalb der Seliae- delhohle,' Wnrzbnrg, 1843, p. 15, and Schitf's ' Untersucliungen,' etc., p. 100. 2 Facts relating to nutritive disorders of the eye, consecutive on spontaneous lesions of the fifth pair in man, are numerous enough, but we have only wished to mention those in which it was well established that the facial sensibility had not been touched. The two following cases, however, are also deserving of notice, although they are not so explicit, in this respect, as those of Bock and Friedreich. A vigorous individual, after a blow received upon the head, became subject to violent fixed pains, on the riglit side of the head, and snfl'ered occasionally from epileptic fits. Afterwards, the pains became localized in the right eye and ear. The eye was red, tumefied, and projecting, but still covered by the paralyzed upper eyelid. Turbid cornea ; iris, contracted and motionless ; brown-coloured at first, tlien greenish. The cornea became, at length, opaque. Post-mortem. — The lower surface of the anterior and middle lobes present, on the right side, several steatomataof the size of a bean, or almond. The Casserian ganglion and tbe three branches of the trifacial are covered over by a stifl" carti- laginous mass The motor oculi is compressed, and its colour altered. The state of tlie sensibility of the skin of the face is unfortunately not given in this case. F. A. Landmaun, ' Commentatio patholoa;ioo-aton»ica exhibens morbum cerebri oculique singularem ;' in-40, Leipzig, 1820, and Schiflf's ' Untersuch.,' p. 51. In the well-known case recorded by Serres, * Journal de Physiologie,' v, 1825, pp. 223, and ' Auatomie compar6e du Cerveau,' in spite of the profound alteration CONTRADICTORY EXPERIMENTS. 13 Apart from the fifth pair, experimental lesions of other nerves are still more rarely found to determine the appearance of trophi- cal troubles in the peripheral parts. We should quote, however, as examples of this species, the remarkable effects produced upon the nutrition of the kidneys by lesions of the nerves supplying them. Amongst the experimenters some, like Krimer, Brachet, Muller and Peipers, A. Aloreau, and Wittich, assert that they can, almost with certainty, produce, by means of these lesions, more or less deep-seated alterations in the kidneys. Others, however, such as Paul Bert and Hermann, on repeating the same experiments under apparently identical conditions, declare that they obtained nothing but negative results. May we not, at least partially, account for this singular contra- diction in the following manner? No renal lesion was manifested when nerve-sections had been complete and thorough; on the con- trary, such lesion appeared, or, perhaps I should say, may have appeared when the section was imperfect, or when the scalpel was replaced by caustics, by ammonia for instance (Corrente, Schiff), these being circumstances eminently proper to determine in the injured nerves a more or less active irritation or even to set up manifest inflammatory action.^ From this point of view the ques- tion would probably deserve to be revised with the help of new researches. We mentioned, a little time ago, the effects of transverse sections and partial destruction of the spinal cord in so far as regards the nutrition of parts deprived of feeling and motion in consequence of such operations. We said that, when the operations did not give rise to inflammatory action in the injured cord (and this takes place in the great majority of cases), there are found in the para- lyzed members simply a degeneration with atrophy of the muscles, very slowly supervening, ulcerations of the derm, and perhaps eschars caused by dragging over a rough surface, or by continuous contact with decomposed urine, and want of cleanliness. In one word, all the effects, to which functional inertia of the hinder mem- ber of animals gives rise, are present, and these only. But the scene changes completely if, in consequence of circumstances that cannot be foreseen, nor as yet produced at will, inflammation is set of the Casserian ganjilion and of the roots of tlie larger fasciculus of the trifacial, there was not complete paralysis of the sen-^itive portion of the nerre, for the whole surface of the face had preserved the sense of feeling. There had been acute inflammation of the right eye, with oedema of the li. Schiippel, " Ueber Hydromilus," in 'Archiv der Heilkunde,' Leipzig, 1865, p. 289. Haytm, in ' Archives de Physiologie,' 1869, p. 263, pi. 7. Charcot et Joflfroy, in ' Archives de Physiologie,' 1869, p. 355. * Charcot, " Leqons faites a la Salpfetriere in 1870." See also Hallopeau, in 'Archives de Medecine,' Septembre, 1871, pp. 277, 305. 48 GENERAL SPINAL PARALYSIS. There exist, indeed, at least two very distinct forms of progres- sive an:iyotrophy correlated to an irritative lesion of motor cells. One of them, which is protopathic^ arises exclusively from the lesion in question, and this form, primarily developed because of an original or acquired predisposition, tends, as of necessity, to be- come generalized. In the other form, to which we called your attention a moment ago, the nerve-cell is only secondarily affected, consecutively on a lesion of the white fasciculi, for instance, and as it were accidentally. Progressive amyotrophy, in the latter case, may perhaps be called symptomatic^ it has less tendency to become generalized, and its prognosis is certainly less gloomy.^ As regards ndnlt spinal paralysis^ and general spinal paralysis (Duchenne de Boulogne), pathological anatomy has not yet given any definite decision. But to judge from the symptoms, it is at least very probable that these affections also depend on a lesion of the motor nerve-cells of the anterior cornua. Adult spinal para- lysis resembles that of childhood by the almost sudden invasion of motor paralysis, by the tendency which it shows to retrogade at a given moment, by the diminution or abolition of faradaic con- tractility showing itself precociously in a certain number of para- lyzed muscles, and, finally, by the rapid atrophy which these same muscles constantly exhibit to a more or less marked extent. A slower evolution, often occurring in a subacute or chronic manner, a tendency to become generalized, especially evident in the first stages, frequent pauses, followed by invasion of hitherto untouched parts, distinguish, on the contrary, general spinal paralysis, and make it resemble progressive muscular atrophy, with which it is sometimes, very erroneously, confounded in clinical practice. The former, however, is clearly separated from the latter by the follow- ing characters: the muscles of an entire extremity or of portion of a limb, are struck, en masse^ in an almost uniform manner, with paralysis or atrophy ; they present, at a period but little remote from the commencement of the disease, very marked modifications of electrical contractility; usually, in conclusion, a period of re- covery supervenes, during which the atrophied muscles regain, at least partially, their volume and their functions.^ Muscular lesions consecutive on affections of the bulbus rachidicus. — This is a subject which has been, as yet, but little explored. How- ever some facts, which have accumulated until they now form a respectable number, gleaned from the history of labio-glossolaryn- geal paralysis and disseminated sclerosis (en plaques) tend to estab- lish that, in the case of the bulbus as well as in that of the spinal cord, irritative lesions of the white fasciculi have no direct influ- ' On the two forms of progressive amyotrophy of spinal origin, see Charcot et Joflfroy in 'Arciiives de Piiysiologie,' 18G9, pp. 75(5, 757. Duchenne (de Boulogne) et Joffroy in 'Archives de Physiologie,* 1870, p. 499. 2 Duchenne (de Boulogne), * De I'eleotrisation localis6e,' 3d edition. INFLUENCE OF MOTOR NERVE-CELLS. 49 ence on the nutrition of muscles. Those, on the contrary, which affect the motor cell clusters distributed over the floor of the fourth ventricle, or the fasciculi of nerve-tubes emanating from these aggregations may, as I have demonstrated, determine a more or less marked atrophy of the muscular tibres of the tongue, pharynx, larynx, and orbicularis oris.^ The summarized account which has been laid before you will suffice, I hope, to place in prominence the remarkable role which, according to the most recent researches, lesions of the anterior nerve-cells play in the production of trophic muscular disorders consecutive on alterations of the spinal cord. This role does not seem doubtful in the pathogeny of infantile paralysis and of the different forms of amyotrophy of spinal origin. Its influence is, certainly, less distinctly demonstrated, though still highly probable, as regards haematomyelia, acute central myelitis, and, in a word, all the irritative affections of the spinal cord in which the gray axis is found to be involved. On the other hand, the absence of all participation on the part of the white fasciculi, and of the posterior cornua, in the development of the muscular affections in questioQ is a fact which henceforth rests on abundant evidence. This acknowledged, gentlemen, we have cause to inquire why lesion of the motor nerve-cells induces that of the muscular fibres, whilst even the gravest irritative alterations of the white fasciculi have no direct influence on the nutrition of the muscles. With respect to the first point, one cannot fail to imagine more or less plausible hypotheses which, however, are evidently prema- ture. The teachings of experimental physiology cannot be called to our assistance here ; its methods of procedure, inferior to those of disease in that respect, are not sufficiently delicate to allow the nerve cells to be attacked in an isolated manner. We must, there- fore, confine ourselves, at present, to registering the facts as they are offered us in clinical practice, illustrated by pathological anatomy, and to point out that the motor nerve-cells, comparable in that respect to the peripheral nerves, possess the power, when they have become the seat of irritation of modifying, by remote action, the vitality and structure of the muscles. As regards the second point, if what we have said concerning the effects of nerve-irritation be referred to, it may seem contradic- .tory, at first sight, that the nutrition of the muscles should not be aft'ected when the white fasciculi of the cord are occupied by inflam- mation. To show that the contradiction is only apparent it will suffice, however, to remind you that, in spite of the analogy of com- ' Compare Charcot, "Note f5ur un cass de paraljsie glosso-layngee, suivi d'au- topsie," in ' Archives de Physiologie,' 1869, pp. 356, 636, pi. xiii. Obs. de Cathe- rine Aubel. Duchenne (de Boulogne) etJoflfroy," De I'atrophie aigue etchronique des cellules nerveuses de la moelle et du bulbe rachidieu," 'Arcliives de Physi- ologie,' 1870, p. 499. 4 50 IMPORTANCE OF THE SUBJECT. position, the white columns are not at all comparable to the nerves. Experiments in fact, reveal, in the latter, properties which are not to be found in the former, and vice versa. Anatomy also shows that the nerve-tubes which constitute the nerves are but to a very small extent the direct continuation of those which, by their union, form the white substance of the cord. These fasciculi appear to be almost entirely composed of fibres which, arising either in the en- cephalon or in the cord itself, establish, after the manner of commis- sures, communications between the spinal cord and the brain, or between different points of the ^ray spinal axis. It was to be anti- cipated, from this, that, in many respects, the white fasciculi of the cord would, under the influence of irritative lesions, behave diffe- rently from the peripheral nerves. When I formed the idea of laying before you, gentlemen, the principal facts relating to the nutritive disorders which make their appearance consecutively on affections of the nervous system, I hoped that my task might be brought fairly to an end, in the course of two lectures. But, according as I advance in this exposition, the importance and extent of the question display themselves in all their distinctness. Notwithstanding the details which I have already given, I am far from having exhausted the subject, and I dare to hope that you will not have cause to regret the time that yet remains to be dedicated to its study. 51 LECTURE III, DISORDERS OF NUTRITION CONSECUTIVE ON LESIONS OF THE SPINAL CORD AND BRAIN. Summary. — Cutaneous affections in sclerosis of the posterior columns : papular or lichenoid eruptions, urticaria, zona, pustular eruptions ; their relations with the fulguraut pains ; the former appear to arise from the same organic cause as the latter. Eschars of rapid development (acute bed-sores in diseases of the brain, and spinal cord. Mode of evolution of this skin-affection: erythema, bullae, mortification of the derma, accidents consecutive on the formation of eschars : a, putrid infection, purulent infection, ganjjrenous emboli ; h. simple puru- lent ascending meningitis, ichorous ascending meningitis. Acute bed-sore in apoplexy symptomatic of circumscribed cerebral lesions. It appears prin- cipally in the gluteal region of paralyzed extremities; its importance in prognosis. Acute bed-sore in diseases of the spinal cord ; it generally occu- pies the sacral region. Arthropathies depending on a lesion of the brain or spinal cord. A, Acute or subacute forms ; they appear in cases of traumatic lesion of the spinal cord ; in myelitis occasioned by compression (tumours, Pott's disease), in primary myelitis, in recent hemiplegia, connected with cerebral softening. These arthropathies occupy the joints of paralyzed limbs. B. Chronic forms ; they seem to depend, like amyotrophies of spinal origin, on a lesion of the anterior cornua of the gray axis ; observed in posterior scleiosis (loco- motor ataxia) and in certain cases of progressive muscular atrophy. Gentlemen : In treating of the nutritive disorders determined by lesions of the peripheral nerves, I gave you to expect that these consecutive affections would, for the most part, be represented in cases of lesions of the spinal axis. It is true, we shall not always find here a servile imitation ; indeed, as a general rule, the trophic disorders of cerebral or spinal origin, as we shall often have occa- sion to note, bear with them the distinctive stamp of their cause. But there are circumstances in which the resemblance between af- fections of central origin and those which depend on a lesion of the peripheral nerves is so striking that discrimination may be a most difficult task. We will cite, as examples of this class, certain cutaneous eruptions which sometimes supervene in the course of ataxia. The cutaneous affections^ to which we have just alluded, may be classified as follows: a, papular or lichenoid eruptions ; b, urticaria; c, zona; d, pustular eruptions, analogous to ecthyma. 54 IRKITATION OF RADICULAR FASCICULI. intense, and where, on a post-mortem examination, I was unable to discover the existence of any alteration whatever, either in the posterior gray cornua, or in the peripheral nerves, or in the spinal meninges. . From this it would appear necessary that we should seek, in the irritative alteration of the posterior columns of the spinal cord, the starting point of the fulgurant pains of ataxic patients. But it seems scarcely probable that all parts of these fasciculi ought to be indiscriminately arraigned on this count: everything, on the contrary, induces us to believe that the sensitive fibres, issuing from the posterior roots, which compose a portion of the internal radi- cular fasciculi should alone be incriminated. These fibres would participate, from time to time, periodically, in the irritation whose permanent seat is in the columns themselves; and thus would be produced those paroxysms of shooting or flashing pains which, in accordance with a well-known physiological law are referred to the periphery, although in reality due to a central cause. How are we to understand the appearance of the cutaneous eruptions sometimes observed in ataxic patients, at the very time of the occurrence of fulgurant paroxysms of abnormal intensity ? It is certain that the nerve fibres which form the internal radicular fasciculi are not all sensitive; there are, for instance, at least some amongst them which assist in the accomplishment of reflex actions ; there are others also, no doubt, at least it is what these cutaneous eruptions tend to demonstrate, which belong to the system of cen- trifugal nerves and which possess a more or less direct influence over the exercise of the nutritive functions of the skin. The irri- tation of the latter class of fibres, an irritation more difficult to set up than that of the sensitive fibres, should be invoked to explain, in the cases 1 have above alluded to, the production of papular affections at one time, and at another, of vesicular, pustular, or gangrenous disorder. Are the posterior fasciculi the only departments of the spinal cord, the irritation of which is capable of determining such affec- tions? This is a question which must remain unanswered for the present. All that can be said is that such eruptions have not yet been observed, except where there was some complication, in cases of irritative lesions confined to the antero-lateral columns, or to the anterior cornua of the gray matter; and as to the part which the posterior cornua may play, in this respect, we are in the most com- plete ignorance upon that subject. On the other hand, some facts have been collected which tend to establish that zona is sometimes developed under the direct influence of partial lesions of the encephalon. Thus, in the case of an aged woman attacked with hemiplegia, whose history has been recorded by Dr. Duncan, an eruption of zona appeared on the thigh of the paralyzed side ; motor paralysis had supervened almost simulta- RELATION OF ZONA TO ENCEPHALIC LESIONS. 55 neously with the eruption, and both passed away nearly at the same time.^ In the case of a child, recorded by Dr. Payne, the zona, which marked out the course of superficial branches of the anterior crural nerve, showed itself three days after the development of a hemi- plegia occupying the same side of the body as the eruption.^ These cases, which can be multiplied, are undoubtedly very interest- ing; unfortunately, they have been related in a very summary manner only, and caution is needed, I think, in drawing conclusions from them, which may prove premature. I can, in fact, cite a case in many respects analogous to the preceding, which I recently observed at La Salpetriere, and where the cause of the zona was most probably the irritation of a peripheral nerve. Here, again, the seat of the vesicular eruption was in the inferior extremity of the paralyzed side, where it followed the distribution of the super- ficial twigs of the cutaneous perineal nerve. It showed itself also, simultaneously with the hemiplegia which, making an abrupt appearance, was correlated to the formation in one of the cerebral hemispheres of a focus of ramollissement, itself being determined by the embolic obliteration of a posterior cerebral artery. As to the zona, it was produced, I believe, after the following mechanism, a spinal arterial branch,^ arising, no doubt, from one of the lateral sacral arteries was, on a post-mortem examination, found to be ob- structed by a blood-clot, and to form a comparatively voluminous cord, adhering to one of the posterior spinal roots of the cauda equina. It is probable that, on its passage through the sacral fora- men, this arteriole, exceedingly distended by the thrombus, had compressed either the spinal ganglion, or an initial branch of the ischiatic nerve, so as to set up irritation in it. A vegetating ulce- ration, which was noticed on one of the sigmoid valves of the aorta, appears to have been the starting point of all the accidents which we have just described."^ ' • Jonrnal of Cutaneous Medicine,' &c., 69. Erasmus Wilson, October, 1868. 2 ' British Medical Journal,' August, 1871. 3 One of the rami inedullce spinalis, see N. Rudinger, ** Arterienverzweigung, in dem Wirbelcanel, &c.," in ' Verbreitung des Sympathicus,' p. 2, Miinchen, 1863. * The following are the principal details of this case which presents a fine ex- ample of ulcerous endocarditis, with multiple emboli and a typhoid condition. The patient Lacq, .... aged 22 years, a soldier, was admitted on the 28th Decemlijer, 1870, to the Salpfitriere ambuluice (fever ward). He had been suffer- ing, it seems, from an intense fever for two or three days. On the day of admis- sion the following symptoms were noted : severe cephalalgia, pains in the loins, diarrhoea. The patient cannot swallow the smallest quantity of liquid without being taken with nausea and vomiting. Skin hot, pulse very frequent. It was regarded as a case of typhoid fever. Noisy delirium during the night. Next day, 29th December, was noticed the existence of an almost complete hemiplegia of the leftside. Tlie paralyzed members were not rigid ; incomplete facial paralysis, on the left side, likewise existed. The eyes are constantly directed to the right side, and there is nystagmus. Pulse 120 ; rectal temperature 40. 50 Cent. On the breast, forearms, and thighs, the skin shows a great number of little ecchy- 54 IRKITATION" OF RADICULAR FASCICULI. intense, and where, on a post-mortem examination, I was unable to discover the existence of any alteration whatever, either in the posterior gray cornua, or in the peripheral nerves, or in the spinal meninges. . From this it would appear necessary that we should seek, in the irritative alteration of the posterior columns of the spinal cord, the starting point of the fulgurant pains of ataxic patients. But it seems scarcely probable that all parts of these fasciculi ought to be indiscriminately arraigned on this count; everything, on the contrary, induces us to believe that the sensitive fibres, issuing from the posterior roots, which compose a portion of the internal radi- cular fasciculi should alone be incriminated. These fibres would participate, from time to time, periodically, in the irritation whose permanent seat is in the columns themselves; and thus would be produced those paroxysms of shooting or flashing pains which, in accordance with a well-known physiological law are referred to the periphery, although in reality due to a central cause. How are we to understand the appearance of the cutaneous eruptions sometimes observed in ataxic patients, at the very time of the occurrence of fulgurant paroxysms of abnormal intensity ? It is certain that the nerve fibres which form the internal radicular fasciculi are not all sensitive; there are, for instance, at least some amongst them which assist in the accomplishment of reflex actions ; there are others also, no doubt, at least it is what these cutaneous eruptions tend to demonstrate, which belong to the system of cen- trifugal nerves and which possess a more or less direct influence over the exercise of the nutritive functions of the skin. The irri- tation of the latter class of fibres, an irritation more difficult to set up than that of the sensitive fibres, should be invoked to explain, in the cases I have above alluded to, the production of papular affections at one time, and at another, of vesicular, pustular, or gangrenous disorder. Are the posterior fasciculi the only departments of the spinal cord, the irritation of which is capable of determining such affec- tions? This is a question which must remain unanswered for the present. All that can be said is that such eruptions have not yet been observed, except where there was some complication, in cases of irritative lesions confined to the antero-lateral columns, or to the anterior cornua of the gray matter; and as to the part which the posterior cornua may play, in this respect, we are in the most com- plete ignorance upon that subject. On the other hand, some facts have been collected which tend to establish that zona is sometimes developed under the direct influence of partial lesions of the encephalon. Thus, in the case of an aged woman attacked with hemiplegia, whose history has been recorded by Dr. Duncan, an eruption of zona appeared on the thigh of the paralyzed side ; motor paralysis had supervened almost simulta- EELATION OF ZONA TO ENCEPHALIC LESIONS. 55 neously with the eruption, and both passed away nearly at the same time.^ In the case of a child, recorded by Dr. Payne, the zona, which marked out the course of superficial branches of the anterior crural nerve, showed itself three days after the development of a hemi- plegia occupying the same side of the body as the eruption.^ These cases, which can be multiplied, are undoubtedly very interest- ing; unfortunately, they have been related in a very summary manner only, and caution is needed, I think, in drawing conclusions from them, which may prove premature. I can, in fact, cite a case in many respects analogous to the preceding, which I recently observed at La Salpetriere, and where the cause of the zona was most probably the irritation of a peripheral nerve. Here, again, the seat of the vesicular eruption was in the inferior extremity of the paralyzed side, where it followed the distribution of the super- ficial twigs of the cutaneous perineal nerve. It showed itself also, simultaneously with the hemiplegia which, making an abrupt appearance, was correlated to the formation in one of the cerebral hemispheres of a focus of ramollissement, itself being determined by the embolic obliteration of a posterior cerebral artery. As to the zona, it was produced, I believe, after the following mechanism, a spinal arterial branch,^ arising, no doubt, from one of the lateral sacral arteries was, on a post-mortem examination, found to be ob- structed by a blood-clot, and to form a comparatively voluminous cord, adhering to one of the posterior spinal roots of the cauda equina. It is probable that, on its passage through the sacral fora- men, this arteriole, exceedingly distended by the thrombus, had compressed either the spinal ganglion, or an initial branch of the ischiatic nerve, so as to set up irritation in it. A vegetating ulce- ration, which was noticed on one of the sigmoid valves of the aorta, appears to have been the starting point of all the accidents which we have just described.'* ' 'Journal of Cutaneous Medicine,' &c., 69. Erasmus Wilson, October, 1868. 2 'British Medical Journal,' August, 1871. 3 One of the rami ineduUce spinalis, see N. Rudinger, " Arterienverzweigung, in dem Wirbelcanel, &c.," in ' Verbreitung des Sympathicus,' p. 2, Miinchen, 1863. * The following are the principal details of this case which presents a fine ex- ample of ulcerous endocarditis, with multiple emboli and a typhoid condition. The patient Lacq, .... aged 22 years, a soldier, was admitted on the 28th Deceiuiber, 1870, to the SalpOtiiere ambulmce (fever ward). He had been suffer- ing, it seems, from an intense fever for two or three days. On the day of admis- sion the following symptoms were noted : severe cephalalgia, pains in the loins, diarrhoea. The patient cannot swallow the smallest quantity of liquid without being taken with nausea and vomiting. Skin hot, pulse very frequent. It was regarded as a case of typhoid fever. Noisy delirium daring the night. Next day, 29th December, was noticed the existence of an almost complete hemiplegia of the leftside. The paralyzed members were not rigid ; incomplete facial paralysis, on the left side, likewise existed. The eyes are constantly directed to the right side, and there is nystagmus. Pulse 120 ; rectal temperature 40. 50 Cent. On the breast, forearms, and thighs, the skin shows a great number of little ecchy- 66 DECUBITUS ACUTUS: ACUTE BED-SORE. You will observe that, in this case, the coexistence of the hemi- plegia and of the vesicular eruption resulted to a certain extent from a fortuitous coincidence. However it be, in default of zona, there are other trophic disorders of the skin, the existence of which may sometimes be attributed to the influence of an encephalic lesion. This is a fact which, I hope at least, will soon be placed beyond doubt. II. Eschars of rapid development. Decubitus acutus : acute bed-sore} — I hasten to leave the questions of eruptions occurring in locomotor ataxia, which, on the whole, have but a secondary importance, in order to draw your attention, in a very special manner, to another affection of the skin which holds a most important position in the clinical history of a considerable number of the diseases of the brain and spinal cord. The cutaneous affection, which I am about to discuss, shows moses, somewhat resembling flea-bites, — frequent respirations, sibilant rales. — Tympanites. On the antero-external surface of the left paralyzed leg, there exists an eruption of zona which answers exactly to the distribution of the superficial twigs of the cutaneous perineal branch of the musculo-cutaneous nerve. The first group of vesicles is seen above and below the patella ; a larger group is dis- posed in a vertical straight line which descends to the middle third of the leg ; the third group occupies the neck of the foot before and inside of the external mal- leolus. The eruption is tolerably developed. It is remarked that some traces of it existed the day before, that is to say, previous to the hemiplegia. On the 30th, the eruption is in full vigour. The patient succumbs at 4 o'clock in the after- noon. Autopsy. — One of the sigmoid valves of the aorta is ulcerated and covered with vegetations, fibrinous, soft, and reddish in appearance. The mesenteric glands are somewhat red and swollen, but there exists no trace of dothienenterioal eruptions or ulcerations in the small or large intestines. Numerous ecchyraoses are observed on the visceral and parietal pleurae, in the pericardium, and in the peritoneum. The spleen and kidneys present infarct! in diflferent stages of development. Right cerebral hemisphere ; on many points of the occipital lobe the pia mater, which is much injected, presents large patches of sanguine suflfusion. The lobe itself is softened througliout nearly its whole extent; the cerebral matter there assumes a grayish colour, and at one point in the midst of the softened parts we note au effusion of blood, as big as an almond. The posterior cerebral artery of the same side is completely obliterated by a thrombus. The spinal cord, prepared with chromic acid, and examined in thin sections, presents no perceptible alterations. At the Cauda equina, on the left side, we found adhering to one of the posterior spinal roots which give origin to the sacral plexus, an arteriole (spinal branch, arising from the lateral sacral artery) distended by a blood-clot. The obliterated artery, equal in size to a ciow-quill, may be followed from the point wliere the root has been cut not far from the corresponding sacral foramen, to the spinal cord ; upon this it can still further be followed the whole length of the lumbar enlargement, where it ascends along the posteiior median fissure, contrary to the usual arrangement of the posterior spinal arterial plexus. 1 Decubitus (when qualified by tlie adjectives acutus, chronicus, ominosus) signifies, not the position of the patient in bed, but the bed-sores supposed to result from such position. This term, though etyniologically objectionable, is generally em- ployed in foreign hospitals. As its adoption in this translation might confuse, and appears to be unnecessary, the term *' bed-sore'' has been substituted (S.). MODE OF E\rOLUTIO]Sr. 57 itself at first under the form of an erythematous patch, on which vesiculae and bullae are rapidly developed ; it terminates very often in mortification of the skin and subjacent tissues. Usually it occupies the sacro-gluteal regions ; but it may also appear almost indifferently on all parts of the trunk or members subjected, in the decubitus, to a somewhat continuous pressure. Even a very slight and very short pressure suffices to make it appear in certain cases. Finally, there are other cases still, though these indeed are very exceptional, in which it seems to be pro- duced without the intervention of the least pressure or of any other occasional cause of the same kind.^ This is a very different affection from all those various eruptions which are so commonly remarked over the sacrum in patients con- demned by different disorders to long maintain a recumbent posi- tion in bed. These eruptions which are sometimes erythematous and lichenoid, sometimes pustular and ulcerous, sometimes papular, having a deceptive resemblance to syphilitic sores [plaques tnu- queuses\ are generally occasioned by repeated and prolonged con- tact with irritating substances, such as urine or fecal matters. They, as well as acute bed-sore, may become the starting points of genuine eschars; but the acute bedsore is distinguished from the former by important characters, namely: firstly, by appearing shortly after the commencement of the primary disease, or follow- ing on a sudden exacerbation ; and, secondly, by a very rapid evolution. On account of the peculiar interest belonging to it, the affection, in question, certainly deserves to be designated by an appellation proper to itself. One of the few authors who have made it a special study, Herr Samuel, has proposed to characterize it by the name of decuhitus acutits or eschar of rapid formation. He desires thus to distinguish it from decubiUis chi-onwus, that is, from the dermal necrosis which appears long after the invasion of the disease which occasions its existence. We propose to accept this appellation, whilst reminding you, however, that the mortification of the skin is not everything in decubitus acutus? It answers, on the whole, to the most advanced phases of the morbid process. It may happen, indeed, that the vesiculae or bullae will dry up and disappear with- out that portion of ihe derm, on which they were seated, present- ing the least trace of necrosis. This is principally observed when, they are produced on parts where the pressure has only been of short duration, of little intensity, and, so to speak, accidental, as over the ankles, on the inner surface of the knees, the legs, or the thighs. Now, it behooves you to be able to recognize the signifi- 1 Browu-Sequard, 'Lectures on the Central Nervous System,' Philadelphia, 1868, p. 248. Couyba, ' Des Troubles Trophiques,' &o., These de Paris, 1871, p. 43. 2 See note 1, p. 56. 58 CHARACTERISTICS OF ACUTE BED-SORE. cance of these vesicals and bullae, from their first appearance on the scene; for, even at that period, they enable us under certain circumstances to formulate a prognosis, with certainty. The opportunity has been given me, many times, of followingas it were day by day, hour by hour, the evolution of the acute bed- sore^ in cases of apoplexy consecutive on hemorrhage, or on soften- ing of the brain which we so often meet with in this hospital.^ I can refer to the observations I made in regard to this, in the general description which follows, for I have been able to establish, from another stand-point, that the acute bed-sore connected with brain-diseases does not essentially differ from that which arises under the influence of spinal lesions. Some days or even some hours only after the manifestation of the cerebral or spinal affection, or again, following on a sudden exacerbation of these affections, there appear on certain points of the skin one or many erythematous patches, variable in extent and irregular in shape.^ The skin there has a rosy hue, sometimes it is dark red, and even violet, but the colour disappears momentarily on pressure with the finger. Under somewhat rare conditions, which hitherto I have met with almost entirely in cases of spinal lesions, there appears besides, involving the derm and subjacent tissues, an apparently phlegmonous tumefaction^ which may be ac- companied sometimes by acute pain, if the region has not been previously smitten with anaesthesia. On the morrow, or after- morrow, vesiculse or bullae make their appearance towards the central part of the erythematous patch ; they contain a liquid, sometimes colourless and perfectly trans- parent, sometimes more or less opaque, reddish, or brown-coloured. Matters may remain so, as we have already mentioned, and then the vesicles and blebs soon wither, dry up, and disappear. At other times, however, the elevated epidermis becomes torn, drops off in pieces, and lays bare a bright red surface strewn with bluish and violet points or patches, corresponding with a sanguine infil- tration of the derm. In such cases the subcutaneous connective tissue, and sometimes even the subjacent muscles are themselves already invaded by sanguine infiltration. This fact I have re- peatedly verified by post mortem examination. The violet patches extend rapidly in width and their edges soon run together and unite. A short time after, there supervenes in the affected part, a mortification of the derm which, at first super- ficial, soon grows profound. From that time, the eschar is con- stituted. Later on comes the development of the work of reaction • Charcot, " Note sur la formation rapide d'une eschare h. la fesse du c6te para- lyse dans rh6miplegier6centede cause c6r6brale," ' Archives de Physiol, noruiale et pathol.,' t. i, 1868, p. 308. 2 I have ascertained, anatomically, that in such cases the derm is infiltrated with leucocytes, as happens in erysipelas. CONSECUTIVE AFFECTIONS. 59 and elimination, followed, in favourable cases, by a period of re- paration which is too often impeded in its course, it is unneces- sary for me, I think, to expatiate on this point. I have been occupying your attention with minute details, but I trust I shall induce you to acknowledge that they have their own peculiar interest. R. Bright thought them sufficiently worthy of notice and novel enough to believe he should insist upon them in his "Reports of Medical Cases," and should get wax models made of the bullae o^ acvte bedsore observed in a case of traumatic para- plegia.^ These models still figure, no doubt, in the museum of Guy's Hospital. Since then, as far as I know, this subject has but slightly ar- rested the attention of observers, with a few rare exceptions.^ It would be unjust, however, not to acknowledge that, in cases of typhus and typhoid fevers, a cutaneous affection, which offers the closest analogies with this disorder and which, perhaps, partly depends on analogous conditions, has been minutely described in France by Piorry,^ and in Germany, by Pfeiifer." ' It will not be deemed inappropriate to quote here the remarks which R. Bright has appended to his cases of aflFections of the spinal cord, witii rapid forma- tion of bullae and eschars, which he has consigned to his '* Reports of Medical Cases," (t. ii, ' Diseases of the Brain and Nervous System,' London, 1831). Firm comes a case where softening of the spinal cord supervened, without any known external cause, in a young woman aged 21 ; the lesion occupied the lumbar en- largement immediately above the cauda equina. The case suggested the following reflections : — " Another curious circumstance connected with paralysis of the lower extremi- ties is illustrated by this case : the tendency which is observed in such affec- tions to the formation of vesications or bullae, which frequently make their appearance in a night, on some part, as the knee, the ankle, or the instep, where accidental pressure or irritation has taken place ; they contain a limpid fluid which after a few days becomes opaque. It has sometimes struck me that this connection between interrupted nervous action and the formation of bullse, might hereafter be found to throw light on that most singular disease herpes zoster which, from the peculiar pain with which it is accompanied, as well as from its strict confinement to one side of the body, seems to be connected with some pe- culiar condition, perhaps the distension of the sentient nerves." (p. 383.) Three other cases relating to traumatic lesions of the spinal cord (caused by a fall from a height, the passage of a wagon, &c.) are commented on as follows : — "The two most remarkable points to be incidentally noticed in the foregoing cases are, first, the diseased state of the bladder, resulting from its diminished power to resist injury, and from the changes taking place in the condition of the urine, detained in its most depending part, which becomes one of the most fre- quent causes of fatal irritation in paraplegia ; — and secondly, we observe the occurrence of bullae on the paralyzed limbs, to which circumstance I have already alluded in some remarks made at p. 383; the general inability to resist injury is likewise marked by extensive sloughing of all the paralyzed parts on which pressure is made." (p. 423.) 2 After R. Bright, we must specially refer to Sir Benjamin Brodie ('* Injuries of the Spinal Cord," ' Med.-Chir. Transactions,' t. xx, 1837), and Brown-Sequard {loc cit.). 3 A. Touze, " Des dermopathies et des dermonecroses sacro-coccygiennes," Thfeses de Paris, 1853. * Kercheusteiner's "Bericht," in 'Henle und Pfeiifer's Zeitschrift fur rationelle Medicin,' Bd. v. See also Wunderlich, ' Pathologic,' t. ii, p. 285. 60 CONSECUTIVE AFFECTIONS. Let us return, gentlemen, to the bed-sore provoked by diseases of the nervous centres. You know too well the accidents which eschars, from whatever cause arising, are capable of engendering for me to indulge in a detailed description. Allow me, however, to sketch out in a few words the principal amongst them, for you must expect to see them often figuring in the last period of a great number of affections of the brain, and especially of the spinal cord. The eschars, if they but attain a certain extent, constitute, as you are aware, dangerous foci of infection; and, in fact, putrid intoxication, denoted by a more or less intense remittent fever, is one of the complications they most commonly provoke. Next comes purulent wfectwn, with production of metastatic abscesses in the viscera.^ This species appears to be seldom met with. We shall also notice gangrenous emboli. In this variety, thrombi impregnated with gangrenous ichor are transported to a distance and give rise to gangrenous metastases, which are principally observed in the lungs. This is a point upon which Dr. Ball and myself have insisted in a work published in 1857.^ But long before us, and even long before the theory of embolism had been Germanized, M. Foville had expressed his opinion that a consider- able number of cases of pulmonary gangrene, observed in the insane, and in different diseases of the nervous centres, are caused by "the transport into the lungs of a part of the fluid which bathes the eschars of the breech."^ The process of mortification tends gradually to invade the deeper tissues. The ruin that results is sometimes carried to the highest degree; thus the trochanteric serous burs^ may belaid open, the trochanter denuded of its periosteum, the muscles, the nerve-trunks, and arterial branches of a certain calibre laid bare. But the most dangerous accidents are those determined by the denudation and loss of substance of the sacrum and coccyx, the destruction of the sacrococcygean ligament, and the consecutive opening of the sacral canal or arachnoid cavity. In consequence of these disorders, the pus and the gangrenous ichor may proceed to infiltrate the fatty cellular tissue which envelops the dura mater, or even, if this membrane be destroyed in any point, it may pene- trate into the cavity of the arachnoid.* • Billroth uiid Wackerling, in ' Langenbeck's Archiv fiir Klin. Chir.,' Bd. i, 1861, § 470. Fracture of the sixth dorsal vertebra, rapid formation of eschar on sacrum. Manifest symptoms of pyaemia : six or eight abscesses on the surface of the kidneys. Midderdorf, ' Knochenbriich,' § 62. Fracture of the eighth dorsal vertebra. Rapid formation of eschar; pyaemia; metastatic abscesses in the lungs. 2 «« De la coincidence des gangrenes viscerales et des aflfections gangr6neuses ext6rieures, in ' Union Medicale,' 26 et 28 Janvier, 1860. 3 ' Dictionnaire de M^d. et de Chir. Prat.,' t. i, p. 556. * B. Brodie, loc cit., p. 153. Velpeau, * Anatom. Chirurgioale.' Ollivier (d' Angers) ' Trait§ des maladies de la moelle 6pini5re,' t. i, pp. 314, 324, 3d edi- PATHOGENY OF ACUTE BED-SORE. 61 Under sucb circumstances, grave cerebro-spinal complications supervene; they may be collected into two principal classes. At one time we see a simple purulent ascending meningitis ; at another, a sort of ichorous ascending meningitis, of which Lisfranc and Bail- larger have reported many remarkable examples. In such a case, it is found that a puriform, grayish, acrid, and fetid liquid steeps the meninges and the cord itself, sometimes the lower part only is bathed in it, sometimes the whole cord. This liquid is occasionally found at the base of the encephalon, in the fourth ventricle, in the aqueduct of Sylvius, and even in the lateral ventricles. In all these points the cerebral matter is discoloured at its surface and to a certain depth, taking a slaty bluish tint which has several times been considered, but very wrongly, as constituting one of the characters of gangrene of the brain.^ M. Baillarger was the first, I believe, to recognize the real nature of this alteration. What we have to note there is, above all, a phenomenon of imbibition, maceration, and dyeing. Remark that always, when ichorous cerebral meningitis has a sacral eschar as its starting point, the slaty tint is found throughout the whole extent of the spinal cord, it is constantly better marked there than in the encephalon, and more manifest the nearer you keep to the eschar. On the con- trary, in the case where a sanious ulcer of the face, a cancroid for instance, after having destroyed the bone, has denuded the dura mater, the slaty coloration induced by ichorous maceration may, as I have many times observed, remain limited to the anterior lobes of the brain, in the regions corresponding to the bottom of the ulcer. To these complications which I have been only able to indicate in a very summary manner, we must with Ollivier (d' Angers) con- nect the grave cerebral or cerebro-spinal symptoms, as yet but ill- defined, which rapidly terminate life in a great number of cases of disease of the spinal cord. We have now to enter upon details and to show you the prin- cipal circumstances under which acute bed-sore is produced, under the influence of lesions of the brain and of the spinal cord, as well as the varieties of position and of evolution which it pre- sents, according to the variety or seat of the lesion which has provoked its appearance. We shall also have to inquire whether the mode of production of this trophic lesion of the skin comes under the general theory which we have hitherto had to accept. With this aim, we shall successively review the different affections of the brain and of the cord which may give rise to acute bed-sore. tion, 1837. Moynier, " De I'eschare du sacrum et des accidents qui peuvent en resulter" ('Moniteur des Sciences Medicales et Pharmaoeutiques,' Paris, 1859). Lisfranc, 'Archives Ggnerales de Medecine,' 4e annee, t. xiv, p. 291. \ ' Dubois (d'Amiens), 'Memoires de I'Aoademie de Medecine,' t. xxvii, p. 50, 1865, 1866. 62 BED-SOEE IN CEREBRAL LESIONS. A. Of acute hed-sore in apoplexy symptomatic of cerebral lesions in focal centres. It is especially observed in the apoplexy consecutive on intra-encephalic hemorrhage, or on partial softening of the brain. But it may also be produced in meningeal hemorrhage, in pachymeningitis, and finally in cases when intra-cranial tumours give rise to apoplectiform attacks. The latter have often given me opportunities for observing it in patients attacked with partial encephalitis caused by wounds received in battle.^ The erythema, in all cases of this kind, usually shows itself from the second to the fourth day after the attack, rarely sooner, some- times later. It affects a peculiar position. It is not in the sacral region, so commonly invaded in cases of spinal affection, that it I The courtesy of my colleague, M, Crnveilhier, surgeon to La Salp&triere, en- ables me to record the following fact, which I give as an example of the last- mentioned class. The patient, Louis Ernst, a Saxon soldier, was picked up, at Villiers, on the field of battle, Nov. 30, 1870, and brought to the ambulance of La Salp6triere, the same evening about nine o'clock. A bullet had traversed his skull, piercing it through and through ; one of the orifices was situated on the upper part of the forehead, a little to the left of the median line ; the other, on the right side, about the middle of the parietal bone. The cerebral substance protruded, like a mush- room, through the last-named orifice. The temporal region and the upper eyelid of the right side were eccbymosed and tumefied ; profound coma. December 3d, somnolence ; the patient, when interrogattd sharply, mutters some inarticulate sounds ; he puts out the tongue perfectly, when told ; deglutition proceeds with ease. Almost comp'ete hemiplegia is found to exist, with flaccidity of the mus- cles of the members of the right side. From time to time, without provocation, a sort of spasmodic contraction occurs in the superior member of this side, causing momentary pronation of the arm. The diaphragm seems to be also, from time to time, the seat of analogous contractions. The respiration, irregular at times, is calm, without stertor. There is no deviation of head, or eyes. The labial commissures are not drawn to one side. Sensibility appears much blunted over all parts of the body. No vomiting. Pulse very frequent, 140. December 4th (fifth day), same state as the previous day, but the somnolence is more intense than yesterday: contractions of the facial muscles are induced with diflS- culty, on forcibly pinching the skin. Involuntary passage of urine and feces. Skin warm, covered with perspiration ; axillary temperature 41° C. The com- mencement of an eschar is observed on the right (gluteal eminence (the parah/zed side) ; nothing/ of fhe kind exists on the left. On the inner surface of the right thigh, a little above the knee, on a point where the flexed left knee seems to haiie exercised a rather prolonged pressure during the n'ght, a bulla is found about the size of an almond, full of a lemon- coloured lignor and surrounded by an erythematous zone, of Utile extent. The left knee, in the part where the pressure must have been, shows no trace of erythema or of epidermic elevation. The patient succumbed on the 5th December. Autopsy. — The two cerebral hemispheres, at their middle and superior parts, in the points corresponding to the internal extremities of the anterior and posterior marginal convolutions, are transformed into a confused mess, partly bluish (slate-coloured). On a transverse section it is found that the softening extends to the centrum ovale (raajus) of Vieussens, to the vicinity of the lateral ventricles, which, however, it does not attain, even on the left side, where the focus of the encephalitis is much more extensive, in all directions, than on the right. The optic thalami and corpora striata are perfectly normal. In the vicinity of the softened parts of the brain, the dura mater is covered with a neo- membrane, of fibrinous character, and purulent in parts. The cranium is found to be fractured in several parts, in the neighbourhood of the orifices which gave passage to the projectile. BED-SORE IN CEREBRAL LESIONS. 63 develops, nor on any point of the median parts, but towards the centre of the gluteal region, and, most usually, if there be unilateral lesion of the brain, exclusively on the side corresponding with the hemiplegia (Fig. 3.) Fig. 3.— Gluteal eschar or the paralyzed side in a case of apoplexy, consecutive on hemorrhage : a, mortified portion ; b, erythematous zone. On the morrow or after morrow, the bullous eruption and then the echymotic blotch make their appearance on the central part of the erythematous patch, that is, about two inches from the inter- gluteal fissure, and about an inch and a half beneath a supposi- titious line, drawn from its upper extremity, perpendicularly to its direction. Next, mortification of the derm supervenes in this same point, and it rapidly spreads, if the patient survive; but it is rather rare, on the whole, for the acute bed-sore of apoplectic sufferers to reach the stage of confirmed eschar. It is likewise uncommon to observe, in addition to the gluteal eruption, bullae or vesicles developed on the heel, the internal sur- face of the knee, and, in short, on the several points of the para- lyzed lower extremity which may be subjected to a slight pressure. I should not omit to point out to you that, according to my observations, this skin-affection appears but very exceptionally in cases which are to have a favourable termination ; its appearance therefore constitutes a most inauspicious sign. We might, in fact, call it decubitus ommosus, or ominous bed-sore, by way of distinction. 6i DECUBITUS OMINOSUS: OMINOUS BED-SORE. This symptom, I repeat, is rarely deceptive, and as its existence may be discerned from the first days, it consequently acquires, as you will understand, a great value in doubtful cases. The very marked lowering of the central temperature, beneath the normal rate, observable at the outset of an attack, is to my knowledge the only sign that can rival the preceding, in cases of sudden hemi- plegia. The circumstances in which acute bedsore of apoplectic patients develops, evidently do not permit us to refer to the intervention of pressure on the parts where it appears, as the only element in its production. The pressure is the same on both nates, but the eruption is exclusively produced, or at least always predominates in that of the paralyzed side. Many a time I was careful to make the patient repose upon the non-paralyzed side, during the greater part of the day, and this precaution has not in any way modified the production of the eschar. Besides, what, in such a case, could be the influence of a pressure which is only in operation for two or three days? Nor can the irritating contact of urine be given as the cause. In several cases, I have had this liquid drawn off hour by hour, day and night, during the whole time of the disease, in order to avoid as much as possible the irritation of the skin of the seat, and in spite of every care, the eschar was produced in accord- ance with the rules T have indicated. What may be the organic cause of this singular trophic lesion ? I was long under the impression that this lesion should be con- sidered as one of the effects of neuroparalytic hyperaemia, which betrays itself always, in a more or less prominent manner, you are aware, in members struck with hemiplegia of cerebral origin, by a comparative elevation of temperature. But this hypothesis is, as we shall see, open to a number of objections. The facts which will be set forth, as we proceed, render it probable that we must here recognize the irritation of certain regions of the encephalon, which, in the normal state, are believed to exercise a more or less direct influence over the nutrition of different parts of the external tegument. B. Of acute bedsore of spinal origin. When acute bed-sore appears under the influence of a lesion of the spinal cord, it shows itself in the very great majority of cases in the sacral region — and consequently above and internal to the chosen seat of eschars of cerebral origin. Here it occupies the median line and extends sym- metrically, on either side, towards the adjacent parts. (Fig. 4.) It may, indeed, happen that only one side will be affected — in the case, for instance, where a lateral half of the cord is alone engaged, and then the cutaneous lesion frequently shows itself on the oppo- site side of the body from the spinal lesion. The influence of attitudes here plays an important part. Thus it is customary when the patients are so placed as to repose on TRAUMATIC MYELITES. 65 the side, during part of the day, to find, besides the sacral eschar, vast necrosive ulcerations developing on the trochanteric regions. It is also common enough to see, contrary to what happens in cerebral cases, that the different parts of the paralyzed limbs which are exposed to even slight and brief pressure, as the ankles, heels, and inner surface of knees, present lesions characteristic of acute bed-sore. Eschars may also show themselves, but indeed very rarely, on a level with the apex of the scapula, or over the ole- cranon process.^ Fig. 4 — Eschar of the sacral region in a case of partial myelitis occupying the dorsal region of the spinal cord: a, mortified portion ; b, erythematous zone. Speaking generally, we may say that the spinal lesions which produce acute bed sore are also those which give rise to rapid muscular atrophy and to other disorders of the same class. The almost simultaneous development of these different consecutive affections makes it seem probable, already, that they have a common origin. It behooves us to remark, however, that this rule is far from being absolute. As a matter of fact, it is a characteristic of certain spinal aff'ections that rapid muscular atrophy is developed without being accompanied by eschars; whilst there are others, on the contrary, • W. Clapp, 'Provinc. Med. and Surg. Journal,' 1851, p. 322, and Gurlt, /oc cit. p. 110, No. 76. 5 66 TRAUMATIC MYELITES. where the eschars may be produced without the nutrition of the muscles in the paralyzed limb being affected. This is, in truth, a fact of great interest from the standpoint of pathological phy- siology, and one which we shall take care to bring into promi- nence (Fig. 4). (a) We will mention, in the first place, the traumatic lesions of the spinal cord, those in particular which result from fractures or luxations of the vertebral column. Numerous cases of this kind, recorded by Bright,^ Brodie,^ Jeffreys,^ Ollivier (d'Angersy Lau- gier,^ Gurlt,^ and some others,'' show with what rapidity sacral eschars may be produced in such cases. In order to enable you to form distinct ideas, in relation to this, I shall request permission to relate briefly some of these cases. In one case, reported by Dr. Wood, of New York,^ there was fracture of the seventh cervical vertebra, resulting from a fall down stairs; death took place four days after the accident. From the second day, redness of the sacral region was noticed, and a bulla formed at the coccyx. Hsematuria supervened on the third day. A fall from a height determined complete diastasis of the sixth and seventh cervical vertebrae; death supervened sixty hours after the accident, and, at that period, a well-marked bed-sore was already visible. This fact is recorded by Dr. Buchner, of Darm- stadt.^ One of Jeffrey's cases relates to the fracture of the fourth dorsal vertebra; a confirmed eschar occupied the sacral region, from the fourth day. The eschar supervened three days after the accident, in a patient whose history has been narrated by Ollivier (dAngers), on the authority of Guersant, and who had received a bullet in the body of the eighth dorsal vertebra. Another case, given by Jeffreys, is particularly worthy of interest. The patient had fallen, from a ladder, a height of twenty-five feet. On post-mortem examination it was found that the bodies of the seventh and eighth dorsal vertebrae were broken in several pieces, and had been much displaced. On the day of the fall, the skin was cold, and the pulse barely perceptible. All the parts below the fracture were deprived of sensibility and motion. Next day, there were continual erections; "then supervened phlyctenge in > R. Bright, 'Report of Medical Cases,' t. ii, pp. 380, 432, London, 1821. 2 H Brodie, ' Medic. -Chiiurg. Transactions,' p. 148, t. ii, 1836. 3 JellVeys, "Cases of fractured spine," in ' London Med. and Surg. Jouru.,' July, 1826. * Ollivier (d'Angers), /oc. cit., t. i. 5 Laugier *' Des Lesions traumatiques de la moelle ^piniere," 'These de con- cours,' Paris, 1848. <> K. Gurlt, ' Handbuch der Lehre von den Knochenbruchen,' 2 Th. i. Liefer Ilamm. 1864. 7 See an interesting chapter on this subject in Herr Samuel's work, loc. cit., p. 239. 8 Gurlt, loc. cit., Tableau No. 97. . ^ Gurlt, loc. cit., No. 8l). TRAUMATIC MYELITES. 67 the region of the sacrum," and, on the same day, " the patient re- covered his sensibility." I point out this last feature to your atten- tion, because many authors have endeavoured, very erroneously, as you see, to make ansesthesia play an important part in the patho- geny of acute bed-sore of spinal origin. The persistence of sensi- bility, in the parts situated below the lesion, is also marked out, in a more or less explicit manner, in a case recorded by Colliny,^ re- lating to a fracture of the seventh cervical vertebra, where the eschar appeared on the fourth day, as well as in a case mentioned by Ollivier (d'Angers),^ where there was fracture of the twelfth dorsal vertebra. The eschar, in the latter case, made its appear- ance on the thirteenth day. It is useless to multiply these examples, for all surgeons agree in acknowledging that the rapid formation of eschars is one of the most common of the phenomena consecutive on spinal lesions re- sulting from fracture with displacement of vertebriB. According to Gurlt, whose opinion as regards this subject is based on the study of a very large number of observations,^ it is from the fourth to the fifth day after the accident that the first symptoms of acute bed-sore most usually commence to appear; but they may, as we have just seen, set in much earlier, as on the second day, and even sooner. It seems, and the remark has been made by Brodie, that the production of eschars occurs early in proportion as the lesion affects a high point of the cord. On the other hand, it would result from the statistics drawn up by J. Ashhurst that nutritive troubles become frequent in proportion as the wound is lower down. Thus, according to this author, eschars were only observed in three cases, after lesions of tlie cervical region (being ^'y per cent.); twelve times (or 2^3 per cent.) for the dorsal region, whilst as regards the lumbar region, the proportion rose to 12 per cent, (seven cases).^ Priapism, clonic convulsions of variable intensity, supervening in the paralyzed members, either spontaneously or induced, tonic convulsions coming on in paroxysms — all those symptoms, which usually reveal a state of irritation- of the cord and meninges, have been many times mentioned among the phenomena which, m frac- tures of the vertebral column, precede, accompany, or closely fol- low the precocious formation of eschars. In such circumstances, as we have already seen, anaesthesia, of the parts smitten with motor-paralysis, is not a constant fact. As to the remarkable elevation of temperature of which these parts • Quoted by Ollivier (d'Angers), loc. cit. 2 Sensibility was also preserved in Dr. Biichner's case, quoted above, where the eschar appeared before the close of the third day. 3 See Gurlt, loc. cit., p. 94, analysis of 270 cases. * J. Ashhurst, "Injuries of tlie Spine, with analysis of nearly 400 cases," Phila- delphia, 1867. 68 TRAUMATIC HE MIP AR APLEGI A . sometimes become the seat in consequence of vaso-motor paralysis,^ it cannot now be ascertained whether it was then present or not, the attention of the observers not having been drawn to this par- ticular phenomenon. We shall note, on the contrary, as a symptom which shows itself frequently at the same time as the acute bed-sore, the emission of sanguinolent urine, alkaline in reaction, and some- times purulent. This is a fact to which we shall have occasion to revert. Necroscopical examination, hitherto, has not, in general, revealed anything in connection with spinal lesions which can be considered peculiar to the cases where rapidly developing eschars are produced. We frequently, however, find mention made of alterations of the spinal cord, which place beyond doubt the exist- ence of an inflammatory process; the presence of purulent infiltra- tion, and even the formation of abscesses in the midst of the softened parts, have been observed in several instances. h. The study of cases of hemiparaplegia, consecutive on wounds involving only a lateral half of the spinal cord, may furnish useful information concerning the pathogeny of acute bed-sore, and of some other trophic disorders of spinal origin. We learn, from the experiments of M. Brown Sequard, that, after wounds of this kind, there supervenes in animals motor-paralysis of the lower extremity, on the same side with the lesion. The limb presents also a more or less marked degree of exaltation of tactile sensibility, and it like- wise offers a notable elevation of temperature correlated with vaso- motor paralysis. The opposite limb preserves, on the contrary, its normal temperature and power of motion, whilst the tactile sensibility is much lessened, and may even be extinct. All these particulars are exactly reproduced in man under analogous circum- stances. In his case, as in that of animals, we may also find differ- ent trophic derangements supervening, which appear almost simul- taneously, and which are all manifestly due to spinal lesion. Among the nutritive lesions of this kind observed in man, we would especially point out the rapid diminution of the (faradaic) electrical contractility of the muscles, soon followed by atrophy, — a particular form of arthropathy to which I shall refer in a few ' In a case of fracture of the vertebral column in the dorsal region, observed by J. Hutchin?ou, on the second day after the accident, the temperature of the feet, taken at the inner ankles, rose (to lOlO F., or) above 380 Cent. In the normal state, according to observations made in London Hospital, by Dr. Woodman, tlie thermometer placed between the two first toes gave an average of 27. 5° C. (81. 50 F.)., the maximum being 34.50C. (94© F.), and the minimum 21. 50 C. (70© F.). See J. Hutchinson, "On Fractures of the Spine," in 'London Hospital Reports,' t. iii, 1866, p. 363. See also H. Weber and Gull, in ' The Lancet,' Jan. 27, 1872, p. 117. Clinical Society of London. [See also Mr. J. W. Teile, " Case of Remark- able Elevation of Temperature" after injury of the spine, in a young lady, where 1220 F. (50O C.) is stated to have been observed, « Lancet,' 1875, p. 340 ; and J. Hutchinson, "On the Temperature and Circulation after Crushing of the Cervical Spinal Cord," ' Lancet,' 1875, pp. 714, 747.]. (S.) TRAUMATIC H E MIP A R APLEGI A . 69 moments — and finally, acute bed-sore. It is a remarkable thing that, whilst the arthropathy and muscular atrophy are to be found in the limb on the sanie side with the lesion, the eschar seems to prefer, as we have already remarked, to show itself on the member of the opposite side, where it occupies the sacral region, and the gluteal, in the immediate neighbourhood of the former. This pe- culiar disposition of the eschar in relation to the seat of the spinal lesion is, according to what M. Brown-S^quard has told me, a con- stant fact in the case of animals; in man, it has already been several times observed. As an example of the class, I shall briefly cite the following facts ; A man, aged twenty years, whose history has been related by M. Yigues,^ received on the back of the thorax, between the ninth and tenth dorsal vertebrae, a sword cut which, to judge from the symptoms, injured the left lateral half of the spinal c<'>rd chiefly. Motor paralysis immeiliately ensued, which, at first affecting both the lower extremities, appeared from the next day to be almost entirely confined to the left leg. Hyperaesthesia is very manifest in the latter member; the right limb presents, on the contrary, a well-marked obnubilation of sensibility, whilst the power of motion has nearly quite returned. The symptoms showed rapid improve- ment up to the twelfth day after the accident; on that day it was remarked that, without perceptible cause, the left leg, still more sensitive than in the normal state, had increased in volume, and also that in the left knee-joint there had accumulated a quantity of fluid sufficient to keep the patella raised half an inch above the condyles. Two days later an eschar was observed occupying the riglit lateral part of the sacrum and right gluteal region. The case recorded by MM. Joffroy and Salomon,^ of one of Dr. Cusco's patients, which was recently communicated to the Societe de Biohgie^ reproduces, as it were, the foregoing case, even in its smallest details. In the former, as in the latter, after a traumatic lesion affecting one lateral half of the cord in the dorsal region, we find motor paralysis supervening in the inferior extremity that corresponds to the injured side; this limb presents a notable aug- mentation of temperature — a fact not mentioned by Yigu^s. though probably present — and manifest hyper^esthesia; whilst the opposite limb, unharmed in its motor functions, oft'ers a remarkable dimi- nution of all kinds of sensibility whilst preserving the normal temperature. In addition, and this is the point which we desire to put especially forward, shortly after the accident, and without any appreciable cause, there supervened an arthropathy in the knee of the paralyzed limb, whilst, in the vicinity of the sacral region, • Browu-Sequard, •Journal de la Physiologie,' &c., t. iii. p. 130, 1863. 2 ' Gazette Medicalede Paris,' Nos. 6, 7, 8, 1872. 70 TKAUMATIC HE MIP AR APLEGI A . the nates of the member deprived of sensibility but not paralyzed in motion, became the seat of an eschar.^ I take the following case from an interesting work by Herr W. Muller:^ in this instance the arthropathy is not mentioned; on the other hand, we find mention of rapid .wasting of the muscles of the paralyzed limb, preceded for several days by a well-marked diminution of faradaic contractility. In all other matters, Miiller's observation is in conformity with those of MM. Vigues and Joflfroy. The case is that of a woman, aged 21, who received a stab with a knife in the back, at the fourth dorsal vertebra, the weapon, as the autopsy demonstrated afterwards, had completely divided the 1 On account of the interest connected with it, we shall mention the principal details of this case. The patient, Martin, aged about 40 years, was stabbed with a poignard, in the night of the 15-16th February, 1871. The weapon entered at the third dorsal vertebra. The direction of the wound is downward, backward, and to the right. Having been brought to hospital immediately after the wound, it was observed that, even then, the left inferior extremity was completely stricken with motor- paralysis, whilst the corresponding member on the other side showed nothing of the kind. February 16th, in the morning, the following note was made: Left lower extremity, complete motor-paralysis. The limb is perfectly flaccid ; no trace of contraction, or rigidity, no spasmodic movements, nor subsultus. On the contrary, sensibility appears in the same limb to be exaggerated in all its moc' the least touch of the skin, especially near the foot, causes pain. Pressure has the same effect. A slight pinch or a tickle is followed by very painful sensations. Finally, the contact of a cold surface also produces painful sensations which the patient compares to those producible by a series of prickings. Right lower ex- tremity : all the voluntary movements are perfectly normal, but per contra, the sensibility is almost completely destroyed. Complete analgesia ; sensitiveness to touch almost null. The coniact of a cold body is marked by an obscure dull prickling sensation. The insensibility is not limited, on the right, to the lower limb ; it ascends to a level with the nipple. The urine and feces passed invol- untarily. February 24th (eighth day). — The same phenomena are observed ; in addition it is noted that the left (motor-paralyzed) limb is warmer than the right. The patient complains of a sensation of constriction or rather of compression at the base of the thorax. March 5th (seventeenth day). — The patient complains of troubled sight : the left pupil is more contracted than the right, and the vessels of the left eye are more voluminous and more numerous than those of the right eye. The evacua- tions have again become voluntary, for two days past. The state of the lower extremities is still unchanged. March 13th (twenty-fifth day). — The right nates, since yesterday, has been the seat of vivid redness, and the epidermis has already fallen off from a part of the erythematous patcli. March 14th. — The derm is denuded to the size of a crown-piece on the right nates, near the sacrum : it is also ecchymosed (acute bed-sore). On Feb. 24th, it had been already remarked that some pain was felt when the left knee (motor- paralyzed limb) was moved; to-day, it is noted that this joint is swollen and red, and that it is, b'.sides, the seat of spontaneous pains, exaggerated on movement (spinal arthropathy). March 24th. — An ulceration, this day covered with granulations, has formed on the right nates, on a level with the ecchymosed patch. The swelling, redness, and pains have almost completely disappeared from the left knee. 2 W. Miiller, " Beitrage zur pathologisch Anatomie und Physiologie des meu- Bchlichen Kuukenmarkes," Leipzig, 1871. Obs. i. SPONTANEOUS MYELITES. 71 left lateral half of the spinal cord, two millimetres above the third dorsal pair. On the very day of the accident complete paralysis and hypergesthesia of the left lower extremity was observed ; the opposite limb was anseesthetic, but not paralyzed. On the second day it was found that the muscles of the paralyzed member and those of the lower part of the abdomen gave no reaction under the influence of faradaic stimulation, whilst, in the homologous parts of the opposite side, the electrical contractility remained normal. On the eleventh day an eschar was formed, occupying the sacral region and extending to the right gluteal eminence. On the same day, it was remarked that the paralyzed limb had notably wasted away, measuring about two inches less in circumference than the anaesthetic member. Death occurred on the thirteenth day. On a post-mortem examination, the borders of the spinal wound appeared tumefied, and of a reddish-brown colour; a thin purulent layer covered it. Below the wound the left lateral column, throughout its whole length, offered the anatomical charac- teristics of descending myelitis. The simultaneous appearance of different trophic disorders noted in these cases, and in some others of the same kind, seem to indi cate a common cause. This cause, to all appearance, is nothing other than the extension to certain regions of the inferior segment of the cord, of the inflammatory action originally set up in the immediate vicinity of the wound.^ That being admitted, it would seem legitimate, relying ou the facts stated in the preceding lecture, to assign the rapid and general atrophy of the paralyzed muscles, noted in Herr Miiller's G-ise, to the invasion of the anterior cornu of the gray substance throughout the whole extent of the cord, whence nerves are given forth to the paralyzed muscles ; the invasion in question taking place either progressively by direct downward propagation ; or indirectly by the lateral columns. This lesion of the anterior cornu we shall men- tion, in a moment, to explain the developme-nt of the arthropathy described in the observations of Vigu^s and Joffroy. Now, witfi respect to the eschars, their appearance on the side opposite the spinal lesion tends to establish that the nerve-fibres (whose altera tion, under such circumstances, provokes the mortification of the external tegument) do not follow the same course as those which influence the nutrition of joints and muscles, and that they, on the contrary, decussate in the cord in the same manner as the nerve- fibres subserving the transmission of tactile impressions. 1 In a work, recently published, I have endeavoured to establish that, after wounds of the spinal cord, irritative lesions such as hypertrophy of the axis- cylinders, proliferation of myelocytes, &c., may be observed at some distance from the spinal wound, above and below it, scarcely twenty-four hours after the acci- dent. Charcot, "Sur la tumefaction des cellules nerveuses, motrices, et des cylindres d'axe des tubes nerveux dans certains cas de myelite,'' in 'Archives de Physiologie,' No. 1, 1872, p. 95. Obs. i. 72 PATHOLOGY OF BED-SORE OF SPINAL ORIGIN. Another item of information which we get from cases of hemi- paraplegia consecutive on a unilateral lesion of the spinal cord, is this, namely : acute bed sore may show itself independently of all neuroparalytic hyperasmia, since we observe it forming upon that side of the body where the vasor-motor nerves are not affected. c. I shall now mention the case where myelitis results, not, as in the preceding instance, from a wound or attrition of the spinal cord, but from indirect traumatic influence, such for example as an eftbrt made in raising a weight. Acute bed-sore may, in cases of this kind, be produced as rapidly as though there had been fracture of the vertebral column, as the following fact recorded by Dr. Gull demonstrates : A man, aged 25, by trade a labourer in the London Docks, felt, after lifting a load, a sudden pain in his back. He was able to walk to his home, about a mile off. On the morning of the second day after, his lower limbs were completely paralyzed ; two days later, or four days after the accident, an eschar had begun to form (m the sacral region, and the urine which flowed from the bladder was ammoniacal. The patient succumbed ten days after paralysis had set in. At the post-mortem examination, it was noted, after careful scrutiny, that the bones and ligaments of the vertebral column presented no lesion; in the neighbourhood of the fifth and sixth dorsal vertebrae the spinal cord was transformed throughout its whole breadth into a thick liquid, muco-purulent in appearance and in colour both brown and greenish.^ Following the example of traumatic myelites, spontaneous acute myelitis also very frequently determines the precocious formation of sacral eschars, principally when it sets in suddenly, and when the evolution is rapid. In order not to enter on lengthy details, in connection with this matter, I shall confine myself to indicating some examples illustrative of this class of cases. The sore has been noticed on the fifth day in a case reported by Mr. Duckworth,^ on the sixth day in the case of a patient under the care of M. Woil- liez, which M. JoiiVoy has communicated to me; on the ninth day in an observation of M. Engelken, on the twelfth day in another case related by the same author;^ finally, in a case of a cervico- dorsal meningo-myelitis, published by MM. Voisin and Cornil, the eschar formed on the sixth day .^ These examples might be easily increased. Acute bed'Sor^ frequently accompanies haeniatomyelia (which indeed appears tO be, at least in a certain number of cases, only an accident of centr? 1 myelitis) ; thus we found it in the case of Duriau, > W. Gull, "Cases of Paraplegia," in 'Guy's Hospital Reports,' 1858, p. 189, Case xxii. 2 ' The Lancet,' 6.Nov., 1869, p. 638. 3 Loc. cit., • Pathologic der acnteii Myelitis,' Zurich, 1867. < 'Gazette des Ilopitaux,' 18G5, No. 26. INFLUENCE OF THE GRAY SUBSTANCE. 73 already quoted, where mortification showed itself in the sacral region only four days after the appearance of the first symptoms.^ We may als(^ observe rapid mortification of the skin of the sacral region supervening, even in spinal diseases of slow evolution, when a new course of active irritation intervenes on a sudden, or when acute inflammatory action is suddenly superadded to the initial lesion. Not only the exacerbation of partial sclerosed myelitis, but the sudden irruption into the rachidian cavity of pus emanating from an abscess, in the case of a patient suffering from vertebral disease may, as I can attest, determine the rapid formation of eschars. The same result would be likewise produced in case a tumour occupying the central portions of the cord should, by its presence, provoke the development of acute myelitis. Several ex- amples of this kind are on record.^ If the evidences which we have collected here do not yet allow us to construct a pathogenic theory of acute bed-sore of spinal origin, they at least suffice, if I mistake not, to exhibit the principal con- ditions of the phenomenon. Manifestly, we must- relegate to a secondary position the influence of pressure ; and also that of vaso- motor paralysis which may be completely absent, as we have seen in relation to the herni paraplegia resulting from the traumatic lesion of a lateral half of the cord. On the whole, the dominant and ever present fact is the active irritation of a more or less extensive region of the spinal cord — mostly showing itself, anatomically, by the characteristics of acute or superacute myelitis, and, clinically, by the assemblage of symptoms which are assignable to this kind of lesion. To explain the production of trophic disorders which issue in sacral mortification, here again it is not to absence of nerve-action that we should appeal, but to irritation of the spinal cord. This conclusion is in conformity with the experimental results which show that, in animals, the development of gangrenous ulcerations over the sacrum do not supervene on ordinary sections of the cord, but only in cases where inflammation has been set up in the neigh- bourhood of the spinal lesion. It is scarcely probable that all the constituent parts of the cord are indiscriminately apt, under the influence of irritation, to pro- voke the development of acute bed-sore. The great frequency of this accident in cases of haematomyelia, and of acute central mye- litis, where the lesion occupies chiefly the central regions of the spinal cord, seems to designate the gray substance as playing a pre- dominant part in this respect. And this power is no doubt shared in by the posterior white fasciculi, for we know that the irritation of certain parts of these fascicol-i has the effect of determining the ' 'Union Medicale,' t. i, 1858. p. 308. 2 Amongst others see MacDovvel's "Case of Paraplegia," in ' Dublin Quarterly Journal,' 1862. 74: INFLUENCE OF THE GRAY SUBSTANCE. production not only of different cutaneous eruptions, but also, though rarely indeed, that of dermal necrosis.^ On the other hand, it is perfectly established that all portions of the gray matter should not be indifferently accused; "some of them, in fact may, as we have already suggested, undergo the gravest lesions, without acute bed-sore ever supervening. Such are the anterior cornua, whose lesions, per coritra, have, as you are aware, a most decided influence on the nutrition of muscles and, as we shall soon see, on that of joints also. Hence it is that sacral eschar is often absent in infantile spinal paralysis, and in adult spinal paralysis — diseases which are charac- terized anatomically by acute inflammatory lesions, systematically limited to the area of the anterior cornua; whereas, those other diseases, which alfect the skin, depend upon irritative lesions oc- cupying, either the central . and posterior portions of the gray matter, or the posterior white fasciculi. From this particular point of view there is reason to recognize, in the spinal cord, the exist- ence of two regions endowed with very distinct properties. Now, since these regions may be affected either separately or simultane- ously, it follows that, in clinical practice, acute bed-sore and acute muscular atrophy will sometimes appear separately, and that they will sometimes, on the contrary, coexist in the same individual. From what precedes, the influence of irritative lesions of the spinal cord upon the development of acute bed-sore seems to us placed beyond doubt. Herr Samuel has, however, advanced a contrary opinion; he thinks that the spinal cord does not play any part herein, and that the spinal ganglia or peripheral nerves are alone implicated. We shall mention elsewhere the arguments on which this theory is based ; but we are now able to point out that it is in formal contradiction with what has been noted in the numer- ous cases of traumatic myelitis affecting an elevated part of the cord — the cervical region, for instance, or the superior portion of the dorsal region — cases where acute bed-sore supervenes in the sacral region, and certainly without the direct participation of the spinal ganglia, or of the peripheral nerves. The cases of hsemato- myelia, or of spontaneous central myelitis, followed by precocious eschars, are likewise adverse to the views of Herr Samuel. It is not alleged, however, that the irritative lesions of the peri- pheral nerves, and perhaps also those of the spinal ganglia, may not sometimes have the efiect of determining the rapid formation of eschars. No doubr, the examples published of dermal necrosis developed in consequence of a puncture, incomplete section, or compression of a nerve are rare enough ; but many of them are thoroughly convincing.^ In connection with this, I will relate the • See ante, Lecture iii, § 1, p. 52. 2 See amongst recent published facts, a case reported by Dr. W. A. Lanson. LESIONS OF THE XERYES. 7o case of a female patient which I have been recently studying at La Salpetri^re. She had, on the left side, an enormous fibrous tumour which compressed, in the pelvis, the roots of the ischiatic and crural nerves of the corresponding lower extremity. There had resulted a paretic state of this member, accompanied by acute pains running along the track of the principal nerve-trunks. One morning, shortly after the appearance of the first symptoms of compression, it was remarked that an eschar had rapidly formed near and to the left of the wSacral region. The inner surface of the left knee, likewise, in a spot which had been pressed upon by the right knee for a consider- able time during the night, in consequence of the attitude of the patient when asleep, presented some pemphigoid bullae, full of a brownish liquid, which soon gave place to an eschar. Nothing of the kind was developed on the right knee. This is perhaps the place to mention that spontaneous zona which, in certain cases at least, is very probably connected with the inflammation of some nerve, may, according to the remark of Rayer,' occasionally issue in the more or less deep mortification of the skin. I have been often a witness to this fact, occurring among the aged persons in this hospital, and I have been many times able to satisfy myself that pressure on the spot occupied by the eruption did not here play an essential part. As to acute bed-sore of the breech, I am much inclined to believe that, in a certain number of cases, it should be attributed to an irritative lesion of the nerves of the cauda equina. A case recently published by M. Couyba, in his inaugural disser- tation, may be cited as one of several examples of this class.^ III. On Arlhr 02)0 tides of Cerehral or Spinal Origin. — Nutritive disor- ders consecutive on lesions of the nervous centres not unfrequently take up their seat in the articulations. The varieties presented ('The Lancet,' 30 Dec, 1871, p. 913), and two cases of Dr. Vitrac ('Union Medi- cale de la Gironde,' t. ii, p. 127, and ' Revue Phot, des Hopitaiix,' 1871). ' Rayer, 'Maladies de la Peau,' t. 1, p. 335. 2 A young private in the Garde Mobile received a bullet wound, at the outposts of Clainart. The projectile liad entered near the anterior extremity of the tenth rib on the left side, and had emerged on the right side of the vertebral column, about three inches from the spine, on a level with the second lumbar vertebra. Paresis, with acute hypersesthesiaof the lower extremities, followed. On the right gluteal eminence a bulla (which quickly gave place to an eschar) appeared on the fifth day after the accident. The eschar extended in a progressive manner, so as at last to cover the whole of the sacro-gluteal region. Death occurred on the nineteenth day. Post-mortem. — A purulent mass covers the anterior and posterior surfaces of the cord, and extends from the cauda equina to the cervical region. The cord itself when examined, ffrst, in the fresh state, next in numerous hardened sections, did not exhibit any alteration. On the other hand, a certain number of nerve-tubes in the nerve-filaments which form the cauda equina presented the anatomical characters of fatty granular degeneration. — Couyba, ' These de Paris,' 1871. Obs. xiii, p. 53 7b SPINAL ARTHROPATHIES. by these articular affections, according to the nature of the cere- bral or spinal lesions from which they arise, have led me to estab- lish two principal categories. A. The first comprises arthropathies of acute or subacute form, accompanied by tumefaction, redness, and sometimes by pain of a more or less severe character. This form was indicated for the first time, if I mistake not, by an American physician, Pcofessor Mitchell,' who observed it in the paraplegia connected with Pott's disease of the vertebrae, in which, however, it is very rare, in my opinion.^ It happens more frequently as a consequence of a trau- matic lesion of the spinal cord, as we find from the sufficient evi- dence of the cases, above quoted, which have been recorded by MM. Vigues and Joffroy.^ A case of concussion of the cord, re- lated by Dr. Gull, supplies an analogous demonstration.'' Acute or subacute inflammation of the joints of paralyzed limbs may supervene also, in spontaneous myelitis; as examples of this class I may mention a case reported by Dr. Gull,^and another case which M. Moynier published in the "Moniteur des Sciences Medi- cales" for 1859. The second case relates to a young man, aged eighteen, who, after lodging for a long time in a damp place, and undergoing great fatigue, had presented all the symptoms of sub- acute myelitis. Paralysis of motion began to show itself on the 25th of January; it became complete on the 9th February. On the 23d of the same month, the skin of the sacral region presented an erythematous patch which gave place to an eschar, on the 5th of March. On the 6th of this month, there was severe pain in the right knee, which was swollen, and in which the sensation of fluc- tuation v/as perceptible. In addition, there was painful tumefac- tion of the tibiotarsal articulation of the same side. On th-e 9th of March, the knee had decreaseii in size, and on the same day, eschars made their appearance on the heels. The autopsy revealed a focus of ramoUissement situated not quite two inches above the Cauda equina. Finally, in a case of central myelitis in a child, having its origin in the neighbourhood of a solitary tubercle situated in the cervical region of the cord. Dr. Gull records the formation of an intra-artic- ular effusion, occupying one of the knees, at the time when the paralysis began to invade the lower extremities.'^ It is remarkable to see these arthropathies, consecutive on the • Mitchell, "American Journal of the Medical Sciences," t. viii. p. 55, 1831. 2 I have, however, seen one knee become the seat of a subacute arthropathy in a woman suffering from paralysis consecutive on Pott's disease. Tliis case has been recorded in the thesis of M. Michaad, " Sur la meningite et la myelite dans le raal vertebral," Paris, 1871. 3 Loc. cit., pp. 91, 92. < Gull, "Guy's Hospital Reports," 3d series, t. iv, 1858. Case xxvii. 6 Gull, idem, Obs. xxvii. 6 Gull, loc. cit., Case xxii. ARTHROPATHY OF HEMIPLEGIC PATIENTS. 77 different acute and subacute forms of myelitis, frequently forming, when the muscles of the paralyzed limbs are beginning to waste away, or again when an eschar is being rapidly developed on the breech. The arthropathy of hemiplegk patients^ first described I believe in 1846, by Scott Alison,^ afterwards by Brown-Sequard, and the ^ Scott Alison, "Arthrites occurring in the Course of Paralysis," Note read be- fore the Medical Society of London, Jan. 16, 1846, 'The Lancet,' t. i. p. 276, 1846. It is manifestly to the arthritis of hemiplegic patients, such as we have described it ('Arch, de Physiologic,' t. 1), that the note of Dr. Alison refers. It is a characteristic of the affection to remain confined to tlie paralyzed limbs, and not to extend to the sound members. The affected joints are hot, swollen, and in some cases painful, either spontaneously or on movement made. The parts most frequently affected are the knee, elbow, wrist, hand, and foot. This form of arthritis seems to show itself chiefly in cases where the hemiplegia is consecu- tive on encephalitis or on brain softening. Two cases, selected from a number of others of the same kind, and cited as examples, deserve to be briefly recorded here : — Case I. — A woman, aged 49 years, who had long enjoyed perfect health and had never suffered fiom any form of arthritic disease, was sudilenly struck with liemiplegia ; some days after, tumefaction and heat at the wiist of the paralyzed Fide set in, and a little later on, the knee and foot of the same side became swol- len and painful in their turn. There was no oedema. Tlie paralyzed limbs were rather rigid. On post-mortetn examination, partial softening of the brain was discovered. Each renal pelvis was filled with little calculi of uric acid. Case II. — A man, aged 54, house painter, who had experienced several attacks of gout, was struck with sudden hemiplegia. Soon after the wiist, the hand, and the foot, became hot and swollen. The paralyzed limbs were rigid. At the autopsy, the brain appeared softened, and a voluminous blood-clot was found in one of the lateral ventricles. Dr. Alison endeavoured to explain the occurrence of arthritis in the course of (hemiplegic) paralysis, by showing that "the healthy relation between the living tissues and the materials of the blood was disturbed. Two morbid conditions gave rise to this disturbance, viz., a state of reduced vitality in the paralyzed parts, and the presence of exciting and noxious agents in the blood. In proof of this various facts were referred to, and the author related two singular cases cf the inflammatory red line of the gums following the use of mercury, in paralysis of one side of the face, being strictly confined to the paralyzed side of the mouth. The p.'iralyzed paits were in fact more delicate tests of poisons than parts in a state of health. In proof of the presence of exciting agents in the blood the gouty diathesis of the second case and the lithic acid calculi in the pelvis of the kidney of the first case, were adduced." We, in ourturn, would point out that, most certainly, these cases are altogether exceptional, as regards the question at issue, for most frequently, as may be understood from a perusal of the cases published in our work ('Archives de Physiologie,' t. i.) the arthritis supervenes in hemiplegic patients as a moie or less direct consequence of the cerebral lesion, quite apart from all influence of gout, rheumatism, or other diethetic condition. Hence, whilst acknowledging the accuracy of Dr. Alison's clinical descriptions, I am unable to endorse the pathogenic theory which he has proposed. I am, however, far from denying that the articulations of paralyzed members, in cases of hemiplegia of cerebral origin, may, as Dr. Alison holds, be particularly dis- posed to become foci of elimination for other agents previously accumulated in the blood. I myself communicated to the Societe de Biologic, at the time of its occurrence, a case in which this particular disposition was very prominent. A woman, aged about 40 years, had been suddenly struck with right hemiplegia three years before her admission into my wards. The paralyzed limbs were strongly 78 PATHOLOGICAL ANATOMY. anatomical and clinical characters of which I have made known, belongs, if I mistake not, to the same category. In this second variety, as well as in the first, the arthropathies are limited to the paralyzed limbs and mostly occupy the upper extremities. They supervene, especially, after circumscribed cerebral ramollissement {en foyer)^ and, more rarely, as a consequence of intra-encephalic hemorrhage. They usually form fifteen days or a month after the attack of apoplexy, that is to say, at the moment when the tardy contracture that lays hold on the paralyzed members appears, but they may also show themselves at a later epoch. The tumefaction, redness, and pain of the joints are sometimes marked enough to recall the corresponding phenomena of acute articular rheumatism. The ten- contractiired now and again, tlie several joints of these limbs, the knee especially and the foot, were the seats of tumefaction and pain. The patient, being aphasic, in a high degree, it was impossible to ascertain if she had been previously sub- ject to gout or rheumatism. At the autopsy, we found a vast ochreous cicatrix, the vestige of a focus of cerebral hemonhage, situated exterior to the extra-ventricular nucleus of the corpus striatum. In most of the articulations of the limbs on the right side, which had been hemiplegic, the diarthrodial cartilages were incrusted towards their central parts with deposits of urate of soda, both crystallized and amor- phous. The joints of the limbs, on the other side, presented no similar appear- ance. Some white strise, which were found on microscopical and microchemical examination to be formed by urate of soda, were noticed in the kidneys. It is undoubtedly most remarkable to find, in this case, that the gouty deposit forms exclusively in the joints of the paralyzed members ; but, I cannot too often repeat that facts of this kind are exceptional, and, in any case, they have noth- ing in common, from a pathogenic point of view, with the ordinary arthritis of hemiplegic patients (' Cas d' Hubert,' see Bourneville, ' Etudes cliniques et ther- mometriques sur les maladies du systeme nerveux,' p. 58). The merit is due to M. Brown-Sequard of having directed atteJitiou anew to the arthropathy of hemiplegic patients, and of having determined the organic cause, better tlian Dr. Alison had done. He thus expresses himself in a lecture pub- lished in ' Tlie Lancet ' (" Lectures on the Mode and Origin of Symptoms of Dis- eases of the Brain," Lecture i, Part ii, * The Lancet,' July 13, 1861). After hav- ing admitted that the painful sensations, such as formication and prickling, which are experienced in the paralyzed members, in consequence of a cerebral lesion, result generally from a direct irritation of the encephalic nsrve-fibres, he adds: — " It is most important not to confound these sensations (which are referred sen- sations, like those taking place when the ulnar nerve has been injured at the elbow joint) with other and sometimes very painful sensations in the muscles or in the joints of paralyzed limbs. These last sensations very rarely exist when the limbs are not moved, or when there is no pressure upon them ; they appear at once, or are increased by any pressure or movement. They depend upon a subacute inflammation of the muscles or joints, which is often mistaken for a rheumatic affection. This subinflammation in paralyzed limbs is often the result of an irritation of the vaso-motor or nutrition nerves of the encephalon." Before M. Brown-S^quard, and before even Mr. Scott Alison, many physicians had already remarked the arthritis of paralytic patients, but without bringing out the interest connected therewith. Consult R. Dann, ' The Lancet,' t. ii, p. 238,1841. Duraud-Kardel, 'Maladies des Vieillards,' p. 131. Paris, 1854, Ob- servation, Lemoine. Valieix, 'Guide du Modecin Praticien,' t. iv, 1853, p. 514 Grisolle, 'Pathologie Interne,' 2nd edition, t. ii, p. 257. CLIXICAL CHARACTERS. 79 dinous sheaths are, indeed, often affected at the same time as the articulations. I have shown that we have here a true synovitis with vegetation, mul,ti plication of the nuclear and fibroid elements which form the articular serous membrane, and augmentation in number and volume of the capillary vessels which are there distributed. In in- tense cases, a sero-fibrinous exudation is produced, with which are mingled, in various proportions, white blood-corpuscles that may become abundant enough to distend the synovial cavity. The diarthrodial cartilages and ligamentous parts have not hitherto appeared to present any concomitant lesion perceptible to the naked eye. On the other hand, the tendinous synovial sheaths, in the neighbourhood of the aflected joints, take part in the inflammatory process, and appear greatly congested.^ It is needless to insist upon the interest which pertains to these arthropathies as regards diagnosis, — articular rheumatism, whether acute or subacute, being an affection often connected with certain forms of cerebral softening, and one which, indeed, shows itself also, occasionally, after traumatic causes capable of determining shock in the nervous centres. On the other hand, many alieclions of the spinal cord are erroneously attributed to a rheumatic dia- thesis in consequence of the co-existence of these articular symp- toms. The clinical characters which render it easy to recognize arthropathies correlated with lesions of the nervous centres, and which allow them to be distinguished from cases of rheumatic arthritis, are chiefly these: 1st. Their limitation to the joints of the paralyzed members. 2d. The generally determinate epoch in which, in cases of sudden hemiplegia, they make their appearance on the morbid scene. 3d. The coexistence of other trophic troubles of the same order, such as eschars of rapid formation; and (when the spinal cord is involved) acute muscular atrophy of the paralyzed members, cys- titis, nephritis, &c. B. The type of the second group is to be found in progressive locomotor ataxia. Allow me to fix your attention for an instant upon this species of articular affection, in which I take a paternal ' Charcot, " Siir qnelqnes artliropatliies qui parai:ssent dependre d'line lesion du cerveau on de la irioelle epiuiere," 'Archives de Physiologie,' t. i, p. 39G, PI. vi, figs. 1, 2, 3, 4, 5, 6. Paris, 1868. The arthropathy in question should appa- rently not be confounded with the articular atfection which has been descrihed, in latter days, by Herr llitzig of Berlin, " Teber eine bei schweren Hemiplegien, Auftretende Gallenkaffection," in ' Virchow's Arcliiv,' Bd. xhiii, hft. 3 u. 4,1869. Tills species appears, especially, when the hemiplegia is of comparatively old date, and the patients have been able to walk for some time ; it chiefly occupies the shoulder-joint, and re.sults principally from the displacement of the ar- ticular surfaces, occasioned by the paralysis of the muscles which surround the joint. 80 ARTHROPATHIES OF ATAXIC PATIEXTS. interest, all the more lively because the signification I attached to it has had to encounter many sceptics. And at first, a word as to the clinical characters of the arthropathy of ataxic 'patients} This disorder generally shows itself at a determinate epoch of. the ataxia, and its appearance coincides, so to speak, in many cases with the setting in of motor incoordination. Without any appreciable external cause, we may see, between one day and the next, the development of a general and often enor- mous tumefaction of the member, most commonly without any pain whatever, or any febrile reaction. At the end of a few days the general tumefaction disappears, but a more or less considerable swelling of the joint remains, owing to the formation of hydarthus ; and sometimes to the accumulation of liquid in the periarticular serous bursoe also. On puncture being made, a transparent lemon- coloured liquid has been frequently drawn from the joint. One or two weeks after the invasion, sometimes much sooner, the existence of more or less marked cracking sounds may be noted, betraying the alteration of the articular surfaces which, at this period, is already profound.^ The hydarthus becomes quickly re- solved, leaving after it an extreme mobility in the joint. Hence consecutive luxations are frequently found, their production being largely aided by the wearing away of the heads of the bones which has taken place. I have several times observed a rapid wasting of the muscular masses of the members affected by the articular disorder. Ataxic arthropathy usually occupies the knees, shoulders, and elbows; it may also take up its seat in the hip-joint The anatomo- pathological information which we possess respecting it, is as yet very imperfect. However, one character is apparently constant, namely, the enormous wearing down which is exhibited in a \(^.Yy short space of time by the articular extremities. At the end of three months, this head of a humerus which I show you, and which belonged to a female patient in whom we were enabled to study the, invasion of the arthropathy, was, as you may remark (Fig. 5), to a great extent destroyed. I would call your attention to the fact, that you do not find on this specimen, the bony burr around the worn articular surface, which would not fail to be present if this were a case of common dry arthritis.^ I now place before you in order to establish the contrast, a knee- joint also taken from a woman who presented the symptoms of ataxic ' Charcot, "Siir quelques Arthropathies," &c., p. 1. 'Archives de I'liys.,' t. i, 18G8. 2 In some cases the cracking sounds have preceded, by several days, the ap- pearance of the general tmuefaction of the member ; but, as a rule, the latter is the first symptom observed. 3 Compare Charcot, " Ataxie locoraotrice progressive, arthropathie de lepaule gauche. Resultats n6croscopiques," in 'Archives de Physiologie,' t. ii, p. 121, 1869. CLINICAL CHARACTEKS 81 arthropathy, but in whom the articular affection was of much older date. Besides the wearing down of the articular surfaces which, as in the preceding case, is carried very far, you notice here the presence of foreign bodies, of bony stalactites, and, in a word, of all the customary accompaniments of arthritis deformans. These latter alterations, I repeat, were absolutely wanting in the first case. On this account, I am led to believe that they are nowise necessary, and that they are produced in an accidental manner, and to all appearance chiefly by the more or less energetic move- ments to which the patients sometimes continue to subject the aiTected members. Fig. 5. — Upper extremity of a lu-altliy humerns, and a Immeriis presenting tlie lesions of ataxic arthropathy. I wish to confine myself at present to this indication of the most general features of the arthropathies of ataxic patients, for this is a subject which I propose to treat hereafter in more detail. What I have to say will suffice, I hope, to show that the articular af- fection in question is, itself also, the expression of trophic dis- orders directly dependent on the lesion of the spinal nerve- centre. But here are the principal arguments upon which I base my opinion. I would point out, in the first place, the absence of all traumatic or diathetic cause of rheumatism or of gout, for instance, which miorht explain the appearance of the articular disease in the cases which I have studied. Herr B. Wolkmann^ has said that the arthro- pathy of ataxic patients is simply the result of the distension of the articular ligaments and capsules, in consequence of the awkward manner of walking peculiar to this class of persons. The cases, which are now numerous, in which our arthropathy affected the upper extremities, and occupied either the shoulder or the elbow, are sufficient to prove that the interpretation proposed by Wolk- Caiistatt's ' Jahrf sbericht; 1868-^69, 2 Bd., p. 391. 82 PATHOGENY. mann could have but a very narrow bearing. The influence of a mere mechanical cause cannot be invoked, at least not as a principal agency, even in cases where the arthropathy occupies the lower extremities. I have, in fact, taken care to point out, supporting my words by oft repeated clinical observations, that the articular afl'ection in question is developed at a comparatively early epoch of the sclerosis of the posterior columns, and at a time when motor incoordination is as yet null, or scarcely manifest. The clinical characters of our arthropathy are, besides, really special. Its sudden invasion, marked by the general tumefaction of the member; the rapid alterations of the articular surfaces; finally, its appearance at, as it were, a determinate epoch of the spinal disease with which it is connected, constitute so many pe- culiarities which are, if I err not, found together in no other articular affection. But here is a more direct argument. Holding as we did that the arthropathy in question is a trophic lesion consecutive on the disease of the spinal cord, we yet could not think of connecting it with any of the common alterations of progressive locomotor ataxia — with sclerosis of the posterior columns, posterior spinal menin- gitis, or atrophy of the posterior roots of the spinal nerves. On the other hand, a minute examination of many cases had taught us that it was impossible to invoke a lesion of the peripheral nerves. It is in the gray matter of the anterior coruua of the cord that the starting point of this curious complication of the ataxia is to be found according to our belief.^ It is not very rare to find the spinal gray matter affected in locomotor ataxia; but the lesion is then generally found in the posterior cornua. Now, it was quite different in two cases of locomotor ataxia, complicated with arthro- pathy, in which a careful examination of the cord has been made; the anterior cornua were, in both cases, remarkably wasted and deformed, and a certain number of the great nerve-cells, those of the external group especially, had decreased in size, or even dis- appeared altogether without leaving any vestiges. The alteration, besides, showed itself exclusively in the anterior cornu correspond- ing to the side on which the articular lesion was situated {¥\g. 6). It affected the cervical region, in the first case, where the arthro- pathy occupied the shoulder; it was observed, a little above the lumbar region, in the second case which presented an example of arthropathy of the knee. Above and below these points, the gray matter of the anterior cornua appeared to be exempt from alteration. It may be asked whether this alteration of one of the anterior cornua of the cord, which microscopical examination reveals, may ' See Charcot et Joflfroy, " Note sur une lesion de la substance grise de la tnoSUe fipiniere, obseiv6e dans un cas d'artliropathie li6e k lataxie locomotiice progres- sive," 'Archives de Physiologic,' t. iii, p. 30G, 1870. ARTHROPATHIES IN PROGRESSIVE AMYOTROPHY. 83 not be a result of the functional inertia to which the corresponding member has been condemned on account of the articular lesion. This hypothesis must be rejected because, on the one hand, in both of our cases, the members affected by the arthropathies had pre- served to a great degree their freedom of motion ; and, on the other hand, the lesion of the gray matter diPiered essentially here from that which is produced after the amputation of a member, or the section of the nerves supplying it. From what precedes, I hope to have made it appear at least highly probable that the inflammatory process, first developed in the posterior columns, by gradually extending to certain regions of the anterior cornua of the gray matter was able to occasion the development of the articular aaection in our two patients. If the results obtained in these two cases are confirmed by new observa- ai vi%-^^. Fig. 6. — A^ Right anterior cornu. A\ Left anterior cornu. jB, Posterior gray commissure and central canal. (7, Anterior median fissure, a a', Anterior external cell-group, h b', Anterior internal cell-group, c', Right posterior external cell-group. The corresponding left group (cj is almost altogether absent. tions, we should be naturally led to admit that arthritic affections connected with myelitis, and those observed to follow on cerebral softening are likewise due to the invasion of the same regions of the gray matter of the spinal cord. In cases of brain-softening, the descending sclerosis of one of the lateral columns of the cord might be considered as the starting point of the diffusion of inflam- matory work. MM. Patruban,^ Remak,^ and quite recently, Ilerr Rosenthal,^ have observed in progressive muscular atrophy, arthropathies which by their clinical characters are closely allied with those of ataxic patients. This is nothing surprising, if we remember that a pri- » Patruban, * Zeitschrift fur prakt. Heilkunde,' 1862, No. 1. 2 Remak, ' Allgemeine mediz nische central Zeitung,' March, 1853, 20 st. 3 Rosenthal, ' Lehrbuch der Nerveukrankheiten,' p. 571. Wien, 1870. See also Benedikt, * Elektrotherapie,' t. ii, p. 384. 84 VISCERAL ECCHYMOSES. mary or secondary irritative lesion of the nerve-cells of the anterior cornua of the spinal gray matter appears, in the majority of cases, to be the starting-point of the amyotrophy which, in clinical prac- tice, is usually designated by the name of progressive muscular atrophy. For to-day, gentlemen, I shall stop here in this investigation, which I expect to bring to a conclusion at our next conference. LECTURE IV. NUTRITIVE DISORDERS CONSECUTIVE ON LESIONS OF THE BRAIN AND SPINAL CORD (Conclusion). AFFECTIONS OF THE VISCERA. THEO- RETICAL OBSERVATIONS. Sdmmary. — Visceral hypersemia and eechymoses consecutive on experimental lesions of different portions of the enceplialon, and on intra-encephalic hemor- rhage. Experiments of Schiff and Brown-Sequard : personal observations. These lesions seem to depend on vaso-motor paralysis : they should form a separate category. Opinion of Schroeder van der Kolk, relative to the rela- tions alleged to exist between certain lesions of the encephalon and different forms of pneumonia, and pulmonary tuberculization. Hemorrhage of the supra-renal capsules in myelitis. Nephritis and cystitis consecutive on irritative spinal affections of sudden invasion, whether traumatic or sponta- neous. Rapid alteration of the urine under these circumstances ; often remarked contemporaneously with the development of eschars in the sacral region ; its connection with lesions of the urinary passages which are due to direct influence of the nervous system. Theory of the production of nutritive disorders consecutive on lesions of the nervous system. Insufficiency of our present knowledge, with respect to this question. Paralysis of the vaso-motor nerves ; consecutive hyper- semia ; trophic disorders not produced. P^xceptions to the rule. Irritation of the vaso-motor nerves : the consequent ischsemia seems to have no marked influence on local nutrition. Dilator and secretor nerves : researches of Ludwig and Claude Bernard ; analogies between these two orders of nerves. Theoretical application of trophic nerves. Samuel's hypothesis. Exposition. Criticisms. Conclusion. Gentlemen: The reverberation of lesions of the nervous system is not felt only in the peripheral parts, in the skin, bones, and muscles, the viscera themselves may also be influenced by these lesions. It is known that certain alterations of the encephalon, VISCERAL ECCHYMOSES. 85 especially those which affect the optic thalami, the corpus striata, and particularly the different parts of the isthmus, whether caused experimentally, or spontaneously produced, are occasionally fol- lowed by the manifestation of certain visceral lesions. Thus in some experiments made by Professor Schiff' and by Brown-Sdquard^ there frequently supervened in the lungs, stomach, or kidneys, either simple hyperaemia or real ecchymoses, consequent on traumatic irritation of the optic thalami, corpora striata, pons Varolii, and bulbus rachidicus, etc. Again, nothing is more com- mon, as I have shown, than to find in man, in cases of apoplexy symptomatic of cerebral softening, but especially in cases of intra- encephalic hemorrhage in foci, patches of congestion and real ecchymoses on the pleurae, the endocardium, and the mucous mem- brane of the stomach.^ What is the reason of these singular alterations? Professor Schiff does not hesitate to look on them as being simply the effects of the paralysis of the vaso-motor nerves. 1 am very much inclined, for my part, to believe that the patho- genic process is here more complex. Nevertheless, the direct influence, so to speak, of neuro-paralytic hyperaemia on the develop- ment of ecchymoses, in apoplectic patients, seems well established by the following case which T communicated to the Societe de Bio- logie, in 1868. A female in La Salpetriere was struck with apoplexy, followed by hemiplegia of the left side, and succumbed a few days after. The paralyzed members had presented a comparatively consider- able increase of temperature. At the autopsy, we discovered in the right hemisphere a recent hemorrhagic focus, occupying the corpus striatum. The epicranial aponeurosis presented on the left, or hemiplegic side, a wine-red colour, and, here and there, spots of ecchymosis. The abnormal colour and the ecchymoses stopped suddenly at the median line. The right half of the epicranium had preserved its customary pallor: no traces of ecchymosis were to be found. Spots of ecchymosis were observed in the substance of the pleurae, of the endocardium, and of the mucous membrane of the stomach."* However it be, the visceral lesions in question differ by import- ant characteristics from the affections which form the principal object of our studies. Those are congestions and ecchymoses, as we have said; the symptoms of inflammation are never super- added without the intervention of some accessory cause, a thing ' SchiflF, 'Gazette Hebdomadaire,' t. i, p. 428. ' Lezioni di Fiziologia sperimen- tale sul systema uervoso eiicefalieo,' pp. 287, 297, 373. Firenze, 1866. ' Le90us sur la Physiologie de la Digestiou,' t. ii, p. 433. Florence, 1867. 2 'Societe de Biologie,' 1870. 8 'Coraptes Rendus de la Societe de Biologic,' 19 Juiu, 1869. Paris, 1870. * Ibid., annee 1868. Paris, 1869, p. 213. 86 HEMORRHAGE OF SUPRA-RENAL CAPSULES. altogether unnecessary, as you are aware, in cases of common trophic lesions. We have consequently grounds for placing in a separate category, at least temporarily, the congestions and ecchy- moses which make their appearance consecutively on lesions of different parts of the encephalon. Again, some authors, Schroeder van der Kolk amongst others, consider that the different forms of pneumonia, and even of pul- monary tuberculization, which frequently supervene in the course of certain encephalic affections, depend, in such circumstances, on the influence of lesions of the brain and medulla oblongata upon the lungs. But it must be acknowledged that the cases upon which the alleged connection rests are not yet sufficiently convincing.^ S/mial lesions, as well as lesions of the encephalon, may be followed by the production of visceral ecchymoses. It will suffice for me to remind you that if the lumbar cord be wounded with a puncturing instrument, in a guinea-pig, effusion of blood into the supra-renal capsules occasionally follows.^ It seems right to recall this experiment of Brown-Sequard, because human pathology sup- plies us with analogous facts. Quite recently my friend Dr. Bou- chard has told me of a case of acute myelitis, observed in Professor B^hier's wards, and promptly terminating in death. At the autopsy, besides the lesions of partial myelitis, recent hemorrhagic foci were discerned in the substance of the supra-renal capsules. But, I repeat, congestive and ecchymotic lesions appear to form a separate order. On the other hand, the affections of the kidneys and of the bladder, to which I wish now to call your attention, are, by the general bearing of their characteristics, allied to the group of trophic lesions, properly so called. You are aware that nepliritis and cystitis are very common com- ' Scliroeder van der Kolk. " Atrophy of the brain," Sydenham Society, 1861. The author dwells on the fact that, according to the statistics published in his Treatise on the Spinal Cord, all the epileptic patients wliose tongues were bitten, succumbed in consequence of phthisis, pneumonia, or marasmus. He adds that, according to Durand-Fardel, patients attacked by brain-softening almost always die of a pulmonary aflfection, and lie quotes Enpel's statistics which support this view (' Prager Vierteljahrschr.,' vii Jahrg.. Bd. iii). He refers to the experiment, now of old date, in which Schiff believed he saw, in the rabbit, tubercles (?) de- veloped in the upper lobe of the lung after the section of the ganglion of the pneumogastric nerve (' Wunderlich's Archiv,' 6 Jahr., 8 lieft, pp. 769 et seq.), and finally points out that, among the observations collected by Brown-Sequard in his " Recherches sur la Physiologie de la protuberance annulaire" ('Journal de la Physiologie,' t. i), there are a certain number where phthisis and pneu- monia occasioned death. Cruveilhier, Andral, and Piorry had long since noted the predominant part which, according to them, acute pneumonia plays iu the issue of apoplexies determined by cerebral softening or hemorrhage. According to the observations which 1 have collected at La SalpOtribre, lobular or lobar inflammations of the lungs would be less frequent, under the circum- stances, than these physicians seem to believe. 2 Brown-S6quard, " Intluence d'une partie de la moelle 6piniere sur les capsules surr^uales," 'Comptes Reudus de la Sooiete de Biologie,' 1851, t. iii, p. 146. NEPHRO-CYSTITIS. 87 plications of irritative spinal affections, of sudden invasion, whether they be of traumatic origin, or spontaneously developed. It has been long recognized that, after fracture of the vertebral column with consecutive lesion of the spinal cord, the urine fre- quently undergoes rapid alteration. Dupuytren pointed out, as you may recollect, that in such circumstances the catheter left in ihe bladder to guard against retention of urine, became rapidly coated with a calcareous incrustation.^ But it was Brodie espe- cially, who called attention to the characters presented by the urine in the case of persons stricken with traumatic paraplegia.^ On the eighth, on the third, and on the second day, he has observed the urine become alkaline, and exhale a fetid amraoniacal odour, at the moment of emission. Soon afterwards, it contained blood-clots, inuco-pus, deposits of ammoniaco-magnesian phosphates. It would, in fact, be easy to gather from authors a very great number of cases in which the urine-changes, noticed by Brodie, have occurred in the first days following on paraplegia, determined by fracture of the vertebral column.^ At the autopsy, in such cases, more or less ad- vanced lesions of purulent nephro cystitis are found.* But traumatic lesions of this kind are, in general, little suited to illustrate clearly the relations which exist between inflammation of the urinary passages, and alterations of the spinal cord. For it can always be supposed, if strictly considered, that a fall or con- cussion violent enough to produce fracture of the spine, may have determined the vesico-renal lesions by the same shocl<. It is otherwise when we have to deal with an affection, sponta- neously developed in the spinal cord, or with a wound determined in this organ by the blow of some sharp weapon. Now, even in cases of this kind, it is common to find, a short time after the invasion of the paralytic phenomena, a more or less marked modi- fication in the constitution of the urine, connected with nephro- vesical alterations, not unfrequently of a serious character. I shall confine myself to mentioning, by way of example, the following facts. In one case, previously described, of hemi paraplegia caused by a knife stab, the urine became alkaline on the third day, and soon after muco purulent. Death occurred on the thirteenth day. At the autopsy, very evident inflammatory lesions were found in the kidneys, ureters, and bladder.^ In an analogous case, » OUivier (d'Angers), loc. clt., t. i, p. 372. 2 Brodie, ' Medico-Cliirurg. Transaotions,' loc. cit. 3 See Stanley, 1st case. Urine strongly ainmouiacal on the fifth day; 2d case, ammonia 'al urine on the fourth day. ' London Medico- Chi rurg. Trans.' t. xviii, p. 1. Jeffreys : urine ammouiacal and sanguineous, the seventli day (OUivier, d'Angers, loc. cit.:, t. i, p. 322). 4 Molendrinski, " Bruchdes Zvveiten Lendenwirbels," Langenbeck's 'Archiv,' xi Bd., 1869, p. 859. 5 Case of W. Miiller, see ante^ ' Third Lecture,' p. 70. 88 ALTERATIONS OF URINE. reported by M. Brown-Sequard, on the authority of Dr. Maunder,^ the urine was likewise found to be alkaline, a very short time after the accident. Cases of this kind are very interesting inasmuch as they show that a unilateral and very circumscribed lesion of the cord suffices to determine a more or less grave and generalized affection of the urinary passages. Alike in spontaneous acute myelitis, of sudden invasion, and in hsematomyelia, is the appearance of ammoniacal, sanguineous, and muco purulent urine a fact of frequent occurrence, soon after the manifestation of paralytic symptoms. Thus the urine was already greatly altered on the fifth day, in the case of acute myelitis, which we have quoted from Dr. Duckworth;^ on the sixth day, in that given by M. Joft'roy.^ It was ammoniacal the fourth day, in Dr. Gull's patient;"^ sanguineous the third, and purulent the ninth, in a case recorded by Herr Mannkopf.^ In the case of hasmatomyelia, recorded by M. Duriau,^ the urine was ammoniacal and contained blood clots the fourth day; it pre- sented the same character the sixth day and became gradually purulent in a case reported by Ollivier (d'Angers) on the authority of Monod.^ In this instance, there was hemiparaplegia, consecutive on the presence of a hemorrhagic focus occupying a lateral half of the spinal cord. You will find, in the work of M. Rayer, the description of lesions, frequently grave, affecting the kidneys, the renal pelves, and the bladder, to which these changes in the urine should be attributed.^ Many of the observations, just cited, contain an item of informa- tion the importance of which cannot escape your notice. It is mentioned that the urine which until then was normal became, as I have said, ammoniacal, sanguineous, or muco-purulent, at the very time when eschars were being developed on the sacral region, and when the electrical contractility was beginning to grow feeble in the paralyzed muscles.^ 1 ' Jonriial de Physiologie,' t. vi, p. 152, 1863. 2 See ante, 'Third Lecture,' p. 72. s Idem, p. 72. * Idem, p. 72. 6 ' Berliner Klin. Wochenschrift,' t. i, No. 1, 1864. 6 'Third Lecture,' p. 72. ? Ollivier (d'Angers), loc. cit., t. ii, p. 177. 8 Rayer, ' Traite des maladies des reins,' t. i, p. 530 et seq. "According to my observations," Rayer writes, " in the diseases of the spinal cord, when the urine contained in the bladder is alkaline, it is so, not because of a decomposition diflScult to be explained without atmospheric contact, and in a short space of time, but rather by a vice of renal secretion which should be attributed, in most cases, to an injlammatory irritation of these organs.''^ As regards the description of alterations in the urinary passages, consecutive on acute afl'ections of the spinal cord, consult, Kiigelken, loc, cit., p. 12. Mann- kopf, ' Bericht iiber die Veisammlung zu Hannover,' p. 259; and ' Berlin. Klin. Woch.,' t. i. Compare, Rosenstein, ' Nierenkrankheiten,' 2 Ed., p. 287. Berlin, 1870. 8 Ollivier (d'Angers) had already remarked that, in traumatic paraplegia, when the urine alters at an early period the eschars are found to form rapidly iu the sacral region. Loc. cit., t. ii, p. 37. THEORETICAL PORTION". 89 How are we to understand so rapid a development of the inflam- matory lesions of the urinary passages after acute affections, spon- taneous or traumatic, of the spinal cord ? Manifestly, the paralytic retention of the urine cannot here be pleaded, at least not as the sole, nor even as the predominant, pathogenic element. Neither is it possible to attach great weight to the opinion^ which would attribute the urine-changes, in such circumstances, to the intro- duction of unclean catheters, carrying vibriones. In point of fact, the introduction of vibriones into the bladder could only be a chance occurrence, whilst the appearance of ammoniacal, sangui- neous, and purulent urine, in the course of acute myelitis is, like the production of eschars, what may be termed a regular fact. The notorious insufficiency of the pathogenic conditions just enumerated, renders it at least highly probable that there is a direct action of the nervous system engaged in the production of the affection of the urinary passages which we are considering. The cause of this affection, as of the other trophic lesions which often show themselves at the same time, would therefore be the irritation of certain portions of the spinal centre, and more particularly, no doubt, of the gray substance. Theoretical Portion. Gentlemen: In the foregoing series of studies, we have often had occasion to acknowledge that the development of the trophic disorders, ensuing after lesions of the nervous system, is not in general (contrary to a wide spread opinion) the consequence of absence of action of different parts of that system. Far from that, these affections would result, in our view, from the irritation set up, under certain conditions, either in the peripheral nerves or in the nervous centres themselves. Thus, we find ourselves possessing a view, which is of primary importance to the pathologist, and you, without further explanation, can readily divine the practical deduc- tions to which it may guide us. But it must next be ackowledged that this wholly empirical notion marks only the first step taken towards the scientific know- ledge of the phenomena, which observation has allowed us to esta- blish. For, if we know the mode of initial alteration and its seat as well, there remains yet to be determined, in the first place, the means by which this lesion reacts upon the peripheral parts. Evidently his reaction is produced by means of the nerves, but that also, from a theoretical point of view, is an insufficient datum. It is necessary to endeavour to be more precise, and to seek what is the element, in that physiologically complex totality called a nerve, by which the transmission is operated, and also the mechan- ism of this transmission. ' Traube, ' Munk. Berliner Klin. Woohensch.,' p. 19, 1864. 90 VASO-MOTOR THEORY. 1 approach the question jast raised, with an almost absolute certainty of not being able to answer it by rigorous arguments. Perhaps, I should have avoided it, desirous of not wasting your valuable time, if I were not convinced that it behooves us at least to show the inanity of a theory which professes to resolve it, and which to-day enjoys an almost uncontested sway. You are not unaware, gentlemen, of the considerable influence which has been attributed to the vasomotor nerves in the explana- tion of pathological phenomena. I am far from wishing to ignore the fact that a goodly number of these phenomena do, indeed, directly depend either on the dilatation or on the contraction of the smaller vessels, determined by nervous influence. But in so far as the trophic disorders which form the object of our studies are con- cerned, I hope that it will not be difficult to show, from a brief examination, that the vaso-motor theory is altogether insufficient. In order to attain this aim, I am induced to remind you of some of the experimental facts which have unveiled the functions of these centrifugal nerves whose ultimate ramifications go to animate the muscular coat of the smaller vessels. I shall, in the first place, recall the phenomena noticed when these nerves have been paralyzed in consequence of complete section, for instance. Section of the vaso-motor nerves^ has the immediate effect of producing a paralytic dilatation of the vessels to which they are distributed. Hence results a state of hypersemia, termed neuro- paralytic, which has been especially well studied in cases of section of the great sympathetic nerve in the cervical region, but which is to be found with almost identical characters after a great num- ber of lesions of the nervous centres or of the peripheral nerves. The consequences of this hypersemia are, from our point of view, particularly worthy of interest. You know that the part answering to the divided nerve, presents a relative elevation of temperature, which appears solely to result from the afflux of a greater quantity of blood. You know that throughout the whole extent of the hyperaemic territory an exaltation seems also to ensue of all the vital properties of every element and every tissue. At least, the sensitive as well as the motor nerves, and the muscles themselves become more excitable,^ and the latter preserve, longer than is usual after death has occurred, their proper contractility.^ Never- theless, in spite of these new conditions — and this is a point which requires to be set prominently forth — the accomplishment of the intimate acts of nutrition appears to be modified in nothing essen- * For the physiology and pathology of the vaso-motor nerves, consult, Viilpian, "Le9ons sur I'appareil vaso-moteur," reoueillies par C. Carville, Paris, 1875 (Note to the second edition^. 2 Brown-Sequard, * Lectures on Physiology and Pathology,' Philadelphia, 1860, p. 1457. 3 Brown-Sequard, lac. cit. Joseph, in ' Centralhlatt,' 1871, No. 46. NEURO-PAKALYTIC HYPEREMIA. 91 tial. Thus, in the experiments of M. Oilier,^ agreeing in that re- spect with those of M. Claude Bernard, there is not found to supervene, in young animals after section of the great sympathetic in the neck, either an acceleration or an exaggeration in the growth of the parts of the face, even when subjected for months to neuro- paralytic hyperaemia. Nor does it appear that this hypersemia, however intense or prolonged it may be, has ever the effect, save under exceptional circumstances to be hereafter mentioned, of determining by itself the development of inflammatory action. And if the experimenter intervenes and applies agents capable of provoking inflammation, the morbid process determined by this influence goes through its course in the hypersemic parts as if under normal conditions; it offers no special characters, except, indeed, that the injured parts tend to heal with greater promptness. It is true that, in reference to the latter points, M. Schiff pro- fesses a very different opinion. He affirms, in fact, that changes of nutrition originate in the hypersemic parts, in cases of vaso- motor paral3'sis, under the influence of the slightest local mechanical irri- tant,^ and that inflammation here readily takes on a destructive character.^ But upon this subject he is in direct opposition to MM. Snellen, Virchow,* and 0. Weber.^ ■ In a recent experiment, besides, Herr Sinitzin states that after the extirpation of the superior cervical ganglion on one side, the introduction of a slender piece of glass into the cornea of the same side caused merely a very slight inflammatory reaction, sometimes scarcely noticeable; whilst on the opposite side, in the selfsame animal, its introduction caused, on the contrary, a most active inflam- mation with purulent infiltration of the cornea, iritis, panophthal- mia, etc.^ M. Claude Bernard, indeed, long since pointed out that ablation of the superior cervical ganglion appears to retard the manifestation of the nutritive disorders occasionally determined in the eye by section of the fifth pair of nerves,^ and Herr Sinitzin has arrived at the same results in his experiments. From this you may perceive that, contrary to the opinion of Professor Schiff', neuro-paralytic hyperaemia does not create in the parts it occupies, a peculiar predisposition to the production of trophic derangement. It would even seem that these parts are better able to resist the action of disorganizing causes and that any disorder set up there is more speedily repaired than elsewhere. In man, so far as this question is concerned, little difference is to • Oilier, ' Journal de la Physiologie,' t. vi, p. 108. 2 Schiff, * Physiologie de la digestion,' p. 235, t. i. * Lezioui di Fisiologia,' Fireiize, 1866, p. 35. 3 Sohiflf, ' Digestion,' t. ii, p. 423. * Virchow, ' Cell-pathologie,' 4 ed., p. 158. 5 0. Weber, * Ceutralblatt,' 1864, p. 148. 6 Sinitzin, * Centralblatt,' 1871, p. 161. ^ Claude Bernard, 'Systeme Nerveux,' t. ii, p. 65, 1865. 92 NEURO-PARALYTIC HYPEREMIA. be found occurring, from what is observed in animals. At all events, neuro-paralytic hypersemia has been seen to persist for a long period in parts of the body, as for instance in the face, without any nutritive disorder ever supervening. M. Perroud has collected a certain number of cases of this kind, in a memoir read in 1864, before the Medical Society of Lyons. It sufiices indeed, to glance at the numerous works which, of late years, have been published upon Angioneuroses to perceive that nutritive disorders are a rather rare accompaniment of neuro-paralytic hyperasmia. A new argu- ment may, perhaps, be added in support of the thesis which we uphold. It is this: The elevation of temperature, tested by means of a thermometer, is, we have said, a phenomenon indissolubly linked with the existence of partial hypersemias of neuro-paralytic origin. This local hyperthermia should necessarily exist in parts presenting the trophic derangements we have described, if these were really dependent on a neuro-paralytic cause. Now that does not happen, as a general fact. If a marked elevation of tempera- ture has been many times observed in those regions of the body where an eruption of zona, consecutive on neuralgia, or neuritis had developed;^ on the other hand, it may be said that irritative lesions of the peripheral nerves, in the conditions when they usually determine trophic disorders, appear to be accompanied rather by a lowering of the thermal standard than by its elevation. This low- ering has been observed at every period of the nerve-affection ; it has been noted near the commencement,^ still oftener in the ad- vanced stages.^ When spinal lesions are concerned, it is true that occasionally the members subject to trophic troubles, rapid muscu- lar atrophy, bullar eruptions, or eschars, exhibit a more or less marked elevation of temperature.'* But at other times, perhaps ia the majority of instances, this phenomenon is absent; thus it is ab- sent in partial myelitis,^ and in infantile paralysis f — the same rule ' Horner, quoted by 0. Wyss, * Archiv der Heilkunde,' 1871. See note to p. 563. Charcot, ' Neuralgie du nerf cubital. Eruption du Zonasur le trajetduuerf affects ; examen theruiometrique,' These de Mougeot, Paris, 1867, p. 101. 2 Folet, " Cas de Contusion du plexus brachial, observe par M. Lannelougue," 'Etude sur la temperature des parties para!ys6es,' Paris, 1867, p. 7. ' Hutchinson, loc. cit. Earle. " Medico-Chirurg. Trans.," vol. vii, 1816, p. 173. Yellowly, id., t. iii. W. B. Woodman, in 'Sydenham Society's Transactions.' Translation of Wunderlich, * On Temperature in Diseases,' p. 152. S. W. Mitch- ell 'Injuries of Nerves,' Philadelphia, 1872, p. 175. In two oases of nerve-wounds with " glossy skin," the region occupied by the trophic lesion was from one to two degrees warmer than the corresponding region of the healthy limb. But above this point, the thermometer marked one degree lower than on the healthy limb. H. Fischer, " Ueber trophische Storungen nach Nervenverletzungen an den Extremitilten," in ' Berliner Klin. Woohenschr.,' 1871, No. 13. The temperature of the limbs, on which the most varied tropliic disorders occur, is, at first, higher than that of the healthy members, afterwards it is relatively lower ; but tliere are many exceptions to this rule. * Levier, "Cas d'llematomyelie," loc. cit. ^ Mannkoff, loc. cit. s Duohenue (de Boulogne), loc. cit., 3d edition, p. 398. NEURO-PARALYTIC HYPERiEMIA. 93 holds good for cases of slow evolution, such as, for instance, pro- gressive muscular atrophy.^ You observe, from what precedes, that the trophic disorders con- nected with irritative lesions of the nervous centres may, in a con- siderable number of cases at least, occur without that elevation of temperature which should, I repeat, be necessarily present in all cases, if they really originate in hyperaemia, consecutive on para- lysis of the vaso-motor nerves. Hence it follows that nenro-paralytic hyperaemia and the pro- duction of trophic derangement are, in ordinary conditions, phe- nomena independent of each other. But as we suggested, a little ago, there are circumstances in which, contrary to the usual rule, local nutrition may receive a serious blow from the mere fact that the part has been withdrawn from vaso-motor innervation. This happens, as experiments attest, when the whole organism has been subjected to potent debilitating causes. Thus a vigorous animal has long had the great sympathetic nerve divided on one side of the neck ; nevertheless, no injury has been experienced in the parts corresponding to the distribution of the divided nerve. But let the animal fall sick, or be deprived of food, then the scene changes immediately, and we see, says M. Claude Bernard, inflammatory phenomena ensue in that side of the face which corresponds with the experimental section. On that side, even without the inter- vention of any external agent whatever, the conjunctiva and the pituitary membrane rapidly begin to suppurate.^ It is legitimate to suppose that the animals in which Professor Schiff saw trophic lesions supervene, consecutively on neuro-para- lytic hyperaemia, under the influence of the slightest mechanical irritation, had been suffering from the debilitating conditions noticed by M. Claude Bernard. In man, the same concurrence of circum- stances ought necessarily to determine effects analogous to those observed in animals, and we may, indeed, question whether some of our trophic derangements are not really produced in this manner. Such is, perhaps, the case as regards the acute bedsore of apoplectic patients. Here, in fact, the general condition is most unfavourable, and the gluteal eschar occupies precisely that side of the body which on account of the motor paralysis, presents a relative eleva- tion of temperature, evidently connected with vaso-motor hyper- aemia.^ However it be, this pathogenic interpretation can have but a ' Landois uiid Mosler, in 'Berliner Klinisch. Wochenschr.,' 1868, s. 45. For examples of depressed temperature supervening after spinal injury, see J. Hutch- inson : "Temperature, etc., after crushing of the cervical spinal cord," • Lancet,' pp. 713, 747. 1875. (S.) 2 Claude Bernard, ' Physiologie da Systeme Nerveux,' t. ii, p. 535, Paris, 1858 'Medical Times and Gazette,' p. 79, t. ii. 1861. 3 See ayite, Third Lecture, p. 62. 94 IRRITATION OF VASO-MOTOR NERYES. very restricted application, for acate bed-sore arising from lesion of the nervoos centres may appear in many cases, after hemi-lateral lesions of the spinal cord for example,^ on parts of the body where the vaso-motor innervation is not visibly affected and apart from every symptom indicative of great depression of the organism. We have now to inquire whether the irritation of the vasomotor nerves can aocoont for the phenomena which are not explained by the paralysis of the same nerves. Let ns first take experimental irritation. Partial ischaemia, of a more or less intense character, is the most prominent resalt of ihis irritation : it may be carried so far that not even a drop of blood flows on pricking the skin.* The parts, in which vascular spasm thus impedes the circulation, grow pale and cold; their vital activity decreases; the excitability of the muscles and of the nerves fells below the normal standard.^ It is natural to think that grave nutritive lesions, tending to necrobiosis or to sphacelus, should necessarily result from the prolongation of such a state. But it is important to observe that this is commonly a question of a temporary phenomenon, lasting at longest for a few hours only. For by the very fact of the prolongation of the irri- tation the action of the nerve seems to exhaust itself, and hyper- aemia, generally, soon follows on anaemia.* However, by repro- ducing, at short intervals, the irritation of the vaso-motor nerves, it is possible to cause the ischaemic state to predominate for a certain time. Still I do not believe that any trophic lesion would be ever experimentally produced, by this method. Herr O. Weber, who, by means of an ingenious apparatus, says he has kept up, for nearly a week, irritation of the cervical sympathetic nerve, of a permanent character, so to speak, and marked by a thermal de- crease of 2° C, has not seen the slightest trace of nutritive trouble supervening in the corresponding side of the face.* Cases con- nected with human pathology yield the same testimony. Thus it is not rare to find, in certain cases of angvcmeuroses, amongst hys- terical patients for example, a very intense and very persistent partial ischaemia; yet trophic troubles never show themselves, ander such circumstances.* As to the instances of spontaneous gangrene, which have been attributed to vascular spasm, they would not have, to judge from my own observations, the significa- tion assigned them; for, in all cases of this kind which I have happened to meet with, I have found the calibre of the vessel ■ See OMic, p. 72. * Brovn-Seqnard, 'Coarse of Leetnres,' &c., p. 147, Philadelphia. • Bffovn-Seqoard, loc. cit., p. 142. « WaUer, * Proc- Rojal Society, London,* toI. ii, 1860-72, p. 89 et seq. • O. Weber, * Centralblatt,' No. 10, 1864, p. 147. * UigfioiM, * Soeiete de Biologie,* 1859, p. 274. Charcot, in < MoaTement M^i- eal,' Noa. 2», 26, Ire serie ; No. 1, nooireUe serie, 1872. CONSECUTIVE ISCHEMIA — DILATOR NERVES. 95 occluded by an alteration of the arterial walls, or obstructed by a thrombus.^ From the foregoing observations you perceive that it is neither to a paralytic nor to an irritative affection of the vaso-motor nerves, properly so called, that we should attribute the trophic disorders which supervene in consequence of lesions of the nervous system. Physiological experiments, in these latter years, have revealed the existence of centrifugal nervous filaments, the irritation of which has the effect of determining dilatation of the bloodvessels, and consequently hypereemia of the region to which these nerves are distributed. Whilst irritation of the common vaso-motor nerves produces ischaemia, irritation of the dilator nerves determines, on the contrary, a more or less intense hypersemia. The chorda tympani may be considered, at the present moment, as the prototype of dilator nerves. But nerves endowed with similar properties exist in the face,^ in the penis,^ and in the abdomen.* There are probably others in existence also in many parts of the body. We are far from possessing a certain knowledge of the mode of action of these nerves. According to the hypothesis adopted by M. Claude Bernard, this is how we should explain the remarkable afflux of arterial blood which takes place in the submaxillary gland, under the influence of the chorda tympani. In the opinion of that eminent physiologist, the irritation of this nerve is transmitted to the little ganglionic masses which are distributed in great numbers on the intra-glandular extremities of the nerve. These would, in their turn, react by a sort of nervous interference^ on the nerve- filaments of the great sympathetic or vasoconstrictor, and paralyze their action. Tims the chorda tympani, and the same doubtless should be said of all the other dilator nerves, would play the part of a check nerve in relation to the vasomotors. Hence, as you see, the result of the action of the dilator nerves would, according to this theory, be simply vaso-motor paralysis.^ Now, if it be true ' See the Thesis of M. Beiini, ' Recherches sur qnelques points de la gangrene 8pontan6e,' Paris, ]867. Obs. v, xi, xvii. 2 Claude Bernard, 'Revue Scieutifique,' t. ii, 2 serie, 1872. SchiflF, 'Digestion,' i, p. 252. 3 Erector nerves of Eckhardt, * Beitrage zur Anat. und Phys.,' t. ii. Loven, • Bericht der Sachs. Ges.,' 186(J. * Claude Bernard, loc. cit. ^ Claude Bernard, loc. cit., p. 1204. ^ For a clinical illustration in the human subject of the physiological theory, see " Note sur la Paralysie vaso-niotrice generalisee des meuibres superieurs," par le Dr. Sigerson (Publications du ' Progres Medical'), 1874, Adrien Delahaye, Paris ; or Translation by Dr. Barnard Ellis, New York. The following are some of the principal features of this case, to which Dr. Du- chenue (de Boulogne) invited the writer's attention, and which, at tlie request of that eminent physician, was made the subject of a detailed study, from patho logical and physiological stand-points. The extract is taken from Dr. Barnard Ellis's translation : — ^^History. — The patient C — , aged 50, a copper-trimmer by trade, is a man of 96 DILATOR NERVES. that vaso motor paralysis, even when carried very far, as happens for instance in cases of complete section of the vaso-motor nerves, robust constitution, and florid complexion, who has hitherto enjoyed excellent health. He has had neither cough, nor colic, nor any of the symptoms usually assigned to copper-poisoning, whether the heart, the respiratory, or the digestive organs be considered. The hands, which are in an abnormal condition, present no lesion except the cicatrix of an old whitlow on the left forefinger. He came to be treated for impotence, and that, at first, was all he complained of; but other phenomena were soon discovered, some of which were traced back several years. By careful questioning the following facts were elicited. In 1872 he was aware of a weakness in the arms and legs, but most especially in the knees. This sensation, however, neither became localized nor remained constant ; it seemed to flit through all his members. In 1873, he noticed that it predominated in the left knee. This uneasy sensation, which gave no pain, and was transient, seemed to ascend along the leg from tlie calf to the thigh ; and the proof that it was not merely a subjective sensation lies in the fact that the weakness of the leg in- creased so much at times that he was obliged to sit down. He usually recovered, however, in a few minutes, and was able to go about his work as before. No aggravation of his symptoms occurred when he walked cut; on the contrary, the exercise did him good, and after a brisk walk of half an hour he felt a marked sensation of pleasurable ease. This disorder, as we see, was intermittent, showing itself after intervals of comparative health. In January last (1874), however, he was attacked, in a more enduring manner, in both upper and lower extremities, — the feeling of debility being greatest in the left arm and right leg. So much was he enfeebled that, whereas when formerly attacked he could lift a weight of about two or three pounds, he became at this time unable even to keep his forearm flexed on his arm. He preserved, the power of flexion, but not the power of maintaining it, as, in a few seconds, the forearm would fall of its own weight. At this stage, the muscular force of the hands, tested by the dynamometer of Dr. Duchenne (de Boulogne), was equivalent, on an average, to 43 kilogrammes, or 94.6 lbs. The colour of his hands had become a deep red, and this florid flush extended up the forearms, gradually diminishing in intensity. Let us add that, notwith- standing the vascular disturbance, there was nothing that could be referred to the existence of scleroderma, to which there was some superficial resemblance. The patient complained of great heat in the hands and forearms, and this in- crease of temperature was plainly perceptible to all who touched them ; and it is a very remarkable fact that their sensibility was so greatly augmented, that everything he touched — instruments, wood, or paper — appeared to him as cold as ice. He was troubled with formication in the forearms, which increased to a painful degree when he rubbed his hands together as when washing them. Heat aggravated and cold diminished the pain, — facts of which he liad become aware on using cold and warm water. As to the inferior extremities, they presented difi'erent phenomena. There was, indeed, debility, as has been remarked, but the symptoms of the disease seem to have decussated. Whilst the left arm was the weaker, the right leg was the more feeble. Instead of the hypeisesthesia which we observed in the hands, there was a notable loss of sensibility in the right foot, so that he did not feel the giound when walking. This foot seemed to him asleep or benumbed. There was, at times, slight formication in the right leg, but very little in the left. Nor was there a hypothermal condition here, as in the upper extremities. Although the temperature of the soles of liis feet seemed normal to himself, during the daytime, it had been remarked that, when he was lying down and during the night, they were ice-cold to the touch. In the lumbar region, he had experienced an intense itchiness, as if he had been beaten with nettles. This unpleasant sensation was not constant, and had only appeared five or six times in all, and then only in the morning and at night, when lie was dressing or undressing and exposed to the cold air — phenomena occasionally present in the case of persons sutferiug from urticaria. There were SECRETOR NERVES: LUDWIG's RESEARCHES. 97 is not a cause of trophic disorders, the same rule must plainly hold good as regards the paralysis produced under the influence of the dilator nerves. But, gentlemen, as you will see further on, the mode of action of the dilator nerves may be considered from an altogether different point of view. I would remind you of the fundamental experiments of Ludwig, relative to the influence of certain nerves on the secretion of the submaxillary gland.^ Notwithstanding the criticisms which have assailed the conclusions drawn from his experiments by this cele- brated physiologist, these conclusions do not appear to have been shaken. I have to request your permission to enter into some details in reference to this subject; they are absolutely necessary for the object we have in view. When you irritate the peripheral end of the nerve proceeding to the submaxillary gland — a nerve supplied as we now know from the chorda tympani — the following phenomena are observed. A very abundant secretion of saliva is produced, the quantity may be so large that, in a short space of time, the volume of saliva secreted shall greatly exceed the volum.e of the gland itself. This fact demonstrates at the outset that we have not to deal here with a simple phenomenon of excretion, or expulsion of previously secreted saliva. According to the views of Stilling and of Henle, which pre- vailed at the time Ludwig published his first investigations, one might be tempted to explain the phenomena in question by admit- ting that the irritated glandular nerve acts upon the veins of the gland, causing them to contract. The augmentation of the tension of the blood, consequent on the venous contraction, would, by this hypothesis, be the cause of the augmentation of the salivary secre- tion. But Ludwig has shown that ligature of the veins, without concomitant irritation of the glandular nerve, does not increase the no wheals perceptible. It is highly interesting to note that when this urtication made its appearance in the loins, the formication disappeared from the upper extremities. As tliere was reason to suspect the existence of ocular troubles, we interro- gated his memory, and found that he had observed something like a mist before his eyes, especially at night. This disorder had, in fact, reached such a point in January, 1874, tbat he had given up attempting to read. On the left eyeball, a harmless pterygium was remarke Frey ' Hatidbuch der Histologie,' etc., 2e edit., p. 354; Leipzig, Suliulte, ' De Retiiue Structure,' 1867, p. 22 ; KoUiker, 'Gnweblehre,' 5e edit., 18(J7, t. iv, p. 257. 2 Vulpian, ' Lecjons sur la Pliysiologie,' etc., p. 316. 3 See Vulpian, ' LeQons de Pliysiologie,' pp. 237 and 298; Riudfleisch, * Lehr- buch der Patliologisch Gewebelehre,' pp. 10 et 20, 186G. PATHOLOGICAL HISTOLOGY. 145 hand, to proteine molecules, and, on the other, to corpuscles which at first preserve the appearance of myeline, but which, in conse- quence of ulterior modifications, soon present all the characters of fatty granulations.^ Fig. 12. — Patch of sclerosis in the fresh state : a, lymphatic sheath of a vessel distended by volnminous fatty globules ; h, a vessel divided transversely. Tlie adventitious coat is separated from the lymphatic sheath by a free space, the fatty globules which distended the sheath haviijg je Dr — , is frequently seized with causeless fits of laughter, which pile caniiot control. Having been subject, before tbe invasion of the disease, to fits of anger, she has noticed, with regret, that they have increased sime that period. (H.) On the other hand, one of two patients, whose oases I had an opportunity of .'•tudying, in Profe sor Behier's wards in the Hotel Dieu, did not exhibit any marked intellectual disorder, although she hfd been many years in liospital. The second patient, whose symptoms were more advanced, >eemed to wake from a dream, when spoken to, then, trying vainly to fix his gaze on the speaker, he answered intelligently, but the (gradually increasing) difficulty of enunciation made conversation painful. (Sigerson.) 2 " Ueher multiple inselformige Sklerose des Gehirns und Riickenmarks' (' Deutsch. Archiv,' 8 Bd., 1 heft, Leipzig, 1870, p. 14). 3 One of the patients, Aspasie B — , observed by M. Liouville, in M. Vulpian's wards, had liallucinations ; Rosine Spitale, whose history we have abridged (Bourneville et Gu6rard, he. c/<.,p. 92 from M. Valentiner, fell into stupor some months before the fatal termination of the disease. (B.J PARESIS OF THE EXTREMITIES. 161 her. During twenty days she refused all kinds of noarishment, and we were forced, during the whole of that time, to administer food by means of the stomach pump. To-day, these "accidents have almost entirely vanished. Nevertheless, the voices are still heard from time to time. You see the patient has been taken, during our examination, with convulsive laughter which she can- not moderate, and which will soon be followed by a shower of tears. IV. In order to conclude the descriptive study of the case which I have presented you, gentlemen, as a type of multilocular sclerosis of the nervous centres, it only remains for me to direct your atten- tion to the state of the lower extremities. You have seen that Mademoiselle V — cannot rise from her seat, stand erect, or attempt to walk, if she be not strongly supported by two assistants. It is easy to note that the cause of this motor impotence is, principally, a pseudo-tetanic rigidity which has seized on the lower extremities, and which, though very marked when the patient is j seated or reclining, becomes exaggerated to the highest degree when she attempts to rise or walk. This contracture of the lower limbs, at present permanent, only manifested itself quite recently in the case of Mademoiselle V — ; it is, in fact, a symptom of the advanced stages of the disease. In the evolution of the morbid process it is always preceded at a con- siderable distance by a paretic state^ presenting some peculiar fea- tures, with which I will first endeavour to make you acquainted. In reference to this particular point the clinical history of Mademoiselle V — has been traversed by certain incidents which, without being exactly exceptional, still do not constitute the rule. Consequently I am forced to put it aside for the moment, reserv- ing the right of soon returning to it. In the following description I will draw upon details recorded in a certain number of cases which I have collected, and in which the paretic period was de veloped in accordance with the normal conditions. Paresis of the limbs. — We have here a more or less marked de- cline of the motor power of the limbs, which is frequently mani- fested at the very outset of the disease, and which is not usually connected with any notable disturbance of sensibility. , Generally one of the lower limbs is first and solely affected. It feels heavy and difficult to move; the foot turns at the least ob- stacle in walking, or the whole limb suddenly gives way under the weight of the body. The other limb is seized, sooner or later, in its turn; however, as the paresis advances with extreme slow- ness, the patients are still able, for yet a long while, to walk about with more or less ease and to attend to their occupations, but at 11 162 UNUSUAL SYMPTOMS. last the day comes when, owing to an aggravation of the motor' paralysis, they may be confined to bed. The upper extremities are themselves invaded, either simultaneously or one after the other, usually at a period far removed from the invasion of the dis- ease. Frequently in the commencement there are remissions; thus, it is not rare to see the enfeebled lower limbs resume, for a time, their original energy. Such remissions may even occasion- ally t^ke place two or three times. I point out this peculiarity to your notice because it certainly is not found, to the same extent, in other chronic diseases of the spinal cord. I should revert for a moment, in order to lay stress on the fact, already noticed, of the absence of disorders of sensibility. The patients do, indeed, sometimes complain of formications, and of a feeling of numbness occupying the enfeebled limb; but these symptoms are usually transient and but little marked. Besides, it is easy to ascertain that cutaneous sensibility, in the affected mem- bers, is almost alwa3^s preserved, in all its modes. The girdling pains, the fulgurant crises, which play so prominent a part in the early stages of progressive locomotor ataxy, are absent here. It is the same thing with respect to that loss of the sense of position of parts, which also belongs to ataxia. This does not occur in regular multilocular sclerosis, and patients affected by the latter disease can, with closed eyes, determine with exactness the position which has been given to their limbs. Nor has the closure of the eyes any marked influence on the power of the patient to hold himself erect, or on his manner of walking. His gait is uncertain, embar- rassed, titubating, on account both of muscular weakness and of the tremor which, sooner or later, is superadded; the feet, held apart in order to enlarge the basis of support,drag awkwardly over the ground, from which it is hard to raise them. When titubation is very much marked the patients threaten to fall at every step, and they do, in fact, frequently come to the ground. The lower extremities are not flung forward, in an abrupt manner and con- vulsively, as we so commonly see them in sclerosis of the posterior columns. The sphincters are very rarely affected by the weakness which invades the muscles of the limbs, and this contrasts with what occurs in many spinal affections, where you see, at a very early stagf», vesicular and rectal troubles superadded to the other symptoms. Finally, to complete the picture, we should lay stress on the habitual absence of trophic disorders of the muscles in the paraplegia connected with multilocular sclerosis. The enfeebled muscles preserve almost to the last their prominence and firmness; tested by faradaic exploration they do not present, at any stage, traces of notable enfeeblemeat of electric contractility. Intermixture of unusual symptoms, — I made mention, as we pro- ceeded, of a certain number of symptoms which I took care to ATAXIC SYMPTOMS. 163 eliminate, because they do not belong to the regular type of the disease. It is necessary to inform you now, by way of corrective, that these symptoms do intermingle, in certain cases, with ihe or- dinary phenomena of multilocular sclerosis, and even become so very prominent that an observer, if not forewarned on the subject, would perhaps be almost necessarily mistaken. Under this aspect, the record of Mademoiselle Y — may furnish us with valuable in- formation. I extract, therefore, some details from it, dated March 24, 1867, that is to say, over three years ago. At that period, when, indeed, the paresis and tremor were so far advanced in the lower limbs as to make it impossible for the patient to walk, ex- cept by the help of two assistants, the following symptoms were noted: Whilst walking, the feet are slightly thrown forward, "as with ataxic patients." When the eyes are closed there is " exag- geration of the titubation, loss of -equilibrium, and the patient would certainly fall if not strongly upheld by two assistants." In the lower limbs "tactual sensibility has diminished in a marked manner. The patient, with closed eyes, cannot tell what position has been given to her limbs. She experiences in them, from time to time, violent paroxysms of fulgurant pains." Finally, the ex- istence of a girdling pain has been noted. You have recognized, in this enumeration, nearly the whole series of phenomena which serve clinically to characterize progres- sive locomotor ataxy. Some of them are to be found present to- day in our patient, but they appear, generally speaking, in a very attenuated form, or relegated to the background. Do we mean to say that, even at the time when they seemed to predominate, they were of a nature seriously to embarrass the diagnosis? No, de- cidedly not, and 1 am convinced that, in all cases of the kind, you could avoid deception by bearing in mind the following observa- tions: — The very fact of paresis of the lower limbs (which does not exist in posterior sclerosis, or which, at all events, only shows itself at an advanced stage) being found mixed up with the ataxic symp- toms, should put you on the true path. If it have preceded them the case is still clearer. You will also certainly have to chronicle the coexistence of some of the symptoms which belong only to multilocular induration, namely — tremor of the extremities, im- peded enunciation, vertigo, nystagmus, etc. It is necessary, be- sides, to clearly understand the reason why ataxic symptoms are sometimes manifested in the course of multilocular induration, as I announced above. There is here in my opinion, no question of a combination of the elementary forms of two diseases — progres- sive locomotor ataxia and cerebro-spinal disseminated sclerosis. As for myself, I have never, in a post mortem examination, met with the coexistence of multilocular gray induration and posterior' />f5- ciculated sclerosis : and, without denying that such an association 164 AMYOTROPHY. could exist, I believe it to be at least infinitely rare. It is, on the contrary, common enough for the sclerosed patches (which, as a rule, principally occupy the antero-lateral columns) to cross the postero lateral fissures and encroach on the posterior columns. Occasionally even, I have seen them, when they were confluent, involve a large portion of the substance of these columns through- out the whole extent of one of the regions of the cord, the lumbar region for instance. Now, in all cases of this kind, ataxic symp- toms were manifested to different degrees of intensity during life. I have no doubt but that a similar arrangement will one day be found to account for the fulgurant pains, the motor incoordination, and, in a word, for all the phenomena of the same order which are stated in the record of Mademoiselle V — } Unusual symptoms of another kind may also be superadded to the regular symptoms of muUilocular sclerosis. In several cases, which were otherwise well characterized, I have seen an atrophy of certain muscles, or groups of muscles, supervene, which recalled, both by its position and its mode of invasion, progressive muscular atrophy. I have twice had the opportunity of ascertaining the anatomical cause of this new complication ; in both cases the irrita- tive process, of which the sclerosed foci are the seat, had, in certain regions of the cord, extended to the nerve cells of the anterior cornua of the gray matter, and these cells had, in consequence, un- dergone great alterations. Now, according to the researches which I have detailed to you, it is but little doubtful that progressive ' Cases of disseminated sclerosis, in which the posterior columns were involved so as to occasion some of the symptoms of locomotor ataxy, are numerous enough. We may mention, first, the case of Paget, recorded by Craveilhier in his ' Atlas ;' then the three cases which were related at length in our memoir. The first is that of the woman Broisat (disseminated sclerosis, principally occupying the posterior columns), wlio succumbed in M. Charcot's wards ; the two others, which were perhaps more characteristic, inasmuch as the symptoms and lesions of loco- motor ataxia were more prominent, were quoted from Friedreich. Finally, we will briefly summarize another case, whicli we noted during the siege, in M. Mai'rotte's wards : Josephine Leg — , aged forty-six years, a silk-winder, has been suffering for two years. She presented the following ataxic symptoms — difficulty of walking with closed eyes ; notion of position, with respect to lower limbs, greatly lost ; frequent fulgurant pains in the knees and legs: girdle pains. But, along with those .symptoms, these were noted, i. e., considerable paralytic enfeeblement of the lower limbs ; preservation of the diflferent modes of sensibility in the upper and lower extremities ; visual integrity. This woman succumbed to pyelo-oystitis, complicated with sacral eschais. Autopsi/ : — Sclerosed patches on the left external motor oculi and on the optic nerves; sclerosed patches on the pons Varolii, the right superior crus cerebelli, etc. ; sclerosed patches on the surface of the lateral ventricles, in the interior of the centrum ovale, on tlie anterior face of the bulbua rachidicus, and in the fourth ventricle. In the spinal cord we found, 1st, a sclerosed patch, four inches long, occupying the left posterior column ; 2(1, another of less length and breadth on tlie right posterior column ; 3d, beneath it, another rather circumscribed patch occupying both posterior columns ; and 4th, on the antero-lateral surfaces of the cord, many small patches of sclerosis. (B.) CONTRACTURE OF EXTREMITIES. 165 amyotrophy, whether protopathic or consecutive, most frequently arises from an irritative lesion of the great nerve-cells, termed motor cells. ^ Permanent contracture of the limbs. Spinal epilepsy. — It is time now to revert to the contracture noticeable in the lower extremi- ties of the patient V — , which, at present, constitutes a permanent phenomenon that you may study as a most perfect type. This, gentlemen, is an habitual symptom of the advanced phases of mul- tilocular sclerosis. It does not follow on paresis, suddenly and without transition. At a certain stage of the paretic period there supervene, either spontaneously or under the influence of certain excitations, paroxysmal phenomena, during which the lower ex- tremities are stiffened in extension, whilst, at the same time, they are drawn together, and, as it were, adhere to each other. These fits, which last for some hours, and occasionally for some days, are at first separated by intervals of greater or less length. Later on they become closer, and, at a given moment, permanent contracture is definitely established. When matters have reached this point, the following symptoms are observed — the lower extremities, as happened during the fits, are in extension ; the thighs are extended on the pelvis, the legs on the thighs; the feet assume the attitude presented in talipes equinus (varus); the knees, moreover, are so closely drawn together that you cannot separate them without great effort. Both lower limbs are very generally affected simul- taneously, and to the same extent; their rigidity is sometimes so marked that, in lifting one of them, whilst the patient is in bed, you, at the same time, lift the lower half of the body, all in one piece, as it were. Only in rare cases, and in the later stages of the diseases, does flexion of the thigh and leg predominate over ex- tension. Permanent contracture may invade, in exceptional cases how- ever, the upper extremities, which are also generally placed in forced extension and straitly applied to each side of the body. We ' Erbstein (' Deutsches Archiv fiir Klinische Medicin,' t. x, faso. 6, p. 595) has related the history of a patient who succumbed to disseminated sclerosis (the bulbo-spinal form), in whom, during life, atrophy o( the anterior portion of the tongue had been observed. An histological examination afterwards showed — 1st, numerous foci of de^^eneration, not only interposed between the fasciculi of the liypoglossal nerve at its origin, but also involving them and consequently inter- rupting their continuity. A section showed that the nucleus of the hypoglossal nerve was replaced by an islet of sclerosed tissue. 2d. The muscular fibres of the anterior portion of the tongue had undergone fatty degeneration ; the lesion had invaded some of the muscular fasciculi at the base of the organ. In a patient named Vincent, who succumbed to disseminated sclerosis, M. Charcot noticed atrophy of the muscles of the thenar eminence. The palm of the hand was hollowed out, and the tendons of the flexor muscles were very plainly defined. (B.) 166 SPINAL EPILEPSY. have here, gentlemen, to deal with a spasm which occapies simul- taneously and with almost equal strength the antagonistic muscles, for, when the limbs are flexed, it is almost as difficult to extend them as it is to bend them when they are extended. When the extremity of one of the feet is grasped by the hand, and somewhat abruptly extended on the leg, there ensues almost immediately throughout the whole extent of the corresponding limb a sort of convulsive trembling, which recalls the tremulatiou determined by strychnine poisoning. This tremulation, which must not be confounded with the peculiar shake that supervenes on purposed movements,, is not always limited to the limb in ques- tion; it is sometimes propagated to the other limb, and then the agitation may occasionally become so intense as to shake the whole body, and even the bed on which the patient reclines. It persists in some cases for several minutes, and even much longer, after ces- sation of the act which set it going. You may cause it to stop at once, as M. Brown-Sequard has shown, and as I have often since .observed, by grasping, with the hand, one of the great toes of the patient and flexing it suddenly and forcibly. Immediately after this operation the tetanic rigidity and convulsive trembling cease in both members, which become temporarily " perfectly supple and pliable as after death, before rigor mortis supervenes."^ The con- vulsive tremulation may be determined by faradization, by pinch- ing the skin of the leg, or, more rarely, by kneading the limb, by the influence of cold, or by tickling the sole of the foot. It also comes on sometimes spontaneously, or at least apparently so, some- times because of an effort made by the patient, as in vomiting, defecation, raising himself in bed, or getting out and placing his foot upon the floor. It is also provoked by an attempt to walk, for permanent rigidity does not always absolutely prohibit this act; the patients can sometimes hobble along on their toes, the heel being raised from the floor. Finally, this tremulation may also be temporarily produced, along with rigidity, even during the course of the paretic period, under the influence of one or other of the several modes of excitation which we have just reviewed. Gentlemen, the phenomenon, whose principal characters I have here sketched, is nothing other than the spinal epilepsy described by M. Brown-S^quard. We observe it present in the case of Mademoiselle Y — in what I have proposed to call the tonic form. This form, which is the type most commonly met with in gray multilocular induration, may be placed in opposition to the salta- tory form, which predominates, on the contrary, in progressive locomotor ataxia and in some other spinal affections. Permanent contracture of the limbs and spinal epilepsy must not any longer detain us. These symptoms, in fact, do not exclusively 1 Brown-S^quard, 'Archives de Physiologie,' t. i, p. 158. APOPLECTIFORM SEIZURES. 167 belong to multilocular sclerosis of the nervous centres. Far fronci it. They shall, therefqre, be studied apart, both generally and in their relations with the different affections of the spinal cord in which they show themselves. LECTURE VIII. APOPLECTIFORM SEIZURES IN DISSEMINATED SCLEROSIS. PERIODS AND FORMS. PATHOLOGICAL PHYSIOLOGY. ETIOLOGY. TREATMENT. Summary. — Apoplectiform seizures. Their frequency in disseminated sclerosis. General considerations on apoplectiform attacks in general paralysis, and in cases of circumscribed cerebral lesions of old standing (hemorrhage and ramollissement). Pathogeny of apoplectiform seizures ; insufficiency of the congestion theory. Symptoms: state of the pulse ; elevation of the central temperature. Apoplectiform seizures in old cases of hemiplegia. Import- ance of temperature in diagnosis. Periods in disseminated sclerosis. First, second, and third periods. Symptoms of bulbar paralysis. Forms and duration of disseminated scle- rosis. Pathological physiology : relation between symptoms and lesions. Etiology. Influence of sex and age. Hereditary predisposition. Previous nervous aflfections. Occasional causes : prolonged action of moist cold ; traumatism ; moral causes. Prognosis. Treatment. Gentlemen: I purpose calling your attention to-day, in the first place, to certain cerebral accidents which may happen to com- plicate the symptomatology of cerebro-spinal disseminated scle- rosis. I refer to apoplectiform seizures^ which are occasionally encountered several times in the course of the disease, and which sometimes close the fatal scene. These attacks have not hitherto appeared in the case of Mademoiselle V — , whose clinical record is otherwise so complete inmost respects; but nothing assures us that they will not some day show themselves. In fact, this is not a rare complication; I find it mentioned in about a fifth of the cases which I have collected, and I have personally observed it in at least three instances.^ I Case III of the memoir of M. Vulpian, communicated by M. Charcot. Case of the patient Byr (Charcot) ; case of Nicolas, presented to the Sooiete de Biologie, by M. Joffroy. 163 APOPLECTIFORM SEIZURES. The group of symptoms, which constitutes an apoplectiform seizure, does not exclusively belong to rnuUilocular sclerosis. It is found in a number of affections which involve several points of the cerebro-spinal axis at once, and particularly in progressive general paralysis. It is, indeed, in the latter disease that these congestive attacks — as they are commonly called, at least in France — have been specially studied on account of their frequency. They are met with there in all the various forms which they assume. The description of such attacks, in progressive general paralysis, has given rise to numerous divisions and subdivisions. But, in point of fact, all the varieties of form which clinical observation has revealed — I mean the graver kinds — may be classed as belong- ing to two fundamental types, namely: — 1st. Apoplectiform attacks (the "pseudo-apoplexy" of British au- thors), and 2d. Epileptiform^ or convulsive attacks. The characteristics of both types may, however, be inter- mingled and confounded in the same paroxysm. The first type only has been, up to the present, met with in disseminated scle- rosis; but it cannot be doubted that, when observations relating to this disease shall have accumulated, they will enable us to fill up the picture. Among the other organic diseases of the nervous centres in which apoplectiform or epileptiform attacks are frequently observed, I shall confine myself to certain circumscribed cerebral lesions of old standing, and accompanied by permanent hemiplegia. Such are cerebral hemorrhage and brain- softening when occupying regions of the encephalon, the lesion of which has the effect of almost cer- tainly determining the cerebro-spinal alterations known under the name of descending fasciculated scleroses. Between these partial lesions of the brain and progressive gene- ral paralysis it seems, at first glance, that no point of contact exists. However, gentlemen, here is a character which brings them together: the observations of M. Magnan and those of Herr West- phal have shown that, in general paralysis, there is very often superadded to the lesions of periencephalitis a sclerous alteration, sometimes diffuse and sometimes fasciculated, which occupies the crura-cerebri, pons Varolii, medulla oblongata, and certain regions of the spinal cord, at the same time. Now, these cerebrospinal lesions (as much on account of their mode of distribution as be- cause of the peculiar nature of the morbid process) deserve to be assimilated to the descending fasciculated scleroses consecutive on hemorrhage or softening of the brain. We know, on the other hand, that, in multilocular sclerosis, the sclerosed patches occupy not only the spinal cord and the brain proper, but are likewise very commonly found in different parts of the isthmus cerebri, APOPLECTIFORM SEIZURES. 169 and particularly in the bulbous rachidicus. You see, by this, that the existence of irritative lesion-?, disseminated nearly everywhere in the cerebrospinal axis, but always present in the isthmus cere- bri, is a chiiracter common to all those affections, so different in appearance, in which the so-called congestive attacks supervene. I would especially point out to your attention the constant existence of the bulbar lesion, which is, in all probability, a predominant element in the production of these attacks. However this may be, gentlemen, we have here permanent altera- tions of slowly progressive evolution. They cannot, consequently, without the assistance of other lesions, explain the development of accidents which are, for the most part, suddenly produced, and which may rapidly disappear without leaving any trace. I am not un- aware that many physicians, even at the present day, put forward the theory of a partial sanguine congestion — a fluxion which, ac- cording to the needs of the case, should affect this or that portion of the encephalon. As regards myself, I cannot endorse this hypo- thesis. In order to justify my scepticism in this matter, I will appeal to the reminiscences of those among you who, in this hos- pital, were attached to the department for the insane. How many times have they not been disappointed in not finding, on post- mortem examination, the congestive lesion, which they expected? But I shall appeal, above all, to the cases which I have had oppor- tunities of collecting in my accustomed field of study. Many a time have I had occasion to see patients, long suffering from hemi- plegia, the result of brain-softening or intracephalic hemorrhage, succumb to epileptiform or to apoplectiform attacks. Now, in such cases, no matter what attention I gave to the autopsy, I have ever found it impossible to discover, whether in the nervous centres or in the viscera, any recent congestive lesion, oedematous or other, which could explain the grave symptoms that had characterized the fatal termination of the disease. I have never met with any but. old lesions — ochreous foci, yellow patches, or foci of cellular infiltration — on which depended the hemiplegia, and the secondary degenerations of the mesocephalon and of the cord, which are the consequences of these partial lesions of the cerebral hemispheres. In short, I believe that, in the present state of science, the absence of proper lesions is, anatomically speaking, a common characteristic of these attacks, whatever be the form they assun\e or the disease with which they are connected. In what relates to the symptomatology of the apoplectiform and epileptiform attacks, in order not to enter upon the details of a regular description, I shall confine myself to mentioning the fol- lowing peculiarities. The scene generally opens unexpectedly, without any marked preliminaries, sometimes by rapid and more or less intense obnubilation of the intellectual faculties, sometimes by profound co.na, suddenly supervening. In certain cases con- 170 APOPLECTIFORM SEIZURES. vulsions are added, which recall those of ordinary epilepsy, but which are usually localized in one side of the body (epileptifonn attacks). In other instances there are no QonY\i\s\o\\?> {apoplectiform attacks). In both cases it is frequent to find, developed from the outset, a more or less complete hemiplegia, sometimes with fiac- cidity, sometimes, but more rarely, with rigidity of the paralyzed members. The symptoms may gradually grow worse in the course of a few days and induce death. This is usually heralded by the rapid development of eschars on the sacral region. If, on the other hand, the patient is destined to survive, the* disappearance of the symptoms soon becomes manifest, hemiplegia is the only one that holds out for some time, but sooner or later it also dissipates without leaving any trace of its existence. These attacks usually recur several times, generally after long intervals, during the course of the disease. So far as disseminated sclerosis is concerned, they have been noticed thrice in Case III of M. Vulpian's memoir, thrice in Zenker's case/ and up to seven times in that recorded by M. L^o^ In every instance, these fits left after them a notable and persistent aggravation of all the symptoms of the original disease. The sketch which I have given you, gentlemen, would be too imperfect if I did not call your attention to the troubles of circu- lation and temperature which, as a general rule, show themselves in the course of these attacks. The pulse is always more or less accelerated; but, besides (and this is the important point), the temperature of the central parts rises rapidly; it may, in the hours immediately following the invasion, reach 38.5° 0. (= 101.3° F.), or even 39° (= 102.2° F.),, and frequently, at the end of twelve or twenty-four hours, it rises to 40° (= 104° F.), and remains at this elevation for some hours, without necessarily entailing a fatal re- sult. But if the patient is to survive, the temperature soon di- minishes rapidly. An increase above 40° 0. is ^almost always followed by a fatal termination. These modifications of central temperature have been studied by Herr Westphal in the epileptiform and apoplectiform attacks of progressive general paralysis ; I have met with them again in the attacks which supervene in patients suffering from hemiplegia of old standing^ consecutive on hemorrhage or on softening of the brain. In order the better to settle your ideas upon this subject I think it will be useful to summarize the details of two cases relating to the last-named species. The first case is that of a woman, aged thirty-tvvo years, affected by hemiplegia of the right side, dating from childhood. There existed general atrophy, rigidity, with shortening of the limbs, ' Bourneville et GaSrard, loc. cit., p. 112. ( 2 Jijid., p. 112. THERMOMETRIC RESULTS. 171 and paralysis, such as are generally found in like cases. This woman was subject to epileptiform attacks. She was brought to the infirmary some hours after a more than usually severe attack. On the evening of her admission her temperature was above 38° C. (=100.4° F.); next day it had reached 4° C. (=104° F.). The fits became subintrant ; they were repeated about a hundred times a day. Eschars formed rapidly on the sacral region, and death supervened the sixth day. On that day the rectal temperature stood at 42.4° C. (=108.32° F.). On post-mortem examination there was found, at the surface of the left cerebral hemisphere, a considerable depression answering to a yellow patch, the remnant of a vast focus of ramollissement. The whole hemisphere, more- over, was atrophied. No trace of a recent lesion could be found, neither in the nervous centres nor in the viscera. The second case is that of a woman, aged sixty years, afflicted with right hemiplegia consecutive on cerebral hemorrhage, dating from two years previously. This patient had already experienced several epileptiform or apoplectiform attacks, which, however, were generally slight. One day an intense and prolonged epileptiform attack supervened, which was followed by an apoplectiform con- dition. Two hours after the setting in of these accidents, the rectal temperature was 38.8° C. ( = 101.84° F.); five hours later, it rose to 40° C. (=104° F.). Next day, in spite of the cessation of convulsions, the temperature was 41° (—105.8° F.); and the day following, being the day of her death, it reached 42.5 C. (=108.5° F.). The autopsy showed two ochreous foci, one occupying the corpus striatum, the other the substance of a convolution. There existed no recent lesion capable of explaining the accidents which had determined death. I have as yet had no opportunity of following, day by day and at different periods of the day, the changes of central temperature in a case of apoplectiform seizure supervening in a patient affected with disseminated sclerosis. Nevertheless, we can gather partial results from different cases, which leave no doubt that, even in this respect, matters proceed exactly in the same way in multi- locular sclerosis, as in progressive general paralysis and in circum- scribed lesions of the cerebral hemispheres. Thus, the patient whose history has been related by Ilerr Zenker was, towards the close of his life, taken with an apoplectiform attack, followed by hemiplegia of the right side. Now, on the day of the seizure, his pulse being at 136, the temperature reached 39.6° C. (=103.28° F.). Next day, the thermometer marked 40° C. (=104° F.). The day after, the paralysis had ameliorated and the temperature had fallen back to the physiological figure. In the case of the patient Nolle, narrated by M. Leo, an apoplectiform attack came on in the even- ing. Next morning early, the pulse numbered 144, and the tem- perature stood at 38.5° C. (=101.3° F.). This attack, the seventh 172 DISSEMINATED SCLEROSIS — PERIODS. that the patient had experienced, was followed on the same night by death. In the case of N — , whose record was compiled in my wards by M. Joffroy, five hours merely after the invasion of an apoplectiform attack, with incomplete loss of consciousness and general resolution of the members, the rectal temperature stood at 40.8° C. (=104.64° F.), and the pulse at 120. Next day the apoplectiform symptoms were dissipated, and at the same time the pulse and the temperature had returned to what they were in the normal state.^ If I have dwelt with some tenacity on the changes which the temperature of the body presents,.in the apoplectiform and epilep- tiform seizures of general paralysis, and of some other cerebrospi- nal affections, it is because, in my judgment, we find a characteristic therein which may, in certain cases, be pi^ofitably used in diagnosis. It is not necessary, I think, to enter into a long discussion in or- der to show how difficult it is, in presence of a patient who has just been stricken with apoplexy, accompanied or not by convul- sions, to decide from the mere contemplation of external symptoms whether we have to deal with true a'poplexy^ resulting from the actual formation of a focus of cerebral hemorrhage or of ramollisse- ment, or whether, on the contrary, we have before us a simple congestive attack. Well, an examination of the central temperature would supply, in such cases a decisive test. I have, in fact, demon- strated by repeated observations^ that in true apoplexy, especially when it depends upon cerebral hemorrhage, the temperature con- stantly diminishes, some moments after the attack, and afterwards remains, generally for at least twenty-four hours, below the nor- mal standard, even when intense and reiterated convulsive fits occur. Now, we have just seen that, in the so called congestive attacks, the temperature, on the contrary, from the invasion of the first symp- toms, rises above the physiological standard and tends to become gradually more and more elevated during the whole continuance of the attack. Periods and Forms of Disseminated Sclerosis. Gentlemen, after having considered, one by one, the different elements which compose the symptomatology of multilocular scle- rosis where we have to deal with a complete case, one which has already arrived at an advanced stage of its evolution, — it is next proper to show, in a general view, how these elements are grouped ' ♦Soci(5t6 de Biologie,' t. i, 5 pgrie, 1869-70, p. 145. 2 Charcot, *' Note s^r la temperature des parties centrales dans I'apoplexie liee h. l'h6morrhagie c6rebrale et au raraollisseinent ducerveau," in ' Comptes Rendus des Seances de la Societe de Biologie,' t. iv,4e serie, 18G7, p. 92. See also Charcot, ' Legons sur la thermometrie eliuiqn^', publieea dans la Gazette Jtehdomadaire,'' 1869, pp. 324, 742, 821 ; Bourneville, ' Etudes cliniques et thermomutriques sur les Maladies du Syst^me Nerveux,' Paris, 1870-73. FIRST PERIOD. 173 and arranged in the different phases and forms of the disease. The affection is, in truth, far from presenting itself clothed in all its attributes, at every epoch of its coarse. At the outset it may be constituted by the union of two or three symptoms only; and, b'esides, there are cases where the symptomatic series remains in- complete until the fatal end. Now, it is, especially, when the dis- ease is yet at an early stage, or when it assumes an imperfect form, that it is important to know how to recognize it by the slightest indicia. I have proposed to establish three periods in the progressive development of the disease. The first extends from the moment when the first symptoms appear to the epoch when the spasmodic rigidity of the members reduces the patient to almost absolute im- potence. The second comprises the space, usually of considerable length, during which the patient, confined to bed, or barely able to take a few steps about the room, still preserves the integrity of his organic functions. The third commences at the moment when, all the symptoms of the disease becoming simultaneously aggravated, the functions of nutrition suffer in a manifest manner. We will take occasion, as regards this ultimate period, to notice the disorders which, in the common order of things, mark the last phase of the disease and accelerate its fatal termination. I. First period. — The mode of invasion and of concatenation of symptoms presents certain varieties which deserve to be pointed out to your notice. Sometimes, the drama is begun by the cephalic symptoms. Thus, the patients commence by complaining of habitual giddiness, and more or less transient diplopia ; little by little, difficulty of enuncia- tion, and finally nystagmus, show themselves. The union of these symptoms would already constitute a sufficiently characteristic group, one which, even if tremor provoked by movement and pa- resis of the limbs were not superadded, should of itself enable us to establish a diagnosis, on strong probabilities. But such is not the most common mode of invasion. Generally, the spinal phenomena first reveal themselves, and so common is this circumstance that during many months — nay, even for years — the patients may present no symptoms other than an enfeeblement, a more or less marked paresis of the lower extremities, displaying a tendency to become aggravated, in a slowly progressive manner, and to extend to the upper extremities. In such a case, the posi- tion of the clinical observer is necessarily an extremely difficult one. For, in short, paresis of the lower limbs is a somewhat trite symp- tom, one common to a crowd of different diseases; still, it shows itself in multilocular sclerosis, as you remember, with some peculiar 174 REMISSIONS. features which may indicate the right path to follow. Thus, how- ever marked it may be — setting aside exceptional cases where the lesion predominates in the posterior columns — it is not accompanied by any trouble of sensibility, nor by any perceptible disorder of nutrition in the muscular masses. Add to this that, as a rule, there is no functional derangement of bladder or rectum. Finally, it is not rare to meet with remissions^ and "even with complete intermis- sions, which give rise to hopes of a decided cure.^ But it is clear that these indicia, even with the aid of all the others, only supply very vague data. Certainty can hardly be secured unless the pe- culiar tremor, or some of the cephalic symptoms, are superadded to the spinal symptoms. Hitherto, gentlemen, I have shown you the invasion and ulterior concatenation of accidents as slow and progressing in a uniform manner. That., in fact, is by far the most usual case; but it is im- portant you should know that, in certain exceptional circumstances, the disease may set in suddenly and unexpectedly, or after a few preliminary symptoms, of little significance. Thus, vertigo and diplopia having suddenly shown themselves, paresis and titubation may follow in a few days, so that the disease is thus, as it were, immediately established. This, to take one case amongst several, is what happened as regards the young woman named Vinch — , whom some of you may have seen in our wards. Sometimes the beginning is marked, as in the case of one of Valentiner's patients, by an abrupt invasion of paresis in one of the lower extremities; or again, as occurred in M. L6:>'s case and in that of one of my patients, whose history M. Yulpian has related,^ the invasion is inaugurated by an apoplectiform attack, preceded for some days or weeks, by vertigo and cephalalgia, and followed by temporary hemiplegia. Finally, gentlem.en, there is yet another variety, to which I must call your attention, where the invasion is marked by an affection J In our memoir, we summarized a certain number of cases in which remissions were found so complete as to enable the patients, who had been paralyzed, to re- sume their occupations. (See loc. cit. obs. iv, ix, x, xi, &c.) In an observation recorded by M. Vulpian, which we also quoted (p. 139), there was a series of alternate ameliorations and aggravations. We shall briefly Indicate them : When the disease was still recent, there supervened, after an attack of small- pox, a quasi-complete recovery. This improvement lasted for three years. At the end of that time, the menses were suppressed ; new, but slight, symptoms showed themselves, which disappeared on restoration of the catamenia. Two years after, the patient had an attack of jaundice, followed by new symptoms. These improved, but on bronchitis supervening, the paresis of the limbs reappeared in a more marked form, and, after successive remissions and recrudescences, became perma- nent. Sometimes the remission is incomplete, and only affects certain symptoms, par- ticularly incontinence of urine and of feces. In a patient, whose case vvas noted by Ilerr Baerwinkel, there was also a brief remission. (B. ) 2 Vulpian, *' Note sur la Sclerose en Plaques de la Moelle Epinicre," Obs. ii, * Me- moires de la SocieteMedicale des Hopitaux,' 18G9. SECOND PERIOD. 175 which is mostly regarded as foreign to the principal disease, al- though it is, in my opinion, intimately bound up with it, on the contrary, by a link not recognized until now. I allude to the gastric or gastralgic crises^ whichever you please to call them, that are occasionally very severe, and are accompanied by lypothymia, by repeated vomiting, &c. These crises have often opened the drama, and been quickly followed by the usual symptoms of multi- locular sclerosis ; it is not rare, also, to find them several times recurring and intermingling with these symptoms, during the early stage of the disease. Of this class, a case reported by M. Liouville^ and that related by Herr Zenke- furnish good examples. These accidents are all the more worthy of notice inasmuch as we shall find them again, with nearly the same characters, in other forms of scle- rosis of the spinal cord, and particularly^ in fasciculated posterior sclerosis {locomotor ataxia)^ but chiefly in its initial phases. In such a case, these gastric crises, coinciding or alternating with the ful- gurant pains of the limbs, may actually be, along with diplopia and perhaps a little titubation when the eyes are closed, the only symptoms of the disease in question, whose true nature is then too often misunderstood.^ These same gastric crises are found, as my friend Dr. Duchenne (de Boulogne) and I have observed, in the form of suhacide or chronic central myelitis^ which reproduces the symp- toms of general spinal paralysis. But I do not wish to delay any longer on this subject, which I intend soon to resume and to discuss in detail, as its importance deserves. II. Second period. — In general, from the close of the first period, multilocular sclerosis shows itself arrayed in most of the symptoms which characterize it. These symptoms become aggravated and intensified during the second period, and spasmodic contraction of the limbs is superadded, either with or without the accompaniment of spinal epilepsy, in consequence of which the patients who, until then, had been able to walk or hobble, with more or less difficulty, are thenceforth rendered almost quite powerless, and definitely confined to their rooms or beds. The contracture which marks the commencement of this period is almost always a very tardy symptom; it seldom shows itself till two, four, or even six years after the appearance of the first accidents of multilocular sclerosis. * * Memoires de la Societe de Biologie,' 5e serie, t. i, p. 107, Paris, 1870. 2 See what M. Charcot has said, in reference to this subject, in his lectures deliv- ered at La SalpStriere in 1868 (Dubois, ' Etude sur quelques points de I'ataxie locomotrice,' Paris, 1868, " Des crises gastriques,"p. 56 ; 'Le(jous sur les anomalies de I'ataxie locomotrice,' 1873, iegon ii, p. 32). 176 THIRD PERIOD. III. Third period. — The commencement of this final period is marked, as I mentioned to you, by the progressive enfeeblement of the organic functions; inappetency becomes habitual, diarrhoea fre- quent, and soon a general emaciation supervenes which grows more and more evident.^ At the same time, there ensues an aggra- vation of all the symptoms proper to this disease, the obnubda- tion of the intellect proceeds even to demeatia, the difficulty of enunciation is carried to its extreme, and the patient can only utter an unintelligible grunting; then the sphincters become para- lyzed, and it is not rare to find the mucous coat of the bladder affected with ulcerous inflammation. Then, on the sacral region and on all points of the lower limbs submitted to prolonged pres- sure, eschars app'ear which occasionally assurtle enormous dimen- sions, and, consecutively, comes the whole series of accidents which depend on this complication, purulent burrowing sores {fusees), purulent or putrid poisoning, etc. Death follows without delay. In most cases the patient's existence may be abridged by some intercurrent disease;^ pneumonia, caseous phthisis, and dysentery may be numbered amongst the most frequent of these terminal affections.^ * At this period of the disease, especially, we notice the supervention of disor- ders which may, perhaps, be classed among trophic troubles. Such are — 1st, softening of the vertebrae, of the trochanters, of the head of the tibia, of the bones of the tarsus, &c. (Bourne ille et Gruerard, loc. cit., cas du Doctenr Pennock, p. 83) ; 2d, a eyphosis and (right) scoliosis, mentioned in one of Friedreitdi's cases (B. et Gr., loc. cit., pp. 213 and 214) ; 3d, an efi'usion of liquid into the two femoro- tibial articulations (Obs. de M. Malherbe). (B.) 2 In the cases which have since been published, we most usually find the ter- minal diseases indicated by M. Charcot. It follows from the statistics we have collected that pulmonary diseases (pneumonia, purulent pleurisy, tubercular phthisis) are by far the most prominent. We should also mention the occurrence of acute bed-sore, oi pi/elo-cystilis (one ease), and of oedema (jlottid's (one case). (B.) 3 In this manner, the patient Vauthier (the subject of the preceding lecture) succumbed, and the patient Bezot, who long occupied bed No, 10, Salle St. Luc. We shall rapidly summarize the principal facts of their clinical history: — I. Vauth — (Josephine C ; was admitted March 21st, 1867, to M. Vulpian's wards, and died .January 7th, 1871 (aged thirty-two), in M. Charcot's charge. From fourteen to twenty-one years of age, she suft'ered from vertigo followed by vomit- ing. Pregnancy, at twenty-one, pat an end to vomiting. Disseminated sclerosis showed itself at the age of twenty-three years, six months : weakness of the lum- bar region, very great fatigue of the lower limbs, lancinating pain in the right leg, enfeeblement of the sight, diplopia. At twenty-five years, feebleness of the arms, which are occasionally affected by pains. 1867. — Nystagmus, diplopia. Integrity of the muscular masses, loss of idea of posit on as regards lower limbs. Paresis and tremor of the upper extremities. Tactual sensibility largely lost everywhere. Momentary improvement under nitrate of silver. 1868. — The patient can no longer stand erect; the symptoms are more marked on the right side than on the left; the tremor of the upper extremities has aug- mented. Frequent fulgurant pains, especially in the left half of the face. Fits of giddiness coming on at close intervals. Nystagmus more marked. In May, BULBAR PARALYSIS. 177 I have reserved for special mention the appearance of some symp- toms of bulbar paralysis, because they may, by an abrupt aggra- M. Vulpiaii administered two pills of 0.025 gram, (or nearly ^ grain) of extract of Calabar Bean. Soon after, a fit of weakness, tremor exaggtrated, cold sweats, pallor of the face (these plienomena are, perhaps, due to the Calabar Bean), From July, three pills of Calabar Bean. In November, M. Vulpian suppresses the Calabar Bean, and as incontinence of urine has latterly supervened, he prescribef* three pills of 0.03 gram, (or nearly ^ grain) of extract of Belladonna. The in- continence of urine, after presenting some transient improvements, ceased alto- gether in the course of December. 1870 (January). — Psychic disorders (see ante, p. 160). In the course of this year the symptoms noted augmented in severity; and, besides, symptoms of bul- bar paralysis made their appearance. Tliese became rather rapidly worse, and the patient died, as it were asphyxiated, Feb. 7th, 1871. Autopsy. — Numerous sclerosed patches found to exist in the brain and spinal cord. On account of the ataxic symptoms presented by the patient, the lesions of ihe spinal axis deserve mention. There were sclerosed patches throughout the whole length of the lateral columns. As to the posterior columns, they are affected nearly throughout, but, principally, from the lower extremity of the dorsal region upwards. Fig. 15 represents the lesions observed on a section taken from the upper part of thy M. Charcot, the vomiting might not be attiibutable to the supplemental elimination of urea by the stomach, M. Ch. Fernet requested M. E. Hardy to analyze the urine and the vomited matter. From a summarized table of these analyses, it appears that " the urea was always present to a noteworthy amount (from 0.55 gr., to 1.87 grammes) in the vomited matter ; also, when the secretion of urine was suppressed, the quantity of urea contained in the vomited matter was gradually increased during that space of time. From the 17th to the 27th Sept., the quantity rose from 0.62 to 1.08 grammes. Finally, from the day when the urine issuing from the bladder reached what might be considered a normal amount, the urea diminished iu the gastric secretion, disappearing doubtless at the same time as the vomiting." A moral influence — the administration of the pills termed ^'•fulminantes^'' {mica 202 HYSTERICAL HE MI ANAESTHESIA. taining only 50 centigrammes of urea per 1000 grammes. Now, in the case of our patient, the urine contained 15 grammes of urea per 1000 grammes, — an amount approximating to the normal standard. Judging from this, gentlemen, the obstacle in hysterical ischuria would not lie in the ureters. Where then does it reside? Should we invoke an influence of the nervous system analogous to that which Ludwig discovered in the case of the salivary gland? In the absence of all information on this point, we are compelled to leave the question in suspense. LECTURE X, HYSTERICAL HEMIANESTHESIA. Summary. — Hemiansesthesia aud ovarian hypersesthesia in hysteria. Frequent association of these two symptoms. Frequency of hemiansesthesia in hys- terical patients ; its varieties, complete or incomplete. Characters of hys- terical hemiansesthesia. Ischaemia and the " Convulsionnaires." Lesions of special senses. Achromatopsia. Relations between hemiansesthesia, ovarian hypersesthesia, paresis and contracture. Variation of symptoms in hysteria Diagnostic value of hysterical hemiansesthesia; necessary restrictions. Hemiansesthesia depending on certain encephalic lesions. Its analogies with hysterical hemiansesthesia. Cases in which encephalic hemiansesthesia resembles hysterical hemiansesthesia. Seat of the encephalic lesions capable of producing hemiansesthesia. Functions of the optic thalamus ; British theory ; French theory. Criticism. German nomenclature of different parts of the encephalon. Its advantages as regards the circumscription of lesions. Cases of hemiansesthesia recorded by Tiirck; special seat of the encephalic lesions in these cases. Observation of M. Magnan. Alteration of special senses. Gentlemen, — There are two points in the history of hysteria, upon which I wish to lay particular emphasis, in this and the fol- lowing lectures. These are, on the one hand, hysterical hemiances- ihesia, and on the other, ovarian hyper cesthesia. If I set these two panis) — caused a sudden change in the condition of Marie L — , dating from the 17th September. The vomiting ceased, tlie secretion of urine resumed its course. Finally, the patient left the hospital, in very fair health, in the course of Novem- ber. M. Ch. Fernet, in concluding his note, points out the numerous analogies between this case and that of M Charcot's patient. We may mention also a thesis of M. Secouet, ' Des voraisseraents ur^miques chez les femraes hysteriques,' (Paris, Avril, 1873), which contains the report of a case that, though imperfect in some respects, should apparently be classed iu the category of hysterical Ischuria. (B.) OVARIAN HYSTERIA. 20^ phenomena side by side, it is because they are generally found associated together in the same patients. With reference to ovarian hypergesthesia, I hope to render evident to you the influence of pressure on the ovarian region — an influence formerly acknow ledged, but afterwards denied — over the production of the pheno- mena of the hysterical seizure. I shall show you that this operation determines, either the premonitory symptoms merely of the hys- terical fit, or, in a certain number of cases, the complete seizure. You will thus be enabled to verify the accuracy of the assertion formerly made by Professor Schutzenberger, with respect to this phenomenon, in spite of the contradictions offered by certain ob- servers. 1 shall likewise show you a method which I have discovered, or rather re-discovered, which, in the case of some patients, enat)les us to arrest the course of even the most intense hysterical fit, — I refer to the systematic compression of the ovarian region. M. Briquet denies that this compression has any real effect. That is an opinion which I cannot share, and this leads me to make a general remark in reference to M. Briquet's book.^ The work is an excellent one, the result of minute observation and patient industry, but it has perhaps one weak side; all that relates to the ovary and the uterus is treated in a spirit which seems very singular in a f)hysician. It exhibits a kind of prudery, an unaccountable sentimentality. It appears as though, in reference to these questions, the author's mind were always preoccupied by one dominant idea : " In attempting to attribute everything to the ovary and uterus," he says for instance, somewhere, " hysteria is made a disorder of lubri- city, a shameful affection, which is calculated to render hysterical patients objects of loathing and pity." Keally, gentlemen, that is not the question. For my own part, I am far from believing that lubricity is always at work in hys- teria; I am even convinced of the contrary. Nor am I either a strict partisan of the old doctrine which taught that the source of all hysteria resides in the genital organs; but, with Schutzen- berger, I believe it to be absolutely demonstrated that in a special form of hysteria, — which I shall term, if you please, the ovarian form, — the ovary does play an important part.^ Five patients whom I shall present to you in succession are, if I mistake not, manifest examples of this form of hysteria; you can verify the accuracy of the description I am about to give, by personal exami- nation. • Briquet, 'Traits cliniqne et therapeutique de I'liyslerie,' Paris, 1S59. 2 (xrisolle (' Traitd de Pathologie Interne,' 9e edit., t. ii, p. 84i) mentions the case of a girl, aged 22, who had neither vagina nor uterus, and yet was subject to most violent fits of hysteria. On autopsy, MM. Chassaignac and Pi-evost could discover no trace of a uterus, but found, iu the ovarian regions, two bodies which were apparently the ovaries. The patient had, every month, exhibited all the symptoms of pre-catamenial congestion. (S.) 204 HYSTERICAL HEMIANESTHESIA. I. You are all acquainted with the hemmncesthesia of hysterical patients. There would be some ingratitude in not knowing the nature of this symptom, for it has been discovered by purely French investigations. Piorry, Macario, and Gendrin, have each of them, in his turn, described it and dwelt upon its characteristics. Not long after them, Szokalsky made it known in Germany ; but nothing remained for him to do save to confirm by observations, which are, however, very meritorious, the facts that had been already declared by our countrymen. In order to keep within bounds, I shall enter upon a discussion of complete hemiancesthesia only, such as we find in intense cases. This will be sufficient for my present purpose. Even in the degree mentioned, it is a frequent symptom, since according to M. Briquet, it obtains in 93 cases out of 400. Considered with respect to posi- tion, we find, according to the same author, that in 70 cases the left side is affected, and in 20, the right. You know what happens under such circumstances. Supposing that the two halves of the body are vertically divided by an antero- posterior plane, one entire side — face, neck, body, &c. — will have lost the sense of feeling; and though this loss of sensibility very often affects the superficial parts merely, — the external tegument, — yet it sometimes also invades the deeper regions, affecting the muscles, bones, and articulations Hysterical hemiancesthesia shows itself, as you are aware, under two principal aspects; it is complete or incomplete. Analgesia^ with or without insensibility to heat or cold, or thermoansesthesia is one of the commonest varieties of this species. The distinct manner in which the anaesthetic parts are separated from the healthy parts is also an important characteristic of hysterical hemiansesthesia. On the head, face, neck and body the demarca- tion is often perfect and very closely corresponds with the median line. Another symptom, well deserving of mention, is constituted by the comparative pallor and coldness of the anaesthetic side. These phenomena, conjoined with a more or less permanent ischas* mia, have been many times observed. Examples of them have been given by Brown-Sdquard and Li^geois.^ A difficulty in induc- ing bleeding by pricking the anaesthetic parts with a pin may, in intense cases, be a characteristic of the ischaemia in question. I noticed this peculiarity on a former occasion. The matter came under my observation in this way : on leeches being applied to a patient affected by hysterical hemianaesthesia, I saw that their bites yielded very little blood on the anaesthetic side, whilst on the ' Liegeois, ' M6moires de la Soci6te de Biologie,' 3e serie, t. i, p. 274. L HYSTERICAL HEMIANESTHESIA — ISCHURIA. 205 healthy side it flowed as usual. Grisolle, who, you are aware, was a very wise and exact observer, had noted the same phenomenon. This ischaemia which, indeed, is rather rare when so intense, may furnish an explanation of certain reputedly miraculous occurrences. Thus, it is stated, that, in. the epidemic of Saint Medard, the sword- blows given to the " Convulsionnaires" did not cause bleeding. The reality of the occurrence cannot be rejected without examina- tion. If it be true that many of these " Convulsionnaires" were guilty of trickery, we are nevertheless compelled to acknowledge, after an attentive study of the question, that most of the pheno- mena which they presented, and of which history has given us a naive description,^ were not entirely simulated, but merely amplified and exaggerated. It has been critically demonstrated that hysteria carried to an extreme, was almost always the active agent in these cases ; and in order that a wound, such as that made by a sword, should not, when inflicted on- these anaesthetic women, have caused bleeding, it was only necessary, as you may infer from what pre- cedes, that the instrument should not have entered too deeply. There are other characters also of hysterical hemianeesthesia which are deserving of all our attention, from a clinical as well as from a theoretical point of view. The mucous memhranes are affected, on one side of the body, in the same manner as the exter- nal tegument. The organs of the senses themselves are affected to some extent in the anaesthetic side. Taste may have vanished in the corresponding half of the tongue, from tip to base. The sense of smell is less acute. Yision is weakened in a very remarkable manner, and if amblyopia occupy the left side, we may meet with a most noteworthy phenomenon, to which M. Galezowski has called attention, and which he designates by the name of achromatojma. However, we shall return to this topic. Hysterical hemianesthesia does not seem to affect the viscera. Thus, to mention the ovary merely, we find hypersesthesia and not anaesthesia present. That organ may be very painful on pressure, when the abdominal wall is perfectly insensible. Now, gentlemen, there exists a most remarkable relation between the position of the hemianaesthesia and that of the ovarian hyperaesthesia. If the former occupy the left side, the hemianaesthesia occupies the left side, and vice versa. When ovarian hyperaesthesia is double, it is the rule that the anaesthesia shall present itself in a generalized form, and it consequently occupies nearly the whole, or quite the whole of the body. Not only does such a relationship exist between the seat of the hemianaesthesia and that of the ovarian hyperaesthesia, but a similar relationship exists with regard to the paresis, or to the contracture 1 Cane de Montgeron, ' La Verite des Miraules opeiv'S a I'intercessiou de M. de Paris et autres Appelants,' &c., 1737. 206 OVARIAN HYPERESTHESIA. of the limbs. Thns, when the parCvsis or the contracture supervenes, it always shows itself on the same side with the hemiansesthesia. The hemianaesthesia, as described, is, in the clinical history of hysteria, a symptom of the greater importance, inasmuch as it is well-nigh permanent. The only variations which it exhibits, are dependent upon degree, on the intensity of the phenomena which constitute it, and occasionally, we should also mention, on the fluctuation of some of these phenomena. Achromatopsia belongs to the number: it was distinctly and repeatedly observed in one of our patients, a few weeks ago, from whom it has now completely disappeared. It is necessary to bear in mind that hemiansesthesia is a symptom which requires to be sought for, as M. Lasagne very judiciously remarks.^ There are, in fact, many patients who are quite sur- prised when its existence is revealed to them. II. I propose now to investigate to what extent hemianj^sthesiai such as we have described it, is a symptom proper to hysteria. In reality, it is very rare for it to be reproduced, with the general grouping of all its characteristics, by any other disease. Its well- established existence is, therefore, a valuable indication, one which will often reveal the real nature of many sympioms, which would otherwise remain doubtful. That is a point on which M. Briquet was right to lay great stress. In order to illustrate the importance of this fact, he relates the case of a woman who, after a violent emotion, fell rapidly into a more or less profound coma, with or without premonitory convulsions {i. e., the comatose form of hys- teria), and who was seen, on recovering her senses, to be stricken with more or less complete hemiplegia. Here we have a group of symptoms which it is not very rare to meet with in practice, and, on such an occurrence, it may happen that the physician will feel himself placed in a very embarrassing position. Now, the presence of hemianaesthesia, arrayed in all its characteristics which would most probably be found on such occasion, might then, according to M. Briquet, indicate the true path to the observer. This asser- tion is perfectly accurate; I have no fault to find with it, except as regards one point. If it be true that hemianaesthesia is an almost specific symptom, inasmuch as it is not found with the same characteristics in the immense majority of cases of material lesions of the encephalon (hemorrhage, softening, tumors), we cannot admit this to be an absolute characteristic. It is, above all, inaccurate to say that the liemianoifithesia ^ developed under the influence of encephalic lesions, always differs from hysterical hernia ncesthesia, by the fact that, in the ' 'Archives Geuc-iales de M^Jeciue,' 18G4, t. i, p. 385. HEMIANESTHESIA OF ENCEPHALIC ORIGIN. 207 former case, the shin of the face does not participate in the insensibility^ or that, ivhen it exists, it never occupies the same side as the insensibility of the members. This is an inaccuracy which has been reproduced, almost in the same terms, in the otherwise very interesting thesis of M. Lebreton.^ I feel some repugnance in again attacking the remarkable work of M. Briquet, but the more estimable the work — and it is justly esteemed, — the more serious become any inaccuracies which may have slipped into it. This reflection will, I hope, justify me in criticizing it. Gentlemen, there are cases, which, though indeed exceptional, are thoroughly authentic, where certain circumscribed cerebral lesions ((71 /b?/^?-), may cause the production of hemiana3Sthesia with all the signs that characterize it in hysteria — or very nearly all. Allow me to discuss this subject, in some detail. The classic doctrine, at least amongst us, — a doctrine which, besides, appeals to the data of clinical observation, and to those furnished by experiments on animals, — teaches that circumscribed cerebral lesions {en foyer) .^ which so profoundly affect the power of motion, especially when they occupy the region of i\\Q optic thalamus and corpus striatum^ produce but little effect as regards sensibility. From th.s point of view, gentlemen, the result is said to be always the same, whether the lesions occupy specially the corpus striatum, the optic thalamus, or the rampart of the amygdalae (claustrum). x^t first glance, when in presence of the suddenly developed lesions which determine an apoplectic fit, and which affect any one of the points just enumerated, the symptom which strikes the observer is a hemiplegia, more marked in the upper than in the lower ex- tremity, and accompanied by flaccidity. In the face, the paralysis usually affects the buccinator and the orbicularis oris ; the tongue also is mostly protruded to the para- lyzed side. In addition to motor-paralysis comes paralysis of the vaso-motor nerves, manifested by an elevation of temperature in the paralyzed limb. Occasionally, this vaso-motor paralysis makes its appearance from the outset. As to sensibility, it is not modified in a perceptible manner, or at least not in a durable manner. The special senses present no serious alterations, except some complication supervenes, as where embolism of the arteria centralis retince occurs (in cases of brain- softening consecutive on the migration of a valvular vegetation), or where compression, by contiguity, of the tractus opticus, happens (on occurrence of a somewhat voluminous hemorrhagic lesion). Such is a summary of the symptoms which are met with in the ' Lebreton, ' Des differeutes varietes de la paralysie hyst-h-ique,' The se de 1 aris 18G8. 208 ENCEPHALIC LESIONS. immense majority of cases of hemorrhage and softening affecting the points of the encephalon we have mentioned. Undoubtedly, gentlemen, that is what takes place, in the great majority of cases. But, the chapter of exceptions accompanies the rule. There are cases, and I have myself observed several of this kind, in which sensibility is affected in a predominant manner, and in which anaesthesia persists, even after the recovery of motion. Such alterations of sensibility may present themselves with the following characters. The anaesthesia affects one entire half of the body and stops just at the median line. The corresponding half of the face, both as regards the skin and the mucous membranes, shows insensibility, exactly as in hysterical hemianaesthesia. Then also analgesia Siud thermoancBsthesia may be observed, with conservation of tactual sensibility, as MM. Landois and Mosler^ have ascertained. Finally, there are also cases, though of more rare occurrence and as yet imperfectly described, but having still their own importance, which render it probable that, under such circumstances, altera- tions of the special senses may exist on the side opposite to the encephalic lesion, or, in other words, on the same side with the hemiansesthesia. The physicians of the last century have already remarked these exceptional phenomena. Borsieri, among others, relates the history of a patient who, three months before, had been stricken with apo- plexy, and in whom anaesthesia still persisted, although the power of movement had returned. He quotes some other cases of the same kind from different authors.^ Analogous cases have been mentioned by Abercrombie, Andral, and, in later days, by Hirsch,^ Leubuscher, Broadbent, Hughlings- Jackson,^ and especially by Ttirck. The latter alone has been able to furnish decisive data in reference to the position occupied by the encephalic lesions in such cases. When the hemiansesthesia presents itself with these characters, the optic thalamus is almost always affected in a predominant, if not in an exclusive manner. For my own part, I have seen hemi- ansesthesia superadded to hemiplegia, in many patients affected with cerebral hemorrhage, and, in such cases, on post-mortem ex- amination I always found the lesion of the optic thalamus, the existence of which during life I had ventured to announce. From what precedes, gentlemen, should we conclude that the lesion of the optic thalamus is the real organic cause of the hemi- ansesthesia observed in all these cases ? That is a question deserving of discussion. I am thus led to speak of the physiological theory, which may be called the British theory^ because it was, I believe, • Landois et Mosler, ' Berliner Klin. Wochens.,' 1868, p. 401. 2 Borsieri, ' Inst, pract.,' vol. iii, p. 7(3. 3 Hirsch, 'Klinische fragments,' L Abth., p. 207, Koenigsberg, 1857. * H. Jackson, 'Note on the Funotions of the Optic Thalamus.' In 'Loudon Hospital Reports,' 1866, t. iii, p. 373. FRENCH THEORY. 209 first published and maititained by Messrs. Todd and Carpenter, two British authors. According to this theory, the optic thalamus is the centre of perception of tactua4 impressions ; it would, in some degree, correspond to the posterior cornua of the gray substance of the spinal cord. The corpus striatum would be the terminal of the motor tractus and connected with the execution of voluntary movements ; it would be analogue of the anterior cornua of the cord. This theory of which Schroeder van der Kolk^ has shown him- self the avowed partisan, is, if we might use the word, the antipodes of the French theory, which you will find set forth in a very com- plete manner in M. Vulpian's Lectures. According to the latter view, the centre on which sensitive impressions are transformed into sensations would not be in the brain proper, because an ani- mal, from which the brain, including the optic thalamus and the corpus striatum, has been removed, continues to see, to hear, and to feel pain, &c. The centre of sensitive impressions would there- fore reside lower down, in the protuberantia and perhaps also in the crura cerebri. Under this hypothesis, the following is the manner in which its advocates regard, in the pathological domain, those authentic facts which show a lesion of the optic thalamus coinciding with the decrease or abolition of sensibility on the side of the body stricken with hemiplegia. They say, and their allegation is perfectly cor- rect, that, in such cases, we have frequently to do with recent lesions, such as intra-encephalic hemorrhage, or ramollissement^ or tumours — lesions by which the optic thalamus is extremely distended and which, consequently, may have the effect of determining the compression of the adjacent parts, — of the crura cerebri for instance. It is, on the other hand, well established that, in a number of cases, the optic thalamus may be injured, even gravely and throughout a large portion of its extent, without being followed by any special disorder in the transmission of sensitive impressions. To the last argument, the British authors, M. Broadbent^ among others, oppose the plea that the optic thalamus, the presumed cen- tre of sensitive impressions, should doubtless be assimilated to the gray axis of the spinal cord — the latter, it is known, continues to transmit these impressions even when it has suffered the most serious derangement, if only a small remnant of gray matter persist, capable of connecting its lower with its upper extremities. I con- fess that the comparison seems to me far-fetched, especially from the moment it is laid down as a principle that the optic thalamus should be considered a centre; for, so far as regards the transmission • Scliroeder van der Kolk,' Pathol, nnd Therapie der Geistenkrankheiten.' Braun- schweig, 1863, p, 20. 2 Broadbeut, ' Medical Society,' London, 1865, and 'Med.-Chir. Review.' 14 210 REQUISITE CONDITIONS. of sensitive impressions, the gray axis of the cord is manifestly merely a conductor. However this may be, gentlemen, such is the state of the ques- tion. In my opinion, the disputed points cannot be definitely solved, except by means of careful clinical observation, verified by studious anatomical investigations, the chief aim of which should be to establish, with great precision, the seat of the encephalic lesions, to which the symptoms recorded during life might be cor- related. And the circumstances of the case should be such that the influence of compression, or any other phenomenon, acting by contiguity, would be completely eliminated. Now, gentlemen, in the present state of the science, the cases which include all these conditions are extremely rare, so far, at least, as my knowledge goes. We may, however, mention as approximating to this ideal, the cases which were presented by L. Tiirck to the Academy of Sciences of Vienna,' to which I have already alluded. They were four in number. In the instances recorded by L. Tiirck, there had been, gentlemen, either old hemorrhagic foci, then represented by ochreous cica* trices, or ramollissement foci arrived at the stage of cellular infil- tration. In all the cases, the hemiplegia resulting from the presence of foci had disappeared long before death, but the hemianaesthesia had persisted until the fatal end. The portions of the encephalon affected by the alteration are carefully mapped out. The German nomenclature of the different parts of the enceph- alon, however forbidding it seems to us, on account of its multi- plicity of strange terms, yet presents in my opinion, an incontestable advantage, that, namely, of supplying a very complete topographical map, if I may make use of the comparison, where the smallest hamlet receives a name. The French nomenclature has, no doubt, the advantage of tending to simplification, but this is sometimes to the detriment of absolute exactness; it is often incomplete. Now, with respect to the question which occupies us, there is no detail, however minute, which ought to be neglected. We must, at all hazards, take heed of the slightest details, for we are quite ignorant, in the actual state of the science of the brain-physiology, whether some little point, which has no name in the French nomenclature, may not be a position of primary importance. Availing ourselves, therefore, of the nomenclature in use beyond the Ehine, let us endeavour to become familiar with the topography, in order that we may accurately recognize the seat of the lesions, in the observations recorded by L. Tiirck. I place under your observation, a frontal section taken across the cerebral hemispheres, immediately behind' the corpora mamniillaria ' * Sitzungsber. der Kais. Akademie der Wissensohafteu za Wieu,' 1859. V. infra, the analyses of these cases. TOPOGRAPHY OF ENCEPHALIC LESIONS. 211 (Fig. 18). You recognize on this section, just exterior to the middle ventricles, the nucleus caudatus (or intra- ventricular nucleus of the corpus striatum), which, in this region, is merely represented by a very small portion of gray matter, — beneath and interior to it, the optic thalamus^ here largely developed ; external to this lies the capsula interna^ formed principally by bands of white substance which are simply the prolongations of the lower stage of the crura cerebri ; these proceed to expand in the centrum ovale to assist in constitutinsr the corona radiata: — external to this is the extra-ven- tricular nucleus of the corpus striatum^ in which you distinguish three secondary nuclei denominated by the numbers 1, 2, 8 ; the third, or outermost, is sometimes designated by the term putamen. Still more external is a thin lamina of white matter, the capsula externa^ and finally, a small band of gray substance, the rampart (or claus- trum) {Vormauer)} Pro. 18. — Transversal section of brain, — a, optic thalamus ; — 6, corpus striatum, lenticular nucleus ; — c, corpus striatum, caudate nucleus ;—f^ indication of the radiatinj? corona of Reil ; — 2, 2', 2", apoplectic foci (Obs. ii, in ' Ttirck's Memoir,' v. infra, pp. 212-14) ; — 3, vestige of an apoplectic focus (Obs. iii,. in 'Turck's Memoir'). Now, gentlemen, in the cases recorded by Herr Tiirck, the lesions had invaded alike the superior and external portion of the optic thalamus, the third nucleus of the extra- ventricular portion of the corpus striatum, the superior portion of the capsula interna, the ' The vormauer of German anatomists, the avant-mur, rempart, or noyau ruhan^ oi the French, is a band of gray matter which, arising from the superior portion of the amygdala, curves round towards the white substance of the convolution bound- ing the fissure of Sylvius. (S.) 212 OBSERVATIONS OF TURCK. corresponding region of the radiating corona, and the adjacent white substance of the posterior lobe. We have consequently complex lesions to deal with here, but they, at all events, allow the region which requires investigation to be circumscribed. Further researches, when sufficiently numer- ous, will enable us soon to ascertain the fundamental lesion, to which the existence of the hemiansesthesia should be attributed. Some other cases of hemianaesthesia, of cerebral origin, which have been published since those of Tiirck appeared, testify to lesions occupying the same circumscribed regions of the encephalon ; they make, however, no important additions to the results obtained by that observer. Such amongst others, is the case recorded by Dr. Hughlings Jackson,^ — here again the alteration was not confined to the thalamus; it extended to the extra-ventricular nucleus of the corpus striatum, and consequently the capsula interna must have been affected in its posterior portion. It was the same in the case described by M. Luys,^ the median centre of the optic thalamus was affected, but the alteration had invaded the corpus striatum, (probably the extra-ventricular nucleus). To recapitulate, we may conclude I believe from what precedes that, in the cerebral hemispheres, there exists a complex region, lesion of which determines hemiansesthesia ; the limits of this region are approximately known, but, at present, localization can- not be carried any further, and no one has a right to say that in the region in question, the optic thalamus should be inculpated rather than the capsula interna, the centrum ovale, or the third nucleus of the corpus striatum. Up to the period in which we write, anaesthesia of general sensi- bility alone appears to have been observed, as consecutive on an alteration of the cerebral hemispheres, so that obnubilation of the special senses would remain as a distinctive characteristic of hysteri- cal hemiansesthesia. But it may be doubted whether the organs of these senses have been attentively explored in the cases of hemi- ansesthesia of cerebral origin, hitherto published ; the records are silent with respect to it.^ ' The disease was not strictly limited to the thalamus. . . . Outwards the disease extended through the small tongue of corpus striatum which curves round the outside of the thalamus, and thence up to the gray matter of the con- volutions of the Sylvian fissure. ('London Hospital Reports', loc. cit., t. iii, p. 376.) 2 Luys, ' Tconographie photographique des centres nerveux,' p. 16. 3 At the period when this Lecture was delivered, we were only acquainted with the observations of L. Tiirck by the brief mention made of them in Rosen- thal's 'Treatise on Diseases of the Nervous System.' Since then, thanks to the courtesy of M. Magnan, we have been enabled to procure the complete translation of Turck's memoir (Ueber die Beziechung gewisses Krankheitsherde des ijrossen Gehirnes zur Anasthesie,' Aus dem xxvi Band, S. J 91, des Jahrganges, 1859, des Sitzungsberichte der Mathem. Naturw. Classe der Kais. Akademie der Wissen- chaften). We think it useful to give the substance of this work. After recalling DESIDERATA. 213 For my own part, I am inclined to believe that the participation of the special senses will be one day recognized, when care shall tlie fact that, usually, in hemiplegia caused by the formation of apoplectic foci in the brain (hemorrhage and ramollissemeiit), the sensibility re-appears very promptly as a general rule, the author relates four cases where, on the contrary, the anaesthesia persisted in a high degree of intensity. Case 1.— Fr. Amerso, aet. 18, In August, 1858, left hemiplegia, speedy re-ap- pearance of motor power. 12th. Nov. — The movements of the left iipper extremity are rapid and energetic; those of the corresponding inferior extremity exhibit slight paresis. Very intense anaesthesia exists on the left side (limbs, body, etc.)* Facial sensibility is diminished, on this side only. Formications from time to time through all the leftside. Died, 18th March, 1859. Autopsy. — At the base of the corona radiata of the right hemisphere, imme- diately outside of the tail of the corpus striatum, appears a lacuna of the size of a pea (cellular infiltration). The anterior wall of this lacuna is two lines behind the anterior extremity of the optic thalamus. Two or three lines farther off, an- other lacuna is seen, of smaller dimensions, which extends to four or five lines behind the posterior extremity of the thalamus, so that as the usual length of the optic thalamus is eighteen lines, the portion of the corona radiata which lies im- mediately a^ljacent to the tail of the corpus striatum was perforated, fore and aft, by the old focus of ran;olIissement for an extent of eleven lines. A similar focus involves the external portion of the third part of the lenticular nucleus. It com- mences nearly two lines behind the anterior border of the optic thalamus and ends at about four lines from the exterior extremity of the optic thalamus. In its course of one inch long, it occupied the greater length of the internal side of the third part of the lenticular nudeus. and part of the capsnla interna. In the pos- terior half of their course, then two foci were not farther part, in one place, than the distance of one line. It follows, that in this place, almost all the corona was separated from the internal capsule and the optic thalamus. Spinal cord. — Col- lection of granular bodies somewhat abundant in the left lateral column, rare in the anterior column. Case 2, S. J., set. 55. — Apoplectic attack, followed by hemiplegia, Oct. 25, 1851. Two months after, the paralysis of the extremities disappeared to such an extent tliat the patient could extend the arms, grasp objects with some strength, and walk without help, but lamely. Oct., 1855. — Anaesthesia of the left extremi- ties (face and body also benumbed, but in a less degree) persisting since the attack. Power of motion recovered, but the limbs of the left side are more feeble than those of the right. Died Oct. 31, 1858. Auto/>sy. — Old flat cicatrix, about five lines in breadth and eight in length, situated at the superior and external part of the right opt c thalamus. The cica- trix begins four and a half lines behind the left anterior extremity of the op ic thalamus, and ends eight lines farther off. Lying parallel to this cicatrix is another, an inch long, occupying the third part of the lenticular nucleus ; it be- g ns two lines behind the anterior extremity of the thalamus and ends nearly three lines in front of its posterior extremity (fig. 18. 2, an 1 2'). There was, bes:des. a lacuna n the right inferior lobe (fig. 18, 2"), another in the anterior lobe of the same side, two as big as a pin's head in the anterior part of the riglit optic thalamus ; two in the pons Varolii, and finally, one in the right and superior portion of the left hemisphere of the cerebellum. No secondary degeneration of the cord was obseived. Case 3. — Fr. Hasvelka. aet. 22. November 1st, 1852. Apoplectic attack, hemipleg'a on the rigliN with intense anaesthesia of the corresponding half of the body. At the en 1 of five weeks, diminnton of motor paralysis. February 3, 1853. — Motion quite free, on the right .'■ide. The ent re right half of the body is the eeat of very marked anaesthesia (scalp, ear, face, and body). The anaesthesia is equally noticeable in the eyelid, no-tril, left half of the lips, and not only on the outer but al-o on the inner side. The riuht conjunctiva is less sensitive than the left When the right nostril is t'ckled, the sensation is less felt than in the l«(t. Same difference between the right meatus au litori'is, and the le't. In the rijiht half of the mouth (tongue, palate, gums, cheek), the sensation of heat is 214 DESIDERATA. have been taken to seek for it. My opinion is founded on the fol- lowing basis; — There exists in the clinical history of the organic diseases of the nervous centres a symptomatic sign but little known, and little remarked as yet, which I shall have occasion some day to discuss in detail before you. This is a kind of rhythmical convulsion which occupies an entire half of the body, including the face (in many instances at least), and which assumes sometimes the appearance of the clonic jerking of chorea, sometimes that of the tremor of para- lysis agitans. This hemilateral trembling occasionally presents itself as a primary affection; at other times it supervenes consecu- less vivid than in the left. At terior extremity of the thalamus and extends two or three lines in front of its pns erior extremity. Anferi rly, it is half a line, and posteriorly two or three lines beneath the superior surface of the thalamus, whicii is considerably dep>es«ed in this direction. An inch long and four or five lines deep, the focus touches a large extent of the posterior part of the radiation of the cms cerebri, a part of the internal capsule, and, perhaps, a part tilso of the lenticular nuc eus Spinal Cord. — Accumulation of granular bodies in the poste- rior part of the right lateral ces, reaching the extremities of the thalamus. They were from e'ght lines to an inch in leugtb, reaching even two inches into the white substance. The regions affected were: the superior and external part of the thalamus; the third part of tiie lenticular nucleus; the p^^sterior part of the ititernal capsule, comprised between the iha'amus and the lenticular nucleus; the corresponding portion of the white substance of the super'or lobe opposed to it. Several of the-e regions were always nffecte 1 together. 'JMie fibres which proceed from the white substance of the hetnispbere into the external part of the optic thalamus were con- stantly affected. HEMIANESTHESIA AND CEREBRAL LESION. 215 lively on a hemiplegia, whose invasion was sudden. In the latter case, it commences to appear at the epoch when motor paralysis begins to improve. The lesion consists in the presence either of a focus of hemorrhage or of ramolissement, or in that of a tumour. In all cases of this kind, which I have hitherto observed, and in the analogous facts collected from various authors, the lesion in question occupied the posterior region of the ophthalmic thalamus and the adjacent parts of the cerebral hemisphere exterior to it. Now, hemianaesthesia is a tolerably common — but still not a con- stant — accompaniment of this group of symptoms, and it occupies the same side of the body as the tremor.^ It existed in a high degree of development, in a male patient whose history M. Magnan has recently communicated to the Societe de Biohgie; m his case, the form of tremor of which I have tried to give you a summary notion, showed itself in a most marked manner. Everything tends to show (I cannot be more positive as there was no autopsy) that the encephalic lesion was, in this man, of the same sort, with respect to position, as that which I found in my patient. Now, in this case, M. Magnan ascertained, in the clearest manner, that tactual sensibility was not alone in- volved ; the special senses were themselves affected, as they are in hysterical hemiansesthesia. On the side stricken with hemian^es- thesia, the eye was affected with amblyopia, the sense of smell was lost, and taste was conipletely abolished. Hence, it becomes probable, if I am not mistaken, that complete hemiansesthesia, with derangements of the special senses, — and con- sequently, such as is presented in hysteria, — may, in certain cases, be produced by a circumscribed lesion of the cerebral hemispheres.^ ' See a Lecture of M. Charcot (in ' Le Progres Medical,' 23 .Janvier, and 6 Fev- rier, 1875), on ' Hemichoree post-hemiplegique.' (Note to 2d edition.) 2 The views expressed in this Lecture, relative to hemiansesthesia of cerebral origin, have received further clinical confirmation from the incidents of a case, which we noted, in M. Charcot's wards. (Progres Medical,' 1873, p. 244), and from the experiments on animals conducted by M. Veyssi^re (Recherches cliniques et experimentales sur I'liemianesthesie de cause cerebrale,' Paris, 1874). This work also contains some interesting clinical notes. (Note to the 2d edition.) 216 LECTURE XI. OVARIAN HYPERiESTHESIA. Sdmmary. — Local hysteria of Britisli authors. Ovarian pain ; its frequency. Historical remarks. Opinion of M. Briquet. Characters of ovarian hyperaesthesia. Its exact position. Aura hysterica : first node ; globus hystericus, or second node ; cephalic phenomena or third node The starting-point of the first node is in the ovary. Lesions of the ovary ; desiderata. Relations between ovarian hyperesthesia and the other accidents of local hysteria. Ovarian compression. Its influence on the attacks. Modus operandi. Ovarian compression as a means of airesting or preventing hysterical con- vulsions known in former times. Its application in hysterical epidemics. Epidemic of St. Medard — the remedy termed "secours." Analogies which exist between the arrest of hysterical convulsions by compression of the ovary, and the arrest of the aura epileptica by ligature of a limb. Conclusions, from a theiapeutical point of view. Clinical observations. Gentlemen, — By the somewhat picturesque and certainly very practical term local liysieria, British authors are accustomed to designate most of the accidents which persist, in a more or less permanent manner, in the intervals between the convulsive fits of hysterical patients, and which almost always enable us, on account of the characteristics they present, to recognize the great neurosis for what it really is, even in the absence of convulsions. Hemioncesthesia, paralysis^ contracture^ fixed painful points occu- pying different parts of the body (rachialgia, pleuralgia, clavus hystericus), according to this definition, come under the head of local hysteria. Among these symptoms there is one which, on account of the predominant part it, in my opinion, plays in the clinical history of certain forms of hysteria, seems to me to deserve your entire atten- tion. I refer to the pain which is felt in one side of the abdomen, especially in the left, but which may occupy both sides, at the extreme limits of the ?iypognstric region. This is the ovarian pain, concerning which I said a few words in my last lecture; but I do not wish to make unreserved use of this term before justifying the hypothesis which it implicitly adopts — and this, I trust, will be an easy task. This pain I shall enable you to touch, as it were, with the finger, I OVARIAX PAIN. 217 in a few moments, and to observe all its characteristics, by intro- ducing to 3^our notice five patients who constitute almost the whole of the hysterical cases, actually existing among the 160 patients who occupy the department devoted in this hospital to women affected by incurable convulsive diseases, and reputedly exempt from mental alienation. II. You already perceive, from this simple indication, that iliac pain is a frequent symptom in hysteria; this is a fact long recognized by the majority of observers. Let it suffice, as regards former times, to mention the names of Lorry and Pujol, who, most particularly, noticed the existence of hypogastric and abdominal pains, in hysterical cases. It is singular, after this statement, to find that Brodie, who was perhaps the first to recognize all the clinical interest which at- taches to local hysteria, does not treat of abdominal pain in a special manner.^ It seems as of traditional custom that the practical spirit of English surgeons should be attracted by the clinical difficulties which the local symptoms of hysteria present. Mr. Skey, who in this respect may be regarded as continuing Brodie's work, in a very interesting series of lectures on local or surgical forms of hysteria,^ as he calls them, expatiates on the iliac pain, or pain of the ovarian region, which, in his opinion, is very common, and which, according to his view, but contrary to what really occurs, is chiefly met with in the right side. You are aware that, in France, Schutzenberger, Piorry, and N^grier, have laid special stress on this symptom, which they un- hesitatingly attribute to the abnormal sensibility of the ovary. In Germany, Romberg has followed Schutzenberger on this topic; however, it is to be remarked that, as regards our contem- poraries, most of the German authors pass in almost complete silence over all that relates to this hypogastric pain. This is the case, for instance, with respect to Hasse and Valentiner. Hence, it is clear that this symptom, after having enjoyed a certain degree of favour, doubtless on account of the theoretical considerations connected with it, has gone somewhat out of fashion, at present. Symptoms, also, as you see, have their destiny : Habent sua fata. I should not be surprivsed if the otherwise very legitimate influence of M. Briquet's work counted for a good deal in the production of this result. It now becomes our duty to examine how far we ought to follow this eminent author in the path which he has marked out for us. • Brorlie, * Lecture illu.>*trativp of certain nervous affections,' 1837. 2 F. C. Skej, ' Hysteria — Local or Surgical foims of Hysteria," six lectures, Loudon, 187U. 218 OVAKIAN PAIN. III. I am far from saying that M. Briquet did not recognize the very frequent existence of fixed abdominal pains in hysterical cases. lie has even coined a new word to designate these pains coelialgia (from xoi-kU^ the belly), and a word, even though it be merely a word, is still something that arrests the mind. In 200, out of 430 cases of hysteria, M. Briquet met with coelialgia. How- ever, I should point out to you that, under this name, he includes alike the pains of the upper part of the abdomen and those of the iliac and hypogastric regions, but the latter are confessedly the most common. At first glance, therefore, it seems as if the difference between M. Briquet and his predecessors were merely an apparent one. Now, it is nothing of the kind, and here is the chasm which divides them. Whilst MM. Schutzenberger, Piorry, and Negrier place in the ovary the chief seat — the focus, so to speak — of the iliac pain, M. Briquet only admits the existence of a simple muscular pain, an hysttrical myodynia. According to his view : 1st, pain of the pyra- midalis or of the lower extremity of the rectus abdominis has been mistaken for uterine pain ; 2d, pain of the lower extremity of the obliquus abdominis takes the place of the so-called ovarian pain. Such is the thesis of M. Briquet. IV. Let us investigate together, gentlemen, the basis on which this opinion rests. In order to arrive at our object, I am about to refer to the observations which I have been enabled to collect upon a large scale in this hospital. I shall, therefore, proceed to describe this pain, such as I have learned to know it. 1st. Sometimes it is an acute, nay, a very acute pain ; the pa- tients cannot tolerate the slightest touch, nor suffer the weight of the bedclothes, etc.; they shrink suddenly, and as if instinctively, from the finger of the investigator. Add to this a certain degree of tumefaction of the abdomen, and you have the clinical appear- ance o^ false peritonitis — the spurious peritonitis of British authors. It is manifest that the muscles and the skin itself share in the suf- fering here. The pain then occupies a considerable extent of the surface of the body, and, consequently, is not easily localized. However, Todd^ remarks, and I have frequently verified the accu- racy of his statement, that in certain cases, a circumscribed cuta- neous hyperassthesia occupies a rounded dermal space of from two to three inches in diameter. This hyperaesthesia has its seat partly • Tod(i, * Clinical Lectures ou the Nervous System.' Lecture xx, p. 448, Lon- don, 1856. AURA HYSTERICA — NODES. 219 in the hypogastrium, partly in the iliac fossa, and corresponds, ac- cording^ to this author, to the region of the ovary. 2d. In other cases, the pain does not spontaneous^ show itself; it requires pressure to discover it, and, under such circumstances, we note the following phenomena: «, there is a general anaesthesia of the shin; 5, the muscles, if relaxed, may be pinched and raised without causing pain; c, this preliminary exploration proves that the seat of the pain is neither in the skin nor in the muscles. It is consequently necessary to push the investigation further, and by penetrating, as it were, into the abdonsinal cavity by pressure of the fingers we reach the real focus of the pain. This operation allows us to make certain that the seat of the pain in question is usually fixed, that it is always nearly the same; and indeed, it is not uncommon to find that patients point it out, with p)erfect unanimity. From a line uniting the anterior superior spines of the ilia, let fall the perpendicular lines which form the lateral limits of the epigastrium, and at the intersection of these vertical and horizontal lines will be found the focus of pain, as indicated by the patient, and which becomes further manifest on pressure being applied by the finger. Deep exploration of this region allows us readily to recognize part of the superior inlet which describes an inwardly concave curve; this is our guiding point. Towards the middle part of this rigid crest, the hand will usually meet with an ovoid body, elon- gated transversely, which, when pressed against the bony wall, slips under the fingers. When this body is swollen, as often hap- pens, it may attain the size of an olive, or of a small Q^g, but with a little experience its presence can be easily ascertained, even when it is of much smaller dimensions. It is at this, the period of exploration, that the pain is chiefly determined; it then, manifests itself with characters which may be called specific. This is no common pain we have to do with, but a complex sensation which is accompanied by all, or some, of the phenomena of the aura hysterica ; such as they spontaneously show themselves before an attack. When the sensation is thus deter- mined, the patients recognize it as familiar — as having felt it scores of times. In short, gentlemen, we have succeeded in circumscribing the initial focus of the aura, and, by the same act, we have provoked irradiations in the direction of the epigastrium {the. first node oiihe, aura, to use M. Piorry's terminology) sometimes complicated with nausea and vomiting, then, if the pressure be continued, there soon supervene palpitations of the heart, with extreme frequency of the pulse, and finally, the sensation of the globus hystericus is developed in the throat (second node). At this point terminates the description, given by authors, of the ascending irradiations which constitute the aura hysterica. But, 220 AURA HYSTERICA — CEPHALIC SYMPTOMS. judging from my own observations, the enumeration of symptoms, if thus limited, would be incomplete; for an attentive analysis allows us to ascertain the presence, in most cases, of certain ce- phalic disorders which are evidently the continuation of the same series of phenomena. Such are, for instance (in case of compres- sion of the left ovary), the intense sibilant sounds in the left ear, which the patients compare to the strident noise produced by the whistle of a railway engine — a sensation as of blows from a ham- mer falling on the left temporal region — and, lastly, a marked ob- nubilation of sight in the left eye. The same phenomena show themselves in the corresponding parts of the right side, when pressure is applied on exploration of the right ovary. The analysis cannot be carried further, for when matters have arrived at this point, consciousness becomes profoundly affected, . and, in their confusion, the patients no longer retain the faculty of describing what they feel. Besides, the convulsive fit soon super- venes, if the experiment be persisted with. Leaving out of the question the phenomena which relate to the last phase of the aura hysterica (the cephalic symptoms), I have just been describing to you, gentlemen, the whole series of phenomena obtained in the experiment of Sohutzenberger, and we are thus led to acknowledge, with this eminent observer, that compression of the ovarian region, simply reproduces artificially the series of symptoms that spontaneously present themselves in the natural course of the disorder. I am well aware that, according to M. Briquet, the aura hysterica starts, in the immense majority of cases, from the epigastric node ; neither do I forget that, in support of his assertion, this author quotes an imposing array of figures. But we must not always bow to statistics, and it may be fairly asked whether M. Briquet, who has shown himself somewhat severe upon the "ovarists," has not in his turn allowed himself to be carried away by some preoccu- pation which made him neglect to inscribe the initial iliac pain in the series of phenomena of the aura. If I am to judge from my own observations, this iliac pain al- wavs precedes in point of t;me, however small the interval may be, the epigastric pain, in the development of the aura, and con- sequently it constitutes the first link of the chain. Y. It remains for me, gentlemen, to establish that this particular point, where the iliac pain of hysterical patients resides, corre- sponds exactly with the position of the ovary, then I shall have rendered it highly probable, if not absolutely demonstrated, that POSITION OF OVARY. ' 221 the painful oval body, whence the irradiations of spontaneous or provoked hysteria start, is really the ovary itself. Generally, I believe, an imperfect idea is formed of the precise position which the ovary occupies during life. When, the abdo men being laid open, and the intestines raised, we find in the pelvis behind the uterus, in front of the rectum, the appendages of the uterus flabby, shrunken, and as it were shrivelled, it is plain that we are in presence of appearances not at all answering to vital con- ditions. It is evident that, after death, the arterial network of the Fallopian tubes and of the ovaries (the vascular wealth and erectile properties of which have been so well illustrated by my friend Professor Rouget, of Montpelier), has long ceased to fulfil its func- tions. Again, it must not be forgotten that the laying open of the abdomen most certainly alters the true relations of the appendages of the uterus to other parts. This is proved by the fact that, in frozen corpses^ the ovaries occupy a more elevated position, —one which recalls to some extent their admitted position in the new- born inftint. In the diagram before you, which is copied from the 'Atlas' of M. Legendre, you see a horizontal transverse section of the body of a woman, aged 20; its plane passes three-quarters of an inch (2 centimetres) above the pubis, and divides one of the ovaries in twain, whilst the other, lying superior to it, escapes. From this it appears that, in the adult female, the ovary should be situated on a level with or even a little above the superior inlet, (or brim of the pelvis) jutting over into the iliac fossa along with the Fallopian tube. This result accords in every particular with that given by palpation applied to the living body. I will add that if you pass a long needle perpendicularly through a corpse laid on the dissecting table, at a spot corresponding with that where hysterical patients complain of iliac pain, you have every chance — as I have frequently found — of transfixing the ovary. This position of the ovary appears, in fiict, to have been im- plicitly recognized by Dr. Chereau in his excellent treatise on diseases of the ovary ,^ when he remarks that, in women, where the abdominal wall does not offer too great a resistance the tumefac- tion, or even the sensibility only, of the ovary may be ascertained. The introduction of the finger into the rectum would not be a superior mode of exploration, according to our author, except in cases where the abdominal parietes present an invincible obstacle. Gentlemen, after all these explanations which I have just dis- cussed, I believe I have a right to draw the conclusion that it is to the ovary, and the ovary alone^ we must attribute i\\Q fixed iliac pain of hysterical patients. It is true, that at certain epochs, and in severe cases, the pain, by a mechanism which I need not at present indi- ' E. Q. Legendre, * Auatomie Chirurgicale horaolograpliique,' etc., pi. X, Paris, 1858 2 Chereau, ' Etudes sur les maladies de I'ovaire,' Paris, 1841. 222 ' HYSTERICAL OVARIA. cate, extends to the muscles and to the skin itself, so as to justify the description given by M. Briquet; but I cannot too often repeat that, if limited to these external phenomena, the description would be incomplete and the true focus of the pain misapprehended. VI. This would be the place to investigate what is the anatomical condition of the ovary in cases where it becomes the seat of the iliac pain of hysterical patients. In the actual state of affairs, we can unfortunately only give you some rather vague information, in reference to this subject. There occasionally exists a more or less marked tumefaction of the organ, such as was found in the case of blennorrhagic ovaritis recorded in the memoir of M. Schutzen- berger. But this is rather an exceptional circumstance, and it is proper to remark that common inflammation of the ovary may exist with all its characters, and yet there shall supervene no irra- diations^ as described, neither spontaneously nor under the influence of pressure. M. Briquet has not failed to set this circumstance prominently forward, and here he is perfectly right. Hence we must emphatically declare that every ovarian inflammation is not indifferently adapted to provoke the development of the aura hysterica. Ovarian tumefaction in hysterical patients is sometimes completely absent, at- other times it is but little marked; and it seems probable enough that the tumefaction of the ovary, in such cases, is the result of a vascular turgescence analogous to what is exhibited after the occurrence of certain neuralgic affections. Patho- logical anatomy has not hitherto supplied us with any positive data in relation to this question ; at present, therefore, you may desig- nate the state of the ovary either by the term hyperhinesis (Swe- diaur), or ovarialgia (Schutzenberger), or ovaria (N^grier) — the name, indeed, matters little, when the fact is well established. YII. It being conceded that the ovary is the starting-point of the aura hysterica, at least in a group of cases, it vvill not be uninteresting now to show that an important and, in some sort, an intimate relation exists between the ovarian pain and the other phenomena of local hysteria. You can in fact discern, gentlemen, in the patients to whom I call your attention a remarkable concord between the seat of the iliac pain and the manner in which the concomitant symptoms are localized. I will not revert to the cephalic phenomena of the aura which, as I stated a little ago, are manifested on the same side with the ovarian pain; I will confine myself to showing that the hemi- anoesthesia^ i\iQ paresis^ and the contracture of extremities^ occupy the HYSTERICAL OVARIA. 223 left side when the ovaria is situated on the left, and vice versa. I will also point out to you that when the ovarian pain occupies both left and right sides, the other phenomena become hilateral, pre- dominating however on the side where a greater intensity of iliac pain is felt. On several occasions, we have noted in some of our patients an abrupt change of the seat of ovarian pain. The patient Ler — is one of these. When the ovaria, in her case, predominated in the left side, the cephalic symptoms of the aura, the contracture of ex- tremities, etc., showed, for the time, their maximum of development on the same side — predominating afterwards on the right side, when the right ovary became again the more painful. It must not be forgotten that ovarialgia appears to be a constant phenomenon, one eminently permanent, in the form of hysteria winch engages our attention, so that, taken in connection with some other indication of the same category, it may guide your diagnosis in difiicult cases. YIII. It remains for me now, gentlemen, to enter upon an exposition of facts which will probably be considered by you as the main feature of this study. These facts, in reality, are of a nature, if I err not, to set out in still greaterprominence the truly predominant part pertaining to ovarialgia in one of the forms of hysteria. You have just seen how methodical compression of the ovary can determine the production of the aura, or sometimes even a perfect hysterical seizure. I propose now to show you that a more energetic compression is capable of stopping the development of the attack when beginning, or even of cutting it short when the evolu- tion of the convulsive accidents is more or less advanced. This, at least, is what you can very plainly discern in two of the patients whom I have placed before you. In their cases, the arrest of the convulsion, when compression has been properly applied, is total and final. In the others, the manipulation merely modifies the phenomena of the seizure in varying degrees, without, however, producing complete cessation. And be kind enough to note care- fully that we have to deal in all of them, not with common vulgar convulsive hysteria, if I may so express myself, but with convulsive hysteria in what is unanimously recognized as its gravest type — I mean hystero-epiUpsy. Let us suppose that one of these women is taken with a seizure. The patient suddenly falls to the ground, with a shrill cry ; loss of consciousness is complete. The tetanic rigidity of all her members, which generally inaugurates the scene, is carried to a high degree ; the body is forcibly bent backwards, the abdomen is prominent, greatly distended, and very resisting. 22i OVARIAN HYSTERIA. The best condition for a perfect demonstration of the effects of ovarian compression, in such a case, is that the patient should be laid horizontally in dorsal decubitus, on the floor, or, if possible, on a mattress.* The physician then, kneeling on one knee, presses the closed hand or fist into that iliac fossa, which he had previously learned to regard as the habitual seat of the ovarian pain. At first, he must throw all his strength into the effort in order to vanquish the rigidity of the abdominal muscles. But, when this is once overcome and the hand feels the resistance ofl'ered by the rim of the pelvis, the scene changes and resoluticm of the convulsive phenomena commences. The patient soon begins to make numerous and sometimes noisy attempts to swallow ; then consciousness returns almost at the same time, and now the woman either moans and weeps, complaining that you are hurting her (as in the case of Marc—) or else she ex- periences relief, and testifies her gratitude; ''Ah! c'est bien! cela fait du bien !" is always the cry of the patient Gen — , under such circumstances. Whichever happens, the result in short is always the same, and if you but continue the pressure for two, three, or four minutes, you are almost certain to find all the phenomena of the seizure disappear as if by magic. You may, besides, vary the experiment and at your pleasure, by removing the compression and again ap- plying it, you can stop the seizure or allow it to recur as often almost as you like. When once we have definitely overcome the obstinate resist- ance which the abdominal parietes always offer at first, it is not necessary to employ all one's strength, and the application of the two first fingers of the hand to the presumed seat of the ovary is sufficient to produce the desired effect. Plowever, the operation, if it require to be prolonged for some minutes, is always rather fatiguing to the physician. I have contemplated modifying the modus operandi. Perhaps, you might make use of a bag filled with shot, such as M. Lannelongue has employed for a diff'crent purpose, or the appli- cation of an appropriate bandage might be tried — this is a question to be considered. At present, the assistants in the wards who have been instructed in the method of manipulation described, apply it day by day in the case of those patients to whom it is really beneficial. ' It may not be amiss to remark that, if the seizure occur whilst the patient is reposing, the method of compression described can also be applied without remov- ing her from bed. Applied in this manner, by Professor Charcot, I have been a witness to its instantaneous eflfect, in the hysterical wards of La SaltpGtriere. (S.) COMPRESSION OF THE OVARY. 225 IX. Tt is singular enough, gentlemen, that a method the practice of which is so simple and which, undoubtedly, is capable of rendering real service, should have fallen, as it has fallen in our days, into complete disuse. As I have already intimated, the invention of this process is far from being my own : it may possibly be traced to a very ancient period ; it is certain that it dates from a time ante- rior to the sixteenth century. The following is what I have learned in reference to it, from some researches made rather hurriedly, amongst the dustiest, and therefore the least frequented, volumes of my library. Willis,^ in the 17th century, in his treatise on convulsive disease, expressed himself as follows: 'It is certain,' he says, 'that the con- vulsive spasm which comes from the belly is arrested and can be prevented from ascending to the neck and head by a compression of the abdomen, determined by arms being clasped round the body, or by means of bandages drawn very tight.' He states also that he succeeded himself in stopping a fit, by pressing energetically with both hands joined together upon the lower part of the belly. But Mercado^ (in 1513) had long previously advised the use of frictions on the abdomen, with the object of reducing the womb, which he supposed to be displaced, according to the old doctrine.^ One of his countrymen, Monartes, it seems, went about it in a more determined manner, for he placed a large stone on the patient's belly during the seizure. It does not appear, however, that this custom prevailed widely; fori do not find it mentioned in Laz. Riviere, nor in F. Hoffmann. Boerhave alone, at the beginning of the 18th century, insists anew upon compression of the abdomen duiing the hysterical seizure; it should be applied, according to him, by means of a cushion placed under sheets drawn tight, and extending from the false ribs to the crests of the ilia. In this manner, he says, you give almost certain relief to the patient, provided the sensation of the globus hystericus has not yet ascended beyond the diaphragm.'* In modern times, Recamier, reviewing this method, which, as you see, was already ancient, placed on the belly of the patient a cushion upon which an assistant took his seat. His example has been but little followed, so far as I am aware, except by N^grier, the Director of the School of Medicine of Angers, whose 'Collec- tion of facts relating to the history of the ovaries and of the hys- J Willis, ' De Morbis Convulsivis,' t. ii, p. 34. 2 D. L. Mercatua, ' Opera, tit. iii, De virgiuum et viduaram affectionibus,' p. 546, Francof, 1620, 3 JNegrier, " Receuil de faits pour servir a I'liistoire des ovaires et des aftectious hysteriques de la femme," Augers, 1858, pp. 158, 169. * Vau Swieteu, 'Comon.,' t. i.i, p. 417. 15 226 HISTORICAL SKETCH. terical affection of females,' published in 1858, does not, however, appear to have attracted much attention. The process adopted by N^grier is a more methodical one than those employed by his predecessors; in the application of compression, it is the ovary he aims at, 'a strong and broad pressure exerted by means of the hand upon the ovarian region is sufficient in many cases,' remarks Negrier, 'to ward off and completely suppress the convulsive seizure.' But, let us put aside for awhile the methods of regular medical practice, and see what have been the processes by means of which, in certain celebrated hysterical epidemics, the assistants gave relief to the "convulsionnaires." Among the modes of succour adopted, we find mention made of one very curious custom well worth examining, the original notion of which must, in all proba- bility, have been owing to the suggestion of some "convulsion- naire;" I allude to compression of the abdomen. There are, in fact, hysterical patients, who, on experiencing the premonitory pains of the aura, instinctively seek relief in compression of the ovarian region. Such is the case, for instance, as regards one of our pa- tients, named Gen — , whose symptoms have been already discussed. This woman has long been accustomed to arrest the development of a seizure by compressing the left ovary; she generally succeeds when the invasion of the attack does not take place with great mpidity. If she fail in her effort, she calls on the attendants to help her in the operation. Let us examine a little more closely these incidents of convulsive epidemics, as we find them narrated in history: they supply mate- rial for a retrospective study which is not devoid of interest. The learned Hecker, writing of those who were affected with St. John's Dance,^ remarks that they frequently complained of great epigastric pain, and requested to have their abdomen com- pressed by bandages. But, in reference to this subject, we find the most interesting documents in connection with the epidemic of St. Medard,^ as it is called. You are aware how this took place when the religious exaltation of the Jansenists, persecuted on account of the Bull Unigenitus, was at its climax. The epidemic, which began at the tomb of Deacon PSris, who died in 1727; presented two distinct periods. The first was chiefly remarkable, at least from our point of view, on account of the cure of a certain number of sick persons, amongst whom were several suffering from well attested permanent hysterical contracture.* In the second period, predominated con- » Hecker, "Dansede St. Jean," Aix-la-Chapelle, 1374, " Epidemie de St. Witt," h. Stia-bourg, 1437. 2 Cane de Montgeron, loc. cit. 3 Bourneville and Voulet, " De la contracture byat6rique permaiiente," pp. 7-17, Paris, 1872. HYSTERICAL EPIDEMICS. 227 vulsions of a more or less singular character, but which, in short, differ in nothing essential from those which characterize hysteria when it assumes an epidemic form. Now, it was at this period that the practice of giving the secours (as it was called) made its appearance in the epidemic of St. Medard. Of what did this succour consist? In most cases methods were employed to cause firm compression of the abdomen, or else vio- lent blows were given it with some instrument. Thus there were: 1st, the succour administered by means of a heavy andiron, with which the abdomen was repeatedly struck; 2d, the succour given by means of a wooden beetle or large pestle, which differs little from the former; 3d, in this case, a man clasped his two fists to- gether and thrust them, with all his might, against the abdomen of the "convulsionnaire," and, the better to succeed, he called other men to assist him; 4th, three, four, or even five persons got upon the body of the sufferer — a "convulsionnaire," called by her co- religionists, Sister Margot, had a particular predilection for this species of succour; 5th, finally, there is a case where long bands were disposed so that they might be drawn tight to left and right, and thus compress the abdomen. These modes of succour, which- ever kind was adopted, were always, it appears, followed by great relief. Hecquet, a physician of the period, declined to see in these con- vulsions, which others attributed to divine influence, anything but a natural phenomenon, — and so far he was perfectly right. But I cannot share his opinion when, in his work entitled, 'Du Naturalisme des Convulsions,' he maintains that the modes of succour were nothing else than practices suggested by lubricity. For my own part, I do not well see what lubricity could have to do with blows of pestles and andirons administered with extreme violence, al- though I am far from forgetting what a depraved taste may give birth to, in this affection. I believe it is very much simpler and very much more legitimate to admit that the succour — apart from the amplifications suggested by a love of notoriety — corresponded to an empirical practice, the result of which was to give great relief in cases of hysterical seizures. X. You have assureilly remarked, gentlemen, the analogies which exist between this arrest of hysterical or hystero-epileptical con- vulsions, determined by abdominal compression, and the arrest of convulsions which is sometimes effected by a lifjnture of the limb from which the phenomena of the aura, in such cases, take their rise. This, perhaps, is the place to remind you that a sudden flexure of the foot causes, as M. Brown-Sequard has shown, the immediate cessation of the convulsive tremulation of spinal epilepsy^ 228 CONCLUSION. observable in certain cases of myelitis. You are not aware that, in experimental pathology, these clinical facts find, to some extent, their explanation. I cannot «nter into details at JDresent, let it suffice to remind you that numerous experiments on animals bear testimony to the fact that suspension of reflex excitability of the spinal cord may be caused by irritation of the peripheral nerves. Thus, the experiment of Herzen shows us that, in the case of a decapitated frog (which was consequently placed in an excellent condition to augment to the utmost the reflex excitability of the spinal cord), if the lower portion of the cord be irritated it will be impossible, so long as this excitation subsists, to call into action the excitability of the superior extremities. And, on the other hand, if you tie a ligature tightly round the upper extremities of a frog, similarly decapitated, so long as this ligature remains, the excitation of the inferior extremities will not be followed by reflex movements. This, at least, is what is demonstrated by Lewisson's experiment. However, although these facts are more easily analyzed they are not, in the actual state of science, more easily explained than the corresponding phenomena observable in man. XT. Time presses, and I cannot dwell any longer upon this subject. I should, however, have liked to show you the importance, from a practical point of view, of suppressing severe fits of hysteria, or, at least, of moderating their intensity. But this aspect of the question may be more appropriately illustrated when I shall have described, in another conference, the consequences which follow reiterated fits, — otherwise termed the hydero-eqnleptical acrae} I will confine myself, at present, to formulating as follows, one of the conclusions deducible from the present study: — Energetic compression of the painj al ovary has no direct influence over most of the permanent symptoms of hj/steria, such as contracture, paralysis, hemiayicesthesia , etc.; hut it has a frequently decisive effect xipoyi the convulsive attack, the intensity of which it can diminish, and even the cessation of which it may sometimes determine, XII. I have, in conclusion, gentlemen, to introduce to your observa- tion the patients whom I have had chiefly iu view in the preceding description, and to point out the most salient peculiarities which they present. 1 In French, elnt-de-mal h/st^ro-epileptiqw. French pathologists employ the terra etat (status aKjun) to rovoked trepidition of the. foot. (J. M. C.) ' According to Herr Hasse (' Handbuch der Path.,' etc., 2 Auflag, Erlangen, 1869) Herr Althaus was tlie first to point out the absence of facial paralysis, and of lingual and buccal deviation in liysterical hemiplegia. This is not the case ; the character in question had been, previously, prominently set forth in R. B. Todd's "Lectures on the Nervous System." 2 V. ante. Lecture X on " Hemianaesthesia." 238 CHARACTERS OF HYSTERICAL CONTRACTURE. respect to the mode of evolution of her affection. The following is a succinct account of her history. There were not, it appears, any hysterical antecedents in her case. The disease set in, when she was 34: years of age, after a violent moral shock, with a seizure accompanied by loss of con- sciousness. This attack, according to all probability, assumed the epileptic form of hysteria. Etch — , in fact, fell during the fit into the fire, and she bears on her face the traces of the burn which she then received. Renewed attacks, at times plainly hysterical, at times exhibiting some of the aspects of epilepsy, supervened, re- peatedly, during the following years; but, at the age of 40, appeared the permanent symptoms of hysteria which we have at present to study. We should, therefore, mention in what concurrence of cir- cumstances they were developed, for we shall find there some characteristic features. a. Menstruation which, until then, had been regular, became disordered ; the patient, from time to time, had vomitings of blood ;^ there was considerable tympanites, with acute pain on pressure in the left ovarian region. This pain was of a special character, being accompanied by peculiar sensations which radiated towards the epigastrium, and which were noticed by the patient as heralding most of her seizures. These symptoms, including the tympanites, and retention of urine, are still in existence. b. Almost simultaneously with the occurrence of these pheno- mena. Etch — became subject to persistent retention of urine, w.hich necessitates the constant employment of the catheter. c. Matters were still in this state, when, in October, 1868, there supervened a very severe attack, accompanied by convulsions and followed by an apoplectiform condition with stertorous breathing ; then hemiplegia suddenly made its appearance. Now, gentlemen, this considerable tympanites^ these pains in the ovarian region, this retention of urine^ constitute a group of symp- toms the importance of which is nearly decisive in diagnosis. Nothing similar is to be seen in the premonitory symptoms of hemiplegia arising from cerebral lesions, whilst it is very common, on the contrary, to find these symptoms preceding the appearance of the permanent phenomena of hysteria, whether hemiplegia or paraplegia. This is a point which M. Briquet has not failed to bring out; it is likewise properly noticed, so far at least as hys- terical paraplegia is concerned, by Dr. Laycock, in the following terms: "In hysteria, more or less severe paralysis of the lower extremities is always accompanied," he might have added, "and preceded," " by a corresponding degree of perturbation in the func- tions of the pelvic viscera ; this perturbation is manifested by con- • This is a frequent accident in hysterical patients, when there is a notable derangement of the catamenia. HEMIPLEGIC AND PARAPLEGIC FORMS. 239 stipatioti, tympanites, vesical paralysis, increase or diminution of the urinary secretion, ovarian or uterine irritation, etc."^ d. When Etch — was admitted a year ago (June, 1869) to La Salpetri^re, the hemiplegia had been seven or eight months in ex- istence. Independently of the characteristic peculiarities, already mentioned, the state of the paralyzed members could be, itself, quoted in favour of the hysterical origin of the paralysis. Thus, whilst the upper extremity was in a state of complete and abso- lute flaccidity, the lower extremity presented a very marked rigid- ity of the knee. This would be a considerable anomaly in a case of hemiplegia, consecutive on cerebral lesion ; for, in such a case, the slowly ensuing rigidity prefers to manifest itself in the upper extremity. c. The contracture which at present occupies the upper ex- tremity, only dates from a few months back, and it was developed suddenly, and without transition, after a seizure. It is not in this way, as you know, that we find the tardy contracture supervening, which results from hemorrhage or ramollissement of the brain. In the latter case, contractuie always sets in slowly and in a progres- sive manner. Thus, gentlemen, by taking note of all the circumstances which have just been enumerated, nothing is more easy than to ascertain the real cause of the disease in the case of our patient Etch — . In the following observation, which relates to a case of hysterical paraplegia,^ the same facilities for making a differential diagnosis may be found. 11. Alb — , aged 21 years, a foundling, has been afiected for about two years with permanent contracture of the inferior extremities, which are, as you may observe, in extension and quite rigid. As in the case of Etch — , muscular contractility is not diminished. The members are emaciated, but this emaciation affects them gen- erally, and is due to the fact that the patient is subject to almost uncontrollable vomitings, which hinder her from taking sufficient nutriment. We have likewise to note an almost complete anal- gesia of the paralyzed members. Now, the following are the thoroughly decisive symptoms which allow us to establish the diagnosis. a. Alb — ■ has been subject to hysterical fits since she was sixteen years of age; Z>, she has been for four years affected with retention of urine, which generally requires the employment of the catheter ; c, she presents enormous tympanitic distension of the abdomen ; d^ ' ' Treatise on the Nervous Diseases of Women,' London, 1840, p. 240. 2 This case was already referred to in Lectnre XL A detailed account of the syniptoms may be found in tlie memoir, ' Comte-rendu des observations recueil- lies h, la SalpGtriere, coucernant I'epilepsie et I'hystero-epilepsie.' (B.) 240 HYSTERICAL CONTRACTURE — PROGNOSIS. the ovarian regions are painful on pressure, and if the exploration be pressed, an hysterical seizure is soon provoked ; e, contracture of the inferior extremities supervened suddenly, without transition, and this is a symptom which we have already had occasion to emphasize in the preceding case. Now, such symptoms are not to be met with during the progress of sclerosis of the lateral columns. III. Thus, gentlemen, nothing, I repeat, is simpler than the clinical interpretation of these two cases, so far as the diagnosis is con- cerned. But here is a point where, in these and in analogous cases, serious difficulties may arise. What will become of these patients? In their case, paralysis with contracture has persisted, without amendment, for four years. Will this contracture sonie day be resolved, or will it, on the con- trary, persist indefinitely, and so become an incurable infirmity? These are questions which we must ask, without, however, pledg- ing ourselves to give categorical answers. A. It is possible that, in spite of its long duration, this contrac- ture may, without leaving any trace of its existence, disappear — perhaps to-morrow, or in a few days, or a year hence. We can foretell nothing concerning it. In any case ^ if recovery takes 2^l(^ce, it may be sudden} From one day to the next, resumption of the * Dr. Layuock remarks that a woman may have been bed-ridden for several mouths, and quite unable to use her lower extremities, tlie pliysician may have given up all hope of being of any assistance to her, when suddenly, under the influence of some potent moral cause, she will be seen to rise from her bed *' no loneer the victim of nerves, but the vanquisher," as Thomas Carlyle says, and walk about as well as if she had never been stricken with paraplegia. This is one of the terminations of hysterical paraplegia which the physician should never lose sight of, and which well shows what risk he runs in pronouncing a case of this kind to be incurable. T. Laycock, * A Treatise on the Nervous Diseases of Women,' London, 1840, p. 289. (Note to first French Edition.) This anticipation was fulfilled durino: the present year, as regards the first men- tioned of the two patients to whom allusion was made in this passage, italicized in the first edition. The state of Etch — on the 21st of May, may be tlius summed up: retention of urine, with periodic ischuria, during nine years ; contracture of the right lower extremitv ; contracture of the members on the left side, of six years' standing: contracure of the jaws, necessitating the use of the stomach- pump, of one year's standing ; aphonia, lasting during ten months. On the 22d May, at a quarter past seven o'clock in the evening, she was seized with a fit, marked chiefly by great oppression : contracture of the neck-muscles, on the left, which twisted the chin b»^hind the left shoulder. The patient does not lose con- sciousness, she believes she is going to die ; she shrieks — tlie contracture of the jaws vanishes. She tosses about, the attendants endeavour to restrain her ; with her right arm, which iias become free, she repels those who hold her. She wants to go to the window for air ; and, being opposed, her passion increases, and under this influence it was observed that contracture of the right leg disappeared, and that this was followed by disappearance of that of the left leg, and next by that of the left arm, in succession. Etch — is allowed to rise; she walks about; in eighteen hours recoveri/ was complete, or nearly so. Dating from the next day, tlie urinary secretion became normal again. The amblyopia and anesthesia SUDDEN" RECOVERY 241 normal state may occur; and if it should happen, that at this pe- riod the hysterical diathesis is exhausted, the patients may once more take their place in everyday lil'e. In connection with this, gentlemen, I cannot resist pausing a moment in presence of these rapid and often unhoped-for recoveries from a disease which, during such a length of time, had made itself remarkable on account of its tenacity and its resistance to all thera- peutic agents. A sudden strong emotion, a concurrence of events taking powerful hold of the imagination, the reappear- ance of long-suppressed cata- menia,etc. — occurrehcessuch as these are frequently the occasions of those prompt recoveries. I have seen in this hospi- tal, three cases of the kind which I request your permis- sion to briefly summarize. 1st. In the first case, there was contracture of a lower extremity (fig. 23), of at least four years' standing. On ac- count of the misconduct of this patient, I was obliged to give her a stern admonition and declare that I should turn her out of the hospital. Next day, the contracture had entirely disappeared. This fact is the more im- portant, because convulsive hysteria existed only as a bye-gone fact in her memory. For two or three years past, the contracture had been the only manifestation of the great neurosis. 2d. The second case, like- wise, concerns a woman af- fected by a permanent contracture of one member only. The hys- terical crises, proper, had long disappeared. This woman was Fig. 23. —Hysterical contracture of the right lower extremity. did not completely disappear until a few days bad elapsed, and the patient has only retained some cracking sound in her joints, principally in those of the left leg, as vestiges of her permanent contracture. In conclusion, the only traces of former accidents to-day, are some slight cracking sounds in the joints of the limbs previously aflFected by contracture. (B.) (Note to the Second French Edition.) 16 242 INCURABLE CONTRACTURE. charged with theft; the contracture, which had lasted for two years, vanished suddenly on account of the moral shock caused by this accusation. 3d. In the third case, the contracture had assumed the hemi- plegic form ; it affected the right side, and was particularly evident in the upper extremity. Recovery took place almost suddenly, eighteen months after invasion, on account of a sudden disappoint- ment. At that time there was no anaesthesia, and the patient, whilst confessing to having experienced strange nervous derange- ments, denied the existence of any real hysterical seizures in the past. It is necessary to recognize, gentlemen, the possibility of those recoveries which, even at the present day, have been cried up as miraculous by some, but of which only charlatans take the credit to themselves, in self glorification. In former times, similar cases were frequently cited, when it was sought to prove before sceptics the influence of the supernatural in therapeutics. From this point of view, you will read with interest an article published in the Revue de Philosophie Positive (ler Avril, 1869), by the venerable M. Lit- tre. I allude to an essay entitled, Un fragment de Medecine rSiro- spective (Miracles de Saint Louis), in which is found an account of several cases of paralysis cured after pilgrimages to St. Denis, to the tomb where the mortal remains of King Louis IX had recently been deposited. Three of these cases are especially interesting to us on account of the exactness of their details. They relate to women, still young, who were suddenly seized with contracture of one of the lower extremities, or of both members on the same side of the body, which likewise presented considerable anaesthesia. In these cases, recovery took place suddenly, in the midst of circumstances well adapted to strike the imagination. You see, gentlemen, that things have little changed since the close of the thirteenth cen- tury.^ But if the recovery of these patients is possible, and even prob- able, it does not necessarily take place, and it may be that the con- tracture will persist, as an incurable infirmity. This is an asser- tion, which it will not be difficult for me to justify. But, allow me to point out to you that, in most authors, you will only find vague, uncertain, and far from satisfactory assertions in reference to this subject. a. I introduce to you a patient, now aged 55 years, who, eighteen years ago, was seized, after an hysterical attack, with paraplegia accompanied by contracture, the principal characters of which you ' Very little, in reality, for the professedly miraculous cures, concerning which so much noise has been made in these later days, do not differ in any perceptible character from the miracles of Saint Louis. The reader may convince himself of this by a perusal of the work recently published by M. Diday, entitled, * Exameu Medical des Miracles,' etc., Paris, 1873 (Bourneville). SCLEROSIS OF LATERAL COLUMNS 243 can still recognize. At the beginning, the contracture from time to time gave evi- dence of temporary amend- ment. But, for over sixteen years, it has never under- gone the least modification. In this case, we have a real rigidity of the muscles, with predominance of the action of the extensors and adduc- tors. Even after sixteen years of immobility of the lower extremities, the liga- mentous parts are not af- fected, at least not in the knees, as we have been ena- bled to verify by an explo- ration made when the pa- tient was under chloroform. The deformity of the feet alone, which resembles that of talipes equino-varus, was not modified during this ar- tificial sleep. The muscles of the legs and thighs are markedly atrophied, and fa- radic contractility is dimin- ished there. During many years, hysteria seems to have been completely exhausted in this woman, and it has become very im- probable that any event could henceforth alter, in any way, the state of her lower extremities. (Fig. 24.)^ h. What condition then has supervened thus to maintain the existence of this paraplegia with rigidity of the limbs? Evidently, in recent cases of hysterical contracture, the organic modification which produces permanent rigidity, whatever it may be, whatever seat it occupy, is very slight, and very fugitive, since its correlated symptoms may disappear suddenly and without transition. It is certain that, with the means of investigation which we possess at the present day, the most minute necroscopic scrutiny would not be capable of discovering, in such cases, the traces of this altera- tion. But is it the same with respect to inveterate cases? No, gentlemen, I believe I can assert, basing my opinion on my know- ledge of an analogous case, that in this woman there supervened. Fig. 24. — Hysterical contracture of both in- ferior extremities. 1 For a detailed account of this case see p. 53 of the memoir entitled ' De la contracture permaneute,' etc. (B.) 244 SCLEROSIS OF LATERAL COLUMNS. at a certain period, a sclerous lesion of the lateral colunnns, which would be discernible now, if an examination were possible. It has happened to me, in fact, once to discover, in the case of an hysterical woman (who was for ten years affected with con- tracture of all four members, which had suddenly supervened), a sclerous lesion which occupied symmetrically the lateral columns throughout nearly the whole length of the spinal cord. On seve- ral occasions this woman experienced temporary remissions of the contracture, but after a last seizure, it had become definitely per manent.^ It is undoubtedly legitimate to draw from the foregoing fact.s^ some inductions relative to the pathological physiology of hysterical ' Societe Medicale des HSpitaux, Seance du 25 Janvier, 1865. Precisely as we, sonietimes, find a spinal lesion, anatomically perceptible, in inveterate eases of liysterical contracture, so also may visual troubles be accompanied by lesions of tbe fundus, wliich an ophthalmoscopic examination will reveal. A student of La SaltpStriere, M. A. Svynos, has given in his inaugural thesis (' Des Amblyopies et des Amauroses Hysteriques,' Paris, .Juiliet, 1873) nearly all that relates to this subject. He has, in particular, described in detail the ophthalmoscopic phe- nomena noted on different occasions in the case of Etch — . In this case, which has been repeatedly referred to (Lecture IX and XI), no lesion was discovered for a long time in the fundi's of the left eye, affected by hys- terical amblyopia ; but a later examination, made March 20th, 1873, by M. Gale- zowski, revealed the following alterations: 1st, the papilla is uniformly red over its whole extent, a phenomenon consecutive on cipillary congestion ; 2d, the h tr- ders oj the papilla are effaced, blurred, on account of a diffuse serous exudation which extends along the vessels over the retina ; 3d, the principal branch of the central artery, which is distended in the lower part of the retina, presents a fusiform dila- tation, whilst near the papilla it seems to be in a state of spasmodic contraction. According to M. Galezowski : "There is reason to suppose that all these disorders are due to spasmodic contraction of the arteries in some places, and their dilatation in others. Hence the occurrence of papillary congestion in some parts, and of anfemia in others, a state of things resulting in peri-papillary serous infiltration.'' (B.) See also the case recorded by M. Bonne toy, in ' Le Mouvement Medical,' 1873, p. 276. (Note to the First Edition.) In all the patients affected by hysterical a7nhIi/op a, who were recently examined by M. Landolt at La Salp&triere, the visual field for white and for colours was found to be concentrically diminished, even in cases where visual acuity and cen- tral perception of colours are normal in the eye of the non-anaesthetic side. All the functions of the retina of the eye, on the affected side, have proportionately de- creased 2 To the cases mentioned by M. Charcot, the following, noted in his wards, should be added, confirming as it does his teaching in every particular. Berthe Chat — , aged 18 years and a half (July, 3 873), was subject from child- hood until her twelfth year, to epistaxis, always supervening in the right nostril ; and from the age of twelve until she was fifteen, to cephalalgia, afl'ecting her at monthly periods nearly. At fifteen, without any known cause, and irrespective of any appreciable hereditary influence, she had suddenly a convulsive seizure, with loss of consciousness. Rare during her sixteenth and seventeenth years, these attacks were multiplied in the course of her eighteenth year. Some of them, which belong to the category of simple hysteria, recur during every two or three months ; others partaking of the nature of hystero-epilepsy appear every month, with tolerable regularity. The occurrence of the catameiiia (in January, 1873) did not modify, iu any perceptible manner, the frequency and character of the convulsions. HYSTERICAL CONTRACTURE — PROGNOSIS. 245 contracture. According to the considerations we have mentioned, the lateral columns, or at least their posterior portions — which pre- side over permanent contracture in cases of disseminated or fasci- culated sclerosis — are indicated as being the seat of organic modi- fications, which are at first of a temporary character, and give rise to hysterical contracture. In the course of time these modifica- tions, whatever they may be, give place to deeper material altera- tions, — genuine sclerosis is established. This may not be, perhaps, beyond the resources of our art, but, in any case, its existence most assuredly no longer allows us to hope for that sudden disappear- ance of contracture which forms one of the most striking characters of the disease, when it has not as yet reached the most advanced phases of its evolution. Does there exist any sign which would enable us to indicate, with certainty, the character of the case; to ascertain, for instance, whether the sclerosis has, or has not definitely taken up its abode in the lateral columns? I do not believe, gentlemen, that in the actual state of science, a single symptom can be mentioned which offers, in this respect, an absolute worth in prognosis. Convulsive irepklfUion o^ i\\Q contractured members, whether pur- posely induced, or spontaneously supervening {spinal epilepsy)^ a certain degree of emaciation of the muscular masses, a slight dimi- nution in the energy of electrical contractility, ought not, judging from my own observation, to make us altogether despair of seeing the contracture disappear, without leaving any trace behind. On the contrary, atrophy, limited to certain groups of muscles, espe- cially if fibrillary contractions be added, similar to those we At the time of her admission to La Saltpetiiere (Se-t. 1872), this young eirl pre- sented ou her right side : 1st, comiletehemianaestliesia ; 2d, ovarian hy[)ersestlie- sia. October 8. — After an attack, accompanied hy delirium Lasting for about twelve hours, contracture of the right lower extremity witli talipes eqiiiiio-varus super- vened ; the contracture is complicated by an almost constant tremulation (spinal epilepsy). From the 10th to the 25th of October, the situation is unchanged, in spite of the occurrence of a liystero-epileptic fit. October 30. — Convulsive paroxysms, in which hysteria predominates. During the second paroxysm, the persons who held the patient lest she might hurt her- self, felt the right leg, vrhicii till then had been in extension, become suddenly flexed upon the thigli, and when the patient came to her senses, the contracture had ceased. Chat — retained a certain degree of debility in the right inferior ex- tremity, principally in the foot which was turned inwards. November. — ]]erihe walks without limping: the right foot stitl turns inwards occasionally, and its point knocks, at times, against the left foot. Sometimes, also, the right leg is taken with a trembling which lasts five or six minutes, and which is followed by a sort of numbness that generally remains during the course of the day. "Then I can no longer feel my leg," says the patient. 1873.— The muscular debility has progressively diminished. To day (July 8) Chat — is as strong on one side of the body as on the other ; the right hemiana&s- thesia and ovarian pain have not changed. This case is an additio-nal proof that hysterical paralysis, with contracture, may suddenly disappear without the assist- ance of any intervention. (B.) 246 HYSTERICAL CLUB-FOOT. observe in progressive muscular atrophy, or a very marked de- crease of faradic electricity, ought to make us suppose not only that the lateral columns are profoundly injured, but, also, that the anterior cornua of the gray substance have been invaded. I have not observed, up to the present, these latter symptoms except in cases of hysterical contracture of very old standing, and which left but little hope of ever again seeing the affected members resume their normal functions. I will add, in conclusion, that the existence of a spinal organic lesion, of more or less gravity, will be placed almost beyond doubt if, under the influence of sleep induced by chloroform, rigidity of the members only gives way slowly, or even persists to any marked extent. In my opinion, so long as these symptoms are not distinctly manifested, we should despair of nothing. It is besides important not to forget that lateral sclerosis, even when completely established, is far from being an incurable disorder, as I hope soon to prove to you. In the case of the patients to whom I have called your attention, the contracture occupied either tVie whole of one member or of two members, or even more. But there are cases in which spasmodic rigidity remains limited to some portion of a member, as the foot for instance, when it produces a sort of hysterical club-foot (talipedal distortions, of M. Laycock). Quite recently, Dr. R. Boddaert com- municated to the Medical Society of Ghent a most interesting case of this kind.^ The contracture had occasioned the deformity, known as talipes varus. Similar cases have been collected and published by Dr. Little,^ by C. Bell,' by Dr. F. C. Skey,-* and by some other authors. If it were not for certain reasons of propriety, I could, in my turn, gentlemen, relate in all its details the history of a case which resembles that published by M. Boddaert. Let it suffice to inform you that a young girl, at present twenty- two years of age, very nervous, and belonging to a family in which nervous affections predominate, was, three years ago, suddenly seized with painful contracture of the muscles of the left leg; it could be assigned to no cause, and she had not previously shown any characteristic symptom of hysteria. This contracture, which made the foot assume the attitude of most marked talipes equino- varus, gave way to several remissions in the course of the first year, but during nearly two years it has remained stationary and seems permanent (June, 1870). • 'Aiinales de la Sooiete de Medeoiiie de Gand,' 1859, p. 93. 2 A ' Treatise on the Nature and Treatment of Club Foot and Analogous Distor- tions,' London, 1839, Case 35. 3 'The Nervous System of the Human Body,' 3d Edition, 1836, Case 177. * * Hysteria, etc. : Six Lectures Delivered to the Students »)f St. Bartholomew's Hospital,' 1866, 3d Edition, London, 1870, p. 102. HYSTERO-EPILEPSY. 247 Several of the muscles of the leg have become greatly atrophied ; they likewise present very marked fibrillary contractions, and respond but feebly to electrical excitation. Hence, I believe that there is little chance of seeing the contracture become resolved, more especially as it shows but very imperfect amendment during sleep, induced by chloroform. I will also point out a most interest- ing peculiarity, from a clinical point of view: this young girl has experienced hysterical seizures in the course of the last few months only. LECTURE XIII. HYSTERO EPILEPSY. Summary. — Hystero-epilepsj. Meaning of this term. Opinions of authors. Epileptiform hysteria; hysteria with mixed crises. Varieties of hystero" epilepsy; hystero-epilepsy with distinct crises; hystero-epilepsy with com- bined crises, or attaques-acces (seizure-fits). Differences and analogies between epilepsy and hystero-epilepsy. Diagnostic signs supplied by exami- nation of central temperature in hystero-epileptic acme, and in epileptic acme. Epileptic acme ; its phases. Clinical characters of hystero-epileptic acme. Gravity of certain exceptional cases of hystero-epilepsy. Case recorded by Wunderlich. Gentlemen, — In the brief clinical description which I gave you, in reference to each of the patients who had passed under your observation at our recent conferences, I studied to bring out the principal characters presented by the convulsive seizures to which they are subject. You have been able to recognize, with ease, that we have not here to deal with common attacks, which can be assigned at once and without discussion to the classic type. Nor is it merely by their great intensity that these convulsive phenomena are distin- guished, but also by the form they a.ssume; and what most strikes the observant witness is to find amongst the clonic convulsions of hysteria, certain more or less marked features which recall the phenomena of ejnlepsy. In point of fact, the convulsive form of disease which is found in all these cases, is that which has been designated, in these latter times, by the name of hystero-epilepsy ; and, remember, it is the only form met with in these patients. These women would not, therefore, be simply hysterical patients, they are all hyslero- epileptical. In what respect do they differ from ordinary hysteri- 248 HYSTERO-EPILEPSY. cal patients? This is a question concerning which it is important to have a clear understanding, and in order to secure that object, I request your permission to treat the matter at some length. If we keep to the terms of the denomination generally employed — hystero epilepsy — it would appear as if no misunderstanding could arise. It signifies that in patients, so affected, hysteria is present in combination with epilepsy, so as to constitute a mixed form, a kind of hybrid composed half of hysteria and half of epilepsy. But does this appellation, in reality, accurately interpret the phe- nomena? Superficially looked at, it would seem to do so, since we have recognized in the seizures some of the features of epilepsy. This, in fact, is the manner in which most modern authors appear to understand the term. According to their view, hystero-epilepsy would be a mixture, a combination of the two neuroses, varying in proportions in different cases; it is not epilepsy alone, nor hysteria alone, but both together. Such, I repeat, is the most popular doctrine. However, it is far from being universally accepted, and the camp of its adversaries still reckons many adherents. These refuse to admit the legiti- macy of this hybrid, half-epilepsy, half hysteria. They do not, in- deed, deny thnt epilepsy and hysteria may coexist in the same individual. The most superficial observation would protest against any such assertion. There is nothing to authorize the belief that these diseases are antagonistic, and it might even be possible, though it has not been proved, that patients affected by one of them, might by that very fact be predisposed to contract the other. But, under such circumstances, it is added, the convulsive accidents remain distinct and separate, without exercising reciprocal influ- ence over each other, in any marked manner, and, above all, with- out mingling confusedly so far as to justify the creation of a mixed intermediate species, in one word, of a hybrid. What, then, according to this view, is the signification of those attacks, the existence of which is so clearly established by the very cases that form the foundation of our study, and in which epilepsy seems mixed up with the ordinary symptoms of convul- sive hysteria? Epilepsy would^ in their opinion^ he present here only in the external manifestation; it would not be substantially existent. In other words, we would have, in these cases, hysteria solely and always present, taking on it the semblance of epilepsy. The term epileptiform hys- teria^ which, if I err not, Louyer Villermay was one of the first to employ, would serve to designate these mixed attacks. The con- vulsion., epileptic in form, would here apf)ear, as it appears in so many other affections of the nervous system, as an accessory EPILEPTIFORM HYSTERIA. 249 e]ement, without altering in anything the nature of the original disease. II. That, gentlemen, is the thesis to which I give my entire adhe- sion. It has already been maintained by some most competent authorities. Of them, I may cite Tissot, Dubois (of Amiens), San- dras, and M. Briquet, who are very explicit on this question. "Hysterical seizures," says M Tissot, "sometimes closely resemble epilepsy. Hence, they have been classed as a particular form of hysteria, under the name of e'pileptiform hysteria. But, neverthe- less, these seizures have not the true characters of epilepsy.''^ M. Dubois (of Amiens), considers epileptiform hysteria, as hys- teria with an extra degree of intensity superadded to its symptoms,^ Sandras expresses a similar opinion.^ M. Briquet, whose article on this subject bears the mint-mark of the soundest observation, says that this species of hysteria^ with mixed attacks, is only a particular form of hysteria — is simply very intense hysteria, — the prognosis is not essentially modified: the nature of the cause which occasioned the hysteria and certain con- ditions special to the aftected individual, account for the modifica- tions observed in the form of seizure. The nature of the hysteria is not, itself, radically altered. Be good enough to remark, gentlemen, that this is something more than a mere question of words; it is a question also of no- sology, and consequently, a question of diagnosis and of prog- nosis. These circumstances will, I trust, suffice to justify in your eyes the details on which I am obliged to enter, in order that the conviction which I entertain niay take its place in your minds. III. Let us, therefore, inquire upon what basis the prevailing doctrine reposes. Hysteria and epilepsy, it is alleged, may be combined in different ways in the same patient. M. Beau, who studied in this hospital, states that he found this combination in 82, out of 276 patients. It takes place in different modeS; and the following cate- gories may be legitimately established. A. In the first group, the hysterical seizures and the epileptic fits remain distinct; this is what M. Landouzy proposes to call hystero-epilepsy with distinct crisis. Well, gentlemen, that would be the most frequent form, seeing that 20 out of the 32 cases reported by M. Beau belong to it. Two subdivisions, however, should be established in this species: — • Tissot. 'Maladies des Nerfs.' t. iv, p. 75. 2 Duiinir, 'De IHyster* E, ilepsie.' p 11. 3 Sauuras, 'Maladies Nerveuses,' t. i, p. 205. 250 HYSTERO-EPILEPSY — VARIETIES. 1st. Epilepsy is the primary disease : upon this stock hysteria becomes grafted in due time, that is to say, most frequently at the period of puberty, under the influence of certain causes, and of moral emotions in particular. A case which M. Briquet quotes from Landouzy deserves to be summarized for your instruction as bearing upon this point. A young woman, who had been affected with epilepsy from her child- hood, got married at the age of eighteen. The disease, which she had concealed, soon showed itself. Hence arose vexatious disputes which engendered hysteria. The attacks, proper to the two neuroses, were separate and preserved their specific characters, without either being influenced by the other. A reconciliation having taken place on account of her pregnancy, between the patient and her husband, domestic peace was re-established which caused the hysteria to cease, but the epilepsy persisted. 2d. At other times, epilepsy is superadded to hysteria. This condition appears to be much rarer than the preceding. M. Briquet, however, reports a case which came under his own observation in which the attacks were distinctly separate. The mind becomes obscured, in the long run, in patients belonging to this class, owing undoubtedly to the influence of the epilepsy. 3d. Some other combinations, of a secondary order, have been mentioned. Thus: — a. Convulsive hysteria coexists with minor epilepsy ^ (Beau, Dunant). b. Convulsive epilepsy is superadded to some of the phenomena of non-convulsive hysteria, e. ^., contracture, anaesthesia, etc. We have a case of this kind among our patients. But these different combinations alter nothing in the essence of things. Most frequently the two diseases, in hystero-epilepsy, exist simultaneously and proceed their several ways, without re- acting on each other in any serious manner, each of them preserv- ing its own characteristics and proper prognosis. With respect to this first form of hystero-epilepsy all authors are agreed. The second form only is concerned in the debate. B. In this form, the hysteria and the epilepsy are coeval; they both develop at the same time. Here the crises do not remain distinct; they have never been so. From the outset, the inter- mingling had been effected, and, in subsequent attacks, the two convulsive forms will always show themselves combined, though in varying proportions, without being ever, at any moment, com- pletely dissevered. • The jietit vial of French authors. This form of the disease, so distinct from the common form, to which the name epilepsy is popularly applied, and yet so iuiportant in itself, especially when questions of hereditary predispositions arise, seems to deserve a distinct designation. (S.) HYSTERO-EPILEPSY — VARIETIES. 251 To this condition the name of hystero-epilepsy with combined crises has been given. In the technical jargon long employed in the special wards of La Salpetriere, these crises, in such cases, are called ^^ aitaques-acch^^ (which we may translate " seizure fits''). IV. Is there really any epilepsy in these mixed crises? Such is the question which we have now to discuss. With this view, it is right that we should take the description of hystero-epilepsy with mixed crises, as agreed upon by authors, and examine it under all its aspects. From M. Briquet, in especial, I borrow the descrip- tion of the seizure-fit. It seems to me to be in complete con- cordance with the results of my own observation. a. From the outset, the mixed attack assumes its proper character; from that moment, it is epileptiform hysteria. I would recall to your memory the patient Etch — , who, in her first attack, fell into the fire, and injured her face.^ b. The hysterical aura, such as we have described it, always con- stitutes a premonitory symptom. This aura, generally of long duration, occupies the abdomen, the epigastrium, — at all events, it does not affect the head alone from the very first, nor one of the extremities, as takes place in epilepsy with aura. Hence it is per- fectly exact to say that patients suffering from hystero-epilepsy with mixed crises are nearly always forewarned in sufficient time to enable them to take precautions or to seek a place of refuge, when the fit is coming on. c. In the convulsive attack, the so-called epileptic phase generally presents itself first, to open the scene. The drama begins — a sud- den shriek, extreme pallor, loss of consciousness, a fall, distortion of the features — then tonic rigidity seizes on all the members. This rigidity, remark it well, is rarely followed by the clonic con- vulsions, brief in duration, limited in oscillation, predominating on one side of the body, such as we see them in true epilepsy. Never- theless, the face may become greatly tumefied and violet-colored. There is foaming at the mouth, and the foam is sometimes bloody on account of the tongue or lips having been bitten. Finally gen- eral relaxation of the muscles may follow, with coma, and sterto- rous respiration during a less or greater length of time. d. To this first phase, which I repeat is the one chiefly con- cerned in the dispute, the clonic phase succeeds. Then all is hys- teria : great gesticulations, having a purposive character, supervene, and sometimes violent contortions are made, characteristic of the most various passions, such as terror, hatred, etc.^ At the same time paroocysmal delirium breaks out. ' Lecture XI. This patient is also meutioned in Lecture IX. 2 See ante, figures 19, 20, and 21. 252 EPILEPSY AND H YSTE RO • EPILE PS Y. e. The termination of the attack is marked by sobs, tears, laugti- ter, etc. These different phases do not always succeed each other in so regular a manner; they get entangled occasionally, and now one, now the other predominates. In the patient C — , for instance, the tonic phase prevails to a great extent over the other, and some- times it is almost exclusively manifested. V. We have arrived, gentlemen, at the critical point. In what does this hysteria with complex crises differ from ordinary hysteria, if it be really separate? In what does it resemble true epilepsy, if there be reason for such an approximation ? Is the appearance of tonic convulsions a novel and unwonted fact, in the classical description of the common hysterical attack? Certainly not. It is not really exceptional, in common hysterical attacks (when no one thinks at all of interpolating the epileptic element), to see the supervention of tonic convulsions occur, having an epileptiform character, especially at the beginning of the seiz- ure. All authors are agreed upon this point. These convulsions are occasionally so marked that M. Briquet has been induced to establish, side by side with the clonic or classic hysterical seizure, a species of seizure in which semi-tetanic stiffness predominates in the body and members. Does it not, therefore, seem already prob- able that the so-called epileptic form is, properly speaking, only the exaggeration, the highest degree of development of this variety of common hysteria ? Yl. If, on the other hand, we turn our gaze upon true epilepsy, we shall meet with a certain number of characteristic peculiarities of which we can easily make profitable use. We should point out, in the first place, that, according to the description already given, the epileptic type is never represented in the seizure fits, save in an imperfect manner, in rough outline as it were; but, indeed, that alone would not be a decisive argument. Here is a more significant character. Never, in descriptions of hystero-epilepsy with mixed attacks, do you find mention made either of the petit mal^ or of the epileptic vertigo. We might also add, as supplying material for an import- ant distinction, that, in this form of hystero-epilepsy, even the most intense epileptiform attack is judging from our own observa- tion modified and sometimes even arrested in its development by compression of the ovary. This never happens in true epilepsy, as we have over and over again assured ourselves by experiment.' • V. ante, Lecture XL EPILEPTIC ACME — TEMPERATURE. 253 In cases of mixed attacks, even when frequently repeated, it is acknowledged by authors, that obnubilation of the intellect and dementia are never the consequences of these seizures. This is contrary to what would almost necessarily follow, if epilepsy were really in question. I cannot do better, in connection with this, than recall to your mind the case of the patient Ler — , who, for nearly forty years, has been subject to the most violent epilepti- form hysteria. This woman is, no doubt, odd, and whimsical in her ways, but her intellect remains what it was at the outset. The information we have received, on inquiries made, do not permit the survival of any doubt as regards this fact. In short, in cases of this kind, the prognosis is nothing diff'erent from that of intense hysteria. Such is likewise the opinion of M. Briquet. From this consideration a practical conclusion is deducible, well calculated to command your attention. There is, lastly, another characteristic on which T beg leave to dwell at some length, because it has not hitherto been noted, so far as I am aware, and because, in my judgment, it is decisive. This characteristic is yielded by thermometrical exploration; and I hasten to seize the opportunity which presents itself now of showing you, by a new example, the advantage which may be derived from this mode of investigation in the clinical treatment of diseases of the nervous system. It is not, gentlemen, that the tonic epileptiform convulsions of hysterical patients differ, in any respect, from the convulsions of the epileptic attack, so far as changes of central temperature are con- cerned. The tonic hysterical seizure, if it have but a certain in- tensity, raises the temperature by 1° C. (=1 8° F.), nay, by a de- gree and some tenths (88°, 88.5° C.= 100.4° F., 101.8° F.), exactly as we find to result from an attack of true epilepsy. This is a fact the accuracy of which we have had many opportunities of testing in these wards.' But if, as regards thermic elevation, the attack of epileptiform hysteria and the attack of true epilepsy be identical, it is quite otherwise when we have to deal with those fast following fits that constitute what, as regards epilepsy, have been called in France les series or eUit de mal (=s status epilepticus, — which we may trans- late by the term epileptic acme). Of this epileptic acme we can distinguish two kinds: the m,inor acme, {les petites series)^ constituted by from 2 to 6 fits, and the major acme {les grandes senes\ in which from 20 to 80, or even more fits, have been reckoned in the twenty-four hours. I address myself exclusively to the latter, because the phenomenon, on which T wish to lay stress, then manifests itself in its typical state of full develop- ' Bournevillft, 'Etudes Cliuiques et Theruioinetriques sur les Maladies du Sys- teme Nerveux.' 254 EPILEPTIC ACME — TEMPERATURE, ment. In such cases, gentlenieu, that is to say, when a great number of true epileptic fits succeed each other, within a brief space the central temperature becomes remarkably augmented ; and, most assuredly, this thermic increase cannot be attributed exclusively to the repetition, any more than to the intensity, of tonic muscular contractions, for the convulsions may completely cease for several days, whilst the temperature nevertheless persists, during this time, at a very high elevation. We can observe and follow these peculiarities on the diagram which I place before you, and which represents the changes of central temperature in the patient Chevall — , during the course of the epilejitic acme which she has recently experienced. (Fig. 25.) Jours. 1 2 3 i 5 6 7 8 — i 40! 38! /I \\ — \ i ^ 1 / V r 7 \ 1 \ 1 \ / \ J Va / \ too; 37.° •W: 36! -v \l \ / \ \ \ \ . ! \ y I \; V V t \f ' ^ \ > I \ \ ,' \ ,' '■ Jk= ^ z^^ Fig. 25.— Temperature (C.) taken shortly after the eleventh fit. From the evening of the first day until the morning of the second, thirty-one fits occurred, -f- Temperature after a remission of four hours. After this the fits take place at greater intervals, and cease ou the third day. The dotted line re- presents the state of the pulse. It must be borne in mind that this elevation of temperature is, in the great majority of cases, even after complete cessation of the convulsions, an omen of the darkest significance. It is, besides, most frequently accompanied by a general state of the constitution which, of itself, gives much cause for apprehension. Thus, some- times, a more or less marked delirium exists, which M. Delasiauve HYSTERO-EPILEPTIC ACME. 255 attributes to meningitic congestion; sometimes, on the contrary, a more or less profound coma — the apoplectiform congestion of authors — is found. In both cases we observe great prostration, dryness of the tongue, tendency to rapid sloughing over the sacrum ; lastly, occasional production of transient hemiplegia, the cause of which has not, as yet, been revealed by any post-mortem examination. However, and this is a most important datum to note, this eleva- tion of temperature, even when it exceeds 41° C. (=105.8° F.), and is accompanied by the grave symptoms just enumerated, is not to be regarded as a sign necessarily heralding a fatal termination. You perceive by the record of Chevall — , that a patient may still recover, even from the midst of all these grievous circumstances. Aug- mentation of temperature above 41^ C. (=105.8° F.) is not, there- fore, necessarily terminal \n such cases; consequently, the assertions published by Herr Wunderlich, and after him by Ilerr Erb, in re- lation to this point, must be subjected to abatement.^ ' The case of the patient Chevall — is related at full length, up to 26tli March, 1872, in our 'Etudes Cliniques et Thermometriques sur les Maladies du Systeme Nerveux' (Obs. xxxiii, p. 285). Since that perio(l,Chevall — Edmee has been seized with new accidents issuing in a fatal termination. We tliink it all the more use- ful to relate them here because, besides completing the former record, they supply additional proof in corroboration of the opinions stated by M. Charcot in the pre- sent lecture. 1873, February 9. — For about a week Chevall — has been tetchy and irritable ; sometimes she has been so violent that constraint was necessary (maniacal excite- ment). February 10. — Last night the agitation augmented ; Chevall — prevented the other patients fronj sleeping, by her cries. She, however, became calm after three o'clock A. M. Three fits were noted during the ni{;ht. From one o'clock 1*. M. till three o'clock P. M. the fits multiplied. At three o'clock: pulse 100; rectal temperature, 38. 60 C. (=101.480 F.). February 11. — Yesterday, from one o'clock till nine o'clock P. M., forty-three fits were counted ; and from that until seven o'clock A. M., seventy fits ; from seven o'clock till eleven o'clock A. M., when this note was taken, there occurred thirty- five fits. The following is a description of the fits: Five or ten seconds before their occurrence, the pupils (especially the left) be- came widely dilated. Sometimes, in addition, we have little complainings, grind- inc: of the teeth, and, exceptionally, a slight cry. The fit begins : the eyeballs are subjected to very marked convulsive niovements (nystagmus) ; the face grows padid, and is deviated to the left; the gaze, at first fixed and direct, is averted to the left. The left arm rises, and then stiffens, simultaneously with the ri^it, which, however, rests upon the bed. The tetanic stiffness next invades the lower extremities. At the end of a few seconds, we notice semi-occlusion of the left eye- lids, which are agitated, like the muscles on the same side of the face, by rapid convulsive movements. Ten to fifteen seconds after, the face and eyes turn to the right ; the body inclines to the right ; the left eyelids open, and remain nearly motionless ; but, to make up for this, the convulsions seize upon the right eyelids and the muscles of the right side of the face. The mouth, at first drawn to the left, is now drawn to the right. The clonic convulsions manifested during this phase, which had at first invaded the members of the left side, now predominate on the right. Finally, the fit concludes by snoring, extreme lividness of the face, and foaming at the mouth. At the close of the fit, the pupils resume their normal dimensions. During the remissions the patient is in complete resolution. When raised and let go the limbs fall inert. Energetic pinching provokes a slight raising of the left 256 HYSTERO-EPILEPTIC ACME. I should remind you, in passing, that this rapid increase of tem- perature is far from being the exclusive appanage of the epileptic acme; it is likewise observed in the so-called congestive, apoplecti- form, or epileptiform attacks of progressive general paralysis, as was first pointed out by Herr Westphal, who has, however, offered an interpretation of the fact which is little in conformity with the reality.^ It is also observed in the very similar attacks which may arm, but nothing in the right. When the soles of the feet are tickled, reflex movements are set up, which are more intense on the left than on the right. Tlie right eye is not injected, whilst considerable hypersemia of the lower half of the left eyeball and a lesser vascularization of the lower lid exist. The nostri s are pulv£ ^ ilUUJ - ^JeCT rO RECALL m 07 04 -1 00 PM 1 1 '1 ^i'«: