the first touches of his malady came upon him six weeks before his entrance into hospital; the debut of his troubles can, then, be accurately fixed at eight weeks and a half. Here is what has taken place. Naturally of a poor constitution, this individual has, nevertheless, all his life enjoyed excellent health; of a lively disposition, alert at his work, he was fond of a morning and evening of taking long walks, in order to compensate for the excessive confinement imposed by his profession. A little more than eight weeks ago, after returning from a walk of many hours, he, for the first time, experienced a numbness and some pains in his feet, hands, legs, and forearms; these pains were dull and continuous, they never presented themselves in a lancinating form, and they always remained limited to the points indicated. During the first days these phenomena were not continuous; a night's rest was sufficient to dissipate them, and the man renewed his daily work. A little later, and these pains disappeared, but they were replaced by an unusual clumsiness in his daily work. This workman, whom a long prac tice had rendered skillful, finds himself with difficulty accomplishing the delicate manipulations of his trade, then he reaches a point at which he finds that he spoils many of the pieces he has in his hands, and vanquished by necessity, he renounces his work without being otherwise sick. This was towards the end of the third week. Eight days later, it was not only pain and inaptitude which he experienced in his upper limbs, but there was a true powerlessness, the movements of the hands and feet were abolished. Another week passed, and walking is no longer possible; the troubles of motility in the lower limbs have increased so rapidly that, three or four days after having lost the faculty of walking, the patient can no longer sustain himself upon his limbs. Then alone does he take to his bed; this was at the commencement of the sixth week; this man, who is very intelligent, it is scarcely necessary to say, was profoundly afflicted with this state of powerlessness, but it was not the less surprising to him that he experienced no other accident than the increasing disorder of motility; upon this point he

affirms, categorically, that in proportion as he lost the motion of a part of one of the limbs, that the part fell away, and became deformed with an extreme rapidity. In the middle of the sixth week a new phenomenon arises, this is a complete fall of the right wrist; three days later (the 4th of July) the patient has entered hospital.

He is, indeed, profoundly emaciated, but this emaciation, or rather this false emaciation, like that which we have studied as appertaining to muscular atrophy, is neither uniform nor general. Certain regions are shrunken, and consequently deformed; besides these, there are others which have preserved their form and their natural volume; on the other hand, the shrunken parts are the only ones which have lost their motility, the movements persisting in the others; it is necessary then, before everything else, that we should be perfectly fixed in mind regarding the seat and extent of the deformities-that is to say, the atrophies.

In the upper limbs they are confined to the forearms and the hands, but they do not occupy homologous points on the two sides. In the right forearm there is no trace of the normal projection or rotundity formed by the external group of the radials and supinators; the posterior face of this segment of the limb is completely flattened; one being able to press the fingers deeply into the radio-cubital space; on the hand the interrosseous spaces are normal, but the complete shrinking of the thenar eminence contrasts in the strongest way with the salient rotundity preserved by the hypothenar. On the left the shoulder and the arm are intact, as on the right; on the forearm it is the salient anterior portion which has disappeared; to the outside and posteriorly, the muscular reliefs are normal; on the hand the thenar eminence is of satisfactory volume; it is the salient hypothenar which is flattened down, and the interrosseous spaces show themselves hollowed.

In the lower limbs the atrophied condition is similar on the two sides; the muscular reliefs of the limb and of the foot have entirely disappeared; in the region of the calf of the leg

particularly, the skin forms a great flabby pocket, empty by the loss of the gastrocnemials. No disorder seems to exist in the thighs, however; the relief of the adductors is less marked on the left than the right. Despite the extent and the degree of these deformities, there is no other vicious attitude than the drop of the right wrist, of which I have already spoken; but it is also as complete as possible, the hand being appended to the forearm, like an inert mass, and the digital extremities supple and lightly flexed; arm almost in contact with the anterior antitracheal region; imagine that upon a cadaver not yet rigid, you have cut the extensor tendons entire, the fall of the wrist you would thus obtain would not be more pronounced than that which exists in this patient.

I have already told you that the motorial powerlessness is not more uniform than the atrophy, and that it is distributed like it; the phenomena of akinesia are thus disseminated, and to seize them in their totality, for appreciating exactly the seat it is necessary to have recourse to a rigorous and patient analysis. The necessity is the same (never forget it) whenever the disorders of movement are not affected by the regular distribution of one of the common forms of paralysis; it is only by a severe analysis that you will come then to locate precisely the extent and the sphere of the akinesia, after which you can rely with confidence upon these first contributions in searching out the signification of these phenomena and the seat of the cause giving them origin. The study of the diverse normal movements shows us clearly which are the ones abolished, and which are the ones remaining; but be on your guard in adhereing to the first order of teaching; the propositions which they express are, necessarily, numerous and confused, and the conclusion which they contain does not disengage itself with sufficient clearness. It follows, therefore, that you should advance two successive steps in your consideration of the question, transforming the complex results of analysis into a rigorous synthesis, and for doing this you have only to resolve the two subjoined anatomical equations; from a knowledge of the abolished

movements deduce the conception of the muscles which have become impotent; that is the first step, or the first equation. From a knowledge of the powerless muscles, deduce the idea of the nerves affected; this second and last step conducts you to a synthetical conclusion which contrasts happily by its clearness with the diffuse results of the initial analysis. An examination of the troubles of motility in our patient goes to show you, in all its plainness, the importance and the utility of this method, which I cannot too much recommend to you.

On each side the motions of the shoulder and the arms are preserved, from whence results this singular condition; that the patient can elevate and carry to his head his forearm, and his completely inert hand, the inferior segment of the member possibly following the elevation of the arm, the motility of which, I repeat it, is possible on the right and on the left. In the right forearm the movements of extension and supination are totally abolished, there is not a vestige remaining, the fall of the wrist in complete pronation can be foreseen. The flexion of the fingers seems likewise lost; but a more attentive examination demonstrates that there is room for a distinction, which has all the precision of a physiological dissection, and is of a considerable interest. This is what occurs on efforts at flexion; when the forearm and the hand being sustained in a position intermediate between pronation and supination, or in complete supination, and the patient is commanded to close his hand, the thumb, the index and middle fingers remain immobile despite an energetic excitation of the will; but the fourth and fifth fingers flex themselves; this flexion commences by the articulation of the third phalanx with the second, and it is carried up to a contact of the point of the ring-finger with the palm of the hand; voluntary flexion of the hand upon the forearm only takes place in the inner half of the wrist, it is not direct, it is accompanied by a very marked adduction of the cubital border of the hand. The movements of separation and approximation of the fingers are abolished, save in the first interrosseous space the isolated movements of the little finger are good, but

the extension, the flexion, and abduction of the thumb are impossible.

Here are certainly very complex disorders, phenomena very contradictory, and in these terms it appears scarcely possible to deduce any precise conclusion; but for the conception of the functional troubles, substitute that of the affected muscles, and this first trnsformation will conduct you to significant propositions; the results of this minute analysis can, in effect, be thus expressed; in the upper limb, of which the muscles of the shoulder and the arm are sound, all the muscles of the posterior region and the external region of the forearm are inert; it is also the case with those of the anterior region, with the exception of the anterior cubital, and the internal half of the deep flexor; on the hand the thenar muscles are inactive, as are the interosseous of the three last spaces; the adductor of the thumb, the first dorsal interosseous, and the hypothenar muscles have preserved their motility. Observe all this well;: but do not stop here; arriving at our second anatomical equation, grouping these disorders of muscles according to the distribution of the nerves animating them, and we obtain a synthetical formula of valuable preciseness; on the forearm and the hand all the muscles suppled by the median are inert; the muscles innervated by the cubital have preserved their motility with the exception of the interosseous of the three last spaces.

Let us pass on to the left upper limb. The movements of extension and of supination are entirely normal, the flexion is not totally abolished, but it is compromised; it is null in the articulations of the third with the second phalanges, light in the superior articulations, perceptible in the metacarpo-phalanges, and a little less marked at the level of the wrist. When the patient obeys the orders given him, employs all the energy of his will to produce a complete flexion, which,. in reality, is scarcely accomplished, one observes a singular phenomenon, this is an energetic contraction of the biceps and the anterior brachial; the useful effect of the voluntary excitation of the flexor muscles of the hand and wrist cannot be obtained, it