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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<ls, obnubilation and subse- 
 quently complete opacity of the cornea. The right Casserian ganglion was of a 
 grayish-yellow, tumefied, and moist with a serous exudation. Tiiat portion of the 
 ganglion where the ophthalmic nerve arises was red and injected. The roots of the 
 larger fasciculus presented a dirty hue, contrasting with the colour of the lesser 
 branch, which had remained healthy. The three nerves, on issuing from the 
 ganglion, were of a yellow colour, which disappeared at their exit from the cra- 
 nium. 
 
 • See 'Zeitschrift fiir ration. Med.,' 35 Bd., p. 343. 
 
14 IRRITATION OF SPINAL CORD. 
 
 up in the vicinity of the spinal lesion. Then, indeed, as M. Brown- 
 Sequard has shown, and as I have had many opportunities of ob- 
 serving, muscular change takes place with great rapidity; in but 
 a few days after the operation, the alteration is very manifest. 
 The emaciation of the muscular masses soon becomes appreciable, 
 and makes very quick progress. Eruptions appear on the skin 
 which promptly issue in the formation of ulcerations and of eschars, 
 though the most minute care be taken to preserve cleanliness. 
 They develop especially in those regions which are subject to 
 pressure, to friction, to prolonged contact with the urine; but they 
 may also make their appearance apart from these conditions, al- 
 though the cases are rare.^ 
 
 I might dwell at length on these trophic troubles connected 
 with traumatic inflammation of the spinal cord in animals, but it 
 will be more appropriate to recur to the matter when studying the 
 features of myelitis, spontaneously developed in man. Besides, I 
 have no desire to prolong overmuch this incursion into the field of 
 experimental physiology. We have already obtained one result, 
 if I mistake not; the facts quoted suffice, it seems to me, to estab- 
 lish that the abolition of the action of the nervous system has no direct 
 immediate influence on the peripheral parts — on the other hand, 
 they make it appear at least extremely probable that morbid excita- 
 tion or irritation of the nerves or nerve-centres is of a nature to 
 give rise to the most various nutritive derangements in distant 
 parts. 
 
 By what means or mechanism does this irritation of the nervous 
 system react upon the peripheral parts, and determine there lesions 
 of nutrition such as those we have mentioned? Are these due to 
 an irritation of the vaso-motor nerves or to their paralysis? Or 
 do they depend on an irritation of those hypothetical nerves, which 
 anatomy as yet knows not, and which are sometimes called trophic 
 nerves? These are questions which we shall have to discuss here- 
 after; at present we must return to the domain of human patholo- 
 gy, and I hope to make you acknowledge that the principle already 
 set out by experimental physiology has its application here in a 
 still more manifest manner. This principle shall be our clue, and 
 it will lead us, I hope, to comprehend why lesions, which appear 
 
 ' It is doubtless in the same manner, that is, by invoking the existence of 
 inflammation about the injured point, that we shonhi explain the disorders that 
 sometimes occur in the nutrition of the eye, in many animals, after section of 
 a lateral half of the t^pinal cord, in the back. The affections of the eye (ulcera- 
 tions, melting away of tlie cornea, purulent conjunctivitis), observed by M. 
 Brown-Sequard in the guinea-pig (' Comptes-Rendus de la Society de Biologie,' t. 
 ii. 1850, p. 134), have been met with by M. Vulpian, in the frog, after the section 
 of the corresponding half of the cord, near the medulla oblongata (this fact was 
 orally communicated). Such affections do not supervene in all animals which 
 have been thus operated on, and it is at least highly probable that they arise 
 only in cases where, consequent on the section, an inflammatory action was set 
 up in the superior segment of the spinal cord. 
 
TRAUMATIC NERVE- LESIONS. 15 
 
 at first sight similar and which are referable to the same points of 
 the nervous or peripheral systems, should produce, in pathological 
 cases, results so opposite and even so contradictory in appearance. 
 The trophic troubles which we purpose to pass in review are 
 produced : — 
 
 1. By lesions of the peripheral nerves, which lesions may be 
 either due to traumatic causes or spontaneously developed. 
 
 2. By lesions of the spinal cord and of the medulla oblongata. 
 
 3. By lesions of certain portions of the encephalon. 
 
 Trophic Disorders consequent on Lesions of the Nerves. 
 
 Let us commence by considering lesions of the nerves. They 
 present the simplest conditions of study. Surgery, in this respect, 
 supplies us with records of great value; for traumatic lesions of 
 the nerves are occasionally to be observed in the human organism, 
 under conditions of simplicity comparable with those accompany- 
 ing the experimental lesions inflicted on animals. 
 
 A. At the outset, I shall establish what I consider to be a fun- 
 damental distinction between these traumatic lesions of nerves, the 
 importance of which you will soon perceive. 1. The lesion some- 
 times consists of a clean and complete section, in which case the 
 effects are merely, speaking generally, those resulting from the 
 absence of nerve-action ; 2, sometimes, owing to contused or lace- 
 rated wounds, the lesion is of such a nature as to set up irritation 
 in the nerve, in which case, and then only, we see arise those tro- 
 phical troubles to which I invite your attention. Let us first con- 
 sider the cases belonging to the second group. 
 
 The traumatic nerve lesions in question may give rise to morbid 
 phenomena affecting the skin, the subcutaneous cellular tissue, the 
 muscles, the joints, and the bones. You are aware that the last 
 American war has furnished occasion for some very important 
 studies on this subject; they have been given to the public by 
 Drs. Weir Mitchell, Morehouse, and Keen in an interesting work 
 of which we shall often avail ourselves^ To one of my former 
 students, the late lamented Mougeot, we also owe a very remarka- 
 ble treatise on cutaneous affections developed under the influence 
 of lesions of the peripheral nerves. It is not to be expected that 
 I can enter into details, and consequently I must refer any of you 
 who desire to investigate this question fully, to the thesis of Mou- 
 geot, in which all records relative to the subject have been most 
 carefully brought together.^ 
 
 ' S, Weir Mitchell, G. R. Morehouse, and W. W. Keen, ' Griinshot Wounds and 
 other Injuries of Nerves.' Philadelphia, 18G4. Extract in * Archives Generales 
 de Medecine,' 1865, t. i. This work has been translated into French by Dr. 
 Dastre (1874). 
 
 2 J. B. A. Mougeot, * Recherches sur quelques troubles de nutrition consecu- 
 tives aux affections des nerfs,' Paris, 1867. 
 
16 AFFECTIONS OF THE SKIN. 
 
 a. Skin affections. — The accidents which traumatic nerve-lesions 
 may occasion in the integuments are of several kin4s: — 
 
 1. The first includes eruptions of various forms, but chiefly those 
 characterized by vesicles and bullae. We shall cite, in the first 
 place, the zona {herpes zoster), which is frequently observed in such 
 cases, and which on that account might be designated zona trau- 
 matica. I described, at the time, a very fine specimen of this kind, 
 observed at the hospital of La Charite, under the treatment of my 
 master, Eayer.^ The American surgeons, already mentioned, have 
 described, under the name of eczematovs eruptions, an affection of 
 the skin which may be placed with this form. 
 
 2. The second kind includes pemphigoid eruptions, of which I 
 have also described a well-marked specimen. Here we see the 
 pemphigus bullae developing with great rapidity, and reappearing 
 from time to time on different parts of the tegumentary system 
 supplied by the wounded nerve. They leave after them well-nigh 
 indelible scars. This kind of eruption is sometimes seen on vicious 
 cicatrices, and is then most probably due to irritation set up in 
 some nerve-filament which has been either strained or compressed 
 in the cicatricial tissue. 
 
 3. In. the third place we may note a cutaneous redness, which 
 resembles erythema pernio;'^ and a certain tumefaction of the skin 
 and subcutaneous cellular tissue, as remarked by Hamilton, which 
 simulate phlegmon (pseudo-phlegmon).^ 
 
 4. Finally, we have that cutaneous affection which has been de- 
 scribed by the American surgeons under the name of "Glossy 
 
 • "A patient, admitted into Dr. Eayer's wards in 1851, had during the troubles 
 of June, 1848, received a bullet in the outer inferior part of the thigh. Some 
 time after the wound had healed, acute pains in the leg supervened, which were 
 almost continuous, but with occasional exacerbations. These pains, which 
 seemed to start from the cicatrix, extended to the dorsum of the foot, and fol- 
 lowed evidently the course of the nerves. This neuralgia, which resisted all 
 means of cure employed, was several times, during the patient's sojourn at La 
 Charite, accompanied by an eruption of herpetic vesicles, arranged in groups 
 closely resembling those of herpes zoster and occupying the skin of the painful 
 parts." Charcot, " Sur qnelques eas d'affection de la peau, dependant d'nne 
 influence du syst^me nerveux," 'Journal de Physiologie,' t. ii, Wo. 5, Janvier, 
 1859. 
 
 In the same Journal, an analogous case was recorded by M. Rouget. " A hus 
 bandman, whilst leaping a trench, received a charge of rabbit-shot from his gun, 
 in the middle region and on the inner side of the left arm. In the bottom of the 
 wound, which was over three inches wi<le, one saw the brachial artery, the torn 
 basilic vein and several contused nerves, especially the internal brachial cuta- 
 neous. The wound healed quickly enough, but in about from two and a half to 
 three months, there supervened a herpes-like eruption on the posterior-internal 
 part of the forearm, occupying an area of some two inches in diameter, in a por- 
 tion of the forearm deprived of feeling. Examples of herpes following on a con- 
 tusion over the course of a nerve (Oppolzer), or resulting from a strain or an 
 effort (Thomas), are far from rare." ( Vide Mougeot, loc. cit., p. 38.) 
 
 2 Charcot, loc. cit., 'Eruption particuli^re siegeant sur la face dorsale d'une 
 main et des doigts, et probablemeut consecutive h, la 16sion des filets nerveux qui 
 se distribuent ^ ces parties.' 
 
 3 Mougeot, loc. cit., p. 30. 
 
AFFECTIONS OF THE BONES. 17 
 
 Skin." The skin becomes smooth, pale, and bloodless; the sudori- 
 parous glands are atrophied, and their secretion is diminished; the 
 epidermis is cracked, and the nails likewise are cracked and curved 
 in a very remarkable manner. Here, in fact, we have to deal with 
 a peculiar inflammation of the skin, which recalls some of the fea- 
 tures of the disease known as scleroderma. 
 
 b. Affections of the Muscles. — The muscles waste away often in a 
 very rapid manner, and lose sometimes partially, sometimes com- 
 pletely, their electrical contractility. But this muscular atrophy 
 will form the subject of a special study. 
 
 c. Affections of the Joints, — Traumatic nerve-lesions produce, in 
 relation to the joints, symptoms which recall in a marked manner 
 the features of subacute, articular rheumatism. These arthropathies 
 usually terminate in anchylosis. 
 
 cl. Affections of the Bones. — Under similar circumstances we occa- 
 sionally find periostitis produced, often followed by necrosis. 
 
 But I shall not proceed further with this brief enumeration, as 
 what we have seen will suffice for our purpose. It is important, 
 especially at present, to endeavour to specify, as exactly as possible, 
 the particular conditions under the influence of which these trophi- 
 cal troubles are developed, after traumatic lesions of the nerves. 
 
 Paget, who was one of the first to call attention to these acci- 
 dents, does not hesitate to confess his ignorance in relation to 
 them.^ The American surgeons, on the other hand, whom we have 
 already quoted, have succeeded in determining the conditions in 
 question, and their testimony is the more valuable to us here, be- 
 cause it is based upon observation alone, wholly empirical, and 
 free from any preconceived idea. After having remarked, as in- 
 deed Paget had done before them, that these consecutive affections 
 are almost always preceded or accompanied by burning pains (evi- 
 dently correlated to an irritative condition of the injured nerve), 
 whilst anaesthesia is almost altogether absent, they explicitly point 
 out that these disorders usually take place after contusions, punc- 
 tureSj incomplete sections of the nerves^ — that is to say, after traumatic 
 causes which are most competent to produce neuritis, or at least 
 the neuralgic condition. On the other hand, and upon this our 
 authors insist, these derangements are not observed to follow com- 
 plete sections of the nerves, the common consequences of the abolition 
 of nervous action being the only phenomena perceptible in such 
 cases. 
 
 It should be added, in conclusion, that the peripheral affections 
 which are attributable to nervous irritation, occur spontaneously 
 in the majority of cases, without the intervention of pressure, or of 
 any external cause whatever.^ 
 
 ^ Paget, 'Medical Times and Gazette,' Loudon, March 26, 1864. 
 2 'Gunshot Wounds,' etc., loc. cit., pp. 71-77, and 'Archives Gen^rales de 
 Mgdecine,' t. 1, 1865, pp. 188, 191, 194. 
 
 2 
 
18 INFLUENCE OF NERVE- IRRITATION. 
 
 But these can only be looked upon as very general conditions: 
 we should be able to penetrate more deeply and seek whether there 
 does not exist in the affected nerves a constant anatomical lesion 
 that can be correlated with the manifestation of the peripheral 
 lesions. Unfortunately, we must confine ourselves here to pointing 
 out a lacuna which future research will not, undoubtedly, fail soon 
 to fill. However, the symptoms, taken as a whole, plead already 
 in favour of the existence of a neuritis. In addition, we may ap- 
 peal to the necroscopical results which have been obtained, in 
 certain cases of organic nerve-lesions, in which the whole series of 
 peripheral affections that we have learned to recognize as a conse- 
 quence of traumatic lesions may be observed. In fact, in these 
 cases (which will shortly engage our attention), the affected nerves 
 have been sometimes found tumefied, infiltrated with exuded mat- 
 ter, and greatly congested. Examined under the microscope, we 
 discern a more or less well-marked multiplication of the nuclei of 
 the tube-sheaths (sheaths of Schwann) or of those of the neurilemma 
 and sometimes, moreover, all the signs of granular degeneration of 
 the medullary cylinders. Nothing as yet, however, proves that an 
 irritation capable of determining the production of remote trophic 
 troubles may not exist in the nerve without being betrayed by 
 such comparatively coarse lesions. It is opportune here to point 
 out that every neuritis does not necessarily entail the manifestation 
 of trophic troubles. The case is quite otherwise. In order that 
 these should follow, the intervention of certain circumstances is 
 required, which analysis has not as yet enabled us to describe. 
 The fact mentioned stands out in contrast with what we know of 
 those lesions which supervene, in distant parts, after complete 
 nerve-sections, for the latter may be looked upon as obligatory 
 and inevitable consequences of every nerve lesion which absolutely 
 deprives the parts in question of the influence of the nervous 
 system. 
 
 However this be considered, the influence of the irritation of a 
 nerve upon the development of the nutritive derangement with 
 which we are concerned, is set under a strong light and rendered 
 manifest, as it were, by the observation of cases in which these acci- 
 dents, after a temporary disappearance, are seen to be reproduced 
 on every reappearance of the irritative cause. As an example, I 
 will mention a well-known and often quoted case, which Paget 
 relates on the authority of Dr. Hilton : — 
 
 A patient, under treatment in Guy's Hospital, for fracture of the 
 inferior extremity of the radius was found to have acquired a volu- 
 minous callus which compressed the median nerve. Ulcers that 
 proved rebellious to all curative efforts had formed, in consequence, 
 on the skin of the thumb and of the first two fingers of the hand. 
 By flexing the wrist so as to relax the soft parts of the palmar sur- 
 face and thus to relieve the nerve from compression, it was always 
 
SPONTANEOUS NERVE - LESIONS. 19 
 
 found possible to bring about the cure of the ulcers in a few days 
 But as soon as the patient tried to make use of his hand the nerve 
 was again subjected to compression and the ulcers were observed 
 to reappear with but little delay .^ 
 
 B. It now remains for us to consider those trophic disorders 
 which arise in consequence of spontaneously developed, non-trau- 
 matic, nerve lesions. As I have given you to understand, we shall 
 here encounter the whole series of affections which we have just 
 reviewed. This circumstance will permit me to deal briefly with 
 the matter; it is enough to quote some typical examples, the 
 majority of which I borrow from the rich treasury of facts accumu- 
 lated in M. Mougeot's work^ 
 
 To demonstrate the existence of a transition I will mention, in 
 the first place, certain cases in which an influence, not properly 
 traumatic but yet belonging to the mechanical order, has deter- 
 mined an affection of the nerve. It is manifestly in this manner 
 that trophic disorders of the eye, consequent on lesions of the tri- 
 facial, are produced, as in such cases the cause is usually found to 
 be this, namely, that intracranial tumours, developed in the vicinity 
 of the nerve, determine in it by compression a more or less active 
 irritation without effecting any solution of continuity in the nerve- 
 tubes. Cancer of the vertebral column may, as you are aware, 
 bring on softening of the vertebrae to such an extent that the 
 laminae give way and the intervertebral notches are narrowed. 
 The nerves in their transit through these foramina are consequently 
 compressed, irritated, and sometimes become inflamed. Under such 
 circumstances I have seen an herpetic eruption occupy, on the right 
 side, all the cutaneous regions supplied by branches of the cervical 
 plexus, in consequence of the compression to which the nerves that 
 go to form it were subjected, in their exit through the spinal fora- 
 mina. The cervical portion of the cord itself and the roots of the 
 cervical nerves were healthy, as the post-mortem examination 
 showed, but on opening the right foramina the spinal ganglia and 
 the nerve trunks were found tumefied and of a vivid red colour. 
 Moreover, in the ganglia as in the nerves we saw, on a microsco- 
 pical examination, that there had been a vast multiplication of 
 nuclei. On the contrary, the ganglia and nerves of the left side 
 presented no trace of alteration.^ 
 
 It is highly remarkable to find that an inflammation, strictly 
 limited to the spinal ganglia and nerves, may be developed spon- 
 
 ' J. Paget, ' Lectures on Surgical Pathology,' v. i, p. 43. 
 
 2 Mougeot, loc. cit., chap, ii, " Des lesions organiques des nerfs et des troubles 
 de nutrition cons§cutifs." 
 
 3 Charcot et Cotard, " Sur un cas de zona du cou avec alteration des nerfs du 
 plexus cervical et des ganglions correspondents des racines spinales posterieures," 
 'Memoires de la Societe de Biologie.' Annee 1865, p. 41. 
 
20 INFLAMMATION OF THE SPINAL NERVES. 
 
 taneously and without the intervention of any mechanical cause, 
 giving rise nevertheless, as Yon Barensprung has shown, to an 
 herpetic eruption, in those cutaneous regions to which the nerves, 
 under irritation, are distributed.^ There are some reasons for 
 believing that a considerable number of cases of spontaneous 
 herpes make their appearance in consequence of a neuritis of this 
 kind.^ The spinal ganglia also have been found much altered, 
 although neither the spinal cord, nor the anterior and posterior 
 nerve-roots, nor even the intercostal nerves themselves participated 
 in the lesion. A case in point has been recently noted by Herr 
 E. Wagner.3 
 
 An individual, aged 23, suffering from pulmonary phthisis, com- 
 plained, towards the close of his existence, of an herpetic eruption 
 occupying the region corresponding to the ninth and tenth inter- 
 costal nerves of the left side. On post-mortem examination, it was 
 found that the bodies of the six inferior dorsal and two superior 
 lumbar vertebrae had been attacked by caries. The dura mater in 
 the region corresponding to these vertebrae was surrounded exter- 
 nally by a thick layer of caseous pus which extended to the nerve- 
 sheaths and spinal ganglia. The dura mater itself was thickened 
 and split into two laminjB, especially in the neighbourhood of the 
 ninth, tenth, and eleventh dorsal nerve-roots. Although the lesions 
 of the dura mater seemed as well marked on the right side as on 
 the left, yet the ninth, tenth, and eleventh dorsal ganglia of the 
 left side only were swollen and presented appreciable alterations 
 under the microscope. In these three ganglia the nerve-cells had 
 disappeared, and in the immediate vicinity of their vacant alveolae 
 were seen all the signs of abnormal proliferation in the connective 
 tissue, carried to an advanced stage. 
 
 In many cases of chronic spinal meningitis, accompanied by 
 thickening of the dura mater, I have myself observed the concomi- 
 tant inflammation of the spinal nerves (in their passage through 
 the meninges) give rise, not only to more or less well-marked 
 atrophy of the muscular mass, but also to vai'ious cutaneous erup- 
 tions which generally presented the appearance either of zona or 
 of pemphigus. In a lecture delivered at Dublin,* M. Brown- 
 Sdquard had previously pointed out the existence of special cuta- 
 neous eruptions on the arms in cases of spinal meningo-neuritis 
 localized in the inferior portion of the cervical region. 
 
 • Von BarHiisprung, " Beitrage zur Kemitniss des Zoster," ' Archiv fiir Anat. 
 und Physiolog.,' No. 4, 18G5, and ' Canstatt's Jahresb.,' 1864, t. iv, p. 128. 
 
 2 Mougeot, loc. cit., p. 65. 
 
 ' R. Th. Bahrdt, " lieitrage zur ^Etiologie des Herpes Zoster," Diss. Leipzig, 
 1869, and E. Wagner, " Patliolog. Anatomisclie und Klinische Beitrage znr Kennt- 
 niss der Gefasnerven." * Archiv der Heilkunde,' 4e heft, Leipzig, 187U, p. 321. 
 
 * 'Quarterly Journal of Medicine,' May, 18(55 [pp. 11, 12 of special edition]. 
 
LEPEOUS PERINEURITIS. 21 
 
 Erythema, zona, muscular atrophy, and certain arthropathies 
 have been correlated, by M. Dumeiiil, with chronic progressive 
 neuritis,^ and by M. Leudet with peripheral neuritis, consecutive 
 on asphyxia from charcoal fumes.^ 
 
 But it is, above all, in ancesthetic lepra that we encounter in their 
 full development the trophical disorders which we have studied in 
 connection with traumatic nerve lesions. The initial morbid pro- 
 cess here consists, as we learn from the important researches of 
 Herr Yirchow,^ in a leprovs perineiiritis characterized by a special 
 cell-proliferation, in the space between the nerve-tubes, which de- 
 termines their slow destruction. The nerves, then, frequently 
 present in their course a spindle shaped swelling which may some- 
 times be readily recognized, during life, in regions where they lie 
 superficial, as the ulnar nerve at the elbow, and thus assist in the 
 diagnosis. These alterations give rise, at the outset, to symptoms 
 of hyperaesthesia, and afterwards to those of anaesthesia. 
 
 W ith the exception of zona, which I have not seen mentioned 
 anywhere, we find in these circumstances almost the whole series 
 of the trophical lesions which we have already described: «, pern- 
 phigus as pemphigus leprosus ; 6, "glossy skin;" c, muscular atro- 
 phy ; rf, periostitis and finally necrosis. When the latter lesions 
 attain a high degree of intensity we may have occasionally to note, 
 you are aware, the loss of part of a member. This often happens 
 without pain; because, when it does occur, anaesthesia is usually 
 present (/e/;m mviilans)} Some have attributed these various acci- 
 dents and mutilations to the effects of the anaesthesia. It- should 
 not, certainly, be regarded as the sole efficient cause; for it is not 
 only proved that this merely facilitates the intervention of external 
 agencies, but also that it can be relegated to a secondary position, 
 and even eliminated altogether if we take into account the cases 
 given by Dr. Thomson in which there was absolutely no anaes- 
 thesia." 
 
 We have here been able only to pass rapidly in review the dis- 
 orders of nutrition which result from irritative lesions of the peri- 
 pheral nerves. In the following lectures we will return to the 
 subject again, but our principal object will be to describe the tro- 
 phical troubles which are correlated to lesions of the brain and 
 spinal cord. 
 
 ' Damenil, 'Contributions pour servir h. I'histoire des paralysies p^riph^riques, 
 specialenient de la iievrite.' 'dazette Hebdomadaire,' 1868. Nos. 4, 5, G. 
 
 2 Leudet, ' Recherches sur les troubles des nerfs periplieriques et surtout des 
 vaso-inoteurs, consecutifs a I'asphyxie par la vapeur du charbou," 'Archives 
 Ggnerales de Medecine,' Mai. 1865. 
 
 3 K. Virchow, "Die Kraukhaften Gescliwiilste," ' Nerven-Lepra,' t. ii, p. 521. 
 1864-5. 
 
 * F. Steudener, ' Beitrage zur Pathologie der Lepra Mutilans.' Mit 3 Taf. Er- 
 langeii, 1867. 
 
 5 A. S. Thomson, 'Brit, and For. Med.-Chir. Review,' 1854, April, p. 496, 
 quoted by H. Virchow. 
 
22 
 
 LECTURE II. 
 
 NUTRITIVE DISORDERS CONSECUTIVE ON NERVE-LESIONS (Continued^). 
 AFFECTIONS OF THE MUSCLES. NUTRITIVE DISORDERS CONSECUTIVE 
 ON LESIONS OF THE SPINAL CORD. 
 
 Summary. — Anatomical and functional modifications occnrring in muscles under 
 the influence of lesions of the nerves supplying them. Importance of elec- 
 trization as a means of diagnosis and prognosis. Researches of Dr. Duchenne 
 (de Boulogne). Experiments: Long persistence of the electrical contrac- 
 tility and of normal nutrition of muscles, after the section or excision of 
 motor or mixed nerves in the case of animals. Pathological cases : Diminu- 
 tion or speedy abolition of the electrical contractility, followed by rapid atro- 
 phy of the muscles in cases of rheumatic paralysis of the facial nerve, and of 
 irritative lesions of mixed nerves, whether of traumatic or spontaneous origin. 
 Cause of apparent 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 con- 
 tractility, followed by rapid atrophy of the muscles. Experiments of MM. 
 Erb, Ziemssen, and 0. Weiss. Contusion and ligation of nerves are irritative 
 lesions. Difference 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-SSquard. 
 
 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 affecting the gray substance to 
 but a slight extent vertically, e. g., partial myelitis, tumours. Pott's disease ; 
 h, extensive fasciculated lesions of the white posterior or antero-lateral col- 
 umns, without the gray matter participating; e. ^., 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.— 6, irritative lesions of the large 
 nerve-cells of the anterior cornua with or without participation on the part 
 of the white fasciculi : infantile spinal paralysis, spinal paralysis of adults, 
 general spinal paralysis (Duchenne de Boulogne), progressive muscular atro- 
 phy, etc. Predominant influence of lesions of the gray matter in the produc- 
 tion of trophical troubles of the muscles. These facts can be interpreted by 
 means of Brown-S6quard's proposition. 
 
 Gentlemen: In the preceding lecture, whilst sketching the his- 
 tory of nutritive troubles consecutive on nerve-lesions, I purposely 
 
AFFECTIONS OF THE MUSCLES. 23 
 
 avoided dwelling on the anatomical or functional modifications to 
 be found in muscles under the influence of these lesions. I desired 
 to reserve this question for a special study. In reality, as you 
 will soon acknowledge, this is a subject s\irrounded by difficulties 
 of all kinds, and is even now the object of a thousand contro- 
 versies. 
 
 You are aware of the great progress which has been made in 
 the clinical history of paralytic affections, under the influence of 
 the labours of Dr. Duchenne (de Boulogne). But you know also, 
 without doubt, that a considerable number of the facts discovered 
 by this eminent pathologist seem to be in flagrant contradiction 
 with the results obtained by physiologists in their experiments 
 upon animals. 
 
 What is the reason of this discordance? In what direction are 
 we to look for means of effecting a reconciliation between them ? 
 These are desiderata which I do not undertake to answer in a 
 manner perfectly satisfactory on every point. Yet I must not 
 recoil from before the difficulty ; I am bound, at least, to examine 
 it. To be candid, I feel some repugnance to treat a question, 
 where the results of the electrical exploration of nerves and muscles 
 must be continually referred to, in the presence of men who have 
 made so profound a study of this mode of examination. But if 
 they meet with criticism, I hope they will accord me their gene- 
 rous indulgence. 
 
 I. 
 
 We may say, in a general manner, that electro-diagnosis, if I may 
 invent a term, announces and demonstrates (in certain pathological 
 cases where a somewhat intense lesion of a mixed or motor nerve 
 has taken place), the rapid and great diminution, it may be even 
 the total disappearance of that property which is known by the 
 name of electrical contractility. Yet, on the other hand, experi- 
 ments on animals appear to show that, after lesions inflicted on 
 nerves, the muscles preserve for a comparatively long time, even 
 indefinitely, according to some authors, the property of contracting 
 under the stimulus of electricity. 
 
 You will readily understand the interest which, from our point of 
 view, belongs to the recognition and study of facts of this kind. It 
 suffices to remind you that the enfeeblement and, d fortiori^ the 
 loss of electrical contractility, rapidly ensuing on the lesion of a 
 nerve, are, as clinical observation has frequently shown, the first 
 term of a series of phenomena which, if the physician do not inter- 
 vene, almost necessarily entail, in certain cases, the more or less 
 complete atrophy of the muscle and sometimes the total loss of its 
 functions. 
 
 In order to set out in a clearer light the discordance to which 
 
24 EXPERIMENTS ON ANIMALS. 
 
 I have called your attention, allow me, gentlemen, briefly to recall 
 the experimental facts in question : — 
 
 A. It was proposed, in these experiments, to seek out the modi- 
 fications which take place in the properties of muscles and in their 
 anatomical structure, after the section or excision of the nerves 
 supplying them. Experiments abound ; they have been made and 
 repeated by MM. Longet, Schiff, Brown-Sequard, Yulpian, and it 
 must be added that the results which they have given appear, at 
 least as regards essential points, to be quite concordant. The fol- 
 lowing are the principal incidents of these experiments that seem 
 to call for notice here. 
 
 When a nerve has undergone section or partial excision, its peri- 
 pheral extremity begins, from the fifth to the sixth day after the 
 operation, to undergo even in its finest ramifications a series of 
 alterations whose ultimate consequence is the disappearance of the 
 medullary cylinder, whilst the axial filament appears, on the con- 
 trary, to persist almost indefinitely.^ 
 
 ' Professor Scliiflf has shown that, in cases of nerve-degeneration following on 
 section, the axis cylinders persist, contrary to what M. Waller had asserted ; he 
 found the filaments in the nerve-fibres of nerves of mammalia, which had been 
 cut five months previously. " We have also recognized," says M. Vulpian 
 C LeQons sur la Physiologie du Systfeme Nerveux,' 1866, p. 236), '* the existence of 
 this axial filament at the end of more than six months. It appears to me very 
 probable that it persists beyond this space." 
 
 Since the above was written, M. Ranvier ('Comptes Rendus de I'Academie des 
 Sciences,' 1872) published the result of his researches on nerve-degeneration, 
 and demonstrated the destruction of the axis-cylinder. Having had opportuni- 
 ties of examining his preparations whilst studying in his laboratory, I may be 
 allowed to state that the continuity of. the axis-cylinder was plainly shown to be 
 broken, at intervals; it has been objected, in a German periodical, that this 
 might be an appearance due to the reagent en)ployed, but the allegation is in- 
 valid, seeing that the production of the result does not depend upon the use of 
 one reagent. The following is a brief summary of M. Rauvier's conclusions. 
 The interannular segment constitutes an histological unit. It Is formed by 
 Schwann's sheath, lined by a layer of protoplasm containing a lenticular nucleus ; 
 beneath is the medullary sheath, through which passes the axis-cylinder, which 
 is probably enveloped in a protoplasmic layer, reflected at the annular constric- 
 tions which terminate the segment. Twenty-four hours after section of the ischi- 
 atic or pneumogastric nerve, in a rabbit, the nuclei in question are slightly 
 swollen, and the outer protoplasmic layer becomes granular. Forty-eight hours 
 after section, the tumefaction of the nucleus is greater, and the protoplasmic 
 layer forms lumps that jut into the medullary matter, and give it an irregular 
 shape. After the seventy-second hour, the nucleus is so swollen as to fill nearly 
 the width of the tube — there the nieduUary matter, completely interrupted, 
 leaves a space occupied by a mass of protoplasm sprinkled with fatty granula- 
 tions, and inclosing the nucleus. The protoplasm is also swollen at diff"erent 
 points and has driven back the medullaiy sheath, reducing it to a mere thread, 
 or completely dividing it. Towards the end of the third day the axis-cylinder is 
 cut across, opposite each nucleus. This fact explains tlie loss of excito-motricity 
 in a nerve, which supervenes at about this date after section, according to Longet. 
 From the fourth day, the degeneration goes on increasing, and on the sixth, the 
 medullary matter is reduced to minute fragments, whilst the protoplasm which 
 has become very abundant contains a considerable number of fatty granulations 
 and its nuclei have multiplied. From the seventeenth to the twentieth day, the 
 proliferation of nuclei does not actively proceed. When the nerve is examined 
 
ELECTRICAL CONTRACTILITY. 25 
 
 On the other hand, fronri the fourth day, that is to say, before 
 even the lesions of the degeneration are appreciable, the nerve 
 (according to M.Ynlpian, loc. cit., p. 235) is found to have already 
 lost the faculty of being excited by different agencies, and in par- 
 ticular by the electrical stimulus. There is no difference of opinion 
 in reference to this point. With respect to the muscle, it does not 
 present, at first, any modification whatever of the electrical con- 
 tractility. The decrease, and still more the utter loss of this pro- 
 perty, if they do ensue, are never produced until after a considerable 
 lapse of time, and very slowly. Hare, again, there is no divergence 
 of opinion. If some physiologists state they have seen the electrical 
 contractility lessened, or even lost, at from six to twelve weeks after 
 the section of a mixed nerve, M.Schiff'has, on the contrary, under 
 some circumstances found it perfectly preserved at the end of four- 
 teen months.^ The same statement holds good if the section be 
 made of an exclusively motor nerve. M. Longet had already shown 
 that, whilst the motricity of nerve is, as we have said, entirely 
 abolished four days after section, the muscular irritability, in so 
 far as the facial nerve is concerned, persists in the corresponding 
 muscles for over three months.^ After excision or section of the 
 facial nerve, MM. Brown-Sequard and Martin-Magron have seen 
 the irritability of the facial muscles survive, in the case of guinea- 
 pig and rabbit, for nearly two years. ^ M. Vulpian has also borne 
 testimony to precisely the same effect.'* About the year 1847, in 
 the laboratory of my excellent master, Martin-Magron, whilst 
 working in a field, which my sensitiveness in reference to animal 
 suffering soon caused me to abandon, I was able personally to 
 observe the almost indefinite persistence of electrical contractility 
 in the corresponding muscles, after the excision of the facial nerve. 
 
 in transverse section, very few axis cylinders are found in the tubes on the 
 twentieth day. These remarks refer to tlie peripheral end of the divided nerve : 
 the process of degeneration in the central end is very diiferent. The medullary 
 matter is decomposed into fine granulations, accreted in oval clusters, the nuclei 
 multiply and the protoplasm augments, without, however, i-egmenting the medul- 
 lary matter, by jutting masses. On the contrary, the nuclei are flattened 
 betweei^ the axis-cylinder and Schwann's sheath. The axis-cylinder itself per- 
 sists, its connection with the nerve-centres being preserved, it energetically lesists 
 tbe destructive action of the nuclei and protoplasm. Hence, M. Ranvier has 
 come to the conclusion that the alterations undergone by nerve-tubes, in the peri- 
 pheral portion of a divided nerve, which are commonly called degenerative, have 
 not this character in so far as the cellular elements of the nerve-tube are con- 
 cerned, for this, on the contrary, displays phenomena of formative activity which 
 have an opposite meaning to that of degeneration, in the language of anatomo- 
 patliologists (G. Sigerson). 
 
 • Schiff, 'Lehrbuch der Physiologie des Menschen,' 1858-59, p. 18: M. Schiff 
 asserts that he saw, in two cases, an excitability of the muscles persist for four- 
 teen months after section of the corresponding neives ; the hypoglossal nerve had 
 been divided in one case, and the ischiatic in the other. 
 
 2 Longet, 'Anatomie et Physiologie du Systeme Neiveux,' t. i, p. 63, 1842. 
 
 3 Brown-Sequard, ' Bulletins de la Societe Philomathique,' 1847, pp. 74 et 88, 
 'Bulletins de la Societe de Biologie,' t. iii, 1851, p. 101. 
 
 ■* Vulpian, loc. cii., p. 235. 
 
26 EXPEEIMENTS. 
 
 The result is so palpable, striking, and easy of observation that 
 most physiologists have come, if I mistake not, to question whether 
 muscular irritability ever disappears completely in consequence of 
 the section or excision of the nerves. They concede, at most, that 
 in such a case there may be produced, in the course of time, a less 
 or greater degree of enfeeblement of the contractile property of the 
 muscles. Almost all of them point out that if the electrical stimu- 
 lation sometimes becomes powerless to determine contraction of 
 the muscles, yet this will be produced under the influence of me- 
 chanical irritation. • 
 
 It was to be supposed that the nutritive or trophical modifica- 
 tions corresponding to these functional changes would likewise be 
 very slowly produced and but slightly apparent. This, in fact, is 
 what seems to take place. Most authors appear to agree in recog- 
 nizing that the atrophy of the muscle and its histological degenera- 
 tion supervene only when a very long time has elapsed after the 
 nerve section. According to M. Longet,^ when, three months after 
 division of the facial nerve, a post mortem examination was made, 
 scarcely any traces of atrophy, however slight, were to be observed. 
 But he doubtless refers to an examination made with the naked 
 eye. M. Schiff' asserts that, when the paralysis consecutive on a 
 nerve-section is of old standing, the muscles show a certain amount 
 of wasting. It is probable that a certain number of muscular 
 fasciculi waste away and disappear. In most cases, the microscope 
 reveals that a considerable number of these fasciculi undergo fatty 
 degeneration and present an accumulation of fat in their inter- 
 spaces.^ M. Vulpian's researches have given analogous results, 
 but, according to this author, the fatty degeneration of the muscu- 
 lar fibre is often completely absent.^ 
 
 Before comparing the facts of pathology with the results of ex- 
 periments on animals, it is important to clearly understand the 
 conditions under which the latter have been conducted. In the 
 first place, the physiologist makes a section or excision of the mus- 
 cular nerves ; in the second place, he resorts to direct electrical 
 stimulation, applied to the denuded nerve or muscle. He makes 
 use of galvanism, almost exclusively, as an agent of exploration, 
 and takes no heed of the difference which may exist, as to their 
 action on nerve fibre or muscular fascicle, between the excitation 
 obtained by means of induction (or interrupted) currents, and that 
 determined by the galvanic (or continued) current. These are cir- 
 
 » Longet, loc. cit., p. 63. 2 Scliiff, loc. cit., p. 175. 
 
 8 Vulpian, loc. cit., in cases of paralysis, consecutive on nerve-section : besides 
 the atrophy of primitive nerve-fibres which is produced in tlie course of time, M. 
 Vulpian has long since remarked the proliferation of the nuclei of the sarcolem- 
 ma, and some other indicia of inflammatory action. This is a very interesting 
 fact, since noted by other observers, and one to which we shall have occasion 
 again to refer (see note ' i/j/'r^, pp. 29-30). 
 
PATHOLOGICAL FACTS. 27 
 
 cumstances which it is important to note, especially in relation to 
 the experiments which 1 shall call old, although they do not yet 
 date from a very remote period. We shall see afterwards that 
 quite recent researches, in which the action of both currents has 
 been comparatively studied, have yielded results apparently differ- 
 ent in some respects from those furnished by former experiments. 
 
 B. Let us now take the field of human pathology into considera- 
 tion. The facts which it offers us are connected with lesions of 
 mixed or motor nerves which either take place spontaneously or 
 supervene in consequence of a wound. 
 
 In the first place, we will dcvscribe the phenomena observed in 
 cases of peripheral paralysis of the facial nerve and, particularly, 
 where that paralysis is due to the influence of cold (rheumatismal 
 paralysis a f rigor e). M. Duchenne (de Boulogne) has shown, as you 
 are aware, that in such a case, the electrical contractility of the 
 muscles of the face is remarkably lessened and even appears some- 
 times to be extinct,^ before the end of the first week. You will 
 remark that between this period of seven days, which according to 
 M. Duchenne may mark the beginning of the decrease of electrical 
 contractility in rheumatismal paralysis of the facial nerve, and the 
 term assigned by some physiologists for the persistence of the same 
 property in animals, after nerve-section, the difference is great. 
 Nevertheless, researches again and again renewed have demon- 
 strated the perfect accuracy of M. Duchenne's assertion. Quite 
 recently also, in a case of rheumatismal paralysis of the facial nerve, 
 Dr. Erb, having had an opportunity of following the course of the 
 symptoms from day to day, noted that, on the ninth day, the elec- 
 trical contractility had already diminished to a considerable extent.^ 
 In a similar case, recorded by Dr. Onimus when, eight days after 
 the invasion of the disease, the induction current was resorted to, 
 the paralyzed muscles did not present the slightest contraction.^ 
 
 The same fact is usually remarked in cases of peripheral paralysis 
 of the facial nerve, resulting from causes other than the influence 
 of cold^and likewise in those of traumatic paralysis of nerves of 
 extremities. The last-mentioned generally follows, as you know, 
 on abrupt compression, contusion, or concussion of a mixed nerve, 
 as a consequence, for instance, of scapulo-humeral luxations. The 
 electrical contractility has been many times found very notably 
 lessened from the tenth, and even from the fifth day in the mus- 
 cles, struck with paralysis, after such and similar accidents.^ 
 
 Clinical observation demonstrates, you must know, that, as a 
 
 ' Duchenne (de Boulogne), 'Electrisation localisee,' 2e edition, 1861, p. 669. 
 
 2 W. Erb, ' Zur Pathologie und Pathologischeu Anatoraie Periplierischer Par- 
 alysen,' in ' Deutscli. Archiv,' t. iv, 1868, p. 539. Gradolf's case. 
 
 3 'Gazette des Hopitaux,' 30 Juin, 1870, p. 298. 
 
 * Duchenne de Boulogne, loc. cit. Obs., p. 191, Paralysie suite de luxation 
 scapulo-humeral. Obs., p. 193, Paralysie suite de contusion du nerf cubital. 
 
28 ALTERATION OF THE MUSCLES. 
 
 general rule, the muscles which thus present a prompt diminution 
 and, above all, a prompt disappearance of electrical contractility 
 are soon affected by atrophy which sometimes becomes very rapidly 
 manifest, especially in the case of paralyzed limbs. It would be 
 highly interesting to study, in the several phases of their develop- 
 ment, the histological alterations to which this rapid wasting of 
 muscular masses is assignable; but this is a subject in relation to 
 which we possess as yet but little exact information. It seems, 
 however, to follow from some researches and particularly from a 
 case recorded in detail by Dr. Erb, that these lesions have nothing 
 in common with passive fatty degeneration, pure and simple, such 
 as we find in muscles that have been long condemned to inactivity. 
 They appear on the contrary to present the clearest characteristics 
 of an inflammatory process, to wit, a more or less marked hyper- 
 plasia of the interstitial connective tissue, recalling to some extent 
 what we see in cirrhosis, and a multiplication of the nuclei of the 
 sarcolemma. Concurrently with the development of these altera- 
 tions, the muscular fibres undergo a very evident decrease in their 
 transverse diameter, but they preserve, in most instances, their 
 striated appearance. The fatty granular degeneration of the mus- 
 cular fibres is rarely met with, in these cases, and appears to be 
 altogether accidental.^ 
 
 ' The following is an abridgment of the observation recorded by Dr. Erb in his 
 interesting memoir : — 
 
 Peter Schmieg, aged 22 years, suffers from pulmonary phthisis in its last stage, 
 and likewise has caries of the petrous portion an I mastoid process. An abscess 
 has burst in the vicinity of the latter. On the 22d of March, 1867, almost com- 
 plete paralysis of the left facial nerve occurs. The paralysis is particularly 
 evident in the frontal muscle. Investigation of the electrical contractility having 
 been made, first on Maich 24th (the second day of the disorder), next on the 3d 
 April (12th day), by means of faradization, it was found normal on both dates. 
 On the 17th April (26th day), for the first time, it is ascertained that the frontal 
 and zygomatic muscles of the left side contract but feebly under faradaic stimu- 
 lation. On the 30th April (39th day), faradization no longer causes contraction 
 in these muscles, the other muscles of the left side of the face respond but feebly 
 to the stimulus. Death supervenes May 2d (40th day). 
 
 Post-mortem. — The trunk of the facial nerve bounds an abscess which has 
 opened behind the ear : it is denuded to a certain extent. The nerve-trunk is 
 enveloped on every side by a mass of indurated connective tissue. This connec- 
 tive envelope closely adheres to the external nerve-sheath of the nerve, which, 
 however, is still free within it. To the naked eye, the branches of the facial 
 nerve offer no perceptible modifications ; on the other hand, the left frontal mus- 
 cle is pale, flabby, and thin. Where the nerve-trunk is enveloped by the mass 
 of connective tissue, there is found, interposed between the nerve-fibres, a quan- 
 tity of fibrous connective tissue, with numerous oval nuclei, faintly granular. 
 A certain number of the nerve-fibres themselves present the several stages of 
 fatty degeneration. Many of the fibres have preserved their normal character. 
 Some of the filaments supplying the frontal muscle scarcely show any but de- 
 generated nerve-fibres ; other filaments belonging apparently to the trifacial have 
 all their fibres in a normal condition. The left frontal muscle is greatly altered: 
 thick septa of newly formed connective tissue are observed, interposed between 
 the primitive mnscular fasciculi. The latter are much reduced in bulk, and 
 contain a large quantity of nuclei. On mo^t of the atrophied fibrils the striation 
 
ALTERATION OF THE MUSCLES. 29 
 
 It is clear that if, in the muscular atrophy which physiologists 
 obtain, in the long run, by section or excision of the nerve, the 
 histological lesion were always fatty degeneration without trace of 
 irritative action, the contrast would be extrennely manifest. But 
 unfortunately for the simplicity of things, we see that this, perhaps, 
 is not the case.^ 
 
 remains distinct ; on others it is scarcely perceptible. A certain number of the 
 primitive (ultimate) bundles present the characteristics of waxy alteration, but 
 none of fatty granular degeneration (W. Erb, loc. cit., ' Deutsch. Archiv,' Bd. 5, p. 
 44,1866). 
 
 ' We reserve the right of returning upon this delicate point in the course 
 of our lectures. At present, let it suffice to note that irritative lesions of mntcles 
 quite similar to those which liave been described, have been recently recorded by 
 very competent observers, in several animals, after section and excision of mixed 
 or purely motor nerves, that is to say, outside the conditions which comnionly 
 cause irritative nerve-lesions. Thus, when he had cut out a portion of the isclii- 
 atic nerve, Dr. Mantegazza (' Histologisch-Veranderungen nach der Nervenduich- 
 schneidung,' in 'Schmidt's .Jahresb.,' p. 148, t. 136, 1857, and ' Gaz. Lomb.,' p. 
 18, 1867), found, after the thirtieth day, the muscles pale, the connective tissue 
 interposed between the primitive (or ultimate) fasciculi evidently hypertrophied, 
 the fasciculi (themselves diminisJied in bulk) presenting a manifest multiplica- 
 tion of the nuclei of their sarcolemma, but still preserving their transversal 
 striae. A considerable number of the fasciculi showed a granular aspect, but the 
 granulations dissolved in acetic acid. Professor Vulpian lias, likewise, met with 
 identical alterations in tlie lingual muscles of a dog, fifty days after the avulsion 
 of the central part of the hypoglossal nerve ('Archives de Physiologie,' t. ii, p. 
 577, 1869). The absence of fatty degeneration in the primitive fasciculi, the 
 atrophy of these fibres with persistence of the transversal striation, and the pro- 
 liferation of the sarcolemma-nuclei, have also been observed by M. Vulpian (/oc. 
 cit., p. 559) in the muscles of the human leg, in a case of resection of a segment 
 of the ischiatic nerve dating from five montlis before. That being the case, we 
 are led to admit that complete sections, excisions, and avulsions of nerves do 
 occasionally determine irritative lesions in them : or else- if further observations 
 should prove the fa(;t recorded by MM. Mantegazza and Vulpian to be constant — 
 that the muscular lesions wliich follow passive lesions of motor or mixed nerves 
 are not essentially different, histologically considered, from those which super- 
 vene on irritative lesions of those nerves. If the facts should support the second 
 hypothesis there would still be occasion, we think, to differentiate, in spite of so 
 many analogies, between muscular alterations connected with functional inertia 
 and those consequent on nerve-irritation. It appears, in fact, t^ be demonstrated 
 that the latter supervene with much greater rapidity, and are preceded and 
 accompanied by more or less marked modifications of electrical contractility, 
 which do not show themselves in tlie former with the same characteristics, 
 and only make their appearance at the end of a comparatively very long lapse 
 of time. 
 
 It is to be desired that a series of researches were instituted with the special 
 object of elucidating the question which has just been raised. There does, 
 indeed, already exist a certain number of facts tending to demonstrate that 
 immobilization may, by itself alone, and outside of all nervous influence, pro- 
 voke in certain organs and tissues, all the characteristics of inflammatory action. 
 I shall cite but one exantple: we know the articular affections, described by MM. 
 Tessier and Bonnet, which supervene when limbs are condemned to immobility, 
 as the treatment of certain cases of fracture requires. Quite recently, M. Menzel 
 undertook a series of experiments, wliich consisted in immobilizing, by plaster 
 of Paris bandages, a certain number of articulations of dogs and rabbits. Now, 
 from the fifteenth day, the synovial membrane was found to be vividly injected 
 and tumefied, the articular cavity contained red corpuscles, white corpuscles, and 
 epithelial cells; finally, the cells of the diarthrodial cartilage were found to be 
 
» 
 
 ■bafyiBiiicavfcMi 
 
EXPERIMENTS. 81 
 
 probably have given no result. Some facts, borrowed from the 
 domain of experimental physiology, furnish similar evidence. 
 
 When, in the case of a rabbit whose right fticial nerve had been 
 cut across about a month before, electricity was applied through 
 the shaven and moistened skin, to the right facial muscles, no appa- 
 rent effect was produced, whilst extremely strong contractions were 
 caused, when the homologous region of the left side was acted on. 
 But, when the muscles were denuded on the right side, where the 
 nerve was cut, and electricity applied to them, very marked con- 
 tractions were produced. Again, a segment of the left external 
 popliteal nerve, about two inches in length, was excised, the animal, 
 this time, being a vigorous horse. One month after the operation, 
 the hair was shaven off the antero-external surface of each leg, and 
 the electrodes of a pile were applied. On the healthy leg ener- 
 getic contractions followed the application ; but no contraction was 
 caused in the other, when the same test was attempted. Then, the 
 paralyzed muscles were denurled and the stimulus was applied to 
 them directly, the minimum power of the instrument being em- 
 ployed. Lively contractions were the consequence.^ A consider- 
 able number of similar examples could, doubtless, be collected, 
 without difficulty. Hence, it is demonstrated that exploration 
 through the skin can only supply approximative data, and that it 
 does not reveal the real state of the electrical contractility, but such 
 as they are, the data furnished are not the less exact and must be 
 considered as of the highest importance, for it is impossible not to 
 acknowledge that the great decrease or apparent loss of contrac- 
 tility, detected by exploration through the skin, corresponds to a 
 diminution or, at least, to a very great modification of this property. 
 
 Another question which requires to be considered relates to the 
 nature of the electrical agency employed in exploration. Galvani- 
 zation, as I mentioned just now, has been almost the only means made 
 use of in the experiments concerning nerve sections in animals, 
 whilst in clinical practice, following Dr.Duchenne's method, the work 
 of investigation has been pursued until lately, by means of faradiza- 
 tion, exclusively. Now, it follows from researches made a few years 
 ago in Germany, and recently taken up in France, that galvanization 
 has often power to cause muscular contractions even where faradi- 
 zation seemed to indicate an absolute loss of electrical contractility. 
 
 This fact, recorded for the first time by Baierlacher, in 1859,^ in 
 a case of facial paralysis, has been remarked since, either under the 
 same circumstances, or in different cases of paralysis consequent on 
 traumatic lesions of mixed nerves, by Schultz,^ Brenner,^ Ziemssen,^ 
 
 ' Experiment of M. Chauveau, in Magnin : 'ThtJse de Paris,' p. 21, 1866. 
 2 Baierlacher, ' Bayz. arztl. Intelligenzbl.itt,' 18(39. 
 8 Schultz, ' Wiener medic Wochenschr.,' No. 27, 1860. 
 
 * Oriinewaldt, ' Ueber die Lahmungeu des Nerv. facialis.' Pet. med. Ztsch.,Bd. 
 iii, p. 321 ff., 1862. 
 
 5 Ziemssen, ' Elektricitat in der Med.,' 2 aufl., 1864. 
 
32 FARADIZATION AND GALVANIZATION. 
 
 Rosenthal/ Mejer,^ — by Bruckner,^ in pseudo-hypertrophic para- 
 lysis, and, finally, by Hammond, in infantile paralysis. From this 
 it will be seen that galvanization may still reveal contractile 
 power present in many cases of paralysis, whether arising from 
 rheumatic or traumatic causes, when an exploration, conducted by 
 faradization only, would indicate a profound alteration of electrical 
 contractility. But, even though this is the case, the character 
 drawn from the abolition or rapid decrease o^ faradaic contractility 
 would subsist, not the less, in all its value; it will still allow us to 
 maintain the contrast between paralyses from nerve-lesions, such 
 as clinical practice usually -presents, and paralyses determined in 
 animals by nerve-section, since the character in question is deficient 
 in the latter cases. 
 
 We have now to examine if the nerve-lesions which provoke a 
 prompt modification of the electrical contractility, soon followed by 
 muscular atrophy, can be assimilated without reservation, as some 
 authors appear to believe, to nerve sections, as performed upon 
 animals. In reality, gentlemen, this is not at all the case, and, if I 
 err not, it is in this circumstance that we must seek the knot of the 
 disputed question. We may say, speaking generally, that the sec- 
 tions or excisions of nerves do not usually set up, in these, any 
 reactive process. The degeneration of the fibres of the distal end, 
 which follows the operation as a necessary consequence, may be con- 
 sidered, supposing no complication to interfere, as a purely passive 
 process. The muscles supplied by the divided nerves are necessarily 
 smitten with functional inertia; but they do not appear to undergo 
 any other changes than those which, in the course of time, result 
 from inaction." 
 
 Very different are the affections of the nerves to which are assign- 
 able, in man, the disorders that constitute the object of our study. 
 They arise almost always when of traumatic origin, as we have 
 said, under the influence of causes such as concussion, contusion, 
 compression, imperfect division — all eminently calculated to pro- 
 voke, in the different tissues which enter into the composition of a 
 nerve, the development of irritative action. In fact, it is not rare, 
 in cases of this kind, that muscular wasting of a rapid type, gal- 
 loping atrophy as it were, announced almost from the outset by 
 the diminution and loss of the faradaic contractility, should be pre- 
 ceded, accompanied, or followed — where a mixed nerve is concerned 
 — by more or less acute pains, or by abnormal sensations, all being 
 indicia of the irritation set up in the sensitive nerve-fibres.^ To these 
 pains may often be added the appearance of trophical skin-disorders, 
 
 ' Rosenthal, * Elektrotherapie,' etc., 2aufl., 1869. 
 
 2 Meyer, ' Die Elektricitat,' etc., 2 aufl., 1861. 
 
 3 Bruckner, ' Deutsch Klinik,' No. 30,. 1865. 
 
 * See ante, note ', pp. 29-30. 
 
 * Ducheune (de Boulogne), loc. cit., Obs. ix, x. 
 
IRRITATIVE NERVE-LESIONS. 33 
 
 pemphigoid eruptions, glossy skin, herpes — which we have come to 
 recognize as one species of the effects of irritative lesions of the 
 cutaneous nerves, and which are never seen, in any shape or form, 
 after simple sections of the nerve trunks.^ The phenomena of 
 spontaneously developed diseases lead to identical conclusions. 
 Sometimes caries of the petrous bone exists, the trunk of the facial 
 nerve lies in the pus, where it is completely surrounded, as in the 
 case which Dr. Erb records, by a dense sheath of newly formed con- 
 nective tissue.^ At other times, the nerve is compressed by a slowly 
 developed tumour which must irritate, for some space of time, the 
 nervous fibres before completely crushing them — nay, there is none 
 of the series, even including so-called rheumatismal paralysis, or 
 paralysis a frigore (though here we, as yet, lack positive evidence) 
 which should not apparently be attributed to inflammation of the 
 connective sheathing of the nerve-trunk.^ I am not unaware that 
 complete nerve-sections are somewhat frequently met with in sur- 
 gical practice: I know also that in such cases you may see atrophy 
 of the muscles and loss of electrical contractility supervene. But 
 I do not believe that many cases of this kind can be adduced in 
 which an observer has noted /'row the first days diminution or loss of 
 faradaic contractility^ and from the first weeks, atrophy and degeneration 
 of the muscles. Although I have made some researches on this 
 subject, I have not found, up to the present, any cases unquestion- 
 ably possessing this characteristic. 
 
 We are thus induced, gentlemen, to have recourse here also to 
 the luminous distinction proposed by M. Brown Sequard : nerve- 
 irritation alone is capable of determining rapid and early atrophy of 
 the muscles, preceded by decrease or disappearance of faradaic contrac- 
 tility. Complete nerve- division does not induce atrophy and loss of elec- 
 trical reaction until after an incomparably greater lapse of time^ as in 
 the case of prolonged iiiaction. 
 
 That being conceded, we have now to seek in what manner — an 
 irritative nerve-lesion being given the existence of which has been 
 recognized — we can derive from it, as a more or less direct conse- 
 quence, the rapid loss of electrical contractility, the early atrophy 
 of the muscles, and, in a word, the whole series of phenomena 
 
 ' To mention one example, see the case recently reported by Dr. Constantin 
 Pan! ('Soci-te de Therapeutique,' Seance du 7 Mai, 1871, in 'Gazette M6dicale,'p. 
 257, No. 25, 1871). One of the most remarkable derangements of nutrition pro- 
 duced by nerve-lesions is the emaciation or atrophy of the muscles supplied by 
 these nerves. Tliis atrophy may exist alone, or may be associated with other 
 nutritive disorders of the same kind occupying the skin and it» appendages 
 (Mitchell, Morehouse, and Keen, 'Gunshot Wounds,' etc., p. 09). 
 
 2 See P. Brouardel, 'Lesions du rocher, carie, necrose, et des complications qui 
 en sont la consequence,' Extrait du ' Bulletin de la Society Anatomique,' Paris, 
 1867. 
 
 3 F. Niemeyer, ' Lehrbucb der Spec. Pathologie und Therapie,' 7e aufl., 2e Bd. , 
 p. 3d5. 
 
 '6 
 
34 IKRITATIVE NERVE-LESIONS. 
 
 which clinical observation discerns in the cases that engage our 
 attention. 
 
 The enfeeblement or loss of contractility is, you are aware, next 
 to motor paralysis (which, in the vast majority of instances, heads 
 the procession), the first fact which we take note of, in such circum- 
 stances. Some authors seem to see, in this symptom, a very simple 
 consequence of the loss of excitability in the nerve, supervening 
 here at an early period (about the fifth day), as in the case of nerve 
 sections, and assignable to degeneration of the medullary sheaths, 
 beyond the injured part. It appears certain that the contractions 
 of the muscles, caused by electricity, are more marked when we 
 can act upon them through the medium of the nerves, than where 
 the stimulus, in consequence of the distinction of the nerve-fila- 
 ments, can no longer bear upon the contractile substance itself. 
 But however this may be, if the opinion to which we refer were 
 well founded, the marked enfeeblement or apparent abolition of 
 the electrical contractility supervening some d/iys after the opera- 
 tion should be a constant fact, after nerve-sections; since in such 
 cases the distal end of the nerve always loses its excitability at the 
 end of five or six days. Now, we know that this is not the case. 
 On the other hand, it is by no means proved that nerve-lesions 
 which induce early loss of electrical contractility are always suffi- 
 ciently intense to completely interrupt the continuity of the nerve- 
 fibres and determine the destruction of the medullary cylinder. A 
 certain number of facts might, in truth, be cited which tend to 
 demonstrate that the continuity of the nerve persists, at least to 
 some extent, even after lesions which rapidly occasion the appear- 
 ance of the most evident trophic disorders in the muscles. 
 
 Thus, after a traumatic lesion bearing on the course of a nerve, 
 we sometimes see the power of motion remain, and only become 
 enfeebled when trophic lesions have supervened in the muscle.^ It 
 is important to note, besides, that muscular and cutaneous sensi- 
 bility are often preserved, in a nearly normal condition, in cases of 
 lesion of mixed nerves, even when rapid enfeeblement of the elec- 
 trical contractility and consecutive muscular atrophy are carried 
 very far. This is a fact to which due prominence has been given 
 by MM. Duchenne(de Boulogne),^ Mitchell, Morehouse, and Keen.^ 
 
 Is it probable that, in such cases, the motor- fibres would have 
 
 ' See the observation quoted by Duchenne (de Boulogne), loc. cit., p. 207. 
 
 2 '* hi paralytic diseases consecutive on traumatic lesions of mixed nerves, the 
 functional derangements affect the sensibility of muscles less than their contiac- 
 tility. Thus, a luxation of the shoulder-joint having occasioned a lesion of the 
 nerves that supply the arm, forearm, and hand, I have known the patient to com- 
 plain of rather marked muscular sensation, even when these muscles did not 
 exhibit the slightest contraction under the influence of the most intense electrical 
 excitation. Cutaneous sensibility is less affected than muscular sensibility, in 
 these same nervous lesions." — Duchenne (de Boulogne), loc. cit., p. 216. 
 
 3 Mitchell, etc., loc. cit., p. 97. 
 
MODE OF ACTION. 35 
 
 undergone great alterations, whilst the sensitive fibres, intermingled 
 with them throughout the nerve, would have alone been spared ? 
 But take an argument of a somewhat more direct bearing. After 
 certain affections of the spinal cord, such as haematomyeJia, acute 
 central myelitis, infantile paralysis — diseases in which the initial 
 lesion occupies most especially the gray matter — it is common, 
 when irritative nerve-lesions are in question, to see a diminution or 
 a total abolition of the electrical contractility supervene in the 
 muscles of the paralyzed member. The muscular nerves have 
 been several times examined, in such cases, under the microscope; 
 sometimes, they appeared normal, at others, they presented to a 
 certain degree the changes characterizing fatty granular degenera- 
 tion, but then these alterations were not at all in proportion, either 
 in extent or in intensity, to the muscular disorders. We shall have 
 occasion again to refer to this important fact. 
 
 You see by what precedes that, in my opinion, the rapid aboli- 
 tion of electrical excitability observed after nerve-section cannot be 
 altogether assigned to the fatty granular degeneration of the medul- 
 lary sheath, and to the loss of excitability of the nerve fibres, 
 which would be the consequence of this alteration. If this be so, 
 it becomes very probable that the phenomenon in question is, at 
 least in part, the effect of some change supervening in the consti- 
 tution of the contractile substance, under the influence of the irri- 
 tation transmitted to the primitive muscular fasciculus through 
 the terminal nerve-branches. The rapidity which may mark the 
 production of this trophic trouble is not an argument against our 
 hypothesis. Experience, in fact, demonstrates that under the influ- 
 ence of certain causes, such, for example, as the abrupt inter- 
 ruption of the course of arterial blood, the muscular fibre may 
 experience still more rapidly — after a few hours merely — a modi- 
 fication which is undoubtedly closely analogous, for it also reveals 
 its existence by the abolition of the specific contractile power of 
 the muscle.^ 
 
 To judge by the usual concatenation of phenomena, discerned 
 by clinical observation, this alteration of the contractile fibre, 
 manifested externally by modifications of the electrical contractility, 
 would be the precursor and the first term of a series of graver 
 
 ' " I divided one ischiatic nerve in each of two rabbits and two gninea-pigs. 
 Ten days after, I perceived that the divided nerve produced no movement when 
 I galvanized it. The muscles contracted actively wlien I applied both poles to 
 them. Having noted this, I tied the aorta below the origin of tlie renal arteries, 
 and three hours after I again tried the effects of galvanism. There were no con- 
 tractions set up in the leg, neither when I stimulated the nerve, nor when I 
 directly stimulated the muscles. I then loosed the ligature ; at the end of a very 
 short time, the muscles again became irritable. The ischiatic nerve did not re- 
 cover its lost property. In this experiment the muscles of the leg, after having 
 completely lost their irritability, only recovered it by nutrition, since neither the 
 nerve-centres nor the divided ischiatic nerve could give it." — (Browu-Sequard, 
 'Journal de Physiologie,' t. ii, p. 77, 1859.) 
 
36 ALTERATION OF THE CONTRACTILE FIBRE. 
 
 lesions which gradually lead to the wasting of the muscle, and 
 sometimes induce the complete and definitive abolition of its func- 
 tions. Observations, to which we have already referred and to 
 which we shall hereafter return, appear to indicate that the lesions 
 in question are largely of an irritative nature. One might be 
 tempted after that, following the wanderings of the theory at pre- 
 sent in vogue, to consider these lesions as the more or less direct 
 consequence of a paralysis of the vasomotor nerves, concomitant 
 with the paralysis of the motor muscular nerves. Amongst the 
 arguments which have weight against this view, we may confine 
 ourselves to pointing out one, namely, that the requisite signs of 
 vaso-motor paralysis — the repletion of the bloodvessels and the 
 augmentation of the temperature — are not to be seen, except on 
 very exceptional occasions, in those patients who, after a nerve- 
 lesion, suffer from paralysis with rapid diminution of electrical 
 contractility. 
 
 Numerous facts attest, on the contrary, that the skin is generally 
 pale and bloodless, whilst, at the same time, the local temperature 
 is manifestly lowered from the very beginning.^ 
 
 II. 
 
 Such, gentlemen, was the solution of the vexed question, which 
 I had accepted, when I became acquainted with some new investi- 
 gations that had been carried out in Grermany. The results fur- 
 nished by these researches, where numerous experiments on ani- 
 mals are paralleled with pathological facts, seemed to me, at first 
 sight, destined to destroy the whole edifice. For, indeed, to judge by 
 the conclusions formulated by the authors, the opposition between 
 passive and irritative lesions of the nerves, considered in reference 
 to their effects on the contractility and the nutrition of muscles, 
 would be anything but established. I shall set out by declaring 
 that the experiments to which I allude, instituted by Dr. Erb, in 
 1868, and by MM. Ziemssen and 0. Weiss, at the same period, but 
 independently, appear to have been most carefully conducted. It 
 remains to be seen whether they have the signification which has 
 been attributed to them. 
 
 Various nerve-lesions — by contusion, ligature, and section in a 
 very few cases — having been produced in rabbits, it was purposed 
 to make daily observations of whatever modifications of electrical 
 contractility should take place, as regarded nerves and muscles, 
 under the action of the continued current and of faradization, each 
 being employed in its turn. The electrization was applied some- 
 times through the skin, as in clinical cases, sometimes directly, as 
 in physiological research. Dr. Erb also undertook the task of fol- 
 
 ' Duchenne (de Boulogne), loc. cit., p. 234. Mitchell, loc. cit.^ p. 134. Folet, 
 'Etude sur la temperature des parties paral^'sfies,' Paris, 1867, p. 7. 
 
EXPERIMENTS ON ANIMALS. 87 
 
 lowing as far as possible, from day to day, the histological altera- 
 tions corresponding to the changes of electrical excitability. 
 
 Let us, in the first place, examine the phenomena observed in 
 these cases in connection with the injured nerves. Suppose that 
 the ischiatic nerve of a rabbit has been injured from being crushed 
 with a forceps. The lesion may be either slight or severe. If it 
 be severe, an almost immediate loss of the electrical contractility 
 is noted, whether galvanism or faradization be employed. On the 
 regeneration of the nerve, the recovery of the excitability takes 
 place slowly as regards the central end, but quickly, on the contrary, 
 in the distal. If the lesion be slight, the electrical excitability 
 returns rapidly to the central end, whilst it never completely ceased 
 to exist in the peripheral extremity. 
 
 You see that these first results do not diverge perceptibly from 
 those obtained in former experiments, since it was likewise shown 
 by them that a divided nerve loses its excitability from the first 
 days. 
 
 Let us now study the phenomena which, in the new experiments, 
 are set prominently forth by the electrical exploration of the 
 muscles. Here, gentlemen, the results diverge in a marked manner 
 from those furnished by former experiments, and approximate, on 
 the contrary, very closely to pathological facts. 
 
 Thus, /amc?a?'c exploration indicates, from the first days, a dimi- 
 nution, and afterwards — from five to fourteen days in intense cases 
 — total abolition of the contractility. 
 
 This is not all. Galvanic exploration, also, detects an enfeeble- 
 ment of the muscular contractions, from the first days; but, after 
 the second week, this enfeeblement is followed by an exaltation 
 which persists during the whole period of faradaic depression, 
 and which disappears in its turn, when faradization resumes its 
 power. 
 
 The muscular lesions whichcorrespond to these modifications of 
 electrical contractility have been studied with great care by Dr. 
 Erb; for many reasons they deserve the name of cirrhosis of the 
 muscles, proposed by Dr. Mantegazza.^ They distinctly and com- 
 pletely recall those lesions which the first-mentioned author pointed 
 out in a case of facial paralysis, observed in man. 
 
 The first alterations make their appearance in the interstitial 
 connective tissue: from the first week there is an accumulation of 
 numerous rounded cell-elements, recalling the tissue of granulation ; 
 these afterwards assume an elongated form, disappear, and give place 
 to undulated connective tissue. The muscular fasciculi do not begin 
 to show any alterations till about the second week. At this period, 
 the diminution of their diameters is already noticeable. This atro- 
 phy makes rapid progress. However, the transversal striation per- 
 
 ' Vide supra, note, p. 29. 
 
38 CONTUSION AND LIGATURE OF NERVES. 
 
 sists, and the fibres never offer any trace of the alterations cbarac 
 terizing granular fatty degeneration. On the other hand, from a 
 very early period, the nuclei of the sarcolemma are seen to multiply 
 and group together in little collections, whilst concurrently with 
 this the contractile matter presents different phases of those modi- 
 fications of structure known as waxy degeneration. 
 
 Such are the phenomena pointed out as consecutive on nerve- 
 lesions which, according to our authors, would be equivalent to 
 complete sections. Well, I have no hesitation in declaring that 
 this, parallel is far from being secure from criticism. The results 
 obtained by Dr. Erb and by Dr. Ziemssen relate to conditions, un- 
 doubtedly, comparable with those which pathology gives us, but 
 not at all with those which were determined in the old experiments. 
 Let us see how these observers have proceeded in the great majority 
 of instances. It will be found that they almost always ligatured 
 the nerve more or less tightly, or else crushed it more or less com- 
 pletely with a forceps. Now do not these circumstances furnish 
 ample reasons for presuming tiiat irritation of the nerve filament 
 may have intervened here, as, in our opinion, it intervenes in patho- 
 logical cases ? 
 
 But there is no question of a mere presumption. The existence 
 of an inflammation occupying not only the neighbourhood of the 
 contused points, but even the whole length of the peripheral por- 
 tion of the injured nerve, is placed beyond doubt by the descriptions 
 of Dr. Erb himself. The neurilemma, especially, shows the charac- 
 teristic signs of the inflammatory process; from the first week, 
 rounded cell-elements, having a solitary nucleus, are seen accumu- 
 lated in great numbers. At a more advanced period, a more or 
 less thick layer of fibrous tissue is found interposed between the 
 nerve-filaments which have undergone the different phases of fatty 
 degeneration. As a consequence, the nerve-bundle has acquired a 
 consistence which enables it to resist dilaceration more tenaciously 
 than a normal nerve. 
 
 It seems to us rational to admit that in these experiments, as in 
 the cases relating to man, the irritative lesions which occupy the 
 nerves extend their influence to the muscles. It may, indeed, 
 appear difficult to conceive that a nerve, which has undergone the 
 alterations of fatty degeneration and is deprived of its motricity, 
 should still possess a certain amount of vitality, and be capable, 
 under the influence of an irritative lesion, of reacting on the mus- 
 cular fibre, and determining trophic disorders therein. It is proper, 
 however, to point out, in reference to this, that the irritation prob- 
 ably dates from the very moment when the nerve was ligatured or 
 contused. It is certain, besides, that the vitality is far from being 
 definitely destroyed in nerves completely separated from the ner- 
 vous centres, since the work of regeneration can proceed without 
 
SECTION AND EXCISION OF NERVES. 39 
 
 the distal and central ends being united.^ It is useful to remember, 
 also, that it is only on hypothetical grounds and without proof 
 positive, that nerve-tubes deprived of their medullary matter and 
 reduced to the axis-cylinder, are said to be denuded of every kind 
 of vital property. 
 
 We must not forget, however, that ligature and contusion are not 
 the only means employed in the experiments of Drs. Erb and Ziems- 
 sen. These authors have also made sections and excisions of nerves, 
 though in comparatively few cases. They state that the results are 
 always identical, whether complete section or contusive lesion be in 
 question. But if we go back to the details of the observations, it is 
 not difficult' to see that this conclusion cannot be accepted, without 
 reserve. We find in Ziemssen's work, especially, a very significant 
 chapter, considered from this point of view. It treats of cases in 
 which excisions of the ischiatic nerve were made, the excised por- 
 tions being some millimetres in length. Now, the results obtained 
 in consequence of such a lesion are very different from those which 
 this, author and Dr. Erb remarked after ligature and contusion of 
 nerves. They resemble, in many respects, the facts gleaned from 
 physiological experiments. Thus, in the first place, the electrical 
 contractility diminishes, after excision, in a progressive manner, 
 but very slowly. It does not seem to be abolished until many 
 months have passed, — not disappearing at an early period, varying 
 from the fifth to the fourteenth day, as happens in the case of con- 
 tused lesions. In the second place, we do not meet here with that 
 opposition between the effects of faradization and those of galvani- 
 zation which was observed in cases of contusion, and which exists, 
 as you remember, in most of the pathological cases where man is 
 concerned. These two modes of exploration, on the contrary, 
 produce precisely parallel effects: faradaic contractility and gal- 
 vanic contractility grow weak together, and together resume their 
 wonted intensity, on the regeneration of the nerve which, indeed, 
 requires to be long waited for.^ 
 
 • Vulpian, ' Syst6me nerveux,' loc. cit., p. 269. 
 
 2 Compare the observation No. ii, fig. 3, in the memoir of Ziemssen and Weiss 
 {loc. cit., p. 589), relative to a case of lifjature of the anterior tibial nerve in a 
 rabbit, with the observation No. ii (p. 593), concerning excision of the ischiatic, 
 in a rabbit also. In the first case, faradaic contractility seemed extinguished 
 from the 12th day after the operation, whilst galvanic contractility, on the other 
 hand, increased from the 2d day, and kept to a high level until the moment 
 when faradaic contractility approached its normal standard again (the 44th day). 
 In the secon'l case, on the contrary, both faradaic and galvanic contractility 
 became enfeeble<l together and progressively, but in a very slow manner. They 
 ceased to be manifest almost simultaneously about the middle of the third 
 month only, and made their appearance together about four months and a half 
 after their cessation. MM. Ziemssen and 0. Weiss express themselves in the 
 following terms in reference to the effects of the excision of the ischiatic in a 
 rabbit. "In animals, on which this operation had been performed," "galvanic 
 excitability declined progressively, and this enfeeblement was not preceded by 
 a stage of exaltation. It proceeded slowly, at the same rate as the enfeeblement 
 
40 LESIONS OF SPINAL CORD. 
 
 If I do not deceive myself, we may conclude from this sketch 
 that, when there is question of complete section or of excision of 
 the nerves, the recent observations harmonize on all essential points 
 with the old researches. On the other hand, the results obtained 
 by MM. Erb and Ziemssen, from the employment of contusion 
 and ligature of the nerves of animals, are comparable with the 
 phenomena which occur in man in consequence of irritative lesions 
 of mixed or purely motor nerves. 
 
 Now, if this be so, the dissidences which we pointed out at the 
 beginning of this study are smoothed away, and consequently we 
 have reason to acknowledge, in speaking of muscular affections, 
 the fundamental distinction between the effects of the absence of action^ 
 and those of morbid action, of the nervous system which we have already 
 put prominently forward in discussing cutaneous and articular 
 affections.^ 
 
 Trophic disorders consecutive on lesions of the Spinal 
 
 COKD. 
 
 Irritative lesions of the nervous centres, like those of the nerves, 
 have the power of producing remote trophic disorders in different 
 parts of the body. In the exposition of these consecutive altera- 
 tions which we are going to offer you, we shall again find the 
 whole series of morbid affections (with the exception of some slight 
 differences) which we have remarked taking place after nerve- 
 lesion. The knowledge of their history, which we have already 
 gained, will singularly facilitate the task that remains to be ac- 
 complished. 
 
 We may say, in a general manner, gentlemen, that the shin^ the 
 muscles^ the joints, the bones, and the viscera, may become the seats 
 of various trophic disorders, consequent on lesions of the spinal 
 cord and of the brain. 
 
 of farado-muscular excitability. Galvanic excitability disappeared in the second 
 half of the 3d month, to reappear towards the 7th or 8th mouth" (^toc. cit., pp. 
 592 et 593). 
 
 ' Recent experiments made by M. Vulpian (* Archives de Physiologie,' t. iv, 
 1871-1872, pp. 757,758), confirming on almost every point those of MM. Erb and 
 Ziemssen, establish that the effects of section of peripheral nerves upon the phy- 
 siological properties and structure of the muscles do not essentially differ from 
 those caused by the application of various irritative agencies, to the same nerves, 
 such as local contusion, ligature, and cautery. On the other hand, the histo- 
 logical observations of MM. Neumann ('Archiv f. Heilkunde,' Leipzig, 1868), 
 Ranvier (' Comptes Rendus de I'Academie des Sciences,' 30th December, 1872), 
 Eichhorst (Virchow's 'Archiv,' 1874, 12th December), have placed beyond doubt 
 that in the peripheral extremities of the divided nerve alterations are constantly 
 produced, e. gr., multiplication of the cells of the inter-annular segment, which 
 betray the presence of an irritative process. The opposition between the effects 
 of nerve-section and of nerve-irritation cannot, after this, be any longer main- 
 tained in the strict terms in which it was set out in this lecture {Author's note to 
 the 2d Edition). 
 
CONSECUTIVE MYOPATHIES. 41 
 
 Let US take the affections of the muscles, in the first place, since 
 the investigation we have just concluded has led us towards that 
 question. The considerations we are about to set forth concern- 
 ing these affections relate only to lesions of the spinal cord and 
 medulla oblongata; for it is at least very doubtful whether lesions 
 of the brain proper have ever the effect of directly producing 
 alterations of the muscular tissue, and this, as we shall see in due 
 time and place, is a fact of the highest importance. 
 
 Muscular lesions consecutive on affections of the spinal cord. — Of 
 irritative spinal lesions, there are some which determine the very 
 rapid production of all the kinds of functional and organic muscu- 
 lar alterations which we have been studying, as consequences of 
 nerve-lesions. There are others, on the contrary, where the elec- 
 trical contractility and the trophic condition of the muscles are 
 preserved in perfect integrity, during a comparatively considerable 
 lapse of time, for months and occasionally even for years. The 
 muscle, in the latter case, only becomes slowly altered, under the 
 influence of the functional inertia to which the limbs, stricken with 
 motor paralysis, are subjected. Hence we find it possible to sepa- 
 rate the irritative spinal disorders into two very distinct groups, 
 which we shall pass successively in review. 
 
 A. In the first group we place those of the irritative lesions of 
 the cord which, as a rule, do not directly modify the nutrition of 
 the muscles. They have one character in common: — all tend to 
 limit themselves to the white fasciculi of the cord, and if the gray 
 matter be, at times, invaded, the region of the anterior cornua is 
 respected, or at least the great multipolar nerve-cells which occupy 
 that region are spared. Such are the different forms o^ fasciculated 
 sclerosis, whether it be protopathic or consecutive on a circumscribed 
 lesion {en foyer) of the brain or spinal cord, whether it occupy the 
 posterior fasciculi only, or the lateral fasciculi only, or both simulta- 
 neously; so long as the express condition stated be fulfilled, that 
 is to say, so long as the integrity of the great nerve-cells be pre- 
 served, the lesions in question may attain their highest degree of 
 development, may, for instance, invade the white fasciculi in their 
 whole width and their whole height, without direct deterioration 
 to the nutrition of the muscles animated by nerves issuing from 
 the injured portions of the cord.^ 
 
 The scene would necessarily change, if the irritative process, ex- 
 ceeding the limits usually assigned it, happened to extend from 
 the white fasciculi to the anterior cornua of the gray matter; then, 
 in consequence of the participation of the motor-cells, a more or 
 less rapid and thorough atrophy of the muscles might supervene. 
 
 ' Charcot et Joffroy, "Deux cas d'atrophie mnsculaire progressive avec lesion 
 de la substance grise et des faisceaux antero-lateraux de la moelle epiniere," in 
 'Archives de Physiologie, t. ii, p. 635. 
 
42 CONSECUTIVE MYOPATHIES. 
 
 It is in this way, as I have pointed out elsewhere/ that the symp- 
 toms of general spinal paralysis or of progressive amyotrophy are 
 sometimes superadded to the classic symptoms of posterior or lat- 
 eral sclerosis, etc. We have quite recently seen many cases of this 
 kind where we had opportunities of observing necroscopically, in 
 the most distinct manner, the alteration of the nerve-cells to which, 
 according to my view, the trophic muscular lesion should be at- 
 tributed.^ 
 
 1 Charcot et Joffroy, loc. cit., p. 354. 
 
 2 See, amongst other cases, that recently published bj one of my students, M. 
 Pierret,* ' Sur les alterations de la substance grise de la moelle epiniere dans 
 I'ataxie locoraotrice considerees dans leurs rapports avec I'atrophie musculaire 
 qui complique quelquefois cette affection, (in ' Archives de Physiologie,' etc., t. iii, 
 p. 599). In this instance, phlegmasic action had extended from the posterior 
 columns to the right anterior cornn of gray matter, following the course of the 
 internal radicular fibres of the corresponding side, the consecutive muscular atro- 
 phy was exactly limited to the members of the right side (vide fig. 1). 
 
 The following is a succinct account of a case wiiich shows well the mechanism 
 by which consecutive unilateral fasciculated sclerosis may, by extending to the 
 gray matter, determine the production of muscular atrophy: — 
 
 A woman, aged about 70 years, had been stricken with left hemiplegia, con- 
 secutive on the formation of a blood-clot in the right cerebral hemisphere. The 
 members of the paralyzed side, which had at an early period been contractured, 
 commenced to diminish in bulk, not quite two months after the attack. The 
 muscular wasting affected all parts of the paralyzed members, in an uniform 
 manner; it was accompanied by a very marked decrease of electrical contractility 
 
 * Fig. 1. — The figure is illustrative of M. Pierrett's case (a summary of which is 
 appended); it represents a transverse section of the spinal cord taken from 
 the lumbar enlargement. A. Posterior roots. B. Internal radicular fasci- 
 culi traversing the area of the posterior columns. The sclerosis is seen lim- 
 ited, in the posterior columns, to the course of these fasciculi On the right, 
 the phlegmasic process has extended, along the course of the radicular fasci- 
 culi to the right anterior cornu, C. This cornu has evidently suffered dimi- 
 nution, in every diameter, moreover the external group of motor cells has 
 completely disappeared, and we find in its place a dense, opaque, apparently 
 fibroid tissue, containing numerous disseminated myelocytes. 
 
CONSECUTIVE MYOPATHIES. 43 
 
 The same rule holds good for disseminated sclerosis {sclerose en 
 plaquesy and for the diffused scleroses. The same may be said of 
 primary partial myelitic affections or of those determined by tumour- 
 pressure, Pott's disease of the vertebrae, etc. These different dis- 
 eases have no direct influence over the nutrition of the muscles so 
 long as they do not involve the system of motor nerve-cells. 
 
 We can scarcely conceive of an exception, save in those very 
 rare cases, where the lesion, though circumscribed to the white 
 fasciculi, occupies that portion of the cord traversed by bundles of 
 nerve tubes, from which issue the posterior roots. If these bundles 
 should be at all involved in the alterations, the equivalent of a 
 lesion affecting the peripheral nerves would necessarily be pro- 
 duced.2 
 
 B. The second group will include those affections of the spinal 
 cord, the almost inevitable consequence of which it is to determine 
 more or less grave disorders in the nutrition of the muscles. This 
 group may be separated into two subdivisions: — 
 
 1st. The first includes those acute or subacute lesions, whether 
 diffuse or circumscribed (em foyer\ which involve a great length 
 of both the white and the gray substances, but which generally 
 predominate in the latter. They are commonly followed by great 
 
 and made rapid progress. At the time when the atrophy became evident, the 
 skin of the affected members, on all points subjected to the slightest pressure, 
 presented bullae, which soon gave place to eschars. At the autopsy, we observed, 
 on examining hardened sections of the brain, that the descending fasciculated 
 sclerosis of the left lateral column had been propagated to the anterior cornu of 
 the gray matter of the corresponding side, and had there caused atrophy of a 
 certain number of the motor-cells. 
 
 ' In the case of a woman, suflfering from raultilocular cerebro-spinal sclerosis, 
 whom we treated some years ago, one of the sclerosed patches had invaded, near 
 the raid-cervical region, almost the whole of the gray matter of the cord, for a 
 certain height, and the anterior cornua in particular. At this level the nerve- 
 cells mostly presented grave atrophic lesions, and a good nuniber of them had 
 vanished, without leaving any trace. The woman's liands presented the deforma- 
 tion known as a (jriffe, i. e., they were claw-like. The muscles of the thenar and 
 hypothenar regions, as well as the interossei were atrophied; the forearms also 
 showed great atrophy, limited to certain groups of muscles. 
 
 2 In reference to partial myelitic aflfections, whether protopathic, or determined 
 by the vicinity of a tumour, the following remark will not be out of place: They 
 are most commonly found at a point of the dorsal region of the spinal cord, which 
 they occupy for but a very small extent, in height. It would follow from this 
 arrangement that if, whether primarily or in consequence of concentric extension 
 of the morbid process, the anterior cornua of the gray matter became involved, 
 the muscular lesions which result therefrom would ])e confined to very circum- 
 scribed regions of the thorax or even of the abdomen, and might not betray 
 themselves during life, by any perceptible symptom. At all times, the nutrition 
 of the muscles of the extremities, if there be no complication, remains perfectly 
 intact, when the partial myelitis occupies the position we have just mentioned. 
 It would be quite otherwise in any case where a focus of myelitis, even though 
 very much circumscribed, should occupy certain parts of the cervical or lumbar 
 enlargements. The muscular lesions supervening, in consequence of the invasion 
 of the anterior cornua, would then have their seat in the extremities and would 
 betray their presence by functional disorders, and by alterations of form, iu those 
 parts, which could not long escape attention. 
 
44 CONSECUTIVE MYOPATHIES. 
 
 modifications of electrical contractility, and by a rapidly developed 
 atrophy of nnuscular fibre. 
 
 I will refer to <tcute central myelitis^ in the first place. When it 
 has been somewhat generalized, and occupies, for instance, a con- 
 siderable portion of the dorso-lumbar swelling, the early diminution 
 of electrical contractility in the lower extremities is a symptom 
 which probably is never completely absent. Herr Mannkopf has 
 seen, in such cases, the electrical contractility remarkably altered 
 seven days after the appearance of the first symptoms.^ When 
 the patients are not too quickly carried off', you may follow the 
 development of the correlated phenomena — the atrophy of the 
 muscular masses soon shows itself, and the histological lesions of 
 the primitive (ultimate) fasciculi become promptly perceptible. 
 
 According to MM. Mannkopf^ and Engelken,^ these lesions are 
 chiefly remarkable on account of the proliferation of the nuclei of 
 the sarcolemma. They bear, in fact, the stamp of the irritative pro- 
 cess. Here, also, fatty degeneration of the primitive fasciculi is an 
 exceptional incident. As to the nerves which supply the affected 
 muscles, they were found by Herr Mannkopf, after repeated ex- 
 aminations, to be sometimes healthy, sometimes affected by com- 
 paratively slight alterations nowise proportionate in intensity to 
 the severity of the muscular lesions."* 
 
 Spinal apoplexy (hcemaiomyelia) should be mentioned in the 
 second place. This is an affection which, considered from the 
 standpoints of pathogeny and pathological anatomy, differs essen- 
 tially from common intra-cerebral hemorrhage; for, in haemato- 
 myelia, the effusion usually takes place in the midst of tissues which 
 have already suffered modification from inflammatory action. The 
 blood is chiefly effused in the gray matter, which it often invades 
 throughout the major part of its length. When this happens, 
 diminution or even abolition of electrical contractility, supervening 
 early in the muscles of the paralyzed members, is a symptom which 
 seems constant. It was observed fourteen days after the develop- 
 ment of the first accident, by Levier;^ on the very day of the 
 attack, by Colin (?); on the ninth day, in a case recorded by 
 Duriau.^ Spinal apoplexy is an affection which, in general, is 
 rapidly fatal; it has as yet furnished no opportunity of observing 
 the histological lesion of the primitive fasciculi and the atrophy of 
 the muscular masses, which would doubtless not fail to follow if 
 life were prolonged. 
 
 It is probable, gentlemen, that fractures and luxations of the verte- 
 
 ' Mannkopf, 'Amtlicher Bericht uber die Versaramlung Deutsolier Naturforscher 
 und Aerzte zu Hannover,' p. 251. Hannover, 18G6. 
 2 Mannkopf, loc. cit. 
 
 * Engelken, ' Beitrag zur Patholog. der acnten Myelitis.' Zurich, 1867. 
 ^ Vide supra, p. 36. 
 
 5 Levier * Beitrag zur Pathologie der Riickenmarksapoplexie.' Inaugural-dis- 
 sertation. Bern, 1864. 
 
 6 Duriau, ' Union M§dicale,' t. i. 1859, p. 308. 
 
LESIONS OF MOTOR NERVE-CELLS. 45 
 
 hral column^ by producing an irritation of the cord which from par- 
 tial tends to become general, nnaj have the effect of determining, 
 as Dr. Duchenne (de Boulogne^) has remarked, a prompt diminu- 
 tion of electrical contractility in the muscles of the paralyzed 
 member. 
 
 2d. The affections which compose the second category are the 
 product of more delicate lesions. These are, in fact, limited, in a 
 seemingly systematic manner, to the gray matter of the anterior 
 cornua, the entire extent of which they rarely invade ; we see them 
 often very exactly localized in the circumscribed oval space occu- 
 pied by a group or cluster of motor cells (Fig. 2). 
 
 Fig. 2. — Fragment of a transverse section of^tlie spinal cord taken from the lum- 
 bar region, in a case of infantile spinal paralysis occupying the right inferior 
 extremity. The right anterior cornu of gray matter is represented. The 
 lesions affect exclusively the antero-external group of nerve-cells : a, cervix 
 cornu posterior is ; b, postero-external group of nerve-cells ; c, antero-external 
 group. The cells of the latter group have completely disappeared, whereas 
 those of groups 6 and d are perfectly distinct ; d, internal group ; e, the com- 
 missure. 
 
 The neuroglia, in the affected parts, becomes usually opaque, 
 denser, strewn with numerous myelocytes and consequently ex- 
 hibits the signs of inflammatory action. At the same time, the 
 nerve-cells present different degrees and different modes of atrophic 
 degeneration. But what are the elements first affected? Every- 
 thing leads us to believe these to be the nerve cells. It would, 
 
 ' Ducbenne (de Boulogne), Observation, p. 246, loc. cit., fracture of the verte- 
 bral column, about the middle of the dorsal region. The spinal cord softened for 
 several inches, in tbe dorso-lumbar region. Enfeeblement of the electrical con- 
 tractility from the sixth day after the accident. 
 
46 INFANTILE SPINAL PARALYSIS. 
 
 indeed, be difficult to comprehend how the alteration could show 
 itself strictly localized in the vicinity of the cells if its starting point 
 were in the neuroglia. There are cases besides, in which the 
 atrophy of a certain number, or even of a whole group, of nerve- 
 cells is the only alteration which can be discerned, on histological 
 examination. The connective web preserves its transparency, in 
 those points, and all the characters of normal structure, with but 
 few exceptions. There are other not less significant cases, also, 
 where lesions of the neuroglia appear much more developed about 
 the central parts of a cluster of nerve-cells, than in the peripheral 
 portion, and also much more manifest in the immediate neighbour- 
 hood of the cells themselves, than in the intervals between them, so 
 that they appear like so many centres or foci, whence the inflam- 
 matory process radiated outwards for some distance in every direc- 
 tion. On the other hand, it cannot be admitted that the irritation 
 was originally developed in the peripheral portion and ascended to 
 the central parts along the anterior nerve-roots, for the latter gene- 
 rally present, on a level with the altered points of the cords, only 
 comparatively trifling lesions and not at all of intensity proportion- 
 ate to the lesions of the grsij matter. It appears evident, from all 
 that precedes, that the motor nerve-cells are, in reality, the primary 
 seat of the evil. Usually, it is true, the irritative process next in- 
 vades the neuroglia, its second stage; and extends step by step to 
 the different regions of the anterior cornua; but that is by no 
 means necessary. Hence we must, a fortiori, regard as a consecu- 
 tive and purely accessory fact, the extension, in certain cases, of 
 the morbid process to the antero-lateral fasciculi, in the immediate 
 neighbourhood of the anterior cornua of gray matter.^ 
 
 Infantile spinal pa7^ahjsis is, up to the present, the most perfect 
 type of the affections which compose this category. The numerous 
 researches made recently in France, in reference to the spinal lesions 
 on which they depend, concur to indicate, as an essential fact, the 
 profound alteration of a large number of motor-cells, in those 
 regions of the cord whence the nerves emanate which supply the 
 paralyzed muscles.^ In the vicinity of the atrophied cells, thecon- 
 
 ' The views set forth above relative to the r61e of the so-called motor nerve- 
 cells in the pathogeny of progressive muscular atrophy, infantile paralysis, acute 
 central myelitis, and of all the amyotrophies arising from spinal causes, in gene- 
 ral, were stated in a lecture which I delivered at La Salp6triere in .June, 18138. 
 Cf. Hayem. 'Archives de Physiologie,' 1869, p. 263. Charcot et Joffroy, id., p. 
 7.56. Duohenne (de Boulogne) and Joffroy, id., 1870. These views have been 
 utilizerl in the recnnt work of Dr. Hammond, * A Treatise on Diseases of the Ner- 
 vous System,' Sect. iv. ' Diseases of Nerve-cells,' p. 683, New York, 1871. 
 
 2 On atropliy of the motor nerve-cells in infantile paralysis, consult Prevost, 
 in ' Comptes Hendus de la Society de Biologie,' 1866, p. 215. Charcot et Joffroy, 
 •' Cas de Paralysie Infantile Spinale, avec lesions des comes anterieures de la 
 substance grise de la moelle 6pinicre," in 'Archives de Physiologie,' p. 135, 187 0, 
 pis. V et vi. Parrot et Joffroy, id., p. 309. Vulpiiin, id., p. 316. H. Roger et 
 Dnmaschino, " Rt^clierches Anatomiques sur la Pnralysie Spinale de I'Enfance," in 
 ' Gazette Medicale,' Nos. 41, 43, et suiv., 1870 (fig. 2). 
 
PROGRESSIVE MUSCULAR ATROPHY. 47 
 
 nective network almost always offers manifest traces of an inflam- 
 matory process. Judging from the general aspect of the phe- 
 nomena, we are induced to admit, as a highly probable hypothesis, 
 that, in infantile spinal paralysis, a superacute irritative action 
 suddenly seizes on a large number of nerve-cells and makes them 
 promptly lose their motor functions. Some cells, which have been 
 but slightly attacked, will recover their functions some day, and 
 this phase corresponds to the amelioration of symptoms which 
 always supervenes at a certain period of the disease. Others, how- 
 ever, have been more severely involved, and the irritation of which 
 they were the seat is transmitted along the nerves to the paralyzed 
 muscles which, in consequence, suffer trophic lesions of a more or 
 less serious character.^ However it be, it is known that diminution 
 or even loss of faradaic contractility may be observed, in certain 
 muscles, barely five or six days after the abrupt invasion of the 
 first symptoms. The emaciation of the muscular mass makes rapid 
 progress, besides, and soon becomes evident. The alterations 
 which, on histological examination, are found in the affected mus- 
 cles are these : firstly, simple atrophy of the primitive fasciculi with 
 the transverse striae preserved ; and, secondly, the marks of a more 
 or less active proliferation of sarcolemma-nuclei on some isolated 
 fasciculi. The accumulation of fat, sometimes seen in old cases, 
 seems to be a purely adventitious phenomenon.^ 
 
 Progressive muscular atrophy offers for our stiidy the irritative 
 atrophy of the motor cells in its chronic form.^ Here we are not 
 concerned with a superacute irritative process suddenly invading 
 the nerve-cells, and laying hold on a large number of them. These 
 are now affected successively, one by one, in a progressive manner; 
 a considerable number of them are spared, even in the most seriously 
 compromised regions, until nearly the last period of the disease. 
 The development of the muscular lesions corresponds to this mode 
 of evolution of the spinal lesions. Thus, it is rare that the trophic 
 disorders affect simultaneously all the primitive fasciculi of a muscle; 
 hence it follows that the latter may respond, in a more or less im- 
 perfect manner to the command of the Will, and still enter into 
 contraction under the influence of electrical excitations, even when 
 its volume has been very markedly diminished.^ 
 
 1 Charcot et Joflfroy, loc. cit. 2 /ft,V7., loc. cit.; Vulpian, loc. cit. 
 
 3 On atrophy of the motor-cells in progressive muscular atrophy, see Luys, 
 'Societiede Biologie,' 1860. Dumenil (de Rouen), "Atrophia musculaire grais- 
 seuse progressive, historie critique," Rouen, 1867. " Nouveaux faits relatifs h la 
 pathogenie de I'atrophie musculaire progressive," in ' Gazette hebdom.,' Paris, 
 1867. Lockhart Clarke, " On a Case of Muscular Atrophy," ' British and Foreign 
 Medico-Chirurgical Review,' July, 1872. "A Case of Muscular Atrophy," Beale's 
 'Archives,' t. iv, 1867. "On a case of Muscular Atrophy," in ' Medico-Chir. 
 Transactions,' t. iv, 1867. (>. 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<l. Applying the ophthalmoscope, Professor 
 Panas found that the fundus of the right eye was normal, whilst there was a 
 very marked excavation of the papilla of the left eye, the fundus of which was 
 slightly congested. 
 
 Let us note, in conclnsion, that during the continuance of his ailment he com- 
 plained of great thirst, ami of unusual drowsiness after meals." 
 
 This patient recovered under treatment by faradization, as related in the 
 treatise already mentioned (S.). 
 
 » Ludwig, ' Mitth. der Zurich Naturforsch,,' 1851. 'Zeitschr. fiir rat. Med.,' 
 n. f. Bd. i, p. 255. ' Wiener Med. Wochenschr.,' 1860, x. No. 28, p. 483. See also 
 the works published by Ludwig in co-operatiou with Becher, Rahn, and Gianuzzi. 
 
 7 
 
98 ludwig's researches. 
 
 secretion of saliva. That second hypothesis should, therefore, also 
 be eliminated. 
 
 But perhaps the irritation of the glandular nerve which, as you 
 are aware, has the effect of inducing dilatation of the arteries, may 
 determine the secretion, simply because it momentarily augments 
 the afflux of arterial blood into the gland? This argument is 
 rendered invalid by an experiment made by Ludwig, which shows 
 that, during irritation, the manometric pressure in Wharton's duct 
 is superior to the pressure of the blood in the arterial conduits. 
 Besides, the hypersecretion of saliva from irritation of the chorda 
 tympani is still exhibited, after ligature of the arterit\s supplying 
 the gland — in the case of an animal killed by bleeding — or even in 
 the case of a head separated from the body. Let us also add this 
 most remarkable fact, namely, the saliva and the venous blood 
 which flow forth from the submaxillary gland, whilst the glandular 
 nerve is being stimulated, present, as MM. Ludwig and Spiess^ have 
 shown, a higher temperature than the arterial biood which passes 
 into the gland.^ 
 
 Judging from the general bearing of these results, it appears 
 evident that the influence of the nervous system on the submax- 
 illary secretion cannot be explained by the simple phenomena of 
 vascular dilatation and constriction. We are induced to recognize 
 in the glandular nerve a two-fold property, since, in addition to its 
 influence over the vessels, the dilatation of which it determines, it 
 also exerts an immediate action on those parts of the gland which 
 accomplish the chemical act of secretion, or, in other words, upon 
 the secreting cells. This influence of the nerve upon secretion 
 seems, indeed, to be the fundamental fact, for it shows itself, in 
 consequence of excitation, even when the effects of the concomitant 
 dilatation are annihilated. As, on the other hand, it does not ap- 
 pear possible, experimentally, to suppress separately the secretor 
 action, leaving the dilator action alone persisting,^ it is legitimate 
 to suppose that the latter depends on the former as a more or less 
 direct consequence. 
 
 We had, therefore, reason to inquire what might be the link of 
 connection between the excitation of the secretor elements deter- 
 mined by stimulation of the nerve, and the hypersemia which 
 
 ' Ludwig und Spiess, ' Sitznngsber.,' d. v., Ak. Math. CI., 1857, Bd. xxvr, p. 584. 
 
 2 In reference to this, see a Lecture of M. Vulpian, * Revue des Cours Scien- 
 tifiqnes,' «d annge, 1865-1866, p. 741. 
 
 3 By recent exporiments, however, M. Ileidenhain seems to have been able to 
 demonstrate that, in the chorda tympani, ditterent nerve-fibrils are devoted to 
 Becretion and to circulation in the submaxillary gland. He states tliat in dogs, 
 placed under the influence of woorari, after injection into the jugular vein of a 
 dose of atropine suflBcient to completely paralyze tlie cardiac filaments of the 
 pnenmogastric, the stimulation of the cliorda tympani no longer determined the 
 tilightest secretion. Nevertheless, there was an acceleration of the venous cur- 
 rent which did not notably differ from the acceleration determined by irritation 
 of the chorda, before poisoning. 'Archives de Physiologie,' 4 Juillet, 1872. 
 
THEORY OF ATTRACTION. 99 
 
 follows that excitation. Several pbysiolocrists have thought that 
 we have here to deal with an attraction which the secretor elements 
 of the gland should exert upon the blood. "So that to the force 
 hitherto known as assisting the return of the circulating blood to 
 the heart and which is termed vis a tergo, we should add a new 
 attractive force in correlation with the intimate nutrition of the 
 elements, a force named by many authors vis a fronteV^ Is this a 
 purely theoretical conception, unsupported by experiments, and 
 merely destined to cloak our ignorance? By no means. The 
 works of H. Weber, Schuler, Lister, etc.,^ contain numerous ex- 
 perimental facts calculated to render evident the attraction which 
 the tissues can exercise, under certain conditions, over the circuhit- 
 ing blood. I will cite two facts of this sort as examples, in which 
 the phenomena may be studied apart from any intervention of the 
 nervous system. I borrow them from a lecture on the Theory of 
 Secretions, delivered in the Museum of Natural History, by Pro- 
 fessor Yulpian.^ 
 
 If you cut all the nerves of a frog's limb and then determine an 
 excitation by placing a small drop of nitric acid on the skin of the 
 web of its foot, a more or less intense hyperaemia will be produced 
 in this point, at the end of a certain period. The second fact 
 is conclusive. An e^g on the fourth day of incubation presents 
 a very distinct vascularity of the umbilical membrane. At that 
 period, there cannot be the slightest question of nervous influence. 
 Now, if you place a small drop of nicotine on any point of 
 this vascular area, there ensues around this point so great a con- 
 gestion that almost all the blood flows thither. In truth, this 
 hyperaemia, this stasis by irritation of the tissues, displays itself, at 
 first glance, with I know not what semblance of a metaphysical 
 conception. But an eftbrt has long since been made to give an 
 interpretation of this phenomenon on physico-chemical grounds. 
 Thus, in 1844, Dr. Draper* remarked that where a capillary tube 
 contains two liquids, of different natures, if one of them have a 
 greater chemical affinity for the parietes of the tube than the other, 
 motion ensues, and the liquid which has the greater affinity pushes 
 the other before it. The arterial blood having a greater affinity 
 for the tissues than the venous blood, saturated with the products 
 of disintegration, it should follow that the venous blood would be 
 driven back. According to this hypothesis, it would suffice to 
 quicken the chemical process of nutrition, in order to increase the 
 intensity of motion (or afflux), and herein the action of the nerves 
 may intervene. The phenomena of stasis are capable of being 
 
 • Vulpian, 'Revue des Cours Scientifiques,' t. Hi, p. 744. 
 
 2 See O. Weber, * Handbuch der Chirurgerie,' t. i, p. 111. 
 
 3 Vulpian, loc. cit., p. 743. 
 
 * Draper, " A Treatise on the Korces which Produce," &c., New York, 1841, 
 Savory, 'British and Foreign Review,' t. xvi, 1855, p. 19. 
 
100 IRRITATION OF GLAND- NERVES. 
 
 explained in an analogous manner, by an appeal to the laws of 
 osmosis (blood-stasis, by diffusion).^ 
 
 However it be, whatever may be the explanation of the pheno- 
 mena, you perceive that the attraction which the tissues, under the 
 influence of certain agents, exercise upon the blood is a fact experi- 
 mentally established, wholly apart from any action of the nervous 
 system. Now, in order to apply this datum to the case of the 
 submaxillary gland, it suffices to admit that the glandular nerve, 
 when subjected to excitation, induces a modification of the intimate 
 nutrition of the secretor cells — and then, in consequence of this 
 change, vascular dilatation would take place. 
 
 Anatomy seems, besides, to throw a new lio;ht upon the question 
 by showing that the terminations of the glandular nerves pene- 
 trate into the secretor cells.^ Herr Ileidenhain has even endea- 
 voured to demonstrate that a gland, of which the nerves have been 
 subjected to a somewhat prolonged irritation, presents a histological 
 constitution differing in some respects from that of a gland in a 
 state of repose. The old cells, termed mucous cells, appear in fact, 
 after the irritation, to be replaced by young cells of recent forma- 
 tion.^ If the views of Herr Heidenhain be conlirraed, we should 
 attribute to the nerve a direct influence, so to speak, upon the de- 
 velopment of gland-cells.^ 
 
 The hypothesis which has just been formulated in relation to 
 secretor nerves, might apparently be extended to other nerves in 
 which experimental physiology has discerned the property of de- 
 termining the dilatation of vessels under the influence of stimuli. 
 These nerves would act primarily on the inter-vascular elements 
 and quicken therein the movements of composition and decompo- 
 sition. Yascular dilatation would follow, as a consecutive pheno- 
 menon. In support of this view, one may here also invoke the 
 teachings of anatomy which, in these latter days, has, it is stated, 
 succeeded in following, at least in the frog, the nerve-endings even 
 into the nucleoli of the corpuscles of the cornea, and of the con- 
 junctival cells of the nictitating membrane.^ 
 
 ^ 0. Weber, loc. cit. 
 
 2 E. F. W. Pliiger, "Das Nerveugewebe tier Speicheldriise," in Strieker's Hand- 
 bucb, t. i, p. 313. 
 
 3 Heidenhain, " Studien der Pbysiologischen Instituts," Be Breslau, 1868, and 
 Strieker's Handbucb, loc. cit., p. 330. 
 
 4 According to M. Ranvier ('Traduction de Frey,' p. 437), and M. Ewald 
 (* Jabresber.,' t. i, 1870-1871, p. 55), the results obtained by Herr Heidenhain 
 ought to be interpreted as follows: Under the influence of the irritation of the 
 gland-nerves, the cells called mucous cells simply lose the mucus they contain 
 and resume the appearen(^e of parietal gland-cells. There would consequently 
 be no formation of new cells here, as Heidenhain asserts. 
 
 5 See Kiihne, in ' Ciraz. Hebdom.,' t. ix, No. 15, 18G2. Lipmann, "Endigung der 
 Neiven ira eigentlichen Gewebe und im hinteren Epithel der Hornhaut des 
 Froscbes," in Virchow's ' Archiv,' 38e Bd., p. 118, 1869. Eberth, in ' Arohiv fur 
 MikiQS. A::at.,' Bd. iii. 
 
TROPHIC NERVE THEORY. 101 
 
 This interpretation was long since proposed by M. Brown-S^- 
 quard,^ and Professor Schiff seems to countenance it when he ac- 
 knowledges that "active dilatation appears to be alien to the proper 
 coats of the vessels and to take place through the medium of the 
 inter-vascular tissues."^ 
 
 The incursion which we have made into the domain of physiology 
 was undertaken with the intention of collecting, as we went, evi- 
 dences which we can now profitably apply. It is requisite, indeed, 
 to fix your attention for a while upon the trophic nerve theory^ as it 
 is called, which, in default of other hypotheses whose insufficiency 
 was admitted, has been sometimes recurred to in order to explain 
 the production of nutritive lesions developed by an influence of 
 the nervous system. Now, by this theory, at least as it has been 
 formulated by Herr Samuel, the supposititious nerves would be, as 
 it were, constructed after the model of the secretor nerves in this 
 respect that, like them, they would exercise, in the normal state, a 
 direct influence over the nutrition of the parts where it is supposed 
 their ultimate terminations are distributed. Their physiological 
 role would be, not to operate directly, but to quicken, throughout 
 the tissues, those exchanges which constitute elementary assimilation 
 and disassimilation, just as the function of the secretor nerves is to 
 set at work in the gland-cell an inherent property, indefeasibly con- 
 nected with the phenomena of intimate nutrition. The autonomy 
 of the anatomical elements in accomplishing the nutritive act is 
 therefore not at all overlooked ; it is only proposed to consider 
 the trophic nerves as forming, in their totality, a perfecting appli- 
 ance peculiar to superior organisms. 
 
 So much for the physiological aspect of the theory: Now, as re- 
 gards its application to the interpretation of pathological phenom- 
 ena, it is easy to conceive that a frequent result of morbid irrita- 
 tion set up in nerves, endowed with such properties, would be to 
 carry disturbance into the intimate nutrition of the innervated parts, 
 and to provoke therein, occasion serving, the consecutive develop- 
 ment of the inflammatory process. Suppression of the action of 
 these nerves would, on the contrary, have no other effect than that 
 of lessening the intensity of the nutritive movement, and circura- 
 scribed atrophy is mentioned as an example of the trophic disorders 
 which may thus supervene. 
 
 These are the general features of the theory ; as to the details, 
 it was to be anticipated that an hypothesis created by the need of 
 explaining as yet but little known phenomena, insufficiently ex- 
 amined at the period of its publication, was destined to become 
 speedily antiquated. That, in fact, is what has happened. It can- 
 not be admitted to-day, that all the trophic nerves have their central 
 
 ' Brown-Sequard, * Researches ou Epilepsy,' p. 70. ' Central Nervous System,' 
 pp. 148, 172, 174. 
 
 2 Schiff, ' Le90us sur la Digestiou,' t. i, p. 256. 
 
102 THEORY OF SAMUEL. 
 
 origin in the posterior spinal ganglia, or in the analogous ganglia 
 of the cranial nerves ; for the cases are numerous, as you have seen, 
 v^here a lesion, situated in the central portion of the spinal cord, 
 or even in the encephalon, provokes the manifestation of trophic 
 derangements in the peripheral parts. Henceforth, also, we must 
 take count of facts, unknown when Samuel's book appeared, which 
 place beyond all doubt the influence of lesions of the anterior nerve 
 cells on the development of different kinds of myopathies. 
 
 1 have never shared in the disdain with which the theory, that 
 has just been briefly described, was almost universally met. It has 
 ever seemed to me that, in spite of its imperfections, it was worthy 
 of being recommended to the attention of physicians because it ex- 
 plains better, in my opinion, the phenomena which they are called 
 on to observe, in practice, than all the other hypotheses previously- 
 invoked. I am very far, however, from wishing to ignore the ob- 
 jections alleged against it. In the first place, the existence of tro- 
 phic nerves is not, certainly, demonstrated anatomically; it must 
 be admitted, moreover, that most of the experiments made on ani- 
 mals by Herr Samuel, with the object of revealing their existence, 
 have not been felicitous. Some, when repeated by other observers, 
 have not hitherto reproduced the stated results; others have had 
 to be given up, as tainted with numerous causes of error. ^ But 
 all the arguments directed against this theory have not so much 
 value as these. If, for instance, we were bound to condemn the 
 hypothesis of trophic nerves, by the mere fact that it is useless in 
 physiology, I would point out that the utility of the secretor nerves 
 was only recognized, as an afterthought. We should, in like 
 manner, be necessarily compelled to recognize the utility of trophic 
 nerves, if experinients should at any time declare in their favour. 
 Again, it is difficult to believe that the part played by the secretor 
 nerves is absolutely special, and wholly unexampled in the organ- 
 ism. With these nerves we can already compare the dilator nerves, 
 if it be true that they act according to the mechanism already indi- 
 cated. We should place also beside them, following the recent 
 observations of Herr Goltz, the nerves of absorption which, accord- 
 ing to this physiologist, act upon the endothelial cells of the blood- 
 vessels in the same way as the nerves of secretion act upon the 
 glandular epithelium. On the whole, we do not see that any reason 
 exists to decree, a 'priori^ that the trophic nerves shall not, some 
 day, be called to a place in this group.^ 
 
 However this be, before adopting a theory which cannot subsist 
 without calling out a whole system of nerves whose existence is as 
 yet problematical, it is necessary to make sure, by every means, 
 
 ' See Tobias, ' Vircliow's Archiv,' bd. xxiv, p. 579, and 0. Weber in * Central- 
 blatt,' 1864, p. 145. 
 
 2 Goltz in * Prtiiger's Arcbiv,' t. i, v, p. 53, and 'Journal of Anatomy and Physi- 
 ologj,' 2d series, May, 1872, p. 480. 
 
CONCLUSIONS. 103 
 
 that it is really impossible to explain the phenomena, the interpre- 
 tation of which is required, by appealing to the properties of the 
 different nerves already known. We must take care not to infringe 
 the axiom of Logic, Haud mvUipUcanda entia absque necessitate. 
 Now, the vaso-motor theory being eliminated, there yet undoubt- 
 edly remains much to be done from this point of view. 
 
 There is one opinion, amongst others, which has not received 
 attention, so far as I know, and which perhaps deserves to be taken 
 into consideration. The numerous and decisive experiments which 
 have been recently made on the connections formed by uniting ends 
 of divided nerves possessing different functions, such as the hypo- 
 glossal and lingual nerves for example,^ have shown that excita- 
 tions, produced on any point of a sensitive or motor nerve-fibre, 
 are propagated at once and simultaneously in centripetal and cen- 
 trifugal directions. From this, it is allowable to suppose that 
 pathological irritations, developed on a sensitive nerve, either at 
 its central origin or on some point of its course, reverberating in a 
 centrifugal direction to the ultimate extremities of the nerve fila- 
 ments, ^. e., to the papillae of the derm, or the substance of the rete 
 mucosum,^ could there provoke inflammatory action, in certain 
 cases. In this way we could comprehend, for instance, the some- 
 what frequent development of pemphigoid or bullar eruptions, and 
 of zona, in consequence of lesions affecting the posterior fasciculi 
 of the cord, or the sensitive spinal roots. With respect to the 
 motor nerves, I do not see any serious reason to prevent us from 
 admitting that pathological irritations, affecting the nerve cells of 
 the anterior cornua, would sometimes be transmitted to the mus- 
 cular fasciculi, by means of the nerve filaments which, in the 
 physiological state, transmit voluntary excitations. A certain 
 number, at least, of the trophic disorders, consecutive on lesions of 
 the nervous system, would perhaps find their explanation in this 
 hypothesis, without its being necessary to have recourse to the 
 trophic nerve theory. 
 
 We have arrived, gentlemen, at the conclusion of this patho- 
 genic discussion, and, as I allowed you to perceive from the begin- 
 ning, the question in dispute still awaits its solution. I shall not 
 regret, however, the course of explanation we have followed, if, bv 
 placing before your eyes the documentary evidences of the case, I 
 have succeeded in inspiring you with the desire of entering more 
 deeply into an investigation which concerns, to such a supreme 
 extent, the pathology of the whole nervous system. 
 
 ' Vulpian, * Physiologie dii Systeme Nerveux,' p. 290. 
 
 2 See Langerhans, ' Vircliow's Archiv,' Bi. 44, aud A. Biesadecki, Strieker's 
 Haudbuch, p. 595. 
 
PAET SECo:^^D. 
 
 PARALYSIS AGITANS A^^D DISSEMINATED SCLEROSIS. 
 
 LECTURE F. 
 
 ON PARALYSIS AGITANS. 
 
 Sdmmary. — Of tremor in general. Its varieties. Intermittent tremor. Con- 
 tinuous tremor. Influence of sleep, rest, and voluntary motion. Distinction 
 established by Van Swieten. Opinion of M. Gubler. Tremor, according to 
 Galen. Paralysis agitans, and disseminated sclerosis — independent dis- 
 eases. Parkinson's researches. French works : MM. See, Trous.-eau, Char- 
 cot, 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 propulsion and 
 retropulsion. Invasion : its modes, slow or abrupt. Period of stationary 
 intensity. Head and neck not affected by tremor. Alterations 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. Tempera- 
 ture 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: tliey differ 
 from those of disseminated sclerosis. Duration of paralysis agitans. 
 
 Necroscopical results. Inconstant lesions in paralysis agitans ; fixed 
 lesions 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. Pre- 
 disposing causes. Influence of age. Paralysis agitans appears at a more 
 advanced period of life than disseminated sclerosis. Sex. Hereditary 
 predisposition. Influence of race. 
 
 Gentlemen : Those amongst you, who, this morning, passed 
 through our wards, were probably surprised to find collected there 
 so great a number of female patients, in whom tremor seems to 
 constitute the paramount or at least the most striking symptom of 
 the disease which they labor under. This gathering of patients, 
 
106 OF TREMOR IN GENERAL. 
 
 forming a genus apart, I purposely contrived. In that way, I 
 desired to enable you to recognize, by means of a comparative 
 study, certain shades of distinction and even marked differences 
 whi<^h the examination of isolated cases does not allow you so 
 readily to discern. 
 
 At first glance, you may have thought the scene monotonous in 
 character. Indeed, to a superficial observer the phenomenon of 
 tremor in all these women must appear identical, or almost so; one 
 thing alone strikes the gazer's glance, as peculiarly noticeable, it is 
 the diversity in position and intensity of the rhythmical oscillations 
 of the limbs. But a more attentive inspection soon allowed you 
 to distinguish, under this apparent uniformity, different features 
 which at first had completely escaped you. 
 
 Thus, to mention merely the most manifest fact, you have been 
 enabled to remark that some of our patients do not tremble except 
 when executing a coordinated movement with a member, as in the 
 act of raising a glass of water to the lips to drink, or again when 
 they attempt to rise from their chairs in order to walk about. In 
 the latter case, every part of the body may be shaken by energetic 
 convulsive movements, rendering it difficult and sometimes even 
 impossible to stand upright or to walk along the floor. On the 
 other hand, when they are at rest and not affected by any strong 
 emotion, these same women, whether seated or lying, present the 
 most natural attitudes; the different parts of their bodies are no- 
 wise agitated, and if you saw them only under such circumstances 
 you would certainly not suspect the disease which has possession 
 of them. 
 
 In a second series of cases, on the contrary, the tremor is con- 
 tinuous, permanent; it agitates the members unceasingly, allowing 
 them no peace, and if purposed movements exaggerate it at times, 
 repose does not cause its disappearance. In reality, during waking 
 hours, when the affection is intense, there is no truce for those 
 patients. Whatever be the position they assume, whether they 
 sit or lie down, they are always trembling. Sleep alone puts a 
 temporary stop to the spasmodic agitation of their members ; but 
 hardly have they awaked than the tremor makes its appearance 
 anew and soon resumes its former intensity. 
 
 Thus, if we take count merely of this primary distinction, founded 
 on the influence of repose and of purposed movements over the pro- 
 duction of tremor, it becomes already possible, as you perceive, to 
 gather into two principal groups the patients whose cases occupy 
 our attention. 
 
 The first group would comprise those in whom tremor is only 
 shown when an intentional movement is made; whilst the patients, 
 in whom tremor is a constant symptom, or from whom it rarely 
 departs, except during sleep, would constitute the second group. 
 It must be noted, however, that each of these groups, far from 
 
VARIETIES OF TREMOR. 107 
 
 forming a liomogeneous whole, embraces numerous morbid species, 
 of very different natures, in spite of tlie analogy impressed upon 
 them by the possession of this symptom in common. 
 
 The distinction which I strive to make manifest to you is, in my 
 opinion, of the highest importance in the history of chronic diseases 
 of the nervous system, accompanied by tremor. In our own days, 
 it has V)een almost universally misunderstood, and, if I mistake not 
 you will seek in vain for a trace of it in our classic authors. How- 
 ever, as M. Gueneau de Mussy has justly pointed out in a recent 
 clinical lecture,^ the physicians of the last century had taken it into 
 consideration, and perfectly understood its value. 
 
 Van Svvieten, among others, expressly recognized the two kinds 
 of tremor ; nay more, he endeavored to connect each of them with 
 a particular physiological condition. Allow me, here, to invite 
 your attention to the commentary on the 625th Aphorism, where 
 you will find a physiological interpretation of the tremor-symp- 
 tom that is far from being devoid of interest even for a modern reader. 
 
 Thus, according to Van Swieten, the tremor which persists, during 
 repose in bed, results from an irritation that affects the nervous 
 centres in an intermittent and rhythmical manner. This would 
 consequently be a convulsive phen<:)menon — tremor condns. 
 
 On the other hand, the tremor which is exclusively shown, during 
 the execution of voluntary movements, would depend on a defect 
 of stimulus, the result of an insufficiency of the nervous fluid whose 
 function it is to cause contraction of the muscles under the influence 
 of the will. This, therefore, would be a paralytic tremor — tremor 
 a dehilitate. 
 
 An interpretation of the phenomena, which does not radically 
 diverge from the foregoing, was published, a few years ago, by 
 M. Gubler, one of the few modern authors who have upheld the 
 distinction between the two kinds of tremor.^ M. Gubler notes 
 that, in certain cases, the tremor consists, not in a succession of 
 contrary movements withdrawn from the influence of the will, but 
 in alternate contractions and relaxations of the muscles in action, 
 whether employed to alter the position of a limb, or of the whole 
 body, or to preserve the natural attitude of the various parts. 
 Here the muscular contractions, instead of proceeding, as in the 
 normal state, gradually, imperceptibly, and without shock, take 
 place on the contrary by jerks, and as if by interrupted current, 
 with intervals of rest. This pathological condition, which according 
 to M. Gubler might be designated wz^sc?^Zrt?' astasia, stands distinctly 
 apart from that condition in which tremor is not determined solely 
 by the contractions required to maintain the corporeal attitude or 
 in obedience to mental command, and taking place by jerks. lu 
 
 ' Mussy, 'Gazette des Hopitaux,' 1868. 
 
 * ' Archives Gen^rales de Medecine,' 5e serie, t. xv, 1860, p. 702. 
 
108 PARALYSIS AGITANS. 
 
 the second case, involuntary and purposeless contractions really 
 exist, and are incessantly excited by an internal stimulus. 
 
 The classification must, in truth, be a most natural one, for it 
 dates from long before Van Swieten : Galen had established it. 
 He also, in fact, distinguished two kinds of trembling: one, which 
 he designated tpffio? (tremor), is the paralytic shake ; the other, which 
 he styled ytax^oj (palpitation), is the clonic, spasmodic, convulsive 
 agitation^ 
 
 But the physiological aspect of the disease must not detain us 
 any longer, for we could not think of entering, at this moment, into 
 a discussion which would be premature. Let it suffice that we have 
 put prominently forward those characters which can be recognized 
 by the simplest observation, irrespective of any theoretical pre- 
 possession. It is because these have not been considered, that the 
 two affections which are to form the object of our first clinical 
 studies — paralysis agitans and disseminated sclerosis — have remained 
 until to-day, confounded under the same rubric, although they are, 
 in every respect, perfectly independent of each other. Both, indeed, 
 reckon tremor amongst their most important symptoms; but, in the 
 first, the rhythmical oscillations of the limbs are nearly quite per- 
 manent, whilst in the second they only supervene on the attempt 
 to execute intended movements. We have just pointed out a dis- 
 tinctive character which already enables us to lay down a broad 
 line of demarcation between the two affections. However that is 
 far, indeed, from being the only one which we have to set before 
 you, as you will hereafter perceive. 
 
 Paralysis agitans, which shall first engage our attention and of 
 which I have shown you several well marked examples, was the 
 first to be inscribed on nosological lists. Its histor}?-, however, does 
 not reach far back. The first regular description given of it only 
 dates from 1817; it is due to Dr. Parkinson, who published it in 
 a little work entitled " Essay on the Shaking Palsy." From that 
 period, paralysis agitans has been often mentioned in England and 
 in Germany; but in France it remained almost unheard of until 
 these latter years, for, if I mistake not, it was first described, in an 
 explicit manner, b}^ M. G. See in his memoir on Chorea, where it 
 figures among the diseases that might be confounded with St. 
 Vitus's Dance. 
 
 In 1859, M. Trousseau in his Lectures on Chorea succinctly tabu- 
 lated the principal characters of paralysis agitans. Three years 
 later M. Vulpian and I published a study on this subject in the 
 Gazette Hebdomadaire? We had but recently been appointed to 
 La Salpeiri^re, Desiring to inform ourselves fully as to the nature 
 and characters of this disease, which we were called to observe, 
 
 ' Gr. V. Van Swieten, ' Commentaria,' t. ii, p. 167. Paris, 1771. 
 2 'Gazette Hebdomadaire,' 1861, pp. 765, 816, et 1862, p. 54. 
 
HISTORICAL SKETCH. 109 
 
 on a large scale, we were struck by the insufficiency of the details 
 to be found in existing works. This led us to collect the facts 
 which lay under our observation, and, uniting these with the 
 accounts given by foreign authors, we traced a tolerably complete 
 history of paralysis agitans, considering the period. 
 
 From that date, this disease obtained the right of domicile in 
 classic works. In the second edition of his lectures, Trousseau 
 devotes a considerable space to its consideration. It figures in the 
 last edition of M. Grisolle's book, and in B,ejno]ds^s Micyclopceclia ;^ 
 but in all these descriptions, and our own does not at all escape this 
 reproach, there is complete confusion between paralysis agitans 
 and disseminated sclerosis. The line of demarcation between these 
 two diseases was for the first time indicated by myself, if I mistake 
 not, in the thesis of M. Ordenstein.^ It behooves us therefore to 
 establish a parallel between these two affections, by comparing them 
 with each other in the threefold relations of symptoms, causes, and 
 lesions; for that purpose, we shall refer to the afore-mentioned 
 documents and to the numerous observations which we have col- 
 lected in this hospital. It will be easy for you to discern in the 
 patients whom T have gathered together in these wards, the cha- 
 racters which I am about to insist on. 
 
 FUNDAMENTAL CHARACTERS OF PARALYSIS AgITANS. 
 
 Paralysis agitans, separated from foreign elements, is, gentlemen, 
 at present a neurosis^ in this sense that it possesses no proper lesion. 
 In the different accounts that have been published we see incon- 
 gruous lesions mentioned; some of these belong to disseminated 
 sclerosis; others, by their multiplicity and their variability, yield 
 support to our opinion that, up to the present time, paralysis 
 agitans can lay no claim to any definite material lesion. 
 
 It assails persons already advanced in age, those especially who 
 have passed their fortieth or fiftieth year. This limit, however, is 
 not absolute, for M. Duchenne (de Boulogne) has told us of a case 
 where the patient was a youth of sixteen. However it be, its 
 natural place is amongst the diseases of the second period of life. 
 But it would be going too far to consider it as being a senile 
 disease. 
 
 Frequently the causes remain unknown. However, of the etio- 
 logical data two deserve to be cited: 1st, damp cold^ such as that 
 
 ' ,T. Reynolds, 'A System of Medicine,' t. ii. p. 184; art. 'Paralysis Agitans,' 
 by W. R. Sanders. 
 
 2 ' Sur la paralysie agitante et la sclerose en plaques generalisee,' These de 
 Paris, 1868. Cohn, however, had remarked that in two cases of multiple indu- 
 ration of the brain and spinal cord, the tremor was only exhibited after move- 
 ments which the patient wished to make, but never in a state of repose, nor 
 during sleep, "Ein Beitrag zur Lehre der Paralysis agitans," in ' Wiener Med. 
 Wochenschr.,' Mai, 1860. 
 
110 . SYMPTOMS OF PARALYSIS AGITANS. 
 
 arising from a prolonged sojourn in a badly ventilated apartment, 
 or in a low dark dwelling on the ground floor, etc.; 2d, acute moral 
 emotions. The latter cause appears to be tolerably common. One 
 of the patients, whom you have visited, was seized under the fol- 
 lowing circumstances: Her husband, one of the Garde MumcipaJe, 
 formed part of the troops who fought against the insurgents in 
 1832. Having seen her husband's horse return riderless to the 
 barracks, she received a great shock, dreading some disaster. That 
 very day she began to tremble, and the shaking, which at first was 
 localized in the right hand, extending gradually, invaded each of 
 the other members in succession. I shall have occasion to quote 
 numerous examples of the same kind for your information. 
 
 The symptoms of paralysis agitans are not all of the same value. 
 The most striking symptom consists of a tremor, existing even 
 when the individual reposes, limited at first to one member, then 
 little by little becoming generalized, whilst respecting, however, 
 the head. To this phenomenon is superadded sooner or later an 
 apparent diminution of muscular strength. The movements are 
 slow and seem feeble, although dynamometrical experiments prove 
 that this diminution is not real. This motor impotence appears to 
 be due in part, as we shall see, to the rigidity which prevails in 
 the muscles. 
 
 A singular symptom is that which, frequently at an early, but 
 usually at a late period, comes to complicate the situation — the 
 patient loses the faculty of preserving equilibrium whilst walking. 
 In some patients also we notice a tendency to propulsion or to 
 retropulsion : without feeling and giddiness, the patient is, in the 
 first case, propelled forward, and, as it were, compelled to adopt a 
 quick pace; the individual is unable, without extreme difficulty, to 
 stop — being apparently forced to follow a flying centre of gravity. 
 
 A peculiar attitude of the body and its members, a fixed look, 
 and immobile features should also be enumerated among the more 
 important symptoms of this disease. 
 
 The march of paralysis agitans is slow, and progressive. Its 
 duration is long — sometimes it has gone on for thirty years. The 
 fatal term supervenes either by the advance of age, or because 
 of intercurrent diseases which may be accidental or occasioned by 
 marasmus, confinement to bed, etc. In the first case, an acute 
 disease, such as pneumonia, occurs: in the second, death takes 
 place from a sort of nervous exhaustion, nutrition degenerates, 
 the patient cannot sleep, eschars are formed and conclude the 
 morbid scene. 
 
 Such, gentlemen, are the more general characters of paralysis 
 agitans. But in order that you may the better comprehend their 
 significance, it is proper to enter more deeply into a study of the 
 symptoms and to show how they arise, increase, and are connected 
 with the different stages of the disease. To this end, and in order 
 
SLOW INVASIO:^'. Ill 
 
 to give greater clearness to our description, we will establish 
 several periods which we shall describe, in due order. 
 
 Let us examine, in the first place, the manner of its invasion. 
 Experience teaches that paralysis agitans sets in sometimes slowly 
 and progressively ; sometimes, on the contrary, in an almost abrupt 
 manner. 
 
 A. Sloio invasion. — In the immense majority of cases, the inva- 
 sion is insidious, the disease first showing itself as slight and 
 benignant. The tremor is circumscribed to the foot, the hand, or 
 the thumb. This symptom, apparently of so trifling a nature, long 
 remains solitary. It presents, however, certain characters which 
 require to be recognized, and on which we shall lay stress. Is the 
 hand attacked? Its several segments are seen to oscillate over 
 each other, stirred by an almost pathognomonic motion. The patient 
 closes the fingers on the thumb as though in the act of spinning 
 wool; at the same moment the wrist is bent by rapid jerks upon 
 the forearm, and the forearm on the arm. 
 
 At this stage of the disease the tremor may be merely passing 
 and transitory. It breaks out when least expected, the patient 
 enjoying complete repose of mind and body, and it frequently 
 occurs without his being conscious of it. The act of walking (even 
 where the upper extremities are affected), the act of gras[)ing, lift- 
 ing, taking a pen, writing, any effort at all of the will, may at this 
 epoch often suffice to suspend the tremor. Later on, it will be no 
 longer so. Moreover, as it augments in intensity and persistence, 
 the tremor invades little by little, and not without observing cer- 
 tain rules in its progress, the parts wliich have hitherto remained 
 sound. If, for instance, it first affected the right hand, at the end 
 of some months or of some years, the turn of the right foot will 
 come; next the left hand, and after that the left foot will be, 
 successively, assailed. 
 
 Decussated invasion is more rare. I have, however, at least 
 twice seen the affection first seize the right upper extremity, and 
 pass next to the left lower extremity. It is much more common 
 to see the tremor confined for a long time to the members of oue 
 side of the body {liemifplegic type\ or to the two lower extremities 
 {paraplegic type). The head is always nearly quite respected at 
 every stage of the disease, even in the most intense cases; and this 
 is a character to which we shall, hereafter, give prominence, for the 
 contrary is often observed in the cerebro-spinal form of dissemi- 
 nated sclerosis. 
 
 I have to ask your utmost attention to a mode of progressive 
 invasion which, although exceptional, is not the less worthy of 
 interest. The tremor is not absolutely the first sympton recorded. 
 It may possibly be preceded sometimes by a very remarkable feel- 
 ing ol fatigue, sometimes by rheumatoid or neuralgic pains, which 
 are occasionally most severe, occupying the member or the regions 
 
112 STATIONARY PERIOD. 
 
 of the members which shall soon be seized, but secondarily, by the 
 convulsive agitation. I might quote several cases of this kind to 
 you, and, in such circumstances, it is not rare to find that some 
 traumatic cause exists, such as a puncture, as Romberg has seen, 
 or, as I have myself observed, a violent contusion of the member 
 which was ultimately taken with pain and trembling. The paraly- 
 sis agitans which sets in, after this manner, behaves itself, however, 
 throughout its ulterior* course in the ordinary way, and its progress 
 is effected in accordance with the same laws. 
 
 B. Abrupt invasion. — When, in consequence of a moral cause, a 
 shock of terror for instance, tremor suddenly supervenes, it some- 
 times occupies one member only, sometimes it seizes on all the 
 members at once, from the very commencement. After persisting 
 for a few days it may possibly improve or even vanish. But, later 
 on, after a series of alternate improvements and exacerbations, it 
 takes up its abode in a permanent manner. This, at least, is what 
 we have seen very distinctly occurring in several cases. 
 
 The duration of this initial phase varies from about one to two 
 or three years, whatever may have been the manner of its invasion. 
 
 C. Period of stationary intensity. — When paralysis agitans has 
 acquired its perfect development, the trembling, besides invading 
 several members, becomes, at least in severe cases, almost incessant. 
 Its intensity, however, is not the same at all times. Different 
 circumstances, formerly without influence over it, now augment it. 
 Moral emotions count amongst these, and the exercise of voluntary 
 movements. In addition, we find a kind of crises — paroxysms 
 occurring spontaneously, without appreciable cause. On the other 
 hand, natural sleep, and sleep induced by chloroform, always anni- 
 hilate the convulsive jerking, for the time being. 
 
 ^3 
 
 Fig. 7. — Specimen of liaiidwritiug in paralysis agitans. 
 
 At this stage of the disease, especially, the peculiar characteristics 
 of the tremor are displayed in all their fulness ; then also we occa- 
 sionally find the rhythmical and involuntary oscillations of the 
 different parts of the hand recalling the appearance of certain co- 
 ordinated movements. Thus, in some patients, the thumb movec 
 over the fingers, as when a pencil or paper-ball is rolled between 
 them ; in others, the movements are more complicated and resem- 
 ble what takes place in crumbling a piece of bread. I have shown 
 you some examples of this kind. These are, if I do not mistake, 
 
PHYSIOGNOMY. 113 
 
 peculiarities which belong specifically to the tremor of paralysis 
 agitans ; I do not believe that they are to be found in any other 
 species. They have been clearly recognized by M. Gubler {loc. cit.), 
 who, having occupied the position of clinical clerk in La Salp^tri- 
 dre, was enabled to study the disease on a large scale.^ 
 
 The hands and neck, we repeat, remain unaffected ; this is the 
 rule. Far from trembling, the muscles of the face are motionless, 
 there is even a remarkable fixity of look, and the features present 
 a permanent expression of mournfulness, sometimes of stolidness or 
 stupidity. The nystagmus which so frequently figures in the 
 symptomatology of disseminated sclerosis, has no existence in 
 paralysis agitans. Nor are the muscles of the jaws affected by 
 convulsive agitation. Nevertheless, it is not uncommon to find that 
 the tongue, even when inclosed in the buccal cavity, is stirred by 
 a well-marked tremor, which augments when the organ is protruded. 
 Sometimes the lips adhere, as though firmly pressed together, so 
 that the red portion is no longer visible, and the cutaneous surface 
 seems puckered.^ There is no real difiiculty of speech, but the 
 
 ' The tremor causes the handwriting to exhibit characters which are somewhat 
 special. When the disease is commencing, the writing at first glance seems nor- 
 mal, but when examined with a magnifying glass inequalities are perceived, 
 some parts being thicker and heavier than others. Later on, in the period of 
 stationary intensity for instance, the changes are more marked and consequently 
 plainer. The specimen. Fig. 7 (p. 112), represents the writing of a patient whose 
 case we studied at the Hopital St. Louis, in 1869. Tlie strokes forming the letters 
 are very irregular and sinuous, whilst the irregularities and sinuosities are of a 
 very limited width (Bourneville). 
 
 On a careful examination of this specimen of writing it will be perceived that 
 the down-strokes are all, with the exception of the first letter, made with com- 
 parative firmness and are, in fact, nearly normal — the finer up-strokes, on the 
 contrary, are all tremulous in appearance, and it is to the unsteadiness of these 
 linos that the peculiar character of the writing here is principally due. From 
 this I would infer, that the flexors of the fingers were, at this stage of the disease, 
 less affected by tremor than the extensors, and that, amongst the latter, the inter- 
 ossei were probably the earliest affected. This inference will not be without in- 
 terest for those who remember the attention which Dr. Duchenne (de Boulogne) 
 gave to the conduct of these muscles in the various paralytic and atrophic affec- 
 tions of the hand (Sigerson). 
 
 2 All these characteristics are found well marked in the case of the patient, 
 Marie- Anne Perd. . ., who is still under M. Charcot's care (Salle St. Alexan- 
 dre, No. 9). The head, held in a somewhat fixed position, is slightly bent forward. 
 The features are, so to speak, without expression ; the brow-wrinkles, similar on 
 both sides, are deeply marked; the eyelids are less mobile than in the normal 
 state, on account of a species of contraction in the supraciliary muscle which 
 appears habitual and which deepens the brow-wrinkles. When the patient is 
 requested to close her eyes, she does so, without effort, she says ; but the upper 
 lids are then stirred by little convulsive movements which would rather lead one 
 to suppose that it required a certain force to keep them closed. And, in fact, if 
 they be kept in this position, the convulsive movements (a kind of rapid winking) 
 augment in direct ratio with the continuance of the test, so that the occlusion 
 ceases to be complete. The eyes look straight forward : there is no nystagmus. 
 When, in examining the sensitiveness to light of the pupils, we attempt to open 
 and close the eyelids, in alternation, a certain resistance is met with, in the latter 
 
 8 
 
114 MODIFICATION OF UTTERANCE. 
 
 utterance is slow, jerky, and short of phrase : the pronunciation of 
 each word appears to cost a considerable effort of the will. If the 
 tremor of the body be intense it may happen that the utterance 
 will be tremulous, broken, jolted out as it were like that of an in- 
 experienced rider on horseback, when the animal is trotting. How- 
 ever, in both cases, we should only recognize in this a phenomenon 
 of transmitted tremor.! Finally, the patients seem to speak between 
 their teeth. Deglutition is accomplished with ease, though perhaps 
 slowly ; frequently in cases of somewhat old standing the saliva, 
 accumulated in the mouth, is involuntarily allowed to escape. The 
 respiratory muscles do not seem to share in the convulsive disorder 
 of the extremities. We have to remark, however, that some pa- 
 tients experience an almost continual feeling of oppression. 
 
 We shall now point out a characteristic which, we believe, was 
 overlooked by Parkinson as well as by most of his successors : we 
 allude to the rigidity to be found, at a certain stage of the disease, 
 in the muscles of the extremities, of the body, and, for the most 
 part, in those of the neck also. When this symptom declares 
 itself, the patients complain of cramps, followed by stiffness, which, 
 at first transient, is afterwards more or less lasting, and is subject 
 to exacerbations. Generally the flexor muscles are the first, as 
 they are always the most intensely, affected. When this muscular 
 stiffness has become permanent it causes the patients, in many cases, 
 to assume a characteristic attitude. Thus on account of the rigidity 
 of the anterior muscles of the neck, the head, as Parkinson re- 
 marked, is greatly bent forward, and, as one might say, fixed in 
 that position ; for the patient cannot, without much effort, raise it 
 up, or turn it to the right or left. The body also is almost always 
 slightly inclined forward, when the patient is standing. 
 
 case, which is due to the convulsive movements of the upper lids that tlie patient 
 cannot control. The gaze is, in some sort without expression. 
 
 The lips are drawn together and somewhat pouting, as thougli a muscular con- 
 traction maintaiued them in apposition; it follows that the naso-labial furrows 
 are shallow, like the jugo-mental. The upper lip is motionless, the under lip is 
 moved by a very fine tremor at the labial commissures. The patient is obliged 
 to make an effort in order to open her mouth ; she can only open it imperfectly, 
 and cannot keep it open for a few minutes. She appears to account for this cus- 
 tomary and as it were permanent apposition of her lips, when she says, " EUes se 
 coUent ensemble mes levres" (Bourueville). 
 
 ' In reference to utterance, we may quote a fragment of the record of the patient, 
 Perd. . . . Utterance began to grow difficult, in this woman, two years ago: 
 and during the last year the difficulty has considerably increased. When the patient 
 speaks, her lips tremble, and the enunciation of the first syllables is laboriously 
 accomplished ; her utterance is tremulous especially at first, gradually, as she goes on 
 speaking, the tremulousness grows less, and the words are pronounced in a stronger 
 voice. The patient seems to speak between her teeth ; her lips scarcely separate 
 and the jaws are, as it were, adherent each to each. The tongue is stirred by a 
 uniform and general tremulousness, even when lying in the buccal cavity, and when 
 it is protruded the motion augments. The patient asserts that she cannot keep it 
 out long: "It comes back, in spite of me," she says. The mouth is often full of 
 saliva, and Perd. . . attributes to this fact part of her difficulty of utterance (B). 
 
ATTITUDE OF UPPER EXTREMITIES. 
 
 115 
 
 The attitude of the upper extremities deserves to be noticed. 
 The elbows are habitually held a little apart from the chest, the 
 forearms being slightly flexed upon the arms; the hands, flexed 
 upon the forearms, rest upon the stomach.^ In the course of time, 
 the hands, on account of the permanent rigidity of certain muscles, 
 present deformations which it is necessary to be acquainted with, 
 as they have frequently rendered diagnosis difficult. 
 
 Fig 8. — The writing hand. Habitual attitude of the hand at a somewhat 
 advanced stage of paralysis agitans. 
 
 Commonly, the thumb and index are extended and apposed, as 
 if to hold a pen; the fingers slightly inclined towards the palm, 
 are all deviated outwards to the near side (Fig. 8). 
 
 The fingers, in many cases, alternately flexed and extended at 
 their several articulations, present a series of inclinations which 
 have a deceptive resemblance to certain types oT deformation ob- 
 served in chronic progressive rheumatism (Figs. 9 and 10). 
 
 Fig. 9. — Digital deformation, simulating that of primitive chronic articular 
 
 rheumatism. 
 
 The distinction, however, is usually made with ease, if the ob- 
 server be forewarned and on his guard. In cases of paralysis agitans 
 there is found, in fact, neither the articular tumefaction and stiff- 
 ness, nor the osseous deposits and cracking sounds observed in 
 nodose rheumatism. 
 
 With respect to the lower extremities, the rigidity of the muscles 
 
 ' See case of the patient Gav. . . described in the appendix. The inclina- 
 tion forward has since become more decide<i. Moreover, slie now exhibits a 
 tendency to incline towards the right side. This lateral inclination is found to 
 exist also in another of M. Charcot's patients named Bau. . . 
 
116 att'itude of lower extremities. 
 
 is sometimes so intense as to suggest the existence of real para- 
 plegia, with muscular contracture. In the case of the two female 
 patients, to whom I directed your attention in the wards, their 
 lower limbs, as you have seen, are rigid in semi-flexion ; they can 
 neither be flexed nor extended without considerable difficulty. The 
 knees are drawn together in adduction : the feet are stiff* extended, 
 and turned in, simulating the malformation known as talipes equi- 
 nm {varus) club-foot ; the toes are raised and recurved so as to form 
 
 Fig. 10. — Digital deformation, simulating that of primitive chronic articular 
 
 rheumatism. 
 
 a griffe (or claw) on account of the extension of the first and con- 
 comitant flexion of the second phalanges. Nevertheless, these 
 women still retain the power of moving their lower extremities, 
 though slowly indeed and with difficulty : they are even able, as 
 you have witnessed, to walk in a kind of a way, without assistance 
 or support. I have pointed out to you, gentlemen, that, contrary 
 to what takes place in true paraplegia with contracture, we do not 
 here discover that tetanic tremulation, which, whether arising 
 spontaneously or provoked by certain attitudes, characterizes one 
 of the varieties of spinal epilepsy. This symptom, on the other 
 hand, is generally found in' the paraplegia which frequently accom- 
 panies disseminated sclerosis, and this is a distinguishing character 
 on which we shall have occasion to lay stress in diagnosis. 
 
 As Herr Benedikt has remarked in his recent treatise on Electro- 
 therapeutics, the habitual rigidity of a certain number of muscles 
 undoubtedly contributes, to a great extent, in rendering movement 
 laborious. But this is not, we believe, the only cause that should 
 be recognized. However, it is this rigidity which, determining the 
 general attitude, is the reason that the patients, shrunken upon 
 themselves as it were, seem to move all of a piece ; that their joints 
 appear "soldered together," to use a common but fairly descriptive 
 term which I borrow from a patient; and that, finally, the head 
 and body are kept inclined forward— a circumstance which has 
 certainly its own share in producing that tendency to fall forward 
 which the patients experience in walking.' 
 
 Gentlemen, there are cases, though these are rare indeed, in 
 which muscular rigidity is a symptom of the early stage of the 
 
PARALYSIS AGITAXS ^VITHOUT TREMOR. 117 
 
 disease, and a really predominant one. I have recently observed 
 an example which belongs to this category. The patient had 
 scarcely noticed the tremor which, in fact, showed little intensity 
 in his case, and was confined to one hand. He already displayed, 
 however, in a high degree, the peculiar attitude of the body and 
 its members, the difficulty of movement, and the' characteristic 
 gait.^ Such cases are exceptional. Most commonly muscular 
 stiffness only appears, or becomes prominent, in the advanced 
 
 ' The following case, whicli we abridge, belongs to tliis category of exceptional 
 facts. Gnill. . ., aged 53 years (Salle St. Alexandre, No. 10, La Salpetriere), 
 after liaving, for some time, suffered from cephalalgia, wandering pains of a 
 lancinating character, and a feeling of constriction at the epigastrium, noticed, 
 four years ago, that the different joints of the right upper extremity were growing 
 stiff. To this phenomenon, weakness was superadded. The stiffness and debility 
 invaded, successively, the left lower extremity, the left arm and afterwards the 
 right leg. In 1870, a tendency to propulsion and retropulsion made its appear- 
 since. Tlius when the patient ascended the stairs to her lodging, she was pro- 
 pelled forward, and only stopped when she could lay hold on some resisting body ; 
 " without this precaution," she said, ''I'd upset." 
 
 To-day, her condition is as follows: Head slightly bent forward, neck stiff. 
 The brow is deeply furrowed, especially over the eyebrows, which are uplifted 
 as are the upper eyelids: hence the physiognomy has a sort of stolid look. 
 Utterance is free. In walking, the patient takes short steps and keeps the arms 
 close to the body, the forearms flexed, and the hands joined together, as if for 
 support. The fingers, taken together, are slightly bent and gathered ; the whole 
 hand is inclined outward towards the ulnar side. All the joints are stiff, but iu 
 different degrees, the stiffness being greatest on the right; side. Sensation is 
 preserved. During the night, the patient experiences a feeling of cold which 
 passes down from the shoulder to the wrist, and returns in fits lasting from five 
 to six minutes. The members, especially the right arm, feel heavy. Wlien the 
 patient wishes to rise from her chair, and is hindered from helping herself by 
 grasping adjacent objects, she catches the legs of the chair with her hands in 
 order to draw forward the pelvis, then she puts her hands lower down on the 
 sides of the chair, and after some efforts and a kind of balancing to and fro, she 
 succeeds in getting up. 
 
 Her slumber is generally short. During the night, Guill. . . keeps herself 
 covered with the sheet only, having a thin petticoat spread over her knees because 
 they are cold. A coverlet, she says, " would be too warm and too heavy." Let 
 us note also an incessant need of change of posture (or fidgetiness). She is 
 scarcely seated for four or five minutes when she asks to be placed further for- 
 ward, then to one side, &c. Some moments after, she requests that her legs 
 (which have a tendency to adduction) shall be separated; then she begs to be 
 helped to rise. All these symptoms suffice to show that we have here a case of 
 paralysis agitans. Nevertheless, although the disease is of four years' standing, 
 there is scarcely any trembling, the right hand alone being affected by it, and 
 that only for the last three months. From this it will be seen that it is possible 
 to diagnose paralysis agitans, even when tremor is absent (B.). It was the same 
 with respect to another patient whom M. Charcot observed, a short time ago 
 (1872). This man, aged 50 years, was attacked by "Parkinson's disease" in 
 consequence of a strong emotion occasioned by the attempts of the Federalists, 
 during the time of the Commune, to incorporate him in their battalions. In his 
 case, all the symptoms and especially the attitude were present, but tlie tremor 
 was likewise deficient. Finally, Mr. Gowers has communicated to M. Charcot a 
 case, noted by him, in the National Hospital for Epilepsy and Paralysis of London ; 
 the patient, a woman named Anne Phillips, exhibited all the symptoms of paraly- 
 sis agitans, excepting the trembling, which is barely perceptible in her move- 
 ments. (B.) (Note to the second edition.) 
 
118 MUSCULAR STRENGTH — PECULIAR GAIT. 
 
 phases of paralysis agitans. .Now, when it begins to be manifest, 
 the patients have long experienced, in the execution of movements, 
 a notable want of ease which is due to another cause. 
 
 You will readily discover, in some of the patients whom I have 
 shown you, that laboriousness in the execution of movements which 
 is dependent neither on the existence of tremors, nor on that of 
 muscular rigidity; and a somewhat attentive examination will 
 enable you to recognize the significant fact that, in such cases, 
 there is rather retardation in the execution of movements than real 
 enfeehlernent of the motor powers. The patient is still able to accom- 
 plish most of the motor acts, in spite of the trembling, but goes 
 about performing them with extreme slowness. We noticed this 
 fact a few moments ago, in its relation to the faculty of speech; 
 there is a comparatively considerable lapse of time between the 
 thought and the act. One might suppose that the nervous influx 
 cannot be set to work, in her case, until after extraordinary efforts, 
 and, in reality, the slightest movements occasion extreme fatigue. 
 This group of phenomena has been frequently taken as an indica- 
 tion of a real paralytic enfeeblement. Nevertheless, you will have 
 many an opportunity of assuring ^^ourselves that in cases where 
 the disease has not yet reached its last limits, the muscular power 
 is retained, in a remarkable degree. This fact has been verified, 
 on several occasions, by means of the dynamometer: in some cases, 
 even, the curious phenomenon was noted of the greatest amount of 
 measured force being present in that member which was to all ap- 
 pearance the weakest and most tremulous.^ 
 
 Yet a word upon the gait peculiar to patients affected by para- 
 lysis agitans. You have seen some of our patients get up slowly 
 and laboriously from their seats, hesitate for some seconds to step 
 out, then, once started, go off in spite of themselves at a rapid rate. 
 Several times they threatened to fall heavily forward. Does this 
 
 1 We have examined the amount of dynamometrical force present, in six of 
 M. Charcot's patients. The following are the results : — 
 
 1st. Perd. — Eight explorations : average on the right side, 60 ; on the left, 42. 
 
 2d. Guill. — Nine explorations: average on the right side, 67 ; on the left, 63. 
 
 3d. Berr. — Thirteen explorations; average on the right side, 59.6; on the 
 left, 41.4. 
 
 4th. Gav. — Five explorations : average on the right side, 39.6 ; on the left, 
 43.4. 
 
 5th. Beau. — Five explorations: average on the right side, 65.5; ou the left, 
 42.3. 
 
 6th. Dan. — Five explorations: average on the right side, 41.4; on the left, 
 33.3. 
 
 If these figures be compared with the standard average 85, which we obtained 
 by similar explorations in the case of five persons of the same age as our patients, 
 it becomes evident that the dynamometrical force, far from being preserved in 
 paralysis agitans, is, on the contrary*, diminished. It is all the more difficult to 
 explain the divergence between the old opinion and our facts, since in two of our 
 patients this diminution is as well marked at the early stage of the disease as at 
 the most advanced. Finally, in three casf'S, the dynamometrical enfeeblement 
 is greatest on the side where tremor predominates (B.). 
 
PROPULSION AND RETRO PULS ION. 119 
 
 irresistible tendency to adopt a running pace depend exclusively 
 on the centre of gravity being displaced forward by the inclination 
 of the head and body? This explanation, which may, perhaps, be 
 admissible in some instances, will not serve for all. There are, in 
 fact, certain patients who, in contradistinction to those described, 
 tend to run backwards when in motion, and to fall backwards, 
 although their bodies are manifestly inclined forward. Besides, 
 propulsion, like retropulsion, is not absolutely connected with the 
 bent attitude of the body, for it is sometimes seen at an early pe- 
 riod of the disease, even before there is any inclination of the body 
 at all.^ In short, these are not constant and necessary phenomena; 
 they are even frequently enough absent, and are to be found in the 
 symptomatic tables of diseases other than paralysis agitans, as in 
 certain cases of cerebral lesion, for example. It is, however, right 
 to mention that, in the latter event, they are often connected with 
 vertigo, whilst in paralysis agitans the movements of propulsion 
 and retropulsion do not supervene in consequence of any feeling 
 of giddiness. 
 
 The symptoms which I have just reviewed are not, gentlemen, 
 the only phenomena which deserve to arrest your attention. 
 
 • These plienomena are very evident in a patient under M. Charcot's charge 
 (Salle St. Alexandre, No. 22). This woman has attained a more advanced stage 
 of the disease, without liowever being bed-ridden, than the two patients men- 
 tioned in the preceding notes. All the symptoms of the disease are met with in 
 her case ; but we shall merely select from her history the facts which relate to 
 propulsion and retropulsion. Suppose, when seated, she is directed to arise and 
 walk, what do we observe ? She hesitates for a few moments, then bends the 
 body forward, atid after swinging herself to and fro, as it were, suddenly rises. 
 When up, she does not set oft' at once; she seems to require to poise or balance 
 herself first; she appears in some sort uncertain, the body being inclined for- 
 ward; finally, she decides to start. Slow at the outset, her gait is gradually 
 accelerated, and, after a course of ten yards, she rushes forward at such a rate 
 that if, at a given moment, she did not find some obstacle to lay hold on — a bed, 
 chair, or wall — she would fall suddenly. In this ca:?e, therefore, propulsio.i is 
 as manifest as possible. 
 
 Retropulsion is sometimes overlooked because, in order that patients should be 
 conscious of possessing it, they must have had some special occasion to walk 
 backwards. M. Charcot employs a very simple method of exhibiting its exist- 
 ence. When the patient is standing, it suffices to pull her, unexpectedly and 
 slightly, by the skirt, in order to make her immediately commence walking back- 
 ward ; the retrograde movement soon becomes very rapid, and would be quickly 
 dangerous if proper precautions were not taken (B.). 
 
 The fact of the phenomena of propulsion and retropulsion being both present in 
 the same patient furnishes an argument in support of Professor Charcot's propo- 
 sition that the propulsive tendency is not absolutely connected with the forward 
 attitude. In this case, the woman when stopped in the midst of an onward walk, 
 being caught by the gown and gently pulled back, immediately began to recede, 
 and this without any perceptible change of attitude. As mention has been 
 made of the existence of a stolid look, in such patients, it will not be uninterest- 
 ing to note, in relation to the question of the influence of disease on the mental 
 faculties, that although this patient was in an advanced stage of the disease and 
 had the characteristic facial signs, her mind appeared still active (in 1874). 
 " EUe va comme une machine," said an observer, on seeing her walk. "Mais 
 Gui, comme une machine h, vapeur," was her quick response (Sigerson). 
 
120 DISAGREEABLE SENSATIONS. 
 
 Paralysis agitans is not merely one of the saddest of diseases, inas- 
 much as it deprives the patients of the use of their limbs, and 
 sooner or later reduces them to almost absolute inaction; it is also 
 a cruel affection, because of the unpleasant sensations which the 
 sufferers experience. Usually, indeed (the neuralgic cases which 
 we have already described being excepted), they are not affected 
 by acute pains, but by disagreeable sensations of a special order. 
 They complain of cramps, or rather of a nearly permanent sensa- 
 tion of tension and traction in most of the muscles. There is also 
 a feeling of utter prostration, of fatigue, which comes on especially 
 after the fits of trembling; in short, an indefinable uneasiness, 
 which shows itself in a perpetual desire for change of posture. 
 Seated, the patients every moment feel obliged to get up ; stand- 
 ing, after a few steps they require to sit down. This need of change 
 of position is principally exhibited at night in bed by the more 
 infirm, who are incapable of attending on themselves. The nurses 
 charged with their care will tell you : "They must be turned now 
 on the right side, now on the left, now on the back." Half an 
 hour, a quarter of an hour, has scarcely elapsed until they require 
 to be turned again, and if their wish be not immediately gratified 
 they give vent to moans, which sufficiently testify to the intense 
 uneasiness they experience. In spite of these different troubles, 
 the transmission of the cutaneous sensitive impressions is not 
 altered in paralysis agitans; cold, heat, a pinch, the slightest touch, 
 are all perceived, as in the normal state, and with the vvonted 
 rapidity. 
 
 But there is one very troublesome sensation which the patients 
 experience, and which I have not found mentioned in any descrip- 
 tion ; this is an habitual sensation of excessive heat, so that you shall 
 see them in the heart of winter throw off^ the bedclothes, and in 
 the daytime only retain the lightest garments. All the cases under 
 our charge give evidence in favour of this assertion. It is a pecu- 
 liarity worth noticing, although no reason can be given for it, that 
 this sensation of heat is especially felt in the epigastrium and the 
 back. Still it may affect the limbs and face also. It is not of 
 uniform intensity at all times. It appears to attain its maximum 
 after the paroxysms of trembling, and it is then frequently accom- 
 panied by profuse perspiration, which is sometimes so great as to 
 necessitate a change of litien; but it may also be found in patients 
 who do not thus perspire and who are but little troubled with 
 tremor. 
 
 The knowledge of this fact long since led me to inquire whether 
 the central temperature was altered in these patients. Now expe- 
 rience has proved to me that, whatever may have been the intensity 
 of this subjective sensation or of the tremor, the (rectal) tempera- 
 ture remained at the physiological limit (87.5° C. = 99.5° F.). 
 
 You will not be surprised, gentlemen, to find that the muscular 
 
SEXSATION OF HEAT — TEMPERATURE. 121 
 
 contractions, even when so energetic and general as are those we 
 note in certain cases of paralysis agitans, do not give rise to an 
 accumulation of heat in the central parts. These muscular con- 
 tractions are dynamic. Now, you are aware that static muscular 
 contractions alone, as M. Beclard has pointed out, occasion an ele- 
 vation of temperature thermometrically appreciable. From this 
 point of view, as we, M. Ch. Bouchard and myself, have endea- 
 voured to establish, in an essay communicated to the Societe de 
 Biologic,^ convulsions may be classed under two heads: — 
 
 1st. Static, in which tonic contractions predominate ; these aug- 
 ment the temperature to a more or less marked extent. To this 
 category tetanus and epilepsy belong. 
 
 2d. Dynamic, in which clonic convulsions predominate. These 
 do not affect the temperature in a marked manner. Thermometri- 
 cal explorations, which we have repeated many times in cases of 
 paralysis agitans, and in some cases of chorea, characterized by 
 excessive agitation, seem to us to have placed the latter point be- 
 yond all doubt.^ 
 
 In connection with this question it would be interesting to 
 determine wliether the urine, in paralysis agitans, presents any 
 important modification in its chemical composition, and, particu- 
 larly, any augmentation in the proportion of sulphates, inasmuch 
 as, according to Dr. Bence Jones, such changes take place in chorea 
 and delirium tremens — diseases in which there is great muscular 
 expenditure. This is a desideratum which we propose some day 
 to make good.^ 
 
 Gentlemen, the symptoms we have described to you persist, such 
 
 ' "Surles variatious de la temperature centrale qui s'observent dans certaines 
 affections conviilsives et sur la distinction qui doit 6tre etablie h, ce point de vue 
 entre les convulsions toniques et les convulsions cloniques." — 'Memoires de la 
 Societe de Biologie,' 1866. 
 
 2 This statement is corroborated by five new cases. Five explorations made in 
 the case of Ber. gave an average temperature of 37.480 C In the case of Guill, 
 three explorations gave 37. 60. lu the case of Dan. three morning explorations 
 gave 37.30 C. ; and four evening explorations, 37. 80, In the case of Grrav. two 
 morning explorations gave 37^; and four evening explorations 37.6°. In the case 
 of Ban. three morning explorations gave 37. lO; and four evening explorations 
 37.45°. The pulse in the first case reached 90 ; in the second, 86 ; in the third, 
 84; and in the fifth, 80. The number of respirations, in these cases, was 
 normal (B.). 
 
 3 Researches have since been made, in reference to this subject, bv M. P. 
 Reguard in the laboratory of Sorbonne, — two of tlie patients in M. Charcot's 
 wards being placed under examination. In both cases, the urine contained a 
 nearly normal proportion of urea, but a less than normal proportion of sulphuric 
 acid. The average of fourteen specimens gave 19.50 grammes of urea ; and 1.25 
 instead of 2 grammes of sulphuric acid. It follows from these analyses that the 
 excretion of sulphates is diminished in paralysis agitans, contrary to the opinion 
 advanced by Dr. Bence .Jones when treating of chorea. In the latter affection, 
 indeed, Lehmann and Gruner have always found a diminution of sulphates. 
 Vogel, on his side, arrives at the same results, and he thinks that the contrary 
 conclusions of Dr. Bence Jones must be attributed to the insufficiency of the 
 analytic method employed. — Note to Second (^French) Edition. 
 
122 TEKMINAL PEKIOP. 
 
 as we see them, for a less or greater lapse of time ; then, sooner 
 or later, there comes a period that heralds the fatal issue, which 
 may be called the terminal 2^^^1'iod. The affection pursuing its 
 course, the difficulty of movement increases, and the patients are 
 obliged to remain, the whole day long, seated on a chair, or are 
 altogether confined to the bed. Then, nutrition suffers, especially 
 the nutrition of the muscular system. There may supervene, as I 
 have twice observed, a genuine fatty wasting of the muscles. At 
 a given moment, the mind becomes clouded and memory is lost. 
 General prostration sets in, the urine and feces are passed uncon- 
 sciously, and eschars appear upon the sacrum. In such cases, the 
 patients succumb to the mere progress of their disease, by a sort 
 of exhaustion of the nervous system ; and it is perfectly true, as 
 several authors have remarked, that at this "terminal period the 
 tremor, however intense it was before, is frequently seen to dimin- 
 ish and even to disappear.^ On a post-mortem examination, it is not 
 common to find any important visceral lesion capable of accounting 
 for the occurrence of death. VV^e do not observe, for instance, 
 the lesions of caseous pneumonia, or of tubercular phthisis, which, 
 as we shall see, usually terminate the existence of women attacked 
 with disseminated sclerosis or with progressive locomotor ataxia. 
 
 Such, however, is probably not the most usual kind of death in 
 paralysis agitans. The fatal termination, in fact, is frequently 
 owing to an intercurrent disease. Trousseau thrice beheld death 
 supervene in consequence of pneumonia, and I have noticed the 
 same thing myself in several individuals suffering from paralysis 
 agitans. Was this complication due to the habit which such pa- 
 tients have of remaining uncovered, even in the coldest weather, 
 on account of the sensation of interior heat they experience ? We 
 are unable to affirm it. 
 
 Let us not forget, gentlemen, that paralysis agitans is one of the 
 grave affections of the nervous system whose duration is the longest. 
 It may last for thirty years. The symptoms of the third period may 
 themselves, as I have witnessed, linger on for four or five years. 
 
 If I have dwelt thus minutely upon the symptomatological de- 
 scription of paralysis agitans, it is because it constitutes, even at 
 the present hour, nearly the whole of the history of this disease. 
 
 The few autopsies which have until now been made on persons 
 supposedly affected by paralysis agitans may be grouped into three 
 classes. 
 
 The first class includes the cases in which no perceptible lesion' 
 has been met with in spite of the most attentive explorations. 
 
 • In the case of a patient under M. Charcot'.^ charge (Latouil — Marie-FranQoise) 
 whose clinical history is given, in exteuso, in the thesis of M. Claveleira, the 
 trembling completely disappeared the second day before her death (De la Paraiy- 
 8ie Agitan,' 1872, p. 35). 
 
PATHOLOGICAL ANATOMY. 123 
 
 Several facts of this kind have been placed on record by different 
 authors. For my part, I have noted three well-marked cases of 
 paralysis agitans in which the results of the autopsies were alto- 
 ofether nes^ative. At other times, we find mention made of com- 
 monplace lesions, particularly of senile cerebral atrophy ; now this 
 may exist, as is well known, without- the slightest tremor having 
 been ever present. 
 
 The second class comprises the observations published by some 
 authors, — Bamberger, Lebert, and Skoda, for instance, — under the 
 head of paralysis agitans, and in which lesions have been found 
 that, in all probability, pertain to disseminated sclerosis. Such are 
 the cases of Bamberger, Lebert, and Skoda. Was paralysis agitans 
 really the disease under consideration, or were not the clinical 
 symptoms rather those of disseminated sclerosis? The latter was 
 certainly the fact, at least as regards Skoda's case. We shall, 
 however, revert to this question, on a future occasion. 
 
 Finally, the last group contains the case given by Parkinson and 
 that of Oppolzer. In Parkinson's case, which, by the way, he 
 relates at secondhand, it appears that there was an augmentation of 
 volume^ with induration of the pons Varolii^ of the medulla oblongata^ 
 and of the cervical portion of the cord^ and that in addition to this 
 the nerves of the tongue and those of the arm were apparently 
 tendinous. The latter necroscopical detail, with others unnecessary 
 to mention, seems of a kind to throw doubt upon the value of this 
 case from an unatomopathological point of view. 
 
 As to the account given by Professor Oppolzer it is scarcely 
 more conclusive in our opinion, in spite of the importance that has 
 been accorded it. On post-mortem examination there was also 
 found an induration of the pons Varolii, which, after microscopical 
 scrutiny, was attributed to a hyperplasia — a proliferation of the con- 
 nective tissue. What are the characters of this hyperplasia? The 
 narrative is silent respecting them. There is no mention, in the origi- 
 nal text, of any atrophy of the nervous elements, nor of any signs of 
 fatty degeneration, two lesions given, for what reason I know not, 
 in the version adopted by Trousseau in his clinical lecture. 
 
 The foregoing considerations show, gentlemen, that the special 
 lesion of paralysis agitans remains to be discovered.^ 
 
 « Since this lecture Wcas delivered (in 1868), M. Charcot has had occasion to 
 make three new post-mortem examinations. The lesions he met with are of two 
 kinds : Those of the first, constant in these three cases, consisted in (a) oblitera- 
 tion of the central canal of the spinal cord by proliferation of the epithelial 
 elements which line the ependyma ; (i) proliferation of the nuclei which sur- 
 round the ependyma; (c) pigmentation of nerve-cells, most marked in Clarke's 
 column chiefly. Of the second kind of lesion, one was peculiar to two of these 
 three cases, and consisted in a multiplication of the amyloid corpuscles — one was 
 found only in a single case ; this was a sclerosed patch on the posterior surface 
 of the bulbus rachidicus. In the most marked case (of paralysis agitans) there 
 was no lesion of the protubentia or of the bulbus discovered. (For further details 
 see Joffroy, ' Societe de Biologie,' 1871.) 
 
124 EXTERNAL CAUSES. 
 
 The pathological 2)hysiology of the disease is scarcely more ad- 
 vanced than its anatomy. Very shortly, I expect I shall have an 
 opportunity of demonstrating the accuracy of this assertion before 
 you. I shall not dwell upon the subject now, as I desire to con- 
 clude the clinical history of paralysis agitans by stating what we 
 know with respect to the etiology and therapeutical history of this 
 disease. 
 
 Etiology. — A. Among external causes, two especially have a right 
 to be mentioned, in a tolerably large number of cases. First in 
 order comes the influence of violent shocks of the nervous system 
 — fright, terror, the sudden communication of bad news, &c. In- 
 stances of this kind abound in books, and the facts which we have 
 ourselves collected oblige us to put away all scepticism on this 
 subject. 
 
 Of the female patients whom we have interrogated many related 
 how their complaint took its rise in the midst of the political com- 
 motions by which our country has been agitated. It may be suffi- 
 cient to mention the case of the gendarme's wife, which we have 
 already referred to, and that of a woman at present occupying bed 
 No. 2 in the Salle St. Alexandre, who began to tremble after a 
 violent emotion occasioned by the events of December, 1851. Be- 
 sides the instances which came under our own observation we may 
 mention — 1st, a case of M. Hillairet (recorded in our memoir) con- 
 cerning a father who saw his son killed before his eyes; 2d, an- 
 other case, published by Oppolzer, relating to a burgher of Vienna, 
 terrified by the bursting of a bomb beside him ;^ and 3d, a case 
 given by Van Swieten, where a man was suddenly roused from 
 sleep by a fearful thunder-clap. It would be easy to multiply ex- 
 amples, but this could add nothing to what we have already told 
 you. What it behooves you to know is the fact that, in all these 
 patients, the trembling followed immediately, or almost immedi- 
 ately, on the occurrence of the cause. But the peculiar nature of 
 the cause, be it known to you, does not impress any special cha- 
 racter upon the disease. 
 
 Let us note, in the second place, the wfliience of ijrolonged ex- 
 posure to moist cold in the production .of paralysis agitans, an influ- 
 ence which, according to some authors, should suffice to establish 
 
 I In a work published in 1873 ('Berliner Klin. Wocheuschrift,' No. 24, p. 278, 
 etc.), Dr. 0. Kohts reports a number of cases of nervous aflfections, observed at 
 Strasbourg, which the patients attributed to the terror caused by the bombard- 
 ment of that city. The author, who expatiates complacently on that disastrous 
 event, informs us that the number of bombs showered upon Strasbourg amounted 
 in thirty-one days to 193,722, making, as he calculates, 6249 per day, 269 per 
 hour, or from four to five per minute. Amongst the pathological cases quoted, 
 three appear to relate to paralysis agitans : one is that of a woman, aged fifty 
 years, another that of a woman aged sixty-one years, and the third that of a man 
 aged fifty-six years. (B.) — Note to the Second French Edition. 
 
INFLUENCE OF COLD AND NERVE-IRRITATION. 125 
 
 its rheumatic origin. However, one important fact may be alleged 
 against this view, which is that, neither before the development 
 nor during the course of the disease, do we meet with any form of 
 chronic or acute articular rheumatism, some rare cases excepted. 
 We notice, at most, in cases where the influence of cold can be 
 accused, the presence of wandering rheumatic or neuralgic pains. 
 In this connection we may quote the case of a woman to whom 
 your attention was drawn, and whose (elephantine) gait recalls that 
 of the larger pachyderms. This woman, who was engaged in wafer- 
 making, lived for over ten years in a very damp apartment on the 
 ground-floor, and the description she gives of her unhealthy abode 
 leaves no doubt upon the subject. She was, moreover, exposed to 
 frequent chills in carrying on her trade. 
 
 There are cases in which this cause is, in our opinion, far from 
 having played the part assigned to it. Such is that recorded by 
 Romberg relating to a man who, in 1813, was stripped naked by 
 the Cossacks in snowy weather. Is the action of cold to be 
 accused in'this case, or the influence of terror? 
 
 Finally, we will point out a third cause, which has been silently 
 passed over, by most medical writers, in describing this disease, 
 namely, the irritation of certain perii^iheral nerves, supervening in 
 consequence of a wound or contusion. A case mentioned by Ilaas, 
 from Door, in 1852, and quoted by Dr. Sanders, appears to belong 
 to this etiological group. It relates to a girl of nineteen, under 
 whose right toe-nail a thorn had penetrated. She immediately 
 complained of acute pain, and soon after was seized with trem- 
 bling, which, though at first limited to the wounded foot, gradually 
 became generalized. This trembling, it is said, completely disap- 
 peared in the course of time. A termination so exceptional aftbrds 
 us reason to doubt whether this was really a case of paralysis 
 agitans. 
 
 The wife of one of our provincial brethren, whom I attended, 
 received a severe contusion of the left thigh, owing to a fall from 
 her carriage. After some time there supervened in the injured 
 limb acute pain following the course of the ischiatic nerve, and, 
 shortly afterwards, the extremity was aftected by trembling 
 throughout its entire extent. This tremor, which was at first 
 temporary, became permanent later on, and finally invaded the 
 other members. 
 
 With this case we may place that of a midwife, who was also 
 taken with paralysis agitans. This patient, who was under my 
 care in La Salpetri^re for many years, had experienced a violent 
 pain, limited to the course of the nerves of the leg and foot. The 
 parts so affected were the first seized with tremor. The pain, 
 which had arisen spontaneously, and which was at times intoler- 
 able, resisted the most energetic remedies. It persisted until the 
 
126 PREDISPOSING INFLUENCES. 
 
 death of the patient, on whom, unfortunately, no autopsy could be 
 performed. 
 
 B. We have indicated the cases in which the inliuence of an 
 etiological element may be discerned ; but there are others where 
 the most attentive investigations do not lead to any result. Here 
 we are reduced to inquire into the predisposing influences^ which it 
 now remains for us to review. 
 
 In relation to the question of age, we should point out that 
 shaking palsy is not, as has been asserted, a senile disease. It is 
 true that it sets in after forty, and consequently at a later period 
 than disseminated sclerosis. This rule, however, is not absolute ; 
 some instances may be cited in which the disease showed itself 
 at an early age, at twenty, for example, as in a case which M. 
 Duchenne (de Boulogne) has told us of.^ 
 
 Sex appears not to exercise any pathogenic influence ; paralysis 
 agitans is found as commonly in males as in females. 
 
 We possess no precise information with respect to the influence 
 of hereditary predisposition. Unlike locomotor ataxia in certain 
 circumstances, and progressive muscular atrophy, paralysis agitans 
 is not a family disease. The observations which have produced a 
 contrary impression relate to partial tremors that showed no ten- 
 dency to become generalized, and which pertain rather to the class 
 of convulsive twitchings (tics convulsifs). 
 
 There is some reason to believe that the Anglo-Saxon race (in 
 England and North America) is the most subject to this disease. 
 The accounts which I have received from physicians of the countries 
 mentioned, my personal experience, and especially the information 
 with which my friend, M. Brown-Sequard, has supplied me, all 
 yield support to this opinion. 
 
 But even in those countries shaking palsy is not very common. 
 Dr. Sanders, in his statistical table, which comprises England and 
 Wales, and reaches from 1855 to 1863, records 205 cases of death 
 by paralysis agitans — that is, an average of 22 deaths per year 
 (fourteen men and eight women). Finally, this disease figures in 
 the fifth place, side by side with locomotor ataxia, on the etiological 
 list of affections treated at La Salpetritire. 
 
 Treatment, — A few words, in conclusion, gentlemen, upon thera- 
 
 ' M. Fioupe has published in the ' Journal de Medecine et de Chirurgie 
 Pratiques ' (p. 389, 1874) the case of a young girl, under the care of Dr. Siredey, 
 who was stricken with shaking palsy at the age of from fifteen to sixteen years : 
 " Towards the end of the siege of Paris she had one day taken refuge in a cellar 
 to be out of the way of the projectiles, when a shell burst, destroying three or 
 four persons at her side. Seized with violent terror, she fainted away, and when, 
 after a few instants, she carne to her senses, it was soon observed that her right 
 arm was shaken by a slight tremor, which in a little time invaded the right 
 lower extremity also." She presents, at present, all the symptoms which denote 
 paralysis agitans : characteristic physiognomy, fixity of gaze, special attitude of 
 head and body, peculiar gait, propulsion, retropulsioii, &c. (B.) — Note to the 
 Second French Edition. 
 
TREATMENT. 127 
 
 peutical remedies. It is an incontestable fact that paralysis agitans 
 is sometimes cured. Does this cure take place spontaneously, or 
 because of the remedies employed ? The latter hypothesis is but 
 little probable, so far as the majority of these fortunate cases are 
 concerned, for the same drugs, to which the credit of effecting the 
 cure in such cases has been given, have completely failed in other 
 cases. Elliotson administered carbonate of iron, and Brown-Se- 
 quard chloride of barium — each of them had a success to chronicle, 
 and, along with that, cases in which the results were negative. M. 
 Duchenne (de Boulogne) has likewise to record the cure of one of 
 his patients. These instances prove that paralysis agitans is not 
 incurable. But we must confess that we are ignorant of the means 
 employed by nature to produce this result. 
 
 Everything, or almost everything, has been tried against this 
 disease. Among the medicinal substances that have been extolled, 
 and which I have administered without any beneficial effect, I need 
 only enumerate a few. Strychnine praised by Trousseau ('Journal 
 de Beau'), appears to me rather to exasperate the trembling than 
 to calm it. Ergot of rye and belladonna, recommended on account 
 of their anti-convulsive qualities, have not yielded any very profit- 
 able results. The same verdict must be given in reference to 
 opium, which, on the contrary, augments reflex excitability, and 
 which was supposed capable of moderating the tremor because of 
 diminishing the pain. Latterly I have made use of hyoscyaraine, 
 from which some patients have obtained relief; its action, how- 
 ever, is simply palliative. 
 
 Ogle gave Calabar bean without any advantage. As to nitrate 
 of silver, it has always appeared to us to exaggerate the convulsive 
 condition, and this is the more remarkable, because in disseminated 
 sclerosis it sometimes produces a fairly marked amendment, and 
 diminishes the intensity of the shaking.^ 
 
 Finally, we should mention the application of electricity, which, 
 according to some physicians, has brought about several cures. 
 Neither statical electricity nor the interrupted current is recom- 
 mended. These agents, though of benefit, it is said, in chorea are, 
 at least according to Dr. Gull, inefficient as against paralysis agitans. 
 The continued current of a galvanic pile is prescribed. It is not 
 necessary, gentlemen, to remind you to-day that the physiological 
 and therapeutical effects differ remarkably as you make use of one 
 
 1 M. Eulenberg has recently recommended the hypodermic injection of a solu- 
 tion composed of one part of arseniate of potash to two parts of water (' Berliner 
 Klin. Wochenschr.,' Nov. 1872). This mode of treatment, having been tried by 
 us in M. Charcot's wards, gave no satisfactory results ('Progriis Medical,' 1874, 
 p. 245). We have also prescribed bromide of camphor in the case of two pa- 
 tients in the same ward, whose disease had lasted for several years. In the first 
 weeks there was amendment of some symptoms, but this improvement did not 
 persist. It might, perhaps, be well to recur to this therapeutic agent in less ad- 
 vanced cases. (B.)—Note to the Second French Edition. 
 
128 DISSEMINATED SCLEKOSIS. 
 
 or Other of these kinds of currents. However it be, there are at 
 least two cases in which this method of treatment seems to have 
 proved successful. The first pertains to Eemak, the second to Dr. 
 Eussell Eevnolds. It is' proper, therefore, when the occasion offers, 
 to have recourse to the continued current. 
 
 LECTURE YI. 
 
 DISSEMINATED SCLEROSIS. PATHOLOGICAL ANATOMY. 
 
 Summary. — History of disseminated sclerosis; French period; German period; 
 New French investigations ; Macroscopic morbid anatomy ; external aspect 
 of the patches of sclerosis ; their distribution in brain, cerebellum, protu- 
 berantia, bulbus rachidicus, and spinal cord. Patches of sclerosis on the 
 nerves. Spinal, cephalic or bulbar, and cerebro-spinal forms. Characters of 
 the sclerosed patches ; their colour, consistence, etc. 
 
 Microscopic anatomy ; sketch of the normal histology of the spinal cord ; 
 Nerve tubes ; Neuroglia, its distribution ; Cortical layer of the reticulum. 
 Characters of the neuroglia, influence of chromic acid. Arterial capillaries. 
 Histological characters of the sclerosed patches ; transverse sections ; peri- 
 pheral zone ; transition zone ; central region. Longitudinal sections. Alter- 
 ations of the bloodvessels. Examination of the sclerosed patches in the 
 fresh state. Histological lesions consecutive on section of the 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. 
 
 Gentlemen : At our last conference I dwelt upon the distinction 
 which should be made between the different kinds of tremor. I 
 mentioned, at the outset, that they could be divided into two groups; 
 one, in which tremor is in some sort permanent; another, in which 
 tremor only supervenes on purposed movements. Then, proceed- 
 ing from these notions, T cited as an example of the tremor charac- 
 teristic of the first class, that observed in paralysis agitans, the 
 history of which I traced for you. On our way, I noted some of 
 the characters which enable us, in these days, to distinguish this 
 disease from another affection, previously confounded with it, 
 namely, from disseminated sclerosis. 
 
 To this affection, which offers us an example of tremulation be- 
 longing to the second class, i. e., a tremor which only appears under 
 certain conditions, we shall devote the present and succeeding lec- 
 tures. Anatomically considered, disseminated sclerosis forms a 
 clearly defined pathological species ; clinically, the case is different, 
 
HISTORICAL NOTE. 129 
 
 and in this connection we shall have many blanks to fill up. Let 
 us begin by a few words on the history of the subject. 
 
 Historical Note. 
 
 Disseminated sclerosis is found mentioned, for the first time, in 
 Cruveilhier's 'Atlas d' Anatomic Pathologique,' 1835-1842, an ad- 
 mirable work, which ought to be more frequently consulted by all 
 who desire to avoid the disappointment of making second-hand 
 "discoveries" in morbid anatomy. In Parts 22 and 23 you will 
 observe representations of the lesions found in disseminated scle- 
 rosis, and, side by side, you can read the clinical observations 
 which relate to them. I take advantage of this opportunity to 
 commend to your perusal a remarkable chapter on paraplegia. 
 Previous to this epoch, so far as I am aware, there is no trace of 
 disseminated sclerosis to be discovered anywhere. 
 
 After Cruveilhier, Carswell in the article on "Atrophy," con- 
 taine<l in his ^Atlas/ 1838, has had lesions depicted which pertain 
 to disseminated sclerosis. But this author, who has drawn the 
 materials of his work chiefly from the hospital of Paris, does not 
 relate any clinical case in connection with this subject. Even to- 
 day I do not believe that disseminated sclerosis is known in Eng- 
 land.^ I do not find it indicated in any of the standard works 
 published in that country, not even in Dr. Gull's valuable collec- 
 tion.^ 
 
 Thus, up till that time, the principal doc^uments in connection 
 with this disease had been collected in France. From that period 
 forth, during a lapse of several years, this question dropped into 
 almost complete oblivion, and we have to seek in Germany for new 
 indicia. Ludwig Turck published, in 1855, examples of lesions 
 manifestly belonging to disseminated sclerosis; still the physio- 
 logical aspect of it alone engaged his mind f Rokitansky indicates 
 them in his treatise;* Frerichs"^ and Valentine'' record two observa- 
 tions; Rindfleisch,^ Leyden,' and Zenker,^ present in their turn 
 
 ' This lecture was delivered in 1868. 
 
 2 Cases of Paraplegia in 'Guy's Hospital Reports,' 1856-1858. 
 
 ' " Beobachtungen iiber dis Leitungsverniogen des Menschliden Riiclien 
 marks," * Sitzungsbericlite der Kais. Akademie der Wissenschaften, Math. Natur. 
 Class.,' t. xvi, 1855, p. 229. 
 
 * ' Lelivbuch der Pathoiogischen Anatomie,' 1856, Zweiter Band, p. 488. 
 
 5 * Hae.ser's Arclxiv,' Band x. 
 
 6 " Ueber die Sclerose der Gehirns und Riickenmarks" (' Deutsche Klinik,' 
 1856, No. 14). 
 
 7 " Histologische Detail zu der Grauen Degeneration von Hirn und Riicken- 
 marks" (' Virchosv's Archiv,' B. xxvi, Heft unl 6, p. 474). 
 
 8 "Ueber graue Degeneration des Riickenmarks" ('Deutsche Klinik,' No. 13, 
 1867). 
 
 9 "Ein Beitrag zur Sclerose des Hirus und Riickenmarks" ('Zeitsrhrift fiir Rat. 
 Medizin,' B. xxiv, Heft 2 und 3). 
 
 y 
 
130 MACROSCOPIC ANATOMY. 
 
 some elements towards the solution of the problem. There were? 
 however, desiderata to be supplied, and new researches were indis- 
 pensable. It was at La Salpetriere that the question of dissemi- 
 nated sclerosis once more attracted attention amongst us. In 1862, 
 M. Yulpian and myself placed new examples on record. M. 
 Bouchard, founding his remarks on the cases collected by us at 
 the Salpetriere, reopened the subject in a treatise which he read 
 before the Medical Congress at Lyons. 
 
 In the preceding enumeration of authorities, we have taken 
 count chiefly of the works relating to the pathological anatomy of 
 the subject, as we propose to make mention hereafter of those 
 which contain clinical details. To the items of information culled 
 from the writers whose names are mentioned above, we shall add 
 other information drawn from unpublished sources, and, in order 
 to facilitate the understanding of our studies, we shall place before 
 your eyes the anatomical preparations which we have preserved. 
 
 Macroscopic Anatomy. 
 
 Disseminated sclerosis, as I have informed you, gentlemen, is not 
 an exclusively spinal affection. It invades the cerebrum, the pons 
 Varolii, the cerebellum, the bulbus rachidicua, as well as the spinal 
 cord. We shall, therefore, enumerate the alterations which are to 
 be observed, taking the most distinctive cases, in the different parts 
 of the nervous system, viewing them first externally, then in sec- 
 tion. 
 
 We have here to consider a comparatively coarse alteration, and 
 it is surprising that it should have escaped observation so long. 
 On the plates before you, in which these changes are accurately 
 depicted, you see the spinal cord spotted with grayish patches, 
 having a more or less regular outline, but in every case distinctly 
 circumscribed and contrasting widely with the adjacent portion of 
 the cord. 
 
 Sometimes discrete, sometimes confluent, these spots or patches, 
 as you may easily perceive, are disseminated without any apparent 
 order, and as it were by chance, over the whole of the spinal cord. 
 The medulla oblongata itself does not escape, far from it; different 
 portions of the encephalon are also frequently affected. 
 
 But we cannot content ourselves with this simple sketch, and 
 we must enter upon the details of a more regular description. At 
 the outset, we should remark that a mere external examination will 
 give but a very imperfect idea of the lesion. The spots or patches 
 which we have mentioned are not superficial; they constitute real 
 kernels or foci which penetrate into the substance of the tissues. 
 Frequently, indeed, the section itself will reveal the existence of 
 other spots concealed in the interior. 
 
DISTRIBUTION OF SCLEROSED NODULES. 131 
 
 Let US first examine the encephalon. The general appearance of 
 the cerebrum proper has undergone no modification of form, nor, 
 we may add, of colour; for the patches are very rarely found on 
 the gray substance of the convolutions. It is different, however, 
 as regards the central parts. There, in fact, we find the patches, 
 especially on the walls of the ventricles, in the white substance of 
 the centrum ovale, the septum lucidurn, the corpus callosurn, and 
 finally in certain regions of the gray matter, e. g.^ the optic thalami, 
 and the corpora striata. 
 
 The cerebellum generally presents only internal patches, which 
 occupy especially the corpus rhomboideum. 
 
 The hulbus rachidicas^ the pons Varolii^ and the different districts 
 of the isthmus, are very frequently affected by patches of sclerosis 
 which, in such cases, are both peripheral and deep seated. When 
 the bulbus rachidicus is attacked, the patches are found to affect, 
 either singly or simultaneously, the corpora olivaria, pyramidalia, 
 restiformia, and the posterior region where the nuclei of origin of 
 the bulbar nerves are disposed. As regards the pons, the patches 
 generally occupy its anteroinferior aspect. If we ascend higher, 
 we see the corpora mammilaria(or albicantia) and the crura cerebri 
 aff^ected. 
 
 We now come to the spinal cord. Through the pia mater we 
 often perceive the gray spots which assume a rosy tint or salmon- 
 colour, on contact with the atmosphere. But it is especially after 
 the removal of this membrane, a removal easily ejected, that the 
 lesions are clearly perceived. They affect the whole of the cord, 
 being found in the cervical, dorsal, and lumbar regions; they 
 invade all the different columns indiscriminately, are to be found 
 on the sides of the fissures, and attack the gray substance as well 
 as the white. 
 
 The nerves themselves do not escape sclerosis. We see them, 
 indeed, sometimes emerge from a sclerosed patch and yet remain 
 perfectly sound; at other times, we find them affected, in tlieir 
 course, by sclerosed patches quite similar to those of the nerve- 
 centres; this is so, at least, as regards those parts of the nerves 
 which lie adjacent to the centres, for the observations of MM. Liou- 
 ville and Vulpian (which have been frequently verified) leave no 
 doubt upon the subject. 
 
 The cranial nerves that have been found to present sclerosed 
 patches are the optic, the olfactory, and the fifth pair. As to the 
 rachidian nerves we only know that such patches have been ob- 
 served on the posterior and anterior roots; but we are not aware 
 whether they have been thus affected in their extra-spinal course. 
 
 I will not dwell any further, gentlemen, on the topography of 
 the patches of sclerosis; still, I cannot refrain from requesting 
 your earnest attention to the interest which belongs to this question. 
 
132 MICROSCOPIC ANATOMY. 
 
 You observe, in ftict, that these patches, in different cases, occupy 
 very different regions of the nervous centres, and it is clear that 
 this variation of position should be represented by very different 
 functional disorders. It is, indeed, to this fact that the disease 
 owes a large portion of its protean character. We shall return to 
 this subject; at present, you will remark that these dift'erences of 
 position give rise to certain important clinical divisions. Some- 
 times the patches occupy the spinal cord exclusively {spinal form) -^ 
 sometimes they predominate in the encephalon {cephalic or halbar 
 fm^m); finally, the simultaneous existence of patches in the ence- 
 phalon and cord supplies the cerebro spinal form. 
 
 In order to close what I have to say respecting the macroscopic 
 anatomy of the disease, it only remains for me to indicate the 
 principal characters which the patches present when considered in 
 themselves. 
 
 Sometimes they are salient, and, as it were, turgescent ; at other 
 times they are on a level with the adjacent parts; finally, they are 
 sometimes depressed, when of old date. 
 
 Their colour resembles that of the gray matter, from which it is 
 difficult to distinguish them ; but on contact with the atmosphere 
 they assume a rosy hue, and numerous vessels are observed dis- 
 tributed through them. 
 
 These spots have a firm consistence, and, on section, present a 
 clean surface, whence exudes a transparent fluid. 
 
 Such, gentlemen, as regards its simple anatomy, is disseminated 
 sclerosis, or sclerosis generalized in patches; we have now to enter 
 upon its minute histological details. 
 
 In order to bring to a successful issue this undertaking, which 
 relates to facts demanding a careful exposition, I must beg you to 
 grant me both your entire attention and all your indulgence. 
 
 Microscopic Anatomy. 
 
 The method to be followed is simple. We should proceed from 
 a consideration of the normal state of the tissues ; that once 
 known, it will be more easy to deduce the morbid alterations. The 
 preliminary knowledge of the characteristics of the normal state, 
 as regards the organs and the elements whose changes we wish to 
 study, is doubtless familiar to you, and we might, if necessary, 
 enter at once upon an examination of tiie intimate lesions. Never- 
 theless, as you are aware, the histological anatomy of the nervous 
 centres is, in many respects, quite new; many of the questions 
 which it suggests are still disputed; whilst, on the other hand, for 
 the comprehension of pathological lesions, it is not a matter of in- 
 difference to have a more or less well grounded opinion in relation 
 to these questions. These considerations induce us to remind you, 
 at least in a succinct manner, of certain fundamental facts of normal 
 
NORMAL HISTOLOGY. 133 
 
 anatomy. We shall, however, occupy ourselves chiefly' with the 
 spinal cord, an organ of less complexity and more easily studieil 
 than the brain. In order to limit the field of our examination we 
 shall not delay to describe the nerve elements, properly so called, 
 whether tubes or cells, nor shall we dwell on their reciprocal rela- 
 tions or modes of grouping, in the formation of what is known as 
 the white and gray substances. We propose to concentrate your 
 attention on the connective gangue (or matrix) which surrounds 
 these elements on every side. To this connective setting a high 
 interest attaches, especially for the pathologist, because we must 
 attribute to it a supreme part in the causation of certain alterations 
 of the nervous centres, and particularly in the cases which at pre- 
 sent engage our attention.^ 
 
 I. 
 
 A. It will be, I believe, of advantage to inaugurate this study 
 by an examination of thin transparent sections, taken transversely 
 from segments of the spinal cord, which have been properly hard- 
 ened in dilute chromic acid and coloured with carmine. Carmine 
 is here a precious reagent. Thanks to it, certain elements which 
 under its influence assume a vivid hue are thereby set in relief, 
 whilst other elements preserve their usual appearance. Thus the 
 ganglionic cells, their nuclei, their neucleoli, and also the prolonga- 
 tions of these cells, are strongly coloured under the influence of 
 this reagent. The connective matrix also becomes tinted through- 
 out its whole extent, but much less vividly; as regards the nerve- 
 tubes, the axis cylinder alone takes the carmine tint, whilst the 
 medullary sheath completely resists its action. 
 
 All the details which this mode of preparation brings out may 
 be followed on the plate, copied from Deiters,^ which I here ex- 
 hibit; you will afterwards easily find them in the very beautiful 
 sections which I shall have passe 1 before you for inspection, anil 
 which I owe to the courtesy of Dr. Lockhart Clarke. These sec- 
 tions should be at first examined with a low magnifying power. 
 
 In the preparations, as in the plate, the portions pertaining to 
 the white substance of the cord seem to you at first sight almost 
 entirely composed of small regularly rounded bodies, like disks, 
 placed side by side, and having all nearly the sam3 diameter. 
 These are thin cylindrical segments, resulting from section of the 
 
 ' It is known that the first stndies of the connective matrix of the spinal cord 
 date from 1810, and are due to KeufFel ; but it is less knowu that Cruveilliier ia 
 his article on apoplexy in the ' Dictionnaire de Medecine et de Cliirurt^ie pratiques,* 
 publislied in 1820, mentioned it: — '• Le tissu cellulaire .sereux extremeuieiit <lelie 
 qui unit et separe les fibres cerebrales et qui forme une trame excessivemeut 
 tenue" (loc. cif., p. 209). 
 
 2 0. Deiters. ' Uutei'such. iiber Gehirn uud Rlickeumark,' Brauuschwieg, 1865, 
 PL iii, fig. 12.' 
 
134 ON THE NEUROGLIA. 
 
 nerve-tubes, which tubes are, in that part of the cord, disposed 
 longitudinally, having the same direction as the greater axis of 
 the organ, and are here, like the prisms of a basaltic causeway, 
 placed parallel each to each. In the centres of these disks, which 
 are chiefly formed of non-tinted medullary matter, having a bril- 
 liant and transparent appearance, you will see a point or rather a 
 little globule, i. e., the axis cylinder, coloured carmine. 
 
 A somewhat more careful scrutiny soon enables you to note 
 that the disks in question are not exactly in contact, and that they 
 are, on the contrary, more or less plainly separated, each from its 
 neighbour, by an apparently homogeneous substance, which the 
 carmine colours faintly, and which seems to fill like a cement all 
 the interstices that the nerve-elements leave between them. This 
 substance is nothing other than the connective gangue (or matrix) 
 as we called it a little while ago, the neuroglia of Virchow, and the 
 reticulum of Kcilliker. In studying its mode of distribution and 
 arrangement, in the different parts of the section, you will readily 
 perceive that it constitutes an important portion of the mass of the 
 organ. Observe, in the first place, that in the peripheral part of 
 the section it forms a ring or rather a zone of some thickness, from 
 which the nerve-tubes are altogether absent. This zone is covered 
 externally and enveloped, as it were, by the pia mater, with which 
 it contracts only some frail attachments ; it is, besides, perfectly 
 distinct as regards structure from the latter membrane, which is 
 composed of fibrillary connective tissue and is, therefore, built up 
 quite differently from the neuroglia. This zone has been carefully 
 described by Bidder, and by Frommann,^ who term it the cortical 
 layer o^ the reticulum [Rindenschlicht)] we shall see, further on, 
 that, considered from a pathological point of view, it is of incon- 
 testible interest. 
 
 From the internal border of this zone or cortex we see septa 
 arise and proceed, at certain intervals, which direct their course 
 towards the centre of the cord, which they divide into triangular 
 compartments of almost equal size, whose bases are at the circum- 
 ference, and whose apices are lost in the gray matter. Each of 
 these septa gives oft* secondary dissepiments, and these tertiary, 
 which are again subdivided. Their ramifications get interwoven, 
 crossing and anastomosing, so as to produce a web or network 
 with meshes of unequal size. Each of the largest of these meshes 
 may inclose a fasciculus of eight or ten nerve-tubes, or even more, 
 whilst each of the smaller meshes usually contains only one. The 
 reticulated character described becomes especially evident in those 
 portions of the preparation where, owing to the peculiar distribu- 
 tion of the nerve-tubes, the connective skeleton persists alone. 
 
 ' C. Frotnmann, ' Untersuch. iiber die normale uud patliolog. Anatomie des 
 Riickenmaiks,' Jeua, 1864. 
 
ON THE NEUROGLIA. 135 
 
 The neuroglia plays, probably, a more important part in the gray 
 substance than in the white ; there are, in fact, some regions almost 
 exclusively formed by it, as, for instance, the borders of the central 
 canal and the column of the ependyma. It is also predominant in 
 that part of the posterior cornua known as the gelatinous substance 
 of Eolando : in the posterior commissure, which consequently takes, 
 almost throughout its whole extent, a rosy tint in the preparations 
 coloured with carmine, whilst the anterior commissure, on the con- 
 trary, in consequence of the numerous transverse nerve-tubes it 
 contains, is much less affected by the reagent. In the gray sub- 
 stance also, as in the white, the neuroglia presents a reticulated 
 appearance; but, in the former case, the greater intricacy of the 
 trabeculas causes the meshes to be notably smaller, and the whole 
 to assume the appearance of a spongy tissue. In both states, how- 
 ever, it serves as a framework and support for the bloodvessels. 
 
 B. It is incumbent on us now to investigate, by means of more 
 powerful lenses, what is the histological constitution of this con- 
 nective gangue or web, of which we only know as yet the most 
 superficial appearances. Have we here a common connective tis- 
 sue (laminous or fibrillary) ? Certainly not. All observers are 
 agreed upon this point. But, beyond this purely negative notion, 
 almost everything else is disputed in the histological history of the 
 neuroglia. However, one opinion tends to become prevalent here, 
 and thisopinion, if I may judge from impressions arising from per- 
 sonal observations, closely approximates to the truth. According 
 to this view the neuroglia would be formed, like the stroma of 
 lymphatic glands, for instance, after the type of simple reticulated 
 connective tissue (Kcilliker); that is to say, it would be essentially 
 composed of stellate cells, generally poor in protoplasm, having 
 slender prolongations, ramified several times, whose branches unite 
 with other, so as to bind into one system the several cells, and to 
 render them, as it were, joint-partners [Kcilliker,^ Max Schultze, 
 Frommann].^ In this form of the connective tissue there exists 
 but very little amorphous matter in the meshes of the reticulum, 
 and the intermediate fibrillary substance, which is one of the fun- 
 damental characteristics of the laminous tissue, is completely defi- 
 cient here. 
 
 Let us now see what direct examination enables us to discern in 
 thin sections of the cord hardened by chromic acid and coloured 
 with carmine. As in the case of the stroma of lymphatic glands, 
 which we have just taken for example, it becomes us here to distin- 
 guish, in the first place, the cells, and, in the second place, a 
 network of fibroid trabeculse, which binds these cells together. Let 
 us first take note of what is observed in the white substance. The 
 
 ' KoUiker, ' Geweblelire,' 5e Ed., Leipzig, 1867, § 108. 
 2 Loc. cit. 
 
136 ON THE NEUROGLIA. 
 
 points of the reticulum, where several trabeculse meet, form here 
 and there swellings or nodes of different degrees of thickness, situ- 
 ated at almost equal distances from each other. Now, all these 
 nodes, but especially those remarkable bj their great size, present 
 towards their central portion a definite, rounded, and somewhat 
 oval corpuscle, more vividly coloured by carmine than the adjacent 
 parts. These bodies are nuclei, having a well-defined border; they 
 are finely granular, are devoid of nucleoli, and measure each on an 
 average from 0.004 m. to 0.007 m. They are soluble in acetic acid, 
 which causes them to shrink in every direction, and diminishes 
 their diameter sometimes by one half; they are known by the name 
 of myelocytes (Ch. Kobin)/ or neuroglia 7i2<c?e2 (Virchow).^ A thin 
 layer of protoplasm, having no distinctly cellular appearance, usu- 
 ally surrounds these nuclei {myelocytes^ variete noyau), which, at other 
 times on the contrary, are inclosed in a genuine rounded or stellate 
 cell (myelocytes^ variete cellule), and furnished with more or less nu- 
 merous prolongations (from three to ten, according to Frommann), 
 of different lengths.^ 
 
 The prolongations appear to unite with the trabecula3 of the 
 reticulum, which continue them, as it were, without any perceptible 
 line of demarcation. In cases where the cellular form is not distinct 
 the nuclei, either naked or covered only with a thin layer of proto- 
 plasm, look like centres whence arise the trabeculse of the reticu- 
 lum, and whence they radiate in different directions. 
 
 The trabeculae should be studied in their turn, and considered 
 independently of the connections they have either with the nuclei 
 or with the cells which occupy the nodes of the reticulum; their 
 texture varies somewhat, according as we examine them in trans- 
 verse and in longitudinal sections. In the first case they have the 
 appearance of thin homogeneous and brilliant dissepiments of a 
 fibroid nature. Anastomosing, they form meshes, the smallest of 
 which is still large enough to inclose a nerve-tube. Suppose we 
 observe a longitudinal section ? The trabeculas are seen to ramify 
 to an indefinite extent, and produce a network having much finer 
 meshes. This network is disposed in the form of dissepiments, 
 which separate the nerve tubes from each other and inclose them, 
 like a sheath. The interstices which exist here and there between 
 these sheaths and the nerve-tubes seem to be filled up by a small 
 quantity of finely granular amorphous matter. In the normal stale 
 we meet nowhere, amongst these trabeeulae, wiih the slender fibrillse 
 which constitute an integral part of laminous tissue.^ 
 
 1 Robin, * Programme du Cours d'Histologie,' 1864, p. 46; * Diotionnaire Ency- 
 clop6dique,' 2e Serie, t. i, Ire part ; art. Lamineux, p. 284. 
 
 2 Virehow, Die Krankhaft, Geschwiilste, 1864-5, t. ii, p. 127. 
 
 3 In reference to this subject see Hayem and Magnan, 'Journal de la Phjsiolo- 
 gie, etc., No. 1, 1876. Hayem, 'Etudes sur les diverses formes d'Euc6phalite,* 
 1868. 
 
 4 The term tissu lamineux was applied iu 1799 by Cliaussier to the tissue recently 
 
ON THE NEUROGLIA. 137 
 
 In the gray substance the neuroglia is disposed on the same 
 general plan; the meshes of the fibroid network are, however, and 
 especially in parts where the nerve-elements disappear, more serried 
 than in the white substance, and from this cause a spongy appear- 
 ance results, which we have already noticed. Let us add that the 
 stellate cells abound in greater number than elsewhere in certain 
 regions of the gray substance, and that they sometimes attain such 
 a development that it becomes very diiTicult to distinguish them 
 from nerve cells; but we shall have occasion to refer to this point 
 again. 
 
 A dense fibroid network, with close meshes and numerous cells, 
 is found also in those parts of the white substance where no nerve- 
 tubes exist, in the cortical layer {Rindenschlicht), for example, and 
 in the greater septa which arise from it. 
 
 If we can depend upon the preceding description it is incon- 
 testable that the neuroglia deserves to be classed with the reticu- 
 lated connective tissue type, whose essential characters we noted a 
 little while ago. 
 
 But this description has been chiefly traced out, as you have not 
 forgotten, from observations made on fragments of spinal cord that 
 have been subjected to the action of chromic acid for a greater or 
 less extent of time. Now, can it be asserted that the results ob- 
 tained by this method of preparation are beyond the reach of 
 criticism? Such is not the opinion of some authors, amongst 
 whom we must cite, in the foremost place, such masters as Henle 
 and Ch. Robin.^ According to these, the fibroid reticulum, above 
 described, has no real existence, but is an artificial product. 
 
 In the fresh state, before the application of reagents, the spaces 
 between the nerve-tubes are filled (according to them), not by solid 
 trabeculae, arranged so as to form the meshes of a network, but 
 simply by a soft, grayish, finely granular substance, in the midst 
 of which the myelocytes are, as it were, held in suspension. 
 
 This substance has the property of hardening, without loss of 
 volume, under the influence of alcohol and different reagents, of 
 chromic acid in particular; and it is owing to this circumstance 
 that it presents a reticulated appearance in preparations treated by 
 the latter reagent. To these objections, arguments or rather facts 
 have been opposed, some of which possess, we think, almost abso- 
 lute authority. It is conceded that in the normal state an amor- 
 phous matter exists, interposed between the nerve-elements, though 
 in scanty proportion (Kdlliker), and that this matter possesses the 
 
 and still commonly kuown as cellular tissue, which we now call connective tissue. 
 Professor Robin still makes use of Chaussier's term, alleging it to be tbe best, 
 because he says the ultimate elements of this tissue are long filaments, somewliat 
 flattened, thin, slender, soft, and hyaline, smooth, slightly elastic, fasciculated. 
 (Sigerson.) 
 
 J * Diet. Encyclopedique,' loc. cit. 
 
138 ON THE NEUROGLIA. 
 
 properties which have been described. It is also conceded that, in 
 the fresh state, the reticulum is less distinctly defined than in pre- 
 parations hardened by the use of acids. But it is not the less true 
 that, even in the fresh state, thin sections of the white substance of 
 the cord, when placed in iodized serum and dilacerated under the 
 microscope, permit us clearly to discern on their borders the fibroid 
 tractus of the connective tissue (Kolliker, Frommann, Schultze). 
 This result, which it is easy to arrive at in the normal state, is still 
 more readily obtained in certain pathological conditions when the 
 normal arrangements are exaggerated, without being radically 
 altered (Virchow). 
 
 This is what takes place, for instance, as we shall point out, in 
 sabacute interstitial myelitis and in sclerosis proper, when the 
 alteration has not as yet exceeded the first phases of its evolution. 
 
 From all this it has been concluded, and we think the conclusion 
 legitimate, that the chromic acid has no other specific effect than 
 to bring out into better relief the reticulated texture of the con- 
 nective gangue or setting of the spinal cord. The arrangement 
 was previously in existence; it is not produced from nothing by 
 the action of the reagent. 
 
 In order to conclude the remarivs which I have thought it my 
 duty to offer you, in reference to the normal histology of the spinal 
 nerve centre, I have only a word to add concerning an anatomical 
 peculiarity of the smaller vessels, and principally of the arterial 
 capillaries, in the substance of this organ. They possess, like the 
 intraencephalic arterioles, that supernumerary coat which is com- 
 monly known as the lymphatic sheath or Robin's sheath. This 
 sheath is separated, as you are aware, from the adventitious coat 
 by a free space, filled by a transparent fluid in which float some 
 definite elements. You will soon recognize the interest belonging 
 to this anatomical arrangement, when we come to the question of 
 interpreting certain lesions.^ 
 
 ' Since this lecture was delivered, several works have been published on the 
 structure of the neuroglia (see in reference to this subject a critical review by 
 Gombauit, 'Archives de Physiologie,' 1S73, p. 458). In an important work, 
 M. Ranvier, whose labours have contributed so much to our knowledge of the 
 connective tissue, bas shown that the cells, described by Golgi and Boll, are pro- 
 bably artificial pioducts, due to the preparatory method adopted. The connec- 
 tive tissue of the nerve centres is but little different in structure from that of 
 other regions (Ranvier, '* Sur les elements conjonctifs de la moelle epiniere," in 
 * Comptes Rendus de I'Academie des Sciences,' D^cembre, 1873). The neuroglia 
 is composed of little connective bundles of from 0.001 mm. to 0.002 mm. in 
 diameter. " They do not anastomose," says M. Ranvier, "but in some points 
 they cross each other to the number of four, five, six, seven, eight, and even 
 more. At this crossing there is often a round or oval nucleus, having little 
 nucleoli, which is flattened and surrounded by a granular zone. With a good 
 immersion object-glass, magnifying from 600 to 800 diameters, it is easy to per- 
 ceive all these details and to discern in the granular zone a lamina of protoplasm 
 which, with the nucleus, constitutes a little flat cell of the connective tissue. 
 Beneath and above this cell the little fasciculi follow each other. It does not 
 
PATHOLOGICAL HISTOLOGY. 139 
 
 II. 
 
 After these preliminaries, it becomes easy for us, gentlemen, to 
 enter upon the study of the histological alterations of the spinal 
 cord in disseminated sclerosis. The description of these changes, 
 which we are about to give, will be based, principally, on the results 
 of the investigations to which M. Vulpian and myself have long 
 devoted our attention. We shall also have special opportunities 
 of using, after due revision, the researches made, previously or 
 since, on the same subject by Valentiner,^ Rindfleisch,^ Zenker,^ 
 and especially by Frommann,^ who, in reference to the examination 
 of a small fragment of spinal cord, has written a large volume, 
 adorned with remarkable plates, and enriched with valuable docu- 
 ments. 
 
 We shall describe in the first place the appearances which may 
 be discerned: 1st, on transverse sections; and 2d, on longitudinal 
 sections of fragments of the cord hardened by chromic acid. Then 
 we shall describe, from the examination of fresh specimens, certain 
 peculiarities which are not observable in hardened sections. In 
 both cases the coloration of the parts, effected by means of the 
 ammoniacal solution of carmine, will be here, as well as in the case 
 of normal specimens, an auxiliary of great utility of which it is 
 proper to avail ourselves. 
 
 A. When you examine with the naked eye a segment of spinal 
 cord affected by a patch of sclerosis, the morbid part appears 
 divided from the healthy portion, in an abrupt manner, without 
 transition, by a definite line of demarcation. Now this is an illu- 
 sion. Microscopical examination, even when a low power is used, 
 enables us to state that the apparently healthy region bordering 
 the sclerosed patch really presents, to a certain width, very plain 
 traces of alteration. When you pass the apparent limit of the 
 sound parts the lesions become more marked, and they augment 
 gradually in intensity as you approach the centre of the patch, 
 
 seem doubtful to me," M. Ranvier adds, " that this grouping has been taken for 
 a ramified cell ; but that is an error which will be abandoned, I am sure, by all 
 who accurately follow the same method" (which he indicates). On other points 
 of the same preparation may be seen isolated cells, and again (stellate) crossings 
 without cells ; these appearances leave no doubt as to what should be the proper 
 interpretation of the foregoing facts. The reader will be less surprised at the 
 numerous conflicting opinions published as regards the neuroglia, if he will recall 
 the numerous discussions excited by the question of the structure of the connec- 
 tive tissue of the peripheral organs. The real nature of this structure has beea 
 only revealed by recent researches. (Note to the Second Hdition.) 
 
 1 Valentiner, ' Deutsche Klinik,' 1856, p. 149. 
 
 2 Rindfleisch, 'Virchow's Archiv,' 1863, t. xxvi, p. 474. 
 
 3 Zenker, ' Zeitsch. der Ration. Mediz.,' 1865, Bd. xxiii, 3 Reih. p. 226. 
 
 * Frommann, 2 Theil, Jena, 1867 ; see also Rokitansky, ' Sitzungsber.,^ K. M. 
 Klasse, t. xiii, 1851, p. 186; Charcot, ' Soo. de Biologie,' 1868; Bouohard, ' Soo. 
 Auat.,' 1868 ; Hayem, ' Etudes,' etc., loc cit., p. 121. 
 
140 PATHOLOGICAL HISTOLOGY. 
 
 where they acquire their highest degree of development. Whilst 
 proceeding thus, from the circumference to the centre, we are led 
 to recognize the existence of several concentric zones, which answer 
 to the principal phases of the alteration.^ 
 
 a. In the peripheral zone the following appearances are observed: 
 The trabeculse of the reticulum are markedly thickened; some- 
 times they have acquired a diameter twice as great as that possessed 
 in the normal state. At the same time, the nuclei which occupy 
 the nodes of the reticulum have become more voluminous; they 
 are occasionally found to have multiplied, and you may count two, 
 or three nuclei, rarely more, in each node ;^ the cellular form be- 
 comes more distinct, owing to the thickening of the trabeculaj ; 
 the Derve-tubes appear to be further apart each from each — in 
 reality, they have chiefly diminished in volume, and this kind of 
 atrophy goes on at the expense of the medullary sheath, for the 
 axis-cylinder has preserved its normal diameter, or it may even be 
 hypertrophied. The amorphous matter which surrounds the fibres 
 of the reticulum, on all sides, appears to be more abundant than 
 in the healthy state.^ 
 
 h. The nerve-tubes in the second zone^ which may also be called the 
 transition zone, have become still more slender. Many of them seem 
 to have disappeared; in reality, they have been merely deprived 
 of their medullary sheaths, and are now only represented by their 
 axis cylinders, which, indeed, sometimes acquire comparatively 
 colossal dimensions.^ As to the trabecule of the reticulum, these 
 offer not less remarkable alterations. They have become more 
 transparent, their outlines are less distinct; finally, in certain parts, 
 and this is a really fundamental fact, they are replaced by bundles 
 of long and s\QX\dQY fibrils^ closely analogous to those which char- 
 acterize common connective tissue (laminous tissue). These fibrils 
 are disposed in a direction parallel to the greater axis of the nerve- 
 tubes; hence but little of them is seen in transverse sections, except 
 their extremities, which present the appearance of a multitude of 
 very fine dots. They tend, we have said, to usurp the place of the 
 fibres or trabeculse of the reticulum ; but they, also, invade the 
 meshes which contain the nerve-tubes, according as these diminish 
 in size by loss of medullary matter, so that the reticulated or alve- 
 olar appearance which the connective gangue or matrix shows so 
 distinctly in the healthy state, tends to become more and more 
 effaced.^ 
 
 c. The central region .of the sclerosed patch, you are aware is 
 
 » Charcot, ' Soei^te de Biologie,' 1868. 
 
 2 Occasionally some of tliese nuclei present towards their middle region au 
 indentation which seems to indicate the beginning of scission. 
 
 3 Frommann, 2 Theil, PI. ii, fig. 1, and passim. 
 
 * Frommann, Charcot. 
 
 * Frommann 2 Theil, he. cit., P. iv, figs. 1, 2, 3. 
 
PATHOLOGICAL HISTOLOGY. 141 
 
 that in which the most marked alterations are observed. Here 
 all vestioje of fibroid reticulum has disappeared; we no longer 
 meet with distinct trabeculae or cell-forms; the nuclei are less 
 numerous and less voluminous than in the external zones; they 
 are shrunken in every direction, appear shrivelled, and do not 
 take so deep a tint as usual under the action of carmine.^ They 
 may be observed formino^ little groups here and there in the inter- 
 spaces between the bundles of fibrillse. The latter, however, have 
 invaded every part. They now fill up the alveolar spaces, from 
 which the medullary matter has completely disappeared. Never- 
 theless, a certain number of axis cylinders, those last vestiges of 
 the nerve tubes, still persist in the midst of the fibrils; but they, 
 in general, no longer retain that comparatively large volume they 
 occasionally possessed in the early phases of the alteration ; most 
 of them, indeed, have even diminished to such a degree that they 
 might be mistaken, so close is the resemblance, for the fibril fila- 
 ments of new formation, from which, however, we shall soon learn 
 how to discriminate them. 
 
 Such, gentlemen, is the final term of the morbid process, in that 
 form of sclerosis which engages our attention. And this indefinite 
 persistence, as we may call it, of a certain number of axis-cylin- 
 ders in the midst of parts which have undergone the extreme of 
 fibrillary metamorphosis, is, you will be careful to remark, a char- 
 acter which seems proper to disseminated sclerosis. It is certainly 
 not observed, at least to the same extent, in the other varieties of 
 gray induration, whether we have to deal with descending spinal 
 sclerosis, consecutive on lesions of the brain, or with that which, 
 primarily occupying the posterior columns, is justly considered to 
 be the anatomical substratum of progressive locomotor ataxia. 
 
 B. The results of the examination of longitudinal sections con- 
 firm, on the whole, the data which have been laid before you ; I 
 may, therefore, spare you any lengthy details, and confine myself 
 to the following observations which will make you better ac- 
 quainted with some aspects of the neoplastic fibril-formation. la 
 sections of the kind mentioned, the characteristics of this tissue 
 are well seen, and here you can best observe the longitudinal 
 direction of the fibrils, their brilliant appearance which makes 
 them resemble elastic fibres, and their arrangement in slightly un- 
 dulating and ever parallel fascicles. On dilacerating these bun- 
 dles, you will notice that the fibrils of which they are composed 
 are extremely thin, that they are opaque and smooth, that they 
 seldom divide and anastomose, whilst, on the contrary, they are 
 frequently interwoven and entangled, so as to form a kind of 
 felted tissue, and finally that they are scarcely tinted by the 
 action of carmine (fig. 11). The latter characters sufficiently dis- 
 
 1 Frommaiui, Charcot. 
 
142 
 
 PATHOLOGICAL HISTOLOGY. 
 
 tinguish them from the axis-cylinders which, moreover, are gene- 
 rally larger, translucid, and never ramified. They may also be 
 easily discriminated from the fibres of the reticulum, with which 
 they are sometimes mingled, inasmuch as the latter are thicker, 
 shorter, and their borders bristle with branching processes; finally, 
 they differ from the elastic fibres which are so often found in com- 
 mon connective tissue by an important character; they swell up 
 under the influence of acetic acid and form a hyaline transparent 
 mass, which change does not occur in the case of elastic fibres.^ 
 
 Fig. 11 represents a fresh preparation, taken from the centre of a patch of scle- 
 rosis, coloured with carmine, and dilaceiated. In the centre is seen a 
 capillary vessel, supporting several nuclei. To the right and left of this ai*e 
 axis-cylinders, some voluminous, others of very small diameter, and all 
 deprived of their medullary sheaths. The capillary vessel and the axis- 
 cylinders were vividly coloured by the carmine ; the axis-cylinders present 
 perfectly smooth borders, without ramification. Between them are seen 
 slender fibrillse of recent formation, which form on the left and in the centre 
 a sort of network resulting from the entanglement or anastomosis of the 
 fibrils. These are distinguished from the axis-cylinders, 1st, by their diame- 
 ter, which is much smaller ; 2d, by the ramifications which they pre-ent in 
 their course; 3d, by taking no coloration from carmine. Nuclei are seen 
 scattered about; some of them appear to be in connection with the connec- 
 tive fibrils ; others have assumed au irregular form, owing to the action of 
 the ammoniacal solution of carmine. 
 
 Can we proceed further in the study of the fibres, and endeavour 
 to determine their mode of formation? Are they, for instance, as 
 Frommann asserts, partially produced in the very substance of the 
 fibres of the reticulum which they are destined soon to displace, 
 and partially at the expense of the cells and the nuclei of the neu- 
 roglia? Do they arise, on the contrary, as others believe, either 
 
 1 Valentiner, Zenker, loc. cit. ; Vulp'an * Cours de la Faculty,' 18G8. 
 
PATHOLOGICAL HISTOLOGY. 143 
 
 from the preexisting amorphous matter, or from a newly formed 
 blastema? In other words, is there metamorphosis or substitu- 
 tion ? The question, we think, must remain undecided yet awhile ; 
 all that we can say respecting it is that the fibrils have sometimes 
 seemed to take root in the substance of the nuclei or cells, and 
 that this fact, if it were confirmed, might be cited in support of 
 Frommann's thesis. 
 
 I cannot pass over in silence the different alterations which those 
 bloodvessels undergo that traverse the nodules of sclerosis. These 
 changes may be well studied in the longitudinal sections of the 
 cord, hardened by chromic acid. At the commencement, that is 
 to say, in the peripheral zone, the parietes of these vessels, even of 
 the finest capillaries, appear much thickened, and contain a larger 
 number of nuclei than in the normal state. Nearer the centre of 
 the nodule the nuclei are still more abundant, and, besides, the ad- 
 ventitious coat is replaced by several layers of fibrils quite similar 
 to those which are simultaneously developed in the substance of 
 the reticulum.^ Lastly, at the final term of alteration, the walls of 
 the vessels have become so thickened that their calibre suffers a 
 notable diminution.^ 
 
 1 should notice, in passing, the habitual presence of a certain 
 number of amyloid corpuscles in the midst of the fibrillary tissue. 
 But I should at the same time mention the singular fact that these 
 bodies are always less abundant in disseminated sclerosis than in 
 the other varieties of gray induration. 
 
 C. It is not always without difficulty that we succeed in finding, 
 in specimens which have not been prepared with chromic acid, all 
 the details which I have just described. On the other hand, the 
 fresh specimens offer this advantage, namely, they allow us to re- 
 mark certain alterations which would have passed unnoticed if we 
 confined ourselves to hardened preparations only. I allude here 
 to the existence of globules and granulations of an apparently fatty 
 or medullary nature, which we almost constantly^ meet with in 
 more or less considerable numbers in the substance of the sclerosed 
 patches in the fresh state, and which soon disappear without leav- 
 ing any trace when the preparation has been steeped some little 
 time in chromic acid. Now, gentlemen, the presence of these fatty 
 granulations is connected with an important phase of the morbid 
 process, I mean with the destruction of the nerve-tube. However, 
 before entering into a discussion of this subject, I think it useful 
 to begin a little further back and to recall to your memory, by a 
 
 ' Vulpian, ' Cours de la Faculte.' 
 
 2 Fromraarin, Zoc. cit. 
 
 3 This fact is, at least, Tnentioned by all tlie authors who have studied fresh 
 specimens (Valeiitiner, Hindfleisch). It has not been absent from any one of the 
 specimens which I have examined under similar conditions. See also Rokitansky 
 iu * Bericht der Akademie der Wissensch. zu Wien,' t. xxiv, 1857. 
 
144 PATHOLOGICAL HISTOLOGY. 
 
 succinct description, the modifications of structure which the peri- 
 pheral nerves undergo when they are separated, by complete sec- 
 tion, from the nervous centres. 
 
 At the outset I would remind you that, in the peripheral nerves 
 the nerve-tubes are essentially constituted as in the spinal cord by 
 a cylinder of medullary matter and by an axis cylinder, but that 
 they also possess a sheath of connective tissue, the membrane of 
 Schwann, which, according to the most recent researches,^ does not 
 appear to exist in the more slender tubes of the nerve centres, or 
 at least only shows itself there in a rudimentary state.^ You will 
 perceive in a moment that this anatomical peculiarity, though 
 apparently insignificant, is not devoid of interest from the point 
 of view we occupy. 
 
 The following are the phenomena to which I wished particularly 
 to call your attention. Eight or ten days after section of the nerve 
 there supervenes a sort of coagulation of the medullary matter 
 which breaks up into small masses, irregularly globular, with dark 
 sinuous margins, showing a double outline, and having conse- 
 quently preserved all the optical characters of myeline or medul- 
 lary substance. Segmentation making new progress, in the follow- 
 ing days, it will soon be perceived that Schwann's sheath no longer 
 contains irregular masses of myeline, but globules presenting the 
 appearance and the micro-chemical characters of fat. These glo- 
 bules, which are at first rather large, become gradually smaller 
 and smaller as the process of division goes on, and finally they are 
 replaced by very fine granulations, resembling dust, that fill the 
 sheath of connective tissue. Mingled with these is found a certain 
 proportion of paler granulations of a protein nature; and lastly, 
 globules and granulations disappear, and Schwann's sheath, collaps- 
 ing on itself, becomes so plaited and wrinkled that when you ex- 
 amine a certain number of such altered nerve-fibres, placed side by 
 side in the field of the microscope, you would think you beheld a 
 fascicle of filamentous connective tissue. 
 
 What becomes of the axis-cylinder during these changes? 
 Composed as it is principally of proteine matter, it resists for a 
 Jong time the action of the causes which have destroyed the medul- 
 lary substance (or myeline), for it is occasionally still found in 
 the sheath several weeks or even several months after section of 
 the nerve.^ 
 
 To sum up : under the new conditions of nutrition, in which the 
 nerve-tubes are placed by section of the nerve, the medullary mat- 
 ter coagulates, then disintegrates and gives origin, on the one 
 
 > 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 <lisapp.^ared ; re, fatty 
 globules, gathered into small groups, dispersed here and there over the 
 preparation. 
 
 Let us now return to the patches of sclerosis. Here we shall 
 have to study phenomena closely analogous to thosj we have just 
 been discussing. 
 
 In the substance of the sclerosed nodule, in fresh specimens, we 
 almost constantly meet, as already mentioned, with globules or 
 granules presenting the general appearance of fatty bodies. Their 
 number is sometimes considerable. They show themselves under 
 two principal aspects. Some constitute comparatively voluminous 
 masses, whose dark and sinuous edges bound forms which some- 
 times represent irregular oval globules, sometimes are club-like, 
 and occasionally kidney -shaped (Fig. 12). They present a double 
 border like the myeline (or medullary matter), to which they also 
 approximate in yet other respects. Other globules are true fatty 
 droplets or granulations, sometimes free, sometimes aggregated so 
 
 ' According to Robin, the myeline is a substance particularly rich in fatty prin- 
 ciples, and it may, in this respect, be approximated to tiie contents of adipose 
 cells ('Journal d'Anatomie,' 1868, No. 3, p. 309). Walter ('Virchow's Archiv,' 
 20, p. 426) has expressed the opinion that it is constituted by an amalgam or 
 mixture of fatty and albuminoid i)odies, which merely become dissociated in cases 
 of degeneration of the nerve-tubes. See also Rindfleisch, loc. cit., p. 20, § 52. 
 10 
 
146 PATHOLOGICAL HISTOLOGY. 
 
 as to constitute confused heaps or coherent chisters, otherwise 
 called granular bodies^ devoid of nuclei and of enveloping mem- 
 brane.^ Proteine molecules are to be seen mingled here and there 
 with these different granulations. All these products exactly re- 
 semble, you will observe, those which result from the disintegra- 
 tion of the medullary matter (myeline) in cases of nerve-section. 
 
 Let us follow up these analogies. In the longitudinal sections 
 which I place before you, you will notice in certain parts long 
 trails of fatty granulations arranged in a direction parallel to that 
 of the nerve-tubes;^ in the transverse sections they form here and 
 there little heaps, like separate islets, which correspond with tole- 
 rable fidelity to the position of the alveolae. Generally, indeed, the 
 granulations have broken bounds, crossed the borders of the alve- 
 olae, and become scattered over the adjacent tissues. But you 
 cannot be surprised at this, when you remember that the nerve- 
 tubes of the spinal cord are devoid of that cellular coat (Schwann's 
 sheath) which, in divided nerves, incloses and contains all the 
 products of the disintegration of the medulla or myeline. The 
 meshes of the reticulum and the interstices of the fibrillts offer 
 easy ways of escajoe to the globules of myeline, as well as to the 
 fatty granulations, by means of which they may permeate the 
 tissue and spread abroad.^ 
 
 Lastly, we would have you remark that the masses of (appa- 
 rently) medullary matter and the fatty granulations are never met 
 with in the centre of the sclerosed patch, that is, in the region 
 where the work of fibrillary metamorphosis and of destruction of 
 nerve-tubes has terminated; on the contrary they always occupy 
 the external portions of the patch,^ the peripheral and transition 
 zones. Now, as you are aware, the morbid process is here in full 
 activity; here it is that, compressed on all sides and strangulated 
 by the thickening trabeculas of the reticulum and afterwards by 
 the fibrillary fascicles encroaching on the alveolae, the medullary 
 cylinder gradually diminishes in volume and then disappears alto- 
 gether, leaving the nerve-tube at length only represented by the 
 axis-cylinder. The accumulation of medullary or fatty globes and 
 the destruction of the myeline-cylinder consequently take place 
 simultaneously ; we may even add that they proceed abreast, since 
 
 ' Besides these granular bodies proper (^Fettkornchen A (j glomerate) may be found, 
 in sclerosed patches, granular bodies having nuclei, that become coloured by the 
 carmine test, and possess an enveloping membrane (^Fetthornchen Zellei)) ; these 
 are simply cells of the neuroglia undergoing fatty degeneration. See, in refer- 
 ence to the distinction to be drawn between granular bodies, L Pouineau, 'These 
 de Paris,' ISGt! ; Rokitansky, ' Bericht der Akad. der Wiss. zii Wien,' t. xxiv, 
 1857 ; Wedl, * Rndim. of J'atholog. Histolog ,' p. 292, London, 1855. 
 
 2 It is not rare to meet, in the midst of the fibrillje, with axis-cylinders partially 
 denuded, to which globular masses adhere, at intervals, which have the appear- 
 ance of medullary matter. 
 
 3 Charcot, ' Societe de Biologie,' 1868. 
 * 'Ibidem, 
 
PATHOLOGICAL HISTOLOGY. 147 
 
 the former ceases when the latter is concluded. The coexistence 
 of the two phenomena evidently cannot be fortuitous, and, taking 
 note of what precedes, it seems to us legitimate to conclude that 
 the medullary and fatty corpuscles in question are nothing other 
 than the wreck and detritus resulting from the disintegration of 
 the nerve-tubes.^ 
 
 What becomes afterwards of these fatty granulations? They 
 disappear in all probability by absorption; you know that no ves- 
 tiges of them are discoverable in the central regions of the sclerosed 
 patches. This is the place to submit to your notice a phenomenon 
 which undoubtedly is connected with this act of absorption. In 
 the preparations, which I am about to send round for inspection, 
 you will observe that, in those parts where the products of nerve- 
 disintegration are found, the lymphatic sheaths of the smaller ves- 
 sels inclose within their cavities varying proportions of fatty 
 granulations, or even, though more rarely, of corpuscles presenting 
 the characters of myeline. In certain points, thes'e different pro^ 
 ducts are so abundant that the lymphatic sheaths are excessively 
 distended ; the vessels then appear to have swollen to twice and 
 thrice their normal size, and they stand out, like little white tracks 
 visible to the naked eye, on the gray ground of the sclerosed patch. 
 Nevertheless, the coats of these vessels offer no other alterations 
 than those indicated above, which certainly have no relationship 
 with atheromatous degeneration. In short, we have here to deal 
 with a fatty infiltration of the lymphatic sheaths, and not at all 
 with a primary lesion of the vascular parietes. The same phe- 
 nomenon is again met with in cerebral softening from arterial ob- 
 literation; in most of the forms of primary or secondary sclerosis; 
 and, in short, in very different affections of the nervous centres, 
 which, however, have this in common, that they all determine the 
 fatty degeneration of the nerve-tubes. The true characters of this 
 phenomenon appear to have been suspected by Gull,^ and by Bill- 
 roth,3 but it has been principally cleared up by M. Bouchard, in 
 his excellent studies on the secondary degenerations of the spinal 
 cord.* 
 
 The description which has been given you of sclerosic altera- 
 tion, disseminated in patches, relates chiefly to the white substance 
 of the cord; but it may be equally applied, at least in a general 
 way, to the gray matter. In both substances, in fact, the neuroglia 
 is fashioned on the same model, and the alterations effected in it 
 do not essentially differ; consequently, after the remarks already 
 
 1 This opinion has been already very distinctly expressed by Rokitansky in 
 1858. 'Bericht,' etc., loc. cit., 18-37. 
 
 2 "Cases of Paraplegia," 'Guy's Hospital Reports,' Third Series, 1858, t. iv. 
 
 3 'Archiv der Heilknnde,' 3 Jahr., p. 47. 
 
 4 Bouchard, * Archives Generales de Medecine,' Mars et Avril, 1866 ; Theses de 
 Paris, 1867, p. 44. 
 
148 YELLOW CELL-DEGENERATION. 
 
 noted, I shall only make special mention of the modification which 
 the nerve cells experience when, on the gray substance being in- 
 vaded, they become comprised within the area of a sclerosed 
 patch. These cells do not become the seat of nuclear proliferation, 
 contrary to what under similar circumstances occurs in the cells of 
 the connective tissue whose nuclei generally multiply; and this is, 
 in fact, a characteristic which might, if needed, be a help to dis- 
 tinguish one from the other of these two orders of anatomical ele- 
 ments. The nerve-cells undergo a peculiar alteration which may 
 be designated by the term yelloiv degeneration^ on account of the 
 ochreous tint which they assume, and which is occasionally some- 
 what intense; in this state they cease to be coloured by carmine 
 as in the normal state; the nucleus and the nucleolus seem to be 
 formed by a substance having a vitreous and brilliant appearance. 
 It is the same as regards the body of the cell, which, besides, ap- 
 pears as if composed of concentric strata. 
 
 Finally, all parts of the cell are seized by atrophy, which may 
 lead to a comparatively considerable diminution of its bulk, whilst, 
 at the same time, the cell processes dwindle away and disappear.^ 
 
 In the encephalon, and also in the optic and olfactory nerves, 
 the sclerosed patches present essentially the same characters as in 
 the cord; hence we do not think it would be of any advantage to 
 enter into details in relation to them. 
 
 Now that we have reached the conclusion of our study, we may 
 try to array, in their natural order of sequence, the phenomena 
 which go to make up the alteration in question, and thus endea- 
 vour to determine the pathological method by which this morbid 
 change is produced. 
 
 Undoubtedly, the multiplication of nuclei and the concomitant 
 hyperplasia of the reticulated fibres of the neuroglia constitute the 
 initial, fundamental fact, and necessary antecedent ; the degenera- 
 tive atrophy of the nerve elements is consecutive and secondary; 
 it had already begun when the neuroglia gave way to the fibril- 
 lary tissue, though the wasting afterwards proceeded with greater 
 rapidity. The hyperplasia of the vascular parietes plays merely 
 an accessory part. 
 
 In what consists the affection of the neuroglia which marks the 
 beginning of this series of derangements? It is easy to discover 
 there all the characteristics of formative irritation. But, after 
 recognizing the fact that disseminated sclerosis is a primary and 
 multilocular chronic interstitial myelitis or encephalitis, it remains 
 for us to determine the histological characters which distinguish it 
 from other forms of sclerosis of the nerve-centres, and also from 
 several kinds of myelitis or encephalitis which, having their starting- 
 
 • FromiTiann, loc, cit. ; Vulpiai), ' Cours de hi Faeulte,' 18GS ; Charcot, ' Societe 
 de Biologie,' ]8GS. 
 
DISSEMINATED SCLEROSIS. 149 
 
 point likewise in the neuroglia, nevertheless do not issue in fibril- 
 lary metamorphosis. We will endeavour, at an opportune moment, 
 to fulfil this duty. At present, gentlemen, we hasten to leave the 
 department of pathological anatomy for that of clinical observation 
 in order to show you by what array of symptoms disseminated 
 sclerosis of the nervous centres makes its existence knowii.^ 
 
 LECTURE VII. 
 
 DISSEMINATED SCLEROSIS: ITS SYMPTOMATOLOGY. 
 
 Summary. — DiffHrent 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 handwritino: ; characters which distinguish 
 it from the tremor of paralysis agitans, chorea, general paralysis, and the 
 motor incoordination of ataxia. 
 
 Cephalic symptoms. Disorders of vision : diplopia, amblyopia, nystagmus. 
 Impeded utterance. Vertigo. 
 
 State of the inferior extremities. Paresis. Remissions. Absence of dis- 
 orders of sensibility. Commixture of rare symptoms; tabetic phenomena; 
 muscular atrophy. Permanent contracture. Spinal epilepsy. 
 
 In" the preceding lecture we minutely described the anatomical 
 lesions of multilocular sclerosis of the nervous centres. Leaving 
 aside, therefore, this portion of its history we shall proceed, to-day, 
 to point out the series of symptoms by which it makes its existence 
 clinically known. 
 
 I. 
 
 A. It is singular that a morbid state which possesses so distinct 
 and so striking an anatomical substratum, and which, in short, is 
 
 ' In a note published in the 'Archives de Physioiogie' (1873, p. 753), one of 
 Professor Charcot's students, Dr. Debove, has shown cause for the modification 
 of the generally received opinion in reference to the histology of disseminated 
 sclerosis. According to his researches, the sclerosed parts are formed of fibrillge 
 and of Hat cells, quite similar to the cells of common connective tissue. He has 
 succeeded in demonstrating this, througii having employed the method of inter- 
 stitial injections. 
 
 These facts are very different from what was believed witli respect to the struc- 
 ture of the neuroglia (see note, p. 138), before M. Ranvier demonstrated that the 
 connective tissue of the nerve-centres does not essentially differ from that of other 
 organs ; the only striking peculiarity being, according to M. Ranvier, the small 
 diameter of the fibrillary fascicles. — {Note to the Sucond F each Edition.) 
 
150 CEKEBEO-SPINAL FORM. 
 
 not a rare disease, should have escaped clinical analysis for such a 
 length of time. Yet nothing is simpler, as I trust to show you, 
 than to diagnose the affection in question, by the bedside of the 
 patient, at least when it has reached its typical period of perfect 
 development. 
 
 If it be asked what cause so long deferred the recognition of 
 disseminated sclerosis and its admission into nosological charts 
 where it should occupy a place beside other better-known forms of 
 primary sclerosis of the nervous centres, it is proper to point to 
 the diversity of aspects under which it may be encountered in the 
 hospitals. It is, in fact, an eminently polymorphic affection. 
 
 Our anatomo-pathological studies ought to have made you anti- 
 cipate that it would be so. You remember that the patches or 
 islets of sclerosis sometimes occupy the spinal cord exclusively, 
 that in other cases they predominate in the cerebral hemispheres 
 and the medulla oblongata, and that, finally, there are cases in 
 which they are dispersed throughout all the departments of the 
 nervous centres. These varieties of position induced us to recog- 
 nize, from an anatomical point of view, the three following forms: 
 1st, the cephalic form ; 2d, the spinal form; and 3d, the mixed or 
 cerelro- spinal form. It was easy to foresee that each of these forms 
 would be represented by a group of symptoms peculiar to itself. 
 
 B. Let us first, if you please, concentrate our attention on the 
 cerebro-spinal form. It is, in truth, the most interesting in every 
 respect and that which you will have occasion most frequently to 
 observe in practice. Well, even when considered in this type, the 
 disease may assume a variety of masks. Allow me, in support of 
 this assertion, to mention an anecdote which one of my colleagues 
 recently related to me. 
 
 A WQvy distinguished physician, one, however, who was but little 
 familiar with the symptomatology of disseminated sclerosis, had 
 come to visit my friend in the clinical department over which he 
 presides. In order to do him honour, my colleague presented him 
 a case of the new disease, — a very fine specimen of the cerebro- 
 spinal type The patient, leaving his bed, took a short walk down 
 the ward. " This is an ataxic," said the visitor. " Perhaps so," 
 replied my colleague, " but what do you think of the rhythmical 
 movements by which the hand and upper extremities are shaken?" 
 "True," said the visitor, "he is also affected with chorea, or per- 
 haps with paralysis agitans." The patient was then questioned. 
 He replied, but, in replying, showed a marked difficulty of enuncia- 
 tion ; he scanned the syllables in a very peculiar manner ; and the 
 utterance of a word was often preceded by a slight trembling of 
 the lips. " I understand," said the physician, "you wished to puzzle 
 me by presenting a most complicated case. Here are symptoms 
 which belong to general paralysis. Pray don't proceed any further ; 
 
ERRORS IN DIAGNOSIS. 151 
 
 your patifent probably is a living conpendium of all nervous patho- 
 logy." 
 
 Now, gentlemen, I repeat it, this was simply a case, though a 
 very complete one, of the cerebro-spinal form of disseminated scle- 
 rosis. 
 
 0. Paralysis agitans is especially the disease with which this 
 form of sclerosis has been the most persistently confounded, and for 
 which it is, undoubtedly, still the most frequently mistaken. It was 
 because of this confusion that, at the time we laboured to draw 
 forth disseminated sclerosis from the chaos of chronic myelitic affec- 
 tions, we urged M. Ordenstein, then one of our students, to tabulate 
 in parallel columns the opposite characters that divide this disease 
 from paralysis agitans, for the better understanding of the contrast.^ 
 How M. Ordenstein acquitted himself of this duty is known to you, 
 and I do not hesitate to declare that his dissertation marks a serious 
 progress in the clinical history of chronic diseases of the nervous 
 system. 
 
 In recent days, TIerr Baerwinkel, a distinguished physician of 
 Leipzig, after having related a very interesting example of cerebro- 
 spinal sclerosis, which, however, presented no tremor (as some- 
 times happens), seems to insinuate that M. Ordenstein was pleased 
 to create difficulties which had no real existence, in order to give 
 himself the facile satisfaction of surmounting them. According 
 to him, there is no analogy whatever between the two diseases. 
 Dr. Baerwinkel must, doubtless, have forgotten that in ' Canstatt's 
 Jahresbericht' he gave, some ten years ago, the analysis of a case 
 observed under Skoda's care, — in that case, paralysis agitans had 
 been diagnosed during life, whilst, on postmortem examination, 
 patches of disseminated sclerosis were founil in all parts of the 
 cerebro-spinal axis. The case appears to have been noted with the 
 greatest fidelity. It is stated, and this point deserves remark, that 
 the tremor, contrary to what occurs in ordinary cases of paralysis 
 agitans, only showed itself when voluntary movements were made, 
 and subsided when the patient was at rest.^ 
 
 Nor can Herr Baerwinkel have overlooked the case recorded by 
 Herr Zenker in Henle's Journal. Here again the existence of 
 multilocular sclerosis was only revealed by the post-mertern ex- 
 amination.^ During life, Professor Hasse had made a diagnosis of 
 paralysis agitans, and yet, in the syrnptomatological description, 
 there is stress laid on the nature of the tremor, which only showed 
 itself under the influence of emotion or on the occasion of volun- 
 tary movements. 
 
 These examples suffice, I presume, to show you that, in spite of 
 
 ' " Sar la Paralysie Agitaute et la Sclerose en Plaques Generalisee," Paris, 
 1867. 
 
 2 'Vein. Med. Halle,' 13, 1862. 
 
 ^ Zenker, ' Zeitschrift fiir Medizin,' Baud iii, Reihe, 1865, p. 228. 
 
152 EKRORS IN DIAGNOSIS. 
 
 the opinion of Herr Baerwinkel, it is possible to confound the two 
 diseases, since such confasion has been committed by clinical ob- 
 servers whose skill is above all question. 
 
 That being established, I am ready to concede that the different 
 disguises assumed by disseminate(i sclerosis are coarse masks, and 
 that to-day, when recent works^ have illuminated the field of 
 diagnosis, it is scarcely permissible to be caught in the snare. 
 But it is time, gentlemen, to place you in a position to distinguish 
 the characters by means of which cerebro-spinal disseminated 
 sclerosis may be separated from those diseases which more or less 
 closely resemble it. 
 
 II. 
 
 You are not unaware, gentlemen, of what value you must set on 
 clinical descriptions, eloquently detailed at a distance from the bed- 
 side of the patient. They seldom succeed, whatever the effort, in 
 doing more than giving origin to indistinct images which generally 
 leave but a vague and transient impression on the mind of the 
 auditor. 
 
 In order to avoid, as much as possible, falling into the fiiult I 
 have just mentioned, I will proceed in your presence to the me- 
 thodical examination of a patient who presents all the symptoms 
 of the cerebrospinal form of disseminated sclerosis, in the period 
 of perfect development. 
 
 Mademoiselle V — , aged 31, has been suffering for about eight 
 years under the affection which forms the object of the present 
 study. Admitted to La Salpetriere three years ago, she was be- 
 queathed to me by M. Vulpian when he left this hospital, and he, 
 at the same time, gave me, in reference to her case, a detailed and 
 most valuable note. The invasion of the disease dates, we have 
 said, from eight years ago; it is, therefore, a case of old standimi. 
 I will tell yoii afterwards of the different changes which charac- 
 terized the early phases of the evolution of symptoms. For the 
 moment I wish to confine myself to an analysis of her actual con- 
 dition. 
 
 One symptom which, doubtless, struck you all from the first on 
 seeing the patient enter, assisted by a nurse, was certainly the very 
 special rhythmical tremor by which her head and limbs were vio- 
 lently agitated whilst she was walking. 
 
 You have likewise noticed that when the patient sat upon a 
 chair, the tremor disappeared at once and completely from her 
 upper and lower limbs, but only partially from the head and 
 trunk. I lay stress on this latter point, whilst calling your atter»- 
 tion to the lact that the new attitude, assumed by the patient, is 
 
 • Bournevillo et L. Guerard, " De la Scleios« en Plaqiaes Disseminees," Paris, 
 18(»9; Boniiieville, "Nonvelle Etude siir quelques Points de la Sclerose en Plaques 
 Diss6ininees," Paris, 1869. 
 
OF THE TREMOR. 153 
 
 far from being one of absolute rest as regards the muscles of the 
 body and neck. Besides, we must make allowance for the exist- 
 ence of emotion which undeniably plays a certain part here. I 
 shall have occasion to show you Mademoiselle V — when reclining 
 in bed, and in complete repose ; you will then be able to assure 
 yourself of the utter absence of all trace of tremor in the different 
 parts of her body. To cause the rhythmical agitation again to 
 appear throughout the body, it will suffice to make the patient 
 rise from her seat. To bring it back merely in a partial manner, 
 in one of the upper extremities for instance, I will request her to 
 lift a glass full of water, or a spoon, to her mouth. You can see 
 that, in the several acts prescribed by the will, the tremor increases 
 in direct ratio with the extent of the movement executed. Thus, 
 when the patient wishes to lift a glass full of water to her lips, the 
 rhythmical agitation of the hand and forearm is scarcely notice- 
 able when taking hold of the object ; but it becomes more and 
 more exaggerated as the glass is brought nearer to the eyes; and 
 at length proceeds to such an extent that, at the moment when 
 the goal is being attained, the glass is, as you observe, dashed with 
 violence against the teeth, and the water is flung out to a distance. 
 This great disorder is not shown,! repeat, save in the performance 
 of movements of a certain amplitude. As regards petty opera- 
 tions, such as sewing or ravelling linen, the oscillations, on the 
 contrary, are almost null. Some time ago, the patient could still 
 write distinctly enough ; the letters, indeed, were tremulous, but 
 perfectly readable.^ 
 
 I We give below two specimens of the handwriting of a patient named Lernth, 
 who succumbed to disseminated sclerosis in M. Charcot's wards. This woman 
 was admitted to La Salpetriere September 24, 1864. In May, 1865, M. Charcot 
 obtained this fragment of the writing (fig. 13). 
 
 Fig. 13. 
 
 From the month of Juno, Lernth was placed under the nitrate of silver treat- 
 ment (tvvo milligrammes, then four, being administered). Under the influence 
 of this medicine the tremor diminished in a notable manner, as may be judged 
 from an examination of the following specimen of her writing (fig. 14). 
 
 Remark, also, that in May, 1865, the patient was greatly fatigued after writing 
 the three lines, of which a fac-simile is given above; whilst in October she was 
 
/ 
 
 15i OF THE TKEMOR. 
 
 To sum lip, the tremor in question only manifests itself on the 
 occasion of intentional movements of some extent; it ceases to exist luhen 
 the muscles are abandoned to complete repose. Such, gentlemen, is the 
 phenomenon which I have been led to regard as one of the most 
 important clinical characters of cerebro-spinal disseminated sclero- 
 sis. I do not, indeed, pretend to pat this forward as a pathogno- 
 monic symptom; I am not unaware that a tremor showing itself, 
 with somewhat similar characters, is occasionally observed in 
 affections other than disseminated sclerosis, as, for instance, in 
 mercurial poisoning, in chronic cervical meningitis with sclerosis 
 of the cortical layer of the cord, in primary or consecutive sclerosis 
 of the lateral columns, etc. It is not, as we shall see, a constant 
 symptom. But what I wish at present to place prominently before 
 you is the fact that, in disseminated sclerosis, when no other com- 
 plication supervenes, the tremor, if it exist at all, presents itself 
 always with the characters which I have assigned to it. In some 
 this is a symptom which, by itself alone, would suffice to distin- 
 guish multilocular sclerosis of the nervous centres from some affec- 
 tions which so nearly resemble it as to render confusion possible. 
 In reference to this subject I shall enter into some details. 
 
 The tremor of paralysis agitans exists as well when the members 
 are in a state of repose as when they are set in motion by the will. 
 I present a patient in whom the tremor has persisted for long 
 years, without cessation or truce, during the patient's waking 
 
 able to write a dozen lines with ease. We have selected, for the second specimen, 
 the first and last lines of what she wrote. 
 
 Fig. 14. 
 
 £ /^ (^cyi^-/^^. 
 
 .Judging from the specimens in our possession, it is difficult to form an opinion 
 on the characteristics of the handvvriting of patients affected with disseminated 
 sclerosis. Generally, indeed, we have examined the patients at an advanced 
 stage of this disease ; then it is almost impossible to obtain anything beyond a 
 scribble without significance, the more so because we have no term of com- 
 parison. — (B.) 
 
MOTOR INCOORDIXATION". lo5 
 
 hours. It never stops save when this unfortunate woman is 
 plunged in profound sleep. There are cases of shaking palsy 
 where the tremor only shows itself intermittently, but, singularly 
 enough, it is just in such cases that the tremor shows itself rather 
 when the limbs are at rest, and ceases when they are set in motion 
 by the will. You can perceive in another patient, whom I submit 
 to your observation, this peculiar characteristic of paralysis agi- 
 tans. Remark, also, in both these women, that the head takes no 
 share in the trembling; or, if it seem shaken by the oscillations, 
 these are plainly communicated to it by the agitation of other 
 parts of the body, — there is transmission of shocks from the affected 
 members and trunk. The absence of tremor of the head seems to 
 me an almost constant fact in shaking palsy. I will add that in 
 this affection the jerks are of much less extent, more regular, rapid, 
 and serried, if I may so speak, than in multilocular sclerosis. In 
 the latter, the oscillations are larger, and resemble, in many re- 
 spects, the gesticulations of chorea ; this analogy is so close that 
 before the publication of the works which have caused it to be ad- 
 mitted into clinical lists, disseminated sclerosis has been sometimes 
 designated under the names of rhythmic chorea and choreiform 
 paralysis. 
 
 It is, however, always easy to distinguish the odd and disorderly 
 movements of chore.a^ properly so called, from the rhythmical os- 
 cillations of multilociilar sclerosis. Note, firstly, that in the latter 
 case, if the action of the upper extremity when lifting an object to 
 the lips be considered, the main direction of the motion persists in 
 spite of the obstacles caused by the jerks of the tremor, which, as we 
 have just said, augment as the hand approaches its goal. In chorea, 
 on the contrary, the main direction of motion ivould be disturbed from 
 the outside by contradictory movements, quite disproportionate in 
 magnitude, which cause the goal to be missed. Add to this that the 
 movements of chorea show themselves suddenly and unexpectedly, 
 when the limbs are in a state of perfect rest; thus, apart from any 
 act of the will, the choreic patient is seen to thrust out his tongue, 
 make a grimace, or abruptly raise a limb, etc. Now, such things 
 are altogether unknown in multilocular sclerosis. 
 
 When, in progressive locomotor ataxia (sclerosis of the posterior 
 columns), the upper extremities are affected, we find, as regards 
 purposed acts, incoordinated movements which, to some extent, 
 recall the gesticulation of chorea, and the jerks of multilocular 
 sclerosis. The danger of confounding them may be avoided by 
 attending to the following characters. It is to be observed, at the 
 outset, that in the incoordination of the ataxic patients we do not, 
 properly speaking, find any tremor or rhythmical jerks, but rather 
 gesticulations of different degrees of disorder, abruptness, and ex- 
 tent. Examine studiously, in the case of the patient whom I place 
 before you, the movements of the hand when in the act of taking 
 
t 
 156 FREQUENCY OF TREMOR. 
 
 hold of a small object, and you will find truly characteristic pecu- 
 liarities. You see how, at the moment of grasping, the fingers 
 separate excessively, and are extravagantly extended, bending to- 
 wards the back of the hand. Then the object is seized suddenly, 
 with a dash, in an almost convulsive manner by the abrupt and 
 disproportionate flexion of all the fingers. This is a symptom of 
 ataxia; you will never observe anything of the kind in dissemi- 
 nated sclerosis. Lastly, I would add — and this final trait is truly 
 decisive — that, in ataxia, the closing of the eyes has always the 
 effect of exaggerating in a very marked manner the incoordination 
 of the movements, whilst it does not at all modify the rhythmical 
 jerks of multilocular sclerosis. 
 
 We should not, however, forget that some of the symptoms of 
 ataxia are found occasionally mixed up with those of disseminated 
 sclerosis, when the sclerosed islets in certain regions of the cord 
 spread over a certain height of the posterior columns. A case, the 
 history of which may be found recorded at length in Cruveilhier's 
 'Atlas d'Anatomie Pathologique,' may be cited as an example of 
 this class.* It is the case of the patient Paget. In order to grasp 
 and use a pin she required to have her eyes open, otherwise the 
 pin dropped from her fingers. On a post-mortem examination, it 
 was found that one of the sclerosed patches occupied a considerable 
 extent of the posterior columns in the cervical enlargement of the 
 cord. But I shall not now dwell at any greater length upon this 
 point, to which we shall have several opportunities of again refer- 
 ring 
 
 We have hitherto, almost exclusively, studied the question of 
 tremor in its connection with the upper limbs; but we also know 
 that it may affect the head, the body, and the lower extremities. 
 It presents itself, in these different parts, with all the characters 
 that we have described in reference to the upper limbs, that is to 
 say, it is absent in repose, and shows itself on the occasion of pur- 
 posed movements, or in case of attitudes which cannot be main- 
 tained except by the active and more or less energetic tension of 
 certain muscles or sets of muscles. 
 
 In order to complete the characteristics of this symptom, we 
 must enter into a few details. Tremor, gentlemen, as I long ago 
 declared, is an almost constant symptom in the cerebro-spinal form 
 of disseminated sclerosis. It must not be forgotten, however, that 
 exceptional cases exist, in which — though the fact is as yet inex- 
 plicable — no tremor presents itself amongst the symptomatological 
 group. I have myself observed several cases of this kind. But 
 you should note, gentlemen, that tremor may have existed, to a 
 greater or less extent, at a certain anterior epoch of the disease, 
 and may have disappeared at the time when the patient offers him- 
 
 * Cruveilhier, 'Atlas d'Anatomie Pathologique,' livraisou 38, pp. i et ii. 
 
CEPHALIC SYMPTOMS. 157 
 
 self for examination. It is, therefore, necessary, on this account, 
 to question with the greatest care those patients in whom this 
 symptom is apparently absent. 
 
 It is the rule that the tremor disappears when the members are 
 immobilized by permanent contracture, at a more or less advanced 
 period of the disease. Though the tremor sometimes shows itself 
 almost from the very beginning, yet it must be acknowledged that, 
 it is usually a late symptom. In conclusion, gentlemen, it is very 
 frequent and almost customary that the tremor shall not last as 
 long as the disease; it grows less marked as the patients decline 
 in strength, and it sometimes completely vanishes before the fatal 
 end arrives. 
 
 III. 
 
 You are now acquainted, gentlemen, with one of the most original 
 and most important symptoms of sclerosis in generalized patches. 
 A deeper and more circumstantial study of the case which we have 
 before us will enable us to collect many other indicia which are not 
 less valuable. We shall discover in our patient a whole group of 
 symptoms, which I propose to call cephalic^ as opposed to spiyial 
 symptoms. This group comprises certain disorders of vision, of 
 speech, and of intellect. 
 
 A. Let us first apply ourselves to the question of visual dis- 
 orders. These are diplopia, amblyopia, and especially nystagmus. 
 
 a. Diplopia^ as happens also in locomotor ataxia, is an initial 
 symptom, usually quite transient, but yet deserving of passing 
 notice. 
 
 h. Amhlyopia^ on the other hand, is a persistent, and indeed a 
 more frequent symptom of cerebro-spinal disseminated sclerosis. 
 I believe I may affirm that, contrary to what takes place in posterior 
 sclerosis, it very rarely issues in complete blindness.^ This is a 
 peculiarity worthy of notice, especially if you remember that 
 patches of sclerosis have been found, after death, occupying the 
 whole thickness of the nerve-trunk, in the optic nerves, in cases 
 where, during life, an enfeeblement of sight simply had been 
 noted.^ This apparent disproportion between the symptom and 
 the lesion constitutes one of the most powerful arguments which 
 can be invoked to show that the functional continuity of the nerve- 
 tubes is not absolutely interrupted, although these, in their course 
 through the sclerosed patches, have been despoiled of their medul- 
 lary sheaths and reduced to axis-cylinders. 
 
 • In a case reported by M. Magnan ('Archives de Physiologie,' t. ii, p. 765) there 
 was papillary atrophy of botli eyes, with complete blindness. 
 
 2 Case of the patient, Aspasie Byr, conimanicated by M. Vulpian. This obser- 
 vation is recorded, in extenso, in a work by M. H. Liouville, entitled "Observa- 
 tions detaillees de deux cas de sclerose en ilots multiples et dissemines du cer- 
 veau et de la moelle epiniere" (' Memoires de la Societe de Biologie,' 18G8, p. 231). 
 
158 CEPHALIC SYMPTOMS. 
 
 On examining the eyes with the ophthalmoscope, an operation 
 which is generally rendered difficult by the existence of nystagmus, 
 we usually find, under such circumstances, either almost complete 
 integrity of the papilla of the optic nerve, even when amblyopia 
 is far advanced, or a partial lesion ; or, finally, in the rare cases 
 where blindness is complete,' total atrophy (marked by a pearly 
 white coloration, and extreme tenuity of the vessels) with or with- 
 out excavation of the papilla. 
 
 In the case of Mademoiselle Y — we have simply a rather marked 
 amblyopia of both eyes. No well-determined lesion has been dis- 
 covered on ophthalmoscopic examination. It is worthy of notice 
 that, in this case, flashes of light and sparks preceded the enfeeble- 
 raent of sight. I have observed the same phenomena in several 
 other cases of amblyopia connected with multilocular sclerosis. 
 
 c. Nystagmus is a symptom of sufficiently great importance in 
 diagnosis, since it is to be met with in about half the number of 
 cases. It is not found, so far as I know, in locomotor ataxia, save 
 in very exceptional cases. You may observe that it exists, to a 
 very advanced extent, in Mademoiselle Y — . We have there, as 
 you see, a quantity of little jerks or twitches, which cause the eye- 
 balls to oscillate simultaneously from right to left, then from left 
 to right, or inversely. There are cases in which the nystagmus is 
 not present so long as the gaze is fixed on nothing, but shows itself 
 suddenly, in a more or less manifest manner, as soon as the patients 
 are asked to look attentively at any object. 
 
 B. There is a symptom more frequently found than nystagmus, 
 one which is almost constant in multilocular cerebro-spinal sclerosis, 
 since it is noted in twenty two out of the twenty-three cases that 
 we have analyzed, and this is a peculiar difficulty of enunciation 
 which you can study in our patient, where it exists in a typical 
 state of perfect development. 
 
 The affected person speaks in a slow, drawling manner, and 
 sometimes almost unintelligibly. It seems as if the tongue had 
 become "too thick," and the delivery recalls that of an individual 
 suffering from incipient intoxication. A closer examination shows 
 that the words are as if measured or scanned: there is a pause 
 after every syllable, and the syllables themselves are pronounced 
 slowly. The patient hesitates in the articulation of his words, but 
 there is, properly speaking, nothing like stammering. Certain 
 consonants, Z, p, and ^, are peculiarly ill-pronounced. 
 
 There exists in the case of Mademoiselle Y — , as you may ob- 
 serve, a certain slowness in the movements of the tongue , you see 
 that it is even affected by very manifest tremulation when pro- 
 truded. It must not be supposed, however, that this is a constant 
 phenomenon, for I have several times found that speech might be 
 
 1 Case quoted by M. Maguan. 
 
VERTIGO. 159 
 
 impeded to a very great extent without the tongue presenting the 
 least trace of tremor. The tongue always, at least according to 
 my experience, preserves its normal volume, and I have never 
 seen it wrinkled on the surface, as may be noticed in certain cases 
 of labio glosso-laryngeal paralysis with atrophy of the lingual 
 muscles. 
 
 The difficulty of enunciation, at first scarcely perceptible, becomes 
 gradually aggravated during the course of the disease, until the 
 patient's discourse is rendered nearly incomprehensible. In some 
 instances it becomes suddenly aggravated, as if in paroxysms, and 
 then grows temporarily better. 
 
 On the whole, the difficulty of speech which is observed in cere- 
 bro-spinal sclerosis approximates, in many respects, to the corre- 
 sponding symptom of progressive general paralysis. I even think 
 that, in many cases, it would be almost impossible to distinguish 
 between them, if abstraction were made of the assistance given by 
 concomitant phenomena. Add that the approximation may be 
 rendered still closer by the circumstance that, in multilocular scle- 
 rosis, as in general paralysis, the utterance of words is sometimes 
 preceded, as you can verify in our patient, by a slight and, as it 
 were, a convulsive contraction of the lips. 
 
 However it be, this trouble in the articulation, to which I call 
 your attention, is a very important symptom of multilocular scle- 
 rosis. It may potently contribute to settle the diagnosis, princi- 
 pally in those cases, which are indeed exceptional, where tremor 
 of the hand and upper extremities is absent. 
 
 To this symptom may successively be added, especially in ad- 
 vanced stages of the disease, certain disorders of deglutition, of 
 circulation, and even of respiration. These are symptoms of pro- 
 gressive bulbar paralysis^ which ought to give the alarm, because, 
 becoming rapidly aggravated, they have sometimes suddenly and 
 almost unexpectedly determined the fatal termination. On account 
 of the interest attaching to them in prognosis, they shall form the 
 object of a special study. 
 
 C. Vertigo, in about three-fourths of the cases, is one of the 
 phenomena which mark the invasion of multilocular sclerosis of 
 the nervous centres. As far as I can judge from the descriptions 
 given me by the patient whom I have questioned, the vertigo is 
 generally of the gyratory kind. All objects seem to be whirling 
 round with great rapidity, and the individual himself feels as if 
 revolving on his axis. Threatened with loss of equilibrium, the 
 patient lays hold of whatever is mgh him. In most cases, this 
 giddiness returns in fits of short duration ; sometimes, however, it 
 persists almost without interruption for a certain period, super- 
 added to the tremor and paralytic state of the members; it often 
 contributes considerably to render it almost impossible for the 
 patient to stand erect or continue his titubating walk. You must 
 
160 PSYCHIC SYMPTOMS. 
 
 take care not to confound this titubation with the uncertainty of 
 gait which is connected with diplopia; the latter ceases when the 
 patient keeps one of his eyes closed. 
 
 The vertiizo in question is all the more interesting because it 
 belongs neither to locomotor ataxia, nor to paralysis agitans, and 
 may consequently help in forming a diagnosis. 
 
 D. Most of the patients affected by multilocular sclerosis, whom 
 I have had occasion to observe, have presented at a certain stage 
 of the disease a truly peculiar /acies. The look is vague and un- 
 certain ; the lips are hanging and half-open; the features have a 
 stolid expression, sometimes even an appearance of stupor. This 
 dominant expression of the physiognomy is almost always accom- 
 panied by a corresponding mental state, which deserves notice. 
 There is marked enfeeblement of the memory; conceptions are 
 formed slowly ; the intellectual and emotional faculties are blunted 
 in their totality. The dominant feeling in the patients appears to 
 be a sort of almost stupid indifference in reference to all things. 
 It is not rare to see them give way to foolish laughter for no 
 cause,^ and sometimes, on the contrary, melt into tears without rea- 
 son. Nor is it rare, amid the state of mental depression, to find 
 psychic disorders arise which assume one or other of the classic 
 forms of mental alienation. 
 
 One of the patients of Valentiner, usually subject to melancholia, 
 was, from time to time, seized with ambitious mania. A man, 
 whose case has been recently recorded by Dr. Leube^ looked upon 
 himself as destined to become a king, nay, an emperor; he boasted 
 that he possessed a large number of oxen, horses, and beautiful 
 mansions. He was soon, he said, about to form a matrimonial 
 alliance with "a countess," etc.^ 
 
 Mademoiselle V — was seized, a few weeks ago, with a genuine 
 fit of lypemania. She had hallucinations of sight and hearing. 
 She beheld frightful apparitions, and heard voices threatening her 
 with the guillotine. She was convinced that we wanted to poison 
 
 ' A patient, under M. Charcot's care, of whom we shall have occasion to speak 
 ajrain, Horten>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 th<i lumbar region. At this level the posterior columns are 
 completely invaded (fig. 15, c), but especially afiected in the mid-region. The 
 lateral columns are comparatively less injured. 
 
 Fig. 15. — Representation of the lesions observed on a section taken from the 
 uppermost portion of the lumbar region. The posterior columns are invaded 
 throughout their breadth, and the lesion predominates in their middle 
 region. 
 
 11. Bez— (Pauline), aged thirty-five, child's nurse, admitted Feb. 17th into M. 
 Charcot's wards. To the ordinary symptoms of disseminated sclerosis were added, 
 about the month of May, dyspnoea and dysphagia. The difiiculty of deglutition 
 compelled the patient to eat very slowly. Return of food, through the nasal ori- 
 fices, was not observed until near the end. The patient died of asphyxia, June 
 12th, without any rS-les having been noticed in the lungs. 
 
 Autopsy. — Sclerosed patch on thechiasma of the optic nerves, invading the trac- 
 tus opticus. Sclerosed patch in the ventricles and in the centrum ovale. In a 
 section made a centimetre above the inferior border of the protuberantia annu- 
 laris, on a level with the apparent origin of the trifacial nerve, a large and irreg- 
 ular patch of sclerosis is found (fig. 16, b' b'). 
 
 12 
 
178 
 
 DURATION. 
 
 vation, precipitate the course of events, and induce the fatal termi- 
 nation, even before the manifestation of the phenomena of the final 
 period. Contemporaneously with increased difficulty of utterance, 
 there appears a difficulty of deglutition which, though transient at 
 first, soon becomes permanent. Then, from time to time, paroxysms 
 of dyspnoea show themselves, of less or more gravity, and death may 
 supervene during one of these fits. I have recently observed two 
 cases which terminated in this manner. On a post-mortem exami- 
 nation it was seen, in both these cases, that a patch of sclerosis had in- 
 vaded the floor of the fourth ventricle, where it enveloped the origi- 
 nating nuclei of most of the bulbar nerves. (See foot-note 3, p. 176.) 
 After the details which I have laid before you, it seems useless 
 to undertake the particular description of the different/orms which 
 multilocular sclerosis may assume. The cerebral and sjnnal forms 
 correspond to an incomplete invasion of the nervous centres by the 
 sclerosis; it is if you like, the disease arrested in its development, 
 in its progress either of ascent or of descent. The symptomatic 
 series is, therefore, as it were, curtailed; but the symptoms, con- 
 sidered singly, are not modified. The first, or cerebral, form is very 
 rare; the second, or spinal, is, on the contrary, very frequent; but 
 
 Another transverse section, corresponding to the middle part of the corpora 
 olivaria, reveals another patch of sclerosis (fig. 17 c) apparently involving the 
 pneumogastric (fig. 17 a). Microscopic examination of the nerves showed the 
 
 Fig. 16. — a, Pneumogastric ; b, small sclerosed patch ; y, large sclerosed patch. 
 
 existence of numerous fatty degenerated tubes in the hypoglossal nerve, and 
 traces of irritation in Schwann's sheath in the pneumogastric nerve. As to the 
 other organs, and particularly the pharynx, the larynx, and the lungs, they were 
 all healthy. 
 
 Fig. 17. — a, Pneumogastric nerve ; /', hypoglossal nerve ; c, sclerosed patch. 
 
PATHOLOGICAL PHYSIOLOGY. ltd 
 
 on the whole the cerehro- spinal form constitutes the normal type, 
 that which we most often meet with in practice. 
 
 Cerebro-spinal multilocular sclerosis completes, generally speak- 
 ing, its whole evolution in the space of from six to eight years ;^ 
 this establishes another contrast between it and paralysis agitans, 
 the normal duration of which is much longer. The spinal form 
 usually gives the most lengthy respite; it may not terminate its 
 course for a space of twenty years, or even longer still.^ 
 
 Pathological Physiology ; Etiology ; Progno,sis, and 
 Treatment. 
 
 In order to conclude this study, gentlemen, it remains for me to 
 discuss the pathological physiology, the etiology, and finally the 
 therapeutical treatment of multilocular sclerosis of the nervous 
 centres. Unfortunately, the facts and documents which refer to 
 these different subjects are few in number, and as yet mostly im- 
 perfect, so that I shall be compelled to confine myself to a few sum- 
 mary observations. 
 
 A. The cause of the very singular mode of arrangement under 
 which the sclerosed islets are distributed in different parts of the 
 central nervous system, is, at present, completely unknown to us. 
 Herr Rindfleisch^ has stated that the starting-point for the formation 
 of sclerosed foci resides in the vascular system. According to him, 
 the inflammation of the walls of the smaller vessels, always to be met 
 with in the centre of foci during the process of formation, would be 
 the initial fact ; from this central point the irritation is propagated 
 to the reticulum of the neurosrlia, whence it radiates in all direc- 
 tions. It is evident, however, that this explanation only sets the 
 difficulty a little farther back. Besides, this predominant part ac- 
 corded to vessels in the evolution of the morbid process is anything 
 but demonstrated. I am even very much disposed to believe, 
 judging from my own observations, that the alterations of vascular 
 tissue and those of the reticulum advance side by side in parallel 
 lines, without acting reciprocally on each other. Be this as it may, 
 
 • It is rather difficult, at present, to ascertain the mean duration of disseminated 
 sclerosis. In a first collection (BournevilJe et Guerard, loc. cit., p. 148), com- 
 prising-seventeeu cases, we found a mean of from eight to ten years. In another, 
 including thirteen new cases, we found a mean of seven and a half years. The 
 minimum of the duration of the disease was one year (case of M. Malherbe, in 
 ' Journal de Medecine de I'Ouest,' 1870, p. 168, and Buschwald, " Ueber Multiple 
 Sklerose des Hirns und Ruckenmarks," in 'Deutsches Archiv fiir Klin. Medicin,' 
 c. X, fas. iv und v, p. 478, 1872). The maximum is from sixteen to seventeen 
 years. (B.) 
 
 2 In three cases of disseminated sclerosis, with predominance of lesions of the 
 posterior columns, the disease lasted fourteen, twenty-one, and twenty-eight years. 
 (Bourneville, ' Nouvelle etude sur quelques points de la sclerose en plaques dis- 
 seraiuees,' 1869.) 
 
 3 Rindfieisch, " Histol. Detail zu der Grauen Degeneration von Gehirn und Ruck- 
 enmarks" (' Virchow's Archiv,' 1863, t. xxvi, p. 474). 
 
180 PATHOLOGICAL PHYSIOLOGY. 
 
 the question arises whether, if the position of the sclerosed islets, 
 in the different portions of the nervous system, be given, we can 
 deduce therefrom the production of phenomena which, in their 
 totality, constitute the symptomatology of disseminated sclerosis? 
 This is, at least to some extent, possible. We have already shown 
 you that the motor inco-ordination, the loss of sense of position 
 and the fulgurant pains which are found in a certain number of 
 cases, may, in such cases, be attributed to the sclerous invasion of 
 the posterior columns of the cord for a certain altitude. On the 
 other hand, the customary predominance of sclerosed patches along 
 the course of the antero lateral columns accounts, as I shall soon 
 demonstrate to you, for the almost constant existence of the paresis 
 or of the paralysis of the limbs, which is sooner or later followed 
 by permanent contracture. The nystagmus and the difficulty of 
 enunciation are correlated with the habitual localization of nodules 
 in the substance of the protuberantia annularis and the bulbus 
 rachidicus. But there are a large number of other symptoms, the 
 interpretation of which presents much greater difficulty. Such, for 
 instance, is the peculiar tremor which is manifested during certain 
 attitudes of the body, and in the execution of intentional move- 
 ments. I have expressed the opinion that the long persistence of 
 the axis-cylinders, deprived of medullary sheathing, in the midst 
 of the foci of sclerosis, probably plays an important part here. The 
 transmission of voluntary impulses would still proceed by means 
 of the denuded axis cylinders, but it would be carried on irregu- 
 larly, in a broken or jerky manner, and would thus produce the 
 oscillations which disturb the due execution of voluntary move- 
 ments. 
 
 This resistance of the axis-cylinders is certainly not a phenomenon 
 exclusively pertaining to mujtilocular induration ; but it is here 
 manifested in a more marked manner than in other forms of sclerosis 
 of the nervous centres. It may also be quoted, I think, to account 
 for the slowness with which the paretic symptoms advance in dis- 
 seminated sclerosis, and for the long space of time which elapses 
 before they give place to complete paralysis and permanent con- 
 tracture. 
 
 B. What is known in reference to the conditions that preside over 
 the development of disseminated sclerosis comes to very little. It 
 seems, however, to be established at present, that the disease is far 
 more common in females than in males. Thus, of all the instances 
 which I collected in my first treatise, only three or four related 
 to men. The cases which have since been published have not 
 modified this result in any perceptible manner. Adding to the 
 eighteen cases which are mentioned in the monograph of MM. 
 Bourneville and Gu^rard, sixteen new cases, we get a total of thirty- 
 four cases, of which nine relate to males, and twenty-five to 
 females. 
 
CAUSES. 181 
 
 Judging from the same records, it follows that this is a disease 
 of youth, or of the first half of adult age. It has been observed 
 in patients aged fourteen, fifteen, and seventeen years,^ but it seems 
 most frequently to set in between twenty-five and thirty years. 
 It rarely makes its appearance after thirty. On the other hand, 
 forty years seem to be the ultimate limit of life for patients affected 
 by disseminated sclerosis. 
 
 With respect to the influence of hereditary predisposition, we 
 have only one case to mention in which it seems to have played a 
 certain part. This example has been communicated to us by Dr. 
 Duchenne (de Boulogne). 
 
 In the pathological antecedents of the patients themselves we 
 generally find nothing but vague indicia. Hysteria was present 
 in some cases, but in most we only find mention made of ill-deter- 
 mined neuropathies, occasional hemicrania, or neuralgias.^ 
 
 Amongst occasional cavses, we frequently find mention made of 
 the prolonged action of moist cold.'' In one case, the first symp- 
 toms are alleged to have appeared a short time after a fall. 
 
 ' In a work by M. Leub6 (" Ueber multiple iuselformig Sklerose der Geliirns 
 uiid Ruckenmarks," in * Deutsches Archiv,' 8 Bd., 1 heft, 1870, p. 14) we find the 
 record of the case of a child who presented the first symptoms of disseminated 
 sclerosis at the age of seven years. She died aged fourteen years and six months. 
 Summary: slight nystagmus; right facial paralysis ; marked ataxia of the ex- 
 tremities, especially on the left side ; tremor of the head; difficulty of utterance ; 
 atrophy of the legs. Anfopf^y : sclerosis of the pons Varolii and annexes, almost 
 general on the right, disseminated on the left. The cerebrum and cerebellum 
 present, in their cortical layers, a double degeneration, whitish-yellow, or steel- 
 gray, partly diffused, partly disseminated in patches. In the cord, and princi- 
 pally in the medulla oblongata, the sclerosis occupies, firstly, the posterior 
 columns, next the lateral columns, and finally the anterior columns. (B.) 
 
 2 There is, however, an etiological cause which deserves mention, namely, the 
 influence of certain acute diseases on the development of sclerosis. The following 
 facts are given in support of this assertion. 
 
 1st. In a case given by Erbsteiu (' Deutsches Archiv fiir Klinische Medicin,' t. 
 X, fasc. 6, p. 596) disseminated sclerosis set in during convalesence from typhoid 
 fever. The patient, then, suflfered from debility of the lower extremities, and a 
 difficulty of enunciation ; the words were scanned, and the pronunciation was 
 somewhat indistinct and monotonous. 
 
 2d. A patient in M. Charcot's charge, Nic — (.lulie) noticed a certain degree of 
 weakness in her lower limbs, on recovering from an attack of cholera. Some 
 short time after, she had an attack of typhoid fever, after which the feebleness of 
 lier limbs augmented in a slow but continuous manner, to such an extent that 
 she was soon obliged to use a cane. (A. Joflfroy, ' Memoires de la Societe de 
 Biologie,' 1869, p. 146.) 
 
 3d. In the case, recorded by MM. Fontaine and Liouville, it is mentioned that 
 the first signs of sclerosis were preceded by copious bilious vomitings, which 
 lasted from ten to fifteen days. (H. Liouville, in ' Memoires de la Societe de 
 Biologie,' 1860, p. 107.) 
 
 4th. Finally, we will mention the case of a woman named Dr— (Hortense), in 
 whom the first symptoms of disseminated sclerosis appeared soon after she had 
 had a severe attack of smallpox. (B.) 
 
 3 A patient, according to Herr Baerwinkle, experienced a difficulty in executing 
 movements with the right leg, three days after having fallen into water. The 
 action of moist cold has a reality in this case, because the patient allowed his wet 
 clothes to dry upon him. (B.) 
 
182 PROGNOSIS — TREATMENT. 
 
 But the circumstances most commonly assigned as causes of this 
 disease, by patients, appertain to the moral order — long-continued 
 grief or vexation, such, for instance, as may arise»from illicit preg- 
 nancy, or the disagreeable annoyances and carking cares which a 
 more or less false social position entails. This is often the case as 
 regards certain female teachers. Having said so much with respect 
 to women, ^ the question of male sufferers arises. These are, for 
 the most part, persons who have lost caste, and who, thrown out of 
 the general current, and too impressionable, are ill-provided with 
 the means of maintaining what, in Darwin's theory, is called the 
 "struggle for life." In short, the etiology is a somewhat trite one, 
 such as may be met with again, as it were, at the beginning of all 
 the chronic diseases of the central nervous system. 
 
 C. The prognosis has hitherto been of the gloomiest. Shall it be 
 always thus? It is to be hoped that, when the disease has become 
 better known, the physician will learn how to take advantage of 
 that spontaneous tendency to remission which has been noticed in 
 a great number of cases. Nor must it be overlooked that, at the 
 present time, the real nature of the disease is not recognized until 
 the lesions have become well marked, and are consequently but 
 little amenable to the influence of therapeutic agencies. 
 
 D. After what precedes, need I detain you long over the ques- 
 tion of treatment? The time has not yet come when such a sub- 
 ject can be seriously considered. I can only tell you of some 
 experiments which have been tried, the results of which, unfortu- 
 nately, have not been very encouraging. 
 
 Chloride of gold and phosphate of zinc appear to have rather 
 exasperated than improved the symptoms. Strychnine has some- 
 times caused cessation of the tremor, but its influence has always 
 been transient. The same is to be said of nitrate of silver. In 
 several cases, which I have noted, it seems to have had a very 
 favorable influence over the tremor, and the paresis of the limbs, 
 but this influence was not of long duration. 
 
 The exhibition of this drug is formally contra-indicated by the 
 existence of permanent contracture, and especially of spinal epi- 
 lepsy ; its employment, in such cases, v/ould almost certainly have 
 the effect of exasperating these symptoms. The hydropathic treat- 
 ment seetos to have produced a temporary amendment in one case; 
 in another, on the contrary, it completely failed. 
 
 Arsenic, belladonna, ergot of rye, and bromide of potassium 
 have been likewise administered, in disseminated sclerosis, without 
 any marked benefit. The same may be said of faradization and of 
 
 * The ' Lancet' (1873, vol. i, p. 236) has published the summarj of a case of 
 disseminated sclerosis recorded by l3r. Moxon, at Guy's Hospital, in which we 
 find the following causes mentioned — a, febrile disease, accompanied by diarrhoea, 
 which lasted for several weeks ; b, a violent moral emotion experienced by the 
 patient on seeing lier husband in bed with another female. (B.) 
 
\ 
 
 TREATMENT. 183 
 
 galvanism. As regards the employment of the continued current, 
 however, further experiments are required before we can form a 
 definite judgment.^ 
 
 ' Other drugs have also been employed, without better success than resulted 
 from the use of those enumerated by M. Charcot. Such are, phosphorized oil, 
 iodide of phosphetylamine, and Calabar Beau. Since the publication of the first 
 edition of these Lectures several works or observations concerning disseminated 
 sclerosis have appeared. As they only eoufirm the descriptions traced by M. 
 Charcot, we confine ourselves to a simple catalogue. 1st. Timal, " Etude sur 
 quelques complications de la sclerose en plaques dissemin§es." These de Paris, 
 1&73. 2d and 3d. H. Schule, " Beitrag zur multiplen Sklerose des Gehirns und 
 Ruckenmarks," in * Deutsches Archiv fur Klinische Medicin,' 1870, Bd. vii, p. 
 259. " Weiterer Beitrag zur Hirn Ruckenmarks Sklerose" (ibid., 1871, Bd. viii, 
 p. 223). Baldwin, "A Case of Diffused Cerebral Sclerosis" ('Journal of Mental 
 Science,' 1873, July, p. 304). 5th. Moxon, " Two Cases of Insular Sclerosis of the 
 Brain and Spinal Cord" (' The Lancet,' vol. i, p. 471, 609, 1875). 6th. Buzzard, 
 "Disseminated Cerebro-Spinal Sclerosis," (ibid., vol. i, p. 45). 7th. Moxon, 
 *' Eight Cases of Insular Sclerosis of the Brain and Spinal Cord" ('Guy's Hospital 
 Reports,' 3d series, t. xxi, London, 1875). 
 
PAET THIED. 
 
 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 hemianaesthesia. 
 Hemiopia and achromatopsia. Ovarian hypersesthesia. Retention of urine. 
 Tympanites. Convulsive seizures ; trismus. Manifestation of hysterical 
 ischuria. Precautions taken to guard against error. Complete anuria. 
 Uraemio vomiting. Relation of the quantity of urine excreted to the vomited 
 matter. Chemical analysis of vomited matter, urine and blood. Suspension 
 of phenomena. 
 
 Re-appearance 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 calcu- 
 lous ischuria; their tardiness in hysterical ischuria. 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. 
 
 Gentlemen: It is my intention to resume and to complete, in 
 our conferences of the present year, the series of studies which we 
 undertook two years ago, and which were rudely interrupted by 
 the painful events with which you are acquainted. 
 
 At the epoch when we were forced to separate, I was endeavour- 
 ing, by the application of preliminary researches concerning trophic 
 disorders dependent en nervous influence, to show, as you may 
 remember, that many affections of the muscular system hitherto 
 attributed to peripheral causes, are in reality subordinate to lesions 
 occupying well-defined regions of the gray matter of the spinal 
 cord. 
 
 This group of muscular affections, which I propose to call spinal 
 
186 ISCHURIA. 
 
 myopathies^ or myopathies of spinal origin, shall occupy our atten- 
 tion in a very special manner. I will also revert to the interesting 
 group of sclerous affections of the spinal cord, and, amongst others, 
 to that sclerosis which determines the symptomatic phenomena of 
 progressive locomotor ataxia.^ The subject is far from being ex- 
 hausted, and I shall have occasion to point out, in reference to 
 these diseases, many facts which are new, or which were previously 
 but imperfectly known, and which the investigations conducted in 
 this hospital have made clear. 
 
 I intend also to treat of the several kinds o^ paraplegia,^ produced 
 by slow compression of the cord, of chronic spinal meningitis, and 
 of some diseases of the brain and spinal cord, the study of which 
 has been hitherto greatly neglected. 
 
 But before returning with you, gentlemen, to these arduous ques- 
 tions, I cannot resist the desire of taking immediate advantage of 
 a number of very remarkable cases of hysteria which are, at present, 
 assembled in our wards. It is requisite to lay hold, without delay, 
 on this fortunate circumstance, for, on account of the mobile char- 
 acter proper to the great neurosis I have named, the symptoms 
 which are, to-day, manifest in a high development may, on the 
 morrow, have completely vanished. 
 
 Among these cases there is one especially deserving of attention, 
 which shall form the object of our first conference; it is, if I do 
 not deceive myself, a legitimate example of a rare, an extremely 
 rare affection, the very existence of which is disputed by most 
 physicians. 
 
 The study of exceptional cases, gentlemen, is not to be disdained. 
 They are not always mere baits for vain curiosity. Many a time, 
 indeed, they supply the solution of difficult problems. In that 
 respect they may be compared to those lost or erratic species which 
 the naturalist anxiously seeks for, because they show the mode of 
 transition between different zoological families, or enable him to 
 unravel some knotty point of comparative anatomy or physiology. 
 
 Hysterical ischuria is the afifection to which I allude. At the 
 outset, I should explain to you the technical meaning of this desig- 
 nation, which some of you now, probably, hear mentioned for the 
 first time. 
 
 A. Ischuria, stoppage of urine — these terms, technically con- 
 sidered, signif3^ the same thing. Hysterical ischuria has, however, 
 a more restricted meaning. 
 
 There is no question here of a simple retention of urine in the 
 bladder — that is a hackneyed fact in hysteria. You know that 
 very commonly the use of the catheter, in such cases, may need to 
 be continued for months, nay years ; but then the urine withdrawn 
 
 ' See "Lemons surles Maladies du Systeme Nerveux," 2e serie, fascicules 2 et 3. 
 * Cljarcot, loc. cit., 2e serie, faso. 1. 
 
EXPERIMENTS. 187 
 
 from the bladder is abundant in quantity, or, at all events, the 
 amount is not far removed from the normal standard. 
 
 In the ischuria of hysterical patients the obstruction is situated 
 neither in the urethra nor in the bladder. It lies higher up, either 
 in the ureters or in the kidneys themselves, or still more remotely. 
 But that is a point which yet remains to be decided. The principal 
 fact is this, namely, the quantity of urine secreted in the twenty-four 
 hours and withdrawn by the catheter (for hysterical ischuria is al- 
 most always complicated by urethral retention), this quantity, I 
 repeat, is remarkably under the normal amount. It is even fre- 
 quently reduced to zero, and during several days there is, in fact, 
 absolute suppression of urine. 
 
 B. It is proper, in this relation, to establish specific categories. 
 Oliguria^ or even total sup2)ression of urine^ may be only a transient 
 phenomenon in hysterical cases, and one, as Dr. Laycock has rightly 
 remarked, which may frequently occur unnoticed. Thus, we oc- 
 casionally observe in hysterical patients, especially at the catamenial 
 periods, a complete suppression of urine which does not last more 
 than from twenty-four to thirty-six hours. There may, perhaps, be 
 some feeling of uneasiness experienced, and the pulse may be quick- 
 ened ; but, after a short time, a few spoonfuls of urine are expelled 
 and the normal state is restored.^ 
 
 The cases upon which I would fix your attention are very dif- 
 ferent from those to which I have just referred. They present 
 hysterical ischuria at its maximum of development when it has 
 assumed the character of ^permanent symptom. During the lapse 
 of several successive days, of weeks, and of months, the quantity 
 of urine rendered, in the twenty-four hours, may be quite insignifi- 
 cant in amount or almost nil. Occasionally even, there is complete 
 suppression of urine during a series of several days. 
 
 When matters take this turn there is superadded, as it were of 
 necessity, another phenomenon which may be called the comple- 
 ment of the first; I mean repeated ?;o7/^^^^^^s, which take place daily 
 and even several times a day, so long as the ischuria continues. 
 The ejected matter occasionally, it is said, presents the appearance 
 and exhales the odour of urine. It is certain that chemical analysis 
 has, in two or three cases, detected in this vomited matter the pre- 
 sence of a certain quantity of urea. 
 
 To sum up, gentlemen, hysterical ischuria offers, in the human 
 species, a more or less exact reproduction of some of the symptoms 
 observed in animals, in cases of nephrotomy or of obliteration of 
 the ureters by ligature. 
 
 The experiments of Prevost and Dumas, and particularly those 
 of MM. Claude Bernard and Barreswill, teach us, as you are aware, 
 
 ' Laycock, ' A Treatise on the Nervous Diseases of Women,' London, 1840, p. 
 229. 
 
188 HISTORICAL SKETCH. 
 
 that, after these mutilations, a vicarious elimination is effected by 
 means of the intestine. In the matter so eliminated, there have 
 been found, according to some observers, carbonate of ammonia re- 
 sulting from the decomposition of the urea (Claude Bernard), and, 
 according to others, urea itself has been detected (Munck). How- 
 •ever this may be, so long as the elimination is effected, the animals 
 seem to suffer little inconvenience, and it is only when they become 
 enfeebled and the supplementary excretion ceases, that grave phe- 
 nomena present themselves which soon occasion death. 
 
 You perceive the analogies and, at the same glance, are struck 
 by the contrast. Cerebral symptoms inevitably occur, at a given 
 moment, in cases of experiments practised on animals, whilst in 
 hysterical patients the alternation between renal excretion and 
 vicarious excretion may continue for weeks and months, without 
 any visible disturbance of the general health ever resulting. But 
 I do not wish at present to delay upon this point, to which I will 
 hereafter return. 
 
 II. 
 
 Such, gentlemen, is hysterical ischuria, at least in its essential 
 character, according to the few authors who have acknowledged 
 its existence ; for, I repeat, the reality of this disorder has been dis- 
 puted. You will not find it mentioned in any of the recent works 
 or articles on hysteria, not even in the most complete and most 
 justly esteemed amongst them. There is no mention whatever of 
 it, for instance, in the great work of M. Briquet. In short, of con- 
 temporary authors. Dr. T. Laycock, Professor in the University of 
 Edinburgh, is, perhaps, the only pathologist who, in his writings, 
 has given domicile to hysterical ischuria. After devoting to this 
 question a series of articles,^ in which he relates two original cases, 
 Dr. Laycock returns to the subject in his well known work on the 
 'Nervous Diseases of Women' (1840). Everywhere else, if hys- 
 terical ischuria be mentioned, it receives but a passing notice by 
 way of reference, and not without an ironical allusion to those ob- 
 servers who have been so simple as to gravely accept this " pre- 
 tended symptom." 
 
 On the other hand, it is not uninteresting to note that the physi- 
 ologists, Haller first, then Carpenter, and Claude Bernard (these, 
 however, without affirming anything), have shown themselves, in 
 reference to this subject, far less sceptical than were such physicians 
 as Prout and R. Willis. 
 
 Until recently, I shared the almost general incredulity which 
 prevailed in reference to hysterical ischuria, being, indeed, pre- 
 possessed by the teachings of my master, Rayer, who never lost an 
 opportunity of expatiating lengthily on the various deceptions of 
 
 ' 'The Edinburgh Medical Jourual,' 1838. 
 
SIMULATION. 189 
 
 which hysterical patients are guilty. And he did not hesitate to 
 confess that lie, who was himself a sagacious and very keen ob- 
 server, had often nearly fallen a victim to their strategy. Latterly, 
 my opinions have been somewhat modified in presence of the case 
 to which I shall shortly invite your attention. 
 
 Before placing you in a position to judge for yourselves whether 
 or not my conversion has been too precipitate, let us investigate 
 the principal reasons why certain authors pass over hysterical 
 ischuria in silence, whilst others only mention its name in order 
 to relegate it amongst the number of chimseras. 
 
 1st. In the first place, it must be remarked that hysterical ischu- 
 ria is a rare phenomenon, at least in its very marked form, for it 
 is possible, as we have already said, that slight cases may often be 
 overlooked. 
 
 a. Thus, Dr. Laycock, who searched everywhere, could not col- 
 lect more than twenty-seven cases, only two of which came under 
 his own observation. 
 
 h. Let us add that a somewhat rigorous criticism would, most 
 certainly, reduce this number still further. Most of the cases are 
 old ones, dating as they do from the sixteenth and seventeenth cen- 
 turies, and they do not offer those notes of exactness which we re- 
 quire at the present period. Others are manifest impostures. 
 Who could be got to believe, for instance, that a woman could, in 
 twenty four hours, render through the ear half a gallon of a fluid 
 which, on being analyzed, was found to contain urea? And that 
 is not all. This very woman is stated to have, at the same time, 
 ejected a similar fluid by the navel — ''spirted out" is tlie term em- 
 ployed by the author of the report. Yet all these details, and 
 many others besides, are recorded, with the utmost gravity, in the 
 ' American Journal of Medical Sciences' (1828). Permit me, I beg 
 of you, to pass in silence over the name of the physician who made 
 himself responsible for this case. 
 
 2d. This leads me to say a word on simuIatiQu. You will meet 
 with it at every step in the history of hysteria, and one finds him- 
 self sometimes admiring the amazing craft, sagacity, and persever- 
 ance which women, under the influence of this great neurosis, will 
 put in play for the purposes of deception — especially when a phy- 
 sician is to be the victim. As to the case in point, however, it 
 does not seem to me demonstrated that the erratic paruria of hys- 
 teria has ever been wholly simulated and, as it were, created by 
 these patients. On the other hand, it is incontestable that, in a 
 multitude of cases, they l^ave taken pleasure in distorting, by ex- 
 aggerations, the principal circumstances of their disorder, in order 
 to make them appear extraordinary and wonderful. 
 
 The following is the general sequence of things. Anuria or 
 ischuria, with vomiting, exists alone for a certain time, and the 
 phenomenon is consequently reduced to its simplest form. Soon, 
 
190 CALCULOUS OBLITERATION OF URETERS. 
 
 however (especially if the symptoms seem to excite the interest 
 and curiosity of the physicians), pure urine will be thrown up in 
 considerable quantity; it will issue from the ears, the navel, the 
 eyes, and even from the nose, as we read in the account given by 
 the American journal. Finally, if the wonder of the observers be 
 extremely excited, there will probably be vomiting of fecal matters. 
 
 Amongst this class of cases, that which in France attained most 
 notoriety was the case of a patient named Josephine Roulier, 
 who, for over fifteen months, was a prominent personage in the 
 clinical wards of Professor Leroux. This happened about the year 
 1810. The patient had first presented the symptoms of simple 
 ischuria with erratic paruria. Nysten, who records the case, ana- 
 lyzed the vomited matters and detected the presence of urea. 
 Shortly after, there came a flow of urine from the navel, the ears, 
 the eyes, the nipples, and finally an evacuation of fecal matters 
 from the mouth. You see, gentlemen, that the sequence is always 
 the same, whatever be the country or century in which the obser- 
 vations were taken. The fraud was discovered by Boyer. It was 
 found that the use of a strait waistcoat caused cessation of the 
 extraordinary phenomena, and some hard fecal pellets were dis- 
 covered, stored away in the patient's bed ready for use. Unfor- 
 tunately, Nysten had just published his 'Recherches de Physiologic 
 et de Chimie Pathologiques.' It was necessary to make honourable 
 reparation. A note was accordingly inserted in the 'Journal 
 General de M^decine,' and another was appended to some copies of 
 Nysten's book. 
 
 In presence. of these facts, must we conclude that all is imposture 
 in hysterical ischuria? I do not believe it, gentlemen, and I hope 
 you will share my opinion when you shall have been made ac- 
 quainted with all the peculiarities of my patient's history. 
 
 There is another circumstance which is, also, well adapted to 
 throw an unfavourable shadow upon accounts of cases of hysterical 
 ischuria. It is this: apart from hysteria, suppression of urine if 
 it but persist beyond a few days, say three, or four, or five, is an 
 exceedingly serious symptom, which almost necessarily terminates 
 in death. 
 
 Leaving aside those cases of anuria depending on an acute or 
 chronic form of Bright's disease, which are too complex for admis- 
 sion here, I will select as typical the calculous obliteration of the 
 ureters, supervening in persons previously in good health. In such 
 cases, it has happened that sometimes one kidney has been reduced, 
 through antecedent disease, to a fibrous husk filled with cysts, and 
 consequently rendered incapable of fulfilling its function of elimi- 
 nating urine; sometimes, but more rarely, both ureters are oblite- 
 rated at once. It little matters, in so far as our object is concerned, 
 whether this obliteration be accompanied or not by the pains of 
 
EXCEPTIONAL CASES. 191 
 
 nephritic colic. Now, Halford/ Abercrombie, and all authors 
 who have studied these cases agree in stating that if anuria persist 
 beyond four or five days, comatose symptoms, with or without 
 convulsions, inevitably appear and are soon followed by death. 
 
 Life is prolonged a little if even a small quantity of urine can 
 be rendered, but the final result is always the same. 
 
 There is, however, the chapter of exceptions, which we should 
 the less neglect, because we are taking advantage of some of its 
 contents. The following exceptional cases are in the books: — 
 
 1st. In the case reported by Dr. Laing, of Fochabers, quoted by 
 Kobert Willis,^ anuria lasted ten days, and recovery took place. 
 
 2d. In the case of a patient of Dr. W. Roberts (of Manchester) 
 somnolence did not supervene until the eighth day, four days 
 before death.^ 
 
 3d. The most remarkable example within my knowledge of 
 prolongation of life, under such circumstances, is that which was 
 recently published by Mr. Paget, in the 'Transactions of the 
 Clinical Society of London.'* Although there was absolute anuria, 
 the comatose symptoms did not present themselves until the four- 
 teenth day. On the fifteenth the patient passed a certain quantity 
 of urine. There was, however, aggravation of symptoms, and the 
 fatal termination took place on the twenty-third day. 
 
 However it be, you observe that, just as happened in the case 
 of experiments made on animals, here also the contrast is striking 
 between calculous ischuria, which almost certainly kills the patient, 
 and hysterical ischuria, which allows the patient to survive during 
 long months without seriously disturbing the general health. We 
 are thus placed in presence of a grave problem. Is it really in- 
 soluble? This is a question which we purpose investigating at a 
 future opportunity. 
 
 in. 
 
 It is full time, gentlemen, that we should enter upon a study of 
 the clinical case which constitutes the basis of our conference. In 
 the first place we must examine the groundwork to which our 
 observations relate; and, with this object in view, the best thing I 
 can do is to show you the patient, and to point out before you the 
 symptoms that are actually in existence, amongst which you will 
 discern the signs of an intense, inveterate hysteria, marked by a 
 characteristic reunion o^ permanent symptoms. 
 
 Justine Etch — , born in the department of the Basses-Pyrenees, 
 
 1 'Medical Transactions,' published by the College of Physicians, t. vi, 1820. 
 
 2 " Urinary Diseases," London, 1838, p. 35. 
 
 3 See account of this patient in Bourneville, "Etudes Clin, et Therm.," &c., 
 p. 175; and Roberts in ' Mouvement Medical,' 1871. 
 
 * J. Paget. " Case of Suppression of Urine very slowly fatal." In ' Transactions 
 of Clinical Society of London,' t. ii, 1869. 
 
192 OVARIAN HYPERjaSTHESIA. 
 
 is forty years of age. She followed the profession of hospital nurse. 
 She was admitted into this hospital of La Salpetri^re in 1869, so 
 that we can trace the progress of her malady during four years. 
 
 What is her present condition ? That which first strikes you in 
 reference to her is the vast contracture which affects the upper and 
 lower limbs on the left side. This contracture, which ceases neither 
 during natural sleep, nor during sleep induced by chloroform 
 unless the influence of this agent be pushed to an extreme, sud- 
 denly developed itself on the 20th March, 1870, after a severe 
 hysterical fit. We should mention, however, that the arm had 
 previously been quite paralyzed, but flaccid, whilst the corres- 
 ponding lower extremity was already rigid. The latter circum- 
 stance, together with the rapidity with which the contracture made 
 its appearance, authorized us in declaring, at the time, that no 
 circumscribed cerebrallesion had occurred to cause the phenomena 
 displayed. 
 
 Another distinguishing feature which we find, in this patient, is 
 the existence of complete hemiancesthesia, which occupies both 
 the contractured limbs and the left half of the face and body. Not 
 only does this anaesthesia affect the external tegument, but it also 
 extends to those portions of the mucous membrane and of the organs 
 of sense situated on the left half of the body. Thus, with respect 
 to the faculty of sight, we note here the existence of hemiopia and 
 of achromatopsia; this phenomenon was observed by Dr. Galezowski 
 under similar circumstances, and is one to which we shall again 
 return. 
 
 When developed to this extent, hemiansesthesia gives us a group 
 of symptoms which are almost specific; I say almost^ but not abso- 
 lutely^ specific, because we shall soon see that even coarse cerebral 
 lesions, confined to certain portions of the encephalon, may at least 
 partially reproduce them. 
 
 One other very important symptom is presented by Justine 
 Etch — . This is a pain seated just above the left groin. M. 
 Briquet has given this the name of cselialgia^ and regards it as 
 residing in the muscles. For my part agreeing on this point with 
 Negrier, Schutzenberger, and Piorry, I believe its source to be 
 the ovary. Whatever be its exact seat, this pain, which I shall 
 term ovarian hyper sesthesia^ is to a certain extent pathognomonic. 
 Pressure, which exasperates it, causes irradiated sensations of a 
 perfectly special character. These sensations, springing from the 
 ovarian region, successively attain: 1st. the epigastrium; 2d. the 
 neck or throat, — manifesting themselves in these regions by a more 
 or less considerable oppression, the well-known sensation of a ball 
 or globe {globus hystericus)] 3d. the head where the irradiation 
 is characterized by buzzing and whistling in the left ear, by cepha- 
 lalgia with throbbings, which the patient compares to so many 
 hammer-strokes on the left temple, and finally to an obnubilation 
 
CLINICAL CASE. 193 
 
 of sight in the corresponding eye. I confine myself, for the moment, 
 to a simple enumeration of these phenomena, which require a more 
 minute description. 
 
 Among the other symptoms, I must not forget to mention reten- 
 tion of urine and tympanites^ 'w\\\Q)a also are permanent phenomena 
 in this case. Finally, this woman is subject to special seizures, 
 which are sometimes tetaniform, sometimes epileptiform, but which 
 occasionally resemble the common hysterical type. Thus, this 
 morning, you can perceive a symptom which dates from a seizure 
 that took place two days ago. I refer to the trismus which has 
 proved au obstacle to natural alimentation since that period. 
 
 IV. 
 
 The patient may now retire. We shall be able to relate more 
 fully, in her absence, the other peculiarities of her history. It is 
 a real Odyssey. Hence I shall be often compelled to abridge it, 
 whilst taking care, however, to indicate the sequence of the acci- 
 dents. 
 
 The first fit of convulsions occurred in 1855. What the circum- 
 stances were we do not know. The account she gives is quite a ro- 
 mance, a case of rape (?), — a tangled story, the accuracy of which it 
 is difficult to ascertain. It is, however, certain that the seizure in 
 question was apparently one of extreme violence; the patient fell 
 into the fire, burning her face, and you have noticed the indelible 
 stigmata which were caused by that accident. Dating from that 
 period, the fits have continued to show themselves, from time to 
 time, with the same characters, but rather rarely, — about twice or 
 thrice a year. 
 
 Ten years later, retention of urine appears. The patient has an 
 attack of hemiplegia with flaccidity of the left side, after one of her 
 usual fits, and is brought into M. Lasagne's wards. 
 
 Admitted the same year (1869) to La Salpetriere, we note — -Ist. 
 The existence of left hemiplegia, with flaccidity of the upper and 
 contracture of the lower extremity. 2d. Hemianaesthesia and 
 achromatopsia of the same side. The symptoms then presented 
 by Justine Etch — are detailed in the theses of MM. Helot and 
 Berger. 
 
 In 1870 affairs remain much in the same state, only that a new 
 fit has been followed by contracture of the left arm ; and, at that 
 time (in 1870) I showed you this patient as supplying an example 
 of the hemiplegic form of hysterical contracture.^ 
 
 In the month of March, 1871, a fit is followed by flaccid hemi- 
 plegia of the right side. In a month's time, the flaccidity is replaced 
 by contracture. In April, then, we had under our eyes as intense 
 
 1 The lecture referred to, which will be foaiid further on, was first published in 
 the ' Revue Photographique des Hdpitaux de Paris,' 1871, p. 103. Plate xxv of 
 the • Revue ' gives a portrait of this patient. 
 
 13 
 
194 CLINICAL. CASE. 
 
 a contracture of the four extremities as it is possible to conceive; 
 the contracture was absolute, persisting night and day, during sleep- 
 ing and waking, and even resisting the influence of sleep induced 
 by chloroform, or only giving way before the highest dose. 
 
 This woman was, therefore, you perceive, condemned to complete 
 confinement in bed; it was impossible for her to use her limbs. 
 Better conditions could not be desired to render surveillance easy. 
 I took care, moreover, to place near her two devoted patients, bed- 
 ridden like herself, who were ready to reveal all if they should 
 discover any trickery. I had there the best possible police, that 
 of women over women, for you are aware that if women enter into 
 any plot among themselves they very seldom succeed. This state- 
 ment will, I believe, be sufficient to convince you, gentlemen, that, 
 during this first period, simulation was impossible. My friends 
 Professors Brown-Sdquard and Rouget, who saw the patient at this 
 epoch, declared themselves satisfied with all the precautions taken. 
 
 It now remains for us to show you how, in the midst of conditions 
 so favourable to regular inspection, the phenomenon of ischuria was 
 produced. 
 
 The ischuria commenced in the month of April, 1871. Before 
 this a woman employed in the hospital, who catheterized the patient, 
 several times a day, had already noticed that the quantity of urine 
 withdrawn was occasionally very minute, whilst at other times 
 none was yielded for two or three days, or even more, nor were 
 the sheets ever moistened. 
 
 In addition to these symptoms, which persisted during May and 
 June, vomiting soon appeared, and proceeded without effort or 
 straining. I pretended, from the outset, to be nowise surprised at 
 these occurrences, confining myself to directing that the patient 
 should be discreetly watched both night and day. She was never, 
 however, for a moment detected in any deception. 
 
 Cast your eyes, I pray you, on these diagrams which T place 
 before you and you can follow, in the several phases of their evo- 
 lution, the accidents which have presented themselves to our 
 observation. The tabulation begins on the 16th July, 1871, when 
 I caused the urines and vomited matter to be collected separately, 
 day by day. It ceased in October of the same year. 
 
 From the 16th to the 31st of July the quantity of vomited mat- 
 ter varied from 500 to 1760 centilitres, the daily average being 
 one litre (or If pints nearly). The quantity of urine varied between 
 and 5 grammes ; the average in the twenty-four hours being 2.60 
 grammes (or about 88| grains). During this period, there was 
 absolute ischuria every second day. 
 
 In August, the average amount of urine rendered was 3 
 grammes (or 46J grains) ; that of vomited matter was one litre in 
 the twenty-four hours. During the course of this month there was 
 
CLINICAL CASE. 195 
 
 on several occasions, complete anuria, lasting for several days. 
 But, note that the total absence of urine never persisted beyond 
 eleven days. 
 
 From the 1st to the 30th September, the average amount of 
 vomited matter rose to a litre and a half (say 2| pints) per day, 
 whilst that of the urine remained at 2.50 grammes. 
 
 There is one fact brought into prominence, on examination and 
 comparison of the curves recorded on this table, namely, that the 
 curve of the vomiting generally rises when that of the urine falls, 
 and inversely. Owing to this state of alternate equilibrium there 
 has been a tolerably fair balance maintained between the results of 
 these two phenomena. 
 
 What has been the general condition of the patient, as regards 
 Jiealth, during this long period of four months which the investi- 
 gation lasted ? At no time have we remarked any disturbance of 
 the general health worth noticing. The alimentation was, as you 
 can readily understand, very limited; the stomach rejected almost 
 immediately, but without fatigue (a characteristic of hysterical 
 vomiting justly noted by Dr. H. Salter'), the greater portion of the 
 food swallowed by the patient. Yet, notwithstanding these adverse 
 conditions, nutrition scarcely suffered. This, indeed, is a fact well 
 known, apart from anuria, in cases of uncontrollable hysterical 
 vomiting. 
 
 I had believed from the outset that the matter vomited by our 
 patient must contain urea. The first investigations undertaken 
 with a view to detect its presence were, however, fruitless; then I 
 requested the assistance of M. Gr^hant, whose competency in such 
 matters is beyond a doubt. He most obligingly placed himself at 
 our disposal. 
 
 Twenty-two cubic centim^-tres of urine collected on the 20th of 
 October, and representing the whole amount of urine rendered 
 that day, gave, on analysis, 0.179 gramme (nearly 2} grains). On 
 the 11th October the total vomited matter amounting to 1160 
 cubic centimetres, gave 3699 grammes (or 26^ grains) of urea. 
 
 In order to determine if our patient's blood contained a greater 
 proportion of urea than in the normal state, we decided to abstract 
 a little of the venous fluid. In order to accomplish this operation 
 it was necessary to induce sleep, on account of the obstacles pre- 
 sented by the contraction of the members. The operation having 
 been accomplished, M. Grehant found that in the blood taken from 
 Etch — the urea amounted to 0.036 gramme per hundred grammes 
 of blood; whilst in that taken for comparative examination from 
 a healthy individual there existed 0.031 gramme per cent. You 
 see that the results of the two analyses are (almost) identical. 
 
 Unfortunately for the continuance of our investigations, the 
 
 » The ' Lancet,' Nos. 1 and 2, vol. ii, 1868. 
 
196 VARIATIONS OF HYSTERICAL ISCHURIA. 
 
 administration of chloroform had the eff'ect of greatly modifying 
 the symptoms which we had been watching with so much interest; 
 incontinence of urine followed, lasting for several days. The 
 vomiting, moreover, was suspended soon after, and the urine 
 gradually returned to the normal standard. 
 
 Such, gentlemen, are the results of the first series of studies 
 which decided us to undertake the restoration of hysterical ischuria 
 to a place amongst clinical realities. The same phenomena, in- 
 deed, were destined again to present themselves, under a less 
 striking aspect it may be, but one quite as full of interest. In this 
 second phase, no complete anuria occurred, not even temporarily. 
 "We noted a simple oliguria. The matter vomited was not thrown 
 off in such abundance. In a word, if the accidents had been a 
 little less marked, and if we had not been enlightened by the fore- 
 going observation, it is incontestable that the supplemental elimi- 
 nation of urea might have altogether escaped attention. 
 
 Let us briefly observe what took place during this second period. 
 After a more or less complete remission of symptoms, retention of 
 urine was the first to make its appearance again. This was in 
 January. The following month, after a fit, we noted alternations 
 of oliguria and of polyuria, when there were two litres (or 8J pints) 
 passed per diem. In March, the urinary secretion diminished to a 
 decided extent; and, on the 18th of the same month, vomiting 
 again showed itself. From that date, until the 31st of March, the 
 daily average of vomited matter amounted to 500 grammes. In 
 April, the average was 800 grammes for the vomited matter and 
 100 grammes (=1543.28 grains) for the urine. 
 
 During this new phase, in which the disease offered itself for 
 investigation, we were not under so favourable conditions as on the 
 previous occasion. The patient's right arm had become nearly 
 quite free. Hence it was urgent that we should protect ourselves 
 against every possible cause of error. 
 
 In addition to the customary surveillance; which was not relaxed 
 for a moment, we had recourse to the following precautions: the 
 patient's bed was carefully examined from time to time, and neither 
 vessels nor catheters were allowed to remain at her disposal. 
 Finally, I succeeded in persuading her that it might, perhaps, be 
 beneficial on account of the contracture that still persisted in the 
 left arm to make use of a strait jacket. To this she consented. 
 The application of the strait jacket was not, however, absolutely 
 continuous; it was removed at meal times, when the patient was 
 watched by the person who fed her. 
 
 At different periods, during the month, M. Gr^hant analyzed the 
 urine and the vomited matter rendered in twelve days. During 
 
CHEMICAL ANALYSES. 197 
 
 this lapse of time, the daily average of the urine was 206 grammes, 
 cantaining 5.09 grammes of urea. The daily average of vomited 
 matter, amounting to 362 grammes, yielded 2.138 grammes of urea. 
 Adding together the two totals of urea rendered, we obtained the 
 low figure of 5.233 grammes. I can show you a specimen of the 
 oxalate of urea which M. Grrehant extracted from the matter 
 vomited during the four and twenty hours. We shall iiiake use of 
 this result in a moment. 
 
 We did not discover, any more than on the previous occasion, 
 the existence of a supplemental elimination by the skin or intes- 
 tines. The patient is habitually constipated, and we did not 
 observe, at either time, any peculiarity in relation to the external 
 tegument. Her general health has not undergone any noteworthy 
 alteration, and the temperature never was above 37° C. (=98.6° F.) 
 and some tenths.^ 
 
 Thus, gentlemen, this new investigation confirms the accuracy 
 of the first, and both concur to establish the existence of hysterical 
 ischuria^ with erratic paruria as a proven pathological phenomenon, 
 utterly beyond the possibility of simulation. If this conclusion be 
 legitimate, it is obvious that some value must be attached to the 
 records of former cases. It is only requisite to separate the truth 
 from what is fictitious, to eliminate, for instance, certain extra- 
 ordinary phenomena such as the flow of urine from the nose, eyes, 
 &;c., and the vomiting of fecal matter. Some of these accounts, 
 indeed, exhibit, in all their details, the characteristics of a truthful 
 statement. We would place in this category the case reported by 
 Dr. Girdlestone (of Yarmouth), and some others besides. 
 
 VI. 
 
 I desire now, gentlemen, to investigate with you, whether the 
 contradiction we noticed between ordinary anuria observed in man, 
 or experimental anuria produced in animals, on the one hand, and 
 hysterical ischuria^ on the other, be quite as absolute as it seemed at 
 first sight. 
 
 In the first group of cases, death is nearly certain to happen 
 within a brief space ; in the second, the general health is kept up 
 
 ' Etch — has presented, during the present year (1875), a new period of hys- 
 terical ischuria. On examining the table, which represents the quantity of 
 urine rendered each day, and the results of 112 chemical analyses made by M. 
 P. Regnard, we notice that, during tliree months, the patient rendered from 
 fifteen to twenty grammes of urine daily, containing from three to four deci- 
 grammes of urea. Some days, however, in the midst of painful fits, the patient 
 in a few hours emitted up to four litres of urine, containing 27 grammes of 
 urea. Daring this period, Etch — had no vomiting, by whioli urea might have 
 been evacuated, as happened on the occasions specified in the lecture. (See in 
 reference to this communication which we uuade in conjunction with M. P. Reg- 
 nard to the ' Societe de Biologie,' 3 .Juilliet, 1875). We shall have occasion, 
 furtlier on, to mention under what circumstances tins ischuria suddenly ceased. 
 (See Lecture XII ) 
 
198 GRAVITY OF ORDINARY ANURIA. 
 
 in a tolerably perfect state for an indefinite period. The opposi- 
 tion is therefore extremely marked. Is it not, however, possible 
 by a careful scrutiny of all the circumstances, to arrive at the 
 reason of this discordance? I am far from being in a position to 
 solve the problem in a decided manner. Hence, I must content 
 myself with stating an hypothesis which, perhaps, may seem 
 plausible to you, but which I request you, in any case, to take only 
 for what it is worth. 
 
 That animals should always succumb after nephrotomy, or per- 
 manent ligature of the ureters, is very natural. But we have a 
 right to ask what would happen if an experiment could be made 
 in which, for instance, the obstruction of the ureters, instead of 
 being permanent, was intermittent? Would existence be pro- 
 longed if, in such conditions, a regular alternation were established 
 between the renal and the supplemental elimination? In spite of 
 the interest which would attach to the solution of this problem, I 
 put it aside in order to come to the question of human pathology. 
 
 Let us then resume the consideration of calculous obstruction of 
 the ureters, to which we referred above. 
 
 The first remark which suggests itself to the mind is the follow- 
 ing: In our patient, complete anuresis never lasted longer than 
 a period of ten days. Now, according to what we have mentioned, 
 that is not the extreme limit at which, in obstruction of the ureters, 
 the symptoms of urtiemic poisoning necessarily appear, since, in 
 Paget's case, the patient preserved his general health and functional 
 integrity till the fourteenth day. No doubt the quantity of urine 
 secreted by Etch — on alternate days was very minute, but small 
 as it was. it is of real importance; for every author, since Halford, 
 has recognized the great relief and improvement which ensues in 
 the ureter-ischura of calculous patients, on the emission of the 
 smallest quantity of urine. 
 
 Again, we have another peculiarity: — calculous patients are 
 suddenly seized, surprised as ,it were, in the very midst of good 
 health, whilst, to judge from my own observations, hysterical 
 ischuria only arrives gradually at its apogee. Perhaps, there is a 
 question of Jvthit here, of which it is well to take heed. Far be it 
 from me, however, to suppose that hysterical patients enjoy a 
 peculiar immunity, a kind of Mithridatism, with respect to ursemic 
 intoxication. The resistance they present, in the conditions we 
 are considering, is most probably due to another cause — the ques- 
 tion here is rather one of doses. Let me explain. 
 
 The insignificant quantity of urea eliminated by our patient, 
 both in the urine and the vomited matter, must have caught your 
 attention. During a period of twelve days, we have said, she only 
 got rid of five grammes of urea daily. This amount is you are 
 aware, far below what Scherer found in the case of an insane man, 
 who had been fasting for three weeks — from nine to ten grammes 
 
MECHANISM OF HYSTERICAL ISCHURIA. 199 
 
 of urea was the quantity found in that instance.^ We have also 
 seen that there was no reason for believing that, in our patient, 
 there was any elimination of urea by the perspiration^ or the stools. 
 Now, in every case of poisoning, and uraemia is probably no excep- 
 tion to the rule, we must take the close as an element to be con- 
 sidered. 
 
 Is it not, then, most likely that this very diminution of the 
 amount of urea — which doubtless corresponded to a correlative dimi- 
 nution of extractive matters — should account, in our patient, for 
 the absence of every symptom of uraemic intoxication? We are 
 thus induced to admit that in this case of Etch — there was, so long 
 as the ischuria lasted, a decrease of activity in the phenomena of 
 disassimilation, manifesting itself by an absolute diminution of 
 excrementitious matter. 
 
 This condition, besides, is probably common to a group of hys- 
 terical cases. In fact, it has been long remarked that some of these 
 patients when subject to uncontrollable vomiting, hear up wonderfully 
 against the influence of a restricted and insufficient alimentation, 
 without losing their plumpness or suffering any disturbance in their 
 health worth noticing.^ It would certainly be of interest, under 
 such circumstances, to make comparative analyses day by day, of 
 the blood and urine, in order to ascertain the amounts of urea and 
 extractive matters present. We might, possibly, by this means 
 obtain the solution of the problem which I can only indicate here. 
 
 YII. 
 
 What is the mechanism on which hysterical ischuria depends? 
 What is the seat of the obstacle which hinders the secretion of 
 
 • It if5 proper to mention that the difference of sex and condition may have 
 contributed somewhat to this disparity of results. With respect to sex, Beigel 
 taking an average of 58 analyses, found that 35.6 grammes of urea were yielded 
 by a male in the twenty-four hours, whilst a female yielded only 27.6, in the 
 same time. It must also be remembered that Pitch — was in enforced inaction, 
 during the investigation ; and that she seems to have been unable to receive much 
 nutritious food. Lehmann, who found 53.19 grammes of urea ih the urine ren- 
 dered on the eighth day of a strictly nitrogenous diet, was able to reduce t^e 
 amount to 15.41 grammes, by living for eight days on nou-azotized food. These 
 facts go to support Professor Charcot's views. (S.) 
 
 2 According to the researches of M. Favre there are in the normal state only 
 0.43 gr. of urea in 10,000 grammes of perspiration. (S.) 
 
 3 A singular case of this kind is mentioned by Sir T. Watson (' Lectures on the 
 Principles and Practice of Physic,' vol. i, art. l,p. 704, London, 1857). "A roman- 
 tic girl," he says, "was for some months under my care in the hospital with that 
 complaint (hysterical hseuiatemesis). She vomited such quantities of dark blood 
 (which did not coagulate, however), as I would not have believed if I had not 
 seen them. Day after day there were potfuls of this stuff, yet she did not lose 
 flesh, and she menstruated regularly; an<l what was veiy curious, the vomiting 
 was always suspended during the menstrual period and recurred again so soon 
 as the natural discharge ceased. ... At last I sent her away just as bad as 
 when she entered the hospital." She recovered afterwards on getting married. 
 The alternation here may be compared with that pointed out by M. Charcot. (S.) 
 
200 MECHANISM OF HYSTERICAL ISCHURIA. 
 
 urine from being effected ? The urethra and the bladder are evi- 
 dently not incriminated. Is the obstacle in the ureter, or in the 
 kidney itself? No reason exists for suspecting the existence of 
 phlegmasia of the renal glands or the ureters; the composition of 
 the urine, and the other symptoms, likewise, are opposed to such 
 an hypothesis. It is more allowable to consider that we have here 
 to deal with some action of the nervous system. The influence of 
 the nervous system on the secretion of urine is not a doubtful 
 matter. It may suffice to remind you, by way of illustration, that 
 temporary suppression of urine may be produced in dogs by the 
 mere fact of laying open the abdomen, as M. Claude Bernard has 
 observed; and that, in the operation for vesico- vaginal fistula, it 
 also occasionally happens (as Jobert de Lamballe remarked) that 
 the urine may be suppressed for a certain period. 
 
 May it not be that, in the case of our patient, there existed a 
 spasmodic obliteration of the ureters? That these conduits possess 
 very marked contractile properties is an admitted fact : thus, 
 Mulder observed them contracting energetically in a patient suffer- 
 ing from ecstrophy of the bladder, and Valentin reports having 
 noticed a very decided contraction supervening under the influence 
 of irritation of the nervous centres.^ This supposition appears 
 to be supported by analogical reasoning, for in hysterical patients 
 we frequently find long continued contraction of the tongue, the 
 oesophagus, &c. Hysterical ischuria should, consequently, be 
 paralleled with calculous obliteration of the ureters. Unfortunately, 
 there are objections of some weight to be alleged against this 
 view. 
 
 The experimental researches of Herr Max Hermann demon- 
 strate, you are aware, that the proportion of urea to the quantity 
 of urine voided, diminishes when there is counter-pressure of the 
 ureter. If the pressure reach 0.060 millimetres of mercury no 
 more urea is found. 
 
 Mr. Roberts (of Manchester)^ confirmed the accuracy of this 
 
 1 Bonders' * Physiologie.' 
 
 2 "The Pathology of Suppression of Urine," in 'The Lancet,' 1868, May 23 and 
 30—1870, June 18 ; ' Monvement Medicale,' 1871, pp. 22, 32, 128. 
 
 Since this Lecture was delivered by M. Charcot, M. Ch. Fernet has communi- 
 cated to the Societe Medicale des Hopitaux a note entitled " De I'oligurie et de 
 I'anurie hysteriques et des vomissements qui les accompagnent " (' Union Medi- 
 cale,' 17 Avril, 1873, p. 5G6). After having stated M. Charcot's opinions, M. Ch. 
 Fernet reports an interesting case, of which the following is a summary : — 
 
 Marie L — , aged 19 years, chloro-anaemic, menstruated at sixteen years. Her 
 menstruation has always been very irregular. A sister of the patient is subject 
 to frequent hysterical seizures. In January, 1871 , Marie L — got a fright, which 
 threw her into an hysterical fit. In May, extreme debility, uneasiness, pains in 
 the limbs (strengthening regimen, bark, iron, s a-bathing). At the end of the 
 month of August, after a sea-bath, Marie L — was taken for the first time with 
 vomiting. " She began by throwing up the solid food, then, after a few days, she 
 vomited all she took. . . . These repeated vomitings continued, without inter- 
 mission, till the mouth of October, then subsided for a fortnight, when they recom- 
 
MECHANISM OF HYSTERICAL ISCHURIA. 201 
 
 statement in its relation to man. In a case of calculous obstruction 
 of the ureter, there escaped a small quantity of clear urine, con- 
 
 menced with their original intensity and persisted without respite. ... In 
 March, 1872, she was admitted to the Hotel-Dieu (under M. Moissenet's charge^. 
 
 Treatment. — Cold lotions, ice and champagne, blister with morphia, to the epi- 
 gastrium. The vomitings gradually diminished, and only appeared again at 
 intervals : the patient left the hospital on the fifteenth of April, the vomitings 
 having ceased. During the months of May and June, rare vomitings. Tiiey 
 returned in July, after some vexations, and again stopped, owing probably to the 
 influence of bromide of potassium. At the end of July, another emotional disturb- 
 ance set them again in action with their former frequency and persistence. 
 
 Marie L — was admitted a second time to the Hotel-Dieu, on the 18th of August, 
 1872. She then came under M. Ch. Fernet's observation, when she presented 
 the following symptoms: excessive debility ; ansemia very marked, characterized 
 especially by discoloration of the skin and mucous membranes ; intercostal neu- 
 ralgia ; ovarian sensibility developed on the left side, painful on pressure; 
 anfesthesia existing on diflferent points of the skin ; complete plantar annesthesia ; 
 profound analgesia of the superior extremities ; achromatopsia of the left eye, 
 which cannot distinguish yellow tints : vomitings. The patient alleges that, 
 since their appearance, she only voided a very minute quantity of urine, that she 
 often remains for several days without voiding even a drop. 
 
 Septnnher 4. — Milk-diet, exclusively. From the 4th to the 9th September, there 
 was but one emission of urine (about 150 grammes). From this epoch, M. Ch. 
 Fernet caused to be exactly weighed, 1st the quantity of food taken, and 2d the 
 amount of urine voided and of matters vomited, and, after recording these quan- 
 tities day by day, he says : '* The examination of this table allows us to establish 
 a close connection between the state of the urinary function and the vomitings. 
 In a first period, comprised between the ninth and sixteenth September, that is to 
 say, eight entire days, the urine was completely suppressed during the first six 
 days, and its quantity was very scanty during the last two ; now, in this period, 
 the patient, being on a milk-diet, vomited a quantity of liquid matter, at first 
 equivalent to one-half or three-fourths of the fluids swallowed during the lirst 
 four days, then a quantity perceptibly equal to the quantity of milk taken during 
 the last four days. 
 
 " In a second period, comprising nine days (from the 18th to the 2(3th Sept.), 
 the quantity of vomited matters seems to have diminished ; but this is not 
 exactly the case, as we see on comparing it with the quantity of food taken. The 
 diet having been changed, and being now cotnposed of cold soup {hou.dlon'), of raw 
 beef, and of lemonade, the vomited matter still represents almost the whole of the 
 ingesta. Now, during this time, there was a little urine the first two days (15 
 grammes and 250 gr.), but its emission was suspended during the seven days 
 following. 
 
 " Finally, in a third period, lasting four days (from the 27th to 30th Sept.), 
 we see the urinary function re-established, and the amount of urine reaching the 
 normal standard (1000 grammes, 500 gr., 1100 gr. the last two days) : at the 
 same time, the vomitings diminished on the second day and subsided on the 
 third and fourth." 
 
 Desirous of ascertaining whether, as indicated \>y 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 <he tip of the tonsue on the right, and over the 
 space of an inch in len^ith, the patient d^es not feel the taste of salt Same result 
 a< regards the right half of the dorsum and root o^' tlie tongue On the right side 
 a'so, tlie sense of smell is weakened, and vui'm is less d'stinct When the pupils 
 have been mode to contract by bring ng a light c'o-e to the eyes, the right pupil 
 a'terwards dilates more than the lelt, the sen e of hearing is normal on both sides. 
 February 26.— Tlie ansesthes a hits diminislied; the movements a'e more energetic. 
 March 15. — Temporary improvement of vision; no d fference between the two 
 eyes. Aprd 3. — Tl e ansesthes a still exists over tlie right half of the body (on 
 touch, and pinching). Deb lity of vision anj;mented on the r'ght. Died April 4. 
 
 Autopsy. — In the white substance of the lelt superior lobe, is found a focus of 
 ramolissement two ii ches in length and one in breadth. It dipped into the infe- 
 r'or convolut'ons of the ope'culuni, and attained the surface of the brain. Its pos- 
 terior extremity corresponded to that of the opt'c thaamus; its anter'or part 
 greatly exceeded that of the tha amus. In its broadest portion, the focus was only 
 tepaia'ed by three lines from the tail of the corpus striatum. The convolutions 
 lying beneath, were to the extent of a florin, yellow, softened, atid depressed. (F'g. 
 18, 3.) Optic thalamus healthy, perhaj s a little fragment of tlie third part of the 
 lenticular nucleus has been touched. The focus had destroyed a somewhat con- 
 siderable length of white substai ce, and the two external thirds of the foot of the 
 corona radiata. Spinal Core/.— Slight agglomeration of nuclei in the most poste- 
 rior part of the lateral column. 
 
 Case 4. — Anne B — , an aged woman, d"ed 22d February. For many years she 
 had right hemiplegia, with intense ansestliesia of the same side. In addition, 
 sensorial anaesthesia (sight, smell, taste) of the same side, and formications. 
 
 Autopsy. — Old apoplectic focus, pigmetited brown, situated along the outer part 
 of the left optic thalamus, and quite close to the tail of the corpus striatum. It 
 c(:mmences six lines b hind the ai>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 c<dumn. 
 
 To sum up: the f ci were seated at the external periphery of the optic tha'ami, 
 they extended, from before ba- kwards, in the longitudinal axis of the cerebrum, 
 without, in uust ca>es, 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 <i«'signate that period of a disease when the symptoms 
 having attained their utmost intensity, may remain for some time stationary, as 
 it were. (S.) 
 
CLINICAL CASES. 229 
 
 Case I. — Marc — , aet. 23, suffering from hystero-epilepsy since 
 the age of 16. It is not certain to what cause the origin of the 
 disorder should be attributed. However that may be, she presents 
 the following phenomena of local hysteria: hemiancesthesia, ovaria^ 
 and paresis, on the left side. She is likewise subject to frequent 
 vomiting, and has had achromatopsia of the left eye. 
 
 The attacks are preceded by a characteristic aura; the premoni- 
 tary phenomena start from the left ovary, and the cephalic symp- 
 toms are very marked. With respect to the seizures, they are 
 composed of three periods; a, tetaniform, epileptiform convulsions, 
 foaming at the mouth; — 6, (period of contortions) great move- 
 ments of the body and lower extremities; during this stage, the 
 patient gives utterance to strange words, and seems a prey to 
 moody delirium : — c, tears and laughter announcing the end of the 
 attack. In her case, a prompt and absolute cessation of all the phe- 
 nomena is determined by compression of the left ovary. 
 
 Case II. — Cot — , aet. 21, hysteria began at the age of fifteen. 
 The ill-treatment she had suffered from her father, who was addicted 
 to alcoholic excesses, and her subsequent career as a prostitute, have 
 doubtless exerted a certain etiological influence. The local hysteria 
 is still more marked in this case, than in the former one. We have 
 to note on the right side hemiancesthesia, ovarian pain, and perma7ie7it 
 contracture with trermilation of the lower extremity. 
 
 The attack is heralded by a distinct aura, proceeding from the 
 right ovary, and terminating in very evident cephalic symptoms. 
 The convulsions, which are chiefly tonic, are complicated by epilep- 
 tiform phenomena: C — bites her tongue, foams at the mouth, etc. 
 The period of contortions follows, and is very intense. The attack 
 frequently terminates by contortions of the pelvis, with laryngeal 
 constriction, tears, and an abundant flow of urine. In her case, 
 compression of the ovary modifies the intensity of the fit, without, 
 however, arresting it. In the first months of the year, this patient 
 was stricken with the hystero-epileptical acine, to which we will 
 return in another lecture.^ 
 
 Case III. — Legr — Genevieve, was born at Loudun. The coin- 
 cidence is curious — for that, you know, was the scene of the sad 
 drama of which Urbain Grandier was the victim. Genevieve is 28 
 years of age ; her hysteria dates from the period of puberty. Among 
 the permanent symptoms of local hysteria, we observe well-marked 
 left hemiancesthesia, left ovarian pain, with easily discerned tumefac- 
 tion. Her mind, finally, is in a strange state. 
 
 The aura is very distinct,and the cardiac palpitations and cephalic 
 phenomena constitute the predominant symptoms. Each seizure is 
 
 • This case is detailed in full in the treatise by Bourneville and Voulet, ' De 
 la contracture permauente.' Obs. viii, p. 41. 
 
230 CLINICAL CASES. 
 
 divisible into three stages: 1st, epileptiform convulsions, foaming, 
 and stertor ; 2d, then contortions of the limbs and entire body ; 3d, 
 the period of delirium^ during which, at the close of complete 
 attacks, she relates all the incidents of her life. 
 
 Sometimes the patient, in this latter phase, has haUucinations ; 
 she sees ravens and serpents; moreover, she commences a kind of 
 dance, and then she exhibits, as it were, in an embryonic state and 
 sporadic form, a specimen of those dances of the middle ages, de- 
 scribed under the name of saltatory epidtmics (or the dancing ma- 
 nia). In connection with this, I would have you note that certain 
 cases of hysteiia— forming, in some sort, varieties within the spe- 
 cies — present in a rudimentary state the different convulsive forms 
 which are exhibited in a highly developed state in the time of epi- 
 demics. This, indeed, is a point which Valentiner has thoroughly 
 discussed in his interesting work on hysteria.^ 
 
 In Genevieve's case, compression of the ovary determines what 
 we might call a sudden arrest of the attack. She has a clear con- 
 ception of its influence, for she herself tries to compress the region 
 which gives birth to the aura, and when she cannot succeed, she, 
 as we have already mentioned, calls for help from the attendants. 
 
 Case IY. — Ler — , set. 48, is a patient well known to all the 
 physicians who, during the last twenty years, have frequented this 
 hospital, in the discharge of various duties. In other words, hers 
 is a cas cel^hre in the annals of hystero epilepsy. You will find the 
 early portion of her history narrated in the thesis of M. Dunant (of 
 Geneva). Ler — ceased to menstruate four years ago, notwithstand- 
 ing which, the nervous accidents persist. We called on you just 
 now to observe the presence of a rudimentary form of Tarantism 
 in Genevieve's case; Ler — is a Demoniac, one "possessed by a 
 devil," — or, again, she presents the image, not much f^iinter than 
 the reality, of one of those women who were called " Jerkers" in 
 the Methodist Camp Meetings, and who assumed the most horrify- 
 ing attitudes in their paroxysms. (See Figs. 19, 20, and 21.) 
 
 The probable cause of these nervous accidents in the case of 
 Ler — deserves mention. She had, as she says, a series of frights: 
 1st, at the age of eleven, she was terrified by a mad dog; 2d, at the 
 age of sixteen, she was struck with horror at the sight of the 
 corpse of a murdered woman; 3d, at the same age, she was again 
 terrified by robbers, who, as she was passing through a wood, 
 rushed out to despoil her of the money she carried. 
 
 The components of local hysteria, in her case, are formed by 
 JiemirKjesthesia, ovuria^ paresis^ and momentary cordractures of the 
 upper and lower extremities on the right side. Sometimes the 
 
 • Valentiner (Th.), " Die Hysterie uud ihre Heilung," v. q. extract in 'Mouve- 
 ment Metlical,' June, 1872. 
 
CLINICAL CASES, 
 
 231 
 
 phenomena invade the left side, and then, in accordance with our 
 description, we find double ovaria, with double anaesthesia, etc. 
 
 The attacks, which are heralded by a well marked ovarian aura^ 
 are characterized in the first stage, by epileptiform and tetaniform 
 convulsions; after this come great gesticulations of a voluntary 
 characte", in which the patient, assuming the most frightful pos- 
 tures, reminds one of the attitudes which history assigns to the 
 demoniacs (period of contortions, Figs. 19, 20 and 21). 
 
 Fig 1'^ — Attitade of Ler — during the attack ; period of contortion, 
 of a sketch from nature ) 
 
 (Fac-simile 
 
 At this Stage of the attack, she is a prey to delirium, and raves 
 evidently of the events which seem to have determined her first 
 seizures. She hurls furious invectives against imaginary indi- 
 viduals, crying out, " villains ! robbers ! brigands 1 fire ! fire ! Ob, the 
 
232 
 
 CLINICAL CASES. 
 
 dogs! I'm bitten!" — Reminiscences, doubtless, of the emotions ex- 
 perienced in her youth. 
 
 When the convulsive portion of the attack is ended, there super- 
 vene, as a general rule: 1st, hallucination of vision ; the patient 
 beholds horrible animals, skeletons, and spectres; 2d, paralysis of 
 the bladder; 3d, paralysis of the pharynx; 4th, and lastly, a more 
 or less marked permanent contracture of the tongue. 
 
 Fig 20. — Attitude of Ler— during the attack ; period of contortion. (Fac-simile 
 of a sketch from nature.) 
 
 These latter phenomena occasionally render it necessary to have 
 recourse, for several days, to the use of the catheter, and to the 
 employment of the stomach pump for alimentary purposes. 
 
CLINICAL CASES. 
 
 233 
 
 Compression of the ovary, in this case of Ler — , is almost void 
 of effect upon the convulsions.' 
 
 Fig. 21. — Hystero-epileptic attack ; period of contortions, 
 from a sketch made by M. Charcot.) 
 
 (Drawn by M. Richer 
 
 Case Y. — You are already acquainted with this patient, named 
 Etch — ; it is she who furnished us with materials for our lecture 
 on hysterical ischuria? We note, also, in this case, the absence 
 of hemiancesthesia, achromatopsia, contracture^ and ovaria on the left 
 side. The attacks are principally tetuniform and tonic. We have 
 not, hitherto, had the opportunity of testing, in her case, the influ- 
 ence of ovarian compression upon the convulsions. 
 
 ' We published the detailed account of this patient's case in the 'Progres 
 Medical,' (Nos. 18-33, 1875). 
 2 Vide ante, Lecture ix. 
 
234 
 
 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. 
 
 Gentlemen, — In his standard treatise on hysteria, M. Briquet, 
 though he does not give to the history of permanent contracture^ 
 which may affect one or several members in hysterical cases, all the 
 consideration that in my judgment it deserves, yet traces with a 
 sure hand the most salient features of this symptom. This, he 
 writes, is a rare complication. He had, in fact, only met with it 
 six times at the period when he published his work. In one case, 
 the contracture occupied one limb only; in two others, it appeared 
 under a hemiplegic form ; and in the last three cases, it assumed the 
 paraplegic form. It is perfectly true that hysterical contracture 
 can present these several aspects. You will, besides, verify the 
 fact for yourselves, as I am fortunate enough to be able to place 
 under your observation two patients, one of whom presents the 
 hemiplegic form and the other the paraplegic form of hysterical 
 contracture. We are thus enabled to make you touch with the 
 finger, as it were, the most interesting peculiarities connected with 
 this singular manifestation of hysteria. 
 
 I. 
 
 Etch — , now aged 40 years, has been affected for twenty months 
 with left hemiplegia. You perceive the superior extremity of this 
 side is in semiflexion (fig. 22); it is the seat of considerable rigidity, 
 a fact attested by the difficulty experienced in trying to increase 
 the flexion, and the impossibility of obtaining complete extension.^ 
 
 The left lower extremity is in exterjsion ; its several parts are, so 
 to speak, in a forced posture. Thus the thigh is strongly extended 
 on the pelvis, the leg upon the thigh. The foot presents a most 
 
 ' At the present moment (July, 1873) the contracture of the left extremities is 
 observable, with all the characteristics described in the lecture, which was de- 
 livered in June, 1870. [Etch — has since recovered, see ivfrd,, pp. 240-1. S.] 
 
HYSTERICAL CONTRACTURE, 
 
 235 
 
 marked example of talipes equino- varus. la addition to this, the 
 adductor muscles of the thigh are, also, spasmodically contractu red. 
 In short, all the joints are alike rigid, and the whole limb forms 
 as it were an inflexible bar, for, by grasping the foot, you can raise, 
 in one piece, the inferior portion of the patient's body. I lay par- 
 ticular stress upon this attitude of the lower extremity, because it is 
 very rare in hemiplegia arising from circumscribed cerebral lesion 
 {enfoyer)^ and is, on the contrary, as it were, the rule in hysterical 
 contracture. In the latter case, permanent flexion of the thigh and 
 leg is, to judge from my own experience, a really exceptional fact. 
 
 Fig. 22. — Contracture of left upper extremity. 
 
 We have here a permanent contracture in the rigorous sense of 
 the word; I have assured myself that it is nowise modified during 
 the profoundest sleep; in the daytime, there are no alternations of 
 increase or remission. The slumber alone, which chloroform pro- 
 cures, causes it to disappear if the intoxication produced be con- 
 siderable. 
 
236 HEMIPLEGIC FORM. 
 
 Although the hemiplegic contracture by which our patient is 
 affected is, I repeat, of nearly two years' standing, you perceive 
 that the nutrition of the muscles has not sensibly suffered. I 
 should also add that the electrical contractility has remained nearly 
 normal. 
 
 I would point out to you, in passing, that, by forcibly setting 
 back the point of the foot, you determine in the contractured lower 
 extremity a trepidation which sometimes persists long, even when 
 the foot is let go, and allowed to resume its former attitude. You 
 are aware that this same trepidation is very commonly met with in 
 paralysis with contracture, arising from an organic spinal lesion, 
 as, for instance, when the lateral columns are affected with sclerosis ; 
 but I have likewise seen it, in a number of cases, in which hys- 
 terical contracture ended suddenly in the patient's recovery. 
 Hence, you will observe that this phenomenon is not one of abso- 
 lute worth, so far as an anatomical diagnosis is concerned.' 
 
 ' In 1868, in the course of my lectures at La Salpetriere, I called attention to 
 the peculiar trembling which, in certain patients affected by paralysis, or even 
 by paresis, of the lower extremities, was produced in the foot when it was c night 
 by the point and suddenly turned back (y. A. Dubois, " Etude sur quelques 
 points de I'ataxie locomotrice progressive," 'These de Paris,' 1868). 
 
 The trepidation, thus provoked, generally stops as soon as the foot is no longer 
 kept in dorsal flexion ; sometimes, however, it persists for a little time after. 
 Limited to the foot in manj' cases, it extends often to the entire litnb, and some- 
 times even to the lower extremity of the opposite side. In cases where the 
 trembling in question can be provoked by the method described, it frequently 
 also shows itself, either spontaneously (at least apparently so) or under the in- 
 fluence of the movements made by the patient to raise himself in bed, to rise 
 from it and stand, or ag in whilst walking. 
 
 Trepidation of the foot, whether provoked or spontaneous, shows itself in vari- 
 ous circumstanct^s when the lateral fascicles of the spinal cord have become, 
 throughout a certain extent, the seat of a slow connective proliferation. These 
 conditions are, it is plain, the same as those in which, at a later period than the 
 trembling, the production of permanent contracture takes place. Tfius spontane- 
 ous or provoked tremulation, whether limited to the foot or generalized, is 
 observed in si/mmetrical sclerosis of the lateral columns, in dissenvnated sclerosis, 
 whenever the spinal foci occupy the lateral tolumns to the extent of some inches 
 in length. They are seen when s'ieros s d cendens has been established consecu- 
 tively on compression of the cord, caused by a tumour ; in acute or subacute 
 transverse mi/elitis ; or, again, in lateral sclerosis, consecutive on certain crrebral 
 lesions such as, for instance, circumscribed ramollissement, or hemorrhage of the 
 opto-striate bodies, involving the capsula interna. The trenulation in question 
 is, therefore, not the appanage of any one disease in particular; it is connected 
 with affections of very different origin, but in which 1 4eral sclerosis is a common 
 feature. However, its presence in cases of hysterical contracture, terminating 
 abruptly in recovery, shows that it cannot always be attributed to a perceptible 
 material lesion of the lateral columns (Dubois, loc. cit., Charcot et Joffroy, 
 * Archives de Physiologie,' 1869, pp. 632 et seq. ; Charcot, ' Legons sur les Mala- 
 dies du Systeme Nerveux,' Ire Edition, pp. 218, 307, 319). 
 
 Quite recently Herr Westphal and Herr Erb have each devoted to the study of 
 this symptom a treatise, accompanied with ingenious physiological views. Ac- 
 cording to these authors, provoked tnpidation of the foot (which is designated by 
 Herr Westphal under the name FiiszpJiauomenon) would be a reflex phenomenon, 
 having its starting point in the tendons (W. Erb, " Sehnenreflexe bei Gesiinden 
 und bei Riickenuiarkskranken," * Arohiv fiir Psychiatrie,' iv Band, 3 heft, p. 
 
CHARACTERS OF HYSTERICAL CONTRACTURE. 237 
 
 Leaving out of the question the difference we have mentioned 
 respecting the attitude of the lower extremity, all the other peca- 
 liarities we have described might, strictly speaking, apply to a case 
 of organic hemiplegia, resulting from a deep-seated lesion of the 
 encephalon, as hemorrhage or ramollissement, for instance. 
 
 Another feature of resemblance is the following : hemiplegia 
 showed itself suddenly in Etch — during a seizure. After this 
 attack, the patient remained for several days without consciousness. 
 
 Having indicated the analogies, I must point out the differences. 
 They are numerous and emphatic, and in point of fact, nothing is 
 more simple than to assign hysterical contracture to its proper 
 cause, by taking note of characters which are almost always present. 
 
 1st. Remark, in the first place, gentlemen, the absence of facial 
 paralysis and of deviation of the tongue, when that organ is pro- 
 truded. You know that these phenomena always, on the contrary, 
 exist to some extent in hemiplegia resulting from circumscribed 
 cerebral lesion.^ 
 
 2d. Observe also the existence of an analgesia and of an anaes- 
 thesia, which may be termed absolute, extending over the entire 
 paralyzed half of the body, and consequently occupying the face, 
 trunk, etc. This alteration of sensibility involves not only the 
 ekin, but also the muscles, and perhaps the bones ; it stops exactly 
 at the median line. 
 
 This kind of generalized anaesthesia, occupying a complete half 
 of the body — head, trunk, and members — this quasi-geometrical 
 limitation of the anaesthetic portion by a vertical plane dividing the 
 body into two equal parts, are, as it were, the peculiar property of 
 hysteria.^ However it happens, this symptom is very rarely ob- 
 served in hemiplegia of cerebral origin, and in case of spinal hemi- 
 plegia, that is, of hemiplegia resulting from a unilateral lesion of 
 the spinal cord, the anaesthesia, as M. Brown-Sequard has shown, 
 would occupy the side opposed to that affected by motor paralysis. 
 
 3d. We have many other distinctive characters to point out. 
 The patient is intelligent, and we have no reason to suspect her 
 sincerity. She can, therefore, give us authentic information with 
 
 792, 1875 ; C, Westphal, " Ueber einige Bewegungs-Erscheimnngen an geVahraten 
 Gliedeni," Idem, p. 883; W. Erb, " Ueber eineii weiiigbekaiinten Spinalen Symp- 
 tomeiuomplex," in * Berliner Klin. Wochenschrift,' 1875, No. 26). 
 
 In some cases of paralysis of tbe upper extremities, wben, for example, we 
 have hemiplegia consecutive on lesion of the internal capsule, and when per- 
 manent contracture is not too marked, we can succeed, by suddenly extending 
 the fingers, in producing a spasmodic trembling of the hand, similar in every 
 respect 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. 
 
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 6 
 
 7 
 
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 too; 37.° 
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 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<iru'ent. The di<:estive tube presents no particular symptoms ; there was a 
 stool after enema yesterday; Ch — micturates in bed. Erythematous patch ou 
 the left gluteal region, profuse perspiration, augmented at intervals. At eleven 
 o'clock: pulse 120: respiration 49, noisy ; rectal temperature, 40.80 (=105.-140 
 F.). At noon pulse 130; respiration 60 
 
 Six o^clock P. M. — Seventy-six fits have been noted since eleven o'clock A. M. 
 of which thirteen occurred after half-past four o'clock P. M. Respiration GO ; 
 rectal temperature, 41. 30 C. (=106.340 F.). Copious persp'ration over the whole 
 body, on both sides indifferently. The entire left side of the body (face, trunk, 
 &c.) is plainly warmer than tiie right. 
 
 The eyelids are half open ; the eyes turned up; the pupils are moderately di- 
 lated (the right still the more enlarged). Before every fit dilatation of the pupils 
 augments in a remarkable manner The nystagmus seems to appear almost simul- 
 taneously. Neither vomiting, nor stools, nor micturition. Same condition of 
 right gluteal region. Coma. Stertorous breathing. 
 
 Eight 0^ clock P.M. — Pulse — ; respiration 70; rectal temperature 41. 20 C. 
 Fourteen fits. From this time fortii the patient had no more fits. She died at 
 three o'clock in the morning. Vaginal temperature (taken by another) was 41.20 
 (=101.100 F.). At eleven o'clock in the morning on the 11th February, z. e., 
 eight hours after death, rectal temperature 40O (:=104O F.) (the corpse remaining 
 in the bed). The pupils are moderately dilated, and both equally. Numerous 
 livid stripes or wheals on the belly, ba«k, buttocks, and thighs. 
 
 Post-mortem, Feb. 18. — The bones, dura mater, and sinuses present nothing ab- 
 normal! The quantity of cephalo-rachidian liquid is not augmented. Sanguine- 
 ous suffusion on the convex surface of the cejebral hemisplieres, especially on the 
 right. Arteries, at the base of brain, healthy. Weight of encephalon, 1360 
 grammes. The pia mater is very slight y injected at base of brain ; most markeil 
 at the sphenoidal lobe. The pia mater is easily detached ou both sides, and the 
 brain is equally moist. 
 
 Right hemisphere. — It weighs 5 grammes (=77.17 grs.) more than left. On 
 certain convolutions, chiefly those lying adjacent to the Sylvian fissure, we note 
 a hortensia coloration, some little abrtsions, and, on a few, a very fine red punc- 
 tuation. The convolution of the cornu Ammonis presents a very evident indura- 
 tion. This induration, which ascends interiorly along the said convolution, pro- 
 dominates at its extremity. 
 
 Left hemisphere. — The cornu Ammonis presents an induration much less marked 
 and circumscribed at its extremity. 
 
 Nothing notable in the cerebellum and isthmus. 
 
 Spinal cord. — The gray substance, viewed with the naked eye, seems a little 
 deformed. 
 
 Thorax. — Considerable congestion of the lower half of the lungs. There is, 
 moreover, a focus of red, recent hepatization in the lower lobe. 
 
 Heart, stomach, spleen. — Healthy ; no ecchymoses. Liver, not congested. Kid- 
 neys, anaemia of cortical substance ; pyramids distinct. Bladder, nothing. Ute- 
 rus, fair size ; recent corpus luteum ou one of the ovaries: small cysts on the 
 other (B.). 
 
 ' Westphal, loc. cit. 
 
TEMPERATURE. 257 
 
 supervene in the course of disseminated sclerosis,^ and, lastly, in 
 the attacks accompanied or not by convulsions which take place in 
 cases of old cerebral foci (hemorrhage or ramollissement) or of cere- 
 bral tumors, whatever their origin. This thermic increase con- 
 trasts, in a remarkable manner, with the initial decrease which 
 almost always exists at the moment of the formation of a cerebral 
 hemorrhagic focus, — and that, as I have demonstrated, is a charac- 
 teristic which may be profitably used in making a diagnosis. 
 
 But it is time to return to epileptiform hysteria, from which this 
 digression has somewhat separated us. Complex fits are observed 
 in hystero-epilepsy precisely as in true epilepsy. Landouzy speaks 
 of one hysterical patient who had up to 100 fits a day. The hys- 
 tero-epilejHical acme may, besides, be prolonged over a considerable 
 space of time. Georget quotes the case of a woman who suffered 
 from an almost continuous succession of fits extending over forty- 
 five days. 
 
 In the case of our patient Co — , whose seizures bear such a pre- 
 dominant and strongly-marked epileptiform character, the paroxys- 
 mal acme persisted over two months^ and, at times, the accidents 
 attained the highest degree of intensity. Thus, to mention one 
 instance, on the 22d of January, the epileptiform convulsions 
 followed each other, without interruption, from nine o'clock in the 
 morning until eight in the evening ; from eight until nine o'clock 
 there was a resting space, after which the atacks came on again, 
 as though with renewed vigour, and persisted, without the least 
 lucid interval, for about the same length of time. We may with- 
 out any exaggeration calculate that in round numbers she expe- 
 rienced from 150 to 200 epileptiform fits in the space of a day at 
 that period. 
 
 Does not the persistence of such a state, without a fatal termina- 
 tion, already indicate by what an abyss true epilepsy is separated 
 from hystero epilepsy ? " If that were not hysteria," said the ex- 
 perienced head nurses of these wards, speaking of Co — , whose 
 seizures they watched, "if it were really epilepsy, the woman 
 would have succumbed long ago." This remark is thoroughly 
 well-founded and perfectly correct. 
 
 "Well, gentlemen, here is the point upon which, especially, I wish 
 to lay stress, — never, during that long convulsive period, was the 
 rectal temperature modified in a perceptible manner, in the case of 
 Co — ; on an average it stood at 37.8° C. (= 100.4°F.), it only rose 
 to 88.5° C. (= 101.3° F.), in a quite exceptional and transient man- 
 ner. (Fig. 26.) 
 
 I should add that, during all this time, the general condition of 
 the patient never gave us the least uneasiness, in spite of the in- 
 sufficiency of her alimentation and the enormous amount of mus- 
 
 » V. anU, Lecture VIII. 
 
 17 
 
258 
 
 TEMPERATUEE. 
 
 cular force she must have expended. Again her mental condition 
 was, by no means, so deeply modified as it would necessarily have 
 been if the disease had been true epilepsy. At no period was 
 there involuntary evacuation of urine or feces. In the brief re- 
 spites allowed her by the fits, the patient rose to satisfy the require- 
 ments of nature. In these intervals, also, which were in truth very 
 brief, the hysterical character of the disease showed itself in all its 
 fulness, especially during the first weeks. A flower twined in her 
 hair, fantastic curls, an old bit of mirror attached to the bed -post, 
 — these things sufficiently attested the favourite occupations of this 
 woman during her intervals of ease. 
 
 Jmm 19 20 21 22 23 24 25 26 
 
 
 A 
 
 T^ 
 
 38° .^:i t^ 
 
 ^^^"^ :s s^^ 
 
 Sh'^SV 
 
 2 t 
 
 
 
 37° X 
 
 Fig. 26. 
 
 But I desire, above all, to call your attention to the thermal state 
 which careful investigation enables us to discover. It would, in 
 short, follow from what precedes that, whilst, in the majoi^ acme of 
 epilepsy, the temperature rises very rapidly to a high degree, and 
 the position of affairs becomes extremely critical, — in the major 
 acme of hystero-epilepsy on the contrary, the temperature rarely ex- 
 ceeds the normal standard, whilst the concomitant general state of 
 the patient is not of a kind to inspire uneasiness. It is not neces- 
 sary, I think, to dwell at any length upon this topic in order to 
 emphasize so striking a contrast. 
 
 I do not, however, gentlemen, want you to take in its strictly 
 literal meaning the last term of the proposition which I have just 
 enunciated ; it undoubtedly applies accurately to the great majority 
 of cases, but the chapter of exceptions exists. It would not, in 
 fact, be unexampled to find hysteria terminating in death during 
 the convulsive phase. It is true that this sad result is nearly 
 always owing to a peculiar kind of attack, the dyspnoeic seizure} 
 But I repeat, the convulsive fits may themselves be the cause. 
 As an example, I may remind you of a case of this character pub- 
 
 » Briquet, loc. cit., pp. 383 et 538 
 
HYSTERO-EPILEPSY — FATAL CASES. 259 
 
 lished by Herr Wunderlich.^ It relates to a case of hjstero- 
 epilepsy, comparable in many respects to that which I have just 
 described. 
 
 ^ The following is a translation (after M. Teinturier) of Wunderlich's case to 
 which M. Charcot alludes : 
 
 Note. — Eight weels of apyretic hysteriform convulsions, ivithout apparent danger. 
 Sudden and deplorable change, without augmentation of paroxysmal intensity. Death 
 in the course of a few hours, loith a temperature of AZ^ C. (=109 •40F.) 
 
 Anna Vogel, set. 19, servant, had twice menstruated in the fortnight before 
 falling ill, but otherwise in good health, was taken with convulsions, for the first 
 time, on the 13tli August, 1855, after a severe scolding, according to her own ac- 
 count. The convulsions came on again, in the evening of the 17th, and in the 
 morning of the 18th, and continued almost uninterruptedly throughout the night, 
 from the 18th to the 19th. Admitted at noon on the 19th. She presented at 
 midnight slight subsultus in the left arm, in which the presence of paralysis 
 without insensibility had been noted. Then she experienced a feeling of anguish 
 (constriction in the epigastrium), gave a slight cry, and had convulsions, first in 
 the left half of the face, and then in the right also ; the mouth was open, the eye- 
 lids were alternately opened and closed, the eyeballs turned greatly upwards. 
 Then supervened violent and rapid clonic convulsions in the lower extremities 
 and pelvis, by which these parts were projected forward, backward, and sideways. 
 The face was cyanosed, and foam flowed from the mouth. At the end of a minute, 
 deep and superior breathing ; relaxation of the limbs and face. Afterwards sleep, 
 apparently peaceful ; lastly, yawning, opening of the eyes, and return to conscious- 
 ness after six minutes. 
 
 The patient is in good condition, her tongue is little loaded ; the temperature 
 is 38.12CC.(=100.GO F.), the pulse 140 (after the fit) ; nothing abnormal. She 
 says, however, that she cannot move her left arm, and requests that it shall not 
 be touched, because otherwise she will get convulsions. Nevertheless, she can 
 grasp strongly with tlie left hand. 
 
 In the night of the 19-20th six seizures ; and in the day following, seven seizures. 
 No albumen in the urine; considerable uric sediment. Tongue loaded. Tempera- 
 ture, morning and evening, 38.120C. (=100.60 F.) ; pulse 132 ; respiration 24—32. 
 In the night of the 20-21st, seven seizures ; thirteen seizures till the morning of 
 the 22d. Temperature, 37. 76^ (=:99.9(JOF.) ; stools normal ; urine slightly turbid 
 from the presence of albumen. 
 
 From eight to sixteen fits a day, in the following days. Condition otherwise 
 tolerable ; no marked elevation of temperature, which is generally normal, never 
 above 38.120 C. (=100.60 F.), except one evening, when it reached 38.750 
 (=101.750 F.) ; pulse usually above 112; tongue loaded. On the 16th, confluent 
 vesicular miliary eruption on the finger tips. Urine charged with phosphates, 
 without albumen. During the seizures she sometimes loses consciousness, some- 
 times not ; occasionally shrieks greatly. Sensibility persists in the left arm and 
 leg. 
 
 1th September. — The fits become more frequent, last Severn 1 days without 
 interruption ; during the seizures she often talks and sVirieks. Frequent evacua- 
 tions of urine and feces in bed. Improvement, then stationary condition until the 
 evening of the 2d October, when the patient presents a marked attack of collapse. 
 In the night of the 3d no particular seizui'es. In the morning agitation of the 
 arras and divergent strabismus. The head inclined forward and to the left ; 
 consciousness preserved; slight cyanosis. From ten o'clock forth, deglutition 
 impossible ; at noon, trismus ; at a quarter to two o'clock, strong convulsions, not 
 affecting the head ; pulse extremely frequent ; temperature, 41. 870 ; intense cy- 
 anosis, foaming at the mouth; tracheal rale. Died at a quarter past two o'clock ; 
 temperature, 43. lo C. (=109.580 F.). A quarter of an hour afterwards, tempera- 
 ture 42.750 C. (=108 950 F.). 
 
 Post-mortem. — Body in good condition ; large cadaveric spots in the lower part ; 
 no muscular rigidity. The cranium and its contents gorged with blood ; posterior 
 convolutions slightly flattened ; cerebral substance rather hard. Slight turbid 
 
260 HYSTEKO-EPILEPSY — FATAL CASES. 
 
 The patient in question experienced epileptiform attacks for more 
 than eight weeks, though in number they were somewhat limited, 
 and not accompanied by any marked augmentation of temperature 
 when suddenly — without known cause, without the intervention of 
 new accidents — the scene changed two days before death ; the pa- 
 tient fell into collapse, and in a short space of time the temperature 
 rose to 43° (= 1094° R). 
 
 This example, gentlemen, will suffice to show you that, in pre- 
 sence of a case of hystero-epileptic acme, whatever be its intensity, 
 or however great the chances of a favorable issue, it would be im- 
 prudent to abandon ourselves to a feeling of complete and absolute 
 security. 
 
 thickening of the pia mater at the base of brain. Capacity of cerebral cavities 
 nearly normal, parietes usual consistence. Pons and medulla injected with blood, 
 dirty grayish red. Lungs congested and oederaatous. Heart normal. Liver fatty 
 here and there, exsanguine ; bile, clear and dark brown. Spleen, small, soft, pale 
 brown, exsanguine. Stomach dilated, otherwise normal, as were the intestines. 
 Kidneys greatly gorged with blood : concretion size of half a pea in calyx of left 
 kidney. Uterus normal. Ovaries containing numerous cysts, as large as peas 
 (Wunderlich, ' Arohiv der Heilkuude,'t. v, p. 210). 
 
APPENDIX. 
 
 CASE OF PAEALYSIS AGITANS. 
 
 Antecedents. — Probable cause of disease. Commencement; the members 
 successively invaded by debility. Tremor of the head^ then of the 
 limbs. 
 
 State of the patient in 1874 ; general attitude. Tremor. Gait : 
 propulsion and retropulsion. Temperature, pulse, etc. 
 
 Modifications supervening in the disease, from July, 1874, until 
 July, 1875. 
 
 Gav — Annie Marie, oet. 62, was admitted to La Salpetrie, 
 December 3 1st, 1872; came under M. Charcot's charge (Salle St. 
 Alexandre, No. 8), on the 12th November, 1873. 
 
 Antecedents. — Her father, a carpenter, died of an accident when 
 she was only twelve years of age. Her mother, who succumbed 
 at the age of seventy-four, was of a nervous disposition, easily 
 moved to passion, but had been affected neither by tremor nor by 
 paralysis. Her only sister died of pleurisy at forty. None of 
 her relations, so far as she was aware, suffered from nervous affec- 
 tions nor, particularly, from tremor. 
 
 Gav — arrived in Paris at the age of four. Her childhood and 
 youth passed without the occurrence of any incident worth notic- 
 ing. From the age of fourteen she menstruated regularly.- Hav- 
 ing married at the age of twenty-eight, she has had five children. 
 Pregnancy and confinement generally favorable. Of the five chil- 
 dren, the eldest (a boy), died during the Commune, aged 35; the 
 second and third (boys also) enjoy good health ; the fourth, a fe- 
 male, aged 28, is subject to nervous attacks at long intervals; the 
 fifth died at birth. 
 
 The patient assures us that she has never had any serious ill- 
 ness; never, for instance, was affected by rheumatism or chorea. 
 Although she had been a costermonger for thirteen years, she 
 never gave way to excess in drink. She has always lived in 
 healthy lodgings, well exposed to the sunshine; she was happy in 
 her home, and never suffered from any privations. 
 
 Invasion of the disease. — Her affection first showed itself in 1868, 
 under the following circumstances. Her third son, of whom she 
 
262 APPENDIX. 
 
 was particularly fond, unexpectedly told her one day that he had 
 enlisted as a soldier. This news greatly afflicted her ; she wept 
 nnuch over it, and from the following day was aware of a weakness 
 in her right arm. Soon after, the left arm was taken in the same 
 way, then the right lower extremity was invaded, and (simultane- 
 ously) the left. During the night-time she had cramps in her legs 
 which made her cry out. Next she experienced weakness in the 
 loins. At the time of her entrance into hospital (December, 1872) 
 she was not so weak as at present (July 8th, 1874). The trembling 
 began to invade the members, affecting first the right upper ex- 
 tremity, in the early months of 1873. Lastly, she noticed about 
 the same time that she was affected by retropulsion ; one day, 
 having missed her step, she felt herself compelled to walk back- 
 wards in spite of herself. 
 
 Present state (July 8th, 1874). — The general attitude of the pa- 
 tient, when standing, is that described by M. Charcot in Lecture Y. 
 The body and head are bent forward ; the neck is stretched and the 
 head seems as though fixed on a rigid stem. The features are 
 quite immobile; the brow is but faintly marked with wrinkles; 
 the eyelids are moderately open ; the patient can, however, raise 
 or lower them with ease. The eyes, but slightly expressive, are 
 directed forward; the patient must turn her whole body in order 
 to look aside. Sometimes the lips adhere, but generally the mouth 
 is half open, the lower lip, relaxed and hanging, allows the dental 
 arch to be seen, the saliva flows involuntarily. The lips and 
 tongue do not tremble. Deglutition, it appears, is almost always 
 laborious. 
 
 The arms are held slightly apart from the chest; the fore-arms, 
 half flexed, are so placed that the hands rest on the umbilical 
 region, whilst the elbows are somewhat apart from the body. The 
 thumb, slightly inflexed, rests usually on the forefinger; the other 
 fingers are slightly bent and gathered together. Both hands are 
 disposed in the same manner. 
 
 The legs approximate, though the knees do not touch. If the 
 legs are separated, the equilibrium becomes uncertain. Whether 
 the eyes are open or closed the attitude of the patient is the same. 
 
 She sits down heavily, and all of a sudden. She cannot rise 
 until she get assistance, and even then the attendants have to use 
 strength to raise her. After hesitating, she begins to walk, ad- 
 vancing first with short steps, afterwards hurriedly, — there is pro- 
 pulsion. "Sometimes," says Grav — , "I am driven very far, until I 
 meet a wall, — and if I don't, I fall." The existence of retropulsion 
 is also marked : to observe it, it is only necessary to pull the 
 patient gently by the skirt, — the method adopted by M. Charcot. 
 Immediately she begins to walk backwards, and with such rapidity 
 that she would soon fall if not watched. The hesitation of the 
 patient, before returning, is greater than before beginning to walk. 
 
APPENDIX. 263 
 
 The trembling is scarcely noticeable, especially when she is at 
 rest. The head trembles, at times, a little more than the hands. 
 When these are hanging by the side, they generally remain motion- 
 less. The patient can incline her head more than it is usually 
 inclined, but it is impossible for her to raise it in extension com- 
 pletely, because "the vertebral column is stift'." 
 
 Neither cephalalgia, nor vertigo, nor giddiness. The intellect 
 is preserved and the memory good. Her sleep is less abridged 
 than we find to be the case with most patients suffering from the 
 same complaint. She would even sleep well if she were not fre- 
 quently waked up by pains in the heel "that prick me, and you'd 
 think 'twas water running inside the heel." She complains of a 
 constant feeling of heat, and only keeps a sheet over her even in 
 winter time. 
 
 We have mentioned the state of her strength, measured by the 
 dynamometer (Note to Lecture V) and that of her temperature, so 
 we shall not revert to these points. 
 
 July, 1875. — The weakness has gone on increasing. The general 
 attitude remains the same; however, the head and trunk are more 
 and more inclined forward ; besides, a sort of lateral inclination has 
 occurred, in consequence of which the right half of the body pre- 
 cedes the left half in walking. 
 
 At present, the lips are almost always adherent each to the 
 other; the upper lip is puckered; sometimes, according to the 
 patient, both of them are stiff". The dental arches are not pressed 
 against each other. It would seem as if the patient drew her lips 
 together to diminish the trembling of the chin ; in spite of this 
 precaution, her legs are stirred by little twitching movements, 
 which, to use her own words, remind one of the motion of rabbits' 
 lips. The tongue trembles even within the mouth ; when protruded , 
 the trembling is augmented. 
 
 The trembling of the head is composed of antero-lateral, and 
 sometimes lateral, shakes, of very limited extent. These oscilla- 
 tions are transmitted to the head by the body, as was mentioned 
 in the course of the lecture. When the patient is sitting, her legs 
 tremble, and her feet beat rapidly on the floor, striking little blows. 
 To sum up: — trembling has progressed, so far as the head and 
 lower extremities are concerned; but in the upper extremities 
 there is little alteration. Let us also notice the necessity of chang- 
 ing position (fidgetiness), which was little marked in 1874, and 
 was only experienced during the day, is much more manifest at 
 present, and torments the patient not only during the daytime, 
 but whilst reposing in bed (at night). Her sleep is less than it 
 was formerly. The patient still takes exercise in the ward and in 
 the courtyard of the infirmary (B). 
 
INDEX 
 
 ACHROMATOPSIA, hysterical, 192, 205, 
 229, 233 
 Acme, epileptic, 253 
 
 hystero-epileptic, 228, 255 
 Amblyopia, hysterical, 244 
 
 in disseminated sclerosis, 157 
 Amyotrophy, protopathic (see Atro- 
 phy, muscular) 
 symptomatic : in hysterical con- 
 tracture, 245 
 of cerebral blood-clot (note), 43 
 of hemilateral lesion of the cord, 
 
 71 
 of disseminated sclerosis, 43, 
 
 164 
 of lateral sclerosis, 42 
 of posterior sclerosis, 42 
 Anaesthesia, its role in bed-sore of spinal 
 
 origin, QQ 
 Analgesia, 204, 208, 239 
 Angioueuroses, 92 
 
 of hysterical patients, 94 
 Apoplexy, spinal, 44 
 Arthritis, deformans, 81 
 Arthropathies of ataxic patients, 3 
 symptoms, 78 
 seat, 79 
 
 lesions of the joints, 80 
 alterations of cells of anterior 
 
 cornua, 82 
 in progressive muscular atro- 
 phy, 83 
 of cerebral and spinal origin, 75 
 in traumatic hemiparaplegia, 69 
 of hemiplegic patients : historical 
 sketch, 77 
 
 Arthropathies of hemeplegic patients — 
 mode of invasion, 78 
 lesions, 79 
 
 clinical characters, 79 
 Articulations, trophic affections of, 17 
 
 (see Arthropathies) 
 Ataxia, locomotor, cutaneous affections 
 in, 51 
 relation between these af- 
 fections and fulgurant 
 pains, 52 
 differences dividing ataxia from 
 the tremor of disseminated 
 sclerosis, 155 
 in disseminated sclerosis, 163 
 Atrophy, muscular, 3 
 
 consecutive on section of the 
 
 ischiatio nerve, 7 
 arthropathies in, 83 
 progressive, 83 
 
 irritative lesions of nerve-cells 
 
 in, 47 
 tendency to become general- 
 ized, 48 
 Attack, apoplectiform, in disseminated 
 sclerosis, 168 
 its frequency, 167, 170 
 in general paralysis, 168 
 
 pathogenesis, 169 
 in cases of apoplectic foci of old 
 standing, 169 
 varieties, 168 
 symptoms, 169 
 pulse and temperature, 170 
 Attaques-acces, 251 (see Seizure-fits) 
 Attraction (theory of), 99 
 
266 
 
 INDEX, 
 
 Aura, hysterical, 192, 219 
 
 characters of, 219 
 
 first node, or ovarian pain, 219 
 
 second node, or globus hyste- 
 ricus, 219 
 
 third node, or cephalic pheno- 
 mena, 220 
 
 influence of compression of the 
 ovary on, 220, 223, 224, 227, 
 229, 230, 233, 252 
 Avant-mur (see Claustrum), 211 
 
 ■HED-SORE, 56, 94 (see Decubitus) 
 -*^ Bromide of camphor, 127 
 Bulbus rachidicus, muscular lesions con- 
 secutive on affections of, 48 
 lesions of, in paralysis agitans, 
 
 123 
 in disseminated sclerosis, 131, 169 
 
 CALABAR BEAN in paralysis agitans, 
 127 
 in disseminated sclerosis, 183 
 Capsule, internal, 211 
 Capsules, supra-renal, hemorrhage of, in 
 
 spinal lesions, 86 
 Cells, nerve-, motor nerve-cells in ante- 
 rior cornua of the gray substance 
 of the cord, 41 
 lesions of these cells : acute form 
 
 (infantile paralysis), 46 
 chronic form, progressive muscular 
 
 atrophy, 47 
 role of motor nerve-cells in the pro- 
 duction of trophic troubles, 49 
 yellow degeneration of, 143 
 lesions of, in disseminated sclerosis, 
 164, 165 
 in hysterical contracture, 245 
 Cerebrum, anatomical views concerning, 
 
 210 
 Chorda tympani, a dilator nerve, 95 
 Chorea, disorderly movements of, com- 
 pared to tremor of disseminated scle- 
 rosis, 155 (see Hemiohorea) 
 Cicatrices, vicious, 16 
 
 Cirrhosis of muscles, 37 
 Claustrum, 211 
 Coelialgia, hysterical, 192, 218 
 Compression of the ovary, 224 
 
 its influence on hysterical seiz- 
 ure, 223 
 modus operandi, 224 
 historical sketch, 225 
 Congestion, apoplectiform and epilepti- 
 form, 255 
 Contractility, electrical, after patholog- 
 ical and after experimental nerve- 
 lesions, 25 
 in hysterical contracture, 246 
 in fractures and luxations of the 
 
 vertebral column, 44 
 in hsematomyelia, 44 
 in acute central myelitis, 44 
 in disseminated sclerosis, 147 (see 
 Myopathies) 
 Contracture, permanent hysterical, 192, 
 229, 230, 234 
 action of chloroform on, 235 
 convulsive tremulation in, 236 
 hemiplegic form, 234, 237 
 characters differentiating it 
 from organic hemiplegia, 237 
 hemiparaplegic form, 234, 239, 
 
 242 
 prognosis, 245 
 sudden recovery in some cases, 
 
 242 
 reputedly miraculous cures, 
 242 
 incurable contractures, 243 
 lesions in, 244 
 
 pathological physiology of, 245 
 permanent, in sclerose en plaques 
 
 (disseminated sclerosis), 164 
 tairdy, in hemiplegia of cerebral 
 
 origin, 78 
 of the ureters, 200 
 Convulsionnaires, 205, 226 
 
 demoniacs, 230 
 Convulsions (arrest of), in hysterical 
 cases, by compression of the 
 ovary, 224 
 in spinal epilepsy, 227 
 
INDEX. 
 
 267 
 
 Corpora opto-striata, lesions of, their ef- 
 fects, 207 
 French theory, 209 
 British theory, 208 
 Currents, electrical, differences between 
 continued aud Interrupted, 26 (see 
 Faradization) 
 Crises, gastric, 175 
 Cutaneous diseases, 14, 15, 20, 63 
 
 DECUBITUS ACUTUS (acute bed-sore), 
 56 
 mode of evolution, 57 
 consecutive affections, 60 
 in apoplexy symptomatic of cerebral 
 
 lesions in foci, 62 
 seat, 63 
 
 pathogeny, 64, 93 
 of spinal origin, 58, 64 
 seat, 64 
 
 in traumatic myelitis, 66 
 influence of position of spinal lesion, 
 
 67 
 in traumatic hemiparaplegia, 68 
 in spontaneous myelitis, 72 
 epoch of manifestation, 72 
 role of gray substance on its pro- 
 duction, 73 
 Influence of nerve-lesions on, 75 
 Degeneration, waxy, of the muscles, 38 
 Delire des grandeurs, ambitious delir- 
 ium in disseminated sclerosis, 3 60 
 Diplopia in disseminated sclerosis, 157, 
 
 174 
 Dynamometer in paralysis agitans, 110, 
 118 
 
 T^CCHYMOSES, visceral, in circum- 
 ^ scribed cerebral lesions (endocar- 
 dium, stomach, pleura, bladder), 
 85 
 of the epicranial aponeurosis, 85 
 in spinal lesions, 86 
 Electro-diagnosis, 23 
 Emboli, gangrenous, consecutive on acute 
 
 bed-sore, 60 
 Encephalitis, 62 
 
 Endocarditis, ulcerous, with multiple 
 
 emboli and typhoid state, 55 
 Epidemics, hysterical, 225 
 of St. Medard, 205, 226 
 of St. Louis, 242 
 Epilepsy, its relations with hysteria, 
 247, 249 
 description of a fit, 248 
 spinal, in hysterical contracture, 
 
 236, 245 
 in disseminated sclerosis, 166 
 its forms, 166 
 
 arrest of, 227, 252 (see Acme) 
 Eruptions, eczematous, 16 
 
 lichenoid and pustular, 51 
 pemphigoid, 16, 21, 75 
 Erythema pernio, 16 
 Eschar of nates, 3 
 
 of rapid formation, 56 
 its position in apoplexy, 62 
 in apoplectiform attacks, 169 
 sacral, 3 
 
 in locomotor ataxy, 53 
 in epileptic acme, 256 (see Decubi- 
 tus) 
 Etat de mal, epileptic, 256 
 
 hystero-epileptique, 228, 252 (see 
 Acme and Temperature) • 
 
 Excitability, electrical (histological al- 
 terations corresponding to diminution 
 of), 37 
 Experiments of Erb, Ziemssen, and 
 0. Weiss, 36 
 
 FASCICULI, internal radicular, 54 
 irritation of, in posterior sclerosis' 
 54 
 Faradization and galvanization, differ- 
 ence of action, 26, 32, 37, 39 
 in disseminated sclerosis, 182 
 Foot (deformity of), in paralysis agi- 
 tans, 116 (see Trepidation), 
 club, hysterical, 243, 246 
 Fulgurant pains, 53 
 
 GAIT, in paralysis agitans, 118 
 Granglion, superior cervical (effects 
 of its extirpation), 91 
 
268 
 
 INDEX. 
 
 Glossy skin, 16 
 
 Grriflfe in a case of disseminated sclero- 
 sis, with lesion of the nerve-cells, 
 43 
 in paralysis agitans, 115 
 
 ITANDS, deformities of, in paralysis 
 ^^ agitans, 115 
 
 in rheumatism, 142 
 Hsematomyelia, 44 
 pathogeny, 44 
 diminution or abolition of electrical 
 
 contractility, 44 
 alteration of urine, 88 
 Hemiaiiaesthesia, hysterical, 192, 202, 222 
 historical sketch, 204 
 lesions of special senses, 204 
 relations between hemianaethe- 
 sia, ovarian hyperaesthesia, 
 paralysis, and contracture, 
 205, 222 
 characters which separate it 
 from hemiausesthesia of cere- 
 bral oi-igin, 207 
 of enceplialic origin, historical 
 sketch, 208 
 . its characters, 208, 210 
 
 cases reported by Tiirck, 208 
 212 
 Hemichorea, 214 
 Hemiopia, 192 
 
 Hemiparaplegia, traumatic, 68 
 arthropathies in, 68 
 muscular atrophy in, 70 
 alteration of urine in, 87 
 Hemiplegia in apoplectiform attacks, 
 168 
 hysterical, 234 
 Herpes zoster (see Zona). 
 Histology, normal, of the nervous sys- 
 tem, 133 
 Hyperemia, neuro-paralytic, 85, 90 
 Hyperaesthesia, ovarian, 192, 202, 205 
 its frequency, 217 
 historical sketch, 217 
 clinical characters, 218 
 anatomical lesions of the ovary, 
 222 
 
 Hyperaesthesia, ovarian — 
 conclusion, 228 
 clinical cases, 229, 232, 251 
 Hysteria (see Contracture, Epidemics, 
 Hemianaesthesia, Ovarian hyper- 
 aesthesia, Ischuria, Secours), epi- 
 leptiform, 249 
 ovarian, 203 
 severe, 228 
 local, 217 
 Hystero-epilepsy, 223, 247 
 meaning of the term, 248 
 with distinct crises, 249 
 varieties of, 250 
 nature of, 252 
 temperature in, 253 
 epileptic acme, 257 
 severe cases of, 257 
 
 IMMOBILIZATION of members (eflfeots 
 J- of), 6, 10 
 
 Inco-ordination, motor, 155 
 Infection, purulent, sequela of bed-sore, 
 
 60 
 Intoxication, putrid, sequela of bed- 
 sore, 60 
 Irritability, muscular, 25 
 Irritation (role ofj of nerves in the pro- 
 duction of trophic derangements, 14 
 Ischaemia, hysterical, 205 
 Ischuria, hysterical, 185 
 transient, 187 
 permanent, 187 
 historical sketch, 188 
 simulation, 189 
 differs from ischuria caused by 
 
 calculus, 191 
 clinical case, 191 
 diagrams indicating amount of 
 vomited matter and of urine, 
 194 
 chemical analyses, 195 
 remissions, 196 
 reality of, 197 
 
 •comparative benignity of, 199 
 gravity of caloular ischuria, 
 
 198 
 mechanism of, 199 
 
INDEX. 
 
 269 
 
 KIDNEYS (lesions of) consecutive on 
 nerve-sections, 86 
 experimeutal contradictions, 13 
 
 T EPRA, ausesthetic, 21 
 ■■-^ Lesions, irritative, I 
 
 12 
 
 ocular, consecutive on irritation of 
 
 the Gasserian ganglion, 10,12 
 
 on section of the trifacial nerve, 
 
 10 
 owing to spontaneous lesions of 
 fifth nerve, 12 
 Lingual muscles, contractured, 232 
 
 MENINGrlTIS ascendans, simple purn 
 ^'^ lent, or ichorous, consecutive on 
 bed-sore, 61 
 chronic cervical, 20 
 of St. Medard, 205, 216 
 Medulla spinalis, effects of transverse 
 
 section, 6, 13 
 Miracles of St. Louis ,242 
 Muscles, trophic or nutritive affections 
 of, 22 
 in infantile paralysis, 49 (see 
 Amyotrophy, Atrophy, My- 
 opathy, Sclerosis, dissemin- 
 ated) 
 Myelitis, acute central, 44 
 
 diminution of electrical con- 
 tractility in, 44 
 lesions of supra-renal capsules, 
 
 86 
 alterations of urine, 88 
 gastric crises, 175 
 partial amyotrophy, 43 
 spontaneous, 72 
 traumatic, 65 
 Myodynia, hysterical, 218 
 Myopathies consecutive on lesions of 
 the spinal cord, 40 
 
 VTEPHRO - CYSTITIS consecutive on 
 
 -^^ spinal lesions, 86, H7 
 
 Nephrotomy, 187 
 gravity of, 198 
 
 Nerves, contusion and ligature of, 39 
 excision of, 39 
 patches of sclerosis on, 131 
 Nerves, dilator, 95 (see Chorda tympani) 
 facial (paralysis of), 25 
 glandular (irritation of), 100 
 ischiktic (result of section of), 6 
 secretor (researches of Ludwig on), 
 
 97 
 trifacial (result of section of), 7, 19 
 Samuel's experiments, 10, 102 
 spontaneous lesions, 11 
 trophic, 15, 101 
 
 origin of these nerves, 101 
 vaso-motor, 103 
 
 (role of) in reference to nutri- 
 tion, 9, 14 
 irritation of, 94 
 Neuritis, 17, 18 
 
 trophic disorders connected with, 19 
 Neuroglia, 134 
 
 Nutrition (influence of the nervous sys- 
 tem on), 3, 4, and passim 
 Nystagmus in disseminated sclerosis, 
 158 
 
 OBLITERATION of ureters by calculi, 
 190 
 duration, 191 
 gravity, 197 
 Oliguria, hysterical, 187 
 Osseous system (trophic affections of), 
 
 17 
 Ovarialgia, hysterical, 192, 205, 222 
 Ovary (position of), 220 (see Compres- 
 sion, Hypersesthesia) 
 
 pARALYSIS agitans, 129 
 •*- historical sketch, 108 
 
 nature, 109 
 
 general characteristics of, 109 
 modes of invasion. 111 
 symptoms, stationary period, 
 
 112 
 tremor, 112 
 attitude of body, 114 
 its value in diagnosis, 116 
 sine tremore, 117 
 
270 
 
 INDEX. 
 
 Paralysis agitaiis — 
 
 painful sensations, 120 
 terminal stage, 122 
 terminations, 122, 123 
 pathological anatomy, 123 
 physiological anatomy, 124 
 causes, 124, 126 
 treatment, 126 (see Propulsion, 
 Retropulsion, Utterance) 
 Paralysis, bulbar, symptomatic of dis- 
 seminated sclerosis, 177 
 consecutive on nerve-lesions, 32 
 general progressive, characters 
 which assimilate it to dissemin- 
 ated sclerosis, 150, 159 (see Apo- 
 plectiform attacks) 
 general spinal (adult), 48 
 
 its analogies and differences 
 with infantile paralysis, 48 
 hysterical, 193, 240, and passim 
 infantile, 46 
 
 anatomical lesions, 46 
 labio-glosso-laryngeal, lesions of the 
 
 motor cells, 48, 159 
 pseudo-hypertrophic, 32 
 rheumatic (state of the muscular 
 contractility in), 27 
 Paraplegia, traumatic (alteration of 
 
 urine in), 87 (see Hemiparaplegia) 
 Paresis of the lower extremities in dis- 
 seminated sclerosis, 161 
 remissions, 162 
 Petit mal, epileptic, 252 
 Pharynx (paralysis of the), 232 
 Phlegmon (pseudo-), 16, 58 
 Preliminary remarks, 1 
 Propulsion in paralysis agitans, 110, 
 
 116, 119, 262 
 Pulse in apoplectiform attacks, 171 
 Putameu, 211 
 
 TJEMISSIONS, 112, 162 
 
 ■*^*' Retention of urine in hysterical 
 cases, 187, 238, 232 
 
 Retropulsion in paralysis agitans, 110, 
 119, 262 
 
 Rigidity of the limbs and neck in para- 
 lysis agitans, 114 (see Contracture) 
 
 QALIVATION in paralysis agitans, 114 
 
 
 
 Scleroderma, 17 
 
 Sclerosis, fasciculated, 41 
 descending, 168 
 
 disseminated (en plaques), lesions 
 of motor cells in, 41, 43 
 
 lesions of the bulbus in, 48, 131 
 and paralysis agitans, 123 
 historical sketch, 108 
 lateral, in hysteria, 243 
 posterior, complicating dissemi- 
 nated sclerosis, 163 (see Ataxia, 
 locomotor) 
 macroscopic anatomy, 130 
 distribution of sclerosed patches in 
 brain, 131 
 
 in spinal cord, 130 
 
 on the nerves, 131 
 aspect of sclerosed patches, 132 
 histology, 139 
 alteration of vessels in, 143 
 nature of the lesion, 144, 148 
 spinal form, 132, 178 
 cephalic or bulbar form, 132, 178 
 cerebro-spinal form, 151, 179 
 causes of error in diagnosis, 151 
 diplopia, 157 
 amblyopia, 157 
 cephalic symptoms, 157 
 nystagmus, 158 
 vertigo, 159 
 facies, 160 
 
 psychic symptoms, 160 
 state of lower extremities, 161 
 unusual symptoms, 162 
 ataxia, 163 
 
 muscular atrophy, 164 
 contracture of limbs, 165 
 spinal epilepsy, 165, 236 
 apoplectiform attacks, 168 
 periods, 172 
 remissions, 174 
 gastric crises, 175 
 intercurrent diseases, 176 
 bulbar paralysis, 177 
 duration, 179 
 
 pathological physiology, 179 
 cause, 181 
 influence of acute diseases, 181 
 
INDEX, 
 
 271 
 
 Sclerosis — 
 
 prognosis, 182 
 treatment, 182 
 
 " Secours" (les) in relation to the con- 
 vulsionnaires, 226 
 
 Sections of nerves, complete or incom- 
 plete, 15, 17, 24, 36, 144 
 
 Simulation in hysteria, 189 
 
 Spasm (see Contracture) 
 
 Speech (see Utterance) 
 
 rPARANTISM, 230 
 
 ■^ Temperature (significance of de- 
 crease of, in cerebral apoplexy), 
 64 
 diminution of, accompanying irri- 
 tant nerve-lesions, 93 
 dependent on irritation of the great 
 
 sympathetic (cervical), 94 
 in paralysis agitans, 121 
 in apoplectiform attacks, 171 
 in hystero-epileptiforra attacks, 253 
 in epileptiform acme, 254 
 in hystero-epileptiform acme, 258 
 Tongue (contracture of), 232 
 Thermo anaesthesia, 204 
 Tremor, in general, 105 
 
 difference as regards repose and 
 
 movement, 106 
 varieties, 107 
 historical sketch, 108 
 in paralysis agitans, 112, 154 
 in disseminated sclerosis, 156 
 influence of movements, 154 
 characters distinguishing it 
 from chorea, 155 
 motor inco-ordiuation, 156 
 Trepidation provoked, of the foot in 
 hysteria, 239 
 in sclerosis of the lateral columns, 
 
 240 
 in disseminated sclerosis, 239 
 in descending sclerosis, 239 (note) 
 Trismus, 193 
 
 Trophic derangements, 3 
 
 differences distinguishing them 
 from passive lesions, 6 
 
 consecutive on lesions of the 
 peripheral nerves, 4 
 
 traumatic causes, 17 
 
 spontaneous lesions, 19 
 
 theoretical views, 89 
 
 vaso-motor theory, 90 
 
 attraction theory, 99 
 
 trophic-nerve theory, 101 
 
 Samuel's theory, 102 
 
 criticisms, 102 
 
 conclusions, 103 
 
 in disseminated sclerosis, 176 
 Tubercle of spinal cord, 76 
 Tympanites, 193, 238, 239 
 
 UREA in hysterical vomited matter ; 
 in alvine evacuations after nephro- 
 tomy ; influence of pressure on its 
 production, 187, 195, 197, 202 
 Ureters (spasmodic contracture of), (see 
 
 Obliteration) 
 Urticaria in locomotor ataxy, 51 
 Utterance (modifications of) in paralysis 
 agitans, 113 
 in disseminated sclerosis, 158 
 
 VERTIGO, in disseminated sclerosis, 
 159, 174 
 epileptic, 253 
 Vomiting, hysterical, 196, 198 
 ursemic, 187 
 of blood, 238 
 
 yONA, 16, 19, 21 
 
 ^ in locomotor ataxy, 52 
 
 dependent on partial lesions of en- 
 
 cephalon, 54 
 with modifications of the derm, 75 
 local elevation of temperature, 93 
 
 Zoster, herpes (see Zona) 
 
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