S E M I N A R S I N NEUR0LOC;Y-VOLUME
11, N O . 2 JUNE 1991
HISTORICAL NOTES
Gower's Sign
In his Preface to this issue, Orrin Devinsky mentions the book Borderland of Epilepsy by Sir William Richard Gowers (1845-1915), a practitioner of medicine who became a leader in clinical neurology.' According to Kalinowsky, it was not Gowers but Bastian who, in 1867, first described "a degenerating tract in the spinal cord, which from 1880 on, however, became known as 'Gowers' tract' [or column. Italics mine.] Gowers did not appreciate the distinction for he was averse to eponymic designation~."~ Appreciative or not, Gowers came to be linked by name, in addition, to a s i g ~of~ hip-extensor weakness (alternatively characterized as a maneuver that permits persons with such proximal weakness to move from a lying to an erect position); another sign or test: pain of sciatica produced by passive dorsiflexion of the foot when the leg has been raised with the knee straight; a dzstul form of muscular dystrophy (or myopathy); a localized panatrophy, with wasting of all subcutaneous tissues; and a mixture useful for the treatment of migraine, which Walton considered efficacious, if "old-fashioned," and for which he gave the formula in a fairly recent edition of his textbook of neurology.9tedman's Medical Dictionary, 21st edition, also associates a contraction with the name of Gowers, defining it as a "front-tap contraction," or a "contraction of the calf muscles when the anterior surface of the leg is struck." (I can't imagine what it signifies; I hope someone will let me know.) Stedman's adds further mystery with Gowers' disease, which has two definitions: "(1) saltatory spasm; (2) pseudohypertrophic paralysis." His syndrome is "paroxysmal attacks of vasovagal syncope." (In case you are worried, I have no intention of pursuing any of these subjects further.) Since many, at least, of thzse observations by Gowers are highly regarded, I have not been surlgO prised to discover that, in many carefully prepared
textbooks, another person has attempted t o attach his or her name to almost all of them.'-"' To understand what I mean, please refer to References 4 through 20, which constitute a list, alphabetically arranged, of textbooks readily available to me for inspection; I am certain that the list is not complete. What all of them have in common is reference to the name "Gower." When I write "his or her name" with regard to Gower, this textbook person whom we cannot identify from biographical material but whose name has often appeared in the neurologic literature, I do so out of ignorance, no first name being available to help to establish gender. Other examples that lend additional importance to this name-substitution problem are easy to find. Examples in which the name is similar enough to the name of a famous physician to tieceive the unwary are found in the eponyms Gra\-e's disease, Hodgkins' disease, and Wilm's tumor, all of which appear in print regularly in reputable books, although the frequency varies, as expected, with the frequency of the more familiar name. I n Sir Roger Bannister's textbook," for instance, along with the rather common "Grave's disease," just mentioned, there is a textual insertion, with accompanying index citation, for "Uithoff's sign,"22 with a description of the phenomenon most often connected with the name of the German ophthalmologist Uhthoff. I believe that there is more than a superficial explanation for what is going on here, and that that is why efforts to get rid of the problem at the lexical level have failed. Recall that, during a portion of his editorship of Neurology, Lewis Rowland decreed or at least endorsed removing the possessive ending from all eponyms, leaving the reader with Bell palsy and other unfamiliar-sounding designations. I was happy to see the possessives return, but they do cause trouble; those who accept
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
David Goldblatt, M . D.
the "obvious" explanation for Gower's sign and Grave's disease will say that, if we had stayed with Gowers sign and Graves disease, we would be better off. I debated against that viewpoint in my first essay tor this journal, pointing out that Milkman syndrome, for instance, distracts the reader into thinking of alternative meanings.':' Another approach to the Gower's problem might be to accustom our ears to "Gowers's." 1 fbund that construction only once in the textbooks I surveyed," even though the gods of grammar long ago ordained it. Strunk and White's very first "elementary rule of usage" states, "Form the possessive singular of nouns by adding 's. Follo~lthis rule whatever the final collsonant."'"'Burns's poer-ns" is an example that they give. 1 have already hinted at my own conclusion about what is going on, but I never found an arcane explanation cornpelling until an "insertion" took place into one of my own papers. I wrote an article about Bayard Taylor Hortonahhat began with two quotations from his writings. When the article appeared in print, I was flabbergasted to find the name "T.H. Horton" attached to each of the quotations. (This was not his younger son, Thomas, but truly an unknown person.) Since I would never make such a mistake in the first place, and since if I did my copy editor would catch it, 1 have now concluded, after lengthy reflection, that there has to be an occult explanation. 1 was so embarrassed about it at first, when I thought it was just an oversight for which I would have to take responsibility, that I even wrote another article about Dr. Horton to try to make u p for my error. Now I see the second article more as exorcism than as expiation. It has not come out yet, and I can only cross my finger^.^' Gowers, who had more than his share of eponyms, could be disdainful of them if' he liked. Not everyone feels that way. Stedman's dictionary lists Goldblatt's clamp, hypertension, kidney, and phenomenon; I am glad that those terms provide one way of keeping my father's name alive, even if they hardly serve to epitomize his admirable qualities." But what about the many scientists and clinicians who have made important original contributions but whose names are not immortalized in the fashion that is under consideration in this essay? (I should give an example, but a name does not readily come to mind.) My chagrin when I first discovered the name of an unknown person in my article about Dr. Horton has been replaced, now, by this conviction: in some manner over which even the most careful authors, editors, and publishers can exert n o control whatever, departed persons whose names we have
neglected o r forgotten are responsible for creating a special kind of typographical error. 1 believe that we will never succeed fully in understanding this occurrence until we gain more understanding of their world and their motivations. They are, as St. Thomas said of the unborn, "not known to men.""' Gower, then, may be a name o r a pseudonym. Could it be a pseudonym for Charlton Bastian? Could his shade, mischievously o r even maliciously, be causing the words "Gower's sign" to occur so many times in scientific articles and scholarly texts? Rernernber that Bastian deserves to be recognized for the first description of "Gowers'" anterior spinocerebellar tract.' Bastian entered the spirit world just half a year after Gowers-in this important respect, Gowers was first-and it would be worth the time of someone even more pedantic than I am to discover when Gower's sign first appeared in print. In terms of motivation for the behavior that I suspect is occurring, it is relevant to note that Bastian preceded Wernicke in describing "Wernicke's" aphasia,' and that his own eponym (Bastian's Law) has been forgotten: "He was the first to show [1890] that in total transverse lesions of the upper spinal cord the reflexes below the level of the lesion are abolished and muscle tone is lost (Bastian's Law)."' Yet we know that standard accounts of spinal shock pass directly from Marshall Hall's report in 1850 to Von Monakow and Sherrington in the early years of this century, completely circumventing the Law. Another candidate for instituting an invidious, incorporeal act against Gowers might be Duchenne d e B ~ u l o g n e , " ~since ) pseudohypertrophic muscular paralysis was Duchenne's before it was Gowers' disease. Because the world (of men) knows that fact, however, n o extraordinary cffort on the part of the defunct Duchenne would seem to be needed."' I contend that considerations of this sort are not trivial. They are proper for someone who lives in a democracy. Fair and equitable distribution is involved. If the dead deserve fair treatment, so, too, d o the living, of course, and I can give an example of a growing problem for us as well: there has recently been a burgeoning of popular attention to cases of multiple personality, accompanied by an increasing scientific literature. What was once a rarity has become a commonplace. Moreover, those individuals who possess more than one personality seem to be vying for the largest number, and cases in which hundreds of personalities occupy one body are being recognized. You should be concerned about this. Where d o these people leave the rest of us? How marly people d o you know who have no personality? Do
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
HISI'OKICAI, NOTES
191
I need to spell this out? I leave you to draw your own inferences. I will now summarize the main contention of this article in a poem, with a familiar poet as ghostwriter. I am deliberately not stating his name, as a little experiment: if all of my punctuation survives the publishing process unaltered, I will know that he is not upset. I wish all of his companions felt that way. Gower's Sign In many a text (or its index, Where a work has often gone sour) Comes a flaw in a book's composition That I know as the Sign of Gower. I should quote the mistake verbatim: O n the actual faulty line (Or in Legend o r citation) It appears as "Gower's sign." You will find it in books from Macmillan; Raven Press; and Little, Brown. Williams and Wilkins, and Saunders, And Davis have fallen down, Along with Butterworth, Oxford, And Appleton and Lange, Harper and Row, C.C; 'Thomas, and the Year Book Medical gang. You may think it a venial error Of the most forgivable sort: It just leaves Sir William Gowers Sitting a letter short. That's some reason to expunge itBut the effort will be in vain! And, rising like the phoenix, It will appear again. It's a message-not a typo. Let's accept it; let's be brave. Let us reinterpret "Grave's disease" As a message from the grave. If you fully understand me (If you share this belief of mine) It's "a feather . . wafted downward" T h a t is truly "Gower's sign."
REFERENCES 1. C;ritchley M. Sir William Gowers 1845-1915. .4 biographical appreciation. London: Heinemann Medical Books, I949 2. Kalinowsky LB. Henry Charlton Bastian (1837-1915). In: Hayniaker W, Schiller F, eds: T h e founders of neurology, 2nd ed. Springfield, 11.: Charles C; Thomas, 1970:405-7 3. Walton.JN. Esserttials of neurology, 3rd ed. Philadelphia: J B Lippincott, 197 1:432 4. Alpers K j , Mancall EL. Cliriical neurology, 6th ed. Philadelphia: FA I)avis, 197 1:889 Gower's [sciatic] sign
VOI.UME 11, NUMBER 2 JUNE 1991
5. llradley W(;, I)aroffKB, Fenichel (;M, Marsden 77:36 (;ower9s sign, 37
11, N O . 2 JUNE 1991
HISTORICAL NOTES
Gower's Sign
In his Preface to this issue, Orrin Devinsky mentions the book Borderland of Epilepsy by Sir William Richard Gowers (1845-1915), a practitioner of medicine who became a leader in clinical neurology.' According to Kalinowsky, it was not Gowers but Bastian who, in 1867, first described "a degenerating tract in the spinal cord, which from 1880 on, however, became known as 'Gowers' tract' [or column. Italics mine.] Gowers did not appreciate the distinction for he was averse to eponymic designation~."~ Appreciative or not, Gowers came to be linked by name, in addition, to a s i g ~of~ hip-extensor weakness (alternatively characterized as a maneuver that permits persons with such proximal weakness to move from a lying to an erect position); another sign or test: pain of sciatica produced by passive dorsiflexion of the foot when the leg has been raised with the knee straight; a dzstul form of muscular dystrophy (or myopathy); a localized panatrophy, with wasting of all subcutaneous tissues; and a mixture useful for the treatment of migraine, which Walton considered efficacious, if "old-fashioned," and for which he gave the formula in a fairly recent edition of his textbook of neurology.9tedman's Medical Dictionary, 21st edition, also associates a contraction with the name of Gowers, defining it as a "front-tap contraction," or a "contraction of the calf muscles when the anterior surface of the leg is struck." (I can't imagine what it signifies; I hope someone will let me know.) Stedman's adds further mystery with Gowers' disease, which has two definitions: "(1) saltatory spasm; (2) pseudohypertrophic paralysis." His syndrome is "paroxysmal attacks of vasovagal syncope." (In case you are worried, I have no intention of pursuing any of these subjects further.) Since many, at least, of thzse observations by Gowers are highly regarded, I have not been surlgO prised to discover that, in many carefully prepared
textbooks, another person has attempted t o attach his or her name to almost all of them.'-"' To understand what I mean, please refer to References 4 through 20, which constitute a list, alphabetically arranged, of textbooks readily available to me for inspection; I am certain that the list is not complete. What all of them have in common is reference to the name "Gower." When I write "his or her name" with regard to Gower, this textbook person whom we cannot identify from biographical material but whose name has often appeared in the neurologic literature, I do so out of ignorance, no first name being available to help to establish gender. Other examples that lend additional importance to this name-substitution problem are easy to find. Examples in which the name is similar enough to the name of a famous physician to tieceive the unwary are found in the eponyms Gra\-e's disease, Hodgkins' disease, and Wilm's tumor, all of which appear in print regularly in reputable books, although the frequency varies, as expected, with the frequency of the more familiar name. I n Sir Roger Bannister's textbook," for instance, along with the rather common "Grave's disease," just mentioned, there is a textual insertion, with accompanying index citation, for "Uithoff's sign,"22 with a description of the phenomenon most often connected with the name of the German ophthalmologist Uhthoff. I believe that there is more than a superficial explanation for what is going on here, and that that is why efforts to get rid of the problem at the lexical level have failed. Recall that, during a portion of his editorship of Neurology, Lewis Rowland decreed or at least endorsed removing the possessive ending from all eponyms, leaving the reader with Bell palsy and other unfamiliar-sounding designations. I was happy to see the possessives return, but they do cause trouble; those who accept
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
David Goldblatt, M . D.
the "obvious" explanation for Gower's sign and Grave's disease will say that, if we had stayed with Gowers sign and Graves disease, we would be better off. I debated against that viewpoint in my first essay tor this journal, pointing out that Milkman syndrome, for instance, distracts the reader into thinking of alternative meanings.':' Another approach to the Gower's problem might be to accustom our ears to "Gowers's." 1 fbund that construction only once in the textbooks I surveyed," even though the gods of grammar long ago ordained it. Strunk and White's very first "elementary rule of usage" states, "Form the possessive singular of nouns by adding 's. Follo~lthis rule whatever the final collsonant."'"'Burns's poer-ns" is an example that they give. 1 have already hinted at my own conclusion about what is going on, but I never found an arcane explanation cornpelling until an "insertion" took place into one of my own papers. I wrote an article about Bayard Taylor Hortonahhat began with two quotations from his writings. When the article appeared in print, I was flabbergasted to find the name "T.H. Horton" attached to each of the quotations. (This was not his younger son, Thomas, but truly an unknown person.) Since I would never make such a mistake in the first place, and since if I did my copy editor would catch it, 1 have now concluded, after lengthy reflection, that there has to be an occult explanation. 1 was so embarrassed about it at first, when I thought it was just an oversight for which I would have to take responsibility, that I even wrote another article about Dr. Horton to try to make u p for my error. Now I see the second article more as exorcism than as expiation. It has not come out yet, and I can only cross my finger^.^' Gowers, who had more than his share of eponyms, could be disdainful of them if' he liked. Not everyone feels that way. Stedman's dictionary lists Goldblatt's clamp, hypertension, kidney, and phenomenon; I am glad that those terms provide one way of keeping my father's name alive, even if they hardly serve to epitomize his admirable qualities." But what about the many scientists and clinicians who have made important original contributions but whose names are not immortalized in the fashion that is under consideration in this essay? (I should give an example, but a name does not readily come to mind.) My chagrin when I first discovered the name of an unknown person in my article about Dr. Horton has been replaced, now, by this conviction: in some manner over which even the most careful authors, editors, and publishers can exert n o control whatever, departed persons whose names we have
neglected o r forgotten are responsible for creating a special kind of typographical error. 1 believe that we will never succeed fully in understanding this occurrence until we gain more understanding of their world and their motivations. They are, as St. Thomas said of the unborn, "not known to men.""' Gower, then, may be a name o r a pseudonym. Could it be a pseudonym for Charlton Bastian? Could his shade, mischievously o r even maliciously, be causing the words "Gower's sign" to occur so many times in scientific articles and scholarly texts? Rernernber that Bastian deserves to be recognized for the first description of "Gowers'" anterior spinocerebellar tract.' Bastian entered the spirit world just half a year after Gowers-in this important respect, Gowers was first-and it would be worth the time of someone even more pedantic than I am to discover when Gower's sign first appeared in print. In terms of motivation for the behavior that I suspect is occurring, it is relevant to note that Bastian preceded Wernicke in describing "Wernicke's" aphasia,' and that his own eponym (Bastian's Law) has been forgotten: "He was the first to show [1890] that in total transverse lesions of the upper spinal cord the reflexes below the level of the lesion are abolished and muscle tone is lost (Bastian's Law)."' Yet we know that standard accounts of spinal shock pass directly from Marshall Hall's report in 1850 to Von Monakow and Sherrington in the early years of this century, completely circumventing the Law. Another candidate for instituting an invidious, incorporeal act against Gowers might be Duchenne d e B ~ u l o g n e , " ~since ) pseudohypertrophic muscular paralysis was Duchenne's before it was Gowers' disease. Because the world (of men) knows that fact, however, n o extraordinary cffort on the part of the defunct Duchenne would seem to be needed."' I contend that considerations of this sort are not trivial. They are proper for someone who lives in a democracy. Fair and equitable distribution is involved. If the dead deserve fair treatment, so, too, d o the living, of course, and I can give an example of a growing problem for us as well: there has recently been a burgeoning of popular attention to cases of multiple personality, accompanied by an increasing scientific literature. What was once a rarity has become a commonplace. Moreover, those individuals who possess more than one personality seem to be vying for the largest number, and cases in which hundreds of personalities occupy one body are being recognized. You should be concerned about this. Where d o these people leave the rest of us? How marly people d o you know who have no personality? Do
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
HISI'OKICAI, NOTES
191
I need to spell this out? I leave you to draw your own inferences. I will now summarize the main contention of this article in a poem, with a familiar poet as ghostwriter. I am deliberately not stating his name, as a little experiment: if all of my punctuation survives the publishing process unaltered, I will know that he is not upset. I wish all of his companions felt that way. Gower's Sign In many a text (or its index, Where a work has often gone sour) Comes a flaw in a book's composition That I know as the Sign of Gower. I should quote the mistake verbatim: O n the actual faulty line (Or in Legend o r citation) It appears as "Gower's sign." You will find it in books from Macmillan; Raven Press; and Little, Brown. Williams and Wilkins, and Saunders, And Davis have fallen down, Along with Butterworth, Oxford, And Appleton and Lange, Harper and Row, C.C; 'Thomas, and the Year Book Medical gang. You may think it a venial error Of the most forgivable sort: It just leaves Sir William Gowers Sitting a letter short. That's some reason to expunge itBut the effort will be in vain! And, rising like the phoenix, It will appear again. It's a message-not a typo. Let's accept it; let's be brave. Let us reinterpret "Grave's disease" As a message from the grave. If you fully understand me (If you share this belief of mine) It's "a feather . . wafted downward" T h a t is truly "Gower's sign."
REFERENCES 1. C;ritchley M. Sir William Gowers 1845-1915. .4 biographical appreciation. London: Heinemann Medical Books, I949 2. Kalinowsky LB. Henry Charlton Bastian (1837-1915). In: Hayniaker W, Schiller F, eds: T h e founders of neurology, 2nd ed. Springfield, 11.: Charles C; Thomas, 1970:405-7 3. Walton.JN. Esserttials of neurology, 3rd ed. Philadelphia: J B Lippincott, 197 1:432 4. Alpers K j , Mancall EL. Cliriical neurology, 6th ed. Philadelphia: FA I)avis, 197 1:889 Gower's [sciatic] sign
VOI.UME 11, NUMBER 2 JUNE 1991
5. llradley W(;, I)aroffKB, Fenichel (;M, Marsden 77:36 (;ower9s sign, 37
