Morvan’s Disease. 
BY 
B. SACHS, M.D., 
PROFESSOR OF MENTAL AND NERVOUS DISEASES, 
S. T. AEMSTRON G, M. D., Ph.D., 
INSTRUCTOR IN MENTAL AND NERVOUS DISEASES, 
NEW YORK POLYCLINIC. 
AND 
REPRINTED FROM THE 
■Neto Yorft f&ctrical Journal 
for April 30, 1892. Reprinted from the New York Medical Journal 
for April 30, 1892. 
MORVAN’S DISEASE. 
B. SACHS, M.D., 
PEOFESSOE OP MENTAL AND NBEYOUS DISEASES, 
and S. T. ARMSTRONG, M. D., Ph. D., 
INSTRUCTOR IN MENTAL AND NEEYOUS DISEASES, NEW YORK POLYCLINIC. 
In 1883 Dr. Morvan, residing in a little town in Brit- 
tany, published a paper on a disease that he had observed 
there to which he gave the name of analgesic paresis and 
panaritium of the superior extremities, or pareso-analgesia. 
In this paper he stated that at the commencement the dis- 
ease was limited to one extremity, subsequently passing to 
the other, and always terminating in the production of one 
or more felons. 
In the cases as first described by Morvan the symptoms 
are initiated by a weakness of the muscles, and sometimes 
by a pain in the forearm, that is succeeded by a swelling of 
the member, with the formation of deep palmar fissures and 
felons, usually painless, with phalangeal necrosis. It was 
for the latter condition that the physician was consulted, 
and at that period there was usually paresis of the muscles 
of the affected region that was afterward followed by 
atrophy of the thenar, hypothenar, and interosseous mus- 
cles. While faradization would produce energetic con- 
tractions in the muscles of the forearm, no reaction would 
Copyright, 1893, by D. Appleton and Company. 2 
MORVAN’S DISEASE. 
be obtained in the atrophied muscles. There was analgesia 
of the forearm, sometimes of the arm, neck, and chest; and 
also thermal, but no other anaesthesia. Exertion produced 
occasionally hyperidrosis of the analgesic region ; and the 
existence of vaso-motor disturbance was further evidenced 
by the bluish or mottled discoloration of the affected part 
in cold weather, and the occasional formation of phlyc- 
tsenulae. Of his reported cases, seven were in males and 
two in females, and the disease had lasted from a few to 
twenty-five years without involvement of other regions. 
It seems to us that the report that Morvan made of 
what seemed to him to be a new disease should be con- 
sidered in giving it a place in nosology. The existence of 
paresis, loss of pain sense and thermal sense, circumscribed 
atrophy of the forearm or hand muscles, and trophic dis- 
turbances evidenced by the formation of cutaneous fissures 
and felons, would constitute what is known as Morvan’s 
disease. In all reported cases of the disease made at a 
subsequent date these have been the essential symptoms, 
and the following case is added to the literature of the 
subject, the patient having been presented for examination 
to two medical societies of this city: 
W. H., aged twenty-eight, a native of Germany, a laborer, 
was referred to Dr. Sachs’s clinic at the New York Polyclinic 
by Dr. Gerster. The patient had a venereal ulcer and a bubo 
in the right groin ten years ago, but otherwise he has always 
been healthy until four years ago, when he was employed as a 
dish-washer, his hands lost their muscular power, there was 
slight twitching and enlargement of the fingers, and the skin of 
the fingers and hands became thickened and fissured. He was 
treated by a physician, and the enlargement in the fingers sub- 
sided, except in the index and third finger of the left hand, in 
which felons formed, that were incised without causing any 
pain. He thought that the condition of his hands resulted from 
the use of soda in the wash-water; but it is now four years 3 
MORVAN’S DISEASE. 
since he stopped washing dishes, and his hands have not im- 
proved. At the time of examination the skin of each hand was 
of a purplish color, that was intensified by cold weather, the 
discoloration under such influence extending up the arm. 
The hands themselves presented the following appearance: 
Fig. l. 
Eight. The skin on the dorsum seems to be normal, but on the 
dorsum of the fingers it is thickened; there is a slight con- 
tracture at the second phalangeal joint in all of the fingers, but 
more pronounced in the middle and index fingers. There is a 
small eschar on the dorsum of the thumb, but this member is 
not contractured. There is a marked atrophy of the first dorsal 
interosseous muscle. On the palmar surface the skin is thick- 
ened, and there are numerous ragged excoriations, especially on 
the finger-tips and at the base of the middle and ring fingers; 
in these excoriations deep fissures, having indurated edges, have 
formed. On the anterior surface of the right forearm is an area 
of dermatitis resembling a mild degree of ichthyosis. At the 
bend of the elbow there is an area four inches long by an inch 
wide, in which there are numerous small depressed atrophic 
areas that might be described as a dermatrophia circumscripta 
albida; the patient thought that this had resulted from carry- 
ing a basket on his arm, the markings resembling somewhat MORA7AN’S DISEASE. 
those that would be produced by the pressure of the twisted 
willow in the handle thereof. There is a scar over the olec- 
ranon, caused by an incision (painful) for an abscess in 1890. 
Left hand: The skin on the dorsum and palmar surfaces of the 
hand and fingers presents a similar appearance to that of the 
right hand, hut the nails of the index and middle fingers are 
thickened and deformed, and the end of the index finger is 
conical while that of the middle finger is clubbed. The nail of 
the latter finger presents white opaque strife, and a portion was 
examined microscopically to see if these striae were caused by a 
mycelial growth; but no fungus was found. There is moderate 
atrophy of first dorsal interosseous. Dynamometer showed ; 
Manus dextra, thirty kilogrammes; maims sinistra, sixty kilo- 
grammes; but this disparity has been lessened during the course 
of the electrical treatment, and the muscular power is almost 
equal at the time of writing this report, though it is yet less 
than that of a healthy man. The muscular sense was normal, 
and, excepting in those muscles above mentioned, no atrophy was 
apparent. The forearms were well developed and were equal 
in circumference. The tactile and pressure senses wrere normal, 
the patient locating a straw drawn over the skin, and discrimi- 
nating between different weights. The pain sense is abolished 
in an area on the dorsum of the right hand ; also over the dor- 
sum of the fingers, hand, and ulnar side of the left forearm ; 
but there is no loss of pain sense in the palms or the anterior 
surface of either forearm. Fig. 2 show's the analgesic areas 
on the hands; the test was made by forcing a needle into 
the flesh. The temperature sense did not recognize a tempera- 
ture of 212° F. on either forearm, excepting at the flexure of 
the elbow, where it felt hot; but at this point a temperature of 
150° F. felt cold. Temperatures of 190° to 200° F. wrere recog- 
nized as warm on the upper portion of the arms and hack, 
though lower temperatures were called cold. In the regions 
above mentioned a temperature of 32° F. was not recognized as 
very cold, even if it was placed on a spot on which a tempera- 
ture of 212° F. had just been placed. These observations wyere 
made with test tubes containing boiling water and a freez- 
ing mixture. There is fibrillary twitching of the muscles of MOEVAE’S DISEASE. 
5 
the forearm and hand. Fig. 1 shows the atrophy of the inter- 
ossei, the deformity of the fingers of the left hand, and the slight 
Fig. 2. 
tendency to the main en griffe. An electrical examination 
showed an absence of the faradaic reactions in the extensor, 
thenar, and interossei muscles, though the flexor group reacted MORYAN’S DISEASE. 
well. Galvanic reactions, AOO>KOCinthe extensor muscles 
of each forearm and the interossei. It might be here stated 
that since the treatment by electricity has been commenced, the 
faradaic reactions have returned in the extensor groups and the 
difference in the galvanic reactions is diminishing. 
There is no history of pain in the forearms preceding the 
appearance of the other symptoms; his attention was first 
called to his hands by the fact that, when immersed in hot 
water, he had no sensation of its heat—a phenomenon asso- 
ciated with the swelling and inability to use his hands. When 
his entire skin is perspiring his forearms will be cold. He has 
had to give up positions as a waiter because he has been unable 
to firmly hold articles of glass or crockery in his hands. 
In this case we have paresis of the muscles of the 
hand; analgesia of certain regions of the dorsum of the 
hands and of the posterior aspect of one forearm; ther- 
mal anaesthesia of both forearms, and felons on one hand 
—the congeries of symptoms constituting Morvan’s dis- 
ease. 
The pathology of the disease, and, in fact, whether there 
was any such morbid entity as this disease, has been ques- 
tioned. Osier (2) considers it a peripheral neuritis of toxic 
origin, and Gowers (3) considers it a peripheral neuritis 
with myelosyringosis.* This theory that the disease is a 
peripheral neuritis seems to be verified by an examination 
of Morvan’s first reported cases; his first case is one of 
traumatic neuritis following a fall, with persistent motor 
and sensory paresis for ten years; his second case present- 
ed symptoms of multiple neuritis, in which the affection of 
the nerves of the lower extremity disappeared in the course 
of years, certainly a result that would never have occurred 
in myelosyringosis; his third case seems to be one of 
* Our attention has been called to the barbarism in the composition 
of syringomyelia, and we have adopted myelosyringosis as a term that 
avoids the etymological error in the more usual word. MORVAN’S DISEASE. 
7 
chronic neuritis, as is evidenced by the occurrence of pain- 
ful paroxysms during twenty-four years; his fifth case re- 
sembles traumatic neuritis; and his seventh case resembles 
one of multiple neuritis. Monod and Reboul, in their re- 
port of a case of the,disease, took the position that it was a 
variety of peripheral neuritis, having found in an examina- 
tion of the nerves of an amputated finger an acute paren- 
chymatous and interstitial neuritis. Dejerine (13) thought 
that the frequent appearance of the disease in the popula- 
tion of a small province showed that it was a neuritis of 
toxic or infectious origin. 
Surgical pathology teaches us that felons do not origi- 
nate spontaneously, but in consequence of the introduction 
of the Streptococcus pyogenes ; and the fact that the felons 
are usually painless seems to show that the micro-organism 
gains access to the tissues in consequence of the trophic 
disturbances, and that the felons are merely an incident that 
might be prevented in such cases by due attention to cleanli- 
ness. 
The dissociation of sensory symptoms is the chief 
argument against the theory that Morvan’s disease is due to 
peripheral neuritis, but there is evidence that all sensations 
are not equally affected in neuritis, as has been asserted by 
Starr (6); and possibly the paucity of such records is due 
to failure to make special tests. 
As it is a physiological fact that the conduction chan- 
nels of the tactile, pain, and thermal senses lie in different 
parts of the spinal cord, it seems a justifiable assumption that 
their peripheral terminations are also different. And that 
recorded cases justify this assumption is evidenced by the 
cases of Weir Mitchell (6), in which there was a lessened 
sense of pain with no loss of touch; those of Gowers, in 
which he has seen loss of pain sense while the muscular 
sense is preserved; and those of Grainger Stewart (7), in 8 
MORVAN’S DISEASE. 
one of which the thermal sense was diminished while the 
pain and muscular senses were normal, and in another the 
thermal and pain senses were diminished and the muscular 
sense was normal. The latter case is especially serviceable 
in supporting the possibility of the existence of such phe- 
nomena in neuritis, because the necropsy showed that in 
the median, ulnar, and tibial nerves certain “ bundles of 
nerve fibers were totally, others partially destroyed, while 
some were comparatively healthy ” ; and in the cervical en- 
largement of the spinal cord there were tracts of second- 
ary degeneration, affecting only the columns of Goll and 
the outermost part of the lateral columns. 
These cord degenerations were in consequence of an 
ascending neuritis, and an explanation of the gliomatosis of 
the cord, in cases of Morvan’s disease, is possible on the 
ground that there was an ascending neuritis of the sensory 
fibers, with later slow gliomatous degeneration in their 
tracts in the spinal cord. Gombauit (8) found in a necropsy, 
in a patient who had Morvan’s disease for forty-four years, 
intense changes in the peripheral nerves, with a mild degree 
of sclerosis of the posterior horns and columns. These 
facts justify the statement of Gowers regarding this disease, 
that “we must be cautious in inferring that the pathologi- 
cal state is the same in origin in all cases.” But physio- 
logical, pathological, and clinical data support the idea that 
a peripheral neuritis may be the cause of the disease, though 
Morvan himself considers it is of spinal origin. 
Myelosyringosis so closely resembles Morvan’s disease 
in its early stages that several prominent neurologists—such 
as Bernhardt, Jolly, and Charcot—have considered them 
identical; and the latter proposed that the congeries of symp- 
toms constituting the former disease should be denominated 
myelosyringosis of Morvan’s type, Now, myelosyringosis is 
purely pathological condition that may include, according MORYAN’S DISEASE. 
9 
to Cheron (10), first, dilatation of the central canal, or 
myelohydrosis ; second, the excavating myelitis of Joffroy 
and Charcot; third, the peri-ependymal sclerosis of Hallo - 
peau; and, fourth, gliomatosis of the region of the central 
canal. And with these various pathological conditions 
Joffroy and Achard concluded (11), from a study of the 
disease in general, that often a sufficient number of the sup- 
posedly pathognomonic signs are not present to allow a 
diagnosis to be made; again, that where all of these signs 
are present they may suddenly disappear, and a spontaneous 
recovery is hardly to be expected in such a disease—in 
other words, a peripheral neuritis has been mistaken for 
myelosyringosis. In the following table we present a com- 
parison of the essential features of both diseases: 
Mye losyringosis. 
Morvan's Disease. 
Felons rarely present, and 
only as a symptom of a 
trophic disturbance. 
Fissures rare. 
Formation of painless 
felons. 
Palmar cutaneous fis- 
sures. 
Analgesia of areas sup- 
plied by the segment of the 
affected cord; usually arms 
and upper half of trunk; 
rarer in lower part of trunk 
and legs. 
Analgesia of fingers, of 
hand, and forearm ; later and 
rarely of arm and neck. 
Thermal anaesthesia of 
analgesic and other regions; 
sometimes unequal for heat 
and cold, sometimes per- 
verted. 
Thermal anaesthesia ex- 
tending moderately beyond 
the analgesic areas. 
Muscular atrophy of re- 
gion supplied by nerves 
emerging at or immediately 
Muscular atrophy usually 
limited to thenar, hypothe- 
nar, and interosseous re- 10 
MORVAN’S DISEASE. 
below the level of the af- 
fected segment of the cord. 
Tactile sense sometimes 
lost. 
Often neuralgic pains in 
joints of the affected region 
and in the spine. 
Occasional Romberg 
symptom. Unsteadiness of 
movements. Paralysis of 
one vocal cord; of tongue 
or face. Dysphagia. Dysp- 
noea. Cardiac irregularity. 
Inequality of pupils. Occa- 
sional nystagmus and ptosis. 
Occasional spastic paralysis 
of lower limbs. 
Bones may become thick 
and brittle and tabetiform 
joint changes may occur. 
Bilateral in eighty per 
cent. 
Mains de pr'edicateur in 
consequence of predomi- 
nance of extensor paralysis 
[Morvan], 
Symptoms usually devel- 
op slowly, increasing gradu- 
ally in the course of years ; 
death from exhaustion or im- 
pairment of function. Re- 
covery rare. 
gions ; more rarely the fore- 
arm. 
Tactile sense normal 
Pain may precede the 
other symptoms, rarely per 
sist. 
No Romberg symptom. 
Rarely any affection of 
hones (excepting necrosis 
from felon) or joints. 
Bilateral in forty-five per 
cent. 
Main en griffe in conse- 
quence of predominance of 
flexor paralysis. 
Symptoms usually devel- 
op rapidly; most often con- 
fined to the forearm and 
hand. No extension of 
symptoms in from ten to 
forty years. Recovery, or at 
least marked improvement, 
not infrequent. MORYAN’S DISEASE. 
11 
Joffroy and Acliard (14) reported a necropsy made on a 
woman who had, forty-five years before her death, painful 
felons of both hands, leaving deformities of the fingers re- 
sembling Morvan’s disease; sensibility both to pain and 
heat was, just before her death, greatly diminished in the 
palmar surface of her hands and fingers, and the tactile sen- 
sibility was diminished ; but there was no muscular atrophy 
and the electrical reactions were normal. She also had 
kyphosis. At the necropsy not only was a cavity found in 
the spinal cord, but the nerves of the forearms had under- 
gone extensive degenerations; these latter they regard as 
secondary to the lesion in the spinal Cord, just as is the 
peripheral neuritis that has been observed in posterior 
spinal sclerosis. It might be questioned whether, excepting 
in physical appearance, this case presented any similarity to 
Morvan’s disease. The felons were painful; the deformi- 
ties that followed them did not interfere with the useful- 
ness of the hands; the muscles were not atrophied; the 
electrical reactions were normal; and the sensory disturb- 
ances occurred at the age of seventy-five, when sensation 
would naturally be rather sluggish, and even then a tem- 
perature of 140° F. was recognized as something warm, and 
the pin prick was indistinctly felt in the thickened skin of 
the palm and fingers. 
We do not desire to maintain that cases of myelosyrin- 
gosis do not present symptoms in the earlier stages of the 
disease closely simulating all the phenomena of Morvan’s 
disease; and it is furthermore probable, as Joffroy and 
Achard have stated, that lesions in the bulb may produce such 
symptoms, and that supposed cases of Morvan’s disease have 
really been cases of myelosyringosis. But we would main- 
tain that cases of the latter disease of sufficiently long stand- 
ing will present later and more serious complications than 
those reported as characteristic of the former malady. MORVAN’S DISEASE. 
12 
That it is not necessary to found tlie existence of the 
disease on a pathological condition in the spinal cord is, we 
think, demonstrated by the observations of Charcot, who has 
found sensory dissociation in hysteria just as it is observed 
in the disease under consideration, and myopathic phe- 
nomena also. These would leave the felons as the single 
absent symptom, and we know their presence is due to a 
definite cause. Minor, of Moscow, has observed sensory 
dissociation in traumatic myelaematoma ; and the presence 
of this dissociation is so frequent in anaesthetic leprosy that 
the possibility of the identity of that and Morvan’s disease 
has been broached. 
For instance, Dr. Zambaco (12) has held that both my- 
elosyringosis and Morvan’s disease are identical, and that the 
disease is only a form of anaesthetic leprosy that has been, so 
to speak, attenuated by the manners and climate of Europe ; 
this has been warmly controverted by Thibierge (16), and 
one of us can personally state that there is no resemblance 
between the present case or those reported cases that have 
been consulted and the cases of anaesthetic leprosy he has 
observed in the southern American states and in Norwegian 
leper hospitals. 
We believe that Raynaud’s disease, erythromelalgia, and 
sclerodactylia are sufficiently typical not to be confused with 
Morvan’s disease. 
While, therefore, it is to be distinguished from myelo- 
syringosis, hysteria, and, in leprous countries, from anaes- 
thetic leprosy, we believe the presence of other phenomena 
in those cases will enable a diagnosis to be made. 
From the preceding presentation of facts, and our own 
experience with myelosyringosis and neuritis, we infer that 
the typical cases of Morvan’s disease may be due to a pe- 
ripheral neuritis. On the other hand, we have conceded that 
cases of myelosyringosis may so closely resemble Morvan’s MORYAN’S DISEASE. 
13 
disease as to make a distinction impossible ; but the strict 
limitation of the disease usually for many years and the 
early appearance of the painless felons, as well as the im- 
provement, if not recovery, in given cases would weigh 
strongly in favor of the diagnosis of Morvan’s disease rather 
than myelosyringosis. And, lastly, it must be conceded that 
it is possible for an ascending neuritis to lead to gliomatous 
degeneration in the central canal of the spinal cord, such 
cases presenting later the typical clinical features of myelo- 
syringosis. 
1. Gaz. Tiebd. de med. et de chirurg., August 81, 1888. 
2. Principles and Practice of Medicine. 
References. 
3. Manual of Diseases of the Nervous System, vol. i, 1892. 
4. Arch. gen. de med., July, 1889. 
5. Am. Jour, of the Med. Sci., May, 1888. 
6. Injuries of Nerves and their Consequences, 1872. 
7. Bowlby. Injuries and Diseases of the Nerves, ISW. 
8. Gaz. des hop., April 30, 1890. 
9. Prog, med., March 15, 1890. 
10. VLnion med., November 14, 1889. 
11. Arch, de med. exp., January, 1891. 
12. Gaz. hehd., 1891, p. 196. 
13. La Med. mod., July 10, 1891. 
14. Arch, de med. exper., vol. ii, 1890. 
15. Gaz. hehd., 1891, p. 199. REASONS WHY 
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