V ASO-MOTOR AND TROPHIC NEUROSES. 
GANGRENE-ANGINA PECTORIS.-EXOPHTHALMIC GOITRE.-PRO- 
GRESSIVE MUSCULAR ATROPHY.-PSEUDO-MUSCULAR 
HYPERTROPHY.-EPILEPSY.-TETANUS.-PAR- 
ALYSIS AGITANS-ATHETOSIS - 
CHOREA.-HYSTERIA. 
BY 
JAMES J. PUTNAM, M.D., 
OF BOSTON, 
PHYSICIAN TO OUT-PATIENTS, MASS. GEN. HOSP.; LECTURER ON DISEASES OF THE NERVOUS SYSTEM, HAR- 
* 
VARD UNIVERSITY. MIGRAINE. 
603 
MIGRAINE. 
BIBLIOGRAPHY. 
Fischer: Exp. Studien zur therapeutischen Galvan, des Halssympathicus. 
Deutsch. Arch, ftir klin. Med., XVII., 1875.-Ringer: British Medical Journal, 
1874, 725.-Schulz, H.: Allg. med. Centralz., 1875, 61.-Randon: Revue de ther. 
med. chir., Feb., 1876.-Chaumier, E.: Un chapitre de 1'histoire des maladies 
constitutionnelles, la migraine. 4to, Paris, I., These No. 358,1878.-Schumacher: 
Ergot in the Treatment of Angioparalytic Megrim. Lancet, London, 1878, II., 
212-213.-Seuere, I.: Du traitement de la migraine par le chloral. Bull. gen. de 
therap., Paris, 1878, XCV., 365-367.-Schwarz, B.: Ein Fall von scheinbarer 
Hemikranie mit todtlichem Ausgange. Wien. med. Presse, 1878, XIX., 270-271. 
-Bonnal, L. A.: Migraine ophthalmique datant de vingt-cinq ans caracterisee 
par des acces douloureux avec symptomes epileptoides traitee et guerie par le 
bain d'air chaud. Rev. mens, de med. et de chir. Paris, 1878, II., 279-282.- 
Galezowski: Etude sur la migraine ophthalmique. Arch. gen. de med., Paris, 
1878, CXLL, 669; 1878, CXLIL, 36-56.-Ketli, K.: Hemikranie bei einem 
syphilitischen Individuum; Heilung durch Quecksilber. Pester med. chir. 
Presse, Budapest, 1878, XIV., 33-36.-D'Ancona, N.: La emicrania in rapporto 
alia sua terapia. Gazz. med. Itai. prov. Venete, Padova, 1877, XX., 49; 57.- 
Hache: Migraine hereditaire et constitutionnelle datant de plus de trente ans 
compliquee depuis deux ans de gastralgie rebelle; traitement par 1'electricite 
statique; guerison. Union med., Paris, 1877, XXIV., 30, 525-526.-Seguin, E. 
C.: A Contribution to the Therapeutics of Migraine. Med. Rec., N. Y., 1877, 
XII., 774-776.-Mitchell, S. W.: Brit. Med. and Surg. Jour., 1879, 444. Mi- 
graine in a Child 7j years old. 
We have only to report as specially important a few points in the 
treatment of this disease. E. C. Seguin has called attention anew to the 
value of cannabis indica, given in the "continued dose" daily, for 
months together, with the idea of treating, not the paroxysms, but the 
disease itself. This mode of using the drug was described in 1872 by 
Richard Greene {Practitioner}, whose statements Dr. Seguin reviews and 
corroborates. The dose for an adult female is 0.02 to 0.03 of the solid 
extract three times daily; for an adult male, 0.03 to 0.04. From this 
dose he has seen no unpleasant effects of consequence. This treatment 
has met with favor at the hands of a number of other practitioners, 
among them the writer, though no extended account of its use has come 
to my knowledge. In two cases I have seen an annoying degree of 
drowsiness follow the use of even the smaller dose, and a less quantity 
was found sufficient to diminish considerably the number and severity 
of the attacks. For some cases it is valueless. 
Under the head of ophthalmic migraine a great variety of ocular 604 
ANGINA PECTORIS. 
symptoms have been described, some of them such as often precede attacks 
oi ordinary migraine, such as pain, amblyopia, scotoma, photophobia, and 
hemiopia occurring periodically. For an extended discussion of this 
subject the reader is referred to papers by Galezowski and by Bonnal. 
The careful experimental work of Fischer, as to the effects of galvani- 
zation of the sympathetic upon the cerebral circulation, is worthy of study 
as bearing on the theory of the action of galvanism in migraine. This 
treatment is probably far less efficacious than was formerly supposed in 
directly modifying the cerebral circulation. As oberved in animals, such 
results are extremely slight and often altogether wanting, and at best 
are not to be brought about by closures or interruptions of the circuit, 
but rather by letting the current flow. Eulenburg also, while confirm- 
ing his earlier statements as to the therapeutic value of the galvanic 
treatment of migraine, points out, himself, the significance of Fischer's 
experiments, and says that Przceivoski likewise found the cervical sympa- 
thetic inexcitable by interruption or closure of the circuit, but respon- 
sive to the polar action of the continuous current as evinced by unilateral 
changes in the temperature of the face, which fell a little when the 
kathode was applied, and rose, though but very slightly and temporarily, 
under the influence of the anode (2d edition v. Ziemsseris Cyclop.). 
ANGINA PECTORIS. 
BIBLIOGRAPHY. 
Huppert: Reine Motilitatsneurose des Herzen. Berl. klin. Wochenschrift, 
1874, S. 19-22.-Cordes: Angina Pectoris Vasomotoria. Deutsches Arch. f. klin. 
Med., 1874, XIV., S. 141.-Lusting: Zur Lehre von den vasomotorischen Neuro- 
sen. Diss., Breslau, 1875.-France medicale, 1875, Nov.-Johnson, G. : On the 
Relation between Angina Pectoris and Peripheral Arterial Contraction, and on 
the Modus Operandi of Nitrite of Amyl as a Remedy for the Disease. Brit. M. 
J., London, 1877, I., 770.-Gairdner: Angina Pectoris and Allied States, includ- 
ing Certain Kinds of Sudden Death. Syst. Med. (Reynold's), London, 1877, IV., 
535-599.-Richter, F.: Angina Pectoris als central bedingte Neurose. Deutsch. 
Arch. f. klin. Med., Leipz., 1877, XIX., 357-365.-Traube, L.: Zur Lehre von der 
Angina Pectoris. Ges. Beitr. z. Path. u. Physiol., Berlin, 1878, III., 172, 183.- 
Clark, A.: Angina Pectoris Associated with Disease of the Aorta. Brit. M. J., 
Lond., 1878, II., 314.-Leroux, C.: Angine de Poitrine, Mort subite, Atherome 
arterief, Compression du Pneumogastrique droit. Progres med., Par., 1878, VI., 
523.-Huchard, H.: Angine de Poitrine et Pulmonaire, Paral. Consec. du Nerf 
pneumogas. Union med., Par., 1879, XXVIII., 433-489.-Murrell, W.: Nitro- 
glycerin as a Remedy for Angina Pectoris. London Lancet, 1879, I., 80, 113, 151, 
225. 
For an interesting systematic discussion of this disease, among publi- 
cations later than the first edition of this Cyclopaedia, the reader is 
SYMPTOMATOLOGY AND PATHOLOGY. ANGINA PECTORIS. 
605 
referred to a paper by Gairdner in the fourth vol. of Reynold's System 
of Medicine, which hardly admits of brief analysis. The frequency with 
which the pain is accompanied or replaced by a sense of indefinable dis- 
tress, referred, so far as it can be localized, to the chest, but infecting 
also the patient's mind with a feeling of profound anxiety or a fear of 
impending death, is strongly dwelt upon. 
Gairdner agrees with Eulenburg in believing that in fatal cases of 
angina pectoris there probably is always some organic disease interfering 
with the structure, nutrition, or innervation of the heart underlying the 
paroxysms of pain, vaso-motor phenomena, and the other nervous symp- 
toms. The neurosal symptoms may, however, undoubtedly exist by 
themselves, as is pointed out by Richter, and indeed the relation between 
the organic changes discovered after death and the neuralgic attacks is 
still unknown, nor is the cause of death always clear. Thus Leroux 
reports a case of sudden death where there was extensive atheroma of 
the aorta with periarteritis; also hypertrophy of the left ventricle, but 
no other signs of cardiac disease. It was impossible to trace out the 
nerves of the cardiac plexus from the midst of the thickened tissue by 
which they were surrounded, but the fibres of the sympathetic system 
just above this point were normal. The right pneumogastric was closely 
adherent to an enlarged gland near a bronchus, but on microscopic 
examination its structure appeared normal. The coronary arteries were 
in all essential respects normal. 
Richter lays stress on the fact that heart-disease is often entirely 
absent, and collects the arguments in favor of the view that angina is a 
primary central neurosis, probably of cerebral origin. Thus he points out 
that the paroxysms are liable to be brought on or intensified by cerebral 
excitants, such as tobacco, anxiety, over-work, and that the characteris- 
tic symptoms find their analogues in some of the phenomena of hysteria? 
lesions of the pons, and other central affections. 
TREATMENT. 
Dr. George Johnson discusses the mochts oiwrandi of the amyl treat- 
ment, recommended by Brunton and others, and while fully confirming 
the previous statements as to the value of the remedy, he combats the 
view that it acts as at first suggested, that is, by diminishing arterial 
spasm, believing, on the contrary, that it is equally efficacious in cases 
where the peripheral arteries, instead of being contracted, are dilated, as 
shown by flushing of the face. He thinks the drug works in virtue of its 
direct antineuralgic properties, having found it remarkably efficacious 
in a case of facial neuralgia, and he quotes Dr. Talfourd Jones as having 
had a number of similar experiences. In view, however, of the remark- 
able fact that nitroglycerin, which closely resembles amyl nitrite in its 
physiological action on the arterial system, likewise relieves the paroxysms 
of both angina and trigeminal neuralgias, it seems clear that it is 
after all the fall of arterial tension, perhaps by modifying the cerebral 
circulation, which is the active factor in both cases. 606 
EXOPHTHALMIC GOITRE. 
Our knowledge of this effect of nitroglycerin in angina is due to 
William Murrell, who took up the experiments of Field and others, and 
also recognized the therapeutic indication to be drawn from them. The 
action of this drug upon the circulation comes on more slowly than that 
of amyl (six to eight minutes), and passes off more slowly. It is capable 
of checking the attack when present, and what is more remarkable, had, 
in the three cases in which it was used by Murrell, a more or less per- 
manent effect. The dose is one to fifteen drops of a one-per-cent solution 
in alcohol, to be taken three or four times daily for weeks or months. 
In experimenting with thirty-five persons, he found a difference in 
susceptibility, but obtained similar effects in all cases. The unpleasant 
symptoms are intense throbbing of all the arteries of the body, headache, 
prostration, even syncope of five or ten minutes' duration. In one case, 
each dose caused an immediate and rapid secretion of urine. Extended 
investigations will be looked for with great interest. 
EXOPHTHALMIC GOITRE. 
{Basedow's Disease.} 
BIBLIOGRAPHY. 
Ferrol: Union med., 1874, No. 153.-Bartholow: Chicago Journal of Nerv- 
ous and Mental Disease, July, 1875.-Raynaud: Arch. gen. de med., Juin, 1875, 
p. 679.-Bulkley: Chicago Jour., etc., Oct., 1875.-Benedikt: Nervenpatholo- 
gie und Elektrotherapie. Leipz., 1876, II., 1.-Blake, E. T.: Amyl Nitrite in 
Exophthalmic Goitre. Practitioner, Lond., 1877, II., 189-193.-Yeo, I. B.: A 
Case of Exophthalmic Goitre with New Phenomena. Brit. M. J., London, 1877, 
I., 320-322.-Benicke, F.: Complication der Schwangerschaft und Geburt mit 
Morbus Basedowii. Ztschr. f. Geb. u. Gynak., Stuttg., 1877, I., 40-42.-Lowen- 
stamm: Struma exophthalmica (Morbus Basedowii). Med. chir. Centralbl., 
Wien, 1877, XII., 101.-Lacoste, J. B.: Contribution a 1'etude du Goitre Exoph- 
thalmique. 4to, Par., These, No. 505, 1877.-S&E, G.: Symptomes de la Maladie 
de Basedow. France med., Par., 1878, XXV., 689, 697.-Chvostek, F.: Weitere 
Beitrage zur Pathologie und Therapie der Basedow'schen Krankh. Allg. Wien, 
med. Ztschr., 1878, XXIII., 33, 87, 238.-Smith, R. S.: Exophthalmic Goitre; 
Lesions of the Cervical Ganglia. Med. Times and Gaz., Lon., 1878, I., 647-9.- 
O'Neill, W.: Exophthalmic Goitre and Diabetes Occurring in the Same Person. 
Lancet, Lond., 1878, I., 307-309.-D'Ancona, N.: Un secondo caso.di gozzo exof- 
talmusnico guarito colla galvanizzazione del simpatico al collo. Indipendente, 
Torine, 1878, XXIX., 175, 185.-Cuffer: Debut de Maladie de Basedow, sans 
Goitre, in Exophthalmus; Troubles Vaso-moteurs Predominants du Cote Gauche 
Palpitations. France med., Par., 1878, XXV., 442-443.-Duroziez, P.: Du Souf- 
fle des Arteres cardiaques dans le goitre exophthalmique. Gaz. med. de Par., 
1878, VII., 4, S. 540-542.-Becker, O.: Der spontane Netzhautartierenpuls bei 
Morbus Basedowii. Klin. Monatsbl. f. Augenheilk., 1880, XVIII., S. 1. 
SYMPTOMATOLOGY. 
The observations of the past few years have enriched somewhat our EXOPHTHALMIC GOITRE. 
607 
data from which to study this mysterious disease, without, however, 
bringing us materially closer to a satisfactory explanation of its phenom- 
ena. Thus it appears (Keo, Cuff er) that the exophthalmus may precede 
the other symptoms by a considerable interval, and may remain for a 
long time unilateral; also that exophthalmus of one side may occur sim- 
ultaneously with enlargement of thyroid on the opposite side, a fact also 
noticed by E. T. Blake. In Yeo's case, the right lobe of the thyroid first 
became enlarged, and the left eye prominent; later the left lobe of the thy- 
roid and the right eye became simultaneously involved. In proportion as 
the eye began to protrude, first on one side, then on the other, the eye- 
lashes and eyebrows fell gradually out. Yeo points out the frequency 
with which obstinate diarrhoea is observed in these cases as a significant 
symptom, and O'Neill records an observation in which the cardinal 
symptoms were associated with diabetes of a marked type, both diseases 
making their appearance together, and leading to the patient's death. 
In a case reported by Fuller, one symptom is noticed which has been 
observed by other writers, and also by myself, but is not mentioned by 
Eulenburg. This is a change in the pitch of the voice, which becomes 
like that of a child, possibly on account of pressure upon the recurrent 
laryngeal by the enlarged thyroid, but more probably from derangement 
of the central innervation. 
The second edition of the Cyclopaedia contains the following {Eulen- 
burg'): "In a case reported by Fereol, besides the cardinal symptoms 
(struma of the right side, exophthalmus, palpitation), headache, nausea, 
vertigo, and tremor were present, as well as unsteadiness of the gait, with 
tendency to fall to the right, and diplopia, traceable to paresis of the 
right trochlearis. There was, moreover, diminution of the muscular 
power on the right side of the body, with hyperalgesia, while on the 
left side there was hypalgesia, and on both sides increased reflexes. I 
have myself seen a case in which there was paralysis of the abducens, and 
another in which paresis of the lower extremities was present." 
" Raymond has seen in four cases the discoloration of the skin known 
as leucoderma or vitiligo, and quotes Trousseazi as reporting another of 
the same kind. The latter writer, as well as Stellwag (cited by Neu- 
mann), Bartholow, and Bulkley, have observed the occurrence of urti- 
caria or a very similar affection in the course of the disease. " 
The spontaneous pulsation of the retinal arteries is sometimes present, 
sometimes missed, and if, as Becker believes, it is of nervous origin, it may 
perhaps come and go like the other symptoms. Of seven cases observed 
recently by Becker, it was present in all but one, at the time of his exam- 
ination. 
Our knowledge of the pathogenesis of the disease has been materially 
advanced by an experimental research of Filehne's. This has shown that, 
in rabbits, the section of the anterior portion of the restif orm bodies, 
without further injury of the medulla, is capable of exciting two of the 
classical symptoms of the disease, namely, the rapid action of the heart 
and the exophthalmus, and, though rarely, even the enlargement of the 608 
EXOPHTHALMIC GOITRE. 
thyroid in addition. That this rapid pulse was due to destruction of the 
vagus-tract was shown by the fact that, after the operation, neither exci- 
tation of centripetal nerves would slow the pulse in the usual reflex man- 
ner, nor section of both vagi quicken it further. That the exophthalmus, 
on the other hand, was not due simply to injury of the sympathetic 
system of fibres is also evident, since it could be induced even when the 
cervical sympathetic had been previously destroyed. It was less easy 
to excite this symptom than that of the rapid pulse. The enlargement 
of the thyroid was brought out only once and then by an extensive gal- 
vano-caustic operation upon the corpora restiformia. The immediate 
cause of the exophthalmus was believed to be vascular engorgement. 
These observations would remove the primary lesion of the exoph- 
thalmic goitre from the cervical sympathetic, and refer it to the medulla 
oblongata, where it probably belongs. Even were there no experimental 
evidence for this view, it would be easier of acceptance tlian the others, 
since it is more readily conceivable that a disturbance of the complex co- 
ordinating centres and tracts of the medulla oblongata should give rise to 
this curious array of symptoms, than that they should follow lesions of 
the sympathetic nerves themselves, whose functions are simpler, and not 
of such a character that any single influence of either a paralyzing or 
irritating nature would readily explain the phenomena actually met with. 
PATHOLOGICAL ANATOMY. 
With regard to the lesions of the nervous system, R. S. Smith reports 
a case in which the lower left cervical ganglion was found to have been 
destroyed and replaced by a calcareous mass. The nerve-cells in the 
other ganglia looked somewhat shrunken, but it was thought, with 
reason, that this might be attributed to the action of the chromic acid 
in which the specimen had been hardened. Wilheim found in another 
case degenerative changes in one of the upper cervical ganglia. 
TREATMENT. 
Further testimony as to the value of mild applications of electricity 
in the cervical region is given by Chvostek and by Wilheim', while See 
vaunts the combined use of hydropathic measures and veratrum viride 
(gtt. x.-xx. of the tincture daily in divided doses, continued for weeks 
and months. Compare Cyclop.). 
E. T. Blake records improvement in the subjective and cardiac symp- 
toms in one case from the continued use of amyl nitrite (gtt. -j^-ii., 3 
t. d. on sugar), but corroboration of the value of this treatment is 
wanting. 
Ringer quotes R. T. Smith as having had excellent results in two 
cases from the continued use of tinct. belladonnas (m v.). The local 
treatment of the goitre by injection, galvano-puncture, etc., is not to be 
recommended. PROGRESSIVE MUSCULAR ATROPHY. 
609 
PROGRESSIVE MUSCULAR 
ATROPHY. 
BIBLIOGRAPHY. 
Reschansky: Beitr. zur Lehre vender progr. Muskelatrophie, Konigsb., 1874. 
-Poncet: Gaz. med., 1875, No. 25.-Balmer: Archiv d. Heilk., XVI., S., 327.- 
Vaeter, von Artens: Allg. Wiener med. Z., 1875.-Erb: Arch. f. Psych, und 
Nervenkrankh. V., Heft 2.-Lubimoff: Arch, de phys. normale et pathol., 3, 
ser. I., 1874, p. 884.-Pierret and Troissier: Ibid., 1875, No. 5, p. 735.-Char- 
cot and Gombault: Ibid., 1875, No. 5, p. 739.-Berger: Ein Fall von Sclerosis 
lateralis amyotrophica. Deutsche Zeitschr. f. pract. Med., 1876.-Luderitz: Bei- 
trag zur progressiven Muskelatrophie. Diss., Jena, 1876.-Renaut and Debove: 
Gaz. des hop., 1876, No. 22.-Pierret, A.: Note sur uncas d'atrophie musculaire 
progressive caracterisee au debut par de la retropulsion irresistible. Rev. mens, de 
med. et de chir., Par., 1877, I., 413-424.-Pick, A.: Zur pathologischen Anato- 
mie der progressiven Muskelatrophie. Prag. med. Wchnschr., 1877, II., 758-763.- 
Nunn, W. T.: Sections of Spinal Cord and of the Phrenic Nerves in the two Forms 
of Progressive Muscular Atrophy. Tr. Path. Soc., Lond., 1877, XXVIII., 9.- 
Dieulafoy: De l'atrophie musculaire progressive et de la sclerose laterale amyo- 
trophique. Gaz. hebd. de med., Par., 1877, 2 s., XIV., 789-805.-Worms, J.: Note 
sur un cas d'atrophie musculaire progressive avec paralysie glosso-labio-laryngee. 
Arch, de physiol, norm, et path., Par., 1877, 2 s., IV., 706-717.-Weiss, N.: Ueber 
progressive Muskelatrophie, Wien. med. Presse, 1877, XVIII., 691. -Lichtheim: 
Progressive Muskelatrophie ohne Erkrankung der Vorderhorner des Riickenmarks. 
Arch. f. Psychiat., Berl., 1878, VIII., 521-548.-During, L.: Ueber die progres- 
sive Muskelatrophie und ihr Verhaltniss zur progressiven Bulbarparalyse. 8vo, 
Erlangen, 1878.-Vergenes, J.: De 1'adispose sous-cutaneedans ses rapports avec 
les atrophies musculaires (Valeur semeiologique de ce signe), 4to, Paris, 1878, No. 
314.-Cullingworth, C. J.: Clinical Study of a Case of Progressive Muscular 
Atrophy, Affecting chiefly the Trapezius, Rhomboids, and Latissimus Dorsi. Med. 
Times and Gaz., Lond., 1878, II., 121-125.-Schultze: Ueber die Beziehungen 
der progressiven Muskelatrophie zur Pseudohypertrophie der Muskeln. Arch. f. 
Psychiat., Berl., 1878, IX., 169.-Steffanini: Caso d'atrofia musculare progr. con 
alterazione di ganglia simpatici. Arch, delle• science med., II., No. 3, 1878 (J. 
bericht v. Virchow u. Hirsch, 1878, II., 114).-Shaw, J. C.: Progressive Muscular 
Atrophy and its Pathology. Proc. M. Soc. County Kings, Brooklyn, 1878, HL, 
46M9.-Rumpf, H.: Zur Function der grauen Vordersaulen des Riickenmarks. 
Arch. f. Psych., etc., X., 1, 115.-Coredoin, J.: Etude clinique de la paralysie 
spinale aigue et de l'atrophie musculaire progressive chez le meme individu. 4to, 
Paris, 1879, No. 584.-Leyden: Ueb. Bulbiirpar., etc. Arch. f. Psychiatric, VIII., 
641.-Charcot (Brissaud): Sclerose laterale amyotrophique. Prog, med., 1880, 
Nos. 1 and 3.-Debove: (Rapid muse, atr., without lesions in the cord or 
nerves.) Prog, med., 1878, No. 45.-Eisenlohr, C.: Idiopathische Muskellahmung 
u. Atrophie. Cbl. fur Nervenh.kunde, 1879, No. 5. 
PATHOLOGICAL ANATOMY AND PATHOGENESIS. 
The old discussion as to whether this is a disease of myopathic or of 610 
PROGRESSIVE MUSCULAR ATROPHY. 
neuropathic origin, which for a time had lulled, has recently sprung up 
afresh apropos of a case reported by Lichtheim, where wide-spread mus- 
cular atrophy of progressive character, beginning in the muscles about 
the shoulder, and apparently excited by a local strain, was found 
after death to be unassociated with any pathological change worth men- 
tion, either in the peripheral nerves or the spinal cord. Regarding this 
case as a typical one, Lichtheim concludes that the changes in the gan- 
glion-cells in the anterior cornua of the spinal cord do not necessa- 
rily constitute the essential primary lesion of progressive muscular 
atrophy. The justice of this conclusion is not, however, universally 
admitted. Among others, Erb and Schultze deny our obligation to 
accept Lichtheim's as a typical case, saying that neither the clinical his- 
tory nor the microscopic appearance of the muscles was absolutely path- 
ognomonic. Thus the traumatic origin of the attack suggests that the 
atrophy may possibly have been secondary to articulai' disease in the 
shoulder at the outset, though it appeared later to run a typical course, 
and the case was an unusual one in several minor respects, such as in 
the occurrence of paresis of some of the facial muscles, without, however, 
the usual symptoms of bulbar paralysis, with which, as is well known, 
progressive muscular atrophy is so apt to be complicated. Still, even 
the authors cited admit the importance of Lichtheim's observation, as 
well as the fact that we must improve our means of diagnosis before we 
can distinguish clinically such cases as these from the typical forms of 
the disease. This, they think, may eventually be possible through care- 
ful electrical tests. With regard to the muscular changes, they claim 
that in true progressive muscular atrophy, the atrophy is characterized 
by acute degenerative processes, such as multiplication of nuclei, disap- 
pearance of the transverse striation, waxy degeneration, etc., whereas 
Lichtheim observed only a simple atrophy of the muscular fibres, with 
increase and fatty degeneration of the interstitial connective tissue. 
The importance of this criticism may, in its turn, be called in question. 
Thus Leyden (Klinik der R.marks-Krankheiten) thinks we are still far 
from being able to dogmatize about the nature of the typical histological 
changes. That the symptoms of progressive muscular atrophy are almost 
invariably associated with, and often distinctly due to degenerative 
lesions of the great nerve-cells in the anterior cornua of the spinal cord 
no one to-day can doubt, so that, as Erb remarks, it has become almost 
superfluous to publish furthei' illustrative cases of this kind. On the other 
hand, it is evident that the group of cases hitherto classed under this name, 
■while they join hands with the recognized amyotrophic spinal affections 
on the one hand, do so none the less with the primary myopathic dis- 
eases on the other, to which the case of Lichtheim and those known as 
pseudohypertrophic paralysis may belong, and it is probable that this ele- 
ment has not of late years received due recognition. It will be very 
. satisfactory if it turns out, as Rumpf suggests, that the presence of the 
degenerative reaction of the muscles to galvanism may serve to mark out 
. a doubtful case as being of neuropathic origin. Erb has found this PROGRESSIVE MUSCULAR ATROPHY. 
611 
reaction in a few cases of progressive muscular atrophy, and is inclined 
to think that it is always to be discovered in certain muscles and at cer- 
tain stages of the disease, if searched for with sufficient care. The diffi- 
culty of recognizing it is sometimes increased by the fact that the feeble 
and slow contraction of the diseased fibres may be masked by the more 
rapid and vigorous contraction of relatively healthy parts of the same 
muscle. 
Other good observers have searched for this degenerative reaction in 
vain, so that its value as a sign of neuropathic, as distinguished from 
myopathic, muscular atrophy is not definitely settled. The discussion 
as to the pathological anatomy of progressive muscular atrophy would be 
simplified if all observers would, with Leyden, agree provisionally to 
consider in a group by themselves the cases of so-called " hereditary " 
muscular atrophy. The disease in these cases, affecting, as it does, the 
lumbar muscles and those of the lower extremities before those of the 
arms and hands; making its appearance usually in childhood; and often 
in several members of the same family, either in the same or in succes- 
sive generations, appears more closely related to pseudo-muscular hyper- 
trophy (v. next chapter) than to the typical progressive muscular atrophy 
of adults. Furthermore, the examination of the spinal cord, in "hered- 
itary" muscular atrophy as in pseudo-hypertrophy, has as yet given 
negative results, though the number of autopsies (one by Meryon and 
several by Friedreich} are as yet too few to be conclusive. It is to be 
remembered that the term "hereditary" for some of these cases is, if 
literally taken, a misnomer, since it is by no means always possible to 
find evidence of the existence of the same disease in former generations. 
All that the word should be taken to imply is, that the causes of the dis- 
ease in a given case are not post-natal, but pre-natal in the widest sense 
of the term. 
Mobius believes, in spite of the negative results of post-mortem ex- 
amination, that the cause of the muscular atrophy, even in the "heredi- 
tary " cases, is to be sought in the central nervous system, mainly because 
in these cases there are so often other signs of disturbance in the func- 
tions of the brain and cord, etc. To form a decided opinion on this 
point would be premature. 
It is difficult to say through just what agency the lesions in the 
anterior cornua of the cord act upon the muscles in progressive mus- 
cular atrophy, so as to excite inflammatory and degenerative changes in 
them, even if we grant, with the vast majority of observers, that this 
actually happens in the great bulk of the cases. It is evident that the 
lesions beginning in the ganglion-cells are not always propagated per con- 
tinuum through the peripheral nerves, for in some cases-that of Erb and 
Schultze for instance-the motor nerves have been found intact. 
The hypothesis of special trophic cells has not met with general favor, 
but recently Rumpf, in an able paper, has defined more physiologically 
and clearly than has been done before, the view that the motor nerve- 
cells may lose so much of the trophic influence of which they are sup- 612 
PSEUDO-MUSCULAR HYPERTROPHY. 
posed, to be the seat as to permit the muscle to degenerate, and. yet retain 
enough to nourish passably the nerves by which the two organs are 
united. 
More prudent and. philosophical than either of the extreme views 
(myopathic and neuropathic) as to the primary lesion of progressive mus- 
cular atrophy seems to me the opinion dr hypothesis expressed by Leyden 
(Klinik der R.marks-Krankheiten, Bd. II., p. 506), as follows: " I regard 
this disease, therefore, as a process of progressive degeneration . . . 
which attacks the musculai' system, the motor nerves, the motor ganglion- 
cells, and the motor nerve-tracts in the spinal cord, parts which are all 
functionally associated, and finally, in its fullest development, involves 
and destroys the motor nuclei of the medulla oblongata " (bulbar 
paralysis). 
The pathological relations of the amyotrophic diseases of neuritic ori- 
gin,, important as the subject is, cannot be discussed here. They are 
treated of at length by Leyden in a recent exhaustive paper {Zeitschrift 
fur klin. Med., I., 3, 1880). 
With regard to the implication of the sympathetic system in progressive 
muscular atrophy nothing is to be added which should change the con- 
clusions arrived at by Eulenburg in the first edition of this Cyclopaedia. 
One case by Steffanini (known to me only through a reference in Virchow 
and Hirsch''s J.bericht, by Bernhardt') is of interest because: besides pig- 
mentary and fatty changes in the sympathetic ganglia, the spinal cord 
is said to have been found in a healthy state. 
PSEUDO-MUSCULAR HYPER-. 
TROPHY. 
BIBLIOGRAPHY. 
Korwatzki: Deb. dieHypertr. d. quergestreiften Muskelgewebes, Erl., 1874.- 
Ord, W. M.: Case of Ps.-m. H., with a few Observations on Surface Thermom. 
Med. Chir. Tr., LX.-Clarke and Gowers: Med. Chir. Trans., 1874, p. 247. 
Bruenniche Hosp. Tid. 2 R , 1 Aarg., p. 257.-Mahot: De la par. pseudo-hypertr. 
These de Paris, 1878 (3 cases ; lack of mental power; also commented on by 
Bag).-Bjornstrom, F.: Upsala lakara foren. forhandl., Bd. XII.-Bao: Hosp. 
Tid., 2 R., Bd. 4.-Brieger: Deutsch. Arch. f. kl. Med., 1878.-Mobius, Samuel: 
KI. Vortrage, No. 17. (Relation between P.-m. H. and Progr. M. Atr.)- 
Kesteven: Jr. of Ment. Sc., Oct., 1879.-Bennett, A. Hughes: P. M. H. in an 
Adult. Brain, Vol. 2, No. 3.-Goetz, R.: Beitr. zur Atr. M. Lip. Aerztl. Intell. 
Bl., 1879, No. 39. (10 cases; etiology: dampness and insufficient nourishment.) 
Webber, S. G.t Pseudo-hyp. Par. Boston M. and S. Jr., 1879, 460.-Gowers, W. 
R.: Pseudo-h. Par. London, 1880, PSEUDO-MUSCULAR HYPERTROPHY. 
613 
PATHOLOGY. 
The latest facts with regard to this disease are well summed up in a 
recent monograph by Gowers. Of the 220 cases there analyzed, 102 were 
apparently isolated, and 118 were grouped in 39 families. 
Six new autopsies have been made since the publication of the first 
edition of the Cyclopaedia, viz., by Clarice and Gozvers, Brieger, Bag, 
Schultze, Kesteven, and Goetz. 
In Clarke and Gowers' case, there was found extensive "granular de- 
generation " of the interstitial tissue here and there throughout the 
entire spinal cord, but especially in the lower dorsal region, where in 
each half of the gray substance there was an area of disintegration 
amounting to an actual cavity outside of each posterior vesicular column. 
At the lower end of the conus medullaris one group of nerve-cells was 
wanting. The great nerve-cells of the anterior cornua were, however, 
"conspicuously healthy," the lateral columns essentially normal, and the 
changes found are ascribed by the authors to either ascending neuritis or to 
repeated venous congestion, for which opinion the grouping of the lesions 
around the posterior nerve-roots and the blood-vessels, as well as the his- 
tory of the patient, afforded good grounds. . 
In none of the cases were changes in the ganglion-cells analogous to 
those found in progressive muscular atrophy described, though it is worthy 
of note that Schultze and Barth speak of the number of these cells as being 
strikingly small-a condition which may have been due to the same remote 
cause with the impairment of the muscular development, without any 
closer association existing between them. In Gowers' case, however, the 
number of the cells is expressly stated to have been normal. Bag found 
signs of degeneration in the lateral columns of the cord. In Kesteven's 
case, besides wide-spread vascular changes, there were small, whitish 
spots scattered through the brain and cord, within the limits of which 
the nerve-fibres seemed to have been almost wholly destroyed; and the gang- 
lion-cells, though as a rule normal, were here and there somewhat 
granular and pigmented. Goetz (description known to me only through 
an abstract in the Cbl. fur med. Wiss., by Bernhardt} found the gang- 
lion-cells healthy, but speaks of a gelatinous connective tissue present 
both in the white and gray substance, by which the nerve-fibres seemed 
to have been compressed. 
Eulenburg joins with Friedreich in describing the disease pathologi- 
cally as a chronic myositis with hyperplasia of the interstitial connective 
tissue, a designation which both consider to cover also the muscular 
changes in progressive muscular atrophy. 
Gowers appears to incline to the view that the substance by which the 
muscle is replaced is a sort of pathological new-growth, a myo-lipoma, 
indicating " a congenital nutritive and formative weakness of the striated 
muscular substance," rather than as simply the result of inflammation. 
In this connection he describes a curious tumor found by him attached 
to the conus medullaris of the spinal cord (not in a case of this disease). 
It appeared at first to be made up of fat-cells alone, but on examination 614 
EPILEPSY. 
proved to contain muscular fibres and connective tissue as well, closely 
resembling a fragment of pseudo-hypertrophic muscle. Yet it had 
formed entirely apart from the surroundings and influences which have 
been supposed to give rise to the disease in question. 
Great interest attaches to the discussion as to the relation which 
pseudo-muscular hypertrophy bears to progressive muscular atrophy. 
As was observed in the chapter on the latter disease, this discussion 
would be simplified if the clinical distinction between the usual adult 
form of the affection and the so-called "hereditary " form were, at least 
provisionally, recognized by all. 
The likeness of some cases of the disease before us to cases of this 
last-named division of progressive muscular atrophy is strong reason for 
considering them as belonging in one group, especially when we reflect 
that enlargement of muscles is not pathognomonic of pseudo-muscular 
hypertrophy, since it is occasionally met with, and that, too, pre-emi- 
nently in the calves of the legs, in cases of progressive muscular atrophy, 
both as a result of hyperplasia of the fatty and connective tissues, and in 
consequence of a true muscular hypertrophy {Leyden, "hereditary" 
form); and further, that the enlargement in pseudo-muscular hyper- 
trophy may give place*to a diminution in bulk, and vice-versa, in the 
course of the disease. 
As for the relation between our disease and the typical adult form of 
progressive muscular atrophy, this is certainly very remote, even if in- 
deed it exists at all. ' 
For reference to other cases of interest see the bibliographical index. 
EPILEPSY. 
BIBLIOGRAPHY. 
LasJjgue, C.: De 1'epilepsie par malformation du crane. Ann. med. psych 
Paris, 1877, XVIII., 5 s., 161-178. Also Arch. gen. de med., Paris, 1877, II., 5- 
20.-Vielle, A.: Quelques considerations sur 1'epilepsie et plus specialement sur 
1'epilepsie associee avec certaines malformations du corps en general et de la 
tete en particulier. 4to, Paris (These No. 237), 1878.-Garel, J.: Recherches 
cliniques et statistiques sur la valeur de 1'asymetrie faciale dans le diagnostic de 
1'epilepsie. Lyon med., 1878, XXVII., 5-43.-Magnan: Des rapports entre les 
convulsions et les troubles circulatoires et cardiaques dans 1'attaque d'epilepsie. 
Gaz. med. de Paris, 1877, VI., 390.-Westphal: Eigenthiimliche mit Einschlafen 
verbundene Anfalle. Arch, fur Psychiatric, etc., B. 7, p. 632.-Fischer, F., Jr.: 
Epileptoide Schlafzustande. Arch. f. Psychiatr. u. Nervenkrankh., Berlin, 1877, 
VIII., 200-203.-Bouchut: De 1'epilepsie chez les enfants et des vertiges epilep- 
tiques. Gaz. d. hop., Paris, 1877, L., 66-73.-Bourneville: Compte rendu des 
observations recueillies a la Salpetriere, concernant 1'epilepsie. Progres med., 
Paris; 1877, V., 623, 643, 655.-Huppert, Max: Die Albuminurie in dem epilepti- 
schen und paralytischen Anfall. Arch, fur Psychiatric, etc., 1877, p. 189.- EPILEPSY. 
615 
Martin, H.: De la mortalite des enfants des epileptiques, etc. Ann. med. psych., 
Paris, 1878, XX., 364 368.-Delasiauve: Le manage des epileptiques. Jr. d'hyg., 
Paris, 1879, IV., 339. Jackson, J. H.: Lectures on the Diagnosis of Epilepsy. 
Med. T. and Gaz., London, 1879, I., 223.-Sommer, Wilhelm: Erkrankung des 
Ammonshorn als aetiologisches Moment bei Epilepsie. Arch, fur Psych., etc., X., 
631. (Contains full list of references.)-Lupine, R.: De 1'epilepsie survenant a la 
suite d'ecarts habituels de regime, chez des individus tres-sanguins et de son traite- 
ment. Rev. mens, de med. et de chir., Paris, 1877, I., 573-587.-Gowers, W. R.: 
On the Use of Iron in Epilepsy. Practitioner, London, 1877, XIX., 241-246.- 
Schultz: Ein Fall von Hemmung epileptischer Anfalle mit nachfolgender 
Heilung. Berl. klin. Wchnschr., 1877, XIV., 659-661.-Vallender, E.: Coupi- 
rung epileptischer Anfalle durch subcutane Apomorphininjectionen. Berl, 
klin. Wchnschr., 1877, XIV., 185-6.-Martin, A.: Dangers des preparations 
opiacees chez les femmes hysteriques. Mouvement med., Paris, 1877, XV., 488- 
498.-Bourneville: Influence de la compression ovarienne sur la contracture 
hysterique recente. Progresmed., Paris, 1877, V., 487-488.-Pison, E.: De 1'effi- 
cacite du bromure de potassium dans le traitement de 1'epilepsie. 4to, Paris 
(These No. 444), 1877.-Seguin, E. C.: Report on the Use of Chloride of Potassium 
in Epilepsy. Proc. Therap. Soc., N. Y., 1878, 21-28. Also N. Y. Med. Jour., 
April, 1878.-Sinkler, W.: Cannabis Indica in the Treatment of Epilepsy (Case'. 
Phila. Med. Times, 1878, VIII., 607-609.-Rockwell, A. D.: On the Use of 
Electricity in the Treatment of Epilepsy. Med. Rec., N. Y., 1878, XIII., 264- 
266. Preliminary Report upon the Use of a Mixture of Chloral and Bromides in 
Epilepsy. N. Y. M. J., 1878, XXVII., 535-539.-Agnew, D. H.: Successful Case 
of Trephining for Epilepsy. Phila. Med. Times, 1878, VIII., 578-580.-Eche- 
verria, M. G.: De la trepanation dans 1'epilepsie par traumatismes du crane. 
Arch. gen. de med., Paris, 1878, CXLIL, 529, 652.-Poirier, P.: Des moyens 
d'arreter les attaques hystero-epileptiques, et en particulier, de la compression 
des ovaires. Progresmed., Paris, 1878, VI., 993-994.-Spitzka, E. C.: Some Re- 
marks on the Treatment of Epilepsy and Epileptifrom Conditions. Physician 
and Pharmac., N. Y., 1879, n. s., XII., 247-249. -Kunze, C. F.: Ueber die Behand- 
lung der Epilepsie mit Curare (Ber. d. 51. Verhandl. deutscher Naturf. u. Aerzte 
in Cassel). 
ETIOLOGY. 
In a valuable series of Gulstonian lectures. Dr. IF. R. Gowers has 
given some important statistical information based on the careful analysis 
of 1,450 cases observed by himself, from which the following facts are 
taken with regard to hereditary transmission of the disease, which, in 
the main, bear out the views expressed by Nothnagel. 
In the inquiry, certain affections believed to be related to epilepsy, 
viz.: insanity, hysteria, chorea, paraplegia, and infantile paralysis 
occurring in near relatives, are admitted as indications of transmissible 
taint. In this sense, thirty-six per cent of the cases showed evidence of 
neurotic inheritance, and this was true of the cases of hystero-epilepsy in 
about the same proportion with those of true epilepsy. 
The females of the family suffer from this influence more than the 
males (fifty-seven against forty-three per cent), but, nevertheless, when 
the disease is inherited from the father's side (which is relatively uncom- 
mon), the reverse is true, the liability of males being twenty-two per 
cent greater than when it comes from the mother's, while the mother's 
taint is transmitted much oftener to girls. 616 
EPILEPSY. 
"We may now see, in part at least, why females preponderate so much 
more in cases of inherited disease than when there is no inheritance. 
First, the inheritance is more frequent from the mother's side than from 
the father's, and secondly, when the inheritance is from the mother's side, 
girls suffer in a much larger proportion than boys." 
As to the nature of the disease in the parents from whom epilepsy 
seemed to have been inherited, the same affection was present in the large 
majority of instances, insanity in some form being the next most com- 
mon. 
In some cases the family tendency was remarkably strong; in one, not 
less than fourteen members, in four generations, being affected. 
An equally striking instance is reported by L. C. Gray. 
The influence of alcohol in exciting to the transmission of epilepsy 
is verified-though for but a limited number of cases, under treatment in 
the Salpetriere-by Martin, and the same writer points out that the 
actual infecting power of the ancestral taint is made less evident by the 
figures given than it would be, but for the fact that epileptics have but 
few children, and many of these die young. Similar views are held by 
E. C. Mann, of Hartford. I 
The following may here be quoted from the second edition of Noth- 
nagel'^ article: "It is still a matter of doubt whether the marriage of 
near kin serves as a predisposing cause of epilepsy, as a certain number of 
cases have seemed to show. The feeling has been growing gradually 
stronger that the harm resulting from such marriages-so far as the 
influence of the consanguinity per se is concerned-has been overrated. 
Henry Huth takes this ground, and George Darivin has come to the 
conclusion, from careful statistical investigations, that numerical evidence 
does not support the current belief. If the husband and wife are both of 
healthy parentage, the fact that they are blood relations has not been 
shown to entail disease to their descendants." * 
Gowers, like Nothnagel, has not been led to attach much importance 
to phthisis as a predisposing cause of epilepsy. 
It is but proper, in connection with these statements as to hereditary 
transmission, to see what light, even of a speculative nature, there is to 
guide us in determining which the facts are among those offered or to be 
sought for, which have the most real significance. What lesion, in 
short, is it which is transmitted? Is the vice of structure or nutrition 
in the nerve-centres, whose " discharge " causes the epileptic fit, inherited 
in the very form in which it existed in the parent, or is it some more gen- 
eral disorder of nutrition, centring, perhaps, round the processes of diges- 
tion or circulation, which causes epilepsy as it might cause any one of a 
variety of diseases? It is manifest that this question is an important 
one, as Hughlings Jackson long ago pointed out, for, if the cause or the 
* In. spite of this verdict of non-proven, there is much circumstantial evidence 
for the view that consanguineous marriages may cause both epilepsy and blind- 
ness or mutism, and in making a practical decision it is well to err on the safe 
side. EPILEPSY. 
617 
partial cause of the perverted nutrition which underlies the hyper-irrita- 
bility of the ganglionic centres is, for instance, of circulatory origin, we 
are neglecting the direct path of inquiry in not turning our attention to 
that condition in the patient's ancestry rather than to other diseases of 
the nervous system, which, however often associated with epilepsy, may 
be so only in so far as both spring from similar causes. 
This is the position taken by Ilughlings Jackson. The various neu- 
roses mentioned have, as he says, as yet no recognized pathology, and 
neither the presence of them nor of epilepsy itself in the parent can 
therefore be taken to prove that epilepsy maybe inherited as epilepsy, or 
as a nervous disease at all. Jackson's hypothesis is still without definite 
support, but is nevertheless not rebutted, and cannot be till we have 
learned better how to localize the lesions of epilepsy and to examine their 
nature. 
The statistics of Goivers are worthy of mentio% here, as showing in 
greater detail than has been done before, the influence of age and sex in 
determining the outbreak of epilepsy, though his figures support the 
statements of Nothnagel and others. 
Thus we find that between the ages of nine and sixteen, while puberty 
is being established, the frequency with which chronic epilepsy begins 
is on the steady increase, then that it begins to fall off pretty rapidly. 
Further, in the case of girls, the figures between twelve and sixteen 
run up much higher than they do for boys, and this is especially true of 
the hereditary cases. 
It is impossible not to be struck with the similarity of these curves to 
those given by H. P. Bowditch and others, which show the relative rates 
of growth of boys and girls at this period. In them the line for the girls 
crosses that for the boys at twelve, and continues to diverge from it till 
fourteen and a half, when it rapidly approaches it again, though girls re- 
main taller and heavier than boys till over fifteen. It is evident that the 
increase in the rate of growth is not the sole cause of the preponderance 
of the epileptic tendency in girls at this period, since the maximum of 
the latter occurs (Gowers') at sixteen, that of the former at fourteen and 
a half, a discrepancy for which various causes suggest themselves as pos- 
sible. 
In connection with the greater frequency with which epilepsy first 
shows itself during the period of puberty, the observations of Lasegue 
must be mentioned, according to whom a large proportion of these cases 
are due to malformations of the cranium, detectable by careful measure- 
ment about the face and head, but centring at the base of the skull and 
associated with abnormal ossification at the sutures near the foramen mag- 
num (comp, the original art. in this Cyclopaedia, by Nothnagel). 
A more extended notice would be given of these observations, but that 
doubt has been thrown on their importance by the parallel investigations 
of Garel, who shows that this asymmetry is not much more common in 
epileptics than in healthy persons. Nothnagel also emphasizes the fact 618 
EPILEPSY. 
that patients with epilepsy are often in blooming health and free from 
deformity. 
Among the exciting causes of epilepsy, carefully enumerated and 
studied by Goivers, rhachitis is especially worthy of mention, both be- 
cause it is, as he thinks, a frequent cause, through the imperfections of 
nutrition of the nervous system which it entails, and because it is in a 
measure curable. 
The infancy of children with this disease, especially if they inherit 
likewise an epileptic taint, is to be watched over with extreme care. 
SYMPTOMATOLOGY. 
Careful observations by Magnan as to the condition of the heart, and 
the blood-pressure, during epileptic attacks m the dog, occurring as a re- 
sult of absinthe poisoning, have shown that during the period of tonic 
spasm the blood-pressure rises very high, and the heart beats strongly and 
rapidly, but with short excursions, with incomplete diastole. During the 
period of clonic spasm the blood-pressure falls again rapidly, even far be- 
low the normal, and the heart's action becomes very slow. That these 
phenomena were not the result of the convulsion itself was shown by the 
fact that they did not occur if the vagus had been previously cut. 
Among unusual symptoms of epilepsy may be mentioned the liability 
to fall asleep at unseasonable times, while talking, at table, even while 
walking in the street. Cases of this kind have been reported by Westphal 
and later by Fischer, and I have seen a marked instance of the kind. 
Westphal's case was not, in the ordinary sense of the word, distinctly epi- 
leptic nor does he give it that name. Besides the attacks in which the 
patient actually fell asleep, he had others in which he was only asleep to 
appearance, retaining some degree of power to hear and understand what 
was said, and besides this he had seizures which could perhaps better be 
called cataleptic than epileptic. The case reported by Fischer was more 
evidently epileptic, and the seizures were preceded by either mental con- 
fusion or a sense of heaviness and discomfort in the limbs. In the case 
observed by myself, one well-marked though slight epileptic attack had 
been seen by the patient's friends, and indirect evidence was found of 
others. All three cases were of several years' duration. 
With regard to the constitution of the urine after epileptic attacks, 
Huppert reiterates his former statements as to the frequency with which 
albumen and even hyaline casts are found, and that too in the urine of 
women as well as of men, and under circumstances which show that this 
is not a result of venous congestion, but of arterial changes of tension. 
Analogous effects attend the paralytic attacks which occur in progressive 
paralytic dementia. In many of the transitory apoplectic seizures which 
occur- in the course of progressive paralytic dementia albuminuria is also 
seen. This is especially true of those attacks which are characterized by 
elevation of temperature, while there are others, both of a paralytic and 
epileptiform nature, where it is absent. 
Huppert concludes by saying: "This much, at any rate, may be EPILEPSY. 
619 
looked upon as certain, the albuminuria is a much more common conse- 
quence of (recent) affections of the central nervous system than has 
been supposed, and even accompanies processes that have usually been 
characterized as psychical disorders, such as attacks of acute excitement." 
Hughlings Jackson has recently described again, in three lectures 
before the Harveian Society, his views as to the nature of epilepsy and 
the epileptic attacks, and though they have been stated in similar lan- 
guage on former occasions, yet it has been thought worth while to attempt 
a brief abstract of them here, because they do not seem to me to have 
attracted the amount, or still more, the kind of attention that they 
deserve. This is, no doubt, due in the main to the philosophical style 
and language in which the reasoning is couched, and to the unusual 
point of view from which the subject is regarded, which has given his 
papers the air of a contribution rather to psychology than to medicine, 
and has caused them to be often misunderstood, and often set aside as 
" theoretical." 
As a matter of fact, it is a pre-requisite to the comprehension of this 
branch of cerebral physiology and pathology that the physician should 
be familiar with the elements of psychological reasoning, but, with that 
granted, the views of Jackson seem to me the most lucid, straightfor- 
ward, simple, and well-grounded that we possess. 
The usual belief on the continent of Europe with regard to the 
pathology of epilepsy, and that held pre-eminently by Nothnagel, is that 
it is an affection, functional or organic, of the pons and medulla oblon- 
gata. When we come to study the grounds for this opinion, we find them 
so scanty that the whole doctrine hardly deserves to be looked on as more 
than a pure hypothesis, in spite of the very able arguments of Nothnagel 
in its support, and as a hypothesis it seems to me far less direct and 
simple than that of Jackson, which looks upon epilepsy not as being 
one and the same thing in every case, perhaps not so in any two cases, 
but as differing according as one or another portion of the ganglionic 
matter of the brain takes on this peculiar irritability which constitutes 
the disease. 
In order to seek out the portion of the diseased part in any given 
case, Jackson interrogates the attack itself with all its attendant phe- 
nomena, and especially the earliest manifestations of the attack, as 
reflecting, though crudely, the functions of the ganglionic centres which 
are involved. It is true that the " vaso-motor " doctrine rests on the 
apparently broad footing of the celebrated experiments of Kussmaul 
and Tenner, as well as on the fact that the parts named contain ganglia 
(Krampf-centrum), the excitation of which is capable of producing gen- 
eralized muscular convulsions, and vaso-motor centres, which no doubt 
control the blood-supply of the whole body, and may modify that of one 
part, as the brain, without the rest. Still it is questionable whether 
these arguments, drawn from physiological experimentation, important 
as they are, have not been pushed too far, so as to draw away the atten- 
tion from other lines of research. 620 
EPILEPSY. 
It is a habit with many writers to speak of cases of epilepsy, or so- 
called epileptiform convulsions, if they are due to irritation of the cor- 
tex cerebri, as Jacksonian or cortical epilepsy, but, as a matter of fact, 
the special merit of Jackson's work lies less in his pointing out that the 
primary lesion of many cases of epilepsy is probably situated in the cor- 
tex, than in his indicating the proper method of investigating all cases 
of epilepsy. There seems, certainly, to be no presumptive reason why the 
convulsions of epilepsy should not, and sometimes may not have their 
origin in an excitation of the "convulsion-centre" of the pons varolii 
as well as of other parts, if only it could be shown from the character of 
the convulsion that this diagnosis was probable. In other words, it is 
premature to regard epilepsy as a definite disease, always repeating itself, 
like one of the exanthemata, but all that we have a right to affirm is, that 
the single common element in different cases of epilepsy is a permanent 
liability on the part of ganglionic matter somewhere to enter into undue 
activity, to "discharge," either from causes which if external are slight, 
or are internal and bound up in the life of the organism. To say where 
this ganglionic matter is situated is a question for special investigation 
in each case, though there are unquestionably certain locations, within 
wide limits, which are affected by predilection. 
We should not speak of epilepsy, but of eirilepsies, seeking for differ- 
ences between them in the character of the auras and the other early 
manifestations of the attacks, before the picture has become confused 
by the too great generalization of the symptoms. 
So far, it would seem, that we can go safely. When it comes to 
deciding as to the ultimate cause of this " dischargeability " or irritability 
of these various nervous centres, we enter into the domain of hypoth- 
esis, and certainly the simplest explanation would not be that which 
considers the vaso-motor centres in the medulla to blame for all the 
varied forms in which epileptic attacks show themselves. It is far easier 
to assume, with Jackson, that these imperfections of nutrition of the vari- 
ous nervous centres are purely local, leaving it as a matter for future 
investigation whether their ultimate cause is a congenital vice of devel- 
opment on the part of the tissue-elements, or an imperfection of the 
local blood supply, or both. But, it will be said, it is comprehen- 
sible that these minute localized lesions, situated, no doubt, oftenest in 
the cortex cerebri, should cause localized symptoms, such as muscular 
spasms, but not that they should cause all the phenomena of a full 
epileptic attack. Nor is this supposed to be the case. It is only main- 
tained that the epileptic discharge begins in these circumscribed portions 
of ganglionic matter, spreading thence both "laterally and downwards" 
(in a physiological sense) through the other cerebral centres; just as 
when we make a strong effort to grasp something with the hand, the 
innervation spreads gradually from the nervous centres concerned chiefly 
with the hand to those of the forearm, of the arm, the shoulder, the 
neck, the face, and the arm of the opposite side of the body, even involv- 
ing sets of muscles whose contraction adds nothing to the efficiency of EPILEPSY. 
621 
the original and still central effort. Even the occurrence of disturbances 
of the animal or organic functions of the body, hallucinations of smell, 
sight, hearing, pallor of face (spasm of arteries), salivation, etc., are well 
explained on this hypothesis, both through psychological reasoning and 
through experimental evidence, since there has been no more striking 
result of the recent investigations into the physiology of the cortex cere- 
bri than the discovery that its functions are closely related to those of 
the parts concerned in organic and vegetative life, the heart, the blood- 
vessels, the glands, etc. 
In the recent papers alluded to, the author devotes himself mainly to 
the study of the seizures of what is clinically known as epilepsy proper, 
characterized by early loss of consciousness, rapidly and widely spreading 
spasm, etc., setting aside the so-called epileptiform convulsions (mono- 
spasms, or what is sometimes described as cortical or partial epilepsy), 
in which consciousness is lost late if at all, and the muscular convul- 
sion spreads less rapidly .and less widely, not as belonging scientifically in 
a different genus, but for reasons of convenience. 
Jackson shows that, in these cases of epilepsy proper, the "discharge " 
which causes the fit takes place, not in the ganglionic matter of the so- 
called "motor region of Hitzig and Ferrier," in which the discharge 
causing the epileptiform convulsions originates, but in other parts of the 
cortex, where nervous arrangements exist which serve as the anatomical 
substratum of the higher mental operations, but points out that the 
significance of the complex features of these seizures is hardly to be 
understood till the simpler " partial " attacks have been studied. 
The difficult task of summarizing Jacksori's searching analyses will 
not be attempted here. The reader is referred to his various papers, as 
well as to the recent lectures of Gowers, by whom the opinions of Jackson 
are in the main adopted. 
I must also abstain, for want of space, from discussing at length the 
important question as to what we are to understand by "post-epileptic" 
states. 
Hemkes, and more recently Pfleger, have reported quite a number of 
instances of the mysterious sclerosis of the cornu ammonis; the latter 
twenty-five times out of forty-three cases, the former six times out of 
thirty-four cases. Neither writer looks upon this as a primary lesion, 
but either as secondary, or else as indicating generalized cerebral disease. 
Still more lately, Sommer has given the results of an exhaustive study 
of this subject in a monograph (Arch. fur Psych., etc., X., 3), in which 
he has collected and analyzed ninety records of autopsies in which some 
change of the Ammon's horn was found, besides describing an accurate 
topographial and histological investigation in a case of his own. He be- 
lieves that the relation between the lesion and the epilepsy is far more 
than accidental or secondary, the former occurring, as it does, in about 
thirty per cent of all fatal cases, and he thinks that the sensory auras 
PATHOLOGICAL ANATOMY. 622 
EPILEPSY. 
which are so common may originate in disease of the part in question, 
to which sensory functions have been attributed by Ferrier. The theory 
is suggestive, but at present hardly more, and the fact that the cornu 
ammonis of both sides is usually involved seems to me to militate against 
it. 
The microscopic changes found in Sommer's case consisted essentially 
in a disintegration and disappearance of ganglion-cells, with degeneration 
of the adjacent fibrous tracts. 
Gowers thinks, and I cannot but agree with him, that, from the 
physiological stand-point, the nature of the " epileptic condition" of 
ganglionic matter is to be sought, not in " increased irritability " or 
" hypernutrition," but in the loss of the inhibitory function of the nerve- 
cell. The researches of the physiologists ( Wundt) certainly lead to the 
belief that tension or self-inhibition is a function of all ganglionic matter 
which is first to suffer when the nutrition is impaired. 
TREATMENT. 
Whatever be the views, anatomical or physiological, which each may 
hold as to the nature of the change in the nervous centres which under- 
lies the epileptic state, nobody will object to the proposition that it is 
one with which a local imperfection of nutrition somewhere has much 
to do. Attempts to cope with this condition have followed mainly two 
lines, the dietetic and the sedative. The most successful attempt of the 
former kind has been by the disuse of animal food, which is still a 
cherished means of treatment (compare especially Morson, West-Riding 
Asylum Reports, Vol. V., 1875). Lopi.no has reported a carefully studied 
case, of much therapeutic interest, where both these methods were suc- 
cessfully combined. 
The patient was a plethoric man and the attacks had been recurring 
with great frequency, four or five times each night. 
The treatment consisted in the use of a bland and very restricted 
diet, the employment of frequent venesections, by which the globules 
of the blood were reduced by nearly two millions to the cubic centimetre, 
and the administration of large doses of digitalis and bromide of potas- 
sium combined, the latter alone failing to accomplish the desired end, 
and both failing to do so if unassociated with the bleeding. At the end 
of forty-four days after this treatment had been got fairly under way, the 
patient had had no attack. It would not do, as Lepine says, to treat all 
cases of epilepsy with bleeding and depletion, the more so that it was 
formerly a favorite means of treatment in the French hospitals and has 
since fallen into disuse, presumably because too indiscriminately em- 
ployed. At the same time, it cannot be assumed too hastily that it is 
only in " plethoric " cases that this method is applicable. That would 
be to take for granted a greater similarity between the local and the gen- 
eral condition than is justified by our present knowledge. No doubt, 
however, these would be the best cases to begin the investigation upon. 
There are, similarly, classes of cases, as Gowers has shown, where EPILEPSY. 
623 
iron is distinctly useful, others where it seems injurious, though we can- 
not always recognize them in advance. 
With regard to the effects of trephining in traumatic epilepsy, new 
instances of success are reported from time to time. 
Echeverria gives a table of one hundred and forty-five cases of tre- 
phining for traumatic epilepsy, claiming to be all reported up to 1878. 
The question as to the value of this treatment is not one that admits of 
solution by statistical investigation, the cases are so utterly different; but 
that good effects sometimes followed is indisputable, even where the 
operation was done as late as ten, fifteen, even twenty years after the 
injury, and even, what is more remarkable, where no affection of the 
inner table was found. 
J. F. West has recently reported a case of this latter kind and sug- 
^sts that the irritation causing the epilepsy may have originated in the 
lesions of the outer layers of the bone, referring to a case following 
necrosis of the tibia, where operation gave relief. 
E C. Seguin reports observations showing the uselessness of chloride 
of potassium as compared with the bromine salts in controlling the par- 
oxysms, and on the value of the combination of bromide of potassium 
with chloral hydrate, both in moderate doses, as, at any rate, often mak- 
ing it possible to dispense with the large and sometimes objectionable 
doses of bromide. 
Gier sing studied with great care the comparative value of a number 
of drugs, in three cases, occurring in one family, and followed for a series 
of years. With each drug the dose was gradually increased till it 
seemed to have reached the limit of its usefulness. The main results 
were as follows: 
Extr. of cal. bean, given during 862 days. Attacks every 9.5 day. 
Brom, of potass. " " 444 " " " 18.5 " 
" " with 
■ bellad. 
[ or " 2,390 " " 36.2 " 
. atrop., 
" " with digitalis, 986 " " " 23.6 " 
" " " valerian, 329 " " " 54.9 " 
Of other new remedies tried often enough to make statements about 
them of suggestive value, I will mention, subcutaneous injections of 
curare, used by Kunze in eighty cases. The mixture employed was: 
Curare 0.3 
Aq. dest . 5.0 
Mucilag gtt. 2 
Of this, eight drops were injected every fifth to seventh day for several 
weeks at a time, alcoholic drinks being meantime avoided, and, in obsti- 
nate cases, milk diet enforced. 
Six cases are reported as having been radically cured. 624 
EPILEPSY. 
The first signs of toxic effect were slight amblyopia and mental con- 
fusion. (IC's original papers I have not been able to see.) 
Sometimes the systematic aborting of epileptic attacks is capable of 
exerting a permanent influence upon the epileptic condition. This is 
shown in a case referred to by Gowers, where th*e fits wrere checked by the 
old method of tightening a ligature round the arm, with the effect finally, 
that the auras always ceased of themselves at the seat of the ligature, 
and no fits followed. 
Another successful method of aborting attacks is by the subcutaneous 
injection of apomorphine (Vallender), and-what is more important, 
because oftener practicable-the ingestion of a handful of common salt 
Nothnagel, Schulz). The effect of these agents is, no doubt, produced 
through their inhibitory action, and it is very interesting, as Gowers 
points out, to see that a condition of permanent inhibition may at timc^ 
be thus set up, the process underlying the aura learning, as it were, to 
call into existence through frequent association, the counter process, by 
which, when artificially excited, it had itself so often been checked. 
Unfortunately, it is only very exceptionally that we are in a position to use 
these remedies with the necessary promptness and regularity; the salt, 
however, more so perhaps than any other. 
One patient of my own believed himself able to check his attacks in 
this way. 
The remarks by Gowers upon treatment, in the Gulstonian lectures 
upon epilepsy above referred to, are worthy of mention, though less for 
their statistical value-his notes covering but 562 cases-than on account 
of the evident care with which the observations were made. The only 
new remedy that is brought forward is borax, and since in this distress- 
ing malady any treatment that can be used without danger is especially 
welcome, I quote the paragraph concerning this, entire: "In several 
inveterate cases in which bromide had no effect, I have tried borax. In 
some cases it did no good, but in twelve its value was most distinct. I 
may mention one or two. In one, fits which had continued on bromide 
and on zinc, ceased entirely on borax for three months, and then only 
recurred whefi the medicine was discontinued. In another case, the fits 
continued, about one weekly, during three months' treatment on bromide 
and on belladonna. Borax was then substituted; the fits at once ceased, 
and for five months the patient had not a single fit; then he had one in 
each of the two following months; the dose of borax was increased, and up 
to the present time, eight months later, no other attack has occurred. 
" In a third case, one or two attacks occurred once a fortnight, on bro- 
mide. Borax was substituted, and for five months the patient had not a 
single fit. 
" The doses given have been ten or fifteen grains twice or three times 
a day. 
" It produces in some patients gastro-intestinal disturbance, and. rare- 
ly, a form of dysenteric diarrhoea. 
" By others it is well borne, and one of my patients has taken forty-five EPILEPSY. 
625 
grains a day for twelve months without the slightest inconvenience, and 
says that no medicine has ever done him so much good. In cases in 
which bromide fails, borax certainly deserves a trial." 
Some interesting experiments by Dr. Ramskill upon the action of 
picrotoxine on four epileptic patients are quoted, by which it appears 
that the subcutaneous injection of fifteen to eighteen milligrammes 
almost invariably excited a severe fit, usually preceded by its regular at- 
tendant aura. Neither in these nor in seven other cases in which smaller 
doses (one to four milligr. daily) were employed, was any favorable 
therapeutic effect found to attend its use. 
Dr. Gowers, also, had used picrotoxine in a few instances, but only 
in one had its action been found to be beneficial. On the other hand, 
Planat, Hambursin, Couyba speak with much favor of the effects of 
the drug, though the number of cases reported is but few. 
Hambursin {Bull, de VAcad. de med. de Belgique, 1880. Abstr. in? 
the Jr. de med. et chir. pratiques, 1880, p. 177) prescribes the alcoholic 
tincture of Cocculus Indicus in the dose of ten drops, to be increased 
gradually, day by day, to one hundred, or even one hundred and fifty; 
and thinks that Planats maximum dose of sixty drops is often too small, 
since the system soon becomes habituated to the remedy and a larger 
dose is required to produce a given effect. It can be used in conjunction 
with bromide of potassium, if desired. His report covers six cases. 
Couyba {Jr. de med. et de chir. prats., 1880, 214) describes with 
some detail the case of a child five years of age, in which, as long ago 
as in 1877, he used picrotoxine with great benefit, basing the treatment 
on the physiological action of the poison as pointed out by Gubler. 
The patient had been epileptic since his second year; and for the past 
year the attacks had recurred regularly once a month. Bromide of 
potassium, in doses of three grammes a day, had failed to influence them. 
On the 6th of January, 1877, the picrotoxine treatment was begun, 
0.0005 being given in pill, at first twice daily, then three times, as the 
period of the February attack approached. The largest dose at any time 
was five pills daily, and from time to time the treatment was entirely 
suspended. During 1877 there were but three full attacks, and three 
of migraine or vertigo in place of others. During 1878 there were two 
full attacks and four of vertigo; during 1879 one attack of vertigo ; 
during the first four months of 1880 (date of writing), no attacks of any 
kind. 
The conclusions of Gowers with regard to the alkaline bromides do 
not differ essentially from those which command the acceptance of most 
observers, viz., that, either alone or in combination, they usually relieve 
more or less, and occasionally cure. The most active combination was 
found to be that with digitalis, and this, too. even when no cardiac symp- 
toms were present. 
Reasoning from the assumption that the bromides owe their efficacy 
to their increasing the molecular stability of the nerve-cells, by inducing 
some nutritive change in them, Dr. Gowers concluded that there is no 626 
TETANUS. 
reason to limit their dose to the amounts necessary to check the fits, and 
has tried giving much larger quantities every two or three days, increased 
gradually even up to an ounce at a single dose. 
This, he says, produces in some patients headache only; in others, 
slight stupor, reaching its maximum on the second day. On account of 
the varying susceptibility of different persons, however, he recommends 
not beginning this method of treatment with a larger maximum dose 
than half an ounce. Even this dose, one would think, should never be 
used except under the physician's very eye. 
It is unfortunate that there exists so much difference of opinion with 
regard to such points as the effect of combining the so-called tonics, or 
stimulants, such as quinine, iron, strychnine, with the bromides, or as 
to their action in epilepsy when given alone (see for instance a discussion 
in the American Neurological Association, apropos of a paper by Dr. L. 
C. Gray, speaking very favorably of the use of quinine with the bro- 
mides, published in the Chicago Journ. of Nervous and Mental Diseases, 
for July, 1880), or again as to the effect of a low, or non-animal diet. 
It may be that a portion of the disagreement is due to the fact that 
the various observers have dealt with different classes of cases (see 
Lepine's case, above), although on this point we cannot speak with cer- 
tainty. 
TETANUS. 
BIBLIOGRAPHY. 
Chopard, A.: Contrib. a 1'etude du tetan. Paris, 1876 (contains numerous 
'references).-Baruch, S.: Report of the Committee on Tetanus. Tr. S. Car. M. 
Ass., Charleston, 1877, 79-83.-Beard, G. M.: The Endemic Tetanus of Eastern 
Long Island. Tr. Am. Neurol. Ass., N. Y., 1877, II., 50-75.-Taylor, F.: Report 
on Cases of Tetanus. Guy's Hosp. Rep., London, 1878, XXIII., 339-385.-Wet- 
more, C. H.: On Tetanus in the Hawaiian Islands. M. and S. Reporter, Phila., 1878, 
XXXIX., 117-119.-Yandell, D. W.: A Study of Four Hundred and Fifteen Cases 
of Tetanus. Brain J. Neurol., London, 1878, I., 340-347.-Ratton, J. J. L.: 
Brain, V., 2, No. 4, 1879. On the Origin of Tetanus.-Tyson, J.: The Results of a 
Minute Examination of the Spinal Cord in Two Cases of Acute Tetanus. Practi- 
tioner, Lond., 1877, XIX., 109-114.-Laveran, A. : Contribution a, 1'anatomie 
pathologique de tetanos et de la nevrite ascendante aigue. Arch, de physiol, 
norm, et path., Par., 1877, IV., 695-705.-Ringer, S. and Murrell, W.: Further 
Observations and Experiments Regarding the True Nature of Tetanus. Jour. 
Anat, and Phys., Lond., 1877, XI., 517-528.-Aufrecht, E.: Zur pathologi- 
schen Anatomie des Riickenmarks beim Tetanus. Deutsche med. Wochenschr., 
Berl., 1878, IV., 160-192.-Coats, J.: On the Pathology of Tetanus and Hydro- 
phobia. Med. Chir. Tr., Lond., 1878, LXL, 79-94, 2 pl.-Traube, L.: Ein paar 
Bemerkungen uber Tetanus. Ges. Beitr. z. Path. u. Physiol., Berl., 1878, III., 
561-562.-Woods, G. A.: A Contribution to the Pathology of Tetanus or Lockjaw. 
Lancet, Lond., 1878, II., 326-328.-Ross, J.: The Pathology of Tetanus. Med. TETANUS. 
627 
Times and Gaz., Lond., 1878, II., 527.-Jackson, Hughlings: Remarks on the 
Comparison and Contrast betwixt Tetanus and a certain Epileptiform Seizure. 
Med. Times and Gaz., Lond., 1878, IL, 484-485.-Fox, E. L.: Contribution to the 
Pathology of Tetanus. Tr. Bristol Med. Chir. Soc., 1878, I., 60-64. - Carrington, 
R. E. and Wright, G. A.: Note of a Case of Tetanus in which Extensive 
Lesions were found in the Spinal Cord. Guy's Hosp. Rep., Lond., 1879, 3 s., XXIV., 
185-190.-Amidon, R. W.: Some New Points on the Pathological Anatomy of 
Tetanus. Arch, of Med., N. Y., 1879, I., 265-282, 1 pl.-Ross: Trans, of the Path. 
Soc. of London, 1879, p. 215.-Doran, Harris: Lond. Lancet, April 10th, 1880.- 
Wagstaffe: A Case of Traumatic Tetanus Treated by Profuse Sweating, Cured. 
Brit. M. J., Lond., 1877, II., 563.-On the State of Therapeutics in Tetanus. 
Practitioner, London, 1877, XIX., 115-121.-Thorpe, J. C.: A Case of Traumatic 
Tetanus Treated with Large Doses of Tincture of Aconite. Recovery. J. Neu. 
and Ment. Dis., Chicago, 1877, IV., 297-300. - Spratley : Two Cases of Trismus 
Successfully Treated with Gelseminum. Liverpool and Manchester M. and S. 
Rep., 1877.-Owens, J. E. : Lacerated Wound of Fore-Arm; Treatment by 
Calabar Bean; Stretching of Brachial Plexus; Death. Chicago Med. Jour, and 
Exam., 1877, XXXV., 599-604.-Nankivell: Two Cases of Traumatic Tetanus 
Treated by Stretching of the Median Nerve ; Death in both Instances. Lan- 
cet, Lond., 1878, I., 311-312.-Callender, G. W.: Nerve-Stretching in Tetanus* 
St. Barth. Hosp. Rep., Lond., 1878, XIV., 193-195.-Fenn, C. M.: Nerve-Section 
in Traumatic Tetanus. Am. M. Bi-weekly, Louisville, 1878, VIII., 217-218.- 
Klamroth: Fall von Tetanus traumaticus, erfolglos mit Nervendehnung behan- 
delt. Deutsche med. Wochenschr., Berl., 1878, IV., 546-547.-Morris, H.: A 
Case of Acute Tetanus Treated by Stretching the Great Sciatic Nerve. Brit. M. J., 
Lond., 1879, I., 933. -Morris, H.: Nerve Stretching in Tetanus. Lancet, Lond., 
1879, II., 963.-Johnstone, A. W.: Nerve Stretching in Tetanus. Lancet, Lond., 
1879, II., 892.-Klin, E. and Knie, A.: Casuistischer Beitrag zur Behandlung des 
Tetanus traumaticus mit Nervendehnung. St. Petersb. med. Wochenschr., 1879, 
IV., 307.-Thomas, L.: Tetanos consecutif a une plaie de la main; elongation du 
nerf median; cessation de la contracture et des spasmes; mort par infection 
purulente. Bull, et mem. Soc. de chir. de Par., 1879, n. s., V., 173-176.-Hutch- 
inson: Nerve-Stretching in Tetanus. Rep. by Mr. Wilson. Med. Times and Gaz., 
Lond., 1879, I., 618.-Clark, H. E.: A Case of Tetanus Treated by Nerve Stretch- 
ing. Glasgow M. J., 1879, XII., 11-17.-Ransohoff, J.: Tetanus; Nerve-Stretch- 
ing; Cure. Cincin. Lancet and Clinic., 1879, n. s., II., 41-43. [For further 
references to nerve-stretching in tetanus, see the C.bl. fur klin. Chir., 1879-80.] 
ETIOLOGY AND SYMPTOMATOLOGY. 
Dr. G. M. Beard has investigated the tetanus of Suffolk Co., Long 
Island, New York, where both the spontaneous and traumatic form are 
endemic, and concludes that it is probably due to the dampness of the 
ocean air, combined with local dampness of the soil. It has been on the 
decrease for the past ten or fifteen years. 
Dr. Yandell, from the analysis of 415 cases, comes to conclusions 
not essentially differing from those of other observers. He finds, in accord 
with Dr. Taylor, who gives an analysis of 51 cases treated at Guy's Hospi- 
tal, that the length of the period supervening between the injury and the 
outbreak of the symptoms is an important element in the prognosis, "the 
largest number of recoveries being found in cases in which the disease oc- 
curred after the lapse of nine days from the injury." 
Of Taylor's cases, those due to the slighter injuries ran on the whole 
the milder course. 628 
TETANUS. 
According to Yandeld, the disease is more fatal if it occurs during 
pregnancy. 
PATHOLOGICAL ANATOMY. 
Quite a number of cases have been reported in which positive changes 
have been found in the central nervous system of persons dying with 
tetanus. The significance of these changes is, however, a matter of 
doubt. Thus Coats reports the examination of five cases occurring in 
man, and one in the horse, where changes were present analogous to 
those described by earlier writers, viz., 1, great overfilling of vessels, oc- 
curring irregularly; 2, granular exudations around the vessels, with occa- 
sionally small hemorrhages, etc. These changes were most marked in 
the medulla, but present to a less degree in the pons, cerebral ganglia, 
and even in the convolutions. " Gaps " in the tissues are spoken of, and 
are believed to be due to the falling out of vessels with the exudation mat- 
ter surrounding them. In the accounts of other writers, similar spaces 
(vacuoles, etc.) are described and even figured. It is questionable, how- 
ever, whether such spaces, whether empty or filled with il colloid " mate- 
rial, may not be the result of shrinkage during hardening. The absence 
of distinct signs of inflammation in their vicinity makes it improbable 
that they are of myelitic origin. The convolutions were examined in 
two cases, and a yellowish material seen surrounding the blood-vessels 
there. 
The nerve coming from the injured part was examined in one case 
and found healthy 
Aufrecht found intense and wide-spread pigmentary degeneration 
("parenchymatous inflammation") of the ganglion-cells in the lumbar 
and cervical enlargement of a patient who died on the third day after the 
outbreak of symptoms. In the cervical and upper dorsal region were also 
numerous globular bodies of fatty appearance, perhaps similar to those 
spoken of by Coats and Quinquaud as occurring in the neighborhood of 
blood-vessels. Woods found great vascular engorgement, especially in the 
neighborhood of the hypoglossal and pneumogastric nuclei, also in the 
spinal cord, especially around the central canal, and the portion nearest 
the seat of injury. 
In the same neighborhood there was a diffused infiltration of the parts 
with leucocytes, and granular disintegration, especially in the posterior 
columns. 
The author regards these changes as being secondary to an increased 
reflex excitability of the spinal centres, which he thinks may arise from 
various causes. Laveran found diffused interstitial disease of the cord, 
as well as of a limited segment of the nerve coming from the injured part, 
through its whole length, without change in the ganglion-cells. The 
case was one of severe crushing of one leg, causing death on the four- 
teenth day. 
In the case described by Carrington and Wright, of a patient who 
died on the sixth day after his injury (severe burns of the leg) and eight TETANUS. 
629 
hours after the outbreak of symptoms, the right half of the cord, in the 
cervical region, was distended laterally, and after hardening, a cavity was 
found running the whole length of the cervical enlargement, in the right 
cornu, and a similar but smaller cavity in the left half of the lumbar en- 
largement. The vessels everywhere were engorged, and the tissues imme- 
diately adjacent to the cavities somewhat altered, but no other marked 
signs of disease were present, except thickening of the pia mater in the 
diseased region. 
Amidon has studied the topographical distribution of the lesions in 
one case with great care, though the changes themselves-which varied 
from vascular engorgement to localized disintegration and vacuole forma- 
tion-are not essentially different from those which have been ascribed 
by other writers to congestion and post-mortem influences. The impor- 
tant point is, that they were found mainly confined to the tracts oc«upied 
by the trigeminal, part of the facial, spinal accessory, and hypoglossal, 
none of these parts being, however, entirely destroyed. The glosso- 
pharyngeal and pneumogastric tracts were but little involved. For the 
interpretation of the clinical phenomena, in the light of these lesions, 
the reader is referred to the original paper. 
It is evident that accurate topographical researches of this kind may 
give a significant value to alterations of structure not pathognomonic in 
themselves. 
Hoss has recently described lesions which differ from those of other 
writers, in that the ganglion-cells in certain locations, throughout nearly 
the whole length of the cord, are said to have either disappeared or become 
greatly shrunken. These cells seem to have occupied rather the central 
portions of the anterior columns, being the outlying cells of the princi- 
pal groups. The vesicular column of Clark, is also said to have suffered, 
especially in the lower cervical and upper dorsal region. There was 
everywhere a considerable but diffused infiltration of leucocytes. In the 
medulla, some of the anterior and internal cells of the hypoglossal nu- 
cleus were affected, while the body of the nucleus was healthy, and the 
nuclei of the pneumogastric and spinal accessory were also involved. 
These observations, in view of the negative results of other exami- 
nations, are not be received without careful criticism. In two cases 
studied recently by Doran and Harris, no such shrinking of the cells, 
as is spoken of by Boss, was found, nor any other important changes. A 
few of the transparent spaces filled with clear material, noted by Coats 
and others, were seen. 
The same doubts are pertinent to-day that were raised by Schultze 
in 1877, whether these various changes are to be looked upon as the 
causes or as the concomitants and results of the real lesion, whatever that 
may be. Congestion is met with in other organs besides the cord, and 
exudation is a common consequence of congestion. Even vacuoles of 
considerable size have been found in perfectly healthy cords, and still 
more in those which had been the seat of vascular engorgement and exu- 
dation, as the result of changes occurring post mortem during hardening. 630 
TETANUS. 
It appears certain, at least, that in some well-authenticated cases no 
changes of note have been found either in the nerves of the affected part, 
or in the central organs. 
These criticisms would be in a measure disposed of if it could be 
shown that the lesions found in tetanus, even if slight and not pathog- 
nomonic, predominated in those central tracts which corresponded to the 
affected groups of muscles. The lesions are at any rate not so definite 
and uniform, either in character or location, as those which have been 
found in the more recent cases of hydrophobia by Gowers and several 
others, and are, therefore, more likely to be secondary to the functional 
disturbance of the nerve-centres than the cause of the latter. 
It is easy to conceive, with Woods, that the excessive vascular en- 
gorgement, when present, should influence the nutrition of the ganglion- 
cells, but less easy to explain the engorgement, either by calling in the 
aid of peripheral nerve-injuries, or by referring it to increased excitabil- 
ity of the nervous centres. 
TREATMENT. 
It has become evident that no "specific" is likely to be found for 
tetanus. This fact should be recognized, as Dr. H. C. Wood points out, 
and our efforts directed towards meeting the symptomatic indications of 
each case by a judicious combination of remedies. These indications are, 
to ward off exhaustion, by giving nourishing food at short intervals 
(eggs and milk, scraped raw meat, brandy), and to prevent the convul- 
sions from becoming a source of danger in themselves. In deciding 
upon doses of the various narcotics, it is to be remembered, Wood says, 
that nervous centres are less susceptible to them than in health. "Po- 
tassic bromide may be given up to gms. 30.0 daily without danger, and 
chloral may be risked in doses of gms. 2.50 to 3.00 if necessary." Wood 
prefers to keep opium and chloral for use at night, relying mainly on 
potassic bromide through the day, and using calabar bean and curare 
as adjuncts. 
It is to be remembered that (according to YandeWs conclusions from 
the analysis of 415 cases) "when tetanus continues fourteen days, recovery 
is the rule, and death the exception, apparently independent of the treat- 
ment." Chloroform is often of great service. The doses of calabar bean 
sometimes given are enormous, up to gms. 5.50 of the alcoholic extract 
in one day, in a case reported by Read. Nerve-stretching as a cure has 
not fulfilled what was hoped of it, and in some cases the operation has 
even been followed by increased violence of the spasms (yide Bibliograph. 
Index.) This treatment, however, still finds warm adherents among 
distinguished surgeons, and as it has often seemed to be of service, it is 
well worth trying, especially where surgical interference is called for, 
either in connection with nerve section, or in place of it, as being the 
milder operation. 
It has been recommended to stretch the nerve as near as possible to 
the spinal cord, and by a series of quick, forcible pulls. There seems PARALYSIS AGITANS. 
631 
no doubt that in this way the reflex excitability of the cord can oe low- 
ered (v. Bost. Med. and Surg. Jour., August 24th, 1880). 
PARALYSIS AGITANS. 
BIBLIOGRAPHY. 
Rabot: Lyon Med., 1874, Bd. 22.-Huchard: Union med., 1875, 7.-Schultze, 
F.: Ueber das Verhaltniss der Paralysis agitans zur multiplen Sklerose des Riicken- 
marks. Virchow's Arch., Bd. 68, Heft 1, S. 120.-Westphal: Paralysis agitans. 
Vorwiegende Betheiligung der linken Extremitaten, des Kopfes, Unterkiefers und 
der Mundmusculatur; Autopsie. Negativer Befund. Charite Ann., Berl., 1876, 
III., 361-371.-Boucher, A.: De la Maladie de Parkinson (Paralysie agitante) et 
en particulier de la forme fruste. 4to, Paris, 1877 [These No. 76]. - Hardy: 
Paralysie agitante a forme fruste. Gaz. d. Hop., Par., 1877, L. 913-914.-Cheron, 
J.: De la Modification importante que subit la constitution chimique de 1'Urine 
dans la Paralysie agitante (Phosphaturie). Progres med., Par., 1877, V., 903-905. 
-Maragliano, E.: Sulla paralise agitante. [Ext. Gior. ven. de Sc. med., 1877, 
XXVII., 1878, XXVIII.] In his : Lezioni di clin. med. 8vo, Venezia, 1878, 
60-105. -Debove : Note sur un cas de lateropulsion oculaire dans la paralysie agi- 
tante. Progres med., Par., 1878, VI., 116-117.-Charcot: Par. agit. a forme 
fruste. Gaz. des Hop., No. 2, 1878.-Grasset, J., et Apolinario, B.: Note sui- 
1'etat de la temperature peripherique dans un cas de paralysie agitante et sur 
I'lnfluence des Contractions musculaires sur la temperature peripherique nor- 
male. Progres med , Par., 1878, VI., 216-217.-Herterich, M.: Zur Lehre der 
Paral. agitans. Wurzburg, 1878.-Bauer, J.: Zwei Faile von Paralysis agitans 
mit todtlichem Ausgange. Ann. d. stadt. allg. Krankh. zu Munchen, 1878, I., 
134-140.-Demange: Rev. Med. de 1'Est., Oct. 15th, 1879 (abstract in the Revue 
des Sc. Med.). 
Several of the French observers (Charcot, Boucher, Hardy, Brochin* 
Bourneville) have done good service in calling attention to the partial,, 
abortive forms (formes frustes) in which this affection sometimes appears. 
Charcot has already shown (in his Mal. du syst. nerv.) that of the- 
four or five characteristic symptoms-trembling, rigidity, paresis, altered 
expression of face and carriage of body-the rigidity, though usually of 
late occurrence, may come on at the very outset, and it now appears that 
the trembling, which usually ushers in the case, may be long delayed, or 
only present from time to time, even though the other symptoms are- 
recognizable beyond question. 
Boucher is inclined, on the whole, to regard the general look and 
carriage of the patient as the most significant sign. Hardy confirms the 
statement of Charcot that the oscillation of the head is, in all but rare 
cases, only apparent, being in reality compensatory to, or communicated 
by the movements of other parts of the body. Westphal, on the other 
SYMPTOMATOLOGY. 632 
PARALYSIS AGITANS. 
hand, thinks this is not such a very rare symptom, and reports several 
cases where it was present beyond dispute. 
In one of Westphal's cases, the head was habitually carried thrown 
somewhat backwards, instead of forwards, as is the rule. 
Another curious symptom is that observed by Debove, consisting in 
an impairment of the lateral motion of the eyeballs. This caused 
especial annoyance in reading, the patient finding great difficulty in 
bringing his eyes from the end of one line to the beginning of the line 
below. In another of Westphal's cases the trembling came on four years 
after the occurrence of cerebral hemiplegia, and affected, first, the paretic 
hand, then the other. The involuntary movements were, however, 
persistently slower on the paretic side, where there was also some rigidity, 
but no notable atrophy. The sensibility was slightly diminished, and 
was reported to have been more so previously. 
The cause of the subjective sense of warmth so often complained of 
by these patients has been studied by Grasset and Apolinario, and is 
ascribed to an actual increase of the superficial heat of the body, which, 
in one case, was found to be 36.8 (C.), against 33.6 (C.), which they 
found to be about the average surface temperature in health, taken by 
the same method. 
Cheron has studied the character of the urine in eight cases, though 
in two only for any considerable length of time. He found the total 
quantity greatly increased, and the excretion of phosphates augmented 
even up to three times the normal, and thinks that these changes, together 
with muscular feebleness, may often be recognized considerably earlier 
than the trembling. 
PATHOLOGICAL ANATOMY. 
The recent post-mortem examinations show the same discrepancies 
with those of earlier date. 
In one case observed by Herterich (known to me only through an 
analysis by Eisenlohr, in the C. bl. fur Nervenheilkunde, etc.) in which 
the symptoms followed typhoid fever-though only after an interval of 
some years, during which the patient had suffered from weakness and 
impaired motion of all the extremities-a disseminated sclerosis of the 
spinal cord was found, recalling the observations of Cayley, Bourillon, 
Schultze, and others. There was also an extensive patch of degeneration 
in the floor of the fourth ventricle, reaching forward even as far as the 
left crus cerebri. There was, unfortunately, no microscopic examination 
made. The trembling had begun in the lower extremities, but otherwise 
the symptoms seem to have been characteristic. 
In Schultze's case, which was carefully observed and critically dis- 
cussed, the symptoms were still more typical, and the post-mortem 
changes analogous, in so far as that there were multiple patches of scle- 
rosis present in both. 
It is impossible to say in what relation these lesions stood to the con- 
tinuous muscular tremor in the cases referred to, any more than we can PARALYSIS AGITANS. 
633 
tell in what relation they stand to the characteristic movements of the 
cases known clinically as mutiple sclerosis, with which they are habitually 
associated. All that we can say is, as Schultze points out, that the absence 
of the symptoms usually seen in the latter affection, and the presence of 
those met with in typical cases of paralysis agitans, does not justify us 
in excluding the pathological diagnosis of "multiple sclerosis." It is 
improbable that, from the clinical stand-point, these two affections are 
really akin to each other, yet, in these cases the symptoms of the multiple 
sclerosis seem to have been either replaced or masked by those of the 
paralysis agitans, and, inasmuch as both disorders are capable of appear- 
ing in such incomplete (abortive) and anomalous forms, it is easy to 
imagine that the difficulties in the way of a differential diagnosis might 
occasionally be considerable. 
In two cases observed by Bauer (also known to me only through a 
brief reference in the C. bl. fUr med. Wissensch.), the mass of the brain as a 
whole was found diminished, and in one the medulla oblongata and upper 
part of the spinal cord notably shrunken. 
In a case of Westphal's the post-mortem investigation, macroscopic 
and microscopic, gave entirely negative results, and this, as a matter of 
fact, Westphal, in common with most observers, believes will prove to be 
the rule in typical, uncomplicated cases of the disease. 
Certainly such positive results as have been reported have brought us 
no nearer to a physiological comprehension of the disease. 
In view of the negative post-mortem results in cases examined by such 
careful observers as Westphal, the theory of the disease advanced by 
Demange loses in weight. This author found, on microscopic examination 
of the cord in a typical case of paralysis agitans, which had been under 
observation for several years, very slightly-marked sclerotic changes here 
and there in the antero-lateral columns, together with peri-ependymitis, 
and-what he regards as of more importance-slight changes in the sen- 
sitive tracts, viz., posterior nerve-roots, columns of Goll, vesicular columns 
of Clarke. Demange believes that the characteristic movements are the 
reflex result of irritative processes going on in the sphere of the posterior 
nerve-roots, at first perhaps functional in character, but eventually inflam- 
matory, though rarely becoming sufficiently developed to cause anaesthesia. 
Westphal's case was, however, of six years' duration, yet no changes 
were found. 
To show that cerebral activity, while it may control, does not cause 
these movements, Demange reports also an interesting case where hemi- 
plegia came on during the course of paralysis agitans. For several days 
the patient was unable to use the muscles of the affected side, but the 
trembling continued undiminished. 
TREATMENT. 
Of new measures the most important is nerve-stretching, which has 
been done once in a case of Westphal's, with, however, only temporary 
benefit. 634 
ATHETOSIS. 
The patient was a man of fifty-eight, and the trembling had come on 
apparently in consequence of a severe burn. All the large nerve-trunks 
of the left arm, the part mainly affected, were laid bare just below the 
axilla and stretched both peripherally and centrally by Bardeleben. 
The trembling recurred slightly from time to time during the first ten 
days after the operation, but grew, on the whole, less and less. On the 
eleventh day, however, the irritation due to a subcutaneous injection of 
morphia brought back the former condition of affairs. Westphal remarks 
that in view of even this temporary result, and of the intractable nature of 
the affection, further attempts of the kind are justifiable, but justly calls 
attention to the fact that we have not yet sounded all the dangers of 
forcible nerve-stretching, and that he has observed a case where such treat- 
ment, applied to the crural nerve, was apparently the cause of a circum- 
scribed myelitis, due to the dragging upon some of the nerve-roots. 
Seguin has been able to cause temporary, but only temporary, cessa- 
tion of the trembling, by the use of hyoscyamia, especially if given sub- 
cutaneously. The dose of the crystallized alkaloid is 0.0001 to 0.0002. 
I have seen striking effects of a similar kind from the use of the fluid 
extract in one case. 
ATHETOSIS. 
BIBLIOGRAPHY. 
Berger, O.: Berl. kl. Wochenschr., 1877, XIV., 31-45.-Lauenstein: Deutsch. 
Arch. f. klin. Med., 1877, XX., 158.-Ewald: Dementiaparal. Athetosis; Corticaler 
Erweichungsherd. Deutsch. Arch., 1877, XX., 591.-Ringer: Case of Athetosis 
Accomp. by Unilateral Sweating. Practit., Lond., 1877, XIX., 9; and 1879, 161. 
-Jewell: Tr. Am. Neur. Ass., N. Y., 1877, II., 213.-Goldstein: 8vo, Berlin, 
1877.-Seguin, E. C.: Tr. Am. Neur. Ass., N. Y., 1877, II., 92.-Lange: Hosp. 
Tid., R. 2, Bd. 4, 1878.-Oulmont: (These No. 8) Paris, 1878, 4to; also Rev. mens, 
de med. et de chir., Par., 1878, II., 81-94.-Dreschfeld: Ibid., 766.-Landouzy: 
Bull. soc. anat. de Par., 1878, LIIL, 15, 549; also Progr. med., 1878, VI., 79-96 
(autopsy).-Kuessner: Athet. Beweg. bei einem Paralytiker ohne Herderkran- 
kung im Gehirn. Arch. f. Psych., 1878. VIII., 443.-Janeway: Post-Paral. 
Chorea. Hosp. Gaz., N. Y., 1878, 366.-Gnauck: Ueb. primitive Athetose. Arch, 
f. Psych., 1879, IX., 300.-Erb: Ibid., 277.-Beach, F.: Athet. of Both Sides of 
the Body, not Assoc, with Epilepsy. Br. Med. Jr., 1879, II., 815. 
SYMPTOMATOLOGY. 
It appears to be now universally conceded that whatever be the cause 
of the characteristic symptoms of athetosis, the affection is closely akin 
to several other forms of mobile spasm, and possibly also of continuous 
spasm, which follow hemiplegia of cerebral origin. 
The analysis of these different forms of cerebral hemi-spasm which is 
given by Gowers., and of which the results are summed up in the ATHETOSIS. 
635 
following table, is well calculated to bring out the relationship between 
them : 
POST-HEMIPLEGIC DISORDERS OF MOVEMENT. 
Fine. 
Coarse. 
Regular (continuous 
or on movement). 
Tremor 
Certain regular movements 
due to interossei, prona- 
tors, etc. 
Quick clonic 
9 
spasms, of 
intermitting 
. 6 
' 
Irregular (continuous 
or on movement). 
Choreoid. 
Continuous 
spasms, or inco- 
ordination of 
movement. 
Jerking. 
Slow, mobile spasms, 
of remitting type. 
Continuous.-"Athetosis. " 
On movement.-Slow, cramp- 
like inco-ordination. 
"Spastic contract- 
ure" of hemiple- 
gic children. 
Tonic spasms, varying 
Fixed rigidity, unvary- 
ing. 
Of interossei, conspicuous. 
Of flexor longus digitorum, 
Conspicuous-late rigidity. 
The following are the clinical facts which seem to call for special 
attention: 
(1.) All these forms of spasm occur almost invariably in cases where 
voluntary power over the affected muscles is present to a greater or less 
degree, for example, generally during the recovery from hemiplegia. 
(2.) In the vast majority of cases, the movements are unilateral, but 
occasionally, as in chorea, they are bilateral. 
(3.) As a rule, the movements succeed hemiplegic attacks, or other 
signs of localized cerebral disease, but in some cases they come on gradu- 
ally, without preceding paralysis. 
(4.) The subjects of the disordered movements are sometimes epilep- 
tic, and at the time of the seizure the muscles which are the seat of the 
mobile spasm are first and pre-eminently attacked; furthermore, the 
position given to the limb at the outset of the seizure is sometimes that 
which it is apt to assume under the influence of the semitonic spasms; 
again, this same position is sometimes assumed as an "associated move- 
ment," whenever the opposite healthy limb is moved. 
(5.) Voluntary innervation, even if finally relatively successful in its 
aim, has usually at first the effect of increasing any existing spasmodic 
action of the muscles. 
(6.) The spasms which are especially the subject of this paper, 
whether mobile or spastic, affect by preference the smaller, more rapidly 
acting muscles of the limb (in the upper extremity, the interossei), while 
the fixed spasms, constituting the so-called " late rigidity " of hemiplegia, 
affect especially the larger, more slowly acting muscles (long flexors). 
The slow, mobile spasm (athetosis) is usually confined to the extremities, 
but occasionally the muscles of the neck and face are affected as well. 636 
ATHETOSIS. 
The relationship between these different forms is shown by the fact 
that not only do they originate under similar circumstances (after hemi- 
plegia, etc.), but they are interchangeable in the same person, or the 
arm may be affected in one way, and the leg, at the same time, in 
another-thus, in one case, the leg by a mobile spasm and the arm by a 
fixed spasm. This same interchangeability of the different forms of spasm 
is shown strikingly in an interesting case, reported by Kahler and Pick, to 
which reference will again be made further on. Here, both fingers and 
toes were in the first place in rapid, ceaseless motion, of the "piano-forte 
player " type (Remak). Later, the movements were more extended and 
jerky, like those which have been considered as typical of hemichorea; 
while finally they had the slow character distinctive of athetosis {Gold- 
stein). 
As will be seen, Gowers ranks even the "late rigidity " of hemiplegia 
among these spasms. At any rate, as he says, it does not deserve to be 
classed as a permanent contracture, since it varies so much under differ- 
ent circumstances. Contrary to the mobile spasms, it affects the long 
digital flexors, and respects the interossei. 
Hughlings Jackson's theory as to the "late rigidity," that it is of cere- 
bellar origin, is well known, and deserves consideration here. 
Oulmont gives an analysis of all the cases hitherto published which 
seem to him to deserve the name of athetosis, and confirms Charcot's 
opinion that hemiansesthesia is usually present at one time or another in 
the course of the affection. 
Out of twenty-six cases it was noted eleven times, and in a number 
of others no search had been made for it. In some of these cases, its 
absence was distinctly recorded, however, as Gowers also points out. In 
all but four of the twenty-seven cases, there had been hemiplegia, and 
even in two of these four a cerebral lesion of some kind. 
Oulmont describes also, under the name of double (bilateral) athetosis, 
a kindred malady which a few observers have spoken of, but which, on 
the whole, has been slighted, or perhaps classed as chronic chorea. 
Dreschfeld reports two typical cases, observed at the Idiot Asylum in 
Lancaster. Claye Shaw has described others, and in fact they are per- 
haps not very rare. I have myself followed two such cases carefully for 
many years, and have seen, but not studied, a third. 
The symptoms, as Oulmont shows, date from early childhood, or may 
even be congenital. They are not preceded by paralysis, but are apt to 
be associated with idiocy or imbecility. 
This was not true, however, of a case seen by Gowers, nor of either of 
the three instances which have come to my own knowledge. The move- 
ments are less violent than in those of the typical athetosis, especially so 
long as the patients are at rest; other muscles of the face are usually in- 
volved, as well as those of the limbs. The sensibility is unaffected. 
These cases show no tendency to spontaneous recovery, though the 
patients are capable of increasing their voluntary control very materially 
by persistent and systematic exercise. ATHETOSIS. 
637 
The prognosis for the unilateral athetosis is likewise, as is well known, 
of the poorest; nevertheless, occasionally a case does unexpectedly well. 
Thus Gowers reports one case which recovered entirely under the influ- 
ence of the galvanic current applied daily, from the back of the neck to 
the affected muscles; and Gnauck another which likewise recovered under 
the same treatment, with the addition of potassium bromide. 
One of these cases was of the post-paralytic variety ; the other was 
idiopathic (or primary), and the symptoms had already been present 
once, and had disappeared under the use of the bromide of potassium. 
PATHOLOGY. 
The cases are now sufficiently numerous in which definite anatomical 
lesions have been found, in one or another of these forms of cerebral spasm, 
but a pathogenetic theory is still to be expressed only in the vaguest 
terms, nor is it yet certain how far the different varieties alluded to can 
profitably be classed together. 
Gnauck points out, in a carefully written paper, that the cases of 
primary athetosis, those namely which are not associated with other 
symptoms of organic cerebral disease, and which may be either unilateral 
or bilateral, should be taken as the types of the affection, the remainder 
constituting the vast majority being classed as "symptomatic." 
Gnauck quotes an autopsy recorded by Oulmont, the only one which 
has been made in a primary case of this kind, in which a focus of soften- 
ing was found in the left corpus striatum and nucleus lenticularis, the 
symptoms having been confined to the right side. 
Until we understand better the physiological pathology of the affec- 
tion, it seems to me that this distinction of primary and symptomatic 
must be received with caution. 
Raider and Pick, who review the pathological anatomy of the re- 
ported cases with great care, consider that the other symptoms of organic 
disease-the hemiplegia and the hemianaesthesia-are, so to speak, acces- 
sory symptoms, the essential pathological condition consisting in a state 
of irritation of the pyramid-tract (Flecksig') in the internal capsule, due 
to lesions which may or may not be sufficiently severe to cause paralysis 
and secondary degeneration of the cord. 
Twelve autopsies are cited (by Lepine, Raymond, Gowers, Laiienstein, 
Landouzy), in nine of which the thalamus opticus was found to be the 
part mainly involved, in two the nucleus lenticularis, and in three the 
internal ca^ule, all these regions bordering immediately on that portion 
of the internal capsule which is traversed by the continuation of the 
pyramid-tracts. To these is to be added the instructive case reported 
by themselves, where the outer half of the thalamus opticus was diseased, 
and at one point, opposite the posterior end of the nucleus lenticularis, 
the internal capsule in its whole thickness. 
As additional evidence that an irritative process in the great motor 
tracts is the cause of these symptoms, a case is quoted from Ewald, 
where analogous movements were found to have been probably due to the 638 
ATHETOSIS. 
presence of a small tumor in the right anterior half of the pons, in close 
contact with the pyramid-tract; also, from the Lancet of 1871 (p. 852), 
another case, of crossed paralysis of the face and limbs, with mobile spasm 
of one arm and choreic movements of both legs, due presumably to glioma 
in the fourth ventricle. 
Another instance of a like kind, though without autopsy, is given by 
Goivers, and one is also quoted by him from Bastian, where the symp- 
toms indicated lesion of the crus cerebri. The bilateral occurrence of 
the symptoms in some cases may perhaps, likewise, point to the pons as 
the seat of the lesion. 
The observation of Rosenbach, now confirmed by every one, that 
patients with locomotor ataxia often have slight, involuntary, slow move- 
ments of the hands and feet, is also brought up to show that these symp- 
toms of mobile spasm may be associated with lesions low down in the 
cord. Much physiological work remains to be done, however, before we 
can claim to have an accurate conception of the pathogenesis of this class 
of symptoms. 
It is not to be forgotten that Ewald and Kuessner report cases of 
athetoid movements of typical character, associated, in the one case with 
localized cortical lesions (temporal lobe), in the other with no macro- 
scopic lesion whatever. The patients were, however, in both cases gene- 
ral paralytics. The hemianaesthesia in these cases of athetosis is, of 
course, readily explained by the nearness of the lesion to the posterior 
region of the internal capsule, and I cannot but think, with Charcot, 
that the essential lesion for many cases will turn out to be in the cen- 
tripetal rather than in the centrifugal tracts. 
A very interesting case was recorded by Ringer in 1877, of athetosis 
with temporary hemiplegia and hemianaesthesia, and accompanied by uni- 
lateral sweating, all on the right side. Within a year an account of the 
autopsy has been published, which shows that there was very extensive 
disease of the left corpus striatum, nucleus lenticularis, and thalamus 
opticus. 
Ringer holds the view which, if it be expressed sufficiently vaguely, 
is essentially like that held by Gowers, Jewell, Kahler and Pick, and no 
doubt others, that the symptoms are due to the spreading (irradiation) 
of the motor impulses passing from the cortex cerebri to the muscles (or 
coming as centripetal excitations from other parts of the nervous system) 
within these damaged tracts, so that they set up what, in a physiological 
sense, might be called associated movements. Furthermo^, it is sup- 
posed that, in virtue of the disordered nutrition within the masses 
of affected gray matter spontaneous motor impulses may originate in 
them. 
It is certainly unscientific to speak of these lesions, as so many do, as 
causing the characteristic movements by direct irritation of motor 
tracts. 
When one reflects on the character and regularity of the movements 
and their persistency, it is far more philosophical to regard them as the CHOREA. 
639 
effects of the activity of one or many organized nervous centres, and to 
speak of them rather as "permitted " by the removal of inhibitory con- 
trol than as due to irritation. 
Any comprehensive theory would have to take into account the fact 
that these mobile spasms are sometimes associated with returning con- 
trol after hemiplegia, sometimes are entirely independent of hemiplegia, 
and occasionally {Bernhardt) occur in company with complete par- 
alysis. 
With regard to treatment, the favorable action of galvanism and 
potassium bromide in a few cases has been referred to above. 
CHOREA. 
BIBLIOGRAPHY. 
de Boyer, H. C.: Choree cardiaque. Progres med., 1875, No. 52.-Dickinson, 
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logic und Therapie der Chorea. Archiv fur Psychiatric und Nervenkrankheiten, 
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Sarthe, 1877, Le Mans, 1878, 32-38.-Luton, A.: Existe-t-ilunenevrosequimerite 
specialement le nom de choree rheumatismale ? Mouvement med., Par., 1877, XV., 
364-366.-Charcot: A Lecture on rhythmical Hysteric Chorea. Brit. M. J., Lond., 
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Wien. med. Bl., 1879, II., 350.-Gowers, W. R., and Sankey, H. R. O.: The 
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case of Chorea with Typhoid Fever supervening. Med. Examiner, Lond., 1877, 
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I., 857.-Purckhauer, H.: Propylamin gegen Chorea minor. Aerztl. Intell. Bl., 
Munchen, 1878, XXV., 1-4.-Richter, F.: Zur Therapie der Chorea minor. Deut- 
sches Arch. f. klin. Med., Leipz., 1878, XXI., 373-387.-Stone, W. H.: Thymol in 
Chorea. Med. Times and Gaz., Lond., 1878,1., 261-262.-Gray, L. C.: The Arsen- 
ical Treatment of Chorea. Proc. M. Soc. County Kings, Brooklyn, 1878, III., 273 
-298.-Sturges, O.: On the Management of Chorea. Med. Tinies and Gaz., Lond., 
1878, I., 302, 559; II., 69-70.-Van Bibber, J.: The new Treatment of Chorea, 8vo, 
Baltimore, 1878 [Reprint from Trans. M. and S. Faculty of Maryland, 1878].- 
Wright, R. T.: Subcutaneous Injection of Curara for Chorea. Lancet, Lond., 
1878, IL, 253.-Hammond, W. A.: On the Treatment of Chorea with hypodermic 
Injections of Arsenic. St. Louis Clin. Rec., 1879-80, VI., 193-196.-Garin, Henri: 
Du traitement de la choree specialement par 1'arsenic et les injections hypoder- 
miques de liquor de Fowler, Lyon, 1879, 90 pp. 4to, S. No. 14.-Dresch: Choree 
guerie en huit jours a la suite de 1'emploi du salicylate de soude. Bull. gen. de 
therap., etc., Par., 1879, XCVL, 506.-Mitchell, S. W.: Chorea and its Treatment 
by Salicylate of Soda. Boston M. andS. J., 1879, C., 447.-Sturges, O.: The Path- 
ologies of Chorea in their Application. Med. T. and Gaz., Lond., 1880, I., 257,286. 
ETIOLOGY AND SYMPTOMATOLOGY. 
An interesting illustration of the suddenness with which fright may 
bring on chorea is given by Henry Day, who was present at the very 
moment of the attack. A passer-by, on a country road, saw a boy (nine 
years old) climbing an apple-tree, and, thinking him to be in a dangerous 
position, indiscreetly called to him to come down. The boy, alarmed, 
lost his hold and fell to the ground, striking on the front of the body. 
He had received no injury, but, as soon as he had recovered his breath, 
shouted and screamed with seeming fright, and "then and there" the 
symptoms of bilateral chorea showed themselves, first in the arms and 
shortly afterwards in the legs. He recovered in less than a month. 
The opinion advanced in the early edition of this Cyclopaedia, that an 
intimate relation may exist between chorea and rheumatism, is still upheld 
by most writers, though as to the nature of this connection we are fully 
in the dark. v. Ziemssen (Cyclop., 2d Ed.) reports at length an interest- 
ing case where chorea, in a violent form, developed during the course of CHOREA. 
641 
an acute articular rheumatism, with endocarditis and pleuritis, and dis- 
appeared again in the course of three weeks, even before the articular 
symptoms had entirely gone. Gee gives a similar case, where, however, 
the movements were slight in amount, and the pains in the joints slight. 
There was peri- and endocarditis, with a fatal issue. Nothing whatever 
could be found in the brain to account for the choreic symptoms. 
Endocarditis may occur in association with chorea without, so far as 
is known, having been due to rheumatism. This is illustrated by two 
cases reported by Boyer (v. 2d Ed. v. Ziemssen, p. 465) in addition to those 
recorded in the first edition of the Cyclopaedia. 
Finally, Mitchell and others have noted cases in which rheumatism 
has immediately followed chorea, instead of preceding it. 
With regard to the season of the year in which chorea is the most 
prevalent, Gerhard gives an analysis of eighty cases coming under his 
observation in Philadelphia which seems fully to confirm the view of Dr. 
Mitchell and himself, that by far the greater number of cases, and espe- 
cially relapses, begin in the spring. In recent publications Mitchell still 
adheres to this opinion. 
In the experience of others, this fact has not been fully confirmed. 
An analysis of the cases which have come under my own observation, in 
the Out-Patient Dep. of the Mass. Gen. Hosp, during the past nine 
years, would show that the winter and spring are in Boston about 
equally prolific, the six months from December to June bringing in a 
much larger number of cases than the other half-year. In other climates 
perhaps another rule would prevail. 
To the cases mentioned by v. Ziemssen of chorea occurring in aged 
people may be added a few isolated instances {Russell, Berdmet). 
Charcot contributes a clinical lecture on this subject, in which he 
says, and Berdinet essentially agrees with him, that this chorea is often 
associated with dementia, and not especially connected with acute articu- 
lar rheumatism, or even with rheumatic gout, and that it is incurable. 
Gowers calls attention to an important point which has never been 
dwelt upon in the descriptions of the choreic motor symptoms, namely, 
that cases differ greatly in respect to the proportion which the involun- 
tary movements bear to the loss of voluntary co-ordinating power. 
Gowers believes he has noticed that " when such a disproportion exists, 
the inco-ordination is in excess of the spontaneous spasm early in an 
attack, and the spontaneous spasm is in excess of the inco-ordination late 
in an attack and during relapses." 
Sturges also calls attention to an (apparent) lack of co-ordinating 
power, in an interesting series of papers, to be referred to later, but 
thinks it is not a true ataxia, in the sense of ataxia from organic disease, 
inasmuch as it may be now present, now absent, or, at any rate, vary 
greatly in amount at different times. 
Gowers further observes that: 
1. The choreic movements may be confined to one arm, both legs 
being free from movement, although that in the arm is violent. 642 
CHOREA. 
2. When the chorea affects considerably one arm and leg, although 
the other arm is quite free from movement, it will generally be found, 
on close examination, that there is some degree of affection of the other 
leg. 
3. Occasionally the affection of the other leg is as great as that of the 
leg of the side on which the arm is affected. 
''The affection may thus be unilateral in the arms, bilateral in the 
legs." If the observation is confirmed, it will be one, as is held by 
Goiuers, to place parallel with the physiological fact that the use of the 
legs is predominantly bilateral, that of the arms unilateral. Gowers has 
observed in several cases, in confirmation of the statements by Rosenthal 
and Benedikt, that the irritability of the nerves of the affected limbs, in 
hemichorea, is greater than that of the nerves of the opposite limbs. 
He could not satisfy himself, however, that the opening kathode-reac- 
tion was greater than normal in the same cases. 
PATHOLOGICAL ANATOMY. 
There is but little that is important to record on this point, v. 
Ziemssen's opinion still inclines toward the embolic theory, first advanced 
by Jackson, on interesting theoretical grounds. Besides two cases re- 
ported by Jackson where emboli were found, the latter quotes Bastian 
as having discovered them in three others. Dickinson examined seven 
cases without succeeding in finding them, but observed, instead, intense 
congestion of the cord, with occasionally small haemorrhages, and marked 
congestion also in various parts of the brain, especially the corpora striata. 
Congestion also was the marked feature in the cases of Hutchinson 
and Kretschy: in the former's case there was also thickening of the cere- 
bral arachnoid here and there, and localized softening in the cord. In 
Gee's case, though peri- and endocarditis were present, nothing of great 
importance could be found in the brain. 
Gowers and Sankey have reported two examples of chorea in the dog, 
with careful examination of the nervous centres. In one case the move- 
ments were universal and so severe that, through them and some paresis 
of the hind legs the animal was unable to walk, though he could move 
his limbs and tail with a good deal of force while lying on the ground. 
After the cervical cord was divided, the movements ceased in the parts 
supplied by the spinal cord, but continued in those supplied by the 
medulla oblongata. On examination, there was found scattered irregu- 
larly through the cord, medulla, and cerebellum, but not in the hemi- 
spheres or corpora striata, a marked leucocytal infiltration of the tissues 
adjacent to the blood-vessels, in both the white and the gray substance, 
and likewise a granular, slightly disintegrated condition of the nerve- 
cells. In the second case, in which the movements had been slighter 
and confined to one fore-leg, none of this vascular change, except " turges- 
cence" here and there, was found, but the nerve-cells in the right half of 
the cervical enlargement in its lower half (whether on the same side with 
the affected limb was not known) were found swollen and granular. A CHOREA. 
643 
similar change was present in the right posterior vesicular column in the 
lumbar region. The authors regard the change in the nerve-cells as 
secondary to a functional "over-action," and the vascular condition as a 
further result. I have recently had the opportunity of examining the 
brain and cord of a kitten affected with the disease in an absolutely typi- 
cal form-one of four out of a large and healthy litter that had pre- 
sented the same symptoms-and could discover absolutely no deviation 
from the normal state. In the second case of Gowers and Sankey, the 
movements persisted after section of the spinal cord in the cervical 
region. 
On the whole, it must be confessed that anatomical study lends but 
little support to the theory which supposes chorea to be of embolic 
origin, or of definite organic origin at all. The objections to these theo- 
ries are well summed up by Sturges, who looks upon the affection as of 
functional origin and analogous to hysteria. His arguments are forci- 
ble, and deserve careful consideration, especially as they bear directly 
upon the question of treatment. 
TREATMENT. 
The arsenical treatment of chorea still counts the warmest adherents, 
in spite of newer remedies, and further evidence is furnished that, if 
given by subcutaneous injection, the effects are better than when it is 
used by the stomach, and the chance of gastritis diminished. Gann has 
had excellent results in thirty-three cases, giving in this way foui' to five 
drops of Fowler's solution, properly diluted, every few days. Hammoncl 
goes up to much higher doses than these, even ten drops to a child of 
eight years, and thirty-five drops to an adult. He recommends the neigh- 
borhood of the deltoid as the best place to inject. 
Sometimes, as v, Ziemssen points out, the injections cause pain and 
inflammation, and it is to be remembered that the fatty degeneration of 
the glands of the stomach is in part an effect of the constitutional as well 
as the local action of the poison, and is, therefore, liable to occur even 
when it is given hypodermically. 
Weir Mitchell has treated a number of cases, with excellent results, 
by sodium salicylate, tried first in cases complicated with rheumatism, 
but found efficacious as well in others. Dresch has had equal success 
with this treatment in one case. 
Propylamine, in dose of 1.0 to 1.50 pro die, divided into hourly 
doses, has been successfully employed (Purckhauer, Nathan Weiss, 
quoted in Virchoiv and Hirsch's J.bericht), and Drummond and 
Wright speak favorably of subcutaneous injections of curare. I have 
had but little experience with either of these remedies, and no general 
judgment has been passed on them. * 
The books often speak of the favorable action of gymnastics in chorea, 
but it is perhaps rarely appreciated that, to, get these results, a degree of 
persistence and system is usually required which implies trained super- 
vision and the expenditure of much time. This is illustrated by the 644 
HYSTERIA. 
description of a method successfully used by Tidemand, in a case of a 
year's standing (Virchow and Hirsch's J.bericht), where the patient was 
kept on his back most of the time for two or three months, and was 
exercised daily by a skided teacher once every twenty or thirty minutes 
through four hours in the forenoon and three in the afternoon. 
In judicious hands, some sort of moral management, as is urged by 
Sturges as a substitute for all medicinal treatment, might be eminently 
useful. It is founded on his belief that the symptoms of the disease 
are closely associated with the operation of the higher cerebral functions 
in their relation to the muscular system, and aims at "diverting the 
child's attention from its perverted movements, while at the same time 
tacitly discountenancing them." 
HYSTERIA. 
BIBLIO GRAPH Y. 
Lotz : Die psychische Lahmung d. Stimmbander. Correspondenzbl. f. schweizer 
Aerzte, 1873, Nr. 16.-Schnitzler: Ueb. Sensibilitatsneurosen d. Kehlkopfs. 
Wien. med. Presse, 1873, Nr. 46.-Svynos: Des amblyopies et des amauroses 
hysteriques. These de Paris, 1873.-Cartiaux: Hysterie confirmee chez une 
femme privee de vagin et d'uterus. Gaz. des hop., 1873.-Fernet: De 1'oligurie 
et de 1'anurie hysteriques et des vomissements qui les accompagnent. Union med., 
1873.-Bourneville: Etudes cliniques et thermometriques sur lesmalad. dusyst. 
nerveux. 2. fascic., 1873.-Penzoldt: Ueb. d. Paralyse der Glottiserweiterer. 
Deutsches Archiv f. klin. Med., Bd. XIII., 1874.-Emminghaus: Wirkung der 
Galvanisation am Kopfe bei Aphonie. Archiv fur Psych, und Nervenkrankheiten, 
Bd. IV., 1874.-Ferran: Du vomissement de sang dans I'hysterie. Paris, 1874.- 
Lorey: Des vomissements de sang supplementaires des regies. These de Paris, 
1875.-Fabre: De I'hysterie chez 1'homme. Aimal. med. psych., 1875.-Bonne- 
maison: Sur en cas d'hysterie chez 1'homme. Arch, gener. de med., 1875.- 
Bonnefoy: Des troubles de la vision dans I'hysterie. These de Paris, 1874.- 
Bach: De la coxalgie hysterique. These de Paris, 1874.-Lafou: De la toux 
hysterique. These de Paris, 1874.-Hudson: Epidemic of Hysterical Epilepsy 
and Tetanus. Lancet, 1875.-Holst: Ueb. Neurasthenie und ihr Verhaltniss 
zur Hysterie und Anamie. Dorpater med. Zeitschr., Bd. VI., Hft. 1, 1875.- 
Da Costa: Hysteria with Lung Symptoms Simulating those of Phthisis. Phila. 
Med. T., 1878, VIII., 267.-LasJigue, C.: Des hyst. peripheriques. Arch. gen. de 
med., 1878, CXLL, 641.-Furstner: Ueber die Anwendung des Inductionsstroms 
bei gewissen Formen der Magenerweiterung. Berl. klin. Wochenschr., 1876, Nr. 
11.-Tittel: Ein Fall von Hamathidrosis. Arch. f. Heilkunde, XVII. Heft 1, 1876. 
-Seeligmuller, A.: Ueber epidemisches Auftreten von hysterischen Zustanden. 
Allg. Zeits. f. Psychiatrie, Berlin, 1877, XXXIII., 510-528.-Reynard and Richer: 
Etudes sur 1'attaque hystero-epileptique faites a 1'aide de la methode graphique. 
Rev. mens, de med. etdechir., Par., 1878, II., 641-661.-Charcot: On Disturb- 
ances of Sight in Hysteria. Med. Times and Gaz., Lond., 1878, I., 55-56.-Char- 
cot: Episodes nouveaux de 1'hystero-epilepsie. Zoopsie. Catalepsie chez les 
animaux. Gaz. d. hop., Par., 1878, LI., 1097-1099.-Charcot: L'attaque hysterio- 
epileptique. Gaz. d. hop., Par., 1878, LI., 1121-1123.-Charcot: Details comple- HYSTERIA. 
645 
mentaires relatifs a 1'hystero-epilepsie. Gaz. d. hop., Par., 1878, LI., 1145-1147. 
Potain: Hysterie a forme vesicale. Gaz. d. hop., Paris, 1878, LI., 281-282.-von 
Hesse: Hemianaesthesia hysterica. Arch. f. Psychiat., Berl., 1879, X., 271-273. 
-Scholz, G.: Ueber Hystero-Epilepsie. Arch. f. Psychiat., Berl., 1879, IX., 
636-662.-Buzzard, T.: Hysterical Hemianaesthesia of the Left Side, Defective 
Electrical Excitability of the Right Cerebral Hemisphere. Lancet, Lond., 1879, 
IL, 685.-Roberts, W.: Cases of Hysteria in Boys. Practitioner, Lond., 1879, 
XXIII., 339-345.-Welponer: Eine Frau, an welcher wegen Hystero-epilepsie die 
Entfernung beider Eierstocke vorgenommen wurde. Anz. d. k. k. Gesellsch. d. 
Aerzte in Wien, 1879, 148.-Poirier, P.: Des moyens d'arreter les attaques 
hystero-epileptiques et en particulier du compresseur des ovaires. Progres med., 
Par., 1878, No. 52, VI., 993.-Le Rolland, Joseph: Considerations sur 1'influence 
de la grossesse sur la marche de 1'hysterie et de 1'epilepsie. Par., 1879, 56 pp. 4to, 
No. 92.-Shaffer, N. M.: The Hysterical Element in Orthopaedic Surgery. 
Arch, of Med., N. Y., 1880, HI., 40-56.-Schmidt: Ueb. das Vorkommen der 
Hysteria bei Kindern (Inaug. Diss.). Strassburg, 1880, Cbl, f. N. Heilkunde, etc., 
1880, No. 9 (Schaefer' 
Charcot: Lond. Lancet, 1878, No. 3etseq.-Charcot, Luys, Dumontp allier: 
Brit. M. J., 1878, II., 548. Many papers in the Gaz. hebdom., and Progr. med. 
for 1877,1878, 1879.-Bourneville, Regnaud, Vigouroux, Raynaud, and others 
vide gen. index art. " Met. Ther.," also under Soc. de Biol.).-Westphal, Bern- 
hardt: Ber. klin. Wochenschr., 1878, July 29th and March 11th.-Wilks: Brit. 
Med. Jr., 1878, July 20th.-Eulenburg: Deutsche med. Wochenschrift, 1878, Nos. 
25 and 26.-Bennett: Brit. Med. Jr., Nov. 23d, 1878.-Tuke: Jr. Ment. Sc., Lond., 
1879, N. S., XXIV., 598.-Vierordt: C.bl. f. d. med. Wissensch., 1878, XVII., 1. 
-Sigerson: Brit. M. J., Lond., 1879, I., 143.-Beard: Pop. Sc. Monthly, May, 
June, July, 1878. Chicago Jr. of Nerv. and Ment. Dis., 1877 and 1878. A Prac- 
tical Treat. on Nervous Exhaustion, 1880, N. Y.-Petit: Bull. gen. de therap., 
1879-1880.-Garel: Lyon med., 1880, XXXIII., 53.-Franz Muller: C.bl. f. 
Nervenheilkunde, etc., 1879, 26.-Erlenmeyer: C.bl. f. Nervenheilk., etc., 1879, 
315.-Bennett: Brain, 1878, III., 331. 
Metallo-Therapeutics, Etc. 
ETIOLOGY. 
In the second edition of the Cyclopaedia, Jolly quotes Parant-Ducha- 
telet (La prostitution dans la ville de Paris) as saying that prostitutes 
suffer relatively seldom from hysteria, but ranges himself with Scanzoni 
as of the opposite opinion. 
The etiological moment is not purely, however, in their case, the ex- 
cessive genital irritation, but in part the excitement and unfavorable 
hygienic conditions amidst which this class of women live. 
Jolly speaks also of the fact that bodily injuries, such as falls, blows 
on the head, and the concussion of railway accidents, may act as an excit- 
ing, and possibly also as a final cause of a condition to which the name 
hysteria could hardly be denied ; though, in the case of the railway acci- 
dents at least, it is probable that the mental excitement and agitation 
play at least as important a part as the concussion. 
Rustic populations afford a less number of the lesser hysterical affec- 
tions-those which border on neurasthenia-than the civic. Still, as 
Jolly justly remarks, the severest examples of true hysteria often come 
from the country. This is well illustrated by an interesting case reported 646 
HYSTERIA. 
by Gairdner, occurring in a girl of eighteen, of cheerful and even lively 
disposition, living happily in strict retirement, with two aunts, visiting 
and visited by nobody, of fair general health. 
The systematic study of hysteria, in all its branches, has been vigor- 
ously pursued in France during the past few years, especially by Charcot 
and his pupils, in the great field of La Salpetriere at Paris, and it is, 
therefore, to the results of their labors that I shall principally refer, be- 
sides citing briefly the most important facts added by Jolly in the second 
edition of the Cyclopaedia. 
Charcot and Galezoioski have investigated with care the hysterical 
loss of vision, and find that color-perception of these patients disappears 
according to a certain law, violet being the first color to go, and blue the 
last, for most cases, though it occasionally happens that the perception 
for red is the last to disappear, these cases forming then another type. 
The usual order is violet, green, red, orange, yellow, blue. These obser- 
vations are important, because it would appear from them that the per- 
ception for the different colors is lost in hysteria in the same order as 
from causes of different nature. 
A case of hysterical amaurosis, of great persistence, is reported by 
Mendel {Jolly'). It came on suddenly, not after an attack, lasted eight 
months, and then disappeared entirely. The results of the ophthalmo- 
scopic examination were invariably negative. 
Cases of ataxia in hysterical patients have occasionally been observed, 
the inco-ordination sometimes affecting single muscles (especially those 
of the eye), sometimes an entire limb, sometimes the entire muscular 
system, coming from time to time and disappearing again spontaneously. 
Two cases, possibly belonging in this category, have been under my 
own care, where there was room for doubt whether the true diagnosis 
was hysteria or disseminated sclerosis. Both the patients were highly 
nervous, unmarried women; the inco-ordination was confined to one 
hand, appeared only during voluntary efforts, and was of a year or 
more's duration at the time the patients first presented themselves. 
Cases of paralysis of the abductors of the vocal cords are reported by 
Penzoldt, v. Ziemssen, Johnson. 
Lasegue has described, under the name of " hysterie peripherique," 
a group of cases of considerable interest, characterized by the fact that, 
although the patients do not necessarily exhibit the general hysterical 
temperament, the slightest peripheral irritation causes in them muscular 
spasms, which persist with extraordinary obstinacy, finally perhaps to 
disappear with great suddenness. Such are certain cases of rheumatic 
torticollis, and of blepharospasm from slight and passing irritation of the 
conjunctiva. Lasegibe says : " The transition from the typical hysteria 
to the other (functional) diseases of the nervous system is not abrupt, 
but by imperceptible gradations. The term " hysteroid " as well deserves 
a place in our nomenclature as ' epileptoid,' 'rheumatoid,' etc." 
SYMPTOMATOLOGY. HYSTERIA. 
647 
Roberts and Schmidt bring additional evidence of the occurrence of 
hysteria m children. 
The differential diagnosis between the contracture of hysteria and 
that due to joint-disease has been carefully studied by Shaffer. Both 
forms yield to the complete anaesthesia of ether and chloroform, but the 
former alone is said to disappear during sound sleep, whether natural, or 
induced by moderate doses of chloral and opium. 
In hysterical contracture, moreover, there is only the atrophy of dis- 
use, with but little or no change in faradic reaction; in contracture from 
joint-disease, the atrophy is more marked, and the faradic reaction dim- 
inished. 
The phenomena constituting the attacks of hystero-epilepsy, or hys- 
teria major (Charcot) have been investigated with the utmost care by 
Charcot and his pupils at the Salpetriero, even to the extent of register- 
ing the different phases of the muscular spasm by means of Marcy's tam- 
bour ingeniously attached to the forearm. 
The seizure as a whole is regarded as a phenomenon of pure hysteria 
at bottom, the epileptic element affecting solely the external form of the 
paroxysm. 
The attack is said to be preceded by prolonged auras of various 
kinds, epigastric, cardiac, auditory, visual, etc. Then occurs, first, the 
epileptoid seizure, with its tonic and clonic phase, the whole lasting, to- 
gether with the period of resolution which forms the longest part, four to 
five minutes. The muscular spasms of this stage are cut short, in Paris, 
both by compression over the ovaries and in other ways. 
Poirier has even devised a mechanical contrivance to be worn con- 
stantly, with pads resting in the ovarian region, which could be rapidly 
pressed inward at the outbreak of the attack. 
On the other hand, Gotoers has not been led to attach the same im- 
portance with the French writers to ovarian compression, as a means 
either of provoking or arresting these attacks. 
The first period then gives place to the second, that of the contor- 
tions, which consist in co-ordinated convulsions of the most varied kind 
throwing the body into every conceivable attitude. 
The third stage can best be imagined if the patient be supposed to be 
passing through a series of exciting, emotional dreams, gay, sad, almost 
always obscene in character, and illustrating his mental states by ex- 
travagant but fitting gestures and attitudes. 
In the fourth, the terminal stage, the patient's mind is filled with ter- 
rifying visions, often representing animals of various and unusual kinds, 
which, Charcot says, are apt to appear and disappear towards the anaes- 
thetic side of the body, if hemianaesthesia is present. 
The occurrence of such definite attacks as these has not been signal- 
ized by writers in other countries (compare, for example, the descriptions 
given by Gowers in his recent lectures on epilepsy), perhaps, because of the 
fact, which is beyond question, that the characters of hysterical affec- 648 
HYSTERIA. 
tions differ greatly among different races cf people, as well as at different 
times and places. 
Thus Brodie long ago pointed out the greater frequency with 
which hysterical joint diseases are met with in England than in other lands. 
PATHOLOGICAL ANATOMY. 
In the second edition of this Cyclopsedu Jolly reviews the differing 
theories which have been proposed, to explain, or more closely define, the 
pathological condition of the nervous system which underlies hysteria, 
without, however, giving in his adherence to either of them. Thus, im- 
poverishment or abnormal composition of the blood is often absent. 
Erethism (reizbare Schwache) or irritability with exhaustibility, is not 
always to be made out. The attempts of recent writers to elevate the 
latter condition into a clinical entity under the name of neurasthenia are 
characterized as artificial and unpractical, and it is claimed that almost 
all the cases on which the symptom-group is based belong either to hys- 
teria or to hypochondria, or else are instances of the effect of outside influ- 
ences of various kinds upon a nervous system naturally feeble. Since 
Jolly wrote, Beard has published a comprehensive work on this subject, 
in which references are given to the literature of the matter and a careful 
attempt is made to establish the symptomatology of neurasthenia on a 
firm basis. To this the reader is referred. 
My own view of the question is that it is useful to classify cases under 
the headings of neurasthenia, hysteria, and even to make still further 
subdivisions so fast as a sufficient number of similar cases can be found to 
justify them, but to do so purely and avowedly for reasons of clinical 
convenience, recognizing the fact that these different groups shade insen- 
sibly into one another, or occur mixed in varying proportions; that many 
cases present themselves which belong in neither distinctly, but in an in- 
termediate class; and, finally, that we know nothing of the pathology of 
any of them. 
Probably the first real step towards unravelling the mystery of these 
affections will come from the side of physiology and psychology. 
An indication of the direction in which more light is to be sought is 
perhaps already furnished by the various writings of Hughhngs Jackson 
and others, as well as in the definition given by Jaccoud that the character- 
istic of hysteria is a predominance of the involuntary innervation over 
the voluntary innervation. 
That typical cases of neurasthenia are distinguishable from typical 
cases of hysteria, both as regards their etiology, their clinical history, and 
the manner in which they respond to treatment, is hardly to be doubted, 
or to put it better, the symptoms described by Beard are so well marked 
and occur so often in company, as to deserve a separate clinical desig- 
nation, especially as they are almost as common in males as in females. 
Typical hysterical symptoms may, however, and often do occur in the 
course of neurasthenia, the same soil serving for the growth of both 
affections. Of this, the following case may pass as'an illustration. METALLO-THERAPEUTICS. 
649 
A young lady, between twenty and thirty, intelligent, of well-balanced 
temperament, and belonging to a healthy family, was prostrated for two 
or three years with the typical symptoms of neurasthenia (exhaustibility, 
tender spine, photophobia, neuralgia, with but few fleeting or emotional 
symptoms) and gradually recovered to a large extent. One day after this, 
while feeling pretty well, she received some trifling injury in one hand, of 
which the local symptoms amounted to little or nothing. Shortly after- 
wards, however, she began to suffer from a sense of powerlessness, 
subjective disturbances of sensibility, and some pain in the hand, arm, 
and eventually leg, trunk, and face, on the side of the injury, without 
there being any external sign of disease whatever, and these symptoms 
have persisted for nearly a year, constituting what might be called a 
hysterical hemi-paraesthesia. 
METALLO-THERAPEUTICS. 
Any account of the recent investigations on hysteria would be incom- 
plete without some mention of the remarkable experiments of which the 
great hospital La Salpetriere has been the chief theatre, and which are 
indicated in the terms metallo- and magneto-therapeutics, although those 
names utterly fail to suggest the scope of the present investigations. The 
main facts are briefly as follows: As long as thirty years ago, Dr. Bury, of 
Paris, insisted upon the effect of the cutaneous application of isolated 
pieces of metal in curing the anaesthesia of hysterical patients, asserting 
that the metal found to have this action-for all patients did not react to 
the same kind-would, if taken internally, have a very beneficial influence 
on the general condition of the patient. For a long time Burq's statements 
obtained no credence, but at last Charcot interested himself in them, and 
with Burq himself and others began to make systematic researches in 
the wards of the hospital. The usual mode of procedure was to take a 
patient with hemi-amesthesia, which was so complete that large pins 
could be thrust through the most sensitive portion of the skin without 
causing pain, often involving also the nerves of special sense, and place 
on the forearm or the leg a few discs of metal, isolated from each other, 
but fastened on the under side of the same strap. 
In fifteen or twenty minutes, the sensitiveness would begin to return 
to the skin above and near the metallic discs, and then gradually to the 
whole anaesthetic region, and at the same time the corresponding parts 
on the opposite side of the body would begin to lose their sensibility, 
until eventually the anaesthesia had complely transferred itself. 
Usually these effects disappeared soon after the removal of the metals. 
Not only cases of hysterical anaesthesia, but a small number of those where 
the anaesthesia had been associated with organic cerebral disease, have 
been thus successfully treated. The therapeutic interest of these dis- 
coveries has, however, now become entirely overshadowed by their physio- 
logical interest. 
It was then found that the electrical currents, so feeble as to be appre- 
ciable only to a delicate galvanometer, would exert a similar action with 650 
METALLO-THERAPEUTICS. 
the metals; also that not only could anaesthesia be removed or transferred 
in the manner stated, but hysterical contractures, of years' duration, could 
be likewise cured or transferred to the opposite limb, by bringing a large 
magnet into the neighborhood of the affected part or inclosing it in a sol- 
enoid, etc. 
Whatever interpretation one may choose to adopt for these phenomena, 
some of their features will always present a peculiar scientific interest, 
and this will attach not least to these observations with regard to the 
transfer of symptoms from one side to the other, as showing a sort of 
functional antagonism between them, which, perhaps, finds its parallel 
in the so-called antagonism between the two retinae. Tn the recent hyp- 
*notic investigations of Haidenhein, the independence of the two halves of 
the body, under certain conditions, is strongly brought out. 
The metallo- and magneto-therapeutic experiments of Charcot have 
been repeated the world over, with every possible modification, and have 
already given birth to a voluminous literature. It would be impossible 
to follow the subject in all its branchings and not even desirable to do so, 
since to interpret fairly all the evidence would be a task only suited 
to an expert, both in physiology and still more in experimentation upon 
human beings, yet without such interpretation the bare facts would soon 
lose their interest. I shall, therefore, content myself with mentioning 
the most significant discoveries. In the first place, it has shown itself 
clearly that not metals and magnets alone, but various other substances, 
such as mustard plasters, bits of wood, metals with silk coverings, vibrat- 
ing rods, etc., are capable of producing the results mentioned, wholly or 
in part. On the other hand, Charcot and McCall Anderson claim to have 
found that,when false magnets were substituted for true ones, or electro- 
magnets deprived of their magnetism without the knowledge of the 
patients, the results failed to appear. Schiff brought about what he be- 
lieved to be tactile anaesthesia of a dog's fore-paw, by extirpating the cor- 
responding portion of the cortex cerebri in the parietal region, so that 
cutaneous irritation no longer caused reflex movements as on the healthy 
side, and found the sensibility return aftej the limb had been exposed to 
the action of a solenoid. This important experiment has not, so far as I 
know, been repeated by others, and all observes do not agree with Schiff 
and Munk that cutaneous anaesthesia exists after the lesion alluded to. 
Vierordt tried the experiment of laying pieces of zinc upon the belly of 
frogs, after first destroying the cerebral hemispheres to prevent voluntary 
movements, and showed that thereon the reflex contractions which fol- 
lowed stroking and pinching the toes occurred much more readily. 
On the other hand, neither Schiff nor Gamgee was able to excite 
changes in the physiological properties of the bared sciatic nerve of the 
frog by exposing it to the influence of strong electro-magnets. 
If we regard the clinical facts from the purely physiological side, we 
are able to find as y«t no sufficient cause for the removal of the anaesthe- 
sia, and the other phenomena alluded to. 
There is no physiological influence common to all the agencies which METALLO-THERAPEUTICS. 
651 
have produced these effects except possibly a feeble excitation, or, accord- 
ing to Schiff's hypothesis, a molecular agitation of the nerves and nerv- 
ous centres, even granting that the mere neighborhood of metals or 
magnets could exert this action. On the other hand, there are perhaps 
other influences at work in all these experiments, not strictly physiologi- 
cal (in the usual sense) in character. These are influences of cerebral 
origin, though not necessarily such as are present to the mind of the 
patient. Of course, it need hardly be said that the possible influence of 
these agencies has been considered by all the best experimenters on this 
subject, and that steps have been taken to eliminate them. The question 
is, have these precautions been sufficient ? From the first there has been 
a strong party who have answered this question in the negative. This 
party includes those who believe, with Carpenter and Tube, that the 
phenomena are those of " expectant attention," and those who refer them 
to the class of so-called "trance" phenomena {Beard), in which the in- 
voluntary, subconscious innovations play the most important part. 
Until recently, Beard was a strong supporter of the view that this 
latter influence had not been sufficiently considered, and could not be 
until the sources of error in the usual methods of investigation had been 
more succinctly recognized. In his last publication, however, Beard 
admits that he cannot point out the flaws in the later experiments of 
Charcot, McCall Anderson and Franz Muller, the important condition 
being apparently fulfilled, "that the patient should be deceived all the 
time." 
I am myself not prepared, without still further circumstantial evi- 
dence, of a kind which perhaps cannot be furnished till we learn more 
about this little-studied question of the interaction of the voluntary and 
involuntary life, to abandon Beard's first, strong position. Perhaps the 
systematic study of hypnotism, which is now being vigorously pursued, 
both in France and Germany, will throw more light on this*' kindred 
subject. 
The investigation of these phenomena, while belonging both to psy- 
chology and to physiology, has hitherto received but little systematic 
study from the representations of either of these sciences being rather 
shunned by each body as coming more properly under the cognizance of 
the other. It is verbally but not practically recognized, that in the acts 
of all of us, and not alone of the class of somnambulists, mesmerists, and 
hysterics, the involuntary life plays by far the most prominent part. 
The lack of a full and. practical recognition of this fact, that between 
hysterical and healthy persons there is not a gulf but a bridge, has led 
some of those who have written upon this subject to point to a few cases 
in which hemianaesthesia of organic, cerebral origin has likewise been 
relieved by metallo-therapeutics, as ruling out the mental influence 
which, in the case of the hysterical patients, might have been looked 
upon as the active agent. 
The counter-criticism is important, but by no means so much so as 
has been maintained. It is evident that, even in these cases, the hemi- METALLO-THERAPEUTICS. 
652 
anaesthesia, though remotely of organic origin, is not so in the sense that 
all the conducting tracts between the periphery and the nervous centres 
have been severed, for in this case the recovery would involve slow and 
protracted nutritive changes, such as the formation of blood-vessels, 
multiplication of cells, absorptive processes, and the like; whereas, as 
Vulpian long ago showed, this anaesthesia may disappear quite rapidly 
under strong cutaneous faradization. The cause of its existence is, 
therefore, evidently a subtle one, possibly of an inhibitory character ; or, 
more probably, due to a sluggishness, or inability, on the part of con- 
sciousness to recognize, without strong impulse from without or within, 
impressions coming through imperfect or unaccustomed channels. 
However this may be, the pathology of organic cerebral anaesthesia is 
plainly still too obscure to justify positive a priori judgments as to what 
the nature of the remedy must be which should remove it.