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THIS
FAIRCHILD
DIGESTIVE   FERMENTS
Are appreciated abroad as well as at home.
American Exhibition, Loudon,
   GOLD MEDAL.
National Health and Home Exhibition,
   Albert Palace, London, 1887'.
   DIPLOMA OF HONOR
      (Highest \wanl.)
Sanitary Institute of Great Britain,
    PKIZK MEDAL.

International Sanitary Exhibition
   Exhibition D'Osteud, 1888.
    GOLD MEDAL.
TRYPSIN, EXTRACTUM PANCREATIS, PEPTONISING TUBES,
    PEPSIN, PEPTOGENIC MILK  POWDER, ESSENCE
          OF PEPSIN, DIASTASIC ESSENCE
                 OF  PANCREAS. 
V 
      CLINICAL LECTURES
               ON

  Certain  Diseases
              OF THE

Nervous    System
                BY


       PROF. J. M. CHARCOT,
                 V\\
Professor to the Faculty of Medicine Paris, France, Physician to the
 Salpetriere, Member of the Institute and the Academy of Medicine;
     Honorary President of the Anatomical Society, etc.
             TRANSLATED BY


          E. P. HURD, M. D.,

Member of the Massachusetts Medical Society and of the Climatological
          Society, Newbury port, Mass.
    1888.
GEORGE S. DAVIS.
 DETROIT, MICH. 
       \\'/v\








   Copyrighted by
GEORGE  S.  DAVIS.
       1888.
 
TABLE OF  CONTENTS.
                      LECTURE I.

                  Spiritism and Hysteria.
                                                   Page.
Summary.—Influence of intellectual excitations on the de-
    velopment of hysteria; belief in the supernatural, of
    the marvellous; practice of spiritism.
        Account of an epidemic of hysteria  in a family
    of three  children inhabiting a  military penitentiary,
    and addicted to spiritism.
        Antecedent nervous and rheumatic attacks—De-
    scription  of the attacks—Hallucinations of fright; per-
    manent and variable stigmata—Conclusions.........   i

                      LECTURE II.

          On Isolation in the Treatment of Hysteria.

Summary.—Retrospective details respecting  a little epi-
    demic of hysteria.   The treatment ought to  compre-
    hend three points; A.  Psychical'or moral treatment,
    including: i. Separation from the place where the hys-
    teria developed;  2. Separation from each other of the
    persons affected; 3. Suppression of all visits on the
    part of parents or friends.  B. Medical treatment: 1.
    To modify the diathesis, if any exist (rheumatism, for
    instance); 2. Static electrization; 3. Methodical hydro-
    therapy.
        Preponderant influence of isolation.  Example—
    The treatment has been adopted  (not first proposed)
    in Germany and in England........................  13 
VI.
                     LECTURE III.

     Choreiform  Movements and Tremblings; Rythmical
                         Chorea.
                                                   Page.
Summary.—The  Trembling of Multilocular Sclerosis—Of
    Paralysis Agitans—Senile Tremor—Tremor with Slow
    Oscillations — With  Rapid Oscillations — Vibratory
    Tremblings — Hysterical Tremor — Alcoholic, Mer-
    curial Tremor—The  Tremor of General Paralysis—
    Of  Basedow's  Disease—Chorea—Characters  of  the
    Involuntary   Movements   of  Sydenham's  Chorea—
    Chorea and  Hemichorea,  Pre- and  Posthemiplegic
    — Athetosis  and Hemiathetosis—Rhythmical  Chorea
    — Characters  of  the Movements — They  Manifest
    Themselves  Under the Form of Crises — They  are
    Cadenced, Systematic,  and Reproduce, more or less
    Faithfully,  Certain   Movements  of  Ordinary   Life
    (Chorea Saltatoria, Malleatoria)—The Disease  is Gen-
    erally Linked to  Hysteria—Prognosis  Varying  Ac-
    cording to Cases..................................  32

                     LECTURE  IV.
     Muscular Atrophy  Consequent on Certain Articular
                         Lesions.
Summary:—Articular Traumatism—Consecutive Paralysis
    and Muscular Atrophy—Modification of the Galvanic
    and Faradic  Contractility—Contractions  Provoked by
    the  Electric  Spark—Exaggeration of  the Tendinous
    Reflexes—Simple Muscular Atrophy—There is no Ne-
    cessary Relation Between  the Intensity of the Joint
    Affection and  that   of  the  Paralytic  and  Atrophic
    Phenomena—The Extensors of the Joint are Affected
    in a Predominant Manner—The Muscular Lesions are 
                            VII.
                                                     Page.
    Under the  Dependence  of  a Deuteropathic  Spinal
    Affection.........................................  50


                      LECTURE V.

Contractures of Traumatic Origin—Painless Tic of the Face in
                   an Hysterical Patient.

Summary.—I.   Influence of Traumatism  on  the Localiz-
    ation of  Certain  Diathetic Determinations—Contrac-
    ture of Traumatic  Origin in  Subjects  who Present
    Spasmodic Rigidity in the Latent State.—Exaggera-
    tion of the Tendon Reflexes in Hysterics.—II.  Typi-
    cal Tic non Douloureux of the Face—Contracture of
    the Muscles of the  Face  in an  Hysterical  Patient—
    Simulation......................................  88

                     LECTURE VI.

    Muscular Atrophy Consecutive to Articular Rheumatism.

Summary.—Muscular Atrophy in  the acute, subacute, or
    chronic Athropathies.  Relation between the Localiza-
    tion of the Atrophy and the Seat or  the arthropathy.
    Types of  primary chronic articular  rheumatism:  1.
    Primary generalized  or progressive chronic Rheumat-
    ism; 2. Chronic articular rheumatism, fixed or partial;
    3   Nodosities of Heberden.
        Generalized chronic Rheumatism causes Amyotro-
    phies predominating  in the extensor muscles of the
    diseased joints.   Exaggeration of the  tendon reflexes.
    With the  amyotrophy there exists a  Contracture in  a
    latent state.  Reflex  Spasmodic Contracture of joint- 
VIII.
                      LECTURE VII.

         On Six Cases of Hysteria in the Male Subject.
                                                     Page.
Summary.—Hysteria in the male is  not so rare as one
    might suppose.  R61e  of traumatism in  the  develop-
    ment of  this  affection;  railway  spine.  Tenacity  of
    hysterical stigmata in typical cases in both  sexes
        Account of  three  typical  and complete  cases  of
    hystero-epilepsy in the male.  Striking  resemblance
    which  these cases bear to  each  other, and to corre-
    sponding cases observed in the female sex.........  .   97

                     LECTURE  VIII.

      Concerning Six Cases of Hysteria in the Male Sex,
                        (Continued.*)

Summary.—Abdominal forms of the  hysterical  attacks  in
    man.—detail of  a case in which the seizures took the
    aspect  of partial epilepsy.—Diagnosis  of  this  case;
    importance of  the hysterical stigmata.
        The convulsive seizure  may be  wanting  in  hys-
    teria of the male — Description of a case of bronchial
    monoplegia in a man aged nineteen  years,  hysterical
    —Difficulties of diagnosis in these cases.............  131 
AUTHOR'S   PREFACE.
     The lectures which Dr. E. P. Hurd  has decided to repro-
duce in this volume pertain for the most part to hysteria,  and
especially to hysteria in the male sex.  This is a subject which
for a number of years has attracted my attention and been
made by me a theme of study, and I am surprised  that it  has
been so long ignored, or at least so far neglected, for it is  one
of the most interesting subjects of nervous  pathology.  Male
hysteria belongs truly to every-day medical practice, and  not
to know it, not to be aware that it exists both in the man of
culture and in the working man devoted to manual labor, is to
render  one's  self liable to  frequent mistakes, and  mistakes
which may be quite serious from  a professional point of view.
     I recognize, moreover,  the  fact that if,  more fortunate
than most  of  my contemporaries, I  have been able to study
this affection under its divers  aspects, this task  has certainly
been facilitated by the great  number of  patients who present
themselves every day at the clinic  of the Salpetriere.  I have
also been struck by the fact that male hysteria is  found with
the same characters in men belonging to all  races,  all nation-
alities.   So, when my views were first made known, I did not
hesitate to  affirm that those of my confreres in foreign  coun-
tries who made a point of disputing (at least as  far as their own
country was concerned) the existence of the  facts which I  had
pointed out, would in  time acknowledge the  justness  of  my
positions.  The event has proved that I was right.  From all
quarters of the world, at the  present time, observations simi-
lar to my own  are multiplying.   I  take pleasure in thinking
that  through  the publication of works  like  this which  Dr.
Hurd now  presents  to  the medical profession of the United
States, the  question of hysteria in  the  male  sex will receive
from physicians in that great republic the attention  that  it de-
serves, and that thereby science will be enriched by new facts
and make still further advances.
                                            Charcot.
     Paris, August ist, 1888.
      I  AA 
TRANSLATOR'S  PREFACE.
     Jean Martin Charcot was born in Paris, Sept. 29, 1829, so
that now he is in his 60th year.  Appointed interne of the hos-
pitals in  1848, physician of the Central Board of  Hospitals  in
1856,  physician to the  Salpetriere  in  1862, Dr. Charcot  began
in that hospital in 1866 a course of theoretical and clinical teach-
ing on Chronic Diseases, Diseases of Old Age, and Diseases of
the Nervous Sy*tem, a course that was  kept up by a series  of
lectures given every year till 1878.  Chief of the Department of
Clinical  Medicine  from 1853 to  1855,  "agrege"in  i860,  he
was elected to the chair of Pathological Anatomy of the Faculty
of Medicine of Paris in 1872.  From this time till 1881 he gave
every year, regularly,  the official course  (theoretical and  prac-
tical)  of pathological anatomy.   Since Jan. 2st, 1882  Dr. Char-
cot has held the  Chair of Clinical  Instruction in  Diseases  of
the Nervous System at the Salpetriere.   An enumeration of all
the titles and honorary offices which have been bestowed upon
Prof.  Charcot would take up too much space  in   this preface,
for he is  " honorary member" or " corresponding member" of
the principal scientific  and medical societies of Europe, besides
being connected with several in  this country.  A  few only  of
these  titles will be here given:
    Member of the Academy of Medicine, Paris, 1872.
    Corresponding Member of the Royal Society of Natural Sciences of
Brussels, 1874.
    Corresponding Member of the New York Society of Neurology and
Electricity, 1874.
    Honorary Member of the Clinical Society of London, 1874.
    Honorable Member of the Harveian Society of London, 1878.
    Member of the Institute of France (Academy of Sciences), 1883.
    Honorary Member of the King's and Queen's College of Physicians
in Ireland, 1887.
     Doctor of Laws of the University of Edinburgh.
    Honorary doctor of the University of Boulogne.
    Honorary Member of the Society of Physicians and  Surgeons of St.
Petersburg.
    Honorable doctor of  the Faculty of WUrzburg, etc., etc. 
XI
      Dr. Charcot has been connected  with the founding and
 management of three medical reviews; the "Archives of Nor-
 mal  and  Pathological  Physiology,"  published  by  Brown-
 Sequard, Charcot and Vulpian  (Vol. I appeared in  1868);  the
 "Revue Mensuelle de Medecine et de  Chirurgie," published
 by Charcot,  Chauveau, Oilier, Parrot, and Verneuil (this jour-
 nal first appeared in  1877); the "Archives  de Neurologie," a
 Quarterly Review of  Nervous and Mental Diseases, published
 under  the direction  of J. M. Charcot—Editor in Chief, Dr.
 Bourneville; this journal was founded in  1880.
      I  shall  enumerate as  rapidly as possible  Professor Char-
 cot's leading contributions to medicine.
      1.  A study of the affection described under the names of pri-
 mary asthenic gout, nodosities of the joints, chronic  articular
 rheumatism (primitive form), (Thesis for the doctorate, Paris,
 1853).
      Charcot's researches  on this disease comprehend a vast
 number of clinical and necroscopic observations  made at the
 Salpetriere.  One of the most important facts brought to light
 by these researches is that  affections of the heart such as
 endocarditis  and pericarditis belong to the generalized  form
 of chronic articular rheumatism, as  well  as to acute articular
 rheumatism.   Another result of these researches is to establish
 an identity between  the affection known in surgery under the
 names of dry arthritis, arthritis deformans, morbus coxa senilis,
 etc., and nodular rheumatism.   In other words, we have not
 here two distinct diseases, but two forms of one and the same
 disease.  One of these forms is chronic primitive articular rheu-
 matism, fixed or partial, the other is chronic primitive ariiculai
 rheumatism, generalized or progressive.   The separation of gout
 and chronic articular rheumatism is maintained in all its rigor-
ousness.  In this study, Dr. Charcot describes the symptomat-
ology in a strikingly original manner.   Among the etiological
circumstances, he insists especially on the  prolonged action of
cold and moisture  combined,  a  condition  often  realized  bv
habitual sojourn in badly lighted, damp, habitations. 
XII
     2.  Of the non-existence of an  excess of uric  acid in  the
blood in subjects affected with nodular rheumatism.
     In this treatise, Charcot  shows, as the result of his  re-
searches, that the presence of uric acid cannot be detected in
the serum of the blood in chronic articular rheumatism, while
in acute and chronic gout the existence of crystals of uric acid
has always been clearly recognized.   This fact separates  gout
from all forms of rheumatism, whether acute or chronic.
     3.  Alterations of the cartilages in gout.  (1857).
     The author of this  treatise, having had the occasion to
examine fragments of cartilage  from  a  gouty patient, found
them infiltrated with urate of soda under both  the  amorphous
and crystalline form,
     4.  Contributions to the study of the anatomical alterations
of gout, and especially of the kidneys and joints in gouty patients.
(In collaboration with M. Cornil).
     In this memoir Charcot considers  the  alterations of  the
kidney observed in the gouty, and gives some  new researches on
the alterations of the joints.  Gouty nephritis is  by no means
rare; it is attended with deposits of  urates in various  parts of
the kidney, and frequently with  the  symptoms of  renal colic.
The lesions may  be those  of parenchymatous  or  interstitial
nephritis, and the general symptomatology  is that  of  chronic
Bright's disease.
     5.  On the structure and mode of development of the giant
cells in tubercle.   (1878).
     In this paper the author endeavors  to  show: (1)  that  the
giant cell is constituted in principle by a mass of cellular ele-
ments heaped together (endothelial mass).
     (2) That the elements constituting this little mass under-
go a particular modification  which may be called  vitreous trans-
formation,  having for  effect  to bring about  the  agglutination
and fusion of the different cells  which are affected, while the
nuclei  enter into active proliferation.
     (3) That this  vitreous  transformation,  ending in caseifi- 
XIII
cation, proceeds from the centre to the periphery of the cellular
mass, which explains the different aspects which the giant cell
presents in sections.
     6.  On painful paraplegia supervening in  certain  cases  of
cancer.
     In this communication, Charcot shows that the frequent
coincidence of cancer of the breast with an aggregate of symp-
toms which he proposes to designate as painful paraplegia, is
due to secondary deposits of cancerous  matter  in the bodies of
the vertebrae,  especially in the lumbar region.
     7.  On acute miliary carcinoma.
     An interesting treatise embodying some observations ex-
emplifying  the  close  similarity which exists  between  acute
miliary carcinoma and  acute miliary tuberculosis.
     8.  Typhoid Pyrexias.—Eruptive  Fevers.—Cholera.
      Under the above  head we have several valuable articles
on fevers, and on cholera.
     9.  Laryngeal affections in typhoid fever.
     (In collaboration with M. Dechambre.)
      10.  Anatomical and nosological characters of yellow fever
and grave icterus.
      11.  On the epidemic which prevailed in  St. Petersburg in

      12.  Note on the  temperature of  the rectum   in Asiatic
 Cholera.
      13.  Alterations  of the  Blood.—Leucocythcemia.—Melan-
cemia.
      The above  papers,  whose  names only  are  mentioned,
were founded on original observations  and have materially ad-
vanced science in reference  to the subjects to  which they per-
tain.
      Charcot's contributions to diseases of the  vascular system
have been considerable.  The following are especially worthy
of mention:
      14.  On sudden death from obstruction of the  pulmonary
artery  by blood clots in  cases of phlegmasia  alba dolens and phle-
bitis obliterans.  1858. 
XIV
      This work, which contains the first observation  of  death
by pulmonary embolism published in France, contains a very
extensive analysis of the German  works on the subject.   The
author describes fully the  symptoms which  characterize  acci-
dents of this kind, gives precise indications as to diagnosis and
prognosis, and  a  careful  study of the mechanism which pre-
sides over the displacement of clots in the venous system.
      15.  Case  of acute rheumatism  with comatose symptoms,
then hemiplegia; softening  of the  cerebrum; multiple fibrinous
deposits in several of the viscera, and in particular in the spleen.—
Dysenteric  Lesions  of the  colon.—Endocarditis  with fibrinous
vegetations.
     The above memoir contains much that was new at the
time of its appearance in  1852.   The  labors of Virchow and
Kirkes in the same direction were  not then known in France.
     16.   Gangrene of the foot and of the leg;  multiple fibrin-
ous deposits in the kidneys, spleen, liver,  etc.  1856.
    This observation pertaining to a subject affected with cal-
careous incrustations  of the  sigmoid valves is a  striking ex-
ample of  those  arterial and  capillary embolisms  which  have
since that epoch been made the subject of so much study.  In
this memoir Charcot sets forth and criticizes Virchow's theory
of embolisms, then scarcely known in France.
     17.   Notes on a case of multiple fibi inous tumors containing
a puriform matter, situated in  the right vent* icle of the heart, etc.
1852.
     18.   Remarks on some fibrinous cysts containing a puriform
matter, observed  in  two cases of partial aneurism  of the  heart.
1854.
     19.   On acute ulcerative endocarditis of typhoid form, based
on a case  of ulcerous affection  of the tricuspid valve  with
typhoid state, and the formation of multiple abscesses  in both lungs.
(In common with M. Vulpian. 1861-1862).
     The three  memoirs given above contain the first  observa-
tions of the kind published in France, and have been the  point 
XV
of departure of  quite  an extensive medical  literature. '5 The
paper on ulcerous endocarditis of itself'marks an era in modern
medicine.
     20.  On arterial thrombosis supervening in certain cases of
cancer.   1865.
     In this paper Charcot shows that in subjects affected with
cancerous disease of long standing,  arterial  thrrombosis, with-
out previous alteration  of the wall of the vessel,  may  take
place as well as venous  thrombosis,  although the latter is far
the most frequent.
     The five following papers pertain to  diseases of the re-
spiratory organs:
    21.  Pathological  anatomy  of   acute  broncho-pneumonia.
1857.
     22.  On chronic pneumonia,  i860.
     23.  New anatomo-pathological  and clinical researches  on
the chronic pneumonias (Cirrhoses of the lung.)  1878.
     24.  Studies in experimental pathology relative to pneu-
monokoniosis.   1877.
     25.  Anatomopathological researches on  phthisis; tuber-
culosis of the lungs.  1877.
     The treatise  on broncho-pneumonia contains a more pre-
cise description than medical science had heretofore  possessed
of the  microscopic lesions of  the  pulmonary parenchyma  in
acute broncho-pneumonia  considered at its highest degrees  of
development: 1, the splenized  portions, occupying the greater
part of the extent  of the pulmonary lobule;  2, nodules of peri-
bronchial hepatization,  disseminated, like  the  islands of  an
archipelago, among the parts  affected with splenization.  The
histological examination shows that in these latter parts the  al-
veolar cavities  are filled with swollen,  globular epithelial  cells
and a few leucocytes.   The constitution of the  peri-bronchial
nodules is as follows: around a lobular or acinous bronchiole,
blocked (as is generally the case) by a muco purulent concre-
tion, the pulmonary alveoli, in two  or three concentric rows, 
XVI
have their cavity distended,either by an accumulation of leuco-
cytes, or, (as oftener happens), by leucocytes embedded in a
fibrinous exudation, which besides contains a few epithelial
cells.   The existence of  this fibrino-purulent  exudation in  the
peri-bronchial nodules shows that the presence of  fibrine and
leucocytes  in the pulmonary alveoli can no longer  be  consid-
ered as a peculiar characteristic of the  hepatization of  lobar
pneumonia.
     There is much  that  is new  in  the treatises  on  chronic
pneumonia, and especially under the head of pathological  an-
atomy,  in  which  study  Charcot has  introduced  system and
definiteness where there  was before vagueness and  confusion.
     In  the study  of pneumonokoniosis,  Charcot  records a
series of interesting experiments  on guinea pigs which were
made to inhale in  bags two hours  every day certain kinds of
mineral or  coal dust.   It was  found,  on  killing the animals,
that these powders had penetrated the air cells, and were fol-
lowed by certain lesions, such as swelling of the pulmonary
endothelium, and proliferation of these  cells,  and consecutive
sub-acute inflammation of the  alveolar wall itself and  thicken-
ing of this  wall,  leading to concentric contraction of the alveo-
lar cavity.
     Charcot shows that the facts of experimentation—symp-
toms and lesions—exactly correspond with the facts of  pneu-
monokoniosis,  anthracosic, silicic,  siderotic,  observed  in man
as a result  of an occupation exposing him to the action  of solid
particles diffused in  the air.
    A resume of Charcot's lessons on tubercle (conferences  de-
livered before the Faculty, 1877 and  1878) would be of  great
interest, but such abstract would take up all the space allotted
to this preface.
     26.  Dr. Charcot's  contributions to medicine  under  the
head of Diseases of  the  Liver, Biliary Passages and Kidneys,
have been  summarized in a work  entitled "Lessons  on Dis-
eases of the Liver, etc.," and  published in 1S77, second edition 
XVII
(enlarged), 1882.  The " Lectures on Diseases of the Kidneys "
was translated into English by Dr. H. B. Millard, New York,
in 1878.
     When the history of  medicine shall be properly written
(a task which will require more than one Aristotle) the additions
which each individual shall have made to the existing fund of
knowledge will be properly recorded.  Such a work does  not
yet exist,  and  it is necessary to search  through  countless
memoirs, which  are often  buried in  the "Archives"  and
" Comptes Rendus " of learned Societies, to  find what one is
looking for, in order to render to  the  indefatigable worker the
credit that to him is due.
     Several of Charcot's memoirs on  the pathology of  the
liver have been invaluable additions to our  knowledge  of  the
subjects  of which they treat.   He first  experimentally deter-
mined, in guinea pigs,  hypertrophic cirrhosis of the liver of
biliary origin, and showed its identity with the disease which
develops in man as the result of  obstruction  of the  common
bile duct.
     The different phases  of the morbid process may, accord-
ing to Charcot, be  thus summed  up:  angiocholitis, periangio-
cholitis, cirrhosis.   The disease in man, as is now well known,
is often produced by the arrest of  a gall stone in the  ductus
choledochus, or by compression of the  latter by a tumor (cancer
of the head of the pancreas, for instance).  In these cases,  the
connective tissue frame-work  of the  hepatic gland undergoes
hyperplasia, and the whole organ enlarges.
     Charcot's researches  on the common or atrophic form of
cirrhosis of the liver (gin drinker's liver), have hardly been  less
fruitful.  He has, more than any of his  predecessors, insisted
on periphlebitis as the cause of this affection, and shown  the
extension of the inflammation from the veins to the connective
tissue,  which'forms bands or rings around the lobules (annular
cirrhosis),  compressing them  and   causing  that   granular
(atrophic) condition first described  by Laennec.   His obserya- 
XVIII
 tions clearly differentiate this  form from the  other types of
 interstitial hepatitis.   Charcot's researches on grave icterus, on
 interstitial nephritis (which he was the first  experimentally to
 produce in animals by ligature of one of the ureters,  an ex-
 periment which brought out this striking fact that the alteration
 of the epitheliums precedes the connective-tissue-proliferation),
 and on the various forms of Bright's disease, have been  equally
 original, and are monuments of pains-taking industry.
      Charcot has made many contributions to the literature of
 skin diseases; the following are here mentioned only by  title:
      27.   On erythema, produced by the action of electric light,
 1859.
      28.  Bronzed coloration of the skin with fatty  alteration of
 the supra-renal capsules {Addison's disease).   (In  collaboration
 with Vulpian) 1858.
      29.  Note on several cases  of skin disease dependent on the
 influence of the nervous system over nutrition, 1859.
      30.   On a case of zona  of the neck  with alteration of the
 nerves of the  cervical plexus and corresponding ganglia of the
posterior spinal rootst 1866.
      31.   On scleroderma, 1872.
      32.   On rapid or sudden blanching of the hair,  1861.
      33.   Clinical lectures on the diseases of old age.  Paris, 1878.
 American translation by L. H. Hunt, 1881.
      In the preparation of this, in many respects the most im-
 portant work heretofore published on the subject,  Charcot was
 aided by the researches and studies  which he has  previously
 made on gout and rheumatism.  Seven chapters are taken up
 with a consideration of gout in its various forms in the aged,
 and nine with rheumatism, the  chronic  articular  forms being
 especially dwelt upon.  There are several original chapters on
 " The Febrile State in the Aged," and on the  "Clinical  Im-
 portance of Thermometry in Old Age."   Dr. Charcot has also
 made some observations "on the  Pneumonia  of Old Age,"
 which are recorded in the inaugural thesis of  Dr. Bergeron. 
XIX
      34.  Atheromatous alterations of the arteries, and endar-
 teritis deformans.
      The above treatise comprises the  second fasicule of the
 " Lessons on the Diseases of Old Age," second  series.   We
 here  find  an  exposition  of  the  epoch-making discovery of
 Charcot and Bouchard  of the miliary aneurisms, consequence
 of  endarteritis and cause of the  cerebral hemorrhages which
 characterize especially the apoplexies of old age.
    The following papers pertain  to the pathology of old age:
      35.   Observations relative to  spontaneous gangrene in aged
patients.
      36.  On Senile osteomalacia.
      37.  On the trembling called senile, senile chorea of some
 writers,
      38.  On common chorea in old people.
      In the enumeration of Charcot's works, there should fol-
 low here three memoirs on Basedow's Disease, whose obscure
 pathology Charcot has done much to clear up by his careful ob-
 servations.  His first treatise on the subject was  read before
 the Biological Society in 1856.   Exophthalmic  Cachexia, here-
 tofore almost unknown  in France, is described in this paper on
 the basis of a remarkable  case observed in Charity  Hospital.
 The writer attributes the symptoms of this disease to a vascular
 neurosis, finding expression  in  palpitations of  the heart  and
arteries, tumefaction of the thyroid gland,  and  double  exoph-
thalmia.
      Charcot's contributions to the study of the diseases of the
nervous'system—memoirs and treatises  more than a hundred
in number—are altogether too numerous to obtain mention in
the limited space allotted me by the publisher for this  preface.
Nervous pathology is the most difficult part of human pathology,
requiring the nicest  pains in  dissection and  preparation, the
highest powers of  discrimination.    Every  department  of
morbid innervation has  been enriched by Charcot's discoveries.
I shall only allude to his principal  contributions: 
XX
     42.  Clinical and anatomo pathological researches on cerebral
ramollissement and encephalitis.
     This  work,  made with the assistance of Vulpian,  first
brings out the fundamental distinction between  cerebral  ram-
ollissement and encephalitis, the former being due to ischaemia
rather than to congestion.  The precursory symptoms are dif-
ferent; dizziness and mental enfeeblement characterize ramol-
lissement,  delirium,  convulsions, contractures, belong more
particularly to encephalitis.  The tardy contracture so frequent
in the paralyzed limbs of  patients suffering from  old ramol-
lissement is to be referred to consecutive  lesion of  the  spinal
cord (secondary descending sclerosis.)  According to Charcot,
conservation of consciousness with sudden invasion of paralysis
belongs rather to ramollissement; variable hemiplegia belongs
to it exclusively, and aphasia almost exclusively.
     43.  New Researches on the Pathogeny of Cerebral Hemor-
rhage.—In collaboration with M.  Bouchard.   English transla-
tion by T.  S. Maclagan, 1872.
     In  this work, founded  on a  multitude  of  observations,
cerebral hemorrhage, particularly in  the  aged, is  referred  to
rupture of aneurisms of the small arteries of the cerebral  sub-
stance.  These aneurisms are a  millimetre or  more in size,
and have never been wanting in any  case  of  cerebral  hemor-
rhage  observed by Professor Charcot.
     44.   On secondary degenerations of the spinal cord, 1859.
(In  common  with  M. Vulpian.)  Cruveilhier and  Turck had
already called attention to these degenerations as consecutive to
lesions of  the  hemispheres, and Charcot  and Vulpian  in this
memoir  add a number of facts confirmatory of the observations
of the German pathologists.  The subject is presented by them
in a new and clearer light, with considerable  additions  to our
knowledge; they  also record similar degenerations following
lesions en foyer of the spinal cord.
      45.  (a) Localization in Diseases of the Cerebrum, (b) Study
of motor localizations in the cortex. 
XXI
     The above titles  comprehend  two  works published by
Charcot, in  1876.  The first has been translated into English
oy Dr. Millard.
     Charcot, in the main, accepts the  new  views of cerebral
localization  set  forth  by Ferrier,  Hitzig, Franck and Pitres,
Nothnagel, etc.   His views, based on a vast number of  obser-
vations made in  the  Salpetriere, are treated at length  in  the
above works; they have recently been  popularized  by him in
an article in the  Forum for August, 1888, entitled: "The Topo-
graphy of the Brain."
     This publication embodies a course  of  lectures delivered
before the Faculty in 1875.
     46.  Localizations in the cerebral ganglionic masses of the
hemispheres of the cerebrum—lesions of  the internal capsule  in
particular.
     The symptoms  which accompany lesions limited  to  the
central gray nuclei  (lenticular nucleus, caudate nucleus, optic
thalamus) are those of  common  cerebral hemiplegia, which is
generally  little  pronounced,  temporary,  and  consequently
benign.
     On the other hand, lesions of the internal capsule produce
a very pronounced and relatively persistent hemiplegia.  Tardy
and permanent  contracture of the paralyzed limbs is the habit-
ual consequence.  If the lesion occupies the  anterior two-thirds
of the capsule, the paralysis will pertain  exclusively to move-
ment, if, on  the contrary, it affects the  posterior third of  the
capsule cerebral hemianaesthesia necessarily follows.
     47.  Clinical  characters of cerebral hemianesthesia by or-
ganic lesson.
     48.   The focal lesions of  the cerebral  hemispheres  which
produce hemianesthesia  determine crossed amblyopia, and not lat-
eral hemiopia.
      The two above memoirs, which are among the most orig-
inal productions of  our author, are further contributions to the
study of cerebral localizations. 
XXII
      49-  Secondary degenerations of the spinal cord in cortical
 lesions of the hemispheres.
      In  this memoir  Charcot shows  that  lesions of the so-
 called motor zone,  even without participation  of the internal
 capsule, determine  secondary spinal degenerations.  It is an-
 other powerful argument in support of the modern doctrine of
 motor localizations in the cortex.
      I shall be obliged to pass over Charcot's valuable contri-
 butions to the "study  of  localizations  in diseases of the spinal
 cord."  A work with the above title comprises the lectures de-
 livered before the faculty in 1880, and  has been translated into
 English and German,  and there is an American translation  by
 Prof. Comegys, of Cincinnati.
      It is well known  that the  histological  labors of the past
 fifty years, besides differentiating the  spinal cord into its ner-
 vous and connective-tissue-elements, have brought to light the
 fact that it is composed of numerous centres and  "systems"
 having special functions;  to elucidate  the properties of  these
 several parts,  physicians and physiologists  have wrought
 earnestly, and what was once a terra incognita is now becom-
 ing tolerably well understood.  Few, if any, have contributed
 more to our knowledge of the spinal cord in its physiology and
 in its pathology than  Prof. Charcot.  His  discoveries in the
department of the scleroses alone—locomotor ataxia, multilocular
 sclerosis, fasciculated sclerosis of the lateral columns, also  in
 the department of infantile paralysis, amyotrophic paralysis of
 the adult, labio-glosso-laryngeal paralysis, would have  given
him a lasting name,  besides rendering him a  benefactor of
 mankind.
     Dr. Charcot's  contributions to nervous diseases are for
the most part embodied in the following works:
     " Lecons sur les  Maladies du Systeme Nerveux.   Vol.
I.   1877.
     " Lec,ons sur les  Maladies du Systeme Nerveux."   Vol.
II.   1877. 
XXI1I
      These two volumes have  been translated and  published
 by the Sydenham Society.
      "Leconssur les Maladies du Systeme Nerveux."  Vol.
 III.  1887.
      These volumes comprise each about 500 pages, and are
 profusely illustrated.
      I  have but one  observation to make relative to style:
 Charcot seems to me to add to the merit of original investiga-
 tion and  independent, fruitful  thought, the  possession of a
 clear and picturesque  style.  His Ideas come clothed in just
 the right  words,  and  this  is eloquence in a scientific sense.
 He is one of the most  translatable of  writers,  for seldom  can
 any  other form of words so well express his meaning as those
 which he  has  chosen;  his mind is, in fact essentially cosmo-
 politan.
      In the above enumeration of  writings,  I  have simply
 culled from more than two hundred treatises, all emanating from
 the same fertile hand and brain.  Possibly many of those which
 I have omitted are more important than those which  I have
 mentioned.
      The discoverer of scientific truth is to be envied.   I  can
 imagine no task more worthy of the human mind than the
 search for and the unfolding of  new facts in nature.   I  believe
 that  when the  discovery pertains to the laws and  processes of
 the human economy, physiological and  pathological, the sub-
 ject becomes one of transcendent importance, for here is some-
 thing that immediately concerns  our  welfare,  and that of all
 our  fellow-men.  Therefore  I  would rather  have  been  the
 author  of those  three works  of Charcot  last  enumerated,
 than  have  written  Paradise   Lost, the  Inferno,  or  Don
 Quixote,  and  this  because above the  literary  I  value  the
scientifi:, and above the aesthetic, the practical and useful. The
literary  man may evolve "out of his  inner  consciousness " a
work of genius which shall captivate the masses, and yet shall
afford nothing but pleasure and entertainment; the scientific 
XX1V
man, on  the  contrary,  who  would  find  out  the nature  of
hypertrophic cirrhosis  of the liver must make  many careful
autopsies and dissections, under circumstances  that would be
repulsive to most persons,  and must  spend wearisome hours
over the microscope, he  must,  moreover,  perform numerous
vivisection experiments on animals in  order to determine the
conditions of the disease,  and must patiently watch the results,
and this involves a long and toilsome work.  Nor can he hope
as his reward that  "the masses" will be interested in his
work, but his recompense must ever  be the satisfaction which
he feels in his chosen pursuit, the consciousness  of being use-
ful, and  the appreciation of the few whose approbation he
prizes.  A Zola or a Dumas  may publish works  which shall
run  through ninety-five  editions.  But Zola and Dumas will
soon be forgotten, while Charcot will ever rank among the im-
mortals of this  earth.
     Charcot's  life,  if it has not been a very eventful, has been
a very busy one, and he is still in the flower of his manhood,
just as able to do effectual work as ever.  It is hoped that the
cares of an ever increasing practice will still leave  him time
for original investigation.
    The   present volume  was  culled from  Vol.  Ill of the
"Lessons on Diseases of the Nervous System," which has not
heretofore been translated into  English.  Charcot's studies  of
late have been rather in the department of  the so-called func-
tional diseases of the nervous system  than of the organic.
     I have to thank Professor  Charcot and his obliging pupil,
Dr. Marie, of the Salpetriere, for assistance in the  preparation
of this volume.
                                     E. P. Hurd, M. D.
Newburyport, Sept 20th, 1888 
LECTURE  I.
            SPIRITISM AND  HYSTERIA

Summary.—Influence of intellectual excitations on the develop-
     ment of hysteria; belief in the supernatural, of the mar-
     vellous; practice of spiritism.
         Account of an epidemic of  hysteria in a family of
     three children inhabiting a military penitentiary, and  ad-
     dicted to spiritism.
         Antecedent nervous and rheumatic attacks—Descrip-
     of the attacks—Hallucinations of fright; permanent and
     variable stigmata—Conclusions.
     Gentlemen:—It is incontestable that everything
which vividly affects  the  mind,  everything  which
powerfully stimulates the  imagination, favors the de-
velopment of  hysteria in persons predisposed thereto.
Of all causes productive of  these  traumatisms of the
cerebral  functions, there is perhaps none  more  effica-
cious, and whose influence has been oftener  acknowl-
edged, than inordinate  belief in the marvelous, in the
supernatural, a belief which is  fostered and  exagger-
ated by excessive religious observances, or—to descend
to a  kindred order of  ideas—by spiritualism and  its
practices.  It is sufficient to recall to  mind  certain
facts which  are matters of  history, such as that of the
" Possessed  Maiden of  Louvres "  in the sixteenth cen-
tury, whose imagination  had  been  kept  in  constant
tension,  before her "possession," by the lost  spirit
which reappeared  every  night in the house where she
      2 AA 
                      --2 --
lived;* and  there is a recent interesting instance of an
epidemic  of hysteria  affecting  six  children  of one
family in  Bretagne whose minds had  been fed  with
fantastic stories in which witches and  ghosts played
the principal part.
    It has been my lot to observe  one of these  little
family epidemics, the principal actors in which  I am
going to present to you to-day.   The epidemic merits
a particular description, as much with reference to its
mode of development as for the  light which  it sheds
on the study of hysteria in  children,  and  particularly
in young boys.  It is  in a  military penitentiary  that
the facts occurred which I am going  to relate.
    Life in  a penitentiary must be dreary enough at
the best; moreover, by reason of the discipline which
must necessarily prevail  in such  institutions, even the
apartments of the military keepers cannot but partake
of the gloom and severity of the  place.   The lodgings
occupied  by  Monsieur  X., adjunct  lieutenant, are
situated on  the third floor;  access  thereto is obtained
by a dark stairway; the apartment itself is insufficiently
lighted, for  all the windows,  which look upon  the
prison yard—which, it is true, is a spacious one—are
situated high up, near the ceiling, and  admit but  little
light.  Monsieur X., who has lived in the penitentiary
three years and a half, is forty-three  years of  age; he

    * Proces verbal fait pour delivrer une fille possedee par
le malin esprit a Louviers, 1591. Bibliotheque diabolique, 1883. 
                     —  3  —
seems  to  be quite intelligent, although his military
career  has been one of  slow and moderate advance-
ment;  I shall say more  about his  mental state  pres-
ently.  His general health is good, and  there are few
pathological antecedents on his side.  At the age of
thirteen,  he suffered from   an  affection which  was
febrile at  its commencement, but  was followed by a
delirious state  which lasted six months.
     Madam X.,  aged thirty-six  years,  and married
since 1879,  is a  very nervous woman;  she is  quick-
tempered, emotional,  and fretful; has, however, never
had convulsive attacks of any sort.  It is not so, how-
ever, with her mother, who  died  in March,  1884, at
the age of seventy-two years, of a cerebro-spinal affec-
tion, and who  every year had two or three returns of
well-marked  hysterical  fits.   We  may   note, finally,
that  her father was  a  constant  sufferer from rheu-
matism.
     Monsieur and Madam X. have had  four children;
three are  still living;  the  fourth  died, probably of
athrepsia,  at the age of two and one-half years.
     You see before you the oldest of  the three living
children—Julie, aged thirteen and one-half years; she
was  born  before  full term—at  seven  and  one-half
months—and  she remained a long  time  weak  and
puny, having been brought  up on a bottle.  For the
last three years she has  been boarding at a convent in
the neighborhood of the penitentiary.   From her in-
fancy she  has  been very nervous.   At the convent, as 
                     —  4 —
at home, she has been unruly and difficult of manage-
ment, laughing and crying for the most trifling cause.
In 1883, she menstruated for the first time; these first
monthly periods were accompanied by violent cramps;
menstruation then ceased, and has not  since returned.
Every year  she comes home to spend her vacations
with her parents at the penitentiary.   It  is proper to
state that, prior to the events I am about to relate, she
had never witnessed any convulsive  crises.
    I also  bring before you the younger of the boys,
Francois, aged eleven years, who is  pale  and anaemic
like his sister.  At the age of four months,  he  had
convulsions, and from the time that  he  was two years
old he suffered  from pains in the  joints of the lower
extremities,  knees and feet.   These  pains, which have
lately returned  on various occasions,  are sufficiently
severe to keep him in bed.   He takes  his meals  at a
boarding-house near the penitentiary, and comes home
at night to sleep.
    Jacques, the elder of the boys, aged 12 years, also
anaemic, shares his brother's mode of life.  For several
years he has had convulsive tics, affecting chiefly the
mouth, as you can yourselves see.  During the month
of August last, the entire  family  were  home  passing
the holidays together—the father and mother busy
with their usual occupations, the children playing to-
gether in the yard  of the  penitentiary,  almost always
alone, for belonging to the families of the other officers
there was only one child,  four years  of  age.  Life in a 
                     —  5  —
house of correction must, as I have before said, be
very tiresome: apart from the regular routine, there is
little in the way of diversion; hence, in order to break
this  monotony, the wives of the prison officers  had
been in the habit now for more than a year of devot-
ing themselves with passionate interest to spiritualistic
practices, holding seances which were conducted every
other day by  a female  friend of one of them.   This
diversion was very much to their taste; in fact, they
all became pronounced spiritualists, and none more so
than Monsieur and Madam X.   The latter, moreover,
applied herself eagerly to  the reading of books treat-
ing  of "occult sciences," books which she did  not
hesitate to allow her daughter to read.   As for Mon-
sieur X.—who had at  first  been quite  indifferent to
spiritualism—since the month  of   March,  1883, he
never missed taking part in  table-tipping on Fridays,
it having been revealed to him by raps one day that on
some Friday he would become a medium and have the
power to call up  the spirit of his mother.  So it hap-
pened that Julie was present .at a spiritualistic seance
during 'the  Easter  holidays; this  did  not, however,
much affect  her.  Coming  home during  the August
vacation,  she had  already participated  in  several
"circles," in which, however, she had had no part ex-
cept to lay her hands on the table;  but on Friday, the
29th, her father made another  attempt  to  find if his
turn for being medium had not come.  He interro-
gated the table, and the latter,  instead  of  designating 
_ 6 —
him, as he hoped it  would, replied by raps:   "Julie
shall be medium."   The whole of Friday was devoted
to a seance which was almost uninterrupted. The next
day, at nine o'clock in the morning, the family and two
or three neighbors again formed a circle.  They called
up  the  spirits of various persons, and,  about three
o'clock in the afternoon, the table rapped  an order for
Julie to write.   She thereupon seized a pencil, but the
same  moment her  arms became stiff and her  eyes
fixed.  The father,  in  his fright, threw a glass  of
water in her  face.  She  came  to herself,  but  her
mother, having a presentiment of the danger, forbade
her to have anything more to do with table-tipping.
She did not,  however,  realize  the influence  of her
neighbor whose friend was a medium, and attended
the seance in her company.   This neighbor, desirous
of communicating with the spirit of her sister,  took
Julie home with her, and the seance recommenced.
About seven o'clock the table tipped, the spirit was
declared present, and"Julie said  to it:  "Please sign
your  name."   Immediately,  she  herself,   in   her
quality  of  medium and  " under the  inspiration  of
the spirit," seized a  pencil with  trembling  hand and
wrote " Paul  Denis" with a flourish.   The hand-
writing  was that of  a man;  the  P and D, moreover,
were written in such odd  characters that the  young
girl has never since then been able to trace letters like
them.   The signature was no sooner terminated  than
the hand that  had written them was convulsed.   Then 
Julie, with a shrill  laugh, rose immediately, and, like
one mad,  in wild delirium ran back and forth through
the house, uttering inarticulate cries, then rolled over
and over on the floor, presenting a series of hysterical
paroxysms characterized chiefly by contortions (clown-
ism).   The  next day and the following days,  the  fits
reappeared very often—twenty to thirty a day.   So
affairs went  on till  the fifteenth  of November, Julie
continuing to have convulsive crises  and being little
benefited  by the application of  divers means, and, in
particular, of hydrotherapy.
    Several days previously, Francois, the younger of
the boys, who,  like his brother, always took a great in-
terest in spiritualistic performances, was attacked with
pains in the joints, which,  at  that  time, kept  him  in
bed.   All at once, on the 15th of October, he  rose  in
bed,  and exclaimed that he saw lions and wolves; then
he leaped out of bed pounded the doors, declared that he
saw his father a corpse, that he saw robbers, whom he
attacked with  a short  sword; then he lay down and
rolled on the floor, crept on his belly, and assumed
certain well characterized  passional  attitudes.  Two
days later, Jacques had an  aggravation  of his facial
tics; then  seeing  his mother weeping, he exclaimed:
" I will kill myself if you weep  ! "  Then attacks  of
temporary delirium came on, during which he  mutter-
ed incoherent phrases and saw robbers and  assassins,
whom he tried  to strike.
    It was on the 9th  of December  that  the father 
                     —  8  —
and mother, in their affliction—all treatment having
been  without avail—brought their children to the
Salpetriere.   Separation and isolation were becoming
more and more necessary, for when one of the child-
ren had a fit, the others speedily followed the example.
    Julie,  whose  pathological antecedents you now
know, and whose age is thirteen  and a  half  years, is
tall and stout for her age, quite well  developed,  al-
though, as  I told  you, her  courses, which  came  on
once or twice in 1883, have not yet been permanently
established.   Despite of what her mother has informed
us, she seems to be of a  mild  and  quiet  disposition.
On the first  day of her entrance,  as  well as on the sub-
sequent days, she had several fits which were in gen-
eral characterized as follows:  All at once, sometimes
after a brief and variable aura, she fell backward, the
arms were separated from the trunk, the hands being
in pronation, the fingers clinched.   Then quite fre-
quently supervened one or more  attacks characterized
by a unilateral arching of the body; and lastly the
clonic phase presented itself, in which  the body was
jerked  back  and forth, the head  at  times  was  almost
brought in contact with the  pelvis, or the arms were
projected violently into the air, the  head still resting
on  the pillow.    During  the attack,  Julie  uttered
moans, had fits of laughter, but did not speak.  The
fit,  which  was  composed  of  a  series  of seizures
similar  to  what I  have described,  lasted  quite a
long  time—three-quarters  of  an   hour,  an   hour, 
                      — 9 —
or an hour and a half.  It was easy to stop or provoke
a fit at will by pressing one of  the  hysterogenous
points which the patient  presented.   Julie, in  fact,
possesses certain  permanent  hysterical stigmata; al-
though she  has neither cutaneous  anaesthesia  nor
ovaria [ovarialgia], she has numerous hysterical zones,
situated opposite each other, on  the two  breasts, on
botn flanks (externally), on both calves,  and the  two
external malleoli, and on the  internal  aspect  of the
right elbow joint.   The examination of the eyes, made
by M.  Parinaud gives results which are characteristic.
There exists, in fact,  on the right, a very marked con-
traction of the visual field; moreover, not only is the
circle of red situated  outside of the circle of blue, but
it even plainly extends outside  of that of  the white
light.  The same  phenomena exist on  the  left  side,
though less pronounced.  The other special senses are
intact.
     Francois, the youngest of the boys, aged  eleven
years,  has also certain permanent stigmata apart  from
the seizures which I have just described.   Thus, on
the morning of his admission, we noted an area of an-
aesthesia embracing  the whole face; this  patch  was,
however, variable, for the following days the insensi-
bility was limited  to the median  region of  the  fore-
head and nose.   The rest of the external integument
is notably hyperaesthetic.  All the special  senses are
affected; the taste is totally abolished, the insensibility
of the tongue is complete, the pharyngeal] reflex [no 
                     -- IO  —
longer exists, the  pituitary membrane and  the smell
are in similar condition, the external auditory meatus
is insensible, and hearing is very obtuse.   The exam-
ination of the visual field is also very  demonstrative;
the contraction is quite  marked  on the left, and not
only is the circle of the red outside of the blue, but it
also extends beyond the circle of white light.  On the
right, the contraction  is less marked, and  there  is no
transposition of colors.  Francois has from one to five
fits every day; some of them last two hours.   He pre-
sents clearly the phenomena of minor and  major hys-
teria {petit and grand mal hysterique).  The first, or
minor hysteria, is  characterized  by a  contracture of
the orbiculares of both eyes, which may last from three
to five minutes without loss of consciousness; or another
symptom referable to  the petit mal may present itself;
the boy smites with his fists or stamps with his foot, and
pronounces certain incoherent words,  and all is over.
But generally  the preceding  phenomena are followed
by a series of characteristic paroxysms constituting a
fit.   The upper and  lower  limbs become rigid, the
eyes are  closed, the body  is stiffly bent  into  a bow.
Then the boy throws himself  upon the floor, creeps on
his  belly, smites the floor, crying out at the assassin of
his  hallucination; he struggles and kicks and endeavors
to defend himself against his imaginary  foes.   The
tonic phase  is now repeated, and the fit is thus consti-
tuted by  a series of accessions, one set  of  phenomena
running into another or predominating over the others. 
                     — II —
It is a remarkable circumstance that, when  you com-
press the left hand, the fingers of which are extended,
you arrest the paroxysm instantly.  You cannot, how-
ever, provoke an attack in  this way.   The  skin  over
this region does not present any disorder of  the sen-
sibility.
     Jacques, aged twelve yeare,  pale and anaemic like
his brother and sister, is  the least  sick of  the three,
though he has one, two, and sometimes three  or  four
attacks every day.   While  there are not, in his  case,
any permanent stigmata,  there is a marked preponder-
ance of the petit mal over the  grand mal.  We know
that, before these fits came on, he  had convulsive tics
of the face; these are  now  exaggerated, especially at
the  beginning of the seizure.   He  makes  wry faces,
the   labial commissures are  drawn  outwardly;  he
mumbles, closes his  eyes, utters  certain  incoherent
words, and all may be  over.  But sometimes,  as a
sequel of these phenomena, or even at  the  outset, the
eyes close, the body stiffens, is arched  like  a  bow,
then the  child starts and runs or  walks  to and  fro,
speaks in a loud tone of voice, cries out at some im-
aginary thief, and finally throws himself  on his bed,
when the fit ends, or another one begins,  lasting  rare-
ly longer than a quarter of an  hour.
     These facts have seemed to  me to merit a particu-
lar attention.   These are not, in truth, fugacious symp-
toms of hysteria which these children present. Julie has
been sick for four months, and, if the isolation seems 
                     -- 12 --
to have somewhat calmed her crises, as well  as  those
of her brothers, it is no less true that the fits  threaten
to continue yet a long time, for you  cannot bring to-
gether those children without all three of them  im-
mediately having a convulsion.   The whole history of
this little family epidemic  is, moreover, very  instruc-
tive.  It makes you a witness of the genesis and evolu-
tion of the disease in a family of nervous and arthritic
persons under the domination of  two diatheses whose
alliance is a most fruitful source of neuropathy.   It
gives ^ou an idea of  the influence  exercised by the
kind of life one leads and the conditions of habitation.
Lastly, it indicates clearly the danger there is, especi-
ally to persons nervously predisposed,  in superstitious
practices, which unfortunately have for them so  great
an attraction, and in that constant tension of mind and
imagination to which  those are  brought who  apply
themselves to spiritistic performances  and the search
of the marvelous, an occupation in which children take
s© much delight. 
LECTURE  II.
ON  ISOLATION  IN  THE  TREATMENT  OF HYS-
                       TERIA.

Summary.—Retrospective details respecting a little epidemic
     of hysteria.  The treatment ought to comprehend three
     points;  A. Psychical or moral  treatment, including: i.
     Separation from the place where  the hysteria developed;
     2. Separation from each other of the persons affected; 3.
     Suppression of all visits on the part of parents or friends.
     B.  Medical treatment: 1. To modify the diathesis, if any
     exist  (rheumatism, for instance); 2. Static  electrization;
     3. Methodical  hydrotherapy.
        Preponderant influence of isolation.  Example—The
     treatment has been  adopted (not first proposed) in Ger-
     many and in England.
     Gentlemen:—Before returning to  the principal
subject of our present studies, I  thought it would be
of use  to  tell you something about those three child-
ren belonging to  one  family, whom I  brought before
you  on the  19th of last December.  I  have no inten-
tion of  repeating the history of this little epidemic of
hysteria, developed urgler the influence of  the  practice
of spiritualism; all the  details I have given you in my
previous lecture.   I shall call to  your mind only cer-
tain particulars  needful to refresh your memory as to
the condition of these children at the time they were
presented  to the clinic, in  order that you may be en-
abled to-day the  better to judge of the modifications 
                     —  14 —
which have been effected  in them under the influence
of the measures we have adopted and of the treatment
which we have instituted.
    The family, I may remind you, consists of three
children—two boys and  a girl.  It is with the latter,
aged  13^  years, that the affection began, August 28,
1884,  as a sequel of a seance of spiritualism which was
prolonged from 9 o'clock  in the morning till  7 p. m.,
and in which Julie played  the role of medium.  At
the  end of the seance, she  was taken with convulsive
paroxysms, which were repeated from fifteen to twenty
times  a day, till the admission of the whole family to
the  Salpetriere,  December  9, 1884.  You  remember
that the two brothers had followed the deplorable ex-
ample  set  by their  sister,  and   November  15  the
younger of the  two, Frangois, aged  11 years, about
six  weeks  after the  famous seance of  spiritualism
(which, by the way, had made no  impression on him),
was taken with a fit of hysterical  delirium while still
confined to his bed by an  attack of rheumatism.  Two
days  later, November 17,  Jacques, the older of  the
boys,  in his turn, had fits  and delirium with hallucina-
tions.                         •
    From this  time forth  the three  children could
never come together in the house  without having fits.
The  girl would  begin, her brothers would follow her
example, and this  would happen  several times a day;
this unfortunate state  of  things, of course, could  not
be allowed to continue.  Then it was that the parents 
                     — '5 —
besought us to interfere, and that we proposed to take
their children into  our service,  to which  they  con-
sented,
    I.   The proposition which I made to thfe parents,
itself, contained a series of  therapeutic considerations
which I must now set forth.   Admission to  the hospi-
tal enabled me to effect:
    The removal of the patients from the place where
their disease first declared itself;
    The absence of the father and mother, who  had
themselves become  very nervous, and whose presence
would, necessarily, according to my long and invaria-
ble experience on  this  point, prevent any effective
treatment;
    The respective separation of the three children.
    The girl, in fact,  was placed in one of the female
wards of our clinical department.   The two boys were
put in the ojily male ward which we  possessed at that
time.   The respective isolation of  the three patients
was not, then, altogether complete; we had, however,
done the best we could to keep them apart.   Such, in
my mind, should  be  the fundamental conditions of
treatment:  the parents consented no longer to see the
children but with  my permission, and I deemed my-
self warranted in assuring them that, in all  probabil-
ity, in a few months we should be  able to send home
their children completely restored to health.
    Such was the moral or psychical side of  the treat-
ment proposed;  we reckoned, of course, on  carrying 
— i6 —
out at the same time the medical  treatment, properly
so-called.   The children confided to our care were, all
three,pale  and  anaemic, and needed reconstituents,
among which bitters and ferruginous tomes hold  the
first place.   There was an indication, also, to endeavor
to modify  the rheumatic diathesis, which was so well
marked, at least  in one of them.
    As for those agents which are addressed particu-
larly to the hysterical state, we counted  much on put- *
ting in practice  the  treatment by static electrization
which  renders us  every day, in  these cases, so great
service, and this especially in default of a methodical
hydrotherapic treatment, our hydrotherapic  establish-
ment of the Salpetriere not being yet in good working
order.  We did not form any expectation  on the em-
ployment  of the bromides,  experience  having long
taught us that this class of medicaments, which almost
always acts well  (at least to  a certain  extent) in epi-
lepsy, remains completely  inefficacious, not only in
ordinary  hysteria,  but  also  in that form of hysteria
which seems most  to resemble epilepsy, namely, hys-
teria with  epileptic form, or  hystero-epilepsy.   I  say
nothing of  opium in  large doses, or of  any other anti-
spasmodics, the employment of which  I  do not con-
demn altogether, but which seem to me totally to have
failed in such cases.
    II.  But I must confess, gentlemen, that if I had
a mind to put in practice all the  therapeutic agents,
so-called, I should rely most on  isolation,  that is to 
                      —  17  —
 say, on  moral treatment,  although,  in  the  particular
 instance of these children, it was necessarily incom-
 plete.  It fact,  it  was possible for all  three  of the
 children to meet in  the hospital even—a thing which
 has often  happened; moreover, the two brothers oc-
 cupied  the  same  ward, and, like  their sister, could
 have before their eyes, and on different occasions, in
 the common sleeping-rooms, various manifestations of
 convulsive hysteria.  But  we could not help this,  and,
 in my judgment, it was better for them to live in these
 conditions than  to  remain under the   paternal roof,
 in  perpetual  contact  with the father  and mother,
 and in close relations with them all the time.
     I cannot too much insist upon the capital import-
 ance  which I attach to  isolation  in the treatment  of
 hysteria, where, indisputably, the psychical element in
 the majority of  cases  plays  a considerable, if not a
 predominant, part.   It  is now nearly fifteen years  that
 I have firmly held to the necessity  of isolation in  this
 disease, and  all that I have seen during this time only
 tends to confirm me more  and more in  my  opinion.
 Yes, it is  necessary to  separate  growing and adult
 children from their father and mother whose influence,
 as experience shows, is especially pernicious.   Experi-
 ence,  I repeat, proves this absolutely, although it may
not always be easy to assign a  reason for this, especi-
ally to mothers, who are apt to give a deaf ear to such
considerations, and generally yield  only at the last ex-
tremity.
     3 AA 
                     —  i8 —
     In city practice, isolation, such as I have  urged,
is, in fact, of  every day occurrence  in cases of this
kind, and the conditions for  such isolation in a city
like ours are ample and  excellent.   In Paris, for  the
last fifteen years, hydrotherapic health-institutes (mai-
sons de sante) treat such  patients with  complete suc-
cess, possessing admirable arrangements for this end.
In the  provinces, isolation is  more  difficult to effect,
for establishments  suitably furnished  and managed
are generally wanting: it  is quite possible to organize
private health-resorts  on a small scale, but you readily
understand that they  would  necessarily be  poorly
equipped for  doing thorough and systematic work.
     In the hydrotherapic maisons de sante, the patients
are placed under the direction  of competent and  ex-
perienced nurses who are generally  Sisters of Charity,
who  have become by long practice, very expert  in the
management of this kind of patients.  A kind but firm
control, much calmness and patience, are here  indis-
pensable conditions.  The parents  are systematically
kept away till the day when, by  reason of a notable
improvement in  the condition  of their children,  the
latter are permitted, as a recompense, to see them; first,
at long intervals, then  oftener, as  recovery  becomes
more pronounced.  Time and  hydrotherapy,  to  say
nothing of the  internal  treatment,  accomplishes  the
rest.   For my part, I  have the  firm  conviction that in-
cipient hysteria,  especially in young subjects and par-
ticularly in males, may often be nipped in  the bud,  if 
                     — 19 —
it is possible to persuade the parents to take energetic
measures  from the very start, and not to wait till the
disease takes root and  developes in  consequence of
having been too long left to itself.
    III.   In order to make plain this remarkable in-
fluence of isolation in  the treatment of hysteria in
young subjects (in this category marriageable girls
being included), I might cite  numerous  instances in
which it has proved to be singularly efficacious.  But,
not being able to  enter  into long details,  I will give
you the particulars of one case which seems to me to
be a typical one, and very appropriate to my purpose.
    My narration concerns a young girl of Angouleme,
thirteen or fourteen  years of age, who, for five  or  six
months, had grown very rapidly, and who,  all at once,
utterly refused all  nourishment, although there was no
trouble with deglutition, or any disorder on the part
of the stomach.  It was  one of those cases that border
on hysteria, but which do not  always properly belong
to it,  but which have been described  by Lasegue in
France, and  by Sir William Gull  in England,  under
the name  of nervous dnorexia, or  hysterical anorexia.
The patients do not eat, they are  not willing or able
to take food, although there is no mechanical obstacle
to the passage of the food or to  its sojourn in  the
stomach when once ingested.   Sometimes they eat on
the sly, but not always,  as has been supposed; and,
although the parents  themselves  favor this deceit by
placing  articles of  food in places where they may 
                     -- 20 --
easily find  them  and devour  them  unobserved,  yet
alimentation remains  always insufficient.   The family
waits weeks, months, always hoping that the desire
for food will return.   The repugnance of these patients
for eating cannot be overcome by entreaties, supplica-
tions,  or violence.  Then emaciation ensues, and may
attain extravagant proportions;  it is  no exaggeration
to say that these patients become living skeletons.  And
what a life !  Cerebral torpor succeeds the unnatural
agitation of the first period; for a long time walking
and standing have become impossible; the patients are
confined to their beds, where they can scarcely move;
the muscles of the neck are paralyzed, the  head  rolls
as an  inert mass  on  the pillow;  the extremities are
cold and cyanosed, and  the wonder is expressed how
life can continue in such a  physical wreck.
    The parents have long  been alarmed,  but  this
alarm has reached its climax when affairs have come
to this point; nor are such fears without good founda-
tion, for^ fatal termination threatens, and  I  know at
least four instances in which death ended the scene.
    Such was almost the situation of the little patient
of Angouleme, when I  received  a letter  from  her
father, setting forth  the  lamentable  condition of  his
child  and entreating  me to  come  and see her.   Such
a  journey on my part, I replied, was unnecessary;  I
could, without seeing the patient, give  the proper ad-
vice.   " Bring the child to  Paris," I  said, " place her
in one of our hydrotherapic establishments, leave her 
                     -- 21 --
there, or at least impress it upon her mind that you
have quit the Capital, then let me know,  and  I will
take charge of the rest.   To this letter, no  reply was
made.
    Six weeks later, one morning  a  practicing physi-
cian of  Angouleme came to  my office in an anxious
state of  mind, and  told me  that the  little  patient,
whom he had been treating, was in Paris, in one of the
establishments that  I had  designated;  that she had
been going on from bad to worse, and  in  all  proba-
bility had but a few days to live.   I  asked why I had
not been informed of the  arrival  of the young girl.
He  replied that  the   parents  had  refrained  from
notifying me because they had resolved not be sepa-
rated from their child.   To this  I  responded that the
principal element, the condition sine  qua non of my di-
rections, had  been  neglected,  and  I  declined any
further  responsibility in this  unhappy case.  Never-
theless,  yielding to his entreaties, I went to the hydro-
therapic establishment  in question, and there I  saw a
lamentable spectacle: that  of  a grown-up  girl, four-
teen years of age, who had reached  the last stage  of
emaciation and marasmus, prostrate in bed, extremities
cold and purplish, voice extinct, head drooping, and
presenting, in all the   leading features, the  picture
which  I have just given you.  There was really oc-
casion for being anxious, very anxious.
    I took the  parents one side, and, after severely
remonstrating with them, I told them that there re- 
                     -- 22 --
mained, in my opinion, only one chance  of success,
namely, that they should go  away, or seem  to  go
away, immediately, and leave their child to the care of
strangers.  They might say that they were  obliged,
for some cause, to depart immediately for Angouleme,
and put upon me the responsibility for this procedure.
At all events the child must be  made  to believe that
they had taken their departure, and  the  sooner the
better.  Their  consent was difficult to obtain, not-
withstanding all  my remonstrances.  The father, in
particular,  could not understand why a  physician
should insist that a parent should separate  himself
from his child  in time of danger; but I was firm in my
conviction, and urged  it  upon  them  with  all my
powers of  persuasion; the mother  yielded first,  and
the father finally consented  under  protest,  having
little faith in the success of this experiment.
    The isolation was effected; its results were rapid
and marvelous.   The child, remaining alone with the
Sister of Charity who had  care  of her, and the resi-
dent physician, cried for an hour or two, but mourned
much less  on  account  of the separation than  one
would have expected.  That very evening, in spite of
her repugnance, she consented to take half of a little
biscuit soaked in wine.  The days following, she took
a little milk, wine, broth, and a small quantity of meat.
Alimentation was  established,  and  went on  progres-
sively but slowly.
    At the end of a fortnight,  there was considerable 
                     — 23 —
improvement in her condition.  She was taking a fair
amount of food;  her strength returned with  plump-
ness,  and,  at  the  end of a month, I  saw the young
girl sitting  in an  arm-chair  and capable of  holding
her head erect.  She could walk a little;  then hydro-
therapy was resorted to,  and,  after two months,  dat-
ing from  the outset of the treatment, she  might have
been considered as almost well; as far as strength, ap-
petite, and flesh were concerned, there was  little left
to desire.
    Then  it was  that  the young patient,  on being
questioned by me, made this confession:   "Till papa
and mamma had left me, and till  I saw that you were
master  (for I well  knew that  you wanted to  make a
prisoner of me),  I could not be convinced that my
case was serious, and, as I  had a horror of eating, I
refused to eat.   When I saw that you  were master, I
was afraid, and spite of my repugnance, I endeavored
to eat, and  my appetite by degrees came  back."  I
thanked her for confiding to me this statement, which
is itself a lesson.
    IV.  I might easily multiply instances illustrative
of the  favorable  influence of  isolation, judiciously
carried out, in the treatment  of certain nervous dis-
eases  which do not, strictly speaking,  belong to the
category of mental alienation, and of hysteria, or  even
of neurasthenia in particular.   What I have just  said,
in fact, respecting hysterical anorexia,  I may also say
respecting most forms of the  hysterical neurosis.  But 
                      — 24 —
it suffices me, for the present,  to  have called  your at-
tention to the curative influence  of isolation; it  is a
subject to which I shall have occasion many  times  to
return, without doubt, in this course of lectures, being
one  on which I  have spoken every  year for fifteen
years,  and many of the lectures which I  have devoted
to it have been  published.   This method has,  more-
over, won general  acceptance, for I see  that in Ger-
many,  in particular, as well as in  England and Amer-
ica, its efficacy has  begun  to  be authoritatively  pro-
claimed.   Therefore I make  bold  to claim  for  our-
selves  and our institution the priority in this matter,
for,  if I  mistake  not,  the method  legitimately be-
longs to  us, at least as far as the  treatment of  hys-
teria and allied  affections  is  concerned.  Isolation,
in fact, is the capital element in the method  of treat-
ing neurasthenia and certain forms  of hysteria, advo-
cated  the last  few  years  by Weir  Mitchell in the
United States, Playfair in  England, and Burkhart  in
Germany.*
     V.  But  I  see that it  is  time to return to our

     *  R. Burkhart.—Zur Behandlung schwerer Formen von
Hysterie und Neurasthenic (Volkmann's Sammlung, 8 Oct.,
1884.)
     [In a foot-note,  Charcot shows that, while to the school
of Salpetriere belongs the credit, in these  modern  times,  of
most effectively systematizing isolation in the treatment  of
hysteria, yet such treatment is really of ancient date,  the neces-
sity of which was recognized by physicians hundreds of years 
                      — 25 —
 young  patients.  You will  be interested in  knowing
 how they have  been  faring  the  last six weeks, since
 we instituted the treatment  in which, in my judgment,
 isolation has played the principal part.  In  a general
 way, amelioration  has been observed  simultaneously
 in all three,  beginning with  the boys, as I have before
 told you.
     The youngest,  Francois, may be  considered  as
 well.   He has had no  convulsive attack  for a fort-
night,  and  yesterday he went  home  to spend  the
 holiday with his father;  I   understand that  he  has
 stood this test well  and  triumphantly.  I have  not
 quite as good news to tell you of Jacques, the  older
 brother, who, moreover, was the  last taken.  The
grand  crises have  completely left him; nevertheless,
they have been  replaced by slight attacks of vertigo,
quite like  those of epileptic vertigo, which,  however,
have become very  infrequent the  past fortnight.   He
did, however, at his  father's house, where he  accom-
panied  his  younger  brother one day, have  one  of
those slight  vertiginous crises which I am in the habit
of designating petit-mal-hysterique.
ago.   He cites Jean Wier  (1564), who, in a book entitled
"Histories, Disputes, and Discourses on Illusions and Impost-
ures of Devils," urges the necessity of removing these " pos-
sessed " girls (hysterics) from their parents and friends to suit-
able religious asylums,  where suitable  moral  instruction and
discipline might be imparted, and where they might be dispos-
sessed of the demoniacal influence.l 
— 26 —
    The young girl did not  accompany her brothers
home, but has remained at  the  Salpetriere,  for  we
were far less sure of her than of her brothers.  She is,
moreover, not yet cured, although from day  to day
her crises diminish in intensity, in length, and in fre-
quency.  She would certainly have got along a  great
deal faster if, in the ward which she occupies, she had
not been in constant communication  with  patients
afflicted with hysteria major, attacks of which she sees
every day.   But we have not been able  to do better
by her, not having any separate ward at  our disposal.
However, her condition has much improved; for, what
is pretty  decisive evidence, the  children have all three
of them  been several times  together  in the  electro-
therapic  room without any attack supervening.
    I am going to present to you first the boys, then
the girl, for, as I have said, I am  not so confident of
her, and  I fear lest the sight of this assembly may  dis-
turb her  to such a degree as to provoke some  sort of
hysterical attack.   I will also show you, in connection
with all three, that the  hysterical stigmata have under-
gone modification, as well as  the spasmodic  or deliri-
ous crises; this is an important  fact, for I do not think
that we can consider an  hysterical  patient as cured
while the stigmata still persist.  Here is little Francois,
aged eleven years; he has  advanced the farthest to-
ward  recovery.  You observe that he has a better ap-
pearance than formerly; the  tonic treatment and  the
hospital  fare (which  is,  however, not yet  what it 
                     — 27  —
should be) have improved his general health.  As for
the stigmata, I will recall to your mind that these con-
sisted, in his case, in a general  anaesthesia limited  to
the face, and especially to the forehead.   He did not
perceive odors, and his pituitary membrane was not
influenced any more by perfumes than by ammonia or
acetic acid; hearing was obtunded, and we  could in-
troduce little horns of  paper into the external  audi-
tory  meatus  without  the  sensibility being affected
thereby.   The general sensibility of  the  tongue,  as
well as the taste,  was completely abolished;  we  could
put aloes or sulphate of quinine on the tongue  with-
out eliciting the least perception of its presence.
     In this connection, I may  mention that a  fort-
night ago I showed this little patient to my eminent
confrere of London, Dr. J. Russell  Reynolds, who
was making a brief stay in Paris, intending to call his
attention to these troubles of gustation.   I own that
I was agreeably surprised to  see our' little  man  draw
back his tongue with a hideous grimace; this indicated
to me that our method of  treatment had  borne  its
fruits, and that the patient  was on  the road  to re-
covery.   His condition, moreover, has not ceased  to
improve, as far as the taste is concerned, as you your-
selves can  judge.
    Vision, as you know, presented also quite special
disturbances,  which, if it is true that they  do not
properly belong to hysteria, are met  so frequently  in
this affection  that  we can ascribe to them a  great 
I
                     — 28 —
diagnostic importance.  The contraction of the visual
field was very pronounced on both sides, but, while
on the right there was no transposition  of colors, on
the left side not only was the circle of red outside of
the circle of blue, but it  also  passed  beyond  that of
the  white light.   A  new  campimetric  examination,
made ten days ago by M. Parinaud,  showed  us  that
all these  troubles had vanished,  and  that vision  had
become normal.
     I have already told you that the crises had com-
pletely disappeared; let me remind you how numerous
they were, for they averaged three  a  day for a  long
time, giving a total of twenty to  twenty-five attacks
per week.
     I now present to you little Jacques, oldest of the
boys, twelve years of age, who was taken last, though
less seriously than his brother, and  did not have any
permanent hysterical stigmata.    In  him the minor
form {petit-mal-hysterique) greatly  predominated  over
the major (grand-mal-hysterique);  nevertheless, there
was one  time when he was having fifteen fits  a week.
For the last fortnight, he has had but two attacks  of
vertigo;  one  of these  happened  yesterday under cir-
cumstances which I  have  mentioned.   In  this  con-
nection,  I  may say,  once  for all,  that  cases  of this
kind are an imitation of epileptic vertigo, or petit mal,
nothing  more.  The epilepsy is only in the form, not
in  the  substance; and,  in  reality, petit-mal-epileptic
and petit-mal-hysterique  are  two things  radically dif- 
                      — 29  —
ferent.*  You will  remark, furthermore, that, if the
general  condition  of this  child  has improved,  he  is
still, in many respects, far from being well.
     Here is little Julie,  the oldest of the three.   It
seems to me that she has grown  taller and  stouter
within a month;  at  any rate,  her condition is much
more satisfactory.   As to her hysteria, you remember
that she was having on an average, every day four or
five attacks or series of attacks which lasted from half
an  hour to  an hour  and a half.    For the  last fort-
night, she has not had these fits oftener than twice or
three times a week;  they are  less  violent, and hardly
last a quarter of an  hour.   You  know  that she  had
certain well-characterized  hysterogenous points, situ-
ated on both breasts, the external part of both flanks,
the calves, the two external malleoli, and the internal
part of the right elbow-joint.   The zones on the two
breasts, the calves, and  the  right elbow have disap-
peared;  there  is  no longer ovarian  sensitiveness
(ovarie), but there are a  few patches of anaesthesia ir-
regularly distributed on  the left side.  The hysterical
amblyopia,  which in her case  was very  pronounced,
has not now existed for ten days; lastly, as I  have told
     * See in this connection, i,  Bourneville and  Regnard,
Iconogr. photogr. de la Salpetriere, t. i, p 49, and t. ii, p. 202.
Bourneville, Clinical and Therapeutical Researches on Hysteria.
etc.  (Compte rendu du service des  enfants de  Bicetre pour
1883, p. 100.) 
                     —  3° —
you, she can with safety meet her brothers, no  attack
being provoked thereby.
     Such is the situation, and there is every reason to
expect that we shall soon see the  end of this little
family drama, or, if you  please, comedy, for there is
nothing of a very serious  or gloomy character in all
these events.  In about ten days, we shall  send  the
oldest boy home; the youngest  goes to-day,  and  the
girl will leave  us a little latter.*
     I present for your meditation  the lesson which
the story of these children brings with  it.    I  believe
that by means of the measures which I have set forth
we  may sometimes  succeed in nipping in  the bud,
especially in males, nascent hysteria, hysteria of child-
hood.   I  am now speaking of this latter only, for,
when this neurosis  has  become inveterate in adults,
the chances of success,  though  still great, are much
more doubtful.   As  far  as these children  are con-
cerned,  I believe that, despite the nervous predisposi-
tion which seems so pronounced in  all  of  them, they
will henceforth, for a long time, if not forever, be free
from hysterical manifestations.  The parents, taught
by sad experience, will certainly henceforth keep them
from the practices of spiritualism. Knowing the weak
points in their children, they will endeavor, I hope, by
    * The youngest of the boys is to-day completely cured;
for more than a fortnight, the gill has had only one slight at-
tack during a visit of her parents at the Salpgtriere 
                     — 3i  —
the help of a hygienic discipline, which shall  compre-
hend as well  physical as intellectual and moral  cul-
ture, to avert any further occurrence of like untoward
incidents. 
LECTURE  III.
CHOREIFORM MOVEMENTS AND TREMBLINGS.
              RHYTHMICAL CHOREA.

Summary.—The Trembling of  Multilocular Sclerosis—Of Par-
     alysis  Agitans—Senile Tremor—Tremor with Slow  Os-
     cillations—With Rapid Oscillations—Vibratory  Tremb-
     lings—Hysterical Tremor—Alcoholic, Mercurial Tremor
     —The Tremor of General Paralysis—Of Basedow's Dis-
     ease—Chorea—Characters of the Involuntary Movements
     of  Sydenham's Chorea—Chorea and Hemichorea,  Pre-
     and Posthemiplegic — Athetosis  and  Hemiathetosis—
     Rhythmical  Chorea—Characters  of  the  Movements—
     They Manifest Themselves Under the  Form of Crises—
     They are Cadenced, Systematic, and Reproduce,  more
     or less Faithfully, Certain Movements of Ordinary Life
     (Chorea Saltatoria,  Malleatoria)—The Disease  is Gen-
     erally Linked to Hysteria—Prognosis Varying According
     to Cases.

     Gentlemen:—I desire to speak to you to-day, in
connection with certain cases of multilocular sclerosis
which I have shown you in former lectures, of divers
tremblings  and  other involuntary  movements  with
which the peculiar and almost characteristic trembling
of this affection might  be  confounded.   I  have  laid
stress on the particular characters  of the trembling of
multilocular sclerosis, and  already I have pointed out
to you that it only manifests itself on  the occasion*of
intentional  movements  of  some  extent  (intentional 
                     —  33 —
tremor,  intentionzittern  of German writers); that it
ceases to exist when the patients are left to complete
repose—when they are lying in their beds, for instance.
If, on the other  hand, the patient  assumes a sitting
posture,  the muscles of the neck and trunk are brought
into exercise to maintain the  erect position of the
body,  and there supervene  oscillations of  the  head
and trunk, while the limbs are at rest.  If you wish to
cause the rhythmical  agitation to reappear in a partial
manner,  in one of the members for  instance, you will
ask the patient to lift a glass of water  or  a spoon to
his mouth.  This act requires a voluntary movement
of considerable extent, which is  the  necessary condi-
tion for bringing on  the tremor, which does  not or-
dinarily manifest itself in  petty movements, such as
threading a needle, sewing, etc.  The oscillations are
scarcely  noticeable at the moment  of taking hold of
the tumbler, but they became more and more exagger-
ated to reach their maximum as the glass  is brought
to the mouth.  This special character of the tremor of
disseminated sclerosis is readily indicated by a tracing
made by the enregistering apparatus.   Part i, Fig.  i,
represents the intentional  trembling of disseminated
sclerosis.
    The horizontal line A  B indicates the state of re-
pose.   The point B represents the moment  when the
voluntary movement begins; B C marks the direction
of that movement, during which the trembling is de-
noted by the broken line x y z, each segment of which
is the longer the farther it is removed from the point B.
     4 AA 
                      — 34 —
     Such is the trembling  of  multilocular  sclerosis.
In order the better to set forth  the  particular charac-
ters  which  distinguish  it,  I propose  to employ the
method of contrast; in other words I  shall compare
this kind of tremor with  other  tremors belonging to
quite different  diseases, although several have  been
confounded with it till a very recent period.
                                  J
                       Fig.  i.
    This figure is the schematic representation (in part) of the tracing
obtained by the graphic method in two hospital patients.
    Let us begin  with paralysis  agitans.  Like the
tremor of  multilocular sclerosis, that of Parkinson's
diseasejs composed of rhythmical  oscillations, but of
little  extent and short duration.   You  can  observe
these  characters in the patient whom I now bring be-
fore you.   You will notice that  the  hand  and the
fingers tremble individually, but you should mark well 
                      — 35 —
 the quite particular attitude of the hand.   The phal-
 anges are extended, the  one upon the other, while the
 fingers are flexed upon the metacarpus.   The thumb
 is adducted, and its pulp rests on  the index-finger, as
 if about  to  hold  a pen; and  the movements which
 keep all these parts in agitation resemble sometimes
 the  act of  rolling  a paper ball or  crumbing bread.
 This tremor is continuous, and  (what is an important
 fact) manifests itself apart from all  voluntary move-
 ment. If you command  the patient to raise a glass of
 water to  his mouth, you  will notice,  perhaps, the tre-
 mors augment in amplitude, but you  will never witness
 those oscillations with large curve which are character-
 istic of multiple sclerosis.    Their character  is  well
 shown in  the tracings made with the enregistering ap-
 paratus.   Part 2 of our figure represents the trembling
 of paralysis agitans.   You  see, at  a  glance how the
 two tracings differ in the portion B C.  Take  the part
 A B, the line of the rest: you see that it is cut by little
 broken lines corresponding  to the continuous tremb-
 ling.   At the point B the voluntary movement begins;
 from this point the components  of  the broken  line
 x y z are a  little longer  and more irregular  than  in
 period of  repose, but they are never so much so as  in
 multiple sclerosis.
     Remember, also, that in Parkinson's  disease the
tremor does not in general  affect the head, and if the
latter seems to participate in the involuntary move-
ments, it  is in reality only the seat of communicated
movements. 
                     - 36 -
    The tremblings of multiple sclerosis and  of par-
alysis agitans are slow oscillations—four or five  per
second on an average.   This same slowness of the os-
cillations is observed in senile trembling.   Here  are
two women affected with this kind of tremor.  In one
of them,  by name La.,  aged  seventy-three years,  the
disease began at the age of sixty years in the index of
the left hand, after  receiving an injury.   In the  other
patient, Les. by name,  aged eighty years,  the tremor
first showed itself more than fourteen years ago—dur-
ing the siege  of Paris, after  a violent  emotion.   In
these  women, the hands and the fingers tremble indi-
vidually, as in Parkinson's disease.  The head partici-
pates  in the shakes, and its movements in the horizon-
tal and vertical direction, succeeding each  other with-
out regularity, during which the patient seems  to  be
gesticulating yes and no, are quite characteristic  of the
oscillations of the head in the trembling  called senile.
    Before passing to  the  category  of rapid  oscilla-
tions,  I wish to mention a species of  trembling which
holds  the  mid-place  between  the  two—hysterical
trembling.  We have at present in our wards two men
who are affected with this kind of trembling.  In one
of them the oscillations are five, in the other seven per
second.   I  can only mention, on passing, this  kind of
trembling,  proposing  to  return  to  it  later and con-
sider  it more  in detail, and make of it, though only
provisionally, from  the point of view of the rapidity of
the jerks, a category  intermediate between the first 
                     — 37 —
and second groups.  To a second  class I shall  assign
the tremblings with  rapid oscillations, which  I shall
call vibratory tremblings.  The number  of  jerks here
reaches eight or nine per second, and this is the only
apparent difference which separates this group from
the  first.   We include in  this  group:  i.   Alco-
holic trembling.   2.  Mercurial trembling.  3.  The
trembling of  general  paralysis.   4.  That of Base-
dow's disease.   A distinction may  still  be made be-
tween the three first and the  last in taking into con-
sideration this  fact, that in the  former  the fingers
tremble by themselves, while in Basedow's  disease the
individual  trembling of  the fingers does not  exist.
This character may be readily shown by the  graphic
method, as Dr. Marie has done.   If you place  in the
hand of the patient an elastic ball communicating by
a tube with  the sensitive drum of an enregistering ap-
paratus, you  will see  that  in  the cases  where the
fingers tremble by themselves the  tracing  is strongly
undulated, while in  Basedow's disease it  is reduced
to a straight  line, or one  broken  by very slight un-
dulations.
     By the  side of these tremors—/. e.,  these jerkings
with rhythmical oscillations,—there is another class of
involuntary  movements which might be, and which in
fact  has been, confounded with the  trembling of dis-
seminated sclerosis—I refer to chorea and  choreiform
movements  in general.   Here we  have no longer  to
do with rhythmical oscillations, but with gesticulations 
                     - 38 -
with large sweep, disorderly and purposeless.  These
gesticulations do not present any kind of rhythm, and
they are  meaningless—/. e., they do  not  imitate any
movement  of expression or  profession.   They exist,
like the preceding, during times of rest, and are exag-
gerated during intentional  actions, when, also, contra-
dictory gesticulations disturb the general direction  of
the movement, and cause it to miss its goal; while in
multiple sclerosis, and in the other forms of trembling
of which  I have  spoken, the general direction  of the
movement, if it be interrupted  by the jerks which agi-
tate the member, is, nevertheless, always preserved as
a whole.   However,  despite these  capital differences,
there are certain outward similarities between choreic
movements and  those of multiple sclerosis which long
led certain distinguished authorities to regard multiple
sclerosis as a sort of chorea.  Duchenne, of  Boulogne,
who well recognized  the congeries of signs of multiple
sclerosis, but who knew nothing of it from an anatomo-
pathological  point of view, called  it choreiform par-
alysis.  I desire, then, to speak briefly on the general
subject of chorea.
     We  have,  first,  common chorea,  called rheumatic
chorea, chorea minor, which has also been called Syden-
ham's chorea, and which must  be  differentiated  from
the true dance of St.  Guy, the great  epidemic chorea,
chorea  major.  It  affects  principally, as you know,
children of  from five to fourteen years of age;  more
rarely, adults and old men.   You  remember, doubt- 
                     — 39 —
less, the patient Flor., whom I presented to you as an
example of common chorea.   In this young girl the
disease is on the decline, and  the intervals of rest
which separate the involuntary movements are  to-day
of considerable length.  But  under the influence  of
an  emotion,  as  during the medical  examination,  or
even without any apparent cause, there  are often seen
little jerks or twitchings in the  left upper extremity.
The patient  brings her  hand suddenly against her
body, or rubs it several  times  against her  thigh  in
alternate movements of pronation and supination.   In
this patient (and  this is an  exception to the general
rule) the intentional act does not exaggerate  the con-
vulsive movement;  and if you ask her to lift a glass
of water or a spoon to her mouth the direction of the
movement  is not always disturbed, and  the end is
attained with  sufficient certainty, which is  far from
being always the  case in chorea.  The face is likewise,
in its left half, the seat of involuntary twitchings and
grimaces.
     In the  same group  of  incoordinate  choreiform
movements we shall also  place prehemiplegic  and post-
hemiplegic chorea.  The movements are, in  fact, here
of the same nature; the only essential difference is in
the pathogeny, the disease being, in these latter affec-
tions, associated  with  definite cerebral  lesions, local-
ized after a certain fashion.
     The same may  be  said  of athetosis, which, in a
natural classification, ought to be placed alongside of 
                     _ 4o —
chorea and posthemiplegic  hemichorea.  In athetosis
there is no  rest,  and the movements are in no sense
coordinated.   I  shall  not  stop  to describe the con-
tortions of the fingers, their alternate flexion and  ex-
tension;  I  have  already  shown  you  examples  of
athetosis.   I will only remark that  it differs  notably
from chorea in this  respect, that the movements  are
less sudden, more slow than in this latter disease (one
might liken them to the agitation of the tentacles of
a polyp), and they also differ in  being  limited  to  the
fingers and wrists, to the feet, and to  the toes, although
sometimes there are twitchings of the face and of  the
platysma.   The patient cannot  hold anything in  his
hand, or lift anything to his mouth; if you put any
object in his hands, he immediately  lets it fall to  the
ground.   In cases of double athetosis, these pheno-
mena  sometimes  present  a gross  similarity to  the
trembling of disseminated sclerosis.
     Thus are  constituted  the  two first  groups  of
tremors, and I am going now to  speak of an affection
which forms our third group.  It also bears the name
of chorea, although it differs considerably, as you will
see, from Sydenham's chorea and its kindred affections.
This  takes  us away somewhat from the subject of
multilocular sclerosis, but I do  not  wish to miss  the
opportunity of bringing before you a certain  number
of typical cases which we are rarely  fortunate  in find-
ing together, for the disease in   question is  relatively
infrequent. 
                     — 41 —
    In rhythmical chorea we find  neither oscillations
nor vibrations, as in tremor, nor the aimless bizarre
gesticulations of common chorea; but if the  affection
is  itself also characterized by involuntary,  impulsive
movements, these  movements are complex; and be-
sides (what is an  important fact),  they occur accord-
ing to a regular rhythm:  they are cadenced.  They
have  not then, as you see, the character of irregu-
larity of  the choreiform  movements which I  have
just described.   We  might almost call them  systematic,
because they seem to be coordinated according to a
certain plan, imitating,  for example:  i, certain move-
ments of expression, such as dancing (chorea saltatorid);
2,  certain prof essional acts, as the movements of rowers
or blacksmiths {chorea  malleatoria).  In a word, there
is  a more or less  faithful  reproduction  of voluntary,
logical,  purposive acts.
    The disease under consideration seems generally
allied to hysteria, or to  be of hysterical origin, although
it  may,  in some cases, exist by itself, apart from every
phenomenon ordinarily characterizing hysteria.   You
shall,  moreover, yourselves see how the transition be-
tween  these two states may be effected, for, without
longer dwelling on these generalities,  I  am  going  to
bring before you three patients, who  present in dif-
ferent degrees the  symptoms of  rhythmical chorea.
One of  them, Flor. by  name, is already known to  you.
But you have only seen her when passing through the
wards, and she merits  a more  thorough  study.  She 
                     — 42 —
has been in our service  more than six months, and I
made her the subject of a lecture more than a year
ago.  From this you infer that we have here  a stub-
born affection, from which patients are with difficulty
delivered.  This woman is twenty-six  years old.  She
has been twice married;  first at  eighteen, then at
twenty years of age.  She has had three children.  She
is of an irritable temper; is married to  a workingman,
cailed a "smart" man, by the way, but whose frequent
"sprees" are  the subject  of lively  quarrels  in the
family.
    You will find nothing in the hereditary or personal
antecedents deserving  of  special mention.   Three
years ago, after her last confinement, she began to ex-
perience the folloging symptoms:   Often  after dinner
she felt a fullness in the region of the stomach, with
pulsation; then there was the sensation of a ball in
the throat.   She then fell into a sort of a swoon, with
numbness over the whole body; this ended in a fit of
crying.   She had also, at this time, attacks of  spitting
and vomiting  blood  (neuropathic  hemorrhages of
Parrot).  Lastly, I may add that she had a right-sided
hemianesthesia, which, however, was quite slight;  this
has to-day passed  over to  the left, without modifica-
tions of the visual field, or other sensorial troubles.
She has never had ovarian irritation (ovarie).   These,
gentlemen, are the stigmata of  the  great neurosis;
they have  to-day  almost completely disappeared, but
their former existence is sufficiently proved to enable 
                     — 43 —
us to confirm the hysterical nature, or at least origin,
of the affection from which she is suffering now.
    The onset of the accessions of rhythmical move-
ments  dates from  May 15,  1884—i.e., a  year ago.
They came on for the first time on the occasion of a
family  wrangle, which took place during the menstrual
period, and after one of those hysterical crises  which
she was in the habit  of having  after dinner.  Then
was constituted the  chorea in  its  permanent form, the
accessions supervening at  all hours, except  during
sleep.  The attacks lasted from  an hour to an  hour
and a half, being  separated by intervals which were at
first short, but at the  end  of several weeks  became
much longer, and to-day spontaneous  crises are rare.
We have found that we can provoke  them readily  by
certain manoeuvres.   Static electricity seems  to  have
produced the amendment which has of late been ob-
served; it is  under  its  influence, without doubt, that
the hemianesthesia  first went over to the  other side,
then disappeared.  But the disease  is, I  think, far
from being completely cured.  I remember a young
Polish woman whose malleatory paroxysms of the arm,
coming on by crises  of one or  two hours' duration
several times a day, continued for  seven years.   I  do
not know whether she is actually cured yet;  and, more-
over, I  am  going presently  to  show you  a patient
whose attacks have  lasted more than thirty years.
    The present condition of Flor. is the following: I
have told you that  there are spontaneous  crises and 
                    — 44 —
provoked crises.   The  first generally come on after
meals; they are,  in some sort, relics of the  former
postprandium  hysterical attacks.   The patient then
feels  a  pain and beatings in the  epigastrium, and a
numbness "all over."   The right arm then begins to
jerk, and is soon  followed by the left, and by the lower
extremities.  You witness, then, a succession of varied
acts of a very complex  kind, in which you  can recog-
nize the characters of rhythm, of cadence, and a  per-
fect imitation of  certain intentional and well-directed
movements, such as I spoke of in my general descrip-
tion.  When  the  onset  is  spontaneous,  the  crisis
appears without  any  aura, other  than a beating or
twitching of the right eyelid.
    The provoked crises are brought about by pulling
the right arm, or by striking with a hammer over  the
patellar tendon, as you  see me now doing.   When the
fit is  excited by pulling  the  arm, immediately   this
member begins  a series of rapid  rhythmical move-
ments, in which the patient seems to  be  beating eggs;
then she flexes her fingers, apposes  the pulp to  the
thumb,  and, elevating the arm, makes the gesture  of a
public speaker who is making a demonstration.  From
time to  time the  whole  right upper  extremity is exer-
cised  in wide  movements  of  circumduction.  The
lower extremities are likewise agitated  in their turn,
and  if  the patient  is  standing and  supported, she
dances alternately on each foot, imitating quite accu-
rately the Bourrie, or the dance of  the Tsiganes, or 
                     — 45 —
of the Zingari of Andalusia.  During the entire attack
the patient is completely conscious, and what is quite
remarkable, when any  one happens to be  standing
near her, and she is on the point of executing one  of
those great movements,  which might result in hitting
violently her neighbor,  she calls out to this person  to
keep out of her way.  It seems, then (and this  is an
important fact from a  psychological point  of view),
that the act  is preceded by a  mental  representation
which  warns  the patient of what  is  coming.   You
may question her during the paroxysm, and she will
tell you that she does not suffer, that she is only  very
much fatigued  and incommoded by violent palpita-
tations.   At times she stops and rests a moment; you
would think that the attack was over; but no, it com-
mences  again, and the  same phases are  reproduced.
The entire duration of the attack varies from one  to
two hours.  She is then  put to  bed, and  all is  over;
when she  rises, she complains of being a little fatigued.
    Yon are now about  to witness a similar crisis  in
another patient,  as a sequel of similar  movements.
This is  the  woman, Deb.  by  name,  in  whom the
chorea has now  lasted more than  thirty  years; only,
the patient has been somewhat better lately, in this
respect, that  the spontaneous  crises have been ex-
ceedingly rare;  they now  appear only when  pro-
voked.   She  is to-day  sixty-seven  years  old.   The
menopause passed a long time  ago, so that we can
no longer count  on  that to bring about a favorable 
                     — 46 —
change in her condition.   I shall, moreover, show you
several instances of the same sort in  the  description
of hystero-epilepsy which I am going to give in an-
other lecture.  Actually, no permanent sign of hys-
teria remains in our patient, and you find none of the
residua of this neurosis, except a  tendency to violent
emotional outbursts  and the  accessions  of  rhyth-
mical chorea.  The attacks are  easily  provoked  by
pulling  at the arm,  or  by percussing the  patellar
tendon,  as in our other patient.   But before bringing
on  one   of  these  attacks I will give you the  main
points of the history of the disease.   The  commence-
ment dates back to the age of  thirty-six  years.  At
this  time,  being  out riding  with her  husband, she
met  with a  severe  accident—the carriage was   upset
and  she was precipitated over a  steep  embankment.
Following the  great  fright which  she experienced,
she lost  consciousness, remaining in  this state  three
hours; then she  had a  convulsive  crisis, a severe
hysterical fit, followed  by contracture of the  limbs
of the right  side, then by barking.  It was  at the end
of several months only that the rhythmical crises ap-
peared just as we see them to-day; they were  then,
moreover, more intense and more prolonged.
     Look at this patient  at this moment.   We have
no need to do anything  to provoke an attack, for the
emotion  which she  experiences  before such an  as-
sembly in the amphitheatre has brought one on.  In
the first phase we see the rhythmical shocks of the 
                     — 47 —
arm, the malleatory movements;  the  patient has her
eyes shut.  Then to this period succeeds a period of
tonic spasms  and of torsion of the arms and head, re-
sembling partial epilepsy.  This is truly a relic of her
old convulsive  hysteria.  Lastly,  there are cadenced
movements of  the  head to  the  right  and left, rapid
movements, and not  easily explained,  for  I  ask  my-
self, to what do they respond in the series  of physio-
logical actions ?  At the same  time the patient utters
a sort of cry  in a singing tone, a modulated plaint,
which never varies.  And here we find the character
of coordination, of  apparent adaptation, which  is pe-
culiar to rhythmical chorea.   The crisis ceases  under
our eyes spontaneously.  During its entire  duration
the patient has never once lost consciousness.
     You see  by this example  that rhythmical chorea
may be in some cases a grave affection; not that it di-
rectly menaces life, but because it may persist a very
long time, and  become a horribly oppressive infirmity,
preventing the patients from pursuing any occupation,
and  obliging them to estrange  themselves from  so-
ciety by reason of the terror which their fits cause, and
the sentiment of repulsion of which these  unfortunate
beings feel themselves the object.
     Happily, matters are not always so gloomy in the
history of rhythmical chorea, and I am able, in  con-
trast with  the two  cases  to which  I  have just  called
your attention, to present to you a third patient, in whom
the rhythmical choreic movements exist only in the 
                     — 48 —
rudimentary state, supervening by spontaneous or pro-
voked  crises,  as in  our first two  cases,  but  here
always mingled with  the symptoms of ordinary con-
vulsive hysteria.  In  a  word,  the rhythmical  chorea,
which in this third  patient takes  on  the  malleatory
form, is an  accompaniment of the hysterical parox-
ysm, not detaching itself  therefrom  to  individualize
itself.
    This  patient, Bac.  by name,  aged twenty-nine
years,  a seamstress,  has been in  our service  since
January 6, 1885.  In  her hereditary and  personal an-
tecedents we find no trace of neuropathy.   At the age
of twenty-two  years, as  a consequence of intense  grief
at the death of  a relative, she had veritable  fits of
hysteria, in which were  already manifest the  choreic
movements of  to-day.   From  1878  to  1884,  she  had
only four or five convulsive crises as a result of being
crossed in her wishes.   I note, on passing, that she
has had several attacks  of  blennorrhagic arthritis in
the right  wrist,  left knee,  which have doubtless co-
operated, to some degree, in bringing about her actual
neuropathic condition.  There are  no sensorial trou-
bles, no modifications of the sensibility, other than  a
slight anaesthesia to cold on the  left side;  there  is  a
sensitive ovarian  point on  the right;  so that in  this
instance  (as is sometimes  seen)  the  ovaria  and the
hemianesthesia are crossed.
    When the attacks  come  on  spontaneously,  they
begin by a feeling  of  discomfort  in the epigastric 
                     — 49 —
 region, and by palpitations; sometimes  the  sensation
 of a ball in the throat exists.   There has  never been
 any cephalic aura.  You can, moreover,  provoke an
 attack by pulling on the left arm  and by shaking it at
 the same time, so as to imitate the malleatory  choreic
 gesticulations.  At first the left arm begins to  present
 malleatory movements, which the right  arm executes
 shortly after.    But at the  same  time the whole
 body stiffens, the head  and inferior extremities re-
 maining unmovable.   From time to time the  latter
 take  on  a trembl.ng movement,  the  eyes  remain
 closed, or the eyelids quiver.   Occasionally,  the body
 arches itself into the form  of a bow, and this inter-
 rupts the monotony of the attack.   Pressure over the
 right ovarian region stops the convulsion,  and then
 for a moment the patient remains without speaking or
 moving.
     Here the hysterical origin of the affection  is still
 more pronounced than in the first two patients.   The
 rhythmical disease is not detached from the hysterical,
 as an autonomous affection.  The case is also,  I hope,
 less grave in  consequence.  In  short, in this  patient,
 apart from the malleatory phenomena, we  have to do
 with  fits  of  quite  an  ordinary  character, belonging
 rather to the  minor hysteria than  to hysteria  major,
the attacks rarely occurring, and then on the occasion
of an emotion.  We may hope that under the influence
of an appropriate treatment the attacks will disappear
along  with  the  rhythmical choreiform  movements
which accompany them.
      5 AA 
LECTURE IV.
MUSCULAR ATROPHY CONSEQUENT  ON CER-
           TAIN  ARTICULAR  LESIONS.

Summary:—Articular Traumatism—Consecutive Paralysis and
    Muscular Atrophy—Modification  of the Galvanic and
    Faradic  Contractility—Contractions Provoked  by the
    Electric Spark—Exaggeration of the Tendinous Reflexes
    —Simple Muscular Atrophy—There is no Necessary Re-
    lation Between the Intensity of the Joint Affection and
    that of the Paralytic and Atrophic Phenomena—The Ex-
    tensors of the Joint are Affected in a Predominant  Man-
    ner—The Muscular Lesions are  Under the  Dependence
    of a Deuteropathic Spinal Affection.
    Gentlemen:—By its  origin,  the affection from
which the patient whom I am about to present to you
suffers may be called surgical; it was, in fact,  in  a
traumatism that it originated.  But, by the fact of the
traumatism there is produced a spinal affection,  of  a
particular kind, which still  persists to day,  although
now for a long time the arthritis, the  immediate  con-
sequence of the traumatism, has ceased to exist, and  it
is in this condition that the patient claims  our atten-
tion and our help.
    This young man, B----by name, aged twenty-
three years, employee in a telegraph office, has always
been healthy heretofore, and  has  presented  nothing
worthy of note in his  antecedents  except  that  a 
                      — 5i —
 maternal uncle had  some  mental disorder for which
 he was consigned to an asylum.
     This patient is brought to you on a litter, although
 he is capable of rising and walking; this  is because I
 wish to point out to  you certain peculiarities which
 cannot well be observed except when the  patient is in
 bed.
     I shall first call your attention to the fact that the
 general condition is excellent; good  vigorous appear-
 ance, good appetite, all the  organic functions are well
 performed.
     The affection from which he  suffers consists  ex-
 clusively in a difficulty in walking,  and it is, as you
 will see, the  usage of the right leg,-or rather of certain
 muscles that move that member, which is at fault.   It
 is about a year since the patient began to  be troubled
 in his power of locomotion.
     A methodical  examination shows us  that  when
 the patient is in bed, the right inferior member executes
 normally all its movements  except one, the extension
 of the leg upon the thigh.  The movements of abduc-
tion and adduction of the  thigh, the flexion of  the
thigh on the  pelvis and of the  leg on the thigh,  the
 isolated  movements of  the  foot, the movements  of
flexion and extension  of the foot on the leg,  are free;
but the extension of the leg is wanting.  So,  when he
wishes to extend  the leg placed in semiflexion, he
contracts the extensors of  the thighs by sliding  his
heel along the plane of the bed, or he helps  elongate 
                     — 52 —
the member with his hands or with his other foot.   It
is, then, you see, the extensors of the leg which are at
fault.   It  is  the  muscles  innervated  by the  crural
nerve,  and  more  especially the triceps, which  are
affected.
    The patient can oppose, although  with less force
than with the sound limb,  the attempts  of extension
or of flexion which you  make upon the joints  of  the
hip and foot; he resists  also very well when you  try
to straighten the flexed  knee, but he  opposes only a
feeble resistance to  forced  flexion of the leg on  the
thigh.
    In short, although there is but little relative  en-
feeblement of the muscles of this limb, it is principally
the action of the triceps which remains to-day at fault.
    This  paralysis, limited to  the  extensors  of  the
knee, also makes  itself manifest when the patient
wishes to get out  of bed on the left side and  under-
take to walk.  You see how, in order to get  out of
bed, he raises the right leg by the aid of the  left foot,
in order to make  up for the impossibility of  extension
of the right knee.  He walks without a cane, but  you
will remark something  strange  in his  mode of pro-
gression;  note, moreover, that his condition has much
improved during  the past few days;  when this  patient
was admitted, the characters of the  gait,  which  was
then greatly impeded, were much more pronounced.
You can, however,  remark that  while at each  step in
advance the left knee  bends, then  extends, there is 
                     — 53 —
hardly any attempt at flexion or extension of the right
knee; it is in the hip that the movement takes  place;
the right lower extremity, too long as it were, performs
a movement of circumduction as if it were all  of  one
piece, and as if the knee joint did  not exist.   Formerly
there was a tendency in the point of the foot to drop,
and this rendered walking  still  more difficult;  this
paresis of the muscles which flex the foot on the leg
has since disappeared.
     It is important to remark that there is no pain on
the occasion of movements, so that  the difficulty in
walking cannot in this way be explained;  the joint is
also perfectly free; it is then in the nervous system or
in the muscles that we are to look for the cause  of the
motor impotence.
     A more  attentive  examination of the affected
limb, moreover, enables us to detect a number  of  im-
portant particulars.   You notice, first, a diminution of
the  entire  member; this  was  formerly  still  more
pronounced.
     Mensuration gives:
                         ON THE RIGHT.  ON THE LEFT.
At the upper part of  the thigh,    48 cent.       52 cent.
Above the knee............   37  "        38  "
Around the calf of the leg...   33  "        35  "
     But even without having  recourse to  mensura-
tion, it  is easy  to  see that  the anterior aspect of
the right thigh is considerably  flattened, as  if  ex-
cavated,  besides  the  muscles of  this  region  are 
                     — 54 —
flabby, and  lack  their usual plumpness even at  the
moment of  contraction.
    There exists, then,  not only a paresis, but also
a modification  of the nutrition, an  atrophy of  the
triceps muscle.   The thigh  and  knee of that side
seem  also to be  colder than  on the other side,  but
without any marked trouble  of the cutaneous  sensi-
bility.
    Add, to complete the description,  the  results of
the electric exploration, which show us the state of
nutrition of the muscles.   At  the time of the admis-
sion of this patient, eight days ago; (a) the galvanic and
faradic excitation of the  crural  nerve at the fold of
the groin gave scarcely any  contraction; (b) over the,
points of election, faradization with a strong current
by the apparatus  of Du Bois-Raymond  (the bundle of
iron wires being shoved fully  into the  cylinder) pro-
duced scarcely any reaction;  you  would  have  said
that the muscles were absent.   From this last charac-
ter, you would have expected  to see galvanization pro-
voke the reaction which  is observed  when  the  nutri-
tion of the muscles is profoundly affected, as  takes
place after experimental  section of the nerves,  or in
infantile paralysis  when  there is  destruction  of the
motor cells, or as  in grave cases of facial paralysis.   In
such cases, and we have  here  one of  the characters of
what  is called in electro-diagnosis the reaction  of de-
generation, the galvanic  excitability is  exalted, at the
same  time that there is weakening  or absence of the 
                      —  55 —
faradic excitability;  in  the case  before us, however,
there was nothing of the kind, the galvanic  current,
even with fifty elements, whatever might  be  the  dis-
position of the poles, gave no  more  contraction  than
the faradic current.   There was, then, a quantitative,
and not a qualitative modification of the reaction; one
might from that  conclude  that  we had before us  a
case of simple atrophy,  and not an atrophy  of degen-
eration.*
     What is moreover remarkable, this  muscle, which
remains almost inert, whether  under the influence of
the will, or that of electric  excitations  (direct or in-
direct by faradic or galvanic excitation of the  nerve),
contracts quite energetically when, on the patient be-
ing placed on the stool  of the static  electric-machine,
a spark  is generated over  the  right rectus  cruris or
vastus internus, (the vastus externus makes an excep-
tion in this respect that it has preserved a certain  de-
gree of faradic and galvanic excitability).    Add  that
the  mechanical  shock  imparted  to  the right rectus
femoris provokes an  evident contraction, and that the
     * Rumpf has studied in the service of Prof. Erb the elec-
tric reactions  of  the muscles in cases  of  joint  affections
(shoulder, knee, etc.)  He  has found, and his results have
since been a number of times confirmed by those of Erb, that
in these cases there is a simple diminution of the electric  ex-
citability, and never any  qualitative modification, and this  ab-
solutely distinguishes these muscular alterations from  degen-
erative atrophy. 
                     - 56  -
percussion of the patellar tendon determines very pro-
nounced convulsive starts, not only in the  member
percussed, but which  also become general,  and are
very manifest in the two upper members, and especially
in the left.  It is true that percussion of the  patellar
tendon  on the left side provokes shocks  almost as
intense.   By sudden straigtening  of the point of the
foot, no trembling is  produced either in the left in-
ferior member or in the right.
    All the other muscles of the limb present the nor-
mal electric reactions.  It has not always been so, ac-
cording to the statement of  the patient; thus, there
was a time when the gastrocnemii  and the muscles of
the front aspect  of the leg  did not contract equally on
both sides; since then, however, there has been an im-
provement.   Note, in passing,  that  there have never
been any  troubles of micturition or defecation.
    It now  remains for us to  search for the reason
and the signification of the phenomena which we have
so  attentively  studied.   In  brief,  this  patient  is
affected with a paralysis  with simple atrophy, almost
exclusively localized in the extensors of  the leg, with
profound   modifications,   quantitative  only,  and not
qualitative, of the electric contractility.
    The localization of the  disorders already suffices
to guide us to a diagnosis.  We know to-day, in accord-
ance with numerous studies,*  that atrophic paralysis
    * John Hunter's Complete  Works, vol. i, p. 581 (French
Ed.).  A. Ollivier, Des Atrophies Masculaires.   These agreg., 
                      —  57 —
of the extensor muscles, or at  least predominating in
the extensors, is a frequent complication  of different
spontaneous or traumatic lesions  affecting the corre-
sponding joints; thus, as the result of divers lesions of
the  scapulo-humeral  articulation we  often see  the
deltoid atrophy; as a sequel of arthritis, of sprains, etc.
of the hip, the glutei muscles are sometimes affected in
the same way; if  it  is  the knee which  is  injured, the
triceps femoris  is affected  in  its  nutrition and its
motility.  These  facts, which were  known to Hunter
and  Paget,  have  been  more explicitly signalized  the
last few years by Ollivier, and  lastly by LeFort, and
in the valuable thesis of Valtat, where it is  shown  ex-
perimentally in animals (guinea pigs and dogs)  that
when arthritis has been determined by irritant injec-
tions, it is the muscles of the whole limb, but more
particularly the extensors  of the  joints, which are af-
fected.   And in these cases the atrophy which  has all
the features  of simple  atrophy without any irritative
character, supervenes very rapidly; it may be estimated
at twenty per cent, at the end of eight days, and forty-
four per cent, at the end of fifteen days.
1869.  Le Fort, Soc. de Chir., 1872.  Sabourin, De 1' atrophec
musculaire rheumatismale.  These de 1873.   Paget, Lessons
on Clinical Surgery, 1877.   Vallet,  Muscular  Atrophy  Con-
secutive to Joint Diseases.   These,  1877.  Darde,  Atrophies
Consecutive to Joint Affections.  These  de  1877.  Guyon et
Fere, Notes on Muscular Atrophy Consecutive  to Certain Trau-
matisms of the H'p, Progres Med., 1881. 
                     - 58 -
    Well then, can this order of causes and this rela-
tion between the muscular affection and the affection
of the joint be invoked in explanation of  the  pheno-
mena before  us ?   Most  assuredly.  You will  meet
with such  a traumatism  in the history  of  our pa-
tient, and it will not be necessary to go farther to find
the cause of the  disorders observed; at  the origin  of
all this train of morbid accidents there was an injury
affecting the knee  and confined to that joint.
    It was  about  a  year  ago,  May 5, 1881, that B.,
in leaping over a  fallen tree,  hit  and hurt his  right
knee; he did not fall, and there was no  very severe
pain, nevertheless  the contusion was sufficient to tear
his pants.   He  was  able to walk, and performed a
march of three kilometres without difficulty,  but be-
ing obliged to descend a hill, he experienced  some
amount of stiffness in the knee,  and  was  obliged  to
stop.   Then, for  the first time,  he noticed  a drop
of blood on the front  of the knee, which was  not the
seat of any swelling.   When he got up  he could not
walk except with the help  of a cane.
    During the eight days which followed, there was a
little swelling of the joint;  the patient remained in bed,
but without fever.  The physicians who attended him
appeared astonished  at the contrast which existed be-
tween the arthritis which seemed very slight, relatively
but little painful, and the motor impotence, which was
considerable.  A silicate bandage, kept on for  three
weeks, did  not improve matters, and when the reten- 
                      — 59 —
 tive apparatus was removed, there was the same con-
 trast, the same surprise of the physician in attendance,
 who  could  not understand  how,  coincident  with  a
 painless arthritis, such  pronounced  motor impotence
 could exist.   It was not till four months after the in-
 jury that a treatment  appropriate to the situation was
 employed, viz., faradization;  it was then only that an
 amendment  took place,  and that walking became less
 difficult.
     The relations which exist  between this  paralysis
 which still persists at  the end of a year, and a slight
 traumatism which has produced only a trifling  degree
 of arthritis, has nothing about it which should surprise
 you, if you consult  the  natural history, to-day suffi-
 ciently well known from recent labors, of atrophic par-
 alyses, which may be called articular, or  which have an
 articular cause.
     If, in fact,  in a great number of  cases, the proto-
 pathic arthrites, spontaneous  or traumatic, which de-
 termine the atrophic paralyses, are painful  affections
 of great intensity, this is far from being always the
 case.  Thus, a simple sprain, soon to all appearances
 well, a simple hydrarthrosis, an affection which is not
 inflammatory, and  not painful, and (as in our case)  a
 slight arthritis,  may determine  the  same  troubles.
 There is no necessary relation between the intensity of the
joint affection and that of the paralytic and atrophic phe-
 nomena.
     As far as concerns the permanence of the deutero- 
— 6o —
pathic accidents (paralysis and atrophy) after the ces-
sation of the protopathic affection (arthritis), persistence
is to a certain extent the rule; we have here in the his-
tory of  paralysis of articular  cause a fact which is of
the greatest  interest both  from a pathological  and
clinical  point of view.
     The clinician ought, in fact, to be aware of this
remarkable circumstance.   He ought not in presence
of a slight arthritis, when  the  phenomena of  motor
impotence or atrophy  are  well marked,  to  risk his
reputation by a favorable prognosis, or promise a for-
tunate issue in a brief  space of time;  the prognosis
will be very likely to be erroneous.  You  will  see, it
may be, months roll by, leaving the member still  use-
less, although now for a long time the arthritis is  only
represented by  a little  puffiness of the  periarticular
tissues,  or it may have no longer left any trace of its
existence.
     These particularities lead us to inquire what  may
be  the physiological reason  of this  singular complica-
tion of articular affections;  a  knowledge of this  may
guide us in the direction of the treatment.
     Most contemporaneous  authorities  seem to be
settled with regard to this point of theory; the joint
affection has by the medium of the irritated  articular
nerves reverberated upon the spinal center, and there
it has modified the centers from  which  emanate the
motor nerves and the nerves which preside  over the
nutrition  of the muscles. 
— 6i —
     There exists, it is believed, in the spinal cord  a
relation more or  less direct between the cells of origin
of  the articular  centripetal nerves and the cells  of
origin of the the  motor and trophic nerves of the ex-
tensor muscles (the cruralis  in the case which now
concerns us), since the result  when it  is produced  is
constant, that is to say, that always in  the case  of  ir-
ritation of the nerves of the knee,  it is upon the ex-
tensor muscles (triceps), or at least more especially on
these muscles, that the atrophy  falls.   I  say more
especially, for the irritation, starting from the  articu-
lar nerves,  may  spread by diffusion  away from the
distribution of the crural nerve to  the  muscles of the
leg  and  foot.   In the  articular affections of the
shoulder,  the elbow, and  hip, it is  always in  the
extensors that the atrophy  predominates, although  it
may comprehend several other muscular groups  of
the member.
     Remark that no other of the theories proposed
can be accepted.   Thus, some have sppken  of a pro-
pagation of the  articular inflammation by contiguity
and continuity to the  muscles in  the neighborhood;
but the atrophy exists at the same  degree throughout
the entire extent  of the  muscle, and, moreover, experi-
ments show that it is a simple atrophy, without trace
of inflammation, without myositis.   The hypothesis of
atrophy by  prolonged  repose is  not  admissible; the
joint affection is often so slight as to  necessitate rest
of but very  short duration;  and, moreover, according 
— 62  —
   to this theory, how are we going to explain the almost
   exclusive localization of the atrophy in the extensors ?
        We  are then  reduced  to the  admission  of a
   deuteropathic spinal affection, and it is in consequence
   of this affection  that  the paralysis and atrophy  are
   produced.  But in  what consists  the  modification  of
   the medullary center?  It is not a profound modifica-
   tion of the cells of  the anterior horns;  for  we  know
   the effects of profound alterations of these elements'
   in infantile paralysis, where there is reaction of degen-
   eration, to wit, exaltation of galvanic excitability and
   depression  of  faradic excitability; unless,  in conse-
   quence of the affection being far advanced, the muscle
   is quite destroyed—then  there is abolition of both
   modes of excitability,  but with hardly any possible re-
   turn.  Here, on  the contrary, we see that by an  ap-
   propriate treatment, already the  electric reactions re-
»   appear.   We have then to do with a sort of  inertia, or
   torpor of the cellular element.
        Must we therefore conclude that if, in  a  case of
   this kind, you have recourse at the onset to an appro-
   priate treatment  you will obtain a rapid cure ?  This
   is very probable, and this leads  me to speak of  the
   treatment.
        Before we proceed, however, to this  subject, I
   must again call your attention to the exaltation  of the
   tendon-reflexes  of the  lower extremities.  Is  this a
   peculiarity of the subject, or is there a morbid state of
   exaggerated reflex excitability throughout  the  whole 
                     -  63  -
extent of cord  outside  of the region where, on the
other hand, the motor cells are in the state of torpor
which we were just supposing to  exist ?  This seems
very likely, in accordance with some other facts simi-
lar to that which now  concerns us,  and of which  I
shall have occasion shortly to speak to you.
     But I come now  to the treatment.  We have here
a dynamic spinal  lesion, without  profound modifica-
tion, as far as we know, and we may,  without fear, in-
sist upon the electric  treatment; the  results  obtained
hitherto  are an encouragement for the future.  Static
electricity appears thus far to have been attended with
remarkable   results   in  restoring excitability where
faradization and galvanization have remained without
effect.  We have then to make a choice  (and  this is
sometimes a  matter of some difficulty) between static,
galvanic, and faradic  electricity; we may employ each
in turn.  I shall reserve for a future occasion the ex-
position  of how the treatment shall be managed.
     In this case,  the spinal affection,  taking its origin
in the joint, presents  itself in a benign form, the issue
will be favorable, and this is  habitually the  case.  It
is possible  that in  certain cases  the  spinal  affection
and the consecutive muscular affection are more  pro-
found.
     You must not forget, moreover,  that  the paresis
and atrophy are not  the  only deuteropathic troubles
which  may  result from  an  articular lesion.   This
group of facts is  more  complicated.  Thus, certain 
—  64 -
arthrites or articular traumatisms have been known to
produce, by reflex action, a contracture limited to the
muscles of the joint or extending to  the entire mem-
ber.  Cases of this  kind  are,  indeed, very frequent,
and we know that in these conditions, the  joints  take
a  position in flexion,  the flexors prevailing over the
extensors.  In other cases the atrophy and  contracture
are combined.
     These  varieties  of  spinal  affections,  produced
under the  influence  of a cause always the same in ap-
pearance,  particularly interest us, and we shall   have
occasion to return to them in  connection with several
patients who are now present in  this hospital.

            Note by  Dr. Romain Vigoureaux.
     As has been stated above, in certain  cases,  a muscle ab-
solutely inexcitable by  faradic and galvanic currents contracts
very well under the electric spark.  This fact, already alluded
to  by Prof.  Charcot in a lecture on Static Electricity (Revue de
Med. 1881,  No. 2) shows how relative and contingent are the
actual data of electro-diagnosis.  It is one of the striking phe-
nomena  connected with this  method of diagnosis that one
may, by  relying exclusively on the  usual modes of testing
galvanization and faradization—declare  to  be  electrically
inexcitable a muscle which contracts normally as  soon as you
have recourse to another mode of electric excitation.
     It will not do, however, to assume that this superiority of
action of  the electric spark is the rule.   Static  electricity may
not show itself any more efficacious than faradic or galvanic in
provoking the contraction of an affected muscle.  This is what
we have observed  this very week in a female suffering from in-
complete atrophy of the muscles of the neck and  upper limbs. 
                          - 65  -
 with diminution (not absence) of the  faradic and  galvanic re-
 actions.
      However this may be, facts like that which has just been
 studied by Prof. Charcot prove the importance of static electri-
 city in electro-diagnosis.   Henceforth to the faradic and gal-
 vanic reactions we must add  the Franklinic reaction.
      It remains for the future to determine  the  clinical  signi-
 ficance of this reaction.
      Let us come now to the treatment of  the  patient.  Since
 the lecture, he has been treated to three seances of Franklinism
 which make the whole number of seances  eight.   There  has
 been  a  sensible improvement, which contrasts well with the
 previous state, which  continued stationary for many months,
 despite the different treatments resorted to.  Walking is easier,
 the faradic and  galvanic  reactions  are becoming more and
 more apparent.  Nil at the commencement with the maximum
 current of the faradic machine, and a current of more  than 20
 milliamperes of the galvanic, we now obtain considerable con-
 traction in the affected muscles with a moderate faradic current
 (the rod of iron wires being drawn out four or five centimeters),
 and a galvanic current of nine or ten milliamperes.
      This is an important point—these two  reactions have re-
 appeared  simultaneously; for both there has so  far  existed
 only the kathodal contraction of  the closed circuit   In  other
 words, the  faradic current causes  contraction  only when  the
 muscle is  excited with the negative pole.
     As for the galvanic current,  we  only  obtain contraction
 by making the excitation with the negative pole,  and this con-
 traction is produced only at the moment of making the current.
*  *  *   There is, then, a simple diminution of excitability,
without qualitative alteration.  These  details confirm the judg-
ment  expressed by Prof. Charcot in his lecture,  that we  have
here nothing but a case of simple atrophy.
     As for the manner of conducting the electrical treatment,
      6 AA 
—  66  —
we have, as the Professor  says, our choice between  faradiza-
tion, galvanization,  and Franklinization.   In the actual state
of things, it will be difficult to give a  peremptory reason for
the preference of one  over the other of these means.  The
simplest course will be to continue the static electrization.  Its
good effects have been evident thus far, and it is of easy appli-
cation.   This will not prevent  us,  moreover,  from  resorting
now and then to other forms of electricity.
     It remains to indicate with more precision how the treat-
ment is to be carried  out.   We know  by experience that the
electric spark acts  most  favorably on  the nutrition  of  the
muscles; we have notably  treated with success by  this means
an old facial paralysis, of  peripheral origin, and in which the
electric reactions were completely abolished.
     But (and this is a  point  on which we  insist), in order to
obtain therapeutic results,  strong sparks, obtained by means
of a metallic rod or ball, are not indispensable.  In the case of
our patient, they have been  chiefly a means  of  exploration;
for purposes of treatment, it is  sufficient to produce by means
of a wooden rod tufty jet  discharges (en aigrette), much less
strong, and incapable of giving rise to any contraction.   This  is
the procedure which has  already given us success in certain
atrophies (considerable in  extent) of rheumatic origin.  *  *  *
      Practically, it is well to know this, for it is  often a diffi-
cult matter to provoke at will the contraction of a diseased
muscle.
      Theoretically, we see the most evident trophic action ob-
tained by an electric discharge whose quantity,  as compared
with that of  ordinary galvanic  currents (in electrotherapy),  is
absolutely a matter  of  no account.  It will not do, then,  to
accept without reserve  the views of writers who  attribute  to
quantity the trophic effects of the current, reasoning, without
doubt,  from the analogy of the chemical effects.  It  is highly
probable that the question is not as simple as all this. 
                         - 67 -
     In fine, the patient who was the subject of  the foregoing
lecture, has given us occasion for again  justifying  the usage
which we make at the Salpetriere of the static machine.
     In the present state  of electro-therapy no  reason exists
a priori for either accepting or condeming a method; it is then
to experience alone that we are to look for arguments  for or
against static electricity. 
LECTURE V.
CONTRACTURES OF TRAUMATIC ORIGIN—PAIN-
      LESS TIC  OF THE  FACE IN AN HYS-
               TERICAL PATIENT.
Summary.—I.  Influence of Traumatism on the Localization
    of Certain  Diathetic  Determinations—Contracture of
    Traumatic Origin in Subjects who  Present Spasmodic
    Rigidity  in  the  Latent  State.—Exaggeration  of  the
    Tendon Reflexes in Hysterics.—II.  Typical Tic  non
    Douloureux of the Face—Contracture of the  Muscles of
    the Face in an Hysterical Patient—Simulation.
    The service of the clinic contains at this moment
several cases which in my judgment are very interest-
ing and quite  worthy of being made the subject  of
your  special  attention.   Now, several  of them may
leave  us in a few days; in others the morbid accidents
which I am desirious of bringing  to your notice  are
among those which sometimes disappear all at once
and unexpectedly.   I thought, then, that  it would be
prudent to improve  the  occasion  and  to make these
facts the subject of the present lecture.

                        I.
    The first case which I am going to present to you
will enable you to recognize  the  influence which  the
most  common  traumatic lesions  sometimes have  on
the development of the phenomena of local hysteria,
and on that of the contracture in particular. 
                     - 69 -
     It has  long  been known  that certain affections
 subordinated to a diathetic disease sometimes develop
 on the occasion of a traumatic  lesion.  It is the usual
 habit for these  affections  to  localize  themselves at
 once in the  very parts where the prick, the contusion,
 the sprain were produced.  This is  the  case, for in-
 stance, with regard to acute articular  rheumatism  or
 gout, as I have long remarked; so, in a gouty subject,
 nothing is more common than to  see, apart from  the
 regular attacks of spring or fall, a supplementary at-
 tack supervene as the  result of a fall,  for  instance.
 And what is very  remarkable,  while the spontaneous
 attacks localize themselves in the usual place  of elec-
 tion, the supplementary attack  will have  for its seat
 the  shoulder  or the knee,  or whatever one of the
 joints has been the subject of the contusion or sprain.
 This is a fact which  is to-day well understood, and
 the last few  years Prof. Verneuil and his pupils have
 shown the interest and  importance belonging to the
study of phenomena of this kind from a surgical point
 of view.
     But what is less known, perhaps, is that certain
local phenomena of hysteria, and in particular the con-
tracture of a limb, sometimes manifest themselves in
the same way and under the same influences.
    I come  now to the clinical  exposition, after which
I will call your attention to the  lessons which we may
derive from  the case.
    This great girl, aged thirty-four  years, is one of 
                     — 7o —
the oldest occupants of the division for simple epilep-
tics; she has, in fact, been here for more than  twelve
years.   She belongs to  that category of patients which
is designated in our hospital under the name of hystero-
epilepsy with distinct crises.
     I owe you a short explanation relative to the sig-
nification of this word; it means that this girl is affected
with two diseases,  whose  attacks present  themselves
separately; sometimes it is the hysterical crises which
manifest themselves  (the  seizures  as  they call  them
here),  sometimes   the  crises of  epilepsy (the fits).
We  designate, on  the   contrary,  under  the  name of
hystero-epilepsy with mixed crises, the cases in which the
hysteria exists  alone, but in which  the  disease also is
characterized in the regular attacks by four  periods,
of which the first has the appearance of epilepsy (epi-
leptoidphase, epileptiform hysteria).   We have proposed
the denomination of great hysteria to characterize this
form, and take the  place of this word hystero-epilepsy
with mixed crises, which only leads to confusion.
     Our patient is  affected at the same time with hys-
teria major  (grande hysterie) and  with true  epilepsy,
the fits of epilepsy  coming on in the night time with
biting of the tongue, involuntary emissions of urine, etc.
Formerly, that is to say, prior to the last five years,
the hysteria predominated over the epilepsy; thus in
1874 we reckoned in  one  month  244  attacks of hys-
teria, and  62  epileptic seizures;  but since  1876  the
hysterical attacks have  shown a tendency to disappear 
                     — 71 —
and  the  epileptic fits, although  less numerous now,
and presenting themselves at the period of the menses
only hold decidedly the first place.
    One of the  peculiarities of the  attacks of hyste-
ria  at  the time when  they  manifested themselves
simultaneously with  the epileptic crises, is, that they
were  frequently followed by contractures of the right
lower extremity, lasting a fortnight, a month, etc.   It
was  on the right side that the hemianaesthesia  and
ovaria existed; it was on the right also that the  pro-
dromic phenomena of the attack manifested themselves
(tinnitus aurium, beatings in the temples, etc.).
    The hysterical phenomena had almost completely
vanished during  the  last few years, and the patient
was considered by us for five or six years as no longer
hysterical, but as an  epileptic,  whose crises,  moreover,
tended to diminish if not in intensity at least in num-
ber.
    But the 16th of  May, that is to say five days ago,
an accident happened which  has shown  us that  the
hysteria is far from being extinct in this woman, and
that the diathesis still remains menacing, though here-
tofore in a latent state.   B----was going as usual to
the shop where she works, feeling as well as she had
felt the previous days; by maladroitness, and without
having experienced  any faintness, any dizziness (she
is very explicit  on this  point), she made a mistep on
the stair-way, fell heavily on her left side, and slipped
down a dozen steps like  an inert mass.  Two of  her 
                     — 72 —
companions lified her up; she was not much  hurt,
and to-day the only trace of the contusion consists in
an ecchymosis which covers the external malleolus of
the left side.  But, immediately after the fall, walking
became very difficult, and the reason of this lay in the
existence of a rigidity which affected the joints—hip,
knee, and  ankle, of  the  left inferior  member which
had sustained the shock.  We saw the patient the next
morning, and found her in the condition in which you
see her to-day, as we shall show you presently.
    The patient is  presented  to  you lying on her
right  side.   The left inferior  member  is very rigid
about the knee and ankle.  Extension  and flexion are
equally impossible;  the  resistance is the  same in
whatever way you  desire to move  the limb.  The
flexor  and  extensor  muscles are both in a state of
contraction as  you  see;  only,  as is habitual in this
kind of contracture,  in what  concerns  the  inferior
member, it is  extension  which predominates; the
thigh and the leg are extended, the  foot  is  flexed
upon the sole by reason of the predominant action
of the calf muscles;  in  other words  the three seg-
ments of the member are  in a straight line,  the foot
taking the position  of direct talipes-equinus.  I may
add that the inferior  member, which might be  com-
pared to a rigid bar, is in adduction; if  you succeed in
turning it from the middle line  and then  leave  it to
itself, it returns to its first position, as  if by the move-
ment of a spring.  Besides, this  member has  taken a 
                     —  73  —
twist at the hip joint by reason of which  the  patella
and  the points of the foot  look almost  directly in-
wards.  Moreover, there is no swelling, no pain in the
joint, nothing which you would be  likely to refer to
the fall, unless it be the ecchymosis in the neighbor-
hood of the external  malleolus, of which I have spoken
above.
    I must here  remark that this forced  attitude of
the limb came on rather suddenly.   We have here, as
I  have previously made clear to  you, one  of  the
characteristics of the spasmodic contracture of hys-
terics,   in  contradistinction  to  the contractures of
organic cause.   Thus, in the spasmodic paraplegia of
transverse myelitis, of multilocular sclerosis, etc, it  is
not all at once that things come to this; this  change
comes about  slowly; in a first period you  have para-
plegia with  flaccidity of the  limbs, there is only exag-
geration of the tendinous reflexes; in a second period,
you see accessions of rigidity; in a third, the  rigidity
establishes itself in extension or semiflexion, and lastly
in a fourth period, which is almost never observed, or
at least exceptionally, there  is  an  invincible rigidity,
which  makes the limbs seem  like stiff bars.
    One of the most interesting characters of hysteri-
cal contracture, is as you  see, that it  may  attain its
maximum all at once.
    The appearance of the contracture, under circum-
stances like those I have just mentioned, in  a  subject
known to have been affected with hysteria in  a high 
                     — 74 —
degree, and to have been before a sufferer from con-
tracture, ought naturally to lead us to suspect that an
hysterical storm is approaching.  We  ought, then, to
inquire if there were not other of  the stigmata of hys-
teria manifest in this patient as a sequel  of  the  trau-
matic  shock,  at  the same  time  as the contracture.
This is in fact what we  do  find;  the hemiansesthesia,
which  formerly occupied the right side, latterly ceased
to exist for several years; it has reappeared, but now
it occupies the left side, the side on which the  shock
took place, and which is the seat  of the contracture.
The anaesthesia occupies the whole of the  left  side,
the limbs, the trunk, the face, with the exception of
the parts bordering on the organs of sense,  as some-
times happens in such cases.   There is no ovaria.
    Aside  from  these  particulars, there is nothing
worthy of mention,  unless it be the insomnia which
has now lasted for five days, and the  appearance of
the menses which came  on at  their proper time,  two
days ago.   Now it is at  the menstrual period that  the
crises  of epilepsy from which  this  patient suffers,
habitually make their appearance, and it was then that
formerly her hysterical paroxysms came on.   It  is at
least very probable that  in  a few days we  shall wit-
ness another  outbreak of this kind, following which
the contracture will disappear as  suddenly or almost
as suddenly as it came.  It is for this reason that I
have insisted on bringing this  woman before you  to-
day; for an  opportunity to  show  you an  hysterical 
                     — 75 —
contracture of traumatic origin may not again occur
for a long time  But, you will ask me, are you quite
certain that the traumatism has had on this spasmodic
rigidity of the member the influence  which you sup-
pose ?   May it not be simply an instance of fortuitous
coincidence ?  In support of the  proposition  which I
affirm, valid reasons are not lacking.
    Let us take, first, the argument derived from con-
siderations outside of hysteria itself.   I have  already
had occasion to call your  attention to  the similarity
which exists between spasmodic paralysis of the limbs
in the  hysterical,  which  is unconnected  with  any
material spinal affection, and  spasmodic  hemiplegic
or paraplegic paralysis  due to  a  medullary  lesion.
Thus, in hemiplegia consecutive to  a  lesion  of the
brain, occupying  the internal capsule,  and affecting
the tract of the pyramidal fasiculus, the members may
remain flaccid, but  the  contracture exists  there, in a
latent state, if I may so speak, as is shown by  the ex-
aggeration of the tendon reflexes (ankle clonus, knee
jerk); and sometimes in repeating for some time the
shocks on the  patellar tendon, you produce a tempor-
ary contracture which lasts several  minutes.   In such
conditions, then, there is always  the  liability to con-
tracture, and this may  develop  if a  traumatic lesion
supervenes, and it will manifest itself in the very part
which  has been  the  seat  of  the  contusion,  of the
sprain, etc.  Thus in a hemiplegic woman whose case
has been reported  by  Terrier, there ensued a con- 
                     - 76  -
tracture which lasted  several months.   I  might cite
numerous examples  of the  same  kind relative,  not
only to hemiplegia, but  to  paraplegia, which took on
the spasmodic character under the influence of a trau-
matism.  Moreover, to determine the contracture in a
member  affected with a flaccid paralysis, a violent
traumatism is not necessary, too rude  a faradization,
the application  of  a  vesicatory, of a  stibian plaster,
may produce the same effects as the shock.
    The theory which enables  you to fix  these facts
in your mind, is the following.   There  exists in these
cases of paralysis which have for cause a material  les-
ion, a hyper-excitability of  the gray substance, and in
particular of the motor cells of  the anterior cornua, a
particular state which I  have proposed,  for want of  a
better word, to designate  under  the  name of strych-
nism; now, cutaneous  irritations, the irritation of cen-
tripetal  nerves  in  general augment  the  already ex-
aggerated excitation  of the  motor cells, which over-
flows its  bounds, and the centrifugal nerve transports
the excitation to the muscles which it innervates.
     But  it  is time to return to hysteria.   In  many
hysterical patients, on the  side  of  the  anaesthesia
principally, but  sometimes to some extent  over  the
whole body, there exists an exaggerated reflex excita-
bility, although  you may find a paresis, a well-marked
dynamometric feebleness.   It is not astonishing, then,
that an excitation of the centripetal nerves, tendinous
or otherwise, should determine the same effects as in 
                     —  77  —
 cases where there exists a lesion of the nerve centers;
 the spasmodic paralysis of the members without rigid-
 ity, may, in the same conditions transform itself  to a
 paralysis with contracture and rigidity of the joints.
     I might refer to numerous instances of the same
 kind, some of which are reported in the first volume of
 my lectures delivered in the Salpetriere.  In one case, as
 the result of a fall upon the back of the head, we saw
 supervene a contracture of the wrist, which lasted sev-
 eral months; I have also observed the same phenomenon
 as the sequel of bruising the  hand in the gearing of a
 machine; another hysterical subject who had had the
 dorsum of the foot jambed against the arm of  a chair
 was affected with contracture of the foot, etc.   Brodie,
 who was well-acquainted with such facts and who was
 the first to  point them out in 1837, in his book " On
 Certain Local Nervous Affections," gives cases of con-
 tracture of the upper limb after pricks of the finger.
    Such facts  are  of  the greater  interest that the
 contracture determined by the traumatism is often the
 first manifestation of the  hysterical  diathesis.   Thus,
 a common traumatism  produces  a  contracture in  a
young subject that  up to that day never had presented
 any nervous ailment; examine closely, and in all like-
lihood you  will see  some accompaniment which will
 convince you that hysteria is  concerned in  the case;
it will  be  very  strange if you do not find under such
circumstances some trace  of  hyperaesthesia, of anaes-
thesia, an ovarian pain,  or some  other indication of
the  same kind. 
                     — 7» ~
    I can, moreover, enable you  to  witness this ten-
dency to contracture which often  exists to a very high
degree in some hysterical patients, and it is not neces-
sary even that such patients shall be afflicted with the
great hysteria, the hysteria of  convulsive paroxysms,
but simply with common hysteria.
    I present to  you two  young hysterical females,
the cheery  expression  of whose countenance, and
the passion  for finery rendered manifest by the rib-
bons and flowers with which they are adorned,  offer
a striking contrast with the mien  of  our  first  patient,
whose physiognomy betrays an intellectual state con-
siderably affected  by his frequent epileptic fits.  One
of these patients presents an  anaesthesia  in patches,
and a left ovaria; she has  spontaneous contractures
following her attacks.  The other has hemianaesthesia
on the left side, her right side is analgesic,  and she
has double ovaria.  You see that by repeated percus-
sion of the patellar tendon and the tendo Achillis, the
leg places itself  in extension, while the  foot  flexes
itself in the  positiou of talipes equinus; this attitude is
fixed, the rigidity of the member  is absolute; you can-
not communicate to it any movement of  extension  or
of flexion; we have here, in fact,  a contracture of the
most  characteristic kind which may last  for  several
hours if we  do not arrest it by exciting the antagonist
muscles by the same process which we have just em-
ployed to provoke the  contracture.  What we have
just done with the lower extremity, we can  do with the 
                     — 79  —
upper.  If with a percussion  hammer I make a series
of taps upon the flexors of the fingers about the wrist,
you see the hands and fingers take a position  of  ex-
aggerated flexion, and remain fixed in contracture.
    I think that I have said  enough to put in clear
light the influence of traumatic lesions on the develop-
ment of contracture in hysterical  patients,  and, aside
from  hysteria,  in  subjects  predisposed  by  certain
organic lesions.   We  shall many times have  the  op-
portunity in the course of our studies of applying this
interesting notion to the explanation of certain pheno-
mena otherwise inexplicable.
    But I come back to the contracture of our patient
B.  What can we do for it ?  Wait the  natural, easily
predicted  constitutional revolution, which will soon
put an end to  it.  But supposing that it should persist ?
As it is a unilateral contracture, we have a simple de-
vice which may be efficacious—we may,  by means of
a magnet, or by the action of other agents  of the same
order, provoke a transfer of the contracture to the op-
posite side,  and it may happen that after a large num-
ber of  these  transfers  the  contracture will exhaust
itself.
                        II.

    There has lately come to  our out-door clinic,  a
little patient whose case borders on,  if it  does  not
actually belong to the domain of hysteria.    This  pa-
tient is a young Jewess, of St. Petersburg, aged fifteen 
— 8o —
years, who has never  yet  menstruated;  she has now
been an out-door patient for about six weeks.   She
has come to Paris to be cured,  not being able to be
cured elsewhere.   I do not know whether we shall be
able to  give her the  relief which she demands, or
rather, which her father demands for  her.   You  will
understand  presently  why  I  make this reservation.
We have here, or we seem to have, a case of painless
tic of the face;  but  the affection presents itself with
special characters which differentiate  it considerably
from the normal type.
    Here  is another patient, gentlemen, whom I shall
have occasion to show you on  another occasion,  and
who is a fair example  of the painless  tic of the face
under its common form.  It is  an old hysterical  pa-
tient, or rather, it is a  woman still hysterical  although
she is more than fifty years old, and in  whom the at-
tacks af hystero-epilepsy have long since disappeared;
but there remains a  left hemi-anaesthesia, and on  the
same side, she has a facial tic which dates from four
or five years ago.   This tic manifests itself  by par-
oxysms, which  repeat themselves frequently  during
the day, and it is characterized by a very rapid  wink-
ing of the  eyelids, and a trembling—amounting to two
hundred times a minute—of the left  labial commis-
sure; the platysma participates to some degree  in  the
convulsion.  This is the common type.
    Consider now our young patient; here the spasm
comes on when  we desire it.  You see her with a com- 
— 8i —
 press over her right eye which is kept at rest; there is
 nothing particular to notice about the face.   But we
 will now take away the compress;  if we remove it
 gently, without disturbing the ball  of the eye,  which
 is  protected  by the  contractured  lids,  there is  at
 once produced a contraction  of the muscles  of the
 right side of the face.   If we uncover  the  eye, the
 spasm is produced still  more  energetically, and we
 bring  about a frightful  and  fixed distortion  of the
 features.   The result never fails;  repose as soon  as
 the compress is in place,  contracture as soon as  it is
 removed.
     Thus,  there  exists  a remarkable difference be-
 tween this case and the preceding, and so great is  it,
 that we are led to ask if we have not before us one  of
 those singular cases of simulation, of which the history
 of hysteria is full.
     It should be stated in this connection that the af-
 fection from which this  girl suffers was preceded, a
year ago, by a  spasm of the right  orbicularis muscle,
which came on without  known cause, without pain.
A little while afterwards,  she had nervous crises with
laughing, weeping,  outcries.    Last  August, after a
local electrization, the spasm of the  face declared it-
self just as you see  it to-day.
    Let us examine matters a litte more closely. The
existence  of a blepharospasm  in  nervous, hysterical
subjects is nothing  rare which should cause surprise.
Let even this spasm extend to the  face, there is noth-
     7 AA 
— 82 —
ing strange about this; it is seen  in  a multitude of
cases.    Lastly, nothing  is  more  natural  than  that
the spasm should be kept in check  by pressure exer-
cised on certain  points.   De Graefe long time ago
called  attention to the existence of  these  points of
arrest, which the physician ought to  search for,  and
which  the patients  often find of  themselves  acci-
dentally.   In  the case before  us  the  point of arrest
is the eyelid itself, or the supra-orbital arch.
     But here is where the  series  of strange  phe-
nomena  begins.  The pressure exercised by the little
pad  is a very  slight  affair; and, on the other hand,
if it were only a matter of  pressure, this ought to be
efficacious  as  well when  we practice it ourselves by
applying the pad and in tightening it by  the aid of a
bandage, as when this operation is performed  by the
patient herself.  Now in  reality this  is not the case.
There is, then, a personal influence at work here which
demands our  earnest  attention.   I will go farther,
and  declare not merely my suspicion,  but my  firm
conviction.  Yes, this young  patient is guilty of simu-
lation, or, at least, of exaggeration.   I  fully admit the
reality of the blepharospasm, but, as far as the spasm
of the muscles innervated by the inferior facial is con-
cerned and of  the platysma, I believe  it to  be  super-
added, invented, simulated.  It is probable that the
physicians in St. Petersburg who saw this young  girl
had come to the same  opinion, in  fact, they had  got
ready for the operation of resection of  a nerve and the 
                     - 83 -
 patient was chloroformed, when for some reason  they
 desisted from  proceeding any  farther.   The spasm
 has continued, nevertheless, just as you  have seen it
 to day.
     But, you will ask,  what interest has this young
 girl in feigning a part ?   I have already  had occasion
 to tell you that the hysterical  often dissimulate with-
 out any well-defined end, for the mere love  of the
 thing. The passion for notoriety—what various shapes
 does  it assume ?   To  deceive, or seem to deceive,
 the physicians of St. Petersburg, then those  of Paris,
 afterward to baffle the faculty of Vienna,  and thus to
 make the tour of all  Europe,  would  not this have a
 sufficient interest ?
    I will  add, that placed  on the electric platform,
 the eyelids uncovered, the young  patient seems  per-
 ceptibly fatigued;  at the end of a quarter of an  hour
 she appears to be out of  breath; her body is covered
 with a cold sweat, and an attack of convulsions is im-
 minent.  We have not been willing to  carry the ex-
 periment any farther.
    Under such circumstances,  what is  to  be done ?
 We must  wait, and  say nothing.  We do not wish, at
 present, to  disclose our opinion to the father any more
 than to the child, for fear of losing  their confidence
 We shall only carry out a treatment which shall serve
 as a placebo.  I hope that our young patient may re-
main some time in our service,  and that  I shall  have
occasion to present her to you again. 
—  84 —
                    NOTE by dr. fere.
     Since the lecture, Mile. A. has been  isolated from her
family.   She entered the hospital May 27th, and had no other
treatment but the application at a distance of magnets to the
side of the spasm, and  several seances of static electrization.
April 1st, under the influence of electrization, the spasm dimin-
ished momentarily,  and the sensibility increased.  Till the 18th
June, nothing particular happened; but on that day she had an
attack of spasms with piercing cries and  contortions, predomi-
nating always on  the right, the side of the spasm.  During the
month of July we made use almost every day of the magnet at
a distance; the contracture of the lower  part of the face insen-
sibly disappeared.  July 26th there remained nothing but the
blepharospasm.   The  next  day,  after  being  crossed  in  her
wishes,  she  had  quite a violent fit; the eye has  remained
normally  open  ever since,  and  the  fits have been since then
several times repeated. 
LECTURE  VI.
   MUSCULAR  ATROPHY  CONSECUTIVE  TO
           ARTICULAR   RHEUMATISM.

Summary.—Muscular Atrophy in the acute, subacute, or chronic
     Athropathies.  Relation  between the Localization of the
     Atrophy and the Seat of the arthropathy.   Types  of pri-
     mary chronic articular rheumatism:  i. Primary  gener-
     alized or progressive chronic Rheumatism; 2. Chronic
     articular  rheumatism, fixed  or  partial; 3. Nodosities of
     Heberden.
        Generalized chronic Rheumatism causes Amyotrophies
     predominating  in the extensor muscles of the diseased
     joints.   Exaggeration of the tendon  reflexes.  With the
     amyotrophy there exists a Contracture in  a latent state.
     Reflex Spasmodic Contracture of joint-origin.

     Gentlemen:—I  am  about to present to you  a
patient who  will bring us  back to the study of those
amyotrophic paralyses  which have recently  occupied
our attention.
     You have, in  fact, not forgotten that young em-
ploye of the telegraph department, who,  as  the  result
of a shock  affecting the  right knee, and causing in
this  joint  an arthritis which was, however, very slight,
has been suffering, for almost a year, from an atrophic
paresis  localized chiefly in  the  triceps  cruralis of the
right side, and which has since then rendered walking
very difficult.
     Traumatic  lesions are far  from  being  the only 
— 86  —
causes which can produce such untoward events.   It
is, indeed, well established that the most diverse lesions
may conduce to the same results.
     The fact  is well demonstrated in reference  to
acute articular rheumatism,  acute gout  (Bouchard,
Debove), and  blennorrhagic rheumatism.   What has
just been said of the acute or sub-acute arthropathies,
may be  repeated   with  respect  to chronic articular
rheumatism.   In all  these  joint affections, acute  or
chronic, the amyotrophy comes on according to the
laws indicated in  a  previous lecture, i. e.,  it localizes
itself predominantly in the extensor muscles of the
affected joint; thus it is the gluteal  muscles which are,
for the most part, affected when there  is an arthritis
of the hip: it  is the  triceps cruralis if the knee  is
affected; it  is  the  triceps  brachialis if the lesion  is
seated in the elbow, etc.
     This relation between the seat of the joint  affec-
tion  and the localization of the muscular  atrophy  is
even sufficiently regular and constant to be utilized  in
certain cases of difficult diagnosis.   Thus,  in certain
arthrites, in certain cases of morbus coxa senilis not far
advanced, when the physical signs  are  with difficulty
appreciable by  reason  of the deep situation of the
joint, the very marked flattening of the hip  of the cor-
responding side resulting from  atrophy of the  lower
fasciculi of the great gluteus muscle may also be con-
sidered as a very significant indication.  Long before
the muscular atrophies of  joint origin  were known, 
                     —  87  —
Adams called attention to this flattening of the gluteal
region in certain chronic affections of the hip.*  The
case which I am going to present to you belongs to
the category of chronic articular rheumatism.
     I must first premise that I have proposed to refer
to  three fundamental  types, the  quite  varied forms
under which this affection presents itself, f
     i.  Primary Chronic Articular Rheumatism, Gen-
eralized or Progressive.—This is the nodular rheuma-
tism of medical writers; it has a chronic  course  from
the onset, and presents an almost invincible  tendency
to become  generalized.  The small joints of  the ex-
tremities, those of the hands in  particular,  generally
the metacarpo- phalangeal are the ones which are first
affected, and  they are taken symmetrically.   Then,
after a time, most  of the  other  joints are slowly but
surely invaded.  During  all the long  course  of the
disease, the patient has often to endure severe  pains
which are frequently  accompanied with  febrile  reac-
tion.
     2.   Primary  Chronic  Articular   Rheumatism,
Fixed or Partial.—This  disease,  which presents the
same characters of chronicity at first as the previous
form, remains, in general, localized in one  or  two of
the large joints, and there produces  profound  altera-
    * Adams, A Treatise on Rheumatic Gout, London, 1857.
    f Charcot, Traite de la Goutte de Garrod, note p. 602.
Maladies des Viellards, Second Edition, 1874 p. 197, et seq. 
                     — 88 —
tions..  It has ofter been described in surgery under
the names  of  dry arthritis, of  morbus  coxce senilis,
when it affects the hip.   It is accompanied with pains
of slight  intensity, and all febrile  reaction is  wanting.
    3.  Nodosities of Heberden.—This is the  affection
described by Heberden under  the name of digitorum
nodi.  Very generally,  though wrongly,  referred  to
gout,  it occupies almost exclusively the articulations
of the phalangines with the phalangettes,  and some-
times of the phalangines with the  phalanges;  it spares,
on the contrary, the  metacarpo-phalangeal, which are
predominantly affected in nodular rheumatism proper.
    It hardly need be  said that  dry  arthritis is the
anatomical substratum of all these clinical forms, but
to each one of them corresponds a certain modification
of the anatomo-pathological type.  These three forms,
in fact, are not absolutely separated; they are connect-
ed by insensible  transitions.  There  are cases which
are in some sort intermediate,  and the case which we
are now about to study belongs at the same  time to
chronic  partial   articular  rheumatism,  and,  if  you
please, to chronic generalized articular rheumatism; it
is chronic  partial  rheumatism  extending to  a  great
number of joints.
    The patient, L. by name, aged  51 years, hair-dresser,
had  enjoyed good  health up to the  age of 44 years.
During the last nine years, he has unfortunately occupied
a dark and damp  basement room back of a shop, and
there, during the  night, he has  often suffered  from 
                      - 89 -
 cold.  This  influence of a  damp  habitation in  the
 etiology of chronic  rheumatism  is  one of the deter-
 mining causes the most often alleged  and the least
 contested, and  it is  very remarkable  that  the  joint
 pains do not generally appear till several years after
 the period when the noxious influence has  begun  to
 exert itself; there is here, then,  a sort of incubation.
 So, in our patient, it was not till  the end of five years'
 sojourn in this damp, dark room that the first arthro-
 pathies manifested themselves.   The joints have been
 affected in the following order:  the wrists first, then
 the shoulders, then  the ankles,  knees,  hips,  elbows;
 lastly the fingers in a slight degree, and the cervical
 joints.  This successive invasion has taken place dur-
 ing a period  of  four years.  The pains  have been  of
 little intensity; the swelling slightly pronounced; there
 has never been either redness or  fever; the patient has
 never been obliged to keep his bed, but he  has  been
 hampered and impeded  in certain movements of the
 wrist necessary to his occupation; then  a  rapid  ema-
 ciation  supervened,  and a  great muscular  enfeeble-
 ment, making walking extremely difficult, and oblig-
 ing him to give  up his occupation.
    Actually, it is an easy matter to recognize the dis-
 eased joints,  and the  alterations  with  which they are
affected are quite perceptible.   These joints  are  for
the most part the seat of cracklings, the left shoulder
especially, and the knees.  The  knee joints contain a
certain quantity of liquid, and  the soft parts which 
                     — 9° —
surround them are  evidently tumefied.  Cracklings
also exist in the wrists, elbows and several of the finger
joints of both hands.  In short, without more words,
we find in a great number of joints the classical char-
acters of dry arthritis.
     But the point to which our attention ought  es-
pecially to be directed is the wasting of  the  muscular
masses.  We have not to do here with a general ema-
ciation in the rigorous  acceptation of the word,  but
with an amyotrophy localized chiefly in certain muscles
or in certain groups  of  muscles,  and we  find it pre-
dominating  in  the extensors, as we might  have ex-
pected.   Thus, at the shoulders we  note a flattening
of the deltoids; the triceps brachii is markedly wasted,
while the biceps has  still preserved a certain fullness
and rotundity.   The glutei  are considerably flattened,
and this is in relation with  the affection of the coxo-
femoral joints.   In the thigh,  the  femoralis  is much
more atrophied than the mass of  the flexors,  and  the
same law holds with  regard  to all the diseased joints.
     The modifications of electric reactions which the
muscles  present are here,  also, purely quantitative,
and not  qualitative modifications.   Only  one muscle
is excepted, namely,  the vastus externus of the right
side which offers the reaction  of degeneration,  con-
sisting in this, that the faradic excitability is enfeebled
while the galvanic is exalted.   This is the sole excep-
tion; everywhere else the  electric reactions indicate
a simple atrophy,  without profound  alteration  of 
                     — 9i  —
nutrition.  Certain of  these  atrophied  muscles  are
the seat of very appreciable fibrillary contractions, the
deltoid,  for instance,  the  triceps femoris, the glutei;
and some of these muscles are manifestly excitable by
simple direct percussion, as you see is the case  with
left deltoid in particular.
    To  these  trophic  lesions of the  muscles corre-
sponds a motor  impotence  which is  the more  pro-
nounced the  greater the amyotrophy happens to be.
Walking is difficult,  rather by reason of  the amyotro-
phic paresis, than by reason of the pain.   As for the
hands, the dynamometric force is very  limited:  thus
it is represented by 10 for the right hand,  and 12 for
the left, the normal mean being about 80.
    A more attentive examination  enables  us to see
that in the upper members  it is  the extensors which
are at  fault, as might  have been  expected; thus, for
example, it is very easy to  overcome the extension of
the elbow, while the  limb placed in flexion resists
quite well the efforts made to extend  it.   We remark
the same thing in relation to the wrist joint and to the
knee.
    You see, then, that every thing in respect to  this
patient harmonizes well, in  all essential  particulars,
with what we have seen  in the telegraph operator
whose  atrophic paralysis came  on in  consequence of
an injury.  We may then  conclude that  the arthro-
pathies of  generalized  chronic  articular rheumatism
determine just as do the traumatic arthrites,  that re- 
                      — 92  —
verberation to the spinal center whose consequence is
amyotrophic paralysis predominating in the extensors.*
     But between the two  cases, there is,  on another
point, a resemblance to establish.  When showing you
the telegraph operator, I  called your attention, as  a
matter of interest, to the exaltation  of  the  tendinous
reflexes, marked not only in the diseased member,  but
also in the member  that apparently is  not  diseased,
and concluded therefrom that  the spinal  affection,
whatever it might  be,  which is developed in con-
sequence of the arthritis, is much more extensive than
one would  at  first  have supposed.   Well,  then, this
same phenomenon,  revealing the exaltation  of the re-
flex excitability, is seen  in the patient  whom  I  show
you to day, and in a yet much more pronounced  de-
gree.  Thus,  in the  two inferior  extremities, lifting
the point of the foot determines a very manifest trep-
idation, especially if the  patient  makes an effort to
resist this extension.  In order that  you may now well
appreciate  the  exaltation of the patellar reflexes,  I
     * Debove (Progres Medical  1880, p. ion) has had  occa-
sion to study under the microscope  the muscles of a chronic
rheumatic patient affected with muscular atrophy, and  he has
noted certain characters which justify classing these amyo-
trophies along with myopathies of nervous origin: to wit,  an
irregularity of the atrophy, which attacks, in different degrees,
not only the fasciculi of the same  muscles, but even the  fibres
of the same fasciculus; ?nd a considerable degree of sclerosis of
the interstitial connective tissue. 
                     — 93 —
place the patient sitting on the edge  of  the  bed, the
extremity of the feet resting  on the side of a chair.
You see that on both  right and  left,  the  percussion
of the patellar tendons has for an effect to  determine,
at each stroke, a movement in the shoulders, especially
the  left.  Thus, I  repeat, every time  that  you strike
the  patellar tendon, whether on the right side or  on
the  left,  there is a contraction of the  deltoid, of the
trapezius, of  the pectorals major, and the shoulder is
manifestly raised, and engages  in its  movement the
entire upper limb.
    We find, then, here in the lower limbs the elements
which constitute spasmodic paraplegia at  the  period
when the permanent contracture, though not  yet de-
veloped,  is at the same time imminent.
     Now, these phenomena are so pronounced that an
astute practitioner has been led to  think that in this
case the spinal lesion was primary, the  arthropathies
and the amyotrophy being secondary.  But the evolu-
tion of the morbid phenomena  protests against this
view; the arthropathies are in  reality  the  primary
fact, the spinal affection which  gives  origin to the
amyotrophy is but secondary.
     It is not without interest to  add  that apart from
this exaggerated reflex excitability,  marked by the ex-
altation  of  the tendinous reflexes,  a  characteristic
which shows itself as well in the upper extremities  as
in the lower, we find no other symptom which can  be
referred  to a spinal affection.  Thus, there is no dis- 
                     —  94 —
turbance of the cutaneous sensibility, no girdling pains,
no trouble in the emission of urine, etc.
     Thus, as you see from what  goes before, in cases
where the amyotrophic paresis predominates, the con-
tracture exists, so to speak,  potentially,  in  the latent
state.
     This leads me to remark that if in certain arthro-
pathies the amyotrophic  paralysis is, as in the  forego-
ing case, the capital fact,  it  is not so in other articular
affections where the spasmodic contracture  is the pre-
dominating symptom.
     It has long been taught in surgery that in certain
arthrites,  in the  painful forms in particular, the  af-
fected joints become rigid; they are  then  ordinarily
fixed in a state of flexion. Thus,  in coxalgia, the thigh
is bent on the pelvis; in  the fungous  arthritis of the
knee, the leg is flexed on the thigh, etc.
     Pathologists  have long discussed the  causes of
this rigidity of the joints and the deformity therefrom
resulting.  You are not ignorant that in the school
of Bonnet, at  Lyons, it is taught that this  rigidity is
due chiefly to  the instinct of the patient, who endeav-
ors to give the joint a fixed  position in order to avoid
the pain as much as possible.  Some have spoken of
the weight of  the parts  as  being an  element in the
case,  the liquid accumulation in the  joint, etc., but in
all these  explanations the spasmodic, involuntary con-
traction is relegated to the second place.  To-day, on
the contrary, if T mistake not, this  spasmodic, invol- 
                     — 95 —
 untary  reflex  contraction is regarded by most sur-
 geons as the primary fact, and we have, consquently,
 come back to the  doctrine of Hunter.
     In  a book, little known in France, entitled " Rest
 and Pain,"  Hilton, Surgeon  of  Guy's Hospital, has
 neatly  expressed what may  now  be  regarded  as
 the  prevalent notion:   "When  the  joint cavity is in-
 flamed, or in any  way irritated, the  influence  of this
 condition is transmitted to the spinal cord, and thence
 reflected by the intermediation  of the  corresponding
 motor nerves  on the various muscles which move the
 joints."
     Prof. Duplay, in several passages  in his book, as
 well as  Pitha, has given his adherence to this theory.
     Now we have, in the case under consideration, a
 spasmodic contraction affecting at once the extensors
 and the flexors, but that  of the latter predominates,
 so as to determine the direction of the deviation. We
 do not appear to have to  do here with a  contraction
 which is intentional or instinctive, designed to attenu-
 ate the pain; for in many cases, and in particular, in
 what concerns the hip, we know that we are obliged,
 in order to attenuate the pain, to oppose this very con-
traction by producing forced extension.   M. Masse *
 has, moreover, made this interesting remark, that dur-
ing sleep  these contractures are often  enormously
    * Influence of Attitude of  the Limbs on  Their Joints;
Montpellier, 1878. 
                     - 96  -
exaggerated, while they are perceptibly lessened during
the waking hours, when the patient is  in condition to
struggle against them.
    Without denying the  influence of the accessory
causes, we are then forced to  admit that the reflex,
spasmodic contracture is in these cases  the  principal
agent of  the  articular  deviation.  This  view, in my
opinion, finds  full confirmation in the  study of the re-
markable  deviations which so habitually take place in
chronic, generalized,  and  progressive  articular rheu-
matism (nodular rheumatism).   This is a point which
I endeavored to establish in my inaugural dissertation
thirty years  ago, and  to which  I wish to refer  in  a
future lecture.
    It cannot be without interest, moreover,  to bring
clearly into view the fact that  by the  side  of the
amyotrophic paralyses of articular origin, there  exist
spasmodic contractures also connected with an altera-
tion of the joints, that the amyotrophies, as well as
the contractures, are due to  a  spinal  affection deter-
mined by  reflex action, and lastly, to elucidate the re-
lationship which seems to exist between these  two
orders of facts, in appearance so wide  apart. 
LECTURE VII.
ON  SIX  CASES  OF  HYSTERIA  IN  THE  MALE
                     SUBJECT.

Summary.—Hysteria in the male is not so rare as one might
     suppose.   Role of traumatism in the development of this
     affection; railway  spine.  Tenacity of hysterical stigmata
     in typical cases in both sexes
        Account of three typical and complete cases of hys-
     tero-epilepsy in  the male.  Striking resemblance which
     these cases bear to each other, and to corresponding cases
     observed in the female sex.

     Gentlemen :   We shall study to-day  hysteria in
the male sex,  and in order the better to  compass the
subject, we shall consider male hysteria more particu-
larly in adolescent subjects, or such  as are in the vigor
of age and in full maturity, that is  to  say,  in men of
from twenty to forty years, and we shall give  atten-
tion more especially to that  intense, very pronounced
form which  corresponds  to  what is called in the
female great  hysteria, or hystero-epilepsy with  mixed
crises.   If  I   have   decided  to take up  this subject
which I have touched upon  many times  already, it is
because we have actually in our clinical service at the
present time a truly remarkable collection of patients
whom I shall cause to appear before you, and  whom
I shall study with you.   I have for  my object especi-
ally  to  make  you  recognize   and  prove   by  your
senses the identity of the great neurosis in both sexes,
     8 AA 
                     - 98 -
for in the comparison which we -shall make as we go
on of the symptoms of hysteria major in the  female
and in the male, every where we shall have occasion to
remark the  most striking  similarities, and  here and
there  only, certain differences  which, as  you will see,
are of but secondary importance.
    Moreover, this question  of hysteria in the male
subject is one of the questions  regarded  as  of  special
interest at the present  day.   In France, during  the
last few years it has much  occupied the attention of
physicians.   From 1875 to 1880 five inaugural  disser-
tations on hysteria in the male were defended  before
the Faculty of Paris, and Klein, author of one of these
theses written under the direction of Dr. Olivier, suc-
ceeded in compiling eighty  cases of this  affection.
Since then the important publications of Bourneville
and his pupils have appeared;  of Debove,  Raymond,
Dreyfus and  some others; and all these works tend to
prove, among other things, that cases of male hysteria
may be met with quite frequently in ordinary practice.
Quite  recently, male hysteria  has been  studied in
America by Putnam and Walton,*  principally in con-
nection with  and as a sequel of traumatisms, and more
especially of railroad accidents. They have recognized,
along with Page, who has also interested  himself in
    * I. Putnam, Am. Journal of Neurology, 1884, p.  507;
Walton, Arch, of  Med., 1883, t. x. 
                      —  99 —
 this question in England,* that many of those nervous
 accidents designated under the name of railway spine,
 and which, in his opinion, might better be called rail-
 way brain, are in reality, whether appearing in man or
 in  woman,  simply hysterical  manifestations.  It is
 easy, then,  to understand the  interest which such a
 question has to the practical mind  of our confreres of
 the United States.  The victims of railroad accidents
 quite naturally claim damages of the companies.   The
 case goes into court; thousands of  dollars are at stake.
 Now, I repeat, often it is  hysteria  which is at the bot-
 tom of all these nervous lesions.   Those  neuropathic
 states, so grave and so tenacious, which present them-
 selves as the sequel of " collisions " of that kind, and
 which render their victims unable  to  work or pursue
 any regular occupation for months and for even years,
 are often only hysteria,  nothing but hysteria.   Male
 hysteria  is then worthy of being studied  and known
by the medico-legalist, for he is often called  upon  to
give his  opinion, in matters concerning  which  great
pecuniary  interests are at  stake,  before  a  tribunal
which would be likely to be  influenced (and this cir-
cumstance  renders his task the more difficult) by the
disfavor which is still attached to the word hysteria on
account of prejudices profoundly rooted.  A thorough
    * Page,  Injuries of the Spine and Spinal Cord without
Apparent Mechanical Lesion, and Nervous Shock.  London,
1885. 
                    --  IOO —
acquaintance not only with the disease, but  also with
the conditions under which it is produced, will be on
such occasions the more useful from the  fact that the
nervous disorders often ensue without any  traumatic
lesion, and simply as a consequence  of the  psychical
nervous shock resulting from the accident; frequently,
moreover, they do not come on immediately after the
accident, but some time afterwards, when, for instance,
one of the victims of the  collision, who may have been
disabled by fracture of the leg, will have got well after
being incapacitated  for work for three or  four months;
another, perhaps, may have  been suffering from ner-
vous troubles which are destined to prevent him from
working for six months or a year, but which have not
reached their full intensity.   You see how delicate  in
such cases  is the mission of the medical  jurist, and it
is this medico-legal  side of the question  which seems
among our American  confreres to  have  awakened a
new interest in the study of hysterical neuroses here-
tofore a little neglected.
    In proportion as the disease has been better stud-
ied and better known (as habitually happens  in sim-
ilar circumstances), cases become apparently more and
more  frequent, and  at the same time, more easy of an-
alysis.  I just told  you  that  four or five years ago,
Klein, in his thesis, had collected eighty  cases of hys-
teria in men; to-day, Batault who is preparing  in our
hospital  service a  special work on the  subject, has
been able to gather together 218 cases  of  the same
kind,  none of which belong to our clinic. 
                     — ior  —
     Male hysteria is, then, far from being rare,   In-
 deed, gentlemen, if I were to judge  from what  I  see
 every day among us, these cases are very often mis-
 understood,  even by very distinguished physicians.
 It is granted that an  effeminate young man may, after
 certain  excesses,  disappointments,  deep  emotions,
 present  various phenomena of an  hysterical nature,
 but that a vigorous mechanic, well developed, not en-
 ervated by an indolent or too studious mode of  life, a
 fireman  of  a  locomotive, for  instance, never before
 emotional, at least in appearance, may, as the  result
 of a railroad accident, a collision, a  car  running off
 from the track, become hysterical just like a woman—
 all this has never entered into the imagination of some
 people.   Nothing,  however,  is better proved, and
 pathology must adjust itself  to this new conception,
 which  will hereafter  take its place along  with  other
 propositions which are to-day received  as  demonstra-
 ted truths, after having long fought their way through
 scepticism, and often through ridicule.
    There is a prejudice which doubtless contributes
 much to oppose the diffusion of right knowledge rela-
 tive to hysteria in the male sex; I refer to the  relative-
 ly false  notion generally entertained of the clinical
 tableau of this neurosis in the female.  In the male, in
 fact, the disease often presents  itself as an  affection
 remarkable  by the permanence and  tenacity of  the
symptoms which  characterize  it.   In the female, on
the contrary—and this is  without doubt that which 
                    --  102  --
seems to constitute the capital difference between the
two sexes in the estimation of anyone who does not
thoroughly and radically  know  the disease in the
female—what is generally believed to be the character-
istic feature of  hysteria is the instability, the  mobility
of the symptoms.  In hysteria, it is said, observations
of the disease in the female being  naturally taken  as
the basis of this opinion,  the  phenomena  are  mobile,
fugacious, and the capricious march of the affection is
often interrupted by scenes of the most unexpected
nature.   Very well, but, gentlemen, this mobility, this
fugaciousness is far from being a universal character-
istic of hysteria, even in the female, as I have shown
you by numerous examples.
    Yes, even in females there are cases of hysteria with
durable, permanent phenomena, extremely difficult  to
modify, and which sometimes resist all medical interfer-
ence.   Cases of this kind  are numerous, very numer-
ous, if, indeed,  they  do  not  constitute the majority.
This is a point to which  I  shall return shortly.   But
for the moment I content myself  by remarking, only,
that the permanence of the hysterical symptoms in the
male, and their tenacity often prevent the medical at-
tendants from recognizing their true character.   Some,
in presence of phenomena which resist all therapeutic
modifiers, will believe, I imagine,  if there exist senso-
rial troubles with nervous  crises  simulating  more  or
less the  epileptic fit, that  they have to  do with  an
organic localized lesion  (lesion  en  foyer), an  intra- 
                     — 103 —
cranial neoplasm, or if it is a case of paraplegia, with
an organic spinal lesion.  Others will willingly admit,
or will even affirm, that there can be  no question in
these cases of an organic  alteration, but simply of a
dynamic lesion; but in view of symptoms whose tena-
city  does not comport with the scheme which  they
have  in  mind  of hysteria,  they will think  that  they
have before them a special  disease, not yet described,
and which merits a place by itself.
    A mistake of this kind seems to me to have been
committed by  M. M. Oppenheim  and  Thomsen, of
Berlin, in a memoir * which contains, however, a great
number of interesting facts, carefully observed, if not
always well interpreted, at least according to  my way
of thinking.  These gentlemen have observed hemi-
ansesthesia, sensitive  and sensorial, like  in  all points
to that of hysterical patients, in  seven  observations
similar to those of Putnam and Walton.   These cases
had to do with firemen, conductors, workingmen, vic-
tims of rail-road or other  accidents, all  of whom had
sustained a blow on the head, a concussion,  or a  gen-
eral  shock.   Alcoholism,  lead-poisoning, etc., were
not factors in these cases, and the fact was recognized
that, according to every  probability, there existed  no
organic lesion in these subjects.
    We have here, then, a set of cases quite like those
of Putnam and Walton, but differing from  the  latter
*Arch. de Westphal, Bd. XV. Heft 2 and 3. 
                     — 104 —
 in this respect that the German authorities  are not
 willing to concede that these are cases of hysteria,
 which to their minds constitute  something peculiar,
 some  undefined, undescribed  pathological state, de-
 manding a new place in the nosological category. The
 principal arguments which Oppenheim  and Thomsen
 adduce to the support of their thesis are the following:
 i. The anaesthesia is obstinate; we do  not see there
 those capricious  changes which  are  characteristic (?)
 of hysteria.  It lasts just  as it is for months and for
 years.  2. Another reason is  that the psychical state
 of the  patient is  not that  of the  hysterical.   The
 troubles of this  order in  these patients have not the
 changing, mobile  traits of  hysterical manifestations.
 The patients  are conspicuously depressed, melancholic
 after a permanent sort, and without  great fluctuations
 in the degree of their melancholy,
     It is impossible for me to agree  with  the  conclu-
 sions of  MM. Oppenheim and  Thomsen, and I hope
 to show you,  gentlemen, 1, that the sensorial hysterical
 troubles may in the female, even, present a remarkable
 tenacity, and that in the male it is often so; 2, that in
 the male in particular, the depression and the melan-
 cholic tendency are most commonly observed  in the
most marked, the least contestable cases of hysteria.
We do not indeed ordinarily observe in  the male sub-
ject, although this is assuredly not a distinctive  char-
acteristic  of the  first order,  those caprices,  those
changes of character and humor,  which belong  more 
                    —  i os  —
commonly, but not necessarily, to the  hysteria of the
female.
    But it is time, gentlemen, to bring to an end these
preliminary remarks, in order to come to the principal
object of  our lesson  to-day.  We  shall  proceed  by
clinical  demonstration to study together  in  detail a
certain  number  of perfectly characteristic cases of
male hysteria.  While thus engaged we shall bring to
view the likenesses and the differences that exist be-
tween the  symptoms of hysteria observed  in men  and
those with which we are familiar every day in the cor-
responding form of the disease  in women.  Lastly, I
intend to  present after the manner of a summary, cer-
tain general considerations on the great hysteria (hys-
teria major) as seen in the male sex.
    But before coming to my subject  proper, I desire
briefly to  remind you  by  two  examples to what extent
in the female the permanent symptoms of hysteria, the
hysterical  stigmata, as we are wont to call them  for
convenience, may show  themselves fixed, tenacious,
and consequently exempt from that proverbial mobility
which has been  attributed  to them, and which  some
writers regard as characteristic of the  disease.  I shall
not refer  now to the  six or  eight  subjects of  great
hysteria actually assembled in our wards.   Certain of
them  have presented for  months and even for  years a
simple or  double anaesthesia which our best and most
appropriate therapeutic modifiers can influence  only
for a few  hours.   I will limit myself to presenting to 
— 106  —
you two women who are veritable veterans of hystero-
epilepsy, and who now, being rid for several  years of
their great attacks, and discharged  from the medical
service, exercise in the hospital the functions of do-
mestics.   The first,  L. by name,  well known in the
history of hystero epilepsy, and noted  for  the  " de-
moniacal " character which her convulsive crises  pre-
sented, is to-day 63  years of  age.  She entered the
Salpetriere in 1846, and I have  not  ceased to have
her under observation since  1871.   At this  time she
was affected, as she is still to-day, with  a right hemi-
anesthesia, complete, absolute, sensorial and sensitive,
with ovaria on the same side, which, during  this long
period of fifteen years, has never been modified,  even
temporarily, whether by the action many times tried of
3esthesiogenous agents, whether by the progress of age
and the menopause.  Six years ago, at the time when
our  attention was more  particularly  directed to the
modifications which the visual field undergoes in the
hysterical, we detected in this patient  the  existence
in a marked degree of the classic contraction of the
visual  field,  which was  pronounced  on  both sides,
but  much more so on the right.   The  repeated ex-
amination once or  twice every year since  then has
never failed to reveal the  permanence of this contrac-
tion.
     The other patient, Aurel by name, aged 62 years,
and  in whom the great  seizures, replaced sometimes
by  certain  symptoms of angina pectoris, have  only 
                     — 107  —
 ceased within a dozen of years,  presented as far  back
 as 1851, according to a precious note dated that very
 year, a  left hemianesthesia,  complete and absolute,
 sensorial and sensitive, which, as you can observe for
 yourselves,  exists this  very day,  after a lapse of  34
 years.  This patient has been  under our observation
 for fifteen years,  and never  has  the  hemiansesthesia
 in question ceased to present itself during our often-
 repeated examinations.   The  double contraction  of
 the visual field, very  plain on  both sides, but more
 pronounced on the left, which the campimetric exami-
 nation has enabled us at the present time to  find, al-
 ready existed with her five years ago.
   .  This is enough; I think, to  show you how stable
 and permanent  in  these women are  the  stigmata  of
 which no one would think of disputing the  hysterical
 nature, and how little this corresponds to the  notion,
 erroneous by reason of being carried too far, which is
 generally entertained of the evolution of the  symptoms
 of the disease.
    I come now to the study of  our  male hysterics.
    Case 1.—Rig * *  *, aged  44 years,  clerk in an
 oil factory,  entered the  Salpetriere May  12, 1884,  or
 about a year ago.   He is a large, strong man, of firm
muscles; was formerly a cooper, and endured without
fatigue arduous toil.  The hereditary antecdents  in
this patient are very remarkable.   His father  is still
living, aged 76 years.   From  the age of  38 to 44 the
the latter, by reason of disappointments and pecuniary 
— 108  —
losses, suffered  nervous  attacks, as to the  nature of
which the patient can  give  us but little  information.
His mother  died at the age of  6^, of asthma.   His
mother's great uncle was epileptic, and died in conse-
quence of a fall into the fire  during one of  his  fits.
The  two daughters of this uncle were  also  epileptic.
Rig * * * has  had seven  brothers  and sisters who
have  never had  any nervous diseases.  Four are dead;
among the three living, one sister is  asthmatic.  He
himself  has  had nine children, four of whom died
young.  Of the five who are  still living,  one daughter
fifteen years  old has nervous  crises; another, aged ten
years, has attacks of hystero-epelepsy which  Dr.  Marie
has  witnessed in this very  place; another daughter  is
feeble in intelligence; lastly, two boys  present  nothing
in particular to  note.
     In the personal antecedents  we find the following
facts:   At the age of 19 or  20 years, the patient  was
attacked  with acute  articular   rheumatism,  without
lesions of the heart.  The last attack lasted six months,
and it is, perhaps, to the rheumatism that we are to
attribute the deformation of the hands, which we note
in this patient.  While a child, he was very timid, his
sleep  was troubled by dreams  and  nightmares, and
besides he was addicted to somnambulism.  He would
often rise in the night-time and  go to work, and the
next morning he would be much  surprised to  find his
job done.  This state continued  from 12  to 15  years.
He married at 28 years of age.  We do not find in his 
                    —  109  —
antecedents either syphilis or alcoholism, vices from
which coopers are not  always exempt.  He came to
Paris when 32  years old, working at first  with  his
father, then employed as shop clerk in an oil refinery.
     In 1876, when 32 years of age,  he  met with his
first accident.   He cut  himself quite deeply  with  a
razor which he was sharpening, as some people are in
the habit of doing, by strapping it back  and forth on
the front aspect of the fore arm.  A vein was cut, and
the blood spurted; under the influence of the  hemor-
rhage and the fright, the  patient lost consciousness
and fell to the ground.    He was a long time in recov-
ering, remaining two months  profoundly anaemiated,
pale and without power to work.
     In 1882, consequently about  three  years ago, he
was lowering a barrel  of wine into the cellar, when
the cord which  held it gave  way;  the  barrel rolled
down the  stairway and would  certainly have crushed
him if he had not jumped to one side, he did not, how-
ever, save himself sufficiently to avoid a  slight  wound
of the left hand.   Despite the fright which  he  ex-
perienced, he was able to get  up and help  raise  the
cask.   But five minutes  afterward, he had  an attack
of loss of consciousness which lasted twenty minutes.
Coming to himself, he was unable to walk, so weak
had his limbs become, and  he was  taken home  in  a
carriage.  For two days, it was absolutely impossible
for him  to work; during the night his sleep was  dis-
turbed by frightful visions and interrupted by cries of: 
                    —  no  —
help! I am killed!  He went over again in dreams the
scene in the cellar.   He had nevertheless resumed his
work, when ten days after the accident, in the  middle
of the night, he had his first attack of hystero-epilepsy.
Since this time, the attacks returned  almost  regularly
every two months; and  often  in  the interval, during
the night, whether at the moment of the first sleep or
about the time of waking, he would be profoundly dis-
turbed  by visions of ferocious animals.
    Formerly as  he came  out of these  fits, he re-
membered that he had been dreaming during  the at-
tack, a phenomenon which no longer exists.   He im-
agined that he was in a dark  forest pursued  by rob-
bers or  frightful  animals, or  the scene  of the cellar
was acted over again, and he saw wine  casks rolling
upon him and threatening to crush him.    He  affirms
that never, during these  seizures, or in the  interval,
has he  had dreams or hallucinations of a gay or agree-
able character.
    About this time, he went to St. Anne Hospital for
advice and treatment. The physicians there prescribed
for him bromide  of potassium, and  this medicine (a
fact to be noticed) has never  had the least influence
on the  attacks, although administered for  a long time
till the organism  was saturated with  it.  It was under
these conditions  that Rig----, was admitted to the
Salpetriere, and at his entrance we made note of the
following state.
    The patient is pale, anemic, has but little appe- 
                     —  Ill  —
tite, especially for meat, to which he prefers acid foods;
in short, the general condition is far from satisfactory.
The hysterical stigmata  in  this patient are  very well
marked.  They consist in a double anesthesia in patches
of great extent, for pain (pinching, pricking)  and for
cold.  Sensorial anaesthesia in general does  not exist,
except to a very mild degree; taste and smell are nor-
mal; hearing is nevertheless quite perceptibly blunted,
especially in the left ear; the  patient  hears  no better
when the sonorous object is applied  to the cranium.
As far as vision is concerned, the  symptoms are much
plainer,  and alone suffice, in a measure, to  enable  us
to affirm the hysterical  nature  of  the affectjon.   He
presents, in fact, on both sides a notable contraction  of
the visual field,  more marked,  however, on  the  right.
He distinguishes all the  colors, but the visual  field  of
the blue is more contracted than that of the red, and
passes within the latter,  a phenomenon when it is met
with, which is quite characteristic,  as far as I know, of
the visual field of  hysterical  patients; of this I have
many times shown you  examples.  Lastly, to  finish
what I have to say of  the  permanent stigmata, there
exist  in Rig * * two hysterogenous  points,  the one
cutaneous,  seated below the last  right false ribs, the
other deeper, in the popliteal  space of the right side,
at a point  where  the patient has a cyst,  which  is
the seat of extreme  pain  of  spontaneous   origin.
There does  not exist in this patient any  testicular
point.   Pressure  exercised  over  the spasmogenous 
                    ---  112 ---
points, whether accidentally  or  voluntarily, produces
all the phenomena of the hysterical aura; precordial
pain, constriction of  the  neck,  with the sensation  of
a ball, hissings in the ears, and beatings in the temples,
these  two last phenomena constituting, as  you know,
the cephalic aura.  Those  points  whose  excitation
may provoke the  attack with singular  facility are,  on
the other hand, but feebly spasm-checkers (spasmo-fre-
nateurs), that is to say, their  excitation, even when  in-
tense  and prolonged, arrests but imperfectly the attack
in the process of  evolution.
    In the mental state of Rig----, to-day  as in the
past, it *s always  anxiety, fear, distress, that predomin-
ate.   He cannot  sleep in the dark;  in full day he does
not like to be alone; he is of excessive  sensitiveness,
and he experiences great fright at the sight or remem-
berance of certain animals, such as rats, mice, toads,
which he often  sees, moreover, in terrifying night-
mares, or in hallucinations occurring when half asleep.
He is always sad; "I am weary  of   myself," he  says.
He manifests a certain mobility of mind characterized
by the fact that he can apply himself to nothing, and
that he undertakes and abandons with the same  facil-
ity five or six tasks at a time.  He   is  intelligent and
has a fair amount of education.   He  is, moreover, of
a mild disposition, and totally devoid of vicious pro-
pensities.
     The  attacks  are   spontaneous   or  provoked.
Whatever  may be the manner  of  their origin, they 
                    —  H3 —
always begin by a keen sensation of smarting or burn-
ing in the region of the spasmogenous points, to which
succeed first a pain in the epigastrium, then the sen-
sation of constriction of the neck and of a ball, finally
the cephalic aura consisting of sibilant noises in the
ears, and beatings in  the temples.   At this moment
the  patient  loses  consciousness,  and  the paroxysm
proper begins.  It is divided into four periods which
are quite clear and distinct.   In the first, the patient
executes certain epileptiform  convulsive  movements.
Then comes the period of great gesticulations of salu-
tation,  which  are of extreme violence, interrupted
from time to time by an arching of  the body which is
absolutely characteristic, the trunk  being bent bow-
fashion,  sometimes in front (emprosthotonos), some-
times backward  (opisthotonos),  the feet and head
alone touching the bed, the body constituting the
arch.  During this time the patient  utters wild  cries.
Then comes the third period, called  period of passion-
al attitudes, during which he utters words and cries
in relation with the sad  delirium and terrifying vis-
ions which pursue  him.  Sometimes it is  the woods,
the wolves, or other frightful animals, sometimes it is
the cellar, the stairway, the  rolling  cask.   Finally he
regains consciousness, recognizes the persons around
him and calls them by  name, but  the delirium and
hallucinations still continue for some time.  He looks
all around and under the  bed for the  black beasts
which threaten him; he examines his arms, thinking to
      g aa 
                     — 114 —
find there the bites  of the animals which  he  thinks
he has felt.  Then he  comes to himself,  and the at-
tack is  over, although it is generally  sure to  be re-
peated  a  few  minutes later, and  so  on,  till after
three  or four successive  paroxysms, the patient  at
last completely  regains the  normal  state.    Never
during  the course of  these crises  has he bitten  his
tongue  or  wet  his  bed.
    For more than a year, R. has  been subjected  to
treatment by static  electrization, which,  in  cases  of
this kind, as you know, often gives us good results; we
have prescribed at the  same time all the tonics and
reconstituents  imaginable.   Nevertheless, the  phe-
nomena which we have just described, the permanent
stigmata and fits, persist just as they were, without ap-
preciable changes; they seem, in short, having already
existed  almost  three years, to be  of  the kind  that
undergo very slow modification.  We have, however,
certainly here, as you will all agree, a case of hystero-
epilepsy with mixed  crises (epileptiform  hysteria) as
clearly characterized as possible, and it is plain that
the stability of the stigmata, on which we have suffi-
ciently insisted, should not an  instant stay our diag-
nosis.
    To conclude this case, so perfectly typical, I will
still further call your attention to  certain  particulars
which the clinical analysis has disclosed.   In the first
place, I will mention particularly the nervous  heredity,
so strongly pronounced in his  family: hysteria  in the 
                    —  H5  —
father (very probable at least); great uncle and cousins-
german of the  mother epileptic;  two daughters, one
of  whom  is hysterical,  the  other hystero-epileptic.
You will frequently, gentlemen, meet with these  con-
ditions of heredity in the hysterical male patient, and
find them,  perhaps, more marked even than in the
female.
     I must remind you, moreover, how in our patient
the hysterical  manifestations  were developed on  the
occasion and as the result of an accident which threat-
ened his life.   Could the traumatism which was  the
consequence of the accident (and  it was nothing but a
trifling wound of the finger) have sufficed of itself to
cause the  development  of  the nervous  symptoms ?
This is possible, but  I would  not affirm  it.  It  is al-
ways necessary, alongside of  the  traumatism, to take
account of a factor which very probably has  played  a
more important part in the genesis of these accidents
than the wound itself.   I  refer to the terror experi-
enced by the patient at the moment  of  the  accident,
and which found expression shortly afterwards in loss
of consciousness followed by temporary paresis of the
inferior  extremities.  This same psychical element is
found, apart from the traumatism, in some of the cases
described by Putnam, Walton, Page, Oppenheim and
Thomsen, where its influence, often predominant, can-
not be misunderstood.
     This  fact of  the development of  the hysterical
phenomena  on the occasion  and as the  result of  a 
— n6 —
shock with or without traumatism, where emotion has
played a  great part, you will  also  find, gentlemen,
in most of the  other  patients who will  presently be
shown to you.
    The cases which are now to be presented for your
study are in many respects patterned after the preced-
ing, and this will be my excuse  for not entering  into
lengthy details  respecting them.
    Case  2.—Gil * * *, aged  32 years,  a gilder of
metals, entered the Salpetriere  in Jan.,  1885.   There
is nothing peculiar to note in his hereditary antecedents.
His father, who was a very passionate man, died at the
age of 60 years from paralysis, which did not, however,
follow a fit  of  any kind.   His mother,  who died of
tuberculosis, was a nervous woman, but  never  had
any fits.
    The personal antecedents are much more  interest-
ing to study.  When 10 years old, he was addicted to
somnambulism.   Since  his  childhood, he has been
afraid of  the  dark, and during  the  night has been
subject to  hypnagogic-hallucinations  and to  night-
mares.  In early life, he made an abuse of coitus; he
feels from time to time a sort of irresistible impulsion
towards women.  He  would often leave his work to
run after some  woman of the town, and  after obtain-
ing his desire,  would return immediately to resume
his  occupation.  He  is, moreover, an insatiable mas-
turbator.   He  is, nevertheless, intelligent, is a clever
workman,  and learns  easily.  On occcasions he  is 
                     — 117 —
 given to music; he plays the violin and accordion.
 He is very fond of going to the theatre;  nevertheless
 is of  a  rather gloomy and taciturn  disposition, and
 habitually seeks solitude.
     His occupation, in  which  large  use is made of
 mercury, has never produced  in him  any accidents
 which may be referred to mercurial poisoning.  There
 are no signs  of alcoholism; none  of syphilis.
     His first fit took place at the age of twenty, with-
 out known cause.   He was seated on the imperial of
 an omnibus, when he  felt the first warnings of the
 coming seizure.  He had just time to get down,  when
 the convulsive  attack took him in the street.  The fits
 thereafter returned quite frequently.  He reckoned at
 one time as many  as four or five  a month.  It  seems
 that at  this  time  in some of the  paroxysms he would
 make urine.  The convulsive crises were for  several
 years  becoming less and less frequent,  and he was
 having  considerable  exemption   from   his  malady,
 when  in 1880  he  was the victim of an assault in the
 night-time.   He received a blow  from a  hammer on
 the head, in the right parietal region, fell without con-
 sciousness, was robbed, and left for dead on the  spot.
 He was picked up and carried to the Charity, to M.
 Gosselin's ward, where he remained for  three or four
 days without consciousness.   An erysipelas developed
 several days later around the wound on  the head pro-
 duced  by the blow, and  at the moment of recovery
there  began  an intense  headache of a peculiar char-
acter which still continues to-day. 
— n8 —
    For a long time after this accident he  remained
plunged in a sort of hebetude from which he came out
by degrees, although incompletely, for since this time,
even in his best days, it is impossible for him to apply
himself to work or to any occupation whatever, even
to reading for any length of time.  So he fell into a state
of utter wretchedness.   Moreover,  the   convulsive
seizures, from which for a while he had obtained  re-
spite, returned  and  became more intense and  more
frequent than ever, and for this  reason, in  February,
1883, he presented himself at the Hotel Dieu, where
he was admitted.  He  remained there till March, 1884.
    It was  there  that  the left hemianesthesia, com-
plete  and absolute, just as we  find  it to-day, was  for
the first time noted.  The fits which were then frequent,
and  were regarded, it would   seem, by the hospital
staff  as  due to epilepsy, were  for  almost thirteen
months treated by bromide  of  potassium in  large
doses, but without the  least result.
    When the patient  was admitted to the Salpetriere
in January,  1885, this is what we found:  The general
state, as far as the functions of nutrition are con-
cerned, appears to be  quite  satisfactory.  He eats
well,  and is not  anemic.  On the other hand, one
would not fail to note  in  him   a  psychical depression
which is very marked.   He is gloomy, taciturn, dis-
trustful, avoids the gaze  of people, and has very little
intercourse  with the other patients in the  wards.  He
does  not interest himself  during the day in any occu- 
                    —  II9 —
pation,  in  any  diversion.   The  left hemianethesia,
already noticed  at the  Hotel Dieu,  is complete  and
absolute as far  as  common sensibility is concerned.
The sensorial troubles on this same left side are  also
very pronounced.   There is notable  dullness of hear-
ing; complete loss of smell and of taste; in the left
eye, complete  achromatopsia regularly noted by M.
Parinaud, and contraction of the visual field extremely
pronounced for white light.  Contrarily to what usually
happens in cases of this kind, the extent  of the visual
field, and the notion of colors,  are absolutely normal
on the right side.  There  does not,  moreover,  exist
any trace of lesion of the fundus of the eye on either
side.
     He constantly complains of an intense headache,
which  is gravitative, or  rather constrictive, general,
occupying  the occiput, the  top of the head, the  fore-
head, the temples especially, and more pronounced on
the left side than on the right.  He seems  to  himself
to be wearing a  heavy  and  tight  helmet, which  com-
presses and  constricts his head.   This cephalalgia,
which, as I have said, is  permanent,  is somewhat ex-
aggerted just before and  after the fits.  It is especially
violent when the patient undertakes any occupation,
when he attemps, for instance, to read, or  to  write a
letter.
     The attacks of which we have been many times
witness in our wards, present the following characters:
They may be spontaneous or provoked, in both cases 
— 120 --
differing by  no essential character.  Three hystero-
genous zones have been discovered: two of these oc-
cupy on the right and on the left the infra-mammary
regions; the third is in the right  iliac region;  on this
side, however, pressure of the cord and testicle do not
produce  any abnormal  sensation.   When you press
lightly on the hysterogenous  patches whose  seat has
just been  indicated, the patient  immediately experi-
ences all the  symptoms  of the  cephalic aura, to wit,
beatings  in the temples,  sibilant noises in the  ears,
vertigo,  etc.  But, if you persist ever so little  in  your
compression, the attack  inevitably comes  on  rapidly.
A few epileptoid spasms, of  but short duration, open
the scene.  They are soon followed  by divers contor-
tions and  great movements of salutation,  interrupted
from time to time by the arching attitude (arc de cercle);
during this time the patient  does not cease to  utter
wild  cries.   A convulsive laugh,  tears,  and sobs ter-
minate the attack.  On waking, G----retains no re-
collection of what has happened.  The hysterogenous
points are in this patient but  incompletely spasm-
restraining; when they  are  compressed  during the
attack, the fit is suspended for an instant, but speedily
resumes its customary course.  Whether provoked or
spontaneous, the attacks generally  repeat  themselves
successively a certain  number of  times  so  as  to con-
stitute a series; never, in such cases, is the rectal tem-
perature higher than 37.8° C.
     According to the brief  description above given, 
                     -- 121 --
you  will  notice  that the  case of G.  resembles in
many particulars that of Rig. (Case i), from which  it
differs in only a few particulars,   In both cases, there
are the same hysterical stigmata, the same melancholic
tendencies;  the same kind of attacks, with this peculi-
arity relative to  G.,  that in  him the aura  is evolved
with great rapidity, and that in the crisis the passional
attitudes are wanting.  Let us note the few differences
to which it is worth the while to  call the attention rela-
tively to the second  case.
    We have said that in some  of the  attacks, G. bites
his tongue and urinates in his clothes.   This fact has
been sufficiently noticed by us.   We were for  a short
time lead  to believe  from this that we  had here a case
of hystero-epilepsy  with distinct  crises,  to wit: true
epilepsy on one side,  hysteria major on  the  other,
manifesting themselves under this form of separate at-
tacks.   A more  attentive examination  has convinced
us that it  is not so.   All the attacks  in G. have the
character of hysteria major, and it is during the course
of these attacks that sometimes he bites  his tongue,
and that sometimes  he urinates in his  clothes.  But
biting the tongue and the involuntary emission of urine
are far from being univocal characters of  the  falling
sickness.  These accidents may be observed  in hys-
tero-epilepsy apart from all complication of true epi-
lepsy.   This fact  is of rare occurrence, it  is true;  I
have, nevertheless, observed and  published a  certain 
                     -- 122 --
number of cases which  were perfectly demonstrative
thereof.*
    In  finishing what concerns  this case,  I will call
your attention to the headache from which  G. suffers
continually, and which  is  exasperated by application
to the least occupation.   With  all the particularities
which I have mentioned above, cephalgia of this kind
does not belong to the tableau of hysteria;  it is met
with, on the contrary,  almost as a necessary element
in neurasthenia, of which it constitutes one of the pre-
dominant characters,  and in which we equally observe
the physical and mental  depression which exist  at so
high a degree in our patient.  I  have endeavored to
impress upon you the fact that in  him  these  divers
symptoms came on as the result of a blow  which he
received on his  head.   Now,  gentlemen, the neuras-
thenic state with the  entire congeries of  phenomena
which Beardf assigns  to it in his remarkable mono-
graph, is one of the nervous  affections which are de-
veloped  most  frequently  in  consequence of shocks,
particularly in railroad accidents.  To this fact testify
many of the observations reported  by Page in  his
monograph  on " Injuries  of the Spinal  Cord and

    *Some months later this patient died suddenly after tak-
ing surreptitiously an enormous dose of chloral.  The autopsy,
absolutely negative as far as  the nervous  centres were con-
cerned, completely confirmed the diagnosis.
    fG. M. Beard, Neurasthenia.  New York,  1879. 
                    — 123 —
Nervous  Shock."*  I  have  myself  met with  two
instances  absolutely  like  those  published by  this
writer, one of which concerns one of our confreres  in
Paris.   From this there is reason to  believe that  two
quite distinct elements coexist in our  patient G.  In
the first place, the  neurasthenic state, the immediate
and direct consequence of the shock of which he was
a victim three years ago;  in the second place, the
hystero-epilepsy with all the train of symptoms which
characterize it.  The latter existed before the accident;
it has  been,  however,  considerably  aggravated  since
then, as you can judge  by referring  to the details  of
the case.
     I come now to the examination of the third pa-
tient, who belongs absolutely to the same group as the
two preceding.
     Case  3.—The patient whom you see before you,
Gui. by name,   is twenty-seven years  of  age,  by
occupation a  lock-smith.  He entered February  20,
1884, in the  service of my colleague, Luys.  Of  his
parentage he knows only that his father  died at the
age of forty-eight years, a confirmed drunkard;  his
mother is still living, and never seems to have suffered
from nervous affections.   He has had seven brothers
and sisters; only one  of his  brothers is living;  this
one has never been sick and is not nervous.
    At about the age of twelve or thirteen years, Gui.
*See also C. L. Dana, Medical Record, Dec. 6th, 1884. 
                    —  124 —
became very cowardly, and  could not remain alone
in a room without a feeling of fear and anxiety.  He
was not,  however, irritable or petulant.  At school,
he learned easily, and later, at about the age of seven-
teen or eighteen, he showed himself adroit and intel-
ligent  in his  occupation.  Several times, even, in the
competition for prizes offered  for excellence in his
special branch of work, he obtained medals.  Unhap-
pily, about this  time an immoderate passion for women
and for  strong drink was  developed in him.  He
worked all day long, like his comrades, but when the day
was done, he was often in the habit of going to balls,
or passing the night in some groggery, or house of ill-
fame.  These excesses  were repeated  on  occasions
several times a week, and naturally deprived him of
the necessary sleep.  They did  not, however, seem to
fatigue him,  for the next day  he would  go back to
his work  as ordinarily and acquit himself of his tasks
satisfactorily.
     In 1879, when he  was twenty-one years of age,
during one of his nocturnal expeditions, he received a
blow from a knife which penetrated the left  eye.  He
was immediately carried to the Hotel Dieu, to the ser-
vice of M. Panas, who shortly afterward  practiced
enucleation of this eye.  On  leaving the  hospital G.
speedily renewed his disorderly life.
     About the beginning of  1882, it frequently  hap-
pened that at the moment when he closed his  eyes to
to sleep, he seemed to see a monster in human form 
                    —  125  —
advancing towards him.  In  alarm  he would utter a
cry, open his eyes, and the vision would disappear, to
return, however, as soon as he would again attempt to
go to sleep.   He then fell into an extremely painful
state of anxiety, and often remained thus a part of the
night without being able to obtain any sleep.
    These  hypnagogic  hallucinations  had  already
lasted about  six months, when, in July, 1882, he was
the victim  of a new accident, more terrible than the
first.  He was occupied in propping a balcony at the
third  story of a house, at a time when he was, perhaps,
under liquor, and fell down upon the  street, alighting
upon  his feet, as he affirms.   For more than an hour
he remained unconscious.   On  waking, he was  again
carried to the Hotel Dieu, to the ward of Prof. Panas.
It seems that the surgeons at that time feared the ex-
istence  of  a fracture  of the  cranium.    Recovery,
nevertheless, was not long delayed, and at the end of
two  months, the patient was able  to return home.
Shortly afterwards, the terrifying nocturnal  hallucina-
tions  reappeared, and the spasmodic seizures began to
manifest themselves  for the  first time.   These  were
not at first as characteristic as they subsequently be-
came.   They consisted, chiefly,  in attacks of vertigo
coming on all at once,  and followed  by rigidity, then
by trembling of the limbs.  There was no loss of con-
sciousness.   These  attacks  were, however, not  very
frequent.
    Things  remained in the same condition for almost 
-- 126  —
eighteen months.   At the end of this time, the  reme-
dial  measures adopted by  the  various physicians to
whom  the  responsibility of the case had  been com-
mitted having remained without effect, Gui. made up
his mind to enter the Salpetriere (service of Luys).
     Shortly after  his  admission,  Gui.  became  sub-
ject  to frequent  attacks  of  abdominal  and gastric
colic, followed  by a  feeling  of constriction of  the
pharynx, and subsequently by spells of vomiting which
supervened  without  effort.  These symptoms, which
would yield to no treatment, ceased suddenly  at  the
end of about six weeks.  About this time, there was
first  noticed the existence of the right hemianesthesia,
and also of the peculiar trembling of the right  hand,
to be presently considered.
     In January, 1885, by reason of a change  in  the
hospital staff, the  patients  of  Dr.  Luys passed  over
to our wards, and it  was then  that I saw Gui, for
the  first time.  He is, as you  know, a man of good
muscular  development, and  vigorous; his  general
health  seems good.  The mental condition has  not
presented any great deviation from the normal.   The
hypnagogic hallucinations have  for more than a year
completely disappeared.  Gui. is not melancholy.  He
converses freely with  the other patients  and makes
himself useful in the hospital.
     The hemianesthesia is complete and absolute on
the right side; neither  touching nor pricking is per-
ceived on this side of the body.   The organs of sense 
                     -- 127 —
are also profoundly affected on this  same side,  hear-
ing, smell and taste in particular.  As far as the organ
of vision is concerned, a methodical  examination dis-
closes very characteristic modifications.  On  the right
side—you have not forgotten that the left eye is gone—
the visual field is extremely contracted. The red only
is perceived by this eye, and the circle of  this color is
reduced almost to a  point.
    The  trembling,  of  which  mention was  made
above, and which occupies the right hand, is  remark-
able by the  perfect  regularity of its rhythm  as noted
by the aid of the enregistering apparatus.   It consists
in oscillations, of which the number  is five per second
on an average.  In this respect, it holds consequently
the medium between the  trembling  with  slow oscilla-
tions, such as  characterizes paralysis agitans, for in-
stance,  and  the vibratory  tremblings—with  rapid
oscillations—of  general paralysis, and of Basedow's
disease.  It is not exaggerated under the  influence of
voluntary movements.  The patient  can use  his hand
in eating and drinking, and can even write   passibly
well, provided that he supports with his left hand his
right wrist, a maneuvre which  causes the trembling to
cease for an instant.   The muscular  sense  is wholly
intact in the entire extent of the right superior mem-
ber.
    The only hysterogenous  zone noted in  Gui. oc-
cupies  the  testicle  and the  tract of  the  spermatic
cord almost as far as the groin of the right side.   The 
— 128 —
skin of the scrotum on this side is very sensitive, and
when you pinch it rather strongly you produce exactly
the same effects as if you compress the  testicle  itself,
or the cord, /. e., the development or  the arrest of the
attack, as the case may be.
     These attacks, whether  they are spontaneous or
provoked by the artificial excitation  of this hystero-
genous zone, are  always preceded  by a sensation of
painful  aura perfectly characteristic, which takes  its
origin in the right testicle, mounts up toward the epi-
gastric and cardiac regions, then  to the throat, where
it determines a strong constriction, and finally attains
the head where sibilant noises are produced, especially
in the right ear, and  beatings, principally  in  the
temple of the same side.   The  patient then loses con-
sciousness completely; the epileptoid  period is begun;
at first the trembling of the right hand is augmented
and precipitated, the eyes are convulsed upwards, the
limbs are extended, the fists clenched, then writhed in
exaggerated pronation.   Presently the arms approach
each other in front of the abdomen by reason of con-
vulsive contraction of the  pectoral  muscles.   After
this supervenes the period  of contortions, character-
ized chiefly by extremely violent movements of saluta-
tion which are intermingled  with  disorderly gesticula-
tions.  The patient breaks or tears everything which
is in reach of his hands.  He takes  postures and atti-
tudes the oddest imaginable, so as fully to  legitimize
the denomination of clownism which  I have  proposed, 
                      — 129 —
 to designate this part of the second period  of the fit.
 From time to time the contortions above  described
 stop for an instant to give place to the attitude so
 characteristic called " arc de cercle " (a bowing or arch-
 ing of the body).   Sometimes it is a veritable opistho-
 tonos in which the loins are separated from the plane
 of the bed by a distance of more than fifty centimetres,
 the  body resting on the head  and  heels.   At other
 times, the arching  is made  in  front,  the arms being
 crossed upon the chest, the legs in the air,  the  head
 and  trunk  bent upwards, the  hips  and loins alone
 resting on  the bed.  Lastly,  at  other times, in the
 attitude of arc de cercle the patient rests upon one side
 or the other.  All this part of the seizure is very fine,
 if I may so  express myself, and  every one of these de-
 tails deserves to be fixed by the process of instantane-
 ous photography.   I pass before you the figures which
 have thus been obtained by M. Londe.   You  see that
 from the point of view of art they leave nothing to be
 desired, and moreover they are very instructive. They
 show, in fact, that in what concerns the regularity of
 the periods and the typical  character of the divers
 attitudes,  the  attacks in  Gui.  yield  in  nothing  to
 those which we observe every day  in  our hystero-
 epileptics of the female sex,  and this perfect  resem-
blance is the more worthy of note  from the fact  that
Gui. has never entered the dormitories where  the
females are  placed during  their  seizures,  so  that
we cannot assume in his case the influence of contagi-
ous imitation.
      IO AA 
                    —  T3° —
    Only the period of hallucinations and of passional
attitudes is wanting in this patient.   Sometimes, how-
ever, we have seen  towards the end  of  the crisis his
physiognomy express alternately fright  or joy, while
with his hands  extended  in vacancy he would clutch
at some imaginary object.
    The end of the  attack in our  patient  is  often
marked by a sort of motor aphasia which in  general
does not last  more than eight or ten  minutes, but
which  on one  occasion  continued  almost six  days.
Then, when the patient wishes to speak, certain hoarse,
inarticulate  sounds are all that he  can  utter; he  be-
comes  impatient and excited, but  nevertheless  suc-
ceeds in making himself  understood by very expres-
sive gestures.   It sometimes has happened to him on
such occasions  to take his  pen and write very legibly
a few quite correct  sentences.
    I have said enough respecting  these cases, which
from every  point  of view are quite typical.  But  I
have not yet finished with hysteria in the male subject.
We shall find it, in the next lecture, quite,as charac-
teristic in three other patients  belonging to our clinical
service as in the cases which I have just  presented. 
LECTURE  VIII.
CONCERNING  SIX CASES OF HYSTERIA IN  THE
                    MALE SEX.
                     (Continued.)
Summary.—Abdominal forms of the hysterical attack in man.
    —Detail of a case in which the seizures took the aspect
    of partial epilepsy.—Diagnosis of this case; importance
    of the hysterical stigmata.
        The convulsive seizure may be wanting in hysteria of
    the male.—Description of a case of brachial monoplegia
    in a man aged nineteen years, hysterical.—Difficulties of
    diagnosis in these cases.
    Gentlemen:—1 am  intending  to  finish  to-day
the study which we began in the last lecture.   I shall
proceed as I did on the  previous occasion, mainly by
the method  of  clinical demonstration.   Our material
of male hysterics is far from being exhausted.  Three
new patients are going to be presented to you; in con-
nection with them the principal details of the observa-
tions  which  concern them will be communicated to
you; I shall let the facts speak for themselves, and I
shall only set forth by a few short commentaries the
more important lessons which these cases furnish.
    Case 4.—The subject who is about to.be presented
to you does not quite belong to the class of cases with
which we have thus far been occupied, in this  respect
that he is still  quite a  boy,  and  yet  nearly a full
grown man.  But the disease,  as you will see, seems 
                    — 132 —
in him endowed with  that  character of permanence
and  tenacity which we  have already met in the pre-
vious cases.
     The  patient  Mar. aged sixteen years,  entered
our  clinical  service April  29th 1884,  *'.  e.  a  year
ago.   He was born and lived till the age of  fourteen
years in the country.   His mother is said to have had
in 1872  several attacks of  hysteria.   His  paternal
grandfather was intemperate and of a  very  violent
character.  This is  all we  can elicit relative to his
hereditary antecedents.  As  for the patient himself,
he is a large boy, well developed, although  he had  in
his childhood certain strumous  manifestations, to wit:
runnings  from  the ears,  glandular  swellings in the
mastoid  region.  He is intelligent,  of a rather gay
character, and has never been timid; but he has been
subject to very violent  fits of anger, going so far in
these paroxysms as to break everything in  his  reach.
Two  years  ago he  became apprentice  in Paris  to
a baker.   Shortly  after  he had  an attack of  con-
gestion of the  lungs  and  the enfeeblement which
this  sickness produced was  certainly not without in-
fluence  in the development of  the nervous  symp-
toms which shortly  followed.   Some time afterward,
while still convalescent, he had  a severe fright.  He
was,  he  says, attacked by two  young men one  night
in the street; he fell almost  immediately  without con-
sciousness, and was carried in this state to his em-
ployer's house.  He did not show any mark of injury. 
                     — !33 —
 From  this  moment  he remained for several days
 plunged in a sort of  hebetude.   He began to be
 subject nights to very painful nightmares, which still
 torment him to-day.  He believed that he was a party
 in  a fight,  and  he awoke often with loud  outcries.
 Lastly, at the  end of a fortnight the attacks of hysteria
 commenced.  They  took  place at first every  day,
 presenting themselves in series of eight or ten; some-
 times the attendants counted two series  in the same
 day; then the  fits diminished little by little in number
 and intensity.
     At the moment  when  the  patient  entered  the
 Salpetriere we noted the following state:  " The hys-
 terical stigmata are very plain; they consist in an  an-
 esthesia in patches, scattered irregularly over the whole
 body, and in  which  the insensibility is  complete to
 touch, to cold, and to pain.   Hearing, smell,  and taste
 are obnubilated on the left side, and, as concerns vis-
 ion, we notice the existence of a double contraction of
the visual field,  more  pronounced  on the right side.
 On this side the  patient does  not  distinguish violet,
while on the  left side  he  recognizes all the  colors;
but on both sides (a remarkable phenomena  to which
 I have many times called  your attention, and which
we have already met with in  the  first of our subjects)
the visual  field of the red  is more extended than
that  of  the  blue—the  opposite  of   what  takes
place,  you know, in the normal  conditions.    There
exists   but  one  hysterogenous point,  which   occu- 
                     — 134 —
pies the left iliac region.  To-day, moreover, although
the disease began two years ago, the attacks come on
spontaneously,  at  quite  short  intervals, about  every
ten or twelve days.    They  may be very easily  pro-
voked by a certain amount of even  moderate pressure
over  the  hysterogenous  point.   A more energetic
pressure exercised over  the  same  point arrests  the
attack.
     The fit, whether spontaneous or provoked,  is al-
ways preceded by an  aura; an iliac pain on the level
of the hysterogenous point, a sensation of a ball which
rises from the epigastrium to the throat, buzzings in
the ears and beatings in the temples.   Then the fit
begins; the eyeballs roll upward in their sockets,  the
arms stiffen  in  extension,  and the patient, if  he is
standing, loses consciousness and  falls.  The epilep-
toid phase is in general  little  pronounced and  very
short, but the period of great movements and of  con-
tortions which  follows  is excessively violent and of
long duration.  The  patient utters cries, bites  every
thing in his reach, tears his clothes, makes the  great
classic movements of  salutation, which he  interrupts
from time to time by  taking the attitude so character-
istic of arching of the body (arc de cercle).  The scene
terminates by the phase of passional attitudes, which
is very well pronounced in him, and  differs a  little
according to the  occasion.  Thus,  when  the fit has
been spontaneous, it may happen that  the  hallucina-
tions accompanying the attack may have a gay char- 
                     — i35 —
acter, while,  if the crisis has been  provoked by ex-
citation  of  the hysterogenous zone, the  delirium is
always sad, furious, accompanied with abusive words:
"wretches, villians, devils !"
     Generally several  attacks follow in  succession,
so as to constitute a series.
     In regard to this patient, I  will limit myself to
signalizing the permanence and fixedness of the con-
stituent elements of the hysteria, and -in this respect
this case is an instance  of what is  often observed in
the male subject. Thus, as you have already remarked
in our young patient, although two years have elapsed
since the onset of the disease, the convulsive crises are
still frequent to-day, despite all we have  been able to
do, and the hysterical stigmata, the sensorial and sen-
sitive anesthesia, have  not sensibly varied since the
day when we studied these  signs for the first time.
There is nothing to indicate that there is likely now
to be any change.
     It is not ordinarily  so with young boys, particu-
larly when the disease is developed in them before the
age of  puberty.  At this age (at least this appears to
be the  result of the numerous observations which  I
have been able to make) the  hysterical symptoms are
generally much  more fugacious,  much more mobile,
however well marked they may have been, and  gen-
erally yield readily to an appropriate treatment.
     The case which I am now about  to  bring  before
you, and which  concerns a  young  man  of 22 years, 
                    —  i36 —
belongs, like the preceding,  despite an anomaly in the
form of the attacks to which I shall  presently return,
to the type of hystero-epilepsy.
    Case 5.—The patient, Ly., mason, aged 22 years,
entered the clinical service  of the  Salpetriere March
24, 1885.   He was  born  in  the  country in  the
suburbs of Paris;  is a young man  of medium height,
poorly developed, and of rather debilitated appear-
ance.   His father,  who is a carter, is a drunkard.  His
mother, who died of tuberculosis, formerly had attacks
of hysteria.  Lastly, we find in the  family a maternal
grandmother still hysterical,  although she has attained
the age of  82  years, and two  maternal  aunts,  both
affected with hysteria.  Here are antecedents of  cap-
ital  importance;  four  hysterical   persons  and  one
drunkard in the same family!   The personal  anteced-
ents are  no less interesting to recount.   Our patient
has always been of little  intelligence, feeble minded;
he  never  could  learn anything at  school, but  apart
from this mental weakness,  he does not present any
very characteristic psychical troubles.  He confesses
to having been in  the habit  for a long time of drink-
ing five or six glasses of brandy a day, and a consider-
able quantity of  wine, but  he  assures us that he has
given  up  this  habit since he has been  sick.  Three
years ago, he had  an attack  of erysipelas  of  the  face,
followed shortly by  an attack  of acute rheumatism,
which was, however,  quite  light, as it did not  keep
him in bed but a fortnight.  The same year he was 
— i37 —
under treatment for a tape-worm, and took pome-
granate  bark.   The remedy produced  the  desired
effect; the patient first voided fragments of the worm,
then  the  entire worm.  But  the  sight of  the  tenia
which he found in his stools affected  him very  un-
pleasantly, and the emotion which he experienced was
so vehement that for several days  he  suffered from
slight nervous disorders, such  as cramps,  pains, and
convulsive shocks of his limbs.
    A year ago, while working at his trade  in Sceaux,
the son  of one  of  his comrades was rudely struck
by  his father; L., who was  a  witness of  the scene,
attempted to interpose, but evil happened  to him  in
consequence, for his infuriated comrade turned  his
blows upon him;  and when he took to flight, threw a
large  stone at  him, which fortunately did not hit him.
The  fright,   however,  which  L.  experienced  was
very severe; immediately he was taken with trembling
in his limbs, and on the night which followed it was
impossible for him to sleep.   The insomnia persisted
on  the following day; moreover, night  and  day he
was troubled  with distressing notions.   He  fancied
himself suffering again from the assaults of his tenia,
and going through  the treatment which he had  en-
dured in  its  removal; moreover, he  had pricking
sensations in his tongue, could not eat,  felt  weak, and
worked  in pain.  This  state  had lasted  a  fortnight,
when  one evening about six o'clock his first convulsive
seizure came on.  Since the morning of that  day, he 
                    -  138 -
had  been suffering from pain in the epigastrium with
the sensation of a ball rising, of  choking, and of buz-
zings in  the  ears.   At the moment  when the attack
began, he felt (so he says) his tongue drawn to the
left side  by a sort of involuntary, irresistible traction.
Then he lost consciousness, and when he came to him-
self,  we were  told that his frame was contorted toward
the left, his limbs agitated with trembling;  and when
once the  convulsions had stopped, he began talking
in a loud tone of voice  without waking.  During the
months which followed, he continued to have fits just
like this every eight or  ten days, and he  was obliged
during this  long period  to refrain  from all work by
reason of the state of  weakness in  which  he found
himself.   These crises were considered as epileptiform
attacks of alcoholic origin, and for almost  a year he
was subjected to treatment by bromide of  potassium
in large doses, but  without any benefit whatever being
derived therefrom.   On  the  day which followed  his
admission to the Salpetriere, there was a succession of
five fits which came on  without provocation, and at
which  I was not present.
     The next day, a methodical examination  of  the
patient revealed the following condition; generalized
anesthesia in disseminated patches; considerable con-
traction of the visual field on both  sides;  the field of
red is more  extended than  that of  blue;  monocular
diplopia.  There exist  two spasmogenous points, the
one over the  right clavicle, the other below the last 
                    —  139 —
false  ribs of the same side.   Rather hard  pressure
made over this latter spot caused immediately, on our
first examination, a fit which we were able to study  in
all its details.   It is preceded by the classic aura; epi-
gastric constriction, a feeling of a ball in the neck, etc.
At that very moment, and before the patient  has lost
consciousness, the tongue becomes stiff, and is  drawn
in the  mouth  towards the left side; we  can tell by
means of the finger that its point is carried behind the
molars of  that side.  The mouth,  half open, is  also
drawn to one side, the  left labial commissure is devi-
ated to the left, and all the left side of the face  takes
part in  this deformation; even the  head  is  strongly
twisted toward the left.   The patient at that period,
and  for some time previous, has lost consciousness.
Then the  upper limbs become rigid  in  extension, the
right first, then the left.   The inferior members, how-
ever, remain flaccid, or, at least, are  but slightly rigid.
The movement of torsion toward the left, at first  so
well marked in the face, rapidly becomes generalized,
and the patient rolls upon his left  side;  then  clonic
convulsions replace the tetanic.   The limbs are agita-
ted with frequent, short, vibratory movements.    The
face is  the  seat  of sudden  starts,  then  supervenes
a complete relaxation  without stertor.   But at this
moment the  patient seems tormented  with  fearful
dreams.   He doubtless goes over again mentally, the
scene of the struggle with  his  comrade.  " Wretch !
Prussian !  he  would  kill  me,  the villain  !"  Such 
                    —  140  —
are the words which  he  utters  with  perfect  dis-
tinctness.   Then,  all  at once, he  changes  his  at-
titude; you see him,  seated on  his  bed,  by turns
passing his hand  down his leg as if he  were  en-
deavoring to rid himself of  some reptile which, wind-
ing itself about the leg, was trying to creep  up his
thigh; he speaks of the "tape  worm" which  was so
long a terror to him.  The  scene  of Sceaux again
comes  back: " I  will  kill  him, I  will shoot  him ! "
After this period, marked by delirium and the  corre-
sponding  passional attitudes, the epileptic  period re-
produces itself, thus ushering in a  new fit, which  is
distinguished in nothing from the first,  and which may
be followed by several  others.    Pressure  over  the
hysterogenous points may however interrupt the par-
oxysm in the divers phases of its evolution.   On awak-
ing L. seems  astounded, stupefied, and  he  assures
us that he remembers nothing that has taken place.
    All the  attacks which  we have witnessed (and
these have been  quite  numerous),  whether sponta-
neous or provoked, have  presented exactly  the same
character.  Always we have seen reproduced  in  the
same order, systematically, and even in respect  to the
least details, the  divers  incidents  of  the  epileptoid
phase, beginning by the tongue and  face,  just as I
have described them, then the  various scenes of the
delirious phase.
    You have here, gentlemen, an attack  of hystero-
epilepsy, which, by one side, differs notably  from the 
                     — 141 —
classic type.   In the first period, in fact, we see the
convulsive accidents reproduce, even  to  an  almost
perfect imitation,  the symptoms of partial  epilepsy,
while the contortions, the great movements, the arch-
ing of the body are absolutely wanting.   But we are
acquainted with this  variety of the hystero-epileptic
fit in  the female; although it is  quite rare, I  have
nevertheless had occasion to show you latterly several
typical examples of it.   It  was, moreover,  last year
the subject of an attentive study by my former clinical
chief, Dr. Ballet, physician to the hospitals.*  In com-
paring the case  which has just  been before  us with
the cases which are the subject  of  this  memoir, you
will be led to recognize once more the truly  striking
features  of resemblance which  affiliate the  hystero-
epilepsy of the  male  with  that of  the female,  even
when, ceasing to consider exclusively the fundamental
type, you open the chapter of anomalies.
    Another anomaly, less rare indeed and less  unex-
pected, in the hysteria of the female is the absence  of
convulsive crises.   You know, in fact, that  according
to the teachings of Briquet,  about one-quarter part of
hysterical women do  not have  fits.   The disease  in
such a case, without  losing  any of its  autonomy, is
only represented symptomatically by  the permanent
stigmata, to which are sometimes added several morbid
    * Ballet et Crespin, Attacks of Hysteria in the Form of
partial epilepsy (Arch, de Neurol. 1884, Nos. 23 and 24). 
— 142 —
accidents, spasmodic or otherwise, such as a nervous
cough,  permanent  contractures,  certain arthralgias,
certain paralyses, hemorrhages taking place by divers
passages etc.; now the convulsive attacks may  equally
be wanting  in the hysteria of  the male.   The case
which I am  going to bring before you now,  when it
was first presented to us, was a good example  of this
kind.    The disease has in a certain sense undergone
completion since  then,  for the patient now  has fits.
But for a long period of eleven months this was one
of those masked cases which are not very  easy of  in-
terpretation, at least  in certain respects, as you will be
able to judge.
    It was,  then, the 10th of last March that the boy
whom you now see, first appeared at our clinic, suffer-
ing from a left brachial monoplegia, without any trace
of rigidity, the limb being flaccid and flexible to a per-
fectly normal degree.  This paralysis had now lasted
ten months,  and came  on several days after a  trauma-
tism affecting the anterior  part of the left  shoulder.
There was no trace of  paralysis or even of paresis in
the corresponding inferior extremity or  in  the face;
there  were, moreover, despite  the  already  remote
date  of the  onset,  no  traces  of  atrophy of  the
paralyzed muscles, a circumstance which, joined  to
the absence of any modification in the electric re-
action of the muscles, led us immediately to eliminate
the influence (at  least  the local, direct  influence) of
traumatism.  We were struck, moreover, at seeing the 
                     — '43 —
skin of  the carotid regions lifted by  violent arterial
throbbings.  The  Corrigan pulse was well marked.
Auscultation of  the heart revealed the existence  of  a
murmur with the second sound and  at the base,  and,
moreover, we found in the antecedents of the patient
the history of an attack of acute articular rheumatism,
which had kept  him  in bed five or six weeks.   The
idea came to us, in consequence,  quite naturally, that
this monoplegia depended on a  localized cerebral
lesion  in  the cortex, strictly  limited  to  the motor
zone, in the  brachial  centre,  and  itself consecutive
to the valvular affection of the  heart.  But a more at-
tentive study of the case  soon undeceived us.   With-
out doubt, the monoplegia in question takes its origin
in a cerebral cortical lesion for the most part localized
in the motor zone of the arm; but we have not to do here
with a gross material  alteration—the lesion is purely
"dynamic," usine  materia," of the  kind of those,  in
fact, whose existence we are obliged to  assume in order
to explain the development and  persistence of divers
permanent symptoms  of  hysteria.   This is, at  least,
what results very clearly from  the  detailed examina-
tion which we are about to make of our patient.
     Case  6.—The patient, named Pin., aged 18 years,
mason by occupation,  entered the  Salpetriere March
u, 1885.   His mother died at  the'age of 46  years
from the  effect of " rheumatism"; his  father  is  a
drunkard.  One of his sisters, aged  16 years, is  sub-
ject to  frequent nervous  attacks.   The patient  is  a 
                    —  144  —
young man of robust appearance  and vigorous mus-
cles, but the functionment of the nervous system  has
always left much to be desired.   From the age of  five
to seven years he suffered incontinence of urine.  He
has always been deficient in intelligence;  his memory
is weak; and he never learned much at school.  More-
over he was timid,  and  suffered from nightly terrors.
From a moral  point of view he is ill balanced.   From
the time that he was nine years  old  he often  left his
home and slept under bridges, or in the waiting rooms
of railway stations.   His father  apprenticed him to  a
fruit dealer, then to a confectioner, and to other trades-
people,  but he was always getting into scrapes.   One
night he was arrested, in company with a band of
young vagabonds, and sentenced to the Reformatory
of Roquette, where his father left him for a  year.
    Two years ago, when he was 16 years old, he  was
taken with an  attack of  acute  articular  rheumatism,
preceded by an attack of erysipelas of the face, and  it
is quite probable that from this  period we must date
the organic alteration of the heart which we note in
him to-day.
    May 24, 1884,  or eighteen  months afterward, P.,
then a mason's apprentice, fell from a height of about
two metres, and remained for several minutes without
consciousness upon the place  where he fell.  He  was
carried to his home, and there several contusions were
found on  the  anterior aspect  of  the left  shoulder,
knee,  and  ankle; these contusions were slight, and did 
                     — 145 —
not  seriously interfere with the  use  of the  affected
parts.
     For several days, it was thought that things would
remain where they were; but on the 27th of  May, i.e.,
three  days  after the  accident, P.   perceived  that
his left  upper limb was becoming feeble.   He  then
went to see a physician, who detected, it would seem,
a paresis of all the movements  of the left arm, with
anesthesia of this member.   On the  8th of June, that
is, 15 days after his  fall, and  11  days after the  com-
mencement of the paresis, he entered the Hotel Dieu.
There he was examined with care, and the  physicians
recognized the well  characterized signs of aortic in-
sufficiency.   The parts which were bruised were not
the seat of any pain,  whether spontaneous or provoked
by active or passive movements.   Incomplete paralysis
of the left superior member.  The patient  could  still,
though  incompletely, flex the hand  on the forearm,
and the latter on the arm, but all movements of the
shoulder were  impossible.  The paralyzed limb was
quite flexible in all its joints; there were no traces of
rigidity.*  The  face and the left inferior extremity
were absolutely  normal; as far  as motility was  con-
cerned, it was a  clear case of monoplegia in the true
sense of the word.  The study of the sensibility  gave
     * The notes of this case while under observation at the
H6tel Dieu were taken by Mile. Klumpke, interne, and kindly
furnished us by this lady.
     II AA 
                    —  146 —
the following results:  There existed already at this
period a  generalized  left-sided  hemi-analgesia; the
anesthesia was complete and confined to the paralyzed
limb.   At this  time there  was noted the binocular
contraction  of  the  visual field, much more  marked,
however, on the left side, and which we shall  find so
existing to-day.  In fine, the  25th of  June, i.e., 22
days after the onset of the  paralysis, the  latter had
become absolutely complete.  The diagnosis remained
uncertain, the treatment inefficacious.  Faradization,
several times applied to the  left side, had for  its  effect
only to render the sensibility less obtuse on the trunk,
face,  and inferior  extremity.   The  anesthesia and
paralysis remained as they were in the left upper limb.
The contraction of the visual field had undergone no
modification  at  the time that P. quit the Hotel  Dieu.
     It was on the eleventh of March  of this year, ten
months after the fall, and nine  months after the
complete  establishment of  the  monoplegia,   that  P.
entered the service of the  clinic  of  the Salpetriere.
We then  verified the antecedents as I have just stated
them, and,  moreover,  a  minute clinical  examination
disclosed  a pronounced  aortic insufficiency.    There
exists a murmur  with  the  second sound  and at the
base; the arteries of the  neck are  lifted by  beatings
which are apparent  to the sight; Corrigan pulse;  capil-
lary pulse perceptible on forehead.
     The motor paralysis of the left upper limb, which
is seen to be inert, hangs along the  side of the  body, 
                     — '47 —
 and falls heavily when, on being raised, it is abandoned
 to itself, is complete, absolute.   There  is no trace of
 voluntary movement, or of contracture.   The muscu-
 lar masses have preserved their volume; their normal
 relief and electric reactions, faradic as well as galvanic,
 are in no respect modified.  Very slight relative aug-
 mentation of the tendinous reflexes of the elbow  and
 forearm.  Cutaneous anesthesia absolute to contact,
 to cold, to pricking, to the most intense faradization,
 along  the whole extent of  the limb,  hand, forearm,
 arm and  shoulder.   In its  relation  to the trunk,  this
 anesthesia is limited by a circular line producing an
 almost vertical plane, which, passing by the hollow of
 the arm-pit, trenches a little on the sub-clavicular hol-
 low in front, the  external  two-thirds of  the  shoulder
 blade behind.   The insensibility extends in the same
 degree to the deep parts;  you  may, in fact, faradize
 powerfully the muscles, the  nerve trunks themselves,
 make energetic traction on the articular ligaments,
 subject the different joints  to  movements of violent
 torsion, without the patient having the least conscious-
 ness of it.  The loss of the different notions  attached
to the muscular sense is equally complete; the patient
 is unable to determine, even approximatively, the at-
titude which has been  impressed on  divers segments
of his limb, the place which  they occupy in space, the
 direction and nature of the  movements to which they
are subjected,  etc.
    Aside from the left upper member, there does not 
                     — 148 —
exist on that half the body any modification of mo-
tility, whether of the face, trunk or inferior extremity,
but all over this side we find the  analgesia already
noticed during the sojourn of  the patient at the  Hotel
Dieu.  The examination of the visual field  gives  us
on the right side the normal state,  while  on the left
there  is an enormous contraction; moreover, the circle
of red is transferred outside of that of blue.  There
has then been produced in the visual  field since  the
sojourn in the Hotel Dieu a modification  which it is
interesting to note.   Moreover, we find that  hearing,
smell, taste, tested by the ordinary methods, present a
very marked diminution of  their acuteness on the left
side.
    It now became our task  to determine as  far  as
possible the nature of this singular monoplegia, super-
vening after a traumatism.  The  absence  of atrophy
and of all  modification of the  electric reactions of  the
muscles in a case where  the paralysis goes  back  ten
months, ought to cause  us to reject at once the  hypo-
thesis of a  lesion  of the brachial  plexus; while the
absence of amyotrophy of  itself, as well as the  inten-
sity of the troubles of  sensibility,  compel us  to  set
aside the notion that this may be one of those paralyses
so well studied by Lefort and Valtat, which  come on
in consequence of traumatisms affecting a joint.
    A brachial  monoplegia may  supervene, though
very exceptionally, it is  true, as the  result of certain
lesions of  the internal capsule, as is  shown by a fact 
                     —  149  —
 recently published by Drs.  Bennett and Campbell in
 Brain;* but in such  cases we do  not certainly meet
 with the sensorial and sensitive hemianesthesia which
 is sometimes  superadded to  total hemiplegia of  the
 ordinary kind following lesion of the capsule.
     The  production in  the  right  hemisphere of  a
 small foyer  (local lesion), whether from  hemorrhage
 or  from softening determined  by embolism in con-
 sequence of the organic affection of the heart, a  dis-
 ease-focus which we might suppose limited strictly to
 the motor zone of the arm—such a lesion, I say, might
 account for the existence of a left brachial monoplegia.
 But on this supposition, the paralysis would have come
 on all at once, after a shock, however slight, and  not
 progressively;  it  would   almost  certainly,  several
 months after the onset, have been characterized by  a
 certain degree of contracture, and  by a well marked
 exaggeration of the  tendon-reflexes; lastly,  it would
 not surely have been accompanied with trouble of  the
 cutaneous and deep sensibility so pronounced as those
 which we observe in our  patient.
    We are compelled then  to eliminate in our diag-
 nosis this last hypothesis,  and that  of  a spinal lesion
 will not bear discussion for an instant.  On the other
 hand, our attention has been drawn from the very first
to the very significant hereditary antecedents  of  the
subject, to his psychical state and to his habits, to  the
* Brain, April, 1885, p. 78. 
                    — i5° —
troubles  of sensibility,  diffused,  though unequally,
over all of one side of the body, to the contraction of
the visual field so  pronounced  on the left side,  and
marked by  the transposition of  the circle of the red;
in fine, to the modifications of activity of the other sen-
sorial apparatuses  on the same  side;  all this has led us
almost irresistibly, in the absence of  any  other hypo-
thesis equally probable, to  interpret this  case as an
example of hysteria. Moreover, the clinical characters
of the monoplegia, its traumatic origin even—and in
reference to this latter point I must  refer you to what
I have said before—were not at all at  variance with
this view.  In fact, the limitation of  the  motor para-
lysis to one member, without participation at any time
of the corresponding side of the face; the absence of
marked exaltation of the tendinous  reflexes, of mus-
cular atrophy, and of all modification of  the  electric
reactions, the absolute resolution of  the  limb  remain-
ing several months after the onset of the paralysis; the
anesthesia cutaneous  and  profound, so  complete in
the paralyzed member, and the utter loss of all notions
relative to the muscular sense; all  these  phenomena,
when we find them united and clearly marked as  they
are in our  patient, suffice  largely to reveal the  hys-
terical nature of a paralysis.
     In  consequence,  the  diagnosis " hysteria"  was
frankly, resolutely adopted.  It was true that the  con-
vulsive seizure was wanting; but you  well know that this
is not at all necessary to the constitution of the disease, 
                     — i5i —
and this  circumstance ought  not, we  felt, to stand
in the way of a diagnosis.  As a result of this view of
the case, the prognosis changed  completely its  char-
acter; we were no longer in the presence of an affec-
tion of organic cause, perhaps incurable; we could then
hope, despite the long duration of the  malady, to  see
supervene  spontaneously, or under the influence  of
certain practices, some one of those sudden modifica-
tions which are  not  rare in  the  history of  hysterical
paralyses, and of those in particular which are attended
with resolution.   At all events we could foresee that
sooner or later the  patient would  get well.  A subse-
quent event was destined soon to justify our previsions
and at the  same time fully confirm our diagnosis.
     The fifteenth  of  March, four  days  after  the
entrance of the  patient, we made careful  search—a
thing which had not been done before—to see  if we
could find  any hysterogenous zones.  We  found one
situated under the left mamma, another over  each  of
the iliac regions; still another over the  right  testicle.
We remarked that even a slight excitation of the infra-
mammary zone readily determined the  phenomena  of
the aura: sensation of constriction of the thorax, then
of the neck; beatings in the  temples, sibilant sounds
in the ears, especially in the  left ear.   On  pressing  a
little harder we saw P. all at  once lose  consciousness
and fall over backwards with stiffening  of his mem-
bers; and we witnessed the first attack  of hystero-epi-
lepsy which the  patient had  ever had.  This attack 
                     — 152 —
was, moreover, quite typical; to  the epileptoid phase
soon succeeded that of the great movements.   These
were  of extreme  violence,  the  patient in his move-
ments of salutation went so far  as  to  smite  his  face
against  his knees.   A little after, he tore his  clothes,
his bed  curtains, and turning his fury upon himself, he
bit his  left  arm.   The  phase of  passional attitudes
then set in;  P. seemed a prey to  a furious delirium; he
reproaches,  provokes and excites to violence some im-
aginary personages:  "Hold ! take your knife; come,
strike !"  Lastly he recovers consciousness and affirms
that he  has no remembrance of anything that has hap-
pened.
    It is to be remarked that during the entire continu-
ance of  the  first attack, the left superior member took no
part in the convulsions; it  remained  flaccid and  com-
pletely inert.  From this time onward, the fits were
repeated every day, spontaneously,  several times  dur-
ing the  day with precisely the same characters  as the
provoked attack.    During one  of  these, which  took
place on the night of  the 17th of  March, the patient
wet his  bed. There were two fits  on the 19th.  On
the 21 st there  was a new crisis  during which the left
arm trembled.   On waking, the patient, to his great as-
tonishment  found  that he  could  move the divers
segments of this member, of the use of which  he had
been  totally deprived during the  long period of al-
most 10 months.   The motor paralysis  was  not com-
pletely  cured, however,  for there remained  a certain 
                     — i53 —
degree of paresis, but there was a  considerable im-
provement.   Only, the troubles of sensibility persisted
to the same degree as in the past.
     This cure, gentlemen, or more properly speaking,
this attempt  at a cure, after the  diagnosis  which  we
were led to make,  did  not  surprise us.   But in our
judgement it supervened prematurely, unseasonably.
In fact, it was no longer possible to enable you to wit-
ness de visu, in all their  plentitude (as  we had  hoped
to do), the character of  this monoplegia, so excellent a
subject for study.   The idea then occurred to me that
perhaps by acting on  the mind of the patient  by way
of suggestion  in  the waking state (I had previously
found that the subject was not hypnotizable) we might
reproduce the paralysis, at least for  a  while.  There-
fore the next morning, finding  P.  just  coming out
of a  fit  which  had  in no way modified  the  state
of things, I endeavored to persuade him  that he was
again  paralyzed.   "You believe yourself  cured," I
said to him with assurance, "it is a  mistake; you can
not  raise your arm  or bend  it; see, you can not
move  your fingers,  you are  unable  to  grasp my
hand."  The  experiment   succeeded  wonderfully,
for after a  few  minutes, while  I  was talking, the
monoplegia returned just as  it was the  day before.
I was not  at  all disturbed, I may here say, as to the
result  of this paralysis  artificially  reproduced,  for I
knew by long experience that in a matter  of hypnotic
suggestion, what one has made one can  unmake.    The 
                           —  154 —
       paralysis, however, did not last longer than 24  hours.
       The next day a new attack came on, following which,
       the voluntary movements were definitely reestablished.
       This time, all the new  attempts of suggestion  which.
       we made were absolutely powerless.   It now remains
       for me to inform you of the modifications which, as
       far as voluntary movement is concerned, have been ef-
       fected in the limb formerly completely paralyzed.
            The patient as you see, can move  at will  all the
       parts of this member.  But these movements have but
•      little energy, they yield to the least resistance opposed
       to them, and while  on the right,  the dynamometric
       force expresses itself in the hand by the figure  70, on
       the left it gives only the figure 10.   If then, the motor
       impotence is not as  absolute as formerly, it still per-
       sists  to  a  sufficiently high degree.   Moreover, the
       troubles of sensibility are just as they were, not only
       in the limb which is the subject of  paresis, but also on
       all the left side of the body including the organs of
       sense; the  fits, besides, remain frequent.  Truly, as
       you see, we  have here  only  an improvement   in the
       condition of the arm, and we are far from having at-
       tained a cure.
            I propose in connection  with  this  study  of hys-
       terical paralysis by  traumatism, which I intend soon
       to bring before you at length, to take up again certain
       of the facts contained in this interesting case, in order
       to give them their full value.  For the present, leaving
       one side the monoplegia, which really  constitutes but 
                     — 155  —
an episode in the history of the disease, I  shall dis-
miss the  subject  by expressing the  hope that I have
made it plain to you that in this man, as  in  the  other
five cases, before  presented, the great hysteria  (hys-
teria  major) exists, endowed  with  its  characteristic
attributes.
    Gentlemen, in studying  with you, in these two
lectures, these six cases, so significant and instructive,
which chance has  placed in our way, I have  desired
especially to convince you that hysteria, even grave
hysteria, is not a rare disease in the male, and that it
is likely to appear now and then in private  and  hos-
pital practice, where  only  the prejudices of another
age could cause  a  failure  to recognize it.  I have
dared to hope that after so many proofs which  have
been accumulating these last five years, this  notion is
destined hereafter to keep in your  minds  the  place
which it deserves to hold. 
 
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Antiseptic Midwifery.
    By Henry J. Garrigues, M. D.

On the Determination of the Necessity for
 Wearing Glasses.
    By D7B. St. John Roosa, M. D.

The Physiological,Pathological and Ther-
 apeutic Effects of Compressed Air.
    By Andrew H. Smith, M. D.

GranularLidsandContagiousOPhthalmia.
    By W. F. Mittendoff, M. D.
Practical Bacteriology.
    By Thomas E. Satterthwaite, M. D.

Pregnancy, Parturition and the Puerperal
 State and their Complications.
    By Paul F. Munde, M. D.
SERIES II.
The Diagnosisand Treatment of Haemor-
  rhoids.
   By Chas. B. Kelsey, M. D.

Diseases of the Heart. Vol. I.
   By Dujardin-Beaumetz, M. D.

Diseases of the Heart. Vol.11.
   By Dujardin-Beaumetz, M. D.

The Modern Treatment of Diarrhoea and
  Dysentery.
   By A.'B. Palmer,  M. D.

Intestinal Diseases of Children.
   By A. Jacobi, M. D.
The Modern Treatment of Headaches.
   By Allan McLane Hamilton, M.  D.

The Modern Tieatment of Pleurisy and
 Pneumonia.
   By G. M. Garland, M. D.

How to Use the Laryngoscope.
   By an Eminent Laryngologist.
Diseases of the  Male Urethra.
   By Kessenden N. Otis, M. D.
The Disorders of Menstruation.
   By Edward W. Jenks, M. D.

The Infectious Diseases.      In 2 vols.
   By Karl  Liebermeister.
SERIES III.
Abdominal Surgery.
   By Hal C. Wyman, M. D.  Ready.

Diseases of the Liver.
   By Dujardin-Beaumetz, M.D. Ready.

Hysteria and Epilepsy.
   By J. Leonard Corning, M. D.  Aug.

Diseases of the Kidney.
   By Dujardin-Beaumetz, M. D.  Sept.

The Theory and Practice of the Ophthal-
 moscope.
   By J. Herbert Claiborne, Jr., M. D.
     September.

Modern Treatment of Bright's Disease.
   By Alfred L. Loomis, M. D.
     October.
Clinical Lectures on Certain Diseases of
  Nervous System.
    By Prof. J. M. Charcot, M. D.
     October.

The Radical Cure of Hernia.
    By Henry O.  Marcy, A. M., M. D.,
     L. L. D.   November.

The Treatment of Diseases of the Blad-
  der, Prostate and Urethra.
    By H. O. Walker, M. D.  Nov.
Dyspepsia.
    hy Frank Woodbury, M. D.  Jan. '8o

The Treatment of the Morphia Habit.
    By Erlenmeyer.  December.
     Translated by J. B. Mattison, M.D.
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