- The Lhermitte's sign was first described by
Pierre Marie and Chatelin in 1917. Lhermitte
reported on this symptom in 1920, and in 1924 he
published the seminal article on the subject. In
1928, it was Introduced to the American
literature, and it was around that times that
the symptom became will known. The historic
development of this observation into an eponym
is documented.
-
- Many symptoms, signs, maneuvers, and
diseases in the neurologic literature are known
by their eponyms. Yet, in some cases, the
reasons for a particular designation are
somewhat unclear and obscure or, from a strict
standpoint, are even incorrect. When does an
observation become an eponym? How, why, and by
whom is attribution given? This article is a
review of the historic evolution of what is now
called Lhermitte's sign.
-
- On Dec 20, 1917, Pierre
Marie and Chatelin reported an observation
to a meeting of the Centers of Military
Neurology in Paris. In some patients with head
injuries, they described "pins and needles"
sensations traveling the spine and limbs on
flexion of the head.
-
- Less than a month later, Babinski
and Dubois described a patient who had a
sensation of an "electric discharge" when
flexing the head, sneezing, or coughing. The
patients of Pierre Marie and Chatelin had no
neurologic deficits, and they assumed that the
symptom was caused by pressure on the nerve
roots when the head was flexed. The patient of
Babinski and Dubois, however, had a hemiplegia
from a Brown-Séquard syndrome secondary
to a laceration of the spinal cord in the neck
on the same side of the body as this peculiar
symptom. Thus, they suggested that the symptom
was caused by an intramedullary lesion.
-
- At the meeting of the Neurological Society
of Paris on Jan 10,1918, Jean
Lhermitte (1877-1959) commented that this
symptom had been observed by. Marie and
Bénisty in patients with traumatic
lesions of the cervical spinal cord, and that
they had described the complaint at the meeting
of Dec 2, 1915. However, this may have been a
personal comnunication made by Marie to
Lhermitte during World War 1 while Lhermitte was
working under him at Salpêtrière
Military Hospita (Paris) or at the 1915 meeting
because Marie and Bénisty made no mention
of such a symptom in their article. On might
also speculate that Lhermitte learned of this
symptom from Bénisty, who had given a
paper just before the presentation of
Babinski,and Dubois. Lhermitte agreed that the
symptom was likely the result of irritation of
the spinal cord. Ribeton in his thesis for the
doctorate of medicine (Paris, 1919) entitled
"Pain in the Form of an Electric Discharge
Secondary to Neck Trauma," thanked Dubois for
"his medical notes on patients who sought
medical help at the Neurology Service of
Babinski at
L'Hôpital de la Pitié in Paris,
but credited Lhermitte for his ideas on the
pathogenesis of the symptom. He also
acknowledged Lhermitte's many contributions on
the subject of injuries to the spinal cord. In
1920, Lhermitte' elaborated further on the
origin of the symptom in patients with
concussion of the spinal cord by implicating
involvement of the posterior and lateral
columns. Clearly, Lhermitte was fascinated and
intrigued enough by the unusual features of this
symptom to separate it from the "radicular
pains, hyperalgesias, and causalgias" present in
patients who had experienced trauma to the
spinal cord. In the 1920 article, he credited
Babinski and Dubois with the first description
of the pain and its electric shocklike
characteristics.
-
- The seminal report on the subject was
presented by Lhermitte et al to the Neurological
Society of Paris at the meeting of July
3, 1924, and was entitled 'Pain of an Electric
Discharge Character Following Head Flexion in
Multiple Sclerosis".
-
- They presented the case of a previously
healthy 43-year-old
woman with paresthesias involving both legs.
A month after onset of this symptom, the patient
experienced "upon bending of the head, a violent
shock in the neck and a pain resembling an
electric current which traveled the body from
the neck to the feet." In this presentation,
Lhermitte et al agreed with Guillain's views on
the peculiarity of some of the sensory
complaints in patients with multiple sclerosis.
They also stressed the abundance and diversity
of sensory symptoms in their patient and the
importance of these symptoms in the diagnosis of
multiple sclerosis. In particular, they called.
attention to the "pains of an electrical
discharge nature" never previously reported in
the literature on multiple sclerosis. This
presentation expanded what had been, until then,
rigid criteria for the diagnosis of multiple
sclerosis as set by Charcot.
They argued further that the symptom originated
in the spinal cord, specifically in the cervical
segments, and was caused by demyelination with
preservation of axonal continuity in peripheral
nerve injuries, as noted earlier by Tinel for a
similar symptom.
-
- This report was followed with another in
1927 in which Lhermitte and associates presented
two more patients with the same sensory
complaint on flexion of the head. They commented
that the symptom was not truly painful but was
unpleasant and that both patients' descriptions
of the symptom were uniform despite different
backgrounds and education, which made the
complaint fairly specific although not
pathognomonic of multiple sclerosis. Again,
Lhermitte stated that the symptom may occur
early in the disease when no other signs are
present.
-
- One of the patients, on a visit to New York,
was presented by Wechsler at a meeting of the
New York Neurological Society on Oct 4, 1927,
and his case was reported in 1928 in the
American literature. The patient was an
electrician who claimed he could light an
electric bulb held in his hand whenever he
brought on the symptom by flexing his head. For
this reason and other unusual findings,
discussants were skeptical of the origin of his
complaints and suggested that they were, in
part, of hysterical origin.
-
- Soon after this publication, Lhermitte chose
to respond to these suggestions, particularly to
the possible nonorganic origin of the peculiar
sensory complaint he had previously reported. He
reiterated his strong belief that the patient
had multiple sclerosis and stressed that the
symptom was of "great significance" in
suggesting the diagnosis of multiple sclerosis.
In his article, Lhermitte stated that the
symptom of electric shocklike sensation had been
described by him and by Babinski and Dubois at
the same time, presumably in 1918. By 1928,
other publications had validated his
observation. So far, it is clear that although
the symptom had been described previously by
others, Lhermitte was the first one to associate
it with multiple sclerosis, to emphasize its
importance in early diagnosis of the disease,
and to propose its pathogenesis. But, when did
it become the Lhermitte's sign?
-
- At a meeting of the Chicago Neurological
Society on Nov 21, 1929, Patrick presented a
report entitled "The Symptom of Lhermitte in a
Patient With Multiple Sclerosis." He believed
that the suggestion by Lhermitte that this sign
was only seen in patients with multiple
sclerosis and spinal cord trauma was too
inclusive, and that as a "diagnostic aid it
[the symptom] is not very significant."
Of course, the case presented and the title of
the report suggested otherwise. The definitive
term Lherinitte's sign first appeared in the
title of a presentation by Read to the annual
meeting of the Neurological Society of Chicago
on May 23, 1931. Until 1933, the sign had been
known in England as the "barber sign". Whether
this phenomenon is a symptom or a sign has been
debated but is now a moot point.
-
- Lhermitte wrote his last article on the
topic in 1933. In it, he acknowledged the
presence of the sign in other diseases, such as
pernicious anemia with subacute combined
degeneration of the spinal cord noted by Olkon.
No doubt he would have accepted the occurrence
of the sign in other neurologic problems, such
as radiation myelopathy, compressive cervical
myelopathy, and cisplatin toxicity, among
others. Lhermitte had never stated that the sign
was pathognomoule of any neurologic
disease.
-
- By the early 1930s, it appears that this
peculiar symptom (or sign) was beginning to be
recognized in the American literature by its
eponym. In the French literature of 1949,
Alajouanine et al reaffirmed that the sign of
Lhermitte was the result of pathologic'
processes involving the cervical spinal cord,
specifically the posterior columns. They
suggested that flexion of the head to elicit the
symptom was indicated whenever a spinal
condition was suspected, and that the maneuver
be given the name of Lhermitte. Finally, the
Lhermitte's sign became widely known and
popularized in the English-language literature
after it appeared as a separate entry in the
classic book on multiple sclerosis by McAlpine
et al in 1955. It may be relevant to note that
McAlpine had some training at the neuropathology
laboratory of the University of Paris after
World War I, and he collaborated and published
with Lhermitte in the middle 192Os.
-
- In many ways, the story of the Lhermitte's
sign is reminiscent of the history of other
well-known symptoms, signs, and maneuvers in
neurology that are now known by eponyms. At
first they are described, but only after someone
else has written about them, given a fuller
description of them, suggested the pathogenesis,
and insisted on their importance does an
eponymic sign or symptom become accepted and
popular. Without doubt, the odd nature of the
complaint and its presence in such a common
neurologie disease as multiple sclerosis had
something to do with making Lhermitte's sign one
of the best known and most commonly used eponyms
in the neurologie literature. Indeed,
attributing the name of Lhermitte, a superb
clinician in the classic tradition of the French
semiologic school of his epoch, to this sign is
warranted, deserved, and indisputable.
-
- References
-
- 1. Gutrecht JA, Espinosa RE, Dyck PJ. Early
descriptions of common neurologic signs. Mayo
Clin Proc 1968;43:807-814.
-
- 2. Marie P, Chatelin C: Sur certains
symptômes vraisemblablement d'origine
radiculaire chez les blessés du
crâne. Rev Neural 1917; 31:336.
-
- 3. Babinski J, Dubois R: Douleurs à
forme de décharge électrique
consécutives aux traumatismes de la
nuque. Presse Med 1918;26:64.
-
- 4. Marie P, Bénisty A: Syndromes
cliniques consécutifs aux lésions
indirectes de la moelle cervicale, dans
certaines plaies du cou. Rev Neurol
1915;29:1300-1305.
-
- 5. Ribeton J: Etude clinique des douleurs
à forme de décharge
électrique consecutives aux traumatismes
de la nuque, thesis, Faculté de
Médecine, Paris, 1919.
-
- 6. Lhermitte J: Les formes douloureuses de
la commotion de la moelle
épinière. Rev Neurol
1920;36:257-262.
-
- 7. Lhermitte J, Bollack J, Nicolas M: Les
douleurs à type de décharge
électrique consécutives à
la flexion céphalique dans la
sclérose en plaques: Un cas de forme
sensitive de la sclérose multiple. Rev
Neurol 1924;39:56-62.
-
- 8. Charcot JM: Leçons sur les
maladies du système nerveux faites
à la Salpétriere. Paris, V. Adrien
Delahaye & Co, 1877, pp 221-247.
-
- 9. Lhermitte J, Levy G, Nicolas M: Les
sensations de décharge électrique,
symptôme précoce de la
sclérose en plaques, clinique et
pathogénie. Presse Med
1927;35:610-613.
-
- 10. Wechsler IS: A case of multiple
sclerosis with an unusual symptom. Arch Neurol
1928; 19364-365.
-
- 11. Lhermitte J: Multiple sclerosis:
Sensation of electrical discharge as early
symptom. Arch Neural 1929:,22:5-8.
-
- 12. Trioumphoff A: A propos du
symptôme de décharge
électrique de la sclerose en plaques.
Presse Med 1927;35:948.
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- 12. Bériel L, Devic A: Sur uncas de
douleurs à type de décharge
électrique dans la sclérose en
plaques. Lyon Med 1928;141:559-561.
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- 11. Roger H, Reboul-Lachaux J, Aymes G:
Dysesthésies rachidiennes à type
de décharge électrique par flexion
de la tète dans la sclérose en
plaques. Encephale 197;22:500-501.
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- 15. Patrick HT: The symptom of Lhermitte in
multiple sclerosis. Arch Neuroi
1930,23:1O75-1077.
-
- 16. Read CF Multiple sclerosis with
Lhermitte's sign. Arch Neurol 1937:227-228.
-
- 17. Lhermitte J: Le signe de la
décharge électrique dans les
maladies de la moelle épinières:
Sa signification sémiologique. Gaz Hop
1933;106.1077-1080.
-
- 12. Goldblatt D, Levy L The electric sign
and the incandescent lamp. Semin Neurol
1985;5:191-193.
-
- 19. Olkon DM: Subacute combined degeneration
of the spinal cord with the symptom of Lhermitte
in 'pernicious anemia, and report of a case. J
Nerv Ment Dis 1933;77:256-258.
-
- 20. Alajouanine T, Thurel R, Papaioanou G La
douleur à type de décharge
électrique, provoquée par la
flexion de la tète et parcourant le corps
de haut en bas. Rev Neurol 1949;81:89-97.
-
- 21. McAlpine D, Competon ND, Lumaden C:
Multiple Sclerosis. New York Churchill Living
stone, 1955, p81.
-
- 22. Lhermitte J, McAlpine D: Clinical and
pathological résumé of combined
disease of pyramidal and extrapyramidal systems
with special reference to new syndrome. Brain
1926;49:157-181.
-
-
- Jean
Lhermitte
- 1877 - 1959
-
- Les
douleurs à type de décharge
électrique consécutives à
la flexion céphalique dans la
sclérose en plaques
- Un cas de
sclérose multiple
- Lhermitte J, Bollak J, Nicolas M.
Revue Neurologique 1924;
31; 56-62
-
- Le
signe de Lhermitte
- J. Cambier La Presse
Médicale 1993; 22; 32;
1611-1614
-
- Modern
neuropsychology in France:
Jean
Lhermitte
- F. Boller Cortex
2005; 41, 740-741
-
- La
douleur à type de décharge
électrique, provoquee par la flexion de
la tête et parcourant le corps de haut en
bas
- Alajouanine T, Thurel R, Papaïoanou
Revue Neurologique 1949; 81; 2;
89-97
-
- Lhermitte's
sign From
observation to eponym
- Gutrecht JA. Arch
Neurol 1989; 46; 5;
557-558
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