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CYCLOPEDIA
OF the
PRACTICE  OF   MEDICINE.

        Edited by Dr. H. von ZIJ2MSSEN,
          PBOFESSOB Or CLINICAL MEDICINE IN MUNICH, BAVABIA.

                  VOL. XIV.

DISEASES  OF THE  NERVOUS SYSTEM,
                      AND
         DISTURBANCES OF SPEECH.
Prof. A EULENBURG, of Greifswald; Prof. H. NOTHNAGEL, of Jena; Prof.
   H. VON ZIEMSSEN, of Munich; Prof. F. JOLLY, of Strassburg; Prof.
     A. KUSSMAUL, of Strassburg; and Dr. J. BAUER, of Munich.
                   ^raruelattij 1$
E. BUCHANAN BAXTER, M.D., and ALEXANDER MORISON, M.B., Edin., of London; DAVID F.
 LINCOLN, M.D., GEORG-E B. SHATTUCK, M.D., SAMUEL G. WEBBER, M.D., of Boston;
    and J. HAVEN EMERSON, M.D., and JOHN A. McCREERY, M.D., of New I'ork.
    ALBEET H. BUCK, M.D., New York, , ^.
          EDITOB OF AMERICAN EDITION.    g A^.*1^1   --^^"JC*' v



            NEW YORK:      ^lPUA^>
WILLIAM WOOD AND  COMPANY;
         27 GREAT JONES STREET.
               1877. 
iv           BIOGRAPHICAL  SKETCHES OF THE AUTHORS.

gen der Wlirzburger medicinische Gcsellschaft, 1856, Band 6.   " On Rigor Mortis,
etc.," Prager Vierteljahresschrift, Band 50, 1856.   "Researches on the Origin and
Nature of Epileptic Spasms and  Epilepsy in General," Frankfurt, 1857 (published
in conjunction with bis friend A. Tenner).  " On the Rupture of  the Inner Mem-
branes of the Cervical Arteries  in Death by Hanging,"  Virchow's Archiv, 1857.
" On the Death of Limbs after Injections of Chloroform into the Arteries," Virchow's
Archiv, 1858.  " On the Absence, Malformation, and Doubling of the Uterus; Mis-
conception and the Migration of the Ovum," Wurzburg, 1859.  In the autumn of
1859 Kussmaul removed to Erlangen, where he became Professor of Internal Medi-
cine and Director of the Medical Clinic and Polyclinic, remaining in this city until
the spring of 1863.
    Of numerous dissertations which have  appeared under his authority, such as
that of Max Doederlein, "On the Diagnosis  of Cancerous Tumors in the Right
Hypochondrium,"  1860, which perhaps  deserves  special notice, there are also:
"Researches  on  Constitutional Mercurialism," Wurzburg, 1861.  "On  Sexual Ma-
turity," Wurzburger medicinische Zeitschrift, 1862.  " Contributions to the Anatomy
and Pathology of the  Urinary Apparatus," Wurzburger medicinische Zeitschrift,
1863. "A Free Concretion in the Pericardium," Ibid., 1864.  In the spring of 1863
he accepted a call to Freiburg in Breisgau.  Here he received calls to Basel, Konigs-
berg,  Greifswald, Tubingen, and  Breslau, all of which he refused.   In  Freiburg
he published numerous articles. Of these we may mention  the following:  " On the
Diagnosis of Embolism of  the  Mesenteric Artery," Wurzburger med. Zeit., 1864.
" The Cold in the Head  of Infants," Henle and Pfeufer's Zeitschrift f. rationelle
Medicin, 1865.   " On Congenital  Narrowing and Closure  of the Pulmonary Arte-
ries,"  Ibid., 1865.   "The  Developmental Periods  of Exact Medicine."  " On the
Causes and the Phenomena of our Death" (two public addresses), Freiburg, 1865.
" On  Periarteritis  Nodosa" (in conjunction with  Prof.  R. Maier), Deutsches
Archiv, 1866.  "The Lungs and  Bronchial Glands  after Incineration," after ana-
lyses  by  Dr.  C.  W. Schmidt, Ibid.,  1866.  "On Poisoning  by the Chloride  of
Zinc" (in conjunction with  Dr. Honsell), Klinische Wochenschrift, 1866.  "Several
Observations  on Rare Affections  of the  Liver," Ibid., 1867 and 1868.  "Sixteen-
Observations  on Thoracentesis in Pleurisy, Empyema, and  Pyopneumothorax,"
Deutsches Archiv  f. klin. Med.,  1868.  " On the Treatment of Gastric Dilatations,
by a New Method—the  Stomach-Pump," Ibid., 1869. " Twenty Letters on the Inocu-
lation of  Variola and Vaccinia—A General Exhibit of the Vaccination Question,"
Freiburg,  1870.   "On  Rheumatic Tetanus," Berl.  klin. Woch., 1871.  "On  the
Pathological Anatomy of Chronic Saturnismus " (with R. Maier), Deutsches Archiv,
1872.   " On the  Doctrine of Tetanus," Berl. klin. Woch.,  1872.  "On an Abortive
Form of Tetanus," Deutsches Archiv f. klin. Med., 1873.   "On Spontaneous Grad-
ual Closure  of the Trunk of the Great Vessels of the Neck," Deutsche Klinik,
1872.  " On Progressive Bulbar Paralysis," Sammlung klinischer Vortrage, by Volk-
mann, 1873, No. 54.
    In the  autumn of 1876 he went to Strassburg, to take the direction of the Clinic
and Polyclinic.  Professor  Kussmaul  married Louise Wolf, in 1850.  One of his 
               BIOGRAPHICAL SKETCHES  OF  THE  AUTHORS.            V

  daughters is the wife of Professor Czerny, who was recently called from Freiburg
  to Heidelberg, as the successor of the deceased Simon.

V    Albert Eulenburg  was born August 10, 1840, in Berlin.  His father was the
  well-known orthopaedist, who  first  introduced the Swedish movement-cure into
  Germany, and utilized it in a  scientific  manner.  His studies were carried  on in
  Bonn and Berlin, and in the year 1861:  he took a prize  on the following question
  proposed by the Berlin University: " On  the Influence of Cardiac Hypertrophy and
  Disease of the Cerebral Arteries on the Occurrence of Cerebral Hemorrhage," Vir-
  nhow's Archiv, Band XXIV.  His graduation dissertation of the same year was
  " De argumentis irritabilitatis muscularis recentioribus."  In 1863 he became Assist-
  ant Physician at the University  Hospital  in Greifswald;  in 1864 he took the prize
  founded by Hufeland's Society, for the best work on the hypodermic  injection  of
  remedies, printed in 1865, under the title "The Hypodermic Injection of Remedies
  —after Physiological Researches and  Clinical Experiences," August  Hirschwald,
  second edition,  1869; third  edition,   1875.   In 1866 he established himself as a
  private instructor at the University of  Berlin.   From, 1869 to 1871 he was Assistant
  at the Polyclinic of the University.  He took part in the campaigns of  1864, 1866,
  and 1870 to 1871; in the  latter year he published his " Manual of Functional Nerv-
  ous Diseases," August Hirschwald, Berlin; and  in 1873, in  conjunction with  Dr.
  Paul Guttmann, his "Pathology of the Sympathetic."  Since 1874 he has been Pro-
  fessor of Medicine at the  University of Greifswald.  Eulenburg has also published
  numerous  small articles  in the  domain of neural pathology and electrotherapy, as
  also in experimental pharmacology (on  quinine, narcein, bromine, calcium, trans-
  fusion, acute  poisoning by phosphorus, nitrite of amyl, etc.), most of which have
  appeared in the Archives of Anatomy and Physiology and Pathological Anatomy,
  and in the German Archiv fur klinische Medicin.   Eulenburg is an honorary mem-
  ber of the New York Neurological Society, and corresponding member of the New
  York Society of Neurology and  Electrology.
     Frederick Jolly was born in Heidelberg, November  24, 1844, but in 1854 his
  family moved to Munich, where he attended the gymnasium, and in the autumn  of
  1862 the university.   He  studied medicine in  Munich and Goettingen, and in the
  former city he was for two years Assistant at Pfeufer's Medical Clinic.   While in
  Berlin and Vienna he turned his attention chiefly to mental diseases, then entered
  the Bavarian  Lunatic  Asylum of Werneck, as  Assistant, later accepting a similar
  position at the insane department of the Julius Hospital  in Wurzburg.  There, in
  1871, he was installed as private instructor, and in 1873 responded  to a call  as
  Extraordinary Professor of Psychiatry and Director of the Psychiatric Clinic at the
  University of  Strassburg.   In the beginning of  the year 1875 he was made full pro-
  fessor.  His literary productions relate in part to the domain of the anatomy and
  physiology of the nervous system, in  part to  questions of psychiatry and  neural
  pathology.  They are :  " On the Ganglion-Cells of  the Spinal Cord," Zcitsch. f. wiss.
  Zoologie,  XVII.   "A Case  of Faulty  Development of the Bulbus in  the Human
  (Male)  Brain," Zeitschr. f. rat. Med., 3, XXXVI. 
Vi          BIOGRAPHICAL  SKETCHES OF THE AUTHORS.

   " On Traumatic Encephalitis," in Strieker's Studien aus dem Institute f. expen-
mentelle Pathologie, 1869.  "Researches on Cerebral Pressure and on the Blood-
Movements in the Skull," Wurzburg, 1871.
   "Report on the Insane  Department  of the Julius  Hospital," Wurzburg,  1873.
The Archiv f. Psychiatrie also  contains some articles by him, on " Psychoses in
Consequence of the Campaign of 1870 and-1871," on " Multiple Cerebral Sclerosis,"
on "The Electric Examination  of those having Hallucinations of Hearing," "On
the Care of the  Insane  at Home in Scotland."  Various other articles have also
appeared in the medical  weeklies.

   Herrmann Senator was born December 6, 1834, in Gnesen, where he pursued
his early studies.  From 1845 to 1853  he attended  the Frederick William Gymna-
sium in Posen, and then the  University of Berlin, where he graduated  in  1857.
On March  1st of  the following year he received his  medical degree and  established
himself in Berlin.  During his period of study he was for a  year and a half an
amanuensis under Johannes Mueller, and as such  he  was chiefly concerned with
anatomy and physiology.
   From 1860 onward he devoted himself to  state medicine, and later mostly to
general pathology and medical chemistry in Virchow's Pathological Institute (under
the instruction of W. Kuehne).  In August, 1868, he established himself as instruc-
tor, and from 1869 to 1872 pursued the study of clinical medicine at the clinic of
Traube.
   In March, 1875, h§ received charge  of the inner department of  the  Augusta
Hospital, and the polyclinic attached  to it, and  in September of the same year he
was made  Extraordinary Professor of the Medical Faculty.

   Eugene  Seitz was born at Vilbel, in the Grand  Duchy of Hesse, and  since
the year 1856 has held the position of  Professor of Special Pathology  and Thera-
peutics at  Giessen, having at the same  time the management  of the medical clinic.
While assistant and private instructor in Giessen and Tubingen, it was his inten-
tion to become an oculist, and  he commenced  a manual of ophthalmology,  but
relinquished it to Professor  Zehender  when  his  attention  was  turned  towards
general medicine.   His principal work has been the complete recasting of Nie-
meyer's Manual of Special Pathology, which, at  the death of  the latter,  was placed
in his hands.  He also wrote a text-book on Percussion and Auscultation of  the
Respiratory Organs, which was published at Erlangen in 1866.  Among  the smaller
productions of his pen, and the numerous inaugural dissertations prepared under
his directions, the following are the most  important: "Percussion of the Upper
Borders of the Lungs" (Diss.  Heyer).  " On the Changes in the Lungs during Dis-
ease" (Diss. Neidhart).  "On Changing Respiratory Murmurs," Deutsche Arch. f.
klin. Med.  " Researches on  the Arterial Pulse by Means of Marey's Sphygmo-
graph" (Diss.  Arcularius).  "Percussion of the Spleen" (Diss. Schuster). "Situs
viscerum  inversus"  (Diss.  Steinhauser). " Simple Scleroma  of the  Skin"  (Diss.
Nordt), etc. 
            BIOGRAPHICAL  SKETCHES OF THE AUTHORS.          vii

   Carl Ferdinand Hermann Immermann was born in Magdeburg on September
2, 1838.  After completing his courses at the schools of his native city, he entered
the university in the autumn of 1856.  From this year on until 1861 he attended
the high schools of Halle, Wurzburg, Greifswald, Tubingen, and Berlin, and in the
latter city obtained the degree of Doctor in Medicine.  In 1861, the following year,
while in Berlin, he also passed the Prussian state medical examination.  During
1862 and 1863 he continued his studies in Berlin, Vienna, and Paris, making it his
special object to attend clinics and courses, in preparation for his intended career
in the field of clinical medicine.  In Easter, 1864, he visited Tubingen, to take the
position of Assistant at the Medical Clinic of Felix von Niemeyer, whose clinical
instruction he had followed with  particular zest  as  a student,  and whose  very
warm interest and attention he had always enjoyed.  Though he did not establish
himself formally as an instructor, he still gave practical courses in clinical diag-
nosis ; but, after remaining two years, at the solicitation of Professor von Ziemssen
he moved to Erlangen and received from him the position (which had just become
vacant) of  Assistant at the Medical Polyclinic.   In the summer of 1866 he estab-
lished himself as private instructor.   During the following two years he continued
his service as Assistant at the Polyclinic and Instructor, while he delivered lectures
on separate branches of Special Pathology, such as Diseases of the Skin and Syphi-
lis, on Materia Medica and the Art of Prescribing^and continued to hold courses in
clinical  diagnosis as  before in Tubingen.  Finally, in the autumn  of 1871,  he
responded  to a call from Basel, and since  that time has been  serving as Regular
Professor of Special Pathology and Therapeutics, Director of the Medical Clinic,
and  Physician  in Chief at the City Municipal Hospital.  His literary productions
are:  " De morbis febrilibus  questiones  nonnullae, adjectis morborum historicis,"
Diss. Inaug.,  Berlin, 1860.  " Contributive Cases to the Theory of the Rise in the
Temperature  during Fever," Deutsche  Klinik, 1865, Nos. 1-4.   " On Vertigo  in
Diseases of the  Posterior Fossa Cranii, and their Connection with Actual Oscillation
of the  Body,"  Deutsches Archiv f. klin. Med., Bd. I.,  S. 595 ff.  From  von  Nie-
meyer's clinic,  "Four Cases of Cerebral  Disease,"  Berl. klin. Woch., 1865, p.  177.
" On the Pathogenesis and Etiology of the Visible Respiratory Swelling of the Cer-
vical Veins," Habilitation essay, Erlangen,  1866.   "Stricture  of Both Principal
Trunks of the Pulmonary Artery through Chronic Interstitial Pneumonia," Deutsches
Archiv  f. klin. Med., V., p. 235.  " Pneumonia and Meningitis," Ibid., V., p. 1 (in
connection with A. Heller).  " The Cold-Water Treatment of Typhoid, after Obser-
vations at the Erlangen Clinic and Polyclinic," Leipsic, 1870 (in connection with  H,
von Ziemssen).   " On  the Therapeutics of the Diurnal Variations of Temperature in
Typhoid Fever," Deutsches Archiv f. klin. Med., VII., p. 561.  " On the Therapeu-
tic Aims of Internal Medicine at the Present Time", opening address in assuming
charge of the Medical Clinic in Basel, Leipsic, 1871.   "On Morbus  Brightii and
its Treatment," Correspondenzblatt f. Schweizer Aertze, 1873, No. 11.   "On  Pro-
gressive Pernicious Anaemia," Deutsches Archiv  f. klin. Med., XIII., p. 209.

   Dr.  F.  V. BiRcn Hirschfeld was born May 2, 1842, near Rendsburg, on the 
Viii         BIOGRAPHICAL SKETCHES  OF  THE AUTHORS.
 Manor Cluvensieck, in Holstein.  His grandfather on the mother's side, an English-
 man, having daughters, but  no sons, was  very desirous that his name should  be
 preserved by the children, whence the double name.  The German portion belongs
 to an old Thuringian Lutheran family, which can be traced back into the sixteenth
 century.
    His school education was obtained at the gymnasia of Kiel and Hamburg, and
 in the year 1862 he matriculated as a student of medicine in Leipsic.  After nearly
 five years of study, broken in  1866 by long active service in hospital, he was made
 assistant  to Professor E. Wagner at the University  Polyclinic and then  at the
 Pathological Institute.  After several years of activity in these positions he entered
 upon the career of a government physician, for a year and a half studying mental
 diseases and acting as physician  of  the provincial institutions Sonnenstein and
 Colditz in Saxony.  In the year 1870 he received the position  of prosector at the
 Dresden City Hospital, and was soon after made instructor in pathological anatomy
 in the educational course of the Sanitary Corps of the Royal Saxon Army, and later
 was made circuit physician of the Provincial Blind Asylum.  Of his more impor-
 tant scientific works the following are to be mentioned : 1. On a Case of Cerebral
 Deficiency in consequence of Dropsy of the Septum Lucidum, Diss. Leipsic, 1867
 (published in the Archiv f. Heilkunde, 1867).  2.  The Development  of Cancer of
the  Testicle, Archiv der Heilkunde, 1868.   3.  Cases  of Embolism in Tumors,
Archiv der Heilkunde, 1869.   4. On Miliary Tuberculosis after Abdominal Typhus,
Arch, der  Heilkunde, 1870.   5. On the  Question of Cylindroma, Arch, der Heil-
kunde, 1870. 6.  Acute  Splenic Tumor, Ibid., 1872. 7. Investigations on Pyaemia,
Ibid., 1873.  8. Transfusion  of Lamb's Blood (in conjunction with Dr. A. Fiedler),
Deutsches Archiv f. klin Med., XIII.  9. Contributions  to the Pathological Anat-
omy of the Hereditary Syphilis of New-born Children, Archiv f. Heilkunde, 1874.
10. Manual of Pathological Anatomy, Leipsic, 1876-7 (Vogel). 
CONTENTS.
                                EULENBURG.
                                                                          PAGE
Vaso-Motor  and Trophic Neuroses.
    Hemicrania.............................................................    3
               Bibliography................................................    3
           History.........................................................    4
        Etiology............................................................    5
        Symptomatology and course..........................................    9
           Analysis of symptoms............................................   14
           Course and prognosis.............................................   22
        Treatment..........................................................   23
    Angina Pectoris........................................................   31
               Bibliography............................  ...................   31
           History.........................................................   32
        Etiology...........................................................   35
        General description and course........................................   37
           Pathological anatomy............................................   39
           Analysis of symptoms............................................   41
           Diagnosis and  prognosis..........................................   50
        Treatment..........................................................   51
    Unilateral Progressive Atrophy of the Face.................................   57
               Bibliography................................................   57
           History.........................................................   58
        Etiology............................................................   59
        Symptomatology and course. ....,...................................   60
           Analysis of symptoms...........................................   64
           Vasomotor and trophic theory....................................   65
           Implication of the trigeminus.....................................   67
           Implication of the facial nerve.....................................   69
           Implication of the cervical sympathetic............................   70
           The theory of Lande.............................................   71
           Diagnosis and  prognosis..........................................   72
        Treatment....................................................... • • •   74 
X                                CONTENTS.
                                                                            PAGE
    Basedow's Disease........................................................  ' °
                                                                              75
                Bibliography...............................................
            History.........................................................  77
        Etiology.............................................................  78
                                                                              on
        Symptomatology and course....  .....................................
            Duration........................................................  86
            Pathological anatomy........  ...................................  ""
            Analysis of symptoms and theory of the disease....................  89
            Diagnosis and prognosis..........................................  99
        Treatment........................................................... 101
    Progressive Muscular Atrophy............................................ 105
                Bibliography............  ................................... 105
            History........................................................ 108
        Etiology............................................................ 110
        Symptomatology and course......... ................................ 117
            Pathological anatomy............................................ 133
            Analysis of symptoms and theory of the disease.................... 141
            Diagnosis and prognosis.......................................... 147
        Treatment......................................................... 148
    Pseudo-Hypertrophy of the Muscles........................................ 153
                Bibliography................................................ 153
            History......................................................... 154
        Etiology............................................................ 156
        Symptomatology and course..........................................157
            Pathological anatomy............................................ 164
            Analysis of symptoms and theory of the disease..................... 169
            Diagnosis and prognosis.......................................... 173
        Treatment.......................................................... 173
    True Muscular Hypertrophy.............................................. 175
                Bibliography................................................ 175
        Etiology'............................................................ 1?5
        Symptomatology..................................................... 176
            Theory of the disease.............................................178
                      (Translated by David F. Lincoln, MD.)
                                 NOTHNAGEL.
Epilepsy.....................................................               183
                Bibliography................................................ 183
            Introduction...............................                       jg4
            Experimental researches........,.............                     193
        Etiology............................................................ 200
            Pathological anatomy........................                      014
        Symptomatology...........................................         219
            The epileptic seizures...............................               020 
                                 CONTENTS.                               XI

                                                                           PAOH
            Epilepsia gravior.................................................  221
            Epilepsia mitior.................................................  234
            Transition forms;  loss of consciousness with local spasm............  235
            Irregular forms of the attacks and the epileptoid states.............  2:37
            Consequences of the paroxysms..................................  244
            Frequency of the seizures........................................  247
            The interparoxysmal condition....................................  252
        Pathology..........................................................  259
            Course and sequelae..............................................  273
            Prognosis........................................................  276
        Treatment..........................................................  279
            Treatment of the seizure itself.  ..................................  295
Eclampsia........  .......................................................  299
                Definition..................................................  302
        Etiology............................................................  302
        Symptomatology....................................................  307
        Pathology.........................................................308
            Prognosis.......................................................  310
        Treatment..........................................................310
                    (Translated by J. Haven Emerson, M.D.)
                                   BAUER.
Tetanus.................................................................... 315
                Bibliography................................................ 315
            Introduction.................................................... 316
        Etiology............................................................. 319
        General description of the disease..................................... 3o0
            Pathological anatomy............................................ 333
            Pathogenesis....................................................337
            Analysis of symptoms............................................ 340
            Processes of decomposition.............................  ......... 352
            Terminations and prognosis...................................... 355
            Diagnosis....................................................... 358
        Treatment.......................................................... 360
                    (Translated by Samuel G. Webber, M.D.)
                                EULENBURG.
Catalepsy................................................................. 369
                Bibliography................................................369
        Etiology............................................................ 370
        Symptomatology and course.......................................... 372
            Pathological anatomy and theory of the disease.................... 377
            Diagnosis and prognosis..........................................381
        Treatment..........................................................382 
XH                              CONTENTS.
                                                                           PAGE
                                                               ............ 385
Tremor...........................................................
                Bibliography.............................................   J
        Etiology....................................................         ' 387
        Symptomatology and course....................................
            Theory of the disease............................................
        Treatment....................................................
Paralysis Agitans..........................................................*
                Bibliography................................................
        Etiology............................................................39G
        Symptomatology and course..........................................
            Pathological anatomy and theory of the disease..................... 401
            Diagnosis and prognosis.......................................... 4"°
        Treatment.......  .................................................. 406
    Athetosis............................................................. 409
                Bibliography...............................................  40J
        General description.................................................. 40 J
                     (Translated by  Samuel G. Webber, M.D.)
                               VON  ZIEMSSEN.

Chorea.................................................................... 413
                Bibliography................................................ 413
            History and definition........................................  ... 415
       Etiology............................................................ 422
       General  description.................................................. 428
            Analysis of the symptoms........................................ 431
            Course, duration, and results..............,....................... 441
            Pathological anatomy............................................ 445
            Experimental investigations...................................... 455
            Diagnosis....................................................... 460
            Prognosis.......................................................461
        Treatment.........................................................461
                     (Translated by David F. Lincoln, M.D.)
                                    JOLLY.
Hysteria.................................................................. 473
                Bibliography................................................473
            General observations.............................................47o
        Etiology............................................................ 47G
            Pathological anatomy and pathogenesis............................ 488
        Symptomatology.................................................... 493
            Disorders of sensibility........................................495
            Motor disturbances............................................ 5jj 
                          CONTENTS.                            Xiii

                                                                   PAGE        •
    Disturbances  of  the  circulation, and disorders of secretion and ex-
        cretion ....................................................  523
    Hysterical attacks..............................................  531
    Psychical behavior; hysterical mental disturbances.................536
    Progress and results.............................................  546
    Diagnosis.......................................................  550
    Prognosis.......................................................  555
Treatment..........................................................558
    Prophylaxis....................................................558
    Treatment of the fully developed disease..........................  561
    Treatment of particular symptoms................................571
             (Translated by Alexander Morison, M.B.)
                                 KUSSMAUL.

                           Disturbances of  Speech.

                                 CHAPTER I.
Human Speech, the Logos, the Agent by which Definite Thoughts are expressed,
    as contrasted with the Speech of Animals.—Unconsciously evoked, it serves
    the Ends of Consciousness................................................ 581

                                 CHAPTER II.
Speech as an Act of Expression and as a Something Expressed................... 582

                                 CHAPTER III.
Speech as a Movement of Expression and an Acquired Reflex...................  583

                                 CHAPTER IV.
Preparatory  Stage of Speech in Interjection and Imitative Gesture.—Its Retrogres-
    sion during Sickness to its Earlier Stage of Development....................584

                                 CHAPTER V.
The Principle of Sound Metaphor............................................  588

                                 CHAPTER VI.
Origin of Intelligent Speech from Word-roots. —Intuition and Intelligent Concep-
    tion.—Sensory or  Instinctive in contrast to Intelligent Judgment.—Speech as
    an Associated Conception-reflex and as an Act  of Will.—The Three Stages of
    Language : Preparation, Diction, and Articulation.......................  . • 590 
xiv
CONTENTS.
                                CHAPTER VII.
                                                                            PAGH
Speech as the Agent of Intelligent Cognition.—Dialectical Thought as opposed to
    Thinking in Objective Images.—The  Relative Independence of  Conceptions
    upon Words.............................................................

                                CHAPTER  VIII.
Words as Symbols, and the Facultas Signatrix.—Finkelnburg's Asymbolia, or Ase-
    mia and its Forms.—Relation of Aphasia to Asemia......................... 603

                                CHAPTER  IX
Speech as the Grammatical Moulding of the Material of Thought which has been
    perceived and logically and  metaphysically elaborated.—Speech as a Patho-
    logical Symptom and Object.—Definition of Disturbances of Speech, according
    to their  Nature, as Dyslalia,  Dysarthria, Dysphasia, and Dyslogia or Dysphra-
    sia.—Lalopathia and Logopathia or Logoneuroses.—The Centre of Speech a
    great Central Organic Mechanism......................................... 610

                                 CHAPTER X.
Speech as  a Product of Instruction, of Practice, and of Habit.—Memory a Funda-
    mental Power  of  the Nervous System.—Its most general Vital Conditions.—
    Amnesia Totalis and Partialis.—The Historical Aspect of Speech Amnesia.....614

                                CHAPTER XL
Co-ordination of Movements.—Impelling and Restraining Forces.—Goltz's Croak-
    ing Experiment.......................................................... 621

                                CHAPTER  XII.
Speech and Consciousness.—Deliberation.—Readiness of Speech.................624

                                CHAPTER XIII.
Emotional Readiness of Speech.—Humor  and Disposition.—Mental  Readiness of
    Speech.—Collectedness.—The Speech of the Emotionally Disturbed and of the
    Insane.................................................................. 625

                                CHAPTER  XIV
The Development of Articulation  in the Child.—The Significance of Sounds in  the
    Word................................................................... 629

                                CHAPTER  XV
The Sensory Reflex Sources of Phonetic Speech, and the Regulating Sensory  Prin-
    ciple of Articulation..........................................             qoa 
CONTENTS.
XV
                                CHAPTER XVI.
                                                                            PAGiC
Imitative Articulation.—Is there a Direct Reflex Tract from the Acoustic Nerve to
    the Basal  Centre of Sound, or does it lead through the Cerebrum ?—Experi-
    ments of Vulpian and Danilewsky.—Persistence of Imitative Speech.—Loss of
    Voluntary Speech....................................................... 638

                               CHAPTER XVII.
Interjectional or Emotional Speech.—Its Preservation after the Loss of Voluntary
    Speech.—Explanation thereof.—Theories of Hughlings Jackson and Jaccoud.. 642
                             (Anonymous translator.)

                               CHAPTER  XVIII.
The Phonic Centre below the Corpora Quadrigemina, or Basal Phonic Centre.—Its
    Share in the Formation of Articulate Sounds. —Theories of Cruveilhier, Ley-
    den, Schroeder van der Kolk, and Jaccoud.—Peculiarities  of Structure which
    seem to make the Medulla Oblongata a Suitable Locality for the Co-ordination
    of Phonic Movements.—Clinical Facts which  render  the  Implication of the
    Medulla and Pons in Articulate Utterance a Certainty.—Disorders of Articula-
    tion in  Progressive Bulbar Paralysis.—Significance of the Bulbar Nuclei.—
    Bulbo-nuclear  Stammering.—Disorders  of  Articulate  Speech consequent  on
    various other Lesions of the Medulla Oblongata and Pons, likewise on Insular
    Sclerosis of the Brain and Spinal Cord.—Basal Kinesodic Dysarthries,  Intra-
    cerebral and Extracerebral —Bradylalia and " Scanning" Utterance.—Relation
    of the Mechanism of Phonation to  the  Synthesis of Syllables and Words.—
    Stammering,  Stuttering, Blundering Enunciation of Syllables,  Atactic and
    Amnesic Aphasia. —The Cerebellum in its Relation to Articulate Utterance... 650

                                CHAPTER XIX.
General Account of the Conducting Fibres and  Ganglia  through which  Speech-
    Impulses pass from the Cortex Cerebri to the Basal Phonic Centre.—The Cor-
    pora Quadrigemina  and Optic Thalami  in their Relation  to the Faculty of
    Speech.—The Channels between the Crusta of the Cerebral Peduncles and the
    Cerebral Cortex, as made out by Gudden and Veyssiere.—Anterior and Posterior
    Centro-hemispheric Dysarthries of  Conduction.—In most  Human Brains the
    Main Current of Centrifugal Impulses in  Speaking passes  downward through
    the Left Cerebral Hemisphere, a Side current through the Right One.—The
    Connection of the Motor Channels of Speech with the Central Aggregates of
    Gray Matter.—The  Gray Matter of the  Corpora Strata  in its  Relation  to
    Speech.—Broadbent's Hypothesis.—Unequal Value of  Existing Clinical Mate-
    rials for the Localization of  the Functions concerned  in  Speech, according to
    the Anatomical Nature of the Lesions..—Strio-capsular  and Strio-nuclear Dys-
    arthries.—The Domain of Dysphasic Troubles begins beyond the Corpora Striata
    in  the Hemispheres proper (Hirnmantel).—The Path traversed by the Articu- 
XVI
CONTENTS.
    latory Impulses for Literal Phonation in the Anterior  Portion  of the Corona
    Radiata, and its Relation to the Associative and Commissural Channels  in the
    Hemispheres Proper..................................................... "6*

                                 CHAPTER XX.
Sensory Channels of Language.—Meynert's " Tone-Field."—Central Laboratory of
    Word-Images.—The Problem of the Elaboration of Elementary  Sensations into
    Perceptions with Reference to the Localization of the Mind. —Relation of Con-
    sciousness to the Psychical Functions in General and to Sensation in  Particu-
    lar.—Latent Consciousness, Personal Consciousness (Consciousness of the Ego),'
    and Self-Consciousness.—Lower or Instinctive, and Higher or Intelligent Judg-
    ment.—Relation of the Mechanical  to the  Mental (Psychical) Work of the
    Nervous System.—Excito-motor  Faculty, Goltz's Faculty of Adaptation, Psy-
    cho-motor Faculty, or, Sensory-motor Reflex  Action, Percepto-motor Reflex
    Action, and  Ideo-motor Reflex Action or Free-Will.—Discursive and Intuitive
    Thought.—Explanation of the Marvels of Language by the Laws of Organic
    Evolution, and the Mechanical Principle of Reflex Movement  Inherent in  all
    parts of the Nervous System, including the Cortex Cerebri..................690
                     (Translated by E. Buchanan Baxter, M.D.)

                               CHAPTER  XXI.
Concerning the Functions of the Cortex of the Cerebrum, and their  Localization in
    General.—The Theory of Flourens as to the Functional Equality of the Differ-
    ent Parts of the Cerebrum, and the Law of Substitution in Contrast to Hi zig's
    Theory of the Functional Difference of the Cortical Convolutions.—Deductions
    from Veyssiere's Discovery touching the Functional Difference of the  Anterior
    and Posterior Cortical  Tracts.—The Will  as a Sensory Motor Process, and the
    Act of the Will as a  Realized  and a Suppressed Movement.—Concerning the
    Ganglionic Formation of the Key-board of the Will.—Is it at  once a Motor-
    centre and Centre of Co-ordination, or only the latter?—The Ways of Solving
    this Vexed Question : by Anatomy, by Comparative  Anatomy, by  Experiment,
    and by Clinical Observation.—Experiments by Irritation.—Experiments by
    Mutilation, and the consequent Temporary and  Permanent Disturbances of
    Function.—Explanation  of the Restoration  of Functions.—Character of the
    Permanent Derangements  of  Sensation  and Motion after Mutilation of the
    Cortex.—The Convolutions contain Sensory as well as Motor Apparatuses___705

                               CHAPTER XXII.
The Guiding Principles for the Localization of the Cortical Functions of Speech,
    and the Nature of these Functions.—Experiments touching the Cortical Centre
    of Movements of the Mouth.—Clinical Difficulties in the Localization of the
    Functions of Speech in the Cortex.—Necessity  of the Law of Substitution for
    the Explanation of Clinical  Experiences  as to the  Results of  Circumscribed
    Removal of Cortical Substance.................................           717 
CONTENTS.
xvii
                               CHAPTER XXIII.
                                                                           PAGE
Literature of the Locahzation of Speech.—Gall.—Bouillaud.—Marc Dax.—Broca.
    —Formularization of the Questions to be asked at this Point.—Does the Entire
    Destruction of the Two  Anterior Lobes cause Loss of Speech ?—Do Aphasic
    Disturbances originate only in Lesions of the Anterior Lobes, and especially of
    the Anterior Hemispheres  proper ?—Do Aphasic Derangements occur only, or
    even principally, in Lesions of the Left Cerebral Hemisphere ?—Do Lesions of
    the Left Anterior Lobe lead more frequently to Aphasic and Mingled Anarthvic
    and Aphasic Disturbances than those of  other Portions of  the Brain ?—What
    Region of 4/he Left Anterior Lobe  do we find oftenest Injured in Aphasic De-
    rangements ?—Does the unusually frequent Concurrence of such Derangements
    with a Lesion of the Left Island Region bear any Relation to  the great Fre-
    quency of Left-sided Embolic Softenings ?—Is  the Third Frontal Convolution
    of Vital Importance for Speech ?—What is the Basis of the Pre-eminence of the
    Left over the Right Hemisphere in Speech?—Broca's  Theory.—Causes of the
    Predominating Use of the Right Hand. —Can one distinguish, within the Cor-
    tical Region of  Speech, Centres for the Motor Co-ordination of Words and
    Acoustic Word-Images ?.................................................. 725

                               CHAPTER XXIV.
The Two Great Classes of Cortical Derangements of  Speech:  Dysphasic  and  Dys-
    logic.—The  Conceptions of Aphasia in a Clinical or Practical Sense,  and of
    Aphasia in a Theoretical Sense in Reference to Speech, do not cover  each
    other.—The Aphasia of Practitioners includes also Verbal Anaithria.—Review
    of the  Cortical  Dysphasic Derangements,  which Clinical Teachers include
    within  the  Frame of the  Sketch of  Aphasic  Disease,  and of those which
    they exclude............................................................ 747

                                CHAPTER XXV.
Atactic Aphasia,  Agraphia, and Amimia....................................... 751

                               CHAPTER XXVI.
Amnesic  Aphasia.—Simple Aphasia  of  Recollection (Erinnerungs-Aphasie), and
    Aphasia with more intense Disturbances of Memory.—Influence  of Word-
    Amnesia  and of Aphasia  in  General  upon Mental Activity — Complicated
    Forms of Amnesic Aphasia...............................................757

                              CHAPTER XXVII.
Word-Deafness.—Word-Blindness.—Derangements of the Impressive or Perceptive
    Speech-track in General.—Alexia and Kindred Derangements in the Compre-
    hension of the Symbols of Expression.—Apraxia and Aphasia................ 770

                              CHAPTER XXVIII.
Schematic Diagram of the Centres and Tracks of Speech.......................778
                    (Translated by George B. Shattuck, M.D.) 
xviii
CONTENTS.
                               CHAPTER XXIX.                            pagb

Paraphasia.—Importance of Attention for Correct Speech.—Paraphasia due  to
    Absence of  Mind,  and  Choreic  Paraphasia. — Paragraphia.—Paralexia.—
    v     .  .                                                    ...........  783
    Paramimia.........................................................

                              CHAPTER XXX.
Syntactic Disturbances of Speech.—Agrammatismus and Akataphasia............  791

                                CHAPTER  XXXI.
Aphasia as a Disease, and its Manifold Causes.—Functional Aphasia.—Hysterical
    Speechlessness.—Congenital Aphasia.—Prognosis and Treatment of Aphasia..  798

                              CHAPTER XXXII.
Syllable-stumbling. — Impairment of  Speech  in Progressive Paralysis,  with
    Dementia...............................................................805

                              CHAPTER XXXIII.
Dyslogical Derangements of Speech, or Dysphrasias.—Aphrasia Voluntaria, Parano-
    ica, Superstitiosa,  and Various other Forms of Dysphrasia.—Hemming and
    Hawing, Cluttering, Hesitating and  Confused Speech.—Obstructive  Dysphra-
    sia, Verbal and Thematic Paraphrasia.—Influence  of Words, Word-phantasms,
    and Delusions on Speech.—Perversions of Speech in Idiots, Particularly in
    Microcephalia.—Influence of Congenital Absence  of the  Corpus  Callosum  on
    the Intelligence.........................................................  811

                              CHAPTER XXXIV.
The Two Spasmodic  Laloneuroses: Stuttering and Aphthongia.—Nature, Symp-
    toms, Causes, Diagnosis, Prognosis,  and Treatment of Stuttering.—Remarks
    on Aphthongia..........................................................825

                               CHAPTER XXXV.
Stammering and Lalling.—Dyslalia,  Alalia,  Mogilalia, Paralalia.—Dyslalia  due
    to Deficient Practice and Defective  Education. — Comparison of the Defective
    Articulation of Sounds in  Individuals, Nations, and Races.—Defective Enun-
    ciation of Particular Sounds : Rhotacismus, Pararhotacismus, Lambdacismus,
    etc.—Mechanical Dyslalia.—Hottentotism.—Dyslalia Laryngea, Nasalis Aperta
    and Clausa, Lingualis, Dentalis and Labialis............................... 844

                               CHAPTER XXX"\
Deaf-Mutism and the Education of Deaf-Mutes................................865
                      (Translated by John A  McCreery, M.D.) 
VASO-MOTOR AND TROPHIC NEUROSES.
EULENBURG. 
 
HEMICRANIA.

           (Migraine.)
 Wepfer, Observat. med. pract. de affect, cap.—Fordyce, Historia febris miliaris et de
    hemicrania dissertatio.  London, 1758.—Tissol, Traite  des  nerfs et de leurs
    maladies.  Paris, 1783. T. III. 2.—Schoenlein, Allgemeine und specielle Thera-
    pie. 1832. IV.—Andral, Cours de pathologie  interne (3. ed.). 1839.— Valleix,
    Traite des nevralgies ou affections douloureuses des nerfs. 1841.—Pelletan, De
    la migraine, etc. Paris, 1843.—Romberg,  Lehrbuch der Nervenkrankheiten. 2.
    Ann.  1851. I.—Leubuscher,  Krankheiten des  Nervensystems. 1860.—Da Bins-
    Raymond, Zur Kenntniss der  Hemikranie. Archiv  fur Anat. und Physiol. 1860.
    p. 461.—Brown-Sequard, De  l'hemicranie, etc., in Journal de physiol. 1861.—
    Lebert, Handbuch der praktischen Medicin. 1862.  II. 2.—Eulenburg  and Lan-
    dois, Die vasomotorischen Neurosen. Wiener  med. Wochenschrift. 1867. No.
    87.—Frommhold, Die Migraine und  ihre  Heilung durch  Elektricitiit.  Pest,
    1S68.—Ferrand, Union med.  1868. 14.—Moellendorf, Ueber Hemikranie. Archiv
    fur path. Anat.  XLI.  p. 385.—Hasse, Krankheiten  des Nervensystems. 2. Aufl.
    1869.—Eulenburg, Lehrbuch  der functionellen  Nervenkrankheiten. 1871.—An-
    stie, Neuralgia and the diseases that resemble it. London, 1871.—Alihann, Bei-
    tnige zur Physiologie und Pathologie der Circulation. Dorpat, 1871.—Brunner,
    Zur Casuistik der Pathologie des Sympathicus. Petersb. med. Zeitschrift. N\
    F. II.  1871. p.  260.—Berger, Das  Amylnitrit, ein n(U°s Palliativmittel  bei
    Hemikranie. Berl. klin.  Wochenschrift. 1871.  No. 2.—Hoist,  Ueber das Wesen
    der Hemikranie  und ihre elektrotherapeutische Bchandlung  nach der polaren
    Metliode. Dorpater med.  Zeitschr.  1871. II. p. 261.—Clifford Allbutt, British
    Med. Journal. 1872. 10.—Liveing, On megrim,  sick headache, and some allied
    disorders. London, 1873.—Lasegue, De la migraine, Arch. gen. Nov.  1873. p.
    580.—Berger, Zur Pathogenese  der Hemikranie. Virchow's Archiv. LIX. Heft
    3 und 4. 1874.  p. 315.—E.  Fraenkel, Zur  Pathologie des Hals-Sympathicus.
    Diss. Breslau, 1874.

    By hemicrania we understand a  series of symptoms, of which
the most characteristic are spontaneous  attacks  or fits of pain in 
 4    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

 the head, limited to one side, though often not distinctly bounded.
 As a rule, the intervals between the attacks are quite consider-
 able, and are free from pain.  The disease is usually very chronic,
 tormenting  the  patient for many years, or his whole life, and is
 largely dependent upon congenital  tendencies,  or  predisposition
 to neuropathy.

                           History.

   The name "hemicrania" occurs in the old authors, but not
 always in a  sense exactly corresponding to the description given
 by us.  For instance, BartholinJ  describes  by the  name of
 " hemicrania periodica" a case which seems in all likelihood to
 have been a typical supra-orbital neuralgia, occurring at fixed
 hours in the day.  The older authors in general (Wepfer, Tissot,
 and others)  confound the  disease with supra-orbital neuralgia ;
 even Schoenlein, who classes hemicrania among the neuroses of
 the genital  system, and  names it "hysteria cephalica," places
 the seat of pain in the ramifications of the frontal and  temporal
 nerves.  Among modern pathologists who adopt this position
 may be specially mentioned Lebert, Stokes, Anstie, Clifford All-
 butt.  Those who entertain these views have subdivided the dis-
 ease in a somewhat arbitrary way, according to the presumed or
actual, the predisposing or  occasional, cause. Sauvages assumed
 ten such causes ; Pelletan distinguished a " migraine stomacale,
irienne, uterine,  plethorique ;" Monneret and Fleury, a "mi-
graine  idiopathique" and  " sympathique," in which division
 Valleix coincided, without giving a decided opinion regarding the
localization  of the disease.  Piorry placed the seat of  migraine
in the nerves of the iris !  An important step was taken by Rom-
berg when he associated hemicrania with " hyperesthesia of  the
brain," or cerebral pain, distinguishing it  sharply from periph-
 eral neuralgia, and plainly naming it "neuralgia  cerebralis."
 He was followed by Leubuscher, among others, who calls hemi-
 crania  "true  neuralgia of the brain."  The negative  merit of
 Romberg's view was certainly greater  than the positive ; a dis-

         1 Misc. curiosa sive Ephemerid. nat. curios. I. 1684. p. 130. 
HEMICRANIA.—ETIOLOGY'.
0
tinct demonstration of the cerebral origin of hemicrania was by
no means given by Romberg and Leubuscher.  The  latest steps
in the study  of  hemicrania are  specially  connected with the
interesting observations  of  du Bois-Reymond,  which  led  this
celebrated physiologist to assume that certain forms of migraine
were caused by a unilateral tetanus of the vessels of the head, or
tetanus in the district  supplied  by the cervical sympathetic
("hemicrania  sympathico-tonica").  Moellendorff, on the other
hand, sought at a later  time to show that hemicrania depended
on unilateral relaxation of the vessels of  the head, from want of
energy of the  vaso-motor nerves.   For a number of years  past I
have taken a point  of view  between these two, and affirmed the
partial correctness of both by attempting to show that a certain
class  of cases  of migraine must be understood as vaso-motor in
origin (kk hemicrania vasomotoria"); but this class must be sub-
divided into the  sympathicotonic and  the angio-paralytic or
neuroparalytic forms.    This distinction, which is not without
its value in therapeutics, seems to  have met with rather general
acceptance,  as shown by later works (Brunner,  Berger,  Hoist,
and others).

                          Etiology.

   The etiology of hemicrania, as  of so man^ other neuroses, is
very little understood.  In fact, we know only a number of what
are called "predisposing circumstances "  of so general a charac-
ter that they claim almost equal importance in the causation of
a number of other diseases of the nervous system ; this very cir-
cumstance, however,  is  one  which throws some light upon the
famihr relation between hemicrania and the other  neuroses of
this group, and enables us to refer  them all to one common basis,
under the denomination of "constitutional neuropathies."
   Among these  predisposing circumstances we should attach
very special importance to the influences of sex, age, and heredi-
tary tendency.
   1.  Sex.—The female sex is very much  more disposed to hemi-
crania than  the male, the proportion being about that of 5 to 1.
In the policlinic of  Berlin, among  the poor of the lower orders I 
6     EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

counted in fifteen months only two cases among men to thirteen
in women.  In private  practice among  the better  classes  the
preponderance  among women is equally evident.  It is proper
to remark that the predisposition to neuralgias in general is
decidedly greater among women  than among men ;  but by no
means is  this the case  with the other neuralgias to the same
extent as with hemicrania.   Within the period of time above
specified I counted thirty cases of superficial cutaneous neuralgia
in men to seventy-six in women,  a  proportion of 2 to 5.  The
predisposition of women, however, to  other forms of neuralgia
about the head (those of the trigeminus- and occipitalis) appears
quite as decided as that to hemicrania.  In  my  tables the pro-
portion of cases in males and females respectively was, for trige-
minus neuralgia, 5 to  24 ; for occipital  neuralgia, 2 to  10.  In
neuralgias of the extremities a directly opposite ratio appeared,
viz., brachial neuralgia,  4 to 2; lumbar neuralgia, 3 to 0 ; sciatica,
11 to 3. This predisposition of the female sex to hemicrania, and
to neuralgias of the head in general (trigeminal and occipital),
is certainly a circumstance deserving of attention.  It points out
to us the possible relation of these neuroses to normal or diseased
menstruation, to the catastrophes and crises of the sexual life
in women, to the pathological alienation of the entire nervous
activity (hysteria) which is peculiar to women.  Yet,  on the other
hand, it is beyond question that the male sex may, though more
rarely, be attacked with  neuralgia, and it follows that those
authors have certainly gone too far, who (as for instance, Schoen-
lein) explain hemicrania as simply dependent  upon diseases of
the female generative system, and as a mere symptom of hysteria.
   2. Age.—Youth is decidedly predisposed to the development
(or, more correctly  speaking,  the  outbreak) of migraine.  The
ingenious Tissot  affirmed, albeit with some degree of exaggera-
tion, that the person who should not be attacked  by migraine
before the twenty-fifth year of life would  remain exempt there-
from for  the rest of his days.  The disease may occur  during
childhood, although at this period neuralgia is one  of the rarest
of all occurrences.  The only cases of neuralgia  that  I have
observed  earlier than the tenth year were cases of hemicrania in
girls, developed upon a decided hereditary  basis (see further on). 
HEMICRANIA.—ETIOLOGY.
7
The development of puberty very especially favors the outbreak
of hemicrania;  most hemicranias, whether hereditary  or not,
make their first appearance at this  time.   The period  when
hemicrania is  most common is decidedly that between puberty
and the fiftieth year of life, or  thereabouts;  it is certainly rare
by comparison in later life, as some of the old  cases get well, and
new ones do not develop.
   3. Hereditary predisposition.—The fact of inheritance is as
well  established in hemicrania, and its occurrence is almost as
common, as in various other neuralgias and certain neuroses (epi-
lepsy, paralyses, hysteria, insanity, etc.).  The  disease follows the
female line, being usually inherited from the mother only, and by
the daughters only.  This is a  natural inference from what has
been said  about sexual predisposition.  If hereditary tendency
is present,  girls of even four or five years may be attacked by
migraine, as I have  repeatedly observed.   In  the case of a girl
aged nine, who had had exquisite attacks of hemicrania from her
fourth year upward, the mother had suffered from hemicrania
from her earliest youth, and one sister was subject to epileptic
attacks.   This frequency  of hereditary transmission, and the
related fact of occurrence in childhood, compel  us to include it
with the neuroses above enumerated in the class of constitutional
neuropathies,  first distinctly formulated by  Griesinger,  the
essential characteristic of which class must probably be stated as
consisting  in congenital  anomalies in the primary structural
development of the central nervous apparatus.  It must, however,
be admitted that  no defensible  and  satisfactory statement of
what these anomalies are has }*et been made.   Another circum-
stance adds weight  to this view:  it is extremely  common to
observe, not only a community  in  inheritance, but also  a coin-
cidence  or alternation between  hemicrania and  certain other
members of this  group,  especially epilepsy  and insanity. As
instances of this, it is sufficient to point  out the fact that, in those
epileptics who are predisposed by inheritance and constitution,
attacks of migraine are among the commonest accompaniments
of developed epilepsy, both in early and in later years ; and that
in families which have tendencies to constitutional neuropathic
diseases there are often individual members who  suffer with 
8     EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

migraine, while others are attacked with epilepsy, insanity, and
other morbid conditions of this class.
   The  great probability of a constitutional neuropathic origin
in many cases of  migraine  ought not to mislead us into a one-
sided view, which excludes other causes, as has happened now
and then in the case of other neuroses.  The influence of heredity
and  constitutional  tendency,  however  weighty, ought to  be
balanced in our minds  by the equally important possibility of
other factors, which may be termed, in a sense, accidental.
   Compared with the  predisposing influences of sex, age, and
inheritance,  the  effects  of  such  circumstances as  dyscrasise,
habits of life, social  position, occupation, etc., are less easily
demonstrated in hemicrania.   The influence of certain dyscrasise
in producing  hemicrania cannot, at  all  events, be  distinctly
shown.   Anaemic, chlorotic,   syphilitic, arthritic persons, and
those suffering from  mercurial dyscrasia, are  doubtless often
attacked by hemicrania, but  hardly oftener  in  proportion than
other persons, unless we take the unjustifiable step of calling
every symptomatic headache  in such persons hemicrania, as has
been  done.   Neither has  hemicrania  a  special  right to  be
regarded as a symptom of hysteria, although the headache  of
hysterical persons,  called  "clavus," has  some resemblance  to
hemicrania.   Still less justified are we  in laying weight (as is
often done) upon  the influence of general or so-called abdominal
plethora,  or  of sedentary, idle,  or  too opulent and luxurious
habits.  Hemicrania occurs in all professions and ranks  of life :
it  is a disease of the poor day-laborer's wife as well as of the
rich and blas'ee lady of fashion, although the former is not in a
position to pay as much attention to her migraine and to make
claims upon the attention of others on its account.  Among men
it affects the slender and weakly as well as the robust and those
who bear the  traces of indulgence in  the pleasures  of the table.
While it  is certainly obvious that learned men and those who
work with their heads suffer relatively often from migraine, yet
they owe this fatal favor not to their sedentary life, and still less
to an indulgence in luxury, but rather to the concentrated tension
of their mental activity, to the excess of functional stimulation of
the brain, continuous  or unnaturally increased from time  to time. 
               HEMICRANIA.—SYMPTOMATOLOGY.              9

   Of the  direct causes  of hemicrania  we know really nothing,
and it is better to confess this ignorance at once than to make
long detours in reaching a confession.   That migraine stands in
a certain etiological connection with local or general disturbances
in the circulation of the blood, is a fact that did not escape the
attention of older observers.   The special frequency of attacks
in women at the time of menstruation,  and the identity in type
with the latter phenomenon,  as  well  as the  improvement  or
disappearance  of  the disease after the climacteric period, must
have called their attention to  this point.   The observations and
conclusions recently published by du Bois-Reymond,  Moellen-
dorff, and  others,  respecting the mode in which local disturb-
ances of circulation  occur in  many  cases of migraine,  have
apparently brought the  problem nearer to its  solution ;  but, in
truth, the  result of this has only been the pointing out of the
nervous paths which, by their periodic excess  or  depression of
function, bring about the local disturbances of circulation which
often accompany the attack of migraine.   The causal relation of
these local  disturbances  to the characteristic  and  cardinal phe-
nomena of the attack of migraine is still in great need of an
explanation, and  the real etiology of migraine has, in point of
fact, nothing to show, since the cause of  the abnormal periodic
excitement, or of the periodic variation in the excitability of the
nerve-paths in question,  is completely veiled in obscurity.  (Cf.
below, "Analysis of the Separate Symptoms.")


                         Pathology.
               General  Symptoms and Course.

   The disease called  hemicrania may be  described as a  succes-
sion  of attacks,  between which occur intervals  of longer or
shorter duration,  usually free from symptoms.  The  separate
attacks agree,  on  the whole,  in  certain cardinal symptoms, but
are distinguished by considerable points of difference, sufficient
to justify the establishment of distinct types of disease.
   The attack of migraine is often preceded by certain prodromal
symptoms.   The patient feels on the day before, or in  the fore- 
 10   EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

 noon of the day of the attack, a  slight depression, a sense of
 pressure in the head, weariness, and indisposition to continued
 work.  The attack is often al so preceded by paresthesia in the
 region of the higher  organs of sense (musca3 volitantes, tinnitus
 aurium),  as  well as by a chill, morbid yawning,  sneezing, or
 nausea.  In  some cases a violent enteralgia or gastralgia has
 been observed on the evening preceding each  attack (Tissot,
 Berger) ; in other cases extreme hunger has  been a prodromal
 symptom (Willis).
   The patient  often  wakes  with the characteristic pain; in
 other cases it comes  on by degrees in the course of the day ; but
 it almost never  comes with the lightning rapidity  of neuralgic
 pain, as is  the  case, for example, in  so many attacks of tic
 douloureux, which may also be evoked in its  fullest severity by
 the  most trifling external causes.  The pain of hemicrania, as
 the  name implies,   is generally confined to  one-half  of  the
 cranium, but not so strictly as that the limit of pain does not
 move back and forward across the median line.   The left side is
 far oftener  attacked than  the right—in my observation, in the
 ratio of two to one.   Then  there are not a few persons who are
 attacked by turns on each side ; but in this case one side of the
 head is usually attacked  oftener  and more  severely  than the
 other.  I have observed such cases—which may be designated as
 hemicrania  alternans—in considerable numbers, and must make
 the remark  that this  special  class presents in an exceptionally
 distinct manner the vasomotor disturbances which are presently
 to be described.
   The pain is, on the whole, not  so much a variable or mobile
as a  fixed pain, however great may be its variations in intensity.
It is not usually distributed  uniformly over  the whole side of
the cranium, but is usually worse either on the fore part or else
 on the side or  middle parts—the frontal, parietal, and temporal
regions.  The epithets which patients  apply to it—dull, boring,
bursting—are interesting, as differing from those we commonly
hear in other  neuralgias, especially in prosopalgia (as piercing,
 tearing, darting, etc.), and as  agreeing  more with  the descrip-
 tions applied to clavus hystericus and cephalsea syphilitica.
   Real painful points, in Valleix's sense, are entirely absent 
HEMICRANIA.—SYMPTOMATOLOGY.
11
in pure hemicrania.  The supra-orbital and temporal branches of
the trigeminus are usually insensitive to pressure.  The so-called
parietal  point is  oftener found—a spot  sensitive  to pressure,
somewhat above the tuber parietale, which has been referred, in
rather a forced manner,  sometimes to the recurrent  branch of
the trigeminus, sometimes to  anastomoses of various  cutaneous
nerves (frontal,  temporal, and occipital).   Probably it is merely
a  cas*1 of cutaneous  hyperalgesia, such as often exists in the
attack of migraine, both in a circumscribed and a diffuse form.
In many cases  the greater part of the forehead,  temples, and
parietal  region is  sensitive to very light touches.  On the other
hand, a deep, diffused pressure upon these parts will  often give
some relief to the pain.
    Besides these hyperalgesias  of the affected side of the head,
we find in many attacks of migraine, especially those which are
connected with vaso-motor disturbances, that deep pressure gives
decided  pain when applied to the region  corresponding to the
ganglion cervicale supremum of the cervical sympathetic, or to
the ganglion cermcale medium ; sometimes also when  applied to
the spinous processes of the lowest cervical and the first dorsal
vertebrce.
   Besides these  cutaneous  hyperalgesias, there  may  exist  a
pathological acuteness  of the sense of touch (Jiyperpselaphesia)
in the affected side, as  O. Bergerl has lately shown by accurate
tests  of  the  sensibility in a case accompanied by fluxionary
hyperemia (hemicrania angio-paralytica).  For instance, in cor-
responding parts of the frontal region he found the diameter of
the circle of  perception of touch to be on the right or  affected
side one  line, while on the left side it was four  lines.  Variations
of temperature of 0.4° C. were perceived on the right side, of 0.8°
C. on the left;  and, similarly,  the electro-cutaneous  test indi-
cated sensibility at a minimum distance between the coils of 160
rnillim. on the right, 120 on the left.
   The attack of hemicranial  pain is often conjoined  with nau-
sea,  vomiting, and the  paralgiee  already  mentioned   in  the
region of the opticus  and  the  acusticus,  namely,  muscas voli-
1 Virchow's Archiv. LIX. Heft 3 and 4. p 324. 
12    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

tantes, fiery circles before the eyes, tinnitus, etc.   The unpleas-
ant,  foul  taste,  of  which many patients complain before  and
during the attack, is probably a paralgia of the nerves of taste,
and  is not connected with  gastric derangement,  as is usually
supposed.
   In a great number of cases the attack is accompanied by
peculiar  local irregularities of circulation, temperature,  and
secretion,  and by  peculiar  phenomena in connection with the
eye, which may be comprehended under the designation of vaso-
motor and oculo-pupillar symptoms.   According to the group-
ing and the coincidence  in  point  of time of these phenomena,
two forms, in a sense typical, can be distinguished, which are
marked with perfect clearness in but a few cases, while in  others
they are only confused and indistinct, or irregularly mixed.
   1.  At the height of the  attack the face is pale  and sunken
upon the side which  is  painful, the eye is  sunken, the pupil
dilated, and the  temporal artery feels like a hard cord.  The ear
is also pale, and colder than the other ear; the temperature of
the external meatus may fall from 0.4°  to 0.6° (J., according to
my measurements.  (I cannot regard as correct the much greater
differences of temperature  which  some authors claim to have
found.)  The pain is aggravated by circumstances which increase
the blood-pressure in  the head, as stooping, coughing, etc., and
increases synchronously  with the  pulsations of the carotid.  I
have observed that compression of  the carotid upon the affected
side may also increase the pain  in  such cases, while compression
of the carotid on the well side gives relief.   The salivary secre-
tion may be abundant and viscid (O. Berger).  Towards the end
of the attack the pale part of the face and ear becomes reddened,
with a sensation of heat and a rise in temperature, redness of
the conjunctiva,  lachrymation, and sometimes contraction of the
pupil (previously  dilated) ;  the heart palpitates,  the pulse is
hastened, a general warmth is felt ; there is abundant vomiting,
a desire to make water, discharge  of watery urine, and in some
cases a diarrhceal watery stool.   Attacks following this general
course are called hemicrania spastica or sympathico-tonica.
   2. At the height of the attack the affected side of the face is
reddened, hot, and turgid, the conjunctiva brightly injected, the 
HEMICRANIA.—SYMPTOMATOLOGY.
13
 secretion of tears increased, the pupil more or less closely con-
 tracted.  Sometimes we find also a narrowing of the palpebral
 fissure, retraction of  the globe, and a falling of the upper lid,
 with difficulty in performing  its motions.  The ear of the side
 attacked is also red  and hot;  the temperature  of  the  outer
 meatus is raised—in my observations, from 0.2° to 0.4° C.  The
 secretion of sweat  is increased ; sometimes there  is ephidrosis
 unilateralis.   The  temporal artery is enlarged and beats with
 increased force ;  sometimes the carotid of the affected side does
 the same.  Compression of the last-named vessel eases the pain,
 while  compression of  the other carotid makes it worse.  The
 pulse may be retarded, beating from forty-eight to fifty-six times
 a minute (Moellendorff), while the radial  artery is small and con-
 tracted ;  in some cases  these phenomena are not present.   The
 examination  with the ophthalmoscope shows, in a  few cases,
 dilatation of the arteria and vena centralis retinas on the affected
 side, contortion of the vein, and dilatation of the vessels of the
 choroid, and a darkening of the tint of the fundus oculi (Moel-
 lendorff) ; but sometimes the condition is normal (Berger,  upon
 the authority of  H. Colm's examination).  Towards the end of
 the attack the reddened portions of the face become gradually
 paler, and the other phenomena pass off  at the  same time.   For
 the attacks which follow this type I have proposed  the name of
 hemicrania angioparalytica or neuroparalytica.
   There seems to  be  a rare form  of hemicrania, of which the
 single paroxysms present alternately the  symptoms  of the  sym-
 pathicotonic and of the neuroparalytic  forms.  A case of this
 sort has  lately been described by Berger,1 in which the angio-
 paralytic attacks used to run a milder course than  the sympa-
 thicotonic,  and especially with less vomiting.  I have observed
 a case of this description, in which I was  able to demonstrate in
 some attacks an increase of temperature  in the auditory meatus
of the affected side,  in others a diminution of temperature.
   In  many cases, which present in other respects the sympa-
thico-tonic or the neuro-paralytic type,  the oculo-pupillar symp-
toms are  entirely absent.  Finally, there are cases  of migraine
'L. c. p. 335. 
14    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

which seem to present no local vaso-motor disturbances, in which,
especially, no difference in the color and temperature of the two
sides of the head can be shown to exist during the attack.
   The duration of the attacks is, as a rule, from a few hours to
half a day;  they more  rarely last a whole day or several days,
with  alternations of severity.  The  gradual diminution of the
pain,  which marks the termination of  the attack, is apt to occur
towards evening ; the patient then usually feels exhausted, and
falls into a sleep, from which, in the majority of cases, he awakes
free from pain.  The attacks usually occur  at considerable inter-
vals of time, and quite often repeat themselves in a very distinct
type,  seeming to have a preference for intervals of three or four
weeks.  In the female sex the paroxysms often, but by no means
always, coincide with the appearance of  the catamenia.   The
intervals, as a rule, are quite free from pain, or other morbid
symptoms, except that  there is sometimes a tenderness in the
region of the ganglion supremum and of the spinous processes.
In the atypic cases, and sometimes also in  those which retain a
strict type, bodily and  mental exertions,  mental disturbance
(especially anger), as well as drafts of air, inequalities of temper-
ature, the use of warm  drinks, and  disturbances of digestion,
may aggravate or even bring on an attack.


                 Analysis of the Symptoms.

   For reasons to be explained hereafter, it seems expedient not
to begin the analysis with the cardinal symptom,  pain, but with
the vaso-motor and oculo-pupillar symptoms above sketched.
   The group of symptoms called hemicrania sympathico-tonica
is to be explained by supposing (as is implied in the name, given
by du Bois-Reymond) a unilateral  tonic  spasm  of the vessels
of the head,  caused by tetanus in  the  cervical region of the
sympathetic,  or in the spinal centre of the cervical sympathetic.
The condition of  the temporal artery, the  anemia of  the  face,'
the fall in temperature, the  sunken eye, show that the blood-
vessels of  the suffering half of  the head  are in a state of  tonic
contraction at the height of an attack.  If the  cause which pro-
duces the  contraction is taken away, then the excessive effort is 
            HEMICRANIA.—ANALYSIS  OF SYMPTOMS.           15

followed by a state of relaxation, in which the vessels give way
to lateral pressure more  than usual.  This secondary relaxation
explains the redness of the conjunctival mucous membrane, the
lachrymation,  and the redness and  heat of the ear which occurs
towards the close of the attack.   The tendency to vomit, which
very often  indeed goes with  this form  of  migraine,  can  be
explained by the variations in intracranial blood-pressure, which
are a necessary accompaniment of the fitful contractions of the
vascular muscles, alternating with partial relaxation, as is usual
in tonic spasms.
   A supposed tonic cramp of the vascular  muscles, affecting
the one side of the head  in this  manner, can  only originate,
according to our knowledge  of  physiology, in the sympathetic
nerve of the corresponding side, or in the spinal centre for the
fibres of the sympathetic—that is, in the corresponding half of
the cilio-spinal region of the cord.  This form of  migraine is
therefore to be referred to a morbid stale of the cervical  sympa-
thetic, or of the corresponding region of the cervical cord, which
is liable to  periodic aggravations.  In favor of this hypothesis
the following reasons may be urged with special force ;
   1.  The alterations in the pupil.—The dilatation during the
height of the attack depends on an increase in  the tonic excita-
tion of the  dilator fibres, which arise from the  cilio-spinal centre
and follow the course of the cervical sympathetic ; the subse-
quent contraction  depends on a secondary  diminution  in in-
nervation,  corresponding to the  condition of the vaso-motor
fibres.
   2.  The local  sensitiveness in the region of the ganglion cer-
vical e supremum {sometimes also the g. c. medium), and at the
spinous processes of the lowest  cervical and  uppermost dorsal
vertebra, corresponding  to the  regio cilio-spinalis of the  cord ;
occurring during the attack, and sometimes even in the intervals
of freedom from pain.
   3. It is  also proper to mention  the increase in the salivary
secretion (which is sometimes greater, sometimes less ; Berger
saw over two pounds discharged  in  a  single attack),  and  its
increased viscidity; for there are secretory fibres destined for
the salivary glands which follow the course of the cervical sym- 
16    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

pathetic,  experimental irritation of which produces a parallel
effect in animals.
   The objection made by Brown-Sequard and Althann against
the supposition of a unilateral tetanus of the vessels of the head,
namely, that Kussmaul and Tenner s experiments have proved
that arterial anemia of the brain must produce epileptic spasms,
cannot  be sustained ; for when the cervical sympathetic is actu-
ally irritated in experiments,  or its central end  is tetanized, we
see only the symptoms of unilateral contraction of the vessels,
and  lowering of temperature without  convulsions.  The same is
the fact in pathological irritations of the sympathetic of unques-
tionable character in the human subject.1  Probably in  hemi-
crania sympathico-tonica there is nothing like an equal anemia
of the entire half of the brain, but rather a temporary inequality
in the circulation of the several provinces and regions—perhaps
especially in  the case of the layers of  the cortex, which are sup-
plied from the vessels of the pia.
   The  symptoms  of hemicrania  angio- or neuro-paralytica
are to be referred to a condition the reverse of the preceding—a
condition  of relaxation of the blood-vessels  in  one half of the
head, caused by a diminished innervation  of  the vessels, and
therefore due to a lessened action on the part of the correspond-
ing cervical sympathetic or its spinal centre.  The redness, heat,
and swelling of the side of the face,  the injection of the conjunc-
tiva, the lachrymation, the redness and increased temperature of
the ear, the increased secretion of sweat, the occasional ephidro-
sis unilateralis, the dilatation of the temporal  artery and carotid,
the dilatation,  demonstrated in some cases, of the vessels of the
fundus  oculi, are easily  explicable by the  relaxation  and in-
creased fullness of the vessels of the head, by the arterial hyper-
emia due  to diminution of the  activity of the vascular nerves.
Whether this relaxation of the vessels of the head may be pre-
ceded by  a stage of primary contraction, of  spastic cramp, per-
haps of very  short duration, has as yet neither been proved nor
disproved by any direct observation.
  1 Cf. Eulenburg and Guttmann, Die Pathologie des Sympathicus. Berlin 1873.
3 et seq. 
             HEMICRANIA.—ANALYSIS OF SYMPTOMS.          17

    The hypothesis of affection of  the cervical sympathetic or its
 spinal centre in hemicrania  angio-paralytica is supported, not
 only by the local tenderness  of the sympathetic and the spinous
 processes, which is often demonstrable, but more particularly by
 the concomitant oculo-pupillar symptoms.  The contraction  of
 the pupil depends on a loss of energy in the dilator fibres which
 run in  the cervical sympathetic ; the narrowing of the palpebral
 fissure, the retraction of the bulbus, the occasional ptosis, depend
 on a loss of energy  in  the smooth (non-striated) muscles of the
 eyelids,  discovered  by H.  Mueller  (especially the palpebralis
 superior and the muse, orbitalis).1  These symptoms  are well
 known as following  the experimental section of the sympathetic
 in animals,  and as accompanying a great variety of pathological
 conditions in man, which involve an interference with the conduc-
 tivity of the  cervical  sympathetic (as inflammation,  compres-
 sion by tumors, wounds, especially those that divide the nerve,
 etc.).  It is impossible to go farther into this point at present.
    The retardation of the pulse during  the  attack is probably a
 s}rmptom of partial  hyperemia of the brain due to relaxation of
 vessels, or of the consecutive anemia  of  other regions  of the
 brain,  especially the medulla oblongata.  According  to  the in-
 vestigations of  Landois, retardation of  the pulse occurs both in
 artificial anemia and  in the (venous)  hyperemia  of  the brain
 produced by compression of  the  superior vena cava ; this is the
 case even after  extirpation of both cervical sympathetics, but not
 after destruction of the medulla oblongata or  section of both
 vagi.  This retardation of the pulse,  which in case of a maximum
 of cerebral hyperemia may go to the extent of arresting  the heart
 and may be connected with epileptiform convulsions, depends,  as
 Landois  has shown, upon  a direct, not  a reflex irritation of the
 medulla oblongata  and the  vagi; section of the latter  in the
 period of hyperemic retardation of the pulse is directly followed
 by increased rapidity of the pulse.2
    The medulla oblongata being also the centre of  most of the

   1 Cf. Hoi'ner. Ueber eine Form von Ptosis.  Monatsbl. f. Augenheilkunde. 1869. VII.
 p. 193.  Nicati, La  paralysie du nerf sympathique  cervical. Etude clinique.  Lau-
; sanne, 1873.
   s Centralbl. f. d. med. Wiss.  1865. No. 44 ; 1867. No. 10.
           VOL.  XIV.—2 
 18   EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

 vaso-motor nerves of the body, it follows that an irritation of this
 important part of the brain is entirely adequate to explain the
 small and contracted radial artery observed in this sort of cases
 (Moellendorff), the  icy coldness of hands and  feet,  not to be
 relieved, the chilly sensations felt over the whole surface of the
 body, and, finally, the suppression of the perspiration during the
 attack,  often with the sole exception of the affected side of the
 head.   The contraction of the peripheral arteries caused by the
 increase of tone is followed, as always, by a stage of dilatation, of
 secondary relaxation.   The latter  condition  may explain the
 phenomena of increased secretion of  saliva and urine, as also
 the swelling of the  liver and hypersecretion  of bile described
 by Moellendorff,  and the increasing plethora of the abdominal
 organs and inclination to broncho-tracheal catarrhs and emphy-
 sema of the lungs.   (See below.)
   If we now turn to the  cardinal and  pathognomonic symptom
 of hemicrania, the unilateral pain, occurring only at intervals,
 we encounter  the double question:  Where, in what regions of
 the peripheral or central nervous system, does the hemicranial
 pain originate % And how does it originate ? Unfortunately, we
 cannot answer the first question at all, at the present time;  the
 second we can answer only hypothetically.
   As regards the seat of pain, we have already pointed out that
 most of the older, and many of the later authors place it in the
 cutaneous (frontal) branches of the first division of the trigeminus;
 yet, so great a number of points have  been shown  in  which the
 neuralgias of these branches of the trigeminus differ from hemi-
 crania, that the above view can hardly be regarded as admissible.
 If it be  assumed that the trigeminus is concerned  in the  origina-
 tion of  the pain, we  ought, I think, at all events to restrict our
 assumption  to those branches which go to  the dura mater, and
 which, by  the way, arise from all three divisions of the trigeminus,
namely: the nervus  tentorii of Arnold, from the first division,
which passes  through the tentorium to the sinuses,  a branch
running with the arteria  meningea media from the second divi-
 sion, and  the nervus spinosus of  Luschka from the  third.  The
 possibility that these nerve-branches may be implicated in hemi-
 crania can neither be directly disproved nor directly proved ; at 
            HEMICRANIA. — ANALYSIS OF SYMPTOMS.          19

the most, the character and apparent localization of the sensation
of pain (see above) might  be regarded as supporting  the  view
that it  originates within the dura  mater.   We know  nothing
certain of the nerves of the arachnoid ;  but  in  the pia numerous
nerves are found, following the vessels  in the form of plexuses,
and some of  them entering the cortex along with  the vessels
(Koelliker).   These nerves originate in part from  the  vertebral
and carotid  plexuses of the  sympathetic, but  partly also  from
cerebral nerves  at  their exit (Bochdalek),  and especially  from
the trigeminus.   Probably all or most of these nerves must be
regarded as  vascular nerves ; and probably we are not in error in
ascribing to them, as we shall immediately explain,  a  consider-
able part, whether direct or indirect, in the origin of hemicranial
pain.
    Romberg's view, which located the pain in the cerebral mass,
had no other essential foundation  than the " associated sensa-
tions" occurring in the  region of the fifth nerve and the nerves of
sense, and the manifest injurious influence of moral  and mental
exertions.   The uncertainty of these  foundations  is  evident;
Hasse1 also  remarks, and correctly, that, judging from  the anal-
ogy of the other neuralgias,  "associated sensations" of several
cerebral nerves  and reflex  phenomena caused  by them are no
reason for  refusing to regard  the  intracranial and meningeal
branches of  the trigeminus as equally the seat of pain.
   In cases of hemicrania sympathico-tonica, du Bois-Reymond
first proposed the theory  that the  tonic spasm of  the smooth
muscular fibres of the vessels themselves was what  was felt as
pain, after the analogy of those painful sensations which occur
in the striped muscles  in spasm of the  calves, or in tetanus, and
in the smooth muscles of the uterus in labor, the intestine during
colic, etc., or as  the skin is found to be  painful in the cold stage
of intermittent fever.    Probably this pain is caused by pressure
upon the nerves  of sensation that are distributed in the muscles;
this pressure, and in consequence the pain also, will increase
when the tetanized muscles are subjected to an  increase of ten-
sion, as is, for instance,  the case in spasm of the calves when the
1 Krankheiten des Nervensystems. 2d Ed. p. 73. 
20    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

muscles are stretched by means of their antagonists, or by sup-
porting the soles of the i'eet and resting the weight of the body
on the latter.  The same effect will be produced, in case of  teta-
nus of the muscles of the vessels,  by an  increase of lateral blood-
pressure within the vessels.   Thus the observation that the pain
increases with the  rise in blood-pressure, and simultaneously
with  the pulsations of the  temporal artery, finds  a rational
explanation.
   This ingenious  theory of du Bois-Reymond's  does not  fit
cases of hemicrania neuro-paralytica, nor those cases of migraine
which are  unaccompanied by any marked  vaso-motor disturb-
ances.  It  seems to me, therefore, that  another interpretation of
the pain is preferable—one applicable to the latter cases as well
as the former, and less indirectly.  The variations in the arterial
supply, the temporary anemia or hyperemia of the  half of the
head, might furnish a cause  for irritation of  the sensitive nerves
of the head, either in the skin, the  pericranium, the meninges,
the sensitive regions of the brain  itself, or  in all these parts
together, and such irritation might cause the hemicranial par-
oxysm.  That nerves of  sensation  are intensely  excited, and
react with  pain when the  calibre  of  the vessels that  accompany
and irrigate them is altered, and especially when this alteration
takes place with some suddenness,  is a fact not rarely observed
in a great variety of neuralgias (prosopalgia, sciatica, etc.); the
neuralgias which zoster causes—principally  in the  trunk,  but
also in the face and  extremities—may be referred with great
probability to this source ; and,  in  general, local and systemic
anomalies  in circulation may be looked on as one  of  the  most
important  causes of neuralgic affections in the nerves of almost
any part.   The increase in the  pain  of  hemicrania upon bowing
forward, coughing, etc., the peculiar influence of compression of
the carotids, are likewise explained by the variations of intracra-
nial blood-pressure.  The case  above  described, in  which  the
pain increased when the carotid of the same side was compressed,
and diminished when that of the other side was compressed, shows
very strikingly,  at any rate, the favoring influence of local anae-
mia.   Probably, in migraine, the local anomalies of circulation,
without regard to their special mode of origin, are to be regarded 
            HEMICRANIA.—ANALYSIS OF SYMPTOMS.          21

as the essential and universal causal condition, while, on the
other hand, tetanus or relaxation of the muscles of the vessels
exercises rather an indirect influence, confined to single cases,
and acting through the local anosmia or hyperemia of which it
is an important cause.  The inequality and inconstancy of the
oculo-pupillar and  of the vaso-motor phenomena as well, speak
loudly in favor of this view.  It cannot appear at all unaccount-
able that, in the angio-paraly tic and hyperemic form of migraine,
temporary increase of  blood-pressure, increased fullness of the
small arterial  and venous vessels, should act as an irritant upon
the sensitive nerves exactly as the opposite condition of vascular
spasm  and local anemia does.  Experiments have proved that
diminution and increase of the supply of blood, local hyperemia
and  anemia,  agree in  many other respects in  their mode of
action ; that,  for  instance, the well-known epileptoid  attacks
occur not only in anemia of  the  brain (as in the experiments of
Kussmaul and Tenner), but also in hyperemia of the same organ,
caused by arrest of the venous current discharged from the brain
by closure of the vena cava superior ;* and that, in like manner,
the effect  upon the heart's activity and the rate of the pulse is
quite analogous in both cases.
   If the interpretation of the hemicranial pain here given is the
correct one, it explains also some of the minor symptoms,  such as
the paralgio3 in the province of the nerves of sense, which may
with probability be referred to irritation of their respective cen-
tral organs (or perhaps of their  peripheral apparatus ?) in conse-
quence of  the  periodic vacillation in the supply of blood.  The
cutaneous hyperalgesia, the hyperpselaphesia observed in a few
cases (larger),  are likewise referable to the change in the amount
of blood held by the skin, especially in the case of arterial lry-
peremia of the latter.   The  tendency to vomit was referred by
du Bois-Reymond to fluctuations in the blood-pressure within
the brain, which, however, may be due, not  solely to spasm of
the vessels, increasing and  relaxing by turns, but  also to some
other causes of a mechanical  nature  capable of producing ane-
mia or hyperemia.  The ecchymoses in the conjunctiva of the
1 Hermann and Escher in Pflu ger's Archiv. 1870. p. 3.        * Landois, 1. c. 
22    EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

corresponding eye, observed by Berger as accompanying hyper*
emesis, depend probably upon the mechanical action of violent
vomiting, during a period of  changed  tension in the  vascular
walls that predisposes them  to rupture.   The watery stools
observed at the close of certain attacks are probably due, like
other excesses of secretion that occur at this time, to the general
condition of secondary exhaustion of the vaso-motor nerves after
spasm of the latter.   In this synopsis many special points have
to remain comparatively neglected for want of space.

                   Course and Prognosis.

   The course of migraine is very chronic,  with hardly an excep-
tion.  The disease may last a lifetime, or the greater part of one,
sometimes with scarcely any change in severity, sometimes with
an increase or diminution.  But it very often happens that, with
the advance  of age—say  after the fifty-fifth year of life—the
attacks gradually become less frequent, and even wholly cease;
the climacteric years of women  seem especially to exercise a favor-
able  influence in this respect.   In a few cases the malady disap-
pears at an earlier period spontaneously, or under the influence
of remedies.  This I have observed chiefly in young persons who
were free from  any demonstrable predisposition, such as heredi-
tary  tendency, etc.
   The prognosis of hemicrania may be called favorable, in so
far as it never directly produces any severe effects  which seri-
ously threaten health or life.   Although Moellendorff says that
a "plethora  of the abdominal organs" and a great  tendency
to broncho-tracheal catarrhs and emphysema of  the lungs are
developed in all persons who are subject to migraine, yet it must
be said that this is a most exaggerated statement;  the matters
it refers to are not properly the consequence of migraine as such,
but are co-ordinate effects of the same cause—namely,  of those
local  and general  disturbances of  circulation  which  we  have
learned to recognize as prominent factors of hemicrania.
   On the  other hand, the  prognosis is decidedly unfavorable
as regards the disease itself.   A spontaneous disappearance  is
rarely to be hoped for  in youth, and not  with  certainty in old 
HEMICRANIA.—TREATMENT.
28
age.  The results of treatment are, upon the whole, very unsat-
isfactory, yet it must be  admitted that of late  our improved
knowledge of the  causes  of  the  complaint has enabled us  to
enter upon a rational plan  of treatment,  which  is  somewhat
more successful.   Old cases, and  those  dependent on a heredi-
tary taint  (neuropathic  predisposition),  present  of  course  the
least hope of a cure, either spontaneously or by treatment.

                          Treatment.

   A treatment directed to the causes  of hemicrania, in our
present state  of ignorance of these causes, is but too plainly
impossible.   As for those special  cases  in  which a  unilateral
tetanus or paralysis of  the vessels of  the head produces  the
attacks of  pain, the causes which  periodically  excite or depress
the cervical sympathetic or its spinal  centre, and the nature of
the sympathetic affection itself, are entirely obscure at present.
   The treatment required by the disease is partly general—that
is, corresponding at least in theory to the indicatio morbi; and
partly symptomatic or palliative, consisting in attempts to con-
quer the single attacks.   Of  the general treatment, the greater
part depends on empiricism ;  of  the  palliative,  a  few points,
deserving of attention at least, are rationally derived from late
pathological  discoveries.   It  is, however,  not always  easy  to
draw a sharp line between these two classes of  treatment, in the
case of the  remedies most in use.
   Among  the great number  of remedies administered empiri-
cally, the preparations of iron, quinia, and caffein are by far the
most popular, and certainty not without reason, although the
universal agreement in praising them  seems to show  that they
have usually been adopted without clear  views, or even with
quite wrong  views of their action.  The preparations of  iron,
especially the carbonate,  so much praised by Hutchinson, Stokes,
and others, are hardly specifics against migraine, but may serve
to improve  the constitution of anemic  and weakly persons who
are  victims  of migraine as of other  forms of neuralgia.   In
recommending quinia, as also such analogous remedies as quin-
oidin and bebeerin, the anti-periodic effects of  the remedy have 
24    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

been chiefly regarded, and  the  tolerably regular recurrence of
the attack has encouraged a hope of corresponding success with
the remedy.  But experience shows that the use of quinia, no
matter in what form, does not ordinarily affect  the regular peri-
odicity of the attacks, especially when they occur at wide inter-
vals ;  but that a considerable dose  of quinia (from seven and a
half to eighteen grains), given once or  more often,  may some-
times shorten an attack or arrest it at once.  It is  possible, as
A. Bernatrik' and others have pointed  out, that this  favorable
effect of quinia,  and the  analogous action of caffein,  depend
chiefly on the fact that  the drugs produce an increased activity
of the vaso-motor nerves, an elevation of arterial tension, in cases
where  this is pathologically depressed.   At least, according to
some observations, the quinia seems to have the greatest effect in
the angio-paralytic or neuro-paralytic form of migraine.2
   Caffein is given either pure or in the form of citrate, which is
really only a mechanical mixture of caffein and citric acid ; and
usually in pastilles, containing from one-half to one grain each.
This is probably the most popular prescription in migraine.  I
must confess that the continued use of caffein in the inter-parox-
ysmal periods seems to  me, like that of quinia, to be of  less value
than the single or repeated large dose of  one or two grains before
or during the attack.   The same is the case with the subcutane-
ous administration of caffein, which I have tried repeatedly.  The
guarana paste, which has been much praised as a specific, and
recently by Wilks 3 among others, and which has been needlessly
incorporated into the German pharmacopoeia, is known  to  con-
tain as its active principle guaranin, which is perfectly identical
with caffein.   Thanks to the puffs it has received, it  still retains
a special popularity with those who suffer from migraine.
   These  facts entitle  us  to  place a  special confidence in the
action of  another  remedy, in cases of the angio-paralytic form.
This remedy is ergotin (aqueous  extract of ergot), which we
know  to produce contractions of the blood-vessels  ;  an action
1 Wiener Med. Presse. 1867.  No. 28.
2 Cf. Eulenburg and Guttmann. Pathologie des Sympathicus. p. 26.
3 British Med. Journ. April 20, 1872. 
HEMICRANIA.—TREATMENT.
25
which, according to Wernich, Holmes, P. Yogt,1 and others, is
probably  effected by  means  of the vaso-motor centre in the
medulla  oblongata.   I  have lately used  this  remedy (which
Woakes2 recommends very highly), both in migraine and in the
non-unilateral cephalalgia vasomotoria,3 with decided success,  in
doses of from nine to fourteen grains daily in  the form of pills.
Berger4 employed the  remedy in the form of subcutaneous injec-
tions in two cases of angio-pararytic hemicrania, with a repeat-
edly favorable action upon the symptoms.
   I will  mention  only a few other remedies — some of recent
renown, others of an old fame newly revived.   Such are strych-
nia, arsenic, nitrate of  silver (Clifford Allbutt),  sulphate of nickel
(Simpson), bromide of  potassium (Ferrand, J. D. Davis), chloride
of ammonium  (Anstie),  oil of turpentine (Warburton  Begbie),
lupulin (Huguier).    In former times  the  "digestives" were
popular, especially the  great multitude of  bitter and aromatic
remedies.   The  causal relations of migraine to disturbances  of
digestion, especially to those of the stomach, which were said  to
be removed by the latter remedies,  are  quite as problematical as
are the curative successes of the drugs in the  presence  of the
actual disease.
   Among the sjias and loater-cures, the best  reputation is pos-
sessed by  the iron springs and iron-moor-baths (Pyrmont, Fran-
zensbad, Schwalbach, Reinerz), and the sea-bath ; the reputation
is not undeserved, though the benefit is usually for the most part
transitory.  The continued use  of  the  treatment in cold water
establishments, and the residence in lofty mountain regions (as
St. Moritz, where there are also iron-springs), have often proved
of benefit in my  experience.
   In treating the  single attack, it has long  been  known that
certain precautionary measures are indispensable, in order to
exclude as far as possible external sources of  irritation, and to
ensure mental and  physical quiet.   The posture should be that
of rest, and in the anemic form the patient should lie flat on the

              1  Berliner klin. Wochenschrift. 1872. No. 10.
              2 British Med. Journ. 1868. II. p. 360.
              "Berliner  klin. Wochenschrift. 1873. No. 15.
              4 L. c. p. 330. 
 26   EULENBURG.— VASO-MOTOR AND TROPHIC NEUROSES.

 back, with the head a little raised ; she should remain in a moder-
 ately lighted chamber, noises and disturbance of every sort being-
 kept away. These are indispensable precautions during an attack
 of hemicrania, and they usually diminish its severity and dura-
 tion.  The administration of palliative medicines, however, is
 found less useful upon the whole than in other forms  of  neural-
 gia ; sometimes they seem even to do harm, by annoying and
 disquieting the patient, who often longs for nothing more than
 to be let alone, knowing  full well from her  own experience and
 that of others how uncertain is  the effect of remedies.  In such
 cases,  therefore,  we  should avoid the useless  and unwelcome
 7roXv7rpay/xoavpr), which is so  unsuitable to  the  character of a
 scientific physician.   Among the older palliatives, cold and com-
 pression often do some good, though but to a very slight and
 temporary extent.  It is  very proper to keep an ice-bag applied
 for a long time to the forehead and temple.  The weight of the
 bag has also an advantage in the compression it exercises ; for
 this reason, and because of its  superior cooling effect, it finds no
 substitute in  cold applications or even ice-cloths ;  besides, all
 wet applications have to be changed often, wet  the patient, and
 therefore, if they do  not  produce a very speedy and convincing
 effect, must be soon given up.
    Compression of the head against a firm body, by the support-
 ing hand or by a cloth wound firmly about the head, are palliative
 remedies, known to most patients, but very  slight and transient
 in their effects.  Of much  more certain result, in the cases before
 described, is the compression of the carotid, a procedure which
 only the physician himself can execute, which most patients bear
 unwillingly, and but a short time, and which relieves only for so
 long as it is actually applied.
   In regard  to the  use  of narcotics  during the  attack, the
 opinion expressed  concerning palliatives in general will apply—
 whether  the administration by  the mouth or the  subcutaneous
 syringe is preferred, whether opium and its  alkaloids, or bella-
donna and similar  remedies  are tried.  The comparatively, small
benefit of  hypodermic injections in  hemicrania,  as compared
with their success in other neuralgias, must be ascribed partly to
the circumstance  that in  this  case  no single  nerve-branch or 
HEMICRANIA.—TREATMENT.
27
cutaneous nerve-district is  affected, so  that the favorable local
action of  the narcotic is of no advantage.   Thus, ex juvantibus
el  non juvantibus, it is often easy to  distinguish a hemicrania
from a frontal neuralgia.  If a few physicians have observed very
good  results, and sometimes a permanent  cure, from  the injec-
tion of morphine in hemicrania, it is possible that in such cases
there  may have occurred a confounding of hemicrania with symp-
tomatic headache of another sort, or with  frontal and temporal
neuralgias.
   The epidermic application of narcotics  and anesthetics (e. g.,
friction wuth  ointment  of belladonna or  veratria, rubbing  the
head with pomade of chloroform, according to Cazenave's direc-
tions)  is  certainly of still  slighter value,  though not  wholly
doubtful.
   Of the symptomatic action of quinia,  caffein, and ergotin in
the angio-paralytic form of migraine, we  have spoken before.   On
the other hand, another and a very recent remedy seems to play
an important  part  in the sympathico-tonic form, namely,  the
nitrite of amyl.   The indication for its use depends on the fact
that it possesses the power of dilating the blood-vessels, although
whether  by acting on their contractile elements (Richardson,1
Lauder Brunton,2 Wood3) or by paralyzing the vaso-motor sys-
tem (Bernheim 4 and others), is as  yet unsettled ;  when inspired,
it  causes almost instantly an intense reddening of the face, a feel-
ing of great heat in the head and face, injection of the conjunc-
tiva, great acceleration of the  pulse, with  diminished tension of
the radialis ; if the inhalation is continued, symptoms of fainting
may easily supervene.   Berger5 first used the nitrite of amyl in
a case of migraine, evidently of the sympathico-tonic form, with
almost instant effect;  the pain was "charmed away," as it were,
and did  not return during the day.  Vogel and Hoist,6 and I
  1 Med. Times and Gazette. 1870. II. p. 469.
  2 Arbeiten des physiologischen Instituts zu Leipzig. 1869. p. 101.
  3 American Jour, of Med. Science. July, 1871, p. 39, and Oct. p. 359.
  4 Pfiueger's Archiv f. Phys. VIII. p.  254.  Compare also Eulenburg and Guttmann,
Zur Kenntniss und Wirkung des Amylnitrits. ReicherVs und du Bois-Reymonds Archiv.
1873. p. 441. Pick, Centralblatt. 1S73. No. 55.
  6 Berliner klin. Wochenschr. 1871. No. 2.
  6 Dorpater med. Zeitschrift, 1871. II. p. 261. 
28    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

myself also, have seen the momentary disappearance of the pain
in cases that presented the features of vascular spasm, but the
pain returned in most  instances after some time.  In these inha-
lations the greatest care must  be taken, especially if the  patient
is anemic ;  beginning with a  dose of one  drop,  we may  by
degrees rise to three  or five drops, and in  case of need repeat
the inhalation after a time.   Anything more than a palliation
of the trouble I have never  seen; but Hoist  states that in a
female patient the attack itself was not only cut short, but the
following attack was postponed longer than usual.
   Hoist stated, as the result of observation in his own case,
that in pronounced attacks of migraine the free use of any warm
drink gave relief at the moment when general perspiration broke
out.  It  is necessary to remind the reader that in many cases of
migraine the use  of  warm  drinks provokes  or aggravates  the
attacks.  The inhalation of carbonic oxide gas, praised by A.
Mayer,1 may perhaps  derive its good effects from the known fact
that it paralyzes the vaso-motor nerves, and thus may probably
remove a temporary spasmodic condition of these nerves.
   Another modern remedy of great importance, both in reliev-
ing the symptoms of various  forms of migraine,  and perhaps
also in accomplishing a permanent cure, is the constant galvanic
current.
   This remedy seems to have a destiny, such as hardly any
other possesses, in the treatment of hemicrania, for it places in
our hands the power of exercising a real and  powerful influence,
locally limited, regulable in respect to quantity and quality,
upon the cervical sympathetic and the upper  regions  of  the
spinal  cord in the human  subject.   The   electrical  method,
based in part  upon   du Bois-Reymond's  and Moellendorffs
theories,  and in part developed  independently,  has  therefore
accomplished much in conquering the disease, and  has success-
fully adopted certain empirical procedures in its treatment.  Ex-
amples are  furnished by Benedikt,2 Frommhold,3  Fieber,4 M.

         1 Wiener med. Presse. 1865. No. 46.
         2 Elektrotherapie. Vienna. 1868 [and new ed. in 1875].
         3 Die Migraine und ihre Heilung durch Elektricitat. Pesth,  1868.
         i Compendium der Elektrotherapie. Vienna, 1869. 
HEMICRANIA.—TREATMENT.
29
Rosenthal,1 Althans," and others.  Hoist3 was the first to carry
out practically, in connection with the polar method of Brenner,4
a really methodical  and rational application of the constant
current, based on the diagnosis of the several forms of migraine,
a point upon which I insisted as necessary, several years ago.
   Hoist's method consisted  in placing one electrode, the one
from which  special action was expected, upon the cervical  part
of the sympathetic, at the inner edge of the sterno-cleido-mastoid
muscle—this electrode is long and narrow and has considerable
surface ; the other one is placed on the palm of the hand, and the
circuit closed.  In hemicrania sympathico-tonica the pole on the
neck was made  positive ; the current (from ten to fifteen ele-
ments) was closed suddenly, and after a passage of two or three
minutes was gradually stopped.  In hemicrania neuroparalytica,
on the contrary, the negative  pole was applied to the above spot,
while the current was not only suddenly closed in the metallic
part of  the  circuit, but was made to produce a powerful excita-
tion by  means of repeated closures and openings, or in some cases
by reversals.  The former procedure, intended to  bring about a
direct diminution of the excitement, was used more commonly
by Hoist, especially in cases where the condition of  the muscles
of the vessels was uncertain;  for he regards as the primary cause
of  every  hemicrania, even if  it manifests itself in its  secondary
stage of paralysis, an abnormal excess of excitability of the vaso-
motor nervous system of certain vascular territories (or cerebral
regions);  and when this abnormal  excitability is lessened, it is
probable  that the disposition to a secondary stage of  relaxation
of  the  vascular  walls is removed.   The  observations made  by
Hoist, some thirty in number,  are  very much in favor of the
practice above described.   Usually a sense of comfort and relief
came in a very short  time ; in a few cases  there was a lengthen-
ing of the intervals  between attacks.
    The  induced  current has also been recommended, especially
by Frommhold and  Fieber.   The  former prefers the primary

   1 Handbuch der Diagnostik und Therapie der Nervenkrankheiten. Erlangen, 1870.
   J Treatise on medical electricity, etc. 3d edition. London, 1873.
   3 L. c, p. 275 et seq.
   4 Lehrbuch der functionellen Nervenkrankheiten. p. 131. 
30    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

induced current, and applies one of the poles to the median line
of the back of the neck, high up, the other upon the forehead or
the arcus  superciliaris.   Fieber recommends the use  of  the
so-called electric hand: the patient takes one conductor in his
hand, the operator holds  the other in his left hand, while press-
ing the palm of his right firmly  upon  the patient's forehead,
which  is previously wetted.  Fieber says that  this  treatment
seldom fails, and sometimes produces surprising results.   Alt-
haus, on the contrary, found faradization useless in most cases,
while the passing of the constant current continuously through
the head was of value. 
ANGINA   PECTORIS.
Rougnon, Lettre addressee a M. Lory, sur une maladie nouvelle. Besanoon, 1768.—
    Heberden, Med. Transact. Vol. III.  1772.—Forbes, Cyclopaedia of Pract.  Med.
    Vol. I.—Desportes, Traite de l'angine de poitrine.  Paris, 1811.—Jurine, Memoire
    sur l'angine de poitrine. Paris, 1815.—Laennec, Traite de l'auscultation. 2. ed.
    II.—J!  Heine, Ueber die organische Ursache  der Ilerzbewegung. Archiv f.
    Psych. 1841. p. 236.—Larligue, Memoire sur l'angine de poitrine. Paris, 1846.
    Gaz. med. 1847. No.  39.—Canstatt, Klinische Riickblicke und Abhandlungen.
    Erlangen, 1848.—Trousseau, De la nevralgie epileptiforme. Arch. gen. de med.
    1853. Jan. p. 33.—Philipp, Deutsche Klinik. 1853. No. 41.—Romberg, Lehrbuch
    der Nervenkrankheiten. 3. Aufl. 1855.— Willcs, Med. Times  and Gaz. 1855. No.
    246.— Waldeck, Deutsche Klinik. 1856. p. 437.—Bamberger, Krankheiten des
    Herzcns. 1857.— Oppolzer, Wiener med. Wochenschrift. 1858. p. 721.—Fincham,
    Med. Times and Gazette. 1859. p. 591—Mason, British Med. Journal. Oct. 1859.—
    Moorhead, Lancet. July 26,  1859.—Lussana, Monografia delle nevralgie brachi-
    ali con appendice intorno alia angina pectoris.  Milan, 1859.—Gilineau, Gaz.
    des hop. 1862. Nos. 114, 117, 120.— Beau, Oomptes rendus.  1862. p. 179. Arch.
    gen. 1862. II.  i>.  122.—Savalle, Arch. gen. 1862. II.  p.  250.— Bergson and
    \V<ddcck,  Deutsche Klinik. 1862. No. 5. p.  48.—Cohen, Des nevroses vasomo-
    trices. Arch.  gen. de med. 1863. II.  pp. 564 and 696.—Eicliwald,  Ueber das
    Wesen  der Stenocardie  und  ihr  Verlmltniss  zur Subparalyse des Herzens.
    Wiitzb. med. Zeitschrift. 1863. p. 249.—Lancereauz, De i'alteration de l'aorte
    et du plexus cardiaque dans l'angine de  poitrine. Gaz. med. 1864. p. 432.—
    Tiller sparger, Die Herzbraune. Neuwied and Leipzig, 1865.—Philipp, Berl. klin.
    Wochenschrift. 1865. Nos. 4  and 5.—Surmay, Union medicale. 1866. No. 80.
    p. 34.—Landois, Der  Symptomencomplex  " Augina pectoris " physiologisch
    analysirt,  nebst Grundlinien einer rationellen Therapie. Correspondenzblatt fiir
    Psychiatrie. 1866.—Friedreich, Lehrbuch der Herzkrankheiten. 1867. — Colin,
    Gaz. hebd. 1867. No. 29. p. 455.—Dickinson, Transact, of the Pathol. Soc. 1867.
    XVII.  p.  53.—Lauder Brunton, Lancet. July  27, 1S67.  p.  97'.—Nothnagel,
    Angina pectoris vasomotoria. Deutsches Archiv f. klin. Med. 1867. p. 309.—
    v. Dusch, Lehrbuch der Herzkrankheiten. 1868.—Eulenburg and Landois, Die
    vasomotorischen Neurosen. Wiener med. Wochenschr. 1868. No. 65.—Leishman,
    Glasgow  Med. Journal. 1869. p. 556.—Lockhart Clarke,  St.  George's Hosp. 
32    EULENBURG.—VASO-MOTOR  AND  TROPHIC  NEUROSES.
   Reports. IV. 1869. p. 11.— Haddon, Edinb. Med. Jour. XVI. p. 45. July, 1870.
   — Ogle, British and Foreign Med. Rev.  Oct. 1870. p. 447.— Blatin, Bull, de
   ther. 1870. pp. 337 and 385.—Sanderson  and Anstie, London Clinical Society.
   Feb. 11,  1870.— Wood, Amer. Jour, of  Med. Sci.  1871. p. 359.— Eulenburg,
   Lehrbuch der functionellen Nervenkrankheiten. 1871.— Anstie, British Med.
   Jour. Nov. 11, 1871.—Peter, Nevralgie diaphragmatique. Arch. gen. April and
   June, 1871.— Grodsensky, Inaug. Diss. Berlin, 1872.—von Huebner, Archiv fiir
   klin. Med. XII. 1873. Heft 5.

   We designate by the name of angina pectoris a group of symp-
toms, of which the most characteristic are the following : Pain in
the region of the heart, occurring in paroxysms, which usually
radiates over  the left side of the thorax and the left  arm, more
rarely over both  sides and arms ; the pain  is associated with a
peculiar sensation of anxiety and constriction, and often also
with other motor, vaso-motor, and sensitive disturbances.  Steno-
cardia is another name for these attacks.  The period between
the  paroxysms is free from pain,  and usually from all  other
symptoms.   The disease, therefore, bears the plainest marks of
a neurosis, and  may be  classed,  according to its  symptomatol-
ogy, with  the visceral neuralgias, including  cardialgia,  colic,
hysteralgia, and so forth.


                            History.

   Heberden  gave it the name of  angina pectoris, from the tor-
turing anxiety (angina  from angi; badly  translated by  Herz-
braeune, in  German).    At the  same time, or a  little earlier
(1768), the disease was described by Rougnon.   Later observers
described it under the following names, now antiquated : Asthma
convulsivum  (Eisner, 1778), Asthma dolorificum (Darwin, 1781),
Diaphragmatic Gout (Butler, 1791), Asthma arthriticum (Schidh,
1793), Syncope anginosa (Parry, 1799),  Sternalgia (Baumes,  1806),
Sternocardia  (Brera,  1810),  Pneumogastralgia  (Teallier, 1826),
Cardiodynia  (Baumgaertner, Harless).  The majority of  these
synonyms show ignorance regarding the true nature of the dis-
ease ; they lay weight sometimes on the  apparent seat of pain,
sometimes on the analogy with attacks  of asthma or syncope,
sometimes on the supposed connection with  arthritis,  which was 
ANGINA PECTORIS.—HISTORY.
33
especially noted 1)}' English observers.   Parry first called atten-
tion to the coincidence of stenocardiac  attacks with  ossification
of the coronary arteries of the heart, and Percival in 1773 to the
coincidence with diseases of the abdominal organs.  Testa, Brera,
Latham, and others explained the attacks as due to enlargement
or dislocation of single  organs of the  abdomen, which pressed
mechanically against the heart.
   Most later pathologists have  either assumed an exclusively
nervous origin for the disease, or else  have assumed the  exist-
ence of  a nervous, dynamic form in addition to the  organic, or
the  one complicated with heart-disease ;  of the former,  the
origin was assigned to  a great variety of nerve-trunks more or
less remotely  connected with  the heart.  Sometimes the  phre-
nic nerve (Bouillaud), sometimes  the  intercostals (Jolly), were
thought chiefly implicated ; but  the vagus (Lartigue, Desportes,
Chapman)  and the  sympathetic (Lobstein, Laennec)  were  the
favorites,  yet they  failed to  bring the phenomena of angina
pectoris  into  agreement with the  known  functions  of  these
nerves,  which have been only  very recently explained.   The
disease was regarded  as  essentially a neuralgia of the nerves of
the heart; thus Laennec called  it neuralgia cordis, Trousseau
an  "epileptiform  neuralgia,"  and Romberg and Friedreich a
hyperesthesia of  the cardiac plexus.  Others  laid stress  not
only on the neuralgic character of the disease, but  also on  the
accompanying symptoms, especially the paroxysmal alteration
of the action  of the heart ; and  thus Dommes and Jahn desig-
nated the condition as paresis or paralysis, Stokes1 as a tempo-
ran' increase  of weakness,  in  a  heart  already weakened, with
fatty change in its muscle (and  with hyperesthesia) ;  Bamber-
ger, contrary to Stokes, as increased action of the heart, hyper-
Idncxis,  with hyperesthesia ; von Dusch as hyperesthesia, with
spasms of the  heart; Eichwald as over-exertion of the heart, due
to mechanical obstacles to its activity ;  others (as Barkow) even
called it a trophoneurosis of the heart, cardioneurosis trophica.
Sonic autopsies of Lancereaux's (1866) pointed to an affection of
the cardiac plexus; the  aorta and the coronary arteries were, at
 1 Diseases of the Heart and Aorta. Dublin, 1854, p. 486.
VOL.  XIV.—3 
34    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

all events, found altered in the same cases.   Almost at the same
time Cahen (1863) expressed the belief that angina pectoris must
be classed with the vaso-motor neuroses.  Although this assump-
tion of Cahen's was quite untenable and incorrect, yet in some
respects it gave a decisive turn to  the controversy ; he deduced
the symptoms of angina pectoris  from  a  vaso-motor neurosis
accompanying intercostal or bronchial neuralgia—that is, from a
spasm of the  blood-vessels of  the  heart or the lungs.  He  was
quite aware that there was absolutely no proof of  this supposi-
tion at that time.  Traubex thought  it possible  to refer certain
symptoms of  the stenocardiac attack (the rapidity of  pulse  and
the diminished size with increased  tension  of  the blood-vessels)
to an increased  excitement  of the vaso-motor nervous centre.
Landois (1868) first  subjected  all  the symptoms of angina  pec-
toris to a thorough and systematic physiological  analysis, and
divided the disease,  in accordance with the  results of this analy-
sis, into four classes, caused respectively by :  1. Disturbance of
the  activity  of  the  excito-motor  cardiac  nervous  system; 2.
Conditions of irritation in the region of  the cardiac branches of
the vagus ;  3.  Reflex excitement, due to irritation of  the organs
of the abdomen {angina pectoris reflectoria) ;  4. An affection of
the vaso-motor nerves of all, or of  most regions {angina pectoris
 vasomotoria).
    Subsequently, in 1867,  Nothnagel described some cases of
 angina pectoris  vasomotoria, and  Landois  and I described  it in
 our monograph upon the  vaso-motor neuroses ;  finally, Gutt-
 mann and I examined into the part taken  by the  several nerves
 belonging to the cardiac plexus, and especially by the sympa-
 thetic.2 The view of the nature and pathogenesis of  the disease
 thus  obtained, though very defective, was  considerably enlarged
 by  a series of physiological  experiments  upon  the sphere  of
 action of the cardiac and vaso-motor nerves (v. Bezold, Goltz,
 Bernstein,  Ludwig,  M.  and E.  Cyon), or, to speak more cor-
 rectly, it was first rendered tenable by these experiments.  Path-
 ological anatomy has as yet  contributed  little that  is  of use;
1 Symptome der Krankheiten des Respirations- und Circulationsapparates. S. 41.
2 Pathologie des Sympathicus, in Griesinger's Archiv f. Psychiatric p. 688. 
                ANGINA PECTORIS.—ETIOLOGY.              35

angina pectoris belongs to that class of neuroses which show
most convincingly how much we owe to the discoveries of experi-
mental physiology and their pathological application, and how
far mistaken  in point of fact those are  who  expect  to find in
pathological anatomy the source of every improvement in neuro-
pathology.  Perhaps no ray of light would ever have penetrated
the obscurity  in which this disease was  wrapped if Physiology
had not shot forth those  lightning-flashes of hers, which  threw
such a wonderful illumination upon the whole matter.

                            Etiology.

   Only  a few scanty indications  of the  etiology  of angina
pectoris  can  be  given.   We  do not here, nor subsequently,
include in this statement  the stenocardiac attacks  which are
properly symptoms of certain chronic diseases of  the heart,
such as insufficiency of  the aortic valves, stenosis of  the aortic
orifice, fatty  degeneration of the  heart;  nor  those other cases
due to the circumstance, hardly possible to distinguish during
life, of ossification  of  the coronary  arteries.   The etiology of
these cases is that of the  cardiac diseases named, and of endar-
teritis deformans.   But if  we confine ourselves to the uncom-
plicated cases—those of angina pectoris in  the narrower sense,
and especially angina  pectoris vasomotoria, we have but very
few points upon which to base our etiological views.  It has been
considered (after the formerly prevalent fashion) that the dys-
crasie  constituted predisposing influences ;  especially was this
thought to be  the case with arthritis, and even a so-called hemor-
rhoidal diathesis. As for the supposed connection Avith arthritis,
the case is probably one of coincidence of arthritis with endocar-
ditis and  endarteritis, and the stenocardiac  attacks referable
to organic diseases  of  the heart or ossification of the  coronary
arteries.  A connection between arthritis and the pure angina
pectoris cannot be established upon any theoretical ground, and
the cases contained  in  recent literature,  which  have  been more
closely sifted, do not show  a trace of such  a relation.   It were
superfluous  to lose  a  word in speaking of the hemorrhoidal
diathesis.  It  seems  more reasonable to ascribe a favoring infiu- 
36    EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

ence to anemia ;  at any rate, we see a greater frequency of angina
pectoris, as of many other neuralgias (e. g., intercostal), in ane-
mic persons.   In other cases a hereditary tendency is unmistak-
able ;  this fact and many other circumstances connect the disease
with the group  of constitutional neuropathies,  not to  mention
the peculiar connection often  existing with other diseases of the
group, such  as.hysteria, insanity,  and epilepsy.   Attacks of
angina pectoris  may  form a  symptom  of hysteria; they may
herald the epileptic attack, or may alternate with it; they may
precede the  outbreak of maniacal or melancholic  conditions, or
may constitute  an  intercurrent symptom of well-marked and.
long-standing disease of the mind.   The nature of the etiological
connection here  existing is certainly quite hidden from us;  the
terms we are  compelled to put up with for the present, as neuro-
pathic constitution, congenital  preformation,  etc.,  give us no
explanation,  but only  formulate our ignorance with precision;
at the best, they are but hints for future investigation.
   The possible  predisposing influences of age and sex cannot
3^et be established with sufficient certainty. It is unquestionably
true that  angina pectoris, without hereditary tendencies or con-
stitutional anomalies,  may occur at an  advanced age.  But when
it  is said  that the disease belongs  chiefly to advanced age,  the
statement seems to rest upon a  confounding of the true angina
with stenocardiac attacks due to cardiac anomalies, atheroma-
tosis, etc.  The male sex is attacked far oftener than the female-
Forbes says,  in  the proportion  of 11  to 1—perhaps because it
is more exposed  to the influences which we are about to mention.
   As a direct cause of the disease, even in persons predisposed,
we must regard the influence of exposure to cold.  Some good
observations  are decidedly in  favor  of this  view ;  thus,  for
instance, Huebner saw a case in which the attacks appeared for
the first time in a robust man of seventy-four, after a long ride
in a post-wagon in cold  weather.  The harmful influence of
damp and cold residences is especially  mentioned by Nothnagel.
Besides, the  excessive smolcing of tobacco seems to deserve to be
regarded as  an  etiological factor.   Beau  describes eight cases
in which  the attacks  ceased  when  smoking  was stopped,  and
returned when the  patients began to smoke  again.   The like is 
         ANGINA PECTORIS. —COURSE OF THE DISEASE.       37

reported by Savalle,  Championnere, and Blatin, and I myself
have made out  several quite analogous cases; I have also ob-
served very exquisite cases of angina pectoris in a }Toung anemic
cigar-maker, who had smoked a large  number of strong cigars
daily for several years.  Finally, certain morbid conditions of
the thoracic organs, by involving the nerves of the cardiac plexus,
and  morbid conditions of the  abdominal  organs, probably  by
irritating, in a reflex  manner, the sensitive nerves of the abdo-
men, may produce the symptoms of angina pectoris.  (See below,
"Anatomical Alterations," and "Analysis of Symptoms/')


        General Description and Course of the Disease.

   Angina pectoris must be described as composed of attacks,
separated from one another by  longer or shorter intervals.  The
intervals are usually free from symptoms.  They usually begin
rather suddenly, without any other premonitory signs than pain,
which begins at the region of  the scrobiculus cordis or the lower
part of the breast-bone, and shoots out sometimes over the left
side of the chest and neck, and sometimes up along the sternum
to the left arm or to both arms.   In the latter case the pain is
less in the right side of the chest and the right arm than it is in
the corresponding part of the  left  side.  With the pain, which
is often  called  "constrictive,"  there  is  associated a  peculiar
feeling of anxiety, of impending death—a feeling which is not
rarely met with in other visceral neuralgias, such as cardialgia
and  colic.  The  suddenness with which the attacks  come on is
especially striking ; the patients  are not rarely overtaken  by it
while walking or at work.  The duration of the single paroxysm
is usually short, commonly only a few minutes ; but sometimes
the attack does not end with the first paroxysm,  intermissions
or remissions being followed  by repeated exacerbations, so that
the entire attack is made up of a series of partial attacks, as is
the case in many neuralgias.
   Along with the disturbances  of  sensibility, disturbances of
the action of the heart and of the movements of circulation and
respiration are usually seen,  which may present great variety.
The beats of the heart are sometimes small, wanting in energy, 
 38   EULENEURG.—VASO-MOTOR AND TROPHIC NEUROSES.

 intermittent, and even interrupted by considerable pauses ; some-
 times, again, they are increased, become violent,  and are  accom-
 panied by a very great increase in the force of  the beat.   At the
 height of the attack of pain, the action of the heart seems usually
 to be weakened, or  even arrested ; in the intermissions or remis-
 sions, on the contrary, it  is often  much strengthened, or even
 extraordinarily violent.  The pulse  shows similar variations; in
 the radial artery it is sometimes small and  of  slight tension,
 sometimes strong and full; sometimes, even in  the cases where
 the action of the heart seems increased, the radial  arteries exhibit
 but a  slight  elevation and low tension.  We  often find  at the
 beginning of the attack a cord-like  hardness and contraction of
 the peripheral arteries, while later they are full and soft.  Sphyg-
 mographic tests also show an increase in arterial  tension  in the
 beginning of the attack, but later a diminution (Lauder Brunton).
 The respiration  also  is hastened, is  even violent, dyspnoic, but
 sometimes retarded  and superficial,  or even  quite arrested.  But
 the latter symptoms are  essentially effects of  the pain.  The
 patient dreads to take a full breath ;  if persuaded to try, he usu-
 ally succeeds perfectly well. This dependence of the action of
 respiration upon pain has already been  noticed by Parry.  The
respiration may also be quite free during the  attack, as I have
myself observed  in some instances.   The  disturbances  of the
 action of the heart  and the circulation are shown by changes in
 the amount of blood present in the peripheral parts and in their
 temperature.   During the  attack the skin is  often pale, cold,
 dry, almost bloodless in the hands  and feet, the face pale and
 sunken;  a general  sensation of chill, chattering of the  teeth,
 paralgic sensations (formication and  prickling) in the tips  of the
fingers, may be caused by the cutaneous anemia.  Towards the
 close of the attack,  or after it, there may be the  contrary condi-
 tion of redness, swelling, increased sense of warmth in the skin,
 and abundant perspiration may be secreted.
   The course of the disease is almost always extremely chronic.
The attacks recur (as in the case  of epilepsy) at extremely varia-
ble intervals ; they  may sometimes be suspended for  years; in
 some cases they may occur for a time every day  without  visible
 cause.  I have never observed a regular periodicity in marked 
        ANGINA PECTORIS.—ANATOMICAL ALTERATIONS.      39

angina pectoris.  As occasional causes, exposure to cold, bodily
and  mental exertion (especially exhausting bodily movement),
and  mental excitement, may  be  named  as  provocative;  the
attacks may sometimes be excited or made worse by pressure
upon some  points that are sensitive during the attacks, or con-
stantly sensitive.  Such points are the spinous and  transverse
processes  of the cervical  and  upper dorsal vertebre, and the
region of the inferior angle of the scapula.   It is rare that a dimi-
nution and spontaneous disappearance of  the  attacks occurs as
time passes on ; on the contrary, it is much more often the case
that they grow worse and more frequent,  the remissions being
shorter and marked by exhaustion.

                  Anatomical Alterations.

   We do not here describe those forms of angina pectoris which
are complicated by  faults in the  valves of the heart, or fatty
degeneration of  this organ, nor those forms which are  caused by
atheromatous  processes in the  aorta, and  especially by ossifica-
tion  and contraction of the coronary arteries.   Anatomical con-
ditions of  the latter sort, usually connected  with defects of the
aorta or other  abnormalities, have been described in earlier times
by  Hofinann,  Jenner,   Black,  Parry, Birch,  Kreysig,  Ritter,
Sluis, Ring, Crisp;  in later times by Philipp,  Wilks,  AValdeck,
Oppolzer,  Fincham,  Mason, Moorhead, Dickinson, Colin, Lock-
hart, Clarke, Haddon,  Ogle,  Grodsensky  (Traube), and  others.
That  these  changes  do not furnish the exclusive basis  of  the
symptoms has been shown by the discoveries of Senac,  Corvisart,
Bianchi, and others, who even found extensive  ossification of the
coronary arteries without symptoms of angina pectoris  having
been observed  daring life ;  also by the negative results of exam-
inations by Jucine, Johnston, Lentin, Erdmann, Desportes, Heu-
singer, Jahn,  who have demonstrated a complete integrity  of
the coronary vessels in  decided angina pectoris.
   The nervous  apparatus of the  heart formerly received little
or no attention at autopsies.  The  first positive statement seems
to have been made by Heine  (1841), who speaks of pathological
changes in the cardiac branches of the vagus, and also in  the 
40    EULENBURG.—VASO-MOTOR AND TROPHIC  NEU HOSES.

phrenic nerve.  The case was that of a patient treated by Skoda
at the Vienna clinic, suffering with peculiar attacks, in the course
of which  the heart stood quite a till for some seconds, usually
during  the  period  of from  four  to six  pulsations, while the
patient  suffered from the feeling of inexpressible anxiety.  At
the autopsy, which was made by Rokitansky,  the right phrenic
nerve was seen  involved  in a dark  blue hard knot,  dotted with
concretions of lime.  Among the lax, pale gray cords that made
up the plexus of cardiac nerves was seen the cardiacus ma gnus,
which, rising from the plexus between the pulmonary artery and
the descending aorta, just below the arch, entered into a black
nodule of the size of a hazel-nut, and was thickened before enter-
ing the latter.  The descending branches of the left  vagus upon
the anterior aspect of  the left bronchus appeared similarly inter-
fered with by a nodular blackish blue  lymphatic  gland that lay
beneath them.
   In connection with  this an observation  of Haddon' s' should
be mentioned, concerning the case of a man affected  with angina
pectoris, in whom the left phrenic  nerve was found  compressed
by a bronchial gland of the size of  a hazel-nut, situated close to
the root of the left lung, and  infiltrated with black  pigment.
The nerve-tubes at the spot seemed not interrupted,  but slightly
granular.  The  right  phrenic  nerve was normal, the vagi and
recurrentes were also normal.   The aorta was in a state of ather-
omatous degeneration  and aneurysmal dilatation.
   Anatomical  changes in the  cardiac plexus have  been found
by Lancereaux  in  a patient aged forty-five, who exhibited the
usual symptoms of angina pectoris and  died in  one  of the
attacks.  At the autopsy there appeared  a  contraction of the
coronary arteries, and  an alteration of the aorta at the point
where the  cardiac plexus lies upon it; the plexus was in a vas-
cular condition.  A few of the  bundles of the latter were envel-
oped in  exudation, and the outer sheath was thickened.  Micro-
scopic examination  showed an abundant accumulation of  round
nuclei, which had pressed asunder and compressed the  nerve-
tubes ; the medullary  contents  of  the latter appeared orayish
1 Edinburgh Med. Journal. XVI. p. 45. July, 1870. 
         ANGINA PECTORIS.—ANALYSIS OF SYMPTOMS.        41

and granular.   In two other cases Lancereaux found a change of
the aorta at the same spot, with the same characteristics, likewise
associated with considerable narrowing of the coronary arteries,
which makes it  possible that  there was an affection of the car-
diac  plexus, analogous  to that in the first case; but the  point,
unfortunately, was not investigated.

Analysis of the Symptoms and Special Symptomatology of the
                       Several Forms.

   According to the above description, the cardinal symptoms
are the pains under the sternum, the feeling of anxiety, the dis-
turbances in the action  of  the heart and  the circulation  of the
blood, while the changes in the mechanism of respiration are to
be regarded merely as consequences  of  the pain.   We shall
attempt  to refer the first set of phenomena to definite disturb-
ances of the innervation of the heart, consisting in an abnormal
increase or diminution of the  activity  of the nerves forming the
cardiac plexus.
   The pain with which the attack begins arises most  probably
in the nervous plexuses of  the heart;  this assumption cannot be
demonstrated with the same anatomical certainty as in the case
of the peripheral nerves whose course  is  exactly known  to us,
but  one  circumstance in favor of it  is the  fact  that  the pain
always,  or nearly always,  begins at the spot which corresponds
with the site of  the heart,  and is most acute at the same point.
Under normal circumstances, it is  true, the heart, like  all invol-
untary  organs,  is not  very sensitive; but  we need  no more
wonder  that a stimulation of its sensitive nerves in  pathological
conditions  should excite  such extreme  pain, than that such
should  be  the  case  with other organs of vegetable  life.  The
heart derives its sensitive  nerves from the vagus,  as the experi-
ments of Goltz  have  shown in the case of the frog's heart, and
those of Gurbocki in that of  the rabbit's heart.  In mammalia
other sensitive nerves than those from the vagus seem to enter
into  the cardiac plexus ; for, in spite of the section of both vagi,
the animals manifest pain when the auricles are mechanically
irritated.  Accordingly, we must perhaps  ascribe a sensibility to 
42    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

the sympathetic fibres which form so essential a part of the car-
diac plexus, and especially so as the character of the pain closely
resembles that observed in other irritations of the sympathetic
nerve, as in gall-stone colic, in enteralgia, etc.
   This neuralgia of the cardiac plexus is sometimes idiopathic,
but more commonly it is probably due to mechanical infiltration,
pressure, and other injuries  of the  plexus.   Such causes natu-
rally occur to the mind in certain cases of  organic disease of the
heart, ossification of the  coronary  arteries,  valvular disease of
the aorta, and so forth.  The cardiac plexus lies behind and below
the arch of the aorta and in close proximity to it, so that morbid
processes in this vessel  may give rise to lesions of  the neighbor-
ing plexus, as is clearly shown by the results of the  autopsy
made by Lancereaux.   Why these violent attacks of pain occur
only at certain periods, in the form of paroxysms, while their
supposed  cause continues in existence, is  no better understood
than in  the case of other neuralgias.
   In those cases where there is no  organic change in the heart,
we have no idea of the immediate cause of the pain in the cardiac
region.  Those changes, whether of increase or of diminution of
the action of the heart,  which occur  during the attack, cannot be
the sole cause of this violent pain;  for the most extreme devia-
tions from the normal  action of the heart—both  the  increase
which occurs  in aortic defects, and  the diminution during fatty
change of the muscular  tissue—produce a feeling of constriction,
but never a pain like that of angina pectoris ; while moderate
degrees  of irregularity in the functions of the heart are often not
felt at all.
   For  this reason I cannot fully agree with Eichwald's theory
of the cause of the pain and the nature of the stenocardia.  As
before stated, he ascribes the attack to arrest of the activity of
the heart, due to mechanical obstruction, and explains  the pain
as a consequence of the exertions made by the heart to overcome
the obstruction, since it is found that every over-exertion of a
voluntary muscle is painful.   Though Eichwald explains the
phenomena of the attack very well  by means of his theory, yet
it is necessary to remark that a change in the action of the"heart
has  not been shown to be the first symptom of a stenocardiac 
         ANGINA PECTORIS.—ANALYSIS  OF SYMPTOMS.        43

attack ; on the contrary, the  patient is  seized in  the  midst of
the most perfect health, without having had any palpitations.
Neither is the action of the heart during  the attack by any means
so violent as to produce  such severe pain.  Even if we admit the
existence of obstacles to  the activity of the heart in certain cases
of angina pectoris, yet  the heart, in  cases of obstacles in. the
aortic or pulmonary system, usually responds in quite a different
way, namely,  by increasing the force  of  its beats.  And finally,
in those cases of angina pectoris in which the heart, under objec-
tive examination, seems quite normal, it is impossible to under-
stand how such hinderances  can exist; for the assumption of
Eichwald, that irritation  of  the vagi  may constitute such  a
hinderance, is only tenable when the pulse is retarded.   And
again, why should a rhythmic retardation of the heart constitute
an obstacle to the movement of  the blood ? We can at any time
lessen the rate of the pulse by proper drugs, under pathological
circumstances, without ever observing in consequence abnormal
sensations.   I have seen a pulse of only  twenty-eight in  the
minute, owing to the  presence  of central disease, without  the
patient's feeling the slightest abnormal sensation.  It is, therefore,
doubtful whether a change in the rate of  action causes the pain.
   In interpreting the pains which radiate from the precordial
region to other parts of the body, especially the thorax and arm,
we must recollect the anatomical relations of the cardiac plexus
and its connections with  the nerves of the neck and arm.1 Those
pains which  shoot into  the region of  the cervical  nerves  are
explained  by the connections between the superior cardiac nerve
(from the ganglion cervicale primum) and the anterior branches
of the four upper cervical  nerves ; those extending to the arm,
by the numerous connections of  the ganglion cervicale medium
and inferius (from which the middle and inferior  cardiac nerves
originate)  with the four lower  cervical  nerves, uniting in  the
plexus brachialis, and  the  first dorsal  nerve.  The fact that  the
pains are more frequent in the left arm than in the  right is  per-
haps caused in part by the situation of the heart and aorta upon
the left side,  which naturally gives rise, in case of  disease of
1 Compare especially Lussana, 1. c. 
44    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

these organs, to mechanical interference (Zerrung) with the nerves
of this side, and in part by  the fact that the anastomoses of
the nerves are  believed to be closer on the left side.  The pains
in the front surface of  the chest are explained by the branches
of connection between the dorsal nerves and the brachial plexus.
Radiating pains in the region of the diaphragm also occur, which
may be referred to the connection of the phrenic nerve with the
fourth and fifth pairs of cervical nerves,  and through them with
the cardiac nerves.
   That the pain of angina pectoris is sometimes confined to one
spot—the precordial  region, and sometimes shoots  out  over
manifold nerve-paths, is mainly  due, apart from mechanical con-
ditions, to the varying intensity of the irritation acting upon the
cardiac plexus.  According  to  the analogy of other  nervous
affections we may assume that in this case the number  of nerve-
fibres that participate increases  with the intensity of the irrita-
tion.  In  several cases, which I had the opportunity to observe
for a considerable time, the  extension of the pain  was always
great in proportion to the severity of the initial pain in the car-
diac region ; in attacks of moderate severity the shooting to the
left arm  was almost wholly wanting,  the pain reached only to
the shoulder, and even the front part of the left half of  the chest
was affected in a smaller extent of territory.
   Certain accompanying symptoms referable to  the vagus,  as
difficult swallowing, vomiting, and difficulty in phonation (Lar-
tigue), are probably also  to be  regarded as  due to irradiation.
They must be referred to the numerous connections between the
sympathetic and the vagus, especially the share which the latter
takes in the formation of the cardiac plexus.
   The peculiar feeling of anxiety and oppression seems also to
be connected with the pain in the heart; this is, at all  events, a
more natural assumption than that which derives the feeling of
anxiety from an impeded action of the heart.   In several visceral
neuralgias we find a sensation which quite corresponds with that
feeling of oppression,  while the  latter  is entirely  wanting in
many much severer obstructions  to the circulation (as in the
various valvular affections).
   The disturbances in the action of the heart and the circula- 
         ANGINA PECTORIS.—ANALYSIS OF SYMPTOMS.        45

lion, which, in so great a variety of forms, accompany the steno-
cardiac attack,  cannot be supposed to depend upon a  single
distinct portion of the nervous apparatus, especially in the lack
of pathologico-anatomical facts.  They must, in accordance with
our present knowledge of the  physiology of the innervation of
the heart and blood-vessels, be referred  to several very distinct
sources, namely, disturbances  in the automatic, the regulative,
and the sympathetic nerves of the heart, and. in the vaso-motor
nervous system.   In this point of view there may be recognized,
at least in theory, four possible forms of angina pectoris (as it
were,  four roots), though the isolated existence of these forms is
by no means established with sufficient certainty.
   1.  Automatic system of cardiac nerves.  Influences  which
act directly upon the ganglion masses embedded in the muscle of
the heart, such as toxic substances introduced into the ventricu-
lar cavity, or  solutions into which the entire heart is plunged,
are known to be capable of producing immediate annihilation of
the contractions  of a  heart which has  been removed  from the
chest  and still pulsates.   According to the experiments of Lan-
dois,1  the disturbance of this  automatic  action of the  cardiac
ganglia,  which takes  place under the direct action of certain
poisons, may be of two sorts : if weak solutions are injected into
the endocardium of the frog a  stimulation of the ganglion cells
occurs, with an increase in the rate of speed of the heart;  but if
the solutions are stronger, the ganglia are rapidly paralyzed and
the heart is arrested.   In a similar way the ganglia of the heart
may be affected  in pathological conditions.   If their rhythmic
activity is interfered with in any way, either by the existence of
abnormal resistance to the movement of the blood, as in aortic
disease and atheromatous processes ; or if the ganglion receives
too little blood, as in contraction and closure of  the  coronary
arteries ; or if the latter are affected in conjunction with the mus-
cular tissue of  the heart, in myocarditis or fatty degeneration—in
an}- of these cases the action of the heart may be changed in one
of two ways: either  the  rapidity of its movements is increased,
if  the above pathological influences produce an irritation of the
1 Die directe Herzreizung. Greifswalder med. Beiti-iige.  II.  1864. S. 161. 
46    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

ganglia, or it is diminished, if the influence produced be a para-
lyzing one.  The assumption,  therefore, that in a stenocardiac
attack the automatic ganglia are disturbed in their activity, may
agree very well with the fact that the action of the heart during
the attack is sometimes increased,  sometimes diminished.  The
form of angina pectoris, accompanied by disturbance of the auto-
matic ganglia, might be denominated the cardial  excito-motor
form, or the cardiocentric ganglions form.
   In favor of the theory of an involvement of the ganglia of the
heart—perhaps due to a deficient supply of blood,  as  in case of
disease of the aorta and  contraction of  the coronary arteries
—another  experimental fact may be  adduced.   Von Bezold1
observed in every case a change in the beats of the heart, when
he cut the vagi, cervical sympathetics, and the cervical medulla,
and then closed the large  coronary arteries or several of their
branches  with forceps.  After ten or fifteen seconds  the beats
became less frequent, then irregular, with alternations  of slow
and quick contractions, and in a minute or a minute and a half
the ventricle was entirely relaxed.  If the closure of the vessels
was suspended, the pulsations began afresh and soon became
quite regular.
   2. Regulative system of cardiac nerves.  In the majority of
cases of angina pectoris the rapidity of the pulse is  increased;
if, therefore, the vagus were affected, we  should have to infer
that it was in a state of temporary paresis, causing a diminution
of its regulative action upon the heart.  But some cases occur,
with retardation of  the pulse, and  even with a temporary arrest
of the heart, which are probably due to a state of irritation in
the vagus, which therefore might be  called the regulative form
of angina pectoris.   Under this  head must be placed the case
related by Heine (see above), in which  the  autopsy  revealed,
among other  things, changes in  the vagus;  also  two cases by
Canstatt,  in which a temporary arrest of the action of the heart,
with a feeling of great anxiety, formed the chief symptoms.
   Eichwald also mentions a case in which a hysterical attack,
whenever it occurred, was always accompanied by a stenocardiac
1 Centralblatt 1867. No. 23.— Compare also Suchtschinsky, ibid. 1868. No. 3. 
         ANGINA PECTORIS.—ANALYSIS OF SYMPTOMS.       47

paroxysm,  during which the pulse was retarded, with increased
force in the single beats ; the pulse was hard and full, but at the
same time the beats were few and slow.  If the paroxysm lasted
somewhat  longer, the  pulse  became irregular, intermitted, and
even became imperceptible for whole minutes.   The action of the
heart was of a similar character in two other cases of angina pec-
toris, in one of which the patient was hysterical, and in the other
a pneumonia  had produced a great  loss  of strength, and  the
paroxysm  was provoked  by a violent  mental agitation.   Eich-
wald therefore thinks that in such cases there is a state of irrita-
tion in  the region of  the vagus; in favor of this supposition is
the observation  that in such cases other symptoms referable to
the vagus occur, as difficulty of phonation and of swallowing,
and that the change  in the action of the  heart in  this kind of
angina  pectoris  is closely related  to  the experimental results
obtained in irritating  the vagus.  For in slight irritation of  the
vagus the beat of the heart, as in the beginning of a stenocardiac
attack, becomes slower and stronger ;  if the irritation is greater,
as in an attack  of  longer duration, the action of  the heart is
retarded, and even more or less stopped.  The paroxysm of pain
is also very well reconcilable  with the theory of irritation of  the
vagus,  since the sensibility of the heart depends chiefly upon the
ramifications of the vagus.
   Besides  the cases of angina pectoris  that  are  due to direct
irritation of the vagus, there  are certain others which occur with
especial frequency in diseases of the  abdominal organs, which
physiological facts allow us  to consider as reflex vagus-neuroses
(according to Landois,  angina pectoris reflectoria).   It is known
that the heart can be brought to a stop in diastole by irritation
of the sympathetic fibres in the abdomen, just as by direct irrita-
tion of the vagus ; there must, therefore, be fibres of the sympa-
thetic which enter the  spinal  cord by the rami  communicantes,
and, passing upward through the dorsal to the cervical portion,
there transfer  their impression of  irritation to the centre of ori-
gin  of the vagus ; for if both vagi have been cut, or the medulla
oblongata destroyed, the  irritation of the  sympathetic  has no
longer any  effect upon the heart.   Cases reported in older litera-
ture, in which  disease of the abdominal viscera was  accompanied 
48    EULENBURG.—VASO-MOTOR AND  TROPHIC  NEUROSES.

by stenocardiac attacks, are found in the monograph of Ullers-
perger.   From later  literature I will  mention a case of angina
pectoris, in which a course of treatment directed toward the liver,
which was in an enlarged condition, immediately produced  an
amelioration of the general symptoms;l  the stenocardiac attacks,
which previously occurred whenever  violent bodily motion was
indulged in, disap2Deared entirely.  There was no affection  of the
heart in this patient.
   3.  Sympathetic  cardiac system.   The accelerator  nerves of
the heart,  running in  the course of the sympathetic, demon-
strated  by von Bezold,  permit us to refer certain cases of angina
pectoris, with accelerated  action  of the  heart, to an increase in
the activity of the rhythmically-acting  cardiac ganglia, due to
the influence of the sympathetic.  We might designate this form
as sympathetic excito-motor angina pectoris, in contradistinction
to that  caused by a direct affection  of the automatic cardiac
ganglia.   Since  all the sympathetic  fibres  of the  heart, from
whatever source arising, are united in  the cardiac plexus, the  lat-
ter furnishes a specially probable source  of abnormal activity of
the heart;  and this  assumption is notably supported by  the
autopsies reported by Lancereaux.
   4.  Vaso-motor nervous system.  In disturbances of the inner-
vation of the vaso-motor  nerves (which likewise run  with  the
sympathetic, for the most  part), a change in the tone of the ves-
sels must occur, and  in consequence a change of blood-pressure,
which may react upon  the heart in two ways : if these  nerves
are irritated, the result will  be a contraction of the vessels; if
they are in a paretic condition, the vessels will be dilated.   In
the former  case the contracted condition of  the peripheral circu-
lation creates an  obstacle to the emptying of the heart, and
therefore the  blood-pressure rises throughout the aortic system,
with an increase of force in the  action of the heart ;  while in the
latter the resistance  is  lessened, the aortic pressure diminished,
and the heart works with less force.
   This is the class of cases  for which Landois has offered  the
very suitable  name of  " angina pectoris vasomotoria."   With
1 Bergson, Deutsche Klinik. 1862. p. 48. 
          ANGINA PECTORIS.—ANALYSIS OF SYMPTOMS.       49

them belong those described by Nothnagel, in which, the heart
being quite healthy, attacks of angina pectoris occurred  under
the form of general  arterial spasm, often produced by the influ-
ence of cold.   After some  premonitory symptoms of abnormal
sensation in the extremities, as numbness, the feeling of cold, and
so forth,  a sensation of anxiety and palpitation followed, and
even a dull pain, beginning at the heart and spreading  into the
left thoracic region.   The objective phenomena corresponding to
these symptoms were pallor and loss of temperature in the skin,
diminution of  the sensibility of the skin, cyanotic discoloration
of the  extremities ;  the radial  artery was  sometimes a  little
smaller than normal, the sounds of the heart clear, the action of
the heart rhythmical and sometimes increased in force, the num-
ber of beats unchanged.  The attacks were relieved by treatment
suited to relieve  vascular  spasm, by such  remedies—especially
irritants and warmth—as increase the flow of blood to the skin.
Nothnagel explains  the palpitation  in these cases as due  to the
resistance to the action of  the heart  presented by the extensive
contraction of the circulatory apparatus ; the feeling of constric-
tion and pain in the  region of the heart he takes to be due  to the
excessive  exertion of the heart, thus assuming  an explanation
like that of Eichwald.
   Whether, in addition to the vaso-motor nerves, the depressor
nerve discovered  by Ludwig and Cyon, which seems to  act as a
regulator of  the variations  in blood-pressure, can assist  in caus-
ing the disturbances of circulation in the stenocardiac attacks, is
a question which  cannot at present be judged.
   It follows that we have these types, namely :
   1.  Excito-motor cardiac or cardio-centric, ganglionic angina
pectoris, from direct lesion of the automatic excito-motor ganglia
of the heart; it may assume the form of irritation (with increased
rapidity of pulse), or of paralysis (with retardation of pulse).
   2.  Regulator angina pectoris, from lesion of the cardiac sys-
tem of nerves of arrest (vagus),  a. Direct neurosis of the vagus,
either in the form of irritation (retarded pulse and increase in
force of pulsations of heart,  full, hard pulse, with disturbance of
phonation and deglutition ;  sometimes a temporary arrest of the
heart), or, more rarely, in the form of paralysis (acceleration of
          vol.  xiv.—4 
50    EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

pulse),  b. Reflex neurosis of the vagus (angina pectoris reflec-
toria), originating in disease of the abdominal organs, with the
symptoms of irritation of the vagus.
   3.  Excito-motor sympathetic angina pectoris, from lesion of
the accelerator nerves of the heart which run with  the  sympa-
thetic.  (Symptoms as in the first form.)
   4.  Vaso-motor angina pectoris,  from affection of the vaso-
motor nerves, running in  the  sympathetic for the most part—
either in  the  form  of  irritation  (contraction  of  the  vessels,
increased  pressure, with normal or but slightly increased fre-
quency of pulse;  symptoms of arterial anemia, paleness and
coldness of  the  skin, etc.) ;  or, more  rarely, in the  form of
paralysis, with the opposite set of symptoms.  Of  course, the
complication of these principal  types  and their confusion with
each  other are not at all impossible.   The great variability of
the circulatory symptoms accompanying  the attack is thus
paralleled in the variety  of the pathological conditions.

                  Diagnosis and Prognosis.

   The pathognomonic  symptoms of  the  attack are  such as
hardly permit confusion in the diagnosis of angina pectoris ; but
this is not a very great gain.  The practically important thing to
know is whether there be organic disease of the heart or vessels,
or whether the disease  be a pure neurosis ; and, if the latter,
what  is the special form  of disease, or (which is the same thing)
what  is its point  of origin in the several nervous regions.  This
problem will often be hard of  solution, especially as the physi-
cian seldom is in  a position to view the attacks, and to apply the
proper corrections  to the  descriptions given by the patient or
his friends.
   The prognosis of angina pectoris depends first upon the ques-
tion whether or no there are complicated diseases of the vascular
apparatus (valvular disease, fatty degeneration, sclerosis of the
arteries).   If such  exist, the prognosis is naturally bad, in pro-
portion to the severity  of the fundamental  lesion.   In  purely
nervous  angina pectoris,  the  prognosis, as  concerning  life,  is
favorable upon the whole, for grave sequele and death are rarelv 
               ANGINA PECTORIS.—TREATMENT.             51

caused  by the stenocardiac  attacks,  however severe thev mav
seem.   Some cases are, indeed, reported  in which death is said
to have occurred in the course of the attack ; but these seem—
and Lancereaux's  autopsies support  this view—to be  cases in
which the aorta and the coronary arteries were greatly altered,
with consecutive changes in the cardiac plexus, and they,  there-
fore, ought not to be classed as purely nervous.  This differentia-
tion, it is true,  will often be without value in actual practice, for
the special diagnosis  cannot  be  sufficiently relied upon, and
therefore, if the attacks are at all of a nature  to arouse  our
apprehension, we ought to be fully warned against too sanguine
hopes.  As regards the disease, the prognosis is certainly quite
unfavorable, as a radical  cure, by nature  or  by art, is observed
in an extremely minute proportion  of  the  cases.  It  is most
favorable in cases which,  without constitutional predisposition,
can be traced to such proved evil influences as tobacco-smoking,
exposure to  cold,  etc., and usually take the form of angina
pectoris vasomotoria.  In those cases, also, which appear under
the form of reflex neuroses of  the vagus, there may be hopes of
a cure after the abdominal disease is relieved,  provided the latter
can be accomplished.

                          Treatment.

   In cases in which physical  examination shows the presence
of valvular disease or fatty degeneration of the heart, etc., or in
which the various senile  changes, peripheral arterio-sclerosis,
etc., permit us to infer atheromatous disease of  the aorta and
the coronary arteries, the treatment of angina pectoris is essen-
tially the same as that of the fundamental lesion.  In cases, also,
where  other  causes,  such as  abdominal  disease  or  excessive
tobacco-smoking, are found, we shall  begin  the treatment of
angina pectoris  by removing these.  Commonly, however,  the
causes of the affection are unknown  or obscure, and the causal
treatment is, therefore,  out of the question in most cases.
   We possess, however, as in  the case  of all diseases of which
the etiology and pathogenesis are enveloped in a natural or arti-
ficial obscurity,  a goodly number of remedies, empiric, symp- 
52    EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

tomatic, or so-called specific,  most of which are wholly useless,
while the rest confine their action  to  palliation,  or  produce a
radial cure only by way of exception.
   The general  and local blood-lettings during  the attack, for-
merly so much  praised, will hardly be  thought of  at present by
any one ;  while, on the other  hand,  all  sorts of so-called deriva-
tive remedies, as frictions, mustard  poultices, stimulating baths
for the feet and hands, stimulating embrocations,  and so forth,
are still very popular.  It is certain  that the latter  are more use-
ful than the  internal  administration of  the  so-called nervines
and antispasmodics, valerian, musk, castoreum,  camphor, succi-
nate of ammonia, and the  like, as well as of the narcotics.  Other
tilings recommended in the attack  are the application of  cold,
and in some cases of warmth ; inhalations of ether  or chloroform
in small doses, not sufficient to produce full narcosis (Romberg);
narcotic clysters;  endermic and hypodermic administration of
narcotics.   As regards the latter, lrypodermic injections of mor-
phia doubtless  often  exercise a palliative  action during the
attack, not only upon  the pain,  but also  on  the associated dis-
turbances of  circulation.   This may perhaps be ascribed, for the
most part, to the paralyzing  action of  large  doses of morphine
upon  the vaso-motor nervous system (Wolff, Mendel).  I have
observed very decided symptomatic benefit  of  this kind  from
morphine injections,  not  only  in  uncomplicated (vaso-motor)
angina pectoris, but also  in a case accompanied by an affection
of the valves (insufficiency of the aortic valves, with stenosis at
the ostium venosum sinistrum and hypertrophy  en  masse).  I
have seen  slighter benefit  resulting from atropin and from coniin
(recommended by Erlenmeyer) when injected  subcutaneously.
In those well-defined cases characterized by  violent  accelerated
action of the heart, due to abnormal irritation of  the automatic
ganglia or the excito-motor sympathetic fibres, the class of spe-
cial "heart poisons,"1  such as atropin, nicotin, coniin, aconitin,
delphinin, veratrin, physostigmin, etc., may yet be found appli-
cable.
   The nitrite of amyl is  a remedy which, in  many cases, is jus-
1 Cf. Boehm, Studien iiber Herzgifte.  Wurzburg, 1871. 
ANGINA PECTORIS.—TREATMENT.
53
tified both upon rational grounds and by its  power to relieve
symptoms.  Brunton, arguing from the  fact  that the arterial
tension increases in the stenocardiac attack, has recommended
the inhalation of this remedy, the effect of which, as was  stated
in reference to hemicrania, is to produce a  dilatation of the capil-
laries,  probably through peripheral palsy of the  vaso-motor
nerves.    Leishman,  Sanderson and Anstie,  and  Wood, like
Brunton,  found the results beneficial; while  Fagge  found the
remedy inactive.  Probably the favorable  effect may be confined
to cases possessing the character of vascular spasm.  As it so
easily causes syncope, it should  if possible be used with even
greater care than in cases of hemicrania.
   The general treatment of this  disease is more a puzzle than
even the symptomatic ; the remedies are many, the  cures few.
Various metallic preparations have been much praised ;  the
forms of iron, sulphate of zinc (Perkins), cyanide of zinc (Cop-
land), nitrate  of silver (favorably mentioned  by Romberg and
others in  hysterical angina pectoris), and arsenic (lately recom-
mended in high terms by Lebert, Cahen,  and  Philipp).   I have
tried the latter without any important benefit in several cases of
uncomplicated angina pectoris.  I have also used the bromide of
potassium, as well as the bromide of calcium, which  Hammond1
proposes for a substitute,  but without permanent effect; the lat-
ter in  quantities up  to five grammes per diem.  Others have
strongly recommended quinine, phosphoric acid (Baumes), inha-
lations of  oxygen  (Kneeland), digitalis, hydrocyanic acid, and,
in view of the supposed arthritic origin  of the disorder, those
remedies called antiarthritic.  Laennec recommended the wearing
of a  magnetic  plate.  Somewhat  more regard  must  perhaps  be
given to the so-called derivation by  the application of irritating
plasters, issues and setons in the cardiac region. Koehler, Witt-
maack, and others have obtained a cure by this method in a few
obstinate cases, after  the failure of most of the usual remedies.
The induced current, in the  form of  the faradic brush, seems to
act in a similar way.  Duchenne* affirms that he has not only
1 New York Med. Journal. 1872.
8 Electrisation localisee. 2d. ed. p. 967. 
54    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

arrested very severe attacks  instantly and completely by cuta-
neous faradization of the nipple and region of the breast, but that
he has, by protracted use of this means, produced a permanent
cure in  two cases, one of the uncomplicated  nervous form and
one of the hysterical form.
   Any treatment, or rather any attempt to treat,  that claims to
be based upon reason, will in future have to distinguish between
the several forms  of  angina  pectoris more closely than  has
usually been done.  Cutaneous irritation, and especially cuta-
neous faradization, which acts most quickly,  may perhaps have
a great part to play in certain forms of the disease, owing to its
power of  acting  reflexly upon the nerves of  the  heart and the
vaso-motor nervous  system.  This action is,  of course,  of  two
opposite kinds, in the  case of weak and of strong irritations.
The former strengthen the contractions of the  heart, accelerate
the circulation, and  contract the vessels,  by reflex excitation of
the excito-motor and vaso-motor nervous system ;  but the latter
weaken the contractions of the heart, retard the circulation, and
dilate the vessels, by reflex excitation of the regulator nerves of
the heart and paralysis  of the vaso-motor centres.   In analyzing
the symptoms we have seen that  the disturbances of the action
of the heart and the circulation of the blood  in angina pectoris
usually possess  the character, either of an irritation  of  the
excito-motor nerves of the heart, or of irritation of the vagus, or
of increased excitement of  the  vaso-motor  system  of  nerves
(angina pectoris  vasomotoria).   Of  these three types, more or
less clearly defined,  only the first and the last can call for or
justify the employment of severe cutaneous  irritation ; that is,
those cases which are marked  by a powerful,  rapid,  violent
action of  the  heart, arteries contracted to a cord, small, tense
pulse, etc.  But when  the  symptoms of irritation of the vagus
and of vascular paralysis are most prominent,  or when,  during
the attack, the  symptoms very  soon  revert  to this  type, then
cutaneous irritation must not be used  at  all, or  only in  its
weakest form.
   The therapeutic use  of the constant current  must be founded
upon a similar consideration of  the symptoms of each  special
case.   If  correctly employed, it  is probably  a remedy of chief 
               ANGIXA PECTORIS.—TREATMENT.             55

importance, and perhaps the only direct remedy for angina pec-
toris.   But  the nature of the  symptoms will direct us  when to
select methods of application which produce reflex excitation of
the regulator nerves of the heart, and when to  prefer direct gal-
vanization  of the  cervical sympathetic and  cervical vagus.  I
have only been able to use the former procedure—in three cases
of accelerated action  of  the heart without organic disease—but
could not continue the application long in either instance. The
effect was distinctly good ; the attacks became less severe ; and
in one case ceased entirely, while previously they  had made
their  appearance  almost daily.   In a  fourth  case,  recently
brought  under treatment, the attacks have become rarer and
milder.  The method  used consists  in the application of  strong
stabile currents, rising to the number of 30 elements;  the posi-
tive  pole,  with a broad  surface, is placed upon the  sternum,
while the negative is placed on  the lower cervical vertebre.
Von Huebner has lately obtained a permanent cure  by similar
methods in a case which seemed to have a rheumatic origin.   He
placed the positive electrode upon the fossa  suprasternalis, and
the negative upon the cervical ganglia  of the sympathetic, on
both sides in succession ;  then he placed the positive pole upon
the lowest cervical ganglion,  and the negative upon the sensi-
tive  spots, at the angles of  both shoulder-blades.  At first only
very weak currents, of from  4  to 6 elements,  were borne.  The
attacks ceased from the first session, and did not return  ; and by
degrees it became possible to use stronger currents, of from 8 to
10 elements. 
 
UNILATERAL  PROGRESSIVE   ATROPHY  OF
                          THE  FACE.
             {Hemiatrophia facialis progressiva.)
Parry, Collections from the unpublished writings. I.  p. 478.—Romberg, Klinische
    Ergebnisse. Berlin, 184G.  p. 75, and Klinische Wahrnehmungen und Beobacht-
    ungen.  Berlin, 1851. p. 83.—Stilling, Physiologische, pathologische und medi-
    cinisch-praktische Untersuchungen uber die Spinal-Irritation.  Leipzig, 1840. p.
    325.—Bergson, De prosopodysmorphia sive nova atrophiae facialis specie. Diss.
    inaug.  Berlin, 1837.—Hueter, Singularis cujusdam atrophiae  species nonnulli.
    Diss.  Marburg, 1848.—Schott, Atrophia singulariuin partiura corporis quae sine
    causa cognita apparet trophoneurosis. Diss.  Marburg, 1851.—Moore, Dublin
    Journal. 1852.—Samuel, Die trophischen  Nerven.  Leipzig, 1860.—Eulenburg
    und Landois,  Die  vasomotorischen Neurosen.  Wiener  med. Wochenschrift.
    1866.— Hering, Archiv f. klin. Chirurgie. IX. 1.  1867.—Baerwinkel, Beitrag zur
    Lehre von den neurotischen Gesichtsatrophien. Archiv der Heilkunde.  1868.
    IX. p. 151.—Guttmann, Ueber einseitige Gesichtsatrophie durch den Einflusa
    trophischer Nerven. Archiv f. Psychiatric  1868.  I. p.  173.—Panas, Session
    of the Societe de Chirurgie. May 5, 1869.—if. Meyer, Sitzung der Berlin med.
    Gesellschaft.  Nov. 17, 1869.— Hitzig, Sitzung der Berl. med. Gesellschaft.  Dec.
    1, 1869.—Lande, Essai sur l'aplasie lamineuse  progressive (atrophie du  tissu
    connectif), celle de  la face en  particulier.  Paris, 1870.—Eulenburg, Lehrbuch
    der functionellen Nervenkrankheiten, 1871.—Seeligmueller, Ueber Sympathicus-
    Affectionen bei Verletzung des Plexus brachialis. Berl.  klin. Wochenschrift.
    1870. No. 26, and  1872,  No. 4.—Brunner. Zur Casuistik der Pathologie des
    Sympathicus.  Petersb. med.  Zeitschr.  K  F.  II.  1871. p.  260. — Tanturri,
    Emiatrofia facciale progressiva e trofonevrosi di Romberg. II Morgagni.  1872.
    No. 11.  12.—Fremy, Etude critique de la trophonevrose  faciale. Paris, 1873.
    —Baerwinkel, Neuropathologische Beitn'ige.  Deutsches Archiv  f. klin.  Med.
    XII. p. 606.—Nicati, La paralysie du nerf sympathique cervical, etude clini-
    que.  Lausanne,  lSl'i.—Charcot, Lecons sur les maladies du  systeme nerveux.
    2emeedit. Paris.  1875. 
58    EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

   This extremely rare disease is characterized by a chronic loss
of substance in one side of the face, which  usually begins in
the external soft parts and passes  successively to the  deeper
tissues; the neurotic nature of  its origin is  not proved  by pa-
thological anatomy, but is  rendered very probable  by internal
and external reasons.

                           History.

   The  first case of this sort seems  to have  been described by
Parry in 1825.  Bergson, in 1837,  described  a case  taken from
Romberg's  policlinic,  and  pointed out  the  possibility of the
implication  of the nerves  of the vessels.  Stilling, in his very
interesting work on Spinal  Irritation, to which far too little at-
tention has  been paid, and which promises in its title much less
than it actually contains, mentioned a case observed by Schuch-
ardt,  and explained the atrophy as due  to a  functional disturb-
ance  of the vascular nerves, especially  those which run  in the
trigeminus to the vessels of the head.  His hypothesis that this
was  a case  of "diminished reflexion of the sensitive vascular
nerves upon the corresponding vaso-motor nerves"  is certainly
somewhat forced.   The disease was more exactly described by
Romberg (1846 and 1851), who conceived it to be a primary tro-
phoneurosis—an assumption thoroughly established by Samuel
in his pioneer work upon the trophic nerves.  Axmann-Hueter,
Moore, Baerwinkel, Guttmann, M. Meyer, Hitzig, Bitot-Lande,
Brunner, Tanturri, and others,  have added  to our knowledge of
the disease by separate observations, as  yet very few in number.
The  disease was considered theoretically by Moore as  a distinct
form of progressive muscular atrophy in the region of the seventh
pair of  nerves, while Baerwinkel referred it  to a disease  of the
Gasserian or the spheno-palatine  ganglion, Brunner to a perma-
nent  state of irritation in  the cervical sympathetic, and  Lande
quite denied  its neurotic character and preferred to  assume a
genuine primary atrophy of the  adipose  tissue.  The discussion
upon these points  is still open.

   In the first accounts no special  name was given to the disease, while Romberg
described it  simply as " trophoneurosis," and Bergson more specifically as  " proso- 
       UNILATERAL  PROGRESSIVE  ATROPHY  OF THE FACE.     59
podysmorphia."  Later authors chose the  terms "neurotic atrophy of the face"
(Samuel, Baerwinkel), or facial trophoneurosis.  More lately Lande has proposed
the name "aplasie lamineuse progressive" or "atrophie du tissu conjonctif," which,
however, presupposes that the atrophy is confined to certain tissues, a supposition
by no means justified by the results of  examination in most cases, especially ad-
vanced ones. I consider the designation " hemiatrophia facialis progressiva" as the
completest and most suitable, since the  essential features of the disease, as estab-
lished by all previous investigations, consist in its  limitation to  one side and its
tendency to progress. The term seems to me also preferable to that of "neurotic
atrophy of the face," as the latter is based  upon a hypothesis regarding the origin
of the disease—a very probable one, but not yet demonstrated.


                             Etiology.

    As regards predisposing influences no hereditary transmission
of  the disease has as yet  been  observed.  But it is certain that
youth and the female sex are predisposing  circumstances.   Out
of  16 reported cases which may with certainty be classed under
this disease, 5 were observed in men, 11  in women.  In all the
cases the disease commenced before the twenty-fifth year of life,
namely, at the ages of 2, 3, 6, 7,  10, once each; at 11 three times  ;
at 12 once, 13 once, 15 twice ; at 18, 22, 23 and 24  once each.
    It is noteworthy that the  disease has a special predilection for
the left side of the face ; among  sixteen cases, thirteen were upon
the left and only three on the right side.
    In  a  few  cases  the outbreak was preceded by scarlatina
(Bergson), measles (Hueter),  whooping-cough and a local herpetic
eruption  (Schuchardt).   As occasional  causes,  a severe  cold
taken by exposure to draft and the like are sometimes mentioned,
sometimes a traumatic lesion ; Schuchardt, for example, speaks
of a fall  on the head, which left a cicatrix on the right parietal
bone, below the coronary suture.  In several cases the commence-
ment of the atrophy has been preceded for a longer or shorter
time by notable disturbances of innervation, especially symptoms
of sensory or motor irritation.   Tearing  pains in the head, and
pains in the corresponding side of the forehead or superior maxil-
lary region, are  frequently  mentioned;  also,  toothache (Baer-
winkel).   In one  case (M. Meyer) the patient had suffered from
epileptic fits for several years previously ;  of these fits there were 
60    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

two sorts: one severe,  lasting several hours, and separated by
long intervals ; the other slight and more frequent, in which the
side of  the  face which  afterwards  atrophied was the only part
much affected.  In Brunner s case also, epileptic attacks, occur-
ring for the first time  during  pregnancy, continued for a year
before the outbreak of the disease.  In Parry's case a (hysterical ?)
left hemiplegia preceded the disease, with transitory disturbance
of intelligence, but these  had passed away two years before the
beginning of the disease.  In a case observed by Axmann and
Hueter, the patient, a journeyman  weaver, aged thirty-two, had
suffered  from irregular spastic contractions of the  masticator
muscles of the left side,  which commenced in the seventh year of
his age, and began to grow less frequent from his fourteenth year,
but had never quite left  him.  These spasms were associated with
an increased delicacy of sensation in the region of the left trige-
minus, especially  the first and second branches, differences of
temperature being noted with much greater clearness and sharp-
ness than on the right side.  The atrophy developed itself not
long after the appearance of  these phenomena ;  it is remarkable
that it was chiefly confined to the region  supplied by the third
branch,  namely, the temporal and inferior maxillary region.

                   Symptoms and Course.

   The first and most striking symptom, in  a certain number of
cases, consists in  a  peculiar spotty discoloration of the skin,
associated with a thinning and emaciation of  the latter. A white
spot appears on the face, and gradually spreads ; the spot, pale
or perfectly  white at first, may  afterwards  get a yellowish or
brownish  tint, as  is often observed in  cicatrices after burns.
Sometimes several such white spots are formed at once or succes-
sively, and afterwards run together to one spot of considerable
extent.   The discolored spots soon become the seat of a marked
atrophy, which comes  to view  either about the same time with
the discoloration, or some time later.  The skin seems sunken at
these places, and as the disease goes on, it becomes deformed by
pits of  greater or less size  and  depth.  These are manifestly
caused by the loss of subcutaneous fatty tissue, which proceeds 
       UNILATERAL PROGRESSIVE ATROPHY OF THE FACE.    61

so far that, in places where there was formerly an abundance of
fat, the skin lies  directly upon the bones, can be raised with
difficulty, and when raised its  folds  are  often as  thin  as  two
millimetres.   It is, however,  certain that the  proper  tissue-
elements of the cutis, and even the epidermoid structures, take
part in the disease ; this is shown by the  frequency with which
the nutrition of the hair, the secretions of the skin,  and other
functions are disturbed.  The change in the structure of the hair
of the beard, the eyelashes and  brows, and even  the hair of the
head on the same side, may precede the formation of  the above-
mentioned  spots  and pits; neuralgic  sensations  may  be,  or
may not be, associated with it.  The hair sometimes loses its
color and turns perfectly  white ;  it  sometimes falls  out, or its
growth is more  or less interfered with.   Sometimes only a  few
streaks  of the hair of the head or of the lids and brows are dis-
colored.
   The cutaneous secretion is in most cases much  diminished or
wholly stopped on the atrophied side.  This is especially  true of
the secretions of the sebaceous follicles, while the sweat-glands
often act in a normal manner.   The contractility of the smooth
muscular fibres  of the skin,  as, for  instance, under electrical
stimulation, remains  unaltered.  In  more  advanced stages  the
atrophied skin often feels  rough, or even  cicatricial, and  some-
times desquamates rapidly.  The cutaneous sensibility has rarely
been found lessened (only by Tanturri).  In some cases,  on  the
contrary, an increased susceptibility to external stimuli, as that
of electricity, is said to have been remarked in the affected por-
tions of the skin.  But subjective sensations, paralgic or neural-
gic phenomena in  the  corresponding regions,  have often been
conjoined  with the loss  of color and the  disappearance  of  the
hair.  Besides these precursory neuralgias of the trigeminus,
especially the supraorbital branch, neuralgic attacks have been
observed during  the development and progress of several  cases.
In other instances no  painful  sensation  has  been felt  in  the
affected side of the face, either before or during the progress of
the disease, so that pain is, at all  events,  not a necessary and
pathognomonic symptom of the morbid process.   In two  cases,
observed by Lande in Bitot's wards, the patients complained of 
 62    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

 a continual feeling of itching in the  skin, and of constriction as
 if a rubber mask were applied to the seat of atrophy.
    The deeper tissues are affected differently and very unequally
 by  the impaired nutrition, but it is necessary  to  remember
 that it is very hard to make a just or even an approximate esti-
 mate of the degree of implication in regard to them.
    The muscles of the affected side appeared in most cases quite
 unaffected,  even after  the process  had  run  on for years ; no
 lessening of their volume  was observed ; they contracted  with
 their normal energy and reacted to the electric stimulus just like
 the muscles of the well side.  In other cases their volume was
 lessened, and sometimes fibrillary twitchings have been observed.
 The face often  seemed  to be somewhat drawn towards the atro-
 phied  side.   In the case examined by Guttmann and  myself a
 distinct emaciation and atrophy could be seen in  the  muscles of
 mastication innervated  by  the trigeminus—namely, the masseter
 and temporalis.  The movements of mastication were also weaker
 upon the atrophied side, and the electric contractions wrere less
 energetic.   In  all the  muscles, however, which received their
 nervous supply from the facialis, there was  no visible want of
 symmetry.  In several  cases, however, this want appeared in the
 muscles of the upper lip ;  not only the skin, but also the portion
 of lip  covered by mucous  membrane, was decidedly  thinner on
 the atrophied side than on the other, so  that only a small strip
 of red was to be seen, and when the mouth was partly opened an
 oval aperture was formed before the lips had parted on  the
 other side  (Hueter, Bitot and Lande, Hitzig).  Since the corre-
 sponding part of the upper lip is mainly composed of  fibres of
 the orbicularis oris,  a  partial atrophy of this muscle  must be
 supposed to exist.
   The larger blood-vessels, so far as they were accessible to direct
examination, seldom showed any distinct changes.   The large
arteries of the face,  especially—maxillaris externa, temporalis,
etc.—appeared unaltered in calibre, in most cases.   In some cases
they are said to have been smaller than  those on the well side.
The atrophy laid  the arteries and veins open to sight  and touch,
and this circumstance  may readily have given  rise to mistakes
regarding their calibre. 
      UNILATERAL PROGRESSIVE ATROPHY OF THE FACE.     63

   The tone of the small arteries seems, as a rule, to be retained
or even increased.  For, while  the atrophied parts are  usually
pale or quite  white, they  are  still capable of  blushing under
mental influences, under excitement  or in exertion.   A sudden
suspension or diminution of the tonic contraction must therefore
be supposed to take place in this case.  Local electrical stimula-
tion (cutaneous  faradization  and galvanization) also will often
redden the pale spot.   But in some cases the power to turn red
in response to  psychical influence is lost,  so  that when the well
side blushes the  atrophied side  remains white ; in such cases the
electric stimulus is also without effect.  But the power to blush
may return, without any improvement taking place in  the vol-
ume and coloration of  the parts.  These  circumstances show us
at least that distinct changes  in the vascular tone are  not neces-
sarily connected with the atrophy.  The  temperature of  the skin
on both sides of the face also feels the same ; and the thermom-
eter, applied externally, in the mouth or in the external auditory
canal,  shows no  difference.
    The bones of the face in some cases have been found by exact
measurement to be decidedly atrophied, and in parts  very much
so.  This is true of both the  lower and the upper jaw, and the
smaller facial bones connected with the latter (malar bone).   The
cartilages, e. g., those  of  the nose,  lose  in size  in the course of
time.  In one case there is said to have been an abnormal lax-
ness and dryness in the articulation of  the  jaw on the affected
side.  The teeth may  experience consecutive alterations in con-
sequence  of atrophy of  the  upper  and  lower  jaw ; as  the jaw
retreats, the teeth push each  other out of place, and  the  upper
set interferes with the lower.  In one case, that of a child, an
incisor  tooth  was missing on  the atrophied side, and  its next
neighbor was very imperfectly developed.
    Of the organs in the interior of the mouth, the tongue may be
diminished in  size on the affected side, which is said to be the
reason why it  deviates  towards  this side when put out;  but the
latter circumstance is much more likely to be due to  atrophy of
the outer parts and the upper lip.   The vault  of the palate, the
soft palate, and the uvula may also take part in the atrophy.
The secretion  of saliva and the movements of  swallowing were 
64    EULENBURG.— VASO-MOTOR  AND  TROPHIC  NICUROSKS.

not interfered with  in any case ; but  in one case,  in  which the
external atrophy had reached as far as the region of the larynx,
the pronunciation of the letter r was somewhat impeded.
   The functions of taste, smell, hearing, and  seeing were not
interfered with in any of the cases reported ; in one  (Bitot), in
which the hearing was affected, this was owing  to accidental and
unessential complications.  The secretion  of  tears  is normal.
The orbital fatty tissue  behind the  globe of  the eye often  disap-
pears at the same time with that of  the face, which makes the eye
upon  the atrophied side  appear sunken  and  smaller,  and the
opening of the lids narrower.
   In Brunner's case, which is peculiar in several other respects,  the  opening of the
lids was wider and the eyeball more prominent; the pupil was at the same time dilated
and sluggish in reaction.  The conjunctiva  was pale and deficient in blood; the
secretion of tears and mucus diminished. The outer ear of the affected (left) side
was much thinner, smaller and colder than  that of the right; the temperature in
the auditory meatus lower by nearly 1°, in the left side of the  mouth by 0.2° C.
Pressure upon the ganglion cervicale supremum gave pain upon the left side, but not
on the right.  The rate of the pulse varied from 88 to  100 in the minute.

   The disease is always slow and very protracted.   The cases
hitherto reported  have been under  observation from three to
twenty-three years.   In most cases the disease  marches steadily
and regularly forward; in some a brief  pause seems to  occur
which very soon gives way to a new onset of the disease.  Whe-
ther at a certain point of its  progress a permanent  arrest occurs,
cannot yet be determined; but a few  cases (Tanturri, Baerwinkel)
appear to bear  testimony to  this, and even  to permit  the possi-
bility  of a spontaneous improvement.   No extension beyond the
affected half of the head has been  observed as yet.   The general
health of the patient is not at all interfered with by the disease;
he often enjoys perfect health, except there be some  complica-
tions,  such as epilepsy.


                   Analysis of the  Symptoms.

   The historical account has already shown how great a variety
of theories have been set up to explain the symptoms.  In gene-
ral we can distinguish between theories which assume a neurotic 
      UNILATERAL  PROGRESSIVE  ATROPHY OF THE FACE.    65

origin  for  the  disease and  those which regard the atrophy as
idiopathic, and independent of disturbances of nutrition.  The
neurotic  theories differ among themselves chiefly in respect to
the point whether the vaso-motor or the trophic nerves are pri-
marily affected;  whether the  disease is  to  be regarded as an
angioneurosis or a trophoneurosis ;  and with this question is as-
sociated the one regarding the implication, exclusively or chiefly,
of various nerves of the head, especially the facialis, the trige-
minus and its ganglia, and the cervical sympathetic.  It will
presently appear with how little  certainty we are able to answer
these questions.  The absolute want of data from pathological
anatomy throws us back upon the data of physiology and expe-
riment, which,  beautiful and abundant as they are, yet present
but a dim and confused, often suspicious analogy with the phe-
nomena of the disease.  I will state at once that, in my view, it
is not probable that all the cases observed can be explained by
one and the same scheme, but that some cases show most clearly
a neurotic  origin (sometimes certain branches of  the  trigeminus
being  primarily affected, sometimes the  cervical sympathetic),
while in other cases a neurotic origin cannot be quite denied, but
neither can it be maintained by distinct evidence.
   The necessity of establishing such a distinction may be better
seen by an analysis of certain cases, which are especially instruc-
tive from the pathogenetic point of view.

               Vaso-motor and Trophic Theory.

   Bergson, who was the first to speak of the possibility of a
primary affection of the vascular nerves,  supported his view by
the fact that in the case described by him the carotid of the left,
or atrophied side, pulsated less strongly than that of the right.
This symptom  is not only too indefinite, but  it was absent in
most of the cases.   Stilling, who attempted  to formulate  more
exactly the degree of implication of  the vaso-motor nerves, sup-
ported his  view by the case of Schuchardt, which has already
been mentioned repeatedly.  This was the case of a girl of twen-
ty-six,  the  right side of whose  face had been undergoing a pro-
cess  of slow atrophy ever since her third year, and was now
          VOL.  XIV.—5 
66    EULENBURG.—VASO-MOTOR  AND  TROPHIC NEUROSES.

extremely wasted ; the cause assigned was a fall from her nurse's
arm, which had left a scar on the right temporal  bone below the
coronary  suture.   Stilling explains the  atrophy by "a dimin-
ished reflexion  of  the sensitive nerves of the vessels upon the
corresponding vaso-motors," the sensitive nerves intended being
the branches of the second division of  the trigeminus, distributed
upon the arteries of the face ; the cause was possibly a circum-
scribed lesion of those  fibres, due  to  shock, laceration or extra-
vasation,  occurring at the time of the fall.  But  it is hard to see
why we need assume  a lessened  reflexion from sensitive to vaso-
motor fibres, and  not rather a direct lesion of  the latter  as a
cause  of  atrophy, since the  functions of sensation and sense in
the region of the trigeminus were in no respect altered.
   Romberg, as already related,  had  designated  the disease as a
trophoneurosis, without explaining himself precisely as concern-
ing its origin.  Samuel developed more  fully the relation of the
disease to the trophic  nervous system.   He justly urges that a
lesion of  the vascular nerves, with a resulting diminution or stop-
ping of the circulation of the blood, cannot be considered as a
cause of the disease.  For in such cases the result would probably
be inflammation, softening, gangrene, and never  simple atrophy;
or a collateral circulation would be established,  and with  it the
nutrition would  again be  rendered  normal.  Neither  irritation
 nor paralysis of the vaso-motor nerves, experimentally practised,
 gives rise to the symptoms of simple progressive  atrophy of  all
 or most  of the tissues,  such as exists  in  the  present disease.
 Samuel therefore considers  that the lesion must concern certain
 trophic nerves, the paralysis of which causes a falling out of the
 hair and the nails of  the fingers  and toes, besides other  symp-
 toms, the like  of  which has been  observed  in experimental sec-
 tions of nerves performed upon animals.
   The interesting experiments of Mantegazza,1 who followed out in detail the his-
 tological changes of the several tissues after section of nerves, have shown that the
 deeper tissues (muscles, bones, periosteum, connective tissue, lymphatic glands, etc.)
 take part  in the consecutive alterations; for instance, the muscles become atro-
 phied, and the bones experience a great change of nutrition, which is always  con-
 nected with loss  of  weight.  The muscular atrophy which is associated with
Giornale Veneto di scienze mediche. ser. 3. torn. 6. 1867. 
       UNILATERAL  PROGRESSIVE ATROPHY OF THE FACE.     67

interstitial growth of connective tissue ("muscular cirrhosis") has also  been con-
firmed by Vulpian,1 Ziemssen, Weiss, and Erb, in their well-known experiments.
After experimental sections of nerves we observe not only atrophy, but also hyper-
trophic and hyperplastic  alterations.  Mantegazza observed hyperplasia of the con-
nective tissue and periosteum, hypertrophy of  the medulla, osteophyte formations,
and  hypertrophy of  the lymphatic glands to the extent of sixfold.   A  somewhat
isolated case, related by Stilling, may perhaps be  brought into connection with
these facts;  in  this  instance an injury suffered by a  nerve was  followed, not by
atrophy, but by hypertrophy of one whole half of the face in connection with  dis-
turbances of sensibility and motility in the region of the trigeminus.
   The much discussed question of the existence or non-existence of the trophic
nerves cannot be entered  upon in this place.   Although of late the hypothesis of
trophic nerves  has been regarded  as needless or as unproved by  many (Lande,
Onitnus), yet the majority of authors are strongly inclined to answer the question in
the affirmative,  and  agree with Samuel in regarding their presence as a necessary
postulate in accounting  for the origin of the various forms of neurotic atrophy.
This view is presented, with especial force, by Charcot.2  The wholly negative posi-
tion  taken by a few authors is hardly to be justified,  in consideration of the existing
facts of histology and physiology.   Apart  from the  experimental conclusions of
Schiff, Meissner, Samuel,  Mantegazza, and others, the region of the trigeminus is
certainly  proved by histological examination to  contain nerves which are directly
joined to cells, and in all probability govern the processes of nutrition in them.  "We
need only point to Pflueger's investigations upon the terminations of the nerves in
the cells of the salivary glands, and those of Lipmann  and Klein upon the nerves of
the cornea, and of  the  membrana nictitans  of  the  frog.  "We  can certainly, as
Charcot has done, distinguish the secretory from the trophic nerves (in the narrower
sense), and thus considerably restrict the territory of the latter.3


                  Implication of the  Trigeminus.

    It has  been already stated  that Stilling thought it  necessary
to assume the existence of a partial  affection  of the  trigeminus,
especially  of the vascular nerves  contained  in the  second  divi-
sion,  in the  case  of Schuchardt.   Still  more instructive is the
case observed by Axmann and Hueter, in  which spastic contrac-
tion of  the muscles of chewing, and a hyperesthesia, or sharp-
ening of  the sense  of temperature,  preceded, upon the affected
side, the development of  the disease.

  ' Arch, de Physiol. 1869. Vol.  II. p. 539.
  2 Arch, de Physiol.  1869.  Vol. II. p. 157 et seq.
  3Cf. Eulenburg. Ueber vasomotorische und  trophische  Neurosen.  Berlin, klin.
Wochenschrift. 1872.  No. 2. 
68    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

   The atrophy remained limited, in this case, to the parts of the face (regions of
the temple and lower jaw) which are supplied  by the second division, but within
these limits it was extreme.   The region of the left cheek and temple seemed flat-
tened ; the muscles of chewing  much reduced  in size; the temporal fossa almost
double its proper depth; the layer of fat gone;  the left half of the lower jaw much
shortened and thinned ; the hair on the temple and the whiskers were wanting  on
the left side, while they were quite abundant on the right.  The last grinder tooth
of the left lower jaw was wanting; the tongue was put  out towards  the left, and
its left side was only half as broad and  thick  as the right.  The right cheek was
6'" thick, the left only 3"'.

   In this case  it is  certainly  natural to assume a connection
between the atrophy  and  an affection of the trigeminus, espe-
cially its third division.   The muscular branches of this  division
seem to have been subjected to irritation, at first  frequent, then
by degrees more  seldom, which  probably extended in like man-
ner to the adjacent vaso-motor-trophic nerve-tubes, and involved
the sensitive fibres in part.   We would here mention that cases
are by  no means  rare in which,  one branch of the trigeminus (by
preference the first) being affected with symptoms of sensory irri-
tation,  as a supra-orbital neuralgia, the skin  and hair of the same
region  are also found affected.   The  transition from such cases,
as observed  by  Romberg,  Anstie,1 myself,2 and  others,  to  cer-
tain  cases of circumscribed atrophy, is quite  gradual,  and  in
describing neuralgic  symptoms  in conjunction with trophic, it
often depends only upon the temporary preponderance of one or
the other group of symptoms, or the subjective estimation of the
author, whether  a  case  shall be described  as supra-orbital  neu-
ralgia  with  trophic  disturbance,  or  as  circumscribed  atrophy
with neuralgic symptoms.

   The following case presents an example of  this; it is given by Romberg  under
the name of " trophoneurosis."  A girl, aged twenty-one, having received an
injury in the parietal region, became subject to attacks  of pain in the left parietal
region, to which was added a depression of the left temple, gradually increasing
in depth, and falling out of the hair of the same region.  Examination showed a
furrow or depression six lines broad, beginning about  one inch from the median
line, and extending from the edge of  the orbit straight up to the left lambdoidal
suture.  In  the portion of  this depression which passed over the parietal bone all

      1 Reynolds, System of Medicine. Vol. II.  London, 1868. Art. Neuralgia.
      2 Lehrbuch der functionellen Nervenkrankheiten. p. 99. 
      UNILATERAL PROGRESSIVE ATROPHY OF THE FACE.     CO
the hair was wanting, and the eyebrow close to the foramen supraorbitale was also
quite thin.   Attacks of pain at regular intervals in the posterior portion of the fur-
row, accompanied by obscuration of the senses and a great feeling of anxiety, were
present at the time of this examination.

   The view of Baerwinkel is also noteworthy.  He is inclined to
place the seat of disease in the ganglia of the trigeminus.   In
one case,  in which the region of the infra-orbital nerve was alone
affected by the atrophy, Baerwinkel thinks it necessary to infer
that the spheno-palatine ganglion formed the point of origin ; in
a second,  in which the atrophy extended to all the branches of
the trigeminus,  the ganglion Gasseri.  Since some (though not
decisive) experiments  seem to show that the trophic fibres which
join the peripheral nerve-trunks arise wholly or in part from the
spinal ganglia and that of the trigeminus, it appears that Baer-
winkel's explanation of the atrophy is satisfactory ; only,  in the
second case, it is rather surprising to see the absence of neuro-
paralytic  ophthalmia, which has often been observed in cases of
morbid alteration of the Gasserian ganglion (Landmann, Serres,
Bock, Friedreich and  others).

              Implication of the Facial Nerve.

    It is  not inadmissible to make the seventh pair  of nerves
assist in the explanation, since its trunk, as shown by the experi-
ments of  Schiff, Samuel, and others, probably contains trophic
and vaso-motor fibres.  But the assumption of Moore is  decidedly
erroneous, which supposes that in this affection there is a special
form of progressive muscular atrophy, limited to the muscles
innervated by the facialis.  It is enough to point to the fact that
in some cases muscular atrophy is entirely wanting ; that it is at
any rate a very  subordinate symptom as compared with the dis-
turbances of nutrition in the integuments, and that when present
it  affects  the  motor region of  the fifth  nerve  (the muscles of
chewing)  far more than that of the facialis.   Moore himself says
that in his case the energy of the facial muscles seemed not at all
lessened,  but is  of the opinion that this is  owing to the fact that
these muscles are not  required to make any great exertion, and,
therefore, a diminution of their powers cannot be easily detected. 
70    EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

          Implication of the Cervical Sympathetic.
   Until lately there seemed to be no cases of this extremely rare
disease which furnished ground for tracing a relation between it
and  any affection  of  the sympathetic;  attention was rather
called, by the facts above stated, to the vaso-motor-trophic fibres
which run with the trigeminus.   But since these  fibres, before
passing into the  trigeminus, run partly in  the cervical sympa-
thetic, the possibility remained that the latter might be involved,
which found an indirect support in the circumstance that partial,
slight atrophy of  one side of the face has been observed in a few
cases after traumatic or other lesions of the cervical sympathetic
(Seeligmueller, Nicati).  These were cases of paralysis of the
cervical sympathetic.  Seeligmueller describes two observations
bearing on this point.   In the first there was  an affection of the
sympathetic, in a child, connected  with traumatic paralysis  of
the right brachial plexus from fracture of the clavicle and neck
of the scapula inter partum.  In this case there was myosis and
perceptible atrophy of the right side of the face.  In the second
there was a gunshot wound of the  left sympathetic and a part
of the brachial plexus ; here also there was a decided emaciation
and  flattening of the left cheek, in addition to the usual oculo-
pupillary symptoms.  Nicati  regards the emaciation  of the cor-
responding side of the face, conjoined with pallor,  depression of
temperature, suppression of perspiration, as distinct symptoms
of paralysis of the sympathetic ; he assigns them to an advanced
stage or " second period."  Brunner, on the contrary,  considers
himself bound to assume a permanent state of irritation of the
corresponding cervical sympathetic in the very marked case of
unilateral facial  atrophy which  he describes.   The symptoms of
that  case corresponded entirely to  the usual  results of experi-
mental  irritation of  the cut sympathetic of  the neck or the gan-
glion cervicale supremum:  dilatation  and  deficient  reaction of
the pupil, widening of  the palpebral fissure, exophthalmus, defi-
ciency of the secretion of tears, mucus,  and sweat, lowering of
the temperature of the whole left side of the face.  The left gan-
glion supremum was also painful when pressed upon.    Brunner
therefore assumes that a continued irritation of the sympathetic, 
      UNILATERAL PROGRESSIVE ATROPHY OF THE FACE.    71

perhaps caused by inflammation  or  a tumor, produced a  con-
tinued spasm of the blood-vessels, and by this means a gradual
atrophy of the left side of the face.   The palpitations and the
epileptic fits, which were present in this case, might be traced to
abnormal  innervation  by the sympathetic.  Brunner  thinks he
can exclude an involvement of  the trigeminus and facialis ; the
slight pains in the atrophic side of the face were, perhaps, expli-
cable by muscular sensation or disturbance of nutrition.
   Disregarding a few questionable points in this explanation,
Brunner1 s case stands  as yet  too mnch alone to allow us to draw
from it general conclusions in respect to pathogenesis.

                      Theory  of Lande.

   According to Lande the disease is not a neurosis, but a genu-
ine primary atrophy of the fatty tissue.   He considers that the
fatty tissue disappears altogether, while of the connective tissue
proper only the cells and  fibrils perish, the elastic tissue remain-
ing  unaltered.   The persistence of the latter leads again  to a
retraction of all the tissues, by which the skin is pressed firmly
against the subjacent parts, producing the irritation of the sen-
sitive  nerve-fibres and the  pallor of  the skin.  He seeks to
explain the symptoms of cutaneous anaemia and the neuralgic or
paralgic sensations—as itching—by this retraction of  the elastic
fibres  in the absence of other  connective-tissue elements.   The
apparent atrophy of the muscles  depends, according to him, not
upon  a disappearance of the  muscular substance proper, but
only of the connective tissue which surrounds and penetrates it.
The atrophy of the cartilages  of  the eyelids  a^l ahe nasi, and
even that  of the bones,  is  interpreted by  him as due to the
 changes in other tissues, especially in the blood-vessels.  As the
blood-vessels of the skin, in consequence of the loss of connective
 tissue, are compressed and lose part of their bulk, so also do the
blood-vessels in the perichondrium and periosteum.  These mem-
 branes, moreover, become  contracted in  consequence of the
 destruction of all their  elements except the elastic tissue, and
 thereby not only diminish the arterial supply of the  cartilages
and bones, but also, by  compression, aid the atrophy of  these 
72    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

organs, which is further directly assisted by the loss of the con-
nective-tissue elements that enter into their composition.
   Not only the pallor of the integuments, but also the dryness
of the skin, its rough or cicatricial feel, and the alterations in
the nutrition of the hair,  are explained by Lande as due to the
compression experienced by the hair-follicles and the follicles of
the sebaceous  glands connected with them.  The secretion of
sweat remains intact for the most part, because the sweat-glands,
lying deeper, escape compression longer.
   Lande's theory is based on the presumption that the loss of
cellular tissue precedes  the first  visible symptoms—pallor of
skin,  discoloration of hair, and abnormal pigmentation of the
affected region, since the latter symptoms are brought about by
retraction of  the  persistent elastic tissue and the consequent
constriction of the capillaries.  Lande, therefore, believes that
he can entirely exclude a neurotic origin of  the disease,  and,
regarding it  as a  genuine affection of the  cellular  tissue (tissu
lamineux), he proposes for it the designation, "aplasie lamineuse
progressive," or " atropine du tissu connectif."
   This assumption of Lande's has only  the value of a hypo-
thesis, for the anatomical proof of the primary and exclusive
disappearance  of  the  cellular tissue in the skin and the sub-
cutaneous  structures, bone, cartilage, muscle,  etc., is by no
means established.   From  the clinical  point of view, without
doubt, many objections can be raised against it.   The repeated
instances of occurrence after a local  traumatic injury, the pres-
ence of precursory symptoms of a sensory  or motor character in
the region of the trigeminus, or of such forerunners as epilepsy
and hemiplegia^fhe confinement to single nerve-districts,  and,
above all,  the very fact of the atrophy  being unilateral and
sharply defined in the median line,  are decidedly in favor of the
neurotic origin in the majority of cases.


                   Diagnosis and Prognosis.
   Congenital defect of symmetry in  the two halves of the face
need not be confounded with this disease.  Although it may be
very marked, so that one side of  the face is  decidedly smaller 
      UNILATERAL PROGRESSIVE ATROPHY OF THE FACE.     73

than the other, yet the other changes in nutrition are wanting,
the color is  normal, the growth of the hair unaltered.   But,
besides  these congenital irregularities, acquired want of symme-
try may be developed secondarily to deviations of the vertebral
column, in torticollis  or scoliosis.  Especially in the so-called
habitual scoliosis, consisting of a curve in the dorsal region, with
the convexity towards the right, and sometimes a compensating
curve of the cervical vertebrae in the opposite direction, the right
side of the face is very often found the smaller.  This is not the
place to discuss the doubtful  question of the mode of origin of
this asymmetry, which is usually referred to the compression of
the vessels and nerve-roots in the concavity of the cervical  curve.
But confusion with hemiatrophia of the face may be  avoided  by
observing the want of change in the  tint of the  face, in the
growth  of the hair, etc., not to mention the existence  of  devia-
tion.
    Mistakes  in diagnosis may  perhaps be  made in  cases of
arrested development of one  side of the face, due  to a traumatic
injury  received during  youth.   Panas' has described such a
case,  occurring in a man of twenty-five, who had suffered a frac-
ture of the  lower jaw on the left side,  when  ten  years old, the
result of which was an  arrest in the development,  not only of
this half of the jaw, but also  of the malar and superior maxillary
bones.  The  entire side  of  the face therefore seemed  flattened,
and the nose pushed towards that side.   But  the color and con-
sistence of the parts were normal in this case, and the growth of
the hair quite unaltered. Such  cases  can hardly be  taken  for
true atrophy of one side of the face.
    A little attention will enable one  to avoid confounding a
hypertrophy of the opposite side of the face with this disease.
In the initial stage, however,  certain cutaneous affections (vitiligo
and porrigo decalvans) might be thought of.   In vitiligo we find
the same white decoloration  of the  skin, the  cicatricial feel, the
turning gray and  falling out of the hair, but not the loss of
volume, which is  the  special characteristic of this disease.  In
porrigo  decalvans  inflammatory symptoms and  oedema  of the
1 Soc. de chirurgie, session of May 5, 1869. 
74    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

skin come first; the disease first appears in regular circular
spots; the hairs fall out without previous loss of color, and finally
the disease is contagious, and fungi can be demonstrated (micro-
sporon Audouini).
   The  prognosis is very unfavorable in respect  that  a natural
arrest is no°t to be expected until at least a  very great loss of
substance has  occurred, either  circumscribed or  diffuse.   This
deformity is of the more importance, as the disease affects young
people exclusively,  and chiefly females.   But the general health
is not at all endangered by the disease.
  In only one case, given by Baerwinkel, is a spontaneous improvement  said to
have occurred, and the face to have regained some of its fullness, on the authority
of the mother of the patient, who was a girl of eight.

                         Treatment.

   The  treatment has not been successful.  The internal admin-
istration of a great variety of remedies, the external use of baths,
stimulating frictions, and so forth, have proved quite useless, as
might have been expected.  It is necessary to be  cautious  about
frictions, as excoriations are easily  produced on the  atrophied
parts.   Almost all  cases have been treated electrically  for a
longer  or shorter time—the older  ones with the rotation  appa-
ratus then in vogue, those of recent  times with the volta-electric
induction apparatus or the  constant current.   The use of the lat-
ter is said in some cases to have brought about an improvement
in volume and tint, so that  the power to blush returned, etc.
In the case observed by Guttmann and myself, the local applica-
tion of faradic and galvanic currents for several months, and the
galvanization of the sympathetic,  gave  rise to  no permanent
benefit, though the local galvanization produced a reddening of
the affected side of the face, which  continued for several  hours
 after each session.   Brunner observed in  his  case that when sta-
 bile currents were applied to the two upper sympathetic ganglia,
 the movements of the heart instantly became slower, and the
 pupils  dilated slightly;  the affected side of  the face turned red
 and was covered with an abundant secretion of perspiration. 
BASEDOW'S   DISEASE
   {Morbus  Basedowii;  Graves'  Disease.)
Basedow, Casper's Wochenschrift.  1840. Nos. 13 and 14.—Brueck, ibid. No. 28.—
    Basedow, ibid.  1848.  No. ^.—Henoch, ibid.  Nos. 39,  40.—Begbie, Monthly
    Journ. of Med.  Feb. 1849.—-HeZjpfc, ibid. 1849. Nos. 29 and 30.—Cooper, Lan-
    cet.  1849.  May 26. p. 551.—Lubarsch, Casper's Wochenschrift.  1850. No. 4.
    —Romberg and Henoch, Klinische Wahrnehmungen und  Beobachtungen.  Ber-
    lin,  1851.  p. 197.—Heusinger,  Casper's Wochenschrift.  1851.  No. 4.—Nau-
    mann, Deutsche Klinik. 1853. No. 24.—Stokes, Diseases of the Heart. Dublin,
    18oo.— Koeben,  De exophthalmo ac struma  cum cordis affectione. Diss, inaug.
    Berlin, 1855.—/. Begbie, Edinb. Med. Journ.  1855.—Taylor, Med. Times and
    Gazette.  May 24,  1856.—Charcot, Gaz.  med. de Paris. 1856.—Gros, Note sur
    une maladie peu  connue, etc.  Gaz.  med.  1857.  No. 14.—Pra'el, Archiv fiir
    Ophthalmologic.  1857.  Bd. III. p. 208.—v. Graefe, ibid. p. 283.—Lavrence,
    Gaz.  des hop.  1858.  p. 197.—Fischer, De  l'exophthalmos cachectique.  Arch.
    gen. de m6d. 1859. p. 521 and 652.—Trousseau, Union med.  1860.  p. 437.—
    Ilandfield Jones, Lancet.  Dec. 8, I860.—Aran (in the proceedings of the Paris
    Academie de medecine), Gaz.  med. 1860. p. 712; Gaz. hebdom. 1860. p. 795;
    Arch. Gen. Jan. 1861.  p.  10G.—Dechambre,  Gaz.  hebdom.  1860.  p. 834.—
    Drmarquay, Traite des tumeurs  de l'orbite. Paris,  I860.—Laqueur, De morbo
    Basedowii  nonnulla, adjecta singulari observatione. Diss, inaug. Berlin, 1860.
    —Genouville, Arch. gen.  Jan. 1861.—Cerf  Lewy, De la cachexie  exophthalmi-
    que, these  de Strasbourg.  1861.—Fritz, Gaz. des hop.  1862. No.  88.—Dis-
    cussion in the Paris Academy of Medicine.  Gaz. med. 1862. Nos. 30-36 ; Gaz.
    hebdom. Nos.  30-36 and 38 :  Gaz. des hop. Nos. 83, 84, 86, 89; Arch. gen.
    1862.—nifTelsheim, Gaz. hebd. 1862.  No. 30.—Beau, Gaz. med. 1862. No. 34.
    — Charcot. Gaz. hebd. 1862. No. 36.— Lebert, Die Krankheiten der Schilddriise
    und ihre Behandlung. Breslau,  1862.— Demme, Fortgesetzte  Beobachtungen
    iiber die compressiven Kropfstenosen der  Trachea.  Wiirzb. med. Zeitschrift.
    186-3.  p. 262 and 269.— Brueck, Deutsche  Klinik.  1862. p. 208.—Cros, Gaz.
    hebd. 1862.  p. 541.  No. 35.—Trousseau,  Gaz. med. 1862.  p. 474.—Baillar-
    ger, Du goitre exophthalmique chez les animaux domestiques, Comptes rendus. 
76     EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

    1862. p. 475;  Union m6d.  1862.  p. 116;  Gaz. med.  p.  605; Gaz.  hebd.
    p# 617.—von Recklinghausen and  Traube,  Deutsche Klinik. 1863. No.  29.—
    Bumont, De morbo Basedowii.  Diss, inaug. Berlin, 1863.— Begbie, Edinb. Med.
    Jour. Sept. 1863.  p. 198.— Teissier, Gaz. med.  de Lyon.  1863.  Nos. 1 and 2.
    Fletcher, British  Med. Journ.  May 13,  1863.— Laycock,  Edinb. Med. Journ.
    Feb.  1863. p.  681;  July,  1863.  p. 1.—Peter,  Gaz. hebd.  1864.  No.  14.-
    Trousseau,  Gaz. med.  1864.  p. 180.— von Graefe, Deutsche  Klinik.  1864.  p.
    158  (Sitzung der  med. Gesellsch.  zu Berlin.  9 Miirz, 1864).—Tatum,  Med.
    Times and Gazette.  Jan. 23, 1864. p. 89.—Gildemeester, Archiv fiir die hol-
    landischen  Beitrage zur Natur-und Heilkunde.  Utrecht,  1864.  (III.) p. 416.
    —Handfield Jones, Med. Times and Gazette. 1864. p. 6 and 30. — Laycock, ibid.
    Sept. 24. p. 323.— Schnitzler,  Wiener Med. Halle,  1864.  No. 27.—Rosenberg,
    Berliner  klin. Wochenschrift.  1865.  No. 50.— Paul, ibid.  No.  27.—Moore,
    Dublin  Quarterly  Journal. Nov. 1865. p. 350.— Reith, Med. Times and Gaz.
    Nov.  11, 1865.  p. 521.— Oppolzer, Wiener med.  Wochenschrift. 1866. Nos. 48,
    49.—Geigel, Wiirzb. med. Zeitschr.  1866.  p. 73.—Eulenburg and Landois, Die
    vasomotorischen Neurosen.  Wiener med. Wochenschrift.  1866  and  1867.—
    Friedreich,  Lehrbuch der Herzkrankheiten. Erlangen, 1867.—von Graefe, Berl.
    klin.  Wochenschr.  1867.  No.  31.— Virchow,  Die krankhaften  Geschwulste.
    III. 1867.—Nitzelnadel, Ueber nervose Hyperidrosis und Anidrosis. Diss, inaug.
    Jena, 1867.—Fournier and Ollivier,  Union  med.  1868.  p. 93.—Trousseau,
    Clinique medicale de l'hotel Dieu. Paris, 1868.  3. ed.—von Dusch, Lehrbuch
    der Herzkrankheiten.  Leipzig, 1868.—Begbie, Edinb. Med. Jour. April,  1868.
    p. 890.—Knight,  Boston Med.  and  Surg. Journal. April  19,  1868.—Chvostek,
    Wiener med. Presse.  1869.  Nos.  19-40 and  46.— Cheadle, Lancet.  1869. No.
    25.—Stellwag, Wiener med. Wochenschrift. 1869. No. 44.—Eulenburg,  Berl.
    klin.  Wochenschr. 1869.  No. 27. p. 287.—Benedikt, Wiener med. Presse.  1869.
    No. 52.—Rabejac, Du goitre exophthalmique, these. Paris,  1869.— Wilks,  Guy'a
    Hosp. Reports.  1870.  XV. p. 17.—Solbrig, Zeitschrift fiir Psychiatrik. 1870-
    '71.  Bd. 27.  p. 5.— Andrews,  Amer.  Jour,  of  Insanity.  July,  1870. p. 1-
    Emmert, Archiv fiir Ophthalmologic  1871.  XVII. 1. p.  218. — Chisolm, Med.
    Times and Gazette. 1871.  No. I.—Boddaert, Note sur la pathogenie du goitre
    exophthalmique.  Bull,  de la  soc.  de med. de Gand.  1872.—Chvostek, Zur
    Pathologie und Elektrotherapie der  Basedow'schen Krankheit.   Wiener med.
    Presse.  1871.  Nos. 41-52; 1872. Nos. 23-32.— M. Meyer, Berlin med. Gesell-
    schaft vom 17 Juli,  1872.—Eulenburg  and Guttmann,  Die Pathologie des
    Sympathicus. Berlin, 1873. -Leube, Klin.  Beilage zu dem Correspondenzblatt
    des allg. arztl. Vereins zu Thiiringen.  1874.  No. 28.—E. Frdnkel, Zur Patholo-
    gie des Hals-Sympathicus.  Diss. Breslau, 1874.—Becker, Wiener med. Wochen-
    schrift.  1873.  Nos. 24, 25.—Perres,  ibid.  1874, No. 46.—Smith, Lancet.  1874.
    I. No.  2Q.—Baumblatt,  Aerztl. Intelligent.   1874.  No.  33.—Schulz,  Diss.
    Greifswald, 1874. 
                Basedow's  disease.—history.             77

   By the name of Basedow's  disease we designate a group of
symptoms, of which the chief  are palpitation with accelerated
pulse,  swelling  of the thyroid gland, and exophthalmus.  A
number of  other disturbances, especially in the nervous system,
the circulation,  and (in females) in the  genital sphere, are fre-
quent symptoms, but not quite pathognomonic ; sometimes they
are even secondary in character. The three cardinal symptoms
first enumerated are found associated in the very great majority
of cases, but each one may be absent now and then, or be present
in a degree scarcely passing the limits  of physical health; or
exophthalmus may be present  alone, in which case (unlike the
affection which  is due  to local intra-bulbar  causes) it always
attacks both eyes, and is  combined with other general  disturb-
ances of health.

                           History.

   Parry, in  1825, certainly  described  some cases of this disease
under the designation of " enlargement of the thyreoid gland in
connection with enlargement or palpitation of the  heart," but
among the eight cases mentioned by him exophthalmus is only
once mentioned.   St. Yves,  Louis, and Demours seem  to have
known the disease.  Basedow was certainly the first to give an
accurate description, while the English usually assign the credit
of the discovery  to Graves.   Contributions to the natural history
of the disease have  been made  by  Stokes, Charcot, Trousseau,
Fischer, Genouville,  von Graefe, and others.   The theory of the
disease  has gradually assumed new forms;  the  first observers
(Basedow, Helfft, Lubarsch,  Cooper) and many since them have
sought to find its essential cause in a morbid  crasis, like that of
chlorosis, while others (as Stokes) considered the heart the point
of origin, and later observers, for the most part, have regarded
the disease as a  neurosis (Handfield Jones, Fletcher, Laycock),
referring it especially to the cervical sympathetic (Koeben, von
Graefe, Aran, Trousseau, and others), or  to the spinal centres of
the cervical sympathetic, the cervical medulla  spinalis,  and the
medulla oblongata (Geigel, Benedikt).   The few data of patho-
logical anatomy have not yet  given a decided result.  I have 
78    EULENBURG.—VASO-MOTOR  AND  TROPHIC NEUROSES.

explained at length in former works the relation  of  the several
symptoms to the nervous  system, and must continue to uphold
the neurotic theory as a necessary postulate,  while I regard the
question of localization in definite sections of the nervous system
(especially in the cervical sympathetic or its  centres) as not yet
solved, and at present unsolvable.

   Synonyms.— While Basedow himself described the disease as " Glotzaugenkrank-
heit" (referring to the projection of the eyeballs), it has been pretty generally called
by his name in Germany, as in England by that of Graves.  Its two chief symptoms
have given it the name of struma exophthalmica (goitre  exophthalmique, exoph-
thalmic goitre) ; the exophthalmus by itself has given the name of cachexia exoph-
thalmica ("exophthalmos cachectique" of Fischer).  Lebert proposed the name of
" tachycardia strumosa exophthalmica," which at least includes the whole trio  of
symptoms.


                           Etiology.

   Of the  predisposing causes the  influence  of sex  and  age  is
first  to be  considered.   The female  sex is  affected decidedly
oftener than the male, in about the ratio of two to one. The
middle period of life, between puberty and the climacteric years,
is  also affected with  especial frequency.   In childhood  the dis-
ease is very rare, but some  cases are  reported ; thus Devol ob-
served it in a girl of two and a  half years, Rosenberg in one of
seven years, Solbrig in a  boy of eight, and Trousseau in one of
fourteen.    It  is  rare beyond the  climacteric period;  Stokes
relates the case of a woman of sixty.  It is, however, necessary to
add that the disease itself or its complications very often shorten
life considerably.
   Hereditary influence  is  in some  cases  probably  of impor-
tance ; but the observations  on this point are not yet sufficient.
In the above-mentioned case  of Solbrig's, of a boy  of eight years,
the mother is said to have suffered from Basedow's disease.
   The favorable  or directly causal influence of a bad  crasis of
the blood,  especially in chlorosis and  an&mia, has been affirmed
and denied with about equal frequency.   To prove  the depen-
dence upon chlorosis, various authors have urged the frequency
of the disease in the female  sex  after puberty,  the frequent dis- 
Basedow's disease.—etiology.
79
turbances of menstruation during or (more especially) before the
beginning of the disease,  and the  occasionally favorable effect
of pregnancy (Charcot,  Trousseau, Corlieu).  But the asserted
dependence upon chlorosis  is  contradicted  by  the fact  of  its
occurrence in men, in women beyond the climacteric period, and
in children, and in fresh-complexioned persons without a symp-
tom of chlorosis or anaemia; it also sometimes develops itself
acutely from accidental causes.   Upon the  whole,  therefore, it
seems better to consider the ansemia of Basedow's disease not as
a primary factor, but  as only a consecutive  symptom, common
to many chronic diseases.
   The influence  of a  neurotic predisposition seems undeniable
in certain cases, at least.  In favor of this we have the frequency
of the occurrence of the disease in connection with hysteria, to
which  Brueck  called  attention,  and with epilepsy  and mental
disease.   In a case  described by Gildemeester, epileptic  fits
preceded the attack by several  years, disappearing  one year
after the commencement of Basedow's disease, and not reappear-
ing. Interesting cases  of Basedow's disease,  with mental dis-
turbance, have been published by Geigel,  Solbrig, Andrews, and
others.   I  have observed  several such, and  once, in a  woman,
morbus Basedowii  simultaneously  with  tic convulsif, and with
alternate attacks  of mania and melancholia.
   Finally,  in some well accredited cases,  quite accidental inju-
ries, traumatic  or otherwise,  seem to have caused the outbreak
of the disease.  Thus, mental excitement (Solbrig), violent fright
(Laycock), forced cohabitation (von Graefe),  injury to the head
and application of leeches  (von Graefe), and injur}r of the occiput
(J. Begbie),  have  been  stated to be causes of the sudden appear-
ance of the disease.  The importance of these causes can, how-
ever, hardly be judged of in  the cases given.

   Possibly climate has  some  influence.  Lebert  states that the disease is more
common  in North Germany than it  is in Switzerland and France.  I find it not
common  in Berlin; but it seems  more so on the Baltic coast.  Judging from the
literature, it would seem to be thought specially frequent in England.  There are,
unfortunately, no statistics to appeal to. 
80    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

                   Symptoms and  Course.

   The  disease usually  develops  very slowly ;  yet  there  are
exceptional cases,  in  which it begins brusquely  and  all  the
symptoms appear in the course of a few days.  Such cases seem
to be chiefly  caused  by accidental  injuries of  the above-men-
tioned sort (psychical excitement,  or wounds).    In  this class
belong the cases  of von Graefe, Laycock,  Solbrig, and others.
Peter describes a case observed by  Trousseau ; the patient was a
woman, and her disease  developed itself  in a single night, as a
result of profound grief for the death of her father.   During that
whole night her nose bled profusely.
   A few cases of sudden origin may also run an entirely acute
course, and may recover in a short  time.   It may therefore be
proper to  separate  such cases under the designation of acute,
from the usual or chronic form of the disease.   In the case of
Solbrig the recovery was complete  in ten days.
   Very often the first symptoms  of Basedow's disease are pre-
ceded for a considerable while by symptoms of various sorts,
especially  that multiform  group known  as hysteria ;  in  some
cases by epilepsy (Gildemeester).   The first  symptom is  usually
palpitation, which at first occurs only at intervals,  but  by
degrees becomes more permanent,  and, as it were,  habitual.  It
is conjoined with acceleration of the pulse, which  at  first may
not be constant, but afterwards may  become permanent,  without
remission,  so  that  the pulse maintains  a continuous,  uniform,
quite enormous rate.   I observed for a long time a patient who
had a pulse of 144 every day and at  every hour of the day, with
scarcely any variation at all.  In lighter cases the  rate averages
from 90 to 120 beats ;  in  others it  may reach 200 (M' Donnell'),
and in one observed by Gildemeester it was at times too rapid to
count.
    It is a characteristic fact that the  ordinary remedies for lower-
ing the pulse often  produce no effect.  In a few cases the palpi-
tations and the changes in the rate of  the pulse are entirely
absent.  In fifty-eight older ones collected by von Dusch,  this
1 Dublin Journ. of Med. Science. Vol. XXVII. p. 203. 
        Basedow's disease.—symptoms  and course.      81

was the case  three times.  More  lately Chisolm, Leube,  and
others  have contributed observations  bearing upon this point.
In Leube's  case the rate reached 82 only once ; in Chisolm's it
was 8."5, while there were no palpitations at all.
   Physical examination of the heart reveals nothing abnormal,
as a rule.  The most that is found is an occasional systolic mur-
mur, usually plainest at the apex, and probably only indicative
of anamiia.  Other circulatory phenomena have been observed :
these are occasional epigastric pulsation,  increased force of the
pulse  in the carotids  and their  larger branches, especially the
thyroids, and a whirring and  blowing that may  be  heard by
auscultation before the struma is  developed, pulsation of the
retina (Becker), and in rare cases pulsation of the liver.   Lebert,
who observed this phenomenon  three times,  regards the  hepatic
pulse  as arterial,  and distinguishable from the venous by its
slighter intensity ;  it is the less likely to be confounded with the
ordinary epigastric pulsation, as it is oftenest felt just over the
right lobe of the liver.
   When these symptoms of disordered circulation have lasted
for some weeks or months, the second chief symptom, struma,
is developed, slowly or rapidly, often within the  course of a few
days ; its usual form  is that of a swelling of soft, elastic consis-
tency, distributed uniformly over the whole  thyroid gland. It is
less common to find only one lateral lobe affected ; in other cases
both are involved, but one more so  than the other.  Very rarely
the struma appears before the palpitation ; still more rarely it is
wholly absent—according to von Dusch, in three  cases out of
fifty-eight.   The surface of the tumor  is often marked by veins,
greatly dilated and crowded with blood; the hand laid upon  it
feels almost  everywhere a distinct fremissement, and auscultation
reveals loud blowing  sounds,  often  increased  during  systole.
These symptoms may  subsequently  diminish or disappear, while
the tumor assumes a  somewhat  firmer and  more resistant con-
sistency.  This seems to depend on the  fact that the early hyper-
emia and dilatation of vessels yield  at a later period to  an actual
hyperplasia  of the glandular tissue.   The struma of Basedow's
disease seldom reaches a considerable extent.  It is also  worthy
of note that the size of the tumor is  subject to frequent changes;
         VOL. XIV.—6 
82   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

mental disturbance, the action  of medicine, various changes in
the other conditions of the disease, and above  all, pregnancy,
have an  unmistakable influence.  According to Stokes, Graves
observed two  cases, in which  each attack of palpitation was
accompanied by a swelling  of  the  thyroid gland, which disap-
peared when the attack was past.  Similar cases, in which the
tumor was observed to increase or decrease according to the force
of the beat of the heart, have been reported by Henoch, Begbie,
Marsh, Gildemeester, and others.
  Exophthalmus makes its  appearance soon after the struma—
in a few cases before it—and  still more rarely as the initial symp-
tom, preceding the struma and the palpitations (in one case of
Mackenzie's and one of Chvostek's).  It is almost without excep-
tion bilateral.   A few cases  of the unilateral sort are mentioned
(Mackenzie,  Foerster quoted  by  Lebert,  Schnitzler,  Chisolm,
Emmert), but  some suspicion  must remain in  respect to the
diagnosis of these  cases.  (See  "Diagnosis.")  Sometimes  the
exophthalmus comes  earlier in  one eye  than in the other, and
often it is not equally developed upon both sides.  Sometimes
it may be wdiolly wanting (in four out of fifty-eight cases, accord-
ing to von  Dusch), while in other  instances it  forms the only
cardinal  symptom (Prael, Degranges, and Sichel,  quoted by
Fischer), in  which cases it is associated with other sorts of gene-
ral disturbance,  so that the  terms "exophthalmie cachectique"
or "cachexie exophthalmique"  seem not unsuitable.
    In degree,  the  exophthalmus varies  extremely ;  sometimes
there is  but a slight prominence of the  eyeball, sometimes the
protrusion is so excessive that no part of  the globe is covered by
the eyelids  ; and even luxation of  the  globe may occur (Pain
quoted by Trousseau).  The prominent eyeball has an unusual
lustre  and  a  peculiar stiffness ; in fact, if the deformity  has
existed long, it  often loses  its  mobility in great part or wholly.
The exophthalmus is not  always  equally  distinct, but often
increases and  disappears, proportionately to the  force of the
pulsations of  the heart, and sometimes  ma}^ be diminished by
light pressure  on the eyeball.  It is almost always accompanied
by a phenomenon, first observed as characteristic by von Graefe:
the upper lid  loses its power to move in  harmony with the eye- 
        BASEDOW'S DISEASE.—SYMPTOMS AND COURSE.      83

hrdl in the act of looking up or down.   This want of agreement
between the movement of the lid and the raising or depressino- of
the point of view is not caused by the exophthalmus as such, for
the movement of the lid is not impaired in exophthalmus occur-
ring  from other causes, such as  tumors of the orbit, while in
Basedow's disease, if ever so little developed, it is weakened or
suspended.  That this phenomenon is independent of the exoph-
thalmus  is further shown by  the  fact that it  may disappear
during the  course of the  disease,  without any improvement
having taken place in the latter, and this may be a spontaneous
result or may follow the use of narcotic injections.   According
to von Graefe, the  phenomenon is therefore pathognomonic, and
is extremely  important  in  diagnosticating  slight degrees of the
disease, in  cases where the eyes hardly project more  than the
normal amount, and where there is no struma.   He observed a
patient whose  only symptoms were this  defective agreement
between the movements of the lid and the raising or lowering of
the glance, and palpitation of the heart; the diagnosis of  Base-
dow's disease was made  upon this evidence  alone.  I have seen
no such cases ; but in one case, with great protrusion of the globe,
I have seen the movement  of  the lid almost normal, scarcely
diminished beyond ph}"siological limits ; in like  manner also, in
another case,  with moderate exophthalmus.  I, therefore, do not
incline to grant a pathognomonic value to this sign, although its
very great frequency must certainly be admitted.
   Another and a rarer group  of symptoms must  perhaps be
regarded in some cases as secondary, as a sequence of the exoph-
thalmus and the defective power to depress the upper lid.  These
symptoms are disturbances  in  the nutrition of the bulb,  espe-
cially in the outer coats of the eye, the conjunctiva and cornea.
The impairment of the powrer of moving the lid prevents the eye
from receiving its due share of  moisture, whence come dryness
in the conjunctival sac, distention of  the conjunctival veins, and
conjunctivitis.   The lachrymal  secretion is  often increased.  In
the majority of cases nothing worse  occurs;  but in bad  cases
severe disturbance of  nutrition of the cornea  follows, closely
resembling what occurs in neuroparalytic ophthalmia, and per-
haps explicable in the same way.  (See below, "Analysis of the 
84    EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

Symptoms.")  The cornea first loses its sensibility ; on its  sur-
face dry yellow spots appear, which gradually enlarge, and the
final result is the formation of an eschar followed by diffuse desic-
cation or even perforation.   In other cases infiltrations occur at
several points of the cornea at once, and ulceration or even  per
foration occurs.  It is remarkable that these disturbances in the
nutrition of the globe are common in men (Basedow, Prael, Nau-
mann, von Graefe),  although in a few instances also observed in
women (Lawrence, Tatum, Teissier).
   The accommodation  is usually unaffected in Basedow's  dis-
ease,  though sometimes weakened in consequence of  deficient
mobility of  the  globe.   Ophthalmoscopic examination usually
shows, according to von Graefe, a dilatation and  increased  tor-
tuosity of the retinal veins.  Becker observed, besides this, spon-
taneous pulsation  of the retina  in two  cases.  In the immense
majority of  cases the pupil is quite  unaltered—a  fact of  the
more importance, as the exophthalmus produced experimentally
in animals, as in death by suffocation  or by  paralysis of  the
heart, is always accompanied by dilatation of the  pupils.  It is
true that the statements of authors regarding  the  pupil are  not
quite in  accord ; some authors (Romberg, Reith, Geigel, Fried-
reich, Cazalis quoted by Trousseau, Fournier and Ollivier) speak
of dilatation of pupils, but this  was probably not connected
with Basedow's disease,  as the patients in question were probably
myopic.  Gildemeester in one case found  the pupils at first much
dilated, afterwards  contracted ; Cheadle found a slight dilatation
with  entirely regular reaction; Nitzelnadel in one case contrac-
tion ; Emmert in some  cases contraction,  in others dilatation.
Von Graefe, however, informed the  author that  among nearly
two hundred cases of Basedow's  disease  he had not once found
dilatation of the pupil.  Neither have I myself seen it in cases
of genuine morbus Basedowii; but I have had occasion to state
that there are cases of struma with slight unilateral exophthal-
mus and accelerated pulse, which  cannot be taken as cases of
Basedow's disease, but  as  secondary neuroses of the cervical
sympathetic, caused by the strumous tumor,  characterized by
considerable dilatation of the pupil,  and by the elevation of the
temperature on the affected side of the head (see "Diagnosis"). 
         BASEDOWT'S DISEASE.—SYMPTOMS AND COURSE.      85

   Among the less constant symptoms of Basedow's disease must
 be mentioned the elevation of the bodily temperature, which did
 not escape the attention of the first observers.  The patients feel
 this, even when it is very slight, as a sense of heat, often accom-
 panied  by an increased  secretion  of sweat.  Basedow himself
 pointed out this feeling of heat, and in later literature cases are
 described in which it was so severe that the patients threw off
 their clothes (Trousseau, Fournier and Ollivier).  As a rule, the
 elevation observed by instruments is not very considerable;  but
 it appears rarely wanting when the test is applied  carefully and
 repeatedly.   Paul found in one case an elevation of from 0.5° to
 1° C. ; Teissier often from 1° to 2° ;  Cheadle, in his report of eight
 cases, says that he always found elevation of temperature.  In all
 the cases of my own observing I have found  an elevation of from
 0.5°  to 1° C, at least temporarily ;  and in one case, that of a girl
 of twenty years, whose temperature was taken very often for the
 period of three-quarters of a year,  it always stood from 38.2° to
 88.8° (100.8° to 101.8° F.) in the axilla.   But Charcot and Du-
 mont report cases  in which the temperature was entirely normal.
 This elevation is of course only important in the uncomplicated
 cases, which are not accompanied by febrile disease.
   There is also a  series of nervous disturbances,  not to be con-
 sidered as essential and  pathognomonic, but as quite frequent
 accompaniments, and probably based in part upon an existing
 neuropathic predisposition.  Among these must be included the
 complications with hysteria, epilepsy, and insanity, already enu-
 merated under the head  of etiology ; it  must also be said that
 the slighter degrees of mental alteration, a changeable and espe-
 cially a lachrymose disposition, alternations of excitement and
 depression, etc., are of extreme frequency in the higher grades of
 Basedow's  disease, especially  in  women.  The patients  often
 complain of severe headache, sometimes limited to one side; a
 feeling  of dizziness, complete  inability to work,  weakness of
 thought and memory, and tormenting sleeplessness, and express
a fear of losing their minds.  Sometimes there is excessive appe-
tite ;  oftener loss of appetite, even  aversion  to all food, nausea,
and vomiting, and,  in consequence, emaciation.   All these symp-
toms, and especially the mental ones, are not usually present in 
86    EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

an equal degree, but  may increase, diminish, or at times disap-
pear, proportionally to the leading symptoms of the disease.
   The frequent occurrence of  disturbed  menstruation, particu-
larly amenorrhoea, has  been  mentioned already.   In  a  case
recently related by Leube a slight cutaneous sclerema of the face
and  the  backs of the hands was observed.   Nitzelnadel and
Chvostekl give cases in which a sweating upon one side (ephi-
drosis unilateralis) was observed to coincide with  contraction of
the corresponding pupil; and a case of  hyperidrosis unilater-
alis,  with struma and hypertrophy of the left ventricle, recently
observed by Ebstein,2 may be classified here.
   The duration of the  disease, if we except those rare and in
many respects anomalous cases classed as acute Basedow's dis-
ease, is always very protracted.  Months  and years may pass,
with alternate improvement and relapse.  Not very rarely an
entire recovery occurs, spontaneously or in consequence of thera-
peutic measures.  In some  few cases pregnancy seems to  have
had  a favorable influence  (Charcot,  Trousseau,  Corlieu).  Bnt
usually the progress is  toward the worse- Consecutive changes
in the heart often develop; the  permanently  increased  labor
exacted of the heart  leads  to dilatation  of both  ventricles and
compensating hypertrophy, and a disturbance in  the compensa-
tion may, at a later time, hasten the fatal issue.   In other cases
death occurs during exhausting  marasmus or intercurrent dis-
eases (as oedema of the lungs or apoplectic attacks), or other
complications, as especially tuberculosis of the lungs and valvu-
lar difficulty of the heart. In the case described by Fournier and
Ollivier, and in another by Rabejac (cf. " Anatomical Changes"),
death occurred during progressive gangrene of the  lower extremi-
ties,  without  any apparent cause for this sudden suspension of
nutrition.

                    Anatomical CJianges.

   The number of reports of autopsies is very small, which  need
not surprise us, as patients with Basedow's disease seldom enter
1 Wiener med. Wochenschrift. 1872. Nos. 19 and 20.
2 B. Fraenkel, Diss.  Breslau, 1874. 
           BASEDOW'S  DISEASE.—ANATOMICAL CHANGES.        87

 hospitals, and still more  rarely  remain there till  their  death.
 The anatomical examination of the struma  has usually shown a
 dilatation of the veins, or considerable development of the arte-
 ries  ^Smith and MacDowell, quoted  by  Stokes, Naumann, J.
 Banks,  Moore,  Fournier  and Ollivier); the glandular tissue is
 either normal, or in a state of  simple  hyperplasia, or filled with
 cysts and altered by new formations of  decidedly a secondary
 character.
    Behind the  globe  of  the eye a considerable  development of
 fat is almost always found (Basedow,  Ileusinger,  Naumann,  La-
 queur, Traube and Recklinghausen, Peter, Fournier and Ollivier,
 and  others); sometimes with this there  is atheromatous change
 of the ophthalmic  artery  (Naumann), or,  as in  Traube's case,
 advanced fatty degeneration of the  eye-muscles, probably caused
 by disuse and  stretching.   Move attention has lately been paid
 to the nervous system,  and  especially, since  the well-known
 experiments  of Claude Bernard, to the sympathetic in the neck
 and  its  ganglia.   Upon  this point  the  reports vary greatly.
 While most  authors  have  obtained positive results  (Trousseau
 quoted by Peter, Reith, Cruise and  McDonnell quoted by Moore,
 Traube and Recklinghausen, Biermer,  Virchow, Geigel, Knight),
 others have not been  able to  show any changes  in the sympa-
 thetic and its ganglia (Paul, Fournier and Ollivier,  Rabejac,
 Wilks).

   The case described by Peter, remarkable for the suddenness of its commence-
 ment (see above), ended fatally in eight days.  At the autopsy (by Lancereaux), the
 chief morbid appearance was a predominance of the connective tissue, and a dimi-
 nution of the nerve-elements in some parts of  the  cervical sympathetic, more in the
 right and  less in the left inferior  ganglion,  while the upper and middle ganglia
 seemed quite normal.  The cardiac plexus presented no striking alterations.
   The case of Reith was a man of twenty-four; the disease had lasted a long time.
 The principal result of  the autopsy (Beveridge) was to show an enlargement of the
 middle and lower cervical ganglia; they were hard and firm, and under the micro-
 scope showed an infiltration with a grayish mass.   The cord of the sympathetic,
 also, and the branches sent off from it to the lower thyroid and the vertebral artery,
 were enlarged and in a state of tuberculous change.
   In the case examined by Cruise and McDonnell, the lower cervical ganglia of both
sides were almost obliterated, and  replaced by  cellular and fatty tissue.  In the case
of  Traube and Recklinghausen a striking thinness of the sympathetic and its gan- 
88    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

glia is spoken of; no other changes were to be found in the sympathetic or vagus.
Biermer mentions in a letter the case of a man in whom there was great atrophy of
both sympathetics, especially the right.   Virchow found in a man who died with
dropsical symptoms, a  hypertrophy of the heart, with very extensive  myocarditis
and enlargement of the thyroid gland, and also a very considerable enlargement and
interstitial thickening of the cervical sympathetic, especially in the upper and lower
ganglia.
   In Geigel's case (a man of  forty-eight) both  cervical sympathetics  were found
ensheathed in remarkably thick connective tissue, abounding in fat, but the micro-
scope discovered no change in the nerves proper, nor, except intense brown pigmen-
tation, any in the ganglia ; neither was there to be seen any increase  of interstitial
connective tissue.  The cervical parts of both vagi, both in the fresh condition and
after  preservation in Mueller's fluid, were normal.  The  following  changes  were
also found: obliteration of  the central canal of the  spinal cord, much fullness of
the small and of the minute vessels of the cord ; in the direct neighborhood of the
central canal the medullary substance was quite hard, and there was a slight pro-
liferation  of the neuroglia; there was also a tumor  on the synchondrosis spheno-
occipitalis.
   In Knight's case (a man of thirty-three), the left lower cervical ganglion of the
sympathetic was larger than the right, the amount of connective tissue quite large,
while the nerve-cells were decidedly smaller and less pigmented than usual.  In the
middle and upper ganglia of the sympathetic of the  left side the nerve-cells  were
much smaller than on the right.   The nerve-fibres in  the left sympathetic were one-
half the size of those of the right.
   Paul found nothing abnormal in the thoracic and  cervical portions of both  sym-
pathetic cords;  nothing in the  lower cervical ganglion.   In the fresh condition,
as well as after staining with carmine, the nerve-fibres and ganglion-cells  appeared
of entirely normal dimensions, with distinct nuclei and nucleoli, some colorless, some
pigmented.
   In the oft-quoted case of Fournier and Ollivier there were found no changes in
the cervical, thoracic, and abdominal cord of  the sympathetic.  The examination
was made with great care by Ranvier upon carmine preparations.   Both the nerve-
fibres and the ganglion-cells were entirely normal; increase of connective tissue was
nowhere present.  In Rabejac's case (a woman of fifty-eight) the sympathetic was
examined microscopically by Bouvier, and found entirely normal.  Wilks found no
coarse changes in the ganglia of the sympathetic, which even seemed unusually white;
microscopically there was found nothing  abnormal except an increase  of the con-
nective-tissue fibres.

    These  few facts,  so heterogeneous  in  character,  must not be
applied  to the  pathogenesis  and theory of  the disease without
the greatest  care.    It  is true  that there are only four negative to
eight positive  reports regarding the sympathetic ;  but  some of 
         Basedow's disease.—analysis of symptoms.     89

the latter are such  as hardly involve necessary disturbances of
the functions of the sympathetic.  Thus, in Geigel's case there
was only a thickening of the connective-tissue sheath, while the
nerve-fibres,  ganglion-cells  (except for  the  pigmentation), and
interstitial connective tissue were normal. It seems to me worthy
of note that in the few carefully examined  cases where there
were positive changes in the sympathetic, the lower ganglion is
spoken of with  considerable unanimity as the one chiefly or ex-
clusively affected (Peter, Reith,  Cruise and McDonnell, Virchow,
Knight).  With the lower ganglion the middle one  has once
been found affected (Reith), and the upper one once (Virchow);
in Knight's case the upper and  the middle ones were altered, but
less so than the lower.   It must be remarked that Ebstein, in the
case of hyperidrosis unilateralis with struma and hypertrophy
of the left side of the heart, already mentioned, found striking
changes  in the left  cervical sympathetic,  chiefly in the lower
ganglion, consisting of varicose  swelling of the blood-vessels with
much pigmentation of the ganglion-cells.  By the kindness of
Dr. Ebstein I myself had opportunity to confirm this fact at the
Breslau meeting  of naturalists.  In most  cases  of undoubted
Basedow's disease the alterations occurred in both sympathetics,
but in some the affection was  not equal, being more developed
on the right  side (Peter,  Biermer), or the left (Reith); in Knight's
case the left  sympathetic seems  to have been affected exclusively.
In Geigel's case there were  also changes in the spinal cord, which
do not admit, however, of a direct interpretation.

   Analysis of the Symptoms, and Theory of the Disease.

    Let  us now attempt  an analysis of the leading symptoms,
with the object of forming a general theory of the disease ; we
shall  be obliged, at the best, to content ourselves with a some-
what unsatisfactory result.
    We will  first speak  of  the  struma,  because the attempt has
often been made to make  the  other symptoms depend upon it
(Koeben,  Piorry, Cros,  and others), although the struma is by
no means the first symptom in  the majority of cases. Trousseau
and others considered the struma (as  they did the exophthal- 
90    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

mus) to be the consequence of a  congestive state of the upper
half of the body, while the disturbed menstruation, or aim-nor-
rho?a, was supposed to depend on a deficient supply of  blood to
the lower  half  of the body.   The cause of the hyperemia was
sought, in obedience  to the analogy furnished by Bernard's ex-
periments, in a dilatation  of  the  vessels, owing to paralysis of
the vaso-motor  nerves running in the cervical sympathetic.   Cer-
tainly there are some facts which support this explanation :  the
small arterial branches of the carotid, pulsating strongly,  often
tortuous and visibly prominent ; the frequently rapid growth of
the tumor, its softness; the perceptible pulsation of  the thyroid
arteries, the  blowing  sounds  audible over  them; the alternate
enlargement  and diminution  of the tumor proportionate to the
force of the  pulsation of the  heart, and the abnormal  develop-
ment of the thyroid arteries and veins, as shown by the  patholo-
gical anatomy.   On the other hand, there is  as yet no experi-
mental evidence that a section  of  the  sympathetic can  produce
struma.   This proof must be insisted upon, especially as struma
is a  very  common  complaint in  animals,  and even occurs  en-
demically  in  the  regions where men  are affected with it  (Vir-
chow, Baillarger).   Boddaert also  has  proved  that tying  the
internal and  external jugular veins and  the inferior thyroids in
rabbits and guinea-pigs produces a swelling of the thyroid gland.
The origin of Basedow's struma  nia}^ therefore be regarded as
very probably due to a dilatation of the arterial and venous ves-
sels ; its connection with paralysis of  the vaso-motor nerves (or
with the sympathetic) must, however, be regarded for the present
as matter of question.

   Of late, an explanation directly opposed  to this has been offered by Benedikt.
He regards the dilatation of the vessels as  due,  not to paralysis, but on the  con-
trary to irritation of the  dilator nerves, which also run in the sympathetic.   He
bases this view  upon the  recent experiments of Bernard, Schiff, Ludwig,  and
Loven, which seem to prove the existence of nerves which dilate the vessels actively.
These  experiments,  it is  true, relate only to a few nerve-districts (nervi erigentes
penis, according to Loven;  the nerves of the parotid which arise from the facial;
muscular arteries, according to Ludwig and Hafiz),  and mostly admit  of another
interpretation.  Neither  can we satisfactorily explain the  mechanism of such an
active dilatation  of  arteries consistently with their histological structure. Benedikt
attempts such an explanation by pointing to the longitudinal muscle-cells in the 
          BASEDOW'S  DISEASE.—ANALYSIS OF SYMPTOMS.       91
 wall of the vessels, the shortening of which over the tense column of blood he
 thinks must cause a shortening of the arterial tube, with dilatation.  Whether this
 view agrees with the fact will perhaps be shown by later observations; in the laro-e
 arterial vessels the active dilatation cannot certainly occur in the manner described
 as they possess  no muscular cells.  As regards the thyroid arteries, which are spe-
 cially concerned in  the production of struma, Moeller, at the suggestion of Bene-
 dikt, has examined them, and has found between  the intima and the adventitia, as
 well as in the latter itself, a pretty thick layer of smooth muscular cells.  Certainly
 Beiiedikt's explanation, if correct, would render the theory of the disease extremely
 simple  (see below).

    The second cardinal symptom, the exophthalmus, is probably
 referable to  various genetic factors.    Doubtless  it  is  largely
 dependent upon venous hyperemia and increased development
 of fat in the  cellular tissue of the orbit.  The existence or abnor-
 mal hyperemia during life is rendered probable  by the analo-
 gous  condition  existing in struma, and also by the observations
 which show that the exophthalmus often diminishes when  the
 palpitations  of  the  heart  grow less, and, vice versa, increases
 when  the palpitations  are worse;  while the globe of the eye is
 further  observed  to be easily  pushed back by the finger, and
 after death to recede into the orbit spontaneously.
    In  favor of the possibility of  a mechanical forcing forward of
 the eyeball, we  have many analogies.    In new-born children a
 slight exophthalmus is observed after a tedious labor, due to pres-
 sure and checked circulation ; the same is observed after instru-
 mental labors;  also  in the  mother, when she  has made violent
 efforts in parturition.   Exophthalmus may also arise from vari-
 ous other causes,1 quite mechanical  in their nature, which lead to
 serous infiltration of the  retro-bulbar fatty  tissue  (as  nephritic
 dropsy), and  also  from  congestion  of the head.a  A variety of
 other causes,  not including tumors of the orbit—such as  violent
 exertion,  convulsions, etc., may  cause exophthalmus from  in-
 creased blood-pressure in the orbital veins (Demarquay).3   With
 these cases may be classed a remarkable observation  of Deces,4

  1 Demarquay, Traite des tumeurs de l'orbite, p. 171 and 183 (cases of Roche and
Lecorche).—Fischer, 1. c. (observations XVII. and XVIIL).
  * Demarquay, 1. c. p. 189 (observation of Sichel).
  3 L. c. p.  157 et seq.
  4 These sur l'anevrysme cirsoi'de; cf. Gaz. hebdomadaire,  18G2, p. 482. 
92    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

who saw an exophthalmus of the left eye appear in a woman
after violent congestion of the head, and disappear again when
the neighboring temporal  artery grew larger, and the covering
skin became red and puffy.  The results of ophthalmoscopic ex-
amination  in Basedow's disease also justify the assumption of
venous  hyperemia.   And lastly,  Boddaert has quite recently
produced a considerable  exophthalmus in  rabbits and guinea-
pigs, by artificial intra-ocular hypersemia due to tying of the two
internal and external jugular veins, with section of both cervical
sympathetics.   This lasted for some days, and did not disappear
until the venous hyperemia  had become reduced, owing to  the
establishment of collateral circulation.
   The  second cause of exophthalmus, the considerable increase
in the quantity of  fatty  tissue behind the eyeball,  has  been
directly proved by a  series of autopsies, and I have convinced
myself in one very marked case that this factor certainly plays
a leading part in the development of  the symptom.  Perhaps a
third cause ought to be added to these two, namely, the con-
traction of the smooth muscles of the orbit,  composing the mus-
culus orbitalis,  discovered by H. Mueller, which  lies in the
neighborhood of the fissura orbitalis inferior, and is innervated
by the sympathetic.   Claude Bernard has shown that section of
the cervical sympathetic,  or  of the  anterior roots  of  the  two
upper dorsal nerves,  produces retraction of the eyeball, while
galvanic stimulation of the peripheral ends after section causes
dilatation of the palpebral  fissure  and exophthalmus.   This
exophthalmus is probably mainly caused by contraction of Muel-
ler' s muscle.  The latter is very poorly developed in man, and is
opposed by very powerful  antagonists,  the straight muscles of
the globe; but  I do not think that the circumstance has been
sufficiently attended to, that  the latter muscles undergo a grad-
ual fatty degeneration in Basedow's disease, as I found in the
above-mentioned case ; so that their antagonistic action is greatly
weakened or lost.   H. Mueller has,  moreover, discovered other
smooth  muscles  in the upper and lower lids, which may assist
in protruding the bulb by enlarging the palpebral fissure.   That
these muscles receive their nerves from the sympathetic is proved
by R. Wagner's and Mueller's experiments  upon executed crim- 
        BASEDOW'S DISEASE.—ANALYSIS OF SYMPTOMS.       93

inals, in which electrical  stimulation of the cervical sympathe-
tic  caused the eyelids to open.  Remak had previously shown
(in  1855) that irritation of the  cervical sj'inpathetic in animals
produces  a raising  of the upper  lid.   Finally,  Sappey1  has
described smooth muscles in the orbital aponeurosis, which are
supposed  to  assist in protruding  the  bulb wdien  the  cervical
sympathetic is irritated.
   The theory which explains Basedow's exophthalmus by the
action of the above muscles encounters a considerable difficulty,
owing to the fact that a permanent tetanic contraction of these
muscles must be assumed, a state for which we have no  cer-
tain physiological analogies.  It may also be properly doubted
whether the force of this weak muscle is adequate to produce an
exophthalmus of so marked a character as often exists in Base-
dow's disease.  Even the  most powerful experimental irritation
of the cut cervical sympathetic, in  animals, is not able to bring
about so decided a protrusion.   But, on the other hand, it must
be remarked that the degree of this protrusion varies a good deal
from time to time, and  these variations may perhaps be referred
to corresponding oscillations in the condition of tonic stimulation
of the sympathetic fibres  which supply  the muscle.   Another
circumstance has much weight in confirming this theory, namely,
the  fact that von  Graefe's  symptom is usually associated with
the  exophthalmus ;  that  is, a want of agreement  between  the
movement of the lid,  and the raising or depressing of the glance.
The cause of this  insufficiency in the motion of the lid is said by
von Graefe to be due to anomalous innervation (spasmodic con-
traction) of the smooth muscles of the orbit, which  receive their
innervation from the sympathetic,  since these parts probably
regulate the movement of  the lids  which is associated with  the
shifting of the plane of vision.
  A close examination  of these questions would lead too far.  I
am  compelled to believe,  in  view  of all  these facts, that  the
venous congestion and retro-bulbar growth of fat certainly play
the chief part in Basedow's disease, but that the participation of
   1 Academie des sciences, session of October 21, 1867.—Prevost and Jolyet, ibid.
Nov. 18, 1SG7 (Arch, gen., Jan. 1868, p. 104). 
94    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

the smooth orbital muscles innervated by the sympathetic cannot
be wholly excluded.   Another question, not  yet answered, is,
whence the  venous congestion and the  increase of orbital fatty
tissue come ; and whether these may not also be connected with
the vaso-motor trophic fibres running in the sympathetic.  (See
below.)
   The  third cardinal symptom of the disease (in point of time
usually the first), the palpitation with acceleration of the pulse,
wTas  once commonly supposed to be a symptom of the anremia
or chlorosis.   I need  only refer back to what  has already  been
said in disproof of this idea, as it has at the present day but few
supporters.   Stokes's view, also, which makes the palpitations
symptoms of a primar}^ heart-disease, needs no further refutation.
Of late the increased  activity of the heart in Basedow's disease
has been considered due to a disturbance of the functions of the
cervical sympathetic.   In the  trunk of the latter, as von  Bezold
has  shown,  run the excito-motor fibres, which originate in the
central  nervous system—the fibres which  accelerate the action
of the heart.  Irritation of the cervical sympathetic increases the
rate  of the pulse; the assumption of  a permanent condition of
irritation in the cervical sympathetic  would, therefore, explain
satisfactorily the increase in the contractions of the heart.  Such
an assumption of course encounters the difficulty of supposing
that there can be a permanent condition of irritation in certain
groups  of nerve-fibres.  Friedreich has attempted a somewhat
different explanation.    He thinks that the vaso-motor nerves
which originate from the sympathetic are in a state of paralysis,
which  may  produce  a dilatation of the coronary arteries,  an
increased flow of blood to the muscle of the heart, and thereby
an increased excitement  of the ganglia of the heart.   According
to this view the accelerated action is caused directly by increased
activity of the automatic ganglia of the heart, and only indirectly
by the  sympathetic.  But this view does  not differ essentially
from the former, for  the  sympathetic nerves of the  heart are
commonly supposed  to  have the function  of transferring the
excitement coming from their centre to the ganglia of the heart.
Whether this transference is caused by an increased flow of blood
to the ganglia, or by  an increased irritation  of the  sympathetic 
        BASEDOW0S DISEASE.—ANALYSIS OF SYMPTOMS.      95

fibres which are connected with them, is certainly a subordinate
point in relation to the question before us.
   A theory  of  the  disease, to deserve the name, ought to be
able to derive all the symptoms, or at least the three cardinal
ones, from a common source.  We have already seen that this
demand is not satisfied by the hypothesis of a primary chlorotic
basis (Basedow),  or  a primary  cardiac affection  (Stokes).  A
better success ought to  be  expected of the neurotic  theories,
especially that which assumes a primary implication of the cer-
vical sympathetic or its  spinal centres.  Some have sought to
derive all three symptoms from an affection of the s}Tmpathetic ;
some, only the exophthalmus  and the  palpitations, leaving the
struma as an independent affection, or even calling it the cause
of the sympathetic lesion.  The last hypothesis with which we
shall have to do, originates with Koeben.   He considers that the
struma exercises pressure upon the cervical sympathetic, which
causes exophthalmus. Piorry  and Cros entertain the same view.
But it is contradicted by the fact that the struma often appears
at the same time with the exophthalmus, and sometimes later,
even many years later (Desmarres1), or may be wholly wanting
in spite of the  existence of exophthalmus in a  high degree.
Besides, the ordinary struma,  winch occurs endemically and is
often harder and bulkier than that of Basedow,  produces no
exophthalmus, or but a  very  trifling amount.  In  cases where
compression of the sympathetic  by tumors is proved to exist
(struma  or enlargement  of  lymphatic glands),  the exophthal-
mus is wiiolly wanting, or is quite trifling in amount (see below,
"Diagnosis"), while in such cases considerable mydriasis exists,
which is not  observed in Basedow's disease.  Finally, the ex-
ophthalmus does not diminish in proportion to the diminution
of the struma, as would be expected if it were due  to the effect
of pressure.   In one case  Charcot found the exophthalmus
equally intense, although  the  tumor had  disappeared  and the
rate of the  pulse had become  normal.  And, rice versa, Taylor
saw the exophthalmus disappear and the general health improve,
without any diminution in the size of the tumor.
1 Fischer, 1. c. observation III. 
96    EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

   The referring of all symptoms  to a primary affection of  the
sympathetic has been attempted especially by Aran and Trous-
seau,  upon the basis of Bernard's experiments.  Against this
very tempting view there is one chief difficulty : certain symp-
toms (especially the struma) are such as are commonly supposed
to follow experimental section, or paralysis of the sympathetic;
others, on the contrary, might be caused by galvanization, and
may be presumed to indicate a permanent condition of irrita-
tion in  the sympathetic.   This  difficulty would  certainly be
removed if Benedikt's assumption could be  established, which
refers the struma  to an active irritation of dilator nerves which
run in the sympathetic.  But this  assumption, as we have seen,
lacks  at present an adequate support.  There remains,  moreover,
a second objection, already stated, which lies in the  difficulty of
conceiving of a permanent state of irritation continued for years
together.
   While Benedikt  seeks to regard the struma as  a  symptom
of irritation, and thus to  bring  it into an  analogy with  the
other  leading  symptoms, Friedreich, on the contrary,  as we saw
above, interprets the palpitations as a  symptom  of  paralysis
of vaso-motor  nerves.  The exophthalmus might  likewise be
referred, at least in part, to a vaso-motor paralysis which causes
congestion of the orbit, and in this way an apparent agreement
might be reached.  Finally, it may be allowable to suppose that
the cervical sympathetic may be at one and the same time in a
state of irritation and of paralysis, that some fibres are irritated
while others are placed in a paretic condition by the causal
lesion.  Affections of peripheral nerves afford analogies of appar-
ently  opposite conditions existing together in the same nerve.
For example, in neuritis there may be symptoms of  irritation in
the motor fibres with diminished sensibility, and vice versa.  In
the same fibres we often find apparently opposed conditions: in
the sensitive, a diminution and an increase of sensation (anesthe-
sia dolorosa); in the motor, diminution and  increase of move-
ment (paresis or paralysis with spasms and contractures).
   The  difficulties that lie in  the  way of assuming an involve-
ment  of the sympathetic  have led several authors,  especially
Geigel and Benedikt, to place the seat of the disease farther up 
        Basedow's disease.—analysis of symptoms.      97

in the cervical medulla or the medulla oblongata.  Claude Ber-
nard has shown that the oculo-pupillary and the vaso-motor
nerves  which  run in the  sympathetic have centres, not in one
part of the cord, but at different levels.  Section  of the anterior
roots of the two first spinal nerves produces (according to Ber-
nard) only the oculo-pupillary symptoms, for the fibres which
originate in the cilio-spinal centre leave the spinal cord at this
point; but section of the  ascending cord of the thoracic sympa-
thetic  between  the  second and fourth ribs produces only the
vascular and thermic effects, dilatation of the vessels and eleva-
tion of temperature upon  the side operated on.  Geigel assumes
that the point of origin of the lesions of Basedow's disease is  to
be sought in these two centres, and that one of them—the oculo-
pupillary—is  in a condition of irritation; while the other—the
vaso-motor—is in a  state of paralysis.  In truth, this does not
solve the problem,  but only  transfers it from the peripheral
trunk  of the sympathetic to the  sympathetic centres  in the
cervical medulla spinalis.   And wiry, in two centres so near each
other,  opposite  conditions should prevail for  years together, is
no  less difficult to explain than their co-existence in different
fibres of  the .cervical sympathetic itself.
    Benedikt places the seat of the disease in the medulla oblon-
gata,  and  not in the cervical sympathetic, because fibres are
often affected  which belong lower down in the  sympathetic ; for
when a variety  of nerves, originating from the central nervous
system at various points,  take part in one affection, that affec-
tion must  be  located  in  that part of  the nervous system where
all  the fibres involved lie near together, and that part is here the
medulla  oblongata.  Against this argument it  must be said that
the symptoms on wilich it is based (disturbances of the abdo-
minal  organs,  amenorrhoea, etc.) are by  no  means  necessarily
connected with vaso-motor fibres running in  the sympathetic.
They are, rather, complications or secondary symptoms, depend-
ent on the abnormal action of the heart, etc., and they constitute
no  urgent reason for regarding the centre of the vaso-motor
nerves in the cervical cord as the original seat of the disease.
   The data furnished by  pathological anatomy are partly  in
favor of, partly against the supposition of a primary affection of
          VOL.  XIV.—7 
98    EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

the sympathetic.  If we regard the question for a moment as
decided in the  positive sense,  it  cannot be  denied that  the
remaining subordinate symptoms can be explained without vio-
lence from this point of view.   The want of agreement between
the movements of the lid and changes in the plane of vision has
already been explained.  The ophthalmia is perhaps due in part
to the insufficient protection given by the lid, and the conse-
quent  want of  moisture of the globe;  but  this  can hardly
account for the whole, since the same unfavorable state of things
exists  in  paralytic lagophthalmus  (e.  g., after facialis palsy),
without, as a rule, affecting the eye at all.   Basedow's ophthal-
mia is probably analogous to the so-called neuro-paralytic form
occurring  after section of the trigeminus, and the loss of sensi-
bility of the cornea,  which occurs in  severe  cases,  especially
favors this view.  Since fibres of the sympathetic enter into  the
trunk of the trigeminus, it cannot be said to be impossible that
Basedow's ophthalmia may be a result of disturbances of inner-
vation of  these fibres.   Whether the fibres  thus implicated  are
vaso-motor or trophic (as Meissner is inclined to think  in respect
to neuro-paralytic  ophthalmia) must  remain for the  present
unsettled, owing to the uncertainty of our present knowledge of
trophic nerves.  Charcot1 regards  neuro-paralytic ophthalmia,
like other trophic disturbances, as a phenomenon of irritation,
a consequence of inflammatory stimulation, like that which is
developed in the nerve after partial section, as in the experi-
ments of Meissner and Schiff.
   The  lachrymation, which is a  frequent  symptom, may  be
referred to a change of innervation of the fibres which  pass from
the sympathetic into the first branch of  the trigeminus.  Perhaps
this constant wetting of the conjunctiva with tears explains  the
rarity  of  the occurrence of malignant inflammations of  the
cornea  in Basedow's disease.   The   ephidrosis unilateralis,
which is  present  in a few cases,  might also be referred to a
paralysis  of the vaso-motor fibres that run  in  the sympathetic,
especially as  in the  cases  described  (Xitzelnadel,  Chvostek)
myosis of the same side is said  to have  existed.
1 Lemons sur lcs Maladies du Systeme Nerveux.  Paris. 1872-3. 
       BASEDOW'S DISEASE.—DIAGNOSIS  AND PROGNOSIS.     99

   Stellwag explains the dilatation of the pupil, in  the  few
cases in wiiicli it co-exists with Basedow's exophthalmus, as  due
to a paralysis of the pupillary branch of the oculo-motor nerve,
consequent upon cerebral neuro-paralytic  dilatation of vessels.
The  isolated paralysis  of this  branch,  the other fibres of  the
motor  oculi remaining unaffected, is referred by him to the  fact
that the branches destined for the  pupil do not  join the other
oculo-motor fibres until after the latter have crossed the crura
cerebri, and that they have been proved to originate from several
centres of various function.  Yet the dilatation of the pupil, if
present, may be explained  much more easily by referring it to
an irritation  of the dilator fibres of the sympathetic,  and  the
contraction which exists in other cases to a paralysis of the same
fibres ;  and yet,  assuming a  sympathetic origin,  the almost
unvarying  absence  of dilatation of  the pupils presents a great
difficulty, for changes in the diameter of the pupil are  the most
constant symptom in other  lesions of the cervical sympathetic,
such as mechanical or traumatic injuries.1   I wish to call atten-
tion again  to the fact that  certain autopsies show a preponder-
ance of affection of the lower cervical ganglion, while the upper
and middle ones  arc? scarcely, if at  all, affected.  It is possible
that this may constitute the reason why mydriatic symptoms are
usually absent  in Basedow's disease.


                  Diagnosis and Prognosis.

   It is evident tnat there may be difficulty in  making  the diag-
nosis, especially at  the beginning of  the disease.   We shall have
to infer the existence of  the disease in some cases, even in the
absence of one of the  three leading symptoms, and even where
on!)'  exophthalmus is  present, provided  it  be  bilateral  and
accompanied by  general  disturbance.  Among the subordinate
symptoms, the  feeling of  heat, the elevation of temperature, the
want of agreement between  the motions of the lid and depression
of the visual plane, possess  a certain diagnostic value.   It must
also be remembered that, of the leading symptoms, some may
1 See Eulenburg and Guttmann, Pathologie des Sympathicus. pp. 5 and 6. 
100   EULENBURG.—VASO-MOTOR  AND TROPHIC  NEUROSES.

not only be quite absent, but  may temporarily disappear, while {
the others persist, and that  their order  of appearance  may also
vary very much.
   As regards differential  diagnosis, cases of primary struma
with consecutive irritation of the sympathetic are of  special
importance.  In such cases a moderate degree of exophthalmus
and a more or  less  considerable  amount of  palpitation, with
accelerated  pulse, may very closely resemble Basedow's disease.
   A case which clearly belongs to this class is related by H. Demme (mydriasis
and slight exophthalmus in a man with cystic struma). At the autopsy the cervical
cord of the sympathetic was found upon the left side reddened, and with the sur-
rounding  connective tissue in a state of serous infiltration.   There was no micro-
scopic change.  I have for a long time observed a case which belongs  to this cate-
gory.  It was that of a young  lady, very slender, who had a tuberculous affection
of the apices of the lungs.   She had a vascular struma, almost confined to the right
side, with a very much developed mydriasis, a perfectly immovable iris, and a
moderate exophthalmus of the right eye, with paresis of accommodation; a perma-
nent depression of temperature could  also be demonstrated in the auditory meatus
of the affected side, which was 0.3° or 0.4° C. lower than the other.  Chills fre-
quently occurred towards evening, during which the face was pale.   The pulse was
very quick (128-140); forcible  palpitations of the heart; loud, blowing murmurs
over the struma, increased during systole.
   Calabar bean acted favorably for a time upon the mydriasis and the paresis of
accommodation; the symptoms were also temporarily relieved during the local use
of galvano-puncture, which produced  for a time a considerable reduction in the
size of the tumor, and also a lessening  of the rate of the pulse by from twenty to
thirty beats per minute.
   A means of establishing a differential diagnosis between this
neurosis of  irritation, produced  mechanically by struma, and
genuine Basedow's disease, is  afforded by the unilateral symp-
toms of pupillary and vascular irritation, viz., mydriasis, pare-
sis of accommodation, depression of  temperature in the ear of
the affected  side  ; in  true Basedow's disease the exophthalmus is
bilateral almost without exception, the  pupillary symptoms  are
absent, the  temperature of  the  meatus is either unchanged or
shows a uniform elevation corresponding to that of the  axilla.
   The prognosis will be seen to be unfavorable for  the most
part.  Yet the possibility of a spontaneous disappearance, or of
removal by  medical treatment, is not to be excluded.  The pros-
pect  of  succeeding in this will be the greater, the more satisfac- 
               BASEDOW'S  DISEASE.—TREATMENT.           101

 tory is the general health of the  patient, and the more certainly
 we can exclude organic changes of the heart, dilatation, valvular
 lesions, etc;., or a neuropathic tendency and severe disturbances
 of innervation.

                          Treatment.

    The earliest attempts at treatment were based upon the belief
 that the disease depended on anemia or chlorosis.   Remedies
 were therefore chosen which are supposed to improve the compo-
 sition of the  blood, to  give strength, and to relieve  chlorosis-
 above all, quinine and iron.   Though the belief upon which this
 theory was founded can hardly be defended at  the present day,
 yet it cannot be denied that, when these remedies are used prop-
 erly and  perseveringly, a  surprising success  is occasionally
 attained,  even if  there were failure  in  a good  many  cases.
 Traube's method may be regarded as the best.   It consisted, as
 he  himself has told us, in combining quinine and iron in such a
 way that each of the two remedies is used alternately for about
 three wTeeks ;  the quinine  in  a moderate dose  (five  grains  per
 diem), and the iron in the form of Vallet's pilular mass.  Traube
 has obtained very favorable results from this method in a series
 of cases in wiiicli the whole of the symptoms were relieved for
 years at a time, the patient enjoying perfect health.
   Besides these so-called strengthening remedies, those which
 depress the pulse {digitalist  veratrin) have been much  used.
 Experience has shown  that  these drugs, which are  efficient  in
 other  diseases, often fail of their action in  Basedow's disease
 (von Graefe, Geigel,  Cerf Lewy, Fritz, and others), and that their
 therapeutic value is really little or  nothing.  The debilitating
 modes  of  treatment, such  as  blood-letting, derivation, prepara-
 tions of iodine and arsenic, often seem to  produce direct harm.
 As regards the forms of iodine, which seem to be demanded  for
 the relief of struma, it is said  that they do effect some benefit in
 this direction,  but that they also increase the palpitations, and in
 some cases have done a good deal of  harm.   Smith has recently
seen good results from  the use of belladonna, and ascribes the
effect to the stimulus it  exercises  upon the sympathetic. 
102   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

   The cervical sympathetic has recently been directly treated
by galvanization with the constant current,  in accordance with
the theory of a primary affection of the sympathetic.  Von Dusch
appears  to have been the first to treat a case for a considerable
time in this way, and he  succeeded in reducing  the rate of the
pulse from 130 to 70 or 64 beats, and in diminishing the exoph-
thalmus.
   My  own first experiments in this  method  of  treating the
sympathetic in Basedow's disease were made in 1867, upon a lady
aged fifty—sent to me for treatment by von Graefe—who had an
habitual pulse of 108-130, with abnormal tension of the carotids.
When her  cervical sympathetic was galvanized by placing the
negative pole upon it, with a very weak current  (from 6 to 8
elements), the pulse wras observed to sink gradually to 84, or even
to 70, wiiile the tension  of the carotids  and radial  arteries con-
tinually diminished.  The patient felt  much better at the same
time.   Since  then I have employed galvanization of the sympa-
thetic in six other cases of this disease,  mostly very severe ; but,
as the patients came  from a distance, they could remain  but a
short time under treatment,  and the results, as respects both the
improvement  of the leading symptoms  and the general health,
wrere  therefore  but small.  But I  was  able  to ascertain  with
certainty that at each session, after  a short application of elec-
tricity, the rapidity and force of the heart's action were consider-
ably lessened, and sometimes a marked soothing influence upon
the mind was  observed.   As a rule, my method was to apply the
negative pole to the cervical ganglia of each  side in turn, or to
both at once by means of a divided electrode.   In a few cases the
struma  was attacked at the same  time by galvano-puncture;
but I have seen only  doubtful and transient results  from this
practice, though it was usually very well borne.

   Chvostek has recently made some very thorough observations upon the action of
galvanization on  the sympathetic.  Thirteen cases were treated by this method,
mostly for a long time,  all of  which were considerably improved, or even nearly
cured; and this, sometimes, after a very  few applications. Galvanization had an
important influence, especially in procuring the recession of the exophthalmus and
the struma, while its effect in the way of lessening the action of the heart was very
slight in several cases.   M. Meyer reports equal success ; he obtained so decided an 
               Basedow's  disease.—treatment.            103
improvement in four cases of quite marked Basedow's disease, that only a few traces
of the leading symptoms remained. In addition to the manifest success of galvani-
zation in reducing the struma and exophthalmus (the pulse remaining as high as
before), Meyer speaks strongly of the benefits accruing to the general health, as shown
by relief to the chlorotic symptoms and reappearance of the menses in normal quan-
tity and character.1 Leube also observed a considerable improvement in the above-
mentioned case, during galvanization of the cervical sympathetic.

   A careful  regulation of the  habits is of special  importance in
Basedow's  disease: avoidance  of all excitement and  of great
physical  exertion, as well as of coitus; a mild, nutritious diet
largely composed of milk  and vegetables, an entire avoidance of
all exciting drinks, such as coffee, tea, and alcoholic beverages ;
a life largely  spent in the open air, especially in the country, or
in mountain  health-resorts of  moderate  elevation.  Among the
mineral  springs those containing  iron deserve the preference ;
long and repeated cures in Franzensbad, Pyrmont, Schwalbach,
etc., are  sometimes of  evident value.   But the whey cures and
grape cures, though still excessively popular, do not deserve the
recommendations they get, if only for the injury they often inflict
upon the general health.
   Of the individual symptoms, those which affect the eye may
require  special local  treatment.  For the  exophthalmus, von
Graefe recommended  painting with tincture of iodine  between
the eyebrows and the upper lid, or  frictions with  ointment con-
taining iodide of potassium, compresses, local electrization, and
in severe cases even tarsorrhaphia as a  protection against malig-
nant affections of the cornea.    If the latter appear, the eye must
be protected  from all injury,  and covered with wet compresses ;
in some cases it may be well to employ tarsorrhaphia.
  1 Perres, on the contrary, observed in one case which was treated by galvanism only
a considerable diminution of the pulse, while the struma remained unaltered. 
 
PROGRESSIVE   MUSCULAR  ATROPHY.
               (Atrophia  muscularis progressiva.)
Van Swieten, Commentarii  in  H.  Boerhave aphorismos. III. 1750. p. 370.—Aber-
   crombie, Pathological and  practical researches on diseases of the brain and  the
   spinal cord.  Transl.  into German by Gerhard von dem Busch. 1829. — Daricall,
   London Med. Gaz. VII. 1831.  p. 301.—Bell,  The nervous system of the human
   body. London, 1830.  Transl. by Romberg under title Physiologische und prak-
   tische Untersuchungen des Nervensystems.  1832.—Romberg, Klinische Ergeb-
   nisse. Berlin, 1846.— Dubois, Gaz. med. de  Paris.  1847. No. 47. p.  926.—Du-
   chenne, Session  of Acad,  de med.  May  21, 1849.—Romberg, Lehrbuch  der
   Nervenkrankheiten.  1850.  III. p.  159. 3. Aufl. 1857.—Aran, Recherches sur une
   maladie non encore  decrite du systeme musculaire (atropine musculaire pro-
   gressive). Arch. gen. de med. t. XXIV. Sept. and Oct. 1850.—Thouvenet, These
   sur la paralysie  musculaire atrophique. Dec. 1851.—Romberg, Klinische Wahr-
   nohmungen und Beobachtungen. Berlin, 1851.—Men/on, Med.  Chir.  Trans. 2d
   ser. vol. 7. London,  1852.  p.  81.—Duchenne, Union medicale.  1852; Bull,  de
   therapeutique. 1853.  p. 295, 407, 438.—Cruveilhier, Arch.  gen. Mai, 1853. p.
   501 ; Gaz. med. de Paris.  1853. No. 16.—Bouvier, Gaz. med.  de Paris, 1853.
   No. 15. p. 232.— Landry, Ibid. No. 17. p. 2G1.—Burq, Gaz. des hop. 1853. No.
   53.—Xiepce, Gaz. med. 1853. No. 17. p. 260; Arch. gen. Mai,  1853. p. 626.—
   Chambers, Med. Chir. Transactions.  XXXVII. 1854. p. 19.—Guerin, Arch. gen.
   Mai,  1854. p. 626.—Cohn, Giinsburg's Zeitschr. f. klin. Med. V. 1854. p. 360.—
   Schneevogt, Niederl. Lancet. Sept. and Oct. 1854.— Virchow, Handbuch der spe-
   ciellen Pathologie und  Therapie. I. Erlangen, 1854. p. 322.—Betz, Prager Vier-
   teljahrschrift. XLIII.  1854. p.  104.—Robin, Comptes rendus des seances de la
   soc. de biologic. 2e ser. I.  1854. p. 5. — Oppenheimer, Ueber progressive fettige
   Muskelentartung. Diss. Heidelberg, 1855.—Hasse, Krankheiten des Nervensys-
   tems. Erlangen,  1855.— Warhsmuth,  Henle und  Pfeufer's Ztschr.  f. rat. Med.
   VII.  1855.  p. 88.—Gros, Gaz. des hop. 1855. No.  50.—Eisenmann, Canstatt's
   Jahresbericht, 1855.  III. p. 86.— Valentiner, Prager Vierteljahrschrift. XLVI.
   1855. p. 1.—Virchow, Arch. f. path. Anat. 1855. VIII. p. 537.—If. Meyer, Wiener
-* 
106   EULENBURG.—VASO-MOTOR  AND  TROPHIC NEUROSES.

    med. Wochenschr. 1855. Nos. 41 and AZ.—Diemcr, Gunsburg's Zeitschrift. 1855.
    VII. l.—Cruveilhicr, Arch  gen.  de med.  Jan. 1856. p. l.—Eulenberg (sen.).
    Deutsche  Klinik. 1856. Nos.  11-14.—Reade,  Dublin Jour, of Med. Science.
    Nov. 1856. p. 399.— Vigla, Gaz. des hop. 1856. No. U6.—HeJfft, Allg. med. Cen-
    traizeitung. 1856. No. 12.—Moussons,  Gaz. des hop. 1857. No.  108.—Barton,
    Dublin Hosp. Gaz. 1857. June  15.—Frommann, Deutsche Klinik. 1857. No.  33.
    p. Zn.—Friedberg, Pathologie  und Therapie der Muskellahmung.  AVeimar,
    1S5S.—Roberts, An essay on wasting  palsy. London, 1858.—Baerwinkel, Pra-
    ger Vierteljahrschrift  LIX. 1858.  p.  Wd.—Sandahl, Hygiea.  1858.— Rodet,
    Union med.  1859. No.  2G.—Luys, Gaz. med. de  Paris. 1860. No.  22—Leubu-
    scl^r,  Krankheiten des Nervensystems.  1860.—Legendre, Gaz.  med. de Paris.
    1860.  No.  23. p. 365.—Duchenne, Electrisation localisee. 2e ed. Paris, 1861.—
    Dumenil, Gaz. hebd. 18 Janv. 1861. p. 38.—Anstie, Med.  Times and Gaz. Febr.
    1861.—Clarke and Gairdner, Beale's Arch, of  Med. Oct. 1861. p. 1. vol. Ill —
    Gull,  Guy's  Hosp. Rep. 3d series. VIII. p.  244.  1862.— Remak, Oesterr. Zeit-
    schr. f. prakt. Heilk.  1862.  p. 1 and 29.—if.  Meyer, Deutsche Klinik. 1862. No.
    7.—Ilemptenmacher, De  aetiologia atrophiae muscularis progressivae.  Diss.
    Berlin, 1862.—Guthzeit, De novissimis observationibus  ad atrophiae muscularis
    progressivae naturam et thcrapiam spectantibus. Diss. Berlin, 1862.—Malmsten,
    Hygiea. 1862.  p.  555.—Lockhart Clarke, Brit,  and  For. Med.  Chir.  Rev.
    July,  1862.  p.  215;  Beale's Archives of Med.  vol. IV.  1863. p. 26.— Vul-
    pian, Union  med. 1863. No. 49.  p. 159.—Friedreich, Ueber degenerative Atro-
    pine der spinalen Hinterstriinge.  Virchow's Archiv. 1863.  XXVII. p. 1. — Voisin,
    Gaz. hebd. 1863. No. 37; Gaz. des hop.  1863.  No. 110. p. 437.—L. Meyer, Vir-
    chow's Archiv.  1863. XXVII.  p. Aid.—Trousseau, Gaz. des hop. 1863. Nos. 12
    and 14.—Foerster, Handbuch der speciellen  path. Anatomic  2. Aufl. 1863.—
    Ruehle, Greifswald. med. Beitriige. II. 2.—Duchenne, Comptes rendus. 18. Janv.
    1864.  p. 168.—Jaccoud, Bull, de  la soc. med. des hop. 1864 ; Union med. 18G5.
    t. XXV. No. 4. p.  60.—Remak, Application du courant constant au traitement
    des nevroses.   Paris,  1865.—Schueppel, Ueber  Hydromyelus. Archiv der Heil-
    kunde. VI. 1865. p.  295. —Bergmann, Petersb. med. Zeitschrift. VII. 1865. p.
    83.—Brugnoli,  Gaz.  med. Lombard.  1866.  No.  23.—Dumenil,  Gaz. hebdom.
    1866.  Nos. 4-6.—Fieber, Die diplegischen Contractionen. Berl. klin. Wochen-
    schrift.  1866.  No. 25. p. 261.— Menjaud, Gaz. des hop.  1866.  No. 3. p. 10.—
  '  J. Simon, Nouveau dictionnaire  de med. (Art. " Atrophie musculaire progres-
    sive.")  Paris, 1866.  t. IV. p.  27.—Buudrimont, Journal  de Bordeaux. Mars,
    1866.  p. 148.—Clarke, Med. Chir. Transactions. 1866.  XLIX p. 171 ; 1867. L
    p. 489.— Dumenil, Gaz. hebdom.  1867. No. 29.—Sicarzenski, Die progressive
    Muskelatrophie. Berlin, 1867.—Trousseau, Clinique med.  de l'hotel Dieu.  2e
    ed. German  transl. by Culmann. 1868.—L.  Clarke,  Med. Chir. Trans. LL
    1868.  p. 249.—M. M".yer, Die Elektricitiit  in ihrer Anwenduno- auf praktische
    Modicin.  3.  Aufl. B-rlin, 1868.—A. Eulenburg, Ueber  diplegische Contractio-
    nen geliihmter  Muskeln.  Centralblatt f.  d.  med. Wiss.  1868.  No. 3.— Eulen-
    burg and Guttmann, Pathologie des Sympathicus.  Archiv f.  Psychiatrik unci
A 
        PROGRESSIVE MUSCULAR  ATROPHY.—DEFINITION.     107

    Nervenkrankh.  I. 1868.—Landois and Mosler, Neuropathologische Studien.
    Berl. klin. AVochenschrift.  1868.—Benedikt, Elektrotherapie. Vienna, 1869.—
    J. Grimm, Virchow's Archiv.  XLVIII. 1869. p.  445.—v. Bamberger, AViener
    med. Presse. 1869.  Nos. 27  and 28.—Nesemann,  Berliner klinische AA'ochen-
    schrift. 1868. No. 37; 1869. No. 52.— Ollivier, Des atrophies musculaires, these.
    Paris, 1869.—Erb, Deutsches Archiv fiir klin. Medicin.  V. 1869. p. ^.—Char-
    cot and Joffroy, Arch, de la phys. normale et pathologique. II. 1869. p. 354.—
    Hayem,  ibid.  p.  263. — de  Silva Lima, Union,  med.  1869. No.  141.—Stein,
    Deutsches Archiv f. klin. Med.  VI. 1869. p. 593.—Leyden, Archiv f. Psychia-
    trik und  Nervenkrankheiten.  II. 1870. p.  648.—A.  Eulenburg, Virchow's
    Archiv.  XLIX. 1870. p.  446.—Joffroy, Gaz. med.  de Paris.  1870.  No. 10. p.
    129.—M. Rosenthal, Handbuch der Diagnostik und Therapie der Nervenkrank-
    heiten. Erlangen, 1870.— Wilks, Guy's Hosp. Rep. 3d series. XV. 1870. p. 1.
    M. Rosenthal, Allg. med. Centralzeitung. 1871. No. 7.—Gerhardt,  Berlin, klin.
    Wochenschrift. 1871.  No. 23. p. 2G5.—.1. Eulenburg, Virchow's Archiv. LIU.
    1871. p. 361.—Hallopean, Arch, de med.  Sept. 1871. p. 277, 305.—Hammond,
    Treatise on Diseases of the  Nervous System.  New York, 1871.—Kussmaul,
    Ueber die fortschreitende Bulbarparalyse und  ihr VerhaTtniss zur  progressiven
    Muskelatrophie.  Sammlung Klinischer Vortriige. No. 54.  Leipzig, 1873.—
    Friedreich, Ueber progressive Muskelatrophie u. s. w.  Berlin, 1873. — Charcot
    (Lccons cliniques sur les maladies du systeme  nerveux), Klinische Vortriige
    fiber Krankheiten des Nervensystems. German trans,  by  Fetzer.   Stuttgart,
    1874.—Leyden, Klinik der  Riickenmarkskrankheiten.  I. Berlin, 1874.—Mark-
    usy, Zur Lehre von der progressiven Muskelatrophie und progressiven Bulbar-
    paralyse.  Diss. Breslau, 1874.


    The chief of this group of symptoms is a wasting of the vol-
untary muscles, which is gradual, progressive, extends to amove
or  less considerable part  of all  the apparatus of motion,  and
usually observes a very distinct order of march.   This  definition
excludes at once all those forms of muscular atrophy which origi-
nate in constitutional diseases (as that occurring after such acute
diseases as typhoid fever, and that in constitutional diseases and
cachexias like cancer and syphilis).  It also excludes those which
can be showm to be dependent upon loss  of motor innervation,
or which depend on congenital defects, arrests of development
or growth,  and which  usually affect simultaneously all  the tis-
sues of one extremity, one-half  of  the body, etc.   Progressive
muscular  atrophy  is further  a severe  disease, ending with the
complete annihilation  of the functions of the muscles affected,
very  rarely curable,  and in many  cases leading directly to 
108    EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

death.   It is  characterized  anatomically  by the  nature of the
pathological changes in the muscles, consisting in chronic myosi-
tis, interstitial proliferation of connective  tissue with secondary
destruction of the muscular fibres, and finally, fibrous degen-
eration;  the  anatomical changes in  the  nervous system, how-
ever, do not at  present  admit  of so  simple  and comprehensive
a statement of their nature and significance.


                                History.

   Swieten, in describing lead-palsy (1754), gives an account  of a case  of this
nature, without explaining it.   In the  first half of our century such cases were
repeatedly given by Abercrombie, Darwall, Charles Bell, Romberg, Graves, Dubois,
and Duchenne, mostly without any careful distinction of their character.
   The great Charles Ball] has made some interesting remarks  in connection with
a case named by him a local palsy of the muscles of the extremities, but which must
certainly be counted in with the disease  we are describing.  He says:
   " These affections of particular muscles, or classes of muscles, imply a very par-
tial disorder of the nerves.  A disease of the brain, or  a disease in the course of the
nerve, must  influence the whole limb, or that portion of  it to which the nerve or
nerves are distributed.  But in these cases particular subdivisions of the nerves
included  in  the same sheaths, or running the same  course, are affected.   I am
inclined to attribute such partial defects to the influence of visceral irritation.  In
that case it must still be the influence of the sympathetic nerve  which produces it;
and yet, on the other hand, it seems impossible to account for such entire loss of
motion without the intermediate influence of the  brain."
   The hint contained in this argument received, at first, little attention.  Even
Romberg, who described three cases  of the sort in his Lehrbuch (1850), reckons
them among the " paralyses dependent  on the spinal  cord as a  conductive appara-
tus," and treats of them accordingly under the title of  spinal palsies.  Abercrombie
also makes only the very general remark that this must be an obscure local nervous
affection;  Darwall says the same.  Duchenne first called attention to the anatomical
changes in the muscles,  discovered by  himself, and in a memoir addressed to the
Paris Academy in  1849 characterized them as " atropine musculaire avec transfor-
mation graisseuse."
   In spite of predecessors like these, Aran, in 1850, spoke of the disease (and not
without justification) as a " hitherto undescribed" affection of the muscular system,
for which he proposed the term  " atropine musculaire  progressive."  He sought to

   1 Phys. und path. Untersuchungen des Nervensystems. Deutsch  von Romberg. 1832.
p. 364.  [" The Nervous System of the Human Body." London, 1830, case LXXXVIII,
p. clxii.—Trans.] 
          PROGRESSIVE MUSCULAR  ATROPHY.—HISTORY.         109

place  the essential cause of it in an excessive  irritability of the muscular system,
which led to its  fatty degeneration, without previous  involvement of the nerves,
saying:  "Le travail morbide est primitivement et uniquement dans le systeme mus-
culaire."  Quite otherwise did Cruveilhier conceive of the disease, claiming  for
himself  a priority of description, and naming it "paralysie musculaire atrophique,"
or "paralysie musculaire progressive atrophique."  He regards the paralysis as due
to the muscular atrophy, but  explained the latter as dependent upon atrophy of the
anterior roots of the spinal nerves, or, indirectly, upon degeneration of the gray cen-
tral substance of  the  cord, from which he said that the anterior  roots originated.
The proof of  this opinion was presented chiefly in the autopsy of the rope-dancer
Lecomte : " dont le nom restera attache a l'histoire de cette maladie."   (See "Ana-
tomical Changes.")
   Since Aran  and Cruveilhier first led the way with their works, the  generality of
authors who have treated of progressive muscular atrophy have been  divided into
two great parties.  Some, with Aran, regarded  the disease as  a primary muscular
iiffcetion—a myopathy,  although in detail they differ more or less  widely from
Aran's views.  Of such are Muryon, Oppenheimer, Hasse, Friedberg, and Duchenne,
the latter of whom, as  we have seen, pointed out the  fatty degeneration of  the
muscles before Aran, and proposed the designation " atrophic musculaire graisseuse
progressive."  Others, like Cruveilhier, laid stress on the neurotic character of  the
atrophy, its  dependence on and relation to certain parts of the nervous system.  In
this regard,  it is true,  the widest differences of  opinion have arisen; single autop-
sies, or  purely theoretic deductions, have served as the basis for assuming as  the
primary seat of disease,  in one case  the peripheral nerves (Guerin); in others, after
Cruveilhier,  the anterior roots (Bouvier, Gros, Valentiner, and others);  or again, the
spinal cord  (Eisenmann, Cohn,  Leubuscher, Baerwinkel, Joffroy,  Ollivier, Hayem,
Gull,  Lockhart Clarke, Grimm, et al.) ; or finally, the sympathetic with its ganglion
(Schneevogt, Remak,  Jaccoud, J. Simon).  AVe cannot follow out in detail the dis-
cussions which have been had upon this point, and wdiich were sustained with more
vigor formerly than  now.   Very recently, Friedreich has  fully  and thoroughly
established the myopathic theory, which he had previously defended.   The weight
of his arguments and  observations is undeniable ; and yet there may be many wTeak
points which he has failed to cover,  and it is certainly quite premature to regard the
neuropathic  theory as defeated.  The latter has now resolved itself, witli most of
its defenders, into the assumption of a primary disease of the motor nerve-cells, or
ganglion-cells of the anterior cornna, which are supposed to exercise a trophic  influ-
ence on the voluntary muscles.   This theory, supported by the results of autopsies
made by  Luys, Dumenil, Clarke,  Schueppel,  Hayem, Charcot and  Joffroy, and
others,  numbers some important adherents, including Hammond ; Leyden '  also
seems to recognize it,  and of late even Duchenne appears to lean towards it.  It
finds an eloquent  and ingenious supporter in Charcot, who refers progressive mus-
1 Klinik der Riickenmarkskrankheiten.  I.  pp. 123, 154. 
110   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.
cular atrophy to a chronic irritative atrophy of the anterior ganglion-cells, which
are gradually, successively, and progressively attacked.  (Cf. " Theory of the Dis-
ease.")  Although I cannot deny that  the neuropathic theory, and  especially
Charcot's form of it, seems to me the most satisfactory, and the one best in accord-
ance with the pathological facts and the physiological assumptions; and although
in another place' I  have stated  it as my own belief, nevertheless, I hope in the
following pages to speak without prepossession,  and to do equal justice to the
different points of view, especially as I regard the question as entirely unripe for a
present decision.
   Several synonyms remain to be mentioned in addition to those
named above.  These are :  Paralysie amyotrophique; myopathic
paralysis, or paralysis ex alienata musculorum  nutritione (Fried-
berg) ; paralysis atrophica (Eisenmann); paralysie rhumatismale
peripherique du mouvement (Guerin).   All these names are un-
suitable, as  they imply a "paralysis";  they have not found
acceptance.

                            Etiology.

   Various authors (Meryon, Roberts, Trousseau, and  others)
have believed in the  existence  of a diathesis, a  predisposing
anomaly of constitution, as forming the basis of progressive mus-
cular atrophy, but they have not been able to state exactly what
constituted this diathesis.  Friedreich defined it more distinctly
as "a nutritive and formative weakness of the muscular tissue,
causing an increased  tendency to  irritative  and  degenerative
disturbances of nutrition  in  the said tissue.^  This definition is
based upon the myopathic theory, which has been so remarkably
presented by Friedreich.   Other  authors, in accordance with the
neurotic theory, believe that they  can explain the disease by
reference to  a  neuropathic  predisposition,  such  as must be
assumed in  many cases of hemicrania, of angina  pectoris,  etc.,
and consider that this view finds a powerful support in  the fre-
quent combination with other unquestionable neuroses, as pro-
gressive bulbar paralysis, tabes dorsalis, mental disease, especially
dementia paralytica.   They look for  this predisposition in an
  1 Ueber vasomotorische und trophische Neurosen. Berl. klin. Wochenschrift.  18*-
No. 2. 
        PROGRESSIVE MUSCULAR ATROPHY.—ETIOLOGY.      Ill

originally defective formation of certain  regions of the central
nervous system, probably those masses of ganglion-cells in the
cord which are  regarded  as centres of muscular nutrition.  It
were needless to dispute this view in detail; at  present  nobody ,
seems able to give a concrete statement of his notions about it, and
we must confine ourselves  to rather vague descriptions.  It is far
more important to make clear the point that a diathesis of some
sort or other must be assumed to exist in at least a large number
of cases.  Among the facts which  support  this  view,  that  of
heredity is of the first importance.  Roberts, in 1858, was able
to prove a hereditary tendency  in  eighteen out  of sixty-nine
cases, and Friedreich mentions four from his own observation.
Especially interesting is a case described by Hemptenmacher,  in
which the disease could be traced far and near among the ramifi-
cations of a connection, composed  of three families,  which were
united by repeated marriages and conld all be traced back to one
pair of ancestors living a hundred and fifty years ago.   In this
case only males were attacked, and the women were spared, even
when  they were themselves  the medium  of transmission of the
disease.  In another case, of  which  Friedreich1 also traces out the
family relationships with exactness, the disease was inherited not
only by male, but also by female members of the family ; a woman
transmitted it to her children, though they were the product  of
three distinct marriages.   Trousseau mentions a family in which
the great-grandfather, grandfather, father, and son, suffered from
the disease,  the  course of  which closely coincided in  all the
generations.   A circumstance which is sometimes connected with
heredity is the appearance of several cases in one family, espe-
cially among children of one father and  mother;  yet the same
occurs  in some  cases  where inheritance  cannot be proved,  or
where at least both parents and other ancestors were healthy.
Thus, Meryon  describes  a  case  in  which  four brothers were
attacked by the  disease;  Eulenburg senior  described the his-
tory of twin  brothers  who,  without any  visible cause, wrere at-
tacked simultaneously and  in exactly the same manner in their
eighteenth year by progressive atrophy of the lower extremities.
1 Ueber progressive Muskelatrophie, etc. p. 43, Obs. XII. 
 112   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

In a case which has but  lately come  to my notice,  affecting
the family of a Count L----,  out of seven children, two brothers
and two sisters were attacked, while the remaining three brothers
were spared.  The brothers were aged from eighteen to twenty
years when attacked; one was an officer, the other a law student;
of the  sisters one was older, the other  younger.  The parents
were perfectly healthy, but an uncle had suffered from epileptic
dementia.   In another place I have related  the case of three
sisters, separated in  age  by intervals of  three or four years, in
whom  the disease developed itself  at exactly the same  period
(the eighth year) and took the  same  course, beginning with  the
lowTer extremities.1  In this case no hereditary  tendency could be
proved.
   As regards the influences of sex and age, the male sex  shoAvs
a decidedly  greater tendency than the female.   In the latest and
most comprehensive statistics, those of Friedreich, in 176 cases
only 33 were females, that is, about 19 per cent.  ; of 28 cases of
which I possess notes, 17 were in men, 11 in women.   It  would
be natural to  ascribe this to the greater amount of severe and
exhausting labor performed  by men, which, in fact,  appears to
constitute one of the causes in a certain number of cases ; but
this explanation does not suit in cases where the disease appears
in childhood,  and attacks  only  the male  children of a family.
whether there be a provable hereditary taint or not.   Here I "will
merely point to the case above mentioned, described by Hemp-
tenmacher from  Friedreich's Clinic, in  which  all the  female
members of  the family remained unaffected.  The same was the
case  also in  Meryon's  observations : in  one, four sons were
attacked,  and seven daughters remained  unaffected ; in another,
eight boys were attacked, while the  four sisters were not.  In the
case  described by Eulenburg senior, that of the  twin brothers,
their sisters  were not attacked.  It might therefore be supposed
that  the original defect in the formation of the muscular system,
or of certain parts of the central nervous system, is produced or
transmitted  oftener in the male than in the female sex.   Yet in
1 Virchow's Archives, vol. LIIL Heft 2 und 3. p. 361. 
        PROGRESSIVE  MUSCULAR ATROPHY.—ETIOLOGY.     113

some instances the opposite fact seems to exist, the female chil-
dren in one family being exclusively affected.1
   As  regards the  influence of age, the period  of  middle life
(from 30 to 50 years) is usually spoken of as the most frequently
affected.   Statistics certainly agree with this view. AVachsmuth,
among 49 cases,  found 13 under the age of 5 [ \ 15], 8 from lo to
'50, 22 from 30 to 50, and only 6 over 50 years.  Ehrhardfs and
Friedreich" s figures are similar.  Of  my own patients, as far  as
could be ascertained, 7 acquired the disease before the age of 10,
0 before their 20th year, 2 before the 30th, 8 before  the 40th, 5
before  the 50th, and no one later.  It follows that a considerable
percentage falls  within the period of youth, about one-half with-
in the first thirty years,  and  almost the same  number in the
years of middle life, while the development of  the  disease  in
advanced  age seems quite  exceptional.   Upon  examining the
cases singly, it  appears that those dependent on a hereditary
basis, or upon any  congenital pre-formation, come to view at an
earlier period of life, usually before  the close of the 20th year,
while individuals who  have no specific diathesis,  and whose dis-
ease owes  its origin to  the accidental  injuries,  hereafter to be
described, for the most part belong to the middle period of life,
which is the most exposed to these influences.
   Among the other causes wdiich favor or perhaps directly pro-
voke the  origin of the disease, acute exhausting diseases, and
certain constitutional  dyscrasia,,  such as lead intoxication and
syphilis, must be mentioned. Not a few instances  stand recorded
in which the disease is said to have developed during the con-
valescence from acute disease, as after typhoid (Moussons, Bene-
dikt, Gerhardt), after  measles (Eulenburg  senior, Nesemann),
after acute  articular  rheumatism   (Anstie, Friedreich), chol-
era  with very protracted typhoid (Friedberg).    In the case  of
the  twin brothers,  the disease followed an attack  of measles
which affected both at  once.  Charcot and Joffroy have seen the
disease occur immediately after childbed.   Other authors have
laid it  to  excesses  in  venery, or onanism (Aran, Oppenheimer,
  1 While writing these words, three sisters were brought to me from another family,
suffering from the disease, while their brothers were well.
          VOL. XIV.—8 
114   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

Diemer).  In Johnson s and Clarke's case the disease is said to
have developed in a child in consequence of vaccination.  Prob-
ably these  and similar  circumstances would not have had any
influence but for the existence of a predisposition.  As regards
lead-poisoning, a diffused affection of the muscles may certainly
be one of the  symptoms of  chronic saturnism, and this affection
may bear a great resemblance to a certain rare group of cases of
progressive muscular atrophy, namely, the multiple or general-
ized form.  Yet it were advisable, if only upon grounds of gene-
ral fitness,  completely to separate this saturnine affection of the
muscles from progressive  muscular  atrophy  in the  narrower
sense.   The same may be  said of  those rarer cases of diffused
disease of the muscular apparatus which are said to have origi-
nated in the action of constitutional lues, and which improve or
get quite well under the employment of antisyphilitic remedies,
as iodide of potassium (Niepce, Rodet).
   Among the more direct  causes, exhausting muscular activity
is to be mentioned, in the first place, however few in number may
be the cases in which  excessive and unwanted efforts  can  be
proved to  have been a cause.  In favor of this view is the fact
that progressive  muscular atrophy seizes upon certain muscles
and certain groups with a distinct predilection, and in an almost
regular order of succession, preferring the upper extremities, and
usually beginning with the right, and of  the right selecting cer-
tain muscles of the hand and the ball of the thumb ; moreover,
the fact of  the great preponderance of the male sex and the lab-
oring class.  There  are also some cases in which the outbreak of
the disease has Jbeen preceded by a great strain upon the power
of  the muscles  first  or  principally affected.   Betz observed
atrophy of the right side three times in smiths and saddlers, who
had to do heavy work with their right hands ;  Gull observed the
same in a tailor after excessive exertion.  In one, mentioned by
Hammond,1 the disease is said to have been caused by an exces-
sive use of one thumb and finger in playing faro  !  In some of
those rarer cases, in which the left upper extremity was the first
attacked, there were special circumstances ; thus, in Friedreich's
1 Psychological and Medico-legal Journal, Sept. 1874, p. 175. 
        PROGRESSIVE MUSCULAR ATROPHY.—ETIOLOGY.     115

case of a dragoon, who  may have exhausted his left hand by
holding the bridle in riding;  in a worker in morocco-leather,
who used to press hard with his left hand (Yoisin); in a musi-
cian, wdio for four years played several hours a day on the bass-
viol (Schueppel).  And in the cases in which the disease did not
begin in the hand, but in the muscles of the  shoulder or the
lower extremities, an excessive use of the muscles attacked could
sometimes be  shown ; thus  Schneevogt mentions two  cases of
primary atrophy of the shoulder muscles, especially the deltoid,
one of the right  side, in a  sailor who had to  pump for  days
together while the ship was leaking ; the other  of the left side, in
a woman who  always carried her child  on her left  arm while
suckling it.   Friedreich mentions  a case in  which continued
threshing was considered to be the cause of atrophy of the right
arm and shoulder, and the scapular and thoracic muscles of the
same side.  Leinweber tells of a musketeer who, in consequence
of handling his piece, was  attacked by atrophy of the left pec-
toralis and serratus magnus.
   A primary affection of the lower limbs, commonly beginning
with the lumbar muscles, is most frequent in  children (as  Rob-
erts stated), and seems  to be due  to the preponderant use of
these  muscles  in  standing  and walking, in playing in a sitting
and bent posture.  In the cases of diffused disease (Friedreich's
" general muscular atrophy "), the influence of universal exhaus-
tion, of excessive  use of a great number of muscles, may some-
times be traced, as in a case by Vigla.   In all,  Roberts was able
to trace the effect  of hard labor as a  factor in twenty-five  cases
out of sixty-nine.  As  to how this acts  we are totally in the
dark.   From  the  myopathic  point of view we can imagine that
an excessive increase of functional physiological stimulation in a
muscle may become a direct  cause of disease, as is the case in
other organs, and  that perhaps certain  products of decomposi-
tion, occurring in excess during exhausting muscular activity
(carbonic acid,  lactic acid),  exercise an irritating chemical action
upon the muscular tissue.  Yet the exhausting muscular toil is
not sufficient by itself to explain the disease in certain persons,
but has to be helped out by  supposing a congenital or acquired
disposition—a  favoring individual diathesis. 
116   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

   Besides exhausting labor of the muscles, rheumatic and trau-
matic lesions have been particularly blamed as direct causes.  It
is plain that these two circumstances will often coincide, for per-
sons who have to work hard with  their hands are particularly
exposed to atmospheric  and traumatic influences.   Yet  some
cases seem to show the directly favorable influence of exposure
to cold and  wet.   Thus, Dumenil saw atrophy of  the lower
extremities appear after long-continued standing in the water in
fishing for trout; Friedreich, in the case of a man who was fre-
quently exposed  to the cold while chopping wood in  the forest
in winter.  E. H.  Richter saw a total atrophy of  the hands in a
man who had suffered from severe sweating of the hands, and
used therefore  to bathe them in ice-cold water and snow;  Men-
jaud saw this after long-continued work in  the wet and cold.   It
is of course right  to separate from these the cases, more frequent
in number, in which severe exposure to cold has caused a partial
paralysis with  secondary wasting.  As  regards traumatic  influ-
ences, they may be either lesions of the nerve-trunks with sec-
ondary atrophy of  the muscles, or direct lesions of the muscular
substance (e. g., by crushing).  The latter  forms are designated
by Friedreich as primary traumatic muscular atrophy, and he
relates a very instructive case in which,  after the  hand had been
crushed, the atrophy extended progressively upwards over the
entire upper extremity,  and finally led to the complication of
bulbar paralysis.1   I have formerly described a case in which the
hand was compressed for several hours, after which symptoms
entirely similar to muscular atrophy appeared.4   Finally, there
occur cases in which inflammatory irritation seems to be propa-
gated from neighboring organs (especially the shoulder and hip
joints), or cicatrices or suppurating wounds appear to be the
cause—cases which are grouped together by Friedreich as  "my-
opathia propagata."  Friedreich  relates  several cases of this
sort3; but they are hardly to be considered as cases of progres-
sive muscular atrophy in the narrow sense, and deserve mention

   1 L. c. p. 236.  Observ. XXIV.
   2 Zur Galvanopathologie und Therapie der Liihmungen. Berlin, klin. Wochenschrift.
1868. No. 2.
   3L. c. p. 152. Obs.  XVIII. and XIX. 
        PROGRESSIVE MUSCULAR  ATROPHY.—SYMPTOMS.     117

here only as showing the possibility of  the origination of exten-
sive myopathies, per  contiguilalem,  from  peripheral foci of
irritation  and inflammation, without any previous lesion of the
corresponding nerve-trunks and without the intervention of neu-
ritis descendens.  Whether it be proper to include here the cases
cited by Clarke, Hasse, Friedberg, and others, in which a person
who has fallen from  a railway carriage, or been thrown  by his
horse,  etc., becomes  a victim to  atrophy  of certain  groups,
especially the muscles of the  shoulder,  must  remain an open
question,  since  the injury in such cases may equally well havo
fallen upon the  peripheral nerves.1

                    Symptoms  and Course.

    The cardinal symptom, though  often  by  no means the only
one, is the atrophy with its gradual development and its succes-
sive extension to certain groups  of  muscles  ; the diminution in
bulk of the muscle, accompanied by a corresponding impairment
of function.  In by far the majority of cases the disease  begins
with the muscles of  the upper extremity, usually the right arm,
in agreement with the greater use to which  the right is  put in
labor.  According to the latest statistics of Friedreich the disease
began (among 146 cases) one hundred and eleven  times  in  the
upper extremity, twrenty-seven times in the lower, eight times in
the lumbar muscles.   Cases are very rare in  which the  facial
muscles are first attacked (Cruveilhier), or  those of the tongue
(Roberts).  In the latter instances there was  perhaps a combina-
tion with  bulbar paralysis.   Sandahl found that the right upper
extremity was first attacked thirty-seven  times, the left upper
fourteen times, and both at once eleven times.  Among the mus-
cles of the upper extremity the interossei are first invaded almost
constantly ; and of these the interosseus externus primus is first
attacked—in my experience always  so.  The  affection can often
be diagnosticated in its earliest stages, when the wasting of the

  11 lately observed  a case of this kind in a colleague.  Pressure, experienced duriDg
the operation of version, produced at first a circumscript atrophy of the extensor carpi
radialis, and afterwards an atrophy and corresponding functional debility of most of the
muscles of the forearm. 
118   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

interossei is inconsiderable and the falling in of the interosseous
spaces is not striking, by the diminished power of the interossei,
especially the external ones ; if, for example, the patient's thumb
(in abduction) and his three last fingers are held, and he is told to
straighten the index and then abduct it, or separate it from the
middle finger, the movement is weakly performed, and the excur-
sion of the finger is less than in the other hand, unless the disease
has attacked both ; fibrillary  twitchings will also be easily seen in
this  experiment.   I  take pains to make this statement, because
several authors (Roberts, Wachsmuth, Friedreich) make the sur-
prising observation that when the hand is the part first attacked,
the muscles of the ball of the thumb are, as a rule, the first seized
upon.  I have always seen the latter muscles preceded in the
order of attack by the interossei, that is, by the first external
interosseus.  In the thumb the opponens and the weaker adduc-
tor pollicis are first and  most affected, while the extensors and
both abductors and  flexors of the thumb remain spared for a
long time, or altogether.   The same is the case in the  ball of the
little finger.  In a few cases the disease begins, not in  the mus-
cles  of the hand,  but  in  those of the shoulder, selecting from
these almost  exclusively the deltoid.   In such instances  the
cause may generally be traced to an exhausting effort made with
the shoulder muscles (see above); but I have once observed the
deltoid attacked primarily in the  person of  a lady living under
the most favorable circumstances,  and by no means exposed to
any injury  of this sort.  In her case the interossei were the next
affected ; conversely,  when  the interossei  have  been the chief
seat  of primary lesion, I have repeatedly found  the deltoid the
second point of attack, the  interjacent muscles, meanwhile, re-
maining  untouched.   This typical course, and  the progression
by leaps, involving successively muscles and groups of muscles
which  are widely separated  (which  is  certainly observed  in a
number of  cases),  are of  special  importance in  relation  to  the
theory of the disease.
   Still more  rarely, the disease begins with certain muscles of
the upper region of the trunk (pectoralis major, serratus magnus)
or with the lumbar muscles.  I consider  myself justified  by the
cases before me in saying that in those few instances where the 
        PROGRESSIVE MUSCULAR  ATROPHY.—SYMPTOMS.     119

disease is stated to have begun in the  above-named j>ectoral
muscles,  the disease  was not a  proper classic atrophy  of the
muscles, but a circumscribed atrophy of  certain sections of the
musculature of the thorax, caused by special mechanical inju-
ries.   On the  other hand, those  cases wdiere  the disease began
with the lower extremities, and especially with the lumbar mus-
cles, were almost always cases of children ; and in most instances,
perhaps in all, its first appearance took the  form, more  or less
clearly marked in the different muscles, of pseudo-hypertrophy,
which I agree with Friedreich in regarding  as merely a peculiar
modification of progressive muscular atrophy,  chiefly confined to
childhood (see the following section).   The pure progressive
muscular atrophy of the adult, therefore, will be found charac-
terized by beginning at the upper extremities and by attacking
limited  districts, whether the interossei  or the deltoid  be the
first to suffer.  The very rare cases in which  numerous muscles
are said to have been attacked simultaneously must therefore, in
my opinion, be separated from  common progressive muscular
atrophy and be classed as a special  form under the name  of
"multiple" or "diffuse" atrophy of the muscles, especially as
these cases are characterized in their course  by special malignity
and acuteness, slight tendency to pauses, and a rapid and un-
broken development.1
   The emaciation of the muscles attacked, the  loss of exterior
contour,  usually makes  constant progress  proportional  to the
growing loss of function, and produces deformities  correspond-
ing to the seat  of the muscles—as, for example, the depression
between the bones in disappearance of the interossei; the flat-
tening of the ball of the thumb, and that of  the little finger ; the
prominence  of the upper end of the humerus and the acromial
process  of  the scapula when  the deltoid is  affected.  Yet the
external loss of volume cannot always be taken as a measure  of
the inner atrophy of muscle  ; it does not always correspond with
the changes in function, nor with the electric reaction hereafter
to be described.  A clear and perfectly satisfactory explanation
of the difference has  been given by Friedreich, who points out
1 Cf. Friedreich, 1. c. p. 28. Case V. 
120   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

the anatomical changes  upon which it is based.   For, while the
loss of volume can be due to  progressive wasting of muscular
elements and retraction of the  connective  tissue which prolifer-
ates in the perimysium internum, an  interstitial diffuse fatty
hyperplasia may occur in any stage of the disease, and especially
in the early stages ; earlier authors incorrectly  supposed it to
be a constant and characteristic factor of the muscular affection.
This occurs especially in the muscles of the low-er extremities,
more rarely in those of the shoulder  and upper  arm, still more
rarely in those of  the hands and forearm.   If there  is a consid-
erable degree of interstitial fatty hyperplasia, the volume of the
muscles may remain apparently normal, in spite of  a complete
loss of function, and, usually,  of the electric reaction as well;
an excess of volume, a pseudo-hypertrophy, may even occur, as
is especially the case in the muscles of the calf when the loss of
substance in the upper extremity is marked.  The fatty muscles
in such cases are characterized by their  soft, spongy,  lipoma-like
consistency; the functional  and electric  tests,  and, still more
certainly, the  removal of the tissue by excision  or the harpoon,
give decisive proof.  In a few cases, a well-developed panniculus
adiposus may conceal even an advanced  atrophy, especially in
the muscles of the arm  and shoulder of corpulent women.
   A symptom of extreme frequency, both in the initial stage
and during the entire course of the disease, until the muscle is
wholly gone, consists in fibrillary contractions ; that is to say,
visible contractions of single  bundles of fibres  following  each
other in successive impulses, or running in waves over the sur-
face of the muscle.  Sometimes they are only single  movements
of lightning-like rapidity, and sometimes they form a continuous
series of oscillations of greater or less  intensity.  Usually they
appear  spontaneously—that is, without visible external  cause;
but they are  often provoked or increased by external circum-
stances ; for instance,  when  such  parts  of the  body  as  the
shoulder and thorax, usually covered, are  exposed to the air, or
when active and  passive movements are  tried,  and especially
when the parts are stroked or  otherwise mechanically irritated,
or when electrical irritation is employed.    An  explanation of
this symptom  will be attempted in another place, in connection 
        PROGRESSIVE MUSCULAR ATROPHY.—SYMPTOMS.     121

with the statement of the theory of the disease ;  for the pres-
ent it  is  sufficient to say that its pathognomonic importance,
though overrated by the first observers, certainly deserves to be
rated highly,  owing  to the frequency and the earliness with
which  the symptom appears.   Far less common than  these
so-called fibrillary (more properly "fascicular") contractions are
the clonic or tonic  contractions of  entire muscles or groups of
muscles, which also are sometimes produced or  increased by
external irritation, and  are accompanied  by distinct locomotor
phenomena in the parts concerned, and by intense pain, after the
analogy of the well-known cramp of the calf.
   As the muscles lose their power  in the progressive course of
degeneration, permanent contractures and deformities are often
developed, which present something typical  in their appearance,
owing  to  the  fact  that some muscles are  spared while their
neighbors are attacked.  The case is quite analogous to  that of
the so-called essential paralysis  of childhood, in which certain
muscles or groups of muscles are usually selected, only that in
childhood  the conditions for the development of  permanent
deformities are more favorable, which insures  their greater fre-
quency.  The commonest  deformity is the  so-called  clawed
hand (main en grille, Klauenhand, clasped hand), which consists
in permanent flexion of  the  last two phalanges of  the  fingers
while they are extended at the metacarpophalangeal joint.  This
deformity is caused by  atrophy of  the internal and external
interossei (as Duchenne first strikingly proved  by faradic exper-
iments), which, acting together,  flex the  fingers at the first
phalanx and  extend them in the second  and third.  When,
therefore, the force of the interossei is diminished or reduced to
nothing, the above effect must occur, owing  to the  preponder-
ance  of their antagonists, the extensor  digitorum  communis,
the  extensor  indicis, and extensor digiti  minimi on the one
hand, and the flexor digitorum sublimis and profundus and the
lumbricales  on the other.  The deformity  is therefore pathog-
nomonic, not so much  of progressive muscular atrophy as of
wasting of the interossei ; I have, for example,  observed it very
well developed in a case of atrophy of those muscles, caused by
dhect  traumatic  lesion (compression).  In  consequence  of  the 
122   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

atrophy which usually occurs in  certain muscles  of the ball
of the thumb—namely, the opponens and the adductor—there
occurs a corresponding deviation of the thumb with  abduction
and  extension in the first phalanx, and  flexion in  the second.
In the shoulder-joint an atonic subluxation often occurs, espe-
cially in children, with dislocation of the head of the humerus
in the direction of  the coracoid process.   A  similar dislocation
with hyper-extension of the arm may also appear, though more
rarely, in the elbow-joint.  Atrophy of the scapular and dorsal
muscles may also  lead to various forms of dislocation of the
scapula and scoliotic or kyphotic  bending of  the vertebral  col-
umn.  Severe deformities of the lower extremity are exceptional,
at least in  adults,  while in children the various  forms of club-
foot may appear, especially the paralytic pes varo-equinus caused
by atrophy of the muscles of  the calf and preponderance of the
antagonists, tibialis anticus and posticus.
   The electrical reaction of the affected muscles corresponds in
general with the loss of volume and of voluntary power.  This
fact wTas noted by the earliest observers, as regards the faradic
current. There is, therefore, no proper diminution of the electro-
muscular (farado-muscular) contractility ; in proportion as the
contractile elements of the muscle  disappear, the  visible effect of
direct intra-muscular faradization becomes weaker  and weaker,
and in extreme cases imperceptible.  Some authors suppose they
have observed a disproportionate  loss of farado-muscular con-
tractility  ; but they may easily have been deceived by the com-
pensatory lipomatosis, which  is capable of quite  concealing the
loss of muscular tissue.
   It may be affirmed without question that the direct faradic
stimulation affords the best gauge of degree of degeneration of
the  contractile elements, and  a far exacter test  than  voluntary
motility,  or the electric  motility  as  tested by stimulating the
nerve (with faradic electricity;  the " motricite " of Flourens).
In both the latter tests the results  are far harder to estimate; if
 the  energy of the will  is great, or if irritability is increased, or
 the  peripheral nerves are more easily invoked to action, the effect
 of stimulating  may be far too great; that is, it may lead to an
 over-estimate of the power  remaining in the muscle.  This is 
        PROGRESSIVE MUSCULAR ATROPHY.—SYMPTOMS.     123

especially the case in the initial stages  of the disease, in which
there is often an atrophy of  the integuments and an  increased
reflex irritability, which easily give rise to mistakes on the part
of  inexperienced  persons.    For  the  same reasons  voluntary
motility and indirect (faradic)  excitability  are retained  longer
than  farado-muscular contractility, although  they grow con-
stantly  less ; but at the last,  when degeneration is complete, and
the muscles are cirrhotic and shrunken, even these are entirely
powerless to provoke reaction.   In all cases that I have been
able to  examine carefully I have seen the indirect faradic irrita-
bility disappear some time before voluntary motility, which is in
perfect  agreement with the  action of the  constant current,  of
which I shall presently speak.
   Some authors have observed in the earlier stages an increased irritability under
the action of the induced and the constant current, in direct and indirect applica-
tion. Leaving out of view the  sources of error, these cases (certainly very rare)
must probably be referred to a temporarily heightened irritability of the intra-
muscular  nerve-twigs, Avhich (according  to  Friedreich) is due to inflammatory irri-
tation communicated from the muscular tissue.  This may also  account for the
prolonged closure-reaction (closure-clonus) mentioned by Benedikt.
    The  test of  the constant current  gives in  general a quite anal-
ogous result.   In direct galvanization the muscles, and especially
the interossei, usually continue for a long time to contract in the
normal  way, but the force  of the  contraction  gradually grows
less, proportionally to the progress of the atrophy and the loss
of voluntary motion, so that  stronger and stronger currents are
required to  produce a  minimum  of contraction at closure  or
opening of  the circuit.  I have always  noticed that the reaction
to very  strong constant currents held out longer than that to the
strongest faradic currents ; it is true that sometimes battery cur-
rents of sixty or more elements (Siemens)  must be employed,
and the current frequently closed and  opened ; and sometimes
contraction  can only be obtained by reversals of currents.  It is
important to establish in  this way the  last relics, as it were,  of
remaining vitality in the muscle, especially as the prognosis and
treatment may in some cases be affected by the fact.   The  gal-
vanic excitability of the nerve-trunks also  remains unimpaired
for a long time.  In later stages a  quantitative diminution of the 
124   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

reaction may occur, perhaps caused  by secondary degenerative
changes in the  peripheral  nerve-trunks; the peripheral excita-
bility,  in  such  cases, seems  to have  suffered more than the
capacity to conduct voluntary impulses, as we have observed in
some cases of severe peripheral, especially traumatic, lesions of
the nerve-trunks.  In this regard the fact observed by M. Rosen-
thal is of interest; the nerve-trunks behaving differently at dif-
ferent  points in their course, so that while  electric stimulation
applied to a portion situated near  the  centre may  produce nor-
mal effects, its  results may be  less than normal, or  even  quite
wanting, when  a more peripheral  tract is  stimulated.   Besides
these quantitative changes, qualitative alterations in  the muscu-
lar reaction may attend a  later  period  of the disease, consisting
of a slight deviation from Brenner's law of contractions,  namely,
an increased  reaction under anodic closure, and, less  commonly,
under cathodic  opening.   These phenomena, analogous  as they
are to certain others,  point to severe degenerative  changes in the
peripheral nerve-trunks and muscles.    Reversal of  formula, and
the extreme degrees of qualitative  deviation from the formula of
reaction have never been encountered  by myself  in  progressive
muscular atrophy.
   It is proper in this place to mention  one other interesting anomaly of reaction,
whose frequent occurrence in progressive muscular atrophy was first remarked by
Remak.  I mean the so-called "diplegia contractions.'"'  Remak found that contrac-
tions could be produced in the atrophied muscles of the arm, when the positive
electrode was placed  in an "irritable zone," which extends from the  first to the
fifth cervical vertebra, or, still better, in the carotid fossa or the triangle between the
lower jaw and the external ear, while the negative was put below the fifth cervical
vertebra.  The contractions were always upon the side opposite to the  anode, but
when the electrodes were applied in the median line they occurred  on both sides;
if the current was very weak, they were limited to the muscles most severely affected.
Remak  regarded these as reflex contractions, originating from the superior cervical
ganglion of the sympathetic, and especially as the patient perceived a sensation
behind the ball of the eye  when the current was closed ; he made some extensive
theoretic conclusions, about which we shall have to speak later.   "While  Fieber and
Kenedikt could not  produce the diplegic contractions, Meyer, Drissen, and Erb (in a
case reported by Friedreich ') confirmed Remak's statement.  For my part, in spite of
regular attempts, I have succeeded in demonstrating the diplegic contractions in only
1 Case V. of Friedreich's, above quoted. 
        PROGRESSIVE MUSCULAR ATROPHY.—SYMPTOMS.      125
one case of progressive muscular atrophy, and here the phenomena by no means
followed the order as stated by Remak.  I also entirely disagree with Remak as
regards the interpretation of this symptom, and believe that they ought to be taken
as genuine reflex contractions, independent of the sympathetic, and caused either
by excessive irritability of the central reflex apparatus, or by an abnormal excita-
bility of the muscles themselves.1

   Among those symptoms which occupy a secondary place in
respect to frequency and dignity, the disturbances of sensibility,
the vaso-motor and trophic disturbances, and the oculo-pupillary
phenomena deserve  a special consideration.
   The sensibility, in the majority of cases, presents no  change
worth mentioning.  But in a certain number of cases the develop-
ment of the affection in the muscles, or at least its higher grades
of development, are preceded by paroxysms of pain in the affected
parts.   Sometimes  the pains  follow the course and distribution
of single nerve-trunks, as that of the median and ulnar nerves in
the arm ; sometimes this is not recognizable, and the pains  seem
rather to take their  origin in the muscles themselves, in the sensi-
tive nerves which supply muscular tissue.  The latter explanation
is at least favored  by the circumstance  that  compression and
active or passive motion provoke or increase the pain, as  also,
that electro-muscular sensibility seems to be increased in a few
cases.  In later stages, after the neuralgic and  hyperalgic symp-
toms have passed  away, or  even while  they  still  continue, a
moderate degree of  anaesthesia is often developed in the form of
partial paralysis of sensation (dulling  of common  sensation,
analgesia with normal sense of touch 2), especially in the finger-
tips and hands.   The farado-cutaneous sensibility may present a
similar diminution.   I have never observed higher degrees of loss
of sensibility in cases of uncomplicated  progressive muscular
atrophy.   Paralgic symptoms, as  a sensation of cold and numb-
ness in the  finger-tips,  formication,  etc.,  are more common.
Finally, the  exaltation of reflex excitability must be mentioned
here; for, independently  of  the diplegic  contractions, which
  1 Cf.  Centralblatt.  1868. No. 3.
  ! Cf.  Landois and Mosler. Neuropatholog.  Studien  Berl. klin. Wochenschrift. 1868.
Na45. 
126   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

probably are due to this cause, abnormal reflexions  may  occur
(e. g., when needle-pricks, tickling  of  the  spies, etc., are em-
ployed),  especially in the initial stage of progressive muscular
atrophy.
    Vaso-motor trophic disturbances of various degrees and extent
may occur in the affected regions.  The temperature of the  limbs
that have been attacked is sometimes  a little elevated in the
beginning ;  Baerwinkel demonstrated  in one case a local eleva-
tion of 1° with a full radial pulse ; Frommann found  on the side
first attacked a  rise of  0.2° or 0.3° C.    In  most  cases, and in
advanced stages, a local rise of  temperature cannot be demon-
strated, and at  a later period a decided lowering may occur,
which, according to M.  Rosenthal, may amount to 4° C.   The
color of the parts is usually normal;  sometimes it is pale, and
rarely of a distinctly livid or cyanotic character.   In a few  cases
a local ischemia is observed from time  to time, especially of the
hands and fingers, a sudden coldness and paleness of the parts,
followed by relaxation of  the vessels,  redness,  etc.,  such as
occurs in the well-known forms  of  vaso-motor neurosis.  It is
also worthy of note that in a few cases excessive local sioeatings
occur, wdiich usually seem to pass into a general increase of the
secretion of sweat.
   Of the trophic disturbances (in the stricter sense of the term),
an atrophy of the outer  integuments must be mentioned, which
often accompanies the muscular lesion.  It affects all the layers
of the integument,  the epidermoidal tissues  as well as the cutis
and the  subcutaneous tissue, but scarcely ever reaches an ad-
vanced degree, even when the muscular disease is far advanced,
and may  be wholly wanting. Here perhaps we  ought also to
mention the painful swellings of the joints  {arthritis nodosa),
first spoken of by Remak,  and observed chiefly in the  early
stages of  the atrophy; Remak conceived of them as "neuro-
paralytic inflammations,"  and connected them with the sympa-
thetic.  I have observed them in some of the phalangeal joints
in several cases, which were treated  early ; likewise  in one case
of primary disease of the  right deltoid where the  corresponding
shoulder-joint was affected  in  a pronounced  manner.  These
joint-affections are doubtless genetically related to the "neuro- 
         PROGRESSIVE MUSCULAR  ATROPHY.—SYMPTOMS.      127

trophic" arthropathies of tabes dorsalis, of  which Charcot1 has
spoken, except that  the latter are more  frequent in the  large
joints,  as the  knee, shoulder, elbow, etc., and  therefore are  of
greater pathological importance.
    Oculo-pupillary symptoms, of  the sort previousry described
under  Hemicrania and Basedow's disease, occur comparatively
rarely in progressive muscular atrophy, but they deserve a spe-
cial attention on account of their theoretic relations.

   Contraction of the pupil was mentioned by Schneevogt (1855) and Baerwinkel
(1858).   The first exact description originates with Voisin, and relates to a case in
Bouillard's clinic.  The patient was a man, aged forty-four, and had suffered seven
or eight years with the disease—first in the left, then in the right arm.  His left eye
was the first attacked;  a contraction of the pupil appeared, which reduced it to
half the size of the other, but did not prevent its reacting normally; the cornea was
flattened, so that its most prominent portion seemed nearer by one millimetre to the
iris.  In a few months the same phenomena occurred in the right eye; both  pupils
were equally contracted, and reacted slowly, the cornea was equally flattened on
both sides, and the sight of both eyes was poor.  In a case  given by Menjaud, of
muscular  atrophy chiefly confined to the distribution of the median  and ulnar
nerves of both  arms, there existed a considerable contraction of the left pupil.
Bergmann also observed in one case contraction and slow reaction of the left pupil;
M. Rosenthal found unilateral contraction in four cases; Friedreich found  in one
temporary contraction and sluggish reaction of both pupils.  These few positive
observations are far outnumbered  by  the negative;  for example,  Duchenne, in
remarking on Voisin's account, says expressly that among several hundred (!) cases
he never once met with the phenomenon.   And in all those which I have examined,
I have never  been  aide to make out these disturbances of innervation of the eye.
They must, therefore, be looked upon as a very rare complication  of compressive
muscular atrophy.

    Of the general  symptoms, fever must first  be mentioned; it
may occur in a few cases of progressive muscular atrophy,  espe-
cially in  the initial  stage,  either as repeated attacks of  chill or
as a continuous increase of temperature, very slight in amount,
which lasts  for  days or even months.  Remak is,  as far as I
know,  the first  who  has  called attention  to  the  existence of
febrile  symptoms  in  connection with arthritis  nodosa in the ini-
tial stage of the disease ; he drew from its presence a fresh proof
of the  connection  he  assumed  to exist  with  the  sympathetic
1 Archives de physiologic I. 1868. II. 1869. 
128    ULENBURG.— VASO-MOTOR AND  TROPHIC  NEUROSES.

nerve or the sympathetic centres in  the spinal cord.  It remains
for further observation to decide whether these  initial symptoms
of fever are most common in the cases which  are  accompanied
by acute arthropathy, and wdiether  they perhaps are connected
with the latter.  In the later stages there may occur transitory
or permanent elevations of temperature, which may be variously
interpreted ; they are usually dependent on complications (dis-
eases of  the lungs, decubitus, etc.), but in a few cases they seem
essentially to depend  on the pyrogenic  action of products of
inflammation  and  decomposition,  reabsorbed from the muscles
and infecting the blood (Friedreich).
   Friedreich mentions the case of a man of twenty-eight years, whose pulse usually
exceeded 120, who suffered from elevation of temperature that lasted continuously
over seven months, striking pallor of the face and the mucous membranes, frequent
dryness of the tongue, disposition to diarrhoea, constant and  abundant excretion of
urates, and a considerable swelling of the  spleen. The final result could not be
known. No similar cases have as yet been reported.
   Among the general symptoms may be mentioned the changes
in  the secretions  of the sweat  and  urine  which have been
observed  in some cases.   An excessive sweating (hyperidrosis)
of a generalized character occurs especially  in the later stages
(Frommann, Friedreich) ;  its  origin   and its  relation to  the
other symptoms are at present wholly uncertain (see "Analysis
of Symptoms.")  Concerning the qualitative  and quantitative
changes  in  the composition of  the urine, there are but few and
very  discordant statements.   Friedberg  and  Frommann each
observed in one case a deposit  of  lime in the urine; the  latter
found the urine pale,  turbid, slightly alkaline, with abundant
sediments of carbonate of lime, wdiich he believed to originate
from the atrophied muscles.  Bamberger, however,  found in one
case urea and chloride of  sodium in  normal or increased quan-
tity, great increase of sulphuric acid,  and considerable diminu-
tion of the uric and phosphoric acids.  An examination of  the
blood at the same time showed a  considerable  increase in albu-
men and  blood-corpuscles.  More important, but  not  yet con-
firmed by other observations, is the  increase of creatinin in  the
urine,  observed by M. Rosenthal in  three cases.    Friedreich
found the urine acid in three cases, of quite high specific gravity, 
        PROGRESSIVE MUSCULAR ATROPHY.—SYMPTOMS.      129

containing more or less constant  sediments of urates, and free
from albumen.  It is greatly to be wished  that the number of
exact and full examinations of  urine might be increased, with
the view of explaining the chemical changes  in muscular sub-
stance produced by the disease.
   In passing now to  the  consideration of the progress of  the
disease, we have, in the first place, to make  a few remarks upon
the manner in which it extends itself, and the irradiation of
the myopathic process.  This important point,  unfortunately, is
not yet so clearly made out by clinical observation as might be
desired.  We have seen that the disease begins most often with
certain muscles of  the hand (interossei, ball  of the thumb), more
rarely  with the shoulder (deltoid),  still more rarely with  the
lower extremities (lumbar muscles) or the muscles of the  trunk.
In the ordinary course of the disease, when the upper extremities
are primarily or exclusively affected, a series of muscles belong-
ing to  the forearm, upper arm, and region  of  the shoulder,  are
gradually implicated.  The influence of contiguity in the prog-
ress of the disease, a  continuous passage from affected muscles
to their  neighbors, a  direct propagation of the inflammatory
(myositic) process,  due to propinquity, can  by  no means,  in my
opinion, be certainly shown.  It is contradicted by the circum-
stance already mentioned, that the primary affection of the inter-
ossei is very often  followed  directly by that of the deltoid, and
vice versa,  the  intervening muscles remaining  intact.   The
adherents of the myopathic theory, it is true, help themselves
out with the assumption that two centres of disease may exist at
once—in the muscles  of  the hand and in the deltoid.   They
describe  the disease  as ascending from the former  to the fore-
arm, and as descending from the  latter to the upper arm, and
crossing laterally to  the muscles  of the chest and  back.'  The
case is  similar,  according  to them,  in  the lower  extremities,
where the process  usually ascends from the legs to the thighs,
buttocks, and  loins, or from the loins to the higher muscles of
the trunk, and seldom descends from those  of the buttocks and
loins to the lower extremities.  It is true, it  is just as easy to
     1 Cf. Friedreich, 1. c. p. 230, and elsewhere.
VOL. XIV—9 
130   EULENBURG.—VASO-MOTOR AND  TROPHIC NEUROSES.

admit  a still  greater plurality of  centres  of this sort, one for
each single muscle attacked,  as it is to grant  several  centres
which  gradually unite in one.  But, leaving  the question of
propagation  by  contiguity  unsettled for  the  present, there
remain two other important  points in respect to the progression
of the muscular  disease.   One relates to the way in which the
process is limited, especially to segments of  the skeleton marked
by the greater joints ; the other, to the habitual escape of certain
muscles and groups of muscles.  In a  large number of cases the
disease, beginning with  the muscles of the hand, does not pass
beyond the wrist, or, at least, remains comparatively  stationary
for a very long time ;  in other cases another series of muscles in
the forearm, especially the extensors, are affected, and a bound
seems set to the progress of the disease at the elbow-joint.  Con-
versely, when the disease begins at the shoulder,  the muscles of
the upper  arm only are often  attacked, while those of the fore-
arm are spared.   In atrophy of the leg the knee-joint seems to
set an upward limit to its progress.   It is true, as  Friedreich
states,  that this bound can be passed,  and, after the process  has
overleaped the joint, it may attack  the neighboring limb, and
there make more  or less progress.  But in this case also, accord-
ing to Friedreich's view (which  is  supported by several autop-
sies), the spreading takes place entirely per  contiguitatem, e. g.,
from the biceps and brachialis  anticus to the body of the supina-
tor longus, wdiich lies directly  upon their insertions  ; also  to the
extensor carpi radialis longior and brevior, and the upper part of
the extensor digitorum  communis, which lies next to  the latter.
Besides,  the temporary or permanent arrest by no means always
takes  place at the joints, but often  enough occurs  before the
disease reaches them, as may occur at any point whatever of the
trunk.  There  are even cases  in which the disease arrests itself
in the body of a muscle, so that only a few larger  or smaller
segments of  muscular bundles are affected,  while  the rest are
perfectly sound.   Friedreich describes such  a condition in the
cucullaris, deltoid, and the glutei.   It is remarkable that all
these muscles possess a double or even a more numerous  supply
of nerves.   As respects the relative  or absolute immunity of
certain muscles, those of the neck and head are affected only in 
        PROGRESSIVE MUSCULAR ATROPHY.—SYMPTOMS.      131

exceptional cases.   The instances where  some muscles of  the
head,  especially those of  the  lips  and  tongue,  are  affected,
usually belong to a combination with progressive bulbar paraly-
sis, or to progressive glosso-labial atrophy, which is still distin-
guished by some as an independent disease.  The striped mus-
cles of the organs of the higher  senses (extrinsic muscles of  the
globe and internal muscles of the ear) seem never to be affected.
The diaphragm, the straight muscles of the abdomen, and those
of the larynx, are unquestionably affected  in some cases, though
rather rarely.
    It remains to say that the symmetric muscles of both halves
of  the body are usually affected, but by no means to the same
degree and extent,  Often, even after a long continuance of  the
disease, its intensity is much  less in one extremity than in  the
other; and  in  these  cases  the  peculiar condition of  a crossed
attack is often developed,  in which one upper and the opposite
lower extremity are chiefly affected.   I have elsewhere described
several very marked cases of this sort, some of  them in  connec-
tion with pseudo-hypertrophy of the lower extremities.1
    With the exception of certain cases already described,  the
course of the disease is generally very protracted.  Its progress
is usually extremely slow, especially at the first, and produces
at first no trouble, and particularly involves no danger to  the
general health or to life ; its results are confined to the local dis-
turbances caused by the increasing disability of motion.  A spon-
taneous retrogression of the process in the muscles after they are
once atrophied, with a spontaneous disappearance of the clinical
symptoms which depend upon the atrophy, never takes place,
as far as we can judge.  But there is no doubt that the disease
may remain stationary for a  longer or shorter  time, even  for
years, at any period  of its progress ; this has  been shown by
what has been  said above.  Can this arrest continue, not only
for years,  but  permanently—that is,  so that there will be no
relapse during  the normal period of life? We  are hardly en-
titled to answer this question in the affirmative with the expe-
rience we  have  had,  and especially when we reflect that our
1 Virchow's Archives, Vol. 49. p. 446 ;  vol. 53. p. 361. 
132   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

knowledge of the disease does not  extent beyond twenty-four
years in all.
   The first serious danger to life in progressive muscular atro-
phy occurs when the respiratory muscles are attacked ; though
the most  important of these, namely,  the diaphragm and  the
muscles of the larynx, as well as the  recti abdominis, are usually
spared.  Yet the very  frequent affection of the large accessory
muscles of  breathing,  as the  pectoralis major, serratus anticus
magnus, cucullaris, etc., may  be  an indirect source of danger;
slight diseases of  the  respiratory apparatus, impediments  to
breathing  which  would otherwise be easily overcome, such  as
simple catarrh of the bronchi, may,  under some circumstances,
produce asphyxia and  death.  In other cases death is caused by
the rapid  progress of bed-sores,  during which the patient, espe-
cially when the lower extremities and the muscles of the trunk
are affected, grows more and more helpless, cannot leave his bed,
cannot even change his position without help,  which circum-
stance, especially if the muscular layer  of the back be atrophied
or the integuments thinned,  exposes him very greatly to  the
danger of  bed-sores.
   A cause of death which does not  lie in the disease itself con-
sists in  the complications  wdiich may  be allied to the  disease.
One of these is so frequent, and  is clinically so nearly allied to
progressive muscular atrophy, that it must be considered not as
an  accidental combination,  but as a combined disease, arising
from the same or similar pathogenic causes.  This is progressive
bulbar paralysis.  We shall speak further of its relation to pro-
gressive muscular  atrophy,  when  we  come  to  the  theoretical
discussion of the latter; at present let it be  simply remarked
that it may form a cause of death, either by producing a gradual
palsy of the muscles of swallowing and of the larynx, or,  when
it occurs in the apoplectic form (Joffroy), it may be accompanied
by hemorrhage in the rhomboid  fossa, or by embolism or throm-
bosis of the vertebral artery, with immediate palsy of the respi-
ratory centres.  In many cases death has been caused by acute
intercurrent affections  of the lungs  or  chronic miliary tubercu-
losis, either while  the disease  is in  full progress  or  after it
appears to have been arrested. 
  PROGRESSIVE MUSCULAR ATROPHY.—PATHOLOG. ANATOMY. 133

                     Path ological Anatomy.

   We must distinguish the anatomical changes in the muscular
apparatus  from  those in various parts  of  the nervous system.
We begin with the former, partly because  the conditions them-
selves are simpler and more constant, partly because their inter-
pretation is clearer  than is the case with the alterations in the
nervous system.
   We have information regarding the diseased muscle in the living subject, de-
rived from  excision or from explorative puncture  with Middeldorpffs harpoon,
Duchenne's emporte-piece histologique, or similar instruments.  This procedure has
been less used  in progressive muscular atrophy than in pseudo-hypertrophy, which
is probably due to the fact that the introduction of the trocar into a hyper-volumi-
nous muscle seems easier of execution than when there is an atrophied mass to deal
with.  Excision of muscle is dangerous, and ought decidedly to  be rejected; it
leads, as I have convinced myself in a case recently operated upon by another, to a
long-continued suppuration, even if the wound at first behaves very well; extensive
erysipelas and severe general symptoms have  also been  observed (Friedreich).
Puncture is  free  from these dangers, but does not always  lead to certain results,
partly because?the muscle is not penetrated, and partly because the portion removed
may happen to be unaffected; it must, therefore, in many  cases, be repeated.

   While most of the earlier investigators, especially Meryon,
Duchenne,  Cruveilhier, Wachsmuth, Valentiner, and others, re-
garded the  process as simple fatty degeneration of the muscular
fibres  with  secondary disappearance,  and finally a perishing of
the sarcolemma, others, as Robin, Friedberg,  Foerster,  Schuep-
pel and Hayem,  defended more or less decidedly the inflamma-
tory theory, considering the  fatty metamorphosis of the primi-
tive fibres as secondary and subordinate.  The  results of Charcot
and  Joffroy,  Dumenil, and others, are less definite.   Recently
these questions have  been brought  to a conclusion by the inves-
tigations  of Friedreich, which I think fully exhaustive  and  con-
vincing upon this point.  According to these, the disease  con-
sists in an  essentially inflammatory  process,  a  "polymyositis
chronica  progressiva."  The first changes begin in  the perimy-
sium  internum as hyperplastic growth  of  the interstitial  con-
nective tissue in its finest ramifications among the single primi-
tive bundles.    At  the  same time  there  occur phenomena of 
134   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

irritation in a  greater or smaller  number of primitive bundles,
in  the form of swelling  and multiplication of the muscular cor-
puscles, and especially proliferations of  their  nuclei, and some-
times parenchymatous granular cloudiness  of the cross-striped
fibrillary substance.   In a few cases  hypertrophied  muscular
fibres, and a dichotomous or trichotomous division of the hyper-
trophied fibres (Friedreich), was seen.    During  this increase in
interstitial tissue,  the wasting  of the muscular  substance goes
on in various ways, partly by simple  emaciation and progres-
sive  dissolution without  loss of transverse  striation (sometimes
preceded by longitudinal, transverse, or elementary fission),  and
partly by waxy or fatty degeneration.   The  final   result  is a
more or less complete fibrous  degeneration  {cirrhosis)  of  the
muscle.  An accessory process, by no  means  constant or essen-
tial,  is  the diffused lipomatosis of  the muscle,  which appears
sometimes early, sometimes late in the course of the disease.

   It  is important to  know that the development  of fat, where  present, always
begins outside of the proper muscular elements, within the hyperplastic interstitial
connective tissue.  In the early stages it is easy to show the process of origination
of fat-cells from the corpuscles of the connective tissue, by the latter  becoming
filled with larger or smaller drops of fat which run  together into globules, as Vir-
chow has described  it.  If the  lipomatosis occurs at a stage  when the atrophy of
the muscular elements  proper  has  not yet reached a great degree of development,
we can see yellowish streaks  and lines of fatty tissue through the muscle, which in
other  respects looks normal.  In the highest degree of fibrous degeneration the
muscles, according to their original shape, assume  the form of thin, hard, reddish
gray cords, or else of tendinous membranes, in which light reddish stripes and
islands are seen, the relics of the old muscular tissue.  But if a considerable devel-
opment of fat-cells subsequently occurs within the already  cirrhotic muscle, its
volume may increase again, so that it regains or overpasses its former dimensions,
as is especially the case in the calf of the leg; but  a  section of an  extreme case of
this lipomatosis shows the muscle changed into a mass of fatty tissue, which exhi-
bits the original fibrous  structure of the muscle and the course of the former bun-
dles of fibres by the direction of the streaks of fat; the remains of muscular sub-
stance  are represented by a few reddish, gelatinously transparent streaks in the
lipomatous tissue.  The cause of the lipomatosis is at present quite obscure, but it
must be referred to local peculiarities of nutrition, rather than to general character-
istics, as its predilection for certain muscles proves.  In regard to the other ana-
tomical details the reader must be referred to Friedreich's complete account.1
1 L. c. chap. 2. pp. 46-92. 
  PROGRESSIVE MUSCULAR  ATROPHY.—PATHOLOG.  ANATOMY. 135

   The statements of different authors regarding the pathologico-
anatomical  changes  in the nervous system unfortunately dis-
agree widely.  This is  especially true of  the older accounts, and
is explained partly by the  defectiveness  of  the old methods  of
investigation, and partly by the circumstance that,  being pre-
possessed for one or  another view, investigators  have turned
attention sometimes to one, sometimes  to another section of the
nervous system.   The  anterior spinal nerve-roots were  the first
to assume importance, owing to Cruveilhier's view ; Cruveilhier
himself found a high degree of change  in them in  two cases.
   The first of these was the case of the rope-dancer Lecomte, which was mentioned
in the introduction.   The brain and cord and posterior  roots were normal, but  the
anterior roots from their point of exit to where they unite with the posterior were
greatly  atrophied.  The muscular branches proceeding from  these trunks were
smaller in size than the cutaneous, and in  them the neurilemma  preponderated over
the muscular substance.  In those nerves which ramify in the  ball of  the thumb
scarcely anything but neurilemma existed.  In the second case the anterior roots
were found similarly atrophied, by comparison with the posterior; the ratio of their
thicknesses in  the cervical region was 1:10 (normally 1:3); in  the  dorsal and
lumbar  regions as 1 : 5 (normally  1: 1J or 2).  The  posterior roots, brain and cord
were unchanged in this case also.
   Atrophy  of  the  anterior spinal roots was confirmed by the
following authorities; in some cases it is mentioned in  connec-
tion with other changes :  Reade,  Dumenil (two cases),   Schnee-
vogt,  Valentiner,  Menjaud,  Clarke  (three cases),  Trousseau,
Vulpian (two cases),  Luys,  Jaccoud (two cases),  Schueppel,
Grimm,  von Recklinghausen, M.  Rosenthal, Hayem,  Charcot
and Joffroy, Baudrimont, Friedreich (two cases).  On the other
hand, the integrity of the anterior spinal  roots is expressl}r stated
by Oppenheimer, Axenfeld, Aran  (two cases), Colin, Friedberg,
Meryon, Virchow, Clarke (in the case observed with Gairdner),
Frommann, Gull, Friedreich (four  cases), Tuerck, von Reckling-
hausen (second case from Bamberger's Clinic), Joffroy, and Fre-
richs (case described by Swarzenski).   Thus twenty-six  positive
observations  stand  opposed to  nineteen negative.  In a few
reports of autopsies, not here given, the anterior roots receive
no special mention.
   While Cruveilhier had found  the spinal cord itself uninjured,
Valentiner,  on the contrary, discovered  in 1855 a central softening 
136   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

of the medulla in the neighborhood of  the  three lowest cervical
and the uppermost dorsal nerves.  The  elements of the region of
transition from gray  to white substance were obliterated ;  the
softened places showed  numerous granule-cells.   Schneevogt
found also, in addition to the lesions of  the  sympathetic, of
which more will be said presently,  a softening of the cord from
the fifth cervical to the second dorsal nerves.  Frommann, in the
case observed in Leubuscher's Clinic, describes  as the leading
alteration a red softening,  involving chiefly the anterior and
lateral columns from the medulla oblongata downward ; it in-
volved especially the commissures and the innermost parts of
the anterior columns, lying next to the commissure.  Luys seems
to have been the first to call attention to  the frequency of the
affection in the gray substance;  he found the latter, in  the
neighborhood of the cervical enlargement, full of very hypersemic
vessels, wiiicli were studded and surrounded with granular exu-
dation (fat-granule cells).  The same granular masses, and many
corpora amylacea, wTere scattered through  the gray substance.
The  ganglion-cells of the anterior cornua had almost disap-
peared in the part affected, and were replaced by those (granular
masses ; only here and  there could a few ganglion-cells be recog-
nized, in a state of decided retrogressive metamorphosis, brownish
in color, full of dark granules, and with their anastomoses and
processes  broken off  or entirely  wanting.   The  degeneration
affected principally the left anterior cornu, corresponding with
the seat of the muscular atrophy, which was chiefly on the left
side, and the left-sided atrophy of the anterior roots.
   This observation of Luys furnishes an important contribution
to the changes of the gray substance, especially  of the anterior
cornua.  For further developments of this point  we may especi-
ally refer to the numerous and careful examinations by Lockhart
Clarke.   In all the six cases described by him,  more or less
extensive changes in the gray substance were found, with especial
implication of  the anterior ganglion-cells, and in part with
changes in the white columns and the spinal roots.  The  changes
consisted partly in great dilatation and crowding of the blood-
vessels, partly  in gray softening  with  fatty granular deposits
("granular disintegration "), which must clearly be regarded as 
  PROGRESSIVE MUSCULAR ATROPHY. —PATHOLOG. ANATOMY.  187

 the result of  irrilatine inflammatory processes, and partly in
 induration with abundant hj-perplasia of connective tissue and
 atrophy of the nerve-elements.   Especially  important are  the
 changes (observed previously by Luys) in the multipolar gan-
 glion-cells of  the anterior cornua, in the description of which
 Clarke agrees  entirely with other observers (Dumenil, Schueppel,
 Hayem, Charcot, and Joffroy): brownish  discoloration, granula-
 tion, thinning and loss of the processes, diminution of the size of
 the cell-body,  and its transformation into non-nucleated angular
 bodies, which  sometimes glisten, or possess indistinct boundaries,
 with final complete disappearance of the cell.  The cause of this
 change  is  probably  without doubt  due to  the  inflammatory
 softening or hardening of the gray substance of the anterior
 cornua,  in  cases  where such inflammatory  changes  are found.
 A\ nether in other cases, as Friedreich supposes, the  atrophy of
 the ganglia is possibly due  to the  suspension of the  physical
 function of the muscle for years, may remain an open question.
   A disease confined chiefly or wholly to the gray substance is
 found noted in another series of autopsies.  Gull  found, as  the
 leading  change, a considerable dilatation  of the spinal canal in
 the cervical region, between  the  fifth  cervical vertebra and  the
 origin of the third and fourth dorsal nerves.   The cavity thus
 formed  was full of a  serous fluid ; the gray substance  had dis-
 appeared, with the exception of a thin layer which surrounded
 the cavity and could be stripped off like a membrane ; the white
 medullary strire and the roots seemed normal.   The observations
 of Schueppel  are very similar,  except  that  the  hydromyelia
 extended down to the tenth dorsal vertebra.  Hayem  also found
 the gray matter of the cervical region  exclusively affected (indu-
 rated), especially in the anterior cornua, while  the white columns
 were quite normal.    Grimm found in his  case a considerable
 enlargement of the central canal at the expense of the gray sub-
 stance, which wras flattened by pressure to a ring-shaped plate.
 The cord also  presented in its lower cervical  and  upper  dorsal
 regions a fusiform swelling, composed of  a  new formation (me-
 dullary  sarcoma).  Upon  microscopical  examination the gray
 substance appeared  composed of fine connective tissue with its
fibres much interlaced,  amongst which a few nerve-fibres and 
138   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

some atrophied nerve-cells were visible.  In the white substance
there was hyperplasia of the connective tissue along with increase
of the axis cylinders.  The nerve-roots were in fatty degeneration,
especially the finer fibres of the anterior roots.  Grimm considers
that this observation allows the hypothesis of a chronic myelitis,
as the cause of the lesions found ; he thinks the carcinoma an
accidental complication, which commenced at a later period.
   While these observers found  the gray substance the chief, if
not the only seat of alteration, there  are  not  wanting cases in
which there was nothing found but a degenerative atrophy of the,
white columns of  the cord ; this affected sometimes the antero-
lateral columns (as in Frommann's case), and sometimes the pos-
terior.  Considerable atrophy of  the antero-lateral columns was
found by Baudrimont, Dumenil (and others), though Dumenil
found it conjoined with hyperaemic inflammatoiy changes in the
gray substance and atrophy of the  ganglion-cells.  Virchow was
the first to discover in  the  posterior columns gray degeneration,
visible to the naked eye, with extensive loss of nerve-substance,
deposition of a soft substance with numberless  corpora amylacea
and longish oval granulated nuclei.  The very  same change was
observed by Friedreich in one of his six  cases ;  and in  one of
Clarke's cases, along with disease of  the antero-lateral columns
and the gray substance, there was a preponderant change in the
posterior columns ; and in the case  of Swarzenski's  from  Fre-
richs' Clinic a total transformation  of the latter was found, with
granular deposits.  For the sake of completeness let it be added
that in a few cases the posterior cornua (Joffroy), and  the poste-
rior roots  (Menjaud, Clarke, Dumenil), and the inter-vertebral
ganglia (Dumenil), were found in a state of degeneration, though
this was not confined to them.
    These positive observations upon the spinal cord are met by a
number  of negative ones, in which the organ,  including the
spinal roots, exhibited no trace of  pathological change.   In  this
class must be mentioned the older cases of Landiy, Oppenhei-
mer, Meryon, Tuerck, Colin, Friedberg ; one case by Malmsten;
three cases which are said by Duchenne1 to have  been examined
1 Electrisation localisee. 2d ed.  1861. p. 520. 
  PROGRESSIVE MUSCULAR ATROPHY.—PATHOLOG. ANATOMY. 139

post-mortem in the Paris hospitals (two by Aran, one by Axen-
feld) ;  one  from Bamberger's Clinic, and  four by Friedreich.
My summary of the cases gives a total of 34 decidedly positive
statements regarding the spinal cord, against 15 negative, which
stand recorded in literature.  The attempt to base any statistical
conclusions upon the  present  most  incomplete  and defective
material may  be  considered as  wholly premature.   The old
proverb, "Non numerandse, sed  perpendenda? sunt voces"  is
certainly applicable  here, if anywhere.
   We have to speak, finally, of the changes found in the sympa-
thetic and the peripheral nerves.  Schneevogt seems to  have been
the first to direct his attention  to the  sympathetic ;  he found
(in a case which is further remarkable for the contraction  of the
pupil)  partial softening of the cord and  atrophy of the anterior
roots, with a great amount of destructive change in the cervical
sympathetic ; the latter was  almost converted into a fatty cord,
in which the nerves were pressed aside by interjacent fat-cells
with beautiful crystals ; the cervical ganglia were almost wholly
changed into fat-cells, and the thoracic part  of the sympathetic
was also somewhat abundant in fat.   Jaccoud further found in
two  cases  (men aged fifty-seven, in  Behier's  department) an
atrophy of the anterior cervical roots, and with it a fibrous fatty
degeneration of the  sympathetic, which had made very great
progress.  The  trunk of the cervical sympathetic was absolutely
changed into fibrous connective tissue,  manifestly of very old
date, in which large deposits of fat occurred in places ; in conse-
quence, the nerve-tubes were in a condition  of  secondary atro-
phy, and that in a still higher degree than the spinal roots. The
uppermost cervical ganglion showed what seemed to be the first
stage of the process—a considerable hyperplasia of the cortical
and interstitial connective tissue, but without  atrophy of  the
nervous elements.  The rami communicantes exhibited an atro-
phy  which  corresponded with the  condition of  the anterior
roots ;  the median nerves contained a  large number of healthy
fibres, with  a fewT in a state of pathological change (simple atro-
phy, disappearance  of the medullary sheath, and even of the
axis-cylinder).  Jaccoud infers from the  age of the various pro-
cesses  that  the disease  unquestionably began  in the cervical 
140   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

sympathetic, and spread from thence both  centripetally  (rami
communicantes, anterior roots) and centrifugally (median nerves).
   Changes in the sympathetic are  also  mentioned  by Swar-
zenski (namely, thinning of  its trunk and the two uppermost
ganglia) and by Dumenil (advanced fibrous fatty change of the
cervical and thoracic portion ; abundant hyperplasia of connec-
tive  tissue ; disappearance of nerve-fibres  and regressive meta-
morphosis of the ganglion-cells).   In the  majority of cases no
examination of the sympathetic  was  probably made,  but  a
certain number of good observers testify to its integrity, as Lan-
dry,  Frommann, Menjaud, Hayem,  Charcot and Joffroy, Dume-
nil (3 cases), and Friedreich  (6 cases).   In all, therefore,  there
are 5 positive observations,  to which 14 negative are opposed.
It is  also important that Dumenil, in the one case of sympathetic
degeneration observed by him, found  also  an advanced fatty
degeneration of the spinal ganglia, and of the anterior and pos-
terior spinal nerve-roots in the region of the neck.
   In regard  to  the peripheral nerves, the great majority of
observers have reached positive results  similar to those of Cru-
veilhier and  Jaccoud, of which we have spoken; thus, Schnee-
vogt (nervus ulnaris), Trousseau (n. axillaris, medianus, radialis,
ulnaris),  Virchow,  Friedberg, Hayem, Charcot  and Joffroy, von
Bamberger, M. Rosenthal, Friedreich, and others.   The degen-
erations  were sometimes confined to the finer  intra-muscular
nerve-branches (Friedberg,  von Bamberger) ;  sometimes they
existed  in the larger  trunks  also, and even in the  plexuses
(Rosenthal).  They mostly bore the character of active irritative
processes,  with hyperplasia and  nuclear proliferation of the
outer and  inner  neurilemma,  multiplication  of  nuclei,  and
fibrillaiy thickening of the sheath of Schwann (perineuritis and
neuritis  interstitialis  chronica);  there  was  also swelling  and
varicose  dilatation  of the medullary sheath (Friedreich), with
secondary atrophy of the nerve-fibres, which in some cases were
quite extinct.   It may be that in these cases also, as  Friedreich
supposes, the atrophy of  the nerve-elements is favored by their
permanent inactivity.   In a few cases (Dumenil,  Friedreich)
examination of the peripheral nerves  gave entirely negative
results. 
PROGRESSIVE MUSCULAR ATROPHY.—ANALYSIS OF SYMPTOMS. 141

   Theory of the Disease and Analysis of the  Symptoms.

   We cannot attempt in this place to state, much less fully to
disprove, all the theories  which  have arisen in  the course of
time in relation to the nature of progressive muscular atrophy.
Most of them dispose of themselves after a little reflection upon
the preceding  clinical and pathologico-anatomical facts.   Thus,
the  theory  of  Cruveilhier,  though  ingeniously  constructed,
hardly requires a serious refutation at the present day ; and the
views of authors who placed the origin of  the  disease in the
peripheral distributions, in the anterolateral columns, or even in
the posterior columns of the  cord,  though apparently supported
by single observations, may be passed  over in simple silence.
In regard to the assumption  indicated by Schneevogt, and more
fully developed by Remak, Jaccoud,  J. Simon, and others, that
the primary affection is in the sympathetic, I have already else-
where ' expressed the opinion, after a thorough criticism of the
facts, that  neither  our knowledge of the anatomical facts nor
our physiological analysis of the  symptoms places us in  a posi-
tion  to form a final opinion regarding  the role of the sympathetic
in the disease in question.  At that time  I formulated the ques-
tions :  "Is the sympathetic regularly affected in  these cases?—
and  if  it be, does it become affected  by centripetal propagation
of the  primary muscular disease  to the peripheral nerves, the
roots of the spinal nerves, and the rami communicantes ?  Or,
vice, versa, is the sympathetic  the first to be affected, and does
the disease  extend,  on the one hand,  centrifugally  to  the
peripheral nerve-trunks  and the  muscles, and,  on the other,
centripetally to the  spinal  centres  of the  sympathetic  fibres
involved?"   The first and  principal question I  now think it
necessary to answer  definitely in the negative, in view  of the
considerable number of decidedly  negative  observations pre-
sented by thorough  observers.  With this question the  second
alternative also falls—its only support has consisted of the state-
ments of Jaccoud ; and the first alternative is at least very much
restricted by the large number of cases in which changes of the
1 Pathologie des Sympathicus. pp. 96, 97. 
142   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

peripheral nerves and the anterior roots were found, without a
secondary lesion of  the sympathetic, and without a lesion of the
rami  communicantes (Dumenil).  I therefore can  only regard
the affection  of the sympathetic, which  is unquestionably pres-
ent in some  cases of progressive  muscular atrophy, as a com-
bined affection, characterized clinically by  its special group of
symptoms (oculo-pupillary phenomena,  etc.), after  the  analogy
of the explanation, which, I believe, we must assign to progres-
sive bulbar paralysis when found combined with progressive mus-
cular atrophy.  As in the latter a transmission of the fundamen-
tal pathologico-anatomical change takes place from the cervical
cord,  or vice versa, so in the former there is a diffusion through
the rami  communicantes to the cervical and dorsal portion of
the sympathetic trunk and ganglia.
   There  remain, therefore, for discussion, only two theories of
the disease, namely, the myopathic, which  has remained essen-
tially unchanged  since Aran, and  the  neuropathic,  in the form
which it has lately assumed in consequence of the investigations
of Lockhart Clarke, Hayem, Luys, Charcot, and  others, accord-
ing to wdiich progressive  muscular atrophy is  essentially due  to
primary  alterations in the ganglion-cells of  the anterior gray
cornua, the latter appearing to stand in a relation to the nutri-
tion of the muscles which is as yet obscure and not even directly
proved.
   Those  wdio cling to  the myopathic theory can no longer,  of
course, deny the frequency of pathologico-anatomical  changes
in the nervous apparatus, and especially in the  cord;  they can
only attempt to present the muscular lesion as primary and the
nervous lesions as  secondary,  dependent on  the former. This
is the final  statement of  the  criticism which  Friedreich has
lately carried out against the neurotic theories.  Friedreich for-
mulates the  mutual relation in the following sentences: "Pro-
gressive muscular atrophy, beginning as  a primary chronic myo-
sitis, is capable of producing secondary disturbances of the ner-
vous  system, consisting  in  a chronic neuritis which attacks the
intra-muscular nerves and ascends along the course of the nerve-
trunks to the roots of  the nerves.  The neuritis may further
attack the spinal cord itself,  producing chronic myelitic pro- 
PROGRESSIVE MUSCULAR ATROPHY.—ANALYSIS OF SYMPTOMS.  143

cesses, which are  capable of  extending in  various directions in
the  cord.   The inflammation which is  propagated within  the
nerve-routes  may come to a halt at any point  in its course, and
the  extent to wdiich  the  disturbance of  the nervous  apparatus
reaches is  essentially dependent  upon the degree of  activity of
the  changes  in  the  tissue which are taking place in  the muscle
and furnish the source of irritation.  Besides this, certain regres-
sive disturbances of nutrition of  the  peripheral nerve-fibres, and
of the ganglion-cells of the gray  anterior cornua of the cord, are
to be considered as the results of  disturbed motor function."
   Without desiring to express a decided  opinion—for I consider the question not
yet ripe, not even since Friedreich's work—I wish  nevertheless to call attention to
a few deficiencies which I think still  exist in Friedreich's demonstration.  When
Friedreich adds, after the words we have just quoted, " only by this theory can the
great variety of morbid conditions  found  in the nervous system in single cases be
naturally explained," it is hard to understand him;  we should expect,  on the con-
trary, in  the case  of an inflammatory process which  begins at the  periphery and
travels, by pre-existing paths, in a centripetal direction, to find  a  most constant
and unvarying set of changes in the said nervous organs.  If, moreover, the  lesions
of the cord are to be regarded as the final results of an inflammatory process con-
tinuously ascending in the nerve-paths, it should be assumed that in all  cases, where
degenerative  changes of the gray substance, especially of the anterior cornua, are
present, there will be demonstrable changes also in the peripheral nerve-trunks, the
plexuses,  and the anterior spinal roots.  But this is so far from being  the  case that
Friedreich's neglect to see  this circumstance, or the slight importance  he attached
to it in connection with the theory,  cannot but surprise us.   I will simply  call to
mind cases, such as for instance that described by Clarke and Gairdner, in which
there was an advanced myelitic softening in the cervical part and down  to the third
dorsal nerve,  while the nerve-roots showed no sign of disease; or the  case by Gull,
previously cited, where there was hydromyelia with disappearance of  the gray sub-
stance, without changes in the nerve-roots.  Among  the nineteen cases above men-
tioned, in which there was no change  at all in  the  anterior spinal roots, there  are
several in which  changes of  the spinal cord, sometimes extreme, were present (Vir-
chow, Frommann, Joffroy, Frerichs, and others).   It is of course impossible to say
that these cases were insufficiently investigated; we have only to give up the attempt
to explain them according to a programme.  It is hard to make those  other cases
agree with Friedreich's theory, in which there were  no  changes, or but very slight
ones, in the peripheral nerve-trunks,  while there was advanced  atrophy of  the
anterior roots, and in some cases great alterations of the spinal cord.   The theory,
frequently resorted to by Friedreich, which makes the suspension  of muscular ac-
tion (originating in  an affection of the muscles), slowly and incompletely as it is
accomplished, to be of and  by itself the cause of regressive  disturbances of nutri- 
144   EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.
tion in the peripheral nerve-fibres, and the ganglion-cells of the anterior cornua, I
cannot regard as justified;  neither physiological facts, nor those of experimental
pathology, nor clinical evidence, give a sound support to this assumption.
   The arguments drawn by Friedreich from the manner of progression of the mus-
cular affection and from etiology, I am compelled to regard as equally far from
conclusive.  The etiological facts arc at  least thoroughly ambiguous,  and bear
as  much upon the nervous system as upon the  muscles—e. g., the influence of con-
genital diathesis,  over-exertion, traumatic lesions, etc.  Certain facts also, con-
nected with the manner of extension of the disease, are inconsistent with the
assumptions of the myopathic theory ;  such facts are: the way in which the disease
will remain at a standstill in a muscle, the entire integrity of some bundles of mus-
cles while the disease is making progress elsewhere, the immunity of muscles close
to a diseased point, and the leaping over of the disease to distant muscles, etc.

    The myopathic  theory meets  with a special difficulty in the
frequent co-existence of an undoubted neurosis, progressive bul-
bar paralysis,  with progressive muscular atrophy.  In such cases
the  symptoms  of  the bulbar  paralysis sometimes appear  first,
but more commonly are  developed  after  the muscular atrophy
has commenced.  Friedreich thinks  that in the former case there
has been no true progressive  muscular atrophy, but a paralysis
with secondary atrophy,  caused  by progression of the myelitic
process from the medulla  oblongata to the fibres of the pyra-
mids and the motor organs of the spinal cord (antero-lateral col-
umns).   But the clinical  phenomena and the express statements
of those authors who have observed the combination in question
(Trousseau, Stein, Leyden, and others) are not very favorable to
this  attempted interpretation.   In  the latter case (as in the
observations of Dumenil, Duchenne, Valentiner, Wilks,  Leyden,
and others), Friedreich says that the muscular atrophy is to the
bulbar paralysis  as cause to effect.   He regards  as the  mediate
cause a  neuritis,  which ascends  from the affected muscle along
the nerve-tracks to the cervical part of the cord, extends into the
medulla oblongata, and finally reaches the fibres of origin of the
motor nerves of the head, Avhich  lie together on the floor of the
fourth ventricle.   But we have already seen how doubtful  this
chronic  ascending  neuritis is.   No great  importance  can be
attached to the  circumstance that  the upper  extremities are
chiefly  or exclusively attacked  in all this class  of progressive
muscular hypertrophies,  for this is simply a general rule. 
PROGRESSIVE MUSCULAR ATROPHY.—ANALYSIS OF SYMPTOMS.  145

   Far simpler and more natural is the theory established by
Charcot and  accepted by Kussmaul, which  refers the frequent
combination  of progressive muscular atrophy  and progressive
bulbar paralysis to the genetic relationship  of  the two diseases
from the neuropathic point of  view.   Both are due to analogous
chronic changes (irritative atrophy) of motor  ganglion-cells.  In
progressive bulbar paralysis these changes affect  the  groups of
motor  cells lying in the floor of the fourth ventricle, while in
progressive muscular atrophy the cells of the anterior cornua are
attacked,  gradually and successively,  so  that  many  of  them
remain unharmed in the worst  spots until the latest period of the
disease.  The latter circumstance also explains the fact that the
trophic disturbances seldom affect all the primitive bundles of a
muscle at  once, and  that the muscle still reacts to voluntary or
electrical  stimulation,  even when its bulk is greatly lessened.
The degenerative process itself, as Kussmaul states, has no spe-
cific  character.   We find both the  ordinary gray degeneration
and  the  chronic  indurative   myelitis,  red  softening,  Clarke's
"granular disintegration," or  isolated pigmentary degeneration
of cell-elements.  All these have in common  only the loss of the
large ganglion-cells, which  takes  place in the successive manner
above insisted upon.  The distinction between progressive mus-
cular  atrophy and  bulbar  paralysis  must therefore be sought
only in the difference of location  of the original seat of the dis-
ease ; the  cause of  their combination, only in the  extension of
the primary process.
   Among the separate symptoms of  progressive muscular atro-
phy, the affection of the muscle itself needs no further explana-
tion, as the material necessary for its  comprehension, either from
the myopathic or the neuropathic point of view, is contained in
the preceding sections.  The explanation of the collateral symp-
toms will naturally differ, according as it is drawn from the myo-
pathic  or the  neuropathic theory; but many of them will be
seen to admit but a forced  and unsatisfactory explanation from
the myopathic point of view.  This, for  example, is plainly the
case with the  disturbances of sensibility,  which belong to the
          VOL. XIV.—10 
146   EULENBURG.—VASO-MOTOR  AND TROPHIC NEUROSES.

beginning or the course of the disease.   They are scarcely com-
patible with the assumption of a primary chronic myositis, but
may be explained  naturally by a  primary affection of the spinal
cord, which, as the examinations show, not seldom extends to
the entire gray substance, and in  some cases to the posterior col-
umns and the posterior root-fibres.  The fact that common sensa-
tion is usually more  affected than that of touch, and in some
cases (Mosler and Landois) is exclusively affected, agrees entirely
with a supposed original disease of the gray substance, and the
increased reflex excitability which is observed in  a few cases
may be most naturally referred to the same.
   Local differences of temperature can, at any rate, be regarded
as a result of the myositic process, which first leads to a rise of
temperature, and  later,  when the atrophy is developed,  to a
depression of temperature.  It is harder to explain many local
disturbances of circulation (cyanosis, arterial spasm), and the
frequently associated  atrophy of the integuments, and the arthro-
pathy.   These are more  easily approached by the  neuropathic
theory, as they, after the  analogy of other diseases of the spinal
marrow,  may be referred to vaso-motor-trophic disturbances of
innervation, of spinal origin.
   The oculo-pupillary symptoms, of course, depend either upon
disease of the cervical sympathetic or of the anterior roots, or of
the cervical  spinal cord in the  neighborhood of the  last two cer-
vical and the upper  dorsal nerves.   Voisin concludes from his
case (before described), in which vaso-motor disturbances, eleva-
tion of temperature,  etc.,  wrere absent, that the sympathetic can-
not be the starting-point of those symptoms, but  the anterior
roots, since section of the  latter, according to Bernard, produces
contraction of the pupil and flattening of the cornea.  Neverthe-
less, Bernard's statement that the fibres of the vascular nerves do
not run in the anterior roots, but all originate from ganglia of
the  sympathetic,  is  not  in agreement  with  the  statements of
other observers (Schiff).    Besides, we often see  only  oculo-
pupillary and no vaso-motor-thermic symptoms in  cases of un-
questionable lesion of the  cervical sympathetic. To enter further
into these  questions  is not  now suitable,  as the symptom in
question is a very rare one. 
       PROGRESSIVE MUSCULAR ATROPHY.—TREATMENT.     147

   Among the general symptoms,  the  fever which occurs in  a
few cases may be probably derived from the polymyositis.  The
hyperidrosis, which is a special concomitant of later stages, and
is  sometimes partial and unilateral, sometimes universal, is  a
symptom which may without doubt be of central or sympathetic
origin (compare "Basedow's Disease"); but perhaps Friedreich's
explanation is also admissible, namely,  that there is a collateral
fluxion to the cutaneous vessels, caused  by obliteration of a large
number of the finer muscular vessels in  the rapid atrophy of the
muscles.   The hyperidrosis  should therefore be interpreted like
the sweats of trichina disease and tetanus, wdiich are equally due
to collateral arterial hyperemia of the skin, dependent upon the
impeded muscular circulation.


           Diagnosis, Prognosis, and Treatment.

   The diagnosis may present difficulties in the  initial stage of
the disease.  It is especially possible  to confound the disease
with: a. genuine muscular atrophy, caused by direct, mechanical,
traumatic agencies, as  the atrophy of  the interossei from pres-
sure ; b. secondary  muscular  atrophies in neuritis, which are
likewise generally due to mechanical  traumata or to  rheuma-
tism. To  one or the other of  these categories  it is certain that
many cases belong which are noted in literature as progressive
muscular atrophy, and are said  to  have originated in traumatic
or rheumatic injuries, etc.  If the disease at a later period remains
confined to the muscles originally affected, or to the region of  a
single nerve-trunk, progressive muscular atrophy can be  ex-
cluded ; we have nevertheless already given cases in which exten-
sive  atrophies,  in the  form  of  "myopathia  propagata," have
developed from an originally circumscribed seat of disease.  (Cf.
"Etiolog}^.")   I have also spoken there of the  doubt whether
these forms can be counted as muscular atrophy in its stricter
sense.  It  is hardly possible to confound the disease with central
or peripheral paralysis or paresis (though often accompanied by
secondary atrophy^, if we pay attention  to the history of the case,
its origin,  the suddenness or gradualness of the appearance of
the disturbance of function, the simultaneous or successive attack 
148   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

of the muscles, etc.  Certainly there are also forms of paralysis
of central  origin, in which a  gradual diffusion of the  primary
morbid  process, or its appearance in  multiple  localities, may
cause numerous muscles to be successively attacked ; but these
very forms are easy to distinguish, as  they are  in general  fol-
lowed by no emaciation of the muscle, or at most by a tardy and
slight wasting.  In doubtful cases the symptoms of myositic  irri-
tation (fibrillary  twitchings,  etc.), and the results of electric
examination, and above all,  the microscopical  examination of
fragments  of muscle wdiich have been extracted, may lead  to a
conclusion.  Of the mistakes arising from secondary lipomatosis
of atrophied muscles we have already spoken under " Symptom-
atology."
   The prognosis  of progressive muscular atrophy is generally
unfavorable, but it is by no means so absolutely hopeless as  was
supposed when the disease wTas  first known, and as is still sup-
posed by many.  The  possibility of saving at least a part of the
muscles attacked  cannot be denied as long as there exist in it
uninjured or slightly injured muscular elements—as long, there-
fore, as voluntary motility and the  electrical reaction are not
completely lost.  The  volume  of the  muscle is, however, not  a
means of estimating the condition, since, as we have seen, its  vol-
ume may be increased  even wdien the proper muscular substance
is wholly destroyed.   The prognosis as regards life is deducible
from the remarks upon the general progress of the disease.  Cases
are to be considered especially unfavorable which begin in a mul-
tiple form and  with a tendency to a rapid course ; the prognosis
is decidedly less favorable when the disease co-exists with a dis-
tinct congenital diathesis, or is accompanied  by constitutional
neuropathies,,, or preceded  by  bulbar paralysis, etc.  Finally,
those cases are less promising in which the disease takes its ori-
gin in the muscles of the shoulder or thorax, or passes rapidly
to  them, because  this complication  may  affect  to a dangerous
extent the accessory muscles of respiration.
    The  treatment of  the disease has many successes to boast;
but to gain them it is necessary to  begin as early as possible,
and to persevere with untiring patience  as long as possible!
Both the public and  the physician  often sin against both these 
       PROGRESSIVE MUSCULAR ATROPHY.—TREATMENT.     149

precepts.  I have repeatedly had the good  fortune  to discover
the disease in a very early stage,  when it was just attacking the
interossei ; but, failing to convince the patients of the gravity of
their trouble, and to persuade them to adopt an energetic treat-
ment, I have  seen the  disease develop to an incurable extent
after months and years.  Every specialist in this department has
probably had similar experiences. Unfortunately, I cannot deny
that the attending physician, through indolence or mistake, does
not always show the degree of energy and  perseverance in the
treatment which is so especially desirable in  this complaint.
While in so many other cases we are obliged  to resist the  ten-
dency to  multiply useless remedies, in this  case the  policy of
laisser alter is always to be rejected.
   The treatment may  be in part prophylactic; for in cases of
inherited  tendency, congenital predisposition, etc.,  the subject
should be strengthened by a vigorous course of life, especially
by a rational and regulated course of gymnastics, and should be
prevented, if possible, from selecting a harmful profession, from
excessive exertions, from  rheumatic  attacks, etc.   When the
disease has once appeared it may sometimes be a pressing  neces-
sity to give up the profession adopted,  especially  if injurious,
and to change to one less harmful.  It  is true that we shall but
rarely succeed in getting  our advice adopted;  it is just as in
cases of  co-ordinative  professional  diseases (writer's cramp and
the like); there are usually external difficulties, and often  still
greater internal ones, which prevent  the change being made ;  and
yet there are  a few successes  obtained  with intelligent and will-
ing patients, which must console us  for our numerous failures to
persuade.
   Absolutely nothing is to be expected of internal remedies ;  it
is necessary to give a formal warning against them,  lest the
patient (as too easily happens) neglect the really important arti-
cle of treatment under the belief  that he  is "doing something"
for himself.   In  addition to the tonics (quinine, iron), especial
use has been  made of  nitrate of silver, based on its occasional
success in locomotor ataxia ; also of arsenic, iodide of potassium,
strychnia, and so forth.  In the case of some patients who obsti-
nately refused an electrical and gymnastic treatment, I have been 
150   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

able to use strychnia for a long time, both  internally and in the
form of subcutaneous injections; but  in spite of long  persever-
ance and large doses, wdiich  produced slight symptoms  of intoxi-
cation, I never saw any effect  whatever  from  the use  of  that
remedy.
   The only suitable and really trustworthy remedies are electri-
city and medical gymnastics.   The latter  is perhaps  too much
neglected,  since the  introduction into practice  of  the constant
current  and  the great  advances made in electro-therapeutics
have raised the latter to the reputation of  being almost a sove-
reign  remedy in many diseases  of the nervous and  muscular
apparatus.  Yet undoubted successes have followed  the use of
suitably localized gymnastics2 in this disease, and it  is easy to
see,  from  the theoretic point of view, that we possess in these
active and passive motions an agent of especial efficacy  in respect
to the interstitial changes within  the muscle.   Its  employment,
of course, never constitutes  a reason for not using  electricity at
the  same  time.   Formerly  electricity was applied only in  the
form of induced current, by the local use of wdiich  Duchenne
obtained favorable results.  But of  late the constant current has
gained reputation and deservedly, since there are cases in which
the faradic excitability of the muscles is completely lost, while
the  galvanic  may be in  some slight degree retained,  and since
tolerable success has been  achieved, even in this class of cases,
by persevering galvanization.

   Opinions  are widely at variance in regard  to the most suitable way of applying
the constant  current; they are, of course, much influenced by  the  prevalent theories
of the disease.  Remak, in accordance with the views already stated, recommended
the so-called galvanization of the sympathetics, which has been observed to be fol-
lowed by good results in  the hands of Benedikt, M.  Meyer, Guthzeit, Nesemann,
Erb (in Friedreich), and others.  Of especial  interest is the case of advanced pro-
gressive muscular atrophy, described in full  by Nesemann, in which galvanization
of the sympathetic produced a  complete cure.  In this case, however, a relapse is
said to have  occurred, which did not yield to  the previous method of treatment. M.
Rosenthal observed no benefit from galvanization of the sympathetic ; neither have
   'Cf. M. Eulenburg, Deutsche Klinik. 185G. Nos. 11-14. In a case which has re-
cently fallen under my observation the process of massage, performed in Holland, was
said to have brought the disease to a standstill. 
        PROGRESSIVE  MUSCULAR ATROPHY.—TREATMENT.      151
I ever observed any special benefit from its use, and  for a considerable time have
confined myself in treating this disease to peripheral galvanization and faradization,
which has given me results at least as satisfactory as when I have combined central
applications with them.  As regards details, I will here only state that local gal-
vanic treatment, especially in old cases and when muscular excitability is very low,
often requires at the outset extremely strong currents and methods of application
(interruption, reversal, etc.) ; but, as the excitability increases, weaker currents may
gradually be employed.

   Regarding the balneo-therapeutic treatment, we  have as yet
no observations to be trusted.   Scarcely anything could dpriori
be expected from the usual four weeks' courses in water-cures,
in such a chronic  and  severe  complaint; and the considerable
number of patients  who, with or without their physicians'  orders,
make journeys to the warm baths, cool baths,  or sulphur baths,
can only furnish a subject of regret  to  those who know  that
their time and money are simply wasted. 
 
PSEUDO-HYPERTROPHY  OF  THE  MUSCLES.

             (Pseudo-hypertrophia  musculorum.)
Coste and Gioja, Annali clinici dell' ospedale degli incurabili  di Napoli. 1838.—
    Meryon, Med. Chir. Transactions.  Vol. 53. 1852.  p. IZ.—Rinecker, Vhdlg. der
    phys. med. Ges. zu Wurzburg.  Bd. X.  18G0.—Duchenne, Electrisation localisee.
    2e C'd. 1801.—Spielmann, Gaz. mod. de Strasbourg.  Mai, 18G2.  No. 5. p. 85.—
    Kaulich, Prager Vierteljahrschrift. 1862. Bd. 73. p. 113.— Berend, Allg. med.
    Centralztg.  1863.  No. 9.—Griesinger, Archiv der Heilkunde.  1864. 6. Jahrg.
    p. 171.—Duchenne fils, Arch. gen. de med. Aout.  1864.  p. 191.—Fritz, Gaz.
    hebd. 1865.  No. 34.  p. 529.—Stoffella, Zeitschr. d. k. k.  Ges. Wiener Aerzte.
    1865.  2. Jahrg. Heft 1.  p. 85.—Eulenburg sen.,  Berlin, klin. Wochenschrift.
    1865.  No. 50.—Eulenburg and  Cohnheim,  Vhdlg. der Berl. med. Ges.  1866.
    Heft 2.  p. 191. — Griesinger,  ibid. p. 207.—Sigmundt, Deutsches Archiv f.
    klin. Med. Bd. 1.  Heft 6. I860,   p. 630.—Heller, ibid. p. 616.  Bd. 2. Heft
    6.  1867.  p. 603. — Tuefferd, Essai sur la  paralysie avec surcharge graisseuse
    interstitiellc, these.  Strasbourg, 1866.— Wagner, Berl. klin.  Wochenschr.  1866.
    No. 18.—Seidel, De Atrophia musculorum lipomatosa.  Jena, 1867.— Wernich,
    Deutsches Archiv f. klin. Med.  1867.  Bd.  2.  p.  232.—Guttmann, Ueber soge-
    nannte Muskelhypertrophie (Habilitationsvortrag).  1867.—L. Hoffmann,  Ueber
    die sogenannte Muskelhypertrophie.   Inaug.  Diss.  Berlin, 1867.—Lutz, Deut-
    sches Archiv  f. klin. Med.  1867. Bd. 3. p. 358.—Bergeron, Gaz. des hop.
    1867.  No. 63.—Roquette, Ueber  die  sogenannte Muskelhypertrophie.  Diss.
    Berlin, 1868.—Duchenne, Arch.  gen. de med. Jan.—May, 1868.—Adams, Trans-
    act, of the Pathol. Soc. of London.  1868. Vol.19,  p. 11.—Hillier, ibid.  p.
    12.—Benedikt, Elektrotherapie.  Vienna, 1869. — Jaccoud, Traite de pathologie
   interne. Paris, 1869. I.—Russel, Med. Times and Gaz. May 29,  1869.— B. Fos-
   ter, Lancet. May 8, 1869.—Dyce  Brown, Edinb. Med. Jour. June, 1870.  p.
    1079.—A  Eulenburg, Virchow's  Archiv.   Bd. 49.   1870.  p. MS.—Martini,
   Centralblatt f. d. med. Wissenschaften. 1871.  No. 41.—L. Auerbach, Virchow's
   Archiv. Bd. 53. pp. 234 and 397—A Eulenburg,  ibid. p. 361.— Chvostek, Oes- 
 154   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.
    terr.  Zeitschr. f.  prakt. Heilk.  1871. Nos. 38-40.—Barth, Archiv der Heil-
    kunde.  1871. Bd. XII. p. 121.— Pepper, Philad. Med.  Times. 1871. I. Nos.
    18 and 19.—IF. Midler, Beitriigezur pathologischen Anatomie und Physiologie
    des menschlichen Ruckcnmarks.  Festschrift.  Leipzig, 1871.— Charcot, Arch.
    de phys. normale ct pathologique.  1872. No. 2. p. 228.— Benedikt, Wiener
    med. Presse.  1872. No. 9.—0. Berger, Deutsches Archiv f. klin. Med. Bd. IX.
    p. 363.—Knoll, Wiener med. Jahrbiicher.  1872. Heft 1.  p. 1. —Rakowac, Wie-
    ner mod. Wochenschrift.  1872.  No. 12.—Barsickow, Zwei  Familien mit Lipo-
    matosis musculorum progressiva.  Dissert.  Halle, 1872.—Billroth, Archiv f.
    klin. Chirurgie.  1872. Bd. XIII. p. SV5.—IIitzig, Berl. klin. Wochenschrift.
    1872. No. 49.—Friedreich, Ueber progressive Muskelatrophie, uber wahre und
    falsche Muskelatrophie. Berlin, 1873.—Schlesinger, Wiener med. Presse. 1873.
    Nos. 49 and 51.—Uhde, Archiv  f.  klin.  Chirurgie. 1873.  Bd. XVI. Heft 2.—
    Huber, Deutsches Archiv f. klin.  Med.  1874. Bd. XIV.  Heft 2.

    The disease denominated Pseudo-hypertrophy of the muscles
is clinically characterized  by an abnormal increase of size in
certain muscles,  accompanied by a  diminution or loss of their
functional energy, the  direct cause of which  is a chronic dis-
turbance in  the  nutrition of such  muscles {new formation of
connective and fatty tissue, atrophy of the proper muscidar ele-
ments).   The disease is  certainly very closely related to  progres-
sive muscular atrophy, and is perhaps only a modification of
the latter, due to peculiar circumstances.


                             History.

    Of the cases  belonging to this class, the first  are those of
Coste and Gioja (1838),  Meryon (1852),  and Rinecker (1860) ; but
the  diagnosis from the descriptions  given is not at all certain.
The credit of having been the first to state the specific quality of
the disease,  and  to  point out distinctly the contrast between the
weakened function of the muscle and its excessive size, belongs
unquestionably to Duchenne, who in 1861 published such a case
under the name of "paraplegie  hypertrophique de l'enfance  de
cause cerebrale."   This was  soon  followed by publications from
Kaulich(from Jaksch's  clinic), Spielmann (from  Schutzenberger's
clinic),  Stoffella,  and Griesinger, the latter  of  whom first sub-
mitted  excised portions of muscle to  microscopic tests (applied
by Billroth).  The first complete report of an autopsy was pub- 
PSEUDO-HYPERTROPHY OF THE MUSCLES.          155
lished by  M. Eulenburg  and Cohnheim  in  1866 ;  the result
in regard  to the  nervous system  was  negative;  a monograph,
summing up what was  then known, was  published  soon  after
by  Seidel.    Since  then the  material  has been  increased  by
the addition of a number of  cases, which, excluding doubtful
ones,  may amount to  110,  while the clinical  knowledge of the
disease has been greatly promoted, and the nature of  the patho-
logico-anatomical  process lying at the base of  it has been much
discussed.  But the latter  point, as  regards the muscle, is still
sub jud.ice; as for the  question of  implication of the  nervous
apparatus,  either  primary or secondary, there does  not  exist at
present sufficient  material  for  an exact discussion of  it,  and  we
are compelled to  take refuge in simple hypotheses and possibili-
ties.  In  the last few years  progress has been made in two
respects: on the one hand,  more and more stress  is laid on the
connection  between  pseudo-hypertrophy  and progressive mus-
cular atrophy; and on the other,  attempts  are making to distin-
guish the disease  in question from  one far rarer, which has  been
incorrectly  classed with  it, namely, true hypertrophy of muscle
(L.  Auerbach,  Berger, Friedreich).  We shall speak of the latter
disease in a special chapter.

  Synonyms.—Recent as  is our knowledge of the  disease, and scanty as  is  the
literature, the  number  of names proposed for  it is nevertheless large.  This is a
suitable place to  enter complaint  against an  ill  fashion  which is  growing into
repute, that every author who publishes a single  case of  disease thinks himself
bound to clap  to it a new name, whereby he only adds a fresh and needless obstacle
to a common  understanding.  No name can fully and exhaustively express  the
nature of a disease, more especially of one so obscure and so little explained ;  under
such circumstances, the best designation is always the most neutral, the most indif-
ferent, which simply refrains from premature judgment and avoids positive error.
Such a designation, for example, is  that of "pseudo-hypertrophy." The expression
" muscular hypertrophy,"  used by Kaulich,  Stoffella, Griesinger, and  others, is
unsuitable, as neglecting to take into account  the distinction between true and false
hypertrophy.   Of  the other designations we will mention the following : Paralysie
musculaire  pseudo-hypertrophique,  or paralysie myosclerosique (Duchenne);  para-
lysie avec surcharge graisseuse interstitielle (Fritz, Tuefferd); sclerose musculaire
progressive (Jaccoud); lipomatosis musculorum  luxurians progressiva  (Heller);
atrophia musculorum  lipomatosa (Seidel); diffuse muscular lipomatosis, myopa-
chynsis lipomatosa (Uhde).  By way of criticism upon these and similar terms, it
will suffice to say that the expression "paralysis" does not  correspond with  the 
156   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.
clinical nature of the disease, while the expression " lipomatosis" involves a view
of the histological changes in the muscle which is one-sided,  though not incorrect.


                           Etiology.

   In estimating the causal elements of the disease, our atten-
tion is very  strongly called to the predisposing effects of age
and sex.  As in progressive muscular atrophy, by far the great-
est number belong to the male sex ; of 86 that are adequately
reported, 70 occurred in males  and only 16 in females, which
constitutes a ratio of nearly 9 : 2.  This predisposition of the
male sex is shown still more strikingly by the circumstance that
when several cases occur in a family the male members are some-
times the only ones affected.  In regard to the age, there  is an
apparent difference from muscular atrophy, since pseudo-hyper-
trophy makes its appearance chieffy during childhood, and, as a
rule,  before  the  close of the tenth year.  Among 80  cases, in
which it was possible to  establish the date of commencement
with  accuracy, it began in the period from the first to the fifth
year  45  times;  from the sixth to the tenth, 22 times; from the
eleventh to the  sixteenth,  8 times; five  times the disease made
its  first  appearance in later life, or at least was first  observed
in adult men and women (aged 26, 30, 40, 41, 43  years).  As
Friedreich says, the disease seems to develop later on an average
in women than in men ; in one of the cases observed by me in
the female sex this  was the fact,  as the disease first appeared
at a ripe age, but in  three other cases it began in the eighth year.
   The influence of heredity and congenital tendency is felt here
just as  in  progressive muscular atrophy, in  the appearance of
the disease among numerous members of one family (Barsickow
tells of twenty-four  cases in two families), and  especially when
brothers and sisters are attacked successively  at the same age.
Cases of two children of the same parents being attacked are
numerous ; cases of  three brothers are reported by Heller, Wag-
ner, and Seidel; of  three  sisters, by Lutz and myself; of four
brothers, by  Meryon.   It  is interesting that  the three brothers
observed by Heller had two fathers ; their mother and two sisters
were healthy, but a brother of the mother seems to have suffered 
           PSEUDO-HYPERTROPHY OF  THE MUSCLES.         157

from a similar complaint.   These facts, as in progressive muscu-
lar  atrophy,  permit us to assume a  diathesis as furnishing  a
foundation for the disease, at least in  many cases ; but in both
diseases we are forced to confess our ignorance of the ultimate
nature  of  the diathesis,  and  especially to  leave  undecided
whether it should be regarded as a pre-formed morbid disposition
in the muscular apparatus, or  in certain  (central, myotrophic)
sections of the nervous  apparatus.   In favor of a neuropathic
diathesis, and of an assignment of the disease to the group of
so-called constitutional neuropathies,  the  circumstance may be
mentioned  that in some cases  (not to speak of the frequent cases
where progressive muscular  atrophy  co-existed)  certain  neuro-
pathies, as insanity (Duchenne, Benedikt,W. Mueller, Schlesinger),
have  coexisted, or have preceded the  pseudo-hypertrophy. In
a few (Duchenne, Benedikt), epileptiform convulsions are  said to
have  preceded the appearance of the disease.  In several other
cases the patients (children) possessed  a specially low degree of
intelligence, or there were also anomalies in the external develop-
ment of the skull, either hydrocephalic configuration (Coste and
Gioja, Duchenne, Friedreich),  or asymmetry (Roquette, Hoff-
mann).  Of circumstances of a  more accidental nature which may
have been related to the development of the disease, atmospheric
influences — such  as  frequent over-heating  and  chilling—and
damp, cheerless dwellings, and poverty, are mentioned.  In a few
instances the patients had previously suffered with acute diseases,
especially measles (Stoffella, Griesinger, Hoffmann), or protracted
scrofulous  affections (Wernich,  Seidel); in one case the cause is
said to have been a fall from bed in the fourth year of age.

                    Symptoms and Course.

   The cardinal symptom  is  increase  of volume with simulta-
neous impairment of function in certain voluntary muscles ; as  a
rule it is the muscles of the lower legs, though often also those of
the thighs, which  exhibit  the symptom, either  exclusively, or
at least first  of all,  and most prominently.   While,  therefore,
ordinary progressive muscular atrophy is characterized by the
upper extremities being first affected, and  in these parts  certain 
158   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

muscles of the hand or shoulder first of all, we see in  pseudo-
hypertrophy,  especially if  it  occurs  in childhood, the  lower
extremities first attacked, and in these certain muscles of the
calf, as the gastrocnemius and soleus.  The development of a
considerable excess of volume does not usually occur until the
symptoms of diminished functional energy have existed for quite
a time.  The  latter are especially marked  in standing and in
locomotion.   The children  show  an increasing  uncertainty in
walking, tire very quickly,  fall easily, and cannot rise  without
help.  By degrees it grows harder to stand without support, the
gait becomes  waddling,  or  the child  in walking straddles, de-
presses the point of the toe and raises the inner edge of the foot.
As  the process  extends to  the thighs, sitting down and  rising
from the sitting posture become extremely difficult; in the former
act the patient lets himself drop mechanically upon his seat, and
in the latter he seeks to assist himself by bracing his hands firmly
against his thighs,  unless  this manoeuvre  is rendered impos-
sible by progressive muscular atrophy of the muscles of the arm,
which often co-exists.  If he is examined while lying on his back,
the legs are usually found spread apart, especially at the knees,
while the feet  are nearer each other ; the latter are in the position
of pes varo-equinus, with the soles turned  toward each  other,
the  heels drawn  up quite high, the knee and hip-joints flexed.
Plantar or dorsal  flexion of the foot is executed badly or not at
all; the same is  true of supination  and pronation, while the
extension and flexion of the  toes are usually unimpaired.  Of the
movements accomplished by the muscles of  the thigh, extension
at  the knee-joint is usually  the first to suffer ; adduction and
inward rolling of the leg is also made difficult, while flexion at
the knee is often unaffected.   If the function of the ileo-psoas is
impaired, the patient  is no longer able to  draw up the thigh to
the  body,  or  to raise himself from a dorsal decubitus  to the
sitting posture.   When the impairment of function is very slow
in its progress, so that the  patient continues to walk and  stand
for a comparatively long time, peculiar changes in the carriage
of the body are developed, namely, a considerable lordosis of the
lumbar portion of the spine and a compensatory kyphotic curve
in the dorsal portion. 
           PSEUDO-HYPERTROPHY OF THE MUSCLES.        159

   This position is probably caused by the instinctive effort to
obtain a surer  support for balancing the trunk upon the lower
extremities, by  moving the centre of  gravity forward, and thus
preventing the  body  from falling forward.  At a later period
the kyphotic  position may be very much  exaggerated, owing to
an implication of the muscles of  the  loins and  back, especially
the quadrati lumborum and sacro-lumbales ; or, if the muscular
affection is mainly limited to one  side, a strongly marked scolio-
sis arises.
   These  progressive  impairments contrast  strongly with the
outward appearance of the parts attacked.  The leg and foot,
and often the thigh also, look uncommonly large and volumi-
nous,  and are more or less enlarged in circumference.  In  cases
where the process begins upon one side or remains unilateral, it
is easy to ascertain the increase by measurement; but it is often
sufficient to compare  the patient's leg with that of a well  child
of the'same age, and in many cases a brief period of observation
suffices to demonstrate a considerable growth,  especially in the
calf.  The parts hypertrophied, when felt by the hand, usually
give the impression of a spongy, hard-soft mass of fat,  a great
lipoma, without a trace of muscular tension and resistance.  In
advanced cases  this is true both of the calves and of the  muscu-
lar masses of  the front and outside of the leg, and the front and
inside of the thigh ; sometimes also of the posterior pelvic and
dorsal masses.  It can often  be demonstrated  that the spongy,
lipoma-like feel depends greatly upon  an increase of the sub-
cutaneous fatty tissue, and is therefore most noticeable in places
where nature has  provided an abundant panniculus.   On the
other  hand, single muscles often exhibit a strikingly firm and
hard consistency, although they may be more or less deficient in
functional power, and even completely  insensitive  to the elec-
trical  stimulus  or that of the will.  These  differences  in con-
sistency are dependent on the fact that the disease is sometimes
limited  to excessive lipomatosis,  while  in other cases  this is
combined  with  extreme  proliferation of  interstitial  connective
tissue  and retraction  of the  newly  formed  tissue.  (Compare
"Anatomy of the Disease."')
   When  the disease  ascends  and  finally attacks  the  upper 
160   EULENBURG.—VASO-MOTOR AND TROPHIC  NEUROSES.

extremities, it seldom does so in its original form ;  the form of
ordinary progressive muscular atrophy is  much more frequent,
and we may observe a combination of the latter, in the arm, with
a pseudo-hypertrophy of the muscles of  the  trunk and lower
limbs (or of the legs  below the  knees only).  This is especially
the case with children, but may also occur in adults, as is seen
in a case observed by me (a cook aged forty-four), in wdiich there
was  pseudo-hypertrophy of one lower  extremity,  with great
atrophy of the upper extremities.  On the other hand, there is a
disease which does occur in adults, and which deserves the rank
of a  special form  of disease,  under the  title of " hypertrophia
musculorum progressiva adultorum " (Benedikt), in which the
arms,  especially the  shoulders, are the  regions first attacked,
with hyper-volumen of the  muscles affected.   But  these cases,
for reasons later to be stated, must probably be counted in with
the form of disease designated as " true muscular hypertrophy."
The process in pseudo-hypertrophy is not such  that  an increase
of volume can be detected at one given time in all of  the muscles
of the lower limbs and trunk which are diseased (i. e., function-
ally weakened), for muscles  which are extremely hyper-volumi-
nous  may  lie side by side  with  other  muscles  which,  while
equally feeble, are yet lax, flaccid, and reduced in volume.  The
cause of  this difference  can only be explained by anatomical
explorations.  We can only speak here of our  previous remarks
upon the  secondary and compensatory lipomatosis  of the atro-
phied muscles which accompanies progressive muscular atrophy.
Finally, it  remains to be said that the invasion and progress of
the disease is  not  always symmetrical, and that, even after the
disease has lasted a long time, the hyper-voluminous muscles of
one side may correspond to muscles of normal or even less than
normal volume on the other side.  In the above related case of
pseudo-hypertrophy and progressive atrophy in an old lady, I
saw  a preponderant affection of the left  lower and the right
upper extremity.  I have observed  a similar crossing in several
other cases.
   As in progressive muscular atrophy, the muscles  affected are
not infrequently subject to fibrillary twitchings ; only they are
less  striking to the eye, and, on  account of the masses of fat 
           PSEUDO-HYPERTROPHY OF THE MUSCLES.        161

which  cover  them,  are  less easily seen than in the atrophied
muscles of the arm.   The mechanical excitability of the muscles
is variously increased in a few cases.
   The electrical reaction  of the  affected muscles is  influenced
by two important facts : first,  the atrophy of the proper muscu-
lar elements ;  and secondly, the lipomatosis  of the muscle (and,
to some  extent, of  the  integument lying  over  it).   The  conse-
quence of both these facts must naturally be a weakening of the
reaction, the  former producing a diminution of the contractile
mass, the latter involving  a great increase  in the resistance  to
the passage of the electric  current.  It is therefore evident that
as the  disease makes progress the faradic and galvanic contrac-
tility of the muscle must continually diminish.  This diminution
may go to the extent of completely abolishing the faradic and
galvanic reactions, as I have observed  in the above case in all
the muscles of the left leg and foot, as well  as in the trunks  of
the nerves (peroneus and tibialis).1  In the muscles  of the right
leg, which were much less altered in function and volume, the
faradic and galvanic reaction under direct application was not
lost, but considerably diminished.
   The excitability and  conductivity of the nerve-trunks can  at
least remain  quite  unaltered for  a long  time, and, since in this
case one of the factors  of weakened reaction (increased  resist-
ance, from interposition  of  fatty masses) is absent, a sufficiently
strong current may thus indirectly produce muscular contraction
as long as contractile fibres exist.  Yet by degrees  the  nerve-
trunks also exhibit  a falling away in excitability, especially for
the induced current, which is probably due to secondary degen-
eration in the peripheral nerves (see below).  It is certainly hard
to reconcile with anatomical facts the statements of the entirely
normal electrical condition which  certain authors make (especi-
ally Schlesinger, in  a case lately observed in Meynert's Clinic).
Among the qualitative  changes  in galvanic reaction, the pro-
longation of  the contraction at closure  (closure-tonus) and the
  'I cannot tell where Friedreich found the expression he quotes from me ("in-
tegrity" of the electrical excitability) upon page 317 of his work, especially as he else-
where quotes me (p. 233) as saying precisely the reverse.
          VOL. XIV.—11 
162   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

" Luckenreaktion " of Benedikt deserve mention.   The latter
consists in a weakening or disappearance of the anodic  opening
reaction  as  the current  is increased in strength, and its reap-
pearance when the current is made still stronger.  It is probably
due  (according to Fick) to  the twofold action of  the  current,
whereby the excitability of a nerve is increased, while  its con-
ductivity, on  the other hand,  is  diminished, thus causing a
break ("Lucke") in the series of reactions, at the point where
the increased effect of the current upon excitability is neutralized
by the increased resistance to conductivity.
   Electro-muscular  sensibility has been  found  increased by
several observers (including myself), and  by  some diminished.
The calf-muscles, which are the oftenest affected, are well known
to afford the best means of testing this very uncertain phenome-
non, and I  therefore am inclined  to allow these  observations
somewhat more value than similar ones usually possess.
   Disturbances of sensibility,  of  other kinds,  are  not infre-
quent  at the beginning  and during  the course of  this disease.
Pains in the back and the small of the back, piercing pains in the
lower  extremities, are in many  cases  reported as  premonitory
symptoms.  They seem sometimes to follow the course of certain
nerves, the cruralis or sciatic (Rakowac), or are felt chiefly in the
region of joints (the fold of  the groin, the hollow of  the knee,
etc.); in a lying posture they become less or disappear entirely,
while they are increased by attempts to flex the joints.   Parses-
thesise are also common, especially the feeling  of  cold and of
formication, while ansesthesise, in any considerable degree, are
exceptional.
   Anomalies  of circulation, of  temperature,  and  nutrition in
the parts affected must  also be regarded as frequent.   The dis
eased regions, especially the lower half of the leg and the foot,
have, in the majority of cases, a peculiar coloration, being partly
pale, partly bluish, with a mottled appearance, owing to the ac-
cumulation of  dilated veins in  certain spots;  their temperature
is decidedly lowered, at  least in the advanced cases,  sometimes
standing at 8° or 9° R. lower than that in the axilla.  The secre-
tion is also lessened, as a rule ; the skin is smooth and dry, some-
what disposed to crack, and  seems, as it were,  thinned by being 
           PSEUDO-IIYPERTROPIIY  OF THE MUSCLES.        163

stretched over  the voluminous muscles.   The condition of the
subcutaneous tissue is especially striking.   While in progressive
muscular atrophy the integuments not rarely waste, and  espe-
cially the panniculus adiposus, we see, on the contrary, in pseudo-
hypertrophy, along with the excessive development of fat in the
muscles, an  increase of the subcutaneous fatty tissue which is
sometimes very considerable.
   The course  of the disease  is essentially determined  by the
extent to which the muscular affection has spread.   In the ma-
jority of cases the great skeletal divisions bounded by the joints
seem to present limits, which, however, are not at all impassable.
Thus we  often see the process confined  to the  muscles of the
lower half  of the leg; in  other cases the muscles  of the  thigh
participate at a later period ;  and  still later, the  muscles of the
posterior surface of the pelvis and back.  Pseudo-hypertrophy
of the  upper extremities  is rare,  as above stated,  and  always
secondary ; the increase of volume  is mostly confined to  a few
muscles (deltoid, triceps), while the others are sometimes normal
in size, sometimes diminished.
   The process extends most rarely to the muscles  of the  head,
the neck, and the front part  of the  trunk ; yet  there are  a few
cases showing that these muscles are not wholly free, in which a
swelling of the muscles of chewing, also of the tongue (Coste and
Gioja, Chvostek), the sterno-cleido-mastoids, the  recti abdominis,
etc., has been reported.  Whether the hypertrophy of the heart,
observed in a few  cases (Coste and Gioja,  Rinecker),  can  be
brought into connection with the general muscular affection, may
remain undetermined.  The extreme of diffusion is, perhaps, that
which was attained in a case reported by  Duchenne, in which
almost all the voluntary muscles  (including those  of the  face),
except  the sacro-lumbales and pectorales, were hyper-voluminous.
This was the  case  of a boy  aged ten, whose intelligence was
weak:  it resulted  fatally.  (See "Anatomical Changes.")  The
nature of the disease is such that  there are fewer circumstances
leading to a fatal result than  in progressive muscular atrophy;
for the muscles of respiration,  whether proper or accessory, are
much less often affected.   Yet the great danger which such an
event involves is by no means out of the question,  for pseudo- 
 164   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

 hypertrophy of  the lower extremities is not rarely united,  as we
 have seen, with progressive atrophy of the upper segments  of the
 body.   Whether  children  or  adults  who  are  attacked  with
 pseudo-hypertrophy can attain  to an advanced age is still  ques-
 tionable, as the cases hitherto reported give no sufficient account
 of the matter.   In fatal cases death was commonly preceded by
 disease of the organs of respiration, in the form of acute affections
 of the  larynx and trachea,  pneumonia,  bronchitis, or chronic
 phthisis of the lungs ;  in one case (W. Mueller) by the symptoms
 of dementia paralytica, in one by scarlatina.

                      Anatomical Changes.
   The pathological changes in the muscular tissue can be studied
 in the living subject  by macroscopic and  microscopic examina-
 tion of portions of muscle extracted for the purpose.  As regards
 the methods of  exploration (excision, harpooning), the remarks
 made  in connection  with  progressive  muscular  atrophy  are
 entirely applicable.  Excision is to be rejected ; harpooning only
 is allowed, but does not always  lead to satisfactory and demon-
 strative  results, especially when, as is  often the  case,  the pan-
 niculus adiposus is thickened.   For the present  this procedure
furnishes the chief material for studying the changes in the tis-
 sue of the diseased muscle.  At present there exist but very few
 complete reports of autopsies, only four in all (Eulenburg-Cohn-
 heim, W. Mueller,  Barth, Charcot).  Besides these there  exist
 only the older statements of Meryon, very aphoristic in form, and
in recent times a very fragmentary account by Martini.   A some-
what larger number of examinations have been made upon the
living by Griesinger-Billroth, Heller, Wernich, Duchenne, Russel,
 Knoll, Rakowac, Friedreich, Schlesinger, and myself.1
  Different observers, unfortunately, differ widely in the statement  of the ana-
tomical conditions observed by them, and their disagreement  is  still wider when
they come to interpret and to draw conclusions.  It is impossible to  enter upon
special details in this place, and the reader must be referred to the literature of
cases, and  the pretty complete collection in Friedreich's work.  Nothing  further
than a synopsis and grouping of the principal results can be attempted here.
  1 Auerbach's and Berger's cases are not included here.  (Cf. "True Muscular Hyper-
 trophy.") 
           PSEUDO-HYPERTROPHY OF THE MUSCLES.        165

   As seen by the naked eye,  the fragments of muscle removed
from the  living subject, and  the general  mass of the affected
muscles at autopsies, appear discolored, pale or yellowish white,
and only in less advanced cases of a faint light-reddish tint.  If
the disease has made great  progress,  the muscles of  the  corpse
have a soft, inelastic, almost doughy consistency, their cut sur-
face exhibits an exquisite fatty lustre, and their whole appear-
ance differs so  little from that of the subcutaneous  tissue that
only the striped appearance here and there visible enables us to
recognize the muscle as such ;  in  places abundantly covered with
fat (as the gluteal region) the boundary line between muscle and
panniculus adiposus is sometimes hardly traceable.   Such mus-
cles as are attacked without being hypertrophied look like those
described under the head of Progressive Atrophy.
   The  condition most  frequently showm by the microscopic
examination is an abundant development of fat,  interstitial  or
even interfibrillary,  which must be regarded as the cause of the
increase of volume in  the affected muscle.  It  is, however, very
probable that the development of fat is not the primary fact, but
that it is preceded  by a stage of hyperplastic development  of
connective tissue, so that the whole  must be  spoken of as an
irritative, inflammatory  process, as in the case of progressive
muscular atrophy. The proliferation of connective tissue springs
first from the  perimj^sium internum,  and from the adventitia of
the small vessels; the newly formed connective  tissue appears
to be especially rich in small-celled (sometimes spindle-shaped)
elements and nuclei, which undergo secondary  transformation
into fat-cells.   At any rate,  during the early stages of the pro-
cess, it is common  to  see the fat-cells arranged  in rows  like a
rosary in the midst of a striped basal  tissue, which is  explained,
it  is true, by some authors (Cohnheim) as the empty, collapsed
sarcolemma tubes of  the vanished muscular  elements,  but  is
decidedly affirmed by others (Friedreich) to be hyperplastic in-
terfibrillary connective tissue.   The assumption that the for-
mation  of  fat  is preceded  by a hyperplastic proliferation  of
connective  tissue has been already stated by Billroth (in Grie-
singer's first case), and is shared  by Wernich, Knoll,  Duchenne,
Jaccoud, and  others;  upon this rests  the  designation  of the 
 166   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

 disease as paralysie myosclerosique or sclerose musculaire pro-
 gressive.  This assumption is supported by the fact that in some
 cases the process seems to have been arrested at the stage  of
 lormation of connective tissue, or at least the transformation into
 fatty tissue seems  to  have taken place to but a slight extent
 (Russel, Knoll, Rakowac).
   If the interstitial fat is more abundant, coarser  bundles  of
 muscular fibre are first pressed apart, then the single primitive
 fibres are separated in the same way,  so  that at last an entire
 muscle seems uniformly permeated by  fatty tissue.   The primi-
 tive  fibres become attenuated at the same time, and at last they
 disappear altogether,  leaving behind  them  only  the collapsed
 empty tubes.  This condition I have  myself observed in a fully
 developed  pseudo-hypertrophy  of  the calf muscles,  with com-
 plete immobility and want  of  response  to  the electric stimulus.
 But  where the disturbance of function is slighter the cross stripes
 of the primitive fibres can always  be  found, though the fibres
 for the most part are very much thinned in respect to diameter.
 There  is one  striking phenomenon,  to which Cohnheim  first
 called attention, and which has been confirmed by Knoll, Barth,
 W.  Mueller, and myself, namely,  the occurrence of  decidedly
 hypertrophied fibres along with others which were more or less
 attenuated.  These hypertrophied fibres, of  twice or thrice the
 usual thickness, generally  present  quite a normal appearance,
 and  have only in spots somewhat of a finely granulated look;
 Barth  found  their transverse stripes  very  indistinct.   Cohn-
 heim and Knoll  have further found a dichotomous or tricho-
 tomous division  of  the hypertrophied elements—a  condition
 resembling  that which Friedreich  demonstrated in a  case of
 progressive muscular atrophy.
   That the muscular elements themselves may be implicated in
 the irritative process, is further confirmed by the multiplication of
 the muscular nuclei (Friedreich, Charcot), and by the occasional
fine granular cloudiness of the muscular fibres, which disappears
after the addition of acetic acid, and must therefore be looked
 upon as a parenchymatous exudation.  In W. Mueller's case mus-
 cular fibres with granular contents  were seen, presenting a vari-
 cose  appearance with alternate enlargements and constrictions. 
             PSEUDO-HYPERTROPHY  OF THE  MUSCLES.          167

   As a final  stage  of  the  process we may mention,  besides
the simple atrophy of muscular elements, a fibrillary fissurationi
(Barth,  Charcot,  Friedreich)  or  waxy  degeneration  (Charcot,
Friedreich), while proper fatty degeneration seems to occur only
by way of exception and in a few fibres.

   The post-mortem appearances observed by Martini are quite unique and at pres-
ent seem  hard to interpret, and so are those which Schlesinger obtained by exci-
sion from the living body.  The former states that in the transversely-striped sub-
stance of the primitive bundles there  occurs a peculiar formation of fissural spaces,
which gradually enlarge and fill with a sero-albuminous fluid.   With the progres-
sive disappearance of the striped substance, these fissures run together, and at last
form tube-shaped fibres, which in section are ring-shaped, or (if they retain  their
septa) appear  as  disks  perforated  like a sieve, with a number of round openings.
Martini therefore  designates this process as  "tabular" or "serous"  atrophy of
muscle.  In Schlesinger's case there  was found an abundance of fibrillary and
undulated (wellenformiges) tissue, among which were muscular  fibres in  various
states: some retaining their cross stripes, some in the condition of granule-heaps of
a distinct yellowish color, some irregular in outline, some in the form of roundish
or longish masses;  destruction of muscular masses by  granular degeneration.
Neither proliferation of the interstitial tissue nor increase in the volume of individ-
ual  muscular  fibres could  be  observed, but a considerable vascularity was every-
where present.  Schlesinger believes himself justified in assuming upon the  ground
of this observation that  the abundant fibrillary tissue did not originate by the  ordi-
nary process from connective tissue cells, but from muscular fibres; that the disease
therefore  appeared  first in  the muscular fibres themselves (as a process of  chronic
inflammation), and that the interstitial tissues were therefore drawn to  participate
in the process at  a  later time.  Probably this case is related to those of Rakowac,
Russel and Knoll,  above described.
    As regards the changes in the nervous system, we are at pres-
ent confined to the  few results of autopsies  already mentioned.1
In  the case of  Eulenburg-Cohnheim  the  result of a naked-eye
examination was  entirely negative.   The brain,  cord,  and their
envelopes, also all  the nerve-roots and the trunk of the sympa-
thetic, presented no abnormal  conditions.  The sciatic and crural

  1 The oldest observations by  Meryon (1852), the relation of which to the disease
in question  is certainly somewhat doubtful,  remarked no anomalies  in  the nervous
system. 
168   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

nerves of both  sides were somewhat flattened, but showed no
other changes.  In the case examined by W. Mueller, which was,
however, complicated with dementia paralytica (in a woman aged
thirty-four), there was found an extended degeneration in the
cord, especially in the lateral columns, consisting in a thicken-
ing of the interstitial connective tissue with an increased number
of cells, a diminution of the diameter of  some of the primitive
nerve-fibres, with granular change of  the  primitive sheaths and
partial disappearance of  the axis-cylinders.  In the gray sub-
stance the ganglion-cells were uninjured as far as to the middle
of the lumbar swelling ; farther downwards there was an atten-
uation of the anterior cornua, especially on the right, with atro-
phy of the greatest part of the ganglion-cells contained in them;
the intervening substance was unusually dense and poor in axis-
cylinders.  The  trunks  of peripheral nerves (peroneus,  tibialis,
sciatic) exhibited a considerable increase in the volume  of their
interstitial connective tissue, with groups of fat-cells interposed
here and  there ;  a similar development of connective tissue was
also found in the anterior roots, which were colored gray, but
without any injury to the primitive fibres.
   Barth likewise found extensive changes in the cord and the
peripheral nerves, but is inclined to interpret them as secondary.
They consisted  of wedge-shaped or  roundish spots, distinctly
gelatinous, irregularly distributed  in  the white substance of the
anterior and lateral  columns of the  cord.  In these spots the
nerve-fibres were few ; their  place was  taken by a finely granu-
lar substance, traversed by large, full blood-vessels, and contain-
ing numerous corpora  amylacea.   In the anterior cornua there
was found only a very small number of ganglion-cells, and the
vessels were much dilated.   The sciatic  nerves were strikingly
broad, and the several bundles were pressed asunder by a  depo-
sit of fat.  The  sympathetic was not examined. —Martini men-
tions the lipomatosis of the nerve-trunks only incidentally; his
promised publication of the condition of the cord has not yet
appeared.—In  the case examined by Charcot (the  boy of ten
years observed  by  Duchenne) the examination  of the cervical
enlargement and the upper dorsal part of the  cord gave an abso-
lutely negative  result, and  the same in respect  to  the  anterior 
           PSEUDO-HYPERTROPHY  OF THE MUSCLES.        169

cornua and the large ganglion-cells contained within them.   The
anterior roots and the nerve-trunks (sciatic, median, radial) were
likewise normal.  When the  muscles were  examined, entirely
normal portions of nerve were often found, and only once (in the
psoas) was there in them a very marked hypertrophy of the axis-
cylinders.


     Theory of the Disease and Analysis  of the Symptoms.

   The important question to be answered is, whether the pseu-
do-hypertrophy of the  muscles should  be  looked upon as an
independent form of  disease, or only as a special  development
of progressive muscular  atrophy.   If the independence of the
disease is  granted, the question as to its primary myopathic or
neuropathic origin will have  to be  considered.  If the second
alternative is adopted, the same question will have to be put, but
(according  to  the statements  made  under progressive muscular
atrophy) without any immediate hope of definite decision.
   The chief arguments in favor of the essential  identity of  pro-
gressive muscular atrophy and of  pseudo-hypertrophy are as
follows: (1.) Agreement in the fundamental  histological changes
of the muscle.   Although upon this point,  especially in respect
to pseudo-hypertrophy, we have seen that  there are many un-
solved  contradictions, yet we may be tolerably sure of as much
as this, that in both  diseases the first stage consists of a chronic
irritative process, proceeding from  the interstitial connective tis-
sue and affecting secondarily the muscular elements—a chronic
myositis accompanied by interstitial hyperplasia of the connec-
tive tissue (Friedreich).   In the subsequent  course, in the com-
plications of this originally identical process, differences certainly
arise wdiich require special  explanation.  Another and a weighty
argument is (2.)  the  extremely frequent coincidence of pseudo-
hypertrophy of  single muscles with diminution in the size of
others, near or remote, which are similarly impaired in  their
functions.   Sometimes, and not rarely, a marked pseudo-hyper-
trophy in the lower extremities will be combined with the usual
form of progressive muscular  atrophy of the upper part of the 
170   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

body.   Finally (3.), essential agreement in respect to etiology
and clinical course may be noted.   Points  held in common are:
the preponderance of the male sex ; the influence of a predispos-
ing diathesis, usually congenital, often referable to  hereditary
tendency ;  the occurrence of several cases in one family, the suc-
cessive attack of several brothers and  sisters at a certain  period
of life.   It is plain that the two diseases may take the place the
one of the other, as the example communicated by Russel shows,
where in one family two brothers were attacked by progressive
atrophy, and a third by pseudo-hypertrophy.  As regards the
clinical  coincidence, I will only mention the numerous common
points in the functional and electrical condition of the muscle, in
the manner of extension of the muscular  affection, in the  later
consequences (secondary deformities), etc.
   If, on the  other hand, we group together the principal points
of difference, we find them relating first to the manner in which
the histological  process further develops  itself in the diseased
muscles.   But this difference is  only partial.  The secondary
implication of the muscular  tissue, the wasting and final disap-
pearance of  the muscular elements, partly by simple atrophy,
partly in the form of  fibrillary fission or waxy degeneration, is
common to both processes, on the whole.  It might be said, at
most, that  a  participation of the muscular fibres in the  proper
irritative processes seems  to be somewhat more frequent and
marked in pseudo-hypertrophy  than  in  progressive atrophy;
but we find in the  pseudo-hypertrophic muscles, in addition to
and  subsequent to the initial hypertrophy of connective tissue,
an excessive  development of  fatty tissue, which in a later stage
transforms the whole muscle  and its neighborhood into a spongy
mass of fat, and at the same  time often makes the muscle enor-
mously voluminous.   (In a few  cases, as the observations of
Russel,  Knoll, and others, prove, it seems  that the external in-
crease in bulk may originate  solely in interstitial proliferation of
connective  tissue).  Nevertheless, even in this excessive develop-
ment of fat in pseudo-hypertrophy, the distinction from progres-
sive  atrophy seems to  rest solely upon quality.   We have seen
that the latter disease is not rarely accompanied  by a secondary
lipomatosis of the muscles attacked, and that the atrophied mus- 
           PSEUDO-HYPERTROPHY OF THE MUSCLES.        171

cles are not seldom enabled by this "compensatory" process to
increase in volume up to the point of equalling or even surpass-
ing their former size.  This secondary lipomatosis after atrophy
especially affects those muscles which are the favorite seat of
pseudo-hypertrophy.   Friedreich very properly points out how
much irritative processes in general favor or provoke the patho-
logical development of fat, of which fact numerous instances are
found in the history and etiology of lipomas and of other lipo-
matous proliferations.
   The etiological and clinical differences between pseudo-hyper-
trophy  and progressive muscular atrophy are  most strongly
expressed in the facts,  that the former is almost peculiar to
childhood, while the latter arises more frequently in adults in the
middle  period of life ;  that, further, hypertrophy begins (almost
without  an  exception) in the lower extremities, and very often
remains confined to them, while progressive muscular atrophy, as
a rule, prefers the upper extremities and the muscles of the trunk.
And yet these distinctions, far from widening the gulf between
• the diseases, perhaps help to fill  it; perhaps  they point to the
cause which gives  rise to a divergence in two cases originally
based upon one  and the same histological process.  In  child-
hood, as has been stated in connection with progressive muscular
atrophy,  there exists a circumstance  especially favoring the
development of the disease in the lower extremities, namely, the
great efforts made with these limbs in the acts of standing and
 walking.  If the diathesis be present we should not be surprised
to find just  these parts  first attacked ; and might not childhood
present conditions favoring and accounting for the occurrence of
the process  in  that form which  characterizes pseudo-hypertro-
phy, namely, the excessive  development of fat in the muscles
attacked ?  In fact,  such conditions seem really to exist.  Fried-
reich calls attention to the fact that the fattening of cattle is
favored by youth, by fat-producing nutriment, and by rest, and
that all these circumstances meet  in  the pseudo-hypertrophy of
childhood.  The fact that the lower extremities usually suffer
condemns the child at an early period to continued inactivity,
and his nourishment consists, often to a very great extent, espe-
cially in the lower classes, of the  fat-forming cereals.   It  is true 
172   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

that the pseudo-hypertrophic  development  of fat is not a case
of simple passive fattening, but of an accessory lipomatosis super
vening on  an actively inflammatory process ; yet it is plainly
shown by the frequent considerable increase of the  panniculus
adiposusand the lipomatosis of the nerve trunks (Barth, Martini)
that there exists a certain tendency to general  adiposity. Put-
ting these facts together (though all difficulties be by no means
solved), we may affirm that Friedreich's view is very probable,
which considers pseudo-hypertrophy to be only " a form of pro-
gressive muscular atrophy modified by the peculiar  strength of
the diathesis and by certain special attributes of childhood.''''
   Whether the muscular affection is to be regarded  as primary,
or as a secondary affection dependent on a previous lesion of
trophic nerve-centres,  must  therefore  remain undecided, espe-
cially since the pathologico-anatomical material for determining
the intensity and extension of the lesions of the nervous system
is at present very scanty.  The same fact  interferes with  the
interpretation of the accessory symptoms.  Those disturbances
of the sensibility  which are often present, especially the pains'
and paraesthesise which follow the course of certain nerve-trunks,
may perhaps be referred to interstitial proliferation  of the con-
nective tissue of the nerve trunks (compare the case  reported as
above by W. Mueller), and to  the consequent irritation of the
sensitive fibres.—The anomalies of circulation and temperature
in the affected parts  (the bluish, mottled look,  the dilatation of
the veins of  the skin, the diminution of temperature, and so on)
may depend on the loss of muscular action,  and the consequent
interference with the return of the venous  current,  or perhaps
they may also be due to collateral diversion of circulation to the
skin in consequence  of the obliteration of  numerous muscular
blood-vessels (Friedreich).   But the later  factor may be of sub-
ordinate moment,  as  is shown by the circumstance that some
observers have found the affected muscles  universally  rich in
blood-vessels  (Schlesinger), while  the  skin  was affected  as de-
scribed. 
           PSEUDO HYPERTROPHY OF THE MUSCLES.        173


             Diagnosis, Prognosis, and Treatment.

   The diagnosis  of pseudo-hypertrophy cannot be made with
certainty in its early stages, when the increase in the size of the
muscle is not evident, or is very slight; but a close observation
of its etiology, and the application  of  functional and electric
tests, can help us at least to form a very probable opinion.  The
surest evidence is  furnished, of course, by a microscopic exami-
nation of portions of muscle extracted by the  harpoon,  provided
the necessary precautions be observed—plunging the har/poon as
deeply as possible, on account of the frequent thickening of  the
panniculus—and that the operation be repeated.  In later stages
of the disease no greater mistake is likely to happen than that
of diagnosticating  true muscular hypertrophy, but the  func-
tional and electric tests are sufficient to guard  against this.
   The prognosis,  as  has already been intimated in speaking of
the course of the disease, is somewhat more favorable in regard
to life  than that of the common form of progressive muscular
atrophy, unless perhaps there exists a  tendency to ally itself
with the latter disease.  But, as regards the disease, the progno-
sis is still less favorable.  Those muscles in which a considerable
amount of accessory fat-formation has occurred  seem to be less
susceptible of a functional restitution  than those in which the
chronic process of inflammation is unaccompanied with formation
of fat; and for this reason a cure is but rarely  to be looked for in
the advanced stages of the process.   Statements to the contrary,
made by a few authors,  may often be based upon a mistaking of
this disease for true muscular hypertrophy.
   The treatment must in general be conducted according to the
same principles as in progressive muscular atrophy.  A careful
prophylaxis is of special importance ;  children congenitally pre-
disposed, or the younger brothers or sisters of persons who have
already become affected, must be shielded as far as possible from
injurious atmospheric influences, too early and exhausting loco-
motion,  excess of fat-forming nourishment, etc.   When  the dis-
ease  has commenced,  such internal  remedies as tonics, quinia,
iron, cod-liver oil, etc., are as useless as in progressive atrophy ; the 
174   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

same seems to be true of iodide of potassium, although its use is
defensible upon the rational ground  of its  known power to  pro-
mote the resorption  and disappearance of  fatty tissue.   As
regards the use of localized gymnastics, we  have as yet too few
observations;  but it seems to promise some advantage in the ini
tial stages of the disease, though at  a  later period no success is
to be expected, at least as regards the restoration  of the affected
muscles.  Massage and hydro-therapeutics seem to have been of
value in some cases.—By far the greater part of the  cases have
been treated by electricity for  a longer or shorter period, some-
times with the induced, sometimes  with the constant current.
Duchenne in particular has seen favorable results  from faradiza-
tion (/. e., induced current), and in two  cases has even observed a
cure (!) after treatment for several months.  The constant current
has been chiefly used in galvanization of the sympathetic. While
Benedikt obtained considerable benefit from this procedure, other
authors  (Erb, Chvostek)  observed  no  essential gain, or  even
(Roquette) an  apparent  loss.   The  local  method, of applying
faradization and galvanization to the muscles affected, would
seem therefore to deserve the  greater  .confidence.—Consecutive
deformities require  a  special orthopedic treatment, which, how-
ever, owing to the continuance of the original disease, can  only
palliate the trouble.   In a case contributed by Uhde, where an
advanced degree of  pes varo-equinus existed,  the deformity was
removed, and the power of walking somewhat improved, by teno-
tomy of the tendo Achillis (which was followed by an abscess in
the calf). 
TRUE  MUSCULAR   HYPERTROPHY.

            (Hypertrophia musculorum vera.)
 L. Auerbach, Ein Fall von wahrer Muskelhypertrophie.  Virchow's Archiv. Band 53.
    S. 234 and 397.—0. Berger, Deutsches Archiv fiir  klinische Medicin. 1872.
    Band IX. S. 363.— Benedikt, Wiener med. Presse. 1872. Nr. 9.  Compare also
    his Elektrotherapie, 1869. S. 186.— Friedreich, Ueber progressive  Muskelatro-
    phie, iiber wahre und falsche Muskelhypertrophie.  Berlin, 1873.

    True  muscular hypertrophy is  clinically characterized by a
 noticeable increase in the volume of  the muscles, while the mus-
 cular force may  be increased, or may remain normal, or may
 even be slightly diminished.   Its anatomical basis consists of an
 actual hypertrophy of the muscular elements.

   Partial hypertrophy of the striped  muscles, especially of the tongue, has very
 long been known, as has also the existence of muscular hypertrophy in connection
 with general hypertrophy of one-half of the body, of one extremity, or one side of
 the  head.   But the observation of pure cases of muscular  hypertrophy in the
 extremities, and the separation of these from pseudo-hypertrophy, with which they
 were confounded, or were considered as the initial  stage, is one of the  most recent
 discoveries. The number of observed cases is, therefore, extremely limited.  It is
 doubtful whether an observation of  Graves's belongs to this class, in which sciatic
pains were associated with a hypertrophy of the leg.  The first certain case is that
of L. Auerbach, in which the diagnosis could be confirmed by an examination of
excised pieces of muscle.  "We must also regard  as sufficiently well established
cases two reported by Berger (and perhaps  also a third case by the same), several
by Benedikt, and one by Friedreich.

   In regard to causation, it is to be remarked that four  cases
(Auerbach,  Berger) occurred in soldiers who  had performed severe 
176   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

forced marches during campaigns; two of Berger's cases were
preceded  by ileo-typhus or gastric fever, and a third by a gun-
shot injury of the thigh, without lesion of the larger vessels and
nerves.  Benedikt's and Friedreich's  cases were in  adults;  in (
that of Friedreich  the  subject was  a  maid-servant thirty-three
years old, but in this instance the disease was probably congeni-
tal ; at least, the left arm was said to  have been larger than the
right at birth.   (Benedikt's proposed designation of "hypertro-
phia musculorum progressiva adultorum " seems, therefore, not
improper upon the whole.)
   The cases hitherto observed have mostly affected the upper
extremity (Auerbach, Benedikt, Friedreich), and, as a rule, only
one upper extremity has been attacked ; in Auerbach's and one
of Benedikt's the right, in Friedreich's the left.   In those cases
also in which the disease was seated  jn the  lower extremities
(Berger), it was always confined to one  of them.   In the cases of
Auerbach and Friedreich the increase of volume affected almost
all the muscles of  the arm, and  especially those  of the upper
arm and the  region of the shoulder.  The circumference of the
upper arm was, in Auerbach's case, 5£ and 6£ cm. greater, and
that of the forearm 5 cm. greater  than the corresponding meas-
ures upon the unaffected side; similar  differences are given by
Friedreich, as also a considerable increase in the breadth of the
hand {2%  cm.),  caused  by  hypertrophy of the interossei  and
enlargement of the  ball of the little finger.  In Benedikt's cases
the hypertrophy was essentially limited to the muscles  of the
shoulder (deltoid, pectoralis major, teres major and minor, serra-
tus ant. magnus).  In Berger's cases—which possess, in many
points, the  usual characteristics  of pseudo-hypertrophy—the
muscles of the calf were the first and the most severely affected.
   As regards  the  functional energy  of the  diseased muscles,
Auerbach found that a greater display of force could be made
for brief exertions,  but that fatigue occurred more quickly than
is usual.   Berger and Benedikt found  the power somewhat les-
sened ; Friedreich found it at least as  great as upon the healthy
side.  The consistency of the muscles attacked was hard and firm,
and on contraction they bellied  out  strongly  and compactly.
Fibrillary contractions are  mentioned  by Berger only.  The 
               TRUE MUSCULAR HYPERTROPHY.             177

mechanical excitability was found increased by Benedikt;  under
galvanic tests he found the kt Luckenreactioir' and closure-clonus.
Auerbach found the excitability under constant currents equal
on both sides, but weakened for induced currents on the diseased
side.  Erb (in Friedreich's case) found it normal  on both sides
for both classes of currents, with the exception of the ball of the
thumb, which looked  as if atrophied, and  exhibited  a  corre-
sponding diminution of excitability in the flexor pollicis  brevis
and  opponens,  both under  direct and  indirect applications of
electricity.   In Berger's cases,  on the other hand, the excita-
bility under both classes of  current was diminished, and so was
the reflex excitability.
   Of the condition of extracted pieces of muscle, reports have
been  made  by Auerbach, Berger,  and Friedreich.   Those of
Auerbach are especially careful.  The pieces  of  the deltoid and
biceps which he cut out exhibited  a perfectly normal structure,
but an enormous breadth of the muscular cylinders ; their diam-
eter in the deltoid averaged 120 /<, while specimens  taken by way
of comparison from dead bodies measured only from 58 to 7,1 p.
The muscular cylinders of the diseased (right) biceps had diam-
eters reaching to 10o /*,  those  of the left only 110 p.  By meas-
urement  of  the breadth of the  separate strbe Auerbach proves
that the  enormous increase  in breadth cannot be due  solely to
the contraction following exsection (rigor mortis), but depends
on actual hypertrophy.  A comparative  count of  the muscular
nuclei in one cubic millimetre of  normal and one of hypertro-
phied muscular substance showed  but slight differences, so that
a considerable  growth of nuclei in the hypertrophied muscle
must also be assumed.   The investigations both of  Berger and
of Friedreich likewise demonstrated a considerable increase in
the thickness of the muscular  fibres, amounting  even to a doub-
ling, while the cross striations  were well retained.   Symptoms
of growth of interstitial fat or connective tissue  were entirely
absent, both here and in Auerbach"s case.
   Among the muscular symptoms presented by the above cases,
disturbances of sensibility and circulation deserve especial men-
tion.  The  former were found  only in Berger's cases (violent
neuralgiform pains, formication, anaesthesia)  ; in the other cases
          VOL. XIV.—12 
178   EULENBURG.—VASO-MOTOR AND TROPHIC NEUROSES.

the sensibility of the skin was normal.   In Auerbach's case a
livid coloration  of  the diseased  arm  is  mentioned.  Benedikt
found in one case symptoms which entitled him to assume  an
affection of the sympathetic; the face was redder and the secre-
tion of sweat was increased upon the affected (right) side ; the
pupil was dilated and the sympathetic was sensitive to pressure.
In another case  there existed extensive vaso-motor paralysis in
the face, the neck, on the breast, and over the shoulder-blades,
which disappeared after galvanization of the sympathetic.
   In regard to the theory of the disease the first question  to
settle is, whether the muscular hypertrophy should be consid-
ered an independent disease, or only as a first stage of pseudo-
hypertrophy.  The latter view is taken by Berger and Auerbach.
Auerbach assumes  that the primary excess of nutrition is fol-
lowed  later by a  process  of retrograde metamorphosis with
atrophy of the muscular bundles, and a filling in of the enlarged
interstices with  connective tissue  and fat.  The appearance  of
this stage  of retrogression is hastened  by the abnormal condi-
tions of circulation, especially by the disproportionate growth of
the capillaries enveloping the muscular cylinders, which transfer
their nutritious materials in less abundance than formerly to the
interior of the muscular cylinders, and more abundantly to the
interstitial substance.  In this way hyperplasia of the latter and
atrophy of the muscle-cylinders would necessarily be produced.
But, ingenious as is this theory, the transition from true to false
hypertrophy (or the super-induction of interstitial growth of fat
and connective  tissue) has not been demonstrated by a single
positive observation, while the  favorable clinical results and
the permanent functional and electrical integrity of the diseased
muscles, etc., are entirely inconsistent  with  such  a view.  The
question  whether the  true muscular  hypertrophy should  be
regarded  as a genuine  muscular lesion  or as a tropho-neurosis
(Berger) can hardly be discussed at present, owing to the  entire
want of material for its decision.  The  affection of the cervical
sympathetic  observed in  Benedikt's case may probably  be  re- 
               TRUE MUSCULAR HYPERTROPHY.            179

garded as simply a case of combined disease, such as is observed
in some instances in progressive muscular atrophy.
   Among the symptoms, one deserves especial attention, namely,
the readiness  with  which fatigue  of  the  muscle occurs (Auer-
bach), or even a general weakening of its power (Berger, Bene-
dikt).  Auerbach finds  the cause of this  singular phenomenon
in the  fact that the muscular blood-vessels  do not increase in
proportion  to  the growth of the muscular cylinders,  and that
the restoration of the muscular force after  expenditure must
take place too slowly ; perhaps also the intra-muscular termina-
tions of the nerves are not developed in sufficient proportion to
conduct the volitional impulses readily.  Benedikt, too, attri-
butes the loss of function chiefly to an inadequate growth of the
nervous elements ;  also to pressure  of the  swollen muscular
substance upon the  terminal nervous apparatus, and to a prob-
able primary lesion  of the central  trophic ganglion-cell system.
Friedreich, on the contrary, in explaining the rapidity of exhaus-
tion, admits but one hypothesis, that of disproportion between
the muscular  and  the vascular masses.   The increased power
for  brief  exertion, as in Auerbach's case, rather gives reason to
suppose (according  to Friedreich)  that the hypertrophy of  the
muscle is accompanied pari passu by a hypertrophy of  the
terminal motor nerve-disks, or of the components of the motor
nerve-fibres,  which  serve  in  the conduction of the volitional
impulse—that  is, the  primitive fibrillse  composing the axis-
cylinders. 
 
I
EPILEPSY AND ECLAMPSIA.
NOTHNAGEL. 
 
EPILEPSY   AND   ECLAMPSIA.
II. Boerhaave, Praelectiones academicae de morbis nervorum. Francofurti et Lipsiae,
    1762.—Tissot, Traite des nerfs  et de  leur maladies.  Paris, 1778-80.—J. P.
    Frank, De curandis hominum morbis epitome. Vol. VII.  Viennae, 1821.—An-
    dral, Cours de Pathologie interne.  Paris, 1848, in the 2d vol.—Marshall Hall,
    Memoirs on the nervous system. London,  1837.—Joseph  Frank, Die Nerven-
    krankheiten. Leipzig, 1843.—M.  II. Romberg, A manual of the nervous diseases
    of  man, translated  and edited by E. II. Sieveking, New Syd. Soc.  London,
    1853.—Hasse, Krankheiten des Nervenapparates. In Virchow's Handbuch der
    spec. Path. u. Ther.  Erlangen, 1855.— Trousseau, Lectures on clinical medicine,
    delivered  at the  Hotel Dieu, Paris. Translated by P. V. Bazire.  Revised and
    enlarged ed., by J. R. Cormack,  New Syd. Soc. London, 1870.— Valentin, Ver-
    such einer physiologischen Pathologie der  Nerven.  Leipzig and Heidelberg,
    18G4.—M.  Rosenthal, Lehrbuch  der  Nervenkrankheiten.  Erlangen,  1870.— A.
    Eulenburg, Lehrbuch der functionellen Nervenkrankheiten. Berlin,  1871.—
    Russell Reynolds, Diseases of the  nervous system;  by various authors in  A Sys-
    tem of Medicine.  2d ed.  London, 1872.— W. A. Hammond, A treatise on the
    diseases of the  nervous  system. 3d  ed. New York,  1873.—/.  M.  Charcot,
    Lecons sur les maladies du systeme nerveux.  Paris, 1872-3.   In  addition
    to these, consult the various manuals  of special pathology and therapeutics.
                                Epilepsy.

The general literature cited above may be consulted, and besides: E. Loebenstein-
    Loebel, Wesen und Heilung der  Epilepsie.  Leipzig, 1818—John 67. Mansford,
    Investigations into the nature and causes of epilepsy.—Portal, Natur u. Behand-
    lung der Epilepsie.  Uebers. von Hille.  Leips. 1828.—Ilerpin,  Prognose und
    Behandlung  der  Epilepsie.  Deutsch  bearb. von Frank.   Quedlinburg and
    Leipzig, 1854.—Ddasiauve, Traite" de  FEpilepsie; Histoire, Traitement, MCde-
    cine legale.  Paris, 1854.—Schroeder van der Folk, On the minute structure and 
184
NOTHNAGEL.—EPILEPSY.
    functions of the spinal cord and medulla oblongata, and on  the proximate
    cause and rational treatment of epilepsy ; translated by W. D. Moore.  Lon-
    don, New Syd.  Soc. 1859.—A. Kussmaul and A. Tenner,  On the nature and
    origin of epileptiform convulsions caused by profuse bleeding, and also of those
    of true epilepsy; translated by  E. Bronner, London.  New Syd. Soc. 1859.—
    Broion-Sequard,  The various works of this author on  epilepsy  are cited in a
    foot-note to the text.—Sieveking, On epilepsy and epileptiform seizures, etc.
    2d ed.  London, 1861.— Ch. Bland Radcliffe, Epilepsy and other convulsive
    affections. London, 1859.—Althaus, On epilepsy, etc.  London,  1866.—Russell
    Reynolds, Epilepsy : its symptoms, treatment, and relations to other chronic
    convulsive diseases. London, 1861.—Gonzalez Echeverria,  On epilepsy; anat-
    omo-pathological and clinical notes. New York, 1870.—Nothnagel, Ueber den
    epileptischen Anfall. Volkmann's Sammlung klinischer  Vortrage. Leipzig,
    1872.—Additional short monographs and the essays on  epilepsy in the journals
    are cited in the text.

                          Introduction.

    The history of the development of  the  doctrine of epilepsy
affords one of  the most brilliant examples of  the important aid
which experimentation on animals may furnish towards further-
ing our knowledge of  a diseased  condition.    This disease was
known as far back as medical literature extends  into antiquity.
And this is  not surprising, for the violent  form  of  its  coarsest
manifestations could  not escape even the most superficial obser-
ver.  In the Hippocratic writings we find it characteristically
described.  In course of time a few additions were made to the
symptomatology, and some new remedies—one generally as little
to be relied on as another—were brought into use.  Beyond this
point,  however,  the  knowledge  of epilepsy made no essential
progress  for  many centuries.  Naturally there was  no  lack of
attempts to explain its  symptoms and its nature.  Innumerable
hypotheses,  clever and  foolish,  anatomical and physiological,
philosophical, even theological, were advanced with  this object
in view.  None of them  raised the veil  a hair's  breadth;  none
contributed anything whatever to positive knowledge.   The last
twenty years alone have advanced  us at one time more than the
previous twenty centuries taken  together.    The experimental
researches of two investigators furnished the  starting-point, al-
though some isolated but unsatisfactory attempts had already 
INTRODUCTION".
1S.1
been made in this direction.  In a  series of experiments, which
were carried out in a masterly manner, fit to serve as a model,
Kussmaul opened the way to an understanding of the  epileptic
seizure.   Brown-Sequard,  by numerous experiments upon ani-
mals, first indicated a way, by following which it is perhaps pos-
sible to attain a more accurate knowdedge of the epileptic  slate.
In the course of recent years the efforts of various other inves-
tigators have been added  to these  two fundamental works, and
their results will be alluded to in the proper place.
   Until a short time ago, in spite of the number and variety of
the names for it which have been  gradually adopted,1 no scienti-
fic doubt existed that  epilepsy was a perfectly definite disease
with well-marked symptoms.  As Boerhaave defines it,  Epilepsia
est abolitio subita  omnium functionum  animalium, cum  aug-
mento motuum vitalium et motu convulsivo in omnibus musculis
corporis, so it has always been esteemed as a distinct disease, to
the definition  of  which the idea of  "chronic"  has only  very
lately been added.
   During the last ten years a marked reaction has set in against
this  view.   In the  first place one group of  symptoms after
another, which from a  clinical  point of view apparently showed
the features of epilepsy, has gradually been detached in  propor-
tion as our increasing knowledge proved that definite anatomical
changes in the brain or other organs w7ere the direct causes of
epileptic attacks.  This is true of ursemic  seizures ; also of all
those epileptiform convulsions in which demonstrable gross alter-
ations exist in  the cranial cavity, the effect of which taken alto-
gether may be comprised  in  this,  that either  directly or by
  1 We give some of the Latin designations, without alluding to the numerous popular
names in various modern languages : Morbus sacer, major, herculeus, comitialis, con-
vivalis, mensalis, insputatus, viridellus, vitriolatus, sonticus, caducus, lunaticus, fcedus,
sideratus, scelestus, da^monicus, deificus, astralis,  St. Valentis, and St. Joannis, Ana-
lepsia, Apoplexia parva, Passio Caduca, Perditio, etc.  Compare Joseph Frank, Die
Nervenkrankheiten. 4th vol.—Attempts at an explanation of several of these names
may be found in Josat, Recherches historiques sur 1'Epilepsie. Paris, 1856. 
186
NOTHNAGEL.—EPILEPSY.
simple mechanical conditions they occasion an  anemia of the
brain substance.  In all these cases, and quite properly, we no
longer speak of epilepsy,  but only of epileptiform spasms, as
symptoms of the conditions in question.  In this category belong
the epileptiform, or as they are also called in this  case, "eclamp-
tic,"  seizures  in  profuse hemorrhages,  in hydrocephaloid, in
great hyperemias, in all intracranial diseased conditions which
are accompanied  by considerable diminution of space, and par-
ticularly if  they  develop rapidly,  as  in the  case of important
hemorrhages.  In  our  opinion,  however, this use of the term
"eclamptic " is confusing and unjustifiable.   (Compare  the sec-
tion on Eclampsia, and also the sections in the  twelfth volume
of this work on Anaemia and Hyperemia of the Brain.)
   There can be no doubt  that such  a pathology as that just
sketched agrees with the present position of science.  In this
way a definite group of cases, which were formerly described as
"symptomatic," is done away with ; the spasmodic seizures have
rather been relegated to the rank of a symptom merely, the ana-
tomical basis of which is well known.
   For the same reason the  so-called " toxemic " epilepsy, as a
distinct disease, has been allowed to fall into disuse.  The epilep-
tic manifestations, which may occur in various acute as well as
chronic forms of poisoning,  and among which lead-poisoning has
always played a prominent part, are called forth either  directly
or indirectly by the action of the  poison upon the central ner-
vous  system, in a way which cannot here be more  particularly
discussed.  In these cases,  too, the epilepsy is only a  symptom,
and represents no special form of  disease.l  This whole group,
therefore, of the  "symptomatic and  toxemic" epilepsies will
be left out of consideration  in the following account; the indi-
vidual cases find their place with the corresponding primary dis-
eases.
   In very  recent times, however, we have even gone a step
further.   For quite a  long time  another form,   "  sympathetic
or reflex epilepsy,"  was recognized in  addition to those men-
tioned.   Under this name  were comprehended  those cases in
   1 This is also true of the epilepsy from drinking absinthe, on which Magnan espe-
cially has recently laid so much stress. 
INTRODUCTION.
1S7
which  an irritation of  any kind, affecting any sensitive nerve
whatever could be proved, by the effects of treatment, or could
at least be assumed, to be the source and starting-point of the
disease.  If the irritation and consequently the state of spasm
were persistent, as, e. g., in consequence of a cicatrix, we called
it epilepsy; if it were of an acute kind, e. g., from the eruption
of a tooth in a child, we called it eclampsia.
   Of  late  even this  mode  of  treating the subject has  been
rejected  by several investigators as  erroneous and confusing.
Russell Reynolds especially, whose views on the  pathology of this
disease are highly esteemed,  confidently maintains the opinion
that the so-called sympathetic  or reflex epilepsy is to be rele-
gated  to the group of  " convulsions" simply, and must be com-
pletely separated from epilepsy, with wdiich it has nothing in com-
mon save the symptoms of the  peculiar convulsions :  " epilepsy
should be regarded as an idiopathic disease, /. e., a morbus per
se, which is to be distinguished  from eccentric convulsions,  from
toxaemic spasms, from  the convulsions  occurring in connection
with organic changes of the cerebro-spinal centre, and from every
other known and recognizable disease."  (R. Reynolds, 1.  c, p.
33.) Reynolds allows, to be  sure, that an irritation in the  foot,
in the mucous membrane of the digestive tract, in the lobes of
the brain,  etc., may result not  only in simple  convulsions, but
occasionally even in "epilepsy;" in spite of this, however, he
maintains  that  a sharp distinction  should be established.  In
the case of  convulsions "a condition of increased irritability in
the reflex centre" merely has been  reached;   in epilepsy,  on
the other hand, this condition has "acquired an existence of its
own, and the exalted  irritability thenceforth depends upon  an
altered nutrition, which continues even after removal of the ori-
ginal eccentric source of. irritation."   In their external manifes-
tations, in their duration through a period of years, the two con-
ditions may be wdiolly alike.   The simple convulsions, however,
are distinguished by their pronounced  and constant relation to
demonstrable irritations,  and by yielding to  the appropriate
treatment directed to this irritation.
   From the weight of Reynolds' authority we feel obliged to
enter somewhat more into detail with regard to his views, though 
1SS
NOTHNAGEL. —EPILEPSY.
still but briefly.  We  cannot deem them correct, and we regard
the  division wdiich he makes  as  not fortunate.   It  cannot be
doubted that in epilepsy a peculiar condition, an alteration per
se, exists in the central  nervous system.   But this  "epileptic
change,"1 to the further discussion of which we shall return
below, is,  in our opinion, also found in many cases  that  Rey-
nolds calls eccentric convulsions, and can be  explained simply
according  to  Pflueger  s  laws of reflex action.   The only two
grounds which  he  adduces  for the  division  do not render  it
necessary.  For  at any rate no constant relation can  be proved
to exist between the single seizures  of eccentric convulsions and
any  irritation whatever.   It is a  well-established fact  that in
persons who have become subject  to epileptiform seizures as a
result of  a cicatrix or some such  cause, these seizures do not
occur only or exclusively after irritations of  the cicatrix, but
also quite spontaneously or after  mental changes.  The former,
however, would  necessarily be  the case if we had to  do  with
"reflex manifestations"  only; for certainly, from a physiologi-
cal point of view, the  conception of  these has no other signifi-
cance than that the same connecting link of irritation always
precedes them ;  but if convulsions appear without being pre-
ceded by a definite external irritation, then a  pathological change
of some other kind must already have taken place in  the reflex
centre.  In such cases, therefore, we shall be obliged  to assume
a peculiar change in the pons and medulla oblongata.  But even
the fact that recoveries take place after removal of the irritation
is  by no  means proof of an essential difference, as Reynolds
represents  it, for it  chiefly  concerns cases  wdiich come under
treatment  soon,  in wdiich,  therefore,  the epileptic change has
not yet become  inveterate ;  and it  is well  known,  too,  that
"idiopathic" epilepsies are relatively the most curable  if they
are still recent.  If the  "reflex epilepsy" have been present for
years, it does not always disappear at once on the removal of the
peripheral irritation, but single paroxysms make  their appear-

   1 In the course of this account we shall always employ this expression and not that
of " epileptic condition," which was formerly used  for it, so as to render impossible any
confusion with the "etat epileptique," which is employed  in French in a  wholly
different sense. 
INTRODUCTION.
189
ance,  proving that we have to deal with  something more than a
simple chain of reflex manifestations, for otherwise there would
be nothing to excite any further paroxysm after the removal of
the definite pathological irritant.1 Finally, it does not favor the
idea of simple  reflex convulsions  that  (except  in the  case of
wounds of the head) the first paroxysm  follows only a consider-
able time, perhaps a week, after the establishment of the periph-
eral irritation.
   Accordingly, the form  of reflex epilepsy ought to be retained.
Only  this name does not appear to  us comprehensive enough.
We shall subsequently have  to explain that the epileptic change
is excited and brought about not only by  the peripheral nerves,
but also,  though less  often, by the spinal  cord,  and in less
frequent cases  by the brain.   If,   therefore, those cases  are
designated as idiopathic  or  primary  epilepsy in  which no such
excitation can  be proved, it  is perhaps not injudicious to char-
acterize by a name which commits us to  no  theory, viz.,  "sec-
ondary"  all those other cases in which an affection of the brain,
the spinal cord, or the peripheral nerves,  is  present as a source of
excitement and a starting-point for the disease.   Meanwhile, we
are agreed with Reynolds in  excluding from epilepsy any epilep-
tiform seizures which occur quickly for some few times in conse-
quence of an external irritation, and  disappear just  as quickly
again after  its removal.  The  teething  convulsions of children
furnish the type of these.  Functionally, of course, the process is
here the same  as in true epilepsy;  but in those parts of  the
brain  which will be mentioned further  on, no evidence can be
found of that more  permanent  change which must  necessarily
be present for the characterization of epilepsy.    The name of
Erlanipsia may well be employed for these  conditions, which
Peter  Frank very property designated as  acute  epilepsy.  We
shall enter into this more fully when speaking of Eclampsia.
   Thus, on the one side'  the domain of the epileptic conditions
has been  more  closely limited,  in part correctly and  in part
wrongly, as we have just described, while in another direction it
  1 A pronounced case of this kind has been recently reported byHitzig in his " Unter-
suchungen uber das Gehirn," p. 187. 
190                NOTHNAGEL.—EPILEPSY.

has within the last ten  or twenty years  attained a  markedly
increased extent.   A whole series of cases,  the clinical picture of
which would formerly have fitted into the frame of no  one of the
recognized groups of symptoms, are to-day reckoned as epilepsy,
following the example of Trousseau and especially Griesinger.
The latter writer preferred  the designation  of '' epileptoid condi-
tions;'1 but  we do  not hesitate to call  them  simply epilepsy.
While formerly,  in characterizing the  disease, emphasis was
laid  upon the convulsive symptoms, it  is true that now, from
consideration  of the "little  attacks"  {petit mat), the  opinion
has gradually gained ground  that the loss of consciousness is
to be regarded not only as of  equal significance, but  in it is to
be sought the controlling  element of the epileptic attack.  The
study of the epileptoid conditions has forced this way of looking
at it more  and more into prominence.  In fact, the  varying
forms under which they present themselves, and which will be
described further on, lead  to the conviction that not a complete
abolition of consciousness even, however  short it may have been,
and  without any  muscular  spasm, is  necessary to  character-
ize the disease as epilepsy, but that a simple  dizziness  is suffi-
cient,—in fact, any alteration  whatever  of the mental  activity
occurring paroxysmally,  such as  hallucinations  and the like.
A common  causal  connection, however, viz.,  an altered, i. e.,
increased or diminished, degree of fulness of the vessels of  the
brain, embraces all these varying features of the paroxysms  one
with another, and makes them comparable with the great attacks
of the ordinary forms  of epilepsy.  Of  this we shall say more
hereafter.
   It can be proved from the course of the epileptoid  conditions
that, although characterized  sometimes by the most peculiar
symptoms, they agree essentially with  the  ordinary forms of  the
disease, and  that the epileptic change lies at- the root of them
too.   For instance, they are  often preceded by a distinct indu-
bitable  injury, or  during  their progress  spasmodic  symptoms
occur,  at first of limited extent,  but  which gradually  develop
the well-known characteristic features of the disease; or again
a major attack may appear  suddenly,  when  for  a  long  time
there had existed only the  indefinite epileptoid attacks.  Recent- 
INTRODUCTION.
191
ly,  however,  Westphal'  has insisted  quite  properly that we
should  not go  too  far  in this  direction,  that  we  should not
at once declare every patient to be  an epileptic who occasion-
ally presents  epileptoid  or epileptiform accesses.   According
to his experience, he  regards these attacks as among the most
frequent symptoms in mental and nervous diseases of the most
varied nature, without the character and essential nature of these
diseases being determined by their occurrence in single instances,
i. e., without their being thus stamped as epilepsy proper.  We
shall endeavor further on to determine where the boundary lines
should be drawn in  this matter, what  patients with epileptoid
seizures may yet be regarded as suffering from epilepsy proper.
   While, therefore, we consider the  establishment of these con-
ditions in true epilepsy as essentially correct in the present state
of our knowledge, we cannot say the same for "epil.  spinalis;''
a term which has been brought  into use especially by Brown-
Sequard.   Of course, if we use this designation for  those cases
in which an actually existing epilepsy is developed in  conse-
quence of an affection of  the spine, it would have a certain jus-
tification.  Still it is superfluous, for here the name of secondary
epilepsy, as above proposed, is in our judgment amply sufficient.
We must,  however, very decidedly  protest against  the  abuse
which has  recently come into  vogue  of  describing as  spinal
epilepsy the clonic and tonic spasmodic seizures which occur as
a symptom in  spinal  affections,  which  remain confined to the
extremities or even to the legs,  and are not accompanied by any
trace of  mental  changes.   With just as much propriety could we
speak of a  spinal accessory or median epilepsy in the case of
clonic twitchings of the muscles of the fingers or neck which pro-
ceed from a peripheral affection of the median or spinal accessory
nerve.   In our opinion it is most  judicious  to let the expression
fall entirely into disuse, for on one hand it is unnecessary, and,
on the other, it  only leads to confusion.
   From all that has been  said so far, it follows plainly that it
is not possible  at the  present time to give  a brief definition of
epilepsy.  In the following propositions, the reasons for  wdiich
1 Ueber Agoraphobie, Archiv f. Psychiatrie u. Nervenkrankheiten. Vol. III. 1872. 
102
NOTHNAGEL.—EPILEPSY.
are in  part  to be  found in the course of  the account, are com-
prehended the most important characteristics of the disease.
   Up  to the present  time epilepsy is only a clinico-symptoma-
tological conception, such, e. g., as apoplexy, but not at all an
anatomical one,  as e. g., cerebral hemorrhage.   Nevertheless,
it must, according to  all our  present knowledge, be  adhered to
as the designation  Of a perfectly definite morbid condition.
   This morbid condition is composed of two factors: of a per-
sistent change in the  central  nervous system on the one hand,
and on the other,  of external symptoms, wdiich occur partly in
paroxysms, and are in part continuously present.  The mere form
of the paroxysms does not alone warrant the assumption  of an
epilepsy, for they may be produced in a precisely similar way by
various other causes.
   The anatomical changes which underlie the group of symp-
toms called epilepsy,  and which, in a given case, are somewhat
variable and more or less clearly marked, are to be sought for in
those sections of the  central nervous system which include the
pons, the medulla oblongata, and the upper part of the cervical
medulla.  We are still  unaware whether these  changes, which
constitute the essence of epilepsy, also take place still further
up or down in the brain and spinal cord, but this is not probable.
We must, of course, disregard such changes in the brain and cord
as are a consequence of the seizures.
   These changes and processes in the above mentioned portions
of the brain are up to the present time unknown in  their essence
and nature, and either come into  existence there primarily or
are excited secondarily,  either  by  the peripheral nerves, the
cerebrum, or the spinal cord.
   The group of symptoms in  the individual seizures corresponds
physiologically to  an excitation, or again to a fatigue of all or of
the single motor and vaso-motor nerves, the nuclei, /. e., the reflex
centres of which, are situated in the parts of the brain  referred to.
   Finally,  the  idea of  chronicity belongs to the  characteriza-
tion of epilepsy.  In the so-called acute epilepsy  or eclampsia
the central changes, which properly constitute the essence of ths
disease, are wanting. 
EXPERIMENTAL RESEARCHES.              193
                  Experimental Researches.

   It seems proper  to give before  the  clinical exposition a brief
account of the series of experiments which have been undertaken
for the purpose of  gaining a  clearer insight into the nature of
epileps}r.   In bringing them  together in this place, our  chief
object is to render the subsequent  explanation of the pathology
of the disease easier to understand, and to enable the reader to
obtain a connected survey of the material wdiich can be utilized
in building up  a pathology of the affection.   The experiments
may naturally be divided into two series: the  one refers  to the
mode  of  origin  and  the  character of the epileptic change, the
other to the genesis and nature of  the seizures.
   Brown- Sequard1  for   some  twenty-five years has  occupied
himself almost uninterruptedly with  the artificial production of
epilepsy  in guinea-pigs,  a  species of animals especially well
fitted for the purpose.  In these animals, after the wounding of
various portions of the  nervous  system, an epileptic  state  is
gradually developed ; as after lesions of the spinal cord, section
of one or  both  of the sciatic nerves,2 wounding of the  medulla
oblongata, or, finally, of  the  pedunculus cerebri, or the corpora
quadrigemina.    Of  course we cannot in this place repeat all the
multifarious details, and  therefore present only those which are
most important.   With the peripheral nerves this effect follows
after section of the internal popliteal, the trunk of the sciatic, and
the posterior roots of the nerves of the leg ; with the spinal cord
it most readily follows after  complete section of one lateral half,
but also if the posterior columns,  the gray posterior horns, and
a portion  of the lateral columns are simultaneously divided, or if
only the two posterior, lateral, or anterior columns are separately
  1 His publications on this subject are scattered through various journals ; the results
of his earlier labors are contained in his book :  '' Researches on Epilepsy; its artificial
production in animals, and its etiology, nature, and treatment." Boston, 1857.  Hia
later investigations are found chiefly in the Journal de physiologie de l'homme, Vols. L
Md III., 1858 and 1860, and in Vols. I. to IV.  of the Archives de Physiologie normale
et pathologique {Brown-Sequard, Charcot, Vidpian), 1868-1872.
  8 These facts had already been observed by Vidpian ; compare Arch, de physiologie,
etc., 1869, p  207; and Analoges bei Rana temporaria, by Schiff.
          VOL. XIV.—13 
194                NOTHNAGEL.—EPILEPSY.

cut throuo-h, or if the whole spinal cord is divided, or finally, if
a simple puncture  is made in it.  These wounds  produce the
most decided effect when made in the tract from the eighth dor-
sal to  the second lumbar vertebra, though the result sometimes
follows even after a wound  of any other portion.   After a short
time a state of increased excitability is developed ; spasmodic
twitchings  in  certain groups of muscles first appear, and then
complete epileptic seizures.   On an average, and most frequently,
from four  to  six weeks (11-71 days) elapse before their first
occurrence.  The attacks, in part, break  out spontaneously, or
they are determined by the irritation of a definite portion of the
skin, which Brown-Sequard designates the epileptogenous zone.
This includes the cheek and the antero-lateral region of the neck
(trigeminus and occipitalis), and is  always found on the same
side upon which  the cord or sciatic nerve was wounded, but, on
the contrary,  is on the opposite side in  wounding of the eras
cerebri.  This zone is indicated by a certain degree of anaesthesia.
Slight irritations of it, pulling of  the hairs, and the like, are
sufficient to produce the attack.  Sometimes the epileptogenous
zone extends  downwards almost the whole length of the verte-
bral column.   The attacks now occur with varying  frequency,
sometimes very often.   After the epileptic state has lasted for a
long time, perhaps for years, it gradually subsides,  and in the
same  proportion  the anaesthesia  of the epileptogenous zone
diminishes.  If it has been produced by a section of the sciatic
and a  rapid union of the ends of the nerve has taken place, the
epilepsy also disappears again rapidly. Finally, it is also a very
noteworthy fact  that the young of such guinea-pigs may be
spontaneously epileptic, i. e., without any injury having been
inflicted on them.
    This  is  what  is  most essential in Brown-Sequard's very
numerous  experiments.  The same  facts have been  determined
by Schiff and Westphal.   I may add from my own experiments
upon guinea-pigs that in a very strong animal, in which the cord,
with the exception of  the posterior columns, was divided at  the
level of the third lumbar  vertebra, the most violent seizures set
in at  the end  of only thirty-six hours, death occurring in  the
course of them from oedema of the  lungs; and Schiff  saw them 
                 EXPERIMENTAL RESEARCHES.              195

set in after three and four days. Moreover, the experiments have
been confirmed in regard to cats and rabbits, although not as vet
in a  thoroughly satisfactory manner.  Schiffl has  also observed
convulsions in dogs at the end of the first week after wounding
the cord in the cervical region, yet the animals at  the same time
retained consciousness, quite  contrary  to the case of Brown-
Sequard's guinea-pigs.
   Westphal8 produced an epileptic state likewise  in guinea-pi<t&
in another way.   If the animals are  given light  blows upon the
head, an attack of general convulsions results.  Then, for a con-
siderable time nothing special is to be noted ; but after the lapse
of some weeks the animals behave  exactly in the same way as
those in which the spinal cord or  the sciatic has been wounded,
i. c., upon irritation of the above-mentioned epileptogenous zone,
or even apparently spontaneously,  general  convulsions  break
out in wdiich coma is also sometimes  present, but  at other times
appears  to be absent.  This state lasts for from six weeks to six
months.   At the  autopsy Westphal  constantly found  small
hemorrhages in the spinal  cord and in  the  upper part  of the
cervical medulla.
   Hitzig3 has recently furnished  a further interesting contribu-
tion to the pathogenesis of epilepsy, as he has been able to cause
it by the artificial production of morbid processes in the cortical
portion of the brain.  If, e. g., he removed  the cortical  centre
which  controls  the anterior  extremity,  well-marked  epileptic
seizures,  beginning  spontaneously,  set  in  after  a longer  or
shorter time,-once on the very next  day, or after from three to
six weeks.
   The significance of these various series of inquiries as  to the
etiology  and pathology of the epileptic  state in man we shall
have numerous  occasions to allude  to in the further course of
this account.
   Experiments  have advanced  us  decidedly further in  the
knowledge of the epileptic seizure.  A. Cooper4 even sought to

          1 Lehrbuch der Physiologie. Lahr, 1858-59.
          ! Berliner klin. Wochenschr. 1871. No. 38.
          8 Untersuchungen liber das Gehirn.  Berlin, 1874. p. 271.
          * Guy's Hospital Reports. Vol.  I. London, 1836. 
196
NOTHNAGEL. —EPILEPSY.
prove by experiments, which were, to be sure, very meagre and
defective, that ligation, equivalent to compression of the carotids
and vertebral arteries, induced epileptic seizures.  Travers, like-
wise,  and  Marshall Hall  insisted  upon  the  resemblance of
eclamptic and epileptic paroxysms to the symptoms occurring
after the loss of great quantities of blood.  Kussmaul, however,
was the first, in a work carried  out in  conjunction with Tenner,
to arrive  at a great series of important  and well-established
results.  We can, of course, in this place only quote the most
essential of them.   In the first place,  Kussmaul showed  incon-
trovertibly that,  wdien  the brain is  rapidly deprived of arte-
rial blood, either  by bleeding or by the ligation or compres-
sion of the four great arteries going  to the head, in vigorous
animals not etherized, coma and general epileptic twitchings are
invariably  produced  by it, and that  these  symptoms quickly
disappear when the obstacle to the current is removed, unless it
have remained too long.
   Direct examination of  the  brain, by means of the method
introduced by Bonders, proved the actual presence  of anaemia
of that organ.  Further experiments taught him that the start-
ing-point of the convulsions was to be sought in  the excitable
motor portions of the brain lying behind  the optic thalami; that,
moreover,  the spinal cord during  the seizure serves only as a
conductor, but  that anaemia  of this part  does not result in
twitchings.   A critical view of the symptoms present in man,
and the comparison of them with the results of experiment, led
Kussmaul  and Tenner to the conclusion :  1st, that a circum-
scribed anatomical change in the brain cannot be regarded as the
immediate cause of epileptic seizures (because the coma neces-
sarily points to a simultaneous participation of the  cerebrum);
2d, that the  proximate cause of the seizures might  not be any
change of  long  continuance or constant, or even a grosser one
appreciable by the anatomist, but merely a change of a transient
kind.  In order to prove the hypothesis  that epileptic accidents
may be induced by means of vascular contraction, through the
medium of the vaso-motor nerves, they then endeavored  to pro-
duce amemia of the brain and the paroxysms by faradization of
the cervical sympathetics.  They succeeded  in this,  however, 
EXPERIMENTAL RESEARCHES.
197
only in a single instance, and  then only in an animal in which,
besides this, both subclavians and  one carotid were ligated.   I,
too, have attempted this latter mode of experimentation, with a
negative result.  The  reason of this failure is clear : as I have
proved,1 only a portion of the nerves of the cerebral vessels run
through the  cervical  sympathetic ; according to A.  Schultz,3
indeed, only abnormally.
   Further than this, I  have endeavored (1. c), by irritation  of
the peripheral sensory nerves, to produce, as a reflex effect, con-
striction of the arteries of the brain, and thus a cerebral anaemia.
My positive results have been confirmed by some very success-
ful experiments of Krauspe,3 while avoiding several sources  of
error proved by Riegel and Jolly4 to  exist in  my experiments ;
and certainly this was antecedently probable, judging from our
former physiological knowledge.
   It has therefore been  proved by Kussmaul that cerebral anae-
mia stands in definite relations to the epileptic seizure ; we shall
have to enter into  the details further  on.  How is the case now
with hypersemia of the brain?  Kussmaul and Tenner tested this
question by ligating the internal and  external jugular  veins  in
rabbits,  after section  of the sympathetics in  the neck,  but no
epileptic tremblings broke out.  Quite a number  of years later,
to be sure,  Landois6 maintained this view, though Hermann and
Escher6 re-established the correctness  of the statements of Kuss-
maul and Tenner in regard to rabbits, notwithstanding that in the
case of cats they were able,  by occlusion of the veins which lead
the blood from the brain, to produce exactly the  same group  of
symptoms  as in occlusion  of the  cerebral arteries, although it
was somewhat more slowly developed.
   Besides this, Kussmaul and Tenner made experiments to test
a well-known hypothesis  of  M. Hall,7 according to which the
1 Virchow's Arch. Vol. XL.
! Petersburger med. Zeitschrift. Vol. XL
3 Virchow's Arch. Vol. LII.
4 Ibid. Vol. LIX.
1 Centralbl. fiir d. med. Wissensch. 1867.
•Pflueger's Arch. Vol. III.
' Memoirs on the nervous system.  London, 1837.  Also in various other places. 
198                NOTHNAGEL.—EPILEPSY.

course of the symptoms in the epileptic seizure would  be  the
following :  1st. Excitation of a sensory, spinal, or cerebral nerve,
or even direct central excitation ; 2d. Thereby are caused:  a, a
reflex tonic spasm of the muscles of the neck  especially (trache-
lismus), by which the veins of the neck are compressed (sphagi-
asmus), and thus the comatose symptoms  excited ;  b, a reflex
tonic spasm of the muscles,  closing the rima glottidis (laryngis-
mus), leading to asphyxia, and through this to the general con-
vulsions.  Kussmaul and Tenner established the already well-
known  fact that occlusion  of the  larynx produces  coma  and
convulsions.   They were obliged, in accordance with  the experi-
ments adduced in the foregoing paragraph, to pronounce against
the trachelismus theory. On the other  hand, Russell Reynolds
(1. c.) has shown  that a  contraction of the muscles of the neck
produced by electrical irritation results  in stasis  in the veins of
the neck and cerebral disturbances.
   With regard to the anatomical starting-point of general con-
vulsions in the epileptic seizure, numerous experimental studies
have been published. As already related, Kussmaul and Tenner
established it in the parts of the brain lying between the spinal
cord and the crura cerebri, consequently in the pons and medulla
oblongata; Brown-Sequard and Schiff arrived at analogous con-
clusions.  Then I have shownx that the convulsion centre, /. e.,
that circumscribed  spot  from  which,  the  whole  body  of  the
voluntary muscles may  be thrown into tonic  and  clonic spasms
through reflex excitation, is to be sought  for in  the pons.  In
reference to the spinal cord, Kussmaul and Tenner have already
established  the  fact that in convulsions from excessive bleeding
it serves as a conductor  only ; that no convulsive motions start-
ing from it can be excited  by anaemia.  This fact I have been
able to establish as indubitably correct, in opposition to  certain
recent statements, which, moreover, do not seem to be based on
experiments.2 From this, however,  the conclusion must  not be
drawn that also  in  epilepsy proper the spinal cord acts  simply
as a conductor during the seizure ; for it is of course well-known
that, under certain circumstances, complete epileptic convulsions
1 Virchow's Archiv. Vol. XLIV.
2 Ibid. Vol. XLIX. 
EXPERIMENTAL RESEARCHES.
199
may take their origin from it alone, and this phenomenon has
even led to the designation epilepsia spinalis.1  Still,  some inter-
esting experiments of Brown-Sequard seem to favor the view that
the function of the spinal cord in the seizure is  only that of a
conductor.   In epileptic guinea-pigs he witnessed the  absence
of convulsions in the hind leg of the side  on which  the spinal
cord was divided ;  but besides this he also found  the following:
if a guinea-pig has been made epileptic by section of one poste-
rior column and the neighboring gray substance, wdiile the ante-
rior column is left untouched, the voluntary movements remain
intact on both sides, and nevertheless the convulsions are absent
on the side of  the section.  From this Brown-Sequard concludes
that certain portions of  the spinal cord convey the impulses to
voluntary,  and others those to the spasmodic movements.
   Perhaps still another conclusion can be added to this last
experiment.  We  mentioned above (p. 191)  that it is wholl}*
unknown whether the medulla spinalis  partakes  in the change
which constitutes the  essential feature of epilepsy.  This experi-
ment appears to us, at all events,  not to favor that view.
   Brown-Sequard then made the further observation on the epi-
leptic animals that the commencing seizure,  in which the head is
regularly turned towards the side of the injury, may be arrested
by a sudden vigorous turn towards  the opposite side, and its
further development prevented.   Who does not, in this connec-
tion, at once think of the  popular remedy  of forcing open the
thumb and the like ?  There will also be an  arrest  of  the seizure
if the epileptogenous zone is touched not lightly but strongly, if
it is  burned or cut; in fact,  it thereby loses its epileptogenous
capacity.  The seizure may also be  arrested if a  strong stream
of carbonic acid is brought to bear upon the mucous membrane
of the throat.   This last communication, which wras  only very
recently made by Brown-Sequard, has, indeed, already been con-
tested by Filehne,2 who  never succeeded in cutting  short the
seizure by ever so strong  a stream of carbonic acid.
  ' Compare especially Ildlopeau, Des accidents convulsifs dans les maladies de la
moelle i piniere.  Paris, 1871.
  ' Archiv von Reichert und Dubois, 1873. 
200
NOTHNAGEL.—EPILEPSY.
                          Etiology.

   If the causes  of epilepsy are to be studied, a correct method
of examination must of course be followed.   This would require
no special mention, if a false way of drawing a conclusion were
not often made use of so soon as we have to do with a special
case, in deciding  from any fact whether it be  the cause of  the
epilepsy or not.  We will give an example.   Some one, who has
hitherto appeared well, is violently alarmed, experiences an epi-
leptic attack, and afterwards remains epileptic ; therefore, it is
decided, the fright was the cause of the epilepsy.  We consider
this wrong. The only direct sequence furnished  by the facts is
that the fright provoked the epileptic seizure.
   In our opinion it cannot be kept too prominently before  us,
even in  regard to the etiology, that we must draw a clear distinc-
tion  between the central epileptic change, in the sense in which
we have presented the idea above, and the symptomatic expres-
sion  of  it, viz., the seizures.   The question as to  the causes of
epilepsy, then,  breaks  up into two parts :
   1. What influences  produce the epileptic change ? and
   2. What produce the outbreak of the symptoms f
   There can scarcely be room to doubt that a change such as
that which lies  at the root  of epilepsy and constitutes its essen-
tial character,  a  change of so thoroughly chronic a  kind, can
also, in analogy  with other morbid processes, develop only
slowly and gradually.  It is of course conceivable that some con-
dition, having an acute and  transient action, shall, on some one
occasion, give the first  impulse to the development of the change,
just as occasionally the development of a malignant tumor may
be caused by an injury ;  but  these cases form the marked excep-
tions.
   If we analyze the individual cases of epilepsy according to the
various  conditions, which,  with varying frequency to  be sure,
may, in  accordance with our experience, lead to the development
of the  epileptic  change, they naturally fall  into three  great
classes :
   a. Cases in  which  the  disease  is  produced by factors of a 
ETIOLOGY.
201
kind  not appreciable anatomically,  which  at times affect the
nervous system alone, at others the whole organism.
   b.  Cases in which lesions of a definite anatomical  kind affect-
ing the nervous system act as the cause.
   c.  Cases in which no causes are conceivable, or can be assigned
with any degree of probability, where we must, therefore, assume
a spontaneous development of the disease.
   As to  a. Here inherited tendency  occupies the  first place.
The significance of this at the present day no longer needs to be
proved by statistics and special instances, it is a fact  noticed and
conceded by all observers.  The assertion may suffice that Eche-
verria out of three hundred  and six  patients under his own
observation had eighty  with  a  hereditary  tendency.   And in
regard to  this the idea of inherited tendency should not be taken
in the limited sense, as  if strictly epilepsy only in the ancestors
led to the re-development of the disease in the descendants.  Far
otherwise, daily experience teaches us that the children of those
parents  also may become epileptic who have been mentally dis-
eased, but who have never suffered  from convulsive affections.
The fact is, hereditary disposition must be taken in a far broader
sense, and the proposition may be enunciated that any neurosis
in the parents, whether it be of a lighter or more  serious kind,
may plant in the children the germ which may develop into epi-
lepsy. This  obtains not only in  regard to  hysteria, hypochon-
dria, and  catalepsy, but I have observed cases, where, e. g., the
mother suffered for many }rears from pronounced  migraine, and
with this exception there was absolutely nothing else in the way
of family tendency to be found, and yet a daughter was hysterical,
and a son epileptic ; from my experience I am even inclined to
ascribe to neuralgias of  many years' standing in  the parents a
capacity of producing epilepsy in the children.  There are even
not wanting instances where, in connection  with a mere "nerv-
ousness" of the ancestors, epilepsy made its appearance in the
descendants.  We must, however, also  give special  prominence
to alcoholism, of the great importance of wdiich in  the causation
of epilepsy, as wrell as of other  nervous lesions, in the children of
those  who are victims of it, we can ourselves  add a number to
the already well-known and numerous  examples.   It seems to 
202
NOTHNAGEL. —EPILEPSY.
make little essential difference whether in all these cases diseases
exist in the father or the mother ;  it is not even necessary for it
to be the parents directly ;  a neuropathic tendency in the family
generally suffices.  Occasionally a generation may be skipped, and
it  may even  happen that the progeny of epileptics remain per-
fectly healthy ;  this latter is, to be sure,  but rare, and the advice
given even by Boerhaave, that epileptics  had best remain unmar-
ried, is decidedly judicious, if it  could only  be carried out in
practice.  It  is proved by numerous examples that epilepsy also
belongs among  the various  diseases from  which the children of
consanguineous marriages suffer.

   That phthisis in the parents entails a tendency to epilepsy in the children, is in
our opinion not correct, and if this relation often presents  itself, it  is certainly
explained, as already observed by Hasse, by the actually very great frequency of
phthisis.  All the arguments brought forward again recently by Echeverria in favor
of  the connection between the two diseases lose their importance in view of this
fact.

   If epilepsy is hereditary, the first occurrence  of its symptoms
is  generally  early ; according to Echeverria, before  puberty;
according to  Reynolds, not later than the twentieth year.  Our
own experience agrees with the latter, and  it may, therefore, in
general be assumed that an individual with a  hereditary predis-
position, remaining  healthy up to the twentieth year,  will also
escape epilepsy after that,  so far  as its  development is excited
by the inherited tendency alone.   I will  also add that such indi-
viduals often suffer from  eclampsia as early as  during the first
dentition, but afterwards again remain apparently healthy up to
the outbreak of the epilepsy.
   As compared with inherited tendency, all the other influences
which  affect the organism  or the nervous  system as a whole are
inferior in their  capacity  for  exciting  the  central  epileptic
change.  Such a capacity is ascribed to many influences, though,
as already mentioned, of some it can only be proved with cer-
tainty that they caused the  first seizure ;  on the other hand, some
seem to  have  been actually  capable of  evoking the  epileptic
change, although less frequently than is usually assumed.
   Among the latter the habitual drinking of considerable quan- 
ETIOLOGY.
203
tities of alcoholics—drunkenness, in fact—assumes the first place;
epilepsia potatorum has long  been recognized.   Apart from the
complication wdth the usual symptoms of alcoholism in the inter-
vals, this does not  differ in its seizures from the ordinary form.
The seizures are not always preceded by other severe symptoms
of alcoholism, but  sometimes  even  form the beginning of the
series.  At times the first seizure  appears in conjunction wdth a
severe fit of intoxication, but again at other times just wdien, for
some reason, there has been a temporary total abstinence ; in still
other cases some external accidental cause occasioned  the first
attack.

   It is worthy of mention that the various experimenters have been unable to pro-
duce epileptic seizures in animals by the continued administration of alcohol. We
call special attention to the labors of Magnan,1 who has studied this particular
phase of the action of alcohol.

   The older observers laid great stress on  sexual excesses, and
even announced coitum  parvam esse epilepsiam  (Ettmueller,
Senac).   Of late we have become much more sceptical in regard
to this, and justly so.
   The various  reported cases where a first seizure has taken
place during or as an immediate consequence of coitus certainly
do not prove that the latter produced  the epilepsy.   Still,  how-
ever, continued and great excess in Venere should be regarded as
a veritable, though  extremely rare, origin  of the epileptic change.
This is proved  indisputably by a comparison of the abuse in
Venere, which is so frequent,  with the infrequency of epilepsy
thereafter.   Even the significance of masturbation was  formerly
decidedly exaggerated ; and Herpin correctly observed  that the
causative relation is hard to  establish wdien  a vice is  so wide-
spread.   At all events, its effects upon the nervous system must
undoubtedly be more marked than even  the excessive gratifica-
tion of the sexual passion in the natural way.  Nevertheless,
examples   of  epilepsy  after  onanism  are  very  infrequently
recorded  among careful observers.  Among our own cases we
have but one in which we could ascribe the origin of the disease
to the vice  we have mentioned.  Echeverria insists that here post
1 Besides various other places, compare Archives de Physiologie, 1873. 
204                NOTHNAGEL.—EPILEPSY.

and propter may not infrequently have been confounded, as it is
known that many epileptics first begin to practise onanism after
they have had seizures.  Still more should we doubt that abso-
lute  sexual continence may lead  to the development of the dis-
ease.  Although Tissot declared  this to be an established truth,
and  even Herpin, in the case of  women  at least, would assign
weight to continence as a  "disposing" influence, still, all more
recent observers, with the exception of a few, such as, e. g., Rad-
clifle, from their experience, speak very cautiously in regard to
this.  In  this connection we give  a statement of Althaus1 that
congenital phymosis may lead to epilepsy through the medium
of the masturbation which often accompanies it.
   Close and continuous mental exertion, as well  as powerful
long-continued depressing  emotions, especially grief, were in
like  manner formerly  regarded as influences which  could beget
the epileptic change.  On an impartial survey  of  the  subject
the  conclusion  must  be reached  that,  in view of the frequent
occurrence of the  influences named,  this is at least not proved ;
meantime we cannot wholly reject the possibility of it.
   It is a question requiring further careful investigation whether
certain  general  disturbances of  nutrition, especially scrofula
and rickets, to which epilepsy is  often attributed, may occasion
it, and particularly whether an impoverished, insufficient nour-
ishment may have the same effect. The importance of the latter,
in the development of an "active hereditary nervousness,"  has
recently been again forcibly insisted on by Anstie,2 and in addi-
tion   to several  older  investigators,  Echeverria is  also of the
opinion that cachexia in the parents gives rise to epilepsy in the
children.  And so  calm an  observer as  Hasse  thus expresses
himself in regard to it, viz., that the disturbances  of nutrition
alluded to,  " not infrequently seem to bring about a predisposi-
tion,  in the presence of which  proper exciting  causes may lead
to the outbreak  of  epilepsy."  Very  careful and comprehensive
statistics only can determine this question.
   Finally, there are instances well vouched for where real epi-
lepsy has gradully developed itself from the simulated  disease
when of considerable duration.
1 The Lancet, 1867.            The Journal of Mental Science, 1873. 
ETIOLOGY.
205
   If we, then, make a synopsis of what has just been said, the
result is as follows :  it is indisputabty established with regard to
a certain hereditary predisposition only, that it may develop in
the subjects of it those changes in the central nervous system
which constitute  the essential characters of epilepsy.   This  is
still open  to question  in a greater  or less degree in all other
assumed causes,  and at all events their capacity for  producing
epilepsy is slight compared with the actual frequency of its
occurrence.
   As to b. With reference to another series of causes, we find
ourselves upon a field much more capable of demonstration, for
here we can in part  plant ourselves upon the firm ground of phy-
siological experiment.  We are thinking of those cases in wdiich
definite anatomical  lesions,  acting upon some certain portion of
the nervous system, induce epilepsy ; that is, the  development
of the  central epileptic change.   The  lesions may involve the
peripheral nervous  system, as is most often the case—the brain,
or the spinal cord.
   We have already expressed our views on this subject to the
effect  that wre believe  that  the  "reflex-epilepsy,"  occurring
after wounds of  the peripheral nerves, must  be regarded as
really the  disease, and are  of the opinion that  the central epi-
leptic change is  induced in consequence of a definite excitation
acting  continuously from the sites of those lesions, exactly as
in Brown-Sequard's experiments.  What view  should  perhaps
be accepted as to the connection will have to be touched upon
further  on.  The lesion  is then  at all events an "occasional"
cause;  but it is  in a special case the actual and only cause,
which,  without the aid of other influences, produces the disease.
   Cases of  the kind have already accumulated in such large
numbers in monographs on the subject and in periodical litera-
ture  that  we may perhaps condense from  them some  general
propositions.  The nerves affected are either mixed or sensitive ;
most frequently it is the  sciatic or the fifth, more rarely others,
yet it may,  as occasion  offers, be any sensitive  or mixed nerve.
The lesions generally consist in external traumatic agencies act-
ing upon the trunk, branches, or cutaneous distribution of the
nerves, less often in pressure due to  tumors or in neuromata. 
206
NOTHNAGEL.—EPILEPSY.
In case of wounds of the skin, a peculiar cicatricial formation
may sometimes be found.1   The first seizure almost invariably
appears some weeks or months, or even in some instances, years
after the injury.   The form of epilepsy which  thus arises is
generally marked by an aura  of a sensitive,  motor or vaso-
motor  character, proceeding  from the  region of the  affected
nerve.   Sometimes, during the period wdiich elapses between the
receipt  of  the  injury  and  the  first fully formed  paroxysm,
there show themselves twitchings which  are  either limited to
the territory of the muscles supplied by the  nerve or are  dif-
fused over the whole corresponding half of the body.
   In this category belong  also those cases in which in women
the disease receives its stimulus from the direction of the sexual
apparatus.   The importance of  genital affections in  this respect
is  excessively  exaggerated;  especially  should  those cases be
excluded in  which the menstrual period provokes  simply  the
individual paroxysms, but not the epilepsy itself.  Still, the latter
also seems actually to occur. The connection in these cases must
be regarded  as wholly analogous to the lesions  of other sen-
sitive nerves, i. e., a  persistent anatomical lesion in  the various
parts of the genital apparatus acts through the medium of  the
sensitive nerve involved as a constant  centripetal irritant.
   I am inclined, however, to go even  a step further in this direc-
tion.  There  are cases, of which several  very  pronounced ones
have occurred in my practice, where absolutely none  of the etio-
logical influences mentioned, nor even any of the determining
causes yet to  be mentioned, can be found, and yet where a
blooming child  of from five to fifteen  years is  suddenly over-
whelmed by a  seizure, which is  then repeated in the ordinary
way.  Now, in some of  these patients it can be proved with cer-
tainty that they had suffered from eclamptic convulsions during
the first dentition. I cannot get rid of  the idea  that here the
process, at  first purely functional, which was set up  in the cen-
tral parts at the time  of the teething convulsions,  may have fur-
nished the impetus for the development of the epileptic change.
Further on, in  the chapter  on Pathology, we shall touch upon'
1 Compare Schnee, Two cases of reflex epilepsy.  Zurich, 1861. 
ETIOLOGY.                        207
the possible mode of development which may have taken place
here.   Still the foregoing view may be rejected in regard to some
case?, and another held, according to which the connection exist-
ing between the dental convulsions and the subsequent epilepsy
would be different from that which makes the former alike the
evidence and the result of a  nervous  system already diseased.
This question cannot be positively settled.
    So far we have spoken only of  lesions of  sensitive, or at any
rate of mixed nerves leading to epilepsy.  It seems possible, how-
ever, for lesions of motor nerves also to be sometimes capable of
this.  At least several observations recorded  in  the literature of
the subject point in that direction.  But as this relation has not
yet been determined with sufficient frequency and certainty, we
content ourselves with this brief reference.
   The above-mentioned  experiments  of  Westphal and Hitzig
(11. cc.) have furnished experimental proof of the following propo-
sition, which  w^as  formerly accepted  clinically, but was subse-
quently doubted, viz., that injuries of the skull, and correspond-
ingly, affections of the substance of the brain,  may themselves
lead to the development of epilepsy.

   Hitzig's other experiments, in which irritation of the surface  of the brain by
strong electrical currents was followed by the outbreak of general convulsions, must
of course be entirely disregarded in the inquiry as to the causation of epilepsy,
although these experiments were repeated by Ferrier and others, and even made use
of in theories of epilepsy. The reason is that in them there was only the out-
break of an epileptiform seizure during an irritation, but there was no later devel-
opment of the epileptic state.

   The external injuries which involve the skull  need not by any
means leave behind a lesion which is perceptible externally ; on
the contrary, such would not  only be non-essential for the class
of cases now occupying our attention, but would even bring  the
epilepsy into the preceding etiological group, providing it could
be traced to this origin.  Our interest is now much rather with a
cerebral lesion induced by the violence directly, as in case of  a
hemorrhage,  or indirectly,  as when the  cortical  substance is
wounded  by splinters of bone.  I can add another to the obser-
vations bearing on this point which are collected in the literature 
208                NOTHNAGEL.—EPILEPSY.

of the subject, and "to which Leyden1 has very recently added a
case.   Mine appears to me to be interesting in several ways, and
especially as illustrating strikingly the experiments of AVestphal.
I only emphasize briefly the principal points.
   A boy of eight years, who came of a perfectly healthy family,
had never been seriously ill, and had had no convulsions in teeth-
ing, fell a distance of  twelve feet upon hard ground, striking on
the head.  He lay unconscious for some fifteen minutes, after
which he roused, and at the end of ten minutes more was seized
with a marked epileptic attack.  There was a small scalp-wound
on the right side of the head, wdiich healed in a few days.  After
that for six weeks he was in a condition of perfect health ; then
there  was again  an epileptic seizure,  and from that time they
have constantly recurred, in former years at considerable inter-
vals, of late years every four to twelve days.   They always
occur without an aura, being  but very seldom preceded by a
momentary dizziness.   They invariably begin  by a turning of
the head to the left; consciousness is then first lost, the counte-
nance becoming  pale at the same time, and  general  convulsions
declare themselves.   Interparoxysmal  symptoms  exist  to a
limited degree ;  from time to  time only a little headache; and
sometimes there  appear slight twitchings in the left  half of the
face or in the left arm.   The patient, who is now a vigorous per-
son of twenty-one years, appears to be of rather limited mental
powers, and complains of  a weak memory.  Objectively there is
nothing to be discovered except a cicatrix, about  the size of a
lentil, corresponding to the right coronal suture, and four centi-
metres distant from the median line.  This is not  painful or
adherent, and when touched,  either gently or quite roughly,
no symptoms are  manifested.  No epileptogenous zone is to be
found.
   The fact that epileptiform seizures, recurring once or several
times, may be a symptom of different  diseases of the brain, such
as diffuse  anaemia or  hyperaemia, incipient  hemorrhages and
embolisms, etc., has been already explained.   There are undoubt-
edly cases, however, in which a circumscribed focus of disease
1 Virchow's Archiv. Vol. LV.
• 
ETIOLOGY.
2*09
becomes the starting-point of the epilepsy, exciting  the  develop-
ment of the epileptic change in the medulla oblongata.   In these
cases the anatomical character of the original affection seems to
be of less  importance than its seat.  Affections  of  the cortical
portion seem to us of special significance in this respect.  Thus
it is a long-established rule  that tumors, especially of the con-
vexity, are accompanied, as they say, by epilepsy.  It certainly
is also  true, in regard to many of these  tumors,  that they occa-
sion symptomatic convulsions by their  size or their mechanical
relations leading to secondary anaemia, etc.   Yet there are not a
few cases where a very small tumor, the size of a hazel-nut, found
at the  autopsy in the cortex, has  given origin  to  an epilepsy
that existed for years.1  The same thing is recognized in regard
to exostoses, which affect the cortex, and also in regard to the
remnants of hemorrhagic foci and centres of softening wdien simi-
larly situated.    As  to  the  epileptiform  seizures  of paralytic
patients with mental disease,  Westphal2 expressed  the opinion
several years ago that possibly they were not  due directly to
lesions of the cortex or ventricles, but to a secondary  process in
the pons or medulla oblongata.
   In all such cases it must be assumed that the  original lesion,
in analogy with  the injuries of peripheral nerves,  has led second-
arily to the development of an epileptic change. A more inti-
mate knowledge of the method of this process completely eludes
our view, just as the actual relations in their details still require
the most careful  study.  We only consider the general way of
looking at it just developed as in the main correct.   We shall
speak further on of the clinical peculiarities  of this form of
epilepsy.
  According to  Brown-Sequard's experiments, we might expect
a rather frequent concurrence of epilepsy with diseases of the
xpinal cord.  In reality,  however,  it is not  so, provided we
exclude what is  in our opinion falsely called epilepsia spinalis
(compare above,  p. 198), and count only those cases in which the
genuine central  epileptic change  has developed secondarily, in
  1 Compare especially Griesinger, Cysticerken  und ihre Diagnose. Ges. Abhandlun-
Sen. Vol. I. p. 399.
  2 Archiv fiir Psychiatrie und Nervenkrankheiten. Vol. I.
          VOL. XIV—14 
2f0                NOTHNAGEL.—EPILEPSY.

consequence of a disease of the spinal cord.  Only a short time
ago Westphal entertained doubts of the occurrence of  instances
of this kind, as did also Leyden;1  yet recently several cases
have been made known which scarcely admit of a doubt of their
interpretation, as those,  for example, which have been reported
by Oppler,a Echeverria,3 and Szontagh.4
   With regard to c.  After excluding all those cases where the
influences adduced under a and b have operated, in regard to
wdiich it can be assumed, with a greater or less degree of proba-
bility or certainty, that they were capable of bringing about the
epileptic change, there still remain a  considerable  number for
which not the slightest cause  can be discovered ; for,  as to the
influences presently to be discussed, which are often  adduced as
"causes"  of epilepsy, under the operation of which the symp-
toms break out suddenly, we can allow such a designation to be
valid only in exceptional cases, and even these  may  be entirely
absent.   It even happens that an individual, with no hereditary
predisposition,  etc., who has hitherto been in the full enjoyment
of health, is very suddenly overwhelmed  by a paroxysm in the
night or in his sleep.   In such a state of affairs there remains at
present, in our opinion,  but one assumption, viz., that epilepsy
may be developed altogether spontaneously, without  any induc-
ing influences whatever at present known.
   We remarked just now  that many influences are mentioned
as causes of the disease,  of which it can  only with certainty be
said that they led to the outbreak of the symptoms, i. e., that on
their operation followed  the outbreak of the first epileptic par-
oxysm.  As to many cases,  it seems to us unquestionable that a
fright, or  some  other circumstance, merely called forth  the
explosion—sit venia verbo—while the peculiar epileptic change
had long  before been  developed in the  nervous system ; in an
analogous way, as an insufficiency of the valves of the heart may
long exist, and palpitations,  as a symptom of it, may not be
observed until favored by  some accidental occurrence, such as
-apid walking or the like.  Would any  one, though, be willing
        1 Klinik der Riickenmarkskrankheiten. 1874. Vol. L, p. 110.
        2 Archiv f. Psychiatrie und Nervenkrankheiten. Vol. IV.
        3 Loc. cit. p. 241.         i Wiener med. Presse. 1872. No. 5. 
ETIOLOGY.
211
to-day to say with certainty that this is always so ?  And if anv
one argues in this way :  a severe fright provokes an epileptic
seizure in a perfectly healthy individual, and the development of
the epileptic  change is  excited  only as a result of the unaccus-
tomed functional processes which then take place in the medulla
oblongata, we are not in a position to gainsay such a conclusion.
We are here still moving wholly in the realm of hypothesis ;
but, on this very account, we regard it as advisable at present to
characterize all these so-called occasional causes of "epilepsy"
as such only when they induce  the  outbreak of  the symptoms.
This expresses  the actual state of the case as at present known,
and does not  commit us to  any false assumption.  An extended
investigation  alone will be capable of bringing  to a decision  the
question whether epilepsy can really come into existence in  the
manner indicated ; and, even if  this point were established,  the
first seizure would have to be regarded as only a purely func-
tional process,  based as  yet upon  no change in the  medulla
oblongata or  pons, but which wall itself furnish the stimulus for
the development of such.
   The mere  number  and  the character of these assumed
"causes" of epilepsy vary incredibly.   Joseph  Frank1 brings
forward over a hundred of them, but  prudently  adds,  "which
have excited epilepsy,  or,  at least, single seizures of  it."   It
happens  to every physician to  hear it attributed to the most
heterogeneous influences.   Reynolds has  arranged  these in.four
classes,  and  distinguishes psychical  or physical influences,
eccentric irritation, and  general  organic processes.   We believe
we  can, without disadvantage,  omit a detailed  enumeration ;
only the most important  causes and  those  of  most frequent
occurrence will be selected.
   At the head of the  list stand psychical impressions of  the
most opposite character.  Among them, fright again plays  the
most important part.   Who could  not bring  evidence  of this
from his own  experience ?   But also grief, anger, painful excite-
ments, and joy belong  in  this category ;  in Tissot and Portal
numbers  of striking  examples are pointed out.   Terror is cer-
1 Joseph Frank, Die Xorvenkrankheiten. 1843.  Vol. IV.  Section on Epilepsy. 
212                NOTHNAGEL.—EPILEPSY.

tainly  the efficient cause in those cases where  the  sight of a
person suffering from a seizure  provokes the same  in others;
still, in these cases a pathological imitative instinct has also to
be taken into consideration.   One of the most striking examples
of this is the well-known epidemic of epilepsy in  the Haarlem
Poor-house, reported by Boerhaave.   Not merely an  impression
on the feelings, however, but also mental effort may provoke the
outbreak of the first paroxysm, and even a repetition  of it in the
same individual.   Our literature  even  tells us of cases  where
vivid dreams,  especially if of a terrifying nature, have acted in
the same way.  Under my  own  observation, a girl had  a first
seizure from being obliged to eat the flesh of a cow that she had
taken care of and been attached to.
   The attacks are not infrequently  excited from  the direction
of the genitals.  Some women are subject to them quite regu-
larly at the period of menstruation, in wdiich case  they precede
or follow the latter by a brief interval; and I have observed this
especially in young girls, when the disease declared itself at the
same time with the development of puberty.   This feature, how-
ever, usually disappears after a time.  It  is known that in some
individuals, male as well  as female, the first coitus provokes a
seizure, which is subsequently  repeated every time.  Anomalies
of menstruation may also have  the same effect.  What is true of
the genital apparatus is true also of the organs of digestion.   In
especial,  overloading  of the stomach  with food, but, even more,
the abuse of spirits on some single occasion, has been followed
by a first seizure.   In the  case of a  young merchant who was
under my observation, in whom  no  other etiological incentive
whatever could be found, the first paroxysms likewise followed
upon an abundant meal, but  thereafter without  this exciting
cause.  Occasional diarrhoeas have also induced the outbreak.
Moreover,  various observers have determined the  beginning of
the  trouble during the course of or convalescence  from acute
febrile diseases ;  two cases of the kind have occurred  in my
practice—on one occasion after a pleurisy, on  the  other after
measles.   Intense suffering, in consequence  of external injuries,
or with  internal affections,  has  sometimes brought  about the
appearance of the first seizure.   Tissot and Radcliffe  have main- 
ETIOLOGY.
213
tained the same with regard to  over-exertion and great fatigue.
The latter author lays special stress on this  influence, assuming,
as does Tissot also, that it may develop the disease itself.  With
respect to this latter, Reynolds is able to adduce but one case in
his own experience.  In like manner, but one case has happened
to me, which may perhaps be so explained.  A soldier, who had
previously been as sound as a nut, and who came of a very
healthy family, was obliged during the Austrian  campaign of
1866 to bivouac for eight days and  to march a great deal.  He
then noticed a sensation of rigidity, a feeling of being asleep and
numbness in the right arm, without  lesions of motility ;  this
passed aw7ay after some days.   Some weeks  later, however, after
further hardships in the campaign, he was seized in the bivouac
with an epileptic attack, and this was  subsequently repeated at
greater or less intervals.
   The influences just mentioned  are those which relatively most
frequently lead to the outbreak of the paroxysms ;  with regard
to many others, which are just as active on occasion and  in indi-
vidual cases, we refer to  the instances cited  in the  works of
Tissot, Portal, and especially Joseph Frank.
  There  yet  remain to be  mentioned  some conditions which,
without being capable  in themselves of leading to epilepsy, yet
occasion a certain disposition to the development of it,  to such
a degree that when it is present the special  causes become  more
active.  The  importance of age in this connection is  insisted on
by  all observers.  In fact, this is so prominent that on some
unessential points only  is there  any difference,  while there is
unanimity as to the  main facts.  We only  adduce here the lat-
ter.  Youth is the period of life  wdiich comprehends the begin-
ning and development of the great majority  of cases of epilepsy,
and  this is  particularly true of  the time between the  seventh
and  seventeenth years,  and indeed  this proposition holds not
only for cases where  a hereditary tendency exists, but generally
in all cases.   It  cannot as yet  be explained exactly upon what
this  marked  predisposition of  youth depends.   Of course we
are  inclined  to point to the greater " convulsibility"  of  this
period, and to think particularly of dentition, the development
of puberty, and the development and increase of the whole organ- 
214                NOTHNAGEL.—EPILEPSY.

ism.   But it needs no discussion to show that this does not fur-
nish  the slightest  explanation  of this predisposition ; we must
simply be contented with the fact.1  If now, on the one hand,
the outbreak  of  epilepsy  most often  falls  within  the  periods
named,  there is, on the other hand, no time  of life at which it
may not begin—from the first year to the seventieth (Reynolds)
or the seventy-fifth (Heberden).  It is not true that the  period
of involution in women acts in any way to favor it.
   All other influences are subordinate to age ; in fact it does not
seem decidedly as if a special  importance attached to any one.
This is  undoubtedly so with regard to temperament, the  degree
of intelligence, the occupation, and outward  conditions of life.
Still, in accordance with the  accepted view,  a definite influence
ought to belong to sex, since women are more often subject to
the disease than men.  Several observers of the present day, how-
ever,  arrive  at exactly  the opposite result,  and Reynolds was
able  to determine no pronounced preference for one or the other
sex.   Our own view is  in accord with that of Reynolds ; we also
found epilepsy about  equally  frequent in males and  females.
Climatic conditions, too, so far as is known, appear to be with-
out essential influence on the development and frequency of epi-
lepsy ; it  seems  to occur everywhere.  Joseph Frank, indeed,
speaks  emphatically of its frequency in Northern Russia and
Poland.  Meanwhile, as to the different  regions  of  Germany
(Konigsberg in Prussia, Berlin, Breslau, Freiburg  in Bohemia,
and  also Jena, so far as I can judge from a short  period of
observation), I can prove its quite  uniform occurrence.  Heat or
cold seems to exercise no influence  even upon the  frequency of
the individual seizures.

                    Pathological Anatomy.

  Quite the same  holds true to-day as when  Schroeder van der
Kolk said it nearly twenty years ago : " Gelijk in het algemeen
de pathologische  anatomie van zenuwziekten nog  op een zeer
lagen trap staat-----zoo is de  pathologische anatomie en  zijn de
   1 We have made an attempt at an explanation in the chapter on " Eclampsia," to
which we refer the reader. 
PATHOLOGICAL  ANATOMY.
215
resultaten op het cadaver bij epilepsie nog wel de treurigste von
alien."   Not as if there were any lack of communications on
alleged "characteristic" discoveries in the bodies of epileptics.
Only a few  of them, however,  are of actual importance.  Of
course we shall not here detail all the post-mortem conditions
which have been proved to exist  in the cases of epileptics, and
have been announced as the  anatomical basis of the disease.
With regard to some of  them it  appears to-day simpty incon-
ceivable how any significance at  all could have been attributed
to them, as, e. g., to changes in the pituitary gland.
   If we group  together  the post-mortem appearances,  both
macroscopic  and microscopic, we  find first,  such as can be com-
prehended as standing more  or less clearly related as a source of
the trouble ;  second, such as appear rather as its results; third,
such as with greater  or less  probability exhibit  the  proper ana-
tomical  basis  of the disease;  and  finally,  fourth,  accidental
complicating changes.  As to several,  to be sure, it still remains
wholly uncertain to which group they belong.
   There are very often found irregularities in  the structure of
the skull of various kinds, especially if the disease existed from
youth or was hereditary. The most common of these  is an asym-
metry, more  or less strongly  marked, and wdiich generally shows
itself in a slightly marked paresis  of the left side.1  The bones of
the skull are not infrequently much thickened and sclerotic, but
by no means alwaj^s so ; and they may even  remain normal
though  the disease last  for  a  very long  time, as I was  able to
assure myself this very day at the autopsy of a patient who had
been affected with  epilepsy  for  from  forty to fifty years;  in
some cases, in fact,  they are unusually thin.  If  now we take in
connection with this  the circumstance that osteosclerosis, with
disappearance of the diploe, also occurs in cases of  mental dis-
ease, existing for years without convulsions, there ought to  be
no doubt about the long received opinion that this represents a
resulting condition, perhaps connected with repeated hyperaemias.
Other irregularities occur occasionally, but  by no  means con-
stantly,  such as roughnesses of the internal surface, exostoses,
1 C. K. Hoffmann, Vierteljahrschrift fiir Psychiatric 1869. 
216                NOTHNAGEL.—EPILEPSY.

narrowings of the carotid foramen, etc.   A stenosis of t7w fora-
men magnum and of the beginning of the vertebral canal is of
greater interest, and this originates either in diseased conditions
of the  atlas, axis, or occiput.  A highly noteworthy case of this
kind will  be found quoted by Kussmaul and Tenner (loc. cit.);
Solbrig ' communicates nine of the kind and Hoffmann (loc. cit.)
three others.   There could be no question that the narrowing  at
this place by pressure, or by some other influence  acting upon
the medulla oblongata, produces  the epilepsy, and is thus to be
regarded  as its indirect cause;  it is  equally certain, however,
that in the vast majority this is  not  present, and consequently
furnishes  only an occasional cause of the  disease.
   The meninges of the brain are sometimes normal, sometimes
altered, in particular rendered opaque,  thickened or distorted,
the latter  especially if osteosclerosis exists at the same time.
   Various examinations have been instituted into the weight  of
the brain.  Among the more recent authors Echeverria considers
an increase of its weight to be an established fact, and  looks for
the cause  of it in cerebral exudations  and a proliferation of the
neuroglia.  It is not stated whether the  psychical faculties had
suffered during life in  the  eighteen  brains  that  he  weighed.
Meynert,2 on the contrary, found a decrease of weight in epilep-
tic  insanity,  and, in fact, according  to  him, taking the whole
brain,  the greatest loss  falls upon the cerebellum, while among
the individual parts it falls upon the temporo-occipital portion.
In  the present state  of our knowledge we can regard these
changes in weight only as secondary,  i. e., unessential elements
in the post-mortem conditions of epilepsy.   Asymmetry of the
cerebral hemispheres is more often found, but also occurs in the
same way in other mental disorders.
   Among the  macroscopic  changes  of  the brain—apart from
accidental alterations—we first cite one  which has made a con-
siderable  sensation.  Meynert3  ascertained  the existence of a
" disparity between the  sections  of the two  hippocampi majores
in epileptics, caused by the progressive atrophy of one of them,
and this is coincident with callous or even cartilaginous hardness
   1 Allgemeine Zeitschrift fiir Psychiatric  1867. Vol. XXIV.
   2 Vierteljahrschrift f. Psychiatric 1867.  p. 125 et seq.       a Ibid., p. 396, 
PATHOLOGICAL  ANATOMY.
217
and marked anaemia of  the same, not seldom with a waxy reflex
and transparent appearance on section."  Meynert himself, more-
over, did not go so far as to locate the " seat of epilepsy" in
the hippocampus major, as we have happened to read of in some
places ;  he rather regards the affection of this part as secondary.
This is  not found to be constant, however, so that it cannot be
essential to the disease; and even if it were so, we could make
no use of the discovery at the present time, as the functions of
the hippocampus major are still wholly unknown.   (Compare my
investigations on this subject, Virchow's Archiv.  Vol. LVIII.)
   With regard to changes elsewhere in the brain, we should give
prominence to those of  which we have already said, in  treating
of the etiology, that they might furnish a cause for the develop-
ment of epilepsy,  such  as  small  tumors of the  cortex,  etc.
Finally, the rare cases are yet to be mentioned, where an abnor-
mal distribution  of the gray substance of the brain occurs in the
cerebellum1 or the cerebrum.2  The significance of this  anomaly
and some of its relations to epilepsy are the less certainly estab-
lished, and consequently  explained, inasmuch as  it also occurs
without epilepsy.3
   Since none of the macroscopic changes mentioned as found in
the brain and its envelopes are  constant, and as they are conse-
quently non-essential, the more  interest  enters into the question
whether the microscopic investigation reveals regularly occur-
ring changes in any one portion of the brain.  The answer, it
seems, from  the  investigations especially of Schroeder van  der
Kolk and Echeverria, should be in the affirmative,  and the latter
authority comes to the conclusion that in the medulla oblon-
gata constant  changes can be proved microscopically to exist,
while in other parts of the brain  such are sometimes  absent,
sometimes present at the same time.
   Schroeder van der Kolk reached the conclusion that at  the
beginning of epilepsy no organic change was appreciable.  Sub-
sequently an "albuminous intercellular" exudation shows itself
between  the nerve-fibres, which may lead first to induration and

      1 Mexchede. Bericht der Naturforscherversammlunjr zu Dresden. 1868.
      2 Mcrkd, Virchow's Archiv. Vol. XXXVIII.
      3 E. K. Hoffmann, Henle und Pfeufer's Zeitschrift. Vol. XXXIV. 3. 
218                NOTHNAGEL.—EPILEPSY.

then to fatty degeneration and softening.  Further than this, a
dilatation of the capillaries, with thickening of  their walls, is
specially noticeable, in  consequence of which the posterior half
of the medulla  oblongata appears  more  red and hyperaemic,
whether patients have died in the seizure or not.   The capillary
dilatations lie chiefly in the region of the roots of the hypoglos-
sus and vagus ; more in the former, if the patients bit the tongue
in the seizure, more in the latter, in case they did not.
Different kinds of epileptics.	Hypoglossus.	Corp. olivare.	Raphe.	Vagus.
A. Tongue biters..... B. Not tongue biters..	Mm. 0.306 0.210	Mm. 0.315 0.217	Mm. 0.355 0.300	Mm. 0.237 0.348
Difference...........	+ 0.096 A.	+ 0.098 A.	+ 0.055 A.	+ 0.111 B.
				
   Still,  Schroeder himself  expresses the  opinion that these
changes, which are of course established  in the medulla oblon-
gata in the later  stage of the disease, presuppose a  severe or
even incurable character  in  it, but  that they  are dependent in
their development upon a hyperemia induced by the seizures
themselves, and consequently are results  of them, /. e., do not
constitute the essence of the disease.
   Echeverria ascertained  the existence of the same dilated capil-
laries in the medulla oblongata;  besides these a  granular albu-
minous exudation and granule cells, together with numerous cor-
puscula amylacea (not only in the neuroglia, indeed, but also on
cross-section of the bulb);  the  ganglion-cells were also much
pigmented in many places, especially in the nuclei of the hypo-
glossus and vagus.  Analogous changes occurred in many cases
likewise in various localities  in the cerebrum, the ganglia at the
base,  and  the cerebellum;  but these parts  were frequently
wholly intact, the medulla oblongata alone showing changes in
every case.   It is also worthy of mention that  Echeverria also
frequently found  the cervical sympathetic diseased more regu-
larly even than the brain itself ;  the cells of the cervical ganglia,
in fifteen cases that he investigated,  v/ere the  seat of granular
degeneration and filled with pigment, irregularly shaped,  and 
SYMPTOMATOLOGY.
219
their connective-tissue hyperplastic.  Echeverria would attribute
to these conditions the significance of primary,  not secondary,
changes, because  he  encountered them  so constantly.   It  cer-
tainly  is very  questionable wdiether  any importance  whatever
can be ascribed to the conditions described by Echeverria, espe-
cially those of pigment in the nerve-cells, since A. Labimoff1 has
shown that the pigmentation of the sympathetic nerve-cells is
found as a  regular condition in persons advanced in life, and not
so very rarely even in young persons, who have died of diseases
quite distinct from epilepsy.
   Without considering  detached investigations,  let  us  here
mention the points discovered by L. Meyer.2  This author ascer-
tained, like Schroeder and Echeverria,  a  diseased condition of
the vessels, particularly a wide-spread fatty degeneration, sclero-
sis with localized obliteration, and in isolated places also small
dilatations on  the smallest arteries and capillaries.   These con-
ditions were met  with in  the medulla  oblongata,  the cortical
substance of the cerebrum, and the uppermost part of the cervi-
cal portion of the cord.  Meyer, diowever, is likewise inclined to
regard the  affections of the vessels in many cases as secondary.
And the principal thing is that they are not at all characteristic
of epilepsy, for they are  also met with  in progressive general
paralysis and other diseases.
   If we review the anatomical results, the showing is certainly a
very poor one.   No alteration is shown with certainty to be con-
stant.  Even with regard to,the  changes in the  bulb it is ques-
tionable whether they are  primary or secondary.  There is only
one thing to which the investigations now before us point, viz.,
that,  generally speaking,   the primary  histological departures
from the normal are to be looked for with the greatest probabil-
it}' in the bulb  of  the medulla.

                       Symptomatology.
   The  character  of  the  clinical picture of epilepsy is chiefly

   1 Beitrage  zur  Histol. u. pathol. Anat.  d. sympath. Nervensystems.  Virchow's
Archiv. Vol. LXI.
   2 Archiv f. Psycbiatrie u. Nervenkrankh. Vol. III. 
220
NOTIIX AGEL. —EPILEPSY.
impressed on it by the nature of the individual seizures desig-
nated as "epileptic:'  Besides the paroxysms, patients not infre-
quently also present symptoms belonging to the interval, which
sometimes may equal  in intensity those belonging to the parox-
ysms or even exceed them.  The symptoms of the intervals, how-
ever,  are never distinctive of the trouble as epilepsy in any spe-
cial case ; that,  we repeat, depends on the paroxysms only.


                   I. The Epileptic Seizures.

    For a long time various forms have been distinguished accord-
ing to the character of the attacks.1  At the present time certain
expressions only will be retained in this connection, for the sake
of readier comprehension, because they are associated with long-
received ideas.  We are inclined to adhere to them chiefly in the
interest of a clear demonstration, because the great abundance
of material bearing upon the symptoms  actually demands an
appropriate classification.  Certain of these forms  occur more.
others less frequently, and at the same time there are the various
transitions between them.  The determination of them is natur-
ally in part an arbitrary one. We make choice of the following:
    1.  Epilepsies in which  the  classical paroxysms make their
appearance with coma and general convulsions {E. gravior, haut
mat).
   2.  Epilepsies in which paroxysmal loss of consciousness alone
occurs,  the spastic element, for  the  voluntary muscles at all
events, being absent {E. mitior, petit med).
   3.  Epilepsy in which, with inconsiderable loss of  conscious-
ness, partial twitchings  occur in  the regions of certain muscles,
whereby in the most various ways a transition  is effected between
the cases mentioned under 1 and 2.
   4.  To these we add the irregular forms of seizures and the
epileptoid states.
  1 Thus, e. g., the following classification is found in Peter Frank (loc. cit.) : 1st.
Ratione accessionum: a, E. vaga; b, periodica.  2d. Ratione extensionis: a, E. uni-
versalis ; b, partialis. 3d. Ratione modi concidendi : a, caduca; b cursoria • c, gyra-
toria, etc.  The triviality of such a classification is self-evident. 
SYMPTOMATOLOGY.
221
                   A. Epilepsia Gravior.

   The seizures either set  in with extreme suddenness, or they
are preceded by warnings.1  As it is very difficult to furnish com-
plete numerical data  about the occurrence of the latter, and as
such numbers in our opinion would be  destitute of a special
scientific value,  or, at all  events, would  throw  no light  upon
the pathology of the trouble,  we content  ourselves with  the
approximate statement that prodroma show themselves in some-
where about half of the cases.
   These premonitory symptoms of the  paroxysms have long
been divided into remote and immediate.  For the latter the term
"aura epileptica" is still extensively in use, and  this may also
be retained, provided we have a clear conception that an aura, in
the old sense,  i.  «?.,  the sensation of a breath blowing upon  the
patient, scarcely ever  occurs, and that consequently this expres-
sion  in its transferred meaning should only convey the  same
signification in general terms as  warnings.
   The remote warnings all observers  agree to be very much
rarer than the  immediate, and this I, too, must  confirm.  At  the
longest they occur from  two to  four days beforehand.  In these
cases they almost always  show themselves  under the form of
psychical changes.  Patients become sad  and  of an oppressed
frame of  mind ; they retire into  themselves, or, on the contrary,
they become excited and  talkative, violent and irritable, or quar-
relsome and distrustful.   At the same time they complain of
dizziness, headache, and confusion of the head ; sometimes these
symptoms  even  form the  only prodroma.  After these  have
lasted for one or  several days, the seizure  breaks out, and after-
wards the old condition belonging to the interval returns.  These
remote warnings  show themselves  in individual patients  espe-
cial ly wdien they have remained free from  paroxysms for a con-
siderable time.  But a real  seizure does not always follow upon
them ;  sometimes such a one is confidently  ex2^ected as usual,

  1 In order not to interrupt  the demonstration according to symptoms, we speak here
of "warnings," following the  established custom. In what light we regard their rela-
tion to the seizure proper, we will state in the section on "Pathology." 
222                 NOTHNAGEL.--EPILEPSY.

and yet it remains absent.  Much less often than with the mental
symptoms mentioned do we meet with others.  Keynolds men-
tions  that he has sometimes seen a peculiar  dark coloration of
the skin, especially in the face and neck, as much as twelve hours
before the seizure. A lady under my observation is able to predict
the seizure with certainty every time. While usually her sleep is
light  and rather short, she then has a very deep and continued
sleep.  Still she awakes in the morning perfectly well,  but in the
course of the day the paroxysm breaks out.   Certain  patients
also  feel  for several days beforehand a  leaden weight in  the
limbs or a slight trembling.
   The  immediate prodroma, the  real aura  epileptica, exhibit
a considerably greater variety than the  remote.  The question
whether they should even  be looked upon as symptoms of  the
seizure itself may temporarily be left out of consideration. This
aura  may begin in the territory of the most different nerves,
although more often in certain ones than in others, in the sensi-
tive, motor,  vaso-motor,  and also the nerves of  special sense.
We cannot possibly enumerate the extraordinary variety of its
manifestations in every individual  case ;  we  must  content our-
selves with a general outline.1  The sensitive aura is character-
ized by tickling sensations, or by dragging, tearing pains wdiich
seldom extend  in the definite course  of  a nerve, but generally
over a whole extremity, and, in fact, usually from the periphery,
the toes or tips of  the fingers, upwards towards the head.  In
other cases patients  are affected with general  or one-sided head-
ache ; in others again with violent pains in the epigastrium with
or without a tendency to vomiting, and this in particular Hasse
has often observed in the female sex.   The opposite also occurs,
that is,  a decrease of the  sensory function, whereby the patient
suddenly or more gradually experiences a loss of feeling in one
extremity  or one-half of  the face.  In one of my patients this
sensation always began on the right side of the face and head,
extended downwards  from  the shoulder  over the right arm, as
well as in a centrifugal direction over the corresponding leg, and

   1 Any one who is interested in knowing where to get a knowledge of remarkable and
peculiar warnings will find a collection of such in Joseph Frank, and particularly in
Delasiauve, loc. cit., pp. 21-26. 
SYMPTOMATOLOGY.
223
finally over  the right half of  the  body  too.  In this case as
well as  in some others where  the  phenomenon preceded  the
seizure a sufficient time, say ten minutes or longer, I could make
out a decided diminution in the sensitiveness  to the prick of a
needle and to the impression of temperature.  I have observed a
vaso-motor aura scarcely less frequently than the sensitive,1 and
I am persuaded that many cases must be ranked with  the latter
which  were formerly  counted  among those of  sensitive aura.
In this case patients complain of a feeling of numbness, generally
beginning in the fingers or toes of  one extremity,  accompanied
with decided tickling and a sensation of  coldness and weight.
While this is going on, the affected  parts become very pale and
cold to the touch, and blunted to slight external impressions.
These symptoms also take a centripetal course.  The phenomenon
might also be referred to a participation of the nerves of the ves-
sels if  the attack, as sometimes occurs, is preceded by shivering
or transient burning heat.  Certain patients get a redness in spots
in various parts of the body.    The motor aura is variously dis-
played, ordinarily as a spasm in the region of certain  muscles
or groups of  muscles,  Avhich is generally of a clonic, more rarely
of a tonic,  character, sometimes also as a  trembling or  shaking
motion.  Here, too, the extremities are affected most frequently,
then the muscles of the face, the orbicularis palpebrarum, other
muscles much less frequently, e. g., those of the ear (Romberg),
the sterno-cleido-mastoid,  etc.   It belongs among the  decided
exceptions  when the seizure is ushered in by the opposite condi-
tion, the paresis or even complete  paralysis of an  extremity (I
have myself seen two  cases of this kind), and in regard to such
cases it is always doubtful if we  have to do with a  genuine epi-
lepsy.   (See  further on under  the remarks on  Epileptic Palsy.)
Now and then spastic phenomena in the region of the internal or-
gans showT  themselves as a prelude to the paroxysm; thus rum-
bling in  the belly, straining at stool  and on passing water, draw-
ing up of the testicle, palpitations, etc.2 Besides these,  the litera-

  1 Farther on, under Pathology, I will enter more fully into the peculiar form de-
scribed in recent times as Epilepsia Vasomotoria.
  2 The statical conditions, which have been observed as prodroma in  very rare in-
stances, will be considered in another place. 
-J04                NOTHNAGEL. —EPILEPSY.

ture of the subject recognizes a great many instances where symp-
toms referable to the nerves of special sense preceded the seizure.
The optic and auditory nerves are relatively the  most frequent
participants in these cases, which are in any event quite rare ; the
olfactory nerve is much more seldom involved.1 Patients have im-
pressions of light and color, and even at times the hallucination
of corporeal figures ; they hear sounds and voices ;  they experi-
ence sensations of smell which are of a predominantly disagreeable
kind.  Joseph Frank saw a patient in whom the attack announced
itself  by  sensations of  a sweet taste.   In very isolated cases
changes of secretion also develop as  prodromata, as e. g. a pro-
fuse secretion of  tears or perspiration (the latter I have  several
times observed) or an abundant flow of saliva.  Most often, un-
doubtedly, and this accords with my own experience, cerebral
or mental phenomena form the immediate warnings.  It is a fact
that many patients are met with who state  that they are "dizzy"
immediately before the onset of the seizure.   It can certainly be
properly assumed that under this  term  something  else is often
understood, such as overclouding of the  senses,  confusion, etc.
Besides this "becoming dizzy," other symptoms, such as sudden
excitement, loquacity, and the like, form  but seldom the imme-
diate  prodroma.  Finally, an aura occurs now and then which
can be brought into no one of  the classes mentioned.   There are
very  indefinite feelings  of general restlessness, general discom-
fort,  peculiar sensations in various parts of the  body, about
wdiich patients can give no more accurate information.
    The aura does not always show itself exclusively in the sphere
of one nerve or another ; it  is  not so very unusual for the sensi-
tive to be combined with the motor, or the latter  with the vaso-
motor, or for dizziness to be associated with one or more of those
just named.
    The duration of the aura varies within very fluctuating limits;
at one time it may last for two hours, and  then again it runs its
course with the rapidity of  lightning ; a sensation, of  which the
patient afterwards says that it ran up in an instant from the fin-
ger-tips  to the top of  the head, a  scream,  and the  patient is
Compare S<mder in the Archiv fiir Psychiatrie und Nervenkrankheiten. Vol. P7. 
                      SYMPTOMATOLOGY.                    225

thrown  upon the ground.   On  an average, however, the aura,
when present, generally lasts from half a minute to five minutes.
   It happens not at all infrequently that  the customary aura—
as we pointed out in regard  to the remote warnings too—showrs
itself, the patient expects a seizure, and yet it keeps off.  This
may even take place several times in the course of a day, espe-
cially in  epileptics who suffer  from rather frequent and pro-
nounced paroxysms  recurring every few days.   Every one who
has seen many epileptics will recall such as these, in  whom there
often appeared dizziness or  some slight twitching in an arm or
one side of the face, or  tickling in the leg, and yet a veritable
seizure  only occasionally succeeded these manifestations.   One
of my patients had a vaso-motor aura in one leg from six to  ten
times daily,  and yet only on an average  every week an attack
following upon it.
   It will depend essentially upon the view which is held regard-
ing the aura, what significance is  ascribed to the circumstance last
mentioned.  We  anticipate here by saying that, in our opinion,
these abortive aura*, which are indeed free from obscuration of the
senses or any sensation of dizziness, are to be placed  in the same
rank with what is called "petit mal.'n  We shall return  to  this
question.
   The  literature of the subject has various undoubted instances
where, wiien an aura has lasted quite a considerable time, the seiz-
ure has been successfully warded off.  If a dragging sensation
mounts gradually from the fingers to the top of the head, and we
rapidly tie a ligature firmly  about the upper arm, or if,  in case
of a spasmodic flexion of a  finger, this is  forcibly straightened,
and so on, we may  even keep back the attack.   From these par-
ticular occurrences  has  evidently developed the absurd popular
belief in the advantage of bending back the thumb in the seizure
itself.

   To settle this point,  we remark that in all probability, as Brown-Sequard also
asnnnes in his experiments (see above), it has nothing to do with the repression or
breaking up of a process of excitation which is  creeping towards the centre.   The
phenomenon is rather to be viewed as  in the nature of a  "reflex inhibition."
We must here, of course, refrain from a discussion of  the question of what we are
to understand physiologically by this redox inhibition, and only add that results, in
          VOL. XIV.—15 
226                  NOTHNAGEL.—EPILEPSY.
their nature analogous, have been obtained experimentally by Setschcnow,1 Herzen,'
Goltz,3 and myself.4
   Now, whether preceded  by prodroma or  not, the  striking
symptoms  of  the seizure  itself,  with  its  two  essential  leading
characteristics of loss of consciousness and general convulsions,
almost always break out suddenly in overwhelming force all at
once.  Before the patient falls to the ground, or perhaps at the
same moment,  he often utters a  cry, as  Romberg  expresses it,
" shrill and terrifying to man and beast."  This cry is not, how-
ever, characteristic ; at least it is absent more often than present.
We regard it as unimportant to bring forward  fuller  figures as
to the frequency of its occurrence.
   Much has been written on the significance of the epileptic  cry.  So much as this
should be  considered as settled that it is not to be regarded  as the effect of any
mental  action whatever, such as  pain, fright, or surprise, as Herpin and others
thought, albeit in very rare cases patients are not at the moment wholly unconscious.
Still it is generally uttered simultaneously with the loss of consciousness; and we
entirely agree with the conclusion that it is simply of spasmodic origin, i. e., the
product of a spasmodic action of the respiratory and laryngeal muscles, and either
of an inspiratory or expiratory nature.

   Innumerable  accounts, more  or  less true  to  nature,  have
been written of  the epileptic seizure ; some are  distinguished by
an  almost dramatically  excited vividness in  the  description, as
above  all,  those of Romberg and of Esquirol, also those of Tissot
and many others.  Obviously the disease  itself  almost provokes
such a description with its shocking, violent symptoms, the ani-
mal roar, the sudden downfall of the  affected person all uncon-
scious, the terrifying spasmodic movements.  Still, at the expense
of fine language, we prefer a  quiet statement in  the  interest of
scientific clearness.
   In individual cases, and,  in fact,  in  particular seizures of the
same patient, manifold diversities are found, even in the features
of the full epileptic  attack ; these will be  attended to hereafter.

   1 Ueber die elektrische  und chemische Reizung der sensiblen Ruckenmarksnerven
des Frosches. Graz, 18G8.
   2 Experiences sur les centres moderateurs de Taction reflexe.  Turin, 1864.
   3 Functionen der Nervencentren des Frosches.  Berlin, 1869. p. 39 et seq.
   * Zur Lehre vom klonischen Krampf. Virchow's Archiv. Vol. XLIX, 
SYMPTOMATOLOGY.
227
In the first place we want to sketch the type of a seizure as it is
most often displayed.
   Apart from  the prodroma we must  distinguish two periods
of the attack; then there must  be added as the third  an  after-
stage.  While the loss of consciousness is the same in both, they
are principally  to be discriminated by the different character of
the spasms ; in  the first period it is tonic, in the second clonic.
   First period.—Consciousness is completely lost.   At times
the patient falls down as if struck by lightning ; instantly and as
if by a stroke he is deprived of all mental functions.  This comes
so quickly that he falls headlong  in any attitude or place quite
regardless of  his surroundings.  If the  convulsion  does not
declare itself at the very same moment-, he falls like a dead mass,
evidently  in consequence of the sudden relaxation of all the
muscles ;  still this condition of things happens extremely sel-
dom.   At other times the loss  of consciousness comes on more
gradually, as in the course of a few seconds, and the sufferer
gains time enough to  assume some recumbent position volun-
tarily.   Generally, however,  the arrest of  all  mental activity
lakes one so by surprise  that from the beginning of the seizure
no recollection is retained of  the facts of the case.   It  is not
necessary  to draw attention to the fact that in deep coma every
conscious  sensation is wanting ; it is well known that this goes
so  far that patients  have  sometimes  fallen  into the fire  and
burned  themselves.   But even reflex processes are  absent in
many cases  ; the iris does  not  contract under the stimulus of
light, the  lids are not closed when the conjunctiva is  irritated;
at other times, again, reflex processes are  present;  the lids close,
and the limbs are drawn together when cold water  is dashed
upon the body (Romberg).
   The tonic spasm now declares itself.  Its extent is variable ;
in the severest cases it involves the wdiole muscular system.  The
pupil is fixed, sometimes appearing to have a pronounced expres-
sion of some mental emotion, anger, etc.,  the countenance dis-
torted, the jaws closed upon each other, the head drawn  to one
side, or backwards ;  there is general opisthotonus with marked
extension of the extremities (with an astonishing spreading asun-
der of  the fingers and toes, or  also very   great incurvation of 
228
NOTHNAGEL.—EPILEPSY.
the foot—Tissot),  sometimes emprosthotonus, or even—in fact,
quite frequently—one half  of  the body shares in this to excess
with  curvature  in  that direction, and with an alternating  ten-
dency to one or the other side ; tonic contraction of the muscles
of the throat (trachelismus—M.  Hall),  of those of respiration
(with absolute arrest of breathing), and of the laryngeal muscles.
In a child four and a half years old, that was under my observa-
tion there followed  upon the cry, uttered when consciousness was
already gone, a sharp, strong, whistling inspiration lasting for
some seconds, such as is observed  only in pronounced spasm
of the glottis, and  then the clonic spasm.—The tonic influence,
however, is not always so general and so strong ; sometimes it is
limited to  certain  groups of muscles only, sometimes but very
slightly pronounced.  And if it is general, certain regions may be
attacked rather than others ; most frequently it is first marked in
the muscles moving the head and in  those of the globe of the eye
and the face.—As  already stated, the tonic spasm sets in either
simultaneously with  the coma, or rarely  somewhat later, or it
may even begin a little earlier; in the latter case the scene opens
with fixation of  the eyeball, distortion of the  face, and turning
of the head. We likewise remark here that occasionally the tonic
spasm is wholly wanting, and the scene begins at once with clonic
twitchings; but the opposite also occurs in rare cases, namely,
the convulsive element is indicated by a tonic fixedness only, in
which the  rigidly extended extremities  at  the utmost undergo
only a slight shivering movement. The latter point will be more
fully discussed hereafter.
   The coloration of the face changes.  While the earlier observ-
ers spoke almost exclusively of a dark cyanotic discoloration,
later ones report pallor just as often.   Both  are correct; both
changes occur, and, in fact, generally in the  same patients  one
after  the other.  My observation agrees with that of Radcliffe,
Sieveking,  and Brown-Sequard, that in the majority of cases the
patients  grow pale at the beginning of the seizure.   Sometimes
its approach is indicated in  this way :  the countenance changes
before the loss of consciousness or the  tonic spasm is developed;
at other times all  begin at the  same time.   The pallor then
lasts during the whole of the first period, or it is present at the 
SYMPTOMATOLOGY.
229
very beginning  only,  and even before the clonic stage has
declared  itself the face has already acquired a dark tint.—Still
it must be remarked that sometimes the  hue of  the face remains
unchanged during the wdiole initial period, and  at other times it
is dark-red from the very beginning.  The latter appears to be
the case particularly if just at the beginning a decided  spasm of
the muscles of the throat prevails with compression of the jugu-
lar  veins and  spasm  of the glottis.—In recent times attention
has also  been  directed to  the condition of  the fundus oculi.  It
is obvious that an ophthalmoscopic examination during the con-
vulsions is hardly practicable.   Still we have some observations
made during the prodromal stage (Echeverria and others) which
show that sometimes, but not always, amemia of the fundus is
present.   Unfortunately it is  not stated how the coloration of
the face behaved in these cases.—The iris is generally dilated at
the beginning of the attack.
   The state of the pulse is variable.  In certain cases it remains
unchanged  both  during the  first period  and  throughout the
whole attack.  At other times no examination at all is possible
during the convulsions.  According to other observers, however,
it is "small"  during  the tonic stage, i.e., the radial artery is
somewhat  narrowed and  the  wrave reduced.   With regard to
tension and regularity, the reports of various authors again differ
very much.  It may happen  that the pulse at the wrist  is not
felt at  all, while the carotids  are beating and the action of the
heart is normal.

  Echeverria gives drawings of sphygmographic curves, according to which the
pulse before the seizure was higher, distinctly dicrotic, and accelerated.

   The tonic stage is generally of short duration, often only a few
seconds long,  so that it is overlooked by  the laity in consider-
ation of  the performance  which now follows it, or it may last
from one-quarter to one minute.   Upon this then follows the
   II. Period  of clonic spasm.—The  profound  unconsciousness
continues wholly  unchanged ;  but instead  of  the tonic mus-
cul;ir contraction  the  most violent convulsions now set in, the
form of  which is  so well known that it  is used as the type
in describing analogous spasms arising from the most different 
230                NOTHNAGEL.—EPILEPSY.

sources.  We may spare ourselves a detailed account, and call
attention only to the following:  almost all the voluntary mus-
cles of the extremities, trunk, and head take part in the epilepti-
form twitchings.   Through these are brought about  in the full
seizures positions and attitudes of  apparently the most impossi-
ble kind, which vary with surprising rapidity.   The  violence  is
sometimes so considerable that the most dangerous wounds are
received ; fractures and dislocations have been observed, breaking
of the teeth or portions of them,  deep laceration of the tongue,
and rupture of muscles, not to mention the wounds and excori-
ations  of the skin which arise from the  headlong way in which
the body is thrown about.  Very often the clonic jerkings are
interrupted one or more times by tonic spasm, so that  the patient
again becomes rigid ; or. while certain parts are undergoing vio-
lent  clonic spasmodic movements, others are in a state of fixed
tonicity.  Even if the clonic action is very general, it may still
very often be evident  that one half of the body takes a more
active share in it than the other. Usually, but not always, saliva
shows  itself  at the mouth of  the sufferer in the shape of foam,
which may be tinged with blood from wounds of the tongue and
buccal mucous membrane.—Increased peristaltic  action of the
intestines occurs  with rumbling  in  the  belly and discharge of
flatus and faeces,  sometimes tympanites,  probably from air that
has been swallowed, also ejaculation of semen,  rarely vomiting,
and  occasionally  escape of urine with so much  force even as to
rise in  a stream five or ten feet  high (Tissot, Portal).—The respi-
ration  is forcible  and quickened, while  again it  may  be spas-
modically interrupted.  The consequence of  this  and  of the
violent action of the muscles is  a marked venous hypersemia.
The  jugulars  are swollen up,  the face  acquires  a deeply cya-
notic color,  and  the eyeballs  protrude.   Sometimes  subcutane-
ous vessels are ruptured with  the formation of ecchymoses in
the skin, especially in and around the eyelids,  as well  as some-
times in the  internal organs,  yet we have noticed that cerebral
hemorrhage forms one of the  very rarest accidents  in connec-
tion with the epileptic seizure.  The older observers  speak  of
discharges of blood from the  rectum and vagina, and of  bloody
tears.—The pulse,  provided it can be tested  during  the vio- 
SYMPTOMATOLOGY.
231
lent action of the muscles, is nowr fuller than in the first period,
and frequent.
   After this wild scene has lasted a variable time, from half a
minute  to three minutes,  and only  in  very exceptional  cases
longer, the time of course appearing to bystanders very much
greater, the after-stage of the seizure is developed.  The convul-
sions either stop suddenly or wear off more gradually, and  the
patient  either lies with his limbs  completely relaxed, if the sen-
sorium still remains profoundly affected, or the muscles at once
recover their normal tonicity.  Here and there isolated  supple-
mentary jerkings still occur, or perhaps a tremor runs over  the
whole body.—The return of consciousness takes place in various
ways.  As a rule, the patient still lies in a deep coma for some
minutes after the cessation of the spasms.   Then he  opens his
eyes, wakes as  if out of a deep sleep, looks confusedly around
him, closes his eyes again,  mutters something incomprehensibly,
groans, sighs, or even speaks, but all as if his mind were wander-
ing.  At this period he also responds to any considerable sensory
irritant, or when called to.   The distressing  cyanosis diminishes.
The iris contracts.   The  respiration grows more quiet, deeper,
ordinarily uniform, though sometimes in a measure intermittent,
or at all events irregular in rhythm and depth ; after violent and
prolonged convulsions rales are heard in the  chest, which evi-
dently arise from a considerable  accumulation  of fluid in  the
bronchi, caused by the venous stasis during the spasmodic stage.
The pulse becomes gradually more quiet and full; Echeverria in-
deed demonstrated  with the sphygmograph a decided decrease
in the height of the pulse-curve during the comatose after-stage;
it only  became higher again after from  ten to fifteen minutes.
Yoisin' states that  the ascending  branch  of  the wave of the
pulse is higher than normal, and that the curve is characterized
by a pronounced dicrotism—appearances which outlast the seiz-
ure by from half an hour to several hours.  The skin is soft and
often  covered with an abundant perspiration ; sometimes the
discharges spoken of above only now make their appearance.
We will add here that ophthalmoscopic examinations after the
1 Annales d'hygiene publique. 1868. Avril. 
232
NOTHNAGEL.—EPILEPSY.
seizure have shown a marked hyperemia of the fundus oculi,
wliicli may last for twenty-four hours.
   Thus a quarter of an hour after the seizure the patient may
find himself wholly in his previous condition, sometimes without
the slightest bad results.  There only remains the deficient recol-
lection of all that happened  to him in the moments just past.
Only seldom, however, does the seizure pass off so rapidly and
leave  so  few traces behind.  As a  rule, the  after-stage  lasts
longer ; perhaps a somnolent state follows upon it, or an abnor-
mally deep sleep, the duration of wliicli varies from half an hour
to several hours; and if the attack was quite violent, the patient
feels fatigued, unnerved, and as  if bruised all over.   The mental
tone  is altered  at  times, and becomes depressed and irritable.
Still occasionally, especially when psychical  prodromata of con-
siderable duration have preceded it, patients feel relieved after
the seizure, are freer mentally.   It occurs exceptionally that the
sleep after the attack lasts for many hours, even for twenty four,
before patients are  again completely masters  of themselves ; and
in two cases under my observation the somnolent condition
extended  over  two days.   Some  other  sequelaB, which occur
much  less frequently, must  be mentioned later, after the other
forms of the seizures are described.
   The temperature of the  body after the epileptic  attacks has
been  measured  by various authors, without a complete agree-
ment having yet been arrived at;   of course it is  understood
that we are here  speaking of  single seizures,  not  of such as
rapidly follow one upon another,  the etat  epileptique  of the
French. Williams,1 while considering his efforts as only slightly
successful,  concludes that after strong convulsions, especially
after  tonic spasm, the  temperature may rise as much as 3° F.
Clouston  expresses himself rather indefinitely, and moreover,
Bourneville2 recognizes his procedure as  defective.   This latter,
and  also Yoisin, found a very slight  elevation,  say a few tenths
of a  degree.  Westphal,3  with  whom we agree, made up  his
1 Medical Times.  1867. Vol. II. p. 225.
s Etudes cliniques et thermometriques sur les maladies du systeme nerveux. 1873.
3 Archiv fiir Psychiatrie u. Nervenkrankheiten.  Vol. I. 
SYMPTOMATOLOGY.
233
mind that an elevation of  temperature after the isolated seizures
of epileptics is exceptional.
   The changes  that may  take  place in the urine evacuated
after the  seizures as to its quantity and  quality have attracted
special attention  since  Reynoso  and  Heller  maintained that
sugar was temporarily present in it after the attacks.  With rare
unanimity has this opinion been contested ; Michea, Delasiauve,
Sieveking, Hasse, Reynolds, Echeverria  (with the exception  of
one  case), Ebstein,1  M. Huppert,2 I, and various  others,  have
never been able to discover sugar.  Probably the earlier accounts
resulted from errors in the methods  of  examination.   The  same
negative  conclusion has been reached  by most  of  the authors
named with reference to the  occurrence of albumen.  On the
other  hand, a considerable conformity of  views prevails as  to
this, viz., that after the attack  a  quantitative change  sets in  so
far as that the amount of urine  is  decidedly increased, and  at
the same  time of  a clearer color, while  its specific gravity is not
essentially  altered.   Ebstein, indeed, was  able to arrive at no
constant results as to the increase of urine.  According to several
observers, such as Parkes, Gibson, and Echeverria,  the amount
of urea is at the same time increased, generally also that of the
phosphates,  while no increase of the uric  acid could be proved.

   M. Huppert  (loc. cit.)  asserts recently that  every fully formed epileptic seizure
is immediately followed by a distinct transient discharge of albumen in the urine,
lasting from two to eight, generally from three to four hours.  For the precautions
to be observed in the  determination of the albumen we  must refer to Mie original
article.  Vertigo usually remains  free from appreciable albuminuria.  Huppert, in
addition, ascertained the startling fact that in about half the cases of pronounced
attacks, though  less often after undeveloped ones, the urine first passed contained,
besides albumen, hyaline cylinders and quite numerous spermatic filaments.  The
cylinders disappeared  sooner than the albumen, for in the second urine passed they
were  but very seldom  encountered.  After mere epileptic vertigo, cylinders and
spermatic filaments were both absent.

   The cases which I have examined since  the  appearance  of
Huppert1 s work  on albuminuria,  have not  yet  been numerous
1 Deutsches Archiv f. klinische Medicin. Vol. XL
2 Virchow's Archiv. Vol. LIX. 
234
NOTHNAGEL.—EPILEPSY.
enough to enable me to give  an opinion.   Still I may even now
say that I have occasionally  found the reaction for albumen
faintly declared.

                    B. Epilepsia Mitior.

   Formerly onty the full paroxysms just described, and those
to be  mentioned hereafter, which were accompanied by more or
less pronounced local spasms, were characterized as epileptic; in
the presence of these only was the disease assumed to exist; but
fuller observation has taught us the fact  that epilepsy may man-
ifest itself  in the form of seizures, whose only characteristic  is
a loss of consciousness, without any visible outward spasmodic
element, or at most accompanied by fixation of the eyeball. At
the present day it  requires no detailed  demonstration to show
that these and the forms described under C, are actual  epilepsy.
In former times they were often ascribed to " apoplectic conges-
tion of the brain," an abuse against which Trousseau  in particu-
lar warmly protested.   Still I consider it as  equally injudicious
to designate  these forms  as  "epileptic dizziness."   There  is
almost without exception more than a dizziness ; there is com-
plete arrest of consciousness.  We shall return later to the matter
of epileptic dizziness proper.
   The  time during which unconsciousness  lasts is  very brief,
generally only from a few seconds to half a  minute, yet it may
even continue for from four to eight minutes, as I have convinced
myself.  As a  rule, consciousness is lost without any premoni-
tions: while eating, the patient lets his spoon and knife drop, his
look  becomes  fixed ;  sometimes this lasts only  so  long as to
excite the attention of those around him ;  then he resumes eating
again.  While  in the midst of  talking, he suddenly stops; after
a brief absence  of mind he goes on  again.  While walking upon
the street he stops still, but need not necessarily fall if the arrest
of consciousness is brief enough.   It may even happen that the
more  automatic actions are  not once interrupted,  the sufferer
goes on  walking, continues to  play on the  piano, and the like.
But, on  the other hand, when the  absent-mindedness is longer,
he may fall dowm, or, if riding, be thrown from  his horse.  At 
SYMPTOMATOLOGY.
235
times such a  patient is thrown down suddenly and lies there
unconscious, until he shortly rouses himself ;  an inexperienced
person would  be disposed to look upon  the  attack as a para-
lytic stroke, although  in apoplexy the overthrow of the brain
scarcely ever happens so suddenly.  (Compare Cerebral Hemor-
rhage.)
   As  already  observed, these seizures generally overtake  one
without warning ; yet the most various aurse are also sometimes
noticed.  The most common warning, in my  observation at least,
consists in a  sensation of dizziness,  in  flashes,  and  darkness
before  the eyes.  Reynolds  asserts that the color of the  face in
these seizures  may on  occasion show all the variations men-
tioned  above, of  course excepting cyanosis ;  in my patients a
sudden pallor could generally be made out, which both preceded
and outlasted the loss of consciousness.
   While in the  majority, to be  sure,  after-effects are wholly
absent, so that patients are quite  unaware  that anything what-
ever  has just happened to them, at other times, even  after slight
attacks, symptoms show themselves which last for some time, it
may be for several hours—in most  instances  a  suppressed voice,
bad  humor, and surliness ; or headache and  forgetfulness, or de-
pression and fatigue wdth a tendency to sleep.  We shall have to
discuss further on how these conditions are to be distinguished
from simple faintness,  with  which they  have not  very infre-
quently been confounded by inexperienced observers.

C. Transition-Forms ; Loss of Consciousness with local Spasm.

   Epilepsia mitior in the form just described, i. e.,  complete
arrest of consciousness without any  spasm visible  externally,
certainly belongs to the exceptions.  On the other hand, we
quite often meet with transition-forms between it and the  major
attacks, in which  slight spasms occur together with coma.   For
the description of these attacks we may in the  main simply refer
to epilepsia mitior, especially as concerns the duration, the after-
effects, and the loss of consciousness.  To these, however, spas-
modic phenomena now come to be added.
   The locality, the intensity, and the nature of these are subject 
236
NOTHNAGEL.—EPILEPSY.
to the greatest variation.  Trousseau gives a very lively descrip-
tion of  these  so-called  abortive  attacks, and mentions various
examples in illustration.
   It happens but seldom that tonic  and  clonic spasms appear
together or in succession as in the major attacks ; as a rule, there
is in this form only one  or the other kind.  All the various possi-
bilities of the picture so constituted, which come under observa-
tion, cannot be detailed ; a brief indication of them must suffice.
In one patient the spasm betrays itself only by firm closure of
the eyelids, in another by strabismus, or by twitchings of certain
of the facial muscles,  or by violent contortions of the face, move-
ments  of the lips, shutting  the  jaws firmly, chewing motions,
rolling the tongue back and  forth,  a  constrained turning of the
head in some direction,  or shaking  movements of it.  Reynolds
frequentty observed  arrest of the respiration by spasm of the
external respiratory muscles and the  diaphragm, and  in conse-
quence  slight cyanosis.   Together  with these symptoms on the
part of the muscles of the head and back, or even without these,
there may occur local spasms in the extremities, or, less often, in
the trunk ; certain fingers are rigidly bent  or stretched ; one arm,
one leg, or even two extremities  become stiff ; or the parts men-
tioned  are moved to and fro by rapid clonic twitchings.   Or a
slight tremor runs over  the whole body.  Compare, too, the sec-
tion further on about  Epileptic Hemiplegia.—Again,  there are
cases wliicli are  closely allied in their external  features to the
major attacks, inasmuch as the whole  body is subject to  slight
tonic and clonic  convulsions, which,  however, from their very
slight degree of  intensity and their very  short duration, rather
suggest to the novice an analogy with the pronounced attacks
than prove it.  It is quite unprofitable to undertake to enumer-
ate  here all the possible multifarious  varieties  of the picture;
the reality surpasses any description.
   In the case of epilepsia gravior the unconsciousness always
outlasts  the  spasms.  This  may also be  the  case  in  the  form
which  now occupies our attention,  though  the opposite  fre-
quently  occurs   here,  i. e.,  the  patients  are   already  them-
selves  again,  while  the spasm  still continues.  This  was  very
striking  in one  of  my patients, where a rigid  extension and 
SYMPTOMATOLOGY.
237
stretching asunder  of  the fingers, that positively could not be
overcome, lasted for some minutes after the brief unconscious-
ness had completely passed away.
   Herpin remarks that in these forms consciousness is only
slightly affected, not by any means wholly abolished.  Although
this may also occur, I must still, from my own observation, agree
with llasse that in the  great majority an arrest of consciousness
takes  place,  which,  although often only very transient, is still
complete4.


J). Irregular Forms of the Attacks, and the Epileptoid States.

   We  speak of both together, because numerous  transitions
occur  here, and a complete separation is not only contrary to the
nature of the thing, but would also introduce much that is arti-
ficial into the description.
   There is  a great variety of forms under which at times the
epileptic attacks may  exhibit themselves,  and which yet have
long been recognized as such.  They must be sketched first;  we
will afterwards return  to the epileptoid states, properly speak-
ing.
   To-day it is regarded as almost an axiom that the most essen-
tial character of the seizure is to be sought for in the loss of
consciousness.  Now, there  are,  however, in contradistinction to
all those hitherto described, certain cases in which the coma is
absent.   We do not mean simple vertigo epileptica,  but parox-
ysms with distinct convulsions, but without arrest of conscious-
ness.  At all events, the spastic symptoms are here chiefly of a
local character, analogous  to those which we  have  described
among the transition-forms  (C),  but there occur, although very
seldom, strongly marked tonic and clonic epileptic twitchings, in
which the patient, although  all the time possessed of conscious-
ness and  sensation, at  the utmost experiences a slight confusion
and obscuration  of his senses.    I  saw a pronounced case in a
young fellow of sixteen, P. W.; in this  instance typical parox-
ysms were observed, in which the patient's face at first became
of a deathly pallor;  he then lost consciousness and fell into
general twitchings ;  these alternated with others, in which, with- 
238                NOTHNAGEL.—EPILEPSY.

out this pallor and without coma, violent clonic spasms appeared
occasionally, but only in the arms and legs.
   The literature of the subject  contains a series of examples,1
where at times the abnormal motor activity displayed itself in
a different way from the tonic  and  clonic spasms  heretofore
described.  Thus it has been observed that the patient at first
ran violently, but was even then  unconscious and at once began
to suffer from the twitchings, or he began by moving round in a
circle.   Sometimes, also, the convulsions are entirely  wanting,
and are  only replaced  by the motions of walking and running.
I have myself had  a  patient under treatment in whom, in place
of the usually pronounced major paroxysms, there occurred at
times some in which he ran up and  down  his room in a state of
complete unconsciousness. Hammond relates an analogous case,
and Trousseau another.
   The  greatest  attention of physicians, especially in forensic
medicine, has long been turned to the important cases in which
epilepsy has declared  itself by  periodically recurring attacks
of mental disturbance instead of the ordinary major or minor
paroxysms.  We  shall  see, hereafter, when  we  consider the
immediate abnormal  consequences of  the ordinary attacks, that
the  severest  states  of excitement may arise in connection with
an attack, just as we  saw that mental  changes may occur before-
hand as prodroma.   Thus  it may also happen in a  more ex-
tended sense that mental disturbances arise in place of the whole
seizure, and  present  a picture completely at variance with the
usual one of epilepsy.
    For the details from a psychiatric and  medico-legal point ol
view, we must refer to the special wTorks treating of them.  We
can here take up only so many of them as  necessarily belong to
the outline of an exposition of epilepsy in  general.  This topic
is treated of with considerable fulness by Falret,' and we follow
him in essentials.
    Falret  believes  that in the delirium epilepticum  a slighter
  1 Compare the older ones cited in Wicke's Versuch einer Monographic des
tanzes.
  2 Archives gener. de med. 1860. Vol. II. and 1861. Vols. I. and II. 
SYMPTOMATOLOGY.
239
and a severer form must be distinguished, just as is done in the
ordinary seizures, and that they present differences in the degree,
but not  in the essential nature of the symptoms.  It is common
to both  forms for patients  to be affected  paroxysmall}- with an
excitement which is at times announced  by warnings, but often
breaks out quite suddenly.  This  excitement, almost without
exception, has a  maniacal  character, and is evidenced by the
violence and suddenness of  the  acts which the patients perform.
It disappears almost as rapidly and  unexpectedly as it came, and
the patient returns to his  previous mental condition ; he has
afterwards either no recollection at all of the paroxysm and the
acts done in it, or a very dim and confused one.   There are vari-
ous intermediate forms between the  slight and the severest cases.
   In the mild form of epileptic delirium the inclination to  wan-
der round sets in, either after  the previous occurrence of the
mental prodroma which have  been mentioned,  or,  sometimes,
very suddenly ; or the patients, as  they  afterwards assert,  "are
driven by an irresistible force " to perform acts of violence. Most
frequently they throw themselves upon other persons and strike
them, or they destroy objects about them, or  they even  wound
themselves in a senseless way. At other times their acts are want-
ing in this character of excitement, and, instead, the most singu-
lar tilings make their appearance.  Thus cases are known in which
delicate and perfectly respectable persons suddenly use the most
obscene language for a short time.   The case reported by Trous-
seau is often  quoted, where a high  judicial officer suddenly, in
the midst of the session, went into the adjoining room and there
urinated in the corner, then returned  to the hall and continued the
session, and had no recollection of wdiat had occurred. A patient
under my observation was at times  subject to a peculiar confu-
sion, so  that  she  committed the most foolish acts; e. g., if she
had just made a fire on the hearth she put into it knives, spoons,
and whatever happened to  be  in her hand, instead of wood.
After the  lapse of a few seconds or half a minute, she came to
herself again and was conscious of the acts of folly she had com-
mitted.  The symptoms of paramount importance, however, and
which are constantly referred to, are when in paroxysms of this
kind patients are sometimes urged, by a sudden motive "im- 
240
NOTHNAGEL.—EPILEPSY.
pulse," to certain acts which ultimately assume a  character of
public danger.   Here belong, at least in part, the violently^  con-
tested questions of  pyromania, kleptomania, and  dipsomania.
It is far from our intention to discuss this  question in the pres-
ent place; it belongs much  more in the domain of the alienist
and of forensic medicine.  AVe would only remark, in accordance
with the careful observations of  various authors and  the mate-
rial, scantyT, it  is true, which we have ourselves seen in this  con-
nection,  that it appears unquestionable that such a transient
mental disturbance takes the place of an attack as an expression
of epilepsy.
   The severe  form  of epileptic delirium exhibits much more
formidable features than the mild, for in this a transient,  furious
mania of  the  most violent kind  breaks out, and is hardly sur-
passed  in intensity  by any other sort of maniacal aberration.
Patients of  this kind are met with almost exclusively in  institu-
tions, at any rate after the first seizure  has occurred.   AVe have
indicated above, after Falret, the  general characteristics of  this
delirium.  Still we must here call special attention to the reck
less impulsiveness of the acts, for they generally culminate in a
senseless destructive fury.  Patients annihilate everything about
them ; the most shocking murders, perpetrated in this way, are
recorded in  the annals of science.  At times certain mental pro-
droma make the unhappy patient aware of the approach of the
seizure, so that he can warn  those around  him  to protect them-
selves (we ourselves  know of a pronounced  case of this kind);
but at other times the passion for destruction breaks upon  him
so suddenly that no  escape is possible.  The sufferers often relate
afterwards that they have had hallucinations, usually of a repul-
sive and frightful character,  in which a red color has recurred in
varied fashion  with notable frequency.  It  also happens that
patients are  very violently but rather connectedly delirious.
   After an  average duration of from two to four days  the mani-
acal condition  passes off and the sufferers return  to a rational
state—provided, of course, their mental powers are not too much
enfeebled—without retaining,  in  favorable  cases, more  than a
dreamy consciousness of what has occurred.   Sometimes  this
transition is accomplished in a few hours. 
SYMPTOMATOLOGY.
241
   AATe now turn to the description of the epileptoid states.  AATe
have already pointed out in the introductory sketch that numer-
ous wholly indeterminate  morbid features were included under
this name by Griesinger, but we have also mentioned the protest
entered against it by AA'estphal.   In  the essay,1 wdiich he unfor-
tunately left incomplete,  Griesinger speaks  especially of  two
groups of symptoms which  he ascribes to epilepsy :  the  first
group included many kinds of attacks of giddiness ; the second,
morbid states,  which in practice are  usually regarded as hypo
chondria or hysteria, but which,  according  to Griesinger, are
epilepsy with strongly marked intermediary symptoms and very
slight and incomplete seizures. AATestphal, on the contraiy, urges
that such epileptoid seizures are among the most frequent symp-
toms in almost all the different diseases which belong among the
mental and  nervous affections.   Taking this view of it, then, we
should have to  reckon general progressive paralysis, e. g.,  as
epilepsy on account of these epileptoid or epileptiform seizures.
There is doubtless much that is correct in this  objection of AArest-
phal; but, on the other hand, we believe the same should be said
of Griesinger's theory.  In fact,  so long as our knowledge of the
nature of epileps}^ is so inadequate, and so long as any one may,
and even must, without contradiction look upon all the different
groups  of symptoms described above as epileptic seizures,  it
appears to us that we cannot deny the right of considering other
combinations of symptoms also, under  the circumstances, as the
expression of epilepsy.  If, now, we would not fall into the error
so properly emphasized by Westphal, the boundaries must  be
clearly defined within which we are still to regard  an anomalous
combination of symptoms as an expression of epilepsy.  In this
view we would enunciate the following  rules :
   Those  states should  be  regarded  as  epileptoid,  /. e.,  as
caused by a central  epileptic change, in which symptoms show
themselves  paroxysmalty, for the  development  of  which the
same physiological processes, according to our present knowl-
edge, should,  or, at any rate, may be assumed,  as produce
(when developed in greater intensity  or extent) the usual epilep-
 1 Archiv f. Psychiatrie und Nervenkrankheiten. Vol. I.
VOL. XIV—16 
242                 NOTHNAGEL.—EPILEPSY.

tic  attacks.   Furthermore,  it  should be kept  clearly  in  mind
that,  as in genuine epilepsy, these paroxysms constitute  the
principal feature of the disease, while the symptoms of the  inter-
val, on the contrary,  stand in the background, or are so little
pronounced that no other nervous or mental affection could, with
any probability, be made out from them.   The only exception
would be when  they can be shown to be in some  sort  a conse-
quence of the epilepsy.   The certainty as to wdiether the case be
one of genuine epilepsy or not, is to be gathered from the occur-
rence sooner or later of real paroxysms in place of, or alternating
with, these questionable seizures.
   AA^e by no means fail to recognize the fact that even on this
theory there may be discussion about many cases as to whether
they should be classed as "epileptoid" or not.  Still, the way
of looking at  it  proposed by Griesinger appears  to us, practi-
cally and  scientifically, very important, and it was for this reason
that we desired to  make at least an attempt to formulate this
question in more precise terms.
   What now are the clinical features of these epileptoid states %
It would be impossible to detail  them here fully in their multi-
form variety ; we can only give a characterize tion of a few types.
   In  the first series we  must mention " attacks of giddiness',"
as well as the mere slight sense of oppression, without the actual
loss of consciousness, as in epilepsia mitior.  These vertigos are,
as  Griesinger properly  insists,  often ascribed to all  possible
causes, congestions of the brain, disturbances of digestion, and
the like, while  epilepsy is not  thought of.  The same investi-
gator  points  out more fully what are  the indications which
should arouse our attention in such a vertigo, in a way to  make
our diagnosis positive.  From the various  histories of patients
under my  observation, I extract  the following, as well describing
this epileptic vertigo :

   A clergyman, of twenty-eight,  had frequently suffered  as a boy  from night
terrors, which he called "nightmare."   No hereditary influences are to  be dis-
covered. He was healthy up to two years ago, when he suddenly, without warning,
became "faint,"  fell down,  and was unconscious; afterwards, for three days, he
was very weak and afflicted with headache. Since this time he has suffered, with-
out having in any way changed his mode of life, from very frequently recurring 
SYMPTOMATOLOGY.
243
attacks of vertigo.  These are often preceded by palpitations of the heart;  some-
times they are introduced by a peculiar "twisting" sensation in the region of the
stomach, wheiice it rises " into the throat," and  even  up to the back of the head ;
then the patient's face becomes red, he has a sense of heat in the head, and is
sei/.ed with such a  decided giddiness that he has to take hold of something to
avoid  falling.   Sometimes, in connection with it, a general trembling and qualm-
ishness runs over him.  These seizures come frequently, in part  after mental exer-
tion, but in part quite spontaneously, even when lying still.—It is now still further
characteristic that  the patient,  after having latterly  for almost two years been
afflicted with these attacks of giddiness only, has had four attacks in which he fell
to the ground, became very pale, according to the statement of those about him,
lost consciousness completely for from one to two minutes, and was possessed by a
general spasmodic rigidity.—Objectively there is not the slightest thing  to be dis-
covered.

   If we analyze  this  case  more thorough]y, the following cir-
cumstances present themselves which lead us  to  look with  sus-
picion  upon  the vertigo  : in youth,  the striking nervous  man-
ifestations ;  an  unmistakable aura proceeding from the stomach :
marked  change  in the  color of  the  face ; palpitations of the
heart,  without  the least change in the circulatory  apparatus,
and often without anything to occasion it, as when  lying still  ;
sometimes trembling at  the same  time.   To these  there were
added, as the case went  on, unmistakable  epileptic paroxysms,
with eclipsis and muscular  rigidity.
   The following condition,  although presenting wholty different
characters, must,  I believe,  be considered as epileptoid :
   The patient,  a robust man of thirty-two, is stated to have come from a healthy
family; was formerly healthy;  had only suffered while a student from " a slight
sense of oppression in the head." In his youth he had been somewhat addicted to
onanism.  The present occurrences  have existed for four years, and recur at  inter-
vals of from a week to a month, while between times the patient is perfectly well.
Either spontaneously or after  mental  efforts there suddenly begins a glittering
before the eyes,  with obscuration of the visual field, especially on  the  right side.
Then a peculiar  sort of dreamy condition  sets in;  the patient  recognizes his sur-
roundings, but his thoughts are, " as it were, under a spell," and he has to think
constantly of one and the  same circumstance.   He hears  what is said by  those
around him in  a dull way,  and as if from a distance.  This condition lasts for
about half an hour, during which time, according to the statement  of his family,
'lis face assumes a very pallid hue.  After the seizure there is a feeling of creeping
and numbness in the right or left half of the body.  Then he is again perfectly
well. 
244                  NOTHNAGEL.—EPILEPSY.

   Finally, we also present as an illustration the medical history
of a student of theology, twenty-three years of age.
                                                         «
   A brother suffers from pronounced epilepsy.  The patient himself was entirely
well up to his eighteenth year, only he masturbated between the ages of twelve and
eighteen.  Then one day, at dinner, without any known cause, he suddenly became
dizzy and at once fell down unconscious;  it cannot now be ascertained whether
there were convulsions with this seizure.  Since then seizures of the following kind
have developed themselves at intervals of from one to three  weeks, during which
the patient has been perfectly well.  Be the patient where  he will, he suddenly
experiences a peculiar impression of white light, not to be more accurately denned.
Thereupon he believes that he is transported to some entirely strange, and usually
imaginary region (" heaven or hell"), though he still knows that he is in the street
or in college, and can even salute passers-by in this dreamy state—consciousness is
never completely lost.  His mother states that the patient during the seizures looks
flushed, but afterwards pale, and that his hands  are " spasmodically clutched to-
gether."—The patient made use of a cold-water-cure and of potassium bromide and
ext. cannabis indica in large doses.  The seizures described disappeared; but others
set in, which last one or two minutes  and in which the patient is actively excited,
speaks confusedly, and is abusive.

   AAre  do not wish to  add to the number of these examples,
because it would  be impossible to exhaust the great variety of
the features they present.  For our  part we are of  Griesinger1 s
opinion,  that such states belong to  epilepsy.  The  aim of  the
inquiry is to establish where the limits of the territory must be
drawn, and wdiether various  other states  should and must be
included in it, of which we can take no account here in a manual,
because their title to belong here can be still further contested,
as in  the case  of  the  epileptoid  neuralgia of Trousseau and
others.
    AA"e now  once more  return,  after describing  the  various
forms  of  the paroxysms, to  their  immediate consequences.  It
was stated above that, as a rule, the patient returns to his nor-
mal condition after a deep sleep of longer or shorter duration;
after the  mild attacks,  often with surprising  quickness.   Still
at times the paroxysm comes to a close in another way.
    In the first place it is to be stated here that very marked con-
ditions of exaltation  may follow upon the  convulsions.  Their
character is generally perfectly analogous  to that  of epileptic
delirium,  /.  e., the patients are very highly excited and maniacal, 
SYMPTOMATOLOGY.
245
and the delirium is characterized by the same senseless, impulsive
outbreaks of fury as in the cases where it takes the place of the
whole seizure.  A further description may therefore be omitted.
This mania lasts for a variable length of time, for one or a few
hours,  sometimes  even for two or three days.   On other occa-
sions, the patient for a considerable  time after  the seizure  is
stupid, apathetic,  and only  very gradually comes  back to his
former status.  Again, at other times, simple conditions of hallu-
cination  or  somnambulism are established. —As a matter of ex-
perience, these serious  consequences  are almost exclusively ob-
served in case of epilepsia gravior, although the intensity of the
seizure and  its immediate sequelae by no means always stand in
the same relation to  each other, as it also happens  that  occa-
sionally a milder epilepsy is followed by an uncommonly  violent
and protracted after-stage.
   Certain other manifestations are also at times  to be reckoned
among the  immediate consequences of the seizure,  which,  from
their clinical features, we may characterize in general as paraly-
tic manifestations, with which aphasia would also be associated.
The paralytic manifestations  are  partly motor, partly sentient,
and partly sensorial,  such as  deafness, loss of the sense of taste
and of sight.  Echeverria counts up a great plenty of them.
Todd was the  first to  describe  "epileptic hemiplegia"  fully;
recently Hughlings Jackson,1 especially, has given  close atten-
tion to the  study of  it.  According to our experience, we must
agree with Reynolds and H. Jackson that  these resulting condi-
tions or complications of the attacks  are not  directly dependent
upon them as such.2  With regard to the cases where a lasting
paratysis remains after an epileptic, or in this case more prop-
erly  an epileptiform, seizure, there  can be no doubt that some
grosser material change of structure exists within the skull, that
in fact we can assume the existence of no epilepsy in the true sense
of the word,  but that  the convulsions  are simply the sjnnptoma-
  1 Compare, besides the various articles in the journals, his article on " Convulsions "
in Reynolds' System of Medicine.
  2 As Reynolds forcibly expresses it: " There seems to me to be no more reason for con-
necting the paralysis with the epilepsy than there would be for us to connect bronchi-
tis, cancer, or corns with this disease." 
246
NOTHNAGEL.—EPILEPSY.
tic expression of an anatomical cerebral lesion.  Moreover, when
these cases are investigated, further symptoms will  be found
without trouble, which are referable to such a lesion.   Usually
there are  tumors,  embolisms  in the territory  of the artery of
the fossa of Sylvius, less frequently hemorrhages ; still,  in refer-
ence to the latter,  we would add, so as to avoid misunderstand-
ing, that we mean  primary hemorrhages, such as are themselves
followed by convulsions, not such as might originate during the
seizure  as a result of the venous stasis, because, as we have
already remarked several  times, this last accident  hardly ever
occurs.  As we cannot enter more closely into this subject in this
place, we  must refer the reader to the other sections of the pres-
ent work which treat of it.
   AATe can express ourselves just  as briefly with regard to the
unilateral convulsions and the hemiplegia—permanent  or tran-
sient—which follows them.  It is true that sometimes unilateral
twitchings occur even in genuine  epilepsy, as was stated above
under the head of irregular forms of the seizures ; but these are
almost always rather partial and insignificant, and at the utmost
they are occasionally interchangeable with  complete paroxysms
—and even in these,  if they recur with  increased  regularity,
we  must always be suspicious  of  an organic cerebral  disease.
If, however, a patient suffers exclusively from violent unilateral
convulsions, and if transient or permanent paralyses or pareses
of the affected parts remain after  them, we may almost always
with considerable  certainty assume the existence of an organic
brain lesion.
   Now there are also cases  in  which  patients  suffer for a
considerable  time  from completely developed epileptic parox-
ysms, which are  frequently  repeated, and  after which there
remain constantly, or, at all events, quite often, pareses or paral-
yses of motion or sensation,  which are recovered from again,
however, after some time.   What is the state of things in these
cases ?   Even if it be not possible to assign a cause with absolute
certainty,  still the  conditions hitherto known to have been found
on post-mortem examination and a full analysis of all the symp-
toms  indicate that here  also  the  grosser  anatomical  lesions
always come into play.  As in the case of epileptic hemiplegia, 
FREQUENCY OF THE SEIZURES.
247
the site of these latter is often to be sought for on the convexity
or in the hemispheres of the cerebrum.  AVhen speaking of the
etiology,  we have expressed ourselves to  the  effect that in our
opinion such anatomical lesions of the cortex are capable of pro-
ducing the "epileptic change;"  in this way  we could  actually
speak of an "epileptic hemiplegia" if a true epilepsy originated
in this way, still  this would  be only a  play upon words, for, in
fact, it is not the attack which occasions paralysis, but  the ana-
tomical lesion itself.  It is true, the method of the pathogenesis
still remains obscure.  AVe may, at most, conceive that transient
disturbances  of  the  circulation  round about the  anatomical
lesion, which accompany or result from the attack, give rise to
the transient paralysis.
   Aphasia  after epileptic attacks we only  mention  here  by
name, as this combination of  symptoms is treated of in its pro-
per connection in another part of  the present work.
   On beholding a severe seizure,  it would be thought, especially
by the laity, from the violence of the symptoms, that death would
more often occur.  On the contrary, it is, in fact, astonishing how
very seldom the individual paroxysm as  such causes death  by
the convulsive movements and their immediate consequences.
At the utmost it is occasioned  by unfortunate  accompanying
accidents, as, e. g., by severe wounds,  or most often in this way,
viz., that the patients, if alone, fall so unluckily  that  they
lie somehow  upon  the face,  and the mouth  and nose are ob-
structed,  as a result of wdiich suffocation of course followrs ;  or,
again, by a  seizure occurring just as they are eating, in which
case the  food gets  into the larynx and may lead to  immediate
suffocation.   Suffocation from  spasm of the glottis, however, is
among the greatest rarities.   The case is different,  of course, if
the paroxysms are  very frequent and follow  rapidly one  upon
another ;  then, it is true,  patients not  infrequently die, and in
quite a variety of ways.   AVe shall shortly recur to this more in
detail.

                 Frequency of the Seizures.
   Observations have always been made, of course, as to the fre-
quency of the epileptic seizures,  and among the  more recent 
248                NOTHNAGEL.—EPILEPSY.

investigators, Reynolds, especially, has busied himself particu-
larly with the inquiry into the question of how all sorts of influ-
ences  affect  their  absolute  frequency,  their  form,  and their
mutual relations.  Detailed  discussions of this  sort,  which are
appropriate in  a monograph, can  only be touched  upon in a
manual in their most essential parts.
   The prevailing rule is that  the paroxysms generally recur
very irregularly.  The literature, it is true, furnishes the records
of many instances in which a certain periodicity, a certain rhythm
is not to be denied,  and every physician of some experience will
be able to add to them.  Thus,  in many patients the paroxysms
recur at definite times of day, or once a week, or once every two
weeks, or every other  day ;  sometimes with women, in a certain
loose connection with  menstruation, or, at all events, monthly,
from which has arisen the wholly untenable popular belief in
the influence of particular phases  of  the moon.  For all these
cases it holds true that such a rhythm is only temporary,  transi-
tory, frequently even  only  apparent, because quite inconstant,
and  that with  the same patients the seizures may again  depart
widely from the type.   The rule, then, is the irregular recurrence,
and more  or less regularity is  to be regarded as an accidental
circumstance, not depending upon  the nature  of  the disease or
upon regularly recurring extraneous influences.
   The frequency of  the paroxysms varies within  extremely
wide limits; some patients have one seizure a year, others have
thousands.   AAre regard  it  as  rather an unprofitable piece of
trouble to  count up the numbers so as to get at the average fre-
quency in many epileptics.  Even in one and the same patient,
however,  a  noteworthy  variation  sometimes takes place,  al-
though, when calculating for considerable periods, the average
with the same individual undergoes slighter changes ;  thus there
may be one  paroxysm weekly, then after one weekly interval
there may be  three or  four, then again a  cessation for  two
months may ensue, and  then again  a seizure.   The free inter-
vals may become still greater,  even apart from the influence of
any medication, a circumstance which must be recognized and
taken  into  consideration when estimating the value  of  thera-
peutic measures.   After such  a considerable pause  the  first 
FREQUENCY OF THE  SEIZURES.
249
paroxysms wliicli again occur are apt to  be of greater violence,
and to appear rapidly one after another.  Investigations as to
whether the attacks occur more frequently at the beginning of
the disease or increase in frequency as the duration of the mala-
dy increases, furnish no positive results.  At times they are more
frequent at the  beginning and then diminish,  and the opposite ;
only it might be said to be  very generally true that when the
epilepsy is incurable, as its duration  increases, the frequency of
the paroxysms often increases.
   Besides, no definite numerical statements can  be made as to
the proportionate frequency in the same patient of isolated
attacks  and those  which occur in groups.  These groups of
seizures themselves, however, require a more minute discussion.
They  may be  composed of  from four to  one  hundred single
seizures, or even more, in twenty-four hours.  Delasiauve saw in
a boy of fifteen within one month a "collective seizure," which
was composed  of the  incredible number of 2,500 "fragmentary
seizures."  It is evident that so numerous attacks rapidly suc-
ceeding one another must have an extraordinary effect upon the
patient.   The French have introduced  a  special name for this
state in which the patients remain in a coma in consequence of
the rapidly following attacks, viz., etat de mat  epileptique (status
epilepticus—compare  the note given on p.  188). Bourneville (loc.
cit.) gives detailed attention  to this very subject;  Obersteiner,1
too, has quite recently described three cases of the kind, and we
have ourselves once observed a case of the  same sort. In Bourne-
ville's account  an enormous increase of  temperature, which may
even rise to 42° 0. (107.6° P.), is brought forward as specially
characteristic.   Starting from  this period,  the patients lying in a
deep coma and with the temperature mentioned,  a  turn  may be
taken in several  directions.   Either  the  temperature advances
still further and a fatal result takes place,  or, on the other hand,
all the symptoms gradualty subsiding, the  patient recovers ;—the
former event seems to  be somewhat the more frequent.  At other
times, even if  death be not  immediately dependent  upon  the
convulsions, the case may still  take an unfavorable issue;  the
1 Wiener med. Wochenschrift. 187o. 23. 
250                NOTHNAGEL.—EPILEPSY.

temperature  advances anew,  consciousness becomes  still  more
obscured, and the  patient succumbs, sometimes  being afflicted
with bed-sores,  with the symptoms of profound collapse. At
times even this second advance of temperature is overcome.—The
post-mortem appearances, as brought forward by Bourneville,
give no satisfactory explanation of the cause of death.  In two
cas<_>s under my  observation,  after  seizures   thus  frequently
repeated, there set in marked oedema of  the  lungs,  in one of
them a  commencing pneumonia also,  and the patients died with
the symptoms of these affections in deep stupor and high fever.
Westphal also witnessed an advance of  temperature with parox-
ysms following coup sur coup and ending fatally.  It cannot at
this time be positively decided whether this high temperature in
the etat de mat depends simply upon the violent convulsions,  or
wdiether it is to be set down as analogous in  its own peculiar
nature to the as yet unexplained rise of temperature in the death
agony in diseases of  the  central nervous system.  It appears  to
be unquestionable that the latter point also bears its  part in the
cases that end fatally; still,  we cannot  well speak of a rise of
temperature  in the death agony when the patient recovers, and in
those cases the  effect of the intense muscular  movements  must
be brought in to assist in explaining it.

   Bourneville observed hemiplegia in the  majority of the cases  that he saw.
Those where an autopsy was made confirmed what was stated above incidentally to
epileptic  hemiplegia, viz., that gross anatomico-pathological conditions were
found. In no instance, however, is this hemiplegia in any way characteristic of
the etat de rnal.

   The  fact  that  the  seizures often appear  at  night, during
sleep, is of great importance.  In regard to this,  too, statistical
inquiries have been  undertaken, from which we  only arrive  at
rather indefinite results, for it has been ascertained from a very
large total, that on the average  "epilepsia diurna " is somewhat
more  frequent than  "epilepsia nocturna,"—so far at least  as
information  regarding  night attacks could be  obtained.  Of
course the same patient may occasionally have his attacks just
as well by day as by  night.—Trousseau groups  together, in a
practical way  well suited to  the  purpose,  the conditions  in 
FREQUENCY OF THE SEIZURES.
251
the presence of  which we may,  with more or less certaint}^
assume  that  seizures  take place  at night.   This  is  impor-
tant to know,  because  it happens that with  some patients
epilepsy begins with  attacks exclusively nocturnal.  Our atten-
tion will be attracted by the resulting mental conditions  spoken
of above, such as depression, stupidity,  headache,  and the  like,
if persons previously healthy  complain of these on  some occa-
sion on waking in the morning.  AATe attain to certainty if invol-
untary discharges of urine or fasces have taken place  in the
night, if the tongue  has been bitten, or  small hemorrhages into
the skin are found.
   AVe have so far spoken only of the frequency of the seizures
in general; the  relative frequency of the various forms  now
demands a  brief consideration.  The results arrived  at by var-
ious observers in regard to this differ from each  other in some
points, but agree in others.  Except where we make some special
comment to the contrary, we can confirm, from our own  experi-
ence, the following propositions, which were in  part  established
by Reynolds :
   There are  epileptics in whom only the  major attacks  take
place, others again who suffer from  the mild form only, with  no
pronounced  spasmodic manifestations, or  but  very few.  The
latter group is veiy small in proportion  to the wdiole number of
epileptics, the former  very much  larger.   There is  a general
agreement so  far as this.  Not  so with  reference  to another
question.   There are,  namely, in  the third place,  patients in
whom, as we have already^ pointed out incidentally, the different
forms of the seizures occur jointly,  and  they consequently  have
alternately  major attacks  and mere fits of dizziness, with  or
without partial twitchings.  It is confirmed by all that this com-
bined form is more frequent than  the epilepsia  mitior alone ; it
is only a matter of discussion whether it is rarer than or nearly
as frequent as the pure epilepsia gravior.   From my own expe-
rience, I adhere to the opinion that the combined and  the uncom-
plicated  severe forms are  just about equally frequent.   The
influence exercised by the combination upon the course  of the
disease we shall touch upon further when speaking of the prog-
nosis.  According to Reynolds's careful inquiries, we ought not 
252
NOTHNAGEL.—EPILEPSY.
to take the view that the number of the major seizures would be
diminished by intercurrent light  ones, or that again the latter
occurred vicariously for the former, but that  the petit  w«/ is a
simple advance in the intensity of the disease.
   Epilepsy may  first manifest itself  in the form of either the
greater or the lesser attacks.  Reynolds has established the fact
that where the  tendency is inherited, the  onset is more com-
monly with the major than with the minor.   Echeverria confirms
this.  In determining the  character of the  seizures, the age at
the beginning of the disease is of much less essential significance.
It is just as little  susceptible of proof that the  length of time
during which the malady has  lasted  exercises  any  modifying
influence upon the nature of the attacks

             II. The Inter paroxysmal Condition.

   Although the seizures constitute the peculiar essential symp-
toms  of  epilepsy,  still the condition which  exists during the
interval between them also  deserves attention corresponding to
the often strongly  marked symptoms which it offers.   This
attention has already been given to it  in part, particularly with
reference  to  the mental state of  the  patients.  Its importance,
however,  was first fully appreciated by Russell Reynolds, at
whose hands the  subject has received a careful and  thorough
examination.
                   General Constitutional Relations.

   A  decided protest against the  opinion which has  prevailed
since  Hippocrates, viz.,  that epilepsy may occur,  on occasion, in
any state of  the constitution, has  been offered almost alone by
Radcliffe, and he  maintains that the peculiar, typical  condition
of the system at large in epileptics is weakness and depression of
the circulation (the powers  of the circulation  are always defec-
tive).   This view of Radcliffe's, however, has not been assented
to,  because  it is  too much opposed  to every-day observation.
There are undoubtedly miserable, weak epileptics enough, but
those are  decidedly more numerous in wdiom the bony frame-
work, the muscular strength, the color of the  skin, the deposit 
             THE INTERPAROXYSMAL CONDITION.          253

of fat and the energy of the condition of the circulation do not
depart in the least from the normal; there are even occasionally
some who are noticeable for their Herculean frame and strength.
It is equally impossible to prove that the duration of the disease
leads to any habitual changes in this respect.
   As the constitution may be perfectly normal, so in the case
of certain epileptics ma}^  all pathological appearances on rhe
part of  the  nervous system be absent;  i. e., many  epileptics
appear to be ailing only at the time of the paroxysms, exhibiting
in the intervals the appearance of thoroughly  and completely
healthy persons.  And  in fact this obtains not merely with recent
patients, and where the paroxysms  are infrequent,  but  even
sometimes where the duration  of the disease has been consider-
able, and after frequent seizures.   This fact  is of high signifi-
cance, for it proves, first, that the seizures are actually  the essen-
tial feature in the disease, because the constant one;  secondly,
that the symptoms of  the interval, because inconstant, may de-
pend upon merely accidental or secondary changes ; finally, that
we are right in seeking for the primary and proper seat of the
epileptic change in the  medulla oblongata and pons, and not in
the nervous system at large, precisely because, as we shall prove
further on, the manifestations of the seizure maybe derived from
antecedent processes in these parts alone, while the syxmptoms of
the interval, which must be referred to the cerebrum  and ulti-
mately to the spinal cord, may be entirely absent in the disease
when fully developed.
   The interparoxysmal manifestations which occur may involve
the motility, the sensibility, or the mental faculties.
   Motor manifestations.—AVhen speaking of the motorial aura
it was stated that the  spasmodic movements  of which this aura
consists  were also often observed without a  seizure  following.
But associated with these there also occur  motor phenomena in
the intervals. As rightly observed by Reynolds, and  as can be
easily determined, they  may  show  themselves in a  threefold
form : as a  simple  muscular  trembling, as clonic, or as  tonic
spasms in single groups of muscles.   Quite frequently we have
two or even all three of  them together.   The clonic spasm is the
most frequent, the tonic the least so.  I  have  seen a perfectly 
254
NOTHNAGEL.—EPILEPSY.
typical instance of the latter, as the only symptom of the inter-
val, in the shape of  a periodically recurring  cramp  of  the calf.
According to Reynolds, some seventy-five per cent, of epileptics
exhibit some such motor change in the intervals.
   Sensory manifestations.—These are rather less than more fre-
quent  than the motor manifestations.  Quite apart from the fact
that the disturbances exhibited by the sensory aura also occa-
sionally occur alone, without any subsequent seizure, that they
are, in fact, symptoms of the interval, we chiefly observe head-
ache, persistent sensations of dizziness and dull confusion of the
head.   It is only exceptionally that  these attain an especially
high degree.
   Mental manifestations.—The  fact that disturbances of the
mind are present during the intervals  has been known for a long
time, and has  always commanded the greatest interest.  Many
alienists  have  even  gone so far  as  to declare such epileptics
insane.  This opinion is, however, decidedly incorrect; it can
only be  a deduction from  observations which have  been made
exclusively in  institutions.   The results  of  those wdiich have
been collected from  private practice are of  a wholly different
tenor.
   It is undoubtedly possible for an absolutely healthy state of
mind to coexist with epilepsy.   Reynolds, in fact, reckons from
his own cases that  this is true of a third of all patients.  It
is  well known that  historical  tradition tells  of  numerous very
highly gifted men who suffered from  epilepsy, and whose deeds
do not allow the recognition of any mental deterioration (Caesar,
Napoleon, Petrarch, and others).
   If mental disturbances occur,  as is certainly the case in the
majority,  according to what has just been said, these may again
be very various in their nature, and  especially in their degree.
There are all transitional stages from such slight alterations that
they can be discovered only by careful attention, up  to the high-
est degrees of mental disease, in which the human characteristics
of the  individual gain expression only in  certain traits,  perhaps
only in the power of speech.  AAre are not willing to reproduce
such statistical statements as are available, because,  although so
far carefully  compiled, they are  still too  small.  Only be it 
             THE INTERPAROXYSMAL CONDITION.           255

remarked  in  general, that  fortunately  the  slighter degrees are
far the more frequent.
   The most common and often also the first mental lesion is a
weakening of the memory,  and on this point we are agreed with
others.   Here  again,  as in almost  all  cases, the  peculiarity
obtains that the memory is principally  enfeebled with regard to
what has happened most recently, while it exists in perfect fresh-
ness with regard to things long past. A  diminution in the sharp-
ness of apprehension is decidedly less frequent.  Then again,
the character and disposition are frequently altered.  Patients
become gloomy,  out of  humor, depressed,  or  violent, irritable,
"nervous,"  distrustful,  easily angered.  Or the disposition is
changeable, often without any appreciable reason.
   These slighter degrees of mental disturbance  may now last
for a year, or continue always to exist as such.  At other times,
however, a constantly advancing disease of  the mental life then
forms a transition stage to wdiat is ultimately mental death or
complete imbecility.  Patients decline into marked hypochondria
or melancholy.   And further, to make  use of the words of Grie-
singer, "the  memory decreases, the imagination  grows dull, the
fancy loses its  richness  of coloring, its intensity and warmth,
and the spirit is withered.   The physiognomy and bearing are
altered, the lips  of patients grow thick, their features coarse,
and they acquire a hideous  expression of countenance.  ... A
final decline into imbecility is  the sad destiny of many of these
patients. . . . Cases of epileptic imbecility are to be regarded as
wholly incurable ; the other  forms of insanity, complicated with
epilepsy, as curable only  in exceptional instances."—Further
details in reference  to  this  subject belong in the department
of mental disease, and therefore cannot  be touched upon here.
   On  the other hand, we now turn to a brief discussion of a
very important question, which, again,  has been most carefully
treated in its various aspects by Reynolds,  wdiose statistical
results form the  basis of what follows.   Are there any definite
conditions, which, belonging  to the nature  and progress of epi-
lepsy, have an  action which  favors the  development of mental
lesions '.
   Hereditary predisposition  and the time of life at which the 
256
NOTHNAGEL.—EPILEPSY.
disease began, as well as general constitutional relations, play no
appreciable part in developing them.  According to Reynolds,
however, the  length  of  time  during which  the epilepsy has
existed  has  just as little significance.   This view,  which is
opposed to that advocated by Esquirol and  many others, evi-
dently finds its support in the simple fact that there are many
persons  advanced  in life, who have been epileptic from  their
youth, and in whom there exist only slight mental disturbances
or none at all.  But a short time ago I treated a  lady who had
been epileptic for twenty-six years, and who suffered from only
a moderate impairment of memory and at  times from a some-
what  sad disposition, and in whom the power of judgment was
only slightly  impaired.
   There is a prevailing agreement in the opinion that no rela-
tions  of any kind  whatever exist between  the mental disturb-
ances and the seizures.  Here  Reynolds,  by an exact statistical
method, has arrived at noteworthy results  which differ in several
respects from the generally received opinions.
   The first result arrived at is that the number of  the paroxysms
simply,  through which the patient has passed, stands in no rela-
tion whatever to the mental change ;  how large soever the num-
ber may have been, by that circumstance  alone the intellectual
faculties are  not impaired.   Reynolds asserts that eleven men
under his observation had endured an average of 2,000 seizures
(one 18,455, seven  more than a thousand) without a single men-
tal  disturbance  having followed.    On the other side,  such a
change has been observed after no more than from six to twenty
paroxysms.—Moreover, the opinion  that the more violent the
separate attacks  are in their  symptoms, the more the  mind
suffers, is not confirmed by close examination.
   On the other hand, it appears that the rapidity in the  reap-
pearance of the  separate attacks is  of a greater  significance, in
that the intelligence is more  impaired by a  frequent recurrence
of them.  Yet even here there is no constant  ratio  of dependence,
for now and again certain patients remain free notwithstanding
that the seizures return often, and, on the contrary, others have
their minds affected even with infrequent attacks.  This  latter I
have myself  seen in one case where there was  a repetition of the 
SYMPTOMATOLOGY.
257
attacks but four times a year; it is true, the  lesion was a very
slight one, so far as my observation of this patient extended.—
As regards the form  of the  seizure, it may still be  stated that
many persons regard  those cases as decidedly the more unfavor-
able, so far  as  the development  of intellectual  disturbances is
concerned, in which epilepsia mitior is present together with the
severer form of  the disease.
   AA"e will now submit to a  brief consideration the question
whether in any way single cases  of epilepsy present  clinical
varieties in accordance with etiological  influences.   The analy-
sis of the individual cases of illness certainly teaches that this is
the case to only a limited degree.   Still we regard even a slight
influence in this respect as important enough  to be considered
here in view of the significance of the question raised in its rela-
tion to therapeutics.
   First, is epilepsy stamped with a special character by reason
of an inherited predisposition?  It is true, we have  incident-
ally touched upon this point in the course of our exposition, but
we wish once more  to gather  together here what  there  is that
bears upon it.   According to experience such patients sometimes
suffer from eclamptic attacks even in their first dentition ; if not
then, the first  beginning of the disease almost invariably shows
itself in early youth, even up to fifteen or seventeen years of age,
and only very rarely after twenty.  Reynolds has concluded from
his cases that hereditary  predisposition is not without influ-
ence upon the character of the seizure, since when  it exists epi-
lepsia gravior is much  more often developed without the milder
form.  Still the relation is by no means constant, for in certain
cases epilepsia mitior also occurs.   More important, particularly
for prognosis, is the knowledge of the fact that, in spite of inher-
ited  predisposition to  the disease,  mental disturbances  do not
appear more frequently than where  this is absent, while a priori
one is perhaps  inclined to make a more unfavorable prognosis in
these cases.
  Secondary  epilepsy, i. e., that form in which peripheral or
         VOL. XIV.—17 
258                NOTHNAGEL.—EPILEPSY.

central  anatomical lesions serve as the starting-point  for  the
development of the disease, presents some peculiarities.
   If a pathological condition of irritation of ^peripheralnerveis
the influence which gives rise to the epilepsy, its picture has the
following special features:  Almost  invariably a certain length
of time passes prior to the occurrence of the first seizure ; at least
it  is so recorded in the observed cases which can with  positive
certainty be counted in this category.  This is of variable length,
averaging some weeks, but at times amounting to months or even
longer.   Even during this  period painful sensations not seldom
show themselves:  either clonic  or tonic  spasms  in  the tract
of the affected  nerve, or the two  combined.  These  abnormal
phenomena remain confined to the  nerves or they spread more
widely, but scarcely ever  extend beyond the side of the body
originally  affected.   Then the pronounced  spasmodic  seizures
appear with loss of consciousness.  These  are always ushered in
by an aura, which may be in different  cases of a motor, sensory,
or vaso-motor kind, but, as a rule,  is characterized by the fact
that it is always of like nature in the same patient.   It begins in
the region  of the injured nerve, and hence  arises the importance
of a constantly uniform aura in judging of a special case of epi-
lepsy.  If such be found, one must always be closely on the watch
for some sort of a peripheral lesion.   Not as if analogous uniform
auras did not  occasionally present themselves in other forms, but
in those mentioned they are the rule. The  symptoms above indi-
cated often appear in the intervals, and they also precede  the
outbreak of the first attack.—Moreover, in these  cases, if there
happen to be  a  cicatrix  on  the body, one may sometimes, but
not  always, produce a seizure by pressing upon or touching it.
At the same time it is worthy of note  that an actual "epilepto-
genous"  zone,  as in the case  of  the guinea-pigs which were
experimented on, is never distinctly  marked.   I have  myself
continually sought for it in vain in patients affected.   So much
the more interesting is the  case of Ogle's, in wdiich there was an
extensive portion of the body, the upper extremity, by touching
which a seizure could be produced.1
1 Lancet. 
PATHOLOGY.
259
   Somewhat different features, again, are presented by  those
epilepsies  which  owe their development to the existence of a
small circumscribed lesion of the brain on one side.   AVe must
think of this form, if the following symptoms are present:  the
attacks begin either very suddenly—this, to be sure, would be
without any significance ; or, as is more frequently the case, they
are introduced  in some  constantly uniform and  peculiar way.
There first occurs, for instance, a tonic or clonic spasm in a par-
ticular  group of muscles or  even  only in  a single  muscle, as in
the region supplied by the facial or even only by single branches
of it, as in the orbicularis palpebrarum, or in the region supplied
by  the spinal accessory, or  in certain fingers, etc.  Hence  the
spasm  sometimes  spreads over the corresponding half of  the
body before it becomes general.  I believe  that great importance
should be attributed to this peculiar stereotyped commencement.
Here, on  the other hand, the sensory aura, wdiich  plays so great
a part  in  epilepsy from peripheral causes, retires decidedly to
the background;  it  occurs only very exceptionally, if at  all.
Further than this, the occurrence of a paralysis or  paresis, unila-
teral, or even limited to the tract of a single nerve,  is of the high-
est significance, if it  be  present, though it is not constantly ob-
served.   AVe have already expressed ourselves more full}T on
this point above.   AA"e believe that no special weight should be
attached  to  the other symptoms.   In particular, marked and
characteristic symptoms in the intervals would give the case  the
stamp of  a symptomatic epilepsy, i. <?., one not strictly genuine.

                         Pathology.

   In the  introduction we have already expressed our opinion
to the effect that  we very decidedly consider epilepsy as  a defi-
nite disease, well characterized cases of which are perfectly typi-
cal, and  can be confounded wdth  no other nervous affection.
Then, to  be sure, as we  depart from  this  fixed centre, cases at
the most  various extremes  occasionally come under observa-
tion, in which it  may well be a matter of discussion wdiether
they still belong  to epilepsy, so indefinite are the  features of
the picture.   Still, epilepsy has this peculiarity in common with 
260
NOTHNAGEL. —EPILEPSY.
many other affections,  even such  as are well marked and are
so-called anatomical organic diseases.
   Another point, certainly, is much more interesting and im-
portant,  and that is  the numerous connections which epilepsy
has with various other nervous affections, the intimate recipro-
cal relation in wdiich it  stands  to  them.  Naturally this obtains
reciprocally7 for the latter just as much, but the relation in the
case of epilepsy is more striking,  because  this is one of the
more frequent among the well-characterized nervous affections.
   Now, these mutual relations are variously exhibited.   In the
first place, they are manifested in the matter  of hereditary trans-
mission.   Concerning this we refer  to what we have said above
when speaking of the etiology,  and do not consider it necessary to
refer to it here again.   Then again,  in one and the same individ-
ual,  epilepsy may exist side by side with other nervous diseases.
AAre  have  already mentioned  the  mental disturbances,  when
speaking of symptomatology; but  other neuroses  may also be
present at the same time with epilepsy ; thus, e. g., the combina-
tion with hysteria is by no means extremely rare ;l we have our-
selves  seen chorea minor and  epilepsy at one time in the same
patient.  Moreover, in  an individual afflicted with a hereditary
neuropathic condition,  several forms of nervous disease may ap-
pear one after another;  in childhood St. Vitus's  dance,  later
epilepsy, or else cataleps}^ migraine, and other neuralgias,  form
the advance-guard of epilepsy.  Furthermore, such cases as the
following are in the  highest degree instructive, e. g., two which
have recently been published by Hitzig,2 wdiere after an external
peripheral wound there first developed in the same patient epi-
lepsy and  then  choreic movements, and in  a second paralysis
agitans, and then epileptoid seizures.—Of course, we cannot here
enumerate all the various possibilities which  have been noted in
individual instances ; we will  refer to only one very interesting
relation.   There are namely a number of cases  where certain
members  of neuropathic families  have suffered  from diabetes
mellitus,  while  the others  wrere mentally  diseased, epileptic, or

   1 Of  course,  we are not speaking here of  the seizures of so-called hystero-epi-
lepsy.
   2 Untersuchungen uber dasGehirn.  Berlin,  1874. p. 186 et seq. 
PATHOLOGY.
261
generally "nervous;" also saccharine urine and epilepsy  have
been observed  in one  and  the  same  patient simultaneously.1
Ebstein reports the same thing with regard to diabetes insipidus.3
   In view of our almost complete ignorance of  the real nature
of almost all of the diseases indicated, it would be  a mere idle
playing with words if we should attempt to discuss these recip-
rocal relations  more minutely.   This must be  postponed to a
future  time when we are better informed; for the  present  we
must be contented with simply placing the facts on record.
   It may be regarded almost as a necessary postulate, speaking
from the present standpoint of  science, that a disease  of such
long duration and with a group  of  symptoms in most cases so
distinctly marked,  must have   as a  foundation  anatomical
changes  in some portions of  the nervous system.  But what
are the parts where the seat of epilepsy is  to be sought f  Is it
in definite regions, or spread more  generally over the  nervous
sj-stem I
   To arrive  at a correct answer to this question one ought, in
our opinion, to base the inquiry on only the really typical cases.
If this be neglected, our position wall be so far set back.   As in
the study of the malarial affections one would begin not with
masked  fevers, or such as are accompanied by severe cerebral
symptoms and pigmentary embolisms,  but with the ordinary
forms, so in epilepsy should we follow  the same course.
   Now we have already stated several times that in determining
the character  of our  disease, the real emphasis should  be laid
upon the paroxj^sms,  for the very simple reason that  quite often
no  symptoms whatever  are  present during the intervals.  If,
however, the seizures are the principal events, often alone betray-
ing the epilepsy, then it can only be logical  for us to locate the
real seat of the disease in those  parts of the nervous system from
which the paroxysms  take their origin.   AATe shall have to prove

  1 Compare Griesinger, Studien uber Diabetes. Arch. f. physiolog. Heilkde. 1859,
and Vortrag zur Eroffnung der Klinik u. s. w., ibid.  1866.
  3 Deutsches Archiv f. klin. Med. Vol. XL  p. 344  et seq. 
262
NOTHNAGEL.—EPILEPSY.
hereafter  that  this part  embraces the pons and medulla oblon-
gata.   TJiepons and medulla oblongata are then the seat of epi-
lepsy ; if  any anatomical changes exist, they are to be  sought
for in these parts.  Now, although  up to the  present time, as
has been observed in the section treating of this  subject, even
histological inquiries have produced but a minimum of results,
still even the little that is known about this is  likewise  calcu-
lated to turn our attention to the parts that are already known.
   The opinion just advanced as to the seat of epilepsy is shared
by the majority of painstaking investigators  of this disease; we
mention, e. g., only Schroeder van der  Kolk, Reynolds, Eche-
verria, in part also Brown-Sequard and Kussmaul.
   An attempt to generalize  the anatomical seat of epilepsy has
sprung up again in certain quarters, to extend it as much as pos-
sible over  the  cerebrum  and spinal  cord, just  as the ancient
authors prior to Bouchet and Cazanvililh already located it in
quite a general sense in the brain.  Still, in our opinion, the
reasons now advanced in support of this are just as little conclu-
sive as the earlier ones  were.   Thus they refer to the  settled
fact, which was also recently  determined  experimentally by
Hitzig {vid. sup.), that epilepsy  can be excited by wounding the
cerebrum,  in pretended proof that the seat of epilepsy must  be
sought in  the  cerebrum  also.   Hitzig himself has indeed been
cautious about drawing  this inference; he only prudently ex-
presses the opinion that wounding the cortex of the brain may
lead to epilepsy.  AAre share this latter  opinion entirety,  as  we
have already declared when speaking of the  etiology.  Here  we
have to deal with exactly the same relation as in the case of peri-
pheral wounds which are followed by epilepsy.  In this case no
one thinks of seeking for the seat of  the disease in the wounded
sciatic, nor in  a case of  tetanus do we  look for the seat of the
affection in the irritated branch of  the  plantar nerve, but  we
only fix upon the wounded peripheral  nerve  as the starting-
point, and we  must  proceed in  just  the  same way, in the case
before us, with the lesions  of the cerebrum.1—Just as little can

   1 It seems to us  so self-evident that we should not conclude (as Eerrier, e. g., does)
that the seat of epilepsy is to be sought for in the cortex cerebri, from the circum-
stance of epileptiform twitchings occurring on active electrical excitation of the cor- 
PATHOLOGY.
263
we acknowledge another reason sometimes assigned for the "dif-
fuse" nature of epilepsy.  The cases with abnormal paroxysms,
namely, are appealed to,—those  in  which mental disturbances
are especially  prominent, or where such actually take the place
of the epileptic seizure (delire epileptique, etc.).  AVe shall pres-
ently explain what interpretation, in our opinion, should be put
upon some of these cases.  For the explanation of  others among
them, however, it is amply sufficient  to assume the existence  of
those physiological processes which are called  into  play in the
ordinary attacks;  and the departures from the usual form  of
the paroxysm are explained by merely unessential modifications
of the processes present in all seizures.  AVe shall discuss this
point also by and  by.—Finally,  we may adduce  as proof that
there is no participation on the part of the spinal  cord in the
real  epileptic change,  and  that  the spinal cord  is not to  be
regarded as the seat of epilepsy, the interesting experiment  of
Brown-Sequard's  mentioned on  a preceding page  (p.  198),  in
addition to Kussmaul's and  my own experiments with reference
to its non-participation in the causation of convulsions.
   Now, although in regard to the majority, especially of typi-
cal cases,  we firmly maintain that the real seat of the disease
is in the pons and medulla oblongata, we wash to protest against
the idea that we deny a participation of other parts also of the
nervous system.  Such a participation may happen in two ways.
In the first  place, it  is possible that secondary changes may  be
set up, e.  g., as a consequence  of the seizures, and caused  by
the processes to which  these give rise, although  we still have
very little knowledge of these  secondary manifestations.  Per-
haps  dilatations  of  the vessels,  e. g.,  in  various parts of the
brain, or,  again, lesions of nutrition of the  nervous tissues, wdth
their consequences, which are dependent upon  anomalies in the
circulation,  are to  be taken  into account  here.   But then  we
must undoubtedly  assume for a definite group of  cases a more
generally diseased  condition  of the  nervous system, which did

tex, that we  do not believe it necessary to waste a word of proof on  it.  With
equally good  or still better reason have I been able to draw the same conclusion from
my own  experiments, in which a simple wound with a needle in  the cortex cerebri
produced epileptic seizures (comp. Virchow's Arch.  Vol. LVIII.). 
264
NOTHNAGEL.—EPILEPSY.
not arise secondarily, but which is  primary  equally with the
epileptic change in the pons  and  medulla oblongata; this is
especially so of cases where the epilepsy is not pure, but is com-
bined with other neurotic and  mental affections, independently
of whether the  latter preceded it or were present at the same
time.   Then, however, we have no  longer exactly a  pure epi-
lepsy, and it would be self-evident that  such cases could not
determine the seat of typical epilepsy.
   AVe now turn to the  principal question, In  lohat does the
essence of epilepsy  consist f   What are the morphological or
functional changes underlying it f  The answer to this must
unfortunately, even at the present day, prove very inadequate.
   In  the section on pathological anatomy  we have seen that
the gross anatomical and the histological discoveries so far made,
on the one hand,  refer to changes which are palpably secondary,
and, on the other, are of the most varied character.  No single,
definite, invariably recurring abnormality  of tissue has yet been
determined.  In so far as it is at present  allowable and possible
to arrive at a more general conception, I may express my views
on this subject as follows :
   Probably no  uniform,  constantly  recurring  histological
change generally forms the basis  of  epilepsy.   I am much
more  disposed.to believe  that various anatomical changes may
call forth the  group of symptoms which constitute the disease,
provided that these changes always affect the same parts of the
pons  and medulla oblongata,  i. e., such as are anatomically
and physiologically equivalent.   The sensory nerve, for example,
always responds with the same functional expression, i. e., with
pain,  to wholly different impressions—in  part those which are
coarsely demonstrable,  such as moderate compression or neu-
ritis,  in part those which elude anatomical  recognition,  such
as malarial infection ; the phenomenon of  tremor, also, is excited
by various impressions upon the spinal cord ; and in this same
way are we inclined to represent to ourselves the  relation of the
anatomical changes, whether coarser or finer,  to the production
of the epileptic group of symptoms.   Further inquiry will teach
us whether this view is true or false.
   With regard to the other question— What are then the func- 
PATHOLOGY.
265
tional changes which the pons and medulla oblongata undergo
in epilepsy ?—the answer can be given with somewhat greater
precision.  Schroeder van der Kolk, Brown-Sequard, and Rey-
nolds have already expressed themselves to the  effect that we
have to deal with an "increased irritability" of  the reflex ner-
vous centres situated in these sections,—an opinion in which
we thoroughly share.  Or, to state the case differently :  In con-
sequence of  the changes which, in epilepsy,  occur in those gan-
glion-cells of the medulla and pons, through  the agency of which
reflex processes take place,—changes which at times are probably
only molecular in their nature,—these reflex centres respond from
time to  time much more easily than  normal ones to  irritations
which either act  visibly from  without, or are developed in some
unknown way in themselves.  At  the same time these centres
respond with motor manifestations the intensity of which far
surpasses the normal degree,  but which in their  nature do not
differ from  the  normal  reflex movements.—AATe are certainly
still wholly in the dark as to the influences which induce this
exaggerated excitability.  It is possible, in analogy with other
physiological processes,  that a plethora  of blood in  the parts  of
the brain concerned may play a part here, but it has not  as yet
been proved  to  be so.  It is possible also, in regard to other
cases, that, if the ganglionic apparatus and the conducting chan-
nels leading  to them were thrown into activity at the time of an
attack, and were affected by a violent form of excitation the first
time, such as terror or some decided irritation coming from the
periphery or the cortex, this  apparatus would  thereby get into
a condition  of  unstable  equilibrium,  so  as subsequently  to
respond to slighter irritations with an excessive  reaction ; and
this is precisely what is exhibited under the  form of the seizure
Still, as  all these questions  and ideas are as yet merely hypo-
thetical, we must here,  in  a manual, content ourselves with
merely indicating them.
   With the circumstance last mentioned, we  have  approached
another point in the pathology of  our  disease which has been
up to the present  time  wholly uninvestigated, and which, con-
sequently,  we can only touch upon cursorily.  It concerns the
question, In what  way do the different etiological influences 
266
NOTHNAGEL.—EPILEPSY.
produce epilepsy f  As to most of them, no answer whatever can
be given ; as to some among them, such as violent mental impres-
sions, or decided peripheral irritations acting but a single time,
we have already attempted to give an answer.   But even for those
cases in wdiich the state of things is apparently the most trans-
parent, any actual clue, in  the shape of facts, is wanting.  AVe
are thinking, namely, of the secondary  epilepsies which are ex-
cited by wounds of the cortex, of the spinal  cord, especially in
the experiment on guinea-pigs,  and  of the  peripheral nerves.
AAre  are acquainted neither with  the centripetal nor  with the
centrifugal channels along  which  the irritation is  propagated,
nor do we know of what kind the change so propagated is—neuri-
tis, or what—nor even whether this dissemination takes place con-
tinuously ot per saltum, although the latter is highly probable.1

   Thanks to experimental investigations, we are better informed
on the question of the starting-point and mechanism of the epi-
leptic  seizure  than on the uncertain  topics which  have just
been spoken of.  In this direction the work of Kussmaul, espe-
cially, has paved the way.  As we have already referred in  gen-
eral, under the section on  "Experimental  Researches," to the
special investigations which here come under consideration {vide
supra), we may limit ourselves in  this place to a brief compre-
hensive statement.2
   Two symptoms are to be regarded as essential in the seizure:
first, the mental disturbance, which generally  manifests itself as
a more or less distinctly marked loss of consciousness ; second,
motor disturbances, under the form of  more  or less extensive
convulsions.   The primary starting-point for both is to be sought
in the pons and medulla oblongata.
   It certainly requires no discussion to show that the  loss of
consciousness depends directly upon an abolition of the activity
of the cortex cerebri; but, in the first place, this participation of
the hemispheres is secondary,  while the processes which lead to
  1 Compare R. Klemm, Ueber Neuritis Migrans. Inaug. Dissert. Strassburg, 1874.
  8 Compare my lecture, "Ueber den epileptischen Anfall," in Volkmann's collection
of clinical lectures, No. 15, where I have made a brief analysis of its symptoms. 
PATHOLOGY.
267
it  arise primarily from  the medulla  oblongata.   Besides, there
can be no doubt that not merely the nerve-fibres,  but  the gang-
lion-cells of the pons and medulla oblongata acquire activity at
the time of the seizure.  If a special  proof were  still required,
this would be furnished by the peculiar form in which the con-
vulsions are generally manifested in the seizure, to wit: as a rule,
first a tetanus of brief duration, and then a decided clonic spasm.
This form of movement  can only take place wdien the  excitation
traverses ganglion-cells,  with  the exception of  certain  special
conditions, wdiich do not come  under consideration wdien speak-
ing of epilepsy.1  The ganglion-cells, however, the excitation of
which  results in the general  epileptic spasms, with  participa-
tion of almost  the  whole  muscular  system, lie  united in  the
parts of the brain above-named, as anatomical investigation and
physiological experiment teach us.  In the pons  lies the " con-
vulsion centre," /. e., that tract, through the excitation of which
general convulsions arise (compare above, p. 198).   Deiters has
pointed out that in the pons exists the first central termination
of the motor-fibres which come from the periphery ; at the floor
of the fourth ventricle lie united the  gray nuclei  for  the motor
cerebral nerves ;  moreover, in  the medulla oblongata is found
the so-called  respiratory centre, and finally also  the vaso-motor
centre, which, as we shall presently see, is concerned in the gene-
sis  of  the cerebral symptoms.—AVe have  already pointed out
that epileptic convulsions do not originate in the spinal cord.
   Not merely the convulsions,  but also the other phenomena of
the seizure, particularly the loss of consciousness,  are  explained
by an excitation  of  the  central  apparatus located in the pons
and medulla  oblongata, and, in fact,  of the vaso-motor centre.
The symptoms  so evoked by the activity of the nerves which
constrict the vessels are in part accessible to direct observation,
and we have learned to recognize them in the account of the way
the seizure begins—with pallor of the face, dilatation  of the
pupils, and frequent arrest of the pulse.  Now, what takes place
in  the  vascular region  of that part of the head which is visible

  1 Compare Setschenow, Ueber  d. elektr. u. chem.  Reizung d. sens. Riickenmarks-
nerven d. Frosches. Graz. 1868, and  Xothnagei, Zur Lehre  vom klonischen Krampf,
Virchow's Arch. Vol.  XLIX. 
268
NOTHNAGEL. —EPILEPSY.
obtains also within the cranium ;  anaemia occurs there  also.  At
the present time this is to be regarded as mere conjecture, based
only  upon  the analogy drawn from the  anatomical  relations.
This  assumption,  however,  has  gained very essential support
from  what has been discovered  with the ophthalmoscope, and
from  Brown-Sequard's observations on epileptic guinea-pigs.1
   That anaemia of the cerebrum  can produce loss of conscious-
ness we know directly from Kussmaul's experiments.  In every
respect is the  conclusion justified  that the epileptic coma is
caused by an  excitation of the vaso-motor centre (in particular,
that for the nerves of the cerebral vessels) in the medulla oblon-
gata.
   According to my conception  then—for the more particular
elucidation of which I must refer to the lecture already cited—
the convulsions do not depend upon an anaemia  of the pons, act-
ing as  an excitant  upon  the  convulsion centre, an opinion we
sometimes find advanced; for, according  to that, the  primary
and indispensably necessary element in the seizure wrould always
have to be the excitation of the vaso-motor centre, and the effect
of it—the anaemia—would be secondarily to throw the rest of the
motor apparatus into activity.—That anaemia  of the pons can
occasion convulsions is  placed beyond  all doubt by Kussmaul'8
experiments, but that this is the case in the real epileptic seizure
is by no means proved.   On the contrary, there are many reasons
opposed to it (cf. loc.  cit.).  My opinion rather is that the exci-
tation of the  vaso-motor centre and that of the centres for the
muscles are co-ordinate;  that both go on side by side, and are
independent of each other.
   Upon this  view alone do a series  of otherwise incomprehen-
sible peculiarities, such as are  observed in many seizures, become
capable of explanation.   Among these may be mentioned, in
the first place, the occurrence of epilepsia mitior (without con-
vulsions) ; secondly, the  occurrence of  twitchings before the
  1 Whether the vaso-motor nerve discovered by Benedict in the floor of the fourth
ventricle deserves consideration in connection with the circulation within the skull, and
particularly in the epileptic attack, cannot as yet be decided in view of the novelty of
the facts communicated by B. 
PATHOLOGY.
269
coma ; then again, the fact that convulsions may occur wholly
without loss  of consciousness, although this very rarely hap-
pens ; finally, the commencement of certain cases with cyanosis,
caused by primary spasm of the muscles of the throat  (trache-
li smus).
   117^ then is the stimulus which throws into activity the sets
of apparatus which have been mentioned ?  In  the cases wdiere
{e. g. in secondary epilepsy) pressure upon a cicatrix determines
a seizure, it is incontestably the sensory excitement advancing
centripetally; and quite in analogy with it  a peripheral action
upon a sensory nerve  can often be made out; at other times it
appears to be a mental impression, when the process of excite-
ment  advances downward from  the cortex  to the pons and
medulla  oblongata.  For many cases, however,  no  determining
influence  of  any  kind  whatever  can be  proved;  the  attack
breaks out as the spark darts from  a strongly charged Leyden
jar, to use the simile of Schroeder van der Kolk.  Hypotheses can
be set up to account for these cases also, but we  consider it judi-
cious to suppress them, as they are only hypotheses.
   In giving  the  history of the  symptomatology of the seizure
we  give  prominence to the necessity of distinguishing several
periods in it.  Now it is very probable that such a distinction
obtains, not merely in the external sketch of the symptoms, but
also for their pathogenesis.  If, namely, we consider a patient in
the so-called second stage of the  attack, with the  veins of the
head and neek filled to distention, the face  markedly cyanosed,
and the  eyeballs projecting,  nothing supports  the assumption
of a cerebral anaemia,  but everything points much more to  an
intense venous hyperaemia within  the skull, which  is the result
of the spasmodic contraction  of the muscles of the neck.  The
excess of carbonic acid in the blood which is present in the skull
is then still further increased by the marked interference with
the respiration,  resulting from the spasm of  the respiratory
muscles.   Further than  this, we know from direct experiments
(compare above) that great venous hyperaemia of the brain may
produce  general convulsions, and  we also know the same from
the symptoms attending the final act of life in suffocation.
   From this the conclusion  seems to be warranted that in the 
270
NOTHNAGEL.—EPILEPSY.
further course of the attack  loss of  consciousness and  spasms
are caused and maintained by venous hyperaemia.  The possible
objection that interference with respiration and venous stasis are
not intense enough in the epileptic seizure to be capable of pro-
ducing these serious results, appears to be without  significance
in view of the special conditions here  present.   For,  as we have
seen above, wTe are forced to maintain in epilepsy the existence
of an  abnormally increased excitability of the central nervous
apparatus involved, so  that even  slighter irritations than usual
are capable  of setting it  in action ;  and then it would also be
possible that these systems of apparatus, if already thrown into
activity, might be maintained in  that state for a certain time by
even a weaker irritant,  although this cannot be actually proved.

   This might be the proper place to discuss the questions  of the way in which
anaemia  produces coma, hyperaemia convulsions, etc.  We have already touched
upon these matters in part in another portion of this work, apropos of cerebral
anaemia and hyperaemia, and in part they are exclusively of a physiological nature,
so that we must decline a further discussion of them here.

   If the pathogenesis of  the ordinary seizures can be very little
cleared up at the present  time in any respect proportioned to its
prominence, it is very much more difficult to gain an insight into
the processes which go  on in connection with the abnormal forms
of seizure, and with the epileptoid states.  The idea which natu-
rally suggests itself is  to  assume that in them also disturbances
of the circulation in the cranium constitute the essential feature,
and the same in the case of epileptic delirium and many epileptoid
forms.   An  attempt at an  explanation of this kind has been
actually made by certain investigators, and we must admit that,
according to our opinion, a solution of the riddle under consid-
eration is perhaps to be looked for earliest in this direction, but
we are moving meantime purely in the realm of speculation.  In
many cases,  in those, e. g., wdiere patients  in  the seizure  walk
around in  a state  of  unconsciousness,  there is absolutely no
point to be seized, even for an attempt at an explanation.
   Closely related to the  pathogenesis of the seizure  is the ques-
tion of the significance of the prodroma.  How  is the so-called
aura to be interpreted—how does  it originate—in what relation 
PATHOLOGY.
271
does it stand to the seizure itself ?  Opinions are much divided
regarding these points, for, while some authors put the so-called
"warnings" altogether aside, others attribute great importance
to them.  How far the latter view is correct in reference to treat-
ment and diagnosis has been already or will yet be considered.
At the moment the essential question for us is in regard to the
relation of  the prodroma, and more particularly of the "imme-
diate" prodroma, to the seizure itself.  Our own opinion in re-
gard to this is as follows :
   The immediate "prodroma" belong to the seizure as a part
of itself ; they are  therefore rather symptoms,  and  not pro-
perly prodroma.  In connection with this,  too, it has already
been said that they cannot,  as  a centripetal irritation,  cause
the outbreak of the seizure.   AAre are much more inclined  to
believe  that we must assume  the  origin of every aura to be
central.
   Unfortunately, in this place we cannot enter into a  detailed
proof of our view ; we must limit  ourselves to the presentation
of certain leading points.
   The possibility of this view must  be conceded if, as wre do
not doubt,  our idea of  the origin of  the seizure itself be correct,
/. e., if the excitation of the different "centres,"  located in the
pons and medulla oblongata, be co-ordinate.  Just as the excita-
tion of the vaso-motor centre frequently precedes that of the
"convulsion centre," and just  as  sometimes trachelismus sets
in first (compare above),  in the same way is it conceivable and
possible  that  the  excitation in the groups of  ganglion-cells,
which  leads to the (spasmodic)  innervation of an arm, a leg, or
single  muscles, may also occur  as the first  link in the  chain of
symptoms.  The same  thing is repeated in the  circumscribed
vaso-motor prodroma,  among wdiich we  reckon the ambulatory
seizures with vertigo and confusion wmich are  so frequent, for
these obviously represent only a lower degree,  a first step, in
the subsequent loss of consciousness.   The  sensory symptoms,
too, may likewise be conceived of  as  eccentric, i. e., caused by
central processes ; this view only requires to undergo a modifi-
cation  for the cases where a peripheral lesion has furnished the
starting-point for the trouble. 
272
NOTHNAGEL. —EPILEPSY.
   In many forms  of  epilepsy the so-called prodroma, espe-
cially the motor ones, are already regarded as belonging to the
seizure.   These are particularly the cases in which a lesion of
the cortex has caused the disease, and  in  wliicli spasmodic phe-
nomena always usher in the seizure in the same manner.  Here
one might be disposed to abandon this view as altogether impos-
sible.
   The attempt has been made to find  a leading objection to the
central origin of  the aura in the  fact that one sometimes suc-
ceeds by a  so-called  interruption  of  it,  such as by putting a
ligature on the extremity, etc., in preventing a further outbreak
of the attack itself.  This objection,  however, is without any
force, since, as we mentioned above,  we are here  dealing  not
with the interruption of a process of irritation which is creeping
towards  the centre,  but with a  "reflex  inhibition."  One  can
scarcely think of a more striking  proof of this than Odier's case
furnishes, which is cited almost everywhere (compare Romberg,
and Portal).   In this case the attack was ushered in by twitch-
ings in limited groups of muscles ;  it could be repressed by com-
pression of the arm—and post mortem a lesion of the cortex was
found as the starting-point which caused the epilepsy.
   On  the  other hand, no  proof whatever  has as yet been
brought  forward to  show that,  as Reynolds,  e. g., expresses
himself,  the aura should be regarded as a peculiar peripheral
condition analogous  to that already  existing  in  the medulla
oblongata, and it rather seems that this viewT is more difficult to
reconcile with the genesis of  the seizure and with the symptoms.
   According to their prominence, the partial twitchings and the
other phenomena, which so often  occur in epileptics during  the
intervals without being followed by an attack every time, must
be considered as incomplete seizures, after the manner of epilep-
tic vertigo and the petit mat.
   Finally,  we must  add a few words  on  epilepsia vasomotoria,
which has of late been described  as a special form.  In general,
we understand by this  term  those cases in which the symptoms
of arterial vascular spasm are more strongly marked than usual,
especially where  they are observable for a  longer or shorter
time before the outbreak  of  convulsions and the loss of con- 
COURSE AND SEQUEL.E.
273
 sciousness.  From this, however, we cannot deduce the propriety
 of setting up a special vaso-motor form.  For, in  the course of
 our exposition, we have often enough insisted that only very few
 seizures  run their  course absolutely  without vascular spasm ;
 loss of consciousness is, in fact, always dependent upon it.  It
 does not then  at all change  the nature of  the  thing whether a
 greater or a less peripheral extension  of the vascular spasm occur
 before the appearance of the severe symptoms of the attack.  So,
 if we would attribute special importance to this, we must like-
 wise, if the  coma  has been  preceded  by rather decided partial
 twitchings, affirm  the existence of an epilepsia motoria,  or, in
 case of a marked sensory aura so-called, an epilepsia sensitiva,
 which certainly is not correct, or at all events useful.
   At the same time, these  cases with marked vascular spasm
 have their significance in reference  to the  theory of the seizure,
 inasmuch as  they give  essential support  to the assumption of
 vaso-motor cerebral anaemia.  The conditions described by Lan-
 dois1 and myself as angina pectoris  vasomotoria are particu-
 larly instructive in this connection.   In one of my patients who
 was suffering from this affection, which is undoubtedly of  vaso-
 motor origin, there were developed, in connection with a decided
 sense of dizziness, slight clonic twitchings in the extremities ; in
 a female  patient who quite recently came under my observation
 there occurred almost complete  loss of consciousness ; and Ber-
 ger 3 even noticed that  in  some instances  the symptoms of  the
 angina pectoris vasomotoria developed  into a complete epilepti-
 form seizure.

                    Course  and Sequela.

   True epilepsy is an  eminently chronic  disease; it lasts  for
 years, in  very  many cases even to  the  end  of  life.   It  is a
 very exceptional occurrence when a genuine epilepsy disappears
 again  after a few months.  The conditions which were formerly
 described as acute  epilepsy are for the  most part something

  1 Correspondenzblatt f. Psychiatrie. 1866.
  5 Deutsches Arch.  f. klin. Med. Vol. III.
  3 Die Lahmung des N. thorac.  longus.  Habilitationsschr. Breslau. 1873. Note to
P. 22.
         VOL. XIV—18 
274                NOTHNAGEL.—EPILEPSY.

entirely  different, and  only present a  certain resemblance to
epileptiform seizures.  It indeed sometimes happens that, by an
unlucky accident, death occurs during the paroxysm, after the
disease has existed for-but a short time; but occurrences of this
sort furnish no reason for denying the essentially chronic course
of the malady.  Besides, we have already declared that death in
the seizure itself, and in direct consequence  of it, is one of the
greatest rarities.
   AAdien speaking of the frequency of the sekures, we treated
of the causes which had an effect in giving rise to  them,  and in
characterizing the course of  the  disease mentioned many points
of importance, so that only a few details remain to be referred
to.   AVe  are  principally concerned with the  question whether
there  are definite influences xohich have a modifying effect upon
the course of the disease.  Particulars bearing upon this have
been communicated by various observers ; Delasiauve, especially,
has taken upon  himself a careful discussion  of  the influences
which here come under consideration.   From the statements
before us, with which our own experience agrees, it appears that
in general the most different conditions, whether seated in the
patient himself, or in the circumstances  surrounding him, or in
accidental changes beginning from without, or  brought about in
the organism  itself, exert only a very slight modifying influence
upon  the course of epilepsy.  And if certain conditions do act in
this way, the effect is not uniform ; i. e., with the same condition,
it may at one time be unfavorable and at another favorable.  A
more  constant and essential influence  can  be proved for but
very few7 causes.  The principal of them are the following :
   Excess  in  alcoholics almost  always leads to  an exacerba-
tion or to the outbreak  of attacks, even  if spontaneously, or in
consequence  of medication, they have  been for a considerable
time held in  abeyance; of course, this is not invariably so.  It
is also maintained by certain  observers that even the moderate
drinking of wine and beer is unfavorable.  Relying upon these
statements, I have  always been accustomed to prohibit the use
of alcoholics  altogether, and in consequence I cannot judge of
their  influence from my own experience.   The same obtains
with  regard  to tea and coffee  as  with regard  to alcoholics. 
OURSE AND SEQUELAE.
275
Excesses in eating also act not infrequently like  those in the
use of wine.   Whether certain definite articles of food are  more
hurtful  than  others is questionable, or should be considered as
depending on individual idiosyncrasies.   It is certain that coitus
sometimes induces seizures ; it does not always do  so, however,
and, on the other hand, examples are known where the practice
of it  made the  paroxysms temporarily less frequent.   AVith
regard to menstruation,  we have already briefly expressed our
opinion above;  its effect  is extremely variable.  Sometimes,
when the disease already exists, an aggravation of the seizures
in frequency  and intensity takes place  with the setting-in of
menstruation  ; sometimes they occur with special severity^ imme-
diately  before or after the period  ; again  at  other  times the
attack occurs only in exact coincidence with the menses.  On
the other hand, however,  instances are known where an im-
provement in the disease, chiefly in respect  of a diminution in
the individual paroxysms, was established with the  first appear-
ance of  the menstruation, or at the  time of the separate periods,
or where the disease  showed  improvement when menstruation,
which had previously been irregular and painfrd, became regu-
lar, or even in certain  cases  entirely disappeared. Equally7 vari-
able is the influence  of  pregnancy.  We only add  the  fact,
said to  be sometimes observed, that women during pregnancy
remain free from seizures  when  carrying a boy, but not when
carrying a girl; or also the opposite.—Further than this, the
influence of  strong mental impressions upon the causation of
seizures is indubitable ; yet the  real course of  the  malady7 is
but seldom changed by them.—The question w7ould be worthy
of comprehensive statistical investigation, how  other  intercur-
rent diseases of various kinds influence  the  course  of epilepsy.
Up to the present a few general propositions hold in regard to
this, and are  comprised in the following: acute diseases,  dur-
ing their existence, generally result in  a cessation of the  seiz-
ures ;  only very  exceptionally do they lead to a complete dis-
appearance of the  malady; at  times  this  is witnessed  even
after accidental external wounds, burns, and  the  like.  Chronic
affections act in very different ways  ; at  times they intensify, at
times mitigate the seizures;  at others, too, they remain wholly 
276
NOTHNAGEL.—EPILEPSY.
 without influence.—A further series of influences do not act at
 all upon the course of the disease, or, if so, it is in a way that is
 as yet unknown;  such are temperament, season, atmospherical
 changes, occupation,  and many others.
   The sequels of epilepsy are comprised exclusively in  the
 mental changes.   AArhen speaking  of the symptoms of the in-
 tervals, we have already remarked  how Reynolds has  recently,
 particularly by his careful statistical showings, brought about a
 decided reaction against the opinion formerly maintained, espe-
 cially  by  alienists,   that  epilepsy would  always,  or almost
 always, lead to mental disorders, with the characters described
 above.  From  these  thorough researches of Reynolds, wdiich,
 indeed, do not refer to hospital patients, it appears that mental
 disturbances, as consequences of the seizures, only take place if
 the latter follow each other in unusually rapid succession.
   Since it is a fact that mental changes  of some kind are quite
 often found in epileptics,  the question arises whether these  are
 not somehow caused secondarily by the "epileptic change," even
 if they cannot be regarded  as consequences of the seizures.  For
 many cases this can  just as little be denied as proved; in those
 cases,  however, where a mental  change  has  shown  itself \erj
 early, after only a few seizures, such an idea would be untenable.
 Here, however, another  aspect of the question must evidently be
 kept in mind, namely, the multiform relations in which epilepsy
 stands to other neuroses of the most different kinds.
   Our opinion is that mental lesions in many, perhaps in most
 epileptics,  are  the results neither  of  the seizures nor of  the
 epileptic change, but  are co-ordinate with the latter ; that is to
 say, these individuals  have a neurotic  disposition,  either in-
 herited or acquired, under  the influence  of  which epilepsy and
mental affections are simultaneously developed, either spontane-
 ously or as induced by demonstrable causes.

                         Prognosis.

   There is agreement  as  to this,  that epilepsy is one of  the
 severest diseases  of  the nervous system, not merely  from  its
violent seizures, which  often, from their  absolutely  sudden 
PROGNOSIS.
277
appearance, may interfere in every way with the social life of
the patient; not merely from the serious mental disturbances
which appear with them and in  consequence of them ;  but also
particularly  from its rebellious obstinacy to  treatment.   The
question has  been propounded  in all seriousness by some per-
sons, whether epilepsy is at all curable.  It is curable ;  that will
certainly be quite generally conceded at the present day.  AAdth
regard to the  proportionate  number of cures,  views certainly
differ somewhat.  Most  observers, however,  are also agreed in
this, that the percentage of cases cured is quite a small  one.  In
general, therefore, the  prognosis  must  be regarded as rather
unfavorable. — AAre  purposely refrain,  in the  following  para-
graphs,  from  giving  figures, because  no great value can be
attached to them, as the series of observations of the individual
authors were made from wholly  different points of view ; some-
times the cases were  collected in institutions, sometimes in pri-
vate practice;  sometimes the conception of epilepsy  is  more
strict, sometimes more liberal, etc.
   In the first  place, there are very isolated cases of spontaneous
cure, in which the malady disappears without any treatment;
they are reckoned at from four to five in the hundred.
   In the second place,  an improvement may  be wrought by
treatment to such an  extent that the individual seizures  come
less often.  This result is  not so very unusual. A  temporary
improvement, indeed, will be quite frequently obtained, but it
may also be permanent.
   In the third place, some cases are actually completely cured.
Certainly, very few observers have been  able  to verify the ex-
perience of Herpin, according to which -some fifty per cent, of
all epileptics would be curable.  In general,  complete cures may
always be regarded as exceptions ; but it cannot be denied that
Herpin had actually shown a series of permanent cures, even if
we were inclined to regard his own  statement as too favorable,
for, according to Aroisin, the permanent cure of many of  Herpin's
patients had lasted for ten years after his death.  To  him un-
doubtedly belongs the credit of having again vigorously empha-
sized the possibility of curing epilepsy, and of counteracting the
mischievous do-nothing policy. 
278
NOTHNAGEL.—EPILEPSY.
   Finally, into a fourth group, and that unfortunately the most
numerous, fall all the cases in which every therapeutic endeavor
remains without effect.
   The following circumstances have an effect upon the progno-
sis in special cases,  either for better or for worse :
   The age of  the patient at  the beginning of the  trouble ; be-
fore the twentieth year  the prognosis is, cceteris  paribus, more
favorable.  Herpin regards those cases as having still better pros-
pects which  first  begin  after the fiftieth  year.—There is also
scarcely any difference of opinion on the point  that the cura-
bility diminishes in the same degree with the duration of the dis-
ease.   Herpin formulates this more fully still when he says that
the duration in itself  does not make the prognosis worse, but
the number of  seizures suffered in a given time ; i. e., the  possi-
bility of cure is greater  when  an epileptic subject has experi-
enced  twelve attacks in the year than when there  have been a
hundred and twenty.  If there have been  more  than five hun-
dred  seizures,  the  prospect for  recovery is equal  to nothing.
Opinions are at variance with regard to the  significance of very
long intervals ; we  regard them  rather as favorable.  AArhether
the attacks happen by day or by night can scarcely be of im-
portance.  Likewise we do not believe that the character of the
separate seizures, whether  epilepsia gravior or mitior,  materi-
ally alters the  prognosis  with reference to  curability.—In view
of the variety of the particular etiological influences, it requires
no long demonstration to show that they are of great and very
different  value in prognosis.   Those cases have always  been
regarded as the more favorable in which a peripheral  cause pro-
duced  the epilepsy, for here,  of course, the curability of this
itself comes  to  be a question of the first moment.  But even if
the condition just named exists, we must always be quite circum-
spect if the epilepsy has already lasted for a long time, and we
cannot count implicitly  upon restoration  to  health.   Central
causes render the prognosis very unfavorable.  Still,  if we do not
have to deal  with material lesions, but with a mental influence
merely, the affair assumes a somewhat better shape.  Hereditary
epilepsy is generally esteemed  incurable; yet Herpin and  Rey-
nolds, e. g., have seen marked exceptions to this rule.  The same 
TREATMENT.
279
holds, according to the latter observer, for the disease when due
to masturbation.   Reynolds lays it  down as a general proposi-
tion  that those cases are least amenable to treatment in which
the source of the disease is involved in the greatest obscurity.
   The question of what significance attaches to the frequency, the form, and the
combination of the seizures, and various other influences having reference to the
development of mental lesions, has been already discussed above.

                          Treatment.

   Small, indeed, is the actual encouragement derived from look-
ing through those chapters of  medical literature, from the oldest
to the  most  recent times, which  refer to  the treatment  of epi-
lepsy.   The methods and the remedies change ;  but the final
result always remains the same beggarly one.  There is no sin-
gle article which acts with anything like an approach to the cer-
tainty of, e. g., quinine in malarial diseases, no single method of
treatment which  could be even  approximately compared with,
e. g., the electrical  treatment of traumatic peripheral paralyses.
Many remedies and methods of treatment have isolated successes
to show, but nothing is to be depended on ; nothing, even on
careful  discrimination of cases, affords a sure prospect of recov-
ery,  or  even of improvement.  From time to time it  has been
supposed that a panacea has been found, or a veritable curative
process discovered, until  the reaction conies again all  too soon.
Then we are the  richer  by a remedy wdiich in favorable cases
shows a few results in recovery, or improvement,  more than its
predecessors ; but the search begins anew.
   By this we do not wish to say that we regard better hopes for
the future as illusoiy.  This is just as little allowable as it would
have been before the discovery of the itch insect and the intro-
duction of the balsam of Peru to be willing to deny the possibil-
ity of the absolutely certain  process for curing scabies  wliicli
now  really exists.   For the present we must unfortunately con-
tent  ourselves with the existing remedial agents.   But the more
insufficient these are, and the more authoritatively  they are
recommended, so much the greater  is our duty not to manage all
patients on  one model, but here, as  everywhere in the field of 
280
NOTIIN AGEL. —EPILEPS Y.
therapeutics, to proceed on the one correct principle of individ-
ualizing.   The physician wdio treats every epileptic who comes
under his observation indiscriminately with wdiatever happens to
be the prevailing  fashionable remedy,  with nitrate of silver or
bromide of potassium, with oxide of zinc or valerian, with gym-
nastics or hydropathy, will have fewer successful results  than
are generally attainable.
   The therapeutic measures in each individual case have gener-
ally a threefold object.  They resolve themselves into a causal
treatment, a general and dietetic treatment directed  to the ner-
vous system, and the  employment of definite medicaments.
   The causal treatment is unfortunately possible  in very few
cases, as appears at once from a review of the etiological relations,
which are  generally  so obscure ; but wdiere a  causal influence
accessible to treatment can be found,  efforts must be made  to
remove it.   At the same time experience teaches us that, even  in
case of the  removal of the assumed or actual source of the dis-
ease, this itself does not always disappear.  The morbid state in
the pons and medulla oblongata  is already so far advanced that
it presents  itself as an affection wholly independent of  the pri-
mary source.  A  knowledge  of  this fact is important for the
avoidance of prognostic errors and therapeutic illusions.
   Primarily the causal treatment claims consideration in those
cases wdiere a peripheral lesion  shows  itself as a starting-point.
Literature recognizes  a great number of instances where, by the
extirpation  of a  cicatrix, of a tumor pressing  upon a nerve,  or
by the opening of an abscess, the epilepsy was caused to disap-
pear.  The same is true of a series of pathological conditions  in
the internal organs. All the varieties which are possible here can-
not, of course, be cited in detail; a careful review of the history,
a thorough  examination of the  patient, must lead to the right
course in  each individual case.  AAre  would only  call special
attention to one  point: formerly, in  case an aura was very pro-
nounced  and constantly  recurred in the same fashion in the
course of the same nerve, not only was the suspected finger, but
even the hand or arm amputated, or neurotomy performed, with-
out thereby curing the epilepsy.  To-day it would be only in the
most exceptional cases that a particularly bold  operator would 
TREATMENT.
281
venture on so violent a step as this, especially as it is known that
the most typical forms of aura may  be of central origin.  It
could be thought of then only when there was great probability
that a peripheral wound furnished the starting-point for the dis-
ease.  But  even in these cases we would  caution against the
severe  operations  with removal  of extremities,  because  it can
never be known whether even after them the epileptic change
will not remain behind.
   It may be observed, by the way, that those  cases where the
disease persists  after neurotomies and amputations seem  to us
very much to favor the opinion  advanced above  of the eccentric
nature of the aura.
   The practice of trephining is also to be reckoned with the
causal treatment.   Although  adopted  in  former times  most
extensively in every case which resisted  medical treatment, and
although warmly recommended by Tissot, in the course of time
it has been continually less and less frequently  practised.  It is
certainly true that in individual cases the disease was cured, and
these brilliant successes, rare though they were, have always been
an incentive to further  trephining ; even Echeverria reports three
striking cases, regarding the ultimate effect  of wdiich, to be sure,
nothing can  yet be said, because an immediate arrest  of the
seizures proves nothing.   But even if  it must be conceded that
all  the favorable cases were not those  merely  of S}7mptomatic
epilepsy, that, in other words,  trephining may become a  causal
remedy {e. g., if exostoses from an injury  to the cranial  bones
have led to true epilepsy), though not necessarily so, any more
than in the case of excision of a peripheral  cicatrix, still, in any
given  case,  all influences should  always be  most  carefully
weighed, as an absolutely certain diagnosis can never be estab-
lished even  under the  conditions  that w7e are here considering.
Consequently, we cannot with Hasse "urge that any indication
whatever that warrants trephining should be followed," but we
are willing  to grant that the operation, in  accordance with our
present experience, is generally allowable,  and we must regard
its  success in any particular case as a  piece of good  fortune,
which could not have been predicted.
   The causal treatment must take another direction if  general 
2S2
NOTHNAGEL. —EPILEPSY.
constitutional anomalies have caused the epilepsy or led to its
outbreak. The measures to be taken against drunkenness, rachi-
tis or scrofula need not here be particularly detailed.  When gen-
eral plethora or anaemia is present the question of its treatment
is more important.  In respect to both of these,  individual ob-
servers  have overshot the mark, though in the former more than
in the latter.  At the present day we are agreed as to the essentials
in this matter, viz., that with epileptics anaemia and especially a
weakly  constitution always  require  an appropriate treatment,
the details of which are well known; that plethora, on the con-
trary, requires direct medical treatment only when  present in a
very marked degree.  In the latter  case the familiar curative
procedures appropriate to the case  should certainly not be neg-
lected, and among them in certain cases the  abstraction of blood
may even find a  place ; yet the need of a lowering mode of
treatment, even in the beginning of the disease, must always be
reckoned  among the exceptions.   It is less to  be feared that
any  one will fall into the  opposite  error,  committed by Rad-
cliffe, of using a tonic treatment for every epileptic indiscrimi-
nately.
   The causal treatment directed  to other etiological relations is
still more impotent than in the case of those already mentioned.
Where a decided mental change has led to the disease or brought
about an outbreak, the attempt has been made to effect a curative
action by a similar one, as by sudden fright, by threats,  and the
like.  But who is in a position to estimate the results of these?
And in  opposition to the few cases, on which the authority for
such a procedure mainly rests, where an accidental violent men-
tal emotion  produced an improvement or arcest of the epilepsy,
there stand the much more numerous instances where the}7 have
caused  a  decided aggravation.   For this reason also the best
physicians have constantly advised against them.—Finally, the
removal of an inherited tendency may be the only object of pro-
phylaxis.  Romberg thus expresses himself in reference to this:
"in families where epilepsy is a pathological  entail, marriage of
the members among themselves is to be prevented, and the veteri-
nary  principle of crossing with  thorough-bred stock is  to be
introduced."  According to what has been said already, this 
TREATMENT.
283
advice must be extended not only to epileptic persons, but to the
neuropathic in general.
   Apart  from those enumerated,  there  may  still occasionally
be various separate influences which demand therapeutical con-
sideration, the detection of which must be left  to the skill of the
physician, as general rules cannot be laid  down for them.  Thus,
e. g., it has been determined that epileptic seizures occurred with
greater  violence and  frequency  when a  cutaneous eruption of
some standing has been healed, and that they disappeared on
the re-appearance  of the exanthem.  These and analogous rela-
tions must always be carefully considered.
   If we are not successful in getting at  any causal indication,
the treatment of the central epileptic change must be attempted.
To this end we make use of dietetic measures, and, in addition,
of curative  procedures, wliicli are either  to act locally upon the
brain in the pons or medulla oblongata, or to  influence the ner-
vous  system at large,  and, finally, of medicines to which are
ascribed either an  effect in  subduing "the exalted irritability"
of the central organs,  or, more vaguely, a "specific" relation to
epilepsy.
   For the regulation of the diet, in a stricter sense, the eating
and  drinking, very positive indications are sometimes presented
to us, as  in pronounced  anaemia or plethora.   Thus w7e have
already expressed  ourselves to the effect that alcoholics, tea, and
coffee must be entirely forbidden to epileptics, or—in case this is
for any reason inadmissible—should be allowed only in the very
smallest quantities.  The disadvantages,  too, of  luxurious and
sensual  living have already been insisted on;  in  general terms
patients are always  better  off for a temperate and well-regu-
lated  mode of life. Cheyne relates the instance of  an epileptic
physician,  in whom the  seizures occurred so much the more
rarely, the fewer and more easily digested were  the things he ate,
and who, in consequence of  this  observation upon himself, lim-
ited his daily nourishment to water and about three and a half
pints  of cow's milk ;  this he  continued, as stated, for fourteen
years and  recovered.   An exclusively milk diet could, however,
be long continued, only in very exceptional cases.  Tissot gives
a  selection of the various aliments which  are suited to or inju- 
284                NOTHNAGEL.—EPILEPSY.

rious to epileptics.  Still, in this respect one  is,  in part, to be
guided by the different individual peculiarities, and much must
be made dependent upon the observations made by the patients
upon themselves.  As a general  rule, it can only be laid down
that if  no direct indication for an invigorating  procedure is
offered by the condition of the  patient, a preponderance of vege-
table and milk diet is to be observed.
   Light,  not exhausting mental effort, and the avoidance, as
far as possible, of  emotional feelings, are essential adjuvants in
treatment, according to all that has been said above.   It is quite
wrong, however, to attempt to forbid  mental  work entirely to
epileptics; on the contrary, a moderate, quiet exercise  of  the
mental faculties is, as a rule, very advantageous.   The same is
true of physical labor; walks  and simple  gymnastic exercises,
free from danger, are very good for patients, only they must not
be carried  to complete fatigue.  AA"e even know of certain in-
stances where epileptics have recovered by a mere change in their
mode of life,  where, e. g., instead of a sedentary in-door life they
have taken to gardening.
   I must, from  my  experience, regard water-cures as a very
important means in the treatment of epileptics.  Through them I
have seen, although not complete recovery, at least a very essen-
tial improvement take place. To be sure, I cannot claim this for
all cases, but those in which no effect at all was visible were very
old, inveterate epileptics, in which  frequently a  failure of  the
mental powers existed at the same time.  Still, in these hydro-
therapeutic doings one must not be satisfied wdth  merely being
rubbed down at home, but the treatment must be methodically
carried out for from  six  to twelve  weeks in a cold-water cure
institute.  It  is most judicious  to leave the kind of hydro-thera-
peutic treatment to the physician of  the establishment, and I
would only insist in general, that I regard douches upon the back
and  head, and plunge baths, as rather injurious  than useful.
AATith reference to the selection of the institution it  depends less
upon the  geographical position  than  upon the physician who
conducts the establishment.  It  is readily  understood that dis-
cretion,  no less than the changes taking place in  the medical
personnel of the establishment, prevent our giving more positive 
TREATMENT.
285
statements in regard to this.  Only a marked degree of anaemia
should be looked upon as a contraindication to the water-cure.

  River and sea baths  are far below the methodical water-cure in efficiency;
besides, there should be  considered against them a circumstance which, although
extrinsic, is still always worthy of attention, to wit, the danger of drowning, to
which patients are exposed if they are overtaken by a seizure while bathing without
special supervision.—As to warm baths, I have no experience at my command; yet,
according to the existing statements of other authors, no special benefit is to be
expected from them.—Here, too, we must mention the treatment recommended by
Chapman, by  means of the application of ice-bags along the spine, the details of
which are well known.   Beigel declares in general terms that Reynolds has seen
" excellent service" from them; Chapman describes several instances of decided
improvement.  In several cases where I have tried this method in epilepsy, I can
boast of no noteworthy result.

   A great deal was expected  from electricity.  New experiments
were made with every new  improvement  in the apparatus ; the
curative effects,  however, in  epilepsy always remain insignifi-
cant, and  therefore we  believe we may omit any  account of the
separate experiments.    AVhen  the constant current  was  first
introduced in the shape of imqnxrved apparatus (Remak), its use
also in epilepsy was recommended from the most  different quar-
ters.  All  thoughtful electro-therapeutists are agreed, however,
that even  the constant galvanic current accomplishes  only very
moderate results; and meantime it should not be lost sight of
that in many instances  other  curative agents were employed in
connection with electricity, or at the same time with it.  I myself,
even after long-continued use of it, have never observed anything
more  than an improvement  as  the most favorable result, but no
perfect  cure.   Still, w7e cannot  doubt,  in view  of  the definite
statements of  certain  authors, that  sometimes  a cure  can be
effected by the current, so that, of course, we must not push our
scepticism  too  far, although it derives some support  from  the
fact that the constant current has not been in the  hands of phy-
sicians much longer  than  from  ten  to  twelve  years.  At all
events, however, it is  certain  that we should  not  expect  too
much from electricity.
   The application of the current is usually made in numerous
combined ways.  At first the  electrodes are placed  high up on 
286
NOTHNAGEL. —EPILEPSY.
either side of the nape of the neck, so as to act upon the medulla
oblongata and the pons ; afterwards galvanization of the cervical
sympathetic is generally practised.  According to the  particular
case, we may combine the transmission of currents  transversely
through the cranium, or through the spinal column,  or the treat-
ment of special nerve-tracts, in wdiich an aura has been particu-
larly pronounced.
   In former times, especially, great weight was .aid upon the
establishment of so-called counter-irritations, notably  in  the
nape of the neck.  This was done in the most various ways, from
dry-cupping  to  the  seton.  The most famous  advocate of the
set on in recent times has been  Schroeder van der Kolk.  Mean-
while, the majority of observers have tried this and other counter-
irritants quite in vain ;  we have ourselves introduced setons in
some cases  without observing the slightest change in the disease.
Some advantage  might be expected from the slighter counter-
irritants, but only where there was considerable hyperaemia of
the brain during the intervals.
   In passing, two curative procedures may here be mentioned, which, to be sure,
are no longer used, but each of which has in its time played a great part; these are
ligation of the carotid and tracheotomy. We know to-day that neither of  them
can cure epilepsy, and they have been abandoned as dangerous operative proced-
ures.  It  may be allowable to give a single historical notice of  tracheotomy, for
which, indeed, the recommendation  of  M. Hall is brought forward.  This writer
himself, however, in his  earlier works1  mentioned tracheotomy as a remedy only
11 against the most extreme degree of coma  after the epileptic seizure," and then
says, " but it is a strange idea that tracheotomy could prevent the epileptic convul-
sion."

   AAre now come to the section on so-called specific remedies.
Every one who writes on epilepsy feels himself tempted  in  this
chapter to  renew  the old  complaint of  the  glaring contrast
between the immense number of remedies recommended and the
extremely few cures effected.   Still, we would leave general  con-
siderations wholly aside ; they can lead to nothing here.  Only
the question may be raised whether it is essential  to the inter-
est of the subject, and of our exposition of it, to adduce here by
   1 E. g., On the Diseases of the Nervous System. Translated by Wallach. Leipzig,
1842. pp. 390-1. 
TREATMENT.
287
name the hundreds of medicinal substances wdiich have ever been
tried for the relief of epilepsy.  AATe do not at all believe so ;
whoever  is interested in this may go over the  separate names in
the different monographs, among which w7e  mention particularly
those of Loebenstein-Loebel, Portal, Delasiauve,  and, besides
these, the chapters treating of epilepsy in Tissot and Joseph Frank.
It appears to us really more proper as well as more in the interest
of the  practical physician,  to mention only those articles as to
which we have a more general  experience, those in which the
best observers  recognize  a considerable efficiency, and of which
they have had  more than an ephemeral experience.   One may
also without harm disregard a special grouping of the articles.
   First, as  one of the oldest remedies, we mention the radix
raleriance.   The most famous observers, especially those of the
last century, have insisted on  its usefulness, and it would be
considered  as indulging  in unwarranted scepticism if one were
unwilling to concede, in the face of the very positive statements
which are made, that essential improvements, i. e., absence of
the seizures for years, and even individual recoveries, are achieved
with the valerian root.   AVe can ourselves give no decisive ver-
dict on this matter, for the  reason that we have not employed it
alone, but always in  combination with other substances.—Upon
what its  curative properties in epilepsy depend, no satisfactory
explanation can be given. At the most, the experiments with oil
of valerian, made very recently  by Grisar,1  might furnish an in-
dication, for the frogs, to which 0.02 gramme  (three-tenths of a
grain) of it was given, became quiet and apathetic, exhibited a
diminished reflex-irritability, and finally became completely stu-
pefied, but gradually recovered.   The diminished reflex-irritabil-
ity appears to depend upon an influence affecting the spinal cord
as well as the centres in the brain which excite spasm.—Practi-
cally it would certainly be of the highest importance to know the
special conditions, so as to  be able to determine accurately the
cases in which valerian would be of more service than other arti-
cles. Unfortunately,  this too is wholly unknown ; for  the older
  1 V. V. Giisar, Exper. Beitriige z. Pharmacodynamik der atherischen Oele. Bonn,
1873. p. 62. 
288               NOTHNAGEL.—EPILEPSY.

statements in regard to this are much too indefinite, and there
are none more recent.   As to the different preparations, the root
has been given in the form of powder,  or as infusions, extracts,
and tinctures.   According  to my own  experience, which agrees
with that of others, the form of powder is the most appropriate.
The doses at flrst should be small, about 0.5 gramme (seven and
a half grains) three times  a day,  and should then gradually be
increased to a  total daily quantity of  25 grammes (about six
drachms).
   In the same category  with valerian  we  place  the  radix
artemisim (vulgaris). The wormwood was given in ancient times,
and again in the  first decennia of  this century.   It too is very
apt to prove inefficient.  Still my experience with it in some cases
has determined  me to bring forward  the remedy here.   These
were  cases  where almost  everything  had  been tried without
the least benefit.   AVhen I  finally had  them take  the radix arte-
misiae, after a short  time  a decided remission in the number of
the seizures became  manifest.   I lost sight of the. patients, so
that I can make no report of the  final issue, but even the result
stated seems to me an improvement worthy of note, especially
after zinc, silver, atropine, bromide  of  potassium, valerian, elec-
tricity,  etc., had been given entirely without effect.  Besides, my
observations were on patients at  the time of puberty, in whom
epilepsy had developed without hereditary  predisposition  or
other ascertainable influences ;  in a girl of  about sixteen there
existed marked molimina  menstrualia.  The old recommenda-
tions  praise wormwood especially in the epilepsy of women with
demonstrable  lesions  of  the  genital  apparatus. I direct the
remedy to be used in the form of an infusion, 15  grammes (three
and three-quarter  drachms) to be taken daily.
   No other vegetable  remedies are  the least worthy  of mention;
the improvement or cures  obtained  through them are so isolated
that it is quite impossible to judge whether we have to do with
accidental occurrences or with  a causal connection.  Only a few
substances belonging among the narcotics furnish an exception
to this.
   Belladonna was praised even by the earlier physicians (Stoll,
Theden, Hufeland, and others),  and  there are numerous cures 
TREATMENT.
289
described which are stated to have  been attained by it.  One of
its most zealous advocates is Trousseau.  Recently, instead of
the herb, the alkaloid, atropine, has come into favor.  It is said
that recovery has  been brought about by this too.   Although
we  ought  not to disregard the positive statements  of certain
authors, still we cannot from  our own experience join in  the
praise of this article except to a limited extent, inasmuch as we
have, to be  sure, sometimes been able to effect an arrest of  the
seizures for a month by injections of atropine, but  never a cure.
The experience of others agrees with this, e. g., that of Reynolds,
who obtained by means of belladonna, which I have never given
alone, an amelioration in the case of various patients (a cessation
of many of  the indefinite troubles of various  kinds from which
epileptics  often suffer,  such  as nervous uneasiness,  trembling,
and disturbed sleep), but no complete recovery.  The valerianate
of atropine, from which certain persons had great expectations,
seems to possess no advantage over the other salts of the  alka-
loid.  Just the same is true of hyoscyamus as of belladonna.
   The remaining narcotic substances, almost all of which have
been tried at times, are actually of no more service, in fact are less
serviceable than deadly nightshade and henbane, and may there-
fore very well be entirely dispensed with.  In regard to opium in
particular, it is generally recognized that it is of no benefit in the
cure of epilepsy,  but it  may  be most  opportunely employed
according  to general indications in combating  certain manifesta-
tions symptomatically.  Hasse,  as  well as Morgagni, witnessed
benefits from it in  nocturnal  seizures, if the patients were not
plethoric and were freely purged beforehand.—Inhalations of
chloroform,  too, may be added here, with regard to wdiich it is
certain that they accomplish no curative effect.  A difference of
opinion even prevails as to their utility in respect to the occur-
rence of  the  individual  paroxysms, since, on the one hand,
they have  been seen to delay7 the development of the paroxysms
and limit  their intensity, and,  on the other hand, to act in ex-
actly the opposite w7ay.   From wdiich it may be safely inferred
that chloroform inhalations are not of essential benefit.
   In the  list of metallic remedies, the most various have like-
wise been  tried.  The majority are acknowledged to be wholly
          VOL. XJV.—19 
290                NOTHNAGEL.—EPILEPSY.

inefficacious.  To only a few do different authors ascribe a  cer-
tain action  in epilepsy, and in regard to one alone  there pre-
vails a greater degree of unanimity regarding its curative powers,
although there is wide divergence of opinion as to their degree.
This one remedy is the oxide of zinc (flores zinci).  Having been
first ordered now and  then  in the last century, it acquired a
great reputation, especially through Herpin, although Ilufeland
also esteemed  it very  highly.   Herpin relates  that  he cured
twenty-eight out of forty-two individuals  by the oxide of zinc.
This result, which Hasse rightly remarks upon as " unprecedent-
edly" favorable, necessarily prompted to the decided employ-
ment of the remedy.  Unfortunately,  later observers  could  not
corroborate  this ; but, as we have already had occasion to remark
above, it would be quite incorrect for us on this  account to dis-
pute altogether the results obtained by Herpin, for recently Aroi-
sin has established by Investigations the lasting character of  the
cure  in several  of  the patients treated  by Herpin;  and, in
fact, the different observers always assign a favorable action to
zinc above any other of the older  remedies.  My own observa-
tions are not uncomplicated, because  I have always  ordered it
together with other therapeutic measures; but if it be allowed
in a limited sense to draw conclusions  from such  mixed methods
of treatment, I could plead decidedly for the retention of  the
oxide  of zinc in  the materia medica of epilepsy.  I  have also,
with  Herpin, found  the remedy more efficient with patients
under twenty years than in those of more mature age.   I ordina-
rily begin with small doses, three centigrammes (half a grain) at
a dose three times a day, and increase gradually up to from 1 to
1£ decigr. (a grain and a half  to two and a quarter grains) at a
dose.  If no unfavorable symptoms on the part  of the digestive
tract are  produced, we may occasionally give  even  somewhat
larger doses.    Only when its use has been continued for some
four months without the least  effect, do I discontinue  its further
administration; otherwise I have given it for from six to twelve
months.  Usually I order the oxide of zinc in the combination in
which it is  given in the old pulvis anti-epilepticus, i. e., in con-
nection with radix Valerianae and  the extract of belladonna or
hyoscyamus. 
TREATMENT.
291
   Of the other metallic substances, only the ammonio-sulphate
of copper and the lunar caustic deserve mention.   The ammo-
nio-sulphate of copper has  been much longer in use than the
oxide of zinc,  but is very seldom given at  the present time.   If
recent observers deny it  the efficiency of  the latter, their testi-
mony is, as I have already insisted in another place,1 simply insuf-
ficient, in the face of the statements positively made by the older
authors.  The difficulty consists in determining on the particular
cases for its employment.  I have there (loc. cit.) compiled what
can be gathered from the published communications in regard to
this.  " If ammonio-sulphate of copper has led to a remission  of
the seizures or to a cure, it has done  so much more generally
with adults, less often with  children  (the reverse of the action
exerted  by zinc).  The cases seem  to  comprise generally torpid,
phlegmatic individuals, and not so much 'the irritable and ner-
vous.'   A necessary condition for the administration of the rem-
edy, which is  not to be  given on  an empty stomach, is  a good
state of  the digestive apparatus."  Moreover, I will  not  neglect
to add that I have  myself given the preparation in only a few7
cases, and then without noteworthy effect, after various attempts
at a cure had already been made.
   Nitrate of silver for a  long  time played a great part  in
the treatment of epilepsy,  and certain of  the older  observers
believed that  they had  effected more cures by it than by any
other remedy.   This opinion has  very much changed.  Of
course,  as  in  regard to  the ammonio-sulphate  of  copper, the
positive statements of  earlier writers cannot be  simply  denied.
Of course, the lunar caustic is sometimes given even at the pres-
ent day ;  but confidence in its curative  power is  very  much
shaken.   In the cases under  my own observation, just  as with
the ammonio-sulphate of copper,  I  have myself obtained no
convincing result;  on the  contrary, I can subscribe word  for
word to the remark of Reynolds, that patients have  come to  me
whose skins were colored of a blackish blue  by the use of the
article for years, whose epilepsy, however, remained unchanged.
In  my  opinion,  the lunar  caustic may at  times  be ordered
1 My Handbuch der Arzneimittellehre. Berlin, 1874.  2d EL p. 335. 
292    •            NOTHNAGEL.—EPILEPSY.

experimentally, when the better approved remedies and modes
of treatment have produced no result.
   AA"e now turn to that medicine which in the last ten years has
undoubtedly been given  to most epileptics ; that is, bromide of
potassium.  Some praise it as the sovereign remedy against the
disease;  others say that they have observed scarcely more  than
transient benefit from it in isolated cases ;  the majority, however,
place the bromide of potassium, at  all events,  higher than all
anti-epileptics which we have hitherto possessed.  The literature
relating to it has already become so considerable  that we think
we can venture to make a summary of the  general verdict, and in
doing so must abstain from  a citation of  the  different  authors;
our own experiments are comprised in what follows.
   Bromide of  potassium is not an infallible, sovereign anti-epi-
leptic, but it is certainly of more service than all other remedies.
A small number of cases are cured (so far as we can speak of cur-
ing in view7 of the as yet brief existence of this treatment *);
another  group resists any action of  the remedy—the disease
remains entirely  unchanged ; a third, and this the largest num-
ber, experiences a more or less marked improvement.
   Although some authors do not acknowledge  the cures, or, at
any rate,  have  not themselves observed them, still all, with the
exception  of a very few,  are  agreed  in  this, that bromide of
potassium makes the seizures less  frequent, and,  where they
have previously been frequent, extends the intervals  to  several
months, and even longer, without  their then recurring in accu-
mulated  numbers or greater intensity.   Even  this result is of
extraordinary value, as every  one must  allow, in view of the
frequent failure of our other remedies and methods of treatment,
and it assures to bromide of  potassium a  place  in the therapeu-
tics of epilepsy.
   The arrest of  the  seizures  sometimes coincides with the  very
beginning of the treatment, which is scarcely the case with any
other remedy7.  It is  true they sometimes  set  in  again  at  once if

   1 WTith regard to the cures, I have spoken sceptically in my Pharmacology, 2d Ed.;
yet it seems to me—retaining the limitation in the text above—that this is now scarcely
open to question, in view of the numerous communications which have since appeared,
and which have been made privately to me. 
                        TREATMENT.                      293

the remedy is omitted ;  but the positive statement is  made by
various  observers, and very recently also by A. Otto,1 that fre-
quently the mental  disorders of epileptics undergo a decided
improvement at the same time, so that patients may even return
to a normal condition from a state of commencing idiocy.
   At the same time, as  we would once more  remark, it should
not be forgotten that even bromide of potassium may at times
remain completely inactive, and this I must corroborate from a
series of instances that have occurred in my own practice.
   In the beginning it  was  believed that  in  certain forms the
bromide of potassium was more efficacious  than in others.  The
more extended becomes the material for observation,  how7ever,
the less proof is there of this.  Etiology, duration of the disease
(up to certain moderate  limits), the  frequency, form,  or absolute
number of the seizures which have already  taken  place,  seem to
exercise no influence  upon the possible action of  the  bromide of
potassium.
   Questions as to the mode of  action of the  bromide of potas-
sium, and what the  real therapeutic agent  in  it  is,  whether
bromine or the alkali, we may here  be  at liberty to leave unan-
swered ;  these belong in the special books on pharmacology.
Special emphasis, on the other hand, should be laid on the mode
of employment.  Almost all observers are agreed as to these twro
points, that the remedy  must be given for as long a time as pos-
sible continuously, and  in large doses.   In  adults we begin with
five grammes a day,  and increase to ten or fifteen ;  when there
is great tolerance of the preparation, even to twenty grammes
(five drachms) a day.  It is, of course, understood that there
must be breaks in its administration if  the  well-known patholo-
gical accompaniments set in, such  as disturbances of the diges-
tion, diarrhoea, acne,  and furuncles. AA nen of great intensity,
they may occasionally necessitate a  complete withdrawal of the
remedy.
   In cases where the bromide  of potassium alone has been of
very little or no service,  an effect has sometimes been gained by
certain observers from combining it  with another remedy ;  thus
1 Archiv f. Psychiatrie u. Nervenkrankheiten. Vol. V. 
29-1
NOTHNAGEL.—EPILEPSY.
bromide of  potassium has been combined with oxide  of  zinc,
with conium (Echeverria1), and with other articles.  Of these
various combinations we ourselves have tried only that with In-
dian hemp,  according to Clouston's method8 of administering it
in psychoses, but have been able to  gain  no positive conviction
of its greater efficacy.
   AVith this we close the enumeration of anti-epileptic reme-
dies, and  will only just briefly summarize the manner in which
the  curative measures  should  be conducted  when a  patient
comes freshly under treatment.  First  and foremost, after  very
thorough investigation of the etiological relations and an exami-
nation of the patient, comes if possible a causal treatment. If
this  is not possible, or if it does not attain the object, then a
general dietetic treatment should be instituted (which, of course,
must have already been partly brought into use during the causal
treatment) according to the rules laid down above.   Add to this
the administration of bromide of potassium,  with ultimately the
employment at the  same time of the constant current;  then in
summer a cold-water treatment in case there is no special contra-
indication to its use.  If with  these  measures, after perhaps the
combination of the bromide of potassium with cannabis Indica or
conium, no effect appears after a considerable time, the bromide
of potassium and electricity are to be abandoned, but the general
dietetic management is to be observed,  and the cold-water treat-
ment may even be repeated ; at the same time we should now give
oxide of zinc with valerian root and extract of henbane or deadly
nightshade.   If all these things  have been tried in vain, any one
of the other remedies mentioned  above may now be tried, or some
one of the immense number of  those that are elsewhere recom-
mended.  In order to make things complete, we simply set down
some of them here:  assafcetida, castoreum, stramonium,aconite,
digitalis, squills, animal oil of Dippel, oil of turpentine, quinia,
phosphorus,  strychnine,  selinum palustre,  gratiola, etc.,  etc.
1 Philadelphia Med. Times.  Nov. and Dec, 1872.
8 Referred to in the Centralbl. f. d. med. Wissensch, 1870 and 187L 
TREATMENT.
295
             TJie Treatment of the Seizure itself.

   It would, of course, be of considerable importance if we were
able to ward off each individual seizure.  Unfortunately, this is
practicable only in rare cases.  It is wholly impossible in cases
where the paroxysms break out suddenly ;  the  full paroxysm
may sometimes be prevented, but only in cases where some con-
siderable time elapses prior to  the  loss of  consciousness, and
where the so-called premonitions  precede it for a length of time.
To accomplish this, a firm ligation of the extremities has at  all
times  been in general use in those where a distinct  aura showed
itself.  Possibly the following will also succeed—after the anal-
ogy of experiments on animals—if, in case the seizure,  e. g., is
ushered in by an infolding  of  the fingers, w7e  attempt  to bring
them at once by a rapid and forcible action into a position of
hyperextension.   (AAre need  not  lay  any further stress on the
fact that the senseless forcible extension of  the  thumb when a
seizure has already occurred is not to be confounded with this.)
There are quite numerous cases of  this  kind indicated in the
literature of the subject.
   Now, if such premonitory symptoms are absent,  the suppres-
sion of the seizure will be much more difficult. Formerly, com-
pression of the carotids was proposed with this object. Kussmaul
has already exposed the untenable character of  the theoretical
arguments  on which  this  was  recommended, and Hasse has
shown the practical difficulties in carrying it out, which are be-
sides quite palpable.   Favorable results from compression of the
carotids have also been reported only with extreme  infrequency.
—The uncertainty of the inhalation of chloroform, to which that
of ammonia is very analogous, we have already considered above.
   Very recently the inhalation of  nitrite  of amyl has been
recommended for cutting short the paroxysms.  If we consider
the  usual mechanism of the seizures on the one hand, and on the
other the physiological mode of action of the nitrite of amyl, as
far as this  is yet established, this recommendation is d priori
perfectly correct, and the effects so aimed at have also been actu-
ally reported.  At all events, these inhalations of nitrite of amyl 
296
NOTHNAGEL.—EPILEPSY.
at the very beginning of the seizure are worthy of further trial.
AATe would only refer very decidedly to one point in  this con-
nection.  This remedy  should only be  tried where the patients
become pale at  the very beginning, where indications of cerebral
vascular spasm .are present.  It  should not be administered if
the color of the face is cyanotic from  the outset.  Further care-
ful observation is required to teach us  how it behaves  when the
facial color remains unchanged from the beginning.
   "The seizure, when once begun,  wears itself out; we may
banish the  idea of interrupting it, for the well-being of the epi-
leptic patient is greater the more complete the seizure, particu-
larly after a long interval has elapsed."  This dictum  of Rom-
berg has still to-day its complete significance.    The external
measures, the object of wdiich  is to protect  patients from inju-
ries, the loosening of tight bands when possible, and  the like,
require no  special description in this place.  They are  governed
by the external circumstances in wliicli the patient is overtaken
by the attack.  Unfortunately, it is but seldom possible to pre-
vent the biting of the tongue.   If the seizure  has already broken
out nothing can be thrust  between the teeth. And even if the
patient has time enough to put some kind of  wooden wedge be-
tween his teeth,  wounds of the tongue  are not always avoided.
In such cases we must always be careful lest objects of  this
kind get into the  throat during  the  convulsions  and  produce
suffocation.
   As  the comatose stage often lasts for some hours after the par-
oxysm, it is  necessary in this, should  the patients present no
threatening symptoms, to guard against all  excessive  officious-
ness, or rather to do nothing, but leave the patient quietly to his
sleep.  Active interference is  demanded only where the parox-
ysms  follow each  other in rapid succession,  and where the
status  epilepticus is developed.  Unfortunately this is often of
no avail.   Of  the various remedies  employed,  blood-letting,
either  local or general,  when there is strongly-marked hypere-
mia of the brain, seems on occasion to be the most useful.  Cold
to the head, purgatives, and the  most  various internal medica-
ments  are  quite inefficacious.   AA^hen  the paroxysms are very
violent, a  careful  trial  might be made  of inhalations of ckloro- 
SIMULATION OF EPILEPSY.               297
form.   The most approved remedies are to be employed against
any threatening oedema of the lungs, wdiich may develop, such
as large blisters upon the chest, or acetate of lead in large doses
given at short intervals.


                  Simulation of Epilepsy.

   It is well known that epilepsy is the disease which is perhaps
the most often simulated ;  military surgeons especially and those
occupied with medico-legal cases have  frequent opportunity  of
verifying this.  The free intervals and the striking, frightful form
of the paroxysms, which at the same time excite sympathy, are
the chief influences which induce  impostors to make  this  par-
ticular malady the object of their study.  The endeavor has
therefore always been made to find indications  for the diagnosis
of real from simulated attacks ;  very numerous instances, how-
ever, teach us that this distinction is not alway7s easy.
   We refrain from enumerating here all the points which have
been assigned as capable of furnishing differential proof, because,
with few  exceptions, none  of  them have  this  character.   It
proves nothing that the imitator should choose time, place, and
surroundings for the seizure, that he  should  fall down  in the
way he might  be  expected to, that he should turn his thumbs
in again if they have  been forced  out, and  do many other
things, because they may also  happen in real  epilepsy.   The
physician  wall rather  need to make use of a variety of attend-
ing circumstances, and  must avail himself of much  acuteness
in order to get at the truth, and then it is sometimes amusing
to see  into what awkward traps persons fall who have produced
seizures most true to nature.   The experience of every physician
versed in this  matter will furnish to order a collection of anec-
dotes  bearing on it.  But if the impostor is cunning enough not
to lay himself open,  even if he has to endure painful proce-
dures, which were formerly carried almost to cruelty, what then %
Are there  no symptoms of the  seizure wdiich cannot  be  volun-
tarily  imitated ?  Sometimes there really are such, and any par-
oxysm may be  regarded as genuine in which  the  following
symptoms show themselves :  pallor of the countenance and dila- 
298
NOTHNAGEL. —EPILEPSY.
tation of the pupils at the beginning of the seizure, failure of
the pupil  to react when a  bright  light falls  upon it.  But,
unfortunately7,  these trustworthy tests cannot always be turned
to account,  for  the opposite conclusion,  that every attack in
which these signs are absent is  simulated, is not correct.   In
the section  on Symptomatology we  have spoken in detail on
these points.
   It would be of the highest significance for the diagnosis of
simulated epilepsy if the assertion of Huppert were confirmed,
that transient albuminuria occurs after every pronounced attack.
Still, we must fii^st wait for the confirmation of this.  Equally
uncertain is  the  change  in  the  sphygmographic  trace of the
pulse, on  which  Voisin lays stress for purposes  of diagnosis,
and which  is said to occur only after  genuine seizures (compare
above). 
ECLAMPSIA.
   J. P. Frank says, in defining this disease, "eclampsia, epilep-
sia puerilis, a  priori (sc.  epilepsia) differt, quod acuta sit, ince-
ilt'iis cum  febre continua, interdum cum intermittente."  Since
then the conception of eclampsia has so far changed that  Hasse
used it simply as a synonym for " acute epilepsy," i. e., those
forms of spasm are denominated eclampsia which resemble epi-
lepsy  in their  outward character, but which occur only  a few
times, passing  rapidly away, and end  either in death or  in re-
covery.
   Good observers, and among them  Hasse himself, have now
excluded from  eclampsia a series of spasmodic attacks, although
in external features they bear a great resemblance to those of
epilepsy ;  in particular, all those convulsions which are simply
the expression of gross anatomical changes in the nervous system,
especially  in the brain.   Nevertheless, even at the present day,
at least in German literature, the appellation  "eclampsia" is
quite generally used as a  collective name  to  designate epilepti-
form spasms which appear under very different conditions, pro-
vided only that they be acute, soon disappear again, and do not
subsequently return.  In consequence of  this the same  chaos
reigns to-day regarding  eclampsia as formerly prevailed  about
epilepsy.
   We are of opinion that we should go  decidedly further, and
designate by the  ancient  name of epileptiform seizures all  the
convulsions which appear simply as  a symptom in the course of
various other diseases, even if they be only acute and transitory ;
or, in  order  still less to commit  ourselves in advance, that we
should use the  simple expression—general spasms.  Just as  the 
300
NOTHNAGEL.—ECLAMPSIA.
titles colic and icterus have disappeared from special pathology,
and have been relegated to general pathology, so with advancing
knowledge must w7e continually take away from that which was
once, and still is, reckoned as eclampsia ;  very many of the pro-
cesses  once  included under this  conception have already been
recognized as  simple symptomatic  convulsions, the process at
the foundation of which can be very easily made out,  and of
course these must  accordingly be treated of in the symptoma-
tology of these fundamental diseases.  Among them belong con-
vulsions from  hemorrhages or other rapid and profuse losses of
nutritive fluids, especially in  children, as  also  those which take
place in  cases of very great hyperaemia of  the brain,in cases of
cerebral or  meningeal hemorrhage or embolism,  or sometimes
in the  course of cerebral tumors and abscesses.   The physiolo-
gical connecting link, which is common to  most of  these cases,
is cerebral anaemia;  for  the special data  in regard to this the
reader may compare the sections  treating  of it in  the present
work.   It does not  occur to any one at  the present day to
speak of eclampsia in such a case.—Another group, too,  which
formerly furnished a large contingent to the "cases of eclamp-
sia," has been separated ; we refer to the convulsions occurring
in the course of diseases of the kidneys.  It  is not our purpose
in this place to enter more minutely into the still vexed question
of the way in which the convulsions and the cerebral symptoms
generally  arise in  renal diseases, whether  by oedema together
with anaemia  of the  brain, or by the overloading of the blood
with excrementitious matters ;  this likewise belongs in other
places  in this work.  At any rate, however,  it is superfluous and
confusing to apply a special name, like  eclampsia, to a manifes-
tation wliicli does not at all occur as an  independent disease, but
only incidentally,  under  definite conditions, as a symptom in
the course of other diseases.—AVe must say exactly the same of
the greater  part at least of  the convulsions which sometimes
appear in pregnant, and particularly in parturient  women, and
occasionally even at the present time seem to lay claim to a spe-
cial position under the  name of Eclampsia gravidarum et par-
turientium.   The  conditions under which the convulsions of
parturient women occur are  very  numerous and variable, and 
DEFINITION.
301
we shall have  to show hereafter that certain cases of these con-
vulsions  should, in fact, represent a  special disease, for which
the name once in use may be retained.  Others of them, how-
ever, in wliicli the patients had albuminuria  before  the confine-
ment, must undoubtedly be interpreted in the same way as the
spasms just mentioned as occurring in the course of kidney dis-
eases, /. e., they form a link in the chain of symptoms  of the
latter, and not a separate disease.1
   But we go  a step further.    In our opinion it  is not even
correct to keep  to the special name of eclampsia for the convul-
sions with loss of  consciousness which so often occur in children
at the beginning of .acute  febrile diseases,  as in pneumonia, ery-
sipelas, and the acute general exanthemata,  also as an introduc-
tion  to  poliomyelitis anterior acutissima  atrophica  (the  spinal
paralysis of children).   Here, too, we have to deal with a  symp-
tom  of  another fundamental disease, not with a special affec-
tion ; and on this account we may here refrain from a discus-
sion  of  the question whether  the fever as  such, the elevated
temperature,  or a possible hyperaemia of the brain, or some
other influence, furnishes the cause of the  convulsions.  It is
possible, of course, that  in  some  of  these  febrile  convulsions
the same processes  are actually  going on  which  characterize
eclampsia (according to our assumption), but at present it is not
proved.
   Finally, there must also be distinguished from eclampsia the
seizures which sometimes  appear in severe chronic lead-poison-
ing.  It has nothing to do with the matter  whether the saturnine
cerebral symptoms arise from the immediate action of the lead
upon the nervous  elements of the brain,  or whether they  are
brought about through  an intermediate action upon the vessels
(anaemia)—they represent  only one of  the  symptoms that result
from the organic changes effected by the lead.
   What is there now remaining of what was formerly  recog-
nized as eclampsia ?  And are we altogether justified  in still
retaining this name ?  AA"e believe so, and are of opinion that the
  1 We can of course only touch upon this question here so far as it is related in a
very general way to " eclampsia."  For the particulars about eclampsia parturientium
we must refer to diseases of the kidneys and of women. 
302
NOTHNAGEL.—ECLAMPSIA.
title of eclampsia should be reserved a.s the name of an inde-
pendent affection,  which,  it is  true, can  at present only  be
defined by its clinical symptoms.  AVe propose that the desig-
nation  eclampsia should be made use of for  those  cases  of
epileptiform spasms ivhich—independently of positive organic
diseases—present themselves as an independent acute malady,
and in which—so  far as our  present  knowledge allows us to
judge—the same processes arise, generally in the way of reflex
excitement, and the same mechanism in the establishment of the
paroxysms comes into play, as in the epileptic seizure  itself.
In this way, as we see, the designation of eclampsia as an acute
epilepsy finds greater authorization ; at the .same time it is dis-
tinguished from true epilepsy by the lack of a persistent central
change, which latter  impresses upon epilepsy the character of a
chronic condition.  In the case of eclampsia, where this chronic
change is absent, the manifestations, the seizures, disappear with
the removal of the exciting irritation.

                            Etiology.
   Hughlings Jackson properly insists that only  in extremely
rare cases are simple peripheral  irritations  alone  capable  of
exciting epileptiform convulsions  or an eclamptic seizure, and
that this is  possible only if a certain physiological or patho-
logical  peculiarity  on the part of the nervous  system already
exists.  All observers are agreed as to this, that such a disposi-
tion to  eclamptic  seizures—such  a  convulsibility,  as it  is ex-
pressed—belongs particularly to  early childhood.   This is  so
striking that a special class  has  even been formed under the
name of eclampsia infantum.
   Upon what depends  this great tendency of the nervous sys-
tem in childhood to react upon peripheral sensory excitements,
not only with local  twitchings, but  even with  general convul-
sions and loss of consciousness,  while  they  remain without any
further results in grown persons? That this is not at all de-
pendent upon an inherited neuropathic  tendency,  or at least
only very exceptionally  so, is evident from  the fact that even on
the  most thorough  investigation  very often not the slightest 
ETIOLOGY.
303
trace of it can be discovered.  Sometimes, to be sure, such an
inherited  disposition seems to exist,  since at times we see all
the children of a family affected with eclampsia.   Moreover, it
does not  depend  upon whether  the  children  are weakly or
strong, thin or fat, lively or apathetic.   True, it seems that con-
vulsions  occur more readily in the  presence of some morbid
anomalies than otherwise, as especially in rachitis ; but it is very
certain that such are absent more often than present.  From the
whole body of observations we should rather come to the con-
clusion that it is not due to definite pathological  states, but that
the physiological constitution of the central nervous, system in
children is so modified  as to cause them, upon very slight irrita-
tion, to respond with spasms which may advance even to eclamp-
tic seizures.
   This conception is, in fact, quite generally recognized, and
certain pathologists, as, e. g.,  H. Jackson, even seek to give an
explanation for  it.   This author, indeed, calls  attention  to the
fact that  the nervous system of children is, in the first  place,
still undeveloped, and, in the  second,  is undergoing develop-
ment.  Meanwhile this interpretation is one so very generally
adopted that it scarcely contributes anything to the elucidation
of our question.
   In this connection we would refer to the well-known physio-
logical fact that all  reflex acts  take place much more  actively
after  removal of the cerebral hemispheres, which  is also ex-
pressed  by saying that the latter exercise an inhibitory  action
upon the occurrence  of  reflex  acts.   This reflex inhibitory  action
proceeding from  the hemispheres, which was  repeatedly ridi-
culed after the labors  of  Setschenow were made  known, has
been again rehabilitated,  particularly  by the experiments of
Goltz.1
   To render this reflex inhibitory action of the cerebral  hemi-
spheres intelligible, a voluntary suppression of reflex movements
has generally been assumed.   This undoubtedly sometimes hap-
pens,  but AVernicke2 has, in our  opinion, correctly indicated
1 Functionen d. Nervencentren des Frosches. Berlin, 1869. pp. 39 et seq.
' Der aphasische Symptomencomplex. Breslau, 1874. p. 11. 
304               NOTHNAGEL.—ECLAMPSIA.

another influence, namely, the passing over of every centripetal
irritation, wdiich takes place in a normal state  of  the nervous
system, not only into  the reflex paths, but also into the hemi-
spheres.   By this  division a certain sum of  the  living  force
required in the irritation-process is claimed  for the cerebrum;
consequently the resulting movement must now be weaker, as,
cater is paribus, the reflected movement is proportional to the
strength of the irritation which gives rise to it.   Various cir-
cumstances, the more  particular discussion  of which in this
place we  must decline, only  favor the view that in very early
childhood the sum of the living force, which is required for the
" accessory circuit" (AA'ernicke) in the cerebrum, is essentially
less  than in later years.   For this reason the irritation passes
much  more vigorously to the reflex  channels, and  produces in
them more  powerful effects, i. e., these  very spasmodic symp-
toms.—AVe give the foregoing conception, with all  reserve, as a
hypothetical attempt at  explanation of the unusual  tendency
to convulsions in early childhood which has been  experiment-
ally  determined.
   Eclampsia in adults—in the sense of our  former definition-
occurs with disproportionate rarity.   It is not possible to deter-
mine what is the nature of the conditions of the nervous system
which predispose to it.
   Only in a very general way observation teaches that  anamic
and  so-called  irritable and nervous  persons, even  though  they
be robust, are the soonest attacked by  eclamptic  seizures; at
least mention is made of these characteristics in most of the
detailed  histories of patients.   Although we  can explain these
constitutional anomalies on neither physiological nor anatomical
grounds, we must nevertheless  retain  them as clinical concep-
tions.
   Exciting causes of the seizures,   a. In Childhood.—Gener-
ally, although not always, a definite  influence, an external irri-
tant, can be proved to exist, with the operation of which the out-
break of the eclampsia coincides, and regarding the causal  rela-
tion  of wdiich to the latter no doubt  can be entertained, as  after
its removal complete recovery follows.  The  intensity of these
irritations need not be particularly great; it may even happen 
ETIOLOGY.
30o
that  they are indicated  by no other symptom, and that we are
first  led by the eclampsia  itself to  seek more  thoroughly for
their presence.  By far the most frequently these sources of irri-
tation involve the sensory nerves of the mucous membrane of the
digestive tract from the mouth down to the rectum.  The " teeth-
ing convulsions" of children have always played an important
part  with mothers, and  they actually do occur quite frequently,
especially during the first dentition and when the eruption of the
teeth is somewhat difficult. If these convulsions are more often
observed during the cutting  of the eye-teeth and  molars than
during that of the incisors, this may  be for the reason that the
latter,  as a rule, come through  more easily.—Equally  well
known are the  "convulsions  from worms."   Very  numerous
instances are recorded in the literature of the subject, and every
physician will be able to add to the number, where violent con-
vulsions in children have been excited by the presence of round
worms in the intestine,  and have ceased with their expulsion.
And here we  may very  properly remark how perfectly w7ell  the
little patients were feeling up to  the onset of the eclampsia,
and  how completely ignorant the parents are  apt to  be of  the
existence  of the round worms, prior  to the time of their dis-
covery.—In other  cases, again, indigestions furnish  the excit-
ing cause, or  vomiting,  or  diarrhoea; and here also belong the
oft-detailed instances when  children  have been visited with
eclamptic paroxysms on  taking the  breast  after the mother
or nurse has  undergone some violent  mental  change.   We cer-
tainly need not here consider at length that these cases should
not be confounded with  those where children present the symp-
toms of hydrencephaloid as a consequence of profuse diarrhoeas;
here  it is often very vigorous,  well-nourished children which are
seized with eclampsia at the commencement of fresh attacks of
diarrhoea.—It is established by numerous examples that occa-
sionally even irritants which affect other sensory nerves, e. g.,
those of the external integument, may likewise provoke eclamp-
tic seizures.
   Experience, however, further teaches that eclampsia may be
caused in other ways than through centripetal  irritations.  Thus
it is  sometimes observed after violent mental impressions like
          VOL. XIV.—20 
306               NOTHNAGEL.—ECLAMPSIA.

terror or excitement.  Cases even occur in which not the slight-
est exciting cause can be made out.
   b. In Adults.—As already mentioned, eclampsia is much more
rarely observed in advanced age than in childhood.  But here,
too, external sources of irritation, sometimes of  very insignifi-
cant intensity, play a prominent part among the inducing causes.
Here,  too,  these may proceed from the most different sensory
nerves, from the external skin (wounds* or burns), from  the mu-
cous membranes, especially that of the intestine (even in adults
eclamptic seizures have been  noticed as a consequence of tape-
worms), from the genital organs, the ureters  and gall-ducts on
the passage of calculi, etc.  AVe consider it unnecessary to repro-
duce the particular observations bearing on this.
   To eclampsia parturientium only must we  recur once more in
this place.  We have already remarked above that certainly most
of the accidents to which this  name is applied should be  held to
be entirely distinct from eclampsia, but that a few cases  of con-
vulsions in pregnant and parturient  women  must really be re-
garded as eclampsia.  This is  the fact with those cases where no
albumen whatever is present,  or merely a trace, after the parox-
ysms only, and probably then the result of the latter.  The mode
of origin of many of these eclamptic paroxysms, which occur in
the period of gestation without kidney affections, is certainly
very obscure, and we can only learn from further experiment in
what way they act;  but AVernich2 has furnished an attempt to
explain some of these cases, which seems to us deserving  of
attention.  AArernich, namely, observed in some such patients
pronounced symptoms referable to a considerable pressure upon
the sciatic nerve from the enlarged uterus.   His opinion now is
that this  lesion of the sciatic might act in a similar way as the
injury of  the same nerve in guinea-pigs, i.  e., that thereby a
condition of increased irritability might  be  established in  the
pons  and  medulla oblongata.  Then,  if a further irritation in
the region of some  other peripheral nerve be added to it, par-
  1 Marowslty, e g., communicates a very exceptional case of this kind.  Deutsch.
Arch. f. klin. Medicin.  Vol. III.
  2 Berl. klin. Wochenschr. 1872. No. 42. 
SYMPTOMATOLOGY.
307
ticularly of  the sensory nerves of the sexual organs {intra par-
trim, etc.), the eclamptic seizures would break out, according to
the analogy  of the  irritation of the epileptogenous zone  in the
guinea-pigs.—These  cases would  really then  have to be con-
sidered as eclampsia parturientium (in our sense).
   Even in adults the disease may, as in children, be called into
existence on some rare occasions by mental influences.
   From all that has previously been said, it is self-evident that
we cannot speak of a special pathological anatomy of eclampsia.
If patients die in the seizures, then the conditions found post
mortem  are  either incidental  and subsidiary, or they are con-
nected with some inducing cause, or finally,  they are direct re-
sults  of  the convulsions  themselves.  Definite changes  of the
central nervous system, which would be characteristic of eclamp-
sia, are unknown.

                       Symptomatology.
   In the description  of the symptoms we may briefly sum up
what we have to  say as follows :
   "With children the  disease either sets in suddenly, i.  e., the
seizures  constituting it overtake them in the midst of perfect
health, or more or less marked premonitions precede its outbreak.
These warnings may be of two kinds :  they are either connected
with the inducing causes,  and consequently have not the least
that is characteristic about them (diarrhoea, redness and painful-
ness of the gums, symptoms of worms),  or they proceed from the
nervous  system  itself.  In regard  to the latter there may be a
great diversity ; the following are most  frequently observed :  the
children do not sleep quietly,  often start up violently, but as if
frightened; if  they already have teeth, gritting of  the teeth is
not infrequently observed.  In the waking state  the little  pa-
tients  are often cross,  wilful, and sullen.   Besides the gritting
of the teeth, other spasmodic  contractions in single muscles or
groups of muscles may also appear, most  commonly in  single
muscles of the eye (strabismus and rolling  of the  globe),  in the
facial muscles (risus sardonicus), bending in of the fingers, exten-
sion or incurving of the feet.
   Now, whether phenomena of this kind  have gone before or 
308               NOTHNAGEL.—ECLAMPSIA.

not, the proper characteristic convulsions break out very sud-
denly.  AVe need not here  give  any extended description of
them, for these eclamptic paroxysms behave throughout exactly
like the major epileptic attacks ; so it is sufficient simply to refer
to these latter.—If an inducing cause is discoverable, and can be
easily removed, the seizures also then generally disappear.  If
the removal of the etiological influences is impossible,  the con-
vulsions are repeated ; sometimes this happens even after do-
ing away with the source of  irritation.   Thus the paroxysms
may follow one  after another on  three, four, or five days; be-
tween them the  children either seem to  be quite well, or they
remain in a somnolent state,  quite in analogy with  the status
epilepticus {etat de mat).   In this case  the issue is generally
fatal, the coma being, indeed, continuous.  But even when the
paroxysms are less frequent and the intervals greater, eclampsia
is always a more dangerous affection in small  children than in
adults.  It is true, the percentage of recoveries decidedly exceeds
the fatal cases ; but  the popular dread  of  the convulsions of
small children has a real  foundation so far as that they succumb
during the attack itself to spasm of  the glottis or venous hyper-
aemia of the brain much sooner than adults.
   It must also  be added that the partial muscular twitchings
and  the like, previously described as "precursors,"  are  fre-
quently observed under analogous etiological conditions, without
true eclamptic paroxysms being associated with them.
   In adults the attacks generally appear suddenly, if the induc-
ing cause is actually in  operation ; thus  intra partum, after a
wound, etc.  Definite premonitions,  which would be referable to
the eclampsia itself, generally do not exist.  Here, too, the par-
oxysms have a character as pronounced as in genuine epilepsy,
so that a description is unnecessary.


                         Pathology.

   We have previously expressed the opinion that we ought not
to employ the designation  eclampsia, as is now customary in
practice, for all  forms of spasm which occur  occasionally and
transiently  under the form  of epileptic  seizures.   AVe should 
PATHOLOGY.
309
rather understand by this term only such cases as are similar to
the true epileptic attacks, not merely in their external clinical
features, but  in the mechanism of their development.  It is
hardly necessary for us  to bring forward special proof that this
resemblance does exist in the fullest degree in regard to the par-
oxysms which  we have above indicated  as "eclamptic."  The
identity  of pathogenesis of our eclamptic attacks  and  of the
proper epileptic ones is recognized in almost every quarter.   Here,
too, as in the  major epileptic seizure, we have to deal with an
excitation of the reflex centres situated in the pons and medulla
oblongata (especially the vaso-motor and convulsion centres). For
the same reasons  as  in the case of epilepsy, the study of the
single cases necessarily leads to this conclusion.
   But, as opposed to epilepsy, no persistent change in the parts
of the brain mentioned  exists in eclampsia,   Consequently, the
latter is also not chronic, but the disease ends  with a few parox-
ysms following quickly after  each other, or even with a single
one.   As another consequence, this disease scarcely  ever breaks
out spontaneously,  but is almost always excited by a centripetal
irritation.
   Furthermore, in eclampsia  a  certain "predisposition" must
also be assumed to exist ;  but,  in our  opinion, this is to be re-
garded otherwise than in the case of epilepsy, as in eclampsia we
have to deal with conditions which are not limited to the pons and
medulla oblongata alone, but either affect the whole nervous sys-
tem, or in them perhaps the central portions mentioned may even
be wholly intact (as in eclampsia infantum), or,  finally, such,  if
limited possibly to the pons and medulla oblongata, as rapidly
disappear again on the  removal of the inducing cause (as per-
haps in the form of eclampsia parturientium mentioned above).
   Of the connection and the reciprocal relation which sometimes
exist between eclamptic seizures and epilepsy, we have already
treated apropos of the latter.  The partial muscular  twitchings,
especially in children, often precede the proper eclamptic seiz-
ures, or even sometimes appear without  the latter, notwithstand-
ing the presence of causes that usually produce them.  These
twitchings should be judged of in the same way  as the aura epilep-
tica and the interparoxysmal twitchings which occur in epileptics. 
310                NOTHNAGEL.—ECLAMPSIA.

                           Prognosis.

   The prognosis, so far as a restoration to health is concerned, is
favorable in eclampsia, since the  inducing causes of  it are gene-
rally accessible to treatment,  and the general "predisposition"
present may likewise either be  to  a certain  extent combated
(anaemia, nervousness), or corrects itself (the period of childhood).
But, since the possibility of  an  epilepsy in process  of develop-
ment  must always be borne  in mind, the favorableness of the
prognosis is liable to a certain limitation. Meantime the danger
that permanent  sequelae, such  as paralyses,  contractures,  or
idiocy, may remain after  the seizures, is to be feared in very ex-
ceptional cases only,  because it  is extremely rare for the parox-
ysms  as such to occasion material intracranial lesions, and, on the
other hand, the cases where such were already present, and had
general convulsions  associated with  them as  a symptom, cer-
tainly do not belong to eclampsia.
   The seizure itself in an adult is subject to the same prognosis
as in the case of epilepsy.1   AAre have  already expressed our-
selves above about eclampsia  in childhood.

                          Treatment.

   The therapeutic measures  must, if possible, be directed alike
against the  underlying  tendency and  against the  inducing
causes.  In regard to the former, it frequently happens that  no
direct treatment is  possible,  especially  in  small children, and
also in adults, if we have nothing definite to take  hold of.  If
anaemic  conditions are present,  we must proceed against them
according to well-known  modes of cure.  In the same way where
there is great  " nervousness or nervous irritability," the curative
procedures which generally are of avail must be brought into
use.  (Compare the appropriate  section of the present work.)
   Every source  of irritation, of which it may be assumed that
  1 The paroxysms of parturient women cannot be judged of with reference to their
danger, as the observations at present available consider all forms of spasm in these
patients indiscriminately. 
TREATMENT.
311
it has excited  the spasmodic seizure, must be removed by suit-
able remedies.  Very frequently, on taking it aw7ay, the attacks
vanish at once.  These are the cases formerly so much spoken of
as cures of epilepsy  by  anthelmintics,  by calomel,  etc.   Of
course, we need not here  go into  the  details of the particular
cases.  The treatment will need to be very various, according to
whether constipation or diarrhoea exists, whether helminthiasis
is  present, or the disturbance of a peripheral nerve,  an acute
indigestion, overloading of the stomach,  or difficult dentition.
It is denied in many quarters  that in the last-mentioned case
scarification of the gum is of the benefit claimed for.it.  I confess
that I still employ this in teething children  with eclamptic
seizures, if I find the gum swollen and reddened in certain places
where the eruption of a tooth is to be expected.
   How are we to act in the presence  of the seizure itself ?  In
adults, on the same principles as in the real epileptic paroxysm;
for the sake of  brevity, w7e refer to the rules laid down when
.speaking of it.  But  in children also  w7e  should guard against
officiousness ;  it will be  necessary to interfere only when affairs
take a  threatening  turn.    Of course,  we are not  to expect
that a spasm of  the glottis  already existing in the  seizure
itself can  be averted by enemata with musk or assafoetida, or
b}7 mustard-plasters.   Still, if  a persistent  coma, with symp-
toms of hyperemia of the brain,  has  followed upon repeated
attacks, after the analogy of the status  epilepticus, we may try
active measures of this kind, together with cold affusions to the
head, and also, according  to circumstances, irritating enemata
or even local abstractions of blood.   Oxide of zinc and the other
"nervines" seem  to  exercise no noteworthy  effect upon these
eclamptic  outbreaks wiiicli are rapidly repeated, or recur one
after another  on  several days.   Further observation alone can
teach us what will be  the  action in this respect of bromide of
potassium  (in the form of enema) which  has been  so  much
praised of late. 
 
t
TETANUS.
BAUER. 
 
TETANUS.
   The very copious bibliography of the subject will be found carefully collected
in several monographs;  especially the following:
IF. Trnka de Krzowitz, Comment, de tetan.  Vindob., 1777.—A. S. Friedrich, Diss.
   inaug. de tetan.  traumat.  Berlin, 1837.—Blizard  Curling, A treat, on tetan.
   London, 1836.—Funic, Die Riickenmarksentzundung. Bamberg, 1849.—•/. Gim-
   elle, Mem.  et observat.  du tetanos.  Journ.  de  Bruxelles. 24. Vol. 1857.—
    Thamhayn, in Schmidt's Jahrb.  Bd. 112.
Manuals and Cyclopaedias:  Rochoux, Encyclopadie der med. Wissensch. nach d.
   Diet, de med. frei bearb. von Schmidt und Meissner.  Leipzig, 1833.—J. Copland,
   Diet, of med.—C. Canstatt, Handb. der med. Klinik. III. 1.—M. H. Romberg,
   Lehrb. der Nervenkrankh.  I. 2.— K. E. Hasse, Krankh. des Nervensystems.—
   M.  Rosenthal,  Handb. der Nervenkrankh.  Erlangen,  1870.—Bednar,  Die
   Krankh. d. Neugeb. u.  Saugl.  Bd. II.  Wien, 1851.—Handbuch der  Chirurg.
   von Pitha u. Billroth.—Tetanus, von E.  Rose, I. Bd. 2. Abth.  1. Heft. 1. Liefg.
Bazille, Observ. sur le tetanos.  Paris, 1788.—A. Colles,  On the cause of the disease
   termed trism. nasc.  Hosp. Rep. Vol. I.  Dubl. 1818.—Fhfkh, Ueber den spora-
   dischen Starrkrampf  d. Neugeborenen.   Stuttg. 1825.—R. Froriep, Ueber die
   Ursachen des Wundstarrkrampfes.  In Neue Not. aus dem  Gebiete der Natur-
   und Heilkunde.  No.  1.  1837.—Larrey,  Mem. de  chirurg. milit. et  campagnes.
   Paris, 1812-1817.—J.  Morgan, A lect. on tet.  London, 1833.—Lepelletier, Rev.
   Med. 1S27.  torn. IV.—J.  Schneider, Vers,  einer Abhandlung  iiber den Kinn-
   backenkrampf  neugeb. Kinder.  Fulda, 1805.—J. Swan, An essay  on tetanus.
   Lond. 1825.—Schoeller, Neue Zeitschr. fiir Geburtsk. Bd. Y.—Kniesling, Deut-
   sche Klinik.  1849.  No. 7.—v.  Tscharner, Ueber den Tetanus. Bern, 1841.—v.
   Dusch, Zeitschr.  f. rat. Medic.  1852.—Rokitanshy, Ueber die  Bindegewebs-
   wucherung u. s. w. Sitzungsberichte  d. Wiener Akad.  1857.—H.  Demme, Zur
   path. Anatomie des Tet.  1859 ; and allg. Chirurgie der Kriegswunden. 1861;
   and Schweizer Zeitschr.  II.  1864.— Heiberg, Norsk Mag.  1861.— Wunderlich,
   Archiv der Heilk. 1861,  1862, 1864, 1869.—E. Giintz, Beobacht. iiber Temp. u.
   s. w. Diss. Leipzig, 1862.— Leyden, Virch.  Archiv.  Bd.  26. 1863.—L. Concato,
   Sul tetano.  Bologna, 1865.—Billroth u.  Fick,  Vierteljahrschr. der Ziiricher 
316
BAUER.—TETANUS.
    naturforsch. Ges. VIII.  1863'.—Hutchinson, Med. Tim. and Gaz. 1861, Apr.—
    Richardson, Brit. Med. Journ.  1859.— Brown-Sequard, Journ. d. Progr. des sc.
    med.  9. Sept. 1859 ; and Bull, de Ther.  1861.— Koenig, Das Gesicht des Tet.
    Arch, der  Heilk. 1871.— Kussmaul, Berl. klin. Wochenschr. 1871.—Clifford
    Albutt, Trans,  of the  path.  soc. XXII. — Michaud, Arch, de phys. norm, et
    path.  Nr. 1.  1872.— Verneuil, Gaz. des Hopit. 1872.—A. Vogel, Deutsch. Arch.
    f. klin. Med.  Bd. X.—Lockhart-Clarke, Med. chirurg. Transact. Vol.48. 1865.
    —Dickinson,  Ibid. Vol. 51.  18QS.—Heinecke, Deutsche Zeitschr. f.  Chirurg.
    Bd. I. S. 267.

                           Introduction.

    A high degree of  perfection was reached even  in very early
times in the mere description of tetanus ; the explanation of the
symptoms, however, followed  all  those changes  through which
scientific pathology has passed during the centuries.
    Among the writers  of antiquity, Aretseus has given the best
and most concise description ; he has also stated the causes of
the disease,  for  the most part, in  accordance with the views of
the present day.
   The causes of tetanus, according to him,  are very numerous; it occurs especially
after injuries, also after exposure to cold: hence most of the cases are encountered
during the winter season.   But the disease may also follow abortion, or a blow
upon the neck.  Women are more disposed to it than men; and of the different
ages, childhood is especially liable to the  affection, though in a less dangerous
form.1

    During the years which followed there were many who wrote
concerning tetanus, and among these contributions may, in truth,
be found numerous correct observations and sound views, though
errors  are also  not wanting.  But an essentially clearer insight
into the nature of tetanus was not, indeed, obtained until surgery
had risen to considerable importance, such as it attained during
the time, and especially by the instrumentality, of Ambrose Pare;
for, with surgery arose also an interest in  this  affection, which
most frequently presents itself in  the form of an accidental sur-
gical disease.
    AVith the  introduction  of firearms there was  gradually de-
De causis et signis acut. lib. 
INTRODUCTION.
ol /
veloped  a surgery  of  war—military surgery—and in  the great
number  of  battles rich opportunities were afforded the military
suigeons to observe traumatic  tetanus ;  in fact, most  of  the
literature of the subject has  been contributed by military sur-
geons. Further, the colonies of European nations in hot climates,
where the disease is very common, furnished material for and
developed an interest in,  the study of tetanus.1
   The knowledge of tetanus  was at first not directly favored by
the great advancements made in pathological  anatomy, but  the
development of  physiology and experimental  pathology has
essentially advanced the  knowledge of the pathology of tetanus.
   By tetanus  is denoted  a form of disease in which numerous
groups of muscles remain in a condition of continuous tonic
spasm;  the tonic contraction generally begins in the muscles
which move the lower jaw, the  oesophagus, and the neck, and
spreads  thence  to the  body,  especially to  the extensors  of the
vertebral column.  The tonic  spasm  continues uninterruptedly,
but generally paroxysmal  exacerbations are observed, whereby
also clonic convulsions may be produced, following which again
partial relaxation may  take  place.   These  exacerbations fre-
quently follow peripheral irritation ; in  a  word, the reflex-irri-
tability is increased.   Accordingly, the term tetanus refers to a
form of  spasm, and the  conception  of the disease is  a purely
functional one, without determinate anatomical basis.
   Tetanus, in general, is that condition of the muscles in which the separate motor
impulses follow each other in such rapid succession that relaxation of the muscle
is not possible, and it remains uninterruptedly in a state of contraction.  Even in
those cases in which  the spasm seems to be continuous, it is  evidently the result of
separate centrifugal impulses, which, "however, act upon the muscle as a unit, and
keep it in a state of contraction.  Tetanic contractions are  therefore tonic spasms ;
they correspond to no anatomical unit, but are found in  various irritative con-
ditions.

   Clinically the tonic  muscular  spasms are not pathognomonic
of tetanus; they of  themselves have no specific peculiarity, but
their arrangement and  succession give the disease its character.
Therefore it is clearly desirable to draw the line of distinction as
' Regarding the numerous essays on tetanus, consult J. Gimelle, 1. c.  pp. 12 and 13. 
318
BAUER.—TETANUS.
sharply as possible between tetanus, as it is characterized by its
entire group of symptoms, and other similar processes.
   In tetanus the tonic muscular  spasms  do not affect all the
muscles in the same degree ; they always implicate certain groups
of muscles more distinctly than others.   In  this way by the
overpowering  traction  of  certain muscles  the  body undergoes
changes  of external form.   Formerly great value was attached
to these changes of posture, and ever since Hippocrates these
variations  have been the  foundation of the division of tetanus
into different varieties.  Much the most frequent is that in which,
besides the locked  jaw,  the contraction  of the long extensor
muscles of the back and the muscles of the  neck draws the head
backwards, and bends  the vertebral column into the shape of a
bow with the convexity forwards ; this was  called opisthotonos.
Then they also distinguished an orthotonos, when the body was
stretched out straight,  and an  emprosthotonos, when the verte-
bral arch  was  directed backwards.  When the closure of the
mouth was alone prominent,  the case was called trismus.   To
this original division Boenecken afterwards  added another form,
pleurothoionos  (or  tetanus  lateralis,  according to  Sauvage),
when, by the contraction of the muscles on one side, a lateral
curvature of the body occurred.   There was a protracted discus-
sion concerning the last  named variety, and its existence was
denied by many.  Quite recently E.  Rose  has  not  only denied
the existence of pleurothotonos, but has also pronounced against
the division according to the varying posture of the body, since
he recognizes opisthotonos  as  the true and only form of tetanic
muscular contraction.   This much is certain, the frequency of
opisthotonos so far preponderates that the other varieties propor-
tionately disappear, and hence no division need be made. * Most
authors acknowledge that they have seen only opisthotonos, and
appeal, for the other forms, to isolated meagre accounts of others.
But it may very well be supposed that some delusion or mistake
lies at the foundation of these isolated observations ; this seems
to be  the  case, according to E.  Rose's criticism,  in  Larrey's
reports, who even deduced the subsequent spasmodic  position
from the situation of the wound on the anterior or posterior part
of the body. 
ETIOLOGY.
319
  There is also no ground for considering trismus as a special variety of tetanus,
since such a division at best can correspond only to a quantitative difference.  But
the distinction is also not valid, because generally the muscles of the neck are also
implicated, though perhaps only  to a slight degree.  Hence, trismus is a partial
manifestation of tetanus, a synonym for locked-jaw.

   Another classification is founded upon the course of the dis-
ease as regards its duration, an acute and a chronic variety being
distinguished—the latter also  called tetanus  mitis.  But this
classification is also defective, as is proved by a consideration of
the  differences in the course  of  the disease  at different times.
Tetanus in very many cases ends fatally within a  few days ; but
if convalescence sets in, it is gradual, the symptoms  disappearing
very slowly during the  course of weeks.   It  is exceptional for
death to occur at a  late period.    Such  are the differences in
the  course  of  the symptoms.  It is claimed that the acute and
chronic forms likewise differ in their symptoms ; but seeing that
many cases of  the so-called  chronic  or mild variety prove fatal
within three or four days, this designation is at all events not
very happily chosen.  The  best  plan would  be  simply to  lay
stress upon the intensity and extent of the manifestations, and to
drop every attempt at further divisions of the subject.


                           Etiology.

   The  knowledge  of the etiology  of  a disease is but  little
promoted by selecting Latin terms to express the current views
in regard to the causes which give rise to it, and  attempting by
this means to establish a classification.  This is true of the early
and pernicious etiological  grouping of tetanus, which chiefly
recognized four varieties :  a traumatic,  a rheumatic,  an idio-
pathic, and a toxic tetanus.  These designations, which are still
in use, are to  be rejected,  if for  no other reason, because they
are in part given to diseases  which  are  not at all related to
tetanus—e. g.,  to intermittent and hysterical toxic spasm.
   The number of persons attacked with tetanus is small under
any  circumstances.   In  the greater number of patients the out-
break of tetanus is preceded by an injury ; more rarely, in cases
unaccompanied by any  external injury, patients give a more or 
320
BAUER.—TETANUS.
less distinct history of  having taken cold ; and in quite isolated
instances  there is a  so-called  spontaneous development of the
disease, although in the latter  class of cases different observers
have assigned the most diverse causes to the individual attacks
which have come under their notice.
    Tetanus also appears in new-born children, and, indeed, within
a short time  after birth, as a rule within  the first nine days of
extra-uterine life.  As  this period of time is rarely overstepped,
the disease must be considered as  connected with the falling off
of  the umbilical  cord.  It is  at  present  generally agreed that
tetanus neonatorum is to be considered as of traumatic origin.
    The  numerical relation of  tetanus to  other diseases is not
the same in all places, since in  some districts, especially in  trop-
ical countries, this disease occurs much more frequently than in
temperate and more frigid zones.  At the same time it is true
that  there is  a difference between  different  races of men living
together in these tropical climates ; the colored races being  more
subject to the affection than the Europeans living amongst them.
The latter, however,  are attacked  more frequently than at home.
Finally, in one and the same  place there  are variations in the
frequency of tetanus at different times.
   The frequency of  tetanus in a temperate climate can be approximately seen
from the following comparison:
   In a period of thirty-two years 113,020 patients were received at Guy's Hospital,
of which 72 had tetanus ;  therefore, one case of tetanus among 1,570 patients. In
comparison with the whole number of deaths, the deaths from tetanus during the
period from  1848 to 1853 in Guy's Hospital amounted on an average to 0.056 per
cent., in London to 0.0025 per cent., in  the  whole of England  to 0.0031 per cent.1
In the Vienna general Hospital in the years 1855-64 among 239,911 patients there
were 50 cases of tetanus; therefore one case to every 4,798 patients.2
   E. Rose reports concerning Berlin, that  in the Bethanien Hospital in the years
1847-64, 0.08 per cent, of all the patients died of tetanus,  and in  comparison
with the total number of fatal cases the mortality from  tetanus was 0.69 per cent.
In the whole city, in the  year 1867, of 683,673 inhabitants 275 died of tetanus,
that is, 0.04 per cent, of the population, but of these 266 were new-born infants.3
   1 See the  comparison by Thamhayn in Schmidt's Jahrb. 1861. Bd. 112, and A.
Poland. Guy's Hosp. Rep. Vol. III. p. 3.
   2 M. Rosenthal. Handb. der Nervenkrankh. p. 337.
   3 E. Rose, in Handb. der Chirurg. v. Pithau. Billroth. I. Bd. 2 Abth. 1 Heft. 3. Liefg. 
ETIOLOGY.
321
   Besides demonstrating the rarity of the disease, these statistics with regard  to
certain districts in Europe also show differences in the frequency with which teta-
nus occurs in these various places.   These differences become yet more marked if
tetanus in newly born infants  is considered.  Curling states that in England the
disease is very rare among the newly born; in Dublin, however, J.  Clarke reports
concerning his establishment that until the year 1782, 2,944 children among 17,650
died of this disease.   Clarke  sought the cause of this excessive mortality in the
impurity  of the air, and  hence provided  for  purifying it.  Afterwards, among
8,033 children only 419 died of this disease.1  According to the report of Holland,
the disease is usually rare in Iceland, while upon the neighboring island of Heimaey
the population  would die out if it were not recruited by immigration, since almost
all the children die of tetanus.  The disease prevails in the same way in St. Kilda,
one of the islands off the  west coast of Scotland.2  In Stockholm, in the year 1834,
Cederschjold saw a very great mortality among the children in the lying-in asylum,
as in six months about 40 died of tetanus.3  In some parts of Germany, too, the
disease is at times observed with greater frequency, as in Fulda, also in Hungary;
while it is reported from  Paris,  Vienna,  and St. Petersburgh that the newly born
are rarely attacked with tetanus.
   M;my authors make statements in regard to  the frequent occurrence of  tetanus
in tropical regions.  Even Bontius gave this information in regard to India.   The
most  unfavorable  reports, especially  during the  eighteenth century, were made
with regard to tropical  America (Guyana  and  Cayenne) and the  West India
Islands.  According to the accounts given, tetanus in these regions must be looked
upon as a veritable public scourge, and it greatly injured the prosperity of the col-
onies, owing especially to  the excessive mortality among negro children.  Accord-
ing to Rainal, in Louisiana half of  all the newly born negroes died, and also a
large number  of the  white  children;   he found  the Antilles equally as  dan-
gerous at this  period of life.4   Hancock makes the same  statement in regard  to
the colonies  at Essequebo and Demerara.5  According to Fourcroy, at St. Domingo
80 out of every 100 negro  children died before they were nine days  old.6  Barrere,
Bajon, Poupee Desportes, Mosely, and others, have written to the same effect.
   According to  all these statements, the negroes suffer by far the most severely
from the  mal de machoire, the whites and  Indians in  a much less degree.   Thus
Campet writes  that the disease  appeared frequently among the negroes, but not
among the whites.7  Anderson remembered no case among the sailors at Trinidad
      1 Transact, of the Royal Irish Acad. Vol. III.
      2 See Curling. 1. c.
      3 See Friedrich, 1. c.
      4 Histoire philosophique.
      B Edinb. Med. and Surg. Journ.  Vol. XXXV.
      6 Curling, 1. c.
      7 Trait, pract. des mal. des Pays chaud.
VOL.  XIV.—'21 
322
BA UER. —TETANUS.
during many years.1  Dazille, who practised a very long time in the colonies, and
had abundant experience with this disease, reports that among the white children
tetanus was more rare; also that among an equal number of wounded a larger pro-
portion of negroes than of whites were attacked with tetanus.2 In tropical America
the disease still prevails at the present time among the newly born, so that, accord-
ing to Maxwell and Grier,  a large number always die from this cause.3
   A numerical statement  of the frequency of tetanus in the East Indies in recent
times proves that there, too, it occurs much more frequently than with us.  Peat, at
Bombay, met with  195 cases of tetanus among 26,719 sick between the years 1845-
51, or an average of 0.73 per cent;  Morehead, during six years, found 0.8 per cent.
In the years 1848-53, in Bombay, the proportion of  fatal cases of  tetanus was 3.9
per cent, of the whole number of deaths.  According to  Peat, among 11,929 natives
161 suffered from tetanus; among  2,733 Europeans, 21, a proportion of 1.3 per
cent,  and  0.77 per cent.   Thus, a larger number of natives were attacked than
of the Europeans.4

   The reasons which may possibly lie at the foundation of these
periodical  and local  variations  in the  frequency of  tetanus will
be more correctly appreciated when the conditions which contri-
bute to the causation of the disease shall have  been  more accu-
rately considered.  It has already been mentioned that, in by far
the greater proportion of the cases, tetanus occurs after a previ-
ous  injury, so that a causative connection between the two must
certainly exist.  But since  among the daily occurring injuries
only a small fraction gives rise thereto, it is clear that the occur-
rence  of traumatic tetanus must also depend  upon other more
special .conditions.   The question arises  whether a part of these
conditions is to be found in the peculiar conditions of the wound.
   a.  First of all, so far as relates to the nature of  the wound,
statistics show that the majority of  cases of traumatic tetanus
occur  after lacerated and crushed  wounds, with  intrusion  and
presence of foreign bodies ; therefore after  gunshot wounds and
burns.  Yet the form of the injury is  not absolutely important,
and every  variety of wound, howsoever it may be produced,
may give rise to tetanus ;  its occurrence is,  however, rare after
clean cuts  and stabs.   Moreover,  cases  of  tetanus  occur which
are clearly traumatic without any external injury, so that an in-
1 Edinb. Med. chirurg. Trans. Vol. II.           z E. Rose, 1. c.
2 Observat. sur le tet.                        4 Thamhayn, 1. c. 
ETIOLOGY.
323
ternal lesion or concussion of certain centres of innervation must
be presumed.1
   b. The extent and severity of  the wound stands in no direct
relation to the frequency of tetanus ;  for if extensive destruction
by crushing, tearing, burning,  compound  and  simple fractures,
amputations, etc., may be followed by tetanus, yet it is much
more frequently found  after quite insignificant  injuries, which
are entirety disregarded by the patient, or quite escape notice.
   c. The seat of the wound, the  region of the body which has
suffered, is a matter that exercises a decided influence in these
cases ;  for wounds of the extremities are the ones most frequently
followed by traumatic tetanus.  Hence, by many, as by Hunter,
Stafford, and others, special importance is ascribed to injuries of
the tendons.
   d.  The condition of the wound, its tendency to heal, gives no
sure criterion by which to judge  of  the liability to the disease.
Some surgeons specially  emphasize the fact that tetanus is fre-
quently  associated  with wounds which  subsequently lead to
extensive necrosis in their neighborhood (Rose).   It  is further-
more  stated that wounds with considerable swelling,  with dif-
fused  redness  and  increased  temperature,  are  often  observed
where  tetanus sets in.   This connection may, indeed, exist, but
these  factors can be found only  in extensive wounds, while in
the great majority of  slight injuries the same result  must be
brought about by other causes.2
   e. Tetanus may also occur when the wound has  completely
healed, and a cicatrix has formed.  There  is no limit to the time
which  may elapse between  the injury and  the  outbreak of te-
tanus.   The condition of the cicatrix may also vary; it  may pre-
  1 Cases of the latter sort are well known.  Lately P. Guttmann has described such
eases (Archiv f. Psych, u. Nervenkrankh. Bd. I. p. 730), in one of which, after death,
no peripheral nor central injury could be found.—A short time since I saw a boy, in
whom unmistakable and fatal tetanus occurred after a fall upon his neck without any
peripheral wound.
  8 It must not be forgotten that the wound may first assume an unfavorable condi-
tion under the influence of tetanus, though, according to the assertion of Travers and
others, the cicatrization of the wound frequently enough progresses without interrup-
tion. 
324
BAUER. —TETANUS.
sent no special peculiarity, while, in other cases, the nerves have
been found distorted by its  contraction, or foreign bodies  have
been found included in the cicatrix.
    According to the tendencies in the character and course of the
wound certain conditions  are indeed to be found which, by  their
frequent recurrence in tetanic affections, indicate a causative rela-
tion.   But this  influence  can  only be predisposing,  their signi-
ficance only that of accessory agencies,  since they are  often
entirely wanting, and because  also the nature of their  influence
upon the body varies greatly in different cases.

   There is scarcely any injury, however severe  or slight, which has not been the
occasion of traumatic tetanus.   The outbreak of tetanus shows indeed a certain
analogy  to metastatic pyaemia, since with both every possible kind of injury may
under certain conditions give rise to  the disease (e. g., I  saw a robust  man  in his
twentieth year die of pyaemia after the  extraction of a tooth skilfully performed).
Pyaemia  does not result from being wounded, but from the disintegration and car-
rying away of thrombi, and we must suppose the origin of tetanus to be somewhat
similar.
   Examples of the different varieties of injuries which have  been followed by
tetanus are found mentioned in rich profusion by Curling, E. Rose, ond others.  It
has been seen to follow the extraction of teeth, the application of cupping-glasses,
the sting of a bee, or the catching of a fish-bone  in the throat, and it has resulted
from the application of  a blister or the use of setons,  or even from cutting the
nails too closely.  As an offset against these insignificant lesions, severe injuries and
capital operations also in numerous cases appear as the cause.  If the larger collec-
tions of cases be studied, a marked preponderance of the slighter injuries is observed
—small  lacerated wounds, injuries by splinters-of wood, nails, etc.  At the same
time it is certainly to be remembered  that these  slight injuries occur with extreme
frequency in ordinary life, and that the total number of such far exceeds the num-
ber of severe injuries.
   The locality of the injury is given by Thamhayn in 395 cases, as follows:

            Hand and finger..........Ill times, or 27.42 per  cent.
            Thigh and leg............ 97    "    25.08    "
            Foot and toes............ 87    "    22.19    "
            Head, face and neck...... 44    "    10.99    "
            Arm and forearm......... 31    "     8.09    "
            Trunk................... 25    "     6.28    "
                                                    *
   According to Curling's table, in 128 cases the injury occurred 110 times on the
extremities.  But since the limbs are  the most  exposed to wounds, Curling has
examined a table of 510  injuries with reference to this point, and found 317 of 
ETIOLOGY.
325
them occupying the limbs.  Hence the proportion of injuries of the limbs in tetanus
is greater than in wounds in general; i, e. .wounds of the extremities are more liable
than others to give rise to tetanus.

    Different views prevail as to  the other conditions which, with
the co-operation of  the wound,  cause the outbreak of tetanus.
The assertion made by many, that  every case of tetanus is trau-
matic, but the injury is often overlooked,  needs no special refu-
tation.  A consideration of the relative frequency of wounds and
of tetanus shows satisfactorily that some special cause must exist
in  the individual that  is wounded in order to insure  the devel-
opment of the subsequent disease.  It always has been and is
still held by many that the cause  is to be found in the fact of
the person's "taking  cold;"  according  to which theory  the
influence  of  external temperature on a wounded person, espe-
cially its  rapid variation, acts as the immediate occasion  of  the
outbreak of tetanus.  By some observers  the importance  of  the
climatic  and atmospheric  influences  is alone acknowledged, by
others yet greater  importance  is  ascribed  to the unfavorable
influences which may act upon the wound in the most various
ways,  to its improper treatment and irritation (E.  Rose).
    Military  surgeons,  under  whose  observations, indeed,  most
of  the cases of  tetanus come, have everywhere noticed that  the
frequency of tetanus among the wounded  was evidently depend-
ent upon the influence of the temperature.   Thus, Larrey, sur-
geon-in-chief of the French army during the Egyptian campaign,
saw the disease chiefly  when the wounded were directly exposed
to wind and storm and rapid changes of temperature.1  Cullen
considers  the influence of cold  moist air  as an essential condi-
tion.  Hennen states  that, after the battle of El-Arich and after
the capture of Jaffa, many wounded were  attacked with tetanus
when  they lay in tents on the damp ground.2 Huck mentions
that after the battle of Ticonderoga  nine  of the wounded had
tetanus after exposure to the  cold  during  the  night in open
boats.3 Schmucker noticed the occurrence of tetanus in Bohemia
after the  slightest wounds when cold nights followed hot days.4
1 Mom. de chirurg. militaire et campagnes.    3 Med. observat. and inq. Vol. III.
2 Principles of milit. surg.               * Chirurg. Wahrnehmungen.  Bd. II. 
326                   BAUEE.—TETANUS.

The same opinion was held by Dazille, Chalmers, Bajon, Hillary,
Dupuytren and others.1
   What cold causes in many cases follows in others from other
kinds of unfavorable influences, e. g., from improper treatment
of the wound.  Lately E. Rose in particular has advanced this
proposition, and supported it  by arguments drawn partly from
his own experience.   It was the custom in St, Domingo to treat
the negroes who had been flogged with sharply irritating embro-
cations to protect them from tetanus, from which many suffered.
Dazille abolished this treatment, and with the best of results,
   What Dazille accomplished among the negroes may  be as-
serted in general terms  to be true of the present age, viz., that
there is  a decrease in  the  frequency  of  tetanus among the
wounded as compared with former times, and this fact is decid-
edly in favor of the view advanced by E. Rose ; for, in the  course
of time, nothing has so much changed as the treatment of wonnds
in its widest sense.  Dickson was one of  the first to refer  to the
diminution in the frequency of this disease, and explained it by
the improved methods of treatment.2  There are, indeed, no com-
prehensive statistics in regard  to  the earlier marine and land
wars which would allow of a direct comparison, but isolated data
still  permit an approximative  judgment.  G. Blanc states  that
of 810 wounded 30 were attacked with tetanus.3 J. Lind saw 5 die
of tetanus out of 6 cases of amputation,4 and others have made
similar reports.  Modern history has only one such example to
offer, namely, the battle  at Lyon  in the year 1834, where  of 277
wounded 12 died of tetanus.  On the other hand, the great wars
of the present day, especially the American civil war  and the
last contest between Germany and France, show no such propor-
tion  of cases of  tetanus  among the great numbers of sick and
wounded.  (According to a report in regard  to Werder' s corps,
  1 An interesting story concerning trismus neonatorum is told of a midwife whose
sense  of heat was diminished after a sickness, so that she prepared too hot baths
for her little charges, and lost such an unusual number of children from trismus
that the attention of the officials was attracted thereby (oral communication of von
Ziemssen).
  2 Med. chir. trans. Vol. VH.
  3 Diseases of seamen.             4 An essay on the most effect, means, etc. 
ETIOLOGY.
327
among 24,262  sick, with 7,182 wounded, there were 45 cases  of
tetanus).
   It is consequently probable that very different influences may
contribute to the occurrence of tetanus among the wounded ; but
necessarily the  operation of  so  heterogeneous influences must
agree in one point.  Most of the facts tend  to prove that the
common result of these influences is a peculiar irritative condi-
tion of the peripheral nerves.

   The facts which prove the origin of tetanus through centripetal conduction of
disturbances in the peripheral nerves will be given later.  In an etiological  point
of view the peripheral  nervous irritation is the  only point wherein the different
causes agree.  Certain examples point still more decidedly in this direction.   Thus
foreign bodies, especially when imbedded in  nerve trunks (Hennen, Dupuytren,
Beclard), are a special  source of danger; so are also the tearing and twisting of
nerves, as sometimes happens from  the application of ligatures (Brodie, Dazille,
and others), and  hence certain operations that  arc attended with special liabil-
ity to the accident (castration, for example).   The same may likewise be said of
ascending neuritis.  From the analogy existing between these and other facts,  we
know that in all such conditions the disturbances are less likely to be due to posi-
tive interruption of conduction and destruction of nerve-fibres  than to woundim*
of the nerves with retention of their conductive power.

   The etiological conditions already mentioned  hold true  also
in the tetanus, or, as it is usually called, the trismus of the new-
born.  The condition of the  wound at the umbilicus, like that  of
wounds in  general, shows no definite and regular changes.  In
most cases it is perfectly healthy.
   Tetanus occurs also in connection with  parturition or  after
abortion ; but this is exceedingly rare.  Here too we have condi-
tions which may be considered similar to a wound.
   Man)7  cases of  so-called  spontaneous tetanus may perhaps
be regarded, etiologically speaking,  as belonging  to  traumatic
tetanus, since  in persons thus affected diseased processes have
been found in  the interior of the body wliicli may have given rise
to a state of irritation in the peripheral nerves of internal  organs.
The variations in  this respect  shown  by  different  cases are
almost as numerous as  the cases  themselves, and it is of course
generally impossible to establish the real causative  connection
between these  conditions and tetanus. 
328                     BAUER.—TETANUS.

   Intestinal worms are more frequently accused of being the cause of tetanus than
anything else, and the proof is also derived ex juvantibus.  But tetanus has likewise
been observed in many other diseases.  Bright  saw it in acute rheumatism, with
pleurisy and pericarditis; Rosenthal, in ulceration of the rectum.   I  have myself
seen a young man die of tetanus which appeared during an attack of pleurisy with
exudation.  If such  conditions as the irritation of worms are sufficient to produce
tetanus, it follows, as a matter of course, that the cause of the affection may often
escape observation even on a post-mortem examination.

   Concerning the relation between tetanus and  the fact of hav-
ing taken cold no more can be said than with regard to the origin
of other diseases that result from catching cold.  The statements
of patients on this  point are often very decided :  a rapid change
of temperature  accompanied  with a severe  chill, staying in a
moist room, sleeping on  the  damp ground,  being wet through
while in a perspiration,—these are often  the starting-points for
the disease.
    Some points still remain to be mentioned in the etiology of
tetanus in general,  which, however, contribute but little to the
understanding of the nature of its origin.   Thus statistics show
an excess of males over females ;  youth and middle age are also
numerically more severely taxed than advanced age.  So, too,
the robust and muscular are said to be more frequently attacked
than the feeble.

   Friedrich's tables give 253 cases of traumatic origin, 210 of which were males
and 42 females; Curling  found 112 males and 16 females.  According to the col-
lection made by Thamhayn, which comprised the statistics of Poland, of Lawrie,
and other reports from Glasgow, and  110  other cases, 329 occurred among males
and 68 among females.  Yet these numbers do not give the true proportion, since
in traumatic tetanus, to which most of these cases belong, the greater liability to
injury among men must be considered.1  The  statements in regard to new-born
children vary.
   If the newly born are left out of consideration, the statistics of Friedrich show
that the greater proportion of those attacked are between fifteen and twenty years
of age;  according to Thamhayn they are between ten and thirty.

    According  to the testimony of many physicians the  mental
 condition has also  an influence  upon the occurrence of tetanus.
   1 See, in regard to this, among other references, Med. Times and Gaz., 1854. VoL
XXIX. p. 376. 
ETIOLOGY.
329
Thus military surgeons have noticed the disease more frequently
among the conquered than among the victors.  Lately, Erichsen
in particular has emphasized the importance of ps37chical impres-
sions ; it is claimed  that severe fright alone may be sufficient to
excite an attack.1
   A very large number of cases of poisoning are characterized by
the occurrence of muscular  spasms ; yet the nature and  succes-
sion of these spasms vary  much with different poisons.   The
prototype of an agent which may produce spasms is strychnia.
By this poison the extensors are especially thrown into tetanic
contractions, and  there  is  opisthotonos.    Hence,  the  tetanic
spasms of strychnia are clinically very similar to  tetanus, and, in
dividing this disease according to its etiological factors, a  variety
called toxic tetanus has been introduced, and strychnine poison-
ing has often been regarded as the type of this form.
  The cause of this strychnine  spasm is to be found in  an abnormally increased
irritability of the gray substance of  the spinal cord, so that very slight irritations,
which would otherwise have  no effect, are  able to excite severe general reflex
motions. The arteries are contracted, the blood-pressure is increased by irritation
of the vaso-motor centres.  The irritability of the peripheral nerves is not thereby
increased, the irritability of the  sensitive nerves seems even to be diminished.

   Brucine is very nearly allied to strychnia in its effect; but it
is somewhat weaker in its action.  An alkaloid is also found  in
opium, which is capable of exciting very severe spasms, namely,
thebain.   Ergotismus  spasmodicus is characterized, in severe
cases, by painful contractions of the flexors or by general teta-
nus, besides other symptoms ; hence, ergotin belongs to the group
of tetanizing agents.  Picrotoxin and coffein  also possess  similar
peculiarities.  This is by no means a  complete  enumeration of
the poisons wliicli exert a tetanizing action ;  several others have
this influence.
   Tetanus  occurs also in  animals under the same conditions
under wliicli it occurs in men, especially in horses, goats, and
sheep. There are periodical and local variations in the frequency
of tetanus  in animals  also;  traumatic tetanus  is  likewise the
most frequent variety, and is especially common after castration.
1 Pissling, Virch. Jahrb. 1872.  p. 82. 
330
BAUER. —TETANUS.
             General Description of the Disease.

   Tetanus, as a rule, begins with mild symptoms which gradu-
ally increase  in  severity to the maximum.   The patients feel at
first a sense of stiffness in  the neck, together with diminished
mobility of the  lower jaw and tongue ;  deglutition is  difficult.
There is no constitutional disturbance, only a painful tension is
felt in the above-named group of muscles.  Then an increase in
the symptoms follows at a slower or more rapid rate ;  the stiff-
ness  becomes more marked and extends to the muscles of the
back and of the  abdomen ;  finally,  all the muscles  of the trunk
may be implicated.   The preponderance in the action of the long
extensors of  the spinal column is so great that the back is bent
with its convexity forwards, while the head is drawn back.  The
facial muscles of expression also become stiff, and this gives to
the features  a characteristic appearance.  Finally, the muscles
of the extremities may be affected with the spasms; only the fore-
arms and hands frequently, according to some authors always,
remain unaffected,  at least among adults.  The succession  in
which the separate groups of muscles are attacked, therefore, is
in a descending order.   The cramp  gives the contracted muscles
a board-like  hardness, and  opposes considerable resistance  to
voluntary motions and also to passive motions, because of the
impossibility of causing relaxation of the antagonists.  Some-
times the whole body can be raised up by the head, like  a lifeless
pillar.  The power  of swallowing is very much interfered with,
and the voice is generally altered.
   The consciousness, the intelligence, is not disturbed, except
in a few cases just before death ; but generally there is complete
sleeplessness.  The tonic  spasms are  continuous ;  they extend
from above downwards and increase in  intensity.   Death may
soon end the scene without the development of other symptoms.
E. Rose has  especially  described this course as typical  of acute
tetanus.  Yet this picture is not the rule  ; much more frequently
paroxysmal exacerbations of the tonic  spasms are seen, which
last  some  minutes and then  give  place again to  the  previous
rigidity.  These attacks, in which the  muscles contract to their 
           GENERAL DESCRIPTION OF THE DISEASE.        331

utmost limit with lightning rapidity, give the body the severest
shocks ; they occur spontaneously or upon any intended motion
as well as upon the most insignificant irritation applied  to the
periphery and the nerves of special sense.  Of course, the reflex
irritability  is  increased to a high degree.   These shocks may
follow one another  in rapid succession  so  that  the character of
clonic  spasms  is assumed.   The frequency with wliicli these
parox}7sms are repeated, and this may be  every  half hour  or
oftener, is of great consequence in estimating the severity of the
case ;  for a large number of patients die during the paroxysms.
With the increase of the tonic  spasms the constitutional  symp-
toms  become more serious, for by the rigidity of the thoracic
muscles the respiration  is interfered with,  and the  descent  of
the diaphragm is hindered by the contraction of the  abdominal
muscles.  The patients experience a sensation of oppression and
anxiety, they  complain of pressure in  the pit  of  the stomach,
they are restless, and from the curvature of the vertebral column
can find no easy posture in which to lie.  The muscular contrac-
tion generally causes severe cramp-like pains,  and the tormenting
thirst, and frequently also the hunger, which cannot be satisfied
on account of the locked jaw, join to make the  whole condition
of the patient one of terrible torment.
   Micturition  is either  normal or  there is  retention of  urine,
which is secreted in diminished  quantity ;  involuntary  urina-
tion is very rare.   Evacuation  of the bowels  is  always very
sluggish.
   The skin is generally covered with profuse perspiration.  The
temperature, as a rule, is normal in this disease, or but slightly
raised ;  it may, however, be enormously  high, though  this is
generally the case only just before death.
   As a rule, in the beginning,  and often also in the further
course of the affection, the pulse is only moderately accelerated
to 80-90 beats  ; after longer duration it  rises to 100, or even  to
120; but just before death, with the increase  of the temperature,
the frequency is much greater, rising even to  180.
  At this stage a slight delirium may also appear.
  By the parox}7sms of spasms the sufferings of the patient are
all greatly increased ; the pain grows more severe in proportion 
332                  BAUER.—TETANUS.

to the amount of contraction ; the dyspnoea becomes so great as
to threaten suffocation.  This is said to occur from spasmodic
closure of the glottis, as well  as from spasm of the diaphragm.
But, in  my opinion, the  immediate danger of the dyspnoea, as
causing a fatal termination, has been  exaggerated,  since the
narcotism from carbonic acid causes a relaxation of the spasms,
and  hence a diminution of  the danger to life.   The patients
become  cyanotic, to be sure, but the sudden occurrence of death
certainly depends in most cases  upon stopping of the heart.
   In by far the majority of cases the disease proves fatal: from
the rapidly increasing muscular stiffness or from the attacks of
spasms, generally  in  consequence  of  the  cardiac  paralysis.
Finally, the fatal termination may occur with the characteristics
of weakness and exhaustion  caused by the frequent spasms and
the consequent difficulty of  propelling the blood through the
lungs, and gradual weakening of the  circulation ; or the spasms
relax, there is  increased rapidity of the pulse and rise of tem-
perature,  and  the patient dies thus.  The fatal  termination
occurs generally within the first five  or  six days, or even sooner
—rarely later;  yet cases are known  wdiere death from exhaus-
tion has occurred  as late as  the twentieth day.  The establish-
ment of convalescence is always  gradual, generally occurring in
cases where  the greatest severity  of symptoms has  not been
reached;  there is  then a successive  abatement of the attacks,
and also of the tonic spasms.   Many  weeks or more may elapse
before complete return to health.  Sometimes the patients feel
themselves to  have entirely  recovered,  only a stiffness of the
muscles and difficulty in moving still remains some time longer.
Severe subsequent disturbance, deformities and curvatures from
persistent contractions  are indeed described, but  it is at least
questionable whether these belong to tetanus.
   In children also tetanus  may consist exclusively  of a tonic
spasm,  without clonic  convulsions.  The  spasm begins as tris-
mus, and, indeed,  in many cases it remains limited to the locked-
jaw ; hence the designation trismus has been specially employed
therefor.  Even before the disease is fully established, the chil-
dren are restless, cry out often, and frequently lay hold of the
breast, to let it go again. To  the tonic spasms,  which extend 
PATHOLOGICAL ANATOMY.
333
downward, but also implicate the extremities more frequently
than with adults, may be united, as in  adults, the severest par-
oxysms, which are brought on in part by insignificant peripheral
irritations, because of the increased reflex irritability.  Among
nurslings the disease leads rapidly to  collapse, signs of  which
are quickly seen.  Death  may occur  in  a few hours ; it com-
monly takes place on the second or third day.  The  fatal termi-
nation is very  seldom delayed,  and recovery is yet more uncom-
mon, even when  the spasms are limited in extent or amount
simply to trismus.


                   Pathological  Anatomy.

   Externally the dead body shows no peculiar changes.   Usu-
ally rigor mortis sets  in  rather soon after death,  depending
doubtless upon the strong acid reaction in  the previously active
muscles.  According to Curling's statement, the rigor is more
persistent and more  fully developed than is ordinarily the case.
Although the  rigor mortis occurs early, yet the muscles which
were  contracted  during life relax  first,  for the cause  wdiich
excited the tonic spasms ceases to act with death, and has noth-
ing in common with the rigor mortis.

   According to the observations of Nysten, the rigor generally sets in many hours
after death, after the spasm has previously entirely  disappeared; this statement
is also confirmed by AVedemeyer, Wunderlich, and others. Sommer maintains that
he has seen the spasm of the muscles of the jaw pass immediately into rigor mortis.

   For a long time changes have been  sought in  the central
nervous system  of persons  who  have  died with  tetanus.   In
earlier records, too, many positive results are found, especially
concerning the condition  of  the spinal cord.  J. Gimelle gives
an exhaustive  resume of the  results of  autopsies.  Yet  most of
the changes mentioned consist chiefly in anomalies in the  blood
supply, hyperaemia of the cord and  of  its membranes.  Similar
reports are  made concerning the  changes in the cranial cavity.
Sometimes extravasated blood and collections of serum were also
found.
   These and similar results  were considered  by many phy- 
334                  BAUER.—TETANUS.

sicians sufficient to give tetanus a place among inflammatory
diseases, especially of the  central conducting  apparatus.   In
individual cases unmistakable  signs of inflammation and soft-
ening were indeed found whereby the inflammatory nature of
tetanus seemed to be established beyond a doubt.  But it was
afterwards evident that in some of these  positive reports other
pathological processes had been confounded with the conditions
above named  (Funk); then, again, the many negative  results
given could not be ignored (Benj. Brodie, Ollivier, and  others,
although Ollivier declared in  favor  of  the existence of  spinal
meningitis) ;  and  finally,  the  statements with regard  to  the
existence of hyperemia of the  cord and its membranes  had to
be referred in part to post-mortem suggillation, since the pre-
caution has not always  been taken to lay the body upon its
abdomen.  Hence  the question still remained open when Roki-
tansky described a proliferation of connective tissue in the form
of embryonic  tissue as being a constant condition  in tetanus.
Rokitansky found this foreign gray substance scattered through
the white substance  in the cord.  The bulk of the cord was
increased; it  swelled up and bulged out more than  usual on
section, and had a firm elastic consistency.  The  principal micro-
scopical changes were an increase of nuclei and destruction of
the medullary substance ;  here and there agglomerations of fat
granules were found,  and a few amyloid bodies.   The substance
in question is found after death in a number of diseased condi-
tions, and may finally change into fibrous connective tissue or
into indurated tissue ; but in  view of the rapid and extensive
destruction in tetanus it does not reach this point.1  Rokitansky
found a similar change in the peripheral nerves.
   This discovery of  Rokitansky was  fully  confirmed by H.
Demme in many  cases ; the increase of  connective tissue was
furthermore reeognized by E.  Wagner in Wunderlich's cases,
and in Fechner' s cases the same changes were found in the ante-
rior and lateral columns.  The statements of Rokitansky have
not received any further confirmation.  Leyden has proved that
the changes found by Rokitansky and Demme are not constant,
1 Sitzungsberichte d. Wiener Akad. 1857. Bd. XXIV. 
PATHOLOGICAL ANATOMY.
335
and in part depend upon deceptive appearances,  the result of
imperfect methods of examination.1
   More recentty, in addition to many negative results of post-
mortem examinations,  some few observations have been  made
public in which demonstrable changes had taken place.  Lock-
hart Clarke, in particular, has described such changes ; besides
great  hyperaemia, he found centres of  softening in the gray sub-
stance, and  also  in  the white substance.   Yet he did not con-
sider  that the group of tetanic symptoms depended upon these
changes.2  Dickinson has likewise described masses of exudation
found in the gray and white substance, by which a destruction
and crowding aside of  the tissues was produced.3  Michaud also
found hyperaemia and  dilatation of the vessels, and an abundant
increase of nuclei.4  Benedikt found in one case hyperaemia of
the spinal cord, especially about the cells of the anterior cornua,
and granular degeneration of the cells,  but no increase  of nuclei.3
Notwithstanding  these positive results, those cases must also be
taken into account in which careful examination shows  no such
changes.   The only change usually met with is increased fulness
of the vessels.6
   With regard to the  condition of the peripheral nerves, espe-
cially in traumatic tetanus, the older reports  state that marked
changes were frequently to be seen at the seat of the wound.
Foreign bodies were found imbedded  in the  nerve-trunks ;  the
nerves were crushed  and torn ; there was also  inflammation and
thickening, but always  confined to the vicinity of the injury.
The observations of Lepelletier  were  hence of importance,  he
being  the first to describe the occurrence of an  ascending neuritis
in one who  died  from  tetanus.7  Then Froriep in  several cases
  1 Virchow's Archiv. Bd. XXVI. 1863.
  8 Mud. chirurg. Trans. Vol. XLVIII. 1865.
  1 Ibid. Vol. LI.  1868.
  4 Arch, de phys. normal et path. 1872. and Friedreich, Die progressive Muskel-
atrophie.
  5 Nervenpath. und Elektroth. 1874. p. 270.
  6 In nine cases which he examined, E. Rose found an increase of the weight of the
brain above the average, which, however, was only a secondary phenomenon.
  7 Revue Mod. 1S27. torn. IV. and in Curling, 1. o. 
336                    BAUER.—TETANUS.

found red spots and varicose swellings of the nerves,  alternating
with  parts which remained  healthy, and  this change extended
from  the seat of the injury to the spinal cord.1  Similar  changes
were  mentioned by Curling.   This  condition of neuritis ascend-
ens, though not constant (Hasse), has yet been found repeatedly,
and is of great value in the explanation of  the whole process.
   Changes  of  an  inflammatory character  in  the sympathetic
nerve have been mentioned by some observers, as by Aronssohn,
Dupuy and Andral.   Swan considered these changes in the sym-
pathetic, especially in the cervical and the semilunar  ganglia, as
being of great value in explanation of the nature of the disease,
but  riie existence of these  changes  has  not been further con-
firmed.
   The voluntary muscles have generally a pale color ; frequently
rupture of individual bundles and extravasation of blood can be
seen, and, indeed, this rupture of the muscles may be very exten-
sive.   More frequently, still, these lacerations are only microsco-
pic.   In single cases fatty degeneration of the muscles  has also
been recorded."  (According to J. Ranke the amount of  fat con-
tained in the muscles increases during tetanus.)
   The statement of Desportes that the thighs were sometimes
fractured by the power of the muscular action is rather incred-
ible.
   For a long time the  greatest attention was paid to the question whether the
heart  is affected in tetanus.   In a case observed by Howship, at the autopsy,
eleven hours after  death, the heart  was found extremely contracted. Watson also
saw the heart strongly contracted  and hard as cartilage.  No doubt,  these con-
ditions depended upon rigor mortis. In one case of strychnia poisoning Rosen-
thal found numerous ruptures of the muscular fibres and small extravasations. This
circumstance merits no special discussion.
    The changes in the internal organs  are not always constant,
and  are  either accidental  or  secondary.   Thus there  may be
hypostasis and oedema in the lungs, or ecchymosis in the pleura.
 The  liver is generally described as anaemic, the spleen  as small

   1 Neue Notizen.  1837. Bd. I.
   2 The changes in certain organs known to be produced by an elevation of the tem-
 perature of the body are rarely found in tetanus, because the high temperature is usu-
 ally only of short duration just before death. 
PATHOGENESIS.
337
and containing little blood.   The intestines are normally dis-
tended or greatly contracted, in  some cases hyperaemic (M'Ar-
thur).  The kidneys either show no change or they are overfilled
with blood, cyanotic.  Parenchymatous changes in the kidneys
are more rare.  Griesinger found them once, and they must  be
supposed to have  existed in  those cases of the  disease observed
by Kussmaul.   The pharynx and oesophagus were found greatly
contracted by Larrey, and the mucous membrane of a lively red.
   In  newly born children, besides many negative  cases,  there
have been noted  more frequently than in adults serous transu-
dation into the vertebral canal, over-distention of  the blood-ves-
sels of the membranes and extravasations of blood into the brain
and cord; but  the same weight only is to be attached to these
changes as has been mentioned above. The umbilical wound has
been found changed in various ways, but often enough there has
been nothing noticed at this spot,  or  the changes w7ere exactly
like those found  on perfectly healthy children.  Dr. Schoeller
frequently noticed an inflammation of the  umbilical arteries.   In
some cases phlebitis is also found, or inflammation of the peri-
toneum in the vicinity of the umbilicus.

                       Pathogenesis.

   The symptoms which are found in a case of tetanus point to a
disease of the central nervous system; but it is inadmissible  to
consider tetanus as an inflammation  of the  spinal cord, as was
formerly done ;  the anatomical changes of the cord  do not sup-
port such a view, and they are also too inconstant.  Neither can
the existence of a  degenerative process, with proliferation of con-
nective tissue, in the  sense indicated by Rokitansky, be proved ;
this anatomical explanation appeared, from the  beginning, to  be
insufficient to account for the  symptoms, since the anatomical
changes correspond to no simple form of disease,  but the same
changes are found in  connection with very  different diseased con-
ditions (Demme, Wunderlich).
   The lack of a satisfactory anatomical basis on  the one hand,
and, on the other, the manifold peculiarities in the course and
the origin of  tetanus, have repeatedly given rise  to the suppo-
         VOL. XIV—22 
338                  BAUER.—TETANUS.

sition that this disease is the result of infection.  Among others,
Heiberg  has sought to establish this theory ; he declares that
tetanus is  a blood-poisoning in which the tonic  spasms  are
excited by changes in the muscles  themselves, while only  the
clonic  spasms are caused by reflex action.1   This hypothesis,
however, is so arbitrary, and is in opposition to so many facts,
that it may be dismissed without further consideration.
   As  a more accurate knowledge  of reflex manifestations was
obtained it was seen that  tetanus  depended on  reflex action,
the muscular spasm being reflex.  This view was supported espe-
cially by Romberg, who looked upon the increase of the reflex
irritability as the chief element in  tetanus, this  increased irri-
tability being gradually developed  under  the influence  of  the
peripheral irritation.   According to  this view a  typical example
of the combination of tetanic  symptoms was found in the teta-
nus due to strychnia poisoning, which does indeed  depend upon
an  exaggerated irritability of the gray substance of the spinal
cord.  This  explanation is doubtless sufficient for certain forms
of toxical spasms, especially that due to  strychnia poisoning;
yet the influence of other  agents which give rise to spasms, as
nicotin and pikrotoxin, is probably exerted directly upon  the
nervous centres which cause the spasms.
   But the clinical symptoms of tetanus do not fully agree with
those of strychnia poisoning.'  The muscular spasms in essential
tetanus are at first continuously tonic in the muscles of mastica-
tion and generally also in those of the neck ; gradually they
increase in  intensity and extend downward, but there are no
paroxysms.
   According to the purely reflex  theory the phenomena in
tetanus must be connected in the following way : an irritation
from the periphery is carried  inward in an unbroken, regular
current, whence it follows, according to Pflueger's  law, that in
the medulla oblongata the transmission of  the motion is made to
such motor  tracts as have their origin therein (muscles  of  the
jaw, of the  tongue,  of the oesophagus).    At first  the conduc-
tion of irritation follows only the  primarily affected  (injured)
1 Norsk Mag. XV. and Thamhayn, 1. c. 
PATHOGENESIS.
339
nerve-fibres, because the etiological conditions  of tetanus  cause
abnormal irritability  of these.   Later, the reflex irritability  in
general is  exaggerated, so that the irritation of any  sensitive
libre whatever excites general reflex spasms.  According to this
view the increased reflex  irritability is  an abnormal  function
which, under the stipulated conditions, occurs  without any pri-
mary anatomical change.
   It is easily seen that in this sense  the reflex theory cannot
be unconditionally accepted.  Thus, those cases of tetanus which
follow a wound of the neck or of the occipital region, the connec-
tion of which with tetanus cannot well  be denied, are scarcely to
be explained otherwise than by direct irritation of the centres
controlling  the  spasm.   It cannot be  easily proved whether in
other cases of  tetanus  a direct and not a reflex irritation may
also occur.  Different opinions may be held as to the nature of
this irritation.   It is  possible that the  peripheral irritation acts
upon the vaso-motor system of  the central motor organs, so that
the spasms occur in consequence of reflex disturbance of  the
circulation.1  The disturbance  of  the  circulation may lead  to
further  pathological consequences, especially to  exaggerated
reflex irritability which may  arise  sooner or  later as  a purely
spinal symptom in the course of tetanus.   But it is also possible
that there may be a progressive extension of the diseased process
from the affected peripheral nerve towards the centre,2 which acts
directly upon that as an irritation, and  the  presence of ascending
neuritis in some cases seems to give support to this view.   Ana-
tomical changes may thus follow  which are, at least partially,
beyond control, but  which  need  by no means always be  the
same.
   The last supposition is  supported by marked analogies, and
if these are followed out  more fully, the  conclusion is reached
that tetanus is  first of  all only a symptom which may appear
under many different conditions.
  1 See Benedikt. Xervenpath. u. Elektroth.  1874. p. 368, and Heinecke, Deutsche
Zeitschr. f. Chirurg Bd. I.
  2 See, among others, E. Hitzig, Unters. iiber das Gehirn  p. 192. 
340                    BAUER.—TETANUS.
                  Analysis of the Symptoms.

   The time which  elapses between the  occurrence of an injury
and the outbreak of the tetanic symptoms varies greatly ; gener-
ally it is from five to ten days, but the spasms may begin after a
few hours, and, on the  other hand, weeks may  intervene.  In
rheumatic cases the fact of having taken cold is generally recog-
nized but a short time before the beginning of the  symptoms.
Among the new-born  the disease usually appears from  four to
eight days after birth,  but may be delayed longer,  until the four-
teenth  day.

   Groetzner mentions a patient, who underwent amputation, who was attacked with
tetanus the moment the crural nerve was included in a ligature,  and died after six
hours.1  A very marked  example of the rapid outbreak of the disease is found in
the frequently quoted case of Robison : a negro wounded himself in the finger with
a piece of porcelain, and after half an hour was attacked with tetanus.  On the
other hand, very long intervals  are also known to occur;  Ward, of Manchester,
reports a case where the symptoms first appeared ten weeks after the injury-
According to Friedrich's investigations, in  one case three months intervened.  Mor-
gan saw one case wherein tetanus appeared two months after the wound healed;
the autopsy showed that a splinter of wood was included in the  cicatrix.3

    The first symptoms are  generally almost imperceptible, the
very  earliest changes frequently being noticed immediately after
awaking  from sleep.   Yet undefined disturbances of the general
health, and pains  similar  to rheumatism, which are  hard to
define, may also be noticed some  time previously.   Renewed
sensitiveness of  the wound,  with shooting pains radiating there-
from, may also be included  in the list of these so-called prodro-
mata.  The commencement is occasionally, though rarely, acute,
with  a  single marked chill.
    The spasms.—The  tonic spasms usually begin  in the muscles
of the lower jaw and oesophagus, and extend downward to  other
muscles ;  sometimes the  attention is first excited on protruding
the tongue.  At first the lower jaw can still be separated from the
1 Der Krampf, insbesondere der Wundstarrkrampf. Breslau, 1828.
5 According to Curling, 1. c.
* A lecture on tetanus. 
ANALYSIS OF  THE SYMPTOMS.
341
upper; swallowing, even chewing, can still be performed ; only a
stillness  and tension is noticed in the neck.   Patients with these
symptoms may still remain out of bed for some days in tolerably
good condition.   But the increase and extension of the symp-
toms may also be very rapid, so that in a few hours the disease
is fully developed.

   It is stated that, as an exceptional form of the disorder, the spasms may first
appear in the injured part and extend to others; while the muscles there are con-
tracted and from time to time thrown into convulsions.1

   As the disease progresses the  jaws are more fully closed.
Sometimes the two rows of teeth are  firmly pressed against each
other, the  spasm  of  the oesophagus  also  increases,  so that  the
introduction of even small quantities of fluid is rendered  ex-
tremely  difficult  and fatiguing.   The locked jaw cannot be
opened by any power that can be used.  Speech is difficult, and
the voice is altered from the difficulty of moving the tongue, and
also because the muscles of  the larynx are implicated.  As the
facial muscles of expression are affected the expression becomes
quite characteristic;  the forehead is wrinkled, the eyebrows  are
drawn upward as when one  is fatigued, the eyes are staring and
motionless ; the pupils are generally  contracted, but there is
rarely strabismus ; the mouth is drawn out laterally, the corners
are drawn down and the teeth  are  partially uncovered by the
lips ; the naso-labial folds are strongly marked.  In this way the
expression of  the  face is greatly altered, and  there is  seen mir-
rored in it a singular mingling  of opposite  feelings.2   The
patients look unusually anxious and  frightened, but also, at  the
same time, wildly excited, and the mouth is in a half-laughing,
half-crying position ; hence  the name "risus sardonicus."   The
altered features of the pale countenance  cause the patients to
appear older.  Thus, Farr states that a man twenty-six  years  old
was taken for  sixty.   The stiffness of  the neck, slight at first,
  1 Dupuytren, Trait, theor. et prat, des bless, par armes de guerre ;  and Key, Guy's
hosp. rep.  Vol. V.
  ■ Of course, this mingling of expressions arises from an undue preponderance in the
power of certain muscles during- a general spasmodic contraction of all the muscles
supplied by the facial and trifacial nerves.—Consult Kocnig, 1. c. 
342                   BAUER.—TETANUS.

increases until the head is firmly fixed  backward.   The state-
ment of Curling that in this  way the so-called nutator capitis
may change its action and become an extensor muscle, depends
upon a false idea of the action of  the sterno-cleido-mastoid.  The
lono- extensor muscles along the vertebral column bend the back
with  its convexity forward, the chest arches forward strongly,
so that it seems very broad, and  the body may finally rest only
on the occiput  and sacrum.  The epigastrium is sunken in, the
abdomen flattened, and, like all the contracted muscles, gives a
characteristic sensation of  hardness to the touch.  In this way
that spasmodic position of the body  is  brought  about, which
according to old custom is termed opisthotonos.
   The muscles of the extremities are more rarely affected by
tonic  spasms,  those of the legs being  somewhat more  liable
thereto, while,  according to E. Rose,  the forearms and hands
invariably escape; a statement also made by other observers.
But  this is  certainly a rule with many  exceptions, as is easily-
shown in some cases by trying to perform passive motions with
the forearm, when the increased resistance of the  contracted
muscles will be perceived.  In the extremities, too, the  position
of extension is the one usually assumed, yet in single joints there
may be flexion.  Finally, it may be mentioned that  spasmodic
erection also occurs.  The tonic spasms  may vary in the differ-
ent cases in extent and severity, yet they are characteristic of
tetanus. In some cases the spasm consists from the beginning to
the end in a persistent rigidity of the muscles, but in most cases
there are paroxysms in which  the muscular  contraction is sud-
denly increased, to remain for a while in that condition, and then
again to yield  to the previous comparatively relaxed condition.
This  sudden and  universal  muscular  contraction throws  the
body  into severe  spasm.   From the  synchronous traction of
antagonistic muscles there is generally no marked locomotion of
the different parts of the body, the opisthotonos  becomes more
marked, the head is pressed backward into the pillow, the body
is thrown forward into a bow,  and the  limbs are  stretched out
with a  severe  shuddering of the  whole body.   The tongue may
be caught between the teeth and be severely bitten.  The attacks
may follow  each  other so rapidly that the spasms  may have 
ANALYSIS OF THE  SYMPTOMS.
343
more of a clonic character.   Trembling of the muscles seems to
be rare, though Wunderlich and Kussmaul  noticed it.  During
the paroxysm  the patient becomes cyanotic, and is tormented
with a sense of suffocation from the contraction of the pharynx
and glottis, and a feeling of  mortal dread  ; he foams at  the
mouth, and his chest seems as if wedged between unyielding pil-
lars.  The frequency with which these attacks recur varies in
different cases.   It is also less at the commencement of the  dis-
ease, increases  during its course, and finally, in cases wliicli  end
favorably,  or  towards the  fatal termination, decreases  again.
Sometimes the  attacks are more  frequent during the night than
during the  day.  Thus the free intervals vary from ten minutes
to hours.   The duration of the spasmodic attack also varies ; as
a rule one or two shocks run through the body and then there is
rest  again,  but  the  severest  spasms  may last  many  minutes,
indeed,  with slight remission,  even hours.
   The attacks recur in part spontaneously, without any recog-
nizable external cause, in part from the most insignificant irrita-
tion acting  upon the nerves of sensation, or the organs of  the
higher senses.   Frequently  a proposed voluntary motion gives
rise to the spasmodic action, and this  is especially the case with
efforts at swallowing,  so that the disease bears a resemblance to
hydrophobia.1   The  peripheral impressions which give rise to
general spasms are frequently extremely insignificant;  the rust-
ling of a dress,  the jar of a step,  feeling the  pulse, are sufficient.
Kussmaul correctly remarks that often a grosser irritation, such
as pricking with a needle,  causes no spasm, especially if  the
patient is prepared for it.
   In traumatic cases it is stated that touching the wound will sometimes very
readily excite an attack. A sort of  aura is also described which sometimes arises
in the wound before the attack.

   The origin of these spasms has already been discussed, and
but little remains to be added.   The condition is one mainly of
  ' This predominating implication of the muscles of deglutition is not very frequent.
Rose supposes that those cases are accompanied with spasms of deglutition in which
the exciting injury is in the region supplied by the cerebral nerves.  Rose designates
these cases especially as cerebral tetanus, or tetanus hydrophobicus. 
344
BAUER.—TETANUS.
tonic spasms, which persist continuously while consciousness is
retained,  and must be  looked  upon  as  co-ordinated.   This
circumstance,  as  well  as the order  in  which  the  muscles  are
attacked by  the spasms, shows that they arise directly from  the
centres which control the spasms.  The paroxysmal exacerbation
of the spasms following insignificant irritations, as is seen in  the
later stages  of the  disease,  must be looked  upon  as due to
increased reflex irritability.   Moreover,  observation shows that
the central inhibitory influence over reflex action is in its normal
condition, for the attacks ane more easily avoided if the patient
is forewarned in regard to the sensitive impression.1
   Compared with the  spasms,  motor paralysis is  exceedingly
rare in the  course of tetanus.  Some observations  of Rose  are
interesting.   He saw paralysis  of  the  facial  nerve in cases in
which the injury giving rise to the attack was in the domain of
the facial.  This exception, according to the correct explanation
of Rose, was doubtless dependent upon an ascending  neuritis,
which may all the  more readily cause paralysis of  the facial in
view of the  course which this nerve runs  through the osseous
canal.  The  circumstance that  the  paralysis  was  unilateral is
greatly in favor of this  view.
   Other paralyses have not  been noticed in the course of the
disease ; but, as terminations or sequelae, not only have weakness
and  interference  with muscular  action from persistent stiffness
been observed, but also paralysis.
   Strabismus, wliicli is sometimes noticed,  is usually, according
to Wunderlich, a precursor of death.
   During  the whole course of  the  disease the intelligence is
characteristically clear and undisturbed ; only exceptionally does
delirium appear  a short  time before death.  The  higher senses
are  equally  free  from disturbance.   Sleeplessness is another
characteristic symptom,  and  is  usually persistent; but if the
patient does  fall asleep, the spasms entirely cease, to recur when
he awakes ;  the same is true during narcosis.
   With the occurrence of the tonic  spasms the general health

  1 A description of the changes in the muscles which  occur during their activity
cannot be given  here ;  only the relations of the increased muscular activity to the
metamorphosis of tissue are of unusual interest, and are therefore briefly mentioned. 
ANALYSIS OF THE SYMPTOMS.
345
is seriously disturbed ;  the difficult respiration, the contraction
of the chest and oesophagus, the constrained and distorted posi-
tion of the body, the impossibility of swallowing, with the pres-
ence of thirst  and hunger, make the  situation of the patient
extremely distressing.   All these tormenting symptoms increase
during the paroxysms of spasm  until they are unendurable,  and
the patient is thrown into a state of extreme anxiety and excite-
ment.  The same is true  of the pain  caused by the muscular
spasms, which  may often become very severe.   A painful sense
of pressure in  the pit  of  the stomach is  very constant; most
patients  complain  especially in regard to this.  Chalmer  and
others consider this pain as truly pathognomonic of the earlier
stages of the disease.
   The pains in the muscles have the same character as is found
in other varieties  of spasm, e. g., cramp in the calf of  the  leg.
Besides these cramp-pains, which are caused by the pressure of
the contracted  muscles  upon the  sensitive nerves, there is  also
hyperesthesia.   Tscharner  says that  pressure  upon the con-
tracted  muscles excites severe pains ;  Demme also noticed in-
crease of sensibility to pain.
   On the other hand, Demme  found very decided decrease of
the acuteness of the sense of touch  and of  temperature.  This
observation stands almost  alone in these respects,  partly, per-
haps, because the examination  has not always been made ;  yet
this change of the conduction of the sensitive nerves is certainly
not frequent.    Perverted sensations, or  paresthesias, are also
reported in some few cases.

  The stiffness of the  muscles does not cause the above-mentioned  sense of pain
in all patients; sometimes it is felt only during  the paroxysm.  Indeed, single
cases are reported in which during the severest attacks no pain is felt.  G. Blanc
mentions that in  one  patient the severest  muscular  contraction  caused only a
pleasant sensation of tickling.

   The skin in  most cases is almost constantly covered with pro-
fuse perspiration ;  this is greatly favored by frequent attacks of
spasms.   The explanation  of this symptom is clearly this, that
the increased muscular action increases the blood-pressure in the
cutaneous vessels, and thereby the action of the sweat glands is 
346                   BAUER.—TETANUS.

increased.   That this secretion of sweat  exercises  no marked
influence over the course of the bodily temperature,  though the
vaporized moisture abstracts heat from the body, may be con-
cluded from what is  found in  other  varieties  of  diseases where
sweating  occurs  with both high and low temperatures.  The
appearance of sudamina in connection with this is frequent, and
is of no further significance.

  A. Vogel noticed furuncles in one case, but referred their presence to large doses
of bromide of potassium, which had been used.

   During the persistence of  cramp  the  respiration is only
slightly changed in frequency ; the patients breathe from twenty
to twenty-four times per minute,  or  even  less, but with greater
effort and with a painful sensation of increased resistance.
   The  auxiliary  muscles  of  respiration  are affected by the
spasm ; the contracted abdominal muscles offer resistance to the
diaphragm.  Hence it happens that the secretion  of the bronchi
necessarily accumulates,  and cannot be removed by coughing,
since the preponderating  action of the inspiratory muscles dur-
ing  the  spasm seriously interferes with  the  falling-in of the
thoracic walls from their weight and with the  forced expiration
necessary in coughing.
   During the convulsions there is decided interference with the
breathing ; the patients become cyanotic and have the sensation
of want of air, of danger of suffocation.  The dyspnoea is caused
in part by the spasmodic narrowing of the glottis, but especially
by the spasm  of the more powerful inspiratory muscles and the
implication of the diaphragm.   The thorax is spasmodically in
the position of inspiration, the diaphragm is also drawm down-
ward ; thus the expiration is  seriously restricted.  In one case
reported by Wunderlich  the  respiration  was unusually slow,
twelve  to  sixteen in the minute ;  during the  paroxysms the
respiratory action ceased,  the  abdomen projected forward, the
intercostal muscles remained  stiff.   The  return  of  respiratory
action began  with the diaphragm,  which, though  previously
contracted,  sank  still lower.   An  opinion has already been
expressed as to suffocation being  the cause of death. 
ANALYSIS OF THE SYMPTOMS.
347
  On account of the spasm of the glottis, tracheotomy has been proposed and per-
formed, but always with unfavorable effect, for the pulmonary symptoms (bronchitis
and accumulation of secretions) increase to a dangerous degree afterwards.1

   The pulse during tetanus may be entirely normal, or below
the normal number,2 and between the paroxysms it is, as a rule,
normal or only slightly accelerated.   But the frequency varies,
depending upon the attack of spasm, since with every shock the
pulse rises  ten or twelve beats, and becomes lower when this
relaxes.  Exceptions are  sometimes  found; thus Hennen, Mac-
grigor and  Morrison saw the pulse unaffected during the sever-
est attacks.  But during the paroxysm  the frequency of the
pulse may be much increased,  it may even reach  180.  This
enormous frequency is  seen most often in the last stage, and at
that  period the symptom does  not  depend upon  the spasms,
which only cause  an additional  increase  in the otherwise high
pulse; thus Griesinger in one  case noted  a pulse of 170, while
during sleep it was 140.  This excessive frequency is indeed the
result of many factors ; it only remains  to inquire which is the
more important.   The simultaneous presence of a high temper-
ature  certainly has  an influence.  Yet probably an  abnormal
action of the cardiac nerves is the most important factor, though
at present it is not possible to decide whether there is diminu-
tion of  the  tone of the pneumogastric nerve or irritation of the
sympathetic.  In favor of trie latter supposition  is the  quality
of the pulse, which  is found to be small and irregular, pointing
to a vaso-motor irritation.
   According to  Liston the vessels may be contracted to such a
degree that even amputation may be performed without the loss
of a drop of blood.   The contraction of the vessels reacts upon
the heart as an accelerating cause through the increase of resist-
ance.  The resistance is also considerably increased during the
attacks  of  spasms by  the muscular contraction,  so  that the
increase and decrease in the frequence of the pulse is dependent
upon the accession and cessation of the spasms.
  The heart  may suddenly cease acting during the attack ;  this
1 Med. Times and Gaz. London, 1854. p. 4G2.
2 See J. W. Ogle, Transact, of the Clinical Soc. 1872. Vol. V. 
348
BAUER.—TETANUS.
can be determined by experiments upon animals, and agrees with
observations upon patients.  This does not denote the existence
of tetanus of the heart, as is evident a priori, and is still further
proved by the cessation which occurs during diastole.  Probably
the cause is to be found in  the sudden  increase of resistance,
especially as  there  is also exhaustion and cardiac debility;  or
there may be irritation of the pneumogastric.
   Increase of temperature in tetanus has been  recognized for a
long time; it was noticed by de Haen, then by  Bright and Pre-
vost.  Nevertheless, opinions have been very much divided as to
whether  tetanus  is a febrile process or  not;  thus  Hillary,  0.
Beirne and others  asserted that  tetanus ran its course without
fever.  Lately this  fact has been made the subject of so numer-
ous investigations, under the stimulus of AVunderlich, that the
result may be summarized thus : Tetanus  causes no increase of
temperature or only a slight increase, and  this, according to J.
Ogle, occurs especially in the evening.1  Of course, there may be
fever if the wound or some  other complication causes it.   On
the other hand,  in many cases of this disease  it is found that
the temperature rises to an excessive height, and this exacerba-
tion occurs generally a short time before death—in one  case of
Wunderlich it was 44.75° C. (112.73° F.) in the  axilla; it has
also been found that after death the temperature continues to
rise  for  a considerable time.   This elevation of  temperature
shortly before and after  death  has  been frequently noticed
since Wunderlich, but it may also be wanting  in fatal cases of
clearly marked tetanus (J. Ogle, E.  Rose).
   An understanding of these  relations has been much favored
by experiments  upon animals.   The investigations of Leyden,
then of Billroth  and Fick, agree perfectly in their results:  In
tetanus caused  by  electrical irritation  of  the spinal cord the
temperature rises enormously,  and also continues elevated after
death (Billroth and Fick).  In each attack the temperature sinks
somewhat during the first moment, then it rises continuously,
and, indeed, this rising  lasts some time longer than the muscular
contraction.  Before the contractions the temperature is lower
1 Transact, of the Clinic. Soc. V. 1872. 
ANALYSIS OF THE SYMPTOMS.
349
in the muscles than in the rectum, but with the spasms this rela-
tion is reversed.
    The same occurs in tetanus from strychnia poisoning.1
    These  high temperatures,  as they are seen  in  many cases
during the final stage of tetanus, have been referred by many to
the muscular  spasm, therefore to increased production of heat.
When a muscle falls into a state of contraction  it not only be-
comes demonstrably warmer, but there is  in truth more heat
produced in the acting muscle.  The increase  of  temperature
during muscular action is found not  only in  the muscles  them-
selves which are in action, but also in the whole body ; but  in the
body  collectively the increase is very slight (according  to Davy,
0.70 C. [li° F.]).
    The increase of temperature in muscles in a state of activity
was proved by Becquerel and Breschet, then wdth better methods
by Helmholtz.   Solger has reported the increase  of  temperature
in excised muscles, and also the diminution at the beginning and
the continued increase after the cessation of contraction, and has
designated these phenomena as  negative temperature  variation
and as supplemental increase ;a but, according to Heidenhain, the
temperature increases immediately with the beginning of  the
tetanus, and the negative variation is an error of  observation.3
Ziemssen has shown the increase of temperature also in  the layer
of skin which  lies above the contracting muscle.'
   These facts do not, however, conclusively  prove that  more
heat is really produced during the activity of  muscles ; that the
rise in temperature is really caused by increased production  of
heat.  Billroth  and  Fick,  indeed, also  found that during an
attack of  tetanus the temperature rose  much more rapidly  in
the muscle than in the rectum,  while during rest  the tempera
tare of the  group of  muscles examined was  lower  than that  of
the rectum.  These observations are enough to render it  prob
able that there is an actual increase in the production of heat
  1 Guentz. Beobachtungen iiber die Temperatur beim Tetanus; and A. Muron, De
la cause de l'elevat. Gaz. med. 1872.
  • Stud, aus dem physiol. Instit. zu Breslau. 2. Heft.
  3 Mech. Leistung, Warmeentwiekelung u. s. w. bei der Muskelthatigkeit.
  4 D. Elektricitiit in d. Medic. 
3o0                   BAUER.—TETANUS.

during muscular action, and this view is more firmly established
if the products of tissue change  during rest and  during ac|^)n
are compared.  Voit  has  shown that muscular  action is^bt
accompanied with any marked increase in the decomposition of
albumen in the entire body, while, according to Pettenkofer and
Voit,  the excretion of carbonic  acid  is  very much  increased
during muscular action.  Thus, during action more heat is pro-
duced, besides the mechanical power, and, indeed, the excess may
equal the entire heat-producing power of the non-nitrogenous
substances which  are  more decomposed in  consequence of the
muscular action, while probably the production of mechanical
action belongs only to the albuminoid substances, and a trans-
formation of  heat into mechanical power  within the body is
improbable.
   The explanation of the extraordinary temperature in tetanus,
on the ground of  muscular action, seems  to obtain  still further
support  from the circumstance  that in it the muscular action
consists chiefly in tonic spasm.  A muscle in a state of tonic con-
traction, according to J. Beclard, produces more heat than when
employed in ordinary work, and, according to Ch. Bouchard and
J.  M. Charcot,  spasmodic  actions may  be divided into  two
groups with reference to variations in temperature, viz. :  one
group with static  contractions,  which cause a greater or  less
increase  in temperature ;  the other,  with dynamic contractions,
which have no influence upon the temperature.  Such a distinc-
tion is, however, by no means always correct.  But if the above-
mentioned influence upon the temperature  is ascribed to tonic
spasm, on the ground that such spasm  accomplishes no external
work, this is surely a mistake.1
   But  in settling the question of the increased production of
heat during muscular activity we by no means settle the matter
of the abnormal elevation of temperature during tetanus ; indeed.
the most cogent reasons exist against accepting  the one as an
explanation of the other.  We know how slight an increase of

   1 The error, indeed, is evident from the simple consideration that that amount of
heat which corresponds to the mechanical work accomplished by a man is so slight that
an increase of the temperature of the body cannot be explained thereby, especially as
the specific temperature of the body (the muscle) is very high. 
                 ANALYSIS OF THE SYMPTOMS.              351

temperature occurs from  severe muscular action.   Furthermore,
clinical observation shows that in tetanus,  notwithstanding the
most  severe spasm, the temperature may be, and generally is,
normal until it rises a short time before death,  often  simulta-
neously with a cessation of the contractions.
   The possibility of a regulating  power which maintains the
temperature of the body at  about a certain  standard, notwith-
standing varying degrees of heat-production, exists in tetanus
just as well as in a normal condition, as is proved by the fact of
the temperature remaining  normal  in spite of the muscular
cramps.  It is  certainly more correct to refer the increase of tern
perature towards the end of life to a disturbance of this  regulat-
ing power than to an increased production of heat beyond the
limit which can be compensated for.
   The extraordinary  high  temperature occurring just before
death does not belong  exclusively to tetanus. The same condi
tion is found  likewise  in injuries of the cervical vertebra?, the
most instructive example of which was  observed  by Brodie (dis-
location of the fifth and sixth cervical vertebra*, with a tempera-
ture of 43.90  C.  [111.02°  F.] without  muscular spasm).  Very
nearly the same is seen in other cerebral and spinal affections, as
is shown in cases reported by Wunderlich/
   The question of the regulation of the temperature of the body
is as yet by no means settled.  It is a fact that complete  division
of the spiual cord in the neck causes the temperature rapidly to
sink, unless the rapid loss of heat is prevented  by external means.
A communication is  thereby interrupted in the cervical  portion
of the cord which, normally  proceeding from the central  system,
prevents the rapid loss of heat.  If, however, the communication
is not interfered with, and  the centre is irritated, the temperature
rises.   The further details of  the question are unimportant for
our purpose;  yet,  for  the  present, we may regard the  vaso-
motor centres as among the  organs  governing the regulation of
heat, without danger of falling into any serious error.
   Hence we are led to the conclusion that the excessive increase
  1 Archiv der Heilkunde. 1864. Bd. V. See also Guentz, Allg. Zeitschr. fur Psych.
1868. 
352                    BAUER.—TETANUS.

of the  temperature in  tetanus arises from  an  irritation  of a
centre of  innervation  which normally is  concerned in effecting
the escape of the variable amounts of heat  produced within the
body.   At the same time the production of heat is increased by
the exaggerated muscular action.
   A post-mortem increase of temperature  has been noticed
since de Haen after death from various causes ; only in tetanus
alone it is common  for the  post-mortem  increase  to  be very
great, as Wunderlich  first stated.   The reason for this elevation
of temperature after the cessation  of the circulation, according
to Huppert, and also  according  to Fick and Dybkowsky,  is to
be found in the setting free  of  heat during  the stiffening of the
muscles, on the coagulation of the myosin.  At the same time,
with the cessation of  the circulation, the circumstances govern-
ing the giving off of heat change, the exchange from one layer
of the body to another  is accomplished by conduction  without
the intervention of the circulation.

                  Processes  of Decomposition.

   Condition  of the  urine.—The amount  of  urine passed  in
twenty-four hours in  tetanus  is usually below  the  average in
health, even in  persons fasting ; on cooling, there is generally a
deposit of the urates previously held in a saturated solution by
the elevated temperature.   The reaction is  strongly acid, corre-
sponding to the concentration (only  exceptionally alkaline by
decomposition), and the specific gravity is proportionately high.
The urine is rich in brown coloring matter.
   Exceptional cases occur in which large quantities of  urine containing but little
coloring matter  are evacuated, but these depend probably upon complicating cir-
cumstances.  Tetanus is then distinguished, by the amount of urine excreted, from
some other forms of spasms with a large amount of urine (urina spastica). Textural
diseases of the kidneys can hardly play any part here, but a number of other condi-
tions coexist with this diminution of water in the urinary secretion, such as profuse
perspiration, difficulty in drinking, diminished pressure in the aorta.  Experimental
investigation has not yet settled most of the questions concerning the influence of
the renal nerves upon  the  action  of these organs, while the varieties of  spasm
plainly point to such an influence.  The experiments of  CI. Bernard, Eckhard, and
others, are as yet not sufficient for pathology. 
ANALYSIS OF  THE SYMPTOMS.
353
   Albuminuria  occurs,  but  not  habitually;  the  proximate
causes of this may, indeed, vary ;  it may result from congestion,
especially in  the later stages,  or from  complication with  renal
diseases, which occur independently of  the tetanus, as must be
supposed in the case reported by Kussmaul.1  As yet too little
is  positively known in regard to the influence of innervation to
take it into  account as a factor.  Albuminuria is not a frequent
occurrence  in  tetanus ; very many negative facts are found in
medical  literature, and in five cases wherein I  examined the
urine I found no albumen.
   An observation of Griesinger is deserving of mention.  In a case of traumatic
tetanus he found in the urine, which had  a dense deposit, numerous pale casts,
without albumen. At the autopsy  there  was  found only desquamation  of the
pyramidal portion.5

   The presence of  sugar in  the  urine  in  tetanus is also of
interest.  This was first noticed by Demme.   A. Yogel has also
described a  case of rheumatic  tetanus in which there was sugar
in the urine.   Yogel refers the phenomena  to irritation of the
spinal cord.3  This is, however, very rare.
   The urine in tetanus  generally possesses, to a very  great degree, the peculiarity
of  reducing the  oxide of copper,  but without'  depositing oxydul. The fluid
changes color by boiling, and takes a clear dark-yellow color.  The amount  of this
reducing substance is, of course, only dependent upon the concentration.
   The excretion of  nitrogen in  the  urine in tetanus was first
determined  by Huppert in a  case of rheumatic  tetanus.  The
variations in the daily amount of urea  were so great (45.2 and
12.2 grms.) that they could only have been dependent upon the
absorption of varying amounts of nourishment.   The demand
for nourishment, according to his statements, was  very  active,
but the appropriation of the nourishment was much interfered
with.4   On  the contrary,  Senator, after  examining two cases,
came  to  the conclusion that  there was no increase in the excre-
tion  of nitrogen  as  compared  with that  in  a person who was
      1 Berl. klin. Wochenschrift. 1871.
      2 Arch, der Heilk. 1862.
      3 Deutsch. Arch, fiir klin. Medic. Bd. X.
      4 Arch, der Heilkunde.  1862. p. 177.
VOL. XIV.—23 
354                   BAUER.—TETANUS.

fasting;  that  the  course of the  decomposition  of albuminoid
matter was independent of the attacks of spasm, and that it was
not even  clear  that  the increased temperature  exercised any
influence thereon.1 I arrived at  the  same result  in  two cases
where  I carried out experiments to determine the  decompo-
sition of albumen.
   Hence also in the pathology of tetanus the proportion estab-
lished by Voit holds good, that the activity of the muscles takes
place independently of the decomposition of albumen.
   Among the  components of  the urine  containing nitrogen
creatinine is of  interest on account of the relations to muscular
action ascribed to it by earlier observers.  Senator,  in his cases,
found  but a  very small  quantity of  creatinine in the urine,
agreeing with the facts  established by  Nawrocki for individual
muscles, and  more extensively for  the whole body by  Voit.
Creatinine  or  creatine, therefore, stands in  no relation to  the
activity of  the muscles ; hence in general tetanus there is no
increase in its amount.
   Senator even found the  amount of creatinine diminished in comparison to that
of urea; this would  support the view  that by muscular action a portion of the
creatine and creatinine is transformed into other compounds, which is quite possible,
according to the data given by  Voit.
   No direct estimate has been made of the amount of carbonic
acid produced through the decomposition of the non-nitrogenous
substances.   Yet from other well-known facts it may be inferred
with great certainty that it is increased  proportionately with the
muscular action.
   In regard to the digestive organs it may be mentioned that the
tongue  is generally dry and coated, the saliva is tenacious and
ropy.
   The thirst is  very great and distressing on account of the loss
of water through the skin and the difficulty in taking liquids.
The desire for food  is often not at all diminished, there is the
most acute hunger, and  food is well borne when the stiffness of
the jaws does not prevent its being taken.   On account of the
above  difficulty,  therefore, the patient  may actually suffer
1 Virchow's Archiv. Bd. XLVIII. 1869. 
TERMINATIONS AND PROGNOSIS.
355
severely from hunger.  This fact shows that the gastro-intestinal
digestion is at least not always deranged.
   Constipation is a common symptom in tetanus ; the freces
also have an  intensely strong odor and an unusual appearance
("like sloughs"), depending upon the length of time they have
remained in the intestines.  The constipation is probably depend-
ent upon the  rigidity of the abdominal  muscles  and anomalous
peristaltic action, but only in a slight degree upon the spasms of
the sphincters.  The anomalous peristaltic action may be found
in the failure of regular propulsive motion ;  evidently cessation
of motion as well as  persistent spasm may check the propulsion
of the contents of the bowels,  and it is quite possible that in
tetanus the muscles of the intestines may be in a state of spasm.
   Micturition is  not seldom affected, and the urine cannot be
voided voluntarily ; involuntary micturition  during the parox-
ysm  or as a symptom  of  paralysis  during  the later stages is
more rare.  This is more common among children.  According
to E. Rose the retention  of urine  depends  upon the deficient
action of the abdominal walls, and this is certainly a cause, but
not the  only  one.   There is at the same time also spasm of the
sphincter vesica?, or, rather, a loss of ability to relax that muscle.
The abdominal muscles are indeed in a state of rigidity, but they
are not withdrawn from the control of the will.  The retention of
urine  is also by no  means  constant, and will frequently cease
spontaneously if the patients are put  into a warm bath for a
while.

               Terminations and Prognosis.

   The symptoms described may be present with more or less
severity in individual cases, they may also in part be wanting ;
and it is the  variations in this  respect which give to each case
its individual character and  mark the intensity of the disease.
Thus, there are extremely light cases in which, besides trismus,
there is at most only some stiffness of the neck ; such cases occur
especially from the effects of a chill.  In adults their termination
is favorable, yet it cannot be positively foretold wdiether there will
be a further development of the symptoms ; but in children even
trismus is very dangerous. 
356                   BAUER.—TETANUS.

   So soon as the symptoms are developed to their full  extent,
the danger to life is extremely great, and among the newly born
the fatal termination of tetanus is so constant that the occasional
cases of recovery have been looked upon as being probably errors
in diagnosis ; still,  individual cases of  recovery are  certainly
seen.  Among  the different  symptoms there  are  also  certain
whose presence is peculiarly significant of danger.
   Most physicians consider the  rheumatic variety as less dan-
gerous  than the  traumatic; by  others, however,  this,  too, is
denied.1   It is difficult to form a definitive opinion  in  regard to
the rate of mortality in tetanus.   In the  first  place  it  may be
questioned whether in certain  collections of statistics the milder
and insignificant cases have been included; then the collection
of the cases separately published is open  to the objection that
the  favorable  cases are  more frequently  published  than the
unfavorable, as  the object  generally is to call  attention to the
results of therapeutic  measures.   Thus,  the  tables  given by
Friedrich and Curling do not harmonize with the army reports.
The truth will be found to lie midway between the two, as the
latter show too high a rate of mortality on account of the unfavor-
able circumstances which are connected  with  the care of the
wounded in war.
   In the tables given by Curling, of 128 patients 58 are noted as recoveries; hy
Friedrich, of 252 cases 128 proved fatal.  On the other hand, Macgrigor, in his
report of  the English  and Spanish war, declares that among some hundreds of
patients there were only few cases of  recovery.  According to II. Demme, of 86
cases of tetanus in the Austrian and Sardinian-French war 80 were fatal.
    According to an old surgical rule,  tetanus is the more likely
to end favorably the longer the period of time between the causa-
tive injury and the occurrence of  the tetanic symptoms.   Statis-
tics justify this  statement; for, according to Poland's collection
in Guy's Hospital, 96.7 per cent,, and in the Glasgow Hospital,
96.6 per cent,  of the cases of tetanus proved fatal  when the
 symptoms appeared within ten days after  the  injury, while the
 entire mortality is  84.2 and 87.5 per cent. (E. Rose).
    Different authors ascribe  peculiar prognostic value to single
1 The Dublin Journal of Med. Science. 1872. III. p. 185. 
               TERMINATIONS  AND PROGNOSIS.             357

symptoms.   Thus, Laurie says,  those cases are especially serious
where during the first days of the disease every attempt to swal-
low causes an attack of suffocation.   Wunderlich sees the first
signs of the fatal  catastrophe in the occurrence of a slight stra-
bismus ; the danger of a very frequent pulse is especially insisted
upon  by Parry.   The  prognostic value  of  these and  similar
separate  signs is, however, always rather limited.  Yet  almost
all physicians agree in this, that where the paroxysms are severe
and of frequent occurrence, there is great danger to life.
   A quickly fatal termination is the rule in cases  where the
rigidity rapidly increasing  becomes very great—in the so-called
acute cases,  according  to E. Rose.  Cases are  recorded  where
death occurred in the short space of a few hours ; thus,  Whytt
saw a young  girl  die after ten  hours.   Especially in the newly-
born death generally follows in a very short time.  Most of the
fatal cases occur within  the first ten days from the beginning of
the disease.  Among Friedrich's 128  fatal cases 83 died within
the first four days, and according  to the statistics of Poland,
covering 262 cases, 63 per cent, died  during  the first five days,
and 88 per cent, during the first ten days (E. Rose).
   Hence we deduce  an important prognostic rule, namely, that
after the first days the probability of recovery rapidly increases.
This has been long known, and found expression in the Hippo-
cratic aphorism, according to wliicli tetanus  ends in recovery if
the fourth day of  the disease can be survived.   This  rule is, of
course, not true within such  narrow limits, as death may occur,
exceptionally, even after the course of weeks.  These exceptions
depend upon the fact, either that the  paroxysms of spasms are
renewed after they had once ceased,  or death takes place from
exhaustion and complications.  The paroxysms of spasms exert
a special influence upon the extreme  mortality during the first
stage of the disease ;  their long  continuance renders life impossi-
ble ; and hence, if their severity does not quickty diminish, they
prove fatal.  In fact, death frequently occurs during an attack.
In other cases the spasms cease, and death follows during a mild
delirium, generally with greatly increased frequency of the pulse
and high temperature.
   In cases of recovery the convulsive attacks diminish, becom- 
358
BAUER.—TETANUS.
ing lighter and less frequent, and after a time entirely cease.
The rigidity still continues for a while ; it disappears very gradu-
ally, and  not  in  any particular order.   Hence, it is generally
many weeks before complete recovery ; indeed, a certain irregu-
larity in muscular action, the sense of stiffness, may persist quite
a long time.  Possibly ruptures and  hemorrhages have an influ-
ence in this direction.  The  return of sleep is also a favorable
indication.
   In certain cases of tetanus permanent consequences, paraly-
ses, have  been reported.   This is,  however, very rare if, indeed,
the accuracy of these observations may not be doubted.

                         Diagnosis.

   In well-marked cases the features of tetanus are so clear that
there is no difficulty in the diagnosis.  Yet, at the beginning of
the disease the obscurer symptoms may be easily overlooked, or
their importance underestimated  ;  in  cases  of  disease among
nurslings, especially, the disturbance in  nursing  should lead to
local examination.  Then, too, it is possible to confound this dis-
ease with some others, both  in its  beginning and during a more
advanced stage; finally, there are  cases which, according as
views differ, will be called tetanus by some  and a different
disease by others.
   In by far the majority of cases trismus is the first symptom
of tetanus; rarely is it the only one.  But as the stiffness of the
jaws may occur from  various circumstances,  it  is  especially
necessary to examine whether it  may not depend upon some
local cause, as angina, parotitis, disease of the  teeth or of the
articulations, etc., and this is not a difficult examination.
   The diagnosis of those cases of tonic bilateral spasm in the
domain of the trigeminus, which depend upon other causes, and
are  not  to be regarded as tetanus—the so-called  masticatory
facial spasm (see this Cyclopedia, Vol. XL p. 301)—must depend
upon a  consideration of the  etiology  and the accompanying
symptoms.  Furthermore, the statement of E. Rose is of value
here, according to which, even in the light forms of tetanus, the
cervical  muscles are slightly affected,  so that  simple trismus 
                         DIAGNOSIS.                       359

must be considered of rare occurrence when the conditions are
present which may give rise to tetanus.
   It has been already stated that tetanic spasms may occur in
connection with a great number of morbid processes, and that the
succession and order of  the  spasms  especially  determines the
diagnosis.  Thus it is easy to  recognize general convulsions as in
uraemia, likewise other forms of spasm, as  epilepsy,  paralysis
agitans with muscular stiffness, etc.   Hysterical spasms, too,
can easily be distinguished from tetanus, though the resemblance
is so great that a hysterical  tetanus has been described ;  but an
interval  of uncertain length,  which is entirely free from  spasm,
follows the paroxysms in hysterical  disease, and then the hys-
teria can also be recognized by other symptoms.   Diseases of the
spinal cord, accompanied with symptoms of motor  irritation,
especially myelitis, are likewise not difficult  to distinguish from
tetanus by the order of succession of the spasms and the para-
lytic symptoms which appear  at the same time.
   In certain stages tetanus  may be confounded with cerebro-
spinal meningitis, even with  tubercular basilar  meningitis, as
both  give rise to stiffness of  the neck.  But in  the two latter
there is rarely trismus, and the accompanying symptoms of both
processes would prevent any prolonged mistake.
   That  form  of  spasm known by the name of  tetany can be
sufficiently distinguished from tetanus by the very different suc-
cession of the spasms, the perfect intermissions, also by  Trous-
seau's symptom and the result of electrical examination (see this
Cyclopaedia, Vol. XL).
   It  is of interest and important  to recognize during life the
difference between essential tetanus and cases of toxic origin,
especially strychnia poisoning. (For a more accurate account of
this, see this Cyclopedia, Vol.  XVII., also the proof of the pres-
ence of poison in cases of poisoning.)1  The principal diagnostic
points may be summed up as  follows :  Essential tetanus  begins
with trismus, and gradually descends to lower muscles; the in-
crease of reflex irritability is  at  first  not very marked; on the
other  hand there is no intermission  of the  tonic spasms.   In
1 Compare also L. Hermann, Lehrb. der Toxikologie. 1874. 
360
B A U E R. —TET A N US.
strychnia  poisoning the general  reflex spasms appear immedi-
ately in their full intensity, but there are perfect intermissions,
and they soon end in death or recovery.  Besides, in the tetanus
caused by strychnia, the spasms chiefly affect  the extremities,
the hands, but in tetanus it is  not so.  In  strychnia poisoning
there are gastric symptoms, and consciousness is lost, symptoms
which do not occur in tetanus.  These diagnostic differences are
not so clearly marked as the above statements would lead one to
suppose, and they are well defined only in cases of acute poison-
ing when compared with the lighter cases of tetanus ; in chronic
poisoning  the phenomena are different.
   It is scarcely necessary to mention that tetanus must not be
confounded with hydrophobia, as formerly happened ; the latter
resembles  tetanus only in the reflex spasm of  the  muscles of
deglutition, but otherwise the  two diseases have little in com-
mon.  (See this  Cyclopedia,  Vol. HI.)

                         Treatment.

   The  history of the treatment of tetanus is very instructive,
showing how little prospect  there is of establishing any thera-
peutical proposition by purely empirical means. There is scarcely
a remedy, especially if it has  any influence upon the nervous
system, which has not been used in the treatment of tetanus, and
been praised for its success.   On the other hand,  we see again
also that  so-called empiricism  can never be without theoretical
ideas, and is always founded upon them.1  Thus the notion that
tetanus was of an inflammatory nature, led, as a natural conse-
quence, to the use of antiphlogistic remedies :  bleeding and mer-
cury.   Mercury was highly recommended by Donald  Monro,
and was subsequently often used even to salivation ; but Larrey,
J. M'Gregor, Mosely and others, declared that its use was with-
out good  effect and injurious, and cases have been reported in
which, indeed, the  outbreak  of  tetanus was connected  with the
fact of the salivation.   It is scarcely necessary to say that mer-
curial stomatitis occurring with  the tetanus  is not a matter of
1 See Med. therap. Worterbuch von Ch. Siegert.  1856. 
TREATMENT.
361
indifference.  General blood-letting, which formerly retained its
reputation in the treatment of tetanus,  notwithstanding many
contra-indications, has in a great measure lost its reputation,
owing to the lack of inflammatory changes found in the body.
Tetanus is  no longer treated by blood-letting, unless  it be in
Italy.  The spasms may, indeed, temporarily cease after bleed-
ing to syncope, but it is scarcely necessary to refer to the irritat-
ing effect of cerebral anemia upon the motor centres.   Besides,
there are numerous other reasons which  forbid extensive bleed-
ing in the treatment of tetanus.  Individual cases of recovery are
not sufficient to offset these contra-indications.
   No attention need be paid to this nor to an entire  series of
similar procedures in treatment.   I believe that'the symptoms of
tetanus  present very decided  indications, since  there cannot be
any question of a truly specific line of treatment.
   As tetanus is  of  traumatic origin in the vast majority of
cases, and as we cannot avoid the conclusion that improper treat-
ment of the wound  and unfavorable hygienic  conditions have
great influence upon the occurrence of the disease, it is indispen-
sable to use all possible care in the  treatment  and care of the
wounded, according to the well-known principles of surgery, and
especially is the influence of sudden and severe changes of tem-
perature to be avoided.
   If a  case of tetanus is  dependent upon the lesion of a peri-
pheral  nerve which can be reached,  it seems necessary to cut
short the peripheral irritation according to the best of our ability.
This  proposition has been  long recognized, and the solution of
the problem has been sought in various wrays.   Amputation and
excision must  appear the most  certain means to eradicate the
evil by the roots ; these procedures have often been put  in prac-
tice,  and were especially praised by Larrey, and  even at the
present  time the  discussion in  regard to them has not ceased.
Ulearly this question  only relates to secondary operations, when
the symptoms of tetanus are coming on or are already present;
that is,  to operations which are performed on account of the teta-
nus, and for no other reason.   But the most satisfactory reasons
exist  in opposition to amputation ; the wound left thereby itself
again presents  a  seat of  irritation for the ends of  numerous 
362                  BAUER.—TETANUS.

nerves,  and these may under  some circumstances give rise to
tetanus even after primary amputations.   Then the discovery of
ascendino- neuritis, with all  its consequences, would contraindi-
cate amputation, as the object sought by the operation would
not be gained.  Among the opponents of amputation we find the
most celebrated  surgeons, such as A. Cooper, Dupuytren, and
others.  The indication present should be fulfilled  by milder
measures, by division of the nerves, which was first done by G.
Hicks.  The  most striking results of this method were obtained
by Murray, and many examples of its favorable influence have
since been reported.  The only objection to the general practice
of immediate section of the  nerve may be found in the fact that
it is frequently necessary  to follow it by more extensive surgical
interference, and that, if  there is  ascending neuritis, the source
of the disease is not reached.
   Nevertheless, surgical  treatment opens a wide and influential
field: the careful treatment of  the wound  itself, removal of for-
eign bodies,  dilatation  of  wounds where the  secretions are
retained,  in some cases resection of the nerves, are of the greatest
and most pressing importance.  It is  especially necessary that
every manipulation of the wound  should be under the influence
of an anesthetic.  Again, the nerve-trunk if  already inflamed
should be handled as  little as possible, and we should hardly
attempt to get along without the local use of morphia.
    A further indication is to diminish or remove the central irri-
tation,  and to hold in check  the  excessive irritability already
present.  The first of these purposes cannot be attained in any
better way than by the use  of  narcotics and hypnotics.  Among
the different agents of this class opium and morphia are the ones
almost universally used, and, indeed,  by many physicians in
enormous and even incredible doses.   Both agents have certain
properties which render them objectionable for this purpose, i. e.,
their primary stimulating effect,  which may manifest itself by
 exciting spasms, though this is rare in man.  In fact, they are prac-
 tically and properly being more and more supplanted by chloral
 hydrate; this is superior to every other means, even the inha-
 lation of chloroform, for the accomplishment of the purpose in
 hand.  Hashish or cannabis Indica, which has been recommended 
                         TREATMENT.                      353

 by some physicians, is too uncertain as a hypnotic, and its action
 is not sufficiently well known to justify its use in this connection.
 Tobacco, which has been highly praised in the treatment of teta-
 nus  by many physicians (especially Curling), exercises a favor-
 able influence upon the  spasms by its powerful paralyzing action
 upon the cerebrum and  spinal cord. But it also possesses serious
 disadvantages, especially by its primary stimulating action, and
 the extreme depression which follows  its use.  Hence, the desired
 object of diminishing the  irritability can be better attained by
 the use of bromide of potassium. Calabar bean or physostigmin
 is also  to be  recommended for this purpose, as  it at the same
 time also diminishes the irritability of the motor nerves.
   As the tetanic spasm may evidently also be affected if only
 the irritability of the motor nerves and of  their  termination in
 the muscles be diminished, various remedies have been used in
 tetanus which act in this manner.  Among these are included
 prussic acid, belleulonna, and especially curare.  In controlling
 the spasm w7e do not, of course, consider the tetanus as cured,
 but only that one symptom is removed,  the importance of which
 has been sufficiently discussed.   Cases enough are known where
 the fatal termination has followed, notwithstanding the interrup-
 tion of the spasms.   This fact, of course, will govern  the choice
 of remedies so that  other injurious consequences may not follow
 their action, especially in regard to the heart.  Considering these
 circumstances, the control of the  spasm will be  attained most
 satisfactorily by the use of hydrate of chloral and bromide of
 potassium.
   The cold  bath and  cold douche must be looked upon as anti-
 quated  and  heroic  means, wdiose efficacy,  in their time, was
 regarded by Wright and Currie, and especially  by Brodie,  as
 beyond all doubt.  Certainty, cases have been known in which a
 severe attack  and  consequent  death  have  occurred when the
 patient was put into the  water, but there have also been cases of
 rapid improvement.  That this procedure is, in truth, dangerous,
 is evident from the fact  that the influence of cold is a powerful
 irritant of the sensory nervous system.   But  the possible efficacy
 of  this method must be sought  in this  same powerful sensory
irritation, as the  severe excitation must produce subsequent ex- 
364                  BAUER.—TETANUS.

haustion ; hence an influence must be exerted upon the distribu-
tion of the blood and upon the nerves of the vessels.   However,
the possible danger attending their use is  an argument against
having recourse to baths, but they are a very valuable agent, and
I ought to point out a special indication for their use, viz., that
stage of the disease accompanied with excessive elevation of tem-
perature, often combined with cessation of  the  spasm, delirium,
etc.   Under  these circumstances a bath,   especially  one with
gradual reduction of the temperature, meets the double indica-
tion of lowering the temperature and exerting a reflex influence
upon  the brain, etc.   The  warm full bath,  especially recom-
mended by French practitioners in the rheumatic form, can have
scarcely any other object than to equalize the irritability of the
sensory nerves, change the distribution of the blood, and prevent
variations in temperature.   The  fact is, that patients  find the
warm water very pleasant, and on this ground its use is certainly
justified, though the experience of different physicians varies in
regard to its  influence upon  the  spasms and the  course of the
disease.  The vapor bath, likewise employed, offers the same ad-
vantages only in less degree, but the objections to it are greater.
(Stuetz's alkaline bath is antiquated.)
   To prevent the spasms, care must be taken to put the patient
under such conditions as to avoid all irritations, as noises, jar-
ring, changes from light to  dark, and changes  in temperature.
The patient should be forewarned of  every unavoidable touch.
   A very important task is to support the strength;  by most
observers the greatest emphasis is laid upon this, to place at the
disposal of the organism as much power as  possible by means of
food and stimulants.  Feeding is rendered very difficult by the
closure  of  the jaws, the introduction of solid food is often im-
possible, and even  the administration and swallowing of fluids
may be prevented.  Hence, the proposal is quite rational in such
cases, during anesthesia, to introduce food through the stomach-
tube, perhaps through the nostril. Besides, the difficulty caused
by the locked jaw may be met by the use of nutritive enemata.
   Even  to the present day English physicians emphasize the
importance of caring for the  free  evacuation of the bowels.
There are certainly some arguments in favor of  this, for an evac- 
TREATMENT.
365
nation of the bowels rarely occurs spontaneously, And the accu-
mulation of feces is accompanied with a series of consequences
which may most disastrously influence  the result in tetanus.
Probably this object can be attained without danger by the exhi-
bition of powerful  cathartics  according  to  the English custom,
yet an energetic irritation  of the intestines in this way does not
harmonize wdth the other indications, and had better be avoided.
   The  treatment hitherto mentioned  fulfils the indication of
relieving the patient's  suffering  and overcoming the sleepless-
ness.  The field of therapeutic effort is not in all cases exhausted
thereby; individual symptoms may  still require special  treat-
ment, as rapid pulse, retention of urine, impending suffocation,
immoderate sweating, etc.
   The use of electricity in the treatment of tetanus is still to be
mentioned.  As yet few trials have been  made with this agent;
these are in  part negative,  in part positive in their results; the
question is still open.
   The  treatment of tetanus neonatorum must be conducted
according to the same  principles, of course with the changes
rendered necessary by the  difference  in  age ; the very few7 cases
of recovery have been ascribed chiefly to the opium treatment. 
 
CATALEPSY.
EULENBURG. 
 
CATALEPSY.
Wedel, De affect,  soporosa et  catalepsi.  Jena, 1708.— Tissot,  (Euvres.  t. XIII. c.
   XXI.—J. Frank, Prrccepta II. vol. I.  sect. I. p. 478.—Georget and Calmeil,
   Diet, de med., Art. Catalepsie.—Leubuscher, Ueber Abulie. Dainerow's Zeitschr.
   1847.—Blasius,  Ueber  Stabilitiitsneurosen.  Archiv d. phys. Heilk.  1851. S.
   234.—Skoda, Zeitschr. der k. k. Ges. Wiener  Aerzte. Nov., 1852.—L. Meyer,
   Chaiite-Annalen. 1854. H. 3.— Puel, Mem. d. l'Acad. de Med. 185G.— Buchanan,
   Glasgow med. journal.  1857  and 1858.—Schwartz, Rigaer Beitnige z. Heilk.
   1857.  Bd. IV. S. 118.—II.  Meissner, Archiv d. Heilk. 1860.  S. 572.— Mosler,
   Virchow's Archiv XX. 1861.  S. 15.—Jones, British med.  journ. G. June, 1863.
   —Macedo, Siglo medico. June, 1864.—Lasegue, Arch. gen. de Med. 1864. I.
   1865.  II.  p. 385.-—Hartmann, "Wiirtemb.  med. Correspondenzbl. 1866.   No.
   Z7>.Smoler, Memorabilien, No.  7. 1866.—M. Rosenthal, Wien. med. Presse.
   1867.  No. o.—Hiase, Archiv d. Heilk. 1868. II. 5. p. 492.—Stiller, Wiener
   med. Wochenschr. 1868. Nos. 103 and  104.—Hasse, Krankheiten des Nerven-
   systems.  2d edition.  Erlangen, 1869.—Benedikt, Elektrotherapie.  1869.— M.
   Rosenthal, Handbuch der Diagnostik  und Therapie der Nervenkrankheiten.
   Erlangen, 1870.—Hcntl/idd Jones, Studies on functional nervous diseases.  Lon-
   don, 1870.—Holm, Nord.  med.  Arkiv. III.  Nos.  14, 19.  1871.—Tamieson,
   Edinb. med. journ.  July,  1871. p. 29.— Corlieu, Union med. 1871.  No. 69.—
    Watcher, ibid. No. 74.—Glas, Upsala Lakareforen. Forh. VII. p. 17.— Wilhelm,
   Wiener med. Presse. 1872.  No. 30.

   By catalepsy is  understood  a diseased condition  of  rare
occurrence, which is paroxysmal in its manifestation.   Its path-
ognomonic symptom consists in this, that the muscles remain in a
state of contraction  into  which they enter at the beginning of the
attack, so that certain positions of equilibrium are maintained
by the limbs without spontaneous change, while passive changes
of posture, sometimes of very singular nature,  can be easily
made (so-called liexibilitas cerea).   As a rule, the attacks  are
           VOL. XIV.—24 
370
EULENBURG.—CATALEPSY.
accompanied with diminution or loss of sensation and conscious-
ness.   The affection occurs, on the one hand, as one of the many
manifestations of hysteria, on the other hand, as a symptom of
chronic cerebral disease (softening, tubercular meningitis)  and
poisoning, but also as an independent uncomplicated affection.
   Synonymous terms are: Morbus attonitus (Celsus) ; synochus;  eclipsis; hysteria
cataleptica;  trance. (By the latter name some authors understand especially attacks,
occurring in persons of an hysterical disposition, which are midway between true
catalepsy and somnambulism.)


                           Etiology.

   The causes of catalepsy in hysterical patients are the same as
those of the hysteria;  this may also be said in regard to  the
cataleptic phenomena when occurring as symptoms of chronic
softening, tubercular meningitis, etc.   The etiology of uncompli-
cated, idiopathic catalepsy is almost entirely unknown.   We
venture to assume that  catalepsy belongs  to the large  group of
diseased conditions designated by Griesinger constitutional neu-
ropathies, whereby its near connection with other neuroses of this
group (hysteria,  insanity,  epilepsy,  chorea,  etc.) is indicated,
and also that a predisposition dependent  upon congenital pre-
formation of certain portions of  the central nervous system gen-
erally precedes the  appearance of the cataleptic  attack.  This
supposition is yet further supported by  the fact that we  not
rarely observe catalepsy in families in which certain  members
are disposed to other nervous disturbances  of this group, espe-
cially to chorea and epilepsy;  or that the person afflicted with
catalepsy is also subject to other, especially to convulsive neu-
roses  of  the  most  varied  nature; or that primarily  epileptic
attacks preceded  the cataleptic.  Likewise the circumstance is
of importance that  catalepsy, like other  neuroses depending
upon  constitutional  predisposition (as chorea,  epilepsy,  hemicra-
nia),  may appear  at a very early age.   Catalepsy has been
noticed at five years of age.—As to the influence of age, the dis-
ease is most frequent in youth, especially at the time of puberty;
in advanced age catalepsy occurs only exceptionally.  There
does  not  seem to be any  marked difference in predisposition 
ETIOLOGY.
371
between the two sexes.  The supposed preponderance of females
depends upon the influence of hysteria, which, indeed, furnishes
a large contingent to the cataleptic condition in its wddest sense.
Besides, chlorosis also may possibly  exercise a causative influ-
ence among women.
   Of the more accidental influences which may give rise to cat-
alepsy, first to be mentioned are strong emotions, the influence
of which is almost undisputed.  For  example, Jones  saw a case
of catalepsy in a man sixty years old, caused by his horror at
the sudden death of his wife;  Rosenthal saw  a case in a boy
twelve years old, which came on after great excitement.  Further,
over-excitement in certain spheres of mental action undoubtedly
has a certain value as an etiological factor; especially is this
true of fanatical devotion to certain religious ideas, mystic subtil-
ties, and speculations, though it must not be denied that, on the
one hand, such a mental bias itself  in  certain cases is often to
be looked upon as a manifestation of a diseased, unnatural ner-
vous action.  On the other hand, also, the etiological connection
appears more clearly with the nearly allied condition  of ecstasy
and somnambulism than with catalepsy proper.—In certain cases
malarial infection is mentioned as the cause of typical attacks of
catalepsy; also dreams and atmospheric influences (probably,
however, only  with  previous predisposition) may  excite cata-
lepsy.  Thus, Schwartz noticed in a boy seven years old, in con-
sequence of rough maltreatment, first, a choreic condition, which
later passed into catalepsy.  Jamieson saw a cataleptic attack in
a girl eighteen years old,  after a  severe blow on the right side of
the back—yet  the same girl, two years  earlier, had  a similar
attack after a fright.  Hartmann  observed catalepsy after evacua-
tion of  pus in a chlorotic woman, who had had mastitis with
formation of an abscess during  the child-bed state.—Finally, it
must not be forgotten that cataleptoid symptoms may be volun-
tarily simulated by both men and women, and  that a rich field
is here offered to skilful deception, which almost never fails in
producing the desired result.  Numerous old and recent examples
show in this direction the most  interesting characteristic proofs
both of  the persistence and routine of  the  deceiver and of the
credulity of the deluded public. 
372
EULENBURG.—CATALEPSY.
                   Symptoms and Course.

   The complete portraiture of catalepsy is.composed of a suc-
cession  of separate attacks, wliicli are separated one from the
other by a  longer  or  shorter  interval,  often  entirely without
symptoms, often filled with complicated disturbances.  The indi-
vidual attacks themselves differ very  much in intensity and
extent, and show the pathognomonic symptoms of the cataleptic
condition more or less well marked.  On this account a distinc-
tion  has been made  between catalepsia vera and  catalepsia
spuria.   The  latter, indeed, includes  very heterogeneous condi-
tions, and is in part identical with the form called  " trance" or
" catalepsia hysterica ;"  in part also it includes the symptoms
of ecstasy  and somnambulism, without sharply  defining  the
boundary.   Since it is, however, essentially a manifestation of
hysteria or of  certain chronic cerebral  affections, we must refer
to the appropriate diseases for a description of the symptoms.
   The  attacks of catalepsia  vera  occur suddenly, as a  rule ;
more rarely there are prodromal symptoms,  consisting in an
undefined sense of  discomfort, headache, vertigo,  trembling of
individual muscles,  hiccough, etc.   Sometimes  the patients stop
suddenly in the middle of  a sentence  or of  a motion, as if
enchanted, with open mouth  or raised arm, as the sudden stiff-
ness  seizes the muscle which  is acting.   In genuine catalepsy
this  peculiar  condition of stiffness, or rather  of extreme mus-
cular tension,  extends very rapidly over all the voluntary mus-
cles,  though not always over all  in equal proportion;  more
rarely the  stiffness is  only  partial or  unilateral.  The affected
muscles have a firm feeling, and offer more or  less  resistance to
passive  motion.  This resistance gradually ceases, and the mus-
cles,  though  still  contracted  and firm, yet  yield  to  passive
motions, so that the limb can be placed in any desired position,
in which it then again  remains without change.  It is this won-
derful property which  has received the name of wax-like flexi-
bility (flexibilitas cerea).   But there seems to be a great amount
of exaggeration in the  description  of  this condition, or, at least,
in its highest degree  it  is one of the most  rare phenomena. 
SYMPTOMS AND COURSE.
373
Apart from the passive mobility of muscles  apparently so  stiff,
the peculiarity of the condition is this : positions which normally
—that is, under the influence of the will—either cannot be taken,
or, on account  of pain and weariness, can  be  maintained  only
temporarily, in catalepsy  become persistent for a  longer or
shorter time—a phenomenon  which may be explained by the
more or less complete loss of consciousness, and probably in part
by the reflex  muscular tension (see "Theory of the Disease'').
The phenomena just mentioned can be most easily produced in
the upper extremities, and, indeed, more  easily  in those portions  «
of these  in which the joints  are  smaller and  the surrounding
mass of muscle is less, so that changes  in  the position of the
thumb, the fingers, the hand, can be produced  more easily than
malposition of  the shoulder, or elbow.  The same is true of the
lower extremities  ; only, for analogous reasons,  it is much more
difficult to produce decided  change  of  position than in corre-
sponding  divisions  of  the arms, and the attempt is much  less
successful; yet sometimes it is possible to produce very wonder-
ful postures, not  only of the  extremities, but also of the whole
body ; as, for example, the patient can be placed in bed upon his
pelvis, with his arms raised, and the legs directed upward at an
acute angle, so that the body takes the shape  of a V.  Much
that is reported in  old authors concerning  the wonderful posi-
tions  of  those  possessed and the  convulsed,  concerning their
soaring in the air, etc., is  certainly to be referred to cataleptic
muscular spasm.  Moreover, the condition does not persist  long
in its full intensity ; as a rule, after some minutes  there is  a
diminution of the stiffness, so that the limbs obey the laws of
gravity, and the  arm  raised  horizontally sinks somewhat; the
extended hand is  slightly flexed ; sometimes also a slight trem-
bling gives notice of the  slowly appearing exhaustion of  the
muscles.
   The consciousness  is frequently entirely lost from  the com-
mencement of the attack; the patients do not give the least  sign
of sensation or will,  and later can remember nothing concerning
the attack.  In other  cases,  at least in the beginning of  the
attack, there  is a dull consciousness, or such  may  be present
during its whole  duration.   Then also,  as  a rule, there is  not 
374                 EULENBURG.—CATALEPSY.

complete analgesia ; weak irritations are not noticed indeed, but
stronger  ones (as severe faradic metallic pencilling) may excite
pain, and the patients afterwards remember the  sensation.  In
one  case reported by  Puel  it is said that  even  hyperesthesia
existed during the attack.   The slightest touch, a light noise,
caused gritting of the teeth, smothered cry, weak motions.   Also
in a case reported by Lasegue there was hyperesthesia of the
left half of the body,  while on the right side, which was chiefly
cataleptic, there was anesthesia.  The reflex irritability is quite
variously affected; sometimes  it  is entirely  lost;  sometimes
reflex  actions are performed ;  e. g., the eyelids  close on touching
the conjunctiva ;  the pupils react to light; on the application of
strong odors, the  eyes water, the face Hushes, and the pulse is
accelerated.  It is especially deserving of notice that  a disturb-
ance of consciousness  may continue for a while after the cessa-
tion of the attack,  and the ability of co-ordinating motions {e. g.,
speech) may return very slowly.
   In one case, during the attack, M. Rosenthal found the electrical reaction per-
fectly normal for both faradic and galvanic currents;  in another case, however,
the electro-muscular contractility, as well as the galvanic irritability of the  nerve-
trunk and  plexus, was decidedly increased.  In this case,  where there was liexi-
bilitas cerea, the position taken on account of the faradic irritation of the extensors
or flexors of the arm, or as a result of the galvanization of the corresponding nerve,
was not maintained after the cessation of the irritation; the hand returned to its
former position.   Benedikt also mentions a case with clearly marked flexibilitas
cerea, where the  galvanic  nervous irritability (radial,  median) was  somewhat
increased.   The faradic irritability was found, sometimes by direct, sometimes also
by indirect irritation, diminished in certain groups of muscles (interossei, quadriceps
cruris, the flexors of the leg).1
   As a rule,  the general vital functions undergo no  marked
change during the attack.  The respiration is generally of normal
frequency, sometimes rather slow, more frequently of diminished
or irregular  intensity, so that  lighter and deeper inspirations
alternate.  The pulse  may also be  slower, wdth slight excursion
and diminished  tension of the  arteries.  The  temperature gen-
erally remains normal, but in certain cases is decidedly lowered;
thus, in a case observed by Skoda, during the attacks the body
1 Nervenpathologie und Elektrotherapie. 1874. p. 305. 
SYMPTOMS AND COURSE.
375
was often very  cold, and this  coldness once continued forty-
eight hours.  Very severe cases,  in which, with icy cold skin, the
pulse and respiration became so  weak  as  to be imperceptible,
may have led the laity  to consider the patients  apparently or
truly dead.   Such cases form the foundation for the many exag-
gerated and wonderfully distorted stories in regard to cataleptic
persons who have seemed to be dead during several days, or
who have been  buried alive.  It is  perfectly natural that the
above  phenomena,  as also the wronderful  peculiarities  of the
cataleptic condition,  should always make a specially  weird
impression upon the  laity, and thus  give material for exaggera-
tion and invention.   But all such stories  cannot be consigned
unconditionally to the region of fable, as many medical authors
are all  too ready to do.   The older stories,  concerning apparent
death and  burying alive, are certainly so distorted and misrep-
resented that even in the most favorable case it is difficult to
discover the grain of truth upon wliicli they are founded.   But
more recently there are  cases on record which show the possi-
bility  of such occurrences.  Besides the above-mentioned case
by Skoda, there is a similar report by Hasse, who saw a girl of
very nervous disposition,  twenty years old, lie about eight weeks
entirely unconscious after jumping into the water, whose condi-
tion alternated between  attacks of spasm and a cataleptic con-
dition ; in  the paroxysms, which finally lasted nearly all day,
the patient was  deathly cold and seemed dead.  Wilhelm also
noticed in a girl eight years old, subject to somnambulism, that
in the attacks, accompanied  with  liexibilitas cerea,  there was a
coolness of  the skin and a livid  color of  the face (the urine  also
was alkaline during the attack).
    The duration of the separate attacks is very variable : some-
times they continue only a few minutes, sometimes hours, even
days ;  in the attacks  described  as so protracted, there are gen-
erally  remissions  or  intermissions, in which the consciousness
returns, the patients  at  least partially recover, then an internal
or  external irritation again  gives rise to the attack.  Strictly
speaking, it is rather a  cycle of attacks quickly following one
another, as  is  seen  in   many  severe  neuralgias  (prosopalgia,
angina pectoris,  etc.).—Sometimes the condition disappears quite 
376
EULENBURG. —CATALEPSY.
suddenly;  the patients recover at once full consciousness and
the normal  use of their  muscles, take up their employment
which  had been interrupted,  continue  the  sentence  previously
commenced, and conduct themselves as if not the slightest thing
had intervened.   Such cases are,  however,  exceptional.  Much
more frequently the patient's recovery is only slow and gradual;
they are at first somewhat stupefied, as if just awaking from
an unusually sound  sleep.   Sensibility is still diminished, the
power  of  the  will weakened ; a certain amount  of stiffness of
the muscles still remains for  some time, which renders motion
difficult and slow.
   In simple uncomplicated cases of catalepsy there are gener-
ally no symptoms in the intervals between the attacks, or they
are limited to a certain irritability and lack of nervous harmony,
sometimes also  slight lassitude, more  frequently vertigo and
headache.  It is indeed very doubtful whether these symptoms
are to be considered as the result of the  cataleptic attack, or as
the manifestation of  a neurotic diathesis.  In  simple catalepsy
there is rarely any mental symptom noticeable during the inter-
mission between attacks ; the intelligence may even be remark-
ably developed {e.g., in  cataleptic children).—Of course, this is
not the case where the catalepsy is merely one of a number of
modes  in which hysteria is manifested, or where there is a com-
plication with other neuroses (insanity, epilepsy,  chorea, etc.).
Then there may be most varied symptoms, sometimes very severe,
during the intermission, and to enumerate all such would require
too much time ;  it is  only necessary to mention as most frequent
the occurrence of hysterical  convulsions,  delirium,  maniacal
attacks, hallucinations, and finally the combination with ecstasy
and somnambulism.
   The course of the disease is very irregular,  but in by far the
larger number of cases it is chronic.  Those cases  which seem to
be caused by a malarial infection form almost the only exception
in this respect;  in  such  cases the attacks follow the regular
course  of  other malarial neuroses (usually quotidian), are some-
times  accompanied with fever and sweating,  and yield to the
usual antimalarial remedies.   Occasionally a case which  has as
its cause an accidental injury  (fright, injury) may be considered 
                    THEORY  OE THE DISEASE.                377

 as ended after a few attacks occurring  in rapid succession or
 even after a single  attack.   But generally the affection extends
 through many years, if not the entire life.  Important individual
 peculiarities  are  caused by the frequency of  the attacks,  the
 duration of the intermissions, also  by the presence or absence of
 complications.
   As among epileptics, so  among cataleptics  there is a  small
 number wdio, with  a clearly  marked predisposition, nevertheless
 suffer from  only a small number of attacks, which are separated
 from each other by intervals of many years.  Others, again,  are
 found who have the attacks comparatively often, or periodically,
 now frequently, now rarely  ; still  others, finally, in whom  the
 slightest  external influence  is sufficient  to excite  a cataleptic
 attack  at any  time.    The  greatest susceptibility to  irritation
 among  the  latter class is  found in  hysterical patients,  and to
 these belong that condition described by Lasegue  as  " catalepsie
 passagere," where sleep, a cataleptic muscular stiffness, etc,  can
 be produced by laying  the hand on the eyes, or by closing  the
 eyelids  in any other way.   Similar phenomena were observed by
 Lasegue also in many males who were emaciated and  debilitated,
 or affected with uncertain cerebral symptoms.—A fatal termina-
 tion is almost never caused by the cataleptic attacks themselves;
 but death is frequently the consequence of the original affection,
 or of some complication.


      Anatomical Changes  and Theory  of the Disease.

   The  number of autopsies heretofore published is extremely
 small; they relate besides  to such complicated diseased condi-
 tions, that they furnish no essential instruction as to  the  patho-
 genesis of catalepsy.

  An examination reported by  Schwartz relates to  the case of the boy already
 referred to, who, after an injury, had at first attacks resembling chorea, later catalcp-
 tico-tetanic attacks, and after two years died from anrcmia  and  marasmus.  There
 was found in this case, besides a serous effusion in the arachnoid, a softening of the
 corpus striatum and optic thalamus, especially on the left side ; along the posterior
surface of the  spinal cord, from the cervical  to the lumbar enlargement, was a
brownish-red, jelly-like mass, arranged in groups, covering the dura mater.  The 
378                 EULENBURG.—CATALEPSY.
spinal cord seemed healthy.  (There was no microscopic examination.)-Meissner
examined a man, forty-seven years old, who had suffered from catalepsy for six
years, and in the three last years also from maniacal and epileptic symptoms, with
paralysis of the right side; he found in the anterior cerebral fossa over the ethmoid
bone an epithelioma growing from the dura mater; the anterior third of the right
cerebral hemisphere, as far as the cortex, was much softened, also the outer part of
the  right corpus striatum.—Lasegue found no change in the  brains of two men
affected with catalepsy.
    If we examine more closely from  a physiological  point of
view  the combination of symptoms known as catalepsy,  it  is
especially the cataleptic muscular tension  (or rigidity) and the
liexibilitas cerea which as pathognomonic attract the most atten-
tion.   Most authors are inclined to the opinion that the  catalep-
tic  rigidity  is only  an increase  of the normal tonus of the
voluntary muscles, occurring occasionally in the attacks.  How-
ever,  the existence  of this  tonus is  not  accepted  beyond all
question ; yet a small number of experimental facts tend to sup-
port the opinion that there is a reflex tonus depending probably
upon the ganglion cells of the spinal  cord.   It may still remain
doubtful whether the excessive increase of this normal muscular
tonus causes a weakening or interruption in the conduction of the
impulse of the will  in the central organs, or, on the other hand,
whether the diminution of the voluntary innervation causes an
increase in  the reflex tonus of the muscles.  At  all events, even
when consciousness is not entirely lost, we always see the catalep-
tic muscular rigidity associated with diminution of the  influence
of the will in the affected muscles. Without the aid of a muscu-
lar tonus the phenomena of the cataleptic  attack are difficult to
explain.  At least it is only a circumlocution without explanation
to  refer with Blasius to the general law of the  stability of the
nervous system, or with L. Meyer to a faculty of retaining a
position after cessation of the voluntary  innervation.

   If—as seems enjoined by reasons to be  yet considered—we look upon the cata-
leptic  muscular contraction as reflex, without adopting the theory of  a muscular
tonus, we must imagine that in the cataleptic attack there are conditions especially
favorable for the excitation of reflex action in the entire voluntary muscular system.
The abolition  of sensation and the influence of the  will during the  attack, the
complete loss of consciousness generally noticed, show that there is a temporary com-
plete or incomplete cessation of cerebral function. The removal  of the cerebral 
THEORY OP THE DISEASE.
379
volition and the entire psycho-motor action renders it more easy for the occurrence
of reflex muscular action, which is often prevented by the will.  But besides,
possibly at the same time, those reflex inhibitory centres discovered by Setschenow,
situated in the corpora quadrigemina and optic thalamus (in frogs), and possibly in
the upper part of the medulla  oblongata, are  thrown out of action.  Though this
view can be received  only with reserve as purely hypothetical, yet one fact rather
tends to give it some  support, namely:  the observation often made that narcotics
and anaesthetics, at a certain stage of their action, before the production of narcotism,
may give rise to slight epileptic phenomena.1  From experiments made by Malkie-
wicz under the direction of SetschenoAv, we know that a number of toxic substances,
among them alcohol and morphia, exert a decidedly paralyzing influence upon the
cerebral reflex inhibiting centres, and it is rational to refer the cataleptic muscular
contraction occurring from the use of narcotics and anaesthetics, as well  as the
reflex spasms sometimes seen during opium poisoning, to diminution or absence of
the function of the cerebral inhibitory organs. Certainly, hereby only one link in
the chain of the cataleptic phenomena  is explained, and by no means is a special
explanation of the cataleptic condition given, but only the common preliminary
condition of such an explanation is furnished.

   The explanation of the  "liexibilitas cerea"  is  perhaps still
more  difficult than that of the cataleptic muscular rigidity.  This
difficulty does not, however, lie in  the point  where  one is most
accustomed to look for it;  namely, that  unusual or  unnatural
positions can be assumed and maintained for a long time.  The
possibility of such  positions is much more simply explained by
the absence of volition with persisting reflex action and co-ordi-
nation, /. e., wdth unrestrained or even exaggerated function of
the reflex apparatus and the co-ordinating centres of the spinal
cord and  medulla oblongata.  The integrity of these centres ren-
ders it apparently possible  that in  the  cataleptic  attacks the
balance  can be  maintained in  such abnormal  positions  as the
above  described  V-form, to which normally the influence  of the
will would be  opposed.  That it is truly  the influence  of the
will which  (consciously  or  unconsciously) exclusively or chiefly
hinders or inhibits the taking of such postures is seen  according
to my view very convincingly in the simple fact  that skilful pre-
tenders can imitate the cataleptic phenomena—even the abnormal
  1 I have myself seen an exquisite case of flexibilitas cerea, alternating with trismus,
opisthotonos, and general convulsions, in a patient poisoned by morphia  (by 0.09
gramme [a grain and one-third] of hydrochlorate of morphia). 
380               EULENBURG.—CATALEPSY.

positions  of  the limbs—so as  to completely deceive.  Here the
will not only does not oppose such co-ordinations as are usually
resisted, because painful, tiring or useless, but, on the contrary,
it  is specially directed  to produce  them, and is very strongly
interested in maintaining them.—Hence, the chief difficulty does
not lie in this direction ;  but rather in the great instability of the
position taken notwithstanding the apparent tendency to stabil-
ity ;  in the circumstance that an impulse from without, a slight
pull  or push, etc., immediately gives  the limb a  new position,
calls into play a new combination of the reflex and co-ordinating
apparatus, which  again  remains fixed until another impulse is
received.  The most reasonable, and on many accounts most evi-
dent, explanation is that the passive motion by means of the sen
sory muscular nerves acts reflexively upon  the motor centre (or
the co-ordinating centre of the spinal cord).   Nevertheless, many
considerations opposed  to  this occur to us ; first, the fact that
the reflex irritability in catalepsy is not increased, but frequently
seems diminished or abolished.  Doubts may perhaps be raised
as to this by the supposition of a different relation of the sensory
muscular  nerves and the sensory cutaneous  nerves as well as
of the centres  of co-ordination  and  other reflex   apparatus.
But  upon  what does it  depend that, while a passive motion
easily  causes a  change in  the  position of the limbs, which  is
permanent, the most powerful faradic or galvanic irritation of
muscles or nerves does not  have the same effect?  (See " Symp-
toms.")  Yet, in the latter case there is certainly a  much more
intense irritation of the sensory muscular  nerves than can be
caused by moderate passive extension or shortening! — Bene^
dikt remarks in regard  to  the flexibilitas cerea:  "Since every
muscle by every extension loses as much  power as it gains by
contraction, it is clear   that  when once  antagonistic muscles
have  that  tension which is suitable to maintain a portion of
the body in a  certain position, the  same  tension  is sufficient
for all positions in the direction of those muscles."  This remark
is  correct, but yet cannot  answer  the above-mentioned contra-
diction.  Rosenthal  also only  states more precisely the same
thing,  but does not explain it,  when he  says :  "While therefore
the irritation, acting directly upon the skin or electrical irritation 
                 PROGNOSIS AND TREATMENT.              331

of muscles or nerves, gives rise to no reflex action, at least which
may cause the position artificially produced to be permanent, the
indirect irritation of  external influence can be reflected from the
sensory nerves, especially of the bones and the  joints, upon cer-
tain groups  of  muscles.   The  so-called waxy mobility  is then
a reflex contraction."—To  the  latter view we are at all events
driven ; but  just the how %  and wherefore I of the form of reflex
action is, alas ! still unknown to us.

   The special analysis of the remaining secondary and subordinate phenomena of
the cataleptic attack must under these circumstances be of little value; what we
may know or imagine, is for the most part deducible from that which has already
been said.

            Diagnosis, Prognosis, and Treatment.

   In well-marked cases of catalepsy there  is no difficulty in
diagnosis, if by that term is understood a combination of symp-
toms characterized especially  by muscular  stiffening and the
liexibilitas cerea. Conditions wherein these pathognomonic phe-
nomena do not occur are then not catalepsy, or at least not cata-
lepsia vera, and may well be included in the  large and quite
indefinite  category  of catalepsia spuria, or, according to their
special characteristies, among  the choreic, epileptic, hysterical
forms of spasms.  Only a persistent and cleverly executed sim-
ulation could give  rise  to  diagnostic difficulty,  or  at least to
doubt.  That such a simulation  is possible  is shown by different
examples from  ancient and modern  records (among  others, the
cases from Corlieu  and Walcher  often referred to in writings).
Prolonged  observation,  more careful testing  of the  sensibility
and reflex  irritability, perhaps, too,  the examination of  the elec-
trical reactions,  would,  as  a rule,  afford  a  safeguard  against
deception.
   The prognosis of  catalepsy,  so far as concerns life,  is favor-
able, if we except complications ;  so far as  concerns the disease,
it is generally  unfavorable, since in the  majority of cases  a
spontaneous recovery, or one due to  treatment,  is  not  at all
probable.   Yet, as Ave  have seen, there .are  exceptions; espe-
cially do those cases,  caused by a malarial  infection,  running  a 
382               EULENBURG.—CATALEPSY.

typical  course, furnish a  better prognosis ; the same is true in
regard to many cases of catalepsy occurring in relatively healthy
persons  from more accidental  causes (injuries, mental shocks,
etc.)  In inveterate cases, with nervous predisposition and severe
complications (hysteria,  insanity,  etc.),  the  prognosis is,  of
course,  especially unfavorable.
   Two  problems  may be proposed  in the treatment: first, to
stop the attack, or cut it short; then, to  prevent the return of
the attacks.  The  latter task can be undertaken wdth confidence
of success only where there are grounds  for  believing that the
cause can be removed, as in malarial infection.  In such cases
improvement or recovery has been obtained by the use of quinia,
as is shown by the reports of Medicus, Eisenmann,  Glas, and
others.  In other  cases quinia alone  or combined with morphia
(Hartmann) has been of  benefit.   Favorable results have  been
obtained also by the  use of tonics, iron,  ergot (Glas), morphia
and the cold douche (Smoler), and by electricity in  the form of
the induced current (Macedo).  The constant current has hereto-
fore given no good result (Benedikt, Rosenthal).   Rosenthal also
found in one case  that the subcutaneous injection of  curare had
no marked influence.
    As to wdiether a palliative treatment of the attack is to be
recommended or not, cannot be  decided off-hand  ; at all events,
the  danger of interfering, claimed  by one  party, is  not clearly
proven—but also, certainly,  the efforts  heretofore made  have
given few positive results.  In one case of Lasegue's a bleeding
during  the attack had no influence upon the cataleptic condition.
Calvi thinks that  by  the injection of tartrate of antimony into a
vein of the arm he caused  the  cataleptic rigidity to disappear.
Jones recommends for  the same  purpose w7et  packing,  cold
douche, and  the induction current.  In  the hysterical cases
designated  by Lasegue,   " catalepsie  passagere,"  the patients
awake  from their somnolence sometimes under  slight external
irritation, e. g., from sprinkling with water ; but in true catalepsy
a very strong cutaneous  irritation  has often no influence.—The
use of  such palliative remedies should be especially advised in
attacks which last very long, as well as in  the rarer cases which
are accompanied with more severe disturbances of the circulation 
TREATMENT.
383
and respiration, great weakness of the cardiac action—a condition
simulating death.   In very protracted cases or in those attacks
which consist of a series of attacks rapidly following each other,
separated by imperfect  remissions, lasting  through many days
and weeks, artificial feeding by the stomach-tube or by nutritious
enemata may also be necessary. 
 
TREMOR.

   (Trembling.)
v. Swieten, Commentaria.  t. II.  p. 167. Paris, 1771.—Merat, Traite" de la  colique
   metallique. 2d. ed. Paris, 1812.—Tanquerel des Planches, Traite des maladies
   de plomb. Paris, 1839.—Romberg, Nervenkrankheiten.  2. Aufl. 1851. Bd. II.—
   Brown-Sequard, Experimental researches applied to physiology and pathology.
   New York, 1853.—Schiff,  Lehrbuch  der Physiologie.  1859. Bd. I.—Gubler,
   Arch. gen. de med. 5. ser. XV. 1860. p. 702.— Valentin, Versuch einer physio-
   logischen Pathologic dor Nerven.  Leipzig und  Heidelberg, 1804. 2.  Abth.—
   Sanders, Edinb.  med. Journal. 1865, May.—Ferrand, Union medicale. 1868.
   No. 62; No. 107.—Gueneau de Mussy, Gaz. des hop.  1868.  Nos. 48, 50.—A
   Eulenburg, Zur Therapie des Tremor. Berl. klin. Wochenschrift. 1872. No. 46.—
   Cazenave, Gaz. med. de Paris.  1872. Nos. 18,  19, 27.—Oulmont, Bull. gen. de
   ther. 15. Dec. 1872.

   By  tremor or  tremor musculorum  (muscular  trembling) is
understood a clonic spasm of the  voluntary muscles,  consisting
in slight oscillatory contractions following each other in rhyth-
mical  order.   Tremor is therefore only  a  symptom, wliicli is
found,  with others, locally in neuritis,  more extensively also in
certain central neuroses (disseminated sclerosis of  the nerve-cen-
tres ; paralysis agitans), and in chronic poisoning (alcohol, opium,
lead, mercurial  poisoning); but it  may also appear under some
circumstances as an independent  disease,  or at least as the only
noticeable symptom  {tremor  essentialis s.  simplex)—as a rule,
with a very chronic course and gradual development.

  The synonyms arc:  Astasie musculaire (Gubler); dysteria agitans  (Sanders).
          VOL. XIV.— 35 
386
EULENBURG.—TREMOR.
                          Etiology.

   Simple uncomplicated tremor occurs especially in advanced
age {tremor senilis).  Those forms which  depend upon chronic
disease of the brain and spinal cord, as also toxical tremor, are,
on the other hand, not dependent upon any particular time of
life, and are observed most frequentty in middle age, or, indeed,
even in youth. However, simple tremor may exceptionally occur
in persons who are still young, so that the terms "tremor sim-
plex" and "tremor senilis" do not exactly coincide.
   I have not noticed that women (as Hasse states) are more dis-
posed to tremor than men.  Though tremor may occur as one of
the manifestations of hysteria, yet this is not very frequent.
   Toxic tremor depends specially upon those conditions which
lie at the foundation of the corresponding chronic poisoning;
tremor mercurialis and saturninus are especially  professional
diseases: the former is found especially among gilders, looking-
glass  manufacturers, and  artisans in quicksilver;  the latter,
among hat makers, and others, who  are exposed to the vapors of
lead.   Yet, tremor mercurialis may  arise from medicinal poison-
ing.  The mercurial tremor is relatively much more frequent and
characteristic than the saturnine.—The tremor caused by alcoho-
lic intoxication is seen exclusively among drinkers {tremor pota-
torum)—that which depends upon opium, among opium-eaters.
—Also chronic poisoning by nicotine,  or the other injurious sub-
stances found in tobacco and tobacco  smoke, seems to cause tre-
mor.  I have repeatedly met this symptom among young cigar
makers who smoked to  excess.  Also the immoderate use  of
coffee and tea, further the prolonged use of small doses of quinia,
so it seems, may give rise to tremor  in some cases.
  As causative may also be mentioned exhausting diseases (espe-
cially typhoid),  great  bodily and  mental exertions, excess  in
venery,  onanism.   Trembling occurs temporarily  in diseases
accompanied with fever, especially during  the  chill.   Sometimes
tremor has been  seen in young persons  immediately after the
receipt of an injury (fall upon the back, a thorn under a toe nail,
Sanders).  Frequently the cause  of habitual  tremor cannot be
discovered. 
SYMPTOMATOLOGY AND COURSE.
387
                 Symptomatology and Course.

   Apart from the various  complications, muscular  trembling,
even in  simple tremor, shows a great difference in intensity and
extent.  In the beginning, and in slight cases of the affection, the
trembling  is noticed, as a rule, generally or exclusively when
voluntary  motions are attempted,  and then  affects especially
those muscles  whose action is  intended, or neighboring syner-
getic, or antagonistic muscles (muscles of  the  hand and arm in
raising a weight or on attempting to write).  Yet often  also dis-
tant groups of muscles  are immediately or gradually  affected,
whereby sometimes the extension seems  to follow the laws of
reflex action, as the symmetrical muscles of the opposite side are
first called into action, then the muscles of the upper part of the
body {e. g., the muscles of the head  when  the arm is  moved) ;
later, and generally with much less strength, also the muscles of
the lower  limbs.   The origin of the tremor has, in such cases,
much similarity with choreic movements ; yet, herein is a differ-
ence, that the trembling up to a certain degree can be suppressed
or moderated  by increased force of will,  while strong  effort of
the will in chorea generally causes an increase of the tumultuous
motions.  Also the perfect concentration of the attention, espe-
cially strongly exercised mental power, may sometimes tempo-
rarily cause a cessation or remission of the muscular  trembling.
On the  other  hand, this  often disappears when there is more
complete bodily and mental rest, with mechanical support of the
trembling  limb,  while reposing in a horizontal  position,  and
almost always during sleep.  In a similar way the tremor of
drunkards and opium-eaters may be  made to disappear tempo-
rarily by renewing the use of alcohol or opium.
   In simple tremor, trembling rarely reaches that degree of
intensity which is seen in that variety which is accompanied with
paralysis, as may be seen in its prototype—paralysis agitans (see
the following section). Hence, w7e generally notice only scintillat-
ing oscillating vibrations of separate groups of muscles; the affec-
tion rarely reaches such severity as to show spasmodic contrac-
tion of all the muscles, and thus resemble shaking palsy.   The
power of the affected muscles,  so soon as the trembling ceases, is 
388                EULEXBLKG.—TREMOR.

entirely normal; and even while the trembling persists it  is not
much diminished.   The electrical (faradic and galvanic) reaction
of the agitated muscles shows no change.   Sensibility and reflex
irritability are also not affected.
   All the voluntary muscles of the body may be affected by
tremor; yet the affection much the most frequently begins in the
arm, and  extends then in the manner already mentioned; more
rarely the muscles wliicli move the head,  or those of the  lower
limbs, are flrst attacked.  The  facial muscles of  expression, the
muscles of mastication, and those of the tongue possess, indeed,
no immunity,  but in simple tremor are very seldom affected, but
in toxic and febrile  tremor they are frequently implicated.  (The
irregularity  of the  heart's action, known as "tremor  cordis,"
occurs under quite different conditions, and  presents no precise
points of comparison.)
   The duration of tremor is generally exceedingly protracted.
The  affection  in  most cases continually increases in severity,
so that  the  trembling occurs no more merely when a motion is
intended  and  upon special  occasions, but  (at  least during the
day) persists continuously with variations of exacerbations and
remissions, with, at most, short intervals of  quiet.  Only excep-
tionally, in chronic  trembling, which  has  become habitual,  is
there seen spontaneous improvement or  recovery.   Of course,
however,  cases of tremor  may occur—especially in  young per-
sons and where the affection is due  to accidental injuries  {e. g.,
wounds)—which have a favorable course, as the symptom, after
a relatively  short duration, ceases  spontaneously or after a seem-
ingly insignificant treatment.
   Among the various forms of toxic tremor, tremor mercurialis
presents a combination of symptoms  which have  the greatest
resemblance to paralysis  agitans, and hence, by some authors
(Copland, for instance) are considered completely identical there-
with.  This similarity relates as  well to the intensity and the
extent of the  tremor itself as  to secondary paretic  symptoms
and  the  accompanying cerebral, especially psychical symptoms
(see  "Paralysis  Agitans").—In  tremor  saturninus there have
usually been noticed  long  previously other symptoms of chronic
saturnine intoxication (lead  colic,  lead paralysis, often also 
                  THEORY OF THE DISEASE.               389

arthralgia,  etc.) ; the  trembling, moreover,  much more rarely
extends to the whole muscular structure ; as a rule, it is rather
limited to the upper extremities  and to individual facial  muscles
(orbicularis, levator anguli oris) ; again, there may be added  to
the tremor many other disturbances of the nervous system—par-
alysis,  anaesthesia,  amaurosis, and the combination  of  the so-
called encephalopathia saturnina: delirium, coma, epileptiform
convulsions, etc.—Likewise  only slight  resemblance with simple
tremor is seen in the trembling which occurs in chronic  alcohol-
ism, and which forms one of the  most ordinary symptoms of this
condition.  Here also the trembling begins usually in the hands,
extends gradually to the arms, body, legs, even to the lips and
tongue, and may increase finally even to a shaking of the body.
so as to interfere with standing or walking.  The tremor pota-
torum is strongest during fasting, especially in the morning, and
is less  after  the use of spirit.  Further,  progressive muscular
weakness and paralysis may set  in, as well as numerous  nervous
disturbances: creeping sensations, arthralgia, anaesthesia, clonic
and epileptiform convulsions, and the combined phenomena  of
delirium tremens.   Besides, there are usually present previously
the disturbances excited  in  other organs by the abuse of spirit,
especially in the digestive organs.—In the tremor of opium-eaters
are seen at  the same time other symptoms of chronic opium poi-
soning (contracted  pupil, constipation, etc).  The tremor which
depends upon the action of nicotine may sometimes be unilateral,
or at least affect one-half of the body more than the other, yet it
is generally  accompanied  with various nervous disturbances
(muscular weakness, dizziness, neuralgia, myosis, etc.).

                   Theory of the Disease.

   In  the general  consideration of tremor, two questions arise
which are of great interest theoretically :  what sort of change
or irritation of  the motor nervous elements, what specific mode
of irritation,  excites the  anomalous  reaction wdiich is  termed
tremor ?—and wdiat portions of the nervous  system are the seat of
its action, the point attacked by the  irritation ?—From the lack
of pathological facts, we must depend upon the results of experi- 
390
EULENBURG. —TREMOR.
mental physiology, which here also does not fail us.  As  Schiff
first discovered, the phenomenon of trembling is seen frequently
in muscles which are experimentally deprived of the influence of
the will.   This is  most strikingly seen in the muscles  of  the
tongue in dogs after section of the hypoglossus.   The vibratory
motion of the bundles of muscular fibres are clearly seen through
the overlying mucous tissue, and, when  the section is on  one
side only, this is  seen only on  the  paralyzed side, and can be
noticed as well when the  tongue is  protruded as when it rests
quietly within the mouth.  When the contraction of one mus-
cular bundle ceases, that of a neighboring bundle  begins;  but
there is no regular extension of  the trembling, and the organ is
not moved thereby.  Similarly,  in rabbits, after section  of  the
facial, there is a continual oscillation of the whiskers ;  in birds,
after  section of the motor  oculi, there is trembling of the  iris
(which is provided with striated  fibres).  Likewise, trembling is
seen in the muscles of a limb when laid bare, whose  nerves have
been  separated from their centre.  Yet, this phenomenon does
not appear immediately after the separation,  but  first some days
later ; towards the end of  the first week, it gradually reaches its
maximum, and then may continue months or even years.   It
forms therefore only a secondary effect of nerve section,  and is
probably to be considered as the consequence of the progressing
centrifugal degeneration of  the  peripheral portion of the nerve.
As  the well-known recent investigations of Erb, Ziemssen, and
Weiss have  shown, this causes consecutive changes  in the mus-
cles (in the form  of interstitial myositis), which perhaps may
also favor the existence  of tremor  under the above-mentioned
conditions.
   Pathological observations in men offer  many points of  resem-
blance with these  experimental data, in  so far  as  that we see
tremor occur as a common symptom in cases where the  influence
of the will has ceased or has become weakened, often locally in
paralyzed or  atrophied  muscles.  Besides  the trembling  in
neuritis, in  paralysis agitans, in sclerosis of the nerve centres,
etc., here belongs  also the trembling found in nervous persons,
the energy of whose will is  temporarily or permanently affected
(e. g., hysterical persons), and in the aged, who, in consequence 
THEORY OF THE DISEASE.
391
of general  disturbance  of nutrition, have no longer the normal
control over their muscles ; the trembling in the chill  of fever,
after exhausting disease, etc., as  well  as, finally, the tremor
which depends upon the influence of poisonous substances wliicli
may act upon the functioning of the central or peripheral ner-
vous system, in part irritating, or in part paralyzing.  Under all
circumstances there is presented to us a condition  of the motor
apparatus depending upon disturbances  of the voluntary inner-
vation, from nutritive changes in  the central or in the peripheral
portion  of  the motor nervous system.   While the influence  of
the will upon the  motor  centre  is  diminished,  there is an
increased irritability of  the motor nervous elements in all other
regions of the motor apparatus, or in some single region, in  con-
sequence of which the slightest irritations which are physiologi-
cally inoperative {e. g., the usual circulatory and nutritive  pro-
cesses) give rise to that pathognomonic anomaly in  the muscular
reaction.  Hence, there  was undoubtedly some justification for
placing  tremor midway  between akinesia and  hyperkinesia, for
allowing it  (in the words of Romberg) " to form the bridge from
spasm to paralysis."  On the other hand, it seems so much the
less necessary to divide  trembling into two varieties—a paralytic
and a convulsive—as is done  by van Swieten, Gubler,  Charcot,
Ferrand, especially if the convulsive form depends (according  to
Ferrand) upon a weakness of the  muscular tone.
   In reference to the point whence general  tremulous motions
arise,  experiment has not heretofore given decisive answer.   Ear-
lier investigations by Magendie, Volkmann, and others, point  to
the spinal  cord;  thus,  B. Volkmann mentions that trembling
can be experimentally produced by subjecting the spinal cord  of
a decapitated animal to the  influence of a weak  current from
a magneto-electrical apparatus,  and turning  the  wheel rather
slowly.1  Onimus, again, refers trembling to the cerebellum, as
the common  organ of muscular  tone.  He saw in ducks, after
destruction of a small portion of the cerebellum, once also when
a clot of blood pressed upon the posterior part of the cerebellum,
  ' Article " Nervenphysiologie " in B. Wagner's Handworterbuch der Physiologie. p.
488. 
392
EULENBURG.—TREMOR.
a persistent rhythmic trembling of the head, especially motions
of the bill.  The question of the  cerebral or  spinal  origin of
tremor will come up again when we consider paralysis agitans.
Ferrand locates the point of origin of " convulsive" trembling in
the spinal cord, in its gray  substance,  which,  according  to
Vulpian, regulates  the  muscular  tone as a reflex act.   Sanders
also seeks to refer the cause of what he calls  " dysteria agitans,"
which agrees essentially with simple tremor, to an increased irri-
tability of the motor centres of the spinal  cord, which can be
referred to an ansemia of its gray substance.   The supposition of
a spinal origin of simple tremor is strengthened also by the fact
that usually the muscles  innervated  by the cranial nerves are
spared (see above).  On the other hand, other forms of tremor,
in which the facial muscles of expression, the muscles of mastica-
tion, the muscles of the  tongue, are frequently affected, are prob-
ably of cerebral origin.   This is especially true of mercurial and
alcoholic tremor, which can be referred to a cerebral origin, from
the accompanying  paralytic or other concomitant  symptoms,
especially  psychical; possibly  the same is  true of the tremor
caused by opium, tobacco, quinia ; also of that from fever.


                         Treatment.
   Of course, in all those cases wherein the cause can  be dis-
covered and  removed, the treatment of tremor must first of all
be causal.  This is  especially true in  cases of tremor  caused by
poison,  by the injurious influence of  occupation,  the abuse  of
liquor, or other indulgence.  In the treatment of mercurial and
saturnine tremor the elimination of the poison must be favored
as much as possible.  For this purpose (besides  the  means of
simply  increasing  the secretions) iodide of  potassium, sulphur
baths, and other preparations of sulphur are held in especial,
though scarcely justifiable, esteem.
   In those forms  of tremor which are not  amenable  to causal
treatment,  a  large  number  of  the  most different and in part
heroic means have been  used empirically—generally, indeed,
with most insignificant  results.  However, the tonics (ferruginous
preparations and waters, quinia) have  obtained the most general 
TREATMENT.                       393
recommendation, also residence at high altitudes, and use of hot
spring baths (Ragatz-Pfaefers). According to my experience these
remedies,  at  least in the severe  and old cases,  are  insufficient.
Also,  I have  never seen any results worth  mentioning from the
use of narcotics (morphia, chloral, calabar bean, curare, etc.),  or
of bromide of potassium.   The best results comparatively have
been obtained by me in simple tremor by the methodical use  of
subcutaneous injections of  arsenic.   (Fowler's  solution  diluted
with two parts of distilled water—of which from six to ten min-
ims,—about half of an ordinary hypodermic injection syringe,—
is to  be given for a dose.)   These  injections can be continued
daily for a long  time without  the appearance of toxical or other
unpleasant symptoms ; they have this especial advantage over
the internal use  of arsenic, that the disturbance of the digestion
caused by the latter does not occur, and they are more  certain
in their action.  Hoist and others (according to  oral communica-
tion) have also obtained favorable results in tremor by the injec-
tion of arsenic.
   Of the internal remedies  otherwise recommended may  be
mentioned, among others, hyoscyamin, from which Oulmont has
obtained  very marked  effects  in tremor  mercurialis, as  also  in
two cases with severe senile  tremor.  I have  used the hyoscyamin
up to one-twentieth of a grain daily for a long time without effect
in a very severe and old case of tremor of probably alcoholic
origin, wliicli had obstinately  resisted the arsenic injections.—In
mercurial  tremor,  Gueneau  de Massy recommended the phos-
phide of zinc (one-half grain  daily, given  in pill-form); Lafon
and Gardanne saw benefit  from electricity; Brockmann  from
the cold water douche with  sulphur  baths, and  the internal use
of nervines.   Huss has recommended fusel-oil  (amylic alcohol)
in tremor potatorum.

   As palliative, especially in extreme trembling of the hand, mechanical appliances
can he used to fix the  hand, and so render writing possible. Cazenave, among others,
lias lately contrived a special apparatus for this. 
 
PARALYSIS   AGITANS.

      (Shaking Palsy—The Trembles.)
Parkinson,  Essay  on  the shaking palsy.  London, 1817.—Todd, Art. Paralysis in
    Cyclopedia of pract. med.— Romberg, Nervenkrankheiten.  2. Aufl. 1851.  Bd.
    U.—Blasius, Stabilitiitsneurosen. Archiv d. phys. Heilk.  1851. S. 225.— Base-
    dow, Casper's Wochenschrift. 1851. No. 33.— Remak, Galvanotherapie. Berlin,
    1858.—Reynolds,  Lancet.  3. Dec. 1859.—Cohn, Wiener med.  Wochenschrift.
    1860. No. 18. ff.—Skoda, Wien. Med. Halle,  1862. 13. — Charcot and Vulpian,
    Gaz. Hebd.  1861. p. 7G5  and 816;  1862. p. 5L — Topinard, Gaz.  des Hop.
    1866. No. 21, 46. — Ordenstein, Sur la paralysie agitante et la sclerose en plaques,
    these.  Paris, 1867.— Sanders in Reynolds' System of Medicine. Vol. II.  Lon-
    don, 1868.— Yillemin, Rec. de mem. de med.  etc. milit. 3. s6r.  XXV.  p. 116.
    Aug., 1870.—Handfield Jones, Studies on functional nervous diseases. London,
    1870.—Ball, Med. Times and Gaz.  1. Oct., 1870. p. S85.—Bourillon, Gaz. des
    Hop. 1870. No. 50, hl.—Betz, Memorab.  No. 3. 1870.— Althaus, Med. Times
    and Gaz.  1870. II.  p.  643.—Meredith  Clymer,  Lectures  on the  palsies and
    kindred disorders of the nervous system.  Med. Record. 1870.—A Eulenburg,
    Lehrbuch der funetionellen Nervenkrankheiten.  Berlin, 1871.—Meschede, Vir-
    chow's Archiv. Bd. L. Heft 2.  1870.— Chvostek, Wiener med. Wochenschrift.
    1871. No. 37-39. —Joffroy, Gaz. des Hop.  1871. No. 151.— Murchison and
    Cayley, Transact,  of the path. soc.  XXII. p. 24. 1871.— Joffroy, Arch, de phys.
    norm,  ct path. 1872.  No. l.— Claveleira, De la paralysie agitante. 1872.—
    Kuehne, Inaug, Diss. Berlin, 1872.—A. Eulenburg, Berl. klin. Wochenschrift.
    1872. No. 46.— Charcot, Klinische Vortrage iiber die Krankheiten des Nerven-
    systems. Deutsch  von  Fetzer.  Stuttgart,  1874.—Benedikt, Nervenpathologie
    and Elektrotherapie. Leipzig, 1874.

   By shaking palsy or paralysis  agitans is understood a com-
bination of symptoms, the  chief  elements of which, as  its  name
implies, are two phenomena : a gradually increasing  motor weak-
ness and  a trembling in  the voluntary muscles of the body, the 
396             EULENBUKG.—PARALYSIS AGITANS.

latter, however,  preceding  the paralytic symptoms, or  at least
being present in a greater degree.

   As Galen already distinguished two kinds of trembling (rfafytoj and rpf^oj), and
van Swieten a "tremor a debilitate" and "tremor coactus," it seems to have been
a more or less complete differentiation of paralysis agitans, at least of its allied dis-
orders, and simple tremor.  Yet Parkinson (1817) was clearly the first to accurately
describe the disease.  Nevertheless it was afterwards many times  confounded  in
part with chorea, in part with other forms  of trembling, finally, in part with an
affection only recently fully recognized—multiple or disseminated sclerosis of the
nerve centres (sclerose en plaques disseminfies).  While Trousseau and See, in their
work on chorea and  other diseases, cleared up also the distinction between this dis-
ease and paralysis agitans, the distinction between the latter and multiple sclerosis,
which was  more difficult to settle,  was shown by Charcot and Ordenstein (1867).
A succession of works concerning multiple sclerosis, which have  appeared  since
then  (by Bourneville, Loo, Baerwinkel, Sclmele, Liouville, Leube, Erbstein, Jolly,
and others) as well as some  new post-mortem examinations in paralysis agitans,
have assisted materially in more exactly distinguishing the two diseases one from
the other.  Yet the  number of pathologico-anatomical examinations is still very
small, and  is not at  all sufficient to justify the forming of a satisfactory theory of
the clinical combination of symptoms in paralysis agitans.
   Synonymous  terms: Chorea festinans (Sauvages); chorea procursiva (Bernt);
sclerotynbe festinans, etc.


                              Etiology.

   Paralysis agitans is  a disease  which occurs at  a relatively
advanced age.   It  is rarely seen  below forty, is most frequent
after sixty years.   Its  appearance  in childhood is most uncom-
mon ; yet Meschede mentions a case where the disease showed it-
self  in a boy twelve years old (it is said after being kicked in the
face by a horse).   Duchenne  observed a case where the affection
occurred in the  twentieth year.   Men are much more frequently
attacked than women.   Special predisposing causes can scarcely
be proved.  One must, however, consider as such, age, particu-
larly the  senile  condition of  the heart and of the blood-vessels
connected therewith.  Yet organic disease of the heart or arterial
sclerosis  have not by any means been found in all  cases of paral-
ysis agitans during  life,  or even at the autopsy, when such has
been made.  Hereditary influences have hitherto,  at least, not
been proved to exist.   In England and North America the affec- 
SYMPTOMS AND COURSE.
397
tion should be especially frequent, yet it belongs also even there
to the more rare affections.  (According to Sanders there are in
England  and Wales on an average  twenty-two fatal cases of
paralysis agitans yearly, of which  fourteen are males, eight
females.)
   The affection seems  to occur chiefly in persons in the lower
stations in life,  who are  found in unhealthy situations,  have
worked hard, do not inherit robust constitutions, and also have
been subject to violent  emotions.  Many observers mention the
effect of  violent emotions, especially a sudden fright:  e. g.,
one by van Swieten of  a man who was awakened by a frightful
clap of thunder ; another by Oppolzer of a man who was fright-
ened by the bursting of a bomb at his side ; a third by Hillairet
of a man who saw his son murdered before his eyes.  In all these
cases the outbreak of  the  trembling followed immediately the
exciting  emotion.   In  other cases a wound  is mentioned as the
direct cause, e. g., in the case of Meschede, already referred to,
also in many  cases reported by Sanders and Charcot,  which,
however, according to  their descriptions, seem to belong to sim-
ple tremor rather than  to paralysis agitans.  In one case by Betz
cold bathing of the head and hands, with a cold drink, was men-
tioned as the cause.

                   Symptoms  and Course.

   The initial and  prominent symptom of the disease, the tre-
mor, appears now as a peculiar trembling, in the form of weak,
oscillating, rapidly repeated vibrations ; now in  strong clonic
spasms, consisting of contractions, wliicli occur by fits and starts
(shaking  palsy).  These motions begin generally  in the upper
extremities, especially the hand and forearm, and gradually in-
vade also the  lower limbs, and also the facial muscles.   In the
latter case there is sometimes also disturbance of articulation
(stuttering).  More  rarely the muscles  of  the body are impli-
cated, among these especially the muscles of the neck, so that
there is trembling or pendulum-like motion of the head.  In indi-
vidual cases the tremor remains confined to one-half of the body,
or, indeed,  to  a single  extremity  (generally an upper).  As  a 
898           EULENBURG.—PARALYSIS AGITANS.

rule, both sides of the body, though in unequal degree, are suc-
cessively attacked.  In  the same patient the trembling does not
have always the same intensity and extent; sometimes it contin-
ues with undiminished  severity for days ;  sometimes there are
remissions lasting  many days, or it temporarily leaves one limb,
or a muscle, while it appears in others with greater  severity.
When the  patient lies  down, it is generally weaker or ceases
entirely.  In other cases the trembling is, indeed, never entirely
wanting, but paroxysmally it increases to a great intensity, and,
indeed,  the occurrence of such paroxysms is clearty favored by
bodily or mental exertion.  But in general the trembling is com-
pletely independent of  voluntary motor impulses as well as of
passive  motions, and  this circumstance  is  of great value  as a
means of diagnosis to distinguish it from many forms of chorea
and  also from the trembling in  disseminated  sclerosis of the
nervous centres.
   The  paratysis occurs generally secondarily after a longer or
shorter  persistence of  the tremor, and gradually increases in
intensity and extent, yet it almost always remains partial, and
not rarely is more circumscribed  or is irregularly developed in
different muscles  or  muscular  groups.    As in  various  other
paratyses, the extensors of the limbs are affected by preference,
while on the other hand a corresponding stiffness appears in the
flexors.   In many  cases there  is no  diminution in the motor
power (measured,  for example, with a dynamometer); again, a
marked  delay  is seen  in executing an  intended motion,  as in
speaking, combined with a disproportionate weariness (Charcot).
The electrical reaction for the induced as  well as the galvanic
current  is  entirely normal  in  the affected muscles, as I have
convinced rm7self in some very old and severe cases.  The  trem-
bling often  abates in all  the muscles, or in those especially impli-
cated, while the paralysis increases.   It is quite exceptional for
the involuntaiy muscles of the bladder and the rectum  to be
affected by the paralysis.
   In many cases there  is developed gradually in the muscles of
the limbs, also of the trunk and neck, a condition  of excessive
stiffness, recalling  the rigidity of  catalepsy, which,  at first  tem-
porary,  becomes later permanent, and may give rise to deform- 
SYMPTOMS AND COURSE.
399
ities.  By the rigidity of the  anterior cervical muscles the head
is bent strongly forward (as  Parkinson remarked), and can be
raised or  rotated only with difficulty.   The body is also inclined
forward,  which causes the appearance of  a tendency  to fall for-
ward  noticeable in walking.  The elbows usually stand some-
what  off  from the thorax ; the forearm is slightly  flexed on the
arm ;  the fingers are semi-flexed,  inclined towards  the ulnar
border of the hand, and in the various joints alternately flexed
and extended (as is seen in arthritis deformans) ; thumb and
index fingers are frequently extended and approached one to the
other  as  in  the position for writing.   Similar deformities are
developed in the lower extremities by the predominant contrac-
tion of individual muscles, especially of the muscles of the calf :
the knees are adducted ; thighs and feet  are  in the well-known
position of equino-varus.  Of course, the difficulty  of performing
any motion, especially locomotion, is greatly increased by this
muscular contraction and the rigidity, which  finally  becomes
permanent;  the patients  in  walking give the impression as  if
they moved  forward drawn up together, as if their joints were
grown together (Charcot).   Moreover, the  advent of the stiffness
occurs usually in an advanced stage of the affection ; it is only
exceptionally noticed in the  beginning.—Another  more uncom-
mon phenomenon is the inclination to certain forms of compulsory
motions,  especially to a tendency to run forward.  The patients,
with difficulty and slowly, begin to walk, but then are obliged,
without stopping, to move quickly forward ; hence, they easily
fall forward.  This tendency to run forward has been explained
by the fact that from the inclination of the head and body for-
ward  the centre of gravity has been displaced ;  however,  this
explanation  is not satisfactory, or at least is not  applicable to
all cases,  since in certain cases the opposite form of compulsory
motion,   the  tendency to move  backward,  is  noticed.   In  a
patient, who had otherwise the impulse to move forward, Char-
cot could excite the impulse to move backward  by  lightly
pulling his coat when he was standing still;  then immediately
there  was a  propulsion  backward  which  soon  became  very
impetuous-, and the patient was in danger of falling  backward
if precaution was not taken  to prevent it.—Meschede noticed 
400           EULENBURG.—PARALYSIS AGITANS.

in the  case already quoted  the propulsion forward to occur at
the same time with an attack  of laughter in a patient with very
limited mental powers.  In a case described by Topinard there
was propulsion forward besides change of  countenance, satyria-
sis  and glycosuria ;  the latter symptom was improved by the
use of  Vichy water, while the others increased.
   The temperature of the body measured in the axilla or in the
rectum, notwithstanding the unremitting muscular action, is not
increased in paralysis agitans, as is shown by the older observa-
tions (Charcot and Bouchard,' Ordenstein) as well as by my own
observations.   Also in  many cases which I  have repeatedly
examined the temperature  of the external auditory  canal  has
not deviated from the normal.—Charcot explains the absence of
increased temperature thus :  it is found only in "static" {i. e.,
predominating tonic), not in "dynamic" (predominating clonic)
spasms—in tetanus, for example—but not in chorea and paral-
ysis agitans.—Nevertheless, although  the temperature of  the
body is normal, there is often  a subjective sensation of increased
warmth, especially after a  paroxysm of trembling, sometimes
also in connection with copious secretion of perspiration.
   Apart from this sensation  of excessive warmth, disturbances
of sensation are noticed, now  in the form of disagreeable sensa-
tions (crawling and pricking in the hands and feet), now in  the
form of partial, generally incomplete anaesthesia—yet they may
be entirely wanting even in advanced cases of paralysis agitans.
Functional disturbance  of  the  nerves of special  sense (optic,
acoustic) are  rarely noticed.  But other cerebral  symptoms of
the most varied  kind are  rather frequent: headache,  vertigo,
sleeplessness,  psychical  disturbance,  hypochondria.  In a few
cases there is well-marked melancholia ; in other cases there are
hallucinations, and maniacal attacks are noticed.  Not rarely after
the affection has continued rather long, there  is  a weakness of
memory and of judgment, generally a dulling of the entire men-
tal functions.
   The course of  the disease is generally very protracted, its
duration, at least  many years,  sometimes even  thirty years.
1 Momoires de la soc. de biol. 1866. 
ANATOMICAL CHANGES.
401
Generally after the above-mentioned  symptoms  have continued
a long time, there occurs increasing  exhaustion of the nervous
system, diminution of power, and the patient, almost immovable,
has bed-sores, which finally cause death.  It is deserving of notice
that sometimes, a few days  before death,  the trembling entirety
disappears (Claveleira,  Lebert).   In  other cases death  results
from some intercurrent  disease,  especially pneumonia, pleurisy,
variola, typhus.—Improvement  and  even recovery have been
noticed by individual authors. Yet there is reason for the suppo-
sition  that in the cases of  pretended recovery  the disease was
not paralysis agitans.  This  supposition is strengthened when it
is noticed how many authors,  especially English authors, con-
found  this affection with choreic  conditions.  Handheld  Jones
believes it must be admitted that there is a double form of paral-
ysis agitans ;  one entirely incurable, occurring in old persons
and depending upon organic changes in the central  nervous sys-
tem ;  the  other,  in younger  persons, curable and probably not
dependent upon organic  changes.   It is evident how untenable
such a differentiation is,  and that only the cases of the first class
can properly be called paralysis agitans.   The cases quoted by
Jones from Reynolds, Graves, Sanders, and his own  observations
afford abundant proof of the superficial and uncritical manner in
which  the most varied  conditions—of chorea infantilis,  simple
tremor without paralysis, etc.—were all grouped together under
that curable form of paralysis agitans.


       Anatomical Changes and Theory of the Disease.

   The number  of autopsies  heretofore   reported  is  not very
great, and many of  them, besides, give in  part contradictory
results, while others are  entirely negative.

  The oldest reports of positive changes are those by Parkinson and Marshall
Hall; the former found in one case hardening of the pons, the medulla oblongata,
and the cervical cord ; Marshall Hall, a sclerosis of the pons and the corpora quad-
rigemina.—Stoffella found in a man, seventy-nine years  old, in Oppolzer's clinic,
who had been affected for rive  years, atrophy of the brain with secondary effusion
of serum in the ventricles and  the membranes, and an apoplectic  cyst, the size of
;l  pea, in the right optic thalamus;  the pons and medulla oblongata were firmly
          VOL. XIV.—26 
402
EULENBURG.—PARALYSIS AGITANS.
indurated;  the arteries at  the  base  calcareous, and  the lateral columns of the
cord, especially in the lumbar region,  permeated with grayish opaque lines, which,
as well as the  induration in the pons and medulla oblongata, consisted of new
connective tissue.—Lebert mentions  that in one case he found a shrunken sclerotic
nucleus in the upper part of the cord, probably the result of previous inflammation.1
—Cohn found in one case (a man forty-nine years old) well-marked cerebral atrophy,
and  in  another (a man seventy-four years old), atrophy of the spinal cord at the
level of the second cervical vertebra.—In a woman, thirty-four years old, who had
been sick two years, and finally died from variola, Skoda found extended sclerosis
of the central organs; the walls of the ventricles, fornix, pons, medulla oblongata
and  spinal cord were  very firm; both optic  nerves were flattened and sclerotic.
In some opaque reddish patches of the brain the  nervous tissue had disappeared,
and  its place was  taken by newly-formed connective tissue, which likewise caused
the sclerosis  of the pons and medulla oblongata.   There  was besides oedema of
the pia;  the neurilemma of the nerves of the upper extremities was thickened;
the muscles had undergone fatty degeneration. — M. Rosenthal  found  softening
of the pons,  of a  portion of the medulla  oblongata, and, accidentally, absence of
the corpus callosum ; Leyden, in paralysis agitans  of the right side, found a sar-
coma of the left optic thalamus and great flattening of the pons ;  Chvostek, affec-
tion of the left side, a hardening of the cortex of the right sphenoidal lobe and of
the right hippocampus major, as a consequence of encephalitis ; the large pyramidal
ganglion  cells of the hippocampus had completely disappeared, and only the neu-
roglia with the unchanged vessels remained.
   Cayley, in a patient seen by Murchison (who died of  typhoid fever after suffer-
ing twelve years),  found changes in the spinal  cord which, in part, depended upon
chronic processes, in part, upon acute,  which might well be referred to the typhoid
fever.  The former consisted of thickening of the cortical layer of connective tissue
with increase of its nuclei;  development of irregular tracts and islets of connective
tissue, rich  in  nuclei,  which penetrated from the cortex into the substance of the
spinal cord, but only in the cervical and dorsal regions quite near the exit of the
posterior  nerve roots;  the widely  dilated central canal was filled  with cells  of
different  forms and sizes, some like leucocytes, some  elongated, never having the
character  of normal epithelium.
   In a case reported by Bourillon there seemed  to" be, judging from the imperfect
description, a sclerosis in patches.
   In the often quoted, symptomatically complicated case of Meschede, on section
the ependyma of the  lateral ventricle seemed covered  with granulations with a
spotted, marbled  appearance.   In the posterior lobe of the right  half of the cere-
brum were gray masses, which were in  part connected with the cortex of the convo-
lutions, in part were isolated.  The medullary mass of the frontal  and occipital
lobes was markedly sclerotic, also certain  parts  of the optic thalami and corpora
striata.  The medullary substance of the cerebellum was as firm as cartilage, and
1 Handbuch der praktischen Medicin.  Band II.  4. Aufl.  1871.  S. 633. 
                         ANATOMICAL  CHANGES.                     403

pervaded by numerous gray islets;  its corpora dentata were quite atrophied.  Me-
dulla oblongata and  pons also  atrophied.  The spinal cord  atrophied and hard-
ened ; in its middle portion, especially on the left, were small  regions changed into
gray masses.  Microscopic examination showed, in the foci of the posterior lobe,
ganglion cells and connective tissue elements ; all the other abnormally gray parts
showed the ordinary changes  of  gray  degeneration.—In connection  with these
changes it seems to me that  a statement made by Meynert' deserves notice, though
not specially pertinent here.  In a  general  paralytic, with a  tumor chiefly on the
right, Meynert found the weight of  the corpus striatum and lenticular nucleus,
including the isle of Reil, left side = 38 grms., right side = 44 grms.; the weights
of the two frontal lobes were equal.
   Opposed to these positive results, Petraeus found (in the Copenhagen  hospital)
no changes in the nervous system; as  apparent cause of death a fatty degeneration
of the heart and  pneumonic induration of the right lung.  Also an autopsy by Olli-
vier furnished negative results.   In a case described by Kuchne, from  Frenchs'
clinic (a man forty-nine years old, sick for five years, death from  pleurisy  and bed-
sores), there was  nothing abnormal except oedema of the brain and spinal cord; the
most careful microscopic examination of  the pons and  medulla oblongata,  etc.,
showed nothing pathological.—Th.  Simon (according to oral  communication)
found no changes in the nervous system nor  in the sympathetic in four autopsies at
the Hamburg hospital.—The detailed reports by Joffroy, the results of which were
essentially negative, are  of  especial interest.   They relate to four  cases noticed
by Charcot, all women (three of these are described in Ordenatein's dissertation).
Macroscopically  there was no change in the medulla oblongata and the spinal cord.
The microscopic  examination showed in three  cases an  obliteration of the central
canal (by increase of the epithelium of the ependyma), a more or  less well marked
pigmentation of  the ganglion cells, especially in Clarke's columns, and  amyloid
bodies  in varying  number.  Besides, one case showed still the remains of an old
circumscribed meningitis at the apex of the calamus scriptorius, and another  a
small superficial sclerotic  spot in the medulla oblongata.  The latter changes, on
account of their inconstancy, must be looked upon as without significance as causes
of the disease ;  but Joffroy also  believes  the changes, heretofore  found to be con-
stant, are to be considered as common phenomena occurring in all old people in
consequence of senile  degeneration.   At  most, according  to his view, they can  be
considered as standing in a certain relation to senile tremor  and  the  analogous
trembling of paralysis agitans.   According to this the origin of the tremor should
be referred to the spinal cord.   In the fourth case Joffroy missed also the above-
mentioned  changes, so that the  result was  entirely negative.—According to his
latest statement, Charcot has made in all six autopsies in paralysis agitans;  of these
three were entirely negative, three gave results already mentioned.

   If we look over the above-mentioned autopsies, we find cases
1 Wiener med. Presse. 1871. No. 25. 
404           EULENBURG.—PARALYSIS AGITANS.

in which there were absolutely no  changes in the nervous sys-
tem, or these were very slight, probably senile  changes in the
spinal cord  (Petraeus, Ollivier,  Th.  Simon, Kuehne,  Joffroy,
Charcot);  others showed exclusively changes  in  the spinal
cord (Lebert,  Colin, Cayley,  Murchison), or finally in the brain
(Marshall Hall, Cohn,  M. Rosenthal,  Leyden, Chvostek);  yet
others, finally, showed extensive  changes in the brain and spinal
cord  in the  form of  sclerosis  (Parkinson,  Stofella-Oppolzer,
Skoda,  Meschede).  In view of such  contradictions, we are at
present compelled to be very cautious in forming conclusions as
to the pathological anatomy  of paralysis agitans and the theory
of the affection.   Not  even  can  the question, whether  the dis-
ease is  of cerebral or spinal  origin, be answered with certainty
from  the material already possessed,  though, as we have seen,
some  facts at least seem to  show that the origin of one initial
and important symptom, the  tremor, is in the spinal cord.  Some
authors (as Remak) have in a measure cut the knot by  suppos-
ing a cerebral and a spinal  form  of the paralysis; the former
(according  to Remak) should be  characterized symptomatically
by a tendency to fall, while in the spinal variety this symptom
is wanting.  This distinction  is, however, entirety artificial, and
the case of the pretended paralysis  agitans cerebralis, mentioned
by Remak,1  cannot with certainty be considered as paralysis
agitans on account of the entire want of paralytic phenomena.
   From the  changes found in the brain must be excluded, as
without significance, those depending upon senile atrophy (Cohn,
Stofella), since undoubtedly they  may also occur without the
tremor.   In other cases without  senile atrophy  or  in addition
thereto  there are circumscribed foci of disease, sometimes in the
optic  thalamus (Leyden), sometimes in the hippocampus major
(Chvostek), or in the pons and medulla oblongata (Marshall  Hall,
Rosenthal,  Stofella).  The  localities of these foci are so  various
that we are prevented from forming any conclusions in regard to
the pathogenesis of paralysis agitans.  Certain symptoms {e.  g.,
the glycosuria noticed  by Topinard)  as  also certain  autopsies
favor the supposition entertained  by some authors, that the pons
1 Galvanotherapie. p. 447. 
PROGNOSIS AND TREATMENT.
405
and upper part of the medulla oblongata must be considered the
original seat of the disease ; on the other hand, the same suppo-
sition is in decided  opposition to the autopsies where that part
of the brain has been  found normal, and to the case of Larcher
who, in isolated  sclerosis of the pons, found  symptoms which
differed entirely from those of paralysis agitans.—Certain cases,
finally, in which  were found extensive changes of the  central
nervous system, although the symptoms are more or less similar
to those of paralysis agitans, must probably be regarded as mul-
tiple sclerosis in patches (Parkinson, Skoda).
           Diagnosis, Prognosis and  Treatment.

   The diagnosis of paralysis agitans may, especially in  the
commencement, be difficult.   It is most easily confounded with
simple, senile or toxic tremor, and with disseminated sclerosis
of the nerve-centres.   Paralysis  agitans may, however, be dis-
tinguished  from senile trembling  by the greater intensity  of
the tremor,  by its  occurring before senescence,  in its further
course more certainly by the addition of  paralysis and the other
disturbances of innervation.   The  history of the case is especially
valuable in distinguishing tremor mercurialis,  saturninus, alco-
holicus,  etc.  The statements in  the  previous chapter furnish
proof also how the clinical history, especially of tremor saturni-
nus and alcoholicus, deviates essentially from  that of paralysis
agitans, while, however, tremor mercurialis very closely  resem-
bles it.  Close attention will guard against  mistaking between
this disease and the rare affection  lately described  by Hammond
as " athetosis,"' and the same is true in regard to chorea.
   The differential diagnosis between paratysis agitans and scle-
rosis of  the nerve-centres disseminated  in  patches is of espe-
cial importance.   In  this, too, there is  usually trembling and
progressive  paralysis;  there may  be further disturbance  of
speech, contractions,  paraplegia,  and  partial anaesthesia, more
rarely even mental disturbance.  The course in both  affections
is of many years' duration, and the prognosis is equally unfavor-
able. But in sclerosis the initial symptom is a progressive motor 
406
EULENBURG.—PARALYSIS AGITANS.
weakness, which increases to paralysis, while in paralysis agitans
the tremor always precedes by a longer or shorter time; and
also in sclerosis  the paralysis  begins, without exception, in the
lower limbs,  while the symptoms of paralysis agitans are first
noticed in the upper extremities.  The tremor in sclerosis is very
much like that of paralysis agitans, but differs from it in that it
is not spontaneous, only occurs during passive motions or when
an  active motion is contemplated.  Less important  differences
are that in sclerosis sometimes  headache and vertigo precede by
some  time the  other symptoms; that irregular apoplectiform
and cataleptic attacks often interrupt the course of the disease;
that the reflex irritability is considerably increased, especially  if
the spinal cord  is likewise affected with  sclerosis ; and finally,
that sclerosis not rarely occurs in younger persons, between
twenty and forty years of age.
   The prognosis of paralysis agitans,  as  I remarked  when
speaking of the course of the disease, is absolutely unfavorable.
The cases in which improvement or recovery have occurred must
be considered as of doubtful diagnosis (see below).  In individual
cases the prognosis is so much the more unfavorable, that is, the
fatal  termination is to  be  expected so much  the sooner, the
earlier the  paralysis and the  other  disturbances of innervation
are added to the tremor, as also the older and  the more debili-
tated the patient already is.
    Under such circumstances  the treatment can be almost only
palliative.  The best that can be hoped is that the disease should
remain a long time stationary, or that single, especially torment-
ing, symptoms should be mitigated, as the tremor.   Yet such a
result can only rarely be attained.
    Certainly  in medical literature cases of recovery are reported,
after, indeed, the use  of very  different modes  of treatment.
Elliotson  has obtained  such  by  means  of  carbonate of iron,
Brown-Sequard  by chloride of barium, Reynolds by the  use of a
Pulvermacher's  chain, Remak by the constant current, Jones by
hyoscyamus, Villemin by bromide of potassium, Betz by warm
baths.  If  the "cured"  cases are more critically considered, the
identity  of some with paralysis agitans is decidedly doubtful;
in some the duration of the good result is not at all assured, but 
TREATMENT.
407
at most a temporary  effect—disappearance  for a  while  of  the
muscular tremor—is proven.
   The case of Reynolds, for example,  must have been quite
recent, as the symptoms first appeared fourteen days before the
treatment.  There was vertigo and great numbness with trem-
bling  of the whole right upper extremity,  the temperature of
which in the region of the biceps was increased 4° F.  An hour's
use, five times repeated, of  Pulvermacher's chain removed  the
tremor ; continued treatment restored the power of the arm per-
fectly in one month !—In the (as to diagnosis very doubtful) case
of Jones at first str}7chnia,  iron, and ether, as also faradization
of the arm were useless, even injurious, while hyoscyamus caused
an improvement  not  otherwise characterized.  Jones  naively
explains the inefficiency of  the  first agents and the efficacy of
the hyoscyamus, by the statement that in his case, "as generally
in chorea and epilepsy," there was increased irritability of  the
nerve-centres ; hence, they required not the tonic but the calming
medicines.  Charcot has also obtained a quieting effect upon his
patients by hyoscyamus,  but it was only temporary.   I have
myself not been able  to get any benefit from the long-continued
use of the  extract of hyoscyamus, or the hyoscyamin (advised
by Oulmont for tremor).
   Remak's case  of pretended paralysis  agitans  cerebralis,
already mentioned, must be  considered at least of doubtful diag-
nosis, since no mention is made  of paralytic symptoms.  There
was tremor, most  marked on the left side, in the form of severe
shaking and twitching of the limbs with tendency to fall for-
ward, pain  in the right side of the forehead and right temporal
region, also conjunctivitis of the right eye.  Remak supposed a
stasis in the anterior lobe of the right cerebral hemisphere, and
applied a stabile  current  to the temporal region.  After eight
days'  treatment the pain in the temple and the eye disappeared,
as also the tendency to fall and the tremor of the right side ;  the
shaking of the left side remained unchanged.
   Hitherto I have seen no good  results  from the use of the con-
stant current (galvanization of the head  and the sympathetics).
Not once could  any palliative effect be obtained by this  means ;
it was not  possible with the strongest current I could  use  to 
408           EULENBURG.—PARALYSIS AGITANS.

obtain even  a remission  or a  temporary  interruption  of the
tremor, as I had hoped.   In one case I could use a current from
fifty Siemens' elements passed  through the head (the two elec-
trodes placed on the mastoid processes), without causing vertigo,
etc. -f  even here  there was no  diminution of the tremor.  The
peripheral faradization  and  galvanization  is  likewise without
effect.—Benedict also states that  hitherto  a cure of paralysis
agitans by the use  of electricity has not been  obtained, though
he thinks that the prognosis of this disease would  be more favor-
able under early galvanic treatment.   He  has himself noticed
a few good results  in  cases just beginning, and, besides, in one
case a momentary  effect  upon the  accompanying dyspeptic
symptoms, for after galvanization  of  the sympathetic and the
cervical enlargement there was immediately an improved appe-
tite.
   In Villemin's case, in which  iodide of potassium (up to three
grammes  a day)  was used with benefit, the diagnosis was not
certain; probably,  judging by  the symptoms described,  it was
a case of multiple sclerosis.
   The case described  by Betz was that of a gardener, sixty-five
years  old, whose disease  began half a year previously from the
effect of catching cold, and was cured by six warm baths (27° R.
[93° F.])!— I will take this opportunity to  say that  in genuine
paralysis  agitans the water cure is  usually  contraindicated.
Especially objectionable  are hot  baths ; lukewarm baths and
those moderately cool are at least  not injurious.   Lebert thinks
that by sea-bathing he  has in  one case  caused  the disease to
remain stationary.
   Concerning the treatment by corrosive  sublimate, advised by
Jones (but without personal experience), and that by strychnia,
advised by Trousseau, I have no experience.  According to Char-
cot, the latter agent seems rather to increase the tremor ; Charcot
also saw no favorable result from  the use of ergotin and bella-
donna, which were used on account of their anti-spasmodic effect.
  1 In aged persons it is quite often possible to use an unusually strong current to
head—probably on account of the senile thickening of the walls of the skull and
obliteration of many osseous canals, which very much increases the resistance. 
                 DESCRIPTION  OF THE DISEASE.              409

   The means which I have used in hopes of at least a palliative
effect are :  subcutaneous injections of morphia, of curare, and of
Fowler's solution ;  also internal use of chloral hydrate, calabar,
bromide of potassium, and  nitrate of silver.   The injections of
morphia and curare produce occasionally a temporary cessation
of the tremor; the subcutaneous  injection  of arsenic is much
more successful in this respect, used in the form and dose advised
under Tremor.   In one case  of well-marked  paralysis agitans
fifteen injections, in another  four, produced a very marked dimi-
nution of the spasm, which in the first patient lasted two months.
I have noticed no marked  effect from the above-mentioned inter-
nal  remedies either  upon individual  symptoms or  upon  the
general course of the disease.   Also Althaus found hydrate of
chloral, Ogle calabar, Charcot nitrate of silver, useless in para-
lysis agitans;  the latter seemed even to increase  the  spasmodic
action, which (as Charcot rightly remarks) is all the more remark-
able, as in multiple sclerosis it produced a considerable improve-
ment and diminished the intensity of the trembling.
                           Appendix.


                    ATHETOSIS.

Hammond,  Treatise on diseases of the nervous system. New York, 1872.—Med.
   Times  and Gaz. 16 Dec, 1871. p. 747.—?%. Fischer, Athetosis.  Boston Med.
   and surg. Journ. 30 May, 1872.— Clifford  Allbutt, Cases of athetosis.  Med.
   Times  and Gaz. 27 Jan., 1872.—Currie Ritchie, Note on a case of athetosis,
   ibid. 23 March, 1872.

  In 1871  Hammond described under the name Athetosis (aSeros) a combination
of symptoms somewhat  resembling paralysis agitans, the  chief characteristic of
which is a ceaseless motion of the fingers and toes, which does not permit them to
remain in any position in which they are placed.  According to the descriptions
given by Hammond himself and some other American authors, the involuntary
motions observed consisted in part of alternate flexion and extension of the fingers
aud toes, in part of complicated motor phenomena, which were at times more severe,
did not cease during sleep,  could, however, be controlled and limited for a short 
410
EULENBURG.—ATHETOSIS.
time by position and extraordinary effort of the will.  The phenomena seem to
have had partially the  character of associated  movements, as while  the fingers
moved the arm was hard and rigid—during motion of the toes the muscles of the
calf were in tonic contraction.  In  several cases there was at the same time dis-
turbances of sensation (pain, sense of numbness or falling asleep); there was also
change of temperature in the affected limbs.—Most of the observations were  made
on  persons  affected with epilepsy or mental disease ;  only in one case was there no
other cerebral symptom.  With the  exception  of the latter case, the patients were
all  men in middle life (between thirty-three and fifty-five years).   As to treatment,
bromide of  potassium proved of service in two cases ; in one case a four months' use
of galvanization and  faradization  gave no marked result.
    No autopsies have as  yet been made.   Hammond  supposes the seat of the  affec-
tion is in the intracranial ganglia, or in the upper portion of the spinal cord.   It is
more likely that the combination of symptoms  known  as athetosis is dependent
upon changes, possibly circumscribed, of  the centres of  motor innervation in the
cerebral hemisphere.  The characteristic limitation to certain groups of muscles, the
frequent occurrence of associated movements in the form  of contraction, the associa-
tion with epileptic attacks, seem—according  to  the investigations of Hitzig—to
support the supposition of an  irritation of these centres.  In this connection it is
to be remarked that the athetosis may be unilateral. In Fischer's case it was limited
to the fingers of the  right hand.  I have myself lately  seen a case which may be
considered as belonging  here, where  the left foot alone was affected.  So soon as the
patient—a man thirty-three years old—touched the floor  lightly with the tip of his
foot, there immediately began a rhythmical alternate contraction of the flexors and
extensors of the toes,  to  which was added tonic contraction of the muscles of the
calf, which ceased as soon as the whole sole of the foot was firmly planted on the
floor.   (In  this  case there were  still other symptoms,  which led  me to give a
diagnosis of disseminated sclerosis.) 
CHOREA.
VON" ZIEMSSEN. 
 
          CHOREA.

Chorea  St. Viti.   St.  Vitus' Dance.
The older  literature  is  very extensive,  and  is  presented very completely  in
    Wickers  monograph.—Sydenham,  Schedul.  monitor, de novae febris  ingressu.
    Opera univ. med. edid. K'uhn. Leipzig,  1827.  p. 468 ff. und p. 531.— Wich-
    mann, Ideen zur Diagnostic. III. Ausg.  Hannover, 1827. Bd. I.—Ketterling,
    Darstellung des Veitstanzes.  Regensburg, 1805.—Bouteille, Traite1 de  la choree
    ou danse de St. Guy.  Paris,  1810. — Bernt,  Monographia Choreas  St. Viti.
    Prag,  1810.  Deutsche Ausgabe mit Zusatzen von Solder.  Prag, 1826.— Wag-
    ner, Pathologisch-therapeutische Abhandlung fiber den Veitstanz.   Wurzburg,
    1817.—Rufz, Recherches sur  quelques  points de l'histoire de la choree chez les
    enfants.  Archives generales, 1834, Fevr.  p. 215  ff.—Roth,  Ueber den Veits-
    tanz  und einige ihm verwandte Formen.  Dissertation.  Mvinchen, 1843.—
    Wicke, Versuch einer  Monographic des grossen Veitstanzes und der unwillkiir-
    lichen Muskelbewegung.  Leipzig, 1844.—See, De la choree.  Rapports du Rhu-
    matisme et des maladies du cceur avec les affections nerveuses et convulsives.
    Mem >ires de 1'Academie nationale de Mcdecine.   Vol.  NV.   Paris,  1850.  p.
    373  ff. — Leudet,  Sur les chorees sans  complicat.  terminees  par  la mort.
    Archives gcnSrales.  Sept., 1853.  p.  285.—Romberg, Lehrbuch der  Nerven-
    krankheiten. Bd. I. S. 510 ff. Berlin, 1853, und Klinische Ergebnisse. Berlin,
    1846.  S. 19 ff.— R. B. Todd, Clinical  lectures  on  paralysis.   II. Edit,  Lon-
    don, 1856. p. 428 seq.; and Lectures on Chorea. Lancet, April, 1843.—Moynier,
    Sur le traitement de  la choree.  Archives generales, July, 1854.—The same,
    Journal de Med. dc Bruxelles, 1858. No. 59.—Mosler, Chorea bei Schwangeren.
    Virchow's Archiv.  Bd. XXIII.  S. 149.  1862.—Kirk.es. On chorea, its relation
    to valvular disease of the heart, and its treatment. Med. Times and Gazette, 1863.
    Nos. 677 and G78.—Bricheteau, Relation  d'unc epidemie de choree,  observed
    alTIopitalNecker.  Archives generales, 1863. I. p. 433 seq. and 532 seq.—Hillier,
    Cliorea in connection with heart disease. Med. Times and Gazette, 1863, August
    *.  p. 142.—Fischl, Chorea  minor in gravida.  Wiener allg. med. Zeitg. No. 16.
    1865.—Hine, A case of myelitis, presenting all the symptoms of severe Chorea. 
414                   VON ZIEMSSEN.—CHOREA.

    Death  on ninth day.  Autopsy.  Med. Times and Gaz. 788. 1865.—r>». Die
    Chorea und ihr Zusammenhang mit Gelenk-Rheumatismus, Peri- u. Endocarditis.
    Medic. Jahrbucher.  Zeitschrift der Gesellsch. der Wiener Aerzte. Bd. XXI. p.
    115. 1865.—Russel, Med. Times  and Gaz., 1866.— Monckton, A case of Chorea,
    ending fatally,  complicated with disease of heart and brain. Brit. med.  Journ.
    No. 305.  1866.— Roger, Recherches  cliniques  sur la  choree, sur le rhuma-
    tisme et sur les maladies du cceur des enfants.  Arch, gener., 1866. II. 1867. I.
    54_75.__Ibidem, 1868, Jan.—Avril.  Gazette des Hopitaux, 1870.  Nos. 65 u. 66.
    —Richter, Sitzungsberichte der  Dresdener Gesellschaft fiir Natur- und Heil-
    kunde.  5. Jan., 1867.—Tuckwell, Some remarks on maniacal chorea and its
    probable connection with embolism. Brit, and For. Med. Chir. Journal. October,
    1867.—Sam. Wilks, Med. Times  and Gazette, p. 117. 1868.—The same, Brit.
    med. Journ.  July 30.  p. 115. 1870.—J". W. Ogle, Remarks on Chorea St. Viti.
    Brit, and For. Med. Chir. Review, Jan. 1868.-7%. Meynert, Ueber die geweb-
    lichen Veriinderungen in den Centralorganen des  Nervensystems bei einem Falle
    von Chorea minor.  Allg. Wiener med. Zeitung.  Nos. 8 u. 9.  1868.—R. Arndt,
    Chorea und Psychose.   Archiv f. Psychiatrie und Nervenkrankheiten.  Bd. I.
    1868.—Steiner, Klinische Erfahrungen iiber Chorea minor. Prager Vierteljahrs-
    schrift.  1868.  IV.  S. 45.—The same, Zum Wesen der Chorea major und der
    Katalepsie.  Jahrb. f. Kinderheilkunde.  N. F. II.  S. 205 ff.  1869.— The same,
    Epidemie von Chorea minor. Jahrb. f. Kinderheilkunde. N. F. III. S. 291. 1870.
    —Kretschmer, Ueber den Veitstanz.  (Frerichs)  Dissertation.  Berlin, 1808 —
    J. Hughlings Jackson,  Observations on the physiology and pathology of hemi-
    cliorea. Edinb. Med. Journ., October, 1868. p. 294 ff.—Med. Times and Gazette,
    March  6,  1869.—Douglas, On the use of Indian Hemp in Chorea.  Edinb.
    Med. Journ., March 1869. p. 717 ft.—Barnes, Chorea in pregnancy. Medic. Times
    and Gazette, 1868. Aug. 1; and Obstetrical transactions X. p. 147. 1869.—Law-
    son Tait, Dublin  Quarterly  Journal,  Febr.  1869,  p. 203. — Broadbent,  Re-
    marks on the pathology of chorea. British Med.  Journal. April 17, 24, 1869.—
     Carville, Gaz.  med. de Paris.  No.  50.  1869.— Tuckwell, St. Barthol.  Hosp.
    Rep. V. p. 86. 1869.—Mohamed  Said, De la Choree  et de la douleur,  provo-
    quee chez  les choreiques.  These.  Paris,  1869.—Leidesdorf,  Ueber  Chorea
    minor in ihrer Beziehung zu psychischen Storungen. Wochenblatt der Ges. der
    Wiener  Aerzte.  No. 12 u.  13.  1869.—Fried. Weber  (Chor.  gravid. 1  Fall).
    Berliner Wochenschrift VII. 5.  1870.—J".  Russel, Med. Times and Gazette.
    1868, May  30;  1869, Jan. 16;   1870, Jan. 8 ; April 2.—Prick,  Ueber Chorea.
    Dissertation (Frerichs). Berlin, 1870.— Legros und  Onimus,  Recherches sur
    les mouvements choreif ormes du chien. Comptes rendus, 1870. LXX. p. 1046 et
    seq.—The same, Quelques recherches sur  les mouvements, Journal  de  l'Ana-
    tomie et de  Physiologie. 1870. No. 4.—E. L. Fox, Med.  Times and Gaz.
    p.  423.  1870.—Gray,  Ibid.  Dec.  17, 1870. — Clouston, Journal of  Mental
     Science.  1870.—Sieckel, Chorea gravidarum.  Diss,  inaug.   Leipzig, 1870 —
     Cray and  Tuckwell, Cases of Chorea, treated on the expectant plan.  Lancet.
     Dec. 2  and 9, 1871.— L. Meyer, Chorea und Manie.  Archiv fiir Psychiatrie 
HISTORY, DEFINITION.
415
u.  Nervenkrankheiten.  II.  S.  535  ff. 1871.—Dickinson, Clin.  Lectures on
Chorea.  Lancet I.  15.  1871.—H.  T. Butlin, Cases of Chorea,  treated with
Sulphate  of Zinc. Lancet, 1872. Nos. 17 u. 18.—Ritter, Gedanken iiber die
anatom. Grundlagen der Chorea. Memorabilien. 1872. No. 10.—G. Huntington,
On chorea. Philadelph. Med. and Surg. Reporter.  1872.  p. 15.— C.  H. Jones,
Clinical lecture on cases of chorea. Med. Press and Circul. Jan. 10. p. 25. 1872.
—Fehling, Chorea gravid.  Archiv fiir Gynakologie.  VI. 1. S. 137.  1873.—
R. Arnoldi, Ueber Chorea gravidarum. Diss, inaug. Berlin, 1873.—A. W. Foot,
Unilateral chorea, disease of the corpus striatum and optic thalamus on the side
opposite to affected.  The Dublin Journ. of Med.  Science.  October, 1873.—E.
Long Fox (Congenital Chorea), The British Med. Journ.  1873. No. 653.—Lan-
douzy, Gazette med.  de Paris. No. 24. 1873.—IT. Leube, 3 in iitiolog. Connex
zu einander stehende Erkrankungen an Chorea St. Viti. Klinische Beilage zu
den Correspondenzblattern d. Allg. arztlichen Vereinsvon Thiiringen. 1874. No.
5.—De Beauvais, Deux observations de choree mortelle.  Gaz. des Hopit. 1874.
Nos.  150 u.  151.— P. H. Pye-Smith,  Guy's Hospital Reports.  3.  Ser. XIX.
p.  341.  1874.— Weir Mitchell, Post-paralytic chorea.  The Americ.  Journ.
of the Med. Sciences.  1874. Vol. 136. p. 352 et seq.—C. Golgi, Sulle alterazioni
degli  organi centrali nervosi  in un caso di  Corea gesticolatoria associata ad
alienazione mentale. Rivista clinica. 2. S. IV. 12. p. 361 (Reprint).  Bologna,
1874.—M. Benedikt, Nervenpathologie  und Elektrotherapie. II. Aufl. I. Abth.
S.  251 ff.  Leipzig, 1874.—Gotthold, Ueber Chorea.  Diss,  inaug. Wurzburg,
1874.—Bodo Wcnzel, Ueber Chorea major und minor. Schmidt's Jahrbiicher. Bd.
162. S. 193 ff. 1874.— Weinberger, Zur Pathogenese  und Therapie der Chorea.
Wiener med. Presse.  XV. No.  47.  1874.—Pollock, Treatment of Chorea with
Inhalations of Chloroform.  Lancet I.  25. p. 871. 1874.—Elischer,  Ueber die
Veriinderungen in den  peripher. Nerven, im Riickenmark und im Gehirn bei
Chorea minor. Virchow's Archiv. Bd. 61.  1874. S. 485 und Bd. 63.  1875. S.
104 ff.— M. Rosenthal, Klinik der Nervenkrankheiten. II. Aufl.  S. 576 ff. Stutt-
gart, 1875. — Charcot, De l'hemichoree post-hemiplegique. Progres med. 1875.
Nos. 4 and 6;  and Gaz. des Hop. 1875. No. 30.
                        History,  Definition.

   The origin  of  the term  chorea  (Xopeta,  dance) or St. Vitus'
dance, and of most of its synonyms  : St. Modestus' dance, saltus
Viti, St. John's dance, ballismus {/3a\\Lo-/j,6<;, dance), choreomania,
orchestromania,  epilepsia saltatoria,  danse de St. Guy,  etc.,  is
traced to  the  middle  ages  ; in  their  original application  these
phrases  signified  simply  that  pandemic  dancing-mania,  which
made its first appearance as a wide-spread mental disorder after 
41G
VON"  ZIEMSSEN.—CHOREA.
the disappearance of the  plague in the second half of  the four-
teenth century, in the neighborhood of the Rhine.1

   In the year 1375 the psychical pandemic disorder extended from Aix over the
whole region of the Rhine and Moselle as far as Holland.  In the records of the
time it is still spoken of as St. John's dance.  The name of St. Vitus' dance is first
met with in the Strasburg epidemic of 1418, when, under  the magistrate's order,
those affected were  led in troops to the  chapel of St. Vitus in Zabern, that they
might be quieted by processions, masses, etc.
   As regards St. Vitus, the legend informs us that he removed from Sicily when
a boy, at the time of Diocletian's persecution of  the Christians in the year 303, and
suffered martyrdom in Florence,  in company with Crescentia and his tutor Modes-
tus.  His mortal remains, after repeated removals, are said to have  been interred
in the cloister of Korvey in  836.  This cloister, and other churches and chapels,
erected to his memory, became subsequently objects of pilgrimage for sick persons
of all sorts, and especially for those affected with the plague of dancing.2
   As a pandemic disease, the dancing-mania died out in the fifteenth century, but
traces have remained upon the Rhine till our own days, and especially in the
so-called dancing procession  (" spring procession'') to the grave of  St. Willibrod
of Echternach, the  origin of  which can be traced  to the plague of 1376, which
passed through Luxemburg, and is contemporaneous with the great epidemic of
dancing-mania in Aix and Cologne.

   Subsequently the name chorea  St. Viti was  extended to the
sporadic cases  of spasmodic movements of the body, those forms
of disease which nowadays are usually called  chorea magna and
cliorea minor.    But the so-called tarantismus and the raphania
were finally included under chorea.
   The confusion  which  arose  from  this  throwing together of
most  unlike processes  rendered it impossible to form a definite
idea  of the separate forms  of disease.   This  may be seen most
                 1 " At Strasburg, many hundred began
                    To dance and leap, both wife and man,
                    In open market, lane and street,
                    By day and night;  many did not eat
                    Until to an end their madness came ;
                    St. Vitus' dance they did it name."
—Konigshoven, the oldest  Strasburg chronicle.  Edited  by Schiltern. Strasburg, 1C98.
p. 1085.  Quoted by Pecker, Die Tanzwuth. p. 7.  (Epidemics of the Middle Ages.)
   - Cf. Hecker, Die Tanzwuth; and Ilaeser, Die Geschichte der epidem. Krankheiten.
Jena, 1865. p. 172 et seq. 
HISTORY, DEFINITION.
417
clearly in  the dreary chaos of the literature of chorea compiled
by Wicke in his complete monograph upon the malady.
   It is  undoubtedly Sydenham that first evolved  the  modern
conception of chorea from the mass of foreign matters that sur-
rounded it in the middle  of  the seventeenth century.  His de-
scription leaves nothing to be desired for clearness and  precision:

  Chorea St. Viti convulsionis est species, quae ut plurimum pueros puellasve a
decimo aetatis anno ad pubertatem usque invadit; primo se prodit claudicatione
quadam vel potius instabilitate alterutrius cruris, quod aeger post se trahit fatuorum
more; postea in manu ejusdem lateris cernitur, quam hoc morbo adfectus vel pec-
tori vel alii alicui parti adplicatam nullo pacto potest  continere in eodem situ vel
horaa momento, sed in alium situm aliumvc locum convulsione quadam  distorque-
bitur, quidquid aeger contra nitatur.   Si vas aliquod potu repletum in manus porri-
gatur, antequam illud  ad os possit educere, mille gesticulationes circulatorum instar
exhibebit;  cum enim poculum recta linea ori admovere nequeat, deducta a spasmo
manu, hue illuc aliquamdiu versat, donee tandem forte fortuna, illud labiis propius
adponens, liquorem derepente in os injicit atque avide haurit, tamquam misellus id
tantum ageret, ut dedita opera spectantibus risum moveret (1. c. p. 468).

   Sydenham  essentially completed  the  separation of cliorea
from  the foreign elements  that  had  been  confounded  with it.
Nevertheless, the idea has subsisted till quite lately, that there
is some close  relationship between the chorea minor  sive Anglo-
rum  and the cliorea major sive  Germanorum, names used since
Sydenham chiefly upon Wickman's authority.  In the  writers of
the last century we find again the confusion of chorea with  the
pandemic diseases of  imitation, with somnambulism,  and even
with raphania.1
   The retention of the term chorea has helped to keep  up  the
confusion of ideas.   For this reason  several attempts have been
made to change the  name for one more significant.  SchaefTer,2
who regarded the two so-called forms of chorea only as different
grades of development of the same disease, proposed, towards the
close of the last century, to give to our chorea the designation of
   Cf. Hofmei/er, Von der Griibel- und Krumen- oder Schwerenothskrankheit. Berlin,
1742.—Brmdel, Praelectiones academicae.  Bd. II. p.  86 seq. 1793.—Bouteille, Traite
de la choree.  Paris, 1809.— Bernt (1. a).
  •Salzburger med. chir. Zeitung.  1793. IV. S. 248.
          VOL. XIV.—27 
418                VON ZIEMSSEN.—CHOREA.

" morbid irritability or muscular unrest;"  and Thilenius,1 in the
same spirit, proposed the name "involuntary muscular motion."
Wicke adopted the latter definitively," in order to get rid of the
notion that both diseases were but different forms of one species
of disease."
   These propositions have not been received with favor.   Con-
trary though it be to common sense to call the grotesque per-
formances  of folie  musculaire a dance, yet  the term chorea has
made itself so much at home that the attempt to  supplant it by
a  fitter one  could  but fail.  At the present time, while our
knowledge of the anatomical disturbances which form the basis
of chorea is in  its infancy, we are simply unable to substitute a
name based  upon  pathological  anatomy for  that  taken from
symptoms; so  that the attempt  to find a new name is hardly
worth the while.
   Yet, I must insist upon having the name of chorea restricted
to the disease which is about to  be described, and that the so-
called chorea magna sive Germanorum should be entirely ruled
out.
   It is my conviction that the group of symptoms called cliorea
major  is  not a disease sui generis,  but is only the product of
genuine psychoses  and cerebrcd maladies  on the one hand, and
of hysteria and wilful simulation on the other, such as so often
and  so abundantly  flourishes in hysterical ground at the period
of puberty.  I have been led to  this view both by a thorough
study of the literature of the subject and by a series of very
characteristic  cases observed  by myself ;  and neither Hasse s
(1. c.) and  Rosenthal's (1. c.) statements, both of whom regard
chorea major as a distinct species of disease, nor the recently
published observations of Franque,2 Steiner,3 Bohn,4 Bodo AVen-
zel,& and Wysocki,6 have been able to convince me of the  con-
trary.
•Med. chir. Bemerkungen. Th. II. S. 4 ff. Frankfurt a. M , 1814.
2 Journal fiir Kinderheilkunde.  1867. S. 226.
3Jahrbuchf. Kinderheilkunde. N. F. Bd. II. S. 205. 1869.
4 Ibid.  S. 194. 1874.
5 Schmidt's Jahrbiicher u. s. w. Bd. CLXII.  S. 195.  1874.
 Wiener med Wochenschrift.  Bd. XXV. Nos. 14 and 15.  1875. 
HISTORY,  DEFINITION.
419
   That Proteus, which  is  described under  the name of  chorea
magna, contains in reality but one characteristic mark,  and that
is the associated  spasmodic  movements which  are  often per-
formed with a  certain fitness, but usually have an extravagant
and violent character.  But we  have the same right to count all
the associated spasms of  hysterical patients as chorea major—the
spasms of  single extremities as  well as those of the whole body,
those of the muscles of respiration as well as those of the larynx.
By the  same right also  all those  striking forms  of  associated
spasm which are observed in insanity, epilepsy, in cases of cere-
bral tumor, etc., must be added to the species " chorea major."
I cannot regard it  as justifiable to select a single group of symp-
toms from  diseases of such  varied character, solely  on account of
its striking nature and upon the authority of tradition.
    As illustrations, let me  offer a few instructive instances from
my own practice.

   Case I.—So-called chorea major in an  hysterical woman.
   M. B., a delicate young lady of eighteen years, with anteflexio uteri, decidedly
hysterical, and to all appearances an onanist, over-indulged by her weak  mother,
was said to have suffered in the summer  of 1873 with spasm of the  glottis and a
remarkably deep and hollow-sounding cough.  Since the autumn of 1874 she has
suffered from periodical spasms  of respiration, with enormous acceleration of the rate
of breathing  (up to eighty in the  minute), beginning usually in  the forenoon and
lasting four or rive hours.  Since Christinas she has suffered  from associated spasms
of the whole  body,  commencing towards evening at very nearly the same hour, and
going on in the maddest way till near midnight.  The patient performs like a com-
plete acrobat; sometimes her body rolls itself into a ball, again it springs out to its
full length, and again opisthotonus occurs, in which the body is bent far backward,
is perfectly rigid, and its whole weight is supported by the skull and the tips of the
feet.  During this exhibition she utters the greatest variety of inarticulate sounds.
The consciousness does  not seem to be lost.
   Rapid improvement in a cold-water establishment.

   Cask II.—So-called chorea magna in an hysterical woman.
   S. D., get. seventeen (in the medical policlinic of Greifswald), hysterical, daughter
of an hysterical mother, suffers  from violent spasms, of which she usually predicts
the coming.   Called to such an  attack, I find the patient held upon the bed by four
compassionate neighbors "to prevent her doing herself harm."  She strikes about,
foams, rattles in her throat, barks like a dog, etc.  When let alone she creeps about
the room on all fours, leaps  on tables and cupboards, imitates the noise of various
animals.   Powerful induction  currents and the pouring on  of cold water stop the 
420
VON  ZIEMSSEN.—CHOREA.
attack quickly and with equal success on each subsequent  occasion, but they also
have the effect of  making the patient scold fiercely.

   Case III.—So-called chorea magna in a case of cerebral tumor.
   H. W., set. forty, a shepherd (at the 2d medical clinic in Munich), has suffered
for years with  the symptoms of a  cerebral tumor  (headache, dizziness, paralysis
agitans of the right arm, etc.), and has presented the severest associate spasms for
a long time.  The latter occur quite regularly every third or fourth day, and last an
hour or  two.  During  these attacks the patient  expends  an enormous  muscular
force in performing the  strangest involuntary  movements  (Zwangsbewegungen,
compulsory movements),  especially  rolling of  the body;  continually repeated
efforts to turn over backward, in which the head and neck strike the pillowed side
of the bed  with full force and the legs dangle in the air ; the most rajiid shaking
of the head and right arm together;  striking upon the chest with the fist; crossed
jerking of the extremities;  violent tonic spasms of breathing, etc.—In the course of
the summer a mental affection, in the form of general confusion of ideas, super-
venes.   The  patient declares that his clothes have  been changed, is very irritable
and fractious, runs away from the hospital in bare feet, wanders by night, etc.

   Case 4.—So-called chorea magna, simulated.
   C. B., ret. fourteen  (medical clinic of Erlangen),  carpenter's apprentice to  a
strict master; after every  trifling correction he  is  attacked by  apparent uncon-
sciousness,  with  general associated muscular spasms; he is removed to the house
of his weak  and credulous parents  — and how  often is the false indulgence of
parents  a cause of chorea  magna! — where the  attacks increase  in  violence,  and
assume the form  of the so-called greater  St. Vitus'  dance.  Of course, great sym-
pathy is expressed for  the boy; he  becomes an object of  universal curiosity, and
at the request of  his orthodox parents  prayers  are offered in  the churches, he
affirming that God alone can aid him.   Finally, however, at the urgent instance
of his relatives,  in spite of much opposition from  the boy  and  his parents, he is
brought  to the medical clinic.  Here I had opportunity  directly to  observe the
first  attack.  It was without question simulated, and was  arrested instantly by
the application of severe induced currents.   The  same occurred  at  the  second
attack.   The patient, unmasked, makes his escape privately ;  the attacks have not
returned.

   Case 5.—So-called chorea magna,  simulated.
   A. L.,  set. twelve,  son  of   a  gardener.  (Medical policlinic of Greifswald.)
Great reluctance  to  attend school.   Repeated punishments are followed by attacks
of chorea magna, with the character of  an impulse to run  and  climb, which are
most distinct when  there are spectators present.  He mounts upon the stove, the
wardrobes, climbs upon the trees, the roof of the house, and attracts  great atten.
tion.   He  is recognized as a pretender, and  is  rapidly cured by cold affusions,
He subsequently perpetrates many other impostures. 
HISTORY, DEFINITION.
421
   Hereditary tendency  to hysteria,  bad education, indulgent
parents, credulous physicians, play the chief part in the produc-
tion of these degenerate forms of hysteria, and in exaggerating
the simulated spasms to  the form of  chorea magna.  A charac-
teristic feature, as it  always seemed  to  me, was the surprising
effect of severe, sudden, unexpected stimuli, like powerful elec-
tric currents  or  cold affusions.   When  once  these means have
been employed without  regard to the  patient's feelings, it  is
enough on a  second occasion simply  to bring the induction
apparatus or the water-jug, in order  to  cut short the attack in
the beginning.   But  these remedies  have no  effect, or but very
little, in the general spasms of epilepsy or cerebral disease.
   Cases will  occur  in  wliicli  it is exceedingly  hard to tell
whether psychosis, cerebral disease,  hysteria, or simulation  is
before us ;  this is confirmed by the recently published observa-
tions of the above-cited authors.


                         Definition.

   In the absence of  a thorough comprehension of the nature of
chorea, it is at the present  time quite impossible to define the
disease. We can onhy aim at a grouping, as  complete as may be,
of the most important  points of this peculiar set  of  symp-
toms.  But even this is attended with great difficulties, owing to
the multiplicity of the phenomena ; and the  separation of essen-
tial from non-essential must remain  subject  to the  individual
judgment of authors.
   We understand by chorea a neurosis,  of which the seat (as it
seems) may sometimes be the  brain alone, sometimes the entire
nervous system ; characterized by incessant incoordinate twitch-
ings  or jerks of groups of muscles, which sometimes are  spon-
taneous in  origin, and  sometimes are  excited by  voluntary
impulse, which occur almost exclusively in the  waking state, and
are accompanied by  a more  or  less developed psychical dis-
turbance. 
422
VON ZIEMSSEN.—CHOREA.
                             Etiology.

   Chorea is mainly a disease of the  time of bodily development;
the period most affected is that from the second dentition to the
close of puberty.

   The statistics of the hospital for children at  Paris are said by See (1. c, p.
448)  to have included  in twenty-two years 531 chorea patients.   Of these there
were  28 under  six years of age, 218 from six  to ten, 235 from ten to fifteen.
A careful tabulation of the cases of which the beginning was  known (191  in
all) gave the following figures.  The disease began

           At less than 6 years........................11 times.
         From 6  to  11  "   ........................94  "
           "   11  "  15  "   ........................57  "
           "   15  "  21  "   ........................17  ':
           "   21  "60 "   ........................12  "

   The  statistics of  Rufz, Reeves, Steiner,  etc.,  agree with the
above,

   Among Steiner's 52  patients four were less than six years old, 46 between six
and eleven, and 6 between eleven  and  fourteen.   In Guy's Hospital, Pye-Smith
found

           2- 5 years old, 5 patients........ 2 males, 3 females.
6-10	62	a	......15	d	47
11-15 <	44	a	......17	it	27
16-20	19	n	...... 3	u	16
21-26	5	it	...... 0	u	5
38	1	"	...... 1	«	0
   In the middle and later periods of life the disease is very rare,
but  distinct cases have been  observed in  the forties and fifties
by Andral, Reeves, and Frank ; and in  the sixties and seventies
by Jeffreys, Bouteille, Powel, and Maton.   Next to these  pe-
riods, that of  infancy is the least exposed; and the number of
cases grows less in proportion as we approach the period of birth
(See).   A  few cases of chorea have  been observed in infants at
the breast by Simon and Constant, and even just after birth by
Monod, Fox, and Richter. 
ETIOLOGY.
423
   Fox  calls his  case one of congenital chorea.  The child, a male, was born six
weeks before the period, and from the first hours of his life he suffered from vio-
lent clioreic movements.  In his third year he is said to have had epileptic attacks,'
hut they did not occur either before or after that time.  In his thirteenth year,
when observed by Fox, the power of speaking and walking was  defective, but
intelligence was normally developed. The chorea was much improved by an arseni-
cal treatment.
   Richter also mentions congenital chorea in two girls, whose mothers had suffered
a severe fright when  advanced in pregnancy.  The children  suffered from their
birth with clonic  spasms which  ceased during sleep, and at a later  period  almost
wholly disappeared.


   Of  the sexes, the female is decidedly more troubled than the
male.   Of See's  531  patients, 393 were  females,  and  138 males.
Among  Rufz's patients in the  children's hospital  at Paris, the
proportion of females to males was 138 : 51 ; with Hughes,  73 : 27 ;
with Steiner, 40 :12 ; with  Pye-Smith, 106 : 42. In 27 adult cases,
between the ages of twenty and  seventy, Hasse found nearly the
same proportion, viz., 19 : 8.
   Hereditary transmission does occur,  but is certainly  rare.
But hereditary tendency to chorea,  as  to other  diseases  of  the
nervous system—as  hysteria, epilepsy,  etc.—or rather, an  here-
ditary transmission  of a special  susceptibility to irritation, an
impressionability of the nervous system,  on the one  hand, and of
a  general weakness of the entire constitution on  the other hand,
is  very often demonstrable.


    untington, of Long Island, with his father and grandfather (also physicians),
says he  lias observed entire families of  choreic persons, in which the disease was
propagated until once a generation had been overleapt,  when the hereditary dispo-
sition in that family ceased.  In these cases the chorea began between the twentieth
and the fortieth year of  life, attacked men and  women alike, and usually led to
mental disease, often associated with suicidal tendencies, and finally to death (?).


   All circumstances which are  adapted to increase  the  excita-
bility of the nervous system at the period of  sexual development
are of  great influence; such as a bad, indulgent  education, pre-
mature excitement of the sexual passion, onanism,  psychical
excitement, etc. 
424
VON ZIEMSSEN.—CHOREA.
   Fautrel' and Wendt2 speak especially of the consequences of self-abuse, prac-
tised in great excess previous to puberty.  Fautrel's patients were all onanists.  It
is impossible to get statistics regarding this point, so that it must remain hard to
estimate its importance as a cause or a predisponent.

    Among adults, we have  to mention  as predisposing  circum-
stances pregnancy, and disturbances of menstruation and san-
guification (chlorosis, anaemia).
    The  immediate causes may be very  various.   Psychical dis-
turbances, whether acting acutely in the form of fright3or dread,
or bringing  to bear the slow depressing  influences of sorrow and
fear, of  pain or discontent, are without doubt powerful agents
in bringing the disease to an outbreak, especially in predisposed
persons.
    Among the mental  causes  must be included  imitation, or
what may be called  the contagiousness of chorea.  A number of
accredited facts exist which prove the possibility of a propaga-
tion of the disease by psychical contagion among those children
in the neighborhood who are  predisposed through hysteria, ner-
vous tendency, or education, as in the  brothers  and sisters of  a
patient,  or the children of a boarding-school.  Besides the older
observations of  Mullin,4 Cramp ton,5 Eckstein6  and  Uwins,7 we
must  here mention  the recent  observations of  Bricheteau and
Leube.

   Leube saw two girls, of the ages of sixteen and seventeen, hysterically predis-
posed, who acquired chorea in consequence of intercourse with another girl, aged
twelve, who had  the disease; but the trouble was of short duration, yielding
quickly to galvanization and psychical treatment.
   Bricheteau's observation is still more striking.  Into the hopital Necker, in a
ward where there were girls who were hysterical or who had formerly been chorea-

   1 Sedilbt's Journ. gener. de med., etc. T. XXXIX. p. 319. 1810.
   2 Kinderkrankheiten,  Breslau, 1835.
   3 See, for instance, the case by Romberg (Nervenkrankheiten. p. 516) of a girl aged
ten, who was severely frightened in the morning by a dog that sprang at her and
barked loudly, and in the evening was seized by chorea.  See also the observation on
p. 432.
   4 Edinb. Med. and Surg. Journ. V. 1. 1805.
   5 Transactions of the  College of Physicians in Ireland. V. p. 110. 1824.
   6 Horn's Archiv f. med. Erfahrung. Bd. III. S. 301. 1803.
   1 Edinb. Med. and Surg. Journ. V. p. 405.  1812. 
ETIOLOGY.
425
tic, a girl with chorea was admitted, and within six days eight other patients in the
same ward were taken with chorea.  The further spread of the disease was arrested
by isolating the chorea patients.  The intensity of the symptoms varied greatly;
some of the attacks lasted for months.
    Here we have  to do with serious and protracted affections,
the origin of which,  in the way  of contagion,  can hardly be
doubted.   At all  events, a distinct predisposition seems to be
necessary to  propagate  the disease by  imitation ;  otherwise the
number of instances would be much greater than it is.
    As regards the geographic  distribution of chorea, the state-
ments of Rufz (1. c), that the disease is less frequent in the  warm
zones, has not been confirmed by the researches of Hirsch.1  The
question of the  frequency of chorea in different countries, and of
its  extension to north and south, to east and west, is one which
cannot at the present time be decided, even in a temporary way,
for, as Hirsch observes,  the statistical material of civilized  coun-
tries conies only from hospitals and from the  practice of single
physicians, and therefore is valueless  for scientific pui poses  ;
while the  reports as to  the existence of the disease in different
parts of the world are so few that no general conclusions can be
attempted at present.
    The  same is the case with  the  influence  of seasons and
weather ;  we have no useful statistical basis.
    As regards the causal relation existing between cliorea and
other diseases, the case  of rheumatism, and especially of  acute
articular  rheumatism and its  complications, deserves especial
attention.  From  the  beginning  of our century the relation of
chorea to  rheumatism has been  observed, and  the English and
French  authors  have taken special pains  to show that articular
rheumatism  and  its cardiac complications are  an  important
source of chorea.
    In judging of this question, we have scarcely any but French
and English statistical reports at our disposal.   The first statis-
tics of the sort originated with Hughes,and were printed in Guy's
Hospital Reports for 1846.  They include 108 cases of cliorea, of
which 14 were complicated with rheumatism and heart disease.
1 Historisch-geograph. Pathologie. Bd II. S. 570. Erlangen, 1864. 
426               VON  ZIEMSSEN.—CHOREA.

Ten years later,  the same author, in connection with E. Burton
Brown, published  in Guy's  Hospital Reports for 1856 a second
report, embracing  209 cases.  Among 104, in which it was pos-
sible to make careful examination as  to  the  history  and the
bodily condition as regards rheumatism and  affections of the
heart, there were but  15 in which rheumatic accidents  had not
preceded the attack, and a cardiac murmur could not be demon-
strated.   According to  Kirkes,1 almost  all cases of chorea are
caused by endocarditis.
   Of the French authors, See  and Roger are the most zealous
upholders of the causal relation of chorea and rheumatic affec-
tions in the widest sense.   See (I. c, p. 414) found among 128
chorea patients 61  who suffered at the  same time with articular
inflammations and  pains in the  joints.
   This coincidence seems the more remarkable,  as rheumatism
is rare in childhood.   See gives the following striking figures to
show this.  Among 11,500 patients received in the course of four
years in the children's hospital  there were only 48 cases of rheu-
matism without  chorea,  and 61  of rheumatism with chorea.
   Roger finds the coexistence  of the two so frequent, that he is
inclined to regard it as the expression of a pathological law, and
to regard both as one and the same affection under two forms.
   Spontaneous  acute rheumatism  is far more common in chil-
dren (according  to Roger) than  is usually supposed ;   that is,
from the fifth year and upward.   Before the fifth year it is cer-
tainly rare.  As  a sequel of  scarlatina, called out  by exposure to
cold, rheumatism of the joints is common, is usually confined to
the neck and arm, is  of slight severity, lasts but a short time,
and is more rarely complicated with affections of the heart, etc.
The spontaneous articular rheumatism of children is oftener sub-
acute than acute,  and attacks  only a  small number of joints;
but the frequency of the complications with  endocarditis and
pericarditis is none the less great, and it is the  light cases rather
than the severe that are complicated with chorea, which prefers
the period of the decline  of  the disease for its  own attack.
According to Roger, children who have  passed through rheuma-
1 Med. Times and Gaz. 1863. 
ETIOLOGY.
427
tism are predisposed  to chorea by that circumstance, and eice
versa, choreic children are in danger of being attacked sooner or
later by rheumatism.   Both diseases have the same tendency to
relapse.
   Wry different from these statements of English  and French
authors are the results of the observations made  by Steiner ' in
Prague.   He saw, among 252 cases  of chorea, only four which
originated during the  course  of acute articular rheumatism.
Steiner expresses his suspicion that this wide difference is due to
local influences.
   My own  observations, though few, tend to confirm  Roger's
statement.   Among twenty-one cases there were  four in which
the first attack, or a relapse of chorea, followed acute articular
rheumatism, directly or after a considerable time.
   If we add to these observations the considerable list reported
by older and newer writers (Copland, Seahouse, Forgues, Bright,
Babington, Hughes, Monckton,  Hillier,  Romberg, Trousseau,
etc.), who establish a causal relation between chorea and rheuma-
tism, we cannot doubt the closeness  of the connection.  How to
explain it will be our object in a later portion  of this paper.
   As regards the relations of chorea to other diseases, it may be
connected  with a great variety of inflammatory and other pro-
cesses in the central  organs of  the nervous system  and their
membranes,  or may develop from scarlatina,  bodily injuries,  or
disturbances of the uterine  functions ; but causes of these sorts
are so rare that we may regard them as merely constituting the
last impulse towards  the outbreak  of a disease for which pre-
parations are already made.
   The relation of chorea to pregnancy deserves special mention.
To the interest felt by the gynaecologists in this point during the
last ten or twenty years we owe a number  of careful essays,
among which the statistics of Robert Barnes2 are especially valu-
able.  Barnes's collection of fifty-eight cases—fifty-six in preg-
nant women and two in women in child-bed—has been enlarged
by Bodo Wenzel3 by eight more cases, of which four come from

             1 Prager Vierteljahrschrift, 1868. Bd. III.  S. 51.
             J Obstetrical Transactions. X.  p. 147. 1869.
             3 Schmidt's Jahrbb. Bd. CLXII. S. 199 ff.  1874. 
428
VON ZIEMSSEN.—CHOREA.
Sieckel,1 one from Friedr. Weber,2 one from James Russell,3 one
from  II. Thompson and Hall  Davis,4  and one from  Fehling.5
According to these figures, chorea occurs oftener in pnmiparae
than in pluriparae ;  of  51, 31 were primiparse.   The majority of
the patients were from twenty to twenty-Miree  years of age.
Chorea begins oftener in the first than in the second half of preg-
nancy ; of 57 pregnant women, the beginning of whose attack is
noted, 22 were seized in the first three months,  23 in the second
three,  and 12 in the last three.   No regularity or order can be
discovered in the relation  of chorea  to pregnancy,  as Wenzel
carefully shows.  Chorea sometimes occurs in persons who have
already suffered from it during childhood or puberty ; and in the
above  list  of sixty-six there are found fourteen who  had had
chorea previous  to  pregnancy ;  sometimes it attacks women in
pregnancy for the first time ; sometimes it occurs in first  preg-
nancies and not in later ones ; sometimes it repeats itself in every
subsequent pregnancy, or it may not  appear at all  till a later
pregnancy ; sometimes  it begins  in the first months and disap-
pears  before delivery;  sometimes it begins in the later months
and ceases at delivery, or lasts beyond it, or even makes its first
appearance at the time of confinement.   The latter case seems to
be the rarest, and exists in only two of the sixty-six.
   As a proximate cause of the attack, violent fright is  assigned
in seven cases.   Rheumatism and  endocarditis are noted as pre-
ceding the attack in only  seven cases.
   The relations  of  chorea to mental disease will  be spoken of
later.

                          Pathology.

                    General Description.

   The disease is very often ushered in by disturbances of the
mental faculties and the general health,  of longer  or shorter

                1 Inaugural dissertation.  Leipzig, 1870.
               2 Berlin, klin. Wochenschrift. VII. 5. 1870.
               3 Med. Times and Gazette. Jan. 8, 1870.
               * Lancet.  II. October 15, 1868
               5 Archiv f. Gynakologie. VI. 1. S. 137. 1873. 
           GENhKAL DESCRIPTION OF THE DISEASE.        429

duration ;  these are sometimes wholly absent.   It is particularly
in the very acute cases, caused  by fright, that  the characteristic
muscular twitchings form a first symptom.
   When there are prodromal symptoms they consist of a strik-
ing change in the temper, a fretful, discontented, or  apathetic
behavior  in  children  formerly  cheerful  and  brisk,  unusual
changeableness of temper, sudden and causeless  change from
sadness to excessive mirth, or the reverse.  At the same time the
mental energies fail, the patients become inattentive,  forgetful,
absent, and their schoolmaster is apt to be the first to notice this
in their awkward  and silly behavior, and to blame them for it.
There also  occur  hyperesthesia? 'and paresthesia?  in the nerves
of sense and sensation, weakness of the motor apparatus, dis-
turbance of appetite and sleep.
   Of the characteristic choreic disturbances of motion, the  first
indication is given by a general restlessness of body, which will
not let the patient remain long in one position, and by a remark-
able clumsiness  in performing common simple  actions.  The
patients work about in their seats, drop things they are holding,
their  writing becomes bad  and  illegible, their sewing useless,
their piano-playing confused.   At this stage the disease  is com-
monly not recognized  by the parents and teachers, who punish
it as carelessness or neglect.  As the trouble grows worse, twitch-
ings of groups of muscles in the arms, shoulders, and face occur,
which the  patient at first tries to  conceal by executing a  volun-
tary and rational movement directly after. But these involuntary
twitchings soon extend down over the whole apparatus of animal
motion, and not  only interfere with willed actions, but by the
frequency  of their  spontaneous  occurrence keep  the  body in
continual unrest.   In spite of his best efforts, and the powerful
influence of his parents'  blame, his comrades'  ridicule and the
presence of strangers, the child is unable to prevent the muscular
contractions for any length  of  time.  Often the volition is not
even able  to diminish  the  spontaneous jerking; in  fact,  the
muscular unrest is often aggravated by the effort.
   The want of order with which the muscular jerks pass from
one member to another,  the tireless activity of the muscles in
spite of the purposeless and useless nature of the acts,  the light- 
430
VON ZIEMSSEN.—CHOREA.
ning rapidity of the jerks, and the slow and careful way in which
intended motions are performed, the spasmodic grimaces, alter-
nating with periods of  expressionless,  almost idiotic, rest, all
contribute  to  form a most characteristic picture,  which it  is
scarcely  possible to mistake.   Sometimes one arm is bent or
extended ;  sometimes the fingers are spread apart; the shoulder
raised ; the head jerked in one or another direction ;  the features
are drawn into the greatest variety of contortions ; the eyes rolled
hither and thither; the  mouth  is sometimes  opened, sometimes
closed ;  the jaws are separated and  brought together, sometimes
so violently that teeth are broken off;' the tongue is extended and
drawn back with the velocity of lightning, or is rolled around in
the mouth.  The spasms of the  trunk give rise to active locomo-
tor movements of the whole body ; the patient is thrown from
his chair or out of bed.   The legs  are actively engaged ; some-
times they scuff on the  floor when the patient  is sitting; some-
times they  are suddenly drawn to the trunk, so that if the patient
is walking  he falls,  or is  turned  or hurled to one side or another.
Thus the spasmodic play of the muscles leaps about in the mad-
dest way,  sometimes affecting  one side more  than  the other,
sometimes  both  sides.   At last  every purposed movement is
impossible; the patient  can no longer  eat without help, as he
spills everything, drops  his cup, and fails to  reach his mouth
with the fork or spoon ;  he can  no longer dress himself, and the
disturbance in the apparatus for phonation and articulation pre-
vents connected speech.
   The functions of the sphincters of the bladder  and rectum
remain unaffected, as do those of the automatic apparatus of the
heart, of respiration, and  of  deglutition as far as the latter is
involuntary.
   When the patient is  once  asleep, the muscular action almost
always ceases,  but it is  very hard to get to sleep ; the rest is
imperfect, and  is disturbed by bad dreams.   On awaking, the
scene of tumult begins again.
   ' In a case by Tuckwell that ended fatally, in a girl of ten, three of the lower cutting
teeth were broken off by the spasms of the muscles of mastication ; the exposed guui
was by degrees worn to shreds by the upper teeth. 
ANALYSIS OE THE SYMPTOMS.
431
  The terms "insanity of muscles,'' "folie musculaire," applied by Bellingham
and Bouillaud to the confused play of the muscles, is very appropriate.

   Tin,' mental depression with which the disease begins usually
increases considerably during its course ; the patients  are freak-
ish,  obstinate,  selfish, violent to  excess  even  towards their
parents; and with these changes there is often joined a  failure
in intellectual power,  with  incapacity  to  think, imperfection of
judgment,  weakness of memory—which is extremely disquieting
to parents, especially in the educated classes.
   The  improvement in all the  symptoms takes place in most
cases very  gradually, and is often interrupted by relapses. Psy-
chical changes  are  especially unfavorable, and may greatly re-
tard convalescence.


                 Analysis of the Symptoms.

  Disturbances of the motor functions.—The involuntary muscu-
lar contractions, which are the characteristic feature of this dis-
ease, either occur spontaneous^,  or as  the result of an attempt
to perforin some ordinary action, which provokes irregular asso-
ciated movements.   In light cases  the latter are the more com-
mon, and the spontaneous jerkings are  few.  In severe cases  the
former are the more frequent;  the whole body is continually
thrown  about by the  explosive  muscular action;  the extrem-
ities art1  thrown out, etc.  The disturbing associated acts which
accompany intended motions are less noticed  in such cases,  be-
cause the patient, feeling  himself incapable of every act, is as
passive as possible.   He must be clothed, fed, led about, or even
carried by  his attendants.
   The extension of  the affection to the animal muscular system
varies very much according  to the severity of the case.  In slight
cases it is confined chiefly  to the head,  shoulders, and U])per ex-
tremities ; but in severe ones there  is hardly a voluntar}7 muscle
in the whole  bod}7 but is  affected to some extent, excepting the
sphincters  of  the bladder  and  rectum,  which  always remain
unaffected, and the muscles  of the ear,  regarding which we have
no positive statement.  A considerable degree of cliorea  of the 
432
VOX ZIEMSSEN.--CHOREA.
muscles  of the  pelvis  and lower extremities  makes  walking
impossible, even with support on both sides.  Not only does the
patient involuntarily take such long steps that lie loses his bal-
ance, but one leg or  the other bends while walking,  or  is drawn
up toward the pelvis so  that he falls down.  The choreic motions
of  the  legs become very distinct when the patient is led  by an
attendant.
   In one of my patients, a boy of ten, son of a tailor from the country, the chorea
was caused by a sudden fright from hearing a shot fired unexpectedly close to him
while gathering hope.   It reached a great height in a few hours; the boy could
not walk without support, for the long steps he took turned his body around, now
to the right, now to the left, and made him  fall.  When  led by two assistants he
took enormous strides, but while doing this both legs were suddenly thrown across
each other,  or drawn up so that the heels touched the nates, and the patient, held
up by the arms by his attendants, dangled in  the air.  When in bed  the movements
continued in  the same manner.  Sometimes the legs were drawn up to the body,
sometimes both arms were thrown violently above  the  head, then down again,
crossed over the breast, etc.

    Some authors say they have seen crossed choreic contractions
in which the muscles of the right arm and left  leg are  affected,
or the reverse ; but the reported observations  are not  demonstra-
tive.1
    Restriction to  one lateral  half  of the body, the so-called
hemichorea, is much oftener observed.  In  it the unilateral char-
acter is not confined to the extremities, but extends to the face
and the  apparatus  for  articulation  and  swallowing.   It  is re-
markable that the left side is oftener  affected  than the right, and
in bilateral chorea the left side is often worse  than the right.
    Ewart,* in 1760,  reported cases of this sort  of unilateral, espe-
cially left-sided,  chorea, which  were followed by those  of Be
Haen,3  Gardane,4 and Rufz.5  The fact was afterwards contested

   1 Woeltge's case (in his Observationes Med. Gottingen,  1783, p. 5, cited in Wicke, p.
279), which forms the basis of the statements commonly made concerning crossed cho-
rea, is of  a very doubtful and ambiguous character.  So are the observations of Albers
iHufeland's Journ. f. prakt. Heilk. I  S. 152 ff., 1795, given in Wicke, p. 459. Anhar.g'.
   2 De chorea St Viti. Edinburgh, 17G0.  Quoted by See.
   3 Praelectiones in H. Boerhavii instit pathol. Vienna?, 1780.  Tom. III.  p. 624 seq.
   4 Gardane, Observ. en faveur de la Med. Electr.  Paris, 1768. Quoted by Wicke.
   5L. c. p., 224. 
                ANALYSIS OE THE SYMPTOMS.              433

by Duges,1  but was established by  the statistics of See  and
others.   According to  See's  observations,  out of 154 cases in
which the seat of the  motions was carefully noted, the affection
was confined to the left side, or was more  marked there, in 97
cases.  Of pure hemichorea, he states the ratio of left to right
side as 37 : 27.   Pye-Smith observed, among 150 cases, 33 con-
fined to one side, of which 15 were on  the  right and 18  on the
left.  Russell observed, among 97 cases, 29  confined to one side,
and of 54 that involved both, the disease began as unilateral
in 43.
   Exhaustion of the muscles chiefly involved might be expected
to follow such incessant activity; but it is  remarkable that  this
does not occur.   The patients complain of nothing but a general
weakness.  The explanation of  this absence of local exhaustion
is probably to be found in the excessively short duration of the
individual contractions  and the constant change in  the seat of
the spasm.
   Complete repose of the muscles occurs  during sleep  in  the
great majority of cases, but  rare instances occur in which  the
spasms do not entirely cease in sleep.  These, according to Cyon,
are cases of reflex origin (chorea reflexoria), and appear "in the
peri- and endocarditis of articular rheumatism, in disturbances
of the female generative system, in cases of intestinal worms, and
perhaps with some cutaneous diseases/'  But it must not be for-
gotten that while a reflex origin of chorea seems to be verj7  fre-
quent, the persistence of the  spasms  during sleep is a very rare
phenomenon.
   The intoxication of chloroform and the sleep of chloral arrest
the spasms at once ; whether this is true in  all cases  cannot  yet
be determined.  In all  cases in which I have caused chloroform
to be inhaled to the point of producing narcosis, or have given
chloral  hydrate—and these were; all severe cases—the muscular
disturbance ceased at once and completely.
  After awaking  the  movements  are at  first moderate,  but
increase with the first attempts at voluntary motion, as  in rising
or dressing, and soon reach their former violence.
1 Essai physiologico-pathologique. Tom. I. No. 23. Paris, 1823.  Quoted by See.
       VOL. XIV.—28 
434
VON ZIEMSSEN.—CHOREA.
   Bernt (1. c, p. 24) states that certain positions of the body may cause the appear-
ance or disappearance of the spasms; he supports this by two observations by
Tulpius and Thirmaier, and makes two classes—chorea sedentaria (Tulpius' case of
a hysterical female who is  said to have been affected with  chorea only when in a
sitting posture), and chorea stataria (Thirmaier's case  of a man who was always
brought to his feet by the spasm, although they tried to fasten him to his bed or
arm-chair).  But both cases are very doubtful, and cannot well be included with
our chorea.
   As regards the reaction of muscles and nerves under the elec-
trical current little is known.   M.  Rosenthal'  found distinct
increase of  the electro- (farado-) muscular contractility in three
cases  of  hemichorea which had come  quite  early  under his
observation ; and  the galvanic test showed a high degree of excit-
ability, which appeared both in the fact that weak currents pro-
duced contractions at  cathodic closure (KaSZ),2 or even  tetanic
contractions (KaS  tetanus),—and also  in  the  contractions pro-
duced at  cathodic opening  (KaOZ).    Benedikt3 also usually
found, in galvanic examination, that  all  the  tests exhibited a
considerable increase  of  reaction, and, in  particular, that  the
cathodic  opening  reaction (KaOZ) was produced by  a current
very  little  stronger than  that required for cathodic closure re-
action (KaSZ).
   No law can be deduced from these scanty data at present.
Not  only do  we  require a much larger collection of facts  to
enable us  to  answer  the question  wdiether  chorea is  always
accompanied by  an  increase  of the farado- and galvano-mus-
cular excitability, but the observations ought to inform us sepa-
rately of the condition  of electrical excitability at the beginning,
during the course, and in the decline of the  disease.  Finally,
it  is  necessary to test the  excitability of  the  muscles and their
motor nerves separately,  giving special heed that the conditions
requisite to scientific  accuracy of  observation  are  observed.
Unfortunately, the estimation  of the degree  of electro-muscu-
lar contractility is still very much a matter of individual judg-
ment.  For the present  we can do no  more  than to establish
1 Klinik der Nervenkrankheiten. p. 581.
'2 For an explanation of these formulae, see Vol. XL of this Cyclopaedia, pp. 271-274
3 Nervenpathologie und Elektrotherapie. p. 256. 
                ANALYSIS OF THE SYMPTOMS.             435

with care  the minimum of excitability by working with as con-
stant a source as  possible (Siemens's elements) and Siemens's
rheostat.
   The occurrence of painful points and points painful upon
pressure  in chorea has been examined by Triboulet,  Rousse and
Perigault, and Mohammed Said, who have shown that the nerve-
trunks of the affected regions, and even the parts covering them,
are sensitive in  various degrees  to pressure,  and that in the
severest cases  the  patients complain of spontaneous pain.  In
hemichorea the affected side, with few exceptions, is alone pain-
ful ; but  if the other side  afterwards becomes involved,  its
nerves become painful  also.  The painfulness is in  direct ratio
to the violence of the choreic movements.
   A participation in the choreic movements  on the  part  of the
vegetative muscular system is generally denied, or is regarded as
very rare.   And, in truth, the facts which favor this view are too
ambiguous to  permit of such an interpretation.   In the case of
such automatic  actions as the respiration, in which the will  is
capable of influencing  the rapidity and rhythm of  the  move-
ment, irregularities are  often observed in the  act,  whether of
inspiration or expiration, which can only be  interpreted as cho-
reic.  I have  paid especial  attention to this point, and have
reached the following conclusion :
   Impaired  or  lost power of speech  depends not solely upon
the choreic disturbance of the functions of the muscles of articu-
lation, but may  be due to chorea of the muscles of the abdomen
and glottis. The  implication of the abdominal muscles is best
shown by  the effect produced upon the act of expiration, which,
especially when forcibly performed, assumes an irregular, jerking
character.   The effect is most marked when the patient is caused
to sing, or to speak continuously as  in counting.  In  slight
cases  this  produces only a deficiency in the power of continuing
the equal  pressure of expiration required for vocalization; the
pressure soon  ceases, and rather  suddenly, so  that the patients
can bring  out  only a few  syllables  or numbers,  which are
interrupted by a hasty inspiration.  In severe cases they can
utter only  one syllable or number in one expiratory effort, and
between every two syllables there is a remarkably hasty inspira- 
436               VON ZIEMSSEN.—CHOREA.

tion;  others  drive out their syllables or numbers forcibly, and
their  speech  has something of an  explosive character.   As the
case improves, the number  of  syllables which can be  spoken
with a single effort increases.  The  explosive contractions of the
abdominal muscles are perceptible to  the touch.
   Chorea of the laryngeal muscles, of which no cases have been
published, is in my observation  a  usual accompaniment of the
severe form  of  the  disease.  It  is characterized by insufficient
force and  duration of the tension  of the vocal cords in  phona-
tion,  owing to a want of co-ordination  and persistence in the
muscular act; the  patient is unable  to sustain a tone in  singing
for any considerable  time, or to  utter several words together
without interruption.  The singing tone is suddenly interrupted,
and the last syllables of the words are cut off in  the effort to
make the next inspiration.   In  reading aloud  a great  deal of
muscular force and of breath is expended, so that the patient is
soon very tired.  That the tension of the vocal  cords in phona-
tion  is often insufficient  I  have been able to  show in several
cases by the relatively  deep pitch and monotony  of the voice,
which disappeared  as the patient improved, giving  place to the
normal pitch and modulation of the voice.  With the laryngo-
scope it is very easy to watch the restlessness  of the laryngeal
muscles, the twitching contractions of the closers,  openers, and
tensors of the cords.
    Many authors speak of a chorea  of the heart, by which they
understand palpitations or irregularities of rhythm, which con-
tinue while the disease  is at its height, but neither before nor
after.
    Cases  of arhythmia are certainly very rare, and  there is
hardly anything published about it.  Romberg (Nervenkrank-
heiten, p. 214) could not discover any abnormal variation in the
movements of the heart, in spite of continued observation. Hasse
(1. c,  p.  167),  on the  contrary,  observed  two  patients whose
pulse occasionally  intermitted without any demonstrable disease
 of the heart.
    Simple accelerated action of  the heart, sometimes with a full
 hard pulse,  sometimes with a soft  and small pulse,  is often men-
 tioned, and has been repeatedly observed by us.  According to 
                    ANALYSIS OF THE SYMPTOMS.                437

 Stiebel,1  the palpitations  are especially prominent during  the
 decline of the disease.
    Reeves » has lately described chorea of the heart as a peculiar nervous affection
 of the heart, often connected with chlorosis and general cliorea, but also occurring
 apart from them, in which there occur nightly attacks of palpitation and distres°s
 for breath, with free intervals; attacks which, therefore, have a great resemblance
 to those of angina pectoris.  In this description we can find nothing characteristic,
 nothing which differs from the nervous palpitations which are so frequent in young
 patients; and we wish to state clearly our belief that it would be very improper to
 give the name of chorea of  the heart to anomalies  of this sort in the rhythm and
 rapidity of  the heart, as Reeves has done.  Such a name would only lead to fresh
 confusion.  In our opinion, the name chorea should be restricted to those arhyth-
 miaj and palpitations which develop during, and as a consequence,of, actual chorea.
 The influence of the restless muscular action upon the aortic pressure and  the work
 of the heart must necessarily be counted as a factor which may influence the pros-
 sure and rate in the same way as a choreic disturbance of innervation may.
    The pupils are  very  commonly  dilated-a  fact which  most
 authors  have reported,  and   which  I have observed in  almost
 every case.  The  reaction under  the influence of light is often
 very much diminished, as Hasse, M. Rosenthal, and others,  have
 stated.  I have repeatedly seen the dilated  pupils react  very
 sluggishly to the impression of light; and in one case, where the
 chorea was chiefly localized in the  right half of the body, and
 the right leg was a little dragged  in walking,  the  pupils  were
 both dilated,  but  the right considerably more so than  the left.
 Of course, a dilatation of the  pupil is a very common and often
 seemingly causeless  phenomenon with  children, and  it  is not
 proper to assign it a causal relation  to  chorea unless the pupil
 has been  found to be of normal size both before and after the
 disease—a precaution  which,  it would  seem, has scarcely  ever
 been taken.  It would  be desirable to observe also the  behavior
 of the pupils in sleep and during the muscular rest procured by
 chloral hydrate and chloroform.
   M. Rosenthal, who once saw  the dilatation of the pupil disappear spontaneously
after the termination of the chorea,  was not able, even by direct electrical stimula-
tion,  to change the pupil during  the continuance of the disease; he therefore

   'Klin.  Beitriige zur Heilwissenschaft.   Frankfurt a. M, 1823. p. 43-07.
  • Heart diseases in Australia with observations on aneurism of the aorta.  Mel-
bourne, 1873.   Schmidt's Jahrbb.  Bd. CLXI. 1874.  p. 131. 
438
VON ZIEMSSEN.—CHOREA.
regards the phenomenon as the expression of a spasm of the dilatator pupillaa
muscle, caused by irritation of the centrum cilio-spinalc—an assumption, however,
which is quite hypothetical.
   In regard  to this, as to so many other points, we are com-
pletely in the dark.
   The reflex motions appear to be executed normally in all cases.
   Sensibility appears, according to the observations which we
have, but rarely affected.  In these  rare cases there has been
sometimes observed a diminution of cutaneous sensibility in one
or both halves of the body (Charcot), and of the acuteness of
the senses of hearing, smell, taste,  and sight;  sometimes a gene-
ral hyperesthesia and hyperalgesia of the skin and the senses.
But the small number of the observations made upon this point,
and their incompleteness, and especially the neglect to  test the
kinds of cutaneous sensibility separately, render it undesirable at
the present time to make much use of them.
   The feeling of  muscular pain, in spite of the most violent
spasms, seems not to occur, or but rarely.
   Sensitiveness  of single vertebra?  to  pressure,  found  and
emphasized by Stiebel,  is not only without doubt  very rare (for
experienced authors, as Hasse and  others,  were unable to find
it), but could hardly claim any real  importance even if it were
more common ; the many examinations into that which  is called
spinal irritation have shown how frequent and how destitute of
significance this phenomenon is, especially in nervous and hys-
terical persons.
   As to vaso-motor and secretory disturbances, I have not
been able to discover them.  Nothing whatever is said by authors
about them.
   Psychical disturbances are rarely absent, although in the
lighter cases they are but little  developed,  and consist only of
irritability and changeability of  temper.   In the  severer cases,
especially when of long duration, the character seems to change
for  the  worse:  good-natured  persons become passionate; the
peaceable, quarrelsome ; the cheerful, timid and recluse ; the pious
lose their scruples and are disobedient; the intelligent appear
childish and simple.  In connection with the stupid look and the
apish grimacing behavior, these  signs of depressed intelligence 
ANALYSIS OF  THE SYMPTOMS.               439
and altered character, especially when occurring in older children
at and after  the  period of puberty, are apt to  terrify the non-
medical mind; and the physician is often obliged to reassure the
relatives, who apprehend  that idiocy will be the result.  Hasse
is inclined  to derive the frequent weakness of mind,  the want of
attention,  the  failure  of  memory,  the incapacity  for  orderly
thought and logical judgment,  from the anemia,  the general
bodily weakness, and the continual diversion of thought caused
by the muscular contractions.   I should prefer, however, the
view which derives them from slight anatomical changes in the
central apparatus of the nervous system, especially since intelli-
gent patjents of the upper classes, who have  passed the period of
childhood, require a considerable time after the cure of the cliorea
before they wholly regain their mental  powers;  and  since  sig-
nificant changes have recently been found in the brain in certain
cases of chorea (see further on).
   The explanation of  these facts must rest  upon future investi-
gations.
   It is but rarely that the psychical disturbances persist or lead
to general  paralysis (cf. Results).
   Apparatus of  respiration and  circulation. — Besides the
clioreic disturbances of the respiratory muscles above mentioned,
no morbid symptoms, upon the part of the respiratory organs,
have  been  observed.
   As regards the organs of circulation,  the  doubtful arhythmia
of the action of the heart has already been spoken of.   An accel-
eration of  the pulse at  the height  of the disorder is quite con-
stant,  and  may probably be explained as due  to the  continual
muscular effort and the mental disturbance.   With the improve-
ment in the symptoms of  spasm  the frequency of the  pulse
diminishes.

  In a girl of ten, observed by me, who entered the medical clinic at Erlangen at
the end of the third week of an attack of hemichorea, and was discharged nearly
cured after seventeen days' treatment  with arsenic and lukewarm baths, followed
l>y shower-baths, the rate of the pulse wras taken twice a day in bed.  It averaged
89 for the first six days, in the second period of six days 83, in the last five days
76. The maximum and  minimum for the first period  were 104 and 80, for the
second 88 and 76, for the third 80 and 72. 
440
VON ZIEMSSEN.—CHOREA.
   Physical examination of the heart often reveals anomalies,
which depend partly upon the residual consequences of an old
endocarditis, and are partly of a purely functional nature.  The
former are characterized by valvular murmurs and by the pheno-
mena consecutive to the valvular disturbances in question;  the
latter only by a systolic valvular murmur at the mitral, some-
times in the fornl of a soft-blowing sound,  sometimes  a harsh
sound,  or even  a distinctly marked rough murmur, although
there be no increase in the second pulmonary sound, no enlarge-
ment of the right ventricle, nor any  other sign of increased ten-
sion demonstrable  in the  system of  the pulmonary artery.  In
a few cases, when the  second pulmonary sound  is moderately
accented, it  may be very hard  to decide whether there exists an
anatomical  or only a functional disturbance of the valve.  The
pathogenesis of these functional disturbances of the mitral in
cliorea  is quite  as  obscure as  in the cases of anaemia, chlorosis,
acute rheumatism, etc.   That the papillary muscles  are  the pri-
mary cause  of the murmur, or  the change in the valvular  sound,
is, d priori, more likely in chorea than in  any other affection.
As to the frequency of the coexistence of  endocarditis and its
consequences with chorea, see below, under the heading "Ana-
tomical, Experimental, and Theoretical Considerations."
   The bodily heat is not changed, even in severe cases, in spite
of the restless muscular activity.  I have carefully tested this
question in a few cases, and when there has been no complica-
tion, have never found a temperature above 38° C. (100.5° F.) in
the rectum.  In chorea, only  rectal  temperatures can be made
practically useful, for the  motion of  the body makes the deter-
mination of  the axillary untrustworthy, or even quite impossible.
   In the above case of hemichorea, treated for seventeen days in the  clinic, the
rectal temperature was noted twice a  day.  The maximum reached was in three
evening measurements, equalling 38.0°; the minimum  in two cases of morning
temperature, 37.0°.  All the other temperatures ranged  from 37.2° to 37.9° C. (99
to 100.3° F.).
   The nutrition of the patient is as good as could be wished in
slight and brief cases, especially when they are taken from school
and work, and brought nearer  to Nature, in the country or at the
sea-shore.   In severe cases the appetite and digestion  suffer in 
COURSE,  DURATION,  AND RESULTS.
441
proportion to the duration of the disease, the patient emaciates,
loses in weight,1 grows anaemic and feeble, and gets a dry crack-
ing skin.   The perpetual friction very often gives rise to inflam-
matory conditions of the skin (excoriations, eczemas, furuncles).
   The stools are usually rather constipated than the reverse.
   As  regards the  state of the urine  there is much variety of
statement.   Its  quality is generally  noted as normal, its color
is either light or dark.  In  respect to its chemical  composition,
Bence Jones  states that an increased  excretion of urea is con-
stant.  Stiebel and Yeghelm speak of absence of lime, and others
of abundance of urates as  frequent.   C. H. Jones found  that
the excretion of  urea and phosphoric  acid was often increased at
the height of the disease, and diminished during convalescence.
L. Tait observed in a fatal case, in a pregnant woman, much
sugar in  the urine, with a specific gravity of 1031,  no albumen,
and a diminution of the chlorides.


              Course,  Duration, and Results.

   Chorea is always chronic.  The lightest cases, lasting three or
four  weeks, have been  spoken of as acute, and Thilenius has
accordingly distinguished an acute and  a  chronic form.  But the
circumstances alleged in support of  this  view, namely, that the
duration  is limited to three or four  weeks, that all the  muscles
are attacked at once, and  that  the  disease is  fully developed
from its beginning, cannot be considered, as Wicke remarks (1.
c, p. 274), a sufficient ground for making the distinction.
   Nor does it seem necessary to make  the division  into  stages,
which Hamilton and  Dalgairns have attempted.  The  division
into increase, acme, and decrease  does  not exist in nature, and
must be left entirely to the judgment of the observer,  and in the
numerous cases  where  there  are no prodroma  at  all,  it is, of
course, impossible to make a stadium prodromorum.
   The duration is extremely variable.  We find all sorts of fig-
  1 In a case observed by me, a girl of eleven had fallen in weight at the severest
period of her sickness to 55.5 lbs., and during convalescence rose to 61 lbs. in ten days,
making a gain of 5.5 lbs. 
442
VOX ZIEMSSEN.—CIIOl'EA.
ures given, from a few weeks up  to  many years.  Wicke  ob-
tained an average duration of 89 days  from 12o cases, of which
the duration was accurately known ; See, an average of  69 days
from 117 cases.
   According to Moynier's statement (1. c.) the duration was dif-
ferent in the two sexes, being in girls from 33 to 37 days, in boys
from 74 to 81 days.  But it can hardly be believed, in opposition
to all  the  other authorities,  that  so  considerable a difference
should exist.  My own views are decidedly opposed to those of
Moynier, for I have repeatedly observed the disease  to last four
or five months in girls.
   Gray and Tuckwell observed the duration of six and twelve
cases respectively,  under  purely expectant  treatment.  Gray
found  the  longest duration  twenty  weeks,  the  shortest six;
Tuckwell, the  longest  seventeen, the shortest six.  The average
of all was ten weeks, and one and three days respectively.  Hil-
lier also obtains  an average duration  of ten weeks from thirty
cases.  Here is the place to observe that Tuckwell found almost
the same average duration, namely, ten weeks and six days (from
seven to sixteen  weeks) in eight children, who were treated after
Begbie's method, by increasing doses of arsenic, and that Gray
found an average duration of ten weeks and five days in seven
cases treated with various remedies.
   In general, therefore, the duration  of chorea may be consid-
ered as from two to three  months ;  but this statement must not
be taken as giving a trustworthy indication of the probable dura-
tion of an individual case.
   Cases in which chorea lasts many years, or a whole lifetime,
are usually symptomatic, and are chiefly based upon anatomical
lesions of  the  brain and  cord (Cyon's  chorea symptomatica;
See's choree chronique  in the stricter sense, as distinguished from
his choree vulgaire).
   The assumption that  cliorea has a cyclic  course (is self-lim-
ited),' as stated by Gintrac,  with a duration of at least two and
at most three months, is somewhat arbitrary, and stands opposed
to the  experience of every busy physician, but has had the im-
1 Journal de la sociebe de med. de Bordeaux.  Avril, 1845. 
             COURSE,  DURATION,  AND  RESULTS.           443

portant  practical result that all treatment, except the dietetic,
has been declared superfluous and  useless.   But in most severe
cases  in which  the  symptoms last longer than three months
with unabated  severity, it  is easy to  convince oneself of the
incorrectness of the cyclic theory, and of the possibility of quick-
ly influencing the disease by therapeutic measures.   I have had
the opportunity almost every semester, in my  clinic  at Erlan-
gen,  of  presenting instructive cases of this nature  (compare
Treatment of Cliorea).
   The course is seldom quite uniform, even when the disease
has reached its height.  Improvement  alternates with relapse,
and psychical affections of comparatively  small importance af-
fect the  violence of the symptoms very much.   Such relapses in
consequence of  psychical excitement are also very common dur-
ing the period of convalescence.
   Recurrence of the disease is frequent, and occurs at the great-
est variety of intervals.  This may be  due to violent psychical
excitement, or bodily conditions, such as disease or pregnancy,
acting on a person  who is  clearly predisposed.   Most of the
relapses occur  during  puberty,  but  among persons who  were
choreic at or before this period they are  observed at from twenty
to thirty years of life and later.
   The number  of recurrences varies.  Most frequently it hap-
pens but once;  twice is rarer, and more than twice is  still less
frequent.  See  observed thirty-seven among one  hundred and
fifty-eight cases; among these, seventeen  had but one relapse,
thirteen had two, and six had three; in one case seven sharply
marked  attacks could be shown.  Cases of  six relapses  are given
by Rufz and Romberg.  When they are so numerous the  inter-
vals between them are usually but short.
   Whether the season of the year  can  influence the occurrence
of relapses, as Wicke believes, is a matter which requires further
proof.  Among  thirty-five relapses, thirteen are stated by Wicke
to have occurred in  spring,  twelve in  winter, nine in autumn,
and one in summer.
   As to the termination of  the  disease, a  complete cure is by
far the most frequent.   Trustworthy statistics, such as are fur-
nished in many other points by hospital observation, are not to 
444
VON  ZIEMSSEN.—CHOREA.
be had, for the patient's condition after discharge (which usu-
ally takes place at an early period), and such relapses as may
occur, usually remain unknown.   Slight disturbances of coordi-
nation of movement, especially in the upper extremities and the
face, needless haste in executing certain motions, grimaces, etc.,
often remain for years after an apparently perfect cure, and in a
few cases never disappear.
   Termination by incomplete cure is rare.  Either a few symp-
toms of chorea itself may persist, or pareses or paralyses  may
develop in the half of the body which has been more affected, or
else a permanent psychosis is developed in the course of the dis-
ease :  as mania, melancholia,  progressive paralysis ; but  these
events are very rare in uncomplicated chorea.  Usually there is
some cerebral lesion before the chorea commences,  and the latter
is only a transitory  phenomenon which gives way to other and
severer disturbances.
   Death is  extremely rare in children,  especially in uncompli-
cated cases.  In adults, and especially in pregnant women, it is
much more common. See found nine deaths among one hundred
and fifty-eight cases in the children's hospital, or 5.7 per  cent.
The statistics of Wenzel give a  mortality in  chorea gravidarum
of 27.3 per  cent.  Of sixty-four pregnant women, and two women
lying-in who were attacked just after  delivery,  eighteen  died.
Of these eighteen, the number of the  pregnancy is noted in
eleven, of whom six were primiparae, four in their second  con-
finement, and one in her fourth.
   The cause of death is to be assigned, on the one hand, to the
intensity of the disease  itself;  on the  other, to  many serious
affections and complications, as meningitis, encephalitis, myeli-
tis, pericarditis, endocarditis, and embolic processes.
   In cases which seem to be caused by the chorea  itself, the
symptoms  are usually violent from  the first and in a few days
rise to an enormous severity, which is succeeded by sudden col-
lapse, and death follows after more or less of coma, involuntary
stools, etc.   The choreic twitchings  either cease entirely  when
the collapse  begins,  or, in a few cases, they  continue, but  grow
weaker, until death. 
PATHOLOGICAL  ANATOMY.
445
 Anatomical, Experimental, and Theoretical  Considerations.

   The scanty pathologico-anatomical data which we possess are
chiefly drawn from late research.   The older autopsies, collected
by Wicke and See, are nearly useless in determining the nature
of chorea, both because the error commonly made in confound-
ing chorea with the so-called cliorea major and  paralysis agitans
justifies a doubt as to the correctness of the diagnosis, and be-
cause the inferior knowledge and methods of pathological  anat-
omy  previous to the year 1840 confounded essentials with non-
essentials in the points observed.  In  particular, a careful dis-
tinction between old lesions and those which might be associated
with  cliorea, and a minute and  microscopical examination,  are
wanting.  Hasse has stated that  along with th.e positive results
uloubtful as to their interpretation), which consist of hyperaemia
and inflammatory  exudations of the membranes of the  brain—
more rarely those  of the cord,—local  softening and other local
diseases of  the brain or cord, new formations, etc.,  there existed
a number of entirely negative reports.
   See, who compares the autopsies made before his  time with his
own,  finds among 84, 16 with results entirely negative in respect
to the nervous  system ; 34 with  inflammation  of  serous mem-
branes, changes in the heart, etc. (16 arthritis  rheum, multipl.,
11 periendocarditis, 12 pericarditis and  endocarditis,  6 h}rper-
trophy of the heart,  6 meningitis, 3  bony indurations of the
meninges, 6 pleural exudations, 6 peritonitis);  and 32 in which
there were affections of the central nervous system and its mem-
branes, oftenest softening and tuberculosis.
   Although See recognized correctly the close relationship which
chorea bears to rheumatism and endocarditis, he yet  thought that
only a minority  of the deaths should be referred to inflammatory
changes in the heart, and the  majority to the  action of  chloro-
ana)mia and nervous excitement.
   Roger, on the contrary, maintains that the connection between
chorea and disease  of the heart is neither rare nor accidental, but
is just as regular  as  the  connection between  rheumatism and
affections of the heart.  The acute rheumatism  of the joints, the 
446                VON ZIEMSSEN.—CHOREA.

affection of the heart, and the chorea  he makes but three mani-
festations of the same diathesis.  The order in which they appear
is very variable.   The rheumatic diathesis can also develop from
scarlatina.  Among  71 cases of his  "chorea cardiaca," Roger
found simple  endocarditis  forty-seven  times,  endopericarditis
nineteen times, simple pericarditis five times.  But it should be
added that these figures are chiefly based  on diagnoses made
during life, and that  a systolic apex murmur seems in France to
justify the inference  that endocarditis  is present.
   Roger's too general statement was soon  objected to by the
more judicious of his own countrymen ;  Trousseau declared that
in his own experience rheumatism and  chorea often accompanied
or succeeded one another, but not always.
   In Germany and Austria the  connection between rheumatism
and chorea would seem to be much less close, and  certainly not
to constitute a law in Roger's sense.  Steiner, at least, found only
four cases out of. 252 observed by him  in Prague, in wdiich the
chorea had developed from  acute articular rheumatism.  These
numbers seem extremely low ; for my own part, I have found
about one case in five in which it could  be proved that rheuma-
tism had preceded the attack.
   According to the observations of English authors, less impor-
tance should be attached to  the rheumatism than to the endocar-
ditis and its sequelae, which  are very often found in the autopsy
of choreic children,  without previous acute rheumatism.   The
English reports show, beyond a doubt, that in that country deli-
cate vegetations on the mitral valve, less frequently on the aortic
valve also, are very  commonly  found in the bodies of choreic
patients.
   We will extract only a few data.

   Ogle found in sixteen autopsies  of chorea " fibrinous, membranous,  or granular
deposits upon the endocardium of the valves " ten times ;  als^ pericardiac changes
three times, congestion of  the central nervous organs six times, and softening of
the cord once.
   Pye-Smith describes four deaths among  150 cases of chorea, observed in Guy's
Hospital and the Metropolitan Free Hospital during the past three years, and adds
seven  other reports of autopsies not yet published.  Of the 11 cases, 2 were in
males and 9 in females; the ages of the former were 10 and 38, of the latter, 7, 7$, 
                    PATHOLOGICAL ANATOMY.                 447
 12, 13, 16, 18 (twice) ; the age of one pregnant woman is not given.  In all eleven
 cases recent or old endocarditic products were found upon the valves (valvular
 vegetation, with and without coagula, on the mitral alone five times, on the aortic
 valves alone twice, on both at once four times). Twice in the eleven cases the heart
 was hypertrophied (once on the left, once on both sides).  Cerebral hyperemia is
 noted three times, hyperaemia of the spinal cord  once, hydrocephalus, with a cor-
 responding flattening of the gyri three times, pericarditis once, pleuro-pneumonia
 three times, diphtheria twice.  (It is matter for regret that no statements are made
 respecting the results of microscopic examination.)

    In England the doctrine that chorea is a cerebral disturbance
 has found warm supporters since the beginning  of the present
 century.  Of later authors  Todd  was the first to  point  to  the
 importance of unilateral  cliorea and its not infrequent combina-
 tion with hemiplegia as  indicating a cerebral origin;  he has
 pointed out the results of comparative weighings of parts of  the
 brain, made by Aitken in the  case of  a  patient dead of  cliorea.
 These gave  the specific weight of the corpus striatum  and thala-
 mus of the right side as 1.025, on the left 1.031, while  Bucknili's
 weighings  of healthy brains give  a weight of 1.036 for  these
 organs.   By the side of these doubtful  proofs, all the more value
 is to be attached to the careful anatomical examinations to which
 some English  observers  have devoted themselves  with  special
 zeal and success.  In particular,  the names of Kirkes,  Broad-
 bent, Tuckwell, Ogle,  Hughlings Jackson, Barnes, Russel ought
 to be mentioned.
   Kirkes endeavored  in 1850 to prove that inflammatory changes
 in the valves of the heart were the  usual change found in  autop-
 sies of fatal  chorea, and took a considerable part in the causation
 of clioreic symptoms.   Rheumatic affections were in very many
 cases  not demonstrable,  and yet  endocarditic processes  were
 shown  by examinations made during life and  after death ; the
 latter were sometimes  found after death, when no cardiac mur-
 murs  had  been  audible  during  life.   The  opinion of Begbie,
 Watson,  Branson, and others, that a "rheumatic  diathesis" is
 the  common cause  of  affections of the joints, endocarditis and
chorea, Kirkes could not  regard as satisfactory, as  chorea and
valvular  diseases often coincided  without  the  least trace  of a
rheumatic tendency.  He considers it most probable that endo- 
448
VON ZIEMSSEN.—CHOREA.
carditis  is the cause of  the chorea, through the inflammatory
products  of the calves which  become mixed  with the blood and
disturb the functions of the nervous centres.
   Broadbent1 has  used numerous autopsies as  means for care-
fully formulating the cerebral nature  of clioreic  disturbances,
and first  designated  the  corpus  striatum and thalamus opticus
as their location.   A  variety of morbid states of these ganglia
might produce the group of symptoms known  as  chorea ; but
the most frequent, in his experience, was capillary embolism of
the corpus striatum, thalamus opticus, and their vicinity.
   According to the extent of  the embolism, chorea is of greater
or less extent or intensity, and may be  combined with delirium,
mania,  etc.   Besides  embolism,  other  sorts  of  disturbances of
nutrition  in the ganglia,  peripheral  influences which arrest the
reflex process, direct lesion of  the ganglia from fright, mechani-
cal lesion, etc., may act as causes.
   These  views have  been adopted in  the main by the other
English neuro-pathologists,  and  continual attempts  have  been
made to confirm them by  anatomical proofs.

   Tuckwell reports the autopsy of a girl aged thirteen, in whom chorea developed
out of rheumatic fever,  and in three months led to deatli by exhaustion, without
mania or delirium.
   At the autopsy there was found softening of the right middle cerebral lobe, and to
a less extent of the left, without demonstrable embolism.  The  grey cortex was intact
upon the surface, but the deeper layers, and in particular the adjacent white sub-
stance as far as the (intact) corpora striata and thalami, were changed.  Under the
microscope, the walls of the small vessels were covered with fine granular puncta-
tions; the granules were  in some  places scattered, in others heaped together.
   On the auricular surface of the mitral there were numerous fine warty vegetations.
In the kidneys three small arterial twigs were plugged with emboli.
   In a case observed by Tuckwell before death, this author was enabled to demon-
strate  embolic processes as a  cause of the softening of the cerebral convolutions.
The vegetations, which, as a rule, are situated on the auricular surface of the mitral,
are remarkable for their smallness and  delicacy, and  can be easily removed with a
brush, and doubtless also by the current of the blood.
   Very similar is the condition found in a case of acute chorea, observed by Gray:
 .  ' The article cited from the British Med. Journal, in the list of authorities, is a
development of a lecture delivered by Broadbent before the Medical Society in London,
in the year 1865-6, but not published. 
PATHOLOGICAL ANATOMY.
449
embolic thrombosis of the basilar artery, both vertebrals, and both middle cerebrals,
with softening of the anterior and middle cerebral lobes and the dorsal part of the
cord.
   Microscopic embolism of the corpus striatum and small vegetations on the mitral
valves were demonstrated by E. L. Fox in a case of acute chorea, in which the patient
died twelve hours after the occurrence of a cerebral hemorrhage.
   Granule-cells along the vessels in the corpus striatum have  been observed by
numerous authors (Tuckwell, Ogle, etc.).

   Germany  has made but few contributions to the pathological
anatomy of cliorea within the last twenty years.
   Froriep examined the body of a boy of ten who had  suffered
over  a year  from cliorea,  and found an  impression upon  the
lower (anterior) surface  of the medulla oblongata, caused by a
considerable  enlargement of the odontoid process.'
   Romberg2 describes  three autopsies; one  showing a general
atrophy of the brain with hydrocephalus externus ; one internal
hydrocephalus with softening in the neighborhood  of  the ventri-
cles; and a third with  softening of the cervical and dorsal part
of the spinal cord.
   Of two interesting cases of reflex chorea from Frerichs' clinic,3
one was examined post mortem.
   The case was  that of a pregnant woman, and the chorea was  complicated with
mania.  The birth of a dead child occurred  about the thirty-third  week of .preg-
nancy.  In spite  of this, the choreic movements  continued with increasing violence
until death, which took place a week after delivery.  The  autopsy showed a gene-
ral hyperaemia of the brain and its membranes, pachymeningitis interna vascul. et
hsemorrhagica, deposition of bone upon the dura mater, warty excrescences on the
auricular aspect of the mitral, and a remarkably narrow aorta.
   Very valuable anatomical researches, especially of a patholo-
gical  and histological nature, have  been made by some Austrian
observers.
   Rokitansky4 first  pointed out  the occurrence  of  interstitial
growths of connective  tissue in the  central nervous system in
chorea.
  1 Neue Notizen a. d. Geb. der Natur- und Heilkunde. No. 224. p. 57.
  2 Nervenkrankheiten. p. 528 seq.
  3 Dissertations of Arno/di and Fricke.
  4 Ueber die Bindegewebswucherung, etc. Sitzungsberichte der Wiener Akademie der
Wiss. 1857.
          VOL. XIV.—29 
450                 VON ZIEMSSEN.—CHOREA.

   Steinerl was enabled  to confirm the existence of hyperplasia
of connective  tissue in the cord  in one case ; with it there was a
serous exudation and effusion of blood in the spinal canal; in a
second case he found  hyperaemia of the  brain and spinal cord,
serous effusions within the spinal  canal,  and  hemorrhage at  the
upper part at the exit of the nerves ; in a third case the remains
of acute rheumatism  of the joints  and  endopericarditis with  a
turbid serous  exudation in the spinal canal.
   Meynert2 made a microscopical examination of the brain and
cord in one case  and found the principal anatomical  changes
in the  gray substance of  the central ganglia, extending thence
to  the  cortex of  the brain.    The  changes consisted  in pro-
cesses of division  in the  nuclei of  the nerve-cells, interstitial
growth  of  nuclei, and hyaline swelling  of the  nerve-cells with
molecular decay of the protoplasm.   In the cord he found swell-
ing  of  the Saftzellen  of the reticulum [star-shaped interstitial
connective-tissue corpuscles].
    Very remarkable results were found  at Elischer'ss examina-
tion of the nervous  system of a parturient woman with  chorea,
who died at Prof. Koranyi's clinic at Budapest.   The account of
the disease presents an excellent instance of  chorea gravidarum
et puerperarum.
   A.'Cz., aet. twenty-two, laboring woman, was said  to have had chorea in her
eighth year; and in her sixteenth she had two attacks, the first light, the second
severe, confining her for six weeks in the children's hospital.
   First pregnancy, 1870 : chorea reappeared in the sixth month, lasting till delivery
(which occurred normally), and then ceasing.
   Second pregnancy, 1872: reappearance of  chorea in  the fifth month (Decem-
ber).  No relief from treatment.  Admitted to Prof. Koranyi's clinic, February 23,
1873.  Patient emaciated  and pale.  Bronchitis of the right side.  Heart normal.
Excessive unrest of the muscles, worse on the right than  on the left side.  Consti-
pation and retention of urine. Can only eat and drink by  artificial means, and with
the greatest precautions.
   February 28, a child still-born in the night.  The spasms are somewhat relieved.
On the 29th, violent spasms.  Some rest is obtained by small doses of chloral hydrate
(0.6G gram.)  On the succeeding  days endometritis sets in, the spasms increase
enormously, and death occurs on the 3d of March.
       1 Prag. Vierteljahrschr. 1868. Jahrg. 25. Bd. III. p. 45 seq.
       2 Allgem. Wiener med. Zeitung. Nos. 8 and 9. 1868.
       3 Virchow's Archiv.  Bd. LXI. p. 485. 1874, and Bd. LXIII. p. 104. 1875. 
PATHOLOGICAL ANATOMY.
451
   Autopsy:  Hyperaemia and oedema of  the brain and the gray substance of the
spinal cord; hypostatic  pneumonia of the left, bronchitis of  the right lung; par-
tial steatosis of the liver; hemorrhagic erosions of the stomach, cloudy swelling of
the epithelium of the kidney, puerperal peritonitis.
   The microscopical examination embraced the brain, the cord, and, of the periph-
eral nerves, the right median and sciatic.   These nerves are found lessened in size,1
flattened, of abnormal hardness, and of a dirty gray color.  Under the micro-
scope the connective tissue appears  excessively developed, very rich  in granulated
nuclei, and in places  traversed by  small  extravasations from the very full vasa
nutrientia.   The medullary sheaths  are,  in some places,  as it were, covered with
hoar frost;  in others in a state of glassy swelling, apparently of  softer consistency,
their axis cylinders not visible, or only slightly shown by a darker tinge of color.
   Spinal cord.—Membranes hard and much congested.   Abundant proliferation
of nuclei in the adventitia of  the vessels.  In the central canal is contained serum,
and the web of connective tissue surrounding it is harder than usual.  In the gray
substance the four  large groups of  ganglion cells  are distinctly marked off by
encircling lines of connective tissue.   Abundant development of nuclei in this con-
nective tissue, most abundant in the  substantia gelatinosa  Rolandi.   The  ganglion
cells have a coarse, lumpy look,  are  indifferent  to  carmine  (only their  processes
taking a slight tinge), are rusty yellow, contain lumps of pigment, and are without
visible nuclei.  The white substance of the anterior columns is  relatively intact, the
axis cylinders still easily  distinguished.
   The brain also showed regressive metamorphosis (fatty, amyloid, and pigmentary
change) of the nerve-elements and vessels of the large central ganglia, the island
of Reil and the claustrum, with very small secondary extravasations of blood in the
connective tissue, numerous emboli in the smallest vessels, especially in the cortex.
The division of the nuclei of the ganglion cells, found by Meynert, could be made
out by E. only in the  formation  of  the claustrum.   The  granule cells along the
Vessels of the corpus striatum,  upon which Tuckwell  laid  so  much stress, did not
seem important to  E., as he had found  them in other brains, e. g., in that of a
tuberculous person, and that of a person who had bled to death.  He leaves it unde-
cided whether some  of the changes found by him should  not be referred to the
puerperal disease.

   According  to  Elischer,  the  appearances  of  the   peripheral
nerves,   the  spinal cord, and  the brain indicate  that  the morbid
process  is not confined to one  organ, but is diffuse, and depends
on irrilatire processes.   In favor of  the latter view, he mentions
the proliferation of nuclei in the  connective tissue of the periph-
eral nerves and along the vessels of the  cord, the thickening and
  ' At the point where the sciatic left the ischiatic foramen, E. counted only thirteen
bundles of nerves instead of twenty, which is the number known to be usual, 
452               VON ZIEMSSEN.—CHOREA.

the deposits of lime in the adventitia of  the vessels in the thala-
mus opticus and corpus  striatum, the processes of deposition
upon certain portions of the intima, and, equally important, the
proliferation of cells in the formation of  the claustrum, and the
single pericellular nuclei.
   The  irritative processes are  followed, furthermore, by those
regressive metamorphoses which are  most distinctly marked in
the vascular system.
   According to Elischer,  we are entitled to conclude that all the
changes proceed from one source of irritation, which acts dif-
fusely upon all the  nerve trunks, and reaches a high degree of
activity in  only a few spots, where  it produces more  decided
alterations.
   Charcot has expressed himself very recently as in favor of the
cerebral nature of chorea, basing his opinion upon three autop-
sies from cases  of  hemichorea  after hemiplegia (choree post-
hemiplegique), of which he observed five or six.  There existed
anaesthesia of the skin and organs of sense during life, upon the
paralyzed side.  At the autopsies ochre-colored  cicatrices were
found  at the posterior end of the  thalamus  opticus and  the
nucleus caudatus, and at  the hindmost portion of the foot of the
corona  radiata.   In  two  cases  the anterior corpus quadrigemi-
num of the affected side was involved.   Charcot expresses the
suspicion that the changes which caused the chorea were located
in  motor fibres, situated in front and to  the side  of the fibres of
 the corona radiata, which preside over the conduction of sensitive
impressions.
    Charcot  has  also  observed  cases in which hemichorea with
anaesthesia came first, and hemiplegia followed ; and in one such
case he found a collection of blood, as large as a nut, in the pos-
 terior half of the thalamus opticus.   Tumors of this region may
 cause hemichorea, according to Charcot, which may be followed
 by  hemiplegia or may not.  Finally, Charcot has seen hemi-
 chorea  caused in children by partial atrophy of the brain.
    The following report of  an autopsy,  given by Camillo Grolgi,1
 is important, although complicated with mental disorder.
1 Rivista clinica. 1874. IV. p. 361 
PATHOLOGICAL  ANATOMY.
•L"j:j
   The case is that of a teacher, whose  mother was hysterical, and who had been
devoted to Bacchus and Venus from early life.  In his thirty-second  year he was
attacked by chorea, with maniacal excitement.   He passed the following  years
partly in insane asylums, partly with his family.  No change occurred in the chorea,
but the power of his mind diminished perceptibly.  Ten years after the commence-
ment of his disease he entered the hospital for incurables at Abbiategrosso.   The
attendant physician found no  group  of the voluntary muscles free from chorea.
He was forgetful, suspicious, indifferent to relatives and friends, destitute of sexual
appetite. There were alternations of fury and quiet, of voraciousness and absti-
nence.   Death from pneumonia followed soon after his entrance.
   .dwfaps?/.—Pachymeningitic membrane on the right  cerebral hempishere;  dura
mater everywhere thickened, pia mater the same;  meningeal vessels crowded with
blood.   Convolutions of the great hemisphere in part atrophic;  the medullary sub-
stance infiltrated with serum, softened,  hyperaemic, lateral ventricles full of cloudy
serum, ependyma thickened.  Corpora striata much changed, consistency less, glis-
tening red color, and a general gelatinous look.  Spots of gray degeneration at the
outer side of the corpora striata and in  the centrum semiovale.
   In the cerebellum nothing but congestion of the vessels and diminution of con-
sistency.
   Spinal cord.—Membranes thickened, medulla strikingly soft, boundary between
the two  substances of cord not sharp.
   The microscopical examination showed, in the affected convolutions (frontal and
parietal), thickening of the vascular walls, with abundance of nuclei, and a  great
many lymph corpuscles in the perivascular lymph-spaces.  The  ganglion-cells pre-
sented the greatest variety of changes, being small, humpy (hockrig), hard to iso-
late,  and without reaction to one per cent, solution of silver.   Their protoplasma
processes were humpy, convoluted,  thinned.  The axis cylinders were lessened in
diameter, thickened  in knots, and convoluted.  The same change in the ganglion-
cells  was found in the superficial layers of the corpora striata.  There was also an
extensive cretification, with fatty degeneration and pigmentation of the ganglion-
cells.  The same cretification in Purkinje's cells of the cerebellum.
   In the spinal cord, increase of the connective tissue,  amyloid corpuscles in the
medullary substance, sclerosis of the posterior and lateral columns in the cervical
region.  In the gray substance the cell-bodies were strongly pigmented and easily
broken down.

   Golgi  regards  these  alterations  as  the results  of  a chronic
interstitial encephalitis,  and lays emphasis upon  the great simi-
larity  between these histological changes  and those  found  in
dementia paralytica.
   The close connection  between chorea and the  true  psychoses
and epilepsy has  been  pointed out  by  Tommasi,  Wilks, Arndt,
C. II.  Jones, Clouston, L.  Meyer,  Leidesdorf, Russel, and others, 
4^4                 VON ZIEMSSEN.—CHOREA.

and numerous  observations of  the  coincidence  of chorea with
mental disorder (less frequently epilepsy) in the same individual
have been produced.
   Tommasi describes a case in which the symptoms of chorea alternated with those
of dementia paralytica.
   According to Russel,  mental disturbance  accompanies, not only  severe,  but
often slight attacks of chorea. Among thirty-eight cases with changes in the intel-
lect and feelings, he observed six severe cases with delirium and mania.  In three of
these cases the psychical and the choreic changes were manifestly independent of
each other, and should be taken as co-effects of the same cause;  for in one case the
psychical  alienation  appeared before the choreic symptoms, and in another it con-
tinued several weeks after the muscular twitchings had ceased.
   According to Leidesdorf, these frequent changes in disposition and character
are not seldom accompanied by feelings of anxiety and hallucinations of the senses,
particularly that of sight, which latter commonly appear at the moment of  falling
asleep, and greatly distress the patients by their frightful nature.  Leidesdorf saw
maniacal attacks chiefly in those cases of chorea in which the latter had developed
from a febrile complaint.
   Hallucinations of feeling, hearing, smell, and apprehension of being poisoned,
with great confusion of mind,  were observed by Ritti'  in a case of chorea, in
which, after long-continued prodromic symptoms, the choreic twitchings began in
the fingers and extended to other parts.  Recovery in two months.

    In the  spinal  cord alterations have been  repeatedly  found,
namely, hyperemia of the  medulla  and the  membranes,  soften-
ing of  the  cervical and  also  of  the dorsal medulla  (Romberg,
Ogle, Gray,  Golgi, De Beauvais,  Hine,  Brown-Sequard, Lock-
hart  Clarke),  interstitial  proliferation  of nuclei and  hyper-
plasia (Rokitansky, Steiner, Meynert,  Elischer),  and sometimes
serous exudation in the central canal, proliferation of  nuclei  in
the adventitia of  the vessels,  and regressive metamorphosis  in
the ganglion-cells (Elischer).
    The peripheral nerves  have  received attention only in Eli-
 scher' s researches.   He found, as above stated,  the vasa  nutri-
 entia crowded with blood, and small  extravasations in places ; the
 connective tissue between the  nerve bundles  greatly developed,
 very rich in nuclei  ; the medullary sheaths of the nerve-fibres in
 places covered as it were  with frost,  in other places in  a state of
1 Union med CXXXII.  1873.  Virchow-Hirsch, Jahresber.  1873.  ILL S. 42. 
EXPERIMENTAL  INVESTIGATIONS.
455
vitreous tumefaction, seemingly softer  than normal, while their
axis cylinders had  become invisible in great part.   Both the
nerves examined (the  median and  the  sciatic) seemed to  the
naked eye small, flat (abnormally), and of a dirty gray color.
   Before  passing on to formulate a summary of  the nature of
chorea,  based on the previous statements, we have to speak of a
small  number of important  experimental  investigations  made
by French authors.   The object of  these has been to settle the
question as  to the  portion of  the nervous  system attacked  by
the cause of irritation, and what special part was taken by the
spinal cord in chorea.

   Chauveau' took dogs suffering from general  chorea,  cut the spinal cord high
up close to the skull, and found that the choreic movements lasted for hours, until
the death of the animals.   Section of  the dorsal medulla puts an immediate stop
to the twitchings in the muscles of the tail and hind legs.  Chauveau concludes
from these experiments that neither the cerebrum nor the cerebellum is the point of
origin of chorea, but that the spinal cord is the seat of irritation.
   Carville and Bert, with the same experiments, reached  the same results.
   Legros and Onimus2 studied the muscular twitchings of  choreic  dogs  by  the
graphic method.  They found that each individual contraction  occurs  brusquely,
but passes off more slowly, often intermittingly, and is followed  by a period of
repose.  They also observed repose following the injection of chloral hydrate (3.50
gram.) into the rectum.   Section of the cord at the skull left the contractions undi-
minished as long as life was kept up (three or four hours) by artificial respiration.
   Irritation of the posterior columns of the exposed spinal cord with a  scalpel in-
creased  the twitchings. Section of the posterior roots had no influence, as Bert found.
Partial  removal of the posterior cornua and columns was followed by a weakening,
but deeper incisions by a cessation of the movements.  Legros and Onimus conclude
from this, that the nerve-cells of the posterior cornua, or  the nerve-fibres which unite
them icith the motor cells, are the seat of chorea.
   These observers found a striking difference in the action of the constant current,
dependent on the direction in which it was passed.  An ascending current increased
the intensity and  the frequency of the contractions, while a descending current
weakened them considerably.   If  they had  been reduced by poison  or by  the
weakness of the animal, an ascending  current was able to restore them in their  old
intensity.   These effects occurred even when the electrodes did not directly touch
the spinal marrow, but were laid upon the uninjured skin, provided the direction
   1 Archives gen. de med.  Mars, 18G6.
   • Recherches sur les mouvements choreiformes  du chien.  Comptes rendus.  Tom.
LX. 1870. p. 1046. 
456
VON ZIEMSSEN.—CHOREA.
was retained.  Mechanical or faradic irritation of the posterior roots was followed
by a considerable increase of the movements after the stimulus was withdrawn.
   One more  experiment remains to be mentioned, contributed  by M. Rosenthal
(1. c, p. 579) from the Vienna Institut fur experimentelle Pathologie.  A dog with
choreic movements of the right fore-leg was taken, and fine flower-seeds injected
into his left carotid.  Although the voluntary movements instantly and completely
ceased,'the twitchings became strikingly stronger in the anterior extremities, the
eyelids, and the tail, and lasted two days, until the  animal's death.  The autopsy
showed encephalitis of the left anterior lobe, softening of the left corpus striatum,
embolism of the left arteria fossae Sylvii.   Microscopical examination showed spots
of proliferation of connective tissue in  several  parts of the brain  substance.
Rosenthal infers from this experiment that the artificial disturbance of the circula-
tion in the brain, with loss of the influence of the motor ganglia, produced an
increase in the choreic movements, probably through irritation of the  centres of
co-ordination  in  the middle brain and cerebellum.  It  seems to me that this
experiment, as related by Rosenthal, permits of no definite conclusions.

    The scientific material contained in the above presents us with
no constant  anatomical changes in chorea, and fails  to give a
perfectly clear view of the nature of the process,  but  it  offers
very important points in localizing the  process in the  nervous
system, and  in explaining its pathogenesis.  In  especial, it has
been shown by the studies of histological changes  quoted  from
Meynert, Elischer, and others, that we  may hope  in  this way
to reach a better understanding of the matter.   Doubtless a much
larger number of observations and careful autopsies is  needed
before we can safely allow ourselves to make further conclusions.
Let us here recapitulate the most important points.
    As regards the seat of the  disturbances, the  anatomical and
histological investigations of  recent date point first of all to the
brain as the  chief, though not the exclusive, seat of the anatomi-
cal change, but show that the spinal  cord and  the peripheral
nerves may also be drawn within the circle of changes.   The pro-
cess, as it seems, is chiefly confined to the gray substance  both
of the great basal ganglia and  of the cortex, and bears  the ana-
tomical character  of  irritation and  its  consequences, regressive
metamorphosis of nerve-elements and  interstitial  hyperplasia.
These irritative processes  with their results  may,  as  it seems,
remain confined to single regions of the cerebrum, e. g., to one
hemisphere or even portions of  the hemisphere, especially the 
               EXPERIMENTAL INVESTIGATIONS.             457

corpus striatum, the thalamus opticus, the posterior stria? of the
corona radiata, or  may  be extended  diffusely over the whole
brain, preferring the gray substance, at the same  time attacking
the spinal cord and the peripheral nervous system.
   That the cerebrum and, above  all, the great basal ganglia
form  the  chief seat of  the  changes in chorea,  can hardly be
doubted in the present state of  the facts.  Not  only the state-
ments of anatomical histology, but the clinical facts as well sup-
port this view.  Of especial importance are the  frequency  with
which the choreic symptoms are unilateral, sometimes in associa-
tion with  anaesthesia of  the  skin, and the transition  (although
uncommon) from hemichorea to hemiplegia,  and  the converse
process of the  development of hemichorea from unilateral palsy
(Charcot,  Foote,  Weir Mitchell,  Hughlings Jackson); also the
occurrence of unilateral facial palsy, bearing  the marks of cere-
bral origin, appearing at the same time and on the same side  with
the cliorea, and disappearing with it  (Broadbent), the frequent
coincidence of  the chorea with disturbances of mind or disposi-
tion in all degrees, from the slightest mental indisposition to the
severest forms  of  mania and  dementia paralytica, and the deve-
lopment of cliorea subsequent to inflammatory processes in the
contents of the skull (encephalitis, meningitis, tumors).
   In presence of  these facts we cannot attribute a decisive value
to the experiments  of  Chauveau, Carville, Bert,  Legros  and
Onimus, which are believed to show that the choreic changes are
situated not in the brain but in the spinal cord.  AVe believe that
these experiments only render it  probable that in  choreic  dogs
the spinal cord, /. e., the gray substance of the posterior cornua,
plays an essential part in producing the phenomena, but do not
prove that the  brain is quite  unaffected, and that the case is the
same in the human species.  And still, the numerous autopsies
in which  softening of  the  cervical  cord,  or hyperemia of the
cord and  its envelopes  is  found, and the rare cases of  embolic
processes in the cervical cord (Tuckwell), or interstitial prolifera-
tion of nuclei  and connective tissue (Rokitansky, Steiner,  Mey-
nert, Elischer), render it very  probable that the spinal cord plays
a part in chorea in man also.  How frequent these changes  may
be in proportion to those of the brain is a question which cannot 
458                VON ZIEMSSEN.—CHOREA.

be answered until we have a fuller series of careful examinations
of the pathological histology of the  central nervous organs.
The same is true of the changes found  by Elischer in peripheral
nerves.   It is reserved for those observers who shall have the
opportunity  of  examining the bodies  of patients who die in
cliorea, to follow out the changes in the  nerves given by Elischer.
   A question quite as hard to answer as the preceding is that as
to the kinds of irritation which are capable of producing, or
which are required to produce, such momentous disturbances.
   It  can hardly be doubted, after  the cases  which  have  been
published, that embolic  processes  may act as irritant causes.
The enormous frequency of the coincidence of chorea with recent
and old vegetations of the valves, which has been placed beyond
a doubt by numerous autopsies, permits us to suspect that there
exists  a causal connection between the  endocarditic and the
choreic disorder ; and  anatomical researches have demonstrated
to a certainty the occurrence of very small embolic processes in
the vessels of the brain, particularly of  the corpus striatum and
thalamus, and  once in those  of the cervical part of  the spinal
cord (Tuckwell).  True, it remains doubtful whether the relations
of endocarditis  and its results to the  irritative disturbances of
the brain are always such as are due to  the production of embol-
ism, or whether there  may not be some other sort  of connection
—perhaps both may be due  to one and the same unknown irri-
tation.
   The  pathogenesis of reflex chorea is still  more difficult  to
understand, if we retain the anatomical changes in the brain as
the chief basis of chorea.   We need only refer to the numerous
cases of cliorea during pregnancy, which, although a predisposi-
tion commonly exists, yet require the processes in  the uterus to
excite them to action,  and quickly cease after delivery ; also the
cases in which chorea  originates in peripheral  lesions  or cicatri-
cial contractions, and gets speedily well  after excision  of  the
latter (Packard).
   In regard to these pathogenetic questions we find ourselves in
the same position as  in regard to those reflex paralyses which
occur during affections of the intestine, uterus, bladder, or kid-
ney, injuries of peripheral nerves, etc.,  with this difference, that 
                EXPERIMENTAL INVESTIGATIONS.             459

 the  obscurity which  has hitherto prevailed  in regard  to the
 pathogenesis of reflex palsy has been somewhat lessened  by the
 experimental studies of the last ten or twenty years, and espe-
 cially by  the works of Gull,1 Kussmaul,2  Leyden,3Weinberg,4
 Fischer,5 and Klemm.6
   We have at present no actual proof in the  case of chorea of
 an anatomical connection between  the  peripheral irritation and
 the  lesion of the cord, such as may be considered as proved in
 many cases of so-called  reflex  paralysis ;  but the  assumption
 that  an irritative process  is  propagated from  the peripheral
 nerves to  the central organs  has obtained  some support since
 Elischer demonstrated definite changes in the  peripheral  nerves
 in at least one case of chorea,  and since  the experiments  of
 Klemm and the clinical observations of  Lallemand, Martinet and
 Leyden  established  the possibility of a propagation of inflam-
 matory conditions from the  peripheral nerves to the brain and
 the  secondary development  of encephalitis, etc.   It should  in
 these cases be assumed that the  irritative processes in chorea,
 which are propagated from the periphery to the spinal cord and
 brain, and diffuse themselves  in  these  organs, must be less  in
 degree or different in kind from those of neuritic central  paral-
 ysis, as their effect is so different.
   We have no positive means of explaining  the pathogenesis
 of chorea, when caused by violent psychical  impressions (fright,
 anxiety,  etc.);  we  can only  express  a suspicion  that these
 cases, as  well as the similar ones of epilepsy, depend on nutritive
 disturbances in the brain, caused indirectly by  the violent  action
 of psychical emotions upon  the vaso-motor centre, and directly
 by the anomalous  action upon the vascular currents of the  brain,
 which proceeds from  that centre.
   Guy's Hospital Reports.  1861 and 1862.
   Wiirzb. med. Zeitschrift. Bd. IV. S. 56 ff. 1863.
  s De paraplegiis urinariis.  Konigsberg,  1856.  Also, Ueber Reflexlahmungen,  Folk-
nann's Sammlung klinischer Vortrage. No. 2.  1870.
  4 Ueber Reflexlahmungen. Berlin, klin. Wochenschrift. No. 41. 1871.
  5 Ueber Neuritis. Inaug. Diss. Konigsberg, 1869.
  6 Ueber Neuritis migrans. Inaug. Diss. Strasburg, 1874.—Cf. also  Leyden, Klinik
der Nervenkrankheiten.  Bd.  II. 1.  S. 214 ff. Berlin,  1875, and  Erb, Diseases of the
Peripheral Cerebrospinal Nerves, in this Cyclopaedia (volume XL, p. 399 et seq.) 
460
VON ZIEMSSEN.—CHOREA.
   It is manifest that the gravity of the lesions will be very dif-
ferent in the different degrees of intensity of chorea.  The autop-
sies  have  chiefly  been made in  severe cases,  and in them the
degenerative  processes were  found  very  considerable.   In the
light cases, of which the majority recover completely in two or
three months without any considerable changes in the psychical
and  intellectual  sphere, only slight and perfectly curable dis-
turbances  can be supposed to exist.
   The sum of our knowledge of the pathologico-anatomical changes is so small
that it is scarcely of consequence to attempt to explain the way in which they act
upon the functions of the central nervous system, but I will give in this place the
view  of one of  those best acquainted with chorea, namely Broadbent.  He con-
siders that the processes in chorea are always such as merely weaken the force of
the nervous apparatus without destroying its structure.  Hence, the weakness of the
muscular force and the diminution of sensibility, so common in chorea; hence, the
frequent termination in paralysis. He gives to the condition of the system the name
of " delirium of the sensori-motor ganglia of the brain.1'  In ordinary delirium
imperfect ideas  are rapidly evolved, and there is no control over the mental pro-
cesses ; in chorea the control over the motor apparatus is wanting.  The movements
are excessive in number and extent, but without force and precision.


                           Diagnosis.

   With  such a remarkable group of symptoms  the diagnosis
of chorea ought hardly ever to be difficult.  In  particular, it
is hardly possible to  confound  it with the tremor of age, of
drinkers,  of  those poisoned by mercury and lead, or  with paral-
ysis agitans, or multiple sclerosis of  the brain and  cord, if the
physician has had any  experience in  nervous  diseases.   The
partial spasms of single  muscles or  groups of  muscles in the
region of certain nerves,  e. g., the accessorius (external branch)
and  the facialis, and the (Beschaftigungsneurosen)  neuroses of
co-ordination,  connected with the patient's  occupation, such as
writer's cramp,  cannot easily be confounded with chorea if care-
fully examined ; the former occupy definite regions, and remain
confined to  them, while the latter  are produced only by the
special action proper to  the avocation of the patient, and (at
least  in the beginning) appear  only in the  muscles required to
perform the action.   I therefore think it needless to repeat the 
                PROGNOSIS AND TREATMENT.              461

characteristic symptoms of chorea in conjunction with those of
other neuroses.

                         Prognosis.

   This is decidedly favorable, as a rule.   If the disease appears
during the period of bodily development, is primary, and without
complications—if the contractions are not excessive in severity,
if sleep is good, if there are no considerable psychical  disturb-
ances and no complications, the prognosis may be set down as
favorable.  It  becomes  dubious when the violence of the move-
ments is such as to exhaust the patient, and when they continue
daring sleep ; when very little food can be taken, when there is
delirium, collapse, etc.   The  inactivity of remedies which are
usually efficacious may also very properly be taken into  account.
   In determining the possibility of a relapse, in any given case,
we are entirely without resources, except when there is a decided
tendency to the disease ; hence it is necessary to observe caution
in giving an opinion.
   The prognosis of a  relapse, as such,  is less  favorable than
that of the first attack, only when there  are  other undesirable
symptoms, or when the patient is pregnant;  in  the latter class
the prognosis is decidedly less favorable  than in the non-preg-
nant.
   The prognosis of symptomatic chorea in diseases of the brain
and spinal cord is generally doubtful, and in each case  depends
on the gravity of the original disease.

                         Treatment.
   The treatment of chorea has passed through similar changes
to that of epilepsy.   From the most energetic technocratic [sic]
treatment, with frequent bloodletting  and regularly repeated
purgations, as recommended by Sydenham, to  the  most com-
plete therapeutic nihilism, which  affirms  the  uselessness of all
remedies on the ground of the theory of the self-limited nature
of the  disease, we find  all stages of transition.   The  number of
remedies recommended  and used during  the last few centuries
is very large. 
462
VON ZIEMSSEN.—CHOREA.
   In general, the treatment of cliorea is by no means a thank-
less  task.  Without doubt, an intelligent medical action  is of
decided use, and in many cases has a directly curative effect.
   We will first speak of the causal treatment, then consider the
dietetic precautions, and finally, the indications and the effects
of the most important physical and officinal remedies.
   The causal indication cannot in most cases be fulfilled, as the
fundamental trouble is usually quite unknown  to  us, and when
understood, it is either such as to be inaccessible to therapeutics,
as is the case in local disease of the brain and cord, or else it is
only an indirect cause, wliicli gives us no opportunity of exer-
cising a  proper curative action upon the cliorea, as in ansemia,
chlorosis, hysteria, rheumatism, endocarditis.  A suitable  treat-
ment of these  affections may doubtless exercise an alleviating
effect upon  the symptoms of  chorea—although  this is not
always  the case—but  it can neither cure nor prevent a relapse.
And it scarcely needs to  be said that the  physician has but little
power against the disposition, when created by hereditary influ-
ence, bad education, excessive sexual irritation, and self-abuse.
   The application of  venesection, and local bloodletting along
the spine, the application of derivatives, the  methodical use  of
purges—all these have long been  given up, partly as useless,
partly as  injurious.   The stools must of course be regulated, if
necessary, and intestinal worms  be got rid  of, but these  steps
have usually no influence upon the course of the disease.
   It is very important to regulate the entire regimen with care;
not only the bodily, but the mental  dietetics.  First of all, all
occasions for psychical  excitement and  mental or bodily exer-
tion  must be removed.  The child must  be taken at once from
school, and all head-work at home must be stopped.  It is very
advantageous to spend a long time in the country or on the sea-
coast.  In  the case of poor patients, the effect of a well-ordered
hospital  upon the mental condition, the  appetite, and the sleep
is  very  good;  they  enjoy the quiet  of  their surroundings, the
regularity and  order of  their daily life, the abundance of fresh
air, and they are free from the constant apprehension of meeting
with acquaintances.   But no more than this  need be expected;
the dnration  and course  of cliorea are seldom affected by a 
TREATMENT.
463
change  of  place and  habits.   If  self-abuse is  practised, the
parents must be informed that it is necessary to watch the child.
The nourishment should be simple, but abundant and strong;
the patient should spend the greater part of the day in the open
air, as far as the weather allows.
   Sleep is of the very greatest consequence. A quiet and suf-
ficiently long-continued sleep must be secured by avoiding even-
ing excitements, stimulating  conversation, and  too late meals,
by keeping the chamber cool and  dark, by preventing noise in
the patient's  neighborhood, and finally, if necessary, by chloral
hydrate.  This medicine, in my experience, has proved an  extra-
ordinarily valuable remedy in the treatment of chorea, especially
in cases  where the violence of the jerkings interferes with falling
asleep, or the sleep itself is disturbed by spasms.  If the  inten-
sity of the movements exhausts the patient, I  sometimes give
another  dose during the daytime, in order to procure a few hours
of sleep; this usually comes very speedily,  and  the muscular
disturbance is soon quieted.
   The amount of  bodily exercise proper  to be taken should be
judged according to the indications of the  special  case.  When
the chorea is violent both in the lower extremities and the trunk,
walking is not to be thought of; the patient must sit in the open
air or be driven.
   As to  the  methodical gymnastics, which  some authors
recommend as  a really curative procedure, and  others as an
adjuvant, I would postpone it to  the period of decline of the
disease,  and  confine the patient to such  exercises as expend
but a moderate amount of  force.  The  stimulation of  the will-
power, which is produced by the master's word of command,
and the fixing of the attention upon the gymnastic  exercises, aid
the effect of the latter in  ordinary  cases, according to Hasse's
experience.    It need  not  be said  that such efforts must  not
be made in symptomatic  chorea due to a  spinal or cerebral
disease.
   We come  finally to the estimate of the pharmaceutical and
physical remedies  recommended for chorea.  There are  great
difficulties  in the  way of forming  a critical judgment of  the
activity of remedies in a disease whose duration is so variable, 
464
VON ZIEMSSEN.—CHOREA.
whose  course is always  subject to spontaneous remissions, and
which  so often passes away quickly and  easily without  any
medication.  The statistical  method, for these reasons, must be
used with the greatest care, and the  literary material we possess
is not by any means adapted to the formation of statistics.   We
must therefore  test the  effects of  remedies in each individual
case  as objectively as possible, with careful regard to the indi-
viduality of the patient.  The disease is so protracted  that we
have a chance to use one remedy after another,  and to compare
their effects.  This can best be done in  those cases which  have
lasted  for three months without improvement.   The  results of
the  numerous experiments which I have made  in this  manner
are  positive in respect to some remedies and methods, but nega-
tive in  most.
   Of  the so-called nervines, arsenic  deserves  a most promi-
nent rank.   Although it was used in a  few cases  at  the begin-
ning of the present century, it owes its extension to the warm
recommendations of  Romberg (1. c, p. 533).   In  spite of  this,
I am convinced  that  the admirable effects of  arsenic  are far
from getting the credit they deserve, in text-books and in daily
practice.

   The dissatisfaction expressed by many authors  in regard to the action of this
remedy may be traced principally to  the smallness of the doses used.  I have for
many years given, with the best effect, and with no bad consequences, double the
doses mentioned in text-books  of pharmacy and posology, namely, from five to
eight drops of Fowler's arsenical solution for children, and eight to twelve drops
for adults, three times a day.  Many patients bear these  doses for weeks and
months without the slightest gastric disturbance;  others lose their appetite after
using it for a time, and complain of pressure in the  pit of the stomach and burning
of the conjunctivae, disturbances which disappear after a few days' suspension of
the remedy, and by no means contraindicate a resumption.  I have never observed
any severe or prominent disturbances.
   Let it be remarked, that it is improper to prescribe so powerful a remedy in the
form of drops, as the size of the drop is greatly dependent on the form of the edge
of the vessel it is poured from.
   For this reason I strongly advise to dilute the arsenical solution with a consider-
able quantity of aromatic water, e. g., cinnamon water,  and to administer it from a
graduated spoon or vessel.
   Steiner, whose observations show that good results  can be attained with small
doses, associates the arsenical solution with opium when there is much unrest, con- 
TREATMENT.
465
tinuing during sleep; his formula is:  Fowler's solution, eight drops; tincture of
opium, six drops; water, four fluid ounces.  Four tablespoonfuls to be taken daily.
   Eulenburg ' has lately recommended the use of large doses of arsenic, and has
proposed subcutaneous injection as a means of avoiding gastric disturbances. At the
same time, Lewis Smith2 made a similar recommendation. I have treated a number
of cases of tremor, paralysis agitans and chorea with arsenic injections as recom-
mended by Eulenburg, but  the painfulness of  the injections, and especially the
duration of the pain, were so considerable that I had to give them up.
   For young people, who,  in general, bear pain badly, the subcutaneous injection
is not suitable, especially when it is so severely painful as the one spoken of.

    The favorable action of arsenic is usually manifest in a week,
and two weeks are almost  always sufficient—provided  that  the
remedy does not have  to be suspended on account of toxic effects
—to reduce the symptoms of chorea to a minimum.
    In several obstinate  cases  I have been able to obtain  the
clearest proofs of the prompt action of the arsenic, after bromide
of  potassium, oxide of zinc, electricity, and the water treatment
had been employed by me with little or no effect.  But these
were all idiopathic cases.   It must be decided by further  obser-
vations,  whether  the  favorable effect  occurs in chorea  s}7mp-
tomatic of affections of the  brain and spinal cord, and in reflex
chorea.   The trial  is  certainly worth making.   As regards  the
other so-called  nervines, some  have  praised the  preparation of
zinc, especially the  oxide,  valerianate,  and  sulphate.   So   the
nitrate of silver, sulphate of copper, and other copper salts,  sul-
phate of  aniline, bromide  of  potassium, calabar  bean and its
preparations, strychnine, valerian, and asafcetida.

   The oxide of zinc was given by Hufeland in doses of fifteen grains three  times
a day.  Steiner combines it with saccharated carbonate of iron in cases of  anaemia
(saccharated carbonate of iron, thirty grains ;  oxide of zinc, twenty grains ; sugar,
two drachms.   Make into  a powder,  of which a knife-pointful is to be taken
thrice daily). Sulphate of  zinc has recently been praised by Butlin.3  He begins
with small doses and increases to emetic doses, but as soon as nausea is produced,
lie goes back to smaller doses, or suspends the  treatment entirely.  Improvement
is said always to occur, often cure.
   Zur Therapie des Tremor u. d. Paralysis agitans.  Berliner klin. Wochenschrift,
1872.  No. 46 ; and p. 303 of this volume.
  2 Medical Record, 1872.                    s Lancet, 1871.  No. 17 and 18.
          VOL. XIV.—30 
466
VON  ZIEMSSEN.—CHOREA.
   The salts of copper are reported  by Bergeret and Mayencon' as having been
used successfully by themselves.
   Sulphate of aniline has been given  by Turnbull in doses of from three-quarters
to one and a quarter grains thrice a day, with reported good success; but Steiner's
subsequent experiments' gave no satisfactory results.
   Bromide of  potassium, much recommended,  especially by Dumont, Gallard,
Hough, Kesteven, has  lately been tried carefully by  Steiner2 and myself.  Our
results entirely agree in this point, that  bromide  of potassium is not a remedy for
chorea;  its use, even  for several weeks, gives rise to  no improvement, or but  a
trifling amount.
   Among the preparations of  calabar bean, the powder and the tincture (five parts
of the bean to thirty-five of alcohol) are recommended by Harley and Ogle as
efficacious in doses of  ten or twenty drops three  times a day.   Eserin, the active
principle of calabar bean, has very lately been tried  by Bouchut3 in 437 cases.
He  gave  it pure, sometimes  in the form of sulphate, in doses of from one-thirty-
second to one-twelfth of a grain (for children from seven to twelve years old), for
a considerable period.   In doses of one-twelfth of a grain it gave rise to  pallor,
nausea or vomiting, salivation, sweating; the pupils varied in their behavior; there
was a very unpleasant paralytic state of the  diaphragm.  These troublesome symp-
toms, which lasted from one to three hours, were never observed by B. after doses
of one-twenty-fifth, given twice or three times a day.   He states that by this treat-
ment chorea was cured in an average of ten days (?).  There have been  no control-
experiments.
    The use of strychnia seems to have  been entirely given up since the unfavorable
criticism  of SSe (1. c, p. 502) upon the results of the strychnia experiments made by
Rougier,4 Fouilhoux,5  and Trousseau.6  There is hardly any  mention made  in cur-
rent literature at present of the use of  strychnia in chorea. It is probably best not
to resume the use of the medicine.

    Hypnotics and anaesthetics may be  entirely dispensed with in
slight  and moderately  severe  cases ;  but  they are  of  priceless
value in extreme cases, where  the excessive muscular restlessness
and sleeplessness  threaten to exhaust the organism.   I decidedly
prefer  chloral  hydrate ;  it almost  always acts  promptly and
surely ; by day or night a dose of from fifteen to eighty grains is
followed by quiet sleep and cessation of the muscular activity.

             •Journ.  de l'Anat. et de Physiol. 1874.  1 seq.
             2 Jahrb. f. Kinderheilkunde. III. 1870. p. 297.
             3 Bulletin gener. de therapeutique. No. IV. 1875.
             4 Recherches sur la morphine et la strychnine. Lyon, 1843.
             5 Oaz. med. Paris, Octobre, 1846.
             6 Bull, de l'Academie de Mod.  Tom. XII. p. 397. 1846. 
TREATMENT.
467
   Other authors have recommended  chloral hydrate in  severe
cases,  as  Frerichs,1 Gairdner,3 Caruthers,' Briess,4 J.  Russel,6
Bonchut,6 Verdalle.7
   Gairdner saw a case of chorea in a girl of eight years, who took by mistake a
dose of sixty instead of twenty grains of chloral hydrate, and after recovery from
her intoxication was  found to have entirely lost her chorea.—Frerichs  gave it in
the dose of eighty grains to  a male of  seventeen years with  severe chorea.  The
result was a refreshing sleep of five hours.—Russel obtained good results in the
fifth month of pregnancy, after  bromide of potassium had been given in large
doses without  success.—Bouchut's patient  of  fourteen and a half years, with
chorea and dementia, took forty-five grains a day for twenty-seven days, making
in all somewhat over two and a half ounces, spent almost the whole time in sleep,
and suffered no visible bad results from the chloral.  Improvement appeared from
the fifth day of the use of choral, and the cure was complete on the. twenty-eighth
day.
   Verdallc's  patient  of eleven  years took  very nearly three ounces  in  fifteen
days.  The improvement began to appear on the first day the medicine  was given,
or the fourteenth of the disease.

   The fact  that this medicine can be safely entrusted to non-
medical persons  for administration,  and  the further  circum-
stance that its  hypnotic  effects are  not followed  by any bad
consequences, give chloral  in general  the advantage over chloro-
form.
   Chloroform, which was  often employed  in severe cases before
Liebreich's  discovery of  the  therapeutic  value of chloral, is
praised by most  authors of the former time, and by some of  the
present, as  Gfrossmann, Lowes, Barclay,  Banks, Hasse, Batter.
The inhalation, practised once a day  or  oftener, and carried to
the point of half or total narcosis, is preferred  to  the  internal
use.  Whether  choral  hydrate is to  make chloroform wholly
superfluous,  is at the present  time uncertain, but it may at least
be said that the latter will  be seldom required.
1 Dissertation by Frick.
8 Glasgow Med. Jour. 1870. p. 550.
3 Lancet. 1870.  p. 501.  April 2.
4 Wiener med. Presse. No. 5.  p. 102.  1870.
6 Med. Times and Gaz. Jan. 8, 1870.
6 Bullet, gener. de thcrap.  Fevr., 1873.
'Ibid. Mars, 1873. 
468               VON ZIEMSSEN.—CHOREA.

   The narcotics, especially opium  and morphine, are found to
act much less favorably than  the  anaesthetics, and  in general
may be dispensed with.
   Of the physical remedies, mention should be made of electri-
city and hydro-therapeutics.
   Electricity was first used in  the form of friction-electricity by
de Haen and others; afterwards, in the form  of the  induced
current, it was applied by Duchenne to the nerve-trunks  and
muscles, and by Becquerel to the skin, it is said with good effect.
More recently the  galvanic current,  from theoretical considera-
tions, has been more employed, and is greatly praised  by most
electro-therapeutists, as Remak,  Benedikt, M. Rosenthal, Oni-
mus, M. Meyer, Seeger, and others.  The methods in wdiich it has
been employed are very various.  Some recommend the galvan-
ization of the sympathetic, others that of  the spinal cord, others
of the peripheral nerves, with or without the cord ; some consider
the direction of  the current as important, others as indifferent.
M. Meyer employed at each session from twenty-four to thirty sin-
gle shocks of a battery of thirty elements.  All praise the quiet-
ing effects of the galvanism upon  the muscular contractions,
and the rapid improvement from one session to the next.  I have
not had  similar  success.  In four cases, carefully  treated with
daily applications  of a weak current along the spinal column, no
improvement worth mentioning occurred.
   The water treatment has also been urgently recommended by
many older and newer  authors (Stiebel, Dupuytren, Hasse, M.
Rosenthal, and others), but the methods are so various that at
present it is impossible to form  a proper judgment of their value.
All procedures have been  recommended,  from the  protracted
warm bath—I refer especially to  the  prolonged baths  at 2C°
(90° F.), with or without sulphuret  of potassium (four ounces to
a bath), wdiich have become very popular in France since Baude-
locque—to the cold plunge-bath and the cold affusion.  Judging
from my own experience, I should give the decided preference to
the milder procedure, namely,  brief rubbing down every morn-
ing with wrung-out cloths (one  or two minutes, temperature 15
or 16° R. [65° to 68° F. ;]);  wet  packing, followed by a short,  cool
shower-bath, and, finally,  the latter without  packing.   This 
TREATMENT.
469
milder method is more likely to quiet and refresh the worn-out
body  than the  heroic procedures  of  the  douche, the cold full
bath and half bath.  But I will not say that my small observa-
tion has  been sufficient to  decide  these points.   The hydriatic
method of treating chorea certainly needs  further exact tests.
   To prevent relapses, the physician  should advise a prolonged
residence  in the country or the mountains, or on the sea-coast,
the use of sea-baths or brine-baths, social stimulus, and the care-
ful removal of  all those social and bodily  evils which have been
described at large under etiology as favoring the development cf
chorea.
\ 
•
I 
HYSTERIA.
JOLLY. 
 
HYSTERIA.
   Hysteria has been known to, and described in medicine from the  most remote
period.  If one were to enumerate  the  earlier writings on this subject, almost the
whole of early medical  literature  would  have  to be  cited.   We  confine  our-
selves, therefore,  to mentioning a few of the more important works of the  seven-
teenth and eighteenth centuries, and then those of modern literature.  (Exhaustive
quotations from  ancient  literature  are  to  be found especially in Dubois' Histoire
pljilosoph. de l'hypochondrie et de l'hysterie.  Paris, 1833.)
Sydenham, Opera medica.   Genevae, 1736.—Th.  Willis, De  morbis convulsivis
    and Affectionum  quaj  dicuntur hystericoe et  hypochondr.  pathologia spas-
    modica, etc.   Op. omnia. T. III. and IV. 1706.—Stahl, De hypoch.-hyst. malo.
    Haloa, 1702.— F.  Hoffmann, De morb.  hyst.  vera  indole,  1733.— R. Whytt,
    Observations on  the  nature, causes, and  cure,  etc.   London,  1763.—Raulin,
    Traite des affect, vaporeuses. 1759.—Pomme, Traite  des affections vapor, des
    deux sexes.  2. 6d.it.  1765.— Tissot, Traite des nerfs et de leur maladies. 1779.
Of our own time, the  following of the larger  treatises and monographs are to be
    mentioned: Louyer Villermay,  Traite des maladies nerveuses ou vapeurs, etc.
    1816. — Georget,  I)j l'hypochondrie et  de l'hystel'ie.   1824. — Laycock, A
    treatise on the nervous diseases of women. 1840.—Dubois, the above mentioned
    work. — Landouzy,  Traite complet de  l'hystfirie.   1846. — Brachet,  Traite
    de l'hystijrie. 1847.— Valentiner, Die Hysterie  und ihre Heilung.  Erlangen,
    1852.—Briquet, Traite clinique et therapeutique de  l'hysterie.  Paris, 1859.—
    Todd, Clin, lectures on  paralysis, cert, diseases  of the brain, and other aff. of
    the nervous system. 1856.—Skey, Hysteria, six lectures, etc.   London, 1867.—
    Amann, Ueb. d.  Einfluss  d. weibl.  Geschlechtskrankh.  auf d. Nervensystem,
    mit  bes. Beriicksicht. d. Wesens u.  d. Erschein. d. Hysterie.  Erlangen, 1874.
    9. Aufl. — Charcot, Lecons sur les malad.  du syst.  nerveux.   1872-73.—
    Further, the  chapters on  this subject in the manuals and text-books of dis-
    eases of the nervous system, of  which the following are particularly to be cited
    in this connection: J. Frank, Handb. d. Nervenkr.   Uebers. 1843.—Sandras,
    Traite des mal. nerv. 1851.—Romberg, Lehrb.  d. Nervenkr. 3. Aufl. 1857.— 
474
JOLLY.—HYSTERIA.
    Hasse, Krankh. d. Nervensystems in Handb. d. spec. Pathol, u. Therapie v. Vir-
    chow. 2. Aufl. 1869. — Eulenburg,  Lehrb. d. functionellen Nervenkr.  1871
    (contains no comprehensive description, but much information concerning par-
    ticular symptoms of the disease).—Benedikt, Electrotherapie. 1868.—Rosenthal,
    Handb. d. Nervenkrank.  1870.—Duchenne, De l'electrisation localise.  3. edit.
    1872.—Hammond, A treatise on dis. of the nervous system. New York, 1872.—
    Moreover, the text-books and manuals of psychology may be  consulted, which
    nearly all treat more or less  exhaustively of hysteria, and also the handbooks
    of special pathology, especially those of Canstatt, Wunderlich and others, and
    the sections referring to our subject in the  manuals of gynaecology, of which I
    would especially mention :  Scanzoni, Die Krankh. d. weibl. Briiste und Harn-
    werkzeuge, sowie die dem Weibe eigenth. Nerven- und Geisteskrankheiten. In
    Kiwisch v. Rotterau, Klin. Vortriige u. s. w. 1859.—Marion Sims, Clinical notes
    on uterine surgery.   New York, 1865.
Of the numerous papers  on hysteria, and  particular symptoms of  the  same, which
    have appeared in periodicals, brochures, or  dissertations, I would  cite  the fol-
    lowing :  Sinogowitz, Ueber  Krampfformen  eigenthiiuil. Art und deren Verlialt.
    zu Sexualstor. bei weibl. Indiv.  Rust's Magazin f. d. ges. Heilkunde.  23. Ed.
    1827.—Mondiere, Recherches sur les l'cesophagisme.  Arch, gener.  2. Ser. T.
    I.—Gendrin, ibid. 2. Ser. T. XII. (Anaesthesie.)—Henrot, De l'anesthesie et de
    l'hyperesthesie hyst.  These de Paris.  1847. — Beau,  Recherches clin. sur
    l'anesthesie, etc.  Arch, gener.  4. Ser. T. XVI. 1848.—Macario, De la paralysie
    hyster.   Annal. med.  psych. 1844.—Schiltzenberger, Recherches  clin. sur les
    causes organ.,  etc.  Gazette  med. de  Paris. 1846.—Szokalsky, Von der Anas-
    thesie u. Hyperasthesie, etc.  Prager Vierteljahrsch.  1851.  4. Bd.—L. Meyer,
    Ueb.  acute  tddtl. Hysterie.  Virchow's  Arch.  Bd.  9.—Lasegue, Sur la toux
    hystgr. Arch, gener. 1854.  Parrot, Etude sur la sueur de sang, etc. Gaz. hebd.
    1859.— Wunderlich, Ueb. d.  Eigenwiirme am Schluss todtlicher Neurosen. Arch.
    d. Heilk. 1864.—Lebreton, Des differentes varietes de la paralysie hysterique.
    These de Paris. 1868.—Bourneville et Voulet, De la contracture hysterique. Paris,
    1872.—Svynos, Des amblyopies et des amauroses hyst.   These de  Paris. 1873.
    —Ferran, Du  vomissement de sang dans  l'hysterie.   Paris,  1874.—Then the
    works on  Articular neuroses:  Brodie, Lectures  illustrative  of  certain local
    nervous  affections.  London, 1837.—Esmarch, Ueber  Gelenkneurosen.  Kiel.
    u. Hadersleben,  1872.— Wernher,  Ueber  nervose  Coxalgie. Deutsche Zeit-
    schr. f. Chirurgie.  Bd. I.—Stromeyer, Erfahr. iiber Localneurosen. Hannover,
    1873.—Berger,  Zur Lehre von d. Gelenkneuralgien.   Berl.  klin. Wochenschr.
    1873.—Also of the  numerous treatises on  spinal irritation: Stilling, Physiol.
    patholog., etc.   Unters. iib. die Spinalirritation.  Leipzig, 1840.—Hirsch, Bei-
    trage z.  Erkenntniss  u.  Heilung  der Spinalneurosen.  Konigsberg,  1843.—
    Tuerck, Abhandl. iib. Spinalirritation.  Wien, 1843.—Mayer, Ueber die Unzu-
    lfissigkeit der Spinalirritation.  Mainz, 1849, and  others. 
GENERAL OBSERVATIONS.
47o
                    General Observations.

   The multiform symptoms which are included under the term
hysteria may, without  exception,  be recognized  as the conse-
quences of a functional disturbance of the nervous system.  The
disease therefore belongs to the class of neuroses, and to those
neuroses to which, in the absence  of a sufficient  knowledge of
their anatomical basis, the term functional  must still be applied.
Hysteria is further to be described as a general neurosis, for its
symptoms allow one to infer a participation of the most various
portions of the nervous system—certainly of the brain and spinal
cord,  and, with much  probability, of the peripheral, and par-
ticularly also of the sympathetic nervous system.
   The most constant symptoms of hysteria are those which show
a condition  of increased irritability  to physical and psychical
stimuli.  A peculiar psychical behavior is partly an immediate
consequence  of this abnormal  irritability, and is in part the
expression of greater disturbances of brain  power.   The function
also of motor portions of the nervous system is, as a rule, upset,
partly because these receive an increased impulse on account of
the exaggeration  of sensory irritability,  both in  a reflex and
in a psychical manner,  and partly in  consequence of a direct
exaltation of their own irritability.
   Pain, neuralgia, and hallucinations in the sensory, and con-
vulsions in  the motor  tract  are the further consequences  of
increased irritability.
   But  there  occur in hysteria, not only  the  symptoms  of
increased, but also those of diminished irritability, both in  the
sensory and motor sections.  Anaesthesia may take the place of
hyperesthesia, paralysis that of convulsion, and  these opposite
conditions frequently exist simultaneously in different portions
of the nervous system.
   Finally,  there occur, as symptoms of an apparently alto-
gether different nature, those of altered power of  the  organs of
secretion and  excretion.   Yet  these, too, may undoubtedly be
recognized  as dependent  upon  an  influence of   the  nervous
system. 
476
JOLLY. —HYSTERIA.
   The  authority for including all these various symptoms in
one uniform class of disease  is derived from  the  frequency of
their simultaneous occurrence, and from the circumstance that
they may appear and vanish  alternately, and that, seem they
never so obstinate, and apparently quite localized in any given
section of the nervous system, yet, ultimately, they can always
be proved to depend upon the general condition of the latter.
   The influences under which  this condition develops itself are
various.   Sometimes there is a  peculiar  reaction  {Reaction)
implanted in the nervous system from birth ;  at  others  it is
caused by an abnormal quality of the nutritive fluid; again it
is the consequence of irritants which operate, through the sen-
sory nerves, on the  central organs; or, finally, it results from
so-called psychical stimuli.
   The circumstance that hysteria occurs more frequently in the
female than in the  male, and that different physiological and
pathological processes in  the female  genital organs  have an
unmistakable influence in  its prod action, has given  rise to the
erroneous assumption that  hysteria  is  a  disease  exclusively
peculiar  to  the female  sex, and that  in such it invariably pro-
ceeds from disease of the genital organs (hence also the name, no
longer to be got rid of, from 'varipa, the uterus).   Unmistakable
as is this connection in many cases, it merely indicates one of
the various ways by  which similar functional disturbances of the
nervous system may be caused.


                          Etiology.

   Only in the minority of cases of hysteria  can  those causes
which develop the predisposition to the disease be  separated
from those wliicli cause its actual outbreak.  Frequently both
occur together, or that which in one case stands in a causal rela-
tion may in another produce the predisposition.   A separate
enumeration of both series of cases would therefore only lead to
tedious  repetition, while a consideration of the one must also
show its varying import in  two directions.
   AVe commence  with the consideration of the differing lia-
bility of the two sexes to hysteria.  That the latter is a disease 
ETIOLOGY.
477
occurring with  preponderating  frequency  in the female  has
already been pointed out, as also that it is not exclusively pecu-
liar to her.  In fact, all the characteristic appearances of hysteria
may occasionally be  observed in men—the psychical condition
as well as the sensory and motor disturbances.  Nevertheless, it
is difficult to supply exact information  regarding the relative
frequency of this occurrence, as there exists, in general, a  ten-
dency to restrict as much the diagnosis of hysteria in men as it
is usual to extend  it in women, and as, in  consequence of  this
tendency, hysteria  is very often designated hypochondriasis in
men, and  hypochondriasis hysteria in women.   One can there-
fore only ascribe  to the statistics  which have been drawn up
regarding the different sexual tendency to  hysteria the signifi-
cance of a general approximation to the actual state of affairs.
   Thus, Briquet states that, of 1,000 cases of hysteria which  he in part observed
himself, and in part collected from the statements of others, 50 occurred in  men.
So also he found the ratio among  the predecessors of the hysterical persons ho
observed,  viz., 204 hysterical women to 11 hysterical  men.  Thus one would  have
to assume a tendency to the disease twenty times greater in the female than in the
male.
   We  can only at present  conjecture what are the real causes
of this unequal tendency.  In each case we must distinguish  two
modes of  its production, viz. : there may be,  in  the first place,
congenital peculiarities wliicli render the  nervous system of the
female  especially liable to  a development of the disease ; and,
secondly,  the blame  may be imputed to acquired conditions,
partly due  to the  physical  function  peculiar  to women,  and
partly to their social position.
   With reference  to the first point, a congenital difference of
predisposition in the  two sexes flows immediately from the  fact
that even in  childhood hysteria affects  girls much  more  fre-
quently than boys.   Here, at all events, there can  as yet be no
question of  a difference  of physical function.  The significance
of the  latter, however,  shows itself undoubtedly in more  ad-
vanced life, when we see how frequently diseased and excited
conditions of  the female genital organs  occasion hysteria,  and
how a tendency  to the same diminishes at  an age when the func-
tion of those organs ceases. 
478
J OLL Y. —HYSTERIA.
   The frequency of the appearance of  hysteria is very different
at different ages.   In  childhood,  long before  puberty, well-
marked  hysterical  phenomena occur.  Briquet states that m so
much  as one-fifth  of  all cases the development  of  the disease
takes place before the  twelfth year.  Although the correctness of
this statement has been much doubted, it appears to me from my
own observations to approach tolerably near the truth.  On the
other  hand, the development of hysteria at an advanced age,
after the close of the climacteric period, is rare.  It undoubtedly
arises  most frequently at puberty, and during the following

decade.

   The  following statistics on this point may here be given : of 268 cases, observed
by Amann, 16 occurred at an age between eight and fifteen years;  62 between fif-
teen and twenty-five; 92 between twenty-five and thirty-five; 81 between thirty-
five and forty-five; 12 between forty-five and fifty-five; and 5 between fifty-five
and seventy.   Moreover, in  the following table, the  results of the researches of
Landouzy, Briquet and Scanzoni are placed together:
Outbreak of hysteria at the
       age of
 0-10 years
10-15  "
15-20  "
20-25  "
25-30  "
30-35  "
35-40  "
40-45  "
45-50  "
50-55  "
55-60  "
60-80  "
Landouzy.
 48
105
 80
 40
 38
 15
  7
  8
  4
  4
  2
351
Number of cases	of			Total.
Briquet.		Scanzoni.		
66		__		66
98		4		150
140		13		258
71 24	\	64	\	279
9 9	\	78	1	49
1 3	\	44	\	63
3 2	\	11		24
—		3		5
426		217		994
   The harmony of the above figures is by no means sufficient for
furnishing absolutely  certain results with  reference to  the fre-
quency of the appearance of hysteria at puberty, and during the
succeeding term  of life, till  the commencement of the climac-
teric period.  Briquet considers the period  of puberty as by far
the most favorable, and in support of this advances the fact that
of his  426 cases, 221—that  is, more than half—developed them- 
ETIOLOGY.
479
selves between the twelfth  and twentieth years  of life.  The
figures also of Landouzy  agree with this, while,  on  the other
hand, according to the statistics of Scanzoni and Amann, the dis-
ease  occurred  most frequently in the third and fourth decades.
One must, however, remember that both the latter statistics are
the result of gynaecological practice, and that an unusually large
number, at all events, of these cases of hysteria occurred in con-
nection with disease of  the  genital  organs ; and  further, that
these latter forms develop themselves most frequently during
that  period in which the genital function is most active, and thus
one may regard the results attained as less generally applicable,
and rather as deciding in favor of Briquet.  Testimony is, how-
ever, agreed upon this point, that  in the fifth decade  the devel-
opment  of  hysteria is  much rarer than in both the preceding
decades, and that in the succeeding period a much  more marked
diminution takes place.
   The climacteric period  itself is, as a rule, considered favor-
able  to  the production of hysteria,  and this  view receives the
greater probability from the fact that the various psychical dis-
eases nearly related to hysteria develop  themselves with com-
parative frequei#y at this time.   From the statistics given, how-
ever, no support is gained for this view.
   Among  the most important  causes is a hereditary liability,
which may produce a tendency to  hysteria,  and a  complete
development of the disease.   With especial frequency does an
inheritance  of  like tendencies (gleichartige Vererbung—Heredite
similaire of Morel) exist here, so that the hysteria of parents or
forebears generally has as a  consequence  hysteria of the off-
spring.  Particularly does the transmission of  the  disease from
mother to daughter occur with great frequency.  But, moreover,
the various  other nervous disorders, which have appeared in the
forebears, favor a disposition to hysteria in the descendants, just
os it happens, on the other hand, that hysteria appears in one
generation,  and epilepsy, cliorea, insanity in the next.  These
relations may, from direct evidence, be recognized  in numerous
individual cases.   The study of mental disturbances, in particu-
lar, has furnished a mass of such facts.   But they are  scarcely
}'et to be expressed in  definite figures, as too great difficulties 
480                      JOLLY.—IIYSTEEIA.

underlie the exact arrangement of all the peculiarities of  a suffi-
ciently large number of individual cases.  Here again, on account
of the importance of the matter,  the statements  of Briquet may
be  reproduced,  but  it  must,  at  the  same  time,  be  doubted
whether they are generally applicable.

   Briquet obtained particulars concerning the parents, brothers and sisters of 351
hysterical persons,  and found  that of  these (in all numbering 1,103) 214 suffered
from hysteria and 58 from other diseases of the nervous system.  Thus in all, ner-
vous diseases were proved to  exist in about 25 per cent, of  the nearest relatives,
167 non-hysterical persons, whose family history was in like manner examined, had
among 704 of  their nearest relations  (parents, brothers, and sisters)  only 11 who
suffered from hysteria, and 4 from other diseases of the nervous system—that is,
rather more than 2  per cent.
   As regards the different influence of fathers and mothers, Briquet found that of
282 fathers of hysterical patients of whom he could obtain accounts 6 had suffered
from hysteria and 20 from other nervous diseases, while of  317 mothers there were
103 cases of hysteria and 6 of other diseases of the nervous system.  Further, there
were many more who suffered from hysteria and other nervous disorders among
the sisters than  among the brothers of the hysterical.
   Moreover, Briquet proved the following with respect to the female descendants
of the hysterical:  Of hysterical women who bear daughters, rather more than the
half transmit the disease to one or several of these, and again, rather more than a
half  of the daughters of the latter (i. e., granddaughters) alto become hysterical.
In all, then, rather more  than a fourth  part of  the female  descendants of the  hys-
terical suffer in their turn from hysteria.
   A conclusion cannot  be drawn from Briquet's statements as to the point, among
how many of his patients generally, inherited conditions of  any kind whatsoever
existed, but it  is certain that the number  of these must have been very large.
Amann has recently stated that in 208 cases of hysteria he  proved with certainty a
hereditary tendency 165  times—that is, in 76 per cent. But  here there lacks any
more  exact information concerning the nature of the conditions  originating the
transmission.

    Difficult to state, but certainly of decided influence upon  the
transmission of  a tendency to hysteria, are such peculiarities of
the parents  as do not yet come  under a  definite class of disease,
but  which nevertheless indicate an abnormal  condition  of  the
nervous  system:  unusual  irritability and sensitiveness,  a ten-
dency to excited behavior (explosives Handeln),  and an increased
participation of the  nervous  system on  the occasion of  various
bodily ailments;—in short, all  those phenomena which  one is 
ETIOLOGY.
481
wont to describe collectively as the expression of a neuropathic
disposition or  nervous temperament, and which may go on to
hysteria and other diseases of the nervous system.
   Moreover, various weakly  conditions  in the  parents, arising
from chronic diseases or otherwise, seem to favor the develop-
ment  of a hysterical  tendency in  children.  To phthisis espe-
cially is such  an  influence  ascribed.   Privation,  insufficient
nourishment, and further, an advanced  age of the parents at
the time of birth operate similarly.
   The  transmitted  tendency  to  hysteria may  for  long remain
latent;  in many cases it requires  the addition of a further cause
to effect an outbreak  of the disease ; in  others, again, the con-
genital  taint  is sufficiently strong to develop it independently,
sometimes at so early a period of childhood that it is scarcely
possible to discover a time when absolutely no symptoms of the
disease existed.
   It is  feasible to suppose that5 with so singular an organization
of the nervous system, peculiarities of physical  construction are
connected, from the presence of which a  disposition to hysteria
may d priori be recognized, as also that such peculiarities gener-
ally, without being  inherited,  may give rise to  a special prone-
ness to  hysteria.    Yet, hitherto little that is  satisfactory  has
been discovered upon this point.  One meets with the hysterical
tendency in constitutions the most various ;  robust, full-blooded
individuals as well  as  the weakly and  poorly  nourished may
be affected with it, and also  those  of a  perfectly healthy con-
stitution.   Nevertheless the greater predisposition of weakly
constitutions  is not to  be denied, just as we shall also find that
acquired conditions  of  debility  favor the development  of  the
disease.  Such a condition also probably forms the  connecting
link in those cases in which debility of the parent induces hys-
teria in the descendants.
   Certain peculiarities  of the psychical constitution favor more
than  others thie  development of hysteria.   Particularly such
individuals as combine with a  lively disposition  and  a tendency
to powerful and changing emotions little strength  of will,  are
prone  to hysterical ailments,  as  it  is also just  these psychical
peculiarities which appear in a pronounced manner  in the pic-
         VOL. XIV—31 
482
JOLLY.—HYSTERIA.
ture of complete hysteria.  All circumstances which favor such
a psychical condition also  favor the development  of  hysteria.
On the other hand, the degree of intelligence appears to be quite
immaterial in this relation.  The disease is observed to develop
itself equally in persons highly gifted mentally, in those  of less
capacity, and, finally, in the actually imbecile.
   If we now pass to a closer consideration of the physical influ-
ences which promote a development of the hysterical tendency,
and which can mature an existing predisposition, we find in the
first rank such causes operating as result in a permanent and
general weakening of the organism.   Primary  anazmia pro-
gresses almost, as a rule, to hysterical symptoms ; but  one does
not rarely observe secondary ancemic conditions, which develop
themselves after great losses of blood, after exhausting  diseases,
or in consequence of  insufficient nourishment, also giving  rise to
hysteria.  This is seen, for example, during convalescence from
severe attacks of fever, and in the course of phthisis,  but with
especial frequency in chronic affections of the stomach and abdo-
men.  Of the latter, it is particularly diseases of the female gen-
ital organs to which a distinguished part  in the causation of
hysteria has at all times correctly been allotted.
   The influence of these diseases makes itself apparent in many
ways, partly thus: that the chronic derangements in the nutri-
tion of the entire organism,  the general anaemia,  produce an
abnormal  state  of the  nervous  system.  There is, in addition,
however, a specific influence.  The peculiar  nervous phenomena
which appear in otherwise healthy women at the period of men-
struation,  during gestation, and in  consequence of the  excite-
ment connected therewith, offer a proof that these organs possess
an  especial  relation  to  the  nervous system.   This shows itself
none  the less plainly by the fact that in many cases of pro-
nounced hysteria decided exacerbations of existing symptoms
occur during menstruation  and gestation.   Most clearly, how-
ever, does this appear in those cases in which symptoms of hys-
teria are called forth by irritative pathological conditions in the
genitals, to alter in intensity with the variations in these  condi-
tions, and to vanish with  their cessation. In all such cases the
influence of the  central nervous system  is unmistakable,  and in 
ETIOLOGY.
483
great part induced by the centripetal nerves of the sexual organs
which are excited by pressure, irritation, or inflammatory pro-
cesses.    As  a rule, moreover,  the circulatory apparatus  is
directly implicated at the same time, as sometimes, on account
of the local congestion, and the losses of blood in  consequence
thereof, anaemia is induced in other parts, and, again, owing to
a failure on  the part of the vascular system to empty itself nor-
mally,  plethora and congestive  phenomena are produced.  If,
on the whole, more rarely than anaemic conditions, nevertheless
these  latter states of abnormal vascularity  most undeniably
sometimes help to develop  the  hysterical tendency.   In these
rarer cases one observes the  symptoms of the  disease disappear
if an abundant evacuation of the blood vascular system takes
place.  One  must, however,  be cautious not to deduce a  condi-
tion of  generally increased  vascular fulness  from attacks of
"rush of blood to the head," which appear as one of the phe-
nomena of hysteria, but also occur in anaemic subjects.
   Great, however, as is  the significance in hysteria of physio-
logical and pathological  processes in the female genital organs,
it must nevertheless be  distinctly stated that it may  develop
itself quite independently of their influence.  Not only does the
occurrence of hysteria in  men prove this,  but also its appearance
in women at a time of life when the genitals play no part; and,
further, the  circumstance that one meets with  it in mature life
without  any trace  of an  abnormal condition of the genital
organs.
   Scanzoni  and Amann  found  among the hysterical patients,
whom they examined, nineteen to twenty per  cent, whose geni-
tals were quite healthy.   The statements of von  Franque  give a
similar result.  As in the practice of these three gynaecologists,
at any rate,  cases of  hysteria with disease of the genital organs
occur with unusual frequency, one may, according to these state-
ments, say that at least a fifth and probably a much greater pro-
portion  of  all hysterical women are free from such diseases.
Prom a collection which Landouzy made of the reports of autop-
sies, from ancient and modern literature, it appears that in forty
cases of hysteria, thirteen  times, that is, in a third, changes  in the
genital organs, whether the uterus,  the ovaries, or the Fallopian 
484
.TOLLY.—HYSTERIA.
tubes, were absent.  It must, however, be determined  by much
more extensive statistics whether these numbers express the true
ratio.  I myself believe from personal experience,  though I can-
not give  figures, that on investigation the presence of disease of
the genital organs will be proved in scarcely a half of all hyster-
ical  cases.   It must, moreover, be emphatically stated that even
when they are present, these diseases frequently  play the part
of an exciting cause to a pre-existing tendency to hysteria ; and,
finally, that they may also make their appearance as quite acci-
dental complications.   Conversely, as  regards the frequency of
the occurrence of hysteria with  affections of the genital organs,
the statements of different  gynecologists on  this point vary so
extremely  one from another  that  we must,  in the meantime,
refrain from drawing any conclusion on this  head.   Statements
regarding the significance of different kinds of disease of the sex-
ual organs are more agreed.   Thus, it is generally  stated that it
is the most serious disorganizations of the genitals  (cancer of the
uterus, etc.) which furnish  the smallest percentage of hysterical
patients, while of women affected with versions and flexions of
the womb, as well as with chronic inflammator}^ conditions of
that organ and the ovaries,  a comparatively large  number  suffer
from hysteria.   This is also  not  rarely observed in persons with
an imperfectly developed uterus,  and one  sees  it likewise in
those whose uterus is altogether wanting.
   Of especial  significance in any case are the processes in  the
genitals during gestation, delivery, and lying-in,  both  from the
direct influence which they exercise  upon the organism, and
from the numerous diseases  of the sexual organs wdiich follow in
their train.  Scanzoni states that, of 217 hysterical  patients
whom he had treated, 165, or  75 per cent., had been puerperal,
and that, of the latter, not less than 65 per cent, had borne chil-
dren more than three times.
   Menstrual disturbances, even without disease  of  the genital
organs,   occur  in  many hysterical women,  without its  being
always possible to state in how far they precede or cause the dis-
ease as an independent functional disturbance, or  whether they
are merely to be regarded as a symptom and  consequence of it.
At any  rate, long-continued metrorrhagias  may give rise to 
ETIOLOGY.
485
hysteria by means of the exhausted conditions which they bring
about.  But, as above stated, the increased vascular fullness and
irregularities of circulation, caused  by  a suppression of the
menses, can likewise influence  the nervous system in a similar
manner.
   That hysteria cannot, as formerly believed,  be exclusively
"virginum et viduarum affectio," is satisfactorily  proved by
what has  been said.  But there are  undoubtedly cases of hys-
terior in which the non-gratification of the sexual appetite, i. e.,
sexual  abstinence, exercises a  certain influence  as an exciting
cause.   Especially in the  case of  young widows, who were
formerly  in the full enjoyment of sexual gratification, and  in
those women who, from impotence on  the part of their husbands,
cannot obtain the said gratification, does  the  disease sometimes
develop itself,  and  may be cured under circumstances which
remove the cause.
   More frequently, however, than sexual  abstinence does sexual
oner-irritation, particularly that induced  by onanism, cause the
disease.  It is also the latter agency which is found with com-
parative  frequency  to be  causal in  cases  of hysteria in men.
Moreover, in them chronic diseases of the urethra and prostate
seem to play a part.  Yet there are no corresponding statements
extant  with  reference to  the  frequency of these relations (in
man), as  there are with  regard to  those analogous  in  the
female.
   The last-mentioned causes of hysteria are in no case to be re-
garded as  operating more than in a purely physical manner ; but
herewith there is always observed a simultaneous influence acting
in a directly psychical manner.   Psychical influences generally,
operating in part independently and partly in conjunction with
physical  causes, have the  most  important bearing upon the
development of the hysterical condition.   On this point, it may
be said, as a rule, that  persistent mental  emotions, especially
those of a depressing nature,  operate in this way.  The  sad
sense of failure in one of the objects  of life, which  so often, in
particular,  affects  childless women  and  old  maids ; in other
cases, love-sickness  and jealousy ;  in  others, the  feeling  of
injured vanity  and  wounded  pride;  in others,  self-reproach 
486
JOLLY.—HYSTERIA.
because of secret sins ;  and, finally, grief and anxiety on account
of all the possible accidents and relations of life, are a few of the
more important emotions in question, wliicli need not be further
particularized.   The effect of these varies extremely, according
to the previous  condition of  the psychical soil.   The more sen-
timentality  there exists,  and  the less the individual is  accus-
tomed to  repress his feelings, the more easily do  these assume
a pathological  character  and  influence  the whole state  of the
nervous system.  There are, however,  psychical  excitations so
powerful  as to  overcome an otherwise  perfectly  healthy con-
stitution.    Thus,  one sometimes observes hysteria suddenly
appear in  persons hitherto healthy, after very violent excitement
from fright and fear, or after very acute mortifications and inju-
ries of one's sense of  honor, especially after rape.  Much more
frequently,  however,  all  these influences are but the  exciting
causes of an outbreak of the disease (already existing) or of some
of its paroxysms.
   From all that has been said, it is clear how great an influence
education may  have  both upon  the repression and upon the
development of the disease.   By means of appropriate  physical
and  moral training, the predisposition to disease may be  extin-
guished, just as,  conversely,  the tendency,  existing only in a
slight degree, or not at all, may be artificially roused.  All influ-
ences which favor physical debility are active in the latter direc-
tion  ; that is, both a too delicate nurture, by which a necessary
degree of robustness fails  to be imparted to the body, and a too
Spartan rearing, which exacts efforts beyond the power to per-
form them.   Both extremes are also pernicious in a moral  sense.
By  too great indulgence, pusillanimity and peevishness are
fostered, which  prepare the way for hysterical phenomena; by
undue rigor and intimidation, such  violent disturbance of the
feelings may be called forth,  that  exalted  irritability of the
entire nervous system, coupled with indecision of character, is
the result, calculated to favor the  disease.  An unsettled, crotch-
ety education, however,  now  exceeding in one  direction and
again in another, is fraught with the greatest danger.  In schools,
and  particularly in girls' boarding-schools,  the  foundation of
hysteria is  likewise often laid.   Especially dangerous are too 
ETIOLOGY.
487
great  demands upon  the mental capacity, overburdening with
lessons, and at the  same time stimulating an over-driven ambi-
tion.  The want of  sufficient physical exercise also follows this
as a second  pernicious element, and frequently enough it is just
by this injudicious manner of life that the inclination to mastur-
bation is awakened.
   The  influence of a faulty education  in  the development  of
hysteria cannot be fully estimated,  if  one does  not take  into
account a co-operating circumstance,  which we find even at a
more mature age as a  causal element of hysteria, viz., the rise  of
an imitative impulse.  Hysterical mothers transmit not only the
seeds of disease to their children ;  they also favor its develop-
ment by education and by their own  example.   Above all, it  is
those symptoms which occur in paroxysms, especially  convul-
sions, which provoke  imitation.  But the whole mode of feeling
and thought  also transfers itself from continued intercourse.
As in children,  so also  sometimes in nurses who have for a
length of time attended hysterical patients, this so-called imita-
tive infection is operative ; or in other patients who have been
nursed beside  such ; and, above all,  in people who have been the
accidental witnesses  of an hysterical attack.   In this way an
actual epidemic of hysteria may take place, as is shown by the
convulsive epidemics  of  former ages, and  the less  extensive
attacks of the same nature which occur in  hospitals, cloisters,
factories, girls' schools, etc., at the present day.
   Moreover, one usually finds this sort of infection only opera-
tive in  such individuals as are already otherwise disposed to
hysteria, and  the epidemic  spread of  the  disease  is usually
ushered in by general  predisposing influences.  Thus, as a rule,
want and misery, in consequence of war or  the ravages of  dis-
ease, or owing to the failure of crops,  and famine, have cleared
the way for those  convulsive epidemics which have appeared
and spread through whole  districts  and  populations, usually in
connection with  great political and religious disturbances.   In
the limited epidemics  in hospitals, debility resulting from other
diseases, as well as the enforced inactivity, are  to be  taken into
account as co-operative elements.  In educational institutions  it
is the defects  already mentioned in  the physical and psychical 
488
JOLLY. —HYSTERIA.
regime which may induce the tendency simultaneously in a large
number of persons.
   Attempts to establish a special tendency to hysteria in cer-
tain classes of the population,  especially in certain  ranks and
callings,  have as yet led to no positive results, although without
doubt a  difference of disposition must arise from a variety of
external  circumstances.  A definite influence of nationality and
climate has also as yet failed to  be proven.


          Pathological Anatomy and Pathogenesis.

   One can only speak of changes in the central nervous system
in a negative sense.   Though we discover in a few exceptional
cases grosser lesions of the brain  and spinal cord of various kinds,
yet these can only, in the most  favorable cases, be regarded as a
few of many influences under which like functional disturbances
occur. In other cases, again, it is certainly only  a question of
accidental  complications, as  palpable diseases of the  nervous
system develop themselves in  individuals,  who are  hysterical
independently of such.  The further possibility of  a gradual de-
velopment, from long-continued hysteria, of  structural changes,
in portions of the  nervous system which  at first were  only
abnormally active, requires more proof, and  as   yet facts are
wanting.
   The cases of Charcot, in  which after long-continued "hysteri-
cal" contractions, sclerosis  of the lateral columns of  the spinal
cord was found, appear to argue in  favor of this view, and it is
not to be denied that here it was not merely a question  of  com-
plication in the afore-indicated sense.   Even in cases of  acute
fatal hysteria, changes in the central nervous system have failed
to be discovered.
   That some alterations in the nature of the nervous system
must be at the  foundation of its  altered function cannot be
doubted.   But whether  we are to expect  that those  changes
affect the structure of the nerve elements, or only have reference
to its chemical and molecular constitution, cannot yet be stated.
It is  quite as possible that the microscope may  at some time 
PATHOGENESIS.
489
give us information concerning the nature of this condition as it
is that no information may be derived from this source.
    One can therefore, in the meantime, only discover the basis of
hysteria  in an "abnormal"  condition of  the nervous  system,
which can only be  determined by its  symptoms.   But  this con-
dition, from what we know of the  etiology of the disease, may
be one either  implanted in the nervous  system from  birth,  or
acquired partly by sensory irritation and  partly from the opera-
tion of an abnormal quality of blood.   It develops itself  most
powerfully when all these influences combine.
    All theories of hysteria which attribute its origin exclusively
to the genital organs, are  fallacious,  whether it be that the con-
nection  is explained as reflex  from,  or due  to changes in the
blood of  those organs.   These causes, however, may well play a
considerable part in the production  of particular symptoms.

   In the oldest theories of  hysteria  the  uterus exclusively acted  as a " primum
movens" to the disease.  The ancient Greek physicians gave it credit for wandering
through the whole body, and producing by pressure on different organs symptoms
of disease  in  the latter.  When  Galen demonstrated the impossibility of such
migrations, the opinion arose that, by the retention of seminal fluid or blood in the
uterus, a pernicious influence was  exerted  upon the whole organism.   Sometimes
this was effected by a decomposition  of the fluids, sometimes by the invasion of
hurtful gases (Vapores), and again, by pressure  of the distended uterus upon the
surrounding nerve  distribution (per consensum).  Later, this explanation was gene-
ralized so that irritative conditions of the sexual organs, as  a whole, were supposed
to be at the foundation of hysteria—a view which was last defined by Romberg
thus: hysteria is a reflex neurosis  caused by genital irritation.  All these theories
contain a particle of truth, as they are founded upon a knowledge of particular and
frequently operative causes of hysteria.  That they, however, do not suffice follows
from all that has been stated.  The other view, that the disease  has  its root in the
nervous system, and may  be developed in  this by the  most varied  external influ-
ences, has, since the time of Sydenham, gained more and more adherents, and may
at present be said  to  be  that which is almost universally  entertained.  Opinions
concerning the essence of the disease have truly been diverse. Sydenham considered
an ataxy of the emotions in the brain to be its basis. Pomme thought it was caused
by a hardening (Racornissement) of the nerves.   It cannot  be said  that the ideas
we now form of a " peculiar constitution of the nerve-elements" are much clearer
than those connected witli the expressions quoted, when they first came into use.

   Finally, the question is.  In what portions of the nervous sys- 
490
JOLLY.—HYSTERIA.
tern have we to look for the seat of the individual symptoms of
hysteria %
   We meet with undoubted brain symptoms, not only in great
disorders of consciousness during hysterical  attacks, but much
more commonly and more constantly in the almost never absent
(though, of course, present in very varying degree) exaltations
of psychical irritability.
   This finds expression not only in the subjectively felt, power-
ful excitement of emotion  on little provocation, but also in a
series of convulsive movements perceptible objectively, and tak-
ing place involuntarily.  The following are merely exaggerations
of the  motor symptoms accompanying  the affection  even in
healthy people,  viz. : alterations in the heart's action and in the
respiratory movements, spasmodic contractions in the digestive
canal, cramps in the most widely differing portions of the exter-
nal muscular system.
   The same phenomena may also in such cases be called forth
by means of purely sensory stimulation.
   Here, then, we have to do with diseased reflex actions of dif-
ferent kinds,  whose reflection takes  place in  the brain,  and
whose cause is conjecturally to be sought for in a condition of
exalted  irritability in the sensory portions of that organ.  The
hallucinations occurring in many cases also prove the existence
of such  a condition.  Further, we find a still greater participation
of the brain, in states of more complicated mental disturbance,
taking place in the hysterical.
   We  have now, however, to consider whether all the symp-
toms of hyperaesthesia, pain and spasm  occurring in hysteria,
are to be referred to an affection of  the sensory portions of the
brain.  This may, indeed, be possible, but it does not appear al-
together probable.   Against it particularly does the circumstance
speak, that frequently in the hysterical,  by stimulation of the
circumscribed  hyperaesthetic  and  painful  spots,  strong local
reflex actions are given rise to in their neighborhood, and that,
then, by a continuation of  the stimulus, a gradual spread of the
movements follows, in a manner exactly resembling the theory of
reflex actions in the spinal cord.  It is therefore probable that
some hysterical hyperaesthesias and reflex spasms are to be attrib- 
PATHOGENESIS.
491
uted to a condition of increased irritability in the sensory por-
tions of the spinal cord.   This  condition may extend over  the
whole length of the spinal cord, or exists only in some  parts of
it.
   The pains  and hyperaesthesias, however, occurring in partic-
ular vertebrae in many hysterical people, have  erroneously been
produced as the proof  of such an irritative condition—the so-
called  spinal irritation.1  Vertebral pains may be absent, even
when the signs of increased irritability mentioned are distinctly
present.  The tender vertebrae also do not by any means always
correspond to those portions of the spinal cord which,from other
symptoms, we must consider to be specially irritable.  The pain-
ful vertebra frequently  alters  its position without being accom-
panied by other changes.   In fine, it may, as well as other  pains,
owe its origin to a purely peripheral irritation.
    Lastly, it is possible that in the hysterical there also occurs
an exalted irritability  of the peripheral sensory nerves,  which
is accompanied by symptoms quite similar to those of increased
irritability  of the spinal  cord, viz., by pain, hyperaesthesia  and
reflex spasms.  Direct proof,  however, of affections of this kind
does not exist.  But more than once already fatal errors have been
committed in this respect, in  the case of hysterical patients, as
circumscribed and very obstinate pains in peripheral portions of
the  body, especially  in the  extremities,  have been considered
evidence  of  peripheral  disease, and it  has  been  attempted  to
remove them by amputation of the part.  The unaltered  continu-
ance of such pains, even after repeated amputation (in  one case
  1 Under the term spinal irritation have been, and indeed still are classed, all possible
Bymptoms which one believes may be referred to an irritative condition of  the spinal
cord.  Hence, sometimes vertebral pain is regarded as a symptom pathognomonic, and
in itself proving the presence of that condition (by some,  indeed, pain in the vertebrae
is called spinal irritation), and again other conditions, the most widely differing, pains
and hyperesthesias, convulsions and paralyses, even psychical symptoms of all  kinds,
are regarded as evidences of spinal irritation, so that the  latter constitutes in a great
measure  the clinical picture of hysteria, and, in  part, also that of hypochondriasis.
The irritation itself is partly looked upon as a purely nervous condition, and is, in part,
referred to hyperaemia of the spinal cord.  Hammond has  recently expressed the belief
that it may be explained by anajmia—and that, too, a special  anaemia of the posterior
columns.  There is, however, as little proof for the one view as for the other. 
492                   JOLLY.—HYSTERIA.

Mayo on this account undertook  exarticulation at the hip-joint)
has afforded the certain proof of its having been merely a case of
the excentric transmission of central irritative conditions.
   Nevertheless,  it  must not be considered  impossible  that
peripheral  nerves may also,  in  cases of hysteria,  be brought
into a state of altered sensibility.
   That which applies to hyperaesthesias, is also applicable to
anaesthesias.  The impediment to  conduction may be situated at
the most various portions of the  sensory tract.  It is a priori
probable,  that cases of well-marked unilateral anaesthesia are
caused by  changes in  the brain itself.  On  the other hand, the
circumstance that (even  in cases of unilateral anaesthesia) the
anaesthetic parts occasionally lose at the same time reflex irri-
tability, only points to the fact that in the peripheral portion of
the  tract likewise, there  exists an impediment to  conduction,
either in the spinal cord or in the sensory nerves themselves.
   The motor may in  part be considered a direct consequence of
the sensory irritative phenomena.  The brain as well as the spinal
cord claims the  agency.   But it is extremely probable that a
portion of the spasms which occur, result from a direct increase
of the motor irritability without such a sensory excitation.   The
proof, at least, of a sensory stimulus standing in a  causal rela-
tion is not often obtained.  These spasms may, however, arise,
sometimes in the brain and sometimes in the spinal cord.  Nor,
finally, is the opinion  unjustifiable, that the increase  of reflex
irritability  is in some cases to  be ascribed to the  suspension
of the normal reflex inhibition proceeding from the brain.
   Lastly, hysterical paralyses are not to be localized with abso-
lute certainty.   That  hemiplegias proceed  from  the brain, and
paraplegias from the  spinal cord, is  argued for by the analog}7
with cases in which there is anatomical change in these parts. It
is, however, just as easy to imagine that the converse is true, and
most probable that both occur.  That the impediment to conduc-
tion may be situated in the peripheral motor nerves is improba-
ble from the fact, that, even after the long-continued  existence
of such paralyses, no changes in the electrical irritability arise.
Some hysterical  paralyses again  seem to belong  to the category
of reflex paralyses.  Hysterical contraction, it has already been 
SYMPTOMATOLOGY.
493
mentioned, is regarded by Charcot as the evidence of an affection
of the lateral columns of the spinal cord.
   Whether we are to regard  changes in function of the vaso-
motor and secretory nerves, which play a distinguished part in
many cases  of hysteria,  merely as dependent upon the central
disturbances, or whether peripheral alterations of function also
occur in  such cases, is not decided ;  the latter, however, is  not
improbable.

                         Symptoms.

             General Description of the Disease.

   The symptoms of hysteria develop themselves in the majority
of cases  so  gradually, that it  is difficult to predict a  definite
result.   The first symptoms are generally those  of increased
psychical irritability and peevishness, with which hyperesthesias
and conditions  of excitement in the region of different senses
and exaggerated reflex phenomena are associated. In other cases
the latter changes take  place first, and the psychical alteration
shows itself  later.  Frequently many years pass  before others
are added to these symptoms; but often also anaesthesia and
paralysis develop  themselves early, in particular parts  of  the
body.
   There is another series of cases, in which the disease seems to
begin suddenly, and to be accompanied, too, by one of those fits
which so  often appear in the further course of hysteria.   Closer
investigation  shows that in the  majority of these cases, prodro-
mic symptoms have already occurred  for a longer or  shorter
period, and that the fit merely  signifies a rapid culmination of
certain groups of symptoms.  As an appreciable external cause
is frequently at the bottom of the attack, and as thereafter the
collective hysterical symptoms  are as a rule more distinctly pro-
nounced than formerly, the mistaken idea easily arises that the
whole disease has commenced suddenly.
   In  a smaller  number of  cases, however,  it does actually
develop itself suddenly,  or at least within a few days or weeks,
in people previously quite healthy.  These are cases in which it 
494                   JOLLY.—HYSTERIA.

is  induced  by very  violent  moral  shocks,  or great physical
exhaustion (loss of blood, severe febrile diseases, and so on).
   In their further course the attacks referred to,  which consist
partly of more or less general convulsions, and partly of pecu-
liar psychical disturbances, may play so prominent a role as to
appear to  constitute  the entire  clinical  picture,  so that,  on
superficial observation, all symptoms of disease may seem to be
absent in the intervals between them.   In other cases, after the
attacks, widespread paralyses, contractions,  anaesthesias, and so
on, develop themselves, or those already existing are aggravated.
In yet other cases, the attacks are less violent, and separated by
long intervals, and it  is just in these intervals that severe hys-
terical symptoms develop themselves, compared with which the
attacks are of less importance.   Finally, there are numerous
cases of hysteria in which distinct fits are altogether absent.
   The various symptoms  of hysteria are developed, as these
short  statements  indicate,  in  the  most  confused  alternation,
simultaneously and in succession.   It is, therefore,  impossible
to adhere  in  the description to the order of their appearance;
one  can only arbitrarily enumerate  them  one after another, and
so  point out,  as  far  as  possible, the frequency  of particular
symptoms  and their  mutual relations.  Sometimes  all these
symptoms are observed in a single case, and thus produce an
extremely varied and  multiform clinical picture.  In other cases
only some of them are present, but these are  of so much the
greater obstinacy and  persistence.   It will not, however, be pos-
sible to maintain,  in accordance with these differences, the exist-
ence of different forms of hysteria, distinguished by the predom-
inance of  one or other symptom,  as  by means of the various
transitions  which occur, the connection of individual cases will
be proved.  Never absent are the peculiar alterations of psychical
functions,  to which  particular disturbances  of sensibility  and
motion stand in the closest relation.   Around these the  remain-
ing  symptoms group  themselves, according to the intensity and
general prevalence of  the disease. 
SYMPTOMATOLOGY.
495
            Description of Particular Symptoms.

                     Disorders of Sensibility.

   We commence with the phenomena of increased sensible irri-
tability.
   Hyperesthesia, in one form or another, is never absent in the
course of hysteria.  General hyperaesthesia is met with, affecting
all the senses, as well as that limited to the region of particular
senses or portions of the same.  But, as in other diseased condi
tions, so in hysteria,  that form of  hysteria which consists in
an especial acuteness of  sensory perception is  less frequently
met with (increase of differentiating sensibility [Unterschiedsem-
pfindlichkeit], diminution of reflex contraction [Reizschwelle]).
As  a rule  that form is  most  frequently present (also  called
hyperalgia  and  hyperalgesia), which is  distinguished  by  an
aggravation of the various kinds of pleasure and aversion called
forth by sensory stimuli.   If  this condition  exists in greater
intensity, pleasure disappears altogether, and  stimuli generally
perceptible by the senses produce discomfort and pain.
   Not rarely such  a degree of hyperaesthesia is only produced
by stimuli  of a  particular kind.   There are some sensations, to
others indifferent or pleasant, wliicli in the hysterical produce
the highest degree  of  discomfort (Idiosyncrasie); so also there
are particular stimuli which are to others a matter of indiffer-
ence, or unpleasant, and which awaken pleasure in the hysterical
and are by  them eagerly sought after (Pica).
   Finally, with the hyperaesthesia  to sensory impressions there
is always coupled, in greater or  less degree, a similar condition
towards  psychical emotions.  Such also as have  no connection
with previous conceptions  are accompanied by exaggerated sen-
sations of  desire or repugnance — a psychical hyperesthesia
exists.
   In all  cases in which considerable increase of the sensible irri-
tability takes place, the outbreak of subjective  sensory  excite-
ment is also observed, that is, an excitement which appears with-
out appreciable  irritation  of the  peripheral  sensory apparatus. 
496
JOLLY. —HYSTERIA.
Accordingly there occur with great frequency in the hysterical,
not only pains and neuralgias, but also true hallucinations.
   Hyperesthesia in the region of the organ of sight is some-
times so considerable that the patients are obliged to avoid every
bright light, and as far as possible to betake themselves to dark-
ened rooms.  A peculiar sensitiveness to particular colors, espe-
cially to red,  is observed in some hysterical people, who consider
other colors  pleasant.  Subjective light-phenomena of  a simple
kind, flashes, sparks, and so on, appear occasionally before the
attacks.  More complex appearances, heads, figures, landscapes,
etc., occur, as in the case of nervous persons, generally before
going to sleep, but sometimes also during  the day, as so-called
phantasms, whose subjective nature is recognized without trouble.
True visionary hallucinations appear particularly in attacks of
ecstasy.  These are more distinct  and are often not recognized,
even after the cessation  of the attacks, as a subjective phenom-
enon.  They  may occur at the commencement of  convulsive at-
tacks, and occasionally also on the eve of all paroxysms.
   When patients, in consequence of their abhorrence of  light,
remain for a lengthened period in dark rooms, there arises, from
their dwelling in a feeble light, the capability of detecting varia-
tions  in the latter.  From this one must not, of course,  conclude
that an increase  in the acuteness of vision has taken   place  in
consequence  of the  disease,  although such is undoubtedly the
case in some instances.  On the  other hand, it is a matter of
knowing or unconscious deception when hysterical people are
said to have read with their eyelids quite closed.
   Many of the hysterical are extremely sensitive  to excitations
of the sense  of hearing.  They are  annoyed  by any loud note,
and  often by the slightest sounds.  In this  condition   they are
frequently  aware of events unobserved by the healthy, and,  as
with the sense of sight,  a greater acuteness of the hearing may
be artificiall}7- induced by the strictest avoidance of all  possible
sounds.  But here also  there occur cases of actual exaggeration
of this faculty in consequence of the disease.   As subjective sen-
sations frequently met with,  are to be mentioned ringing,  blow-
ing, roaring,  and so on,  which especiall}7 precede the spasmodic
attacks.  Phenomena analogous to the visionary phantasmata are 
SYMPTOMATOLOGY.
497
rarer.  But, again, true hallucinations of hearing, like those of
sight, occur as well in ecstatic conditions as in other more com-
plicated  hysterical disturbances.   They frequently  constitute
the transition which leads to definite mental aberrations.
   The senses of smell and of taste are with especial  frequency
the seat  of well-marked  idiosyncrasies, whereby the capacity at
the same time increases of detecting substances repugnant to the
taste  or  smell, even when these exist in the smallest possible
quantity.  With this aversion to certain materials, which convey
to others a pleasant scent or taste,  the patients as a rule unite a
peculiar  preference for some  tastes and smells, which are either
a matter of indifference to the healthy, or to which they have an
actual dislike.   Thus it happens  that  the  hysterical eagerly
devour chalk, coal, sealing-wax, and other such things, and have
a decided inclination for repellant odors, such as assafcetida, and
the like.   Cases, too,  of actual increase in the acuteness of the
sense of  smell are known.  Thus Amann relates the  case  of  a
lady who could detect the odor of cherries in a room, and  who
could distinguish  persons by smell.   Hallucinations of taste
and smell  are  not rare  in  the simpler  forms of  hysteria.  In
more complicated cases they greatly encourage the development
of erroneous ideas.
   As in all these  sensory  regions, so also in the case of  the
senses of locality  (Ortsinn),  touch and  temperature,  a positive
increase  of sensibility is  a comparatively rare phenomenon.  In
some well-attested cases, however, a refinement  of  the sense of
touch seems to have been present, by means of which the patients
could recognize  persons  and  objects by  feeling them, with an
accuracy not met with in the healthy.   In some  cases too, as
Eulenburg has correctly pointed out, the  perception of a pulsa-
tory movement at different parts of the body proves a condition
of increased sensibility at these points—that is, when this move-
ment itself is not  exaggerated.  Many  of  the cases, described
in the literature of the subject  as those of so-called refinement
of the sense of touch, evidently rest upon a fallacy.
   Yet in almost no hysterical person is there absent the symp-
tom of exalted sensibility to pain  in  some portion of the  skin
or more  deeply seeded parts, with and without  spontaneous
          VOL. XIV.-32 
498
JOLLY.—HYSTERIA.
pains in the same.  The position and distribution of cutaneous
hyperesthesia varies extremely in individual  cases.  Sometimes
it is distributed  over the entire surface of the body, any move-
ment  is  uncomfortable  to  the patient,  and in  some  cases it
induces general  reflex convulsions.   In other cases  the skin of
particular extremities only,  of  one half of the body, or of differ-
ent portions of the trunk, is affected.  Sometimes in the midst
of  hyperaesthetic regions  there are irregularly  circumscribed
anaesthetic portions, or parts normally sensitive.  The  greatest
increase  of  sensibility frequently exhibits  itself on distinctly
defined portions  of the skin, especially on  the head and back.
On merely touching such places, the patients feel as if they were
hurt, and were pierced with needles, or burnt with glowing iron.
   Objectively there is as a rule nothing peculiar to be remarked
in such portions of the skin, either as regards vascularity or in
any other respect.
   The spontaneous pains in  the skin,  which occur with and
without hyperaesthesia, frequently assume the character of neu-
ralgia, of  which  all known  forms may arise  as a result  of
hysteria.
   Of more deeply seated parts, the  muscles and fasciae are very
frequently the seat of hyperaesthesias  and  pains (myosalgise,
myodyniae) ; moreover, such affections do  not rarely occur in
the periosteum.   In the latter case, if hyperaesthesia of the skin
is not at  the same time present, patients frequently only become
aware  of the condition in  consequence  of accidental pressure
(knocks) on movement, or  from examination specially  directed
to the part.
   Painful  affections of the internal  organs are combined in
many ways with those of the outer coverings.   They  will be con-
sidered together in the description about to be given of abnormal
sensations in particular regions of  the body, as on account of
their  immediate  connection with spasmodic  phenomena they
must not be confounded with these.
   Headache, in one form  or another, appearing periodically.
is  absent in but few of the hysterical.  After the attack many
complain of a vague, confused feeling in the whole head, and
with  this  there is frequently coupled  a smart  hyperaesthesia 
SYMPTOMATOLOGY.
499
of the scalp, in consequence of which combing or gently pulling
upon  the hair  becomes unendurable.   The muscles  which are
attached to the galea aponeurotica, as well as this structure itself,
may also be the seat of severe pain.  Such  also affects the tem-
poral and cervical muscles.   Moreover, in the hysterical, neural-
gias of  the  different branches  of the fifth and of  the occipital
nerves occur, and yet more frequently  than these,  hemicrania,
which is very apt to appear at the menstrual period.   An affec-
tion evidently very closely related to hemicrania is that which
has been already described by ancient physicians as Claims hys-
tericus.   Instead  of the pain of  hemicrania, difficult to localize
and spread over the entire half of the head, clavus  is character-
ized by a sharply defined,  boring, gnawing, and burning pain,
which, as a rule, has its seat in quite a limited area at the top of
the head, somewhat to the side  of  the sagittal suture.   Like
hemicrania,  this  pain,  otherwise not  of  frequent occurrence,
makes its appearance very commonly at the menstrual period,
and also as a result of trivial psychical excitations ; it is accom
panied by general discomfort,  a feeling of faintness, sickness,
and vomiting, and lasts, as a rule, for a few days, and in rare
cases for several weeks.
   Pains and  abnormal sensations occur in the region of the
throat, both in the skin and in more deeply seated  parts.  The
most important of the latter, which have been grouped under the
name  of globus hystericus, must be mentioned along with the
spasmodic affections.  Hyperesthesia of the mucous membrane
of the larynx is  sometimes  so powerfully developed,  that any
current  of air somewhat colder than usual, or slight admixture
of dust  in  the  air inhaled, produces severe pain and attacks of
coughing.   Here  and there  on  the mucous membrane  of the
mouth and tongue, there likewise occur great sensitiveness and
pain, without local changes being a demonstrable cause.
   Painful affections in  the region of the breast.   Sometimes
hyperesthesia of  the skin  over the breast reaches such a pitch,
that any touch becomes unendurable by the patient, and even
moving the  arms  causes pain. Besides the hyperaesthesia, mas-
todynia, neuralgia of the mammary gland, is observed in some
cases,  and this, like  the former,  undergoes exacerbations, espe- 
500
JOLLY.—HYSTERIA.
dally at the menstrual epoch.   Much more frequently, however,
than these comparatively rare affections, do intercostal neural-
gias occur, and yet more often one finds some portion of the in-
tercostal muscles, or particular ribs painful, without the presence
of the typical symptoms of neuralgia.
   At different parts of the sternum,  too, and particularly in the
neighborhood of the ensiform process, great sensitiveness to pres-
sure is  frequently met with.  Still oftener there occur in  this
region spontaneous pains of a heavy, dull  character, which are
usually  coupled  with a feeling of oppression and anxiety.  It
is probable that these pains, which are frequently not to be local-
ized with absolute precision, are caused in many cases by an ex-
cited condition of the nerves of the heart.  Especially may this be
assumed with tolerable certainty if the  heart's  action is at the
same time exaggerated, as is usually  found to be the case in the
severer  attacks of  precordial  anguish.   In some rare cases of
hysteria all  the  symptoms  of angina pectoris are  observed.
Moreover, hyperesthesia of different parts of the thorax usually
induces more or less impediment to respiration, and it is evident
that in this way also, and without any original implication of the
nerves of the  heart, a  feeling of  oppression may be caused.
Besides,  it so  happens  that a sensation of palpitation of the
heart may subjectively  be present in a very  marked degree,
without  its  being possible to  determine the slightest sign  of it
objectively.   In such cases  it is possibly merely a question of
hyperesthesia of that portion of the chest wall against which the
heart's apex strikes.
   Painful affections of the  abdomen.  Universal and generally
distributed pains over the entire belly appear most frequently
in connection with the general tympanites to  be described later,
and as a natural consequence of it.   Therewith one often finds a
high degree of sensitiveness  to the slightest touch, so that it is
impossible for the  patient to bear the  pressure of garments or
bed-clothes.  Defective  observation might in such cases lead to
the erroneous  diagnosis of a  peritonitis,  to  which the  absurd
name of  hysterical peritonitis has been given.  In other cases
hyperesthesia  exists without coming to the  surface,  and often
indeed is demonstrably situated deeper than the skin.   It is difli- 
SYMPTOMATOLOGY.
501
cult to determine  in  such cases, where  patients are extremely
sensitive  to  any pressure upon the abdominal wall, and espe-
cially to the concussion produced by coughing and sneezing,
whether we have to deal with hyperesthesia of the peritoneum,
as Valentiner believes, or with such an affection of  the abdom-
inal muscles.  In  circumscribed  pains, too,  in the abdominal
region, one is dubious how much  to attribute  to the muscles,
and how much to the viscera situated beneath them.
   Simple cardialgias are of frequent occurrence, which, taken
in connection with the persistent vomiting likewise often pres-
ent, may lead to the erroneous diagnosis of round ulcer of the
stomach.  As the latter is also occasionally met with in the hys-
terical, caution in forming a diagnosis  is  always  imperative.
Some hysterical  patients  continually  have  the feeling  of a
foreign body in  the  stomach,  which  occasionally  changes  its
position,  and causes much anxiety.  The exaggerated feeling
of hunger, which  recurs within  a  short time after  meals, and
frequently causes patients  to take  altogether incredible quanti-
ties of nourishment, appears  to  indicate an abnormally excited
condition  of the sensory nerves of  the stomach.  On the  other
hand, pains in the insertions of the  straight  muscles of the
abdomen and of the diaphragm,  rather than pain in the stomach
itself,  appear  more frequently to  be at the foundation of the
feeling of pressure and tightness  in the epigastrium met with
betimes in most hysterical patients.
   In the hypochondria, likewise,  persistent  pains  and hyper-
aesthesias, which  especially  affect the  muscles,  are frequent
phenomena.   Many of the so-called inflammations  of the liver
and  spleen,  which the hysterical  maintain  they have so fre-
quently suffered from, are  merely to be  referred to  such condi-
tions. Moreover, pains changeable in position and character occur
in the region of the small and  large intestines ; these likewise
are sometimes to be attributed  to the external coverings, but at
others must be regarded as  true enteralgie.  EspecL^j interest-
ing are the pains occurring in the hypogastric regions, which, in
some cases, one can refer to affections of the ovaries.  Even in
the older writings, we find several  such  cases related.  Bj7 the
researches of Schuetzenberger, attention has afresh  been directed 
502
JOLLY.—HYSTERIA.
 to these symptoms, and Charcot1  has,  quite recently, minutely
 described them.  In one case, Schuetzenberger2 observed the out-
 break of hysterical fits at  the close of an attack of inflammation
 of the ovary, and could by pressure upon the painful ovary arti-
 ficially  produce these.  In other cases,  and in  the complete ab-
 sence of swelling  and other inflammatory symptoms, he found
 the ovarian region very tender,  and by pressure upon it,  he like-
 wise produced first pain and a feeling of tightness in the  epigas-
 trium, then the  same  sensations in the  throat,  whereon,  by con-
 tinued pressure, loss  of consciousness  and general convulsions
 followed.   Charcot saw these phenomena supervene in like man-
 ner, and could  further determine  that,  before the advent of un-
 consciousness, there occurred ringing in the ears and darkening
 of  the field of vision  ; and that, too, at first upon the side corre-
 sponding to the painful ovary.   The other phenomena also pres-
 ent in such cases (paralyses,  contractions, anesthesie, and so
 on) are  said to have preponderated on the  corresponding half of
 the body, and if the affection of the ovary changed its position,
 the other  symptoms are likewise said  to have  crossed.  On the
 whole, Charcot found the  left more frequently affected than the
 right  ovary.  In accordance with somewhat numerous researches,
 recently instituted, I must contest the opinion that this phenom-
 enon (which has been designated  ovaralgia or ovaria) is  one of
 frequent occurrence in the hysterical; when it is present it must
 be  placed  in the same category as the hyperesthesie of other
 parts.   Inflammatory conditions  and  demonstrable changes in
 the ovaries generally,  as Schuetzenberger has already shown, are
 only  exceptionally the cause,  and the phenomenon,  that by
 pressure upon the tender spot,  an attack ushered  in by an aura
 can be produced, is also observed in other hyperesthetiu parts
in quite the same way.  Schuetzenberger himself mentions some
cases  in  which,  independently of  the ovary, the attacks could
likewise be produced  by  pressure  upon  the  epigastrium  and
upon  the back.   I have myself  seen it induced  several times by
pressure upon tender vertebre ;  and yet more frequently,  on the
 1. c., p. 283.  A few other writings are referred to in the same place.
»1. a, pp. 748, 768, 829. 
SYMPTOMATOLOGY.
503
occasion of an internal examination of the genitals, at the mo-
ment when the finger is passed through the vaginal orifice.
   The external genitals  are, in the hysterical,  not rarely the
seat of spontaneous pains and hyperesthetic conditions.  Espe-
cially at  the menstrual period do some feel  a  very annoying
irritation  and burning in the  labia and at the vaginal orifice,
usually coupled with  venereal desire.  Sometimes these sensa-
tions, which, as a rule, are the cause of onanism,  continue  inde-
pendently of menstruation.
   Pain and hyperesthesia in the bladder and  urethra occur
most frequently in such hysterical patients as suffer from actual
diseases of the genital organs, and also as a result of the spasms
which  take place in  these parts;  sometimes, however,  they
appear as purely nervous phenomena, without any demonstrable
cause.
   Hysteralgia, as a purely nervous functional  disorder, appears
to be of extremely rare occurrence, while,  on  the other hand,
pain and sensitiveness of the uterus, in connection with textural
changes, are frequently met with in the hysterical.  In particu-
lar instances one observes, what used to be  considered the rule
in hysteria, a direct dependence of the  attacks upon uterine con-
ditions ; thus, attacks are occasionally perpetuated  by changes
in its posture, which disappear on improving the latter by means
of pessaries, to reappear when these are removed ;  or severe pain
and general convulsive attacks arise when  diseased  portions of
the uterine mucous membrane are touched by  the  sound or
therapeutic agents.
   So-called coccygodynia—pain in the region of the coccyx,
with great sensitiveness of that bone to the touch or to the con-
traction of the muscles in its neighborhood, seems only excep-
tionally to occur as a purely hysterical  symptom, and must then
be regarded as analogous to the hysterical vertebral pain.
   Painful affections of the back are met with in most hysteri-
cal patients.  The hyperesthesia of the skin is  sometimes quite
confined to small portions over or between the scapule.  The
most frequent symptom, however, is pain, spontaneous and pro-
duced by pressure, in the vertebre and their surroundings.
The sensitiveness is sometimes limited to the spinous processes, 
504
JOLLY.—HYSTERIA.
and at others is more laterally distributed in the muscles of the
vertebral column.   If the skin itself  does not participate in the
hyperesthesia, the patients  frequently  first remark  the symp-
tom when it is specially sought for.   In other cases it appears as
a result of considerable  exertion—after prolonged walking or
standing :  finally, in  yet  other cases spontaneous back-ache is
complained of.  In these cases it is apparently a question partly
•of hyperesthesia  of  the  vertebral periosteum,  partly of exag-
gerated muscular sensibility, and partly of true neuralgie.   The
latter are  especially  related  to  intercostal neuralgie, and the
painful points to the side  of  the vertebral column are  often none
other than the points painful on pressure peculiar to such.   One
usually sees the symptom of pain  in the back make its appear-
ance alternately at different portions of the  vertebral column  ;
sometimes it is simultaneously present in vertebre widely apart,
and again it is fixed for a  lengthened period in  particular  verte-
bre.  In the latter case, to the great  injury of the patient,  it has
frequently been considered symptomatic of an affection of the
vertebre,  or even of disease of the spinal cord.   Especially,
however, has it been,  and  still frequently is, looked upon as the
sign pathognomonic of  an irritative condition of the  spinal cord
—the so-called  spinal irritation.    There exists, however, no
clear  reason wiry in this respect  back-ache  should have any
greater significance than  neuralgie,  myodynie, and hyperes-
thesie  arising in other  portions of  the body, which may all
equally be considered phenomena proceeding  excentrically from
the spinal  cord.  The pain in the back also as little  proves the
old idea of the existence of a condition of  hyperemia of the
spinal cord, as it  does  the more recent one of an anemic con-
dition of the same.
   Hyperesthesia of the skin and  muscular pains,  as already
mentioned, are very frequently met with in the extremities.  An
excited condition of the sensory nerves of the muscles is, at any
rate, at the bottom of a feeling which has  been described as
"uneasiness in the limbs."   This is the same sensation as  many
otherwise healthy women experience at the menstrual period,
and which is wont to appear  in most people after great muscular
exertion, and  particularly after riding.  It is possible, as Valen- 
SYMPTOMATOLOGY.
505
tiner believes, that partial muscular contractions accompany this,
but the peculiar sensation may also exist without these.
   Finally, of especial interest are the pains and hyperesthesia
occurring in articular  regions, which  are  sometimes mistaken
for severe joint  diseases.  This affection, first described by Brodie,
has had  the peculiar fate of having been considered by some
authors of frequent and by others of rare occurrence.  Its exist-
ence has been  altogether denied  by some, while  others have
expressed the opinion that it may perhaps be a disease only met
with in England.   According to Brodie's description, the hip and
knee-joints are  most frequently affected, but it occurs  in others,
and especially in the wrist and finger-joints.  Pressure upon the
articular  region produces severe pain ; but this  has its seat rather
in the soft  parts surrounding the  joints, than in  the articular
surfaces,  whose forcible apposition does not, as in true joint-dis-
ease, produce a violent shock.  After a prolonged  existence of
the affection, which may continue for years, a  slight swelling of
the articular region may take place, which,  however, is likewise
distinctly situated in the surrounding  soft parts.   It does  not
produce actual deformity and muscular atrophy ; but from the
uninterrupted  stretching  of the  muscle in the neighborhood an
alteration in the shape of the joint may easily be simulated.  The
entire phenomena are sometimes liable to a rapid change,  xlfter
continuing  for  years,  they may suddenly disappear, in con-
sequence of some moral influence or other.  The fact that there
are pure  articular  neuroses, and  that not only  in the hysterical,
will scarcely be doubted at the present day.  On the other hand,
these are not with us, and  as it appears also in France, among the
frequent phenomena of hysteria.  It may be questioned whether
they can easily  be mistaken for chronic articular  inflammations ;
yet this mistake must have been very frequently made in Brodie's
time, as he  does not scruple to  state, that "of women of  the
higher classes of society in whom joint-diseases  are most com-
monly diagnosed, at least four-fifths suffer from hysteria  and
nothing else."
   The same thing has occurred here as in the perfectly anal-
ogous case of affections  of the vertebre ; pain  and sensitiveness
have been regarded as quite sufficient evidences  of inflammation; 
506                   JOLLY.—HYSTERIA.

then the entire antiphlogistic armamentarium has, as a rule, been
forthwith dragged to the rescue, and the patients condemned to
abstention from movement, and  thereby the disease has  been
aggravated so as to become persistent.   Moreover, as Valentiner
very properly points  out,  another error in diagnosis  may be
equally easily made, as that may be considered hysterical arti-
cular hyperesthesia which is merely rheumatism in an hysteri-
cal patient.

                         Anesthesia.

    Diminution or loss of sensibility, temporary or persistent, may
arise in the hysterical in the region of all the senses. Anesthesia
of the sense of touch is the most frequent; but Gendrin, who first
more precisely described this affection, goes much too far when
he maintains, that in  every case of hysteria, from beginning to
end of the disease, general or partial loss of sensibility is present.
As little  can I confirm the assertions of Henrot and Szokalsky,
that after hysterical  attacks, without exception,  anesthesia in
one part  of  the skin  or another  may be  demonstrated ; when
such is the case, the examination may have been limited to that
period of the attack in which semi-consciousness and apathy
prevail.
    It  is,  however, true that anesthesia of the skin and of the
deeper parts appears most frequently  after hysterical attacks,
and that, as a rule, if it has diminished in the interval between
attacks, it is again aggravated by  a fresh fit.   Szokalsky states
that it occurs in a more pronounced form and more universally,
after  more  severe than after milder  attacks.   Extensive and
persistent anesthesia  may,  however,  disappear after  a  fresh
attack ; further, in place of the part at  first affected, others may
be attacked, or the part formerly anesthetic may become hyper-
 esthetic.
    In the majority of cases in which anesthesia occurs, sensibility
 to pain alone is diminished or removed, while the sensation of
 pressure  and heat  is  normal;  cases  in  which all sensation is
 absent are  of  less frequent  occurrence.   In  these, moreover,
 manifold differences occur, as sometimes the appreciation by the 
SYMPTOMATOLOGY.
507
skin of distance (Raumsinn) and of pressure (Drucksinn) suffers
loss, but variations of  temperature are correctly  felt, while in
other cases the perception of this, too, is completely lost.
   Anesthesia extending over the whole surface of the body is
most rarely observed ;  that limited to one half  of the body,
hemianesthesia,  occurs rather  more frequently,  the left  side,
according to the  statements of  Briquet and  of Charcot, being
attacked by preference.  Anesthesia is most frequently met with
in some  of the  limbs or in a portion of them.   Especially often
is it situated on the dorsal surface of the hands and feet, as well
as in  the region of  the outer ankles; sometimes  it appears
isolated  at different parts of the skin. With the more widespread
form of anesthesia of the skin, a similar condition of the mucous
membranes is usually coupled, in which the normal reflex actions
can then no  longer be excited.  In cases of unilateral anesthesia,
one finds the mucous membrane  only of the affected half of the
body insensible.   Sometimes the vessels of anesthetic portions
of the  skin are  persistently  contracted.   Such  parts usually
appear pale  and  cold, and it is difficult to  succeed in  causing a
flow of blood by pricking with needles.
   It has  been assumed aright, that in many known cases in
wliicli  hysterical  persons  have  intentionally  mutilated  their
bodies in the  most revolting manner,  pushed  a  number  of
needles under  the skin, swallowed  pointed bodies,  or inflicted
deep burns,  analgesic states have been  present, in  consequence
of which those mutilations have been painless.1 But it is  also
  1 In one such case which was recently under my care this could be directly proved.
An hysterical woman, who had formerly suffered much from general convulsions, and
had for years complained of pains of all kinds in consequence of hysteria, fell without
known cause into a state of violent excitement, in which for the first time during the
course of her disease many extremely painful  haUucinations of hearing and sight
appeared for a few days.  In this condition she managed one day, in the absence of her
nurse, to open the door of the oven, and to  extract with both hands glowing embers,
which she pushed firmly into her sexual parts.   A deep burn on the inner surface of
the hands, as well as on both labia, and the inner surface of the thigh, was the result.
The patient, whose hallucinations ceased from  that moment,  afterwards maintained
that she had wished in this peculiar manner to take her life ; and that she had no pain
while being burned either in the hands or genitals, although she had distinctly felt the
heat of the  embers.  During the slowly progressing cicatrization, too, no pain occurred
in these parts, usuaUy so sensitive. 
508                   JOLLY.—HYSTERIA,

possible that the peculiar mental condition of hysterical patients
may be the cause of  their ignoring pain actually felt, and ap-
pearing not to feel it.   The desire  to create  a sensation and to
render themselves interesting from  their condition may induce
such  a morbid increase  of  the power of will that  the  most
excruciating  agonies may be borne with a  stoical  indifference.
Such patients are as a rule very willing to serve as subjects for
physiological investigations, and under such circumstances allow
themselves to be tortured with  the  most powerful skin-irritants
and  the  strongest  electric currents, if they  only  believe that
thereby they  become  interesting or acceptable to the investi-
gator. To the  question, "Do  you  begin to  feel pain?"  they
answer, " Not in the least ; I can easily bear it."
   With the loss of cutaneous sensibility, a similar loss of sen-
sibility in the  muscles,x  as  well as in the  bones  and joints,
may be united.  In this  case patients  lose the power of appre-
ciating with  closed eyes passive movements  imparted to  their
limbs. Thereby the power of spontaneous muscular contraction
may remain  normal or  be altered  in  varying degree.  Some-
times this kind of anesthesia is coupled with paralysis, at other
times with catalepsy.   In  the case of an hysterical patient here
wdio   suffers  from cataleptic  fits, together with the flexibilitas
cerea, which  is as a rule limited to  one arm,  there is complete
loss  of sensation in this  arm,  so that the patient neither  feels
the most  painful impressions, nor is she with closed eyes aware
of what is done with her  arms.   With the subsidence of the cata-
leptic state the anesthesia is also wont in this case to disappear.
In anesthesia of the ocular  muscles Szokalsky saw the regula-
tive (mimischen) movements of the eyes suffer in a high degree.
   Anesthesia of the  mucous membranes, usually appearing in
connection with the  general cutaneous  anesthesia,  sometimes
also  occurs alone, and is  then generally coupled with diminution
or loss of reflex excitability.   Thus foreign bodies may come
in contact with the anesthetic  conjunctiva without  producing
reflex spasm, lachrymation or reddening.  In anesthesia of the
nasal mucous membrane, it  is  not  possible, by tickling with a
See Vol. XL of this Cyclopaedia, p. 233. 
SYM PTOMATOLOGY.
509
feather  or  brush, or  by  means  of  powerfully irritating sub-
stances, to give rise  to sneezing, and  the pharyngeal mucous
membrane may be equally titillated without  the  occurrence of
vomiting.   In  such cases  the senses of smell  and of taste may
likewise be abolished,  or remain unaffected.  Further, besides an
hyperesthesia of the respiratory tract, an anesthesia of the same
has been described, as a  result of which  irritating  vapors  (of
ammonia,  sulphur, etc.)  may  be introduced into  the  larnyx
without causing cough.   It is scarcely possible to state whether
anesthesia of the bowels occurs, as these parts are normally en-
dowed with a low degree of sensibility.   On the other hand, one
frequently finds them hyperesthetic in cases of extensive anes-
thesia  of the skin and muscles.  The abdominal wall may then
be insensible,  while deeper pressure in  particular regions calls
forth severe pain.
   The  collection  of  large quantities  of feces in the rectum,
which sometimes occurs in the hysterical, seems in some cases to
be induced by anesthesia  of the mucous membrane in question.
   The mucous membrane of the genital organs and  of the
urinary passages is likewise found to be insensible in some hys-
terical patients.   In the latter  case,  the filling of the bladder is
not observed, and this may go on to great distention of the same,
and secondarily to dribbling ; in  such a case the passage of the
catheter through the urethra is not  felt.  Complete anesthesia
of the vaginal mucous membrane, with consequent absence of all
sexual desire in copulation, Scanzoni  could only determine in
four of his numerous patients, in whom,  besides, feeling was
occasionally blunted  only on the dorsal aspects  of the hands
and feet.  This phenomenon, according to Amann, occurs much
more frequently.
   I have  already adverted to  a case  of diminished sensibility
to pain in the external genitals.   On the other hand,  as a case
of Scanzoni's proves, a universally distributed  anesthesia of the
skin may occur without anesthesia of the genitals.
  Finally,  anesthesia  may arise  in  the other sensory regions
with and without concomitant cutaneous anesthesia.   With the
one-sided occurrence of the latter there sometimes  exists loss
of taste in the corresponding half of the tongue, and of smell in 
510
JOLLY.—HYSTERIA.
the corresponding  nostril, as well as unilateral  amblyopia and
deafness.
   Of visual disturbances amblyopia, as well as complete amau-
rosis, is observed.   Both as a rule appear after severe hyster-
ical attacks, but may also develop themselves in the absence of
these.  According to the statements of Charcot and Galezowsky,
the condition occurs unilaterally, pretty often,  and indeed gen-
erally  in  conjunction with  hemianesthesia  of  the  same  side,
although  the patients themselves as a rule are not aware of this.
Galezowsky found a state of " dyschromatopsia,"  loss of the
power of  distinguishing color, to be the lowest degree of ambly-
opia ;  then  he noticed  a partial limitation of the field of vision,
partly in its  peripheral portions,  and partly so  that one-half
was  dark (and, in the left eye, the outer half of  the correspond-
ing retina), so that in the one eye there existed a condition of
hemiopia, while in the  other the sight was normal.   Amblyopia
and  amaurosis in both eyes are rare events.   I myself  have
found the former  distinctly pronounced only   in  one eye, in
which it repeatedly arose after severe hysterical attacks, on each
occasion again to disappear after a few days.   In ninety-three
cases of anesthesia in  different  sensory regions, Briquet found
amblyopia six times.
   Ophthalmoscopic examination generally discloses no changes,
and  this was so in the  cases observed by me.   In a  patient in
Charcot's ward,  in whom  amblyopia  had existed  for a  long
time without ophthalmoscopic  changes,  Galezowsky, however,
saw  an infiltration and capillary reddening  of the  disk,  with
fusiform  dilatation  of  the arteries, finally make its appearance,
and in another, as Svynos relates, the rapid invasion of atrophy
of the  optic nerve could be determined.  It is questionable indeed
whether, in the latter case, one could still speak  of hysteria.1
   Hysterical deafness is  likewise occasionally  observed in
severe cases of hysteria, and that too in one ear  as well  as in
  1 Consult in particular upon this condition, besides works in general on hysteria, m
which hysterical blindness is fully considered, Charcot, Leeons, etc. ;  Mesnet, These sur
les paralysies hysteriques 1852 ; and Svynos, These sur les amblyopies et les amauroses
hysteriques 1873. 
SYMPTOMATOLOGY.
511
both, and in the absence of any demonstrable disease.  It also
generally  continues after  severe  attacks,  and  combines with
other  anesthesie.  T^ike hysterical blindness, it may suddenly
disappear, and be supplanted by other hysterical symptoms.


                    Motor Disturbances.

                        1. Convulsions.

   The  convulsions occurring in hysteria are to be regarded
partly as reflex,  and in part as arising without the recognizable
co-operation of a centripetal stimulus.
   To the former one may  also in a  wider  sense  allot  those
caused by mental excitation, which  in their typical gradation
(Abstufung) and spread show a mere  exaggeration of the invol-
untary7 movements called forth by the emotions in health.   We
shall begin with  a description of the forms of  spasm met with in
particular sections of the muscular  system, in order thus  to
learn  their  manifold  combinations in  the so-called fits.  An
abrupt distinction of  reflex spasms, from those due to a direct
excitation of  motor parts,  can neither be carried  out in this
exposition, nor is it always possible in practice.
   Spasms in the Digestive Canal.—The most frequent form  is
that which  occasions  the so-called  globus  hystericus.   This
symptom is only absent in a few of the hysterical, but in indi-
vidual cases is very variable in its character and in the frequency
of its recurrence.   Patients  usually have the sensation as if a
foreign body,  generally of  the  shape of a ball, passed upward
from the  stomach  or some part  of the  digestive tube,  and
remained impacted in  the  region  of  the throat.  The ball fre-
quently arises in this part, without  changing its position fur-
ther.   After continuing for a  longer or shorter  period, the
feeling gradually becomes less  marked, or suddenly  vanishes.
The ball seems to flatten.  Sometimes, instead of this sensation,
only that of a tightening in the throat exists, similar to  that
which so easily develops itself  in the healthy from  emotions  of
anxiety or fear.  Some patients do not feel the movement of a
ball, but of  some  other differently  shaped  body, such as a 
512                  JOLLY.—HYSTERIA.

kernel, a bean, and so on, or of an animal creeping about in the
throat—of  a worm, as  one of my  patients  constantly  affirms.
Not rarely  the sensation of something present is so distinct that
patients think  they can pull it out of the throat with their
fingers.  The entire phenomenon is apparently caused by peri-
staltic contractions  of  the  oesophagus passing  upward (less
frequently  the  movement is observed to be reversed—the ball
descends), and partly by a circular tightening of the pharyngeal
muscles.1   It sometimes arises spontaneously,  especially as the
forerunner  of a general convulsive attack; it is,  further, the most
usual accompaniment of psychical  excitement in the hysterical,
and finally, often  develops  itself in an evidently reflex manner.
The latter regularly occurs in some patients while eating ; occa-
sionally particular kinds of food produce the bolus, and now
solid, and at other times fluid food is most easily borne.  In some
cases the  symptom is  so strongly pronounced that it  appears
with every attempt to swallow, and compels the sufferer to take
almost no  nourishment, so that  one has to employ the oesopha-
geal tube to feed the  patient.   In others the globus is induced
by the mere exertion of speaking or singing.  An hysterical lady
whom I know has had to abandon her singing exercises entirely,
as, with every attempt she makes, the ball in her throat is felt to
rise, and does not  as a rule subside for some hours.   In such
cases it is sometimes sufficient merely  to think  of  the causal
irritation to call forth the spasm.
    With the spasmodic symptoms in the pharynx a similar con-
dition of  the  tongue  is occasionally  combined.   With each
attempt at movement, the latter is violently and irregularly con-
tracted, being drawn sometimes to the  side, at others upward,
and again pushed backward,  so that  articulation as  well as
swallowing may be materially impeded.
    The globus  occurs  not  only in  the  throat, but also in the
abdomen,  as the sensation of a body rising from the region of
the symphysis  toward the stomach.   Some patients aver that
they distinctly feel the womb pass upward to the stomach, and
  1 At all events I cannot convince myself of the correctness of Eulenburg's view,
we have not here to do with motor, but merely with sensory phenomena. 
SYMPTOMATOLOGY.
513
then arrive at the throat, a declaration which has constituted the
basis of the oldest theory of hysteria.   Probably this  has, as a
rule, been due to abnormal sensations in the genitals, causing
reflex contractions in  the stomach, oesophagus, and pharynx.
Sometimes, also, powerful peristaltic movements occur in partic-
ular parts of the bowels, which are felt through the abdominal
wall, and  still further convince the patient  of the presence of a
movable bod}7.  Spasmodic  strictures in different portions of the
small and large intestine may, moreover, arise alone and  cause
local or general swellings.   When such local swellings continue
for a length of time the  appearance of  a tumor of  the bowel, or
other abdominal  organ, may be given rise to, especially if fecal
masses accumulate at the constricted point, and these do not reveal
their true nature  by a tympanitic note.  Spasmodic phenomena
occur in the stomach as one  of the symptoms of  cardialgia.
They are  seen most evidently  in so-called  hysterical vomiting.
Patients who suffer thus, usually vomit after each meal, the food
reappearing very soon, almost quite undigested.  Less frequently,
too, mucous and bilious matters are vomited while  fasting.  The
appetite often suffers only slightly in consequence ; the patients
try ever  anew  to  take  fresh nourishment,  notwithstanding  the
hopelessness  of the attempt,  and have  generally an  especial
desire for fluids.   In other  cases, again, the appetite fails com-
pletely, and then, as  the symptom  usually persists for many
months,  well-marked conditions of debility arise.  But,  when
the patient apparently stands on the brink of the grave, a sudden
change almost always takes place ; the symptom which has bid
defiance to every  remedy disappears of its own accord, and  the
patient rapidly recovers.   Concerning the hysterical vomiting of
blood, which is, as a rule, unconnected with this habitual and
continuous vomiting, see further on, as also concerning the vomit-
ing which  accompanies  an  hysterical retention of urine.   The
form here described has evidently the greatest  similarity7 to the
vomiting, frequently so obstinate, which appears during  the early
months of pregnancy;  like that,  it arises  in  a pre-eminently
reflex manner, soon after the introduction of substances into the
stomach.  The obstinate eructation also, which is often met with
m hysterical persons, especially after the attacks, is mainly a
          VOL. XIV.—33 
514
JOLLY.—HYSTERIA.
reflex act, and is caused by a  great development of gas in the
stomach, but also occurs without palpable or visible distention
of the gastric region.
   Spasmodic movements in the  organs of respiration.1—-There
sometimes occurs in  the hysterical a temporary acceleration and
exaggeration of breathing,  without giving rise  to  a feeling  of
embarrassed respiration.  Further, temporary spasmodic pauses
in inspiration and expiration take place, especially in conditions
of psychical excitement.   Moreover,  one sees  true  asthmatic
attacks  arise,  with an acute sense of oppression and anxiety,
and with distinct  interference with expiration.  Occasionally it
is observed that these symptoms, due apparently to spasmodic
contraction of the bronchial muscles, may be induced in a reflex
manner by a diseased uterus, either in consequence  of force em-
ployed in examination,  or by irritation of the inflamed  mucous
membrane (asthma uterinum).
   Singultus occasionally sets  in as a  very annoying symptom
after hysterical attacks.  In some cases this has been  seen to
continue with  great severity for days.   Much  and irresistible
yawning is likewise  observed in  attacks of greater  or less dura-
tion.  Convulsive  laughter and weeping may usher in or follow
the general attacks, but may also arise alone as independent fits.
It may frequently be shown that some corresponding psychical
impression  originally formed the basis of  these  conditions.
Not  only is this, however, on the whole quite unimportant, but
these paroxysms,  extremely painful in their  more  pronounced
manifestations, often enough arise without any psychical cause.
   The  vocal  muscular apparatus may also  be thrown into a
state of spasmodic excitement.   Loud screams frequently occur
at the beginning of, and during the attack, and some patients
thus imitate the cries of animals by miawing, barking, howling,
and  so  forth.   Such screaming  fits are observed with  especial
frequency during the epidemic spread of hysteria.   Moreover, in
the intervals of the attack, sometimes while speaking, an inartic-
ulate sound or involuntary exclamation annoys the  patient. Of
  1 Consult the exhaustive description  of these phenomena in Volume XL  Erh
Peripheral neuroses. 
SYMPTOMATOLOGY.
515
the frequently  occurring spasms of the laryngeal muscles, the
spasmodic closure of the glottis is of  especial importance, as it
often produces alarming suffocative symptoms, and in rare cases
has even caused death.   This form of spasm is also coupled with
attacks elsewhere, especially with the tetanic form of the same ;
it  can, however, also occur alone, and accompanied  merely by7
the corresponding dyspnceic movements.
   Spasms in the urinary and generative organs.—Spasmodic
retention of urine occurs  in many  hysterical patients,  partic-
ularly in connection with painful  affections of the genitals, but
also without demonstrable change in  these.   Increased inclina-
tion to micturate is often  combined with  this.  On introducing
the catheter into  the bladder, a considerable  obstacle has to be
overcome  in  such cases.   The great  irritability of  the  vesical
muscle is  shown  in some hysterical cases by the veiy frequent
inclination to micturate without the existence  of increased secre-
tion,  or impediment to evacuation.   Spasm  of the  constrictor
cunni, which possibly  always  arises in a reflex manner, and is
the cause of so-called  vaginismus, has already been mentioned
in speaking of hyperesthesia of the vaginal orifice.
   Besides those already described, local spasms may take place
in all possible sections of the muscular  system of  the  head,
trunk, and extremities, as  a symptom  of hysteria.  These occur
;is clonic or tonic spasms, sometimes in  fits, at other times persist-
ently  in the territory of one or several peripheral motor nerves.
Their more minute description may here be dispensed with by
referring to the chapter on  this  subject in volume XI.   But there
yet remains to be mentioned the generally distributed muscu-
lar uneasiness of frequent occurrence  in  the  hj-sterical.   Here
we have to  do partly  with the spontaneous contractions, now
liere,  now there, either affecting an entire muscle or some of its
groups of fibres, and  partly with combined  movements, which
appear either as direct  or reflex, and which may also occur more
universally in consequence of the  slightest mental disturbance.
The facial muscles especially are incessantly active in many of
these patients, so that  the physiognomy has a somewhat restless
and unsettled character, which has been considered by some
authors to be an infallible sign of hysteria.   From  the further 
516                   JOLLY.—HYSTERIA.

progress  of  this  general  muscular uneasiness, there  proceed
either attacks of general clonic convulsions or the  symptoms of
chorea minor, which is not  rarely observed as a particular inci-
dent in severe attacks of hysteria.  The description  of general
convulsive attacks is given  further on.   A peculiar form of
spasm  likewise, permanent contraction,  can only be removed
after paralysis.

                          2. Paralyses.

   Paralytic conditions of the muscular system  of the bowels
and stomach are, if  not the  cause, at any rate the usual con-
sequence  of  the local and  general tympanites  which is so fre-
quently met with in the hysterical.  The latter phenomenon arises
more frequently at the  close  of hysterical  convulsive  attacks,
but also  occurs independently of  these.   It frequently  forms
within a very short time, and by  no means  always during the
period of digestion.   It comes on very rapidty, especially after
mental agitation, and at other times without a known cause.  In
some  patients I have seen it appear for a  lengthened period
regularly every morning, and reach its  climax about mid-day.
Sometimes it attains such a degree,  that the patients can be kept
afloat in a bath  by means of the balloon-like distention of their
bellies.   The  appearance generally vanishes after  having  lasted
for a short time, as  by the powerful action of the  abdominal
walls,  or the contraction  of  the  resuscitated muscles of the
stomach and bowels, a forcible evacuation of gas takes place
from above  downward.  Occasionally,  however, it persists for
days. The patients are unable to effect a spontaneous evacuation.
In such cases one can often cause the whole stomach to collapse
within a  short  time, by forcible pressure upon the  abdominal
walls, or  by powerful faradization of the same, when,  with an
audible sound, gases rush from mouth and anus.   In other cases
the introduction of  the intestinal tube is necessary to give vent
to the flatus.1
   1 In the great hysterical epidemics of former centuries, tympanites was commoniy
observed at  the close of paroxysms.  The patients were relieved  by bandaging the
abdomen tightly, by striking it with the fists, or treading upon it with the feet, and
thus the accumulated gases were evacuated. 
SYMPTOMATOLOGY.
517
   The gases are, as a rule, almost quite odorless, whence it may
arise that in cases in which they inaudibly escape from the anus,
a disappearance of the tympanites without the escape of flatus
is apparently observed.  This is at all events much more proba-
ble than that a rapid absorption  of a large quantity of gas by
the intestinal wall should take place.  Nothing certain is known
concerning  the source of this so frequently sudden development
of gas or  of its composition.  The distention is undoubtedly
sometimes caused by swallowing  air,  at which some are known
to be very expert.  The excessive distention may give rise second-
arily to a paralysis  of  the walls of  the stomach and bowels,
which  renders a  spontaneous  expulsion of flatus impossible.
But  in other cases  it can only arise from the contents of the
intestine.  Whether it can also be generated by the blood circu-
lating in the walls of the intestine is doubtful.
   Paralytic or paretic  states  of  the  muscular  system of the
bowel are  also often the apparent cause of the extremely obsti-
nate constipation met with in the hysterical.
   Paralysis of the muscles of the esophagus and pharynx also
occurs as a symptom of hysteria.  Swallowing is  thereby ren-
dered difficult, or altogether impossible, while the oesophageal
tube introduced glides  without obstruction into the  stomach.
This condition, wliicli torments  the patient exceedingly, and  by
interfering with nutrition induces a high degree of exhaustion, it
is frequently possible to  cure almost at once, by  using the tube,
or by  employing electricity or other stimuli.  In other cases
feeding must be undertaken with the tube for some time, and
improvement takes  place with the removal of  the general de-
bility.
   Paralysis of the vocal cords is the most frequent of hysterical
paralyses met  with in the respiratory organs.   This generally
appears suddenly, sometimes  after  an  attack,  but  more  fre-
quently without such, and is  then chiefly induced  by some
psychical excitement.  The  patients either completely lose the
power of speaking aloud or the voice seems husky, disappearing
with any considerable effort.   Sometimes,  while engaged in lively7
conversation, a sudden loss of voice ensues.  With this  hysteri-
<&l apJiuuia, difficulty in  moving the  tongue may be  united, so 
518                   JOLLY.—HYSTERIA.

that patients  can no longer even  whisper, but  can only make
themselves understood by signs.
   Examination with the laryngeal  mirror shows vocal cords
quite normally colored, in simple hysterical aphonia, and in the
vast majority of cases exhibits paralysis of the constrictor glotti-
dis, sometimes on one side,  at other times double.   The musculi
thyreo-arytenoidei intend are often paralyzed ; this is, however,
more rarely the case with  the dilatator glottidis.  Hysterical
aphonia may disappear as rapidly  as it supervened.  Sometimes
psychical excitement is the remedy, at others the most varied
methods of  local  treatment -.—external manipulation  of  the
larynx, the introduction of the mirror, systematic lessons in
intoning, electricity applied externally or directly to the affected
muscles.  There always, however,  remains  a tendency to after-
effects, which is proved by the fact that after repeated recurrence,
the paralysis  does not disappear  so  readily as it did  at first;
some cases bid defiance to all treatment for  years,  until they are
finally cured by some accident.
   Paralyses  of particular  muscles of respiration occur, like
other circumscribed  hysterical  paralyses,  but  they are rare.
Temporary paralysis  of the diaphragm, which one sometimes
sees after  epileptic, may  possibly occur  after hysterical fits,
but  I am  ignorant of any such  observations.    Paralysis  of
the bladder is met with in the hysterical,  both secondarily, in
consequence of spastic retention of urine, and  also as a primary
symptom.
   Paralysis  in the extremities.—This  sometimes appears in a
hemiplegic and at others in a paraplegic form ;  now  only  one
extremity is affected, and again there is crossed paralysis of an
upper and the  opposite lower extremity ; in some cases total
paralysis of all four extremities has been observed.  Of the facial
muscles, those acting upjon the eyeball only very  rarely partici-
pate  in the  paralysis.  On the other  hand,  paralysis  of  one
levator palpebre superioris, or  of both these muscles, is met with
pretty often.  Moreover, paralysis in the territory of the facial
nerve and  of  the hypoglossal is extremely rare.   In otherwise
perfectly complete hysterical  hemiplegia,  drawing of the face
towards the healthy side, so constant in apoplectic hemiplegia, 
SYMPTOMATOLOGY.
519
and the pushing of the protruded tongue to the paralyzed side,
can almost never be determined.
   Besides paralyrsis affecting  entire limbs, such a condition is
met with in the extremities in the territory of particular motor
nerve trunks ; these are, however, rarer than the  more  general
paralyses.  The degree of paralysis may be very different, begin-
ning with mere weakness and heaviness of the limb,  to absolute
loss of  motion.  The  commencement is often  sudden,  as  the
paralysis is left fully developed after an hysterical attack ; in
other  cases it  comes  on  gradually without a preceding fit:
patients  complain  of  a feeling of weakness in  one or  other
extremity; this shortly increases in intensity and extent, until
finally a greater or less degree of  paralysis is established.  The
behavior of  the  p>aralyzed muscles to the electric  current is
normal; the  excitability both  for the induced and for the con-
stant  current remains  unaltered,  even  after a persistence of
the paralysis for years ;  it is  only on account of the atrophy
induced  by long disuse,  which, however,  never attains  a high
degree, that the response to electricity may at a later period be
less energetic.
   In the great majority of cases a certain  degree  of anesthesia
develops itself  in the paralyzed parts ; but not by any means so
that the amount of each  condition stands in any definite rela-
tion.   Total anesthesia  may  occur without  paralysis, and,
though rarely,  the converse may also be the case.  If anesthesia
is present,  the muscular parts also, as a rule, participate, and in
consequence  of this, sensation  on electric contraction  of  the
muscle  is  absent.  Duchenne  has  proposed this condition  of
diminished " electro-muscular  sensibility"  as an infallible sign
of hysterical paralysis, by  means of which one may  distin-
guish this especially from apoplectic palsy.  Against  this it
must be remarked that  anesthesia, at least to any considerable
amount, may be absent in hysterical  paralysis,  and that where
cutaneous  sensibility exists, it is simply impossible  to estimate
exactly  the degree of electro-muscular sensibility, and moreover,
that in  apoplectic  paralyses anesthesia is also sometimes met
with, and that, too, with complete loss of muscular sensibility.
   If this  diagnostic sign is therefore only applicable  to some 
520
JOLLY.—HYSTERIA.
cases, it is, as a rule, possible  to  recognize the character of the
paralysis from  other symptoms  present.  Hysterical paralysis
does not appear unless other and distinct signs of hysteria are
coexistent, such as spasmodic attacks, with and without refer-
ence to the paralysis present,  hyperesthesia in the most varied
parts, and particularly the characteristic psychical symptoms.
A paralysis, then, which appears  in an extremely hysterical sub-
ject, must always suggest the possibility of its being a symptom
of hysteria.
   In doubtful  instances  the progress of  the case  furnishes
information: hysterical  paralysis  is  sometimes of very short
duration, continuing for a few hours, days, or weeks,  after an
attack,  and  then  completely disappearing,  perhaps  to return
after  subsequent fits.   If these conditions have  already fre-
quently shown themselves, one will rarely be in doubt as to the
diagnosis.  In other cases the mode of extension of  the paralysis
is characteristic ; it appears crossed from the commencement, or
it is at first pronounced on one half of the body, quickly disap-
pears from hence, and  suddenly shows itself on the other side,
and possibly also makes several such changes of position.  But
there are other cases in which the paralysis continues for years
unchanged in extent, and in these cases the diagnosis cannot with
absolute certainty be made for a long time.  It may especially be
confounded with hemiplegia from disseminated (Herderkrankun-
gen) brain disease,  and with paraplegia, the result of disease of
the spinal cord.   The latter  error often arises, particularly in
those cases in which in paralyzed hysterical  patients  decided
hyperesthesia, due to disordered sensibility, is at the same time
present in the vertebral region.  The  skin of  the back  of such
patients, covered with  cicatrices,  is frequently an eloquent wit-
ness of the diagnosis  formed, and which was followed by an
active derivative  treatment.   It  must nevertheless be acknowl-
edged that the heroic remedies of burnings and caustics now and
then cause an hysterical paralysis to disappear just as suddenly
as any other remedy which is  employed against the disease, or
as some accidental, purely psychical influence.   Finally, the
most important criterion for  making a diagnosis is the sudden
disappearance,  through the agency  of  a moral influence, of  a 
SYMPTOMATOLOGY.                     521
paralysis which had  continued for years, and bade defiance  to
all  treatment.  The  diagnosis may, however, be attended with
peculiar difficulty in those  cases in which it has  to  be distin-
guished from  multiple sclerosis of  the brain  and  spinal cord—
a disease in which likewise a frequent change of locality of the
paralysis, a coming and going of it, is often observed, and whose
attacks of an apoplectic character may be deceptively  simulated
by  hysteria.   The diagnosis  of severe forms of  hysteria  from
this disease is often first made after long-continued observation.
   A condition  of permanent contraction  not  rarely develops
itself in  the  palsied extremities.   In some  cases  this  appears
simultaneously with  the  paralysis.   After  a  convulsive attack,
one extremity or half of the body, or both upper or lower extrem-
ities remain in  a state of tonic  contraction, wliicli cannot at  all
be  overcome  by the  will  of the patient, and  passively  only by
great force.
   In other cases paralysis  continues for a  length  of  time, and
then gradually or suddenly contraction supervenes after a  fresh
attack.   In the upper extremities spasmodic flexion of the  fore-
arm, hand, and fingers is  almost always present.   In  the lower
extremities, on the other hand, according to Charcot, who has of
late redirected attention to  this affection, spasmodic extension at
the hip, knee, and ankle-joints is the  rule, with which contrac-
tion of  the femoral  adductors may also be associated.    To this
rule there are, however, exceptions,  as the  following case, noted
by me in Wurzburg,  proves :

  In a cook, twenty-eight years of age, who had, some time  before her reception
into the Julius Hospital, suffered at her own home from a tedious abdominal affec-
tion (probably purulent oophoritis, with bursting of an abscess into the rectum),
together with peculiar psychical symptoms, there developed itself powerful persist-
ent tremor of the left leg, which  hindered the patient  in walking. A few  weeks
later general convulsive attacks made their appearance, in which the right leg was
thrown into a state of tonic extension, and the left into tonic flexion, while violent
clonic convulsions followed in the facial and lingual muscles. These very frequently
repeated attacks,  coupled with complete loss of consciousness, usually lasted for
one or two minutes; they terminated in a soporose condition, which quickly  passed
off.  After the attacks, the rigid  extension of the right leg comrdetely disappeared
on each occasion; the flexion  of the left, on  the contrary, very soon  became per-
manent, and in such a manner that  the leg at the knee-joint was bent  at a right 
522
JOLLY. —HYSTERIA.
angle, and could not be straightened by exerting the greatest force.   But the
semiflexion of the femur and the clubbed position (varus) of the foot  could be
easily adjusted.   The contraction of the knee could only be overcome  when
most deeply under the influence of chloroform.  After persisting for  about a year,
this as well as the anaesthesia present in the same leg and the hysterical fits disap-
peared, on the occasion of the  patient being attacked by  typhoid  fever.  Dur-
ing the following three  months none of  her numerous hysterical symptoms
returned, of which, oft-repeated vomiting of  blood, great salivation  appearing in
paroxysms, tympanites, and nervous deafness, may be mentioned. The patient then
died of rapid tuberculosis of the peritoneum, the source of which was to be refer-
red to chronic inflammation of the Fallopian tubes and the structures surrounding
the uterus.  Both ovaries were  atrophied, and the  tunica  albuginea thickened.
The stomach was free from ulcers and cicatrices; in the bowel numerous slaty spots
were recognized as the remains of the former typhoid affection. The brain and
spinal cord were microscopically healthy.

    Contraction,  like paralysis, ma}7 last for years, and like this
may  suddenly be cured b}7  all possible moral  influences.   But
there  are also cases which resist every influence, and  in which,
after continuing for decades, atrophy  of the  affected muscles
with  diminished  electric  response  finally sets  in.  Under the
deepest influence of  chloroform  the  contraction can then no
longer be overcome.
    It  is feasible to suppose that in such cases the at first purely
functional disorder may later go  on to  material changes in the
nervous system, that is, that  the  supposed condition  of  excite-
ment, of whose material basis we are ignorant, after continuing
for a lengthened period, is accompanied by grosser changes at its
place  of  origin.   Charcot  has related a case in which  this may
have  occurred.   In a female hysterical patient, who had suffered
for ten years from contraction in all four extremities, which had
at first disappeared several times, but  later became  permanent,
sclerosis  of  both   lateral   columns  was found on examination.
Against this it may be urged that the sclerosis was in this case
the original disease, merely by chance complicated with  hysterical
symptoms.  At any rate, as Charcot himself says, it is impossible
to state  the  exact  period  at which  sclerosis develops  itself in a
case of hysterical  contraction.
   As in contractions and palsies, caused by anatomical changes
in the brain and spinal cord, so in hysterical conditions  of  this 
SYMPTOMATOLOGY.
523
kind tremor is frequently observed, which appears in the paral-
yzed extremities, especially on attempting movement.  But this
may also occur as an independent symptom of paralysis and con-
traction, and then appear in quite the same way as  in paralysis
agitans.  An analogous  shaking palsy in the head is also some-
times observed.   Less marked degrees of tremor may, moreover,
occur in the tongue, the facial muscles, and the  hands, in most
hysterical patients, as quite transitory  phenomena, which may
be called forth by the slightest psychical excitement.

Disturbances  of the Circulation, and Disorders  of  Secretion
                       and Excretion.

   Changes in the power and frequency of the hearts action are
often met with in the hysterical.  The disturbances are, as a rule,
transitory,  less frequently permanent.  In most patients it  only
requires trivial psychical or sensory excitants to produce power-
ful palpitation^ which is felt not only subjectively by the patient,
but may also be  appreciated objectively, as the apex-beat seems
increased, and strong synchronous pulsations are sometimes found
in the whole cardiac region.  The frequency of the heart's action
is almost always at the same time increased.
   The  pulse in  such cases is sometimes small and hard, at
other times full  and soft, corresponding to  the varying state of
contraction of the muscular  coat of the vessels. The  more or less
complete paralysis of this coat often rapid]}7 succeeds a tempora-
rily excited condition.  In place of the paleness existing at first,
general reddening of the skin and profuse perspiration set in, and
at all possible portions of the body, at which no pulse is at other
times to be felt,  vascular pulsation, appreciable subjectively and
objectively, occurs.  Such transitory exaggerations of the heart's
action are also found in  the hysterical, without a demonstrable
psychical or sensible cause  ; they are also not very rare symp-
toms in  the course of hysterical convulsions.  In the  latter, more-
over, the heart's action is not by any means  always increased;
much more frequently,  in  contradistinction  to  the spasmodic
movements in all other muscular parts, its normal activity is di-
minished.  A feeling of fullness and oppression in the chest,  with 
524
JOLLY. —HYSTERIA.
anxiety, is a regular accompaniment of palpitation.  Its influence
upon consciousness (Gehirnthatigkeit) is very variable, and in
accordance with the conduct of the vessels of the brain at the
same time.  A feeling of confusion and oppression in the head,
as well as giddiness, is only rarely absent  in severer  attacks of
palpitation.
   Considerable iceakening of the heart s action, and  especially
such as supervenes suddenly, is also met with in the hysterical.
This  may  usually be determined in the fainting  fits which so
easily arise in some of these patients, and together with the
accompanying  anemia of  the brain apparently causes these at-
tacks. The occurrence of the latter is favored by a simultaneous
and general diminution of vascular tonus, which, in the presence
of a  weakened heart's  action, has  as a necessary consequence an
accumulation of blood in the more deeply situated parts of the
body.  The diminished heart's  action is  likewise very remark-
able in attacks of catalepsy,  but seems to reach its  highest
degree in those rare comatose  states  wliicli last for  days, and
which have been designated hysterical trance.
   In the ordinary state, apart from all fits, the action of the
heart and of the pulse is in  many hysterical persons perfectly
normal,  as regards both  frequency and force.   An habitual
weakness of these occurs in those by no  means rare cases in
wliicli chlorosis and anemia  exist as  causes or concomitant
symptoms  of hysteria.  The real blame of the occasional dis-
orders of cardiac and vascular action mentioned is often appar-
ently to be attributed to these conditions.
   Independently of the state of the heart's innervation, vetriet-
tions in the state  of  contraction of the muscular coat of the
vessels occur  in a great many hysterical patients,  producing
remarkable appearances, particularly in the vessels of the skin.
As an habitual condition, one finds with especial frequency pale
and  cold extremities, while the  face is  much reddened,  and the
patients complain c f an overwhelming sense of heat in the head.
At remarkable variance with this, the mucous membranes are
sometimes  bloodless,  both the conjunctiva  and lips being very
pale.  Even when  the color  of  the face is usually normal, one
generally notices in the hysterical a great  tendency to  become 
                      SYMPTOMATOLOGY.                  525

pale and to blush.  With the  reddening of the  skin,  profuse
perspiration of the face then-, as a rule, takes place.  The same
appearance is also met with at other portions of the cutaneous
surface.  Thus, the hands especially, which when at rest are dry
and cool, often become warm and moist on the slightest attempt
at manual labor, such as writing and the like.  This  is also the
case in the  lower extremities.  In  other  cases perspiration  is
increased over the  whole body ;  cases of  unilateral  sweating are
also occasionally seen in the  hysterical.   Local hyperemia  of
the skin does not rarely accompany the neuralgic affections which
occur in hysterical persons.   Herpes, too, is sometimes observed
along with it.  In the extremities, in which  the joint affections
previously mentioned arise, Brodie frequently observed the typi-
cal variations of vascularity and temperature take place, in such
a manner that icy coldness and paleness of these existed  for some
hours daily, then elevations of temperature, with reddening and
sweating appeared, which continued for about the same period,
and then for a time gave place to a normal  condition.
   Of especial interest are the bleedings from  the skin and vari-
ous internal  organs met  with in hysterical  persons, in conse-
quence of local congestion.  To estimate  this aright, the state of
menstruation must next be considered.  This is, in many hysteri-
cal women, perfectly normal; yet in nearly a half of  such patients
disorders of this function of one sort or another occur :  sometimes
bleeding, profuse and frequently repeated ;  at other times abnor-
mally little, and only occurring at long intervals.   Sometimes
these are undoubtedly7 the result  of anatomical changes in the
genital organs ; at other times, whether appearing with or with-
out such changes, they are, in  the  manner previously  stated, the
cause of hysteria.  Amenorrhoea may further be the mere result
of the anemic condition causing the hysteria ; it may, however,
in the absence of anemia, also arise from an altered innervation
of the uterine vessels, dependent upon hysteria.  Likewise, in a
perfectly normal state of the genitals, profuse hemorrhages take
place from them, which can only be explained by an abnormal
state of congestion, arising from altered innervation.
   In cases  of amenorrhoea of  the form last mentioned, there
occur collateral  determinations  of blood to  other  organs, and 
526
JOLLY.—HYSTERIA.
hemorrhages may take place which are to be regarded as vicari-
ous for  the  deficient  menstruation.  Such hemorrhages have
especially been seen to occur from the mucous membrane of the
nose and throat, also from the stomach and lungs, and in rare
cases from the most widely differing portions of the cutaneous
surface, without its being possible to determine other changes in
these parts  than  those which are connected with any hemor-
rhage.
   All these bleedings,  however, also occur in the hysterical
independently of the menstrual period, and without the menstru-
ation itself being at all disordered.   One can then only conclude
that one has to do with  local congestion of the  affected organs,
due to abnormal innervation.
   Hysterical hematemesis only occurs in  isolated cases. But
in such  one  occasionally sees it  take  place very copiously, and
with frequent recurrence, sometimes daily, or every two days, for
a long time, and under certain circumstances producing highly
exhausted conditions.   The vomited blood is, according to the
time it has been in the stomach, sometimes little  altered, and at
other times appears as dark masses of clots,  or in the well-known
form of a material resembling coffee-grounds.  It is  also found
more or less abundantly in the stools.  In two cases which I have
myself seen, pains in the stomach, and a feeling of weight or full-
ness in the epigastrium, usually preceded  the vomiting of blood
for some time ; after the vomiting, the patients felt relieved, and
remained for some time free from pain.  In  other cases, as they
have recently been described by Ferran, severe fits preceded the
vomiting, and the stomach-ache reached an unbearable degree, so
that the patients were much distressed and discomforted ; giddi-
ness and noises in the  ears  were associated with this, and the
patients fell into a swoon-like condition.  After a few minutes
they again recovered, and then for  the  first  time  blood was
ejected from the stomach, with violent retching.
   The discrimination  of these  hysterical  hematemeses from
such as  arise from gastric ulcers in the hysterical is, moreover,
extremely difficult, and  one  can, as a rule, only be certain after
prolonged observation.  The  slight influence upon  the general
state of  the  patient, the absence of gastric disturbances in  the 
SYMPTOMATOLOGY.
527
intervals, and the close connection with the fluctuations of  other
nervous disorders, are usually characteristic of hysterical hemor-
rhages.  But there are cases in which all these  landmarks fail.
The appetite and  general condition are much depressed, and
other hysterical phenomena are less pronounced.  In these cases,
the final issue, sudden  arrest of the bleeding and its reuewal
by other hysterical symptoms, often first affords certainty.
   What has been said of hematemeses, in great measure applies
to hemoptyses in the hysterical; as purely hysterical symptoms,
they occur perhaps even more rarely than  the former.  Again,
hemorrhages of both kinds are frequently simulated ;  to render
themselves interesting, patients produce blood, which may have
come from any other source, as vomited or expectorated, or they
drink the blood of animals and then irritate themselves, so as to
vomit artificially.  One must therefore  be  constantly on  one's
guard against deception.   This remark  is still more applicable
to the blood-staining of  the sweat and tears sometimes observed,
and especially to those greater hemorrhages from particular, cir-
cumscribed  portions of the skin.  The latter are said  to joccur
particularly on the hands  and feet, and on the chest and fore-
head,  and in such a manner that a bladder-like elevation of the
epidermis first takes place, when the serum in the bulla, at first
clear,  becomes of a bloody color,  and then, after flattening of the
skin, a flow of blood takes place, often  tolerably abundant, and
persisting for a length of  time.   This phenomenon, described as
stigmatization, in which superstition beholds a recurrence of the
wounds and bleeding of Christ, has in most known cases become
so suspicious, from the conduct of  the patients themselves, and
from  that  of  the priesthood,  who have derived great benefit
therefrom, that it may be doubted whether we have not as a rule
to deal with mere fraud.   At any rate, those cases  are not con-
vincing in which a rigorous inspection has  been avoided.   This
also applies to various  cases  which have been related in  more
ancient literature, in wliicli not only is blood said to have issued
from all possible parts, but also urine and feces, sometimes from
flie umbilicus, and  at other  times  from the eyes,  ears, or any
other  part whatever.  On  the other hand, the possibility  must
not be denied that, under certain circumstances, in  consequence 
528                   JOLLY.—HYSTERIA.

of rupture of the smaller vessels, bloody admixtures may appear
in the sweat and tears, and that thus  also  more  considerable
hemorrhages may occur.  This seems to  have been the case in a
patient observed by Parrot, in whom, at different times during
general convulsive attacks,  an escape of bloody-colored fluid was
noticed from the  skin  of the fingers,  the knees, the thigh, the
chest, and also from t\ie conjunctiva.  In other cases, again, the
occurrence of an extravasation of blood into and under the skin
has been noted, on the  solution of the continuity of which bleed-
ing followed ; this was so in a case  of Astley Cooper's, quoted
by Laycock,1 in which  there was  bleeding from  the breast, and
likewise  in a case of bleeding from the scalp related by Magnus
Huss.

        Other  Anomalies  of Secretion and Excretion.

   Salivation  sometimes occurs with great intensity after hys-
terical fits, and more  rarely it is met with as an independent
symptom, occurring daily  apart  from fits.  In some cases also,
as Valentiner correctly points out, the salivation  is only appar-
ent,  and arises from the circumstance that, on  account of  spasm
or paralysis in the pharynx, the saliva is not swallowed, and
therefore escapes  from  the  mouth.   The opposite condition, too,
of abnormal dryness of the mouth, with a parched and burning
sensation, is found in some hysterical patients, and causes them
to drink incredible quantities of fluid.
   Gastric Secretion.— With the  spasmodic states of the stom-
ach, mention has  already been made of hysterical vomiting (not
bloody).  It has yet to  be remarked  that with this a considerable
increase of the gastric  secretion may frequently be determined,
as large quantities of fluid  are ejected, even in a perfectly fasting
condition.  The appetite is thereby  generally  much diminished.
Sometimes, on the contrary, the  patients are very hungry, and
  '1. c, p. 214.  "In a young lady, seventeen years of age, the breast appears
Bwollen.   There are one large and several smaller extravasations of blood, resembling
those due to leech-bites.  This escape of blood, from which she has repeatedly suf-
fered, begins about a week before, and ceases a week after menstruation." Laycock
himself also mentions bleeding from the nipple. 
SYMPTOMATOLOGY.
529
take all possible  nutriment, although they are aware that  they
cannot retain it.  It is a characteristic feature that occasionally
particular, and indeed very substantial, articles of diet may  be
borne without vomiting.   Thus it is not rarely possible to put a
stop to it by allowing the patient to eat perfectly raw bacon  or
raw minced beef,  with whole peppercorns.
   In some cases hysterical vomiting  is the result of  a vicarious
act of the  stomach;  that is, it has been repeatedly observed
when the secretion of the kidneys is either  lessened or altogether
suppressed.   In a  case  of the  latter description Charcot  suc-
ceeded in demonstrating  urea in  the vomited matter.  Fernet
also  determined the same in one  case. In  a case of the same
kind which  I noted last  year, this could  not  be proved.   But
here the suppression of urine was never so  complete as in Char-
cot's case, as from 100 to 200 c. cms. of urine  were daily voided.
   As regards the abnormal accumulation of  gas in the stomach
and bowel, the reader is referred to what has been said regarding
paralysis of these parts.   The obstinate constipation of frequent
occurrence has also  there been discussed.  It  has yet to be men-
tioned that in other  patients there exists a great tendency7 to pro-
fuse watery diarrhoea, which is unmistakably related to the other
nervous symptoms, and may arise  especially after  mental emo-
tion, just as suddenly as it occasionally disappears.   It produces
exhaustion much less frequently than copious vomiting does.
   Abnormalities of urinary secretion are very frequent in the
hysterical.  A decided increase, as well as diminution of urine
occurs.   The former  takes place  temporarily, especially  after
convulsive attacks ; under such circumstances a very copious,
clear urine,  of low specific gravity, is often  (not always) secreted
(urina spastica).  Diminution of urine—true ischuria—is usu-
ally a more persistent symptom,  which is often coupled with
spasmodic closure of the neck of the bladder, so that  the small
quantity of urine which exists  must be removed by the catheter.
Charcot, whose observation has already been mentioned,  has
proved that, in  the  small  quantities which are still excreted, a
relatively large quantity of urea is  present.   I can also state the
same of the case I have examined.  As Charcot therefore says,
it cannot be a question of diminished secretion  in  consequence
         VOL. XIV—34 
530
JOLLY.—HYSTERIA.
of spasmodic closure of the ureters, as the quantity of urea must
then also be relatively diminished ; but the cause of the dimin-
ished  secretion is  evidently to be sought in the kidneys them-
selves,  and indeed  probably  in  their vascular  system.   The
possibility of tolerating such conditions is afforded by the excre-
tion of urea by other organs.   This has already been proved by
Charcot in the case of the mucous membrane  of the stomach;
but it is probable that in  other cases  the mucous membrane  of
the bowel, as well as the skin, can act  in a similar manner, just
as this is observed  in contracted kidney, acute  nephritis, and  so
on.
   Increase of the  uterine and vaginal secretion is undoubtedly
of so frequent occurrence in the hysterical because the chronic
diseases of the genital organs, as a consequence of which fluor
albus  appears,  are particularly often  met with in  such cases.
But there are  also alterations of this secretion which must be
attributed to nervous influences.   Thus, immediately after hys-
terical attacks, a decided increase of an existing leucorrhcea has
often been seen to occur.  This may  also, however, take  place
periodically with a perfectly normal  mucous  membrane,  and be
dependent upon the state of the nervous system generally.
   A governess was under treatment in the Lunatic Clinique at Wurzburg, who at
the age of forty years suffered from hysterical symptoms of various kinds, especially
from globus, paroxysmal tympanites, and variable hypersesthesise,  and neuralgia,
and whose disposition was decidedly depressed, though at  times  very lively, and
particularly erotic.   In this case, for several months, simultaneously with the tym-
panites,  which usually developed itself in the forenoon, there appeared a very pro-
fuse, thin fluor albus, which had its source partly in the uterus and partly in the
vagina, without its  being possible, however, to recognize with the speculum any
abnormal condition of the uterine or vaginal mucous membrane, beyond the moist
state of their surfaces.  The fluor only appeared periodically, but then frequently in
such a manner, that within a short time the  patient's linen was soaked; repeatedly
it completely disappeared for a day, and in consequence of emotional excitement a
great increase could always be determined.  Local treatment with  alum had  no
decided effect upon the symptom; but along with the tympanites it quickly and
completely disappeared  when the patient was put into a lively state of excitement
by the visit of her sister, who overwhelmed her with reproaches.

   Briquet found an increased secretion of milk, taking place at
any unwonted period, in an hysterical patient.  The secretion 
SYMPTOMATOLOGY.
531
had begun in her case during her first pregnancy, and continued
for years afterwards, uninterrupted  or diminished by renewed
pregnancy.   The sensitiveness of the breast was at the same time
so great that the patient could not suckle her children.

                     Hysterical Attacks.

   Many of the forms  of convulsion  already described, when
they occur alone and transitorily, may be  designated hysterical
attacks.  In a restricted  sense  one understands  by the  latter
those  convulsions  of a  generally  distributed  clonic and tonic
character with  which peculiar psychical symptoms are  very
frequently united,—or even the transitory appearance of these
psychical disturbances alone, without convulsions.—Such attacks
sometimes take place without a demonstrable cause; in  other
cases  they are the result  of over-excitement of the most varied
description ; still more frequently they arise from trivial psychi-
cal excitation.  The  consciousness  of being under observation,
and the desire to attract  attention, may cause an  increase and
exaggeration of this,  as of all other hysterical symptoms.  In
many  patients an increased tendency to  attacks is  shown  at the
menstrual periods.   At the commencement of  the latter a sensa-
tion, analogous  to  the epileptic aura, is present,  frequently in
the form of the globus ascendens; or it is ushered in by a pain-
ful dragging in  the  extremities, or pain and  giddiness in the
head, or singing in the ears and darkening of the field of vision.
Or, again, the patients feel generally unwell and out of humor,
are in a high degree irritable,  and are then so excited, by the
slightest cause, that the attack takes place.  In milder cases this
consists of general rhythmical clonic convulsions of the extremities
and head.  Respiration is at the same time much quickened and
exaggerated ; occasionally a temporary spasmodic interruption or
irregular action of the respiration occurs.  Consciousness is not
lost therewith.  The patients can still dispose of themselves or lie
so as to avoid injury; they hear what is said in their neighbor-
hood, are roused  by more powerful  physical irritants ; and it is
sometimes possible, either  by such,  or by means of a powerful
moral  impression, suddenly7  to  put an  end to the attack.  A 
532                   JOLLY.—HYSTERIA.

single attack rarely lasts more than a few minutes ;  sometimes,
however, a series of these follows almost immediately one  after
another.
   1.  Of the more severe hysterical attacks, one form is met with
which cannot be distinguished from epilepsy.   Consciousness is
completely lost; the convulsions have alternately a tonic and
clonic character; the respiration is extremely slow and stertor-
ous ;  the tongue,  too,  participates in the spasm ; foam issues
from the  mouth, and  after the attack the tongue and lips are
occasionally seen to be bitten.  Such attacks are called  hystero-
epileptic.   Quite the same  exciting condition in the brain evi-
dently constitutes their basis, as in the so-called "true" epileptic
fits.   The condition here only appears as a symptom of hysteria,
while in other cases it  is produced by other  causes, the most
varied.
   2.  The  more severe hysterical attacks  may assume yet more
complicated forms, which, by some at least, are still considered
as belonging to the category of hystero-epilepsy.  Thus, in parti-
cular, tetanic symptoms occur ; the highest degree of opisthotonos
may develop itself; the patients are bent forward  like a  bow,
merely  resting on the ground with head and heels;  or other
distortions of the  trunk and various peculiar contortions of the
limbs occur.   The patients  then often statuesquely maintain for
some time such a forced position, then  the mildest movements
and distortions, following one another rapidly,  again make  their
appearance.   The  most remarkable positions  are imparted  to
the extremities: the legs are  thrown  into the  air, or contracted
in  extreme  flexion, and  again  extended  in  violent  treading
movements, then forcibly crossed, or  the  feet approached to the
face.  Patients swing their arms in the air,  close their fists, beat
with  them upon the ground or their own  bodies, tear their hair,
and then again, with  fingers outspread  in extreme extension,
perform the most peculiar gestures.  The  countenance is dis-
torted with grimaces,  sometimes assumes a jovial grin, and again
an irate, wrathful expression.  Then  the whole body is in com-
motion.   The  patients roll violently round their long axis, or
cast themselves with force, sometimes  forward and sometimes
backward on to the ground, or strike their heads forcibly against 
SYMPTOMATOLOGY.
533
walls, so that it is only with great care that they are preserved
from injury.   Loud screams, singing, ejaculation of  particular
words, and fits of laughing and weeping, may appear simultane-
ously or  alternately  with other  symptoms.  The  duration of
these attacks varies from a few minutes to several hours ;  with
slight intermission they are sometimes seen to  continue for sev-
eral  days.   Consciousness is the  while apparently always con-
fused, although it is not  rarely possible  to induce reaction by
powerful irritants, and sometimes thus suddenly to  terminate
the attacks.  Usually  hallucinations  and delirium are present,
which, in  part at least, appear to be the cause of the peculiar
movements of patients.  Frequently also delirium, as a so-called
"psychical aura,"  constitutes the commencement of a regular
convulsive attack.  (Consult on this  the section  on Hysterical
Mental Disturbances.)   After the  termination  of the more com-
plicated, as of the simpler attacks, there either follows a sudden
transition  to  the normal state, when merely lassitude is com-
plained of, or the patients fall forthwith into  a deep sleep for
several hours, from which they awake without a distinct remem-
brance of  what  has occurred, or confusion and delirium still
continue for some time.
   3. Another variety  of  convulsive  attack in the hysterical,
which is closely related to the last described, and may combine
with or proceed  from  it, is the  cataleptic.   Sometimes the
condition  of  cataleptic rigidity appears  limited  to particular
limbs; it  is frequently met with spread over the whole body,
and  is combined with  absolute incapacity for  any spontaneous
movement, generally with a diminution of reflex  action.  Con-
sciousness is  sometimes perfectly  retained in this state, so that
after its disappearance patients  can state  exactly what  has
occurred to them  during the attack.  Sensory comprehension
may, indeed,  be extraordinarily acute.  On the other hand, all
sensation is sometimes  wanting ; but hence lively hallucinations
appear, and the patients exist altogether in a dreamland, with-
out being  conscious  of the actual state  of  affairs.  After the
return of consciousness, recollections  there anent  are  generally
very  hazy.  Cataleptic  fits may continue much longer than the
other convulsive attacks of the hysterical.   Cases are  known in 
534
JOLLY. — H YST EI' IA.
 which they have lasted, with slight  intermission, for months.
 In  other cases they disappear in a few hours, or appear only
 very transitorily in alternation with other symptoms.  Moreover,
 from these conditions of true catalepsyl with waxy rigidity of
 the .limbs, we cannot distinctly separate those other conditions,
 likewise  occurring in fits, in which,  with a quite analogous
 psychical behavior, the muscles  are perfectly lax, the extremi-
 ties when raised drop the moment they are let go; as well  as
 those conditions in which, with every attempt at passive move-
 ment, contraction takes  place in the  antagonistic muscles, and
 thereby motion is rendered difficult or impeded.
   This  irregular conduct is  often seen simultaneously  in differ-
 ent groups of muscles ; or in the same attack the waxy flexi-
 bility alternates with both the other conditions. In cases of com-
 plete  relaxation  of the muscular system,  it  happens  that the
 respiration becomes extremely weak, and the action of  the heart
 and of the pulse is scarcely any longer to be felt.   These are the
 cases which have been described as " hysterical trance,'''1 and in
 which also a superficial  examination  or insufficient knowledge
 has occasionally led to the assumption of actual death.
   Finally,  as regards the attacks of somnambulism, sleep-walk-
 ing, wakefulness, magnetic sleep, Jiypnotism, and ecstasy, and
 whatever else those attacks have been  named which are met with
 in the hysterical,  they  are  merely  varieties of  the form last
 described.  We have always in  such  cases to deal with dreamy
 conditions.  When thus  affected, patients  can, actuated by the
 promptings of their dream, execute various complicated move-
 ments, when, like animals whose brains have been removed, with-
 out noting their surroundings, they are guided by stimuli affect-
ing the senses, cleverly avoid obstructions, and under  the most
 dangerous circumstances preserve their corporeal equilibrium.
 Sometimes they answer particular questions addressed  to them
in a perfectly rational manner : in these answers the influence of
  1 The term catalepsy is used in a very varied sense; by us, as a rule, only for the
state of  flexibilitas cerea; sometimes for all the above described conditions of loss of
voluntary motion without complete loss of consciousness; by some English authors also
for the more complicated attacks of hysteria mentioned above under 2, in which con-
vulsive movements are executed with apparent premeditation. 
SYMPTOMATOLOGY.
535
the revelations  of  their dream  is frequently to be recognized.
Moreover, as the sensory apprehension, as already mentioned, is
occasionally quickened, so apparently wonderful powers of dis-
tinguishing objects and persons by means of the different senses
are observed.    One must,  however, be very sceptical in testing
such statements.  For, on the one hand,  there frequently exists
in the patients  themselves, who suffer from such attacks,  a ten-
dency to exaggeration and deceit; and, on the other hand, they
are easily  misled by their  friends, who  are either themselves
superstitious, or trade upon the superstition of  others.    The
peculiar conditions  are  then ascribed  to a  supernatural or
divine influence, and  in order to render the pretended wonder
still more wonderful, it is  embellished with all  manner of false-
hood.1
   It has finally to be mentioned that these various conditions
of catalepsy, ecstasy, and so on,  may sometimes occur spontane-
ously, without  a known cause, or in consequence  of  powerful
emotions, but  also that it is sometimes possible (and indeed to
the exclusion of all deception) to induce them artificially.  As is
known,  this may be accomplished in perfectly  healthy people,
but, nevertheless, more frequently in the nervous, and especially
in hysterical people, by various manipulations.  It appears to be
a point in all contrivances undertaken for  this purpose to fix the
attention on one object, or  to direct the attention very stead-
fastly in one direction.  The condition is most frequently induced
by  the  subjects  directing  their  eyes fixedly upon  a  dazzling
object;  sometimes  it may  be called forth by one placing the
fingers for   some time  upon the eyeballs,  or  by spreading a
cloth  over the head of the patient.  It may sometimes be pro-
duced by passing the hand over the skin, or by various mysteri-
ous gestures, which arrest  the  attention of the  patients,  or
finally, by the determination of the latter to subjugate them-
  1 Consult, for example, the abundant Uterature which has already appeared in Bel-
gium concerning that most recent hysterical wonder, Louise Lateau.  The most note- '
worthy production on this subject is that of the Belgian psychological physician, Lefe-
bure, to wit: L. Lateau de bois d'Haine, sa vie, ses extases, ses stigmates. Louvain,
1870. 
536
JOLLY. —HYSTERIA.
selves to certain ideas.  In some animals  also, as is well known,
one may induce quite similar conditions by keeping their bodies
fixed for some time, or by holding dazzling objects close to  their
eyes.1


    Psychical Behavior.   Hysterical Mental Disturbances.

    Various psychical  peculiarities and disorders of the hyster-
ical have already been mentioned in the preceding pages.  A
comprehensive  description of these  extremely variable symp-
toms, and a statement of  the relations existing between hysteria
and other mental disturbances, is still necessary.
    In the milder and more frequent cases, exalted mental irrita-
bility is the most prominent psychical symptom.   Pleasant as
well as unpleasant emotions are provoked with unwonted ease.
Patients are  timid, easily overcome by any unexpected occur-
rence, sentimental and sensitive.   Every trifle annoys and upsets
them, and there is this peculiarity, that a more recent stimulus
may  often effect a diversion in  an exactly opposite  direction.
A despondent disposition, in which everything annoys and pain-
fully7 affects the patients, and in which they feel miserable and
incapable of doing anything, may immediately succeed an equal-
ly lively,  frequently  exuberant  and  frolicsome tone,  in which
they see all things in a rosy light, and are often capable of extra-
ordinary exertion.  Peevishness is the  leading characteristic of
the hysterical;  it is   the  expression of  exaggerated  psychical
activity.
   Nothing else is possible than that, under such circumstances,
unpleasant emotions should on the whole preponderate, as exces-
sive activity always   has a  tendency  in that  direction.    An
   1 This has been longest known in the case of fowl, which may best be "hypnotised"
by holding their bodies gently but firmly on a table, while with the other hand the head
is directed to the same.  A chalk line drawn on  the table past the beak favors the
development of the phenomena.  Czermak has recently demonstrated the same in other
birds.  It is, moreover, very easy,  as the same authority has shown, to call forth this
phenomenon in crabs, which it is only necessary to hold between the fingers for some
time to see them remain motionless in the most forced attitudes.  A similar condition
may not rarely be observed in rabbits and guinea-pigs. 
SYMPTOMATOLOGY.
537
unamiable disposition is therefore as a rule pronounced in the
hysterical, is a source of grief  to  the patients themselves, and
renders  them objects of solicitude and anxiety to their friends.
In more matured cases the condition is more painful, melancholy
alone prevailing, and not rarely continuing for years, and any
change of disposition which even then does not fail  to occur is
yet only partial, more endurable periods sometimes interrupting
those which are altogether grievous.   In these states of ill-
humor, pains felt in different parts of the body always play a
distinguished part.   These, as we have seen,  are partly the im
mediate consequence of exaggerated mental activity, and to some
extent arise independently in consequence  of increased irritabil-
ity in particular sensory tracts.   In both,cases  they serve to
nourish the existing diseased tendency,  and promote and main-
tain the same,  just as conversely an exaggeration of abnormal
sensations and involuntary movements is caused by the attention
with which  their physical  state is noted by the patients.  It
will, howrever,  be evident  hereafter that  abnormal  sensations
alone cannot by any means generally be regarded as the cause
of hysterical ill-humor,  any more  than this  can occur  in the
purely hypochondriacal tendency,  which  is met with  uncon-
nected with  hysterical symptoms.
   The exaggerated psychical irritability of the hysterical  usu-
ally finds expression also in the appearance of various idiosyn-
crasies and peculiar inclinations.  Some hysterical people, in the
presence  of, or  by reflecting upon,  particular  and  altogether
indifferent objects, experience the highest degree of repugnance
and  distaste.   Especially  often  does the aversion  to certain
animals  exist,  such  as frogs, mice,  spiders,  cats, and so on,
whose presence  frequently  calls forth  regular  paroxysms of
excitement, convulsions, and fainting.  Others, on the contrary,
render themselves conspicuous by the excess of their apparent
partiality for particular animals, cats, dogs, birds,  and the like.
In their intercourse  with their  fellow-creatures, too, they fre-
quently show themselves to be ruled by the  most violent  and
altogether unfounded antipathies and sympathies.  Hatred  and
love for particular individuals occur in unwonted measure  and
without definite  motive, and are displayed,  now7 toward one  now 
538                   JOLLY.—HYSTERIA.

toward another, according to the accidental changes of disposi-
tion.
   The sexual processes which so frequently play a part  in the
causation of hysteria quite often leave their impress  upon the
psychical picture.  Although it is absolutely incorrect to deduce
hysteria  exclusively from insufficient sexual satisfaction, as was
formerly done, and to consider all hysterical women as amorous
and nymphomaniacal, yet it is not to be denied that the imagi-
nation of many such takes an erotic direction, and that in some
cases sexual sensations  prevail.   It may be determined with
tolerable frequency, in the case of exquisitely hysterical maidens
and  women, that  an exaggeration of  symptoms  occurs in the
presence  of men.  ,Some ailments evidently owe their  origin
simply to the desire to be physically examined by the physician,
or at least to retain him as long as possible in their presence.
As a rule, therefore,  those physicians are preferred by the hys-
terical who  lend a ready ear to all their complaints, and trouble
themselves most with them.   Such men, however, by no means
alw7ays exercise the  most favorable  influence upon the diseased
condition.
   But it is not only  to the physician  and in  consequence of
sexual excitement  that the hysterical are troublesome and  prone
to exaggerate their symptoms.  Their entire disposition causes
them to be burdensome to their friends, and chiefly in this way:
the feeling that they are destined to suffer more than others on
account of  their unfortunately nervous constitution renders them
selfish, and regardless of those other " rougher" natures.  They
wish it to  be understood,  not only that they are ill, but that
they have  to suffer in  an  altogether  unprecedented manner.
Frequently it is much less  of their bodily ailments that they
complain than of their life's destiny, which they consider a very
hard one.  One very often meets with this kind  of exaggeration
in elderly hysterical females, in whom, in fact, external circum-
stances have furnished elements  calculated to embitter and to
develop the hysterical condition, whether it be that they have
not  attained  the  longed-for goal of  matrimony, or that they
have not found in marriage corresponding physical and  moral
satisfaction, or whether it be that as widows they have to endure 
                      SYMPTOMATOLOGY.                   539

grief and want, or finally, that they must needs part with their
grown-up and now independent children, and regard their lives
as objectless and  desolate.   They frequently assume the mask
of resignation and quiet endurance ;  but  although they protest
against  any  attention,  and  ever  maintain  that they" are not
worthy of regard, yet are they annoyed and made ill by every
trifle, and demand  the most constant solicitude  from  their
friends,  whom  they continually torment  by their  resigned air
and indirect reproaches.
   But  the  same  thing is  also met with  in  every degree in
younger hysterical girls and women, although, upon the whole,
their exaggerations have more frequently reference to symptoms
of disease.  Some, in order to arouse attention and consideration,
injure and burn themselves,  maintain purulent cutaneous  sores
by using irritating  ointments for  a length  of time,  swallow
needles, or stick these under the skin in the most  varied situa-
tions, or  attempt to  hang, drown, or poison themselves, and so
forth.  Their arrangements are, as a rule, so made in such cases
that the attempt  is noticed  and  frustrated  in time by  their
friends ; but  real attempts at suicide are also met with, or acci-
dentally such a design proves fatal,  even against the will of the
patient.   Others try to attain  the  same desired end by direct
falsehood and deceit, which is sometimes carried out with  such
cunning as to cheat  for long their  friends and  physicians, but
they are as a rule easily detected.
   Again, it has happened that the  hysterical have  drank urine
and eaten even excrement, to vomit the same, and give rise to the
belief that the said substances proceed from their stomach.  As
regards  cutaneous hemorrhages which  are frequently seen in
the hysterical, it has already been  stated  that  they only arise
spontaneously in rare cases, and are  as a rule  artificially pro-
duced by deceivers.  Some hysterical people would lead one to
believe that  urine issued from  their navels, breasts, ears, eyes,
and so on  (a phenomenon which,  under  the name of  paruria
,jrratica, was of yore generally recognized as a symptom  of hys-
teria).  Others have  introduced living or dead  animals (toads,
frogs, worms, etc.)  into the anus or genital organs, and in the
presence of  a credulous public have reproduced  them.   Yet 
540
JOLLY.—HYSTERIA.
others pretend to have  had no evacuations from their bowels for
months or years, to have existed without food, or to  have lived
upon consecrated wafers, and so on.1
   In  other cases the  tendency to lie and cheat takes yet more
objectionable forms ; the patients intrigue against their friends,
state that they are  the victims  of the animosity of  the  latter,
maintain that they have been  persecuted and outraged,  and
sometimes play their part so well that not only the general pub-
lic, but also physicians and judges are deceived.
   Another symptom which sometimes appears very prominently
in severer forms  of  hysteria  affords the clue to understanding
some of these occurrences.  This is  the deep-rooted and persist-
ently painful tendency, unbroken by any pleasant emotion, to
" uncontrollable impulses " (Zwangvorstellungen).  The patients
frequently can only affirm that they feel themselves driven to do
something bad to procure peace ; sometimes it is particular acts
which float before their imagination, and the  thought of which
pursues  them continuously until they  are carried out.  Occa-
sionally they are  compelled to mutilate themselves, and again to
injure others.  Sometimes they succeed by loud abuse and cries
to avoid  their impulse;  at other times they  rave, sing, dance,
make a noise, and destroy everything  they can lay hands upon,
with the full consciousness and in the belief that they may thus
gain relief.  At other times, finally, it is the thought that their
friends are anxious to render them uncomfortable by wicked and
underhand  devices,  which pursues  them in like manner,  and
occasions falsehood and deceit.
   1 Although medical works in which such marvels are credulously referred to have
happily become rare (in the older writings  they naturally play a great part), yet such
are not altogether wanting even at the present day.  The pamphlet of Lefebure on
Louise Lateau, the stigmatised and wafer-nourished, has been already mentioned.   Of
others undertaken in the same spirit, there is one, published in 1858 by Dr. I. Ch. Seitz,
of Pest, viz.: The history of a rare and incomprehensible disease, etc., with an appen-
dix on frogbirths.  We are therein told of a young girl from whose eyes fruit pips
sprang, from whose ears and navel faeces escaped, and from whose anus and genitals
fleshy shreds came away,  while worms with black eyes were vomited, and many other
such things; further, of a woman from whose genitals four and twenty living and dead
frogs were passed, some of these indeed with cords  of attachment.  The birth of the
frogs was witnessed and believed in by several physicians. 
SYMPTOMATOLOGY.
541
   It would be very unjust to conclude from the frequent ten-
dency to deceive met with  in the hysterical, that most of their
symptoms, including convulsions, paralysis, and so on, were, as
a rule, intentionally produced and simulated.  But we can well
understand that many of the symptoms which awaken such a
thought are the involuntary  results of the lively and peculiarly
powerful imagination which is coupled with  the existing irrita-
bility of the patients.
   This is seen most  distinctly in those cases in which hysterical
symptoms are transmitted from one individual to another by
means of psychical infection.   This  occurs partly in individual
sporadic cases and partly more extensively in actual epidemics.
It is generally  the hysterical fits of different kinds (the most
complicated forms of convulsions as well as the states of cata-
lepsy, ecstasy, and the like) which so multiply ; but paralyses,
anaesthesias, and hypersesthesise may also similarly infect.  As
has been already stated, it  is always individuals already predis-
posed upon whom this infection is operative, and in more exten-
sive epidemics  universally active predisposing causes may be
demonstrated.  But  the repetition of particular symptoms of a
peculiar kind in almost every epidemic is only to be explained
by supposing that the powerful excitement caused by the repre-
sentation of certain sensory and motor phenomena brings about
the actual occurrence of the latter.
   Not less distinctly is the influence of the imagination seen in
a converse manner, when it ameliorates or abolishes hysterical
symptoms.  The conviction  awakened  in the  patient, by what
means soever, of the possibility of cure,  may almost suddenly
abolish apparently the most  severe  and obstinate symptoms of
disease,  which  may  have existed for many years.   It is some-
times possible for the physician or for other people to  influence
the patient, and by their conversation to create such  a convic-
tion.  In other cases the efficacy of particular remedies becomes
an article of  faith with the  patient, and  by this faith are  they
cured, equally whether we  have to do with medical or with any
other remedies.  All possible quack ointments, homeopathic,
sympathetic and religious influences may, under certain circum-
stances,  have the same effect, if it be only possible  to create a 
542                  JOLLY.—HYSTERIA.

sufficiently firm conviction in the  patient.  Threats are likewise
effectual in some cases, and especially during the epidemic prev-
alence of  the  disease.  From  all that has been said, it immedi-
ately follows that the power and energy of the will undergo many
alterations in  the hysterical.  Generally  speaking, it may be
said, that in a ratio corresponding with the  exalted  sensitive-
ness of the patient, impulses  of the will increase in frequency
and power, but that the frequent change of temper compromises
the consequences of this.   The eccentricity of  many of the hys-
terical is shown in never-ending undertakings and their abandon-
ment, and in spasmodic and imperfect work, without requisite
energy.  But in other cases one finds in them  so great an endur-
ance and resolution of will as is scarcely to be found in less sen-
sitive people.  Testimony  is  borne  to a one-sided energy of will
in those cases, in which  they subject themselves to  the most
excruciating physical  pain, and endure the  same with stoical
indifference, merely to  render themselves objects of interest, or
in which they perpetrate  the  most complicated  frauds, with a
like intention.  Moreover, in  useful matters, e.  g., in nursing,
in activity in  benevolent  societies, and so forth, an incredible
amount of endurance and  self-sacrifice is exhibited by the hys-
terical. If it is only possible to arouse their enthusiasm for any
object,  or  to  awaken  their  emulation,  it may happen  that
patients who have hitherto lived in the  greatest indolence and
self-indulgence, and who have appeared  incapable of executing
the slightest work continuously, suddenly undergo the greatest
exertions and are roused to an untiring and persistent activity.
   But more frequently the power of will is small.  At most the
patients rouse themselves  to transitory and limited endeavors;
on the wdiole,  they are the apathetic prey of their whims and
fancies, which, through this very failure of will energy, take the
upper hand in all their  dealings. Even  the wish to make up
their mind  upon necessary matters causes a  painful sensation,
and the slightest exertion  seems an insurmountable barrier.
   In  some cases this abulia reaches such  a degree  that the
patients, when perfectly conscious, abandon almost every move-
ment,  do not  leave their  bed, take no nourishment, and some-
times even do not observe the most necessary7 cleanliness.  It is 
                      SYMPTOMATOLOGY.                   543
 only when one attempts forcibly to drag them from their couch,
 tnat they prove, by the energetic  resistance  called into action,
 that they have not altogether lost the power of motion.
   Hysterical  mental disturbance.—By this term  one under-
 stands  those  conditions  in which the  psychical  symptoms of
 hysteria described are present in a more pronounced form  and
 persist for a longer time.  Strictly  speaking, the simpler attacks
 of hysteria may also be considered psychoses, and in any case
 the limit to which the term mentioned has been pushed  is quite
 undefined.  The degree of disturbance, as a rule, decides the
 point less than its duration.  Grave disorders of  consciousness
 occur in connection  with hysterical attacks,  such  as hallucina-
 tions with erroneous ideas, dreamlike conditions, transitory out-
 bursts of mania,  and so on.  Sometimes the entire hysterical
 paroxysm is constituted simply by such psychical phenomena.
 But these temporary disturbances,  which are  soon succeeded by
 a normal state, are generally described  merely as  deliria, while
 one finds the  term hysterical mental  disturbance  only  applied
 when persistent psychical changes exist.   Intermediate condi-
 tions are, however, numerous.  It is rarely that in patients who
 suffer from complicated attacks the psychical behavior is in the
 intervals perfectly normal.   Some of the lively images which
 appear during such paroxysms are  subsequently considered real.
 If the deliria are frequently repeated, and these, as a rule, take
 much the same form, a few false ideas gradually remain; later,
 more complicated insane creations are developed.
   The  subject of the delirium varies with the former  mental
 condition of the patient.  It is frequently religious ;  the sufferers
 see heaven open and have divine visions, converse with the saints,
 and hear and promulgate prophecies in prose and verse.  In like
 manner  do the  attacks  of  "being possessed" (Besessensein)
 arise, which have their origin  in religious discourses, and which
 played a great  part  in  the  hysterical epidemics,  especially of
 former centuries, but also at  the present day  are not altogether
 rare.   Patients think they can recognize the devil or some other
 wicked spirit in their interior, feel that they are urged to phys-
ical strains and cramps by the same, and are compelled by these
unclean  agents, in spite of themselves, to utter unholy  words, 
544                  JOLLY.—HYSTERIA.

blaspheme God, laugh at the priest, and so on.  Others talk in
a different key, according as one or another spirit urges them to
speech   Quite analogous, but less known to the superstitious,
and  therefore less used by such, are the cases in which  patients
feel themselves magnetized, electrified, or physically acted upon
in some other indefinite manner, and refer their convulsions  and
peculiar contortions to these physical agents.
   In other cases patients  are  transported to fairyland, where
milk and honey flow,  and are overwhelmed with power  and
riches, and where, finally, the Prince is not wanting who raises
them to his throne. Above all, an erotic character is rarely absent
in these deliria; it appears as  well in the visions  of  heavenly
brides as in the declarations of the possessed  of Satan,  and as in
those influenced by  magnetism or  otherwise.  It is seen most
pronounced in those cases in which patients erroneously suppose
that they have been ravished by those  who have access to their
person. "  And in  such  cases details are  sometimes  recounted
with so much minuteness,  and deviate  so little from what is
possible, that on  several occasions trials have been instituted
upon such accusations, and in a few instances convictions have
followed.
    If such attacks  of transitory psychical disturbance only rarely
appear, their impression is gradually obliterated, and the remain-
ing mental life of  the patient is not further influenced.  If they
multiply, however, persistent mental aberration is more and more
induced.  But patients are even then sufficiently wide awake for
a long time, and  conceal their mad  ideas,  the continuance of
which  is only to  be recognized  by their  ecstatic  and fanciful
 demeanor, or by their peculiar, reserved, irritable  and irascible
 behavior.  Hallucinations  sometimes  cause  them, even  in the
 intervals of attacks, to betray it.  The delirium easily breaks out
 in consequence of external causes and  excitations; but much
 more frequently does one find that it makes its appearance in
 a perfectly periodical manner and without demonstrable cause,
 being regularly introduced  by  a condition  of greater irritability
 and ill-humor.
    In other cases  there arise continuous psychical disturbances,
 which are not particularly  affected by the fits, although certain 
SYMPTOMATOLOGY.                   545
typical variations in the  intensity of the  symptoms  always
exist.
   The character  of the affection in a portion of these  cases is
merely that  of melancholy, and that, too, in its  purest and
simplest  form.    Without ever having hallucinations or mad
ideas the patients feel constantly wretched,  anxious, incapable
of enjoyment in the  society of others, complain  of  a miserable
sense of  desolation and  a painful inability to make up their
minds or work.   Under these circumstances those uncontrollable
impulses before mentioned usually appear, and urge them to self-
mutilation or attempts at  suicide.   It is just in these cases, too,
that one frequently finds the desire to intrigue against, slander,
and injure others, thereby to  derive a certain satisfaction  for
their own ailments.  Hence, these patients cause much unpleas-
antness both in the family and in asylums for the insane,  in
which they have frequently to be confined.
   This is still more true of the second  form of continuous hys-
terical mental disturbance,  the  phenomena  of which  correspond,
as a rule, to  the clinical picture of so-called folie raisonnante.
This almost always affects patients in whom  the tendency,  at
least,  to hysteria is  congenital, although occasionally  symp-
toms of it first appear at a later period.  Such patients are com-
pletely ruled  and hindered in their work by  their ever-changing
fancies; though sane enough  to  know that  thereby they come
into conflict with  their surroundings, they are unable to curb
their inclinations and impulses ; the moral sense that  they should
strive against this is either originally absent  or is lost in conse-
quence of the disease.  For any useful or steady employment
they are unfit, but pursue their own selfish aims with the great-
est perseverance ;  the sexual appetite is often  strongly developed
in them, and  indulged in  a shameless manner;  not rarely they
are given  to  drunkenness.  The desire to  multiply vices is the
predominant  feature in their endeavor; in  the most  adroit fash-
ion they cheat, lie, and steal,  and in the latter case, usually,  see
the necessity of casting suspicion upon the innocent.  They fre-
quently go to work with much spirit and cunning, and ever seek
to cloak or palliate the perversity of their actions by  clever argu-
ment.   An overweening egotism at the same time characterizes
         vol. xrv__35 
546
JOLLY.—HYSTERIA.
all they say ; without laboring under actually erroneous ideas of
their position, yet they always have a sense of superiority, and
imagine all must  make way for them.  The weakness present in
all the ingenuity, moreover, reveals itself  in these as in cases of
folie raisonnante  arising from other causes, in the never-failing
belief in the incontrovertible nature of the arguments adduced.
But  many of  their falsehoods and deceptions are usually the
expression of  deeper  disturbances  of intelligence.  They7  them-
selves believe  what they say, their memory deceives them, and
reproduces  previously related falsehood in the  sense of their
ruling passion.  Sometimes they also suffer  from hallucinations
which may gradually transform themselves into completely estab-
lished erroneous ideas.  Occasional more powerfully excited con-
ditions are rarely  absent, and are produced either by conflict with
their friends or arise spontaneously.  Confusion, delirium, loss
of ideas, and pronounced maniacal states are thus developed.
   Finally,  primary   derangement  (primare  Verriicktheit),
which  may develop, partly with and partly without hallucina-
tions, may be  described as a third  form of chronic hysterical
mental disturbance.  These cases are closely allied to those aris-
ing from  paroxysmal delirium, of which we  have already spo-
ken.  The delusion of being possessed, magnetized, or otherwise
haunted, and ideas of importance (Grossenvorstellungen) of the
kind described, may gradually develop without the assistance
of fits.   Here, too, sexual ideas are not, as a rule, absent.  Con-
ditions of this kind always advance progressively, and gradually
lead to  ever greater fixation and increase of erroneous  notions,
and finally, to imbecility.   In other forms of hysterical mental
disturbance, also, this  is usually the ultimate  result; yet they
may retain a considerable amount of intelligence much longer.


                   Progress and  Results.

   Hysteria is almost always a chronic disease, which exists for
many years, and, as  a rule,  only  completely disappears at an
advanced age.  Even  cases  commencing  suddenly,  in  which  a
violent  succession of severe symptoms  is frequently observed,
rarely recover quickly ; usually, after a comparatively short time, 
                    PROGRESS  AND RESULTS.                547

 a remission occurs ; but distinct hysterical symptoms continue,
 which on every opportunity may become aggravated.
   To determine exact stages  in the progress of hysteria is im-
 possible, on account of the great variability of individual cases.
 In cases with a powerfully developed predisposition the increased
 irritability and peevishness is  well marked, even in childhood ;
 the convulsive attacks generally first  occur later,  at puberty.'
 On the whole, they are met  with at this period most frequently,
 and often completely  disappear, after its termination, without
 the disease  on that  account ceasing to  exist.   On the  contrary,
 it  is just then that other, and  especially the psychical phenom-
 ena, appear more prominently and persist.
   The intensity  of  the psychical phenomena, moreover, stands
 in no constant relation to that of the  other symptoms.  There
 are hysterical persons,  in whom the peculiarity of the psychical
 behavior is only evident in a^small degree, while paralyses, pains,
 ansesthesise, and  so  forth, are powerfully  developed,  and fre-
 quently remain obstinately  fixed for a long time at particular
 parts  of the body (so-called  local hysteria),  while in other cases
 the psychical symptoms come to the front, and there are merely
 indications of the rest.
   Numerous changes  almost always occur in the course of hys-
 teria,  both  as  regards  the combination of  particular symptoms
 and their intensity.   Exacerbations  often occur regularly at the
 menstrual period;  they are.  moreover, induced by the most
 varied external influences.  Remissions may likewise  be thus
 induced ; sometimes they appear without any recognizable cause,
 and occasionally interrupt in an altogether unexpected manner
 the fatal  monotony of symptoms,  when one has looked upon
 recovery as no  longer possible.
   These  remissions  are, as  a rule, only transitory, and after a
 longer or shorter  period, either the former or  other hysterical
 symptoms again make  their  appearance. Many of the so-called
 cures of hysteria are, in fact, nothing else than such remissions ;
 the continuance of the disease  is distinctly shown by the fact,
 that the  slightest  cause is sufficient to  call forth severe symp-
toms again.   At all events, the  complete cure of hysteria before
the period of involution is a rare event.  It takes place most 
548                   JOLLY.—HYSTERIA.

frequently in those cases in which the disease has been acquired
and in which it is possible  to remove the exciting injurious infiu-
ences.
   The higher degrees of hysterical mental disturbance, as a
rule, first develop themselves after the disease has existed  for
a long time;  these are, moreover, for  the most  part cases of
inherited hysteria.  Sometimes they first distinctly appear at  the
climacteric period, which  is in  other  cases the  turning-point
towards  recovery.  It  sometimes  also  happens  that the first
symptoms of hysteria appear at puberty, that the disease then
remains latent to  a certain extent, again  to reappear in a pro-
nounced manner at the period of involution.
   We have repeatedly spoken of mild and severe cases of hys-
teria, and it  is evident that there are very different  degrees,
from those  simple forms  of increased  irritability to  the rooted
psychical alterations, the attacks of general convulsions,  and  the
widespread paralyses and anaesthesia which one  sees in other
cases.
   But it is scarcely possible more definitely to limit the differ-
ent degrees of hysteria.  If (like Dubois) we regard as a  test  the
violence of the hysterical fits and the degree of  disturbed con-
sciousness during  these, we  shall  form quite erroneous conclu-
sions.  There are cases with fits, very severe, but separated by long
intervals, and it may happen that in  these intervals scarcely any
noteworthy disorders exist.   In other  cases fits are altogether
absent, but the psychical function is so persistently abnormal,
and all attempts at cure are so perfectly fruitless, that we cannot
certainly regard the latter as milder than the former.  One can,
as a rule, best determine the amount of disturbance by the degree
of persistent psychical abnormality, although this again affords
no  measure  of the intensity of  other symptoms.   If fits, paral-
yses, anaesthesia?, and contractions associate themselves with the
severer psychical disorders, we have to deal with the most aggra-
vated  forms of the disease.   On the other hand, those cases are
often comparatively  mild  in which, by  psychical infection, con-
vulsions and other phenomena, even grave disturbances of con-
sciousness, are called.forth,  the appearance of which under other
circumstances would have to be considered very serious. 
PROGRESS AND RESULTS.
549
   Hysteria has only rarely an influence upon the duration of
life in  the case of  those  affected by it.   Even states of extreme
marasmus, which are  occasionally  produced  by  it (hysterical
vomiting,  haemorrhage, etc.), are rarely of such  evil omen as
when  they result from other diseases.   It happens  more  fre-
quently that  exhausted conditions,  otherwise originated, which
produce hysteria, cause the fatal termination.  But  cases are also
known in which the disease alone was to blame for this, and in
different ways  in particular cases.   Under the  name  of  acute
fatal hysteria cases have  been described, in which, after a course
of severe hysterical disorders, which, as  a rule, have owed their
existence to a psychical influence, death has occurred within a
few days or weeks.   In some of these cases numerous and pow-
erful epileptiform convulsions appeared  ; as in the case of true
epilepsy, a cyanotic condition developed itself, the patients  col-
lapsed, became  soporose, and  in  this state died.  Wunderlich
was able in one such case, shortly before death, to determine a
distinct rise of temperature to 43° C.  [109.5 Fall.], without its be-
ing possible to discover a local process in  the nervous system or in
other organs as a cause for this.  In Rullier's frequently quoted
case (These de Paris, 1808), epileptiform  fits appeared, and also a
persistent  sense  of  constriction  in the pharynx  and larynx, so
that a clinical picture,  similar to that of hydrophobia, was given
rise to.  The patient  in  question,  a girl fifteen years of age,
became ill in  consequence  of a fright during menstruation,  and
after her  condition had lasted for  two days,  she died in an
epileptic fit.  In her case, also, no changes were  discoverable in
the brain.   The cases related by L. Meyer are of rather a differ-
ent nature.  In these, acute insane excitement of a nymphomani-
acal character was first developed ; general convulsions followed,
as also  contractions and rigidity in particular  muscles;  the
patients quickly collapsed, and died after the disease had existed
for a few weeks.  Here, too, any change in the nervous system
was absent.  Nothing  definite  can be said concerning the true
cause of death in such cases.   It can only be surmised that the
diseased processes in the nervous  system itself,  which occasion
the delirium  and the  other symptoms, also ultimately  cause
paralysis of the respiratory muscles and heart, as  in those con- 
550
JOLLY.—HYSTERIA.
ditions of so-called delirium acutum which are quite identical,
but arise without hysterical symptoms.
   But the  fatal  results described occur not merely in  acute
cases of hysteria.   After a tedious  and chronic course, a like
violent episode may put an end to the disease and life ; as a rule
milder chronic disturbances have preceded for a length of time
the so-called acute conditions, as, for example, is stated in the
three cases related by Meyer.  Also in a second case of hysteria
with  a  fatal  result,  related by Wunderlich, the disease was
chronic ; a patient who had suffered for years from all possible
hysterical symptoms, paralyses, hyperaesthesiae, loss of sight and
smell, going on even  to difficulty in swallowing, and vomiting,
fell into  a state of marasmus, without evident physical cause,
got more and more emaciated, and finally died with febrile symp-
toms, without the necropsy revealing changes within or without
the nervous system which could  be Regarded as the cause of the
phenomena observed.
   Indirectly, in consequence of hysteria, death may take place
in those  cases in  which patients mutilate themselves, with or
without the intention of  suicide.  It has been already stated,
that the attempts at suicide of such frequent occurrence in the
hysterical are only rarely undertaken in earnest.  I know several
such patients, who have already attempted all possible kinds of
suicide, have cut  their throats,  throttled, hanged, and burned
themselves,  leaped into water, and swallowed phosphorus and
sulphuric acid, but on each occasion,  under circumstances which
rendered rescue probable.  But cases are likewise known in which
suicide has  actually been effected by the hysterical,  and, more-
over,  instances in which  death  resulted  from self-mutilations
undertaken with other intent.  Thus, swallowed needles, which
frequently pass through the stomach and bowels without much
difficulty, have in some cases penetrated the walls of the digestive
canal, and caused  fatal peritonitis.

                         Diagnosis.

   There is  no difficulty  in diagnosing hysteria if we have to
deal with fully developed  cases, and  have an opportunity of 
DIAGNOSIS.
551
watching a considerable portion of its variable career.   Indeed,
it is  frequently possible to recognize the presence of the disease
at first sight from some characteristic symptoms,  above all from
the psychical behavior.
   In other cases, difficulties arise in various ways.  In the first
place, it is scarcely  possible to distinguish hysteria distinctly
from those conditions of so-called  neroousness, nervous tempera-
ment, increased  irritability, or whatever else it  may be desig-
nated.  In these states all the actual elements of hysteria exist,
and their  progressive development merely is necessary for  the
outbreak of the disease.  We may therefore regard it as an hys-
terical tendency,  or  mild degree  of  hysteria.   By taking this
view we can  say with Sydenham, that the  majority of women
are hysterical.  It is, however,  more convenient to  maintain  the
distinction as much as possible, as otherwise our conception of
the disease becomes  extremely hazy : the tendency  to the dis-
ease  also  does  not by any  means necessarily progress  to  the
disease itself; it may remain undeveloped, and from allied influ-
ences may also favor the development of  other  forms of nerve
disease.
   From what point, then, is the term hysteria applicable?  The
frequent change of temper, the  exaggerated sensibility to psychi-
cal impressions also occur in nervous  persons ; some, too, of  the
spasmodic symptoms appear in these,  such as globus and  the
increased action of the heart and respiration, etc., frequently on
very  slight occasion.   At any rate, it is questionable to make  the
diagnosis of hysteria dependent upon the presence  or absence of
a particular symptom. But  its presence may be assumed with
certainty,  if the  psychical peculiarities which mainly character-
ize it are distinctly pronounced and  persist,  if the  variations of
temper make their appearance without any external cause and
are excessive  in all directions,  and if the corresponding altera-
tions of volition and of  the imaginative faculty exist.  Under
such  circumstances, some at  least  of  the characteristic disorders
of  sensibility and motion  may always at  the  same  time be
demonstrated.  Indications  at least  of attacks  are  present, if
only  in the form of occasionally occurring fits of laughing and
weeping, of globus, singultus, and  the like.   But one must like- 
552
JOLLY.—HYSTERIA.
wise number  those  cases  with hysteria in which the fits are
developed in a characteristic manner, with a less severity of the
persistent psychical symptoms, whether they be the general con-
vulsive attacks, or those of catalepsy, ecstasy or hypnotism. On
closer observation it may nevertheless always  be determined in
such cases,  that the psychical  alterations, though, it may be,
trivial  in comparison with the severity  of the fits, are yet never
completely absent.
   Other individual symptoms of hysteria may also appear in so
characteristic  a form that they can easily be recognized as hys-
terical, even when the psychical condition is less marked.   This
applies both to the different forms of paralysis, and anaesthesia,
and to spasms and  painful affections in particular organs.  But
the difficulties of  diagnosis become greater the more isolated such
symptoms appear, and the more obstinately they remain fixed
in particular parts of the body.  The point to  be determined in
such cases usually is, whether so-called  "local hysteria" or more
deeply-seated anatomical changes of the part affected are present,
and  it is  evident that this point is of the greatest importance in
reference  both to prognosis and therapeutics.   In  describing
particular symptoms, notice has already been  taken of the mani-
fold difficulties which beset this part of  the differential diagnosis,
and  of the  deplorable mistakes which may be committed with
regard to this subject.   It may in general  be said, that the
most careful investigation of the whole  state of the patient in all
suspected cases, is as indispensable as the minutest examination
of the parts  in which the local symptoms appear.  The absence
of visible and  palpable changes in the organs which are the seat
of severe pains, frequently affords a good reason for the assump-
tion of the nervous  character of the  disease.   But oftentimes it
is only after long observation that it is possible to attain cer-
tainty  as  regards this, and  particularly also  as  to  whether a
combination of hysteria with local disease does not exist.
   With regard to the discrimination of certain cases of hysteria
from cases of actual disease of the vertebre  and  spinal cord,
reference may in all essentials be made  to what has been already
said.   Pain  and sensitiveness  of the vertebrae, which are so
frequently met  with in the hysterical, are comparatively rare 
DIAGNOSIS.
553
phenomena in diseases of the  spinal cord.  The exciting causes
wliicli are wont to induce hysterical paralyses  (as a rule, psychi-
cal influences) do not easily lead to organic changes in the spinal
cord.   But it is  not to  be denied that  cases of the latter kind
occur, as also that hysterical paralyses do not always distinctly
proceed from such influences.   Some cases of  hysterical para-
plegia, with disorders  of sensibility, exalted reflex excitability,
and contractions, so completely resemble others  in which myeli-
tis or sclerosis exists in  particular portions of the cord, that the
diagnosis is only formed from the progress of the case, and from
symptoms  otherwise present.  It will be least possible to dis-
tinguish cases of so-called  paralysis ascendens acuta, which run
a favorable course, from hysterical paralyses progressing simi-
larly.  Moreover,  there  are some cases of multiple sclerosis of
the brain and spinal cord,  which  can only with  certainty be
diagnosed from hysteria in their later stages, and by the final
issue.  These  are  the  cases in which the paralytic phenomena
frequently  alter their  position, paroxysmal exacerbations, and
frequently  as sudden ameliorations, take place,  and convulsive
attacks and disturbances of consciousness of a like complicated
nature, as in hysteria, are met with.  The disorders of  degluti-
tion and articulation,  also characteristic of  the  former disease,
are now and again observed in  hysterical people.   Hysterical
hemiplegia  is, as a rule, easily  distinguished  from paralyses
caused by apoplexy and encephalitis, by the  well-marked  dis-
orders of sensibility, and by  the absence of facial and  lingual
palsy, yet in certain localized  affections  of  the  brain the same
symptoms occur as in hysterical hemiplegia,  and  occasionally
the cnaraeteristic disorders of sensibility are absent in the latter.
The appearance  of secondary trophic changes  in  the  palsied
extremities almost always argues the material character of the
disease.
   To distinguish  the  convulsive attacks of  the hysterical from
those of the epileptic is in some?cases as easy and simple as it is
in  others impossible.  Attacks occur in exquisitely hysterical
persons which must in  all  respects be regarded as epileptic, and
wliicli can only be recognized as symptomatic of hysteria in that
they, like  the other  symptoms of this disease,  are changeable 
554                  JOLLY.—HYSTERIA.

in their outbreak, and may be  supplanted in  the  most variable
manner by other symptoms.   Their definition  as hystero-epi-
leptic can only be understood in this sense.  At all events, the
same exciting process  in  the brain  constitutes the basis of the
individual attack, whether it arise as the result of hysteria, or
in consequence  of one of  those other numerous causes, which
induce true epilepsy.
   Under certain circumstances, the differential diagnosis between
hysteria  and  hypochondriasis may be very  difficult.   Some
have regarded these as essentially the same, and by one of these
names have  described both diseases,  or  have classed them under
the general name of vapeurs, etc., or even, like Bouchut, extended
the signification of  general nervousness  so far that  the most
varied cases of hysteria and hypochondriasis could be included
in this term.   Others finally have considered the hysteria of the
female, and  the  hypochondriasis of  the male, as phenomena of
one and  the  same  disease, which  merely receives a different
impression from the varying psychical  constitution of the  two
sexes.   I believe we must in the meantime maintain the distinc-
tion between the two diseases, although it is not to be denied that
they present many points of  alliance  and pass over into one
another.   In cases of hysteria in which the characteristic pecu-
liarities of the psychical conduct exist, and particularly the per-
petual variations in temper, they cannot easily be confounded.
Paralyses of the kind met with in  the  hysterical  almost never
occur in the hypochondriacal, convulsive attacks only much more
rarely and not in the same variety as in the hysterical.  On the
other hand, a sort of ill-humor supervenes in some cases which
can only be described as hypochondriacal.  The phenomena of
hypochondriasis here  associate themselves with hysteria, as do
in other cases the  phenomena of epilepsy, or  those  of chorea.
Conversely,  the phenomena of hysteria may  later  appear in
cases at first purely hypochondriacal.  We must first possess a
more exact knowledge than we at? present do of the physiological
connections of the symptoms  of both  diseases, and of the  pro
cesses in  the nervous system which constitute their basis, before
we can more sharply establish the boundaries between  them, and
probably also in other important directions. 
PROGNOSIS.
555
                         Prognosis.

   The  prognosis  of hysteria, quoad vitam, is almost always
favorable.  Cases of a fatal issue of the disease (from suffocation
in consequence  of  spasm of  the glottis, or in coma after severe
convulsive or cataleptic fits, or from exhaustion after conditions
of intense excitement,  of an  acute  or chronic character) are so
extremely rare that one may  in the ease of hysterical people be
unconcerned  even with such symptoms as must awaken  the
gravest  anxiety when they appear as  a result of other diseases.
This applies,  for example, to  the marasmus which sets in after
persistent hysterical vomiting, or after repeated hemorrhages, as
also to  the  profound syncopies which sometimes  make their
appearance in patients,  with and without fits, and so on. Never-
theless,  we must always remember the possibility of  a fatal issue
in such  cases.  If  other physical diseases exist,  in  whose train
the hysteria first arose,  these  may of course render  the progno-
sis, as to the life of the  patient, unfavorable.
   But  rarely as  hysteria,  pure and simple,  causes death, so
rarely does complete recovery from  it take place.   Even where
the latter has apparently been effected, it is, as a rule, observed
that the slightest  cause is sufficient to reproduce  the disease.
In this respect, the prognosis appears most unfavorable in those
cases in wliicli the tendency to the disease is congenital, and in
which symptoms of it first appear in childhood.   In such cases,
an exaggeration of these may usually be predicted to occur dur-
ing the  period of puberty, although  it is true that after  the
termination  of this period considerable remissions sometimes
take place.  But there likewise then occur further exacerbations,
which cannot always be distinctly referred  to particular exciting
causes.  The last hope of such patients is the age of decrepitude,
but again, it  is just the period of involution which frequently
induces  exacerbations, and gives an  impetus, especially to  the
nore inveterate and, in  their  prognosis, absolutely  unfavorable
forms of mental disturbance.
   The most  favorable prognosis may be given  of those cases in
which the tendency to hysteria, and the disease itself, have been 
556
JOLLY.—HYSTERIA.
acquired from  demonstrable  physical ailments  amenable  to
treatment.  A persevering treatment is most frequently rewarded,
particularly when the causes are states of  exhaustion  resulting
from severe maladies,  or  after great  but not persistent  hemor-
rhages ; also when  hysteria has been induced by affections of
the genitals, the cure of which is possible, or by conditions which
are in  themselves  of a transitory nature,  as in  many cases of
chlorosis.   If, on the other hand, the  causal diseases are them-
selves of a  chronic and  incurable nature,  if they do not also
threaten the life of the patient, the prospects of curing the hys-
teria are bad.  But even  in cases in which the fundamental ail-
ment can be removed, and in which there  is no congenital pre-
disposition, we  must not be too sanguine in our expectations.  It
is  very  frequently observed  that  the altered condition of the
nervous system continues, even when  the  cause which induced
it no longer exists.  It is  indeed  frequently possible to  get rid
of the more acute and grave symptoms of  the disease; but the
tendency to further outbreaks remains implanted in the nervous
system, and on every opportunity again comes into play.
   The  same applies  to  cases of  hysteria caused by powerful
psychical excitement. They do not by any  means always justify
the favorable prognosis, which we  might expect from the short
duration of the injurious influence.   On  the  other hand,  the
forms of the disease which arise purely from psychical infection,
are sometimes  rapidly cured by simply isolating  the patient or
by suitable moral and physical treatment.
   The  prognosis  with respect to the intensity  of particular
stages of the disease differs from that regarding its progress as
a whole, as  also from  that respecting individual  symptoms of
hysteria.  We  have already  repeatedly spoken  of the unex-
pected remissions which may occur after the long continuance
of apparently grave  symptoms.  Such remissions take place, in
cases both of congenital and acquired hysteria, sometimes with-
out evident cause, and again in consequence of moral influences
of the most varied description; at other times  these remissions
are to be attributed  to the fact that the cure or improvement of
the physical diseases constituting the basis of  the hysteria fol-
lows by natural or artificial means.  These remissions may under 
PROGNOSIS.
557
certain circumstances  be so complete that it is with difficulty
we can recognize the continuance of the disease, or flrst observe
it by the reappearance at a later period of exacerbations, unex-
pected and without sufficient external cause.  Sometimes, how-
ever, merely the predisposition to hysteria persists, and consid-
erable exciting causes are necessary again to cause an outbreak.
   The individual symptoms in  the sensory and motor spheres,
both alterations of circulation and those  of secretion, are col-
lectively capable of recovery, even when they have existed never
so long  or been repeated never so often.  It cannot positively be
predicted of any one of  them whether it will persist or disap-
pear ; but one usually finds that, if the  same symptom repeat-
edly shows itself, it  becomes more obstinate, and later can no
longer be removed by the same means as on its first appearance.
It can almost never be predicted what symptoms of hysteria will
yet transpire in the course  of a given case, although the fre-
quency  of certain combinations, such as paralysis  with  anaes-
thesia, spasms with  increased sensibility  to pain,  and so on,
sometimes affords ground for surmise  in this respect.
   Deeply rooted and  persistent psychical disorders afford the
most unfavorable prognosis of particular symptoms.  Transitory
phenomena of this kind, even when they are very violent, may
remain without any greater significance for the further progress
of the case.   But  if  the signs of moral  perversity,  of  folie
raisonnante,  are  once distinctly developed, or if  fixed erroneous
ideas have formed, a complete restoration is almost never to be
expected.  This is more likely to occur in the purely melancholic
conditions of the hysterical, if these have not already played a
prominent part in the active development of the disease,  and
thus become an ineradicable habit.
   The attacks of ordinary insanity, which make their appear-
ance in some cases of hysteria for a  shorter or longer period, are
likewise capable of complete recovery (Riickbildung),  but are
apt to induce irremediable conditions of psychical weakness. 
558
J OL LY. —HYSTERIA.
                         Treatment.

                       1. Prophylaxis.

   The rarity of complete cures of the disease, when it has once
fully developed, renders it the more important to combat and
impede its small beginnings, lest from a condition of hysterical
predisposition the disease itself  should be evolved.  Such an
influence is  chiefly possible in childhood and youth ;  but the
physician, of course, is, as a rule, consulted when the evil con-
sequences of a defective regime  come  to light, and we  have
already to treat no longer the tendency, but the disease itself.
If one has an opportunity of giving timely advice in cases of
congenital predisposition, we must treat in accordance with the
indications,  which have already  been mentioned in discussing
the etiology, that  is, insist upon the avoidance of those educa-
tional defects which  notoriously assist the  development  of
hysteria.  As physical debility so frequently exercises an inju-
rious influence in this  respect, it  must  be combated by  all the
means at our command.  Diet  especially must be superintended,
and we must take  care that the children  only receive sustaining
and easily assimilable  nourishment.  The unlimited indulgence
which some  parents exercise in this respect merely leads to this,
that children constantly upset their stomachs with dainties, and
generally acquire a repugnance to all wholesome and nutritious
food.  States of exhaustion and marasmus in a high degree and
quite a host of hysterical symptoms sometimes develop  in this
manner  at an early period, which one may rapidly diminish, if
it be possible to gain so much authority  over a child that it will
submit to a rational regulation of its  diet.  It is no less impor-
tant in  such cases of threatened effeminacy and  weakness to
attend to the "hardening"  of  the  body against influences of
weather,  and to their becoming used  to  muscular  exertion.
Regular exercise in the open air, cold  baths in summer, swim-
ming, gymnastics, and the like,  must be very  strongly  recom-
mended for such children, while allowing them to sit still in the
house for any length of time, and anxiously shielding them from
every draught and from all exertion in any degree uncomfort- 
TREATMENT.
559
able, must be considered decidedly dangerous.   Inuring oneself
to physical pain in such a case is of itself a procedure tending
to corporeal robustness. Particular care must also be taken that
the timidity and anxiety so frequently present in nervously dis-
posed children  be removed, and that they accustom themselves
to suppress such emotions and to overcome their fear of certain
animals, of remaining in dark rooms, of being alone, and so forth.
   Apparent, however, as is the importance of  these principles,
it is not  superfluous to give  warning  that the  proper limits  be
not overstepped in  such a case, as we  so frequently find  they
are ; the  hardening process is carried on with a species of fanati-
cism, which, disregarding the powers  of endurance of the indi-
vidual  in question, saps his  strength instead of promoting  it.
It is just these nervous children of whom we are speaking wdio
are so  often weakly out of doors ; if  they are now incited  to
exertions to which they are not  equal, the consequent exhaustion
is the greater, and self-confidence disappears, instead of increas-
ing.  If t*hey are, notwithstanding, forced by threats and pun-
ishment  to attempt what  they cannot accomplish,  one is the
more certain to  produce natures timid, anxious, and irresolute,
and therefore quite  under  the control of their feelings.  People
must equally be put upon their guard against accustoming  chil-
dren suddenly and by violent  means to frights and surprises.
Various cases are known in which just by such attempts (as, for
example, suddenly leaving them  alone in the  dark, or forcing
them to touch animals of which they were afraid, and so on) the
hysterical predisposition has been confirmed, or the outbreak of
severe  symptoms actually induced.   An influence  upon the
mental has, in the main, to be exerted according to the  same
principles as  upon  the physical  development.    Here,  too, we
must take into  consideration aright the  individual to be dealt
with, and avoid extremes.  Moreover, it is specially important
in this case to eschew the evil consequences of too great endea-
vors, such as are frequently made by nervous children of preco-
cious intellect, in a measure spontaneously, and partly urged by
ambitious parents or teachers.
   All these regulations for education are of great importance  at
the period of puberty,  as at this time many injurious influences 
H60                  JOLLY'.—HYSTERIA.

come into operation which further the development of hysteria.
At this period, indeed, it is  often  too late to combat effectually
the  seeds of the disease, which  have been already firmly im-
planted.   Particular attention must be  paid to the chlorosis
which most frequently makes its appearance in girls  at this age,
and  which is to be  treated on recognized principles.  Nothing
further has to be added to what has already been said as  regards
the appropriate physical and mental training at the period of
puberty, except  that we must avoid allowing children to leave
childhood too soon, and that we  must carefully strive  against
the tendency to fancifulness and abandonment to fantastic ideas
so frequently met with at this time.  Further inferences  to be
drawn from these principles are self-evident.
   Little in particular  has to be said of prophylactic measures
against hysteria in adult life.  These are principally to be taken
into  consideration when a  tendency to hysteria has arisen in
consequence  of physical diseases or psychical  excitement, or
even when the disease  itself has already broken out, but again
disappeared, the  tendency to  a fresh attack merely remaining.
In such case the  same  rules, on the whole, are to be considered
as in the treatment of the  disease itself.  AVe must also here
consider the advice frequently given, that girls in whom a ten-
dency to hysteria exists ought to marry early, as well as the
seeking the welfare of nervous women generally in marriage, that
is, in sexual congress.  In some cases good may be thus effected,
presuming that the marriage is a happy one, and does not in
itself carry the elements of such  influences as favor the develop-
ment of hysteria,  and presuming,  further, that we have  to deal
with  individuals  physically strong, full-blooded,  and  already
perfectly developed.  Much more frequently, however, is this
injurious  than beneficial, and it  is positively objectionable to
advise early marriage in  the case of weakly, anaemic girls, in
whom the entire physical development is retarded.  Even when
matters progress favorably at first, we observe almost regularly
in such  cases that the influences of pregnancy and delivery over-
tax the existing powers, and cause an outbreak of those symp-
toms which we had  hoped  to avoid by the occurrence of these
processes. 
TREATMENT.
561
     2. Tlie  Treatment of the Fully  Developed Disease.

   This may be undertaken in two ways : first, we may seek to
remove the causes which  have induced the abnormal  condition
of the  nervous system, and, in the next place, strive to remove
this condition  itself by means operating immediately  upon the
nervous system.
   a. A removal of the cause of the disease can, of course, only
be attempted in those cases in which these are positively known ;
but even where this is the case, the statement which has been
made in considering the prognosis is frequently applicable, viz.,
that the affection of the nervous system may become independent
and persist, although the cause wliicli originated it may have
ceased  to operate.   With  this reservation, we must next  try to
fulfil the causal indications in those cases in which conditions of
physical disease are the only or chief causes of the malady.  We
have most frequently  occasion to take the field against states of
primary and secondary anaemia, and to employ the dietetic and
medicinal  agents known as tonic  and strengthening.  It is for
this reason, of  course,  that the different preparations of iron, and
especially the use of ferruginous waters, play so distinguished a
part in the treatment of hysteria.   In most of these  cases it is,
moreover, necessary to take into especial consideration the con-
dition  of the  digestive canal, and  the tonic treatment will fre-
quently first be possible after the existing catarrh of the stomach
and bowels, the want  of appetite, and the hyperaesthesia  of the
stomachic mucous membrane have been removed by appropriate
means.   But, as these functional disturbances also arise in con-
sequence of hysteria, it sometimes happens that  we can effect
nothing against them by the usual remedies, and hence it is indi-
cated that the treatment of the hysteria  itself must  in the first
place be undertaken, that we may then fulfil the causal indica-
tion after an amelioration in its individual symptoms.  Even in
cases of hysteria in which other remedies are indicated, and in
which particularly the psychical treatment is of value,  the possi-
bility at the same time exists of promoting  recovery by institu-
ting a strengthening treatment, calculated to improve the quality
of the blood and to increase its entire bulk.
         VOL. XIV—3G 
562
JOLLY. —HYSTERIA.
   More rarely than for strengthening treatment, there are indi-
cations for diminishing the quantity of blood in the hysterical,
by generally weakening measures or by direct bleeding.   The
venesections, for the employment of which people had formerly
a great predilection, and which were repeated in the case of some
hysterical patients with incredible frequency,  are at the present
day scarcely to be mentioned amongst the remedies employed
against the disease.  In fact, it is only very exceptionally that
indications for it arise, unless the nervous phenomena present
may with probability be regarded as the consequence of hyper-
aemia of the brain, in unmistakably full-blooded  individuals,
and particularly if in  severe convulsive attacks in  such people
great cyanosis is developed and suffocation threatened.   In the
extremely rare cases of the latter description,  opening the jugu-
lar vein  in the  neck is  preferable to venesection at the usual
place.—Amenorrhoea, with general plethora, as it is observed in
some cases of  hysteria (occasionally even as the cause of the
plethora), may be an indication for  general  bloodletting.  But
in these  cases it will be well, in the first place, to try the recog-
nized emmenagogues, savine, etc.,  and, if these prove ineffectual,
to bleed, not by venesection, but by the application of leeches to
the vaginal portion of the uterus.  We must, however, remember
that the failure of  menstruation in the hysterical is much  more
frequently the  consequence than  the cause of the  disease, and
that the reddened  and  bloated countenance which  we see in
many hysterical people is absolutely no proof of the existence
of general plethora, but is  much  more likely to accompany dis-
tinct  anaemia.   The cases,  therefore, in which bloodletting is
beneficial are comparatively  rare, while,  on the other hand,
positive  injury is very frequently done  by  this means.  This
also applies to  other  debilitating modes  of treatment,  such as
derivatives,  the repeated administration of emetics and purga-
tives, which are still considered by some physicians indispensa-
ble in the treatment of hysteria,  as  also to purulent discharges
maintained for a length of  time by setons, fontanelles, and the
like.  Even where these remedies,  under the name of revulsives
and derivatives, are employed against  particular symptoms of
hysteria, we see them much more  frequently injure than benefit, 
TREATMENT.
563
while they invariably contribute to a deterioration of the general
state of nutrition.
   The fulfilment of the causal  indications is of the greatest
importance in many cases  in wliicli affections of the genitals
originate the hysteria.  We cannot here consider in detail the
different  methods of treatment for particular forms  of these
affections; this belongs to the subject of gynecology.  Accord-
ing to the state of the case,  the  local use of caustics and astrin-
gents, of injections and sitz-baths, the introduction of the pessary
and sound, as well as appropriate operative measures, will be
necessary.  The application of leeches to the vaginal portion of
the uterus is also much more frequently indicated for inflamma-
tory changes in the womb than  for the  failure of menstruation
with general plethora, as above stated.   The examination of the
genitals is not to be omitted in any case of hysteria in which
there is even a slight suspicion of a diseased condition of these;
if  such affections exist and are amenable to treatment, this must
in the first place be undertaken.   In this way, surprising  results
are not rarely obtained—if not the complete cure of  the disease,
yet a marked diminution of it,  and an amelioration  of many
troublesome and  hitherto very obstinate symptoms.  If  at the
same time the other indications are fulfilled, the general anaemia
arising from local disease removed, and proper attention paid to
the psychical conduct of the patient, in such cases even a radical
cure may be effected.
   It is however  quite wrong, as does not rarely happen,  to use
these  local measures (injections,  caustics,  repeated sounding,
bloodletting, and so forth), which are only rational in local dis-
ease, also in those cases in which the state of  the genitals is
negative,  or at most one of insignificant catarrh, slight change of
position of the uterus, without the phenomena of inflammation,
or in those due to pressure,  and the like.  The excessive  use of
these means under certain circumstances is directly injurious, as
they induce diseased conditions, where formerly there were none.
   The pains also and hyperaesthesias which make their appear-
ance in  the genital  aud  urinary  organs without a  peripheral
cause, as well as the spasms of  the same parts, do  not by any
means always  require a local treatment, for, as  we have seen, 
564                  JOLLY. —HYSTERIA.

even as symptoms of hysteria itself they may be eccentrically
projected phenomena.  In such cases, of course, the disappear-
ance of these does not signify a removal of the causes of the dis-
ease.  It is  only rarely possible to fulfil the causal indication
in a psychical respect, because we do  not as a rule sufficiently
know the moral causes of the disease ; but even when this is the
case, it is not usually in the power of  the physician to remove
them.  Only sometimes  can  he effectively go to work, if he has
had  an  opportunity of becoming more intimately acquainted
with the patient's external circumstances, and of gaining his con-
fidence.  The removal of annoying misunderstandings between
the patient and his relatives, his liberation  from circumstances
in which he  feels unhappy, his temporary or permanent removal
from  surroundings injurious to him, the fulfilment of a cher-
ished wish, rendering a longed-for marriage possible, and so on,
may under certain circumstances work wonders.  But that we
may not expect too much in this way, we must remember that the
hysterical carry in their own bosoms the seeds of dissatisfaction
and misery,  and we must not  regard as a cause of the disease
that which is in reality its consequence.
   b. Of the different methods of cure, the object of which is the
removal of the disease when it maintains an independent exist-
ence, we have in the first place to consider the so-called specific
treatment  of hysteria.   The principal remedies  which  have for
ages enjoyed the reputation of specifics are  distinguished by a
penetrating  and in some cases very repugnant odor, while little
else is known of their physiological properties which can render
their mode  of operation intelligible.   It almost appears as if
more was to be attributed to the stench than to the large quan-
tity of carbon and water contained in some of these remedies,  as
insisted upon by Valentiner, by means of which they are said to
be capable of exercising a peculiar influence upon the fatty con-
stituents of the nervous system.   Formerly, when hysterical
symptoms were supposed to depend upon the womb wandering
about,  the  opinion was entertained  that  the latter could  be
driven out  of the positions it had assumed by nasty smells,
while conversely, by means of substances having a pleasant odor,
in the shape of  salves, baths, etc., which quieted the genitals, it 
TREATMENT.
565
could be coaxed to retain or resume its normal position.  Asa-
foetida is perhaps the best known anti-hysterical remedy ;  it is
sometimes to be used in the form  of  pills, and at other times
in that of clysters ; it is also one of the ingredients of the aqua
anti-hysterica foetida. Galbanum is used in quite the same way.
There are probably few physicians now-a-days who hope by
either of these two remedies to be able to perform radical cures ;
they are most  frequently  employed as clysters during severe
hysterical attacks, but even then are of very problematic value.
It is remarkable  that  some hysterical people do not  consider
the odor of asafoetida unpleasant.  Even at the present day vale-
rian is more frequently used than these remedies.  It is some-
times given as  an infusion, and again as  a  simple  or ethereal
tincture; it is  likewise a  constituent of aqua anti-hysterica
fcetida, and is moreover employed as an  addition to cly7sters,
sitz-baths, and  poultices.   On  the  presumption that valerianic
acid is the active ingredient, various salts of the latter have been
recommended for  hysteria,  especially valerianate of  zinc.   An
anti-spasmodic  action especially has been  ascribed to valerian;
it is therefore considered effectual, particularly in those cases in
which general or  partial spasms are  present;  above all, such as
occur in the  muscular system of the  digestive canal.   In  such
conditions,  indeed, it often appears to possess a symptomatic
value ; it cannot, however, effect a radical  cure.  It is a charac-
teristic  circumstance that  some hysterical  people  experience
relief from  the mere smell of valerian,  and  that their bespasmed
condition may sometimes be ameliorated by letting them inhale
some tincture of valerian sprinkled on a cloth.  In a like man-
ner,  purely symptomatically, but without permanent influence
on the disease,  do the  far-famed castor and  musk act in some
hysterical cases, both  of  which, used especially in the form
of tinctures,  are  regarded as specific anti-hysterics.   This is
also  applicable to the  other remedies to  which an  analogous
significance  has been  ascribed,  such as  the preparations of
ammonia, zinc,  copper  and  silver, and also belladonna, stramo-
nium, hyoscyamus,  and  many others,  except that  they are
almost less effectual even,  as  regards symptoms, than those
previously named. 
566
JOLLY.—HYSTERIA.
   Particular mention requires to be made of opium and its pre-
parations, which have  from olden time  played a part in the
treatment of hysteria, and have  also recently been vaunted as a
radical  remedy for  the  same.  Gendrin maintains  that he has
cured half his hysterical patients by a continuous use of opium,
and  Briquet also mentions  cures in cases which were not of too
severe a nature, and had  not  already  become chronic.   It is
recommended  that  one  should  begin with  small and gradually
proceed to large doses, and  then again slowly leave off.  It is cor-
rect, as Briquet asserts,  that the hysterical sometimes exhibit a
great toleration of opium and morphia.  If we wish to produce
an effect in cases in which sleeplessness, general hyperaesthesia,
and the corresponding excitement have attained a high degree, we
must rapidly proceed to doses  of from three  to six grains of
opium several  times a day, or,»with equal frequency, administer
morphia in quantities of from three-fourths of a grain to a grain
and  a half internally or subcutaneously.   This tolerance, how-
ever, is by no  means general.   Some hysterical patients may be
very easily narcotized by quite small doses  ; others cannot toler-
ate the narcotic at all, and  suffer from vomiting and other un-
pleasant consequences  which render the  employment of this
remedy impossible.   One must  not therefore, in any case, begin
with large doses. Now as  regards the value of these remedies,
they are almost indispensable in the  symptomatic treatment of
hysteria.   In  curable cases, as a rule, they greatly assist the
plans of treatment  otherwise indicated, and in many  chronic,
incurable cases, they at  least afford considerable relief  at some
stages of the disease, and to some symptoms.  But that they can
effect actual cures of hysteria, whether by their influence upon
the nutrition of  the nervous system, or by a permanent diminu-
tion  of  the  abnormally  exalted sensibility, is, according to my
experience,  improbable,  as such an effect  in the case of other
mental disorders, in which  likewise the  persistent treatment by
opium and  morphia has been extolled as radically efficacious,
seems to  me unproved. One  must,  moreover, always clearly
bear in mind that by many patients, and especially by  the hys-
terical,  the habit of taking opium or morphia  once formed can
as little be abandoned  as that  of taking alcohol  by chronic 
TREATMENT.
567
drunkards, and that these remedies, after  long abuse, cause
chronic  and incurable states of intoxication, in a manner quite
analogous to the former.  Although we can, to some extent (by
no means always), prevent this abuse in hospitals and asylums
for the  insane,  by discontinuing the use of the remedy, this is
much less frequently  possible in private  practice.   It is  very
dangerous, as unfortunately so often happens, to place the mor-
phia syringe in  the patient's own hands.
   For the more special indications for the employment of other
narcotics and anaesthetics look further on.
   The dietetic  and hygienic treatment of hysteria, in the widest
sense of the word, is  in many cases more  effectual than the
treatment  by medicines.  As regards this,  we have to do partly
with producing an effect upon the nervous system by appropri-
ate nourishment, partly with an influence  exerted through the
sensory nerves, and  partly with a psychical influence,  without
its always being possible to separate these distinctly.   Medicinal
remedies are of course frequently necessary to assist this.  It
must in some cases be our first care to accustom the patient to a
wholesome and nutritious diet (and to do what is occasionally
alone sufficient—combat  the exaggerated sensitiveness and tor-
pidity).  As directions to this effect are most faithfully executed,
when patients suppose they are undergoing a special treatment,
it is very useful to send them to baths and springs  armed with
stringent injunctions.  Urging  them to rise early, to take exer-
cise, and to remain much in the open air is productive of much
good.  The appetite  improves, they are better nourished, sleep-
lessness disappears, and the confidence of patients in their owm
strength is restored.   If distinct  anaemia exists, places where
there are ferruginous springs are  to be preferred; for  the rest
it is much less  a  question of the quality  of the waters drank
than of  the other surroundings.  It is for this reason that a suit-
able residence  in  the  country, especially  in the mountains, is
often more beneficial than in watering-places, properly so called.
It is, in  many cases, advisable to send patients to milk- or whey-
cure institutions, or to grape-cure resorts.  The efficacy of  such
cures is  always  greater at these resorts than when used at home.
Again, the systematic external application of cold  water  is of 
568                  JOLLY.—HYSTERIA.

material importance.   It is beneficial to the majority  of  those
hysterical people in whom a high degree of debility or other dis-
eases do not contraindicate it, if we cause them to wash in cold
water daily, and apply friction to the whole body,  and during
the favorable season of the year to take a cold bath as often as
possible.  The continuous, and, for particular cases,  appropriate
treatment in well  conducted cold-water establishments is very
often of still greater benefit.
   People are generally agreed, also, upon  the favorable influ-
ence of sea-bathing  upon  the  general condition and upon par-
ticular symptoms of hysteria.  Although there is as yet by no
means a perfectly satisfactory explanation  of  the cause of the
efficacy of cold water, yet daily experience teaches us that it can
influence in a remarkable manner the whole body, and especially
the nervous system.   It seems to be a question  in part of excita-
tion of the cutaneous nerves by the stimulus of cold, in part of
the influence of the latter upon the  circulation and the  body
temperature,  and also perhaps of a change in the excitability of
the nervous  system,  produced  directly by the cooling.  The
effects which one usually observes are, diminution of the univer-
sal hyperaesthesia and sensitiveness to centripetal excitants gen-
erally, increase of  the feeling of strength and,  at the same time,
of the power of will, and therewith the mastery of various other
symptoms of disease.  Moreover, under the cold-water treatment,
systematically pursued, we  see,  as a  rule, the  general nutrition
improve, which may perhaps depend  upon  the improvement of
appetite which usually takes place, and the consequently greater
assimilation of nourishment.
   Besides cold water, there are  other remedies  recommended
for hysteria which stimulate the sensory nerves, and whose ope-
ration is regarded as derivative or revulsive. The simplest and
least injurious of these is the electric  current, and especially  the
induced current.   The  general  faradization   recently recom-
mended by  Beard and  Rockwell, in  which the entire cutaneous
surface is, bit by bit,  treated with tolerably strong induced cur-
rents, may sometimes be of use.  We also occasionally see  the
electrical treatment of particular parts of the body, undertaken
for particular symptomatic indications, followed by  an  improve- 
                         TREATMENT.                      5(39

 ment of the general condition.  Yet the uncertainty and incon-
 stancy of this effect seems to argue its occurrence principally in
 a  psychical manner.  This applies also to  other painful opera-
 tions :  the use of rubefacients to  the  skin, the application of
 setons,  fontanelles,  moxas, and so on, which  sometimes,  it is
 true, are of astonishing efficacy, but in other perfectly similar
 cases utterly fail.   Their effect also depends much more upon
 the moral than upon the physical impression they make.
   A proper moral management is, without  doubt,  the most
 important part of the treatment of the hysterical.   Our experi-
 ence of the most varied remedies is that  they owe their efficacy
 really to the psychical  impression which they create ; we also
 see mental excitement of various kinds have so great an influ-
 ence upon the course and severity of  the disease that we may
 almost accord to such influences a therapeutic value.  In fact,
 although complete cures are rare, yet considerable ameliorations
 of the disease, and striking results in the case of particular symp-
 toms, may frequently be obtained by this means, and, above all,
 the operation of other remedies is much assisted by appropriate
 moral treatment.   This itself must vary much, according to the
 individual case, and only in some respects can it be reduced to
 general rules.
   It is, in the first place, requisite that the physician  should
 either possess the complete confidence of the patient, or that he
 should succeed in inspiring it. Every physician has not" luck "
 in the treatment  of the hysterical, but no physician has luck in
 the case of all hysterical patients.   We meet with such power-
 ful idiosyncrasies in some of these toward particular individuals,
 that  intercourse with  the latter becomes impossible, and if the
 physician is one of these unfortunates it is  better for him, as a
 rule, to give place  to another.    Sometimes, however, perseve-
 rance attains the desired end notwithstanding.  But  that we may
 permanently insure the requisite influence, it is absolutely neces-
 sary to show the patients that we are convinced of the reality of
 their sufferings, and  do  not  consider them imaginary as their
 friends usually do.   Nothing is  more  to be deprecated than
unseasonable ridicule.  One may frequently lose the confidence
of  the patient for a long  time by an untimely jest.  It is, how- 
570                  JOLLY.—HYSTERIA.

ever, equally important to make them understand the nature of
their complaint, and to persuade them that they themselves are
in a position forcibly to suppress this or that symptom, and also
that everything which promotes their power of  will also causes
an amelioration of the disease.   The fulfilment of this last indi-
cation, strengthening  the  will, is, on the whole, the  true aim of
moral treatment.   It can only be accomplished when the physi-
cian himself goes to work with this necessary  conviction, and is
not wanting in zeal and perseverance.    He must see to it that
his instructions once given are strictly and regularly carried out,
and he  must  gradually make  ever  greater demands  upon the
patient's volition.   It is, at the same  time, his  duty to divert
the minds of hysterical patients from their sufferings by compel-
ling them to take an interest in other  more amusing and useful
matters.   If we can rouse the ambition  and enthusiasm of the
patients, it is sometimes possible to make  them exert the  same
zeal in the interest of others which they  have  hitherto exhibited
in bemoaning and exaggerating their own morbid symptoms.
   It has sometimes already happened that an "arise and walk"
has been successfully said to hysterical patients, who  have for
years been bed-ridden, and who appeared no longer able to move
a limb.   It is sometimes the belief in the  power of the physician,
or in that of other people, or again, in  the efficacy -of certain
remedies  that  works such  "miracles."  The  greater  the  assu-
rance with which recovery is predicted,  the more certainly does
it take place on such a command being given, or in  the employ-
ment of remedies the most varied.  One  should, however, refrain
from such predictions if he is not sure of his  authority over the
patient.   Without  doubt, moreover, the imaginative faculty of
the patient is roused to a greater degree by  such  means as
rapidly produce appreciable effects than  by those which operate
slowly and imperceptibly.  Hence it happens  that painful reme
dies,  such as electricity, etc., are particularly  efficacious, and
that  patients are much  more impressed by  the subcutaneous
injection of morphia than by its internal administration, and so
on.   For this reason we must frequently not omit to treat local
 symptoms of hysteria by local means, although we are convinced
 of their central  origin.   When we see, as we occasionally do,  a 
TREATMENT.
571
paralysis of the oesophagus  cured by  simply introducing  the
sound, or a paralysis of the vocal cords by a single faradization,
it would be folly not to make use of these means.   But we must
remember that local measures redirect the attention of patients
to the part apparently affected, and that it therefore becomes  our
duty in some cases  promptly to  stop all such treatment, and to
urge patients to abstain from  the same.
   It is  sometimes possible by means of threats, or by causing
sudden fright, to banish severe hysterical symptoms, and cause
the disease  to make an important change for the  better.  Some
hysterical attacks are  occasionally terminated by unexpectedly
soaking  the patient with cold  water,  and  their repetition is
thereby at the same time  prevented.  By threatening this pro-
cedure, or more  powerful  skin irritants, or  the actual cautery,
the epidemic spread in particular of hysterical conditions  has
sometimes been  successfully  averted.  Amann relates the case
of an hysterical patient who suffered from  attacks of tetanic
convulsions  and ecstasy,  whom  her father cured by a sound
thrashing.  When we remember, however, that all these potent
measures of a physical  and moral nature are also active as causes
of hysteria,  w7e cannot regard them as  perfectly innocent.  In
fact, the much vaunted showers of water during hysterical attacks
do not by any means always  give the desired result, but, on  the
contrary, have frequently been  followed by an exacerbation.
One can therefore only use such heroic remedies in case of actual
necessity when others have failed.
   A remark already made must finally be repeated with regard
to all remedies operating  psychically.   They very  frequently
lose in efficacy by repeated employment, and what has been of
use in one attack is not by any means certainly of service in  the
next.  We must therefore always be prepared with a variety of
plans of treatment, and not rarely do we see the state of affairs
remain unchanged after much trouble and a measure of success.


        3.  The  Treatment of Particular Symptoms.

  During the  hysterical fit  special measures are rarely neces-
sary.  We must merely take  care that the patients do not sus- 
572
JOLLY.—HYSTERIA.
tain injury in consequence of their  convulsive movements, and
that their respiration is not impeded by their clothing.   In the
very severe convulsive attacks of a more complicated nature, in
which patients wheel about and make violent movements in all
directions, it is best to let  them lie on a mattress spread  out on
the ground, and to hold  their hands  just so firmly as to prevent
their  injuring themselves.   Binding them tightly  or confining
them in  a  strait-jacket is  to be avoided as much as possible,
as it may easily prove dangerous by interfering with respiration.
Finally, we must not pay too much attention to all these attacks,
but make the friends take no more notice of them than is neces-
sary, as otherwise we merely contribute to their exaggeration. If
such severe attacks are very  frequently repeated we may try to
suppress them by suddenly drenching the patient with a bucket-
ful of water ;  but for reasons before stated we must not make use
of this remedy except in case of absolute need.   In these, as in
milder convulsive attacks, it is quite superfluous to use scented
materials and skin irritants, washing the forehead with vinegar,
etc., and also clysters with cold water, asafcetida, and the like.
Some consider it necessary regularly to shorten the attacks by
the inhalation of chloroform, but thereby their recurrence is not
prevented and  patients  are  merely accustomed to  a remedy
which it is difficult  again to relinquish.
   This is likewise applicable to the use of injections of morphia
and clysters of  opium.   We should only determine to use such
remedies in the case of very protracted, severe attacks which are
exhausting the strength of the patient.   If a peripheral irritation
is  the cause of  the attacks, they may sometimes be suppressed
by the removal of such.  Thus, in some cases, severe attacks have
been averted  by the rectification of a misplaced uterus,  and so
on.  The means recommended by Charcot, of exerting powerful
pressure in the  region of a sensitive ovary, seems unfortunately
to be effectual in altogether rare and  exceptional cases, and then
probably operates in quite the same manner as would any other
powerful sensory stimulant.
   For the so-called hystero-epileptic fits I have in  several cases
found the protracted use of bromide  of  potassium in large doses
have the  same efficacy as in true epilepsy.  As in the latter, the 
TREATMENT.
573
effect seems to be produced in particular cases, and consists gen-
erally in a diminution, and less frequently in complete cessation
of the  fits.  After the discontinuance of the remedy, however,
these usually reappear in all their former violence and frequency.
   In the rare cases in which, from spasm of the glottis during
the fit, danger is imminent, the otherwise superfluous inhalation
of chloroform and ether is indicated above all else, and, further,
the different skin irritants,  and, perhaps, also the procedure
recommended  by Krahmer of passing the finger below the  epi-
glottis  and drawing it upwards, may be resorted to.
   Simple fainting fits require no particular treatment.  On the
other hand, in the conditions of syncope with weakness of the
heart's  action and respiratory movement  continuing for days,
one cannot omit attempting to  produce an  effect  by powerful
counter-irritants, sinapisms, electric stimulation, etc.,  although
these excitants are often perfectly7 impotent.  This applies also
to cataleptic fits.   If these conditions last for a very long time, it
may, moreover,  be occasionally  necessary to feed the patients
artificially, which is best effected by introducing the oesophageal
tube, but when the muscles are  completely relaxed, it may also
be done by passing nutritive fluids through the nose.  There will
rarely be any occasion in such a case for using nutritive enemata.
The constant current applied to the back has sometimes been
found  efficacious for catalepsy;  more  frequently, however,  it
produces no result.
   Special  remedies  are  likewise only necessary in some cases
for limited spasms in particular sections of the muscular system.
Globus will sooner be  removed  by an enlightened moral treat-
ment than suppressed by local  remedies.  Of the  latter I have
recently seen the frequently repeated  application of the constant
current effectual in a patient suffering from very obstinate globus
(the anode was placed at the side of  the larynx), without its
being possible for me to maintain positively that  the treatment
acted otherwise than psychically.  For sp>asms in the muscular
coat of the stomach and  bowels,  sometimes warm, at other times
cold applications to the  abdomen, are found  useful; internally,
on  the other  hand,  opium  and  its preparations, belladonna,
quinine, valerian, and others, are used  with  more or less effect. 
574
JOLLY7.—HYSTERIA.
According to circumstances* clysters of cold  water, or with nar-
cotic remedies added, are indicated, or valerian, asafcetida, and
castoreum may be used as enemata.
   Hysterical vomiting is one of the most obstinate symptoms
of hysteria.  As  a  rule,  the  entire therapeutic armamentarium
may be used against it in vain, until it is arrested by some acci-
dent.   One, of course,  always tries in the flrst place  to remove
any cause for it by administering food which is as unirritating
as possible, milk  diet,  Liebig's extract of meat, etc.,  but this is
only rarely effectual; likewise ice pills, narcotic remedies of all
possible kinds, chloroform, and so on, are usually of  quite tran-
sitory benefit.  In some patients  it ceases if we only allow them
to eat raw ham, or raw mince meat smartly peppered.   In spas-
tic as in paralytic retention of urine, we must not wait too long
before using the catheter, for, as Brodie has correctly remarked,
we sometimes render retention the more  obstinate thereby.  In
some cases warm  sitz-baths, or bathing the entire body, are suffi-
cient to remove this.
   Electricity is,  apart from the general treatment,  the most
important remedy in hysterical paralyses.   Its effect is, how-
ever, by no  means constant; in two perfectly similar cases, for
example, of hemiplegia or paraplegia, it is found in the one to be
immediately and completely successful, and in the other to have
no effect whatever.  After each sitting there is frequently a tran-
sitory but  well-marked effect,  which,  however, soon vanishes,
and only becomes permanent after  numerous  sittings.  Some-
times, too,  it is only possible to remove paralysis in part.
   The most effectual plan is, as a rule, the application of strong
faradic  currents to  the palsied nerves and muscles ;  but, when
this method fails,  it is sometimes  possible to  produce more effect
by using the constant current.   This  must likewise  be applied
directly to  the palsied parts with  power sufficient to  cause con-
traction, and the  circuit  must be repeatedly opened and closed.
Galvanization of  the spinal cord is specially  recommended for
hysterical paraplegias ; this form of  palsy is  usually much more
obstinate than  others.   Local treatment by  electricity is almost
always  effectual in paralyses in the  pharynx and of the tongue,
as well  as  of the vocal cords ; but in  the case of aphonia espe- 
TREATMENT.
575
cially, there always remains a great  tendency to relapses ;  some-
times, indeed, so great that patients  regularly have their natural
voice,  only for a short time after  treatment,  and then  again
become hoarse.   External faradization of the neck, with which
one sometimes treats first attacks of aphonia successfully, must
later be supplanted by intra-laryngeal faradization and galvan-
ization.  In all these paralyses, besides the treatment by electri-
city, passive motion of the palsied parts, and attempts at active
movement, are of the highest importance.  Powerful compression
of the larynx with  the fingers sometimes temporarily restores
lost speech ; in like manner do the involuntary movements oper-
ate which  take place on introducing the mirror, as also sys-
tematic attempts to enunciate.   It  has  been already mentioned
that paralytic dysphagia has sometimes been cured by a single
introduction  of the oesophageal sound.   In  paralyses of the ex-
tremities, also, shampooing and passive  movements are of use;
the various stimulant and oily frictions probably exercise their
influence similarly.   Hysterical  tympanites may occasionally be
rapidly dispersed by powerful faradization of  the  abdominal
muscles, or even by firm compression of the abdomen.   In other
cases  the introduction of  the intestinal tube may be necessary.
Much discomfort is sometimes caused by obstinate constipation,
arising from  paralysis of  the bowels, which it may only be pos-
sible to remove by large clysters and drastic purgatives.
   If  treatment be at all necessary for hysterical anesthesia,
stimulant ointments or powerful faradic currents are used, which
in this case can best be  conducted  to the insensible parts  by
means of a dry metallic brush.
   The hyperesthesias and pains of the hysterical most fre-
quently demand the employment of narcotics and anaesthetics.
Here,  as in other diseases, the use of  opium and its preparations
for the most  varied pains and neuralgias holds  the first place.
It is used in  all  possible forms and preparations, being intro-
duced per os  or in clysters, as ointments or as a subcutaneous
injection.
  Many think that these remedies are more effectual for pains,
and particularly for neuralgias, if applied directly to the painful
parts (that is  especially by subcutaneous injection), than if taken 
576
JOLLY. —HYSTERIA.
internally.   The proofs which are adduced in support of  this
view are not, however, incontestable.  But patients themselves
believe in the local cure, and therefore it apparently takes place.
In  reality it is probably always effected through the centra]
organs.  Preparations of belladonna, stramonium, hyoscyamus,
cannabis, coca,  etc.,  which  are  likewise frequently employed,
are of  much less value than opium and morphia.  Belladonna
is most  frequently used in  painful  affections of  the  digestive
canal.   Caffein is  supposed  to be effectual, especially in painful
head affections.  The anaesthetic effect upon the cranial nerves
ascribed to  hydrate  of croton  chloral, has unfortunately not
been established;  altogether this remedy does  not deserve to
be  classed  as  an anodyne.   Chloral hydrate, again,  has won
such a reputation, that  in many respects it competes success-
fully with  morphia.   This does not,  however,  apply to its
purely anodyne action without  simultaneous narcosis.  While
it is just in this respect that morphia is extremely useful, chloral
hydrate can only be employed as a soporific.   As such (and com-
bating sleeplessness is often the most important indication in
hysteria) it  does very good service.  Given in doses of one,  two,
or three grammes, if  necessary twice a night, it generally pro-
duces a quiet sleep, lasting  for  several hours, which many pa-
tients prefer to the  sleep induced by morphia.   On the  long-
continued use of chloral, slight symptoms of vascular paralyses
appear, which should be noted ; it is, therefore, best to employ
the  remedy temporarily.   Unfortunately,  however,  habitual
drinkers of  chloral are already almost as frequently met with
as opium and  morphia  eaters.   Inhalations  of  chloroform are
likewise used with transitory success in various painful affections
in the  hysterical.  The remedy is often given internally,  espe-
cially in hysterical cardialgia.   Quinine is sometimes  effectual
in hysterical as in  other forms of neuralgia ;  after the long-con-
tinued use of bromide of potassium, also, we not rarely see both
circumscribed pains and states of general hyperaesthesia diminish.
   We  have already spoken of so-called  derivative remedies
which  seldom remain  untried  in  hysterical pain.   They some-
times operate very quickly and  completely;  more frequently
they prove quite inert.  The electric treatment also of hysterical 
                         TREATMENT.                      577

neuralgias,  with the  faradic as  well as the constant current,
oftener leaves us in the lurch than it cures.   Especially have  I
not been able to convince myself that the galvanic treatment of
painful vertebrae, vaunted by Benedikt, is of  any particular ser-
vice.  Passive and active motion seems to be especially useful in
hysterical joint-neurosis ; it is above all things necessary to con
vince patients of the non-inflammatory nature of their complaint,
and to urge them forcibly to overcome their inactive condition.
   We cannot  here enter  more fully into the treatment of  the
more serious hysterical mental disorders.   Patients who are thus
afflicted are usually found in lunatic asylums.
          VOL.  XIV.—37 
 
DISTURBANCES OF  SPEECH.
AN ATTEMPT IN  THE PATHOLOGY OF SPEECH.
KUSSMAUL. 
 
CHAPTER I.
Human Speech, the Logos, the Agent by which Definite Thoughts are expressed as
   contrasted with the Speech of Animals.—Unconsciously evoked, it serves  the
   Ends of Consciousness.

   Like human beings, animals, too, possess abundant means of
expressing their emotions and desires, and of designedly render-
ing themselves intelligible, not only to each  other, but also  to
man.   Among these may be mentioned touch, cries intended to
scare or to entice, sounds of entreaty and of complaint, melodious
song, looks, and gestures.  To some  even organs for the articula-
tion of sound are not  denied.  But the power of uttering a
word,  which, originating in thought, can  in its turn give origin
to thoughts and deeds, the logos  of  the Greeks, which includes
both reason and speech, is only granted to man.  Speech is by
no means a conscious human invention, as was held by Locke
and Adam Smith ;l it is no work of voluntary combination  of
positions  (thesis), but a  work of nature (physis).   It  origi-
nated without consciousness or  intention,  although it is uttered
now with both consciousness and design (Steinthal).
   It may, to be  sure, on  a  mere superficial glance, appear an
unwarranted  conclusion that speech originated unconsciously,
inasmuch  as  conscious and reasoning cognition cannot be ima-
gined without it, and  that the whole  world of our ideas is con-
structed by its aid alone.  But  in this we have nothing but the
application of a  general principle, according to which all con-
scious action  is appropriately preceded by unconscious.   It  is
  1 Max Mueller, Vorlesungen iiber die Wissenschaft der Sprache. Leipzig, 1863.  Bd.
1. S. 20 und Bd. 2. S. 284 et seq. 
582        KUSSMAUL.—DISTURBANCES OF SPEECH.

not alone our sensory and motor apparatuses  that are at first
unconsciously and unintentionally trained to certain purposes
before they serve conscious  ends ; the metaphysical forms  of
cognition  also included in the category of cause, object, prop-
erty, etc.,  as well as the logical of  judgment and inference, find
in grammatical forms their expression before an idea of meta-
physics or logic exist.  Or, as von Hartmannl expresses it: "As
in the course of time human intelligence began to philosophize it
found ready-made a language already richly endowed with forms
and ideas."
                       CHAPTER II.

       Speech as an Act of Expression and as a Something Expressed.

   Human speech is the result of movements wdiich give expres-
sion to thoughts either by indicative gestures, sounds, or written
words.   Under  the term  speech we understand then at one
moment the physico-psychical act of expression  of thought by
which the latter is  converted either into an indicative gesture or
an uttered or written word, and the  thought-series are worked
up  into a sentence; at another, the expressed matter itself, pre-
sented to us as a word  according to form, contents, and syntacti-
cal  arrangement.  As  a something expressed, then, speech may
be regarded as the  object  of  comparative  philology and ethno-
logical psychology,  while  it  is  the province of physiology and
psychology to deal  with it as a physico-psychical act.
   If  the mental or bodily processes by which  speech is pro-
duced undergo morbid disturbances, both the form  and  sub-
stance  of what is  expressed  are  altered, and   the  language
becomes the study of the pathologist.  The latter  has  then the
double task to perform : in the first place  to deal with such dis-
turbances in relation to symptomatology, and nextly pathogen-
etically to refer them back to changes in the organic mechanism
  ' Echo, von Hartmann, Philosophie des Unbewussten.  AbschnittB. Cap. VI.  "Das
Unbewusste in der Entstehung der Sprache." 
SPEECH AS AX ACQUIRED REFLEX.
583
of speech which produce them.   As elsewhere, so here also we
meet with imperceptible transitions from physiological changes
to pathological.   Physiology and psychology on the one hand,
and pathology on the other, serve to throw light mutually upon
one another : to them originally we must look for a clear com-
prehension of the laws governing the formation of language.
                      CHAPTER  III.

        Speech as a Movement of Expression and an Acquired Reflex.

   Those extremely multifarious movements, by which we give
expression  to the  mental processes within us,  may be best con-
sidered under the heading : Movements of Expression.  Many
of these, as, for instance, the play of features  indicating  sweet-
ness, acidity, and bitterness,1 screaming, weeping, and  laugh-
ing, we have no need to  learn;  they are congenital reflexes.
Others,  and among them speech,  must be learned, and are the
outcome of practice.   Children learn to speak without being
able to  account for it, merely  owing to unconscious  impulse,
directed at  the same time by external instruction.  Within they
are impelled to it by feelings and pictorial  intuitions  which
gradually become elevated into intelligent conceptions.  The out-
ward instructing agent utilizes this inner impulse (so useful peda-
gogically from its  tendency to mimicry) by every wise means to
stamp upon gestures, play of features, and utterance, its own
impress.  Thus, we may regard speech in its earliest stages as an
acquired reflex.
   The  chief characteristic of deliberate  intention, which dis-
tinguishes between the acquired and the congenital movements
of expression, is its greater capability of adapting itself correctly
both in form and  degree to the purposes which it has in view.
Owing to this property, it is rather difficult for us to see in them
  1 Conf. my " Untersiichungen iiber das Seelenleben des neugeborenen Menschen.
Leipzig, 1859. S. 16. 
584         KUSSMAUL.—DISTURBANCES OF  SPEECH.

nothing but a play of mechanical contrivances acquired by prac-
tice.  And yet pantomimic acts and  spoken and written words
are nothing but the products of internal self-regulating mechan-
isms,  set in ordered motion by feelings and conceptions, just as
one may set agoing a sewing, calculating, writing or speaking
machine without needing to know their  construction.  We  can
see clearly in this,  however, that just here lies the best guarantee
for the smooth working of these movements and for the accurate
and rapid progress of speech.  The will, finding everything already
prepared,  and  having  simply to  employ   the  preformed  and
well-schooled mechanisms to carry out its designs, is able to do
so with perfect ease.  Just as  a leader,  in disposing of the hun-
dred  thousand members of his  well-organized and well-drilled
army, has only to issue general and comprehensive orders, so we,
for the execution of the most complex series of movements of our
organs  of  speech, require merely to will the expression of a
thought by this w7ord or that sentence, in order to actually utter
it.  Fortunately for us, in  so doing we have not to trouble our-
selves further about the details in the w7orking of the innumer-
able  telegraphic   stations  which convey our   ideas.   If  our
despatch is properly drawn up and handed in, and the organiza-
tion is in good order,  we may be certain it will reach its address.
                       CHAPTER  IV.

Preparatory Stage of Speech in Interjection and Imitative Gesture.—Its Retrogression
           during Sickness to its Earlier Stage of Development.

   In its first, to acertain extent, preparatory stage of  interjec-
tion,  imitative gesture or imitative  sound,  or both  combined.
speech is a sensation and imitation reflex.
   Interjection in its primary form is an outburst of feeling—the
expression of wonder, joy, or any other emotion originating from
the exercise of any of the perceptive faculties.  It is consequently
no mere sensory reflex, as, for instance, sneezing, in which motion
follows immediately upon  the tickling sensation in the  nose. 
           INTERJECTION AND IMITATIVE  GESTURE.        5$-}

And yet there exist transitions  from mere  sensory reflexes  to
emotional reflexes—from the cry of pain which both animals and
infants will utter, even after destruction of the cerebrum, to the
unarticulated cry which escapes  the  mother when she sees her
child in danger.  In both cases a painful feeling  is betrayed by
a reflex cry, but that of the mother is based upon a  reasoning
cognition  in  contrast to that of the anencephalous child.  One
step farther  and  the reasoning  cry  acquires the  form,  in the
scale of reflexes, of an articulate  complaint, or regularly spoken
interjection, as, Alas ! or, Good gracious !  and such like.  The
inner motive remains the same, but the motion is no longer the
same simple natural  utterance, but a word acquired by7 instruc-
tion.
   Imitation, again,  is not  necessarily immediately consequent
on sensation ; it  always implies  a certain amount of attention
and  perception and  pictorial  intuition gained  thereby.   But
while interjection is at first  purely subjective, and but expresses
some feeling of the individual, imitation contains an essentially
objective element, endeavoring as it does to reproduce  in  kind a
given perceived phenomenon by gestures or sounds.
   Interjections and  imitative gestures and  sounds are the ear-
liest germs of pantomimic  and phonetic speech, but as yet not
fully these.  Speaking involves understanding  oneself as well
as others.  AVe speak for the first time when  we comprehend our
own feelings  and intentions, and are able to exchange with others
true, intelligent conceptions, no matter whether this is effected by
gestures or sounds.  Interjection and imitation constitute the
bridge leading up to this comprehension. Interjection and onoma-
topoesis supply to the thinking intellect, which transforms feel-
ings and intuitions into intelligent conceptions, the first words,
or, more strictly7 speaking, word-germs.
   Speech is  only7 possible where the individual lives, feels, imi-
tates, and thinks, in  the  companionship  of his fellow-men.
Strictly speaking, it is  not  a product of individual man, but of
peoqiles.  From the fact that in the earliest  ages all men occu-
pied an  equally low stage of development, there was of course,
among the similarly  living, feeling, and perceiving members  of
the community a mutual understanding of  each other's outbursts 
588         KUSSMAUL.—DISTURBANCES OF  SPEECH.

of feeling and imitative gestures and sounds ; and so these came
to correspond in their  most essential characters.   Thus, not
only did sneezing and screaming come to be understood by every
one,  but also such  gestures and  emotional sounds  as those  of
enjoyment, horror, etc., or the mimicry of cock-crowing, or bark-
ing of  dogs.   Even at the present day savage  peoples render
themselves easily intelligible to one another by means of gestures
and imitative sounds.1
   Some distinguished philologists of our day, and among them
Max Mueller and Lazarus Geiger,2 have improperly denied this
origin  of language  from interjection  and  imitation, or, at all
events,  have estimated its significance at almost nil.   To be sure,
words  of  the present day  display, as a  rule,  nothing  of the
original relation which must have existed between the perceived
phenomenon  and the feelings aroused by it,  or  the phonetic
movements called forth by it from the first word-maker.   In the
course of ages they7 have assumed a marvellous diversity of form
in the mouths of the different nations.  But, for all that,  a large
proportion of words  in all the languages of the world have  still
preserved a certain sound which at once betrays their sense.3 In
our children, however, the onomatopoetic feeling  persists still in
undiminished force,  and their conception of a dog, in spite of
all Mueller's  ridicule  of  the  "bow-wow  theory,"  proceeds
invariably in the  first  instance  from sound-mimicry.    It  is
also certain that speech  is  learned only by onomatopoesis : the
child mimics  its parents' words just as it does the barking of a
dog or bleating of a sheep.   The same feeling makes itself strik-
ingly evident  also in the constant transformation of words and
the reception of strange ones into the peculiar glossaries of indi-
   1 Even deaf-mutes can render themselves easily intelligible to savages.  The panto-
mimic expressions of savages and deaf-mutes are analogous to the dialects of a primal
language. Conf. some interesting facts related by E. Tylor, Investigations of the Early
History of the Human Race.
  2 L.  Geiger, Ursprung und Entwickelung der  mensch. Sprache und Vernunft.
2 Vol. Stuttgart, 1868;  also by the same author, Der Ursprung der Sprache. Stuttgart,
18G9.
   3 Exemp. g., our "pah,"  "phew,"  " tic-tac," "clip-clap," "swish," "hum,"
"crackle," "rumble," "cluck," "pewit," "cuckoo," and soon. 
            INTERJECTION  AND  IMITATIVE  GESTURE.         587

vidual peoples.1  Finally, the art of speaking, whether in poetry
or prose, appeals again and again to this strong feeling.3
   Again, writing springs out of that impulse which urges us to
reproduce all phenomena in mimic representations.  But even so
far back it was a more lofty and artistic impulse which directed
the hands of the ancient inhabitants of the caves, when they7 exe-
cuted the portraits of their contemporaries, the reindeer and the
mammoth;  for here  there was no rude emotional impulse, no
question of satisfying any necessity of  daily life by the produc-
tion of such drawings. It is no doubt a  long step from the picto-
rial representation of a perceived object to that of  a heard word
or phonetic  element ;  for written language involves the analysis
of the structure of the language, so far as words, syllables,  and
accents are concerned, which only becomes possible at a stage of
culture attained later on.  And yet the earliest germs of written
language are found in this artistic impulse of the first inhabitants
of the earth,  whilst its perfecting was  reserved for a period of
much  higher intellectual development.   The hieroglyph is the
parent of phonetic word-writing.  Here then we  have an early
bond between gestures, words, and writing ;  from one soil they
have sprung, three sources of intellectual power—the youngest,
writing,  having come forth in the  full sunlight  of  completed
consciousness.
   In conditions of either transitory or  permanent mental weak-
ness, speech may often be observed to revert again to the  level of
its preparatory  stage.
   Many insane people, for instance,  often give  vent to  their
emotions in  interjectional  expressions of feeling,  at one time in
the form of simple sounds, especially vowels ;  at another,  of  syl-
lables or word-like combinations  of sounds.  These are often
  1 For instance, out of the root tan (to make tense) is formed the (German) word
Donner (thunder); and the  French rouler (from rotulare, rota = a wheel) is meta-
morphosed into rollen, instead of  into ruhlen.   Conf.  Oscar Peschel, Volkerkunde.
Leipzig. 2. Aufl. Entwickelungsgeschichte der menschlichen Sprache. S. 103-117.
  2 In the words of a great German poet, " Die Werke klappern Tag und Nacht," Stein-
t/ial remarks, that not only the word "klappern," clatters (" klappert"), but also the
words "Werke" and "Tag." 
588         KUSSMAUL.—DISTURBANCES OF SPEECH.

entirely  unassociated with ideas, or only so with obscure con-
ceptions.1
   Attention to those imitative utterances to which the name of
" echo speech" has been given was first drawn by Romberg.2
He says : " Sick  people sometimes repeat monotonously words
and sentences uttered by any one close to them, without giving
any evidence of their attention being aroused, and without con-
necting any ideas  with what they say."  He  adduces  several
instances of this, and Bateman3 has lately7 placed  on record a
new  and most striking case of it which occurred in Yoisin's
wards in the Salpetriere.   Many similar  observations  by other
writers might also be mentioned.
                       CHAPTER  Y.

                  The Principle of Sound Metaphor.

   Although not difficult to conceive why man should respond
to the  reception of sounds through the auditory apparatus by
making imitative noises, it  is so  to  understand why sounds
should be chosen as the favorite interpreters of all the  senses ;
yet there is no people on  the face of the earth, however savage it
may have remained, which  contents itself with indicative ges-
tures.   In every quarter of the globe man has acquired a readi-
ness, through the agency of the voice,  with its  extraordinary
variety of sounds and combination of sounds, in ascertaining the
condition of all  the senses, and  of copying down, as it  were,
their pictorial intuitions.   Whence  springs this natural pre-emi-
nence of the voice over gestures as a means of intellectual  inter-
course \
   The sensations through which we obtain a knowledge of things
outside ourselves, however various  the forms they may assume,

   1 Martini, Veriinderungen der  Ausdrucksweise bei Irren. Allgem. Zeitschr. f. Psy-
chiatrie. 1850. Bd. 13. H. 4. S. G05.
   2 Lehrbuch der Nervenkrankheiten.  3 Aufl.  S. G55.
   3 On Aphasia.  London, 1808. p. 75.  Conf. Brosius, Ueber die  Spraohe der Irren,
Allgem. Zeitschr. f. Psychiatrie.  1857. Bd. 14.  H. 4. S. 63. 
            THE PRINCIPLE OF SOUND METAPHOR.          5S9

according to the nature of the senses affected and of the stimulus
arousing  them, may  awaken,  nevertheless,  in the  perceiving
individual very much  allied feelings of pleasure or the reverse,
even to the extent of pain.  We know, for instance, that a start-
ling color may arouse the same feeling within us as a startling
sound, and the one sensation reminds of the other, although con-
veyed to us by a different sense and determined by other impres-
sions.  AVe  institute comparisons between sensations according
to their  relationship in feeling, and so speak of  crying colors
and cold lights, bright, warm, high, and low tones, sweet sounds,
hard  and soft noises,  sharp odors,  mild taste;  and, as  these
examples show, not only do the simple sensations become intui-
tions  gained from the  senses by tentative movements, but they
are helped by unconscious judgment as well.  These intuitions,
then,  convey the general impression of simple sensations, such
as roughness,  hardness, depth, etc., when investigated in respe-ct
to their relationship of feeling,  and are, according to the result,
considered similar or dissimilar. To put the matter figuratively,
we are able  to translate the feelings  of one sense into the speech
of another.
   Manifestly, of all  the senses, that of hearing presides over
the richest range of feeling  ; of all the arts, music,  which by its
harmonies can stir up  the ocean of feeling to the greatest depth.
But the power of mightily influencing an emotional condition is
not restricted  to musical sound  alone ; noises also possess it to a
very  large  extent, and may excite the phantasy powerfully.
Of all hallucinations, those of hearing are  most feared by the
mental physician.   It is in this extraordinary richness of the
hearing sense  in shades of feeling, then, that its capacity lies of
participating  to a  certain extent in the impressions  of all the
senses, and  hence  the voice, although primarily but the inter-
preter of the feelings aroused  through hearing, is, nevertheless,
peculiarly adapted to  express  also the feelings of  all the other
senses.   Furthermore, spoken  words convey the impressions of
all the senses with  the least expenditure of force and time.
   This is what was understood by Heyse1 as the  principle of
1 System der Sprachwissenschaft. S. 94. 
590          KUSSMAUL.—DISTURBANCES OF SPEECH.

sound metaphor :  "A perception of  any one  sense is expressed
by a phonetic composition which produces upon the inner sense
of the hearing apparatus a similar impression to that which the
perception to be indicated evoked through that other sense." l
   Kleinpaul2 regards  it as "almost an accident that  phonetic
speech should have come  so exclusively into use, since there is
very little doubt that, had pantomimic speech been developed by
the use of centuries, it would hardly have been inferior in com-
pleteness, adaptiveness, and variety."  But, in spite of the inter-
esting support which Kleinpaul gives to the theory of the great
capability of development inherent in pantomime,  he has not con-
vinced us of the identity in value between the speech of gestures
and that of phonation.   Deaf mutes, he maintains, may produce
a piece of Shakespeare in the language of signs; but, though this
may be true there,  proof is still lacking that  pantomimic lan-
guage will ever raise up a Shakespeare among the deaf-mutes.
                        CHAPTER VI.

Origin of Intelligent Speech from Word-roots.—Intuition and Intelligent Concep-
   tion.—Sensory or Instinctive in contrast to  Intelligent Judgment.—Speech as
   an Associated Conception-reflex and as an Act of Will.— The Three Stages of
   Language : Preparation, Diction, and Articulation.

   The speech in which we now express our feelings and thoughts
has long forfeited its originality.  It has come down to us as an
inheritance which, having passed through the hands of thousands
   1 I have written to Prof. Kussmaul to know if this quotation has been correctly
translated, or whether there  was a misprint in the German text, as I felt it to be
extremely obscure.  He replies, thanking me for pains I had taken with the quotation,
which, he says, he has put in inverted commas, to show that "they are Heyse's own
words," as he feels " that they are not so clear as they should be, and that a great phi-
lologist like Heyse ought to have expressed his thoughts with more clearness and accu-
racy." He says this translation "appears to express what Heyse meant to say."—
Translator.
   2 On the theory of pantomimic speech, conf. Zeitsch. f. Volkerpsychologie. Bd. VI..
1869.  S. 353. 
             ORIGIN OF SPEECH FROM WORD-ROOTS.          591

of generations, has undergone innumerable modifications.   To
discover the internal and external determining causes of these
latter is the province of philology, and concerns us no further.
The onomatopoesis of the infancy of the human race has, with
the exception  of some faint traces, vanished from the languages
of the nations.  Even our interjections have little any longer in
common with  the utterances of feeling of those earliest days of
mankind,  and they  have only partially preserved their naive
character.   Do we not see this  in the oaths of reprobates swear-
ing by the Holy Sacrament and profaning the holiest names in
Christendom ?  Dogma and  church  history  supply them here
with suggestions for interjectional relief in moments of passion-
ate excitement.
    So far  as comparative philology has  succeeded in following
up to their earliest etymological roots the languages of different
nations by means of a comparison of the oldest literary remains,
we stumble everywhere  upon  well-established  nuclei of lan-
guage which  still display,  though but partially, their original
onomatopoetic character.   Even these word-roots in a philologi-
cal sense are far more than mere sounds  expressive of feeling or
imitation; they are "thought-nuclei" around which, as develop-
mental centres, the whole world of ideas whose possession is  the
joy of humanity at the present day gradually sprang up in word-
structures.1 They are the idea-elements of speedi, as consonants
and vowels are its sound-elements.  In them may be seen faith-
fully reflected the  condition of intellectual development of  the
progenitors of our  great national families (Indo-Germanic, Semi-
tic, Turanic, Chinese, etc.); and etymology in following  up  the

   1 The Aryan root MAR signifies to grind, to pulverize.  From it are derived the San-
skrit malana, to grind or rub; and  a number of words all signifying mill, the Latin
mola, the Greek myle, the Irish meile, the Bohemian myln, and the Lithuanian malunas.
Then the German Mitller (miller) ; MiXhlstein (mill-stone); Mehl (meal); mahlen (to
grind); Mahlzahne (molar teeth, dentes molares), etc.  Metaphorically, MAR acquired
the signification of being ground, pulverized,  worn out, destroyed.  Hence the Greek
maraino, to wear  out; marasmus, wasting;  morior, I die;  mors, death ; morbus, dis-
ease. In Sanskrit, mriye, I die ; mdrta, man considered as a mortal.  In old Slavic,
mfeti, to die ; moru, pestilence, death. In Lithuanian, mir-ti, to die; etc.  In these
examples one sees the aptness of Jean Paul's comparison of language to a lexicon of
obsolete metaphors. 
592         KUSSMAUL.—DISTURBANCES OF SPEECH.

history of the changes  in such ancient thought-nuclei, through
all  the phases  of  the life of these peoples down to the present
day, becomes the history of the genesis of ideas as completed in
the families and later peoples (Steinthal).
   With the creation of word-roots as established speech- and
thought-nuclei,  language was  elevated from  the preparatory
imitative stage to the second real word-forming or  intelligent
stage.   Arrived here, speech is no longer the mirror of mere sen-
sory intuitions.  The individual has now7 at his disposal intelli-
gent conceptions which find in words  a palpable  form cogniza-
ble to the senses.  An intuition is not  an  intelligent concepAion.
The former  is nothing but  the sensory picture, the photograph
of things as they happen to present themselves accidentally, or
were viewed and  copied as a certain  combination of dots and
lines of light and shade, of  wdiite and  black and various colors
optically, or a definite combination of  tones of  different  degrees
of height, loudness,  of body and timbre acoustically.   But it is
not yet the true picture of the object such as we throw off by
our own creative power, marking all its essential characteristics
and rejecting all which  appears to us  accidental  and transient
about it, and this after comparison of  numerous tentative intui-
tions under different circumstances and conditions.   Let a pho-
tograph be never so  successful  technically, it fails to satisfy us
unless  it so represent the object  that we at once  recognize it in its
most essential features.  No one would gratify a friend with a
portrait depicting him  in  the  act of  making  a grimace, even
though technically it might be a masterpiece of photography.
   But we must admit  that even in  the creation of pictorial
intuitions, judgment is  already more  or  less  mixed up.   The
actual  shape of the  object,  the resistance it offers to the touch
and to attempts at  lifting, the intensity with which  and  the
direction from  which the  sound reaches us, we unconsciously
estimate with great  certainty.  Animals deprived of  their cere-
brum and unable  any longer to execute  voluntary movements
still possess visual intuition, which supplies them with the power
of suiting their reflex movements to surrounding  circumstances
(Goltz). There exists, then—a lower, let us call it—a purely sen-
sory or instinctive analysis and judgment, discrimination and 
          INTUITION AND INTELLIGENT CONCEPTION.        593

combination, which has within the brain an origin widely sepa-
rate from the higher and intelligent.  Such a sensory or instinc-
tive analysis and judgment operates, no  doubt, in those reflex
sounds which adapt themselves  imitatively  to certain percep-
tions ;  but the formation of words  which have their origin in
conception is brought about by intelligent analysis, comparison,
and judgment.   Words are more for us than  mere pictures con-
verted  into  sounds of  things  mirrored on the senses; they are
pictorial symbols for things as we have come  to conceive them
through deduction  based upon the  incessant variation of their
phenomena—they are the symbols of ideas (Begriffszeichen).
   Based  upon  the world of  sensory intuitions, which was the
first  to open upon him in a  full  blaze  of  color,  man builds
another colorless world of abstract ideas, but not in such a man-
ner as to demolish the  first formed byr the last; for the sensory
pictures, though gradually paling,  live behind the  ideas,  and
renewed  perception freshens  them  up easily  to their original
vividness.  If the picture grow indistinct, the sharpness of the
idea-outlines obtained  from it suffers  in  consequence, for the
world of ideas has  the roots of its power in the world of sensory
pictures.  Consequently it is  correct to say that the senses sup-
ply us with all the  matter recognized by us, but the intelligence
assimilates it according to the for mule of cognition with which
it is  supplied.  The material  acquired  by the  senses must  first
pass through the  three-fold  mill of  logic, metaphysics,  and
grammar  before  it  really becomes the property of the intelli-
gence.
   From all this it is  clear that words, so soon as speech has
passed the  preparatory stage  of onomatopoesis, are no longer
mere intuition reflexes.  They rather represent  the abstract  con-
ception or idea  upon  which  the  words  are  dependent;  and
between the sensory picture and the word there  exists a wide
field of intellectual  work which must always be engaged before
a word can be uttered.   TJie latter is always the expression and
conclusion of a  movement of thought, which has, no doubt, its
primary source in  sensory perceptions, but is not necessarily
immediately'dependent on these.   Thoughts generate thoughts
as surely as thoughts  are generated by perceptions through the
          VOL. XIV.—38 
594         KUSSMAUL.—DISTURBANCES OF SPEECH.

senses.   For this reason,  since  a distinction  has been  made
between intuition and conception, words have been very properly
regarded as conception reflexes (Steinthal, Lazarus).
   When w7e  employ this  expression we only  mean that  the
reflex mechanism, which executes all  the organic movements
emanating from the nervous system, also generates the complex
movements  of the words which  express  the intelligent  concep-
tions.   To reveal this reflex mechanism in the whole  motion of
its wheels and transmissions,  and the vital forces by which it is
fed, is the province of the physiology of speech.  In speaking, we
see conceptions,  feelings, and sensory intuitions  interlacing with
one another in a most  extraordinarily intricate manner, and so
setting agoing the motor apparatus which accomplishes  the au-
dible utterance of the word.  We  only apparently simplify the
matter by characterizing speech straight off as an act of the will,
or by classifying it according to physiological  terminology under
the associated conception reflexes.  What is called will is no sim-
ple force, but a very complex dovetailed combination of partly
associative, partly reflex processes in the excited nervous system;
and  speech as an act of will is only then explained when we  are
able to localize in the nervous system all the operative special
associations and reflexes—that is to say, to determine anatomi-
cally all the paths by which the  stimulus is  conducted, and at
the same time to establish physiologically  all the sources  by
which it is fed.
   It is already a long established psychological axiom,  quite
apart from all nerve physics,  that  a bare idea, although it may
qualify the will  for the highest efforts, never alone determines a
man to act,  but that  it is always some feeling that does so, such
as of duty, of justice, of pity, etc.  A conception emanating from
sensory intuition as a cold and colorless  abstraction, has as such
no  impellent  motor  power.  Again, we see when an  idea is
expressed in speech that the prime mover of the uttered word is
invariably a feeling.   But even this is not sufficient. For speak-
ing  are further requisite symbols, intuitions of  the intelligent
conceptions themselves which  we have put  into the sensory form
of word-pictures.  Only thus  do we apply the reflex lever  to the
motor apparatuses of the organs of speech.  But this psycholo- 
THE THREE STAGES  OF LANGUAGE.
595
gical comprehension of the subject is still no physiological one.
For what we characterize as feeling, conceptions, and intuitions,
are to the physiologist but the psychical expression of material
processes in the organic groundwork of  the nervous  system,
which is equally  adapted  for the  evolution of the forces  be-
longing  to  mechanical  and psychical  performances.   These
mechanical  and psychical performances course inseparably side
by side, united by the same set of laws ; and  to understand both,
it is first necessary to lay bare the organic conditions in the nerv-
ous system  out of which both together spring twin-like.  It is
the task of the physiology of  speech to ascertain where and
how the nerve-substance is rendered capable  by conceptions and
feelings of  creating language through the medium of word-pic-
tures.
   Let us now reconsider for a moment the most essential points
in the process of talking.  In the first place, a thought is indis-
pensable which we have conceited, and then  an impulse of feel-
ing urging us to express  it.   Next we choose and say the words
which the acquired  language in our memory places at our dis-
posal.  Finally, the reflex apparatuses are called into play which
give  outward  utterance to  the words.   Accordingly, the act  of
speaking consists in three stages or  processes :  (1) The prepara-
tion in the intelligence and feelings of the matter to be uttered;
(2) the diction or the formation of the words  internally, together
with their syntax; (3) the  articulation or formation of words
outwardly, irrespective of their  connection with one another in
the matter spoken.1
  1 These three definitions do not appear to the translator to be as carefully expressed
in the original as might be, but he has thought it his safest course to translate them as
literally as possible.  The word diction is the same word as that used in the original.
—Translator. 
596         KUSSMAUL.—DISTURBANCES OF SPEECH.
                      CHAPTER VII.

Speech as the Agent of Intelligent Cognition.—Dialectical Thought as opposed to
   Thinking in Objective Images.—The Relative Independence of Conceptions
   upon Words.

   In  characterizing  it an associative reflex  we have  not ex-
hausted the meaning of speech.  It is more than merely a motor
process reflectively bound up with thought by associated sensory
symbols.  It is besides this a mental act, without which an intel-
ligent cognition of things cannot be attained.  It not only repro-
duces what  has been thought, but claims thought and generates
thought  anew ;  and  comprehension of what is thouglit  only
becomes possible through speech.
   Animals are capable of forming conceptions, judgments, and
conclusions  of a simple kind, human beings alone of ideas and
more  highly compound  judgments and  conclusions.  The dog
bounding to the door, with a joyous wag of his  tail, as he sees
his master put  on his hat, has a conception of  what is taking
place (Wundt').  Pictures arise in his recollection, and he judges
correctly that his master is preparing to go out; to this he adds
the other judgment,  namely,  the  expectation  that he will  be
allowed to accompany him.  But  these conceptions of  animals
are but little elevated above the  intuition world of the senses.
Their thought only deals with objective images and very simple
abstractions, that of man  with word-pictures and  ideas.  Com-
bining his conceptions with words, he  creates not alone short
symbols intelligible to others, but imparts to his abstractions the
completeness, accuracy, and stability of ideas.  Only as an idea
is the conception capable of a critical analysis and logical dissec-
tion.  It is this which distinguishes man from the brute creation,
namely, that he is not only able  to form  ideas and judgments
concerning things around  him, but is also  able voluntarily to
array these  ideas and judgments as objects  before  himself and
1 Vorlesungen iiber die Menschen- und Thier-seele. 2 Bde. Leipzig. 1863. 
         INDEPENDENCE  OF CONCEPTIONS UPON WORDS.     597

others in a form cognizable to the senses, and to test their accu-
racy dialectically.
   It is  still a vexed question  whether intelligent thought is
bound up  with words (Condillac,  Max Mueller,  Bastian,  and
others), or  is quite independent of words  (Locke, Helmholtz,
Maudsley, Finkelnburg,  and others).
   But it is clear that conceptions and words are different things,
and the  independence of conceptions upon words may also be
easily proved.  For instance, the Lord's Prayer expresses in the
most diverse forms and combinations of words in different langua-
ges the same  religious contents.   Newly discovered  animals  and
invented machines  are earlier recognized than are their names
(Tylor).  We read  aloud to another, thinking all the while of
something  else, and afterwards do not know what we have been
reading about (Finkelnburg).  But the most instructive fact is
one wliicli  each may verify on himself.  We can, for instance,
recall vividly to  our minds all  the essential characteristics of
some person or thing, can accurately conceive a picture of it, or
perhaps set down such on paper; we know how it affects us,  but
we have forgotten the word descriptive of it: this is an "aphasia,"
which falls quite within the range of physiological disturbances.
Conversely, we may not be able to recollect any longer the mean-
ing of a foreign word or artistic expression;  or again,  onomato-
poetic and etymological feelings lead us astray to false and often
ludicrous constructions.   At times, too, thought travels  so fast
that speech is unable to follow it  up.
   But not alone is the independence of conceptions upon words
beyond doubt, but, as has been adduced from the facts put for-
ward by Tylor—and the development of conceptions in children
and animals likewise proves it—conceptions may originate with-
out words.  One thing is  certain,  however, namely, that the con-
ceptions of animals remain far behind those of human beings, and
that only in the latter do  they attain to entire clearness, delicacy,
and well-rounded form as ideas through fjie medium of speech.
   By way  of proof that intelligent thought is not bound up
with speaking, and  is quite independent of words, a number of
facts are quoted, to which we must now devote  our attention
more closely. 
598          KUSSMAUL.—DISTURBANCES  OF SPEECH.

   1. It has  been pointed out  that from birth on,  deaf-mutes
have learned to recognize things  and  relations properly.   A
case related by Kruse,1 bearing upon this point, is particularly
instructive.
   A deaf and dumb boy was found by the police, in 1805, straying about Prague.
Not being able to make anything out of  him, they placed him in an institution for
deaf-mutes, where he received instruction.  When sufficiently educated to give ac-
curate answers to questions put to him, he gave a description of as much of his former
life as remained in his memory.  His father, he said, owned a mill; he described the
furniture of the house and also its surroundings minutely; he  gave a full account
of his life while at home;  how that his mother and sister died, and his father
married again;  how that his step-mother ill-treated him until he ran  away.  But
he neither knew his own name nor that of the mill;  he knew, however, that it lay
to the east of Prague. Inquiries were made, and the statements of the boy were
found to be correct. The police found his home, gave him his proper name, and
secured to him the succession to his father's property.

   From this we see that a deaf  boy who had not learned phone-
tic speech had  nevertheless stored up a multitude of accurate
recollections, and was able by the exercise of judgment to arrive
through them at correct  conceptions of very intricate relations.
But  wdiether he found these conceptions without the slightest
aid from the language  of gestures is not related. There is no deaf-
mute who has  not learned a  number  of gestures by means of
which  he is able to make himself intelligible, if not to strangers,
at least to those belonging to him, unless, indeed, he be idiotic
too.  The  objection  is also admitted that this boy, after being
instructed in the  institution, may have  subsequently brought
many recollections into their proper connection, and now for  the
first  time have understood formerly unintelligible relations.  We
are justified  in this conclusion  by the  combined testimony of
such experienced instructors  of  deaf-mutes as the Abbe  Sicard,
and  Eschke, the director  of the Berlin establishment for the deaf
and  dumb, that deaf-mutes without instruction hardly rise above
the level of animals, as regards reason and feeling.2
   Another  case is also put forward,  namely, that  of  Laura

   1 Ueber die Taubstummen u. s. w. Schleswig.  1853. S. 54.
   2 Conf. E. Schmak, Kurze  Geschichte und Statistik der Taubstummen- Anstalten u.
s. w.  Dresden. 1830.  S. 26. f. 
INDEPENDENCE OF CONCEPTIONS  UPON  WORDS.      599
Bridgeman,' who became blind and deaf in her second year, the
only other sense remaining perfect being that of touch, those of
smell and taste being, the former almost, the latter to a very large
extent, destroyed.  This girl attained nevertheless to a high grade
of culture, was able to grasp the most abstract ideas, e.g., of God
and  of  immortality, and  eventually  became  a schoolmistress.
But this  example  is one of the  very best  proofs  that  speech  is
indispensable for intelligent cognition.

   This remarkably intelligent person, although incapable  of acquiring phonetic
speech, became possessed, thanks to the care and energy of her teacher, Dr. Howe, of
the whole world of thought around her  through the medium of the language  of
touch.   In spite of her high mental gifts, of a remarkable memory, a most lively
power of imitation, and a marvellously accurate sense of  touch capable of almost
any amount of development, she hardly occupied a higher place in her home than
that of an intelligent animal upon whose  instruction one has bestowed much  labor,
and this, although she was the object of the tenderest maternal solicitude. She dis-
tinguished the objects about her home according to their form, density, weight, and
heat, and imitated the movements of her mother by an examination of her hands and
arms; she even learned to sew and knit a little. But in a few months her psychical
condition underwent a marvellous change at the hands of  Dr. Howe, to whom she
came when seven years old, and this through the agency of speech.  He affixed to
a number of common objects, such as knives, forks, spoons, keys, and so on,  labels
on which the name of the article was written in raised letters.  Laura soon remarked
that the crooked lines of the word spoon were as different from the crooked lines
of the word key as the shape of the spoon  was from that of the key.  After this some
small labels with the words printed on them  were put into  her hands.  She soon
noticed  the correspondence of the written words of the label with those on the
various objects mentioned, and gave proof of this by placing the label key upon
the key, and the label spoon upon that article.   All this time she was encouraged
by marks of approbation, such as patting on the head, etc. This method was gradu-
ally extended to all the objects  she could take in her hand.   Later on the separate
letters were placed in her hand and there  arranged into such words as book, key,
etc.;  they were then thrown into a heap together, and she was left to put together
the words book,  key, etc., for herself.
   "Up to this," says Dr. Howe, " the proceeding was  only a mechanical one, and
the result was about as great as if one had taught a number of tricks to a clever dog.
   1 Her history has been related in several reports by her teacher, Dr. Howe, Presi-
dent of the  Institution for the  Blind, in Boston.   Conf. Zeitschr. f. d. ges. Medicin
von Fricke und Oppenheim. Bd. 13. 1840. S. 1.—Froriep's neue Notizen. Bd. 21. 1842.
S. 273.— Boz, America, translated by Moriarty. Th. 1. 1843. S. QQ.—Burdach, Blicke
ins Leben. Leipzig.  1844.  Bd. 3. 
600         KUSSMAUL.—DISTURBANCES OF  SPEECH.
The poor child had sat there in mute astonishment, and patiently imitated every-
thing that was performed before her.  But now the matter seemed to dawn upon
her in its true light, her understanding began to exercise itself, she noticed that she
now possessed the means of arranging for herself symbols of something that lay before
her mind and of showing this to another mind; immediately her countenance beamed
with human reason; she could no  longer  be compared to a  parrot or a dog; the
immortal intellect now seized  greedily upon this new bond  of union with other
intellects !  I could almost point out the momant at which this truth dawned upon
her and poured light over her whole face."

   No more beautiful example could  be given than this remark-
able physiological experiment of Dr. Howe, of the cultivation
of reason,  the formation  of the world  of ideas, through the
agency of words.   We can  now see why the  Greeks compre-
hended in the term  " logos " reason as well as simply a word.
   3. Another instance  may  also be cited in the case of those
children  who, although endowed with hearing, are  unable to
learn  to  speak at all or very imperfectly;  they appear  quite
intelligent, understand what is said  around them, obey orders,
carry out instructions, and so on.1  This, however, has all been
learned in intercourse with  intelligent, speaking persons, by the
aid of words rendered  clearer through gestures, which the chil-
dren, too, had come to understand.   The words  remained  in the
memory united with intuitions, and associated  themselves with
intelligent conceptions, or generated such.  Thus, even the dog,
as a companion of  man, becomes wiser and learns to grasp the
meaning  of many  words.   But, of course,  the  more highly
endowed human being must profit  much  more  by such instruc-
tion  than  the  unreasoning animal,  even though, as a  conse-
quence  of  faulty organization  of  the internal  apparatus of
speech, he may never be capable  of representing by movements
the  word-pictures he  has  laid hold  of ;  unless, of course, the
intelligence, too, is early wrecked.
   4.  Finally, the case of M. Lordat,2 Professor of Medicine at
Montpellier,  is cited, who,  after a fever, suddenly lost  all power
  1 Conf. Waldenburg, klin. Wochenschr.  1873.  No. 8 ;  also Broadbent, Med.  Chir.
Transact. Vol. 55, p. 146, Case 4.
  2 Lordat, Analyse de parole, etc., pour servir a, l'histoire de l'alalie et de la paralalia
Montpellier.   1843. More at length by Proust, Archiv. gen. 1872. p. 666, et seq. 
         INDEPENDENCE OF CONCEPTIONS UPON WORDS.      601

of speech for several months.   In this condition he  was so com-
pletely robbed of his memory for words that he could not  even
understand those spoken to him.  He is stated, however, to  have
been able carefully to  consider his own condition, to combine his
thoughts properly,  and  even  to follow  out the thread of his
lectures as well as before the attack.
   Trousseaul remarks, however, that Lordat may have deceived
himself  as  to the acuteness of his  thinking powers during the
attack, for  during  the rest of his life  there remained behind a
certain weakness of his  mental  power.2  For instance,  Lordat,
who had hitherto  shone  as an  extempore  speaker, was hence-
forth unable to improvise his lectures,  and had always to  read
them.3
   Moreover, before the  attack Lordat was  in possession  of a
world of thoughts acquired by  means  of speech.   No one  will
deny the relative independence of conception upon speech in its
most abstract intelligent form.   It  may be the case, then, that,
in spite of the total destruction of the  memory for words, there
may  have been still  preserved  in  the  mind of such  a  highly
developed thinker  abundant  accumulated material  of thought.
We will even admit that  the thoughts  moved along in  the old
groove ; but we  cannot  believe  that this took place with the
same certainty and smoothness  as  of old, or that  Lordat  was
capable of creating new ideas.
   Again, this personal observation  of Lordat stands alone,  and,
as he was a  decided spiritualist and opponent of  the organicism
   1 Clinique med. T. II.  Art. LVIII. " Aphasie." Bull, de l'acad. de med.  T. XXX.
1864-65. p. 672.
   2 Lordat relates :  " En refiechissant sur la formule chretienne, qu'on nomme la doxo-
logie, 'gloire au Pere, Fils, et Saint-Esprit, etc.,' je sentais que j'en connaissais  toutes
les idees ;  quoique ma  memoire ne m'en suggerat pas un mot.   .  .  ."  On this,
Trousseau remarks :  " J'avoue ne pas com prendre qu'on puisse songer a une formule
de langage  sans se rappeler aucun des mots qui la composent."  For myself, I have
the same feeling as Trousseau.  I cannot understand how one can conceive a formula
without symbols, a word-formula witlwut tcords.
  3 It is also remarkable that Lordat should relate of himself : " L'air stupide, etc.,
.  .  . faisaient  croire a plusieurs qu'il existait en moi un  affaiblissement des facultes
intellectuelles."  Aphasia, without an appreciable disturbance of the intelligence, does
not usually so completely obliterate the latter from the expressions of the countenance. 
602         KUSSMAUL.—DISTURBANCES OF SPEECH.

of the  Parisian school, his can hardly be regarded as entirely
unbiased evidence.  Other thinkers and physicians, such as the
celebrated Spalding, of Berlin (1772),l and the Parisian professor
of medicine mentioned by Trousseau,2 who had both  lost their
memory for words in transient attacks,  without forfeiting the
power of observing and of judging themselves, and of commu-
nicating their wishes to those about them by means of signs, did
show a diminution of their intellectual acuteness and a certain
confusion of thought.
  In  our opinion, there is nothing to be learned from Lordat's
record of his own case (even suppose we accept it in good faith
as correct  in  all  respects) but  this, that ideas,  when  once
acquired, possess a certain independence of words,  but not that
they are acquired without  the help of words.   Objective images
and simple conceptions, such as may be aroused even in an ani-
mal, are called into being without words,  through the medium
of sensory impressions ; and yet any  one may daily observe for
himself, among his domestic  animals, that here, too, indicative
signs, such as pointing to the door or the food-pan, are an essen-
tial item in the generating  of a conception.  But ideas are only
acquired through words of sound, of gesture, or of writing.
   It is quite true that persons deprived of the power of speech
by disease need  not have lost  their intelligence in  the same
measure.   They not unfrequently still display a certain  power
of insight  into things around them by the expression of their
face, by gestures and acts.   Numerous observations  by trust-
worthy physicians may be cited in support of  this, as, for in-
stance,  the following by Broadbent:
  A woman  of seventy had lost, in  consequence of apoplexy, accompanied by
transient right hemiplegia, the power both of speech and of writing, permanently.
She was totally unable to write, while some words, produced in the form of rapidly
  1 Spalding imparted his experiences on the afternoon of the same day to his friend
Sulzer. A notice of these may be found in Moritz, Magazin fiir Erfahrungsseelenkunde.
Bd. I. St 2. S. 38.
  2 Rostan was the professor! Conf. also the statements of a physician who occasionally
suffered from such aphasia, in Westphal, Verhandlungen der Berliner Gesellschaft fiir
Anthropologie.  1874.  S. 101; and those of another educated man, in Spamer, Archiv
fiir Psychiatrie.  Bd. VI. S.  531 and 540. 
WORDS AS SYMBOLS.
603
uttered interjections,  still gave expression to her feelings (e. g., oh, shameful,
shameful!  nasty, nasty !  pity, pity ! that's right! etc.).  She could read, and dis-
played great energy and intelligence in trying to regain her right to administer her
own property, which had been denied her, on the wrong supposition of her weak-
ness of intellect.  Three  years later she succumbed to apoplexy,  with left hemi-
plegia.  Two apoplectic cysts were then found in the upper border of the fissure of
Sylvius, on the left side, one in the posterior part of the third frontal convolution,
one further back, including some of the convolutions of the island of Reil, and the
corpus striatum was atrophied.  The cause for the  last apoplectic  seizure  was not
discovered.

   Such cases force us to the conclusion that, although we arrive
at our ideas through speech, these, as soon as  they are formed,
possess an independence  of words.   Sensory pictures, feelings,
movements  of  expression,  conceptions,  and  ideas,  although
awaking  each other mutually and  associuted most intimately,
nevertheless preserve in relation to one another  a certain auto-
nomy.  Whether without  words  the full integrity,  accuracy,
and fruitfulness  of  thought can  persist, is another question to
which at present no unqualified answer in the affirmative can be
given, in view of  the observations just quoted from  Lordat  and
Broadbent.   We shall return to this subject again in Chap. 25.
                       CHAPTER VIII.

 Words as Symbols, and the Facultas Signatrix.—Finkelnburg's Asymbolia, or
           Asemia and its Forms.—Relation of Aphasia to Asemia.

   Imitation, by delineation, painting, and sculpture, of things
 perceived  around us, contributes very largely to engrave sen-
 sory intuitions upon the memory.  A Napoleon  or a  Frederick
 the Great lives before the inner eye of later generations precisely
 as his picture has represented him.
   What the drawing is for the intuition the symbol is for the
conception, and it is gained from the drawing by  a kind  of
abstraction, as the conception is from the intuition.  It fixes the
conception upon the  memory, and is so closely  united with it,
that  this former is awakened by  the symbol,  and, conversely, 
604        KUSSMAUL.—DISTURBANCES OF SPEECH.

the symbol by the conception.  If we reduce a picture  to a few
striking, i. e., essential  outlines,  the  imagination immediately
fills it out  again to a picture such as existed before.  But the
imagination can do far more :  the child makes a doll out of any
or every piece of  stick or stone in  its  way;  the peasant  is
reminded by a roadside cross of some fatal accident, and also  to
pray for the poor soul  of  the departed ;  we tie  a knot on our
handkerchief to recall  to  our mind, by  the sight of  it,  some
promise or intended business.  Thus, according to fancy, we may
awake in our memory, by this or that sensory phenomenon, this
or  that conception, or  a  whole comprehensive series of them ;
we create voluntarily an intimate relationship between both, an
intelligent bond by means of  which one draws the other after it.
The words  of the phonetic language of to-day have hardly any-
thing any longer in common with the imitative sound-symbols  of
primaeval man, and only by the dictionary are we able to deter-
mine with certainty what is the meaning of this or that word of
a foreign people.  They have become phonetic symbols, whose
association with this or that conception  appears to be purely
accidental.  And, according to the principle of sound-metaphor,
we may exchange visible symbols for audible,  or the reverse.
Phonetic writing (sic,  phonetische Schrift) has  clearly  been
developed  from pictorial writing  and  hieroglyphs, and we are
able at  will to associate with the spoken, as with the written
word, the same conception.
    Now, apart from the symbols which each individual makes
for his own special requirements, and from the letters and loords
of phonetic gesture and written speech, there are  a multitude of
others in use which the human race has  gradually created, and
which  one generation has handed over  to another:  such are,
social and  devotional forms of expression, cyphers, algebraical
formule, geometrical figures, musical notes, and so on.
    These symbols are the current coin of the collective intellec-
tual intercourse between individuals and nations ; they repre-
sent, whether  as words, artistic compositions, natural  formula?,
and so on, the aggregate value of the intellectual property of
humanity.   Moreover, we often even run  a risk of confounding
our actual property with the symbols of value current for it, and 
WORDS AS SYMBOLS.
605
accept words for ideas, faeons deparler for true expressions, the
form for the thing, cultivation for religion, the idol for the Deity.
Savage peoples even go so far as to identify the name of an indi-
vidual with the latter himself.1
  From their neat and well-defined form  symbols facilitate very
materially rapidity  of  comprehension.  An expression of face,
a sound, a single word,  often make a whole situation clear to us.
We simply stigmatize  a man as  a bigot, as blase, etc., and at
once his whole feeling, thinking, and acting stand out before us
as though illuminated electrically.   The eloquence of numbers is
proverbial.  And the more abstract and exact thought becomes,
the more it is elevated out of popular into scientific regions, the
shorter and sharper do the symbols become ; words are no longer
adequate for the task of expression, and  in logic, mathematics,
physics, chemistry, etc., the most mature products  of thought
are consigned  to algebraical formula?.
   But  it would  be  an  error  to suppose  that in symbols there
was nothing but a means of communication with others.  They are
far more ; they are a component part and an essential keystone
of all mental operations.  No thought has attained to thorough
clearness and accuracy until it strikes home  in the form of word
or sentence.  How long do we frequently  torment ourselves over
the solution of a  problem !  At last the proper word or the true
formula suggests itself, and we give vent  to  our satisfaction in a
joyous eureka.  Words, to use a happy  simile of Steinthal, are
as footprints which the  mind leaves behind when it traverses the
paths of thought in search of cognition, and by whose help alone
it is able to make its way with certainty.
   The necessity for  symbols in intelligent thinking is dependent
on the  narrowness  of our consciousness, through whose focus
intuitions and conceptions can only pass in linear succession, or
in other words, in single file.   Hence,  we are only able to think
rapidly  by thinking abstractly, and only accurately when the
abstractions acquire  intuitive perceptibility in a neat, comprehen-
sive form.  The idea in verbal form fulfils  these requirements.
  1 Conf.  the remarkable facts bearing on this noticed  by Tylor (" Forschungen iiber
die Urgeschichte der Menschheit." Mueller, Trans. Leipzig. Cap. 5 and 6) ; also Laza-
rus, " Das Leben der Seele." Bd. 2. 1857. " Geist und Sprache." S. 77  Anm. 
 606         KUSSMAUL.—DISTURBANCES OF SPEECH.

 Without the word forest we should, like the child, see trees upon
 trees, and again trees, but for very trees see no forest;  but with
 the word forest the abstract idea stands before us as a clean-cut,
 comprehensive symbol, with which thought can deal comfortably
 in its further progress.
   Finkelnburg 1 refers the capability of forming words  to  the
 general capability  of creating signs and  symbols.  He  insists
 that speech is to  be regarded as a product of a special symbolic
 function of the mind, the facultas signatrix of Kant.  He sup-
 poses this capacity to exist also among animals who  are able
 to render their wishes known by means of  signs intentionally or
 unintentionally, and to construe the signs of other animals, and
 even of man, correctly.
   But if  we regard  the question more closely, this symbolic
 function will be  seen not to be referrible  to a special symbolic
 power of the mind.   The symbolic capacity is nothing more than
 the impulse  which produces movements of expression, and  the
power of understanding these, and of utilizing them for  the
purposes of intelligent intercourse.  It consists in feelings,  intui-
 tions and conceptions which are most intimately  associated with
 one another,  and  set in motion certain reflex mechanisms.   That
 expressions are  understood and acquire  significance  depends
 partly upon  the  memory, partly upon  the associative  mechan-
 isms of the brain through which it becomes possible for feelings,
 intuitions,  and conceptions to enter into orderly combination
 and evoke each other, mutually following a regular method. The
 organic mechanism  on the one hand, and the force of  habit on
 the other, govern the laws of this association.  The symbolic
 function is a  form of activity of the instinct and intelligence, dif-
 fering from others only in the end to which it is directed,  name-
 ly, the seeking to comprehend and to be comprehended; more-
 over it is, like the first, the resultant of feelings,  intuitions, and
 conceptions on the one hand, and of associative  and reflex me-
 chanisms on the  other.  If  the facultas signatrix of animals is
 not equal  to  the task of forming actual words, the cause is to be
 found solely in the rudimentary development of their intellec-
1 Berl. klin. Wochenschrift. 1870. Nos. 37, 38. 
WORDS AS SYMBOLS.
607
tual capacity, and of the brute brain as an organ of thought.
The animal does not  speak simply  because it lacks an intel-
ligence  and impulse.  But our children begin  to speak early,
because  they  are born  with this intelligence and impulse, be-
cause our brains have acquired in  the long course of develop-
ment of  the human race the predisposing arrangement thereto.
That it is really an unconscious and  irresistible impulse which
first compels children to speak is a matter of daily observation.
It is only  subsequently and by degrees that this  impulse is
subjected to the directing power of the will and the dictates of
custom and reason.
   This view of ours, then, of the symbolic capacity, is not com-
patible with the theory of the existence of a  special organ for it
in the sensorium. It is bound up on the one  hand with memory,
and on the other with the aggregate of the associative and reflex
apparatuses of the organ of thought, combined for movements of
expression.  We do not  mean to say,  of course, that this aggre-
gate of individual apparatuses may not become diseased in its
several parts.  Partial lesions of  the  organ of thought must be
followed by partial damage to the symbolic function.
   In fact, we find partial disturbance of the symbolic function,
whether it be the memory that  is obliterated or interfered with,
or this or that association of conception-groups, or feelings, or
this or that connection of sensory or motor tracts with the reflex
centres.   But suppose these become disordered or are even de-
stroyed as a whole, then the entire symbolic function also suffers
decided  injury, even to complete annihilation.  With  Finkeln-
burg, then, we may, not  incorrectly, from a  symptomatological
standpoint, speak not only  of  asymbolia, but also distinguish
between a partial and general form  of the same.
   We do not  here mean to infer, of  course, that the symbolic
organs can only serve symbolic purposes and not be otherwise em-
ployed.   It depends entirely upon what associations and what
reflex combinations are set agoing by impulse or will as to what
different objects will be accomplished by the same organic  instru-
ment.  We can  use the  tongue both  for eating and speaking,
and may be impelled to the same movements of expression by
different  feelings and  conceptions.    One lowers  his  head in 
 608        KUSSMAUL.—DISTURBANCES OF SPEECH.

 humility, another from fear, a  third from politic calculation, a
 fourth in sign of acquiescence.
    Now,  according  as these or those feelings, conceptions, or
 reflex connections, and as the memory for this or that intuition
 and conception are disturbed, we may observe different forms of
 asymbolia.  Thus during sickness we sometimes see the power of
 forming words by phonetic symbols alone disturbed, while they
 can still be expressed by written ; but, as  a rule, the loss of both
 is impossible, or only certain words and classes of words are lost.
 There are, according to Steinthal,  dfiova-oi, who, having lost the
 words of  a  song, are unable to recall the  notes, while there  are
 others who  only lose the words, but retain their sense for the
 notes.  Finally, many even lose the power of mimic expression
 together with that of phonetic and written  language.   These
 last,  of course, have suffered  severe  losses  in their collective
 mental property.

    That condition in which persons lose  the power of speech
 partially or completely, without their mind being involved, and
 without either a mechanical hindrance in the external apparatus
 of  speech  or  paralysis or  spasm  of muscles or  injury of  the
 nervous structures which preside over the  articulation of the sev-
 eral sounds, is known to pathologists either by the name aphemia
 (Broca), or better, by that of aphasia (Trousseau). Where, under
 similar conditions, there is no loss of speech, but a wrong word is
 substituted for the one meant, the  state is spoken  of as para-
phasia.  Commonly,  however, the  term aphasia is allowed to
 include in its wider sense that of paraphasia and to embrace also
 those conditions in which patients are senseless but make use of
 constantly recurring sound-symbols as  expressions.  Appearing
 under corresponding  conditions, disturbances  in the waiting
 powers are  characterized  either as agraphia or paragraphia.
 With all these the faculty of understanding both phonetic and
 written symbols  may either be destroyed or remain intact.  It
 may be obliterated,  although  both hearing and  sight are un-
 impaired.   Comprehension of written symbols  is far more fre-
 quently lost by aphasic patients than that of spoken words, and
 it has been called alexia.  Here also, when there is a transposing 
DIFFERENT FORMS  OF ASEMIA.
609
of the written words, we may speak of a paralexia. Analogously
one might  distinguish between amimia and paramimia, when
patients  are  unable  to  execute the characteristic gestures and
expressions of  face,  or transpose them,  as,  for instance, when
they make an affirmative instead of a negative gesture, or the
reverse, as has been observed.
   Finally, it has come  to this at the present day, that under
aphasia we no longer understand merely the disturbances in
speech alone, but also the collective symptomatic phenomena,
whether abundant or scanty, under -which the execution or com-
prehension of any given signs by which it is sought to commu-
nicate conceptions or feelings  is impaired  Thus a now species
of sickness has been  created which presents all the light but also
all the dark sides of  purely symptomatic species.   Finkelnburg
is certainly right in proposing instead of the term aphasia, which
only has reference to phonetic symbols, a more comprehensive
one,  asymbolia, which would embrace all  the numerous as well
as different clinical forms of disturbance in the formation and
comprehension of symbols.  With Steinthal, however, we should
prefer the term asemia, the idea contained in "symbol"  being
more restricted than  that contained in " sign." Behind  the sym-
bol there is always an idea  hidden, behind the sign often only a
feeling. We might then speak of  an asemia verbalis, graphica,
or mimica, and of the varieties as. paraphasica, paragraphica,
and par amimica, and, in the case of asemias of expression, of as.
express im, or of  perception of as. perceplim, according  as  the
power of forming or understanding signs is lost. But, of course,
we gain nothing more by this than a more accurate terminology
and a better point of view for observing  the functional nature
of the changing phenomena of the disturbances in question.  It
will be the duty of science  in the future to discover the cerebral
tracts and centres through which the formation and comprehen-
sion of the various signs, phonetic and written words,  numbers,
gestures,  and so  on,  are accomplished.   It will also have to
ascertain  the minute  and gross disturbances in the organic
mechanism out of which the numerous forms of asemia spring.
          VOL. XIV.—39 
610         KUSSMAUL.—DISTURBANCES OF SPEECH.
                       CHAPTER  IX.

Speech as the Grammatical Moulding of the Material of Thought which has been
   perceived and logically and metaphysically elaborated—Speech as a Patho-
   logical Symptom and Object—Definition of Disturbances of Speech, according
   to their Nature, as Dyslalia, Dysarthria, Dysphasia, and Dyslogia or Dyspha-
   sia.—Lalopathia and Logopathia or Logoneuroses.—The  Centre of Speech a
   great Central Organic Mechanism.

   Our conceptions of things are never adequate, but only con-
tain  our subjective judgment as to their nature, which varies
considerably according to the age and stage of development of
the individual and of his nation.   With the strengthening of the
sensory and  intellectual auxiliaries  of cognition  there is an
increase in the breadth and depth of  our inner possessions, and
our wdiole feeling, thinking, and desiring being becomes altered.
Our  conceptions  consequently are not the products of the per-
ception and judgment of things by an unvaried being ; if so, they
would necessarily be unvariable.   They are  the products of a
changing but always at any given moment definitely constituted
being,  whose  cognitions  have arranged  themselves  into distinct
groups and circles of conceptions, and whose feelings and desires
are excited in this or that way by this or that idea.
   The conceptions wdiich we form of things about us are conse-
quently nothing  foreign, external to ourselves, not the  things
themselves with which we are so prone to  confound them be-
cause we only understand things through conception.   Moreover,
they do not dwell of nature  in us, but are merely the  substan-
tial contents of our intellectual personality.  In forming them
we receive them  into  ourselves as organic parts of our mental
being;  we assimilate them, or, to employ a psychological expres-
sion in the place of a physiological, we perceive them.
   This perception through which we come  into possession  of
our conceptions may be compared to chemical action.   New and
foreign conceptions which crowd upon us work with a force,
which in its evidences has much resemblance to affinity. But the
material of thought which they offer must, in the thinking mind, 
          DEFINITION OF DISTURBANCES OF SPEECH.        611

encounter allied elements in order to the  proper march of the
mental action.  Of what use to the savage are the microscope and
telescope, Aristotle and Euclid, so long as he is ignorant of his
A B C, and the  multiplication  table?  But if once the inner
movement takes  place it  depends  upon  the  already  existing
circles of conceptions  what kind of molecular disturbance will
b<> produced by the newly added elements,  what old compounds
will be decomposed or strengthened, and what  new ones will be
generated.  At the same time, under all circumstances, feelings
will be excited and rendered latent,  just as chemical action sets
free and renders latent heat.
   This substantial contents of our cognition, acquired by percep-
tion, must be clearly  distinguished from the logical, metaphy-
sical, and grammatical form into which it is pressed by virtue
of our mental organization. Everything that we become cognizant
of by perception and thought must find  its  way through the
mould of judgment and  conclusion into the being, and there
range itself under the category of cause and effect, object  and
property, time and place,  etc., and find expression in the gram-
matical form of  substantive, verb,  adjective,  etc., as  subject,
predicate, and  so  on.  Through perception the individual, as a
psychological unit, acquires the material of thought, while logic,
metaphysics, and grammar  give form to this material—logic
during its reception into the being,  metaphysics  by its arrange-
ment  within the being, and, finally,  grammar by  the expression
through the being.  These processes ol perception  and of logical,
metaphysical,  and grammatical moulding of the material of
thought are all accomplished autonomously, /. e., independently
of one another, although always dove-tailed one into the other,
and leading the being to the one end, namely, cognition.  Their
autonomy is easily seen  in  these facts, namely,  that  we  may
arrive at wrong conceptions through the most faultless  conclu-
sions, when we start from faulty premises ; that a knowledge of
things is quite compatible with the grossest error in regard to the
origin and nature of the same ;  finally, that the most  flowery
nonsense  may be uttered  in  a perfectly correct form of  speech.
Through this autonomy alone is the  so-called  objectivity of our
judgment, the accuracy of our cognition, guaranteed. A thought 
612         KUSSMAUL.—DISTURBANCES OF SPEECH.

is true when it has fully withstood the triple fire-test of logical
dissection, of metaphysical synthesis, and of grammatical ex-
pression.
   Speech, then, as the expression of thought, must be, on the one
hand, capable  of representing the  matter thought, and on the
other, its logical and metaphysical form.   The child's earliest
words and the word-roots  of  our national languages,  are  so to
speak, but the protoplasm  of  speech.  A root is not yet a sub-
stantive,  a verb, or an adverb, or indeed a part of speech at all,
but only a germ of such.  It  is nothing more  than  the primal
form in which the first very general predicative or demonstrative
judgments as to  things  are laid down ; and only through the
placing  of these primordial wrords in relation one to the other,
by emphasizing them, by their amalgamation, accentuation, and
so on, is  there gradually formed from  such roots a  language
organized out of parts of speech and grammatically suited to all
logical and metaphysical requirements.  The mode in which this
development  takes place  varies remarkably according to the con-
ditions of different peoples.
   Now, if speech be the faithful mirror of the human mind, as it
is constituted under  the endlessly varying  inner and outer con-
ditions of its development  among  nations and individuals, it
must also faithfully reflect the morbid disturbances of the same.
The perverted conceptions  of  delirium,  the wild whirlwind of
thought of mania, the slow and torpid flow of ideas of idiocy,
all find expression through  it.   In all these cases speech is for
us only a symptom of the processes in the regions of perceptive
activity;  it becomes  itself a pathological object when  it is dis-
turbed as an autonomous process.
   As an autonomous  process, speech consists  in articulation
and diction.  The  first is executed as a motor act by the external
organs of speech and the peripheral and central nervous appara-
tuses through which the multifarious co-ordinated inner and outer
movements take place, whose products  are sounds, syllables, and
words.   All  lesions  of  articulation may be styled  dysarthria
disturbances of speech.   But it is usual to designate those which
depend clearly upon gross  mechanical defects  in the external
apparatuses  of speech and their motor nerves as  dyslalia in 
          DEFINITION OF DISTURBANCES OF  SPEECH.       613

contradistinction to the true  or central dysarthroses, which are
either produced by organic lesions or are only functional.
   Diction is a mixed senso-intellectual act, through which words
are not alone combined with conceptions as sensory symbols, but
are also  grammatically formed and  syntactically arranged in
order to give expression to the fiow of thoughts.  Disturbance of
diction may be called dysphasia.
   Dysarthric and dysphasic disturbances taken together may
consequently be considered  as  constituting  what are properly
considered as true disturbances of  speech, and may be combined
under  the name of lalopathia.   The latter then includes dysar-
thrias (including dyslalias) and dysphasias.  In all these dis-
turbances it is only the question of a defect in the purely formal
expression of the movements of thought in sounds, syllables,
words, and sentences, quite apart from the substantial contents,
The thought may be faulty, but expressed in  an  irreproach-
able form.  Conversely a  correct  thought may  be  defectively
expressed, but as soon as the formation of thoughts is disturbed
it becomes a  question of dyslogia and logopathy,  or,  as  some
would say, of logoneurosis,  since every movement  of  thought
takes place through the nerve-substance.  The two ideas of logo-
neurosis and lalopathy consequently do not cover each other.
   Now we have set out with the intention of subjecting chiefly
the dysarthrias and dysphasias to a scientific analysis,  and the
dyslogias only so far as they  lead to disturbances in talking, or
dysphrasias.  Otherwise we should be obliged to include in our
inquiry the whole question of mental disturbances.  We  shall
be  engaged  consequently on  a  pathological  territory lying
between the psychoses and the sensibility and motility neuroses,
and intimately interwoven with  all these, and at the same time
connected, through the mechanical dyslalias, with that domain
usually relegated to surgery.
   For the purposes of speech there exists an apparatus as vast
as it is complicated, consisting of nervous tracts  and ganglionic
centres which  partly  occupy  the position of the loftiest work-
shops of  the  conscious intelligence and of  the will,  and are
partly  reflex  agencies in  which simple  and  ordered  sensory
stimuli are converted  into motion.  Such a thing as a simple 
614         KUSSMAUL.—DISTURBANCES OF  SPEECH.

" centre of language " or " seat of speech "  does not exist  in the
brain, any more than a  "seat of the sour1 in a simple centre.
The central organ of speech is, on the contrary, rather composed
of a large number of ganglionic apparatuses, widely separated
from one another, but connected by numerous tracts, and ful-
filling certain intellectual, sensory, and motor functions.  But
it is probable that none of these apparatuses subserve alone the
objects of speech.  The  nervous mechanisms  can  be made ser-
viceable  for  different  purposes,  and it is  only practice  which
brings about those connections between ganglion cell  and gan-
glion cell, between  ganglionic centre  and ganglionic centre,
which render speech, in  its  more restricted sense, possible,  as
well as all the other  so very numerous means of expressing our
thoughts and feelings.   In this sense alone is a central organ of
speech gradually cultivated,  or, as some will say, created,  in the
brain by language itself, and in this sense do there also exist
central organs for the plastic art, for painting, music, dancing,
and for the forms of thought which do not  give employment  to
words, but to numerical  signs and other pictorial formula?.
                       CHAPTER  X.

Speech as a Product of Instruction, of Practice, and of Habit.—Memory a Funda-
   mental Power of  the Nervous System.—Its most general Vital Conditions.—
   Amnesia Totalis and Partialis.—The Historical Aspect of Speech Amnesia.

   Instruction  is the agent by which we place our children in
the possession  of our  rich inheritance of speech.  We teach
them to utter their feelings and thoughts exactly in those forms
of expression suited to  the  spirit,  the whole nature  of  our
nationality, the time we live  in, and  our position  in society.
From us they learn how to control  their expressions and ges-
tures,  to clothe them in the mode  prescribed by custom and
fashion, to choose from  the  treasury of  words the most current
coin, and  to adopt the rules  of grammar.   By degrees many
strange sounds  disappear, through which the child's first impulse 
SPEECH A PRODUCT OF HABIT.
615
to speak  manifested itself—many  of  the sounds expressive  of
coaxing and of various emotions, through  which mother and
child at first conveyed their feelings to one another, and also the
onomatopoetic utterances characterizing the  different objects  of
the animal kingdom ;  in short, the  natural  language of the
child is overwhelmed by the transmitted language of the nation.
This tremendous change is the result of practice and habit.
   It is practice which  creates the bond through which mental,
sensory,  and motor centres  are united for  the  purposes  of
speech.   What we call  practice is not merely manifested  out-
wardly in the muscles, joints,  and  peripheral nerves; of far
more importance than the constantly repeated visible movements
of the tongue, the lips, the eyes, etc., are the invisible, which,
in the case of phonetic speech, are carried out in  the brain, and,
in the case of written and gesture language, in the spinal cord.
   Practice has two great results : it not only teaches how  to
choose properly the muscles which are responsible for the attain-
ment of definite objects, but it also substitutes for the originally
orderless  and useless expenditure of  force  and explosive dis-
charge, a  regulated use of the motor forces as economical as it is
suitable.   The kicking  and  struggling of a restless infant are
gradually converted  into grasping,  seizing,  toddling,  etc. ; the
clucking  with  the tongue, hissing, sputtering,  and lisping, into
articulated words.   Among  the Hottentots and Kaffres alone
have the sounds of clucking with the  tongue been preserved  in
their alphabet.
   Again, if  we associate a definite feeling  or conception with
any given  movements for a certain number of  times, the latter
will eventually take place involuntarily as soon  as that feeling
or conception is aroused, or conversely.  Certain  musical scores
awaken in our memories certain words, or the words the notes, and
we perhaps sing or whistle them softly to ourselves.   The bond
which  secures  to  our central organs facility of communication
between different stations of sensation, conception, and movement,
is known as habit.   Stations which are  accustomed to correspond
with one another answer each  other's despatches very promptly,
whereas they do not answer  those from others, or  do so  only
with hesitation  or uncertainty.   It would  appear  as though 
616        KUSSMAUL.—DISTURBANCES  OF SPEECH.

stimuli, when repeatedly transmitted from one point to another,
were able to push  aside hindrances  all along  the connecting
tracts  over  which  they pass, and  to  make  the  way  freer,
smoother, and more easily traversed.
   Comparative philology furnishes numerous examples of the
significance of practice and habit.   There exist whole nations, or
single  branches of nations,  to whom the pronunciation of the
letters  r, 1, h, or eh, or of the dental  th, or of diphthongs and
other letters, offers the greatest difficulty, although  they are by
no means lacking in the necessary organs for their  articulation.
And as with the co-ordination of the articulative central stations,
so is it also with  the  association of conception with conception,
and their union with feelings and desires—they are all under the
sway of education  and habit.  How utterly different are the
thoughts, feelings, and wishes excited by the exquisite  muscular
development  of an  Antinous in the breast of a Winckelmann,
full of  ideal art, and those aroused  in the head  of a South Sea
Islander, grown gray  in cannibalism !
   Closely allied to  the  principle of  habit is the power of
memory.  The impressions which external things make upon our
senses  and intellect leave traces behind, just as the movements
which  spring from them.  The more frequently the same impres-
sion is freshened up, the clearer  and  more lasting  are these
traces.   They  may be compared to the invisible pictures  which
the sun impresses upon a prepared silver surface.  Just as these
are charmed  into being by the art  of the photographer, so* are
the "picture-residues"  of  our senses  by allied  or analogous
images, conceptions,  and movements.   In sleep such dream-
images often follow each other loosely and as though  accident-
ally in a panorama,  excited, it is supposed, by stimulation of
the central organs through the blood.
   What we call memory really consists of  two processes :  (1)
the fixing of  perfected impressions in  the form of permanent
traces,  the residua of  stimuli, which remain behind as sensations,
images, conceptions and motor acts (words, grasps of  the hand
etc., etc.)—this is memory  in its  narrower sense ; (2) the call-
ing up again of these different residua of earlier impressions
from where they are stored, which  is known  as recollection. 
                  MEMORY AND RECOLLECTION.               617

Recollection takes place through processes of association, which
may be referred physiologically to the conducting and transfer-
ence of stimuli  from one point of the nervous system to another,
according to the laws of reflex, co-movement, and co-sensation.
   We believe that it is something more than a mere simile when
we speak of recollections being the residua of impressions.  AVe
hold  the view  seriously that, parallel  with  the sensory impres-
sions and their  residua, there are material changes in the nervous
system which the external stimuli  produce  as they traverse the
conducting filaments from nerve-cell to nerve-cell.   If, for every
separate sensation and movement, distinct peripheral and central
receptive points and conductive tracts for  stimuli exist,  there
must be  for every picture, as it is compounded  of  many dis-
tinctly separate sensations, a corresponding distinct combination
of filaments and cells ; also for every motor act and every concep-
tion arising out of  images and motor acts.   Finally, there must
be created just as many concatenations of nerve-cells as there are
feelings, pictures, and conceptions  stored  up in  the memory.
AVithout the hypothesis of some material alteration in the nerve-
substance, it would be impossible to conceive why the inclination
to many movements originally learned, and consequently at first
acquired, should be transmitted to descendants,1 or why certain
intellectual and artistic talents should be inherited from individ-
ual to individual in certain  nations and families.
   Therefore, with Ewald  Hering and  Laycock,2 we must  refer
back  the memory to that general principle  which preserves the
type of the species in the organic world through countless gener-
ations, and secures the transmission of bodily and mentalpecu\
liar ities from  the ancestors to the latest descendant.   To this
Laycock has given the name syneticprinciple.  It is very closely
   1 Conf. Ch. Darwin, The Expression of the Emotions in Man and the Lower Ani-
mals.  Darwin cites a number of interesting examples of such hereditary acquirements.
   5 Th. Laycock, On Certain Organic Disorders and Defects of Memory. Edinb. Med.
Journal, Ap., 1874. The same thought may be found excellently worked out in a lecture
by Ewald Hering, Ueber das Gedachtniss als eine allgemeine Function der Materie,
delivered before the k. Acad. d. Wissensch., 30 May, 1870, k. k. Staatsdruckerei, 1870.
Conf. also an excellent article only  known to me since the conclusion of my work :
Das Unbewusste vom Standpunkt der Physiologie und Descendenztheorie. Berlin. 1872. 
618         KUSSMAUL.—DISTURBANCES OF SPEECH.

connected with  the  commonest laws of development and degen-
eration of the organic and intellectual life.   In receiving and
retaining impressions the  latter introduce a further series of
organic and psychical processes which exercise an influence upon
our whole being, changing  and further moulding it, just as the
impregnation of an  ovum with this or that  semen influences the
future bodily and mental  constitution of the individual to be
developed therefrom.1
   The old view must of course be abandoned, which regards the
memory as a special receptacle in the brain or  in the soul, in
which images and ideas are stored  up and arranged as if in
pigeon-holes.  As we hold, memory is a fundamental power of
the nervous system, bound up with the elementary apparatuses
of nerve-cells and filaments,  and dependent in its achievements
upon its partly congenital,  partly acquired concatenation  in the
central organs.   AAre also  believe in the  existence of memory
among the senses, as well as  in the intellectual and motor cen-
tres.  Long  ago Henle2 was led  to the  belief  in a sensation
memory by the  consideration of  the images retained by the reti-
na. It is really hard to see why a remembered bell-sound should
not ring on in the same spot  in which it rang while the bell was
still vibrating, and where it  still echoed some time after the latter
had ceased to give forth a sound.   Bain,3 from whom we borrow
this remark, is  quite Tight  in this sense when he  designates the
recollection of  a saying as  "suppressed speech," " ready every
moment  to pass over into  uttered  words."  When we recall  a
verse of a song,  or a saying, it is not alone the thoughts  which
present themselves,  but also the words as sound-pictures and
remembered  movements,  and these are even accompanied by
slight movement,  and not unfrequently by articulate action of
the tongue.
   1 These thoughts have been further worked out by Laycock, especially in regard to
the retrogression of the psychical life to  earlier stages of development, in a very
thoughtful article, :' A Chapter on some Organic Laws of Ancestral Memory," Journ.
of Mental Science, July, 1875.
   2 Caspar's Wochenschrift. 1858. Nr. 19.  Also Allgem. Anatomie. 1841.  S. 739 f.
Conf. also the thoughtful remarks on memory and sense-memory, by Draper, History
of the Conflict between Religion and Science. New York,  1873.
   3 Geist und Korper. Leipzig. 1874. S. 109. 
           THE VITAL REQUIREMENTS OF MEMORY.         619

   The commonest vital requirements of memory are :
   1. Supply of the nerves with  adequate nutritive material.
Exhaustion from lack of food, overstrain either of the muscular
or mental powers, weaken the memory.
   2. Proper distribution of the blood dependent on the struc-
ture and innervation of the blood-vessels.  Senile amnesia is an
instance  of  the influence  of  the first item, transient loss of
memory due to plethora, etc., of the second.
   3. Proper condition of the organic soil which talces up nutri-
tive materials from the blood.   Memory is dependent upon the
congenital and acquired conditions of the brain, the greatness of
its nutritive energy and developmental capacity.
   4. The necessary  accumulation  of  assimilated pabulum,
which is chiefly provided for by sleep.  Wakefulness at night
weakens  the memory.
   If the memory is a common function of the nervous system,1
the nature of its contents of any moment must depend upon the
functional capacity of  the latter, which varies according to  the
grade of development of the organism.  The memory of man
differs from that of animals chiefly in the intellectual association
of what is remembered with the abstract idea of the time.
   AVhen memory is thus viewed, it no longer appears wonderful
that it is only partially lost, as  a rule, after cerebral affections.
Sometimes only optic images, sometimes only acoustic, disap-
pear ; now this, now that conception, or single words and knacks ;
indeed, even  words themselves are obliterated, sometimes as a
conceptions, sometimes as sound-images, and sometimes as motor
acts capable of being  remembered.  It is also less remarkable,
then,  that one  man's  memory  is  principally  developed  for
numbers  or formulae, another for names of persons or places,
a third for melodies, a fourth for verse.
   AVe are justified, then,  in speaking of amnesia totalis and
partialis in a tw7ofold but overlapping sense: in the first place, in
reference to the matter contained in the memory; and secondly,
in regard to the extent to  which the disturbance of memory is
spread over the brain.   Total loss of  the cerebral memory must
1 Ueber Gedachtniss des Riickenmarks, conf. Freusberg, Pfliiger's Archiv. Bd. X. 4, 5. 
 620         KUSSMAUL.—DISTURBANCES OF SPEECH.

 reduce an  individual  to the simplest  condition of congenital
 reflex activity.  He relapses into a state of animal stupidity, dur-
 ing which  only breathing, the cardiac movements, swallowing,
 and such like, take place.  But it is only very severe affections,
 involving the whole brain, which produce such consequences.
 It  is the custom, however,  to  characterize also as complete loss
 of  memory those disturbances in which the intelligence has be-
 come a tabula rasa, but in which many acquired forms of move-
 ments, such as walking, grasping  food,  etc., wliicli involve  a
 cerebral memory, can  still, be performed.  Here the sensory or
 instinctive  memory remains, and these  movements can be exe-
 cuted, although only in a clumsy way ;  the intellectual memory,
 on the other hand, is destroyed, and  intelligent speech is impossi-
 ble for that reason, or, at the very most, some senseless sounds
 and sound-compounds are uttered.   In such instances we usually
 expect to find morbid processes diffused over the  whole cortex
 of  the cerebrum, while the  deeper ganglionic centres  of the
 corpora striata, optic  thalami, corpora quadrigemina, etc., still
 perform their functions.  In partial loss of memory of  the intel-
 ligence and speech the cause may be twofold : either there exist
 more or less trifling diffused lesions of the cerebral cortex through
 which  only  the looser and  not the firmer functional concate-
 nations of ganglion-cells are jarred or broken, or there are severe
 circumscribed injuries of  the cortical substance by which the
 sensory or motor circles which close these or those chains of con-
 ceptions of words, are  ruptured.
    That the memories of  early days  are  less  easily lost  than
 those of a riper age, in cases where  the powers fail  in advanced
 life {amnesia senilis), is easy to understand.  Not  only is the
 brain in youth more capable of receiving impressions than in old
 age, but the  recollections of  that time will  pass  far more fre-
 quently across the mind than those  of later years.

   Even the physicians of early classic times  had  noticed the loss  of memory for
/ words through sickness and injury—Hippokrates, Galenus (in several places), Pliny
 (Hist, natur. Lib. VII. § 20), and others. Schenkius (Obs. med. Lib. VII. p. 480. Lug-
 duni, 1585) was the first to notice the connection of loss of speech and of memory
 for words with affections of the brain, and that loss of speech could exist without
 paralysis of the tongue.  Gesner (Sammlungen von Beobachtungen in der Arznei- 
                  CO-ORDINATION OF  MOVEMENTS.              621

gelehrtheit, Nordl., 1772. II. 107), was the first to describe aphasia under the name
of speech amnesia, and Alex. Crichton (An inquiry into the  Nature and Origin of
Mental Derangement. London, 1798.  T. I. p.  337), under the title Diseases of the
Memory, as a special disturbance of the  memory.  Most physicians of the last and
beginning of this century grouped all the forms of loss of speech together under the
name alalia, and dealt with it together with aphonia, from which they only gradu-
ally learned to separate it.  The expression alalia is used by Delius as early as 1775,
in an article "De alalia et  aphonia (Nova acta naturae curiosorum. T. VII. obs.
XVIII. Norimb., 1757).  According to Hammond (New York Med. Record, March
1, 1871. p. 1), an American  physician, Rush, was the  first to distinguish between
different forms of aphasic disturbances of speech  in the following rather rough
way:  1. Forgetting of names and words of every kind.   2.  Forgetting of names
and words, with substitution of others totally different, which have no relation to
the first.   3. Forgetting the name for a  thing in the mother-tongue while the name
for it in a strange or dead language is easily found.   4. A converse relation to No.
3. Dr. Scandella, an  Italian, who  died in New York in  1789, spoke during his ill-
ness first only English, then only French, and,  on the day of his death, only Italian.
5. Forgetting of words, but  not of the letters composing them.  A case of a clergy-
man  is quoted, who was obliged  to spell words in  order to  render himself intel-
ligible.  6. Forgetting how the commonest words are spelled.  7. Forgetting names
and ideas, but not numbers.
                          CHAPTER XI.

Co-ordination of Movements.—Impelling and Restraining Forces.—Goltz's Croaking
                              Experiment.

   The ganglionic centres of  which the  nervous system is com-
posed are as much registering as  regulating apparatuses.   They
enable us to recognize external things  in the form of  images and
conceptions, which leave  behind their impressions, and to give
expression to this cognition by indicative movements  suitable to
the images and conceptions. AAThat we call co-ordination of move-
ments is always accomplished by  the preformed central anatomi-
cal mechanisms according to the  laws  of conduction, collection,
and transference of stimuli.   But the functional combination  of
the ganglion-cells in these centres  is only in part existent at birth,
as for instance,  that for breathing,  the cardiac movements, swal-
lowing,  etc., and that for the instinctive cleverness of  animals 
622         KUSSMAUL.—DISTURBANCES OF SPEECH.

which is nowadays regarded as inherited from progenitors who
had  first to acquire it themselves.  Most of our human  move-
ments, however, are learned by practice.
   But, however co-ordination  is  originally  provided for,  we
find  stimuli acting at one time with  impellent, at another with
restraining force.  Running parallel with all reflex and volun-
tary acts there are constantly actual and suppressed movements.
It is not yet ascertained whether there exist special motor impel-
lent and special restraining mechanisms, but it appears probable
that the same apparatuses provide for both impulse and check,
and that it is merely a question of the measure, origin and direc-
tion of the stimulus influencing them,  what result follows.
   The  celebrated croaking experiment of Goltz throws very
considerable  light  upon the  varying  play of impellent and
restraining forces upon the ganglion-cells functionally combined
for co-ordinated movements of expression. Here we see that in the
respiratory and voice centre there is a bond established  between
the ganglion-cells of the  respiratory and vocal apparatuses, and
that  this "croaking centre"  may be roused to activity at one
moment, or checked at another,  according to  the wish of the
experimenting physiologist.  This, to be sure, the latter can only
bring about by  depriving the frog of that organ which gives this
very lowly organized animal the  power of manifesting its will
clearly  in  relation to  the human  will.  As  long  as the frog
possesses a brain it does not, as a rule, croak whether we stroke
its back much  or little.   As  soon, however, as the cerebrum is
cut away  above the corpora quadrigemina, every  soft stroking
of its back evokes a croak.  But if one  of  its  legs  be now
pinched or ligatured, no  amount of  stroking will call forth a
croak.   By a roundabout way, how7ever, we may  even cause a
frog with an uninjured brain to croak or remain silent, just  as
we will.  If, for instance, we place him on a warm summer even-
ing in his native swamp  and among his kind, he will very soon
commence  to  utter  the  well-known  note expressive of quiet
enjoyment; but if, after a moment, we throw a. stone into the
water near him, he will  cease with the  rest to give  forth any
sound.
   Far be it from us to compare the miserable will of a frog with 
            IMPELLING AND  RESTRAINING  FORCES.         623

the glorious will of man, but the physiological principle of move-
ment springing out of feelings and motives holds good in regard
to the brain  of the frog as much as to that of man, only that
everything in the former is far simpler than in the latter. Condi-
tions  of cerebral  excitation causing a  feeling of comfort and
enjoyment lead a frog to  croak with unvarying monotony on
one evening as on another.  The same condition of cerebral ex-
citation in man draws from his organs of voice the most diverse
forms of joyful song or pleasant w7ords of banter; but if sad news
be announced,  both song and joke are  silenced until  perhaps a
cheering word is spoken in  the circle and the same joyful frame
of mind is restored.
   All human  education tends to the control of the congenital
and acquired reflexes by intelligent and rational motives.  The
inner  impellent and  restraining processes withdraw  themselves
from  our  observation.   The external  means are training by ad-
monition,  example,  and  punishment,  by  motives  of  policy,
equity, morality, and many others.  The schools, the state, and
the church emulate each other in modifying our natural reflexes.
Up into the highest  spheres of free will we may trace the con-
stant  struggle between impellent and restraining forces, between
low but strong, sensuous and  high  ideal but slowly penetrating
motives.   The will which creates free men,  heroes, and martyrs,
grows strong by degrees only,  for our emotions and impulses are
constantly threatening to break through all restraint, like wild
beasts.  Sometimes the intuition of a movement, aye, or even the
conception merely of it, will allure from the recesses within us
reflex gestures, expressions of feature, words and sentences,  to
our great  dismay and sometimes prejudice.   And in cases where
feelings and desires gain the upper hand through morbid excita-
tion, and wild mania sits supreme, then all the barriers of will
are broken down  and speech unrestrained becomes a toy of the
storms of  emotional feeling. 
624        KUSSMAUL.—DISTURBANCES OF SPEECH.
                      CHAPTER XII.

       Speech and Consciousness.—Deliberation.—Readiness of Speech.

   The intellectual contents of our being slumbers unconscious
in our  memory until thrown into vibration by some  vigorous
shock  from without or within.   The vibrations, however, take
place in such a manner that out  of the whole undulating sea of
thought only the highest waves reach the visual field of the con-
sciousness (AATundt), all the remainder moving on unconsciously
in hidden deeps.  And even the loftier waves which do reach  the
visual  field of our mind are not all presented to us at the  same
time with equal distinctness.  AVave after wave, as  it traverses
the field of vision, is always only perceived in one point alone,
the mental focal point, with all  the vividness of perfected con-
sciousness.
   Stein thai  proposes to term as  "vibrating"  all those uncon-
scious conceptions called into  motion within the deeper recesses
of our being, in the discovery  of which  subsequently an analyz-
ing judgment versed in  the secrets of psychological life may
sometimes, but not always, be successful.   These he contrasts,
on  the one hand, with the  motionless unconscious  conceptions
asleep and hidden in the memory, and on the other, with  the
conscious, those which to a certain extent visibly give the start to
a whole series of movements.  AVith equal right three conditions
of sensation may be distinguished, and we may speak of motion-
less, vibrating, and conscious  sensations.   AATe shall  come later
on (Chap. XIX.) to the more detailed  consideration of the rela-
tion of thinking and sensation to  consciousness.
   In speaking, reading,  and writing there always run parallel
with one another conscious and unconscious sensations and con-
ceptions, and there  is reason  to believe that  the mass of  the
merely vibrating is always in excess of the conscious.  This holds
good just as well for the operations of diction as it does, though
to a greater extent, for those of articulation.   Hence, it is not so
wonderful as it would at first  seem that individuals  fully sensi-
ble of what they wish to say are yet  unable to find the  word 
READINESS OF SPEECH.
625
they seek, or that paralyzed persons in uttering the words which
they have learned as a whole, and not letter by letter, or accord-
ing to syllables,  cannot control such syllables  or the several
letters, some  of which may be lacking or find their way into a
wrong position or at a wrong moment, like  a team of unruly
horses.
   Should impressions  work  sufficiently powerfully to give a
shock to the whole being,  the inner excitation must be reduced
more or less in intensity in some way so as admit of deliberation;
otherwise we  have the phenomena before us described by the old
poet in the words "vox faucibus hsesit."  If merely single groups
of conceptions of the being be called upon, the extent to which
they were set in motion will reflect back with such force of feel-
ing upon the  being as to awaken its interest and produce a read-
iness to follow up the thoughts ; and to clothe them in words will
depend upon the age, sex, nation, religion, rank, culture, etc.,
of the individual.  This is known as readiness of speech, and  is
a matter both of feeling and of the intelligence.
                      CHAPTER  XIII.

Emotional Readiness of Speech.—Humor and Disposition.—Mental Readiness of
   Speech.—Collectedness.—The Speech of the  Emotionally Disturbed and of
   the Insane.

   Let us now examine  more minutely the inner preparatory
processes of  speech which present themselves always either only
partially or  not at all to our consciousness, and are also only
partially subject to our will.
   The influence of the state of the feelings or the humor upon
speech is well  known.  A pleasant event, an eventful day, or a
bon mot spoken in the family circle, loosens the thoughts and the
tongue,  puts us in good humor and disposed to chat, to dis-
course, or to  propose  a  toast.  Thoughts  and words  present
themselves to us as though by inspiration.   On the  other hand,
vexatious events, depressing circumstances,  the want of tact  on
the part of a friend, feelings of moral wretchedness, put us out
         vol. xrv— 40 
626         KUSSMAUL.—DISTURBANCES  OF SPEECH.

of humor and render us indisposed to speech and check the cur-
rent both of thoughts and words.
   Intellectual preparation takes place by collectedness or con-
centration  of the attention.   If,  for instance, we  are absent,
incapable of collecting ourselves on account of some unfortunate
sensation or conception,  both  our  thoughts and  speech are
embarrassed ; we are in constant danger of making slips in sen-
tences, words, syllables, and letters.
   Perhaps a glass of wine or a cup of tea may put  us  into the
right humor for speaking.  They act like grease on an axle;
thoughts and words roll  forth smoothly  and lightly in  the
boldest periods and most daring forms  of speech, whereas just
before we may have been struggling  laboriously for a  mode of
presenting  our thoughts.   The same may be observed in the
commencement of fever and in the earlier stages of  mania.  It
is true the unwonted coloring  and  the warmth of expression
may  strike us,  the  motiveless  exaltation  of feeling appear
strange and puzzling, as long as we do not recognize the sick-
ness ;  but  the material quality of  the utterances and their
rhetorical form cannot but be recognized as good, and even per-
haps more than  usually appropriate.  Then, with  the  increase
of the sickness and  excitement, confused images and wild flights
of ideas take the place of the bold, but, with all  their rapidity,
still orderly trains of images and thoughts,  and  we have poly-
phrasia ; or, again, in the case of those  of a lower order of intel-
lect, with trivial  minds, talkativeness, or logorrhea, may regu-
larly degenerate into senseless lingual delirium.   Eventually it
may come  to this, that words and articulated sounds no longer
suffice for  the wild  pressure of  feeling  in which the masses of
conceptions in the  maniac whirl  along chaotically,  and  the
patient shouts inarticulate sounds night  and day  ; and even
when the hoarse voice fails, the effort is  still made.
   Conversely, the miseries  of dyspepsia,  or those following
the abuse of alcohol, may hinder lamentably the wheel-work of
thinking and speaking.  When an individual  in such  a condi-
tion is obliged to think out an idea or to deliver an already well-
considered  speech, he requires a far greater expenditure of force
of will than usual, and a consequently almost  painful strain on 
MENTAL READINESS OF SPEECH
627
the brain, resulting in extreme fatigue of the latter ;  and even so
he  only half attains his object.   The thread threatens every
moment to  snap ;  the  proper word,  presenting itself as if  in
mockery a moment before, vanishes the instant it is  needed, and
another, perhaps resembling it in sound, but differing in sense,
forces itself  on us, producing an unexpected contrast perhaps,
which  is  greeted by the mischievous audience with  peals  of
laughter.  Then  the  speech  drags on hopelessly,  like a heavily
laden wagon with worn-out axle-trees, on a rough road.
   It is in a precisely similar manner that those sunk in melan-
choly experience a difficulty in speech at times almost painful.
They answer slowly, speak low,  in a tedious monotone, or trem-
ulously, sometimes stop in the middle of  a sentence  or word,
and repeat themselves.   In some extreme cases of  melancholy
the patient may only prepare to speak, without really bringing
out a  sound, or in other cases the power to make even the
attempt fails him, and he sits motionless, dumb, and brooding.
   Just as humor is strongly influenced by morbid and unusual
conditions of the body,  so also is the  mental readiness.  If the
whole being of a maniac be filled with wild ideas, his feelings,
perceptions,  desires,  and  conduct will be all determined  by
these, and voice and  speech are changed, as his being itself is
changed.  The patient  commands where he was  before accus-
tomed  to obey, endeavors to teach  where  he  formerly sought
instruction,  contradicts what he would at another time have
affirmed.  He speaks in the language of holy writ,  declaims in
rhyme  and  verses,  mutilates foreign  languages,  or,  mayhap,
creates  a new language  for  himself,' with new  symbols and
words for the new feelings and  conceptions of his inner being.
Again,  he may employ  old words and signs in another sense,
rendering himself quite unintelligible.  Occasionally it is only
those perceptions and conceptions congruent  with  the mania
which produce a perverted manner in an insane  person ; so long
as we do not touch  upon his idee fixe, he  speaks quietly and
intelligently; but the moment we strike the  keys which lead  to
  1 Conf. S/iell, Ueber die veranderte Sprachweise und die Bildung neuer Worter und
Ausdriicke im Wahnsinn.  AUg. Zeitschrift fur Psychiatrie. Bd. 9. 1852. S. 11. ff. 
628          KUSSMAUL.—DISTURBANCES OF SPEECH.

the false chords in  the scale of his ideas, nonsense bursts forth,
and his demeanor, voice, gestures, and words are perverted at
once.
   While  in the  deranged  individual the being is only altered,
the mental constitution  differently conditioned, compounded of
new elements of feeling and conception, which are still in com-
plete readiness and  capable of expression even  with wit and
acuteness {folie raisonnante), it is otherwise with the demented.
Here the whole being is actually shaken in its constitution or
quite fallen into decay, and the mental readiness is more or less
annihilated, like  the  effectiveness of  a routed  army.    Disor-
dered, unconnected conceptions hurry hither and thither across
the overclouded field of the consciousness, like  the wreck  of  the
shattered intellect.
   In the weak-minded, finally, there is, to be sure, a personality
still in existence, but a weak  one, poorly furnished with only
the  coarsest sensuous feelings and  scanty conceptions, only
reacting readily to  very intense impressions,  and then  merely
with sluggish,  dull,  almost meaningless  gestures  and  rough
words ; or,  again,  when it reacts easily,  lapsing into fatuous,
nonsensical, and often disconnected utterances.   Lastly,  in  the
complete blank, as regards emotion and thought,  of  the  wholly
idiotic,  the  capacity of  expression  is gradually  completely
extinguished; where nothing is any longer  present,  there also
nothing can be placed in readiness any  more.'
   1 Conf. the handbooks of mental diseases, especially J. Spielmann, Diagnostik der
Geisteskrankheiten.  Wien, 1855.  S. 26. 100. u. a. a. O.  Esquirol (Traite des malad.
ment. T. II. p. 288) distinguished between several  kinds of mental weakness on the
criterion of speech alone.  In imbecility of the first stage, speech is free and fluent; in
that of the second kind, less easy, and the fund of words poorer.  In the first  stage of
true idiotcy, the idiot has only command over short words and sentences; in the
second, only over one-syllable words; in the third, every articulate expression is lost. 
DEVELOPMENT OF ARTICULATION
629
                      CHAPTER  XIV.

 The Development of Articulation in the Child.—The Significance of Sounds in the
                            Word.

   The performance of speech  is dependent on the power of
 articulation  and diction.   Let  us then inquire more minutely
 into the inner mechanism of both acts, and, in the first place, of
 articulation.
   By articulation we understand the sum total of the inner and
 outer  movements,  by which words  as articulated sound-com-
 pounds are formed, independently of the ideas conveyed in them.
 The articulations of words are their syllables, which, however, are
 as a rule anything but the simplest  elementary sounds:  they
 are themselves compounded of  letters, of vowels, and of conso-
 nants.
   Now, as  articulation is an acquired  power and consists of
 co-ordinated movements  mastered by  practice, we  must in the
 first place inquire how  we come into  possession of it.   Three
 periods of development may be distinguished.
   1. AArithin the first four months, and about the time at which
 the earliest movements of prehension commence, children when
 in a good humor  frequently give vent to their feelings of joy in
 various sounds not prompted by those around them. This "lisp-
 ing  of infants " consists  chiefly of lip-sounds and  vowels, but
 also of Unguals and  palatal noises.  AAre hear  partly the well-
 known sounds of our alphabet, but not yet in the firm and clearly
 defined form which they assume later ;  and  partly other strange
 noises almost incapable of being rendered in our letters, sounds
 of sputtering, hissing, growling, and clucking, etc., e. g., pf, pfi,
 fbu,  tl, dsi, qr, etc., etc. These are only accidentally and loosely
 combined with one another, as a rule.1 These earliest utterances,
 wliicli I may be allowed to call the savage sounds, are of purely
reflex nature.  They are the outcome of  the  same muscular
impulse which leads  infants to  fumble about with  their hands
and kick with their feet, thus paving the way for prehension and
1 Conf. Berth. Sigismund, Kind und Welt. Braunschweig, 1856. S. 28. 
630        KUSSMAUL.—DISTURBANCES OF SPEECH.

walking.  They may be regarded  as those primal sounds with
which man has been endowed from the  commencement of his
existence on  earth,  from  which  have  been elaborated in the
course of countless generations those other sounds which alpha-
bets of the existing languages contain.   It would be interesting,
but would lead us too far, to inquire why different peoples have
cultivated or rejected different sounds ; why the Hottentots, for
instance, have  retained so  many of  the clumsy and hideous
gutturals.
   2. Later, when the  child  by listening learns to distinguish
tones—at that time when it is learning to grasp things with the
hands and to creep about with its feet,  and at which the impulse
towards imitation presents itself with its whole original force—
these savage  noises  are gradually crowded out by the conven-
tional sounds of the  national language.  It is probably due to
an early awakening of the musical sense 1 that children take in
and reproduce the vowels  and diphthongs in those words which
they hear before they imitate the consonants.  This imitation,
however, cannot be said to correspond to a comprehension of the
words.    They  understand  certain of  them without  imitating
them,  and imitate many  without understanding them.  The
great difference between comprehension and conception, on the
one hand,  and  articulation  on the other, presents itself to us,
therefore, as  an object worthy  of  study even  at  the  very com-
mencement of the development of speech.
   These earliest clearly articulated sounds are yet of a very
simple kind.   The child expresses its joy, amazement,  dislike,
and so on, with an  a, aa,  ho, u, da,  etc., etc.  These are pure
reflexes of feeling or interjections.   The imitative sounds are
the well-known baba, bebe, dada, mamma, dodo, dudu, atta, etc.,
which  nurses are over and over again repeating to their little
charges.  But at first the  child does  not connect any distinct
idea with the words mamma and papa;  it imitates the sound
only as an acoustic  picture, and only  by degrees commences to
intertwine the sense  with it which  the nurses have intended.  It
is not without interest to note that children seem to have a strong
  1 Sigismund's  boy sang  melodies with his father, and imitated melodies only in
the higher octaves before he imitated words. (A. a. 0. S. 118.) 
                DEVELOPMENT OF ARTICULATION.            631

inclination to repeat syllables of similar sound two or more times
over,  or to combine syllables in inverted order, as adda, oddo, or,
again, arrange one after another such as have a resemblance  in
ring,  as bimbam,  ticktack: this may probably depend upon the
musical sence.
   The enjoyment  of imitation awakes at  different periods  in
different children, and their  powers  in this  respect are just  as
various. At first  the mimical words of children have only a very
faint  resemblance to those spoken around them, and are mostly
only  understood by  the members of the child's family ; but im-
provement takes  place in this respect with ever increasing rapid-
ity.   Highly endowed  children sometimes acquire considerable
facility before the termination of the first year. Others again only
manifest a pleasure in articulate speech in the second half of the
second year, or even later, and then only make very slow progress.
   3.  At  a  third stage of its  development the child learns  to
associate  certain  definite  objects  with the  words  acquired by
practice, which are  then gradually worked  up into  intelligent
conceptions.  Then for the first time  speech becomes an  expres-
sion of thought, interjection and onomatopoesis are elevated  into
true diction.  It often occurs that a child, after using a word for
a long time,  suddenly becomes aware of its true significance,  and
that marvellous amalgamation of conception and verbal  expres-
sion takes place, the commencement of intelligent language.  At
this stage for the  first time the child creates out of itself, like the
earliest inhabitants of the earth, certain onomatopoetica of things
perceived which, however, must soon give place to the language
of custom.1  In all cases children display a greater readiness  of
   1 A boy of one and a half years, whom I observed almost daily, and who was just
beginning to learn a few intelligent words, e. g., papa, mama, hotto (for horse), and
the demonstrative " da," which he accompanied with an indicative gesture of the finger,
greeted every rolling object, balls, coins, balls of cotton, lead-pencils, etc., with the
ejaculation "Golloh! " This is an intuition-reflex in the form of  a sound-metaphor.
"Goll" imitates not only the noise of a rolling body, but also rolling movement by a
similar one of the tongue.  The additional " oh " appears to be an exclamation of wonder.
A•!. p further and "golloh " might become as "goll" a root-word expressive of rolling
movement.  Conf. a similar observation by Steinthal, Abriss d. Sprachwissensch.  1871.
S. o82. A girl of one and a half years imitateu in this case all rolling movements with
the exclamations " lululu," " bululu." 
632        KUSSMAUL.—DISTURBANCES OF SPEECH.

comprehension for the usual onomatopoetica of the nursery, as
for instance, wauwau, miau, etc., than for the customary indica-
tive expressions  of the popular language.  At this period the
work  of  development of articulation proceeds uninterruptedly
and hand in hand with that of diction.
   From this description of the development  of articulation in
the child, it would appear that the human being at first produces
simple sounds and combinations of sounds of a still indefinite
and more or less accidental  character, by  a kind  of inner
impulse.  He then learns to form these more accurately, and then
passes gently upward from the simple to  the  compound, from
the easy to the difficult, always admitting that there is a great
difference  in both individuals and peoples.  What we  articu-
late without difficulty offers an insurmountable obstacle to the
South Sea Islander,  whose language possesses a very limited
fund of sounds.
   It  would appear that Steinthal's  statement cannot be quite
correct, that we never in our  lives have learned single isolated
sounds which we have combined later on in speaking, but that
we have always listened  to whole words.  This  holds good only
for the acquirement of the popular language, and even' here not
completely.  The fact of learning the popular language is  always
preceded by practice in the savage  sounds  and nursery talk,
which only employs syllables and combinations of syllables, and
constantly appeals in the most attractive way to  the congenital
musical and onomatopoetic feeling.  Later on an etymological
and grammatical feeling springs up which is not congenital, but
the result of education, and this in its turn takes the lead.
   But that even in learning  the popular language  each sound
and each syllable has its own special worth in verbal expression,
is shown by the method which is found most  successful in our
public schools. Here children are made to break the words pho-
netically and to spell them and form them into syllables, in order
that a correct pronunciation  of the words  and the component
parts  of each may be fixed on the memory.  Later, we stamp on
our memories the words of foreign idioms with more ease by
pronouncing them aloud  syllable by syllable.   Moreover, it is a
matter of experience that aphasic persons may be placed again 
STAMMERING AND STUTTERING.
633
 in possession of their powers of speech by being taught to spell
 and form syllables.1   Finally, the study of articulatory disturb-
 ances of  speech teaches us that the formation of letters, their
 union into syllables, and the combination of syllables into words,
 are  separate functions.  These, although in speaking, as a rule,
 they go together, and although they are acquired at the same
 time, may nevertheless be separately affected by disease, and they
 possess consequently a mutual independence due to their differ-
 ent organic mechanism.  It is just as in dancing, which consists
 of a series of elementary forms of movement, flexion, extension,
 abduction, adduction, bending, etc.  These imply for each a spe-
 cial co-ordinative  spinal  centre,  and they  again may arrange
 themselves into higher movement  units of ever increasing com-
 plexity (as, for instance, the separate figures of the " francaise ")
 which are governed as to  their extent and duration by higher
 co-ordinative centres  situated  in  the brain.  There is just this
 difference  apparently,  that in speaking we must only seek  the
 lowest articulation centres in the basal ganglia of the brain, espe-
 cially in the medulla  oblongata and  in the  spinal cord, only so
 far  as  the centres of  the  formation of voice  and respiration
 extend  into it.  For  the sake of clearness  let us glance for a
 moment at those disturbances  of  articulation more commonly
 observed.
   Stammering consists in  an incapacity to  pronounce the let-
 ters properly, while in stuttering there is temporarily a spasmo-
 dic inability to vocalize certain sounds, especially the explosive
 consonants.  Although the  stutterer is able  to produce all the
 letters separately, he  is unable, on account of the  difficulty of
 vocalizing  them, to combine them all so as to form syllables.
 The stammerer suffers from alalia  or anarthria literatis, the
 stutterer from alalia or anarthria syllabaris spasmoelica.
   In stumbling over syllables there is no more inability than in
 stuttering to form sounds correctly, nor is there want of power
 to vocalize consonants, but the stumbler so tosses the letters and

  1 Conf.  an instructive case by Schmidt (Allg.  Zeitsch. f. Psychiatrie. Bd. 27. S. 304).
An aphasic patient was only able to comprehend written and  spoken words when sepa-
rated  into their component letters and syllables, and learned to speak once more by
spelling over and forming syllables.  We give this case in Chapter XXVI. 
 634         KUSSMAUL.—DISTURBANCES  OF SPEECH.

 syllables  one over the other that  distorted words are produced.
 Finally, the atactically  aphasic  person is able to form the
 sounds and syllables of words which his dictionary still contains,
 irreproachably,  and they are frequently very difficult to articu-
 late ; but he is unable to group these sounds  and syllables in
 any other way than just to form such solitary words as he retains
 of all his  former store.  He  may say "kaffe," but not "keffa "
 or "feka " or "fake," as was the case with one of our patients.
   There can be no doubt,  then, that the co-ordination of muscu-
 lar movements  to produce letters  is a  different function and
 connected with  central apparatuses, distinct from those produc-
 ing syllables and words.  It will  be the task of the clinical
 physiologist  to discover these different central  apparatuses, for
 the experimentalist has no means here of elucidating the matter
and can only, at the very most, give some little  support to clini-
cal observation.
   Before we enter upon the question how far we are able at the
present day to  do justice  to this very difficult question, let  us
inquire what are the sensory sources of  co-ordinative excitation
flowing towards the motor  centres of  speech.
                      CHAPTER  XV.

The Sensory Reflex Sources of Phonetic Speech, and the Regulating Sensory Prin-
                       ciple of Articulation.

   It is customary to regard the hearing as both the primary
reflex source  and the regulator of phonetic speech.  But this
view as so expressed we must discard.
   Laura Bridgeman,1 whose history we have related above, lost
her eyesight and hearing about the end of her second year when
she was  beginning to talk,  and in consequence soon lost the
power of speech.  Now, although it may be assumed that she
retained no memory of sounds, which long experience teaches us
  1 Fr. Lieber, On the vocal sounds of Laura Bridgeman. Smithsonian Contributions.
Washington.  Vol. II., 1851, Art. II. 
        SENSORY REFLEX SOURCES OF PHONETIC SPEECH.     635

is the rule in the case of  those who become deaf-mutes so early,1
yet she was able to produce a multitude of sounds.  She took
the greatest pleasure in giving utterance to these, and even went
so far occasionally, in order to indulge herself in noises to  her
heart's content, as to lock  herself up wdien  her teachers  endea-
vored  to  restrain  her in so doing.   These were in fact inar-
ticulate, e. g.,  a kind of chuckling or grunting, as an expression
of contentment, while others, e.  g., " ho-o-ph-ph,"  were better
formed and served for an indication of  astonishment.   Other
sounds, again, she elevated to the dignity of names and bestowed
them on certain persons.   She uttered these latter when those so
denominated approached her, or when she wanted to find them,
or even at times when she only thought of them.  She employed
some fifty or sixty such sounds as names, many of which could
be written down, such as, fu,  tu, pa, fif, pig, ts, pr, lutt, etc.;
many, however, it would be almost impossible  to express in  let-
ters.   She formed,  however, only words of  one syllable, but
frequently reduplicated them two or three times, as fu-fu-fu,  tu-
tu-tu.
   Here, then, we  see how far an intelligent human being can
advance in  the acquirement of  phonetic language wilJiout either
the power  of hearing or that of seeing,  and oidy through  the
medium of the muscular sense and that of touch.'1   It  is not
only able to produce the "savage sounds" of the first stage of
development of the lisping child, but is also able to register them
in the memory,  to combine them into orderly, although very sim-
ple monosyllabic sound-compounds,  and  to associate them with
certain feelings, or even with conceptions of certain persons.
   Deaf-mutes also, as Heinicke has pointed out, sometimes cre-
ate for themselves,  even without direction, a  phonetic language,
though  a very imperfect one.  This observer based his method of
   1 Bonnafont (Bull, de l'acad. de mt'd. T. XXX. p. 860), who has paid much atten-
tion to this point, assures us that children up to their eleventh year who become deaf
from any sickness will soon likewise become dumb (even within half a year), and more-
over, partially or completely so, according to the degree of sickness.  He bases these
conclusions on an observation of more than twenty cases.
   ■ Lieber gives an account of three other deaf-mutes, far less intelligent than Laura
Bridgeman, who never advanced beyond a few unpleasant sounds. 
636          KUSSMAUL.—DISTURBANCES OF  SPEECH.

instructing  deaf-mutes to speak  aloud, for  which he  deserves
such immense  credit, partly upon this  discovery.   The sense of
sight enables the deaf-mute to imitate the movements  producing
sound in the form  presented by the teacher, and the  regulating
power of the sense of hearing is replaced by the muscular sense
and that of  touch.1
   Samuel Heinicke believed also  that he might call in the aid of
the sense of  taste to give precision and permanence to the sounds
acquired by deaf-mutes, but his successors  have abandoned this
idea.
   All  that touch and muscular  sense  are able to accomplish
under the direction of  sight is  shown in a  most interesting way
in the case of  deaf-mutes who have been instructed.  They learn
to articulate and  to speak correctly, though their voice is rough
and unpleasant.   But it is most astonishing to what extent some
of them can acquire the power of articulation.2
   Now, from these facts,  the following  conclusions  may be
drawn:
   1. That at all events hearing cannot be called the only primary
reflex source of those sounds which we employ later in speaking
in a permanent and distinctly  articulate form.  The first  lisp-
ing of the child springs from a feeling of enjoyment, just  as the
frog in the pond croaks from a sense of enjoyment.  These plea-
surable  feelings working in the cerebrum cause  a stimulus to the
   1 There are, moreover, some apparently quite deaf and dumb persons who are great
lovers of music and visitors of concerts, who can distinguish between well and ill exe-
cuted passages, and who applaud or blame with correct judgment.  It is possible, of
course, here, that the vibrations of sound generate musical feelings in the acoustic appa-
ratuses and centres by propagation through  the bones of the skull.  Compare, for in-
stance, some  interesting observations by Mueller (of Pforzheim), Allg. Zeitsch f. Psy-
chiatrie. 1849. Bd. VI.  S. 242.  Kruse, an instructed deaf-mute, was able to distinguish
the tones of different instruments. He compared those of the trumpet to a yellow color,
those of an organ with green, those of a drum with red (Tylor).  Conf. Chap. XXXVI.
   21 conversed one day in hospital for a considerable time with a young bookbinder
just admitted for phthisis,  without noticing anything peculiar about his speech, except
a loud voice and an unusual pedantical accuracy of expression.  It was only on termi-
nating  my examination, after taking down  his clinical history, that I noticed to my
astonishment that I was conversing with an  educated stone-deaf individual.  Noticing
him now more closely I found that be read every word rapidly and with certainty from
my mouth, and that his speech was hard, i.  e., destitute of music and modulation. 
       SENSORY REFLEX SOURCES OP PHONETIC SPEECH.    637

basal centre of sound ; but  this is  not  the first point of origin.
It is possibly a sense of satiety and of warmth proceeding from
the gustatory  and sentient nerves of the skin which gives rise to
this feeling of comfort and to the muscular craving which impels
to the utterance of sound.
   2. Hearing is not an indispensable regulator of articulation.
Tliis axiom, however, must be to a certain extent modified, for it
is only by the co-operation of the hearing  sense  that delicacy
and smoothness of articulation and euphony in speech  are
secured.
   3. The power of imitating phonetic  speech is  dependent on
hearing and sight; but only one of these  senses is  really an
indispensable requirement in  the matter.  Blindness  and deaf-
ness combined, existing from  earliest infancy, admit,  indeed, of
the acquirement of the rudiments of phonetic speech, but render
its full development impossible, while in such a case a language
of gestures and tangible letters and symbols may be learned.1
   4. The full development of the intelligence and the acquire-
ment of a language involving ideas are  always  dependent, at
the very least, on  the sense of touch and muscular sense.   In a
case of blindness and  deafness combined these are essential and
indispensable.   For the power of properly estimating the resist-
ance of the muscles to be set in motion by articulation and of over-
coming this by a simply adequate force, is here just as indispen-
sable as the other, namely, that of  appreciating sensations as to
the position of our members  in space when engaged in move-
ments.  The first is provided for by the nerves of muscular sense
(whose existence,  established  by Sachs, was felt  to be such a
necessity to physiology); the  second by the tactile nerves.
  11 find in Boz (loc. cit. p. 74) the history of a boy, Oliver Caswell, who, like Laura
Bridgeman, had become blind and a deaf-mute, and who was  taught to read by Dr
Howe. 
638         KUSSMAUL.—DISTURBANCES OF SPEECH.

                      CHAPTER XVI.
Imitative Articulation.—Is there a Direct Reflex Tract from the Acoustic Nerve to
   the  Basal Centre of Sound, or does it lead through the Cerebrum ?—Experi-
   ments of Vulpian and Danilewsky.—Persistence of Imitative Speech.—Loss of
   Voluntary Speech.

   With the child an expressed word makes such a strong im-
pression upon the sense of hearing as to impel to imitation, even
when not  understood.  This reflex-motive power dwelling in the
word itself as a perceived sound-picture,  and  quite independent
of its inherent meaning, is seen  in undiminished strength in the
child, all reflex effects being particularly easily produced during
childhood.   But as  the organs of  intelligence  are  gradually
developed, the ever-increasing processes of excitation in the cere-
brum,  and especially  in the cortex, come into  play, checking the
mere sensuous reflexes.  The adult only imitates when carried
away by some unusual force in a word laying hold on his feel-
ings, or with some design, or when from  disease of the cortex of
the brain the restraining influences over the  sound-reflexes are
to some  extent interfered  with.   This will explain the "echo
speech"  of many persons who  have become  mentally weak, to
which  we have  before alluded.
   This speaking, then, from a mere impulse of imitation—the
speech of parrots  and of children learning to  talk — is conse-
quently an acoustic reflex.  The stimulus to the motor-centre of
sound  originates here in the acoustic centre, which receives the
words  as  an orderly succession  of sounds and transfers  them
to the  former.
   The difficult question now arises :  Does this acoustic transfer
of sounds take place behind the  cerebrum or in the cerebrum?
Wundt' is of  the opinion  that the  auditory nerve is excluded
from the territory of the true reflexes ; that it brings about the
numerous incitements to motion wliicli it produces only through
the  cerebrum.2   If this were  correct, the imitation  of  sounds
would be  always effected through the brain.
   1 Grundziige der physiologischen Psychologie.  Leipzig, 1874.  S. 182.
   2 This is by no means quite correct.  Wundt himself describes the acoustic reflexes
of the tensor tympani (p. 49G. Note 2). 
ACOUSTIC SOUND-REFLEXES.
639
   This is not the case, at all events, with the senses of sight and
of touch.  Not  only  do impressions  on the optic and tactile
senses provoke numerous simple reflexes, but a number of  com-
plicated movements, such as those of  running,  jumping, flying,
and swimming, are executed by animals after being deprived of
their cerebrum.   And it  is not alone those animals which bring
these powers into  the world with them, but also  those which
have only acquired them after birth. They even suit these move-
ments to impressions received through the eye in a way which
may be taken as involving a  mental exertion and judgment.
Frogs deprived of their brains  will  spring past an obstacle when
impelled to jump by some painful stimulus (Goltz).  Birds and
mammals, with  all  the brain removed except the corpora qua-
drigemina, will follow the movements of a lighted candle with
the head (Longet').
   Now, is there  really any difference between the  acoustic reflex
and that of sight and of touch \ Is it  always cerebral, or can it,
like the latter, be brought about through the basal ganglia below
the crura cerebri ?
   In an article  by Maudsley2 on the physiology and pathology
of the mind, an experiment of Vulpian3  is alluded to, which seems
to point to the existence of an acoustic sensorium in the posterior
part  of the cerebrum.   "The rat," says Maudsley, "perhaps
from being hunted generation after generation, is a very shy ani-
mal, very suspicious and distrustful, flying before the  slightest
unusual noise. If such, an animal be deprived of  the hemispheres
of its brain, together with the corpora  striata and  optic thalami,
it remains quiet.  But if a low sound, such as cats make, be now
produced, the animal will make  a spring, and  repeat this as often
as the sound is reproduced."
   In  contrast, however,  to this result, which is vouched for by
a celebrated observer, there are  a series of experiments by Dani-
  ' Anatomie u. Physiol, d. Nervensystems. Uebers. v. Ilein. I. S. 385.
  ■ Physiology and Pathology of the Mind.
  3 Lemons sur la physiologie du systeme nerveux, etc. 1866. p. 548.  On referring
to the original, I find that the author, on the strength of this experiment, regards the
pons as the excitation centre for emotional movements, and also as the centre in which
the stimuli of the auditory nerves are transformed into sensations. 
640        KUSSMAUL.—DISTURBANCES OF SPEECH.

lewsky,1 which seem to make it doubtful whether, in the case of
sound-reflexes,  the basal sound-centre can be excited from the
hearino- organs in any other way than through  the lobes of the
brain.   In  the  formation  of  articulate  sounds,  the respiratory
centre  must  be also excited in a certain definite manner.  If
in animals deprived of  their brain we are unable to  excite this
centre  through the  ear, sound-imitation can only be brought
about through the brain.  Now, Danilewsky found that when, on
cats and  young dogs narcotized  with  morphia,  he  applied  a
weak electric stimulus to the gray substance of the supra-Sylvian
convolution (Owen), corresponding to Hitzig's facial nerve-centre
or  the  posterior part of  the  corpus striatum,  the  breathing
became slow, with a preliminary deeper  inspiration.   The  same
effect was produced by shouting in the ear.  But, after removal
of the lobes  of the brain, this reflex action from the acoustic
nerve disappeared.   Such  a mode of breathing  corresponds to
that which speech requires.   An electrical stimulation of the
deeper  portions of the brain, on  the other  hand, caused  more
rapid breathing, which we know is incompatible with speaking.
   From this experiment  of Danilewsky it would appear that
acoustic sound-reflexes can  only come to pass through the
medium of the cerebrum proper.  If this be correct,  the follow-
ing conclusion is forced upon us : as soon as the child imitates
sounds, the  training of the  cerebrum  and its  cortex for the
objects of  speech, through the medium of  reflex mechanisms,
commences.  The moulding and shaping of the primal sounds of
the basal centre into the customary sounds of conventional lan-
guage and into those modifications of syllables and words which
the rules of speech require, have their origin in  the brain proper.
From the latter the paths  to the basal centre and to the muscles
of the organs of speech are traced out and levelled ; and at differ-
ent ganglionic  stations through which the stimulus must  pass,
the cell-connections with  the  basal sound-centre are set up,
through which alone the  various  vocal  sounds are fully repre-
sented  and the formation of  syllables rendered  possible.   It
requires, as a rule,  several years before all the sounds can be
1 Pfliiger's Archiv f. d. ges. Physiol.  Bd. XI. 1875. S. 128. 
ACOUSTIC SOUND-REFLEXES.
641
produced, and many persons are unable their whole life long to
complete the whole task.
   After the destruction of  voluntary  speech, the power of
repeating words spoken aloud by others often remains to those
aphasic individuals not ataxic, although unable of their own free
will to utter these words.  They are incapable of bringing the
word-pictures to  the recollection by conceptions,  but articula-
tion has not suffered.  By the  utterance aloud of others, the
acoustic pictures of the words which can no longer be produced
from within are presented to them from without, and  so the
reflex start to the corresponding movements of sound is rendered
possible.  The same occurs in the echo speech of feeble-minded
persons,  and with the same  impulsive desire  which leads the
child to  repeat words, whether understood or not.
   In our own  experience, aphasic persons are much more suc-
cessful in the repetition  of words spoken aloud by others when
they fix  their  eyes carefully upon  the mouth of  the speaker.
The optic picture of the  sound movements affords a kind of sup-
port to  the  acoustic.  Thus we  see that the same means which
assist deaf-mutes in the acquisition of phonetic language are of
service in the case of those afflicted with aphasia.
   There could be bat one clinical observation which would sup-
port the very improbable theory that imitative reflex speech is
solely accomplished by  a  direct communication  between  the
auditory nerve  and  the motor  nerves  of  speech  in the basal
centre of sound.  After complete destruction of the hemispheric
voluntary tracts, say of both capsulffi internse, individuals so
affected  ought  still to repeat words spoken  by another ;  but,
until such a proof is forthcoming, let us  suppose that imitation
is iuoariably a function of the  cerebrum.   Clinical experience
of  cortical disturbances  of speech  of  an aphasic  character  is
plainly in support of this view.   Imitative reflex speech is  only
found in amnesic aphasia, in which simply the acoustic word-
picture has been lost, but not in ataxic, in which the word as a
motor sound-compound has vanished.
         VOL.  XIV.—41 
642         KUSSMAUL.—DISTURBANCES OF SPEECH.
                     CHAPTER  XVII.
Interj ectional or Emotional Speech.—Its Preservation  after the Loss of Voluntary
  Speech.—Explanation thereof.—Theories of Hughlings Jackson and Jaccoud.

   Both among animals and men the emotions lead to numerous
expressions, whose general principles  have  been investigated
by Darwin1 in his own peculiarly thoughtful way. He has shown
that here, too, it is only by  the discovery of the general laws of
development of the organic  world that we  are  able to fully com-
prehend the question, although it may for all that still be impos-
sible to ascertain with certainty the cause of most of the forms
of expression of the emotions.
   Many human emotional gestures which are common to all
races are to be found also among the lower animals, while others
are peculiar to man.   For instance,  among  the first may be
named the trembling of fear and rage, the writhing of the  body
and shrieking of  mental agony, which  have  a  parallel in the
allied  reflex  expressions  of  bodily pain.   Again, there are
the skipping  and leaping  of  joy  and joyous expectation, the
showing of  the teeth in rage and  defiance, which have become
refined off into a display simply of the side teeth among many
men, as a sign of defiant scorn.   Even the laugh of man has its
analogue in the chattering of some apes.   "The habit of weep-
ing, however,  must have been  acquired at or after that period at
which  man branched off from the common progenitors of the
genus homo and the  non-weeping anthropomorphs" (Darwin).
    A cardinal difference, however, between man and the animals,
lies in the power  of expression of the emotions by articulate
sounds,  which is only enjoyed by  the  former.  Animals,  also,
employ  unarticulated melodious and  unmelodious  sounds for
the purpose of calling, warning, or enticing its kind, and espe-
cially  the  male  to  charm  or arouse  the  female.2   Darwin
  1 The Expression of the Emotions by Animals and Man.  1872.
  ■ Even apes utter in anger sounds much resembling interjections.   A. young female
orang made jealous by the attention of her keeper to another ape, showed her teeth
slightly, and uttered a sulky noise like tisch-schist, turning her back on him at the same
time (Darwin). 
           INTEItJECTIONAL OR EMOTIONAL SPEECH.        643

regards this  as  the primal custom and the earliest stage of
development  of  the voice.  Many animals have only acquired
the habit of  giving vent  to  sounds before unnatural to them,
since  they have  been domesticated.   Thus it is with our house
dogs,  and even with tamed jackals, which have learned to bark,
a sound proper to no species of the genus, with the exception of
the canis latrans of North America, which is said to bark. Some
races  of  tamed pigeons, too, have learned to coo in a new and
peculiar manner.
   The fact  mentioned above, that a musical feeling awakes
much earlier  in  children than sense for words, is probably con-
nected with the  early  existence of musical  feeling in the  ani-
mal world.  Not only is it present in birds, but also in mam-
mals.   There  is an  ape, for instance, one of the gibbons, wliicli
produces exactly one octave of musical sounds, singing the scale
in the same tones upward and downward ; so that it may be
said of this ape "that it alone of all the mammals can sing"
(Owen).  From an observance of this fact, and by the analogy
in other  animals, Darwin  has  been  led to  the following con-
clusion :  "that  the progenitors  of  the human race probably
employed musical sounds  before they had acquired the power
of articulate  speech, and that in consequence  of this, the voice,
when  employed in  any violent emotional excitement, always
tends  to  assume a musical character, on the  principle of asso-
ciation.''    Certain it is that the loudness,  resonance, timbre,
height and intervals of the  voice are determined by the influence
of the different excitements of the mind, as has been shown by
the investigations of Herbert Spencer,1  confirmed  by Darwin s
observations.
   It  is impossible  to discover the primary causes* upon which
depend our natural emotional utterances found among all races
in allied  forms.  The sounds expressive of contempt and abhor-
rence,  however, such as "puh,"  tkpish," maybe  explained by
the fact that  they correspond with the movements  of the  mouth
and nose wdiich we  employ in repelling disgusting  or repulsive
  1 Essays, Scientific, Political, and Speculative, 1858.  The Origin and Function of
Music, p. 359. 
644         KUSSMAUL.—DISTURBANCES OF  SPEECH.

odors  and  tastes.   Later every  unpleasant impression, every
repugnant conception, may be turned  off with  this  movement
and interjection which has become established by habit.
   Now, if  in the case of the primal sounds, which  have their
cause in emotions of enjoyment, we are  led by Groltz's  "croaking
experiment," to  seek the source  of excitation of the centre of
sound by feelings in the cerebrum, how much more so  in the
case of those  interjectional  utterances  and sound-compounds
expressive of emotions of joy, wonder, abhorrence, etc., which
conventional language contains, and which have in many cases
been borrowed from  the language of  intellectual intercourse.
But the feeling to  which  the emotions  may be referred is no
special property  of the mind  seated in  a  special province of the
brain.   It is nothing else than the mind viewed from this special
point of view :  in what strength and form of expression of feel-
ing does the inner man react  towards impressions  when it esti-
mates  the latter in reference to the furtherance  of its own well-
being?  The child and the savage react with coarse, sensuous
feelings, and form estimates according  to raw,  sensuous experi-
ences ;  culture fines off the  feelings  and  mode of  estimating
things to an ideal elevation or refined commonness.
   Emotional stimuli are far more powerful titan those which
are generated by imitation or accompany thought.  They spread
themselves,  consequently, as a rule, not only  over the higher
and lower cerebral centres of motion,  but  also  over  the  spinal
and even  sympathetic ganglia of  the viscera.   To this strength
of the  stimuli  is due the  fact that the emotional speech of chil-
dren and savages, in whom it is unrestrained, is always accom-
panied by lively  and characteristic gestures.*
   The original natural sounds are all combined with  gestures—
they  are  "sound-gestures."    In the imitation of sounds, on
the contrary, the stimulus is more restricted to the  mimic and
sound reflex-centres, while the emotional  stimuli spread them-
selves out over the widest areas of the nervous  system, not
  1 Northerners accompany their language with fewer gestures than do southerners.
The Englishman concentrates almost all his expression of feeling into language, while
the Italian will act a whole comedy in pure pantomine. 
INTERACTIONAL  OR EMOTIONAL  SPEECH.        645
 only affecting the motor-centres for the limbs and trunk,  but
 also those for the breast, and even for secretion, and even act-
 ing on the functions of the senses and intellectorium.  The more
 we acquire the power of representing  abstract conceptions by
 words, and of restraining the feelings by understanding and rea-
 son, the more does the stimulus in speaking  become restricted
 to  the motor territory of  the proper  apparatuses of speech.
 Finally, philosophical thought, soaring into the loftiest abstrac-
 tions,  is accomplished  best in silence.   Softly spoken  word-
 pictures or written pictures,  which only let loose very weak
 stimuli upon the motor-centres of speech, are  the most effectual
 in causing the conception of  thoughts and guaranteeing thor-
 ough deliberation.  AVise men and  deep thinkers are, we know
 from experience, very sparing of words, while children and shal-
 low-pates babble out whatever  occurs to them.
   Now, since emotional stimuli  are  far  stronger than those
 accompanying quiet thought,  and extend themselves over far
 wider tracts of the nervous system, it  is  easy to conceive that
 the capacity  of producing words for the purposes of express-
 ing  thought, or only for their own  sake,  may  be lost,  while
 emotional  speech,  or the  capacity of uttering  interj ectional
 words,  very often continues to exist.    The latter  manifests  a
 certain independence of the former.
   This fact, if not first noticed, was at least first brought into
 prominence by that able observer, Hughlings  Jackson.1  Many
 very interesting  experiences bearing upon this point have been
 recorded both by him, and by Trousseau, Broca, Gairdner, Broad-
 bent, and others.   Persons become  aphasic, /. e., incapable of
 uttering a single word voluntarily, are shown to have given vent
 to interjections, not only short words such as the complaints, O !
 Ach  ! Auau !  which are very common, or Yes! and No!  which
 are often uttered as interjections, but even longer and often very
 difficult words, as  for instance, "Shocking!"  or imprecations,
 and even brief sentences.2   Such aphasic persons have repeat-

  1 London Hospital Reports for 1864.
  ■ During the revision of this chapter a laborer, quite unconscious and with all the
symptoms (afterwards confirmed post-mortem) of acute meningitis, was brought into
hospital.   Within the first twenty-four hours he uttered not a single word, but in the 
646         KUSSMAUL.—DISTURBANCES OF SPEECH.

edly been regarded in hospital, by their attendants or fellow
patients, as  malingerers, from  the fact that after weeks  of the
most obstinate silence to all questioning  and remarks made to
them, they have suddenly in anger burst  out with a  long and
violent oath.  Jackson' and Sir Thos. Watson have even  found
that aphasic persons, unable to reply " No " to a question, have
nevertheless been led to do so by suggestions  designed to make
t hem angry, e. g., were they a hundred years old, or a thousand,
or such like.  One may be then, as Jackson puts  it, speechless,
and yet not  icordless.
   Jackson2 locates the "automatic"' power  of uttering  words
in the  right hemisphere of the brain, and the voluntary  in the
left.  We shall see later on that this latter view may be granted
to be correct in this sense that  right-handed individuals practice
the left hemisphere chiefly or  exclusively for voluntary speech.
But it seems improbable that we practice the language of emotion
only in the  right half of the brain, as  Hughlings Jackson sup-
poses, and for this reason, because emotional gestures are exe-
cuted sometimes with the right hand, sometimes with  the left,
sometimes with both.  In anger we at one moment unconsciously
clench the  right fist, at another both ; in asseveration we raise
the right hand, as also in taking a solemn oath, or  place it upon
our heart ;  an object of detestation we  repel with  that hand
which lies on the  side threatened with its unwished-for contact.
This seems  clearly to indicate  that an  emotional stimulus may
move  the members of the  body from  both  hemispheres, and
hence the thought suggests itself that an emotional outburst of
sound-compounds  also may be  accomplished  by  both hemi-
spheres, or,  in other words, that from  childhood  on both  halves
of the brain are practiced for  interjectional sounds and words,
but only one for true intelligent speech.   If  this latter  be de-
prived of its functions as regards language, the other still remains
for emotional sounds.
morning, as he was lifted from one bed into another in a comatose condition, he burst
out with a long oath. In the evening he died without awaking from the coma.
  1 Brit. Med. Journal.  1871, Dec. 2. p. 641.
  2 At the same place. Conf. also Clinic, and Physiol. Researches on the Nervous Sys-
tem. Lancet, 1875. 
                       AUTOMATIC SPEECH.                   647

    Jaccoud1 supposes automatic speech to be presided over by a
 basal centre of sound situated underneath  the corpora  quadri-
 gemina, and which he tries to localize more precisely, as we shall
 see in the next chapter.  According to him, we have here to deal
 with the products of reflex stimuli of this "spinal" motor and
 co-ordinating apparatus, which replies with sounds at one time to
 acoustic, at another to optic impressions,  while through great
 exertions of the  will also it  becomes excited and betrays this
 condition by monosyllabic and  always similar words.  Now, if
 the words were really always monosyllabic, this  theory would
 have something very attractive  about it,  especially as we know
 from Bell, Romberg, and others, that the voluntary functions of
 the facial and hypoglossal nerves may be lost while their reflex
 action remains intact, and  conversely, that the reflex movements
 may cease while the voluntary are preserved.3
    It is, to be sure, correct that many aphasic persons, even when
 unconscious, continue to repeat automatically over and over again
 simple articulated sounds expressive of pain, as, for  instance,
 u Oh, me ! "  " Ah, dear ! "  until they become comatose.3  Others,
 again, react  to every  question and every function  with some
 senseless syllable, e. g.,  "tan," as  is related of several French
 patients.  Such simple combinations of sound might be regarded
 as analogous to the spinal  reflexes which  issue  from the lumbar
 cord in the form of simple but orderly movements (Freusberg).
 But  the  same  man (Broca's case) who only answered  with the
 syllable " tan/' uttered  from emotion a  long oath  (sacre  nom
   ' Lemons de clinique  medicale, etc. 1874. p. 65.
   2 More at length in Chap. XIX. and at the end of this chapter.
   3 It has recently been my lot to see a young man succumb to endocarditis compli-
 cated with pneumonia and pericarditis.  A few days before death this led to an embolic
 cerebral apoplexy with right hemiplegia and aphasia, at first without any disturbance of
 the consciousness.   This patient gave me to understand by the most expressive signs
 that he was about to follow his departed wife.   He first pointed with the left hand to
 a portrait of the departed on the wall, and then up towards heaven.  He had once
 before his illness confided to me that his wife had told him not long  before her death
 that he would soon  follow her. He was only able voluntarily to utter the  vowel  a.
 Besides this, and even after he had  become unconscious and hardly reacted  to a call
from his mother, he kept continually repeating the complaining sound " Oje." It was
only in the last hours of  life, after he had become quite comatose, that he became com-
pletely silent.  Autopsy  refused. 
648         KUSSMAUL.—DISTURBANCES OF SPEECH.

de   .  .).   Now, was this oath articulated in the brain, and the
short syllable " tan " in the basal centre of sound ?  The oath, at
all events, is of a more reflex nature than the stereotyped answer
"tan."  And what are we-to say of the senseless polysyllabic
words  which many  aphasic  patients employ as a  stereotyped
answer, or of the cases where they have command of two or three
such words as " tschi, tschi," and  "akoko,,, as occurred  in a
patient of Westphal %
   Finally, we see gradual  transitions to  those cases one  of
which Broadbent' has related, in which a larger number of words
give expression to the emotions forced out rapidly in the manner
of interjections, while the power of voluntary speech is entirely
destroyed, the intelligence remaining.  It is  impossible to sever
these experiences forcibly from one another, and  one and the
same explanation must be found for all.
   These facts are in accord with what Hughlings Jackson states,
namely, that the mimic movements of expression of aphasic per-
sons,  such as smiling, laughing, and  weeping, may sometimes
persist as emotional reflexes, while they can no longer be pro-
duced  voluntarily.   Indeed, it may happen that these emotion-
reflexes in aphasic patients are completely out of gear and burst
forth on the least  provocation and with the greatest violence,
like the spinal reflexes in decapitated  animals.  Such cases are
frequently met with in which, as when the patients are addressed
by the physician, or after fruitless efforts to render themselves
intelligible by words, they burst out  into convulsive weeping.
If they are made to laugh, this too is convulsive.
   Again, the power of expressing musical feeling is indepen-
dent of phonetic speech.   Just as  children are sometimes able,
before they can speak, to sing a tune they have heard (Sigismund),
so also is it with  aphasic persons.  Such a patient, unable to
utter a single syllable besides the one " tan," sang " the Marseil-
laise" and "the Parisienne" quite well, but with  no other text
than this incessant  " tan, tan,  tan," etc., etc. (Behier.2)  Indeed, it
sometimes happens that, under the influence of musical stimulus,
1 Conf. Chap. VII. S. 602.
2 Falret, Article "Aphasie," in the Diet, encycl. des Sciences med. T. V. p. 620. 
AUTOMATIC SPEECH.
649
words will make their appearance which could not otherwise be
uttered.   Hughlings Jackson' tells of idiotic  children not deaf-
mutes, who were  only in possession  of a few words, but who
could sing, and when singing could bring out fresh words which
otherwise they had no  power over.
   Fever, too, is said to have generated words in cases in which
the will was  totally unequal to the task, just as  strong excite-
ment of the  brain  by emotions  is  sometimes able  to  do it.
Jackson2 relates a case occurring in the experience of Langdon
Down, in which a speechless idiot came out quite as a speaker
during the delirium of fever !   Aphasic persons,  according to
Brown-Sequard,3  sometimes recover their speech during  delir-
ium.
   In a case of complete abolition of the power to move volun-
tarily the tongue and the muscles supplied by both facials,  Rom-
berg 4 noticed  that the ability to close the lids and to swallow,
through  reflex action, still remained.   Phonetic  speech was
reduced to the mere utterance of the sound "ang" or "ong"  ;
but  when, in  the course of the reading or of the conversation,
the patient happened to laugh or smile, it was observed that all
the facial muscles performed their functions correctly.  But even
from this experience it would not be safe to draw the conclusion
that in this case  the  emotional  excitement  proceeded directly
from a centre governing the motions of laughing, and situated at
the base of the brain, beneath the cerebral hemispheres. Opposed
to this assumption is the statement of Romberg, that the act of
laughing is produced by what is spoken or read in the person's
hearing—that is, by his understanding what  is spoken or  read.
According to  this view,  the excitement would unquestionably
proceed directly from  the  cerebral hemispheres.   The power to
laugh is also  known to be preserved in bulbar paralysis, even
after articulate speech  is no longer possible.  The mechanism at
the base  of the brain,  which governs  the act of laughing, is evi-
dently less interfered with by processes which  affect  the  facial
nerve, than is  the mechanism that controls speech : and the emo-
1 Lancet. 1861, Sept. 2;?.                     * Ibidem.
3 London Medical Record.  June, 1874.            4 Loc. citat. p. 786. 
650          KUSSMAUL.—DISTURBANCES OF SPEECH.
tional path along which the necessary stimulus ordinarily travels
is also capable of bearing greater disturbances than can that over
which the stimulus of the will is transmitted.
                       CHAPTER  XVIII.

The Phonic Centre below the Corpora Quadrigemina, or Basal Phonic Centre.—Its
    Share in the  Formation of Articulate Sounds.—Theories of Cruveilhier, Ley-
    den, Schroeder van der Kolk, and Jaccoud.—Peculiarities of Structure which
    seem to make the Medulla Oblongata a Suitable Locality for the Co-ordination
    of Phonic Movements.— Clinical Facts  which render the Implication of the
    Medulla and  Pons in Articulate Utterance a Certainty.—Disorders of Articula-
    tion in Progressive  Bulbar Paralysis.—Significance  of  the Bulbar Nuclei.—
    Bulbo-nuclear Stammering.—Disorders  of Articulate Speech  consequent on
    various other Lesions of the Medulla Oblongata and Pons, likewise on Insular
    Sclerosis of the Brain  and  Spinal Cord.—Basal Kinesodic Dysarthries, Intra-
    cerebral and Extracerebral.—Bradylalia and " Scanning " Utterance.—Relation
    of the Mechanism of Phonation to  the Synthesis of Syllables and Words.—
    Stammering,  Stuttering,  Blundering Enunciation of  Syllables,  Atactic and
    Amnesic Aphasia.—The Cerebellum  in its Relation to Articulate Utterance.

    Animals which express  their feelings by screaming,  crowing,
croaking, and similar  non-articulate  sounds,  may  still  be  in-
duced to utter these sounds after their brain, up to and including
the corpora quadrigemina, has  been removed.   Anencephalous
monsters and  infants craniotomized during delivery ^re likewise
capable of  emitting  cries  and  squeaks.    The reflex-centre for
such non-articulate sounds must therefore be situated below the
corpora  quadrigemina* its lower  limit in the cord coinciding
with that of  the  respiratory centre.   This reflex-centre—whose
integrity is undoubtedly essential  for the  production of articu-
late as well as of  non-articulate sounds—we shall term the basal
yhonic centre.
    In affirming that articulate sounds cannot be produced with-
out this basal centre, we do not affirm  that it is itself the centre
   1 When I was a student I had an opportunity of dissecting a well-developed anen-
cephalous foetus, born at full time, which was said by the midwife to have squeaked
like a mouse several times after its birth. 
SITUATION  OF PHONIC CENTRE.
051
for articulate utterance,  understanding  by this  the workshop
wherein the formation of literal sounds actually takes place ; the
letter,  as  an acoustic image, being transformed  in accordance
with the phonetic  laws of speech into co-ordinate movements of
the respiratory  organs, the larynx, and  the mouth (which con-
tributes to the formation of vowel-sounds and consonants).  Be-
fore making any such assertion  it would be  necessary to prove
that this delicate elaboration of  crude sounds into  the phonetic
instruments of the intelligence is capable of being effected within
the narrow limits of that basal region.
   True, writers  of authority have confidently localized articulate
phonation in the pons and medulla oblongata, with or without
the addition of the cerebellum.
   As  long ago as 1834, Cruveilhier' arrived at the  conclusion,
based on several instances of atrophy of the medulla, either by
itself or together with the pons,  in which the power of articula-
tion was lost, that  the  centre  for articulate phonation must be
seated  in those parts.
   Leyden * expressed the same opinion in 1867.
   Schroeder van der Kolk 3 ascribed the power of regulating the
contractions of  the  muscles concerned in speech  to  the olivary
bodies.  He believed himself to have discovered  that they are
connected with each other and with the  facial and  hypoglossal
nuclei by commissural fibres.  This hypothesis must  now be defi-
nitely abandoned.  Neither  Deiters nor  Meynert has been able
to find any such commissural fibres, and Clarke has shown that
the evidence furnished by comparative anatomy is dead against
the theory.  The parrot and other animals capable of mimicking
articulate speech possess no olivary bodies, or possess them only
in a very  rudimentary form ;  while the  seal (Seehund), whose
reputation for eloquence still remains to be made,  has  them of
enormous size.
   Jaccoud4 at one time followed Schroeder in placing the centre
1 Arch, gener. de medecine. Juillet, 1834. IV. 416.
2 Berlin klin. Wochenschrift. 1867. p. 78.
3 Bau und Funktionen der Medulla spin, und oblongata, pp. 161, 165.
4 Gazette hebdomadaire. 1864, Juillet 22. 
652         KUSSMAUL.—DISTURBANCES OF SPEECH.

for articulation in the olivary bodies.   Recently, however,1 he
has transferred the function of co-ordinating the movements of
phonation to the "systeme commissural cerebello-bulbaire, i. e.,
the bulbar commissure of the olivary bodies, together with the
commissure of the middle crura  of the  cerebellum, both in the
intra-cerebellar and in the more  central—intra-pontine—portion
of its  course.   As regards the  olivary  commissure, its impor-
tance in relation to articulate speech is  much weakened by the
researches of  Clarke (vide supra).  The significance of  the cere-
bellum and its pontine commissure is based by Jaccoud on a case
accurately observed by Meynert.   But this case is not altogether
conclusive.2
   It must be admitted that various features in the anatomy of
the medulla oblongata appear to  render it a suitable locality for
the co-ordination  of the  movements  concerned in phonation.
First,  it contains  the two  great  vago-accessory nuclei—the sen-
sori-motor nuclei for the respiratory and vocal movements which
are auxiliary to speech.   Secondly, the  motor nuclei of all the
nerves which take part in the muscular  movements of  articula-
tion lie  serially disposed within  a narrow space  in the medulla
oblongata.   Thirdly, the corresponding nuclei of  those nerves
are symmetrically arranged on either side of the raphe,  in such
close proximity to each  other that,  by means of  commissural
fibres  (whose existence has been demonstrated,  at any rate  for
the hypoglossal nuclei), a simultaneous contraction of the homon-
ymous muscles of the tongue, lips, palate, etc.,  may readily be
effected,  even  when  the  impulse is  propagated from  one side
only.   Fourthly, the medulla contains  the nuclei of the portio
mollis and the fifth nerve—the sensory nuclei  of hearing and
touch.  Fifthly, we may fairly  assume  that these sensory and
motor nerve-nuclei, which are probably concerned in the  reflex
  1 Lemons de clinique medic, etc. 1874. p. 73.
  5 In a case of sclerotic shrinking of the pons and cerebellum, attended with mutter-
ing speech, Meynert found the roots and  nuclei of the hypoglossal nerves and the
conducting fibres  of the pons  uninjured, while its  transverse  fibres had undergone
degeneration.   But might not the cicatricial shrinking of the pons have impaired the
conductivity of the longitudinal fibres, thereby giving rise to the defect of speech?
(Wien. med. Jahrbuch. 1864. p. 4.) 
SITUATION OF PHONIC CENTRE.
653
act of phonation, are connected with one  another by  numerous
fibres, although, as might be anticipated from  the difficulty of
the investigation, only a few such connections have hitherto been
demonstrated.   Meynert,1 more particularly, asserts  that the
facial,  vago-accessory,  and  hypoglossal  nuclei are  connected
with the  fasciculi arcuati and  acoustic nuclei  by a system of
intercalated  nerve-corpuscles, abundantly furnished with  pro-
cesses, and surrounding the nuclei on every side.  Finally, there
is reason to believe that acoustic fibres penetrate  into the  cere-
bellum likewise (Clarke);  and this leads Meynert2 to  speculate
that rhythmical auditory impressions may, through the  cere-
bellum, determine the rhythm of movements, and thus perhaps
of uttered sounds likewise.
   We possess,  moreover, valuable evidence on the clinical  side,
which puts the importance of the basal  parts  of the brain in
reference to articulate phonation beyond all doubt, and  proves,
more  particularly, that this function depends on the integrity of
motor nuclei in  the medulla oblongata.
   The  last-named  fact has  been  securely  established  by the
more precise investigation of the  structural lesions in progressive
bulbar paralysis (Leyden, Charcot, Duchenne, Joffroy, Hun, R.
Maier), and in those degenerations of the gray medullary col-
umns of the spinal cord which ascend to the medulla oblongata
(Clarke).  The integrity of literal phonation is bound up  with
the integrity of the motor  nuclei  in the medulla oblongata, more
especially of the hypoglossal, but also of the vago-accessory and
facial nuclei.3  In two cases recorded by Charcot and Duchenne-
Joffroy, the only  abnormality  that  could be  detected  in the
medulla oblongata was degenerative atrophy of  the  corpuscular
elements of  the motor nuclei.4   In  the  other cases,  sclerotic
   1 Archiv fiir Psych. Bd. IV.  p. 419.
   ; Meynert, Wien. med. Jahrb. a. a. O. ;  and Wundt, Grundziige der physiolog. Psy-
cholog. 1874. p. 220.
   3 See my lecture on Progressive Bulbar Paralysis, in Volkmann's Sammlung klin.
Vortrage, No. 54.
   4 I am quite aware of the difficulty there often is in drawing the line between phys-
iological pigmentation of the ganglion-cells and that  granular  degeneration  which
leads to their becoming atrophied and destroyed.  This, however,  in no way alters the 
654         KUSSMAUL.—DISTURBANCES OF SPEECH,

changes were likewise met with in the anterior pyramids and
other motor tracts.   On the other hand, the sensory nuclei, more
particularly those of the auditory, fifth, and  glossopharyngeal
nerves,  were hardly ever,  the  restiform  bodies  never, found
affected.
   As in the course of  these degenerative changes one ganglion-
cell after  another is slowly destroyed in  the bulbar nuclei, we
perceive consonants and vow7els successively crumbling away, as
it were, from the patient's speech,  while his intellectual powers
may be perfectly retained.   His  words grow more and more
indistinct  and mutilated, his stammering passes into an unintel-
ligible muttering, until at last he  is only able to emit  grunting
noises, and  perhaps not even.these.   So long as his hands and
arms escape paralysis,  he continues to communicate his feelings
and ideas  by writing.  The disorder of speech is invariably lim-
ited  (when  there is no cerebral complication) to  the  power of
forming articulate sounds ; the stammering may pass into com-
plete loss  of speech,  but it is never associated  with  a blundering
enunciation of syllables (Sylbenstolpern), or with aphasia.  The
degree in  which the formation of syllables and words is inter-
fered with is  always proportionate to the disorder of liter ed
phonation;  the  architecture, so to speak, of the  words is  not
impaired ; they continue to be correctly put together, though
the materials—the elementary sounds of which they are made
up—may  be inadequate.
   The order in which the elementary sounds  of the alphabet are
lost in this disease is not invariably the same.   It depends on the
order in which  the groups of muscles concerned in the articula-
tion— those  of the lips, the tongue, the palate —  become para-
lyzed.  Should the lips be the first to fail, o and u (oo) are the
first sounds to be obliterated ; i (ee) and e (eh) soon follow7 them.
A (ah) lasts as long as phonation is possible  at all.  When the
tongue loses the power of rising from  the floor of the mouth
before the lips become affected, i (ee)  is the  first sound to go.
The failure of the tongue robs the  patient first of r and sh, then
fact that the atrophy and destruction of these cells entails the annihilation of their
functions. 
             SIGNIFICANCE  OF THE BULBAR  NUCLEI.         655

 of s, I, k, g (hard), t, lastly of d and n.  Palsy of the lips inter-
 feres with the pronunciation, first, of p and/, later, of b, m, and
 v.  Paralysis of the soft palate gives the voice a  nasal twang.
 When sufficiently advanced to permit  a considerable escape of
 air through the nose, it hinders the pronunciation of the labials
 b and p, which come to resemble m, w, or /, because,  as Du-
 chenne was  the first  to point out, the current of air directed
 through  the  mouth  is no longer powerful  enough to  burst
 through the tense and compressed lips.  Should this firm clos-
 ure of the tense lips still continue practicable, the patient will be
 able to utter  b  and p when his nose is pinched, and this shows
 Duchenne's explanation  of the facts to be correct.   We have
 here our first example of  a paralalia  or pararthria literalis,
 whose mechanism is, moreover, fully made out.
    The  importance of the motor-nuclei of  the medulla, for the
 production of articulate sounds is thus securely established.
 Their destruction is followed  by paralysis  and wasting  of the
 muscles concerned in speech, and ultimately, therefore, by loss
 of speech.
    Duchenne  denied that paralysis from disease of the bulbar
 nuclei was followed by muscular atrophy ; but his denial was only
 based on the fact that the atrophy is not always to be recognized
 during life.  The wasted muscles may be so  completely replaced
 by  fat that the size of the tongue is not diminished.  Paralysis
 and atrophy of the tongue,  together loilh fibrillary twitchings of
 Us  muscles and associated disorders of deglutition are inva-
 riably associated with bulbo-nueleetr  stammering — Anarthria
 literalis  bulbo-nuclear is — and must  accordingly be  viewed as
 essential diagnostic marks of the disease.   The reflex  excita-
 bility and electro-contractility of the palsied  muscles appears
 to depend on the degree of  nervous and muscular degeneration
 (Rosenthal').  As a general rule, the  paralysis is limited  to the
 respiratory division of the facial nerve  (supplying the mouth and
 nose), while the orbicularis palpebrarum retains its functional
activity.   The fact is a striking one, and has not hitherto been
 explained.
1 Klinik der Nervenkrankheiten. Wien, 1875. p. 252. 
656        KUSSMAUL.—DISTURBANCES OF SPEECH.

   It is probable that the motor-nuclei of the medulla, or their
constituent nerve-cells, exert an important influence upon the
muscles of articulation,  an influence similar to that exerted by
the large cells of the gray matter of the anterior columns of the
spinal cord on the muscles of the trunk and limbs.   The nutri-
tion and irritability of the muscles in connection with the spinal
cord is closely bound  up with the integrity of these cells, which
is therefore an indispensable condition  of all movement,  whether
reflex or voluntary. And since, even in the higher mammals, the
spinal cord is capable of co-ordinating the simpler  movements
after its separation from the brain (Freusberg), we  may  by anal-
ogy ascribe a  similar power  to the medulla oblongata.  More-
over,  we learn from Exner's experiments,' that a stimulus setting
out from the  brain undergoes retardation in the ganglia  of the
caudex cerebri (Stammganglien) ; that  it subsequently traverses
the spinal cord with great rapidity; that, lastly, it is  once more
delayed, and  at the  same time intensified, before entering the
nerve-roots.  There is  nothing against the view that the primitive
sounds emitted by the infant at birth are movements of so simple
an order as to find  the necessary mechanism for their co-ordina-
tion adequately supplied by the medulla oblongata alone. On
the other hand, it is in the highest degree doubtful whether this
bulbar mechanism is of itself sufficient for the production of all
the elaborate sounds  required by language—sounds which have
to be acquired for the most part with much expenditure of time
and pains, and resembling in this  respect the art of  standing
erect, of walking, of  handling tools, etc.  What is true of these
movements,  which  cannot be accomplished without the aid of
cerebral  ganglia, more especially of the corpora striata, must be
truer still of  the constituent elements of language, whose elabo-
ration is yet  more  closely bound up with the intelligence, and
which are from the  first  combined with  syllables  and  words,
whose value  and  meaning are  determined,  not indeed exclu-
sively, but principally  by the arrangement and collocation of
their constituent sounds.
    Dysarthric impediments of speech,  from stammering to com-
1 Pfluegefs Archiv. VIII.  p. 520. 
SIGNIFICANCE  OF THE BULBAR NUCLEI.         657
plete inability to utter sounds, may be caused, not only by the
gradual degenerative  processes underlying progressive  bulbar
paralysis, but also by various acute and chronic morbid changes
in the  medulla  oblongata, when they involve the motor,  espe-
cially the hypoglossal, nuclei.  To this category belong  hemor-
rhagic  extravasations, circumscribed necrotic  and inflammatory
changes,  abscesses,  tumors,  islets  of  sclerosis,  etc.   So, too,
injury  or disease of the  skull and its periosteum, pressure of
cerebellar  tumors, extension  of inflammatory and degenerative
processes from the pons or from the spinal cord to the region of
the motor nuclei, may  damage the medulla to such an extent as
to interfere with articulate phonation.1
   But even when the integrity of the bulbar nuclei is unaffected,
disease of  the pons alone,  or of the pons in conjunction with the
medulla, may hinder articulate utterance  by interfering with the
transmission  of impulses  from the  cerebrum  to  the nuclei and
the muscular mechanism of speech.  Under such  circumstances
articulate phonation becomes imperfect, either in time or inform.
In the  former case, vowels and consonants are correctly and dis-
tinctly  uttered, but their enunciation—whether singly or in com-
bination—is  too  slow, or interrupted by pauses between the
syllables, or  uneven in rhythm.   The channels  leading to the
muscles of articulation are still all  of  them  open, but they are
obviously less smooth  than usual, or perhaps less numerous—
single fibres or bundles of  fibres having been destroyed, and the
impulses  being obliged to follow a circuitous route.  In cases of
the second class the transmission of impulses is more  seriously
hindered, and can no longer  be effected even along collateral
channels ;  the enunciation  of both vowels  and  consonants is

  1 Cf. P. Dechery, Quelques formes d'atrophie et de paralysie glosso-laryngee d'ori-
gine bulbaire. These.  Paris, 1870.—Rosenthal, Allg. Wien. med. Ztung. 1867. 15 and
16.—The same, Klinik der Nervenkrankheiten. 1875. pp. 195-201, and 237-258. —Ley-
den,  a. a.  O. and in his klinik der Riickenmarkskrankheiten. 1875. Bd. II. p. 157
(Myelomalacie des Bulbus) and p. 65 (Blutextravasat in der med. oblong., der unteren
Halfte des Pons,  und dem linken  mittleren Kleinhirnschenkel).— Wilks, Guy's Hosp.
Rep. 1870. II. p. G7.—Bdlz, Arch. d. Heilk. 1872. p.  192.— Jackson, Lancet, 1872. No.
30.—Eichhorst, Charite-Annalen. Berlin, 1876. p.  206.—Friedreich observed stammering
come on during the extension  of tabetic degeneration of the posterior columns to the
med. oblongata, Virchow's Archiv. XXVI. pp. 391 and 433.
          VOL. XTV.^12 
658        KUSSMAUL.—DISTURBANCES OF  SPEECH.

stammering and imperfect, and the faculty of articulate utter-
ance may  at length be wholly  annihilated.    Such dysarthric
impediments  of speech may be contrasted with the "basal nu-
clear"  group as basal kinesodic dysarthries ; they may be fur-
ther qualified as central or intra-cerebral, to distinguish them
from those peripheric or extra-cerebral, thbugh still  intra-cra-
nial, dysarthries, which  are due  to lesions affecting the motor
nerves  of speech after they have issued from the medulla oblon-
gata.
   It is probable that these "intra-cerebral basal kinesodic dys-
arthries" are not attended, like those of "nuclear" and "extra-
cerebral" origin, by atrophy of the muscles of speech.  Moreover,
in marked contrast with what occurs in nuclear stammering, the
tongue may occasionally be observed in these cases to retain the
power  of executing every kind of movement at will, both rapidly
and correctly ;  it can be protruded far beyond the teeth, raised
with seeming vigor  towards the palate, moved sideways and
backward; chewing and  swallowing  may be satisfactorily ac-
complished, even after speech has grown very indistinct.  These
facts may  be explained in one*of  two ways: we may assume
that the transmission of phonic impulses is more hindered  than
that of impulses for other movements, the paths along which the
former travel being specially damaged ; or—and this is the  more
likely  theory—we may suppose the transmission of all impulses
to be equally impeded, and all the  voluntary movements of the
tongue to be hampered alike; the paresis of those ancillary to
speech being more obvious, however, than that of the rest, which
can only  be detected by the employment of  special methods.
We may notice, for example, that the patient is unable to make
a clacking noise with his tongue as forcibly and readily as he
used to do ;  that he soon gets tired of chewing and swallowing.
The paresis of the lips, too, is often betrayed only by the dimin-
ished loudness of the patient's whistling.  As regards electrical
methods of diagnosis, Rosenthal affirms that, in paralysis due to
tumors in the pons, faradic excitability  of  the facial muscles
and nerve-twigs may be abolished,  galvano-muscular contractil-
ity exalted, galvanic irritability  of the branches  of  the portio
dura diminished or altogether destroyed, just  as in paralysis of 
SIGNIFICANCE OF  THE BULBAR NUCLEI.
659
the facial nerve from extra-cerebral causes.  Whether the same
be true of the tongue likewise, we do not know.
   That articulation is not invariably interfered with by circum-
scribed lesions of the medulla oblongata and pons, may readily be
explained if we reflect that they are neither of them  simple, but
composite organs, made up of a great variety of functionally
distinct centres and conducting fibres.   The consequences of  a
lesion always depend on its precise extent of situation.  At the
present time we  know only  that  for articulate  utterance the
motor nuclei  of the nerves supplying the organs of speech are of
prime importance, the  olivary bodies  of no importance at all.
Concerning the part played by the various regions of the pons
and medulla individually in  relation to this function, we know
nothing.  Whether  the commissural fibres of the middle cere-
bellar peduncles, in  the central portion of their course,  where
they traverse the lower part of the pons,  really possess the signi-
ficance—as  regards  articulation—ascribed  to  them by Meynert
and Jaccoud, remains to be proved by evidence of a more conclu-
sive kind than has been hitherto adduced.1   It  is  to the  precise
   1 Darolles (Progres medic. 1875, p. 629) describes a sharply-defined patch of throm-
botic softening, as big as a small bazel-nut, which was situated in the right upper half
of the pons; it  did not transgress the median line, and stopped short of the pedun-
culus and the point of origin of the middle  cms of the  cerebellum.  This lesion had
given rise (the patient was a woman of thirty-six) to complete right-sided (not alternate)
hemiplegia; the  tongue was nearly motionless, articulation very imperfect, intelligence
unimpaired.  The basilar artery was plugged by a thrombus.  In the year 1873, I my-
self came across a patch of softening situated in the right upper half of  the pons of a
bricklayer, aged fifty-nine.  It was as big as a cherry-stone, marbled  with red and
gray, and consisted (under the  microscope) of a mass of granule-corpuscles amid a
fibrillar reticulum.  It did not transgress  the middle line, but penetrated through the
inferior and  middle zonular layers  (Gurtelschichte), together with the longitudinal
fibres that lie between them.   No plugs were found in the arteries.  The patient had
had a slight apoplectic stroke in August, 1873, after which his left side was paralyzed
for three days.  About the twelfth of December he fell ill again. Along with fever of
a markedly intermittent type (evening temperature from 38°  [100.5° F.] to 41.5° C.
[106.9° F.], morning temperature from 36.2' [97.2° F.] to 39° C. [102.2° F.]), he was
seized with complete paralysis of the left side, including the cheek; sensation was now
and then diminished in the palsied limbs ; the left pupil was permanently and excessive-
ly contracted ; the tongue freely movable, with occasional deviation towards the left.
He was often delirious, but answered questions for the most part correctly; no fault 
660          KUSSMAUL.—DISTURBANCES OF SPEECH.

topographical  determination of  small,  sharply circumscribed
hemorrhagic  cicatrices and patches of necrotic softening in the
substance of the pons and medulla oblongata, that we must look
for information concerning the function of the  individual basal
areas in regard to the faculty of speech.   It will be as  necessary
to give an accurate  description of those  lesions which are not
attended by any disorder of speech during life, as of those which
are.
   The study of  the disease known  as insular  (disseminated)
sclerosis of the brain and spinal cord is of considerable interest
in reference to the centres and channels subservient to  articulate
phonation.
   The disorders  of  speech met with  in this disease are almost
invariably dysarthries.   The nature of  the disorder depends
wholly on the seat of the sclerotic change.  In the purely spinal
form of the disease, articulation—to judge from a single case-
does not appear to suffer.'   Should the changes  be confined to
the  medulla  spinalis and  oblongata (bulbo-spinal form), every-
thing will depend on  their distribution in the substance of the
latter."  Lastly, in the cerebro-spinal  form  of  the disease, dis-
orders  of speech, or at any rate of the  voice, seem always to
exist.   The disorders  of speech  always involve  the faculty of
articulate utterance, hardly ever the  actual  structure of words
(atactic aphasia), or of sentences ; for the cortex  cerebri is seldom
affected by the morbid change,  and  then,  as a rule,  only to a
trifling extent.   The cortex  cerebelli  shares the almost absolute
immunity of the cortex  cerebri.   The  islets   of sclerosis are
was noticed in his articulation.  He died on December 25th.—These two observations
are contradictory, and the contradiction does not at present admit of reconciliation.
   1 PennocKs cases, recorded by Morris.  Cf. Bourneville and Guerard, De la sclerose
en plaques disseminees.  Paris, 1869. p. 76.
   2 In Vulpian's case (Bourneville, 1. c., p. 64) no mention is made of any disorder of
speech; the sclerosis was limited to small islets in the restiform bodies, the olivary
bodies, and the floor of  the fourth ventricle.—On the other hand, in Ebstein's case
(Deutsch. Archiv fur klin. Medic. Bd. X. p. 599), the sclerosis gave rise to monoto-
nous, but not scanning utterance, with indistinct formation of literal sounds, i. e., with
stammering.  In this case the insular deposits did  more than merely interrupt the
fibres of the hypoglossal nerves in the intra-medullary portion of their course; they
likewise penetrated into one of the hypoglossal nuclei, destroying its cells. 
           BRADYLALIA AND SCANNING UTTERANCE.        661

chiefly disseminated through the central  region of the greater
brain, the corpus semiovale with  the gray  matter of the central
cavities (Hohlengrau),  the corpora striata and optic thalami;
they frequently increase in number as we  proceed downward, in
the pons and medulla  oblongata.  Broadly speaking,  the motor
centres  and conducting fibres are more affected by the sclerosis
than those concerned  in sensation ; still,  I  cannot agree  with
Buchwald,'  in terming  the  entire disease a "sclerosis of the
motor centres," and contrasting it with tabes dorsualis.
   Leube3 has pointed out that symptoms of glossopharyngeal
paralysis constitute a part—though usually but a small part—
of the clinical phenomena presented by insular sclerosis of the
brain and cord.  Others 3 have confirmed this  statement.  The
fact is  not  surprising, inasmuch as the sclerosis  may lead to
atrophy and  complete destruction of  the cells in the bulbar
nuclei.4  The patient begins  by stammering, his utterance pass-
ing ultimately into an unintelligible muttering.
   But there are  also cases in which the faculty of articulation
exhibits no such decided impairment.  The power of modulation
is lost; the voice is  pitched  in a monotone, and is occasionally
nasal.   Utterance is not indistinct; it is  merely slow, notwith-
standing an unusual expenditure of effort (bradylalia, or brady-
arthria).  Letters and syllables, though  correctly formed,  no
longer  succeed one another  with their customary  rapidity.  If
the syllables are separated from one another by  marked pauses,
we  call the utterance "scanning."   The patient continues to
possess full command over his tongue, and his power of swallow-
ing is not impaired.  He suffers merely from difficulty and delay
in the  transmission of  motor impulses to the muscles of the
respiratory apparatus, of the larynx and tongue.   The channels
are no longer pervious ; here and there, in  the greater  brain and
mesencephalon, they are interrupted ;  more powerful discharges
of nerve-force  are required, and they are probably conveyed in
  1 Deutsch. Arch, f klin. Med. Bd. X. p. 478.
  5 Ibid. Bd. VIII.  p. 1.
  3 Conf. Schule, ibidem.  VIII. p. 223.
  4 As in Ebstein'8 case, referred to above;  also in one recorded by Joffroy, Gaz. med.
de Paris.  1870. No. 23. 
 662         KUSSMAUL.—DISTURBANCES OF SPEECH.

 part along collateral paths.1   We must also attribute to disturb-
 ances of transmission such symptoms as those noticed in a case
 of  Schuele's,  where "individual syllables were  shot out  with
 explosive  vehemence, while those immediately succeeding them
 were uttered in the hesitating, scanning fashion  characteristic of
 the disease."  This sort of ataxy depends  on a false estimate of
 the amount of  force required  for  articulation, due  to  altered
 resistances in the conducting  fibres.   Closely related  to  this
 phenomenon is  another, which I  had occasion to  observe, for
 years together, in a woman  suffering from insular sclerosis of
 the brain  and cord (case published by Dr. Putzar).  After her
 death we found  very extensive  sclerosis of the medullary layer
 of both hemispheres (just as in Schuele's case), besides a number
 of islets of disease elsewhere.  Her speech  continued quite intel-
ligible to the last ; articulate  sounds, apart from slight hesitation
and sibilation, were  correctly formed ; but her words,  without
being actually  "scanned,"  were  jerked  out in a fragmentary
 sort of way, in a  somewhat bleating tone of voice,  and with
decided effort.   The hypoglossal nuclei  and  the  intra-bulbar
hypoglossal fibres were found intact, on  microscopical examina-
tion of the hardened tissues.2
    It is hardly necessary to state that utterance may be rendered
stammering to unintelligibility, notwithstanding perfect integrity
of the bulbar nuclei and  basal conducting fibres, solely in conse-
quence  of  blocking of those  channels in the hemispheres along
which  impulses are conveyed downward from  the cortex cere-
   1 In a case of insular sclerosis of the cord, medulla oblongata, and pons, without
implication of the cerebrum, which  occurred in my wards, and has been published by
Dr. Engesser (Deutsch. Archiv f. klin. Med. XVI. p. 556), the only fau^t detected in
the patient's utterance was its slowness and slightly hesitating character.  The hypo-
glossal nuclei were unaffected. The conducting channels were interrupted here and
there in the pons and medulla oblongata.  The cerebrum appeared to be in a perfectly
normal condition.
  a Speech is often accompanied by noisy (jauchzend) inspirations.  Leube attributes
this to paresis of the crico-arytaenoidei postici, whose function it is to widen the open-
ing of the glottis.   Hirsch (Deutsche Klinik.  1870.  Nos. 33 to 38) met with a case in
which the patient's slow and indistinct utterance was repeatedly interrupted by laugh-
ter.  This  reminds me of a gentleman suffering from bulbar paralysis, who would
burst into shouts of laughter on the  smallest provocation. 
STAMMERING AND STUTTERING.
663
bri.   This is proved by a case of Jolly's,1 in which the corpus
callosum  and the medullary substance  of  the cerebral  hemi-
spheres were very extensively indurated and of leathery tough-
ness,  while the  great  ganglia—the  lenticular nuclei,  corpora
striata,  and optic thalami—together with the gray matter of the
cerebral peduncles and the bulbar nuclei, were altogether intact.
Towards the close of her life the patient's stammering  grew so
extreme that she was  only able to utter the words "yes" and
"no" intelligibly.  The symptoms came generally to resemble
those of progressive bulbar  paralysis, though the sclerosis was
limited  to the white medullary substance of the hemispheres.
The sensorium remained unclouded to the end.  It is worthy of
note  that, at a  time when her consonants had become almost
unintelligible, the patient  was still able to utter all the vowel-
sounds  in a loud tone  of voice, almost destitute of modulation.
After she had ceased to be intelligible at all, she still, when she
wanted  to speak, emitted  loud, clear sounds in a high-pitched
monotone.  If she tried to  put out  her tongue (which did not
appear  to be wasted), she  failed  in the attempt, the  tongue
rolling  helplessly about in  her mouth.   These  peculiarities,
which have not hitherto  been observed in  progressive  bulbar
paralysis, may possibly serve as a clue to diagnosis in future.
   I consider it a fact of great importance that in insular scle-
rosis,  even when the islets of degeneration are of considerable
size and abundantly disseminated through the  medullary tract
of the cerebrum and down into the cord, it is only the  mecha-
nism of articulate phonation and the  rapidity of utterance that
are impaired—never the co-ordination of syllables and words in
obedience to the laws  of spoken  language,  unless the  cortical
substance be simultaneously  implicated in the degenerative pro-
cess.  We never meet with the blundering enunciation of  sylla-
bles (Silbenstolpern) so common in general paralysis,  or with
true aphasia.  The " scanning" utterance of syllables must not
be confounded with blundering enunciation.   In  the  former,
articulate sounds are correctly combined to form  syllables and
words ;  the syllables are merely separated from one another by
1 Archiv f. Psych. Bd. III. 1872. p. 711. 
664         KUSSMAUL.—DISTURBANCES OF  SPEECH.

brief pauses.  In the latter, both articulate  sounds and syllables
are misplaced and thrown into confusion.  To borrow Westphal's
admirable illustration, the  general paralytic,  in trying to say
"artillery,"  calls it  "artrillerary ;"  the  patient with  insular
sclerosis, on the other hand, pronounces it " ar-til-le-ry."
   Stuttering (Stottern), again, has not hitherto been observed in
cases of insular sclerosis.   But this is not a point on which I am
inclined to lay much stress in connection with the localization of
the functions concerned in speech; for it  depends far more on
the nature  of the process  (sclerosis) than upon  its situation.
Stuttering is not, like stammering, a paralytic defect of articulate
phonation;  it is  a spasmodic  hinderance to the enunciation of
syllables, and more particularly to the vocalization of the neces-
sary sounds. It requires for its production an exaggerated excit-
ability—exaggerated to the point of generating spasm—in that
part of the  articulatory centre which is  specially concerned in
vocalization. This state of spasmodic excitability may be induced
by influences propagated from the most diverse points of the
nervous system ;  it may be caused by  irritation of the bowel
no less than by irritation of the spinal cord  or brain.  Hence, we
must not jump too hastily to the conclusion that the seat of the
lesion to which the stuttering is due is  at the same time the seat
of the faculty by which the vocalization of  syllables is effected.
There  is,  indeed, some ground  for the opinion that  morbid
changes at the base of the brain, when giving rise to considerable
irritation, may cause  stuttering.   Cases  are on record  of  this
symptom  having been brought on by tumors and other lesions
in this neighborhood. Unfortunately, stammering has not always
been clearly distinguished  from  stuttering;  the terms  used
formerly to  be employed without due discrimination ; hence, the
older observations bearing on this point  do not carry much
weight.
   The present is a suitable opportunity  for entering somewhat
more deeply into the relations between  the mechanism of articu-
late phonation (Lautmechanik) on the one hand, and the con-
struction of syllables (Silbenfiigung) on the other.
   The successful construction of syllables  depends for its reali-
zation on the following conditions : First, the muscles of speech 
STAMMERING AND STUTTERING.
665
must be individually capable of adequate contraction.  Secondly,
the phonic-respiratory groups of muscles in the trunk and larynx
must co-operate accurately with the articulatory muscles of the
mouth.  Thirdly, the groups of muscles which form consonants,
and those which form vowels, must fulfil their respective offices.
Fourthly, the attitude  of  the  organs  of  speech in pronouncing
consonants must be correctly joined to their attitude in  pronounc-
ing vowels,  and the  successive transition from one attitude to
another must be suitably accomplished.
   Stammering (Stammeln) consists in a failure of  the  muscles
of speech as regards both their individual contractions and those
combined contractions which are requisite for the enunciation of
consonants and vowels.  The obstacle to their independent or
their co-ordinate contraction may be  of a  coarse, mechanical
nature, situated in the jaws, teeth, palate, etc., or in the  muscles
themselves ; or it may be peripheral, situated in the motor nerves
of the tongue, palate, and face ; or it may be central,  due  to some
failure on the part of the motor centres to originate  impulses of
sufficient power to put the  muscles of  speech in action;  or, the
transmission of the impulses may be disturbed, or they may be
diverted into wrong channels.—Broadly speaking, the  imperfect
utterance of syllables is due to some imperfection in the working
of the external or  internal mechanism of  articulate phonation ;
the stammering may be of external or of internal origin.
   It is clear that when stammering is produced by any of the
above-named causes, the transit of the muscles from one attitude
to another, and the fusion of consonants with vowels ("vocaliza-
tion of consonants"), will likewise be  interfered with; in other
words, the imperfect  utterance of elementary articulate  sounds
will entail an imperfect utterance of syllables.
   But imperfect formation of syllables  may also coexist with
integrity of the mechanism  of articulate phonation ; it may exist
without stammering, and altogether independently of  it.  Stut-
tering and the blundering enunciation of syllables (Silbenstol-
pern) are  purely syllabic faults of speech, and must be rigor-
ously distinguished from stammering.
   Stuttering (Stottern) is due,  not to any peripheric hinderance
of a mechanical kind to the activity of  the organs of speech, nor 
666        KUSSMAUL.—DISTURBANCES OF SPEECH.

to any central failure of motor  power, nor yet to any interrup-
tion of its transmission; it is due simply and solely to a spasmodic
inability to execute that " vocalization of consonants" (union of
consonants with vowels) which is requisite for the formation of
syllables.  The attempt to fuse  a consonant with a  subsequent
vowel into a syllable, sometimes even the attempt to utter a syl-
lable beginning with a vowel, brings on spasm of the muscles of
speech—the spasm not being confined to the muscles actually
engaged in the formation of particular letters, but spreading to
the phonic and respiratory muscles likewise ;  nay.  the  central
irritation occasionally radiates over many other muscular regions
also.  The speaker is left in the lurch, not by the centre for co-
ordinating the movements of articulate phonation, but by that
which presides over the "vocalization"  of sounds with a view to
the construction of syllables.  How this  "vocalization-centre"
is connected with the centre for  articulate phonation, we do not
know.
   In "blundering enunciation of  syllables"  (Silbenstolpern)
the combination of articulate sounds into syllables is interfered
with, not by any external mechanical  obstacles to pronuncia-
tion, or to the  connection of consonants with vowels ;  not by
any central failure of motor energy for articulate phonation ; not
by any  break in the transmission of impulses to the muscles of
speech ; not by any spasmodic hinderance to the "vocalization"
of consonants ;  but by causes situated on  a  higher level.   The
fault lies in  the speakers inability to co-ordinate articulate
sounds  into syllables and syllables into words, as organic units
held together in  conformity with the law of spoken language.
The imperfection of the syllables results from the incorrect in-
terpolation and collocation of articulate sounds—in themselves
correctly formed and correctly joined with one another—in words,
as the organic units of language, and as articulate motor-aggre-
gates. The completed word may be said, in a manner, to assimi-
late its  constituent sounds, to incorporate into a single organic
unity those elementary parts which derive their true significance
only from their relative position and the stress laid on them.
This organic whole—this compound organism  of language—has its
intimate structure loosened; its constituent sounds  fall  apart 
ATACTIC AND AMNESIC APHASIA.
667
and get mixed up with one another; they fail to make their ap-
pearance at all, or they make it in the wrong place, too soon or
too late, with a right or a wrong accent, never twice in the same
order.   Occasionally, moreover, letters which have nothing what-
ever to do with the word usurp the place of others that properly
belong to it.
   In aphasia, finally, the word  as a whole  is wanting, or it is
uttered in  some mutilated form, or one word is substituted for
another.  It is not merely the constituent letters of a word that
drop out of it at random, or are misplaced, or wrongly accentu-
ated, whereby the word is twisted .out of shape; it is the word
itself  that  drops out of our speech,  or presents itself in a new
and not seldom quite mutilated form.  It is no longer the mere
structure of the word that is shattered; the combination of words
into sentences is at fault.  The  aphasia is  termed "atactic"
when  the word,  though still retained as a sensory image and as
a symbol of thought, can no  longer be enunciated as a motor
combination of articulate sounds, though the sounds themselves
may still continue to be correctly formed when occurring in some
other word; but when  the word no  longer exists in conscious-
ness, even as a sensory image,  we  term the aphasia  " amnesic."
The amnesic  does not  include the atactic form of  aphasia;  the
former  may exist without the latter, in which case the  word is
readily  pronounced when recalled to the acoustic memory.
   The study of the disorders of  speech associated with insular
sclerosis and with the various lesions restricted to the medulla
oblongata and pons, brings us accordingly to the probable con-
clusion  that  tlie infra-cortical  regions of the brain  contain
merely  the apparatus  requisite for the mechanical execution
and connection of the movements subservient to articulate phona-
tion; while the formation of syllables and words, as elements of
spoken language, takes place in the  cortical substance itself.

   The cerebellum is usually credited with the function of imme-
diately regulating the voluntary movements  in  conformity with
sensory impressions.  Deiters and  Wundt regard  the cortex
cerebelli as a terminal central expansion, specially designed to
serve as a meeting-place for diverticula from the motor and sen- 
668         KUSSMAUL.—DISTURBANCES OF SPEECH.

sory conducting tracts,  between  which it is, as  it  w7ere, inter-
posed ;  so that the motor provinces of the cortex cerebri, on the
one hand, and the sensory provinces of the general surface of the
body, on the  other, are both represented in it.
    Luys,1 even before Jaccoud, had  assigned  an  important part
in  the  production of  articulate  sounds  to the cerebellum.  He
asserts that disorders  of speech have been  observed in one-fifth
of  the   total  number  of  cerebellar  lesions,  these  disorders
ranging from  simple weakness to  complete loss  of speech, and
being of both an asthenic  and  an  atactic kind.   He found dis-
orders  of speech noted in  fifteen out of fifty-six cases of cere-
bellar disease ;  in five out of the  fifteen there was aphasia.  On
the post-mortem table, new growths (including tubercles) and
hemorrhagic  extravasations were  discovered.2  Now,  although
we cannot dispute the possibility of the cerebellum playing some
part or  other in the  co-ordination of phonic movements and in
the rhythm of speech, still the observations we have at our dis-
posal (some of which date from the last century)  are ill adapted
to serve as a foundation for positive  conclusions.
   The majority are cases of tumor.3   Now, cerebellar tumors often exert pressure
on the medulla oblongata and pons—organs whose importance for articulation is
securely established.  Or they may  give rise  to internal hydrocephalus, often of
enormous  proportions, which hinders the transmission  of motor impulses to the
organs of speech,  and produces amnesic aphasia by dulling the mental faculties.
Neither can we draw satisfactory conclusions  from the rare instances in which
some disorder of  speech was observed to  coexist with softening of, or hemor-
rhage into, the cerebellum,  for the records are too imperfect for our purpose.4
—Of far higher value is Combette's celebrated case of complete deficiency of the
cerebellum5 in an imbecile  girl who died in  her eleventh year. The cerebellum

   1 Recherches sur le systeme nerveux cerebro-spinal.  Paris, 1865.
   2 Benedikt, Nervenpathologie und Electrotherapie. Leipzig, 1874. Abtheilung I.
p. 343.
   3 Ladame (Symptomatologie und Diagnostik der Hirngeschwulste. Wurzburg, 1865)
collected 78 cases  of cerebellar tumors, in only 5 of which was any disorder of speech
noted.—A. Ferber (Beitrage zur Symptomatologie und Diagnose der Kleinhirntumoren.
Marburg, 1875) found imperfect mobility of Ihe  tongue and disorders of speech fre-
quently mentioned in 32 more recent  observations.   The two together were observed
in 8 of the cases.
   4 Cf. e.  g., Andral, Clinique medic. III. edition. Vol. V. p. 495.
   8 Cruveilhier, Anatomie pathol. Livr. XV. PI. V. 
              APHASIA  AND  DISEASE  OF  CEREBELLUM.           6C9

was only represented by little stumps no bigger than  peas;  its middle crura
(Briickenarme) with  the transverse  fibres of the pons were entirely wanting.  The
child, when admitted in her tenth year into an  orphanage, was able to  answer
questions, though her articulation  was not very  distinct ("nettement").  In the
last year of her life, her replies were limited to " oui" and "non."   The atrophy
was probably  a  result  of some slow destructive change;   but Cruveilhier was
unable to satisfy himself whether the change had begun and run its  course before
or after birth. —Dr. Verdelli, of Brescia,1 has lately published a similar case of
atrophy of the  cerebellum  in  an  epileptic, aged nineteen.   The  cerebellum was
reduced to the  size of a nut;  the  pons  measured two  centimetres  in  its trans-
verse, and a little over  one centimetre in  its long diameter; the  medulla oblon-
gata was barely half as broad as usual.  The  cerebral hemispheres  appeared  to
be of normal size.   The  young  man, though paralyzed in the legs, was fairly
intelligent,  joked with the other lads, and followed their conversation.   He was
late in learning  to speak;  he stuttered, and was often unable to utter a parti-
cular  word.—On the other hand, the faculty of  speech  does not  appear to have
suffered in the case of rudimentary development of the cerebellum lately described
by Otto.2  Here, it is true, the rudiment was much larger  than in the two other
cases.   It was made up of the normal  tissue-elements of  the cerebellum.—The
retention of the  faculty of speech in cases of unilateral atrophy of the cerebellum
proves nothing  against the importance of  this organ in regard to  speech; for the
functions of the missing half  may  possibly be fulfilled  by  a vicarious activity—
perhaps associated with hypertrophy—of the other half (Lallement).
                           CHAPTER  XIX.

General  Account of the Conducting Fibres and  Ganglia through which Speech-
    impulses Pass from the Cortex Cerebri to the Basal Phonic Centre.—The Cor-
    pora Quadrigemina and Optic  Thalami  in their Relation to the Faculty of
    Speech.—The Channels between the Crusta of the Cerebral Peduncles and the
    Cerebral Cortex, as made out by Guddenand Veyssiere.—Anterior and Posterior
    Centro-hemispheric Dysarthries of  Conduction.—In most Human Brains the
    Main Current of Centrifugal Impulses in Speaking passes downward through the
    Left Cerebral Hemisphere, a Side-current through the Right One.—The Connec-
    tion of  the Motor Channels of Speech with  the Central  Aggregates  of Gray
    Matter.—The Gray Matter of the Corpora Striata in its Relation to Speech.—
    Broadbent's Hypothesis.—Unequal Value of Existing Clinical Materials for the
    Localization of the Functions concerned in Speech, according to the Anatomi-
1 Schmidt's Jahrb.  Bd. CLXV.  p. 23.
2 Archiv f. Psychiatrie. Bd. IV. p. 730, und Bd. VI. p. 859. 
670         KUSSMAUL.—DISTURBANCES OF SPEECH.
   cal Nature of the Lesions.—Strio-capsular and Strio-nuclear Dysarthries.—The
   Domain of Dysphasic Troubles  begins beyond the  Corpora Striata in the
   Hemispheres proper (Hirnmantel).—The Path traversed by the Articulatory
   Impulses for Literal Phonation in  the Anterior Portion of the Corona Radiata,
   and its Relation to the Associative and Commissural Channels in the Hemi-
   spheres Proper.

   Having established the existence of a basal phonic centre, and
having  endeavored to ascertain the importance of the  medulla
oblongata, pons and  cerebellum in relation to speech,  so far as
the data we possess enable  us to do so, we may proceed to
acquaint ourselves with the ascending and descending, sensory
and motor,fibres and ganglia traversed by  the  impulses  con-
cerned  in speech on their way betioeen this basal  phonic centre
and the cortex of the cerebral  hemispheres.
   Every sensory and motor  province in the body is  centrally
represented, not merely in the medulla spinalis or oblongata and
in the cerebellum, but several times over in the cerebrum itself.
Meynert divides the ganglionic masses of the cerebrum into two
great regions, one  of which receives its fibres through  the fillet
(Schleife) and  tegmentum, the other through the crusta pedun-
culi cerebralis.  The  former includes  the corpora  quadrigemina
and optic  thalami, which he terms ganglia of the tegmentum ;
the latter, comprising the corpora striata and cortex cerebri, he
calls ganglia of the crusta.  The ganglia of  the tegmentum, in
all likelihood,  subserve only the reflex  movements which  are
determined by sensory impressions, either simple or combined, to
form images ; the ganglia of the crusta, on the other hand, sub-
serve the voluntary movements which  originate in states of con-
sciousness.   Ideas, and the volitional motor impulses which tra-
verse the channels of the  crusta, are generated  in the cell net-
works of the cortex, the corpora striata  assisting in the execu-
tion of the  movements  prompted by the will.   The  latter are
undoubtedly accessory  motor organs  of volition,1 though the
exact nature of the aid they render to the will  is not  yet fully

   1 The  basal portion of the corpus striatum seems, moreover, " to stand in a relation
to the organs of smell similar to that in  which the corpora quadrigemina stand to those
of vision, and the optic thalami to those of touch, i. e., to be concerned in the determi-
nation of those movements which depend on olfactory impressions."— Wundt. 
          CHANNELS TRAVERSED BY SPEECH-IMPULSES.       671

understood.  Again, the two great groups of ganglia—that of the
tegmentum and  that of the crusta—are  connected together by a
special system of fibres ;  the cortex cerebri  is in communication
with the tegmental ganglia by means of fibres which convey sen-
sory  stimuli from the  latter  to the  former, and autogenous
impulses inhibiting reflex action from the former to the latter.
   First, then, as regards the ganglia  of the tegmentum.  We
may confidently affirm that the corpora quadrigemina,  though
in their optical  capacity of the utmost importance for  written
language,  are in nowise concerned with speech.
   Concerning the optic thalami, we must express ourselves with
more reserve.  It is true that experiments  on animals have not
hitherto shown  any  appreciable failure of  motor power or of
cutaneous sensibility to follow destruction of the optic thalami1 ;
still, some degree of motor disturbance has been  observed which
seemed to indicate enfeeblement of the muscular sense.2  This
suggests a possible mode in which lesions of the optic thalamus
may impair articulation.   For the rest, the combined hemiplegia
and hemianesthesia  commonly observed  to follow hemorrhage
into the hinder part of the optic thalamus in the  human subject,
and with which a variable amount of disturbance of articulation
is frequently associated, is not, in all likelihood, an immediate
effect of the damage  inflicted on the optic thalamus, but results
from it indirectly, owing to the pressure  of the extravasated
blood on the adjoining internal  capsule (Meynert  and Charcot).
   Pelzcr3 has seen a case of apoplexy in which patches of embolic softening were
found in the posterior and outer third of both optic thalami, in the lateral part of
the corpora  quadrigemina,  and in both  hind lobes of the cerebrum.  The only
motor trouble observed was a somewhat hesitating  utterance; the patient  was
able to  put his tongue  out straight; he was quite blind, and his memory was
impaired.  Ought the hesitating utterance in this case to be ascribed to circulatory
disturbance in the adjacent motor regions, which must have been implicated in the
effects of the plugging of the basilar artery ? Or ought we to regard it as a result of
enfeeblement of the muscular sense, due to the softening  of the thalami 1

   1 Ferrier alone asserts (Arch, gener. de med. October,  1875. p. 503), from experi-
ments on monkeys, that destruction of the optic thalamus causes  universal anaesthesia
of the opposite half of the body.
   2 Cf. Nothnagel,  Virchow's Archiv. Bd. LXII.
   3 Berl. klin Wochenschrift, 1872. No. 47. 
672         KUSSMAUL.—DISTURBANCES OF SPEECH.

   There are also some older observations on  record which warn
us against too absolute  an expression of opinion concerning the
motor insignificance of the optic thalami in man.  Huguenin/for
example,  thinks himself  entitled to  infer, from an observation
published by Duplay,2 that the facial nerve receives fibres from
the optic thalamus.  Durand-Fardel, too,  records  a case3 which
seems to  prove that  articulate speech  may  be  impaired by a
cystiform residue of softening, no bigger than an almond, in the
left thalamus.   Here,  it is true, there does not seem to have been
any actual paralysis.   "Une  gene assez  notable de la parole"
was noticed,  but no palsy.
   Let  us now go on  to consider  the  channels  traversed  by
speech impulses between the crusta and the cortex cerebri.
   Experiments which have  recently been carried out on dogs
in Vulpian's laboratory, with an ingenious instrument contrived
by Veyssiere,4  have taught  us  a great deal  about  the  exact
course of the fibres between the crusta of the cerebral peduncle
and  the cortex.  Moreover,  the  information gained from  the
study of circumscribed  lesions of the central part of the  hemi-
spheres, due to softening and hemorrhage, agrees with the results
of experiment.
   TJie great tract to which Burdach gave the name of " internal
capsule'1'' contains, in the posterior  third of its course, between
the optic thalamus  and the lenticular nucleus, both motor and
sensory fibres.   As they pass on towards the periphery of the
cerebrum, these fibres separate from each other—the motor ones
bending forioard,  the sensory ones  backward.  The anterior
part  of the  internal  capsule, which lies  between  the  nucleus
caudatus and  the  first  segment of the nucleus lenticularis, is
purely  motor,  the  sensory fibres being directed towards those
  1 Allg. Pathol, der Krankh. d. Nervensystems. Th. I. Zurich, 1873. p. 186.
  2 Union medic. 1854. Paralysis limited to the cheek, due to circumscribed softening
in the optic thalamus.
  3 Traite du ramollissement du cerveau. 1873. p. 371.
  4  Veyssiere, Sur l'hemianesthesie de cause cerebrale.  These.  Paris, 1875.—Lepine,
De la localisation dans les maladies cerebrales. These. Paris, 1875. — Carville and Duret,
Archives de physiologie norm, et patholog. 1875. T. II. p. 352. — Charcot, Des locali-
sations dans les maladies cerebrales. Progres medic. 1875. No. 17, seqq. 
         CHANNELS  TRAVERSED  BY SPEECH.-IMPULSES.       C73

convolutions which  are situated behind the Sylvian fissure.  We
may safely conclude with Meynert, that some of these  sensory
fibres,  which ascend from the crusta, bend round directly into
the corona radiata of the occipital lobes before reaching the lower
edge of  the lenticular  nucleus, and without entering into any
connection with gray matter on their way.  These sensory fibres
are said  to have  been traced,  in  the brain of apes, through the
pons and pyramids  into the posterior columns of the spinal cord.
Whether any of  the motor fibres of the crusta which traverse the
internal  capsule on their  way towards the frontal region of the
hemisphere, pass likewise into the anterior corona radiata with-
out any intermediate connection with the gray matter of the cor-
pus striatum (either its caudate or its lenticular  nucleus), is not
equally certain.   This, at any rate, is certain : that many, if not
all, of  the motor fibres of  the internal capsule penetrate into the
cell-networks of the corpora striata.  Further, there can be  no
question  that  the motor  fasciculi of the  crusta  are continued
downward through  the  pons  and  pyramids into the  lateral
columns  of the spinal cord.
   These results  of anatomical and experimental research are in ,
harmony with those reached by Gudden along an altogether dif-
ferent  road.  He removes portions of the brain  from newly-born
animals,  allows them to grow up, and then  proceeds to study
the secondary atrophies resulting from the original injury, with
a view to determine the course  taken by the different sets of
fibres,  and the  connection of  the different centres  with one
another.   His experiments were made on rabbits and dogs.  His
principal conclusions are  embodied in the following brief com-
munication, which he has been  good  enough to send me at my
request.

  " In  the rabbit the frontal region  of the brain extends beyond the limits of
the frontal bone.  If we remove the superficial layers of the hemisphere where
it is protected by  the latter bone, we get atrophy of the middle portion of the
cerebral  peduncle,  and very marked wasting of the pyramid (these changes are
quite appreciable by  the  unaided eye).  If we slice off the surface of the hemi-
spheres where they are covered by the parietal bone, we get atrophy of the lateral
part of the  crusta  of the cerebral peduncles,  and, in a very moderate degree, of
the pyramid also.   Examination of sections shows, in either case, a partial atrophy
          VOL.  XIV.—43 
674          KUSSMAUL.—DISTURBANCES OF SPEECH.

of the internal capsule,  which is differently localized in the two cases, and is in
need of more detailed investigation.  I believe I am justified by my inquiries in
denying that, in  the first case, the corpuscular elements of the corpus striatum
undergo atrophy; this, however, is certain: that a multitude of fibres proceed-
ing from the corpus striatum through the internal  capsule to the forebrain, dis-
appear without leaving any trace.  In the second case,  on the other hand, even
inspection with the naked eye is enough to prove that the thalamus is consider-
ably reduced in size.  This is another point which requires further investigation.
I am convinced that if,  in some future  experiment, I  remove a  portion  of  the
cortex under the parietal bones,  in addition  to that which is  covered  by the
frontal bone, I shall get complete atrophy of the pyramid; while, if I remove
the convex surface of the middle and hind brain without injuring the anterior
strip of the ' subparietal  portion of the hemispheres,' I shall find the pyramid not
atrophied.
   " In the  dog the frontal region of the brain is  wholly covered by the frontal
bone.  Removal of its surface-layers is followed by shrinking of the median por-
tion of the  crusta of the cerebral peduncle and total  atrophy of the pyramid.
Examination of  sections  displays, just  as in the rabbit,  partial  atrophy of  the
internal capsule.   Superficial ablation of the  hemisphere underneath the parietal
bone is followed by shrinking of the lateral  part of the cerebral peduncle; while
the two pyramids remain, as nearly as possible, equal in their external diameters."

    In connection with the  researches of Tuerck and the experi-
ments of Veyssiere,  Charcot has  shown that, in man, blood-clots
and patches of softening situated  in the  hemispheres may give
rise either to purely motor paralysis, or to hemiplegia with hemi-
anaesthesia on the opposite side  of the body; in the former case
the transmission of  impulses is interrupted through the anterior,
in the latter, through the posterior part of the internal capsule;
the interruption being due either to  rupture of the  fibres, or  to
their being compressed by changes  in  their  neighborhood (optic
thalami,  lenticular  nuclei, external capsule,  etc.).   When  the
interruption  is caused by  compression,  conductivity  may  be
re-established  on absorption of  the extravasated blood;  when
due to rupture  of  fibres,  it  is  permanent.   Charcot terms  the
anterior part of the central region of  the hemispheres, damage
to which  is followed by purely motor hemiplegia, "the domain
of the  arterise  lenticulo-striatse  ;"  the posterior region, damage
to which  is followed by  hemiplegia with  hemiansesthesia,   he
calls the  domain of the "arterise lenticulo-opticse ;" the  parts
receiving  their blood-supply from these two sets of arterial twigs 
          CHANNELS TRAVERSED BY SPEECH-IMPULSES.      675

respectively.   Accordingly, when dysarthric imperfections of
speech, resulting from  interrupted  transmission of volitional
impulses,  are  associated  with centro-hemispheric hemiplegia,
they may be ascribed to lesions of the anterior region when unat-
tended by hemiansesthesia ; of the posterior  region, when hemi-
anesthesia exists.  Tims,  we may have anterior and posterior
centro-hemispheric dysarthries of conduction.   The sooner the
defect of  speech disappears after the  apoplectic stroke,  the
greater the likelihood of its having been caused by compression ;
the longer it lasts, the more probably may it be ascribed to rup-
ture of conducting fibres.

   Central blood-clots and patches of softening in both hemi-
spheres,  which damage the whole of the voluntary motor tract
on its way through the right and left internal capsule, necessarily
interfere with articulate utterance, and render speech stammer-
ing,  muttering,  or altogether impossible.—R.  Bright, for ex-
ample, saw lasting difficulty of  articulation and of deglutition,
together with partial paralysis of the limbs, in a case of soften-
ing of both corpora striata.   In regard to this case, and all other
cases of old date, in which one or both of the corpora striata are
stated to have been extensively damaged,  we shall probably be
right in assuming, not the gray nuclei of these bodies only,  but
the white fibres between them likewise, to have been injured.
   But even when the  centro-hemispheric or capsular  channel
for volitional impulses is extensively damaged on one side only,
severe  stammering or  complete loss of articulate utterance may
result.  Experience has taught us that extensive damage to  the
left corpus striatum  is much more  prejudicial  to articulation
than similar injury to the right one.  Blood-clots and patches of
softening in the centre of the left hemisphere, followed by right
hemiplegia, are  much more frequently associated with severe
and lasting defects of  articulation than  corresponding lesions
situated  in the right hemisphere, and  followed by left hemi-
plegia.  Loss of  speech, when it  occurs in connection with the
latter, is usually transient, leaving at worst only a slight impedi-
ment of articulation behind. 
676           KUSSMAUL.—DISTURBANCES OF  SPEECH.

   In a case of softening of the left corpus striatum, Rombergx found consciousness
unimpaired, while the faculty of speech was  totally and irremediably destroyed;
there was permanent right hemiplegia; hemianesthesia and amaurosis were likewise
present at first, but disappeared  in  a  few days.  Andral,2 too, records a case in
which  the left corpus striatum  was almost completely softened, the softening not
extending beyond it;  the intellectual powers were not  affected, but the patient's
utterance was altogether  unintelligible;  there was also hemiplegia of the opposite
half of the body.  The old woman previously referred to, whose case was published
by Durand-Fardel, suffered  for a whole year from difficulty  of speech  without
paralysis after an  apoplectic fit, resulting in the formation of  a cyst in the left cor-
pus striatum.  She then got softening o'f the whole of the left corpus striatum, and
her speech became altogether unintelligible—" elle bredouillait."  Her intelligence
did not seem  to  be impaired.  In a right-handed woman of sixt}r-four, Vulpian
found  an extensive patch of  old softening3 in  the left corpus striatum, occupying
the whole of the lenticular nucleus and the middle portion of the nucleus caudatus.
She had had an apoplectic stroke five years before her death, followed by perma-
nent right hemiplegia  with rigidity.  For several months she continued speechless;
subsequently, however, she regained the power of expressing her meaning pretty
distinctly.
   Bateman 4 has  published  a case in which articulation was severely disturbed by
softening of the posterior two-thirds of the right corpus striatum.  In our own clin-
ical wards we had an opportunity of  seeing  a  right-handed woman of seventy,
who  was struck down by apoplexy six weeks  before  her death.  She  fell to  the
ground unconscious.   When consciousness returned she was  unable to speak, but
the power of speaking soon returned.  Complete hemiplegia and hemianesthesia of
the left side persisted until death.  The tongue was protruded towards the paralyzed
side, the mouth was  drawn to the right, articulation was rather difficult,  but she
was able to express herself quite  distinctly and intelligibly.   A patch of hemor-
rhagic  softening occupied the hinder two-thirds of the right lenticular nucleus; it
involved the external capsule  between the lenticular nucleus and the claustrum,
and the claustrum itself, projecting forward as far as the insular cortex, but with-
out involving either this or the external capsule.  The blood must have compressed
the internal capsule and  the insula when it was first  poured out;  the permanent
effects, however, were  due to the destruction of the posterior two-thirds of the len-
ticular nucleus and the external capsule.

    The familiar fact that  centro-hemispheric hemiplegia of the
right  side  is  often  associated  with  defects of  articulation, fre-
   1 Loc.  cit. p. 946.
   2 Clin. Medicale. Vol. V. p.  327.  Cf., too, Obs. XXIII. p. 338.  Muttering speech
with softening of left corpus striatum.
   3 Mongie, De Taphasie. Paris, 1866. Obs. XVL
   4 On Aphasia, p. 59. 
          CHANNELS TRAVERSED BY SPEECH-IMPULSES.      677

quently amounting to  total loss of speech, which are at once
more lasting and more severe  than the slighter and  more tran-
sient dysarthries occurring with left hemiplegia, proves that the
main current of the centrifugal impulses of speech passes down-
ward through the left cerebral  hemisphere.  But since dysarthric
troubles—though usually of a trifling kind—are noticed, as a
rule, in connection with left hemiplegia likewise, we  must con-
clude that, besides  the main current just referred to, a weaker
accessory current is transmitted through  the right hemisphere.
We  shall see hereafter that this pre-eminence of  the left hemi-
sphere is connected with the right-handedness of the majority of
mankind,  ■/.  e., with the  special training of the left  cerebral
hemisphere for the  execution of voluntary movements.
   Persons rendered hemiplegic and speechless by such centro-
hemispheric  extravasations and softenings are able (as has been
pointed out by Trousseau and  others), provided there be no cor-
tical complications, to  express their thoughts in writing with
the sound hand.   It is hardly necessary to add  that  the first
attempts of right-handed people to write with the  left hand are
usually very awkward.    Specimens of such writing have been
published by Laborde.1

   We know scarcely anything, unfortunately, about the exact
course followed by  the motor fibres subservient to articulation,
on their long journey from the frontal cortex to the basal phonic
centre,  or  about their connection with the central masses of gray
matter.
   Even as regards the medulla oblongata,  on whose intimate
structure  microscopical research has thrown the most light, our
knowledge is exceedingly imperfect.   According to HugueninJ
the will-fibres of the facial and hypoglossal nerves,  on their way
down from the brain, do not penetrate into  the bulbar nuclei,
but receive special motor fasciculi from the latter, in conjunction
with which they issue from  the medulla oblongata to form the
trunks  of  the facial and hypoglossal nerves.   He further asserts
  1 Bulletin de la societe anatomique. VIII. 2me part. p. 386.
  2 Loc. cit. p. 1 (if! and p. 168. The same, Ueber die cerebralen Lahmungen des N. faci-
alis.  Corresp.-Blatt. f. schweiz. Aertze, 1872.  Nos. 7, 8, and 9. 
678         KUSSMAUL.—DISTURBANCES  OF SPEECH.

that the nucleus of the facial receives fibres from that of the abdu-
cens likewise, and, as I have already pointed out, from the optic
thalamus.  Exner's experiments, referred to above, seem to indi-
cate that before a centrifugal  impulse from the cerebrum enters
the nerve-roots, it has to traverse ganglionic masses in which it
is  at once  delayed and intensified.   Again, there is the fact (a
detailed consideration of which must for the present be deferred)
that the bilaterally symmetrical muscles of the larnyx, tongue,
etc., are  thrown into contraction simultaneously in speaking, a
fact which  cannot be explained without assuming the existence
of commissures which at some point or other divert  the impulse
to the  opposite  side.   It is probable, indeed, as I have already
observed, that  excitor currents flow downward through  both
hemispheres ; the current  derived  from the  left  hemisphere
being,  however,  the more powerful and the really operative one,
since destruction of the centro-hemispheric channels on the left
side is of itself sufficient to annihilate the faculty of speech for a
long time, or even permanently.  All these considerations taken
together compel us to believe that commissures and collecting
ganglia are intercalated somewhere or other below  the  cerebral
peduncles.   They tend, moreover, to enhance the importance of
the medulla  oblongata, which we have already had occasion on
other grounds to recognize, in regard to the function of articu-
late utterance.
   Huguenin views those facial and hypoglossal fibres which
are derived from the nuclei as ancillary to reflex movements ;
contrasting thereby  with the  volitional fibres derived from  the
cerebrum.  He  refers to the fact, which was observed long ago
by Bell,  Stromeyer, and Romberg,1 that the power of voluntary
movement  may  be abolished in the  area of distribution of  the
facial and hypoglossal nerves, while  reflex movements continue
to be executed,  and vice versa.  He adds an illustrative case of
his own.2
  1 Bamberg, a. a. O. p. 786.
  s In a boy aged 7 the site of the facial nucleus on the right side was occupied by a
tumor as large as a bean.  The paralyzed half of the face remained flaccid when he
laughed or cried ; but it took part in the movements necessary for whistling and clos- 
         CHANNELS TRAVERSED BY  SPEECH-IMPULSES.      679

   Many authors go so far as to assume the existence of two
facial nuclei,  one  for  the  orbital,  the  other  for  the buccal
branches of the nerve
   The  fibres of the facial decussate,  as  is well known, in the
lower third of the pons.  The decussation of the hypoglossal
fibres probably takes place in the pons likewise, but we have no
precise knowledge on the  subject.
   Whether the masses of gray matter in the cerebral peduncles
take any part in articulate phonation and are connected with
the motor tract of speech, must for  the present be left an open
question.  It is clear,  however,  that  any interruption of the
motor channels in  the peduncles must interfere with articulate
utterance.
   In the cerebrum the buccal fibres of the facial take a different
course from  those  distributed to the  orbit.   It is clear that  in
the hemisphere  the facial nerve must break up into a bush-like
expansion of diverging  fibres,  since lesions in various situations
are followed by partial palsy of the  facial muscles.  Concerning
the course of the hypoglossal fibres in the hemispheres, we are
altogether ignorant.

   We may now go on to inquire whether, and in what way, the
gray matter of the corpora  striata takes part in tke»function of
speech.
   The  ganglia  comprehended  under the collective  name  of
"corpus striatum," viz., the  nucleus caudatus  and  the  three
segments of  the  nucleus  lenticular is, are commonly viewed  as
organs for those combined movements which are determined by
impulses transmitted from the cortex cerebri, e. g., running, leap-
ing,  etc. This view is in harmony with the results of the experi-
ments originally made by Magendie, and recently repeated and
extended by Nothnagel,1  which have led to the latter's discovery
of a circumscribed nodus  cursorius in the  caudate  nucleus.  We
are thus brought to regard the corpus striatum as a rendezvous
for the fibres coming from  the cortex and those going to the pons;

are of the eyelids.  Speech was " awkward. "—Cf.  also Joffroy, Gazette med. de Paris.
Nos. 41, 42, 44, 46.
   1 Virchow's Archiv.  Bd. LVII.  p. 27. 
680         KUSSMAUL.—DISTURBANCES OF  SPEECH.

the two sets of fibres being connected through cell-networks and
nodal points capable of transforming the impulses received from
the cortex into combined movements, whose individual elements
or constituent acts are in their turn co-ordinately executed by
the cell-networks of the medulla oblongata and spinal cord.  Of
course our knowledge on this point is not absolutely certain and
exact.
   Moreover, Nothnagel1 considers himself justified in conclud-
ing from his experiments on rabbits, that all the will-fibres, with-
out exception, traverse the lenticular nucleus.  This is denied
by the French investigators, who attribute the complete annihi-
lation of voluntary movement, which Nothnagel achieved by the
injection of caustic solutions into both lenticular nuclei, to  a
simultaneous  destruction of  the internal capsule,  which, owing
to the small size of the lenticular nuclei in the rabbit, might easily
have been  overlooked on dissection.  Nothnagel,  however, has
lately  published a brief  statement in which  he adheres to his
original assertion.5
   Lastly, Burdon Sanderson3 affirms that, by electrical stimula-
tion of definite points on the surface of the exposed corpora
striata, he has succeeded in producing  the very same combined
movements as those observed  by Hitzig to result from stimula-
tion of definite points in the frontal cortex.  But neither  Ferrier
nor Carville and Duret were able to produce such movements by
electrical stimulation  of  circumscribed areas  of the corpus stri-
atum ; they only observed pleurosthotonos on the  opposite side
of the body.   Moreover, Hitzig asserts  that the  motor points
which Sanderson believes himself  to have detected  in the cor-
pora striata do not correspond in position to those discovered by
Hitzig himself in the frontal cortex.
   The recorded  eases of damage to the  corpus striatum in the
human subject do not, unfortunately, furnish adequate data for
enabling us to decide  on the functional significance of its gray
nuclei, either singly or collectively. We are seldom informed of
the precise extent of  the lesion, and whether it was limited to
1 Virchow's Archiv. Bd. LX.               2 Ibid. Bd. LXVII.
          3 Med. Centralblatt.  XII. No. 33. 1874. 
          CHANNELS TRAVERSED BY SPEECH-IMPULSES.       681

the gray matter, or involved the white fibres as well.  According
to Charcot,  circumscribed lesions of  the gray nuclei alone, and
lesions confined to the white capsular fasciculi, are both of them
followed by hemiplegia on the opposite side of the body.  But
the paralysis resulting from injury to the gray matter is  not so
lasting, and therefore less severe, than that which follows injury
to the internal capsule, the relatively transient character of  the
former being due, in all likelihood, to  the capacity of  the gan-
glion-cells of  the caudate  and  lenticular nuclei for vicariously
fulfilling one another's functions.
   Broadbent assumes that  the corpora  striata are organs in
which  single words, or even  groups of words, are formed and
combined as  motor acts, just  like  the  combined movements
required for running, leaping, etc.   A critical examination of  the
clinical data we  possess does not, however,  substantiate this
hypothesis.   On the contrary, it tends to prove that the co-ordi-
nation of letters to form words takes place higher up—in  the
cortical substance.  Broadbent himself admits one difficulty in
the way of  his hypothesis, viz., that,  while  disorganization of
one corpus  striatum—more particularly the left one—interferes
with speech only for a  time  at the  outside, destruction of  the
third left frontal gyrus (whose importance in relation to speech,
as a motor act, is supreme) is followed by a more lasting impair-
ment of this function.  The transient loss of speech—so far as it
consists, not in a mere inability to utter  articulate sounds, but
in a want of  power to form words—which results from grave
lesions of the corpus striatum, appears to be readily susceptible
of explanation by taking the indirect effects of such lesions into
account.  They must  interfere  with  the functional activity of
those  adjacent regions of the  cortex  which  preside  over  the
formation of words, either by squeezing the blood out of them
or by setting up collateral fluxion in them.  This would afford a
simple explanation  of  the facts,  without any of those elaborate
attempts at elucidation  to which Broadbent  has recourse, and
which we need not enter upon here.
   In the whole of  our medical literature, I know of  only one
case which might be quoted in support of Broadbent" s theory ;
it is only just to add that the case in question was observed by 
682         KUSSMAUL.—DISTURBANCES OF SPEECH.

a very eminent physician.   It might be quoted to prove that an
isolated lesion of the gray matter of the corpus striatum is  able
to annihilate  the  power  of forming words, without interfering
with any other department of volition.
   Andral' relates that a woman, eighty years of age, lost the faculty of speech
quite suddenly (so, at least, her friends said), three years before her admission into
La Pitie.  The loss of speech was not attended by any other cerebral disturbance.
On admission, she was found to be quite speechless, unable to utter a single word ;
but she understood what was said to her, and expressed herself  by means of signs.
She had the use of all her senses, and perfect control  over  the movements of her
tongue and  limbs. Her death was caused by an affection of the heart and bed-
sores.  Nothing was found in the brain except two old patches of softening, con-
taining a grayish, gruelly matter, and as  big as large  peas.  One of them was
situated in the hinder end (the apex) of  the left  corpus  striatum, the other in the
centrum ovale of the right hemisphere.
   Since  lesions of  the  left cerebral  hemisphere are far more
dangerous to speech than lesions of the right one, we may fairly
attribute the loss of speech in the above case to the small patch
of softening in the left corpus  striatum.   But, as Andral justly
remarks,  we cannot  tell  how  long the lesion had been there.
Both patches may have been more recent than the  lesion which
caused loss of speech three years before, and which  may possibly
have eluded  observation on the post-mortem table, for we do not
always  succeed in discovering  the  anatomical cause of speech-
lessness after death.   The coexistence of  the little patch of
softening in the left corpus striatum with the symptom in ques-
tion may not improbably have been an accidental one,  for the
case is unsupported  by  any other  observations  of  a  similar
kind by which its significance might be enhanced.
   But although we are  compelled to reject the opinion that the
corpora striata take  part in the formation of words, they  may
nevertheless participate in the mechanism of literal phonation and
the articulation of syllables—so far as the latter consists in the
mechanical transition from one  muscular attitude to another,
and, more particularly, in the "vocalization " of consonants (com-
bination  of consonants with vowel-sounds).   There is reason to
believe  that  the basal  mechanism of  articulate  phonation  is
1 Clinique medic. Ed. III. Tome V. p. 324. Obs. XVII. 
       THE  CORPORA  STRIATA IN RELATION TO SPEECH     683

inadequate per se for the formation of the literal sounds, and
requires the co-operation of the  corpora striata.  The higher we
ascend in the animal series, the less competent for achieving the
more elaborate  kinds  of  movement do the infra-hemispheric
ganglia of the brain  become, the  less perfect does the indepen-
dence of the lower centres  appear.  Dogs do not seem to be able
to run, after their cerebral hemispheres  have been  removed,
though rats  are still able to do so.   Nay, it remains to be shown
that a dog can bark, as a frog can croak, without its cerebrum.
Soltmann's1 experiments, at any rate, fail to prove that puppies,
from whose frontal lobes the cortical layer is removed shortly
after birth, acquire the power of barking properly as they grow
up.  One puppy, indeed, of those that survived the operation,
learned to run awkwardly in eight weeks'  time; and  Soltmann
mentions,  in one place, that it  learned to bark, a phenomenon
not previously noticed ; in another place, however, he says that
in reality it only squeaked  like a puppy at birth, but never
barked in a manner suitable to its age. There can be no question
that the mechanism of articulate phonation is only developed in
the infra-cortical motor ganglia under the influence of the cortex ;
in fact, as regards the mechanism of speech, the infra-hemispheric
centres may be supposed to stand towards the corpora striata in
much the same relation as that in which the spinal centres stand
towards the  corpora striata as regards the mechanism of running
in man and the higher mammals.  For the correct formation of
literal sounds and their mechanical coaptation into syllables, it
is essential that the motor or articulatory processes set agoing in
the corpora  striata by impulses  derived from the cortex cerebri,
should combine with those that  go on in the basal ganglia ; just
as the corpora striata and  spinal cord have to co-operate in the
act of running.
   The clinical data now at our  disposal do not suffice,  unfortu-
nately, to furnish more precise information  concerning this rela-
tion of the corpora striata to the basal phonic centres.  So much
is certain,  that lesions of the corpora striata may render articu-
late  utterance stammering to un intelligibility, or may even
1 Jahrb. f. Kinderheilkunde. New Series. IX. p. 106. ff.; also pp. 119 and 129. 
 684         KUSSMAUL.—DISTURBANCES OF SPEECH.

 annihilate it altogether;  further, that these  disorders  show
 themselves more  certainly and more severely in proportion as
 extensive areas of the left corpus striatum are damaged.   But
 it must be left for future inquirers to solve the arduous problem
 concerning the difference of effect produced  by  lesions of the
 white and those of the gray matter, and, to discriminate between
 the functions of  the individual components of those  two kinds
 of matter.   The  problem is  a  difficult one, because  we know
 from experience  that small portions of the gray matter may be
 destroyed without any apparent disturbance  of function, or by
 disturbance so insignificant in degree as to be readily overlooked.
 Should the  destruction  be effected slowly, the capacity of  the
 brain for accommodating itself to gradual changes will also come
 into play, the work of  the injured portions of cerebral matter
 being transferred  to those which are still intact.
   This point is admirably illustrated by a very accurate observation of Fuerstner's.1
In a maid-servant, aged thirty,  he found a large part of both lenticular nuclei—
more especially the globus pallidus (two inner  segments of the nucleus) on both
sides—destroyed by symmetrical telangiectatic gliomata.   Notwithstanding these
lesions, it was only towards the close of the patient's life, after and pos§ibly because
of the administration of chloral hydrate, that paretic enfeeblement of the  limbs,
and to some extent of the trunk  also, was observed.  Up to that time she had
shown signs of maniacal excitement; she had been screaming and singing, running
about restlessly, tearing up her clothes,  and attacking those about her.  On the
very day before she died, she answered questions correctly in a low voice.

   This one case  is enough to show that  recorded observations
must be employed with the utmost caution in determining the
functions of the  corpora striata and their constituent parts—
the anatomical  nature,  no less than the position of the lesions,
requiring to be taken into account.   This is true generally of
all attempts to localize  the functions subservient to  speech in
different parts of the brain.   The most certain evidence by far
is that  obtained from cases of  hemorrhage and  circumscribed
softening ;  that furnished by  cases  of  tumor,  sclerosis, and in-
flammatory  deposit is of less  value for  our purpose.   But even
in cases of the former  class we must draw our inferences very
guardedly. We must never forget that, among the earlier effects
1 Archiv f. Psychiatrie. Bd. VI. p. 344. 
        THE CORPORA STRIATA IN RELATION TO SPEECH.    685

 of  bleeding into the substance  of  the brain, we may have, in
 addition  to the  symptoms caused  by the  localized destruc-
 tion of tissue,  others resulting from pressure on adjacent parts,
 wliicli may last for days and weeks.   In  such cases, therefore,
 the later and  more permanent  symptoms are the most instruc-
 tive.  In cases of  softening, on  the other  hand, the earlier
 phenomena  resulting from interference with the collateral circu-
 lation by thrombosis,  embolism,  etc., will  usually disappear
 more quickly, and  the  symptoms  that persist after a few hours
 or  days have  elapsed may safely be attributed to  the localized
 destruction of  tissue.
    I have no doubt that in time we shall succeed, by collecting
 precise observations of hemorrhage and softening in the corpora
 striata, in  making  out   the exact function of its constituent
 parts,  and in  ascertaining whether any  and  what differences
 there may be  between the  purely strio-capsular and the strio-
 nuclear dysarthries—points about  which we are at present pro-
 foundly in the dark.
    In the preceding chapter I have pointed out how important are
 the conclusions we are able to draw from cases of insular sclerosis
 of  the brain as to the localization of the  functions concerned
 in speech.  I called attention to the fact that the morbid changes
 in  this  disease exhibit a decided preference for the central med-
 ullary masses,  and more particularly the motor regions  of  the
 brain,  usually sparing its  cortex ;  further,  that  they occur in
 both hemispheres at once.  Under such circumstances  it is cer-
 tainly  a significant  fact  that  in this disease the mechanism of
 articulate  phonation is alone  impaired, and not the actual co-
 aptation of words.   A  case published by Romberg,1 in which
 circumscribed atrophy of the left corpus striatum, probably due
 to antecedent sclerosis, gave rise to severe dysarthry, is of impor-
 tance in this connection ; for it lends support to the view we have
 already adopted on other  grounds,  viz.,  that  the left corpus
 striatum has more to do with articulation than the right one.
  A schoolmaster, aged sixty, had suffered for eighteen months from  palsy of
the legs without impairment of sensibility.  Articulation was hindered from the
1 Loc. cit. p. 945. 
6S6         KUSSMAUL.—DISTURBANCES  OF SPEECH.
first.  Some time would elapse before he could bring out a word;  when he did,
his utterance was precipitate and attended by a hissing sound.  At a later period
his speech became an indistinct and all but unintelligible muttering, though his
mental faculties remained unclouded and his tongue freely movable.  Schlemm
found the left corpus striatum wasted, the medulla oblongata normal. The ver-
tebral canal was not opened,  so that the cause of the paraplegia was not made
out; there may possibly have been sclerosis of the lateral columns of the cord.
In this case, just as in the insular variety of sclerosis, there was stammering and
muttering utterance without any apparent coarse impediment to the locomotion of
the tongue.
   Tumors of the corpora striata very often interfere with  artic-
ulation ; but there is not much help to be got from these cases in
localizing  the  functions concerned  in speech.   According to
Ladame, of all cerebral tumors, those situated in the pons and
corpora striata are most often attended by disorders of speech ;
the patient's  utterance  has  frequently been noticed to be slow
and stammering ; impediments of  speech depending on impair-
ment of the intelligence and of the memory for words have like-
wise been observed.  The latter fact is readily explained by the
pressure of large and rapidly-growing  tumors  on  surrounding
parts.   Conversely, when the  growth of a tumor is gradual, so
that it rather  displaces than destroys  neighboring parts, allow-
ing them time  to yield or take on one another's functions, the
symptoms invariably caused by destructive processes in the same
region may altogether fail to appear.

   Confining ourselves  to  such cases as are  suited for critical
valuation,  both  on  account  of  the anatomical nature of the
lesion,  and  because  they have been  recorded  with  sufficient
exactness,  we arrive at the following as our principal conclusion:
that the corpora striata form the uppermost limit of that region
within which destruction of cerebral tissue gives rise to noliiing
more than simple dysarthry in the form of retarded or precipi-
tate and "scanning'' utterance, or of stammer ing and mutter i n g,
or even of that total loss of speech which is due solely  to annihi-
lation of the mechanism subservient to liter ed. phonation.  As
soon as we enter the domain of the cortex proper,  including the
radiating medullary matter which is traversed by the great asso-
ciative and commissural fasciculi of  the cortical masses, we find 
THE CORONA RADIATA.
687
ourselves in a region, injury to which is followed by a variety of
added disorders of  speech involving the actual function of con-
structing words.  This great  region,  to  the  consideration of
which we are now about to address ourselves, we  shall term the
"domain of  the hemispheres proper"  (Hirnmantel), distinguish-
ing between their white and their gray regions.
   The functions of the cerebral cortex in relation to speech, and
the disorders of  speech that result from cortical lesions, will be
considered in subsequent chapters.  There  are only two points
into which we need enter at  present.   We have already learned
that  the motor  fibres  of  the crusta pass upward  through the
internal  capsule  and corpus  striatum towards the frontal region
of the hemisphere, where they connect  themselves with the ante-
rior portion  of the  corona radiata; the great majority reaching
this indirectly through the intervening  gray matter of the corpus
striatum, while  some may possibly enter it  directly.  The sen-
sory fibres of the crusta certainly pass, for the most  part, directly
into the  hinder  part of the corona radiata;  whether some  frac-
tion of them may not  previously enter into  connection with the
gray  matter  of the claustrum, and possibly with the hinder part
of the lenticular nucleus also, must for the present remain an
open  question.   We must  now enquire whether clinical observa-
tion furnishes any data capable of throwing light on the course
of the articulatory channel  for literal  phonation in the anterior
part  of  the  corona radiata,  or of the  sensory tract ancillary to
speech in its posterior part.
   A casel that  occurred  in  my own wards  proves conclusively
that small  and sharply circumscribed patches of softening in the
anterior  part of  the corona radiata may cause  hemiplegic pare-
sis with  disturbance of literal articulation.

  In a right-handed man, aged forty-two, a single patch of softening, no bigger
than a  bean, in the white medullary substance of the right frontal lobe between the
corpus striatum and  the cortex, gave  rise to paresis of the left angle of the mouth
and  left arm, together with slight awkwardness  in the production  of articulate
sounds. We did not succeed in making out to our satisfaction whether the mobil-
ity of the tongue was in any way impaired.
1 Frei, Archiv f. Psych. Bd. VI. p. 327. 
688         KUSSMAUL.—DISTURBANCES OF SPEECH-.

   In the  above  case  the accessory current  of articulatory im-
pulses through the right  hemisphere had evidently been inter-
fered with to some extent, but the power of forming words was
not impaired.  It would be interesting to ascertain whether simi-
lar limited  destructions of white medullary matter between the
the corpus  striatum and frontal cortex of the left hemisphere,
through which the main current of articulatory impulses  flows,
would also give rise to a  purely literal disorder of articulation,
or whether the formation of words would be interfered with, and
when.   This would  throw light on the exact distribution of the
motor projection channels of speech among the co-ordinating and
associative channels of the arching fibres which connect the con-
volutions with one another and  assist in the formation of words.
A case  recorded by Farge  proves that lesions of the white sub-
stance of the cerebral hemisphere alone, in the neighborhood  of
the third  left frontal convolution, may, without any simulta-
neous  injury  to the gray matter of the cortex, disturb the power
of forming words.

   The patient was paralyzed on the right side.  The only words he uttered of his
own accord were "Ah, si, ah I " "Ah, bon sens de Dieu !"  The latter phrase he
employed to express pain.  To questions requiring a simply negative or affirmative
answer, his replies were correct enough: " Ah, oui! " or " Ah, non ! " When made to
repeat words uttered in his presence, he  succeeded in the attempt when the words
did not  exceed two in number; when there were more than two he would only
repeat the two first.  The words he pronounced were spoken in a normal tone of
voice and well articulated. After his death a careful examination of his brain, both
with the naked eye and with  the microscope, showed that the third left frontal
convolution was healthy, while the adjacent white substance contained a spot of
gruelly softening as large as a small egg.

   In this case, accordingly,  there was  true aphasia.   Popham'
has placed a similar one on record.  In a case of Jaccoud's,3 too,
there seems to have been aphasia in connection  with a lesion situ-
ated in this region.
   After an apoplectic fit, the patient was found to have right facial paralysis
without palsy of  the  limbs, but with loss of speech.  This passed away in a few
1 Gazette hebdom. 1865. No. 44.            » Bateman, On Aphasia, p. 37.
            8 Dieulafoy, Gaz. des hopitaux. 1867. No. 58. 
THE CORONA  RADIATA.
689
days. After death, two small hemorrhagic cysts were found in the white substance
near the third left frontal gyrus.  In this case the effects may perhaps have been
due merely to compression of the gyrus.

    We have no certain knowledge of the place where those motor
fibres of  the  corona  radiata  which  are subservient  to speech
enter  the  cortical convolutions; we know still less about the
way in which  they are connected with the  cell-networks of the
cortex.

   According to Broadbent, the fibres derived from the cerebral peduncle and the
central ganglia proceed, for the most part, to the margin of the Sylvian fissure;
while the fibres of the corpus callosum betake themselves, for the most part, to the
margin of the longitudinal fissure.   He is of opinion that manygyri—e. g., those of
the insula—receive neither peduncular nor callosal fibres, and are, therefore, con-
nected in an indirect way only, through other convolutions, with the central ganglia,
the peduncle, and  the corpus callosum.  He believes this class of gyri to stand latest
in the order of evolution, to be undeveloped in the brain of monkeys, and probably
to subserve psychical functions alone.

   On the other hand, it is certain that apart from the motor and
sensory  fibres penetrating  into  the  cortex from the cerebral
peduncles and ganglia of the caudex cerebri—apart from the cal-
losa fibres connecting the  hemispheres together—there  exist a
multitude of  arcuate fibres wliicli  traverse  the white substance
of the cerebral hemispheres for the most part  in a longitudinal
direction,  and serve  to  unite  the various  convolutions of the
cortex with  one another; the more superficial fibres connecting
neighboring points,  the deeper ones, such as are farther apart;
these are the "associative fasciculi" of Meynert, to wliicli refer-
ence has been  already made.
   The great task of the  future—to unravel the tangled paths of
feeling, thought, will, and action—makes us feel giddy with our
present inadequate power of  insight.  Yet, even were this  task
accomplished,  we should only have made  one  step towards a
knowledge of the labyrinthine arrangement of fibres in the brain.
For the cortex itself  is traversed in all  directions by countless
millions of fibres, uniting the corpuscular elements into innumer-
able networks, and connecting them with the cell-networks of the
ganglia situated lower down in the brain and cord, and even with
           VOL. XIV.—44 
690          KUSSMAUL.—DISTURBANCES  OF SPEECH.

those ganglionic centres which lie outside the cerebro-spinal axis
in the various organs of the body.


                        CHAPTER  XX.

Sensory Channels of Language.—Meynert's " Tone-Field.''—Central Laboratory of
    Word-Images.—The Problem of the Elaboration of Elementary Sensations into
    Perceptions with Reference to the Localization of the Mind.—Relation of Con-
    sciousness to the Psychical Functions in General and to Sensation in Particu-
    lar.—Latent Consciousness, Personal Consciousness (Consciousness of the Ego),
    and Self-Consciousness.—Lower or Instinctive, and Higher or Intelligent Judg-
    ment.—Relation of the Mechanical to the Mental  (Psychical) Work of the
    Nervous System.—Excito-motor Faculty, Goltz's Faculty of Adaptation, Psy-
    cho motor  Faculty, or, Sensory-motor Reflex  Action, Percepto-motor Reflex
    Action, and Ideo-motor Reflex Action or Free-Will.—Discursive and Intuitive
    Thought.—Explanation of the Marvels of Language by the Laws of Organic
    Evolution, and the Mechanical Principle of Reflex Movement Inherent in all
    parts of the Nervous System, including the Cortex Cerebri.

   The channel for the sensory impressions of spoken words has
its beginning in the peripheral expansion of the acoustic nerve ;
that for written words in the retina.   The former is continued
into the acoustic nuclei  of the medulla oblongata; the latter
passes along the optic nerves and tracts  to the gray matter of the
anterior corpora quadrigemina which  are  believed to  be  the
actual optic nuclei.   True, some fibres pass from the optic tracts
to the  corpora geniculata  and  the pulvinar thalami;  but  the
relation of these fibres to the  act of vision is not clearly  made
out;  they do not  waste  after destruction of  the  eye-balls  in
newly-born  animals (Gudden).   There can  be no doubt that the
nuclei of the optic  tracts in the corpora quadrigemina and optic
thalami are  further connected, on the one hand, with the occipi-
tal cortex through the fibres of the  corona radiata;  on the other,
with  the spinal cord through the tegmentum and fillet (Schleife).
But the course of the individual fibres has not yet been accurately
traced ;l and we are  still ignorant of the locality where the semi-

   1 Hitzig (Centralblatt f. d. med. Wiss. 1874. p. 548), by removing slices of brain-
matter in the region of the hind-lobe, caused blindness of the opposite eye with dilata-
tion of the pupil.—Cf., however, the experiments of Goltz (to be referred to in Chap. 
SENSORY CHANNELS OF LANGUAGE.
691
decussation of the fibres in the optic tract is completed in the
brain.1  As regards the fibres of the acoustic nerve, all attempts
hitherto made to  trace  direct  acoustic channels  between  the
medulla oblongata and the cerebrum, have failed. At the present
moment, Meynert is actually of opinion that the major part of
those fibres reach the cerebrum circuitously through the  cere-
bellum.  At one time2 he thought he had succeeded in following
a bundle  of  acoustic  fibres from  the inner acoustic nucleus
through the tegmentum  as far as  the- claustrum  and into the
cortex of the island of  Reil.   On this  supposed  discovery he
grounded his hypothesis  that the Sylvian fissure was "the tone-
field  of language;"  a  hypothesis which  was very favorably
received.   Unfortunately, however,  it has lost its chief claim to
consideration since its conscientious author found himself obliged
to withdraw his original statement concerning the acoustic origin
of the fasciculus in question.

   It is of the utmost general interest to ascertain at what point
in the sensory tract the optic  and acoustic  images,  resulting
from co-ordination of the impressions on the peripheral expan-
sions of the optic and acoustic nerves, are  perceived.   For our
special  purpose,  the question  may be thrown  into a narrower
shape :  Where  are the images of  spoken  and  written words,
employed  as  symbols to represent states of consciousness, cre-
ated ?   This question must be kept  rigorously distinct  from
another one—Where are those images interpreted and under-
stood as symbols?  The comprehension of  words, /. e., the  con-
nection of  verbal  images  with their  corresponding thoughts,
undoubtedly takes place  in the cortex cerebri, and there only ;
but it does not  necessarily follow  that  the images themselves
originate in the  cortex.  That  they may do so is  possible, but
not  certain.  Just  as a word, in its motor aspect,  consists  of a
series of  individual  movements co-ordinated together in the
XXI.), according to which mutilation of the cortyx, either of the anterior or posterior
lobes, gives rise to blindness, provided only it be sufficiently extensive.
  1 Cf. Charcot's ingenious essay in the Progres med. 1875. Nos. 35 and 49. Likewise
Jastroicitz, Arch. f. Psych. VI. p. 616.
  2 Wien. Med. Jahrb. Bd. XII. 1866. p. 152. 
692         KUSSMAUL.—DISTURBANCES OF  SPEECH.

order of their increasing complexity, so it may be that in its
sensory aspect a word is made up of  a series of elementary sen-
sations, co-ordinated from below upward  into more and more
highly complex forms.   The power to perceive words as sensory
images or combinations may  be  lost witliout any impairment  of
hearing or of sight, and without any appreciable,  or, at any rate,
considerable failure  of  intellect.   Such  disorders of speech,
which we shall have to describe more fully hereafter  as word-
blindness and word-deeifness, prove unquestionably:  (1)  that
the localities where sounds, or lines and dots, are perceived, are
not identical with those in which sounds are co-ordinated  into
and recognized as phonic  images, lines  and  dots as graphic
images ;  (2) that the laboratory for phonic and written images is
not the  same  as  that for  conceptual states  of  consciousness.
Unfortunately, the  experimental  and  clinico-anatomical  data
which might  illuminate this obscure subject are still  wanting.
We are thrown back on generalities.  One thing, however, is
clear  enough from what has  been already said : even if we  sup-
pose  word-images to  be generated  in  the cortex, we cannot
believe them to be generated in the same regions of  the cortex  as
those in which conceptions  originate.  This, of course, is quite
compatible  with the  view that  they  may both originate  in the
same convolutions, but in different cell-networks.1
   If we pass  on  from  these preliminary considerations  to the
problem of the elaboration of the peripheric sensory impressions
into word-images,  we must set out with a clear idea of  the rela-
tion of consciousness to the psydticat functions in  general, and
to sensation in ■particular.   This is the key-stone of the enquiry
concerning the localization of the psychical activities generally,
and concerning the place where elementary sensations  are sum-
med up into images, in particular.
   It is  self-evident that psychical (mental) activity must exist
wherever sensations  are perceived and judgments arrived at;
but it is difficult to determine the exact point at which sensation

   1 Goltz's paper on the effects of mutilation of the cerebrum did not reach  me till I
had completed this chapter (Archiv fiir Physiologie.  Bd. XIII.).  His experiments on
dogs throw some light on the points under consideration.  I shall therefore return to
the subject in the ensuing chapter (XXL). 
EXCITO-MOTOR FACULTY.                693
 and judgment begin.   The cause of the difficulty is  this :  the
 only immediate proof we have of the fact that we  perceive and
 judge is derived from our consciousness of perceiving and  judg-
 ing ; but that others perceive and judge we can only infer, with
 more or less of  probability, from the similarity between their
 actions and our own.   This leaves a wide field open for arbitrary
 interpretation, and one man will see psychical activity where
 another sees only mechanical work.
   From the physiological point of view, none of the mechanical
 work done by the nervous system can be regarded  as a manifes-
 tation of psychic (mental) force.  On the contrary, mechanical
 and psychical activity are joint effects of the excitation <>f ner-
 vous matter, which draws  its supplies of energy from the com-
 mon, storehouse  of the universe.   Inasmuch as a  mental state
 invariably  precedes any movement of the limbs in consciousness,
 as the particular movement  invariably corresponds to the ante-
 cedent  mental state, our movements appear to ourselves  to be
 carried out by the mind (Seele).  In reality, however, both sen-
 sation and  thought originate in the very same molecular changes
 in our nervous matter as those in which our mechanical activity
 has its rise.  To reconcile this seeming contradiction between the
 consciousness of free will, on the one hand, and the dependence
 of all the mechanical operations of the mind on the  material pro-
 cesses  of nerve-stimulation, on the other, is the business, not of
 physiology, but of metaphysics.
   The discovery of  the  reflex mechanism of the  spinal cord
 proved that  a large proportion,  at any rate, of  the acts which
 had previously been attributed to free volition were  really due to
 a mechanical principle inherent in the nervous matter.   The
 spinal  cord, after its separation from  the brain, is  still able to
 execute a  variety of orderly movements ;  but, whereas  these
 movements  were  previously  appreciated by the  cerebrum as
 direct  emanations from the  conscious Ego,  they now no longer
receive  any  immediate recognition in consciousness.   Hence,
spinal reflex acts  ceased to be viewed as psychical phenomena at
all, and were ascribed  to an "excito-motor" mechanism in the
cord itself ; the seat of psychical activity being thus shifted into
some region of the brain, above the spinal cord. 
694        KUSSMAUL.—DISTURBANCES OF SPEECH.

   But the term " excito-motor f as applied to reflex acts, never
achieved a universal popularity ; the term " sensori-motor " was
preferred to it.   The latter is based on the old doctrine that
sensation—a psychical act—is the  mainspring of reflex move-
ments—a  doctrine which,  as physiologists, we are  bound  to
repudiate.  But, while we deny that spinal movements are gen-
erated by sensations, we do not deny that they may be attended
by sensations ;  nay, we are of opinion that this  always happens.
The fact that we  cease to be directly conscious of spinal reflex
acts, when the cord has been separated from the higher centres, is
no proof that the cord is destitute of sensibility and of the con-
sciousness which is indissolubly bound up with sensibility.  It
only  proves that the consciousness of  the Ego (personal con-
sciousness), in which  all psychical phenomena are  synthetically
organized, resides, not in the cord, but in the brain.
   What is commonly understood by the word " consciousness ''
is merely one  of the forms in which consciousness manifests
itself.  We understand by it that illuminated area in the field of
vision of the Ego—not capable of being more precisely defined—
across which sensations and mental judgments follow one an-
other successively in  linear order.  We are only conscious of a
sensation or a mental judgment when they  happen to cross the
threshold of this '-personal consciousness."  Daily experience
shows us, however, that sensations and judgments are continu-
ally taking place below this threshold.  By attending to our
mental processes  we are able at any moment to raise a multitude
of them, which would otherwise have remained hidden, into the
field of consciousness.  For this reason, and also because we are
unable  to  conceive of  sensations and judgments taking place
unconsciously,  we are driven to assume the existence of a latent
consciousness, wliicli  is revealed only in the field of vision of  the
Ego.   What we term "unconscious"  sensation and  "uncon-
scious" judgment are only relatively unconscious processes, dif-
fering from those we  call "conscious" only in taking place  un-
noticed by the Ego, either because the  Ego does not attend to
them, or because they are altogether beyond the limits of his field
of vision.  Personal  consciousness  (consciousness of the  Ego),
which belongs  of right to every  organism endowed with mental 
              THE EXISTENCE OF A SPINAL SOUL.           695

faculties and individuality, must be distinguished, further, from
that supreme degree of consciousness peculiar to man which we
may term self consciousness.   We are aware  of our own con-
sciousness, and  raise it to the level of  an abstract conception ;
this process of abstract reasoning taking place only in the cere-
bral cortex of man, whose powers of thought are far advanced.
   Accordingly, there is nothing to prevent us from assuming
that the spinal reflex acts accomplished by the cord, after its sep-
aration from the brain, are attended by sensation and conscious-
ness.  Admitting  their connection with sensation, we need not
scruple to term them " sensori-motor " acts, and we must agree
with Pflueger in ascribing a '' soul" (Seele) even to the spinal cord.
He grounds his opinion on the purposeful character of many of
the spinal reflex acts in the lower vertebrata ;  these seem to him
to be explicable only on the assumption of a choice of movements
determined by mental judgments.  For it is not the purposeful
character of the spinal acts in itself, but the proof that they are
the manifestation of an "adaptive principle" in the cord, which
must be our  warrant for  their psychical nature.  Goltz, it is
true, was brought by his experiments on the spinal reflex  actions
of the frog to conclusions  different  from those arrived  at by
Pflueger.  He does not think the evidence for the existence of a
"spinal soul" sufficient.  He showed that even the most appa-
rently rational of the spinal reflex acts might be accounted for
by a suitably organized mechanism  in the cord, witliout any
need for assuming them to be an outcome of mental judgments.
But in  proving this, Goltz has by no means proved the further
proposition, that no mental judgments at all are arrived at in the
cord.  To prove that spinal reflex acts are not attended by men-
tal judgments, it would be necessary to prove that voluntary acts
originating in  deliberate choice are immediate mechanical effects
of psychic force and not mediately executed through the organic
mechanism of  the brain.  But this does  not admit of  proof ; on
the contrary,  we are driven  to conclude that all movements
issuing from the brain ought to be referred to the operation of a
general principle of reflex mechanism.
   The experiments of physiologists have shown that the higher
we ascend in the ganglionic system of the cerebro-spinal  axis of 
696        KUSSMAUL.—DISTURBANCES OF  SPEECH.

vertebrates, the more complex are the movements discharged by
internal and external stimuli.  If we remove the cerebrum up to,
or even including, the optic thalami, we  see the  play of move-
ments  continue to be so skilfully adapted  to the environment
that such adaptation seems possible only  on the hypothesis that
it  is guided by mental judgment.   Animals thus mutilated are
still able to run, to jump, to swim, to fly.   And these actions are
performed not merely by such animals as bring the needful fac-
ulties into the world with them, but by such as have to acquire
them after birth.  They adapt those complex movements to sur-
rounding conditions with  a  skilled choice which can only be
ascribed to mind.   The brainless fish will avoid  obstacles while
swimming by turning  now to one  side,  now to another (Yul-
pian).   The  brainless frog  remains quiet; but if  we  pinch him,
he will jump, avoiding any object in his way ; if  one of his legs
has previously  been attached to his belly, he will creep round
the obstacle (Goltz).  Brainless birds and mammals,  indeed, are
unable to avoid obstacles when flying, running, or jumping, like
fishes and frogs;  they knock against them.   The lower  centres
in these more highly-organized vertebrates are  not  so indepen-
dent as this ; but  they are still in some degree independent,  The
brainless pigeon, when thrown into the air, will fly ; it will wink
if a finger be brought close to its eye (Yulpian) ; it will follow the
movements of a lighted candle with its  head (Longet);  it will
often draw its head back if a light be suddenly brought close to
it (Vulpian).  Brainless rats will leap away when  they hear a cat.
Young rabbits  deprived of a brain will  run a few  steps when
pinched;  sometimes they will  do  it  of their own accord,
prompted, in all likelihood, by some inward pain (Yulpian).
   The frog which (when  one leg has been stitched  to its belly)
crawls round an obstacle in attempting to  escape, acts just  like
a man who perceives and reasons, and not  like a mere machine.
The bird wliicli closes its  eye on the approach of a finger, per-
forms a reflex act of which man only becomes capable after he
has learned to see objects, and to judge  of  their movements.1
  1 According to Sigismund, this power is not acquired till about the fourteenth or
Bixteenth week after birth. 
PERCEPTO-MOTOR REFLEX ACTS.
697
The behavior of the rat which springs away on hearing the noise
made by a cat, is like that of a man who  has learned by a men-
tal  process  to establish  a reflex  connection  between certain
acoustic  images  and certain purposeful  movements.  Since we
cannot employ the language of animals to denote what goes on
in them,  we are  obliged  to employ the  human terms by which
we denote similar phenomena in ourselves.
   We speak of " movements adapted  in purposeful fashion
to surrounding circumstances, by means of perceptions which
are associated with mental judgments."  It  is true, as Goltz
points out, that these " percepto-motor " reflex acts still exhibit
a high degree of automatism.  The movements are executed with
machine-like precision, without hesitation  or delay.  But this
proves nothing against the participation of the  mind in their
execution, since the latter is always alike mechanical.  It proves
merely that a precise movement is  associated with a precise per-
ception and a precise mental judgment.  It is in this respect that
such movements  differ from voluntary  movements;  the latter
originate, in animals, from  the conflict of elementary states of
consciousness—in man, from that of higher abstractions ;  a  con-
flict, to which we  give  the name of deliberation, and which
issues in  decision and action.—As every child must have a name,
we  may  call that form  of mental judgment which  manifests
itself in such reflex movements as  originate in the infra-cortical
ganglia, and are adapted to simple perceptions,  a "lower" or
"sensual judgment,"  contrasting  it with  that "higher judg-
ment of the cortical intelligence'' which is associated with a con-
flict  of ideas.  The former may also be termed  "instinctive,"
since it is prone to pass from generation to generation by inheri-
tance, while the growth of the latter is connected with the experi-
ence of the individual.
   We need not scruple,  even in the human subject, to localize
the mental faculty which elaborates sensations  into images and
adapts complicated movements to  those  images by means of an
instinctive judgment,  either wholly or principally in the infra-
cortical  ganglionic apparatus.   The study of hallucinations,
dream-life, catalepsy, chorea magna, and  somnambulism, affords
indications of a  certain  autonomy in the infra-cortical sensory 
698         KUSSMAUL.—DISTURBANCES  OF SPEECH.

and  motor  ganglia.  True, we should  not be  justified in sum-
marily  transferring  the results of experiments  on frogs  and
birds to the human subject.    For in man, the greatly developed
cerebrum enjoys a degree of  supremacy over the  basal ganglia
and  the  cortex, together with  the  corpus  striatum  over the
remaining parts of the cerebrum, which has no anologue even in
the most intelligent of  the mammalia.1   Still, the type of cere-
bral  architecture is, in  all essentials, the same throughout the
vertebrate series, and the same principle of  stimulation,  sensa-
tion, and reflex action holds good  throughout.  If the "divisi-
bility of the  mind"  (Goltz)  is established in the  case of ani-
mals, it must  be true of man also.  Psychical  sensation  exists
throughout the  entire  nervous system, including even its pe-
ripheral ganglia; the perception of images,  and  the faculty of
adapting complicated movements  (running,  jumping,  etc.) to
those images, makes its first appearance in  the intra-cranial
ganglia;  the  will, guided by abstractions of a higher  order, is
associated with the  cortex cerebri.  Every  department of the
nervous system fulfils a  psychical function of its  own ;  and the
higher we ascend towards the cerebral cortex the  more faculties
are aggregated for  the  performance of  more and  more complex
mental  operations.   The sold, though it ultimately feels and
conceives itself to be a self-conscious unity, is really composite.
   Accordingly, it would be  a mistake to suppose that mental
activity is limited to the brain  or the cortex, while all the pro-
cesses that go on at a lower level are purely mechanical.  The
nervous system, as a whole, including its uppermost  termination
in the cortex cerebri, is  at once  a mechanical apparatus and an
organ of mind.  Goltz, whose researches  on  the psychical func-
tions of the nerve-centres are so ingenious, does  not venture to
give any precise definition  of the  nature of the  psychic force
  '■ Soltmanrts assertion (loc. cit. p. 105 seqq.) that puppies which survived the removal
of the cortical layers of one or both frontal lobes succeeded in learning to run (though
late and awkwardly), and to eat their food, shows how little, even in so intelligent a
creature as the dog, the cortex contributes to the motor activities of the infra-cortical
parts of the brain.  We cannot unconditionally reason even from the dog to man.  The
loss of the cerebral cortex and the corpus striatum of one hemisphere produces only hemi-
paresis in the dog, while in man it gives rise to hemiplegia 
PERCEPTO-MOTOR REFLEX ACTS.
699
manifested by the basal ganglia of the frog ; he terms the faculty
by which, in the execution of reflex acts, complex movements
are adapted to perceptions, a "central faculty of adaptation"
(centrales Anpassungsvermogen).  This term, it is true, does not
prejudge  the  question;  but it  does not  help us much, for it
expresses nothing definite.   For, strictly speaking,  all reflex
movements, and even voluntary movements,  are adapted to sen-
sory phenomena.  In the case of a simple  reflex act, such, e. g.,
as closure of the eyelids against  light, the movement corresponds
to an  unformed or  elementary  sensation,  and the  diameter  of
the pupil is very accurately adapted to the intensity of the lumi-
nous stimulus or sensation.  In the case of those " percepto-
motor" reflex acts (Anschauungs-reflexe), which Goltz has before
his mind, e. g., closure of the eyelids against a threatened contact
with the conjunctiva, the  movement corresponds to a reasoned
perception (beurtheilte  Anschauung), such as  originates in the
recognition of an image, e. g.,  of an object  approaching the eye.
Finally, in the case of  voluntary movements, their  character is
determined  by a whole  series of images,  or, more correctly,  of
states of consciousness abstracted from those images. According-
ly, we see that the "faculty of adaptation" is of a very general
kind, belonging  to all nerve-centres  alike, and quite as much
mental  as  mechanical.   The  term is merely  denotative — it
explains nothing ; it connotes  nothing as to  the psychical  or
the mechanical  nature  of the forces and arrangements which
determine the phenomena under  consideration ; it  is concerned
solely with the form assumed by the effect  of the forces in .oper-
ation.
   Neither do I  see any advantage to be gained from the use  of
the term  "psycho-motor"  to denote voluntary movements as
contrasted  with simple  and  percepto-motor reflex acts.  The
mind, according  to my view, has just as much and just as little
to do with reflex as with voluntary acts.  At bottom it is neither
sensations nor perceptions, nor yet states of  consciousness, that
are the mechanical cause of movement; but always the physico-
chemical potential  energies that  are set free in the sensori-motor
centres appropriated to sensation, perception, and ideation, by
physiological stimuli.  We  must either admit  reflex  acts into 
7(.)0         KUSSMAUL.—DISTURBANCES OF SPEECH.

the psycho-motor group, or we must  exclude voluntary move-
ments from it.  Under  such circumstances, it  appears to me to
be all  one  whether we speak  of  psycho-motor or voluntary
movements, of responsive movements in Goltz's sense or percep-
to-motor reflex acts, or,  lastly,  of excito-motor or sensori-motor
reflex acts.  The essential point in all these enquiries is to deter-
mine the special psychical phenomena and motor effects, as well
as the internal processes of stimulation, that are  associated with
the objective activity of each individual nervous centre.  If we
desire to keep on strictly physiological ground, we  must speak
only of  spinal, bulbar,  cerebellar, strio-cerebral,  cerebro-cortical
movements, etc.  But  the time for this  is not  yet ripe,  since
physiology  has  only just begun to use right  methods for the
solution of such problems.
   A needless difficulty has been imported into the question of the
relation of the soul to the mechanical work of the  nervous system
on the one hand, to the processes of stimulation  in the nervous
matter on the other, by  the assumption that activity is psychical
only when it is immediately realized in the personal conscious-
ness.  The fact that only the smallest  fraction of even the high-
est intellectual work takes place in the light of the conscious Ego
was overlooked.  When the child  first begins to think, every
perception furnished by its fresh sensations comes before its con-
sciousness.  But as we get more practised in thinking, the images
of sense grow fainter, /.  e., they sink below the threshold of per-
sonal consciousness; their place is taken  by  concepts clothed in
words,  and  the  act of  thought gains thereby in rapidity and
precision.   Yet more,  many  of the  states  of  consciousness,
which were at one  time knowingly  traversed by thought, are
subsequently  omitted altogether, and  are no longer raised into
the field of consciousness.  The association of ideas is abbrevi-
ated ; thought, in the words of Lazarus, becomes  condensed—
intuitive takes the  place of discursive thinking.   If we are well
trained in the matters of logic  and psychology, we  may be able
to test the accuracy of our intuitions by retranslating  them into
the discursive form and raising our unconscious judgments into
consciousness.   But we  cannot  always do this completely,  even
as regards  our conceptions ; still less as regards  the perceptions 
PERCEPTO-MOTOR  REFLEX  ACTS.
701
obtained on a lower level  of  psychical activity, with which we
operate when thinking.  For instance, if we take the perception
of space, it is possible to show, by means of experiments on per-
sons born blind and restored to sight by operation,1 that we prob-
ably bring with  us into the world only the perception of  space
of two dimensions, the perception of depth having to be acquired
by  trial-movements,  for  whose  comprehension a considerable
degree of physiological and psychological insight is  essential;
notwithstanding which, the perception of depth is  realized by us
in our thinking and acting as though it were some immediate
appurtenance of consciousness, as though it were an inborn feel-
ing of instinctive certainty.  And even the most abstract kinds
of thinking by means  of words and formulse,  such, e. g., as are
used in mathematics, go on in accordance with rules painfully
acquired and subsequently forgotten, /. e., shut out of conscious-
ness, and persisting merely as a "sense of language," "mathe-
matical sense," etc.  The assertion that only conscious activity
is psychical would imply  that  some of the most highly-gifted
brains,  whose intuitions appear so  marvellous to us ordinary
people,  are  really the most devoid of reasoning power.  A Phi-
dias and a  Raphael, a Goethe and a  Shakspeare,  a Newton and
a Leibnitz, would be  mere automata,   Were mind only then
mind, when conscious of its own activity, it would—since the Ego
is only capable of realizing sensations and cognitions one by one
in linear succession—always exist merely as this or that sensa-
tion or cognition  entering at  the moment into consciousness.
But this would  be opposed to the fact that our Ego is made up
of an  enormous aggregate of sensations, images, and cognitions,
all  of which it embraces and fuses  into unity.  The  conscious
manifestations  of  our individuality never originate in this or
that single conscious sensation, perception or  cognition, but al-
ways in a fused  totality of all of them, slumbering  in memory,
lying  hid somewhere  or  other, vibrating  during thought, but
only recalled into personal consciousness in very  small propor-
tion.
  1 Cf. the latest observation of this kind by Hirschberg, Graefe's Archiv. 1875. Heft
I. p. 23. 
702         KUSSMAUL.—DISTURBANCES OF  SPEECH.

   But if we are obliged to admit that even the highest of our
mental operations are to a great extent unconscious,  we  can
scarcely doubt that  those on  lower levels may be so likewise.
In fact, we are driven to conclude that sensation and perception
only become " conscious, " in the vulgar  sense  of the word,
under  definite  organic  conditions  peculiar  to  the cerebrum.
Those conditions are: structural  perfection of the conducting
fibres and  of the ganglia which connect them on the one hand
—the orderly occurrence of the material processes comprised
under the collective name of "stimulation," on the other.
   We find this doctrine in  harmony with the evolution of con-
sciousness  in the history of our globe and  of the human race,
with the  growth of mental life in the animal series and in the
individual  man.  Wherever we turn our eyes, we find uncon-
scious  mental  activity undergoing  progressive  elevation  into
conscious forms.   The unfolding  of  the  mental  powers in the
animal world goes hand  in hand with the ganglionic differentia-
tion of the nervous system.   For the intelligent cognition of
phenomena, the maximum development of the cerebrum and its
cortex, such as we find  in man, is requisite.  But even homo
sapiens is at first, in the impregnated ovum, nothing more than
a punctum saliens;  it is not  till the fifth month that common
sensation manifests  itself by kicks and pushes ;  when he enters
the world to begin an  independent existence, his senses are not
all in working order  ; he is quite deaf, and his visual perceptions
are limited to vague impressions of light and darkness, while he
has already gathered a harvest of  distinct tactile and gustatory
impressions in his mother's womb.1
   The development of the central nervous  system in man tends
likewise to confirm our theory.  The histological investigation of
the brain and  spinal  cord  at different  stages of their growth
shows that the central fibre-systems are  built up in succession.
The fatty  degeneration  of the glia-cells, first recognized as an
incident of normal development by Jastrowitz, as also the forma-
tion of medullary sheaths associated with it,  are far from being
  1 Cf. my researches on the Mental Life of the Newly-born Infant. 1859.  Also
Troeltsch, Lehrbuch d. Ohrenheilk, Leipzig, 1873. pp. 22 and 23. 
DEVELOPMENT OF  THE MIND.
703
 complete at birth;  they are governed  by a principle  which
 amounts to a  systematic  differentiation  of the  central fibre-
 masses (Flechsig ').   Those fibres which subordinate the spinal
 cord to the volitional centres are the last to be developed.  More-
 over, they attain a higher grade of development in man than in
 any  other  animal.   The fibre-systems concerned in voluntary
 movement are the key-stone of the fibre-structure in the medulla
 oblongata and spinal cord (Flechsig).
    Soltmann has shown that the results of physiological experi-
 ment are in harmony with these anatomical facts.   In the newly-
 born puppy about ten  days have to  elapse before the  electric
 excitability of  the cortex  cerebri (or, more correctly, of the
 medullary fibres that issue  from it) is developed,  while that of
 the internal capsule is present from the first.
   The mind, accordingly, begins its work with sensory activity,
 and its earliest (purely reflex) motor acts are definitely prescribed
 to it by the inborn anatomical and physiological  interconnection
 of the ganglionic cell-networks in the peripheral, bulbo-spinal,
 and basal centres.  Shortly after birth, the waves of stimulation,
 ever extending in wider  circles, rise as high as the brain.   Per-
 ceptions and judgments  are continually added in growing abun-
 dance and  increasing differentiation.   True, movements still
 follow stimuli with automatic precision; but they are susceptible
 of purposeful modifications in form under the controlling influ-
 ence of images composed of sensory impressions, and  by virtue
 of assured judgment.  The cortex cerebri begins to share in the
 excitement  of the lower centres ;  its  vibrations, gentle at first,
 increase progressively in  amplitude ; the instinctive mind becomes
 intelligent, fulfilling  movements with  intention, and controlling
 the reflex activity of the infra-cortical centres; in other words,
it becomes endowed with will.  Combinations, at first  few and
simple, but increasing in number and complexity, become associ-
ated in the vast cell-networks of the cortex.  Bain has calculated
with much ingenuity, that the number of combinations  rendered
possible by  the wealth of the cortex in cells capable of  receiving
impressions and in connecting  fibres, is  sufficient for  the total
Die Leitungsbahnen im Grehirn und Ruckenmark des Menschen. Leipzig, 1876, 
 704        KUSSMAUL.—DISTURBANCES OF SPEECH.

 number of states of consciousness existing in the most powerful
 memory and  the most highly-gifted intellect.   There is room
 enough in the physiological  seat of the intelligence for all  the
 impressions derived from the world  of sense; there  is  room
 enough for the whole motor key-board of the human will.  The
 problem of constructing a laboratory of  intelligence, and of will
 determined by intelligent motives, out of organic matter, is thus
 solved in marvellous fashion.  True, the marvel does not begin
 here; it begins at the point where the state of  excitement induced
 by stimulation in a material nerve is converted  into an imma-
 terial sensation.
    According to the description I have just given, sensation con-
 stitutes  the elementary psychical function of the  nervous sys-
 tem.  Its specific energies are determined, first, by  the nature of
 the peripheral sense-organs with which the nervous  apparatus is
 connected ; secondly, by the connections formed by the conduct-
 ing fibres in the central ganglia; just as motor acts are deter-
 mined, on the one hand,  by the muscles and  limbs  to which the
 motor fibres are distributed ; on the other, by the central con-
 nections of those fibres.  Perceptions and states of consciousness
 are not elementary, but compound processes,  originating in sen-
 sations and  movements; and even in  personal consciousness
 (consciousness of the Ego) we can see nothing  more than a higher
 synthetic unity of psychical phenomena.
   By adopting these fundamental principles, we are enabled to
 understand many of the marvels of language and to subordinate
 them to the laws  of organic being.  We are no longer puzzled
 by the origin  of language without consciousness or intention,
 though it is employed with both.  We can perceive  how it  arose
 out of interjection and mimicry; how a language, symbolizing
 conceptions and regulated  by  will, grew out of  meaningless
 sounds resulting from sensori-motor and percepto-motor reflex
 acts,  and gradually assuming an  articulate habit.  We can
 grasp the  distinction between  the  mental and the mechanical
 conditions of speech, and their indissoluble connection with each
 other,  Recognizing the  fact that sensory and motor elements
 are connected  together  by reflex  channels  in the  ganglionic
centres, up to and including the cortex, we are able to dispense 
              FUNCTIONS OF THE CEREBRAL  CORTEX.          705

with  the need, obligatory  on  Jaccoud  and  others,  of localizing
unquestionably reflex phenomena, associated with cerebral disor-
ders of speech, in the infra-cortical ganglia, merely because they
are evidently reflex.   Conversely,  we shall  not  expect  that
liberation of the nerves and muscles  subservient  to  speech from
the  control  of the  will must entail an outbreak of  unbridled
reflex actions on  the  part of the tongue,  lips, etc.   Inhibitory
mechanisms are  abundantly  present both  in and  below the
cortex, though we  are still very ignorant of the distribution  of
the inhibitory and accelerating energies in the various regions  of
the brain.1
                         CHAPTER  XXI.

Concerning the Functions of the Cortex of the Cerebrum, and their Localization in
    General.—The Theory of Flourens as to the Functional Equality of the Differ-
    ent Parts of the Cerebrum, and the Law of Substitution  in Contrast to Hitzig's
    Theory of the Functional Difference of the Cortical Convolutions.—Deductions
    from Veyssiere's Discovery touching the Functional Difference of the Anterior
    and Posterior Cortical Tracts.—The Will as a Sensory Motor Process, and the
    Act of the Will as a Realized and a  Suppressed Movement.—Concerning the
    Ganglionic Formation of the Key-board of the Will.—Is it at once a Motor-
    centre and Centre of Co-ordination, or only the  latter ?—The Ways of  Solving
    this Vexed Question : by Anatomy, by Comparative Anatomy, by Experiment,
    and by Clinical  Observation.—Experiments by Irritation.—Experiments  by
    Mutilation, and the consequent Temporary and Permanent  Disturbances of
    Function.—Explanation  of the Restoration  of  Functions.—Character of the
    Permanent Derangements of Sensation and Motion  after Mutilation of the
    Cortex.—The Convolutions contain Sensory as well as Motor Apparatuses.

    The experience, that sometimes serious losses of the substance
of the cortex are not followed  by permanent disturbances, is the
basis of Flourens'' theory:  that all parts of the cerebrum are
capable of the same functions, and that each can vicariously

   1 Concerning reflex action as the general  principle of all  movements depending on
the nervous system, see Griesinger.  Ueber psychische Reflexactionen.  Archiv.  fiir phy-
siol. Heilk.  1843.— Laycock. On the Reflex Actions of the Brain. Brit, and  For. Med.
Review. January, 1845, and July, 1855.—Ilughlings Jackson. Clinical and Physiological
Researches on the Nervous System.  Reprinted from the Lancet, 1875.  London, 1875.
           VOL. XIV—45 
 706         KUSSMAUL.—DISTURBANCES OF SPEECH.

 perform the functions of every other.   The power of portions of
 the brain to act for other portions Yulpian calls " Loi de Sup-
 pleance." We have learned in Chapter XIX. that the radiation
 of  the  pes  cruris  cerebri upward into the corona  radiata is
 divided  into  sensory and motor districts.    Nothing  in this
 justifies  us  in the assumption that the sensory tracts of  the
 capsula interna can exercise the functions of the motor, or, vice
 versa, the motor those of the sensor}'; or that the  ganglionic
 stations, wliicli are situated upon the centripetal track, have the
 power to forward despatches in  a centrifugal direction, or, vice
 versa, stations upon the centrifugal track centripetal despatches.
 Thus the law of substitution undergoes much limitation, and
 this alone can be granted, viz., that in  the  infracortical cerebral
 regions  sensory  elements  can act for  sensory, and  motor  for
 motor, and  this  only  "in so far as tliey find themselves con-
 nected in a suitable manner" (Wundt).  For, in fact, it is always
 the connections  of the  nerve-elements which  determine  the
 nature of their functions.   This  is the chief basis of  the local-
 ization of the cerebral functions, as of the central functions of
 the nervous system in  general.
   It may now be asked whether Flourens'  theory is  not per-
 haps  correct for at least those parts situated within  the limits
 of  the  cerebral  cortex,  within which,  indeed,  centripetal and
 centrifugal fibres for all the provinces of  the  body are closely
 interlaced.    The effort  has been made of  late, by means  of
 experiments,  to  gain  complete control also  over this limited,
 though yet rather extended field.   To have accomplished this is
 the merit of  Hitzig, whose investigations  led  to new and sur-
 prising  conclusions, and incited to a  great number of fruitful
 researches.  Hitzig arrived at a theory the exact opposite of that
 of Flourens,  viz., that the cortex is divided into locally distinct
 sensory and motor tracts.  In the anteriorly situated tracts are
found circumscribed motor-centres for  the different members  of
 the body, as  e. g., for the fore and  hind  limbs, the jaws and
 tongue,  etc.    Only within these regions and  centres  does he
 regard it possible for the  different nervous elements  to  act  for
 each other.   We cannot enter upon all the details of the lively
 contention for and against these views, which Hitzig  himself at 
             FUNCTIONS  OF THE CEREBRAL  CORTEX.         707

last was compelled to modify ; nor can we mention all the inter-
pretations which the new discoveries  received; but  we must
content ourselves with laying stress upon  the substantial gain,
which in our opinion comes out of it  all for the localization of
the functions of  the cortex, in order to make this available for
the localization of the cortical functions of speech.
   The well-established fact that  the centripetal  paths of the
pes cruris are directed towards the posterior regions of the cere-
bral cortex, and  the centrifugal towards the anterior,  makes it
immediately improbable that the different portions of the cere-
bral cortex exercise similar  functions everywhere.  It forces us
rather to the following assumptions :
   a.  The sensory impressions, which are carried through the
pes cruris to the posterior  regions of the cortex, experience at
the point where they first enter these parts their earliest corti-
cal modification (Yerarbeitung).   They scarcely undergo their
entire cortical elaboration here,  however,  but  most  probably
still pass through  numerous stations, which possibly extend as
far as the  anterior regions of the  cortex.  One  should also not
forget that it is highly improbable that sensory excitations reach
the cerebral  cortex only by the paths which traverse  the  pes
cruris.  The  cortex is also in communication with the thalamus
opticus, which is exclusively, or at  least  chiefly,  of a sensory
nature.  This organ is united to the entire length of the hemi-
sphere by an expanded layer  of  fibres, witliout  our  knowing
even  at the  present day in which regions of the cortex these
bundles of fibres are finally distributed.
   b.  The  complicated process  of cortical  excitation, which we
call will, sends  out its motor impulses through the anterior
regions of the cortex, in which the final cortical elaboration of
the proposed movements is accomplished.
   As a  matter of  course, we do not  mean by this that the will
resides in the frontal cortex, or that this latter  has only motor
functions.    What we  call the will is not only a  motor,  but
always likewise a sensory process.   According to the theory of
reflex action, it expends its efforts first in those sensory districts
where the  impressions from  the senses are raised to the level of
conceptions of the conscious Ego.   The  processes  of cortical 
708         KUSSMAUL.—DISTURBANCES OF  SPEECH.

excitation which we call Reflection (Ueberlegung) here first attain
to the height of a decision or purpose (Entschluss), and then,
endowed with the necessary energy, pass  over  into the  motor
districts of the will.
   This passing over is not, however, to be regarded as a simple
transmission, in the sense  that the  act of the  will—in writing
and  speaking—is  only the translation of  thoughts and  of the
images bound up with thoughts—e. g., of the optical or acoustic
word-images denoting thoughts—into a more or less considerable
quantity of complicated motor aggregations.   Each act  of the
id ill is  always likewise the realization  of a  movement-image
previously sketched out in the recollection, or of an entire  chain
of such movement-images, which are strung together in part
automatically and unconsciously, in part  with design and con-
sciously.   Hence,  the  motor part of an act of  the will is also
united with sensory processes.
   The  question here presents itself, how are we to represent to
ourselves that  ganglionic mechanism which we will figuratively,
but without wishing to convey a  false impression, designate as
the cortical key-board, of the will,  and which has been  styled
at one time '' motor centres of the cortex,''  at another,  '' cortical
motor centres  of co-ordination."   It is still a mooted  question,
whether this  key-board  is to  be regarded  really as  a  motor
centre, or whether it only excites infracortical motor apparatuses
to movement  through sensory channels, since it determines,  by
means  of  previously  registered  images, merely  the  character
of the  movement, in accordance  with the  purposes of the con-
scious intelligence, thus playing only the part of a centre of co-
ordination.
   There can be no doubt that sources of force circulate  in the
cortex,  from which a current develops itself which passes  centri-
petally through the fibres of the pes cruris of  the frontal lobe,
with sufficient power to set in motion the wheels of  the corpora
striata, medulla oblongata, and  spinal cord; in  this  sense the
cortex  has motor power and is  a motor centre.   It is also well
established, that apparatuses exist in the cortex by  means  of
which at the very outset the current is guided to its proper infra-
cortical distribution, as to place and time, and in  this sense  the 
            FUNCTIONS OF  THE CEREBRAL  CORTEX.         709

cortex is  a centre  of co-ordination.   Finally, there is also no
doubt  that these apparatuses for regulating the details of motor
distribution are likewise the same which generate the previously
registered movement-images,  and hence  the motor will-centres
represent likewise sensory apparatuses.  The entire dispute, to
state it briefly, revolves around this one  point—Can the cortex
rightly be  considered as  a motor centre also upon anatomical
grounds ?  Is it provided with any apparatus—such, for exam-
ple, as the so-called motor cells, that are  found in the more
deeply situated motor centres—not only for regulating the infra-
cortical machinery, for  hastening, retarding, or  stopping  its
action, and for attaining  this or that form  of motion, but also
for the generation of living, active force %
   The solution of this question is beset  with no slight  diffi-
culties, because it  is impossible  in the cortex to  distinguish
exactly between centripetal and centrifugal channels.   Hence, it
is not permissible to venture straightway upon conclusions as to
the sensory or motor character of  collections of ganglia drawn
from their situation upon the one or the other track, as one  can
in the spinal  cord, the medulla oblongata, and even higher up
in the cerebrum.   In the cortex, which represents  the  upper-
most termination and point  of rendezvous of the nervous system,
all tracks unite in an endlessly intertwisted tissue of numberless
plexuses of ganglia, and the determination  of the  directions
which  they pursue is perhaps an impossibility.
   We can pursue various methods to determine whether motor
cells  and  apparatuses exist within the cortex,  which fulfill
analogous functions  to those  of the infracortical  motor nerve-
cells and apparatuses.
   Firstly, anatomy may succeed in finding in the cortex,  and
especially in those portions  of the cortex through which the will
sends forth its motor impulses, nerve-cells similarly constructed
to those which are found in the more deeply situated ganglia of
unmistakably motor character.
   Secondly, comparative anatomy should  bestir  itself  to  find
eut whether the  development of certain  regions of the cortex,
and especially of the anterior, stands in  a fixed relation to the
motor  capacities of vertebrates. 
710         KUSSMAUL.—DISTURBANCES OF SPEECH.

   Thirdly, we must determine  by means of experiment and
clinical observation, (a) whether the irritation of certain portions
of the cortex is followed by movements which do not take place
after irritation of other portions of the cortex and brain; and (b)
whether the absence of certain portions of the cortex is followed
by derangements of motion, which can only be explained by the
lack of a motor-impelling power.
   We shall presently  learn  what researches  in  this  direction
have yielded up to the present time, and will now draw attention
to two points only : (1) If it be found from these researches that,
as was already rendered probable by previous  considerations,
sensory functions are consummated  everywhere in the cortex,
it  is not  thereby proved that the cortex may not likewise be
provided here and there, and especially at the points of emission
of the  impulses of the will, with especial motor apparatuses.  It
seems to us that  no important consideration stands in the way
of the hypothesis, that in those layers of the cortex which emit
impulses,  both  motor and  sensory ganglion-cells may exist and
may be connected by communicating fibres.   (2) Moreover, we
will not forget that each act of the will is not only positive, but
also  suppressed motion.   The excitations of  the cortex which
culminate in an act of the will not only advance downward along
the channels of the pes cruris as an impulse, but also in paths
still unknown,  acting as a check.  It is perhaps  by the tracks
of the tegmentum cruris  that these inhibitory  currents  pass
downward.

   The following, then, are the most important  results of our
latest researches into the localization of sensory and motor func-
tions in the cerebral cortex :
   1. Anatomy.—According to Betz,1 the surface of the cerebrum
is divided by the fissure of Rolando into two halves—an anterior,
in which  large pyramid-cells, and a  posterior, in  which layers
of nuclei prevail, so that an analogy makes itself manifest with
the anterior motor and  posterior sensory tracts of  the gray cen-
  1 Betz in Kiew, Anatom. Nachweis zweier Gehirncentren. Centralblatt fiir die med.
Wissensch. 1874. S. 578. 
             ANATOMY OF THE CEREBRAL CORTEX.          711

tral  substance  of the spinal  cord.   The anterior edge of the
lobulus quadratus (prsecuneus) marks the border of the division
on the median surface, as do the fissures of Rolando and Sylvius
on the outer surface.
   Betz, moreover, discovered still within  the anterior  region,
precisely in situations corresponding  to  Hitzig's motor centres,1
in the fourth layer of the cortex, extraordinarily large  pyramid-
cells lying together in heaps, which he  styles giant pyramids
(Riesenpyramiden) ; these present themselves nowhere  else, and
do not reach their full development till after birth.
   2.  Comparative  anatomy.—According to von  Gudden,2 the
frontal brain is much more strongly developed in the four-footed
perpetuum mobile, the squirrel, than in its  near relative, the
quiet rabbit.
   3.  Experiments by excitation.—a.  Numerous experiments
first undertaken by Fritsch and Hitzig, and  confirmed by others,
establish the fact that it  is possible in animals to set in motion
specified groups  of  the  muscles of the  body by  galvanic and
faradic  excitation of  specified portions of the frontal  region of
the cerebral surface—for example, the anterior central convolu-
tion, especially in the case of monkeys.  The weaker  the current
one uses, the  more circumscribed seem to be these excitable dis-
tricts ; with strong, widely diffused currents, movements can be
obtained from  neighboring  districts  lying behind the  frontal
region (Ferrier).   It is not to be supposed, indeed, that the cortex
itself is  susceptible to electricity (Schiff, Eckhard, Hermann, et
ah); it is only the medullary  fibres having their origin in the
cortex which are  irritated.  Eckhard succeeded  in  tracing, by
making a series of horizontal slices, a bundle of these  excitable
medullary fibres (for the anterior extremity) as far as the corpus
striatum.  It is, however, thereby rendered very probable that
excitations of the cortex find their way from specified  points of

  1 In man, in the anterior central convolution, and in an especial lobe first named by
him, on the median surface,  exactly in front of the fissure of Rolando, the  lobulus
paracentralis.  In the dog the giant pyramids lie  in the lobe in front of the sulcus
cruciatus, which he regards as identical with the anterior  central convolution  in man
and the ape, whilst the central convolutions are said to be wanting in the dog.
  * Correspondenzblatt f. Schweiz. Aerzte.  1872. No. 4. 
712          KUSSMAUL.—DISTURBANCES OF SPEECH.

the frontal region through specified  bundles of fibres to specified
groups of'muscles.1
   b. After the discontinuance of  the electrical  irritation of the
so-called motor cortical districts,  the movements  first obtained
repeat themselves everywhere, or  only at certain points, as sec-
ondary  movements,  which sometimes result in  an epileptiform
spasm of  the entire muscular system of the body (Fritsch and
Hitzig).   Eckhard's  statement," that it is never possible to evoke
such spasms from the posterior surface of the brain, seems to us of
great importance, although requiring still  further confirmation.
This observation  reminds  one of  "cortical epilepsy"  in man.
Circumscribed irritation of the brain cortex,  by tumors, cysti-
cerci,  inflammatory  processes,  etc.,  calls  forth at  first partial
muscular  spasms of this or that region of the  body, which may
gradually increase to general epileptic attacks with unconscious-
ness.3   It is still to be settled more exactly, what are the portions
of the cortex in man which, when  subjected to limited irritation,
give  rise  to  spasms,  and whether  especial  partial forms  are
attached to especial localities.
   4. Experiments  by  mutilation.—Mutilation  of the cerebral
cortex in the  rabbit, cat, and dog,  produces disturbances in sen-
sation and motion, whether procured by amputation, by  circum-
scribed  cauterization—by  the admirable method  of Nothnagel
   1 According to Bochefontaine (Gaz. med. de Paris, 1875. No. 52), the electrical irri-
tation of the centres of Hitzig results also in increased secretion  of the submaxillary
salivary glands, contraction of the intestines, the bladder, the spleen, expansion of the
pupils, etc.
   2 Zeitschrift fiir Psychiatrie. Bd. 31. Verhandlung des siidwestdeutschen Vereins
am 2. und 3. Mai, 1874 zu Heppenheim.
   ' Ever since 1861 Hughlings Jackson has frequently, and with emphasis, called atten-
tion to the different forms of " unilateral and bilateral discharging cramps," as he calls
them.  I have  myself lately observed two such cases, in which at first circumscribed
twitchings of the opposite side, and later universal convulsions,  accompanied  in the
latter case by unconsciousness, were contemporaneous with cortical lesions; there were
likewise paralyses of  the opposite side.  In the one case there was a tumor upon the
right, parietal lobe ; in the other case there was a traumatic hemorrhagic softening of
the left third  frontal  convolution, together with softening  of  the temporal lobe.  In
this case there were also present aphasia and hemiansesthesia of the opposite side as far
upward as the neck.
   Bernhard, Samt, Remak, and Gliky, have published similar observations lately. 
THE  LAW OF SUBSTITUTION.
713
in the latter case, or by washing out, by means of  a  stream of
water introduced through holes made by the trepan, the protrud-
ing portions of brain-substance, according to Goltz's method.
   These disturbances are partly of  short duration, in part they
last for months—whether for the lifetime is still to be established.
These latter we will call permanent, under the  supposition that
they never entirely  disappear.  If this supposition be correct,
we must attribute these disturbances to the removal of a func-
tion absolutely confined to the portion of the brain taken away.
   As regards the temporary removal of brain-functions after
mutilation of the cortex (or more properly, indeed, in the experi-
ments of  Goltz, of one of the hemispheres  [Hirnmantel] deep
down in the  white substance), this  condition can be explained
partly,  though not entirely, by  the law of substitution.  The
substitution is possibly a double one: (1) for the portion of the
cortex destroyed, another portion in the same or in the opposite
hemisphere acts vicariously, this new portion having been already
trained  to perform the other's functions, or acquiring the neces-
sary degree of training after the  injury.   One is rather  disposed
to consider the possibility of substitution through parts of  the
same hemisphere  in  cases of slight  destruction, and through
parts of the opposite hemisphere in very extensive ones.   (2) The
conducting channels  are  so  constructed that  the excitation of
separated portions can be accomplished through by-ways (anas-
tomoses between fibres and  commissures), so soon as  the  new
path has been sufficiently travelled.
   The hypothesis of  the substitution of one hemisphere for the
other does not suffice  for all functions, as Goltz, for instance,  has
proved.1  Were  this hypothesis true, a symmetrical injury upon
the hitherto undisturbed half of the brain would evoke bilateral
derangements, when a mutilation had previously been consum-
mated  upon  the first half  and the derangements  had  subse-
quently been obviated by substitution.  But this does not occur.
Goltz mutilated the right half of the  cerebrum  in two dogs who
had recovered from a mutilation of the left cerebrum.  Both dogs
limped with the left fore foot, revolved towards the right, and fell
1 Arch. f. Physiol. 1876. Bd. 13. S. 1. 
714          KUSSMAUL.—DISTURBANCES  OF SPEECH.

gently upon the left side, whilst after the first operation all these
symptoms appeared upon the opposite side.   AVe must therefore
return to the relative autonomy of the  infracortical nerve-prov-
inces, in opposition to the cortex which governs them and binds
them together as a unit  from above.  One can conceive that  the
functions of the infracortical organs are in  some way temporarily
interfered with by  the ablation of parts of  the cortex, and that it
is not at all, or at least not solely, a question of a loss of  cortical
functions; the infracortical provinces resume their activity so soon
as the inhibiting power diminishes and finally vanishes (Goltz).
   In respect to the disturbances of sensation, which arise after
mutilation  of  the  cortex of the brain,  these have  been  investi-
gated with great  exactitude upon dogs by Goltz.  They occur
both as derangements in touch and  in the susceptibility  to pain
of the skin and  as derangements of vision, and  according to
Goltz it is all one whether the excitable zone  of  Hitzig or  the
posterior regions have been injured ;  the degree of derangement,
however, corresponds to the extent of the loss of substance.  The
same also is said  to  be  true of disturbances of  motion, which
manifested themselves after extensive mutilations  of  the poste-
rior as well as of the anterior regions.1
   The  anaesthesia of the skin  is lasting,  although  it  can be
proved later only by means  of the more delicate tests.   The same
is  true  for  sight.   In the beginning, dogs,  after a  considerable
mutilation of one hemisphere, are  always  blind of the eye of  the
other side ; but the sight returns gradually to this eye, and there
remain behind only some very remarkable  disturbances of vision,
which can be demonstrated only with delicate tests.   If  we con-
fine  those animals from which a large  portion of the surface of
a hemisphere has been removed, it matters not whether  from in
   1 Very diverse from these  are the statements of Ferrier (Arch. gen. de med. 1875. p.
503), which he made in the Transactions of the British Med. Association at Edinburgh,
1875, as to the results of his  experiments on mutilation in monkeys.   He distinguishes
between motor and sensory cortical centres.  The convolutions bordering on  the fissure
of  Sylvius are, according to  him, the seat of lesions in paralyses of the opposite side.
The destruction of the frontal regions is without effect upon the movements  guided by
the will, but it affects  the  intelligence ; that  of  the under part of the  temporo-
sphenoidal  lobe destroys taste ;  that of the occipital lobes produces a condition of
depression accompanied  by refusal of nourishment (!). 
THE  LAW  OF SUBSTITUTION.
715
front or from behind,  to the use of the eye upon the side oppo-
site  to  the injured hemisphere, the other eye having been de-
stroyed, they are still able to avoid obstacles  in their path, but
they seem to have lost the perception of depth: they walk over
the side of a table ; they no  longer recognize  their food, except
by smell, and  they are no  longer frightened by  the sight of
tilings ordinarily causing fear.  These derangements cannot be
explained by a loss of intelligence, which still exists to a suffi-
cient extent.
   Lussana and  Lemoigne,  who  observed the same thing in
mutilated pigeons, explained it thus : that after removal of the
left eye and cerebrum the still  remaining right eye is no longer
in correspondence with the still remaining right half of the cere-
brum.   The animal can no longer, therefore, as they maintain,
experience dread at the appearance of threatening forms.  On
the  other hand, they hold that the connection between the right
eye  and the uninjured mesencephalon and cerebellum remains
undisturbed, and  the central  organs  of  locomotion,  which lie
behind  the cerebrum, are uninjured, and are properly controlled
by the  impressions which they receive through the uninjured
eye.  This explanation seems to be as simple as  it is correct
in the case of pigeons; but for dogs,  Goltz regards it as insuf-
ficient,  since in these each hemisphere "seems" to be  in con-
nection  with each  eye.   He  therefore attributes  the disturb-
ances to a loss of the sense of  color and  of place.   From these
experiments it seems to us that the following conclusion may be
drawn:  that in dogs the images which are formed in the sub-
cortical regions of the brain, from the impressions made upon
one retina, unite with the representations corresponding to them
in the half of the cerebrum  on the side opposite to this retina,
and thus arrive  at conscious  perception.  The comprehension
of the images is a function of the cerebral cortex.
   As for the derangements of motion after  mutilation of the
cerebral cortex, these are explicable for the most  part by defi-
cient co-ordination consequent upon diminished sensation. After
inconsiderable losses of substance, one only observes transitory
ataxic disturbances.  After more extensive  injuries,  however,
there come next paralyses of the opposite side, which soon yield 
716         KUSSMAUL.—DISTURBANCES OF  SPEECH.

to symptoms of paretic weakness and ataxia (the back of the foot,
e. g., touches the floor, instead of the ball  of the toes),  and to
circus movements (Reitbewegungen).  Finally, there remains only
an  entire or partial loss of the ability to  use the fore paw for
purposes  similar to those for which man  uses the hand, as in
"giving the paw,"  scratching  the  head,  taking possession of
bones, etc.  From this one sees that the automatic or  machine-
like movements,  such as running, are restored ; that the move-
ments acquired by intelligence, however, are permanently lost,
or are performed with greater difficulty.
   We do not find that the results of these experiments disprove
the presence of motor-cells in the cortex, a thing rendered very
probable by the anatomical researches of Betz ; on the other hand,
they  also fail to prove their existence in this region.   While we
have  learned to regard the cortex as an organ which begets in
dogs a certain class of movements, namely those connected  with
the intelligence, it is still a priori probable, from analogy, that to
it belong  also  those special anatomical apparatuses which are
present in all  other motor  centres,  and which,  as is supposed,
in the form of so-called motor cells, serve to  change latent elastic
forces (Spannkraefte)  into actual  mechanical power, producing
the contraction of muscles and the revising of weights.  Still the
ganglionic arrangement of the cortex exhibits much that is pecu-
liar in contrast to other centres ;  motor cell  groups occupying
entire  convolutions, and corresponding in any  degree  to the
motor nuclei of the  oblongata and the gray anterior columns of
the spinal cord, do not exist in the cortex ; in this sense there are
no purely motor convolutions.   Upon the one hand, the chief y
motor convolutions or centres of Hitzig seem to interpose in
sensory processes, whilst on the other a portion of actual power,
which, in the form of will, turns the motor  wheels, probably
springs from the sensory districts of the cortex.
   It has been very properly pointed out that the derangements
of motion, after ablation of the cerebral cortex in animals, call to
mind the  ataxias and paralyses  which are  observed in the  pro-
gressive paralysis from  cortical atrophy in man.  Meynert has
also repeatedly laid stress upon  the fact  that, after paralytic
insanity with delirium, atrophy of the frontal  lobes is the chief 
                CORTICAL FUNCTIONS  OF SPEECH.            717

lesion.  It has, moreover, been long known that extensive lesions
of the cerebral  cortex result in paralyses  of the  opposite side,
sometimes of a temporary, sometimes of a permanent character,
and it seems that it is rather rapidly developed lesions, as, e. g.,
necrotic and hemorrhagic softenings of the  posterior frontal and
anterior central  convolutions,  which  produce such  paralyses.
This is, however,  all which up to the present moment we  are  at
liberty to affirm in regard to the localization of the cortical func-
tions in  man, and with  the manifold difficulties and sources  of
error which  here  come into play, it is impossible as yet to postu-
late anything more definite as to the functional capacities of indi-
vidual cortical regions.1   So far, the greatest advances have been
made  towards  an understanding of  the  relations  in which the
function of  speech  stands towards  the divisions of the cortex,
and upon  the  consideration of  this we  will  now enter more
closely.


                       CHAPTER  XXII.

The Guiding Principles for the Localization  of the Cortical Functions of Speech,
    and the Nature of these Functions.—Experiments touching the Cortical Centre
    of Movements of the Mouth.—Clinical Difficulties in the Localization of the
    Functions of Speech in the Cortex.—Necessity of the Law of Substitution for
    the Explanation of Clinical Experiences as to the Results of Circumscribed
    Removal of Cortical Substance.
    Now that we enter upon the much discussed problem  of the
localization of the cortical functions of speech, let us take for the
solution of this task the guiding principles from the results men-
tioned in the preceding chapter.
    Our previous  researches have shown what  are the  functions
of speech belonging to the cerebral cortex.   We found  that only
the apparatuses for  the mechanical  consummation and connec-
  1 Compare Samt, Concerning ataxic and paralytic derangements of motion in pro-
gressive paralysis. Arch. f. Psychiatrie. Bd. 5. S. 112. f.—Meynert, Vierteljahrsc.hr. f.
Psychiatrie. 1867. S. 166, und Arch. f. Psychiatrie.  Bd. 4. S. 417.—Bernhardt,  Arch.
fiir Psychiatrie.  Bd. 4. S. 698.—Samt, Zur Pathologie der Rinde. Ibidem. Bd. 5. S.
201. 
718        KUSSMAUL.—DISTURBANCES OF SPEECH.

tion of the movements of articulate phonation exist in the infra-
cortical regions of the brain ; that the formation of syllables and
words, however, as is required for the purposes of speech, takes
place in the cortex.   Articulation, in  so far as  it is an intellec-
tual task, must be regarded as a cortical function. The infracorti-
cal apparatuses for articulation simply accomplish the formation
and union  of sounds in that strength, rapidity, and sequence in
which the cortical sound-keys are struck. * We may further as-
sume that the perception of articulate sounds simply as phenom-
ena of noise,  or of text-characters as  simple optical phenomena,
takes place in the infracortical regions ; whether, however, their
recognition as acoustic or optical images of  this  or that character-
istic form  is completed underneath the cortex, is uncertain;  in
any case, though, their  comprehension, that is, their union  with
the necessary conceptions, their use as signs for the expression
of the thoughts, takes place in the cortex.   Here also take place
the processes of excitation, by means of which a word as  an
acoustic  or optical image  is  transferred in  its  sensory sound-
divisions to  the sound key-board  (Lautclaviatur),  where  the
word-text,  previously transposed into the note-text of remem-
bered movement-images,  is played off.  Finally, the  cortex is
the secret workshop of  the thoughts ; here the representations,
as they develop themselves out of the divers sensory and motor
operations  of the nervous system, are conceived, joined together
in logical  membership,  and  by  means  of especial associatory
processes translated into grammatically shaped and syntactically
constructed word-symbols, which then, through the key-board,
reach motor expression.
    It is almost superfluous to remark here again, that we must
count as a part of  the  cortical division, which has  to perform
these important services,  not only the  several layers of  gray
substance on the surface of  the  hemispheres,  but  also the  mas-
sive fibra? arcuatse in the white medullary substance of  the hemi-
spheres,  which,  as Meynert's  Association-System, unite together
the cortical convolutions  of  different regions.   The fibrous sys-
tem of the corpus callosum also, which unites the cortical convo-
lutions of both hemispheres, is to be  added to  this department.
    We will not enter with high soaring expectations upon  the 
CORTICAL  FUNCTIONS  OF SPEECH.
719
giant task of tracing up to this or that portion of the  cortex,
the different functions of  speech  of  the  cerebral cortex,  since
we have discovered how modest  is  the result which previous
scientific  investigation of  the  functions  of the cortex has .in
general attained in this direction.   AVe will especially turn away
with a  smile from all the naive attempts to locate a "seat of
speech" in this or that convolution of the brain.  It is a priori
probable that an  enormous association-tract  in the cortex has
been assigned to speech,  even though the  sound key-board may
be confined to the anterior cortical regions, through which the
impulses  of will have their outlet,  since it (speech) must be
bound up  with  the entire tract  of conscious  conceptions, and
this indeed stretches across the entire  cortical region.  Probably
the entire cortex takes  part in thought, although the individual
conceptions must  be realized through the  intervention  of differ-
ent plexuses of cells, according to the sensory  sources out of
which they are  formed.   We must not,  indeed, so regard this
localization as if one conception were bound up with one partic-
ular point, and  another with another, or as if one cell served
only for  this and  for no  other conception.  We may assume
that the functional connections, whose excitations are transposed
into  conceptions of this or that  class, extend over wide  regions.
Moreover,  the simplest abstraction is bound up with  numerous
intuitions,  movements, and  judgments of  the senses.   It is fur-
ther  very probable that the same cell  can  enter into very differ-
ent connections,  and aid in  the construction  of  different concep-
tions.   The  cortex, too, is  the very  organ in  which,  after an
injury  to  its substance, the endless interlacing of the channels
contained in it guarantees to the law of substitution  an exten-
sive,  though not unlimited application.
  For  all  those  who  do not hold the view  that words and
thoughts originate from  sources above and outside  the nerve
substance,  the localization of  the functions of speech in portions
of the  cortex follows as  a  necessary postulate  of logic ;  the
reason for this lying in  be fact that, after circumscribed injuries
of the  cortex, sometimes only the motor  word with  its image
of movement, sometimes  only the sensory word as a representa-
tion of articulate sound or of writing is wanting, and sometimes 
720         KUSSMAUL.—DISTURBANCES OF SPEECH.

only the connection between a word and its  conception is  inter-
rupted.  The motor-formation of words must reach completion
by other channels  than  those of the acoustic  and optical  word-
images, and these by still others than  those of conception.   But
so soon as  we attempt to designate more exactly these paths by
the aid of clinical experience, we are brought up against difficul-
ties which are too great for us.  We are speedily led to the con-
clusion that the  paths  of speech are so  intertwined with each
other and  with those of conception,  that we  cannot  succeed  in
disentangling them and marking down the  separate stations  of
the labyrinthine way.  The region of the key-board  of speech
only can be pretty exactly ascertained.
   Physiological experiment, as we might expect, leaves us here
in the lurch ; we  are thrown entirely upon clinical observation.
One solitary result of the experiments of Hitzig and Ferrier with
electrical irritation is of significance  for our problem.  These
investigators assure us that it is possible to evoke movements of
the mouth, tongue, and jaws in dogs and monkeys, by placing
the electrodes on the under part of the frontal lobe, at the point
where it borders on the fissure of  Sylvius.  In the more precise
designation of the place,  they differ somewhat from each other,
it  is  true.    Hitzig locates his  motor cortical  centre  for the
above-mentioned  muscular regions in the monkey in the lowest
part of the anterior  central convolution, whilst Ferrier places
the same close in front of this, in  a region corresponding rather
to the so-called tract  of Broca  in man.  Hitzig found, likewise,
that from this point he obtained not only unilateral movements
of the  regions of the  mouth on the opposite side, but also
bilateral.   It appears, therefore,  that the fibres  of  the cortex
leading to   the  muscles of the region of  the  mouth  proceed
from the designated cortical tract, and that the excitation of one
hemisphere suffices to throw into contraction  the muscles of the
mouth.  The results of  this experiment coincide with a fact,  to
which we shall recur more in detail farther on, viz., that  in man,
in the great majority of instances, it  is the lesions of the frontal
and insular region, and especially of the posterior portion of the
third frontal convolution bordering  on the lower part of the
fissure of Sylvius, the region of Broca, by which speech is much 
                  CORTICAL  FUNCTIONS OF SPEECH.               721

interfered with, and that  lesions of  one side alone suffice to pro-
duce such effects.

    The difficulties which stand  in the way of the localization of
the functions of  speech  in  the  cortex, by  the  aid  of  clinical
observation,  are of several kinds.
    1.  The  coarse anatomy of the  cortex  is a science  of  very
recent date.   All of the older observations are  scarcely available
as  regards anatomical points, and are generally very inexact.

    The  researches  of Gratiolet  (1854) first clearly established the relations as to
form of the surface of the human cerebrum, and made possible a more exact topo-
graphical  description of its lesions, as was first  carried into execution by  Broca
(1861).  The useful little monograph of Ecker1 makes it easy to-day for any one to
accurately designate the position and extent of cortical injuries.
    In order to understand how superficially localizations are recorded  even in the
writings of the best of the older observers, let one cast a glance at the principal
works of such men as Bouillaud, Lallemand, and Rostau, to whom, notwithstand-
ing, the pathology of the brain owes so much.  They are content to indicate the
affected lobe with the general designation,  " in front," " behind," " in  the middle,"
etc., and with an equally indefinite appreciation of the extent of the lesion.  One
seldom learns whether the  cortex or the white medulla, the corpus striatum, cen-
trum semiovale, etc., was  the seat of the  lesion.   Andral and Durand-Fardel are
indeed more exact, although they seldom reach our present  topographical require-
ments, and never in the cortex.   Even so great an anatomical authority as Cru-
veilhier gives an incorrect description of an injured brain, as a reference to his ac-
companying admirable plate shows (compare Chap. XXIIL).  Laborde'2 remarks,
in  a work published in  1866, that, according to  his belief, his predecessors had
overlooked the frequent simultaneous occurrence of points of softening in the cortex
and corpus striatum, only because in examining the brain they had made too hasty
and too few sections; but  his own specifications of  locality are equally unsatis-
factory.
    An anecdote which Broca3 relates is  very instructive.   One  day Duchenne
informed him that Trousseau had found the  region of Broca uninjured in a man
who suffered with aphasia.   Immediately Broca  repaired to the Hotel-Dieu, and
discovered that  Trousseau had overlooked a softening of this tract, which existed
near one of the parietal and island convolutions.   "When a man so  conscientious as
Trousseau allowed himself to be guilty of such an oversight, in the  midst  of the
dispute over Broca's hypothesis,  and after Broca had insisted with the utmost vigor

          1 Die Hirnwindungen des Menschen u. s. w. Braunschweig, 1869.
          2 Le ramollissement et la congestion du cerveau, etc.  Paris, 1866.
          3 Bulletin de la soc. d'anthropologie.  1863. p. 201.
            VOL. XIV.—46 
722          KUSSMAUL.—DISTURBANCES OF SPEECH.

upon the necessity for an exact determination  of locality, what are we -o expect
from the great mass of ordinary observers ?
   The records of cases which Bateman collected together from almost the entire
literature of educated countries, in his monograph " On Aphasia," published in
1869, shows in an astounding manner how badly the material bearing upon disturb-
ances of speech had been dealt with up to  that time, from an anatomical, and, un-
fortunately, also from a clinical point of view.

    2.  Just as little can critics profess  to be  content  with  the
description of derangements of speech by most of the older and
many  of the more  recent  observers.   If anywhere, then here
should obtain the  saying  of Morgagni,  that one  should  weigh
and not count cases.

   In the older observations, stammering and stuttering are not once distinguished
(compare Chap. XXXIV.).  Duchenne first sketched out a more exact delineation of
disturbances of  speech in bulbar  paralysis (1860).  A year later, 1861, Broca first
characterized aphasic disturbances of the cortex in two admirably described cases,
for which he proposed the term " Aphemia," which was  exchanged by Trousseau
for the now commonly used " Aphasia." ' Trousseau afterwards distinguished more
exactly between aphasia  and other  forms  of deranged speech.  Leyden, in 1867,
first contrasted aphasia with anarthria.  William Ogle, in the same year, made a
distinction between ataxic and amnesic aphasia. Steinthal (1871) separated the syn-
tactical derangements of  speech, under the name of akataphasia, from  these other
two forms of deranged word-formation.  How carelessly one  rushed at the diag-
nosis of aphasia, and that not long ago, appears from a remark of John Ogle," that
some one had  brought  a patient to him as aphasic who spoke  indistinctly on
account  of an absence of the tongue !

    3.  It is by no means always easy to carefully establish, accord-
ing to  symptoms, the  category of any given affection of speech,
and to ascertain always what form of dumbness one has  before
one, whether one of difficult and altered speech, or  of  impeded
comprehension of speech.

   What difficulties may we not have simply to establish whether a  man cannot or
will not speak ?   Why an individual does not attend to conversation  ?  Whether
he does not hear it or will not hear it ?  "Whether he does not understand the words
on account of weakened  intelligence, or on account of absence of mind, or because
he no longer recognizes the  word-images ?   Whether he mutilates the words,  and,

   1 According to the suggestion of  the learned Greek scholar, Krisaphis, made up of  d
privative, and <pd<ris, speech.
   - Lancet. 1868. March 21. 
                C0KTICAL  FUNCTIONS OF SPEECH.             72o
stammering, distorts the sounds on account of bad training, on account of con-
genital defective development or paralysis of the tongue, and the like ?  We have
already previously demonstrated how difficult it often is to be sure of the milder
forms of paresis of the tongue, lips, and palate ?

   4. Under such circumstances, one can readily appreciate how
little aid we shall derive, in our task,  from using the statistical
method.   Single observations can outweigh  whole  tables, partly
on account of their extreme exactness, and  partly on account of
their inherent force of demonstration.  This inherent worth is
shown by different factors.   The more sharply a  lesion is con-
fined to one spot, the more  quickly and completely  also  does
the structure  of  the affected spot become injured thereby ; the
healthier the  individual was previously, and the more sudden,
the more marked, the more lasting the subsequent derangement
of speech, with  just so much greater  certainty may we deduce
the disturbance  from the  lesion of the affected spot

   There are many persons, and  especially the debilitated and nervous, who require
but a slight disturbing force to render them speechless for a shorter,  and, indeed,
in some instances, for a longer time.   An excitement of the feelings, a moral shock,
a rush of blood to the head, a rapidly-developed ischamiia of the brain, such as
easily occur in affections of the heart and scleroses of the  arteries, suffice to bring
about in such people dysarthric, dysphasic, or dyslogic disturbances.  Should a cir-
cumscribed coarser lesion be present at the  same time  in such a case, one might
readily commit the error of ascribing to it the disturbance of  speech, although this
perhaps originated in the congestion or ischsemia of other parts.

   5.  Those factors  which establish the intrinsic value of a case
are met with,  in the different morbid processes wliicli lead to the
destruction  of portions  of the  cortex, in  very unequal ratio.
Referring to the previously mentioned  (p.  684) considerations on
this point, we will now only remark that by far the most valu-
able material  for  clinical  stud}' is afforded:  (1) by necrotic  soft-
ening,  especially as a  result of the closure  of small  terminal
arteries by embolism or thrombosis; (2) by injuries wliicli pene-
trate  only the substance of the cortex,  the direction and extent
of which can be  exactly determined.  These  latter are especially
adapted to  elucidate the immediate  consequences of a circum-
scribed interruption and irritation of the cortical tracks.   Points
of softening afford the best opportunity of ascertaining the more 
724         KUSSMAUL.—DISTURBANCES OF SPEECH.

permanent sequences of the removal of a portion of the cortex.
Hemorrhagic foci and abscesses stand in the  second rank.  For
reasons already stated, observations on tumors and scleroses of
the cortex are to be used with the greatest caution.

   6.  The symptoms which follow, either temporarily or perma-
nently, a lesion of the cortex are at times phenomena of stimula-
tion, at times those of paralysis.
   In regard to the phenomena of stimulation, we must not for-
get that they can be evoked by irradiation and reflex action from
distant organs,  with which the  portion  of  the cortex is con-
nected ; their local  interpretation is therefore  always difficult.
This is true, e. g., for the phenomenon of stuttering, which has
been observed, among other things, in the limited encephalitis of
the posterior districts of the cortex.   It does  not show that here,
posteriorly, motor districts were directly involved in the disease.
   If a function is only temporarily wanting,  in cases of paraly-
sis, we are  still not justified  in ascribing this function to the
injured or destroyed portion of the cortex, since its absence may
also possibly be explained as an inhibitory phenomenon due to
irritation, in the sense used by Goltz.   This comes into considera-
tion, namely, in cases of  injury to the brain and inflammatory
deposits ; less so in the necroses due to thrombosis.  The perma-
nent cutting off or disturbance of a function is, on the other hand,
to be referred with certainty to the portion of the cortex ab-
stracted.  If we see the same derangement of function, after
destruction of a portion of the cortex, result in one case as  a
temporary thing, in another  permanently, we may then assume
that this part is, indeed, entrusted in  some degree with the affect-
ed  function; that, however, an  accommodation could only be
brought about in the last, and not in the first case, by means of
substitution.  Without this  hypothesis it is incomprehensible
why lesions of one and the same  cortical division are  followed,
perhaps in three consecutive cases, by permanent disturbances of
function of the same nature, and then in four or five cases by
only  temporary ones.  Since  it is not possible to explain dys-
phasic disturbances by a resumption of the function of infracor
tical  organs, as is permissible for certain locomotor  functions, 
            LOCALIZATION OF THE POWER OF  SPEECH.        72.J

there remains  no other resource  for us but the supposition that
in these cases the vicarious activity takes place through preserved
portions of the  cortex,  either in districts of the same hemisphere
with  the requisite connections, or in symmetrical regions of the
other hemisphere.
   It was noticed even by Broca that the extent of the lesion of a
convolution stands  in no fixed relation to the extent of the con-
sequent aphasic disturbance.   AVe also  sometimes  see incon-
siderable mutilations of  a  certain tract injure a  given function
permanently, and, again, for only a short time.   The reason  of
this is still entirely obscure.  There are, perhaps, in every district
especially important  points  of union  of the cortical  paths  for
wliicli a substitute is more  difficult than for other points.   Great
individual differences also  exist in the  anatomical disposition  of
the  cortical paths,  as Flechsig proved for the paths in  the spinal
cord.
                       CHAPTER  XXIII.

Literature of the Localization of Speech.—Gall.—Bouillaud.—Marc Dax.—Broca.
   —Formularization of the Questions to be asked at this Point.—Does the Entire
   Destruction of the Two Anterior Lobes cause  Loss of Speech ?—Do Aphasic
   Disturbances originate only in Lesions of the Anterior Lobes, and especially of
   the Anterior Hemispheres proper?—Do Aphasic Derangements occur only, or
   even principally, in Lesions of the Left Cerebral Hemisphere ?—Do Lesions of
   the Left Anterior Lobe lead more frequently to Aphasic and Mingled Anarthric
   and Aphasic Disturbances than those of other  Portions of the Brain 1—What
   Region of the Left Anterior Lobe do we find oftenest Injured in Aphasic De-
   rangements ?—Does the unusually frequent Concurrence of such Derangements
   with a Lesion of the Left Island Region bear any Relation to the great Fre-
   quency of Left-sided Embolic Softenings ?—Is  the Third Frontal Convolution
   of Vital Importance for Speech ?—What is the Basis of the Pre-eminence of the
   Left over the Right Hemisphere  in Speech ?—Broca's Theory.—Causes of the
   Predominating Use of the Right Hand.—Can one distinguish, within the Cor-
   tical Region of Speech,  Centres  for the Motor Co-ordination of  Words and
   Acoustic "Word-Images ?

   The  literature  of  the  localization of speech is  associated
mainly  with  the names of   Gall, Bouillaud,  Marc  Dax,  and
Broca. 
726          KUSSMAUL.—DISTURBANCES OF SPEECH.

   Gall is the  proper father of  this  idea.   He distinguished
between "word-sense" and "speech-sense,"  and  referred these
capacities to the frontal lobes behind and above the orbits.
   His pupil, Bouillaud, deduced speech  from two  elementary
processes  connected with  the brain:  the formation  of the in-
ternal words as symbols of thought with the memory of words,
and the formation of, external words.  The latter,  he maintained,
is governed by an especial co-ordinating principle. This "prin-
cipe legislateur de la parole" he located in the  anterior lobes
of the brain, i. e., in  the divisions  of the cerebrum  over the
fissure of Sylvius and in front of that of Rolando.1
   Marc Dax recognized the strikingly frequent  concurrence of
derangements of speech with lesions of the  left  cerebral hemi-
sphere.
   Broca confirmed this, and referred the remarkable fact to the
same causes which make most men  right-handed,  viz., that they
preferably use the  left cerebral  hemisphere in the more delicate
tasks.  At the same time  he ascribed an  important role to the
third frontal convolution, and especially to the posterior third of
the  same, in the power  of articulate speech.   Most people—all
right-handed people, exercise only the left third frontal convolu-
tion in speech.

   Gall has  the great merit of having introduced the method  of  dissecting the
brain from  below upward, of having recognized the  continuous medullary strands
of the brain, and  of having traced them from the spinal cord below up to their
radiation in  the cerebral cortex.  This furnished, therefore, the  necessary anatomi-
cal foundation for the localization of brain-functions: the connection, namely, of
the ganglionic central masses of the brain, by means of isolated bands of fibres, on
the one side with the senses, and on the  other, with the movable members of the
body !2 The word-sense is, according to Gall, merely an especial memory for words,
which is independent of the intelligence, as the case of that child proves, who at
the age of five years learned by heart all  the fables of Lafontaine, and afterwards
still a whole volume of the " Cours de Mathematique " of Bezout.
   Different from this, according to Gall, is the speech-sense, the  philological talent,

   1 That is, not merely in the cortex! Trousseau reckons, among the deeper portions of
the brain, the anterior half  of the island and the corpus striatum as a part of the an-
terior lobe.
   2 Gait et Spurzheim, Anatomie et physiologie du syteme nerveux. Vol. I. -IV. Paris,
1810-1819. 
              LOCALIZATION  OF  THE  POWER OF  SPEECH.          727

the ability to investigate the genius of languages.   In the preface to his great
work he relates in detail how he was  struck, even as a school-boy, with the varying
mental  gifts of his fellow-scholars,  and especially with the concurrence of large
staring  eyes (goggle-eyes) with the ability to  commit  tilings to memory.  By this
observation he was conducted, as he  declares, to his  brain-studies—which form  an
epoch—and, unfortunately, also to his  great errors in phrenology and cranioscopy.
Goggle-eyes, he declared, indicate word-sense, " Schlappaugen "—that is, downward
projecting eyes (yeux pochetgs), speech-sense.
   Thomas Hood published in the Phrenological Transactions, Vol. III.,  of the year
1822, the  first case of aphasia more  carefully described and illustrated by an au-
topsy ;  there was a lesion of  the left frontal lobe.
   Bouillaud's doctrines have been presented in his well-known work upon  cerebral
inflammation,1 in  an especial treatise (1825),2 and in several very lively and often
hotly contested debates  before the Paris Academy of  Medicine.3  He  also made
experiments upon animals as to the functions of the cerebrum, in order to support
Iiis statements.4  He collected  gradually more than five hundred cases of his own
and  others, very few only of which, however, respond to critical demands.   Bouil-
laud properly distinguishes the movements  of  the tongue as an  instrument  of
speech from its movements for other  purposes of the will, and the speech paralysis
of the tongue from its other  forms  of paralysis.  Bouillaud  did  not  succeed  in
gaining the  assent of  a  Lallemand,  Andral, Cruveilhier, Trousseau,  and other
celebrated contemporaries,  to  the localization of his " principe legislateur de la
parole" in the frontal lobes.   The chief objection which was made to  it was that
the power of speech had been preserved after supposed total  destruction  of both
anterior lobes.  On that account Bouillaud offered a prize of 500 frcs. for whoever
should  authenticate such a case.   He never would  acknowledge that it had ever
been observed.
   Marc Dax, a physician of Sommieres (Gard), delivered (1836) to the  meeting of
physicians at Montpellier an essay, which,  in spite of  its surprising contents, long
remained unnoticed.5
    He  had, in every  case of  hemiplegia with implication of speech,  since 1800,
found the paralysis always on the right side  and the  cerebral lesion on the left;
if the lesion existed on the right side,  then  speech was not  affected.  He collected
a  quantity of observations from the  literature of the subject, which seemed to him
   *> Bouillaud, Traite de l'encephalite.  Paris, 1825. p. 157 seq.
   s Recherches cliniques propres a demontrer que  la perte de  la parole  correspond a
la lesion des lobules anterieurs du cerveau, et a contirmer l'opinion de Mr. Gall sur le
siege de l'organe du langage articule. Arch,  de Med.  1825.
   » Bulletin  de l'Acad. de Med. 1839. T. IV.  p.  282-328. Ibidem.  1848. T. XIII. p.
099-779. Ibidem. 1864-65.  T. XXX. p. 575 seq.
   * Magendie, Journ. de physiol. exper. et pathol. T. X. 1830. p. 36.
   ! M, Dax,  Lesions de la moitie gauche de l'encephale,  coincidant avec l'oubli  des
xignes de la pensee. 1836. Published in  the Gaz. Hebdom. 1865, Apr.  No.  17. 
728           KUSSMAUL.—DISTURBANCES  OF  SPEECH.

to establish the coincidence as a law.   This treatise first excited attention when G.
Dax, the son, laid  before the Academy in  1863 an essay,1 in which—referring to
his father's paper,  and to 140  cases, most of which  occurred in  the practice of
others—he postulated  the  constant concurrence of disturbances  of  speech  with
lesions of the left hemisphere.   The reporter Lelut disposed of the subject summa-
rily with a few contemptuously discouraging words, and declared  all attempts to
localize speech to be simply " Phrenology," which he had previously branded in
two brochures as a  " pseudo-science."
   This  gave Bouillaud  occasion to  enter the lists,  not for the support of the
exaggerated and therefore false statement  of  G. Dax, but for the localization of
the power of speech in general, which  led to one of the longest and most import-
ant discussions ever held upon this subject.
   Broca, previously an opponent of Bouillaud's localization of the  power of ar-
ticulate speech, came forward (1861 ■) with  a dogma which excited  universal atten-
tion, and which adopted the hypothesis of Bouillaud and marked its outlines more
precisely : "The integrity of the left third frontal convolution, and  perhaj>s also of
the second, is essential for the development of the power of articulate speech."  His
proposition was  supported by two cases, both carefully observed, and minutely
analyzed.
   In the next two years the Paris doctors, at  the autopsies of all aphasic persons,
to which Broca was invited,3 out of fifteen  cases found fourteen times  lesions caus-
ing destruction in the  posterior third of  the left third frontal convolution.   In all
these  cases the lesion was not confined  to this region; there were always still other
neighboring portions  simultaneously affected,  sometimes  these, sometimes those,
and in different degrees;  but  as to the one point in  question, they all  coincided.
They seemed, therefore, to render it necessary that we should regard  the posterior
third of the left third  frontal convolution, which has  since been  designated as the
region  of Broca, as the portion  of  this  convolution essential  to articulation.  Only
in one case (Charcot's4), Broca found nothing  in the left third frontal convolution
except an unimportant alteration in the form of a  fatty degeneration of the capil-
laries, whilst the left temporal lobe and the left island were extensively destroyed
by masses of softening.
   On top of  this came an observation of Parrot's,5 which seemed especially suited
to place in a clear light the great significance of the left third frontal convolution
contrasted with the right.  In the case  of a woman, afflicted since childhood with
   1 Observations tendant a prouver la coincidence constante des derangements de la
parole avec une lesion de rhemisphere gauche du cerveau. Bull, de l'acad. de med.
1864-65. T. XXX.  p. 17:1.
   2 Sur le siege de la faculte du  langage articule, avec deux observations d'aphemie
(perte de la parole). Bull, de la soc. anat. T. VI. Aoivt, 1861.
   3 Remarques sur le siege, le diagnostic, et  la nature  de  l'aphemie. Bull, de la soc.
anat. Juillet, 1863.
   4 Gaz. hebdom. 1863.  p. 473.                        5 Broca, 1. c. Juillet, 1863. 
            LOCALIZATION OF  THE POWER OF SPEECH.         729

a contraction of the left arm, whose speech was unchanged, the right third frontal
convolution with the island was found destroyed.
   Next,1 Broca proposed a hypothesis for the  explanation of this superiority of
the left  hemisphere;  he attributed it to  the predominating use of the right hand
by the majority of  people, and  on this  basis explained the cases in  which, with
congenital absence  of the left  third  frontal convolution, speech was still acquired.
Such a case, observed by Moreau (in Tours), was  communicated by himself.  A per-
son forty-seven years of age, from earliest childhood an epileptic, learned to speak,
to read, and to sew with the left hand, although the entire left first primitive con-
volution which  surrounds the  fissure of  Sylvius was wanting.  She knew how to
express her ideas very well.  This person was forced to exercise  the right cerebral
hemisphere in sewing and speaking, because the left was not available  therefor on
account of the absence of the first primitive convolution.  The ability  to learn to
speak is therefore,  according to Broca,  dependent upon the integrity of one at
least of  the third frontal convolutions.  Most  people exercise only the left third
frontal convolution for this purpose.

    The questions which  were debated by Bouillaud, Dax, and
Broca, we will now  strive to formulate separately and to answer.

    1.  Does the entire destruction of both anterior  lobes  entail
the loss of the power of speech, f
    The error of Bouillaud's views would be immediately proved,
did observations  exist in which  both  the anterior lobes2 have
been entirely destroyed  without loss of speech.  A well estab-
lished  case of this  kind would  be positive  proof that  speech is
not limited to the anterior lobes.   By such a case  Broca's the-
ory would likewise be   upset,   according to  which articulate
speech is only possible where at least one of the two third con-
volutions of the brain remains uninjured.
    So   far as we  have  succeeded  in  searching the literature,
there  is  no trustworthy  observation  where  one  has found with
unaffected speech a  total destruction  of both anterior  lobes, or
even only of  the collective cortical tracts in front of the  fissure of
Rolando and that of Sylvius.  Those  alleged cases  of this kind
which have been cited against Bouillaud by very well-recognized
   ' Du siege de la faculte du langage articule dans 1'hemisphere gauche du cerveau.
Bull, de la soc. d'anthropol. T. VI. 1865. Juin 15.
   2 We use this designation always in the sense of Bouillaud, according to Trousseau's
commentary. 
730         KUSSMAUL.—DISTURBANCES OF  SPEECH.

authorities, do not  bear criticism.  In this we must do justice
to Bouillaud.
   This is true, namely, of the often quoted case of Cruveilhier,1 which we consid-
ered in the last chapter.   An  idiot, twelve years of age, gave expression  to her
longings for food by clearly articulated words.  According  to the text describing
the case, both anterior lobes were entirely wanting;  according to the drawing, con-
siderable portions of both lobes were preserved, and especially the larger portion of
the left third frontal convolution.
   In order to draw out Bouillaud, Velpeau2  demanded the prize of 500  francs
for  a  case in which a lobulated cancer had professedly destroyed the anterior
lobes; in truth, however, it had left untouched the greater part of them, and espe-
cially  two-thirds of the left frontal lobe.  The subject, a hair-frizzier, sixty-six
years of age, had constantly indulged in obscenity up to the last days of his life.

    On the other hand, it distinctly appears from cases just  men-
tioned and from others since  published,  that sometimes  large
portions of one or both frontal lobes are damaged,  without  artic-
ulate  speech being  on  that account  destroyed.   Among all of
these  cases,  however, there is not one, so  far  as we  have  been
able to discover, in which the third frontal convolutions  on both
sides were wanting.  The cases of mutilation of both frontal  lobes
observed  up  to  the present  time  testify  distinctly, therefore,
neither  against  the  theory of  Bouillaud,  nor against that of
Broca.

   Bergmann 3 has communicated a new  and very remarkable  case of extensive
traumatic injury of both frontal  lobes without loss of speech;  still here also the
upper part of the left frontal lobe, together with the frontal convolutions  of the
right side, remained  intact.

    2.  Do  aphasic disturbances result only from  lesions of the
anterior lobes,  and especially of the parts  of the hemispheres
proper situated  in front of the fissure of Rolando and that of
Sylvius f
    To this the answer is to be decidedly given, that, as well in
temporary as  in permanent  aphasic disturbances, the  anterior
   1 Anatomie pathol. VIII. livr. pi. 6.
   '' Bull, de l'acad. de med. 1843. p. 862.
   s Virchow's Jahresber. fiir 1872. Bd. 2. S. 52.  The observation of Avonde is of a
similar nature, but it excites very little confidence.  (These de Paris, 1866.) 
           LOCALIZATION  OF THE  POWER OF SPEECH.        7ol

lobes have not seldom been found  intact and other regions of the
cerebrum destroyed.  For instance,  aphasia has been observed
in lesions of the island  lobe, of the parietal and temporal lobes,
or of several  of these at the  same  time.   We shall become
acquainted with examples enough of this nature.

   3. Do aphasic disturbances occur only, or even chiefly, with
lesions of the left cerebral hemisphere f
   We have previously seen that  anarthric disturbances of the
severest character proceed from the oblongata, the pons, and the
tract of the intra-hemispherical channels  of the will  (including
the corpora striata) ; nevertheless, as  regards  the latter, it has
been made plain that lesions of the left hemisphere interfere with
articulation much more seriously than do those  of the right.
   If one pays regard to the aphasic and mixed aphasic and
anarthric derangements with and without hemiplegia, equally
whether  they proceed from injuries of the cortex alone, or from
such as involve both this and the caudex cerebri, their strikingly
much greater frequency and permanency of occurrence in lesions
of the left hemisphere must be accepted as an  established fact.
Seguin,1  in New York,  out of 260 cases of hemiplegia with con-
current aphasia, calculated  the proportion of the aphasias in
consequence of left-sided hemispherical lesions  to those  in con-
sequence of right-sided ones, to be as 243 :17, that is, as 14.3 :1.
   The ground  for this remarkable difference has been sought in
the fact that, apart from the question of aphasia, the  left hemi-
sphere is more frequently  the seat of lesions than  the right.
This is,  however, not  correct,  since, according to the investi-
gations which Vulpian and Charcot made at the Salpetriere,
one finds both  hemispheres  about equally often affected.  For
58 hemiplegias  from lesions of the  right  hemisphere, they re-
corded 52 from lesions of the left.

   4.  Do lesions of the left  anterior lobe lead  to aphasic
derangements oftener  than  those of other parts of the  brain ?
To this question we  must also answer unhesitatingly,  Yes.

  1 Quarterly Journ. of Psycholog. Medicine, January, 1868.—In Hammond, A Trea-
tise on Diseases of the Nervous System. New  York, 1872. p. 199. 
732          KUSSMAUL.—DISTURBANCES OF SPEECH.

   It  has been sought to establish statistically the proportion of  aphasias in
lesions of  the left  anterior lobe (verified by autopsies) to those in lesions of other
portions of the brain.  Seguin placed it at 514 : 31.   But the tables, which he col-
lected mainly from  the writings of the two Daxes and of  Bouillaud, do not  stand
criticism.  What shall we  say to this, not to speak of anything else, that these
authors have recorded 466 cases of aphasia, all with lesions of the  left anterior lobe,
and not a single one with lesions of other parts of the brain ?
   Somewhat more  available is the testimony of  Voisin,' who in aphasia found the
left anterior  lobe affected 140 times,  the  right anterior lobe only 6 times.   As for
the rest,  he  speaks of aphasias from lesions in the oblongata  and  pons, which
shows that he did not know how to distinguish at that time between anarthria and
aphasia.
   The most instructive report on this question seems to us to be  that published by
Callender.2  He compared, with reference to this very point, a great number of
lesions of the brain accompanied by hemiplegia, as they presented themselves to
him and to Kirkes in autopsies, one  after another, in the course of a series of years
at St. Bartholomew's Hospital,  in London.  Deducting  two cases of coma with
right, and four  cases  with left hemiplegia, in  which the disturbances of speech
could not be determined, out of thirteen cases  of  right hemiplegia, aphasia was
present twelve times, and only once absent, in which case a hemorrhagic  clot lay
farther behind, that is, under the end of the lateral horn of the lateral ventricle.
In thirteen cases of left hemiplegia, on  the  other hand, genuine aphasia  did not
occur once;  but in four  cases  there  was a slight  indistinctness of  speech from
paralysis of  the muscles.   To  this  are  to be added, moreover, three  cases of pre-
servation of speech with lesions of the left half of the brain, in the  posterior
regions.

    5.  Wh ich portion of the left anterior  lobe does one find most
often affected, in aphasic derangements ?
    The experiences  of  all physicians  agree,  with  singular  una-
nimity,  that it  is  especially the region  of  the island, with the
neighboring portions  of  the  frontal  lobe and  corpus  striatum,
injuries of which give  rise  to aphasic and mixed  anarthric and
aphasic derangements.

   Lobmeyer3 collected 53 carefully  described cases of aphasia, in which an au-
topsy had been made.  In 50 cases the aphasia depended upon a lesion of the left
hemisphere,  and among these the lesion was 24 times in the third frontal convo-
lution; 34 times in it  and its neighboring parts, including the island,  which was 7

   1 Art. Aphasie, Diet, de  med.  et de chir. prat.
   2 St. Bartholom.  Hosp. Reports. London. III. p. 415. 1867. u. V.  p.  3. 1869.
   2 Archiv f. klin. Chirurgie, 1872. XIII. S.  309. 
LOCALIZATION OF THE POWER  OF SPEECH.         733
times concurrently affected; 13 times in the left island; 6 times in this alone;
only twice did it follow lesions of the anterior portion of the frontal lobe, thrice
of the middle lobe at the fissure of Sylvius, twice of the middle and posterior
lobes, four times of the posterior lobe.

   Among  the  lesions leading to aphasia, necrotic  softenings,
from embolism and  thrombosis of the  artery of the fissure  of
Sylvius, play a principal,  even though by no means an exclusive
part.  Hemorrhages, abscesses, and tumors  of  this region pro-
duce the same effect.   Jaccoud, in recalling the  fact  that cere-
bral softenings  from embolism occur much more frequently on
the left than on the right side, and that these take their  origin
mainly  in  the artery of the fissure of  Sylvius, which supplies
this region with blood, is disposed to explain the more frequent
occurrence  of derangements of speech in lesions of the left hem-
isphere simply by the greater frequency of embolism of the left
artery of  the fissure of  S}dvius.   Statistics, however, do  not
justify such an  assumption.
   It is, indeed, correct that in the two tables of Meissner,1 out  of 38 cases of one-
sided embolism of the artery of the fissure of Sylvius or of the  carotid, these arte-
ries were plugged 26 times on the left and only 12 times on the right side.  Bertin2
even  found embolism of the left carotid,  cerebral artery, and the artery of the
fissure of Sylvius, 31 times, and  on the right side only 7 times.  But, if we com-
pare  at the same time the proportion of the foci of degeneration in the brain,
upon the right side and the left  in general, without reference  to their nature, we
shall find  that they occur rather more frequently  on the right side than on the
left.  In 169 cases, Andral3 found these lesions 73 times on the right side only, 63
times on the  left side  only, 33 times in both hemispheres.  Softenings form cer-
tainly a very large proportion of the degenerations of the cerebrum which produce
aphasia; but, in addition to them, hemorrhages, abscesses, and tumors occur as
frequent causes of aphasic disturbances.

   If we take the proportion  (as 31 :7) of lesions from embolism
of the left hemisphere to  those of the right, from the tables of
Bertin, which are the most unfavorable to the right side,  and
compare with this the previously given proportion of aphasias
accompanied by right hemiplegia to those with  left hemiplegia,

             1 Schmidt a Jahrb. Bd. 117. S. 248. Bd. 131. S. 340.
             2 Ibidem.  Bd. 147. S. 288.
             3 Clin. med.  III. edit. J. ?. pp. 377, 378. 
734          KUSSMAUL.—DISTURBANCES OF  SPEECH.

which Seguin found to be  as 243:17, then we have in  the first
case 4.4 :1 only, in the second 14.3 : 1.
   From this it is perfectly certain, not only that the lesions  of
the left hemisphere  are much more frequently connected with
aphasic  and mixed  anarthric and aphasic derangements than
those of the right, but also that it is chiefly the anterior portions
of the left hemisphere, and,  from amongst these, especially the
portions bordering  on the region  of the island, which lead to
such results.

   6.  Is the frontal  convolution of serious importance for arti-
culate speech f
   It was certainly not the result  of chance that out of the first
seventeen cases of aphasia which presented themselves to Broca,
in autopsies from the  Paris hospitals, sixteen times deep-reach-
ing lesions of the cerebrum were observed, which all had this in
common, that they penetrated into the posterior third of the left
third frontal convolution, and that in the  seventeenth  case,  to-
gether  with  a destruction of the  island and  parietal  portion,
there was present at least  a  milder  anatomical degeneration of
the region of Broca.  The two first cases  of Broca carry with
them likewise  such  an  amount of internal  evidence as  is  not
often met with in clinical observations.

   Cask I.—A man, eighty-four years of age, by name Le Long, had an apoplexy,
with unconsciousness, one  year and a half before his death. Aphasia remained as a
sequence until the end—aphasia, without any other paralysis whatever, with good
intelligence, good memory and comprehension.   He performed properly all volun-
tary movements of the tongue, lips, etc., and could make himself comprehensible to
others by means of gestures and five words, which he uttered somewhat indistinct-
ly, although he was able  to articulate  distinctly the sounds of which they were
composed.  We shall return later to the details of the  derangement of speech.
Broca found a point of softening confined to the posterior third of the left second
and third frontal convolutions.
   Case II.—In an epileptic, Leborgne, called Tan, because he answered all questions
with this little word, aphasia, from the thirtieth to the fortieth year of his life,
existed without hemiplegia and with entire power to make himself comprehensible
by signs; whether it developed itself slowly or quickly could not  be discovered.
Then there was added to the aphasia a gradually increasing hemiplegia of the right
limbs and a moderate weakness of the right cheek; the tongue moved freely always.
In addition to the syllable " tan," Leborgne could, when angry, give vent to a long 
             LOCALIZATION OF THE POWER OF  SPEECH.         785

 oath.  He died at the age of fifty-one years.  The autopsy disclosed softening of
 the left frontal cortex throughout a wide extent, involving the left island lobe, and
 the temporal convolution bordering on the fissure of Sylvius; the softening also
 extended deep into the corpus striatum.  Broca made it  highly probable that the
 degeneration arose in the entirely demolished posterior half of the third frontal con-
 volution, confined itself for a long time to this, and then advanced from this point
 to the other affected portions.

    Since then it has indeed been  shown  that injuries of other
 cortical regions can also lead to aphasia, without its  being neces-
 sary that  the region of Broca should be involved; but the con-
 currence of  aphasia, with  lesions  of the left third frontal con-
 volution, has been established with  such striking frequency that
 it cannot be  the  result  of chance.    By  the side  of the observa-
 tions  of Broca  just  communicated can also  be  placed  many
 others of  no less internal value.   One from Th.  Simon,1 e. g.,
 offers  almost an experimentum crucis.

   A perfectly healthy man fell from his horse. He got up immediately, took hold
 of the bridle, and was  about  to vault into the saddle, when a physician, who by
 chance accompanied him, approached and examined him.  He was unable to speak,
 but made himself understood by signs.  No paralysis whatever was present.   On the
 head there was a small wound with depression of the  bone.   Later, when death ensued
 from meningitis purulenta and inflammatory softening oi the brain, a bit of bone that
 had been broken off was found in the left third frontal convolution, which, together
 with the second  and the island, was softened. In the skull there was only a per-
 fectly round hole, no crack or fracture in any part.

    Another observation  from Rosenstein3 affords the proof that
 a hemorrhagic softening only as big as a hazel-nut, in  the left
 third  frontal convolution, can give  rise  to aphasia and agraphia
 as the only symptoms.

   A person twenty-two years old, who suffered from diffuse nephritis, suddenly
 lost in the  last weeks of her life the power of speech.  The countenance was pale,
 the look staring, the pupils dilated; she understood what was said to her, put out
 the tongue when asked, took the drinking-glass when it was offered, tried to answer,
 but only brought out  "ja—ja."  She nodded  approvingly  when one guessed what
 her wishes were,  and tried, when requested, to write; she only scribbled all sorts of
scrawls,  however,  and no letters.  She lived sixteen days longer without the
1 Berl. klin. Wochenschrift. 1871. Nos. 45, 46, 49, 50. S. 599.
-' Ibidem, 1868. S. 182. 
736          KUSSMAUL.—DISTURBANCES OF SPEECH.
aphasia disappearing.  Besides the softening already mentioned, there was only
found in the brain subarachnoidal oedema.  The patient had been for a long time
dropsical.

   The table  of Lohmeyer,  already  communicated,  gives an
approximate representation of the frequency with which lesions
of the left third frontal convolution are found in aphasia, in con-
trast to those of other cortical districts.  Out of fifty-three cases
of aphasia, there are about thirty-four in which this convolution
is affected with other parts of the brain, or alone.
   Circumscribed  points of  softening in  other regions of  the
cortex, with the left third frontal  convolution intact, to which
aphasic derangements could be referred with  the greatest proba-
bility, have been but seldom found  in the right, more frequently
in the left hemisphere.  Peter1 found such a focus in the right
hemisphere, also in  the  posterior third of  the third frontal con-
volution.    In the left hemisphere  Meynert2 saw a  depot limited
to the island and the cortical layer of the operculum.  Bernhard,8
Wernicke4 and Finckelnburgb found the lesions confined to the
left  temporal lobes ; Cornil,6 Samt,7 Tripier,8 and myself,9 to the
convolutions of the  parietal lobe.   Sander10 described a case of
aphasia in a patient suffering from epilepsy,  in which a large
spot  of softening was seated  in the medullary part of  the cen-
trum semiovale, in bundles of fibres which he  considered  to be
fibres radiating from  the  corpus  callosum.  The mass extended
from the  central convolution  through the parietal lobe  as far as
   1 Bullet, de l'acad. de med. 1865. 25 Avril.  Discours de M. Trousseau.  The embol-
ical softening reached downward as far as the corpus striatum. Together with aphasia,
there was right hemiplegia.
   2 Wien. med. Jahrb. 1866. Bd. 12. § 4. S. 154.  Voisin also (Soc. med. hop. Paris,
186S) saw aphasia with a softening limited to the left island.
   3 Archiv fur Psychiatrie.  Bd. 4. S. 726.
   4 Der aphatische Symptomencomplex. Breslau, 1874. S. 43.
   5 Loc.  cit. S. 3.
   6 Gaz.  med. de Paris. 1864. p. 534.
   7 Archiv fur Psychiatrie.  Bd. 5. S. 205.
   B Gaz  med. de Paris, 1874. No. 2.
   9 To this case and to some others of the above-mentioned observations I shall return
later with more exactness.
   10 Arch fiir Psych. Bd. 2. S. 53.  Together with aphasia, there was right hemiplegia. 
           LOCALIZATION OF THE POWER OF  SPEECH.        737

the cuneus, and encroached somewhat even upon the medullary
part of the frontal convolution.  We have already (Chap. XIX.,
at the end) established, by observations of Farge, Popham,  and
Jaccoud,  the  fact  that even  circumscribed  lesions,  confined
entirely to the white substance  of  the  hemispheres proper, can
cause aphasia.
   It is only in the case of the occipital lobes that we have not
succeeded in finding sufficiently exact observations showing that
lesions of this part have led to genuine aphasic disturbances.1
    The left frontal lobe, and especially its third frontal con-
volution, possesses, then, by no means a monopoly of producing
aphasia, although it is most frequently brought about by lesions
at this point.  The island comes next in frequency to the frontal
lobe.   Aphasias, from lesions in other regions,  are always sim-
ply exceptions to the rule. That aphasias are called into existence
by lesions of the occipital lobes, is  still to be more satisfactorily
proved.
   When  we  reflect  how  seldom  indeed,  in  general,  aphasic
derangements  proceed from  lesions of other  regions  than the
posterior  portion of the frontal lobe and the island of the left
hemisphere,  we  shall  lay  great stress upon this uncommonly
frequent concurrence—and the more so when we remember the
perfect union which binds all  parts of the  brain  together,  and
how easily derangements in the circulation,  nutrition, and func-
tion of one part lead  to  the same in other parts.   When a dys-
pepsia, a considerable congestion  of  the  head, an  annoyance,
even, in the case of many persons, impedes  the remembrance of
words, or causes the  stream of thoughts  and phrases to stand
still, why should we be  surprised  that such rough onslaughts
as hemorrhages, plugging of the arterial courses from embolism,
thrombosis, and the like, in different portions of  the cerebrum,
should be  able to throw speech into various sorts of disorders?
On the contrary, one should wonder that the gross circumscribed

   1 The case of Bateman (loc. cit. p. 48) which is quoted as an instance of this kind,
occurred in a person who suffered from confusion of ideas and weakness of thought; it
was a question of dyslogia, and not of aphasia.  The quite unsatisfactorily described
observations of Skae (by Bateman, loc. cit. p. 35). and Magnan {Vivent, De l'aphasie.
These, Paris, 1865. Obs. VI.), and others of a similar character, are also quoted.
          VOL. XIV.—47 
738         KUSSMAUL.—DISTURBANCES OF SPEECH.

lesions of the brain, which lead to the characteristic aphasic dis-
turbances of speech, are found almost  always in one  and the
same region only.  This fact will probably stand out still more
distinctly in  time, the more thoroughly the cases, in which it is a
question  of  genuine, that is, of ataxic  aphasia,  are  sifted out
from those in which there is  only a slight word-amnesia, or per-
haps a dyslogia.
   In consideration  of  all these  circumstances, we  venture to
make the statement that the third frontal convolution  of the
cerebral hemispheres is of vital importance for speech,}  But this
importance must  also probably be granted to the island.  We
must likewise  bring into prominence the  fact  that the third,
frontal convolution and the  island of the left hemisphere evi-
dently play a more important role in speech than those of the
right, and we  must  henceforth seek  for the grounds on  which
this  surprising difference rests.

   7. Wherein lies the reason  of the  greater importance  of the
left over the right hemisphere in speech f
   As we have already stated,  Broca2 connected  the  strikingly
more frequent occurrence  of aphasia, after lesions  of  the left
hemisphere,  with the use  of the right  hand  by most people,
which again  is dependent upon their  being " left-brained," i. e.,
exercising the left hemisphere for the more subtile requirements
of manual dexterity.
   Those  whom  we  style right-handed  ("droitiers")  are left-
brained ("gauchers du cerveau'1), and vice versa.  The greater
skill  of  the  right hand  itself  Broca deduces from the more
rapid development of the left hemisphere, a view which Gratiolet
affirms,  and C. Vogt and Ecker deny.  Moreau's patient,  whose
case  we considered above,  could not be right-handed,  because
from defective development  she lacked  the left  first primitive
  1 Vulpian twice found the two left anterior frontal convolutions the seat of soften-
ing without aphasia {Mongie, De l'aphasie. These. Paris,  1866. Obs. V. and VII.), and
their orbital region once (Obs. V).
  2 Bouillaud has, moreover, claimed priority of the idea in his report to the Acad, de
med., on the 4th and 11th of April, 1865. 
LOCALIZATION  OF THE POWER OF SPEECH.         739
convolution;  she was forced,  therefore, to use the right hemi-
sphere in sewing; when she learned to speak,  she also must have
exercised for  this purpose and learned to use the right hemi-
sphere.  The same is true of persons whose left hemispheres have
been mutilated  in childhood, as  was  the case, e. g., in Parrot's
patient, in whom the left island  and the  third frontal convolution
were found destroyed, or in the woman  whose brain was  sent to
us by Dr. Schaefer,  of Loerrach.

   This person had reached the advanced age of seventy years, and died from
erysipelas terminating in suppuration of the frontal sinuses.  She was an epileptic
from childhood, paralyzed upon the right side, and blind of the right eye.  She
could speak " reasonably well,"  even  a  few hours before  death; she had  " a
certain degree of  intelligence, a propensity for thieving, and religious comprehen-
sion."  The right hemisphere is small,  all the fissures  and  convolutions are well
marked, although in an almost diagrammatic simplicity.  The left hemisphere is
for the  most part transformed into a loose  sac, which is kept in shape by the
apparently unchanged pia, and contains a mere shell of nerve-substance from I to 1
centimetre thick, half amorphous, half fibrous in  its composition.  The first frontal
convolution had alone survived as a more compact mass, especially in the median
and orbital portion;  whilst its cranial surface is narrowed, and, at the still recogniz-
able first frontal fissure,  loses itself  in the above  mentioned  wall  of the sac; in
addition, a small  supra-orbital, and particularly an orbital, portion of the second
frontal convolution is still to a certain extent solid and recognizable; and finally,
the gyrus fornicatus can be traced almost as far back as the posterior extremity of
the corpus callosum.   The parts we have named still show their form by shallow
secondary fissures, whilst  the surface of  the rest of the  hemisphere  is destitute of
any sort of  form; and these parts, in common with the  central portions of the
caudex cerebri and the corpus callosum, which lie exposed  at the bottom of the sac
and are of normal size, compose a cohesive, more compact mass.  The cerebellum
seems as little altered in form upon the left as upon the right side.

   Whereas for most  of  the rougher tasks we use both hemi-
spheres,  we certainly give  preference to  the left for most of the
more delicate  ones.   Only in some—for example, in piano and
violin playing—do we exercise both ; in  violin playing, indeed, in
very  different ways (Wilks).1    For drawing and writing, we
develop the left half  of the  cerebrum—even  the otherwise left-
handed people do this; only those with a defective right arm
use for these purposes the right  brain.    Hence, we cannot doubt
1 Guy's Hosp. Reports. Vol. XVII. 
740         KUSSMAUL.—DISTURBANCES OF SPEECH.

that the centres of innervation of the cerebrum  are supplied in
double for manual tasks, but that most men are, notwithstanding,
right-handed, and use the left brain for most manual exercises
requiring a certain amount of skill.
   Upon  this and upon the experiences  quoted as to the pre-
ponderatingly frequent concurrence of aphasic  derangements
with lesions of the left hemisphere, rests  the hypothesis accord-
ing to which most  men are  "left-brained speakers."  If this
assumption be correct, the following  propositions must be justi-
fied by experience :—
   a. If the portions of the right hemisphere provided for speech,
but  not  functionally  developed, are destroyed  in  right-handed
people, speech should still remain intact,  since those of the left,
which alone have been exercised, remain.  If these,  however, also
fail,  then aphasia must be the result.
   This state of things has several times been met with.  Duval
(in Broca),  Stewart,1 and A. Yoisin J observed  persons who,  at
first the  subjects of  left-sided hemiplegia, retained their speech,
and  lost  it when  right-sided  hemiplegia  was   subsequently
added.
   b. Left-handed people must become aphasic  when the lesions
include the right hemisphere.  Pye  Smith, Hughlings Jackson,
and  John  Ogle  have published  such cases.3  AVadham 4 found
the same concurrence  in the  case  of a young  man who wrote
with his right hand, but was in other respects left-handed,  as
were his four brothers.   This " amphidexter " must therefore
have used the left hemisphere in writing, the right in speaking,
which is indeed surprising, though it strikes us less when we
reflect that he learned to  speak not  only by his own unaided
efforts, but also  much earlier than he did writing with the right
hand, which was compulsory at school.
  1 Medical Times, July 9, 1864.  Circumscribed areas of softening in both fissures of
Sylvius.
  2 Gaz. des hopit. 25 Janvier, 186S. The lesion was situated, on the right side, in the
corpus striatum, without implicating the  corpus lenticulare; on the left, in the cor-
tex of the island, without participation of the frontal convolutions.
  3 Simon, loc. cit., p. 538.
  4 St. George's Hosp. Reports. Vol. IV.  p. 245. 
             OCALIZATION OF  THE  POWER OF SPEECH.         741

    William Ogle1 ascertained the " right- and lef t-handedness "
of  about one hundred individuals affected with  hemiplegia with
implication of speech.   Only three were left-handed  and para-
lyzed also on the left side ; all the others were paralyzed on the
right side.

   As organic causes of right-handedness, which he also verified in apes, W. Ogle
suggests: greater weight and greater specific gravity of the left hemisphere ; greater
richness of the frontal regions in convolutions on the left side (in two left-handed
women examined by Ogle, the reverse was the case) ; the earlier foetal development
of the left hemisphere (disputed by Ecker and C. Vogt) ; finally, the greater afflux
of blood to this side.  He found the common and internal carotid larger upon the
left than upon the right side in twelve out of seventeen right-handed  individuals ;
out of  three left-handed persons there was in two no difference, in  the third the
right common and internal carotid was twice as large as the left.

    It  follows from this that the  repeated observations of  de-
struction of the right third frontal convolution without resulting
aphasic  disturbances8 do not  invalidate the  theory  of Broca,
since  in all these cases  there was either right-handedness, or at
least the left-handedness was not distinctly established.
    Just as little are the generally very rare cases of lesion of the
left third frontal convolution without aphasia adapted to refute
the hypothesis of Broca, when there was left-handedness or when
the right-handedness was not  established.  But  even in those
cases  where right-handedness is proved, the  patient may be in
full possession of speech at  the time when he came under the
observation of the physician,  although previously, after the apo-
plectic attack brought on by the lesion, he was during weeks and
months aphasic.   Simon s had  this  experience, and I  also have
seen a similar case.  Aphasia,  after lesions of the third  frontal
convolution, is, in fact, in many cases only temporary, and one
cannot, therefore, make use  of the  restoration  of speech  as a
   1 Dextral pre-eminence. Philos. Transact. Vol. XLV. p. 279.
   2 See, besides the observation of Parrot, quoted on p. 728, the following : Fernet,
Bull, de la soc. de biol., 1863.— Mangle, De l'aphasie.  These. Paris, 1866.  Obs. 10, 11,
12,13. All from Vulpiari's ward.—Font-Reaulx, Localisation de la faculte speciale du
laugage articule.  These. Paris, 1866. Obs. 19 and 35.  Obs. of Broca and Charcot.
—Simon, loc. cit., Case 1.
   3 Loc. cit., Case 3. 
 742          KUSSMAUL.—DISTURBANCES OF SPEECH.

 valid  argument  against  Broca, because his  hypothesis is pro-
 tected against  this reproach  by the  "law of  substitution."
, Speech, lost by a lesion of one hemisphere, can return when the
 individual successfully exercises the other hitherto unused one,
 as often happens in the loss of facility for writing through para-
 lysis  of  one  hand.   The first  attempts at writing with the
 unpractised hand are rude and scarcely legible, just as the first
 attempts  at speech are very imperfect.    It  is true that the cir-
 cumstances under which  the aphasia is with greater or less facil-
 ity equalized  are not known.   One would expect the restoration
 of speech to  take  place more rapidly in children  and young
 people than in old ones; still this is by no means always the
 case.

    A very debilitated boy, aged five years and four months, lost his  speech, as
 Duval' relates, after a fall from a window, which had as a consequence a depres-
 sion of the  skull.  The wound healed in  twenty-five days; the  boy, however,
 remained dumb  a whole year long, although he seemed very intelligent.   There
 was no  hemiplegia.   One year after the fall he was drowned.  A cyst the size of a
 nut was found in the left frontal lobe, which was situated, if not entirely, at least
 in great part, in the third frontal convolution.

    We have been able to discover only two  observations in the
 literature, in which lesions of the  left third  frontal  convolution
 seem  to have occasioned no  aphasia whatever.  They would be
 of great importance, were it not for the fact that in neither case
 is it stated whether the patient was right-handed.

    Simpson2 found in  an epileptic, who had passed ten  years in the Gloucester
 County Asylum, and in whom  neither  an apoplectic attack nor a disturbance of
 speech had ever been observed, an old brownish yellow spot of degeneration in the
 lower part of the left frontal lobe, which, it is alleged, had destroyed the posterior
 portion of the third frontal convolution. The cortex was only one line in thickness.
    J. Christison s relates the case of a woman, who suffered from attacks resem-
 bling fainting, after which she spoke constantly in a murmuring way.  He found
 a hemorrhagic spot, the size of a nut, in the left third frontal convolution.
  1 Font-Reaulx, loc. cit., Obs. XXIII.
  2 Med. Times, December 21, 1867.  The original unfortunately was not within my
reach.
   3 Edinb. Med. Journ. XIX. p. 15. July, 1873. 
            LOCALIZATION OF THE POWER OF SPEECH.        743

    As  things stand  at present, we may affirm with Simon that
the indispensableness of the third frontal convolution for speech
can be regarded as refuted, when—a thing which hitherto has not
happened—(1) there  should be observed a sudden destruction of
the left third frontal convolution in  a right-handed person, or
conversely of the  right in  a  left-handed person,  without the
occurrence of an aphasia even for a short time; or when  (2) a
destruction of both third frontal convolutions should be found in
an individual who had spoken up to the time of  his death.

   Gonzalez Echeverria ! has published, under the title " Sclerosis of both Anterior
Frontal Convolutions without Aphasia," a case which seems to fulfil the second
requirement of Simon.  But the title is not quite correct, since (1) the person,
sixty-seven years of age,  an epileptic from his youth, suffered  for some months
before his death from giddiness upon attempts at walking, accompanied by diffi-
culty in moving the tongue; (2) later he lost entirely at times the power of articu-
lating, while at other times, indeed, he spoke with  facility.   Derangements of
speech, at all  events, were not wanting.  Then the examination did  not reveal a
total destruction of  the nervous elements composing the frontal convolutions,  but
only diminution of the same with increase of the connective tissue.  We know how
even very extensive  scleroses are wont to spare  a sufficiency of conducting-tracts
and nerve-cells.

    It is self-evident, however, that while we  claim an essential
importance  in speech  for the  third  frontal convolution, we  do
not thereby affirm that the cortical functions of speech are only
fulfilled through the third  frontal convolution on the left  side,
or exceptionally also on the right. The fact that not only lesions
of the third frontal convolution cause aphasic disturbances, but
that, in general, lesions of the  regions  bordering upon the left
fissure of Sylvius (the island with the neighboring frontal, pari-
etal,  and temporal districts) are  those which  are almost exclu-
sively involved in serious and permanent aphasic derangements,
indicates the existence in the cortex of a pretty extensive, though
still limited, speech-tract.    Within this tract,  however, we must
yield an especial importance to the third frontal convolution.

   8. Within the cortical speech-tract can centres for the motor
1 New York Med. Record. Mirch 1, 1869. 
744         KUSSMAUL.—DISTURBANCES OF SPEECH.

co-ordination of words and for the acoustic word-images be dis-
tinguished, from each other /
   One might be tempted to place the motor centre of co-ordina-
tion of words in the region of Broca,  since it corresponds very
nearly to Hitzig's  and  Ferrier's  motor  cortical centre for the
mouth and tongue, and  since the above-quoted cases of aphasia
with lesions confined to  the frontal  convolutions (case Le  Long,
of Broca, and the  case of Rosenstein) can be regarded as of the
so-called ataxic character.  The separation, which has  been at-
tempted by many, of the cortex of the  cerebrum  into  a  motor
portion situated in front of the fissure of Sylvius and a posterior
sensory portion, also suggests the idea of seeking for the work-
shop  of  the  word-images  in the  posterior  regions.   Wernicke
succumbed to this  temptation.   According to his  anatomical
investigations, the  island receives within itself convergent fibres
radiating from  all quarters of the first primitive convolution,
which encloses the fissure of Sylvius.   His idea is that it forms
the psychical reflex arch between the  sensory temporal and the
motor frontal portion of the  first  primitive convolution.   The
third  frontal  convolution he regards  as the central termination
of the nerves of the muscles of speech.
   If  one tests  this  hypothesis by means  of  clinical material,
one comes to  the  conclusion that it finds no sufficient sup-
port in absolute experience.   An earlier, indeed, and  therefore
not entirely reliable,  observation  of Lallemand,1 seems to argue
that even pure ataxic aphasia can proceed from the "middle
lobe," whilst a very exact one of Sanders2  at  least proves that
softening confined to the posterior part of the left third frontal
convolution and the under  part of the anterior central convolu-
tion may, indeed, at first give rise to a complete loss of speech,
leaving behind later only an  advanced degree  of word-amnesia.
As for  the  island, an observation of Meynert's,*  which  leaves
  1 Falret, Arch. gen. de med. Vol. LXXXIII. 1864. T. 1. p. 344.  I shall return to
this case in the next chapter.
  2 Edinb. Med. Journ.  1866.  Vol. XL T. 2. p. 811.  A woman 43 years old suffered
from heart disease, and the softening was presumably of the nature of embolism.  She
succumbed to gangrene of the leg.
  3 Wiener med. Jahrb. 1866. Bd. XII. § 4. S. 154. 
            LOCALIZATION OF THE POWER OF SPEECH.         74,j

 nothing to be desired on the  score  of anatomical accuracy, but
 much  clinically,  shows that  an acute encephalitic  softening of
 the extreme posterior portion of the left island and  of that por-
 tion of the  cortical layer  of  the operculum which approaches
 the surface of the island, is sufficient to produce word-amnesia.

   A girl, twenty-two years old, who suffered from insufficiency and stenosis of the
 valves of the left heart and aorta, was suddenly seized with aphasia two weeks
 before her death.  With complete mobility of the tongue, she was unable to find
 certain words, or used wrong ones, e. g., " yellow" instead of " hands." " Hustcn "
 she changed into "hutzen."

    A prudent abstention from  an answer to the above proposi-
 tion is, therefore, at present to be recommended. It is, notwith-
 standing, remarkable that (1)  the anterior regions of the cortex,
 either alone or in connection with the posterior, are almost with-
 out exception found affected in  cases of pure ataxic or mixed
 amnesic and  ataxic  aphasia; and  that (2)  in %mre amnesic
 aphasia sometimes the anterior, sometimes the posterior cortical I
 regions alone appear affected.   In the  following chapters  we
 will still further establish these  facts by  numerous proofs.   The
 latter statement accords with the known experience that  of all
 the  functions  of  speech the remembrance of words  is the  most
 easily disturbed,  and by the most varied lesions of the brain.

   Piorry ' reports the case of an old priest, who, after a  stroke of apoplexy,
 could no longer find  nouns, and the  autopsy revealed three  old apoplectic cyst
 in the anterior  portion of the left corpus striatum.  "Voulait-il demander son
 chapeau,  ilse servait de verbes, de pronoms, d'adjectifs, pour rendre son idee : Don-
 nez-moi mon  .   .  .  .,  ce qui se met sur la  . .   .  ., mais le mot tete ne lui
 venait pas." etc.   If the cortex was, indeed, uninjured in this case—one must not
 forget that Piorry quotes an old case from memory—we must not conclude from
 it that the power of remembering words is to  be sought in the corpus striatum;
 but the case admits of the interpretation that the  lesion of the corpus striatum
 reacted in a disturbing manner upon the functions of those portions of the cortex
 in which  the recollection of words is accomplished.

   When  we call to  mind the completeness of  the nutritive
union wliicli  exists between different portions of the brain (see
p. 737), when especially we again consider that  the function of

            1  Bull, de l'acad. de med. 1864-1865. T. XXX. p. 793. 
746          KUSSMAUL.—DISTURBANCES OF SPEECH.

one portion of the cortex can without doubt be impeded  by the
serious irritation of another portion functionally connected with
it, the fact  that  the genuine ataxic aphasias proceed  almost
exclusively  from lesions of the  anterior  cortical regions, and
especially of the third frontal convolution,  makes it in  a high
degree probable  that the motor co-ordination of words takes
place here.  Clinical experiences up  to the present time  enable
us to draw no conclusion as to the regions in which the acoustic
word-images are evolved  and  enter into connection with the
corresponding conceptions.
   An extremely valuable observation of Cornil,' with very exact
anatomical details, seems to us capable of being thus interpreted,
viz., that the inflammatory irritation of a posterior portion of the
cortex had reacted with a disturbing and interrupting effect upon
the motor co-ordination of the anterior regions ; thus  lending
support  to the proposition above laid down, that the irritation
of one portion of the cortex can interrupt the activity of another
portion  functionally connected  with it.    The  disturbance  of
speech observed in this case we might designate as eiphasic stut-
tering.

   A young man with phthisis fell a victim to that disease nine  weeks after a light
stroke of apoplexy, which had left behind a great derangement of speech lasting
several days, together with an anaesthesia of the skin likewise  lasting only a few
days.  The patient made every effort to utter words; he remained, however, incom-
prehensible, stuttered, broke off, and began his attempts to speak anew without suc-
cess.  The  muscular sense had not suffered upon the  anaesthetic side.  An inflam-
matory focus, measuring twelve centimetres square, was  found in the left second
posterior parietal convolution.

   Finally,  we will  point still  again to  the important fact,
which increases the  exceeding difficulties of localization of the
functions of speech, that sometimes—although not frequently,  it
is true—we  are unable at the autopsy  to discover any gross
lesion of  the  brain  after  a loss  of  speech  occurring suddenly
amidst severe  cerebral symptoms.  Gairdner,2 of  Glasgow, com-
municated such an observation.
1 Gaz. med. 1864. p. 534.
2 Glasgow Med. Journ. May, 1866. 
DYSPHASIAS AND DYSPHRASIAS.
747
   A man was visited by an epileptic attack, after which loss of speech and a sort
of cataleptic condition remained behind, without coma or evident paralysis.  The
intelligence returned  in great measure, but the speechlessness continued.  The
patient was incapable of expressing his thoughts in words, but copied written docu-
ments, with tolerable accuracy. After ten weeks he died during an epileptic attack.
The autopsy disclosed nothing except a general  and diffuse congestion of  the pia
mater.


                       CHAPTER  XXIV.
The Two Great Classes of Cortical Derangements of Speech: Dysphasic and Dys-
    logia—The Conceptions of Aphasia in a Clinical or Practical Sense, and of
    Aphasia in a Theoretical Sense in Reference to Speech, do not cover each other.
    —The Aphasia of Practitioners includes also Verbal Anarthria.—Review of the
    Cortical Dysphasic Derangements, which Clinical Teachers include within the
    Frame of the Sketch of Aphasic Disease, and of those which they exclude.

    The conception of the cortical derangements of speech is
broader than that of the dysphasic.  The  cortex is not only the
organ of speech, as it is uttered  in words grammatically formed
and arrayed in sentences according to laws proper to them, and
independent  of the individual Ego, but it is also the organ of
the intelligence, which stamps upon speech its  personal charac-
ter.   When the operations  of the  mind suffer disturbances,
then these find their corresponding expression in the speech, and
these  secondary  derangements  of speech  proceeding from the
diseased "Intellectorium" we style  dyslogic, or dysphrasias.
Hence, the cortical derangements  of  speech may be separated
into two  great classes: dysphasic and dyslogic,  or dysphasias
and dysphrasias.  We will first examine more closely the dys-
phasias, ahd later cast a glance over the dysphrasias.
    We have  previously (Chap. IX.) divided all  derangements of
speech as an  independent faculty, into those of articulation and
those of diction;  the former we have designated as dysarthrias,
the latter as dysphasias.   If  we hold fast  to this, then  we must
allow  also cortical dysarthrias, for the  cortex forms words not
only as acoustic symbols for  conceptions, but also as motor ag-
gregates of sound ; it imparts centrifugal impulses, by means of
which the word is handed over as an organized motor unit to the
infracortical  organs of  articulation  for  realization.   Clinical 
748         KUSSMAUL.—DISTURBANCES OF SPEECH.

medicine, however, has paid no regard to this point.  It briefly
styles every cortical inability to form words aphasia, regardless
whether diction or articulation is  interfered with, and contrasts
with each other ataxic and amnesic  aphasia.  The former it re-
gards, after the example of Popham and W. Ogle, as an inca-
pacity for the motor co-ordination of words;  the latter as an
inability to call to mind words  as sensory forms or acoustic
sound-pictures.  In amnesic aphasia there is  lacking the internal
word, that which is comprehensible to the speaker alone ; in the
ataxic form, the production of the external word is affected—the
word which is comprehensible to others, as it is given forth from
the co-ordination of sounds as motor forms through the cortical
key-board of  the will.   Obviously  Steinthal ' is right, when he
disputes the dysphasic character of the so-called ataxic aphasia,
so long as  mere derangements of  simple diction are allowed to
pass as aphasia,
   Strictly  taken, ataxic aphasia is nothing else  than cortical
anarthria of words, verbal anarthria; amnesic aphasia, on the
other hand, is  true aphasia,  incapacity  of  verbal  diction.
When, however, we hereafter designate the cortical anarthria of
words as ataxic aphasia, this inconsistency is justified partly by
the fact that  this last  designation  has  grown too firmly into
medical forms of speech for one to hope to be  successful* in
wresting from it its citizenship, partly by an important practi-
cal consideration.  The cortical inability to form words is in very
many cases  of a mixed nature ; not only the cortical articulation
of the word as a motor sign suffers, but  also its recollection as
an  acoustic sign, and often nothing is more difficult than to dis-
tinguish in a given case where the dividing-line is drawn between
diction and  articulation.
   Further, we  have already (Chap. VIII.) called attention to
the fact that  under aphasia, in the  clinical sense, a great quan-
tity of  symptoms are  embraced, which are  of a very varied
nature.   A  single picture of  the  disease has been constructed,
whose features were gradually  put together from  numerous
separate observations not agreeing at all with each other, and
1 Abriss der Sprachwissenschaft. S. 454. 
               DYSPHASIAS AND DYSPHRASIAS.             740

without a thorough comprehension of the elementary processes,
which constitute speech.
   In the main it is the following dysphasic derangements which
are comprehended under the general name of aphasia :
   1. Ataxic aphasia, or incapacity for the motor co-ordination
of words.
   2. Amnesic aphasia,  or incapacity for the recollection of
words as acoustic aggregates of sound.
   3. Dumbness for words, or the inability, with  good hearing
and sufficiently preserved intelligence, to understand  words as
well as previously.
   4. Paraphasia, or the inability to  properly connect word-
images and the corresponding conceptions, so  that, instead of
the ones corresponding to the sense, misplaced or entirely incom-
prehensible word-images present themselves.
   f>. Agrammatism and akataphasia,  or the inability to form
words grammatically and to arrange them in sentences syntactic-
ally.
   These embrace all the aphasic  derangements recognized by
clinical teachers,  but not all  the actually occurring cortical
derangements of the autonomous function of speech.
   Thus there exists without doubt a retarded, and, a hastened
form of speech—the latter, up  to the point of indistinctness from
interference of the words, both forms having  their origin in an
abnormal course (as to  time) of the cortical excitation  which
forms the basis of the elementary processes, out of which speak-
ing is developed by diction and articulation.   We frequently
observe in meningitis and in different  diffuse cortical affections a
strikingly measured speech, which  we may designate as brady-
phasia;  at  other times,  in  conditions of  excessive  cerebral
excitation,  a  " tumultus sermonis,"  increasing even to incom-
prehensibility, which admits of the interpretation already given.
   A recent observation makes it seem to us even probable that
scanning utterance has  at times a cortical origin, for we saw it
in the  case of a young man during convalescence, who, in con-
sequence of  a depression of the left parietal bone,  remained for
weeks  speechless  after the intelligence with  comprehension of
words had  been rapidly re-established,  and after he had written 
750        KUSSMAUL.—DISTURBANCES OF SPEECH.

down with the unparalyzed right hand incomprehensible letters
and words.  At this time, as a convalescent, he spoke all words
properly, but slowly and scanningly ;  he also wrote them  down
properly, but  slowly.   He moved the tongue in all directions,
but at the same time somewhat slowly.
   AVe have, moreover, previously made  mention (p. 746) of an
aphasic stuttering, which we have good ground to regard as a
cortical derangement.
   Here  also  belongs  that  stumbling over  syllables of which
we have already repeatedly made mention  (Chaps.  XIII. and
XVII.).  AVe  will return to it in an especial chapter.
   In the first place, then,  let us carefully consider the dys-
phasias which the practitioners embrace under the general name
of aphasia.  AA^e shall join to this the consideration of the dys-
graphias or derangements  in  written speech  analogous to the
dysphasias, and which one generally finds described under the
names  agraphia or  paragraphia.   The disturbances  in  the
speech of gestures (Geberdensprache), or dysmimias, will also
be taken into consideration.
   Before we  begin this task, however,  with a  description of
ataxic  and amnesic aphasia, we must again  premise the remark
that we regard both of these designations, against which we have
already raised objections and which we retain  only for objective
reasons, as not happily selected.  Ataxic aphasia is in a certain
sense also amnesic, and amnesic aphasia ataxic.
   If, for example, one considers  memory as a general function
of the  nervous system, then there must be a recollection of the
acoustic  as well as of the motor word-images, by means of which
the co-ordination of sounds into words  is accomplished.   The
recollection of words is therefore a double affair: 1. a recollection
of words in so far as they are acoustic combinations of sounds;
2. a recollection of words as movement-images.  Trousseau, who
always referred  aphasia to a loss of recollection at times of the
word-signs, at times of the action by means of which words are
articulated,  had  always appreciated this correctly.  AA7. Ogle1
also distinguished two kinds of recollections of words : in addi-
1 St. George's Hosp. Rep. V. 2. 1867. p. 95. 
ATAXIC APHASIA.
7.51
tion to that which one ordinarily understands by this term, and
by the aid of which we are  conscious  of a word, he recognized a
second also, by means of which the word is pronounced.  AA^hat
is called ataxic aphasia is therefore always of an amnesic char-
acter.
   On the other hand, amnesic aphasia leads always likewise  to
ataxia, since the co-ordination of  words is determined only in
part by the movement-images ; the acoustic word is also neces-
sary  thereto —it  regulates the  movements, but from  a  more
distant station.  If the word as an acoustic sound-structure,  or
the connection between the acoustic and motor centres, experi-
ences some disturbance, then disordered, confused,  or mutilated
words must  come to the front.   Consequently, we may with
Bastian' even regard paraphrasia, which has its basis in a dis-
ordered connection between the  centre that gives birth  to  ideas
(Alaudsley' s Intellectorium) and  the acoustic word-centre, as an
ataxic derangement of diction, or a dysphasia.
                      CHAPTER XXV.
                Ataxic Aphasia, Agraphia, and Amimia.

   There are cases of entire loss of speech, in which the patients
retain the words in  the memory as  acoustic signs, and still are
absolutely incapable of uttering  them,  although  the intellect
may be clear, and the movements of  the tongue free.   That they
really are in full possession of the acoustic word-signs is clearly
evident  from the fact  that  they can translate the same into
writing.  If, however, they be requested to repeat the sounds or
words from  dictation, it is impossible for them to comply, even
when they are shown  how  the tongue and lips  should move.
They open  the mouth,  twist the  lips, and make grimaces, but
bring forth, at the best, only inarticulate sounds and grunts.

  Thus, Trousseau2 tells of a robust young civil functionary, who, in an attack
of unconsciousness, lost the power of speech  entirely, although there was no paral-
1 Brit, and Foreign Med.-Chir. Rev. 1869. pp. 209 and 470.
8 Clinique Medicale. Tome II. Art. Aphasie. 
 7.")2          KUSSMAUL.—DISTURBANCES  OF  SPEECH.

 ysis of any parts of the body.  He could execute all the movements of the tongue
 and lips with the greatest facility.  He was able to discharge the duties of his office,
 notwithstanding the loss of speech, as he could transact all his business in writing,
 and he delivered to Trousseau  an  exhaustive history of his illness, that had been
 written out by himself.
    Bouillaud l was present, in  the  year 1828, at the autopsy of a young man who
 died in the surgical ward of  Phil. Boyer.   An umbrella had been struck with such
 force into the left orbit, that the eyeball  protruded.  During the eight days that
 he survived, the power of speech was entirely lost, although he could still move his
 tongue. He understood what was  said to him, but was unable to answer.  On the
 other hand,  he wrote down his wishes on  paper, and  stated in writing  that he
 retained his  memory,  but could not utter the words.  There was found a  suppura-
 tive softening of  the left frontal lobe, which had been bored through by the point
 of the  umbrella, the perforation extending as far back  as the anterior end of the
 left lateral ventricle.  The end of the umbrella must, according to the direction
 of the wound, have penetrated the  third frontal convolution.
   Boinet2 relates the case of a man in whose brain a traumatic abscess the size of
 a nut was found in the  region of Broca.'s convolution, and extending as far as
the corpus striatum.   There was no secondary softening of the  surrounding parts,
but there were traces of a very circumscribed meningitis.  After the healing of a
wound made by the trepan, the patient had regained intelligence and memory, but
remained speechless.  He made himself understood by gestures,  played  with his
comrades, copied  from dictation, and wrote out his own thoughts.  In addition to
the speechlessness, there was slight facial paralysis.                 i

    At other times the patient is not entirely speechless ; he  can
still pronounce some words of one syllable,  but  has  to resort to
writing when he wishes to use  any  other words.

   Thus, in the case reported by Lallemand, which is  mentioned on page 744, the
man, who was fifty years of age, retained his intelligence and the power of execut-
ing all  the movements of the body, those of the tongue among the rest, but his
speech was reduced to a few monosyllabic words.   He  could, however, make him-
self understood, as far as his education permitted,  by writing.  Lallemand found
a circumscribed spot of softening on the surface  of the middle lobe.

    Written  speech  constitutes the  most valuable and the most
reliable,  though not the only means of proving that the memory
for  spoken  words  is  retained.  AA^e  must  assume  the same in
those  cases in wdiich  aphasic persons, who have  never learned or
1 Bull, de l'acad. med. T. XXX.  p. 625.
2 Gaz. des hopit. 1872.  No. 30. p. 235. 
                 ATAXIC AND AMNESIC APHASIA.             753

 have forgotten the art of  writing, are able to give expression to
 their thoughts and to answer questions correctly by expressive
 gestures.  It is true that it is easy to be deceived in such cases,
 and the observer must convince  himself by careful and repeated
 examinations, that the patients really understand him.  He must
 himself especially avoid the use of any explanative gestures in
 connection with his  words.  AA"e possess  observations  which
 place the existence of an ataxic aphasia under such  circum-
 stances beyond doubt.  Out of them we may create a second
 variety of this form of derangement of speech.
    Many of these patients  possess still a small stock of words,
 which  they turn to good use in making their gestures more intel-
 ligible.  Others utter only afeio senseless, and often very extra-
 ordinary  syllables and words.   The repetition  of  words from
 dictation is impossible in ataxic  aphasia, even when the patient
 still retains control of a small stock of words.  In this the ataxic
 differs  from the amnesic  form of aphasia (Ogle).   AVe do not,
 however, mean to say that all persons with amnesic aphasia can
 repeat  dictated  words ; the  majority of them can,  but a very
 severe derangement of the recollection of words abolishes like-
 wise  the ability to repeat words from dictation. Further, pa-
 tients with ataxic aphasia are unable to form other combinations
 with the syllables and sounds of the words they are  still able to
 enunciate  (Trousseau).   One aphasic person,  who could say
 uBon jour, monsieur" very well, could not pronounce the word
 "bonbon" at all  (Perroud).  Another,  whose vocabulary con-
 sisted almost solely of  the  odd word u cousisi,v could not utter
 the word " coucon " or " sisi" (Trousseau).   On the other hand,
 they are sometimes able to give vent to even  long and well artic-
 ulated oaths ; we have already (Chapter XVI.) endeavored to give
 an explanation of this strange fact.  The patient who answered
 almost all questions with the word " cousisi" also employed the
 mutilated  word  "saccon,"  which was  evidently  meant for
 " Sacre nom de Dieu" (Trousseau).

  The case of Leborgne, reported by Broca (Chapter XXII., p.  734) illustrates the
last-mentioned fact.   Leborgne accompanied his demonstrative gestures with the
diminutive " tan," or its reduplication " tan, tan ; " when he was not understood,
he became enraged and gave vent to a long and savage oath.
          VOL. XP7.—48 
?.)4         KUSSMAUL.—DISTURBANCES OF SPEECH.

   The case  of Le Long (Chap. XXII., p. 734), also reported by
Broca, is an excellent example of a  defective vocabulary with
constant and unvarying mutilation of some of the still remain-
ing words.   This case shows how, in  ataxic aphasia,  the same
sound may be constantly employed in one  word,  and  just  as
constantly left out in another, a proof that it is not the articula-
tion of the sound in itself  which has become an impossibility,
but its combination  with other sounds in the word.   It is the
construction of the word and not the production of the sound,
that is prevented.  Both defects can,  it is true, occur together,
producing mixed anarthric-aphasic derangements.

   Le Long had at his disposition only five words, with which he supplemented
his very expressive gestures: oui, non, tois instead of trois, toujours, and Le  Lo
instead of Le Long—that is, three perfect and two mutilated words.   He affirmed
with oui, and denied with non ; for all numbers he employed tois, indicating the
exact number which he had in his mind by an adroit use of his fingers;  he desig-
nated himself by Le Lo ;  he used the word toujours when he could not indicate
his meaning by any of the other words.
   Thus Le Long always pronounced the r in toujours correctly and elided it in
trois, as children do who have not yet mastered the difficulty of the conjunction of
the r with  the preceding t; he had permanently lost the power of articulating that
combination of sounds.  The nasal sound, which he articulated in non, he could no
longer add at the end of his own name.

   AVhen agraphia  accompanies ataxic aphasia, it is sometimes
absolute  and  literal, the  patients  being unable to  produce a
single letter with  the pen.   They scribble lines to no purpose
upon the paper, and finally admit unwillingly their inability  to
write.   Others can still  write letters and entire rows  of  letters,
separated here and there in  the  semblance  of words by little
spaces ;  these combinations of letters,  however, are for the most
part unpronounceable:  verbal agraphia.  It is true that among
the unpronounceable rows of letters, we also come across written
words that can be articulated and that have meanings ; but it is,
as a rule, impossible to discover from them, what the  patient
wishes to say.  The words that are most  frequently written cor-
rectly are their own  names, but even  these are often mutilated. c
AVhen they are able to perceive  that they have forgotten how to
write,  and  that the signs on the paper do  not express their 
               1        ATAXIC  AGRAPHIA.                    755

thoughts,  the affection is  ataxic agraphia.   If, however, they
continue to write, without being conscious of these facts, we have
no longer to deal with a simple ataxic agraphia; in such cases
the connection between the idea and its written-image is broken,
or the written-images are  obliterated  in the memory.  As the
aphasic patient can use  his tongue  for all purposes except for
speaking,  so the agraphic patient  can still use his hands in all
sorts of delicate occupations, with the sole exception of writing.
Spamer, e. g.,  saw in Giessen a young agraphic woman who
could sew very skilfully.
   It is evident from these facts, that the centres of co-ordination
for spoken and written words  are different and separated from
each other in position (Marce).1  As we proceed we will  detail
many more observations which prove that derangements in writ-
ten and spoken speech do not  always run parallel.   Since, how-
ever, both faculties are,  as a rule, deranged  together, it follows
that the two centres  are at all events closely  united,  and that
their tracks interlace.
   The sign-speech,  or  the speech  of gestures,  is  more  rarely
affected.   The  aphasias, in  which  the power of expressing the
thoughts by means of gestures is impaired, are always of  an in-
tense and complicated nature.   Here, too,  we meet with patients
who are aware of the fact that the power of pantomimic expres-
sion is lost, while others remain ignorant of the  loss.
   A woman, sixty-one years of age, was struck with apoplexy on January 3, 1862.
After the coma disappeared, she suffered from hemiplegia and hemianaesthesia of
the right side with aphasia.  She  could pronounce occasionally and with effort
the word mami, which she used in answer to all questions, and now and  then the
word non, which caused her still more trouble. Gesticulatory speech was impaired.
She nodded affirmatively with the head  when she wished to answer in the negative,
or raised up two fingers in  order to express four, or five instead of three.  It was
evident from the expression of her face  that she knew very well that she expressed
herself incorrectly.  She died Dec. 15th.
   An apoplectic cyst embraced a great part of the third left frontal convolution,
the entire left island, and  the neighboring  medullary substance along with the
anterior third of the corpus striatum  (Perroud).2

   1 De l'existence d'un principe coordinateur de l'ecriture. Mem. de la soc. de biol.
II. scrie.  T. III. 1865.
  5 Journ. de med. de Lyon. 1864. 
 756          KUSSMAUL.—DISTURBANCES  OF SPEECH.

    A woman was paralyzed on the left half of the body, and aphasic from apo-
 plexy.  She still had at her disposition only the following little phrases which she
 uttered with interjectional sprightliness : "Oui, parbleu ! "  "Tiens!" and " Vous
 comprenez ?" When asked whether she wished to eat, she answered : " Oui, parbleu!"
 what she wished to eat ? "Oui,  parbleu ! " what her name was ? " Oui, parbleu! " or
 also " Tiens!" in a mocking and snappish  tone.  She seemed persuaded that her
 answers were to the point.  She often added, "Vous comprenez?" in the tone in
 which a person would use it who thinks he has convinced the person speaking with
 him.  She often made use of  gestures,  which were as limited and senseless as her
 discourse (Peter).  Here there was amnesic or combined amnesic and ataxic derange-
 ments.

    Trousseau found also that  aphasics  sometimes imitate  ges-
 tures,  but cannot make  them at request, unless they have been
 previously made before  them.  This is not ataxic, but amnesic
 amimia.

   The  patient Paquet, who, besides his name, could pronounce almost only the
 word "cousisi," imitated the movements of clarionet-playing with exactitude, and
 comprehended  also what  they  meant.   When requested a few  moments later to
 make the same motions of clarionet-playing, he reflected, but was generally inca-
 pable of accomplishing this simple pantomine.

    We will close this chapter with an abstract of a case observed
 by AA'estphal, in which  there was in our opinion aphasia of a
 decided  ataxic nature.  It  is impossible to determine  from the
 very meagre account of the case that has been published whether
 it was accompanied by  amnesia.   AAHiat  seems to us especially
 interesting  in this case  is the inability to utter words with the
 exception  of two  senseless word-like  combinations  of sounds,
 while the patient, under certain circumstances,  was  still able to
 articulate letters.

   A  man in  Westphal's' clinic,  who  shortly before had been paralyzed by an
 apoplectic stroke, had the appearance of a person of great intelligence, but was un-
 able either to utter a word spantaneously, or to repeat one after another person.  VThen
 a word was dictated to him, he opened his mouth, made all sorts of grimaces, and
visibly exerted himself to respond  to the  demand, but always gave utterance
instead to the sounds " tschi-tschi," or " akoko."  He was also unable to repeat cer-
tain sounds. When he was told to read aloud from a book—he had learned  to read
   1 Zeitschr.  f. Ethnologie.  Bd. VI. 1874.   Verhandl.  der  Berliner  GeselPch. f.
Anthropologie. S. 94. 
AMNESIC  APHASIA.
757
—he brought forth in a spelling manner (no matter what the letters were in the text
before him), the sounds a, u, se, etc., which he was able, on request, to repeat after-
wards.  When told to put out his tongue, he opened his mouth, without putting it
out at first.  At other times, however, he succeeded in protruding the tongue, which
then showed itself to be freely movable.  Upon dictation he wrote his own name
and that of his wife correctly.
                       CHAPTER  XXVI.

Amnesic Aphasia.—Simple  Aphasia of Recollection (Erinnerungs-Aphasie),  and
   Aphasia with more intense Disturbances of Memory.—Influence of  Word-
   Amnesia and of Aphasia in  General  upon Mental Activity.—Complicated
   Forms of Amnesic Aphasia.

   As Biermerx has  very appositely remarked, the converse of
the Mephistophelian verse :  "AVhen the ideas fail, a word conies
opportunely to hand," a applies to amnesic aphasia.   The idea
is present, but the word is wanting,  although  articulation is at
the service of the word.  The idea of  an object, or of its prop-
erties and relations, rises up in the ihind, but the accompanying
word-image is wanting,  or only partially enters the recollection.
   Two  things are possible here.   Either  the word is entirely
extinguished in the memory, or it still remains there, but does
not get afloat; or, to use a more common expression, the associa-
tion between word and idea is  interrupted.
   Altogether the most frequent form of aphasia is  that in which
the word is still preserved  in  the  memory, but the idea can no
longer bring it  into  recollection, while it immediately emerges
and can  be correctly spoken, as soon  as it is either  spoken or
read before the patient.
   Nasse3 and after  him Falret4 have made from this a special
class of aphasics, viz., those who, the  intellect being intact, can-
not recall certain words, classes of  words, and letters, but  can
   1 Vortrag iiber Aphasie in Zurich, 1 Jan. 1871.  Correspondenzblatt fiir schweiz.
Aerzte I. 8.
   2 " Wo die Begriffe fehlen, da stellt ein Wort zu rechter Zeit sich ein."
   3 Allg. Zeitschr. f. Psychiatrie. Bd. 10. 1853.  S. 525.
   * Arch. gen. de med. 1864. Vol. I. p. 339. 
758          KUSSMAUL.—DISTURBANCES  OF SPEECH.

still repeat and also write out all words which are spoken before
them.  This is simple aphasia of recollection.

   Thus, an  epileptic  could  not utter a single word  spontaneously,  but lie
repeated and wrote without difficulty words that were spoken before him.   (Forbes
Winslow.1)
   Proper  names  and  substantives in  general  are the  words
which are  most  frequently forgotten ; sometimes  verbs,  adjec-
tives and pronouns are also forgotten, and  occasionally all words
have slipped from the  memory.   It is usual to  illustrate the
forgetting of proper names by Crichton's well-known anecdote
of the ambassador at St. Petersburg, who, when asked his name
on the occasion  of making a  visit, had first to  call  out to his
attendant,  "For  heaven's sake, tell me what my name is ! "
   AAThen the aphasic patients do not find the  substantives they
want, they paraphrase them  in such a way that the integrity of
the idea can be clearly recognized.

   A hind,  forty years of age, was unconscious for four weeks after a severe injury
of the head; he regained his recollection of things and places, but his memory for
names was lost.  The nouns had disappeared from his vocabulary, but he still had
command of the verbs.  A pair of scissors he called that with which one cuts ; the
window, that  through which one  sees, through which the room  is illumined, etc.
He had forgotten most of his songs and prayers.  He  recovered his memory subse-
quently (Bergmann 2).

   A  case  observed by  Graves,3 a  thoroughly   trustworthy
authority, is uncommonly interesting, since  it shows that only
the  initial letters  of the substantive,  and consequently only a
portion of the word, may be aroused in the memory by the idea,
the rest of the word not emerging until the corresponding written
word meets the eye.

   A man fifty-six years of age, after an apoplectic  attack, lost his memory for
proper names and substantives in  general, with the exception  of their  first letters,
although the power of speech was  not impaired in other respects.   He prepared for
himself an  alphabetically arranged dictionary of the  substantives required in his
1 Obscure Diseases of the Brain and Mind. p. 510.
2 Allg. Zeitschr. f. Psychiatrie. 1869.  Bd. 6. S. 547.
s Dublin Quarterly Journ. T. XI. p. 1. 1851. 
AMNESIC APHASIA.
759
home intercourse, and whenever it became necessary for him to use a noun, he
immediately looked it out in his dictionary.  When he wished, e. g., to say Kuh
(cow), he looked under K.  As long as he kept his eye upon the written name,
he could pronounce it, but a moment afterwards he was unable to do so.

   On the other hand,  a boy, whom L. Schlesinger' observed, left
out the initial consonants of words in speaking and writing.
   The  boy, who was eight years of age, became speechless  in consequence of a
commotio cerebri, after which he had been unconscious for six days.   Immediately
after the return of consciousness he could make himself perfectly intelligible by
signs, but could neither speak nor write.  He gradually learned both again.  One
month after the  receipt of the injury he was able to speak nearly everything, but
left out invariably the initial consonants of the words.  He spoke and wrote, e. g.,
" Ich ar icht ort," instead  of "Ich war nicht dort."

   The question now  arises, why nouns, and especially proper
names and names  of things, are more readily forgotten  than
verbs,  adjectives, conjunctions, and  the other parts of speech?
The  more  concrete  the  idea,  the more  readily is  the word to
designate it forgotten, when  the memory  fails. Probably the
only reason for this is  that the conceptions of persons and things
are more loosely connected with their names than the abstrac-
tions of their circumstances,  relations, and properties are.   AVe
easily represent persons and things to ourselves witliout names ;
the image  of  sense is here more  essential than the symbol,  /. e.,
the name, which conduces but little to  our  comprehension of
personages or objects.  More abstract conceptions, on the con-
trary,  are  attained  only with the  aid of the words, which alone
give them their exact shape.   Hence verbs,  adjectives, pronouns,
and, still more, adverbs, prepositions, and conjunctions, possess
a much more intimate relation to thought than nouns.  AVe can
conceive that the processes of excitation and the combinations
in the cellular networks of the cerebral  cortex must be  much
more numerous for the creation of an abstract than of a concrete
conception, and that the organic tracts which connect the former
with its  name must be  correspondingly  much  more numerous
than those of the concrete.
   This accounts for the fact  that  forgetfulness  of the names of
1 Wiener med. Presse. 1869. Nr. 37. 
  700        KUSSMAUL.—DISTURBANCES OF SPEECH.

  persons and of things is, even in the fulness  of  health, a very
  common occurrence.  Gradual transitions lead  from th\s pliysio-
  logical to pathological word-amnesia.  Elderly people frequently
  complain of the failure of their recollection for names at a time,
  perhaps, when they  think with the  greatest vigor,  and  long
v  before the morbid senile amnesia sets in.  In riper years, persons
  and objects interest us less on their own account than on account
  of the associations bound up with them, the concrete phenomenon
  less than the ruling idea and the principle governing the pheno-
  mena.  The capacity to  grasp and to hold fast in the memory
  the  laws by which facts are regulated, increases as we advance
  in years, while the memory  for words diminishes.  In senile
~  amnesia, provided it is really morbid, the former  suffers also.
  Past events, even important ones,  vanish from  the  memory;
  things  that occurred during  early life remaining fresh in the
  recollection, when more recent  occurrences have been  entirely
  forgotten.   The patients forget the names of their  best friends
  and even of their own children ; at last they can  only  recognize
  their nearest connections with effort, and gradually fall into a
  condition of senile imbecility.

    Let  us now contrast  the  more profound  derangements of
  memory, which, as a  rule, are of a complicated nature, with the
  aphasia of  recollection.  In the  former we do not have to deal
  with a  simple  loosening of the bonds  between the idea and the
  word.  On the contrary, the words are shattered in their struc-
  ture  as acoustic  combinations  of  sound, and  are sometimes
  obliterated  completely.  In this condition also it is the proper
  names and substantives which suffer in the first instance, and the
  verbs, adjectives, and pronouns in the  second, while the parts of
  speech  which represent rather the  framework of language are
  still unaffected.  The patient distinguishes and understands the
  words when they are  pronounced before him, and endeavors to
  repeat them, but with very varying,  and,  as a rule,  only partial
  success.  AArhen the patient is anxious to learn, and pays strict
  attention, fastening his eye upon the mouth of the speaker, and
  the  word is repeated before  him several times,  he can  often
  reproduce it correctly.  Otherwise it cannot be uttered at all, or 
AMNESIC APHASIA.
7G1
 is articulated  in a mutilated shape ;  sometimes  this, sometimes
 that sound or syllable is forgotten, or the sounds and  syllables
 are incorrectly  combined,  or  alien  syllables  which belong  to
 kindred words  are interpolated or added in place  of  the final
 syllables.  The mutilation and distortion of words occurs in vary-
 ing forms, now in this form, now in that, and not in the constant
 form we find in  ataxic aphasia.   At  the same  time the articula-
 tion of  the sounds is unaffected, provided the case  be  not com-
 plicated by literal anarthria.  The written language is invariably
 affected,  and, as a  rule,  to a  much greater  degree than the
 spoken language.  The letter-signs may be entirely forgotten,  or
 can no longer  be arranged in  the form of words.   In some cases
 a few written  word-images  still emerge from the depths of the
 memory in a  recognizable and  correct, or in  a  mutilated  and
 contorted shape.
    The following case, which came under my  own observation,
 and along with  which I give  the results  of the  autopsy,  will
 illustrate for the reader this form of severe amnesic aphasia.

   A stone-mason, fifty-five years .of age, with extensive atheromatous degeneration
 of the arteries, remained a long time in the surgical clinic in Freiburg, where  he
 was treated for ulcers of the feet.   On March 19th, 1875, these had cicatrized.  Up
 to that time no disturbances of the intelligence or of speech had been remarked.
 On the evening of  March 22d, a weakness of the right arm, and a transient inability
 to find words, suddenly set in; for some days previously  he had suffered  from
 loss of appetite and  nausea.  At noon on March 23d the aphasia returned and this
 time was  permanent.  In the evening there was f>aralysis of the right leg.  The
 patient was transferred to the medical wards.  On the following  day we found
 paralysis  and anaesthesia of  both legs,  with cessation  of the circulation in both
 crural arteries. These serious symptoms were caused by thrombosis of the abdom-
 inal aorta, and resulted in death  on April 12th, from mummification of the legs.
 We had therefore an interval of three weeks in which to study the patient's aphasia.
 The paralysis of the right arm disappeared sufficiently in a few days  (on March
 26th) to allow the patient to use the arm for the purposes of eating, and it gradu-
 ally disappeared almost entirely.  No anaesthesia of the arm could  be discovered.
 In the face and tongue there was no sign of paralysis.
   The patient had lost to a great extent the ability to find words, but not the power
 of articulation.  He repeated all the letters correctly, with the exception of the letter-
 word ypsilon (y),  of which he could only repeat the syllable  yps.   He could not
repeat the alphabet spontaneously; sometimes he began to count instead of to spell,
and broke off in a pout when he discovered his error, and at other times he would 
1
762           KUSSMAUL.—DISTURBANCES  OF  SPEECH.

begin in a careful and resolute manner, and succeed  perhaps in  bringing  forth
several,  even six  or  eight letters consecutively, but would then become silent or
utter a medley of  letters, some of which had been already spoken and some had not.
He was still  able to reproduce in imitation  simple syllables  and even words of
two or three syllables, but would say, for instance, " bobe " instead of " bebo," etc.;
words of more  than  three syllables  he could  not utter.   Instead of " Constantino-
ple " he said " Stozati, Stozate, Stozatalsch."  After prolonged  schooling, in which
he was made to pronounce one syllable after  another, and to watch closely at the
same time the mouth of the person speaking to him, he achieved " Constanti," but
could get no further.  In counting he proceeded sometimes  as far as twelve, some-
times  as far as  sixteen; then followed complete confusion, in  which he at times
perceived that he  was astray, at times not.
   His name, Senn, he found and pronounced  on the second attempt; the name of
his birthplace, Buchheim, only after several fruitless  efforts and with assistance from
others.   To the  question in which county the  village lay came the answer " Here "
(Buchheim is situated in the  county of Freiburg).   "When asked the name of the
county town  which he meant by "here," he  answered in an  animated tone,  "I
shall find it  yet."  He was unable  to find the name, however.  When the word
" Freiburg " was pronounced  before him, he  said  " feig-burg-burg-frei-fro."  He
was made to fix  his attention on the mouth  of the speaker,  and at last he  suc-
ceeded in saying " Freiburg."   He was then asked in what country Freiburg lies?
He answered, "  Of course I know that! " but he was unable to find the word for it.
" Grossherzogthum Baden" was pronounced before  him, and he said, in  attempted
imitation, " grossherzog,  grossfrei."   He could not say knife,  fork, etc., although
he knew them.  We tried to teach him the names for them, sometimes with success
sometimes without.  Instead of " Gabel " he  said " Gasser," instead  of " Loffel,"
" Flofe."  He  wrote his name  with  his  shaky right  hand,  but wrote  " Sen"
instead of " Senn," forgetting therefore the second " n;" when the mistake was
pointed  out to  him, he was unable  to  correct it.   Of his first name "Friedrich"
he could only say " Fri."  He  was  unable  to write down  his age and birthday.
We could not,  on account of the marked presbyopia of the patient, ascertain to
what extent he was able to understand what he read.
   When the patient attempted to speak of  his own accord, he was unable to find
the words. He contented himself therefore with indicating his meaning by gestures.
He still possessed, however, a small store of  words and sentences, of which he made
constant use.  They were the interjections :  "  O, je ! " " O, weh ! "  "Mein Gott!"
" Maria  Josef ! " " Das ist zu arg ! " (that is too hard), " Ja freilich ! "  and now and
then also : " Sacrament! " He summoned persons by " Sie ! " (you).  He answered
questions always correctly with " Ja!" (yes), or " Nein ! " (no),  or " Zu viel ! " (too
much), " Zu arg! " (too bad),  "Nicht so arg ! " (not so bad).  He took the liveliest
interest in everything that took place in the ward.
   On the 6th of  April the patient began to be delirious when left alone.  At this
time he had fever.  He uttered  undistinguishable syllables which were  frequently
reiterated, along with the same expressions of  wonderment  and words of complaint 
AMNESIC APHASIA.
763
as before.   After April 8th he threw in occasionally French words.  Between the
"Maria Josef," "Das ist halt so!" "Das ist's eben ! " "Es ist halt zu arg!" he
would suddenly strike in with " Mon Dieu!  mon Dieu ! "  When requested, e. g.,
to designate the seat of the pains he complained of, he answered, " Pas  toujours! "
Immediately afterwards  he would reply to another question in an irritable  man-
ner, but still in words that showed  a correct understanding of the query : '• O, je
n'en suis pas sur."  We ascertained, on addressing him in French, that he had lived
long in France.   He always answered correctly with : " Oui, monsieur! " " Oui! "
" Non ! " " Mais si! " " Pas trop! "  " Bien ! " and thanked with " Merci! "  To the
question :  " Vous etiez a Paris 1 " the answer was, " Si, j'y etais."  Question : " Was
er dort getrieben ? " (what he did there).  Answer: " J'ai pait .... ! " unintelligible
syllable.    Question :  " Avez-vous travaille ? "   Answer :  " Presque  toujours ! "
Question: "Was?" (What?). Answer: " Travaille- .... chose . ... je  ne sais pas
bien."  He answered eagerly in the affirmative when asked if he had worked in the
Paris chalk quarries, but could give no further details.
   At the autopsy we found  a reddish yellow, circumscribed softening of the left
cerebral cortex in two foci : the larger, 5.5 cm. long and 1.5 to 1.8 broad, occupied
the anterior portion of the " Gyrus angularis" (Huxley, Ecker) ;  the smaller, 2 cm.
long and 0.6 broad, partially destroyed the " Gyrus occipitalis II." where it unites with
the " Gyrus temporalis II." The depth of the foci was only 4 mm.  The branches of
the vessels leading to them were the seat of thrombosis.  There existed no  other
lesions of the brain. Unfortunately, we were unable to ascertain whether the paresis
of the right arm had its origin in thrombosis of the brachial artery or in the lesions
of the cortex.
    Our patient, therefore, was able at  the best to put  together
words of three syllables,  never one of  four.   He presented the
typical picture of loss of  memory for spoken  and written words
without  special complications,  which manifested itself princi-
pally by a forgelfulness  of substantives  and by the markedly
disjointed manner in which he combined letters and syllables in
the spoken words.   The recognition and comprehension  of words
were not noticeably affected.  This case  illustrates  admirably
how em ataxic  impress can be stamped on the utterance of a word
by the disjointed acoustic combination of the same.
    AVe will now describe another case, also observed by ourselves,
in which the  recollection of nouns and verbs  had suffered seri-
ously, and their formation from the sound and syllable elements
but little, while the comprehension of words seemed  affected.
This  case  forms  the  transition to  the  derangements which we
shall describe  in  the following chapter as word-deafness  and
word-blindness. 
764           KUSSMAUL.—DISTURBANCES OF SPEECH.

   A gentleman of fine appearance, sixty-six years of age, with sclerosis of the arte-
ries, and fond of  good living, was in good health until five weeks before he came
under our observation.   At that time, while on a journey  and suffering from obsti-
nate constipation, he began  to be visited by attacks of dizziness attended by un-
usual mental irritability and ill-humor,  with headaches in the right frontal region,
which at times were very severe and  disturbed his rest at  night.   Gradually a
disturbance  of speech developed itself, on account of which I was consulted.  He
greeted me  at first  with some tolerably fluent  sentences, and recalled a previous
accidental meeting  in  Stuttgart.  Presently, however,  he came  to a  full stop in
each new sentence as soon  as he  came to a noun, or used instead a wrong word
(paraphasia). If he was helped over this difficulty, he was able to conclude the sen-
tence correctly, provided he did not stumble across a verb at the  end; if he did,
he generally exchanged it for an inapposite one.   It often seemed to me that the
verb did  not  occur to him,  simply for the reason  that  the  first part of the sen-
tence had vanished from his memory.  His inability  to find the substantives vexed
him;  he tried to paraphrase them, but in doing  so involved himself into more and
more  incomprehensible combinations of phrases, and lost the thread  of his sen-
tence.   He became  tranquil, however, and  joyfully assented when I guessed what
he really wished to say.  Mutilation and  distortion of words occurred only to a
slight extent.
   Being far-sighted, he used glasses in reading, and with  their help read aloud,
somewhat slowly bat correctly, even very long words.  It was  evident, however,
that many words were strange to  him which had been unquestionably familiar to
him  previously.  Thoughtfully  repeating one of these words twice, he remarked,
"I have never met this before."  In speaking the longest words he broke off in
the middle, repeated the first half, and then united both  halves into a well-spoken
whole.  He could write letters, but was unable to write words correctly.  He began
with wrong letters, then wrote perhaps two or three in correct sequence, and finally
finished the word with a number of wrong  letters.  The  effort of writing fatigued
him greatly, and he gladly desisted from it.  The movements of the tongue were
free in all directions and he could whistle loudly.   During hearty laughter a tol-
erably marked drawing  of the mouth towards  the right side was observable, but
no drooping of the left angle of the mouth could be discovered.   The limbs were
free in  all  their movements, but the patient complained of being  easily fatigued.
It was discovered that he had always been  left-handed;  he  wrote, however,  with
the right hand.   This  was  weaker than the left (from want of practice), and, as
has been said, was not paralyzed.  He saw well with both eyes; he had been for
a long time slightly deaf in the  right ear; sensation in the skin  and the  tongue
was delicate.   When the patient was  told  to press  the hand,  to  put  out the
tongue, or to close the eyes, he  spoke some assenting words, " ja,  ja," or " ja
wohl,"  but  did not perform the movements until they had been  made before
him  once or oftener.  He acted in  this like a  person who does  not understand a
request couched in a foreign language, and who can only be  made to  understand
by gestures. 
AMNESIC  APHASIA.
705
   I saw the patient again fourteen days later.  His mental and bodily strength
had in the meantime markedly decreased, and a  left-sided  hemiparesis of  the
face and arm was unmistakably present.  He used the right hand almost entirely,
although he had seldom used it previously, and passed it frequently over the right
side of his head, which seemed to pain him.  He spoke only a few, for the most
part unintelligible words, and no  longer understood what was said to him.  His
food had to be put into his mouth, because he was no longer able to get hold of it
with the spoon and fork (apraxia).  He only ventured to walk when he was led,
and walked then with short mincing steps.  After this time all the faculties of the
patient progressively decayed, and he died three weeks later.
   At the autopsy,  as  the  physicians kindly informed me, the right temporal
lobe was found  swollen, and affactsd  with yellow softening in its anterior por-
tion over an area about the size of a goose-egg, without sharp demarcation from
the healthy medullary substance. At  the  fissure of  Sylvius a portion of this lobe,
about as large as a hazel-nut, was infiltrated with blood.  The softening extended
some centimetres downward into the head of  the nucleus caudatus.  The frontal
lobe was intact.

    At the date of  the first examination in  this case  there was
evidently not only a derangement of association between the con-
ception and the word  in the direction from the former to the lat-
ter, but also a derangement  in the direction from the latter to the
former ;  the expressive as well as the  impressive band of fibres
was affected, while the words were still properly  made up of
their sounds,  whenever it was possible  to drag them from the
depths of  the memory, whether  this were done by the  force of
the idea itself or of the written or dictated words.  At the same
time  this  case shows how the  loss of nouns and verbs can im-
pede the  course of the speech, and  thereby interfere with the
evolution of the thoughts tJiemselces.
    A\;e are  thus led  to  the question  of the relation of word-
amnesia to the intellect.   AYe see, from  the  example just cited,
that this  defect in its severer  grades  renders well  regulated
thinking  aloud impossible.  It does not follow, however, that
silent thought is also incompatible with it.
   There  are many mental combinations  that  are consummated
without words.  To such belong particularly many games.  Thus,
we see many aphasics, who can  hardly find a single word, still
play dambrett, dominoes, cards and  chess with great skill.  The
aphasic Paquet, of whom we have repeatedly spoken, who could
not even count his  age upon his fingers,  and whose  intelligence 
766         KUSSMAUL.—DISTURBANCES  OF SPEECH.

was  considerably  impaired, could still  play cards  well,  and
cheated thereat with a  certain shrewdness (Trousseau).   It is a
remarkable fact  that persons who previously played well some-
times remain masters of the game, not  only when they have
become aphasic,  but also when they have become weak-minded.
Trousseau tells us that when he was Assistant Physician in the
Insane Asylum at Charenton, he was often irritated to the very
depth of his soul, because some half-idiotic person  beat him at
a game of trictrac or chess.
   Mental combinations which bear upon business affairs, and
can  only be set  in operation by the aid of speech, are at times
even admirably  carried out notwithstanding the existence of a
high degee of ataxic aphasia.  AA"e have already cited in Chap-
ter A^II.  an observation  of Broadbent1 s, belonging in this cate-
gory, which places this fact beyond doubt,  and we will now
quote  one from Trousseau that is no less instructive.

   An educated landed proprietor, who could only say "oui" with a heavy lalling
tongue, and could not write at all, suffered not only from anarthria, but also from
aphasia. When requested to pick out the o, u and i, of the word "oui" from a
number of letters more than one ctm. in size, he succeeded in doing so, with some
difficulty, but was not able to  form the word " oui" out of them.  He understood
very well what was said to him. His intelligence was impaired, it is true, as the
members of his household showed, but to so slight a degree that he was still
able to aid his son with useful advice in the management of his large property.
He insisted on being consulted in regard to the leases, indicated by gestures when
any clause displeased him, and would not then rest content until  it was changed
in a manner to suit him.  As a rule, the changes he sanctioned were profitable. 'He
played cards as well as he did previously.

   This patient,  consequently,  thought out  correctly involved
questions  of business,  although he  suffered in an advanced
degree from ataxic aphasia.  It is  not necessary to regard the
decline of his mental power as a consequence of the aphasia;
both derangements could be co-results of the unquestionably
serious organic lesion of the  brain which had  caused permanent
hemiplegia and paresis of the tongue.   Impairment of the intel-
lect is  almost invariably met with in connection with  aphasia,
but  the two derangements do not run a parallel  course,  and
hence  it is advisable not to ascribe an existing mental debility 
AMNESIC APHASIA.
767
to the aphasia, but rather to seek for the cause of both disturb-
ances in a third, the organic lesion of the brain.
   One would think that amnesic aphasia, especially in its more
severe forms, must offer a greater obstacle  to mental  combina-
tions of the  second class than the ataxic variety of  the affection
—that the loss of word-signs must render the thoughts mixed
and confused.  In fact,  unless the affection be merely a light
form of aphasia of recollection, it is almost always accompanied
by a very pronounced diminution of  the intelligence.   Lordat,
however, asserts, as we  have already mentioned in Chap. VII.,
that he  was  able to think rationally in spite of an amnesic apha-
sia with entire loss of the memory and understanding for spoken
and written  words.   As we do not consider ourselves justified in
refusing all credence to Lordat's assertion, although it evoked
many doubts in us, as well  as in Trousseau, we are compelled to
leave  the answer to this question open.

   It  is not always  easy to draw the line between the aphasia of
recollection and deeper disturbances of memory.  AAHiilst in the
former we have to deal only with a disturbance of  the conduc-
tion from the ideational centre to the  acoustic word-centre, with
a diminution consequently of the ability to draw out the word-
signs  from the memory through the  stimulus of the thoughts,
in the latter  the function of the formation of signs and  the
acoustic word-centre itself are involved.  Up to this point  the
conditions of  amnesic  aphasia  can apparenthy be  easily and
clearly grasped.  They become, however, more  complicated and
often  difficult to unravel, when, as in our last-mentioned case,
conduction in the direction from the acoustic word-centre to the
ideational centre, /. e., the comprehension of the signs, is affected;
when, further, the track between the  acoustic and the motor
word-centres is involved in the lesion ;  when the intelligence is
greatly  impaired;  finally,  when,  in  the case  of persons who
know how to read  and write, the optical word-centres employed
in reading and writing and the bands of fibres connecting them
with the ideational centre and the motor centres for spoken and
written words, must be  taken into consideration in the analysis
of the case.   AVe will describe some difficult cases of tins char- 
763         KUSSMAUL.—DISTURBANCES OF SPEECH.

acter here; in the following chapters they will be more minutely
investigated.
    In one  case,  which was published by Dr. Hertz ' in  the last
century, the word-images  very  seldom  came spontaneously  to
the lips,  and then  only  in an  isolated manner;  the  words,
moreover, could only be repeated from dictation, when they were
pronounced several times  loudly before the patient,  while, on
the other hand, in reading  they came to him instantaneously.

   An officer, about forty years of  age, was attacked with apoplexy in August, 1785.
The tongue, hands, and feet, were at first paralyzed.  After  a year he was able to
walk again, and his  hands also had become stronger, but a disturbance of speech
remained behind.  He pronounced distinctly isolated words that happened to occur
to him, or that were repeated before him a number of times aloud  and slowly;
otherwise  his discourse was an incomprehensible muttering.  When a book or
manuscript was put in his hand,  he read easily and distinctly, and not even the
smallest mistakes could be  noticed.   As soon as he laid aside the book, he was
unable to  repeat a single one of the words just read.

    In the following case the restoration of the memory for words
by the aid of written speech and spelling is extremely interesting.

   Dr. Hun,2 of  Albany,  reports the case of a farrier, who suffered from  heart
disease, and was seized one day with congestion of the brain, which threw him into
a state of  stupor  that lasted several days.  He then recovered consciousness and
understood what was said to him,  but although his tongue was freely movable, he
could not find words, and had to make himself understood by signs.  He under-
stood the meaning of the words which were said  to  him, but could not find those
necessary  to give expression to his  own thoughts.   He could not repeat words
that were pronounced before him.  When Dr. Hun pronounced the word which he
sought, he was much rejoiced, but his efforts to  repeat it were fruitless.  If Dr.
Hun wrote it out for him, he was able to spell it, and could then pronounce it after
a few attempts.  He gradually learned by repeated practice to retain and use it.
He made for himself  a tablet on which the necessary words were written out, and
took refuge in this during speaking.  Finally, he learned to do without it.  When
he was unable to pronounce a word, he was also unable to write it.

    AVe  follow this up with  a case in which the entire  domain
of expression and intelligence was deeply involved.  The aphasia
in  this  case seemed  more considerable  than  the agraphia, and
there was evidently a severe disturbance not only of an amnesic,
1 Winslow, loc. cit.
2 Bastian, loc. cit., p. 220. 
                          AMNESIC  APHASIA.                      700

but also of an ataxic nature.   The patient was treated at first
by Trousseau, and later by Charcot.'

   Adele Anselin was at first entirely speechless and paralyzed upon the right side.
The hemiplegia persisted, but the tongue was freely movable, and subsequently she
became able to speak of her own accord  three words or phrases:  "Maman! ma-
man ! " to call people to her; " Peux  pas dire," as an answer to all questions; and
when she was impatient, " Oh, malheur ! "  Besides this she could  count up to fif-
teen or sixteen.  She was somewhat better off in regard to writing, for which she
made use of the left hand.  She was able to write down several short phrases with-
out dictation, e. g., "Monsieur, je vous remercie de toutes vos bontes ! "  She could
also write a few words and short phrases which were dictated to her or which she
read, but she frequently mixed up the words, and generally ended with undecipher-
able hieroglyphics.   She often employed  the wrong pantomimic symbols.  A child-
ish behavior betrayed the  fact that her intellect was affected.  The autopsy dis-
closed numerous foci of softening  in the cerebral cortex, which were secondary to
inflammatory vegetations in the  left heart.   They occupied  chiefly the left island
and the border convolution of the  left temporal lobe, the third right frontal con-
volution, and the right corpus caudatum.

    In the following case, finally,  there was also severe  amnesic
aphasia, along  with serious disturbances of the  understanding
and of  the intelligence in general.   The motor centre for spoken
words had  not  suffered, but the connection  between it and  the
acoustic sound-centre seemed at  times to be interrupted, whereby
the aphasia received a more ataxic impress.

   A patient, whose history was given to us by Sander,2 could speak a number of
words in a tolerably connected manner, but often missed single words, and some-
times could not tell his name, age, and  occupation. Occasionally he was able to
pronounce the most difficult words, e. g., " Schornsteinfeger " (chimney-sweep) six
times in succession.   At other times he repeated incorrectly words that were pro-
nounced before him,  and did not correct  the mistakes, no matter  how often  they
were repeated to him in the proper  way.  He remarked  occasionally, when he did
not know a word, " I did know that, but I cannot say it any more ! "  He could
only count up to  twenty.  When asked how much  six times seven is, he answered,
twenty-six. He could not  repeat the alphabet; when he tried to do so he would
say, a, b, c, 3, 4, 5.  He  could no longer read or write, and  also no longer  recog-
nized individual letters.  He was unable to name  objects placed before him, but
found them correctly when their names were mentioned to him.  When he was told
to look at  his finger,  he raised his hand,  attempted to whistle, and the like.   The

                    1 Font-Reaulx, loc. cit. Obs. 33.
                    2 Arch. f. Psych.  Bd. II. S. 53. Fall 4.
            VOL. XIV— 49 
770         KUSSMAUL.—DISTURBANCES OF SPEECH.

affection ended in imbecility.  The autopsy revealed an extensive focus of soften-
ing in the left hemisphere, in  collections of fibres which, according to Sander,
belong to those radiating from the corpus callosum.
                      CHAPTER XXVII.

Word-Deafness.—Word-Blindness.—Derangements of the Impressive or Perceptive
    Speech-track in General.—Alexia and Kindred Derangements in the Compre-
    hension of the Symbols of Expression.—Apraxia and Aphasia.

    In medical literature we find cases recorded as aphasia which
should not properly be  designated by this  name,  since the
patients were still able to  express their thoughts by speech and
writing.   They had not lost the power either  of speaking or of
writing; they were no longer able, however, although the  hear-
ing was perfect, to understand  the words which  they heard, or,
although the sight was perfect,  to read the  written words which
they saw.   This morbid inability we will style, in order to have
the shortest possible names at our  disposition,  word-deafness
and word-blindness (ccecilas et surditas verbalis).
   These defects seldom occur isolated;  they are  generally
combined with other dysphasic  derangements, with genuine loss
of words of an  amnesic  nature, or with agraphia.   AA7e  have
already  described such  cases  in  which,  besides  aphasia  and
agraphia, there  was impairment in a varying  degree of the
ability to understand the words which were heard or the writino-
which was read.  As, however, a correct appreciation of this re-
markable phenomenon is of the greatest importance for the com-
prehension not only of aphasia as a morbid affection, but also of
the mechanism of speech in general, it is necessary to  make it
the subject of a special examination.
   All disturbances of speech can be  brought under two great
classes, according as the connection between the conception and
the loord is impeded in the direction from the former to the latter,
or vice versa, from the latter to  the former.  Wlien the first hap-
pens, the expression suffers ; when the second, the understand-
ing. 
            WORD-DEAFNESS  AND WORD-BLINDNESS.          771

   AA"e call the entire tract which leads from the nerves of sense
to the  centre  of conceptions the impressive or perceptive; the
other, which compasses the expression of the conception,  the ex-
pressive.  AVhat we style diction and articulation move entirely
upon  the expressive  tract.   The impressive  tract  serves  only
for the reception of words spoken or put into writing by others;
hence, the ability to  learn to speak and to write depends upon
the integrity  of this tract.   From  the clinical  facts  that will
presently be investigated, the conclusion is evident that, as in the
expressive  tract organically different functions are called into
action for the  production of  sounds and words, so in the impres-
sive tract different organs are required for their reception.  For
the understanding for sounds and that for  spoken words, or the
understanding for written letters and that for written words, are
not inseparably bound together, but are different things.  The
understanding for words can be lost, and that for sounds or let-
ters retained.   The perception  of sounds eind murmurs which
are individually  known  as  vowels  and  consonants, and their
arrangement  into the acoustic word-image which becomes the
symbol of this or  that idea,  are different functions, which are
performed in different parts of the centred system.  The aphasia
of Lordat, of which  we have  already repeatedly spoken, is one of
the most interesting examples of entire inability to speak due to
loss of the  memory for words with complete word-deafness and
word-blindness.   AVe will linger a little longer over his case.

   " Je me trouvai prive de la valeur de tous les mots.  S'il m'en restait quelques-
uns, ils me devenaient presque inutiles, parceque je ne me souvenais plus de la ma-
niere dont il fallait les coordoner pour qu'ils exprimassent ma pensee."  This state-
ment, it is true, leaves it uncertain whether Lordat was entirely  deprived of the
word-images;  but it is altogether probable that he was, since he not only could
not utter a single word, but distinctly states that the words fell uncomprehended
upon his ear, although his hearing was preserved and he was able to reflect as  a
physician and philosopher upon his condition.  In the same way the treasures of
writing were closed to him as with seven seals.  He could  spell, it is true, out could not
read.  "En perdant  le souvenir de la signification des mots entendus, j'avais perdu
cclui de  leurs signes visibles. La syntaxe avait disparu avec les mots, Valphabet
seul nCetait reste;  mais la jonction des lettres pour la formation des mots etait une
gtude a faire.  Lorsque  je voulus jeter un coup d'oeil sur le livre que je lisais,
quand ma maladie in1 avait atteint, je me vis dans l'impossibilitg d'en lire le titre. 
 772          KUSSMAUL.—DISTURBANCES OF SPEECH.

 II m'a fallu epeler lentement la plupart des mots."  He describes with deep emo-
 tion the happy moment when, after several wretched weeks, he allowed his gaze to
 wander over his library, and unexpectedly, from out of a corner the words " Hip-
 pocratis opera " flashed upon him from the back of a folio.  Tears  burst from his
 eyes.  That moment marked the commencement of the improvement, which finally
 ended in recovery.

    Another not less  important  observation reported  by   Dr.
 Schmidt,1 of  Munstermaifeld,  shows  that word-deafness  and
 word-blindness can accompany an amnesic derangement of speech
 of an intense grade,  which in  this  case  manifested  itself by
 aphasia,  paraphasia, mutilation and  distortion of words,  and
 agrammatismus.  The words were only perceived as  a confused
 murmur, although the hearing  was very delicate, and although
 the vowels and  consonants could not only be recognized when
 alone, but also  could with some trouble be combined into words.

   A woman, twenty-five years of age, became suddenly unconscious, during severe
 straining at stool, ten days after confinement.  After consciousness returned she was
 not paralyzed, but suffered from aphasia and paraphasia. She found the words
 with difficulty or not at all, reversed or mutilated them, said  "butter" instead  of
 " doctor," threw out letters and syllables, inserted others, used the infinitive instead
 of the proper mood, and  conjugated irregular verbs regularly.  She was thought
 to be deaf  because at first she did not understand a single word.  It was soon dis-
 covered, however, that she heard a knocking at the door or the ticking of a watch
 as clearly as a well person, that she could distinguish between two house-clocks by
 the tone, etc.  Words, on the other hand, as she afterwards stated, were perceived
 only as a  confused murmur.  She  heard  separate  vowels  and repeated them.
 When a word of one syllable was spoken  in the ordinary way, she did not under-
 stand it, but when the different letters were  separated  distinctly from each other,
 so that they stood forth in  the pronunciation, she was able to repeat the word.
 With words of more  than one syllable it was necessary first to pronounce one syl-
 lable distinctly, then another, then the two together, or she would not understand
 the word.  It was the same thing with reading.  She studied  the words very care-
 fully, and tried to pronounce them at first separately, and then together. Recov-
 ery took place slowly.  She did not understand short sentences until  after the lapse
 of half  a year, and then only when  they  were  pronounced slowly and distinctly.
Even at the last there remained some little difficulty in speaking.

    Patients who suffer from word-deafness and  possess  at  the
 same  time  the ability to express  themselves in words, but  use

            1 Allg. Zeitschr. f. Psychiatrie. 1871. Bd. XXVII.  S. 304. 
            WORD-DEAFNESS AND WORD-BLINDNESS.         773

many words in the wrong  places, and  often  distort them, leave
on the minds of observers  the  impression that they are crazed.
The observer must be on his guard to avoid falling into this error,
or into the still greater error, which has also  been committed, of
regarding the  patients  as at  once  deaf  and demented.   The
patients may have perfectly correct ideas, but the correct expres-
sion  for  them is wanting ; the words, and  not the thoughts, are
confused.  They would  even understand the ideas of others if
they could only understand the words.   They are in the position
of persons suddenly set down in the midst of a population which
uses  the same  sounds, but different  words, these striking upon
their ears as  an unintelligible clutter.  They attempt themselves
to speak this language, which perhaps they had once learned
during childhood,  but had almost entirely forgotten long before.
They no longer, however, find  the right words, and those which
they find are uttered in distorted and incomprehensible shapes.
   Baillarger1 demonstrated once that a person who had  been
regarded as both deaf and demented, was really  neither one nor
the  other.   He  concluded, from the  expressive gestures  with
which the woman, who  did not even know  her  own  name  any
more, accompanied,  her disconnected  discourse,  that  perfectly
distinct ideas existed behind  the apparent  confusion.   Unlike
an insane person, she betrayed a knowledge of her own condition,
and never did anything silly.
   Wernicke2 described two very instructive cases of  this kind.
One  of the women whom  he treated for this disease  was con-
sidered by the attendant to be deaf.

   Both women  were advanced  in years.  On a superficial examination, one of
them made the impression that she was insane, partly because her answers did not
correspond to the sense of the questions, partly because she used inverted and dis-
torted words.  The meaning of her sentences, however,  could be unraveled ard
was found to be rational;  moreover, her entire behavior was always sensible.  When
excited she often spoke quite correctly.  When she tried to write she only made
up and down strokes, and was no longer able to produce letters; she had also
lost the ability to read.
   Gradually she learned to speak almost correctly again and to read aloud with-

       1 Bull, de l'acad. de med.  T. XXX. p. 828.
       * Der aphatische  Symptomencomplex. Breslau. 1874. Fall 1 u. 2. 
774         KUSSMAUL.—DISTURBANCES  OF SPEECH.

out hesitation.  She also regained to some extent the power of writing; she could
copy from written manuscript, but could produce in writing only a few self-chosen
or dictated words.
  The other person, who also suffered from, paraphasia, was at first supposed to be
deaf and crazy. At the autopsy there was found, together with atrophy of all the
convolutions, a pulpy, thrombotic softening of the first, and of a great part of the
second left temporal convolution.
   TJiis word-deafness  can only  be confounded with genuine
deafness  when the observer  contents himself with a superficial
examination, since it is easy  to verify the fact that the patients
perceive and pay attention to calls, noises, and murmurs.   Be-
sides, the combination of  aphasia with  deafness is exceedingly
rare; an instance of it will be found in a case of apoplexy re-
ported by Banks.1  -This fact is striking, when we bear in mind
the frequent simultaneous appearance of aphasia and anosmia*
hemianesthesia,3 or hemiopia."'
   Speech-blindness  occurs more frequently than  speech-deaf-
ness.   AVe must be careful, however, not to mistake the results
of a genuine hemiopia, which usually occupies the right halves
of both retinas for an inability to see and to comprehend  letters
and words.
   According  as the letters or words do or do not  fall  upon the
remaining portion of the field of vision,  the hemiopic patient can
at one  time see and read, at another not.  AVhen the power of rec-
ognizing words and letters is still perfect, it is easy to  detect the
hemiopia, but  otherwise it is difficult.  It is then frequently by
no means  easy to say how much of the alexia and paralexia  is to
be ascribed to the hemiopia,  and how much to the more  or  less
complete  loss  of the ability  to apprehend letters  and  words.
The difficulty may also be increased by the  limited power of ex-
pression.   The patient can  perhaps still read  some  word or

   1 Dublin Quart. Rev. Febr., 1865.
   2 Bonnafont, Bull, de l'acad. de med. T. XXX. p. 875.— W. Ogle, Anosmia.  Med.-
chir. Transact. LIII. p. 263.  Compare also the case described in Chap. XXIX., p. 787,
in which the  outbreak of aphasia was accompanied by hallucinations of smell.
   3 We  have detailed several observations  of this sort, reported by Cornil, Perroud,
and others.
   4 Sander,  loc. cit.  Fall 9.  Bernhardt, Berlin,  klin.  Wochenschr. 1872. No. 32.
 Wernicke, loc. cit. Fall 3 u. 9. 
            WORD-DEAFNESS AND WORD-BLINDNESS.         77o

another, but can no longer pronounce it, or, when he tries to do
so, produces other syllables and words.  The real  state of  the
case can then scarcely be unravelled and we stumble across the
most astonishing-phenomena, as witness the observations reported
by AVernicke.   The patients, e.  g., read off, while passing,  the
names upon the tavern-signs on the street, but  are nevertheless
incapable of reading letters and words with a steady gaze.
    They recognize the individual  letters,  but  are  unable  to
put them  together to form words,  or, vice  versa, they read  the
words but cannot read the individual letters.  A patient recog-
nizes the word Goethe on the title of a book, but not  the word
Schiller on that of a  neighboring one.  Long words are perhaps
often read wrongly only for the reason that, while  the  first syl-
lable can still be properly seen, the  rest cannot, and the word
is then filled  out arbitrarily in  accordance with the idea called
up by the first syllable (Bernhardt').
    AVernicke  made a very sagacious remark in regard to  the
ability to comprehend written or printed characters.  He called
attention to the fact that this is  also dependent upon the degree
of intellectual cultivation.  The uneducated man, who is but
little practised in reading, can only understand the words written
with the aid of their spoken images ; he has to read the writing
aloud  to himself, because, for  the understanding  of the sight-
images, he requires  the aid of the sound-images.  The scholar
glances over a page, and understands its meaning without first
translating the written words into  spoken words.  The  first will
present the symptom of  alexia  in addition to the aphasia;  the
other can  understand written language, and his ability to do so
presents the most striking contrast to his inability to understand
spoken language. On the other hand, when he attempts to read
aloud, he may be as aphasic as in spontaneous speaking.
   An observation reported by van den Abeele * leaves little room
to doubt that  a complete text-blindness may exist, although  the
power of sight, the intellect, and the power of speech are intact.

   1 Berliner klin. Wochenschr. 1872. Nr. 32.  A patient with hemiopia, which
remained after recovery from aphasia, saw, e. g., in the  word " zerschmettert" only
the first syllable, " zer," distinctly.
   2 Bull, de l'acad. de med.  beige. Nos. 6 and 7. 
776          KUSSMAUL.—DISTURBANCES OF SPEECH.

   A woman, forty-five years of age, was struck with  apoplexy while in the enjoy-
ment of the most blooming health.  After some hours consciousness returned, but
she was paralyzed upon the right side, and had pain over the left eye; her intelli-
gence was somewhat dull, the memory weak, the speech free.  Six weeks later, the
paralysis and the weakness of  memory and  intelligence had almost disappeared.
Two months after the attack she discovered that she could no longer read printing
and writing.  She saw the text, distinguished the forms of  the  letters, and  could
even copy the text, but was incapable of translating the words into spoken  words
and thoughts.  She could comprehend pictures, and decipher a  rebus ; she under-
stood consequently ideographic representations, but not writing.   When van  den
Abeele published this  observation, the patient had already regained the power to
read some words of one and two syllables.

    Broadbentx  communicates a no  less  remarkable  observation.

  A very intelligent and energetic man, after suffering from cerebral symptoms
(headache, vomiting, delirium), lost entirely the power to read printing  and writ-
ing. He saw the text,  but did not understand it, although he could still write easily
and correctly both from dictation and spontaneously.   His  conversation was good
and his vocabulary very large, but occasionally the names of streets, persons,  and
things  failed him;  he  was  not able to name  on demand the simplest and most
familiar objects which were held up before him.   He died from an extensive hem-
orrhage into  the left  temporal lobe,  with rupture into the ventricle.  Two old
hemorrhages were found, one  in  the lower border-convolution  of this lobe; the
other and larger one, which had produced a softening of the  neighboring cere-
bral substance,  was located in the region between  the lower end of the fissure of
Sylvius and the ventricle at the point where the descending horn was given off.

    In this case,  therefore, the  conduction of  the word-images
to the  motor centre  of co-ordination  for  writing  was  still per-
fect,  while  the  text-images could no  longer be comprehended.
In conclusion,  we must make room here for  a very strange ob-
servation recorded by AVestphal.2

   He exhibited  at the meeting of the Society for  Anthropology,  a retired actor,
who, besides hemiplegia, presented the phenomena of an incomplete aphasia.  He
was intelligent, but his memory for pieces learned by heart was impaired. He spoke
fluently, but he could not find and did not understand a few words.  He could write
very well from dictation, but  shortly after was unable to read  the words he  had
 written, and  he suffered in general from complete alexia.   By  means of a strata-
 gem, however,  as he  himself very clearly explained, he succeeded in  reading the
 word  he had written from dictation  upon the tablet.   He passed his finger over
1 Loc. cit. Case 8.
2 Zeitschr. f. Ethnologic 
            WORD-DEAFNESS AND  WORD-BLINDNESS.         777
each letter of the written word as if he were writing it again and read it while so
doing. He then made a sort of calculation, and counted off the sum of the separate
letters.

   AVe  explain this phenomenon by the theory that the  in-
telligent man knew  how to  transpose  the movement-images of
the written  letters into  acoustic sound-images, and how to com-
bine these into acoustic  word-images.   The case seems to prove,
as Spamer also  assumes, that there is not only a path leading
from the  acoustic centre of word-images to the motor centre for
written words, but also one  from  the  latter to the former.   At
the same  time the case strengthens the theory of the existence
of movement-images, which accompany the production of words
by the action of the muscular apparatus.

   Griesinger called  attention to  the  fact  that many aphasics,
when requested to touch some portion of the body, touch instead
some other part, e. g., the nose instead of  the ear, without being
aware of  the mistake.   He ascribed it to a confounding of the
movements, but it is more correct to ascribe it to  a confounding
of the words heard, as v. Gudden l thought.  There is question
here of  a  state of  confusion in the perceptive and not in  the ex-
pressive tract.

   Just as  the understanding for written words  can be lost, so
can that for figures.   An accountant read off  the sum  766 figure
for figure, but he  did not know what the figure 7 meant before
the two 6 (Trousseau).   Another aphasic, on the other hand, al-
though he could no  longer  count in words, could add and sub-
tract on  paper,  and even   multiply  and  divide  pretty  well
(Proust).
   AVe have already spoken of a patient who had lost the  under-
standing for musical notes, although he was still able to  play
well by ear (Finkelnburg).   Inversely,  Lasegue2 saw a musician
with complete aphasia and agraphia, who could readily set down
in notes any melody which he heard. Another patient of Proust's
  1 Correspondenzblatt fiir Schweiz. Aerzte. Bd. I., bei der Discussion iiber den Vor-
trag Biermer's.
  2 In Proust, loc. cit., p. 310. 
778        KUSSMAUL.—DISTURBANCES OF  SPEECH.

was able to write music in notes, and even  to  compose, and
understood also any melody which he heard, but was unable to
play from notes.
   Sometimes we  see patients copy  drawings,  although they
cannot produce them spontaneously.  AVhether  or not  the re-
verse occurs we are unable to say.
   Many aphasics are no longer able to distinguish or to count
pieces of money ;  they forget the conventional social forms, and
the religious customs and signs ; they even confound  the spoon
and fork, and try to eat soup with the latter.  In the last case
the aphasia is combined with  apraxia—the memory for the
uses of things is lost as  well as the understanding for the signs
by which the  things are expressed.   The former condition must
not be  confounded  with aphasia, which has to  deal  only with
the signs by which the ideas are expressed.   This mistake has
been committed however.  AA"e have seen that the intellect may
be perfectly preserved in cases of aphasia, but this is never the
case in apraxia.

                    CHAPTER XXVIII.
          Schematic Diagram of the Centres and Tracks of Speech.

   Now that  we have arrived at this  point, which permits us to
survey the centres and tracks of speech from the standpoint of
clinical  facts, which are for us  equivalent to as many  experi-
mental  results,  we  think  the time  has come to illustrate by
means  of a schematic diagram the conceptions  which we have
formed in regard to their connections.
   Baginsky,1 AATernicke (loc.  cit.), and Spamer  (loc. cit.) have
preceded us in the attempt to form such schematic drawings.
   The  diagram of  Baginsky is incorrect for two reasons:  it
unnecessarily establishes special centres for the memory, and
directly  connects the centre of conceptions not  only with the
centre for word-images, which is correct, but also with the motor
centre of co-ordination, which we believe to be incorrect.
   AVernicke  made the mistake of locating the centres  in par-
1 Berliner klin. Wochenschr. 1871. Nos. 36 and 37. 
CENTRES AND TRACKS OF SPEECH.           770
ticular regions of the brain.  For  this the localization of the
elementary functions of  speech is not yet ripe.  His diagram,
moreover, only takes into consideration spoken speech,  and is
difficult to understand.
   Spamer avoided AArernicke's error of mixing up the question
of localization with the task of  representing the centres simply
in their connections, as deduced from clinical facts.  We cannot,
however, agree with him in the opinion that the conceptions set
the motor  centres of co-ordination  in action  directly and with-
out the intervention of the word-images.  The  results obtained
from the study of amnesic aphasia speak positively against this
view.   In that form of aphasia the centre for  conceptions and
the centre  for co-ordination are intact, and the word does  not
come  to the surface, simply because the word-signs are wanting
within ; the recollection of the word sign or word-image sets the
word itself free by reflex action.   Evidently, the excitation must 
780         KUSSMAUL.—DISTURBANCES OF SPEECH.

take its course downward from the ideational centre through the
same places of development, when a word is to be uttered, that
it passed through on its way to the ideational centre, when the
word was spoken by another person and perceived by the subject,
   AVe believe that our diagram gains not only in probability,
but also in clearness, by taking this theory into account.

   The circle J designates the ideational centre or centre  of con-
ceptions, in other words all that portion of the cellular  net-
work of the cortex in which ideas are  produced  as a result of
impressions of the most varied description made on  the senses
(object- and word-images).
   B and B' are the sensory centres for word-images, B for the
acoustic (sound-images), B' for the optical (text-images).
   C and C designate the motor centres for the co-ordination of
the sound-movements into  spoken-words (C), and of the strokes
produced in writing into written-words (Cf).
   a Is the acoustic nerve,  o the optic,  Each of these nerves  is
seen to divide into two branches, one of which, however,  is indi-
cated only by points for the sake of clearness.—a b c b d is the
collective  acoustic motor track for  spoken speech, o p q p r the
optic motor track for written speech.  The adjoining punctated
lines and  circles  are intended to indicate that still other tracks
lead from the nerves of sense through other image centres to the
centre for conceptions ; the acoustic nerve1, e. g., also conveys
melodies, and delivers  musical ideas and the sound attributes of
object-images  (song :   the  nightingale), the  optic nerve  brings
gesture-images and  physiognomic attributes  (grimaces : the
monkey).   For the sake of clearness we leave out the tracks  of
the other nerves of sense1, e. g.,  the nerve of taste, and the motor
centres  of co-ordination for all other voluntary expressions, ex-
cept spoken and written words ; the centre for pantomime is also
left out.
   a. b d is the  track for  the  imitative speech  of  children  or
parrots who repeat uncomprehended words ; o p r is the track
for the copying of uncomprehended words ; c b d is the track for
the utterance of the conceptions in spoken words ; qp r for the
writing down of the thoughts.  The track exq forms the eonnee- 
CENTRES  AND TRACKS OF SPEECH.
781
tion  between sound-images and text-images in the centre of con-
ceptions, and renders feasible the change of spoken-signs into
written-signs through the intervention of the  thoughts.
   b r and p d are the tracks between the  centre for spoken-
images and the  motor centre for writing on the one side, and
between  the  centre for written-images and the motor centre for
speech on the other side.   A person who writes down an uncom-
prehended word that he has heard, uses the track ab r;  one
who reads off aloud an uncomprehended written word, uses the
track o p d. In writing down dictated words that are understood,
the longer track a b c b r is employed ;  in reading aloud written
words that are understood, the track op qp  d.

   Let us now examine with the aid of the diagram the pheno-
mena of deaf-mutism and of  the different  dysphasic derange-
ments.
   The deaf-mute can never use the tracks ab cb d and ab cb
r ; they remain closed for him,  because the acoustic entrance
gate  remains unopened.   On  the other hand,  he  can  arrive
at C and C through o ; he can thus learn to write  and speak.  He
learns to transcribe  without conceptive comprehension  of  the
text by the path opr, with conceptive  comprehension by the
path op qp r.  This, however, does not suffice  to unlock and
drill  the  centre C.  For  this purpose he must erect for himself
an optical  image-centre B" for the sounds and words seen com-
ing from the mouth  of the speaker, and construct paths from u
to z, and back through u to d.  This centre  B" acts vicariously
for B, and the path u d for  the path b d.   There are now no
further difficulties about making use of the track qp d, since
the transmutation  of mimic sound-images into text-images, and
vice versa, become  possible through the track  x'.  AVhen the
deaf-mute  transcribes  the words  which  he  reads off from the
mouth of others, he makes use of the track o u r.
   In  complete ataxic aphasia, C is  no longer available, and
hence the tracks b d an&p d are  also unserviceable.  Spontane-
ous speech, repetition  of words uttered by others, and the read-
ing aloud of text, are impossible.   The track a be, for the com-
prehension of words heard, is preserved, as is also the track c b, 
782         KUSSMAUL.—DISTURBANCES OF SPEECH.

by means of which the conception  brings the sound-image into
recollection.  If C is not damaged simultaneously with C— which
happens but rarely, undoubtedly because the motor  centres of
co-ordination for spoken- and writ ten-words lie very near together
—then the patient can still express his thoughts in writing, copy
what he reads, and transcribe from dictation.
   If the track b d becomes impassable, without  the centre C
becoming functionally impotent, the track p d can still officiate,
which it cannot do in ataxic aphasia.  The patient cannot utter
a single word spontaneously, but can read aloud what is written.
—The above-cited observation of Hertz is open to this interpreta-
tion  ; but, since in this case the track cb d was undoubtedly not
entirely interrupted, we can also assume that the excitation of
the track o p q transmitted itself by the path q x cm  J to cb d,
and supplied the force still lacking  to overcome the resistance in
cb d.
   In the amnesic aphasia, which we styled simple aphasia of
recollection, the track c b is only temporarily blocked up.  What
cannot be accomplished, however, through the excitation starting
from J, can be accomplished by the excitation admitted at a,
and  produced by the dictation of the words.   The word-image
now  enters the recollection in B, the reflex bow ab d  can offici-
ate, and the bow b c b  is re-established.   The succor can arrive
through o as well as through a.  In reading, the text-image is
formed in B', which either renders the  utterance of the uncom-
prehended word possible through the path p d by reflex action,
or, and this is the usual way, the image is perceived in J, unites
with the idea, and supplies to this the force requisite to open the
path c b.
   In aphasia, with deeper derangements of memory, the centres
B and B' are in disorder, and the tracks which lead to them and
from  them  are obstructed  in  a varying degree  or  rendered
entirely unfit for use.
   In cases of complete amnesic aphasia and agraphia (Lordat),
in consequence of the destruction  of B and B', the collective
impressive and expressive tracks must be  thrown out of use, and
J he entirely isolated.
   In the cases of word-deafness  with paraphasia,  the track 
PARAPHASIA.
783
ab c suffers, while the track c b still permits conduction to the
more or less weakened and disordered centre B, and  the track
b d is intact.
   In text-blindness  and  inability to  transcribe  the thoughts
with retention of the ability to copy writing witliout compre-
hending it (van den  Abeele), the track p qp is obstructed, the
track o p r  retained.    In  text-blindness with retention  of the
ability to write spontaneously and from dictation (Broadbent),
only the track p q is  obstructed, the  tracks  qp r and ab r are
preserved.
   Finally,  the case observed by AVestphal seems  to prove that
there is not  only a track leading from b to r, but also one from
r to b.
                     CHAPTER  XXIX.

Paraphasia. — Importance of Attention for Correct Speech.—Paraphasia due to
   Absence of Mind,  and  Choreic Paraphasia.—Paragraphia.—Paralexia.—
   Paramimia.
   Under the name paraphasia we describe that disturbance  of
speech in which the connection of the ideas with their word-pic-
tures lias become so disordered that, instead of the appropriate
terms,  words having a different meaning, or altogether strange
and unintelligible expressions, are enunciated.
   The disturbance of speech which is occasioned by impeded
utterance or stammering, in  which the correct words are used,
although in  distorted and confusing shapes, is  not included
under paraphasia.  Neither is this name appropriate for ataxic
aphasia  in  which  the patient,  like an automaton, answers all
questions  with  the same  stereotyped words  or  fragments  of
words.
   The differentiation of paraphasia from  amnesic  aphasia
and  syllable-stumbling, affections with which it is  sometimes
but not necessarily combined,  is more difficult.   It might  be
thought that in paraphasia the faculty of recalling the correct
word is always impaired, since instead of  it a wrong one is
employed; but  this is not necessarily the case.   In fact, the 
784        KUSSMAUL.—DISTURBANCES OF SPEECH.

correct word seems very often  to rise up in the memory either
entirely or in  part, but immediately, before it is spoken, it is
crowded aside  by some other word.  Paraphasia may also exist
when the syllabic construction of  the  words used is perfect.
AArords that are perfect in construction may be substituted  for
others with which they may not possess the slightest similarity
in sound.  Frequently the flow of speech is smooth and continu-
ous,  but  the combinations of  words are meaningless, and give
confused and entirely unintelligible expression to the thoughts of
the speaker.   This affection, the so-called choreic paraphasia,
in which the  entire vocabulary of  the  individual is wrenched
from its normal connection with the intellectorium, can be easily
differentiated from syllable-stumbling, provided the words em-
ployed are borrowed  in  their correct forms from the mother-
tongue or from foreign languages.   The difficulties begin, and
syllable-stumbling and paraphasia  become closely related, only
when the perplexing  words are formed by the combination of
sounds and syllables borrowed from different words.  AVe speak
of syllable-stumbling,  when the words whose sounds and sylla-
bles  are  intermingled folloio  each other in the  sentence;  of
paraphasia, when the words do not properly belong together  in
the sentence, but have risen up in the memory in consequence of
some resemblance in meaning or sound.

   There is a form of paraphasia which does not overstep physi-
ological limits.  It is not an  uncommon thing for sound, heal-
thy men  to make mistakes in speaking, of which they may or
may not be conscious.  These mistakes are due  to absence of
mind.  The same cause—want of attention—which may develop
into  a state of  intellectual confusion, is also usually at the bot-
tom  of the pathological paraphasia.
   By attention we understand that state of mind in the indi-
vidual in which he takes cognizance of the processes that have
been aroused  in the  perceptive  tract  by external or internal
agencies.  It is possible thereunder to conceive of  an excitation
which, taking  its origin in the ideational  centre, would be con-
ducted, not only along the motor  nerves to the accessory mus-
cles  of the apparatus of  speech, hearing,  taste,  etc.,  but also 
PARAPHASIA.
7So
centrifugally along the sensory nerves  to the external organs of
sense.   It is, at all events,  certain that by means of attention
we exercise an influence on the motor and sensory central appa-
ratus of language which is indispensable for correctness of speech.
AVhen the attention flags,  inappropriate words are very often
used, and such liberties may be taken with the accentuation, the
rapidity of speech, and the  literal and syllabic  enunciation, as
to render the speaker unintelligible.
    This attention to what is being said leads to favorable results
only under certain conditions :
    1. It must be accompanied by a feeling of self-confidence.
Timid individuals are more liable to make mistakes in speaking
than self-sufficient and forward persons.
    2. The  thoughts must be fixed on  the idea to be expressed,
and not allowed to wander off to matters not connected with  the
subject.  Men who are easily distracted from a train of thought
by external impressions, or who  do not curb the rapid  flow of
ideas aroused by associations,  are  said to be absent-minded.
They are constantly in danger of losing the thread of the dis-
course,  and of using words which are foreign to the subject.
    3. The attention, while speaking, must  be divided between
the thoughts,  the syntax,   and the words, each receiving  the
modicum that it requires.  AAdien the  individual words engage
the attention too exclusively, the thought and the construction
of the sentence easily slip from the memory, and the speaker is
liable to become entangled  in  a maze  of words and  phrases.
Here we have at the same time akataphasia and paraphasia.
In  pathological  conditions, only very slight  disturbances of the
circulation and nutrition of the brain are often all that is neces-
sary to weaken the power of attention and occasion paraphasia.
Persons who are suffering from fever  or from hunger,  or who
have been stunned, easily become confused in speaking.  This is
still more  liable to be the   case in connection with  all those
circumscribed or diffuse, macroscopic,   organic  lesions  of the
brain which are attended by obscuration of the intellect  and
impairment of the bodily powers in general,  and of the power of
speech in particular.  The thoughts are confused, and the words
are m ixed up in a most perplexing way.
          VOL. XIV.—50 
 786         KUSSMAUL.—DISTURBANCES OF SPEECH.

    It  is especially  words  expressing  things  that are  in daily
 association, that are  liable to  be exchanged for  one  another ;
 thus,  stick and hat, knife and fork, salt and pepper, etc., etc.;
 or  the words for ideas that  are included in the  thought to be
 expressed.   Thus,  a physician suffering from fever  wishes the
 door to be  opened to let  his  dog out, and calls out,  " Open the
 dog."   Or the word which correctly expresses the idea rises  up
 in  the memory, but, before it can be  enunciated,  another word
 resembling it in sound or  in meaning  is suggested and spoken
 in place of the correct one.  Instead of butter, the word mother,
 or  doctor (see p. 772), or cheese, is used ; instead of pamphlet,
 camphor;  instead  of drinking vessel,  chamber-utensil (Trink-
 geschirr, Nachtgeschirr—Crichton)
   In this connection a case observed by Trousseau is very instructive.  A woman
 was affected with aphasia, after recovering from an erysipelas of  the scalp, that
 had been accompanied by cerebral symptoms.  She learned first to repeat words
 spoken by others, and then for several months daily wrote down words in a note-
 book, in order to strengthen her memory. It was interesting so  see  how one word
led to another.  Sometimes the  first, sometimes the second syllable, often also the
rhyme, or a very slight resemblance  in meaning, gave the key to  the following
 word.   Thus,  "chat, chapeau,  peau,  manchon, main, manche,  robe, jupon, rose,
 bouquet, bouquetiere, cimetiere, biere, mousse," etc., etc.

    In  many cases  the  transposition  does  not involve  entire
 words, but particular syllables or sounds are  borrowed from
 words presenting  similarities in meaning or  sound ; or  an ex-
 change of  syllables takes place  between words  that are  con-
 nected together by the association  of  ideas,  or that  belong
 together in the  same sentence.   In the last case the  paraphasia
becomes associated with syllable-stumbling.
   An absent-minded professor, to the great amusement of his hearers, spoke of
 " the two great chemists Mitschich and Liederlich," meaning Liebig and Mitscher-
lich.  Our unfortunate aphasic patient, Senn, called a " Gabel " (fork) " Gasser,"
because, while thinking of " Gabel," the word " Messer " (a knife) also came into
his mind.
    Alliteration  is particularly dangerous for  those who  do not
possess a thorough command  of the power of speech.
   Even the best runners sometimes stumble. We once heard an after-dinner orator,
who was renowned for his readiness and skill in speaking, make a mortifyino- mis- 
PARAPHASIA.
787
take.   He was addressing a large and learned society on the occasion of an anni-
versary dinner, and,  indulging in too rapid a flow  of speech, he welcomed the
members to the "festlichen Fressfreude " instead of to the " frohlichen Festfeiel.',

    In the  slighter  forms of paraphasia  the thread  connecting
word and  idea is only occasionally entangled, but in the severe
forms,  which  we call  choreic paraphasia,  the  entire  web of
connecting threads is involved in inextricable confusion.  AArhen,
as is  almost invariably the case, the connection between the idea
and its written picture is also disordered or entirely broken off,
there  is  no key left which  can  unlock the  meaning  of  this
medley of words or verbal delirium.   A  case of  this sort came
under our  observation many years ago.

    A pedagogue, sixty-five years of age, with rigid arteries, exerted himself beyond
his strength.  In August,  1870, on returning from a walk that had been enlivened
by animated conversation, he sat down at his desk, but soon afterwards sprang up
and cried out:  " I smell  sulphur! don't you smell anything?  I  am struck with
apoplexy!"   He then vomited ; for several  days subsequently he  was affected
with verbal amnesia,  but there was  at no  time any paralysis.  He recovered and
resumed his herculean intellectual labors.   In autumn  he had another  attack of
vertigo without paralysis, which  was followed by a  paraphasia  that rapidly
attained very unusual intensity.  He addressed long speeches to the  persons about
him, but was  nevertheless unable to express even  his simplest wants  in intelligible
terms.   On one occasion, for instance, an entire day  was  expended  in  a fruitless
endeavor to make his sister, who kept house for him, understand that he wanted
her to bring back a bed coverlet that she had taken away. He finally succeeded
in making her understand his desire, by repeatedly striking on the bed. His actions
meanwhile gave no indications of any marked disturbance of intelligence. He still
understood what was  said to him, and was greatly pleased when any one divined
the meaning of what he said himself.  I only saw  him once, on the 23d of February,
1871.  He advanced courteously to meet me when he entered the room, and at once
addressed me  in a long, fluent speech, of which I comprehended absolutely nothing
at all.  It was made up of German words grouped together in an entirely meaning-
less way, but it was evident, from his  countenance and his gestures, that he was
endeavoring to describe his condition.  His demeanor was like that of an animated
speaker lecturing  from a professor's chair.  A  foreigner unacquainted  with our
language would unquestionably have supposed that an intelligent, cultivated man
was delivering a well-digested speech.  He did not seem himself to notice that his
remarks were unintelligible.  I examined him, found no paralysis, and then spoke
a  few encouraging and comforting words, which had the effect of making him
cheerful and happy.   It seemed to me that he actually understood the meaning of
my words, and did not merely guess at them from my countenance.  In the early 
788          KUSSMAUL.—DISTURBANCES OF SPEECH.

part of spring, as I afterwards learned, his intelligence rapidly waned, but he
nevertheless continued for some time to play a good game of cards every evening.
He always employed a considerable portion of his time in writing, and I have now
in my possession a book in which he had written some notes.  The written words
and  signs begin  as follows :  " Insera—Ihrewaesch—Im  Jahre—Wascho—Jnd—
Leib—Kal—7. 8 Juan. 6. Nachsidhidlig unsersehsch t im  1 weiss diesebelse heft,
Sechal forsich  Br schaf 5 bis mich hoff.  Ich habe," etc.  Gradually he began to
confound material objects; he would try, for instance, to eat soup with a fork. He
died, a corporal and intellectual ruin, on April 1, 1871.

    One  of the  most remarkable of the  recorded cases of disturb-
ance of  speech in general, and  clioreic paraphasia in particular,
has been  reported by Dr.  Osborn.1   The connecting web which
unites the ideas with spoken words was in a state of inextricable
entanglement, while that which unites the  ideas  with  written
words was unaffected,  and the  intelligence was apparently per-
fect.  It  was possible to understand what the patient wrote, but
not what  he said.   He himself understood what was said to him,
and what he  read; but  when  he tried  to read  aloud,  he  gave
utterance to a string of curious  words, some of which were Eng-
lish, and  some were not;  a portion of the latter were borrowed
from foreign  languages, but  others  belonged  to  no language
under the sun.

   The patient was a literary,  thoroughly educated man, and had made himself
master of three languages. After an attack of apoplexy, he wras no longer able to
speak in an intelligible manner, although he was not paralyzed and could enun-
ciate with great fluency a great number of words.  Persons who did not know him,
supposed  he was  speaking some  foreign language, so fluently did syllable after
syllable, and word after word issue from his mouth.  He understood all that was
said to him and also what was written, and was himself able to express his thoughts
rapidly in writing, very rarely using incorrect words.  The power of calculating
was unimpaired.  He  could not  repeat words pronounced before him, with the
exception  of a  few monosyllables,  and neither could he repeat the letters k, q, u, v,
w, x, and z, although in speaking he was able to use these sounds with the others.
When he was told to read aloud, he uttered a farrago of words that had no mean-
ing, and  did not correspond  with the written or printed words.   For instance, he
read the sentence: "It shall be in the power of the College to examine or not ex-
amine any Licentiate previous to his admission to a Fellowship, as they shall think
fit," as follows: " An the be what in the temother of the trothotodoo to majorum
1 Dublin Quarterly Journal of Medical Sciences for 1833. Vol. IV. p. 157. 
PARAPHASIA AND PARAGRAPHIA.
780
 or that emidrate eni enikrastrai mestreit to ketra totombreidei to ra f romtreido as
 the kekritest."  Another time, in  reading  the same sentence, he employed different
 words, but his gibberish was equally unintelligible.

    Not only can a sound  and  healthy person make mistakes in
 speaking, but he can also, and even more easily, make mistakes
 in  writing.   AVhile writing, the  thoughts  are more  easily dis-
 tracted,  and consequently  there is  a greater liability  to use
 letters, syllables, and entire words  incorrectly.  AArords present-
 ing resemblances in orthography, as well as those allied in mean-
 ing or  in sound, are liable to be employed for one another.   The
 same is true of  invalids,  in whom  the functional and  organic
 lesions of the brain are more readily betrayed in the writing than
 in  the speech.   Morbid paragrap>hia, like morbid paraphasia,
 presents itself in mild and in severe forms.

   An excellent example of paragraphia by transposition of the words in the sen-
 tence is found in the following certificate, which was given by an absent-minded
 professor to a student who had attended his lectures on inorganic chemistry : " Mr.
 Schmidt has attended my remarkable  lectures on chemistry with inorganic assi-
 duity."

    The case reported by Osborn, in  which the paraphasia was
 almost entirely uncomplicated with paragraphia, has no parallel
 in medical literature.  In every form of dysphasia the power of
 writing is,  as a  rule, even more  impaired  than the power of
 speaking.   A few such cases, which apparent^ might be classed
 with equal reason under  the head of paragraphia, are here given.

   Hughlings Jackson' saw a woman five  weeks after an apoplectic attack,  which
 had been followed by right-sided hemiplegia, and by aphasia that for a week had
 been complete.   The hemiplegia had entirely disappeared at the time  of his
 visit, and the aphasia  had diminished so greatly that he almost overlooked it.
 When, however, the patient attempted to write her name, she wrote, " Sunnil, Sic-
 laa, Satreni," and her address she gave as  follows : " Sunesr nut to mer tinn-lain."
   The same author communicates  the  letter of a gentleman  who suffered from
 moderate verbal amnesia and aphasia, that were consecutive to epileptic attacks.
 It contains a number of incorrectly written or altogether inapposite words, but it is
still possible to ascertain from it the meaning of the writer.  The intellect of this
gentleman was not impaired. In copying he made but few mistakes.  When read-
ing aloud he spoke almost all dissyllabic and polysyllabic words incorrectly.
British and Foreign Medico-chirurgical Review. Jan. 1809. p. 231. 
790          KUSSMAUL.—DISTURBANCES OF SPEECH.

   Bastian, from whose paper we have taken these cases, adds to them a third case
of his own.  The  patient, whose intellect was unsettled, would rapidly lose his
power of attention while speaking, and would then enunciate the words in a drawl-
ing, monotonous manner.   The final syllables of the words were greatly distorted.
Written  words were distorted  in a similar manner, but in a more marked degree.
For instance,  instead of " Royal naval medical office belonging to the Admiralty,"
ha wrote " Roydndendd navendendd oforendendd Belondendd," etc.  In this case
we get a glimpse of something more than paraphasia and paragraphia; it is proba-
bly an instance of dyslogical paragraphia.
   Ferber1 had  under observation a woman,  sixty-five years of age, who was
afflicted  with a paragraphia, that had persisted after recovery from hemiplegia of
the right side and aphasia, both due to an apoplectic attack. She wrote " schriissen *'
instead of " griissen," " schreigen" instead of "schreiben,"  "butter"  instead  of
" mutter," "omdern" instead of "modern," and in her own name put a g in place
of a ch.

    In paralexia incorrect  words are uttered, the  patients either
transposing the syllables of the printed words, or substituting
for them  other words  resembling them  in  meaning,  sound, or
orthography.

   In a case reported by Jougla,'2 the patient, who had been  suddenly seized with
incoherence of ideas complicated by paraphasia, changed letters,  syllables, and words.
He could still spell out the words correctly, but when  he tried to read them aloud
off-hand, he gave utterance to  nondescript words.  For  instance, instead of " ali-
mentaires" and " etablissements," he read " amoulitaire " and " entalismauson."
   A patient of Bouillaud's 3 read instead of "proprigte  de l'gditeur," " St. Pierre,
St. Paul," probably because her thoughts were dwelling on the  feast of Peter and
Paul, which had fallen on the preceding day.

    The term paramimia  is used to  designate  that  affection in
which  the  patient makes an affirmative motion of the head  when
he wishes to  answer in the  negative,  and  vice versa, makes a
negative motion when  he wishes  to  answer in the affirmative.
AVe have already  spoken of these cases.
   1 Berliner klin. Wochenschr. 1869. No.  10.  See also the case reported by J. Schrei-
ber (from Naunyn's clinic), Berliner klin. Wochenschr. 1874. pp. 308 and 320.
   2 Gazette des hopitaux. 1872. No. 149.
    Bulletin de l'academie de medecine. T. XXX. p. 768. 
AGRAMMATISMS AND AKATAPHASIA.          791
                      CHAPTER XXX.

     Syntactic Disturbances of Speech.—Agrammatismus and Akataphasia.

   Steinthal1 justly insists  on the necessity  of  distinguishing
the syntactic disturbances of speech from the faulty use of words.
He proposes to call the former akataphasia, a name partially
borrowed from Aristotle.2
   In the syntactic disturbances the power of  giving expression
to the thoughts is impaired.  The thoughts are expressed by
means of sentences.   Something more  than mere memory for
words is required  for this  purpose,  since, "unlike words, sen-
tences are not stored up in the  memory ready  for use." 3  A
foreign language cannot be acquired from a dictionary alone.
The ability to speak presupposes  the power  to give articulate
expression to all  the delicate shades, and more or less intricate
windings, of the thought which sweeps through the brain.  The
most learned  man  is sometimes  totally unable to communicate
his knowledge to others.
   For the expression  of the developing thoughts we possess two
linguistic aids, viz., the  inflection of loords and  their arrange-
ment in  the sentence, or grammar and  syntax in its narrower
sense; syntax in its widest application includes both.
   The inflection of words is not a property common to  all lan-
guages ;  the Chinese, for instance, like  the sign-languages, has
no real grammar, but only a syntax.  That extraordinary lan-
guage has not yet made any advances beyond the radical words ;
the same word is a verb, a substantive, an adjective,  an  adverb,
or a preposition, according to its  position in the  sentence.  An
individual word represents an abstract idea, to which a concrete
limitation is only given by a varying intonation, or by combina-
tion with a word representing another idea.  The language has
neither declensions  nor conjugations.  In this respect the English
language bears some resemblance to the Chinese.  Sprung ori-
1 Loc. cit., p. 479.                      2 De interpret. C. 4.
        3 Zeitschr. f. Volkerpsychol. Bd. 1. S. 142. 
792         KUSSMAUL.—DISTURBANCES OF  SPEECH.

ginally from languages that were rich in grammatical inflections,
the English has rejected most of these and turned over to syn-
tax the functions which were formerly performed by grammar.
The prattle of children,  too,  presents a certain  analogy to the
language of the Chinese, since the  meaning of their words only
becomes sharply defined by their relative position to one another,
or by the intonation and accompanying gesture.  Moreover, even
in our (the German) language, which  is so exuberant in  inflec-
tions, a change in the position of words often produces an entire
change in their meaning:  "Taschengeld" and " Geldtaschen,"
"ein  Glas AVasser" and "ein  AA'asserglas" are very different
things.
   ATon der Gabelenz' has briefly formulated  the supreme psy-
chological principle of speaking, as follows :  In thinking, the
psychological subject,  i. e., the subject which is to be thought on
or of, precedes the psychological object, i. e., that which is to be
thought of the subject.  In all languages this principle is gener-
ally followed in the arrangement of words and  sentences; as a
rule, the grammatical  terms corresponding  to the psj^chological
subject, precede those that  correspond  to the  psychological
object.
   It  is in the sign-language that the psychological principle
of the evolution of  thought is most perfectly reflected.  Its syn-
tax has been termed  the  natural, in contradistinction to the
more  artificial and greatly varying  syntaxes of the grammatical
spoken-languages.2
   Deaf-mutes in all  countries dispose the  sign-equivalents, for
the different ideas which  they wish  to express, always in the
same  order ; the construction  of their  sentences is entirely inde-
pendent of the syntax of their articulating countrymen.   They
say "horse black" instead  of "black  horse;" "hat  black
bring" instead of "bring a black hat;"  " hungry, to me bread
give" instead of "I  am hungry, give me  bread."   The mute
places first  whatever is  to him the most important,  and leaves
out entirely whatever seems to him superfluous (Schmalz.3).  Or,

  1 Ideen einer vergleichenden Syntax. Zeitschr. f. Volkerpsychol. Bd. 6. 1869. S. 376.
  2 Tylor, Forschungen iiber die Urgeschichte der Menschheit.  Leipzig. S. 30 u. f.
  3 Ueber die Taubstummen. Dresden und Leipzig, 1848. S. 274. 
AGRAMMATISMUS AND AKATAPHASIA.
793
as Scott' expresses it: "The subject comes before the attribute,
the object before the action, the qualifier usually, but not neces-
sarily, after the qualified."
   Inflection emanated from the combination of words, which
led to the fusion  of two or more to form a new one, repre-
senting a modification of  the original meaning of  the principal
root.   It led also to various articulate changes in the component
parts of  a word, which were effected in accordance with settled
rules or  laws.   In this way cases,  tenses, adjectives, adverbs,
etc., were produced, and  it thus became possible to give rapid
and precise expression to  the most dissimilar conditions of time
and space, and to the most diverse relations of things to one
another.   The  wonderful  process of the grammatical develop-
ment of a language extended over centuries, and was swayed by
influences which, at the present time,  are only partially accessi-
ble to investigation.  The individual ability to speak with gram-
matical correctness is, however, the  product of careful and toil-
some training,  for  children do not easily learn to inflect,  to
decline, and to conjugate correctly ; the  uneducated man  sins,
constantly against the rules to  which the educated man adheres.
   The grammatical faults of  speech that are due  to  imperfect
education, must not  be confounded with the mistakes made by
intellectually sound and educated persons, in consequence of a
bad habit, or of a desire for originality, or of absurd fancies.
Still less should they be confounded with those which arise from
disease, and which we designate by  the term dysgrammatical
derangements   or  morbid  agrammatismus.   AATe frequently
meet  with the last as a  complication of amnesic  aphasia and
paraphasia, and several examples of it in this connection have
already been detailed.  They are usually accompanied by grave
disturbances of the intellect, particularly by weakness of the
intellectual powers, or they are the  expression of an insane
caprice.
   In  this category  belongs also  an anomaly  which is very
freqnently observed in the speech of imbeciles and  lunatics.   It
consists in this, that the  subjects do  not decline  or  conjugate
1 The Deaf and Dumb, p. 53. 
794        KUSSMAUL.—DISTURBANCES OF SPEECH.

the words, but make use only of the indefinite substantive and
the infinitive,  and perhaps  of the past participle also.   They
prefer  the weak to  the  strong inflection, leave out the articles,
conjunctions, and auxiliary verbs, omit the prepositions or use
them incorrectly, and employ nouns instead of pronouns.   They
speak of themselves as  "father,"  "mother," "Charles," etc.;
instead of the pronouns "you,"  "he,"  "they," they employ
the proper  names  or   the  unqualified substantives,  "man,"
"woman," "sister," "doctor," etc.  Sometimes they place the
adjective after the noun, or omit the adverbial inflection.   The
result is to give a childish and helpless character to the speech.
   Sometimes these grammatical mistakes are made consciously,
and are the creations of caprice and temper, but more generally
they constitute the automatic, articulate expressions of uncon-
scious  psychological processes.   The same holds true for the
syntactic derangements  in the narrower sense of the term.
   In speaking, only the shortest sentences can be embraced  in
a single conscious glance.  AVhen we begin longer sentences, we
know only what we wish to say ; the fundamental  thought  or
the theme of the sentence alone rises up clearly before us, while
the syntactic development of this thought in words takes  place
in a semi-automatic manner, through the agency of the mecha-
nism of speech.  The more a speaker accustoms language to obey
him, with all the force and subtlety that the spirit of  the people
has stored up in it during  the  lapse of countless generations,
that is to say, the more  it supports him with  all  its  autonomic
power, so much the more does he command it.  The notion that
the thought which the speaker is developing is the only govern-
ing power in the sentence, is incorrect;  the words and the gram-
matical and syntactic laws  are forces  with which the thought
must  reckon.   The speaker must bear in  mind  the points  on
which the sentence, as well as those on which  the thought turns.
Provided he does not lose sight of these, it  is unnecessary for
him to retain a conscious recollection of  all  the parts of the
sentence.  In a long sentence he may lose sight of the commence-
ment, of individual words, and  of entire incidental phrases, but
will still be able to conduct  the sentence correctly to its termi-
nation.   When conscious memory fails him  in consequence of 
              AGRAMMATISMS AND AKATAPHASIA.           795

its natural limitations, he  is aided by a power which, working
with instinctive certainty,  groups the words of  the  sentence
about the essential and pivot-words,  and, provided the correct
form of the sentence has been adopted at the outset, retains  this
form to the end.
    One who  is but little practised in extemporaneous delivery.
succeeds  much  more readily in evolving  artistic  sentences in
writing than in speaking.   In  the  former, the eyes assist the
mind, by means of retrospective glances at the preceding parts
of  the sentence.   Many men who prove but dull conversation-
alists in  a parlor, understand how to  polish  and mount their
thoughts like sparkling diamonds, when  seated  at the writing-
table in their studies.

    The correct diction of  a sentence  in  the grammatical  lan-
guages presupposes three things, and  when any one of them is
wanting,  akataphasia results.
    1.  Unbroken flow of words.
    The aphasic person, who fails to recall perhaps only a single
word, stops in the middle of the sentence,  and, under the most
favorable circumstances, finds himself forced to have recourse to
a paraphrase, which, as a rule, proves  distracting both to him-
self and to the listener.  If the aphasia be marked,  and a large
number of words  be forgotten, a correct construction of  the
sentence is impossible.  In  the slighter grades of paraphasia, the
form of the sentence  suffers less than its meaning, but, in the
choreic form of the affection,  all order and intelligibility are
hopelessly lost.    The following example  of  akataphasia  due
essentially to severe aphasia, is borrowed from Steinthal.

   A man, who was  suffering from aphasia and paraphasia, remarked while hi3
eyes were being examined : " Das eine Auge — Auge ist immer —  Thranen —
thriinig gewesen (One eye — eye has always — tears — been watery). Ich kann gar
nicht — friiher konnt' ich — besonders-----natiirlicher Weise — mit den Jahren
kleine Stiefe — Strippe — Schrift  — die Brille."  The second sentence, which is
greatly mutilated, might be completed as follows: "Ich  kann  gar nicht sehen,
friiher konnt' ich lesen, besonders  grosse Schrift, natiirlicher Weise musste ich mit
den Jahren kleine Schrift durch die Brille lesen."  (I cannot see at all. Formerly
I could read, especially large print, but, naturally, as I advanced in years I had to 
796          KUSSMAUL.—DISTURBANCES  OF SPEECH.
use glasses for small print).  The words in italics are those which the patient left
out.
   2. Perfect grammatical diction.
   Languages vary very greatly in  their grammatical structure,
and  nothing can be more interesting than a  comparative study
of the same.  AAre cannot, however, stop to discuss this subject
in detail at the present time.

   The Chinese language has  no  grammar, but operates only syntactically with
uninflected radical words—radical stage in  the development of language.  The
Aryan or Indo-Germanic and  Semitic  languages take the roots themselves and
remodel them, with a view to  the closer limitation of the thoughts—inflectional
stage.  Midway between these  two classes stand the Turanian or Finnish-Tartaric
languages, in which the roots are fused together to  form new and complete words,,
in such  a way, however, that the principal root, which contains the fundamental
idea,  remains unaltered, and only the secondary elements undergo changes—agglu-
tinative stage.   This fusion takes place in accordance with  a fixed  law.  The
secondary elements, which modify the  fundamental idea,  are dovetailed in be-
tween the primary elements, by which  they are held together.  In the American
languages, which resemble the Tartaric, these compound words are even susceptible
of declension and conjugation.

   As an example of  grammatical akataphasia,  we may adduce
the  following remark of  a feeble-minded girl:  '' Toni  taken
flowers,  nurse come, Toni thrashed."   The patient no longer
made use of articles, pronouns, or  auxiliary verbs ;  she conju-
gated, as children do, strong verbs with a weak inflection.
   3. Correct arrangement of words.
   In  the  Chinese language,  in consequence  of the want of a
grammar,  every deviation from the regular word-sequence must
lead to  misunderstandings.  In German  the scope is freer, but
not  unlimited.  Strictly speaking, even  in German every change
in the order of the words leads to a modification  of  the meaning
which they are intended to express ;  this  modification, however,
is often so slight  that  it is a matter  of indifference how the
words are arranged.   It is  only when unwarrantable changes in
the  regular word-sequence are  made, that the  sentence is liable
to be  misunderstood, or becomes unintelligible.   Thus, to the
question,  "AAras ist dies ? " we may answer, " AA7eisser Zucker,"
or, "Es ist weisser Zucker," or, "Zucker ist es, weisser," or, 
AGRAMMATISMUS AND AKATAPHASIA.
797
 " Es  ist  Zucker, weisser."   But when any one says,  " AA'eisser
 ist es Zucker,"  he commits a grammatical fault;  he is either un-
 acquainted with the language, or  there is reason to suspect that
 he is  not in his right senses.
    Gogol* reports an exquisite example of akataphasia,  in which
 the grammatical formation and the syntactical  construction of
 sentences were greatly affected,  while  the patient, although his
 intellect was impaired,  lacked neither words nor ideas.  He suf-
 fered from intellectual confusion and  verbal  amnesia,  but the
 grammatical and  syntactical  akataphasia  overshadowed  both
 these disturbances.

   A young man in Breslau, who had fought through  the campaign  of 1866, was
 thrown from a wagon in 1869, and received a  severe injury of the brain.   At the
 autopsy in 1872, numerous ochre-colored  spots of softening were found scattered
 through the cortex of  both hemispheres of the cerebrum and in the cerebellum,
 along with traces of a former  meningitis located over the two anterior lobes. After
 the accident, when speaking of his army life, he said: " Da war achtzehnhundert
 drei und sechzig Kiirassier numero 1 hier in Breslau  musste ich haben gewesen."
 That is no sentence;  the following is a little  better:  " Und von achtzehnhundert
 sechs und sechzig da kommts die Preusse, auch das Oestreich gewesen, die schutzen
 von das Oestreich."   In  speaking of the time when he went to school, he said :
 " Ich bin gewesen  als Schiller  — nein,  ich auf das Schiiler — und ich musste
 arbeit auf das Vater und Mutter."  The patient substituted " auf " for most of  the
 connecting words.   " Da haut ich wieder arbeiten auf meines Mutter  und arbeiten
 auf meines Vater."  When asked to give an account of his accident, he said: " Ich
 habe 18G9 als Kutschsr gewesen und  als Kutsche habe welche mir  als ich diene
 haben  es mir meine Pferde als Kutscher bei dem  der Diener gewesen.  Und ich
 musste  es runter auf meine Kutscher und  haben sie meine Eisen und haben sie
 Pferde  auf imin Fuss und meine und da haben sie das Eisen auf meine  Kopf und
 das Blut ist fort."
   This case is also important in  another connection.  The patient, as is evident
 from what precedes, still  had many words at  his command, but could not always
 find the expressions for objects that were known to him.  He could read few words
 correctly, but nevertheless wrote  down correctly words and  figures that were dic-
 tated to him, reckoned accurately, was polite, saluted courteously, and knew the
 sign of the cross.  On the other hand, he urinated in the wash-basin, bit a morsel
out of a cake of soap, and did other things of  a like character, which proved that
he confounded material objects with  one another.   He performed preposterous
acts, or, in other words, suffered from apraxia.   It is evident that the  misapprehen-
1 Ein Beitrag zur Lehre von der Aphasie. Inaugural-dissert, Breslau, 1873. 
798          KUSSMAUL.—DISTURBANCES OF  SPEECH.

sion of material objects, which forms the basis of apraxia, was in this case more pro-
nounced than the misapprehension of the articulate expressions of thought.

   AA"e may also refer here to  a case reported by Forbes AVins-
low,1 in which  the chief affection seemed to be  an akataphasia,
an  inability to place words in their correct  order in  a sentence.
If the words uttered by the patient were written  down, and then
arranged in  order, it became possible to decipher his meaning.

   A gentleman was seized with an attack which presented as much resemblance to
epilepsy as it did to apoplexy, and for two days his life was in danger.  When he
recovered consciousness, he was unable to express his wishes in an intelligible man-
ner.  He articulated the words  correctly, but mixed them up so that it was impos-
sible to understand him, unless his words were first written down and then co-ordi-
nated.  This condition lasted,  with short interruptions, for fourteen days ;  it was
accompanied by severe pains in the occipital region. The patient gradually recov-
ered under the use of venesection and derivatives.
                       CHAPTER XXXI.

Aphasia as a Disease, and its Manifold Causes.—Functional Aphasia.—Hysterical
    Speechlessness.—Congenital Aphasia.—Prognosis and Treatment of Aphasia.

    The clinical picture of " aphasia'1''  has been built up  from
the dysphasic derangements that we have thus far been describ-
ing.  Its varying manifestations, somatic and psychical compli-
cations,  causes,  prognosis and treatment,  have been investi-
gated and described.  AVe regard this standpoint as fairly con-
quered.   AAre  can see no  advantage, as has been already  suffi-
ciently explained,  in  the  substitution of  the  clinical picture
of asymbolia  for that of  aphasia.   The pathology of disturb-
ances of  the  faculty of  speech does not deal with independent
diseases.  Its object  is to describe and  analyze the derange-
ments of the numerous functions which come into play in speak-
ing, writing, and other  modes of expressing the thoughts and
desires :  theoretically, to trace them back to their psychological,
anatomical, and physiological causes, and practically, to deter-
mine, partly from the form of the derangement, partly from the
1 Obscure Diseases  p. 521. 
FUNCTIONAL APHASIA.
790
other morbid manifestations that accompany  it, the nature and
seat  of  the primary alterations in the organ of language, from
which the data for prognosis and treatment can be deduced.
    It is true  that,  at  the present time, we are still  far from
having covered this comprehensive field of  stndy ; we  find our-
selves only too often obliged to  rest content with very indefinite
diagnoses,  compelled  to speak  merely of loss of speech  or  im-
pairment of speech, without being  able to define its nature more
closely.
    This is  especially true of many forms of the so-called func^
tional aphasia, the inability to  speak, which is often  observed
after intense emotion, in hysteria, and  as a symptom  of many
other neuroses.   It is  not even always possible to say, whether
we have to deal with dysphasic or only with dysarthrio  derange-
ment ; sometimes nothing is certain except  the  central  origin of
the impairment of speech.
    Loss of the  power of speech fof* a longer or shorter  period
has repeatedly been known to follow a great fright.  Dr. AVert-
ner, of Wartberg (Hungary), gave me the details of a case  of this
sort.

   A girl, thirteen years of age, was run over by a wagon.  Although she escaped
with some slight scratches, she became speechless and remained so for thirteen
months.  After various methods of treatment had  been tried without success, Dr.
Wertner at last gave her bromide of potassium.  One day, immediately after  tak-
ing the medicine, she threw  herself  into  her mother's arms  and whispered:
" Mother, I will speak again."  After a  few weeks she had entirely regained the use
of language.

    Sometimes a violent emotion will restore the power of speech,
even after it has been lost for a long time.

   According to Herodotus (I, 85) the son of Croesus was dumb, but after the cap-.
ture of Sardes, he saw a Persian  attack his father with a drawn sword, and, horrified
at the sight, he  called out: " Man, do not kill Croesus ! " It is said that he there-
after retained the power of speec*h to the end  of his life.1
   1 Mledemeister  (Allg. Zeitschr. f. Psych. 1874. Bd. 28. S. 485) relates the case of a
woman, who became speechless as she left the wedding breakfast to start on the wed-
ding trip with her husband, and remained so until she happened to see a church burning,
She cried out: " Fire," and at once regained the power of speech. 
 800          KUSSMAUL.—DISTURBANCES  OF SPEECH.

    Hysterical persons  frequently lose  not only the voice, but
 also the power of speech, for minutes, hours,  weeks, or months.
   A cook was subject to sudden attacks of speechlessness, which came on sometimes
 several times a day, and would last for hours. During the attacks she was unable to
 utter a word.  All sorts of treatment were tried, without success.   Finally she was
 directed to say under her breath at the commencement of every attack, the words:
 "God the Father, Son and Holy Ghost," then to turn herself around and to spit
 out, repeating at  the same time inaudibly the words, " That is  for  thee," while
 thinking of the devil.  This remedy  invariably stopped the attack at once.
   A lady, somewhat over thirty years of age, suffered from hysteria, with paraly-
 sis of the legs and of the left arm.   At intervals she lost the power of speech for
 hours or days at a time, but pressure  on any spot in the lateral regions of  the neck
 always relieved this " aphasia "  immediately. On removing from my neighborhood
 she became entirely mute,  and  for a whole year communicated with her attendants
 only by writing.  Finally the right  arm also was affected with paralysis, but she
 still retained sufficient power to point successively with a little wand to the letters
 of a large alphabet, by which means she made  known her wishes and answered
 questions.  Pressure on the neck wa&no longer of any use.   I  had the patient, who
 had  a great regard for me, broughPto my hospital, where I gave her a pleasant
 room and ordered a placebo, at the same time stating in her hearing that I confidently
 expected great results from it.   In eight days she was able to speak as well as ever,
 and could again use the right hand for drawing, writing, and feminine handiwork.
 Six months later she had to return to  her home.  The journey proved very harassing
to her, a paralysis of the bladder set in, the right arm became permanently  para-
 lyzed, and  a few months later she died  with all the symptoms of a diffuse myelitis.

   The word-pictures in such cases  are intact,  as are  also the
 connecting  links  between thoughts and words.   Have we  to deal
 here with a hiatus somewhere  between the picture and  the mus-
 cles?   Or can  it be that the combined cortical and infra-cortical
 excitations, by which the idea is converted into the spoken word,
 are too weak, and that the " traitement moral'' acts by strengthen-
 ing these excitatory phenomena by means of the psychical stimu-
 lation ?
   After epileptic attacks there is often  loss of speech for hours,
days, or  weeks at a time.1  Ogle2 saw complete inability to speak
 set in in  the course  of chorea, and Hughlings Jacksons saw the

   1 Several such observations have been already reported.  Another has been published
by Oooday (Med. Times and Gaz.  1864, Dec).
   2 A. Clarus, Ueber Aphasie bei Kindern. Jahrb.  f. Kinderheilkunde.  1874  Bd  VII
■S. 369 und S. 396.                                a Ibidem. 
FUNCTIONAL APHASIA.
801
same after hemispasmus of the  right side.  In catalepsy  the
power of speech is lost during the attacks, and the same thing
may happen in ecstasy.
   It is  almost useless to enumerate all the diseases, in connec-
tion with  which the  so-called aphasic disturbances have been
observed. AVe have already mentioned the fact, that very trifling
causes  are often sufficient to  interfere  with the  function  of
spe.ech, and  even to abolish it for a time.   It is not surprising,
then, that the most diverse  severe general diseases, particularly
such as are attended by high fever, should present this compli-
cation,  especially as they  frequently give rise to gross, diffuse
and circumscribed lesions of the brain.  Thus, aphasia has been
observed in diabetes (Trousseau), in morbus Brightii (Trousseau,
Hughlings Jackson, Baginsky), in syphilis (Trousseau, Behier),
in saturnismus  (Heymann1),  in alcoholismus  (Trousseau),  in
typhus abdominal is*  m scarlatina  (Eulenburg, Shepherd, and
others), in measles (Schepers,  Calmeil), in  variola (Breganze), in
erysipelas (Trousseau), etc.  Cases have even been reported in
which collections of faces in the large intestine and lumbricoid
worms were  supposed  to have  caused the aphasia,  since it dis-
appeared when the  hardened  fsecal masses  or the  worms were
removed by treatment.
   It is self-evident that all possible morbid processes in the brain
can  cause aphasia.   They   may  do this in  one of two ways :
either  they  involve  directly  and  permanently  the  conducting
fibres and centres of speech, or they impair their functional vigor
more mediately and temporarily by  pressure, ischsemia, or col-
lateral hyperaemia, or  perhaps also by simple  reflex irritation
and radiation.  Thus Schlesinger and Ullmann s saw aphasia fol-
low a simple commotio cerebri.   It is, moreover, frequently met
with as a result of fissures and fractures of the skull, of  incised,
punctured, and gunshot wounds of the brain, of congestion of
   1 Berl. klin. Wochenschr. 1865. Nr. 19-21.
   2 Numerous examples are given by Clarus.  Strange to say, among the cases so far
reported, there are only two '' aphasic " girls to ten '' aphasic " boys.  In eleven of the
cases there was no paralysis ; in one, that was observed in the Julius Hospital at Wiirz-
burg (Gerhardt), there was hemiplegia of the right side, probably of embolic origin.
   3 Wiener med. Presse. 1869. No. 41.
          VOL. XIV.—51 
802          KUSSMAUL.—DISTURBANCES  OF  SPEECH.

the  brain, of meningitis simplex and tuberculosa,1 of  hydroce-
phalus, of abscesses,  tumors and entozoa  of the  brain,^ and of
inflammatory, thrombotic  and embolic softening of the  viscus.
   Broadbent3  and AValdenburg3 have reported very interesting
cases  of congenital aphasia  in intelligent boys, and Benedict'
and Claras (loc. cit.) have  met with  similar cases.   In all of the
four cases the patients were boys.  The mother of AValdenburg's
patient had been seized with aphasia and hemiplegia of  the right
side in the third month of  her pregnancy.   The most interesting
of these observations is the one  reported by Broadbent, which
we will give  somewhat in detail.

   The patient,  who was twelve years of age, understood everything that was said
to him, and did what he was told to do, but could not, as a rule, speak any words
except "yes," " no," " father," " mother"—the last two words he pronounced like
"face" and "moce."  He used also an indistinct  expression  which sounded like
" keeger kruger," and which he employed in  answer to all questions.  Occasion-
ally he  uttered  a few  other words, such as "  all right," " thank you."  He could
write his name, and could copy figures or a  few words from a printed card, but
was unable, when requested to do so, to write down " yes" or "no," or the name
of the  street in which he lived.   He could not understand a written  question, no
matter how simple it was ; for instance,  instead of the "no" that was  expected, he
wrote " baleve" and " ache," instead  of " card," " ke," etc.  Strange to say, while
he was  thus unable to connect the written signs with the spoken sounds, and  did
not  understand  written and  printed  text,  he nevertheless understood figures
to a certain extent;  for instance, he could tell the time by the watch, could write
down his age, and  do other things of a similar character.  His tongue was freely
movable  and he could repeat after  any one, although with some difficulty, the
entire alphabet, also ba, be, bi, bo, bu, etc., etc.

    In spite of  the great mass  of  recorded facts that no longer
admit of denial or suppression, it is as  yet impossible  to deduce
   1 In 1872 I had in my wards at Freiburg, a man, forty years of age, who was subject
to attacks of ataxic aphasia.   In some of the attacks he lost the power of speech com-
pletely, but in others he was able to say " ja " (yes) ; between the attacks bradyphasia
existed.  After his death we found meningitis tuberculosa with tubercular tumors in
the gyrus prsecentralis sinister, in the neighboring convolutions,  and in the left insula.
Gerhardt  (Jahrbuch f.  Kinderheilk. N. F.  IX. S. 324) recently  reported a case of
aphasia in a three year old child, who was suffering from meningitis tuberculosa.
    2 Loc. cit., Case IV.
    3 Berliner klin. Wochenschr. 1873. S. 8.
    4 Wiener med. Presse. 1865. Nr. 49. 
PROGNOSIS AND TREATMENT.
803
any rule of practical value, for the prognosis of the dysphasic
disturbances included under the head of aphasia.   The curabil-
ity of the  aphasia depends partly on the nature of the causa-
tive lesion, partly on its location.   AVhen the primary affection
is  of  a curable nature, such  as the weakness due to inanition
in convalescence from a febrile disease, or simple  cerebral con-
gestion, or  hysteria,  etc.,  we may look for  a favorable result,
even though the loss of the power of speech be complete.  On
the other hand, in incurable affections, such as tubercular menin-
gitis, new growths in the brain, progressive degenerative processes
of the cortex, and the like, there is no prospect of recovery from
the impairment of speech,  even  though it be  but slight.  In the
destructive processes  the prognosis is worse,  when  the lesion is
diffuse  and progressive, than when it is confined to a circum-
scribed region.  In the latter  case it depends on the  manner in
which the conducting fibres and centres of language are affected;
when the injury to these is of a reparable nature—due, for instance,
to compression or to collateral fluxion—the  prognosis is not as
bad as when they are directly and incurably involved.   In this last
case,  again, everything depends on the extent  of  the part in-
volved, and on the question whether or not the lesion is suffi-
ciently  circumscribed, to permit of a compensatory action on the
part of  other bands of fibres and groups of nerve-cells.  Unfor-
tunately, the little  that  we  know about these questions  can
hardly  as yet be reduced to  formulas  of any  practical  value.
One thing  may be safely stated, however, and that  is, that the
age of the patient is an important factor for the compensation of
the injury.   Children have been known to learn to speak, after
astonishingly extensive destruction of the left region of speech,
and even of the entire cortex of the left hemisphere, while in old
persons remarkably small foci  of disease in the cerebral sub-
stance sometimes cause permanent aphasia.   The individual
docility also unquestionably exerts some influence in each case.
   It would be a great gain for us if we could deduce the neces-
sary data for the prognosis simply from the form of the dyspha-
sic impairment, but here, too,  the little we know can be summed
up in a few sentences.  Sometimes apparently severe attacks of
aphasia terminate in recovery (we  may refer as an  example to 
804        KUSSMAUL.—DISTURBANCES  OF SPEECH.

the case of Lordat), while  in other cases slighter derangements,
ex. gr., an amnesia of substantives, remain permanent. As a rule,
however, simple amnesic aphasia  and the paraphasia which pre-
sents the characteristics  of absence of mind, seem to vouchsafe
the best  prognosis, while ataxic aphasia,  amnesic aphasia with
incoherency or entire loss  of the  word-pictures,  and the choreic
form of paraphasia, must be regarded as less promising.
   The prospects  of recovery diminish in an inverse ratio to the
length of time the affection persists without  sign of  improve-
ment.  They become worse also when the aphasia is progressive
and accompanied by paralyses and  by an increasing weakness
of intellect; in this case life itself is usually threatened.
   In the treatment of  aphasia, the  first indication is,  if possi-
ble, to remove  the cause, such as the weakness from inanition,
syphilis,   saturnismus,  hysteria, cerebral  congestion or  in-
flammation, etc.  AVhen this indication has been fulfilled,  and
the impairment of speech itself demands treatment  although
the morbid process in  the brain that occasioned  it  has  dis-
appeared, a methodical course of instruction in speaking  will
be  found very valuable,  provided always a compensation be
still possible.  This instruction must, according  to the nature of
each individual case, be  chiefly directed either to the motor co-or-
dination  of sounds into  words, or to the memory of words.   The
co-ordination  of  sounds  will  be strengthened  by methodical
practice  in the articulation of letters, syllables, words, and sen-
tences, care being  taken  not to allow  the patient to become
fatigued.  He must be taught from the first to watch closely the
mouth of the  teacher.   With this, writing and reading lessons
may be combined when  desired.   At  first only the words in most
common  use should be used ; they should be repeated again and
again until the patient  becomes thoroughly familiar with them,
and not till then are new ones to be added.  By this method we,
as well as other observers  (Trousseau,  Broca,  Ramskill,1 et al.),
have succeeded in bringing about improvement and even cure.
In amnesic aphasia the patient should  be made to repeat daily
the missing words, the  teacher helping him by repeating  each
1 Med. Times and Gazette. Dec. 27, 1862. 
                     SYLLABLE-STUMBLING.                  805

 word, or its first syllables or letters, before him.  When possible,
 the words should be committed to memory from a dictionary.


                      CHAPTER XXXII.
 Syllable-stumbling. — Impairment of  Speech in Progressive  Paralysis  with
                            Dementia.

    AVe  subjoin now to  the  dysphasic troubles  included  by
 authorities under the collective name of aphasia, the affection to
 which the name  of syllable-stumbling has been given.  In this
 affection, the co-ordination of the word as an articulate unity,
 composed of letters and syllables, is affected, not through any
 defect in the articulation of the sounds and syllables, but in con-
 sequence of  a  derangement of the processes by  which  the com-
 plete word is developed from  them.   The words, as  organic enti-
 ties, become loosened at their joints, and their letters  and syl-
 lables fall apart  and become intermingled, or  letters  and syl-
 lables are inserted in words where they do not belong.
    The  distortion of the words in  stumbling  speech must be
 distinguished  from that which is due to the defective  utterance
 of sounds,  or of stammering.   In stammering some particular
 sounds  are  distorted when uttered separately, but the stumbler
 articulates every isolated  sound perfectly  well.   It becomes a
 stumbling-block to him only when he meets it in some word, par-
 ticularly if it be long and alliterative, or when he tries to speak
 rapidly.   If  he speaks slowly,  partly spelling the words, he may
 perhaps  succeed, provided the affection be not of a very severe
 grade, in correctly articulating words that  are otherwise impos-
 sible for  him,  such, for instance,  as  " Constantinopolitanischer
 D udelsackpfeifer,"  or " drei  und dreissigste Reiterschwadron."
 AVhen the articulation of  sounds is defective, the subject often
 succeeds  by a great exercise  of power  in uttering  with a sort
 of explosion, sounds wliicli it  is impossible for him  to  artic-
 ulate, when  he employs only the force required for ordinary
 conversation.1  The stumbler,  on the other hand, attains his aim

  1 I was recently enabled, through the kindness of Dr. Alefeld, of Wiesbaden, to see
a man who presented symptoms indicating a cerebral sclerosis, and who was unable to 
806         KUSSMAUL.—DISTURBANCES OF SPEECH.

the most easily  by avoiding all forcible  articulation, and speak-
ing as slowly and quietly as possible.  The stammerer, like the
syllable-stumbler, replaces letters and syllables by others  that
do not belong to the words, but the  substitution  takes place
in a very  different manner.   The  former inserts only certain
definite sounds in place of other definite sounds ; for instance,
when there is paralysis of the soft palate, he uses  an m, w,  or
j  in  place of a b or p ; ' the latter, on the other hand, huddles
together,  in an arbitrary manner, the letters and syllables  of a
word,  or  even of  several  consecutive words, says   "Keping,"
instead of "Peking,"   " goten  Murgen," instead  of  "guten
Morgen,"  and  " Artrallerie"  or  " Rartrillerie"   instead  of
"Artillerie."
   There  is  one  point,  however, at  which the stammerer and
the  stumbler meet.    The resemblances  of  the sounds to one
another, and the greater or less difficulty that is met with  in
passing from the position  required for one particular sound  to
that required for another, make  themselves  equally felt in the
impairment of speech due to stumbling and in that due to stam-
mering.  It is entirely immaterial whether the transition from one
sound to another is impeded in the motor-centre for the co-or-
dination of words,  or further back in the centre for articulation
proper.  In  both cases  the impulse,  when  it passes  over one
sound, is most readily arrested by  kindred letters,  and always
chooses those which present the least difficulties.
   For this  reason, in  cases of syllable-stumbling as well as in
stammering, we very frequently find a reciprocal interchange
between the closely related sounds: ii  and  i, i and e, ce  and
e, u and o, hard and   soft  consonants,  etc.   Or  the  preced-

utter a single word in such a manner that I could understand  it.  His wife was the only
one who could understand his lisping.  Nevertheless,  he repeated for me the  entire
alphabet, articulating correctly  all  its elements,  but  each individual sound was shot
out, as it were, by a great exertion of strength.   In this case,  apparently the  intra-
hemispheric conduction alone  was seriously affected.   The acts of swallowing and
chewing were not interfered with.
  1 A patient with bulbar paralysis, who was in my wards, pronounced, at a particular
period of his affection, p like w, g like j or ch, c like d, and  i like e.   He pronounced
b, d, m, n, a, o, u, correctly; his e sounded like ce, and he could not pronounce  r, 1, s,
sch, f and k, at all.  The aspirate h could only be articulated when his nose was held. 
                     SYLLABLE-STUMBLING.                  807

 ing  or  succeeding consonant leads to  the  use  of an incorrect
 vowel in the middle of a  word, because the transition  to or
 from the correct vowel is too difficult.  Thus W.  Zenker,1 in
 a very  admirable paper, shows that when  a paralytic patient
 says "Zufall" instead of  "Zufall,"  he employs ii instead of
 u for two reasons : first, because the jump from z to u is greater
 than from z to ii, and  secondly, because the  transition from ii
 to f is  easier than from u to f.   The interpolation of vowels
 also, according to his  argument, is accounted for as an  effort
 to facilitate the transition from one consonant to another, e. g.,
 'k Schewager " f or " Sell wager.''  So also the sounds of the vowels
 are sometimes prolonged, to gain time to put the organs of speech
 into the proper  position for  the articulation of  the succeeding
 consonants.
    Hie co-ordination of the  word into a complete and perfect
 entity formed from letters  and syllables, depends on two condi-
 tions :  1. The acoustic word-pictures must  be correctly put to-
 gether.   This is  no longer the case when  the sounds  and syl-
 lables of the words in a sentence,  or  of long  words,  are inter-
 mixed.   2.  The sounds must be arranged in correct sequence in
 the motor-centre for the co-ordination of  words.  This  is  no
 longer the case, when the patient, whose infra-cortical apparatus
 of articulation  is  still  normal, interchanges  kindred sounds,
 employing by preference those which are most easily uttered, or
 interpolates  uncalled-for sounds, with  a view to facilitate the
 transition.
   Stumbling due  to loosening of the connections of the  word-
 pictures, shades  off into paraphasia,   while  stumbling due to
 derangements in the motor-production  of the words, shades  off
 into stammering.   In  both directions  it is  difficult  to draw the
 boundary lines.   In the first case we call it paraphasia, when the
 distorted words still retain a meaning, although it  is not the
 meaning desired by the patient—when, for instance, "Butter" is
enunciated  instead of  "Mutter," and  " Kaze"  instead  of
 " Kaffee ;" stumbling,  when instead of "Freiburg,"  the patient
  1 Der willkiirlichen Bewegungen Modus and Mechanik in der  fortschreitenden
Paralysie. AUg. Zeitschr. f. Psychiatrie. 1871. Bd. 27. S. 673. 
808        KUSSMAUL.—DISTURBANCES OF  SPEECH.

says  "Feigfro."1   In the  second case,  the  imperfection  of
speech is classed under stumbling and not under stammering,
when the patient is able to articulate correctly all  isolated
sounds without  employing unusual force, and when  the word,
which is uttered at one time incorrectly, can at another time  be
enunciated properly, especially if  success be promoted by atten-
tion and a quiet delivery.
   Great prognostic importance  is  attached  to this syllable-
stumbling, when it accompanies a commencing mental imbecility.
"L'embarras de la  parole est un signe mortel," said Esquirol,
who, when writing these words, had syllable-stumbling  in view.
In fact, it is most frequently observed in  connection  with fatal
progressive paralysis with dementia.  It occurs particularly
in those cerebral diseases in which slowly progressing irritative
processes, involving scattered  points (diffuse  dissemination),
lead gradually to subversion of the cortical  functions and  to
extensive alterations in the minute structure of the  cortex.
Exceptionally,  however, we also meet with it under favorable
auspices.  Four years  ago  a drunkard was  brought  into our
hospital suffering from typhus.  During the course of  the dis-
ease,  which  was attended by moderate fever,  his enunciation
became stumbling to a remarkable degree,  and continued so as
long as the fever lasted.  We apprehended a  complication of
typhus with  commencing progressive paralysis, and  a psycho-
logical expert  who saw the  patient shared  our suspicions.
Nevertheless, complete recovery set in.
    Syllable-stumbling may make its  appearance in the earliest
stage of general progressive paralysis,  at a  time  when  the
motility in general does not present the least sign of diminution,
and when the movements required for the production of sounds
and for all other voluntary objects are still perfect (Parchappe2).
Long afterwards, too,  when the impairment  of speech  has
become permanent and very marked,  the patients  often still
retain power  over  the movements  of the  tongue,  lips, and
cheeks, and  perform the operations of  mastication,  insaliva-
1 Compare Chapter XXIX.
2 Bull, de l'acad. de med. T. XXX. p. 702. 
SYLLABLE-STUMBLING.
809
tion, and swallowing in a most satisfactory manner (Parchappe).
This indicates decidedly an affection of the cortex.  It has been
confirmed in this particular by the results of the microscopical
investigations undertaken  by AVestphal,1 who  in a number of
cases could discover no changes either in the peripheral or in
the bulbar portion of the hypoglossal nerve.  The value of these
negative results is  not in any respect lessened  by the antagon-
istic positive results obtained by Lubimoff,2 who has in a few
cases succeeded in demonstrating a proliferation of  the connec-
tive-tissue  cells,  and degeneration, with granular  destruction
and amyloid transformation, of  the ganglion cells of the nuclei
of the facialis and hypoglossus.
   If we bear in mind the  tendency of the disease to extend to
all parts of the brain and spinal cord, we will not be  surprised to
learn that its ravages often  involve other provinces of language ;
that, in addition to the syllable-stumbling, it begets divers other
forms of impairment of speech,  more particularly actual stam-
mering and stuttering, retarded or precipitate and trembling or
bleating3 utterance, and also numerous derangements of phona-
tion, which have  been thoroughly studied by AV. Zenker.  The
force of the expiration and the tension of the vocal cords are often
permanently and greatly diminished, and the voice becomes weak,
monotonous, and lower in pitch.  Sometimes the patients become
hoarse,  or they become  unable to regulate properly the tension
of the vocal cords  and  the expenditure of wind.   In this last
instance, so much air is expended in the  production of the
first few sounds,  that the patient, in order to continue speaking,
is  compelled to bring his abdominal muscles into play.   This
can be easily demonstrated by  palpation of the epigastrium.
"The voice,  nevertheless, now sinks to  a whisper, and by the
time the sentence is finished the patient is  completely out  of
breath."
   In view of the extension  to other parts of the cortex, and  of
  1  Archiv fiir Psychol. Bd. 1. S. 90.
  2  Virchow's Archiv. 1873. Bd.  57. S. 371.
  3  Duchek (Prager Vierteljahrschrift.  1851. Bd. 29. S. 32) calls this bleating speech
" aegophonic."  With regard to the impairments of speech in paralytics, compare also
Brosius, Allg. Zeitschr. f. Psychiatrie. 1857.  Bd.14. S. 37. 
810        KUSSMAUL.—DISTURBANCES OF SPEECH.

the constantly increasing intensity, of  the morbid processes
which  underlie progressive  paralysis, it  is easy to understand
how other anomalies of a dysphasic nature are gradually super-
added  to the syllable-stumbling, which  often constitutes for a
long time the only dysphasic symptom.   Temporary attacks  of
actual aphasia, which are  sometimes attended by abolition,
sometimes  only by more or less cloudiness,  of the intellectual
powers, are not infrequently observed.   They may be ascribed
to temporary derangements in the circulation of the blood, or,
perhaps, to  swelling of abnormal, spindle-shaped  neuroglia-
cells in the cortex, caused by the  hyperemia (Lubimoff).   Per-
manent aphasia  apparently only  occurs in connection  with
grosser, localized lesions of the cortex.  In the case  of a young
Russian, who was  suffering from progressive general paralysis,
and had previously passed through a severe attack of syphilis,
I observed  transient attacks of complete  loss of speech, accom-
panied by signs of cerebral congestion.  During the attacks the
patient had an imperfect comprehension of  what  took  place
about him.  Between  the  attacks, which occurred but seldom,
his tongue was slightly tremulous, but freely movable, and  he
enunciated correctly  all sounds and  words, with  the  single
exception of  the word "blanchissage," which he was unable to
co-ordinate ; in spite of all his efforts, he  invariably pronounced
it " blanssichage."
   These patients finally become subject  to manifold syntactic
and dyslogical disorders.   They  take pleasure in  hyperbolic
expressions, employ extraordinary, self-created words and inflec-
tions, and  in grammar  and in  the formation of sentences fall
back to the stage of childhood.   The sequence of the sentence is
interrupted, because the thread of thought is broken.  The words
are repeated, in consequence either of psychical weakness or of
convulsive  haste;  in the  former case, "Ich bin—ich bin—ich
bin,"  will be repeated, until finally the patient remembers  what
he wishes  to say; in the  latter, a  rapid "Ich bin—bin—bin—
bin" is heard (Zenker).
   Localized destructive processes  in  Broca's  region  in the
frontal lobe do not seem to  cause  stumbling speech,  but rather
aphasia as understood by practitioners. 
DYSPHRASIAS.
811
                     CHAPTER XXXIII.

Dyslogical Derangements of Speech, or Dysphrasias.—Aphrasia Voluntaria, Parano-
   ica, Superstitiosa, and Various other Forms of Dysphrasia.—Hemming and
   Hawing, Cluttering, Hesitating and Confused Speech.—Obstructive Dysphrasia.
   Verbal and Thematic Paraphrasia.—Influence of Words, Word-phantasms, and
   Delusions on Speech.—Perversions of Speech in Idiots, Particularly  in Micro-
   cephalia.—Influence of Congenital Absence of the Corpus Callosum on the
   Intelligence.

   Under the head of dyslogical perversions of speech,  or dys-
phrasias, we class those affections of speech which proceed from
impairment of the intellect.  A certain  number of  extravagant
and  incorrect terms of speech  that are made use of by imper-
fectly educated or eccentric individuals, or by persons who are
under the influence of certain fixed ideas, or are  suffering from
weakness of mind or melancholia, constitute a transitional stage
between normal speech and morbid dysphrasia proper.
   Another form  of  dyslogia  remaining within physiological
limits  is the dumbness, mutitas sive aphrasia voluntaria,  to
which some mentally sound individuals condemn themselves, for
the sake  of fulfilling religious vows or for  other motives, which
they keep secret.  They  retain  the  power  of  speech,  but they
will not use it.

   Most tourists who  have travelled much in  Switzerland during the last fifteen
years, will remember having met an old pedler, who, for some unaccountable reason,
had condemned himself to absolute dumbness.   He carried on his business by means
of signs.

   Lunatics are often persistently dumb for a long time, even
for months or years ; they may be thought to be perfectly apha-
sic, until they unexpectedly begin to speak—aphrasia paranoica.
It is  said, that after being dumb for years, they have begun  to
speak again shortly before death.  The causes of this dumbness
are various.   In  that severe form of melancholia,  to which the
name  of  melancholia attonita has been given,  the  speech often
remains for weeks to months entombed in the same  numbed con-
dition  or immobility that  reduces all  the  other movements  to 
812         KUSSMAUL.—DISTURBANCES OF SPEECH.

a minimum.   The immobility involves  both the bodily  and the
mental powers ;  all questions are responded to at most by a dumb
smile,  the meaning of which cannot be unriddled.  In cases of
insanity, it is religious  or other delusions,  or frequently also
hallucinations, particularly word-phantasms in the form of warn-
ing, threatening, or commanding voices, that impose  dumbness
on the patients.   God has commanded through the Holy Scrip-
tures,  or the  Czar of Russia has decreed  by a ukase,  or some
terrible subjective or objective voice has ordered, the patient to re-
main dumb for a day, or a month, or forever.  Finally, however,
some unusual event, some severe bodily illness, or perhaps a new
commanding voice, loosens again the shackled tongue.
   Next to  this complete muteness  must be classed  the inten-
tional avoidance of particular words, the use of which is held to
be forbidden for religious reasons or  on the ground of  propriety.
Many wild tribes, immediately  after the death of any person,
banish completely and most solicitously from conversation the
name of the  deceased and all words that  might  recall him  oi-
lier to mind; the words thus  banished are replaced by other
newly-coined expressions.   It may seem droll, but it is neverthe-
less correct,  to designate and class this custom as aphrasia and
par aphrasia  super stitiosa endemica}
   There are persons who have a bad habit of interpolating inap-
propriate words  in their conversation,  either at the beginning or
the end, or in  the middle of  a sentence.   This form  of dys-
phrasia, to which MerkeP gives the not altogether apposite name
of embololalia, and which would be more correctly designated by
the term embolophrasia, is  really nothing more than a foolish
habit,  the cause  of which is  sometimes to be found in the pleas-
ure that weak-headed or affected individuals  take in sonorous
words.
   Thus J. Frank, in his Prseceptis (T. 2. V. 2. Sect. 1. Cap. 2), tells of one of his
pupils who always interpolated the words "hedera" and "federa" in his sentences.
In making a report, for instance, he said: " The patient has slept well, hedera; had
two passages, federa."

   1 Tylor has collected and published a number of examples of this custom (Forschun-
gen iiber die Urgeschichte der Menschheit.  S. 178-189).
   2 Schmidt's Encyklopadie der geo. Medicin. Bd. 6. Art. Stammeln. 
DYSPHRASIAS.
813
   A professor in a gymnasium had a habit of foisting the words " wiederum " and
"dawiederum" into his sentences, particularly  when he desired to be pathetic;
when he wished to attain the very acme of pathos, he terminated  a sentence with
"dawiederumda."  On one occasion he astonished his pupils by informing them of
the death of a comrade, in  the following words: " Der kleine Englander, der erst
einige Tage unserer Klasse angehorte, ist schon in verflossener Nacht wiederum ge-
storben, dawiederumda (The little English boy, who  lately joined  our class, died
again last night, dawiederumda)."
   Another very pedantic and affected teacher embellished his sentences by inserting
the sonorous particles " oe,"  or " oe-doe," or " oe-doe-woe-doe."  He  invariably
terminated  the  morning prayer with  a fervent "oe-doe-woe-doe" inserted  just
before the Amen, which he always pronounced Amem !—"Oe-doe-woe-doe—Amem."

    This fantastic interpolation of  stereotyped words in the con-
versation is also met with as  a result of antecedent cerebral dis-
ease.

   An old General, during the last years of his  life, and especially when excited,
continually interrupted his remarks with the  expletive " mama."  This impediment
made its appearance after a  coup-de-soleil.  He said, for example : "This  miserable
—mama—fellow has expected—mama—other people to—mama—pick his chestnuts
out of the  fire—mama."  Even when  he spoke  Italian, his sentences were inter-
larded with this curious "mama."  His intellect was not impaired.
   Perhaps the case reported by Dieulafoy ' also  belongs to this category.  In that
case there was, combined with aphasia, a singular prefixion of the word "tout" to
all words and sentences enunciated by the patient. It is difficult to decide whether
this anomaly should be classed under dysphasia, or under dysphrasia.  It reminds
us of the "und"  (and) with which, in consequence  of  their  lack  of skill in the
combination of  phrases, children  are wont to begin their sentences; also of the
stereotyped  "Also," "Wie gesagt," etc., with  which many adult persons  initiate
their sentences.  These, however, are errors due merely to want of practice or to bad
habits, while, in  the patient in question, there was positive inability to articulate the
words or sentences without the prefix  "tout."  He could  say "tout-de-meme"  and
" toujours," but not " mSme " or " jour " alone.   He could not say " vin," but could
say " tout le vin," "tous les vins sont bons," "tous les rideaux sont blanchis par la
soeur de  service," etc.

    Some  people take pleasure  in using the  diminutive forms of
substantives  and even of adjectives, ex. gr.,  "Das istgutchen;"
"kleinchen,"  and the like.    Others give peculiar turns to  the
terminal  syllables  of  words  ;  as an  example we may  adduce
'Gaz. deshopit. 1865.  No. 68. 
SI 4         KUSSMAUL.—DISTURBANCES OF  SPEECH.

Fritz Reuter's " Durchlauchting'' and other dialectic distortions,
made with a view to attain comic effects.   In this connection we
must also mention the so-called " Erbsen " speech (Erbsensprache)
of the children.  This is a game in which the syllables " erbs "
or "erbse" and "erbsen" are appended  to all monosyllables,
and are put in place of the final syllables of polysyllables ; instead
of "wiressen Erbsen," for instance, the  players say, " wirerb-
sen esserbsen Erbserbsen."   The  one who repeats this the most
rapidly wins the game.   Among lunatics we meet  with similar
eccentricities.

   A patient of Westphal's,1 who was both insane  and aphasic, almost always
employed the diminutive form of substantives: " Wurmchen," " Engelchen,"
" Federchen," etc.
   Trousseau had a patient, suffering from temporary aphasia, who added the
syllable "tif" to all monosyllabic words, while of polysyllabic words he only
articulated the first  syllable, replacing all the others by the same " tif."  He said
"bontif" instead of " bon " and " bonjour," " ventif" instead of  " vendredi,"
" montif " instead of " monsieur," and so on.

   Persons who become embarrassed and confused when speak-
ing, either  from bashfulness, or because  they do not  exactly
know what to say  or how to express themselves, easily fall into
the anomaly of speech which we call hemming and hawing, the
Germans  Gaxen or Staxen, and  the  French dnonnement.  The
anomaly might  be christened  angophrasia, a term which would
bear some resemblance to the French word.  The individual who
is subject to this defect halts in  his  speech every few moments,
and interrupts the sentence by drawled or iterated vowels, diph-
thongs, or nasal sounds :  a or a-a,  e or e-e, se or ae-ae, oe, eng,
ang, etc.   Frequently, also,  one of  these  prolonged sounds is
affixed to the end of a word, and serves to connect it with the one
that follows.   This anomaly  may  sometimes  persist  as a bad
habit, long after all trace of shyness in speaking has disappeared,
and after the speaker  has perhaps attained great facility and
sureness of diction.   In such a case the discourse may be excel-
lent with regard to its matter, and  in all  other respects to  its
form also, but the occasional interpolation of ce or oe-oc,  ang or

       1 A. Mau, Ueber aphasie. Diss. Berlin, 1872.— Wiedemeister, loc. cit. 
DYSPHRASIAS.
81.")
aeng, and the like, disturbs and distracts the listener.  This hesi-
tancy in speech is seldom observed in women.   It is sometimes
symptomatic of intellectual  impairment, and especially of gene-
ral progressive paralysis (Voisin').
   An analogous, abominable fault is the hemming or hawing
with which inveterate retailers of  anecdotes  are wont to begin
and at intervals to interrupt their recitals, partly in order to call
general attention to what is coming, partly with a view  to gain
time to collect their ideas.   This defect  originates in the efforts
required to clear  the  throat for phonation, when catarrh is pres-
ent,  but after  a  time  the hawking is continued, although  there
may be  no mucus in  the larynx.   In very many cases the re-
spected  speaker would please his  listeners  better  if he would
expectorate his sputum,  and keep  his recollections of " Meidin-
ger " for his own private edification.
   The improper repetition  of words, phrases,  and entire sen-
tences presents some  analogy to hemming and hawing.  AA^hen
the repetition is made intentionally, with a view to  accentuate
certain words or thoughts, and to  impress them on the mind of
the hearers, it is of  course not incorrect. Sometimes, however,
it is  the  result of a bad habit, or of an uncertainty in the process
of thinking or of speaking.   It very frequently accompanies
dysphasic  conditions.   Morel2 has  met with it as a symptom of
hypochondriacal depression.
  A  lady, actuated by the fear of losing her speech, often repeated the same word
or phrase over and over again for a long time.  At other times she would appre-
hend a paralysis, and to guard against it would keep moving her arm in different
directions.

   In  this case, the motive which  led to  the persistent repeti-
tion  of  the  same  word  was apparent.   In  insane persons,
however, it is not always possible  to discover the reason of the
iteration.  Frequently the phenomena remind us of a child who,
automaton-like,  repeats  or   sings  some word or phrase,  some
rhyme or little verse, until the persons around him can no longer

  1 Troubles de la parole dans la paralysie generate.  Arch, de med. Janv. 1876. p. 26.
  5 Traite des maladies mentales. Paris, 1860. p. 300.  " Voix, parole, perte de la
parole." 
81G        KUSSMAUL.—DISTURBANCES OF SPEECH.

endure it.  Sometimes it is the sound of the word, sometimes its
meaning, sometimes both, which  attracts the attention  of the
child, and the word is repeated because it is strange, or because
it has a pleasing sound.  In insane persons we  observe exactly
the same thing.   An  insane man was intensely delighted with
the meaningless word " Kitzfieck,"  which he smilingly repeated
over and over again (Brosius).  Crazy people seek also to impress
others with self-created, or sonorous, or foreign words.  A lunatic
was in the habit of greeting the physician  with the question:
" AAliat says Horace \" which he would follow up with meaning-
less sentences (Brosius).
   Many healthy  persons have a habit,  when conversing, of
speaking the leist word spoken by their interlocutor.  This habit
has its origin  in a desire  to show  that they are attentive and
understand correctly what is said.   It is a special variety of
echo, but it must not be confounded with the reflex echo-speech
of mentally weakened  persons, of which we have already spoken.
It is also met with in lunatics as a manifestation of  a capricious
whim.1
   AVhen the thoughts of a mentally sound man move sluggishly,
as they do, for instance, when he  is oppressed  with sleepiness,
speech often  creeps along with  a fatiguing slowness—brady-
vhrasia.  It breaks off suddenly in the middle of a sentence, or
the thread of  thought becomes tangled, and words are uttered
which show that the drowsy speaker  has  wandered off  to a very
different train  of  ideas.  This phenomenon  must  not be con-
founded  with paraphasia, but should be  classed as paralogia
and paraphrasia.   We find  bradyphrasia  and paraphrasia
developed in a similar manner, in conditions of  morbid  hebe-
tude and intellectual weakness.
    On the other  hand, in restless,   excitable  persons,  whose
thoughts flow  rapidly and tumultuously, we find that the  speech
also acquires a precipitate and tumultuous character.   AVhen to
this natural peculiarity the effects of negligence and of a  faulty
  1 Question :  " How do you do ? " Answer:  "How do you do ? "  Question : "What
would you like to do  to-day?"  Answer: "What would you like to do to-day?
What would you like to do to day ?  What would you like to do ? " etc. (Brosius). 
DYSPHRASIAS.
817
education are superadded, the defect of speech, called by  the
Germans Pottern or Brudeln, by the French bredouillement, and
by the English cluttering, is developed.  AAi'iters on stammering
and stuttering  have designated it by the terms battarismus and
tumultus sermonis, and have with good reason distinguished it
from the former defects, which are altogether different in nature.
Its development is favored by imperfections of hearing.   Clut-
terers speak too  rapidly,  do not take time to articulate clearly
the sounds  and  syllables in the words, and clip syllables and
even entire  words,  especially at the end of the sentence ; entire
sentences even may  be entombed in an unintelligible jargon.
Alcoholism may cause cluttering in its most severe form.  Some-
times it  is symptomatic of irritative, morbid  processes in  the
brain.
   This defect may easily be  confounded with stuttering.  In
very nervous chatterers the breathing may become oppressed, and
in this way a  certain resemblance  to the other affection be
caused ;  they will  then, like stutterers, gasp for breath in  the
middle of a sentence, and, according to Klencke, may even be
attacked with  spasm  of the glottis.  This author states that, at
the time when  the operative treatment of balbuties was in vogue,
a certain operator  cut the tongue of  an unfortunate clutterer,
whom he erroneously thought to be a stutterer, on two different
occasions, of course without favorable results. Klencke afterwards
effected a cure in  this case by  means of the didactic method.
Eleven other clutterers told him that their physicians had recom-
mended the operation for stuttering, as the only means of treat-
ment affording any prospect of cure.
   In general, however, cluttering may be  distinguished from
stuttering by the fact, that it becomes less intense when  the
patient pays  strict attention to what he is saying, while  the
stutterer succeeds best when he allows himself to speak  in an
unconstrained  manner.   The latter acquits himself best in the
circle of his friends and relatives, and is at his worst when he
tries to speak in public ; the infirmity of the former, on the con-
trary, is most marked when he is in the circle of his intimates, and
least noticeable when  he is speaking before strangers.   Colombat
mentions the case of a }*oung preacher who cluttered very badly
          VOL.  XIV.—52 
818         KUSSMAUL.—DISTURBANCES OF SPEECH.

when conversing with his relatives and friends, but when in the
pulpit delivered his sermons well.
   AVhen the cluttering has originated in negligence  or a faulty
education, a cure may be effected by explaining to the patient
the cause of his  defective speech, exhorting  him to think and
speak quietly,  and accustoming him  by means of  recitations,
declamations,  and  methodically conducted  conversations, to
think in a measured style, and to place and articulate his words
properly.
   A  hesitating speech,  with  longer or shorter intermissions,
that are  not, as in hemming and  hawing, filled out with vowels,
diphthongs, or  nasal sounds, constitutes a special form of brady-
logia (bradyphrasia interrupta).  The speaker may, in spite of
the interruptions, be able to finish what he wishes to say, and to
express his thoughts in correctly constructed sentences.  He may
not be so fortunate, however, and may either break down entirely,
or get om the  wrong track and become confused.  A speaker
sometimes comes to a dead stop in the midst of a most animated
description,  because  he has  reached some  turning-point  that
awakens painful recollections in his heart, and, despite his efforts
to proceed, his  words may be smothered in sighs, sobs, and tears.
The speech of the victim of melancholia is  often interrupted in
a similar manner.  He sighs and sobs in the middle of a sentence,
or he becomes  suddenly silent, and it is evident from the expres-
sion of his features  that he is no longer thinking of what he was
saying.   He has given himself up entirely  to his overmastering,
painful feelings.  Sometimes the hesitating speech is the expres-
sion of an  intellectual weakness, that renders the patient inca-
pable of following  out  his train of  thought.   This  may be so
marked,  that he is  unable to carry  on a single sentence to its
natural  end.1  Hallucinations of hearing  also, when they con-
stantly torment the patient, may prevent him from quietly con-
cluding  his remarks.  The "voices" mock  at his words; he
stops, begins again, and so on until, no longer able to endure it, he
loses  all patience, and, careless of what he  was about to say,
breaks out into bitter maledictions of the "voices."  These word-
1 Compare an observation of Solbrig's, Allg. Zeitschr. f. Psychiatrie. Bd. 25. S. 321. 
DYSPHRASIAS.
819
phantasms are sometimes meaningless syllables or corrupted
words.   A  certain patient was greatly irritated,  because he
thought the boys on the street were constantly calling after him
"dcx, dex." A minister often heard the people cry out "bi,bi,"
and from that he deduced the conclusion, that he was about to
be raised to a bishopric.   An insane woman, at night, heard a
voice  from the wall, saying: "Audi er errte, er bemeidet dem
das AA'ort."  She became very much alarmed at these words, and
sought anxiously to find out what these words meant (Snell).
   The hesitating speech  may become confused, although the
confused speech sometimes gushes out in a rapid stream.  AVe
have  already studied the confused speech wdiich is dysphasic
in nature,  and reaches its acme in choreic  paraphasia, but that
form which finds its origin in dyslogia, is much more frequently
met with.  Here the  thoughts are confused in consequence of
absence of mind or  intellectual weakness,  and the  defect of
speech may also develop into a choreic paraphrasia.  The dis-
tracting  influence  which  the word itself may exert  on the
thoughts is a matter of great importance to persons subject to
this defect.  Every  one will be able to recall some  occasion on
which the casual mention, in the course of conversation, of some
name  that happened to be the subject of great and general inter-
est, immediately gave a sudden turn to the  thoughts of the com-
pany,  caused  the speaker  to  break off abruptly his unfinished
sentence and directed the conversation into  an entirely different
channel.   In diseased conditions, such as mania and dementia,
where the association of ideas is destroyed or  greatly relaxed,
this distracting influence of the word makes itself felt in all its
intensity,  and may produce such confusion of ideas that the
patient is  no longer capable of constructing correctly even the
simplest sentences.  In mania, a senseless jumble of  words, con-
nected together only by assonance, alliteration, rhyme,  or the
like, are whirled out, while in the bombastic utterances of de-
mentia,  hundreds of  different ideas may be touched upon; an
idea is suddenly awakened by a word,  a rhyme, or the like, and
is just as unceremoniously crowded out in its turn by some other
thought.
   The  sudden truncation of a  sentence  is not  always the 
820        KUSSMAUL.—DISTURBANCES OF  SPEECH.

result of confusion of thought or absence of mind ; it may also be
due to a  too great fecundity of ideas, which outstrip  the words
that should express them.   Thus,  for example,  the historian
Schlosser, in his lectures at Heidelberg, rushed uninterruptedly
onwards, frequently leaving  his sentences unfinished.  He ex-
pected his hearers to complete them in their own minds.
   This brings  us to a  remarkable phenomenon, which can be
interpreted as a loss of the power to put a stop to certain trains of
thought, when they have once been set in motion.   For instance,
a patient is requested to count up to six, but instead of stopping
there, he counts to ten, to a hundred, and even higher, until he
is interrupted, or until  his voice  and perhaps his memory fail
him.  A patient, who was told to write 2718, was  seized  with an
inordinate fancy for sevens, and wrote  277717.  A certain musi-
cian, whenever  he struck the correct note,  invariably  tacked on
to it a series of notes corresponding to the gamut.
   There is another phenomenon which is dependent on atony of
the controlling power of the mind, and wdiich  is met with partic-
ularly during periods of fatigue and physical weakness.  Some
thought, or perhaps some  incident connected  with the thought,
awakens  a converse idea, which the individual cannot repress,
and to which he is forced by an irresistible  power to give utter-
ance.   In  this category, perhaps, belongs  the convulsive laugh
of nervous  women, when exposed to some terrible trial that agi-
tates them violently.  Some  trivial incident,  such as a snore,
occurring in the middle of a long,  tiresome, sober sermon, will
sometimes put  an entire congregation into a state of  hilarity
that many of the members will be utterly unable to control.  AVe
might also class here such a case as the following : A sick lady,
who was at the same time aphasic, greeted  politely a  physician
called in for consultation, and motioned him to a chair with the
most engaging mien in  the world, but with the words "cochon,
animal."   Her  son-in-law, who understood what she  wished to
say, explained to fhe astonished physician that she meant to
express a polite wdsh for him  to be seated (Trousseau). In what
other way can we account for the fact that  the lady said  exactly
the opposite of  what she felt  and thought ? Utterances of this
sort are usually classed under paraphasia,  but it would be more 
DYSPHRASIAS.
821
correct to ascribe them to paralogia, and to call them paraphra-
sia.
   Finally, we must also bear in mind  the puissant influence
which predominant'political, religious,  social, or literary ideas
exert on the language of healthy men, and ich ich fixed  illu-
sions exercise,  on  the  entire speech  of persons  of unsound
mind.  Individuals who, though mentally sound, are wrapped
up in particular circles of ideas, and are always ready to  dis-
course on their favorite themes  or  hobbies,  are very liable to
digress  from the  immediate  subject of  the conversation or lec-
ture, and to find themselves all at once speaking of  matters that
are entirely foreign to the subject.  This is a thematic paralogia
{paraphrasia thematica).  Those among  the listeners who do
not  know the speaker sufficiently, and are consequently unable
to understand his digression, will  be bewildered, and will prob-
ably ask  themselves: can  the man be  in  his right mind?  In
monomaniacs the  impress of the delusion is evident  on the voice,
accent, carriage, and gestures,  on  the articulate expressions in
words, and on the grammatical and syntactical formation of the
sentences.  The entire appearance of the patient, as well as his
speech,  is altered in  accordance with the character of the delu-
sion ; new words  are created,  and old ones are  rebaptized with
jievv  meanings.   This is  the paralogia of monomania, paraphra-
sia vesana.  For instance, they designate by the term " Maurerei
treiben,"  the power which they believe  their supposed enemies
possess, to pursue them through the thickest walls (Mauer), with
their voices, with  mockery,  taunts,  and  abuses.   Their  own
ability  to hear these voices  they  define as " Feinhorigkeit,"
"durch das Hasenohr horen "  (quickness of hearing, to  hear
with the hare's ear), and so on.  The word-phantasms they  call
k> Maurerwdrter," " Bannworte," "Bannerworte," etc.

   Brosius had in his asylum a young  man who believed himself to be at one time
this and at another time that personage.  Sometimes he was a  famous scholar, and
then with head thrown backward, and resting on the back of his chair, he would
discourse to the children and nurses, delivering his remarks in a deep chest-voice,
with a didactic air and explanative movements of the arms.  At other times he was an
Italian count or a Norman duke, and with chivalric mien and radiant countenance
would boast of his glory and riches.  On these occasions he used the Italian or 
822         KUSSMAUL.—DISTURBANCES OF  SPEECH.
the French language, but interlarded his speech with German sentences.  Again, he
would be an unfortunate man, neglected by all the world, and would give utterance
to his complaints and prayers in  a  low, whining voice, and with a depressed and
cringing air. Sometimes he spoke in a persistent monotone,  with but little accent-
uation and with a moderately pitched voice, sometimes in a passionate style and
with a nasal voice, which he thought to be particularly charming.1
   Before closing this chapter, we must devote  a  short space  to
the consideration of the impairments of speech in idiots.
   The more accurate investigations of recent times seem to  sup-
port the theory of H. AA'agnerand Gratiolet, which ascribes micro-
cephalia 2 to a cessation in the development of the cerebral hemi-
spheres.  The brain remains  stationary at a stage  correspond-
ing to some particular phase of  embryonic life.  Even  the ele-
mental structure of the cerebrum has been found in a condition
corresponding to the earliest  stage of embryonic  development.3
If this be correct, we have  reason to hope that the results ob-
tained by the study of microcephalia,  as well as of other  anom-
alies of the brain due to arrested development, will,  when com-
pared with the  degree of  mental development  exhibited by the
patients during life, furnish valuable data for the localization of
the psychical functions,  and of the faculty of speech in  par-
ticular.
   There are microcephali  who  cannot learn  to speak at all.
The reason for this may lie in  the fact, that their mental develop-
ment has only attained a very rudimentary stage.   They do not
speak, as Griesinger curtly expresses it, because they have noth-
ing to say.   There can be no doubt, however, that the reason is
often to  be found in  an arrested development  of the central
organs of  articulation and speech.   A  case reported  by  L.
Meyer4 furnishes evidence of this.
   This idiot could only utter a few scarcely intelligible words, which were  rather
   1 Snell gives numerous examples of alteration in the manner of speaking and of the
formation of new words.  See Zeitschr. f. Psychiatrie. 1852. Bd. IX. S. 11.
   2 Compare the very clear and exhaustive exposition of our knowledge on this sub-
ject, by Mierzejeveski, of St. Petersburg (Verhandlungen  der Berlmer Gesellschaft fiir
Anthropologie.  Berlin, 1872. S. 100.
   s Mierjeievesky et Bouchernu. Progres Med.  1875. p. 702.
   4 Archiv fiir Psychiatrie. Bd. 5. S. 1. 
DYSPHRASIAS.
823
blown out or chewed out than spoken, and which his relatives construed into
"papa," " mamma," and "uncle."  Mastication, too, was difficult.  On the othei
hand, the child could express himself well by means of  an animated and very
intelligible pantomime, and was  even able to report on  different things that
occurred in the asylum.

    This view will be all the more readily conceded, in view  of the
known fact that even intelligent children sometimes remain inca-
pable of  learning to speak.   The case reported by Broadbent,
which is  mentioned in  Chap. XXXI., is of the greatest impor-
tance in this connection.
    Other microcephali  can  only repeat mechanically, like par-
rots,  a few words that  they have learned by  heart,  without
understanding their meaning  and signification.
    A third class  of these patients learn  to speak to a limited
extent,  and can express a few wishes.   AVhen excited, they can
often utter words that they are unable to articulate under other
circumstances.    J. Mueller  drew  attention to this fact.    The
speech  of  such  idiots is even capable of being  perfected  by
methodical practice;  this was demonstrated in the cases of the
Aztecs, which Leubuscher reported.

    The microcephalus, Elise Schenkel, whom Aebyi examined, gave him very accu-
rate information.  She had even attended the public school for several years, but
was finally obliged to discontinue her attendance, because she was no longer able
to follow the exercises. In arithmetic, especially, she could make no progress, and
it was with great difficulty that she learned  to count up to ten.  Singing was her
gr^at  delight.  Her microcephalic brother, Christian,  who presented the nimble
type, while Elise was only lively, understood simple questions relating to subjects
of daily life, and was able to speak a  few words correctly.
    The  aphasic  Russian idiot,  Mottey, whose case  has  been so  exhaustively
described by Mierzejewsky, gave utterance only to the simplest  syllables, which
were chiefly short, demonstrative, and affectional words: " Hier da, hicr  da, hier
da sie, hier ist est ja, dort, dort;" or " O,  o hier da, jenes;" or "O ba, o ba,
wcssen ist jenes,  wessen ist sie,  dort, dort," and the like.  To all questions
addressed to  him, he  answered: " Hier da, hier da, o, o, hier ist es ja."  When
pleased, and when any one warmed his hands, he would repeat smilingly : " O ba,
o ba, o, hier ist es ja."  His brain  resembled in shape and in the arrangement of
the convolutions, that  of a  human foetus at the ninth month, although the con-
formation of the fossa Sylvii and of the frontal and parietal lobes presented more
1 Archiv fiir Anthropologie.  1873.  S. 263. 
824         KUSSMAUL.—DISTURBANCES OF SPEECH
analogy to the lower stages of uterine life.  It surpassed, however, in size and
weight the brain of a normal foetus, and was more developed than that of the
anthropoid ape.  The idiot was about fifty years of age, and his mental powers were
about as developed as those of a one and one-half year old boy, although the brain
of the latter would weigh more and its convolutions would be developed.  The
cerebellum, pons, and medulla were nearly normal in size ; but the cerebrum had
hardly attained to half the ordinary size.  The nuclei of  the hypoglossi and vagi
were damonstrated microscopically by Prof. Betz.

   Persons  suffering  from  acq air eel  idiot ism  are sometimes
"everlasting  chatterers."  According to Kind,1 this seems to be
the case under two conditions.   In the first place, it is observed
in patients who had already attained a certain degree of normal
intellectual development, before the  idiotism  was  developed.
The words that  had been learned are  then rolled out mechani-
cally in the  most  riotous  confusion ;  but  they do  not  give
expression to  any thought, and are not grouped around any cen-
tral idea.  This last peculiarity serves to distinguish this form of
chattering  from  the logorrhosa of lunatics affected with  inco-
herency of ideas, in whom some  central idea still glimmers out
from the bewildering maze of words.   Secondly, it is observed in
those in whom  the ideas aroused  by  the impressions made on
the senses aTe so transitory, that they are instantly crowded out
by changing  impressions with their  new ideas  and new words.
These two conditions may be combined.
   In congenital  or acquired  idiotism, the faculty for music,
i.e., a good musical ear and  a good memory for melodies, some-
times remains, even when speech is impossible.  These warblers
("Melodientraller"—melody trillers), as a rule, are incapable of
learning anything  else  (Brandes).   According  to Zillner,3 the
dumb  idiots  can be divided  into  two classes—into those who
possess, almost in the normal degree, the power of modulating the
voice, and are able to bring forth in  succession different,  high,
clear notes, and those who can  only  utter a few sharp,  harsh
sounds.  The  tension of the  vocal muscles exerts the most impor-
tant influence on the voice; the hoarse,  harsh notes  are due to

   1 In a criticism on the work of Brandes,  entitled " Der Idiotismus und die Idioten-
anstalten," u, s. w. Hanover, 1862. Schmidt's Jahrb. Bd. 115. S. 233
   2 Med. Jahrb. XL ; Wiener Zeitschr. XXII. 
STUTTERING AND APHTHONGIA.
S2o
their  relaxation.  In idiots who can  speak, we find that it is the
formation of the laryngeal sounds  that is most defective in some
cases,  while in others the formation  of  the lip-  and tongue-
sounds is more affected.
   The study of the  influence which a defective formation of
special parts of the bruin exerts on the development of the intel-
lect  and  of the faculty of language, has as yet  hardly  been
begun.  Quite recently, Sander1 and Knox2 collected and grouped
together  all the cases of defective development of the corpus cal-
losum that could be found in medical literature ; the former col-
lected ten cases,  the latter fifteen.   These cases  show that a
complete absence or a rudimentary development of the  entire
commissural system, which binds  together the two hemispheres
of the cerebrum,  entails  idiocy.   AVhen  the corpus callosum
alone is wanting, the other commissures being present, idiotism
does not always result, but still the patient seems  to stop short
at a very low stage of intellectual  development.  Some patients
with  defective commissural systems  learned to speak, although
they  were idiotic in varying degrees ;  some of them could only
learn a few words, but others were able to answer simple ques-
tions,  and even learned to read and write.  One patient, who
could do both these things, was unable to calculate.
                     CHAPTER XXXIV.

The Two Spasmodic Laloneuroses:  Stuttering and Aphthongia.—Nature, Symp-
    toms, Causes, Diagnosis, Prognosis, and Treatment of Stuttering.—Remarks on
    Aphthongia.

   There are two forms of impaired speech that belong  in the
category of the spasmodic neuroses, viz. : stuttering and aph-
thongia.  In stuttering, the articulation of the syllables and
thereby the entire speech, is  impeeled in a spasmodic manner.
« Archiv fiir Psychiatrie. 1868-69. S. 128.
2 The London Med. Record. 1875. No. 125. 
826         KUSSMAUL.—DISTURBANCES OF SPEECH.

This impediment does not manifest  itself on all occasions, but
is apparent only  at  certain times and under  certain circum-
stances,  which, however,  are  unfortunately very frequently
present.   In aphtliongia a  spasm of the hypoglossus sets in,
wJienever an attempt to speak is made, in consequence  of which
speech becomes altogether impossible.
   AVe will begin with stuttering, which is a very common affec-
tion, while aphthongia,  on the contrary, is an exceedingly rare
disorder.

   Stuttering is a spasmodic neurosis of co-ordination, which
obstructs the utterance  of the syllables, by spastic contractions
at the stop-points for  vowels and consonants in the articulating
tube.  This obstruction may  be  experienced as  soon as  the
patient begins to speak, or it may not be encountered until later
on in the middle of his remarks, although all the syllables had
previously been articulated with perfect correctness.  All iso-
lated sounds are correctly articulated; the affection is a dysar-
thria syllabaris1 and  not a dysarthria literalis.   In the articu
lation of a syllable which  commences with a consonant,  espe-
cially an explosive sound, or more rarely of a  syllable commenc-
ing with a vowel, the speech is suddenly impeded,  and the first
sound  of  the  syllable or the terminal sound of  the preceding
one, is  repeated usually many times, until finally the obstruction
is overcome,  and  the patient  can continue his sentence.  This
spasmodic  obstruction is not experienced at all times ;  intervals
occur  during  which  the stutterer is able to  speak without
impediment.
   If we examine more  closely the processes  that interfere with
the proper sequence  of  the syllables in stuttering, we will find
that the three muscular  actions, the expiratory, vocalic and con-
sonantal, which are combined  in  the enunciation  of sentences,
are not harmonically  co-ordinated.  The regulating centres in the
central nervous system, which preside over the harmonic co-or-
dination of these muscles in the act  of articulating the sounds
  1 Syllaba is derived from crvXKntfww, I include or combine together, scil. consonants
and vo.vels. 
STUTTERING.
827
in the syllables, or, as Merkel expresses it, in the vocalization of
the sounds, are  thrown into disorder by even insignificant peri-
pheric,  and  still more  frequently by centric  excitations.  The
irritation caused by a painful  tooth, for  instance, or most fre-
quently  some  mental  embarrassment,  displaces  these co-ordi-
nating   powers from  their too delicate equipoise.   The  three
above-mentioned muscular actions, that take part in the articu-
late formation of every  syllable, are not correctly balanced, with
regard  either to the force or the duration of the contractions.   In
consequence of this, the current of air employed in speaking has
not  sufficient  power to overcome  the  opposing tension of the
vocalic  or  consonantal  muscles.   On the  one hand the respira-
tory action required for speech is defective,  and on the other the
tension of the  vocalic and consonantal muscles is spasmodically
increased; instead of  contracting smoothly and for  the normal
space  of time, these muscles  are  affected with tonic or  clonic
spasms.

   It was not until the third decade of the present century that the differentiation
of the two defects of speech, stammering and stuttering, was accurately carried out.
The chief credit for this belongs  to the Swiss,  Schulthess.1  About the same time,
the knowledge  of stuttering  and stammering was advanced by the researches of
Serre d'Alais2 and Colombat3 in France, of Arnott4 and Cormack5 in England, and
of Schmalz6 in Germany. Among the earlier investigators Ave must  mention Itard,1
who  declared in 1817 that the  treatment of stuttering had made no progress in
2,000 years.
  Of the later  writers on this branch of medicine,  we may mention especially
   1 Das Stammeln und Stottern, u. s. w.  Z irich, 1830.
   2 Memoire sur le begaiement. Jour, des difformites  1829. No. 2.
   3 Du begaiement et de tous les autres vices de la parole, etc. Paris, 1830.—Traite
madico-chirurgical des maladies de  la voix, etc. Paris, 1834.—Orthophonie. 2. Edition.
Translated into German by Flies.   Quedliuburg and  Leipzig. 1840.—Traite de tous les
vices de la parole et en particulier begaiement, etc. Paris, 1843.
   4 Arnott, in Elements of Physics or Natural Philosophy, 1830.  Chapter "On Artic-
ulation," Appendix.
   5 A Treatise on the Cause and Cure of Hesitation of Speech or Stammering, etc.
London, 1828.
   6 Ueber Stammeln und Stottern. Clarus und Radius, Beitrage. Bd. 1. H. 4.—Also,
Beitrage zu Gehor- und Sprachheilkunde.  II. 2. S. 1.
   1 Jour. univ. de mod. 1817. T. VII. P. 129. 
828           KUSSMAUL.—DISTURBANCES  OF SPEECH.

Lee,1  Poett,2 Lichtinger,3 Klencke,4  Merkel,6  Hunt,6 Rosenthal,1 Violette,8  Cher-
vin,9  Wyneken,10  Coen,n and Schrank.12    Merkel did more than any other to
advance the knowledge of the subject, and his account is  the one which we in the
main  follow.  The physiologists  Charles Bell, Marshall Hall, and J. Mueller also
made stuttering a subject of investigation.—The literature of this impediment of
speech has reached enormous dimensions; every possessor of  an establishment for
the treatment of stuttering  seems to have been impressed with the idea that the
interests of suffering humanity necessitated  his  appearance  as an author.  Their
treatises possess, on the  average, about  as much value as the current pamphlets on
balneology.  Moreover,  a number  of stuttering physicians and laymen have pub-
lished their own experiences, either  alone  or in connection with those of  others.
Bocquerel, Merkel, Wyneken, and  Coen  are instances of physicians who studied
the defect in their own persons.
   With regard to the nomenclature, the ancients seem to have applied the terms:
Iliesitatio linguae seu vocis, /3arrapia-juor,  la-xvocpcovia or  laxo<fra>v[a (Aristotle), chiefly
to stuttering, while blaesitas, TpcivXia-fxos  and rpavXorrjs,  ^eXXicr/zos and -^sWottjs,
were applied to stammering in general, and to its special varieties (Sohulthess).

    According to Merkel, the following conditions are absolutely
essential for the articulate formation of the syllables.
    1. A   sufficient  supply  of  air and  adequate  tension of the
   1 On Stammering and Squinting, etc. London, 1841.
   2 A Practical Treatise on Nervous Impediments of Speech, Stammering, etc.  5th edit.
London, 1842.
   3 Med. Zeitung d. Vereins f. Heilkunde in Preussen. 1844.  Nos. 33, 34, 35.
   4 Die Storungen des menschlichen Stimm- und Sprachorgans, u. s. w.  Kassel, 1844.
—Die Heilung des Stotterns. Leipzig, 1862.  2. Aufl.
   5 " Stammeln'1 und " Stottern" in Schmidt's Encyklopadie der ges. Medicin. Bd. 6.
1844.  2. Aufl.—Anatomie und Physiologie des menschlichen  Sprachorgans (Anthropo-
phonik). 2.  Aufl. Leipzig, 1863.—The same, in Pilz's Zeitschrift Cornelia. Bd. 3. H. 4.
Leipzig und Heidelberg, 1865.—The same, Physiologie der menschlichen Sprache. Leip-
zig, 1866.
   6 Stammering and  Stuttering.   London,  1881—Also, Philosophy of Voice  and
Speech.  1859.
   7 Beitrag zur  Theorie und Heilung  des StotteriibeK  Wien. med. Wochenschrift.
1861.  Nos. 35-38.
   8 Etudes sur la parole et ses defauts, et en particulier du begaiement.   Paris, 1862.
p. 150 sqq.
   9 Du begaiement. Paris, 1867.
   10 Henle und Pfeufer's Zeitschr. f. rat. Med. Bd. 31. S. 1.
   11 Anomalien der Sprache.  In  B. Kraus' Compendium der neueren med. Wissen-
schaften. Wien, 1875. S. 397.'
   12 Baitrag zur Lehre des Stotterabels.  Allgem. Wien. med. Zeitung, 1875.  Nos. 26-31. 
STUTTERING.
&29
expiratory column of air in the air-tubes, and in the accessory
tube as far  as the point where  articulation is accomplished,
Witliout this tension the  constriction or  interruption  of the
audible air-column, with  which the  articulation of the syllable
begins, cannot be transmitted with sufficient  power to the audi-
ble vocal stream.
   2. Subordination of the consonantal to the vocalic muscular
action.  The latter must always predominate.  This is only pos-
sible when the tension in the  air-tubes remains approximately
the same, until the beginning of a fresh inspiration.  During the
entire expiratory interval the respiratory muscular system should
be  kept at the same degree of tension,  which  should  not  be
unnecessarily weakened by the interpolation between the syl-
lables of uncalled for pauses,  during which  the  store of air  is
uselessly squandered, or by dwelling  too long on the articula-
tion of the consonants.
   3. Preservation of a certain rhythm, i.e., of  the proper se-
quence of the different acts, allowing to each its appropriate space
of time.  Those which  must be instantaneous should therefore
not be allowed to extend over more time than is absolutely neces:
sary.  Sometimes  one, sometimes  another of  these fundamental
conditions, is more or less impaired in cases of stuttering.
   1. The apparatus of speech in  the mouth and larynx is, as a
rule, normal, but very often the development of  the thorax and
of the respiratory muscular system is defective ;  stutterers never,
however, possess  that degree  of control  over the respiration
which is necessary for speech.  They do not inspire  sufficient
air, are not sufficiently economical  in its expenditure,  and allow
it to escape without putting it to use ;  they  are  sometimes com-
pelled to stop in the middle of a word to draw breath.

  In over 600 stutterers, Colombat did not find a single one presenting organic
defects of the articulating organs.
  Klencke believes that the primary cause  of stuttering is invariably scrofulosis.
This diathesis prepares the soil, and all that is then  required for  the  gradual
development of  stuttering is the presence of exciting causes.  This opinion is not
tenable. We examined only recently a man of herculean build, a picture of the
most blooming health, who had stuttered from his infancy. Wyneken rejects this
theory of Klencke's in the most uncompromising manner. 
830         KUSSMAUL.—DISTURBANCES OF SPEECH.

   2.  Stutterers are unable to sitbordinate the consonantal mus-
cular action to  the vocalic, or to graduate the two at all cor-
rectly.  In the utterance of the continuous sounds, the stutterer
is  only occasionally  detained longer than is  compatible with
smoothness of speech.  When, however,  he tries to vocalize the
explosive sounds, the characteristic manifestations of his infirm-
ity at once become apparent.  He closes the oral canal at one or
other of the closing points, according to the nature of the letter
to be articulated, and this he does as well as a man who posses-
ses the faculty  of  speech in perfection, could  do it; instead,
however,  of allowing the vowel to  follow  without  delay,  he
presses his  lips, or his tongue  and teeth, or his tongue and
palate more firmly together than is necessary, the  explosive
escape of  the air does not take place, the  other muscles of  the
face and those of the glottis, and even the muscles of the neck
become spasmodically affected like the  muscles of articulation,
gesticulatory movements are made,1 the abdomen is  retracted,
the head is thrown backward and the larynx is drawn forcibly
upward, until finally he works himself into a state of frightful
agitation ;  his heart  beats  forcibly,  his  face becomes red and
blue, his body is bedewed with perspiration, and he may present
the appearance of a complete maniac.  Such a paroxysm of stut-
tering may  be  prolonged until  it becomes necessary for  the
patient to draw breath.  The attempts  to articulate are then
renewed,  and continued  until  at last  the  desired syllable is
more  or less correctly enunciated, provided  the exhausted  pa-
tient does not give it up entirely.  This description applies only
to extreme cases.   In  the  milder forms of the affection there
is a repetition of particular letters and syllables, which greatly
impairs the attractiveness of speech, but does not render it unin-
telligible.
   This inability to combine correctly the vocalic and consonan-
tal action  is not, however, equally marked  at  all times.  The
same person may be able at one time  to enunciate long sentences
  1 The extraordinary and often laughable gesticulations and grimaces of stutterers
were utilized for the stage by the Italians, even in J. Frank's time.  There was a
standing role for the stutterer (il tartaglia) in their comedies. 
STUTTERING.
831
smoothly and easity, while at other times he will stutter fright-
fully.  He is  especially apt to do this  when he is confused or
nervous,  or when he is physically exhausted.  Wyneken, for
instance, after a night of wakefulness, was unable to utter a word.
When conversing with his family or with confidential friends the
stutterer speaks  well, but when talking to strangers his speech
is impeded; he  can declaim,  sing,  argue,  and swear  without
impediment.  Wyneken asserts  that the supposed rule,  that
stutterers can sing  without impediment, is  not universally ap-
plicable.   He  himself  cannot always  say in recitative what he
wishes to,  although  his impediment is  very greatly diminished
when singing.   Schmalz states  that stutterers can whisper with-
out  obstruction,  but Wyneken  denies  this also.  He himself
cannot say everything in a whisper, but he has not investigated
the behavior of others in regard to this point.  Perhaps this con-
tradiction  of views  can be explained by the  assumption that
stuttering,  if severe, is  only prevented by whispering when the
whisper degenerates into a lisp, and the patient learns to reduce
his speech to aphonous utterances.  Persons who have under-
gone the operations of tracheotomy learn after a while to speak
in this way.  According to Hunt, stutterers do not stutter when
they are  asked to do so.  In solitude and in darkness the speech
is, as a rule, unimpeded.
   3. Stutterers do not succeed in attaining the correct rhythm
in speaking, because they close too firmly the glottis in the for-
mation of  vowels, and the accessory consonantal tube in the
formation of explosives, and are consequently unable to relax
them when the proper time comes.  The rhythm is also impaired
by delaying longer than is necessary on the continuous sounds.
The  controlling power over  the  rhythmic progress of speech,
which the will is  accustomed to exert in ordinary conversation,
is, however, more frequently impaired by great mental  irritabil-
ity and nervousness, than  by any other causes.   The  very fear
of stuttering may itself cause the impediment to show itself.
When the  will is supported by  some  powerful ally,  such, for
instance,  as the pathos of a declamation, or the melody of a song,
or the feeling of confidence that animates the patient when  he is
conversing  with his family, or when there is some one at hand to 
832        KUSSMAUL.—DISTURBANCES OF SPEECH.

supply the needed word as soon as the impediment shows itself,
the speech is no longer obstructed.
   Colombat distinguishes two varieties of stuttering, the labio-
clwreic and the gutturo-tetanic.
   In the gutturo-tetanic form, the closure of tjie glottis which
is required for the utterance of a vowel, is unduly prolonged and
develops into a spasm of the glottis.  Stutterers affected in this
way may find difficulty in enunciating the vowels a, e, i, o, u, even
when they occur at the  beginning of a syllable.   Even persons
who suffer usually from no impediment  of speech, are some-
times, in consequence of a sudden emotion, of fear or joy, affect-
ed with a stoppage of the breath, which causes the initial vowel
to stick in the glottis.  In the normal mechanism of the utterance
of g hard, the glottis becomes entirely closed (Merkelx), and this
closure  also frequently becomes spasmodic.  When the stutter-
ing affects the letters k and q, there may be spasm of the glottis
combined with a closure of the posterior part of the oral canal,
and in the case of k of the nasal cavities also.   In this gutturo-
tetanic form of stuttering, the mouth remains open,  and Becque-
rel* named it on that account " begaiement ouvert."
   In the labio-choreic  form, the utterance of the  unfortunate
sufferer is arrested  by the sounds b, p, d, t, w, m, etc. ; he is
unable  to force the  transition to  the  succeeding  vowel.    IIn
repeats the  consonant three  or four times, b b b b, m m m m,
and presses  the lips  forcibly together,  or presses  the tongue
against the teeth, but his efforts are unavailing, until he is forced
to  stop  to draw breath, and  thus gains  time to quiet down.
Becquerel named this form " begaiement ferme.'''1   It is usually
accompanied by an active secretion of saliva, which is spirted out
when the patient opens his mouth.
    In practice,  however, it  is difficult to make this distinction.
 Wyneken asserts, that under  favorable circumstances every
stutterer can  enunciate  every word without difficulty,  while
under unfavorable circumstances every word may be obstructed.
This  may be admitted with the qualification, that the  free inter-
vals occur much more  rarely in  one person than they do in
1 Anthropophonik. S. 853.
2 Traite du bjg.xie.n3nt. Paris, 1847. 
STUTTERING.
833
another ; the gradations are numerous.   The  verbal or syllabic
combinations at which the utterance is arrested are not the same
for different men ;  combinations that one  man  can articulate
without difficulty, may constitute the principal stumbling-blocks
for another person.
   In general, stuttering chiefly occurs in the utterance of the
mute consonants, the so-called explosioa dura and media (b, p,
d, t, g, k), and particularly when they are combined with short
vowels or diphthongs (au, ai, eu).  It is easier to say "Balm,"
"Kam," "Amen," than "Bann," "Kamm," "Ammen" (Wyne-
ken).  The litera continua (f,  ch, 1, r, s, etc.), in the utterance
of which some air is wasted, and which possess  intrinsically a
certain ringing quality, and can be prolonged as long as the breath
holds out, offer fewer difficulties to the stutterer ;  they are more
easily combined with the succeeding vowels.  The  transition from
the position required for the production of the consonant to that
required for the vowel is then not very abrupt. The aspirate h,
which is formed in the larynx, and the rolling sound r, offer the
least difficulties.  The rubbing  sounds ch, 1, s, j,  f, sch, and the
resonant n,  are rarely obstructed, but the  resonant m is more
frequently the cause of delay.  When the sounds chi, cho, fi, fo,
etc., meet with an impediment,  the case is regarded as belonging
to the severer grades of stuttering.
   There are slighter grades  in which the  affection is  only
revealed by an unnecessary prolongation of the letters g, k, w,
etc.  In  our younger days  we  were more amused than was
seemly at the mode of speech  of an  old nurse, who would  say
for instance: "K—h—ommen Sie endlich?  Der K—h—affee ist
schon etw—h—as k—h—alt."
   Stuttering is more marked in the morning than  in the evening.
It is aggravated by fatigue and  exhaustion.  After a moderate
indulgence in alcoholic drinks it abates in intensity, but excessive
indulgence  aggravates it, and sometimes produces it in healthy
persons.  A bodily indisposition of any sort is usually attended
by an exacerbation  of the affection, but in exceptional cases the
defect becomes less marked, or even disappears  entirely when
other diseases set in (Schulthess), or after an  injury, a hemor-
rhage,  and the like.  In the case of a  boy, AVyneken saw the
         VOL. XIV.—53 
834         KUSSMAUL.—DISTURBANCES OF SPEECH.

stuttering disappear when an otorrhoea set in, and return after
the discharge ceased.  A lady stuttered whenever her catamenia
were due. All depressing influences aggravate the defect, and all
moderately  exciting influences, which stimulate the functions,
abate it.
   The most reliable  computation of the relative frequency of
stuttering will be found in a treatise on this affection by Chervin.
In France,  between the years 1852-62,  6,773 conscripts  were
exempted from military  service on account of  stuttering.   He
estimates that there is one stutterer for every 1,000 Frenchmen.
In Germany it is said to be more frequent than in France.
   It  is  said that stuttering is unknown among the Chinese.
This exemption is probably due to the binding influence of the
strongly  rhythmical structure of their language, no less than  six
different  intonations being given  to one and the same word, to
make it  express different meanings.  A  Frenchman in Cochin
China, whose  mother was a native,  stuttered when he spoke
French, but expressed himself  with the greatest facility in the
Chinese language (Colombat).
   Stuttering is very common in  some families, partly in con-
sequence  of  hereditary transmission of the predisposition,
partly as a result of bad example and faulty education.  Schult-
hess, Colombat, and others, report cases in which stuttering was
acquired  by intercourse with stutterers; in such cases the de-
velopment of the defect is due to  imitation,  or to a sort of psy-
chical contagion.  Stuttering is less frequent in women than in
men.  According to Colombat, in 20  stutterers there will  be 18
males and 2 females.  Klencke counted 51 female to 97 male stut-
terers. This comparative immunity of woman is probably due
to the same causes which make all her movements lighter and
more graceful, endow her with finer tact and  greater  charm of
manner, and fit  her  to move in  society  and  to  converse  with
readiness, at an earlier age than man.
   Stutterers are said to  be  usually persons of nervous and
excitable disposition, or  of  a flighty, sanguine  temperament,  or,
at all  events, people of but little power of  will (Merkel).  Wyn-
eken denies the last statement.  For the rest, it is easy to under-
stand the frame of  mind  that leads stutterers,  who,  in con- 
STUTTERING.
835
sequence of their defect of speech,  have been ridiculed  and
kept in the background in society, to withdraw themselves into
their homes,  where, according  to   their temperaments,  they
lead an uncommunicative,  distrustful dream-life, or give them-
selves up  to silent frivolities in a  fickle,  inconstant manner
(Klencke).
    Stuttering often appears temporarily at the periods of denti-
tion and of puberty, or becomes markedly aggravated at these
eras.  Transitory  stuttering is also met with after exhausting
mental work- and night-watching,  after  smoking  too strong
tobacco, during a fit   of  drunkenness,  after epileptic attacks
(Wyneken), in hysterical paroxysms (Hasse),  in onanists, and as
a  consequence of  indigestion and of intestinal irritation due to
worms or  to hardened masses of faeces.  Transitory  and even
persistent  stuttering has been known to occur as a  sequel of
acute diseases, such as  typhus, whooping-cough, etc.   Under all
these circumstances, moreover, a previously existing defect may
become more intense.
    Stuttering may accompany, as a transient or permanent symp-
tom, the most manifold irritative diseases  of the  brain  and
cord—simple cerebral  and spinal irritation  as well  as actual
organic lesions due to traumatism,  inflammation, etc.  In the
chapter on aphasia we described  an  aphasic form of stuttering;
which depended on a circumscribed, cortical encephalitis.  Lich-
tinger differentiates a spinal and a cerebretl stuttering ; the spinal
form he again divides into  centric and excentric or reflex stutter-
ing.   Rosenthal reported  a case in which stuttering was one of
the first symptoms of   tabes.  The  patient was an  officer,  and
the defect of speech was so marked that  he was unable, to enun-
ciate even the simplest  word of command.
   Permanent stuttering probably depends most frequently on
congenital irritability and weakness of the syllabic co-ordina-
ting apparatus; it is  often impossible to discover any exciting
cause.   It makes its appearance then  during childhood, and in-
creases up to the time of puberty ; after that era it gradually di-
minishes, and often disappears spontaneously after middle  age.
In other cases the  patient, by means of  long  and arduous prac-
tice, learns to surmount the defect. 
836          KUSSMAUL.—DISTURBANCES  OF  SPEECH.

    A year ago I was consulted by a young man who stuttered horribly.  He had
formerly bee°n healthy and strong; he was an excellent swimmer, and had saved
several persons from drowning.  The last person whom  he saved dragged him
down to the bottom of  the Lake of  Zurich, and it was only after efforts  which
became almost superhuman under the stimulus of mortal fright, that he succeeded
in struggling to the shore with  his  heavy burden.  The defect of speech made its
appearance immediately after this  adventure.  He underwent a course of treat-
ment in an establishment for stutterers, but was only slightly improved by it.  The
affection had already existed for several years at  the  time I examined him.   He
was remarkably pale, and his tongue trembled a good deal when protruded ; but
there were no other morbid symptoms.

    It would  require too much  time and  space  to  examine  in
detail  the  numerous  theories  of   stuttering  that   have  been
advanced by different writers.   We will  only mention  a few  of
the more prominent  ones.

    Schulthess compared the  stutter-spasm to the convulsive movements of  photo-
phobia and hydrophobia,  and proposed to call the defect  "phonophobia'n or " lalo-
phobia.''''  He admitted consequently the central nature of  the  affection, which was
denied by Malebouche ' and other contemporanies.   These writers attributed stut-
tering entirely to  a want of skill  in  manipulating  the tongue, which demanded a
purely local treatment.—Colombat believed it to be a " lack of  harmony between
the nervous excitation  which follows the thought, and the muscular movements
which should  give expression  to it."   He is evidently a disciple of Rullier,2 who
regarded stuttering as "a disturbance between the  idea  conceived and the
word uttered."  Almost all derangements of speech, however, would fall  under
such a comprehensive category.  Schmalz located  the essence of the defect in a
primary, spasmodic state  of the glottis.—Lee correctly recognized  in stuttering a
" neurosis, which,  like all other neuroses, is intermittent. The concomitant organic
defects are not the causes, but only conditions which favor the development of stut-
tering."—Charles  Bell regarded stuttering as a partial chorea ; he  admitted con-
sequently the ataxic nature of the neurosis.—Du Soitz described it as a neurosis,
marked  sometimes by tonic, sometimes by choreic spasms of the respiratory organs,
by which the action of the will  on  these  organs was  impeded.—Lichtinger saw in
stuttering a predominance  of the excito-motor over the cerebral system.   This  predom-
inance may be brought about in two ways : either the  spinal action is normal and
the cerebral influence is weakened or abolished, or the cerebral influence is normal
and the spinal action  is weakened.   This view,  in which  the stutter-spasm is
regarded as a reflex spasm, was for a time very favorably received by the surgeons,

     1 Precis sur les causes du begaiement et sur les moyens de le guerir.  1841.
     2 Dictionnaire des sciences med.   Bruxelles. 1828.  Art. Begaiement.
     3 Gaz. med. de Paris.  1840. No. 10. 
STUTTERING.
S3?
and led to the operative transgressions  of Dieffenbach and others.—Merkel attri-
butes stuttering to an adxjnamia of the functions of vocalization during speaking, an
adynamia which does not depend  on any anatomically demonstrable, organic defect,
but is located purely and solely in the psychical sphere, and especially in the sphere
of volition, and is dependent on external and physical conditions only in so far as
these may influence the mind itself.—Romberg classes stuttering under the head of
" vocal spasms," but does not attempt to explain the nature of these spasms.—The
more recent writers on nervous diseases, such as Rosenthal, Benedikt, and others,
agree with us in classing stuttering among the  neuroses of co-ordination.  Accord-
ing to Rosenthal, it is dependent on congenital weakness of that portion of the respi-
ratory and vocal  apparatus which is located in the medulla oblongata.   This appa-
ratus, when severely shaken by some psychical impression in early childhood, never
recovers from the shock, but is ever afterwards liable to be excited to uncoordi-
dinated movements by the mere exercise of volition.  The morbid influence extends
to the processes of neighboring  nerve-nuclei, and calls into action the accessory
spasmodic movements of the muscles of the face, eyes, tongue, and neck.—Strange
to say, Coen takes the very narrow view, that stuttering is merely " the result of a
deficient atmospheric pressure" in the lungs,  caused by disturbances of innervation.—
Wyneken believes that in stuttering, the action of the will on the muscles of speech
is fettered by a feeling of uncertainty.  The stutterer is  one who is  " irresolute in
speech."—Schrank defines it to be  a localized nervousness.

    No man should, at the present day, commit the  mistake  of
confounding stammering and stuttering.   The differential diag-
nosis is easy.
    1.  The  individual  sounds, as  such,  present no difficulties  to
the stutterer, but they do  to the stammerer.   It is the  enuncia-
tion of the sounds in their syllabic combinations that the former
finds so  difficult.   Moreover, the  stutterer is least likely to be
impeded in the articulation of  certain  continue, such as r, 1, s,
which usually present the  greatest difficulties to the stammerer.
   2. In stammering, the impeded utterance is not accompanied
by the peculiar stutter-spasm.
   3. The nervous embarrassment which underlies stuttering, is
wanting in uncomplicated  cases of stammering.   The  stammerer
usually speaks better,  the  stutterer worse, when he is questioned
about his defect.
   4. Rhythm  and melody exert an emendatory  influence on
stuttering, but  not on stammering.
   5. Stammering is not  attended by the peculiar want of pro-
portion between the expenditure of the expiratory force, on the 
838         KUSSMAUL.—DISTURBANCES OF SPEECH.

one hand, and of the  phonetic and articulating forces, on  the
other.
   6.  Stammering is frequently accompanied  by anomalies oi
the tongue,  lips, and  articulating  organs in general; but mal-
formations,  defects, paralyses, etc., are rarely observed in con-
nection with stuttering.
   The diagnosis of stuttering from syllable-stumbling is also, as
a rule, equally easy.  In both affections the syllabic utterance suf-
fers in consequence of defects of co-ordination ;  but in the former
the spastic manifestations predominate, in the latter the paraly-
tic ; in the former there is simply a dysarthric impairment of  the
syllabic formation, in the latter there is a combination  of dys-
arthric  and dysphasic  impairments  of the syllabic and word
formation;  in  the former  there  is a  disproportion  between
respiration,  phonation, and articulation, as a result of which  the
ability to enunciate the  sounds in  the  syllable is suspended, in
the latter no such disproportion is noticeable ;  in the  former,
speaking is accompanied by a feeling of  nervous  uncertainty, in
the latter it.is  not;  in the former, sounds and syllables  are
repeated, and syllables  cannot be enunciated in consequence of
the obstructive spasm,  in the  latter, sounds and syllables  are
simply dropped entirely, or are huddled together and interposed
in the wrong places.
   On the other hand, we must not lose sight of  the facts that a
stammerer may become subject to stuttering, and vice versa, and
that stuttering and stumbling may occur together.
   Coen1 has reported a case of simulated stuttering.

   The prognosis depends on the age, temperament, and consti-
tution of the patient, and on the causes, form, degree, and dura-
tion  of the  affection.  It is unfavorable when there is  a hered-
itary predisposition to the affection, or when the  sj^mptoms indi-
cate great congenital  irritability and weakness of the co-ordina-
ting  apparatus ;  when the defect  depends  on some  incurable
irritative process in the central nervous system ; when the affec-
tion is of a severe form and has lasted for a long time, and par-
1 Allgemeine Wiener med. Zeitung. 1875. No. 48. 
                         STUTTERING.                     839
ticularly when the spasms of the glottis are predominant symp-
toms,  or when the  spasmodic movements extend  to distant
groups of muscles;  finally, when the patient is advanced  in
years.
    Slighter grades often disappear spontaneously during middle
age.   Klencke  cites cases in which the  stuttering  made its
appearance after a long confinement to an insufficient and innu-
tritious diet,  and disappeared  after the patients had  been sup-
plied with adequate  nourishment for about a year.  According
to  Rosenthal, young adults,  who  are  obliged  to work for the
means of existence,  and are solicitous about  the future, are,
ceteris paribus, more easily cured of the defect than  immature
boys and girls.  Apparent  cures are not unfrequently followed
by relapses.
    It is said  that the severer forms of stuttering, in consequence
of the violent exertions required for speech,  and the disturbances
of  the circulation thereby  produced, predispose to diseases  of
the heart, to  aneurisms of the  aorta and  carotids, and to affec-
tions of the lungs.

    The prophylactic treatment of stuttering must be directed
against the roots  of the  evil, against the general debility, and
the  local weakness  of the respiratory organs, and  the lack  of
self-confidence  and  of power  of will.   By means  of careful
nourishment, invigoration of the body by cold sponging, baths,
and the like,  gymnastic exercises of the lungs, persistent, strict
supervision of the  mode of using sounds and words, and psychi-
cal measures calculated  to strengthen the character and brace
the  sensory  and intellectual centres, we  will often succeed in
counteracting an existing predisposition, and  even in  curing
the  affection in its earliest stage.  It is,  of course, self-evident
that the physician must also keep in view the causal indica-
tions, and endeavor, to the  best of his power, to remove the dif-
ferent irritative, morbid conditions of the  primse vise, generative
organs, brain, and  spinal cord, which evoke  the affection.

   The treatment  of the  defect itself must be gymnastic and
didactic. 
840         KUSSMAUL.—DISTURBANCES OF  SPEECH.

   By the gymnastic treatment we seek to  invigorate the entire
system of the patient, and his respiratory  organs in particular.
This object is attained by means of proper  diet, hydrotherapeu-
tics, gymnastic exercises, the  Swedish movement cure, and per-
haps  electricity.   Electricity, however, will, at the most, prove
serviceable  only  in strengthening the muscles of the  thorax.
Rosenthal  found  that the long-continued application of  the
induced  and galvanic currents to the head, larynx, and hypo-
glossus, was entirely useless.
   The aim  of the didactic treatment is to re-establish, by means
of pedagogic metfiods, the correct co-ordination of the functions of
respiration,  phonation and articulation.   Great credit is due to
Colombat, Serre  d'Alais and Cormack for the introduction of,
and the  earliest improvements  in, the didactic methods, and to
Klencke and others for their present perfection.   These methods
can be most satisfactorily carried out in special  establishments
for stutterers,  which are under the  control of  physicians who
have  made a special study of the affection.  The stutterer should
enter the family of the physician, who must be at the same  time
the teacher ; as teacher, he must understand how to win  the con-
fidence of his pupil, how to strengthen the  control over  the will
and the  emotions, how to impart logical  compactness to the
thoughts, and  how to give force and measured  cadence to the
movements  of articulation.
   The treatment  begins with exercises in breathing.1  The stut-
terer  must  learn first to fill his lungs completely with  air, and
then  to husband  this air, and to expel it  slowly and with the
proper force.  With regard to the details of this and all  the sub-
sequent  exercises, we must refer the  reader to the treatises and
works of specialists ; among the German works on this subject,
we may mention particularly those of Klencke, Lehweiss,2 Wy-
neken, and  Coen.
   The exercises  in breathing  are followed by  vocal gymnas-
  1 The teacher, Katenkamp, in Delmenhorst, prescribes a period of perfect silence
before commencing these exercises. Wyneken's experience in the Delmenhorst estab-
lishment led him to regard this preliminary period as one of great value.
  2Radicale Heilung des Stotterns, etc. Braunschweig, 1868. 
STUTTERING.
841
tics.  The patient  must learn to pronounce every vowel both
singly and in combination with others.  He is made to call out
the vowels as loudly and for  as  long  a time as  possible,  to
sing them in tones of  different pitch and  power,  and to  pro-
nounce them aloud  and in a whisper.  Each vowel must be pro-
longed so that an  entire sonorous expiration is expended  in
its  utterance, and  must be  repeated  again and again  until
the patient  is  thoroughly convinced that  he  has mastered it
(Wyneken).
   Next comes the  third stage of  the treatment, the exercises  in
the combinations of the consonants with the vowels. They begin
with combinations  in which the vowel precedes the consonant,
then pass to those  in which the consonant  comes first, next  to
those which contain several consonants, and so on. In this way,
and by dint of daily repetitions and constant attention to the
respiration,  the patient will gradually be brought to pronounce
monosyllables, and will then be advanced to polysyllables, next
to simple sentences, and finally  to periods. An entire phrase
must be  spoken like a polysyllabic word,  the articulation being
subordinated as  much  as possible to the  vocalization.  He  is
then allowed to read aloud, first poetry and then prose, and  is
at last permitted to pass to free declamation.
   Finally, after six to twelve weeks of treatment, the rhythmic
exercises are begun.   The pupil  must learn to  keep time,  to
enunciate every  phrase very  slowly, like  a single polysylla-
bic word, to give to each syllable  the same  length, and to draw
breath wherever there is a stop. After a few weeks he should be
introduced  among  strangers,  given  commissions  to  execute,
and so on.  This regulated speech must be continued for sev-
eral months at least.  Relapses are rather common, and necessi-
tate a new course of treatment.  In order to guard against them
as far as possible, the convalescent must school himself to keep
silent, or to have recourse to rhythmic speech, whenever he finds
himself getting excited.
   Many  attempts  have been made to  replace  this didactic
method by mechanical methods,  and also to combine  the two.
The ancient writers tell us that Demosthenes spoke with stones
under his tongue. Klencke employed for a time a wooden plate, 
842         KUSSMAUL.—DISTURBANCES OF SPEECH.

shaped like the body of  the lower jaw, which was placed under
the tongue.  In Paris, in the year 1829, one Sc.hirmann  made
twenty thousand francs by  the sale  of  small round pieces of
wood, as a secret  remedy against stuttering.   Itard invented a
tongue-fork, and Colombat a tongue-bridle.  Merkel fastened a
clasp made of whalebone on one of the molar teeth of the  lower
jaw.  None of these contrivances ever produced a permanent
cure.   Sometimes, indeed, they proved hurtful  by the irritation
they  produced in the mouth, and all of them had at least one
inseparable disadvantage in common, viz., they led the patient
to  regard  as of secondary importance  that exercising of the
will, which is really :he most important of all the means of treat-
ing stuttering.   The apparent success that  followed their  em-
ployment was due chiefly to the circumstance,  that they forced
the stutterer to speak slowly,  and consequently in a measured
manner.
    The genial Dieffenbach1 committed a  great mistake when he
proposed to cure stuttering by operative  measures,  analogous to
those employed with success in the treatment of strabismus  and
club-foot.   He  made open  and  subcutaneous transverse  cuts
through the root of the tongue, and also  excised a wedge-shaped
piece of  the tongue.   He had many followers, who emulated
one another in inventing all sorts of so-called stutter operations.
The beneficial effects of these operations persisted only as long
as the patients found themselves compelled to put a restraint on
the movements of articulation.  As soon as  the wounds healed,
and the pain disappeared, and the  tongue  consequently again
became freely' movable, the stuttering  invariably reappeared.
The history of this sanguinary  epoch in the treatment of stutter-
ing will be found in the works  of  Klencke and Hunt, and  in
Schmidt's Jahrbucher.2
   1 Die Heilung des Stotterns durch eine neue chirurgische Operation.  Ein Send-
schreiben an d. Institut von Frankreich. Berlin, 1841.
   2Bd. 31. S. 136, and Bd. 32.  1841. S. 82.—Froriep divided one of the genio-hyo-
glossus muscles, and Bonnet cut both of them.  Amussat severed the muscular and
ligamentous attachments of the tongue to the lower jaw.   Philipps divided the hypo-
glossi.  James Yearsley, who believed that narrowing of the fauces was the cause of
stuttering, excised hypertrophied tonsils and cut off the uvula. 
APHTHONGIA.                        843
   II.  The  name  aphthongia  or reflex aphasia was  used  by
Fleury '  to  designate  cramps  in the  territory  of distribution
of the hypoglossi,  which set in  wheneeer an attempt to  speak is
made, and  render articulate expression impossible.  They bear
considerable resemblance to writers' cramp.  But few cases of this
affection have  been  published ;  the first  was  reported by  Dr.
Pantliel," of Ems,  and  two others have been recorded by Fleury
and Tallin.3  The spastic excitation of the hypoglossi proceeded
most probably from the cerebrum in all of  the cases ; in two of
them  the  affection- made its appearance after periods of great
emotional excitement, and in the other it set in, accompanied  by
severe  cerebral symptoms,  after an  operation  on  the posterior
part of the mouth.  This  aphthongia, in which the spasm of the
hypoglossi  that renders  speech impossible, is  excited by the
intention to speak, must not be confounded with  the disturb-
ances  of speech  due to  lingual cramps  dependent on various
other spastic neuroses,  for instance, chorea.4

   In Panthel's case, the patient, a peasant boy twelve  years of age, was greatly
excited by the  sudden death of his father.   He fainted at the funeral, and  re-
mained unconscious for a quarter of an hour.   After recovering from the' syncope
he was sound in  body and mind, but for three days he was unable to speak, al-
though he could move his tongue and lips freely, and could swallow without diffi-
culty.   When he  attempted  to speak, his  mouth,  jaw and tongue remained
immovable, but the large laryngeal  muscles supplied by the hypoglossi (the ster-
nothyroid, thyro-hyoid and  sternohyoid  muscles) fell into  visible and violent,
vibrating movements.   The spasms  ceased when the efforts  to speak were discon-
tinued.   Pressure on the muscles relieved the spasms and enabled the patient to
speak; this effect  persisted as long as the pressure was kept up.  Fourteen days
after recovery a relapse set in, which was occasioned by fright and lasted two day6.
   1 Gaz. hebdomadaire. 1865. No. 15.
   2 Deutsche Klinik. 1855. No.  40.
   3 Gaz. Hebdom. 1865. No. 17.
   4See the remarks of Erb in Vol. XL, p. 319, of this Cyclopaedia.  Hoffmann, of
Suhl, reported  a case of severe lingual spasm  which rendered speech impossible
(Schmidt's Jahrb. Bd. 29.  S. 50). The patient was a plethoric man, and a cure was
effected by venesection and low diet." R. Froriep (Studien zur operativen Heilung
des Stotterns. Weimar, 1843) seems to have met with stutterers who were affected with
unilateral contracture of the genio-hyo-glossus.  He recommended, on that account, the
unilateral division of that muscle in the operative treatment of stuttering. 
844          KUSSMAUL.—DISTURBANCES OF SPEECH.

A second relapse of a few hours' duration was brought on by violent emotion a few
weeks afterwards.
   A child, who was suffering from  an inflammatory affection of the neck, was
suddenly frightened, and was afterwards seized, whenever it attempted to speak,
with a spasm of the lingual muscles that rendered it speechless (Vallin).
   In Fleury's case, the patient was a man who had been subjected to the operation
of tonsillotomy.  The operation was followed by marked disturbances of sensation,
loss of taste, aphonia, cerebral congestion, and epileptiform attacks.  On every
attempt to speak, the tongue became immovably fastened to the hard  palate.  The
intelligence was perfect, and the patient was able to write and to calculate.
                      CHAPTER XXXV.

Stammering and  Lalling.—Dyslalia,  Alalia,  Mogilalia, Paralalia.—Dyslalia  due
    to Deficient Practice and Defective Education.—Comparison of the Defective
    Articulation of Sounds in Individuals, Nations, and Races.—Defective Enun-
    ciation of Particular Sounds:  Rhotacismus, Pararhotacismus, Lambdacismus,
    etc.—Mechanical Dyslalia.—Hottentotism.—Dyslalia Laryngea, Nasalis Aperta
    and Clausa, Lingualis, Dentalis and Labialis.

    All  the disorders of speech which  depend  upon defective
enunciation of the literal sounds have been included under the
general head of stammering (Stammeln, balbutiement, balbuties,
dysarthria literalis).  When  stammering  attains  such a grade
that the speech is thereby  rendered  very  indistinct  or entirely
unintelligible,  it is  called  lalling (lallatio).   This is the  term
used to characterize the speech of  children,  before they  have
learned  to pronounce their words  so as to be intelligible to all
persons—during the period  in which  their words consist of badly
articulated combinations of sounds, that can be understood only
by their immediate attendants.  When the attendants are silly
enough to imitate this lalling, and to communicate with the little
creatures  in  similarly mangled sounds  and  words,  the  speech
may retain a childish, lalling character, which  is always unbe-
coming  to an adult,  until long  after the victims  have grown up,
and even throughout the whole of life.
    Stammering is sometimes a congenital, sometimes an acquired
defect;  it is in some cases due to organic lesions, and in others
is simply functional in  its  nature  and dependent on defective 
DYSLALIA.
845
education and faulty practice.   The organic lesion is located
sometimes in the central nervous system or in the motor nerves
of speech,  particularly the hypoglossi, and  sometimes  in  the
external apparatus of articulation, the tongue, palate, etc.
   The  manifold  causes  of central anarthria  literalis have
already been described.  We have, in preceding chapters, inves-
tigated  in an exhaustive manner the morbid processes in the cen-
tres of articulation, that lead to disorders in  the  enunciation of
literal sounds.  For an account of the derangements of the literal
articulation, which are caused by peripheral injuries of the hy-
poglossi and faciales, the reader is referred to  the article by
Erb, in  the eleventh volume of this work, pp. 489 and 523, where
he will find descriptions of glossoplegia and of unilateral and bi-
lateral facial paralysis, of central as well as of peripheral origin.
What we have yet to describe are those two varieties of stammer-
ing which originate: 1. In defective education and faulty prac-
tice;  2. In defects  of the external apparatus of articulation.
Impediments of the latter variety are classed as mechanical dysla-
lia, and both together constitute the  affection to which the term
dyslalia in its strictest sense is applied.  Entire inability to utter
articulate sounds is called alalia,  in opposition to mogilalia, in
which only particular sounds are impossible.   Paralalia is that
affection in which the patient, in consequence either of  some ex-
ternal mechanical defect or of  a bad habit, brings forth a differ-
ent sound from the one which he wishes to utter.

   We will consider first the dyslalia that depends on  defective
education and faulty practice.
   Any one may be unable, even though his organs of speech are
perfectly developed, to utter certain sounds and classes of sounds
which he did not learn during early life.   No living man is able
to pronounce the speech-sounds of all the nations of the earth.
A Lepsius may  succeed  in expressing  them  in  letters, and  a
Bruecke may unravel the mechanism of their  articulation, but
it is beyond the power of  even such erudite philologists  to arti-
culate them all.   In the language of every people we find only
certain  sounds developed, while  others are entirely neglected.
We meet consequently with a national and a dialectic mogila- 
846         KUSSMAUL.—DISTURBANCES OF SPEECH.

Via,  The study of these peculiarities is one of absorbing interest,
but we can only devote a few paragraphs to" them here.1
   Different languages present the  greatest differences with re-
gard to their opulence in sounds.   While the number of  conso-
nants in Hindostanee has, by the adoption of  Sanscrit, Persian,
Arabian,  and Turkish  words, been  raised to  48,  of which 39
originally  sprang .from the  Sanscrit,  the English language
contains" only 20, the Greek only 17,  and the  Polynesian lan-
guages have at most 10, and some  Australian tongues not more
than 8.
   In certain  languages entire classes of sounds are wanting.
Thus the  languages  of  the Six Nations (the Mohawks, Senecas,
etc.), and that of the Hurons,  do  not contain the labials b, p, f,
v, w, m; they lack consequently the words mamma  and papa,
which are found in all other languages, and wliicli  our children
learn to speak at a very early age.  When an attempt was m'ade
to teach the Mohawks to pronounce words containing the letters
b, or p, they declared that they would not consent to make them-
selves ridiculous by closing the mouth in speaking (Tylor).  The
languages spoken by the  natives  of  several of the  South  Sea
Islands contain no gutturals.  The Society Islanders could not
pronounce the name of Captain Cook otherwise than "Tute."
What is for these islanders an impossibility, is the delight of the
Shemites.  Their languages rejoice in a superfluity of gutturals,
some of  which  are  unknown among us.   The  most strangling
sounds that can emanate  from the  Swiss  throat, fall modestly
into the background when  compared  with the gutturals that are,
as it were, vomited up by the Arab.2
   Sanscrit, which is so affluent in sounds, has  no  short e and
o, no soft sibilants and no  f.  The f is wanting in many other
languages—in the Finnish,  the Lithuanian, the  Mongolian, and
  1 For a more detailed account see M. Mueller's Vorlesungen iiber die Wissenschaft
der Sprachen. Bd. II. Vorl. 4.
  2 These guttural sounds which are peculiar to the Semitic languages, the " hha"and
" ain," have given rise to many learned discussions.  Czermak (Sitzungsber. d. mathem.-
naturwissensch.  Klasse der k.  Academie der  Wissenschaften. Vol. XXIX.,  S. 576;
studied, by means of  the laryngoscope, the movements in the larynx that effect their
production. 
DYSLALIA.
847
others.  The d is not employed in the Chinese, the Mexican, and
the Peruvian languages.  The s is wanting in various Polynesian
tongues,  and is replaced by a hissing  h.  The Portuguese dis-
coverer of Brazil noticed that the natives had no f, no 1, and no r
in their language, and he described them as a people without fe,
ley and rey, without religion,  laws and king.  The Chinese do
not use the r.  They say ki-li-sse-tu instead of Christus, Ja-me-
li-ka instead of America.  They replace  the r by 1, which  in its
turn is unknown in Zend and in certain Japanese, American, and
African dialects.   The German  guttural  ch—as in  "ichv—is
wanting in French and English, and in return the Germans do not
possess the nasal vowels of the Frenchman,  and  the th and
the w of  the  Englishman.   The  Russian replaces the German
h  by g, but takes delight in hissing sounds; he has a soft and
a hard sch, a tsch and even a schtsch.  The South African  races
have clicking sounds, and the tribes of the North-west in Amer-
ica have, according to Tylor, chuckling, gurgling, and grunting
sounds, which Europeans find it difficult or impossible to pro-
nounce.
   The living languages are not by any means fixed and immut-
able creations.  Like the nations to whom they pertain, they are
involved in a constant  process of development or retrogression,
which manifests  itself in changes in  the sounels, words and
grammar.   Grimm, in his law of the progressive transmutation
of consonants, has ferreted out the principle which presided over
the consonantal changes, by means of  which the words in the
languages of the Aryan race were developed from their common
roots.  After Grimm had broken the ice with regard to the Aryan
languages, other philologists attempted successfully to discover
the law of orthographical changes in other families of languages.
The question that  now presents itself is, how can we explain this
sound-change \  M. Mueller traces it back  to  the principle  of
dialectic growth.   In the original Aryan tongue,  the  kindred
sounds still ran into one another and were not sharply differenti-
ated ; it was only in the divergent daughter languages, that these
kindred sounds  became distinctly  separated and defined.   In
the development of words allied in meaning  and root, different
nations gave the preference  to the classes of sounds that accorded 
848         KUSSMAUL.—DISTURBANCES OF SPEECH.

best with their special phonetic organizations;  the Hindoos and
Greeks chose the aspirates kh, th, and ph, the Goths the mutae
mediae g, d, b, and the old High Germans the mutse tenues k, t,
p.  Even within fhe limits of these special classes, moreover, we
find here  one and  there another  sound  preferred  in  different
languages.   We  find, for instance, the Sanscrit gharma, heat,
commencing with the guttural aspirate, while the Greek thermos
begins with the dental, and the Latin  adjective formus (same as
calidus) with the  labial  aspirate.   In  support of this hypothesis
of dialectic growth, M.  Mueller  cites the Polynesian  dialects.
In them, according to Halle, no distinctions  are made between b
and p, d and t, g and k, 1 and r,  v and w ; 1,  moreover, is fre-
quently sounded  like d, and t like k.  M. Mueller thinks that
the original Aryan tongue  existed in just such a  condition of
indefinite fixation of sounds, before the Sanscrit, Greek, Gothic,
Sclavonic and Celtic tongues had developed from it.
   In addition  to the progressive phonetic development of lan-
guages which we find associated with this dialectic growth,  we
can also demonstrate an orthographical  decline.  Long words
were condensed into short ones, letters and entire syllables being
discarded.  The French  corrupted pater and mater into pere and
mere, and  the English condensed the Anglo-Saxon  hlaford and
hlcefdige into lord and lady.  M. Mueller ascribes this shortening
of words to the natural  tendency of mankind to choose  the least
fatiguing way of attaining an object, provided it can be attained
as well with little as  with great expenditure  of breath and
muscular  force.   This  explanation,  despite its simplicity,  is
probably the correct  one for the great majority of the cases.
After a time, the concise pere and lord were as readily under-
stood as the longer pater and hlaford.
   These investigations  of the philologists are  of great value to
pathologists, in  the study of the defects in the production of
sounds  that are met with  in isolated individuals  or  in entire
classes of  a people.  For we observe  in individuals  and in
classes of people the  same  inability  to articulate  this or that
sound, the same disposition to replace it by some other  particu-
lar sound,  the same blending of letters and imperfect differ-
entiation  of sounds,  and finally, the same tendency, based on 
DYSLALIA.                      849
indolence, to corrupt sounds, syllables and words, that we meet
with in oil ire nations and races.
   One of the most difficult of the letters is the r.  Our children,
as a rule, do not learn to pronounce r and sch until  after they
have acquired all the other letters. The Incroyables, who assumed
an air of satiety and  gave themselves  up  to a life of womanish
idleness, discarded the r completely,  and even to-day we fre-
quently  see blase and affected  individuals  do the  same thing.
The Incroyables said  Bodeaux instead of Bordeaux, just as the
Darmstadters say Damstadt,  and  many Berliners  say  Keel
instead of Kerl, indicating the r only by a slight prolongation of
the preceding vowel.   Demosthenes,  who has been  accused of
suffering from  every  possible impediment of articulation, per-
haps with a view to utilize him as a brilliant example of phonetic
energy for the encouragement of stammerers and stutterers, was,
according to Cicero,  unable  to pronounce the r.   It has  been
proposed to call the inability  to articulate the r,  Chinoanismus,
because the Chinese have no r in their language.
   The blending of sounds may involve the vowels as well as the
consonants.  The  blending of vowels is observed in many per-
sons who pronounce i almost  like e, and u almost like o.  Schar-
tenmeier, in his edifying song of "Heifer Brehm," rhymes like a
thorough Swabian, as the following lines will show :

                  "Er studirt das Testament
                   Und was sonst fiir Bucher sind."

He makes  Menschen rhyme  to wiinschen, and Mond  to rund,
without the  slightest hesitation.  As instances of the blending of
consonants,  we may mention the case of the Franconian,  who
pronounces  the words " Brod backen " in such a  way that we
are unable to determine whether he says " backen " or " packen;"
also the  case of  the child, who pronounces the word  "komm"
half as "komm" and half as  " t-h-omm."
   Schmalz proposed to designate the interchange of voioels and,
diphthongs  by the term " Phoneentalluxis,"  and  the inter-
change of consonants  by the term " SympJionallaxis."  These
monstrous words may perhaps  be made useful in measuring the
amount of  syllabic co-ordinating power possessed  by literati,
         VOL. XIV.—54 
850         KUSSMAUL.—DISTURBANCES  OF SPEECH.

who are suspected  of syllable-stumbling.—Most of the sound-
defects  belong in this category.   Many are turned  to advantage
in the production of comic effects.  As an example,  we may refer
to one of the standing figures of Kladderadatsch, Zwickauer,  who
employs diphthongs instead of vowels—ii  instead of  i, and 6
instead  of e—not from laziness, but for a reason that M. Mueller
will not allow to be influential in the transmutation  of sounds in
languages, viz., the  desire to make the sounds more  agreeable to
the ear.  What  strikes  Zwickauer1 s ear as  beautiful, however,
sounds only comical to the public.

   A few of the defects of articulation in which only particu-
lar sounds  are affected, have been picked out and christened
with special  names.   In  doing this, no account was  taken of the
causes of the defects ; it is a matter of indifference whether they
are due  to a defective education or to an organic defect.
   1. RTtotacismus  and Pararhotacismus.1   The letter r is the
one whose pronunciation is most frequently defective.
   a.  The synonyms for  rhotacismus are Schnarren, Lorbsen,
Lorken  and Ratschen in  German, Grasseyement or parler gras
in French, and rattling  or burring in English.   There are three
r-sounds : the labial r—an example of which is found in the  brrr
which coachmen  utter,  when they  wish to make  their horses
stand—the lingual r and the  guttural r.   In the European  lan-
guages only  the two last r-sounds are employed.  The use of the
guttural for the  lingual r is termed rattling or burring.   In
many towns and provinces of Germany, rhotacismus is almost
universal. The burring may present certain variations, dependent
on the varying manner in which the posterior part of the tongue
is applied to the palate in  the utterance of the guttural r.   The
uvula and even the glottis  may take part in its production.   The
remarks of  Briicke and of Merkel  on this  subject  are  worthy
of perusal.   Merkel  thinks that a short framum may some-
times  interfere with the production of the lingual  r, and cause
burring.
  1 Compare the remarks of Fournier in the Dictionn. d.  sciences medic. T. XIX.
Art. Grasseyement.—Also Coin, op. cit., p. 422. 
                          DYSLALIA.                       851

   b. By pararhotacismus we understand the  employment of
other sounds instead of r.
   a. Persons who are laboring under this defect,  most frequently
set in motion only the sides of the tongue instead of the entire tip,
and  bring forth an 1 instead of an r.   They pronounce the word
 "Christus" like the Chinese, and like children say "blaten''
instead of  "braten/' and  "gloss" instead of  "gross."  Alcibi-
ades took pleasure in this form of defective utterance, and used
the word "colax," flatterer, when he wished to say "corax," raven.
   /3. Others do not allow  the tongue to vibrate at all, and move
only the lips, so that r sounds like w ;  instead of  " gross, braun,"
they say "gwoss, bwaun."
   7. Many, instead of  making  the  tip  of  the  tongue vibrate,
only strike it  twice against the superior incisors,  and convert the
r almost into two t's (Prochaska').
   8. Others,  again, endeavor to produce the r-sound in the pos-
terior part of the mouth, but succeed as poorly with the guttural
as with the lingual  r, and replace it  by g or  even by the naso-
gutfural ng.  The ng seems  to be used particularly in France.
The  people then say "gagnement"  instead of "rarement," and
"Figango" instead of "Figaro" (Fournier).
   e. In some, finally, the r is preceded by an unpleasant hissing
sound,  like s or ds, which is due to the vibrating tip of the
tongue being pushed too far forward,  perhaps  as far as between
the  teeth.   They say, ex.  gr., "zraison" instead of "raison"
(Fournier).
   It is difficult to cure  burring wdien it has existed from child-
hood.   The patient  must first be taught  to apply the tip of the
tongue properly to the teeth and the palate, and to drive a strong
stream of air against if, so as  to produce a purring vibration of
the organ.   This purring-sound must then be combined method-
ically at first with  vowels, so as to form syllables and  words
(Rede, Rabe, etc.), and later with consonants and vowels, as, for
instance, in  the word "F. . . rrr. . . eiheit."  The patient should
then  be gradually advanced to the most  difficult words, ex. gr.,
u Wrangel," Strumpf (CoenJ).
  1 Physiologie, § 221.
  5 Fournier has described a peculiar plan of treatment for rhotacism, which was ia- 
S52         KUSSMAUL.—DISTURBANCES  OF SPEECH.

   Pararhotacismus is due sometimes  to a deficient  mobility of
the tip of the tongue, dependent on  shortness of the freenum
lingua.  The treatment must then be  surgical in  the commence-
ment, and afterwards dialectic.   Klencke's  opinion,  that  the
defect may also be due  to an habitual spasm of the  genioglossi,
or of other muscles supplied by the hypoglossal  nerves,1 which
may necessitate myotomy, has not been corroborated.
   For the relief of that form of pararhotacism in which an s or
a ds is placed before the r, Colombat  recommended  a special
instrument, called the  " refoule-languer   This  was simply an
ivory plate, which was placed under the tongue and fastened to
the lower incisors by  booklets.
   2. Lambdacismus and paralambdacismus.   Defective  pro-
nunciation of 1.
   There are persons  who find as much difficulty in pronouncing
the 1 as  the r, and who, instead of  it, use d, t, s, j, n or ng
(Klencke, Amman).   Others, like the  Japanese, use  r instead of
1, and say, for instance,  "Horrand"for  "Holland."   A hunter,
who pronounced 1 like  n, was vexed with  his terrier because he
would not draw a badger ; but, instead of the word "schlupfen,"
to slip into  the hole, he used  the  word  "schnupfen," to  take
snuff.  The same man wished  to  say "Lill's Luise  ist verliebt
bis in den Hals," and did it with the words,  "Ninn's  Nuise ist
verniebt  bis in den Hans."
   In some of the Allemannic districts  the sharp 1 after vowels
is pronounced like an 1  mouille or soft j ; " Oel,"  for instance, is
pronounced "Oej."   In other districts the 1  is pronounced like
ow or uw, thus "Oeow,'" instead of  "Oel" (Schulthess).
   3.  Sigmatismus and  Petrasigmatismus.—Under this heading
are classed the defects that are observed in the pronunciation of
S and sch, the S- and sch-stammering.
   a. The s may be pronounced with unpleasant sharpness.  The
French call this " sesseyement."  It  often acquires an unpleasant
vented by the celebrated Talma.  Klencke states that in his experience it has always
proved harmful.  Coen has described it in detail in another place.
  1 Translator's Note.—The author uses the words "genioglossi oder hypoglossi,"
but as there are no muscles called the hypoglossi, the above seems to be the only way
in which they can be translated. 
                          DYSLALIA.                      853

hissing character after the loss of teeth, unless the patient is able,
when articulating  the letter, to stop up  the  opening with his
tongue, so as to present a properly formed air-canal between the
dorsum of the tongue and the incisor-teeth.'  When he cannot do
this, the air is driven through the openings with a hissing noise,
and frequently the saliva is at  the same time spirted out.
    b. Many pronounce the s like the English th. This is effected
by pushing the tip of the tongue  forward  between  the  teeth,
until it touches the under-lip, and at the same time not opening
the jaws sufficiently.   This constitutes the lisping or blasitas of
dandies, but it is also met with as a defect which has persisted
from the time of childhood.
    c. Others  alter  the s into  a rustling  sch  or  a  sharp f, by
enlarging the air-canal between the lips in the shape of a funnel,
instead of narrowing it.  They  say "Joschef," or  " Jofef,"
instead of "Josef."
    d. Others, again, pronounce the aspirated sch or the j of the
French like a silent sch, or even both  the aspirated  and silent
sch only like a silent s ;  they say, for example, "swer" instead
of  " schwer,"  just as children, Danes, and many Low Germans
do.  The Westphalians, as  is  well  known,  pronounce sch like
sk; instead  of " Schinkenschnitte"  and  "heischen,"  they
say " Skinkensknitte "  and  "heisken."—Many pronounce  z
like s.
    e.  Finally,  according to Coen,  many persons,  wdien  they
attempt  to utter the  sch-sound, bring the tongue into the posi-
tion for the 1-sound, but at the same time expel the  air witliout
setting it into vibration,  as if they wished to pronounce sch.  A
rustling, rattling sound is thereby produced, that bears no resem-
blance either to sch or to s.   In Austria, this defect  of  speech is
called  "ein Hdlzel im  Mund  haben"  (to have a bit of wood
in the mouth).   The distortion  of the speech  is still more glaring
when such persons expel the  air through the nose instead of
through the narrowed oral canal.  This leads to the production of
a sound similar to the softened French gn.   Instead of:  "Hast
du schon die sclidne Schwester deines Schiilers gesehen \" they
1 Compare Merkel, Physiologie der menschlichen Sprache. S. 186 f. 
 854         KUSSMAUL.—DISTURBANCES OF SPEECH.

 would ask :  "Hast du gnon die gnone Gnwester deines Gnulers
 gesehen ( "
    When this impairment of speech is due to the absence of
 teeth,  its curative treatment  requires the intervention  of the
 dentist.  AVhen the teeth are perfect, Coen asserts that it is ordi-
 narily only necessary to show the patients the proper position of
 the tongue, and to make them devote a few  days  to assiduous
 practising.   Great persistence and patimce are onlj' required in
 combating the defects described under " e."   First of all, he
 makes the patient practise the ch-sound for a few days.   To do
 this, the posterior part of the tongue must be placed in the ch-
 position,  and the  sound  uttered several  times in  succession.
 The patient is then made to pronounce ch and silent s alternately
 and in  rapid succession.  Finally, he must learn b\y practice to
 hold the tongue in  this double position,  and  to  force the air
 rapidly over the two  narrowed points.
   4.  Gammacismus and Paragammacismus.  Guttural  stam-
 mering.
   There are persons who  remain, throughout the whole of life,
 unable to learn the letters g and k, and who substitute for them
 d or t. In the case  of a Danish nobleman who alwa}rs substituted
 t for k, Amman pressed down  the tongue with his two fingers, so
 that it  could not  be brought into contact with the teeth, and
 told the patient  to pronounce the syllable ka, while the tongue
 was held in that position.  To his great astonishment, the stam-
 merer  found himself  at  once  able  to  pronounce  the hitherto
 impossible letter.
   The following case presents a combination of guttural  stam-
 mering and  stuttering.

   A weak-minded man, who was about forty years of age, was able to pronounce
 all  the letters correctly, except g, k, and  x. The g he pronounced, both separate
 and in words, like d, the k like a sharply aspirated t, and the x like itz.  He was
occasionally able to say g, but never k. His mouth presented nothing abnormal,
except that the velum palatinum hung unusually low.  Some few words which con-
tained gutturals were particularly difficult for him, and the attempt to utter them
 would make him stutter and bring on laryngeal spasm.  " Gurgel " and " delikat "
 are examples of such word^; in the former the difficulty began with the first syl-
 lable, in the latter with the third.  People often made sport of his infirmity. They 
                             DYSLALIA.                        855
 would  give him money to induce him to pronounce the word " Delikatessen-
 G.'scluft," for the sake of the amusement his  useless grimaces and gesticulations
 would afford them.   In order to avoid the guttural, he would, like children, leave
 out the prefix ge before the past participle; instead, for instance, of "Der Kaffe is
 gut gewesen," he would say " Der Thaffe ist dud wesen."

    5.  Other  letters besides  those we have just enumerated may
 also constitute stumbling-blocks for some persons.  Amman tells
 us, for instance,  of a boy who had  a very short under-lip and a
 retreating chin, and was unable in  consequence to pronounce the
 letter f.   He made him bring  the upper-lip and  under-teeth
 together, and the f was then produced by the first expiration.

    II.  We  turn now  to   those  impairments  of  articulation
 which depend on  gross anatomical defects of the  external or-
 gans of articulation, viz., to mechanical dyslalia.
    The  organic defects  that cause this dyslalia may be congeni-
 tal or acquired.    Even when the defects are  very considerable,
 intelligent  children,  provided they are not suffering at the same
 time from congenital  aphasia, make energetic  efforts  to  speak.
 and imitate,  to the best of  their ability, the sounds and words
 used by those about them.1   It is often, however, impossible
 for any except their  nearest  relatives to  understand what is
 meant by the scarcely articulated and unintelligible sounds  they
 utter.    This intense  form  of congenital stammering has  been
 named Ilottcntottismus.  This name  was  adopted in consequence
 of the groundless belief, that the language of the Hottentots is
 confined to a few  indistinct sounds.  This belief was discarded
 long  ago, and its  incorrectness has been most clearly demon-
 strated  by the recent and  learned  investigations of Appleyard
 (18G0) and Bleek  (1862).—We will here describe in detail  a  case
 of Hottentottism, wliicli was due to a deformity of the mouth.

   A seven-year-old boy, of sturdy  build and  intelligent appearance, was brought
to the clinic by  his relatives.  He heard and  understood well what  was said by

   1 The opinion of the earlier writers, of Amman, Schulthess, and others, that children
might be so greatly alarmed by a commencing stuttering, that they would be ever
afterwards deterred from any further attempts to speak (Alalia mentalis, Merkel), still
lacks confirmation. At all events, the children would  not be  so easily frightened by
stammering, as is conclusively shown by the case that is here detailed. 
856          KUSSMAUL.—DISTURBANCES  OF  SPEECH.

those about him, and made great efforts to express his wishes; no one, however,
could understand his scarcely articulated sounds and words, except those who had
by long familiarity learned to divine his meaning.  He repeated all the vowels and
consonants from dictation, but most of them were unrecognizable.  He articulated
the vowels best, but combined them  all with h and gave them a nasal intonation;
his e sounded like i.  All of the consonants b, c, d, t, g sounded like an indistinct,
aspirated e or i. Of all the consonants, h was pronounced the most perfectly;  f, m,
and n also were intelligible.  In articulating m, he did  not close the mouth  com-
pletely, but merely laid  the  lower lip against the  upper row of teeth.  K and q
sounded like h-s-hn, s and x like hu-hn.
   In addition to his faulty articulation, the boy  could only chew and swallow
very slowly.  When he ate soup, some of it would flow back into his plate.  The
saliva dribbled  freely from his mouth.  The current from ten elements of the  port-
able galvanic battery of Stohrer, caused strong  gulping movements in the muscles
supplied by the hypoglossi.
   The boy's head was small and  his forehead narrow.   The circumference of the
head was forty-six ctm. (18-fu in.), the tape being laid over the middle of the  frontal
bone, the convexities of the parietal bones, and the upper angle of the occipital
bone.  The greatest transverse diameter of the head was on a level with the  ears.
The eyes were large, and the interocular space seemed remarkably wide in propor-
tion to the narrow forehead.  The nose and mouth presented nothing  noticeably
wrong in  the way of form.  He suffered from chronic oral and nasal catarrh.  The
teeth were sound and white, and had indented edges and slightly striated  bodies.
The lower teeth projected forward, but  nevertheless, when the mouth was  closed,
lay entirely behind the upper teeth.  The anterior part of the tongue wTas of normal
size, but its posterior part was much thicker; it could  be projected in a straight
line one to two  ctm. beyond the under row  of teeth, but could not, as was  proved
by numerous trials, be moved to either side or made to touch the  palate.  When
its tip was pushed upward, a tense frenulum linguae was  found.  This was divided.
The hard palate was remarkable for the extreme height of its arch ;  in front, in the
region of the foramina incisiva, it  formed a deep pit, in which the saliva collected.
The soft palate  was long and hung low down, resting on the dorsum of the tongue,
the uvula pointing backward and to the left.

    Amman  asserts  that he  saw a girl in Harlem  who was unable
to articulate a single letter with the exception of  t,  and that he
taught  her to  speak correctly in three months.
    We will  now consider separately the evil consequences that
defects of the different parts which make up the external appar-
atus of articulation have on the  enunciation of  sounds.   As a
preliminary, however, we  must devote a short space to the con-
sideration of the office of the  larynx in the articulation of letters.
    A.  Dyslalia laryngea.—The larynx is essentially the organ 
DYSLALIA.
857
of voice, but  it is  also an organ of articulation.  This second
office cannot be denied to it, as long as h and the h-sounds in
general—such, for instance, as the hha and ain of the Arabs—are
retained in the different alphabets. It is a well-known fact, that
the h-sound is produced by the air rushing through  the widely
opened glottis.  On the other hand,  the old controversy over the
question whether the  vowels are  produced in the larynx or in
the mouth, has been decided by Helmholtz in  the following man-
ner : the vowels  are special tones produced in the oral cavity,
when it is put in certain particular positions and blown  upon
from the trachea, and the vibrations of the chorda} vocales of the
larynx serve merely to attune them to different heights.   What
we call a vowel is consequently the clang-tint of the voice, which
results from the form of the  sound-waves in the oral cavity that
has assumed the  shape peculiar to that particular vowel.
   Czermak1 has reported a very instructive observation, which
illustrates well what has  just been said.   In  a case of complete
obstruction of the larynx, which necessitated laryngotomy below
the point of closure, the patient could not produce either a loud
sound  or a  wdiisper.   She nevertheless subsequently  recovered
the ability to speak, although she could, of  course,  only  utter
voiceless sounds. She  spoke in a whisper, producing the sounds
by means of the air enclosed in the pharyngeal and oral cavities;
practice taught her how to condense and to rarefy this air in the
most skilful manner.   She  produced by  this means not only
consonants,  but  also vowel-sounds, which possessed  very dis-
tinctl}T the peculiar characteristics of the individual vowels. She
was, it  is true, unable to pronounce the vowels separately, but
they were produced in  the current  of articulatory movements, by
the consonantal sounds assuming  the specific  characters of  the
vowels.  She even learned to replace the laryngeal h by an anal-
ogous,  feeble,  undecided rubbing sound, which she produced in
the posterior region of  articulation.
   The  larynx, moreover, as the vocal organ, is of radical im-
portance for the articulation, since the production of  the mediae
  1 Sitzungsber. der mathem.-naturw. Klasse der k. Academie der Wissensch. Bd.
XXXV. 
85S         KUSSMAUL.—DISTURBANCES OF SPEECH.

and of the sounded consonants in general, such as the resonants
m, n, ng, is effected  with its  assistance.  In the  production of
these sounds phonation and articulation are intimately combined.
The patient of Czermak  could not for this reason differentiate b
and p, d and t, g and k.  She only succeeded  in  producing the
niedhr, when she managed to force a somewhat stronger stream
of air from without inward in  the oral cavity, through the occlu-
sion  places of the explosive.   The rubbing sounds 1 and lingual
r, on the  other hand, wjre pronounced distinctly  ; the resonant
m was usually replaced by b,  and n by d.
   It is to be  regretted  that  Czermak has not reported whether
or not he succeeded  in this case, in  the attempt  to supply arti-
ficially to the oral organ of  speech  the two things  which  were
alone wanting, viz., air and voice.   He proposed to blow  both
air and sound into the space behind the tongue, through  a prop-
erly  curved, thin tube,  in which  a sounding  apparatus would
be inserted.   We will merely mention the fact,  that Czerny's
ingenious  proposal to extirpate a useless or cancerous larynx,
and replace it by an artificial  one, has recently  been put into ex-
ecution.   The  patients wdio have  been  operated on  were really
enabled, by the introduction  of an artificial larynx,  to speak in
a high-pitched,  monotonous  voice,   resembling  a  trumpet in
tone.1  It must be stated, however,  that persons from whom the
larynx was removed  in toto.  still retained the power to speak
intelligibly in a whisper.   The artificial larynx  merely added
voice to the articulated sounds.

   B.  Dyslalia n a satis et pctlatina.
   The defects of  articulation that  are caused by the  nose
remaining open when it should be  closed, and closed when it

  1 Czerny. Versuche fiber Kehlkopf-Exstirpation. Wiener med. Wochenschrift  1870.
Nr. 2? u. 28. — (Jussenbauer, Langenbeck's  Archiv. Bd. 17.  S. aoi.  Ibidem,  1S75.
Bd. 4. S 22.—Rci/her, Ibidem, Bd.   19. S. ;>)4. —For the case  of a cook, who
suffered from an obstruction of the larynx, Stoerk invented an apparatus that proved
adequate for the purpose (Anzeiger der  k. k.  Gesellsch. der Aerzte in Wien. 1875. Nr.
20).   He attached one end of a T-tube to the tracheal canula, and the other to an
india-rubber tube, which enclosed a reed-pipe.  Rings of hard rubber were inserted in
the wall of this second tube.  The free  end of the T-tube permitted free inspiration,
and by forced expiration a sufficient amount of air was made to pass into the mouth. 
                           DYSLALIA.                       859
should be open, may be classed under the general term  dyslalia
nasalis,  or,  shorter,  rhinolalia.   Two forms  may be  distin-
guished,  an aperta and a clausa.  This dyslalia nasalis is gen-
erally, but not always, a dyslalia pal atina.
   1. Rhinoletlia aperta.
   For the production of the pure vowels and of all the conso-
nants, with  the  exception of the resonants m, n and ng,  the
nasal cavity  must be closed by the velum palati.  For the pro-
duction of the resonants, the  soft palate must  hang down, and
leave the passage  into  the nose open.   When this passage is
constantly open, the voice becomes muffled and snuffling, and the
resonants  become  excessively prominent, while the explosive
will be more or less indistinct, in consequence  of the diversion
into the nose of a portion of the stream of air.
   This  open  rhinolalia,  with marked  snuffling, is most fre-
qnently  met with  as  a  consequence of diphtheritic paralysis,
which is notoriously a bilateral paralysis.  It is often also  the
result of syphilitic einel diphtheritic ulcerations, and, finally, is
not unfrequently due to congenital or traumatic fissures of the
hard and soft palates.   Unilateral paralysis of the  soft palate
also interferes with the purity of the articulation.
   Bruecke 1 studied the impairments of articulation in  a person
whose soft palate hael  been destroyed by syphilis.  The  other
organs of speech were intact.   She articulated the tenues p, t, k,
distinctly,  but not the medhe b, d, g,  because the narrowing of
the glottis, in the phonation which is required for the production
of the media?, diminished the stream of air,  and the subsequent
diversion of  a portion of the stream through the nose left  too
little for  the  production  of the explosive sounds  at the points of
closure in  the mouth.  The  vowels did not have as markedly
nasal a character as  they would have in the case  of a person
with uninjured but hanging velum,  which would allow the air
to pass into the nose.
   We are indebted to  Langenbeck2 for some  communications
on the subject of the  defects of speech which accompany cleft
   1 Sitzungsber.  der k. Academie d. Wissensch. 1858. Bd.  28. S. 03.
   2 Archiv  f. klin. Chirurgie.  1863. Bd.  1.  S. 1-170.  According to Klencke Die
Storun^en etc. S. 102,, it is principally the letters k and g that suffer in cases of cleft 
860         KUSSMAUL.—DISTURBANCES OF SPEECH.

palate.   He remarks that  they have been  as yet but little
studied, and are of a complicated nature and difficult to inves-
tigate.
   Persons with cleft palate  have often, on account of their dis-
agreeable speech, condemned themselves to complete silence, mak-
ing use of oral  communication only when it was absolutely un-
avoidable.   When the defect has been  acquired, the suffering of
the patient is often increased by the galling feeling, that he alone
is to blame for the curse.  When the cleft has been acquired, the
speech is more  nasal, snorting, and whistling ; when congenital,
it is predominantly guttural, but it is equally bad and unintelli-
gible in both cases.  The articulation of the consonants is more
difficult than that of the vowels. The intensity of the deformity
of speech depends less on the extent, than on the seat of the defect.
Defects in the alveolar process, even when they occasion exten-
sive communication  with the  nasal  cavity,  affect the speech
least.  In cases of congenital defect, the impairment of speech is
more considerable when  the  two halves of the palate are in the
horizontal position, than in the rare cases in which they ascend
perpendicularly  towards one  another.   Persons who  are pos-
sessed of an active intellect, learn to regulate the defective forma-
tion of the voice and  articulation much better  than those who
remain undeveloped intellectually.  In consequence of the exten-
sive space which is placed at the disposal of the tongue in cases
of congenital cleft palate, the movements  of that organ  become
excessive, and it rolls about unnecessarily in speaking.   It may
undergo hypertrophy and attain colossal dimensions.  In a case
of Fergusson's,  it  shut  off  completely the pharyngeal  cavity
from the choanae.  When  the cleft involves  the entire jaw, the
functions of the lips and teeth are also  imperfectly performed.
   As a rule, the operations of uranoplasty and staphylorraphy
only partially relieve the defects of speech.  These do not usually
disappear completely, even  when  the operation has been per-
formed in childhood, and years have been  devoted to methodical

palate. Ka, ke, ki are always sounded like ha, he, hi; kle and kre like tie and tre.  A
man with cleft palate addressed Klencke as " Tlenhe."  The same author states that
when there is an opening in tbe hard palate, the letters b, p, d, t, s, v, are accompanied
by a hissing noise. 
DYSLALIA.
861
practice (Passavant).  We must rest contented, when we succeed
in bringing about an improvement.
   The causes  of this want of success are various.   The tongue
feels shackled in the diminished space at its disposal.  The most
influential cause, however, is the shortness, hardness, and stiff-
ness of the cicatricial,  and often persistently infiltrated, velum
palati.  These  conditions interfere with its movements, and pre-
vent the  closure of the nares.   Its muscles  often  take a long
time to recover, and to  regain the necessary power  and ease of
contraction.   Still, Langenbeck has  several times  known  the
speech to become normal  in the course of a year, or even less,
particularly when  the  patients were  intelligent and practised
faithfully.  When  the  defect was acquired, the results were, in
general, more favorable.
   Passavant thought  that better results would be  obtained by
partially uniting the velum  palati  to  the  posterior wall of  the
pharynx ; his  expectations,  however,  have not  proved wrell
founded.
   Billroth1 holds that the cause of the failure is to be sought in
the defective condition of  the uppermost part of the constrictor
pharyngis, which, like a sphincter, should facilitate the apposi-
tion of the velum palati to the posterior pharyngeal wall.
   Within the last few years, American dentists, and after them
Preterre in Paris, and Suersen in Berlin, have constructed excel-
lent obturators,  which  often completely remove  the defect of
speech, especially when it is acquired.   This proxies is has, to a
certain extent,  replaced uranoplasty.  The obturators, however,
cannot always  be tolerated.  They sometimes produce inflamma-
tory irritation,  and even  increase the defect.   They are, more-
over, very dear, and must be renewed from time to time.a
   A cleft of the uvula alone does not exert any influence on the
speech.  In amputation of the uvula, the levator should not be
shortened, unless there should  be a  special indication for it, as
the singing voice might  be thereby impaired (Duncan Gibb3).

  1 Chirurg. Klinik. 1860-67. S. 159.
  2 Schmidt's Jahrb. 1868. Bd. CXLI. S. 135.—Verhandlungen des deutschen Chirur-
gen Congresses in Berlin.  1875.  S. 34-89.
  3 Lancet,  1872. Feb. 6th. 
862         KPSSMAUL.—DISTURBANCES OF  SPEECH.

   2.  Rhinolalia clausa.
   When the entrance of air into the ehoanas during speaking is
prevented by hypertrophied tonsils, adhesion of the velum palati
to the pharyngeal wall, polypi, or similar causes, or when thecho-
arue themselves are obstructed by inflammatory swelling, mucus,
polypi,  foreign  bodies,  etc,  the  so-called obstructed mouth-
tone is produced.  The vocal clang-tints become muffled, and the
articulation of the  nasal sounds suffers to a varying  extent, in
proportion to the degree and the location of the obstruction.
   Czermak l examined a girl fourteen years of age, in whom the
velum p ah di had become adherent to the posterior pharyngeal
wall.  The vel urn, however, could  still be made tense or relaxed,
be arched or flattened at will.  Strange to say, the girl was able
to pronounce sounds  that bore a striking resemblance to the
resonants—the  so-called Purkinje's puffing sounds.  She forced
as much air as  possible  through the phonating glottis into the
closed oral cavity, and then removed the obstruction with as lit-
tle sound as possible.  She  pronounced the vowels a, e, o, u, dis-
tinctly, and also /, when it occurred in the course of  speech  ;
alone, it  was sounded like a crushed e.  The  r was formed by
the tip of the tongue.

   C.  Dyslalia  lingualis.
   1.  It is a remarkable fact, that  very extensive congenital and
acquired defects of the tongue may exist without preventing
speech, or even without rendering it unintelligible.
   Louis,2 on one occasion, when describing a  deformed tongue,
which consisted merely of  two  nodules moved by rudimentary
muscles,  laid great  stress  on the fact that  the speech is less
affected than the  mastication and deglutition, in cases of con-
genital stunting or acquired mutilation of the tongue.
   A few years ago a small book appeared which wTas written by
an Englishman,  Edw. Twisleton,3 and was devoted to  a detailed
investigation of  this remarkable fact.  The work was  written as
an answer to the opinion expressed  by the  learned convert, Dr.
       1 Sitzungsber. d. Wiener Academie.  18G8. No. 8. S. 173-177.
       2 Mem. de l'acad. de chir. Paris. 1774. T. V. p. 486.
       s The Tongue not Essential to Speech.  London, 1873. 8. 232.  S. 
DYSLALIA.
863
Newman, that miracles were performed in the post-apostolic
period, and happen even at  the present day.  One of the most
notorious of these miracles was the recovery of speech by the so-
called  African Confessor, whose tongue was  cut off  at Tipasa,
a.d. 484, at the command  of  the  heretical vandal, Huneric.
Twisleton shows that it is not necessary to assume  a  miracle in
order to account for the Confessor's  recovery of  speech.   He
adduces  a number of well-authenticated facts, from both ancient
and modern times, which prove beyond possibility of doubt, that
cren after  as  much as two-thirds of the tongue has been cut off,
the mutilated person can gradually regain  the power of intelli-
gible speech by means of properly  directed practice.  A  man
named Rawlinson,  whose tongue Nunneley removed with the
ecraseur on a line with the anterior  pillars of the fauces, was
able to speak very intelligibly at the end of  six months. He was
subjected to a careful examination  by Ch. Lyell  and Huxley.
The only letters  he  could not pronounce were d, I and I.   lie
was consequently unable to  pronounce the name of  his  native
place, Leeds.   T and d sounded like/', p, v, or sh ; the sounds
r, s and  sch were also impaired ; k and g at the commencement
of words were pronounced well, but at the end of  words the g
sounded like the German ch (bich for  big).   Paget1 s  experience
accords with this case. He has seen the power of intelligible speech
return after six operations of so-called total  extirpation  of the
tongue.  The only sounds that the convalescents could not  pro-
nounce were d, t and  th, but this did  not make their  speech at
all unintelligible.   Otto Weber1 states, that he has  repeatedly
found the patients able  to speak remarkably well  a  short  time
after the operation  of  extirpation of  the  tongue,  the guttural
letters alone being indistinct.
   We recognize in this ability to accommodate the tongue to its
altered circumstances, and to employ it successfully for the pur-
pose of speaking, even after it has been reduced in size by more
than half, one of the greatest of the many miracles of nature that
we meet  in the mechanism of speech.
  1 Pitha u. Billroth,  Allg. u. spec. Chirurgie. Bd. III. 1. S. 316.  Compare also
Maisonueuve, Gaz. des Hop.  No. 125. 1853. 
864         KUSSMAUL.—DISTURBANCES OF SPEECH.

   2. Congenital and acquired hypertrophy of the tongue some-
times renders speech impossible, and  sometimes merely causes
stammering.   Operative treatment may prove  useful in these
cases.  Surgical measures are also  indicated when the frenulum
is very short and firm, when the tongue is fastened byadhesions
to the wall of the mouth, when tumors  of the tongue, jaw-bones,
lips  or cheeks are present, when the jaw is fixed by cicatricial
contractions, when there is muscular contracture or anchylosis,
and for other mechanical impediments to the free movement of
the under-javv and the tongue.
   Klencke states, that dryness of the oral cavity and lips is also
a frequent cause  of stammering.   This can  hardly prove detri-
mental in any other way than by impeding the movements of
the tongue and lips.   To counteract it  he recommends the chew-
ing of the radix pyrethri.
   The remarkable facility with which some persons are able to
draw the tongue,  especially after the division of the frenulum,
beickward into the pharyngeal cavity, to such  a  depth that it
looks as if it had  been  shortened by excision,  is worthy of
mention here.  Impostors have repeatedly made  use of this man-
oeuvre to excite  pity;  *they represent  themselves as dumb, and
state in writing that the tongue has been cut out.  One of these
impostors, wdio was examined by Dr. Kieme1, asserted  that  his
tongue had  been cut out  by a hostile  soldier in the  battle of
Leipzig.  Another, who, as we have been credibly informed, suc-
ceeded in deceiving a celebrated anatomist, asserted that he had
been mutilated by the hand  of an Arab, while serving  in  the
Foreign Legion in Algiers.

   D. Dyslalia dental is.
   Absence of the teeth and a faulty position of the dental rows
prevent the correct articulation particularly of  s, sch, f,  n, and
the English th; t, i, and u also are not clearly enunciated.2 A
properly constructed  set of false teeth will  correct the impedi-
ment caused by loss of the teeth,  as soon as the wearer has ac-
customed himself to its use.
1 Meissner, Taubstummheit, etc. Leipzig u. Heidelberg, 1856. S. 205.
2 Merkel, Physiologie der menschlichen Sprache. S. 408. 
                        DEAF-MUTISM.                     865
   When the teeth are held too  close together, the vowels and
labial consonants suffer.  A  small clamp  to be attached to a
convenient tooth, has been recommended as a means of treatment
(Krug, Klencke).

   E. Dyslalia labialis.
   Of the labial defects which interfere with the articulation  of
the letters  b, d, p, w, m, and which are amenable to operation,
the most important is hare-lip.
                    CHAPTER  XXXYI.

              Deaf-Mutism and the Education of Deaf-Mutes.

   It is not our intention to discuss deaf-mutism from an otiatric
standpoint.  Congenital deafness, or  the form acquired during
infancy, only interests us in so far as  it leads to dumbness.1
   We will state, first of all, that deaf-mutes are not necessarily
perfectly deaf, as the word would  seem to  indicate.   We find
among  them besides persons who have lost entirely the sense of
hearing, a few also  who are  still able  to hear and  understand
loud calling  and speaking that is carried on behind their backs.
Erhard3 assures us, that  many heard the  tuning-fork when
placed  on the head, and that  a  deaf  and dumb wood-cutter, in
whom  the conduction through the bones of  the head was very
perfect, even heard a repeating watch at a distance of 41 inches.
Nagel3  examined 72 deaf-mutes between the ages  of 7 and  17
years,  and found among them six who could clearty distinguish
words spoken loudly into the ear, and whistling and other noises
produced behind their backs.  In 19 of the  cases every trace of
the sense of hearing was lost.  It is evident, then, that  complete
deetfness is not necessary for the production of deaf-mutism,
and that a high grade of hardness of hearing during childhood

  1 The literature of deaf-mutism has been thoroughly compiled up to the year 1855,
by B. L.  Meissner, Taubstummheit und Taubstummenbildung. Leipzig, 1856.
  - Rationelle Otiatrik. Erlangen, 1859.  S. 370.
  'Monatsschr. f. Ohrenheilkunde. 1868. No. 2.
          VOL. XIV.—55 
866         KUSSMAUL. —DISTURBANCES  OF SPEECH.

may prevent entirely, or to a marked extent, the development of
the power of speech.
   This observation is of practical importance.  We must always
bear it in mind, when seeking for the causes of dumbness or of an
imperfect development of speech in  children.  A child may be
brought by its  parents  to  a physician  to  have its  tongue cut,
because it makes no progress in speaking.  They will assure him
that the defective speech cannot be due  to any trouble with  the
ears, because the  child hears well.  A careful examination, how-
ever, may show that although the child  really hears, it does so
but imperfectly,  and that it  belongs in the  category of deaf-
mutes.

   A very intelligent boy, four years of age, understood what was  said in a loud
voice, but not what was said in the  tone of ordinary conversation. When his
name was called out behind his back in a voice of ordinary pitch,  he made no
sign; but when it was called out loudly, he turned his head immediately. He spoke
quite correctly a few names, such as " Vater," "Mutter," " Karl," which his brothers
and sisters were constantly calling out through the  house, but otherwise could not
speak a word.  We advised the parents to send him to an institution for deaf-
mutes.

   The causes of deaf-mutism differ in no respect from the causes
of ordinary deafness, except in  this, that  they come into  opera-
tion during intra-uterine life or during childhood.  It seems that
the time of puberty is the latest period of life  at which deafness
can deprive persons of the command of speech, which  they have
already acquired.
   In most of the cases of deaf-mutism due to acquired deafness,
this infirmity is developed during the first four years of life;
from that period  until the tenth year the cases become progres-
sively less numerous, and those in which it is developed between
the tenth and fourteenth years are exceedingly rare.   Previous
to puberty the word-pictures have not made so  lasting an impres-
sion  on the memory as is the case  at a later period.   After
puberty  deafness is no longer able to  wipe  out  the  pictures,
although it may seriously deface them.
   It is difficult to  decide  whether the majority  of deaf-mutes
come into the world deaf,  or become deaf after birth.  The  sta- 
DEAF-MUTISM.
867
tistics having reference to this point are very contradictory.  In
Belgium, in the year 1815, the deafness was congenital in 1,376 of
the cases, and acquired in 370 ; in Ireland, in  the year 1851, it was
congenital in 3,534 cases, and acquired in 419.  In Bavaria, in the
year 1858,  there were 2,362  deaf-mutes, four-fifths of whom had
been born deaf ; 5 per cent, of the remaining fifth  had become
deaf after five years of age.  On the other hand, between the years
1850-53 in France, 693 children were born deaf, while 1,092 be-
came deaf after birth.  In  the Berlin asylum, in the year 1871,
there were 152 deaf-mutes, of whom 69 had been deaf from birth
and 79 had become deaf after birth ; of the four remaining cases,
nothing definite could be learned.1
    The dissections of Hyrtl,  Bochdalek and  other excellent
anatomists, prove that imperfect  development of the auditory or-
gans must be classed among the anatomical  causes of congenital
deaf-mutism.   It is certain,  however, that in intra-uterine as well
as in extra-uterine life, the causes which most frequently abolish
the functions of the auditory nerves, are inflammatory processes
in  the cavum tympani  and the  internal  ear.  Several  times
nothing has been found except thickening of the ependyma of the
fossa rhomboidea}
    The careful examinations which Nagel,  Roosa and Beard,3 and
others made of large numbers of deaf-mutes,  revealed in the great
majority of the cases chronic amygdalitis and pharyngitis, per-
foration and  destruction of  the membrana tympani with loss of
the hammer and  anvil,  otorrhoea,  growths in  the  middle ear,
or  a depressed membrana  tympani  and great  narrowness  of
the external auditory canal.
    Gibb4 asserts that by means of the laryngoscope he discovered
an  absence of the vocal  cords in two deaf and dumb married
  1 Compare Boudin, Dangers des unions consanguine II. serie. Annal. d'hygiene
publ. T. XVII.  Folk, Zur Statistik der Taubstummen. Arch. f. Psychiatrie.  Bd. Ill
S. 407.  Conf. Fr.  Majer. Henke's Zeitschr. 1864. H. 2 (Statistik der Taubstummen
und Blinden in Bayern).
  ■> H.  Meyer, Virchow's Arch. 1858. Bd. II. S. 551.  Voltolini, Ibidem, 1863. Bd.
XXVII. S. 171.  Folk, loc. cit.  S. 418.
  3 American Journal. April, 1867. Canstatt's Jahresb. f. 1867.
  4 Med. Times and Gazette. No. 15, 1862. 
868         KUSSMAUL.—DISTURBANCES  OF SPEECH.

people.   No  one else, however, has  met with  any  analogous
cases, although Prinz,' Labus2 and others have undertaken nu-
merous  laryngoscopic  examinations with this view.  Prinz does
not even admit the often quoted opinion of Mansfeld3 of Bruns-
wick, that the larynx and palate are very frequently found mis-
shapen.  He examined, it is true, young deaf-mutes  from 8 to
14 years of age, who had  undergone a course  of instruction,
while among those examined by Mansfeld there were older and
entirely  uninstructed  subjects.   It  is altogether probable that
the narrowness and smallness of the larynx and trachea, which
Engel4 demonstrated by careful measurements on  the dissected
body of a deaf-mute, and the defective development of the velum
palati that Mansfeld observed in one-third of all the cases  he
examined, as well as the thick tongue that he often  found, are all
attributable to the absence of the articulating movements.
   In some deaf-mutes  we  have to deal with a congenital  or
acquired idiotism combined toilh the deaf-mutism.  Both the
affections are  due  to  imperfections  in  the  development of the
brain, or to diseases of that organ, especially affections of  an
inflammatory nature.   Or the idiotism is due to a cerebral affec-
tion, wliicli is  complicated by a disease of the internal ear that
caused the deafness.
   The  deaf-mutes are not  distributed equally over  the earth.
In most of  the  large  states of  Europe the proportion of deaf-
mutes to the inhabitants is a pretty constant one, viz., 1  to 1,580
or 1,590.  In some of the smaller states, however, the proportion
is much less favorable; in Baden it is 1 to 559, in  Switzerland 1
to 503.  This is probably dependent on the cretinismus, which is
endemic in Baden and  Switzerland.   Deaf-mutism is most infre-
quent in Belgium and Holland, where the proportion is 1 to 2,846.
In general, it  is more  infrequent in flat than in  mountainous
countries (Toynbee), probably  only because  cretinism  is more
common in the latter.  Of the 2,362 deaf-mutes in Bavaria in the
year 1858 (1 :1,746), the majority were found in the  regions where

   1 Archiv fiir Heilkunde. 1858. S. 413.
   2 Canst. Jahresber. 1871. Bd. II. S. 490.
   3 Ammon's Monatsschr. Bd. II. H. 1.—Schmidt's Jahrb. Suppl. Bd. III.  S. 311.
   4 Prager Vierteljahrschrift. 1850. 3. 
DEAF-MUTISM.
869
cretinism  occurs.   In the provinces of  Piedmont and  Savoy,
which contain a great many cretins, the proportion of deaf-mutes
in the  year 1861 was 1 to 563 inhabitants in  the former, and 1
to 443  in  the  latter;  in Hesse Darmstadt, which  has many cre-
tins in  the Odenwald,  the  proportion  in 1861 was 1 to  829.
These  exceedingly unfavorable proportions  are never  met with
in regions in which cretinism is not endemic.
   Deaf-mutism is more frequently met with in the country than
in cities.   In  Bavaria the relative  proportion of country to city
cases was as 128 :100. In Berlin there  is only one deaf-mute for
every 2,000 inhabitants.
   In the sixth decennium of the present century, the sum total
of the deaf-mutes  in all Europe, with the exception of  the Turk-
ish provinces, was 145,000.'
   The affection is more  common in males than in females.  In
Bavaria the excess of male subjects was 18 per cent.
   It is a remarkable fact, that the defect is incomparably more
frequent  among Israelites than among Christians.  In Nassau,
in the year 1864, the proportion of deaf-mutes among the Catholics
was 1 to 1,397, among the Protestants 1 to 1,101,  and among the
Jews 1 to 508 ; in  the department of Cologne, in 1869, the propor-
tion was  1 to 1,814 Catholics, 2,638 Protestants,  and  560 Jews
(Lent).  Of 100 deaf-mutes in Bavaria, 25 belonged to the Catho-
lic, 29  to the  Protestant, and 46 to the Jewish religion.   Lieb-
reich,3  who was struck  by  the frequent  occurrence of retinitis
pigmentosa  among deaf-mutes, found  that both the  affections
were most frequently met with in Jewish children, and that the
majority  of these  children came from consanguineous parents.
   The French investigators in particular, and more  especially
Boudin, have laid great  stress on  the consanguinity of the pa-
rents,  as a cause of congenital deaf-mutism.  Boudin ascribes
28 per cent,  of the  cases,  and English  statisticians  25-30 per
cent.,  to  this cause.  According to Majer, 33 out of  1,000 con-
genital deaf-mutes  in  Bavaria are  the  progeny of  marriages
between relatives._____________________________
   , Helfft published comprehensive  statistics of the deaf-mutes in Europe, in the
Deutsche Klinik for 1857.
   * Deutsche Klinik. <J Feb., 1801. 
870        KUSSMAUL.—DISTURBANCES OF SPEECH.

   Several  children in the same family are often afflicted with
deaf-and-dumbness.   Out of 1,000 families that contained deaf
and dumb  members,  Majer counted 100 that contained two  or
more.  Falk  tells of a family in which  six, and of  another  in
which five of  the children were deaf and dumb.  He ascribes the
infliction in both cases  to  alcoholism on the part of  the father.
Strange to  say, the intermarriage of deaf-mutes rarely leads  to
the hereditary transmission of the infirmity.  About one-eighth
of the deaf-mutes came f-om parents who had relatives that were
similarly affected (Majer;.
   The infirmity is met with by far most frequently  in the poorer
classes (Falk).
   Meningitis, scarlet fever, typhus, measles, and otitis interna
are the acute  diseases that most frequently  cause deaf-and-
dumbness during childhood.
   Deaf-mutism is often associated with mental weakness.  One-
sixth of all the deaf-mutes in Bavaria were imbecile ; two-thirds
were possessed  of good capacity,  and one-third of but  little.
Fully 78 per cent, could be taught various employments.  Ac-
cording to Schmalz,1 the intelligent deaf-mute is capable of being
taught to speak up to the fifteenth year of life.
   One of the consequences of deaf-mutism is a defective develop-
ment of the  thorax, the voice, and the organs of  articulation.
The slight development  of the thorax predisposes to pulmonary
consumption, which  very often carries off deaf-mutes soon after
puberty.  Meissner prepared a table of the causes of  death of  51
pupils of the  Deaf and Dumb Asylum at Leipzig.  In  49 of  these.
the cause of  death was  satisfactorily ascertained.   No less than
32 of them succumbed to pulmonary or laryngeal tuberculosis-
all, with one  exception,  between the ages of 12 and 30 years.

   Diagnosis.   Impostors  betray  themselves readily by defects
of orthography when they write,  for all deaf-mutes write with
perfect  correctness and never use provincialisms.   When they
cannot write, they may  possibly be unmasked by means of the
tuning-fork.    Actuated by the fear of betraying  themselves,

   1 Kurze Geschichte und Statistik der Taubstummen-Anstalten und  des Taubstum-
men-Unterrichts.  Dresden, 1830. 
                         DEAF-MUTISM.                     871

they may deny that they feel the vibrating fork when it is placed
between the  teeth  or held over the vertebra?, and in so doing
actually divulge their imposture, since every one feels the vibra-
tions in these situations (Erhard).


                 The Education of Deaf-mutes.

    Even in the sixteenth and seventeenth centuries, philanthro-
pists of different nations sought by instruction in language to fit
deaf-mutes for intellectual intercourse with their fellow-beings,
and to help them to attain a happier and more worthy position
in society.
    The Spanish  Benedictine Pedro de Ponce (1570),  the English
divine John Wallis (1653), the  Swiss physician  Johann Conrad
Amman (1692), who labored for a long time in Amsterdam, and
finally the Portuguese Jew Pareira in Rochelle (1745), have won
for themselves golden names in  the Pantheon of  the  benefactors
of  the human race  by their efforts  in this  direction.  The Abbe
Charles Michel de  l'Epee1 (1771),  however, was the first  who
undertook successfully the difficult  task of teaching deaf-mutes
to speak.  To this task he devoted his entire means and life.  His
instructions,  however, were confined to the written and  sign
languages,  and  the efforts of his  followers  in  France, among
whom we will only mention the  Abbe Sicard, were directed prin-
cipally to the improvement of the methods of teaching required
for this end.
    The  Saxon  schoolmaster, Samuel Heinicke,3  inspired by
Amman's  celebrated treatise,3  solved with wonderful sagacity
and energy the most  difficult problem in the education of deaf
mutes;  he  taught them  to  produce not only signs and  written
characters, but also articulated, spoken  words—he really made
the dumb speak.   His method of instruction was  called the Ger-
  1  Instruction des sourds et muets par la voie des signes methodiques. II. Paris, 1771
and 1774.
  2  H. E. Stoetznerr: SamuelIleinicke, Sein Lebenund Wirken. Leipzig, 1870. Ueinicke
was born in 1729, and died in 1790.
  's  Surdus loquens, seu methodus, qua, qui surdus est, loqui discere possit. Amstelod.,
1692, 12. The treatise was translated into German twice. 
872         KUSSMAUL.—DISTURBANCES  OF SPEECH.

man, in contradistinction to the French method, which is even at
the present day in general use in England.  In spite of numer-
ous  attacks from at home  as well as from abroad,1 Heinicke's
method  has been generally adopted in Germany, and by the
efforts of his pupils Eschke, Reich, the  deaf-mute  Teuscher and
others, it has been brought to a high  degree of perfection.
   It is  obvious that  the German method has two immense ad-
vantages over the French.
   1. It  is only when  the deaf person has  mastered  the spoken
language,  that  he can  be said to be entirely  restored to the
world.   Until then he  is unable to understand, and to make him-
self in turn intelligible to those who  can hear,  unless these have
first acquired the sign-language.
   2. Spoken speech is  a gymnastic  exercise for the lungs  and
air-passages ; it furthers  the development of these organs, and
thereby  strengthens the entire constitution.
   The instruction is  of two kinds :  intellectual and mechanical.
   1. The intellectual aims at the production and combination '
of ideas  drawn from  sensory impressions.  This  is  attained, at
first, by means of pantomimes and  drawings, later by means of
written and spoken words.   At first  only the simplest words are
used,  but  as  the pupil progresses,  the compound words  are
gradually and methodically brought into use.
   2. The mechanical  instruction  aims at  the  production  of
articulated sounds and  words.  The  pupils are taught  to watch
closely the mouth of the speaker as he forms his words, to seize
the mimic sound-pictures, and to reproduce them by imitation.2
The successful imitation of the  visible  sound-motions  is facili-
  1 De VEpee attacked the method of Heinicke in his essay:  La veritable maniere d'in-
struire les sourds et muets. Paris,  1774.—Heinicke answered  with: Wichtige Ent-
deckungen und Beitrage zur Seelenlehre und zur menschlichen Sprache. Leipzig, 1784.
The controversy was resumed in the French Academy in 1853, and was carried on with
great vehemence.  The commission, however, could after all only be brought to admit
that partially deaf subjects can be taught to speak aloud, notwithstanding the fact that
the Germans had long before succeeded in teaching the entirely deaf to speak.  Compare
Meissner, loc. cit., Chap. 12.
  8 Schmalz published a useful popular treatise, entitled: "Das Absehen  des Gespro-
chenen als Mittel bei Schwerhorigen und  Tauben das Gehor  moglichst zu ersetzen, etc.
3. Aufl.  Dresden, 1851. 
                        DEAF-MUTISM.                    873

 tated by studying, by means of palpation, the movements of the
 thorax and  the vibrations  of  the larynx that accompany the
 act of speaking.   By slow degrees the pupils learn to combine
 properly the movements of respiration, phonation, and articu-
 lation.
   The intellectual and mechanical instructions are carried on in
 this way up to a certain time independently of one another, but
 the intelligence and speech  nevertheless react upon one another,
 and become intimately interwoven, just as they do when children
 possessed of the faculty of hearing are learning  to speak.  For
 instance, a seven-year-old deaf-mute in Leipzig  had learned  to
 write very nicely after  six  months of instruction, but he was
 still unable  to understand  what he  had written.  He simply
 copied the written questions that were  addressed to him (Meiss-
 ner).   As his instruction proceeded,  however, he began to under-
 stand the written words.
   The readiness of speech which the deaf-mutes attain is more
 or less perfect, according to their  intellectual and mechanical
 proficiency.  It depends  also on the degree of deafness, which
 may be complete or partial, on the  more or less perfect forma-
 tion of the organs of speech,  and  on the age  at which they
 entered the  asylum.   Their speech always lacks  harmony  of
 sound and accentuation, for the production of which the posses-
 sion of the  faculty  of  hearing  is  absolutely essential.  It  is
 always monotonous, spelling,  hard,  barking  and  too loud.
 Mansfeld ' has studied closely the defects which mark the speech
 of deaf-mutes.  They are due partly to the loss of hearing, partly
 to the defective condition of  the  organs of phonation and artic-
 ulation, and naturally  vary in  accordance with the nature  of
 these lesions.  He distinguishes two varieties of defective speech,
par aphonia  and  mogilalia.   1. Paraphonia.   The  voice  is
unpleasant, rough,  and  even  hoarse,  and  sometimes changes
suddenly from  bass to treble {p. puberum); or it is whistling and
hissing {p. siMlans).  2.  Mogilalia.  The deaf-mute often finds
it difficult to  pronounce certain sounds, particularly  r and  k
{traulismus).   He frequently changes  the  hard into soft con-
1 Amman's Monatsschr. Bd. II. Heft 1. 
874        KUSSMAUL.—DISTURBANCES OF  SPEECH.

sonants, uses s instead of  g,  c  instead of t, d instead of k, 1
instead of r, etc.
   The written  productions of the deaf-mute are remarkable for
their correct  orthography,  which may contrast very  strikingly
with the  want of skill shown in  the  construction of the sen-
tences.
   Von Froriep ' has compiled a short summary of the perform-
ances of deaf-mutes, from which we can form  an opinion as to
the extent to which their intellectual development can  be pushed
by education.   He found among them a few painters, engravers
on copper and mechanicians, one mathematician, several writers,
two poets (Pelissier and Chatelain), and even one musician (the
son of General  Gazan).  The musician wrote a treatise on the
production and differences  of the tones—a companion to the
treatise of the blind Saunderson on colors.
   We have already mentioned the fact that many deaf persons,
or, to speak more correctly, many persons who are hard of hear-
ing, and  others whose  bones still  conduct sounds, are able to
perceive tone-vibrations, and revel in musical feelings.
   The  sense of touch sometimes  attains an  exceptional and
almost incredible delicacy in deaf-mutes.  Pfingsten,2  the Direc-
tor of the Deaf and Dumb Asylum in Schleswig, tells of a deaf
and dumb girl who could  understand almost eveiything that
was said  by watching  the mouth of the speaker, and who con-
versed in  the darkness of night with the servant-girl,  who  slept
in the room with her.  Pfingsten states that he at first refused to
believe this.  He became convinced, however, when he found that
she could understand what was said b}' the servant with averted
face, provided  she were allowed to  lay  her hand on the bare
breast  of  the speaker.  On the other hand, the sensitiveness of
deaf-mutes to painful  impressions  seems to be less than that of
persons who can hear (Itard).
   Combined congenital deafness  and blindness is,  as a  rule,
due to arrested development of the brain or to hydrocephalus,
and is accompanied by idiocy, paralysis, and  incurable dumb-
1 Neue Notizen, etc. Weimar, 1845. Bd. XXXllI. St. 5. S. 72.
8 Schmalz, Kurze Geschichte und Statistik, etc. S. 20. 
DEAF-MUTISM.
875
ness.  Children affected in this way usually die early.1  When
the deafness and blindness are acquired during childhood, the
patient  is  incapable of  learning the spoken language, but can
still learn  the written and sign languages, as is evident from the
history of  Laura  Bridgeman, which was recounted in  Chapter
XIV.  Great intellectual capacity and a sense of  touch wdiich is
capable  of  the most delicate and perfect development, are essen-
tial in such a  case for successful  instruction.2—The combination
of deaf-mutism with blindness does not seem to be  very rare,
since out of 2,100 deaf-mutes in Sweden, in the year 1840, 90 were
at the same time blind."
  1 Compare Sichel, Ann. d'Oculist. LIII. Mai et Juin.  1865.
  2 Compare, Erinnerungen eines Blindgeborenen, nebst Bildungsgeschichte der beiden
Taubstummblinden Laura Bridgeman und Eduard  Meyster.  Nach den franzosischen
und englischen Originalberichten des P. A. Bufau, 8. O. Howe, and H. Hirzel, by J.
O. Knie. Breslau, 1852. 8.
  3 J. Schmalz, Ueber die Taubstummen und ihre Bildung.  2. Aufl.  Dresden und
Leipzig. 1848.  S. 511.
END OF  VOL. XIV. 
 
INDEX.
 Abdominal pains in hysteria, 500.
 van den Abeele, 775, 776, 783.
 Abercrombie, 108.
 Abortion in etiology of tetanus, 327.
 Acid, hydrocyanic, in angina pectoris, 53 ;  in tetanus,
     363 ; phosphoric, in angina pectoris, 53.
 Aconite in angina pectoris, 52 ; in epilepsy, 294.
 Aeby, 823.
 Age in etiology of angina pectoris, 36 ; of Basedow's
     disease,  78;  of catalepsy, 370 ; of chorea, 422 ;
     of  deaf-mutism, 866 ; of eclampsia, 302 ; of epi-
     lepsy,  202,  213; of hemicrania, 6; of hysteria,
     478;  of  paralysis agitans,  396;  of progressive
     muscular atrophy,  113 ;  of pseudo-hypertrophy of
     the  muscles,  156; of  tetanus, 328;  of  tremor,
     386; of unilateral progressive atrophy of the face,
     59.
 Aitken, 447.
 d'Alais, Serre, 827, 840.
 Albers, 432.
 Albuminuria in epilepsy, 233.
 Alcoholism in etiology of epilepsy, 203; of tremor, 3S6.
 Alefeld, 805.
 Allbutt, Clifford, 4, 25.
 Althann, 16.
 Althaus, 29, 204, 409.
 Amann, 478, 479,  480, 483, 497, 509, 571.
 Amman, 852, 855, 871.
 Ammon, 873.
 Ammonia in hysteria, 565; chloride of, in hemicrania,
    25; succinate of, in angina pectoris, 52.
 Amussat, 842.
 Amyl, nitrite of, in angina pectoris, 52; in epilepsy,
    295 ; in hemicrania, 27.
 Anaemia in etiology of Basedow's disease, 78 ; of cho-
    rea, 424; of hysteria, 482.
Anaesthesia in hysteria, 506.
Andral, 336, 422, 668, 676, 682, 721, 733.
Andrews, 79.
Angina Pectoris,  31; bibliography, 31; history,
    32;  etiology, 35; general description  and course
    of  the disease, 37;  pathological  anatomy,  39;
    analysis of symptoms, 41;  diagnosis and progno-
    sis, 50 ;  treatment, 51.
Angina pectoris, symptoms of, in hysteria, 500.
Aniline, sulphate of, in chorea, 466.
Anstie, 4, 25, 53, 68, 113, 204.
Antimony, tartrate of, in catalepsy, 382.
Antispasmodics in angina pectoris, 52,
Appleyard, 855.
Aran, 77, 96, 108, 109, 113, 135, 139, 142.
Aretaeus, 316.
Arndt, 453.
Arnoldi, 449.
Arnott, 827.
Aronssohn,  336.
Arsenic in angina pectoris, 53 ; in Basedow's disease,
    101; in chorea, 464 ;  in hemicrania, 25 ; in pro-
    gressive muscular atrophy, 149,  in tremor, 393.
Artemisia in epilepsy, 288.
Arteries, changes in, in unilateral progressive atrophy
    of the face, 62.
Assafcetida in chorea, 405 ; in epilepsy, 294 ; in hys-
    teria, 565.
Athetosis.   See under Paralysis Agitans.
Atrophia Muscularis Progressiva.   See  under Pro-
    gressive Muscular Atrophy.
Atrophy, Unilateral Progressive, of  Face.   See under
    Unilateral Progressive Atrophy of Face.
Atropin in angina pectoris, 52.
Auditory apparatus,  diseases of, in etiology of deaf-
    mutism, 867; imperfect  development  of, in  eti-
    ology of deaf-mutism, 867.
Auerbach, L., 155, 164, 175, 176, 177, 178, 179.
Avonde, 720.
Axenfeld, 135, 139.
Axmann, 58, 60, 67.

Babington, 427.
Back, pain in, in hysteria, 503.
Baerwinkel, 58, 59, 64, 69, 74, 109, 126, 127, 396.
Baginsky, 778, 801.
Baillarger, 90, 773.
Bain, 618, 703.
Bajon, 326.
von Bamberger. &3, 128, 140.
Banks, 87, 467, 774.
Barclay, 467. 
878
INDEX.
Barium, chloride of, in paralysis agitans, 406.
Barkow, 33.
Barnes, Robert, 427, 447.
Barrere, 321.
Barsickow, 156.
Barth, 164, 166, 167, 16S, 172.
Bartholin, 4.
Basedow, 77, 78, 84, 85, 87, 95.
Basedow's  Disease,  75 ; bibliography, 75 ;  his-
    tory, 77; etiology, 78 ; symptoms and course, 80 ;
    duration, 86 ;  pathological anatomy, 86; analysis
    of symptoms and theory  of the disease, 89 ; diag-
    nosis and prognosis, 99;  treatment, 101.
Bastian, 597, 751, 768, 790.
Bateman, 588, 676, 688, 722,  737.
Baths in  angina pectoris, 52; in catalepsy, 382; in
    chorea,  465, 408;  in epilepsy, 284;  in  hemi-
    crania, 25 ;  in hysteria, 567; in paralysis agitans,
    406;  in  progressive muscular  atrophy, 152; in
    pseudo hypertrophy of the muscles, 174 ;  in teta-
    nus, 363 ; in tremor, 393.
Baudelocque, 468.
Baudrimont, 135, 138.
Bauer on Tetanus, 315.
Baumes, 32,  53.
Baumgaertner, 32.
Beard, 568, 867.
Beau, 36.
Becker, 81, 84.
Beclard, 327, 350.
Becquerel, 349, 468, 828, 832.
Begbie, 442, 447.
Begbie, J., 79,  82.
Begbie, Warburton, 25.
Behier, 139,  648, 801.
Beigel, 285.
Bt-irne, 0., 348.
Belladonna in Basedow's  disease,  101;  in epilepsy
    £89;  in hemicrania,  26;  in hysteria, 565;  in
    paralysis agitans, 408; in tetanus,  36 i.
Bell,  Charles, 108, 647, 678, 828, 836.
Bellingham, 431.
Benedict, 268, 408, 802.
Benedikt, 28, 77, 90, 91, 96, 97,  113, 123, 124, 150, 157,
    160, 162, 174, 175, 176, 177, 178, 179, 335, 339, 374,
    382, 434, 468, 668, 837.
B-'rger. 0.,  5, 10, 11, 12,  13,  15,  21,  22, 25, 27, 155,
    164, 175, 176, 177, 178, 179.
Bergeret, 466.
Bergmann, 127, 730, 758.
Bergson, 48, 58, 59, 65
Bernard,  Claude, 87, 90, 92,  97, 146, 352.
Bernatrik, A.,  24.
Bernhard, 712, 736.
Bernhardt,' 717, 774, 775.
Bernheim, 27.
Bernstein, 34.
Bernt, 396, 434.
Bert, 455, 457.
Bertin, 733.
Betz, 114, 397, 406, 408, 710, 716.
Beveridge, 87.
von Bezold, 34, 46, 48.
Bianchi,  39.
Biermer, 87, 89, 757.
Billroth,  154, 164, 165, 348, 349, 861, 863.
Birch, 39.
Bitot, 58, 62, 64.
Black, 39.
Bladder,  pain in, in hysteria,  503; paralysis of,  in.
    hysteria, 518.
Blanc, G., 326, 345.
Blasius, 378.
Blatin, 37.
Bleek, 855.
Blood, changes  in, in progressive  muscular  atrophy,,
    128.
Blood-letting in Basedow's disease, 101; in catalepsy,.
    382 ;  in epilepsy, 296; in hysteria, 562 ;  in teta-
    nus,  361.
Bochdalek, 19, 867.
Bochefontaine, 712.
Bock, 69.
Boddaert, 90,  92.
Boehm, 52.
Boenecken, 318.
Boerhaave, 185, 202, 212.
Bohn, 418.
Boinet, 752.
du Bois-Reymond, 5, 9, 14, 19, 20,  21, 27, 28.
Bones, changes in, in epilepsy, 215 ;  in unilateral pro-
    gressive atrophy of the face, 63.
Bonnafont, 635, 774.
Bonnet,  842.
Bontius, 321.
Bouchard, Ch.,  350, 400.
Boucherau, 822.
Bouchet, 262.
Bouchut, 466, 467, 554.
Boudin,  867, 859.
Bouillaud,  33,  431,  721, 725, 726, 727, 728, 729, 752,
     790.
Bourillon, 402.
Bourneville, 232,  249, 250, 396, 660.
Bouteille, 417, 422.
Bouvier, 88, 109.
Boz, 599, 637.
Brain, changes in, in catalepsy, 377 ; in chorea, 447;
     in hysteria, 488; in paralysis  agitans, 401 ; in te-
     tanus, 333;  changes in meninges of, in epilepsy,
     216;  affections of,  in  etiology of deaf-mutism,
     868  ; weight of, in epilepsy, 216. 
INDEX.
870
 Brandes, 824.
 Branson, 447.
 B.e^janze, 801.
 Brendel, 417.
 Brenner, 29.
 Brera, 32, 33.
 Breschet, 349.
 Bricheteau,  424.
 Briess, 467.
 Bright,  328. 348, 427, 675.
 Briquet, 477, 478, 479, 480, 507, 510, 530, 506.
 Broadbent, 447, 448, 457, 460, 600, 602, 645, 648, 681,
     689, 770, 783, 802.
 Broca, 608, 645, 721, 722, 725, 726, 728,  729,  734,  738,
     741, 742, 753, 754, 804
 Brockmann, 393.
 Brodie, Benj., 327, .334, 351, 363, 505, 525, 574.
 Brosius, 588, 809, 816, 821.
 Brown, E. Burton, 426.
 Brown-Sequard, 16, 185, 191,  193,  194, 115, 198,199,
     205,  209, 225, 228, 262, 263, 265, 268, 406, 454. 649
 Brueck, 79.
 Bruecke, 850. 859.
 Brunner, 5. 58, 60, 64, 70, 71, 74.
 Brunton, Lauder, 27,  38, 53.
 Buchwald, 661.
 Bucknill,  447.
 Burdach, 599, 672.
 Butler, 32.
 Butlin, 465.

 Caffein in hemicrania, 24 ;  in hysteria, 576.
 Cahen, 34, 53.
 Calabar bean in  chorea,  466; in paralysis agitans,
     409; in tetanus, 363 ;  in tremor, 393.
 Calcium, bromide of,  in angina pectoris. 53.
 Callender, 732.
 Calmeil, S01.
 Calvi, :-.'S2.
 Campet, 321.
 Camphor in  angina pectoris,  52.
 Cannabis indica in epilepsy, 294 ;  in tetanus, 362.
 Canstatt, 46.
 Carbonic-oxide gas in hemicrania, 28.
 Cardialgia in hysteria, 501.
 Cartilages, changes in, in  unilateral progressive atro-
    phy of the face. 63.
 Caruthers, 467.
 Carville, 455, 457, 672, 680.
 Caspar, 618.
 Castoreum in angina  pectoris, 52, in  epilepsy, 294;
    in hysteria, 565.
Catalepsy, 369:  bibliography,  369 :  etiology, 370;
    symptoms and course, 372 ; pathological anatomy
    and theory of the  disease, 377 ; diagnosis, progno-
    sis, and treatment, 381.
  Catching eold in  etiology of pseudo-hypertrophy of
      the muscles, 15? ;  of tetanus, 320,
  Cayley, 402, 404.
  Cazalis, 84.
  Cazanvililh, 262.
  Cazenave, 27,  393.
  Cederschiiiia,  321,
  Celsus, 370.
  Chalmer, 345.
  Chalmers, 326,
  Championnere, 17.
  Chapman, 33,  285,
  Charcot, 67, 77, 79, 85, 86, 95, 98,  109, 113, 127, 133,
      135, 137, 140, 142,  145, 164, 166, 167, 168,193, 350,
      391, 896, 397, 398, 399, 400, 403, 404, 407, 408, 409,
      438, 452, 457. 488, 493, 502, 507, 510, 521, 522,529,
      530, 572, 653, 671, 672, 674, 681, 691, 728, 731, 741,
      769.
  Chauveau,  455, 457.
  Cheadle, 84, 85,
  Chervin, 828, 834.
  Cheyne, 283,
  Childbed in etiology of progressive muscular atrophy,
      113.
  Chisolm, 81, 82.
  Chloral hydrate in  chorea, 463, 466 ; in hysteria, 576 ;
      in paralysis agitans, 409 ;  in tremor, 393; in teta-
      nus, 362.
  Chloroform in  angina pectoris, 52;  in chorea, 467 ; in
      epilepsy, 289;   in  hemicrania,  27;  in hysteria,
      573 ;  in seizure of epilepsy, 297 ; in  tetanus, 362.
  Chlorosis in etiology  of  Basedow's disease, 78;  of
      chorea, 424.
  Cholera in etiology of progressive muscular atrophy,
      113.
  Chorea, 413; bibliography, 413;  history and defl-
       ition,  415 ; etiology, 422;  general description,
      428;  analysis  of  the symptoms,  431; course,
      duration, and results, 441;  pathological anatomy,
      445;  experimental  investigations, 415; diagnosis,
      460 ;  prognosis, 461;  treatment, 461.
  Christison, J.,  742.
  Chvostek, 82, 86, 98, 1Q2, 163, 174, 402, 404.
  Circulation,  disturbances  of, in angina pectoris,  S7,
      45 ; in Basedow's disease, 80, 94; in  epilepsy, 252;
      in hemicrania,  12,  17; in hysteria, 523; in pseu-
^    do-hypertrophy of the muscles, 162 ; in true mus-
     cular hypertrophy,  177 ;  changes in organs of, in
      unilateral progressive atrophy of the face, 62.
 Clarke, J., 321.
 Clarke, Lockhart, 39. 109,  114, 117, 135,  136, 137, 138,
     142, 143, 335, 403, 454,  651, 652. 653.
 Clarus, A., 800, 801. 802.
, Claveleira, 401.
 Climate in etiology  of Basedow's disease, 79 : of deat-
     mutism, 868; of epilepsy, 214: of tetanus, 320, 
880
INDEX.
Clouston, 232, 294, 453.
Coccygodynia in hysteria, 503.
Cod-liver oil in pseudo-hypertrophy of the muscles,
    173.
Coen, 828, 837, 838, 840, 851, 853.
Coffee in etiology of tremor, 386.
Cohn, 109,  135, 138, 402,  404.
Cohn, H., 13.
Cohnheim, 155, 164, 165, 166, 167.
Cold, application of, in angina pectoris,  52 ;  in hemi-
    crania, 26 ; in tetanus,  363.
Cold  in  etiology  of  angina pectoris, 36 ; of paralysis
    agitans,  397 ; of unilateral progressive atrophy of
    the face, 59.
Colin, 39.
Colombat, 817, 827, 829,  832, 834,  836, 840, 842, 852.
Coma in epilepsy, 227 ; absence of, in epilepsy, 237.
Combette, 668.
Compression in hemicrania, 26;  of carotids in seiz-
    ure of epilepsy, 295.
Condillac, 597.
Condition in life in etiology of deaf-mutism,  870.
Conium  in angina pectoris,  52 : in epilepsy, 294.
Consanguinity of parents in etiology of deaf-mutism,
    869.
Consciousness, loss of, in catalepsy, 373 ; in epilepsy,
    234.
Constant, 422.
Constipation in chorea, 441; in tetanus, 355.
Contractions of extremities in hysteria, 521.
Convulsions  in epilepsy, 227,  229;  in  hysteria, 511,
    531; absence of, in epilepsy, 238.
Cooper, Astley, 77, 195, 362, 528.
Copland, 53, 388, 427.
Copper,  preparations of, in chorea, 466; in epilepsy,
    291; in hysteria, 565.
Corlieu-,  79, 86, 381.
Cormac, 840.
Cormack, 827.
Cornil, 736,  740,  774.
Corvisart, 39.
Coste, 154, 157, 163.
Counter-irritation in epilepsy,  286.
Crampton, 424.
Crichton, Alex., 621, 758, 786
Crisp, 39
Cros, 89, 95.                                       *
Cruise, 87, 89.
Cruveilhier, 109, 117, 133,135, 140, 141, 651, 668, 609.
Cry of epilepsy, 226
Cullen, 325.
Curare in catalepsy, 382 ; in paralysis agitans, 409; in
     tetanus, 363 ; in tremor, 393.
Curling, 321, 324. 328. 333,  335, 336, 340, 342, 356,  363.
Currie, 363.
Cyon, 49, 433.
Cyon, E., 34.
Cyon, M., 34.
Czermak, 530, 857, 858, 862.
Czerny, 85S.

Dalgaibns, 441.
Danilewsky, 039, 640.
Darolles, 659.
Darwall, 108.
Darwin, 32, 617, 642, 643.
Davis, Hall, 428.
Davis, J. D., 25.
Davy, 349.
Dax, G., 728, 729.
Dax, Mark, 725, 726, 727.
Dazille, 322, 320, 327.
De Beauvais, 454.
Deces, 91.
Dechery, P., 657.
Deformities in etiology of impairment of articulation,
    S55.
D6granges, 82.
Deiters, 651, 667.
Delasiauve, 222, 233, 249, 274, 287.
Delirium epilepticum, 239; delirium in tetanus, 331,
    344.
Delphinin  in angina pectoris, 52.
Demarquay, 91.
Demme, H., 100, 334, 337, 345, 353, 356.
Demours, 77.
Derivatives in angina pectoris, 52 ;  in hysteria,  562.
Desmarres, 95.
Desportes, 33, 39, 321, 336.
Devol, 78.
Dickinson, 39, 335.
Dickson, 326.
Dieffenbach, 837, 842.
Diemer, 114.
Diet  in chorea,  462; in  epilepsy, 283;  in  hysteria,
    567 ; in stuttering, 840.
Dieulafoy, 688, 813.
Digestion, disturbances  of, in Basedow's disease, 85 ;
    disturbances of organs of, in etiology of epilepsy,
    212.
Digestive canal, spasms of, in hysteria, 511.
Digitalis in angina pectoris, 53 ;  in Basedow's disease,
    101 ; in epilepsy, 294.
Disposition, changes  in, in chorea, 429 ; in epilepsy,
    255.
Disturbances of speech.  See under  Speech, Disturb-
     ances of.
 Dizziness in Basedow's  disease,  85 ; in  paralysis agi-
     tans,  400.
 Dommes,  33.
 Donders,  196.
 Down, Langdon, 649. 
INDEX.
881
 Draper, 618.
 Drissen, 124.
 Dubois, 10S, 199, 548.
 Duchek, 809.
 Duchenne, 53, 108, 109, 121, 127, 133, 138, 144, 154,
     155, 157, 163, 104, 165, 168, 174, 396, 468, 519, 653,
     655, 721, 722.
 Dufau, P. A., 875.
 Duges, 435.
 Dumenil, 109, 116, 133, 135, 137, 138,  140, 142, 144.
 Dumont, 85, 466.
 Duplay, 672.
 Dupuy, 336.
 Dupuytren, 326, 327, 341, 362, 468.
 Durand-Fardel, 672, 676, 721.
 Duret, 672, 6S0.
 von Dusch, 33, 80, 81, 82, 102.
 Du Soit, 836.
 Duval, 740,  742.
 Dybkowsky, 352.
 Dysphagia in angina pectoris, 44.
 Dyspnoea in tetanus, 331, 346.

 Eab symptoms in hysteria, 496, 510.
 Ebstein, 86,  89, 233, 060,  661.
 Echeverria,  201, 202, 203, 204, 210, 216, 217, 218, 219,
     229, 231, 233, 245, 252,  262, 281, 294, 743.
 Ecker, 721, 738, 741, 763.
 Eckhard, 352, 711, 712.
 Eckstein, 424.
 Eclampsia, 299;  definition,  302;  etiology,  302;
     symptomatology, 307: pathology, 308; prognosis,
     310; treatment, 310.
 Ecstasy in hysteria, 534.
 Education, of deaf-mutes, 871; improper, in etiology
     of hysteria, 4S6.
 Ehrhardt, 113.
 Eichhorst, 657.
 Eichwald, 33, 42, 43, 46, 47, 49.
 Eisenmann, 109, 110, 382.
 Electricity in angina pectoris, 53 ;  in athetosis,  410 ;
    in Basedow's disease, 102; in  catalepsy, 382 ; in
    chorea, 465, 468; in epilepsy, 285 : in hemicrania,
    28;  in hysteria, 568, 574; in  paralysis agitans,
    406; in progressive muscular  atrophy,  150;  in
    pseudo-hypertrophy of the muscles, 174 ; in stutter-
    ing, 840 :  in tetanus, 365 ;  in tremor, 393;  in uni-
    lateral progressive atrophy of the face, 74.
 Elischer, 450, 451, 452, 454, 456, 457, 458, 459.
 Elliotson, 406.
 Eisner, 32.
Emaciation  in Basedow's disease, 85;  in unilateral
    progressive atrophy of the face, 60.
Emmert, 82, 84.
Emotional  causes of catalepsy, 371; of epilepsy,  204 ;
    of  paralysis agitans, 397.
                 VOL.  XIV.— 5G
 Enemata, narcotic, in angina pectoris, 52.
 Engel, 863.
 Engesser, 602.
 de l'Epee, Charles Michel, 872.
 Epilepsy,  183;  bibliography,  183; introduction,
     184;  experimental researches, 193 ;  etiology, 200 ;
     pathological  anatomy,  214;  symptomatology,
     219;  the epileptic seizures, 220 ; epilepsia gravior,
     221;  epilepsia mitior, 234 ; transition-forms;  loss
     of consciousness with local spasm, 235;  irregular
     forms of  the attacks,  and  the epileptoid states,
     237;  consequences of  the paroxysms,  244 ;  fre-
     quency of the seizures,  247;  the  interparoxysmal
     condition,  252;   pathology, 259;   course   and
     sequelae,  273; prognosis, 276:  treatment,  279;
     treatment of the seizure itself, 295.
 Epilepsy  in etiology of Basedow's disease, 79; of  uni-
     lateral progressive atrophy of the face, 59.
 Erb, 67, 124, 150, 174, 177, 390, 439, 514, 843, 845.
 Erbstein, 396
 Erdmann, 39.                                     ,
 Ergot in catalepsy, 382; in hemicrania, 24; in paraly-
     sis agitans, 408.
 Erhard, 865, 870.
 Erichsen, 329.
 Erlenmeyer, 52
 Escher, 21, 197.
 Eschke, 598, 872.
 Esquirol, 226, 256, 628.
 Ether in angina pectoris,  52; in  hysteria, 573.
 Etiology.   See Different Diseases.
 Ettmueller, 203.
 Eulenburg, 465, 497, 512,  801.
 Eulenburg, A., on Vaso-Motor and Trophic Neuroses, 3.
 Eulenburg, M., 150,  155.
 Eulenburg, Sr., Ill,  112, 113.
 Ewart, 432.
 Excretion, disturbances of, in hysteria, 523.
 Exercise,  physical,  in chorea,  463;  in progressive
    muscular atrophy, 149 ; in pseudo-hypertrophy of
    the muscles, 174 ; in  stuttering, 840; etiology of
    epilepsy, 213; of progressive muscular  atrophy,
    114 ; of true muscular hypertrophy, 176.
 Exner, 656, 678.
Extremities, extension of, in epilepsy. 295 ; pain in, in
    hysteria, 504 ; paralysis of, in hysteria, 518.
 Eye  affections in Basedow's disease, 82,  87, 91; in
    chorea. 437 ; in epilepsy, 229. 231; in hemicrania,
    12, 15; in hysteria, 496, 510; in progressive mus-
    cular atrophy, 127 ; in tetanus, 344 ; in unilateral
    progressive atrophy of the face, 64.

Face,  appearance of, in epileptic seizures, 228; in
    tetanus, 341.
Fagge, 53.
Falk, 870. 
882
INDEX.
Falret, 238, 240, 648, 744, 757.
Farge, 688, 737.
Farr, 341.
Fatigue in etiology of epilepsy, 213.
Fautrel, 424.
Febrile diseases in etiology of epilepsy, 212.
Fecnner, 334.
Fehling, 42S.
Feinberg, 459.
Ferber, A., 608.
Ferder, 790.
Fergusson, 860.
Fernet, 529, 741
Ferran, 526.
Ferrand, 25, 391, 392.
Ferrier, 207, 202, 071, 680, 711, 714, 720.
Fever in progressive muscular atrophy, 127.
Fick, 162,  348, 349, 352.
Fieber, 28, 29, 30, 124.
Filehne, 199.
Bincham,  39.
Finkelnburg, 597, 606,  607, 609, 736, 777.
Fischer, 77, 78, 82, 91, 95, 410, 459.
Flechsig, 703, 725.
Fletcher, 77.
Fleury, 4,  843, 844.
Flies, 827.
Flourens, 122, 705, 706.
Foerster, 82, 133.
Font-Reaulx, 741, 742,  769.
Foote, 457.
Forbes, 36.
Forgues, 427.
Fouilhoux, 466.
Fourcroy,  321.
Fournier,  84, 85, 86, 87, 88, 850, 851.
Fox, E. L., 422, 423, 449.
Fraenkel,  B., 86.
Frank, 422.
Frank, Joseph, 185, 211,213, 214, 222, 224, 287, 812,830.
Frank, J. P., 299.
Frank, Peter. 189, 220.
von Franque, 418, 483.
Franzenbad, waters of, in Basedow's disease, 103 ; in
     hemicrania, 25.
 Frei, 687.
 Frerichs,  135. 467.
Freusberg, 619, 647, 656.
 Frick, 467.
 Fricke, 449, 599.
 Friedberg, 109, 110, 113, 117, 133, 135, 138, 140.
 Friedreich, 33, 69, 84, 94,  96, 109, 110, 111, 112, 113,
      114, 115, 116, 117, 118, 119, 123, 124,  127,128,129,
      130, 133, 134, 135, 137, 138, 139, 140,  142, 143, 144,
      147,  150, 155, 157, 161, 164, 105, 166,  167, 169,171,
      172,  175, 176, 177, 179, 335, 657.
Friedrich, 351, 328, 340, 356, 357.
Fritsch, 711, 712.
Fritz, 101, 155.
Frommann, 126, 128, 135, 136, 138, 140, 143.
Frommhold, 28, 29.
Froriep, 335, 449, 599, 842, 843, 874.
Fuerstner, 684.
Funk, 334.
Fusel-oil in tremor, 393.

von der Gabelknz, 792.
Gairdner, 135, 143, 467, 645, 740.
Galbanum in hysteria, 565.
Galen, 396, 489.
Galenus, 620.
Galezowsky, 510.
Gall, 725, 726.
Gallard, 466.
Galvano-puncture in Basedow's disease, 102.
Gardane, 432.
Gardanne, 393.
Gastric fever in etiology of true muscular hypertro-
    phy, 176.
Geigel, 77, 79, 84, 87, 88, 89, 96, 97, 101.
Geiger, Lazarus, 586.
Gendrin, 506, 566.
Genital organs, affections of, in hysteria, 503, 515;
    affections of, in etiology of epilepsy, 206 ; of hys-
    teria, 482; treatment of, in hysteria, 563.
Genouville,  77.
Gerhardt, 113, 801, 802.
Gesner, 620.
Gibb, Duncan, 861, 867.
Gibson, 233.
Giddiness in epilepsy, 242.
Gildemeester, 79, 80, 82, 84.
Gimelle, J., 317, 333.
Gintrac, 442.
Gioja, 154, 157, 163.
Gland, thyroid, changes in, in Basedow's disease, 81.
Glas, 382.
Gliky, 712.
Gogol, 797.
Golgi, Camillo, 452, 453, 454.
Goltz, 34, 41, 226,  592, 622, 639, 690, 692, 695, 696, 697,
     698, 699,  713, 714, 715, 724.
Gooday, 800.
von Graefe, 77, 79, 80, 82, 83, 84, 93, 101,  102,103.
Gratiola in epilepsy, 294.
 Gratiolet, 721, 738, 822.
 Graves, 77, 82, 108, 175, 401, 758.
 Graves' Disease.   See under Basedow's Disease.
 Gravity, specific,  of urine, in progressive muscular
     atrophy, 128.
 Gray, 442,  448, 454.
 Grier, 322. 
INDEX.
883
 Griesinger, 7, 154, 155, 157, 164,190, 209, 241, 242, 244,
     255, 261, 337, 347, 353, 370, 705, 777, 822.
 Grimm, 109, 135, 137, 138, 847.
 Grisar, 287.
 Grodsensky, 39.
 Groetzner, 340.
 Gros, 109.
 Grossmann, 467.
 (Juarana in hemicrania, 24.
 Gubler, 385, 391.
 Gudden, 673, 690, 711, 777.
 Guentz, 349, 351.
 Guerard, 660.
 Guerin, 109, 110.
 Gull, 109, 114, 135,  137, 143, 459.
 Gurbocki, 41.
 Gussenbauer, 858.
 Guthzeit, 150.
 Guttmann, 16, 24, 27, 34, 58, 62, 74, 99.
 Guttmann, P., 323.

 Haddon, 39, 40.
 de Haen, 348, 352, 432, 468.
 Haeser, 416.
 Hafiz,  90.
 Hair, changes in, in unilateral progressive atrophy of
     the face, 61.
 Hall, Marshall, 196, 197, 228, 286, 401, 404, 828.
 Hallopeau, 199.
 Hamilton, 441.
 Hammond, 53, 109, 114,  238,  405, 409, 410, 491, 621.
 Hancock, 321.
 Harless, 32.
 Harley, 466.
 Hartmann, 371,  382.
 von Hartmann, Edw., 582.
 Hasse,  19,  109, 117,  202, 204, 222, 233, 237, 281, 289,
     290, 295, 299, 336, 375, 386, 418, 423, 437, 438, 445,
     463, 467, 468, 835.
 Hayem, 109, 133, 135, 137, 140, 142.
 Headache in Basedow's disease,  85;   in  hysteria,
     498.
 Heart,  affections of, in chorea, 436, 445; in etiology of
     chorea, 426.
 Heat, application of, in angina pectoris, 52.
 Heberden, 32, 214.
 Hecker, 416.
 Heiberg, 333.
 Heidenhain, 349.
 Hein, 639.
 Heine, 39, 46.
 Heinecke, 339.
 Heinicke, 635, 636, 871.
Helfft, 77, 669.
Heller, 155, 156, 164, 233.
Helmholtz, 597, 857.
| Hemiatrophia Facialis Progressiva.  See under Uni-
     lateral Progressive Atrophy of Face.
 Hemicrania, 3 ; bibliography, 3 ; history, 4 ; eti-
     ology, 5; general symptoms and course, 9; anal-
     ysis of the symptoms, 14;  course and prognosis,
     22; treatment, 23.
 Hemorrhages in hysteria, 525.
 Hemptenmacher, 111, 112.
 Henle, 618.
 Hennen, 325, 327, 347.
 Henoch, 82.
 Henrot, 506.
 Heredity in etiology  of angina pectoris, 36 ; of Base-
     dow's disease, 78; of chorea, 423; of eclampsia,
     302: of epilepsy, 201; of  hemicrania, 7 ;  of hys-
     teria, 479; of progressive muscular atrophy, 111;
     of pseudo -hypertrophy of the muscles, 156; in
     prognosis of epilepsy, 278.
 Hering, Ewald, 017.
 Hermann, 21,197, 359, 711.
 Herodotus, 799.
 Herpin, 203, 204, 226, 237, 277, 278, 290.
 Hertz, 768.
 Herz, 782.
 Herzbraeune, 39.
 Herzen, 226.
 Heusinger, 39, 87.
 Heymann, 801.
 Heyse, 589.
 Hicks, G.,  362.
 Hillairet, 397.
 Hillary, 326, 348.
 Hillier, 427, 442.
 Hine, 454.
 Hippocrates, 252, 318, 620.
 Hirsch, 425, 662.
 Hirschberg, 701.
 Hirzel, H., 875.
 Hitzig,  58, 62, 189,  195,  207, 260, 262, 339, 410, 680,
     690, 706, 711, 712, 720.
 Hoffmann, 157.
 Hoffmann, C.  K., 215.
 Hoffmann, E. K., 217.
 Hofmann, 39.
 Hofmeyer, 417.
 Holmes, 25.
 Hoist, 5, 27, 28, 29, 393.
 Hood, Thomas, 727.
 Horn, 424.
 Horner, 17.
 Hough, 466.
 Howe, S. G., 599, 875.
 Howship, 336.
 Huck. 325.
 von Huebner, 36, 55.
 Hueter, 58, 59, 60, 62, 67. 
)EX.
884                                         ine

Hufeland, 288, 290, 465.
Hughes, 423, 425, 427.
Huguenin, 672, 677, 678.
Huguier, 25.
Hun, 653,  768.
Hunt, 828, 831, 842.
Hunter, 323.
Huntington, 423.
Huppert, 233, 298, 352, 353.
Huss, 393, 528.
Hutchinson, 23.
Huxley, 763, 863.
Hydrocyanic acid in tetanus, 363.
Hyoscyamus in epilepsy, 289, 290;  in  hysteria, 565;
    in paralysis agitans, 406 ; in tremor, 393.
Hyrtl, 867.
Hysteria, 473;  bibliography, 473 ; general observa-
    tions, 475; etiology, 476;  pathological anatomy
    and pathogenesis,  488; symptomatology, 493 ;
    disorders of sensibility, 495; motor disturbances,
    511; disturbances of the circulation, and disorders
    of secretion  and  excretion, 523;  hysterical at-
    tacks, 531; psychical behavior, hysterical mental
    disturbances,  536;  progress  and  results, 546;
    diagnosis, 550;  prognosis, 555 ;  treatment, 558;
    prophylaxis, 558; treatment of the fully developed
    disease, 561; treatment of particular  symptoms,
    571.
Hysteria in etiology of Basedow's disease, 79.

Ileo-typhus fever in etiology of true muscular hyper-
    trophy, 176.
Imitative impulse in etiology of hysteria, 487.
Injuries in etiology of Basedow's disease, 79; of cata-
    lepsy, 371; of epilepsy, 205; of paralysis agitans,
    397;  of  progressive muscular atrophy, 116;  of
    pseudo-hypertrophy of  the muscles, 157; of teta-
    nus, 319; of tremor, 386 ; of true muscular hyper-
    trophy, 176; of unilateral progressive  atrophy of
    the face, 59.
Intestines, changes in, in tetanus, 337; paralysis of,
    in hysteria, 516.
Iodine, preparations of, in Basedow's disease, 101.
Iron, preparations of, in angina pectoris, 53 ; in Base-
    dow's disease, 101; in catalepsy, 382; in chorea,
    465 ; in hemicrania, 23 ; in progressive muscular
    atrophy, 149;  in paralysis agitans, 406; in pseu
    do-hypertrophy of the muscles, 173;  in  tremor,
    392.
Itard, 827, 842, 874.

Jaccoud, 109,  135, 139,  140, 141, 155, 165, 647, 651,
    652, 659, 608, 688, 705, 733, 737.
Jackson, Hughlings, 245,  302, 303, 447, 457, 645, 646,
    648, 649, 657, 705, 712, 740, 789, 800, 801.
Jahn, 33,  39.
Jamieson, 371.
Jastrowitz, 691, 702.
Jeffreys, 429.
Jenner, 39.
Joffroy, 109, 113, 132, 133, 135, 137, 138, 140, 403, 404,
    653, 661, 679.
Johnson, 114.
Johnston, 39.
Joints, affections of, in progressive muscular atrophy,
    126; pain in, in hysteria, 505.
Jolly, 33, 197,  396, 663.
Jolly on Hysteria, 473.
Jolyet, 93.
Jones, 371, 382, 406, 407, 408.
Jones, Bence,  441.
Jones, C. H., 441, 453.
Jones, Handfield, 77, 401.
Jougla, 790.
Jucine, 39.

Kant, 606.
Katenkamp, 840.
Kaulich, 154, 155.
Kesteven, 466.
Key, 341.
Kidneys, changes in, in tetanus, 337.
Kieme, 864.
Kind, 824.
Kirkes, 426, 447,  732.
Klein, 67.
Kleinpaul, 590.
Klemm, B,., 266,  459.
Klencke, 817,  828,  829,  834, 835,  839, 840, 841, 842,
    852, 859, 865.
Kneeland, 53.
Knie, J.  G., 875.
Knight, 87, 88, 89,
Knoll, 164, 165,166, 167, 170.
Knox, 825.
Koeben, 77, 89, 95.
Koehler, 53.
Koelliker, 19.
Koenig, 341.
van der Kolk,  Schroeder, 214, 217, 218, 219, 262, 265,
    269, 286, 651.
Krahmer, 573.
Krauspe, 197.
Kreysig, 39.
Krug, 865.
Kruse, 598, 636.
Kuehne, 403, 404.
Kussmaul, 16, 21, 145, 185, 196, 197,198, 216, 262, 203,
    266,  208, 295, 337, 343, 353, 459.
Kussmaul on Disturbances of Speech, 581.

Labobde, 677, 721. 
INDEX.                                         885
Labus, 868.
Ladame, 668,  686.
Laennec, 33, 53.
Lafon, 393.
Lallemand, 459, 721, 744, 752.
Lallement, 669.
Lancereaux, 33, 40, 41, 42, 48, 51, 87.
Lande, 58, 59, 61, 62, 67, 71. 72.
Landmann, 69.
Landois, 17, 21, 34, 45, 47, 48, 125, 146, 197, 273.
Landouzy, 478,  479, 483.
Landry,  138, 140.
Langenbeck, 859, 861.
Laqueur, 87.
Larcher, 405.
Larrey, 318, 325, 337, 360,  361.
Lartigue, 33, 44.
Lasegue, 374,  377, 378, 382, 777.
Latham, 33.
Lawrence, 84.
Lawrie, 328, 357.
Laycock, 77, 79, 80, 528, 617, 618, 705.
Lazarus, 594,  605, 700.
Lead-poisoning  in  etiology of  progressive muscular
    atrophy, 113 ; of tremor, 386.
Lebert, 4, 53, 77, 79, 81, 82, 401, 402, 404, 408.
Lccorche, 91.
Lee, 828, 836.
Legros, 455, 457.
Lehweiss, 840.
Leidesdorf, 453, 454.
Leinweber, 115.
Leishman, 53.
Lemoigne, 715.
Lent, 869.
Lentin, 39.
Leo, 396.
Lepelletier, 335.
Lepine, 672.
Leube, 81,  86, 103, 396, 424, 661, 662.
Leubuscher, 4, 5, 109, 823.
Lewy, Cerf, 101.
Leyden, 199, 144, 208, 210, 334, 348, 402, 404, 459, 651,
    653, 657, 722.
Lichtinger, 828, 836.
Lieber, Fr., 634, 635.
Liebreich,  467, 869.
Ligation of extremities in seizure of epilepsy, 295.
Lind, J., 326.
Liouville, 396.
Lipmann, 67.
Liston, 347.
Liver, changes in, in tetanus, 336.
Lobstein, 33.
Locke. 581, 597.
Lockhart, 39.
Loebel, 287.
Loeben stein, 287.
Lohmeyer, 732.
Longet, 639, 696.
Lordat, 600, 767, 771, 782, 804.
Louis, 77.
Loven, 90.
Lowes, 467.
Lubarsch, 77.
Lubimoff, 809, 810.
Ludwig, 34, 49, 90.
Lungs, changes in, in tetanus, 336.
Lupulin in hemicrania, 25.
Lussana, 43, 715.
Lutz, 156.
Luys, 109, 135, 136, 137, 142, 668.
Lyell, Ch., 863.
Lying-in,  in etiology of hysteria, 4S4.

Mac Dowell, 87.
Macedo, 382.
Macgrigor, 347, 356.
Mackenzie,  82.
Magendie, 391, 079, 727.
Magnan, 186, 203, 737.
Magnetism in angina pectoris, 53,
Maier, R., 653.
Maisonneuve, 863.
Majer, Fr., 869, 870.
Malaria in etiology of catalepsy, 371.
Malebouche, 836.
Malkiewicz, 379.
Malmsten, 138.
Mammary gland, pain in, in hysteria, 499.
Mansfeld, 868, S73.
Mantegazza, 66,  67.
Marce, 755.
Marowsky, 306.
M'Arthur, 337.
Martinet,  459.
Martini, 164, 167, 168, 172, 588.
Marsh, 82.
Mason, 39.
Massage in pseudo-hypertrophy of the muscles, 174.
Masturbation in etiology of chorea, 423 ; of hysteria,
    485; of progressive  muscular atrophy, 113 ;  of
    tremor, 386 ; in prognosis of epilepsy, 279.
Maton, 422.
Mau, A., 814.
Maudsley, 597, 639.
Maxwell,  322.
Mayer, A., 28.
Mayo, 492.
McDonnell, 80,  87, 89.
Measles in etiology of progressive  muscular atrophy,
    113; of pseudo-hypertrophy of the muscles, 157 ; 
886
INDEX.
     of  unilateral progressive atrophy  of the  face,
     59.
 Mechanical appliances in tremor, 393.
 Medicus, 382.
 Medulla oblongata, changes in, in epilepsy, 217, 265.
 Meissner, 67, 98, 378, 7*3, 864, 871,  873.
 Meissner, B. L., 865.
 Memory, loss of, in epilepsy, 255.
 Mendel, 52.
 Meningitis in etiology of deaf-mutism, 870.
 Menjaud,116, 127, 135,  138, 140.
 Menstruation, disturbances of, in Basedow's disease,
    86 ; in hysteria, 525 ; in etiology of  chorea,  424 ;
    of hysteria,  484.
 Mental conditions in etiology of tetanus,  328.
 Mental disturbances in chorea, 429  ; in epilepsy, 238;
    in hysteria,  543; in the interparoxysmal condition
    of epilepsy,  254;  in paralysis agitans, 400.
 Mental exertion  in etiology of epilepsy, 204.
 Mental weakness associated with deaf-mutism, 870.
 Mercurial poisoning in etiology of tremor, 386.
 Mercury in paralysis agitans, 408 ; in tetanus, 360.
Merkel, 217, 812, 826, 828, 832, 834,  837, 842, 850, 852,
    855, 864.
Meryon, 109, 110, 111, 112, 133, 135,138, 154.156, 164,
    167.
 Meschede, 217, 396, 397, 399, 402, 404.
 Mesnet, 510.
 Meyengon, 466.
 Meyer, 124.
 Meyer, H., 867
 Meyer, L., 219, 378, 453, 549, 550.
 Meyer, M., 58, 59. 102, 150, 468.
Meynert, 216,  217, 403,  450,  451, 454, 456, 457,  651,
    652, 653, 659, 670, 671, 673, 691, 716, 717,  736, 744.
 M'Gregor, J., 360.
 Michaud, .335.
Michea, 233.
 Mierjeievesky, 822.
 Mierzejeveski, 822, 823.
Mierzejewsky, 823.
Milk, increased secretion of, in hysteria, 530.
Mineral waters in Basedow's  disease, 103; in hemi-
    crania, 25; in tremor, 393.
 Mitchell, Weir, 457.
Moellendorff, 5,  9,13, 18, 22, 28.
Moeller, 91.
Monckton, 427.
Mongie, 676, 741.
Monneret, 4.
Monod, 422.
Monro, Donald,  360.
Moore, 58, 69, 87.
Moorhead, 39.
Moral management in treatment of hysteria, 569.
 Morehead, 322.
 Morel, 815.
 Moritz, 602.
 St. Moritz, climate and waters of, in hemicrania, 25.
 Morgagni, 289.
 Morgan, 340.
 Morris, 660.
 Morrison,  347.
 Mosely, 321,  360.
 Mosler, 125,  146.
 Motion, disturbances of, in chorea, 429, 431; in epi-
    lepsy,  223, 227; in hysteria, 492, 511.
 Motor manifestations  in the interparoxysmal condi-
    tion of epilepsy, 253.
 Moussons,  113.
 Moynier, 442.
 Mucous membranes, changes in sensibility of, in hys-
    teria, 509.
 Mueller, H.,  17, 92.
 Mueller, J., 823, 828.
 Mueller, M., 581, 586, 597, 605, 636,  846,  847,  848,
    850.
Mueller, W.,  157, 164, 166, 168.
Mullin,  424.
Murchison, 4C2, 404.
Murmurs, cardiac, in Basedow's disease, 81.
Muron,  A., 349.
Murray, 362.
Muscles,  affections  of,  in  progressive   muscular
    atrophy, 118, 133: in pseudo-hypertrophy of the
    muscles,  157, 165; in  tetanus, 330,  336, 340; in
    true muscular hypertrophy, 170; in  unilateral
    progressive atrophy  of the face, 62.
Musk in angina pectoris, 52; in hysteria, 565.
de Mussy, Gueneau, 393.

Nagel, 865,  867.
Narcotics in hemicrania, 26.
Nasse, 757.
Naumann, 84, 87.
Nawrocki,  354.
Nerves, peripheral, changes in, in chorea, 454.
Nervines in angina pectoris, 52.
Nervous symptoms in Basedow's disease, 85; system,
    changes in, in angina pectoris, 40;  in Basedow's
    disease, 87; in chorea, 447 ; in hysteria, 488; in
    progressive muscular atrophy,  135;  in pseudo-
    hypertrophy of  the  muscles,  107;  in tetanus,
    333; in etiology of epilepsy, 202,  216; injuries of,
    in etiology of epilepsy, 205.
 Nesemann, 113, 150.
 Neuralgia in hysteria, 498.
 Neurotic predisposition  in  etiology of  Basedow's dis-
    ease,   79;  in  etiology  of progressive muscular
    atrophy, 110.
 Newman,  863.
 Nicati, 17, 70. 
INDEX.
8s:
Nickel, sulphate of, in hemicrania, 25.
Nicotin in angina pectoris, 52.
NUpce, 114.
Nitzelnadel, 84, 86, 98.
Nothnagel, 34, 36, 49, 671, 679, 680, 712.
Nothnagel on Eclampsia, 299; on Epilepsy, 183.
Nunneley, 863.
Nutrition, disturbances of, in chorea, 440 ; in pseudo-
    hypertrophy of the muscles,  162;  impaired,  in
    etiology of epilepsy, 204.
Nysten, 333.

0BEB8TE1NEB, 249.
Odier, 272.
(Esophagus,  changes in, in tetanus, 337 ; paralysis of,
    in hysteria, 517.
Ogle, 39, 258,  347, 348, 409, 447, 449,  454, 466, 753,
    800.
Ogle, John, 722, 740.
Ogle, William, 722, 741, 748,  750, 774.
Oil, animal, of Dippel, in epilepsy, 294.
Ollivier, 84, 85, 86, 87, 88, 109, 334, 403,  404.
Onimus, 67, 391, 455, 457, 408.
Operative measures in treatment of mechanical im-
    pairments of speech, 800, 864 ; in tetanus, 361.
Opium in angina pectoris, 52;  in catalepsy, 382;  in
    chorea, 468; in epilepsy, 289 ; in hemicrania, 26;
    in hysteria, 500;  in  paralysis agitans, 409;  in
    tetanus,  362; in tremor, 393;  poisoning  by,  in
    etiology of tremor, 386.
Oppenheim,  599.
Oppenheimer, 109, 113, 135, 138.
Oppler, 21C.
Oppolzer, 39, 397, 404.
Ordenstein, 396, 400,  403.
Osborn, 788, 789.
Otto, 293, 069.
Oulmont, 393, 407.     t
Ovaries, pains in, in  hysteria, 501.
Owen, 640, 643.
Oxygen, inhalations of, in angina pectoris, 53.

Packabd, 458.
Paget, 863.
Pain, 82.
 Pain in angina pectoris,  37, 41; in chorea, 438;  in
    hemicrania, 10,18 ; in hysLeria, 491, 496 ; in pro-
    gressive muscular atrophy, 125; in pseudo-hyper-
    trophy of the muscles,  162 ; in tetanus, 345;  in
    etiology of epilepsy, 212.
Palate, changes in, in  unilateral progressive atrophy
    of the face, 63.
Panas, 73.
Panthel, 843.
Paralysis  Agitans, 395;  bibliography,  395;
    etiology,  396 ; symptoms and course, 397 ;  patho-
    logical anatomy and theory of the disease, 401;
    diagnosis, prognosis, and treatment, 405.
  Athetosis, 409 ; bibliography, 409; general descrip-
    tion, 409.
Paralyses following an epileptic seizure, 245 ; in hys-
    teria, 492,  516; in tetanus, 344;  of  bladder  in
    hysteria, 518; of extremities in hysteria, 518;  of
    muscles of oesophagus and pharynx in hysteria,
    517 ; of muscular system of bowels and  stomach
    in hysteria, 516 ; of vocal cords in hysteria, 517.
Parchappe, 808.
Pare, Ambrose, 316.
Pareira, 871.
Parkes, 233.
Parkinson, 396, 399, 401, 404, 405.
Parrot, 528, 728, 741.
Parry, 32, 83, 38, 39, 58, 60, 77, 357.
Parturition in etiology of eclampsia, 306; of hysteria,
    484 ; of tetanus, 327.
Passavant, 861.
Pathology.   See Different Diseases.
Paul, 85, 87, 88.
Peat, 322.
Pelletan, 4.
Pelzer, 671.
Pennock, 660.
Percival, 33.
Perigault, 435.
Perkins, 53.
Penes, 103.
Perroud, 753, 755, 774.
Peschel, Oscar, 587.
Peter, 80, 87, 89, 736, 756.
Petraeus, 403, 404.
Pettenkofer, 350.
Pfaefers, baths of, in tremor, 393.
Pfingsten, 874.
Pflueger,  67, 188, a38, 695.
Pharynx, changes  in, in tetanus, 337; paralysis of,
    in hysteria, 517 ; diseases of, in  etiology of deaf-
    mutism, 867.
Philipp, 39, 53.
Philipps,  842.
Phosphorus in epilepsy, 294.                >
Phymosis in etiology of epilepsy, 204.
Physostigmin in angina pectoris, 52.
Pica, 495.
Pick, 27.
Piorry, 4, 89, 95, 745.
Pissling, 329.
Pitha, 863.
Pleura, changes in, in tetanus, 336.
Pliny, 620.
Poett, 828.
Poisoning in etiology of tetanus, 329.
Poland, A., 320, 328, 356, 357. 
888
INDEX.
Pomme, 489.
de Ponce, Pedro, 871.
Pons, changes in, in epilepsy, 265.
Popham, 688, 737,  748.
Portal, 211,  213, 230, 272, 287.
Position of body in catalepsy, 372.
Potassium,  bromide of, in angina  pectoris,  53; in
    athetosis, 410 ; in chorea, 466 ;  in  epilepsy, 292;
    in hemicrania, 25;  in hysteria, 572 ;  in paralysis
    agitans, 400,  409; in tetanus, 363; iodide  of, in
    paralysis agitans, 408;  in progressive muscular
    atrophy, 149;  in pseudo-hypertrophy of the mus-
    cles,  174.
Powel, 422.
Prael, 82, 84.
Pregnancy in  etiology of chorea, 424;  of eclampsia;
    306; of hysteria, 484.
Preterre, 861.
Prevost,  93, 348
Prinz, 808.
Prochaska,  851.
Prognosis.  See Different Diseases.
Progressive Atrophy, Unilateral,  of Face.  See  under
    Unilateral Progressive Atrophy of Face.
Progressive Muscular Atrophy, 105; bib-
    liography, 105; history, 108; etiology, 110 ; symp-
    toms and course, 117 ; pathological anatomy, 133;
    theory of the disease, and analysis of symptoms,
    141; diagnosis and prognosis,  147 ;  treatment,
    148.
Prostate gland, diseases  of, in  etiology  of hysteria,
    485.
Proust, 600, 777.
Pseudo-Hypertrophy of the Muscles, 153;
    bibliography,  153 ;  history, 154;  etiology, 156;
    symptoms and course,  157 ; pathological anatomy,
    164;  theory of the disease,  and analysis of the
    symptoms, 169; diagnosis,  prognosis, and  treat-
    ment, 173.
Psychical causes of chorea, 424; of epilepsy, 211; of
    hysteria, 481, 485 ; disturbances in  chorea, 438 ;
    in epilepsy, 221; in hysteria, 495.
Puel, 374.
Pulse in angina  pectoris, 38;  in Basedow's disease,
    80, 94; in catalepsy, 374 ; in chorea, 436, 439; in
    epileptic  seizures, 229 ;  in hysteria,  523;  in te-
    tanus, 331, 347.
Pulvermacher, chain of, in paralysis agitans, 406.
Putzar, 062.
Pye-Smith, 422, 423, 433, 416, 740.
Pyrmont, waters  of,  in  Basedow's disease,  103; in
     hemicrania, 25.

 QuiNrNE in angina pectoris, 53; in  Basedow's disease,
     101 : in catalepsy,  382;  in epilepsy, 294 ; in hemi-
     crania, 23; in hysteria, 576 ; in progressive mus-
    cular atrophy, 149; in pseudo-hypertrophy of the
    muscles, 173:  in  tremor,  392;  in etiology of
    tremor, 386.

Rabejac, 86, 87, 88.
Race  in  etiology  of  deaf-mutism,  869; of tetanus,
    320.
Radcliffe, 204, 212, 228, 252, 282.
Ragatz, baths of, in tremor, 393.
Rainal, 321.
Rakowac, 162, 164, 166, 167.
Ramskill, 804.
Ranke, J., 336.
Ranvier, 88.
Reade, 135.
von Recklinghausen,  87, 135.
Reeves, 422, 437.
Reich, 872.
Reichert, 27, 199.
Reinerz, waters of, in hemicrania, 25.
Reith, 84, 87, 89.
Remak, 93,  109, 124, 125,  126, 127, 140, 150, 285,  404,
    406,  407, 408, 712.
Respiration  in angina pectoris, 37;  in  catalepsy,
    374; in hysteria,  514; in tetanus, 331, 346.
Reynolds, Russell, 68, 1S7, 188, 189,  198, 202, 211, 213,
    214,  222, 233, 235, 236, 245,  248, 251, 252, 253, 254,
    255,  256, 257, 262, 265, 272, 276,  278, 279, 285, 289,
    291,  401, 406, 407.
Reynoso, 233.
Reyher,  858.
Rheumatism in etiology of chorea, 425;  of progres-
    sive muscular atrophy, 113.
Richardson, 27.
Richter, 422, 423.
Richter, E. H., 116.
Rickets in etiology of epilepsy, 204.
Riegel, 197.
Rinecker, 154,  133.
Ring, 39.
Ritter, 39, 467.
Ritti, 454.
Roberts, 110, 111, 115,  117, 118.
Robin, 133.
Robison, 340.
Roche, 91.
Rockwell, 568.
Rodet, 114.
Roger, 426, 427, 445. 446.
 Rokitansky, 40, 334,  337, 449, 454, 457.
 Romberg, 4, 5, 19, 33, 52, 53, 58, 66, 68, 84, 108, 223.
     220, 227, 272, 282, 296,  338,  391,  424,  427,  436,
     443, 449, 454, 464, 489,  588,  647,  649,  676,  678,
     685, 837.
 Roosa, 807.
       '
 Roquette, 157,174. 
INDEX.
889
Rose, E., 318, 320, 322, 323,  324,  325, 326, 330, 335,
    342, 343, 344, 348, 355, 356, 357, 358.
Rosenberg, 78.
Rosenstein, 735.
Rosenthal. M., 29, 124, 126,  127,  128, 135, 140, 150,
    320, 328, 336, 371, 374, 3S0, 382, 402, 4U4, 418, 434,
    437, 456, 468, 655, 057, 658, 828, 835, 837. 839, 840.
Rostan, 721.
Rougier, 466.
Rougnon, 32
Rousse, 435.
Rubeola in etiology of deaf-mutism, 870.
Rufz, 422, 423, 425, 432, 443.
Rullier, 549.
Rush, 621.
Russel, 164,  166, 167, 170, 447, 454.
Russel, J., 467.
Russell, James, 428, 433.

Sachs, 637
Said, Mohamed, 435.
Saliva, increase  of, in hemicrania, 15.
Samt, 712, 717, 736.
 Samuel, 58,  59, 66, 67, 69.
Sandahl, 117
Sander, 224, 736, 769, 770, 774, 825.
Sanders, 385, 386, 392 397,  401, 744.
 Sanderson, 53, 680.
Sappey, 93
 Sauvage, 318.
 Sauvages, 4, 396.
 Savalle, 37.
 Scanzoni, 478, 479, 483, 484, 509.
 Scarlatina in etiology  of deaf-mutism, 870 ; of unila-
     teral progressive atrophy of the face, 59.
 Schaeffer, 417, 739.
 Schenkius, 620.
 Schepers, 801.
 Schidh, 32.
 Schiff, 67, 69, 90, 98,  146, 193, 194, 195, 198, 390, 711.
 Schirmann, 841.
 Schlemm, 686.
 Schlesinger, 157, 161, 164, 167, 172, 759, 801.
 Schlosser, 820.
 Schmalz,  E., 598,  792, 827, 831, 836, 849, 870, 872, 874,
     875.
 Schmidt,  633, 669, 772, 789.
 Schmucker, 325
 Schnee, 206.
 Schneevogt, 109, 115, 127, 135, 136, 139,140, 141.
 Schnitzler, 82.
 Schoeller, 337.
 Schoenlein, 4. 6.
 Sehrank,  828.
 Schreiber, J., 790.
 Schuchardt, 58, 59, 65, 67.
Schuele, 396, 061, 662.
Schueppel, 109, 115, 133, 135, 137.
Schuetzenberger, 501, 502.
Schulthess, 827, 833, 834, 936, 852, 855.
Schultz, A., 197.
Schwalbach, waters of, in Basedow's disease, 103; in
    hemicrania, 25.
Schwartz, 371, 377.
Scott, 793.
Scrofula in etiology of  epilepsy,  204 ; of pseudo-hy-
    pertrophy of the muscles, 157.
Seahouse, 427.
Secretion,  disturbances of, in hysteria, 523.
Sedillot, 424.
See, 396, 422, 423, 426, 432, 433, 443, 444, 446, 466.
Seeger, 468.
Seeligmueller, 70.
Seguin, E.  C, 731.
Seidel,  155, 156,157.
Selinum palustre in epilepsy, 294.
Senac,  39, 203.
Senator, 353, 354.
Sensation, disturbances of, in athetosis,  410;  in  cho-
    rea, 429,  438; in epilepsy. 222; in  hysteria,  491,
    495;   in  paralysis  agitans, 400;  in progressive
    muscular atrophy, 125 ;  in pseudo-hypertrophy of
    the muscles, 162 ; in tetanus, 345 ; in true muscu-
    lar hypertrophy, 177.
Sensory manifestations in the interparoxysmal  con-
    dition of epilepsy, 254.
Serres, 69.
Setschenow,  226, 267, 303, 379.
Sex in  etiology  of angina pectoris, 36; of Basedow's
    disease, 78; of catalepsy, 371; of chorea,  423 ; of
    deaf-mutism, 869;  of epilepsy, 214;  of hemicra-
    nia,  5; of  hysteria.  476;  of paralysis agitans,
    396; of  progressive muscular atrophy, 112;  of
     pseudo-hypertrophy of the muscles, 156 ;  of  teta-
     nus, 328; of tremor, 386 ; of unilateral progressive
     atrophy of  the face, 59.
 Sexual appetite, non-gratification of, in etiology of
     hysteria, 485.
 Sexual over-irritation in etiology of hysteria, 485.
 Shaking Palsy.  See under Paralysis Agitans.
I Shepherd, 801.
 Sicard, 598, 871.
 Sichel, 82, 91, 875.
 Sieckel, 428.
 Siegert, Ch., 360.
 Siemens,  123.
 Sieveking, 228, 233.
 Sigismund, Berth., 629, 648, 696.
 Silver, nitrate of, in angina pectoris, 53 ; in epilepsy,
     291 ;  in  hemicrania, 25 ; in hysteria, 565 ; in pa-
     ralysis agitans, 409 ; in  progressive muscular atro-
I     phy,  149. 
890
INDEX.
Simon, 422, 741, 743.
Simon, J., 109,141.
Simon, Th., 403, 404, 735, 740.
Simpson, 25, 742.
Skae, 737.
Skin, affections of,  in  Basedow's disease, 85, 86;  in
    unilateral progressive atrophy of the face, 60 ; in
    progressive muscular atrophy,  126;  in pseudo-
    hypertrophy of the muscles, 102 ;  in tetanus, 331,
    345 ; in true muscular hypertrophy, 178.
Skoda, 374, 402, 404, 405.
Skull, changes in, in epilepsy, 215.
Sleep, disturbances  of, in Basedow's  disease, 85; in
    hysteria, 534.
Sleeplessness in paralysis agitans, 409.
Sluis, 39.
Smell, disturbances of sense of, in hysteria, 497,  509.
Smith, 87, 101.
Smith, Adam,  581.
Smith, Lewis, 465.
Smoler, 382.
Snell, 027, 819,  S22.
Solbrig, 78, 79, 80, 216, 818.
Soltmann, 683, 698, 703.
Sommer, 333.
Somnambulism in hysteria, 534.
Spalding, 602.
Spamtr, 602, 755, 777, 778, 779.
Spasms, in the digestive canal in  hysteria, 511; of
    facial muscles in hysteria, 515 ; in organs of res-
    piration in hysteria, 514; in urinary and genera-
    tive organs in  hysteria,  515; in  vocal  muscular
    apparatus in hysteria, 514 ; in tetanus, 340.
Special senses,  disturbances of, in epilepsy, 224.
Speech,  Disturbances  of,  581;   human
    speech, 581; as an act of expression, 582 ; as an ac-
    quired reflex, 583; interjection and imitative ges-
    ture, 584 ;  the principle of sound metaphor, 588 ;
    origin of  speech from word-roots, 590 ;  intuition
    and intelligent conception, 593; the three stages of
    language,  595 ; speech as an agent of intelligent
    cognition, 596 ;  independence of conceptions upon
    words, 597 ; words  as symbols, 603 ;  definition of
    disturbances of speech, 610 ; speech a product of
    habit, 614 ; memory and recollection, 616 ; co-or-
    dination of movements,  621;  readiness of speech,
    625; development  of articulation, 629;  stammer-
    ing and stuttering, 633 ; sensory reflex sources of
    phonetic speech,  634;   acoustic sound reflexes,
    638; interjectional or  emotional speech,  612:
    automatic  speech, 646;  situation of the phonic
    centre, 650;  significance  of the  bulbar nuclei,
    655; bradylalia and scanning  utterance,  661 :
    stammering  and  stuttering,  663;  atactic and
    amnesic aphasia,  667;  aphasia  and diseases of
    cerebellum, 668;  channels traversed by speech; |
    impulses, 009; the corpora striata in relation to
    speech, 081; the corona radiata, 687 ; the sensory
    channels of language, 690 ; the excito motor fac-
    ulty, 693; the  existence  of  a spinal  soul, 695;
    percepto-motor  reflex  acts,  697;  development
    of the  mind,  703; functions of the cerebral cor-
    tex, 705; anatomy of the cerebral  cortex, 710;
    the  law of substitution, 713 ; cortical functions of
    speech, 717 ;  localization of the power  of speech,
    725; the two great classes  of cortical derange-
    ments of  speech, 747;  dysphasias and dysphra-
    sias, 749; atactic aphasia, agraphia,  and  ami-
    mia, 751; amnesic  aphasia,  757; aphasia  with
    more intense disturbances  of memory, 767 ; word-
    deafness, 770 ;  word-blindness, 775;  schematic
    diagram of the centres  and track of speech, 778 ;
    paraphasia, 783;  importance of  advertency for
    correct  speech, 785;  choreic  paraphasia,  787;
    paragraphia,  789;   syntactic  disturbances  of
    speech,  791; agrainmatismus, 793 ; akataphasia,
    795 ; aphasia as a disease, and its causes,  798 ;
    prognosis of  aphasia,  803;    syllable-stumbling,
    805; impairment of speech in progressive  paral-
    ysis with dementia,  809; dysological derange-
    ments  of  speech, 811;  hemming and  hawking,
    815; cluttering, 817;  delusions  of speech, 819;
    paraphrasia, 821;  perversions of speech in micro-
    cephalia, 822 ;  stuttering,  825 ; differential diag-
    nosis between stuttering  and  stammering, 837 ;
    treatment of stuttering,  839;  aphthongia, 842;
    stammering, its etiology,  844 ; sounds that are
    wanting in different  languages,  846; rhotacis-
    mus and pararhotacismus, 850; lambdacismus
    and paralambdacismus, 852;  gammacismus  and
    paragammacismus, 854; mechanical impairments,
    855; dyslalia laryngea, 856;  dyslalia nasalis et
    palatina,  858;  dyslalia lingualis, S62;  dyslalia
    dentalis, 864 ; dyslalia  labialis. 864; deaf-mutism
    and education of deaf-mutes,  865.
Speech,  disturbances  of, in angina  pectoris, 44; in
    chorea, 435 ; in unilateral progressive atrophy of
    the  face, 64.
Spencer, Herbert, 643.
Spielmann,  154, 628.
Spinal cord, changes in, in chorea, 449 ; in catalepsy,
    377  ; in hysteria, 488; in  paralysis agitans,  402 ;
    in tetanus, 333.
Spleen,  changes in, in tetanus, 336.
Spurzheim, 726.
Squills in epilepsy, 294.
Stafford, 323.
Stein, 144.
Steiner, 518, 422, 423, 427, 446, 450, 454, 457, 464, 465,
    466.
Steinthal, 587, 592,  594, 605, 608,  609, 624,  631, 6.32,
    722, 748, 795. 
INDEX.
891
Stellwag, 99.
Stewart, 740.
Stiebel, 437, 438, 441, 468.
StUling, 58, 65, 66, 67.
Stoerk, 858.
Stoetzner, H. E., 871.
Stoffella, 154, 155, 157, 401, 404.
Stokes, 4, 23, 33, 77, 78, 82, 87, 94, 95.
Stoll, 288.
L'tomach, paralysis of, in hysteria, 516.
Stramonium in epilepsy, 294 ; in hysteria, 565,
Stromeyer, 678.
Strychnia in chorea, 466;  in  epilepsy, 294;  in hemi
    crania, 25 ; in paralysis agitans, 408; in progres
    sive muscular atrophy, 149.
Struma in Basedow's disease, 81, 89.
St. Vitus' Dance.   See under Chorea.
St. Yves, 77.
Suchtschinsky, 46.
Suersen, 861.
Svynos, 510.
Swan, 336.
Swarzenski, 135, 138.
van Swieten, 108, 391, 396, 397.
Sydenham, 417, 461, 489, 551.
Symptomatology.  See Different Diseases.
Syphilis in etiology of progressive muscular atrophy,
    113.
Szokalsky, 506, 508.
S/.ontagh, 210.

Tait, L., 441.
Talma, 851.
Tanturri, 58, 61, 64.
Taste, disturbances  of  sense  of,  in hysteria,  497,
    509.
Tatum, 84.
Taylor, 95.
Tea in etiology of tremor, 386.
Teallier, 32.
Teissier, 84, 85.
Temperature of body in athetosis, 410 ;  in Basedow's
    disease, 85 ; in catalepsy, 374 ; in chorea, 440 ; in
    epilepsy, 232,  249 ; in  hemicrania, 12 ; in  paraly-
    sis agitans, 4u0 ; in progressive muscular atrophy,
    126; in pseudo-hypertrophy of the  muscles, 102 ;
    in tetanus, 331, 348.
Tenner, Ki, 21, 196, 197,198, 216.
Testa, 33.
Tetanus, 315;  bibliography,  315;  introduction,
    316; etiology, 319; general description of the dis-
    ease, 330; pathological anatomy, 333; pathoge-
    nesis, 337; analysis  of symptoms, 340;  processes
    of decomposition, 352 ; terminations and progno-
    sis, 355 ; diagnosis, 358 ; treatment, 360.
Tcuscher, 872.
Thamhayn, 320, 322, 324, 328, 338.
Theden, 288.
Thilenius, 418,  441.
Thirmaier, 434.
Thirst in tetanus, 354.
Thompson, H., 428.
Thyroid gland, changes in, in Basedow's disease, 81.
Tissot, 4, 6,  10,  204, 211, 212, 213, 226,  228, 230, 2S1,
 £ 283, 287.
Tobacco in tetanus, 363; in etiology of  angina pecto-
    ris, 36 ;  of tremor, 386.
Todd, 245, 447.
Tommasi, 453.
Tongue, changes in, in unilateral progressive atrophy
   /of the face, 63.
Tonics in  hysteria, 501.
Topinard, 400,  404.
Touch, changes in sense of, in hysteria, 497, 506.
Toynbee, 868.
Trance in hysteria, 534.
Traube, 34, 39, 87, 101.
Travers, 196, 323.
Treatment,   See Different Diseases.
Trembles, The.  See under Paralysis Agitans.
Trembling.   See under Tremor.
Tremor, 385; bibliography,  385;  etiology,  386;
    symptomatology and course, 387;  theory of the
    disease, 389; treatment, 392.
Trephining in epilepsy, 281.
Triboulet, 435.
Tripier, 730.
Troeltsch, 702.
Trousseau, 33, 77, 78, 79, 80, 82, 84, 85,  86, 87, 89, %,
    110, 111,  135, 140, 143, 190, 234, 236, 23S, 23!), 244,
    250, 289, 359, 396, 408,  427, 446, 466, 601, (508, 645,
    077, 721,  722, 720, 736, 751, 753, 766, 767, 769, 777,
    786, 801,  804, 814, 820.
True Muscular Hypertrophy,  175; bibli-
    ography,  175;  etiology, 175;  symptomatology,
    176; theory of the disease, 178.
Tscharner, 345.
Tuckwell, 430, 442, 447, 448, 449, 451, 457, 458.
TuefEerd,  155.
Tuerck, 135,  138, 674.
Tulpius, 434.
Turnbull, 466.
Turpentine in epilepsy,  294 ; in hemicrania, 25.
Twisleton, Edw., 863.
Tylor, 586, 597, 605, 636, 792, 846, 847.
Tympanites in hysteria, 516.
Typhoid fever,  in  etiology  of  progressive muscular
    atrophy, 113 ;  of tremor, 386.
Typhus fever, in etiology of deaf-mutism, 870.

Uhde, 155, 174.
UUersperger, 48. 
DEX.
892                                          ini

Ullmann, 801.
Umbilical cord, falling off of, in etiology of  tetanus,
    320.
Unilateral   Progressive Atrophy of the
    Pace, 57; bibliography,  57;  history, 58; etiol-
    ogy, 59; symptomatology and  course, 60 ; analy-
    sis of the symptoms, 64; vaso-motor and trophic
    theory,  65; implication of the trigeminus, 67; im-
    plication of the facial nerve, 69; implicationapf
    the  cervical sympathetic,  70 ;  theory of Lande,
    71;  diagnosis and prognosis, 72 ; treatment, 74.
Urethra, diseases of, in etiology of hysteria, 485; pain
    in, in hysteria, 503.
Urinary organs, spasms in, in hysteria, 515.
Urine, changes in, in chorea,  441; in epilepsy, 233;
    in hysteria, 529; in progressive muscular atrophy,
    128; in tetanus, 352.
Uterine secretion, increase of, in hysteria, 530.
Uterus, pain in, in hysteria, 503.
Uwins, 424.

Vaccination in etiology of progressive muscular atro-
    phy, 114.
Vaginal secretion, increase of,  in hysteria, 530.
Valentiner,  109, 133, 135, 144,  501, 504, 506, 528,
    564.
Valerian in angina  pectoris, 52 : in  chorea,  465 ;  in
    epilepsy, 287, 290; in hysteria,  565.
Valleix, 4, 10.
Vallin, 843, 844.
Vascularity,  abnormal, of female  genital  organs  in
    etiology of  hysteria, 483.
Veghelm, 441.
Velpeau, 730.
Venereal excesses in  etiology of  epilepsy, 203;  of
    progressive muscular atrophy, 113;  of  tremor,
    386.
Veratria in angina pectoris, 52 ; in  Basedow's disease,
    101; in hemicrania, 27.
Verdalle, 467.
Verdelli, 669.
Vertebrae, changes in,  in epilepsy, 216.
Veytisiere, 672, 674.
Vigla,  115.
Villemin, 406, 408
Violette, 828.
Virchow, 87, 88, 89, 90, 135, 138, 140,  143.
Vivent. 737.
Vocal cords, absence of, in deafcmutism, 867; paraly-
    sis of, in  hysteria, 517;   vocal muscles, spasms
    in, in hysteria, 514.
Vogel, 27.
Vogel, A., 346,  353.
Vogt, C, 738, 741.
Vogt, P., 25.
Voice, disturbances of, in hysteria,  514.
Voisin, 115, 127, 146, 231, 232, 277, 290, 298,  782, 736,
    740, 815.
Voit, 350, 354.
Volkmann, 391, 459.
Volkmann, B., 391.
Voltolini, 867.
Vomiting in angina pectoris, 44; in  Basedow's dis-
    ease, 85.
Vulpian, 67, 135,  193, 392, 639, 660, 672, 676, 696, 706,
    731, 741.

Wachsmuth, 113, 118, 133.
Wadham, 740.
Wagner, 156.
Wagner, B., 391.
Wagner, E., 434.
Wagner, R., 92, 822.
Wakefulness in hysteria, 534.
Walcher, 381
Waldeck, 39.
Waldenburg, 600, 802.
Wallis, John,  871.
Ward, 340.
Water-cures in epilepsy, 284.
Waters, Mineral.   See Mineral Waters.
Water-treatment in chorea,  465, 468.
Watson, 336, 447.
Watson Thos., 646.
Weber, Friedr., 42S.
Weber, Otto, 863.
Wedemeyer, 333.
Weiss, 67.
Wendt, 424.
Wenzel, Bodo, 418, 427, 428, 444.
Wepfer, 4
Wernich, 25, 157, 164, 165, 306.
Wernicke, 303, 304, 736, 744, 773, 774, 775, 778, 779.
Wertner, 799.
Westphal,  191, 194,  195, 207, 208, 209, 210,  232, 241,
    250, 602, 664, 756, 776, 783, 809, 814.
Whooping-cough  in etiology of unilateral progressive
    atrophy of the face, 59.
Whytt, 357.
Wicke, 238, 417, 418, 432, 441, 412, 443, 445.
Wickman, 417.
Wiedemeistcr. 799.
Wilhelm, 375.
Wilks, 24, 39,  87,  88, 144, 453, 657, 739.
Williams, 232.
Willis, 10.
Winslow, Forbes, 758, 768, 798.
Wittmaack, 53.
Woakes, 25.
Woeltge, 432.
Wolff, 52.
Wood, 27, 53. 
INDEX.
893
Wormwood in epilepsy, 288.
Wounds, conditions of, in etiology of tetanus, 322.
Wright, 363.
Wunderlich, 333, 334, 337, 343, 344, 346, 348, 351, 352,
    357, 549, 550.
Wundt, 596, 624, 638, 653, 667, 670, 706.
Wyneken, 828, 829, 831, 833, 834, 835, 840, 841.
Wysocki, 418.
Zenkeb, W., 807, 809, 810.
von Ziemssen, 67, 326, 349,  390.
von Ziemssen, on Chorea, 413.
Zillner, 824.
Zinc, oxide of, in chorea, 465; in epilepsy, 290;  phos-
    phide of,  in  tremor, 393; sulphate of, in angina
    pectoris, 53; in chorea, 465; valerianate of, in
    hysteria, 565.
Yearsley, James, 842. 
 
 
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