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THE NEW SYDENHAM
SOCIETY.
INSTITUTED MDCCCLVIII
VOLUME CXXVIII.
CLINICAL LECTTJEES
OK
DISEASES OF
THE NEEVOUS SYSTEM
DELIYEBED AT
THE INFIRMARY OF LA SALPfiTRlfiRE
• a •
BY
• •
• •
• •
PROFESSOR J. M. CHARCOT,
FBOnSSOK IN THB VACTTLTY OP KEDICINB OV PAKIS; PHYSICIAN TO THB SAXPiTRliBX ; XIXBIB
OP THB INSTITX7TB, AND OP THB ACADBXY OP MEDICIHB OP PRANCB; PBBSIDBNT OP
THB SOClixi ANATOMiqUB, ETC.
VOLUME III
(CONTAINnrO EI0HTT-8IX WOODCXJTS).
TRANSLATED BT
THOMAS SAVILL, M.D.Lond., M.E.C.P.L.,
MEDICAL 8UPEBINTBNDENT OP THB PADDINGTON INPIBlfABY, LONDON;
HONOBABT XEXBBB OP THB SOCliTi ANATOMiqUK, PABIS; TOBMBBLY ASSISTANT PHYSICIAN AND
PATHOLOGIST TO THE WEST LONDON
LONDON:
THE NEW SYDENHAM SOCIETY.
1889.
o
• •
• • ••
• • • •
• •
• • •
PSIirrED BY ADLABD AlTD 8OV4 BABTHOLOHBW CI<O0B.
TRAITSLATOR'S NOTE.
This translation is from the first edition of the third volume
of Professor Charcot's Clinical Lectures. Originally delivered
as part of the course on Diseases of the Nervous System^
these Lectures were edited by the Professor's pupils and with
others were published first in the ' ProgrSs Medical.' After-
wards they were collected into a separate volume.
Many of these Lectures I had the pleasure of listening to^
and have thus been enabled to reproduce them in the English
language with greater precision of meaning than I should
otherwise have done. And^ it may be added^ the attainment
of this result has been further facilitated by the kindness
with which Professor Charcot has answered questions upon
points of difficulty or obscurity, where such have occurred.
Tbe French text is remarkable for its clearness and force of
expression, in spite of the complexity of some of the subjects
treated ; and it has been my desire to preserve these qualities-
in the translation •
THOMAS SAVILL.
CONTENTS.
LEOTUEE I.
mTRODUCTORY.
FAGS
SuMMABY. — Fonndation of the clinical professorsliip of diseases of
the nervons system. — Means of stndj : The Infirmaiy, ont-patient
department, laboratories. — ^Is it legitimate to make the teaching
of nenro-pathology a special branch of medicine P — ^Relation of
anatomical and physiological sciences to pathology. — Conditions
by which those relations should be controlled. — ^Nosological method
of study. — ^Anatomo-clinical method.— Functional diseases of the
nervous system obey common physiological laws.— Difficulties of
their study. — Simulation ...... i
LECTURE II.
ON THE MUSCULAR ATROPHY THAT FOLLOWS CERTAIN
JOmT LESIONS.
SuMHASY. — Traumatic joint disease, and the paralysis and muscular
atrophy which follow it.— Modification in the faradic and galvanic
contractility. — Contractions produced by the electric spark. — ^Ex-
aggeration of tendon-reflexes. — Simple muscular atrophy. — ^No
relation necessary between the intensity of the joint-afiEection and
that of the paralytic and atrophic phenomena.— The extensor mus-
cles of the articulation are most afEected. — The muscular lesions
are dependent on a deuteropathic spinal afEection . . .20
TUl CONTENTS.
LECTURE in.
I. CONTRACTURES OP TRAUMATIC ORIGIN,
n. TIC NON-DOULOUREUX OF THE FACE IN A HYSTERICAL
SUBJECT.
FAGB
SXJMMJLRY. — I. The influence of traumatism in determining the seat
of certain diathetic manifestations. — Contracture of traumatic
origin injsubjects who present spasmodic rigidity in a latent state.
— Exaggeration of tendon-reflexes in hysterical patients. — 11.
Typical case of tic non-douloureux of the face. — Contracture of
the muscles of the face in a hysterical patient. — Simulation . 32
LBOTUEE IV,
ON THE MUSCULAR ATROPHY WHICH FOLLOWS CHRONIC
ARTICULAR RHEUMATISM.
SuMHABY. — Muscular atrophy in acute, subacute, or chronic joint
disease. — Relation between the localisation of the atrophy and the
seat of the joint disease. — Types of primary chronic articular rheu-
matism : i. Generalised or progressive primary chronic articular
rheumatism, ii. Fixed or partial chronic articular rheumatism.,
iii. Heberden's nodes. — Generalised chronic rheumatism deter-
mines amyotrophies which predominate in the extensor muscles of
the affected joints. — Exaggeration of the tendon-reflexes. — ^With
the amyotrophy there exists a contracture in a latent state. — Spas-^
modic contracture of a reflex articular origin . . •44
LECTURE V.
I. REFLEX CONTRACTURE AND AMYOTROPHY OF ARTICU-
LAR ORIGIN.
II. OPHTHALMIC MIGRAINE APPEARING IN THE EARLY
STAGE OF GENERAL PARALYSIS.
SuMMABY. — ^I. Chronic articular rheumatism. — Reflex contracture of
articular origin. — Deformities in chronic articular rheumatism : i.
Type of extension ; 2. Type of flexion. — The hand of athetosis ;
hand of paralysis agitans. — Articular deformities of chronic rheu-
CONTENTS.
PAGE
matism are due to a spinal affection produced by the same meclian-
ism as reflex acts.
U. Progressive general paralysis. — Ophthalmic migraine at the out-
set. — Scintillating scotoma. — Hemianopsia . . • 5^
LECTXJRE VI.
ON HYSTERIA IN BOYS.
StTMMABT. — Hysterical contracture. — Amblyopia. — Hysterogenic
zones. — Phases of the hystero-epileptic attack. — Hysteria in
boys ; the attack ; permanent symptoms.— Importance of isola-
tion in the treatment . . . . . .69
LECTURE VII.
TWO CASES OP HYSTERICAL CONTRACTURE OP TRAUMATIC
ORIGIN.
iSuMKABT. — Latent hysteria without convulsive attacks. — Permanent
spasmodic contracture of traumatic origin. — Two cases compared,
one in a woman, the other in a man. — Heredity. — Ulnar defor-
mity of hand ; experimental study of the deformity by electricity,
and by putting in action the phenomenon of neuro-muscular
hyperexcitability . . . . . . .84
LECTURE VIII.
TWO CASES OF HYSTERICAL CONTRACTURE OF TRAUMATIC
ORIGIN {continued),
^UKMABY. — Investigations into simulation, catalepsy, and contrac-
ture. — Hysteria in the male, frequency, heredity, adult age. —
Masked forms. — Contracture of traumatic origin . . '93
CONTENTS.
LECTURE I.
mTRODUCTORY.
FAGS
SuMMABY. — Fonndation of the clinical professorsliip of diseases of
the nervoiis system. — Means of stndy : The Infirmaiy, ont-patient
department, lahoratories. — ^Is it legitimate to make the teaching
of neuro-pathology a special branch of medicine P — ^Belation of
anatomical and physiological sciences to pathology. — Conditions
by which those relations should be controlled. — ^Nosological method
of stndy. — ^Anatomo-clinical method.— Functional diseases of the
nervous system obey common physiological laws.— Difficulties of
their study. — Simulation ...... i
LECTUBE II.
ON THE MUSCULAR ATROPHY THAT FOLLOWS CERTAIN
JOINT LESIONS.
SuMHASY. — Traumatic joint disease, and the paralysis and muscular
atrophy which follow it. — Modification in the f aradic and galvanic
contractility. — Contractions produced by the electric spark. — Ex-
aggeration of tendon-reflexes. — Simple muscular atrophy. — ^No
relation necessary between the intensity of the joint-afiEection and
that of the paralytic and atrophic phenomena.— The extensor mus-
cles of the articulation are most afEected. — The muscular lesions
are dependent on a deuteropathic spinal afEection . . .20
TUl CONTENTS,
LECTUEE III.
I. CONTRACTURES OP TRAUMATIC ORIGIN,
n. TIC NON-DOULOUREUX OP THE FACE IN A HYSTERICAL
SUBJECT.
PAGE
•SuMMABY.— I. The influence of traumatism in determining the seat
of certain diathetic manife8tationB.^<)ontracture of traumatic
origin injsubjects who present spasmodic rigidity in a bitent state.
— Exaggeration of tendon-reflexes in hysterical patients. — 11.
Typical case of tic non-douloureux of the iace. — Contracture of
the muscles of the face in a hysterical patient.— Simulation . 33
LECTUEE IV.
ON THE MUSCULAR ATROPHY WHICH POLLOWS CHRONIC
ARTICULAR RHEUMATISM.
SuMMABY.— Muscular atrophy in acute, subacute, or chronic joint
disease. — Relation between the localisation of the atrophy and the
seat of the joint disease. — Types of primary chronic articular rheu-
matism : i. Generalised or progressive primary chronic articular
rheumatism, ii. Fixed or partial chronic articular rheumatism.,
iii. Heberden's nodes. — Generalised chronic rheumatism deter-
mines amyotrophies which predominate in the extensor muscles of
the affected joints. — Exaggeration of the tendon-reflexes. — With
the amyotrophy there exists a contracture in a latent state. — Spas^
modic contracture of a reflex articular origin . . •44
LECTUEE V.
I. REPLEX CONTRACTURE AND AMYOTROPHY OP ARTICU-
LAR ORIGIN.
II. OPHTHALMIC MIGRAINE APPEARING IN THE EARLY
STAGE OP GENERAL PARALYSIS.
SUMMAEY. — ^I. Chronic articular rheumatism. — Reflex contracture of
articular ongin. — Deformities in chronic articular rheumatism : i.
Type of extension ; 2. Type of flexion. — The hand of athetosis ;
hand of paralysis agitans. — Articular deformities of chronic rheu-
CONTENTS.
PAGE
matism are due to a spinal affection produced by the same meclian-
ism as reflex acts.
n. Progressive general paralysis. — Ophthalmic migraine at the out-
set. — Scintillating scotoma. — Hemianopsia . . • 5^
LECTURE VI.
ON HYSTERIA IN BOYS.
SuMMABT. — Hysterical contracture. — Amblyopia. — Hysterogenic
zones. — Phases of the hystero-epileptic attack. — Hysteria in
boys ; the attack ; permanent symptoms.*-Importance of isola-
tion in the treatment . . . .69
LECTURE VII.
TWO CASES OP HYSTERICAL CONTRACTURE OP TRAUMATIC
ORIGIN.
SuHMABY. — Latent hysteria without convulsive attacks. — Permanent
spasmodic contracture of traumatic origin. — Two cases compared,
one in a woman, the other in a man. — Heredity. — Ulnar defor-
mity of hand ; experimental study of the deformity by electricity,
and by putting in action the phenomenon of neuro-muscular
hyperexcitability . . . . . . .84
LECTURE VIII.
TWO CASES OF HYSTERICAL CONTRACTURE OP TRAUMATIC
ORIGIN icofdinued).
SuHHABY.-— Investigations into simulation, catalepsy, and contrac-
ture. — Hysteria in the male, frequency, heredity, adult age. —
Masked forms. — Contracture of traumatic origin . . • 93
CONTENTS.
LECTURE IX.
ON A CASE OP SPINAL APPECTION CONSEQUENT ON A
CONTUSION OP THE SCIATIC NERVE.
SuMHABY. — Contusion of the left buttock. — Continuous pains, inter*
mittent pains. — Early muscular weakness. — Muscular atrophy.—
Troubles of micturition, of defsocation, and of the genital func-
tions. — Persistent atrophy of the muscles supplied by the lesser
sciatic nerve of the left side. — Electrical exploration. — Paresis
and atrophy of the gluteal muscles of the right side . . 107*
LECTURE X.
I. DOUBLE SCIATICA IN A WOMAN AFPLICTED WITH
CANCER,
n. CERVICAL PACHYMENINGITIS.
SuMMABY. — I. Double sciatica ; conditions under which this afEection
occurs; diabetes, certain meningo-myelites, compression of the
spinal nerve-trunks at the intervertebral foramina. — The pseudo-
neuralgise of vertebral cancer. — II. Hypertrophic cervical pachy-
meningitis; pseudo-neuralgic period ; paralytic stage; spasmodic
stage. — Illustrative case : recovery with retraction of the flexor
muscles of the leg.^-Radical cure by surgical intervention . I20*
LECTURE XI.
ON A CASE OF WORD-BLINDNESS.
SuMMABY. — Definition of aphasia. — Word-blindness (Wortblindheit).
— ^ase ; sudden onset ; right hemiplegia and motor aphasia,
which passed away ; hemianopsia ; incomplete alexia ; impor-
tance of ideas furnished by movements in mental reading. . 130*
LECTURE XII.
ON WORD-BLINDNESS (continued).
SuMMABY.— History of word-blindness; MM. Oendrin, Trousseau,
Kussmaul, Magnan, &c. — Study of sixteen cases. — Clinical cases.
— Cases followed by autopsy. — ^Localisation.— Frequency of hemi-
anopsia. — ^Nature of the lesion . . . . .140
CONTENTS. XI
LECTURE XIII.
ON A CASE OP SUDDEN AND ISOLATED SUPPRESSION OP
THE MENTAL VISION OP SIGNS AND OBJECTS (PORMS
AND COLOURS).
FAGB
SuMMABY. — Gall, Gratiolet, Ribot, on partial memories. — Partial
destructioix of the difEerent forms of memory.— Visual memory. —
Galton's observations. — Case of sadden suppression of the visual ,
memory.— Its efEects. — Substitution by auditory images. — ^Verbal
amnesia does not correspond to a simple pathological condition. —
The condition is a complex one [complezus] ; in educated persons
four fundamental elements can be recognised in it ; .the com-
memorative auditive image; the visual image; and two motor
elements, to wit, the motor image of articulation, and the motor
image of writing ....... 151
LECTUEE XIV.
NOSOGRAPHICAL REVISION OP THE AMYOTROPHIES.
SuMMABY. — Deuteropathic amyotrophies. — Protopathic amyotrophies.
— Primary myopathies. — Pseudo-hypertrophic paralysis. — Juve-
nile form of Erb. — Myopathy without change of volume in the
muscles, Leyden's form. — ^Analogies between pseudo-hypertrophic
paralysis and Erb's juvenile form. — Hereditary infantile variety
of Duchenne (de Boulogne). — Its characters. — This last variety
is analogous to the preceding ones. — Pseudo-hypertrophic para-
lysis, juvenile form of Erb, Leyden's form, hereditary infantile
form of Duchenne (de Boulogne) are but varieties of primary pro-
gressive myopathy . . . . . .164
LECTURE XV.
TREMORS AND CHOREIFORM MOVEMENTS.— RHYTHMICAL
CHOREA.
SuMKABY. — Tremors of disseminated sclerosis ; oscillations oE large
extent. — Tremors of paralysis agitans, and senile tremors. —
Tremors with small oscillations ; rapid oscillations, or vibratile
«i CONTENTS .
PAGE
tremors. — Hysterical tremors.-— Alcoholic and mercurial tremors.
^Tremors of general paralysis and of Basedow's disease.
Chorea ; characters of the involantary movements of the chorea of
Sydenham. — Chorea and hemi-chorea, pre- and poet-hemiplegic.
~- Athetosis and hemi-athetosis.
Rhythmical chorea ; characters of the movements ; they appear in
crises; they are rhythmical, systematic, and reproduce more or
less f(uthfully the movements of ordinary life or of professional
gesture (dancing chorea, hammering chorea). — The disease is
generally allied to hysteria. — Prognosis varies in different cases . 183
LEOTUEE XVI.
SPIRITUALISM AND HYSTERIA.
-SuHMABY. — The influence of intellectual stimuli on the development
of hysteria.— Belief in the supernatural, in the marvellous ; prac-
tices of spiritualism.
Narration of an epidemic of hysteria which attacked three children
of one family living in a military penitentiary, and addicted to
spiritualism.
Nervous and rheumatic antecedents. — Description of the attacks ;
hallucinations of vision; permanent and transient stigmata.—
Conclusion ........ 198
LECTURE XVII.
ISOLATION IN THE TREATMENT OF HYSTERIA.
•SuMMABY. — Recapitulation of the epidemic of hysteria. — The treat-
ment comprises two parts :
(a) Moral or psychical treatment : i, Removal from the plaxje where
the disease originated; 2, Complete separation of the persons
attacked ; 3, Suppression of all visits from relations or friends.
(b) Medical treatment : i, To modify the diathesis, if one exist ;
rheumatism, for example; 2, Static electricity; 3, Methodical
hydrotherapy.
Preponderating influence of isolation. — Cases. — The treatment has
heen adopted, not invented, in Germany or in England . . 307
CONTENTS, XlU
LECTURE XVni.
CONCERNING SIX CASES OP HYSTERIA IN THE MALE.
PAGE
SuHMABT. — Hysteria in the male is not so rare as is thoaght.-»The
part played by injuries in the development of the al^tion : rail-
way-spine. — Permanence of hysterical stigpmata in well-marked
cases of both sexes.
An account of three typical and complete cases of hystero-epilepsy
occurring in men.— Striking similarity of these cases to each other,
and to corresponding cases in women . . . .220
LECTURE XIX.
CONCERNING SIX CASES OP HYSTERIA IN THE MALE
(continued),
«SuMMABY. — ^Abnormal varieties of the hysterical attack in the male.
— Account of a case in which the attacks assumed the characters
of partial epilepsy. — Diagnosis of the case ; importance of the
hysterical stigmata.
The [convulsive attack may be wanting in hysteria in the male. —
Description of a case of hysterical brachial monoplegia in a young
man 19 years old. — Difficulties of the diagnosis in this case . 244
LECTURE XX.
ON TWO CASES OP HYSTERICAL BRACHIAL MONOPLEGIA
IN THE MALE OP TRAUMATIC ORIGIN.— HYBTERO-
TRAUMATIC MONOPLEGIA.
Summary. — Case of Porcz — : Antecedents, articulai rheumatism. — Fall.
— Monoplegia with ansBsthesia of the arm and shoulder.— Exami-
nation of the patient ; motor paralysis with flaccidity. — Loss of all
kinds of sensibility having a peculiar delimitation ; no trophic
changes ; no modification in the electric reactions of the paralysed
muscles. — Diagnosis ; disturbance or contusion of the brachial
plexus, characters of the symptoms observed in these cases, anaes-
thetic zone corresponds with the distribution of the affected nerves,
trophic changes, modification of the electric reactions . .261
xiv CONTENTS.
LEOTUEB XXI.
ON TWO CASES OP HYSTERICAL BRACHIAL MONOPLEGIA
IN THE MALE DUE TO INJURY.— HYSTERO-TRAUMATIC
MONOPLEGIA (continued).
FAGB
SuMMAET. — Diagnosis continued. — ^Amyofoophies dependent on joint
lesion ; on spinal or focal cerebral lesions. — Symptoms pathogno-
monic of hysteria in this patient ; right hemiansesthesia ; mono-
cular polyopia with macropsy ; bilateral retraction of the field of
vision.
Case of Pin — : Flaccid monoplegia and loss of all kinds of sensi-
bility in the left upper extremity following a fall. — Other hysterical
symptoms ; diminution of hearing, taste, and smell on one side ;
retraction of the field of vision with transposition of the red ;
monocular polyopia; ansasthesia of the back of the throat ; hys-
terogenic aresB ; hysterical attacks followed by an improvement in
the paralysis of the arm.
Psychic paralyses ; their production by suggestion in hypnotism. —
DifEerent states of hypnotism considered in connection with the
possibiliiy of suggestion • . • • • •274
LEOTUEE XXII.
ON TWO CASES OP HYSTERICAL BRACHIAL MONOPLEGIA
IN THE MALE (continued).
SuMMABT. — Production of a monoplegia of the whole upper extremity
in a hysterical subject by suggestion ; its disappearance effected
by the employment of similar means. — Production of paralysis of
the different segments successively in the upper extremity of the
same patient (shoulder, elbow, wrist, fingers). — The sensation and
tendon-reflexes disappear simultaneously in the parts attacked
with paralysis. — Monoplegia can be artificially determined in a
hypnotic by a blow on the shoulder (traumatic suggestion).—
Repetition of the same phenomena in an hysterical subject awake,
but in a natural and permanent condition of hypnotism.
Remarks on the treatment of two men affected with brachial mono-
plegia ; hydrotherapy ; static electricity ; special exercise. — Mode
of action of this last agent ; psychic motor images. — Good results
of treatment ....... 396
CONTENTS. XV
LEOTUEE XXni.
ON A CASE OP HYSTERICAL HIP DISEASE IN A MAN,
RESULTING FROM INJURY.
PAGE
SuMUABY.^-Works of Brodie and other authors on hysterical affections
of the joints. — Characters of hysterical joint disease. — ^Attitude o|
the limb ; special features of the pain, — Case of Charv — ; initial
injury of the left inferior extremity ; attitude of the patient ;
shape of the buttock and gluteal fold. — Considerable clinical
analogies with true organic hip disease. — Distinctive features:
Brodie's sign ; hemianesthesia ; pharyngeal anaesthesia, &c.—
Necessity of examination under chloroform . . • 317
LECTURE XXIV.
ON A CASE OF HYSTERICAL HIP DISEASE IN A MAN,
RESULTING FROM INJURY {continued).
SuMHABY. — Results of an examination under chloroform. — Symptoms
then presented by the patient.-— Mixed or hystero-organic hip
disease.— Hip disease artificially produced in two women pre-
senting the phenomena of great hypnotism. — Different proceed-
ings employed to produce this coxalgia. — Characters of artificial
hysterical coxalgia. — ^Nervous shock. — Traumatic suggestion.—
Method of treating hysterical coxalgia; massage, its good but
transitory results; influence of the psychical state. — Probable
recovery ........ 330
LECTTJEE XXV.
THE CASE OF SPASMODIC CONTRACTURE OF THE UPPER
EXTREMITY OCCURRING IN A MAN AFTER THE APPLI-
CATION OP A SPLINT.
SuiocABY. — Development of a brachial monoplegia having all the
characters of so-called hystero-traumatic monoplegia, due to a blow
from a heavy body falling on the limb. — Fracture of the forearm.
•—Nervous shock ; what it is that constitutes " local shock ;" the
part it plays in the production of hystero-traumatic paralysis. —
XVI CONTENTS.
PAGB
Application of the splint; monoplegia with flacciditj becomes
transfonned into monoplegia with contracture which presents all
the characters of hysterical contracture. — The tendency to spas-
modic contracture is a frequent occurrence in hysteria in either
sex. — The most certain means of producing it is the application of
a ligature around the limb. — The artificial production of contrac-
tures constitutes a veritable stigma of the hysterical state.—
Amelioration of the patient after the different kinds of treatment ;
although the hand still preserves a certain degree of deformity
which does not yield to the action of chloroform, and which appears
to be due to the formation of fibrous tissue . . . 341
LBCTUEE XXVI.
A CASE OP HYSTERICAL MUTISM IN A MAN.
SuMMABY. — Description of hysterical mutism. — It consists of a very
characteristic group of symptoms [Syndr6me] ; aphonia, impos-
sibility of whispering, motor aphasia. — Preservation of the
general movements of the lips, tongue, etc.— The intelligenee is
not afEected; patients preserve the faculty of writing fluently,
and conversing by signs.— Diagnosis of hysterical mutism.— >Its
importance in certain cases. — ^Malingerers. — It is generally very
easy to detect them. — Experimental production of hysterical
mutism in hypnotisable hysterics ..... 360
APPENDICES.
I. Two additional cases of hystero- traumatic paralysis in men . 374
n. Notions of muscular sense and voluntary movement . . 395
III. A case of hysterical hemiplegia followed by sudden cure . 401
IV. Concerning muscular atrophy in hysterical paralysis . . 406
y. On hysterical mutism . . . . . .410
LIST OF WOODCUTS.
Fig. paok-
1. Budiments of the new spinal pathology . . • .10*
2. Diagram showing the arrangement of the apparatus in the expe-
riments on cataleptic immohilitj . . • • ^&
3. Tracings obtained from a hystero-epileptic in a state of hypnotic
catalepsy . . . . • . .16^
4. Diagram of tracings obtained from a man who attempted to
maintain the cataleptic attitude . . . • ^7'
4. Bepresenting the deviation of all the fingers towards the ulnar
side of the hand in chronic rheumatism . . . 55^
5. Showing the left hand of the woman D — . Type of extension . 55
6. Showing the left hand of the woman M — . Type of extension . 56^
7. Bight hand of the woman X — . Type of flexion . . .5^
8. The hand of athetosis, resembling the deformity in the type of
extension ....... 5^
9. Hand of paralysis agitans, resembling the deformity of the flexion
type .,,..,.. 5^
10. Voluntary deformity resembling the extension type of chronic
rheumatism ....... 60
11. Voluntary deformity resembling the extensor type of chronic
rheumatism . . . . . . .61
12. DifEerent phases of the scintillating scotoma, after Hubert Airy . 64.
13. Bepresenting homonymous retraction of the visual field in a case
of ophthalmic migraine . . . . . ,.65;
14. Hysterogenic zones on the front of the body . . . 75.
15. Hysterogenic zones on the posterior surface of the body . . 76>
16. Betraction of the field of vision predominating on the right side
in the case of the child B — . . . . .81
17. Hysterical contracture of the left hand . . • .86
18. Betraction of the visual field . . . . '9^
19. Experiment intended to verify the reality of the contracture of the
hand ........ 96
20. Diagram representing the respiratory movements of the patient
and those of a simulator. . . . . '97
31. Contracture of the left hand . . . . .102
22. Fields of vision ....... 104
23. Extent of the visual field of P—- . . • ^47
24. Ditto ........ 148
XVlll
LIST OP WOODCUTS.
obtained by the
graph
Pig.
25. Extent of the yisoal field of P— .
36. Erb's juvenile form of amyotrophy
27. Mixed form of amyotrophy
38 and 29. Duchenne's infantile amyotrophy
30. Ditto ....
.31. Ditto ....
32. Ditto ....
33. Ditto ....
34. Transitional form of amyotrophy .
35. Ditto ....
^6 Semi-diagrammatic reproduction of tracings
method ....
37 — 48. Bhythmical chorea
49. Arc of circle backwards
50. Illogical attitude .
51. Arc of circle forwards
52. Lateral arc of circle (forwards)
^3. Lateral arc of circle (backwards)
54 and 55. Case of Porcz —
^6 and 57. Case of Deb —
58 and 59. Case of rupture of brachial plexus
60 and 61. Case of Pin —
€2 and 63. Field of vision of Pin —
■64 and 65. Case of Greuz —
66 and 67. Case of Porcz —
€8 and 69. Case of Greuz —
70 and 71. Case of Pin —
72 and 73. Case of Porcz—
74. Case of Pin—
75' Case of Porcz—
76. Hysterical hip disease
77. Ditto ....
78. Patchy hemiansBsthesia
79. Contracture of upper extremity
80 and 81. Contracture of hand
82. Rigidity of fingers
83. Le Log — 's visual fields
84. Distribution of the ansesthesia in the case of Le Log —
8g. Distribution of the ansBsthetic zones in a case of partial paralysis
of the difEerent segments of the limbs
86. Distribution of the anaesthesia in Mouil —
194
FAGB
149
170
172
176
177
180
180
181
181
185
240
240
241
241
242
268
269
271
285
287
298
299
300
301
3"
312
313
323
324
327
347
348
358
379
380
381
392
ShN FRANCISCO, OAL
«^ is not to he removed from WW
■"T ,, '^_ri whatevefT.
undt
LECTURE I.
INTRODUCTOKY.
SuMUAEJ. — Foundation of the clinical professorship of dvteaaea
of the nervovB syetein. — Means of study : The Infirmary,
out-patient department, laboratories. — Is it legitimate to
maJce the teaching of nenro -pathology a special branch of
m^dvAiie ? — Relation of wnatomical and physiological
sciences to pathology. — Conditions by which those rela-
tions should he controlled. — Nosological method of study.
— Anatomo-elinical method. — Functional diseases of the
nervous system obey common physiological laws. — Diffi-
culties of their study. — Simulation.
I.
Gentlemen, — It is now nearly twelve years ago that in
recomiuenciiig within these walls a course of instructionj
■which had already existed for fonr years, I ventured to hope
that this great asylum of human miseries, where so many
leaders of French medicine had achieved distinction, would
become one day a properly organised centre for the teaching
and investigation of diseases of the nervous system.
Where is there to be found, I asked, so much material
specially adapted to this kind of study ? And I pointed out
that very simple modifications in the internal arrangements
of the establishment would enable us to realise its value to
the fullest extent.
Since then I have never ceased to enunciate these views,
to establish their truth by every means in my power (both
in my lectures, and by published works in which I have
received the assistance of my pupils), and to declare to the
world the vast material wealth that exists in this institution.
2 FOUNDATION OF THE PB0FB8S0BSHIP.
You are aware^ gentlemen^ that at length our wishes have
been realised beyond my most sanguine expectations ; and
now, after seventeen years of private initiative, I recom-
mence this course in the name of the Faculty of Medicine of
Paris.
At the inauguration to-day, of the Clinical Chair of Diseases
of the Nervous System, my first words, which are not without
emotion I admit, must be expressive of gratitude towards
those who have created it, and who have confided it to my
care. Let me thank the Chamber that originated the pro-
ject, the Minister of Public Instruction who promoted it, and
my colleagues of the Faculty who, consulted as to the advisa-
bility of its creation, returned a favourable verdict, giving
me thereby a proof of their estimation, by which I am pro-
foundly touched.
Next, I eagerly embrace the opportunity of publicly
testifying the gratitude we feel, both to the Municipal
Council of the City of Paris, and also to the Administration
of Public Assistance, whose prompt and liberal aid has
rendered possible a scheme which without it would have
encountered obstacles well-nigh insurmountable. Thanks to
their help, which really took place prior to the approval of
the University, we are already in possession of appliances
and conveniences that form a veritable Neuro-pathologioal
Institution.
Finally, gentlemen, it is incumbent on me to perform a
duty that I find particularly pleasant, and which revives the
happy friendships of days gone by. I refer to those who
have done me the honour to call themselves my pupils — all
of whom have now become masters, or are on the road
thereto — and would offer them once more the assurance of
my lively and sincere attachment, and exhort them to rejoice
with us in the success of the work in which they have
largely participated.
II,
I have just allnded, gentlemen, to the important modifi-
cations which, with the concurrence o£ the Administrator of
Public Assistance, and the Municipal Council, have been
gradually introduced into the department that I direct, and
I will now ask your permission to enter into the question in
more detail. This will give me the opportunity of indicating
the benefits arising from the installation of the new pro.
fessorship in the Infirmary.
This large group of buildings, as you know, contains a
population of over 5000 persons, among whom are a large
number that come under the denomination of incurables, and
who pass the latter part of their lives here. They are
suhjects affected with every kind of chronic maladies, and
particularly with diseases of the nervous system. Such is
the quantity of material, albeit of a peculiar character,
which has formed the only basis all these years of our patho-
logical researches and our clinical teaching.
The classes which can be carried on under such conditions
are anrely not to be despised. The clinical types of disease
which come under observation are illustrated by such
numerous examples that we are enabled to take at one time
a comprehensive view of an afiection ; and from such a
vantage ground, so to speak, that the gaps made by time in
this or that catagory are lost sight of. In other words, we
are in possession of a sort of living pathologieal museum
whose resources are almost inexhaustible.
It is true that we sometimes miss the heginnings of
disease ; but, on the other hand, we gain by being enabled to
investigate after death the lesions which correspond to the
symptoms studied minutely, and over a long period of time,
during life. And who, I would ask, does not recognise the
decisive influence which microscopic investigations, based
on the anato mo- clinical method, have had on the progress of
neuro -pathology ?
The weak side of the situation which I have just indi-
cated is too striking not to he at once apparent. Tn an
4 MEANS OP STUDY.
Infirmary^ generally speakings the well-marked cases^ the
so-called incurable ones^ are alone admitted; the slighter
and more trivial cases are not seen. And thus one is
scarcely able to observe those delicate symptomatic shades^
which ofttimes alone mark the onset of certain chronic
diseases. And again^ what hope is there of curing or allevia-
ting our patient when the evil has^ through long years^ taken
root in the organism^ and already resisted appropriate
medication ?
These^ then, are the chief imperfections. It was possible
to remedy them by instituting^ at the entrance to the Infir-
mary buildings, an out-patient department, with a dispensary
attached. It was hoped that the chrome sufferers, who often
have a difficulty in obtaining admission to the hospitals, and
who even then do not invariably find the means of treatment
appropriate to their state, would flock to such an institution
in great numbers. In these expectations we have not been
disappointed. The department has been working for two
years, and cases which interest us, by reason of the special
direction of our studies, have come in large numbers. I
shall have many opportunities in these lectures of presenting
to you those who come to the Infirmary as out-patients.
These persons do not object to clinical demonstrations upon
their cases ; quite the contrary. They understand that the
more minutely and the more thoroughly they are investigated,
so much the greater is the chance of their cure or alleviation.
To make this department perfect and complete, it yet
required space within the Infirmary where certain of the
patients, who come to us from outside, could be temporarily
admitted as in-patients. This concession we asked for
many times, and at length the difficulties in the way of its
achievement were surmounted. Happily for our cause it
met with the support of the Director of the Public
Assistance. All the obstactes were one by one removed, and
now we have wards for the temporary admission of cases.
They contain eighty beds — ^forty for women and forty for
men. I know not how to thank M. Quentin for the eamest-
i^ss with which he has seconded our efforts.
LBGITIMAOT OF THK SPHOIALITT. S
Thus, to the Infirmary is added an Out-patienC depart-
ment, and to this, hospital- ward s,^ All forma a complete
whole, of which the different parts are intimately connected,
and which now supplement our other means of teaching and
We poBsesa a Pathological Museum, to which is attached
a studio for moulding and photography ; a well-fitted Labora-
tory of pathological anatomy and physiology, which is in
strange contrast with the narrow, badly-lighted room, that
was the only resort where I and my pupils worked, and
which we dignified by the name of "laboratory," for nearly
fifteen years ; an Ophthalmological room, necessary com.ple-
ment to a neuro-pathological laboratory ; and the Lecture
Hall, in which I have the honour of receiving you to-day,
and which is provided, as you see, with all the modem
apparatus for demonstration.
We posseae, moreover, a service richly endowed with all
the apparatus necessary for the practice of electro-d/iagnosia
and electro-therapy ; and here numerous patients come, three
times a week, to receive the treatment appropriate to their
condition.
The valued assistance which my friend M. Lebas, Superin-
tendent of the Infirmary, has rendered to us in these
arrangements, is truly beyond all praise.
You see, gentlemen, the luxurious means of study that
have been placed in our hands. It is for us now to turn them
to account. So far as I am cencerned, albeit that I have
arrived at an epoch of life when the sun has passed its
zenith, I hope to find enough energy still to enable me to
accomplish the task.
III.
I have still, gentlemen, to make a few remarks touching
the objections, the doubts, relative to questions of principle,
which on the creation of the new Chair have undoubtedly
preaented themselves to the minds of many.
One is sure to be asked, for example, whether the official
conuecration of one more speciality is an event that is both
' Limited to the reception of diseases of the nervous sjatem.
6 THE SPBOIALITY IS JUSTIFIED.
desirable and legitimate ; and whether^ if sach a path were
once marked ont^ the unity of onr science might not be
imperilled thereby. To this it can be briefly replied, that
in the science of medicine in the present day, analysis is
becoming more and more penetrating, and multiplies without
ceasing the number of facts ; and inasmuch as our faculties
of assimilation and our power of work do not develop
pari passu ; no one could seriously pretend to embrace and
to fathom the whole of the science at one time. Specialisa-
tion has therefore become an inevitable necessity. One
must accept it because it cannot be averted.
Still it is important to place a limit on the indiscriminate
cutting up of the science and the barren isolation of speci-
alities, so as not to go to the other extreme, which would
certainly be deplorable. I would point out that an organiza-
tion having this object, already exists, so far as concerns
education, in that our Faculty requires from its Fellows,
from amongst whom the Professoriate is recruited, a know-
ledge of every branch, every department.
Moreover, the danger which would attach to a narrow
specialism is scarcely to be feared in the territory of neuro-
pathology, for that domain has to-day become, no one thinks
of denying it, one of the most extensive that exist. It is
one of those specialities which become enriched most rapidly ;
one, the cultivation of which requires from those who devote
themselves to it, the widest and most general knowledge.
It is then legitimate that henceforth the pathology of the
nervous system should absorb all the efforts of those who
would study it; and that it should claim a place among
the other separate branches which, like it, by the force of
circumstances, are already detached from the bosom of
general medicine.
Another consideration of value in reference to the founda-
tion of the new Professoriate, is that France has often taken
the initiative in the scientific evolution which during the last
thirty years has defined the limits of nerve pathology, and
has thus, so to speak, rendered it a legitimate speciality.
Ought she not to continue the work, or should she leave
other countries to make advances in her domain ?
To promote this object it was necessary to place in the
MPORTANOE OP OLINlOAl STTTDY. 7
hands of a certain number of workers all the means of keeping
abreast with the times. This could only be done by creating
an official Chair for teaching the diseases of the nervous
system ; because^ only an official Professoriate could worthily
respond, by reason of its privileges and its duties, to the
wants of education, and the exigencies of scientific progress.
IV.
It seems to me useless to enlarge on this apology for the
new institution any further, or to mention any other argu-
ments in favour of its cause. And now we must devote
ourselves, as in former inaugural lectures, to initiating those
who have not done us the honour of attending before, into
the methods of the course, which, although of long standing,
is officially confided to me for the first time to-day.
In the first place, let me again remind you that in this
place we shall have to deal with clinical, or, in other words,
purely practical work. That is to say, we shall always
have before us a particular case, or a patient whom we wish
to cure, or at any rate to alleviate. But this end, gentlemen,
can only be attained by the application of information pre-
viously acquired in the different branches of medicine.
True practice has nothing of autonomy in it; it lives by
ideas derived from previous experience and their appropriate
application. Without continual scientific renovation it
would soon become a barren and stereotyped routine. It
can, moreover, be affirmed, in my opinion, that apart from
operations requiring dexterity, ingenuity, and other native
qualities, which without doubt become perfect only by repe-
tition, and which cannot indeed be acquired otherwise, one
can affirm, I say, that the greater the pathologist the greater
the physician.
This subject, therefore, before being examined practically,
can be discussed, briefly at any rate, from a scientific stand-
point.
In this respect, gentlemen, I must be allowed once more
to declare my firm belief that the wide intervention of the
anatomical and physiological sciences in the affairs of medi-
8 NOSOLOGICAL IIETHOD.
cine is an essential condition to progress; a statement which^
by frequent repetition, lias verily by this time become
almost a platitude.
But the point that I wish specially to insist on is this ;
in order that the intervention of these sciences may be
legitimate^ and really fruitful^ it should take place under con-
ditions which should never be forgotten. Allow me to recall
to your minds the opinion which that most illustrious
physiologist, Claude Bernard, thus expressed : — '^ Pathology/^
said he, '^ should not be subordinated to physiology. Quite
the reverse. Set up first the medical problem which arises
from the observation of a malady, a/nd afterwa/rds seeh for a
physiological explanation. To act otherwise would be to risk
overlooking the patient, and distorting the malady. ^^ These
are excellent words, which I have ventured to quote ver-
batim, because they are absolutely significant. They enable
us to clearly understand that the whole domain of pathology
appertains strictly to the physician, who alone can cultivate
it and make it fruitful, and that it necessarily remains closed
to the physiologist who, systematically confined within the
precincts of his laboratory, disdains the teaching of the
hospital ward.
The method most suitable to the exploration of the vast
domains of pathology can be described as the nosological.
It is, in fact, the traditional method, for it is the one which,
ever since medicine has existed, has been employed to inves-
tigate morbid states, to determine their characteristics, their
causation, their correlations, and the modifications which
they undergo by the influence of therapeutic agents. And
facts of this kind, gentlemen, I beg you to observe, neces-
sarily constitute the very foundation of every scientific con-
struction in pathology, and without this basis the physiology
of disease would be but a vain phrase.
If it is necessary, in the category of diseases of the
nervous system, to show all the power of this method, it will
suffice to recall a portion of the inimitable work of that great
representative of French neuro-pathology, Duchenne (of
Boulogne). Without doubt his admirable study of muscular
movements, made by the aid of localised electricity, could
ANATOMO-CLINICAL METHOD.
be, up to a certain point, claimed by the science of phyaiology.
But it is not so with his grand diacovery of those types of
disease termed progressive muscular atrophy, infantile para-
lysis, pseudo-hyper trophic paralysis, glosso-laryngeal para-
lysis, and locomotor ataxy. These results, undonbtedly the
greatest achievements of his work, because they filled spaces
hitherto empty, or occupied only by confused ideas, with
animated living shapes, concrete realities, recognised by all ;
these results, I say, were accomplished entirely by the noso-
logical method/
T.
But this method need not necessarily be restricted to the
observation of the outward manifestation of disease ; it can,
without changing its character, be appropriately applied in
exploring the domain of morbid anatomy by following the
patient into the post-mortem room.
It is often said that the progress of medicine and of patho-
logical anatomy go side by aide. This is specially true in
diseases of the nervous system. One example will suffice to
show that the discovery of a constant lesion in maladies of
this kind is the result of such a co-operation.
The description given by Duchenne (of Boulogne) of loco-
motor ataxy, is most striking and vivid. It rightly takes
rank as a masterpiece. However, there existed for a long
time a hesitation in the minds of many about accepting the
disease as a real entity until the spinal lesion, which had
already been described some years before by Cruveilhier,
was known to be associated with this group of symptoms.
Some authors still continued to believe that the affection
was functional in its origin. But all illusions of this kind
vanished when it became realised that there existed, even in
[' The word nosological in English refers simply to the nomenclature
and classLficatiou of disease, but it is the chnical method of inveHtiga-
tioD in its nideet sense which is here implied; or that method of
investigation which argues from effect to cause, commencing with a.
atad; of disease at the bedside, as distinguished from the converse
method of a priori reasoning, with the teachings of physiology for its
bBBis.— S,]
10
ANATOMO-OLlNIOAI METHOD,
the earliest stages of the diBeaae, an exact and easily recog-
nised anatomical chsjige, an anatomical lesion which could be
detected even in the slight and aberrant forms of the
disease. And it was thus, by this linking of the clinical
and the anatomical features, that the different varieties came
to be grouped around, and classified with, the ordinary well-
marked type which alone had been indicated in Duchenne's
classical description.
In this case as in very many others, it ia the intervention
of pathological anatomy which gives the truly practical
character. It furnishes to noaography more fixed, more
material characters than appertain to the symptoms alone ;
and thus one does not fail to grasp the nature of the con-
nections which unite the lesions to the outward signs.
Without detracting from the importance of the results
obtained in this way, it is certain that the study of morbid
lesions can be utilised in another way, and from a higher
standpoint ; more scientific if you like. It can, when the
circumstances are favourable, furnish the basis of a physio-
logical interpretation of normal or of morbid phenomenaj
Flo. I.— A, A, lateral columuB; a', bands of Tiirck ;
poBterior root zonee ; c, c, posterior horns ; D, D, anl
horua ; F, anterior root zone ; b, columna of OoU.
ANADOMO-OLINIOAL METSOD* It
and at the same time^ as a natural conseqnence, give to
diagnosis more penetration and exactitude.
I show you here a diagram (Fig. i) which represents^
after a fashion^ the rudiments of the new spinal pathology.
Here you see that the cord is divided into much more
numerous regions than were formerly known by the agency
of anatomy and experimental physiology alone. This is the
work of the anatomo-clinical method of study. Each of
these regions can be separately diseased without involve-
ment of the neighbouring regions, and they have thus been
isolated, after the manner of a successful vivisection ; and ta
each of these circumscribed lesions there corresponds a par-
ticular symptomatology, which reveals, to a certain extent,
the special functions belonging to the afFected structures.
Thus, we learn that the pyramidal bands are almost exclu-
sively composed of fibres which transmit impulses from the
brain directly to the cord, and by its mediation to the limbs ;
that the motor cells of the anterior horns hold under their
control the nutrition of corresponding muscles ; that the
anterior horns have nothing to do with the transmission of
sensitive impressions, &c. Here, then, physiology and
pathology become as it were linked together.
Some analogous results have been obtained by the appli-
cation of this same auatomo- clinical method to the study of
localisation in the bulb, and in the cerebral hemispheres, but
I will limit myself to a few remarks on this latter point.
Tou are aware that on the question of cerebral localisation
much uncertainty exists at the present time amongst different
physiologists; some deny emphatically that which others,
with no less authority, affirm. We pathologists look on at
these debates, not with indifference by any means, but at the
same time calmly, waiting with patience until an agreement
may be arrived at.
In fact, the means of research employed by us, such as I
have described, have thus far put us in possession of a certain
number of fundamental facts relative to man, against which
the data furnished by vivisection would never prevail. Thus
we know from reliable pathological observations that a de-
structive lesion of the pyramidal band in its progress through
12 NEUROSES.
the capsule in front of the knee^ produces ordinary permanent
hemiplegia : that the destructive lesions of the posterior ex-
tremity of the internal capsule produces corresponding cerebral
hemianadsthesia. As for the surface of the hemispheres one
need scarcely discuss in the present day the pathological role
of Broca's convolution. We kilow that destruction of the
convolutions of the motor zone produces^ if it be general^
complete hemiplegia^ or^ on the other hand^ a monoplegia
only^ if the lesion be circumscribed to this or that region.
To the irritative lesions of these parts are attached the phe-
nomena of partial epilepsy. Without doubt^ these facts of
localisation do not as yet furnish us with the elements of a
fixed doctrine concerning the physiological functions of
diverse cerebral regions^ but^ such as they are^ they form
most valuable landmarks for the guidance of the physician
through the dij£cult paths of diagnosis.
VI.
From what has been said it will be understood how much
importance we ought to accord in our studies to the anatomo-
pathological method of research. But you are aware> gen-
tlemen^ that there still exists at the present time a great
number of morbid states^ evidently having their seat in the
nervous system^ which leave in the dead body no material
trace that can be discovered. Epilepsy, hysteria, even the
most inveterate cases, chorea, and many other morbid states
which would take us too long to enumerate, come to us like
so many Sphynx, which deny the most penetrating anatomical
investigations. These symptomatic combinations deprived
of anatomical substratum, do not present themselves to the
mind of the physician with that appearance of solidity, of
objectivity, which belong to affections connected with an
appreciable organic lesion.
There are some even who see in several of these affections
only an assemblage of odd incoherent phenomena inaccessible
to analysis, aud which had better, perhaps, be banished to
the category of the unknown. It is hysteria which especially
comes under this sort of proscription. But such a verdict,
on no matter how great authority, would never suffice to
HTSTEHIA MAJOK. 13
illominate the nosological framework. We ought rather to
make the beat of things as we find them, and not allow our-
selves to be disheartened by the difficulties they present.
Moreover, gentlemen, it is the merely superficial observation
that leads men to the opinion I have just mentioned ; a
more attentive study makes ns to see things under an alto-
gether different aspect ; and much credit is due to Briquet
for having established in his excellent book, in a manner
beyond dispute, that hysteria is governed, in the same way
as other morbid conditions, by rules and laws, which atten-
tive and sufficiently numerous observations always permit u8
to establish. Allow me to mention but one example, to
recall to your minds the description of an attack of hysteria
major [la grande attaque hysterique], which is reduced at
the present time to a very simple formula. Four periods
ancceed each other iu the complete attack with mechanical
regularity — ist, epileptoid ; 2nd, great movements (strug-
gling, purposeless) ; 3rd, passionate attitudes (purposive) j
4th, terminal delirium. But the attacks may be incomplete,
each of the periods may appear alone, or again one or two
among them will be found wanting. We understand thus
how many varieties can result from these combinations ; but
it will always be easy to those who possess the formula to
bring them under one fundamental type.
This is interesting to the physician in the highest degree,
who learns thus to take his bearings in what appears to be an
inextricable labyrinth. But that which I am most concerned
to demonstrate here is that in the attack, and I could almost
say as much of the other phases of hysteria, nothing is left to
chance, everything follows definite rules, — always the same,
whether the case is met with in private or hospital practice,
in all countries, all times, all races, in short universally.
There is another important fact in the history of neuroses'
in general, and of hysteria in particular, which clearly shows
that these diseases do not form, in pathology, a class apart,
governed by other physiological laws than the common ones.
[' Diseases of the nervoua system apparently dne to functional or
dynamic causes ; wbiiih ai-e not, so far as we know, attended by any
organic lesion. — &,}
14 SIMULATION OF
It is that their symptomatology approaches^ and often very
exactly^ to that which belongs to maladies having organic
lesions ; and this resemblance is at times so striking that it
renders their diagnosis extremely difficult. It is sometimes
designated by the name of neuromimesis — this property which
functional diseases have of resembling organic ones. Between
the hsBmiansBsthesia so common in hysteria and that which
arises from a central lesion, the analogy is very striking.
There is the same resemblance between the spasmodic para-
plegia of hysteria, and that which arises from an organic
spinal lesion (rigidity, exaggeration of tendon-reflexes, loss
of power without loss of muscular substance). Now
this resemblance, often so disheartening to the physician,
should serve as a guide to the pathologist who, besides the
similarity in the group of symptoms, perceives a similarity
in the anatomical seat, and mutatis mutandis, localises the
dynamic lesion from the data furnished by an examination
of the corresponding organic one.
Thus are we brought to recognise that the principles
which govern pathology as a whole are applicable to neuroses,
and that here also one should endeavour to complete clinical
observation by anatomical and physiological investigation.
vn.
While I am speaking to you of the difficulties that the
physician encounters in the study of neuroses, and of the
means at his disposal for surmounting these obstacles, there is
yet one point that I would wish, before finishing, to draw
your special attention to. I mean simAilation. Not that
imitation of one malady by another, of which we spoke just
now, but of intentional simulation, voluntary, in which the
patient exaggerates real symptoms, or again creates all at
once an imaginary group of symptoms. In fact, we all know
that the desire to deceive^ even without interest, by a kind
of disinterested worship of art for its own sake [culte de
Part pour Fart], though sometimes with the idea of making
a sensation, to excite pity, &c., is a common enough occur-
rence, particularly in hysteria.
THE OATALBPTIO STATE.
15
Here is an element tliat we meet with at eaoh step in the
olinique of this nenrosis^ and which throws (there is no use
in denying it) a certain amount of disfavour on the studies
which are connected with it. But in the present day,
when the history of hysteria has been so often scrutinised,
ransacked so thoroughly, is it really as difficult as some
appear to believe, to discern the real symptomatology from
the imaginary ? By no means, gentlemen, and not to deal
with generalities any longer, permit me now to present to
you a concrete example, chosen from many others, and
calculated^ if I. ^O not mistake, to support the theory that I
defend.
The example I allude to is the condition of catalepsy, pro-
duced by hypnotisation^ in certain subjects of hysteria. The
question is this : Can this state be simulated in such a way
as to deceive the physician ? It is generally believed that if.
Fig. 3. — Diagram showing the arrangement of the appa-
ratus in the experiments on cataleptic immobility, b, pressure
drum of Marey ; P, pneumographe ; o, revolving cylinder ; T, T,
stylographs.
This booh is thepvy^
^^^p6 SIMULATIUN OF
^^^K one arm of a patieDt in a state of catalepsy be hoi-izontally
^^■^ extended, this attitude can be preserved for such a length of
time that the duration alone sufficeB to remove all suspicion of
simulation. However, our observations throw doubt on this.
At the end of ten or fifteen minutes the limb begins to fall,
and, at the end of twenty or twenty-five minutes at the
maximum, it has fallen into the vertical position. Now these
are precisely the same limits that a vigorous man, trying to
keep the same position, can also reach. We must, therefore,
seek some other distinguishing feature.
■
1
Fig. 3.— Tracings obtained fiom a hj ate 10 -epileptic in a
state of hypnotic eatalepej. i, pneumographic tTHcing ; 11,
tracing of preBsuie drum. Eead from left to right In order
i.a,3.
p
OATALEPTIO STATE. ]
With the healthy subject, as with the cataleptic, a pressu
.mm fixed at the extremity of the ont-stretched limb {Fi
E) will serve to register the least oscillations of the am
neanwhile a pnenmograph applied to chest (Fig. 2 p) wi
jive the curve of the respiratory movements.
Now, I show yon here, in an abridged form, what is see
n the tracings thus obtained. In the cataleptic, during th
ivhole time of the experiment, the pen, which corresponds t
he extended limb, traces a perfectly straight, regular lin
Fig. 3, ").
1
1
n
e
2
L.
Fia. 4.— Di^gmm of tr^iciuya obtaiued frum a, man wLd
curve ; 11, tracing of the presaure drum. Read fi'om left to
right iiL order i, 2, 3.
2
18 CATALEPSY IS NOT SIMULATION.
In a person who simulates^ the corresponding tracing
resembles at first that of the cataleptic^ bnt at the end of
a few minutes considerable differences will be seen ; the
straight line becomes crooked^ very undulating^ marked in
places by large oscillations arranged in series (Fig. 4, 11).
Nor are the tracings furnished by the pneumograph less
significant. In the cataleptic the respiration is slow and
superficial^ but the end of the tracing resembles the com-
mencement (Pig. 3, i) . In the healthy person the tracing is
composed of two distinct phases. At the outset^. respiration
is regular and normal. In the second phase there is irre-
gularity in the rhythm^ and prolongation of the respiratory
movements^ corresponding to the indications of muscular
fatigue noted in the tracing of the limb ; then deep and
rapid depressions^ showing the disturbance of respiration
which accompanies the phenomenon of effort (Fig. 4, i).
In short you see that the cataleptic patient is unacquainted
with fatigue ; the muscles yields but without effort^ without
voluntary intervention of any sort. On the other hand^ the
ma/n who simulates succumbs under the double test^ and finds
himself betrayed on both sides at the same time : Ist^ By the
tracing given by the limb^ which reveals the muscular
fatigue ; and 2nd^ By the respiratory curve^ which betrays
the effort made to hide its effects.
It is useless to insist further. A hundred other examples
might be invoked which would only show that the simula-
tion^ which is talked about so much when hysteria and allied
affections are under consideration^ is^ in the actual state of
our knowledge^ only a bugbear^ before which the fearful and
novice alone are stopped. For the future it ought to be the
province of the physician^ well-informed in these matters^ to
dissipate chicanery wherever it occurs ; and to sort out the
symptoms which form a fundamental part of the malady^
from those which are simulated^ and added to it^ by the
artifice of the patient.
And thus do we approach, with prudence no doubt, but
also with confidence, the study of these dreaded maladies,
permeated, as we are, with the surety of the methods of
observation we have at hand.
CLINICAL OBSERVATION. 19
Time presses^ and I must conclnde. I shall be happy if^
in to-day's sketchy I have been able to make yon see the
ideal towards which onr efforts tend. In the solution of the
problems that lie before us^ all the branches and all the laws
of biological science, mutually supporting and controlling each
other, will be brought under contribution. But I maintain
that the preponderating roUy the governing and guiding
principle of all, belongs to clinical observation.
In making this declaration, I am but following the
precepts, and placing myself under the protection, of the
classic masters of the French School ; whose teachings have
shed so much lustre on the Paris Faculty of Medicine, to
which I count it an honour to belong.
i
LBOTXJRE II.
ON THE MUSCULAR ATROPHY THAT FOLLOWS CERTAIN
JOINT LESIONS.
SuMMAEY. — Traumatic joint disease^ and the paralysis and
muscular atrophy which follow it, — Modification in the
faradic and galvanic contractility, — Contractions produced
hy the electric sparlc—^Exaggeration of tendon-reflexes, —
Simple muscular atrophy, — No relation necessary between
the intensity of the joint-affection and that of the para-
lytic and atrophic phenomena, — The extensor muscles of
the articulation are most affected, — The muscular lesions
are dependent on a deuteropathic spinal affection.
Gentlemen, — On account of its origin, the affection from
which the patient, who is about to be presented to you, is
suffering would be called surgical ; it was undoubtedly an
injury which gave rise 'to it. As a matter of fact the
arthritis which was the immediate consequence of the injury
has ceased to exist ; but the same accident gave rise also to
a spinal affection of a peculiar kind which still persists,
and on this account the patient claims our attention and
assistance at the present time.
The man B — , aged 23 years, a telegraph clerk, has always
had good health, and presents nothing of interest in his ante-
cedents other than the fact that his maternal uncle had to
be placed in an asylum on account of mental derangement.
He is brought before you in bed, although he is quite able
to get up and walk, because I wish in the first place to point
out certain particulars which cannot well be observed unless
the patient is lying down.
Tou will notice, firstly, that his general condition is excel-
lent, he is healthy looking, the appetite is good, and all the
ARTICULAR PARALYSIS. 21
organic functions act well. The only affection with which
he is troubled is a disturbance in the walk, and it is, as you
will see, in the right leg, or rather certain of its muscles,
where the power is wanting. This diflSculty of walking has
existed for about one year.
A methodical examination reveals the following facts :
when the patient is in bed, the right inferior extremity can
execute all the natural movements excepting one, extension
of the leg on the thigh. Movements of abduction and
adduction of the thigh, flexion of thigh on pelvis, or leg on
thigh, and all the movements of the foot on the leg, are
free ; but extension of the leg is wanting. Thus, when he
wishes to straighten the leg after it has been previously
placed in a position of semiflexion, he tries to do so by
slipping the heel along the bed, or else he aids it with his
hands, or the other foot. It is, you see, the extensors of
the leg which are at fault, that is, the muscles which are
supplied by the crural nerve, and it is especially the
quadriceps extensor muscle which is affected.
The patient can oppose, although with less force than the
healthy limb, passive movements of extension and flexion
made at the foot or hip-joints ; he can resist the strongest pos-
sible attempts made to straighten the bent knee ; but he offers
but feeble resistance to passive flexion of the leg on the thigh.
In the main, although there may be some relative weak-
ness of nearly all the muscles of the lower limbs, it is chiefly
the power of the quadriceps that is wanting at the present
time.
This paralysis, limited to the extensors of the right knee,
is shown again when the patient gets out of bed and attempts
to walk.
He raises the right leg by the aid of the left foot to
make up for the deficient power of extension of the right
knee. He walks without support, but you notice something
peculiar in his mode of progression ; some of you wiU see
also that he has much improved during the last few days ;
although the characters of the gait are still present, they
w6re much more marked when he came in. Nevertheless,
even now, you can see that at each step forward, although
22 ATROPHY OF MUS0LB8.
the left knee bends and straightens alternately^ the right
knee has hardly any such movement^ all movement is in the
hip ; the right leg seems as if it were too long^ and performs
a movement of circomduction all in one piece^ as if the
knee-joint did not exist. Formerly, the extremity of the
foot had a tendency to drop, which rendered walking still
more difficult ; the paresis of the muscles which bend the foot
on the leg has since disappeared.
It is important to remark that there is no pain whatever
on movement, such as could produce the difficulty of
progression ; the articulation also is perfectly free ; it is in
the nervous system, or in the muscles, that one must seek
for the cause of this feebleness.
By a more attentive examination of the affected limb we
become aware of some other important facts. In the first
place you will find a diminution of volume of the entire
Hmb, which was formerly more pronounced than it is now.
These are the measurements :
Bight. Left.
Upper part of thigh ... 48 cm. 52 cm.
Just above knee .... 37 cm. 38 cm.
Centre of calf 33 cm. 35 cm.
But, even without measurement, it is evident that the
anterior surface of the right thigh is considerably fiattened,
it is almost hollow ; the muscles of this region, moreover,
are without substance and fiaccid even at the moment* of
contraction. There is then, not only a paresis, but also an
alteration of nutrition, an atrophy of the quadriceps muscle.
It is possible that the right thigh and knee are relatively
colder ; but there is no marked alteration of the cutaneous
sensibiUty.
To complete the description, let me add the results of
electrical exploration, which reveals the state of nutrition of
the muscles. At the time when he came in, eight days ago,
(i) galvanic and faradic excitation of the crural nerve in
the groin gave scarcely any contraction ; (2) Faradisation
over the points of election with completely enclosed bobbins
(Du Bois-Eeymond's apparatus), produced little if any re-
action ; the muscles might indeed have been absent. One
BLECTBICAL CONDITION. 23
would^ after discovering tliis latter result^ have expected to
find that galYanism prodaced tlie reaction observed when
the nutrition of muscles is profoundly affected, such as takes
place in experimental section of the nerves, or in infantile
paralysis, when there is destruction of the motor cells, or
again, in severe facial paralysis. In such cases, one finds
what is called in electro-diagnosis the reaction of degenera-
tion,:i. e. increased galvanic excitability, concurrently with
a diminution or absence of faradic excitability; well,
here it was not so ; the galvanic current, even with fifty
elements and with no matter what arrangement of poles,
gave no greater contraction than the faradic current.
Hence, there was a quantitative, and not a qualitative re-
action ; and one could conclude from this that we had before
us a simple and not a* degenerative atrophy.^
Moreover, here is a curious circumstance. This muscle
which remains almost inert under the influence of the will, or
under ordinary electrical excitation (whether direct or indi-
rect, faradic or galvanic) of the nerve, contracts energetically
enough when the patient, being placed on the insulated stool
of a static electrical machine, is made to receive a spark
either in the centre of the rectus f emoris, or of the vastus
intemus (the vastus extemus is an exception in that it has
preserved a certain degree of galvanic and faradic excita-
bility). It should be added that a sharp blow on the body
of the rectus muscle produces a distinct contraction, and
that percussion of the patella tendon determines very pro-
nounced tremor, not only in the limb struck, but general,
and even manifest in the two upper extremities, especially
the left one. Percussion of the left patella tendon produces
tremors equally intense. No trepidation can be elicited by
a sudden bending of the point of the foot, either in the
right ox left lower extremity.
All the other muscles of the limb present normal electrical
^ M. Biiimpf has studied, under Professor Erb, the electrical reaction
of muscles in cases of joint disease (of shoulder, knee, &c.)* He found,
and his observations were aiaply confirmed by those of Erb, that in these
cases there is a simple diminution of electrical excitability, and never a
quaHtative modification, which absolutely distinguishes simple muscular
atrophy from degenerative atrophy.
24 ABTHEITIO AMYOTROPHY.
reactions. It was not^ however^ according to the patient's
account^ always so. Thus at one time the cheeks and the
front muscles of the legs did not contract equally on the
two sides, but lately he has improved. At no time has there
existed any trouble of micturition or defecation.
We must now seek for the cause and significance of all
these phenomena. In summing up the whole, this patient
is afflicted with paralysis, accompanied by simple atrophy,
almost exclusively localised to the extensors of the thigh,
and also by a profound modification, quantitative only and
not qualitative, in the electric contractility.
The localisation of these troubles will help to guide us to
a diagnosis. We know now, after oft-repeated observa-
tions,^ that atrophic paralysis of the extensor muscles (or at
least predominating in the extensor muscles) is a frequent
complication of different idiopathic or traumatic lesions
affecting the corresponding articulation : thus, one not in-
frequently sees atrophy of the deltoid muscle after different
lesions of the scapulo-humeral articulation ; or as a conse-
quence of an arthritis, sprain, or other injury of the hip-
joint, the buttock is sometimes affected in the same manner;
or if it be the knee-joint which is attacked, the nutrition and
mobility of the quadriceps extensor femoris is affected.
These facts, which were known to Hunter and Paget
have been worked out in greater detail in later years
by M. OUivier, by M. Le Port, and in the valuable memoir
of M. Valtat, where it is shown experimentally in animals
(guinea-pigs and dogs) that after inflammation of the knee-
joint, artificially produced by the use of irritating injections,
all the muscles of the limb are affected, but more especially
1 J. Hunter, * CEuvres completes,' trad. Riclielot, T. I, p. 581, Paris,
1839. A. Ollivier, ' Des atrophies musculaires/ These agreg., 1869. Le
Port, * Soc. de Ohir.,* 1872. Sabourin, *De I'atrophie musculaire rheu-
matismale,' These de 1873. J* Paget, * Lemons de Olinique Ohirurgicale,'
trad. Petit, 1877. E. Valtat, * De Tatrophie musculaii*e consecutive aux
maladies articulaires ' (6tude clinique et exp^rimentale), These de 1877.
Darde, ' Des atrophies consecutive a quelques affections articulaires/
These de 1877. Guyon et F^re, " Note sur Tatrophie musculaire consecu-
tive ^ quelques traumatismes delahanche," ' Progres Medical/ 1881, &c.
r
TBAUMATIC ARTHHITI8. 25
the extensors of the articulation. And that in sucli caeea the
atrophy, which presents the characters of a simple atrophy,
without irritative characters, supervenes very rapidly, at the
end of eight days in 20 per cent,, and at the end of fifteen
days in 44 per cent, of the cases.
Well, now, can this causal relationship between muscular
and joint affections be applied in this case ? Tea, undoubt-
edly ; you will recognise its existence after a study of the
past history of the patient, and then it will not be necessary
to go far to find a cause for his condition ; all his troubles
date from an injury, and this injury inTol7ed the knee,
solely the knee.
About a year ago. May 5th, 1881, B — , while jumping
over a fallen tree, knocked his right knee ; he did not fall
nor did he experience much pain, still the blow was enough
to tear his trousers. He could walk, and he accomplished
three kilometres without fatigue, but being obliged to descend
a bill he then experienced a kind of stiffness in his knee
and had to stop. It was only then that he noticed a little
patch of blood on the front of his knee, but there was no
swelling. When he started again he could only walk with
the aid of a stick.
During the eight days which followed there was some
awelKng of the joint ; the patient remained in bed, but there
was no fever.
The doctors who saw him appeared astonished at the great
contrast between the arthritis, which seemed so slight, so
free from pain, and the motor weakness, which was consider-
able.
A silicate splint kept on for twenty-one days did not
mend matters, and after taking it ofi there existed the same
contrast, and the doctor still seemed at a loss to understand
how so much loss of power could exist with such a slight
and painless arthritis.
It was not till four months after the onset that the appro-
priate treatment was employed, faradisation, and it was only
then that he began to mend and his walking to become less
difficult.
i6 tBOGl^OSTS.
In the relationship that here existSs between an insigni-
ficant injury which produced so slight an arthritis^ and this
paralysis of one year's duration^ there is nothing very
astonishing if we consult the clinical history^ so well known *
since recent investigations, of atrophic articular pa/ralysis or
paralysis having an articular origin.
li, as a matter of fact, in a large number of cases, the
protopathic^ joint affections, either spontaneous or traumatic,
which determine atrophic paralyses, are painful and very
severe, it is not always so, by any means. Thus a slight and
easily cured sprain, a simple collection of fluid in the joint,
non-inflammatory and not painful, or, like our case, a simple
arthritis, can occasion the same troubles. There is no rela^
tion necessary between the intensity of the joint affection and
that of the paralytic and atrophic phenomena.
As for the persistence of the deuteropathic' symptoms
(paralysis and atrophy) after the cessation of the proto-
pathic affection (arthritis), it' is for the most part the rule ;
and that is perhaps the most interesting feature in the
history of amyotrophic paralyses of articular origin, whether
looked at from a pathological or clinical point of view.
The physician should certainly be aware of this impor-
tant circumstance. He should not, in presence of a slight
arthritis, when the weakness and atrophy are well established,
risk giving a favorable prognosis, nor promise amelioration
after a short while ; such a prognosis would in all proba-
bility be wrong. You see, months have slipped by and the
limb is still more or less useless, although the arthritis has
for a long while only been evidenced by a slight thickening
of the peri-articular tissues, if, indeed, there be even as much
as that left.
These particulars lead us to ask what can be the physio-
logical explanation of this singular complication of an arti-
cular affection ; such knowledge might serve us as a guide
in the treatment*
^ Primary or originating {irp&Toc, first; trdBoc, disease).
' Secondary oi* resulting (Mnpoct second)^
fATHOLOGt. 27
The favourite theory with most contemporaneous authors
appears to be this; the articular affection reflects certain
irritant impulses along the articular nerves to the spinal
cord, which impulses modify the trophic centres in that organ,
whence emanate the motor nerves and the nerves which
regulate the nutrition of the muscles.
There exists in the spinal cord a relationship more or less
direct between the cells of origin of the centripetal nerves,
and the cells of origin of the motor and trophic nerves of
the extensor muscles (the crural in the case with which we
are concerned) ; hence the result produced is a constant
one, and thus in the case of irritation of the nerves of the
knee it is always the extensor muscles (quadriceps), or at
least those principally, which atrophy. I say principally,
because the irritation, once started by the articular nerves,
can spread by diffusion outside the distribution of the crural
nerve into the muscles of the leg or foot. In lesions of the
shoulder, elbow, hip, the atrophy of the extensors always
predominates, although it is possible that other muscles of
the limb may also be involved.
None of the other theories that have been suggested can
be accepted ; thus, it has been said that the articular inflaiqi-
mation spreads little by little into the neighbouring muscles ;
but the atrophy exists equally in the entire length of the
muscle, and, moreover, experiments show that the change is
a simple atrophy, without a trace of inflammation, without
myositis. Nor is the hypothesis of atrophy by disuse from
prolonged rest admissible ; the articular affection is often so
slight as not to require more than a very brief rest ; and,
moreover, by this theory how can we explain the localisation
of the atrophy almost exclusively to the extensors ?
One is therefore obliged to admit that it is a deuteropathic
spinal affection which gives rise to the paralysis and atrophy.
But of what does the modification in the medullary centre
consist ? It is not a profound modification in the cellules
of the anterior horns ; for we know the effects of a profound
alteration in these elements in infantile paralysis. Here
there is the reaction of degeneration, in which we get
28 TREATMENT.
exalted galvanic and diminished faradic excitability ; except
when the disease is very advanced, and the muscle is quite
destroyed, and then there is abolition of both modes of
excitability ; in which case it is almost impossible to restore
the function. In articular paralysis, on the other hand, we
see that by appropriate treatment the electrical reactions are
already reappearing.
It must be then only a sort of inertia, or torpor, so to
speak, of the electrical elements.
Should one conclude that in a case of this kind, if we
adopt an appropriate course of treatment from the very
beginning, we should obtain a rapid cure ? It is probable,
and this leads me to speak to you of the treatment.
However, before doing so, I ought to say a word on the
exaggeration of the tendon -reflexes of the lower extremities.
Is it a peculiarity of the individual, or is there a morbid
reflex irritability throughout the entire length of the cord,
excepting that region where the motor cells are, on the con-
trary, in a state of torpor as we have just supposed ? This
latter would appear probable from an observation of other
analogous facts which we are now studying, and of which I
shall soon have occasion to speak to you.
But, to return to the treatment, here we have to do with
a dynamic spinal lesion, without profound modification, so
far as we know, and the electric treatment can certainly
be adopted without fear. The results obtained up to the
present time are encouraging for the future. The electric
spark seems already to have played an important role in
restoring the contractility of muscles where faradisation or
galvanisation have produced no effect. At the present time
we have ample choice ; we can employ the electric spark, gal-
vanism, or faradism. I must reserve for a future occasion
the description of how this treatment should be conducted.^
^ As we have just seen, in certain cases, a muscle, absolutely irrespon-
sive to the faradic and galvanic currents, contracts very well with the
electric spark. This fact, already pointed out in a lecture by M.
Charcot on static electricity, shows how relative and contingent are
the actual data of electro-diagnosis. It is very strange that a muscle
electrically inexcitable under the usual methods (galvanisation and
TREATMENT. 29
In this case the spinal affection of articular origin is of a
mUd form^ and the issue^ as is asual^ will doabtless be favor-
able. It is possible^ in some cases^ that both the spinal^ and
faradisation) should contract normally enough from the moment that
another method of electric excitation is had recourse to.
It does not, however, follow that this power of the electric spark is
the invariable rule. Ofbtimes the spark does not prove more efficacious
than the currents in provoking contraction of the aflFected muscle.
Indeed, we have quite recently demonstrated this state of matters in
a woman the subject of incomplete atrophy of the muscles of the neck
and upper extremities, with diminution (not absence) of the faradic and
galvanic reactions.
But whatever practical use they may have, the facts analogous to
those lately studied by M.^ Charcot prove the importance of static elec-
tricity in electro-diagnosis. For the future, to the faradic and galvanic
reactions must be added the Franklinic (or, more euphoniously, Frank -
linian) reaction. Many English and American authors designate static
electricity under the name of Franklinism, and its application, Frank-
linisation. There is at least the advantage of brevity in these denomi-
nations.
The clinical significance of this reaction remains to be determined.
Coming to the treatment of the patient, since the lecture he has been
treated with static electricity (or, better, Franklinised) three times,
making eight times altogether. This has produced an amelioration
which contrasts strongly with his former condition, remaining stationary
as he did for so many months in spite of vaj'ied treatment. His walking,
&c., have improved ; and moreover, strange to say, the faradic and gal-
vanic reactions have reappeared more and more clearly. At the com-
mencement there was no effect with the maximum faradic current, and
a current of more than 20 milliamperes for galvanism ; but now reac-
tions are obtained in the affected muscles with a separation of 4 or 5
centimetres between the bobbins, and 9 or 10 milliamperes.
It is an important fact that these two reactions reappeared simul-
taneously. In both there only exists up to the present time the cathodal
closing contraction. In other words, the faradic cuiTent only gives a
contraction when the muscle is excited by the negative pole (in a recent
article on electro-diagnosis we have insisted on the necessity of taking
into consideration the direction of the cuiTcnt in faradism as well as
galvanism) ; and with galvanism, also, contraction is only obtained with
the negative pole, and at the moment of making the current. All which
conditions, as lately explained by us, can be accurately expressed by
these three letters, K, S, Z. Thus there is simply a diminution of
excitability without qualitative alteration. These details confirm the
opinion expressed by M. Charcot in the lecture, that we have to do with
a simple atrophy.
With reference to the manner in which the electncal treatment should
80 TEBATMENT.
consequent muBCular^ diseeuse may be more serioas than it is
here.
It is important to bear in mind that the paresis and the
atrophy are not the only deuteropathic trouble that can
result from an articular lesion. This group of facts is some-
what complicated. Thus arthritis^ or traumatic joint mischief^
be conducted, we have, as the Professor says, the choice between fara-
disation, galvanisation, and Franklinisation. In the actual state of
matters it would be difficult to assign a reason for giving a preference
to one or the other of these means. The most simple course would be
to continue the static electrisation. Its good effects have been evident
up to the present time, it is a convenient application, and we are not
thereby prevented from having recourse to the exploration of the
ordinary reactions.
It remains to indicate precisely how the treatment should be carried
out. We know hj experience that the electric spark acts in a most
efficacious manner on the nutrition of muscles, and in this way we
have successfully treated a long-standing facial paralysis of peripheric
origin, in which the ordinary electrical reactions were quite aboUshed.
But the point on which we insist is that to obtain therapeutic results,
strong sparks administered from a metal point or ball are not indis-
pensable. With this patient these have simply been used for purposes
of exploration; for the treatment it is sufficient to produce a much
weaker discharge &om a brush, one incapable of giving rise to any con-
traction.
By this proceeding we have succeeded in a case of considerable
atrophy of rheumatic origin. M. le Professeur Agrege Begimbeau (de
Montpellier) has also established, quite independently, analogous facts
(oral communication).
Practically this is valuable information, for it is not always conve-
nient to produce a violent contraction in the affected muscle.
Theoretically, it is well to note that the most evident trophic effect
is produced by an electric discharge, the quantity of which, compared
with ordinary galvanic currents (in electrotherapy), might almost be
overlooked. Hence it is expedient to accept with reserve the views of
authors who take their stand on the physiological properties of the
current, attributing the trophic effects to the quantity, no doubt by
analogy, with the chemical effects. It is very probable that the question
is not so simple as thus stated.
Upon the whole, the patient who forms the subject of M. Charcot's
lecture, gives us ample justification for bringing static electricity more
and more into use at the SalpStri^re.
In the present stage of electrotherapy it is inexpedient to lose sight
of any material contribution. It is from experience alone that one
must draw arguments for or against static electricity. — Bomaik
YlOOTIBOITX.
OONTRAOTUEB. 31
may produce^ hj reflex action^ a contracture limitedj to the
muscles of the joints or involving the whole limb. These
cases are not infrequent^ and it is known^ that under these
conditions the joints assume a flexed position^ the flexors
overpowering the extensors. In other cases the atrophy and
contracture combine.
These varieties of spinal disease^ produced by the influence
of a cause always the same in appearance, are particularly
interesting to us^ and we shall have occasion to return to
them when speaking of several patients which are now in
the wards.
This hook is thepropi^'
COOPER MEDICAL OOLLr.G^,
SAN FRANOISOO, OAL
cmd is not to be removed from the
Lihro.nj Pnnrn by a/ny person or
under auj ^ ttxt whatever.
LECTURE m.
I. OONTEAOTURES OP TRAUMATIC ORIGIN.
II. TIC NON-DOULOURBUX OF THE FACE IN A HYS-
TERICAL SUBJECT.
Summary. — I. The influence of traumatism in determining the
seat of certain diathetic manifestations. — Oontracture of
traumatic origin in subjects who present spasmodic
rigidity in a latent state. — Exaggeration of tendon^
reflexes vn hysterical patients. — II. Typical case of tic-
non-douloureux of the face. — Oontracture of the muscles
of the face in a hysterical patient. — Simulation.
Gentlemen, — At the present moment our wards contain a
large number of cases of very great interest, many of which
are well worthy of being presented to you. Now some of
these can well be postponed for a future occasion, but there
are others in whom the symptoms that I want to show you
are of an evanescent character, and may even disappear all
in a moment in a most unexpected way ; so I believe it
will be prudent to seize the opportunity of showing you
some of these latter cases to-day.
I.
In the first patient that I am going to show you, you will
recognise the influence which the most common traumatic
lesions have on the local development of the phenomena of
hysteria, and on development of contracture in particular.
We have known for a long time that certain diseases,
which are pathologically dependent on a diathesis, are some-
times developed at the instance of a traumatic lesion. It is
TWO KINDS OP HT8TBBO-BPILEP8Y. 33
usual for these diseases to localise themselves at first in parts
where the wound, the contusionj or the sprain is produced.
It is so in articular rheumatism for example, and in gout;
and, as I long ago remarked, nothing is more common in a
gouty subject than to see, in addition to the regular spring or
autumn attacks, a supplementary attack, following a fall for
instance. And the peculiarity is that whereas the spontaneous
attacks become localised in the usual place, the supplementary
attack will be situated in the shoulder or the knee, or some
other joint which has been the seat of a contusion or the
sprain. This is the commonly accepted opinion in the
present day, and during the last few years Professor Vemeuil
and his students have realised the full value of the importance
which attachea itself to the study of facts of this kind, from
a surgical point of view.
But what is leas known perhaps is that certain local
phenomena of hysteria, and in particular the contracture of
a limb, manifest themselves sometimes in the same way and
under the same infiuences.
I will commence at once the narration of the. case, and
as we proceed. I will point out the lessons to be drawn
from it.
This stout woman, aged 34, is one of our oldest inmates in
the division for, common epilepsy ; she has been here in fact
for more than twelve years. She belongs to the class of
cases that comes under the denomination of hystero-epilepay
with distinct crises.
I ought perhaps to give you a short explanation of thq
meaning of this phrase. It means that this woman is
the subject of two diseases of which the outbreaks appear
separately ; at one time the hysterical crises are present (the
attacks, as we say here), at another time the epileptic seiaures
(the Jits) . On the other band, the phrase hystero-epilepey with
mixed crises is meant to include those cases where hysteria alone
exists, but in which also the malady is characterised, in its
complete outbreaks, by four periods, one of wbich, the first
(epileptoid or hystero- epileptiform phase), bears the likeness
of epilepsy. We have proposed for this form the term
hysteria major [la grande hysierie^ so as to replace the
34 TRAUMATISM.
long phrase " hystero-epilepsy with mixed crises,'* which
sometimes leads to confusion.
This patient is, at the present time, suffering from Hysteria
Major and from true Epilepsy also, of which she has attacks
during the night, accompanied by biting of the tongue,
involuntary emissions of urine, Ac. Formerly, that is
prior to five years ago, the hysteria predominated over
the epilepsy; thus in 1874, 244 attacks (of hysteria) were
counted, and 62 fits (of epilepsy) ; but since 1876 the
attacks have shown a tendency to disappear, and the fits,
although they also have been less frequent and occurred
mostly at the catamenial periods, have decidedly held the
chief place.
It was one of the peculiarities of the hysterical attacks in
B — , when they used to occur side by side with the epileptic
fits, that they were frequently followed by contractures of
the right lower extremity, lasting fifteen days, a month, or
more. Hemiansesthesia and ovarian tenderness [ovarie]^
existed at that time on the right side ; it was on the right
side also that the symptoms premonitory of an attack occurred
(buzzing in the ear, beating of the temple, &c.).
The hysterical phenomena have almost completely dis-
appeared of late years, and the patient has been considered
by us during the last five or six years no longer as an
hysterical one, but rather an epileptic, whose seizures were
generally diminishing, if not in intensity, at least in number..
Now, on May i6th, that is a fortnight ago, a symptom
appeared which shows that hysteria is by no means extinct
in this woman, and that the diathesis persists up to the
present time, albeit in a latent condition. B — went as
usual to her work, there having been nothing particular in
her behaviour during the few preceding days, when sud-
denly and purely by accident, and without having expe-
rienced any giddiness or vertigo — she is very explicit on
this point — she took a false step on the top of the staircase,
fell heavily on her left side, and slipped like an inert mass
down a fiight of a dozen steps. Two of her companions
1 "Ovai'ie" is a term used in Prance for a series of phenomena
(sighing, laughter, crying, sometimes convulsions, <&c.) produced by
pressure on the inguinal region. — T. D. S.
PDNOTIONAL AND OEOANIO OONTBAOTIIHE.
35
lifted her np directly ; she was not much hart, and the
only trace of the injury at the present time is a braise
over the left external malleolns, Bnt, immediately after
the fall, her walking became very difficult, and the reason
of this difficulty was a rigidity of the joints (hip, knee,
ankle) of the left inferior extremity, the one that had been
injured.
We saw the patient on the morning of the next day and
found her in the same condition as she is to-day, and which
I will now demonstrate to you.
The patient ia lying on the right side. The left lower
extremity is rigid from end to end. Voluntary extension and
flexion are both impossible, attempts at passive movement
are equally useless, in whatever direction the force be applied.
The flexor and extensor muscles are both in action, as you
see, only, the extensors, as is usual in this kind of contracture,
predominate ; the thigh and leg are straight out ; the foot is
in a state of plantar flexion, as a consequence of the predomi-
nating action of the calf-muscles ; in other words, the three
segments of the limb are in a straight line, the foot being
in a position of talipes equiuus.
I should add that the limb, which is like a rigid bar, ia
also adducted ; if one aucoeeda in bending the limb away
from the middle line it springs back to its original position.
Moreover, thia limb haa undergone rotation inwards at the
hip-joint, so that the knee-cap and the point of the foot look
almost directly inwards. For the rest, there is no articular
pain or swelling, no vestige of the fall, if we except the
bruise in the neighbourhood of the external malleolus above
mentioned.
I should like you to observe that thia strained position of
the limb came on almost suddenly. Thia, as I have already
pointed out, is one of the characteristics of the hysterical
spasmodic contracture in distinction to contractures of organic
origin. Thus, in the spasmodic paraplegia of transverse
myelitis, of disseminated sclerosis, &c,, this condition is not
arrived at all of a sudden. In the first period there is para-
lysis with flaccidity of the limbs, though there ia exaggeration
of the tendon -reflexes ; in the second stage spasmodic 8.tt».c,Vs,
36 HYSTEBIOAL STIGMATA.
of rigidity occur ; in the third, there is a condition of rigidity,
either in a position of extension or semiflexion ; and lastly in
the fourth stage, which is very rarely, if ever, seen, there is
an invincible rigidity, which may be compared to an iron
bar.
One of the most interesting characters of hysterical con-
tracture is, you see, that it can reach its maximum all in a
moment.
The occurrence of contracture under the circumstances just
narrated in a subject known to have been affected with
hysteria in a marked degree, and to have been formerly
attacked with contracture, would naturally make us suspect
that a hysterical storm was imminent. We ought therefore
to inquire whether other hysterical stigmata were not deve-
loped in her after the fall, at the same time as the contracture.
Now, as a matter of fact, it is so ; hemianaasthesia, which was
formerly on the right side, but which had disappeared for
some years, has reappeared, though it is on the left side
now, the side on which she fell, and on which there exists
the contracture.
The anaesthesia occupies the whole of the left side, the
limbs, trunk, and the face, excepting the parts immediately
round the organs of sense, an exemption which sometimes
happens. There is no ovarian phenomena [ovarie] }
Besides these symptoms there is nothing worthy of your
attention, except perhaps insomnia, which she has had for
the last five days, and the fact that the catamenial period
commenced at its natural time two days ago. Now, it is at
the menstrual period that she is usually attacked with the
epileptic fits, and it was then that she was formerly attacked
with the hysterical seizures. It is very probable that she
will have a manifestation of this kind in a few days ; after
which the contracture may disappear in the same manner as
it came, that is to say, suddenly, or very nearly so. It is
on that account that I was so anxious to present this, patient
to you to-day, for it is possible that we might not have
another opportunity of showing you a case of hysteric$tl con-
tracture of traumatic origin for a very long time.
But, you will ask me, are you quite convinced that the
1 Vide note, p. 34.
STRTOHNtSM. 37
injury has had the influence which jou suppose on the
development of the apasmodic rigidity of limb ? May it
not be simply a fortuitous coincidence ? The reasons in
support of the theory I hold are not wanting.
I, Let us first take tbe argnments which are independent
of hysteria, I have already had occasion to point out the
analogies that exist between the spasmodic paralysis of
hysterical patients, or such as are not due to any organic spinal
affection, and the spasmodic paralyses, hemi- or paraplegic,
due to organic lesions of the brain or cord.
Thus, in hemiplegia consequent on a lesion of the brain
occupying the internal capsule in the course of the pyramidal
band, the limbs may remain flaccid. But the contracture
exists there, in a latent state as it were, as ia shown by the
exaggeration of the tendon-reflexes (foot- or knee-jerks) j
and, sometimes by perseverance, by repeated blows on the
patellar tendon, a temporary contracture lasting several
minutes can be produced.
Well, under these circumstances, there is an imminence
of contracture which can be brought on by the occurrence
of a traumatism, and it will manifest itself in the part
which is the seat of the contusion, sprain, &c. In this
manner a contracture was produced and persisted for several
months in the case of a woman recorded by M. Terrier.
Sufficiently numerous examples of this kind could be quoted,
relative not only to hemiplegia but also to paraplegia,
which take on a spasmodic character under the influence of
an injury.
Moreover, to determine a contracture in a limb which is
paralysed and flaccid, the injury need not necessarily be
violent ; an ill-timed faradisation, the application of a
blister or an autimonial plaister, can produce the same
effects as a blow.
The theory which best enables us to fix these facts in the
mind is the following. There exists in cases of paralysis
due to a material lesion a hyper -excitability of the grey sub-
stance, and particularly of the motor cells of the anterior
horns, a special state which I propose, for want of a better
term, to describe by the name of strychnism. Then, cuta-
neous irritations, irritations of the centripetal nerves in
38 TBAITMATIO OONTBAOTUEB.
general^ augment the already excited condition of the motor
cells ; the measure overflows^ and the centrifugal nerve
transmits the irritation to the muscles which it supplies.
2. Now^ to return to hysteria. In many hysterical patients^
chiefly on the anaesthetic side^ but sometimes everywhere a
little^ there exists an exaggerated reflex excitability. And
one finds also a paresis^ a well-marked dynamometric weak-
ness. Hence it is not astonishing to find that an excitation
of the centripetal nerves, whether of the tendons or of other
parts, produces the same effects as in cases where there
exists a lesion of the nervous centres. Under these condi-
tions, paralysis of the limbs without rigidity becomes trans-
formed into a paralysis with contracture.
I could mention numerous cases of this kind, and some of
them are reported in the appendix to the first volume of my
lectures delivered at the SalpStriere. In one case a con-
tracture of the wrist followed a blow on the back of the
hand and lasted for several months. Or again, I have seen
the same symptoms after crushing the hand in the machinery
of an engine; another hysterical patient, whose foot had
been violently pressed against the bar of a chair, was
attacked with a contracture of the foot ; and so on.
Brodie, who was well aware of these facts, and who,
indeed, was the first to publish them in 1837 in his work on
certain local nervous affections, mentions contracture of the
upper extremity following pricks of the fingers.
These facts are all the more interesting since a contracture
determined by an injury is often the first manifestation of
the hysterical diathesis. For example, an ordinary injury
is followed by a contracture in a young person who till then
is not known to have any nervous symptoms ; examine the
case very thoroughly, and in aU probability you will find
some accompaniment that will demonstrate the presence
of hysteria; it will be very surprising 'if you do not find
some hyperassthesia, anaasthesia, ovarian pain, or some indi-
cation of that kind.
3. I can give you further evidence of this tendency to con-
tracture which exists often in a very marked degree in cer-
TREATMENT. 39
tain hysterical subjects — ^not always subjects of Hysteria
Major, but of the affection in its commoner fonja.
I can show you now, in passing, two young persons who
are the victims of this affection, whose flippant air and taste
for finery, rendered manifest by the ribbons and flowers
with which they are adorned, ofEer a marked contrast to
the aspect of our first patient, whose oft-repeated epileptic
seizures have left traces of a profoundly affected intellect on
her physiognomy.
One of them has disseminated patches of anaasthesia and
left ovarian phenomena [ovarie], and she has spontaneous
contractures after her attacks ; the other patient is anaesthetic
on the left side, her right side is analgesic, and she has ovarian
phenomena on both sides. Now you see that by repeated
percussion of the patellar tendon, or the tendo Achillis, the
leg of either assumes a position of extension, and the foot is
bent into a position of talipes equinus. This attitude is fixed,
the rigidity of the limb is absolute, it is impossible to either
flex or extend it ; in short, it is a very characteristic con-
traction, which will probably last for several hours unless
we can undo it by the same proceedings which were employed
to provoke it. That which has just been done on the inferior
extremity can be repeated on the superior. If we take a
pleximeter and with repeated small blows strike the flexors
of the finger at the level of the wrist, you see that the
fingers assume a position of exaggerated flexion, and remain
fixed in a state of contraction.
I think that enough has been said to demonstrate the influ-
ence of traumatic causes on the development of contracture
in hysterical patients ; and also in those who are predisposed
thereto by certain organic lesions quite apart from hysteria.
We shall have many occasions, in the course of our studies,
to apply this interesting idea to the explanation of certain
phenomena otherwise inexplicable.
But, returning to the contracture of B — , what can be
done for it ? In the first place, we must wait and see
whether, as is usual, the disease will of itself come to an end.
But if it persist f Since the disease is unilateral we have
some hold on it ; we may be able by the aid of a magnet or
40 FACIAL TIO NON-DOULOUEBUX.
of agents of the same kind to bring about a transference of
the contracture to the opposite ' side^ and it is possible that
at' the tod of a large number of such transfers^ the contrac-
ture may disappear altogether.
n. ■•.•■/■'■■?.:•■' -^ • ' f JJ^
..' r- ;..''...•. J
At the present time there is a little patient attending the
out'-^titot dfep&rtiStfeikt whtyseJ- history ib "made' up' almost
eTltirelyof hysterical jihenotaiena, if indeed 'there be aught
else. She is a young' Jettt^ss from St. Petfersburg^, fifteen
yeats' old';' shie has never nienstrufeited ; she has been
attendiilg the* OliAiqne' for about ^ix weeks. She corned to
Paris in* the hope 6f ' being cured, having been unable to
bbtsiin relief elsei^here: I krid^ riot if we can give h6r wHat
shy feeekfe;'6rrtithet" what her father asks for her. Ton will
utidbrstand soon why I makiB this reservation.
The case seem&to be one of fadiil fit non-douloureuXy
but the afferction in thir girt appears to have special
characteristics which show consideirabl^ departure front the
normal type.
NbW htei"^, gentleftito, is a' womiari whom I shall have
o6ca'sioli to show yoii for another purpose; and who is afflicted
with facial tte' nto-dotiloureux in the fot»m generally seen.
She is an "hysteric*^ of many yfearfi' stktidirig, ^d indeed she
is one still, albeit that she is fifty years of age, and has not
had- hysterO-epileptic attacks for a lorig tiirie. Bat she has
hemiansBsthesia of the teft side, and on the samd side l^he
'ha6 had facial tic for f6ur or five years. This tic appears
in spontaneous paroxysms which are repeated with grbater
or less fi^eiqttency during the day; and which consist of
blinking of th6 eyelids; and a very rapid Quivering, some
200 times per minute, of the left lateral commissure; the
platysma participates in the convulsion in some degree.
That is the ordinary type.
Now examine our little patient ; here the spasm is pro-
duced only when we wish. You see that with a little pad on
Blepharospasm. 41
the right eyelid nothing particular occurs in the face. But,
we are about to raise the pad ; if we raise it slightly, with-
out uncovering the globe of the eye, which is permanently
protected by the contracted eyelids, a contraction of the
muscles of the right side of the face is at once produced.
If we uncover the eye, the spasm occurs more energetically
still, and results in a frightful distortion and fixed expression
of countenance. The same result is always obtained ; repose
when the pad is there, contracture as soon as it is removed.
Thus there is a remarkable difference between this case
and the preceding. So much so that we are obliged to ask
ourselves whether it is not one of those singular instances of
simulation with which the history of hysteria teems.
It should be stated at once that the affection we now see
was preceded a year ago by a spasm of the right orbicular
muscle which came on without known cause, and without
pain. A little while after this, nervous paroxysms came on,
which were accompanied by laughing, crying and shouting.
In August last, the spasm of the face as we see it now super-
vened after a local electrisation.
Let us examine matters more closely. The existence of
a blepharospasm in nervous or hysterical subjects is not a
rare occurrence, and would surprise no one. That the spasm
should spread to the face is not strange. It is seen in numbers
of cases, and nothing is more natural than that this spasm
should be held in check by pressure directed to certain
points. De Grrcefe some while ago called attention to the
existence of these points of stoppage which the physician
should seek for, and which the patients themselves often find
out quite empirically. In the case before us the stoppage
point would be the eyelid itself, or the supra-orbital arch.
But here is where the strange part of the case commences.
The pressure exercised by this little pad is such a small
matter ; and moreover it is not a question of the pressure
alone, which ought to be efficacious whether applied by us
and tightening it up with a bandage, or done by the patient
herself. It is not so here, and thus there is a personal
influence in the matter which gives us material for much
thought. I will even go further and say that in my mind
there is not only a suspicion, but a conviction. Yes, this
42 TREATMENT.
young woman simulates, or at least exaggerates. I willingly
admit the reality of the blepharospasm ; but^ as for the spasm
of the muscles of the lower part of the face and the platysma
I believe it to be superadded, invented, simulated.
It is probable that the same opinion entered into the minds
of the physicians who saw the young girl at St. Petersburg,
at any rate an operation for section of the nerve-trunk was
prepared, the patient was chloroformed, but they went no
further. Nevertheless, the spasm has persisted in the same
condition as you see it to-day.
But, you will ask me, what possible motive could this
young girl have for simulation ? I have already had occasion
to point out to you [p. 14] that hysterical people often simulate
without any very distinct end in view, by the worship of art
for its own sake. But is not the love of notoriety motive suf-
ficient ? To deceive, or think she deceives, the physicians
of St. Petersburg, then those of Paris, next the Faculty
of Vienna, and thus to make a tour through the whole of
Europe, is not this sufficient motive ?
I should add that when the patient was placed on the
stool of an electric machine, with the eyelids uncovered, she
soon displayed evident signs of fatigue ; after a quarter of
an hour she became quite breathless, a cold sweat covered
the body, and a more or less genuine nervous storm seemed
imminent. We did not care to push the experiment further.
Under these circumstances what is to be done ? We do
not wish just yet to make known our opinion either to the
father or the child ; we are following an expectant treatment.
I hope that the little patient will remain with us some time
yet, and that I shall have another opportunity of showing
her to you.^
^ Since the lecture, Madlle. A — has been isolated from her family.
She came into the Infirmary on May 27th, and the only treatment
employed has been the application at a distance of magnets to the
same side as the spasm, and a few applications of static electricity. On
the ist of April [P June], under the influence of electrisation, the spasm
diminished momentarily and the sensibility was increased. Nothing
particular occurred until June i8th, but on that day she had an acute
attack, with loud cries and some contortions, predominating on the
right side — that of the spasm. These attacks have been repeated
TREATMENT. 43
several times since. During the month of July use had been made
almost daily of the magnet at a distance. The contracture of the lower
part of the face insensibly disappeared; and on July 26th nothing but the
blepharospasm remained. Next day, after being vexed, she had rather
a violent attack, and since then the eye has remained open quite nor-
mally, but the attacks have recurred several times. — Oh. P.
W} . ^
This hook is thejmop*
OOOPBR MBDIOAL OOLLi^G^*
SAN FRANCISCO, QAL
a/nd is not to be removed from the
lAhmrv Poom by (my person or
under ui.j , ■ text whatever.
LBCTUEE IV.
ON THE MUSCULAR ATROPHr WHICH FOLLOWS
CHROinC ARTICULAR RHEUMATISM.
SuMMAEY. — Muscular atrophy in acute, subacute, or chronic
joint disease. — Relation between the localisation of the
atrophy and the seat of the joint disease. — Types of
primary chronic articular rheumatism : i. Generalised
or progressive primary chronic articular rheumatism.
ii. Fixed or partial chronic articular rheumatism, iii.
Heberden's nodes. — Generalised chronic rheumatism
determines amyotrophies which predominate in the ex-
tensor muscles of the afected joints. — Exaggeration of
the tendon-reflexes. — With the amyotrophy there exists a
contractwre in a latent state. — Spasmodic contracture of
a reflex articular origin.
Gentlemen, — I am about to present to you a patient who
will bring back to your minds the subject of amyotrophic
paralyses^ which recently occupied our attention.
You will doubtless remember the young telegraph clerk
who, after receiving a blow on the right knee that lighted
up transient arthritis in the joint, suffered for nearly a year
from atrophic paralysis, chiefly of the right quadriceps
extensor, which rendered his power of walking very imperfect
during all that time.
Traumatic lesions are not by any means the only causes
which can give rise to such a condition. It is well known
that the most diverse lesions can lead to the same result.
The fact is established beyond doubt as regards acute arti-*
cular rheumatism, acute gout (Bouchard^ Debove), and
^ Paralyses due to muscular atrophy {a, neg., /ivc, a muscle, rpo^if
nutrition).
VAEIBTIES OP CHRONIC RHEUMATISM. 45
gonorrlioaal rheumatism. And what has been said of acute
and subacute arthropathies can now be affirmed of chronic
articular rheumatism. In all these joint affections^ acute
and chronic^ the muscular atrophy occurs according to the
law already pointed out [p. 24], that is to say, the atrophy
always predominates in the extensors of the affected joint.
Thus in arthritis of the hip the muscles of the buttock are
chiefly involved, if the knee is attacked it is the quadriceps
extensor f emoris, if it is the elbow, then the triceps brachialis
is the seat of the atrophy, and so on.
This relationship between the seat of the articular affec-
tion and the localisation of the muscular atrophy is suffi-
ciently constant to be of service in cases which present
difficulties of diagnosis. For example, in diseases of the
hip, in certain cases of morbus coxx semlis in an early
stage, when the physical signs are scarcely appreciable on
account of the depth of the articulation, a marked flattening
of the buttock of the corresponding side, due to atrophy of
tbe lower fibres of the gluteus maximus, can be regarded as
a very significant symptom.
Long enough before joint disease was recognised as a
cause of muscular atrophy, Adams^ called attention to this
flattening of the buttock in certain chronic affections of the
hip-joint.
The case which I am about to bring before you belongs
to the category of chronic articular rheumatism. It may be
within your recollection that I have proposed to collect the
many various forms under which this affection appears into
three fundamental groups :^
I. Oeneralised or progressive primary chronic articular
rhev/matism. — This is the nodular rheumatism of some
authors ; it follows a. chronic course from the commence-
ment, and presents an invariable tendency to become gene-
ralised. It is the small joints of the extremities, especially
those of the hands, and most often the metacarpo-phalangeal
joints which are involved in the first instance, and they are
^ Adams, * A Treatise on Rheumatic Gk>nt/ &c., London, 1857.
' Charcot, ' Traits de la goutte de Garrod,' note, p. 602 ; * Maladies
des vieillards,' 2* Ed., 1874, p. 197, et suiv. [* Syd. See. Transl.,' p. 180.]
46 CASE.
generally attacked symmetrically. Then in due course the
other articulations are almost invariably involved. During
the tedious progress of the malady the patient has severe
attacks of pain^ from time to time^ which are frequently
accompanied by febrile symptoms.
2. Fixed or partial chronic articular rheumatism, — This
disease^ which presents the same characteristic of chronicity
from the outset as the preceding, generally remains localised
to one or two of the large joints in which it produces pro-
found alterations. It is well known to the surgeon under
the n*ame of dry arthritis, or of morbus coxas senilis when it
is the hip that is affected. The pains that accompany it are
less intense, and fever is wanting.
3. Heberden's nodes. — This is the affection described by
Heberden under the name of digitorum nodi. Very gene-
rally, but incorrectly, this is confused with gout. It is
found almost exclusively in the articulations of distal pha-
langes; while the metacarpo-phalangeal joints, which are
specially prone to be involved in the first variety, are free.
I need scarcely say that dry arthritis forms the ana-
tomical substratum of all these clinical varieties, although a
slight modification in the anatomo- pathological type is found
in each. These three forms, in fact, are not absolutely sepa-
rate ; one passes into the other by insensible grades. There
are undoubtedly cases which occupy an intermediate posi-
tion, and the one we are about to study partakes of the
characters both of partial and also of generalised chronic
articular rheumatism ; it is a partial chronic rheumatism
which has a tendency to spread to a great many joints.
The man named L — , 51 years of age, and by occu-
pation a hair-dresser, enjoyed good health till he was forty-
four years old. For the last nine years he has occupied a
dark, damp room on the ground floor behind his shop, where
he often suffered from the cold at night. The influence of
a damp habitation is often mentioned, and correctly so, as
one of the principal determining causes of chronic rheuma-
tism; and it is very remarkable that the articular pains
frequently do not appear until some years after the evil
influence has commenced; there is as it were a sort
CASE. 47
of incubation period. Thus was it in our patient^ and it
was not till after five years* residence in this unhealthy
room that the first symptoms of joint mischief appeared. The
joints were affected in the following order : the wrists first,
next the shoulders, then the ankles, knees, hips, elbows,
and last of all the fingers, and the cervical articulations to a
slight degree. This gradual invasion was spread over a
period of four years. The pains were slight and the swell-
ing ill-marked ; he has never had either rigors or fever ;
he has never been obliged to take to bed ; he gradually became
aware of a stiffness in certain movements of his wrist inci-
dental to his occupation, then a rapid loss of flesh and great
weakness came on, making it difficult for him to walk, and
soon he was obliged to give up his occupation.
At the present time it is easy to recognise the affected
joints, the alterations that have taken place in them being so
well marked. Many of the joints are the seat of crackling,
the left shoulder and the knees being the worst. They
contain a small quantity of fluid, and the soft parts around
are evidently swollen. Crackling is to be detected pretty
equally in the wrists, the elbows, and some of the finger-
joints in both hands. In a word, without going more into
detail, we find in a large number of joints the classic signs
of a dry arthritis.
But the point which should most occupy our attention is
the loss of substance in the muscular parts. It is not a
general emaciation in the strict acceptation of those words,
but a localised muscular atrophy which affects certain muscles
or groups of muscles ; and we shall find that it predominates
in the extensors, a point worthy of our special attention.
Thus, on the shoulders the deltoids are flattened, in the arms
the triceps muscles are wasted, while the biceps still pre-
serve considerable substance. The buttocks also are con-
siderably flattened, corresponding to the affection of the
coxo-femoral articulations. In the thigh the quadriceps is
much more atrophied than the flexor muscles, and the same
rule obtains for all the diseased joints.
The modifications in the electrical reaction of the muscles
is here again simply a quantitative and not a qualitative one^
48 ARTHBITIO AMTOTEOPHT.
Only one muscle formH an exception to this statement;
the vastus extemus of the right side, which gives the reac-
tion of degeneration, in that the faradic excitability is
weaker and the galvanic is stronger than normal. This is
the only exception ; everywhere else the electrical reactions
indicate a simple atrophy without marked alteration in the
nutrition. Some of the atrophied muscles are the seat of
very manifest fibrillar contractions, the deltoid, for example,
the quadriceps femoris, and the buttocks. And some of these
muscles are easily excited to contraction by direct percussion,
as you can see in the left deltoid particularly.
Side by side with these trophic changes in the muscles
is a motor weakness, more accentuated in proportion as the
muscular atrophy is more advanced. The patient finds walk-
ing very difficult, more on account of the amyotrophic paresis
than the pain in the joints. The dynamometric force of
the hands is considerably limited; it is represented by lo
for the right and 12 for the left hand, the average normal
strength being represented by about 80.
By a more detailed investigation one recognises that in
the upper extremities it is the extensors that have lost most
power ; thus, while it is easy enough to prevent extension of
the elbow, the arm when placed in a position of flexion can
effectually resist efforts to straighten it. The same condition,
mutatis mutandis , can be made out at the wrist-joint, and
also at the knee.
You see then that the essential features of this case are
in entire accord with those we have seen in the young
telegi;aph clerk whose atrophic paralysis appeared as a con-
sequence of an injury to the knee. Hence, we may infer that
the joint lesions of generalised chronic articular rheumatism
determine, in the same w^>y as traumatic arthritis, a reflex
irritation ,of the spinal centres, which produces in like
manner an amyotrophic paralysis, predominating in the ex-
tensors.^
^ M. Debove (*Progres Medical/ 1880, p. loii) has had the oppor-
ttmity of studying under the microscope the atrophied muscles in a
case of chronic rheumatism, and has observed certain characters which
liable us to class these amyotrophies among myopathies of nervous
origin, i, e, there is an irregularity in the atrophy, which attacks not
POTENTIAL OONTRAOTUEB. 49
Bat^ between the two cases^ there is a yery marked
similitude on another point also.
As an interesting feature in the case of the telegraph
clerk, I referred to the exaggeration of the tendon-reflexes,
which was present not only in the affected limb, but also in
the healthy one ; and we concluded therefore that the spinal
affection, developed in consequence of the arthritis, whatever
it might be, was much more extensive than might at first
have been supposed. Well, this same exaggeration of reflex
excitability is to be found in the patient whom I show you
to-day, and in a still more pronounced degree. Jerking
upwards the point of the foot produces a very manifest
trepidation, which is increased if the patient endeavours to
resist the movement. In order that you may fully realise
the exaggeration of the patellar reflexes, I will cause the
patient to sit on the edge of a chair. You see that the
effect of striking the patellar tendon, either on the right or
left side, is to produce at every stroke a movement in the
shoulders, and particularly in the left one. Every time that
the patellar tendon is struck, no matter of which leg, there is
a contraction of the deltoid, trapezius, and pectoralis major ;
the shoulder is perceptibly elevated, and drags along with it
the whole of the upper extremity.
Thus we find in this case the essential elements of a spas-
modic parslysis at a stage when the permanent contracture,
although not actually developed, is nevertheless imminent.
And these phenomena are sometimes so pronounced that
physicians of considerable experience have been led to think
that the spinal lesion is the primary one, the joint disease
and muscular atrophy being secondary. But the evolution
of the phenomena is against such a view. The arthro-
pathies are in reality the primary facts, the spinal affection
which produces the amyotrophy is only secondary.
It is important to add that, apart from this increased
reflex excitability as evidenced by exaggerated tendon-
reflexes both of the upper and lower Umbs, no other
only the fibres of the same muscle in different degrees, but even the
fibrils of the same fibre ; and the sclerosis of the interstitial connective
tissue has a like irregularity.
4.
50 CAUSE OP DEFORMITY.
symptom can be discovered which could be connected with
a spinal lesion. No abnormality of cutaneous sensibility^
no girdle pains^ no urinary trouble^ &c.
From what has just been said^ you will be led to infer that
in cases where amyotrophic paresis is a leading feature^ con-
tracture exists^ so to speak^ in a potential or latent condition.
I may here point out to you that if in certain arthro-
pathies^ such as the preceding case^ the amyotrophic para-
lysis forms the predominating feature^ it is not the same
in other joint affections where^ on the contrary^ spasmodic
contracture holds the chief place.
It is well known to surgeons that^ in certain joint diseases^
in the painful forms especially^ the affected joints become
rigid. They become fixed ordinarily in a state of flexion ;
in hip disease^ for example^ the thigh becomes flexed on the
pelvis; in pulpy degeneration of the knee-joint^ the leg
becomes flexed on the thigh^ and so on.
There have been many discussions on the cause of this
rigidity of the joint, and the consequent deformity. You
are aware that in the school of Bonnet, of Lyons, great stress
was laid on the instinct of the patient, who endeavours, so they
say, to adjust the joint in that position which gives him the
least possible pain. Others have attributed influence to the
weight of parts, the fluid in the joint, &c. ; always relega-
ting the involuntary spasmodic contraction to quite a secon-
dary position. In the present day, however, it is this reflex
spasmodic contracture, of an involuntary kind, to which
most surgeons attach their faith, and in this way they have
come back to Hunter's doctrine. In a book but little known
in France,^ the late Mr. Hilton, Surgeon to Guy's Hospital,
has very clearly expressed what may be regarded as the
prevailing opinion on this point. " When,'' said he, " the
joint cavity is inflamed or irritated in any way, the influence
of this condition is transported to the spinal cord, and thence
reflected by the mediation of the corresponding motor
nerves to the muscles which move the joint." M^ le Pro-
fesseur Duplay in several passages of his book, and Pitha
also, support this theory.
^ ' Best and Fain/ Ac, 2nd edition, London, 1877.
SPASMODIC OONTEIAOTUEB. 51
NoWj in this instance we have a spasmodic contraction of
both the flexors and extensors at the same time, though it is
the former which determine the character of the deformity.
It does not seem in such cases to be an intentional^ or instinc-
tive contraction, the object of which is to lessen the pain ;
for in many cases of joint disease, and especially disease of
the hip-joint, one knows that it is often necessary by apply-
ing extension to oppose this very contracture in order to
ease the patient's pain. Furthermore, M. Masse^ has made
the interesting observation that whereas these contractures
are often enormously increased during sleep, they become
much less during the waking state, when the patient is in a
condition to oppose them.
Without denying accessory causes, one is bound to admit,
under the circumstances, that reflex spasmodic contracture is
the principal agent in producing the joint deformity. Such
an opinion finds, I believe, full confirmation in the study of
those remarkable deformities which are so frequently met
with in generalised or progressive chronic articular rheuma-
tism (knotty rheumatism).
This was the conclusion that was forced upon me in my
inaugural dissertation thirty years ago, and to which, with
your permission, I will refer. Yet, the exposition of all the
facts relative to this question will demand more time than
is left at our disposal to-day, and I must therefore resume
this subject in the next lecture.
Moreover, it will not be without interest to indicate more
clearly that side by side with amyotrophic paralyses, there
exist spasmodic contractures which are also connected with
alterations in the joints ; that these contractures, like the
amyotrophies, are due to a spinal afEection developed along a
reflex path ; and lastly, to bring into view the relationship
that exists between these two series of phenomena apparently
so different from each other.
^ ' Influence de Tattitude des membres sur leurs articulations/ Mont-
peUier, 1878, p. 104. mi • x 7-^1
This oook IS the propci ^
COOPER MBDIOAL COLL. a.. .
SAN FRANCISCO, CAU
and is not to be Temx>'DeA Jrcyia 1^^
lAhrarv Hoow by cuaij •perrwa ^^
under any '^^ r^tegct wTrwAeow*
LEOTUEE V.
I. REFLEX OONTRAOTURB AND AMYOTROPHY OP ARTI-
CULAR ORIGIN,
n. OPHTHALMIC MIGRAINE APPEARING IN THE EARLY
STAGE OP GENERAL PARALYSIS.
Summary. — ^I. Ohromc articula/r rheumatism. — Reflex con-
tracture of a/rticula/r origin. — Deformities m chronic
articular rheumatism : i. Type of extension ; 2. Type of
flexion. — The ha/nd of athetosis ; hand of paralysis
agitans. — Articular deforr/iities of chronic rheumatism
are due to a spinal affection produced by the sa/me
mechanism as reflex acts.
II. Progressive general paralysis. — Ophthalmic mi-
graine at the outset. — Scintillating scotoma. — Hemi-
anopsia.
Gentlemen, — ^The first patient to whom I wish to direct
your attention to-day presents an illustration of dry arthritis
of the hip, and you will recognise in her the flattening of
the buttock, due to atrophy of the gluteal muscles, which is
capable, as I pointed out in the last lecture, of assisting us
in the diagnosis of difficult cases.
The patient is a woman, sixty-two years of age. She has
not, so far as we can discover, been exposed to the ordinary
causes of chronic articular rheumatism, at any rate she has
not lived in a damp place. She has worked a sewing
machine for several years, and it is this, she thinks, which has
produced the disease of the right hip. All. the other articu-
lations are sound. The malady started about a year ago
with stiffness in the joint ; then she had attacks of pain,
worse at night, starting at the lower border of the buttock,
shooting down the thigh and inner side of the knee. At
one time there was crackling in the joint, but there is
none now. At the present time she has scarcely any
CASE OF AMYOTEOPHY. 53
spontaneons pain^ and there is no tenderness on striking
the great trochanter; there is no marked shortening of
the limb^ bnt it has a considerable tendency to assume
a position of rotation ontwards^ as those of you even at a
distance can detect by the direction of the foot. The
patient can walk fairly well^ and after she has made the
first few steps, she scarcely limps at all ; but when she is
seated it is impossible for her to cross the right leg over the
left^ although she can cross the left one over the right.
The physical signs and the loss of function render it impos-
sible to doubt the existence of an articular lesion^ but even
if these were less marked our attention would be directed
to the joint by the flattening of the right buttock^ which is
very distinct. And not only does the buttock appear very
wasted^ but on palpation it feels softer and more flaccid
than normal. On the right side the fingers can easily
touch the ischium^ but on the left it is not so ; and you can
seCj moreover, that the great trochanter seems much more
prominent on the right side, indicating some atrophy of the
gluteus minimus.
I was anxious to show you this patient because the case
ought to be classed in the same group as the amyotrophies
of articular origin which we are at present studying.
I must now add some further details to the facts I have
already laid before you relative to the spasmodic contractures
that follow joint lesions, and are sometimes accompanied by
muscular atrophy. I attempted, following the doctrine of
Hunter, to prove that these contractures are produced by a
reflex mechauism started in the diseased joint. The exci-
tation of the articular nerves reacts on the spinal centres,
which in their turn reflect this excitation along the path of
the motor nerves to the muscles, both flexors and extensors,
of the joint.
The spasmodic contracture is generally limited to the
flexors and extensors of the affected joints. But, in some
cases, as a consequence of the diffusion of the spinal lesion,
the muscular spasm becomes more generalised, and may even
extend to all the muscles of a limb. I have already
i
54 OASB OF ABTHEITIO OONTEAOTUBK).
drawn attention to cases of this kind connected witli hysteria^
but, judging by recorded cases, such contractures involving
a whole limb, consequent on a lesion limited to a single joint,
may be observed quite independent of hysteria.
The cases reported by Duchenne (of Boulogne), and
described by him under the name of reflex contractures of
articular origin,, may be mentioned in support of this state-
ment, and there is another by M. Dubrueil (of Montpellier).^
M. Dubrueil's case was that of a young man, i6 years
of age, who fell from the top of a ladder and sprained his
left ankle ; three days later contracture appeared not only
in the muscles of the foot, which was flexed and in a state
of adduction, but in those also which act on the knee and
the hip. The subjects in whom contractures of arthritic
origin tend thus to become generalised are evidently predis-
posed thereto, and in this respect the cases may be said to be
akin to the hysterical neurosis.
In order to finish this subject it remains for me to show,
as I promised, that the deformities of progressiva chronic
articular rheumatism (nodular rheumatism) are due, in like
manner, to a spasmodic contracture of the muscles, developed
by reflex action secondary to the joint lesions.
I endeavoured some years back to show' that the defor-
mities observed in such cases, so far as the upper extremities
are concerned, can all be brought, no matter how different
they may seem, under two fundamental types, to which all
acceBSory forms may also be referred.
The symptoms common to both types are these : the
hands are generally in a state of pronation and slightly
flexed ; the deformities are usually symmetrical ; there is
ordinarily a deviation of all the fingers towards the ulnar
border of the hand (Fig. 4).
Now, the characters distinctive of the two fundamental
types are :
^ DabrneU, 'Le9onB de clinique chimrgicale/ Montpellier, 1880, p. 5.
' Charcot, * Etudes pour servir h I'histoire de I'affection d^crite sous
les noma de goutte asthenique primitive, nodosit6s des jointures, rheu-
matiBme articulaire chronique (forme primitivd),'' 'Th^se de Paris,' 1853.
DBFOBUITIBS OF BHBOlt&TIBlt.
FlQ-. 4. — BiBprtuatixtg the derintion of all the flngen towards
0x6 ulnar ride of tli« huid in chiooic rhenma&m. (Drairn by U. P.
Kcher.)
First type, or type of esttenaum. — Beginning at the free
extremities ot the fingers, yon will notice (a) flesdon of the
angnal phalanges, (b) hyper-extension of the second phalanges,
(c) flexion of the proximal phalanges. The woman named
D — , who is l)roaght before you, preeents this deformity in a
very characteristic manner. She is now forty-nine years old,
and the malady commenced when she was twenty, after three
years' residence in a damp hoose. She haa most of the other
joints also affected (Fig. 5).
h g.— Showing the left hand of the woman I>— , Type of estentlon.
(Drawn by M. Bichar.)
Yon will find the same deformity in the hands of the woman
M — , who has had the disease since the menopause (Fig. 6),
66
DBFOfiMITIES OF BHEUBiATISM •
Fia. 6. — Showing the left hand of the woman M — . Type of extension.
(Drawn by M. Richer.)
Second type, type of flexion. — Here we have a hyper -
extension of the ungual phalanges^ and a flexion of the
second phalanges^ as you see in this patient (Pig. 7).
Fig. 7.— Right hand of the woman X—. Type of flexion.
(Drawn by M. Pengniez.)
Such are the deformities which are due^ quite as much as
those occurring in the other joints of the same patients
(kneesj elbows^ Sac), to a spasmodic contraction of the
muscles.
You will remark that the spasmodic contraction has long
since ceased in both of these patients ; but the resulting
deformities persist nevertheless in consequence of the thick-
ening of the periarticular tissues^ the subluxations^ the
shortening of the ligaments which have existed all this long
DBFOEMITY EXPLAINED. 57
while^ wherever the joints have been maintained in a faolty
position by the spasmodic muscular contracture.
What are the arguments that can be advanced in favour
of the theory I hold ?
1. It seems impossible to admit that these strained un-
natural positions can be the attitudes instinctively assumed
by the patients themselves^ in order to avoid pain as much as
possible^ while maintaining the articulation in a fixed position.
In examining such patients during an acute exacerbation of
the affection one recognises that, far from endeavouring to
bring about these forced attitudes, they strive against these
spasmodic contractures, these cramps as they call them, to
which they are subject.
2. The accumulation of fluid within the synovial cavities
gives greater mobility to the joints, and favours the action
of the contracted muscles ; but this element cannot be in-
voked as a predominating cause of the deformity. More-
over, all the joints which in the hand undergo deviation have
not been attacked with hydrarthosis, or even inflammation.
One can add also, without fear of contradiction, that the
weight of the parts plays but a very ineffectual part in the
production of such deformities.
Therefore, by a process of exclusion, we can aflGlrm that
muscular contraction is the only influence which is worthy
of our support.
I should add that there are other powerful, though indirect,
arguments which can be produced in favour of this theory.
I can show you that these same deformities of the hands,
these same articular deviations, which are seen in nodular
rheumatism, are also found, with so many of the same charac-
teristics that they may be mistaken the one for the other, in
cases where there exists no joint affection at all, and where
rigidity of muscles is the only disease present. Thus, for
example, in spasmodic infantile hemiplegia, from which the
patient before you now is suffering, there is a spasmodic
contracture of all the muscles of the upper and lower ex-
tremities of the left side. It dates from infancy, and the
patient is an epileptic, though it is an epilepsy of a special
kind. Never has there been a trace of arthritis, certainly not
58
ATHETOSIS.
in the hands. Now, in this hand, which shows the involun-
tary movements of athetosis, and in which consequently there
is an increased articular mobility in certain movements when
the patient stretches out the hand, ^one sees a deformity
resembling our first type, the type of extension (Fig. 8).
Fi0. 8. — The hand of athetosis^ resembling the deformity in the type of extension.
(Drawn by M. P. Richer.)
The same remarks will be found to apply to Parkinson^ s
disease. A long while ago I pointed out these deformities,
which can only be explained by prolonged contracture of
antagonistic muscles. It is well known that in paralysis
agitans the muscles of the limbs and trunk are in a state of
permanent tension, and thus determine a rigidity of the parts
as firmly as if they were welded together. The most common
deformity in. the hand reminds us of a hand which has
the attitude of holding a pen in the act of writing. It is
the contracture of the interossei which produces it. But in
certain cases one meets with a deviation of the hand wholly
comparable with that which is seen when the joints are
affected with nodular rheumatism. In the case before you
you will recognise the type of flexion (Fig. 9). Under
these circumstances again, the deviation is produced solely
by muscular action, the joints are in no wise affected.
Such then, gentlemen, are the different arguments which
appear to me to show that in chronic articular rheumatism
the distortion of the joints is due to a spinal affection
developed after the mechanism of a reflex act.
pathologi op amyotbopht and oontbaotttbb.
Fis. 9. — Hand of paralyiii agitans, reaembling the deformity of the
flexion type. (Drawn by M. P. lUcher.)
And tiiis brings us again to the statement that joint
affections, when they reflect back their pathogenic influence
on the spinal centres, sometimes determine an exaltation of
the fanctions of the nerve-cella, whence is derived the con-
tractnre of mnseles ; bat sometimes, on the otber hand,
they lead to a depression of these same functions, which
resnlts in amyotrophic paralysis.
It should be added that these two kinds of spinal affection
are sometimes found combined in the same subject. Thus,
in nodular rheumatism, for example, at the very same time
when contracture occurs in the muscles, one sees many of
them, and especially the extensors, undergoing a more or
less marked atrophy- Depression and exaltation of the
functions of the ganglionic elements represent, under these
circumstances, the two saccessiTe stages of the same morbid
process. But, it is in such cases that the functional depres-
sion of the nerve-cell seems to be developed primarily, at
the very outset ; as indeed appeared to be the order of
events in the cases of amyotrophy which I showed you
when we commenced this subject. But you have doubtless
not forgotten that, even in those very cases, the conditions
Tliis hook ts file 5>i"C>;_- ^
QQQpp" "^^^ii;iK\, ^5;,^^^:^,.
urMonrv r\k\ .
58 ATHETOSIS.
in the hands. Kow, in this hand, which shows the involan-
tary movementB of athetosis, and in which consequently there
is an increased articnlar mobility in certain movemente when
the patient stretches ont the hand, ^one sees a deformity
resembling onr first type, the type of extension (Pig. 8).
/ji^^
Fia.8. — TbehandofathetoBig, Teiem1)Uiig;tIiedefonnit;iiithet;peof extenrioB.
(Drawn by M. P. Bicher.)
The same remarks will be found to apply to Parkinson's
disease. A long while ago I pointed out these deformities,
which can only be explained by prolonged contracture of
antagonistic muscles. It is well known that in paralysis
agitans the mnscles of the limbs and trunk are in a state of
permanent tension, and thus determine a rigidity of the parts
as firmly as if they were welded together. The most common
deformity in . the hand reminds us of a hand which has
the attitude of holding a pen in the act of writing. It is
the contracture of the interossei which produces it. But in
certain cases one meets with a deviation of the hand wholly
comparable with that which le seen when the joints are
affected with nodular rheumatism. In the case before you
yoQ will recognise the type of fiezion (Fig. 9). Under
these circumstances again, the deviation is produced solely
by muscolar action, the joints are in no wise affected.
Such then, gentlemen, tu-e the different arguments which
appear to me te show that in chronio articular rheumatism
the distortion of the joints is due to a spinal affection
developed after the mechanism of a reflez act.
PATHOtOOr OP AMYOTBOPHY AND OONTEAOTUEB.
Fia. 9. — Hand of pRralysia agitans, resembling the deformity of the
flexion type. (Drawn bj M. P. lUeher.)
And this brings us again to the statemeiit that joint
affections, when they reflect back their pathogenic influence
on the Bpinal centres, sometimes determine an exaltation of
the functions of the nerve-cells, whence is derived the con-
tracture of muselee ; but sometimes, on the other hand,
they lead to a depression of these same functions, which
results in amyotrophic paralysis.
It should be added that these two kinds of spinal affection
are sometimes found combined in the same subject. Thus,
in nodular rheumatism, for example, at the very same time
when contracture occurs in the muscles, one sees many of
them, and especially the extensors, undergoing a more or
less marked atrophy. Depression and exaltation of the
functions of the ganglionic elements represent, under these
circumstances, the two snccessive stages of the same morbid
process. But, it is in such cases that the functional depres-
sion of the nerre-cell seems to be developed primarily, at
the very outset ; as indeed appeared to be the order of
events in the cases of amyotrophy which I showed you
when we commenced this subject. But you have doubtless
not forgotten that, even in those very cases, the conditions
This hook is tlie -pw^j- ■ ^
OOOBER, MKDIGK^ ^vjiAiv^>ci:..
eDKur\\er\r% r\M_.
60 PATHOLOGY OP AMYOTBOPHY AND OONTBAOTUBE.
which prepare the way for mnBcnlar contpactnre and pre-
diBpose to it, namely, the exaggerated reflexes, are fonnd
combined, as it were, with the mnscnlar atrophy.
There is not then, as one would at first imagine, an oppo-
sition or contradiction between these two kinds of pheno-
mena. Whether it be contracture or amyotrophy which
follows a joint lesion, the spinal lesion is fundamentally the
same. These two kinds of phenomena represent, as it were,
two extreme phases of the same morbid process.
In conclusion, I should like to point oat to you that this
same combination, this same succession of amyotrophy and
contracture, is not by any means a unique occurrence in the
clinical history of spinal affections. It is found very well
marked in amyotrophic lateral sclerosis, of which I recently
showed you a case.'
' Since this lectnre M. Charcot has reoeived &om M. Dreschfeld,
FrofesBor of Pathology at Manchester, the photograph of the hand
Fig, io. — Volnntary deforaiitj resemWing the extoneion tjpe of
chronic rheouimtisni. (Drawn bj M. P. Richer.)
of a student at the College who coold, hj stretching out the second
phalanx and flexing the first and third, produce at will a deformity
GENERAL PABALTSIS.
61
II.
Enough has been said concerning spasmodic contractures
and amyotrophies of articular origin. Now I want to show
you a patient whose disease is of quite a different kind. He
is the subject of progressive general paralysis, and, if we
consider his present condition alone, we shall see that the
case is quite an ordinary one, and the diagnosis of it is easy
enough to establish.
Mr. L — , a Professor of History, came to Prance to
study law ; he is now 35 years of age. He has the following
symptoms : — characteristic embarrassment of speech (which
is almost unintelligible), fibrillar trembling of the tongue,
characteristic tremors of the hands, a collection of intellectual
and moral phenomena, which are grouped under the term
paralytic dementia.
Nothing could be more typical than this case for it is well
known, in the present day, that there exists a form of general
paralysis, which is unattended by *' grandiose delirium
9}
analogoaB to that of chronic rheumatism (Fig. 10). A pupil studying
at the Salp^tri^re can in like mamier produce the same distortion at
Fig. II. — Voluntary deformity resembling the extensor type of chronic
rheumatism. (Drawn by M. Richer.)
will (Pig. 11). These facts show clearly that the deformity is produced
exclusively under the influence of muscular action. — Oh. F.
62 ITS VABIBTIES.
[d^lire ambitieux], and recognised as the paralytic variety,
or general paralysis without madness.
But what constitutes the interesting part of the case is
the narration of the symptoms with which it commenced,
given in a most intelligent manner by the young wife of the
patient.
I would remind you that, according to M. Jules Falret,^
general paralysis, although it assumes an almost uniform
symptomatology when it has reached its full development,
appears under many different aspects at its commencement,
and that these can all be classed under four types or
varieties.
1 . The expansive variety, with delirium of greatness, satis-
faction with oneself, and one's surroundings, &c. These
patients are worth millions of money, or may have preten-
sions to poetry, Ac. This grandiose delirium [delire ambi-
tieux] generally partakes, at the outset, of the characters
of dementia (Falret). Their ideas are changeable, contra-
dictory, absurd; very different from those of ambitious
monomaniacs, who are logical. These mental troubles are
accompanied by a cJBrtain difficulty in the articulation of
sounds, inequality of pupils, tremors, and uncertainty of
movements.
2. The melancholic variety contrasts strongly with the
preceding.
(a) Melancholic delirium, the patients believe they are
ruined, dishonoured, &c.
{b) Sometimes there is an association of hypochondriac
ideas, fear of death ; they imagine that they have maladies
which do not in reality exist, say that they cannot swallow
or micturate, that their passages are blocked, &c. These
troubles may be very marked at the outset, but they are
soon followed by embarrassment of speech, inequality of
pupils, &c.
3. Paralytic va/riety, characterised by the absence of
maniacal ideas. Only there are profound modifications in
^ J. Falret, '* Becherches aor la folie paralytique," ' Th^e de Paris,'
i863- ,
OPHTHALMIO MIGRAINE. 68
oharaoter^ oatbarsts of passion and emotion without motive,
impairment of memory. In tliis form motor troubles pre-
dominate, embarrassment of speech, fibrillar tremors of the
hands and tongue, uncertainty of the walk, staggering.
This is general paralysis without insanity. These patients
are conscious of their decadence, they are able, up to a
certain point, to fulfil their social duties, in spite of their en-
feeblement of intelligence.
4. Oongestive variety, — ^In this form a series of so-called
congestive attacks occur, separated by comparatively healthy
intervals, and being repeated a variable number of times
before the characters of general paralysis become permanently
established.
These so-called congestive attacks take different forms ;
thus at one time it is an apoplectiform attack followed by
a temporary hemiplegia, at another it is an epileptiform
seizure ; or again a condition frequently seen is one where,
without loss of consciousness, there is a numbness of one
hand, or the lips, a temporary embarrassment of the speech
and ideas, a transitory aphasia, &c.
It is this congestive variety in an early stage which
occurred in our patient, and in him the different kinds of
attack seemed to succeed each other.
But the point to which I wish especially to draw your
attention is that most of his attacks were preceded by a
collection of symptoms usually known under the name of
ophthalmic migraine.
The phenomenon presented, in the early attacks, certain
characters from which one would have thought, considering
the state by itself, that it was connected with a mild affection,
although in reality, as the sequel showed, we had to do with
the commencement of a grave, incurable disease.
I shall not enter now on the history of ophthalmic
migraine ; it is a subject that will occupy our attention on
some future occasion. I will simply remind you that in an
ordinary attack of ophthalmic migraine of the typical kind,
a luminous figure appears in the visual field which is at first
64
SOINTILLATINO SOOTOMA.
circular, tlieii semicircular, of a zigzag shape like the
drawing of a fortification, agitated with a very rapid Tibratory
movement ; the image is sometimes white and phosphorescent,
and sometimes it presents more or less marked tints of
yellow, red, or blue. That is what is known as scintillating
scotoma (Fig. 12).
PIB. I a.— Different phases of the scintUljitmg uotomB, after Hubert
Airj (the letters indicate the different colonratiom : B=red, J=yeUow,
B— bine, V— ffreen), ' Philosophical Transactions,' 1870.
The scotoma is often replaced by a temporaryhemianopsia of
the field of vision so that the patient sees only half the
object.
HEMIANOPSIA. 65
An examination of the field of vision, whicli is very
important in such cases, reveals a hemianopsia, generally
homonymous and lateral, but not usually extending quite up
to the fixation point (Fig. 13).
These symptoms are followed by pain in the temple on the
ame side as that on which the visual defect or the spectra
occur, and the eye of the same side is the seat of a tense pain
66 SCINTILLATING SCOTOMA.
not unlike that experienced in acute glaucoma.^ Yomiting*
terminates the attack^ and the patient gets well again.
Such is the ordinary course of events in simple cases of
ophthalmic migraine. In other cases of migraine^ varioua
other troubles are superadded, to which Piorry was the first
to call attention.^ There may be^ for example, a numbness
of the hand, or of the side of the tongue, an aphasia, or
temporary derangement of speech^ epileptiform attacks, &c.*
Now, migraine, even in its graver forms, and with fre-
quent recurrence, may appear in the course of a disease, or
rather of an habitual indisposition ; yet it is not followed
perhaps after ten, twelve, fifteen, years' duration by any
serious consequence.
But do not, with the knowledge of these facts, which are
doubtless those most usually met with, always give a favor-
able prognosis; hesitate to commit yourself, investigate
matters more closely, and reserve your decision.
Several events may happen ; thus as I have pointed out^
there are scarcely any of the usually transitory phenomena of
ophthalmic migraine which may not become permanently
established ; and thus, aphasia, hemiopia, paralysis of a limb,
after having come and gone in a transitory way several times,
may persist indefinitely after a fresh attack.
Lastly, a combination not often met with is that in which
these very symptoms of migraine figure amongst the early
symptoms of the congestive form of progressive general
paralysis. This combination is undoubtedly rare, and has
not been noted, I believe, by authors ; however, I have met
with it on three or four occasions.
This is briefly M. L — 's history. Ever since he was two
years old he has been of an irritable and fussy disposition.
However, he successfully passed his law examination before
the Faculty of Paris last July. The first symptoms which
attracted attention occurred in September, 1881. Then he
* DianoQx, " Scotome scintillant ou amaurose partielle temporaire,""
* Th^se de Paris/ 1875.
* Priory, * Trait 6 de m^decine pratique/ p. 75.
* Oh. Fere, " Contribution a Tetude de la migraine ophthalmique "■
(' Bevue de Medecine/ 188 1).
GENERAL PABALTSIS. 67
had the first aiiacky which oonsisted of ophthalmic migraine
with scintillating scotoma^ and weakness of vision on the right
side, accompanied by embarrassment of speech, paralysis and
numbness of the right arm. This lasted for eight days^ and
then he was quite well again. Eight days later he had a
second attack, without loss of consciousness^ but with
difficulty of speech. The intelligence was obscured for
twenty -four hours, and then, to all appearance^ he recovered
completely ; but he was still nervous and irritable, though
he was able to resume work.
In the month of February, 1882, he had a third attack
with the same symptoms of migraine, only this time there
were, at the commencement, convulsive fits of an epileptiform
character with loss of consciousness. This condition con-
tinued for two hours, during which he seems to have had
a series of convulsions which presented the peculiarity of
predominating on the right side. After this seizure the
difficulty of speech persisted.
Eight days later he had a fourth attack of the same
nature, with a relapse of the difficulty of speech and weak*
ness of right arm. Lastly, on May 5th, he had sl fifth attack,
with paralysis of the right arm, followed on the morrow by
paralysis of the right lower extremity. During the ensuing
five or six days he could say nothing but the words ^' a cause
que." The right arm remained paralysed for a month. It was
from this time that his intellectual troubles really began;
and he became childish. He is docile, but very changeable,
crying or laughing on the slightest pretext. He can scarcely
write spontaneously, but he has managed to copy a page
with a trembling handwriting. The memory is as feeble as
the judgment and will. From time to time he experiences
the scintillating scotoma. He advances, as you see, with a
staggering gait ; his hands tremble and his tongue also ;
his speech is scarcely intelligible ; his physiognomy is
characteristic, look vacant, eyelids drooping, &c. The right
pupil is more dilated than the left ; they act feebly to light
but better for accommodation.
The lesson, gentlemen, to be learned from all this, is that
one must not allow one^s judgment to be led away, because,
in the immense majority of cases, scintillating scotoma.
68 PBOON08I8.
together with the other phenomena which accompany it^ are
things of but little importance.
Beneath a benign exterior it is possible that there may
lie the commencement of a grave disorder, such as shoold
not be overlooked.^
^ Since this lactnre was dellTeied and published in the ' Progr^ MWcal '
M. Parinand baa published a ease of a similar kind (' Archiyes de Neurologie,'
T. V, p. 57).— Ch. F.
COOPER MEPIOAL Cv-^
SftN FRANCISCO. GAL.
and is not to be removed frorrithe
Sfem--. Boon^ by --VP^
he
ON HYSTERIA IN BOYS.
SOMMARY. — Hysterical contracture. — Amblyopia. — Hystero-
genic zones. — Phases of the hyatero-epilectic attack. —
Hysteria in boys ; the attack ; permanent symptoms, —
Importance of isolation in the treatment.
Gentlemen, — I propose in to-day's lectnre to bring before
yoo a. youth who has been attending here for several weeks,
and who presents a series of interesting nervous symptoms.
All these symptoms, as yon will see, can be attribnted to
hysteria, and the case will enable me to show you briefly the
leading features of this malady as it occurs in the male sex,
and especially in early life.
But, in the first place, I think it will serve as contrast, and
to bring out tho features of this particular case if I recall to
your minds some of the chief phases of hysteria in women, as
it occurs in the classical type of hystero- epilepsy with mixed
crises, la grande hystirie, such as we so frequently see in many
of the patients in our wards. I will show you again two of the
hysterical patients whom I have already shown you several
times. One is a woman named B — , 34 years of age, who
presented, as you will remember, a good example of hyste-
rical contracture developed under the influence of an injury.^
Dnring five days the contracture existed in all the articu-
lations of the left lower extremity ; and in addition to that
we discovered that there was an absolutely complete hemi-
anesthesia on the same side, complete at least so far aa
1 See p. 33, el »eq.
70 HYSTERIA IN WOMEN.
general sensibility was concerned. A certain degree of
hemianaestfaesia still persists^ but the contracture has dis-
appeared.
What else has happened since the last time we saw the
patient together ? The catamenia have appeared^ but the
hysterical seizures^ on which we counted to put an end to
the contracture, have not occurred. The only fits that she
has had, which were three in number, presented all the
characters of epilepsy ; . they took place in the night without
premonitory symptoms, the loss of consciousness was com-
plete, there was biting o£ the tongue, &o. They had no
influence on the rigidity of the limbs, and we decided there-
fore to try the application of a magnet to the neighbourhood
of the contracted limb. Several incidents occurred, and
finally the contracture yielded. Now you see the left leg is
almost completely flaccid.
I should add that the tendency to contracture in this
patient does not seein to exist now, for they tell me that the
lipplicatibii of the niagnet to the neighbourhood of the limb
no longer produbes rigidity.^ The same can be said of
faradization, which is productive of no result.
One mote fact to note : Faradization with Du Bois
Baymond^s a{)paratus even at its inaa^mttm has not produced
hitherto, any sensation. However, yesterday we found,
^fter a little perseverance, that the sensibility had slightly
i'^appearod all down the left side. This circumstance
niakes oiie think that in tKis patient the hysterical tendency,
T^ich has so lately reappeared^ is about to cease, and that
fiobn everything will revert to its formisr sf jaite. Pt*obably the
fusibility will becoine re-established on the left side, and
the hysterical manifesttttions will not return> at any rate for
8k time, although the patient will remain liable as heretofore
to epileptic seisSures.
Matters have not quite reached this point with the young
Jewess whom you saW about three weeks ago. You will
remember that 6he had had contracture of all four extremi-
ties for six months. Whether under the influence of static
I . •'
} Jtmaj be jtointed out that thp samt^ agent which oauses a disappearance
oi stigmata in hysterical subjects is frequently capable oi causing iheir
reappearance when they are not present.*— T. D. S.
HBMIANiQSTHESIA. 71
electricity or whetlier spoBtaneoasly we are not sure, but her
•condition has improved. The contracture has disappeared,
first from the upper extremities, then the left lower extremity,
remaining, however, in the right ; and the anaasthesia,
which during the contracture was present in all four limbs,
only persists in the right side now. After a certain number
•of modifications, obtained by the prolonged application of a
magnet, the right lower limb has regained its normal mobi-
lity, but the hemiansQsthesia still persists.
You see that the patient does not feel pricking or even
prolonged and severe faradization. Another fact should be
mentioned, namely, that faradization, acting on the muscles
•and on the nerve-trunks, produces muscular contractions
which do not cease after the current is withdrawn, but
which pass into a state of permanent contracture. Here,
for example^ is the ulnar deformity of hand [griffe cubitale]
•determined by excitation of the nerve behind the elbow;
here is club-foot produced by faradization of the calf -muscles.
You see thus that the contracture exists all the while in a
latent state, and that the slightest excitation is sufficient to
reproduce it for a long time, perhaps as a permanency.
I have pointed out in these two patients the existence of
<hemian89sthesia. It is a phenomenon which occupies an
important place in the clinical history of hysteria, and is
very frequently met with, in some degree at any rate.
Allow me to dwell for a moment on this trouble of sensibility.
The young girl Bl — presents the hemiansssthesia of
hysteria in a form that is altogether characteristic, and suit-
able to study. On the left side there is insensibility to
pricking, cold, and all forms of stimuli. This loss of general
sensibility is found in the upper extremity, the lower
extremity, half of the trunk and the head. You see that
this girl bears the most intense faradization without suffering
the slightest inconvenience, and that the ansssthesia occupies
not only the skin but even the deeper parts, the muscles
and nerve-trunks ; for one is able, by exciting the nerves and
muscles, to determine, "Cirithout producing pain to the
patient, a pronounced and more or less durable contraction.
It is rare if the general sensibility alone is affected. The
72 HYSTERICAL AMBLYOPIA.
sensorial organs of the same side of the body as the anaesthesia
are usually attacked also. In general there is a diminution
of taste, hearing, and of smell. But I want specially to call
your attention to the visual troubles, so interesting from a
diagnostic point of view. In most cases, when there is insensi-
bility of one side of the body and of the face, a more or less
pronounced disturbance of vision is also manifested in the
corresponding eye, a sort of amblyopia which rarely amounts
to amaurosis. A methodical study of this modification of
vision shows the following :
1. Retraction, often very marked, of the field of vision.
Sometimes, when the ansssthesia is double, or when there is
an analgesia of one side and ansBsthesia of the other, there
exists a retraction of the visual field of both sides, but
much more marked on the side where the troubles of general
sensibility are more pronounced. This retraction of the visual
field is most interesting to the physician. The patient can
neither simulate nor exaggerate it, and not uncommonly it
is very accentuated, although the troubles of general sensi-
bility may be but little marked.
2. Another phenomenon which generally accompanies this
limitation of the visual field, consists of a diminution of the
acuteness of vision. There often exists a disturbance in the
perception of forms, and sometimes there is a cloudiness of
luminous perceptions.
3. But a fact which ought particularly to attract our atten-
tion in hysterical amblyopia, is the presence of dyschroma-
topsia, and, to a degree even more pronounced, of achroma-
topsia, that is to say, a diminution or an absolute loss of
the notion of colours. One knows that, in a normal state, all
parts of the retina are not equally apt in the perception of
colours ; thus under physiological conditions the visual field
for blue is wider than that for yellow , and that for yellow
than that for red; and then after red, green, and violet,
which is only perceived by the most central parts of the
retina. In hysterical amblyopia the characters of the
normal state are modified in such a way that the circles
representing the limits of the visual fields for all colours are
concentrically retracted. The violet circle may be so re-
tracted as to become lost ; and then the patient, placed in
HYSTBBIOAL DYSOHROMATOPSIA. 7S
front of the colour, will be unable to name it; the same
phenomenon repeats itself with the green, red, &c. The
yellow and the blue may perhaps be the only colours the
perception of which remains. But even they may disap-
pear, and then we have total achromatopsia, the patient only
recognising the forms of objects, which appear grey, like
an uncoloured photograph seen through the stereoscope.
There is, however, in many hysterical patients a not
infrequent exception to the rule which I have just men-
tioned, namely, that the notion of the two colours, blue and
yellow, remain, although the others have disappeared in the
achromatopsia. I must point out this anomaly, although I
am not now making a complete study of hysterical achroma-
topsia, because it is met with not only in most of the hysterical
women under our observation, but also in the cases of male
hysteria of which we are about to speak. The exception
consists of the fact that the extent of the visual field for red
remains larger than that for blue ; so that, although the
patients may have lost the power of perceiving violet, green,
blue, and yellow, the perception of red remains. Here is a
case that has been studied by Dr. Parinaud, which clearly
demonstrates the phenomenon in question.
In the young girl N — y the right eye is affected to a
certain degree with a retraction of the visual field for all
colours, which remain, however, in their natural order. In
the left eye there is manifest retraction of the visual field
for white light, the different colour fields are narrowed and
in a more marked degree than the opposite side. But,
besides that, and this is what constitutes the anomaly, the
field for red has remained more extended than that for yellow
or for blue ; this last is next to the green, and has become
substituted for the red. If this retraction progresses, it
may happen that the perception of all colours will disappear,
excepting that of red. I dwell on these anomalies because
we shall find them in a certain degree in the hysterical boy
whom you will see to-day.
I will not discuss the nature of these visual troubles in
hysteria. I will only remind you, in passing, that these
phenomena are unaccompanied by any modification appre-
ciable to the ophthalmoscope. There are modifications
74 HYSTEROGENIC ZONES.
neither of the refractive media^ nor of the back of the eye,
there are not even vascular changes ; they are exclusively
•dynamic troubles, as they are called. I ought, moreover, to
remark that these phenomena are not altogether peculiar to
hysteria, excepting perhaps that which relates to the field
of vision for red ; for, with the exception of this last pecu-
liarity, they may be met with in central lesions of the brain
occupying the internal capsule.
We ought to refer to another symptom in the patient now
nnder examination. There exist, on the ansssthetic side,
two points, or rather two aress, where sensation is exagge-
rated. One of these points corresponds to the ovarian region,
the other to the lumbar region right and left of the spinous
processes. These are the hysterogenic points or aresB, which
:are frequently found in hysterical patients, and which some-
times occupy other positions than those now indicated.
Thus, H — , whose anassthesia is general, but more pro-
nounced on the left, presents three hysterogenic zones : the
ovarian, the left lumbar, and the bregmatic.
What are these hysterogenic zones ? They are more
or liess circumscribed regions of the body, pressure on
which, or simple rubbing, produces the symptoms of an
aura, which may be followed, if you persist, by an hysterical
Attack. These points, or rather patches, are, moreover,
possessed of a permanent hyper-sensibility, and before
■an attack are the seat of a spontaneous painful sensa-
tion which consequently forms part of the aura. Some-
times this latter consists of palpitations, sometimes of a
burning sensation. An attack, once started, may often be
arrested by energetic pressure on these same points. It is
an interesting fact and worthy of notice, that these points
are not met with on the limbs,^ but they are to be found on
^ Since the delivery of this lecture M. Gaube has published some in-
teresting observations on hysterogenic zones. According to these investiga-
tions, which were conducted under the direction of Professor Pitres, of
Bordeaux, hysterogenic zones have been found to exist on the superior or
inferior extremities, and these zones were found' to have the same properties
4L8 those met with on the trunk or head (Graube, '' Becherches sur les zones
hyst^rog^nes," * Th^se de Bordeaux,' 1882).— Ch. P.
HTBTHlUKIBHia ZOMHB. 75
the anterior anr&oe of the trook ia the middle line (base of
the stenmrn, zyphoid appendix), jnat below tbe clavicle
(Fig. I4)j below the breasts and in the orariac regiooa of
women, in the ingninal region of men ; on tbe posterior
'IB. 14.— H;iUrogentc toam on the front of tHe body (taken from
' Iconogriq^hie photographique de la Balpelriire,' by Bonrneville
1 Reensrd. vol. iii. d. ^1.
surface (Fig. 15), between the shoulderB, sometimes at the
angle of the.Bcapala, in tbe lumbar region to right or left
of the middle line, or orer the coccyx. In men it is not nn-
finrvTSTfu ^Ll^^^Tv^^^^^^ CiVr{uv*v-~-
76
HTSl^SOaENIC Z0NB8.
oommoQ to find that the testiole, especially if it presenta an-
abnormality of position or development, is the seat of a.
partial hysterogenic zone ; or perhaps the prepnce is exceed-
ingly sensitiTe, and exhibits the same pecnliarity. In the-
Fie. 1 5.— HjBterogenlo
the posterior aorface of the body
(loc. cit., p. 49).
head these patches are Bometimes to be found about the-
lerel of the bregma, on one side or the other.
The extent of these zones is very vuiablej they are not
often larger than a five-franc piece.
HYSTBEIA IN THE MALE. 77
In order to complete these preliminaries upon wliich I
have been dwelling so long, it would be necessary for me to
recall the general characters of the severer form of hystero-
^pilepsy (la grande attaque liyst6ro-6pileptique), but I think
it will suffice if I refer you to former lectures.
Such are the phenomena which are met with in the more
pronounced form of hysteria in women, and on which I wish
at the outset to fix your attention. Well, the greater number
of these characters are to be found in the hysteria of men.
But does hysteria exist in men ?
To this question, whether hysteria also attacks individuals
of the male sex, we can undoubtedly reply in the affirmative ;
and we can add moreover that it is by no means rare.
In a recent thesis, M. Klein,^ a pupil of M. OUivier, has
collected not less than seventy-seven cases of hysteria in
men. The proportion, according to M. Briquet, is one man
to twenty women. This figure is undoubtedly a slight
exaggeration. Nevertheless, my experience enables me to
affirm that hysteria is met with frequently enough in men ;
and that it is attended with all the characters ordinarily seen
in the female sex.
I will only mention one case by way of illustration.
A youth of 17 years, S — , from Moscow, came to consult me
for the first time last year. He is a tall tbin lad, amongst
whose antecedents there is an uncle the subject of melan-
cholia. The patient himself is imaginative, writes poetry, is
fond of music, reads novels with avidity. He has no mal-
formation of the genital organs. For several months he has
been subject to attacks coming on nearly every day about five
o'clock in the evening. In the way of permanent symptoms,
he has left hemiansBsthesia, and on the same side, a costo-
stemal hysterogenic point. Brisk friction on this point
induces an attack. The spontaneous attacks are preceded by
melancholy, beating of the temples, and the sensation of a
ball which spreads from the precordial region upwards to the
larynx. Whether spontaneous or provoked, the attacks
consist of an epileptoid stage, more marked in one half of
the body, tonic and clonic spasms which predominate on the
> Elein, '* J)e VhysiMe ehez I'homme" * Th^e de Paris/ 1880.
78 OASES OF
left side; be loses conscionsness, bat does not bite his
tongue. After which his body assnmes the arc of a
circle with an abdominal convexity. In the third stage,
he gets np and walks with his eyes wide open, and utters
a cry of terror (seeing his dead mother.) At the conclusion
of an attack, laughter, tears, and yawnings occur ; he asks for
something to drink, trembles, says he is cold, &c. By way of
summing up,— the hemianesthesia, the existence of a hysterc
genie zone, and the character of the attacks which have just
been described, amply suffice to establish the diagnosis ; it is
not epilepsy certainly, it is hysteria. A tonic treatment, the
employment of hydrotherapeutic methods, and certain
alterations in the intellectual hygiene, will tend to promote
recovery.
But well-marked cases of hysteria are met with not only in
manhood and adolescence, but are seen even in childhood
before puberty. This is proved by well-authenticated
observations. It would seem, according to M, Klein, that
hysteria in the male is most frequently seen about twenty -
four years of age ; but I think this statement needs con-
firmation.
According to my own observations, hysteria is more
common than is generally believed in boys about twelve or
thirteen years of age. It is met with, as you know, in the
other sex very frequently at the age of ten or twelve years.
Moreover, cases having all the characters of hysteria major
do occur in children both male and female. As an example
of this last kind, I may mention the case of a little boy of
13 years old, whom I saw in consultation with a very
distinguished physician, who displayed the greatest scepticism
about hysteria in general, and particularly about hysteria in
childhood. In presence of the epileptiform attacks, it was
asked whether it was not true epilepsy, or perhaps a conse-
quence of some serious encephalic lesion, a cerebral tumour
for example. The epileptiform seizures existed without doubt,
but they were only part of a series of other manifestations ;
they were followed by the great movements, during which the
child threw himself into the arc of a circle, &c. I was a witness
of one of these seizures. I sought for a hysterogenic point, and
HYSTERIA IN BOYS. 79"
it was found in the left flank ; I pressed upon it and the convul-
sive movements ceased, although consciousness did not return..
In the intervals of the attacks there existed a left hemi-hyper-^
SDsthesia ; besides which this boy had an effeminate air^ and
was surrounded by the playthings of a little girl.
I prescribed tonics ; isolation^ so as to withdraw him front
the influence of his parents, who petted him too much ; and
hydrotherapy. A cure was effected in less than three
months. Unhappily, this child succumbed three years^
afterwards to a pericarditis consequent on scarlatina ; but
the nervous symptoms had never again appeared.
Among all the published cases of hysteria in boys, that of
MM. Bourneville and d'Olier^ is perhaps the most remark-
able, both on account of the care with which the details of
the case were studied, and the accentuated character of the
symptoms. It is an illustration of hystero-epilepsy, of
hysteria major [la grande hysteric] in the strictest sense of
the term. The child was 13 years old, bom of a family
which numbered amongst its members several epileptic
idiots, and one child with depraved instincts. The child in
question, however, was good-tempered and intelligent. In
the intervals of the attacks, left hemiansBsthesia and
amblyopia were found to exist, and three hysterogenic zones-
(bregma, left iliac fossa, and lumbar region) . The bregmatic
point was the most sensitive.
The least shock, the least friction, applied to this point
produced an attack ; and even the comrades of the patient,
having learned the secret, gave themselves the wicked
pleasure of initiating the convulsive seizures by these simple
means. Strong pressure arrested an attack with the samo
facility. The fits were always the same ; epileptoid period,
period of great movements, with the attitude of an arc of a
circle, then passionate attitudes with violent cries. He had^
between November, 1879, and December, 1880, not less than
582 such seizures. He had no true epileptic fits, and there
was no permanent impairment of intellect, in spite of the
frequent repetition of the seizures.
* Bourneville et d'Olier, *Recherches cliniques et th^rapeutiques snr
r^pilepsie, rhyst^rie et Tidiotie,' 1881, p. 30.
60 CASK.
The case of the child whom I am about to show yoa is less
complete^ less precise ; and less rich, if I may say so, in the
very accentuated phenomena. It is a case of minor rather
than major hysteria, although I do not think it is the less
interesting, if only on account of the surrounding circum-
stances.
He is a young Jew of 13 years of age, a native of
Southern Bussia. Both his parents are in good health; the
father is very impressionable and nervous, but without any-
thing very characteristic. You see the child is clothed in
the uniform of a Gymnasium at ... . (Southern
Bussia), which he has attended for the last three years.
He has worked hard ; he has a bright, intelligent look, but
he is small and pale. He has complained for rather more
than a year of pains in his head, but it is only during the
past five months (in January) that the headache has become
intense, returning every evening about five o'clock, and
followed shortly afterwards by convulsive attacks.
The original diagnosis seems to have been somewhat
uncertain ; an organic lesion was mentioned, and the prognosis
given was very unfavorable. The father, who loves his son to
distraction, undertook the voyage, came to Paris, and brought
bim to us fifteen days ago, imploring us to give him the
means of cure, which hj9 had been unable to obtain in his
own country. From the very first interview we were able
to give him hope. The affection is not so serious; not
only will the child live, but we can affirm without hesitation
that the child will make a complete recovery.
If we bear in mind, apart from the other circumstances
of the case, that this young person is the subject of a per-
sistent cephalalgia, with a point of exaggerated sensibility
on the vertex, and that for five months the attack has
occurred every day at the same time, we should have a
strong presumption of hysteria, which a more careful inves-
tigation tends only to confirm. In the periods between the
fits we have ascertained that there is a loss of sensation to
pricking, to cold, and to faradization on the right side ; the
taste, smell, and hearing are also weak on the same side.
He complains that he cannot see clearly with the right eye,
and a methodical examination of the visual field shows a
retraction more marked on the right side (Fig. i6), and
with that eye he can only identify red. Besides these sym-
ptoms there are patches of hypertesthesia on the (
and a hysterogenic zone on tho vertex. About half-past
tour or five {about half-past six by Russian time)j the head-
ache, which is of a sharp stabbing character, becomes worse.
82 TREATMENT.
and is followed by tinkling in the ears. He lias not the
sensation of a ball^ but a sort of thoracic constriction.
The attack may generally be cut short by chloroformiza-
tion. Left to himself he lies down on his left side, with his
head on a little cushion that he always has with him, sobs, and
doubles himself up. The upper and lower extremities are
bent, he hides his head in his hands, and assumes somewhat
the position of emprosthotonos ; he can be roused quite easily.
This lasts three or four minutes, then the limbs unbend, the
eyes fill with tears, and all is finished; no laughter, no
crying, no delirium,
It is interesting to notice the deportment of the father at
the expected time of attack. He takes out his watch,
which is set to the time of his country ; about six o'clock he
questions his son, and asks him if he is suffering. If the
reply is '^ Yes,'* he displays an amount of solicitude which is
respectable no doubt, but which certainly tends to foster the
patient's condition and to maintain the regularity of the
symptoms.
It is not necessary after the preceding account to discuss
the differential diagnosis.
It would be superfluous to compare this case with those
other more classical ones which I have described to you at
the commencement of the lecture, and to point out the ana-
logies which prove that they all belong to the same family.
We have here to do with hysteria> nothing but hysteria ; the
idea of any intracranial organic lesion may be dismissed at
once.
Hence the prognosis, which is in general relatively favor-
able, is absolutely so in this case. There is ho doubt about
the result, because, hysteria occurring in boys is not so
rebellious, according to my experience at any rate, as when
it occurs in little girls. y
I shall prescribe : i, isolation, so as to withdraw him from
the paternal solicitude, which serves only to perpetuate the
excitable nervous condition ; or at least I shall enjoin a
firmer and less sympathetic behavidut on the part of the
father ; 2, the employment of tonics>f 3> static electricity and
hydrotherapy. These, I believe, will effect marvels. I hope
that tte father will not refuse to consent to the employment
of these methods, and that ho will be able in a few months'
time to take back his son to the Gymnasium of ... .
completely cured. ^
' At first the patient nndsrwent treatinent by stntic electricitj every
.other day, and bath -treatment daily, at the same time as a restorative
regimen wsa putsucd. But the father would not consent to be separated
from the child, and every day at the same hour he was in waiting for the
attacli, which in fact did nut fail to produce it in the same manner as it had
done before the treatment was coiomenced- At the end of a month's nn-
-BUFcessful attempt, he (lccide<I to })1ace his child in a aanitorium ; but
daringthe greaterpart of the day he roved continnally around the astablish-
iDent, qnestioning those who camo out as to the condition of his son, who
l>new what was going on and did not feel completely abandoned. Several
weeka passed thus, and nothing occuri'ed ; tbe distressed father wished to
give up the treatment. It was only after much trouble he was made to
nnderstand that until then only a fictitions isolation had been adopted; that,
in conBeqncnce, the treatment bad been altogether incomplete ; and that it
was necessary for him to absent himself altogether, so that bis son should
have no donbt he was alone, quite alone, and would only be liberated when
This was done, and what took place subsequently proved tbe therapeutic
value of (!omplete isolation in caees of this kind. At the end of four or five
days the attacks became modified, less regular and less severe. Fifteen days
later and the attacks no longer occurred ; then the bregmatic hysterogenic
zone disappeared ; and when the patient departed, aboutone month after the
commencement of effectnal treatment, traces of amblyopia were all that was
left of the former symptoms. (Cb. F.)
Tkishoohisilepropc.
OOOPER MEDICAL CULL... ■
SftN FRANGISCO, CAU
a-nd is not to be removed from the
Lihrarv Room by my person or
under auj i ' fecci whatever.
LECTURE VII.
TWO CASES OF HYSTERICAL CONTRACTURE OF TRAUMATIC
ORIGIN.
SuMMAEY. — Latent hysteria without convulsive attacks. — Per-
manent spasmodic contracture of traumatic origin. — Two
cases compared, one in a woman, the other in a man. —
Heredity, — Ulnar deformity of hand ; experimental
study of the deformity by electricity, and by putting in
action the phenomenon of neuro^mvscular hyperexdta-
bility.
Gentlemen, — In the lecture to-day, whicli inaugurates the
new academical year, I shall call your attention to two cases
that have recently come under our observation, and which
several among you have already had the opportunity of
examining. These two cases seem to me to be quite worthy
of occupying our attention for a while, for they present some
striking analogies ; so much so that they seem to be cast
as it were in the same mould, and for several reasons merit
careful comparison.
They both, in fact, offer an illustration of hysteria,
anomalous by the absence of convulsive seizures. They have
besides this, another trait in common, to wit, the existence
of a spasmodic contracture limited to one of the hands, and
developed, as it would seem, under the influence of an
external stimulus.
If one of these cases occurs in the female sex, as is the
rule ; the other, on the contrary, attacks the male ; and
this is a circumstance which should undoubtedly excite your
interest.
Briefly put : i. Hysteria, latent and wanting in that
pathognomonic feature of the disease^ the convulsive attack ;
2. Permanent spasmodic contracture developed under the
CASE. 85
influence of an injury. These are the two points which I wish
especially to emphasise in our study of these two cases ; which
are of different sex truly, but between which there is, as I
shall attempt to show, a marked degree of similitude.
I. After these preliminary remarks, I will commence at
once with an account of the first case.
The patient is a girl of about i6 years old, and as you
see, of delicate appearance. Her physiognomy is calm
enough, and presents nothing very peculiar. She is not
decked out with showy colours, like so many of these patients ;
she does not belong to the buoyant, expansive variety of the
disease. But, it may be noted in passing, these placid
hysterical subjects are not always the easiest to manage.
A few facts in her antecedent history should be mentioned.
After the death of her mother from pulmonary phthisis,
she was placed, at the age of ii, in a home under the
direction of a religious sisterhood. We learn, and this is
a point of interest, that her father died in the Orleans
Lunatic Asylum, where he had lived for three years before
his death. The disease for which he was admitted into the
asylum seems to have been progressive general paralysis, if
one may judge by the fact that he had several convulsive
attacks, after which he remained paralysed. One of her
brothers, 13 years old, who is kept in a charitable institution,
is almost an idiot.
These facts deserve some attention because, as you know,
neuropathic heredity figures conspicuously in the etiology of
hysteria. This cause can be invoked in 30 instances out of
every 100 according to Briquet. In conformity with the
nomenclature proposed by M. Prosper Lucas there are two
kinds of heredity, homonymous heredity or the heredity of
similitude^ where hysterical parents beget hysterical offspring ;
and the heredity by trcmsformation, the parents having been
affected with some other affection of the nervous system,
fiuch as insanity, epilepsy, &c.
There is scarcely anything worth noting in the previous
history of the patient herself besides a severe bronchitis,
which lasted three months. There is a complete absence,
whether in the past or the present, of any of the phenomena
86
QASE.
of convalsive hysteria. Oar patient seems to be absolutely
unacqnainted with hysterical globus, spasms, or convulsions*
As regards her moral condition, the information furnished
by the Superior of the Sisterhood where she lived is not very
explicit : ^' She has an extreme fondness for liberty ; her
conversation and her mind are not refined/* What is there
behind this monastic reticence ? At present we know of
nothing ; but perhaps we shall know by-and-by.
Now I come to the principal fact, the deformity of the-
left hand, which represents as you see a veritable club-hand
[main-bot], and which I designate hysterical (Fig. 17}.
F10. 17. — Hysterical contracture of the left hand. Drawn by
M. P. Richer.
I shall tell you presently what are the circumstances^
under which this deformity was developed ; at present I
will only mention the fact that it has lasted for one year.
During all that time the deformity has been permanent ;.
there has been no cessation, no alteration, except during a
period of two months, when it was modified under the influ-
ence of treatment.
The wrist is free, so also are the other joints of the upper
extremity. The deformity is therefore limited to the hand.
The first phalanges are flexed on the metacarpus, the other
phalanges only present a slight degree of flexion. The
fingers, thus flexed as a whole, are squeezed one on the
other, forming a sort of cone, of which the summit corres-
ponds to the extremities of the terminal phalanges. The-
thumb, in a state of adduction, is itself strongly pressed
against the index finger.
rPNOTIONAL OONTEAOTUKE. 87
It 18 easy to satisfy oneself tbat the muscnlar rigidity is
the sole cause of the deformity, and that the joints and the
ligaments are not affected. The attempts at reduction suffi-
ciently demonstrate this, Chloroformization would be able
to give us instantaneous proof ; but we feared a perturbation
which would have prevented you from studying this defor-
mity de visu.
Furthermore, we find here the characters of a spasmodic
contracture. If, in fact, the flexors are especially affected,
and determine the kind of deformity, the extensors are also
undoubtedly attacked; for it is as difficult to exaggerate
the flexion as to produce extension. This simultaneous
action of antagonistic muscles is one of the characters of
spasmodic contracture, to which I shall return.
In passing, there are some other particulars worth men-
tioning. The deformed band is colder than the other, and
has a bluish tint, denoting a manifest trouble of the vu.so-
motor nerves. There exists an atrophy, or rather a slight
emaciation, not only of the hand, but also of the other seg-
ments of the limb. The forearm and the arm are about one
centimetre smaller than those of the opposite side ; it is not a
true muscular atrophy, but rather a wasting from prolonged
repose. We find, moreover, a diminution of general and
special sensation over all the half of the body on the. same
side as the deformity.
We have here, note it well, a permanent contracture in
the true acceptation of the term. It is to be found
morning and. evening, it persists also during sleep. Of this
we cun easily satisfy, ourselves, thanks to the circumatanoe
that the patient is devoid of sensation on this aide, and the
exploration can be made without waking her. Hence, any
suspicion of trickery can be entirely dismissed from the mind.
Perhaps, before going further, it may be interesting to
enter into some detail relative to the physiology of this con-
tracture, I
What are the muscles which specially act to determine
this defective attitude ,? In the first place it is the ijiterossei ;
for,, as Duchenne (of Boulogne) has shown, these muscles
serve the purpose lof flexing the first phalanx, in, addition to
This hook is the 'proj- i
OOOPER HECWkV QCi\A»ii^,
■A
88 EXPERIMENTAL PKODUtTlON.
which^ the palmar interossei have the action of drawing the
fingers towards an imaginary line passing through the
longitudinal axis of the middle finger^ and consequently of
drawing them all together. But the interossei are not alone
affected^ for the two distal phalanges are also flexed^ and
this attitude is due to the action of the superficial and deep
fiexors.
Therefore one must recognise the action not only of the
ulnar nerve^ which supplies the interossei^ but also of the
median^ under the influence of which the fiexors contract.
But, besides this^ the participation of the median uerve is also
shown by the attitude of the thumb. You will notice in fact
that the thumb is not only in a state of adduction^ but also
at t^e same time in opposition ; for^ not only is it carried
inwards^ but the nail faces^ not directly outwards^ as in simple
adduction, but somewhat forwards. Simple adduction of the
thumb is determined by the adductor, i. e. the true inter-
osseous of the first space, which is supplied by the ulnar
nerve ; but the other movement is produced by the opponens,
which is supplied by the median.
Moreover, we need not confine ourselves to simple asser-
tions relative to the mechanism of this deformity of hand.
We are prepared to demonstrate the condition which has
just been described by means of localised electricity, after
the method of Duchenne (of Boulogne). This kind of ex-
perimentation is rather difficult on normal subjects, because
of the pain produced by faradization ; but that difficulty
does not exist in ansDsthetic hysterical subjects, who lend
themselves, as it were, to the investigation by not experi-
encing any pain.
I bring before you again the woman B — , a hystero-epi-
leptic with left hemiansBsthesia. A black point has been
marked just within the tendon of the fiezor carpi ulnaris ; it is
the point of election for faradization of the ulnar nerve at
the level of the wrist. Yon see that faradization produces
a partial ulnar deformity of hand [jgriffe cubitale partielle] ,
which recalls that of our patient, and in which the interossei
and adductor of the thumb are alone in action. If, again, we
excite the ulnar nerve at the level of the bend of the elbow
we determine a total ulnar deformity of hand [griffe cubitale
DIAGNOSIS OF FUNCTIONAL OONTEAOTURE, 89
totale] with flexion of the last two fingers ; this latter move-
ment being due to the action of the ulnar segment of the
•deep flexor.
These same facts are even more easily studied in subjects
who can be plunged into a state of hypnotic lethargy. We
can in fact profit by the neuro-muscular hyperexcitahility
with which these subjects are affected^ and produce the same
movements by irritating the nerve with some hard body,
simply with a stick, without faradization. The advantage
of this mode of experimentation is that the attitudes which
result are enduring, as you observe in this patient, in whom
you see me produce, by simple pressure on the ulnar nerve
at the wrist, the interosseous deformity of hand [la griffe
interosseuse] ; or, if you like to press on the nerve at the
bend of the elbow, the complete ulnar deformity of hand
[griffe cubitale totale] . After having brought back the hand
to the interosseous deformity, you see I can reproduce
exactly the deformity of our first patient by exciting the
opponens muscle in the palm of the hand. I should like
you to observe that in this hyperexcitable subject the hand,
contracted in a state of flexion, presents all the characters
of spasmodic contracture ; the attitude is fixed, and the flexors
and extensors are both contracting. It is therefore evidently
an influence of the cord. But that is a point to which we
shall return.
After this digression, it is time to come back to our patient.
It has just been shown that the case before us is one of
spasmodic contracture, but now it remains to be seen that
it merits the term hysterical, and that the relatively favorable
prognosis applicable to this class of case can be given here ;
or, in other words, one can hope that in spite of its long
duration and tenacity it will yield to appropriate treatment.
This diagnosis can be based, firstly, on the very intensity
of the contracture, which rarely presents itself to such a
degree when it is due to an organic lesion, a lateral sclerosis
of the cord. Secondly, on its permanence, always in the same
•degree, night and day. In hemiplegic patients the con-
tracture generally relaxes under the influence of sleep.
90 OONTBAOTQBB DIATHBSIS.
Thirdly, the circumstances under which the defective posi-
tion was produced are of great importance. More than a
year ago, 2nd November, 1881, the patient, in breaking a
pane of glass, produced an insignificant wound on the back
of the hand, over the position of the second metacarpal bone,
which healed in four or five days. It was this slight injury
that determined the contracture : this is a feature of great
importance. Besides this, the onset was sudden and with-
out pain. Finally, the deformity persists long after the
wouud is healed. Without doubt, among the subjects of
organic lesions (cerebral, or spinal, descending sclerosis) one
may see the same condition arise in consequence of an injury.
But under these circumstances, generally speaking, the onset
is not so sudden, and there is not the same disproportion
between the triviality of the injury and the intensity of the
contracture ; and, moreover, it has not the same persistence
after the cure of the peripheral irritation.
This tendency to contracture in hysterical patients, this
contracture diathesis, which can be lighted up by a trivial
injury, is very pronounced in some people. I observed a
long time ago that certain hysterical subjects, after a sudden
movement, in throwing a stone for example, remained with
the arm in a state of contracture. We can reproduce the
same phenomenon in the woman M — , whom I show you.
You see that I can, by suddenly bending the foot, deter-
mine a talipes equinus, which will only yield to prolonged
massage. You notice that this contracture is produced in
the waking state, 'and thQ>t it has the same intensity as that
which we produced just now, by means of the neuro-muscular
hyper-excitability in hypnotic sleep.
Applied to the case of our patient, you perceive that this
series of considerations enables us to presume that the affec-
tion is of an hysterical nature. But this presumption,
already a strong one, becomes changed to certainty when a
more attentive study has enabled us. to reveal characteristics
which establish more and more clearly the fundamental nature
of the case.
Although the convulsive attacks are wanting jin this patient.
SBN80BU.Ii CHANGES.
she nevertheless presents a nnmber of nervous troubles^
which constitute quite aa much the characteristic stigmata.
of hysteria.
Tliere exists, in fact, the ovarian phenomena [ovarifi] on the-
left aide; and a left 7iemiajia/^ma,oecupyingnot only the hand
but both limbs, trunk, and head. The patient is qnite nn-
92 DIAGNOSIS.
a£Fectcd by faradization of the skin. There is^ moreover^ a
sensorial hemiansesthesia. The organs of sense are affected
in the same manner as the integuments which protect them.
This point belongs to a question which we have already had
occasion to study in the clinique in a general manner ;^ and
in this particular case a deficiency has been demonstrated to
exist in the sense of hearing by a physician^ M. Walton,'
now visiting our wards. Smell and taste are also affected.
It is the same with vision ; there exists a retraction of the
visual field (Fig. i8) for the perception of light, and for the
perception of colours, with a transposition of the red circle
to the exterior. There is a diminution of tbe acateness of
vision, which is represented by a sixth of the normal.
We find then in our patient all the characteristics of an
hysterical hemianaBsthesia, witb ovarian phenomena. These
troubles of sensation could only be determined by a central
cerebral lesion placed within the sensitive crossway, by
alcoholism, or by lead poisoning. But since we find no
other sign of these affections in this patient, we are obliged
to conclude that all the pathological phenomena are of a
purely hysterical nature. And in short you see that all the
phenomena, which at first sight seemed so irregular, so
strange, is fully explained.
Gentlemen, the hour is already late, we must postpone
the continuation of this investigation till the next lecture.
* Ch. F^r^— " Sur quelques pb^nom^nes observes du c6te de Toeil chez les
bjBt^ro-^pileptiqaes, soit en dehors de Tattaqne soit pendant Tattaqne " (' Soc.
de Biologie/ 1881, et * Arch, de Neurologie," 1882, T. iii, p. 281).
' G. L. Walton — ** Deafness in Hysterical Hemiansesthesia " {* Brain/ pai*t
XX, 1883).
LECTURE VIII.
TWO CASES OP HYSTERICAL CONTRACTURE OF TRAUMATIC
ORIGIN {continued).
Summary. — Investigations into simulation^ catalepsy, and
contracture. — Hysteria in the male, frequency, heredity,
adult age. — Mashed forms. — Contracture of i/raumatic
origin.
Gentlemen^ — ^You have not forgotten that in the last
lecture I proposed to draw a comparison between two cases
which came under notice here about the same time ; in both
of which there exists a contracture of an hysterical nature,
supervening after an injury ; a wound through the breaking
of a pane of glass in one case, a superficial burn in the other.
These two cases, I pointed out, are drawn together by the
most striking analogies, although the one is a young girl of
16 years old, while in the other we have a vigorous man, a
blacksmith of 35 years of age, married, and the father of
several children.
The young girl has already been the subject of most
attentive study. But the male subject, which we were not
able to bring before you the other day, has now been confided
to our care by M. Debove, in whose wards he was, at BicStre.
I will gladly take the opportunity thus afforded to me of
submitting this man to a very thorough examination before
your eyes. I do it the more willingly because it is un-
doubtedly a rare case, instructive in the highest degree, and
consequently well worthy of absorbing your attention for a
time.
But before coming to this case, it will be convenient I
^4 SIMULATION.
think to complete a few details about the young patient
-with whom we were occupied in the last lecture.
You are well aware, gentlemen, that when we are treating
of hysteria, the physician should always have present in his
mind the possibility of simulation, under which the patients
-either exaggerate real symptoms, or sometimes even create
an entirely imaginary symptomatology. Everyone knows that
the desire to lie, to deceive, sometimes even without motive,
by a disinterested cultivation of art for art^s sake, sometimes
with the view of making a sensation, of exciting pity, &c., is
n characteristic common enough in hysteria. It is an element
that is met with at each step in the history of this neurosis,
:and which throws a certain amount of disfavour on the
«tudy of it.
But in the present day, gentlemen, since the clinical
history of hysteria has been ransacked so many times and so
thoroughly, is it truly so difficult as some would have us
believe, to discern the real from the false symptomatology,
i, e. from that which is imaginary, simulated ? No, gentlemen,
it is not ; and not to remain among vague generalities in
regard to this matter any longer, allow me to recall to your
minds a concrete example, chosen amongst many others, and
upon which I dwelt last year.
I refer to the catalepsy induced in hysterical subjects.
The question is this : Can this state be simulated so as to
deceive a physician experienced in these matters ?
It is generally believed that if a cataleptic subject is
placed with the arm horizontally extended, this attitude
will be presierved so long that the duration alone is sufficient
to do away with all suspicion of simulation. This statement
is not quite accurate according to our observations. At the
end of ten or fifteen minutes the cataleptic arm begins to
descend, and at the end of twenty to twenty-five minutes it
resumes a vertical position according to the law of gravity.
Now, a vigorous man attempting to preserve the same posi-
tion is able to attain the same limit. One must, therefore,
seek some other distinctive character.
Let us apply both to the healthy person who simulates
and to the cataleptic patient, — i, a reaction drum to the
extended arm, so as to register the least oscilli^tion of the
L
ITS DETBorros.
limb ; 2, a pnenmograph to the clieat, so aa to obtain the
respiratory moTemeBts. These are the results which are
obtained : a. In the cataleptic patient the pen, which corre-
sponds to the reaction drum connected with the arm, tracea
on the registering roller a straight, perfectly regular line;
in the healthy subject, on the contrary, the straight line at
first oscillates, then becomes broken, and finally presents
great oscillations arranged in series, h. The signs afforded
by the pneumograph are even more significant. In the cata-
leptic patient the respiration remains slow, superficial, regular
up to the end : whereas, in the person who simulates the
tracing presents two distinct parts ; at first the respiration is
regular, and normal; then, corresponding to the oscillations
of the limb, which indicate muscular fatigue, one observes an
irregularity in the rhythm and extent of the respiratory
movements, — tho rapid and deep respiratory depressions
which accompany the phenomena of effort.'
To recapitulate ; i. The cataleptic patient is unacquainted
with fatigue, the muscle yields without effort, without volun-
tarj- intervention. 2. The person who simulates, when put
to the test, is betrayed both by the tracing of the limb which
indicates muscular fatigue, and by the respiratory tracing,
which shows the effort destined to mark the effects of fatigue.
We have within the last few days made a somewhat
analogous arrangement to put the contraetnre of our young
patient to the test. The forearm was laid on a table to which
the back of the hand was solidly fixed by the aid of a bandage.
A little sling containiog the thumb was fixed by a cord passing
over two pulleys and supporting a balance plate in which was
placed a weight of one kilogramme (Fig. 19). The experi-
ment lasted about half an hour, during which time tho thumb
was gradually raised^ and became more and more detached
from the index finger. After the experiment the thumb
immediately returned to its first position without any appear-
ance of fatigue, and quite as firmly as before.
During all the time the pneumograph applied to the front
of the chest registered every respiratory movement, and
this was what the tracing revealed. The respiration was
' See p. 14, et tea.
96
EXPERIMENT.
regular, not too deep, eqnal from the commencement to the
end, quite normal ; there was nothing, therefore, absolutely
nothing which recalled the respiratory trouble that charac-
terises the phenomenon of effort (Fig. 20, A, b).
For the purpose of comparison, a vigorous young man,
one of our clinical clerks, was placed exactly under the same
Fig. 19. — ^Experiment intended to verify the reality of the coutractnre
of the hand.
conditions. He voluntarily placed his hand in the peculiar
attitude presented by the contracted hand of our young
patient. The thumb was applied tightly against the index
finger at the outset of the experiment, it was submitted to
the same continuous traction during the same space of time,
that is to say, half an hour. It yielded little by little, and
became separated by degrees from the index finger against
the will of the experimentalist, who resisted all the while.
There was nothing up to that time to distinguish the
simulator from the patient, but it is in the respiratory
tracing where the contrast becomes manifest. At first, that
is for the first few minutes, the respiration was equal and
regular, but it soon became disordered, the respirations
PNBOMOGUAPHIO TEBT.
became prolonged, marked by deep depressioiiB) and sepa-
rated by large flat-topped curves. It was then that the
phenomena of effort became evident. (Fig. 20, c, D.)
F10. 10. — The Itnea i. and B represent tlie respiratory movements at
the patient ; the lines c and s those of a simalator. Read from left
L.
Thns you see, by an experiment of this kindj that fraud,
if it was a fraud, would have been easily recognised, since we
have in the study of the respiratory curve the means of dis-
covering it.
Evidently it is not poasible to surround oneself with too
many guarantees, in clinical stndiea of hysteria. But please
to notice, gentlemen, that this test, to which we have ^u.t
98 MALE HYSTBBIA.
the little girl, is a sort of crucial experiment ; we have
already collected numerous and sufficient proofs of the
legitimacy of the affection.
I think that I have sufficiently insisted, and that it is well
established in your minds, that the phenomena which we
have studied together in the preceding lecture are perfectly
legitimate pathological phenomena, in which the will of the
patient counts for nothing, absolutely nothing. And now I
hope to enable you to recognise in a minute that what has
just been said concerning the little girl, can be equally
applied, step by step, to the case of the male subject whom
we are now going to consider more particularly.^
At the commencement, it will not be out of place to say a
few words relative to the hysterical neurosis, in so far as it
affects the male sex.
And firstly, does hysteria occur in the male sex ? Yes,
undoubtedly, and it is met with much more frequently than
would at first be supposed. This subject, male hysteria,
is one of those which have been specially investigated by
physicians of late years. Thus, one is able to count not less
than five inaugural dissertations on this special subject pre-
sented to the Faculty of Paris between 1875 and i88o.
Briquet in his excellent work has stated that for every
twenty hysterical women, one man is met with, at least in
Paris, affected with the same malady. This figure I confess
appears to me to be a trifle too large. M. Klein,^ the author
of one of the theses, to which I have already alluded, and
which was written under the supervision of M. Oilier, has
been able to collect from different authors seventy-seven cases
of male hysteria, to which he has added three other personal
observations, bringing the number up to the respectable
total of eighty cases. Hence one is bound at least to con-
clude that hysteria in men is not such a very rare affection
as is generally supposed.
^ The patient was subjected to the repeated application of a magnet, and
the contracture finally disappeared. In the lecture of Januaiy lath, 1883,
M. Charcot was able to show the patient completely cured of her deformity ;
but still preserving the permanent stigmata of hysteria as described above.
— Ch. F. • P. 77.
MALE HYSTEBIA. 99
Another fact is shown in the same work; namely, that when
it occurs in men, hysteria is very often hereditary. This
circumstance occurred twenty-three times out of thirty. It
is generally maternal heredity, and similar^ heredity ; thus
it frequently happens that hysteria in the mother begets
hysteria in the son.
Another general rule derived from a perusal of these various
contributions, is that the hysterical symptoms in the male
appear most frequently, at an adult age, after fourteen years
at any rate, and according to the opinion of M. Reynolds,
who has studied this question in London, between twenty
and thirty years of age, or it may be later. Without doubt,
hysteria in the male may begin in the child before puberty,
from five to fourteen years; but hysteria is more common
in the male adult. And here is another point worthy of men-
tion ; those adult men who are a prey to the hysterical
neurosis do not always present, far from it, feminine charac-
teristics ; they are, at least in a great number of cases,
robust men presenting all the attributes of the male sex ;
they may be Boldiers or artisans, married and the fathers 6f
families ; men in whom one would be very astonished, unless
forewarned, to meet with an affection considered by most as
an exclusively feminine disease.
Lastly, I should add that in man, as in woman, the
neurosis may manifest itself in a masked or latent form.
It is perfectly well established, on the other hand, that it
can appear in man, endowed with all the attributes belonging
to the type of hystero-epilepsy, hysteria major, great hysteria
[la grande hysteric] . Last year I cited several cases which
were very appropriate illustrations of these points. Time does
not permit me to say anything just now touching the analo-
gous mental modifications in the two sexes. I must confine
myself to a statement of the following facts.
I. Sensorial and sensitive hemiansesthesia^that stigma
which almost surely characterises the hysterical condition,
after one has carefully excluded certain affections which
occasionally produce it (focal capsular lesions, plumbism,
* Vide p. 84.
This "book Is tiKe -pvov^^ o
ooopm Tffiii^feA. ^^'v^—
100 MALE HYSTEBIA.
alcoholism) — ^in a word^ hysterical hemiansBsthesia^ are met
with in man just as well as woman. Though it does not^
perhaps^ amount to a retraction of the visual field for luminous
perception^ or to the transposition of the limits of the visual
field for colours. These are not met with in like frequency.
2. The ovarian phenomenon [ovarie], one of the most fre-
quent symptoms of feminine hysteria^ is usually wanting in
the male ; but in them, in some cases at any rate, pressure on
the testicle, when it is retained in the canal, provokes or
arrests an attack.
3. Instead of the ovarie, we find in men hysterogenic
points, having the same characters as in women; but in
him the points of election are chiefly in the bregmatic region,
or on one of the sides of the chest or abdomen, and a very
favourite place is in the left flank.
4. The series of phases of the severe attacks of hystero-
epilepsy [hysteria major] are found equaUy in man and in
woman. (See amongst others the cases of MM. Bourneville
and d^Olier, of M. Fabre (of Marseille), without counting
the four or five cases of the same kind that I have person-
ally observed.)
5. Paraplegic or hemiplegic paralysis, with exaltation or
diminution of the tendon-reflexes, is a phenomenon which is
occasionally seen; much more frequently, it may be said,
than contracture, which seems to have been rarely met with.
But you ought not to expect to find all this assembly
of phenomena united in one male subject. The hysterical
neurosis can be present, and undoubtedly does very often
appear in the male without its great classical attributes, that
is to say, in a masked form, just as it does in the patient
who is about to occupy our attention. I hope, however, to
be able to convince you that, in spite of the absence of its
chief attributes, it is nevertheless with hysteria that we are
deaUng, nothing but hysteria.
The patient is a man 34 years old, a blacksmith, father
of four children, robust enough, and without any sign of
effeminacy. I may tell you at once that we have not been
able to find in him any antecedent taint of a neuropathic
order, neither hereditary nor personal ; no moral emotion can
CASE. 101
be ascertained as tlie actual canse of the complaint^ andj
indeed^ no other cause of any sort excepting the bum. On
June 26th last a bar of iron heated to a white heat touched
his forearm and left hand. The bum^ though slight^ took six
weeks to heal^ and at the present time there remains a
violet-red patch of 3 or 4 centimetres [ij inches] broad, and
10 or 12 long [4 or 5 inches], occupying the lower part
of the forearm and the back of the hand. The accident
does not seem to have caused much emotion, and the con-
tracture does not seem to have followed the injury imme-
diately ; strange to say it became developed gradually. In
the history of hysterical contracture due to a traumatic cause
this is an exceptional circumstance. A few days after the
accident, says he> his arm felt heavy, it became difficult to
bend his fingers, feeling as though they were benumbed ;
but as for the contracture, it came on without the interven-
tion of a fresh cause seven weeks later.
It was on August 15th that he felt pain in the arm, and
he could not sleep ; and the next day his hand presented
the characteristic interosseous deformity, although the thumb
was unaffected. Then, the following day, flexion of the
fingers came on, and finally the thumb became firmly applied
to the fingers. Since then we have seen flexion of the
wrist, and then pronation of the forearm, successively occur.
Let us study this singular deformity of hand a little more
closely. It consists you see of a permanent contracture of
certain muscles, a contracture so pronounced that it resists
every attempt at reduction, and which for three months has
not ceased to exist, not only during the day, but also, and
on this point I lay much stress, during the night. The
shoulder and the upper arm are free, the forearm is in a
state of pronation. The hand is flexed on the forearm ; the
four fingers are fiexed to such an extent that the nails dig
into the palm of the hand. The fingers are strongly pressed
against each other, and the thumb is strongly pressed against
the posterior surface of the second phalanx of the index finger
(Pig. 21).
Here, the most simple physiological analysis shows that
102
PHYSIOLOGICAL INVESTIGATION.
it is chiefly by the action of the median nerve, which sup-
plies the superficial and deep flexors of the wrist, that this
attitude is produced. But the ulnar nerve also plays a part,
for the adduction of the fingers is due to the action of the
interossei. It may be added that there is also contracture
of the extensors, as in all spasmodic contractures.
Observe this attitude of a closed, energetically closed, fist,
complicated with a flexion of the hand, which is also very
forcible. It is, you will notice, an exceedingly forced atti-
tude, an attitude difficult to preserve even for a short time
(Fig. 21).
Fi0. 31. — Contracture of the left hand. (Drawing by M. P. Richer.)
This is a favorable opportunity to remind you of an
ingenuous observation of Duchenne. You know that the
extensors of the fingers and those of the entire hand are
in a sort of antagonism. If you bend back your closed
hand as much as possible, and if you then endeavour to
extend the fingers, the hand becomes slightly flexed. It
is because the effect of extending the hand is to shorten the
extensors of the fingers, and consequently to place them in
a situation less favorable for their action ; whereas on the
contrary, when the hand is extended the conditions are
more favorable for the flexors to act. For an analogous
reason, if you flex the entire hand, the fingers can more
easily be brought into a condition of complete extension.
Let us now consider the combined action of the flexors of
the hand and those of the fingers ; here, also, there is a sort
of antagonism. Thus, in order to strongly flex the fingers
NOT SIMULATION. 108
and clench the fist, as in pagilism, the hand itself must be
extended^ and thus the action of the extensors favours that
of the flexors. If, on the contrary, the fist being closed,
you strongly flex the wrist, then you will notice that the
flexion of the fingers relaxes, and that the fingers have a
very marked tendency to become unbent. You can only
maintain the hand flexed in this position by the help of very
strong effort. This, gentlemen, is a fact of a sort which
dispels the idea of simulation. It is very much to be doubted
whether any resolute person could maintain, without hesita-
tion or intermission, for several hours, and still less for
several days, the truly pathological attitude of this patient.
It is certain, at any rate, that one cannot imagine a man
capable of maintaining it during profound sleep. In this
patient the attitude is preserved during sleep j M. Debove
has assured himself of it, and we have assured ourselves of
it on several occasions. We propose, moreover, to submit
the patient to the pneumographic test ; and I doubt not but
that we shall obtain the same results as in the case of the
young girl whom you have already seen.^
You will acknowledge, I think, that we have to do with
a perfectly legitimate pathological deformity, and not a
simulated one ; a true symptom, and not an imaginary one
artificially produced by the voluntary intervention of the
patient. It remains for me to show that, as in the case of
the girl, it is hysteria with which we have to deal.
I have already said that it is a masked form of the neu-
rosis; the patient has had no attacks, there are neither ante-
cedent circumstances, nor any psychic modifications to note.
But if we refer to the observation which was made by M.
Debove on October ist, and also that which was made by us
a week later we find the following symptoms : — i . A left hemi-
analgesia j pricking produces no pain but a simple sensation of
contact ; cold is less well perceived over the whole of the left
side of the body. 2. A very distinct lessening of the taste,
hearing, and smell, on the left side. We have taken regular
^ The experiment was made under the same conditions and with the same
result as in the young girl. It may be added, that under chloroform only
incomplete resolution of the contracture was obtained, though a complete
resolution had been formerly obtained by M. Debove at the Bicdtre Hospital.
104
HTSTEEICAL STIGMATA.
measarements of the visual field. On both Bidea there is re-
tmction, bat more on the left ; the visnal field for colours
is proportionately smaller, but the concentric circles which
represent the field for each colour have preserved their
relations and their reciprocal proportions ; there is no trans-
position ; no achromatopsia j no dyschromatopsia (Fig- 22).
3. All traces of a hysterogenic zone are wanting.
tBBATMKNt. lOS
What else coald it be but hysteria, in the absence of any
circumstance capable of being connected with a focal capsular
lesion, with plnmbism, or with alcoholism ? And in presence
of a contracture, a deformity of the hand, which considered
by itself carries with it the indisputable mark of a hysterical
origin, surely we are justified in concluding that in this
patient all the phenomena which have come under our notice
belong to hysteria, nothing but hysteria. They present a
truly striking analogy to those we have just met with in the
girl whom we have been studying.
Such was the condition of the patient on October 7th.
Since then, under the influence of treatment, the symptoms
have been slightly modified. A magnet was applied to the
side of the contracture, and then the sensation returned,
without transfer, to the left upper extremity, to the trunk,
the head, the arm, but not to the hand or the wrist. In
the midst of this treatment the patient went out, fearing,
for special reasons, lest he should be cured too quickly.
But he came back again a few days ago, and a fresh appli-
cation of the magnet was made, which has this time caused
the insensibility of the hand to disappear, and has produced
a numbness and commencing rigidity in the opposite side.
M. Debove was not far wrong in the fear which he expressed
of modifying too profoundly a situation which he knew that
I desired you to witness.
At the present time the contracture alone exists in this
man; the hemiansesthesia has completely disappeared, though
there exists a painful feeling of cramp in the contracted
part, which sometimes troubles his sleep. It is therefore
now essentially a latent case, but a case, nevertheless, of
whose hysterical nature, if I succeed in my hopes, you will
by-and-by have not a shadow of doubt.^
^ The repeated application of the magnet had no other result than bringing
back the sensibility to the contracted member. After that the patient was
a martyr to some veiy acute sufferings in the forearm and hand, due
partly to the penetration of the nails into the flesh, and also in a certain
measure to the contracture itself, for the flexor muscles especially were very
sensitive (these spontaneous pains had already been noted, although they
were less intense, when the patient was anaesthetic). As he persistently
asked for some surgical interference, preferring to submit to amputation
166 *BBATifB*r1?.
rather than undergo such pain any longer, M. Charcot decided to have
reoonrse to stretching of the nerve which was the main element in the
production of the deformity, the median. This operation, which had already
heen suggested hy M. Gillette, surgeon at the Bicltre, was performed on
Decemher 26th, 1882, hy M. Terrillon, surgeon at the Salp^tri^re. The
operation was performed in the upper part of the arm, and the median nerve
was twice raised on a director to the height of ahout 8 centimetres [three
and a quarter inches] from its natural position. After recovering from the
chloroform the patient experienced tingling, accompanied hy pains in the
forearm and hand, hut the contracture seemed to persist. After a sleep
of three or four hours he awoke without pain in the forearm and hand ;
the contracture had almost completely disappeared, although the fingers
could not he quite extended. Since then the situation has further improved
altili^augh the extension of the first phalanges is still incomplete, due, as it
would seem, to a retraction of the fihrous tissues ; and, moreover, the contrac-
ture is replaced Jby a paresis of the muscles at first attacked. When showing
the patient cured in the lecture of January 12th, 1883, M. Charcot made
the observation that, besides this retraction of the fibrous tissues which may
be seen sometimes after hysterical contractures of long duration, there exists
a peculiar glossy condition of the skin at the extremities of the fingers, and
particularly of the index finger, which seems to taper o£E like a spindle.
LECTURE IX.
A CASE OF SPINAL AFFECTION CONSEQUENT ON A
CONTUSION OF THE SCIATIC NERVE.
Summary. — Contusion of the left buttock. — Oontinuoua pams,
intermittent pains. — Eh/rly muscular weakness, — MuS'
cular atrophy. — Troubles of micturition^ of defsecation,
and of the genital functions. — Persistent atrophy of the
muscles supplied by the lesser sciatic nerve of the left
side. — Electrical exploration. — Paresis and atrophy of
the gluteal muscles of the right side.
Gentlemen, — The patient who is about to be brought
before you, and who forms the object of our lecture to-day,
offers in my opinion a very singular example of an organic
spinal affection developed after an injury, not of the cord
itself, but of a peripheral nerve.
I am well aware that there already exists among the
records of our science a certain number of facts tending to
show that certain lesions of the extremities, or of the nerve-
trunks, can be reflected back to the spinal centre, and there
determine alterations more or less profound ; but I doubt if
any of these facts present, in the same degree as this case,
the conditions of clearness and simplicity so necessary to
ensure conviction. This will become evident, I think, from
the account of the case, upon which I will enter at once.
The patient is a man, 40 years of age, vigorous, and of good
constitution, as you see. He is the father of two children.
A. I ought to mention, in the first place, that in his
history prior to the actual complaint, there is no circumstance
which can be said to have contributed to the development of
the spinal affection with which he is now afflicted, nor of the
sciatic pain from which he has suffered. This man has con-
108 CASE.
fessed tbat from 27 to 36 years of age^ when be was occupied
as a brewer^s drayman^ be indulged in numerous alcobolic
debaucbes ; be bas bad delirium tremens^ and bas evinced for
some time tbe cbaracteristic tremor of bands. But for the
last four years be bas much improved in tbis respect, and since
he has followed the occupation of a carpenter, be has lived
a sober life. It would appear tbat he has not had syphilis ;
be has certainly not had gonorrhoea ; he has not lived in a
damp room ; be bas never been particularly exposed to cold,
nor has he suffered from rheumatic pains.
B. The circumstances under which tbe pathological con-
ditions we are about to investigate came to be developed
are as follows. On December 28th, 1 881, in the carpenter's
shop where tbis man works, a joist of 3 metres 30 long,
[11 feet] terminating in a square surface whose side
measured about 10 centimetres [4 inches], which was being
moved rapidly in its long axis on a bench by another workman,
struck him violently on tbe left buttock. He thinks he can
indicate precisely tbe exact spot where be was struck ; and
be points to a place midway between tbe ischial tuberosity
and the great trochanter, a few centimetres below the lower
border of the gluteus maximus muscle. Even now, when be
presses on the spot tbe patient experiences a painful sensa-
tion. I should like you to remark, as a fact somewhat
strange, tbat no ecchymosis nor tumefaction appeared at the
seat of injury either on tbe same or succeeding days.
If you will be good enough to look at this anatomical
diagram, you will at once perceive tbat the place where tbe
patient was strtick corresponds precisely to tbe course of tbe
greater and lesser sciatic nerves, just after they have passed
through the great sciatic foramen. These two nerve-trunks
therefore were capable of being, they must have been,
affected by tbe blow.
Although injury to tbe gluteal region is not rare, far
from it ;^ yet it should be remembered tbat contusion of tbe
sciatic nerve is not a very frequent occurrence.
For such an injury to take place, certain very special
conditions are necessary. It may take place when the blow
1 Concerning tbis subject, see an interesting article by M. le Dr. Bouillj,
* Arch. g^n. de m^decine/ 1880, T. U, p. 655.
CASK. 109
is produced by the extremity of a beam or shaft, by the batt«
end of a gnn, or the comer of a piece of marble ; then the
ner^e is squeezed as it were between the external object
and the bony sarface, from which it is only separated by
the gemelli and the qnadratns femoris. But otherwise, and
this is most frequent, when the bnttock is struck by a more
or less flat surface, the nerve-trunk is protected. You see
that the conditions of a contusion strictly limited to the
sciatic nerve existed in the injury ; and there is nothing to
make us suppose that the coxo-femoral articulation has ever
been involved in any way whatever.
Next it is important for you to understand what were the
earlier symptoms in this case. These pointed to an affection
exclusively limited to the sciatic nerve. The symptoms did
not differ at the commencement, which was marked by
a sudden onset, from those which belong to ordinary
sciatica, ischias nervosa, Cotugno's disease. This will
appear from the following.
The blow was violent enough to throw the patient to the
ground. But he soon got up again, and at the same
moment he was seized with pain along the course of the
sciatic nerve and its branches. The pain which he experi--
enced from that moment, and during a period of about three
months, consisted of two elements :
(a) Continuous pam, localised along the course of the
nerve-trunk, particularly in certain places where it was
exacerbated by pressure. We have discovered the existence
of certain tender spots: i, s^ superior femoral point, seated at
the lower border of the gluteus maximus muscle between the
ischial tuberosity and the great trochanter ; 2, a peroneal
point, corresponding to the place where the nerve goes
round the head of the fibula ; 3, an external malleolar point ;
4, a dorsal point on the foot. On two of these points,
blisters have been applied, of which you can still see traces.
These pains were also accompanied by a permanent and
very painful sensation of tingling in the foot and the leg.
(6) Besides the constant pain there existed intermittent
pains, coming in twinges, severe, sudden, shooting, and
uniting, as it were, one fixed painful spot with another. These
110 EABLY MUSCULAR WEAKNESS.
painful twinges were accompanied by very evident clonic
spasm^ in which the leg would be suddenly flexed on the thigh.
The patient^s pains^ both fixed and intermittent^ the tinglings
and the spasms were especiaUy bad at night, increased by
the heat of the bed^ to such a degree that he acquired the
habit of passing his nights seated in a chair.
So far, we have drawn a clinical picture which could be
applied perfectly well to a case of idiopathic spontaneous
sciatica, of rheumatic or any other nature.
Even in the first few weeks which followed the accident,
a certain degree of muscular weakness was manifest in the
left lower limb, considerably impeding the walking and even
standing powers, which could not be entirely connected
with the fear which the patient evinced of increasing the
pain, for this functional impotence persisted even at a time
when the pain was becoming less. About three months
after the accident the pain had almost completely ceased,
but the muscular weakness had very greatly increased ; for
during the ensuing month it was impossible for him to utand
upright and preserve his equilibrium without the support of
objects around him. Atth^end of another month, the fifth
after the accident, he was scarcely able to walk a few steps
in his bedroom, by pushing a chair before him ; and it was
only at the end of six months that he was able to walk with
the aid of a stick, or without support for a quarter or half
an hour, and then not always without fatigue, such as he
can do to-day.
This muscular weakness of a limb after sciatica is not a
rare occurrence, as you know, when the neuralgic affection
has been severe. It is accompanied in such cases, as MM.
Bonnefin and Landouzy have remarked, by a more or less
pronounced atrophy of the muscular substance of the limb.
Ah atrophy of this sort certainly existed at that time in our
patient, although he did not notice it. You will see
directly what are the facts on which this assertion is founded.
Functional weakness and concomitant muscular atrophy,
in common sciatica, cannot, you are aware, be attributed to
prolonged repose. In fact, according to the observations of
M. Landouzy, it ajppears quite early in the disease (at the
AMYOTROPHY IN SCIATICA. Ill
end of fourteen days), after the onset of the first pains, and
even in those oases where the limb has not been placed at
rest. The theory generally accepted in order to explain
this muscular dystrophy in ordinary sciatica is, as you doubt-
less know, the following. It is admitted that the irritation,
with which the centripetal nerve-tubes are affected, mounts as
it were towards the spinal centre, by way of the posterior
roots, and extends to the cellules of the corresponding ante-
rior horns, which are consequently affected. The lesion,
slight or serious, dynamic or organic, of which they are the
seat, has the effect of sappreasing, for a shorter or longer
time, their trophic action. Consequently, the muscles which
are supplied by the centrifugal nerve-tubes, arising in
these ganglionic elements, become in their turn the seat of
a more or less transitory or permanent dystrophic lesion.
One of the proofs which are advanced, and it is not the least
powerful, in favour of the intervention of the spinal centre
in this mechanism is that the atrophy often attacks muscles
which do not come within the distribution of the nerve which
is affected by the neuralgia. Thus, for example, in cases
where the pain has occupied exclusively the trunk of the
great sciatic, the atrophy may be found not only in the
muscles supplied by this nerve, bat also io the gluteus
minimus and medius, which are supplied by the superior
gluteal coming directly from the first sacral pair.
However, contemporary observations tend to show that in
common idiopathic sciatica, functional weakness, and the
muscular atrophy which accompanies it, do not last very
long after the pain has disappeared. But it is not altogether
thus in traumatic sciatica, at least if one can judge from a
case which M. Seeligmiiller has published of sciatica coming
on after a difficult confinement which necessitated the use of
the forceps. In that instance the neuralgia was followed by
a paralytic atrophy affecting the calf-mnscles, which resisted
every measure employed for its relief. We shall see that
dystrophic lesions, quite as grave and involving a large
number of muscles, have occurred in our case.
But I wish now to dwell for a minute on a series of facts
which occurred about three months after the injury^ which
This hook is tKft -pfO'^i.-i ■ ^
OOOTEU mmCKVi ^"CiVJi^^So.-^
112 SPINAL INVOLVEMENT.
form a fnndamental part of all the mischief^ and prove unmis-
takably^ in this patient^ the participation of the spinal
centre.
Well^ about May 15th, at a time when the pains were
becoming less^ though the muscular weakness was increasing^
the patient experienced a painful feeling as of a bar across
the lumbar region^ extending to both sides^ and lasting for
several days. Two or three days afterwards he became
unable to micturate. The next day he urinated drop by drop^
involuntarily, and without kuowing it. Then he went to
the Necker Hospital, where he was seen by M. Gnyon, and
a catheter was passed. It was proved there that he had no
urethral retraction, no enlargement of the prostate gland —
facts which later explorations have confirmed. Since that
time the patient has continued to pass a catheter two or
three times a day ; when he neglects to do it, the urine runs
away drop by drop. At the present time the condition
in this respect is somewhat ameliorated ; he sometimes
urinates voluntarily, though not without effort. But most
frequently he is obliged, as formerly, to use the catheter
regularly.
You will not fail to perceive that this persistent incon-
tinence of uriue necessarily implies an involvement of the
spinal cord. It is almost possible even to localise the lesion
within a very little. The region referred to is the one
where experimentation (Groltz, Budge) has placed the centre
of the vesical reflexes ; it occupies the inferior extremity of
the lumbar enlargement, and corresponds to the point of
emergence of the four last sacral nerves.
You doubtless know that the experiments to which I
allude localise the centre for the muscles of the rectum, and
those also for erection and ejaculation, in the same region.
Well, the clinical facts show that in this patient these two
centres are also affected. In fact, the same day when the
incontinence of urine commenced, he had also incontinence
of faeces, and it still exists to a certain degree. It should
also be added that erections were absent about the same
time, and are still wanting.
Here is a series of symptoms which, I repeat, demonstrate
beyond doubt the existence of a spinal lesion; and this
AMYOTROPHY. llS
lesion^ it may be affirmed^ is not purely dynamic. We have
to do with a material lesion^ anatomical^ probably of an
inflammatory nature ; in shorty a myelitis.
A thorough examination of the patient's lower limbs will
furnish us, moreover, with additional and weighty arguments
in support of this statement.
The patient was admitted into the Salp6triere on Novem-
ber 8th last, in the same state as you see him now. He
habitually walks with the aid of a stick, which he holds
in his right hand. But it is possible for him to walk with-
out support for about half an hour ; then he sufEers extreme
fatigue, especially in the left leg, and he is absolutely
obliged to stop. It is curious that the left limb only should
be complained of by the patient. Nevertheless the right
inferior extremity is also seriously involved, as we shall
see directly.
An examination of the left inferior extremity reveals the
following. The limb, compared with the right, is somewhat
wasted in every part ; according to the measurements, there
is a difference of several centimetres in favour of the
corresponding parts of the right side.
The leg and the foot are cold and mottled with red
spots, besides which the foot is slightly tumefied. This con-
dition reminds us of what is seen in certain cases of long-
standing infantile paralysis. The sensibility, especially the
electric sensibility, is lost over nearly the entire surface of
the left limb. The cutaneous reflexes are normal on both
sides.
The patella-reflex is exaggerated on the right side, normal
on the left. When you strike the left patella tendon, the
patient being seated, it produces a curious phenomenon
which probably also indicates spinal intervention ; at each
stroke the right thigh is seen to go towards the median line
with a distinct movement of adduction.
Now let us proceed to an examination of the movements of
the left leg. First of all as to the muscles supplied by the
lumbar plexus, which have preserved their normal power,
(a) In the muscles supplied by the crural nerve, the move-
ment of flexion of thigh on pelvis, performed by the psoas
114 ACTION OF GLUTBI MUSOLBS.
and iliacns^ is preserved and is forcible; movement of
extension of leg on thigh are also normal, (b) Movements
of adduction are also normal.
It is easy to see^ on the other hand^ that the muscles
supplied by the greater and lesser sciatic nerves, the two
nerve-trunks simultaneously contused, are, for the most part,
profoundly affected, (a) The gluteus maximus is soft and
flaccid. You are aware that, according to Duchenne, these
two muscles are not of much use in standing, but come into
play in movements requiring energetic muscular action, such
as in the act of mounting a chair. You see that our patient
is unable to perform this feat without help, and even then
he prefers to do it with his left leg. (6) The posterior
muscles of the thigh^ flexors of the leg. (c) The muscles
which produce plantar flexion, and dorsal flexion of the foot
are also profoundly affected. It is impossible, for instance,
for the patient to support himself on tip-toe.
Thus all the muscles supplied by the great or lesser
sciatic nerves, or almost all, are seriously involved. Such a
muscular weakness might doubtless be explained, by itself,
by supposing the existence of a lesion of the motor nerve-
tubes, developed in consequence of the contusion below the
point struck. But this explanation is insufficient when it is
borne in mind that the gluteus medius and minimus of this
same left side also participate in the alteration, and that
these muscles are supplied by the superior gluteal nerve,
which is derived directly from the upper branches of the
sacral plexus.
It is known, chiefly by means of Duchenne's researches^
that these muscles have the action, both in standing and
walking, of flxing the pelvis in such a manner as to prevent
its inclination to the right or the left, according as the
muscles of the left or right side respectively are in action.
If you observe the patient in a standing position, you will
at once perceive that the iliac crest of the right side is on a
lower level than the iliac crest of the left. The pelvis is
therefore inclined towards the right. This right-sided incli-
nation corresponds also to the relative lowering of the right
great trochanter, and the lowering of the corresponding
gluteal fold. It should be added that the right shoulder is
CASE. 115
lower than the left, and that the spinal axis is rightly inclined
towards the right. This inclination of the pelvis towards
the right side, of itself enables us to suspect a weakness of
the left gluteus medius and minimus muscles, whose function
it is to lower the left iliac crest so as to place it on the same
level as that of the right side.
This weakness is even more obvious if the patient raises
his right foot from the ground, as in taking the second step
in marching; you see then that the pelvis and the great
trochanter of the right side become lowered, even more
than it was just now. Under normal conditions, at the
moment when the right foot starts for the second step in
marching, the pelvis, owing to the action of the left gluteus
medius, ought to undergo a slight movement of lowering on
the left side, and elevation on the right ; but this is not the
case here, quite the contrary.
When the patient walks, this failing of the gluteus medius
is brought out very clearly at each step by a very pro-
nounced lowering of the iliac spine and trochanter of the
right side ; and as a result the pelvis undergoes a series of
large oscillations, quite obvious and significant.
The gluteus minimus and medius muscles are therefore
affected, and profoundly affected. Now, these muscles are
innervated by the superior gluteal nerve, which in its origin
has nothing in comnjon with the great and lesser sciatic
nerves. This participation of the gluteal nerve can scarcely
be explained except by the existence of a spinal lesion.
The existence of this spinal lesion, already evidenced by
the paralysis of the vesical and anal sphincters, and by
weakness of the genital reflexes, is still further shown when
we carefully examine the right lower extremity, in which
there is a marked weakness of the gluteal muscles and most
of the muscles of the leg.
This paresis of muscles of the right side is accompanied,
as on the left, by an atrophy, an easily appreciable diminu-
tion of volume, though it is not so striking as on the left
side.
It is expedient that we should consider for a moment this
atrophy of six months' duration. The question to settle, and
116 ebb's beaotion.
we shall see how interesting a one it is^ not only from a
theoretical but a practical point of view^ is this^ is the
atrophy that we have here a simple one, unattended by
alteration of the fibres ; or is it a degenerative atrophy, one
which is attended by a profound modification, a degeneration,
of the muscular elements ? You know that the prognosis
depends, in a measure, to the solution of this question. Simple
atrophy usually yields under the employment of appropriate
means, whereas in the degenerative atrophy treatment is
powerless.
Are we in possession of the means of clinically making
this distinction ? Yes, certainly ; the means consist in a
methodical electrical exploration, which to be complete
should be made successively by the aid of both kinds of
current, faradic and galvanic.
In the galvanic exploration (constant current) I may
remind you that one of the poles, the indifferent one, is
applied to the chest, and the other is applied to the nerve or
muscle which it is wished to examine. The latter can be
made to become at will either the positive pole (An. Anode),
or the negative pole (Ka. Kathode). You are aware that
under normal conditions muscular contractions are produced
only at the closing (S. Schliesung), or opening of the
current (0. CEffnwag). Now, in order to obtain a single
contraction (Z. Zuckung) in the normal state with the
weakest possible current, say ten elements, the pole
used must be the negative one, Ka, and the contraction is
thus produced at the moment of closing the current. This
is expressed in electro-physiological language by the formula
KaSZ. To obtain a contraction with the other (the positive)
pole, An, it is necessary to increase the number of elements,
increase them, for example, from ten to fifteen. These results
are represented thus, KaSZ>-AnSZ, and form part of the
formula for the normal reactions. If one finds on exploring
a muscle that AnSZ can be obtained with a larger number
of elements than suffice to obtain KaSZ, the result is repre-
sented by AnSZ > KaSZ. It is then said to be an inversion
of the formula, which inversion forms part of the reaction
of degeneration ; or, in other terms, a reaction which indicates
a more or less profound alteration of the muscular tissue.
SIMPLE AND DEGENERATIVE Al?ROPflY. 117
We shall apply these principles in a minute to the inves-
tigation of the trophic condition of th^ muscles in this
patient ; but it should first be shown what it is that con-
stitutes^ from an electro-diagnostic point of view^ simple
atrophy of the muscles, and their degenerative atrophy.
1 . In simple atrophy the f aradic and galvanic excitability
are only slightly modified. In both cases a stronger current
is required to obtain a reaction than in the normal condition,
but the results are parallel, there is no modification of the
formula KaSZ>AnSZ. An example of these simple atro-
phies is seen after prolonged rest ; or, in certain dynamic
spinal affections developed as a consequence of articular
lesions.
2. Degenerative atrophy has been studied with great care
by experiments on animals, and after division of nerves.
It is shown by the experiments of Erb and Ziemssen, briefly
put, that absence of faradic reaction, and persistence with
modification of galvanic reaction indicates a serious con-
dition, though regeneration is possible ; but, if both galvanic
and faradic reactions are absent, it reveals a graver con-
dition, a degenerative modification of either nerve or muscle,
which is almost certainly irreparable.
In human pathology, gentlemen, these profound modifica-
tions of the electrical reactions, corresponding to a grave
condition of muscular nutrition, are seen in affections of the
peripheral nerves (division, traumatic lesions, &c.) ; and
also in spinal disease when the lesion is so situated that
the ganglionic elements, the so-called motor cells, are pro-
foundly altered or destroyed, as, for example, in infantile
paralysis after the period of possible restoration, or, again,
in central diffuse my elites.
Now let us apply these data to the case of this man.
The examination of the various muscles which are trophi-
cally and functionally affected gives the following results :
1. The crural nerve is faradically and galvanically excit-
able on both sides. The adductor muscles and the quad-
riceps extensor femoris also respond normally to both means
of excitation.
2. In the distribution of the branches of the sacral
118 ELEOTBICAL CONDITION.
plexus we find normal reactions on the right side. On the
left side the gluteus medius is faradically and galvanically
inexcitable. This indicates that the functional shortcomings
of this muscle are connected with an organic lesion^ and
consequently that the difficulty of standing which results^ the
inclination of the pelvis and of the trunk to the rights and
the bending to the right side when the right foot is raised
from the ground^ will probably persist as permanent infir-
mities.
3. What has just been said about the gluteus medius can
be repeated of the gluteus maximus, but this time both
sides are involved. These muscles, which are supplied by
the lesser sciatic, respond neither to faradism nor galvanism,
a reaction of degeneration, predominating on the left. There
is then scarcely a hope of procuring a re-establishment of
the function of these muscles.
4. With reference to the great sciatic nerve, I shall
confine myseK to mentioning the facts which relate to the
calf muscles, and the flexors of the leg on the thigh. On
the left side faradization has no effect ; galvanism only pro-
duces a slight and feeble response. On the right there is also
a reaction of degeneration, but less complete (AnSZ = KSZ) ;
here there remains some hope of ultimate restoration under
appropriate electro-therapeutic treatment. The same can be
said of the calf muscles ; flexion of leg on thigh, and plantar
flexion of the foot can without doubt be restored.
Thus, you see, electrical exploration has furnished us
with data for prognosis, at the same time that it has enabled
us to guess, to some extent, the degree of the spinal lesion.
It certainly occupies the lower lumbar region, and viewing
all the circumstances of the case is probably situated in the
central grey substance. There is no reason to believe that
the anterior or posterior white fibres are involved.
The posterior horns of the grey matter are not obviously
affected, for there is no modification of sensibility, but the ante-
rior horns are certainly involved to some extent in the region
corresponding to the origin of the branches of the lumbar
plexus. The alteration in the cells is not a profound one,
possibly it is dynamic. These cells are in a state of hyper-
excitability which I have proposed to designate by the name
TBOGNOSIS AKD TEBATMENT. 119
" atrychmnism," and which is capable of explaiaing the
exaltation of the patellar reflexes especially on the right side.
Bnt at the level of origin of the branches of the sacral
plexus the alteration of the ganglionic elements is more
profound; a certain number of the cells are modified or
destroyed, which corresponds with the serious alteration in
the gluteal muscles.
The spinal lesion which we have before ns, developed
under the influence of an injury, so far as one can judge
from the evolution of a morbid phenomena, has no progressive
tendency, the worst of the mischief is passed. One could
almost say that the disease is now quiescent, or perhapSj in
the case of certain nerve-fibres and cells, not completely
destroyed, there is a tendency towards recovery.
The treatment should be directed chiefly towards favouring
this restoration of the affected elements. The patient should
be advised not to resume the fatiguing movements of his
lower limbs which are demanded by his occupation for a
long time to come. It is known in fact that old and extinct
spinal lesions are sometimes re-awakened by exercise of the
limbs corresponding to the affected part of the spinal centre.
Thus in infantile paralysis of the left lower extremity it may
happen that the right lower limb may be attacked several
years later, in consequence of a forced march. As to medi-
cation, it should be chiefly directed to the trophic condition
of the affected muscles. We shall also advise methodical
electrization, faradic and galvanic ; massage ; and lastly
liydrotherapy, the influence of which not only on general
but also local nutrition, is undoubtedly one of the moat
beneficial methods of treatment.
L
This hook is thepr-op, ,
COOPER MEDICAL COLL:., .
SAN FRANCISCO, OAL
cwirf M iwt to he removed Jrovn the
Lihrai-v Room by <my peraon or
under auy yi-'-tmj^ lofiatwiw.
LBCTUEB X.
I. DOUBLE SCIATICA IN A WOMAN AFFLICTED WITH
CANCER,
n. CERVICAL PACHYMBNINGHTIS.
Summary. — I. Double sciatica; conditions wnder which this
affection occurs; diabetes , certain meningo-my elites ,
compression of the spinal nerve-trunks at the interverte-
bral foramina, — The pseudo-neuralgise of vertebral cancer.
— II. Hypertrophic cervical pachymeningitis; pseudo-
neuralgic period; paralytic stage; spasmodic stage. —
Illustrative case : recovery with retraction of the flexor
muscles of tJts leg. — Radical cure by surgical inter*
vention.
I.
Gbntlbmen, — The first patient who will bo presented to
you to-day will take your minds back to the history of
symptomatic sciatica^ which occupied our attention during
the last two lectures. It is a subject the practical interest
of which you will not fail to perceive, and this circumstance
will I hope sufficiently justify my dwelling on a few fresh
features of the affection that will be unfolded as we go
along.
A. The patient is a woman named D — , aged 6i years,
a workwoman, whose family and previous histories present
nothing worthy of note. About fifteen years ago she received
a blow on the right breast, and five years later, a tumour
began to develop in this region ; the tumour ulcerated and
eighteen months ago she underwent an operation. But, after
a month the disease relapsed, and it became necessary to
repeat four operations successively in the course of five or
CASE. 121
six months. But still, the growth returned. Lastly, the left
breast was attacked in its turn, and the patient was admitted
into that part of the SalpStriSre occupied by incurable affec-
tions, and placed in the ward reserved for cancerous cases.
Over the door of this ward might well be placed the inscription
which, according to Dante is found over the gates of Hell.
As a matter of fact these affections have proved, up to
the present time, to be beyond the resources of our art.
I will not delay by describing to you the distorted and
indurated cicatrix, and the scattered nodules, which disfigure
the chest of the patient. The interest lies in another
direction.
For the last four months the disease has assumed a new
phase. The general health has decreased, her appetite has
diminished, and she has lost flesh. But, this is the point
which particularly occupies our attention, a little later,
namely, about three months ago, she was attacked by pains
in the lumbo-sacral region, which came on only when the
patient was standing, or walking, or executing movements
in bed, and which disappeared when she was at rest.
Note well, gentlemen, this influence of the erect position,
and of walking, it will help us to determine the diagnosis.
The pains, instead of being circumscribed, soon invaded the
left lower extremity and spread along the course of the
sciatic nerve, where they became continuous; but much
stronger whenever the patient made any movement, or
essayed to stand upright, or to walk.
Soon afterwards, they spread to the right sciatic nerve.
Now it became a double sciatica ; there was pain on both
sides, at the buttock, at the level of the head of the fibula,
and over the dorsum of the foot ; it was increased by pressure
over certain points; and it was on the left side that her
sufferings were most acute.
(a) The patient, moreover, complained of pain in the fold
of the groin, on both sides. Thus there existed a double
crural neuralgia at the same time.
(b) Although the sciatica was not very intense, the pain
became worse on assuming the erect posture to such a
degree that walking was well-nigh impossible. Between the
spontaneous pain, which was almost absent when at rest,
122 CAUSES OP DOUBLE 80IATI0A.
and the pain produced by walking, there was a disproportion
which is not met with in ordinary neuralgia of the sciatic
nerve. Nevertheless there existed no indication of the
existence of a spinal lesion ; thus^ when in bed movements
of flexion and extension of the legs were forcible enough,
there was no exaggeration of reflexes, and there was no
trouble of bladder or rectum.
(c) Lastly, there is another fact which does not belong to
the clinical history of ordinary sciatica. When one presses
or percusses either over the sacrum or lumbar vertebrae,
acute pain is produced; it is here also that the pain
predominates when the patient holds herself upright, tries
to walk, or moves in bed.
What is the meaning of this pain along the course of the
two sciatic nerves ? Is it a common sciatica, accidentally com-
plicating the cancerous affection and, of itself without much
importance ? No, I believe it has quite another signification.
In the first place, the sciatic pain in bilateral. Now, all
clinical observers are quite agreed that double sciatica is
very suspicious of a symptomatic neuralgia, and is generally
connected with a more or less serious protopathic affection.
It cannot be inferred that unilateral sciatica may not sometimes
also be symptomatic. In this particular case, by reason of
the different anomalies that I have pointed out, it can be
affirmed that the case is not one of common sciatica but of
a symptomatic affection. But what is the cause ?
Let us pass in review the principal affections that can
give rise to double sciatica.
(a) In diabetes, it is not uncommon to observe several
different nerve troubles,^ among which should be pointed out
in particular, partial hyperaesthesiae, lightning pains, such as
I have already drawn attention to, and of which several cases
have be6n met with since,^ and symmetrical neuralgias*
occupying by preference the sciatic nerves. But, that
^ Beraard et F^r^, " Des troubles nerveux observ^ chez les diabetiqnes."
* Arch, de Neurologic,' 1882, T. IV, p. 336.
''' Eaymond, * Gaz. m^d. de Paris,' 1881, p. 627.
8 Worms, * Bull, de I'Acad. de M^d,' 2e serie, T. IX. Drasche, " Dia-
betische Keuralgien " ' Wiener med. Wo6cb,' 1882.
ANATOMY OF VERTEBRAL OANOER. 12S
diabetes is not the cause here is shown by an analysis of the
urine on several occasions : it does not give the faintest trace
of sugar.
(b) In certain spinal affections there exist pains along the
course of the sciatic nerves on both sides.
The pains of Locomotor Ataxy do not present the same
characters that are to be found here. In meningo-myelitic
affections we should have a paralysis or paresis of the limbs
and sphincters^ and other spinal symptoms which do not
exist in this case.
(c) If it is not the cord and its membranes which are
affected^ it must be the nerves themselves. What are the
most frequent lesions which by compressing the sacral
plexus, can produce a double sciatica ? A tumour growing
in the pelvic cavity ? But an exploration of the abdomen,
rectum, and bladder do not give any indication of its
presence. The lesion is elsewhere, and must be looked for
in the lumbar and sacral vertebrae. It is there that the
cancerous infiltration has occurred, and has produced the
alteration of the bones by which the nerves are compressed
in the intervertebral foramina ; and it is to this compression
that the pains along the course of the crural and sciatic
nerves must be attributed. That is a physiological and patho-
logical problem which it is easy to elucidate ; but it is more
expedient to enter into certain anatomo-pathological details.
My master Gazalis insisted long ago on this point, that
nothing is so common as the invasion of the bodies of the
vertebrae by secondary deposits of cancer, and especially
when the primitive lesion is situated in the breast, and when
it takes the form of scirrhus. When these secondary deposits
are limited to the bodies of the vertebrae, and are not extensive,
they remain latent. But they sometimes invade the entire body
of one vertebra, which in consequence becomes softened.
Sometimes the articular apophyses, and the lateral masses
which form the intervertebral foramina, are more or less com-
pletely infiltrated; and then the entire vertebra sinks, the
intervertebral foramina become narrowed, and the nerves are
compressed, although the meninges and the cord remain intact.
The consequences of this sinking and compression bQCom^^
124 CLINICAL HISTORY OF VBBTBBEAL CANCER.
evident according as the nerves of the brachial plexus^ the
intercostal nerves^ or the lumbar or sacral nerves are in-
volved ; often of one side only but sometimes of both sides
together.
If we admit this condition in our case^ it explains (i) the
bilateral nature of the sciatica ; (2) the participation of the
crural nerve; (3) the exacerbation of the pain when the
patient stands upright and walks ; as also the tenderness to
pressure or percussion in the sacral and lumbar regions.
The prognosis follows as a natural consequence ; it is not
necessary to insist on its gravity.
Before leaving this case allow me^ gentlemen^ to make a
few remarks relative to the clinical history of vertebral cancer.
1. It is rarely primary ; in general it is a secondary mani-
festation of the diathesis. Very often it follows cancer of
the breast, especially scirrhus, which may only manifest
itself by a simple indurated depression of the skin, of which
the patient is sometimes scarcely aware ; though it is not
exclusively after tumours of the mamma that it developes.
It may supervene in subjects attacked with cancer of stomach,
or of other parts.
2. If there exists a double sciatica with an undoubted
carcinomous a£Fection situated, for example, in the breasts,
it is no good operating ; it is a metastasis.
3. When we have to do with an intense and persistent
neuralgia in a patient of the age for cancer, this persistence
and intensity should attract attention, and one should always
examine the state of the breast, stomach, uterus, &c.
4. These pseudo-neuralgic pains are the most frequent
clinical revelation of vertebral cancer, but it should not be
forgotten that it is sometimes revealed otherwise. Thus, when
the body of a vertebra is invaded, it may happen that a
cancerous button projects into the spinal canal, and then
the cord is compressed. The result of this compression is a
spasmodic paraplegia which differs in none of its essential
features from that determined by Pottos disease, or by an
intra-rachidian tumour. It is not generally accompanied
by pseudo-neuralgic pains if the nerves themselves are not
attacked.
ANATOMY OP PAOHTMENINGITIS* 125
IL
The second patient that I present to you to-day illustrates
an affection known in spinal nosography under the name of
hypertrophic cervical pachymeningitis. The interest of the
case is twofold : firstly, the patient is cured ; and secondly, the
cure has been effected by appropriate surgical intervention.
And it is precisely this useful surgical intervention, in a case
of spontaneously developed spinal affection, to which I wish
particularly to direct your attention.
But allow me, gentlemen, beforehand to recall to your
minds in a few words the anatomical and clinical characters
of this affection, as I have described them in a communi-
cation made to the Biological Society in 1 871, and which are
to be found described more exhaustively in the thesis of
Mons. Jeffrey (1873).
(a) The post-mortem changes are comparatively coarse.
Formerly they were attributed to a hypertrophy of the
spinal cord ; which in fact, when covered by its membranes,
presents at the autopsy a swelling 5 or 6 centimetres long,
and almost completely fills the spinal canal. But the spinal
cord is not really hypertrophied ; the lesions consist (i) in a
chronic inflammation of the dura mater, which sometimes
presents a thickening of 6 or 7 centimetres ; (2) in an
alteration of the nerve-roots that traverse the inflamed
meninges, and which are themselves more or less irritated ;
and (3rd) the cord itself may be attacked in some degree
by a chronic inflammation, but the usual effect is a com-
pression, and resulting therefrom a descending degeneration
of the pyramidal bands, which change may be found down
to the lowest point of the lumbar region.
This anatomo-patholbgical outline, albeit very brief, will
enable you to understand the evolution of the clinical his-
tory, the principal episodes of which I shall now enter upon.
Let it be said at once that the malady is, so to speak, quite
an accidental occurrence, which seems to be produced some-
times by the influence of damp cold ,- it is not an hereditary
126 SYMPTOMS.
complaint like ataxy^and therefore there is nothing to astonish
one in jQnding that the affection is not accompanied by con-
stitutional diathesis.
As regards symptomatology^ three periods can be dis-
tinguished :
The first period, the neuralgic or paeudo-neuralgic period,
is distinguished by sharp pains, very severe, continuous, but
with exacerbations, seated in the neck, in the posterior part
of the head, and characterised by a sensation of constriction
at the upper part of the thorax. These painful phenomena
last four, five, or six months, and then disappear. It is the
theca vertebralis which is here the cause, or rather it is the
nerves passing through it, but not the spinal cord.
The second period, paralytic period, is characterised by
loss of power in the upper limbs. Cervical paraplegia
accompanied by miiacular atrophy, simple atrophy in some
muscles, degenerative atrophy in others. An interesting
peculiarity of the atrophic paralysis is that it specially attacks
those muscles supplied by the median and ulnar nerves,
whereas those supplied by the radial are relatively sound.
As a result of the predominant action of these last we get a
special deformity of the hand, a radial deformity which we
designate by the name of the preacher's hand. How can
this be explained ? Do the nerve-tubes of the radial spring
higher up or lower down than those which constitute the
ulnar or the median, and are they not complicated to the
same degree in the alteration ?
The third period. Sometimes matters remain in this con-
dition, and by and by the malady ends in complete cure,
sometimes indelible atrophic lesions of the muscles remain.
But generally speaking the cord is more or less involved by
the products of meningeal inflammation, or even becomes
invaded by the inflammatory process, and a transverse mye-
litis supervenes leading to a secondary degeneration ; and
then there results a spaamodAc paraplegia with involvement
of the bladder and rectum.
But the paralysis of the lower limbs is not an atrophic
paralysis like that of the upper extremities, it is not in fact
due to a lesion of the roots or anterior horns, but solely a
degenerative alteration of the pyramidal bands. It is,
CASE. 127
therefore, a spasmodic paraplegia, and not an atrophic para-
plegia. Note this peculiarity, that the flexion of the lower
limbs is very pronounced, such as is seen specially in para-
plegia due to compression.
We are now in a position to draw inferences from the
actual facta. It is an ordinary case, quite typical, save on
points of secondary importance. Here in two words is the
patient^s history. She was attacked at the age of 33, after
a sojourn of several years in a cold and damp habitation ;
the painful period lasted six months, the pains occupied
not only the upper extremities, but also the thorax ; the
dorsal part of the cord was therefore involved.
The paralytic period commenced in the upper extremities,
and soon afterwards the lower extremities were attacked.
There existed during more than a year an atrophic paralysis
of the upper extremities with radial deformity of hand, and
a spasmodic paralysis of the lower extremities with excessive
flexion ; the heels touched the buttock. At the end of a
year, perhaps under the influence of treatment, which chiefly
consisted in the application of the cautery to the spinal
region, or perhaps spontaneously, there occurred a pro-
gressive resolution of the paralytic and atrophic phenomena
in the upper extremities. The movements of these limbs,
both of the forearm, arm, and shoulder, returned ; the
muscles increased in bulk, and the deformity of hand
gradually disappeared. In the lower extremities, ame-
lioration occurred almost concurrently; the exaggeration
of the tendon-reflexes disappeared, the muscular rigidity, or,
in other words the contracture, disappeared, and free move-
ment returned to most of the joints, excepting the knees.
At this time there was no longer a flexion of the knees
to an acute angle as formerly, but flexion to an obtuse
angle. And this flexion was not due to a contracture, because
the movements of extreme flexion and some of the move-
ments of extension could be produced in the joint. But
when it was desired to go beyond a certain limit, one met
with mechanical resistance, so to speak, whose seat appeared
to be in the popliteal space. We thought that the obstacle
was situated in the shortened flexor tendons, and also in the
128 SUEGIOAL TEBATMBNT.
thickenings induration^ and retraction of the periarticular
tissues.
Whatever it was due to, complete extension was impossible,
and there was an invincible obstacle to standing and walking.
There was reason to believe that an appropriate surgical
operation would restore to the limbs their normal movement
of extension ; for I had already seen in certain cases of
rigidity due to fibrous retractions supervening in a course of
paraplegia from Pottos disease, good results produced by
section of the fibrous bands or of the involved tendons. I
then consulted my colleague Mens. Terrillon, who confirmed
my opinion, and was desirous to undertake the operation.
The patient was placed in his wards, which she only left a
few days ago. Here is a note made by Mons. Terrillon
which informs us of the principal incidents which happened
while the patient was under his care.
State on admission, — The legs are in a state of semi-
flexion, the skin at the level of the knee, and even the lower
part of the thigh is shiny, smooth, and adherent to the
deeper parts. When attempts at extension are made it is
impossible to obtain more than a limited movement, and on
each side of the popliteal space the tendons of the semi-
membranosus and semi-tendinosus, and of the biceps, can be
felt to be hard and prominent. There can also be felt in this
position a considerable thickening of fibrous tissue which forms
a hard non-circumscribed mass, and which appears to be
the principal obstacle to the bending of the limb. The
patella is firmly fixed against the condyles and is almost
immovable by reason of the peri-articular fibrous induration.
From an examination of the exterior of the joint, and of
the few movements which are still left in the knee, it is
almost certain that there does not exist any intra-articular
adhesion ; and that the impossibility of bending it is due to
the peri-articular fibrous deposits.
July 4th. — The patient was put under chloroform, and the
tendons indicated above on both sides of the popliteal space
were divided. At the same time attempts were made to gently
bend the knee ; but without using much force, because, in
spite of the division of the tendons, the resistance of the
BEMABES. 129
fibrous mass occupying the popliteal space was considerable.
A padded splint was then applied.
July 2otli. — The patient was again anaesthetised. Forced
extension was attempted and the fibrous tissues at the back
of the joint gave way with a loud creaking sound, but complete
extension was not accomplished for fear of injuring the
popliteal artery, which was probably involved in the fibrous
tissue. It was noted that the right leg was a little longer
than the left. The two legs were next placed in plaster
splints reaching up to the fold of the buttock.
July 30th. — Further attempts at Extension were made and
the splints reapplied immediately. The splint was taken oS
on the 15th August. From this time the patient has been
able to stand upright and walk a little ; and since then the
progress has been uninterrupted.^
By way of summing up ; the study of the patient who
has just been presented to you furnishes us with several
valuable pieces of information. I will confine myself to
mentioning the following :
I. Hypertrophic cervical pachymeningitis is not incurable.
The paraplegia which results, although it may be very
marked and accompanied by flexion of the leg on the thigh,
and of long duration, can be cured.
II. But, just as in the case of Pottos disease, and probably
also in other forms of paraplegia by compression, the long
persistence of the flexed position of the lower limbs has
sometimes the effect of determining in the peri-articular
tissues of the knee, and in the region of the popUteal space
an induration, and a retraction which, although the spinal
affection is cured, prevents extension of the joint.
III. Surgical intervention is necessary in such cases. It
alone is able to deliver the patient from a complication
which by itself would for ever prevent him standing or
walking.
^ For several months the walking continued to be difficult because of the
weakness of the muscles after such prolonged inaction. Under the influence
of methodical electrisation their functions have become re-established, and
at the present time (May 4th, 1883) the patient is able to walk round the
courtyard of the Salpdtri^re and to accompUsh a kilometre without fatigue. —
Ch.F.
LECTURE XI.
ON A CASE OP WORD-BLINDNESS.
Summary. — DeHnition of aphasia — Word-blindness [Wort-
blindheit). — Oase; sudden onset ; right hemiplegia and
motor aphasia which passed away ; hemianopsia ; incom^
plete alexia ; importance of ideas furnished by movements
in mental reading.
Gentlemen, — In the following lectures I propose to under-
take the study of aphasia from a clinical point of view.^ It
is scarcely necessary for me to remind you that in this task
we shall enter upon difficulties of no ordinary kind.
In fact, the term Aphasia, considered in its widest
acceptation, comprehends, as you know, all the many various,
and at times subtile, modifications which are presented under
pathological conditions by the faculty which man possesses
of expressing his thoughts by signs {Faeultas signatrix of
Kant) .
Now, it is scarcely necessary to mention that this faculty,
or rather these faculties, which enable us to communicate with
those around us, are without doubt connected with the
highest functions of our central nervous system. Indeed, if
if they do not, properly speaking, form an integral part of
the intellect itself, they have most certainly, as their derange-
ments show, a very decisive influence on the exercise of its
functions. You will understand from this that in such a
delicate analysis we shall have at each step to invoke
^ The lectures to which allusion is here made were delivered during the
summer of 1883, and were published in Italian by Dr. Kummo (* Differ-
ente forme d'afasia/ Milano, 1884) ; the analysis has been given by Dr. Marie
in the * Eevue de M^decine/ T. Ill, 1883, p. 693. The thesis of M. le Dr.
Bernard (Paris, 1885) contains the substance. The lectures themselves will
be revised and published later on.
WORD-BLINDNESS. 131
the aid of notions belonging to the domain of psycho-physio-
logy> ^7 whose help alone we can find our way along these
difficult paths.
But, verily, circumstances seem to have favoured our
efforts, for there is a series of cases, collected by chance in
our wards at the present time, which are truly remarkable,
by reason of their simplicity and freedom from complication.
They will enable us to study the fundamental forms of the
group of symptoms which we call aphasia, disentangled, or
almost so, from every admixture and complication ; and
consequently in an exceptionally favorable condition for a
physiological analysis.
The clinical exposition of one of these cases will form the
object of our lesson to day ; the further development of the
subject will be postponed to another lecture. The case I
allude to offers, if I am not deceived, one of the finest
examples that can be seen of that form of aphasia which has
so recently been studied as a distinct kind by certain authors
under the name of Word-blindness {Wortblindheit, Kussmaul).
I shall not now undertake to define what is understood
by this term ; its meaning will become obvious from the
description as we go along.
M. H. P — , 8Bt. 35, is the proprietor of a linen drapers'
shop at T — . He has been the head of the establishment
for four years ; before that he was the principal assistant in
a shop of the same kind. He is a man of average culture,
his education having been directed towards commerce from
early life. He came into this hospital hoping to be more
thoroughly examined and treated, and he has been under
observation several months. He is intelligent, and he leads
an active life ; he speaks and writes correctly enough. As
he directs his shop himself, he speaks much and writes
many letters each day (twelve or fifteen per diem). He
used to occupy his leisure hours in reading novels and news-
paper articles ; he used to read very quickly, and he had a
habit of moving his lips, pronouncing his words in a low
voice while he read. He has been married ten years, but
he has no children.
As to his family history we have not found any nervous
This booh is tKe jyroj^^v ., ;
ooo?m miaiiioK\i ^vi^i:^.:vc3.>^>
6/WM FRAUG\SC\r\ o^\
132 OASB OF
antecedents in the family; his father is still living and
well ; his mother died of disease of the heart or chest.
Nor does his previous history offer anything of importance.
He was in the Campaign of 1870, in the army of the East,
and he suffered much but was never ill. He has never had
articular rheumatism, nor palpitation of the heart, either
before his accident or since ; and at the present moment his
pulse is regular (80), his heart of normal volume and without
any murmur. The only affection which is worthy of being
mentioned is migraine, which ever since he was 15 years of
age has troubled him three or four times a month. These
migraines, which have existed both before and since his
accident, are sometimes sufficiently severe to oblige him to
lie down for one or two hours. They present the following
characters : (a) the pain, before it becomes general, usually
occupies the right frontal region a little above the eyebrow ;
(b) it seems to be unaccompanied by any affection of vision ;
there is neither transient hemianopsia nor scintillating sco-
toma ; (c) there does not exist any symptom of ophthalmic
migraine accompanied by tingling in the arms or hands
nor by temporary aphasia ; (d) these headaches are never
followed by vomiting.
So much for the pathological antecedents. You see there
is nothing to note that seems to be connected with the
present malady, unless perhaps it be the headache ; that is a
point we shall study more particularly in what follows.
Now let us pass to the history of the actual malady. On
the 9th of October last, when he was out fox-hunting, he
suddenly saw an animal half hidden in the cover ; he took it
for a fox and shot it dead. Unfortunately it was not a fox,
but the dog of a friend, to which this last was much
attached. There were many lamentations and tears on the
part of the owner, and P — was profoundly moved by the
death of the dog and at the distress of his friend. However
he continued the hunt, though without interest, ate but little
at luncheon and without appetite. After luncheon the shooting
was resumed ; a rabbit went by, P — took aim, but at that
moment he fell to the ground. He was paralysed on his
right side, and a few minutes afterwards lost consciousness.
WOBD-BLINDNBSS. 138
The patient^s recollection of what occurred immediately
after the accident is very vague. He remembers that he
was carried to the railway to return to T — ; and during
the transit, which occupied about an hour, he lost all con-
sciousness. He regained his senses for a moment at the
station of T — , which he recognised, but shortly afterwards
he again became unconscious. We learn from his friends
that he was put to bed immediately after arriving home, and
that he slept all the night.
On the loth October in the morning when he awoke;
the right upper and lower extremities were completely
paralysed ; they were absolutely flaccid and powerless. He
stammered in speaking and said one word for another j his
wife relates that he said ''I have a hand in the sun"
(paraphasia). He could recognise at that time persons and
objects, but he could not name them, nor could he even
remember the name of his wife. It is impossible to ascer-
tain if the tongue and mouth deviated to one side, or if he
had any affection of sensibility.
At the end of four days (October 14th) he commenced to
use the paralysed limbs well enough to be able to get up.
He is quite sure that the upper extremity had become compara-
atively much freer than the lower. He dragged the foot for
about a month.
On the 28th October an event of importance occurred.
At that time he had scarcely any difficulty in speech except
that he would occasionally use one word for another. His
hand was free enough to enable him to write legibly. Now
he wished to give an order relating to his business, took a
pen and wrote. Thinking that he had forgotten something,
he asked for the letter back again in order to complete it.
He started to read it, and then he was aware, in all its start-
lingness, of the phenomenon to which I wish to draw your
special attention. He had been able to write, but it was
quite impossible for him to read his own writing.
Here then was a patient who had become all in a moment,
aphasic, or rather paraphasic, and hemiplegic on the right
side. At the end of several days both the aphasia and the
hemiplegia had gone ; he was able to write, he wrote legibly
134 OASB OP
enough to give an order, but when he wanted to re-read his
writing it was quite impossible for him to do so.
His writing at that time was pretty much the same as it was
fifteen [ ? five] days later, that is about three weeks after the
accident. Here is a specimen of it. The letter, dated the ist
November, and addressed to his mother, is very interesting
to compare with another letter dated the 22nd of November,
1880 — ^three years before. The first differs from the second
only by a slight change in the style of writing, the letters
being more vertical, and of a more juvenile form ; and by a
few faults of orthography which consist principally in forget-
ting the s^s and the x's at the ends of words, and in for-
getting the word chez.
We find that, in the letters written four, five, and six
months afterwards, these faults had disappeared, and the
writing had resumed its usual character.
Ever since about the same time it was noticed that it was
quite as impossible for him to read a printed page as to read
a written one.
An incident may be mentioned, which is interesting in
some respects, but which I will only note in passing because
it does not seem to be directly connected with the main
symptoms of the case. Two weeks after the accident, about
the 24th of October, he experienced shooting pain in one
ear, lasting about two days, and followed by a constant
buzzing, which was exacerbated when he was spoken to, or
if he experienced any emotion.
But here is a feature which you will probably regard as
more important, although it does not strictly speaking
belong to the category of derangements of language. About
the 9th of November, that is to say about a month after the
accident, he wished to try and play a game of billiards.
He is a right-handed man, his right hand was perfectly free,
and with it he grasped the cue ; but he perceived at once that
it was impossible for him to play and that this impossibility
was due to the fact that his field of vision was lost on the
right side, so that he only saw half of the green cloth and
half of the board, and that the ball was entirely lost to
view when it entered the right half of the field of vision.
ThiB is the first mention that we find in the history of the
WOED-BLINDNBSS. 185
patient of a right lateral hemianopsia^ which since then has
been studied by us very regularly, and which exists at the
present time although in a less degree.
When the patient came to consult us on the 3rd of March,
1883, he had no paralysis, and no motor aphasia; he could
write fluently and clearly, but it was impossible for him to
read either a written or a printed page ; and he had right
hemianopsia.
Let us study his condition when he came to us the
first time a little more closely. We noted that he was an
intelligent man with a quick eye, firm step, easy gesture,
presenting none of that embarrassed stupid manner that is
so common with aphasics. He then told us his history,
aided here and there by his wife, who was present ; and he
accomplished this task without difficulty, without our noticing
any slowness of speech, any substitution of words, and with-
out the least stammering. We then assured ourselves that
as a matter of fact although he could write freely, he could
not read. We shall go into this subject in more detail in
a minute. For the moment we may mention the following
facts which were observed at the time of his admission.
There was no deviation of the face or tongue, no trace of
paralysis of the upper or lower extremities. The walk was
normal and he could support himself equally well on either foot.
Dynamometric force.
March 3rd. — Eight hand 60 kil.
Left hand 50 „
April 5th. — Eight hand 75
Left hand 59
No affection of tactile sensibility was discovered, no
analgesia, no alteration of muscular sensation. He was able
to appreciate weight and temperature perfectly. No modifi-
cation of taste, hearing, or smell ; vision alone was altered.
No modification of the patella-reflexes on either side.
The existence of right lateral homonymous hemianopsia
is easily detected in the most summary manner ; but a more
systematic study of the vision, and the ophthalmoscopic
examination furnishes us with more precise information,
f9
136 CASE OF
I. There is no modification in the ophthalmoscopic appear-
ances. 2. The right lateral homonymous hemianopsia is
limited by a perfectly vertical line passing through the point
of fixation. It is therefore a typical hemianopsia such as is
usually met with in a lesion of the optic tract. 3. No
diminution in the acuteness of vision in the healthy part of
the field. 4. No modification in the perception of colours.
Now we must concentrate our attention on his faculty for
writing and reading.
I ought to say at the outset that our patient presents
no difficulty of movement in the tongue or lips in the
articulation of words ; and there is no notable alteration in
the intelligence. All his troubles belong to the category of
signs {Facultas signatrix). Besides the impossibility, or
rather the difficulty^ of reading, it should be noticed that he
has some f orgetf ulness of a certain number of substantives and
proper names, though he recollects the names of persons who
are closely connected with him. He has not yet been able
to recollect the names of the streets in Paris which he
formerly frequented, although he sees these streets in his
mind (visual memory), and when he passes along them he
recognises quite well the places by which he passes, the house
for example where he has decided to stop ; but as he cannot
read the names of the streets, and since he has for the most
part forgotten them, he hesitates to go out alone. He recog-
nises perfectly well ordinary objects and names them correctly
when they are presented to him.
In reference to his reading and writing this is the
summary of the examinations which we have made almost
daily. The patient's condition is very notably ameliorated
at the present time, but two periods should be distinguished,
one from the 3rd to the 30th March, the second from the
ist to the 15th April.
He can write his name and address without hesitation, a
long phrase, and even a long letter, without obvious faults in
the orthography, and without omitting words. '^ I write,"
he says, " as though I had my eyes shut, I cannot read what I
write.'^ As a matter of fact he does write equally well with
his eyes shut.
- W0RD-BEINDNE8B. 137 1
He has jnst written his name and we ask him to read it.
" I know well enough," he rephes, " that it is my name that I
have written, but is impossible for me to read it." He has
just written the name of this Infirmary and I, in my turn,
write it on another sheet of paper and give it to him to read. J
He is unable to do so at first ; but he makes further efforts to |
do it and while he is accomplishing the task we notice that J
he traces, with the end of his right index finger, one of the
letters which constitute the word, and with much trouble he
says " La SalpfitriSre." We write, " Rue d'Ahoukir," the
address of hia friend. He traces with his finger in space the
letters which compose the woi'd, and after a moment or two
says, " It is the Rue d'Aboukir, the address of my friend,"
Thus you see the alexia ia not complete for written
characters. But the reading of them ia extremely difficult
to him, and is only possible with the aid of ideas furnished
by movements executed by the hand in the act of writing.
Evidently it is the muscular sense which is here brought
into play, and it is the ideas furnished by it which alone
enable the patient to verify the vague notions which he gets
by vision.
We give him a printed page and he says immediately, " I
can read printing less well than writing, because in writing
it is easier for me to mentally reproduce the letter with
my right hand, whereas it is more difficult to reproduce the
printed characters." In fact he has never been accus-
tomed to trace printed characters with hia hand, as a
painter of letters would be. We made him read a line
of printed characters ; he takes eight minutes to decipher it
and three minutes only to read the same line in written
characters. It is noticed that in reading he always traces
the characters in space with his right hand ; and even after
placing his hands behind his back and telling him to read,
one sees that he traces the letters with his index finger on
the nail of the thumb. When reading printed matter it is
convenient for him to have a pen in his hand ; with the aid
of this he is better able to accomplish the task.
Each day since March 5th, we have given him a task
to read. He roads it without writing the words down, but
always by the aid of tracing the characters in space. It is
i^ ^is book is Qie, 'p\-{jM.\ i . .,
188
CASE OF
to be observed that under the influence of treatment he is
making daily progress. Here is a Table which shows the
gradual progression which he was making.
March 2i8t one
) line
in I
minut€
I 43 seconds.
33rd
99
»»
53 »
a4th
>»
>»
II »
25th
»»
»»
36 „
36th
»>
»»
47 -
37th
»»
»
20 „
28th
>»
>»
36 „
3I8t
>»
»»
21 „
April 1st
»>
>»
20 „
2nd
»»
40
secondc
1.
3rd
»
30
>»
4th
»»
35
>»
7th
>»
38
»>
8th
))
36
»
loth
»>
35
>»
1 2th
)»
27
>»
•
After electrization of the great sympathetic in the neck —
April 13th one line in 31 seconds.
14th „ 30
15th „ 39
1 6th „ 25
»»
»>
So as to thoroughly comprehend the importance of the
notions furnished by muscular movements in the mental
reading of written signs, we made the patient shut his eyes,
placed a pen in his hand and communicated to his hand
passive movements, making him write on paper '' Tours,
Paris ; '^ he said immediately, *' Tours, Paris,^' and the same
results occurred if passive movements were executed in
space without a pen.
In reference to his faculty of reading, the following points
should also be noticed. In reading printed matter the patient
does not now move his lips or speak in a low tone, although
it was his habit to do so in a state of health. He is content to
write only those letters which he does not know well by
sight, or to trace them with his finger in space. He knows
all the letters of the alphabet except q, r, s, t, and especially
X, y, z ; and singularly enough these last three letters which
he does not recognise, and which he cannot decipher when they
WOBD-BLINDNBSS. 139
are isolated, lie nevertheless writes easily enough when they
form part of a word. Thus he can write quickly the
words '' Xavier, Yvan, Zebre/' He has more difficulty in
writing when he is hungry than after a meal. After 15 or
20 minutes' reading he feels fatigued. If he is questioned
on the subject of what he has just been reading with so
much difficulty, he remembers very few of the details except
in the case of figures. Thus, he only vaguely recollects,
that in an article which he read yesterday the question of a
statue of the Republic was discussed, which it was proposed
to make of colossal size, but he recollected very well the
figures 400,000 and 200,000 francs mentioned in the journal.
He has since ma.de progress in this respect.
He knows figures very well, he can see them very well.
He can add and multiply well enough, though he occasionally
makes faults if the multiplication is a little complicated.
When the signification of a word is known to him, he can
read it more quickly than when it is not known, thus :
Republique . . 4 or 5 seconds.
Independance . . i minute.
Pterigo'idiens . . 4 minutes.
He frequently repeats, ''When I commence to read,
although I have much improved, it seems to me as if it
were the first time/'
At the same time that his education is making progress
by daily application, the hemianopsia is concurrently under-
going a progressive modification.
To recapitulate, you see that in this patient the notions
furnished by vision in the act of reading are vague, and
insufficient for the comprehension of the text ; and this it is
which constitutes '' word-blindness J' If he reads it is with
the aid of an artifice ; the series of movements which go to
form a graphic representation of a letter, or of a word, are
alone able to awake in him a precise recollection of the
letter or the word respectively. Briefly put, one can say of
him that he reads only in the act of writing.
By way of contrast I shall call your attention in the next
lecture to the case of another aphasic man whom I will
140 WORD-BLINDNBSS.
show you to-day, and who, though absolutely incapable of
pronouncing a single word, hears all, understands all, reads
mentally with perfect facility, writes freely, and understands
perfectly all that he writes and all that he reads.
You will realise at once from this parallel how profoundly
distinct from one another are the different forms of aphasia,
when they occur, as they so rarely do in nature, quite dis-
entangled from all complication.
OOOVBB. MEWOAL CO^'
S*N FRANCISCO, OAL.
«^ '
LECTURE XII.
ON WORD-BLINDNESS {«»iti»ued).
SnMM4KV. — History of vmrd-blindtiess ; MM. Gendrin, Trows-
seau, Kusemaul, Magnan, S^c. — Study of sixteen caaee. —
Olinical cases. — Cases followed by autopsy. — Localisation.
— Frequency of hemianopsia. — Nature of the lesion.
Gentlemen, — Toa have not forgotten the account that
I gave yon in last lectnre of a man who suffers from a
partial aberration of the faculty of expressing himself by
language. In this patient, the acuteness of vision has not ■
undergone any modification in the left half of the visual
field in the two eyes, but he experiences great difficulty in
spelling out the words, although he can see them perfectly
well, and although he can render his thoughts freely and
correctly in writing.
This affection, I told you, has been of late years considered
as constituting a special kind of aphasia, and has been
described under the names of verbal-blindness, loord-btind-
ness, Wortblindheit, This designation was suggested by
M. Eussmaal, one of the first who initiated the study, not
yet very common amongst us, of this clinical form. It should
be added that our case is distinguished from most others of
the same kind that have yet been published, in that the
phenomenon of word -blindness is to be found more disen-
tangled from every admixture or complication.
It will be useful, I think, in order to bring oat the interest-
ing points of the case more clearly, to compare it with some
of the cases belonging to the same group which have appeared
in different publications.
The nosographical history of word-blindness ia not very
exhaustive. It was, I believe. Professor Kussmanl' who
' KuBsmavl, ' Die Stonmgen der Spraclie,' Leipzig, 1877.
142 HISTORY OP
first described it as a distinct affection^ in 1877. It was
Mons. Wernicke^ who first gave the description of another
form of aphasia to which I shall draw your attention in a
future lecture, and which he has called by the name of
sensorial aphasia; though M. Kussmaul in his systematic
survey of the affection has described it under the name of
word-deafness, Worttaubeit,
However, it must not be believed that word-blindness has
only recently been observed, for curiously enough, in his
' Medecine Pratique,* which was written forty years ago,
M. Gendrin^ speaks of patients who ^' found it impossible
to read, but who could write by a sort of memory of the
movements of the fingers necessary to trace the word ; and
yet when the letter was once written, the patient was not
able to recognise it/'
One of the cases of which Trousseau* speaks in his
clinical lectures belongs to this category. " Here,*' said
this great observer, '''is a patient who cannot read, yet who
can speak wonderfully well. He cannot even decipher the
heading of a journal, he cannot put syllables together ; yet he
is not amblyopic, and he is capable of picking up a pin from
the ground. What is most astonishing about this man is
that he cannot read what he himself has written, although it
is written correctly enough.'' His patient, like ours, had
been hemiplegic and aphasic for several days.
But, as I said, it was M. Kussmaul who pointed out that
blindness for words is capable of being met with clinically
as an isolated condition, and that it represents the patho-
logical condition of a special faculty that may be called, as we
shall soon explain, visual memory of the signs of language,
' These views of M. Kaussmaul have not been admitted
without opposition in France; they have even been the
1 Wernicke, * Der aphasische Symptomen-complex.' Breslau, 1874 ; * Ueber
den wissenschaftlichen Standpunkt in der Fsychiatrie/ Kassel, 1880 ; * Lehr-
buch der Gehimkrankheiten.* Kassel, 1881, Bd. I, p. 206 ; * Fortschritte der
Medicin,* Bd. I, 1883.
' Gendrin, * Traits philosopbique de Medecine pratique,* T. I, p. 433,
1838.
• Peter, "DeTapbasie d'apr^s les le^ns cliniquesdu Professor Trousseau."
Arch. g^n. de MM.,' 1865.
WORD-BLINDNESS. 148
object of some very severe criticism on the part of MM.
Mathieu^ and Dreyfus-Brisac* On the other hand, they
have been favorably supported by M. Magnan, and accepted
in his teaching at the Asylum of St. Anne ; and one of his
pupils. Mile. Skwortzoff, has published in her thesis* a
special chapter devoted to word-blindness, which includes
the description of a dozen cases, of which one belonged
to the author, and two others to M. Magnan.
Since the publication of this work five new cases have
been published, three followed by autopsy, into the details
of which we shall enter further on, and two other cases very
very well described, but confined to the clinical aspect, one
belonging to M. Armaignac,* and another to M. BerthoUe,*^
who designates the disease by the name '^ Asyllabia/^
l^Asyllabie] .
The study and comparison of these seventeen cases
furnishes us with some very interesting clinical information
about the subject of word-blindness.
(i) Generally speaking, the onset of the affection is
sudden, and at its commencement there occurs a certain
degree of right hemiplegia, which soon, however, disappears,
such as was seen in our patient. In the early days there is
mostly a certain degree of motor aphasia, which little by
little disappears, leaving in some of the cases the condition
of word-blindness in a state of isolation. All these circum-
stances, you see, are to be found in our patient. But it is
important to mention that primary word-blindness may
occur, isolated from the very commencement (cases by
Armaignac and Gueneau de Mussy),* and without the com-
plication of hemiplegia.
1 Mathieu, 'Arch. g4n. de Med./ 1879, i^^i-
^ Dreyfus-Brisac, " De la surdity et de la c6cit6 verbales," * Gazette Heb-
domadaire de M^d. et de Chir./ 1881, p. 477.
^ Skwortzoff, " De la c^ite et de la surdite des mots dans Taphasie,**
* Thke de Paris,' 1881.
* Armaignac, * Revue Clinique du Sud-Onest,* 1882.
* BerthoUe, " Asyllabie ou amnAsie partielle et isol^e de la lecture " (* Gaz.
Hebd. de MM. et de Chir./ 1881, p. a8o).
^ Ga6neaa de Mussy, 'Becueil d'ophtbalmolo^e,' 1879, p. 139.
144 ANALYSIS OF SEVENTEEN OASES.
(2) Certain visual troubles are vaguely described in some
of the cases ; hemianopsia^ such as existed in our patient^
is to be found mentioned in one observation only, that of
M. Westphal.^
(3) This same observation of M. Westphal contains
another fact which interests us very much. You have not
forgotten how, in our patient, when he made efforts to read
either written or printed characters, he practically wrote the
letters and the words, or at any rate traced them in space,
with the index finger of his right hand. The ideas fur-
nished by these movements of the fingers appeared to be
indispensable to give value and precision to the vague
notions presented by visual images. In other words, the
patient could only read while writing. Now this same
feature is to be found in M. WestphaPs case, and in one
recorded by Mile. Skwortzoff.
(4) In our case these instinctive ruovements of the
fingers which came to the aid of the patient in visual reading
have been utilised, you will remember, as a means of
treatment. Every day did our patient perform a task
which was set him to read a certain number of lines, aiding
himself by the instinctive movements of the fingers, and
thus revivifying, as it were, his visual memories. We have
seen how much improvement he has made lately in this
respect. In the case of Mile. Skwortzoff the patient was
hemiplegic on the right side, and could only receive, through
the intervention of the fingers of his left hand, but imperfect
notions. Mile. Skwortzoff, acting on the advice of M.
Magnan, had recourse to another expedient. The patient
learned to recognise by their touch large raised letters, and
when he was sufficiently instructed in this way, he obliged
himself to read with his eyes at the same time that he aided
himself by his tactile perception of the raised letters ; but at
the end of several months the patient could only read very
short words in this way.
(5) Now I come to the cases followed by autopsy. These
cases are three in number. One belongs to M. Dejerine,^
another belongs to M. Chauffard,* a third to MM, d'Heilly
1 Westphal, * Zeitschrift fur Ethnologie,* 1874, 4 Mai, p. 94.
^ Skwortzoff, loc. cit., p. 5a.
' ChaaSaid, 'Bevae de M^eoine,' T. 1, 1881, p. 393.
146
and Chan tera esse. ^ Unfortunately the clinical history o£ all
these cases leaves somethiug to be desired, because the
word-blindness is only to be found complicated to a very
considerable degree by word-deafness. However, these
three caseSj the only ones, if I am not deceived, on which
one conld found a supposition as to localisation, agree
perfectly on one point. In all the lesion predoniinates in
the inferior parietal lobule, with or without participation of
the angular gyrus and the first temporal convolution.
It is therefore in the inferior parietal lobule, with or with-
out participation of the angular gyrus, where the lesion
would be situated upon which depends the word -blindness
that we observe in our patient. It should be well under-
stood that this localisation is mentioned with every reserve,
and is only indicated aa the most probable one in the present
state of our knowledge.
Moreover, this localisation will perhaps enable us to
explain in a certain degree the existence of the phenomenon
which plays a very important part in the history of our case,
I mean the symptom of hemianopsia, the existence of
which has been made out with so much precision. It is, aa
you know, a right lateral homonymous hemianopsia. With-
out entering for the moment into a formal discussion of the
question of cerebral hemianopsia, which to be properly
treated would require a long time, I will confine myself
to-day to pointing out that there are a certain number of
cases, seven or eight perhaps, followed by autopsies, which
aeem to establish pretty clearly that the phenomenon of
lateral hemianopsia may be produced by lesion of certain
definite parts of the cerebral cortex.*
Now, it seems to be clear from these cases, that the lesion
in hemianopsia o£ cortical cerebral origin pretty constantly
■occupies approximately the same region as that which we
have indicated as being the seat of lesions attended with
word-blindness. You will observe that we have made
no mention of the date, afforded by experimentation on
.animals relative to the visual centre, because at the
' D'Heilly et Cliantemesse, ' ProgrSa Medical,' 1883,
' Ch. P^r^, ' Contribution it V iinie Aea troubles fonctionneU ie la viaion
jpar leaions c^r^bmleB [amblyopie crois^e et h^mianopaie),' 1882.
IQ
146 RELATION OF HEMIANOPSIA
present time there exists considerable contradiction among
authors who are occupied with the question. Moreover,
supposing that they were all agreed as to the seat of
the visual centre in animals, even in the case of the monkey,
it would require further proof to determine if these results
were veritably applicable to man.
However, the information we possess relative to cerebral
hemianopsia in man will serve to enable us to understand
how, in our case, there is a coincidence between lateral
hemianopsia and word-blindness. The same interpretation
can be applied to the case of M. Westphal.
But you will realise at once the difficulty which here
presents itself. If word-blindness and cerebral hemianopsia
occupy the same seat in the brain — that is to say, the inferior
parietal lobule — the two clinical phenomena ought almost
always to occur associated together. However, that does
not seem to be the case, for it is possible to cite examples of
cerebral hemianopsia without word-blindness, and cases of
word-blindness without cerebral hemianopsia.
However, it is well to note that the phenomenon of
hemianopsia, in cases where it is not so accentuated as it is
in our patient, — in cases, for example, where the line which
limits the visual defect is at some distance from the point
of fixation, — might perfectly well pass undetected unless a
systematic search was made. Future observations will alone
enable us to settle this point. Moreover, the inferior parietal
lobule is sufficiently extensive for the two kinds of lesion to
find place without their being necessarily superposed.
I would remind you in passing that in our patient,
whether spontaneously or under the influence of treatment
it is difficult to say, the hemianopsia has become very
remarkably modified, proportionately as the symptoms of
word-blindness have improved. At the commencement, the
hemianopsia differed in absolutely nothing from the clearly
defined hemianopsia which results from a lesion of the optic
tract, for the line of demarcation passed exactly through
the point of fixation (fig. 23). But at the present time it is
no longer so. The limit of the defect has moved little by
little from the point of fixation, and the extent of the visual
field has gradually increased (Figs. 23, 24, and 25).
TO WORD-BLINDNESS.
147
An amendment of this kind is a rare circumstance, and
quite exceptional in the hemianopsia which depends on a
lesion of the tract. Nevertheless, it is quite capable o£
being one of the clinical features of hemianopsia from
a cerebral c
In conclusion, it remains for ns to seek out what is the
nature of the lesion that has determined the hemianopsia
and word-blindnesB in this patient, and by what mechanism.
148 NATUBB OF L38I0N.
it is developed. Here again, we find ourselves confronted
only with hypotheses more or less probable. Though, alas !
it shonld be recognised that in cerebral pathology, even in
the present day, we are not unfrequently reduced to this
condition.
I need scarcely remind you that the sylvian artery, which
I do not hesitate to point to as the cauBe here, fumiahes
J
branckes both to Broca's convolution, tbe seat of the lesion in
aphasia, and also to the regions which seem to he the seat of
the disease in word-blindness and hemianopsia. Disease of
these arterial branches is the chief cause of a more c
pronounced alteration in the cerebral tissue, but of what
does this vascular lesion consist ? Is it spasm, thrombosis,
or embolism ?
3'His boolt Is rti.e 'pro'^tv ^ ,,
oooY^^ ^isii'i^ ^v:i\2L»^^^
150 PEOGNOSIS.
That^ I fear, cannot be exactly determined. The existence
of frequent and severe migraines would induce us perhaps to
supposOj according to Latham's theory^ the former existence
of repeated vascular spasms in the area supplied by the
sylvian as a predisposing cause.
It seems, in fact^ that the repetition of a vascular spasm
may at length bring about, in certain cases, profound modifi-
cation in the vascular walls ; since, in ophthalmic migraine at
any rate, we sometimes see that hemianopsia, or sometimes
aphasia, at first trax^sitory, becomes established by-and-by
as a more or less permanent symptom; Bat we are not in a
position to state that ikhe migraine of which our patient
suffered was true ophthalmic migraine.
The hypothesis of thrombosis, consequent on arteritis, or
an embolism, can only be accepted with reserve, the first by
reason of the age of the subject, the second because of the
fact that there exists no organic disease of the heart.
I must therefore, in conclusion, content myself with the
following statement. It is probable that the origin of the
trunk of the sylvian artery has been obliterated. This will
explain the aphasia, amnesia, and the paralysis of the two
limbs of the right side, from which the patient suffered at the
outset of the disease. But the circulation soon became
re-established in the area supplied by the first three
branches, and thus the hemiplegia and even the aphasia
disappeared. However^ the ischaamia in the area supplied
by the parietal artery has persisted, and consequently the
nerve-tissue in this region has undergone more or less pro-
found alteration ; and it is for this reason that the hemi-
anopsia and word-blindness have become established in a
permanent condition for nearly six months.
Nevertheless, the lesion, whatever it may be, is not abso-
lutely incurable ; for we have seen that, under the influence of
very simple treatment, the disease has tended day by day to
improve. If this amendment continues, as indeed we have
reason to hope, the patient is much to be congratulated,
because, to judge from the history of other cases that have
been published, word-blindness when once established scarcely
ever improves, and more often remains with the patient as a
permanent infirmity.
LECTURE Xni.
ON A CASE OF SUDDEN AND ISOLATED SUPPRESSION OF
THE MENTAL VISION OF SIGNS AND OBJECTS (FORMS
AND COLOURS).*
SuHMABT. — Oall, Gratiolet, Ribot, on partial memones. — Par-
tial destruction of the different forms of memory. — Visual
memory. — Galton's observations. — Ga^e of sudden suppress
sion of the visual memory. — Its effects. — Substitution by
auditory images.-^Verbal amnesia does not correspond to
a simple pathological condition. — Tlie condition is a
complex one [complexus'] ; in educated persons four
fundamental elements can be recognised in it ; the com-
memorative auditive image ; tJie visual image ; and two
motor elements^ to wit, the motor image of articulation,
and the motor image of writing.
Gentlemen, — In an important work, which is devoted to
the study of diseases of the memory/ M. Th. Eibothas well
pointed out that at the present time, in psychology, the dis-
tinction of partial forms of memory, for the first time indi-
cated by Gall/ has become an established truth. And in this
respect he points out that Gratiolet^ had already recognised
that each sense corresponds to a memory which is its corre-
lative; and that the intellect, like the body, has tempera-
ments, which result in the preponderance of this or that
order of sensations in the natural workings of the mind.
'* In truth," adds M. Eibot, '' the system of faculties, in
psychology, has been established so long that the memory has
^ Lecture edited by M. Bernard.
^ * Les maladies de la m^moire/ Paris, 1881, p. iii, 1 12.
3 * Fonctions du cerveau,' T. I.
* * Anatomie Compar^e/ T. II, p. 460.
152 PARTIAL MEMORIES.
come to be considered as an indivisible whole [une uniif},
and the existence of partial memories has been completely
forgotten, or regarded as an anomaly/' But in psychology,
as in more material science, it is experience to which we
defer for ultimate decision. By the light of this experience
it has been shown that '^ in reality, in an ultimate analysis
there exists special memories, or, as certain authors express
it, local memories/' Now, if it be true that in the normal
state '' the different forms of memory,'' quoting still from
M. Bibot, '^ have a relative independence, it is only natural
that in a morbid state, although one form may be lost, the
others may quite well remain intact. It is a fact which
should now appear simple enousfh, and should require no
explanation, since it results from the very nature of memory -
I shall call your attention to-day to a remarkable patholo-
gical condition, which is well calculated to throw some addi-
tional light once more on the existence in pathology of this
isolated suppression of one of the forms of memory. The case
is one of loss of mental vision for objects {Mental Imagery of
Oalton}) — ^forms and colours — supervening suddenly in a
gentleman, who was capable, as it was proved, even after the
occurrence which deprived him of one of his most brilliant
faculties, of great intellectual activity. The case is so
interesting from many different points of view that it is
worth narrating in extenso?
M. X — , a merchant at A — , was born in Vienna. Ho
is a well-educated man, and is a thorough master of German,.
Spanish, French, and also Latin and Greek. Up to the-
time of the commencement of the affection which brought
him before us, he could read the works of Homer quite-
fluently ; he knew the first book of the Iliad, and he could
repeat without hesitation a passage of which the first line
was recited to him. He knew modern Greek well enough to
correspond on commercial matters in this language. He
was very familiar with Virgil and Horace.
' Francis Galton, " Inquiries into Human Faculty," * Mental Imagery/
p. 83, London, 1883.
^ The notes of this case were taken by Dr. Bernard (of Marseilles), then
my clinical clerk.
CASE. 153
His father^ a professor of Oriental languages at S — ,
possesses a very remarkable memory. So also does his
brother, professor of law at W — . One of his sisters is a
distinguished painter. His own son, who is only seven years
old, is already well up in the most minute historical dates.
M. X — enjoyed for several years an equally remarkable
memory. Like that of his father and his son it was
especially a visual memory. Mental vision would give him
in an instant a picture of the features of persons, and the
form and colour of objects with as much clearness and inten-
sity, he assures us, as the reality itself.
If he wished to recall some fact or figures mentioned in
his voluminous correspondence, made in several languages,
he could do so immediately, and the precise wording of the
very letters themselves would appear before him with the
smallest details^ mistakes, and erasures in their drafting.
If he wished to recite a lesson when he was at school, or
a piece of a favourite author later in life, two or three
readings sufficed to fix in his memory the page with its lines
and its letters, and he could recite it, reading in his mind's
eye the desired passage, which in an instant would appear
before him with forcible clearness.
In adding up figures, M. X — had but to run through
the different columns of figures exhibited before him, how-
ever long they might be, and he filled in the total without
any hesitation at once, without being obliged to go into
minute details, figure by figure, such as is usually done. In a
similar manner he would execute various other operations of
arithmetic.
He had but to recall a passage from a play at the theatre
which he had seen performed, and it at once called up all
the details of the scenery, the performance of the actors, and
the spectacle presented by the audience.
M. X — has travelled much. He liked to sketch places
and scenes which struck him. He drew fairly well, and his
memory would offer to him at will the most exact panoramas*
Did he but remember a conversation, or recall a discourse,
or a given word ; immediataly the place of conversation, the
physiognomy of the interlocutor — in a word the entire scene^
of which he recalled only one detail — would reappear before
154 LOSS OF VISUAL MEMORY
him in all its completeness. The auditive memory constantly
failed M. X — , or at least it never occupied in his mind
any bat a secondary position. Moreover^ he has never had
any taste for music.
About a year and a half ago he was seized with grave
apprehensions on account of certain important debts^ of
which the payment seemed to be somewhat uncertain. He
lost appetite and sleep. Events did not justify his fears ;
but the emotion was so severe that he did not become
calm again^ as he had hoped^ and one day M. X — was
astonished to find that a sudden and profound change had
come over him. At first everything was complete confusion,
and from that time he was aware of an immense contrast
between his new and his former condition. M. X — feared at
the time that he was threatened with mental derangement, so
many things around him seemed new and strange. He had
become nervous and irritable. In every instance the
visual memory of forms and colours had completely disap-
peared, yet he could perceive them when present without
difficulty, and the knowledge of this somewhat reassured him
as to his mental condition. He realised, moreover, little by
little, that he could by other means, by invoking the aid of
other forms of memory, continue to successfully direct his
business affairs. And thus, at the present time, he has become
reconciled to the new situation, the difference of which from
that of M. X — ^'s former condition, as described above, will
be easily detected.
Every time that M. X — returned to A — , whence his
business frequently took him for long distances, it seemed
to him as though he entered an unknown town. He
looked with astonishment at its monuments, houses, and
streets, as though he had arrived there for the first time.
Paris, which he has frequented quite as much, produces the
same effect on him, though the remembrance returns to him
^J degrees, and finally he is able to find his way amongst
the labyrinth of streets. We ask him for a description of
the principal square of A — , of its arcades, of its statue ;
'^I know,'* says he, ''that all those exist, but I cannot
picture them to myself, and I cannot tell you anything about
them.** On several former occasions he had sketched a
AND SKETCHING FROM MEMORY. 155
ground plan of A — , but to-day he tries in vain to reproduce
the principal routes, and completely fails.
Asked to draw a minaret, he reflected, and after having
said that it was a high, square tower, he traced on^ paper
four lines, two long equal « vertical ones, two shorter hori-
zontal ones. The upper one united the extremity of the
two vertical ones, and the inferior one was prolonged on
each side to represent the ground. It is a very elementary
sort of drawing. " You want an arcade ? I hope that I
shall succeed in drawing it, because I remember that a
rounded arch is formed of a half circle, that a pointed arch
is formed by two arcs meeting together at an acute angle,
but I cannot really see in my mind's eye any of these things.^'
The profile of a man's head which M. X — drew at our
request might be the work of a child ; and he confesses
to being aided in this drawing by the faces of persons who
are around him. A shapeless scrawl represents a tree that
we asked him to draw. ^^I don't know, I don't know at
all, how it is done/' says he.
He finds the visual recollection of his wife and his children
impossible. He cannot remember them any better than the
roads and streets of A — , and even when they are before
him they seem fresh to him ; he seems to see new traits in
them, and new characteristics in their physiognomies.
He cannot even recall his own face. Recently in a public
gallery his path seemed to be stopped by a person to whom
he was about to offer his excuses, but it was merely his own
image reflected in a glass.
During our investigations M. X — has complained bitterly
on several occasions of his loss of colour vision. It seems
to occupy his mind more than his other losses. '' My wife
has dark hair, I know it quite positively, yet it is impos-
sible for me to find the colour in my memory. It has as
completely gone as her face and features."
This visual amnesia applies quite as much to the objects
of youth as to more recent images. M. X — cannot repre-
sent in his mind's eye [yisuellemenf] his paternal home.
Formerly he often evoked this memory, and it was a very
vivid one.
The examination of the eye is completely negative. M.
156 SUBSTITUTION BY AUDITORY IMAaBS
X — is strongly myopic to the extent of -- 7 D. As the
result of the examination of M. X — *s eyes, which has been
made with the greatest care by M. le Docteur Parinand in
the ophthalmological room of the Clinique, we find that no
ocular lesions nor functional troubles can be discovered,
excepting perhaps a slight diminution of chromatic sensibility
equally involving all colours.
It should be added that no somatic symptom has ever
preceded, accompanied, or followed the destruction of mental
vision that is found in our patient. At the present time
M. X — is able, like other people, to open his letter press-
copy book, and find there the information which he desires ;
and he can turn over the pages just as well, in order to
arrive at the place he seeks. He cannot remember more
than the first few verses of the Iliad now, and his quotations
from Homer, Virgil, and Horace are but very feeble attempts.
He pronounces in a low voice the figures that he adds up,
and only proceeds* by small imperfect calculations.
When he recalls a conversation, when he wishes to
remember a statement made to him, he knows quite well that
it is the auditive memory that he must now consult, which
is of course an effort to him. Words and speech [when^
*'ecalled^ seem to resound in his ear, with a sensation altogether
new to him.
He is obliged to make efforts of audition in order to
reproduce in writing two lines from a daily journal that we
have given him to read. In reading, moreover, he executes
movements with his lips of which he is conscious; and,
deprived of his mental vision, it has become necessary for
him to have recourse to internal speech and to articular
movements of his tongue and lips in order to comprehend
the lines which he reads. M. X — seems to have analysed
very thoroughly all the mechanisms of his memory, and all
the different observations that we have made about him, he
had for the most part already made on his own behalf.
Since this great change has come over him, M. X — is
obliged, in order to learn a thing by heart, a series of phrases
for example, to read these phrases in a loud voice several times,
and thus affect his ear. And by-and-by when he wishes to
^ [EetrouY^s, literally, met with again.]
MIXED WITH WORD-BLINDNESS. 157
repeat the passage learned^ lie is very conscioas of a sensation
of interior audition^ which precedes the enunciation of the
words, and which is a sensation that he never knew before.
M. X — speaks French very well and fluently, nevertheless
he declares that he cannot think in French, and that he
only speaks this language by translating his thoughts from
Spanish or from German, the first languages which he learnt
when a child.
It is an interesting detail that in his dreams M. X — has
no longer the visual representation of objects. The repre-
sentation of words alone remains to him, and these belong
almost exclusively to the Spanish language.
Besides the loss of the faculty of the visual representation
of objects, word-blindness also exists in the patient to some
extent. When asked to write the Greek and German
alphabets he omits several letters from the alphabet ; thus
in Greek 0, c> <t, Z> ^> ^y X* ■^^ these letters are traced
before him, he recognises them only after having traced
them himself, after several mistakes, and after having
compared them one with the other. If Greek words, into
whose composition these letters enter, are dictated to
him, he understands and writes them clearly and delibe-
rately, whereas, to read the same words written by another
person he is obliged in the first place to write them himself.
From this, one sees that he is obliged to compensate by the
aid of his hand the defect of his visual memory for words, with
which he is affected to a certain degree, in some languages.
However, notions belonging to the category of muscular
sense, furnished by movements of the hand in the act of
writing, are not in him of an exceptional intensity. In fact,
if when his eyes are shut one communicates to his hand the
movements necessary to write — the word Vienna, for example,
— he is incapable of detecting the word which he has been
made to write ; he is obliged to see the word and to read it
in order to name it.
The following letter which the patient has written in
reply to me will complete on several points the case that has
just been related, and will enable you better to understand
158 CHANGE OF CHARACTER.
the temporary derangement, and the permanent destruc-
tion, of faculty which has been produced in the patient in
consequence of this loss of mental vision.
'^ I hasten to reply to your letter, and to ask you to be
good enough to excuse my imperfect knowledge of the
French language, an imperfection which renders the exact
expression of what I wish to submit to you a little difficult.
As I have already told you, I possessed at one time a g^rand
faculty of picturing to myself [representor interieurement]
persons who interested me, colours and objects of every
kind, in a wbrS, everything that is reflected in the eye.
'^ Allow me to remind you that 1 made use of this faculty
extensively in my studies. I read anything I wanted to
learn, and then shutting my eyes I saw again quite clearly
the letters with their every detail ; thus it was also with the
physiognomies of people ; the appearance of countries or
towns that I have visited in my many voyages ; and, as I just
now mentioned, of every object that I had seen with my eyes.
''AH of a sudden this internal vision absolutely dis-
appeared. Now, even with the strongest desire in the
world, I cannot picture to myself the featureis of my children
or my wife, or any other object of my daily surroundings.
Hence, when you realise that I have absolutely lost thi&
power of mental vision, you will readily understand that my
impressions are changed in a corresponding fashion. No
longer being able to represent visible objects, and yet having
completely preserved my abstract memory, I daily experience
astonishment at seeing things which I have known so well
for a long tiine. My sensations, or rather my impressions,
being made new an indefinite number of times, it seems to
me that a' complete change has come over my existence, and
naturally liiy^ bharacter is modified in a remarkable way.
Formerly I wa^'itdpressionable, enthusiastic, and I possessed
a vivid imaginatic)ii ; to-day I am calm, phlegmatic, and my
imagination never leads me astray.
" The faculty of picturing objects within myself being
absolutely wanting, my dreams are correspondingly modified.
At the present time I dream simply of speech, whereas I
formerly possessed a visual perception in my dreams.
" As an example, which may be more convincing, if you
ANOTHER CASE. 159
were to ask me to represent the towers of Notre-Dame, a
browsing sheep, or a ship in distress in the open sea, I
should have to reply to you that although I know perfectly
well how to distinguish these three different objects, and
perfectly well know all about them, they have for me no
meaning at all as regards mental vision.
'' A singular result of the loss of this mental faculty, as I
said before, is a great change in my character and my
impressions. I am much less affected by grief or disap-
pointment. I may mention that having lately lost one
of my relatives, for whom I had a sincere attachment, I
experienced a much less intense grief than if I had still
possessed the power of representing, by my internal vision,
the face of the relative, the phases of the disease through
which he had gone ; and especially, if I had been able to
picture within myself the outward effects produced by his
premature death on the other members of our family.
" I know not if I clearly explain what I experience, but I
may tell you that I possessed at one time in no ordinary
degree the mental vision which is now so completely lost.
It exists at the present time in my brother, a professor of
law in the University of X — , in my father, a professor of
Oriental languages, well known in the scientific world, and in
my sister, a painter possessed of much talent.
" In conclusion, I beg you to remark that I am obliged at
the present time to say things which I wish to retain in my
memory, whereas formerly it toas sufficient for me to photograph
them in my eye. — Paris, ii July, 1883.^^
By way of comparison I should like to mention another
case that I have recently met with of an artist, 56 yeara
of age, who has noticed, to his great grief, that for several
months he has lost the faculty of picturing things to himself,
or of imagining objects, and that he is no longer good at
painting, except for copying ; and even for this kind of work
he is obliged to keep the original constantly before his eyes
in such a way as not to lose sight of it for an instant.
The case of M. X— needs but little comment. We will
confine ourselves to a few brief remarks on this subject.
160 VISUAL AND AUDJTIVE EQUIVALENTS.
It has been seen that the powerful memory which M. X —
•enjoyed only eighteen months ago depended chiefly on his
faculty of representation by mental vision, a faculty which
in him had reached an extaeme development.
In this respect he belonged to that class of individuals of
whom M. Galton^ speaks, and who read, as it were mentally,
«ach word that they pronounce, as though they really saw
them printed ; and who consequently, when it is desired to
express an idea by a sign of language, evoke the visual
equivalent of the word and not its auditive equivalent ; — in
whom the visual representation of objects is sometimes so
powerful that they are capable of projecting on the paper,
so to speak, the internal image, and there fixing it by
drawing. When it is thus developed, this faculty seems,
according to M. Galton, to be an hereditary gift ; and as a
matter of fact the brother, the sister, and the father of
M. X — possessed it in a very remarkable degree.
It is very remarkable that this complete suppression of
internal vision (which prevents M. X — from picturing any-
thing to himself, or of figuring objects or faces to such an
€xtent that the faces he has seen many times always appear
to him as new, and that he can no longer draw from memory,
&c.) has not had the efEect of profoundly modifying his
faculty of expression by language, since the visual repre-
sentation of signs is wanting in him as well as that of
objects, of faces, of countries, &c.
But it should be noted in this respect that from the
moment when he perceived that he was deprived of visual
memory, M. X — was led, instinctively so to speak, to use
his auditive memory, which he had as it would seem sadly
neglected up to that time. Formerly, when he wished to
learn a series of phrases by heart, it was sufficient for him
to have seen them once or twice ; but now in order to obtain
the same result he is obliged to read the phrases several^
times in a loud voice, and when the time comes for him to
repeat the passage learned, he has very clearly the sensation
(new to him) of interior audition which precedes the enuncia-
tion of the words. That is to say, being actually deprived
of the visual image of signs, he has learned to evoke his
^ Loc. cit.| pp. 96, 90
ANALYSIS OF VERBAL AMNESIA. 161 ►
auditive image ; or, in other terms^ his auditive eqmvalent for
words replaces his visual equivalent. It is then a fresh
example of those "substitutions" [suppleances] which are
met with no doubt at each step in the history of aphasia
by those who examine the subject attentively.
You know that in my recent lectures on *^ aphasia,"^ founded
on a clinical analysis of a certain number of appropriate
cases, I endeavoured to show that -what is known as verbal
amnesia, contrary to the opinion very generally held, does
not correspond to a simple pathological condition \unit^ .
The word indeed is a compleams [applied to a class having
several varieties]. One is able to recognise, in educated
individuals, at least four fundamental elements in this con-
dition : — The commemorative auditive image : the visual
image : and lastly, two motor elements belonging to the cate-
gory of muscular sense, that is to say, the motor image^ of
articulation, and the graphic motor image ; the former being
developed by the repetition of the movements of the tongue
and lips necessary to pronounce a word, the latter by a
repetition of the movements of the hand and fingers neces-
sary in writing.
It should be remarked, moreover, that verbal amnesia,
whether auditive or visual, represents, so to speak, the early
stages of affections which, when they are carried to a higher
degree, constitute either word-deafness or word-blindness
as the case may be. Thus when, the idea being present,
one is not able to evoke either the auditive image or the
visual image of a given word, there is said to be verbal
auditive amnesia in the first case, or verbal visual amnesia
in the second ; but when the written words which are seen,
or which resound in the ear, are not recognised, it is
said that there is either word-blindness, or, in the latter
case, word-deafness. We should be able, following out the
same principle, to say that there is verbal motor amnesia — of
a more or less accentuated form, according to the case — when
the motor images, either of articulation or of writing are
wanting.
^ See p. 130, note i.
- Image motrice ; Bewegungshilder, in the nomenclature of M. Kussmaul.
11
162 . VARIETIES.
Finally, it must not be forgotten that, in reference to the
^physiological] mechanism of recalling a word, there would
seem to exist fairly well-marked individual varieties. In
some kinds — and these perhaps form the greatest number —
when it is desired to render an idea by the corresponding
sign, the auditive element exclusively is evoked; in others
the visual element alone; and in other varieties the indi-
viduals have recourse directly to one or other of the motor
elements. These three chief types, moreover, are exclusive
of mixed transitional forms.
If, for the sake of convenience, one were to designate
summarily the representatives of each of these great [physio-
logical] types by the name of visuals, auditives, and motors,
ihe patient, M. X — , would undoubtedly have been a visual.
From this reasoning one would suppose that the suppression
in him, or at any rate the clouding, of internal vision of signs
-ought, necessarily, to bring with it serious disorder in the
^expression by language.
But it is just here where the phenomenon of '^ substitu-
tion " [suppleance] mentioned above comes in. Thanks to
Jthe persistence of the auditive and motor elements of a
word, the compensation has been established to the extent
that, in M. X — , the destruction only betrays itself in reality
by delicate, scarcely perceptible shades, and the function of
language operates very nearly as under normal conditions.
On the other hand, the absence of the visual element in the
constitution of the idea, seems to be a flaw that will be with
-difficulty reparable.
However that may be, it should be well understood in the
present day, that such conditions are quite possible, and that
-examples do actually occur in which there is suppression of a
^hole group of memories, or a whole category of commemora-
tive images, without participation of other groups or other
categories ; and that this is an established fact in pathology
as well as in cerebral physiology. This necessarily leads one
^o admit that the different groups of memories have their seat
in certain circumscribed regions of the encephalon. And
this in turn becomes added to the proofs which go to esta-
blish that the hemispheres of the brain consist of a number
vof differentiated " organs,*^ each of which possesses its proper
OBEEBRAL LOCALISATION. 163
function^ though each one remains in the most intimate
connection with the others. Moreover, this last proposition
is generally admitted in the present day by those who study
the functions of the brain, not only in animals in the
laboratory, but also, and especially, in man, by the processes
of the anatomo-clinical method.
This look is the prop tvi.^ -j
COOPER MEDICAL COLLi^(ii^»
SAN FRANOISOO, OAL.
and is not to he removed from the
lAhrary Boom hy amf person or
under any 'pretext t(;fcateiWt
LECTURE XTV}
NOSOGEAPHICAL EEVISION OF THE AMYOTROPHIES.
Summary. — Deuteropathic amyotrophies, — Protopathic arnyo^
trophies. — Primary myopathies. — Pseudo-hypertrophic
paralysis. — Juvenile form of Erh. — Myopathy without
change of volume in the muscles, Leyden^s form, —
Analogies between pseudo-hypertrophic paralysis and
ErVs juvenile form. — Hereditary infantile variety of
Duchenne (de Boulogne). — Its characters. — This last
variety is analogous to the preceding ones. — Pseudo-
hypertrophic paralysis, juvenile form of Erh, Leyden^s
form, hereditary infantile form of Duchenne {of Boulogne) ^
are hut varieties of primary progressive myopathy.
Gentlemen, — By tlie chances of clinical work we have
at this moment^ collected in oar wards, an interesting
series of cases* which represent the different aspects under
which progressive muscular atrophy may present itself to the
physician.
I propose, therefore, to avail myself of this opportunity,
and in to-day's lecture to take up the subject of muscular
atrophies, or perhaps better, progressive amyotrophies.
As a matter of fact, during the last few years this subject
has reached a somewhat critical phase. The nosographical
history of progressive amyotrophies requires to be revised
by the light of recent observations ; even to be reconstituted
in part on new principles. To-day I can but ofEer you an
' This lecture is edited by MM. Marie and Guinon.
' These cases have been reported in extenso in a publication by MM.
Marie and Guinon " On some of the clinical varieties of Primary Progres-
sive Myopathy," (* Revue de M6decine/ October, 1885).
DGUTGBOPATHIO AMYOTROPHIES. J65
attempt, a mere sketch of such reconstitution, reserving for
a future occasion the task of presenting to you a more
detailed and more settled plan.
In the domain of progi-eaaive amyotrophies matters are
rather more complex than one would at first imagine.
Refering for a moment to my teaching of ten years ago ;
the clinical group of progreaaive muscular atrophies, as we
then divided it, comprised different affections which were
connected solely by exterior, superficial resemblances ; but
which nevertheless all had this in common, that they were
of apiual origin ; that they depended in other terms on a
lesion of the spinal cord, and more particularly of the
anterior horna of its grey substance. However, we were
■enabled to establish at least two fundamental divisions, viz.
I. Deuteropathic^ spinal amyotrophies, iu which the lesion
■of the grey substance is secondary.
II. Protopathic' spinal amyotrophies, in which the lesion of
the grey substance was the only feature, or at least the
pi-imary and fundamental one.
In this first group, that of Deuteropathic Amyotrophies, we
may establish the following distiactioua.
In the^rsi place there are the cases in which the lesion
■of the grey substance is an accessory occurrence, accidental
so to speak, to conditions such as the diffuse myelites, dissemi-
nated sclerosis, tumours of the spinal cord, locomotor ataxy,
&C. This class of spinal amyotrophies can be eliminated
from our present studies, for they can more conveniently
be grouped, clinically, with the diseases on which they
depend.
In the second place there are oases in which the lesion of
the white columns is primary, but always, and necessarily,
followed by a lesion of the grey matter. In these cases it is
the pyramidal bands which are first attacked and then subse-
quently the anterior horna, whose participation nevertheless
is a necessary factor. When the disease occurs in its com-
plete form we have the ordinary symptoms of progressive
muscular atrophy, to which is superadded a spasmodic
element, by means of which it is distinguished from other
' Vidfl note p, 26.
166 PEOTOPATHIO SPINAL AMYOTEOPHY.
kinds. This group is nosologically distinct, and is of
perfectly legitimate constitution. There is at the present
time nothing to add to it, nothing to withdraw.
As for the other great class of spinal amyotrophies>
we have proposed to designate it clinically by the name
progressive Muscular atrophy of the Duchenne-Aran type.
The lesion of the grey motor centres, spinal or bulbar,
is the unique fact, or at least is the primary one. If the
white columns participate, it is but a secondary or accessory
feature. It is^ this class which can be anatomically
characterised by the denomination protopathic spinal amyo^
trophy; or perhaps better, chronic anterior poliomyelitis..
It should be recognised that the constitution of this second
class is less homogeneous than that of the first. It is this
one that is so much discussed at the present time, and which
is in danger of being shaken to its very base ; it is against
this one that the strictures of the critics, so often just, are
really directed. It is in this category that the alterations^
and legitimate separations, have to be made.
It is not that the efforts made in this direction tend
really to compromise the existence of the Duchenne-Aran
nosographical type. There does undoubtedly exist a kind
of progressive muscular atrophy, characterised, anatomically,,
by an isolated lesion of the anterior horns of the grey
matter of the cord, and, clinically, by amyotrophy. One
certainly meets with cases in which the onset, occurring
after twenty years of age, is manifested by an atrophy of
the upper extremities, of the hands, more especially of the
thenar and hypothenar eminences ; and by the progressive
spreading of these alterations to the rest of the limb. Fibrillar
twitchings are met with in these cases, and the reaction of
degeneration in some of the atrophied muscles. It is dis-
tinguished clinically from amyotrophic lateral sclerosis in
that the participation of the bulb, though it may exist, i&
more rare than in the last-named afEection, and especially, by
the fact of the complete absence of the spasmodic element,,
and later on, of contracture.
Formerly this category of amyotrophies was very vast, but
the number of cases which constitute it appear to become
PBIMABY MTOPATHT. 137
fewer and fewer under the influence of newer and more precise'
investigation. In tliis way a certain nuuiber of distinct
varieties are separated from it, such as has been done in the
case of amyotrophic lateral sclerosis. As a result of this, its
extent, already much narrowed, is from time to time becoming
more and more limited, in proportion as the heterogeneous
elements which were annexed to it have become withdrawn.
Now, what the cases ara which modern research is detachiug
every day from the Ducheuna-Aran type is precisely what
we are about to investigate. Under what now guise will
these cases appear to ns ; in what nosographica! category,
shall we find them, or where can we place them ?
Gentlemen, besides the amyotrophies of spinal origin,
there exists a large and increasing class in which progressive
myopathy is more or less generalised, and which is inde-
pendent of all lesion in iho nerve centres or peripheral
nerves. Here we have a protopathic disease of muscle, a
primary myopathy. As an example of this kind of affection
one can mention the fseudo-hy per trophic paralysis or myo-
sclerosis of Duchenne (de Boulogne). It was shown by
Euleuberg and Cohnheim in 1866, and by myself in 1871,
that in these cases the lesion of muscle is completely inde-
pendent of any lesion of the cord or nerves. And in
reference to this matter I might remind you that I protested
at that time against the then reigning tendency to connect
all these progressive myopathies with lesions of the nerve
centres. There are, I declared, undoubtedly cases of
primary myopathy ; and ail the later observations have shown.
this statement to be correct, and also that these primary
myopathies are more numerous and more vai'ied in their
clinical manifestations than was at first supposed.
Bat this form of myopathy, this pseudo-hypertrophic
paralysis which was described by Duchenne (of Boulogne),
that great worker in nearo-nosography, is so different in its
clinical characters from the progressive spinal amyotrophies
that they have rarely been confused clinically. Pseudo-
hypertrophic paralysis is a disease of early youth. It is
scarcely ever met with after twenty years of age. It is
noticed that the child becomes clumsy in his walk, that he is.
168 CASE OP PSEUDO-HYPBBTEOPHIO PARALYSIS.
more easily fatigued than the other children of his age ; for
it is always, quoting from Duchenne's description, in the
lower extremities where it commences. Then the upper
extremities may be attacked in their turn ; but, whatever
be the degree of the afFectiou, the hands are generally
absolved. Finally. the muscles attacked, or at least a great
number of them, present an augmentation of volume, an
enormous increase in size, giving to the limb, or a segment
of the limb, Herculean proportions. Anatomically this
hypertrophy is characterised by lesions of the interstitial
tissue, such as does not exist in the same degree in spinal
amyotrophies. Moreover, and this is a peculiarity which is
not found in Duchenne-Aran disease, heredity plays a great
part in the development of pseudo-hypertrophic paralysis
of the muscles. It often happens that several children are
attacked in one family, and that some of their relatives may
present the same afPection.
The man named Gai — is now 19 years old. The affection
from which he suffers, and which displays all the clinical
features of the myosclerotic paralysis of Duchenne, com-
menced during childhood. You observe the enormous size,
the athletic proportions of the muscles of the calf ; they
present in a state of repose a marked increase over th(
normal consistence, and daring contraction they are as hard
as a stone. The quadriceps extensors are large, projecting,
and knotty, during the contractions. But if you test the
strength of contraction of these muscles, you will obsei've
that although they are Herculean in size, they are far from
being so in power. There exists an undoubted functional
weakness, not a paralytic weakness, that is to say it is not
of nervous origin ; but it more or less exactly corresponds
to the degree of alteration of the muscular fibres. Side by
side with this hypertrophy you will observe in the patient a
notable diminution of volume and also of force in the upper
extremities, particularly the muscles of the arm. This last
is the only point of resemblance which connects the myo-
sclerotic paralysis to the progressive amyotrophy of spinal
origin, and which might possibly lead to confusion, although
they are really so distinct from each other.
ebb's juvenile form. 169
There is another form of muscular atrophy apparently
unconnected with nerve lesions which attacks young people
or infants; and which Professor Erb (of Heidelberg) has
recently described under the name of juvenile form of prO'
gressive muscular atrophy, and which he rightly considers to
be quite distinct from the spinal forms that had been
described up to that time.^ The variety in question is not
perhaps altogether a new discovery, but the description
undoubtedly contains new facts, or at any rate such as have
not been hitherto brought out conspicuously enough. The
disease presents certain striking analogies with pseudo-
hypertrophic paralysis, which are well revealed in Erb's
description. It commences generally before the twentieth
year, more rarely in infancy. It may sometimes present
intermissions of improvement, due possibly to the efficiency
of treatment, although its course is generally progressive.
Nevertheless, it allows patients to live on, who are perfectly
able to procreate, and as a general rule to reproduce amyo-
trophic subjects like to themselves. It starts in the upper
extremities, the arms in particular, and the muscles of the
shoulder girdle (Schultergiirtel) , never in the thenar and
hypothenar (Fig. 26).
The lower extremities may be attacked in their turn.
The calf, as in pseudo-hypertrophic paralysis, remaining in
general free from any diminution of volume. It is atrophy
which appears to be the leading feature ; hypertrophy
is rare, although M. Erb has observed it sometimes in the
deltoids, the triceps, and the muscles of the calf. It is the
diminution of volume of muscles which sometimes leads to
Erb^s variety being confounded with the Duchenne-Aran
disease. In fact, if one examines the cases that have been
collected by Duchenne in his ' Treatise on Localised Electri-
zation,' one finds, as M. Erb pointed out, that a certain number
of them very well correspond with the juvenile form. But
Erb's disease is distinguished from progressive muscular
atrophy of spinal origin by certain distinctive characteristics.
Amongst others there are, the mode of invasion which, in
^ Prof. W. Erb, " Ueber die Juvenile Form der Progressiven Muskela-
trophie, &c. ** (* Deutsch. Arohiv. fiir klin. Med,/ 1884).
170 DIAQSOaiS FEOM SPINAL AMTOTEOPHT.
the juvenile form, never takes place in the hands (thenar
and hypotbenar eminences) ; the absence of fibrillar twitcb-
ings in the atrophied mnscles ; the results of electrical^
examination of the same mnsclea which never give the-
reaction of degeneration ; the age of onset, which is always-
DIAGNOSIS OP ebb's FROM DUOHENNE's PARALYSIS. 171
before twenty years of age ; and finally, from an anatomo-
pathological point of view, the complete absence of all
spinal lesion.
The juvenile form described by Professor Erb is therefore
quite distinct from amyotrophies of spinal origin. But is it
equally distinct from pseudo- hypertrophic paralysis ? I do not
think it is, and here I agree with the opinion expressed,
although with certain reserves, by M. Erb himself in hi&
work, which appears to me to throw so much light on the
question now before us. The apparent hypertrophy in one
case, the apparent atrophy in another, is the only point of
difference. But it should be recognised, I think, that this
distinctive character is not fundamental. The hypertrophy
is not, on the whole, an essential element in the constitution
of the affection called pseudo -hypertrophic paralysis. I
am about to show you a case which marks, in a sense,
the transition between the juvenile form with amyotrophy on
the one hand, and pseudo-hypertrophic paralysis on the
other.
In the child L — , who is now before you (Fig. 27)^
functional weakness is the leading feature; and as to the
modification in the volume of the muscles, either increase or
decrease, it does not exist, a fact with which my Chef de
Clinique, M. Marie, was particularly struck when he first
saw the patient. This case so to speak reproduces, in
respect of alteration of motor power, Brb's juvenile form of
atrophy without the atrophy, and pseudo-hypertrophic
paralysis without the hypertrophy. It is quite possible to
suppose that the alteration of the muscular fibres, which is
the chief cause of the weakness, can occur without modifica-
tion of volume in the muscle. In Lang — , who is now 1 1
years old, the disease commenced during infancy. The
little patient presents the arching of the back, and the walk
so characteristic of pseudo-hypertrophic paralysis. If he is
made to lie down on the ground on his back, he cannot get
up again without the aid of his hands, which, supporting
themselves on his knees, climb, so to speak, along the thighs
until he reaches the vertical position, in a manner quite
characteristic of this disease.
Now, in the next place look at the muscular masses ; not
172
0A8B Oil!' TRANSITIONAL FOBM.
one of you will be able to discover either atrophy or hyper-
trophy. It is not meant to say that this child is very
muscular, but there is no striking modification of volume in
the muscles. The only clinical fact, therofore, which strikes
■one about him is the diminution of force of his
■which are in the appearance normal as regarded their
tvolume.
Where should this case be classed ? Among the cases of
J
lbfden's heueditahy variett. IIS
Erb's juvenile form, or, with the pseudo-hypertrophic pitra-
lysia o£ Dachenne? No, gentlemen, neither with the one
nor the other precisely. It seems to belong, not to a distinct
morbid species, but simply to a. variety representing the
different modes of evolution of one and the same affection,
•primitive progressive myopathy.
Thus we have seen that there are a certain number of
cases which can be abstracted from the Dachenne-Aran
group, but these are not all. I am now going to abow you
two other kinds of muscular atrophy which formerly be-
longed to the too extensive class of Duehenne-Aran's disease,,
but which now we shall be able to sort out, so as to place
them in their true position, that is to say, among the
primitive myopathies.
Here is a young woman of 24 years of age, named
Dall — , who had been attacked with amyotrophy of the
lower extremitieB, or more correctly of the legs. This-
atrophy is very pronounced ; the patient is scarcely able to-
walk without support, and if one examines the gait atten-
tively it is seen to be very peculiar. In fact, as a conse-
qnence of the feebleness of the muscles of the log, the point of
the foot falls when the patient, in walking, raises the leg so
as to carry it forward. As a result of this she is obbged
to flex the knee to an unnecessary extent so as not to allow
the point of the foot to trail on the ground, imitating the-
movements of a high-stepping horse. It is analogooa to-
what is observed whenever the muscles which produce
dorsal flexion of the foot are atrophied, as in alcoholic
paralysis for example, a case of which I recently had the
opportunity of showing you. The disease commenced at the
age of fourteen, in the lower extremities ; then the upper
extremities were attacked in their turn at the age of twenty ;
and at the present time it may be seen that there is, besides
a certain functional weakness of the arms, a slight degree
of atrophy of the hands, which are flattened on the palmar
surfaces on account of the diminution of volume of the thenar
and hypothenar eminences.
Albeit that there is here no trace of heredity, and
although the patient has neither brothers nor sisters subject-
174 doohenne's infantile form.
to the same complaint, this case appears to me^ to belong
to the variety described by Professor Leyden under the
name hereditary variety of progressive muscular atrophy ;
and of which one of the characters is its commencement in
the lower extremities. This form, moreover, is not strik-
ingly different, as it seems to me, from the juvenile amyo-
trophy of Brb ; and it is highly probable that, like this, it
can be classed amongst the primary progressive myopathies
of non-spinal origin.
Here, then, we already have three clinical varieties,
namely, pseudo-hypertrophic paralysis; the juvenile form
of Erb ; and the hereditary variety of Leyden ; which
although possessing certain distinctive characters, can per-
fectly well be regarded as identical in their essence.
Now let us pass to another form, which Duchenne (de
Boulogne) described as representing a variety of pro-
gressive muscular atrophy and to which he gave the
name infantile form of progressive muscular atrophy. It
must be somewhat rare, for it is scarcely mentioned in
standard works. Duchenne, in his 'Treatise on Localised
Electrization,' said that he had met with a score of cases,
find in the ' Revue Photograph ique des H6pitaux ' are to be
found photographs, made by Duchenne himself, which
represent the faces of several patients, who are the subjects
•of this afPection.
Here the disease begins in the face according to Duchenne's
description, and particularly in the orbicularis oris ; the lips
becoming everted in such a manner as to simulate the
habitual aspect of these organs in strumous people. Then
the limbs are attacked consecutively, the arms first and
then the trunk. It is important to note that this infantile
form is hereditary, and one sees in the same family atrophic
parents begetting sons and daughters attacked by an amyo-
trophy, commencing in the face. Prom his account it
would be quite natural to conclude that the amyotrophy is
^ The full report of this case is to be found iii the memoir by MM. Charcot
and Marie, " Sur une forme sp^ciale d*alrophie musculaire progressive
debutant par les jambes et distincte de la forme de Lejden " (' Bevue de
M^ecine,* February, 1886).
CASE. 175
lere connected with a spinal leaioDj as iu the cases of
the Duchenne-Aran type ; of which indeed according to
Duchenne hinaself they only represent a simple variety.
But this supposition is not correct. MM, Landouzy and
Dejerine presented to the Academy o£ Sciences last year
reports of typical cases of the infantile progressive muscula''
atrophy of Duchenne ; and in one of these cases the autopsy
proved that there esisted no lesion, either in the spinal cord
or in the peripheral nerves. Here again, then, we have
■<;ase8 of primary myopathy. I can show you a patient
•who exactly reproduces most of the characters of the de-
scription given by Duchenne.
Mdlle Lavr — is now i6 years old. la her the malady
commenced in earliest infancy hy a complete immobility
of the upper lip, which was especially marked during
laughter or crying (Figs. 38 and 29). She has never been
able to whistle, and if she waa asked to accomplish the act,
it would be noticed that the upper lip, which did not contract,
floated like an empty sail in the wind. She has at the present
time a certain disturbance of the faculty of speech. Certain
letters are particularly ill-pronounced, and she speaks as
though she had a ball in her mouth. This paralysis of the
orbicularis gives to the physiognomy quite a special character.
176
CASE OF DUOHENNB 8 INFANTILE FORM.
The lips are tLick, everted, and elongated into tlie form of
& snout, recftlling the aspect of the lips in strumous people.
But besides this there is a symptoin in our patient
which has not been noted I believe by Dochenne in his
general description ; the upper part of the faco is also
attacked. The little patient cannot wrinkle her forehead,
or elevate her eyebrows ; she sleeps habitually with the eyes
half open, and even in the waking state the most energetic
contraction of the orbicularis palpebrarum will not suffice to
produce complete closure. There is always a chink of
Fio. .,0.
several njillJmetres between the free borders o£ the eye-
lids, through which the globe of the eye can be seen.
This condition has been observed from her earliest years.
At the age of 14, the upper extremities began to be attacked
in tbeir turn (Fig. 30), and atrophy soon appeared — and
here the description of the muscular affection corresponds
absolutely with that of the juvenile form of Erb. Tho
atrophy of the muscles of the arms is considerable, resist-
ance both to flexion and extension is impossible. The
i
OF PBOGEllSSIVB MUSCDLAE ATROPHY. 177
patient cannot raise her arm by a contraction of fcbe ^ele-
vator muscles of the limb, as in the act of blowing the
nose. She is obliged to throw her hand violently upwards
Fio. 3r.
and outwards from the trunk, a movement eo striting that
it attracts one's attention directly (Fig. 31). When she
walks, — which act is typically that of pseud o-hypertrophic
paralysis and includes the arching of the hack, — the arms
swing inertly beside the body.
Vi
Tki
COOPED ^umc^\i Qv:»\:^^
178 ANALOGIES OF EBB's AND DUCHENNE'S AMYOTEOPHY.
I am able to present to you the father of this girl. He
is 44 J ears of age and is attacked with the same affection.
Between the father and the daughter you see the resemblance
is very striking. In him as in her, the face and the upper
extremities, are atrophied. Not the least trace of hyper-
trophy of the muscles has ever been discovered either in
him or in her. He cannot wrinkle his forehead, and the
occlusion of the eyelids is always incomplete. He cannot
whistle, and when he tries to do so, the orbicularis contracts
unequally and forms a sort of knot in the right half of the
upper lip, at the only point where the contraction takes place.
As in his daughter, there is complete integrity of the
muscles of the hand. It may be remarked in passing, that
the muscles of the tongue, and those of deglutition, are
normal ; and one does not find, in a word, any of the bulbar
symptoms which sometimes exist in progressive muscular
atrophy of spinal origin.
This, gentlemen, is a most original variety, one possessing
strong individualities, the commencement in the face par-
ticularly. But is that a specific characteristic, and should
one on that account create a special group for it ? I do not
think so. If you abstract the participation of the face you
have in these patients the very image of the juvenile form
of Brb. It is, then, very probable that there exist
numerous points of contact, to say no more, between these
two varieties; and consequently an analogy with pseudo-
hypertrophic paralysis.
This proposition would be proved, partially at any rate, if
it were found that in some of the cases the onset occurred
in the limbs (juvenile variety), and the face was attacked
only late in the disease ; and that there were other cases
in which several members of the same family presented^
either associated in the same individual, or occurring in
separate subjects, some of the different varieties that we
have just been describing. Well, such conditions are to be
met with. There is a case described by M. Remak^ where
the outset was that of the ordinary juvenile variety, that is
to say where the upper extremities were invaded first of all,
1 Mendel's * Centralblatt/ 1884, No. 15.
PINAL CLASBIFICATION.
whereas the face was also attacked, only mucli later in the
disease, at the age of twenty-nino. And again, Mr. F.
Zimmerlin' has published the history of a family in which
two of the children presented the juvenile variety, the onset
occurring in the upper estremitiea ; whereas a third child
was attacked by the variety where the face ia first involved,
and the lower extremities with pseudo-hypertrophy. Hence,
it follows that the commencement in the face, or simply the
involvement of the face, is not a characteristic worthy of
forming a special class, but simply a variety.
While bearing in mind these cases of transition, the different
forms which we have enumerated, though distinct undoubtedly
in appearance, become fused together into a uniform group
which alone ia worthy of forming a clasa. If matters are
really thus, they are nndoubtedly much less complicated
than they aeemed to bo at first ; and the progressive amyo-
trophies are divided quite eiraply into two great classes;
the Jirst clasa is represented by the amyotrophy of spinal
origin, which comprise the following groups:
(i) Lateral Amyotrophic Sclerosia.
(2) ProgreaaivB Muscular Atrophy of the Duehenne-Aran
type. But this last, lot it be understood, may be reduced
to a much narrower extent, and disengaged from all foreign
elements which do not belong to it, bat which belong to the
following clasa of cases.
The second class consists of Primary Progressive Amyo-
trophies, which include, though only under the head of
varieties, the following .-
(1) Pseudo-hypertrophic paralysis.
(2) Juvenile form of progressive muscular atrophy, de-
scribed by Erb.
(3) Infantile progressive muscular atrophy of Duchenne
{of Boulogne).
(4) Those transitional cases, such as the one I have
shown you, where muscular weakness was the leading
feature; and where one finds in fact, neither atrophy nor
hypertrophy. Finally —
{5) Hereditary form of progressive muscular atrophy
described by Leyden, commencing in the lower extremities.
' Mendel'fl Central blatt," 1883, No. 3.
180
AFFECTION OP MOUTH ONLY
Tho mixed, or transitional, forms allow ua to draw these
different varieties closer together ; or even, it may be, to
group them together. Perhaps in the cases described by M.
Brb, a thoroughly searching examination of the muscles of
the mouth and eyes would have enabled him to find some of
the signs of Duchenne's infantile form. In nearly all our
patients, in fact, even in that one which showed neither
atrophy nor hypertrophy, there exists some difficulty of move-
ment of the muscles of the face. But in the slighter cases
these symptoms are not very striking. It is necessary to
look very carefully in order to find them. We have nnder
observation at this time two other patients, whom, unfor-
tunately, it is not possible for ns to show you to-day, which are
typical cases of the infantile form described by Dachenne
L
Flo, 31. — In this picture tbe exophthalmos it Dotveiy appareDt; but
tiie preaervation of tlie deltoid, and tha atrophy of the bioepi and
thenar lunacies are well Been.
Fis- 33.— Shows the incomplete occlusiou of the eyes, and the
asymmetry of tbe lips when the patient attempts to whistle. (The head
iu this photograph is forcibly pnabed hack.)
(of Boulogne), The father and the son {Fige. 32 and 33)
are both affected in the same manner; and in both, the
J
DISCOVBEBD BY CAEBFUL SEARCH.
participatiou of tbe orbicularis oris, and of the orbicularis
palpebrarum, would perhaps have remained undetected if
one had not examined them very carefully.
F10.3S.
Fio. 34, — Shows tbe incomplete occ
eiteot, tlie aBjinmetry of the lips.
ilionlderB are too farward.
Fis. 3S. — This shona thu deviation of the spinal colamn and of tbe
Bhonldeis.
L
1 82 CONCLUSION.
The son is an example of those cases of transition of which
I spoke just now (Figs. 34 and 35). There exists in him a
very pronounced weakness of the muscles of the upper
extremities, without atrophy or hypertrophy, whereas the
quadriceps extensor of both sides is more voluminous and
harder than under normal conditions.
Thus, all these varieties, so different in appearance, are
nevertheless all linked together, and all constitute one great
class, one morbid entity^ primary progressive myopathy.
Such then, gentlemen, is the outline of this large subject, as
far as I have been able to lay it before you to-day. It certainly
merits being developed and discussed at greater length,^
under the light of the long series of publications which
bear upon this important question. But that is a task
which I hope to be able to fulful on some future occasion.
This hoolis the p■ro^■
COOPER MEDICAL CO^ii -
SAN FRANCISCO, CAL
amd is not to be removed from the
lAbrarv Foora by a«y person or
under u.',ii y:'text whatever.
LECTURE XV.
TEBMOES AND CHOEElFOEM MOVEMENTS.— EH YTHMICAL
CHOREA.'
SoMMARY. — Tremors of dieeeminated sclerosis; oadllattovs
of large extent. — Trerfiors of paralysis agitans, and
senile tremors. — Tremors with small oscillations ; rapid
oscillatioiis, or vibratite tremors. — Hysterical tremors. —
Alcoholic and mercurial tremors. — Tremors of general
paralysis and of Basedow's disease.
Chorea ; characters of the involuntary movements of
the chorea of Sydenham. — Chorea and hemi-chorea, pre-
and post-hemiplegic. — Athetosis and hemi-alhelosis.
Shythmical chorea ; characters of tke movements ) they
appear in crises; they are rhythmical, systematic, and
reproduce more or less faithfully the movements of ordi-
nary life or of professional gesture {dancing chorea, ham-
mering chorea). — The disease is generally allied tohysteria.
— Prognosis varies in different cases.
Gentlemen, — In connection with the cases of disseminated
sclerosis that I have shown you in the last few lectares, I
wish to speak to you to-day about the various involuntary
movements with which the tremorSj so characteristic of this
affectioTi, may he confounded. I have insisted on the
peculiar characters of the tremors of disseminated sclerosis,
and have already shown you that they only become manifest
on occasions of voluntary movement of a certain force (inten-
tional tremors, Intentionzittem of German authors) ; that it
ceases to exist when the patients assume a condition o£ com-
plete repose, by lying down on the bed, for example.
If they are only seated, then the muscles of the neck and
' This lecture wbm edited bj M. Guinon, Int«rDe dea E6pil;aiu.
184 DISSEMINATED SOLEEOSIS.
the trunk are called in requisition to maintain the vertical
position of the body, and they produce oscillations of the
head and of the trunk, although the limbs are in repose. If
you wish to make the trembling reappear in the limb, you
have only to ask the patient to carry a glass or a spoon to
his mouth. This act requires a voluntary movement of suflS-
cient force, which is a necessary condition to bring on the
trembling ; for the tremor does not habitually manifest itself
in the smaller movements, such as threading a needle, &c.
At the moment of grasping the glass the oscillations are
but little marked, yet they progressively increase, and reach
their maximum at the moment when the glass approaches
the mouth. This special character of the tremors of dis-
seminated sclerosis is easily revealed by the tracing given by
a registering apparatus. No. i of Fig. 36 represents the
intentional tremor of disseminated sclerosis.
The line A B indicates the state of repose. The point B
represents the moment of commencing the voluntary move-
ment; B represents the duration of the movement, and
the trembling is represented by the wavy line x y z, oi
which each oscillation is larger the farther we get from B.
Such are the tremors of disseminated sclerosis. In order
to bring out more clearly the special characters which dis-
tinguish it, I wish to employ the method of contrasts. In
other words, I wish to show you this tremor side by side
with other tremors belonging to very different maladies \
although several of them have been confounded with it up
to the last few years.
Let us commence with paralysis agitans. Like that of dis-
seminated sclerosis, the tremor of Parkinson's disease is com-
posed of rhythmical oscillations, but of small extent and of
short duration. You can make out these characters in the
patient whom I will show you now. Notice that the hands
and fingers tremble individually, but fix well in your memory
the altogether peculiar attitude of the hand.
The phalanges are stretched one along the other, but the
fingers are fiexed on tHe metacarpus. The pulp of the
thumb is pressed against the index finger, imitating thus
the position of the hand in the act of holding a pen. The
PARKIN SON^S DISEASE.
185
movements, which agitate all the parts, remind one some-
times of the act of rolling up a ball of paper, or of crumbling
bread. This tremor is continuous, and is manifested — this
is the important point — independent of any voluntary move-
ment. If you tell the patient to carry the glass to his mouth,
you will see perhaps that the tremors augment a little in
a,mplitude, but he will never produce those oscillations of large
•extent, which are characteristic of disseminated sclerosis.
This character is well revealed by tracings taken with the aid
b
9 AAA/vvvvvvvs/vwNrJW> <^W\VvvnV/JI|\|\)I^^V^^
J'iG. 36. — This figure is a semi-diagrammatic reproduction of tracings obtained
by the graphic method in two patients now in the wards.
of the registering apparatus. No. 2 in the figure represents
ihe tremors of paralysis agitans. You see at once on look-
ing at this diagram how the two tracings differ in the
portion B C. The segment under the line A B represents the
time of repose. It is cut up by little waves corresponding
to the continuous trembling. At point B voluntary move-
ment commences. From this point the components of the
wavy line a? y 2 are a little longer and more irregular than
in the period of repose, but they are never so much so as in
<lisseminated sclerosis.
Bear in mind also that in paralysis agitans the tremor
^oes not in general attack the head, and if this seems to
participate in the involuntary movements it is in reality but
the seat of communicated movements.
The tremors of disseminated sclerosis and of Parkinson's
•disease are slow oscillations, with an average of four or five
186 SENILE AND HYSTERICAL TREMORS.
to the second. This same slowness of oscillations is found
again in what is called senile tremor. Here are two women
who are affected with this tremor. In one, the woman
named La — (now 73 years of age), the disease came on at
the age of 60 in the index finger of the left hand, after an
injury. In the other, the woman named Les — , 80 years of
age, it came on fourteen years ago, during the siege of Paris,
after violent emotion. In this woman the hands and the
fingers tremble individually as in Parkinson^s disease. The
head participates in the shaking, on its own account ; the
movements, which are both vertical and horizontal, succeed
each other with regularity, and in these the patient seems, by
her gesture, to say yes or no. These movements are absolutely
characteristic of the oscillations of the head in so-called
senile tremor.
Before passing to the subject of tremors of rapid oscilla-
tion, I wish to mention a kind of trembling that seems
to occupy a place between the two kinds, I mean hysterical
trembling. We have at the present time in our wards
two men who are thus affected. In one the number of
oscillations is five, in the other it is seven per second. I
will only mention this kind of trembling just in passing, as-
I propose to come back to the subject later on in moro
detail. I mention the fact only provisionally just now from
the point of view of rapidity of the jerks, which constitute-
in this respect a variety intermediate between the group of
slow oscillations and the one we are about to consider.
The second class includes those tremors having a rapid
oscillation, which I propose to call vibratile tremors. The
number of jerks in these cases amounts to eight or nine per
second, and this feature appears to be the only difference
which separates the first and second groups. We include^
in it :
(i) Alcoholic trembling.
(2) Mercurial trembling,
(3) That of general paralysis, and, lastly,
(4) That of Basedow's disease.
A further distinction that can probably be made between.
DHORKIFORM MOVKMENTS. 187
the first three and the last-named, rests on the fact that
whereas in the former the fingers tremble individually, in
the latter there is no trembling of the fingers themselves.
This distinction can be easily demonstrated by the aid of a
graphic method such as that which M. Marie has employed.
If a caoutchouc bag, communicating by a tube with the
reaction dram of a registering apparatus, be placed in the
hand of the patient, one sees that in cases where the fingers
tremble of themselves the tracing is very undiilatory,
whereas in other cases, in Basedow's disease, for instance,
we obtain a straight Hne, or at least one only juterruptod by
very slight nndnlatione.
In connection with the subject of muscular tremblings,
that is to say, tremors having a rhythmical oscillation,
which we have just been considering, there is another
variety of involuntary movement which can be, and which
as a matter of fact often is, confounded with the tremors of
disseminated sclerosis. I refer to chorea, or rather chorei-
form movements in general. Here we have to do, not with
rhythmical oscillations, hot rather with gestures, of larger,
unnecessary, and purposeless extent. These gestures do
not present any kind of cadence, and they are altogether
without signification, that is to say, they do not imitate any
expressive or professional niovoments.
They continue, like the preceding ones, during muscular
repose, and become exaggerated during voluntary move-
ment. But those useless gesticulations pervert the general
direction of tho movements, and cause the patient to miss
the mark, whereas in disseminated sclerosis, and in the
other tremblings of which I have just been speaking, the
general direction of the movement, although interrupted by
the jerkings which shake the limb, is as a whole always
preserved. Well, gentlemen, in spite of the fundamental
differences which exist between choreiform movements and
the movements of disseminated sclerosis, it happens that the
most distinguished physicians for a long time regarded
disseminated sclerosis as a sort of chorea. Duchenne (de
Boulogne), who had well differentiated the collection of
eymptoma belonging to disseminated sclerosis, bnt who did
This hook is the 'gro-^x ■ , ,
188 OflOBBA.
not recognise it from an anatomo -pathological point of view,
<5alled it choreiform paralysis. I will therefore say a few
words on the subject of these choreiform movements.
In the first place we have ordinary chorea, so-called
rheumatic ; comprising chorea minor, which might also be
called the chorea of Sydenham, and which should be clearly
distinguished from the true dance of Saint Guy, the great
epidemic chorea, chorea major.
It principally affects, as you know, children from five to
fourteen years of age, more rarely adults and old people.
You doubtless remember the girl named Plon — , whom I
have already presented to you as illustrating ordinary
chorea. In this girl the disease is dying away, and the
intervals of repose which separate the involuntary move-
ments are, at the present time, fairly long. But sometimes,
«nder the influence of an emotion, the doctor's examination,
for example, or sometimes spontaneously, small jerks, more
or less accentuated, become manifest in the upper extremity
of the left side. The patient brings her hand abruptly to
the side of her body, or, making alternative movements of
pronation and supination, rubs her hand against her thigh.
In her, by way of exception, a voluntary act does not
increase the jerkings, and if you ask her to carry a glass or
spoon to her mouth, the movement is fairly well directed,
and the goal is reached with sufficient accuracy, such as by
no means always exists in chorea. The face on the left
side is also affected with involuntary movements, and thus
she makes grimaces continually.
In the same group of inco-ordinate choreiform movements
should also be placed pre- and post-hemiplegic chorea.
Here the movements are in fact of the same nature, the only
essential difference rests in the pathology, the disease being
in such cases connected with cerebral lesions, localised in a
certain manner.
In the same way, gentlemen, athetosis, in a natural classi-
fication, should be grouped with chorea and with post-hemi-
plegic chorea. In athetosis there is no rest, and the move-
KHTTHMICAL CHOEEA. }89
menta are equally in co-ordinate. I need not stop to describe
to you the contortions o£ tte fingers and their alternate
flexion and extension. I have shown you already several
examples of athetosis, I should only like to remark that it
differs notably from chorea io that the movements are slower
(said to be like the movements of the tentacles o£ an octopus),
and lees abrupt than in this last malady ; and that they nre
limited to the fingers and the wrists, to the feet, and to the
toes, although sometimes they have been observed in the
face and eyelids. The patient is unable to hold anything
in his band or carry anything to his mouth ; anything
placed in his hands is immediately allowed to fall. In cases
of double athetosis these phenomena sometimes present a
rough analogy with the movements of disseminated sclerosis.
These, gentlemen, constitute the first two groups of
tremblings or involuntary movements ; but I must now speak
to you of an affection which constitutes our third group.
It also bears the name of chorea, although it differs con-
siderably, as you will see, from the chorea of Sydenham and
the allied affections. The study of these movements will
make us digress somewhat from disseminated sclerosis, but
I fear, if I delay, to miss the occasion of showing yon a
number of cases which one rarely has the chance of finding
collected together, — for it is a very rare affection.
In rhythmical chorea we find neither oscillations nor
vibrations, as in the tremors, nor the inconsistent and
purposeless gesticulations of ordinary chorea. But if this
affection is also characterised by involuntary impulsive
movements, these movements are more complex, and further-
more they often assume a regu lar rhythm or cadence. They
have not, you understand, the regular character of the chorei-
form movements that I have just been describing to you.
They might, indeed, be called systematic because they seem
- or din ate d on a definite plan, imitating, for
1
(i) Cert&ia movemenla of expression such as those of the
dance, and particularly character dances (dancivg chorea)}
' [Choree SaUatoire, vhich it would be more correct etymologicallj to
reader geeticutaiing chorea.^
190 CASE OF
(2) Certain professional acts, such as the movements of
an oarsman or a blacksmith {hammering chorea) [choree
malleatoire] .
In a word, we have here a more or less faithful reproduction
of voluntary or purposive movements.
The disease in question seems to be most frequently
allied to hysteria, or to be even of hysterical origin ; although
it may exist in some cases by itself, independent of all
phenomena indicative of hysteria. You will be able to see
for yourselves, moreover, how a transition may take place
between the two conditions, for without dwelling more on
theoretical considerations I will now place successively
before you three patients who present the symptoms of
rhythmical chorea in different degrees.
The first one, a girl named Plor — ,^ is known to you
already. But you only saw her casually and she merits a
more attentive study. She has been in the wards more
than six months, and formed the subject of a lecture
last year. From this you may infer that it is a very
rebellious affection, of which it is very difficult to relieve
your patient. This young woman is 26 years of age. She
has been married twice, first at the age of eighteen, and then
at twenty. She has had three children. She is of an irrit-
able temper. She was married to a workman, a fine fellow
withal, but the frequent disagreements between them gave
rise to much discord in the home.
Nothing of interest is to be found in the hereditary ante-
cedents, nor in the history of the patient herself. Three
years ago, after her last confinement, she began to exhibit
the following symptoms. She often experienced after dinner,
in the region of the stomach, a sort of swelling and pulsa-
tion, followed by a sensation of a ball in the throat. Then she
fell into a kind of syncopal or lethargic condition, and these
symptoms finally terminated by a fit of crying. About the
same time she had expectoration or vomiting of blood
(neuropathic ha9morrhages of Parrot). It should be added
also that at about the same period there was right hemianaas-
thesia, though not very pronounced. At the present time
^ A more detailed account of this patient is to be seen in the Appendix.
RHYTHMICAL CHOREA. 191
this has passed over to the left side, without modification in
the visual field, or any other sensorial affection : she has
never presented the ovarian phenomenon [ovarie]. These
represent, gentlemen, the stigmata of the great neurosis.
They have almost completely disappeared at the present
time j but their past existence enables us to affirm their more
or less hysterical nature, or at least the hysterical origin of
the affection from which she suffers now.
The onset of the attacks of rhythmical movement took
place on the 15th of May 1884, that is to say, last year.
They occurred for the first time during the menstrual
period, on the occasion of a dispute, and after one of the
attacks which she habitually had after dinner. Then the
chorea became permanently established, the attacks coming
on at any time, except during sleep. The seizures would
last from one hour to an hour and a half, separated by
intervals which were at first short, but which at the end of
a few weeks became gradually longer, until at the present
time they rarely occur spontaneously. We have discovered,
however, that they can be provoked with certainty by
certain manipulations.
Static electricity appears to have produced the amend-
ment which has lately occurred. It is undoubtedly under
its influence that the hemianadsthesia was at first shifted,
and then disappeared ; but I am afraid that the patient is
far from being completely cured yet. I remember a young
Polish girl who had attacks of hammering movements in
the arm, coming on in seizures lasting from one to two
hours, several times a day, which had continued ever since
the age of seven. I know not if she be actually cured yet ;
and furthermore, I shall presently show you a patient in
whom the attacks have lasted for thirty years.
The condition of Plor — , at the present time is as follows.
I have already told you that she had both spontaneous
attacks and such as were provoked. The former usually
come on after a meal, and are as it were a sort of relic
of the original hysterical attacks of the ordinary type. The
patient experiences pain and palpitation in the epigastrium
combined with a feeling as of repletion. Then the right
upper extremity begins to move, and is soon followed by
192 OASES OF
the left, and then by the lower extremities. Then you
witness a succession of various and very complex acts, in
which yon can recognise the characteristics of rhythm, or
cadence, and of a perfect imitation of certain voluntary
purposive movements, such as I mentioned in the general
description with which I commenced. When it is started
spontaneously, the attack begins without any other aura
than a blinking of the right eyelid.
The induced attacks can be obtained by pulling on the
left arm, or by striking with a hammer on one or other
patella tendon such as I am now doing. When you have
excited the attack by means of pulling the left arm, that
arm immediately commences performing rapid rhythmical
movements in which the patient seems to be whipping eggs.
Then she bends her fingers, applying their tips to the thumb ;
and raising her arm, makes the gesticulation of an orator
who is demonstrating. From time to time the whole of the
upper extremity performs extensive movements of circum-
duction. The lower extremities are also affected by move-
ments in their turn, and if the patient is in the erect position
she dances alternately on each foot, very nearly imitating a
jig or dance of the Tsiganes, or of the Zingari of Anda-
lusia. During the whole time of the attack the patient
is perfectly conscious ; and strange to say, when anyone is
placed close to her when she is executing some of these
violent movements, which would have the result of violently
striking the person near her, she warns them to take care
before the commencement of the gesture. It would appear
then, and this is an important feature from a psychological
point of view, that the act is preceded by a mental repre-
sentation which warns the patient of what is about to happen.
You can question her during the attack and she will reply
to you that she does not suffer ; that she is simply fatigued,
and inconvenienced by violent palpitations. After awhile
she stops and rests for a minute ; you think that the attack
is past; but no, soon it all recommences, and the same
phases are reproduced. The total duration of an attack
varies from one to two hours. She then lies down and it is
all finished. When she gets up again she feels somewhat
tired.
KHYTHMIOAL OHOKEA, 19S"
Now you will bo able to see an attack very similar to this
prodaced in anotber patient after similar manipulations,
ia in this woman, named Deb — , that the chorea baa lasted
foi- more than thirty years ; though the malady baa lately
undergone some amelioration in that the spontaneous attacka
bave become extremely rare. One scarcely ever sees tbem
in her now unless they are provoked.
Sho is now 67 years old. The menopause occnrred b,
long while ago, and one cannot therefore count on
it to put an end to her symptoms. I could show you
several examples of this kind in the category of bystero-
epilepsy. At tba present time there does not remain any
permanent sign of hysteria in this patient ; and there is
nothing else to bo discovered in ber except a great suscepti-
bilifcy to emotion, and the attacks of rhythmical chorea.,
The attacks are easily produced either by pulling on tba
arm, or percussing the patella tendon, as in onr first
patient.
But before giving rise to one of these attacks I should
like to indicate summarily the history of her case. The
onset occurred at the age of thirty-six. About this time,
when out driving in a carriage with her husband, she fell
over a precipice with the horse and carriage. After the
great fright which she had thus experienced she lost
consciousness for three hours. This was followed by a
convulsive seizure of hysteria major [grande attaque
hysterique], by rigidity of the limbs of the right side, and
cries like the barking of a dog. It was only after several
months that the rhythmical crises made their appearance,
such as we see to-day, only at the beginning they were more
intense and of longer duration.
Now look at this patient. It will not be necessary for us
to intervene, ' for the emotion that she has experienced at
finding herself before so many people in the lecture room
will save us the trouble of provoking an attack. In the
first phase, rhythmical jerkinga of the right arm, like the
movements of bammeriog, occur. The patient has her eyes
closed. Then after this period there succeeds a period of
tonic spasms, and of contortions of the arm and head,
13
his
It
>ed I
i
1
1
94
FlO. 3?-'
FiO. 40.
Fie. 43-
' The photographfi li
laboratoTf of the SalpSt
OASES OF
Fio. 38.
FlQ. 41.
FlQ. 44.
re reproduced have teen n
dere.
1
Fia. 39-
Fia. 41.
Fio. 4S.
^e bj M. Londe in the
1
1
J
r ■
BHYTHMIOAL OBOREA, 195
FiQ. 46. Fia, 47. Pia. 48.
recalling partial epilepsy. Here probably is a renmant of
tlie convulBive hysterical attack. Finally, measured move-
ments of the head to the right and the left occur ; rapid
movements defying all interpretation, for I ask you, what
do they correspond to in the region of physiological acts ?
At the same time the patient utters a cry, or rather a
kind of plaintive wail, always the same. And here again
we find that character of co-ordination, that apparent adap-
tation, which belongs as a peculiar feature to rhythmical
chorea. The attack ceases spontaneously. Daring all the
time the patient has not lost consciousness for a single'
instant.
You see by this example that rhythmical chorea may be
in certain cases a grave aSection. Not that it directly
menaces life, but that it may persist over a very long period
of time, and become a most distressing infirmity ; prevent-
ing the patient from following any occupation, and obliging
her to live apart from the world by reason of the fear which
these attacks inspire in those around, and the sentiment of
repulsion of which theso unfortunates feel themselves the
object.
Happily, gentlemen, matters are not always so dark in the
history of rhythmical chorea. And I can, by way of contrast
with the last two patients, present to you a third, in whom
the rhythmical choreic movements exist, though in a
rudimentary condition, and presenting in an early stage the
k L J
196 OASES OF
recnrrent attacks, botli spontaneous and provoked, whicli we
liave seen in the other two cases. But here they are always
intermingled with the phenomena of ordinary convulsive
hysteria. In a word, the rhythmical chorea which assomea
a hammering form in this third case, is an accompaniment
of the hysterical attack from which it cannot be altogether
dissociated.
The woman Bac — , 29 years of age, a needle woman, has
been in the wards since the 6th January, 18S5. There is no
trace of nerve disease to be found either in the hereditary
or personal antecedents. At the age of twenty-two years,
after a severe grief caused by the death of a relative, she
suffered from undoubted hysterical attacks, in which even
then choreic movements like those of the present time were
manifest. From 1878 to 18S4 she had but four or five
attacks, and those only as a consequence of annoyances. I
may note in passing, several blennorrhagio arthrites in the
right wrist and the left knee, as having co-operated more
or less in producing a return of the present symptoms.
There does not exist any sensorial trouble, no modification
of sensibility other than imperfect perception of cold on
the left side. An ovarian point exists on the right side ;
and thus the ovarian phenomena and the hemianesthesia
are crossed in a way that sometimes occurs.
When the attacks supervene spontaneously they com-
mence hy a sensation of uneasiness in the epigastric region,
and by palpitations of the heart ; sometimes the sensation of
a ball occurs. There is never any cephalic aura. One can,
moreover, provoke the attacks by pulling on the left arm,
and by jerking it at the same time, so as to imitate the
movements of hammering chorea. At first the left arm
commences to execute hammering movements, which the
right arm soon after executes also. At the same time the
whole body becomes stiff, the head and lower extremities
remaining immobile. At other times the legs begin to
shake, the eyes being closed and the eyelids flickering.
Every few seconds the patient interrupts the monotony of
the attack by making the arc of a circle. Pressure over the
right ovarian region causes the attack to stop, and then for
a moment the patient remains without speaking, or without
J
EHYTHMIOAL OHOBBA.
197
being able to put out the tongue. Here the hysterical
origin is much more clearly revealed than in the case of our
first two patients. The rhythmical malady cannot be
altogether detached as a separate affection. Hence^ the
case is I hope less grave. In shorty the case of this woman^
apart from the hammering phenomena, is one of ordinary
fits belonging rather to hysteria minor than to hysteria
major; the attacks occurring only rarely on the occasion of
an emotion. One can hope that under the influence of
appropriate treatment, these attacks will disappear at the
same time as the rhythmical choreiform movements which
accompany them.
• ■ 1 •
-;/ V
This look is thej[iTQptr
COOPER MBDIOALCOLLiiiGi..
SAN FRANCISCO, OAL.
and is not to be removed from the
lAhrarw Boom by o/n/y person CT
under a^.iy pr^teoct whatever* ■
1 1
I I .N
, - • -•-•I''" ''- - '»':
i . i
LECTURE XVI.
SPIEITUALISM AND HYSTEEIA.»
SuMMABY. — The influence of mtellectual stimuli on the de-
velopment of hysteria, — Belief in the supernatural, in
the marvellous; practices of spiritualism.
Narration of an epidemic of hysteria which attacked
three children of one family, living m a military
penitentiary, and addicted to spiritualism.
Nervous and rheumatic antecedents. — Description of
the attacks; hallucinations of vision; permanent and
transient stigmata, — Conclusion.
Gbntlembn, — It is undoubtedly true that whatever forci-
bly strikes the mind, whatever strongly impresses the
imagination^ is singularly favorable^ in subjects predisposed^
to the development of hysteria. Among all the different
means of affecting the cerebral functions perhaps nothing is
more efficacious^ and nothing whose action may not be more
frequently detected^ than the belief in the marvellous and
the supernatural which is fostered and exaggerated by
excessive religious exercises^ and the related order of ideas,
spirtualism and its practices.
It is sufficient to recall certain well-established facts^ as,
for example, in former times, the incident of the '^ Possedee
de Louviers/^^ whose imagination had been held, before the
*' possession,^' in a constant state of tension by the wicked
spirit which returned each night to the house where she lived.
' This lectoie was edited by M. Gilles de la Tourette.
' Fall report, taken down at the time, relating to the deliverance of a girl
possessed of the devil at Lonviers (159 1), office of the *Progr^ M^cal;'
' BibUoth^que Diabolique ' (1883).
FAMILY HISTOET. 199
And more recently the epidemic of hysteria which attacked
the six children of the aame Breton family, who had been
BatJated with fantastic storiea, where sorcerers and apparitions
played the principal parts.^
We have had the opportunity of observing one of these
little epidemics, of which I am able to present to you the
principal actors, and which merits a detailed description,
both on account of its mode of development and the means
which it afEords of studying hysteria in children, particularly
in little boys. It was in a military penitentiary that the
following incidents occurred.
Life in a penitentiary cannot be very gay. More-
over, in consequence of the arrangements necessary in such
an establishment, the apartments even of the directing
o£Bcials are considerably imbued with the sadness and dis-
cipline of the place. The rooms occupied by M. X — , a
sub -lieutenant, are situated on the third floor. They are
reached by a dark staircase ; and the apartments themselves
are badly lighted ; for all the windows look on to the central
court, a large one, it is true, but they are situated beyond
the reach of the sun, are narrow, and permit very little light
to enter.
M, X — , who has lived in the penitentiary three and
a half years, is 43 years of age. He has pursued his
military career with much indifference, though he appears
fairly intelligent. I shall refer again to his mental con-
dition. He has always enjoyed good health, and there are
no pathological antecedents of importance, excepting that
at the age of thirteen he suffered from an affection which
started with febrile symptoms and was followed by delirium
lantitig for six months.
Madame X — is 36 years of age, and has been married
since 1S79. She is of a neurotic disposition. She is im-
patient, lively, very emotional, but she has never had any
convulsive attacks. On the other hand, her mother, who
died in the month of March, 1S84, at the age of seventy-two,
of a cerebro-spinal affection, was the subject of very
' " Les pOBsddiSB de PWdrao," par te Dr. Barat«ni, ' Progtfes MiMJoal,' No.
33. 1881, p. 550.
200 PEEVIOUS HISTORY.
characteristic hysterical attacks on two or three occasions.
It may be noted also that her father was a confirmed invalid
from rheumatism.
M. and Mdme. X — have had four children, three of whom
are living, the fourth died, probably of asthenia, at the age
of two and a half years.
The child before you now, Julie, is the eldest of the
three surviving, and is 13^ years old. She was born
prematurely at seven and a half months, and in the
early years of her life was very delicate, having been
brought up by hand. From the age of three^ she was
boarded out with someone in the neighbourhood of the
penitentiary. Ever since an early age she has always been
exceedingly nervous. In the convent, as at home, she was.
always disobedient, difficult to manage, crying and laughing
without cause. In 1883 she menstruated for the first time ;
the first periods being accompanied by violent abdominal
pain, and since then they have not returned. Every year
she passed her holidays in the penitentiary with her parents.
It should be mentioned that she never witnessed a con-
vulsive fit.
Now I present to you the youngest of the boys, Fran9ois,.
aged II, who is pale and anaemic like his sister. When
fourteen months old he had convulsions, arid at the age of
two he suffered from rheumatic pains in the joints of his^
lower extremities, the knees and the feet. These pains,,
which since that time have returned on different occasions,,
have been severe enough to keep him in bed. He was
boarded at a pension in the neighbourhood of the peniten-
tiary, but returned every evening to sleep in the apart-
ments of his parents.
The eldest of the boys, Jacques, 12 years old, also
anaemic, lived the same life as his brother. For several
years he has had different varieties of ^^ tic,^' situated chiefly
round the mouth, such as you can see for yourselves
to-day.
In the month of August last the whole family was re-
united for the holidays, the father and the mother follow-
ing their usual avocation, the children playing together in the
courtyard of the penitentiary, almost always alone, because
SPIBITUALISM AND HT8TKEIA.
among the otter officers' families there was only one child,
fonr years old.
Life in the interior of a house of detention is undonbtedly,
as I said, terribly monotonous. Beyond the ordinary
routine, there is scarcely any distraction. Hence it happened
that in order to find relief from this monotony, the wives of the
officers devoted themselves with much earnestness, for more
than a year, to spiritualistic seances, at which a friend of
one of them came to preside every other day. This form of
distraction was very popular, and spiritualism counted many
devotees, amongst whom in particular were M. and Mdme.
X — . Madame, moreover, in addition to the seances, devoted
herself with much fervour to reading books which treated of
occnlt sciences ; books which she did not hesitate to place
in the hands of her daughter. As for M. X — , at first he
■was very indifferent to spiritnalism, but since the month of
March, 1883, he had never omitted to indulge, every Friday,
in table-turning. This day was specially marked ont by
him, because on a Friday he had been promised a medium,
by the aid of which ho could call up the spirit of his
mother.
Julie had already heen allowed to be present at a spiritual-
istic meeting during the Easter holidays, though it had not
affected her. The hohdays began on the 19th of August.
She had already taken part in several meetings, in which
she had only been allowed to place her hands on a table ;
but on Friday, the 29th, her father attempted afresh to
learn if it had not come to his turn to be a medium. He
asked the table, and that article, instead of indicating him,
as he had hoped, replied, " Julie will ie the medium." The
whole of Friday was devoted to an almost uninteiTupted
seance. The next day, at 9 o'clock in the morning, they
again met and called up different persons, and about 3
o'clock in the afternoon the table ordered Julie to write.
She took a pencil, hut at the sume moment her ai'msbecam&
rigid and her look fixed. The father, being frightened, threw
a glass of water in her face; she came to herself, and her
mother, fearing danger, would have forbidden her any more
table-turning. But this did not suit the convenience of the
Beighbour, the spirit of whose friend was present at the seance.
SFIBITnAZISU
DeairotiB of queBtioning tlie soal of a certain persoDj who
it seemed was her sister, she took Julie home with her, and
the seance recommenced. About 7 o'clock the tahlc rapped,
the spirit appeared, and Jalie said to it, " Please to sign your
name." Immediately she herself, in the capacity of medium,
and under the inspiration of the spirit, seized a pencil, and
with trembling hand signed, convulsively, " Paul Denis," with
a flourish. The writing was that of a man j the P and the D,
moreover, presented most curious characters, such as the
little girl has never been able to reproduce since that
occasion. The signature was no sooner made than the hand
which had written it became convulsed, and then Julie, burst-
ing out into a laugh, stood upright, and rushed about the
house as though she were mad or delirious, giving
utterance to inarticulate cries. Soon afterwards she
rolled on the ground, presenting a series of hysterical
attacks, which were characterised chiefly by clownish acts
[clownisme] .
The next and the following days she had a great number
of attacks, twenty to thirty a day, Matters went on thus
till the 15th of November, Julie continuing to have fits which
were scarcely modified by the application of different means
of treatment, and particularly of hydrotherapy.
A few days before this Francois, the youngest of the
boys, who like his brother had taken very little interest in
the spiritualistic performance, had been seized with pains in
his joints which necessitated his staying in bed. All of a
sudden, on the 1 5th October, he sat up in bed, cried out that
he could see lions and wolves ; then he got up, knocked at
the doors, saw his father dead, attempted to kill imaginary
brigands with a sword, rolled about on the ground, crawled
along on his belly, and produced some very characteristic
passionate attitudes.
Two days later, Jacques was taken with an exacerbation
of the tic in the face. Then, seeing hia mother crying, he
called out, " I will kill myself if you weep." And after that,
transient attacks of delirium supervened, during which he
muttered, pronounced incoherent words, saw brigands and
assassins whom he wished to strike.
It was on December the gth that the distracted father
i
AND HTSTBBIA.
and mother, who had tried a lot of ineEEectaal treatment,
brought their children op to Sa]p§tri&re.
Isolation at any rate had become an absolute necessity,
for when one of them was seized with a fit the other two
immediately followed the example-
Julie, whose previous history yon already know, and who
is 134, is a tall girl, well built and well developed, although,
as I told you, the catamenia, which had appeared for the
first time in 1883, have not become permanently established.
In spite of what we learned from her mother, she appears
to be of an amiable and tranquil disposition. On the early
days oE her arrival, and daily since then, she has had
several attacks which in general possess the following
characteristics. All of a sudden, sometimes after an aura
of very brief duration and very varying kind, she throws
herself backwards, the arms become stretched out from the
trunkjthehandsaasnmeapositionof pronation, and the fingers
are strongly flexed. Not unfrequently she performs one or
more semicircular bondings of the body, generally in a lateral
direction, and finally the clonic stage occurs, characterised
by somersaults forwards and backwards, the head touching the
pelvis ; or else the upper extremities are thrown about in
the air, the bead resting on the bed. During the attack Julie
groans, laughs, but never speaks. The seizure, which is
composed of a series of fits analogous to those I have just de-
scribed, lasts sometimes three quarters of an hour, one
hour, and even an hour and a half. It can be stopped or
provoked at will by pressing on one of the bysterogenio
points which the patient possesses. In fact Julie presents
some of the permanent hysterical stigmata. Although she
has neither cutaneous anaesthesia, nor the ovarian phenomena
[ovarie], she has numerous hysterogenic zones situated at
the same level of the two breasts, on the outer side of the
two flanks, the two calves of the legs, two external malleoli,
and on the inner side of the right elbow-joint. An ex-
amination of the eyes made by M. Parinaud gives very
characteristic results. On the right side there is a very
marked retraction of the visual field j moreover, not only ia
the red field situated within the blue, but it is very per-
-ceptibly more extensive than that for white light. The
204 SPIRITUALISM
same phenomena exist on the left side^ although less
accentuated. The other special senses are intact.
Pran9ois, the youngest of the boys, ii years old, also
presents some permanent stigmata, in addition to the attacks
I am about to describe. Thus the day after his admission
we discovered an ansasthetic area which included the whole
of the face. This area was somewhat variable, for during
the next few days the insensibility was confined to the
middle part of the forehead, and the nose. The integument
beyond this is notably hyperaesthesic. All the special senses
are affected ; the taste is totally abolished ; there is com-
plete insensibility of the tongue ; and the pharyngeal reflex
does not exist. The mucous lining of the nose, and the
sense of smell, share the general condition ; the external
auditory canal is insensible, and hearing is very deficient.
An examination of the visual field is very instructive.
There is very accentuated retraction on the left side, and
not only is the red circle outside the blue circle, but here
again it is larger than the field for white. On the right side
the retraction is less marked, and there does not exist the
transposition of colours. Pran9ois has one to five attacks
every day, some of which last as long as two hours. He
presents very clearly the series of phenomena of hysteria
minor and hysteria major [petit et grand mal hysterique] .
In him the first consists of a contracture of the two orbi-
cularis palpebrarum muscles, which lasts from three to five
minutes without loss of consciousness ; or again, the child
strikes out with his fist, or with bis foot, utters a few inco-
herent words and then it is aU over. But more frequently
the preceding symptoms are followed by a^ series of fits
constituting an attack. Then the child stiffens his upper
and lower limbs, shuts his eyes, throws himself into semi-
circles ; then he flings himself on the ground, crawls on his
belly, strikes the earth, calling out about an assassin, and
kicks at and defends himself against imaginary beings.
Then the tonic phase commences again, and thus the attack
is constituted by a series of fits, with confusion, or a very
varying predominance, of one or ^ther phenomenon. Curi-
ously enough, when the left hand with its outstretched
fingers is squeezed, the attack stops instantly ; but it cannot
AND HTSTEEIA. 205
be provoked in this way. TRe skin in this position presents
no affection of sensibility.
Jacques 12 years of age, pale and anaemic like his brother
and sister, is the least serions case of the three: Although hd
has one, two, and sometimes three or four attacks a day,
he does not present any permanent stigmata, and there is a
marked predominance of hysteria minor over hysteria major
in his case. We know that before this illness he was
subject to " tic ^' in the face. This becomes greatly ex-
aggerated at the outset of the attack. He makes grimaces,
the labial commissures are drawn outwards, he mutters, shuts
his eyes, pronounces a few incoherent words, and then
perhaps all is finished. But sometimes, following on these
symptoms, or even at the very outset, the eyes close, the
body becomes stiff, and assumes the position of an arc of a
circle. Then the child runs or walks, talks aloud, calls out
about a thief, and finally goes and throws himself on his
bed, where either the attack ends, or else a fresh series of fits
recommence, lasting rarely more than a quarter of an hour.
These facts seem to me to merit your earnest attention. The
symptoms which these children present are not the transient
phenomena of hysteria. Julie has been ill for four months,
and although isolation seems to have had a calming effect
on her attacks, such as it has had on her brothers, it is
nevertheless true that her symptoms threaten to persist for
a long time still; because one dare not put the children
together again without immediately bringing on an attack
in all three.
The complete narration of the epidemic occurring in this
little household is most instructive in many ways. It will
enable you to understand the genesis and evolution of the
complaint in a ^^ nervous " and ^^ arthritic^' family, and is a
contribution therefore to. the two diatheses, between which an
alliance is so frequent and so potent. It will show you the
influences which may be exercised by different modes of life,
and surrounding conditions. Finally, it clearly indicates to
you the danger, especially in those predisposed to this class
of disease, of superstitious practices, which have unfortu-
nately so great an attraction for those very individuals. It
206 PROGNOSIS.
reveals the danger of tlie constant tension of mind which
necessarily exists in those who are addicted to spiritualism^
or, to gratifying a love of the marvellous — a love that has
such a remarkable hold on the minds of children.
This hook is the pivi'
COOPER MEDICAL COLL;
SAN FRANCISCO, OAL.
amd is not to be removed from the
Lihnxv I^oom by any person or
iind^>- <("H 'i-retext whateoer.
LECTURE XVli.
ISOLATION IK THE TREATMENT OP HTSTEEU.'
SuHMABY. — Recapitulation of the epidemic of hysteria. — Tka
treatment comprises two parts ;
(a) Moral or psychical treatment: i, Removal from
the place where the disease originated ; 2, Complete
separation of the persons attacked ; 3, Suppression of all
visits from relations or friends.
(b) Medical treatment : i. To modify the diathesis, if
one exist J rheumatism ^ot example ; 2, Static electricity ;
3, Methodical hydrotherapy.
Preponderating influence of isolation. — Cases. — Tke
treatment has been adopted, not invented, in Germany
or in England.
GrENTLEMEN, — Before coming to the principal subject of
our lecture to-day, I think it may be useful to give you the
latest particulars of the three children belonging to one
family, whom I presented to you on the 19th December
laat. I do not intend to again relate all the history of this
little epidemic of hysteriaj which originated under the
influence of spiritualistic practices. You will find all the
particulars set forth in the preceding lecture. It is only
necessary for me to remind you of certain details as to the
Btate of the children at that time, so that you may be better
able to judge of the modifications which have been pro-
duced in their condition under the influence of the measures
which we have adopted for their treatment.
The family, I may remind you, consists of three children j
two boys and a girl. In this laat named, who is 13^ years
old, the affection started on the 28th April, 1884, after a
I Lecture edited bj M. Gilles de la Tourelte.
^
208 PRINCIPLES OF
spiritualistic seance which had lasted from nine o'clock in the
morning to seven in the evening, and in which the patient
Julie played the part of medium. At the conclusion of the
finance she was seized with convulsive fits, which recurred
fifteen or twenty times a day up to the time of admission of
the family into the SalpStrifere on the 9th December, 1884.
Shortlv afterwards the two brothers followed the bad
example which had been set them by their elder sister. On
the 15th November, that is, about six weeks after the famous
spiritualistic seance, Frangois, the younger of the two, 1 1
years of age, who was not, however, directly affected by the
seance, was seized with an hysterical fit, accompanied by
delirium, at a time when he was laid up in bed with an
attack of rheumatism.
Two days later, on the 1 7th, the elder of the boys, Jacques,
was in his turn seized with a delirious attack, accompanied by
I'allucinations.
From that time it was impossible for the children to
meet in the house without being seized with these attacks.
The little girl would begin, and then the brothers followed
her example. This might happen several times a day,
tind the position consequently became unbearable. Then
it was that the parents besought us to intervene, and we
suggested to them that we should take the children into
the Infirmary, in which course they gladly acquiesced.
The proposition thus made to the parents contained in
itself a series of therapeutic considerations, which I can now
•explain.
The admission into the Infirmary would enable us to
effect :
(i) The removal of the patients from the place where
their malady had originated.
(2) The absence of the father and mother, who had them-
selves become very nervous ; and whose presence, according
to my former experience, which dates now from a good many
years ago, would effectually check all treatment.
(3) The separation of the three children from one
another.
The little girl was placed in one of the female wards of
the Clinique. The two boys were placed in the only men's
TBEATMENT. 209
ward which we possessed at that time. Thus, the respec-
tive isolation o£ the three patients was not qriite perfect;
though we had at any rate prevented their all being to-
gether. Such in my judgment should be the fundamental
conditions of treatment. The parents consented that they
should only see their children with my authorisation ; and
then I thought we should probably be able in a few months
to send them back home, completely cured.
This was the treatment so far as the moral or psychic Bide
was concerned. We did not, however, propose to lose sight
of the more strictly medical treatment. The children who
were confided to our care were all three pale and anasmic,
therefore we prescribed for them tonics, amongst which iron
and bitters held the chief place. One could also endeavour
to modify the rheumatic diathesis, which was so accentuated
in at least two of them.
As for the agent specially directed to the hysterical con-
dition, we depended upon the employment of static electri-
city, which daily renders us great service in these cdses;
especially bearing in mind that we could not employ
methodical hydrotherapy as- the hydrotherapeutic establish-
ment of the Salpdtriere was not yet completely arranged.
We did not place any hope in the employment of bromides.
The experience we have had for some time past has tended
to show that this class of remedies, which acts almost
always in a greater or less degree in epilepsy, remains com-
pletely inert not only in hysteria proper, but also in that
form of hysteria which most nearly resembles epilepsy, that
is to say, hysteria of an epileptic form, or hystero-epilepsy.
I do not allude to opium in large doses, nor to the numerous
other anti-spasmodics, whose employment I do not absolutely
condemn, but which, it seemed to me, would lead to no
result under the conditions we then had to deal with.
But, gentlemen, I must confess that among all the thera-
peutic agents which it was possible to employ, I relied
chiefly on Isolation; that is to say, on moral treatment,
although it was necessarily incomplete. It was possible,
no doubt, that the children might meet in going about
the Infirmary, such as not unfrequently did actually
14
r
210 IMPOBTANCB OF ISOLATION.
happen. Moreover, the two brothers lived in the same
ward ; and, like their sister, they were doubtless able
to see the m an ife stations of convulsive hysteria from time to
time as they went about the place. But we had no choice,
and in my opinion it was better for them to live under sneh
conditions, than to remain under the parental roof in porpetnal
contact with their father and mother, and in actual com-
munication with each other all the time.
It would not be possible for me to insist too mnch on the
capital importance which attaches to Isolation in the treat-
ment of hysteria. Without doubt, the psychic element
plays a very important part in most of the cases of this
malady, even when it is not the predominating feature. I
have held firmly to this doctrine for nearly fifteen years, and
all that I have seen during that time — everything that I
have observed day by day — tends only to confirm me in that
opinion. Yes, it is necessary to separate both children and
adults from their father and their mother, whose influence,
as experience teaches, is particularly pernicions.
Experience shows repeatedly, though it is not always easy
to understand the reason, that it is the mothers whose
influence is so deleterious, who will hear no argument, and
will only yield in general to the last extremity.
In private practice. Isolation, such as I understand by
the use of the term, is practised daily for cases of this kind
under excellent conditions. In Paris, during the last fifteen
years, establishments of hydrotherapy take patients who are
so disposed in hand with much success. In the provinces.
Isolation is more difficult to effect, because conveniently
arranged establishments are more frequently wanting. One
can, no doubt, create artificial private asylams, but it may
be readily understood that the arrangements are often
seriously defective.
The patients are placed under the direction of competent
and experienced persona. They are generally religious
people who by long practice have become very expert in the
management of this sort of patient. A kind but firm hand,
a calm demeanour, and much patience, are here indispensable
conditions. The parents are systematically excluded up to
the time that a notable amelioration occurs ; and then the
i
AHOBBXIA BTaTHBIOA.
patients are allowed, as a sort of recompense, to see them ;
at first at long intervalSj and then more and more frequently
in proportion as the improvement becomes more obvious.
Time and hydrotherapy, without counting any internal
medication, perform the rest. For my part, I am firmly
convinced that hysteria, recently acquired, especially in
young subjects and particularly in males, could often be
stifled at the outset if it were possible to persuade the
parents to undertake energetic measures at the beginning,
and not to wait until the disease had taken deep root and
become developed from having been a long time abandoned
to itself.
In order to render more .apparent this remarkable in-
fluence which Isolation has in the treatment of hysteria in
young subjects, including young and marriageable girls, I
might quote a number of cases where it has proved itself
most efficacious. But not being able to enter here into
lengthy detail I will confine myself to the following anecdote,
which seems to be quite a case in point. It relates to a
young girl of AngoulSme, thirteen or fourteen years of age,
■who had grown very fast for five or six months, but who
then systematically refused all kind of nourishment, although
she was not troubled with any affection of deglutition nor
any disorder of the stomach.
It was indeed one of those cases bordering on hysteria,
bat which do not always property belong to it, and which
have been so admirably described by Lasegue in France,
and by Sir William Gull in England, under the name of
nervous anorexia or anexoria hysterica. The patients eat
nothing, they do not wish to, they cannot eat, although they
have no mechanical obstacle in the primaa vise, and although
there is no reason against the food remaining in the stomach
when they have taken it. Sometimes they take nourish-
ment in secret, but not always as it has been supposed ; and,
although the parents themselves foster this deceit by pro-
viding them with food which they prefer because they can
consume it in secret, alimentation always remains insuffi-
cient. Weeks and months pass by, and it is always hoped
that the desire for food will reappear. Prayers, entreaties,
212 CASE OF
violence, are unable to overcome their resistance. Then ema-
ciation soon comes on ; it reaches truly extravagant propor-
tions; and the patients, without exaggeration, become nothing
but living skeletons. And what a life ! Cerebral torpor
has succeeded to the fictitious agitation that existed at the
outset. For some while walking, and even standing upright,
have become impossible. The patients are conned to bed
and they are scarcely able to move. The muscles of the neck
are paralysed, the head rolls like an inert mass on the pillow.
The extremities are cold and cyanosed, and one is tempted
to ask how life is carried on in the midst of such decay.
The parents have been alarmed for some time, but the
alarm reaches a very high degree when matters have come
to this point. It is indeed quite justifiable, for a fatal
termination seems to threaten, and I myself know at least
four cases where it has actually occurred.
. Such was very nearly the situation in the case of the little
patient from Angoul6me, when I received a letter from the
father depicting this lamentable condition, and beseeching
me to come and see his child. ^^It is unnecessary forme
to come,'^ I replied ; " I can, without seeing the patient, give
you appropriate advice. Bring the child to Paris, place her
in one of our iydrotherapeutio establishments, leave her
there, or at least when you go away mak^ her believe that
you have quitted the capital, inform me of it, and I will do
the rest." My letter remained without reply.
Six weeks later, a medical man from AngoulSme arrived
at my house one morning, in great haste, tod apprised me
that the little girl, who was his patient, was in Paris installed
in one of the establishments that I had indicated ; that she
was going from bad to worse, . and that very probably she
had but a few days to live. I asked him why I had not been
informed sooner of the arrival of the little girl. He
answered that the parents had avoided doing so because they
were resolved not to be separated from their child. In reply I
told him that the principal element, the sine qua non of my
prescription, had been misunderstood, and I must decline all
responsibility in the unfortunate affair^ However, at his re-
quest> I went to the establisliment indicated^ and there I saw
AKOBI!X[A HT8TEKI0A. 213
a lamentable eiglit. She was a tall girl, I4year8 0f age, who
had readied the last stage of emaciation, in a doraal decubitus,
with weak, voico, extremities cold and hlue, and the head
drooping, reproducing in a word the main features of the
picture I have just sketched to yoa. There was indeed every
reason to be uneasy, very uneasy,
I took the parents aside, and after having addressed to
them a blunt remonstrance, I told them that there remained,
in my judgment, but one chance of success. It was that
they should go away, or pretend to go away, which amounted
to the same thingy as quickly as possible. Thoy could toll
their child that they were obliged for a special reason to
return to Angoul^me. They could lay their departure to my
door, a matter which was of little importance provided that
the girl was persuaded that they were gone, and that they
went immediately.
Their acquiescence was difficult to obtain in spite of all
nay remonstrances. The father especially failed to under-
stand how the doctor could require a father to leave hi3
child in tho moment of danger. The mother said aa much,
but I was animated by my conviction. Perhaps I was
eloquent, for the mother yielded first, and the father followed,
tittering mahdictuma, and having I believe but little con-
fidence in the prospect of success.
Isolation was established ; its results were rapid and
marvellous. The child, left alone with the nun who acted
as nurse, and the doctor of the house, wept a little at first,
though an hour later she became much less desolate than
one would have expected. The very same evening, in spite
of her repugnance, she consented to take half a little biscuit,
dipped in wine. On the following days sho took a little
milk, some wino, soup, and then a little meat. The nutri-
tion became improved, progressively but slowly.
At the end of fifteen days sho was relatively well.
Energy returned and a general improvement in nutrition,
so far that at the end of the month I saw the child seated on a
sofa, and capable of lifting her head from the pillow. Then
she was able to walk a little. Then Iiydrotherapy was brought
into play and two months from the date of the commencement
of the treatment she could be considered aa almost Oom-
214 ISOLATION ORIGINATED IN FBANCE.
pletely cured. Power, nonrishment, appetite, left very little
more to be desired.
It was then that the girl, when questioned, made the follow-
ing confession to me : ** As long as papa and mamma had not
gone — ^in other words, as long as you had not triumphed (for
I saw that you wished to shut me up), I was afraid that my
illness was not serious, and as I had a horror of eating, I
did not eat. But when I saw that you were determined to he
master, I was afraid, and in spite of my repugnance I tried
to eat, and I was able to, little by little.^' I tl^anked the
child for her confidence, which as you will understand is a
lesson in itself.
I should easily be able to multiply examples which clearly
show the favorable influence of isolation, properly carried
out, in the treatment of certain nervous affections not coming
under the head of mental alienation, but of hysteria, or of
neurasthenia.
In fact, what I have just said in reference to nervous
anorexia can be repeated in relation to most of the other
forms of the hysterical neurosis, but it will suffice for the
moment to have aroused your attention to the curative
influence of isolation. It is a subject on which I shall have
occasion to return many times without doubt in the course
of these lectures. I have spoken of it every year for nearly
fifteen years, and several of the lectures that have been
devoted to it have been published. The method has, more-
over, made some progress, for I see that in Germany
principally, and also in England and America, its efficacy has
begun to be loudly proclaimed. But I think that we may
claim priority, for if I am not deceived it belongs legiti-
mately to us, at least as far as relates to the treatment of
hysteria and allied affections. It is, in fact. Isolation
which represents the chief feature in the method that
was described a few years ago by Drs. Weir Mitchell in
America, Playfair in England, Burkart^ in Germany, in the
treatment of neurasthenia and of certain forms of hysteria.^
* R. Burkart, "Zur Behandlnng schwerer Formen von Hysterie nnd
Neurasthenie " (YolkmaDn's ' Sammlang,' 8 Ootobre, 1884).
^ The isolation of hysterical patients has for a long time been considered
PBOOBESB OF CASES. 215
But I see that it is time to oome bact to our young
pationts. I wish to show you what course their affection
has followed during the last six weeks, since the time when
the treatment, in which isolation has played the principal
part, was initiated. An amelioration has occurred in all
tbree, commencing in the boys.
The youngest, Franr^ois, may perhaps be considered aa
cured. He has not had any fits for a fortnight, and yester-
day he celebrated the event at home with his father ; from
which trial he has emerged triumphant.
It is not quite the same with his elder brother Jacques.
He was, you will remember, attacked the last. The serious
fits have completely disappeared in his case. However, they
have been replaced by small attacks of vertigo, like enough
in their form to epileptic vertigo, though these even have
become very rare for the last two weeks ; however, when he
went to see his father in company with his brother he had
one of these little vertigos which I have been in the habit o£
describing under the name of le petit mal hysterique.
The girl did not take part in this expedition ; she
remained at the Salpfetriere, for we were much less sura
about her than about her brothers. She is not yet cared,
although day by day the crises diminish in frequency, in
duration, and intensity.
Her progress would certainly have been much faster in
the ward which she occupies, if she had not been in constant
intercourse with subjects of hysteria major in whom she saw
attacks daily.
But we have not been able to do better, not having an
isolation ward at our disposal. Nevertheless, the situation
as the chief part of their treatment. The following quotation from Jean
Weir (1564) IB sufficient to prove thin : "For the rest, if there be aeveral be-
witched or possessed of the devil in one place, such aa may sometimes
happen in monasteries, principally by means of girls (as being the more oon-
venient agents for the wiles of the devil), it is necessary above all things that
they shoold he Beparated, and that each should be sent away to his relations
or elsewhere ; to the end that they maj be more conveniently trained and
cured, always hnving regard to the necessities of each. And so that all may
not be booted from the same last, as the saying is." (Jean Weir, ' Hiatoires,
dispntes, et discours des illusions et impostoree des dlables, &c.,' II, pp. 173,
174, Edition Bonmerille, Paris, 1885.)
216 FBOGBESa OF CASES.
is very much improved^ for here is a significant fact, the
children have been several times all three together in the :
electro-therapeutic room without any fits having occurred.
I am now going to present to you the boys first .and
afterwards thegirl^ for^.as liihave said, I am not quite so,
sure of her, and I fear that the sight of so large an assemblage
may affect her to the extent of provoking some crisQ3* Then
in the case of the boys first, and also in the girl, I want
you to observe that the hysterical stigmata, las we call them,
have become modified in the same way as the spasmodic
and deliriant crises. That is a, very important point,: because
I do not belie[v.e that one should consider an hysterical
pal^ept cured as long as the permanent ^tigmat^ persist..
Here then is little Frangois, 1 1 years old. It is in him
that the cure is most advanced* . You will notice in the first
place that l^e has a much better aspect than he formerly had.
The tonic medication and the regimen of the hospital, albeit
not of an ideal kind, has done him much good in this respect.
As for the stigmata, I would remiind you that in him, they
consisted of an anassthesia limited tOi the face, and especially
to the forehead, like a- mask. He could npt pprc^ive odours,
nor was the nasal mucous membrane, infiuenced in any < way
by ammonia or acetic acid. Hearipg was blunte4> and one
could introduce into the external auditoiy canal little paper
spills without producing any sei^sation,^ . The general sensi-
bilitiy o£ the tongue and the taste ^v^ere, completely abolished.
One could put sulphate of quininQ,Qr. aloes, o^ th^e tongue
of the patient without his having the least perceptiqn.
In reference to this, last point, about, fifteei; days ago I
p^^^e]|;ited 1;his little patient to my, dist^ingi^ished colles^gue*
from London,^Dr. Russell Reynolds, who was passing through
Paris, proposing to make him acquainted with the troubles
of gustation. I confess to, you that I was very agreeably
surprised.at finding that. the little fellow drew, in his tongue,
and made an ugly grimace ; for it indiciated to me< that our
method of ireatmtot had been^ atteiided with good results,
and that the patient lyas on the rdad to cure. As far as
the t^ste is concerned, the symptoms have not completely
gone, as you will be able to judge for yoiirselveR, . , ,
Vision, you know, in this child 'presented special cha-
PROGRESS OF CASES. 217
raoters. It is true that they do not belong absolutely to
hysteria; but they are met with so frequently that one can
attach to them a great diagnostic importance. The retrac-
tion of the visual field was very accentuated on both sides ;
but although on the right side there did not exist a trans-
position of colours^ on the left the red circle was not only
outside the blue circle but it was even more extensive than
the white one. A fresh campimetric examination made by
M. Parinaud twd days ago has shown that these troubles
were disappearing atfid that' the vision was becoming normal.
I have already told: yott that the crises had completely
disappeared. Allow me to remind you that he had an ave-
rage of three a day, amounting to a total of twenty to twentyr.
five per week.
Now I present to you little Jacques, the eldest of the .
boys, 12 years old, who was attacked last in order, though
less seriously than his brother, and who did not present per-
manent hysterical stigmata. In him the attacks of hysteria
minor [petit mal hysterique] occurred much more frequently
than the attateksof hysteria major [grande mal] . Neverthe-
less he has had fifteen attacks in seventeen days. For fifteen
days he has only had twd attacks of vertigo, and one of those
occurred yesterday, under circumstances of which you are
aware. In connection with this question, I may mention
once again that it is but an imitation of the vertigo of
petit mal 6pileptique and nothing more. It is but epilepsy
in appearance, not in reality ; and, in fact, the petit mal
epileptique and petit mal hysterique are two phenomena
radically and fundamentally distinct.^ You will remark
moreover, that the general condition, of this child has im-
proved, though there is still much to be desired in many
respects.
Here is the little girl Julie, the eldest of the three. She
appears to me to have grown and developed during the month*
In any case her general condition has become more satisfactory.
As for the hysteria, you will remember that she had on
^ See upon thb subject (i) Boumeville et Eegnard, 'Iconogr. pLotogr. de
la Salpdtri^re/ vol. i, p. 49, and vol. ii, p. 202, and (2) Bourneville,
* Recheifchea din. etth^rap. sur I'^pilepsie, Thyst^rie, &c./ Compte rendu du
service des enfants de BicStre pour 1883, p. 100.
218 FBOGBESS OF GASES.
an ayerage four or five attacks^ or rather series of attacks^
every day, which lasted from one hour to one hour and a half.
For the last fortnight the attacks haye not appeared more
than two or three times a week. They are less violent, and
last for scarcely a quarter of an hour. You know that there
exist in her some very well-marked hysterogenic points,
situated at the same level on the two breasts, the external
part of the two flanks, the two calves, the two external
malleoli, and the inner side of the right elbow. The zones
of the two breasts, of the calves, and of the right elbow, have
disappeared. The ovarian phenomenon did not exist, but
instead of this we discovered several ansesthetic arose irre-
gularly scattered on the left side. The hysterical amblyopia,
which was very well marked in her, has not been discovered
for the last ten days. And lastly, as I have already said,
she is able to meet her brothers without incurring an
attack.
Such is the situation now, and there is every reason to
hope that his little family drama, or as one ought to say, this
little comedy, for there is nothing really sombre in all these
occurrences, will soon be ended. In ten days or so more,
we shall send the elder of the boys home to his parents >
the younger will leave us to-day, and the girl will join them
later on,^
I will leave you to meditate on the teaching which the
history of these children implies. I believe that by tho
aid of the means which I have explained, one can very
frequently manage to quench an attack of nascent, or infan-
tile hysteria, at its outset, especially in tli^e male. I speak
now only of this kind ; for when this neurosis has become
inveterate, and occurs in adults, the chances of success,
although still great, are much more problematical. As far
as concerns these children, I believe that in spite of the
neurotic disposition which seems to be in them so accen-
tuated, they will henceforth be free from hysterical manif es-
^ The younger of tlie boys is now completely cured. For more than
fifteen days the little girl has only had one slight attack and that wa&
during a visit of her parents to. the Salpdtri^re.
PEOGNOSIS. 219
tations for a long while, if not for always. The parents,
taught by experience, will certainly for the future avoid
spiritualistic practices, and, knowing the weak side of their
children, will be enabled, I hope, by the aid of physical,
moral, and intellectual hygiene to prevent a return of similar
accidents.
This hooh is the proptj
COOPER MEDICAL COLLx u. ,
SAN FRANCISCO, OAL
and is not to be removed from the
Library Boom by a/ay person or
luuhr any 'pretext whatever*
LECTURE XVIII.
CONCERNING SIX CASES OF HYSTERIA IN THE MALE.*
Summary. — Hysteria in the male is not so rare a^ is thxmght,
"—The part played by injuries in the development of the
affection : railway-spine. — Permanence of hysterical stig-
mata in welUmarlced cases of both sexes.
An account of three typical and complete cases of
hystero-epilepsy occurring in men, — Striking similarity
of these cases to each other, and to corresponding cases in
women.
Gentlemen, — Our attention will be occupied to-day with
hysteria in the male, and in order to bring the subject
within more definite limits, we will consider more particularly
hysteria as it occurs in adolescence, or in the prime of life,
that is, in men from twenty to forty years of age ; and,
moreover, we shall specially examine that intense form
which corresponds to what is called in women hysteria
major [la grande hysterie], or hystero-epilepsy, with mixed
fits. I am induced to approach this subject, which I have
already referred to on several occasions, because we have in
the wards, at this moment, a truly remarkable collection of
patients which I can show you and study with you. My
object, above all, is to make you thoroughly comprehend
the identity of this great neurosis in the two sexes.
Because, in the comparisons which we shall draw as we go
along of the symptoms of hystero-epilepsy in woman and in
man, we sball everywhere come across the most striking
analogies, and here and there only certain differences which,
as you will see, are of minor importance.
Moreover, this question of hysteria in the male is in a
* Lecture edited by M. Georges Guinon, interne du service.
IMPOBTANCK OP MALE HYSrEEIA. 22t
sense the order of the driy jnet now. In France, of lato
years, it hag mach occupied the attention of medical men.
Between 1875 aod 1880, five inangnral dissertations on
hysteria in the male have been presented to the Faculty
of Parie, and M, Klein, wlio under the direction of Dr.
Oliver ia the author of one of these theses, was able to
collect eighty cases of the aifection.
Since then the important publications of M. Bourneville,
and his pupils, of MM, Debove, Raymond, Dreyfus, and
others have appeared, and all these works tend to prove,
amongst others things, that cases of male hysteria can bo
met with frequently enough ill everyday practice. Quite
recently male hysteria has been studied by Messrs.
Putnam and Walton in America,^ principally aa it occurs
after injuries, and especially after railway accidents. They
have recognised, like Mr. Page,* who in England has also
paid attention to this subject, that many of those nervous
accidents described under the name of Railway-spinp,, and
which according to them would be better described as
Railway-brain, are iu fact, whether occurring in man or
woman, simply manifestations of hysteria. Hence, one can
understand the iuterest which the practical minds of our
American colleagues take in such a qoestion. The victims
of railway accidents naturally demand damages from the
companies. They go to law ; millions of dollars are in the
scale. Now, I repeat, it is frequently hysteria which is the
agent in these cases. These serious and obstinate nervous
states which present themselves after collisions of this kind,
and which render their victims incapable of working, or
paying any atteution to their avocations for many months,
or even many years, are very often hysteria, nothing but
hysteria. Male hysteria then, is certainly worthy of being
studied and comprehended by the medico-legist, since the
question arises of heavy damages claimed in a court of justice.
This importance will perhaps tend to remove the discredit
which is still, even in the present day, attached, from deeply
' Putnam, 'Am. Jonrn. of Neurology,' 1884, p. 507 ; Waltcn, ' Arch, of
Med.,' 1883, vol. I.
"Page, 'Injuriefl of the Spine and Sjiinal Coixl witliout Apparent
Mcdiaiiicitl LettionB and Nei'vooa Shocli,' Londou, 1885,
222 TOEQUENOT OF MALE HYSTERIA,
rooted prejudice, to the word hysteria — a circamstaiice
which renders our task the more difficult. A profound
knowledge, not only of the malady, tut also of the conditions
under which it occurs, will be so much the more usefal,
because nervous troubles often occur iu such cases apart
from any traumatic lesion ; Eiud simply aa a result of the
psycho -nervous commotion produced by, yet frequently not
appearing immediately after, the accident. Thus at a time
when one of the victims of the collision who has broten his
leg, for example, is cured by lying up for three or four
months, another will be attacked with an ontburst of
nervous symptoms which will perhaps prevent him from
working for six months, a year, or more j and which may
not even then have attained its full intensity. One sees in
such cases how difficult is the mission of the medico-] egist,
and it ia this side of the question which seems to have
revived amongst our American colleagnes, the study of the
hysterical neurosis, till recently somewhat neglected.
In proportion as the malady has become more studied and
better known, the cases, as generally happens under like
circumstances, have become apparently more and more
frequent, and at the same time more easy of analysis. I
told you just now that M. Klein, in his thesis, four or 6v6
years ago, had collected eighty cases of hysteria in the male ;
but at the present time M. Batanlt, who is preparing in our
clinique a special work on the subject, has been able to
collect 2iS cases, of which nine are in my wards.'
Hence we may conclude that male hysteria is far from
being a rare disease. Well then, gentlemen, if I may judge
from what I daily see around me, these cases are often
unrecognisedj even by very distinguished physicians. One
can conceive that it may be possible for a young effeminate
man, after excesses, disappointments, profound emotions, to
present hysterical phenomena, but that a vigorous artisan,
well built, not enervated by high culture, the stoker of an
engine for example, not previously emotional, at least to all
appearance, should, after an accident to the train, by a
collision or running off the rails, become hysterical for the
same reason aa a woman, ia what surpasses our imagination,
' E. Butault, ' Contiibution k I'^tude do rhyst^rie chez rbomme,' FarU.
inoB 1
lund '
J
r
PEEMANENOE OF SYMPTOMS. 228
Tet nothing can be more clearly proved, and it is a fact
wliich will hare to be accepted. No doubt it will be with
thiSj as it baa been with so many other propoaitiona now
established in the minda of all men, after having enconntered
for years seepticiam, and ofttimea deriaion.
There is a prejudice which without doubt ia a serious
obstacle to the diffusion of a knowledge of hysteria iu the
male ; to wit, the false comparison which is generally made
between the clinical picture of this neurosis in woman and
in man.
In the male, no doubt, the malady often presents itself
as an affection remarkable for the permanence and obstinacy
of the symptoms which characterise it. On the other hand,
in the female, what is believed to be the characteristic
feature of hysteria ia the instability, the mobility of the
symptoms ; and it is this, without doubt which seems to
constitute the important difference between the two sexes in
the minds of those who are not thoroughly acquainted with
hysteria in the female.
Id hysteria, say they, founding the statement naturally on
observations made in women, the phenomena are mobile,
fleeting, and the capricious course of the disease ia
frequently interrupted by the most unexpected events.
Well now, gentlemen, this changeableness, this evanescence,
is, as I have shown you by numerous examples, far from
being an invariable characteristic of hysterical affections,
even in women.
Yes, even among women there occur cases o£ hysteria
where the phenomena are unchanging, permanent, extremely
difficult to modify, and which sometimes defy all medical
interference. And cases of this kind are numerous, very
numerous, even if it be true that they do not constitute the
majority. This is a point to which I shall return, but for
the moment, I am content simply to impresa upon you that
the permanenco and obstinacy of hysterical symptoms often
prevent their being recognised for what they are. Some
people, in presence of phenomena which resist all thera-
peutic agents, believe, in cases where there are sensorial
derangements with nervous fits, simulating epilepsy more or
less, that these must be due to a central organic lesion, an
224 MALE HYSTERIA.
intracranial neoplasm ; or^ if paraplegia be, present, then
that ther6 exists an intraspinal lesion. Others will willingly
acknowledge, or even aflGirm that we have to. deal here not
with an organic lesion, bat simply with a dynamic altera-
tion ; but, that inasmuch as the tenacity of the symptoms
does not correspond with the stereotyped description of
hysteria they have in their minds, they believe the case
to be one of a special disease, not yet described, and
which merits a special place.
An error of this kind seems to me to have been committed
by Messrs. Oppenheim and Thomson, of Berlin,^ in a memoir
which contains a large number of interesting and well ob-
served, if not always well interpreted, facts.
These gentlemen observed sensitive and sensorial hemi-
anassthesia, like in: all points to hysteria, in seven cases
analogous to those of Messrs. Putnam and Walton. It
occurred in stokers, engine-drivers, victims of railway or
other accidents, who had received a blow on the head,
severe shaking, or general shock. Neither alcoholism, nor
plumbism, existed in these bases, and it is acknowledged
that in all probability no organic lesion existed in these
subjects.
They were, then, patients exactly resembling those of
Messrs. Putnam and Walton ; but differing from these
gentlemen, the German authors are unwilling to recognise
that we have to do with hysteria. They regard it as some
special, I know not what, hitherto undescribed pathological
condition, for which they would find an unoccupied place in
our nosological tables. The principal argungients which.
Messrs. Oppenheim and, Thomson furnish in support of their
theory are the following: — i. The ansBsthesia is obstinate ;
one does not see in it those capricious changes which are so
characteristic (?) of hysteria. Its duration is a matter of
months, or years. 2. Another reason is found in the mental
condition of these patients not being that of hysterics. The
patients, are depressed, permanently melanohoHc, and with.-
out much fluctuation in any direction.
It is impossible, gentlemen, for me to subscribe to the
conclusions of Messrs. Oppenheim and Thomson, and I hope
* * Arch, de Westphal./ Bd. xv, Heft 2 and 3.
COMPABED WITH FEMALE HTSTEEIA. 225
to sbow you — latly. That the sensorial troubles of hyateria
can, even in the woman, present a remarkable tenacity ; and
2ndly, It is particularly ia the male that we commonly
observe a melancholic tendency in cases of most marked and
most undoubted hysteria. It is true we do not usually see in
men those caprices, those changes of mind and temper,
whicli more generally, though by no means necessarily,
belong to hysteria in woman ; but one cannot regard this
as a distinctive character of the highest order.
But it is time, gentlemen, to stop these preliminaries,
and to come to the principal object of our lecture to-day.
We will commence by clinical demonstration, studying
together, and with some detail, a certain number of perfectly
characteristic cases of male hysteria. As we go along we
shall reveal the analogies and differences which exist
between the hysterical phenomena observed in men, and
those which we daily see in the corresponding form of the
ailment in women. Lastly, I will present to you, by way of
summary, a few general considerations on hy at ero- epilepsy
[la grande byst^rie] as it occurs in the male sex.
But before coming to the male cases, I should like to briefly
recall to your minds, by two examples, the extent to which
in women the established symptoms of hysteria, the hysteri-
cal stigmata as we are in the habit of calling thom for
convenience' sake, can show themselves fixed, obstinate, and
wholly free from that proverbial mobility which is applied
to them, and which, it is pretended, forms tho characteristic
feature of the malady.
I need scarcely recall to your minds six or eight hystero-
epileptics now collected in our wards. Some of them have
presented for months, or years even, anesthesia on one or
both sides which all the most appropriate therapeutic agents
can hut influence for a few hours. I will confine myself to
bringing to your notice two women, truly veterans in hys-
tero -epilepsy, who, delivered some years ago from their great
attacks, now hold the position of servants in the Infirmary,
The first one named L — , well known in the annals of
hystero- epilepsy, and celebrated on account of the " demoni-
acal " character her convulsive fits presented, is now 63
15
226 FEMALE CASES.
years old. . She came to tbe SalpStri^re in 1846, and she
has been; continually under our obseryation since 187 1.. At
that time she was affected, as she is still, with right hemi-
anaesthesia, all sensitive and sensorial impressions being
completely absent, and with an ovarian hysterogenic point
of the same side ; and neither of these, during the long
period of fifteen years, has been modified even temporarily,
whether by the many times tried aesthiogenic agents^
whether by progressing years, or by the advent of the meuo-
pause. Five or six years ago, at a time when our attention
was particularly drawn to the modifications which the field
of vision undergoes in the subjects of hysteria, we discovered
in her the existence of a very marked retraction of the
visual field, on both sides, but much moi*e pronounced on the
right. . An examination repeated once or twice a year has
never failed to recognise the permanence of this retraction.
The other patient, a women named Aurel — , now 62
years of ago, in whom the great attacks, replaced sometimes
by symptoms of angina pectoris, have continued for a
dozen years, presented even in the year 1851 — as a valuable
note taken at that time establishes — left hemianassthesia,
complete, absolute, sensitive and sensorial, which as yon can
now see for yourselves, still exists to-day, that is to say,
after the long period of thirty-four years ! This, patient
has been under our observation for fifteen years and the
hemiansBsthesia has never ceased, during our oft-repeated
examinations, to be present. The double retraction of the
visual field, well marked on both sides, though more pro-
nounced on the left, which campimetric examination still
discovers, existed in her five years ago.
This is enough, I think, to show you how stable in women
the stigmata, of which no one doubts the hysterical nature,
may prove to be; how permanent, and how little they
correspond with the idea, a fal^e one when too much
generalised, which is usually held concerning the course of
the symptoms in this ailment.
I come now to the study of our male hysterical subjects.
Case I. — The man named Big — , a shop-as8istant> aet.
46, came into the SalpStriere the 12th May, 1884, little
MALE OASES OF HYSTEBO- EPILEPSY. 227
sbort of a year ago. 'He is a big man, strong and well
developed; he wasfortnevly a cooper and stood htirdivorli
without fatigue. The fam't'ty antecedents of this patient, ate
very remarkable. His fuihor \6 still alive and aged seventy-
six years. From thirty-eight to forty-four years of agej in
consequence of disnppoiii tments and monetary losses, he
suffered from "nervous allacks," aa to the nature of which
our palieDt can but imperfectly inform us. His mother, a
sufferer from asthma, died at sixty-five. The great ivnclo
of his mother was epilfiptic, and died in consequence of a
fall into the fire during an attack. Two daughters of this
unch were also epileptic. Rig— has had seven brothers
and sisters who have not presented nervous ailments. Four
are dead, and of the remaining three one sister is asthmatic.
He himself has had nine children, of whom four died in early
life. Of the five who are still alive, one girl fifteen years
old has nervous fits ; another ten years old has hyatero-epi-
leptic fitgjVf'hich M. Marie has seen in this hospital; another-
daughter is of weak inlcUect ; and lastly, two sons present
nothing peculiar to note.
In his personal aydecedents we find the following facts.
At nineteen and at twenty-nine years of age the patient had
attacks of acute articular rheumatism without cardiac
mischief. The last attack continued for six months, and it
is perhaps to rhefimatism that we must attribute the
deformities which exist in his hands. When a child, he
was timid, and his sleep was disturbed by dreams and night-
mares, and moreover he was a somnambulist. He often got
up at night, worked, and on the morrow was very astonished
to find his work done. This condition of things lasted twelve or
fifteen years, and he married at the age of twenty-eight. One
finds in his previous history neither syphilis, nor alcoholism,
although the patient was a cooper. "When thirty-two years
old he came to Paris, working first with his father, afterwards
employed as a shop-assistant in an oil-purifyicg factory.
In 1876, he beiug then thirty-two years old, his first
accident occurred. He cut himself rather deeply with a
razor which ho was sharpening, as some people are in the
habit of doing, on the anterior surface of the forearm. A
vein was severed, the blood spouted out ; and what with the
228 CASE I.
haBmoirliage and fright together the patient fell to the
ground, deprived of sensation and movement. He was a
long while recovering, and remained for two months pro-
foundly anasmic, pale, and unable to work.
In 1882, three years ago, he was lowering a barrel of
wine into the cellar when the cord which held it broke ;
the barrel rolled down the steps, and he would infallibly have
been crushed, had he not had just time to jump on one side.
However, he could not do it quickly enough to avoid a slight
wound of the left hand. In spite of the fright he had received
he was able to get up, and help raise the barrel ; but, five
minutes later he had a loss of consciousness which lasted
twenty minutes. On coming to, he was unable to walk, so
feeble were his legs, and they were obliged to take him
home in a cab. For two days he was quite unable to work,
at night his sleep was disturbed by fearful dreams, and
broken by cries of '^ Come to me, I am being killed I*' and
he saw in his dreams again the scene of the cellar. He did,
however, recommence his work; but ten days after the
accident, in the middle of the night, he had his first attach of
hystero-epilepsy. Since that time the attacks have returned
almost regularly every alternate month, sometimes in the
interval ; and during the night, whether at the moment of
his first sleep, or at the time of waking, he was sorely
troubled by visions of ferocious animals.
Formerly, in coming out of his fits he would remember what
he had dreamed during the attack, but this is not so now. He
would be in a forest pursued by brigands or frightful looking
animals ; or again, the scene of the cellar was enacted before
his eyes ; or he would see casks rolling towards him, and
threatening to crush him. Never, he states, either during
the attacks, or in the interval, has he had dreams or
hallucinations of a cheerful or agreeable character.
About this time he sought advice at St. Anne. They
gave him bromide of potassium, and this medicine, note
well, has never had the least influence over the attacks,
although the drug has been administered in a continuous
manner and in large doses.
These were the circumstances under which Rig — entered
our wards, and the following was his state on admission :
The patient is pale, anaamic, has but little appetite,
especially for meat, preferring acid dishes, and hia general
condition is unsatisfactory. The hysterical stigmata in him
are well marked. They consist of very extensive patches of
anesthesia on both aides of the body, both for pain (pricking
or pinching) and for cold. Sensorial anaesthesia exists in
general but to a small degree ; taste and smell are normal,
but the hearing is markedly defective, especially on the left
aide, nor does he hear any better when a sonorous body ia
applied to the cranium. As to vision the symptoms are
much clearer and would suffice in themselves to allow us to
affirm the hysterical nature of the affection.
He presents on both sides a well-marked retraction of the
field of vidon, more marked, however, on the right. He can
distinguish all colours, but the visual field for blue is mora
retracted than that for red, and passes within the latter, a
phenomenon which when met with is altogether characteristic
of the visual field of hysterics, as far as I know, and o£
which I have shown you examples a great many timea.
And finally, to finish with the permanent stigmata, there
exist in Rig — two ki/sterogenic points, one cutaneous,
seated beneath the lower false ribs of the right side, the
other a deeper one, ia near the right popliteal space, at
the point where the patient has a very painful cystic tu-
mour. The point in the testicle does not exist in Rig — .
Pressure on these spasmogenic points, whether accidentally
or purposely, produce in the patient all the phenomena of
an hysterical aura ; precordial pain, constriction of the neck,
with the sensation of a ball, buzzing in the ears, and
beatings in the temples ; these two last constitute aa you
know the cephalic aura. These points, the excitation of
which can give rise to an attack with singular facility,
are, on the other hand, to make use of the terminology pro-
posed by M. Pitres, only feeble spastn-airestors [spasmo-
frenateurg] ; that is to say, even their intense and pro-
longed excitation, can but imperfectly arrest an attack in
process of evolution,
In the mental condition of Rig — there ia now, as formerly,
always a dominant anxiety, fears, sadness. He cannot
sleep in the dark ; in the daytime he does not like to be
230 CASE 1.
alone ; he is excessively sensitive and expediences gteat
fright at the sight, or even recollection, of certain: animals
guch as rats, mice, toads, which he sees, moreover^ in; his
horrible nightmares> or in his frequent! «^mi-con&cious
hall ucinat ions [hallueinatioi!i» hypnagogiqnes] ." There is in
him a certaii^ restlessness of- mind which betrays' itself by
the fact that he can with equal facility undertake ior abandon
ftve or six occupations almost at once. He is f intellj^nt
and relatively well infoi'med. He is^ moreover, of an amiable
temperament and i? totally devoid of vicious instincts; ; : ■
The attacks may be either .spontaneous- or* provoked.
Whatever be the manner in which they are produced^ they
always commence with a burning sensation near fthespasmo*
genie points, to which there sucdeed, first an Epigastric
pain, then a ball 6nd sense of constriction in., the throaty
lastly, the cephalic aura consisting* of buzzing' in^the eaFS;and
treating of the temples. At that moment the' patient loses
consoiousness and the attack, properly so-called,: beginej^^ It
is divided into four periods quite distinct and separate; ? In
the first, the patient experiences a few epileptiform con-
vulsions.. Then comes the period of the great inovem^nts
of salutation, movements of extreme violence, during wkieh
his body makes from time tc time the charaoteristic arc of a
eircle; at pne time « forwards (emprosthotonos)> at . anotiier
backwards (opisthotonos), the -head and the. feet touobing
^he bed, and the body making a. bridge..:. AH this. while the
-patient gives utterance to savage cries. Then comjeftthe.thir^i
stage, called the period of passionate attitudes, during which
be utters words and cries irn keeping with hia.gloomy deliriula?,,
pj^d the terrifying visions which .persecute him. f Sometimiejs it
is the forest, wolves, horrible animalsi; at othears it is the cellar,
the staircase, or the rolling barrel.- At length he regaii^s
eonsciousness, recognises and names people arpund- him, but
the delirium and hallucinations . persist yet. awhile ;• be .seek^
around him and under the bed for the dark beasts which
threaten him; he, examines his arms, expecting to i find there
the bites of animals which he thinks he'.felt. ,Then he
Qomes to himself, the attack i^ finished) but ivery.ofte^i <)nly
jjo. begin again a few seconds later, until^ after, three ov fouy
successive attacks, the patient regains - his noifmsj eoi^ition.
He lias never bittonhis tongue in thei course of tliese fits,
or passed urine in the bed. '
For nearly a year has Itig— been' submitted to a course
of static; electricity, which we are in the habit of giving in
these caaeSj aa you know, with good results ; and at the same
time we have given him al! the tonics, all the restoratives
imaginable. Nevertheless, the phenomena which have just
been described, the stigmata, the attacks, persist much the
Bame without appreciable change. On the whole they do
.not seom, after three years' duration, to have undergone the
least alteration. However, we certainly have here, you
will all agree, a case of hyatero-epilepsy with mixed fits
.(epileptiform hysteria), as clearly characterised as possible ;
and it is quite certain that the stability of th'e stigmata, on
which we have sufficiently insisted, should not, in the
presence of the other ' symptoms, make us hesitate in our
diagnosis for an instant. ' ■ ■•
In concluding this case, so perteiotly typical, I will refer
again to some peculiaritiea which a clinical an-alysis will
enable you to recognise.
In the first place, I will particularly point oUt the
hereditary neurosis so strongly marked in his family :
hysteria in his father, very probably at least ; his great
■uncle, and first cousin of his mother, epileptics; two
daughters, one hysterical, the other hystero- epileptic. You
■will frequently meet, gentlemen, these hereditary conditions
in an hysterical man, more accentuated perhaps than in an
hysterical woman.
I would remind jou, moreover, how in our patient the
hysterical manifestations were developed in consequence,
and on the occasion of an accident which threatened his
life. The injury which then happened, a slight wound on
the finger, was it sufficient to provoke the development of
the nervous symptoms ? It may be possible, but I should
not like to affirm it. It is always necessary to bear in mind,
that, along with the injury, there is a factor which most
probably plays a much more important part in the genesis
of these symptoms than the wound itself. I allude to the
fright experienced by the patient at the moment of the
accident, ajid which was betrayed shortly afterwards in the
232 CASE II.
case before you, by a loss of consciousness followed by a
sort of transitory paralysis of the lower extremities. This
same psychic element is founds moreover/ in some of the cases
described by Messrs. Putnam, Walton, Page, Oppenheim,
and Thomson, and in which this influence, often predominant,
should not be lost sight of.
This same circumstance of the development of hysterical
phenomena, following, and in consequence of, a " shock,'^
with or without injury, but where emotion plays a great
partj you will find again, gentlemen, in the other cases which
wiU now be brought before you.
Case II. — The man named Gil — ^ 32 years old, a metal gilder,
was admitted into the Salp6tri&re in January, 1885. Nothing
particular was discovered in his hereditary antecedents. His
father, who was a violent man, died at sixty years of age
from paralysis, which came on without any fit. His mother,
who died of tuberculosis, was nervous, but she never had
any attacks.
His personal antecedents are more interesting to study.
At the age of ten he was a somnambulist. As a child he
dreaded the darkness, and at night he was the subject of
nocturnal hallucinations and nightmares. From an early
age he indulged in sexual excesses; he has experienced
from time to time a sort of irresistible impulse towards
women, and he has been a masturbator. However, he is
intelligent, is a clever workman, and easily learns ; in his
leisure hours he was a musician, played the violin and the
accordion. He frequents the theatre, but he is nevertheless
by disposition rather sad and taciturn, and he usually prefers
solitude.
His occupation, in which mercury is employed, has never
produced any symptoms which can be connected with mer-
curial poisoning. There are no signs of alcoholism; no
syphilis.
Sis first attach occurred at the age of twenty without
known cause. He was outside an omnibus when he felt the
first warnings. He had time to descend and the convulsive
attack took place in the street. After this, the attacks came
on rather frequently. He reckoned about four or five a
CASE IJ. 233
mDnth. It seems that on several occaslona he passed uriue
unconsciously. The convulsive seizures were becoming much
less frequent and only returned at long intervals, when in
1880 the patient was the victim of an assault in the street.
He was stabbed with a knife in the head in the right parietal
region. He fell down and lost consciousness, and was robbed
and left for dead in the street. He was found and taken to
La Charite, where he was placed in the wards of M, Goaselin,
remaining for three or four days unconscious. A few days
later, and erysipelas developed around the wound in the head
produced by the knife. At the time when he was recovering
an intense cephalalgia of a peculiar character commenced,
which persists up to the present time.
For a long time after this accident he remained plunged
in a sort of lethargy, from which he emerged only little by
little and very incompletely ; for since that time even at his
best it has been impossible for him to work, or to occupy
himself, or even to read, with any continuity ; and soon he
became melancholic. The attacks, moreover, which had
become infrequent, now reappeared and were more intense
and more numerous than formerly ; for which reason in
February, 1883, the patient presented himself at the Hotel
Dieu. He remained there up to March, 1884.
It was there that the complete left hemianeesthesia, which
still exists, was first discovered. The attacks, which were
then both frequent and severe, seem to have been regarded
as epileptic [mal comitial], and treated for nearly thirteen
months while he was in the wards by bromide of potassium
in large doses, without the least amelioration. When the-
patient was admitted into the SalpStriere (January, 1885)
the following was his state ;
His general condition, as far as concerns the nutrition, is
fairly satisfactory. He eats well and is not antemic. On
the other hand, it is easy to discover a very marked mental
depression. He is sad, taciturn, and mistrustful ; he seems
to avoid observation and does not mix with the other patients
in the ward. He does not devote himself daring the day to
any occupation or any distraction. The left hemianesthesia,
which was already noted at the HStel Dieu, is complete, abso-
lute as far as concerns common sensibility. The sensorial
234 CASE II.
troubles of the same side (left) are also very well marked.
0B this* side ' there is a notable diminution in the hearing ;
complete loss of smell and of tastd ; in the left eye complete
achromatopsia was discovered by M. Parinaud, and q, very pro^-
ndnnced retraction of the visual field for 'white light. Con*
trary to what is generally observed in cases of this kind the
extent of the visual field and the notion of colour^ is abso-
lutely normal on the right side. There is n6 alteration in
the fundus of the eye either on the right or the left side. .
He constantly complained of an iiitense headache of sL
dull, or rather of a constrictive, character, generally situated
over the occiput, the summit of the head, the forehead and,
especially, the temples, and it was more pronounced on the
left tha^ on the right side. It felt as thoagh he carri^ a
heavy helmet On his head which was too tight aiid com-
pressed it^ This permanent cephalalgia was- notably in-*-
creased a' little before and after the attacks. It wai3 spe-
cially increased when the patient attempted the sKghtest
occupation, when he tried to read, for example, or to write a
letter. '-,.'■•.
The attacks, which we have of ten witnessed in the wards,
f)resent the following characters. They may be either spon;-
taneous or provoked, but in either oafee they do not differ ih
any essential particular. Three hysterogenic zones, have
been discovered; one on each side just beneath the right
and left breast, and a third in the right iliac region; but
pressure on the testicle or the cord on this ^ide does not
produce any abnormal sensation. When one presses lightly
on the hysterogenic zones in the position above indicated^
the patient immediately experiences all the symptoms of a
cephalic aura, namely, beating of the temples, buzzingsr in
the »ears, vertigo, &c. ; And if one perseveres a little, an
aftack is surely produced. A few short epileptic spasms
inaugurate the scene. They are soon folio wed. by diver» con*
tortious and the great movements of salutation, interrupted
from time to time by attitudes of an arc of a circh-; and all
the while the patient utters violent cries. Convulsive laughter,
tears, or sobs terminate the attack.^ . On coming round> GriJ —
has not the slightest i recollection of what has taken place.
His hysterogenic points are but very incompletely " spasm^
CASE II. 235
arre&tors '' [si|>a3mx)-freriatetirs] ; for, wlieh pressure «is tndde
upon them dnriia^' an attack^. it ceases for an instant^ iDint
almost immeciiately resumes its eourse. . Whether provoked
or spontaneous^ theattacks generallyrepeat themselves succes-
sively a/certiaiu number. o£ times in such a x^ayas to* consti-
tute a serieia. The rectal temperature undpr these circnm-
stances. has never been ..above 37*8^ 0* [jgg^S^ Faht^.]= • -«
After this brief description you will recognise that the
case of Gilrr- is very much like that of Rig— ^ (Case I) > from
which it difEers only in matters of unlimiiortant detail. -In
both caseB th^re are the. same hysterical stigm.ata/the samie
melancholic tendeoicy:; the ^ same attacks/ with this sole
difference that in €ril— 1 the aiira evolves with great rapi&ity,
and that in: his fits the passionate attitudes are wantii^g ;^^
these are the only differences between the easesi [ '
In some of his attacks Gil — - has bitten his tongue and
micturated involuntarily ; facts which we have purselves ob-
served; We wereat one time led to believe, from this, that
it was a case of hystero-epilepsy with distinct crises ,• that
is to say, true epilepsy at one time, hysteria- major* [grand©
hyst^rie] at another, appearing in the form of 'separate attacki^
A more attentive examination has shown us that it is not so.
AH Gil — ^s attacks have the characters ; of « hysteria juajor
[grande hysteric], and it is in the course of these attacks
that he sometimes bites his tongue and sometimes passes bis
urine involuntarily* . But biting of the tongue and involun-
tary emission of the urine are not by any means unique
characters of the epiplectic fit [mal comitial]. These symp-
toms may bci observed in hystero-epilepsy unas^ociated and
uncomplicated, in any way with epilepsy [mal comitial].
The occurrence is rare no doubt, but I have observed it, and
published a certain number of undoubted examples ^^
Tji concluding, this case I wish to call your attention to the
headache from which Gil — suffered so constantly but which
invariably : became worse whenever he attempted the least
* A few moTitlui later, tftis patient died suddenly afteij having swallowed
an enormous dose ef.ahlortd) t>t which he had secretly possessed himself.
The autopsy was absolutely ne^tive, so far as concerns the nervous centres,
and tends to confirm the diagnosis.
236 NEURASTHENIA.
occapation. Combined with all the particulars that have
been mentioned above^ a cephalalgia of this nature does not
belong to the description of hysteria ; it is met with, how-
ever, as an almost necessary accompaniment of the neuras-
thenic neurosis [neurasthenia of Beard] ^ of which it consti-
tutes one of the prominent symptoms, and in which one also
observes the mental depression that existed to so large an*
extent in our patient.
I particularly pointed out that in this patient the different
symptoms occurred after a blow that he had received on the
head. Now, gentlemen, the neurasthenic state, together with
the collection of phenomena which Beard has assigned to it
in his remarkable monograph, is one of the nervous affections
which become developed most frequently in consequence of
a shock, particularly in railway accidents. This statement
is borne out by several of the cases reported by Mr. Page.*
1 have myself met with two examples absolutely parallel
to those published by this author, one of which relates to one
of our colleagues in Paris. Hence we are justified in ad-
mitting I think that two perfectly distinct elements may exist
in our patient Gil — . In the first place the neurasthenic
state, which was an immediate and direct consequence of the
injury he received three years ago. In the second place
hystero-epilepsy with all the concomitant symptoms that
characterise it. This latter condition had existed before the
accident, though it was considerably aggravated afterwards,.
as you can see by referring to the details of the case.
We now come to the examination of the third patient, who-
belongs to the same group as those you have already seen.
Case III. — The man who is noW coming in, named Gui — ,.
is 27 years old and is a locksmith. On February 20th, 1884,^
he came under the care of my colleague. Dr. Luys. Con-
cerning his antecedents he only knows that his father, who
» G. M. Beard, *Die Nervenschwache (Neurasthenia),' 2e Aufgabe, Leip-
zig, 1883.
2 H. Page, * Injuries of the Spinal Cord and Nervous Shock, Ac.,' pp. 1 70*
and 172, London, 1885. See also L. Dana, "Concussion of the Spine, and
its Relation to Neurasthenia and Hysteria " (' New York Medical Becord,'
Dec. 6, 1884).
died at the age of fortj-eight, waa an inveterate drunkard,
and that his mother, who is etill living, has notj so far as he
is aware. Buffered from nervona affections. He has had
seven brothers and sisters ; only one brother ia living, who
has never been ill and ia not nervous.
About the age of twelve or thirteen G-ui — became very
cowardly, he was never able to remain alone in a room without
experiencing a sentiment of fear, but in other respects he
was neither irritable nor obstinate. At school he learned
easily, and later onj when seventeen or eighteen years old,
he proved to be apt and intelligent in hia calling. Several
times in the educational establishment for locksmiths he
obtained medals. Unfortunately about this time he developed
an inordinate liking for the other sex. He worked during
the day like his comrades, but when the day was finished it
often happened that he went to a ball and passed the rest
of the night with girls! These debauches occurred several
times a week, and consequently he was deprived of his neces-
sary sleep. However, this mode of life did not seem to
fatigue him very much, for on the morrow he returned to
his work aa usual, and performed his task with efficiency.
At the age of twenty-one (in 1879) during one of his
nocturnal expeditions be received a blow from a knife which
penetrated his left eye. He was taken immediately to the
H6tel Dieu, and placed in tho wards of M. Panas, who soon
afterwards enucleated tho eyo. On leaving the hospital
Gui — was not long in returning to hia old abandoned life.
At the commencement of the year 1882 it frequently
happened that at the moment ho cloaed his eyes to go to
sleep he thought ho saw a monster in human form coming
towards him. He cried out in great fear, opened his eyes,
and then the vision disappeared, but only to reappear as soon
as he closed his eyelids. Theu he fell into a condition of
extreme anxiety, and not unfrequently he would remain thus
the greater part of the night without being able to sleep.
These nocturnal hall iicinat ions had existed about six months
when, in July, 1883, he was the victim of a fresh accident,
more formidable than the former one. Occupied in fixing a
balcony on the third floor of a house, he, possibly a little
intoxicated, fell into the street, ahghting, as he affirms, on to
238 CASE III.
hi^ foiet,. .He W9.s ancoBscious for^an hour. .' When lie4awoke
hj^fovind bimsell again in the Hdtel Dievt^ and < again in the
wards of M.Panas. It seems* that they had reason ^ sus-
pect the existence of a fracture of th« skull. However,
recovery took place in due course, and at the end of two
n^iontihs the patient returned home. Soon afterwards the
terrifying hallucinations at night-time returned; and about
this date convulsive attacks occurred for the first time. They
were not at first as clearly characterised as they afterwards
became. They consisted chiefly of attacks of giddiness,
coming on suddenly, followed by rigidity, and then by clonic
spasms of the limbs. There was not any loss of conscious-
ness, nor were they very frequent.
Matters remained thus for nearly eighteen months. At
the end of that time, the remedies given by the different
doctors whom he consulted having produced no effect, Ghii — >
decided to apply at the Salp6tri&re, and was admitted into
the wards of M. Luys. Soon after admission - Gui — became
the subject of frequent attacks of intestinal and gastric colic,
followed by a feeling of constriction of the pharynx, and by
vomiting which came on without effort. These symptoms
did not yield to any medication, but ceased suddenly at the
end of about six weeks. About that time the existence of
a right hemianaesthesia was recognised, and also* a parti-
cular trembling of the right hand, of which more will be said
i^ a few minutes.
In January, 1885, owing to changes in the staff, the
patients of M. Luys came into our wards, and it was then
that I saw Gui- — for the first time. He is, as you see,
a well-built, vigorous young man ; his general condition
sojems satisfactory enough, his mental condition does not
show at the present time anything particularly abnormal.
The nocturnal hallucinations have almost completely disap-
peared during the past year. Gui — is not sad, h© converses
freely with the other patients, and renders himself useful in
the ward.
The hcmianaesthesia on the right side is complete. Neither
touching nor pricking are perceived on this side of the body
at all. • The organs of sense on the same side are also pro-
foundly affected, hearing, smell, and taste in partictilar. As
" CASH- m.
for the eyea, a ihe1;hoclicnl examinatiou reveals verycliapacf-
tGrisfric . modifications ; on the right side-r-you baVe 'not for-
gotten that he has lost the left eye — the visnal field is
extremely retracted, red only is pereeivedj and. the circle of
this colour is reduced nlmosfc to a point.
The trembling of the right liand which was just now men-
tioned is remarkable for the perfect regnlarity of its rhythm,
as shown by the aid of a registering apparatus. It consists
of oscillations numbering, on an average, about five per
second. In this respect, consequently, it holds a position
midway between the tremors of slow oscillationSj such as
paralysis agitans, for example, and the vibratile tremors
such as the rapid oscillations of general paralysis and of
Basedow's disease. It is not exaggerated by voluntary
movement.' The patient is able to use his hand for eating
and drinking, and he can even write passably well by firmly
prei^sing with his left hand on his right wrist, an arrange-
ment which causes the tremors to cease for an instant. The
muscular sense is perfectly preserved in the whole of the
right upper extremity.
The only hysterogenic zone discovered in Gui — ia situated
in the testicle and the course of the right spermatic cord reach-
ing to the groin of the right side. The shin of the scrotum
on this side is very sensitive, and when it is firmly pinched,
exactly the same effects are produced as when one presses
on the testicle itself or on the cord, that ia to say, the deve-
lopment, or, on the other hand, the arrest of an attack.
These attacks, whether spontaneous or provoked by the
artificial excitement of this hysterogenic zone, are always
preceded by the sensation of a well-defined painful aura
starting from the right testicle, mounting upwards into the
epigastric and cardiac region, thence into the throat, where
it produces a feeling of constriction, finally reaching the
head, where it produces buzzinga, chiefly in the right ear,
and heatings, principally in the temple on the same side.
Then the patient loses consciousness, and the epileptoid stage
commences. The tremors of the right hand become much
increased, and the eyes become convulsed upwards. The
limbs' stretch out, and the wrists flex and become twisted in
' ' IJrogre* MMicale,' 1885, No. is.
position of ezag'gerated pronatton. Next the arms cross one
over the other in front of the abdomen owing to a convnlsive
L
contraction of the pectoral nmscles. After this the period
of contortions comeB on^ characterised by extremely violent
J
movements of ealntation accompanied by disorderly gestares.
The patient breaks or tears everything on which he can
lay his handsj and he assumes the strangest and most out-
FiB. S2.— Lateral arc of tircle (forwards).
rageous attitudes in a manner that fully justifies the denomi-
nation of dou-nism, which I have suggested as a designation
for this part of the second period of the attack. From time
to time t1io contoi-tions above describeil stop for a. moment
and give plivce to the cliaracteristic attitude of an " arc of
a circle." Sometimes it is opistliotonos, ill which the loins.
L
Fl&. 53. — Lateral arc of circle (backivorJb).
are separated from the level of the bed by a distance of more
than 50 centimetres [about 20 inches], the body only resting
on the head and the heels. At other times the circle ia made
forwards with the arms crossed over the chest, the legs and
the bead raised in tho air, the buttocks and loins alone
vesting on the bed. And at other times the body is bent
into a lateral " arc of a circle," the patient resting only on
the right or left side as the case may be. All this part of
Gui — 's attack ia very characteristic, and all its details are
worthy of being recorded by the process of instantaneous
photography. I am able to show yon the pictures which
iave been thus obtained by M. Londe. You notice that in
an artistic point of view they leave nothing to be desired,
and for us they are most instructive. They show us, in fact,
that in the regularity of the periods and the typical character
of the different attitudes, Gui — 's attacks differ in absolutely
nothing from those which we observe each day in hystero-
epileptic patients of the female sex. And this perfect re-
semblance is worbhy of all the more attention, in that Gui —
has never been near the wards where the female subjects of
J
CASE in. 243
finch attacks are placed, so that the influence of contagious
inaitation cannot be said to be in operation.
The periods of halliicinatioDa and passionate attitudes are
generally wanting in Gui — . Sometimes, howeverj we have
noticed that towards the end of an attack his physiognomy
expresses fear or joy alternately, and that bis hands extend
into space as thongh he wore searching for an imaginary
being.
The conclusion of an attack in this patient is often fol-
lowed by a sort of motor aphasia, which generally does not
last more than eight or ten minutes, but which on one occa-
sion persisted for nearly six days. When the patient wishes
to speak, a few growling inarticulate sounds come from his
mouth ; he becomes impatient and agitated, but is able to
make one understand by very expressive gestures. It has
sometimes happened even that under these circumstances He
is able to take a pett and write legibly a few correct phrases.
That is the conclusion of the history of this perfectly
typical case. But we have not yet finished witli hysteria in
the male. "We shall find the same features as marked as in
the preceding cases, in three other patients that are now in
the clinical wards [service de la cliuiqnej.
This hookis fhepropLi,^ .,
COOPER MEDICAL COLLi.U-..
SAN FRANCISCO. OAL.
and 18 not to be removed from the
Lihrarv Itoom by any person or
under any -jjidext whatever.
LEOTUEB XIX.
CONCERNING SIX CASES OP HYSTERIA IN THE MALE
(continued)}
Summary. — Abnormal varieties of the hysterical attach in the
male, — Account of a case in which the attacTcs assumed
the characters of partial epilepsy. — Diagnosis of the case t
importance of the hysterical stigmata.
The convulsive attach may he \vanting in hysteria in
the male, — Description of a ca^e of hysterical brachial
monoplegia in a young man 19 years old, — Difflculties^
of the diagnosis in this case.
Gentlemen, — I hope to conclude to-day the subject which
we were considering in the last lecture ; adopting as hereto-
fore the method of clinical demonstration.
In this method we are aided, for the material in our hands
touching the subject of male hysteria is far from being
scanty. Three new patients will be brought before you, and
the principal details concerning them will be unfolded. I
shall allow the facts to speak for themselves, only pointing
out, by a few short commentaries, the teachings furnished
by their cases.
Case IV. — This case does not come quite under the cate-
gory of those already referred to, inasmuch as it is that of
a growing youth, and not a fully matured individual. But
here, also, the disease presents the characters of permanence
and tenacity which we have already encountered.
* Lecture edited by M. Georges Guinon, interne du Service.
CASE 17. 245
Mar—, let. i6, entered onr wards on the 29tli of April,
1S84, that 13 to say, about a year ago. He was born and
lived in the country up to the age of fourteen. In 1872 his
mother had several hysterical attacks. His grandfather was
a dissipated man, and of a very violent character. This is
all that can be learned of his hereditary antecedents.
As to the young man himself, he is well -developed, though
in infancy he suffered from some strumous manifestations,
such as discharges from the ears, and glandular swellings in
the mastoid region. He is intelligent, of a joyous disposi-
tion, and has never exhibited abnormal timidity ; but he has
been subject to paroxysms of anger in which he broke every-
thing he could lay hands on. Two years ago he was placed
as an apprentice to a baker in Paris. A short time afterwards
he had congestion of the lungs, and the consequent enfeeble-
ment of health was certainly not without its influence in deve-
loping the complications which supervened. Some time after-
wards, while yet convalescent, he received a severe fright. He
was, according to his own account, attacked in the street one
evening by two young men. He fell, losing consciousness,
and was in this state conveyed to the house of his employer.
He showed no trace of any wound. From that time he re-
mained during several days in a stupefied condition. He
commenced to be subject to horrible nightmares, which tor-
ment him to the present time. He dreamt that he was being
beaten, and he woke up crying out. About fifteen days later
the hysterical attacks commenced. At first they occurred
daily, and presented a aeries of from eight to ten, sometimes
two aeries occurred in the same day ; then they diminished
in number and in intensity.
At the time of admission into the SalpStriere the following
conditions were noted : — The hysterical stigmata are very
marked. They consist of an anesthesia in patches, dissemi-
nated irregularly over the entire surface of the body, and in
which there is complete insensibility to touch, to cold, and
to pain. The senses of hearing, taste, and smell are blunted
on the left aide ; and with regard to vision, a diminution of
its field exists on both sides, but is more marked on the
right. On this side the patient is unable to distinguish
violet, while on the left he can distinguish all the colours.
246 CASE IV.
But on both sides there exists a characteristic sign to which
I have frequently called your attention, and which we have
already observed in the first of our cases, the field of vision
for red is more extended than that for blue, a condition
as you know at variance with that which exists in the nor-
mal condition. There exists but one hysterogenic point, and
that occupies the left iliac region. Even at the present
time, notwithstanding that the disease has existed for two
years, the attacks came on spontaneously, at short intervals,
about every ten or twelve days. These attacks can bo pro-
voked very easily when a moderate pressure is exercised on
the hysterogenic point. A more energetic pressure on this
point arrests the attack.
The attack, whether spontaneous or provoked, is always
preceded by an aura : iliac pain at the level of the hystero*
genie point, a sensation as of a ball rising from the epigas-
trium up to the throat, buzzing sounds in the ears, and
beating of the temples. Then the attack commences ; the
eyes are turned upwards in their socket, the arms become
stiff and extended, and the patient, if standing, falls to the
ground with complete loss of consciousness. The epileptoid
phase is in general not very marked, and is short; but the
period of great contortions which follows is excessively
violent and of long duration. The patient utters cries, bites
everything within his reach, tears the curtains, and performs
movements of salutation, the body ultimately taking the
characteristic form of an arc of a circle. The scene termi-
nates by the phase of passionate attitudes, which is very
marked in him, and differs somewhat according to the circum-
stances under which the attack has occurred. Thus, wheli
the attack has been spontaneous, it may happen that the
hallucinations are of a gay character ; whereas if the crisis
has been produced by excitation of one of the hysterogenic
zones the delirium is always sombre or furious, and accom-
panied by indecent and reproachful speech. In general^
many attacks succeed one another so as to constitute a series
more or less numerous.
I must point out in this case the permanence and immo-
bility of the hysterical symptoms, as is so often observed in
the male. Thus^ as you may have remarked in our young^
PJiKMANENCE OF STICIMATA. 247
patient, notwithstanding that two years have' now elapsed,
the convulsive crises are now as frequent as ever, in spite of
all our efforts ; and the hysterical stigmata., antesthetic, sen-
Eorialj aud sensitive, have not altered since the day that ho
came under notice for tha first time. There is nothing to
make us to hope that they will soon be modified.
This is not the case usually with young persons, especially
if the disease develops before the age of puberty* At that
period of life, according to numerous observations which I
have collected, the hysterical symptoms are, in general, more
transitoi-y, and no matter how pronounced tliey may be,
they arc most frequently amenable to appropriate treatment.^
I Two dajB after thus lecture was delivered, Professur Charcot admitted
under his care a joung Belgian named Fat — , 21 years of age, spate,
tall, and with fair hair, who, as in the cases referred to, presented the clasaio
characteiibtics of h) stero-cpilepsj with mixed ci'lsen. In thp family his-
tory there was nothing notcworthj save a histary of alcoholic indulgence
in his fathei In the history of his childhood, nuuturnal terrors, frequent
nightmaies, aud sometimes cvcu in: full duylight, visions o£ animals and
horrible iigurcs
InMovember, 1884, Pal — had a bad attack of cholera. His convalescence
■WHB protracted, and for many wcelts ho remained feeble, subject to cramp in
the' inferior extremities, and abdominal pains. Three itfouths after his
WcovEry, being still in hospital, and convalescing, the sight of a dead body
which was being carried frightened liiiu, and almost immediately his £rst
attack supervened.' Asubsequent fright, caused soon afterwards by a practical
joke played un him by another pjiticat.in the same ward, seems to have deter-
mined the condition, for from that period Fal — did not cease to suffer from
terrifying hallnciuutions, and the convulsions took place filmost regularly
every night. Prom the time of hid eutry into the SalpStcibre the following
condition eiisled ; — Scattered patches of cutaneous anesthesia ; a blunting
of the senses of taste and Rmell,oii the left side ; diminution of the field (if
vision limited to t!io right eye j very eitended hysterogenic points in the
form of hyportcathcaio area, occupying in fivnt almost ^1 the abdominal eui-
facc, and behind, the scapular regions, tbe buttocks, the popliteal space, and
the soles of the feet, &c. The attack ounid easily be produced hy modei'atc
fnction of the hypercesthesio arem. After the usual aura it marked epi-
leptoid state followed. Equally chaiiicteriBtic was the period of the great
movements, and the arc of a circle. Finally, succeeded the stage of passionate
attitudes, during which the patient seemed to be a. prey to a sombre or
fui-ious delirium. In this case, as in those we hiVe ConMderiJd, the hysteria
auporvened after an onteeblement of body causWbj 'a sferiou*'lnaIady, and in
consequence of a fright, and here likewise was observed s\\ the genuine
characteristics of hysteria as ordioarily observed in the female^.
248 CASE V.
Apart from an anomaly in the form of attack^ whicli 1
will advert to presently^ the case I am about to submit to your
consideration^ that of a young man of 22, must be con-
sidered^ like the preceding ones^ as belonging to the type
of hystero-epilepsy.
Case V. — Ly — , a mason, sat. 22, entered the clinique of
the Salp6tri6re on the 24th of March, 1885. He was bom
in the country, in the neighbourhood of Paris. He is a
young man of middle height, badly developed, aud has a
rather delicate appearance. His father — by trade a carter —
is addicted to alcohol. His mother died of tuberculosis, and
had had hysterical attacks. Further, in the family history
we find a maternal grandmother also hysterical, who never-
theless attained to the age of eighty-two, and two maternal
aunts the subjects of hysteria. Hence we have very impor-
tant antecedents — four hysterical individuals and an inebriate
in one family !
The personal antecedents are not less interesting. Our
patient has always been of deficient intelligence. He was
never able to learn at school, but otherwise he presented no
striking mental peculiarity. He acknowledges to have
drunk, for a long time, five or six little glasses of brandy per
day, in addition to a considerable quantity of wine ; but he
states that he has abandoned this habit since he became an
invalid. Three years ago he had erysipelas of the face, soon
followed by an attack of acute articular rheumatism, not,
however, of a severe nature, for he was only confined to bed
for fifteen days. The same year he was engaged in efforts
to rid himself of a tapeworm, from which he suffered, and
for which purpose he took pomegranate bark, which had the
desired effect. At first, fragments of the worm were
voided, and then the whole. The sight of the taania in his
excreta so struck him, that for several days he suffered
from slight nervous complications, such as colics, pains and
tremblings of the limbs, &c.
A year ago, while working at his trade at Sceaux, he
witnessed one of his comrades violently strike his son. Ly —
desired to interpose, but his comrade turned furiously upon
him, and while Ly — was fleeing hurled a stone at him.
Fortunately, the stone did not strike him ; but the fright
CASK V. 249
experienced by hy — was very severe. Immediately he was
seized by trembling of the limba, which persisted during the
succeeding night, so that he was onable to sleep. The
insomnia persisted during several days following. By night
and day he was tormented by unpleasant ideas. He fancied
every moment that he saw the tapeworm, or that he was
again engaged in the strife with hia conarade. Further, he
suffered from pricking in the tongue, his appetite was gone,
and ho felt feeble and unable to work.
This condition lasted for fifteen days, wlien one evening
towards six o'clock he experienced his first convalsive
attack. All that day he had suffered from epigastric pain,
the sensation of a globus, and from buzzing noises in the ear.
At the moment when the attack commenced, he tells ua that
he felt his tongue retracted in his month towards the left side
by a kind of involuntary and irresistible action. Then he
lost consciousness, and when he came to himself he was told
that his face was drawn towards the left, that his extremities
were agitated bj' tremors, and that when the convulsions
ceased he spoke in a loud voice without awakening.
During the months which followed, crises of a like nature
were repeated about every eight or fifteen days, and during
that long time he was obliged to abstain from all labour
owing to his feebleness of body. These crises were con-
sidered to be epileptiform attacks of alcoholic origin, and for
almost a year he was treated with bromide of potassium in
large doses, without being benefited in the least thereby.
During the day wbich followed his admission into the
Salpfitriere, he was spontaneously seized with a, series of five
■successive attacks which we were unable to witness.
On the following day, a systematic examination revealed
the following conditions : — Generalised anaesthesia, disposed
in disseminated arete ; considerable diminution of the field
of vision on both sides, the field of the red being more ex-
tended than that of the blue ; monocular diplopia. There
exist two spasmogenic points, the one at the level of the right
clavicle, the other below the false ribs of the right side.
Moderate pressure exercised on the last point immediately
-determines an attack, which we are thus able to study in all
its details.
250 CASE V.
The attack is preceded by the characteristic aura: — epir
gastric constriction, a feeling of a ball in the throat, &c.
At this moment, and even before the patient loses comacious-
ness, his tongue becomes stiffened, and is retracted. in his
mouth towards the left side. It is found by aid of the
finger that its point is carried behind the molars of that side.
The mouth, half opened, is likewise deviated towards the
left side. All the left side of the face shares in the devia*
tion. The head itself is strongly drawn towards the* left.
The patient then becomes unconscious. The upper extre-
mities are extended, first the right and then the left.' The
lower extremities remain flaccid, or at least they are very
little stiffened. The movement of torsion towards the. left,
at first limited to the face, soon becomes general, and rolling
over, the patient lies on his left side. Next, clonic convul-
sions replace the tonic spasm. The extremities are agitated
by frequent vibrations, but of limited extent. The face is
the seat of rapid tremblings, and then follows a stage of
complete relaxation without stertor. But at this moment
the patient Seems tormented by horrible visions. He mentally
sees again, without doubt, the scene of his quarrel with his
comrade, and utters reproachful words : " Scoundrel . . . . ,
Prussian . . . . , struck with a stone, he is trying to kill me."
The words are spoken in a perfectly distinct manner. Then,
all of a sudden, he changes his attitude. Seated on his bed
he is observed to pass his hand over one of his legs in such
a manner as to disengage some reptile which encircles the
limb, and during that time he mutters something about the
worm. The scene at Sceaux comes back to him. ^'I will
kill you . . . . , a gun-shot . . . . , you will see.'' After
that period, signalised by delirium and corresponding passion-
ate attitudes, the epileptoid stage is spontaneously produced,
thus inaugurating a new attack which can in no wise ib^ dis-
tinguished from the first, and which may be followed by many
others. Pressure on the hysterogenic points interrupts the
evolution of the different phases. On wakening, Ly — appears
dazed and stupefied, and he states that he remembers nothing
which has transpired. • .
All the attacks which we have witnessed, and there have
been a considerable number, whether spontaneous or pro-
ANOMALOUS FEATURES. 251
vokod, present exactly tlie same character. The different
phases are always produced in the same order to the minutest
details, the diverse incidents of the epileptoid phase, first
commencing in the tongue and. facOj and then the various
scenes of the delirious phase.
Hero theu, gentlemen, wo have an attack of hystero-
epilepsy, which in oue respect forms a notable exception to
the classic variety. In the first period, indeed, we observo
the convulsive movements roproduce an almost perfect imi-
tation of the symptoms of partial epilepsy ; while the con-
tortions, the grand movements, and the arc of the circle are
wanting. But in the female this variety of the bystero-
epileptic attack is known, and, though rare, I have set before
you recently several perfectly authentic examples, Thit>
subject has, during the past year, been attentively studied
by M. le Dr. Ballet, formerly my chef de clinique, now a
hospital physician,^ In comparing the cases narrated by
Ballet, and that with which we are now concerned, you will be
struck with the resemblance which exists between bystero-
epilepsy in the male and that of the female, not only as
regards the fundamental type, but also the aberrant forms.
Another anomaly, less rare and leas unexpected, in hys-
teria of the female, is the absence of convnlaive -crises. You
are aware that, according to the teaching of Briquet, about
a fourth of hysterical females have no attacks. The dis-
ease in such cases, without losing anything of its indivi-
duality, is symptomatically represented only by the perma-
nent stigmata, with sometimes several spasmodic or othei'
manifestations, such as nervous cough, permanent contrac-
tures, certain arthralgias, forms of paralysis, and hismorrhago
from diverse sources, &c. Now, the attacks may also bo
absent in male hysteria. Tho case which I am about to
submit to you offered a good example of this kind when tho
patient first presented himself before us. I'lie disease has
since become, as it were complete, for at tho present time
tho attacks do exist. But during a long period of eleven
months it was a latent case, and the interpretation of it was
' Bsllet ct Ci-eBpiu, " lies attiiques d'lijBterie a forme ii'epili?p8ie paiiielle,"
ArcL. de Neuroigie,' 1884, Nos. 23 and 34.
252 CASE VI.
sufficiently difficult, at least in certain respects, as you will
be able to appreciate.
On March lotb last the young man before you presented
himself to us with left brachial monoplegia. There was not
the slightest trace of rigidity, the limb was perfectly flaccid.
The paralysis, he informed us, dated from ten months pre-
Tiously, and had come on a few days after an injury to
the front aspect of the left shoulder. There was no trace
of paralysis, or even paresis, of the corresponding lower
extremity nor the face. Nor were there any traces, in spite
•of the long-standing paralysis, of muscular atrophy; a
circumstance which, combined with the absence of any
modification in the electrical reaction in these muscles, led
us to eliminate at once any causal effect — at least, any direct
local effect — of the traumatism. We further noticed that
the carotid regions were the seat of violent arterial throb-
bings.
Well-marked '^ Corrigan's pulse '* and auscultation of the
heart revealed the existence of a diastolic murmur at the
base, and we ascertained that there was a history of an
attack of acute articular rheumatism which had kept him in
bed for five or six weeks. Hence, the idea naturally flashed
upon us that this monoplegia depended on a focal cerebral
lesion of the cortex, strictly limited to the motor zone in
the brachial centre, and consequent on valvular affection of
the heart. But a closer study of the case disabused us of
this idea. Without doubt the monoplegia in question is
due to a cortical cerebral lesion, principally localised in the
motor zone of the arm, but it is not of the nature of a gross
material alteration. The lesion is purely ^^ dynamic,*' sine
materia, of the nature, in short, of those whose existence
we hypothetically suppose in order to explain the develop-
ment and persistence of the different permanent symptoms
of hysteria. That, at any rate, is the conclusion at which
we shall arrive, I believe, from the detailed examination of
our patient, upon which we are now about to enter.
Case VI. — The patient. Pin — , aged i8, a mason by trade,
•entered the Salp6triire on March nth, 1885. His mother
^ed at the age of forty-six in consequence of " rheuma-
tism '' (?) ; his father is an inebriate ; one of his sisters.
CASE VI. 253
BBt. i6, is snbject to frequent nerrous attacks. He is a well-
bnilt, muscular young man, apparently robuet, but the func-
tional exercise of the nervous system has always left much
to be desired. From five to seven years old he was troubled
with incontinence of nrine. He has always shown, a lack of
intelligence, bis memory is feeble, and lie seems to have
made but little progress at school. He was of a timid dis-
position, and the subject of nocturnal terrors. From a moral
point of view he is of unstable equilibrium. From the time
when he was nine years old he often left his father's house
and slept nnder bridges and in the waiting-rooms of railway
stations. His father apprenticed him to a greengrocer, then
to a confectioner, and to other trades, but he always recom-
menced his escapades. One night he was arrested in com-
pany with a band of young vagabonds and shut up in La
Boquette, where his father left him for a year.
About two years ago, at the age of sixteen, be was attacked
with acute generalised articular rheumatism, preceded by
facial erysipelas. It is very probable that the organic dis-
ease of the heart which now exists dates from this time.
Eighteen months afterwards, on May 24th, 1884, P — , then
a mason's apprentice, fell from a height of about 2 metres-
{about 6i feet}, and remained for some minutes unconscious on
the spot on which he fell. He was carried home, and then
they discovered some contusions over the anterior surface of
the shoulder, the keee, and the left ankle-joint — alight contu-
sions which did not seriously interfere with the use of the-
affected parts.
For two days subsequently, matters remained in the same
condition, but on the third day after the accident, May 27th,
P — noticed that his left upper extremity had become feeble.
He then consulted a doctor, who discovered a paresis of all
the movements of the left arm, with antesthesia of the limb.
On June 8th, that is, fifteen days after the fall and
eleven days after the onset of the paresis, be entered the
Hfitel Dieu. There he was examined with care, and the
following conditions were discovered ; Well-marked signs
of aortic insufficiency. The parts which had been contused
were not the seat of any pain, either spontaneous, or provoked
by active or passive movements. There was incomplete para-
254 CASE VI.
lysis of the left superior extremity. The patient was still
able, though sometimes very incompletely, to flex the hand
upon the forearm, and the latter upon the arm ; but all move-
ments of the shoulder were impossible. The paralysed mem-
ber was completely flexible in all its articulations, and there
was no rigidity. The condition of the face, and of the left
lower extremity, was absolutely normal. So far as concerned
the power of motion this was a case of monoplegia in tho
rigorous acceptation of the word. An examination of the
sensibility furnished the following results. At this period
there existed a general hemianalgesia of the left side ; com-
plete anaesthesia only in the upper extremity. There was
also a retraction of the field of vision on both sides, but much
more marked on the left. Finally, on the 25th of June,
that is to say twenty-two days after the commencement, the
paralysis had become absolutely complete.^ The diagnosis
was undetermined, and the treatment proved ineflicacious.
Faradization, many times applied on the left side, resulted
only in rendering the anaesthesia of the trunk, the face, and
inferior extremity less complete. The anaesthesia and paralysis
persisted in the upper extremity. The condition of the field
•of vision was not modified when P — left the H6tel Dieu.
It was on the nth March, 1885, and consequently ten
months after the accident, and nine months after the com-
plete establishment of the monoplegia, that P — entered our
.wards at the Salp^triere. We verified the conditions already
referred to, and a more minute examination furnished the
following results. The aortic insufliciency was very charac-
teristic ; there existed a souffle with the second beat at the
base ; violent arterial beating in the neck, visible to the eye ;
*^Corrigan^s pulse;*' and capillary pulse perceptible on the
forehead.
The motor paralysis of the left extremity is absolutely
complete, it hangs flaccid and inert beside the body. There
is no trace of voluntary movement, nor of contracture. The
muscular masses have retained their normal volume and con-
sistence j and their electric reactions, faradic and galvanic,
are in no way modified. The tendon-reflexes of the elbow
* For all the information relative to his condition at the H6tel Dieu we
are indebted to Madlle. Klnmpke, a pupil in the wards when P-^ was admitted.
CASE VI. 255
and forearm are slightly augmented. Complete cutaneous
ansesthesia to contact, cold, pricking, aud the most intense
faradization throughout the whole extent of the limb, hand,
forearm, arm, and shoulder. In respect of the trunk the
aniesthesia is limited hy a circular line passing almost verti-
cally beside the armpit and snbclavicular space in front, and
the external third of the scapular region behind. The in-
sensibility extends in an equal degree to the deep-seated
parts. The muscles and the nervous trunks themselves may
be strongly far adized, the articular ligaments may be forcibly
twisted, and diverse movements of the joints, torsion, &c.,
may be performed without the least consciousness on the
part of the patient. The ideas attaching to the muscular
sense have eqnally disappeared. The patient is unable to
determine even approximately the attitude in which diverse
segments of the limb maybe placed, the position they occupy
in apace, or the direction and nature of the movements to
■which they have been subjected.
Apart from the left superior extremity, there does not
exist on this side any modification of motor power, either in
the face or the inferior extremity, but in these and over the
left half of the trunk, the analgesia, discovered during the
patient's stay in the Hotel Dien, still exists. An examination
of the field of vision reveals a normal condition on the right
side, while on the left it is considerably diminished; more-
over, the circle of the red is outside that of the blue ; and
thus, since being in the Hotel Dieu, an interesting change in
the field of vision has occurred. Furthermore we discover
by the usual methods that the senses of hearing, smell, and
taste are much blunted on the left side.
We must now endeavour to determine the nature of this
singular monoplegia supervening on the traumatism. The
absence of atrophy and of any abnormal electric reactions in
the muscles in a case of paralysis extending over ten months,
repels, at first sight, the hypothesis of a lesion of the bra-
chial plexus, while the absence of any atrophy alone, and
the intensity of the perversion of sensibility, permits us to
reject the idea that wo have here to do with one of those
cases of paralysis, so well investigated by Prof. Lefort and
M. Yaltat, which are caused by violence to an articulation.
1
I
» 1
256 DUGNOSIS.
A brachial monoplegia may^ it is trae^ in exceptional cases
supervene on certain lesions of the internal capsule^ as lias
been demonstrated^ among others^ by Drs. Bennett and
Campbell in ' Brain/^ but in such a case we do not certainly
encounter the sensorial and sensitive hemianassthesia^ which
is sometimes superadded to ordinary complete hemiplegia from
lesion of the capsule.
The occurrence in the right hemisphere of a little haemor-
rhagic point, or softening determined by embolism in conse-
quence of an organic affection of the heart, a point which
one can suppose limited strictly to the motor zone of the
arm — such a lesion, I say, may account for the existence of
left brachial monoplegia. But on this supposition the para-
lysis ought to supervene suddenly as on a " stroke,^^ however
limited the lesion, and not progressively. It would have been
characterised almost certainly, some months after its com-
mencement, by a certain degree of contraction, and by marked
exaggeration of the tendon-reflexes. It certainly would not
be accompanied by perversions of cutaneous and deep sen-
sibility as pronounced as those we have observed in our
patient.
We are obliged, then, to exclude in our diagnosis this last
hypothesis, and likwise that of a spinal lesion which, as being
inadmissible, we do not think even worthy of discussion.
On the other hand, our attention has been vividly directed
towards the significant hereditary antecedents of the patient,
his psychical state and habits, the perversion of sensibility
(extended — though unequally — over the whole of one side of
the body), the diminution of the field of vision (so pro-
nounced on the left side, and marked by the transposition of
the red circle), and other sensorial troubles on the same
side. All these constrain us, especially in the absence of any
other reasonable hypothesis, to interpret the case as an
example of hysteria. Further, the clinical characters of the
monoplegia, its traumatic origin — and on that point I refer
you to what I have already said — are in no way inconsistent
with this view. Indeed, the limitation of motor paralysis to
one limb, without involving at any time the corresponding
side of the face ; the absence of marked exaggeration of the
1 * Brain,' April, iSSg, p. 78.
DUGNOSIS. 257"
tendon-reflexeB, of muscular atrophy, and of the ordinary
electric reactionSj the ahsoluto stoutness of the member many
months after the commencement of the disease ; the cnta-
neons and deep antesthesia, carried to a high degree in that
member, and the total loss of notions pertaining to the nius-
cular sense, — all these phenomena united in one case, as in-
that of our patient, amply sufficed to reveal the hysterical
nature of the paralysis.
In consequence, the diagnosis "hysteria" was openly and*
resolutely adopted. Without doubt, the convulsive attack
was an element wanting ; bat you do not ignore the fact
that this is not inseparable from the nature of hysteria.
Consequently the nature of the prognosis changed ; we had
not to deal with an affection arising from an organic cause,
perhaps incurable; we were able to anticipate, despite the
long duration of the disease, the occurrence, either sponta-
neously or under the inHuence of treatment, of some one of
those sudden changes which are not rare in the history of
hysterical paralyses, and of flaccid paralysis in particular.
In any case we were able to prognosticate that sooner or later
the patient would recover, A subsequent event soon justi-
fied our hopes, and amply confirmed our diagnosis.
On the 15th of March, four days after becoming our patient,
we diligentlysearched, what had not been done np to this date,
to find whether there existed in him any hysterogenetic zones.
We found one situated under the left breast, another in each
of the iliac regions, and a fourth on the right testicle. It
was noticed that even a slight excitation of the sub-mammary
zone easily determined the diverse phenomena of the aura —
a sensation of constriction of the thorax, and then of the
necb, beating in the temples, and buzzing sounds, especially
in the left ear. But on insisting a little more P — was
suddenly noticed to lose consciousness, to throw himself back-
wards, to stiffen hiu limbs, and then we witnessed the first
attack of hystero-epilepsy which tho patient ever experienced.
This attack was absolutely classic ; to the epileptoid phase
immediately succeeded that of the greater movements. These
were of an extreme violence ; the patient, in the movements
of salutation, went so far as almost to strike his face against
his knees. Shortly afterwards he tore the sheets, the enr-
17
258 CUBE OF THE MONOPLEGIA.
tains of his bed^ and turning his fury against himself, ho
bit his left arm. The phase of passionate attitudes imme-
diately followed, and P — became a prey to a furious delirium ;
he became abusive, and cited imaginary persons to murder,
—"Hold! Take your knife. • . . Quick. . • . Strike!"
Ultimately he came to himself, and he affirmed that he had
no remembrance of what had occurred. It is remarkable
that during the whole of that first attack the left superior
extremity took no part in the convulsions ; it remained flaccid
and perfectly inert. During the following days the attacks
recurred spontaneously many times, always presenting the
same characters as the provoked attack. In one of them,
which took place during the night of the 17th March, the
patient passed his urine in bed. Two other attacks followed
on the 19th. On the 21st a fit occurred, during which the
left arm was agitated. On awakening, the patient found to
his great astonishment that he was able voluntarily to move
the various segments of the limb, of which he had not had
the use for a single instant during the long period of close on
ten months. The motor paralysis was not completely cured,
without doubt, for there remained a certain degree of paresis,
but it was considerably improved. Only, the perversions of
sensibility remained in the same degree as before.
This cure, gentlemen, — or, to speak more properly, this
partial cure — ^after the diagnosis at which we arrived, ought
not to be a matter of surprise to you. But, from our point
of view, it had occurred prematurely. Indeed, it was evi-
dently no longer possible to afford to you ocular demonstra-
tion of the characters in detail of that monoplegia, so worthy
of study. The idea, therefore, occurred to me that, perhaps
by acting on the mind of the patient, by means of suggestion,
oven in the waking state — we had learned previously that
the subject was not hypnotisable — we might reproduce the
paralysis, for a time at least. Thus it was that the following
day, finding P— - just coming out of an attack which had
not modified the state of matters, I endeavoured to persuade
him that he was paralysed anew. "You believe yourself
cured,'* I said to him, with au accent of entire conviction,
" it is an error ; you are not able to raise your arm, nor to
bend it^ nor to move the fingers ; see, yon are unable to grasp
INFLUENCE OF SUGGESTION. 259
my hand/' &c. The experiment succeeded marvellously, for at
the end of a few minutes discussion the monoplegia returned.
I was not atixious on this account, it may be said in passing,
for I know from long experience, that what one has done,
one can undo. Unfortunately this did not persist for more
than twenty-four hours. The following day a new attack
supervened, in consequence of which the voluntary move-
ments became definitely re-established. On this occasion all
the attempts at suggestion which we made were found useless.
To-day it only remains for me to apprise you of the modi-
fications which, as far as voluntary movement is concerned,
have taken place, in consequence of the fits, in a limb which
was at one time completely paralysed.
The patient, you will notice, is able voluntarily to move
till the parts of the limb. But these movements are not
energetic ; they do not overcome the least resistance which
one opposes to them, and while in the right hand the dyna-
mometric force is equivalent to 70, the left hand represents
only 10. Hence, as I have already stated, if the motor
paralysis is not so absolute as formerly, it still persists to a
certain degree. Further, the troubles of sensibility remain
as they were, affecting not only the weakened member, but
all the left side of the body, and comprise the sensorial appa-
ratus. The attacks continue frequently, from which you will
understand that we have here simply amelioration, and for
a complete cure much more remains to be done.
I shall have occasion to refer to some of the facts of this
interesting case when we take up the subject of hysterical
paralyses of traumatic origin, as I hope to do soon.^ For
the present, leaving aside the monoplegia, which constitutes
l3ut an episode in the history of our patient, I wish to point
out to you once more, in conclusion, that, in the case of this
man, as in the preceding cases, hysteria major [la grande
hysteric] undoubtedly exists, endowed with all its character-
istic attributes.
Gentlemen, in considering with you in these two lectures
the six significant cases which chance has placed under our
observation, I have been desirous of convincing you that
^ Vide p» 284.
260 CONOLQSION.
hysteria, even grave hysteria, is not so very rare a disease*
in the male, at any rate in France ; that it may be found
here and there in the ordinary clinical work, where only the
prejudices of another age prevent its being recognised. I
venture to hope that after the numerous proofs which have
lately been accumulated, that notion is henceforth destined
to occupy in your minds the place to which it is entitled.
This hoolis tU P^^t"
COOPER MEDICAL CO^x-.^ ■
SftM fRANClSCO, CAL.
««^ is not to be rem)ved from m
thZTrL^ by any person or
Z:,l.ru. J. ...'.Mt whatever.
LBCTUEE XX.
ON TWO CASES OF HYSTERICAL BRACHIAL MONOPLEGIA IN
THE MALE, OF TRAUMATIC ORIGIN.— HYSTERO-TRAU-
MATIC MONOPLEGIA.'
Summary. — Case of Porcz — , — Antecedents, articular Theuma-
tism. — Fall. — Monoplegia with anaesthesia of the arm. and
shoulder. — lamination of the patient ; motor paralysis
with flaccidity ; loss of all kinds of sensibility having
a peculiar delimitation ; no trophic changes j no modifi-
cation in the electric reactions of the paralysed muscles.^ —
Diagnosis; disturbance or contusion of the brachial plexus,
characters of the symptoms observed in these cases, ances-
tketic zone corresponds with the d/istribution of the affected
nerves, trophic changes, modification of the electric re-
actions.
Gentlbmbn, — To-day's lecture will be devoted to the
clinical study of a ease of right brachial monoplegia origin-
ating some months ago in a man, jet. 25, in consequence of
a fall upon the shoulder, a. form of mouoplegia which presents
serious difficulty in diagnosis. I do not wish to exaggerate
these difficulties, and that you may be satisfied that they
really exist you have but to recall the discussion on this case
at the Societe Medicale des Hopitaux, when the patient was
presented by M. Troisier at the meeting on 25th March last.
' Lecture edited bj M. P. Marie, chef du clinique, et M. G. Giiinon,
interne du aerviec. [The hifitory of one of these cases. Pin — , is commenced
on p. 353 ante.']
' Lecture delivered May lat, 18S5. At the meetiag of the Soci^tS Mudi-
«ale des H6pitam on July 24th laet, Dr. Troisier again exhibited the patient
Porci — , the subject of this lecture {vide ' Gazette Hebdomadaire,' No. 31,
1885). At the same meeting Dr. Joffroy exhibited a patient from our wards,
named Pin — , whose cBse was diaoussed in the preceding lecture, and to which
I shall refer in the next.
1
.4
262 CASE.
You will then observe that the opinions expressed by our
colleagues MM. Per6ol, D6jerine, Eendu, and Jeffrey, on the
nature of the monoplegia, are very diverse, notwithstanding
the very thorough investigation of the case.
M. Troisier has been good enough, and I am glad fco express
my obligations to him, to commit the patient to my charge.
The history, I doubt not, will excite in you a lively interest. .
You will not, I trust, be wearied by the minuteness of
detail into which we shall enter in the analysis of this case,,
not one feature of which is wanting in its practical applica-
tion. The patient is a man, 89t. 25, named Porcz — a cab-
driver, he became an inmate of our clinical wards on the
15th April last. The affection dates from over four months
back, originating, as already remarked, in an accident, tod
it has not undergone any modification during that period..
But before entering into further details, we will say a few
words on the antecedents of this patient.
His mother died at the age of fifty-nine of disease of the
liver ; she was very nervous. Porcz — remembers that on
many occasions when thwarted in anything she was wont to be
affected with fits, in which she fell down and lost conscious-
ness. His father was a great drinker of absinthe, but never
had any nervous attacks. His sister is frequently the subject
of nervous attacks, probably of an hysterical nature. There
does not appear to be any insanity in the family.
Among the personal antecedents the following are dis-
closed : — In infancy, although not particularly nervous, our
patient tells us that when left alone he always feared " rob-
bers.'' At seven years of age he fell from a fifth storey on to
an iron grating, whence he rebounded on to the pavement of
a court. Prom this time his health has been notably en-
feebled, and a short time afterwards the deviation in the
vertebral column, which now exists, commenced. At the age
of sixteen Porcz — entered as a " washer '' with a carriage
company, and shortly afterwards he contracted an attack of
articular rheumatism, which confined him to bed for six
weeks. From this period his right knee has been painful,
and tumefied from time to time, and is at present the seat
of crepittLS. In consequence of this arthritis of rheumatic
origin there is a certain amount of atrophy of the triceps^
CASE. 263
extensor cruris (amyotropliy) of articular origin. This lirab is
notably more feeble than the corresponding one of the oppo-
site side, and the patient limps a little on this side. This
relative feebleness of the right limb dates, I repeat, from
nearly ten years ago, bat it has no connection with the pre-
Bent ailment.
This slight inhrmity, and his miserable appearance, did
not prevent Porcz — from following, since the age of eighteen,
his employment, sometimes of an omnibus driver and some-
times a cabman, .
Let us revert now to the monoplegia and its direct causes.
On the 34th December, 1884, the horse which Porcz — was
driving became restive, and our patient was pitched from his
seat on to the pavement, falling upon his right side, the pos-
terior part of the right shoulder receiving the first impulse.
There was no loss of consciousness, no intense emotion.
Porcz — was able to regain his feet, go to a chemist's, and
mount the bos. The right shoulder and arm were somewhat
painful, but presented no bruising. The movements of the
extremity were difficult, but possible, and Porcz — was able to
drive his cab for five hours afterwards, holding the reins in
his left hand. During the next five days the patient rested,
and the pain and difilcnlty of movement seemed to diminish.
He hoped soon to be able to resume his work, when, on the
30th of December, six days after tho accident, and after a
restless night, he found on awakening that the right superior
e.ttremity was flaccid, hanging motionless, and incapable
of all movement, with the exception of the fingers of the
hand, which he was still able to move a little. Practising
friction, Porcz — noticed the insensibility of the shoulder,
tho arm, and tho forearm, which we observe to-day. It is
perfectly certain that neither at the time of the fall nor
afterwards was there any trace of loss of consciousness, or
any intellectual perversion, any sort of aphasia or embarrass-
ment of speech, any deviation of the mouth or tongue, or
any degree of paralysis in the right inferior extremity. We
have therefore in this case to do with a brachial monoplegia
plus aniBsthesiaj in the most rigorous acceptation of the term.
On tho 8th of January, 1885, our patient presented him-
self at the 116pital Tenon, under M. Troisier, who recognised.
264 CASE.
nine days after the commencement of tlie paralysis^ all the
features which we noted on receiving the patient. To-day,
the ist of May, four months after the commencement of the
monoplegia, matters are in the same state. We find the
patient exactly in the same state as he was four months ago
when examined by M. Troisier, and also when he was pre-
sented a month ago to the Societe Medicale des Hdpitaux.
Let us examine now with some attention this singular
monoplegia, which has existed as you see it .now during four
months, despite the diverse forms of treatment employed.
▲. Motor functions. — Porcz — is unable to perform any
voluntary movement either with the elevator muscles of the
shoulder or those of the shoulder itself, or the muscles of the
arm or forearm. He is able to voluntarily move the fingers
of the hand alone, and these movements are so feeble as not
to be appreciable by the dynamometer.
Observe the absolute flaccidity of the limb. It lies along
the trunk as an inert body, and falls heavily down after
being raised. The patient is obliged to carry it in a sling
to obviate the shocks and blows to which it would otherwise
be exposed at eacb instant. There does not exist, as you
perceive, the least trace of rigidity or contraction. This
recalls the flaccidity of the monoplegia in infantile spinal
paralysis. But here the tendon-reflexes at the elbow and
the wrist are intact, perhaps even a little exaggerated, while
you know it is quite otherwise in that form of spinal para-
lysis. Further, and this is an absolutely distinct charac-
teristic, although the paralysis has existed for four months,
there is no appreciable atrophy or diminished consistence of
the paralysed muscles. Actual measurement of the right
arm gives 23*5 c, of the left 24 c. ; the right forearm 22.5
c, the left forearm 22 c.
B. There exists in the greater part of this limb, besides
paralysis of movement, profound perversions of sensibility,
Sensibility to contact, pain, and cold is completely and abso-
lutely abolished, and this cutaneous ansssthesia, which exists
exclusively in the parts of the extremity where there is motor
paralysis, is marked o£E from the parts retaining tjieir sensi-
bility by lines presenting a singular disposition, especially as
CASE. 265
relating to the hand. Yet it is observable that it does not
correspond with the anatomical distribution of the cutaneous
nerves of the superior extremity, as you can see by looking
at this diagram (Figs. 54 and 55, p. 268).
On the back of the hand the limit of anaesthesia is marked,
«o far as concerns the fingers, by a transverse line situated
s, few centimetres above the metacarpo-phalangeal articula-
tions, while on the palmar aspect the limit is represented by
a line parallel to the fold of the wrist, and about one centi-
metre below it.
Further, the insensibility is not limited to the skin, it
-extends to the deeper parts ; and thus it is that faradization,
no matter how energetic, either of the muscles or the trunks
•of the nerves, while provoking strong contractions, is not
felt. Movements of torsion, or dragging, communicated to
the shoulder, the elbow, or wrist, do not occasion any feeling
whatever, no matter how violent they may be. But on the
palmar surface and on the back of the hand, and over all
the fingers, cutaneous and deep sensibility are preserved, at
least in great part.
Further, in this extremity, the fingers always excepted,
JJie manifestations relating to what is called the muscular sense
are in complete abeyance . To appreciate this it is only neces-
sary that Porcz — should be requested to shut his eyes and to
find his forearm, held away from the body, and seize it by
means of his left hand. At first he gropes in space, more
or less remote from his object, and when he accidentally
finds any part of the member, probably its upper end, he
ranges with his hand over the whole arm until he arrives at
the part at which he is requested to touch. When his eyes
are shut, he does not know whether one bends his wrist, his
»elbow, or his shoulder. But, under like conditions he knows
perfectly well when the same act is practised on his fingers, and
which one is experimented upon. Porcz — has equally lost the
notion of weight of objects placed in the palm of his hand.
When he does not look he is unable to distinguish, without
fingering them, a piece of 5 francs from one of 10 centimes,
they both seem to him equally light.
To epitomise, we have, therefore, absolute motor paralysis
of the muscles of the shoulder and of the arm and forearm ;
266 DIAGNOSIS DISCUSSED.
complete loss of sensibility of the skiD^ of the muscles^ of
the nerves^ tendons^ and articular ligaments, &c. ; complete
absence of all notions relating to the muscular sense in all
the parts which correspond to the motor paralysis ; no rigidity
in the parts deprived of movement, with preservation of the
muscular outline, and slight exaggeration of the tendon-re-
flexes. These are the salient features hitherto disclosed.
But it behoves us to notice again the remarkable and sig-
nificant fact that the muscles present no indications of trophic
perversion, notwithstanding that the monoplegia has already
existed for more than four months. You have satisfied
yourselves that there is no wasting of the members ; I would
add that the muscles, subjected to a rigorous examination, pre-
sent no modification in respect of the electrical reactions either
io faradism or galvanism. There is not the slightest sus-
picion of the reaction of degeneration.
Finally, there is no lividity of the skin, and no oedema.
There exists only, in the affected member, a slight diminu-
tion of the temperature. Thus, the axillary temperature of
the two sides is 36*9°, that of the healthy member on the
anterior aspect of the forearm 32*8°, while that of the para-
lysed member on the corresponding spot is only 32*4°, that
is to say about four tenths of a degree lower.
Such are the phenomena disclosed to us by analysis of
the condition of the paralysed member. There exist in our
patient, beyond what relates to the monoplegia, several other
interesting clinical facts ; but they do not strike one at first
sight, and we encounter them only after pursuing inquiry
in a certain direction. I will reserve the noting of these
peculiarities until, after the discussion, it becomes a ques-
tion of definitely determining the diagnosis.
What, then, is the nature of this monoplegia which we have
been studying so carefully, and of whose clinical characters
we are now cognisant ? Has it any connection with a lesion
more or less pronounced of the peripheric nerves in conse-
quence of a contusion or a shock to the brachial plexus
caused by the fall on the shoulder ? Does it relate to any
spinal lesion ? Or a focal cerebral lesion ? Such are the
questions which now have to be considered.
CASE OF INJURT TO BEACHIAL PLEXUS. 267
The first-named naturally presents itself at ones to thf
mind. There are numerous examples of brachial monoplegia
iu consequence of a fall on the shoulder, and a certain number
of the phenomena observed in our patient appear, at first
sight, to admit of explanation on the hypothesis of shock or
contusion of the brachial plexus. I am happy to be able to
bring under your notice by the side of Porcz — , a patient in
whom brachial monoplegia exists, and caused under circum-
stances similar to those which determined the brachial mono-
plegia in the case of Porcz — . It is true, we have not here to
deal with a fall on the posterior part of the shoulder, as in
Porcz — 's case, but with a violent shock to the same region
caused by a blow from a large heavy beam. The traumatic
conditions are analogous in both cases. Let us see what
have been the consequences in our second case, of which the
following is an abridged history.'
The patient Deb — , a vigorous, well-built navvy, tet. 31,
had always enjoyed excellent health until, on the 3rd of
April, 1884, that ia to say, thirteen months ago, he received
a blow on the posterior part of the left shoulder from the
extremity of a beam, the violence of the shock being such as
to throw him face forwards to the ground. He was at the
same time struck on the posterior and the superior region o£
the cranium by an iron point carrying a block attached to the
end of the beam, and a wound of some extent was the result.
On receipt of the injury there was no immediate loss of con-
sciousness, and during some time afterwards, for five or six
minutes perhaps, the patient remained conscious. He recol-
lects, at least, so he afiirms, that at this moment he felt a sensa-
tion such as to lead him to believe that his superior extremity
was entirely separated from the body. Then supervened a losa
of consciousness which lasted during three hours. When
Deb — came to himself, motor paralysis of the diverse seg-
ments of the member was as absolute as it is at this moment,
the movements of elevation of the shoulder alone being pre-
served. With respect to sensibility, it seems to have been
in the same condition as we find it now.
' Very recently the caso of this patient hm heen given in eMenso by
Mdlle. Klumpke in her interesting work on " Fai'aljses oE the Brnchiul
Plexus" ('Bevue de M£decine,' loth July, 18S3, 5th year, No. 7, p. 604}.
he I
lei' '
From this time tbe patient has sojourned in various
hospitals, where he had been subjected, anhappily for him
-withont resnlt, to varioos forms of treatment, and especially
electricity. This treatment had to be interrupted from time
to time, owing to the intense pain invariably caused by it,
and could never, therefore, be followed ont continuonsly.
I will first direct yoar attention to the derangements of
sensibility. Sensibility of all kinds is absolutely abolished
is the hand, including the fingers, the forearm, and part of the
INJUBT TO BRACHIAL PLEStTS. 269'
arm ; in the same parts deep sensibility is likewise abolished,
and likewise the ideas attaching to the maecnlar sense.
Wherever the cutaneous anfesthesia exists it is as complete-
as we have seen it to be in the case of Porcz — ; only the mode-
of distribution is different in the two cases, for vrhile in the case
of Porcz — the zone of insensibility encircles all the shoulder,
and even beyond, in that of Deb — , on the contrary, the area
is much less limited, embracing neither tbe shoulder nor a
considerable portion of the arm. Thus on the anterior and
external aspect of the arm in the latter case the line of anees^
FiGB. 56 and 57.— Case of Deb^. a. Aaslgctia. h. Abiolnte sntettheua.
270 ANAESTHESIA PEOM
thesia scarcely reaches tbe middle of the limb. On the
external aspect it is higher. Behind it scarcely goes beyond
the elbow, so that the posterior aspect of the arm is almost
normal (Pigs. 56 and 57).
I should like you to observe, gentlemen, that this dispo-
sition of the anaesthetic zone is exactly sach as has been
observed in cases where the brachial plexus has been severely
injured, or even torn across completely, by injury or sur-
gical division, cases of which have been recorded by Dr. Ross,
of Manchester, in his important contribution to ' Brain.^^
You observe from an examination of the plates (Figs. 58
and 59) taken from Ross, and relating to a case of tearing
of the brachial plexus, attended with motor and trophic
derangements, both muscular and cutaneous, which have been
determined by a rupture of all the branches of that plexus ;'
you notice, I say, that the disposition of the ansssthetic
zone is exactly the same as that observed in our patient.
Deb—.
Now, in the last-named case (Deb — ), after noting the motor
and trophic derangements to which we shall return directly,
it must be conceded that there exists a grave and an extensive
lesion of the whole plexus. This distribution of cutaneous
ansssthesia appears to be the pathognomonic expression of
deep and destructive organic lesions affecting all the motor
and the sensory branches of the brachial plexus.
If, now, we revert to the case of Porcz — we notice that
the distribution of the anaesthetic zone is totally different.
It is much more extended upwards towards the trunk than
in the case of Deb — . It involves the shoulder, and con-
sequently, on the hypothesis of a contusion acting on the
course of the nerves, not only the brachial but the cervical
plexus also ought to be involved. Moreover, we know that
in the case of Porcz — the zone of anaesthesia is limited below
by the hand (Figs. 54 and 55). But the disposition of that
line, marking the limit of anaesthesia, does not accord with
the hypothesis of a lesion profoundly affecting all the sensi-
* " Distribution of anaesthesia in cases of disease of the branches and of
the roots of the brachial plexus." — 'Brain,' April, 1884, p. 70.
' With the exception of the conununicating branch from the 4th nerve.
LESIONS OP BEACHTAL PLEXUS.
2V1
tive fibres of the brachial plexus. As we have already re-
marked, it is, on the palmar aspect of the hand, a straight
line at right angles to the long axis of the limb, and parallel
with the fold of flexion of the wrist-joint ; and on the dorsal
FiOB. 5S oDd 59.— Oue of niptare of biaclii&l pleziu (after Bou).
aspect a slightl; carved line with its convexity downwards,
extending a little beyond the middle of the metacarpal region.
Here, then, is a disposition wliich in no way accords with
the cotaneons distrihation of the nerves of sensibility in the
272 IMPOBTANCE OF TBOPHIC CHANGES.
lower portions of the hand (ulnar and radial for the dorsal
aspect^ median and ulnar for the palmar), and which, there-
fore, does not accord with the supposition of a deep and
general lesion of the brachial plexus. The facts to which
we have just referred do not better accord with the hypo-
thesis of a slight contusion, or a simple " commotion ^' of the
plexus, for numerous observations in those cases show, con-
trary to what obtains in our case, that under such circum-
stances perversions of sensibility are little marked, eminently
transitory, or entirely wanting.
In the case of Deb — , which represents a typical example
of a deep, old, and irreparable injury of the brachial plexus,
we also discover trophic derangements, muscular and cuta-
neous, and certain other phenomena which, quite as much
as the perversions of sensibility, contrast singularly with
what we observe in Porcz — . Doubtless in both cases
the paralysed member is flaccid and without traces of con-
traction or articular rigidity; but here is the difference,
in Deb — the paralysed muscles are extremely atrophied.
They present on electric examination the reaction of degene-
ration in its most aggravated form ; the tendon-reflexes are
abolished, the skin is cold, and its surface is marked by violet
spots, especially towards the extremity of the limb, and the
subcutaneous tissue is slightly oedematous.
There is nothing of the kind in the case of Porcz — . Here
you see, notwithstanding the long continuance of the malady,
the muscles have preserved their volume and consistence, they
present no reaction of degeneration, the tendon-reflexes exist,
and the colour of skin and the consistence of the integuments
are normal. These, then, constitute the phenomena which do
not permit of reconciliation with the theory of a serious and
deep lesion of the brachial plexus, notwithstanding the exis-
tence of the malady for four months ; and much might like-
wise be made of the remarkable fact of the non-participation
of the fingers and of the hand in the motor paralysis and anass-
thesia, so marked in all the other parts of the limb.
Thus, gentlemen, the brachial monoplegia which forms the
subject of our present investigation, although occurring under
conditions in which grave or trifling lesions of the brachial
plexus by commotion or contusion might originate, does not
m THE DIAGNOSIS. 273
Teally depend on a lesion of this nature. The seat of the
disease has to be sought for elsewhere in the nerve centres.
Have we therefore to do with a circumscribed organic cere-
l)ral or spinal lesion ? It will, I think, be easy for me to
indicate to you that this is not so.
This look is the prc^ ^
COOPER MEDICAL COi^ut.v.--.
SAN FRANCISCO. OAL
and is riot to be removed from the
lAbro^i'V Room by am/ person or
under a:.j ^.ivtext whatever.
18
LECTURE XXI.
ON TWO CASES OP HYSTERICAL BRACHIAL MONOPLEGIA
IN THE MALE, DUE TO INJURY.— HYSTERO-TRAUMATIO
MONOPLEGIA (continued)?
Summary. — Diagnosis continvsd, — Amyotrophies dependent on
joint lesion; on spinal or focal cerebral lesions. — Sym^
ptoms pathognomonic of hysteria in this patient; right
hemiansesthesia ; monocular polyopia with macropsy ; bi-
lateral retraction of the field of vision.
Case of Pin — ;* Flaccid monoplegia and loss of all hinds
of sensibility in the left upper extremity following a falL
"^Other hysterical symptoms ; diminution of hearing, taste,
and smsll on one side ; retroaction of the field of vision with
transposition of the red ; monocular polyopia ; anaesthesia
of the ba^k of the throat ; hysterogenic areae ; hysterical
attacks followed by an improvement in the paralysis of
the arm.
Psychic paralyses ; their production by suggestion in
hypnotism. — Different states of hypnotism considered in
connection with the possibility of suggestion.
Gentlemen, — In our last lecture we lad before us a re-
markable case of brachial monoplegia in a man, 83t. 25,
supervening on a fall upon the shoulder, in which we were
constrained to believe that the symptoms observed were
not connected with a lesion of the nerves of the brachial
plezus. This opinion we based upon the extent and dis-
^ Lecture edited by M. Marie, clief de cliniqne, and M. Geo. Gninon,
interne da service.
' Continued from p. 252.
HTPOTHEBIS OP A SPINAL LB8T0N. 275
position of the cntaneous and deep-seated aniestliesia, on
the absence of trophic changes, and of Brb's reaction in
the nauscles of the paralysed limb. These same considera-
tions also enable us to conclude at once that we have not to
deal with an example of amyotrophic paralysis which is some-
times the result of tranmatism, affecting an articulation, and
which has been specially investigated by MM. Lefort and
Valtat."
After eliminating these from the diagnosis it remains for
us to examine the two following hypotheses. Does this
monoplegia depend on a lesion localised in the spinal cord ;
or a circnmscribed lesion in one of the cerebral hemispheres ?
We shall not be long detained in discussing the first ques-
tion to which we have more than once referred in the course
of the preceding lecture. A destructive lesion strictly
limited to a certain region of the anterior horn of the grey
matter in the brachial enlargement of the right side, may it
is true, as we see in cases of infantile spinal paralysis, pro-
duce a flaccid brachial monoplegia, without affecting in any
respect the face or the leg of the same side, altogether corre-
sponding in this respect to what is observed in our patient.
But in such cases, not to speat of the sudden development,
accompanied most frequently by a febrile condition of some
days' duration, we certainly observe after a period of eight
or ton days a very pronounced reaction of degeneration
affecting all the muscles, and after four months manifest
atrophy of those muscles. Further, the tendon reflexes are
abolished from the commencement. And again, there would
be no cutaneous anesthesia or loss of the muscular sense. It
is tme that a concomitant lesion of the posterior comua of the
grey substance in corresponding regions of the spinal marrow,
may cause, without doubt, more or less grave perversions of
sensibility. But any such lesion exclusively involving one
of the anterior horns and the region quite limited to the more
posterior part of the posterior horn of the same side, has not
yet been observed, so far as I know ; and if that lesion instead
of remaining limited, as we have already assumed, bad invaded
the median parts of the grey column, then the anseathesia
' Vide Lecture II, p. ao, ante.
276 HYPOTHESIS OF A OBBEBEAL LESION.
would affect not only the side corresponding to tie lesion, but
also the opposite side.
I will not further insist on that point, but we will con-
sider a little more closely the hypothesis of a circumscribed
cerebral lesion. In what region of the cerebral hemispheres
ought any such lesion to be localised in order to produce
the symptoms manifested in our patient? Could it be a
lesion affecting the internal capsule ? Such a lesion as one
might suppose to b6 produced by the shock ; and which would
consist, I suppose, of a patch of hsemorrhagic or capillary
apoplexy resulting from the commotion incidental to the fall.
Such a condition would almost necessarily be accompanied
by some apoplectic symptoms which have not certainly oc-
iCurred in our patient. I would add that a pure brachial mono-
plegia, like the one before us, is almost unheard of in the
history of lesions of the intei*nal capsule.^ It is further
necessary to suppose a lesion strictly limited to the ante-
rior parts of the capsule, and consequently perversions of sen-
sibility would then be wanting. It is therefore higher in the
hemisphere, that is to say, in the grey matter or the parts
immediately subjacent to the centrvmi ovaUy that we ought
to search for the localisation of the supposed organic lesion.
A lesion sufficiently extensive and profound, localised in
the middle third of the median convolutions (frontal and
ascending parietal) necessarily results in a brachial mono-
plegia ; that is now so well established that it is unnecessary
to enlarge upon it. But it is necessary to remark that the
existence of a pv/re monoplegia, without any participation of
either the muscles supplied by the inferior facial, the tongue,
or the inferior extremity of the same side, supervening on a
cortical lesion, is undoubtedly very rare. We can scarcely
collect a dozen such in a total of more than 250 cases ob-
served by M. Pitres and myself, in our work relating to the
question of cortical cerebral localisations.^ But in the case
^ Vide ** A Case of Monoplegia due to Lesion of the Internal Capsule/' by
Drg. Bennett and Campbell, in 'Brain/ April, 1885, p. 78.
' Charcot et Pitres, " Etude Critique et Clinique de la doctrine des loca-
lisations motrices dans I'^rce des hemispheres c^rebraux de Thomme"
('Bevue de M6decine,' 1883, Nos. 5, 6, 8, and 10).
SENSOBT CHANGES IN COETIOAL LESIONS. 277
of this patient^ and this is a fact to be at once appreciated^
it was clearly evident that at no stage of the malady^ not
even at the commencement^ did the face^ the tongue^ or the
inferior extremity present the slightest degree of paralysis
or even paresis. From the outset, I repeat, the superior
extremity alone has been affected.
I would remark that a cortical lesion sufficiently pronounced
to provoke a paralysis of movement, as complete and as dura-
ble as is observed in the case of Porcz — , would necessarily
determine a secondary descending cerebro-spinal degeneration,
manifesting itself clinically by the existence of a certain
degree of contraction in the paralysed member. But it is
perfectly clear that in our case there is not the slightest evi-
dence of any trace of such rigidity, rather, on the contrary,
we observe that the motor paralysis is here remarkable by
the softness and flaccidity of the parts, the diverse segiiients
of the member opposing no resistance to the movements prac-
tised on them. Besides, although the tendon-reflexes are
preserved in our patient, they are not notably exaggerated
as would have been the case in a cortical lesion, with de-
scending degeneration, four months after the appearance of
the disease.
Finally, gentlemen, the perversions of sensibility, so
strongly marked in the case of Porcz — , are not such as would
be observed in a lesion of the cortex which one must suppose
to be limited strictly to the middle third of the median con-
volutions. In a good number of cases of cortical lesion
localised in one of the motor centres, the cutaneous sensi-
bility and the muscular sense may, as yon know, be abso-
lutely intact. That is shown in many of the cases collected
by my former chef de clinique. Dr. Ballet, in his inaugural
dissertation,^ and by a case published by Ferrier in ' Brain.'*
It is true that MM. Bxner, Petrina, Tripier, and more
recently M. Starr* have collected a certain number of ob-
^ G. BaUett, ** Le f aisceau sensitif et les troubles de la sensibilite dans lea
cas de lesions c^r^brales " (' Archiv de Neurologie,' T. IV, 1882, et ' Th^e
de Paris/ 1881, p. 67).
' * Brain,' April, 1883. terrier's case relates to an example of crural
monoplegia.
' ^ Allen Starr, '* Cortical Lesions of the Brain ; a collection and analysis of
the American cases of localised cerebral disease," pp. 48 and 49 (the 'Americaa
278 NATUEE OF THE LESION IN THIS CASE.
SQrvations relative, to lesions limited to thQ median convola-
tions^ in which^ besides the motor paralysis^ it was par-
ticularly noted that sensibility was affected in every manner
(tactile sensibility^ sensibility to pain^ the muscular sense^
&c.). But it appears established^ notwithstanding^ by these
same observations^ that^ if the lesion is limited exactly to
the motor centres without encroaching on the neighbouring
regions of the parietal lobe^ these various perversions of
sensibility are always but little pronounced or eminently tran-
sitory. This contrasts signally, you observe, with what exists
in our case, in which the diverse kinds of cutaneous and deep
sensibility have be^en affected in a high degree and perma-
nently during four months.
These considerationi^ lead us to reject the i4ea that in this
patient there exists a circumscribed cortiaal lesion, as we
have already rejected the notion of a spinal lesion or a lesion
of the peripheral nerves. With what then have we to deal ?
There is without doubt a legion of the nervous centres, but
where is it situ&ted, and what is its nature? It is, I opine,
in the grey matter. of the cerebral hemisphere on the side
opposite the paralysis, and more precisely in the motor zone of
the arm. Further, taking into consideration the extent and
mtensity of the, perversions of sensibility, we may believe, ac-
cording to some recent works, that it is not strictly limited to
the motor sone, and that it extends behind the median convolu-
tions to the adjacent parts of the parietal lobe.^ But cert9.inly
It is not of the nature of a circumscribed organic lesion of a
destructive nature, as would have been the case in the diverse
hypothesis we have passed in review. We have here unques-
tionably one of those lesions which escape our present means
of anatomical investigation, and which, for want of a better
term, w^ designate dynamic or functional lesions. And of
this I ^hall now endeavour to offer you further proofs.
Joumal of Medical Science,' 1884). ''The Sensory Tract in the Central
Nervous System,*' ^ 78 (reprinted from the * Journal of Nervous and Mental
Diseases,' vol. vi. No. 3, July, 1884).
^ Starr (loo. cit.) ; and Bechterew, " IJeber die Localisation der Hautsen-
sibilitat (Tast und Schmerzempfindungen) und des Muskelsinnes an der
Oberflache det Grosshimhemispharen (MendeFs ' Neurol. Centr.-Blatt,' No.
18, 5th Sept., 1883).
HYSTERIOAl STIGHATA. 279
As I have indicated, in demonstrating the symptoms
observed in our patient, there are among them — and of a
kind that are the most important — some which hitherto I
have advisedly passed by in silence, intending to bring them
into prominence at a proper time. That moment is now
arrived. The symptoms in question do not strike the eye
at first. In order to diacover them it is necessary to direct
the investigation on the lines oi a, certain hypothesis which
the presence of these symptoms, if they really exist, would
confirm and justify. You anticipate the hypothesis in ques-
tion — is oar patient hysterical ? Is he the subject of saffi-
■ciontly numerous and sufficiently accentuated hysterical stig-
mata to permit us to afiirm that we have really to deal with
the hysterical diathesis ? In favour of this view the proofs
abound. Here the motor paralysis, the antestbesia and the
other symptoms relate to hysteria. Such is my conclusion,
confirmed on every point very explicitly by my colleague M.
Joffroy, at a meeting of the Societe Medicale des HSpitanx.^
In the Erst place I would point out that in the case of
Porcz — the perversions of cutaneous sensibility are not
exactly confined to the right superior extremity. They are
found though less pronounced, that is in the form of anal-
gesia, over the whole extent of the same side, the face, the
trunk, and lower extremity, "We have here then, so far as
relates to common sensibility, a generalised right hemianffis-
thesia, only much more pronounced on the extremity than
-elsewhere.
If, next, we examine the organs of sense, we find on this
side valuable indications. The hearing is defective on the
right side. The ticking of a watch, which on the left side
is heard at a distance of 50 centimetres {20 inches) or more,
is not heard on the right side beyond 20 centimetres {8 inches) .
Taste is completely lost on the right side. Then, observe the
insensibility of the pharynx. The finger roughly introduced
into the mouth as far as the epiglottis causes, in this patient,
no refiex action. This phenomenon is, as you know, common
in hysteria. Many observers, and particularly M. Chairou,
have called attention to it iu recent years. Having obtained
these preliminary results, we naturally expect to find by an
' Seance du 37 Mars, 1885.
^
280 MONOOULAE POLYOPU.
examination of the field of vision that characteristic retrac*
tion to which I have so often directed your attention. But^
excepting on the first examination we have been deceived in
our anticipations ; we have now under observation a normal
field of vision. I will show you how in this respect matters
changed soon afterwards. However, investigation of the
function of vision was not fruitless ; it demonstrated, indeed,
the existence of a phenomenon which, in the absence of
others, acquires a great importance, and greatly contributes
to identify hysteria in a case of diagnostic difficulty. I refer
to. the Monocular polyopia of hysterical subjects, a symptom
which M. Parinaud^ has investigated for some considerable
time in the patients in my clinique, and which he was the
first, I believe, to signalise.
Monocular polyopia (diplopia or triplopia) is, however, not
exclusively peculiar to hysteria, but it generally occurs in
that affection with special characteristics, by which, accord-
ing to M. Parinaud it may be distinguished from other species
of the same kind.
The crystalline lens, as you know, presents a segmentary
structure, and may be said to be formed of three lenses. It
will, therefore, be perceived that under certain conditions
two or three images may be produced on the retina. This
is a natural defect, as it were, more or less pronounced
according to the individual, which in the healthy condition
is corrected by the normal action of accommodation. It is
easy to comprehend that when the physiological function of
accommodation is affected, monocular polyopia results, and
thus it may be noticed in the paralysis of accommodation
produced by atropine, and in the contraction of accommoda-
tion determined by eserine. In the latter case it is generally
not very pronounced, apparently owing to concomitant myosis.
It is to the contraction of the muscle of Brucke,^ in the
absence of myosis, according to M. Parinaud, that the mono-
cular polyopia of the hysterical ought to be ascribed. Without
functional lesion of the apparatus of accommodation, mono-
* H. Perinaud, " De la Polyopie Minoculaire dans I'Hysterie," &c. (Ex-
trait des ' Annales d'Oculistique,* Gktnd, Mai — Juin, 1878.)
^ La contracture de muscle de Taccommodation dans rfayst^rie a ^t^
6tudi^e par M. Galezowski (* Pi-og. M6d./ T. VI, p. 39, 1878).
HTSTEBICAL MAOEOPSY AND MIOBOPSY. 28 JP
ft
cular polyopia is seen in aged persons^ in commencing cata-
ract^ and in certain cases of astigmatism^ congenital^ or due
to keratitis.
But it will be easy to eliminate^ in a given case, the-
causes of monocular polyopia above mentioned, viz. senile
cataract, astigmatism from lesion of the cornea, or the effects
of eserine or atropia, &c. Further, putting aside the ab-
sence of these causes, the polyopia of the hysterical appears,
as I have said, to be characterised by special features. I
refer to the macrospy and the microspy which, according to
M. Parinaud, are peculiar to this condition, while they are-
not observed in the other cases. Place a pencil before
Porcz — , held vertically at a distance of a few centimetres
from one of his eyes, the other being shut, and he distin-
guishes but one image. But if the pencil is held further
off he distinguishes two images. At eight or ten centimetres
(three to four inches) from the eye they are distinctly sepa-
rated the one from the other. Further, when the pencil is
placed quite near the eye it appears unduly large, while,
held at a distance of from fifteen to twenty centimetres (six
to eight inches) it appears two or three times smaller than it
really is, or than it would be seen normally. Such is the
special monocular polyopia, which, associated with the sen-
sorial and sensitive aberrations under consideration, constitute
a significant feature in a case, especially where neither alco-
holism, nor lead-poisoning, nor lesion of the internal capsule-
is operative. A second examination of the field of vision-
three days ago revealed a new feature. Five days ago the
patient went out on an expedition, and returned very fatigued.
Two days later perimetric examination disclosed concentric
lessening of the field of vision, almost equally marked on both
sides, though without transposition of the red circle.
It will not, after this, be necessary for me to enter into
lengthy detail in order to show that the collection of sym-
ptoms which have been unfolded, so inexplicable on the
hypothesis of an organic lesion of the brain, spinal cord, or
peripheral nerves, admits of a very simple interpretation Ott
the supposition of a dynamic hysterical lesion.
However, I should like to remark that the clinical charac-
282 FBATUEES OP HYSTERICAL PARALYSES.
ters of the monoplegia of Poijcz— do not differ from those
which distinguish undoubted cases of hysterical paralysis.
Confirmation is afforded by reference to the most competent
authorities on the subject. I would point out in the first place
the absence of any participation of the face in the paralysis^ a
fact brought into prominence by Todd,^ Althaus, Hasse,* and
myself/ and by Weir Mitchell in his excellent book on the
nervous diseases of females ;* for my own part I have not
yet found a well-marked exception to this rule. Secondly,
the absence of any modification of electric reaction, of any
atrophy of the muscles, notwithstanding that the paralysis
has existed for several months ; and the persistence of abso-
lute flaccidity of the member without any marked change in
the tendon reflexes ; and also the absence of the muscular
sense in a marked degree, such as is scarcely ever observed
in paralysis of cerebral origin from other causes. Finally, I
would point out to you the marked cutaneous and deep anass-
thesia, its particular mode of distribution and limitation,
which appeared singular at first sight no doubt, not having
been carefully studied, and which does not correspond in
a^y way to the distribution of the sensorji^ei'ves emanating
from the brachial plexus.^ I would not go the length of
' K. H. Todd, 'Clinical Lectures on Paralysis: Certain Diseases of the
Brain, <&c.,' London, 1856. "Again the extent of the paralysis in the limbs,
and the total absence of it in the face and tongue, are certainly evidence in
favour of its hysterical character, for although hysterical paralysis occurs in
all parts of the trunk and extremities, it very rarely, if ever, attacks the
face.*' — Loc. cit., p. 20.
^ Hasse, * Handbuch der Pathol., &c.,' II Auflag, Erlangen, 1869.
^ Charcot, ^ Lemons sur les Maladies du Systeme Nerveux,' T. I, 1st ed.,
p. 351. I2e le^on. — "Remarquez en premier lieu Tabsence de paralysis
faciale et de la deviation de la laugue, lorsque celle-ci est tiree hors de la
bouche. Yous savez que ces phenom^nes existent au contraire toujours k un
certain degr6 " — c'est presque toujours qu*il faut lire — *' dans I'hemipl^gie
par lesion en foyer du cerveau."
^ Weir Mitchell, ' Lectures on Disease of the Nervous System, especially
in Women,' 2nd ed., Philadelphia, 1885. " Unlike the hemiplasy of cerebral
and oi^nic cause, hysterical half -paralysis involves, morei or less, all one
side of the body, excepting the face ; but in a few rare cases the neck is dis-
tinctly afEected." — Loc. cit., p. 35.
' Compare Figs. 54, 55, 56, 57. That arrangement in geometrical seg-
ments limited by circular lines at right angles to the long axis of the member.
ABSIINOE OP CONVULSIVE ATTACKS, 283
asserting tliat all hysterical paralyses necessarily present the
whole of the characteristics enomerated^ but I believe it may
be affirmed that when these characters are found coexisting
in a given case of paralysis its nature should not i*emain
doubtful.
Such are the arguments, and they appear to me conclu-
sive, by which I am constrained to affirm that, independently
of hereditary circumstances, and the existence of stigmata,
our patient must be considered to be hysterical ; further that
the monoplegia itself presents in him all the characteristic
features of hysterical paralysis. In short, all the symptoms
which; we note in Porcz — reveal hysteria, and we find in his
case nothing but what accords with hysteria.
Our diagnosis confirmed^ there remains one concession
which I am constrained to make, viz. : That this is not an
absolutely complete case of hysteria, or, in a word, a classic
case. But this renders it all the more interesting to the
clinical observer, for if the hysterical nature of the affection
is established by the foregoing, it should be remembered
that it does not at first sight strike one as snch, and that it
is necessary to establish the diagnosis by minntely examining
the clinical aspects of the case in their entirety. There is
in reality something wanting in the picture, and that some-
thing, you all recognise, is the existence of hysterical attacks
and, o£ hystero-genic points. Evidently that circumstance
need not seriously . impede us, for the convulsive . attack, as
you know, is far from being a necessary characteristic of
hysteria. According to M. Briquet it is wanting in a third
of the cases of hysteria in the female, and, according to my
experience^ it may be absent in the male, and in equal pro-
portion to the other sex.
To further establish the conclusions at which we have
arrived^ and to give them more weight, it may be useful to
really represents, at least for the limbs, the type of anesthesia of cortical
origin, by whatever cause produced. Only in hysteria that character will be,
in general, much more accentuated and much more easy to recognise than in
the case of an organic lesion, doubtless because in the former condition the
dynamic lesion is much more extended, and may occupy the entirety of some
circumscribed sensitive area of the cortex. — J. M. C.
284 COMPAEISON OF
compare with the present case that of another hysterical
male whom I brought under your notice in the preceding
lecture, and on whose case I dwelt at some length.* I refer to
the patient Pin—, whom I again submit to your examination.
Bearing in mind the principal features, you will recognise that
his history is traced in some degree in that of Porcz— .
As with the latter. Pin — was affected with brachial mono-
plegia in consequence of a fall, only in his case the paralysis
affected the left superior extremity and the anterior aspect
of the shoulder, which was the one that had been struck.
On the nth March, at our first examination of him, the
paralysis was absolute (as in Porcz — ) the face never having
been affected in any degree whatever. The paralysed mem-
ber was pendent, flaccid, and without the slightest rigidity
at the level of the joints ; no amyotrophy nor modification of
electric reaction, notwithstanding that the disease was of ten
months^ duration. Cutaneous and deep anaesthesia exists to
the same degree in both Porcz — and Pin — , only it is more
extended on the hands and fingers of the latter, but it is
limited exactly in the same manner at the shoulder (compare
Figs. 54, 55, p. 268, 60, and 61).
The loss of the muscular sense is equally pronounced in
all the insensitive parts. These perversions of sensibility are
not yet modified^ and at this moment we can prove their
existence in the two patients. Tou see how far the two
cases resemble one another up to this point. Between them
there is almost an identity. The details which follow will
link them together still more closely.
In the discussion on the diagnosis in the case of Pin —
we successively eliminated (as we Have done in the case of
Porcz — ), the hypotheses of a lesion of the branches of the
brachial plexus, any spinal lesion, or any organic lesion of the
central hemispheres, which the presence of aortic insufficiency
in his case might have rendered likely. And we arrived
at the conclusion that the paralysis depended on a dynamic
lesion localised in the grey substance of the brachial motor
zone in the side opposite to that affected by the monoplegia.
The existence of the hysterical diathesis further reveals
itself in this patient by significant features ; analgesia ex-
* Vide p. 251, et seq.
TWO HALE CASUS.
tending over the left side of the head, of the trunk, and
the whole of the left inferior extremity ; hearing, smell,
and taste, tested by the nsnal proceBses, present a marked
diminntion on the left side. The field of vision presents a
Fiss. 60 and 61.— Cue of I^d—
normal condition on the right side, hot on the left there is
s considerable diminntion of its area ;' farther, on this side
' Tfais case shows, with many othen that I coold cite, tbut althongh the
concentric lessening of the field of Tiaiou in the h;ateii«al exists mora fie-
286 PBOGBESS.
the red circle is wider than that of the blue (Figs. 62 and
63). To-day we find on the same side the presence of
monocalar polyopia^ which has not been hitherto noticed. I
would add that the finger introduced into the pharynx as
far as the epiglottis does not cause any reflex action.
Finally, and this is the only feature in which the case of
Pin — differs in a marked manner from that of Porcz — ,
there exists in the former several hypersesthetic hysterogenic
zones ; one situated under the left breast, another in each of
the iliac regions, and one on the right testicle.
On the 15th of March you will recollect that in conse-
quence of a slight excitation of the submaxillary zone. Pin —
was affected with a perfectly characteristic hystero-epileptic
attack. This was the first that the patient had ever experi-
enced. It was succeeded by many others of a like character.
At the present time these attacks frequently occur spontane-
ously. After one of these attacks, on the 2i8t of March, an
improvement in the motor power, which exists at the pre-
sent time, was noticed in Pin — . He is able, as you see, to
voluntarily move all the segments of the left superior extre-
mity. But these movements are not very energetic, they do
not resist the least opposing force. The dynamometric force
on the right is represented by the figure 70, that on the left
only by 10. Thus, if the motor power is not so complete as
it once was, still there 'is much improvement. The derange-
ments of sensibility remain, as they were at the commence-
ment, not only in the impaired member, but over all the left
side of the body and the organs of special sense. Conse-
quently this is not a complete cure, but we have reason to
hope that further improvement will occur, for clearly the
prognosis is not so grave as paralysis arising from a de-
structive lesion in the grey substance of one of the cerebral
hemispheres. Between the case of Pin — and that of
quently on both sides, this is not an absblnte rale. This lessening may be
limited to one side. The case of Gil — , in particnlar referred to in a former
lectnre (p. 232, et «egr.), may be cited as an example. Apropos of this case, I
may observe that the patient having unexpectedly died a few days ago (it
appears he swallowed an enormous dose of chloral which he secretly pro-
cured) the post-mortem examination was absolutely negative as regards the
nervous centres, a &ct plainly confirming the diagnosis.— J. M. C.
HY8TBBI0AL ACHEOMATOPSU. 287
Porcz — the presence of hyBterogenic points in the former
constitates the sole difference j ik all other respects they are
identical. Bnt it may be said that the case of Pin — , more-
complete in some respects, and more easily diagnosed than
that of ForCE — , fills up the hiatus which, so to speak, exists
between the case of Forcz — and ordinary cases of hysteria.
•288 PEOGNOSIS.
It marks the transition^ so that no part of the series is
missing.
Here, then, are two examples of hysterical brachial mono-
plegia of traumatic origin occurring in the male.
I think that I have demonstrated that the brachial mono-
plegia supervening on an injury in the two men who formed
the subjects of the preceding lectures, is of a hysterical nature.
The prognosis naturally follows from the diagnosis, and
it is clear that it will be infinitely less grave in cases of
this nature than in such as supervene on a destructive
organic lesion. Without doubt, in our two patients, the
paralysis, already of long standing, may persist, notwith-
standing its hysterical nature, for months, or perhaps even
years, especially if we do not intervene by means of appro-
priate therapeutic agents. Nevertheless the cure, we can
safely affirm, will take place sooner or later, and our efforts
ought to hasten the occurrence.
But how ? According to what principles should the in-
tervention take place ? That is the question we have now
to resolve. We may have recourse to the empirical measures
which are resorted to in the treatment of hysteria — appro-
priate to rousing vital energies almost always depressed in
such circumstances, such as the repeated application of aestheo-
genip means, and in particular static electricity, prolonged
hydrotherapeutic appliances, &c. But these agents, which
certainly ought not to be neglected, apply rather to the
general condition, and, according to my experience, in so far
as concerns the paralysis, their beneficial effects are long
deferred. Certainly our interference will show itself with
more effect if, instead of relying on empirical notions, it can
be founded on a physiological basis ; if, for example, we can
recognise, at least in part, the mechanism of the production
of traumatic hysterical paralysis.
This problem, bristling with difficulties of every kind, we
must now proceed to face. I do not promise you, be it
understood, a solution on all points, but in endeavouring to
reach our aim we shall perhaps encounter glances at truths
whose practical consequences ought not to be disdained.
To arrive at the point to which I wish to lead you, I shall
PSYCHIO PARALYSES. 289
tave to take a course apparently devioas, and must return
once more to a subject which has already occupied our atten-
tion,' I mean those remarkable paralyses which have been
designated psychical paralyses, paralyses depending on idea,
paralyses by imagination (Paralyses durch Einbildung). Now,
observe, I do not say imaginary paralyses, for indeed these
motor paralyses of psychical origin are as objectiTcly real as
those depending on an organic lesion ; they simulate them, as
yon will soon see, by a number of identical clinical characters,
which render their diagnosis very difficult.
Though they have been known for a long time, these
paralyses were first investigated in a methodical and syste-
matic manner in 1869 by Professor Russell Reynolds, in an
excellent work treating of their etiology, their clinical charac-
ters, and their methods of treatment.^ Their history still
offers several obscure points. It is well known that in certain
circumstances an idea may produce a paralysis, and con-
versely, that an idea may cause it to disappear ; but between
these two ultimate facts, many links remain obscure. Evi-
dently this is a subject which would gain in clearness and
precision if it could be submitted to experimental investiga-
tion.
Well, gentlemen, thanks to recent notions in relation to
the science of hypnotic neurosis, it is possible to call in the
aid of experiment in the study of cases of this kind. We
know that in subjects in a state of hypnotic sleep it is pos-
sible — and this is a notorious fact now — to originate by the
method of suggestion, or of intimation, an idea, or a coherent
group of associated ideas, which possess the individual, and
remain isolated, and manifest themselves by corresponding
motor phenomena. If this be so, we know that if the idea
■suggested be one of paralysis, a real paralysis virtually
ensues, and we see in such case that it will frequently
manifest itself as accentuated as that arising from a de-
structive lesion of cerebral substance. These assertions I
' J. M. Charcot, 'Lezioni oliniche dell' anno soolaatieo, 1881-84; sulle
malattie del aJBtema nervoao, redatta dal Dr. D. Miliotte.— Sulle paralis
lieichiohe,' pp. 103— no, Milano, 1885.
' Russel! Keynolda, " RemarliB on Paralj-sia and other Disoi-dera of Motion
and Sensation dependent on Idea." Read to the Medical Section, Brit. Med.
Assoc., Leeds, July, i86g ; ' Biit, Med. Joum,,' Nov,, 1869.
19
390 PHASES OF CHEAT HYPNOTISM.
am abont to try and justify by placing before you cases of
paralysis prodnced by Buggestion, and which we may con-
sider as typical of psychical paralysis.
At the outset it is my duty to recall to your memory
a certain number of facts with which our former Btadies
have made you acquainted.^ Bearing these facts in mind
you will readily understand what follows. I would remind
you that in the lethargic phase of what is called the great
hypnotism, the mental inertia is ao absolute that in general
it is impossible to enter into relation with the hypnotised
subject or to communicate any idea to him by any process
whatever. But it is not thus in the other two phases of
hypnotism. Thus in catalepsy — I apeak here only of tho
true catalepsy, such I have described — certain phenomena of
suggestion are easily obtained, and owing to their simplicity
and their small tendency to become generalised, they are
relatively easy of analysis. Here then, evidently, the study
of hypnotic suggestions ought to commence. Here, as in
the preceding phase, there is mental inertia, but it is less
profound, less absolute ; it has become possible, indeed, to
produce a sort of partial waking in tho organ of the psychic
faculties. Thus, ono can call into existence an idea, or a
group of ideas connected together by previous associations.
But this group set in action will remain strictly limited.
There will be no propagation, no diffusion of the communi-
cated movement; all the rest will remain asleep. Conse-
quently the idea, or group of ideas suggested, aro met with
in a state of isolation, free from the control of that large
collection of personal ideas long accumulated and organised,
which constitute the conscience properly so-called, the ego.
It is for this reason that the movements which exteriorly re-
present the acts of unconscious cerebration are distinguished
by their automatic and purely mechanical character. Then
it is truly that we see before us the human machine in all its
simplicity, dreamt of by De la Mettrie.^
' J. M. Charcot, ' Essai d'uno distinction nosographiqna dea divera ^tats
nerveux eompris nous le nom d'hypnotismo.' Note comm. a rAcadSmie des
Sciences, 1883. — Id., ' Lezioni cliniche redatte dal Dr. Dom. Miliotti. — SuUe
paralisi peichiche,' pp. 103 — 110, Milano, 1885.
" De la Mettrie, "L'homme tnachitie," '(EuyreB piulosophiques,' T. I,
J
ASSOCIATION OP GESTURE AND PHYSIOGNOMY. 291
In this cataleptic condition, in the greater number of in-
dividuals, the only means by which we can enter into rela-
tion with the person hypnotised is through the muscular
sense. The gesture alone, or the attitude in which we put
the subject, suggests to him the idea which we wish to
transmit to him. By shutting, for example, his fists in an
aggressive attitude, you observe the head carried backwards,
and the forehead, the eyebrows, and the root of the nose
become corrugated with a menacing expression. Or, again,
if you place the tips of his stretched-ont fingers on his mouth,
then the lips relax, he smiles, and all the face assumes an
expression of softness totally opposed to what it jnst mani-
fested.
Haying studied the influence of gesture on the physiog-
nomy, we are also able, as M, Richer and myself have done,'
to study the influence of physiognomy on gesture. But it
is still to the muscular sense that the phenomena are
due which are produced by the action of electricity on the
diverse facial muscles, after the indications of Duchenne
de Boulogne. If we determine, for instance, contraction
of the corrugator supercillii (muscle of anger, D. de B.},
you will observe the face suffused with anger, while the
right arm is placed in an attitude of aggression, and the left
in a position of defence. If, on the contrary, it is the zygo-
matic muscle (the muscle of laughter, D, de B,), which is
excited, the expression of the physiognomy and the corre-
sponding attitude are those pertaining to laughter, These
phenomena, now indicated summarily, I have already brought
under your cognisance.' But the feature to which I speci-
ally wish to call your attention at present is the way in which
each impression thus originated by the intermediation of the
muscular sense remains isolated without diffusion, and fixed,
Aniatcrdttm, 1765; see also T. II, " L'hommo planto. L'homme plus quo
' J. M. Charcot and P. Eicher, "Note on certain faetB of Cerebral Auto-
matignj, Sm. : suggestion by the Muscular Sense," ' Journal of Nervous and
Mental Diseases,' vol. i, No. 1, January, 1883; sea also Bertrand, " Denx
lois psyoho-pliyaiologiqnes," ' Revue Phil osophi que,' pp. 244, 24S, No. 3,
Marcli, J 884.
' J. M. Charcot, 'Lczioni Clioichc,' loo. cit., p. 103.
SOMNAMBULin PHASE.
«o to BpeaV, during all the time tbat the mnscQlar action
maintains the members in tbe expressive attitude artificially
produced.
We now come to the third phase, the somnambulic, which
is the only one that will engage our attention to-day. We
have here to do solely with a state of ohnubilation, mental
torpor more or lei's accentuated. Here, again, without doubt,
the awakening detprmined by suggestion remains partial, but
the number of elements called into operation is less limited
than in the preceding case, and frequently a difEusion occurs
of the induced psychical phenomena sufficiently extensive to
manifest a certain tendency to the reconstitution of the ego.
Hence, it sometimes happens under these circumstances that
the injunction, the suggestion, becomes the occasion of a
certain amount of resistance on the part of the subject. In
all cases this yields to a little insistance. Nevertheless, it
does not always do so without a preliminary discussion.
Let me add that the movements in connection with the ideas
suggested are consequently often very complex ; they have
not, therefore, that character of mechanical precision which
they present in the preceding form ; on the contrary, they
assume the likeness of voluntary acts, more or less premedi-
tated, even to the extent of leading one astray.
Further, in the somnambulic stage all the senses are
intact, and it may be said, indeed, that although the con-
science is in abeyance, the sensibility to communicated im-
pressions is exalted. Ifc consequently becomes easier to enter
in relation by diverse means with the hypnotised person. If
he be urged to look at some object, the simple view of that
object will arouse in that patient a certain number of ideas
asBociated with the nature of the object, and those ideas will
manifest themselves objectively in the form of corresponding
acts. If, by significant gestures, an object or an animal is
figured in space, that animal or that imaginary object will
appear lo the eyes of the hypnotised person as real, and will
call into action a corresponding series of ideas and move^
menfs. And again, in a manner sfcill more perfect, suggeS'
tion can be effected by the aid of speech, either alone, or
better, combined with gestures.
This is enough, gentlemen, to remind yon in a general
tion I
ally ^
J
EXAMPLE. 293
way of the cbief characters of bypnotio suggestion in the
somnambulic period, ancl how unlimited our power is in
this domain, for really we can Tary our action almost with-
out end. Hence you will not be surprised to find that, in
suggesting to a somnambulistic subject the idea of a morbid
state, for example motor paralysis of the extremities, the
paralysis becomes objectively manifest, and thus lends itself
to our clinical investigation.
I would remark, and this is a point interesting in the
highest degree, that that paralysis which wa can make by
the aid of suggestion, we are able at will to modify both in
degree and character up to a certain point, and to unmake
it equally well by suggestion. One can therefore anticipate
that the study of paralysis thus artificially produced may one
day be employed to elucidate the whole group of psychical
paralysis.
After these preliminary remarks we may proceed to the
demonstration of facts. The hysterical girl, Greuz — , who is
now before you, presents on the left side the usual complete
hemianEesthesia ; on the right side there is no appreciable
perversion of sensibility. We shall be able, then, on this
side, easily to observe any perversion of sensibility which
may occur during the evolution of the perversions of motor
power which we are about to provoke. I may inform yoa
in passing that this girl has been subjected only four or five
times to the influence of hypnotism, so that in her case there
is wanting the influence of training [entrainement], pro-
duced in subjects frequently hypnotised, Further, I can
assure you that the phenomena which yon notice to-day are
exactly the same as in our first experiment.
Greuz — is put into a somnambulic state by means of slight
pressure exercised on the eyeballs for a few seconds. The
peculiar rigidity of the members which you observe pro-
duced by light touches over their surface, or even by move-
ments performed at a distance (somnambulic contracture), is
of a somatic nature which, as you know, enables us to appre-
ciate when the sleep ia well established. Then, in order to
determine the production of the phenomena which we have
purposed studying, I proceed by affirming in a loud voice^
294 PAEALTSIS ET SUCQESTION.
" Your right hand is paralysod/' saying to the patient in a tonD
of conviction, " You cannot move any part of it, it hangs by
your side." The patient demurs to some extent.' " Bat
no," she repliee, " you are mistaken. My hand is not in
the least paralysed, you see I move it." And really she does
move it, though very feebly. Then I insist, and always with
an accent of authority. I repeat a certain number of times
my first affirmation. You notice that after a, few minutes'
discussion the paralysis is definitely established. Now we
have really produced a brachial monoplegia whose clinical
characters we must minutely study, for perhaps this mono-
plegia is allied to that referred to in our last lectures in the
case of two hysterical men, Porcz — and Pin — . This we
intend to do.
The motor paralysis which we produce in Greuz — ■ by
hypnotic suggestion is, as you can see for yourselves, absolute
and complete. The right upper extremity in its entirety is
flaccid and hangs by the sido. There is no trace of rigidity
in any of the joints. It falls heavily down after being raised
for a second. The patient is unable to move the arm in any
manner, nor can she flex the wrist or the fingers. Hence
in this iimb ail active movement is abolished, as also all resis-
tance to passive movements. No muscle, I repeat, manifests
the slightest contraction, no matter what efforts are made
by the patient at our solicitation.
Moreover, the sensibility, recently normal, has now com-
pletely disappeared in the whole extent of the limb, You
can prove that the ansesthesia has even invaded the region
of the shoulder and a portion of the right side of the chest.
It not only affects the skin, but the deeper structures, viz.
the muscles, the trunks of the nerves, the ligaments, &c.
Thus, as you see, the most violent torsion of the joints may
be practised without feeling, and faradization of the nerve
trunks to such an extent as to cause violent contraction of
the muscles can be effected without determining the slightest
facial espression of pain or of any sensation whatever. The
tendon-reflexes of the wrist and elbow-joint are very notably
enfeebled.
' Other subjects submit to the suggeBtion without prot-est; there are
nnmeraaa individnal Tarieties in this respect.
J
LOSS OP MUSCULAR SENSE. 295
Lastly, as far as regards tbe muscalar seoae, the former
existence of which I took care you should recognise, you
that it is now completely wanting. The patient, when a
screen is placed before her eyes, ia unable to find with the
left hand any spot whatever indicated on the right, and she
has no notion whatever of tbe movements which wo impart
to the varions articulations o£ the limb.
In short, we have here to deal with a complete monoplegio
paralysis characterised by absolute flaccidityof all the parts,
cutaneous and deep anaesthesia occupying the whole extent
of the limb and extending even beyond, enfeeblement of the
tendon-refleses, and total loss of the muscular sense. These
clinical characters, you will at once recognise, are exactly
those disclosed in our patient Pin — when he entered oar
wards, and which now exist in the case of Porcz — , with
this sole difference, evidently of a secondary order, that in the
latter motion and seiisibility are preserved in the fingers.
.95 n
COOPER MEDICAL COU--"-
S*N FBANOISOO. OAb
LECTUEE XXII.
ON TWO CASES OP HYSTERICAL BRACHIAL MONOPLEGIA IN
' THE MALE (continuedy
SuMMABT. — Production of a monoplegia of the whole upper
extremity in a hysterical subject by suggestion ; its dis^
appearance effected by the employment of similar means. —
Production of paralysis of the different segments success
sively in the upper extremity of the same patient {shoulder,
elbow y wrist, fingers) , — The sensation and tendon-reflexes
disappear simultaneously in the parts atta>ched with para-
lysis, — Monoplegia can be artificially determined in a hyp-
notic by a blow on the shoulder {traumatic suggestion), —
Repetition of the same phenomena in an hysterical subject
awake, but in a natural and permanent condition of hyp-
notism.
Remarks on the treatment of two men affected with
brachial monoplegia; hydrotherapy; static electricity;
special exercise, — Mode of action of this la^t agent; psychic
motor images, — Good results of treatment.
Gentlemen, — We are now furnished with incontestable and
very valuable information. But we are enabled to push the
analysis still further. Thus, instead of paralysing the whole
member by one stroke, we can paralyse it partially, segment
by segment, and by these successive operations we can more
thoroughly investigate the essence of the phenomena.
In order to do this we must in the first place, if you will
allow me to use the expression, " deparalyse *^ our patient.
It suffices for this that we destroy the effects of the initial
^ Lecture edited by MM. P., Marie, chef de clinique, and Geo. Guinon,.
interne du service.
ABTIFICIAL PAEALY8IS BY SEGMENTS.
suggestion by the intermediation of a new suggestion of an
opposite nature. I therefore assure Greuz — that her arm haa
ceased to be paralysed, that she can move the limh as well
as ever. You notice that after a few minutes' discussion the
memher assumes all its normal functions in respect net only
of its mobility, but all forms of sensibility.
And then proceeding successively to paralyse segments of
the member, in the first place I suggest the idea to the patient
that she is unable to move the shoulder-jmnt, and forthwith
she is in reality unable to move it in any direction, while she
freely moves all the other joints, viz. the elbow, the wrist,
and the fingers. Moreover, in every part where voluntary
movement is abolished, nnd there only, observe that there is
not only cutaneous bnt deep insensibility ; thus, in the region
of the shoulder, pricking, faradic excitation, &c., are not
felt ; movements of torsion and extension, however violent,
at the scapulo-humeral articulation occasion no pain. All the
impressions derived from the muscular sense relative to-
passive movements of this articulation are likewise completely
wanting.
It will not be without interest to consider briefly the
extent and limits of that anEBsthesia (Figs. 64 and 65, A).
The insensible portion represents a sort of plate moulded
over the shoulder, similar to the sixteenth century piece of
armour designed to protect that region. Superiorly theline-
which limits the anaesthesia commences at the level of the
base of the neck ; it extends anteriorly almost to the external
border of the stefnum, involving the superior third of the
breast, and is directed obliquely towards the axilla, affect-
ing its entire extent, and prolonged for four or five fingers'
breadth along the axillary portion of the thoracic region.
Behind [A') it takes almost a vertical direction from the bus©
of the neck to about three or four fingers' breadth above the
angle of the scapula. In the transverse direction it extends-
to within four or five fingers' breadth of the spinous pro-
cesses. The arm is almost entirely encased, to continue the
metaphor, in an ancesthetic armulet.
I wish particularly to call your attention to the singular-
manner in which the ansesthesia is limited below. You ob-
serve that the line determined by successive prickings is very
J97^^1
SEGMENTAL Alf^STHESlA
distinctly circular. It forma a line at right angles to the axis
of the limb, about two inches above the flexure of the elbow-
in front, and passing behind jnst above the superior extremity
of the olecranon proGess.'
Fioa. 64 and 6s.— Case of Qranz— .
Such is the aneeethetic region correspondiDg to the isolated
paralysis of the shoulder. We shall now see that this con-
dition is capable of being modified by the same procedure of
suggestion which we have just employed ; and we now deter-
■ Tide note 5, p. 283.
AETIFICIALLT PRODUCED.
299 ^^
mine paralysis of tlie TDOTements of the elbow. As soon as
the motor paralysis of this joint becomes complete you will ■
observe that the zone of anEeatbesia extends lower down and
involves not only the shoulder and the arm, but the elbow
FlOB. 66 nnd 67. — Cmb of Porcz— .
and the forearm. Its inferior limit is formed by a circnlar
borieontal line, situated about two inches above the wrist-
joint, and forming a plane at right angles to the long axis of
the extremity (Figs. 64 and 65, B, B'}.
J'/un U'ok is the pc-j-. .
300
DI8TBIBUTI0N OF THE AN^STHESU.
Let us pass now to another segment, tliat of tlie vsriat.
Here again, in consequence of a new snggestion analogoas
to the preceding, the paralysis creeps onward and the patient
is now anable to move her shoalder, her elbow-joint, and her
Fisa. 68 ud 6g.—
wrist, she is only able to move the fingers of her band.' In
conseqnenoe, the inferior limit oi the anEesthetic zone is again
displaced (Pigs. 64 and 65, 0, C). Ton can satisfy yonrselves
now that it is limited anteriorly by a horizontal line across
COMPAltlSOK OP CASES.
SOI
the hand in a transverse direction almost on the level of the
metacarpo-phalangeal articulation of the thumb ; behind, the
limit extends lower down than in front, and is situated only
a iew millimetres above the line formed by the head^ of the
FiOB. 70 and 71.— Cuse of Pia— .
metacarpal bones, and on the back of the thnmb at the level
of the articulation uniting its two phalanges.
But, gentlemen,, you have doubtless remarked that the
paralysis which we have now determined in Greuz — by a
series of successive suggestions, reproduces, in its minutest
302 UNMAKING THE PARALYSIS.
details the clinical characters presented by the monoplegia
of our patient Porcz^. Indeed^ in the two cases it is actually
the same segments of the superior extremity^ the shoulder^
the elbow^ and the wrist that are affected with motor para-
lysis, the movements of the fingers remaining intact. And
equally in the two cases, wherever the paralysis of move-
ment exists there is cutaneous and deep anaesthesia, and loss
of the muscular sense ; whereas the fingers, where the motor
power remains, present no perversion of sensibility. Truly,
the imitation which we have obtained is perfect ; it extends,
I repeat, to the minutest details. You can convince your-
selves of this by the aid of these figures which I submit to
you, and by comparison of the anaesthetic territory in our
hypnotised subject, and in our patient Porcz — . You observe
that these territories have the same extent, present the same
configuration ; I might say that they are superposable (Figs.
64 and 65, and Figs. 66 and 67) .
That is no doubt remarkable ; but we can go further,
and complete in Greuz — the monoplegia by determining, by
suggestion, motor paralysis in the fingers, which, as you will
observe, is immediately followed by a loss of all kinds of
sensibility in the parts. And now we have a paralysis arti-
ficially produced invading all the parts, and involving per-
version of sensibility as well as perversion of movement which
are exactly identical with the monoplegia observed in our
second case, that of the patient Pin — (Figs. 70 and 71). We
have been ahle, then^ to obtain artificially in our hypnotised
patient by means of suggestion, a perfect imitation of the
monoplegia caused in our two other patients by a process appa-
rently very different, the action of traumatism.
Not to lose sight of the principal object in view in this
series of lectures, I will return in a moment to the important
results which we have realised. At present I desire to
demonstrate a few more facts relating to the hypnotic sug-
gestion, in order to fix in your minds those which we have
already gathered, and to convince you moreover that these
facts are not accidental (forming an appendage to a subject
unique of its kind), but that they may on the contrary be
reproduced with absolutely the same features in a certain
number of, cases.
SENSIBILITY BETAINEU BY SUGGESTION. 303
In the first place I will proceed to " ■unmake " the arti-
ficial paralysis of Greuz — ; operating segment by segment,
as I recently did in producing' it, only now I proceed in-
versely, that is to eay, beginning with the hand, taking in
turn the wrist, the elbow, and the ahouldor snccessively. At
each step of the operation you can prove once more that the
mode of distribution of the anaesthesia corresponds to each
segment of the motor paralysis.
In another hysterical subject named Mesl — I am about
to repeat all the phenomena that have been produced in
Gi-Bua — . Mesl — is hemianjesthetic ou the right side, it is
therefore on the left superior extremity that I am obliged to
operate. The results which follow, as you observe, are
exactly the counterpart of those described in the case of
Greuz — . An identical result has been obtained in the case
of other hemiansesthetic "hysterics" whom we recently
investigated in our wards, and whose cases I might present
to you did time permit.
In subjects of this bind the paralysis of the non-anaaa-
thetic member, determined by suggestion, is always accom-
panied by auEestbesia, cutaneous and deep, loss of the mus-
cular sense, and finally the diminution or abolition of the
ten don -re Hexes in the segments of the member affected with
motor paralysis."*
However, I would further remark that we are able even
in homiaUEesthetic "hysterics," to obtain motor paralysis
without any perversion of sensibility. It suffices to accom-
plish this, as I have many times seen, to persuade the sub-
ject at the moment when the suggestion is made, that
movement atone, will be lost, and that the sensibility will
remain intact. I do not wish to generalise too hastily with
reference to experiments not yet very numerous, but I am
bound to mention that hitherto I have not observed any varia-
tion in the hemianiesthetic "hysterics" to whom I suggested
purely and simply the motor paralysis of the member, with-
out saying anything of neiinhiliiy. I ant not considering at
present the cases of non-antesthetic " hysterics."^
' This fact is not constant ; the tendon- re fleses are sometimes manifeBtly
exaggerated.
' Compare ako Appendix II.
1
304 TRAUMATIC SUGGESTION.
That will suffice for the present on this subject, and I
must now revert to the principal object of to-day's investi-
gation. You perceive that the monoplegia of our two male
patients Porcz — and Pin — _, and the condition designedly pro-
duced in the hysterical patients are, so far as relates to clinical
features, not only comparable to one another, but really per-
fectly identical ; motor paralysis with flaccidity of the parts,
cutaneous and deep insensibility, the delimitation of the anaes-
thesia by circular planes at right angles to the long axis of
the limb,^ the loss or impairment of tendon-reflexes, and the
abolition of all notions of the muscular sense. The syndrome
is, in the two cases, absolutely identical.
There is, however, a difference on one point which at
first sight appears very essential, namely, the mode of pro-
duction of the paralysis. In the case of our two male
patients you have not forgotten that the cause was traumatic,
a blow more or less violent on the shoulder ; while in the
case of our hypnotised females it was suggestion by speech
which occasioned the paralysis. This difference, apparently
so essential, can be made to disappear. For, as a matter
of fact, we can cause in our '^ hysterics,^' re-hypnotised, all
the paralytic phenomena first obtained, not now by means of
a verbal injunction, but through an agency analogous to that
which occasioned the monoplegia both in the case of Pin — - andr
Porcz-^y viz. a shock applied on the posterior part of the
shoulder, by sharply, yet not very forcibly, striking this
region with the palm of the hand. The result is, you see,
not long in appearing. Immediately the patient starts, emits
a cry, and being interrogated as to what she feels, she states
that she experiences in the whole extent of the extremity a
sensation of enervation, of weight and feebleness ; it seems,
she says, as if the member struck did not belong to her, that
it had become strange to her. And then we find that the
paralysis is really established. It attains its maximum at
the very outset, and presents all the clinical features with
which you are familiar.
In this way the resemblance between the two kinds of
cases which we are comparing is strikingly complete even
in its causal bearings. Without doubt in our two male
^ See note 5, p. 282.
HYPNOTISM COMPARED TO NBEVOUS SHOCK. 805-
patients — in the case of the coachman when he fell from the
cab, and the mason when he fell from the window — the
material shock waa much more energetic ; but this simply
amoonts to a question of quantity, not to a generic difference,
of such a nature that it may be attributed to the varying
degree of impresaionability of the subjects. Without doubt
the two men were not at the moment of their fall in a
hypnotic sleep, nor subsequently, when the paralysis was
definitely established. But in this respect it may be inquired
whether the mental condition occasioned by the emotion, by
the Nervous Shock experienced at the moment of the accident
and for some time after, is not equivalent in a certain
measure, in subjects predisposed as Porcz — and Pin — were,
to the cerebral condition which is determined in "hysterics"
by hypnotism.' Upon the assumption of this hypothesis, the
peculiar sensation felt by our hysterical females in the mem-
ber submitted to shock, and which we may suppose to have
been produced in the same degree and with the same charac-
ters in our two male patients by a fall on the shoulder, that
sensation, I say, may be considered as having originated, in
the former as in the latter, the idea of motor paralysis of the
member. But because of the annihilation of the ego pro-
duced by the hypnotism in the one case, and, as one may
suppose, by the -nervous shock in the other, that idea once
installed in the brain takes sole possession and acquires suffi-
cient domination to realise itself objectively in the form of
paralysis. The sensation, in question, therefore, in both the
cases plays the part of a veritable suggestion.'
' It is very probable that, by a mecbaniam of tbis natnre, moat of the
various nervonB afiections become developed wbicb are frequently so obatiiiate
{altbough not connected with any orgnnic lesion), and which our En^d
and AmericaQ colle^ues have studied nnder the names of " Railway Sjnne "
and " Railway Brain." The same mechanism was alluded to when I rm
directing yonr attention (in a preceding lecture, p. asi et »eq.) to the ixftn.
ence eiercised by material shocks, in tboae predisposed, in the prodadjoB tt
hysterical manifestations even in the male.
' So far as conoemB the sensations produced by the shock, our twc naut
patients are anable to enlighten ns. The one, Fin — , in falling ionmiv
lost Gonsciousness; the other, Porcz — , as?ei'tsthat hewasconscioac K^iias-
the one nor the other knows exactly how the affected member Set a: -tut
moment of the accident, nor for some days afterwards. We km -iia: a.
L
I give you, gentlemen, that explanation for what it is
worth, and without attaching to it more importance than it
merits. However, I believe it worthy of being more closety
examined, and tested by more nnmerous observations. And
in the meantime I may be allowed to mention additional
evidence which seems to me to plead in its favour.
There are subjects, and perhaps they are more numerous
than one thinks, in whom most of the manifestations of
hypnotism, both psychic and somatic, may be encountered
in the waking state, without the necessary intervention of
hypnotic practices. It appears that the hypnotic condition
which in the case of others is an artificial state, may be for
those singular beings an ordinary one, their normal condi-
tion. These individuals aleep, if you will allow the term,
while they appear perfectly awake. They comport them-
selves in ordinary life as in a dream, treating as parallel the
objective reality and the dream imposed on them, at least
they make hardly any difference between the two.
I submit for your examination, as an example, a subject
of this kind. I refer to a hystero-epileptic patient well known
to you through former investigations, the woman Hab — .^
For many years this patient has been affected with general
anaesthesia of a permanent and complete nature, and with
Attacks which from every point of view correspond to the
classical type. You notice that, although no hypnotic man-
cenvre has been resorted to, and hence she is presumably
in a waking state, we can obtain contraction by pressure exer-
cised on the muscles, on the tendons, or the norve-trunka
(lethargic contraction) ; and cataleptic immobility of the
extremities placed in the most diverse positions ; and like-
wise, by means of light stroking or movements at a dis-
tance, somnambulic contraction. All these somatic phenomena
occur in this subject commingled as it were at the same
moment, without distinction into periods, contrary to what
obtains in great hypnotism. Bnt from the psychical point of
being awakened, no matter how slight the hypnotiem may hiTe been,
hypnotised Hnbjects retain no conscioasness of what took place during that
' J. M. Charcot, ' Leaioni Cliniche, Ac.,' redatffl dal Di'. Miliotti, Lez.
p. 159, "Dello Stato di malo Ifltero-Epileptico."
-J
MONOPLEGIA BY STFGOESTION IN THE WAKmo STATE.
view they are evidently the features of tlie aomnambulic state
whicli predominate. Well, if proceeding by verbal suggestion
we affirm to this patient, not asleep, I repeat, that her right
arm is paralysed, that she is not able to move it voluntarily,
•we see that immediately flaccid monoplegia is efEectively
produced, endowed with all the characteristics with which
we are familiar ; after which the simple affirmation that she
is able to move her arm, just paralysed, suffices to re-establiah
voluntary movement. Finally, and this is a point specially
interesting at present, by the operation of that kind of trau-
matic suggestion to which I referred a short time ago, and
which consists in the application of a blow sharply applied
to the shoulder, you notice that immediately the member
becomes paralysed anew. This time the identity between the
monoplegia artificially produced and the monoplegia origin-
ating in the cases of Porcz — and Pin — as the result of trau-
matism can hardly be contested, as it appears to me. Not
only from the symptomalogical, but from the pathological
point of view, the similarity is as perfect as it can be, for
neither in the one case nor the other is there the intervention
of the hypnotic practices — everything happens in the state of
leaking. The demons ti-ation, if I mistake not, is sufficiently
■convincing, and I do not believe that in any experimental
physiologico-pathological research whatever is it often pos-
sible to reproduce artificially with more fidelity an affection
which it is desired to study and investigate.
These considerations, gentlemen, have not a purely apecn-
lative import ; they have already furnished ns with certain
practical deductions which, especially from the therapentic
point of view are, as you will see, of some utility.
Our two patients, Porca — and Pin — , have been subjected
for some days to a regular treatment, on which I will say a
few words. The treatment consists of two elements. On
the one hand, it is in a sense indirect, in that it relates
either to the general state or to the hysterical diathesis.
Twice a, day Pin — receives a general cold douche; Porcz —
not being able to sustain the douche, takes a sulphur bath
three times a week. Every other day both are treated with
static electricity. This agent is useful, as you know, to
808 TWO ELEMENTS OP TBBATMENT.
modify perversions of sensibility. Experience has for a long*
time taught us that^ as a consequence of an electro-static
bath^ sensibility^ in most cases of hysterical ansdsthesia, re-
appears^ at first for a time^ for some hours perhaps^ then
according as the baths are repeated^ for a longer period, for
several days^ for example ; and finally by the continuation
of treatment it becomes re-established in a definite manner.
Further^ at the same time that a more or less durable return
of the sensibility takes place^ the other hysterical phenomena,
the attacks^ for example, are favorably modified, or dis-
appear.^
But I wish specially to call your attention to the second
part of our treatment ; it is based on Chat idea which we have
just been discussing, viz. that in our two patients the para-
lysis may have been caused by a mechanism analogous to that
which in the " hypnotics ^' determined paralysis by sugges-
tion. The various attempts at hypnotization which we made
in these two men, and which, if they had succeeded, would
have singularly lightened our task, being unsuccessful, we
were constrained to adopt the following means. In the first
place we acted, and continue to act every day on their
minds as much as possible, affirming in a positive manner
a fact of which we are ourselves perfectly convinced — that
their paralysis, in spite of its long duration^ is not incur-
able, and that, on the contrary, it will certainly be cured by
means of appropriate treatment, at the end possibly of some
weeks, if they would only be good enough to aid us.* In
1 J. M. Charcot, "De TEmploi de I'^lectricit^ Statique en M^decine."
Conference faite h, THospice de la Salp^tri^re, le 26 Dec, 1880. * Revne de-
M^ecine/ 1881, T. I, p. 147.
' The influence of mental impression on movement, says Maadsley ('Le
corps et Vesprit,' p. 269), is shown in the sudden cure of imaginary (P) para-
lysis hy energetic injunction. In these cases the idea of movement, the helief
that it will take place, is, in the inner conscience, the movement itself. It
is the active nervous current which, directed on thq appropriate nerves,.
really causes external movement. — Thfe idea of a particular movement, says
Miiller, determines a nervous current towards the affected muscles, and pro-
duces their contraction. We know that a sudden injunction sometimes =
determines the cure of a psychical paralysis of long standing, and which may
have resisted the most varied therapeutic agencies. Thus, for example, a
patient is forcibly made to leave her bed, in which she may have long-
remained motionless from a paraplegia of this kind ; and being placed oi»i
PSYCHICAL TREATMENT AND EXERCISE. 309
the second place the affected members were submitted to
metbodical exercise. We availed ourselves of the voluntary
movements which still subsisted, though in a feeble degree,
in the two patients, and we endeavoured to progressively
augment the energy of these by a very simple method. A
dynamometer was placed in the hand of each of them, and
tbey were exhorted to squeeze it with all their power, and
to progressively increase the figure indicated by the needle of
the instrument. This exercise was regularly repeated every
hour of the day for three or four days. These attempts
must not be too prolonged, nor too frequently repeated.
We have noticed that when the exercise is excessive, or too
frequently repeated, the maximum figure reached by the
needle declines. It is necessary then to have patience ; an
excess of zeal would, I am convinced, result in fatigue, and
thus retard the expected result.
Here we act psychically. It is well known, unless I am
mistaken, that the production of an image, or of a mental
representation, no matter how summary or rudimentary it
may be of the movement to be executed, is an indispensable
preliminary condition to the execution of that movement.*
her feet, aKe is told to "walk," aad forthwith she walks. Here we have au
eiamplo of a " miraenlous " cure which eiplains many othera. There is
nothing better established than these facta, to which I have freqaantly
borne teetimony (' Le^ona aur lea Maladies du Sjatfenie Nervetu,' T. 1, 3e 6iit.,
P- 35^1 et «uiv. : — P. Janet, ' Revue Politique et litteraire,' No. du 2 Aout,
1884, p. 131). Nerertheleas, we cannot he too guarded, even with the very beat
intentions, against assuming the part of a miracle- worker, for even in a
case of psychical paralysis of an undoubted nature injunction is a remedy,
the mechanism of which we know little. Failure would coffiproiBise the
authority of the operator, and subject him to ridicule. " Never prophesy
unless you are sure," say the English. To proceed by a slow and progres-
sive method of mental training will always be more prudent, and often more
effioicious. — J, M. C.
' Synonyms: Idea or conception oE tbe kindof movement to eiecute, (James
Mill) ; Ideal recall of the movement to ho executed (Bain) ; Motor intuition
■(Maudsley) ; Locomotor faculty (W. Hamilton) ; Mental representation of
the movement to be eseeuted (Spencer) ; Sentiment of innervation (Wundt,
Meynert). See also JameB Mill; Bain, 'Senses and Intellect,' p. 411 ;
Spencer, 'Psychology,' vol. i, and 'Fiist Principles,' pp. 316 and 497 ; H.
Jackson, " Clinical and Physiological Eeaearchea on the Nervous System "
(reprints from the ' Lancet,' 1873, p. 3t6) ; Eibot, ' Philosophic Anglaise,'
p. aSo; Maudsley, ' Physiology of Mind,' p. 350; Wundt, ' Physiolog.,'
Thi.'! book is the piui. ,
COOPER. ^^Ij\"Gk\i ^^\iiV.M^.^
&^^t ">"
310 EXPLANATION.
Bat it is probable that^ in the case of our two male patients,
the conditions which normally preside over the representa-
tion of the mental image have been so seriously affected as
to render its formation impossible^ or at least very difficult,
in consequence of an inhibitory action exercised over the
cortical motor centres by the fixed idea of motor weakness.
It is to that circumstance that the objective realisation of the
paralysis is greatly due.^ If this be so, we can readily con-
ceive that the repetition of the dynamometric exercise would
tend to revive in the centres the motor representation, whick
is a necessary preliminary to the voluntary movement ; and
that, as we have seen, these movements tend to become more
and more energetic, according as they arfe repeated. Fric-
tions, massage, passive movements of the paralysed limb and
those determined by faradization, all such means, I say, act
in the same sense, and may be employed at the commence-
ment of the treatment when the motor paralysis is complete.
Be this as it may as to theory, the treatment we have
adopted, although in operation but for three or four days,
has already given encouraging results.
Thus in the case of Porcz — the dynamometric indication
has increased in that short space of time in a remarkable
manner. The instrument indicated but 15 K at the com-
mencement of the treatment, and you notice to-day that the
figure 40 K is attained. I should like you to remark, in
passing, the depressing influence that the closing of the eyes
exercises in the case of Pin — as to the force developed.
The figure obtained when his eyes are shut is always 8 K. or
10 K. below that obtained when, the eyes being open, he re-
ceives a visual image of the movement accomplished. Hence,
to profit by the dynamogenic influence of the visual on the
motor centre, we advise our patients to attentively regard
the hand during operations with the dynamometer.'
p. 447 ; Feirier, ' Functions of the Brain/ chap, zi ; 0. Bastian, ' Brain the
Organ of the Mind/ vol. ii, pp. 165, 171 — 176, 196, and Appendix, p. 278 ;
Strieker, 'Studien neber de Sprachyorstellongen/ Wien, 1883; Eibot»
'Bevne philosoph./ No. 8, Aoiit, 1883, p. 188; Herzen, 'The Joomid of
Mental Science,' April, 1884, p. 44.
^ See Appendix II at end of this volnme.
' On the dynamogenic influence of sensorial and sensitive excitations, see
PB0GEB8S, '311
ADalogons results h&ve been obtained in the case of
Porcz — , notwitlistanding that in him motor power was more
affected tlian in Pin—, voluntary movement being entirely
aboliahed in the nhoalder, the elbow, and the wrist, and very
Flan. 7* and 73. — Owe of Porci — , July 7tli.
feeble in the fingers. So far as concerns the large articula-
tions, the paralyraa remains the same when the muscular
M. PerS'e researchea (' Bnlletin do la Sooi^t6 de Biolope,' Avril, Jf ai. Jab,
Jmllet, 1885; 'Brain,' Julj, 1885; ' Ravne Philoaopliique,' Octobte, 1885).
PEOGEESS.
1
i ^1
L
1
sepa- I
314 EESTJLTS.
gronps whicb moves tliese joints are called into action sepa-
rately.
But the patient having several times repeated in our pre-
sence the dynamometric exercise, we have observed that on
each occasion the muscles which move the large articulations
have a tendency to contract at the same time. When the
patient presses the dynamometer, these muscles appear under
the skin in marked relief. At this moment you can observe
that the wrist becomes flexed when the fingers press the in-
strument, and how it presents a marked resistance to passive
movements of flexion or extension.
These results, however imperfect they may be, are mean-
while of such a nature as to ■ encourage us in following this
course. I make bold to hope that in a few days — say fifteen,
or perhaps a mouth — we shall have made substantial pro-
gress,
Thia lecture was delivered on. May 39, 1885. And Bubseqneutly when
spBaking inoidentally of the two patienta ander treatment, M. Charcot con-
tinned as folloiCB :
I am happy to be able to show you such progress as
has been made in onr two hysterical male patients dur-
ing the past eight days, in consequence of the treatment
adopted. In the case of Pin — , though matters move slowly,
the progress is very roal. Thus, eight days ago the maxi-
mum dynamometric figure was 40 K ; to-day it is 53 K. And
at tho same time as the dynamometric force is augmented,
cutaneous sensibility is restored, to a limited extent it is true,
at tho level of the shoulder.
In the case of Porcz — , during the past week the needle
of the dynamometer did not indicate beyond 5 K. This week
we have gained somewhat, for on one occasion the figure 1 3 K
has been attained. Besides, cutaneous sensibility is reap-
pearing in the armpit and at tho flexure of the elbow. At
the same time the patient appears to appreciate the notion
of position of the member where the parts have become sensi-
tive. You see therefore that our anticipations seem likely
to be realised. It will not be without interest to follow
closely the changes which will doubtless occur in our patients,
under the influence of more prolonged treatment.
^
PE0GEE8S. 315
These modificafciona we have followed step by step. Each
day tlie results of pressure exercised on the dynamometer
are registered hour by hour; and the progress realised iu
the sensibility is noted daily. From the latter point of view
the condition is now almost stationary in the case oE Pin — ,
and to-day, the i6th of July, there exist only two small areB3
of sensibility on the posterior aspect of the arm. On the
other hand favorable results have been realised in respect
of mobility. In order to realise the progress better, the
figures obtained by the dynamometer, are daily noted in
the morning and in the evening (Fig. 74), so aa to form a
chart.
It will be observed that during the first week of treatment
(commencing on the 5th of June), the increase of force was
rapid and considerablej when the figure increased from 25 K
to 49 K. In the course of the following fifteen days the
average oscillation was between 50 K and 52 K. Eight days
subsequently it attained to 53 K, and finally from the 3rd till
the 17th July it attained to the average figure of between
54 K and 55 K.
We know that in the case of Porcz — , the cutaneous anses-
theaia was absolute at the commencement of the treatment
(5th June) over the whole extent o£ the member, the hand
excepted (vide Figs. 66 and 67, p. 299). Eight or ten days
subsequently it began to reappear at the flexure of the elbow
and in the armpit. On the 7th of July the condition was as
follows (Figs, 72 and 73, p. 311). Sensibility had reappeared
over a good portion of the region of the shoulder, before and
behind ; and over the inner half of the anterior aspect of the
arm patches of sensibility are disseminated here and there
on the portions of the arm and shoulder still anaesthetic.
Sensibility is again re-eatabliahed at the elbow, before and
behind, extending upwards about 10 or 12 centimetres. It
is remarkable to observe that in respect of the hand the limit
of antesthesia does not vary one line. We find in the arm,
more especially behind, and in the forearm, the tendency
peculiar to such cases — via. the limitation of the antesthetic
patches by a circular line at right angles to the long axis of
the member,^ On the shoulder and on the anterior portion
' See note 5, p. 283
316 BESULTS.
of the arm the borders of these patches are, on the contrary,
irregular or jagged.
As to the restoration of movement, the results obtained in
this patient are not less remarkable (Pig. 75). On the 5th
of June the dynamometer gave only 5 K ; at the end of a
week the figure was 11 K ; it was 17 K in two weeks, and
fifteen days later 21 K. On the nth July the patient sud-
denly left the hospital. During the week preceding his de-
parture the average figure was 27 K.
It is thus rendered probable that if the treatment had
been continued a complete return of the sensibility of the
limb, and of movement, would soon have been obtained.
Despite this, it is proper to remark that the cure was not
perfect when (July nth, 1885) we lost sight of the patient,
for the hysterical stigmata — the monocular polyopia, the
diminution of the field of vision, the right hemianalgesia,
&c., — were in no sense modified.^
In the case of Pin — it is the same. In spite of the very
important amelioration produced in the movements of the
left superior extremity, the diverse perversions of sensibility,
Bud the hystero-epileptic attacks, persist almost to the same
extent as when he first came under observation.*
* In the early part of February, 1886, Porcz — , who was then in the
surgical wards, had a dispute with another patient about a game of dominoes.
The emotion which he experienced was so great that the movements of the
paralysed limb returned immediately ; but it was not the same with the loss
of sensibility, which remains up to the present time (February 20, 1886).
• Vide Appendix I, at end of this volume.
LECTURE SXIII.
ON A CASE OP HYSTERICAL HIP DISEASE IN A MAN,
RESULTING FROM INJURY.
Summary. — Works of Brodie and other authors on hysterical
a^ections of the joints. — Characters of hysterical joint dis-
ease. — Attitude of the limbj special features of the pain. —
Oase of Gharv — ; initial injury of the left inferior extre-
mity J attitude of the patient ; shape of the huttoch and
ghdealfold. CoTisiderahle clinical analogies with true organ/ic
hip disease. — Distinctive features : JBrodie's sign ; henti-
ancesihesia ; pharyngeal anaesthesia, Sfc. — Necessity of ex-
amination under chloroform.
Gbhtlkmbn, — The lectnre of to-day will be devoted to
proving that the vigorous yoimg man before you is the sub-
ject of hysteria, and that the pain in the hip of which he
has complained for nearly three years — an affection which
supervened after an injury, and which has rendered it
impossible for him to carry on his work — reveals hysteria,
and that consequently we have to deal with a malady sine
materia which is capable of being cured, not a severe organic
malady which will necessarily result in an incurable infirmity.
In committing myself to this theory, which I hope to be
able to prove beyond doubt, I must confess that the appear-
ance of the patient, which is so far from what is regarded in
the present day as the classical type of an hysterical subject,
is apt to mislead some of those amongst you newly arrived,
who will probably think that I have undertaken an imprudent
wager, or committed myself to a paradoxical opinion in order
to give myself the vain satisfaction of revealing some dialectic
expedient.
318 HISTOBICAL.
But I am convinced that among my hearers those who did
me the honour of following these lectures last session will be
more reserved before passing judgment, and will, I hope,
wait with more confidence until the end of the demonstra-
tion. These will remember that hysteria may exist even in a
robust adult man, in an artisan, neither of delicate nor nervous
organisation, and without intellectual culture ; and they will
also remember that it may occur on this very first occasion
in the form of a purely local manifestation, such as, for
example, a paralysis or contracture of the limb. In the
patient I am going to show you to-day we have in fact
neither paralysis nor contracture, but an affection, at least
this is my view of the case, described for the first time by
Brodie in 1837, wilder the name of ^'hysterical afFection of
the joints.^^^
It is an affection but little known even yet I believe, al-
though since Brodie^s time it has formed the subject of
important works in England,' in France,' in Germany,* and
in Italy.^
It will be useful by way of introduction, and to render our
^ 'Lectures illustrative of certain Local Nervous Affections,' London,
1837, Lecture II, "Various Forms of Local Hysterical Aflfection," p, 35, et
seq. The lectures of Sir Benjamin Brodie have been translated into the
French by Dr. Aigre (* Libraire du Progr^s MMical,' 1880).
^ W. Coulson, " Hysterical Aiffections of the Hip-joint," * London Journal
of Medicine,* vol. iii, 1 851, p. 631. Barwell, * A Treatise on Diseases of the
Joints/ 1st edit., 1861, 2nd edit., 1881, "On Hysterical Pseudo-disdase or
Mock Disease of the Joints." F. C. Skey, * Hysteria : Local or Surgical
Forms of Hysteria; Hysterical Affection of Joints,' 3rd lecture, London,
1867. Sir James Paget, * Lemons de clinique chirurgicale,' trad, du Dr. L. H.
Petit, 3i^me le^on, "Affections neuromimetiques des articulations," p. 274,
Paris, 1877. See also among American authors — S. Weir Mitchell, * Lectures
on Diseases of the Nei'vous System,' Philadelphia, 1885, 2nd edition, p.
218, " Hysterical Joints.'*
' M. A. C. Eoberts, * Conferences de clinique chirurgicale,' recueilles par
le Dr. Doumic, chap, xvi, *' Coxalgie hyst^rique," p. 450. Vemeuil, * Bull,
de la Soci^t^ de Chirurgie de Paris,' 1865-66. Girald^s, 'Le^. sur les mal.
chir. des enfants,' p. 610.
* E. Esmarch, * Ueber Gelenkneurosen,' Kiel nnd Hadersleben, 1872. O.
Berger, "Zur Lehre von den Gelenkneuralgien," 'Berl. klin. Woeh.,' 1873,
p. 255. M. Meyer, "Ueber Gelenkneurosen," 'Berl. klin. Woch.,' 1874,
p. 310-
' Angelo Minich, * Delia coscialgia nervosa,' Yenezia, 1873.
AUTOPSY DUBraC LIFE. 319
clinical analysis more easy, in the first place to recapitulftte
triefly tlie chief features of the classical description of Brodio.
Subsequent authors have added some interesting details, but
they have not, as it seems to me, altered anything essen-
tial.
We have to deal, according to Brodie, with a painful affec-
tion, a neuralgia, a hypersesthesia, so to speak, of the ex-
tremities of the articular nerves, which may find its seat in
diverse joints, and simulate so as to render the diagnosis
extremely difficult, a serious organic lesion of the articula-
tion. The diagnosis of this affection is especially difficult
when it affects the hip-joint ; a non-organic cosalgia may be
BO easily mistaken for a serious organic arthritis, scrofnloua
or other, and vice versa. The absence of material lesion in
the former is, however, sufficiontly demonstrated (i) by the
progress of the malady, which terminates in a complete cure,
and often very rapidly ; {2) by a certain number of autopsies.
Yes, although it may surprise you in an affection which
ia undoubtedly benign, there exist a certain number of these,
though they are most frequently autopsies made during life,
ventable biopsies. In fact, by a singular coincidence, the
patients attacked with this affection clamour loudly for active
sorgical intervention, and thus yon will readily understand that,
when these patients, attacked with a viania opperativa passiva,
as Tester says, find themselves unfortunately in the presence of
surgeons affected with an analogous, though this time active,
madness, mania opperativa aHiva (of Stromeyer), the most
fantastic operations may result from this nnlncky collision.
Amputations have been done. Brodie quotes several instances,
and Coulson also. One mentioned by the last author is
particularly interesting. The patient was a young girl who
had suffered for three years from an affection of the knee ;
the leg remained flexed upon the thigh, the pain became
unbearable ; every surgeon had refused to intervene, but
finally one was found who consented to operate. Amputa-
tion was performed, and an examination of the knee-joint
revealed a normal articulation with the synovial membrane
absolutely healthy, presenting all the delicacy and transpa-
rency of a physiological condition; the bones were a trifle
Ught, offering but little resistance to the saw, the cartilages
te J
820 BBODIE*S DESCRIPTION,
a trifle thin^ such as is commonly seen in limbs that have
remained a long time immovable.^
I might mention several other examples of the same kind^
but I think you will perceive that there undoubtiddly exist
painful non-organic affections of the joints capable of simula-
ting articular afPections due to grave lesions^ and so leading
by an error of diagnosis to the most serious consequences.
But what are the signs that enable one to recognise an
arthralgia sine materia, and distinguish it from an organic
arthropathy ? The diagnosis is particularly difficult when,
as in our patient^ the hip-joint is involved. The following
are the principal characters ascribed to these arthralgiad by
authors, who, however, as I just said, have scarcely been able
to do more than reproduce the description of Brodie.
1. The extremity of the affected side seems shortened on
account of the muscular contraction raising the pelvis on the
correspondiug side.
2. The thigh is in respect to the pelvis in an absolutely
fixed condition in such a way that every movement imparted
to the thigh is immediately communicated to the pelvis.
Here again it is due to the muscular contraction.
As you know, gentlemen^ these two characters are not
peculiar to hysterical arthralgia, for both are invariably found
in organic coxalgia, at any rate in what is commonly known
as the third stage.^ But the foUowiug characters will enable
us doubtless to distinguish the two affections :
3. The pain presents special characters. It is un-
doubtedly situated in the hip and the knee^ and is exacer-
bated by percussion of the hip, the knee, or the heel. But
then, and this is what Brodie has so well pointed out, it is
not exactly limited to the joint itself, it extends to the skin
corresponding to the joint, and stretches upwards over Pou-
part's ligament, spreading over the lower abdomen and even
occupying the buttock. It is therefore a superficial pain
situated, so to speak, in the skin in such a way that pinching
that part of the external integument which covers the joint
is often much more painful than severe deep pressure in the
same region. At night the patients suffering from organic
* Coulson, loc. cit., p. 631.
- Barwell, loc. cit.
DIFFICULTY OF DIAGNOSIS. 821
coxalgia are not infrequently awakened by starting pains in
the hip; those suffering from hysterical coxalgia^ on the
other hand^ though they may be kept awake by the pain,
when once asleep they are not roused by it.
4. The mode of development of the affection and its
course of evolution furnish us with very important parti-
culars. In the hysterical disease it may supervene quite
suddenly, and disappear in the same way, very often after a
moral impression. Or, again, the subject has convulsive
attacks, and it may be after one of such that the coxalgia
makes its appearance, &c.
Finally, Brodie adds that, over the affected parts of the
limb the temperature is not elevated, and that, whatever be
the duration of the affection, no kind of atrophy comes on.
We shall see presently that, although the first of these
statements is true, the second is not always so.
There are, gentlemen, it is no use to hide the fact, many
delicate shades of difference. Further, in difficult cases it may
be necessary to have recourse, as we have been able to do
for the last thirty years, to the employment of chloroform,
so as to determine whether or not the joint is the seat of a
material lesion. However, it is necessary to mention, as
Prof. Vemeuil hai3 shown, that in recent organic coxalgias
an examination by means of chloroform does not always ex-
clude every suspicion of a material lesion, and thus one
cannot assign to this means — at least in the stage referred to
— an absolute diagnostic value.
You see, gentlemen, I hold that the diagnosis between hys-
terical and organic coxalgia presents many serious difficulties;
and, as a matter of fact, in nearly all cases where I have
been consulted I have seen both physicians and surgeons con-
siderably embarrassed.
After these preliminaries let us return to the patient, of
whom I affirm that the coxalgia from which he has suffered
for nearly three years is of a purely hysterical nature.
He is a man of forty-five years of age named Ch — , the
father of seven children. His antecedents, either here-
ditary or personal, present nothing worthy of being noted.
He served for seven years as a Zouave, but during that time
822 CASE.
lie was never iU. , He lias never experienced at any time of
bis life either nervous attacks or rheumatic manifestations.
He has exercised his calling as a sawyer^ and has worked
with a straight saw in the service of one of our great railway
companies. On May 13th, 1883, he was the victim of an
accident : the connecting-rod of a steam engine situated below
the place where he worked struck the plank violently under
his feet^ and he was projected into the air^ so he tells us^ to
the height of two or three metres [six to nine feet]. He
did not lose consciousness^ but he experienced immediately a
sharp pain^ accompanied by a numbness in the limb^ so that
it seemed^ he said^ at the same time both painful and absent.
He was able^ however, to make a few steps ; they earned him
home ; he remained two months in bed, and at first he says
the limb was swollen. At the end of that time he com-
menced to walk with crutches, then he managed to get on
with only a stick. For more than a year his condition has
remained as you see it now.
If we examine the patient first of all lying down this is
what we find. There exists a notable shortening of the left
inferior extremity which corresponds exactly with that which
is observed in organic hip disease in the third stage. The
joint is rigid, the thigh being fixed to the pelvis in an almost
immovable position. The patient complains of a spontaneous
pain in the groin, the hip, and the knee, which pain is in-
creased when one presses out these regions, when one moves
the limb, or when one percusses the great trochanter or the
heel ; and, moreover, I should like you particularly to notice
that the whole of the left limb, thigh and leg, is a little less
voluminous than the right, — the circumference is less by about
a centimetre.
Now, when the patient stands up, if you look at him from
the front (Fig. 76, a) you will see that he stands resting on
the healthy side, holding his stick in his right hand ; the left
foot does not rest on the ground, or only on tip-toe. The
left leg is extended, and is carried a little in front of the
right. This position, as my colleague Prof. Lannelongue —
to whom I showed a good photograph of the patient standing
—said the other day, is the typical attitude of hip-joint
disease when the patient is able to stand upright.
If now we ezamiiie the patient from behind (Fig. 76> b),
we notice in the first place the contrast that exists between the
two buttocks. The right buttock is rounded, and presents the
little fossa behind the trochanter resulting from the contrac-
tipn of the gluteus maximns, but the left seems larger, flatter,
and more flaccid. These characters are to be found in or-
Fiff. 76.
ganio coxalgia, and have been pointed out b; certain authors-^
as possessing much clinical importanoe.
As a matter of fact, this contrast between the two buttocks'
depends entirely upon the attitude of the patient. We are
assured of this by placing beside our patient a healthy indi-
' BarweU,for«xaiivli,.lM.c»t. .;....,.:
324
COHFASISOK WITH A SIMULATED CASE.
Tidoal who 18 accastomed to pose for painters, and wbom we
liaTe inBtmcted to imitate as mach as poBsible (after carefal
study) tlie attitude of the patient. The results of this com-
parative stady are well realised in the drawing that I place
before yon, which has been made from a photograph (Fig. 77).
^^-^
It may be noted that the gluteal fold is higher and larger
on the left than on the right, and that the right is double,
whereas the left is single. The interglateal fold is inclined
upwards from the left towards the right, from the affected
to the healthy side. There exists a fairly marked spinal
cnrratnre, with its concavity towards the left. These dif-
ferent deformities depend in an evident fashion on the ab-
normal position in which the hip is maintained, and especially
FEATDEBS OF THE EIGIDITY. 325
on ita elevation on the afEected side, I should like you to
remark in the last place that thia inequality of volume of the
two thighs and of the two legs is more easily seen in the
upright position,
It is doubtless not necessary to dwell on the halting gait
of our patient, you will recognise that it does not essentially
differ from that presented by individuals who are the subjects
of old- standing organic coxalgia.
In brief, gentlemen, you see that we do not find at first sight
anything contrary to the idea of a serious organic articular
affection which has terminated "without abscess in ankylosis
of the joint.
But is there true ankylosis ? A thorough exploration
under chloroform at the present time, that is to say three
years after the onset of the affection, would enable us to reply
to this question in a very definite way, and I shall return to
thia point directly.
But, I should like you in the first place to examine the
patient from another point of view. Let us accept the hypo-
thesis that he is the subject of a coxalgia sine materia, and
see if the symptoms that he presents correspond to Brodie's
description.
And, firstly, if we consider the general condition of this
man we find that although he has been ill for two and a half
years he has not become enfeebled ; no wasting, no anEemia,
never any fever, and all that time he has had an excellent
appetite. This preservation of the general health is scarcely
in accord with the idea of a grave organic articular affection
lasting for many months, even if it had made a most favor-
able progress.
In the next place you will notice that the rigidity of the
limb occupies not only the hip, but also the knee, and even
■the ankle. Now, these are not the symptoms which belong
to common coxalgia, any more than the relative coldness
and purple colouration of the parts which are so marked in the
knee and teg of this patient.
Again, let db examine the character of the pain which we
iave already noted in passing. This pain, which is intense,
though intermittent, is greatly increased as we have said by
percussion over the trochanter or the heel, and consequently
326 bbodib's sign.
by every attempt made to move the joint. Bat it also has-
this peculiarity^ that it is diffuse and spreads upwards ovei^
Poupart's ligament^ radiating over the lower abdomen^ almost
as far as the left breast, and extends also down to the buttock.
Moreover, when the skin at the level of the groin, or even
over the anterior part of the knee, is raised and sligbtly
squeezed between the fingers it produces an acute pain quite
out of proportion with the degree of force exercised in the
pinch. I should like to insist on the value of this hyper-
SBsthesia of the skin in the neighbourhood of the hip. It
has been discovered by most authors who have written on
hysterical coxalgia ; but it is worthy of being designated by
the name of Brodie^s sign because it is to this celebrated
English surgeon that we owe the value of the sign from a
diagnostic point of view.
I should add that, having remarked the signs of extreme
anxiety presented by Ch — after these excitations of the skiii
in the groin and the knee, the wrinkHng of the face, the
swelling of the veins in the neck and the temples, &c., we
interrogated him as to what he experienced at that moment ;
and the description which he gave us of his sensations corre-
sponds exactly with the description of an ordinary hysterical
aura, namely, epigastric constriction, cardiac palpitations,
constriction of the throat, buzzing in the ears on the left side,
and beatings in the temple on the same side. The same
results occurred after percussion over the great trochanter
or on the heel, or after any attempt at movement imparted
to the hip. Thus you see, gentlemen, that although the-
hysterical attack does not exist in our patient, one can ai
least provoke in him the phenomena of an aura by an excita-
tion of veritable hysterogenic zones, some of which occupy
the skin covering the hip- and knee-joints, and the others,
situated more deeply, appear to be seated either in tha
synovial membrane or the capsule of the joint.
The discovery of the facts just mentioned have naturally
induced us to suppose that a more attentive examination of
this man, conducted in a certain direction, would enable us,,
perhaps, to discover other symptoms in him capable of ren-
dering the existence of the hysterical diathesis still more evi-
dent and tangible. In this expectation we have not been dis-^
SENSITIVE AND SENSOBIAL PBEVEE8I0NS. 827
appointed. A methodical exploration of the difiereut modes
of Benaibility has revealed that over almost the entire half
of the left side of the body — a few arese existing nnaffected
— there is complete ansBstheaia both to pricking and for
temperature (Fig. 78) . In the movements of certain jointB
(feet, hands, wrists, shoulders) the notions of mnscnlar sense
are lost, whereas in others (the elbow, for example) they are
preserved. The special senses, taste, smell, hearing, are nota-i
bly affected on the left side, and on the same side the visual
field is considerably retracted, although the right eye is not
similarly affected. It may be added, and here is a very signifi-
cant character, that the pharynx can be tickled and irritated
in any way yon like without producing the least trace of reflex
action.
All that has been said leads us to the conclnsions :—
Firstly, that our patient i» an " hysteric " ; secondly, that the
328 EXPLORATION UNDER CHLOROFORM.
articular affection from whicli lie suffers presents a large
number of tlie characters which belong to hysterical coxalgia^
and that none of them necessarily indicate the existence of
a profound lesion of the joint. The wasting of the limb itself
does not correspond to the muscular atrophy with flaccidity
which is to be found in organic coxalgia^ and it may be
satisfactorily explained by the relative functional inactivity
during two and a half years. Everything, therefore, may
be of an hysterical nature in this patient whether it refers to
the general or local condition. The traumatic origin of the
symptoms are not, far from it, opposed to this interpretation,
for we know from our former studies that in men, more
perhaps than in women, an injury may have the effect of
developing an hysterical diathesis which has up to that time
remained latent.
Nevertheless, I should be the first to allow that even in
the presence of the arguments which we have accumulated,
doubts may still exist as to the diagnosis. It is not easy,
in fact, in presence of a loss of power so pronounced, and
extending over years, to altogether dispose of the idea of an
organic hip-joint disease. It may be asked amongst other
things whether the hysterical symptoms although pronounced
have not supervened at a given moment, and become grafted,
as it were, on to an organic coxalgia, which would thus have
called into existence the manifestation of the neurosis. It
is evident that the administration of chloroform would alone
dispose of all doubts. Naturally we were anxious to employ
this method of differentiation, but up to the present time the
patient has obstinately refused to allow it to be employed.
But I do not despair of persuading him to listen to reason,
and of his deciding one day to lend himself to a method of
examination which cannot but be to his own advantage.
However, gentlemen, in the absence of an examination
made by ourselves we can avail ourselves of the result of an
exploration which was made scarcely five months ago by
an eminent surgeon. The results of that exploration have
been conununicated to us by a colleague who assisted, and
who states that during the administration of the anassthetic
the joint was discovered to be perfectly mobile, exempt from
any rigidity and from all adhesions.
PROGNOSIS. 329
The conclusions drawn from that examination were the
following : — First, that there did not exist in this patient
any trace of an organic affection of the joint. Secondly,
that this individual very probably was one who simulated.
From the facts we have made out it is difficult for us to
endorse the second of these conclusions.
Most certainly there is no organic disease of the hip-joint
in this patient, that is well-established. He is the subject
of an hysterical coxalgia sine materia, as you may call it.
But however dynamic it may be, the disease is perfectly
legitimate, perfectly real, and nothing, absolutely nothing,
authorises us to tax this man with simulation.
You will readily understand, gentlemen, that as soon as it
is established, as we have affirmed here, that we have to do
with an hysterical coxalgia, the prognosis is much less serious
than it would have been on the hypothesis of an organic
affection. Without doubt, an hysterical coxalgia may be
very chronic, may last for months or even years — and this
case offers us an unfortunate example of this kind — but the
cure must always necessarily follow some day sooner or later.
But what should we do in order to hasten this favorable
termination ? That is a question which to be properly dealt
with requires a somewhat lengthy exposition, and must be
dealt with in the next lecture.
' fc «.'U
This hook is the pror
COOPER MEDICAL CG.
SAN FRANCISCO, OAL
arid is not to he removed from the
Library Room hy any person or
Under ajiy '^j^text whateoer.
LECTUEE XXIV.
ON A CASE OF HYSTERICAL HIP-DISEASE IN A MAN,
RESULTING FROM INJURY {continued).
SuMMABY. — Results of an examination under chloroform. —
Symptoms then presented by the patient. — Mixed or hys-
terO'Organic hip-disease — Hip-disease artificially produced
in two women presenting the phenomena of great hypno^
tism. — Different proceedings employed to produce this
coxalgia. — Characters of artificial hysterical coxalgia,^-'
Nervous shock. — Traumatic suggestion. — Method of treats
ing hysterical coxalgia ; massage, its good but transitory
results; infiuence of the psychical state. — Probable re^
covery.
Gentlemen^ — I bring before you once more the patient
wliom I have already presented to you in the last lecture, as
offering a remarkable illustration of an affection that is now
known by the name of hysterical coxalgia.
You have not forgotten the numerous and weighty argu-
ments by the aid of which this diagnosis was established, but
nevertheless it is possible that certain scruples may still
remain in your minds ; and, as a matter of fact, in the absence
of the administration of chloroform to the patient, we have
not been able to assure ourselves of the integrity of the joint.
Well, gentlemen, these doubts are now removed. The
patient, who, under the influence of I know not what fear,
refused to submit to chloroform, now realises his own interests
better and submitted himself to examination last Friday.
These are the results of our exploration. At the end of
six or seven minutes, after a very brief period of excitement
(contrary to what we had reason to fear in this respect from
what we know of the effects of chlorof ormization in hysterical
EXPLORATION UNDER CHLOROFORM. 331
subjects), sleep became profound. The muscles became per-
fectly flaccid, those of the affected limb being the last to
succumb, and the skin became insensible to pinching, even in
the most hyperaasthetic places. One was able to impart to
the leg and the thigh most extensive movements without
being arrested by the least resistance. Percussion of the
great trochanter or of the heel was without result, and we
were unable to discover the least crackling during the execu-
tion of these movements either by the hand or even with the
stethoscope. The conclusion, therefore, to which we are
driven is, that the joint is perfectly free from adhesions, that
the articular and osseous surfaces present none of those
deformities or lesions which would most certainly exist in a
coxalgia of such old standing as this^ if it had been really of
an organic nature.
I should like to mention the interesting symptoms pre-
sented by the patient as he was coming round. The stiffness
commenced to reappear to a certain extent in the affected
muscles before any painful manifestation was evident in the
joint. The sensibility in the skin had already partly re-
appeared and the patient was beginning to reply to questions
before the sensibility of the deep parts (percussion of the
trochanter or the heel) had become at all marked^ showing
that the deep hypersasthesia was the last to return. But
when he had completely come to, that is to say at the end
of twenty or twenty-five minutes, the deformity, the pain,
and the limping returned absolutely to the same condition as
before chloroform was administered.
Thus, our diagnosis is amply confirmed. But we are not
so sure about the line of treatment which should be adopted.
It is to this side of the question that we must now turn our
attention. But before coming to the question of therapeutics
I think it may be useful to draw your attention to another
point touching the diagnosis of hysterical coxalgia. The
reason I was so desirous of giving chloroform to our patient
was that I thought it quite possible we might be in the pre-
sence of some such combination as the following : (i) Organic
lesions of scrofulous coxalgia ; with (2) Dynamic lesions of
hysterical coxalgia. Our patient most certainly is hysterical^
332 HYSTERO-ORGANIO COXALGIA.
and clearly presents the symptoms of hysterical coxalgia^ but
it might have so happened that these symptoms served only
to mask a true hip-disease. We might thus have a mixed
form, a hystero-organic form, if you like to call it so.
This mixed form ; does it really exist in clinical experi-
-©nce ? Yes, most certainly ; and perhaps it is more freqaent
than we think, although authors do not touch upon it, as far
as I am aware. In view of .the importance of the facts
-perhaps I may be allowed to say a few words upon the sub-
ject. Thanks to the kindness of my colleagues, Messrs.
Lannelongue and JofEroy, I am able to narrate to you three
cases in which this combination occurred under circumstances
which rendered it very diflScult to avoid error. In these
three cases the first impression was that the affection was
hysterical, but a more attentive examination demonstrated
that the hysterical phenomena masked an organic lesion of
the hip which had been overlooked for a time.
* Here is a summary account of the three cases : —
First ease (communicated by Prof. Lannelongue). — ^A boy, ii years old,
whose mother had had numerous hysterical attacks. • The limb on the affected
4side was eoniraeted not only at the hip- hut also ai the knee- and anJcle-joints.
It was not possible to touch this limb without the child being seized with a
nervous attack [attaque de nerfs]. Under chloroform the existence of loud
articular cracklings was revealed. There was a shortening of two centimetres
f about three quarters of an inch], due to the head of the femur over-riding
the cotyloid cavity. Later on symptomatic abscesses occurred.
Second case (communicated by Prof. Lannelongue). — A little girl of 13.
Her father was the subject of infantile paralysis ; her mother had hysterical
seizures up to the age of thirty. When seven years old the patient had painful
contracture of the right foot ; at nine, nervous attacks, and again at ten ;
when eleven she suffered from pain in the right hip with limping. Th^e
occurred a complete remission which made them think thai it was a purely
nervous affection and they consequently allowed the child to walk, A return
4same on and the child was submitted to chloroform. Then cracklings were
discovered and a very great difficulty in bending the joint, consequent on the
deformity of the bone. A deep-seated swelling caused them to suspect an
tkbscess.
Third case (communicated by Dr. Joffroy). — Mdlle. X — , of St. Petersburg,
18 years old. No hereditary antecedents. From six to fourteen she had nume-
Tous nervous attacks which seemed to be of an hysterical nature, somewhat like
partial epilepsy. When six years old she had transient coosalgic symptoms.
When eighteen years old the same symptoms reappeared on several occasions.
At the age of eighteen the same symptoms reappeared five months before the
patient came under notice. Severe pain in the hip and knee; apparent short-
HYSTEBO-OBGANIC COXALGIA. 333
In reference to this combination of organic lesion with hys-
terical symptoms I should like to observe in passing, that you
must not believe that slight material disorders of the organisnn
necessarily exclude hysterical phenomena. It may so happen
without doubt, but if it be so in a few cases, in other cases
which are perhaps more numerous the hysterical stigmata per-
sist during the evolution of more or less serious organic
lesions. This was what occurred in the course of a case that we
have recently had in our wards of acute ai*ticular rheumatism
complicated with endo- and pericarditis, followed by death.
I need not insist further upon this point ; enough has*
been said, I think, to show you that when an organic affection
becomes developed in an hysterical subject, the symptoms
relative to each of the two affections combine in such a way
as to constitute a pathological hybrid, whose clinical history
should be recognised by the physician.
And now to come back to our patient. He is, as has heen
shown, the subject of "hip disease'* of an undoubted hys-
terical nature, without any admixture, without any organic
lesion. Wo may therefore aflSrm that he will probably re-
cover sooner or later ; but when will the cure be effected,
and what means must one employ to arrive at that result ?
I should like in the first place to examine the theory, the
pathological explanation, of these cases, hoping that by the^
way we may meet indications which will enable us to found
our therapeutic intervention on a rational basis. We have
a means at hand — a means that I have already made use of
under similar circumstances. I refer to the artificial pre-
ening ; the patient walked with the aid of cratches, resting the point of the
foot with difficulty on the ground ; no hysterical stigmata. However, in
view of the opinion of the doctors whom she had formerly consulted, the
singular walk of the patient, and particularly the remissions, followed hy the
reappearances, which had occurred for nearly ten years, they inclined towards
the diagnosis of hysterical coxalgia, though with reservation. The employ-
ment of tepid douches at first produced a decided amelioration ; a fresh remis-
sion was thus produced and the patient hecame ahle to walk with very little
pain. However, in the meantime, chloroformization having been performed,,
it was discovered " that complete relaxation of the hip was impossible, and
that the movements imparted to the joint determined characteristic cracklings,,
leaving no doubt as to the existence of very advanced osseous lesions."
834 HIP-DISEASE ABTinCIALLY PRODUCED.
duction of tlie symptoms of hysterical coxalgia, and it is by
the aid of this that one may hope to more readily recognise
the conditions and the mechanism which preside over the
development of the disease.
In this investigation we do not avail ourselves of any animal^
however elevated it might be in the scale of natural history,
but of man himself placed under the mental conditions
special to the hypnotic state.
The two patients that are now brought before you are
women, the subjects of inveterate hysteria, who reveal all
the well-marked features of great hypnotism. They pre-
sent, as you see, in a waking state all the features of hyste-
rical coxalgia, — pain, limping, &c., details into which I need
not further enter. But what I want you to realise specially
is that the affection has been produced by us purposely,
artificially, during the hypnotic state.
Naturally in these patients matters have not been pushed
too far, but even when kept within the bounds of prudence
it is sufficient for us to discover in them all the features of
the affection described by Brodie, albeit under a benign form.
In one of these women it was produced during a somnam-
bulic state by a moderate torsion of the thigh on the pelvis.
She immediately complained of pain in the hip, and also —
please to note this well — in the hnee^ although this latter
had not been submitted to the slightest tension.
In the other patient it was enough to affirm to her when
she was in a state of hypnotism, that she had just had an
attack during which she had received a blow upon the hip.
The animated recital of the supposed incident, and the pic-
ture of the severe pains that would follow, produced the
desired result. Here again, strange to say, although we
had only spoken of a blow upon the hip the patient com-
plained at the same time of a pain in the hip- joint and
also in the knee. And whereas the patient was formerly
anaesthetic on this side, it will now be seen that the skin over
the hip and over the knee is very sensitive. I should like
you to remark that our patients after being aroused from
the hypnotic state are absolutely ignorant of our interven-
tion, and both of them firmly believe that they have hurt
their hips during an attack.
HYPNOTISM AND NEEVOUS SHOCK COMPAEED. 335
You have not forgotten, gentlemen, the two men Porcz —
and Pin — , whom I showed you recently for the second time,
and in whom an hysterical paralysis of the! corresponding arm
was developed after an injury to the shoulder. I demonstrated
to you moreover that this paralysis could be produced seg*-
ment by segment in subjects under hypnotism, either by
means of verbal suggestion, or by the traumatic action of a
blow on the shoulder, which constituted, as one might say,
a veritable traumatic suggestion.
My opinion is that this hypnotic condition, during wliich
^' suggestion " produces these effects, is assimilable in more
points than one to the state which in England has been called
by the name of nervous shock in opposition to traumatic
shochy with which it may often be combined, but from which
it may also remain distinct. This nervous shock is produced
by some strong emotion, a fright, a feeling of terror deter-
mined by an accident, especially when this accident menaces
life, such as may be seen, for example, in railway collisions.
On these occasions a peculiar mental condition is often deve-
loped, recently studied with care by Mr. Page, which is
very intimately connected, in my judgment, with the hyp-
notic state.^ In both of these conditions, in fact, the mental
spontaneity, the will, or the judgment, is more or less sup-
pressed or obscured, and suggestions become easy. And
thus the slightest traumatic action for instance, directed to
a member may become the occasion of a paralysis, of a con-
tracture, or an arthralgia. It is in this way that one so
often sees after railway accidents cases of monoplegia, para-
plegia, or hemiplegia, simulating organic lesions although
they are no other than dynamic or psychical paralyses, very
analogous, to say the least, to hysterical paralyses.
* " We are .... disposed to believe that the primaty seat of func-
tional disturbance lies in the brain itself, and that, as in the hypnotic state,
. . . . there is a temporary arrest in the function of that part of the
sensorium which presides over and controls the movements and sensations of
the periphery " (Page, * Injuries of the Spine and Nervous Shock,' p. 207,
and ed., London, 1885). See also Wilks, " On Hysteria and Arrest of Cere-
bral Action," * Guy's Hosp. Rep.,' vol. xxii, p. 35 ; and Tuke, * Influence of
the Mind upon the Body,' p. 99. We may, I think, write in French indiffer-
ently fl^^ocA? or Choc — Shock, synon. : Fr.,choc; Germ.,shok. SeeKQuain,
' Diet, of Medicine,' London, 1882, art. Shock.
336 PATHOLOGICAL EXPLANATION.
I regret that I am unable to dwell longer on the connec-
tion which I have indicated between the mental state pro-
duced by nervous shocks and that which characterises the
somnambulic period of hypnotism ; but I think enough has
been said to attract your attention to this point and to in-
duce you to make it the subject of your meditations.
With reference to tjie man Ch — suffering from hysterical
coxalgia, you will have perfectly understood, gentlemen, that
in my opinion the coxalgia of this patient must be interpreted
according to the theory applied in our lectures last session
to cases of hysterical monoplegia of traumatic origin.^
You have, in fact, observed the pain and also the paralysis
suggested in the hypnotic state whether by the means of oral
suggestion or by a slight traumatism. And this pain the
observer is able at will to localise to one or other part of the
limb.
Thus, just as there are psychical paralyses produced by
what has been called in former lectures traumatic suggestion^
so also there are spasmodic coxalgias due to the same mechan-
ism. Our patient is an illustration of this. The injury from
which he suffered produced in him a nervous shock and a cor-
responding mental condition. Without doubt his hip has
incurred a concussion, perhaps even a contusion more or less
pronounced. But this local action has not determined serious
organic lesions, and the pain which has been experienced has
only become developed, exaggerated, and definitely estab-
lished as a permanent " arthralgia " by reason of the psy-
chical state produced by nervous shock.
Such, gentlemen, is the theory which I propose. If I have
dwelt a little on this point it is that the treatment follows
as it were naturally from the consideration thereof. We have
here a psychical affection, it is therefore by a mental treat-
ment that we must hope to modify it. But how shall this be
accomplished ? We know from the observations of different
authors that psychical arthralgias, whether of traumatic or
other origin, sometimes recover quite suddenly after some
strong emotion : a religious ceremony, for example, or anything
which strongly appeals to the imagination. Unfortunately,
» Pp. 304 and 305.
MASSAGE. 337^
neither of these means are available for us. "We have attempted
to assume a position of authority^ to persuade the patient at the'
moment when he was coming out of the chloroform narcosis^
at a time when the pain and limping were lessened, that he^
was cured ; but I must confess that we have not been very
successful. May we count on the influence of a simulated-,
operation, following the advice of Hancock and Harwell ? I
am afraid not. Moreover, you understand that when one-
employs means of this kind one should be sure of success, for
to fail under these circumstances would be to run the risk of
losing our patient's confidence. As for the employment of
hypnotic practices, which would perhaps furnish us with
powerful means of action, this man will not hear of it.
For the last twelve days our patient has been submitted!
to a very simple treatment, consisting of massage. Up to-
the present time this treatment has not been followed by
very definite results. Nevertheless I should like you to see^
the application of it so as to enable you to realise the imme-
diate consequences of these manipulations, which are re-
peated on him each day.
You have not forgotten, gentlemen, that Ch — is abso-
lutely hemianassthetic on the left side, excepting certain areas
where the skin is not only sensitive but hypereesthetic. These
hyperassthetic zones are found especially in the region of
the elbow in the upper extremity, and over the hip and the
knee in the lower extremity ; in these regions pinching of
the skin produces pain and all the phenomena of an aura.
Moreover, this hyperassthesia is not limited to the skin that
covers the joint, but involves also the deeper parts (liga-
ments and synovial membrane) ; percussion of the heel or
of the great trochanter are also followed by severe pain,
and so also are movements communicated to the lower
extremity. I would remind you also that this articular
pain is attended by contracture of the muscles which
move the knee, the hip, and ev^n the pelvis ; and that the
tilting of the pelvis thus produced is the cause of the
apparent shortening of the left leg.
Having decided to try the effects of massage on our patient,
I asked Dr. Gautier, who for several years has devoted him-
self in a scientific way to the employment of this agent, to
22
338 EFFECT OP MASSAGE.
be so good as to lend ns his assistance^ which he has very
kindly given us.
We have left the conduct of this treatment entirely in his
hands and he will demonstrate to you the mode of operation
which he employs. You will see that the manipulation con-
sists in the first place of a simple atrohing [effleurage] of the
hand over the left buttock of the patient ; little by little the
hand is pressed more firmly^ and then it becomes a true
deep massage. A week ago the patient supported these
manipulations very badly, but now he bears them much
better ; at the end of four or five minutes you notice that
he ceases to feel the hand that rubs, then he experiences
a heaviness in the whole limb ; and soon he states that he
has '^ ceased to have a leg/* in other words, the whole of the
lower extremity has become completely insensitive ; the hyper-
89sthesic zones over the knee and hip have disappeared, and
one can pinch the skin with impunity. And moreover, the
an89sthesia has extended to the deeper parts, for one can
strike the heel or the great trochanter without producing the
least pain. Finally, and this is still more interesting, the
contracture has disappeared, and one can move all the joints
of the left lower limb in every direction, even with some
roughness, without encountering the least resistance and with-
out the patient showing signs of the slightest pain. And
now you see again that we can, as we have already done
during the chloroform sleep, demonstrate that the joints are
entirely free and mobile, that they are not the seat of the
least crackling, in a word that the synovial membranes
of the articular surfaces are absolutely healthy ; and finally,
that all notions relating to muscular sense are completely
abolished. Thus, gentlemen, we have, properly speaking,
transformed a coxalgia with contracture, into a flaccid hys-
terical paralysis which corresponds precisely with the most
perfect type of that complaint.
How long will these flaccid paralytic symptoms persist ?
Probably from about an hour to an hour and a half. Then
what will happen ? The pain will reappear in the limb, it
will rapidly reach the degree of intensity which it formerly
had, and then the contracture and the apparent shortening
of the limb will reappear. It is therefore a very transient
INFLUENOE OF MENTAL CONDITION. 339
amelioration that we have effected up to the present time by
these applications of massage. But it is a fact that I want
to point out, that for two or three days the return of the
pains and the contracture has not been quite complete, and
the patient himself recognises that as the applications in-
crease in number the coxalgic symptoms improve, and in
this way we hope to arrive some day at the desired result.
We are counting also on another circumstance that I will
narrate to you when the patient has gone out
The circumstance is the following. The affection from
whicb this man suffers was, as I told you, contracted in the
service of a railway company ; and this company is now pay-
ing him every day very nearly the same amount that he
earned by working. If this subsidy should happen to stop
it would be for him, incapable as he is now of earning his
living, and for his seven children, a very great misfortune.
Thus he is in a condition of perpetual inquietude on this point,
of mental depression which is of itself enough to perpetuate
his malady, which is undoubtedly of psychical or, if you like
it better, of mental origin. Now, I have reason to believe
that the administration of the railway company has resolved
to make Ch — a pension on which he will be able to count
for the future; consequently, the mental condition of the patient
will be, T hope, considerably improved when he no longer has
this spectre of misfortune perpetually before his eyes. That
state of mental depression in which he has continually lived
will rapidly disappear. It will become more easy to persuade
bim that his malady is not incurable, that he can and must
be cured, and that he himself can, if he sincerely wishes it,
materially help towards that end. Thus, the practices of
' massage also aiding, all will go. well — at least, I hope so.
Before finishing I should like, gentlemen, to draw your
attention a little more particularly to the results obtained in
this patient by massage. Undoubtedly, you will hesitate to
believe that a simple massage is able to produce effects so
pronounced in every case. Without doubt we know that it
can in the long run ameliorate and even cure articular pains,
&c., but to determine even temporarily a veritable motor and
:fiensitive paralysis of a limb, that is what seems so unusual.
On what then do the singular results obtained in this patient
340 EFFECTS OF MASSAGE IN HYSTERICAL SUBJECTS.
depend ? I tJbink it may be affirmed that they are due to
tlie nature of the subject, to the material with which we
are dealing. It is because it is applied to a hysterical sub-
ject that massage has produced in this man such marked re*
suits. Perhaps one might say that in this case massage re-
presents a sort of local hypnotism. I may mention in sup-
port of this notion that analogous practices applied to two
hysterical hemiansesthesic women in my wards have given
rise to similar results. In less than five minutes we produced
in them, on the sensitive side, an anassthesia of the skin, then
of the deeper parts, and finally a complete but transitory
motor paralysis of the limb, with the loss of muscular sense.
Here again then, is an additional argument in favour of the
existence of the hysterical neurosis in our patient ; but I
believe that I have sufficiently convinced you on this point
and I do not wish to insist any more.
I have. expounded to you the means that we are now em*
ploying in order to arrive at the desired end : will our efforts
be crowned with success ? Without being too confident I
am in hopes that it will be so and that I may have the plea-
sure of showing you in a few weeks, or perhaps in a few
months, the patient, whom we have just studied together
with so much care, cured of the affection from which be has
suffered for nearly three years.^
' The patient left us and abandoned all treatment. We saw him agaiik
six months later and tbe affection was not perceptibly modified.
LECTURE XXV.
THE CASE OP SPASMODIC CONTRACTURE OP THE UPPER
EXTREMITY OCCURRING IN A MAN APTER THE APPLICA-
TION OP A SPLINT.i
Summary. — Development of a brachial monoplegia having all
the characters of So-called hystero- traumatic monoplegia^
due to a blow from a heavy body falling on the limb, —
Fracture of the forearm. — Nervous shock ; what it is that
^constitutes ^Hocal shock;" the part it plays in the production
ofhysterO'traumatic paralysis. — Application of the splint ;
-monoplegia with flaccidity becomes transformed into mono-
plegia with contracture which presents all the characters of
hysterical contra^cture. — The tendency to spasmodic con--
tracture is a frequent occurrence in hysteria in either sex,—^
The most certain means of producing it is the application
of a ligature around the limb. — The artificial prodiiction of
contractures constitutes a veritable stigma of the hysterical
state. — Amelioration of the patient after the different kinds
of treatment ; although the hand still preserves a certain
degree of deformity which does not yield to the action of
chloroform and which appears to be due to the formatian
of fibrous tissue.
Gentlemen, — The patient who forms the subject of our
lecture to-day is, as you see, a man of robust appearance.
He presents another example of those hystero-traumatic
affections to which we have been particularly devoting our
attention during this and last year. One cannot, I think,
collect too many faots in connection with this subject. It
1 Lecture edited by Dr. Babinski.
342 CASE.
has hitherto been insuflSciently explored, and if I am not
deceived, it promises for the future an ample harvest of results
which possess great practical interest.
This man has, as you see, a contracture of the left upper
extremity, which for several months has deprived the limb
of all movement. The contracture became developed at
a time when the limb was enveloped in a plaster splint, the
application of which had become necessary owing to a frac-
ture of the bones of the forearm ; a fracture determined by
a blow from a heavy body — that is to say, half an ox weigh-
ing about 300 kilogrammes [about forty-three stone] — on
this part of the body.
Well, gentlemen, we propose to demonstrate that this con-
tracture, which is a more or less direct consequence of the
injury, is of a hysterical nature. We shall seek afterwards
to interpret the mechanism involved in its development.
Here, in a few words, is the clinical history of this patient.
He is a man, 30 years of age, named Dum — , bom in Dor-
dogne, and only having lived in Paris for the last five years.
There is nothing particular to point out in his hereditary or
personal antecedents. He is a young man without any edu-
cation, and he lived quite in the country up to the age of
twenty-five. He has looked after sheep, attended fairs, and
slaughtered animals for butchers. Since being in Paris he
has worked for different butchers in the town and at slaughter-
houses. He assures us that he has never drank to excess.
He has, it would seem, like most of his comrades, followed
the repugnant practice of drinking every day several glasses
of blood : " I like blood better than wine,'^ says he, " it gives
more force.^^
The accident which particularly concerns us happened
under the following circumstances. About four and a half
months ago — ^the patient cannot be precise about the date —
he was engaged with one of his comrades at the Central
Market in unhooking half the carcass of an ox of considerable
weight ; the hook broke and the patient was knocked over,
falling with his left arm underneath the carcass. He assures
us that he did not completely lose consciousness at the moment,
but he remembers that he was stunned^ and that for several
HYSTEBO-TBAUMATIO MONOPLEGU. 343
instants he did not know where he was nor what took place.
They were obliged to carry him to a chemist's shop near by.
It is probable that the Qiervoiis shock which he experi-
enced then was considerable, for even now there seems to
exist in him a certain degree of amnesia relating principally
to matters connected with the accident, but also to those of
more recent date. There does not appear to be in this respect
any simulation or dissimulation. As we have said, he is un-
able to indicate exactly the date of the accident ; and further,
when he is asked to tell us the place where he now lives he
hesitates ; but almost immediately draws from his pocket a
paper on which his address is written, and we have ascer-
tained that the information it contains is correct. We have,
therefore no good reason for doubting the veracity of his
account.
Eeturning to the circumstances of the accident, he states
that at the moment when it happened he heard the sound
of a crack which seemed to him to come from the left arm^
but he says thaf} at that moment he did not experience any
pain, either on the day of the fall, nor on the following days.
Not only did he experience no pain in the arm at that moment
but he declares '^ that he was unable to feel the limb at all,^*
that " it seemed like dead,^^ or again as though it were
absent " from the shoulder to the end of the fingers.'^ '' In
place of an arm,'^ he adds, '^ it seemed to me that this side
carried a weight of forty pounds.'*
The limb moreover appears to have been absolutely flaccid.
It was able to be moved in all directions although no volun-
tary movement was possible.
From this account it appears that in all probability the
phenomena which occurred in this man's arm, at the time it
was injured, consisted of a superficial and deep anassthesia
and absolute motor paralysis without muscular rigidity ; and
that consequently the symptoms were very similar to those
that we have minutely studied in the preceding lectures, in
male subjects attacked with hystero-traumatic monoplegia.^
You will, moreover, remember how we were able to pro-
duce this same kind of paralysis in several hypnotised sub-
1 Lectures XX. XXI, and XXII.
^844 LOCAL SHOCK.
jects during the somnambulic period by a blow with the fist
of moderate intensity on the upper part of the limb. The
sensations of weight, of absence of the limb, and finally the
weakness which occurred after a blow on the limb in these
oases (as in those where the phenomena are produced inde-
pendent of hypnotism), would be the point of departure of
the " suggestion,'^ which has the effect of developing the
paralysis (already initiated, as it were, by the circumstance
of contusion), and of completing it and establishing it in a
definite fashion. You will remember that such was the theory,
as I proposed it to you, in order to interpret facts of this
nature.^
I am not sorry, gentlemen, to have the opportunity of
pointing out that these sensitive and motor troubles, to which
I have called your attention and which occur in limbs sub-
jected to a contusion, do not belong, far from it, to hysterical
subjects alone. In such subjects without doubt they occur
under the influence of shocks to all appearance very slight,
and they easily acquire a considerable development, out of
all proportion to the intensity of the injury. But they are
also to be found, quite apart from hysteria, in any individual
following a contusion, provided it be of a sufficient intensity.
Thus it is that under the influence of a shock produced, for
example, on the forearm by the penetration of a rifle-ball,
the whole of the limb may become paralysed and insensitive
for a longer or a shorter time. A simple blow without wound
may even suffice to determine phenomena of the same sort.*
One may affirm, I think, in general terms that the lighter
the contusion and the less neuropathic the subject, the less
hysterical he is if one may put it so, then the slighter, more
circumscribed, and more transient are the paretic and senso-
rial symptoms consequent on the blow.
M. Billroth relates* that having inadvertently received a
blow on the back of the hand, it became insensitive, and at
the same time the voluntary movement was for the moment
lost in the fingers, but that the duration of these phenomena
did not exceed three minutes. M. Gussenbauer relates facts
* See specially in Lecture XXII.
^ O. Berger, * Berlin. Klin. Wochensch.,* p. 234, 187 1.
' See G. H. Grceningen, * Ueber den Shock,' Wiesbaden, 1885, p. 78, et seq.
LOCAL STDPOB.
345 \
of the same kind. This collection of phenomena, this syn-
droma [syndrflme], to which I am just now calling yonr
attention has been described by certain authors under the
name of local shock {localershoh, Fischer; localer wnndschreck,
Bardeleben ; lo<:ahr oder peripherer skoh, local shock, Grcen-
ingen, &c.).
Under these circumstances there occnrs a cutaneous and
deep anfesthesia, with more or lesa accentuated motor para-
lysis for a certain distance above and below the pluce where
the blow occurred, sometimes throughout the extent of the
limb ; consequently we have to do, not with a lesion of any
single nerve, but very probably with the result of a participa-
iion of the nervous centres in a reflex manner.
One can, I think, without forcing the analogy too much,
imagine that there is here, as it were, a sketch, a rudiment,
■or germ, of the hystero-traumatic paralysis, and one can under-
stand that in a subject psychicalJy predisposed, this rudi-
mentary paralysis, provoked by the shock, becomes realised
and developed to the full extent by reason of a mental elabo-
ration, by a process of auto-suggestion, the mechanism of
which I have attempted to explain to you in the preceding
lectures,'
This local shoch, relatively benign, must not be confounded
with local stupor^ which has been recently described by Pro-
fessor Verneuil in one of his clinical lectures. In this con-
dition following a blow, which is always severe, there is a
suspension o£ the circulation, of the calorification, and of the
innervation (motor and sensory paralysis), with a threatening
of gangrene. All these symptoms in such a case, according
to Professor Verneuil, would be accounted for by a compres-
sion of the arterial and nerve trunks by a Jeep-seated effu-
sion. Free incision, allowing the blood to flow away, suffices
in fact, to cause all the symptoms to disappear.
However, to return to our patient, the phenomena of local
•shock in his case seem to have been very accentuated, because
not only did the fracture occur without pain, but, further,
' Lectures XX, XXI, and XXII.
' ConceiTiiEg the orthography of the word ahoch nee p. 335, foot-note i.
' See 'L'Union Medicate,' i88(5.
This hook is the pv..
846 CASE.
the limb seems to have been affected with complete anaes-
thesia throughout its entire lengthy at the same time that it
was deprived of all voluntary movement. There existed at
that time without doubt a flaccid monoplegia analogous on
all points to those that we have recently studied in several
hysterical subjects, resulting from injury. In reference to
the flaccidity you will see directly that at the present time
it is not a flaccid paralysis, but a spasmodic contracture ; and
this is just the point that we shall reserve for special dis-
cussion in the sequel, but in the first place it will be well to
examine the incidents which occurred shortly after the
accident.
Two days after the accident the patient decided to go and
consult a surgeon at the hospital of San Antoine. The wrist,
hand, and fingers had become very swollen, all voluntary
movement was lost, though passive movement was possible,
and there did not exist any trace of stiffness in the affected
limb, though it was still, as at the beginning, completely in-
sensitive.
During a period of fifteen days the forearm was kept in a
hollow splint, and covered with carboHsed compresses and
poultices. Then it was decided to apply a plaster apparatus,
which he kept on for forty-five days.
At the end of this time the splint was taken off, and it
was discovered that the upper extremity was contracted.
The elbow and the fingers were in a state of flexion exactly
as you see them at the present time (Fig. 79).
Chloroform was administered, and then they were able
to recognise that there was no articular lesion, no trace of
fibrous retraction, and that it consisted of a true spasmodic
contracture.
Profiting by the resolution produced under chloroform,
they attempted to modify the position of the hand, and to
straighten the fingers. For this purpose a small straight
splint was applied along the palm of the hand, and main-
tained in position by a bandage. But this contrivance was
constantly becoming disturbed owing to the invincible flexion
of the fingers ; they were obliged to take it off at the end
of two days, and the hand left to itself resumed its former
attitude.
CASE. ' 347
Since tbiB epoch a great nnmber of doctors hare been con-
salted, bat no fresh means have been adopted. Quite re-
cently my colleagae M. P^rier, the sargeon of the Lariboisi^re
Hospital, who was consulted amongst others, had the goodness
to send the patieat to me {i6th May, 1886), he being under
the impression that the case was more interestiug to the
physician than to the surgeon.
Yon can now see for yourselves that in this patient the
left upper extremity, habitually carried in a sling, is flexed
to an obtuse angle at the elbow-joint (Fig, 79). The fore-
arm is maintained in a state of supination, and the fingers
flexed on the palm of the hand, showing a marked tendency
to overlap each other. The thumb is bent towards the axis
of the hand, and its nail has produced a deep impression on
the skin of the external surface of the index flnger (Figs.
So and 81].
€18
CHARACTEEIS OF CONTRACTUBB.
The volantaiy movement ia almost completely lost in the
different segmeDts of the limb, and even passive movement
is, by reason o£ tbe rigidity of the different joints, extremely
limited. At the elbow and at the wrist the tendon reflexes
are obviously exaggerated, and a trepidation of the fingers
And the whole hand is very easily produced when attempts
-are made to straighten them.
There is a certain degree of wasting, of atrophy of the
limb, but the electrical reactions are normal. There is not
the slightest trace of the reaction of degeneration.
We have here evidently a spasmodic contractare of neuro-
mascular origin.
It is easy to show that the deformity and the loss of power
of the limb are not in this case the result of one of the com-
plications of another sort, such as may occur after prolonged
rest of the parts, or ol a too forcible compression of them by
means of a bandage.
NOT ANKYLOSIS OR MATTING OP TENDONS. 349*
Prolonged rest of a joint may produce, as you know, in
certain cases and in certain subjects, a growing together of
the synovial surfaces, a sort of arthritis sometimes followed
by fibrous ankylosis (Teissier and Bonnet, Hueter, &c.). This
arthritis is very similar, it may be noted in passing, to those
which M. Bouchard and I have formerly studied in limbs
which have been for a long time rendered immobile as a con-
sequence of hemiplegia of cerebral origin. But the disap-
pearance, beyond dispute, of all rigidity in the present case,,
when the subject is placed under the influence of chloroform,,
suffices to show that it is not this pathological condition with
which we have to deal.
The same test enables us to state at once that it is not a.
matting together of the synovial sheaths or the tendons, nor
yet a hyperplasia, with retraction, of the subcutaneous areolar
tissue. A compression of a nerve-trunk would be able, no
doubt, to produce a paralysis of a muscular group — of the
extensors, for example — and consequently a paralytic contrac-
ture determined by the predominating action of the non-
paralysed antagonistic muscles, but in such a case it would
be easy on the one hand to exaggerate the flexion and on
the other to overcome to a certain degree the predominating-
action of the flexors. But it is exactly the contrary that is
here observed. The action of the extensors is quite a&
difficult to overcome as that of the flexors, and this is, as
you know, precisely one of the characters of spasmodic con-
tracture.
Of late years Professor Volkmann, in the first place, and
after him M. Leser,^ have described a particular kind of con-
tracture which is observed in cases of fracture, especially in
the upper extremities, which follows and is due to the toa
forcible application of a bandage. This contracture seems to
be due to the ischsBmia produced in a limb by the excessive
compression of a bandage ; and it might be assimilated, accor-
ding to the authors above recited, to the rigidity which shows
^ B. Volkmann, ** Die ischaemischen Muskellahmungen und Contrac-
turen," * Ctbl. f. Chir./ 1881, No. 51, * Ctbl. f . die med. Wiss./ 1882, p. 445 ;
E. Leser, ** Untersuch. ueber iscbaemiscbe Muskelcontracturen und Muskel-
lahmungen/' Hallesche Habilitationsschrlft, Leipzig, 1S84 ; ' Centr. fiir
Kiin. Med./ 1885, No. 17, p. 282, and 'Samm. klin. Vorti-aege,' No. 77.
350 NOR MUSCULAR SCLEROSIS FROM TIGHT BANDAGING.
itself in ischsBmic parts in the experiments of Stenon^ or again
in man after ligature of the principal artery of a limb. You
will understand this from the details I have given you in a
lecture that was devoted this year to the study of intermittent
limping produced in man by arterial obliteration.^
The contracture, or better, the rigidity of the limbs which
appears under such conditions, may perhaps be considered as
representing, so to speak, an early stage of cadaveric rigidity
supervening in a living subject, and which, if the experiment
is suflBciently prolonged, inevitably terminates at length in
mortification of the limb. Now this, if I am not deceived,
is the mechanism invoked by M. Volkmann and M. Leser to
explain the development of the rigidity in the cases they
have observed. According to them the phenomenon of cada-
veric rigidity with coagulation of the myosine^ occurs under
these circumstances in some of the muscular fasciculi which
are submitted to a high degree of ischaemia ; while in the
muscular fasciculi less completely involved there supervenes
a condition consisting of a sort of alimentative myositis,
followed first of all by a reabsorption of the coagulated
myosine, then by muscular sclerosis, and lastly it terminates
in a definite shortening of the muscle. M. Leser, in the
experiments which he has made on animals, believes that he
has obtained results which enable him to confirm on every
point the theory proposed by M. Volkmann. But this is not
the time to enter into a critical examination of these works.
I will confine myself simply to pointing out that chief amongst
the clinical characters which distinguish the contraction of
M. Volkmann must be placed, according to him, the exis-
tence of profound modifications in the electrical reactions of
the retracted muscles ; and beyond doubt another equally
important character is the impossibility of obtaining the
resolution of the rigidity of the limb by the intervention of
chloroform administered to its fullest extent.
Now you will remember that in Dum — the results of electri-
' Charcot, * Delia claudicazlone intermittente, &c.,* Lez. raccolte dal Dr.
•G. Melotti di Bologna (* Gaz. degli Ospitali,' No. 73, p. 581, 1884).
' The recent researches of Brown-S^quard throw considerable doubt on the
iiheory of the ** coagulation of the myosine " as a cause of cadaveric rigidity
(' Academic des Sciences/ Octobre, 1886).
OEGANIC AND HYSTERICAL CONTRACTURES COMPARED. 351
zation and those of chlorof ormization are absolutely opposed
to this pathological condition^ and it is rendered abundantly
evident that between the condition of contracture described
by M. Volkmann and that which we have before us no kind
of similitude can be established.
This is enough, I think, to enable one to affirm that the.
deformity of the limb in our patient is certainly the result of
a spasmodic contracture ; and now it remains yet for us to
show, as stated at the beginning, that the contracture in
question is of an hysterical nature.
It may be mentioned that there exists among hysterical
patients quite a number of spasmodic contractures — and the
patient with whom we are occupied offers an example of this
kind — ^which, at least from the point of view of physiological
mechanism, do not differ fundamentally from those which
are developed as a consequence of organic lesion of the nerve-
centres j lesions, as you know, differing both in their nature
and in their situation, but presenting this feature in common,
that they are accompanied by secondary degeneration in the
pyramidal bands. In both cases, no doubt, the spasmodic
rigidity occurs at the same time in antagonistic muscular
groups, extensors and flexors for example ; it is accompanied
by an exaggeration of the tendon-reflexes ; by an epileptoid
trepidation, produced especially when the lower limb is in-
volved ; and finally, under the influence of chloroform pushed
sufficiently far, the resolution of the contracture becomes com-
plete. Such are the close resemblances which connect these
two groups of cases. Nevertheless, in spite of this, hyste-
rical contractures may often be distinguished from contrac-
tures due to a material cerebral or spinal lesion, even apart
from the symptoms found in other parts of the body, by the
aid of certain clinical characteristics which they bear. Thus
for example, in the former, the rigidity of the limb is
generally very marked ; and sometimes moreover it per-
sists in the same condition during sleep, even the most
profound sleep ; whereas in the latter, the contracture, gene-
rally less accentuated, reveals as a rule a manifest relaxation
when the patient sleeps, and this relaxation lasts for several
hours after waking. And again, anaesthesia, which is gene*
352 HYSTERICAL MUSCULAR ATROPHY.
rally but little prouoanced or altogether absent in the con-
tracted limb due to an organic lesion^ may on the other hand
be found to occupy in a very marked degree not only the skin^
but also the deeper parts^ and accompanied by a more or less
complete loss of the muscular sense, when we have to do with
hysteria. Now these local distinctive features of hysterical
contracture we shall find very markedly, as yon will be able
to see for yourselves, in the patient Dum — , and will lead us
naturally to the supposition that hysteria is the origin of the
deformity of the limb.
We must not allow ourselves to be drawn away from this
conclusion by the existence, as I have pointed out to you, of
a certain degree of muscular atrophy and of coldness of the
integuments. These may be explained by the prolonged
rest ; and in this respect I may be allowed to recall to you
the results of recent investigations by my chef de clinique.
Dr. Babinski, which were set forth first in the 'Progr&s
M6dicale,^^ and afterwards in the memoir that appeared
in the ^ Archives de Neurologic.^ These investigations have
induced me to recognise — contrary to the prevalent notion,
to which I had hitherto subscribed without reserve — ^that hys-
terical motor paralyses appear to be ordinarily marked by a
certain degree of muscular atrophy ; and that this condition,
always without accompanying reaction of degeneration, may
perhaps be very extreme and become developed with remark-
able rapidity.
However, the diagnosis towards which we are tending be-
comes more and more legitimate, especially in the absence of all
the symptoms belonging to a focal organic lesion of the nervous
centres, by the results we derive from a search for hysterical
stigmata. There exists on the left side — that is to say, on
the same side as the contracture — complete analgesia ; and on
the same side a fairly marked deficiency of the hearing,
smell, and taste, and also a very manifest retraction of the
visual field. Finally, the attacks themselves are represented
by the following symptoms : from time to time there occurs
in the contracted limb the sensation of an aura which mounts
^ Babinski, ** De Tatrophie musculaire dans les paralysies hyst^riques "
(* Progr^s Medical,* 1886, Arch, de Neurol.,* T. XII, Nos. 34 et 35) ; and also
Appendix IV.
BANDAGING THE CAUSE OF CONTEACTURE. 353
towards the pharynx and produces there a feeling o£ anfEo-
cation. Several times thia semblance of an attack has been
followed by an aphonia lasting for several days. i
I think that sufficient has been said to show you not only
that onr patient is under the ban of the hysterical diathesis,
but also that the contracture of the left superior extremity ia
no other than one of the numerous manifestations of hysteria.
During the preceding exposition it is more than likely that
many of you have had in your minda the following question :
Wby has the flaccid monoplegia produced in this man by an
injury, and comparable in every respect, both in its clinical
characters and in its mechanism, to the hyatero-traumatio
monoplegite which we have studied in the preceding lectures ;^
why, I say, has this paralysis, flaccid at the outset, become
subsequently transformed into monoplegia with contracture ?
Well, gentlemen, in my opinion the application of the ban-
dage to the fractured limb ia the circumstance which has
caused this change. It is, in other words, the pressure exer-
cised for a certain length of time by this bandage that baa
caused the appearance of spasmodic rigidity in the muscles ; a
moderate pressure, undoubtedly, for we have here a muscular
spasm, and not, as I have attempted to show you, that kind
of fibrous alteration described by M. Volkmann aa supervening
on the application of an over-tightened bandage (p. 349).
I hope to be in a position to furnish you immediately with
proof of the proposition that I have just formulated. Here
is another patient whom you already know. The man named
Moui! — , a well-built iahonring man twenty-five years of age,
employed aa a workman at the railway station. I have pre-
sented him to you before as offering a fresh illustration, very
typical moreover, of hystero -traumatic monoplegia.^ The para-
lysis came on after a slight blow [" tamponnement "] on the
right shoulder. You see that the monoplegia thus produced,
and which has existed for six months, is still pronounced ;
and that there is not only cutaneous and deep-seated auEes-
thesia, but also, and this is the point I want you specially to
notice now, the paralysis ia attended with perfect flaccidity
' See especially LectnreB XX, XXI, and XXII.
' See Apfendiz I, Case 2.
23
854 GONTEAGTUBE DUTHESIS IN OUB CASE.
of the limb. Well^ gentlemen^ I think that if a fracture of
the bone of the paralysed limb had been prodaced by the
slight injury which happened to Mouil — ^ and if the appli-
cation of a bandage had been rendered necessary thereby^
we should have had before us to-day not a flaccid monoplegia^
but a monoplegia with contracture comparable with that we
have observed in Dum — . This proposition may, as you will
see, be justified to some extent experimentally. Thus, I will
now apply a few turns of Esmarch^s ligature to the paralysed
and flaccid forearm of Mouil — , and almost immediately you
see a spasmodic contracture occurs in the wrist and fingers
of the hand. This contracture in truth disappears very soon
after the bandage is removed. But, with a full knowledge
of the facts to which I shall call your attention in a moment,
it appears to me legitimate to admit that the contracture in
question may become durable like those of Dum — , if the
application of the bandage is repeated several times or main-
tained in position for a long enough time.
To return now to Dum — , we may presume that there
exists in him a tendency to contracture in the paralysed limb,
analogous to that which has just been prodaced in Mouil —
by the application of a ligature ; and that this tendency has
become developed under the influence of the pressure exer-
cised by the bandage applied to the fracture. In favour of
this presumption it may be mentioned that the tendency to the
contracture exists in Dum — at this very time in his left lower
extremity, that is to say on the same side on which the upper
extremity is contracted. You observe in fact that the appli-
cation of several turns of an Esmarch^s ligature to his lower
extremity below the knee produces rigidity of the leg ; and
that the same applied a few centimetres above the foot
determines the formation of a veritable equino-varus. Con-
sequently there is nothing astonishing in the fact that the
prolonged application of a bandage to the fractured limb has
been able to determine a permanent muscular contracture in
the patient Dum — such as that you have before you now.
This development of a spasmodic contracture under the
influence of a circular compression of the limb, of which I
have just shown you two examples, is assuredly a very curious
CONTEACTUEE AETIFIOIALLT PEODUOED. 355
circumstance, and merits, both from the point of view of its
novelty and of its practical importance, your careful atten-
tion. On many occasions and under many different circum-
stances have we insisted on thie frequent existence in hyste-
rical subjects of contractures supervening under the influence
of various traumatic causes ; or artificially produced at will
by the observer, even in the waking state, by the operation
of certain manipulations.^
As for the last-named condition, that is to say contractures
artificially produced in the waking state, the recent investi-
gations which we have made into this matter in connection
with the case that we have just been considering have con-
vinced us that the subject is one which has not yet been
sufficiently brought out, and which merits further study. Up
to the present time we have been able to affirm, after having
investigated a great number of patients, that the artificial pro-
duction of contractures is an occurrence frequent enough in
hysterical subjects of both sexes ; that the occurrence is not
usual in healthy subjects; and that consequently we have
here a stigma which, in the same way as the retraction of
the field of vision, the sensitive and sensorial hemianaBsthesia,
&c., enables us to discover in certain difficult cases the exis-
tence of the hysterical diathesis. The proceedings which may
be employed to determine these contractures are very diffe-
rent, but we will confine ourselves to mentioning the follow-
ing : repeated percussion of the tendons, traction exercised
on the fingers, application of a vibrating tuning-fork, whether
to the tendons or to the fleshy parts of the limbs, faradiza-
tion, &c. But of all these means, the most efficacious beyond
doubt is the application of two or three turns of an Esmarch^s
ligature or some other band.
With the assistance of my house physician, M. Berbfe, the
application of the ligature has been made in the course of the
last month on a total of seventy hysterical subjects (43 women,
^ See on this subject Charcot, ** De rinfluence des lesions traumatiques snr
le d^veloppement des ph^nom^nes d'hyst^rie locale/' 'Maladies du syst^e
nerveux,* T. I, p. 449, Appendice. — lb., T. Ill, 3*, 7«, et 8* lemons ; Ch. Richet
€tBris8aud, ' Progr^ Medical,' 8 Mai, 1880 ; Paul Richer, ' M^moire inMit
pr^sent^ k TAcad^mie de M^decine,' 1883 (Prix Civrieux) ; P. Descubes,
* j^tude sur les contractures proYoqu6es chez leshjst^riques aT^tat de veille,*
Th^e de Bordeaux, 1885.
866 CONTEAOTUEB DEVELOPED BY LIGATUEB.
27 men)^ some now under treatment in the clinical wards^
some frequenting the out-patient department. Here is a
summary of the most important results that we Iiave obtained
in this series of investigations.*^ The existence of motor para«
lysis in the limb tested is not necessary in order to obtain
the contracture ; in hemiansBsthetic subjects the contracture
is most frequently obtained exclusively in the limbs on the
anaBsthetic side ; it may nevertheless sometimes ber obtained in
subjects equally well on tl^e side which retains its sensation^
but in such cases the contracture is always more pronounced
and more easily produced on the ansBsthetio side. We have
observed in a large number of the patients that the oonirac'^
tiM's produced in the limb was much ^more acceniuaied, and
uvuch mors dwrahU after the cessation of the constriction, when
the experiment had been often repeated and had been continued
for a longer time. The rigidity was sometimes confined to
the limb to which the compression was applied, and was limited
to the parts situated below the ligature, but most often it ex-
tended to the entire limb, and in a certain number of cases
it extended to all the limbs and even to the face. These last-
named circumstances demonstrate, I think, that the contrac-
ture in question is not the consequence of an ischaBnria pro-
duced in the limb by the application of the ligature. On the
contrary, one sees in it the result, without any doubt, of a
peripheral irritation involving a participation of the nervona
centres after the mechanism of reflex acts. Viewed in this
light, in combination with the whole of the clinical characters,,
the contractures produced in hysterical subjects in a wakings
state do not probably differ from the contractures produced
in the lethargic period of great hypnotism, except in the in-
tensity of the phenomena, which are much greater in the*
latter case. Moreover, the contractures produced in hysteri-
cal patients, like those of lethargic hypnotism, generally dis-
appear very easily under the influence of a moderate pressure
on the inuscles antagonistic to those in action ; or again under
the influence of a slight friction of the skin of the rigid limb.
- ' For further details on this subject see P. Berbes, ' Sur la diath^ de-
contracture et en particulier sur la contracture produite sur les sujets hjs-
tiSriques (honunes et femmes) par I'application d*une ligature' (^-Progr^
Medical/ No. 41, 9 Oct., 1886).
PEOGRESS OP 0A8B. 357
However, one must not be too recklese in these experiments
and, to speak only of the contraotore of hysterical patients in
the waking state, it is important not to forget that resolution
is more difficult to obtain when the ligature which produced
it has been maintained longer in position. In fact, gentler
men, these esperiments should never be undertaken except
with great discretion.
But I must not dwell longer on this subject, although it
offers many points of interest, and merits special and thorough
investigation.
Throe or four days after the lecture that has just been con-
cluded, Dum— , influenced by one of those strange caprices so
common in hysterical subjects, even in male ones, determined '
to quit the hospital. The very day of his going ont the con^
tracted limb was submitted to ;methodical massage ; light fric-
tions [frolements] were practised on the different segments
of the limb, by the aid of the hand moistened with glycerine,
at the same time as attempts were made by means of traction
to straighten the fingers and to move the wrist, the elbow,
and the shoulder. This operation, which lasted about ten
minutes, provoked at first rather severe pains along the pal-
mar surface of the fingers where the anaesthesia was not com-
plete ; but it was followed by a very satisfactory result, for
the contracture became very manifestly lessened, the fingers
became straighter, and the patient was finally able to prodnce
fairly extensive movements of his wrist, his elbow, and his
shoulder.
He loft the hospital that same day, and we lost sight of
him for several months. He returned to us a few days ago,
and then informed us that, the contracture having to some I
extent returned a few days after going out, he consulted a |
doctor in the town who treated him by Dr. Burcq's method. i
To-day {October i6th, 1886) he has returned to us with his I
hands and fingers covered with plates and rings of copper, "
which he has had on nearly ever since he left us. '
This is the condition of the patient at the present time. '
In the left upper extremity the sensibility has reappeared; |
it even seems to be exaggerated, especially on the palmar 11
858 FBOOBESS OV 0A8E.
snrface of tfaelutnd, where tlie application of a oold substance
produces a aensation of heat. The deep sensibility and the
mnBcnlar sense are normal. The general sensibility elsewhere
presents no anomaly, and as for the special sensesj we hare
discovered that the taste, hearing, and smell are as active
now on the left as on the right, and that the left visual field
has no trace of concentric retraction. On every poiot ame-
lioration is manifest, and I may add that the phantom attacks
do not now occnr.
Bnt as mach cannotqnite be said with respect to the move-
ments of the left npper extremity. The movements of the
shoulder, the elbow, and the wrist have returned almost to their
normal oondition,and are nearly as exte&sive as the correspond-
ing movements in the limb of the opposite aide, which with-
out doubt is an important result. But the movements of the
fingers, fairly energetic during fiezion (dynamometer, left 25,
right 85), are very limited during extension; and coneeqoently
the hand remains deformed, the fingers being bent so aa to
form an angle of about 90 degrees with the palm of the hand
(Fig. 82}. It is impossible to prodnoe much modification itt
this angle by extension, and all attempts to straighten the
hand give rise to severe pain. In this respect, therefore,
the cure is far from being complete, and it is to be feared
that the cause which prevents extension of the fingers is now
not only the spasmodic contracture of the moscles, bat also,
as we have observed in other cases under analogous condi-
ditionSj the presence of fibroid tissue undergoing retractiou
' LeetnreX.
CONCLUSION. 35&
in tlie palm of the hand. That^ however^ is a point wliich
cannot be completely elucidated except by the employment
of chloroform.^
^ On the 1 8th Oct. last the patient was sabmitted to chloroform. The
sleep was made as profound as possible, and at no time was it possible to
obtain a resolution of the deformity of the fingers just described. Evidently
it is no longer a simple spasmodic muscular contraction. — J. M. C.
LECTURE XXVI.
A CASE OF HtSTEEICAL MUTISM IN A kAN*.
Summary. — Description of hysterical mutism. — It consists of
a very characteristic group of symptoms [Syndrome] ;
aphonia, impossibility of whispering, motor aphasia, — Pre^
servation of the general movements of the lips, tongue, etc. —
The intelligence is not affected ; patients preserve thefa/mlty
of writing fluently, and conversing by signs. — Diagnosis of
hysterical mutism. — Its importance in- certain cases. —
Malingerers. — It is generally very easy to detect them, —
Experimental production of hysterical mutism in hypno^
tisable hysterics.
Gentlemen, — It is in order to compare one with the other
that I present to you two patients whose diseases imply a
prognosis so essentially opposed. In the first, the recovery
will be complete, that is absolutely certain, and I may add
that in all probability it will happen quite suddenly in a few
days, perhaps to-morrow. In the second, on the other hand,
the verdict is prognosis pessima, exitus lethalis, and I might
also add properatus, for the execution of the sentence will
certainly not be postponed more than three or four months ;
this patient is suffering from a permanent organic bulbar
lesion, running a fatal course; whereas, in the other the
lesion is probably of cortical origin, and in any case is of a
purely dynamic order, and as experience shows every day,
of an essentially transitory nature.
However, gentlemen, the affections from which they are
suffering present certain traits in common, and on certain
points they have such marked resemblance that even an ex-
perienced physician may be excused for confounding them.
^ Lecture edited by M. Gilles de la Tourette. The same lecture has been
published in the Gazetta degli Ospedali of Milan, Ylly Nos. 75 and *j6, by
Dr. Melotti.
LIKENESS TO ORGANIC DISEASE. 881
It is precisely for this reason that I have brought them before
you at the same time on the present occasion. This juKta-
position, moreover, will certainly have the advantage of en-
abling ufl to accentuate the contrasts and to bring out clearly
the distinctive clinical characters of the two affections.
Briefly the features possessed by both are as follows. In
one of the patients it is absolutely impossible, and in the
other almost impossible, for him to express hia thoughts
in articular language, and both of them are aphonic. The
aphonia of tlie first is absolute ; he is scarcely able to emit
the smallest hoarse cry, and that only with much effort. The
second is still able to give vent to a few grunting sounds. I
may add that both of them have preserved the power of con-
versing by gesture to perfection. We are able to converse
with both of thorn by signs ; but it is easier to communicate
with them by means of writing. In fact, both our patients
are not only in full possession of their intelligence and
understand admirably all that is said to them, but they are
quite able to render their thoughts in writing exactly as they
conld before the development of tlie disease ; that is to say
in a style and with an orthography quite in keeping with the
education that they have received.
Such are roughly the features of resemblance ; as for the
distinctive characters we shall reserve them for future con-
sideration.
The first patient is the principal object of our lecture to-
day ; the second only having been placed beside him by way
of comparison. Gentlemen, I may at the onset state that in
my opinion this man, thirty-three years old, a gas-fitter by
occupation, is a very good example of what is generally
termed hysterical mutism. But before entering into the ac-
count of his history and attempting to justify that diagnosis,
I think it may be useful, in order to render the demon-
stration clearer and more profitable, to indicate to you in
few words the most important facts that are known about
this singular afiection. You will remember that it is a sub-
ject that we have already dealt with in December last, and
Dr. Cartaz, who gave us his aid in making the laryngoscopic
examinations, has made known the substance of my lectures
362 OHABAOTBRS OP HYSTEBIOAL MUTISM.
on this subject^ adding thereto a few of his own observations
in an interesting memoir based on twenty cases^ of which
six were in my wards.^
Hysterical mutism is not an extremely rare affection ; it
has often been described^ and yon will find it mentioned in
all writings devoted to hysteria. However, I think that the
characteristics of the disease were not sufficiently isolated
until the delivery of the lectures to which I have just made
allusion. And the details into which we shall now enter
may possibly present to some of you the appearance of
novelty.
The chief characteristics which in my opinion distinguish
hysterical mutism and establish it as a true clinical entity^
recognisable by all, are as follows. The facts as I am about
to present them to you are founded, partly on cases that
I have observed myself, and partly on those published by
others.
In the great majority of cases hysterical mutism comes on
quite suddenly. It often fellows' a fright or a violent emo-
tion of some sort ; sometimes it comes on immediately after
an hysterical attack ; or again without any apparent exciting
cause it may supervene in the course of hysterical aphonia.
Lastly, it may become developed in the course of ordinary
laryngitis.
Its duration is extremely variable, sometimes it lasts for
several hours or for several days — in our patient it has ex-
isted for three weeks. It has been known to extend over
months or even years.
Recovery generally occurs, and the disappearance of the
mutism is almost as sudden as was its appearance. It
happens suddenly and like the onset very frequently follows
some violent emotion. Relapses are frequent.
These are the characters as a general rule. But there are
not a few exceptions. Thus, in certain cases the patient is
unable to completely recover, in its entirety, the faculty that he
has lost. He may be able perhaps to whisper, or to speak
in a low voice, although he remains aphonic ; he may be un-
able to speak aloud for a long time. Sometimes — ^and this is
perhaps most frequently the case — ^before recovering complete
^ See Appendix V,
IMPOSSIBILITf OP WHISPERING. BOS'
possession of his speech the patient passes through a period
distinguished by a peculiar stammerings consisting of the
frequent repetition of the same syllables. This defect appears
especially when the words he uses are of a certain length.
Now I come to the exposition of the constituent elements
of the syndroma [g^up of symptoms] . Although the patient
has preserved the integrity of the ordinary movements of
the tongue and lips so that he can move these organs with
agility in all directions, and so that he can blow or whistle
as in the normal state, yet it is impossible for him to articvr-
late a word even in a low voice, or otherwise expressed, to
whisper. Nor is it possible for him, even by paying the
greatest attention, to imitate the movements of articulation
which he sees before him. The patient therefore is mute in
the most rigorous acceptation of the term, for he cannot pro-
nounce a single T^^ord. It may be said even that he is more
than mute, for whereas it is possible for a deaf-mute to give
utterance to very loud inarticulate sounds, the hysterical
mute, note well this singular character, the hysterical mute
is aphonic, in general absolutely so ; or at most, like our
patient, he can only emit, with the greatest difficulty, a little
hoarse sound such as that which you will hear in a minute.
Is not this, gentlemen, a very remarkable association of
symptoms ? Some people will perhaps think directly that
in such a case the mutism is a natural consequence of the
aphonia pushed to a very high degree. The patient is
mute because he has no voice, because the larynx and the
vocal cords do not vibrate properly. . Nevertheless with a
little reflection you will at once recognise, with me, that this-
hypothesis involves a serious error. Hysterical patients who
are simply aphonic — a frequent enough condition — are, it is
true, unable to emit loud sounds, but they can make them-
selves perfectly understood by whispering, and by speaking
in a low voice.
Whispering is nothing else than spoken and articulate
language. The phenomenon is, note it well, absolutely inde-
pendcAt of the laryngeal voice. The truth of this fact was
demonstrated experimentally in the laboratory of M. Marey,
in 1876, and again in 1879 by M. Boudet, of Paris. These
authors have clearly shown by means of the graphic method
864 MOTOR APHASIA.
that the larynx takes no part in whispering ; the vocal cords
do not vibrate, the air traverses the larynx as it traveiMB
the trachea, it passes along a motionless tube, nothing more.
This it is which reveals, perhaps more than anything else,
the truly special character of hysterical mutism. If the indi-
vidual suffering from the affection is unable to whisper, it is
not because he is aphonic, or rather because his larynx does not
vibrate ; it is not because he has lost the common movemients
of tongue and lips — you have seen that this patient Was per-
fectly able to blow and to whistle ; it is because he lacks the
ability to execute the proper specialised movements Aeces-
flary for the articulation of words. In other terms he is de-
prived of the motor representations neceissary for the caUing
into play of articulate speech.
We have, therefore, to do with a motor aphasia and I may
add a purely motor one. It is a rare kind, very rare in the
domain of ordinary organic aphasia. With it other affections
of interior language are mostly associated, in different pro-
portions, such as word-blindness or word-deafness. Or agra-
phia, or finally a diminution of intellectual power more or
less pronounced.
We sh^U see that our hysterical mute does not come within
this latter category. I should like you moreover to remember
— this is a practical feature of the highest importance^— that,
even in the most complete organic motor aphasia the patient
is able to call out, to enunciate a few syllables in a loud voice,
even to pronounce a few words, albeit not appropriate ones^
but perfectly distinct. On the other hand, in labio-glbsso-
laryngeal palsy (of which our second patient offers a Com-
plete example), although there exists paralysis of the general
movements of the lips, tongue, and larynx, the voice and the
articulation of words, although feeble and in the last stage
most indistinct, are generally present in some degree even
up to the end of life. I insist again on these character^,
because in hysterical mutism as I say the patient is dumb, per-
fectly dumb, at the same time as he is without vocal power.
There are some other equally characteristic signs. The
hysterical mute has not only preserved all the faculties of his
intellect, not only does he readily comprehend all that is con^t*
municated to him by means of his ear or his eye, but he is
PEESERVATION OP INTELLIGENCE.
perfectly able, as I said at the com men cement of this lecture,
to make himself understood by pantomimic eigns, and of com-
municating Ms thonghta by writing. All these phenomena
may be met with, no doubt, in a case of labio-glosso-laryngeal
paralysis of bulbar origin — and in this respect we cannot
establish verynmch distinction' between the two affecfcionB —
but in organic aphasia the symptomatology does not assume,
as you know, the same characters.
You are. aware how rare are cases of purs motor aphasia
without complication among organic lesions of the brain.
Together with the loss o£ motor representations of articular
language, there are nearly always superadded, as I have just
said, iu a general fashion or in variable proportions, other
perversions of interior language. The aphasic is quite unable
to read, or reads only with difficulty ; he does not generally
understand, or understands only imperfectly, what is com-
municated to him through his ear, although he is not deaf,
and he may have preserved his intelligence completely. But,
even when none of these complications exist, it will generally
be found that he has lost, at least in great part, the faculty
of making himself understood by gesture. You will recall
how difficult it is to converse in this way with this kind of
aphasic patient. Moreover, in all probability he is unable to
write, for you know how exceedingly rare it is to find people
aphasic from an organic lesion who can write, and in these
individuals the act of writing, if it persists to a certain ex-
tent, is slow, difficult, and very imperfect.
It is quite otherwise in the hysterical mute. He has lost
nothing, absolutely nothing, of his former education, nor of
his intelligence, nor of his faculty of writing. When ques-
tions are put to him he grasps a pen or pencil with singular
readiness, and renders his thoughts in writing with perfect
clBarnesB. The gestures of the patient in such cases are
strikingly graphic, and this feature, jointly with symptoms
of loss of voice and articulate language, enables one to re-
cognise hysterical mutism almost immediately and without
further examination.
I have before narrated, in connection with this subject,
the history of a yonng Spaniard whose case you will find in
extenso iu the memoir of Dr. Cartaz. He was presented to me
366 PEESTSTENOE OF THE PACULTY OP WEITING.
as having been attacked for more than a year with syphilitic
epilepsy, in accordance with which view he had been treated.
I was further informed that very often he would remain
aphasic for several days after the fits. When I saw him
he was suffering from one of these attacks of supposed aphasia.
When I approached the patient he made a sign to me by
carrying his hand tp his throat — a very ordinary gesture of
hysterical mutes under these circumstances — ^that it was im-
possible for him to articulate a single word. ''Speak in a
low voice/' I said to him. With great difficulty he was able
to form with his lips a few silent movements of articulation.
" Cry out/' I said to him. He was unable to emit a single
sound. Then I ascertained that the patient was able to put
out his tongue, to blow, and to whistle as in normal condi-
tions. After this the young Spaniard, nettled and impatient
at my questions, seized a pen and gave me, with remarkable
promptitude by means of writing, some of the details of his
history, as clearly as it was possible for me to desire, although
he wrote in French and not in his mother tongue.
My diagnosis made, I declared him to be a hysteric, which
my colleague thought to be a very imprudent proposition,
probably because he deemed it too precipitate ; but further
examination only confirmed it. There existed in this young
man a hemianaBsthesia, with choreiform trembling on the left
side ; a retraction of the visual field and a deficiency of hear-
ing on the same side, and pharyngeal anaesthesia ; in a word,
all the series of stigmata which left no doubt whatever as to
the existence of an hysterical basis. I may add that the
description of the attack which was then given to us was
very characteristic. It was true hystero-epilepsy, and neither
epilepsy proper nor symptomatic epilepsy ; and by a more
thorough investigation of the antecedents we discovered that
syphilis had never existed, except in the imagination of the
patient, and in that of the physician. The sequel of this
case proved in the most peremptory way that it was with
hysterical phenomena we had to deal, and nothing else.
Founded on the preceding considerations, and on all that
I have since learned of this subject in an experience by no
means short, I think that I am justified in affirming that the
HYSTERICAL STIGMATA. 867
condition, hysterical mutsim, is sufficiently well characterised^
sufficiently original, to be recognised by itself, even in the
absence of all information furnished by concomitant symp-
toms.
And you also, gentlemen, when you have become thoroughly
acquainted with the characteristics, you in your turn will
achieve diagnoses of such rapidity as to be considered by
the unitiated as a sort of magic. Nevertheless it is evident
that the case would remain incomplete if the examination
of the patient was not conducted further. Now, it is very
rarely that the permanent phenomena of hysteria, which for
the sake, of brevity we call stigmata, are completely wanting ;
even the attacks also frequently exist, the retraction of the
visual field, the single or double hemianassthesia, the divers
sensorial troubles, pharyngeal an8ssthesia,^these are the
phenomena which you ought to carefully search for. Their
presence will greatly contribute to confirm your diagnosis.
I may also mention that the contracture of a limb produced
experimentally by a circular ligature is an additional stigma
which our recent researches have enabled us to add ; the fre-
quency of which, both in men and in women, is much greater
than is generally supposed.^
However, one must not forget to mention that, although
the hysterical affection in one subject may take on a poly-
morphous form, it may be found in another reduced to a
single symptomatic element. Thus it is with hysterical
mutism ; it may be sometimes met with completely isolated,
the only evidence of the malady, and this is exactly the case
with the patient that you now have before you.
It is just for this very reason » gentlemen, that it is neces-
sary to attach a great importance to an exact knowledge of
each of these hysterical syndromata taken by themselves, for
it is this knowledge alone which renders it possible to dia-
gnose the affection when it is met with as an isolated condi-
tion. It is fortunate that the natural history of. the sym-
ptoms in the condition we are now considering offers, as a
general rule, features which by themselves are sufficiently
characteristic to enable one to decide, even under relatively
unfavorable conditions, without gi'eat chance of error.
^ See Lecture XXV.
S68 MALINGEBING, HOW DETECTED.
If I insist so mucli upon this clitiical laot> it is because
hysterical mutes^ inore jyerhaps^ than inditiduals attadced
with other manifestations of the nearosis; arid in a large
number of instances^ I know not why^ considered as malin-^
gerers, although in my opinion--I am obliged to say it
again and again-^the.idea of simulation is'^ only too often
based under these circumstanc€^s on the ignorance of i the
doctor. Possibly the error is not of such great importance
when it is a question of diagnosis in private practioe^ or in
hospital; under such circumstances the mistake may be madd
Without very grave inconvenience to the patient.
But if the cade occur in the army, or when it comes in
some way within the jurisdiction of the law^ the results are
very different. Under these circumstanolBs^ the ill-founded
idea of simulation may lead to far moi^ serious consequences,
to grave injustice, and possibly to the employment of barba-
rous means of treatment. For example, very powerful fara^
dization of the laryn:^ is, as you know, not by any means
without danger. Moreover, it is my duty to point out to
you that in these particular cases simulation is perhaps more
easy to dispel than is generally believed. There are very
few simulators, be it known, who have sufficient intelligence
to combine and display, with the object of deceit, all^ the
symptoms that belong to the natural history of hysterical
mutism, without taking from or adding in any Way to this
group of symptoms, at once so special and so complex.
Generally speaking the malingerer may be considered to
be a fantastic person. He gives the reins to his imagination,
and he adds all sorts of embellishments. Recall tO' your
minds the conversation between Sganarelle and Lucinde,
who may perhaps be considered as a perfect simulator.^
'^ Sganarelle. — ' What is the matter^ ? What pain is it that
you feel V '
'^ Lucinde {replying by signs, carrying her hand to her
mouth, to her head, and to her chin) . — ^ Han> hi, hon, han.'
" Sganarelle.-^' Bh ! what do you say V
''Lucinde {continuing the same gestures). — 'Han, hi, hon,
han, han, hi, hon.'
" Sganarelle.— ' What ?'
^ " Le M^decin malgr^ lui/' Scene YI.
ANOTHER CASE. SB?^
" Lucinde. — ' Han, hi, hon/ "
Well, gentlemen, these lian, hi, hon, hati, are evidently
superfluous, and reveal simulation. The legitimate mute re-
mains silent, as I have told you, and if he carries his hand
often towards his throat, it is to show you where in his idea*
the obstacle is ; he would not point to his head and to his
month. This is the way, as it seems to me, by considerations^
of this sort, that simulation often unmasks itself.
Under certain circumstances, gentlemen, simulation may
appear very probable, at first sight, though a more attentive*
examination shows that in reality the symptoms are perfectly
legitimate. As an illustration of this I may mention the
following case which I had the opportunity of observing in
the prison of St. Lazare, thanks to the kindness of my col-
league. Prof. Brouardel. Heldne G — , a young prisoner of
about twenty-four years of age, had directed to a priest,
who she believed had wronged her, the dead body of a
newly bom child well wrapped up and placed in a basket.
The parcel, labelled cheese, arrived by post just at the moment
when the priest was receiving friends. Enclosed with the
body was a small note, thus worded : — ^' Pray for what you
have lost/^ Was not that the act of an hysterical lunatic f
Arrested soon afterwards, Hel^ne G — suddenly lost her
speech after the very first interrogation. This time you will
say the mutism was evidently simulated. Well no, gentle-
men, it was not so in my opinion, and this was also the
opinion of my esteemed colleague, M. Brouardel.
This was my argument ; the natural history of hysterical
mutism, though very little known by the laity, was well de-
picted here.' H61ene G — was mute and aphonic ; she did
not emit the least sound even when startled or excited to
laughter by surprise. Not the least sound, no hin, hi, hon,
han ; not the least unnecessary gesture. The onset was quite
sudden. The hysterical stigmata were, moreover, very pro-
nounced, and of such a nature as did not admit of simu-
lation ; complete general anaesthesia ; ansBsthesia of the
pharynx ; retraction of visual field, &c. And lastly, there
was a feature that is absolutely peremptory ; as in the case
of other hysterical mutes. The patient tvrote fluently and
24
S70 CASE OF HYBTERIOAL MUTISM.
correctly, and it was in this way that Bhe utfas ahU to eommu-
^rUc^t$ with, the magistrate/ and, at lea^t in great fart, tonf ess
her crime. A malingerer, withoat any doubt, would have
pushed; matters to the bitter end/ she would have ceibsed to
l^e able to write, whereas this girl wrofce vrithaat any flaw.
The autopsy of the body of the child having demonstrated
that it had lived? Helene G^ — was convicted of infanticide,
and condemned to three years' imprisonment.
. . But it is tinie, I think, after this digression, to return to
the demonstration of our case. After the foregoing we shall
be able to complete this rapidly.
Theipatient is thirty-three years of age. After having
followed n;iany kinds of occupation, he is now in the service
of the Gkks Company. There does not seem to exist any
nervous heredity in his family history, nor has he suffered
from any illnesses worthy of note, although during a period of
six years, from twenty-^four to thirty years of age, he had
attacks of which he gives us a very graphic description by
the aid of pantomimic gestures. The attacks began with an
^ura, and included, amongst other features, the ^^arcs of a
circle," and great movements; he assures as that he did not
lose consciousness. However, several years previously, when
he was twenty years old, he momentarily lost the qse of his
Benses after hearing a very loud noise which gave him a
great fright. He was married three years ago, and since
then the attacks have ceased. Shortly afterwards, withoat
known cause, other than a laryngitis accompanied by aphonia,
h.e became suddenly mute. He went under the care of M.
Eigal, who cured him at the end of a few weeks quite sud-
denly by the application of a laryngoscopic mirror. It was
three weeks ago, and following the same cause, namely, a
laryngitis of only a few hours' duration, that the mutism
lagain occurred.
You see that our patient presents all the classical cha-
racters of hysterical mutism, such as I have been describing.
When told to call out, to speak, or to whisper, he is abso-
lutely unable to comply. When I persist, he makes the
characteristic gestures, and points with his hand to his throat
aa though he would tell us that the difficulty lies there.
CASE OF BULBAE PAEALYSIS, 871
However, he moyes his tongue and tis lips perfectly in every
direction. He is able to write and render his ideas very well,
and in a style tHat corresponds with his incomplete educatipn.
In this case, beyond the special characteristics pf the mutism,
the fits from which he formerly suffered are the only sym-
ptoms in favour of hysteria, for the patient is quite free from
all hysterical stigmata. Here then the mutism occurs ^s a
solitary hysterical symptom, mono^symptomatic, and yet we
dp not hesitate in the diagnosis for a moment, for the reasons
that I hav^ pointed out and, I hope, sufficienliy made clear
to you*
|Tow let us turn to the second patient. I need not make
a great point of his age-^seventy-one years^-because^a bulbar
affection may become, developed at twenty or younger j, and we
know of hysterical men of forty years and more. But what
I would emphasize is the slow and progrbssive onset of his
difficulty of speech. And again, although he cannot speak,
this patient; can at any r^rte cry out; There is paralysis and
atrpphy of the tongue; his mouth is widened, his lips are
pendent, and he has the aspect of one who is weeping. Ijx
spite of all this the articulation of words is not completely
lost ; he can still — ^though in truth with great difficulty-;—
pronounce some indistinct words. In his case there is not
loss pf memoiy of the movements of articulation, nor is there
motor aphasia, but we have to do with anarthria, consequent
upon the paralysis of the general movements of the tongue
and of the lips.
I may add tliiat the saliva dribbles involantarily away, the
deglutition is Very difficult, and when he drinks Hquid it
returns by the nose'; and finally, at night he has attacks of
suffocation. .
.You see, gentlemen, from this comparison, that between
these two patients there only e^sts. a rough resemblance.
And althongh in both of them, there is a marked cpntrast
between the faculty of writing easily, which remains, and the
impossibility of making their articulation heard, it may be
pointed out that thi^ last phenQmenon is not of the same
order in the two cases^ but is due to absolutely different
mechanisms. ' ' ■ ' . *. *
872. AETIPIOIAL PEODUOTION.
I will terminate this lectare by an experimental demon^^
stration^ and present to you two cases of artificially produced
mutism in two hypnotisable^ hysterical subjects. Prior to
the experiment to which they have been submitted^ these two
women have never been in communication with hysterical
mutes^ although^ on the other hand^ they are daily in contact
with patients who are affected with anarthria due to labio-
glosso-laryngeal paralysia Nevertheless, you will recognise
without difficulty in both of them characters identical with
those which have been described just now in spontaneous
hysterical mutism. These women are unable to cry out^
to articulate a single word, or even to whisper ; and yet the
general movements of the tongue and lips are quite free front
any affection ; they continue to be able to express themselves
by writing and by gesture, and their intelligence is quite
unaffected.
I bring them before you now, awake, but still mute ; I
ought to tell you how the phenomenon of mutism may be
artificially produced. The patient being plunged into the
somnambulic stage of hypnotism, you commence by con-
versing with her for a few minutes, then gradually yotr
approach closer and closer to her, and finally pretend neither
to hear nor to understand her. She makes further efforts to
speak louder, but you continue to practise the same ruse, and
appear not to understand any better than before. Then it
happens that the voice of the subject becomes progressively
lower, and in the last stage aphonia becomes complete and
there is an impossibility of articulation. Artificial mutism^
obtained during the somnambulic period, persists as you see,
in the waking state. I dare not allow this experiment to be
prolonged too much, for I have remarked on many occasions
that hysterical symptoms artificially produced during hyp-
notism are more difficult to be made to disappear in a waking-
state in proportion as they are allowed to persist for a longer
time.^
^ The hysterical patient who formed the main subject of this lectare, and
who was present part of the time, seemed to be vividly impressed by all he-
had heard. The following morning, shortly after waking, he suddenly
regained his speech*
, PATHOLOGY. 373
Gentlemen, the possibility of giving rise to the syndroma
hysterical mutism artificially by meansi of suggestion, appears
to us to indicate sufficiently clearly the point of departure of
all the phenomena; and one is thus able to suppose the
mechanism of its development. It is in the grey cortex of
the cerebral hemispheres that we must seek for the dynamic
lesion whence emanate the symptoms in question ; and the
mechanism that is to be invoked in such conditions is none
other than that which acts in the production of psychical^ or,
if you like it better, mental paralysis.
This theory, which is now founded on a considerable
number of facts and on experience, is applicable, as you
know, to a large number of hysterical affections, particularly
those which arise under the influence of an occasional cause,
such as a violent emotion, a traumatism, &c. It is a subject
that has occupied us many times in several of the preceding
lectures, to which I would refer those amongst you who wish
to acquire further information in the matter.^
* See particiilarly Lectures XXI and XXII.
APPENDIX
I.
TWO ADDITIONAL CASES OP HYSTERO-TRAUMATIC
PARALYSIS IN MEN.
Part of a Lecture ly M. Charcot (1886), edited by Messrs,
Babinshi and Berbez,
(Appendix to Leotures XX, XXI, XX II.)
I. A case of hystero'traumatic paraplegia supervening on a
street a^cddent}
Thb man named Le Log — was bom in a little village of
Brittany, and he is now twenty-nine years of age. One of
his first cousins was subject to epilepsy (a falling down, call-
ing out, biting of tongue, &c.). One of his sisters, who
finally died of typhoid fever, had had '' nervous attacks.*'
The patient has also suffered from typhoid fever, and after
this he remained aphonic for several months.
He came to Paris when twelve years old, knowing but little
French ; at the present time he is able to read, but he can
only write with difficulty. People who know him have given
him a very good character. He has always been amiable^,
and obligiug. He is a steady lad. He is not gloomy, nor
is he alcoholic. By occupation he was formerly a cook's
assistant, but lately, for want of better work, he went into
the service of a florist in the market. His work consisted
in selling in the market during the morning, and in the after-
noon, every second or third day, he went to a horticulturist
at St. Cloud to fetch plants. These he brought back on a
^ The notes of the case are by M. Berb^z, Interne da Service.
ACCIDENT. 375
little hand -barrow, which he drew, while his master's son,
young Coar — , helped by pushing behind.
It was on returning from St, Cloud in this fashion on
October 2istj 1885, about 6 o'clock in the evening, that the
accident happened which was the cause of all his troubles.
On this evening, when it was very nearly dark, Le Log — was
dragging his barrow along the road beside tbe Seine. He
had arrived at the top of the Pont des Invalides, when all of
a sudden, a heavily laden laundryman's van, driven by some
drunken men at railway speed, charged into him. The wheel
of the hand-barrow was struck, and Le Log — was violently
thrown on to the footpath, from which he was picked up abso-
lutely unconscious. The horse of the laundryman's van did
not touch Le Log — , and its wheels did not pass over him.
There was no apparent wound, nor was any blood discovered
about his person. Le Log — was placed upon his own barrow
and was taken in the first place to a chemist's shop, where
he remained for abont twenty minutes, and was then carried,
still nnconficioua, to the Beaujon Hospital,
The preceding details were given by yonng Conr — , and
confirmed, moreover, by a man named L — , a post-office official
at the Palais de I'Industrie, who was present during the colli-
sion. The Biccount which Le Log — himself gives of the affair
when he is questioned is a very different one. He has made out
a long history of the accident in which he firmly believes, and
of which the circumstanOes appear to him from time to
time in his dreams. The laundryman's van came charging
along with much noise; the horse fell right upon him, and
struck him in the breast with its head. He fell down,
struck his head violently on the ground, and finally the
heavy van passed completely over his body, across the upper
part of the thighs. Generally, when his dream arrives at
this point, the patient wakes up suddenly screaming. At the
Hfltel Dieu, and here also at the SalpStriere, he has often
been heard to cry out " Stop ! don't drive on, the horse is
going to crush me."
As a matter of fact, the patient has completely lost all
recollection of what passed at the moment of the accident.
It is very probable that he was affected at the time by an
intense cerebral commotion, followed by a form of anmeaia
S76 APPENDIX I.
which MM. Bibot and Azam have described under the name
-of traumatic retrograde amnesia.
He was transported to the Beanjon Hospital^ where he
xemained during five or six days without consciousness.
Leeches and sinapisms were applied, and an ice-bag was put
x>n his head. When his consciousness returned he was very
surprised to find himself in the hospital ; he remembered
absolutely nothing of what had taken place. It was only
after he had heard the history from those around^ as he him-
self confesses^ that the circumstances of the accident as he
narrates them occurred to his mind.
Several facts relative to his state in the Beau j on Hospital
are worthy of being mentioned, (i) His lower extremities
seemed to him as though they were dead. At first he was
unable to lift them from the bed, except with the aid of his
hands, but at the end of a few days he was able to leave his
bed, go out of the hospital, and walk part of the way home
on foot. (2) He had several large bruises on the hip, the
right groin, and over the lower abdomen. (3) He suffered
with his head in the same way he does now.
After leaving the Beaujon he remained for a week laid up
at home. At that time he had some profuse epistaxes, which
were only arrested by plugging, and which have since re-
curred several times.
He left his house one day to go and see some friends, and
while there was seized with a severe attack, preceded by a
sensation of a ball rising in his throat, and during which he
lost consciousness. He was then placed on a stretcher, and
taken to the Hdtel Dieu.
There he came under the care of Dr. Capitan, Chef de
^Unique de la faculte, who has given us the following infor-
mation concerning Le Log — 's condition during his stay of
imo months at the Hdtel Dieu : '^ During the first week the
patient was in a state of continual coma. After waking
from this he presented for two days all the symptoms of
hysterical mutism. Frequent epistaxes occurred, and were
only stopped by plugging. The motor weakness of the lower
extremities, imperfect at first, gradually became complete.^'
On the 25th March Dr. Capitan had the kindness to send
ihe patient to us* The following are the prominent sym
HYSTEEO-TEAUMATIO PAEAPLEGIA. 377
ptoms that we have observed in him, in addition to the crises
which will bo described by-and-by.
On admission, the *patient was lying in a prostrate condi-
tion of dorsal decubitus, silent, as though he were preoccu-
pied, replying but slowly and unwillingly to the questions
that were put to him. From one day to another he has
varied in his account ; evidently his memory and intelligence
are considerably afifected. The physiognomy, moreover, is
expressive of sadness, hebetude, and from time to time even
stupor, and the speech is embarrassed.
He complains of a dull aching pain in the head, and when
the head is lightly touched or the scalp stroked, he seems to
sufEer acutely. He states that at night-time he has flames
'before his eyes, and terrifying dreams, and all the while
beatings in the temples and dizziness in the ears.
On examining the face it is remarked that the left labial
commissure is raised, and on this side the mouth is partly
open. This was at first thought to be due to paralysis of the
right inferior facial. But on further examination it is recog-
nised to be due to a spasm of the muscles on the left side of
the face, as is evident by the tremors, sometimes slow, some-
times fast, in the labial commissure of this side. When the
tongue is protruded there is no deviation.
The patient is thin ; his pulse is feeble. The skin of the
extremities is warm and always covered with sweat ; the per-
spiration over these parts is from time to time extremely
abundant. The tongue is natural and the temperature normal.
The patient has been able to eat, though he eats but little.
The upper extremities do not present any trace of paralysis
nor of insensibility, although the dynamometric force of the
hiands is rather weak (right 40, left 35). It maybe noticed
also that the hands present slight trembling, which is much
accentuated when the patient carries a glass to his mouth.
But it is the state of the lower limbs that especially claims
our attention. Their voluntary movements are so feeble that
Le Log — is scarcely able to raise them from the bed. He
is able to offer very little resistance to passive movements of
the different joints, though certainly the limbs are not in a
state of flaccidity, for they do not fall like inert masses after
having been raised. Standing upright is possible when he
This boolc is tke 'pre ^
878 APPENDIX I.
is supported on each side^ but lie oscillates and would pro-
bably fall when told to shut his eyes. It is impossible
for him to make a single step forward ; in spite of his best
efforts the feet remain literally fixed to the ground. . Although
the limbs are not flaccid they do not present any of the
characters of spasmodic paralysis ; no exaggeration of the
patellar reflexes, no trepidation on bending upwards the point
of the foot.
The perversions of sensibility observed in the lower limbs
are quite peculiar. They involve both the skin and the deeper
parts. As for the latter, torsion and traction, however vigor-
ously exercised on the different joints (hip^ knee, ankle, &c.),
do not produce the least pain, not the least sensation. When
the eyes are closed the patient is absolutely ignorant of the
position given to the different segments of the lower extre-
mities. For cfxample, when one of the limbs is raised or
flexed at the foot, or one knee is placed over the other, the
patient is quite unconscious of it. Pricking, pinching, the
application of cold and heat to the skin^ are not perceived.
By reason of their wide extent and their accentuated cha-
racter, the perversions of sensibility offer a marked contrast
with the motor troubles. There is no atrophy of the muscles,
and the electrical reactions are normal. No traces of para-
lysis of the bladder or rectum.
The search for hysterical stigmata gives the following re.
suits. Absolute anaesthesia of the pharynx ; one is able, to
push the finger as far as the epiglottis, and to keep it there
for a long time without provoking the least reaction. Taste
is absolutely lost; a morsel of sulphate of quinine applied to
thd tongue is not detected by the patient. There is also
anosmia ; diminution of hearing on both sides ; concentric
retraction of the visual field very pronounced on both sides
(Fig. 83).
We have already pointed out the permanent hypereesthesia
of the scalp which is elicited by the slightest touch or fric-
tion. Friction produces an attack of beating in the temples
and noises in the ears.
The attacks are represented by the following symptoms :-—
Fain in the pharynx, sensation of a ball rising in the throat,
a stifling sensation, beatings in the temples. Very often
HYSTBEO-TBAUMATIO PAEAPLEGIA. 379
epistELxis terrainaies tlie scene ; but these symptoms do not
go any farther.
Now it is necessary to point ont more particularly the
boundaries on the ahdomeii and trunk of the anesthesia of the
Imoer limbs. In front (Fig. 84, a) this limit is represented
by a line following the fold of the groin on each side as far
APPENDIX I.
as the anterior iliac spiue, eiclnding the genital organs.
Behind (Fig. 84, b) it is represented by a line following the
■origin of the gluteal muscles, excluding a V-shaped space in
the middle, which corresponds to the sacmm.
* » * * *
The presence of the classical stigmata and the attacks, albeit
rudimentary, though aafficiently characteristic, enable one to
establish in a peremptory way the existence in the patient
of an hysterical basis. But one can go further, and show
that the paraplegia itself reveals all the characteristics of
psychical or mental paralyses as they may be called. In
.support of this hypothesiB, in the first place there is the
delimitation towards the abdomeii of the anesthesia of the
lower extremities. In front the npper limit follows, as has
HYSTIBO-TBAUMATIO PABAPLBGIA.
381-
been Baid, the line wliicb passes along the fold of the groin,
ezclading the genital organs, and reaching to the iliac spine ;
and behind the boundary line follows the origin of the gluteal
jnusclee, exclnding a v-sb^P^^ space in the centre which
corresponds to the posterior surface of the sacmm (Fig. 84,.
A and b).
Fie. 85. — DlatribntioD of tlie ansitlietic mnei in a oxa of pftriJal
paralyiii of tbe diHereDt foment! of the limbf, attiScially produced
by tnggrestioii in hypnotitable bjitericBl inbjecti (Kiiiuuunliiilio
period).
This disposition is obvionsly different from that which is
fonnd when the annsthesia of the lower limbs is consequent
on an organic lesion situated, for example, abont the middle
dorsal region, and involving more or less profoundly the grey
central matter. Then the anEBsthesia of the lower limbs ex-
tends over the lower part of the abdomen, and is limited by
a line perpendicular to the axis of the tmnk passing througlt
<882 APPENDIX I.
the neighbonrhood of the umbilicas. On the other hand^
the limitation of the anaesthesia in this patient exactly repror
dnces the disposition which — ^as the resnlt of nnmerons ; in.-*
Ye^tigations by M. Charcot on this subject — ^is to be found
when, hy means of suggestion in the somnambulic period, qom^,
plete motor and sensory paralysis of the lower extremity of
the nonr-ansesthetic side is produced in hypnotisahle hemianaes^
thesic hysterical subjects (Fig. 85).^
It should be added that in Le Log — , as in hysterical sub-
jects in question, the ansBsthesia extends to the deeper parts,
and all notions relative to the muscular sense are completely
abolished, and that the loss of motor power is very pro-
nounced.
Hence, as far as concerns the paralysis, the case of Le Log —
does not differ clinically in any essential particular from the
case of hypnotisahle hemianaesthesic hysterical subjects whose
lower limbs have b^en paralysed by means of suggestion.
This renders it very probable that in the two orders of facts
the mechanism of production both with reference to the para-
lysis of motion and of sensation is the same. Now, when in
a somnambulic subject one suggests by speech the idea of the
motor weakness of a limb, and one sees this idea effectively
realised under the special form of paralysis which has just
been described, one can hardly in the present state of science
refuse to admit that it depends upon a dynamic lesion affect-
ing the motor and sensory zones of the grey cortex of the
brain which in a normal state preside over the functions of
that limb. Consequently we are in this way led to propose
as a very plausible hypothesis that in Le Log-— the produc-
tion of the paralysis is due to an analogous process. *
Without doubt, the objections may be raised to this ex-
* Just as has been seen in the case of the upper extremity (Lectures
XXI and XXII), one is able in hypnotisahle anaesthetic subjects during the
somnambulic period to determine by a blow a total or partial paralysis of the
lower limb. When partial paralysis of the movements of the joint (hip,
knee, ankle, &c.) occur the loss of motor power of that joint carries with it
almost necessarily — ^just as in the case of the upper extremity — cutaneous
and deep ansesthedia of the corresponding segment of the liinb. The limits
which separate the different zones of anaesthesia thus produced are represented
here also by circular lines following an imaginary plane at right angles to
the long axis of the limb (Fig. 85, a and b).
HTSTEEO-THAFMATIO PAEALVSIS. 888
plaDation that in the first pla.ce the patient had not been
hypnotised, and in the second the conditions of a suggestion
cannot be foond in this case, — at first sight at any rate.
But in reference to these two points the following circum-
stances may be mentioned.
It ia certain that the mental state which is to be fonnd in
the somnambulic period o£ hypnotism does not constitute the
only condition where, in consequence of the obnubilation o£
couaciousneas, of the facile dissociation of the ego, it may be
possible to awake in the mind an idea or a group of asso-
ciated ideas which, freed from all control, all opposition, may
become developed intoan autonomous condition which acquires
by that very fact an enormous force, and a power of realisa-
tion which is almost without limits.
Among the unconscious or subconscious mental conditions
in which, apart from hypnotic somnambulism, suggestions
are thus easily able to become realised, may be mentioned
certain intoxications, as of haschich for example (Ch, Eichet)
or of alcohol (Magnan). And one may mention also, ac-
cording to M. Page, emotions, physical commotions, trau-
matic shock, with or without direct injury of the cranium,
that is to say with or without cerebral commotion, using this
last term in its surgical acceptation. In fact, experience has
shown for a long time, that under the conditions just named
it is by no means rare to find paralysis clinically comparable
with those we are now discussing.
That being so it will be easily recognised that in Le Log — 'a
history are to be found all the circumstances requisite for
the production of the particular mental state favorable to
the objective realisation of suggestion. It will be remem-
bered that, thrown violently on to the pavement, Le Log —
lost consciousness immediately ; that he remained comatose
for several hours, and that afterwards he was plunged, for
the two or three days which followed the accident, into a
state o£ veritable intellectual torpor ; in a word, he pre-
sented at that time the condition of psychical obnubilation
suitable for the efficacy of suggestions.
But now it may be asked what it was, in the patient thus
prepared, which formed the point of departure of suggestion,
if suggestion there was. This is a good opportunity for re-
384 AUTO-SUGGESTION.
marking that all snggestions are not bronght into play by
means of speech. There are those which become developed
in conseqnence of the perception of an odour^ a taste^ or sight
of a particular object ; or in a word after any sensation what*
ever. And although it most frequently happens that they
are produced by external objects, nevertheless they often
occur in consequence of a sensitive or sensorial modification
developed either spontaneously or accidentally in the patient
himself in a way that is known as auto-suggestion.
In reference to this matter M. Charcot draws attention to
the arguments which have been mentioned in the preceding
lectures^ relative to the mechanism of the development of
hystero-traumatic paralyses; a mechanism in which auto-
suggestion plays the principal part. It may be well here to
advert in the first place to the phenomena of heal ahocT^
described by some authors. This consists of a contusion of
a limb^ for example, which whether of small or great intensity,
produces divers transitory affections of sensibility and move-
ment ; such as a sensation of weight, sometimes true ansBS-
thesia or motor paralysis more or less accentuated either in
the single part of the limb which was the seat of the blow
or of the entire limb. For a shock of a given intensity, the
results vary considerably in different subjects. Thus in a
vigorous man of stable mental equilibrium a blow with the
fist of moderate force upon the shoulder — and what is said
of the shoulder will equally apply to the buttock or the thigh —
will barely produce a transient numbness or heaviness limited
to the contused spot ; whereas in all probability in an hysteri-
cal woman the numbness will be replaced by much more ac-
centuated, more extensive, and more durable perversions of
sensibility. There will be, for example, in this last, simulta-
neously with the feeling of absence of the whole limb, a genera-
lised anaBsthesia of the limb, and a paresis perfectly appreci-
able to dynamometric exploration. It may be added also
that if the same hysterical subject had been plunged into a
somnambulic state the same shock would have determined,
almost to a certainty, a complete monoplegia involving both
sensibility and movement, presenting in a word all the char-
> See Lectures XXI, XXII, and XXIII.
^ Groeningeo, Fischer, Billroth, &c., see Lecture XXYI.
HTSTBEO-TEAUMATIO PARAPLEGIA. 385
racters which distingaish hystero- traumatic paralyses in their
most perfect type of development.
It is evident that the different instances that have been
mentioned represent stages of the same series, and that
the explanation which is invoked for one of them applies
■equally to them all. It will suffice to consider, for example,
the case of the hypnotised subject where the symptoms are
carried to the highest degree, and occur, moreover, under
conditions which are more accessible to analysis. Now, in
this condition, M. Charcot submits that in the very fact of
local shock, and particularly in the sensory and motor phe-
nomena attached thereto, must be sought the point of de-
parture of the suggestion. The sensation of heaviness or
even absence of the limb struck, and, again, the paralysis
■which is never wanting, in some degree at any rate, will
give rise quite naturally, as it were, to the idea of motor weak-
ness of the limb. And this idea, by reason of the somnam-
bulic mental condition so completely favorable to the effi-
cacy of suggestion, comes to acquire, after a period of incu-
bation, a considerable development, and is finally able to
become realised objectively in the form of a complete para-
lysis.
It is quite conceivable that this theory is capable of appli-
cation, in a most perfect manner, to the interpretation of the
mode of development of hystero-traumatic paralyses which
occur in the waking state, quite apart from any hypnotism.
Here the necessary mental modification is determined by the
general nervous commotion {nervous shock) which is sure to
attend the accident. And as for the suggestion itself, it is the
direct consequence, the amplified prolongation, as it were, of
the phenomena of the local shock. In this way it is easily
understood why psychical paralyses consequent on a contusion
so frequently occupy the lirab which received the blow,
A large number of the cases of paraplegia determined by
an emotion, by fear in particular (Schrecklaehmungen of Ger-
man authors),^ are capable of explanation without any doubt
on the hypothesis just mentioned.
' On emotional paralyaes eee especially E. B. Todd, ' Clin. Leot.,' ed.
by Bcale, London, 1861, p, 779 ; 0. Berger, " Emotious nenrose ;" ' Boutsch.
Zeit. f. prakt, Med.,' 1877, Nos. 38, 39, Lejden ; ' Euckenm, Kr.,' I Bd,, pp.
25
886 PARAPLEGU FROM FBAE.
It is well known that in man a sndden and violent emo-
tion^ fright^ for example^ is followed almost necessarily by a
feeling of powerlessness in the lower limbs which may attain
a very high degree^ and all without departing^ so to speak^
from physiological conditions, yet amounting to a veritable
paraplegia, accompanied, may be, by tremor.^ The cerebral
nervous shock inseparable from such emotion produces, in a
subject predisposed, a mental modification which renders
possible the transformation from an emotional, transitory,
'' physiological '* paresis into a veritable paraplegia complete
and lasting. In this way probably it would be possible to
explain a large number of the cases of paraplegia from
thunder.
Coming back again to the case of Le Log — , it only remains-
for us now to inquire how it is that this hystero- traumatic-
paralysis became developed in his lower extremities. It may
be remembered that in the early days after the accident large*
ecchymoses were noticed upon the anterior surface of the
right thigh and on the lower part of the patient's abdomen^
It will be remembered also that at this time he complained
of a feeling of heaviness, of weight, almost a sensation of
absence of his legs, and, moreover, the lower extremities were-
notably paretic. It was very probable that those phenomena,,
together with the presence of the ecchymoses, gave rise to-
the conviction in Le Log — 's mind that the wheels of the vam
which knocked him over '/ passed over the body,'* as he puts-
it. Nevertheless, this conviction, which has even appeared
to him in his dreams,^ is absolutely erroneous. We know it
to be so from the most accurate information furnished to us
by eye witnesses of the scene. But although the thighs^
and the pelvis were not crushed by the weight of the wheels
it is scarcely to be doubted, on the other hand, that these
parts, at the time when the unhappy man was thrown upon
the pavement, were very severely contused in the fall. And
it is precisely the consequences of this local shock whicb
172, 173, and 174; E. Lippe, * Zur Casuist der Schrecklaehmung,' Inaug^
Diss., Breslau, 1877.
* Ch. Darwin, * L'expression des Amotions/ p. 30, et seq,, Paiis, 1877.
^ See a case of paraplegia consequent on a dream, communicated to the
Soci^t^ de Biologie par M. Fer6 (Stance, 20th Nov., 1886).
NEURASTHENIA. 387
have determined the auto-auggestion whence reBuIts the para-
plegia. It is worthy of remark that in the case of Le Log — ,
as in others of the aame kind, the paralysis was not prodaced
at the very moment of the accident, but it was only after an
interval of several days, after a sort of incubation stage of
unconscious mental elaboration.'
Besides the phenomena of aa hysterical kind that have j ugt
been described in Le Log — , there are others which do not
belong to the same category. We have seen that the patient
suffers from a permanent headache of a coostrictive charac-
ter, producing the sensation of a heavy helmet pressing all
parts of the head. All kinds of sound are painful to his ear,
and he does his best to avoid them. It is impossible for hiia
to fix his attention to any matter, or to devote himself to
anything without speedily experiencing very great fatigue.
Moreover, he is silent, and only replies slowly to questions
addressed to him, and as though he resented them. Gene-
rally speaking, he is sad, melancholic, almost stupid, fre-
quently anxious. He is irascible, resents the smallest obser-
vations made to him, and is incessantly asking to have his
place changed in the ward where he sleeps, complaining of
his neighbours, who, ho says, annoy him. He has insomnio,
and is frequently tormented by horrible dreams, relative to
the imaginary details of his accident. Further, his memory
appears to be considerably weakened; he does not even
remember the accident itself, whatever he may say, aud there
is every reason to believe that everything ho states, and his
dreams, are inventions founded more or less on what he has
heard stated with reference thereto. The same may be said
' We have liere a phenomenon of ancoiiBciauB oraab-caDBfliouacd'ebration,
mentation or ideation. The patient, in a case of this sort, is aware of the
result, but he does not preserre any recollection, or he only preserves it in a
vague manner, of the different phascB of the phenomenon. Questions
addressed to him upon this point are attended n'ith no resnlt. He known
nothing or almost nothing. Briefly one can oowpare the process in question
to a sort of reflex action, in which the centre of the diastaltic arc is repre-
sented by regions of the grey coi'tei, whei-e the psychical phenomena relative
to voluntary movements of the limbs are situated. By reason of the easy
disaociation of the mental unity of the ego in rases of this hind, theee centres
can be set in operation without any other region of the psychic organ being
interfered with or forming part of the process.
TRAUMATIC PSYCHOSIS.
^
of occnrrenceB before the accident, and there are in the tablet
of hifl memory large vacant spaces. He cannot, for example,
name any of the masters for whom he has worked, nor can
he say where they lived.
These different phenomena correspond on all points with
the psychical troubles which, with or without the accompani-
ment of hysterical manifestations, so frequently appear in
conaeqnence of a nervous shock, more particularly when the
shock has been preceded or followed by a physical cerebral
commotion. These symptoms Lave been perfectly described
by MM. Skae, Page, Westphal, Moeli, Krafft-Ebing, and quite
recently by M. Guder.' It is evident that these conditions
greatly aggravate tho situation, already sufficiently compli-
cated, in the case of the unfortunate Le Log — . Hysterical
conditions in men are of themselves often very serious, espe-
cially when they are of traumatic origin, by reason of their
tenacity, their duration, and their resistance to rational treat-
ment. The existence of traumatic psychosis [psychoae trau-
matique] adds still more to the gravity of the prognosis, for
it would not be difficalt to cite examples where this state
became incurablo, and terminated in dementia.
The preceding details of Le Log — 's case extend to April
igth, 1886, The following is the progress of the case since
that time. There was no appreciable change daring the
months of May and June j the attacks and the nose -bleedings
were both frequent and severe ; his bad tempers continued,
and sometimes stupor. He also had some anuria from time
to time. The patient's nutrition was bad. He vomited fre-
quently, and had profuse sweats. About the middle of July
the attacks took on a more accentuated spasmodic character.
He struggled more, assumed arcs of circles, tore his clothes ;
^^_ and ho was obliged to be tied down, yet notwithstanding his
^^^k "violence, the lower limbs remained quite immovable. The
^^^1 epistaxis became rarer and less profuse in proportion as the
^^^K convulsions became more severe. On the morning of the
^^^1 ■ Westphal, ' Cliaritg Annalen Jahr. 187S,' S. 379; Eiegler, 'Die im
^^^^^ Eiaetibahndienste Vork. Bevufskranlih.,' Berlin, 1888 ; Moeli, " ITeber phy-
fiigche Stoerungen nacb Eieenbahnumf alien," ' Berl, kiin. Woch.,' 1881, No. I
6 ; Krafft-BbiTig, 'Lelirb. der Psyohint/ 1883, p. 188 ; P. Gnder, ' Die GeisteB-
stiimngeii nucb Eopfvetletzung,' Jena, 1886. I
STJDDEN CUBE.
15th August, 1886, the patient liad a CDnyiilaive seizure
of great severity. There had been no epistaxia. During
the attack, all in a momentj it was noticed that the lower ex-
tremities were being thrown about, and the feet struck the bar
at the end of the bed with so much force that it became dia-
placed. The attack terminated; the patient got up fro
bed and commenced to walk, at first with a certain amount of
hesitation, supporting himself along the wall and by means
of surrounding objects, but at the end of a few hours his
powers of walking became absolutely normal.
Nevertheless, the cutaneous and deep anaesthesia persisted
stili in a very pronounced degree in the lower extremities.
The other stigmata, namely, the retraction of the visual field,
pharyngeal auEesthesia, &c., had not undergone any appreci-
able modification.
Since this epoch the attacks have become less frequent
and less intense. The amelioration in the movements of the
lower extremities has continued, and the patient walks better
and better each day. He has gone out of the infirmary
several times to see his friends, and can accomplish fairly
long distances without too much fatigue. Nevertheless the
cerebral torpor still remains to a certain extent, and the
stigmata and anfesthesia of the lower limbs are not materially
modified {November ist, 1886).
The sudden disappearaiice of the paraplegia after an attack
which presented all the characters of an hysterical seizure
confirms in a very decisive manner the opinion expressed
concerning the nature of the complaint. Nevertheless, the
patient although it is a year since the accident, cannot be
considered as cured, in that the hysterical stigmata persist
in almost the same condition as they were before.
II. Case of hystero-traumatic brachial monoplegia consequent
on a blow on the shoulder}
The man named Mouil — * is robust, vigorous, and well
developed. He is 25 years of age, an agricultural labourer.
' Edited by M. Babinaki, Chef de Clinique de la faculilS.
' B«e Lecture XXV, p. 353, et seg.
390 APPENDIX I.
He was born in the department of Doubs, not far from
Besan9on. A little less than a year ago he was a farm
labourer. Since the month of May, 1885, he has been in
Paris and employed at the railway station in various ways.
He had never been ill before this. He had never been
nervous, and he does not know what it is to have nervous
attacks. He is rather slow, apathetic, somewhat silly, and as
far as one can judge during the eight months he has been in
the wards, his imagination does not seem to be of a very
active kind. There is no nervous malady known to exist in
his family.
Mouil — was in his usual state of health, when on Decem-
ber ist, 1885, at six o'clock in the evening, while he was
working on the line, his right shoulder was squeezed between
the buffers of a waggon and an engine. The contusion was
certainly very slight, for it was not followed by any serious
surgical injury. Nevertheless, under the influence of the
shock the patient immediately lost consciousness and fainted.
He was carried to the station-master's office, and he did not
regain his senses till about twenty minutes afterwards.
It is interesting to note the phenomena which, according
to him, existed immediately after his waking.
1. Respiration was very difficult, and it seemed to him as
though his right upper extremity, the one injured, was absent,
replaced by a heavy body which hung lifeless by his side,
2. There was no immediate tumefaction of the parts.
3. Movements in the shoulder and the elbow were impos-
sible though he was able to move the fingers both at the time
and for three or four days subsequently ; hence it may be
said that the motor paralysis was not immediately complete.
4. He suffered from general weakness, so that he found
it impossible to stand upright or even to raise himself. He
was only able to get up and go out at the end of thirteen
day6.
The patient was carried to the Lariboisiere Hospital, the
one nearest to the Northern Railway Station, on the very
day of the accident, about 8 o'clock in the evening, and was
placed in the wards of Dr. Brun. The next morning they
discovered a slight swelling of the shoulder, and an extensive
ecchymosis over that joint, the subclavicular region, and
HTSTEEO-TRAUMATIO MONOPLEGIA. 391
part of the face. The right upper extremity was completely
•deprived of all movement excepting the fingers, and the limb
was also anaesthetic, insensibility to pricking was absolute
everywhere ; but at this time the deep-seated sensibility was
probably not yet affected, for the movements imparted to the
limb in order to ascertain whether there was a dislocation
or fracture were rather painful. The result of these explora-
tions was completely negative.
It was only on the thirteenth day that the patient was able
to leave his bed. He left the hospital, and shortly afterwards
went into the Hdtel Dieu into the wards of M. Merklen, on
the 13th January, 1886, that is to say six weeks after the
accident. There they recognised all the characters of the
monoplegic affection about to be described^ and the diagnosis
of M. Merklen, like that of Dr. Brun, was that the case was
one of hystero-traumatic monoplegia. A fact which is well
worthy of your attention is that at the time of his admission
into the Hdtel Dieu, a month after the accident, there existed
in the paralysed limb, both of the arm and forearm of the
right side, a very notable diminution of the volume. During
his stay of more than a month in the Hdtel Dieu, faradic
treatment was continued without interruption, and without
any result.
The examination of the patient at the time of his admis-
sion into the Salpfetrifere, March 2nd, 1886, gave the following
results. Monoplegia of the right upper extremity, without
any trace of participation in the face or the lower limb (it
seems certain that the face has never been involved). The
motor monoplegia was complete, the trapezius alone was able
to raise the shoulder. The paralysis was of a flaccid kind,
the tendon-reflexes were not increased, indeed they were
rather diminished.
Affections of sensibility. — i. Cutaneous sensibility of all
kinds was absolutely lost, cold, pinching, &c. The cutaneous
anaesthesia occupied the entire prominence of the shoulder ;
limited on the thorax by an unbroken line following a circular
plane perpendicular to the long axis of the limb when it was
extended (Fig. 86, a and b).
2. The ansBsthesia extended to the deeper parts ; torsions.
392 HT8TEE0-TEAUMA.TIC MONOPLEGIA.
tvistings practised on tlie differeot segmentB of the limb were
quite nnperceired.
3. Notions of mnscular sense were completely lost; the
patient was nnable to say where his limb was, and he could
not tell which finger was moved, &o.
FiO. 86. — Difbribation ot the uueitlieiiB :
Trophic changes. — The wasting of the limb has already beea
mentioned. It should be added that the fingers are pnrpl&
and cold, like those observed in certain organic paralyses.
However, the muscles present absolutely normal electrical
reactions, and the same with the nerves. Faradization, which
produces an energetic contracture of the muscles, produces
absolutely no sensation.
The patient has at no time ever had anything resembling
hysterical seizures, but the permanent sensitive and sensorial
troubles [hysterical stigmata) are very pronounced. There-
HYSTEEO-TRAUMATIO MONOPLEGIA. 393
exists an analgesia oyer the whole of the right side of the
body and face, and everywhere the patient is unable to per-
ceive cold (Fig. 86).
The sensorial troubles are very noteworthy.
1. Very pronounced retraction of the visual field on both
sides.
2. Monocular diplopia.
3. Diminution of hearing on both sides.
4. Diminution of smell on both sides. Taste is absolutely
lost, and one can push the finger far into the pharynx and
maintain it there without determining the least reaction.
The patient is not hypnotisable.
On November ist, 1886, eleven months after onset, in spite
of different methods of treatment, the monoplegia is not modi-
fied in any way. The stigmata persisted in exactly the same
condition. The general condition is excellent. It has been
discovered that the application of a circular ligature produces
very pronounced and durable contractures in the lower limbs
of Mouil — [contracture diathesis].
It is not necessary to dwell at any great length on this
case of hystero-traumatic monoplegia, for it is, so to speak, a
reproduction, even in the most minute details, of the classical
types already described by M. Charcot.^
It is only necessary, therefore, to again remark that the
sensations produced by the local shock were evidently here
the starting-point of the suggestion which has resulted in the
production of a complete sensory and motor monoplegia,
which has persisted as it is now for eighteen months. As
for the state of suggestability, it has doubtless become deve-
loped by the cerebral commotion produced by the nervous
shock. It is a fact worthy of being noticed that the motor
paralysis was not complete at first, and that consequently in
this case, as in others of the same kind, the motor weakness
was only completed after a sort of unconscious mental elabor-
ation.
The amyotrophy, without modifications in the electrical
reactions, occurred somewhat rapidly in this patient. This
rapidly developed hysterical amyotrophy has been recently
^ See Lectures XX, XXI, and XXII.
■394 HYSTEBTCAL AMYOTROPHY.
pointed out several times bj M. Charcot^ and it has formed
the subject of an extensive work published by M. Babinski in
the ' Archives of Neurology/^ A brief summary of MouiPs
case appears in the former part of this volume (p. 353).
^ See J. Babinski, ^'De Tatrophie musculaire dans les paralysies hjs-
teriques" (*Arch. de Neurologie/ Nos. 34 and 35); see also 'Progres
Medical/ 1886, No. 6, et V Appendice, IV.
APPENDIX
NOTIONS OF MUSCULAR SENSE AND VOLUNTARY-
MO VEMENT.
(Appendis to Lecture XXII, p. 303.)
I AM constrained to admit with many authors that the motor
representations, which of necessity precede ttie accomplish'
meat of a voluntflry movement, take place in the cortical
motor centres, their more exact organic substratum being
in the motor cellules of those centres. These motor repre-
sentations are chiefly constituted by the " sentiment of inner-
vation," of " nervous discharge," as it is still sometimes called,
which has its seat in the central organism.
On the other hand, the notions furnished by what is pro-
perly called " muscular sense " [kinEesthetic sense of Bastian)
consist of impressions coming from the periphery, namely,
from the skin, muscles, aponeuroses, tendons, and articular
capsules. These impressions become registered [s'emmaga-
sineraient] in the cortical sensitive centres, where their ideal
recall can take place.
The first alone of these representations is indispensable to
call voluntary movement into operation. The other kind, in
general, intervenes only in a secondary, though very eilectual
fashion, in order to complete, direct, and, so to speak to per-
fect the movement which is ah'eady in process of execution.
We know besides by numerous proofs that the visual image
of voluntary movement contributes powerfully towards the
same result.
It follows, therefore, that if the motor representations hap-
pen to become defective in consequence of a lesion occurring
in the nerve- cellules of the cortical motor centre of a limb,
or in the prolongations which connect them with the centre*
4
396 APPENDIX II.
of ideation^ althougli the kin83sthetic and visaal representa-
tions may persist, then a complete paralysis of the voluntary
movements of the limb results. In a forgotten book which
my eminent colleague Professor Janet has courteously brought
under my notice, I find that Key Eegis, of Montpellier, recog-
nised in 1789 the existence of motor paralysis depending on
a loss of the memory of motor force, due to lesion of certain
parts of the brain (^ Natural History of the Soul,' London,
1789, pp. 26 — 28).
From the preceding statements it will be understood that
the suggestion of loss of power should be capable of deter-
mining in certain subjects a complete motor paralysis, without
the accompaniment of any affection whatever of sensibility
either cutaneous or deep (as I have already mentioned, p.
303), and more particularly without any loss of the notions
furnished by muscular sense. But we have observed that
more frequently a suggestion of this kind, at least when
addressed to ^' hysterics " anteriorly hemiansssthesic, and not
accompanied by any injunction relative to sensibility one way
or the other, — this suggestion, I say, is followed, according
to our experience, not only by paralysis of movement, but by
loss of sensibility in all its modes, including muscular sense.
It may be said therefore, that under these circumstances, para-
lysis of the fundamental apparatus of voluntary movement
carries with it in some way paralysis of the " perf ectioning *'
apparatus. It is further probable that in these cases of paraly-
sis by hypnotic suggestion — as in a large number of hysterical
paralyses with flaccidity, which are in like manner of psychical
origin— the subcortical and bulbar grey nuclei, as also the
spinal nerve-cells (which in the normal state are all in direct
or indirect relation with the cortical motor centres) may
become more or less profoundly affected in consequence of
a. diffusion of the lesion from the higher cerebral centres.
The loss of automatic movement, whatever its origin, and the
abolition or diminution of acts of a purely reflex order, which
under these conditions accompany the paralysis of voluntary
movement, would seem to testify to this.
The followiDg passages appear to me sufficient to indicate the
ideas of the authors whence they are taken, as to the nature and
seat of the psycho-physiological process which originates deliberate
MUSCULAR SENSE. 397
movemeats. "If the idea tends to produce the fact," Bays Bain
('The Senses and the Intellect,' translation of Cazelles, 1874, p.
298), "it is because the idea is already the fact in a more feeble form.
To think ia to restrain oneself from speaking or acting."
" Mental actions take place in the aame centres aa physical
actions. Ordinarily, simple volition suffices to oaiTy them to a
point at which the muscles are set in action" (loc. cit.,p, 305).
" Aa the nerves which the muscles receive are principally motor,
which convey to them the stimulus emanating from the Lrain
. . . . we cannot do better than suppose that the concomitant
sensation of muscular movement coincides with the centrifugal
current of nerve force, and not that it is the result, as in a sensation,
properly speaking, of an influence transmitted by the centripetal
nerves " (loc. cit., p, 59). " In a voluntary act, considered in its
simplest form," says Herbert Spencer ('Principles of Psychology,
vol. i, translated by Ribot and Espinas, p- 539), " we are unable to
find anything save the mental representation of the act followed by
its accomplishment — a transformation of that nascent psychical
change, which constitutes at once the tendency to the act, and the
idea of the act, into a positive psychical change which constitutes
the accomplishment of the act in so far as it is mental. The differ-
ence between a voluntary and involuntary movement of the leg, ia
that, whereas the involuntary movement is caused without any ante-
cedent consciousness of the movement to be made, the voluntary
movement is produced only after it has been represented in conscious-
ness. And since that representation is no other than a feeble form
of the psychical state which accompanies the real movement, it ia
nothing else than the nascent excitation of all the nerves partici-
pating in this function ; which precedes their actual excitation."
Further ('Premiers Principes,' p. 316). "Volition is an initial
discharge along a line which has become, as the result of antecedent
experiences, the line of most feeble reaistance. The transition of
volition to action is but the complement of the discharge." Accord-
ing to Wundt (' Physiology,' Fr. transl., p. 447), " The seat of the
sensation of movement does not appear to be in the muscles, but in
the motor cellules We have not only the sensation of a
movement executed, but that of a movement to be executed. The sen-
sation of movement is therefore limited to a motor innervation, and
hence we call it the sentiment of innervation ('Innervationsgefiihl.')
HerrMeynert expresses himself thus: ('Psychiatrie,' p. 313). "Ich
glaube der erste gewesen zu sein welcher sich dahin aiisserte, dasa
die In nervation svoi^ange von den Hemisphaeren aus, welche man
Willensacte nennt, nichta weiter seien als die Wahruehmuugs und
398 APPENDIX II.
EriDDerungsbilder der InnervationsgefuJde, indem solche, jede Form
der Eeflexbewegungen begleitend, in die Himrinde ubertragen
werden, als die primare Grundlage secundar vod dem Vorderliim
ausgeloster aelinliclieii Bewegungen. Diese Erinnerungsbilder
bekommen dann durcb associations Yorgange die intensitat der
Kraft zugefiihrt, durcb welcbe sie fiir die vom Vorderbim ausge-
benden secundaren Bewegungen, als Arbeitsanstoss langs centri-
fugalen Babnen wirken." In bis * Clinical and Pbysiological
Eesearcbes on tbe Nervous System,' 1876, pp. 20— 37, Hugblings
Jackson adheres to tbe views of Bain, Wundt, and otbers, tbat our
** consciousness of muscular activity " is in great part initial, central,
and realisable in tbe motor centres. According to Maudsley
(* Pbysiology of Mind,' trans, of Herzen, p. 249), " it appears tbat
it is in tbe frontal part of tbe convolutions (cortical motor centres)
tbat tbe muscular sensations wbence we derive our motor intuitions
are stored up. The parts of tbe surface of tbe brain which act as
motor centres are tbe seat .... of tbe conception of tbe
degree and quality of muscular innervation — tbat is to say, of what
are called muscular inductiong.^^ Terrier (* Functions of the Brain,'
Chap. XI) expresses himself thus : '^ In the same manner that the
sensory centres form tbe organic base of tbe memory of sensory
impressions and the seat of their ideal resurrection, so tbe motor
centres of the hemispheres, besides being the seat of differentiated
movements, are the organic base of tbe memory of corresponding
movements, and tbe seat of their re-execution or ideal reproduction.
We have thus a sensory memordy an a motor memory, of sensory
and motor ideas respectively ; the sensory ideas being revived sen-
sations, and tbe motor being revived or ideal movements. The
ideal movements do not form an element less important in our
mental processes than tbe revived sensations of an ideal character.'^
Contrary to these views, Bastian (* The Brain as an Organ of tbe
Mind,* vol. ii., 1882, pp. 209, 165, and Appendix, transl.,) expresses
tbe opinion tbat tbe motor centres, wherever they may be situated,
are the parts whose activity appears to be absolutely free from sub-
jective concomitant phases. It does not appear tbat tbe ideal re-
productions ever take place in these centres .... It is tbe
changes in tbe muscle excited and in tbe contiguous parts — a change
occasioned by tbe movement — tbat beget a group of centripetal im-
pressions whose terminua is tbe kinsestbetic centre (centre of the sense
of movement) .... This, then, is really a sensory centre,
and ideal movements may be revived in it, eitber isolated or asso-
ciated with visual impressions pertaining to it . . . . It is
only productive of great confusion to attribute tbe activity of the
MUSCULAR SENSE. 399*
sensory centres to the motor centres The cerebral
substratum of mind does not embrace in any manner the processes
which take place in the motor centres of the brain, wherever they
are situated. - In other words, we cannot legitimately regard mental
operations as beings even in part immediately due to the activity of
motor centres."
In support of the theory advanced above, we may recall
what is observed in certain subjects, hysterical for the most
part, who, deprived of all forms of sensibility in a member,,
have nevertheless maintained in great part the faculty of
moving that member freely wTien even they are unable to-
have recourse, the eyes being shut, to the directive and dy-
namic influence of the visual image of movement. Our patient
Pin — ^ offers at the present time a good example of this kind.
In him, as we have seen, the cutaneous and deep sensibility
are lost over the whole extent of the left superior extremity,
and while his eyes are shut he does not recognise any passive-
movements imparted to the diverse segments of the member
nor the position thereby resulting. The eyes being open,
general and partial voluntary movements of the member pre-
sent all the characters of the normal condition both in re-
spect of variety and precision. These movements persist in
great part while the eyes are shut, only they are more uncertain
and more hesitating, although never inco-ordinate ; they ope-
rate, in a word, as though he were groping. And again. Fin-
is able, the eyes being shut, to direct his fingers with a cer-
tain precision towards his nose, his mouth, or his ear, or
towards an object placed at a distance, and to succeed in his
aim, though he very frequently misses. He is not able, gene-
rally speaking, when one asks him to do so, to flex one of
his fingers singly. Habitually all the fingers are flexed
together. Occasionally he is unable to say whether he has
flexed his wrist or not, &c. I do not now speak of the dyna-
mometric pressure, which for the affected hand shows 30 K..
when the eyes are open, and only 15 K. when they are closed.
These modifications occurring in the exercise of movement,
in patients of this description, when the co-operation of
kinassthetic and visual representations is wanting, permit us
to discern up to a certain point in what the operation of the-
^ Lectures XIX and XX.
400 MOTOR, KINiESTHETIC, AND VISUAL BEPEESENTATIONS.
fundamental apparatus of voluntary movements normally con-
sists. On the other hand, the study of cases of psychical
paralysis where movement alone is involved reveals the truly
secondary role, however important it may be, of visual and
kinassthetic representations in the normal accomplishment of
voluntary movements.
Perhaps, moreover, there exists in the normal state
varieties in this respect. It is possible, indeed, that at the
moment when a premeditated act is about to be accom-
plished, there is awakened in some people exclusively motor
representations properly so called, and in others kinaesthetic
and visual representations; in other persons better endowed,
sometimes the one and sometimes the other, or both at once.
Difference in education, habit, or hereditary predisposition
may account for these varieties. We can consequently
understand that a lesion of the same nature, of the same
extent, and the same localisation, may in different subjects
reveal itself by different clinical phenomena, according as
individuals belonging to one or other of these categories
may be concerned.
APPENDIX
III.
A CASE OP HYSTERICAL HEMIPLEGIA FOLLOWED BY
SUDDEN CURE.
{From Professor Oharcofs lectures, hy Dr. Marie.)
(Appendix to Lecture XXII, p. 296.)
Gentlemen, — Among last Taesday^s out-patients a girl pre-
sented herself who had been attacked with motor paralysis
in a very sudden manner. I have thought it advisable to
bring her before you this very day, because it is possible
that the patient^s symptoms may disappear at any moment.
Henriette A — , 19 years old, has generally enjoyed good
health. She is a laundress and follows her calling on a boat on
the Seine. Her father, a spectacle-glass maker, who is now fifty
years old, had an apoplectic stroke some time back, followed
by left hemiplegia, and at the present time he frequently suffers
from giddiness. Her mother and sister do not present any
nervous abnormalities.
As for the patient herself, at the age of sixteen she had
scarlatina, and during convalescence she had ^^ nervous
attacks,^' of which she gives the folio wing description: no aura,
loss of consciousness, but no movements of the limbs ; on
waking, sensation of a ball in the epigastrium and desire to
weep ; she has never had biting of the tongue nor involuntary
evacuations during the attacks. These symptoms only lasted
for a year, from sixteen to seventeen years of age ; during that
26
402 APPENDIX.
time the menstruation was very irregular, but since then it
has become quite normal. She has never suffered from
rheumatism, nor shown signs of cardiac disease.
Now that you know the antecedents of this young woman, I
will narrate to you the circumstances under which the disease
developed. During the night of 29th November, while she was
asleep, a shelf situated above her bed slipped and fell, with
all the articles it supported, on to the head of Henriette A — .
She awoke with a start, very frightened by the noise and by
the unexpected blow, and for the remainder of the night she
ivas much upset and could not sleep. The fall of the shelf
did not produce any injury ; Henriette is positive that she
had not the slightest bruise. However, the catamenia which
she was expecting a few days later, came on in the course
of that night.
Next morning, November 30th, she got up as usual, went to
the boat and worked as she was accustomed to do without
experiencing anything unusual. But, about half-past seven
in the evening, when she was going with her bucket in her
hand to fetch some water, her right side suddenly gave way
and she fell. She was unable to rise, her right leg was use-
less and the bucket rolled far away from her right hand, which
was unable to hold it. There was no loss of consciousness,
the very moment she fell she called out for help ; no sensa-
tion of giddiness or faintness ; no convulsions whatever, nor
any other cerebral symptom. The paralysis occupied the
upper and lower limbs of the right side ; but it did not ex-
tend to the face — that is a point you should specially observe.
The loss of power was so great that she was obliged to be
taken home in a carriage.
The following days, 1st, 2nd, 3rd December, the paralysis
of the leg improved somewhat ; but when Henriette A— -
<5ame last Tuesday among our-patients, she was obliged to
be brought in a cab, and it was necessary for her to be vigor-
ously supported when she was brought into the room.
During the four days that have passed since then, the
amelioration has become more pronounced, and as you will
see directly, mobility has to a great extent returned in the
lower extremity.
Let us now turn to the present condition of the patient ;
HTSTEEIOAL HEMIPLEGIA. 403
and firstly we will examine the power of movement. The
right superior extremity is absolutely paralysed, flaccid, and
falls like an inert mass after being raised. Such at least
is the general appearance of the limb, but on examining it
more closely it may be discovered that, although most of the
muscles of the arm and forearm have lost mobility, some have
reserved their power. The forearm can be extended (action
of triceps), but it cannot be flexed (biceps and brachialis
anticus) : flexion of the fingers is possible though it is v«ry
feeble : pronation and supination of the forearm, are im-
possible, as also adduction and abduction of the wrist. But
there are a few slight movements of flexion and extension
of the wrist j the fingers also can be feebly drawn together
and placed in the position resulting from contraction of the
interossei.
As for the muscles of the shoulder, it will be seen that
the deltoid does not contract at all ; the pectoralis major has
almost preserved its usual power ; the trapezius and the other
muscles of the trunk are absolutely normal.
The lower extremity has, as we said, almost regained its
natural strength. It no longer presents the signs of com-
plete paralysis, but rather of a paresis, more marked in some
muscles than others. The patient is able to walk though
she limps slightly. The face, you will notice, presents no
deviation, no paralysis of the orbicularis oris. Nor is there any
paralysis of the muscles of the trunk. In a word, the para-
lysis in this patient is not properly speaking a hemiplegia,
but rather a brachio-crural monoplegia.
The tendon-reflexes, you observe, are not exaggerated;
on the contrary, they are less pronounced on the paralysed
than the healthy side. We have not, therefore a spasmodic,
but a flaccid paralysis.
Next, we must examine the sensibility. There is a fairly
marked deficiency of sensation to pricking and heat in the
right lower extremity. In the right upper limb there is total
anaBsthesia extending over the hand, forearm, and arm as
high as the acromion. The skin of the chest is sensitive, the
limit of separation between sensitive and insensitive areae
being through the middle of the axillary space. There is no
modification in the special senses of sight, smell, taste, an^d
404 APPENDIX.
hearing. No special point of hyperassthesia has been foand
on the body, and no ovarian tenderness.
There remains the muscular sense to examine. For thi»
purpose we instruct the patient, after carefully blindfolding
her, to grasp the right (paralysed) hand with the left (healthy)
one, and you see, gentlemen, that she is quite incapable of
doing so ; she seeks it high and low, and on all sides but
cannot find it. There is not the same condition in the right
lower limb, she has no difiiculty in finding with the eyes
closed her right foot with her left hand.
The condition of the local temperature is a point of some
interest. It is lowered several tenths of a degree on the para-
lysed side, as revealed by the comparative thermomety of
the two sides. There is no abnormality in the general tem-
perature of the body. The general condition in other re-
spects is excellent.
If now, gentlemen, we make a summary of the different
phenomena presented by this patient with a view to diagnosis,
what do we find ? A monoplegia associated with diminution
of the tendon-reflexes, without epileptic or apoplectic cerebral
phenomena ; accompanied by an absolute anassthesia limited
to the arm of the paralysed side and combined with abolition
of muscular sense. And all these phenomena appeared in a
young girl of nineteen who had previously presented hysteri-
cal symptoms.
These are the main features in the case. Are they due
to a focal cerebral lesion— a hasmorrhage or softening ? One
may boldly reply to this question in the negative. These
are not the ordinary characters of hasmorrhage or softening ;
for we have seen that it is not a true hemiplegia in our case
but rather a combined monoplegia, without any participation
of the face. Moreover, there is anassthesia which corre-^
spends absolutely both in position and degree with the para-
lysis of the limbs. Nor is it a hemiplegia of a spinal nature,,
for under those circumstances the paralysis and anassthesia
ought to be crossed, whereas here, they are not only on the-
same side, but absolutely superposable so to speak one upon
the other.
Briefly therefore, it is unnecessary to hesitate longer or
to create imaginary difficulties in the diagnosis. The purely
SUDDEN CURE. 405
hysterical nature of ttis paralysis is strikingly evident after
a. detailed examination of the patient such as we have made ;
and we may accept it without further discussion as a basis
for prognosis and treatment which follow as necesss^ry con-
sequences therefrom.
(Professor Charcot, having remarked that the electrical
examination of the muscles had been deferred because it was
possible that an attempt of this kind might entail a return
of the mobility and sudden cure, and that he wished his
audience to witness any such occurrence, proceeded in the
lecture room to faradize the muscles of the shoulder and arm
of the right side. At the end of a minute the sensibility
had entirely returned to this region, without transfer. A
minute later the sensibility had returned throughout the
entire limb and the paralysis had gone. The patient was
then able to use the arm as well as ever, and went round
among the audience vigorously shaking them by the hand,
desirous of proving how real was the recovery they had just
witnessed.)'
* At that time the weakness of the lower limb, to which no application
had been made, still existed. It remained for two days longer and then
disappeared spontaneously. From that time the sensibility and mobility
have remained absolutely normal.
APPENDIX
IV.
CONCERNING MUSCULAR ATROPHY IN HYSTERICAL
PARALYSIS.
{From Prof. OharcoVs lectures, by M. Bahinaki})
(Appendix to Lecture XXY.)
Among tlie diverse characters of hysteria — that neurosis so
fertile in all kinds of manifestations — is one of a negative
character, which seems to have been regarded hitherto as
quite distinctive. It consists in the absence of trophic
changes. This negative feature has come to take rank as a
law, so that a physician would seem to be justified in reject-
ing a case from the category of hysteria if it presented any
trophic trouble.
Cases recently observed by my master. Prof. Charcot, have
tended to show that this is by no means a constant feature,
and that it is certainly not a law, if indeed it even be a gene-
ral rule.
In fact, four patients in M. Charcot's wards, the victims
of hysterical paralysis, present in the paralysed limbs an amyo-
trophy which cannot be attributed to any cause other than
hysteria. All these patients have been shown by M. Charcot
during his course of clinical lectures. In a future work a
complete exposition of the different cases will be given, but
in the meantime it will not be without interest, in view of tho
novelty of the facts, to give a short analysis, briefly depict-
ing the main characters of these atrophies.
^ See *Progrk Medical/ 1886, No. 6, and 'Archives de Neurologie^
Nob. 34 and 35, 1886.
HYSTEEIOAL AMYOTEOPHY. 407
It should be clearly understood that the characters we are
about to indicate are not absolute, for the number of cases
observed up to the present time are not sufficient to admit
of such a generalisation.
The cases investigated so far are four in number. Two of
these were cases of brachial monoplegia ; the other two were
cases of hemiplegia without involvement of face. In one of
these latter, the paralysis and atrophy predominated in the
upper extremity ; in the other they predominated in the lower
extremity.
The following are the characters presented by the muscular
atrophy in question :
1. It varies in degree, but it may attain very considerable
proportions. In two of the patients there was a difference
of 3 centimetres between the greatest circumference of the
affected and the healthy arm ; and in another patient there
was a difference of 5 centimetres between the two thighs.
2. There are no fibrillar tremors.
3. The idio-muscular excitability appears to be normal.
4. The electric contractility is diminished in proportion to
the degree of muscular atrophy, but there is no reaction of
degeneration.
5. The atrophy may become developed with great rapidity.
In one patient it was quite appreciable fifteen days after the
onset of the paralysis, and a month and a half afterwards it
was very accentuated (3 centimetres difference between the
two arms). In the other patients the development of the
amyotrophy was also very rapid.
6. The retrocession of the amyotrophy appears to be as
rapid as its development. In one case of brachial monoplegia,
ten days after the disappearance of the paralysis, which was
sudden, the circumference of the arm had already increased
one centimetre.
What is the nature of this amyotrophy ? It has just been
mentioned that there was no reaction of degeneration. It
is therefore a simple atrophy, that is to say, an atrophy in-
dependent of any material lesion of the grey matter of the
cord, or of the peripheral nerves. This is a fact of the high-
est importance, but we must proceed further and seek to-
ascertain the mechanism of this lesion.
^08 APPENDIX.
It would seem at first sight quite natural to attribute it to
a functional weakness ; but on a little reflection such an ex-
uplanation is seen to be erroneous. It is well known that
the wasting of the muscular masses which result simply from
functional inactivity of the muscles is slow in its production,
4hat it is never very accentuated, and that it may be com-
pletely wanting, even when a paralysis has lasted a long time.
Thus it was in the patient named Porcz — , who was affected
with hystero-traumatic monoplegia (one of the patients upon
whose case M. Charcot founded his description of this variety
of paralysis, and which is published at length in the ' Progr^s
Medical^ of 1885),^ the muscles of the upper extremity,
although inactive for a whole year, had not undergone the
least atrophy. Now, in the patients in question, the atrophy
develops very rapidly, and very soon assumes considerable
proportions. These characters clearly indicate that this
diminution of volume of the muscles belongs to the catagory
of trophic phenomena.
Nevertheless, such an assertion may appear strange ; for,
is it possible to compare the atrophy we are now discussing
with the amyotrophy that results from an organic lesion of
the anterior horns of the spinal cord, or of the motor nerves,
such as constitutes the type of the trophic lesion ? It is
necessary without doubt to establish a fundamental di^inc-
4iion between these two varieties. But it is equally necessary
'to point out that the expression '' trophic trouble '* does not
imperatively imply a material alteration in the nervous sys-
tem appreciable to our present means of investigation. It
simply means that the incontestable influence exercised by
this system over the nutrition of the tissues is modified or
suppressed. Now, this modification or suppression may be
purely dynamic; and it is evidently a phenomenon of this
order that we have here.
M. Charcot has, moreover, pointed out that we are already
-aware of the existence of atrophies quite comparable to these
hysterical atrophies. The amyotrophies consequent on arti-
cular affections^ are now-a-days considered by most physi-
cians, in conformity with the opinion which MM. Charcot and
^ See Lecture XX.
' Lectures IE oud lU, ainte.
HYSTERICAL AMYOTROPHY. 409
Tulpian expressed long ago, as of reflex origin and result-
ing from a modification in the state of cells in the anterior
.horns of the spinal cord. It is true that this is as yet only
a hypothesis because it does not admit of an absolute ocular
demonstration ; but it rests on very great probability. In
these cases there are purely dynamic alterations of the nervous
system ; the grey centres of the cord, and the peripheral
nerves are normal ; and the muscular atrophy is, like that
in hysteria, a simple atrophy.
M. Charcot has also compared hysterical atrophy to a
variety of atrophy that I have recently described which
occurred in a case observed at the Salpfitriere.^ It was an
amyotrophy which occurred on the paralysed side of a hemi-
plegic patient of cerebral origin followed by descending de-
generation, and which was independent of any change in the
anterior horns of the cord or the motor nerves. Nor was it
in this case possible to doubt the origin of the muscular
aitrophy, as in cases of articular amyotrophy unattended by
autopsy ; it certainly depended on the central nervous system.
Now, since the anterior horns of the cord constitute the
trophic centre of the muscles, and since they are not altered
organically, it must surely be admitted that they are altered
dynamically. The only difEerence between this variety of
•atrophy and hysterical atrophy is that, in the former the
dynamic modification of the anterior horns is consecutive to
an organic alteration of the brain and the pyramidal bands ;
whereas, in the latter case all the modifications in the differ-
ent parts of the nervous system are dynamic.
But whatever hypothesis may be invoked in connection
with these observations, the important and incontestable fact
remains that, contrary to the prevailing opinion, muscular
atrophy may be met with in direct connection with hysteria,
and that the amyotrophy is a simple one.^
* Babinski, * Soci^t^ de Biologic,* stance du Fev. 20, 1886.
^ The existence of amyotrophy in a limb affected with hysterical contrac-
ture has been very explicitly pointed out by M. F. Kalkoff in his inaugural
thesis made under the direction of M. Seeligmuller (* Beitrage zur differ-
ential diagnose der hysterischen und der Kapsularen Hemianesthesie/
Halle, 1884).
APPENDIX
V.
ON HYSTERICAL MUTISM.
{From Prof. Charcot's lectures, by M. Cartez})
(Appendix to Lecture XXVI.)
Among the many varied manifestations of hysteria is one
which, perhaps, up to the present time has not attracted the
attention it merits — that is mutism. Prof. Charcot has treated
of this subject in his lectures^ in connection with several
patients, whose cases he has been good enough to allow me
to report. Side by side with these cases I propose to place
several observations collected from French and foreign sources
which evidently belong to the same category.
Looking to the number of patients of both sexes attacked
with hysteria, it may be stated that mutism is a relatively
rare phenomenon. It is scarcely mentioned in older works
on this subject, and in a certain number of more recent obser-
vations it has been to some extent confounded with aphonia ;
at least, the interpretations offered by the authors tend to
promote this confusion.
If a thorough search were made through all the observa-
tions recorded which refer to the hysterical neurosis, in all the
historical documents relating thereto, a large number of cases
corresponding to this clinical syndroma [syndrome] would
undoubtedly be found. The story of the son of Croesus,
1 Published in the ' Progies Medical,' 1886.
' Delivered in December, 1885, vide * Gazette des H6pitaux ' of January,
1886.
HYSTERICAL MUTISM. 411
mentioned by Herodotus, who, thougli perfect in every other
respect, was dumb until one day, when a soldier was about
to strike his father, he suddenly recovered his speech — this
history is probably an example of hysterical mutism. But
we will confine ourselves to more modem observations.
Briquet in his Treatise says that " Aphonia, and more often
dysphonia, for the patients are still able to speak in a low
voice, is met with from time to time among hysterical sub-
jects.^^ " The aphonia is much more complete than that which
results from paralysis of the muscles of the larynx and from
paralysis of the diaphragm. ^^ However, Briquet cites the
following case of mutism recorded by Watson (' Philosophical
Transactions,* vol. xiv). A young woman had been for a.
long time subject to violent convulsions which were frequently
followed by temporary paralysis of the muscles that were
most severely affected. After one of these attacks she com-
pletely lost her sight for five days. On another occasion she
lost her speech, which returned, however, at the end of a
few days. The convulsions recurred from time to time, and
she again lost her speech and remained completely deprived
of it for fourteen months, during which time her health be-
came quite re-established. Finally, one day after having
danced a great deal, she suddenly regained her speech and
was cured.
In the transactions of the ' Academic des Sciences ' (1753)
is the account of a girl of fourteen who was struck with
paralysis and loss of speech after a fright.
Wells ('Medical Communications,* 1790) reports the
history of a woman who on recovering from an hysterical attack
discovered that she was unable to speak or emit a single
sound, although she was in full possession of her intellectual
faculties. After a fresh attack she recovered her speech.
In 1855, Sedillot reported a case to the 'Academic de&
Sciences * of a patient who had suffered from mutism and
aphonia ever since the age of fourteen ; and who was cured
by electricity.
Richter, of Wiesbaden, has published a very curious case
of a woman who became aphasic regularly every day ; the
intelligence remaining quite unaffected. The attack termi-
nated by an abundant evacuation of urine.
412 APPENDIX.
Bateman (^ Grazette Hebdomadaire/ 1 870) relates several
cases of hysterical aphasia and mentions that at the Societe
Medicale des H6pitaux (1867), when this subject was under
^discussion, M. Moreau regarded the phenomenon as common.
From what I have observed in M. Charcot's wards I do not
believe that hysterical aphasia is so common as M. Moreau
seqms to think. M. Legroux, in his graduation thesis on
aphasia, mentions the possible occurrence of this manifesta-
tion in hysterical subjects, adding, however, that it must not
be confounded with the more or less obstinate mutism of
certain patients.
In the interesting case they have published, to which I
refer later on, MM. Liouville and Debove appear to connect
mutism with a muscular paralysis. '' At other times,'^ they
say, ^^ it (the paralysis) involves certain muscular apparatus
such as that of the larynx, and then, according to its degree,
it produces aphonia or mutism."
Professor Revilliod, of Geneva, who had for a long time in
his wards the hysterical patient who forms the subject of
Case I, seeks for an explanation of the aphonia and mutism
presented by the patient in the paralysis of a special nerve.
Three other cases which he observed at the same time are
published in a most interesting paper which appeared in the
* Revue de la Suisse Romande.'
I have been able to find a certain number of cases of this
kind, which, together with those taken from the wards of
M. Charcot — ^the most important observations published up
to the present time — amount to twenty. The attentive study
that I have been able to devote to these cases enables me to
recognise in this mutism a central psychical affection analo-
gous to that which produces the paralysis of a limb, the
abolition of all or part of the visual field, &c. It is an
aphasia, but as M. Charcot has remarked, an aphasia of a
special type, which one is able, as it were, to diagnose at first
sight and to distinguish from the different forms of aphasia
of organic origin.
I have summarised most of these cases without giving a
minute description of the diverse features indicative of
hysteria in the patient. However, I have made an exception
in the first case, which I have described at length because of
CASES OP HYSTERICAL MUTISM. 413
the interesting details in the history of the patient and the
thorough investigation made by our confreres at Geneva and
Lyons.
Case I (communicated by M. Charcot)— Ch — , 37 years of age,
was admitted on November 8th, 1885, into the Bouvierward, under
the care of M. Charcot.
Family history, — Paternal grandfather died of an affection of the
oesophagus. The brothers and sisters of the grandfather enjoyed
good health ; one of them died at seventy-eight. One of his nephews
was bad-tempered, somewhat hypochondriac, and finally committed
suicide. The paternal grandmother was very nervous, died at
seventy-two of a catarrh (?). In her family there was a lunatic who
died in an asylum. The maternal grandmother had an inebriate
son who was not considered responsible. The father of the patient
had epileptic fits and died of laryngeal tuberculosis at the age of
fifty-seven. The patient's mother, who was very passionate, died of
phthisis. She had eight children of whom Ch — was the eldest.
Of his seven brothers and sisters, one brother died of croup at
three years of age ; two sisters died of phthisis at twenty-four and
twenty-six years. One of them was subject to nervous attacks, and
attacks of cataleptic sleep ; "on waking she was aphonic ; she
articulated quite clearly, but very low, so low that it required ex-
treme attention to understand her." Four sisters are living ; two
are delicate but without any definite complaint. One of the latter
has a rachitic and choreic son.
Ch — was always ailing in childhood. When twelve he was con-
fined to bed for five or six months with weakness. The doctor
treated him for anaemia. " The least sound," he says, " caused me
to faint ; they were unable to converse beside my bed." On two
occasions when he was at school he had haemoptysis. He was nick-
named the philosopher on account of his taciturn character. On
leaving school he went to a college as assistant tutor ; and subse-
quently went for some time into a large private horticultural
establishment.
After some family disagreements and disappointments in love, he
quitted Switzerland his native country and joined the Foreign Army
Corps. During his sojourn in Algeria he drank absinthe to excess,
and contracted intermittent fever. When the war of 1870 broke
out his regiment came to France. At Vierzon he remained eight
days in a delirious condition, caused, so he says, by an attack of
fever. He rejoined his regiment and in the Eastern Campaign he
received a bullet- wound in the left elbow (January 17th, 187 1) for
This hook is tfiep^^
OOOPIR ¥Eai^K\A ^^uu^^--^
414 CASES OP
which his arm was amputated by Dr. Molliere, of Lyons. He then
returned to Switzerland and was appointed manager of a post-office.
It was at this time (end of 187 1) that the first important nervous
manifestation made its appearance. While at supper with some
friends he was seized, towards the end of the repast, with invincible
sleep, and slept with his elbow on the table. His comrades were
quite unable to awaken him. Towards the morning a nervous
attack came on attended with terrible delirium. The doctor sus-
pected an acute meningitis ; and Dr. Mayor, called into consultation,
confirmed this diagnosis. The second day afterwards, the patient
recovered, but relapsed a few days later. Leeches were applied,
but a nervous attack, still more terrible than the first, came on.
However, the fever and the delirium disappeared at the end of
two days.
Up to the year 1875 i^othing abnormal occurred in Ch — 's condi-
tion. In this year he departed for Algeria, where he had obtained
a post of clerk in the Prefecture of Oran. Shortly before his de-
parture he experienced for the first time sudden and violent attacks
of palpitation which would sometimes oblige him to sit down.
Then strange symptoms occurred. " I was unable for whole days
to bear any clothes on my body. My skin seemed on fire and I had
<;ontractions of all my limbs. When I attempted to put on my
clothes it seemed as though I had millions of pins pricking me."
During his journey to Lyons on his way to Algeria he was seized
with feelings of suffocation, and on going into a chemist's shop he
was taken with a nervous fit similar to the preceding, but which
only lasted about two hours. In December, 1877, he had a slight
attack of smallpox.
" In the spring of 1878, while on circuit with my chief, I was
found one morning senseless in my bed. Bleeding and doses of
calomel restored me, but my larynx was almost completely paralysed.
I continued for seventy -two days to articulate my words with diffi-
culty, though I could make myself understood:" The patient
allowed himself to indulge in both venereal and alcoholic excesses.
To escape the frequent attacks of ague he went to the province
of Algiers, and after staying there three years he returned to
Gj-eneva.
In 1 880 he traversed Europe on foot, staying for some time with
his brother-in-law in Prussia. There he was taken a second time
with cataleptic sleep, which disappeared under the infliuence of
bleeding. On waking he had paralysis (with insensibility) of the
left leg and he had also complete mutism. Not a single word could
he speak. " But my intelligence was unaffected, my memory, alone.
HYSTERICAL MUTISM. 415
was a little at fault, for recent events." After this he left Prussia
and returned to G-eneva.
We take the details of his story in Geneva from the case as pub-
lished by Dr. Revilliod. On admission into the hospital, February
nth, 1 88 1, the only pathological phenomena he presented were
absolute mutism and slight numbness of the left side.
On laryngoscopic examination, which was rendered very easy
by reason of the anaesthesia of the pharynx, the following condition
was made out (Dr. Wyss). Abduction and adduction of the vocal
cords are normally performed when the patient pronounces e, i.
The only act which is faulty is the tension of the cords. Although
they approach, they remain festooned and slack, flapping more or
less according to the force of the inspiratory or expiratory current
of air. If under these conditions the patient is requested to in-
crease the effort necessary to produce a sound, the vocal cords,
instead of becoming stretched as they approach, close suddenly, as
though by a spring, and then stick together as it were all along,
so that not only is no sound produced but the impjeded respiration
requires a great inspiratory effort, like the sigh, to restore matters
to their former condition.
The patient. passes his days reading, and in writing veritable
m^moires describing his different impressions. On February 15th,
he wrote that he had pronounced the words " No, do you want any,"
and then that he was unable to continue, the throat being con-
tracted, and as though it were obstructed by an obstacle. His re-
spiration was also more impeded than before.
After several applications of f aradism of the crico-thyroid muscles
and along the course of the superior laryngeal nerve, he was able
to emit a few sounds, then some vowels, though without precision,
and intonation only occurred at the end of expiration. The same
thing happened when he was made to bend his head forcibly, or
when the inferior border of the cricoid was raised. But these exer-
cises fatigued him very much, although he performed them willingly
enough, being convinced that they promoted his cure.
On March 30th he pronounced the vowels easily enough, conso-
nants with more difficulty. On April 30th he could speak and read
in a loud voice, though not without fatigue. After ten minutes'
reading he was out of breath and was obliged to stop to recover
himself. He avoided speaking spontaneously.
It was discovered by the laryngoscope that the vocal cords were
well stretched, but they did not close completely in the middle when
the patient pronounced the different vowels, thus allowing a large
quantity of air to escape unused.
416 CASES OP
On June iStli, 1881, Ch — quitted the hospital, speaking spon-
taneously and fluently without difficulty. He only experienced
dryness of the throat after a long conversation.
The treatment consisted of faradization, and from May 6, subcu-
taneous injections of a milligramme of sulphate of strychnine : plates
of copper round his throat.
After leaving Geneva, Ch — found employment at Lyons. On Sep-
tember J ith, 1882, he was found unconscious in his bed. Bleeding
restored him, but on waking he was again mute, and paralysed on
the left side. He was taken into the wards of Dr. Baymond
Tripier at the Hotel Dieu, where he remained for eight months
and underwent constant treatment by tepid baths, electricity, tonics
and bromides. The patient states that on laryngoscopic examina-
tion the vocal cords were found in the same condition as that dis-
covered by M. Revilliod.
On leaving the hospital he resumed his irregular life, and again
had stifling sensations and vomiting (of bile and of blood !). His
sleep was disturbed by visions and nightmares.
In January, 1883, he went to Valentia to recover some debts-
and the next day he was found asleep at his hotel. He was taken
to the hospital, where on waking he was again found to be mute
and paralysed on the left side.
Then he returned to Geneva and entered the wards of Dr.
Eevilliod, enjoying the full integrity of his intellect and all his
functions, but absolutely mute. The laryngoscope afforded the
same indications as on the first occasion. On June 4th, a fresh
attack of cataleptic sleep. Speech returned a few day later, and
he left on July 2 ist.
The patient is unwilling to enter into the details of events which
occurred in 1884 and 1885. As far as can be learned he had in
1884 five nervous attacks in a month and a half resembling the
first (in 1869) though incomplete. In one he was bled. Twice he
attempted suicide. The last attack of mutism and paralysis lasted
four months, during a journey to Havre. He entered the Salp^-
tri^re on November 8th, 1885.
On admission, he still dragged the left leg a little, and the mutism
was complete. He had nightmares, and hallucinations during his
delirious attacks, sometimes terrible sometimes agreeable, and the
latter were accompanied by involuntary emissions. In the course
of last year, touching his forehead produced the sensation of an
aura which at the present time can be produced by pressure in the
left iliac fossa, circumferential zone above the knee, and on the
scalp of the same side. Exploration of the sensibility reveals on
OASES OF HYSTERICAL MUTISM. 417
the left side apart from tlie three hysterogenic zones, an analgesia
oyer the left half of head, trunk and thigh ; pricking is perceived as a
touch. In the leg ansesthesia is complete ; iu the foot, simple anal-
gesia. On the right side sensibility is intact excepting the hand,
where there is analgesia on the palmar face. The left arm was
amputated in 1 8 7 1 .
Hearing is a little diminished on the left ; there is no retraction
of theyisuaX field, nor achromatopsia. There is almost no sense
of smell in the left nostril. He has noticed for several years that
when he has a coryza there is dryness of the left nostril^ whereas
the other has an habitual running.
There was complete absence of reflex in the soft palate, of the
pharypx and larynx ; ansesthesia is absolute.. It was even possible
to touch the vocal cords with a laryngeal sotmd without producing
reflex action. On examining the larynx the vocal cords were widely
spread apart in a position of deep inspiration. If the patient was
told to make the sounds^ i, e, the vocal cords were seen to rapidly ap-
proach, but leaving between them an ellipsoid space due to the
faulty action of the thyro-arytenoids, tensor and adductor, muscles.
But no sound of any sort is produced. When he was told to pro-
nounce certain consonants, the patient was able by his lips to pro-
duce a slight noise, purely labial. In producing a forced expiration,
a sort of noise is similarly produced, but it does not correspcmd to
any vowel sound.
Ch — has had four attacks of hemiplegia accompanied by aphasia,
always with preservation of intelligence. When the patient is
questioned he does not attempt to make movements of his lips to
express what he wants. He seizes pen and paper with alacrity, and
replies in a high-flown style, often humorous, which denotes an in-
telligence far above the average. When requested to produce the
movements of the Hps necessary for the pronunciation 6i words,
or consonants, he attempts the movements, but neither word nor
consonant. is pronounced. The same thing happens with whistling :
he screws up and protrudes his lips, but no sound issues.
The movements of the tongue were quite free and there was no
trouble of deglutition. The patient is also very positive on this point,
that there has never been any deviation of the mouth or tongue
after any of the attacks. On waking it only seemed to him as
though he had something in his throat which prevented him from
speaking.
Ch — left the hospital at the end of November, still mute. A
few days, afterwards speech suddenly returned to him without
known cause, though for several days he stammered. After
27
418 APPENDIX.
former attacks speecli bad not suddenly returned to bim : be bad
commenced by stammering, repeating twice tbe same syllable, if
tbe word was at all long or complex. He said tbat it seemed as
tbougb air was wanting to finisbthe ends of words.
From tbe daily papers we bave learned tbat Cb — was found a
iew days afterwards in a cataleptic sleep at bis botel.
Case n (communicated by M. Charcot) . M. S — , Felix, of Madrid,
•^6 years of age. Hereditary antecedents unknown. Has had a
'delicate childhood, and frequently subject to chest pains and epis-
'taxes, one of the latter being so severe as to require plugging of the
nares. In bis youth he suffered from stomach-aches and indefin-
rable ailments of a neuropathic order. Tbe patient has constantly
"been in difficulties, and bis uncle is a great worry to him on account
^f his constant remonstrances.
In 1880, according to the statement of his Spanish doctor, the
patient had syphilis, though he denies it himself absolutely. How-
'ever, he underwent specific treatment, and it was after a thermal
course at one of the sulphur bath places that he bad bis first con-
Tulsive fit. Since that time (three years ago) be has had frequent
•** attacks " with loss of consciousness, of which be usually receives
no warning. These fits were regarded as epileptic fits having a syphili-
tic origin. A very energetic specific treatment was instituted, but
the crises only became longer, more violent, and more frequent.
Lately these attacks have been followed by loss of sx)eecn, the
-aphasia lasting a few days and then the normal condition returns.
It was under these circumstances that M. S — presented himself
at M. Charcot's out-patients'. He had been dumb since the last
attack. These attacks were rather sudden, but he has never bitten
his tongue nor passed urine involuntarily. The patient bad a bright,
intelligent look. The tongue was easily moved in all directions ;
no deviation of face. He could perform the movements for whist-
ling and blowing ; deglutition was not impeded in any way ; but he
was unable to pronounce a word, a cry, or even a sound. When
spoken to, he comprehended perfectly, immediately took a pen and
wrote very good answers in French, although he is Spanish,
^thout the least embarrassment. This characteristic circum-
stance was suspicious of hysteria. M. Charcot made the patient
undress and discovered a right hemianalgesia. There was a cer-
tain degree of bypersesthesia in the dorso-lumbar region, but
no true hysterogenic points, neither in tbe testicles, groins, nor
iliac fosssB ; no pharyngeal reflex. Laryngoscopic examination was
not made. Examination of the eyes by M. Parinaud, revealed a
OASES OF HYSTEBIOAL MUTISM. 419
very pronounced retraction of the visual field with spasm of the
accommodation .
The right upper extremity was affected with chorea, like post-
hemiplegic chorea.
The patient was treated with tonics, bromides, and hydrotherapy,
and speech returned a few days later, though he still stuttered
a little.
A month later, November loth, the right hemianalgesia still ex-
isted, and also hemichorea of the right upper and lower extremi-
ties. The chorea of the lower limb was specially marked when the
patient was sitting down.
Here are some specimens of the patient's replies when he departed
a few days later. " I have - - - 1 have just done." " Yes, yes, I
speak a little better." " Wh - - - what ?" Given a journal to read :
^* All all the preparations are - - -, are made for - - -, for the
conference - — , it is reported on good auth - - - authority," Ac.
The same results occurred when given a Spanish journal to read.
In a few weeks' time all symptoms had completely disappeared.
Case m (communicated by M. Charcot). Bill — , Antoinette,
2 T years old, was admitted into the Salp^tri^re under the care of
Professor Charcot. She comes of a family of musicians ; her mother
died of hemiplegia at forty-nine. The patient has had typhoid
fever. At the age of nineteen, after a fright (brokers came to
levy a distraint) she was attacked with chorea which lasted six
months, then by dumbness which lasted for eight days and was
followed by stammering. The mutism reappeared at intervals
after attacks which were accompanied by stifling sensations, con-
strictions of the throat, sensation of a ball, pains in the legs, which the
patient likened to cramps, with swelling. Then hiccup came on with
respiratory spasms, but she has not had attacks of hysteria major.
She had never had stammering or dumbness before the fright.
Left ansesthesia. No laryngoscopic examinations.
Case IV. Larch — , Syndonie, 19 years old, was admitted into the
Salp6triere under Professor Charcot on April i ith, 1885.
' No personal or hereditary antecedents of importance, though
the patient had often complained of pains in the right ovarian
region.
: On April 9th, at 10.30 p.m., she experienced a great fright
•(entered a room where a young girl had died). That night she was
disturbed by nightmares. Next morning at 6 o'clock she let the
slop-pail, which she was carrying downstoirs, suddenly fail out of
her right hand : paresis of the right upper extremity. ' She went
420 APPENDIX.
upstairs and went to bed. At lo o'clock the doctor who was called
in discovered that she had completely lost the power of speech ^
she coTild neither read nor write.
On admission into the hospital the mutism was complete, though
the patient could understand what was said to her ; at least, she
replied by signs to simple questions. The labial commissure waa
slightly raised during repose; more marked when she laughed.
Tongue slightly deviated to right, but she could blow. Sensation
deficient on right side. Taste and smell intact. Audition less on
right than on left side : ticking of a watch heard at 9 eentimetiies
on right, 34 on left. Retraction of right vimial field ; no dyschrom*
atopsia.
Beflex of soft palate not good, fairly marked pharyngeal ansBS-
thesia. On laxyngoscopic examination the mucous membrane of
the larynx was found heaJthy ; vocal cords in complete state of
abduction. If the patient was told to cry out or make the sound 4,
the vocal cords closed incompletely, leaving an open ellipsoid space
(deficient tension of the thyro-arytenoid). No sound was emitted ;
the patient could not even speak in a low voice. Hutism was
absolute. There was then no trace of paresis of right arm.
On April 24th, without any treatment, the retraction of the visual
field had disappeared ; sense of hearing improved ; tension of the
vocal cords was more complete ; patient could say, " And then - - -^
no.''
May 6th, the patient could pronounce a few words. There wa»
then no deviation of the mouth.
This case was the subject of some discussion^ and at the
time of admission Professor Charcot was not inclined to admit
that the case was one of hysteria^ because of the deviation
of the tongue and mouth. The case is therefore published
with reserve, although it seems to us to come within the
category of hysterical manifestation.
The patient left the hospital a few months later, not cthred.
Case V. Gtuk — came into the Salpfitriere under the care of
Professor Charcot.
A man 30 years of age. His first nervous attack occurred in
September, 1882. Since January, i88j, the attacks had always
been followed by transitory aphasia. These attacks, which were
very violent, were classic (aura, loss of consciousness^ tonic and
clonic periods, &c.). When the patient regains consciousness he
IB unable to speak ; he makes a sort of clucMng noise to emphasise
CASES OF HY8TEEICAL MUTISM. 421
the gestures by which he espreases what ho thinka or writes. He
thoroughly uuderstands what is asked him, ajid writes his auBwers
correctly. This condition lasts for a longer or shorter time, which
seems to hear relation to the sererity of the attack ; the duration
averages four to five minutes.
This condition is accompanied l)y subjective phenomena, con-
striction of throat, &c., and in proportion as these disappear the
patient recovers his speech.
During the state of mutism the reflex sensibibty of the pahite is
preserved, and otherwise his condition is normal.
Sometimes the mutism has lasted for a longer time, several hours,
several days. He had a very violent fit on February a4th, 1885,
with spasms and attacks of suffocation, after which the aphasia
lasted for six days. On several occasions the mutism has been
dispersed by a fresh attack. At other times speech has returned
spontaneously j he feels as though " something had given way in
the throat."
Case VI, Lip — , a sculptor, set, 20, came into the SalpStrifiro
under Professor Charcot. On Juno i6th, while in a restaurant, he
was seized with aphasia, and at the same time with deafness, hearing
nothing that was said to him. This deaf-mutism came on after read-
ing a letter in which his father reproached him for his conduct and
refused him money. On his arrival at the hospital he could not hear
when spoken to quietly, but could understand when the question was
shouted into his oar. He would reply very clearly by writing either
in French or Polish to questions addressed to him by writing or
shouting in his ear. No paralysis or troubles of sensibility.
Movements of tongue and lips good ; intelligence intact.
The mutism was not as complete as on the day when he lost his
speech ; he could pronounce a and e. The following days he seemed
to be affected with motor amnesia. Varsovia, written__down before
him in French or in Sclave, was not pronounced satisfactorily : he
said Vavie and Vava instead of Varchava, although he showed by
■writing that be clearly understood the word Varsovia. He rephed
in writing without the least hesitation.
These phenomena lasted for about a fortnight, then the speech
returned and the deafness began to improve.
I can only give a brief summary of the next case, of hyste-
rical aphasia in a child of eleven. The history is given at
length in the thesis of Dr. Peugniez, a pupil of Dr. Charcot
(t On Hysteria in Children,' Paris Thesis, 1885}.
422 APPENDIX.
Case VII. Marie D— , ii years old, was admitted into Prof essor
Charcot's wards April 2ist9 (885.
Her father had frequently had convulsions ; the brother of her
grandfather was hemiplegic; mother healthy; maternal cousin
in an asylum. Brother had had convulsions.
The hysterical phenomena dated from the year 1884. In the
early part of February, 1885, convulsive fits; contracture, Ac. The
voice got gradually weaker &om this time, and the patient became
aphasic. For three months she had only been able to pronounce
a few words : Ah, mamma, I, pa - - - -.
Affections of taste, smell; retraction of visual field; achrom-
atopsia. The patient replied to all questions, '^ Ah, Oh." On May
1 1 th, after a severe fright, she cried out, ** Wicked woman, I am
afraid," and from this moment the speech returned.
Case VJH (published by Dr. Thermes in the 'France Med.^
1879, p. 290.'). Mdlle. X — ,8Bt. 21. On February 15th, 18 76, after
exposure to damp cold — at least, according to the patient's account —
she was taken with a fit of coughing, and soon after the voice became
modified both in quality and intensity. Laryngoscopic examination
(by Isambert) did not reveal any organic lesion, nor inflammatory
condition, and the diagnosis was '' paralysis of the vocal cords from
defective innervation of the muscles of the larynx, and particularly
of the crico-thyroids." Consequently the induced current was ad-
vised, and applied by Isambert himself. But instead of the usual'
amelioration, as expected, the aphonia rapidly degenerated into a
mutism. Many varied medicaments were employed, but without
effect.
During treatment at the thermo-resinous baths we had the
opportunity of examining Mdlle. X — , and certain objective and
subjective symptoms caused us to suspect the case to be one of
mutism grafted on to hysteria of a non-convulsive form ; or rather,
a case of hysteria, the manifestation of which had invaded the
laryngeal region, and particularly the tensor muscles of the vocal
cords ; a paralysis of the laryngeal portion of the pneumogastric^
or paralysis of the motor filaments of the superior laryngeal.
The laryngoscopic examination then made (February, 1877) by
Krishaber revealed that the left vocal cord was immobile, that the
free borders occupied the median line and divided the glottic space
like the perpendicular in an isosceles triangle. The corresponding
arytenoid did not perform movements of rotation on its axis. The
left vocal cord seemed shorter than the other, because of its laxity
CASES OF HYSTEEIOAL MUTISM. 422
and because it was hidden bj the arytenoid. The pharjnx was
slightly hypersemic.
Prescription, hydrotherapy. At the first application, cry of sur-
prise ; the mutism was changed into incomplete aphonia. After a
dozen local and general douches, the aphonia gradually disappeafred,
and a fortnight after the first douche the voice resumed its normal,
character and intensity.
Under the influence of a fall a convulsive attack occurred, on
coming out of which the voice was again lost and the mutism again,
became complete. This happened in 1S77.
The family applied to a quack doctor. At this time (February,,
1878) the mutism was still complete. Hydrotherapy, as on the first
occasion, produced the same result. Mdlle X— cried out and in-
stantly regained her voice, but only for a moment. However, in-
complete aphonia succeeded the mutism. She was able to whisper^
the words being weak and low, but she could be well understood.
Amelioration progressed to cure, and the patient at the time the
case was published had not relapsed for ten months.
Case IX (Lionville et Debove, 'Progr^s MMical,* Februarjr
26th, 1876). A girl of 18, hysterical but generally of good health..
Her mother had attacks of hysteria major. A sister, thirteen years^
old, had frequent attacks, and for two months she had been affected
with trembling, which several doctors had qualified as hysterical
chorea. Father very nervous.
Until the last few years the hysteria had only been manifested
by incomplete attacks. For eighteen months the patient had beea
painfully impressed by the quarrels and violent scenes between her
father and mother ; and it was to this cause that the patient, pro-
bably with reason, attributed her symptoms. About this time, in
fact, she became aphonic, not being able to speak above a whisper,,
and in the course of two months the aphonia grew into mutism.
In the house where she lived they named her "the mute." She
communicated with those around her by means of a slate, which she-
habitually carried. The patient came several times into hospital.
All those who examined her were agreed in the diagnosis of hysteria
cal paralysis of the vocal cords. Different methods of treatment
were adopted without success.
November loth, 1875, she was brought to the H6tel Dieu. She
had no globus hystericus, no hemiansesthesia, no affection of the
organs of special sense. Ovaries, especially the left, were tender on
pressure ; but, briefly, apart from the laryngeal troubles and the
ovarian pain, the patient presented nothing abnormal.
424 APPENDIX.
The laryngeal pamlTBis is not simply a paralysis of moyeme&t,
it is also a paralysis of sensation. Not the least pharj^geal reflex.
Laryngpscopi^ exanunation, by Dr. Monra, revealed a paralysis of
the vocal cords; thei9e made an almost imperceptible movefment
when the patient' tried to «ttut a sound.
Pressuro over the ovary brought on attacks of dry <x>ugh, and a
few stifled cries. The patient was able to articulate these words^ in
an aknost imperceptible voice: "You htirt me." The following
days, the compression was continued (five to ten minutes each time),
and intonation became more and more distinct ; she first ceased to
be aphonic, then mute ; she became able to speak, though in a low
voice, hisdng out her words.
Case X (Debove, * Soc. MW. des H6p.,' November loth, 1882).
X — had been attacked on. different occasions with delirium; irregu-
lar contortions of the face, &c. At certain times X-r ceased to
be convulsed, but was unable to speak ; he corresponded with th^se
around him by means of writing, and thus replied to question^
The fit came to an end, and sleep was induced by stroi^ doses of
chloral and morphine.
Case XI (Sevestre, * Soc. MM. des H6p.,' i88ii). Halz— , set. 22,
was admitted on April 14th into the wards. of M. Sevestre for
paralysis of the right arm which had come on suddenly the night
before. He had previously had, in 1870 and 1874, two sudden
attacks of unconsciousness; in 1877 transitory affections of vision,
fugitive amauroses, which reappeared in 1880. Two years before,
after one of these attacks of blindness, he had become aphasic
for eight days ; the speech returning, then the sight disappeal'ed,
and so on for several tunes.
On the 12th of April he had an attack of aphasia, which remained
till the next day when he suddenly recovered speech, but then
perceived that his left arm was powerless. Oh the 14th this paralysis
was found to be accompanied with incomplete left hemiansesthesia.
The following day the paralysis disappeared. No dyschroqiatopsia.
From the 14th to i8th of April, the patient continued to present
this alternation of transitory phenomena.
Case XIT (Sevestre, iWc?.). Q — , L6on, set. 25, was subjecit to
fits which could be arrested by pressure on the testicle. ^ After one
of these attacks, the patient was affected with a contracture occupy-
ing all the right side of the body ; at l^e dame time he was' quite
unable to speak, though, his intelligence was perfect. After^seTeitd
days the speech gradually returned ^nd the contract^e disappeaf^.
OASES OP HYSTBBIOAL MUTISM. 425
Oasb Xni (Sevestre, ibid,).- In one of tho hospital attendants
who consulted. M. Sevestre for abdominal pains, a right hemianesi^**
thesia -was discovered; skin, conjunctiva, naisal mucous membrane
were all insensitive. The patient stated that, about three months
after the onset of this hemiansesthesia^ one morning on getting up
he had fallen to the ground, without loss of consciousness, but had
been unable to speak for f ortj-eight hours.
Case XIV (Wilks, 'Diseases of the Nervous System,' 1883,
p. 463). A girl set. 22, who had kept her bed for more than a
year on account rof an alEection of i^e spinal cord; Six months
before taking to bed speech had failed her from time to time,
and for a year she had been unable to pronounce a' single
word. She had rieplied by movements of the head and writing oh
a slate. Wilks, when consulted about the case believed it to be
one of hysteria, and promised recovery if the patient would come
into the hospital. After at first refusing, she yielded, and' Wilks,
addressing her with severity, threatened to make her impostui^
public. They took away her slate ; she then attempted to move
her lips as though she were talking. After several efforts, and the
application of electricity, they were able at the end of a week to
make her say " yes " and " no " in a low voice. The voice returned
shortly afterwards, and the paralysis of the limbs also completely
disappeared.
Case XV (Wilks, tbid. p. 465). A woman of 28, who had kept
her bed for four and a half years. She had had nausea, and
pains in the legs, and one day on getting out of bed she had lost
the use of her legs. During the four years the symptoms had
often varied. Paralysis of the hands fifteen months before. For ten
months she had been unable to speak ; the loss of voice had been
sudden; she communicated with those around her by means of
a slate. All treatment had been without success. She came
into Dr. Wilks' wards on April 7th, 1886. As in the preceding
case, she was cured by moral persuasion and electricity. During
the application of the f aradic current on the 24th, she cried out,
" Oh, dear ! yes." She was then able to speaJi slowly, and the
recovery of speech was finally complete. Thei paralysis of the legs
disappeared more slowly.
Case XVI (Case H. in the p3.per by Eevilloid, ' Revue de la
Suisse Bomande,' 1883). A man, aged 48, admitted into the
State hospital as a deaf mute with paraly&is of the left side.
426 APPENDIX.
He could neither read nor write. Complete paralysis of movement
and sensation on the left side, excepting in the face, which although
insensitive was not deviated. The right arm was alEected with almost
continuous rhythmical choreiform movements. The leg was quiet. If
any part of the right side of the body was tickled the right limb re-
sponded with a very pronounced epileptoid clonic trembling. Slight
percussion of the patella tendon produced the same result. Vision
almost lost on the left side> normal on the right. Complete deaf-
ness on both sides. Absolute mutism.
After tonic treatment and electrisation for a fortnight it was ob-
served that the spontaneous tremor of the right arm was diminished.
Voluntary movement on that side had slightly returned. One fine
day, after an application of electricity, the patient shouted with
joy, and laughed violently. Little by little the hearing returned.
It was evident that when they shouted in his ear he heard, and
then he was able to whisper a few words in a low voice. At the
same time the movements and sensibility returned in the left side.
In short, after a month's stay in the hospital, the patient was able
to talk in a low voice, distinctly enough to give information.
After having had some epileptiform fits, he had been hemipl^c
since 1869, and had been deaf and dumb since 1878.
Case XVII (Eevilliod, Case III in the same paper). A woman
of 47, who without being actually hysterical, had suffered almost
continually from manifestations of this neurosis, intractable vomit-
ing, cough, and finally mutism with sternal and spinal pains.
The mutism had returned on four occasions, each time lasting not
less than two months, and sometimes for six months, at which times,
the patient could not open the mouth or put out the tongue.
Neither the loss nor the recovery of voice took place suddenly.
Case XVin (H. A. Johnson, Chicago, * New York Med. Joum.,*^
Nov. 14th, 1885, Paralysis of the Larynx), H. B — , an unmarried
girl set. 24. No change in the structure or form of the larynx.
Vocal cords in a cadaveric position. General health good, menstrua-
tion normal. Iron and strychnine were prescribed for her, and to
live as much as possible in the open air. Faradic and interrupted
galvanic currents were applied. None of these measures produced
any improvement in the condition of the organ. After several
months she departed for the East, and thence to Europe, where she
consulted a large numbesof laryngologists, who prescribed the same
treatment with strychnine, electricity, and tonics. After havings-
OASBS OF HYSTERICAL MUTISM. 427
visited California and tlie Southern States, the patient again re-
turned to Europe, and passed the winter in Egypt. On her return
she placed herself under the care of Dr. Hughlings Jackson, of
London, who had the good fortune to hear her speak after five years-
silence. For three years she had been unable to speak even in a low
voice, or to whisper. The vocal cords had remained in the condition
described until her return from England. At this time she spoke at
times in a loud voice, though only sometimes. On examination it
was then found that during efforts at phonation, the vocal apophyses •
approached each other, but that there still remained a triangular-
opening behind ; in other words, that there was paralysis of the ary-
tenoid muscles, leaving a space through which the air escaped,,
rendering phonation difficult, and producing complete aphonia at
times. From this time, that is for several years now, there had been
periods of a few days, and occasionally of a week or more, when the-
patient could not speak except in a whisper. She was and had
always been in good health, though she was of a lymphatic temper-
ament, and easily tired. The larynx had been frequently examined
in recent years Without finding any modification in the state of the
organ.
There could be no reasonable doubt but that the case was one of
hysterical aphonia, which resisted all treatment until her visit to -
Dr. Hughlings Jackson.
Dr. Jackson's treatment had not differed much from those already
tried. No trace was found of derangement of the uterine or other
organs.
Case XIX (communicated by Dr. ChaufEard). L — , Leonie, a
servant, set. 28, entered the Hopital. de la Pitie on March 27th,
1885. Mother very nervous, father hypochondriac. Two years'
previously the patient had had severe disappointments, then a mis-
carriage. It was about this time that the voice began to change
its character.
On admission there was complete aphonia; the patient could
scarcely whisper. No pain on pressure over the larynx, pronounced
laryngeal aneesthesia. Signs of commencing phthisis. Patient was
very nervous, cried without motive, and got into violent passions.
Hysterogenic points below and external to the left nipple, and in
the corresponding ovarian region. Complete hemiansesthesia on
the right side.
Laryngoscopic examination revealed no lesion, neither paralysia
nor contracture. Application of the mirror was easy ; vocal cords,
pale, perfectly mobile.
428 FBATUBBS OP HYSTBEICAL MUTISM.
Shortly after admission, absolute mutism came on. On the
third day eleetricitj was applied ; after the second application^ the
patient shouted out loudly, and on the following days the voice and
speech returned; a certain effort was necessaiy; articulation -did
not become clear till the end of several days.
Casis XX (Demme, 'Wiener med« Blatter/ December i81^,
1884). The author was performing the operation of dividing the
tendo Achillis for club-foot on a little girl of six without an an»s-
thetic. Before the operation the child had been merry, playing
with her doll, chatting with her father and mother. At the moment
of section of the tendon she uttered a piercing cry, and from that
moment could not speak a word. That lasted eight day 9, during
whicl^, having regained her spirits, she replied by ^signs when
spoken tp. On the morning of the ninth day ^he said " Mamma,"
and repeated it thirty or forty times. By tiie fourteenth day her
vocabulary was enriched by the words ''Papa, b^, schla^sen,
tinikep." Sj the eighteenth day she could say others, and then
her normal state returned.
A perusal of the cases here reported at some lengthy shows
that within a little the cases of hysterical mutism are identi-
cal, and present the following principal characters : sudden
onset ; impossibility of speaking or crying out ; perfect pre-
servation of the intelligence ; return of speech, accompanied
by stuttering which lasts a certain time.
1. The onset is in general sudden ; after a fright, or some
emotion the patient is deprived of speech. We say, gener-
a>lly, because in certain cases (see YIII, XYII, XIX) aphonia
has existed a certain time prior to the loss of speech. In
one of M. Bevilliod's cases, he says that phonation diminished
little by little before it was abolished.
It often happens that on return to consciousness after an
hysterical seizure absolute' mutism is discovered, with or
vnthout other paralysis. At other times, the loss of speech
comes on suddenly without appreciable cause.'
2. It is impossible for the patient to cry out or jBmit a
single sound. He is aphonic; but he is also apbasip, fpr
he cannot articulate words in a low voice. . . . / .
PBATUBBS OF HTSTBBICAL APHOHIA. 429
■ Perliapa I may be allowed to say a few words on the sub-
ject of the distinction between aphonia and aphasia.
Hysterical paralyses of the larynx are very frequent ; cer-
tain authors consider them as the most frequent symptom in
the category of hysteria. It is some of these cases which fur-
nish a means of easy and always surprising success to the
doctor, of instantaneous cure of the patient, occasionally by
the simple application of the mirror. The features are quite
characteristic : sudden onset in neurotic subjects, most fre-
quently bilateral, and involving the tensor and adductor
muscles, much more rarely the abductors. According to the
muscles attacked, and the degree of the paralysis, the aphonia,
is more or leas complete. There is extinction or hoarseness
of voice, impossibility of speaking in a loud voice, though
whispering remains. The patient can make himself under-
stood by speaking in a low voice. It is phonation which is
wanting ; there is no aphasia nor disturbance of intellect.
It is a fact now well established by numerous observations
in the physiology of phonation that the larynx takes no part,
nor do the vocal cords vibrate, in whispering or speaking
in a low voice. The air glides through the laryux in the
same manner as it does through the trachea or bronchial
tubes, without the intrinsic muscles imparting any movement
to the vocal cords. Eosapelly {' Travaux du labor, de Marey,*
1876),^ Boudet de Paris {'Acad, des Sciences,' [^^79), and
other physiologists have shown experimentally by means of
a simultaneous registration of the vibrations of the larynx
and the movements of the lips and tongue, that the first-
named organ is not brought into play in the production of
consonants or even vowels, in the whispering voice.
I should be less concerned to discuss this point if Prof.
Revilliod had not sought to explain by a simple paralysis of
one of the muscles of the larynx the troubles observed in the
patient who forms the subject of Case I. Ch — passed several
months in the wards of the distinguished Professor at Geneva,
for the same symptoms which brought him to the Satp&triere.
The laryngoscope revealed a faulty tension of tho vocal cords.
There existed also a certain degree of auEeathesiaof the isthmus
of the glottis and of the ventricle, troubles dependent on a
■ ride 'ProgriB Medical," Hci. 7 et 9, 1886.
430 THE MUTISM IS NOT DUB TO LARYNGEAL PAEALYSIS.
|)ara1ysis of the superior laryngeal. The patient was abso-
lutely mate on admission.
The way in which Dr. Revilliod interprets tHese phenomena
is as follows : '^ The anaesthesia in the distribution of the
superior laryngeal of itself tends to show that this sort of
•mutism is due to a paralysis of this nerve^ albeit one often
observes mutism without anaesthesia, and anaesthesia without
mutism However, this symptomatic triad (crico-
thyroid paralysis, anaesthesia of the isthmus of the larynx,
sternal pain during vocal effort) courts the supposition that
the superior laryngeal may be alone attacked by hysteria, and
that this nerve enjoys the unfortunate privilege of being easily
affected by this malady ; so that when, in a case of mutism,
the laryngoscope reveals an absence of tension of the vocal
cords, coincident with the integrity of their movements of
abduction and adduction, — ^that is, when paralysis of the supe-
rior laryngeal is combined with a normal state of the recur-
rent — we should be authorised in admitting the hysterical
nature of the affection.'*
I am unable to agree with these conclasions. That crico-
thyroid paralysis, coincident with integrity of the functions
of the adductors and abductors, indicates a hysterical origin
•of the malady is often correct, although there are several
other causes which may give rise to faulty tension. That
this lesion explains a more or less complete degree of aphonia
is also true, but paralysis of the superior laryngeal cannot
explain the mutism; for speech in a low voice subsists when the
larynx alone is attacked, and the loud voice alone is wanting.
In the case quoted by Dr. Bevilliod the mutism was com-
plete, as I myself observed, though when I examined this
patient the laryngeal paralysis was less localised, the crico-
thyroid was attacked, but so also were the thyro-arytenoids.
The mutism was as absolute as before.
Further, in opposition to this interpretation, those cases
may be quoted where a laryngeal paralysis involving other
muscles besides the crico-thyroid exist, together with the
mutism.
In Jarvis's case (XVIII) there was paralysis of the aryte-
noid. In that of Dr. Thermos, Krishaber noted a para-
lysis of one abductor. In certain cases, as in l^is last one.
FBATUEBS OF HYSTERICAL MUTISM. 431
one may see varieties of the laryngeal troubles supervene in the
course of the malady without any modification in the mutism.
There is nothing peculiar about the aphonia in these com-
plex cases. The laryngoscope reveals paralysis of the tensor
and adductor muscles, crico-thyroid, thyro-arytenoid, aryte-
noid ; but the other muscles fulfil their functions ; the vocal
cords open and close as far as the median line when the
patient is instracted to attempt phonation.
There is also a more or less complete anassthesia of the
pharynx or even of the larynx. But this anaesthesia has
nothing special in relation to the aphonia or the mutism.
It is frequently found in hysterical subjects who have no
affection either of phonation or speech.
Thus, in hysterical mutism we find both aphonia and motor
aphasia. This, in fact, is one of the most characteristic
features of the affection. In simple hysterical aphonia, para-
lysis of a group of the laryngeal muscles is a very frequent
occurrence. On the other hand, in mutism it is relatively
rare. And what confirms the central, the psychical nature
of this neurotic manifestation, is that the laryngeal muscles
are not always affected with weakness, and that when they
are more or less involved the functional trouble resulting
from this paresis or paralysis does not afford us an explana-
tion of the phenomena collectively.
3. The intelligence is completely preserved. On being
asked a question, the patient (this is a very characteristic
feature), conscious of his incapacity, does not make a lot of
useless attempts at articulation, but immediately takes a
pen or pencil and gives a very clear and precise reply.
This, I repeat, is a very characteristic feature. On more
than one occasion M. Charcot has recognised the hysterical
nature of the mutism solely from the manner in which the
patients conduct themselves when interrogated. The opinion
of M. Legoux must not, I think, be accepted too rigorously.
He believes that the aphasia is not an element in the dia-
gnosis of hysteria, though he allows that there are undoubted
signs of hysteria which enable us to give this symptom its
true significance. I certainly do not believe that one is able
to dispose in a dogmatic fashion of all the difficulties in the
432 FEATUBBS OP HTSTEBIOAL MUTISM.
diagnosis of nervous affections, or to identify at first sight
every case of hysteriqal origin. But I hold that this collec-
tion of symptoms [syndrdme] by its special and differential
characters, should at once evoke a suspicion of its nature in
the mind of an attentive observer, though one ought not
to omit the further investigation of the patient as to anaas-
thesia, hysterogenic zones, antecedents, &c.
Yet, as a matter of fact, this form of aphasia does not at
all resemble that due to organic causes. In the latter case
the patient makes an effort to pronounce and to repeat the
word he wants, to stammer it out in an unintelligible fashion,
or to reply by some other or some invariable word. There is
nothing of the sort here, no word^blindness, no word-deaf-
ness j intelligence is perfect. Reply foUows question imme-
diately, if the patient knows how to write. At a stage when
speech is returning, when the aphonia is less complete, this
difference is less apparent. Sometimes the patient has diffi-
culty in pronouncing the word because he stutters, though
he can write correctly enough, showing the integrity of his
intelligence and his writing faculty. Now, in certain cases
of aphasia due to an organic lesion this dissociation may be
detected — ^aboUtion of speech, preservation of writing faculty.
But it never exists in such a striking way, and combined
with the vivacity of intelligence which characterises the
hysterical mute.
4. The recovery of speech is rapid in most of the cases^
but it does not arrive ad integrum all in a moment. There
is a stammering or hesitation in the speech during a period
which may vary from a few days to a few weeks. Chauffat
(Case I) remarked this on himself, and the same occurrence
may be noticed in Case II.
It is unnecessary to add that other evidences of hysteria
may be discovered either in the patient or the antecedents.
Frequently there is anaesthesia or hysterogenic zones ; one
patient may have vomiting, another deafness. Such sym-
ptoms help to confirm the dia^osis. When hemiplegia comes
on at the same time as the aphasia it creates some embarrass-
ment in ceirtain cases, but in the hysteric the deviation of
HTSTBBIOAL MUTISM ARTIFICIALLY PBODUOBD. 433
moutli and tongue^ and facial paralysis^ are wanting. • It was
the presence, albeit transitory, of this symptom which alone
cansed us to regard the case of S — (Case IV) as doubtful.
It is easy to reproduce hysterical mutism by means of
hypnotic suggestion. If during the somnambulic period you
converse with the patient, then, lowering the voice, say to her,
" I do not hear.'' " Eh V '' But you cannot speak then V
the patient soon becomes aphasic and aphonic. Being unable
to cry out or to speak, she becomes impatient at not being
able to reply to questions, and if she can write, seizes a piece
of paper and writes hastily, though without embarrassment,
a few lines which convey her thoughts : "1 am unable to
speak. Dear me I You see that I cannot.^' This is exactly
what occurs in the patients we have tried ; but I am only able
to mention, in passing, these researches which ought to form
the object of a special work.
28
INDEX.
A.
AOHSOHATOPSIA, hysterical, 73, 281
AonOK of glutei muscles, 114
Aloohouo tsemos, 186
Amblyopia, hysterical, 72
Amkbsia, verbal, analysis of, 161
AKTOTBOPHIO LATEBAL 8CLEB08I8 (of
Charcot), 165
— PABALYSIS, 24
AuTOTBOPHixs, classification of, 164,
179
AuTOTBOPHY after injury of sciatic
nerve, 113, 117
— hysterical, 352, 394, 406
— in sciatica. 111
Air^STHBSiA, segmental, 298
AirOBBXIA HYSTEBIOA, 211
Aphasia, definition of, 131
— in hysterical mutism, 364, 429
Aphonia, hysterical, 410, 429
cases of, 413, et seq,
Abthbitio amyotbophy, 24^ 47, 61
Athbtosis, 57, 188
ATBOPHIO ABTIOULAB PABALYSIS, 20,
et 96q,
Atbophy, muscular (vide Amyotbo-
phy)
in hysteria, 394, 406
— of muscles after joint disease, cases
of, 20, 45, 52
A2f ATAMO-OLimOAL METHOD, 9
AuTO-snoaBSTiOK, 384
B.
BAin>AaDrG the cause of contracture,
353
Basedow's disease, tremor in, 186
Blephabospasm, 41
Bbaohial MOKOPLEaiA, case of, 341
— PLExrs, cases of injury to, 267,
270, et seq.
Bbodie's sign of hysterical hip disease,
320, 326
Bbomidbs useless in hysteria, 209
BuLBAB PABALYSIS, 361, 371
C.
Canoeb of vertebrsB, anatomy and
clinical history of, 123
Cataleptic state, 290
simulation of, 16, 95
Chlobofobm, effect of, on hysterical
contraction, 346, 359
— in the diagnosis of hysterical hip
disease, 328, 331
Chobea, 187
Chbokio bheumatism, deformities of,
53, et seq,
varieties of, 44
Clinical study, importance of, 7, 19
CoKTBAOTTTBE, arthritic, explanation
of, 49, 56
— artificially produced, 355
-— diathesis, 90, 354
— functional, characters of, 87
— functional and organic, compared,
35, 351
— hysterical, features of, 35, 87, 351
— of articular origin, 48, 53
— of traumatic origin, 34, 38
— produced by application of a splint,
341; different explanations
of, 348
bandaging, 348
— surgical treatment of, 128
— traumatic hysterical, 32, 84^ 817
CoNYiTLBiyE ATTACKS may be absent
in hysteria, 251, 283
CoBTiOAL LESIONS, sensory changes in,
276
CoxALOiA (vide Hip disease)
Cttbb, sudden, of hysterical paralysis,
405
436
INDEX.
D.
Dancing chosba, 189
Defoshity of hand, ulnar, 88 ; inter-
osseous, 89
— in joint diseases, pathology of, 49,
53,56
DBrTBBOFATHIC SPINAL AHYOTBOPHY,
165
Diathesis, contracture, 354
Diplopia, hysterical, 280
DiSSBHINATED SCLEBOSIS, 183
DrOHENNB-ABAN PSOGSESSIYB AMTO-
TSOPHY, 166
Dvohenne's disease (vide Psettdo-
HYFEBTBOPHIC PABALYSIS)
— HEBBDITABY MYOPATHY, 174^ 176
DuMBKEBS (vide Mutism)
E.
Eleotbicity, uses of static, 23, 28,
308
Epidemic of hysteria in a family, 199
Ebb's jxtyenile myopathy, 169
F.
Feab, paraplegia from, 386
Flexobs of fingers and carpus, anta-
gonism between, 102
Functional (vide Hystebical)
— LESIONS are undiscovered organic
ones, 278
G.
Genebal PABALYSIS, case of, 60
varieties of, 61
H.
Hammebing ohobba, 190
Hemianssthbsia, hysterical, 71
Hemianopsia, relation of, to word-
blincUiess, 145
HBMiCHOBBA,pre- and post-bemiplegic,
188
Hemiplegia, hysterical, 401
Hebbdity in hysteria, 85
Hip disease, hysterical, 316
Hydbothebapy, 307
Hypnotic paralysis, 289
— suggestion, 259
Hypnotism compared to nervous
shock, 305
— in a waking state, 306
— phases of, 290
Hystbbia, epidemic of , 199
— in boys, 69 ; two cases of, 204
— in children, three cases of, 203
— in the male, cases of, 77, 78, 79,
80, 98, 101, 220, 244, 261,
343, 360, 374, 389
— male, compared with female, 224
— in the male developed by injury,
231
features of, 99, 100
frequency of, 98
heredity, 99, 231
most frequent age of, 99
not rare, 220
permanence of symptoms in, 223
— — tendency to melancholy, 225
— MAJOB [la grande hyst^rie], 13
— treatment of, 308, 336, 314
Hystebical achbomatopsia, 73, 286
— amyotbophy, 352, 406
— APHONIA, cases of, 413, et eeq.
— CONTBACTUBE, cases of, 33, 40, 341
— CONTBACTUBES, features of, 35, 351
— HEMIPLEGIA, 401
— HIP DISEASE, artificially produced,
334
•— MiCBOPSY and maobopsy, 281
— MONOPLBGIA, 389
— MUTISM, 360, 410; cases of, 413,
et eeq,
— POLYOPIA, 280
— PABALYSES, particular characteris-
tics of, 282
— STIGMATA, 279
permanence of, 247, 279, 367
Hystebo-bpilepsy in men, three cases
of, 226, et eeq.
— two kinds of, 33
Hystebogbnio zones, 74
Hystebo-obganic hip disease, 331
HySTEBO-TBAUMATIC MONOPLBGIA,
261, 343, 374, 389
— PABALYSIS, 261, 874, 889, 401
I.
Intentional tbbmob, 183
Isolation in hysteria, importance of,
209; originated in France,
214
E.
EiNJEBTHBTIC SENSE, 395
L.
Latent hystbbia, 251, 283
Lethabgic stage of hypnotism, 290
Leydbn's myopathy, 173
INDEX.
437
LiGATUBB of a limb caunng contrac-
tiire/865
Local shook, 844
— BTUFOS, 845
M.
Maobopby, hysterical, 281
MaiiB, hysteria in the {vide Hybtebia).
Malik&bbikg, 368
Massagb, 387
Mbhoby, partial forms of, 151 et seq, ;
visual, 161; auditive, 161;
motor, 161
MeKTAL IlCAaBBY, 152
— YISIOK, case of suppression of, 151
Mebcttbial tbemob, 186
MiCBOPBY, hysterical, 281
MoKOOTTLAB POLYOPIA, hysterical, 280
Monoplegia, brachial, 841
— hysterical, 389
— hysterical, cases of, 252, 261
— hystero-traumatic, 261
MoTOB IDEATION, 395 et seq.
MUBCULAB ICOYEMENTB controlled by
kin89sthetic and visual senses,
810 899
— BENBE, 187, 291, 295, 395
MuTiBM, hysterical, 360, 410
artificial production of, 372, 483
cases of, 860, 413 et seq.
Myopathy, primai*y, 167
Myobclebobib, 167
N.
NEBYB-BTBETOHDrG for functional Con-
tracture, 105
NEBYorB BHOOK, 805, 885, 843
hypnotism compared to, 305, 835
Neubabthekia, 236, 887
Neubo-pathology as a speciality, 5
NEimoBBB, difficulty of study of, 13
— obey laws, 12
Nosological hethos, 8 .
O.
Ophthalmic megbaine, 62
Otabian TEin>EBNBSB {see Oyabib)
Oyabib, 34
P.
Pachymbningitib, hypertrophic cer-
vical, 125
Pabalybib agitanb, 184
— by suggestion, 294
— segmental, 297
Pabaplbgia from fear, 886
— hystero-traumatic 374
Pabbsib in sciatica. 111
Pabkinbon'b diseabb (vide Pabalybib
agitakb)
Phabyngeal anjbbthbbia, 286
— BEPLEX in hysteria, 279
Physiological data furnished by
pathology, 11
POLIOHYBLITIB, anterior, 166
Polyopia, hysterical, 280
PbOGBBBSIYE MUBCULAB ATBOPHY, 166
PbOTOPATHIC SPmAL AMYOTBOPHY,
166
PSBUDO - HYPBBTBOPHIC PABALYBIB,
167
Psychic pabalybib, 284
Psychical state, influence of, in
hysteria, 198, 205, 809, 839
— treatment of hysteria, 308, 336
Psychosis, traumatic, 388
R.
Railway bbaik, bailway spike, 221
Reaction of degeneration, 116
Replbx pabalybib, after injury of a
nerve, 107
Rheumatic diathesis, connection
with nervous, 205
Rhythmical chobea, 189
cases of, 190—197
S.
SALPBTBiisBB, mcaus of study at the, 3
Sciatica, after injury to the nerve, 113
— double, causes of, 122
in a cancerous subject, 120
SCIKTILLATING SCOTOMA, 68
Segmental anjesthbbia, 2S2, footnote
5, 298.
— PABALYSIS, 297
Senile tbemobs, 186
Sense, muscular, 395
Senboby changes in cortical lesions,
276, 277, 282
Shock, local, 844
— nervous, 805, 835, 343
Simulation, how detected, 14, 94
Somnambulism, 292
Somnambulic stage of hypnotism,
292
Spbncbb, Hbbbbbt, on motor ideation,
397
Splint, application of, producing con-
toicture, 853
Spinal appbction, following contusion
of the sciatic nerve, 107
29
438
INDEX.
SpntmrALiSK and hysteria, 198
Stigkata, hysterical, 279, 8G7
STBTCHNnriSM, 37, 118, 119
Stufos, local, 345
SiTBBTiTrTiON of One form of memory
for another, 156, 159, 160, 162
Suggestion in hypnotlBm, 292
— paralysis by, 2ffl
— traumatic, 304, 886
SUBGICAL TBBAXMBKT of Contracture,
128
T.
TrnpnuTTBE in hysterical paralysis,
404
Tbhdoit BEFLBXB8 in arthritic amyo-
trophy, 23, 28, 49
in hysteria, 37, 39, 403
TlO K0K-D0VL0T7BBTTX, 40
TBAUHATIC FSY0H08I8, 888
— SUGGESTIOK, 804, 336
Tbbathbnt of hysterical paralysis,
807,337
TsBMOB, different kinds of muacnlar,
183
Tbbmobs, hysterical, 186
Tbophio ohangeb in hysteria, 406
V.
YbBBAL AJOrBBIA, 161
Visual dcagb, influence of, on ' motor
power, 310, 399
Visual hbm oby, 161
W.
Whispbbikg in hysterical aphonia,
363
Wobd-blinsnbss, cases of, 181, 143 ;
definition of — , 189, 142
— localisation of lesion in, 145
— mixed with loss of visual memory,
157
— is one element of verbal amnesia,
161
— connected with hemianopsia, 145
PBDrTBD BY ADLABD AND SON, BABTHOLOICBW OLOSB.
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