Figure 1.
US Army Surgeon General William Hammond During the US Civil War.
This is a wood engraving that originally appeared in Harper’s Weekly on November 21, 1863 (volume 7, p. 748). Hammond described athetosis in 1871.3
Figure 2.
Pioneers in Electrotherapeutics.
Electrotherapeutics regained legitimacy in the 1850s with the work of Guillaume-Benjamin-Amand Duchenne de Boulogne in France (left) and Robert Remak in Germany (right).50–52 Engravings courtesy of the U.S. National Library of Medicine.
Figure 3.
Galvanic Apparatus.
From left to right: Emil Stöhrer’s zinc–carbon (or zinc–platinum) battery, universal electrode handle with ivory interrupter, metallic electrodes of various sizes, and sponge electrode with long handle. Stöhrer (1813–1890) was a noted scientific instrument maker, who established a shop in Dresden specifically for electrotherapeutic equipment. Figure source: Beard & Rockwell, 1871.48
Figure 4.
British Neurologist Sir William Gowers.
Gowers performed a protracted series of galvanic treatments for athetosis.27 Courtesy of the U.S. National Library of Medicine.
Figure 5.
Pioneers of Therapeutic Nerve Stretching.
Therapeutic nerve stretching originated with the work of Prussian-born Austrian surgeon Theodor Billroth (left) and German surgeon Johann Nepomuk von Nussbaum (right).55–57 In 1872 Billroth had argued that surgical manipulation of a nerve was responsible for the relief of sciatica when no compressive lesion was identified at surgery. Subsequently, Nussbaum intentionally stretched the brachial plexus as a therapeutic procedure with reportedly symptomatic improvement. Courtesy of the U.S. National Library of Medicine.
Figure 6.
British Neurosurgeon Sir Victor Horsley.
Horsley performed histological studies of nerve stretching and also of neocortical resection of the precentral gyrus for athetosis.56, 68, 71 In patients with athetosis, both procedures substituted paresis for the abnormal movements. Courtesy of the U.S. National Library of Medicine.
Figure 7.
Histology of Nerve Stretching.
Longitudinal and cross-sectional drawings of an unstretched nerve (A) and a stretched nerve (B) as drawn from specimens obtained by British neurosurgeon Victor Horsley. Figure source: Marshall, 1883.56
Figure 8.
Philadelphia Neurosurgeon William Williams Keen in 1905.
Photograph by R.M. Lindsey. Courtesy of the U.S. National Library of Medicine.
Figure 9.
Excision of the Precentral Gyrus for Athetosis.
Sketches by British neurosurgeon Victor Horsley of the operative field and surgical pathology in a 14-year-old boy with athetosis who underwent excision of the right precentral gyrus in 1908. Far left is the operative field, showing the cut edge of bone. The central sulcus passes in front of (i.e., to the right of) G. Numbers indicate cortical locations that were electrically stimulated. Center illustration is the outline of the removed portion of the precentral gyrus, with notations indicating the motor response to electrical stimulation during surgery: e.e., elbow extension; w.e., wrist extension; w.f., wrist flexion; ul. Ad., ulnar adduction; f.f., finger flexion. Right illustration is a photograph of the excised precentral gyrus after fixation in formalin. The scale at right is in centimeters and millimeters. Figure source: Horsley, 1909.71
Figure 10.
Post-operative Photographs of the Left Arm of Horsley’s Patient After Resection of the Right Precentral Gyrus.
The top photograph shows “‘Voluntary’ movement of the left upper limb in placing the hand on the iliac crest.” The middle photograph shows “‘Voluntary’ flexion of elbow and abduction of shoulder. Fingers continuing to slowly flex.” The bottom photograph shows “Forcible voluntary abduction and extension of limb, showing the effort causes contracture of the digits.” Figure source: Horsley, 1909.71
Figure 11.
Post-operative Photographs of the Left hand of Horsley’s Patient after Resection of the Right Precentral Gyrus.
The top photograph shows the extent of voluntary extension of the fingers. The bottom photograph shows the extent of voluntary flexion of the fingers. Contractures of the fourth and fifth digits are not visible. A prominent wrist drop is evident. Figure source: Horsley, 1909.71
Figure 12.
New York Neurologist Charles Loomis Dana.
Dana proposed posterior rhizotomy, later called “Dana’s operation,” in 1888.65 Courtesy of the U.S. National Library of Medicine.
Figure 13.
New York Surgeon Robert Abbe.
Abbe performed the posterior rhizotomy procedure (Dana's operation) in a patient with athetosis. Photograph from Notable New Yorkers: 1896–1899 (1899) by Moses King.
Figure 14.
Surgical Field During Posterior Rhizotomy.
Figure source: Abbe, 1911.65
Figure 15.
Philadelphia Neurosurgeon Charles Harrison Frazier.
Frazier worked with neuropathologist and neurologist William Gibson Spiller on several neurosurgical procedures for athetosis, including posterior rhizotomy and nerve “transplantation” (i.e., neurotomy and nerve-to-nerve anastomosis).64, 72, 73, 76, 77 Etching by Erwin F. Faber. Courtesy of the U.S. National Library of Medicine.
Figure 16.
Spiller and Frazier’s Approach to Peripheral Nerve “Transplantation.”
This procedure combined section of motor nerves and various modes of nerve-to-nerve anastomosis. In the diagram, A represents the “unaffected” nerve and B represents the “affected” nerve. Spiller advocated these techniques to modulate the activity of the specific motor nerves that were felt most involved in the expression of athetosis in a given patient. Figure source: From Spiller, Frazier, and Van Kaathoven, 1905.64
Figure 17.
Nerve-to-Nerve Anastomoses after the First Procedure.
The specific nerve anastomoses performed by Charles Harrison Frazier on the patient's left arm. Figure source: Spiller, Frazier, and Van Kaathoven, 1905.64
Figure 18.
Nerve-to-Nerve Anastomoses after the Second Procedure.
The specific nerve anastomoses performed by Frazier on the patient’s left arm. Figure source: Spiller, Frazier, and Van Kaathoven, 1905.64
Figure 19.
Postoperative Photographs After a Series of Sequential Nerve Section Procedures and Nerve-to-Nerve Anastomoses.
This young man with bilateral athetosis was treated around 1905 at the University of Pennsylvania by neurologist William Spiller, and surgeons Charles Harrison Frazier and J.J.A. Van Kaathoven. The left-most photograph shows paralysis of the left upper extremity immediately after the patient’s first operation, and marked residual athetotic movements of the non-operated right side. The middle column shows some recovery of motor power of the left arm 120 days post surgery, with limited flexion at the elbow (top), wrist (middle), and fingers (bottom). The right column shows the patient’s ability to move the left upper extremity about 9 months after surgery, raising the arm at the shoulder and flexing at the elbow (top), flexing the fingers (second from top), and extending the fingers (third and fourth photographs). Figure source: Spiller, Frazier, and Van Kaathoven, 1905.64
Figure 20.
Colonel Nathaniel Allison in 1919.
As an orthopedic surgeon at Washington University in St. Louis, Allison had used “muscle group isolation” (alcohol neurolysis) for athetosis and spasticity in a series of studies with Sidney L. Schwab (1871–1947), Professor of Nervous and Mental Diseases at St. Louis University.78–81 Courtesy of the U.S. National Library of Medicine.