Biographies de neurologues
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 L'histoire des neurosciences à La Pitié et à La Salpêtrière J Poirier
The history of neurosciences at La Pitié and La Salpêtrière J Poirier 

mise à jour du
30 mars 2006
Arch Neurol
Lhermitte's sign from observation to eponym
José A. Gutrecht  
Le signe de Jean Lhermitte


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.
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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.
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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.
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