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OCT  10 1964 
 
CLINICAL LESSONS
ON
NERVOUS DISEASES
           BY

 S. WEIR MITCHELL, M.D., LL.D. Edin.
    MEMBER OF THE^WflONAL ACADEMY OF SCIENCES ;
HONORARY FELLOW OF THE EOYAL MEDICO-CHIRURGICAL SOCIETY OF LONDON
  LEA BROTHERS & CO.
PHILADELPHIA AND NEW YORK
       1897 
4
\AG8Zc
 \8ej
 Entered according to the Act of Congress, in the year 1897, by

             LEA BROTHERS & CO.,

In the Office of the Librarian of Congress. All rights reserved.
DORNAN PRINTER. 
PREFACE.
   I  take  this opportunity to thank  my clinical
aids, Drs. John  Madison Taylor,  C. W. Burr, Guy
Hinsdale, John  K. Mitchell, John  H. Rhein,  F. S.
Pearce,  A.  A.  Escliner, aud F. W. Talley for the
careful personal  study given to the cases in  this little
book  and for whatever consequent value they may
have.   I am also indebted to Dr.  John  Madison
Taylor for the representations of erythromelalgia and
for the  other illustrative drawings.
                                      S.  W. M. 
 
CONTENTS.
                      CHAPTER I.

Hysteria:  Psychic Anesthesia for Touch; Psychic Anosmia;
    Psychic Blindness  ........

                     CHAPTER  II.

Recurrent Melancholia: Seasonal Melancholia;  Melancholia
    arising  out  of Menstruation;  Inter-menstrual  Melan-
    cholia ; Melancholia arising out of Dreams or Originating
    in the Post-dormitium; Melancholia during  Digestion  .


                    CHAPTER  III.

Irregularly Recurrent Melancholia with Short Intervals  and
    not in Apparent Relation to Function   ....

                     CHAPTER  IV.

Some Disorders of Sleep.......

                      CHAPTER V.

Choreoid Movements in an Adult Male, probably of Hysteri-
    cal Origin ;  Unusual Hysterical  Movements in a Child ;
    Hysterical Myoclonus.......

                     CHAPTER  VI.
Subjective False Sensations of Cold 
VI
CONTENTS.
                     CHAPTER VII.
                                                          PAGE
 Motor  Ataxia in a Child of Three Years, with Retained
     Muscle-reflexes;  Pernicious  Anaemia, with  Locomotor
     Ataxia and Hysteria     .     .         .     ■    .     .125

                    CHAPTER  VIII.

 Post-hemiplegic Pain; Prae-hemiplegic pain ; Post-hemiplegic
     Disease of Joints; Post-hemiplegic Nodes     .         .  145

                     CHAPTER  IX

 The Treatment of Sciatica    ....                 154

                      CHAPTER X.

 Erythromelalgia: Red Neuralgia of the Extremities;  Vaso-
     motor Paralysis of the Extremities; Terminal  Neuritis .  177


                     CHAPTER XI.

Notes on Surface-temperatures as Affected by Posture of Limbs  205


                    CHAPTER  XII.

Three Cases of Remarkable Spinal Anterior  Curvature with
     Mental Aberration      .....            210


                   CHAPTER  XIII.

Concerning the History of the  Discovery  of Reflex Ocular
     Neuroses, and the Extent to which these  Reflexes Obtain   220


                   CHAPTER  XIV.

Wrong Reference of Sensations of Pain . 
                        CONTENTS.                       y[{


                     CHAPTER XV.
                                                          PAGE
Pseudocyesis;  Spurious Pregnancy...         .     .   236


                    CHAPTER  XVI.

Hysterical Contractures.....         .     .   242


                   CHAPTER  XVII.

Hysterical Contractures {Continued)     .     .         .        275


                   CHAPTER  XVIII.

Rotatory Movements in the Feeble-minded  ....   290
                       ERRATUM.

  Page 53, in chapter heading,for ''melancholia with long inter-
vals," read " melancholia with short intervals." 
 
      CLINICAL  LESSONS

                    ON

NERVOUS  DISEASES.
                CHAPTER  I.

   HYSTERIA: PSYCHIC ANAESTHESIA  FOR TOUCH;
      PSYCHIC ANOSMIA; PSYCHIC BLINDNESS.

  In beginning this record of  the lessons given at my
clinic I  may mention that this service is here carried
on by the visiting physicians with the aid of the junior
staff.  Notwithstanding the small size of the hospital,
the ward and out-services have given  the material for
such activity of clinical  study as few  larger hospitals
can show.
  The work thus done includes  Morris Lewis's well-
known examination with me of the Seasonal Relations
of Chorea;  a like  essay  on  the Summer Prevalence
of the Palsies of  Childhood, by  Sinkler; Osier's work
on the  Spastic Palsies;   Eshner's excellent essay on
Tremors;  J. K.  Mitchell's volume on Remote Con-
sequences  of  Nerve Lesions ;  Hinsdale on Station in
Health  and Disease, and many  papers, by the author
and others, too numerous for more than allusive men-
                         2 
14              NEB VO US DISEASES.

tion.   Still more valuable is  it that here  have  been
proved the availability of  the so-called rest-treatment
in open wards,  and the  possibility of thus giving to
the poor  what is commonly believed to be  attainable
only by the richer classes.
  I  feel  glad to say,  indeed,  that  while  the  papers
named, and a host of others, illustrate the careful scien-
tific use made of our wards and laboratory, we  do not
forget  that the  first object of  our wards is  the  cure of
disease.1
  Certain of these lessons, therefore, will not deal alone
with the many singular cases which are likely to come
before  us, but also with  therapeutic methods  in use
here before they were thought  possible in hospitals,
or that, as I think, are better applied and better  known
within these walls than outside of  them.
  The  first case I ask you to look  at to-day is from
Scott Ward.  Watch her as she enters.   Her self-con-
scious, fixed facies will, or should, strike  you.   Note
her ways.   At  one moment she  seems blind;  at the
next, she moves with swift ease.   Her  case is  full of
these oppositions.  I read it, and all of  it, now, before
her, as she is exceedingly  intelligent, and will  set us
right if we err.   Dr. Pershing, of Denver,  has  greatly
helped us as to the early history, and  saw with clearness
of medical  judgment  into  the true nature  of this un-
usually instructive case, which, owing to its changeful
features, has greatly puzzled me.   I  have now reached
conclusions which carry my comprehension  of it up to
a point beyond which  the case itself does  not  suffici-
ently yield clinical material for a further advance.
 i In the report for 1895 is a list of papers produced by tbe staff and assist-
ants. 
HYSTERIA.
15
  Case I.—B. L., a woman, aged forty-two years,  mar-
ried, applied for treatment October, 181)2, complaining of
blindness.
  Family history.   Her mother's father  was paralyzed.
One of  her  mother's brothers had hydrocephalus, and was
epileptic and  blind for a year and a half before his death
from  typhoid fever when twenty-seven  years  old.  Her
father died  of pulmonary tuberculosis.   One sister died of
some spinal disease, said to have been caused by a fall  three
and a half years previously.
  Personal  history.  The patient has two living healthy
children ; two others died.   She has had five abortions.
She does not use alcohol.  There is no evidence of syphilis.
Nor has she had any serious illness except typhoid  fever
at the age of fourteen years.  For many years the woman
has been greatly troubled by family matters, and especially
in consequence of  a child's death.
  The present disorder began in 1887.  Soon after a mis-
carriage she found  that  it  was  becoming difficult for her
to recognize large objects, while small ones could be seen
easily.   In  reading she was  compelled at last to spell each
word, because  she could see only  one letter at  a time.   She
was fitted with glasses, but no relief followed their use. As
time  passed, vision  grew worse.   As  the  form-fields nar-
rowed she recognized  persons, not by their faces,  but  by
their clothing and general bearing.  She could see a  small
piece of silk or a  pin upon the floor, but could not recog-
nize large objects.
  During the second year she lost, to a great degree, the
power of recognizing colors.  She could walk perfectly well,
and avoided obstacles.   During  the  third year  she  could
still see small objects, but could not tell whether or  not a
house was completely built, or distinguish a  man  from a
horse.   In  the  fourth  year  she  began to strike  against
objects  in walking,  and  everything  appeared dark.   She 
16
NERVOUS DISEASES.
could distinguish between night and day, and even between
a bright and a dim light.
  In December, 1891, she was examined  and treated  by
Dr.  Pershing, who  has kindly furnished me the follow-
ing additional notes: "She  is sent  to  me as being per-
fectly  blind.    Lately  she has  lost  command of  words
and  finds it difficult to carry on a conversation, because
words  do not  come to her mind, and are not understood
when heard,  though she  can readily  repeat them  after
another  person.  Recently something was  said  about a
dust-pan and  brush.   She repeated  the words, but had
no idea  what they meant until  she  handled the objects,
when the idea came back.  She complains of inability to
perform  the simplest arithmetical operations (but this is
inconstant), and also to recognize by touch familiar objects
of dress, such as a belt.  She consulted Dr. Starr and Dr.
Roosa, of New York, in November, 1890.  She could not
name  colors  for Dr. Roosa, but a few days later  sorted
worsteds correctly for Dr. Charles H. Thomas, of  Phila-
delphia.
  " Status preesens.   She  recognizes the difference between
light and darkness.  She cannot count fingers or the win-
dows in  the room.   The pupils  are equal and each reacts
to light  falling only on  the  other eye.   The ophthalmo-
scopic  appearances are normal.   An  interrupted  galvanic
current of  one milliampere applied to either side of either
eyeball gives a distinct subjective flash.   The examination
of the other special senses, in all their forms, general sen-
sibility, motion, and the reflexes, shows nothing abnormal.
She  is  not  led, and in  going out of a room finds the door-
knob without  feeling for it,  though  not  always.  She  im-
proved  under treatment  by massage,  electricity, iron,
quinine,  and  strychnine, and moral means.   Just before
leaving the hospital  she told me that she had thought she
was  totally blind, but  she  knew now that she could  not 
HYSTERIA.
17
possibly  have been  so, because she was in  the habit of
doing many things for which sight  was absolutely neces-
sary.   This statement was volunteered as the result of her
own reflection.   After careful study of the case I was cer-
tain it  was  hysterical."   (The accompanying  diagrams
show the fields of vision taken by Dr.  Pershing.)
  The improvement  in her condition that took place while
in Dr. Pershing's care soon disappeared under the stress of
family trouble.
  Present state (October, 1892).  The face, when at rest, is
vacant  and expressionless.   The woman moves about the
room  with apparent ease, and rarely stumbles against an
object.   While  her  gait is not that of  a  blind person, it
also is  not that of  one with normal vision.  When  any
object  is put before  her eyes she says she cannot tell what
it is.  On being told to cross the room  and speak to a gen-
tleman standing there, she goes in the proper  direction, but
is greatly surprised to find, on hearing the supposed man
speak, that it is a woman.  When a watch is given her and
she is asked to tell what it is by touch, she fails.  If,  how-
ever, it is  put near  enough to her  ear for her to hear the
ticking, she names it immediately.   She fails to recognize
a clothes-brush  by touch, but when she hears me  use it,
says :  "It is what you brush clothes with—a clothes-brush."
The same is true of a nail-brush, except that she  calls
it a hair-brush.  She cannot at first recognize a key by
touch, but, on being told that it has  to do with a door,
says, rather doubtingly, "It  is  a  door—door-knob,"  and
then quickly corrects herself, saying, " No,  it is a door-
key."  She fails entirely to recognize a knife  by  touch.
On being given a pencil she  calls it a  penknife, and adds,
"It is  what you write with,"  and does not seem  to be
aware of her error.  At one examination she was entirely
unable to  tell coins or even to recognize that they were
metal,  but the  next day she  recognized a five-cent piece
                           2* 
Fig. 1.
/SO
2/0
270°
270°
Diagrams illustrating the contraction of fiekls of vision.  The continuous line indicates  the extent of the form-field in this patient,
       the broken lines that of the color-fields—blue, red, and green—in the order named.  The test-papers were 2 cm. square. 
HYSTERIA.
19
after considerable difficulty, and then  quickly told quar-
ters, halves, and dollars.  She could not, however, distin-
guish between a one-cent and  a  five-cent piece.  A pen-
holder, with  pen attached, she  calls  a  pen.   A plate she
names properly,  but calls a  tumbler first a plate, then a
bowl, and finally a tumbler.   A pin, a needle, a book, a
pair of scissors, and a piece of paper she knows instantly
by touch, but sometimes not at all.   She says that a ball
put in her hand is round,  when asked its shape, and recog-
nizes a piece of cardboard cut in the form of a circle.  She
calls a triangular card three-cornered, but all rectangular
cards are to  her square.   An  oval  she  sometimes  calls
square, sometimes round.   After  being told several times
what an  object put in  her hands is, she remembers it and
answers correctly several  days later.
  The sense of contact is  perfect.  There is no anaesthesia.
She  immediately responds when touched, and  can  tell the
point of a pin from  the  head, always answering properly
" dull " or " sharp."  She cannot, however, localize sensa-
tion, so as to name the  fingers, but can put a finger cor-
rectly on the place touched.  The  pain-sense is  normal.
The temperature-sense is normal.
  If  salt  or sugar be put upon the tongue, she names the
former and says the latter is sweet like candy or sugar,
and  taste seems  to  be  correct  as to even more  delicate
flavors.   Given  benzine,  cologne,  alcohol, and oil of tur-
pentine to smell she says  she  recognizes them as different,
but  cannot  name them. •  She says they are unlike.  She
can  write her initials and the first  part of her surname
fairly well, the latter part being  a  scrawl.   She  cannot,
however, write any isolated  letters except o  and c.  She
describes the latter as o  with a piece cut out.   If her hand
be guided in  making letters, she still  fails to recognize
them.  She  cannot even  write  the  letters of her  name
unless she begins at the beginning. 
20
NER VO US DISEASES.
  What may be  called spontaneous speech—I mean the
speech of ordinary conversation—is at the present time
normal,  though she  claims  that  formerly she  misused
words.  For  example, though  she may not  be  able to
name an object when given to her, yet if she wants it she
will use the proper word in asking for it.  Notwithstanding
her claim that she has forgotten how to spell, she spells
short words  correctly.  She also solves  simple  arith-
metical problems.  She is nervous, depressed, and  at times
lachrymose.
  Dr. de Schweinitz  has  examined her eyes and reports as
follows :  " There is divergent squint in the right eye.  The
pupils  are large, reacting slowly to light; the right very
sluggishly.  The discs are grayish-red.   The veins  are full;
the arteries are  small—the smaller in the right eye.  There
is lack of fixation, but the patient  sees light in all direc-
tions.  The right  eye  open (the left closed) perceives ob-
jects to the left of the median line and sometimes in the
middle, but not to the right.  The left eye open (the right
closed) perceives  objects to the left and in  the median
line, but not  to the  right.   There is partial right lateral
hemianopsia.   Given  cards to sort, she matches blue ones
correctly, but confuses red  and  green  and all others.  It
was impossible to take  the color-fields."

  Remarks.  A few  preparatory words may  make
easier for you my after-explanations.  We associate with
known objects their possession of  certain qualities of
dimension, form,  texture, color, etc.   These objects are
mentally classified  and labelled—a pencil, a box,  a
hat, and so  on.  When we  see or handle one  of these
objects, and  find by sight or touch  that it  possesses a
group of qualities, we must determine  on the  label,
after  swift  comparison with  the  collected  complex
memories of things already seen or handled or both. 
HYSTERIA.
21
  It will  help  us to look at this  problem in the most
simple form.   When we examine by sight or touch a
familiar object, a single hint, as it were, may suffice, as
the tick which  suggests a watch.  If the object be very
novel, the examination as to the determinative proper-
ties and their associations and degrees may be long and
difficult.  We store away these acquisitions for compari-
son in certain cerebral centres, visual or tactile, or both.
   As regards olfaction, the questions the examinative
sense, so  to speak, can ask and  answer are  limited.
Usually, as concerns the non-pungent odors, one single
quality is perceived, and from it the individual reasons
by comparison  with past memories  of  scents, and de-
clares the label he is accustomed to  assign  to the odor
in question.  This is very simple, compared to the com-
plexity of the  properties  by which  visual  and tactile
recognitions are made.
   In persons who are "mind-blind," as  Muuk called
it, " the thing  put before them is  seen,  but  suggests no
corresponding psychical idea."  Now what is here meant
by being  seen  is one of two things,  or both together.
The thing seen may be present to the man as an image is
to a mirror, for the mirror has no memory,  and cannot
compare the present with the  past;  or else it is meant
that beside this the object so seen may  present recognized
qualities,  but that  the patient  has no  power to place
these for comparison with those of other periods.   In
neither case can  he label  the object or say what use it
has, although he may occasionally do this  latter,  even
when he cannot name it.  The object may  be seen, its
qualities compared with older memories, its nature or
use be thus known, and yet the power to label it with
the vocal  sign we call a word be lost. 
22
NER VO US DISEASES.
  These sets of conditions are all  seen  in this case at
times.   Thus, I blindfold the woman, and offer to her
nose vinegar,  cologne, asafoetida, valerian.  She says
they are different; does not take one for another.  In
other words, she does not say all alike are odors with-
out difference; but  a clear  perception  of the  single
quality so felt as different in  each cannot be lodged in
relation to former  knowledge for comparison.   Hence
it has no distinctiveness and cannot be labelled.
  It is interesting to study this simple case, and then
that of sight.   Here the partial general  blindness and
the added hemianoptic imperfection complicate mat-
ters, and these conditions vary from day to day.   You
will remember, also, that all  color-sense is dead, except
as  to  blue,  and  that  the  form-field  is  much con-
tracted.  Still, at times she can see the hands of a watch
—not,  however, so as to tell the hour.   At her best
moments  she  may appreciate qualities  sufficiently to
say that one thing is larger than another, but not so as
to say that this is round or square.   At these times she
is able to distinguish  one person from another, but never
to label  them until  they speak.   In her worse ocular
states she cannot  distinguish any  form of qualitative
difference.  You will remember that Dr. Pershing de-
scribes her as having been at one time word-deaf, as
now she is word-blind.
   This  trouble is  better known and more often seen
than the  yet  more curious  form of defect as  regards
touch.   Remember that she can tell heat, cold, touch,
pain in all  degrees.   Occasionally she spontaneously
describes a test-object;  more often she does  not and
yet is able, as the stated inquiries show, to answer cor-
rectly  all the queries  competent to describe an object 
HYSTERIA.
23
Very often  the  final  question, What is it? she cannot
answer; or else, and rarely, says what it is for, but not
its name.    At other  times she cannot reply as to the
qualities as told by touch alone, or tell scissors  from a
corkscrew, a book from a watch; and yet tact is per-
fect.   This  corresponds to mind-blindness.   She  is
mind-touchless.    There  is  psychic  anaesthesia as to
touch; or, to  be more accurate, either this is true, or
else  she  has  lost the  power  of  mentally comparing
new sensations with the stored memories of those long
acquired.
   I  have not spoken of  the localities involved  in  this
triple loss.  Concerning these our knowledge is still in-
complete, and cases of hysterical representation of these
singular symptoms are  least of all suitable to help us.
And certainly this patient is an  hysterical  illustration
of mental  incapacities  to use the  information won
through smell, sight, and touch; and, as I am sure such
cases are very rare, I have thought it worth while to
state for you the reflections which this one has brought
to my mind.  Dr. Pershing had reached a like conclu-
sion early in the case.   Of course, these cases all have
alexia and  agraphia.  It has been suggested that the
various memorial incapacities, such as the total loss of
knowledge of localities or of individuals, may be limited
forms of mind-blindness,as if one room in the many man-
sions of memory were suddenly walled up.  These are,
I think, yet more complex  conditions of  psychic  dis-
order, and only a part  of them may fairly be referred
to the form of  mental trouble which this case exhibits
in so many  varieties.   Finally, we need a better term
than mind-blind, and a good word for  the corresponding
condition  in which touch  and smell are involved. 
24             NERVOUS DISEASES.
  It has seemed to me that all of these curious states of
consciousness as  to  objects seen or felt may be repre-
sented in the changing psychic development of a child—
objects seen in early life  are first represented  as on a
mirror; later, their  qualities are defined; and, lastly,
they are labelled.
  Dr. Pershing writes to me of the  later  history as
follows :
  March 9,1896.  The woman with mind-blindness gradu-
ally grew worse after her return from Philadelphia. While
walking one evening with  her mother,  who is very deaf,
they were both struck by a cable car, but apparently not
seriously injured.   When I saw Mrs. S.  a few  weeks after
this accident she could not talk rationally on any subject,
but kept talking in a senseless, bewildered way, the words
being distinctly uttered with occasionally  a pause, as though
the word did not appear in memory.  " Water-closet" was
repeated with especial frequency, without any logical or
grammatical connection with other words.   The  intellect
was evidently much impaired, and she had to be constantly
attended.  The pupils were widely dilated,  and one eye,
the left, I think, turned out.  The pupils did not  contract
in a bright  light.  The ophthalmoscope showed  nothing
abnormal.
  In the summer of 1894 she came as  an insane patient
to the County Hospital, in my service; but I was  away at
the time, and Dr. Eskridge, who had charge of my patients,
had her taken to St. Luke's  as  a private patient.  That
ended my connection with  the case, but I know  that she
remained demented and was  at times noisy.  She died in
the autumn  of  1<S94. 
CHAPTER  II.
RECURRENT  MELANCHOLIA:  SEASONAL  MELANCHO-
  LIA;  MELANCHOLIA ARISINti OUT OF  MENSTRUA-
  TION;  INTER-MENSTIUAL MELANCHOLIA;  MELAN-
  CHOLIA ARISING OUT  OF DREAMS OR ORIGINATING
  IN  THE  POST-DORMITICM;  MELANCHOLIA  DUR1NC
  DIGESTION.

  I have long had in mind to speak to you of certain
forms of the mental disorder we call melancholia, and
of which at this clinic we  see  so many examples.   It
sometimes offers for our consideration  peculiarities of
origin which have not received the attention they should
have had.
  As usual in these lessons, which are informal, and not
meant to cover the whole medical history of the subject,
I shall limit myself to speak of so much of the matter
in hand as shall appear to  me desirable to dwell  upon.
Assuredly, the treatment of  mental disorders is  one of
the least satisfactory of the varied problems with which
we have to deal.  About nothing do we know less than
of the true pathology  and ultimate cause  of  the  dis-
orders which we group under the name  of insanity.
Indeed,  we are as yet uncertain as to where  within
the skull is the nerve-matter with which we  think or
imagine.   The  abruptly  occurring accidents  to,  or
diseases of, joint, muscle,  or nerve, we can measurably
comprehend;  but when we come to deal with disorders
of the brain  we are at once  face to face with  certain
unanswered questions.
                         3 
26
NER VO US DISEASES.
   While most disorders of the mind are apt to origin-
 ate gradually, and often take a long while to become
 formidable, at other times these troubles spring up sud-
 denly; and this is more frequently the case with all the
 forms of methodically recurrent  disease  of the mind.
 I  do not mean to say that sudden outbursts of mania
 or melancholia, such as, according to the German writers
 and others, are more prone to occur in recurrent exam-
 ples of these disorders, are very common ; but only that
 they are to be met with, and that when we do see them
 they still further emphasize the difficulty of explaining
 that which happens  within the  brain at the  time  of
 occurrence of such outbreaks.  A strong emotion, a
 dream as I shall show, or some as inexplicable cause,
 may occasion forms of temporary or lasting mental dis-
 order, for which we have as yet no reasonable explana-
 tion.  The largeness of the psychical and the smallness
 of  the observable  co-attendant pathological  physical
 conditions never cease to amaze the thoughtful.
  Usually these and all forms of such morbid psychoses
get well slowly; but sometimes recovery even in chronic
cases  is as abrupt  as may have  been the origin, and
then one asks in vain  what could have been the nature
of the morbid factors which, acting suddenly or slowly,
are efficient for years, and perhaps cease  to have  dis-
ordering competency in  a night or a day.  Such cases
are, indeed, rare, as I  have said; but they do exist, and
may be met  with at  times in some of  the  recurrent
melancholias to which  presently I desire more especially
to call attention.
  The individuals who constitute mankind have what
one might call a par of cheerfulness. It varies, of course;
is subject to the vicissitudes called moods, and is  low 
MELANCHOLIA.
27
or high according  to the nature of  that lifelong mood
which we  describe as temperament.  This  climate of
the mind  may be such in certain persons as to defy all
forms of misfortune, and to preserve some sense of hap-
piness in the face of poverty, disease, disaster, and even
death itself.   There are others who so precisely reverse
this happy constitution of mind as to need from me no
further description.  It is quite sure that either mental
attitude can be combated or fostered.   The wisdom
which cultivates cheerfulness until it becomes habitual
is of the mental hygiene of habit.
  The atmosphere of cheerfulness is  often a family gift,
an inheritance; you feel  its presence with some people,
in some houses.  Other men or women carry with them
a certain indefinable air of defeat, discouragement, and
gloom.   Such persons and  such families are not, of
necessity, liable to that morbid condition we call melan-
cholia; for, as Cloustou  has very well  insisted, mere
melancholy and  melancholia are two quite different
things.  The disorder may alight on the most cheerful.
There are, however, persons, and rarely whole families,
who, living continually below the normal level of that
happiness which comes of natural cheerfulness, are of
those who are foredoomed to have, at irregular inter-
vals, attacks of melancholia, and to be always nearer to
suicidal temptations than the rest of mankind.  Such
races should not be perpetuated; but  society has  not
seen fit to protect its future, and I have only once known
an instance of such  a family having resolved, by avoid-
ing marriage, to end what had been ancestral genera-
tions of disaster.
  I was permitted years  ago  to print the record of one
of these  unhappy  races,  now, I believe, extinct.  I 
28             NERVOUS DISEASES.
never used the privilege, and have within a few years
mislaid  the memoranda furnished me by one  of its
number.   I retain a distinct  remembrance of enough
of this history to serve my present purpose.  The people
concerned were none of them remarkable for mental gifts
above the  average of  man.    I  knew four  of  them;
three of  these were sallow and  had  dark  skins  and
black hair;  they described  their parents,  who  were
cousins, as having been of  like appearance.  All of
them who were known to me were physically sluggish,
and more or less  lacking in every-day gaiety; but two
at least were humorous at times, and apparently capable
of amusing others more than themselves.
  In about one hundred and  fifty years, in the various
lines of  descent  known to them, they had  record of
eleven suicides,  nine  having been   males  and  two
females;  there were several epileptics, much  drunken-
ness of  later  years, and  in every  generation  cases
of  insanity—sometimes acute mania, more usually
melancholia.1   When,  quite thirty   years  ago,  the
family became reduced to  three  single women  and
one  man,  an  agreement not to  marry was  reached,
and  was, I believe, scrupulously  kept.   I  saw  two
cases among  these  people.    Both  were in women
between  thirty and forty years of age; both were  pure
melancholias without delusions, except as to  religious
matters;  both were piteous examples of the mental suf-
fering which this disorder may inflict.
  I  have occasionally known, in a long experience, per-
sons who all through life were subject to what are  pop-
ularly called the  " blues,"  to moods of depression and
  i With all of this sad history it is  notable  that there was no instance of
any form of crime. 
MELANCHOLIA.
29
the like, but who throughout escaped true melancholia.
There are, as I have also said, exceptions to this happy
rule, and the family whose history I allude  to were
for the most part sad-minded people.  The only one of
them who  entirely escaped attacks of insanity was  a
quite cheerful woman, who  had the fair hair and  blue
eyes of  a grandmother of another race.
   It is a question how far the individual of breeds like
this one may be influentially hurt by knowledge of  such
a series of  mental disasters among near  relatives.   I
am sure that  most persons so situated would be apt to
feel a dread of the coming of their family peril; but if
this natural apprehension be capable, in turn, of adding
a serious contributive factor to hereditary tendencies,  I
do not fully know.
   I have been many times consulted as to the propriety
of marriage in cases of  those who have been insane, or
who are come of  those rare families in which  neuroses
have been so frequent as to make reasonable a doubt as to
the right to doom offspring to the probabilities of mental
disorders.  There are extreme cases in which decisions
are easy.  It is the other groups which are hard to deal
with; I mean those in which the record is not so terribly
disastrous as in that which I have selected as a typical
instance.  All sorts of  questions are involved:  emo-
tional, social,  economic.   The  quality of  the  previous
insanities is  to be considered, and the nature of  the
causes  which  seem  to  influence the outbreaks.  If it
be a varied family history with which we have  to deal,
the matter becomes difficult, and often anyone, except
a modern psychological  novelist, would, and  perhaps
sometimes should, with reason, refuse to give  positive
advice.
                         3* 
30
NERVOUS DISEASES.
  I should like, did my time permit, to study with you
here this  interesting  problem.   I should like to see it
fully  discussed  by some alienist of large experience,
capable of dealing with it from all points of view.
  Closely connected with this matter is  the advice to
be given as to the training,  and the moral and physical
education of  the children of persons in whose families
there  is or has  been such frequency of mental disorder
as to make it wise to  consider  these  risks while  we are
still able  to  handle the plastic material of childhood.
Here  again is a problem, not unanswerable, and need-
ing to be  largely considered.
  I pass from these hiuts for the reflective, to ask atten-
tion to some of the melancholias which,  as to  origin,
seem  to be  conditionally related  to season,  function,
and other more obscure factors.   In  treating  of this
subject I  shall  for the most part limit myself to cases
of which I  have had personal knowledge, or  which,
having been obtained from my friends, have not been
hitherto put  in print.
   Recurrent melancholia is, of course,  at times only
a  part of the  cycle  of  a  form  of  circular insanity.
I  have endeavored  to  exclude  all such examples.
There is, however, I am  sure, a  form of very mild
circular insanity to which  sufficient attention has not
been given.  In this we have  melancholias of ordinary
or extraordinary type, followed by periods of greater or
less duration, during which the person is neither mani-
acal nor  subject to delusions, as in the  more  typical
circular insanities. In these, to which I now call atten-
tion,  the  interval between  two attacks of melancholia
is merely remarkable for the excessive  gaiety  of  the
patient.  It is often  sufficient to attract  attention as 
MELANCHOLIA.
31
unusual and beyond what  had been observable in the
same  individual during a period of perfectly normal
life.
  The recurrent melancholias I  have seen and desire
to discuss were productively conditioned on season, time
of day, function, such as menstruation or inter-menstrual
periods.   Then, again, there  is melancholia  distinctly
related  to  the meal-time, or, rather,  to  the digestive
period.   Finally, there is the melancholia which is the
strange temporary outcome of dreams, or is related  to
the post-dormitium.   I have elsewhere  written of the
psychoses, and especially of the melancholias and manias,
due to drugs, such as  bromides, trional, cocaine,  or
hemp.1
  It is familiar knowledge that melancholia is apt  to
recur in the person of one who has been once attacked.
These returns may be after a year or less, or after many
years.  Too often where the interval is brief the patient
has never been quite restored to the full normal of cheer-
fulness.   The recovery, too easily  assumed, is only a
lessened state of depression, aud soon again, the  curve
of  melancholia rising, the patient  is said to  have a
second attack.  This truth as to many of the melan-
cholias which return  at irregular and short intervals
has been clearly recognized by many of  our own alieu-
ists.  It is not of this type of irregular recurrence that
I desire now to speak.
  The melancholias which  recur frequently may do  so
at certain times of the  year, and may continue so  to
return year after year.  These cases I may be  allowed
to call recurrent seasonal melancholias.   Some deter-
1 Proceedings of the Association of Physicians and Pathologists, 1896, 
32
NERVOUS DISEASES.
mining connection with the  season  or its phenomena
seems to be efficient in evolving an annual attack.  The
time of onset may vary within a month or two. Usually
it is in  the spring or early summer, and so much more
common is this than attacks in winter, that it has made
me eager to know how far season is influential in setting
the date of such  outbreaks as are primary or recur at
longer intervals.
  Regularly recurrent melancholias may be of  any of
the several species which are included in what  I may
call the genus melancholia.  The termination may be
finally as various as in the ordinary single or irregularly
recurrent examples.
  Well-marked seasonal melancholia is a rare disorder.
The case which I  shall first relate is an admirable illus-
tration  of the malady.   I owe it to the kindness of the
attending physician, Dr. M. V.  Ball, and its complete-
ness to the very  full notes made by my assistant, Dr.
Rhein:
  Case II.—The patient, D.  B., is a Russian by birth, aged
thirty years, married, and has  borne two children.  Her
business is  that of a midwife.   The beginning of her dis-
ease dates  sixteen years ago.   It  consists in a periodical
recurrence  of  a profound state of melancholia.   In her
family history there is strong evidence of predisposition to
insanity.  Her mother suffered from melancholia during a
part of  her life, a  sister kiUed herself while mentally de-
pressed, a second sister is extremely nervous and hysterical,
and two maternal  cousins are afflicted with melancholia.
  The patient's health prior to  the onset of  the  present
affliction was extraordinarily good.  She possessed  an un-
usually  acute  mind, and had  a  most retentive memory
easily acquiring at an early age  command  of three lan-
guages besides her own. 
MELANCHOLIA.
33
  The first symptoms of her malady appeared shortly after
her first menstrual period, at fourteen years.   There was
only a mild mental  depression at this time, which lasted
four weeks, and from which she recovered entirely.  In a
year's time she experienced a return  of the same condition,
which  lasted again four weeks.   A third attack  was in-
duced  by a serious cause of worry eighteen  months later.
About this time her memory began to be rather  less per-
fect, and  she  observed some defect  in her mental powers.
Her first pregnancy was the occasion of a  fourth slight
return of mental depression, quite mild in character and
lacking entirely delusional or suicidal tendencies.
  The first of the regular series was induced  by the death
of her child.   The attack began in March and lasted until
September.   Her symptoms  were  then  precisely  those
which I shall presently describe.   Since that  time, sixteen
years ago, with persistent regularity as the month of March
approaches, she falls into a state of melancholia from which
hitherto there has been no escape.   The  symptoms of the
several attacks vary but slightly ;  her accustomed attitude
is then highly characteristic.  With hands clasped before
her, her eyes  fixed  in  an upward direction, she  remains
seated for hours,  refusing to converse, declining  to  eat,
and frequently weeping.  The recital of her mental con-
dition during  an attack, while most pathetic,  is of  unusual
interest.  There are constantly floating through her mind,
she  says, the most  depressing  thoughts.  Her condition
renders her a burden to  those  about her;  she is unable
to support herself;  her capacity for work is gone; she is
unable to think correctly, to act properly, so that  she con-
siders that, altogether, it would be infinitely more  pleasant
to end all her troubles by suicide.  This idea  is continually
uppermost.   She craves death and is constantly discussing
with herself plans to effect it.  For the sake of those about
her she is dissuaded from killing herself while in the house ; 
34
NER VO US DISEASES.
but to  go out  of doors is quite impossible; no will-power
exists to prompt such a move.  She thinks, if once out of
doors, there would be  no barrier to the consummation of
her desire.  This lack of will induces within her an  intense
hatred of herself, as she says, " like as no one  has ever
hated before."  The mental anguish is so great that bodily
pain is not felt if it chances to occur.  She  has frequently
attempted  suicide by exposing herself  to  cold  night-air
with perhaps only  a  single  garment.   Thus death, she
thinks, could  be  achieved without  inflicting on  her  rela-
tives the ignominy of suicide.  She has unsuccessfully at-
tempted  suicide several  times by swallowing poison. In
several instances the attack has  been precipitated by men-
tal shocks, but  more frequently there  has been no such
exciting cause.  Emotion or disaster at  other seasons will
not bring it  on.  During the intervals she is happy, in-
dustrious, and capable; said to be in a really normal state.
For a short time in a day, now and then, there may be
some trivial  depression, which  she has not the slightest
difficulty in   shaking  off.  AVhen the  month  of March
arrives she is entirely powerless to rise above  these de-
pressed feelings.   She becomes most apprehensive  of  a
return, the  anticipation of  which  seems to lower her
resistance.
   There have been always intense  headaches at these and
of late at other times, which  no  medicine has permanently
helped.  Krafft-Ebing partially relieved her pain for six
months  by hypnotizing  her  every three  davs.   He was
never  successful in  inducing a  very  profound  state of
hypnotism.   At my request,  Dr. Rhein brought about this
condition and made her quite  completely  insensible, pro-
ducing the highest degree  of  hypnotism, during which
suggestions as to relief  of headache were made with con-
siderable success.
   An  examination of her physical condition in health is 
MELANCHOLIA.
35
 as follows : Her station is good ; the knee-jerks are slightly
 increased ; there is no clonus.  The strength of the muscles
 in general is normal.  There is no change in sensation any-
 where.   The tongue is coated, the  digestion is fairly good ;
 bowels irregular during  the attacks, but regular at other
 times.  The  heart and lungs and uterine functions are
 normal.  The urine shows, but only at times, free uric acid,
 and is in other respects natural.  There exists  a slight error
 of refraction in the eyes, but no change in  the fundus and
 none in the form- or color-fields.
   The attack,  as  I  have said, comes  on  in March, and
 usually she may expect it about March 1st.  It lasts until
 August,  and goes  away  somewhat slowly,  becoming now
 better, now worse, until  it disappears.   The  early attacks
 came on abruptly, in  a  single day, and left in the same
 manner.    When  they are  coming on she has anorexia,
 loss of vigor,  and her sense of  duty  and  her  will-power
 are soon  in abeyance.  No efforts seem  to have been made,
 by any radical treatment, to anticipate the coming  on of
 her  trouble.   I hope,  during  the ensuing spring, to make
 some effort  to  relieve her.   My  belief  that there was an
 hysterical basis for  her  melancholia has  been confirmed
 by an interesting incident:
   On January 20, 1897,  this patient was  insulted in the
 street at  night  and pursued by a drunken man.   The next
 day, on  awakening, she had complete loss of  power in the
 legs and insensibility in all forms below the knee.  Dr.
 Rhein hypnotized  her  and she was at  once able to stand
 and move  freely when ordered.  Two  days  later, at my
 clinic, she was  again hypnotized and walked still better.
 This treatment will  be continued, and under it no doubt
 the paretic state will disappear.   As she will now remain
 in the wards, I hope by this and other means to ward off
the annual attack  of melancholia.   The ease with which
the hysterical paraplegia came on points to the possibility 
36              NER VO US DISEASES.
 of  the  recurring  mental disease  having been  hysterical.
 It  does certainly offer also in its history some suggestive
 facts corroborative of this belief.
   In the large experience of my service, Drs. J. K. Mitchell
 and Dr. de Schweinitz have found, as I have before stated,
 very few cases of such changes of the color-  and  form-fields
 as seem to be common in France in hysterical palsies. For-
 tunately, Mrs. B.'s eye-grounds were studied with care some
 time ago and found normal.   Just now the color-fields are
 reversed, and  this  is the first time I have met with this
 symptom in hysterical paraplegia.
   Case  III.—I saw lately a woman, aged  thirty-nine
 years, of a family in which the mother had had  melan-
 cholia.   This  lady, in November,  1888, after some trivial
 worries, became melancholic.   The attack lasted a month.
 In  May, 1892, after childbirth, the  attack recurred and
 lasted until the next February.   Since then she has had
 mild melancholia beginning every August and getting well
 toward  the  close of January.  In  the  intervals she is de-
 scribed as happy and sometimes as too hilarious; but this
 she  denies, and  declares that she is in a perfectly natural
 condition.  The melancholia in this case is of the simplest
 type, and without delusions.
  Case IV.—Another example of melancholia, confined
 to the months of April,  May, and June, was, for the cer-
 tainty of its return, unusually interesting.   R. W.,  aged
 forty years, naval officer, unmarried, of good habits, came
 of a family well known  to me as  healthy and of unusual
 ability.   At the age of thirty-four years he  was perilously
 ill  in the spring with coast fever, while on the shores of
 Africa.   He recovered very slowly, but was never  again
 as vigorous as before.   The  next  spring, early in April,
 he had a sudden and seemingly causeless melancholia, with
suicidal impulses, but without confessed delusions.  All the
previous winter he had been weak  and dyspeptic, with an 
MELANCHOLIA,
37
irritable  bladder and  immense  deposits of oxalates, but
rarely any free uric acid.   The  melancholia  lasted until
July, and this  attack repeated itself, with systematic per-
sistency, every year, seven successive times.  Meantime he
acquired improved health, lost  his oxalates and bladder-
trouble, and was  able to  eat without indigestion if he
were reasonably careful;  nor did the condition  of the urine
to which I have alluded return again during the successive
attacks of  melancholia.  His urine was at these times sin-
gularly free from  the  deposits so commonly seen in these
cases, and in fact in many forms of insanity.  Still, whether
at home or at sea,  in city or country, his attacks returned
every year.  After eight of these  onsets he married, and
thenceforward was not again the victim of melancholia up
to his death, from pneumonia, at the age of fifty-one years.

   Here, again, there was some determining  element in
the spring, but beyond this evident conclusion I am
unable to go.
   I owe the two cases which follow to the kindness of
Dr. Allen Starr:
   Case V.—Mrs.  L.  X., Kansas, born in  1857.   Father
was healthy.  Mother was  a nervous  invalid, and  she has
been nervous from the time she was sixteen.  She has two
sisters who are  neurotic  and one brother who  is  peculiar
but has never  been insane.  One aunt on the mother's
side is said to  be  erratic.   The  patient's  first attack of
depression occurred in 1885, beginning in  February, and
was associated with the sudden cessation of menstruation.
She became discontented, restless, moody,  and depressed
in spirits;  was  wilful and  irritable, so that it was impos-
sible for her to do housekeeping or manage  her family.
Her condition  during the  first  attack was  diagnosticated
by Dr. Barstow, of Sanford Hall, Flushing, as melancholia.
The attack lasted  until July 1st, when it  passed  off sud-
                           4 
38
NER VO US DISEASES.
denly with a recurrence of menstruation.   She had similar
attacks  every  spring, the exact dates of which are not
known,  until 1891.  In 1891 her attack began on March
17th and  lasted until September, the condition of depres-
sion being attended with suicidal tendencies, so that she
had to be carefully watched during the summer of  1891.
I first saw her in November, 1891, and had the charge of
her until  the following March, during which time she suf-
fered from anaemia and asthma, but was normal mentally.
On March 30th, after an  attack of tonsillitis, her entire
manner  and  character  suddenly  changed.  She  became
excited, unduly talkative, restless and irritable, very unlike
herself in appearance, manner, and actions ; and this period
of excitement and restlessness lasted for ten days and then
suddenly  changed into a condition of deep melancholia, in
which she dreaded seeing anyone, was despondent,  cried,
was slow in her mental action, could not concentrate her
attention  or undertake any work  for the management of
her house;  disliked to see her children, was  afraid she
would do them harm, evidently had suicidal  tendencies
though  she  attempted to conceal them;  slept badly, lost
weight rapidly, became anaemic, constipated, and suspicious.
She remained in  this  condition until August  10th,  when
with the recurrence of her menstruation, which had ceased
from  March 30th,  she became apparently suddenly well.
   She had a  similar attack  during the spring or summer
of 1893, 1894,1895, and 1896, each attack beginning with
a  period  of excitement lasting two weeks, followed by a
period of depression lasting several months.  The attack
in 1894 began in April and  lasted until  September.  It
was not benefited by a trip  to Europe.   The attack in
1895  began in May and lasted until September 22d.   The
attack in 1895  lasted from April until  August.  I may
add that  this lady had frequently an excess of uric acid
both  in and out of her attacks.  There were in this case
eleven consecutive attacks of melancholia. 
MELANCHOLIA.
39
  Cask VI.—T. K., male, born in Massachusetts in 1868.
Family history bad.   Cases of insanity  on both father's
and mother's side.  One aunt at present in an asylum with
paranoia.  He was born two weeks before time and weighed
only five pounds, but appeared to be well until his fifteenth
year, when, in the spring, it was noticed he was  acting in
an unnatural manner.  He wished to be alone;  he could
not  fix his attention upon  study;  he became morbid in
various ways and much depressed.  Such attacks have re-
curred every year since that time; that is, from the year
1883.  In 1888 he began to study medicine, and in March,
1889, first  came under my observation with  the previous
history.  Examination showed a large, muscular man, six
feet  high,  and well  developed  physically, with a  very
small head and a degenerate  type  of  asymmetrical  face,
badly formed ears, and high palate.  Physical examination
of internal organs negative; heart rapid, 95, but no mur-
murs.   Good digestion ; no anaemia ; urine normal.  Men-
tal condition of depression.  It is difficult to get him to
talk  ; he remains  quiet for hours; refuses to see anyone;
prefers to stay at  home, and will not see friends or occupy
himself, excepting occasionally with outdoor work in the
garden.  He constantly  reproaches  himself  with various
imaginary  evils, and everything  that  he has done seems
to him to be just  the wrong thing,  and  he says if he
had  not done this or that he would be all right.   This
condition persisted from March until July, when it gradu-
ally  passed  off, and  he was well during the  summer.  A
recurrence  took place in October, 1890, when I saw  him
again in the same depressed  condition,  confused in his
mind, unable  to  read or study,  moody and dull.   His
reaction-times to sight and hearing were carefully tested,
and  found to  be  increased  in duration.  This  condition
lasted until December 23d, when it passed off suddenly.
In September,  1891,  he had a recurrence  of the depres- 
40
NERVOUS DISEASES.
sion, which  lasted  until December  29th.   During this
time he was  melancholy,  unable to  concentrate  his mind
on any work, talked slowly, but had no active delusions.
He spent this period in the Adirondacks, and was out of
doors most of  the time.  Recovered  suddenly; as he ex-
pressed it, "came out from under the cloud."  I did not
see him again until December 26,1894, when he was again
in a  state of depression, and said that he had had attacks
lasting from September until December each year in the
preceding three years.  When I saw him he was in a state
of deep  melancholia.  December 1,  1896,  his  father re-
ported to me that he recovered from the attack in  1894
during the middle of January, but that he had an attack
from September to December, 1895, and that now (Decem-
ber 1, 1896) he is in an attack which began in July.
   This man has therefore had yearly attacks of melancholia
from 1883 to 1896 without  any exception, lasting variably
from three to six months.
   The urine was examined  very many times and with care.
It was not found that the  urea, uric acid, whole quantity
of fluid,  or total of contents had any relation to the pres
ence or  absence of the mental disorder.   There were in
this  case thirteen  attacks—one  each year—at first  in the
spring season,  but later in the autumn or summer.
   Here, too,  as  is not  uncommon  in this interesting
type of  melancholia, the  suddenness of the ending of
the disorder is worthy of  remark.

   Case VII.—An autumnal  example of recurrent melan-
cholia was seen by me many  years ago in a male, aged thirty-
seven years, a  planter, living in a highly malarious part of
South Carolina.   He came of a family  exceptionally free
from insanity and,  too, from  all other neuroses.  At the
age  of twenty-four, in  June,  after a period of emotional
distress,  he became melancholic.   In  the autumn he made 
MELANCHOLIA.
41
a good recovery, and resumed his  business.  Two  years
later  from October he  had, without known  cause,  three
months  of apathetic  melancholia.  This  repeated  itself
two successive autumns.  Then he  had no more until he
was thirty-one, when he had again, in  the month of Sep-
tember, an ague,  and after it four months of simple melan-
cholia.  I saw him when he was aged thirty-eight, and he
had then  had three years  in  sequence  autumnal melan-
cholia, never outlasting the  winter.   I  studied his case in
the last attack.   His urine  was loaded with dumb-bell ox-
alates, and had at times urates or  uric-acid crystals; but
none of these deposits were persistent.  His state of stomach
caused me to advise a skim-milk diet. Under this, as usual,
all uric acid and  oxalates disappeared, but the melancholia
was none the better.  Anti-periodics, such as quinine and
arsenic, had proved of no service, but he was sure that he
escaped attacks if he went north in summer and remained
until January.  I know nothing of  his later history.
  I have  met with other less  striking examples of sea-
sonal  (usually spring-time) melancholia.   I have  seen
others in which  melancholia was one  of  the cyclic
changes of circular insanity, but in which, or at least in
two cases, the melancholia began  always in  the spring,
and was replaced  in  summer by a state of wild excit-
ability, the midwinter mouths being free from any dis-
tinct disorder of mind.
  The simpler  cases are to  me of great  interest   At
my clinics the seasonal relations of certain neuroses  have
in the past been studied with care by Dr. Morris Lewis,
Dr. Sinkler, and myself, and  it is possible that  some
such study of the time of onset of non-recurrent melan-
cholias may prove of interest and value.   So far, my
own  cases have  yielded to the most careful  study no
explanation of their  recurrence at a certain, or near a
                          4* 
42
NER VO US DISEASES.
certain time  of year.  Undoubtedly they were not of
merely lithaemic parentage, and the bare fact that iu
these, as in so many insane people, the urine is at times
loaded with urates or free uric acid or oxalates seems to
be of little or no causal moment.  I think that Lange's
authority  has caused too much  importance to be attrib-
uted to the connection between melancholias and the
presence of free uric acid.
   If  we may trust  the  statements of Pinel  and some
others, there  is in chronic insanities a tendency to ex-
acerbations in summer.   "It  is curious," says Pinel,
"to observe  the effect of the  solar influence on the
return and march of the  larger number of  attacks of
mania"  (whether he means only the wildly insane or
includes  melancholias  is not clear); "it is common to
see them  renew themselves with more or less violence
during the months which follow the spring solstice, pro-
long themselves with more or less violence during the
hot season, and end  for the most part in the decline of
autumn."1  He adds that storms excite  the insane of
all kinds, a  question  which, with our  knowledge of
storms and our complete control of weather statistics
and records,  should  become at once a matter  of careful
and considerate study in some of our great asylums.
   In looking through the literature I find many reports
of irregularly recurrent melancholias, as of several brief
attacks in every year  and the like, but as to seasonal
melancholias  I find little that is satisfactory.  Henry M.
Kurd reports two in the American Journal of Insanity.
One of these  began in July, 1883, and quickly got well.
The second attack lasted  a  month from June,  1886.
1 Is this the case with us? 
MELANCHOLIA.
43
Then they came on in successive years in May, April,
March, and August, lasting two or three months in each
case.   These were onsets of  melancholia agitata  with
delusions.  The rest of the year is stated to have been
a time of  entire sanity.
  Schule, Klinische Psychiatrie, 1886, has an interest-
ing article on  periodical melancholia, in which, while
he speaks of  the singular abruptness of onset  and ter-
mination of some of  these attacks, and of their  being
not rarely regular as to seasonal times of occurrence,
he does  not  state the season in which they are  most
likely to obtain.  He  adds  that periodical manias are
for certain patients so  regular in their recurrence that
the sufferer can with correctness  count on their coming
in certain months.  I do not know of any later and
complete  study of this subject, and, in fact, that which
I have thus stated is incomplete and is lacking in such
detail  as  is desirable.   Here, again,  is  a subject  to
which some one in the great asylums should give present
attention.
  Pinel  and Calmeil  have  as to these points certain
statistics which seem to show that admissions are more
frequent in spring and  summer in France; but these
would be more valuable  if in  place of admission dates
we had dates of the outbreaks, and still more desirable
if we had such statistics in regard to our  own country,
and as to climates which vary from ours and from that
of France.   I  have  been told that recurrent seasonal
melancholias are not quite so unusual  in  Cuba as with
us, and  that they are apt to  come on with  the hot
weather and to pass away with the cold.   I have seen
recently one such case  from Cuba, in which the melan-
cholia came  in several  successive  years—I  think as 
44
NERVOUS DISEASES.
many as six—in the month of May, and ended always
about the first of  January.  The obvious indication in
all these cases would be a change of climate,1 but I do
not know of any case in which this has been employed,
except in the interesting autumnal example  which I
have already quoted.  Nor, may I add, do I know of
any other example of seasonal melancholia in the  au-
tumn, though it is quite possible that the experience of
some of our Southern physicians might furnish me with
instances, and perhaps even of such as can be shown
to be distinctly related to the presence of  malaria.
  The effect of the normal menstrual function on  the
increase of melancholia already present is well known;
but I  do not find it stated anywhere that some per-
sistent melancholias  in women are extraordinarily bet-
ter at this very time, and that the gloom deepens  again
during the interval  between two menstruations.  The
two cases of which I have notes were young married
women.  Both were unusually  simple examples, and
both  recovered after  a year.   It must be  common
knowledge  among  observant physicians  that  many
women are depressed and gloomy during the menstrual
period; but  there are  also cases in which a brief  but
typical melancholia, with or without delusions, and in
some  with suicidal  tendencies,  does develop at this
time and last for a  few days.   As interesting are  the
menstrual melancholias with erotic tendencies, or  those
which  are homicidal.
  Case VIII.—C.  B., of California, a single woman, in
easy  circumstances,  aged thirty-four years,  in perfect
health; had no family history of  insanity  that  could  be

         i In one of Dr. Starr's cases this proved of no value. 
MELANCHOLIA.
45
 traced.  The  father  died  of locomotor ataxia,  with  no
 history of syphilis.   Of late years  during menstruation
 she had had a quite profound and increasing melancholia.
 For a long time she succeeded in hiding this, and the more
 distressing phenomena which later accompanied the condi-
 tion ; but about the date I  have mentioned it became  by
 degrees an agitated state, quite uncontrollable, and in which,
 amid tears and lamentations, she struggled with wild sexual
 desires.  One  or more sexual dreams contributed at these
 seasons to her self-reproach and sense of impurity.  About
 the sixth and last day she began to lose the erotic impulses
 and to talk of suicide.   At  the eighth day she was free
 from all mental and moral  disorder  and in possession of
 her usual entire health of mind.   After two years of this
 torment she gladly consented to lose her ovaries.  She made
 a good recovery, under Goodell's care, but was physically
 feeble for  a  year.   The ovaries,  I may add,  were seri-
 ously diseased.  For  three years  after their removal she
 had slight feelings of gloom and headache at the time when
 the usual term of ovulation would have come round under
 natural circumstances.  Then by  degrees she  ceased  to
 have any further  trouble, and has now been  for  many
 years a perfectly strong, efficient, and vigorous woman.

  Not all such procedures are so fortunate.  Generally,
 this operation gives  temporary  or no relief when the
 melancholia is constant and is  merely accentuated by
 the return  of the monthly flow.   I know of many, far
 too many, cases where  physicians  have advised and
 women have consented to the removal of ovaries under
these conditions, and  where no relief has come about in
consequence of the operation.
  Homicidal  melancholias confined  to the menstrual
epoch are rare. 
46
NERVOUS DISEASES.
  Case IX.— Miss C, of Maine, aged forty years, single,
in easy circumstances; came of a family most of whom in
her generation had been insane.  At the age named, being
then a  large, ruddy  woman,  in notably good health, she
was alarmed to find that she was becoming depressed and
melancholic.  This condition  was absolutely limited to the
period  of  menstruation, and did not begin until  she had
been flowing for a  day.  At first the trouble was by no
means profound, and there was none between her  monthly
flows; but later at these periods she began to have furious
hysterical  convulsions, with visions of men  covered with
blood, and began to wish to kill some one, and this usually
a person dear to her.   This  state continued for quite a
year, and  in the interval  between her periods she was in
a condition  which I should  call one  of melancholy with
occasional hysterical  convulsions rather than  of  melan-
cholia.  She was depressed by the belief that  her family
calamity had at last come  upon her.   But during the in-
tervals she had  none  of  the delusions,  nor of the maniacal
melancholia,  which oppressed the  time of the  menstrual
flow.
  At  this later period  an examination showed that both
ovaries were enlarged.   They were skilfully removed, with
the tubes,  by my friend, the late  Professor Goodell, and
were found to be full of cysts, and one of them to  be three
inches in diameter, while the  other was at least six.  The
effect of this operation was astonishing. The attacks ceased
quite  abruptly,  the  intercurrent distress  of mind faded
away, and she has had, after nine years, no further trouble
of this nature.  I have rarely seen  a more amazingly com-
plete relief.
  More unusual are the cases of  melancholia which
exist  only  during  a  portion  of the  inter-menstrual
period.  I saw  one such case  in consultation many years
ago: 
MELANCHOLIA.
47
  Case X.—The patient, a native of Alabama, was aged
about forty-two years, the mother of seven children, and,
until  her  forty-second summer, was in good health.  At
about this time  she had  an attack of some  kind due to
heat.   There was great exhaustion, and  for a week high
temperature, followed by a good  recovery, with  the com-
mon, subsequent sensitiveness to solar heat.   Two months
after  recovery she  began to be depressed, and  later this
grew into  typical melancholia,  with mild delusions as to
past crimes, great self-depreciation, and  the like.   All of
these  faded away on the  second day of what was  a full
but quite normal menstrual flow.  The  recovery was really
abrupt and complete.   A week after the cessation of the
flow the melancholia began  again, and within three days
became grave.   It was  at  times suicidal, although this
never  resulted in  any distinct effort  at self-destruction.
This sequence repeated itself many times.  I  do not know
how the case ended.
  Case XI. —The second of these interesting cases was that
of an intelligent girl,  aged  eighteen years, handsome and
healthy as to appearance and as to function normal.  She
came of a family in which there was and had been much in-
sanity, more eccentricity, and some persons of  great ability.
At  the age mentioned  Miss K. became, in June, without
known cause, furiously maniacal.  Within a month this
became less and less, and she remained in a state of deep
dejection, speechless and motionless, often with a positive
rain of tears.   As time wore on it was seen that two days
before, during, and after the menstrual flow  Miss K. was
increasingly brighter.   After seven months this was so
remarkably persistent  that at the time of relief she read
and wrote letters, talked and heard talk with pleasure, and
went  back voluntarily to  her  piano, singing  and playing
with taste and charm.
  The second year found this  lady free from mental dis- 
48
NER VO US DISEASES.
order, except for eight days midway between her monthly
flows.  At this time  she  was silent,  or even speechless,
tearful,  and full  of  gloom.  Now  and  then  she would
write an answer to questions, but considered it wicked to
speak.  The approach of  the  menstrual term brought a
rapid increase of good spirits,  and during  the flow  and
later she was  thought to  be natural by those who knew
her best.  At  this season she declared that the time of
melancholia was never so  distinct in  her  memory as it
might have been expected to be.  She forgot its details,
and  seemed to suffer very little from  the  recollection of
what she  had  gone through.  This is  a merciful  and not
a rare feature of  many forms of mental disorder.   The
impression they leave  on the memory has the  evanescent
quality of the  mind's record of  a dream.
  When this  case had lasted  in this state for  two years I
saw her in consultation with the late Professor Charles D.
Meigs.  He was strongly  of opinion that  she should be
bled in  the interval,  and  accordingly  she was bled some
twenty ounces about  ten  days after the flow  ceased,  and
was  also  put  permanently on a diet  chiefly vegetable.
After the  first  bleeding  the  sequent depression in the
middle of the  month was  less, and after four successive
bleedings, which were done much closer to the  time of the
expected attack, it became insignificant.  I then sent her
on a long  ocean voyage, during which her  convalescence
became  complete.   She died fourteen years after, from
an acute intestinal malady, but had never any return of
inter-menstrual or other disorder of the mind.  I ought to
state that long before the lancet was used a great variety
of treatment had been resorted to, and that nothing had
been left undone which I could devise to break up these
attacks.

  I am reminded by this case of three occasions on which
suicidal failures, causing immense loss of blood, resulted 
MELANCHOLIA.
49
in rapid relief in melancholias of the gravest types.   I
have seen another within a very few days of this writing.
   I leave  these facts, which  I have not time here to
discuss, to  the ingenious interpretation  of  others.   I
pass, in this brief summary, to the cases of melancholia
which seemed to have some relation to sleep or its phe-
nomena.   In the  year 1895 I read to the Association
of Physicians and Pathologists a paper on  the Disor-
ders of Sleep.  I then classified the mental phenomena
arising  out of dreams,  or  out of  what  I  called the
prce- or the post-dormitium.  At this time I drew atten-
tion to Baillarger as the only author who had  realized
the importance of this  period, the  post-dormitium, in
connection with  insanity.  The great value of these
facts, and  of those  I added, has  even yet failed to
attract further contributive illustrations.  The cases I
reported were chiefly of hallucinations of the  senses.
Since then I have seen a number of instances in which
the post-dormitium was haunted by sensory delusions of
painful character, followed by an hour or two of really
deep  melancholia in a  waking  state.  It is familiar
knowledge that melancholias are worst on awaking, but
instances of this  brief melancholia  either preceded or
not by sensory post-dormitial hallucinations are more
rare.   A single case will suffice:
   Case XII.—C.  J.,  clergyman,  of Connecticut,  aged
sixty-five years, had, twenty  years  before, a long  and
severe spell of simple melancholia.   At this later date, in
the early spring, he  began to  have, before he was  fully
awake, delusions  as  to  voices reproaching  him.  With
these were  visions  of  droll or  horrible faces.   When he
became  fully conscious these left  him, upon opening his
eyes, but for  awhile  returned  if he  again closed  them.
                          5 
50
NER VO US DISEASES.
A few minutes later the sounds and visions left  him en-
tirely, but for two hours he was the victim of a melan-
cholia so deep as to be once or twice almost overwhelm-
ingly suicidal.   About 11 a.m. this all  passed  away, and
he became so well as to be able to  attend  competently to
important duties during the rest of the day.   These phe-
nomena lasted for years at intervals, and finally ended in
senile dementia of the passive type.

  I have also seen remarkable instances of temporary
but really profound melancholias which  were the out-
come of dreams.   I recall two  such cases.   It may
answer to relate one.   The borderland of unsoundness
of mind  is sometimes subject to a great increase  in the
number  of  dreams, and  these may  be so constantly
horrible  or terrifying as to be a warning of the coming
mental disaster, as has been more than once pointed out,
especially by Baillarger.  It is, however, uncommon to
find  the dream resulting  in  an attack of  agitative or
simple melancholia.  Abnormal fear, irrational anxiety,
may come of it, but not often distinct melancholia.

  Case  XIII.—Mr.  L.,  aged thirty years, an engineer,
consulted me on  account of  nocturnal attacks.  Except
that  he  had frequent ophthalmic megrim,  he was in good
health and free from evil hereditations.  After a period of
great commercial anxiety he had  one  night  a dream of
falling from the trestle of a bridge.   He awoke sweating
and in a state of wild agitation.  He said that  he rose, lit
up the room, and began to walk about.  His affairs seemed
to him hopelessly involved; he figured himself as  weak,
incapable, and untrustworthy.   Life seemed unendurable.
He cried like a  child, and  at last drank a  tumbler of
brandy and fell asleep.   This torment came  again  at  in-
tervals of weeks or months, and later on became frequent. 
MELANCHOLIA.
51
The  dreams  varied, but the results were the same.  A
summer in the woods brought relief, and an ocean voyage
finally rid him of this disorder.

   I shall close this too condensed statement of certain
of the unusual ways in which melancholias arise with
a single example of its production during digestion, in
a case of  intermittent glycosuria:

   Case XIV.—H. R., aged about forty years, a scholar of
uncommon ability, consulted me for a  condition then and
since unknown to my experience.   He had been for years
a  dyspeptic,  suffering much with a sense of weight at  the
epigastrium,  with wind and excess of acid.  Within a few
months the  dinner at 7 p.m. was  followed by the usual
distress, but  later, about 9 p.m., by deep dejection, indif-
ference to life, desire to be alone, tears, and what he called
"fragments of delusions," easily disposed of by the reason,
but  apt  to return.  This condition passed away about 12
at night, and he usually slept well.  These attacks became
of daily occurrence  and were more or again less  severe.
It was soon found that he had sugar in his urine; that the
quantity was least on rising from sleep  in the morning;
that it increased after  meals, and was largest about two or
three hours after dinner, the time at which his melancholia
arose  and deepened.   A  long  course of  skimmed-milk
diet was of great  service, and  later, by eating a carefully
chosen diet  six times daily, he did very well, escaping for
a  long period both the glycosuria and the mental disorder,
which appeared in the evenings and seemed to be  related
to a  rise in  the amount of excreted sugar.  He died of
double pneumonia some years later.

   I recall no other case of melancholia clearly  related to
digestive troubles, or to glycosuria; nor do I think that
ordinary cases of the  mental disease  suffer more after 
52
NERVOUS DISEASES.
meals.  The early morning  hours are, as all alienists
know, the time of greatest misery; the chosen hours for
suicidal thoughts  or  efforts.   When  this sequence is
reversed and the evening is the time of gloom we have,
as a rule,  to deal  merely with the dejection  met with
in some neurasthenics or hypochondriacs, or with an
hysterical  simulation of melancholia. 
CHAPTER  III.
irregulaely recurrent melancholia with long
   intervals  and  not in  apparent relation  to
   function.

   Perhaps there is no more reason to be surprised at
melancholias which recur after a day or days of sanity,
than  as  to  those which  return  after  months or years.
In cases like that quoted at the close of the last lesson
the regular repetition of  melancholia  in  connection
with  the time of digestion  tempts the  reason with pos-
sibilities of explanation; but in the  cases to which  I
now refer, and shall illustrate with a striking example,
no form of explanation as yet seems available.   Never-
theless, it is in the careful study of such melancholias
and their sequent intervals of soundness of mind that
we are offered the best chance of discovering the agen-
cies which can so quickly develop a mental disorder.
   The following case sought advice while I was writing
this paper.  It is  an example of recurrent melancholia
of brief  duration, returning  every two or three days,
and lasting  four hours to twenty hours:
   Case XV.—C.  E.,  retired  merchant, aged sixty-five
years, married.   The  father was  healthy, and died aged
eighty-eight  years ; mother healthy, died aged eighty-four
years.  Three sisters  are alive and well.  Three brothers
died  aged  respectively seventy-five, seventy-four,  and
thirty-eight  years;  one nephew had  melancholia with
delusions.
  Had had  typhoid  fever in 1870—no sequelae; habits
                        5* 
54
NER VO US DISEASES.
good;  no  syphilis.   For  fifteen years  has been  liable
to feel  depressed when his business became troublesome,
or in commercial crises.  His general health is unusually
good.   The  heart  and  arteries are  far better  than is
common at his  age.  He is clear of  head,  competent in
business, sleeps  well.  His  appetite is good ;  his bowels
regular.  Is  liable  to occasional indigestion,  with  non-
acid eructations.  He  has  normal  reflexes;  his  station
is perfect.   The urine shows no albumin or sugar.  The
morning urine,  on  standing, presents a  small deposit of
free  uric acid and urates.  The attacks I  shall  describe
have no relation to the meal-times.   When  away from
home they are fewer  in number, but except as to this  he
knows of nothing which affects  the  number  or severity of
the spells.
  About five years ago Mr. E. began to have brief attacks
of mild melancholia.  They came at irregular  intervals—
weeks apart.   A year later their frequency  and intensity
increased, until ever since they have  continuously recurred
two  or three times a week.  The longest interval is five
days.  They may repeat themselves  every day, on two to
four successive days, or  return  upon  alternate davs with
regularity.   The seasons do not affect  their number, nor
does the time of  day.   He may  awaken in an  attack;  he
may have one at evening, and lose it in  the sleep, which
it does not seem to  make less  sound.    He can  neither
avoid these spells nor lessen their force  or shorten them.
From the time he first feels the attack or sense of dejection
to its climax about half an  hour elapses.  It passes away
even more  abruptly at times, but commonly  is an  hour in
leaving him, dating the time from a sense of  distinct relief
to full possession of his natural cheerfulness.
  While thus afflicted  he  is melancholy, irritable, turns
over and over in mind every possible source of annoyance,
even conjuring up the  worries  of  others with which to 
MELANCHOLIA.
55
perplex himself.  At these times he must be alone;  will
see no one ; contemplates suicide, but has made no suicidal
attempt and does not believe he ever will.  This dejection
he describes as profound, and says that  hope seems dead,
affection valueless, and life  a  torment.   He  has no delu-
sions of sense; then there is a feeling of relief, and, as de-
scribed, the "cloud passes," and he is, as usual, gay, happy,
and equal to any sport or work.

   To illustrate this singular case, I give his own record
of twenty-two successive  days in midwinter:  twelve
were free  from  attacks; on  three he  had brief, mild
spells.   He  had six  sharp  attacks, and  one of great
severity both as to length and excess of melancholy.
   Prof. Samuel Jackson described a case not purely or
very distinctly melancholia, which  recurred  alternate
weeks with sane intervals, and  ended in dementia.   I
can find nowhere, however, a melancholia which repeats
the phenomena of  the case I have given.

   This  gentleman returned January 12, 1897, to permit
of study of his days of melancholia as compared with the
normal  intervals.  Unluckily, but as is usual  with him
when away from home, he had fewer attacks—in fact  but
two in the fortnight of his stay.
   Study of his secretions  by Dr. Pearce  began  by  an
examination which  gave the  following  results:  He  was
feeling  well;  pulse  72 and respiration 18 ;  temperature,
98.5° ;  blood-count,  4200,000; haemoglobin, 90, at 11 p.m.
  The urine for twenty-four hours was over the normal, as
he weighs 140  pounds ;  amount,  forty-five to fifty-five
ounces; specific gravity, 1020.  No abnormal  constitu-
ents  except amorphous phosphates were  thrown  down
after the urine stood a few hours.  At  this time he looked
well and ruddy, and was, as usual, gay and cheerful. 
56
NER VO US DISEASES.
  On January 20th  he had an attack:  notes  taken at  10
to 11 p.m.
  He had  been, as  he said, " fine" until late this  after-
noon, when he  began to  feel badly.   Did  not  wish  to
speak  to  anybody or exert  himself.   Noticed  nervous
cough and accumulation of sticky mucus in throat and
feeling of depression about the " brain" and of pressure
over sternum.   Did not care to go to "opera" on  account
of this "cloud " settling over him.  Went to bed and slept,
but awoke in  two hours in a dreamy state with feeling of
despair and discouragement, the  "cloud" or  haze gradu-
ally falling over  him  until  the  mental  depression was
almost unbearable, and  he was  afraid  he would be an
"imbecile."  Unnatural dread of  the  little  preparation
to go home.  Could  not, through any effort, throw off the
feeling.
  When  seen  at 10.30 p.m. the  eyes were dull and red,
the pupils equal and  responded  sluggishly but equally;
station good; knee-jerks normal;  respirations regular, 18
per minute ; pulse full, compressible, 72 per minute ; tongue
clean and moist; temperature subnormal, 97.6° F.
  January 21st,  reports attack as passing off while we were
talking together at 11  p.m.  Slept well; awoke  at 7 a.m.
Feels "fine."    Says he could do  business to-day better
than  usual, being  clear and competent.   Four  ounces  of
urine were saved during the attack.
  During the day of onset the quantity of urine fell  to
thirty-three ounces.   In another minor attack  it was  in
excess—fifty-five ounces.
  While  in mental  health he passed rather less urea than
is usual; in both  the  attacks it  was materially lessened.
The percentage  of uric  acid  was decidedly increased  in
the more severe attacks, but not in the milder.    Indican
was certainly present in larger amount in the urine of the 
MELANCHOLIA.
57
melancholias than in that passed while  free from depres-
sion, when only a trace was detected.

  I complete this notable case with a table of the days
of melancholia noted during 1896:
  In January  there were  nine bad days;  February, six;
March, ten ; April, thirteen ; May, eight; June not given,
but said to be a bad month;  July, ten ; August, five ;
September,  three;  October, nine; November, five; De-
cember, eight.  Evidently the spring and summer months,
up to August, were the worst.

  Unfortunately, this gentleman was called away before
he  gave  us any further opportunity to study his case,
and it were unwise to draw conclusions from these im-
perfect chemical analyses. 
CHAPTER  IV.
            SOME DISORDERS  OF SLEEP.

  When dealing with  organs  or functions the physi-
ology of which we, in a measure at least, comprehend,
it becomes easy and pleasant to discuss their alterations
from health; but as regards sleep we know little.  The
wildest theories have been entertained concerning  it;
and, after all, we are simply driven to  believe  that  it
is a state of the nerve-cells—and why not of the nerves ?
—in which they become  functionally  actionless  in a
variable degree.   Whether this be true also of the other
cell-structures of  the body we do not know;  and  sleep
may be a universal function, as would seem reasonable
to those who believe  that plants sleep.   It is sure, also,
that the sleeping brain contains less blood,  or that it
circulates less, than  the brain awake, and this is the
limit of  what we know.
  The disorders of sleep arc many.  I have found my-
self driven  to choose among  them, and I shall  limit
myself to a less known group, to some members of which
I was the first to call attentiou.
  In 18761  I described  several of the morbid states of
sleep, and again wrote  of  them  more freely in 1878.2
In  1882, in  my  lectures  on Nervous Disorders  of
Women,  I  dwelt  at greater length on the symptoms
in question, as well as on others which have been much
1 Philadelphia Medical Reporter, 1876.
2 Virginia Medical Journal, 1878. 
SOME DISORDERS OF SLEEP.
59
discussed  of  late in the journals without notable addi-
tions of value.
  In making choice of how I shall treat of sleep-troubles
I have been influenced somewhat by the fact that certain
of these it has been my fortune to see and to study more
than I  have the better known phenomena of dreams,
somnambulism,  and the like.
  The approach to the unconsciousness of slumber, andv
too, the return from it to  the world of volition, may be
medically considered as part of sleep, 'and, as I  shall
show, these periods are often disturbed by certain very
interesting symptoms.
  As we are  falling asleep  the senses go off guard in
orderly and well-known succession—this interval I de-
sire to  label  the pros-dormitium.   When we  begin to
awaken, and  the drowsied sentinels resume their posts,
there is again a  changeful time, during which the mind
gradually regains possession of  its powers—this interval
I may call, in like fashion,  the post-dormitium.
  The Relation of the Prse-dormitium to Insanity.
In the borderland of coming  slumber,  when  we are
not yet overwhelmed by  its full power, the steadying
contradictions of the external world are, in a measure,
by degrees cut  off, whilst the will  still  holds a slowly
lessening rule.  It has long been known to alienists that
the prae-dormitium is apt to be invaded by hallucina-
tions  in those who are becoming  disturbed in mind.
Every student of himself knows, too, what a fairy coun-
try for visions is this intermediate state.  Since, in the
sound, it  is the time for  castle-building, it seems nat-
ural  that, in the disordered, it should serve  to foster
dangerous  hallucinations,  and  that, in rare instances,
these should be limited to  the period in question.  Bail- 
60
NER VO US DISEASES.
larger is the only author who has studied with any care
the relation of the prae-dormitium to insanity.   Of this
he says:
  '' The organs of sense ceasing to transmit to us exterior
impressions, the control of  our ideas escapes us, and what-
ever rises appears, as it were, spontaneous;  at times vague
or confused, fantastic forms  succeed one another, and we
have  of it  all  but a half-consciousness.  At  times more
distinct forms appear, and we are present, as it were, at a
strange spectacle  in which we take no active share, but
which leaves distinct traces  on  the mind.  Any exterior
intervening impression  causes these visions to vanish.  A
sudden  noise, or touch,  or  light awakens fully the senses,
recalls attention, and these phantoms are effaced."1

   The period now in question is of great psychological
interest; nor have the laws which control it been studied
enough.  In childhood it is certainly the time of easily
attained visions,  and in the imaginative this is especially
the case.   As years go ou  the  power to fill this magic
interval with  what we will to  see grows less,  and in
later years is materially impaired  or is altogether lost.
   I have been at some pains to learn to what extent the
capacity to call up, control, and dismiss visions exists
in the prae-dormitium.   The ability to project visually
at  will on  the screen  of consciousness greatly  varies
with  the individual.   Generally in youth it is possible
soon  after  closing the eyes for sleep  to evoke visions.
Some children can control these visions.  They see what
they  will.   This was  at  one time the  case with  me.
Others may will in vain.   They  see  nothing  or only
the crude stuff of  dreams, or else something they did
1 Baillarger : Annales Med. Psych., vols. v. and vi. 
SOME DISORDERS OF SLEEP.
61
 not seek to summon.  Few can  hold these  phantoms.
 They come, they go, change and  vary under  mysterious
 influences, uncontrollable by the will.   Such is  apt  to
 be the case later in life for all who continue to be able
 to possess the power.
   This is hardly the place to go much further into the
 physiology of the prae-dormitium.   I speak of it  only
 because it is the threshold of  sleep and  full  of interest
 to the alienist, and,  indeed, to the neurologist.
   Even this brief study of its peculiarities reminds one
 of the prolonged  condition into  which we are brought
 by the action of moderate doses of such drugs as mescal
 —Anhelonium Lewinii.  The original study of this drug
 by Professor Prentiss and a  later examination by the
 author1 have made clear the remarkable resemblance  of
 mescal intoxication to the natural period I have called
 the prae-dormitium.   I speak here with assurance only
 as to myself, for, as. I have said, we as yet need  a full
 study  of the psychology  of  the  states  which precede
 and follow slumber.
   In a long series of interesting cases Baillarger  shows
 that certain persons, otherwise still sound, are liable  to
 have, between waking and sleep, hallucinations which
 long precede the outbreak of  insanity.   He describes
 instances of such hallucinations of sight  and  hearing as
 lasting from one to  three years, and ending in  grave
 mental disease.  These were usually voices or visions,
fading when the eyes were opened, as occurs  with mes-
cal visions.   In one case  there was something like the
sense of a blow on the head, and then  on the bed, but
nothing comparable in this direction to the phenomena
i British Medical Journal, Dec. 5, 1896.
             6 
62             NERVOUS DISEASES.

of sensory shocks to which I shall  presently call your
attention.
  I  have myself seen illustrations  of  the facts  men-
tioned, and I speak of them here because this is ground
we rarely go over in our examinations of patients.  It
may possibly be found that valuable prognostic indica-
tions as to insanity are to be gained by examination of
the prae-dormitium.
  Before  passing on  to other  matters I may say that
generally, as I have known  them,  these prodromes of
insanity were connected with eye or ear alone.   In but
one case was olfaction concerned.  I will content myself
with a sketch of  it:

  Case XVI.—Mrs. C, aged forty  years, of a neurotic
family, all liable to neuralgic headaches.  One  brother
died of ataxia.   Convulsions  in infancy were common to
all  five brothers  and  sisters, none  ending  in  epilepsy.
Mrs. C, who was  well  except as to headaches, had  a fall
which  injured her nose.  The shock  resulted in persistent
headaches,  without other  cerebral trouble save  complete
loss of smell.  Two years later she had, but only on going
to sleep,  a sense  of horrible odors,  which were  fecal or
animal and most intense.   This lasted several months, and
then were added sounds of voices, which were at first vague,
but  at last accusative,  and soon were heard in  the day.
The  case ended in  melancholia with delirium of  persecu-
tion, during which the trouble as to smell passed away.
  Case XVII.—A. C, a clever lad, of exceptionally able
and normal descent, became insane at eleven years of age,
and  was  long maniacal and  often homicidal.  For  some
months before this outbreak—which  was acute—he  was
troubled by seeing animals on his bed before he fell asleep.
Opening  his  eyes routed them  at once.  The condition 
SOME DISORDERS OF SLEEP.
63
seemed  to have none  of  the peculiarities of the  night-
terrors of childhood.
  I am tempted to add the  brief notes of  another lad's
case, in which the same  period was a time of singular
disorder of  mind.   It is, of course, known to many of
you that the bromides may in some persons (and notably
in the young)  occasion, like mercaptan, profound melan-
choly or maniacal tendencies, which in several instances
in my experience have been  homicidal, or at least madly
destructive.
  Case XVIII.—The lad in question, an epileptic, aged
eleven years, was said to become homicidal from bromides.
I Avas  skeptical  enough to test  the matter.  About the
seventh day of  using full doses of lithium bromide the
trouble  showed itself  in the praesomnic time as visions of
himself killing other children.  They annoyed him greatly,
so that he strove to keep  awake;  but  at last, tired of the
unnatural effort, would fall asleep, Avith too brief an interval
to alloAV of his  being disturbed again.  After several nights
of like distress the homicidal  tendency broke out in abrupt
and dangerous violence  during the daytime.
  There are  epileptic cases in Avhich inhibition of fits
causes homicidal explosions Avhich cease when the fit
comes  on,  and  do not recur for a time, whether bro-
mides are continuously used or not.   In this lad's case
the fits did  not lessen the tendencies to destroy or injure
others.   These lasted as long as the  bromides  Avere
given.  I think Echeverria mentions like cases.1
  There exists also, I may say, a group of cases (not in
the books) in  Avhich the borderland of sleep is haunted

  1 Also the author. See On Exceptional Effects of Bromides.  Transactions
of Association of American Physicians and Pathologists, May, 1896. University
Medical Magazine, June, 1896. 
64
NERVOUS DISEASES.
by hallucinations for weeks or years without their end-
ing of necessity in mental disease; but  it is  quite im-
possible  for  me  here  at this time to dwell on these
interesting cases, of which I  have seen a few, and but
a few.  In no respect  do they differ from the  like cases
reported by Baillarger in which insanity resulted, save
in the fact that it did not.   Voices were heard or dis-
tressing visions seen during the prae-dormitium, and at
no other period.  With time and due  care  these vis-
ions faded aAvay.  Two of the half-dozen I recall were
hysterical women; two were men in busy affairs; and
one, the  worst, a woman of thirty-seven years,  was, I
think, preserved from insanity by the loss of her o\Taries.
  The corresponding time, Avhich comes after  sleep and
before full Avakefulness, is also said by Baillarger to be
troubled  in some by hallucinations, but of  this I have
no experience;1  nor does he  speak of it  as  common.
Tuke also has reported cases.
  There  is yet another and stranger mental  condition
experienced, though rarely, in  the prae-dormitium.  This
is a suddenly acquired  and  sometimes persistent sensa-
tion  of fear or terror without any sensory hallucination.
For  our emotional states we have usually a cause, or at
least  think we have;  but Avhat  I  uoav describe is an
emotion  without  known parentage.   Children may
exhibit this continuous fear after the scare of  a dream,
like  the  echo of  an emotion the cause of  Avhich is
over.
  Sometimes in adults  this lasting sense of alarm is the
product of a dream.  The victim awakens and  continues
even for hours to feel the fear to which his dream gave

 i See, however, as to this, my own later experience—chapter on Recurrent
Melancholia—in this present volume. 
SOME DISORDERS OF SLEEP.
rise.  He  is Avide awake;  lights  the  lamp;  reads, or
tries to; but is still fear-haunted, reason  as  he may.
The patient Avho is liable to this fear may also be sub-
ject to attacks of pure fear Avithout a dream-cause,  and
arising in the time betAveen Avaking and slumber.   He
has then no dream.  Of a sudden, whilst half-awake, the
man is afraid.   It is pure fear, such as the insane have
at times.   I  append a case from my first paper.  Both
forms of the trouble  here mentioned were felt.   The
case is given as  stated by the sufferer, a scholarly, much
overworked man, with no obvious habits, hereditations,
or disorders to explain his condition.   He says:

  Case  XIX—"About the year 1871, being then fifty-five
years old and in  sound health, I Avas troubled with what I
understand to be ' night-terrors,' but unlike any I have
been able to hear of.   Upon retiring I could generally tell
Avhether or  not I  should have this trouble during the night.
These premonitions Avere: a  difficulty in breathing,  not
being able to draw a full breath, owing, as it seemed to  me,
to some obstruction in the lungs;  intense  nervousness;
turning  from  side to side.
  '' I Avould fall asleep and have vivid dreams, and almost
always upon  the same subject, the purport of Avhich was,
that  after long absence from home I returned and found
that some one dear to me had become idiotic.
  "The most  painful attack of this kind occurred in 1872.
That night  I dreamed that after a long absence I returned,
and, upon approaching the city,  I saw upon a steamboat
my aunt.   She had become crazy in my absence and  Avas
under the charge of keepers.   As  I neared the boat to
speak to her  she leaped overboard and Avas droAvned,  and
her body, with a  fearful idiotic leer upon her face, floated
past  me so close that I could touch it.   I awoke with a
sudden start, trembling from head to foot; and, although
                         6* 
66
NER VO US DISEASES.
in a moment I realized that it was but a dream, yet the
feeling of terror,  instead of leaving me, rather increased.
I Avas obliged to rise, light the gas, and leave the room and
remain  for several hours in an adjoining one.  I then re-
turned to bed and slept until morning ;  but the next even-
ing, Avhen it  came time to  retire, the recollections of the
past night Avere  so vivid, and the intensity of the mental
suffering so clearly before my mind, that I could not force
myself  to retire.   My  reason  told  me that  this Avas  a
foolish  feeling, and that I ought to conquer  it; but after
a  severe struggle reason gave place to this  undefinable
feeling  of terror.   That night, and for several nights after-
ward, although I was not  addicted to  drinking, I drank
strong liquor  until my senses Avere clouded, and this I did
intentionally, otherwise I could not have retired.
   "During the daytime, Avhen thinking over this fearful
attack,  I concluded that if  it Avere given me to choose be-
tween passing one such night and being deaf, blind, or lame
for life, I should  choose the latter; nay, I felt that even
death itself would be preferable to such  another night.  I
have  never since  experienced  such intense suffering, but
have passed through it many times in lighter forms.
   "This fall  (1875)  it took  a different turn.  Upon re-
tiring I Avas unable to  keep my eyes closed, because the
moment I closed them a feeling akin to fright Avould cause
me to open them.
   "This Avas like, but incomparably less than, the dream-
evolved terror.  Nevertheless,  it  was bad enough.  It did
not come if, sitting up, I closed my eyes ;  but to lie doAvn
and close them was often enough; or, if the emotion did
not then arise, it seemed to burst upon me just as I was
conscious that sleep was near.  These  attacks Avere the
worst.   I was afraid—and of nothing.   No reasoning
helped  me.  As I  am by nature, despite my professional
life, hardy and courageous,  I was rather ashamed of being 
SOME DISORDERS OF SLEEP.
67
fearful of nothing, knowing that in  battle I had had no
more fear than others, and none that disturbed me.
  "After tossing endlessly for hours I would at last sleep
for an hour or more Avith the sense  of sleeping ill.   If 1
had a bad bout,  I sometimes awakened Avith my mind not
clear and feeling as if I needed effort to steady it."
   Despite these alarming symptoms this gentleman got
Avell after a summer in camp in Maine.
   Others have described  to me this  state of fear in the
prae-dormitial conditiou.   Says one:

  Case XX.—"I have had, like others,  nightmare; but
this comes over me Avhile I am quite conscious, and of this
I am sure.  Whilst yet capable of mental analysis and just
pleasantly drowsing, I simply and abruptly realize that I
am afraid.   I feel it coming.  I  am not paralyzed, as by
nightmares;  I can  moA'e.   If I fully sit up, it is  over;
but if I delay to do so, and it catches me, it stays on for
a minute or two  after I am completely aAvake and master
of myself.  I sometimes lie still with open eyes and seek
to knoAV Avhy I fear, or reason it  over, but  nothing relieves
me.  The fear goes by degrees,  but if at  once I lie doAvn
again and close my  eves it comes back."

   Another mental state, someAvhat akin  to this last (for
fear  and anxiety are near akin), also occupies the prae-
dormitium. It is always an associate of  bad sleep or of
insomnia, and consists in a series of unreasonable fears
and anxieties.   I will let a sufferer tell  his story as he
Avrote it for me.
  Case XXI.—-This sufferer was  fifty years old, of ner-
vous temperament, a man  of restless intelligence,  anxious
always, successful past  the common,  free from disease, en-
dowed  with a perfect stomach, and  habitually insomnic.
He called three hours a good sleep, and for years lived on 
68
NERVOUS DISEASES.
this and an afternoon nap of an hour.   Now and then his
restlessness got worse, and Avas the insomnia of over-vigilant
and excited centres, Avhich furnished a succession of anx-
ieties, each in turn capable of inhibiting sleep.  He says:
  " This trouble haunts the time  close  to sleep.   I lie
doAvn ; am  easy,  and assured of sleep.  Suddenly, I think,
is the  gas  turned  off properly ?  I get up and look ; re-
turn to bed ; get up again, and so on.   At last I become
anxious as  to my son, aged six.   Is he safe in bed ?   Will
he fall out ?  My wife  goes to  see, reassures me, and then
I go myself, and go  a  dozen times.   Next, it is the  fur-
nace, or the locks, or fear  of  fire, until,  Avorn out, I am
surprised by sleep.   It  seems as if this thing Avaits for me
at the gates of sleep, and I can understand that just then
one's fancies may run  Avild.  But once aAvake, the thing
goes on until I  am ashamed of the demands made upon
my Avife, and, too, of my own  folly.   I  knoAV  of  others
who have the same trouble, but never in the day season."
  Sleep-numbness. Nocturnal Paresis or Paralysis.
As sleep-numbness,  this disorder has become  familiar
since I described it in  February, 1876,  and later more
fully in my book in  1882.   Since then, Dr. AndreAV H.
Smith, in this country, and Dr.  Saundby, in England,
have  Avritten of it anew; the  former as  an undescribed
neurosis, and the latter Avithout full knowledge of Avhat
had already been  Avritten.  Dr. Saundby thinks I ap-
pear to have  recognized this  condition, but is of  the
opinion that the  name I  gave—nocturnal  hemiplegia
—in view  of  the occasional  association of temporary
loss of power, is not very appropriate.   In fact, I de-
scribed pronounced cases chiefly, and their duration had
nothing to do with the nomenclature.
  In general, functional day-numbness (as I and others
have described  it), Avhether neurotic, anaemic, goutv, 
           SOME DISORDERS OF SLEEP.         69

diabetic, atonic, or asthenic,  is apt  enough to repeat
itself at night in sleep.  But there are people Avho never
have day-numbness,  and who are, nevertheless, liable
to awaken Avith this interesting neurosis.
  Definitions of it do  not admit of sharp boundaries.
It may be local, transient, a slight numb feeling, a faint
tingling of the fingers, of a leg, or of one side; or else
it may be intense, and present us with  paresis  and real
defects of the touch-  and pain-sense.   In another case
it may show itself, though rarely, as an  alarming mono-
plegia, or as a distinct  hemiplegia, lasting but a feAV
moments, or groAving Avorse during hours.  Again, it
may involve the Avhole  body, but is then apt to be less
severe  than are the hemi- or monoplegic forms.  I have
seen several of  them  in one person; at this time slight
numbness, and at that hemiplegia, alarmingly  positive,
with marked loss of power and with lessened sensibility.
For Dr. Andrew  A. Smith,  waking-numbness  is a
paraesthesia at  the exit from  sleep, and " in this," he
says,  "there is nothing added, and  nothing  taken
aAvay."  But these subjective states, Avhich to-day are
mere tingling or formication, may to-morroAV deepen
into the semblance of hemiplegia,  Avith distinct loss of
sensation.   It is only a question  of degree.  The neur-
asthenic, the hysterical,  the tobacco-poisoned, the gouty,
the dyspeptic,  are  liable to  aAvaken Avith numbness,
tingling, dysaesthesia  of a part, or of both hands,  or of
a side.   It  goes off  in a few minutes.   More rarely
there is a distinct Aveakness of an  arm or side, Avith dys-
aesthesia, very  rarely with  complete  loss  of  feeling.
And so it is that we  may have various degrees of dis-
turbance from  faint  tingling to profound temporary
dysaesthesia, and defects of poAver from  paresis up to 
70
NERVOUS DISEASES.
a brief simulation of  paralysis.   Were  the Avorst of
these simulations to last, they would be  grave enough,
and, in fact, it does sometimes  happen that such states
as I describe may even deepen in intensity after the
patient is fully awake.   In some patients they recur
night after  night, attack  both hands or both  sides on
successive nights, or occur at intervals  for years.   I
may add that I have sometimes seen this symptom in
men apparently vigorous,  and that it also occurs, now
and then, in those Avho have multiple cerebral aneurisms
or endarteritis.   I have seen it, too, over and over, in
convalescent hemiplegics.  They awaken with the palsy
Avorse, a functional condition being for a time added to
that Avhich  had an organic  cause, or the  sound side
suffers, to their great alarm.
   I  give a physician's story of his attack:

  "  Excessive work, with double abuse of tobacco (smok-
ing and chewing), had caused day-numbness, which troubled
the ulnar territories most.  One morning I awakened with
transient numbness of the Avhole left hand, Avith no true loss
of touch.  A week later I had, on awakening, dysaesthesia,
Avith pricking of the whole  right side, including face and
tongue.  I arose, found  leg and arm Aveak,  examined sen-
sation  in the finger-tips and recognized the fact  that with
sensor-points applied to the finger-cushions I could not be
sure of them as tAvo at one-third of an inch separation.   I
was  about to send  for a physician, when the sense of ting-
ling  becoming Avorse in the extremities, the dysiesthesia
grew less, and in two hours I Avas as well as ever."

   It is of  interest that  he soon  after  saAV  a case  of
Avaking-numbuess in a tobacco-using patient, whom he
confidently  reassured, stating  his  own  case.   In fact, 
SOME DISORDERS OF SLEEP.         71
however, the patient OAved his numbness to unrecognized
diabetes, and it ended in gangrene.
  The history of numbness in all its grades points to a
central  origin, but that  it may arise otherwise is also
clear.   In some  cases of neuritis  I  have seen night-
numbness as a first, a transient, and a  repeated symp-
tom preceding the pain by several days.
  Some years ago, whilst writing  my  book on Nerve
Lesions, I froze my right ulnar nerve at the elbow with
alcohol at 0° F.   For ten days afterward I had  more
or less discomfort, and at times acute  pain, but  espe-
cially, on  several occasions, a positive numbness of the
ulnar territory Avith Avhich I aAvakened.  It passed off
with friction in an hour,  but Avas much worse  than the
occasional day-numbness Avhich my somewhat  rash ex-
periment  created.  Yet, for a time,  it Avas purely a
Avaking symptom and faded swiftly.   The more pro-
found examples of hemianaesthesia with paresis as post-
somnic states are, I think, most apt to involve the right
hemisphere.   I recall no instance of aphasic accompa-
niments in the rarer  left  brain disturbances.   In their
varieties these symptoms probably  represent functional
irritations or  inhibitions of quite various parts of the
brain;  unlike their hysteric related states, they are felt
in the face as well as below it, and are  clinically of kin
to the functional anaesthesias  and  pareses  of certain
migraines.
   In some cases, notably in hysteria, waking-numbness
is associated Avith pain in the parts affected,  or  there
are also paraesthetic expressions, as sense of constriction,
of elongation, or of  enlargement of  limbs, etc.  At
times  the sensation resembles the  furious  formication
of aconite-poisoning. 
72
NERVOUS DISEASES.
  In Dr. Ormerod's paper1 on numbness (which is the
best of the English essays) he speaks of the pain suffered
by some of  his cases,  and as to this he is quite correct.
In fact, there are  those who aAvake Avith pain in  arm or
leg, or  both, so intense as to  make the accompanying
numbness seem of little moment.   Pain as an accompa-
niment is also mentioned  by Sinkler, but not as being
severe;  Avhereas  it is in  some  instances of Avaking-
numbness very great.   I add  two or  three cases.  The
first, again  that  of  a physician, I give as he Avrote it.
He says:
  " The preparative causes of my present state  Avere excess
in tobacco and a  practice Avhich left me no  rest.  Then
came a domestic calamity,  and  I broke doAvn Avith  distress
in the  occiput and  an  amount  of suddenly developed
physical feebleness which annoyed me.   I could not walk
up  three  flights of stairs without  resting.   My heart be-
came  rapid—90 to 100 ; my temperature 97.4°,  and at
night 98°.  I Avas struck, too, Avith the Aveakness of my
bladder, the urine merely falling as  it emerged.  All  this
was in  December.  In February I began  to  have night-
numbness, and Avould Avake in the night Avith all four
limbs numb.  The Avorse attacks were those at Avaking in
the morning late.   Early in the night  the symptoms Avere
less notable, or else affected one  limb  only, or one side.   At
times it was mere tingling;  at others, positive  lessening of
sensibility to touch and pain. When this was  the case the
limbs were for a time paretic ; on one occasion so much so
that I fell on getting out of bed.   The trouble has never
lasted more than thirty minutes, and usually Avent off with
great tingling, as of  a  limb  asleep, as  is said.   After
March  I  began at times to have numbness   in daytime,
but rarely so intense as to  disturb feeling.  The tingling
1 St. Bartholomew's Hospital Reports, 1RS3. 
            SOME DISORDERS OF SLEEP.         73

occasionally affected  my whole surface, and Avas  apt  to
begin around the mouth."
   In this case the symptoms were  neurasthenic, and
absolutely no other cause could be assigned for them.
Recovery Avas complete.  The next cases are from Dr.
Fere,1 and are certainly hysterical and of great interest.
   Case XXII.—"Mrs.  V.  came to consult me, for the
first time, at the  Saltpetriere on January 12, 1885.  She
was accompanied by her mother, Avho Avas over sixty years
of  age, but still very agile, and  looked  much  younger
than she really Avas.  The mother had a painful ovarian
spot with slight  anaesthesia  on  the  left side.  Although
the menses had ceased nine years previously,  she had
been subject to migraine, Avith attacks of melancholia, and
occasionally convulsive fits.  The father, Avho had been a
drunkard and profligate, had  quitted  the  house twenty
years before, and no one kneAV Avhat had become of him.
A brother of the father  had 'died in prison  while under-
going confinement for swindling.   Airs. V. had tAvo sisters
born after her.  The one had died of convulsions connected
with teething at the age of eighteen months ; the other died
of convulsions Avhen only six months old.
   " Mrs. V. had  been  a precocious  child both physically
and mentally.   She had Avalked and spoken at a very early
age, and had learned very rapidly at school. She has  never
had convulsions nor tic, but from the age of six has suf-
fered  from frequent migraine, folloAved by vomiting, and
during her whole life  her sleep has been troubled by noc-
turnal terrors  and nightmare.   Menses began when she
was twelve.  At  the age of  seventeen she  had attacks of
chorea in consequence of  worry.  This lasted three months,
and chiefly affected the left side.  At  nineteen she was mar-
ried, and  had  her first  child, a boy, when twenty-three.
1 Brain, October, 1889.
       7 
74
NERVOUS DISEASES.
This child  died of convulsions on the eighth day.   In the
folloAving  year she  was delivered of  a child stillborn.
During her pregnancy she had anorexia and  vomiting,
which ceased spontaneously in the fourth month.
  "Since her chorea Mrs.  V. has always enjoyed good
health, and has had no distinctive nervous outbreaks until
about three years ago.  At the time her husband died she
suffered severe pecuniary loss.  This  induced  insomnia,
followed by  loss of appetite  and emaciation.  By hard
Avork her health became pretty good.  About  tAvo months
ago  she had a very abundant metrorrhagia.  A few days
after this mishap she began  to  feel constrictive pains  in
the head, extending over the Avhole of the cranium, but pre-
dominating in the postero-inferior region, Avhich appeared,
moreoA^er, to be the seat of a constant pressure.  From
time to time she heard a cracking noise in  the  back  part
of the neck, Avhich resounded in the occipital region of the
skull.   At nightfall she Avas seized by  painful fancies,  of
ruin for her mother and her daughter,  of illness for all
her  friends; at  the  same time she was a prey to unusual
pusillanimity and indecision.  Her sleep Avas disturbed by
dreadful nightmares.  She Avas  Avidely aAvake toward six
in the morning, but Avas incapable of making any move-
ment.   She suffered from  distention of the bladder, but
could not  eA'en  think of getting up.   Her limbs seemed
numb to her, and as if wrapped  in cotton.  She appeared
to knoAV the position of her extremities only, and it seemed
to her as if the greater  part of each limb Avas Avanting,
and her hands and feet had been brought up close to her
body.   The sensation is analogous to that experienced by
amputated persons, Avho  say they feel only the extremity
of the absent limb.   She could  make no movement what-
ever.  When daylight was admitted a sensation of numb-
ness and pricking gradually appeared in the extremities of
the  fingers and  toes.  These sensations, occasionally  very 
SOME DISORDERS OF SLEEP.         75
painful, preceded the return of  ability  to  move.  About
eight  o'clock "the patient could get out of bed, maintain
herself in a standing position, and make movements of the
arms.   The  complicated moA^ements of the fingers,  Iioav-
ever, remained almost impossible.  She Avas thus incapable
of fastening her clothes  or of taking up a pin.   When she
had moved her arms and had been rubbed a little her fin-
gers became more supple.  From the time she awoke until
the nearly complete restoration of  movement took in gen-
eral about three hours.   One day, Avhen left  in  a  dark
room until about ten  o'clock, she Avas found in the  same
helpless condition.  Movements of  the head and neck and
of articulation were  not affected.  On examination  no
modification of the external  aspect of the limbs could be
determined.   She  suffered pain in the  region  of the left
ovary and had slight anaesthesia on  the same  side.  The
contraction of the field  of vision Avas tolerably extensive,
and the patient Avas insensible to violet rays in the left eye.
The iris of the left eye Avas of a deeper broAvn and the  pupil
not so large as on the other  side.  Under the influence of
bitters,  iron,  bromide  of potassium,  and hydrotherapy
combined Avith static electricity all these  symptoms dis-
appeared in  the  space of three  weeks, Avith the exception
of pain over the ovary and the hemianesthesia.  This case
was, of course, distinctly hysterical."
   Case XXIII.—Mrs. P. She complained of sudden shocks
in the head which awoke her  abruptly.   These occurred
by night four or five times.  Finally came other troubles
which raised her inquietude to a climax.   When her sleep
became broken, toward four or five  o'clock in the morning,
she found that she could not move  any of her limbs.  This
general helplessness did not last very long, for after  a few
minutes of effort she recovered power of  movement in her
right  hand  and foot, but for the  limbs on the left side
prolonged friction was necessary.  This paresis Avas accom- 
76
NERVOUS DISEASES.
panied chiefly on the left side  by a sensation of  painful
numbness and  pricking.  The  hand especially  Avas cold,
and  the fingers appeared to diminish in volume, the rings
hanging quite loosely.
  This helplessness, which at  first persisted  only a few
minutes, was in a month's time prolonged  for an  hour or
more.  The patient could not  raise herself  out  of bed
until some one had rubbed her energetically.  Even then
she Avould  remain for many hours incapable  of  making
any  delicate movements or  even of simply fastening her
dress.  When the paralysis Avas at its maximum the patient
declared that she was no longer conscious of the existence
of her own body;  that  she was, to use her own Avords, a
pur  esprit.
  Under the influence of cold douches  repeated  twice a
day  at regular hours and a  tonic  treatment of  iron, nux
vomica, and arsenic,  with  bromide of  potassium  given
every evening in moderate doses—one to  three grammes—
her  condition  rapidly  improved.  The  paralytic  numb-
ness  on waking  diminished at  once in duration  and then
in intensity.   At the  end of fifteen  days it  had  almost
completely Aranished.  The  sensations of  shocks  in the
head, Avhich had caused the  patient to aAvake,  disappeared
in turn.  The  anorexia and  pains resisted longer ; at the
end of six Aveeks the pain in the tendo-Achillis  still per-
sisted, but in time it too disappeared.
  It is very clear that a A^ast range of disease  or dis-
order seems capable of causing night-palsy in its A'ariety
of degree.   As concerns the cause, there is much differ-
ence  of  opinion;  some look  upon it  as due to rare
somnic conditions  of the vessels of the brain, while
others,  like  Fere,1  attribute  it to  a  deficiency  of
physiological excitation—"paralysis from irritation."
1 Brain, October, 1889. 
SOME DISORDERS OF SLEEP.         77
 Reflex it surely is at times, and purely local or periph-
 eral but rarely.
   It is needless to discuss treatment.   It means any-
 thing from the treatment of neurosis to that of gout,
 neurasthenia, habits, renal  insufficiency,  diabetes,  and
 Avhat not.
   Sleep-ptosis.   Another form of annoyance to which
 I  have time to give but a passing notice is the ptosis
 of sleep.   Of  this I nowhere  find mention.  The pa-
 tient awakens  Avith  palsied lips;  lifted,  they fall.   In
 some instances it lasts a few minutes or  longer,  or else
 before the disorder  repairs  itself  sleep returns,  and in
 the morning the  patient has it aneAV, or aAvakens with-
 out it.
   I  append  two cases Avhich came under the care of
 Dr.  de Schweinitz:

   Case XXIV.—One Avas that of a woman, aged  sixty-five
 years, as I understand  in good  health and not hysterical.
 There Avas some irritation of the lids and slight general con-
 junctivitis, also there  Avas a slowly ripening double cataract.
 As the vision Avas still fairly good she read much, and if she
 used her eyes freely in the evening Avas sure to experience
 the following trouble : Avaking in the night, she found that
 her eyes could not be opened by the "will. After they Avere
 forcibly opened they remained controllable  by volition
 until  after sleeping  again, Avhen  the  same  phenomena
 recurred.
   The notes are not complete, and although she describes
 the ptosis as spastic, it seems to me to have been only
 a  night-palsy  of  temporary  duration.   A somewhat
 similar  case  was observed  at  my clinic a  few  weeks
ago,  and I have seen a number of them.
                         7* 
78
NERVOUS DISEASES.
  Case XXV.—J. C, aged twenty-nine  years, a AvidoAV,
was in absolute health  after a childless marriage of four
years.   Soon after her husband's death she began to suffer
Avith sexual dreams, and later with  these and hemianaes-
thesia of decisive type Avithout loss of power.  A year from
the beginning of her widowhood she awakened  thrice in
one night Avith paralysis of the lids.  There wTere no eye-
troubles, but the lids as she awakened could not  be lifted
at will.  When raised by  a  finger  they  fell flaccid, and
only by degrees, in an hour, recoATered tone.  This trouble,
unknown to the day,  continued for many months, and,
indeed, disappeared only Avhen this and all other symptoms
were promptly dispersed by a second marriage.
   In  another case the ptosis  Avas like the emotional
spastic ptosis of hysteria Ave see in Avaking hours, and
Avell knoAvn to neurologists:

   Case XXVI.—A Avonian, aged sixty-seA^en years, in good
general health, but full of  notions ;  for fourteen years she
has been the subject of  stubborn retinal asthenopia; the
eye-grounds are, however, healthy ; there is a  considerable
degree of hypermetropia and astigmatism, together Avith in-
sufficiency of the internal  straight muscles.  Each night,
for a long time, usually between  tAvelve and two, she has
been aAvakened OA*er and over by a  feeling that  her eyes
have closed spasmodically.  She arises, forces them open
Avith difficulty, and bathes them,  " because the lids feel as
if they Avere sticky and would glue fast."  The phenomena
repeat themselves, but  never by  day.

   This  case proved,  I believe, very obstinate, and  is
only notable because it is of  nocturnal origin alone.
   Sleep-pain.  I add a feAV Avords as to Avhat is, for
rarity, a medical curiosity.   I find in my note-book
some half-dozen cases of pain in the legs, never known 
SOME DISORDERS OF SLEEP.          79
to the day, and needing sleep as a conditioning factor.
Whenever I have spoken of this obscure disorder to
a patient  he  is  apt, if intelligent,  to  say:  '' No,  not
pain; it is distress."   It occurs in middle life, or later,
and, without  previous disease, comes  on sloA\dy.   In
one  case  it  followed typhoid fever.   The cases are
alike.   A man is Avell in the day;  walks, works, does
as do others.   Some  time after  he falls asleep he is
awakened by aching in the legs, from the sole half-way
to the knees.   There  is but one remedy—motion.   He
rises, Avalks for ten minutes,  is eased, goes to sleep, and
in an hour or two aAvakens to feel the distress and repeat
the  relieving exercise.  There is no unusual  heat or
cold; nor any abnormal appearance.   The matter is
unpleasantly simple, and there is no clue to a cause.
  The case I  now quote from  my note-book I saAV two
years ago.  It is typical of a rare condition.

  Case XXVII.—J.   C,  aged fifty-eight years,  farmer,
Kentucky; married, two healthy  children ;  himself of
sound breed.   Has Avorked hard and  has  never known a
serious illness.  No malaria.  In October,  1886, consulted
me.  I found him a man Aveighing 180 pounds; height six
feet, vigorous, Avith soft arteries; heart beating 76 and per-
fect. He has no piles, hernia, or varicose ATeins.  Eats Avell;
is in all Avays  moderate and regular; does not smoke and
does not cheAV tobacco.  All the reflexes are normal; the
heart and arterial tension healthy.   No organ is diseased ;
can work all day; no tenderness in nerve-tracts.
  About four years ago he began to Avake noAV and then
with distress in the legs.  During the next year  this got
worse, and now  is a source of extreme  suffering and of
disability, because of the loss of sleep it causes.   Within
an  hour  after bedtime he awakens in what he calls tor- 
80
NERVOUS DISEASES.
ment.   From the knee to the toe his legs ache, Avithout
throb or sharp pain.  He rises, walks until weary, goes to
bed, sleeps, and wakes to the same pain or distress.  Again
Avalks, and so on, until day brings relief.
   At the Infirmary  Ave learned that in the attacks the
legs remain normal as  to temperature, reflexes, and elec-
trical  conditions,  as  well as  to sensation.  No  remedies
Avere of. the least use, except morphine, and  I advised its
steady use in despair as to other means.

   Sensory  Shocks.  Another  phenomenon of sleep,
or its borders, and also in the sensory sphere, I described
long ago as sensory shock or discharge.1   This is a more
rare,  but also a more interesting  disorder, than numb-
ness.   Except  my own paper and a small book by a
homoeopathic practitioner,2 I know of no literature on
the subject beyond a few lines of remark on my paper
in an essay of Hughlings Jackson's.   Nevertheless, the
subject is still of interest.
   All the disturbing phenomena  of  sleep at some time
represent themselves, more or  less Avell,  in our Avaking
hours; but   sensory shocks are, of  all  disorders of
sleep,  the most rare in daytime.
   In  the  prae-dormitium Avhile sensation is fading, but
neA-er on waking from sleep, the patient has  in  his head
a sudden and violent sensation, and the forms it assumes
may be classified thus:
   1.  In the sphere of general sensation.   He feels as if
struck, or as if he had  a shock  like that which a sudden
arrest  of  motion  causes;  or it is  a feeling of rending,

  1 Virginia Medical Journal, op. cit.  Lectures on Nervous Diseases, op cit
  2 In Dr. W. S. Searle's book he described sleep-shocks as a neurosis, hitherto
unmentioned in medicine, and was evidently unaware that I had already and
fully delineated its peculiarities. 
           SOME DISORDERS OF SLEEP.         81

or as of a bolt driven through the head.  These are the
most common.
   2. Auditory.  A loud noise, like that of a pistolshot
or of the crash of broken glass, or as  of a bell, or a Avire
sharply twanged.
   3.  Visual.  A flash of light.
   4.  Olfactory.   Sudden sense of an odor.
   5. I doubtfully add  what I call emotional discharges.
These are always mere abrupt sensations of fear, some-
times preceding the sensory shock, and  sometimes fol-
lowing.
   What happens is usually this: A man going to sleep,
but still quite conscious, and able to  observe, feels sud-
denly a shock in the head.   It seems mechanical, as of
a blow, or noise, or else of both ; and, also, there may
be added a flash of light, vivid or like the soft summer
lightning along an evening horizon.  The intensity of
these phenomena may be appalling, and even those who
are used to them greatly dread their  return.  The first
experience is sometimes most alarming.
   In many cases there is an aura.   A physician, Avho
came to me on account of these attacks, first called my
attention to this.   While Avaiting  for sleep  he became
aware of an  indescribable  something Avhich rose from
the feet and hands, and, taking eight or ten seconds to
reach the head, ended in a sound like the crash of glass
houses breaking in a hail-storm, Avith a vivid flash of
yellow light, leaving him for a moment dazed, but able
at once to rise, or to think.   Such is the usual account
given of this aura.  It never varies, save that it may
rise only from the belly.
   All sufferers,  or nearly  all, who  have an aura, say
they can stop the attack by turning over, or sitting up, 
82
NER VO US DISEASES.
or even by opening the eyes.  A friend, Avho had this
trouble OAving to tobacco, says :
  Case XXVIII.—" The shocks Avere of tAvo kinds; one as
if I received in the brain a thump, and one as if a pistol-
shot occurred in the head.  I had for a long Avhile no idea
that the pleasant mistress, Nicotia, Avas  disturbing my in-
ternal economy.   At last, before learning this, I  got used
to these abnormal things, and Avould lie still and feel what
you call the aura.   By the Avay, it is not at all like an air,
but like the surging upward  of something  more positive.
When it gets to the neck I am gone;  the explosion occurs.
BeloAV that I can avert the wretched thing, either by rising
or rolling  over, for it never  comes except I be  on my right
side.  No mental effort suffices to check it."
  I  have notes of two males Avho suffer only if on the
right side, but I  have not ahvays  made  inquiry as to
this point.
  The aura is said at times to be like a tingling, or else
is described as an upward surge of indescribable nature,
and at times rises only from the epigastrium.   Often
there is none.   Once felt  in any case, it usually con-
tinues in  some form to precede all future  attacks.
  There is another form  of Avarning, Avhich  patients
only succeed in  describing  as  a  state of brain Avhich
foretells the shock.  I have heard this called a hum-
ming, or buzzing, Avithin the head.
  Hysterical Avonien are often quite unable to stop the
shocks, or else the aura is too swift to be a timely warn-
ing.   It is rare to find any grave result.   A feAV people
become vertiginous, but not severely.   At  first, alarm
causes emotional scare  and  a quickened  heart, and in
some few, even when repetition has  lessened the terror
of the shocks, they cause a more  prolonged palpitation 
           SOME DISORDERS OF SLEEP.        83

of the heart.   In a feAV minutes, when sleep is again
near, comes another  shock, or  there  are a number  of
slight attacks, as of a bell, or a guitar-string tAvanged,
and  by degrees fading away;  visual discharges  less
commonly recur in this manner.
   I  have  over and over met Avith cases of sensory shock
in the daytime, but only in the hysterical.  In some
feAV  people they occur during  sleep,  and awaken the
patient, but their habitual time is in the prae-dormitium.
   All of these curious outbreaks represent, as a rule, the
"coarse stuff" of sensory product, or something near
it.   There is sense of shock alone, or this in succession
Avith noise or light, or both.   The  noise is more rarely
comparable as to a note of music, or as to a  bell, or a
string vibrating.   And so also  of  the optic explosion.
There is light, violet or pale yelloAV. No visions appear;
no voice  calls.    It is "primary  sensory  stuff,"  and
no more.   In the one case connected Avith smell the
patient had an epigastric aura, and smelt bananas.   She
had  anosmia.
  These singular symptoms are found in some neuras-
thenics, in hysteria, and most often in men as a result
of overuse of tobacco-smoking.  I first kneAV of  it in
my OAvn case, during  an  attack  of  neurasthenia, many
years ago, and soon learned that it was immediately due
to my segar.  I can assure you that one's first acquaint-
ance  with  it is most terrifying.  Bromides and strych-
nine  control it,  as I have elseAvhere stated.
  I  pointed out years ago the interesting  resemblance
of these innocent  attacks to epilepsy,  and Hughlings
Jackson has also noted the fact.  Bennett,1 in a paper
1 Lancet, April, 1889. 
84
NERVOUS DISEASES.
on the Sensory Auras of Epilepsy, describes cases in
which  the signal-aura consisted simply of crude sen-
sation, such as tingling or pain, Avhich he calls sensory
epilepsy.   These are sensory cortex centre explosions,
Avith consciousness and Avithout spasm.
  Next to touch-aura in epilepsy comes most often optic
aura—sense of light, or definite color Avith form.   In
the prae-dormitium explosions the visual phenomena are
still  more crude than in these; but  in epilepsy audi-
tory auras are rare,  and gustatory and olfactory auras
still  more uncommon.   The patient Avho has a special
sensory aura feels  as  if struck a  sharp blow, or per-
ceives  a  noise in   the  head, or  sees  red fire, or a
flash of light, and has no fit.   Or else he  has a sub-
jective taste,  or, like  a physician  I know,  smells
human ordure for half an  hour,  and may or may not
fail to  have the usual  sequent spasms.  These epilep-
sies are very like such  praesomnic shocks  as give  us
in their  completest  form a sense  of  tingling, which,
rising,  ends in a more abrupt  sensory discharge, as of
a sensation of shock, light, or sound, or these variously
combined, as does also occur in epilepsy sometimes, as
I have seen.   Again, too, in the subjects of sleep-shocks
are found those Avho haA^e in the praesomnic state condi-
tions of terror or daze, which are brief, and  represent
like phenomena in the intellectual or emotional sphere,
such as are the dazed or dreaming states of some epilep-
tics.  And, curiously enough, this, too, may in our illus-
trative shocks be preceded by a sensory aura of  one or
two senses—double auras.
  In epilepsy with  auras Ave may have, first, an aura—
i.e.,  a sensory discharge, usually simple tingling—and
then a sense  of  flash or sound, or of light and sound 
SOME DISORDERS OF SLEEP.         85
together;  the centres being, one may notice, in juxta-
position.1
  In praesomnic discharges the discharge is simple,  or
preceded by tingling—true aura—vague epigastric sen-
sations.   The analogy to epilepsy  is closer Avhen,  as
often occurs, an  uncontrollable jerk  or flop of the Avhole
body ends the attack.   With motor centres patholog-
ically over-excited, or capable of being morbidly over-
charged, Avidespread epileptic  motor  phenomena  may
follow the sensory discharges, and in early cases of sen-
sory explosions hysterical convulsions of mild type may
result, and thus bring us still more  near to the sequen-
tial chain  of epileptic conditions.  On the other hand,
epilepsy is not a disorder which haunts the  praesomnic
time.  HoAvcver close the apparent analogy, there must
be a wide  difference betAveen it and these sensory explo-
sions.
  Lastly, there is a form, which I haA7e seen but twdce,
in Avhich  Ave have an aura—a flash, shock, or sound—
and a sense of  pain darting doAvn  the cervical  spine
and then  along both arms to the finger-ends.
  Sleep-jerks.   Chorea.   In the motor  sphere are
certain disorders Avhich trouble the sleep, or praesomnic
state, in hysteria and neurasthenia, and Avhich are only
distinguished from phenomena found in health by their
excesses.   We all have  had the common experience of
a sudden  jerk of  the body as Ave Avere  falling asleep.
This, in  certain cases, is exaggerated as to  degree and
number, and may occur also during  sleep.   I have seen
many cases in  Avhich, scores of  times  in each night,
the  sleeper  was aAvakened  hy a violent movement  of
every muscle at  once.   In others the jerks are of arms
     1 Angular gyrus and  superior tempor o-sphenoidal convolution.
                          8 
86
NERVOUS DISEASES.
or legs only.   Probably, Avhat are  known as  "foot
fidgets," Avhich  oblige the sufferer to move in order to
o-et rid of an ever-recurring sense of unease, are, too,
of like parentage, and  are to be seen in all degrees of
intensity.  I Avas lately consulted by a Western banker,
aged forty-six years, to appearance well. No organ Avas
diseased.   He  had passed successfully through a time
of great  financial trouble, and in its midst his wife fell
ill.  After she recovered he began to be a poor sleeper,
and exhibited in turn a variety of sleep-troubles.  He
had mild forms of shock—i.e.,  light and  noise.   Dis-
use of tobacco aided these and improved his sleep; but,
somewhat later, he began to have jerking in sleep.  An
arm, or the leg, or the body was violently moved, so as
to wake  him up, and this, he declared, took place  count-
less times in the night.   Still later he lay awake with
uneasiness in the legs.  He moved about and got a little
relief.   If he lay still,  he had to move again.
   These motor discharges at times  assume, through
their  frequency and severity, such  importance  as to
affect  health  by the destruction of sleep  which they
occasion. An instance is giATen in my book of a woman
Aveighing two hundred pounds, who spent her nights in
a series  of motor explosions so  vigorous as at times to
break the bed-slats.   She has told me that she believes
herself to  have had as many as a hundred in a night;
the whole  body moving violently in sleep with  a jerk
like the  leaps of a dying fish.
   A different form  of  unease is seen in children Avho
nevertheless seem  to be well.   Their sleep remains un-
broken,  but they  roll over, twist, turn, wriggle, and
continue to do so for hours.  Possibly they are dream-
ing, but of this there is often no evidence, and they are 
SOME DISORDERS OF SLEEP.         87
not affected in health by this extraordinary restlessness,
which  may remain as the habit of a  year or more.   I
have over and over watched these little ones in a sleep
which  permitted them to roll over and bend the body
and move the limbs, until it seemed scarcely possible that
they could remain through it all in a state of slumber.
A little pause might folloAv and then another period of
nearly constant movement.
   In adults such extremity of restlessness is very un-
common, and means more than in childhood.  Of the
hysterical sleepers much  might be  said, but in them
this form of activity during sleep is seen at times.
   In the singular ataxia of hysteria, which I described
a  feAV years ago, the early stages of the  disorder are
apt to exhibit on Avaking an  ataxic condition, which
becomes increasingly  Avorse,  and  at  last  continues
through the waking hours.  More commonly the ataxia
comes on by degrees, and only in the day.
   Lastly, in relation to the motor sphere are the rare
examples of chorea seen only for a time on waking from
sleep, of which  elsewhere I find no  mention.   As re-
gards this, I  may remark that some early ataxics and
some neurasthenics are apt to be unsure of their move-
ments for a little while after waking.
   Case XXIX.—A. B., female, aged fourteen years, men-
struating regularly;  somewhat anaemic, but in other  re-
spects healthy.
   Last  spring, in the month of March, she was attacked
by a singular form of chorea.  She had this trouble at no
time except in sleep and on waking  from sleep; on either
occasion it occurred in attacks Avhich did not last very long.
Her mother, Avho frequently watched her in the night, said
that three or four times in each night  she became restless, 
88
NERVOUS DISEASES.
kicked off the covers, and began to move her hands, slowly
flexing  or extending  them  until  at  last, the  arms also
moving,  a general choreal movement  ensued,  Avhich, at
the  same time, affected  the legs, arms,  and body, but
never the  face.  The  attack affected her  almost ahvays
Avhen she aAVoke from  sleep, during the time  she was suf-
fering from this disorder.  In the warm summer Aveather
it disappeared.  It has returned again recently.  She has
been under my care for some time, so that I haATe had an
opportunity of seeing that she is a person in perfect health,
with no  organic disease about her on Avhich  I  can lay a
finger.  The attacks in  the  night  are very rare, but she
scarcely passes a morning Avithout  waking in  this choreal
condition.  The spasm lasts from a half to  three-quarters
of an hour, and by degrees fades aAvay.  She apparently
has  no  control  over her  mcwements, and  in  this respect
they differ from ordinary choreas, except of  the Avorst kind.

   This special manifestation  of  chorea  must  be ex-
tremely  rare.  In  the  experience of  many years (in
Avhich I have seen a multitude of  cases) I recall but
three or four of this  character.   It is mostly confined
to sleep or  to the awakening state, not apparently ex-
isting during the day.  I have no hesitation,  hoAveArer,
ui classing it as chorea, because it readily yields to the
treatment Avhich is given  to choreal  cases, and because,
in one instance, it occurred  in a child who had had tAvo
previous attacks of  chorea.   This instance is, perhaps,
worth relating:

  Case XXX.—C. J., a clever little boy of about twelve
years—not very strong nor very active-minded ; never rheu-
matic ; heart normal; not very fond of outdoor sports, and
someAvhat anaemic—Avas attacked one spring Avith  chorea,
from which after two months he recovered.   The following 
SOME DISORDERS OF SLEEP.         89
spring he was attacked  again;  this attack  lasted  seven
Aveeks, after Avhich he again got well.  The next spring it was
replaced by the peculiar form of post-somnic chorea of which
I have spoken.  He had absolutely  no chorea during the
day.  He usually woke  up about half-past  seven in the
morning  with choreoid  movements of the  hands ;  both
sides Avere  alike affected.  They Avere  not  in  character
like  those of the girl mentioned above, and Avere more
distinctly under  control.   For half  an  hour, hoAvever,  he
could not pick up anything Avithout dropping  it.  What
struck me Avith  him,  also, Avas that  the face was not con-
cerned in any Avay, nor did it affect  either leg.   Sensation
did not appear to be affected, and he Avas relieved by the
ordinary  arsenical treatment and cold douches.

   Tonic Spasm is another rare trouble born of slum-
ber, and lasting after it.   I quote the only  cases my
note-books afford:
   Case XXXI.—Mr. J. C, aged forty-five years, merchant,
had syphilis and distinct  secondaries  at the age of tAventy-
three years.  Was well at the time  of  the malady about
to be mentioned—that is, he  had no perceptible  organic
trouble.
   About four years ago he began in  the early mornings to
Avake up with  rigidity of the  legs.   This was so extreme
that it was impossible for him to bend the ankles or knees,
or to elevate the knees at all.  If they Avere lifted by an-
other Avith difficulty, they fell sloAvly  in extension.   It Avas
truly, therefore, a distinct tonic spasm.  If at that time he
had excess or defects of knee-jerk, I  cannot learn.
   This state continued to  show itself for over two years,
occurring at intervals ; sometimes taking place every morn-
ing for a week, then lapsing for a month, but never exist-
ing at other times than when he  came out of sleep.  If he
Avoke up  in the night, he occasionally had this same coudi-
                          8* 
90
NER VO US DISEASES.
tion, but  this  was far more rare.   It  was commonly  a
morning affliction, and  lasted  for  a feAV  minutes or at
most an hour.
  After a certain  length of time  the  symptoms  disap-
peared,  but,  owing to a  bout of drinking, they renewed
themselves.   Again  he got  Avell,  and  a period  of  tAvo
years elapsed without further trouble.   He then began to
have  vertigo,  folloAved by  difficulty in  controlling his
water, and  this was  folloAved by incoordination and the
entire  range of  ataxic troubles to Avhich he  is  noAV  a
victim.

   I quote   another  case as a still more  remarkable
example of  rigidity  developed  in  sleep and continuing
for a time after waking:

  Case XXXII.—The patient Avas a man in good circum-
stances, aged forty-five years.  He Avas in the habit occasion-
ally of awakening in the middle of the night with rigidity of
the legs. The limbs were violently extended, the feet being
so completely flexed as to be straight Avith the line of the
legs.  It Avas almost impossible to  lift  the legs  Avithout
lifting the whole trunk, so tightly Avere  the muscles con-
tracted  and  so rigid Avas the Avhole mass, including the
intra-pelvic group.  This  did not seem to  be  due to any-
thing in the way of specific disease nor  to bad  habits.
The man had no disease to Avhich I could relate it, except
that he had been for many years a dweller  in the loAver
part of the city, and had had attacks of  ague year  after
year, and  one very severe  attack of remittent fever.  Be-
yond this  there  Avas nothing,  and these symptoms  had
long since disappeared ;  neither spleen  nor liver Avas en-
larged,  nor, at the time of the  rigidity, was  he suffering
from any malarial difficulties.   The kidneys, heart, and
lungs Avere alike  sound, and  to  this day I remain puzzled
as to the causation of this very peculiar  malady.   I saAV 
SOME DISORDERS OF SLEEP.         91
him  several times, because he used frequently to ring me
up in the night in order that I might Avitness  this affec-
tion, Avhich was painful from the intensity of the contrac-
tion of the muscles.  I have heard him scream from what
he described as " positive agony."  Indeed, nothing re-
lieved  it  except  full  hypodermatics of morphia, under
Avhich  slowly,  Avithin  a  couple  of hours, the  muscles
would relax, but ahvays  after an  attack  Avould remain
extremely sore  for days  together.  He finally  ceased  to
suffer.

  I  have  seen a disorder of the same  kind,  or some-
thing similar,  in hysterical Avomen ; but even among
them it is very rare, and it is not necessary for me  to
go into details.   The state is merely an hysterical curi-
osity.   I mention it  to complete the  list of peculiar
cases which I select from my note-books.
  Respiratory Failure in  Sleep.   I  conclude  this
study of  the disorders  of  sleep  by  calling  attention
to one of very great  interest.   I believe that it Avas
first described  by the  late  Professor  Samuel  Jackson,
but I have been  unable to find his paper, Avhich is not
in the catalogue  of the Army  Medical  Library.    I
recall,  however,  hearing him speak of  cases in his lec-
tures.1
  Where, for some reason, the  respiratory centres are
diseased or disordered, a man may possess enough gan-
glionic energy to carry  on breathing  Avell, while the
Avaking will can still supplement the automatic activity
of the loAver centres.   But in  sleep, these  being not
quite competent, and volition off  guard, there ensues a
gradual failure of  respiration, and the man  awakens
 1 Since this paper was first published others have called attention to this
symptom in sclerosis. 
92
NER VO US DISEASES.
with a sense of impending  suffocation.   This is not to
be confounded with  the hysterical  sleep-symptom of
sense of suffocation, which is probably closer  to the
phenomenon of  nightmare,  and is folloAved  by  or
associated with fear,  and is soon lost on awakening.
  In the cases I  refer to the symptom  is  sometimes a
signal of  dangerous  meaning.   I have  met with it in
extreme neurasthenia, but in worse forms in locomotor
ataxia in its paralytic stage.   I have never seen it in
labio-glossal lingual paralysis, where it should  seem
likely to occur.  In ataxia it may  be  due to sudden
incompetence of the laryngeal muscles, which are liable,
late in ataxia, to become paralyzed.   Usually, however,
it appears to be a failure of the chest and diaphragmatic
movements.
  Case XXXIII.—Mr. C,  aged  fifty-six  years, had pos-
terior sclerosis, but gave no evidence in the day of respira-
tory incompetence, although he Avas distinctly far in the
paralytic state.  When in deep sleep he began to breathe
less and less deeply, and at  last, for a few seconds, not to
breathe at all.   At this moment he moved, twitched, and
at last aAvakened with  evidences of  commencing apnoea
in the color of the lips, tongue, and nails.
  When awake a few voluntary efforts to  respire relieved
him.  These attacks became at last so frequent and perilous
that a nurse sat by his bed  and awakened him as soon as
he began to breathe less and less deeply.
  As time Avent on the trouble increased, and AvheneArer he
fell asleep  respiration ceased  abruptly.   He was finally
Avorn out with loss of sleep, and  died suddenly in  one of
these onsets of respiratory failure.  No post-mortem could
be obtained.
   I have seen two other cases, but none so remarkable
as that I  have briefly  related.   But on the morning 
SOME DISORDERS OF SLEEP.         93
after I wrote these lines I saAv a case in an ataxic  not
yet in the paralytic stage.   Just at the moment of fall-
ing asleep he feels a sense of suffocation, fails to respire,
and, in  great alarm,  sits up.   These attacks probably
differ somewhat from those of  sleep.
  The type differs from that of the ordinary Cheyne-
Stokes respiration, being  merely a  gradual failure to
inhale—a  less  and  less  deep  inspiration,  but  no
sequence of rapid breaths ending in dyspnoea. 
CHAPTER  V.
CHOREOID MOVEMENTS  IN AN ADULT MALE,  PROB-
  ABLY  OF   HYSTERICAL  ORIGIN;   UNUSUAL  HYS-
  TERICAL  MOVEMENTS IN  A  CHILD;  HYSTERICAL
  MYOCLONUS.

  Case XXXIV.—D. F., a white male, aged thirty-seven
years, applied for treatment December, 1894, on account of
spasmodic to-and-fro movements of the head.  The family
history is negative, and the previous health has been gen-
erally good.  He had  typhoid  fever when  ten years old,
and again when  eighteen.   He  has been married fourteen
years, and  has had three  children, of Avhom one died of
dysentery.  Syphilis is denied, and there is no evidence of
it.  His  habits  were good, and  he did not use  tobacco
excessively.
  About three months before coming to the Infirmary he
had been much worried about moving his place of business
to some other part of the country.   He could reach no de-
cision, grew nervous, slept  little, became dyspeptic and very
melancholy.  After  about two weeks spasmodic movements
of the head suddenly appeared.
  Present state.  Every feAV moments the head is  forcibly
jerked backward by the trapezii muscles.  When  lying in
bed the spasm is much less frequent.  It is increased in
frequency during examination, and  for a time  ceases en-
tirely if the attention be  strongly directed to any object.
For  example, while looking at a thermometer bulb the
patient was quiet for five minutes.  During sleep there are
no movements whatever.   While  in the hospital he devel-
oped general  choreiform movements. 
HYSTERICAL MOVEMENTS.           95
  lie is fairly well nourished.  His expression is markedly
melancholic.  Intelligence  is good, but he  is profoundly
apathetic.  He declares that he sleeps very little.  His
appetite is  poor and he suffers much from gaseous eructa-
tions  after  eating.  The thoracic  and abdominal organs
are normal, the station good, and  the  gait  normal.   The
urine  is normal.  Prof, de SchAveinitz examined his eyes,
and reported slight hypermetropic astigmatism Avith in-
sufficiency of  the  interni.
  The patient Avas put at absolute rest in bed, given gel-
semium,  bromide, and chloral, and, later,  hypodermatic
injections of  distilled  Avater.  These  had a Arery happy
effect  upon his insomnia, and, indeed, caused he declared
drowsiness  the  following day.  After about eight weeks'
stay in the hospital he Avas discharged greatly improved,
but still  having occasional clonic spasms  of the trapezii.
There were no sensory changes.   The man Avas emotional
and given to tears. Soon after admission he began to haAre
at times, after exercise, great emotion, or any excitement,
curious movements of  one  limb or of the  trunk.   Thus
the arm would  be extended forcibly, and again and again
for  a  half-hour, or the leg, or both legs, Avith intervals of
twelve to fourteen seconds ; or the Avhole trunk, as he lay,
flopped fish-like until Avearied. The head-movements were
likely to cease when any other form of  spasm Avas present,
but Avere, on  the  Avhole, the most common.  They Avere
generally either  to-and-fro motions or backAvard jerks,
seemingly due  more  to  the trapezii than  to the  other
posterior neck-muscles.  Over all of these movements he
had temporary volitional control. AVhen he thus restrained
them  he said  that the sense of  discomfort  became by
degrees really unendurable, and he had to "let go."

  Remarks.  The resemblance, clinically, to the cases
of  habit-chorea  or habit-spasm,  as  Gowers likes to 
96
NERVOUS DISEASES.
describe the disorder I first called attention to some years
ago, is very striking.   The lad I shall sIioav you to-day
is another illustration  of a  genus  of cases which has
seATeral related species, and such variety as individuality
may occasion.   As in this  case, so also in that of the
boy, hysteria is the potent agent in their production.

  Case XXXV.—B. F., a male, aged  ten  years, applied
for treatment in December, 185)2, complaining of invol-
untary movements of the head.   His father had  had fits
in childhood, and one  cousin has  had habit-chorea.   One
brother died in convulsions when seven  months old.   The
patient had diphtheria  Avhen two years old, scarlet  fever
three years ago,  and measles  last year.  He has always
been nervous.  The mother states that he  is the smallest
boy in his  class and has always stood at the head in his
studies.  She thinks that overstudy in  preparing for ex-
aminations may have been the cause of his illness.   The
present trouble began  about tAvo Aveeks  before application
for treatment.
  There is constant Avagging of the head from side to side,
shrugging of  the  shoulders, and Avinking.  The  patient is
a bright, Avell-made lad, Avith excellent  muscular deA'elop-
ment.   The station is good Avith the eyes  closed.   The
knee-jerks are capricious.   Clonus is absent.  The cremas-
teric reflex is present.  The abdominal reflexes are absent.
The elbow-jerk is present.  The  muscle-jerks in the arms
are very marked.  There  are no palsies.   Speech  and
sensation are normal.   His physical  health  is  good,  and
examination reveals no disease of the abdominal  or  tho-
racic organs.  The foreskin is very  long, but  there are
no adhesions.   There is no genital irritation nor any bad
habit.
  Prof, de  Sclrweinitz  examined his eyes  and reports:
" K. E , V. — 15 xxx.   Round disc, temporal edges clear; 
HYSTERICAL MOVEMENTS.           97
nasal and upper and lower margins hidden by grayish in-
filtration ;  much white  tissue  around  central  vessels.
Veins full, arteries normal.  L. E., V.  = 15/xv (partly).
Similar condition of disc, but blurring of disc less marked.
Slight concomitant  convergent squint.   Eyes Avander in
under cover.   Hypermetropia = 1.5 D.  Slight astigma-
tism.  Diagnosis : hemi-neuritis with hypermetropic astig-
matism, and slight convergent squint."
  The  case Avas diagnosticated as habit-chorea, treatment
given, and the boy told to return in a Aveek.   Two weeks
later he came back shoAving marked changes in the symp-
toms.  Every  feAV  minutes the head is jerked  violently
and suddenly to the right or left    Previously the motions
had been  slow and  gentle.  An  arm  is  very forcibly ex-
tended once,  or  the  legs are flexed  and  extended once.
Similar movements elevate or depress the shoulders.   These
movements are independent of each other; that is to say,
at any given  moment any part may be involved, though
oftentimes the legs move synchronously.   The moATements
are shock-like, sudden, rapid, and  violent.  They  appear
almost as if  willed.   During  sleep they cease  entirely.
Emotional excitement increases them markedly.  Volun-
tary motion of arm or leg decreases them for the time being
in the member used, but has no effect upon the rest of the
body.  While lying  down they are less severe than Avhen
up.  There are no sensory failures.  He Avas given Foav-
ler's solution in increasing doses and ordered to be kept at
rest.
  After a few days the movements suddenly  ceased, but
were immediately followed by attacks of violent, barking,
spasmodic cough, so severe as to alarm his parents.  When
next seen at  the Infirmary he would  every few minutes
make a short, quick, explosive, grunting noise.  When
told to breathe deeply the  cough stopped entirely.  Atten-
tion  produced by having  him fix  his eyes upon a bright
                          9 
9g             NER VO US DISEASES.

object  had the same effect.   Slight  general  choreiform
movements Avere  also present.  Complete cure folloAved
his  admission to the  Infirmary and subjection to the hos-
pital discipline in bed for a feAV Aveeks.
  Remarks.   This case, as  you see, looks  like Avhat
I venture to call  acute habit-chorea.  The same poAver
of control exists for a time as in the man.  The uneasi-
ness under self-control is present.  The abrupt cessation
of other movements when the barking or grunting comes
on is sometimes seen in habit-chorea; but in that dis-
order there are usually frequent  repetitions, never vio-
lent, of the part disturbed.  This lasts for days or longer,
and on ceasing may be replaced by like movements else-
where.   These children may or may not be hysterical,
but the hysteria of childhood often fails to give you a
complete picture of that disorder.   The grunting is not
like the cough of hysterical  women, and is probably
only an incidental product of one of the forms of semi-
spasmodic movement.  At times it is  due to sudden
abdominal muscular contractions.   Clinically and prac-
tically all this is interesting.  Of this you may be sure,
that when adults are afflicted with these forms of tem-
porarily controllable semi-spasmodic motions, you will
find them hard to get Avell.   All the emotionalness of
such temperaments  as incline to motor disorder is in-
creased by their presence.  These people get self-Avatch-
ful, depressed, and Avill-less.   Children are easier to
cure, no matter how grave the malady, or Iioav distinct
the hysteria.  Always Avith them developmental  change
assists, if you know  Iioav  to use  your opportunities.
Isolate them, if possible.   Insist on mild diet—as of
milk or vegetables, or these combined.   Keep them at
rest, and by-and-by offer  little  bribes  to restrain  the 
HYSTERICAL MOVEMENTS.         99
movements.  The slight cases of habit-spasm may be
enduring, and the more severe cases get well, like this
good little felloAV.  There are cases which do not, and
Avhich develop into the  disastrous states of  mind and
body I  have delineated iu  my Lectures on Nervous
Diseases.  These failures are commonly due to the folly
of parents.   There is no worse  enemy  of  a  nervous
child than a nervous mother.  The peculiar  violence
of spontaneous action in the lad's spasmodic movements
recalled to my mind a man Avho,  many years ago, was
my patient.  He was subject—and for periods of a week
or tAvo—to a disorder of which, being a quiet bank-clerk,
he Avas much ashamed.  After a few days  of general
uneasiness, which  made him  restless and inclined to
excessive exertion, he began to have spasmodic actions
—like this boy's—a sense of profound unease for a few
minutes, ending in a single motion of abrupt violence.
A leg Avas thrown upward or back; an arm, Avith the
fist clenched, struck out once with a look of  purpose
about the act which was contradicted by the fact  that
he  had over and over hurt his  hand  by  driving  it
against  some obstacle.  Once or twice  he  had hurt
others.   At times he Avould warn me or another of the
coming risk.  No cause for this peculiar  state Avas ever
found ;  nor do I knoAV Avhat became of the man.
   Some of you may recall the interesting  case seen here
last year, in a Hebrew in middle life, Avho presented a
striking illustration of multiple myoclonus.  I  reported
it Avith other as curious spastic cases to the Neurolog-
ical Association.   I now recall it to state that the man
has become well  and Avalks about like others.   I saw
once, some  years  ago, a similar  case,  and  it  too Avas
hysterical and in  a Hebrew. 
100
NERVOUS DISEASES.
   And now I am able to read you the notes of a case
of multiple myoclonus, clearly hysterical, and in a gen-
tleman Avhom  I  lately saAv in consultation in a distant
State.   As I have so lately discussed the possibility of
these spasms originating in the cord,  I shall not need
to repeat my remarks.

   Case XXXVI.—C. B., aged thirty-five years.
   Family history. Some of the remote ancestors were rather
eccentric  or peculiar in  certain directions.   His paternal
uncle died, aged forty-five years, of acute cerebral disease,
said to have been encephalitis.  One cousin, a son of this
uncle, has had incoordination of all the extremities, cho-
reic movements of the face accompanying voluntary move-
ments  only, and  indistinctness of speech, Avhich were first
noted in  infancy, but Avere not thought to have been con-
genital.
   The mother's labor was normal, no instruments having
been used. The child Avas somewhat backward in develop-
ment ; the anterior fontanelle seems to have remained open
unusually long.  There  Avere decided indistinctness and
difficulty  in  speech, Avhich  only disappeared  after some
years.   At school the boy Avas rather sIoav  and seemed
disinclined to learn.  He Avas ahvays a little peculiar ;  he
had very strong opinions on various subjects which could
not be  readily influenced, and Avere different  from  those
natural to his  companions.   For  some years before  his
present attack (six  years  ago) he  had been considered
rather odd by neighbors.  When  about  seven years old
he Avas throAvn out of a light Avagon and the Avheel passed
over his head.  No evidence of fracture of the skull was
detected and  he seemed well in a feAV days.   When fifteen
or sixteen years  old, and while studying rather  hard at
school, he began to  have severe  frontal,  bilateral  head- 
HYSTERICAL MOVEMENTS.          101
aches, Avhich at first  came after study only, but gradually
persisted, although the study  Avas given up, and  after a
time came in the mornings Avithout apparent cause, lasting
some hours, apparently often connected with the condition
of the weather, being Avorse when there was a cold, piercing,
or bracing wind.  From this time the headaches have per-
sisted, at first coming principally in the spring, Avhile he
Avas free from them during the rest of the year ; later,
occurring at any season, and gradually growing more fre-
quent and  more troublesome,  so that, finally, he gave up
his home in the city and lived entirely in the country.
Study  was found to be  impossible.  Change  of  climate
made his sufferings worse.   The patient  led an  out-of-door
life,  superintending  and  Avorking  on his  farm until his
present  trouble  began.  He  Avas   an  unusually large,
strong, and muscularly Avell-developed man.
   The present trouble began six years ago, some time after
a moral shock in which the emotions were much involved.
He was attacked with unusually severe headaches,  general
lassitude, and inability to work, so that he let his farm for
a time and came to live Avith his parents, Avho had a large
estate in the neighborhood.   While with them  he Avas one
day, when driving, attacked, Avithout apparent  cause,  with
a  fit of coughing, which  lasted some minutes  and Avas of
a  convulsive  character and so violent as  to be alarming.
After this  similar attacks  of coughing came on  almost
daily,  and seemed   to  be  aggravated  or provoked by
driving.  A few days later he began  to have attacks of
violent, involuntary  movements (clonic spasms) affecting
the extremities, being  at first often unilateral, sometimes
on one  side and  sometimes on the  other.  The loAver ex-
tremities were more affected, on the Avhole, than the upper.
The earlier attacks of spasms occurred only on rising in
the morning.   After a feAV Aveeks the coughing-spells  were
largely replaced by  hiccoughs, and  it was  found  that the
                           9* 
102
NER VO US DISEASES.
headaches, the cough, the hiccoughs, and the motor spasms
Avere more or less interchangeable.   Since  this time  the
general features of the affection have remained unaltered.
The motor spasms have gradually become more frequent,
for some years occurring daily at stated hours (periodic),
with frequent intervening  attacks, and now several  times
every day.  The motor attacks consist of very violent, more
or less  regular movements of the extremities, especially the
lower,  when violent  stamping or up-and-down movements
folloAv  each other Avith  great  rapidity; in the upper  ex-
tremities there are regular, coarse movements of  the entire
extremities.  These  attacks come on, especially at  the
regular times, Avithout apparent cause, but are also pro-
duced  at  any time by a sudden, unexpected  touch  or by
any touch Avith Avhich emotion is connected.  They are also
produced by movement (both sensori-motor and moto-motor
spasms).
   The paroxysms of cough disappeared after some months
to a considerable extent, Avhile the hiccoughs lasted only a
feAV Aveeks, the place  of both being apparently taken by the
larger  spasms of the limbs.  During the last three years
there have  been many attacks of retching and  vomiting
(or regurgitation), Avithout nausea, and, for the last  two
years, attacks of Adolent and forcible shouting.
   For a year past some loss of strength has been noticed
and an increase in   the ease Avith Avhich the spasms  are
caused, especially by Avalking, so that they  now largely
preclude any attempt at exercise, as he states  that he is
liable  to  have his legs drawn from under him violently
and suddenly, so that he falls to the ground.   If Avalking
be persisted in, in spite of the spasms, the headache be-
comes  unbearable.   Of late, the trunk has also been  in-
vaded  by the spasms, the  body being frequently bent to
one side, usually the left; and clonic spasms in the trunk-
muscles  sometimes last for hours and  even clays  (once 
HYSTERICAL MOVEMENTS.         103
apparently without remission for four days, but the patient
Avas not seen while asleep), causing great soreness and ten-
derness in these muscles.  There is uoav much  dizziness,
which  began first six  months ago, and now  causes an
additional difficulty in Avalking.
  He has taken food irregularly for years ; of late, not more
than one  meal of solids  a day, and that usually at 11 p.m.,
and the rest of the time weak coffee or milk Avhen wished
for.  The boAvels are regular; the urine negative.   The
face is  now usually pale, but becomes turgid and  congested
during attacks, partly  from the violence of the motion.
The intellect is  unimpaired (broadly speaking).   Sleep has
been good.

   Remarks.  This gentleman, unlike our former case,
is in easy circumstances.   It Avere better he Avere  not,
as he is  able to control his oavii surroundings and to
isolate himself  as he pleases.   The limitations to which
the position, age, and  circumstances of  the case subject
our therapeutics must be clear to you.   When  I  first
examined this most expressively hysterical case I found
my patient up, and after a partial  examination, Avith
increasing signs of fear  and  nervousness, he went to
bed.   There I completed a  long, but, of necessity, im-
perfect study.  He Avas a rather Avell-built, Avell-colored
man, Avith no organic  troubles.   As I went on to make
the ordinary  search as  to  sensation, reflexes, etc., all
beino;  normal, he became all  the time more and  more
convulsed.   If I touched a leg,  it passed at  once into
violent convulsion, and  this at times invoh'ed all  four
limbs, and was so terrible that I thought the bed Avould
be broken.   When he tried to Avalk, and ahvays then
if emotionally disturbed, he Avould begin to stamp in  a
strange way and with swiftly increasing force, and this 
104            NER VO US DISEASES
spastic state, reaching the trunk, seemed then to draw
him down, so that he fell or contrived to get back to
the bed.   I Avas obliged at last to cut short my  exam-
ination, but not before, with the aid  of  his  physician,
I Avas able to reach very distinct conclusions.
   Cases of violent hysteria in the male are not common,
at least in America.   Only once in my life have  I
seen a male exhibit all the acts in the  long drama of
hysteria precisely as Ave so often see them in the female.
I now add the opinion  given in the case of Mr.  C. B.
A careful consideration of the symptoms brings me to
three conclusions:
   1.  That the form of the convulsive attacks brings
this disorder closer to the clinical  delineations of myo-
clonus than to those of any other group of symptoms.
He is liable to have violent stamping, or Avorse, from
standing—i. e., sole-pressure causes it. Also, Avhen cog-
nizant of it, a mere touch  anywhere brings on  clonic
spasms of the legs,  or of the arms under  like circum-
stances.   Voluntary motion may, as in  other  cases,
give rise to like spasms—/. e, the spasms  as to cause
may be sensori-motor or moto-motor.
   2.  Evidently attention increases the seATerity of sen-
sori-motor manifestations.
   3.  For various reasons, this myoclonus seems to me
hysterical.   The transfers, the  interchangeableness of
spasms, headache,  regurgitation,  hiccough, and vocal
symptoms, all point this way.   So do the type of  lar-
yngeal phenomena  and the characteristic regurgitation
without nausea;  and that  the  first  spasms folloAved a
grave emotional disturbance assists us to a like conclu-
sion.   The original injury may have been contributive, 
HYSTERICAL MOVEMENTS.        105
but there is not in the skull any distinct local evidence
of organic lesion.
  If it  all be at last hysteria, or due to the injury but
in its outcome hysteric,  one might look to find sensory
changes; but close examination of the skin is impossi-
ble, and Avithout ether I could not see the eye-grounds
as I Avished  to  do.   It  Avould be Avorth Avhile once to
do this  under ether.   Probably the spasms  have  their
birth in the  cord.   They  seem to me in  quality and
history  functional, and  I  ought to add  that, when off
guard—a rare thing—the  touch of my hand does not
occasion spasm, nor does  his own  touch  of himself,
unless, having  been asked  if it  be so capable, he Avith
pre-attention touches himself.
  Probably he is incurable, but this does not imply the
certainty of his not losing the spasm.   If he were a lad,
I should take him aAvay, and with isolation, massage,
and  electricity treat him, and have hope.   Noav, I do
not advise it.  I should like to see hypnotism used.  I
would  assuredly use arsenic for a year.  I Avould not
let him live Avholly alone or unvisited by friends,  as he
now Avishes.
   Hypodermatic use of arsenic is to be considered.
  1 have little doubt that the injury may have been the
ultimate cause of headache, and  that  he has had  more
or less of chronic meningitis.  If he could have a good
study of the eyes by an  expert, I  should feel  better
satisfied, as the eyes  may, with slight ocular defects, be
competent to trouble a defective brain.  Also, the color-
fields might prove very interesting.
  I gather enough in various Avays to make me think
that Mr. C.  B. Avas never a perfectly normal person in
earlier  youth.   When,  to a person  of such  neurotic 
106            NERVOUS DISEASES.
type,  come accident, emotions, etc., then the Avorst and
the more unusual results are to be apprehended.
  Yet a word before I close the lesson of  the day.   I
have used the label hysteria again and again.   It is,
and as yet must be, a Avord of somewhat loose employ-
ment.   I am not  sure that it is just to apply it here,
because with spastic or other symptoms the patient is
merely emotional;  but certainly we, by common con-
sent, do this, especially in the unusual  forms of spasm
and in cases in which clearly emotion  was the parent
of spasms.   When we have areas of anaesthesia we use
the term in question Avith lessened doubt.   If, too, Ave
find these,  and with them optical anaesthesia for colors
or especially reA^ersals of the color-fields, our doubts are
further lessened. But, after all, it is the grouped condi-
tions  Avhich fully justify such clinical  labels.   Dr. J.
K.  Mitchell and Prof, de ScliAveinitz have shown hoAv
much our American experience as to the eye-symptoms
of hysteria  may vary from that of the French observers. 
CHAPTER VI.
     SUBJECTIVE FALSE  SENSATIONS OF COLD.1

  I desire to draAv attention to a single symptom which
has not, hitherto, received sufficient notice;  it is not of
extreme rarity.
  The cases  I  shall  report are characterized  by the
facts that the patient complains of local or general cold-
ness, and that, as a  rule, the  parts involved have no
abnormal temperature,  or have one the reverse  of  that
complained of.   No doubt there are in medical litera-
ture many  such records,  but  they must be buried in
cases which, being reported under other titles, are diffi-
cult to find.   In the catalogue of the Army Medical
Library there is no heading which covers this symptom.
The meagre material which I  possess could, with time,
have been made larger, as I find that almost every phy-
sician has met with cases of the  kind I  am about to
recount.  I have enough, hoAvever, to enable me to make
a rough division of my cases into at least three  classes:
   Class I.  has a central cause, and must  be of great
rarity.
   ('lass II. is frequently due to neuritis, and is not very
uncommon.   It contains  cases which lack the remain-
ing qualities  of neuritis, and may or may not be due to
local inflammatory nerve-states.
   Class III. is inexplicable or hysterical, and the phe-
nomena are commonly unilateral,  as in the first class.
 1 Transactions of the Association of American Physicians and Pathologists,
1895. 
108             NER VO US DISEASES.

  As these cases have not occurred to me in such com-
petent numbers as to enable me to generalize largely, I
shall relate them with what comment each suggests.
  Class I.  In this class I have but a single case, but
it is so remarkable that I am glad to  present it for con-
sideration.
  Case XXXVII. —Sir P. Broke  AAras  seriously wounded
in the head in the fight between the " Chesapeake " and
the "Shannon,"  in  1813.   He received  a severe  sabre-
wound  on  the  head Avhile boarding the  " Chesapeake."
Of  the later consequences of this Avound I find no very
distinct account  in  the loosely Avritten and tedious biog-
raphy of the patient.
  On  August 8, 1820, Sir P. Broke had a fall from his
horse, Avhich he described as follows:
  "  I Avas stunned by  the  fall,  but  it  Avas only for a
moment, for I  Avas  certainly  dragged  only a feAV yards ;
and  I chiefly remember, as my first perception after the
fall,  that I was  lying on  my back and looking upAvard at
my foot in the stirrup.   I certainly got up unconscious of
injury  and Avalked about  a quarter  of  a  mile  to my
mother's house, Avhence I had just  departed.   I remember
nothing of this Avalk, and my  recollection recommences
Avith my sitting cIoavii quietly in  the  room and telling her
I had had a fall.  I began in a  feAV minutes to have some
sense of stupor, as from  a bloAV on my head,  and, having
gone upstairs  to Avash the dirt off  my head, I then dis-
covered that my head Avas scratched in several places and
bleeding.   The stupor became more oppressive, and I sent
for a surgeon, Avho bled me in the left arm, taking aAvay
ten or twelve ounces of  blood.  This  might be about an
hour and a half after the accident.  The stupor increased
considerably;  I was persuaded  to go  upstairs again and
go to  bed.  This I clearly remember, and that Avhile pull-
ing  my clothes off a violent  retching  and vomiting came 
   SUBJECTIVE FALSE SENSATIONS OF COLD.  109

on, and then my memory again failed me for several hours ;
but on the following morning I Avas perfectly clear again
and had some good sleep.   I felt the usual soreness in the
head  from such contusions, but had no hurt in any  part
of the body nor any uneasiness in my stomach, and  my
appetite Avas unimpaired.   I felt Aveak, but unconscious of
any material injury beyond the bruises I had recei\ed.
   "The usual treatment  in such  cases Avas resorted to to
pre\rent inflammation, and successfully, though my bodily
powers Avere  thereby, of  course,  considerably  weakened.
The first symptoms that I  remember of any affection of the
nerves Avere my perceiving, in the afternoon of the  day fol-
loAving the accident,  a  sense of extreme cold  in  my leg
and foot and  left hand, so that I could not sleep  in com-
fort without a Avorsted glove and Avorsted stocking; and in
the course of  the next  day I discovered that the whole of
the left side Avas strangely affected, the sense of cold ap-
pearing to lie internally upon the  coating of the bones of
the arm, thigh, and leg; and that, though the flesh exter-
nally  was  warm to the  touch and  generally in  a  state of
perspiration, and though the skin appeared perfectly fresh
and smooth, Avithout any sign of withering or contraction,
yet that  skin  over the whole  left side of my person Avas
affected Avith a singular  numbness to the touch.
   "After  a time it became necessary to consult  Sir Astley
Cooper, avIio wrote  to Dr. Lynn in the following language :
   " '  I have  heard  from  Sir P. Broke a minute detail of
his feelings and an accurate history of his case.  The situa-
tion appears to be as follows: On the left  side of the head
the sabre-cut has depressed the bone  and compressed  the
brain  ; and as the edges of the fracture, Avhich are displaced,
have long since united to the skull, all expectation of  any
change in that  part must be abandoned, and the diminished
nervous energy of  the right side, consequent upon  this in-
jury, Avill continue Avithout variation.
                          10 
110
NERVOUS DISEASES.
  '' ' Not so in the right side.   There the mischief has
been an extravasation of blood upon the brain or its mem-
branes, and from  decussation of nerves from the brain to
thebodvthe left side is suffering from diminished tempera-
ture or power  of resisting its changes, and from altered
sensations.  The heart is subject to occasional alteration in
its functions from diminished nervous excitability,  and
hence the pain  felt in its region and the sense of strangu-
lation under which Sir P. Broke occasionally labors.  The
stomach  is also occasionally suffering from its  sympathy
Avith the  brain, and hence those  attacks which drinking
warm  Avater alleviates.   Congestion  in  the  brain from
changes  in position and from OA'er-exertion of mind tends
to a sudden increase of all the symptoms; but this is tem-
porary only.  The probability is that the blood will gradu-
ally absorb if Sir Philip's general health be supported and
he avoids  too  much mental excitement and he preserves
his body from humid circulation.' "
  Nothing is said  further either  by Sir A. Cooper  or the
biographer of Sir Philip in regard to the very interesting
symptoms  described ;  but in Guthrie's Military Surgery,
Avhere first I lit on  the case, that author thus describes it:
  "Admiral  Sir  P. Broke received a cut Avith a SAVOrd
on  boarding the  ' Chesapeake,'  on the  left  side of the
back of  the  head,  which  went through his skull, render-
ing the brain  visible; the wound healed in six months.
After temporary paralysis of the right side he recovered,
Avith a loss of power and a disordered sensation in the sec-
ond, third, and little fingers of the right hand, aggravated
by cold weather and by mental anxiety.
  "Seven years afterward  he fell from his horse and suf-
fered from  concussion of the brain, which added  to his
former sensations by rendering the left half of  his Avhole
person incapable of resisting cold or of evolving heat.  In
a still atmosphere abroad, at 68° F., he said, ' the left side 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  11J

requires four coatings of stout flannel, Avhich are augmented
as the thermometer descends every tAvo degrees and a half,
to prevent a painful sense of cold ; so that when it stands
at freezing-point  the  quantity of clothing of the affected
side becomes extremely burdensome.  When exposed to a
breeze, or in moving  against the air, one or even tAvo oil-
skin coverings  are necessary, in addition, to prevent a sen-
sation of piercing cold driving through the whole frame.'
Moderate horse exercise and generous  diet improved the
general health; the Avarm bath caused a distressing effect;
the shower-bath, cold or tepid, increased  the paralytic affec-
tion.   Frictions with remedies  of all  kinds increased  it
also, and so did sponging with vinegar and Avater, as well
as any  violent, stimulating, quick excitement or earnest
attention to any  particular subject.  The Admiral died
unrelieved, twenty-six years after the receipt of the injury,
of disease of the bladder."

  Owing to the rather vague statements of the surgeons
and the biographer,  we can only infer that the fall may
have given rise to a rupture of a vessel,  supra- or sub-
meningeal hemorrhage, slight motor loss, and irritative
disturbance of sensory regions,  causing numbness of the
opposite side and false sense of cold.
  Occasionally, in hemiplegia, coldness is a symptom
mentioned by  the patient, but not much complained of.  I
recall no case  like this one, but I have distinct remem-
brances of at least tAvo instances of probable clots iiiA'olv-
ing the internal capsule and optic thalamus, causing lack
of muscular sense and numbness on the  left side.  In
both unilateral sense of  cold  Avas  felt, although there
was no fall of temperature.  In one  of them the anaes-
thesia Avas notable, so that pin-pricks Avere not felt and
did not bleed.  Both were adult males.
  In cases of hemiplegia  it is desirable to  know not 
112
NER VO US DISEASES.
only the actual temperatures of the two sides, but also
Iioav well cold and heat are distinguished on both sides:
and, lastly, if  there  be abnormal subjective  sensation
of either cold or heat on the palsied side;  and, too, the
date of this symptom relatively to the attack—because,
clearly enough, even in a cerebral paralysis, the later
comino; on  of  false feelings of cold or heat in the ex-
tremities may be due to peripheral neuritis.
   Class II.   Local sensations of cold ivithout  lowered
local temperatures.
   The three cases which folloAV are none of them as full
as is now desirable,  because the notes Avere made as
mere memoranda for use in the  conduct of the cases,
and before I began to feel a larger interest in the symp-
tom.   All three Avere affected in  the lower half of  the
body—tAvo of them especially in the buttock, Avhich
is a not rare seat of the symptom in question.
   Case XXXVIII.  (Case 281 in  Note-book.)  Local sen-
sation of cold in the buttock*.—J. P., single ; aged fifty-three
years ; Connecticut.   The patient  Avas a man of  fortune,
and had gone through a variety of  excesses, chiefly sexual.
He had had gonorrhoea, but  never syphilis.  There had
been attacks of pain in the legs, arms,  and back, and these
had been  in  a  measure relieATed by various means before
he came under my care.   He also  had a variety of Arague
gastric  symptoms, Avhich greAV out of the hypochondriacal
state.  He had had  tingling of both legs and  feet, some
loss of power in the  right  arm, tenderness upon  pressure
along many nerve-tracks, and a difficulty of using his brain
for prolonged mental exertion, Avhich I believe  to have
been of small moment.
  The  one symptom on account of which I have mentioned
this case was the constant complaint of coldness. 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  113

  When seen by me he was ruddy, in good flesh, and had
no organic disease of any of the viscera.
  The nerve-tracks  above the waist Avere not sensitive, and
he had long been free from neuritic symptoms of the arms.
The two sciatic nerves  were slightly tender from the exit-
points to  the  knee.  The  electrical  tests gave normal re-
sults.  The station-sAvay Avas antero-dextral, and good; knee-
jerk, right seven inches, left one inch, but sensory reinforce-
ments added to the knee-jerk three inches or more right and
left.   Motor reinforcements added about tAvo inches right
and left.   Superficial reflexes Avere normal.  Sexual poAver
someAvhat lessened.  ExcessiATe exercise increased the ten-
derness and also exaggerated the sense of coldness.  This
symptom began to be felt before  he complained of distinct
pain in any region, and his aches Avere so much  better that
it was merely the coldness A\rhich  brought him to me.  This
was positive and  most  distressing.  It affected both but-
tocks  and the  upper half of the  back of both thighs, and
Avas as intense as if  he  were seated on ice.  Occasionally
the calves suffered.
  I saw him  but once, and I do not know how the case
resulted.   The parts complained of Avere Avarm to the touch,
but I  took no note of the actual local temperatures.
  Case XXXIX. (Case 840 in Note-book.)  Subjective sen-
sation of cold in buttocks with actual elevation of temperature.
—J. P. C., coal dealer ; aged fifty-two years.   No syphilis
or gonorrhoea ; much on his feet; uses neither tobacco nor
alcohol.  Married, has two children.   Family healthy and
long-lived.  The  patient  lives in a somewhat malarious
portion of New Jersey, but has not, himself, been subjected
to positive ague.
  About eighteen months ago,  having been  more than
usually afoot  and someAvhat Avorried by business annoy-
ances, he began to have a painful  sensation  of  cold  in
the left gluteal region, and down the back of the thigh
                          10* 
114
NER VO US DISEA SES.
nearly to the knee.  There was nothing of the kind in the
other leg.  This  trouble increased gradually  until it be-
came so positive that he Avas in constant discomfort.   It
has varied very little up to the present time, and, although
better in summer, is yet distinctly felt through  the Avarmest
AA^eather.  Heat  at all times makes him feel comfortable,
and the greatest amount of relief  is obtained  by standing
Avith his back to  a hot fire.  As soon  as he leaves the fire,
however, the  sensation of cold returns Avith all its vigor,
and, in fact,  rarely leaves him.   There is no perceptible
pain in the parts affected.  His station is good ; his knee-
jerk is normal, three  and  one-half inches, and capable of
ready reinforcement, both sensory and motor.   The ankle-
jerk is present and reinforcible ; there is no clonus.   Super-
ficial reflexes exist in integrity.  Electrical reaction of the
limbs normal; Avater and boAvel mechanism perfect; but he
thinks that since this trouble began his sexual power has
lessened.  Digestion  is good, appetite  fair.  All secretions
normal. His  eyes  are exceptionally good, since he is not
yet obliged  to Avear glasses.  An actual examination of
the temperature  shows the left buttock  to  be distinctly
Avarmer than the right; it Avas found to be^° to  |° F.
higher  than on the right side.  The exit-point of  the left
sciatic Avas at times tender.  He declares himself to be not
as  strong as he Avas.  He is someAvhat paler, and has lost
from four to five pounds of flesh.   Always in the morning,
on  rising, he is  nervous—as he says,  a "little trembly."
There seemed to  be no indications, except to look after the
manifest failure of his general health.   Quinine and arsenic
had  already  failed, and long holidays in the  mountains
proved valueless.  Iron Avas given in  moderate doses, as
well  as strychnine and cod-liver  oil.  Within a Aveek or
two he began to  gain in health.  His weight improved, but
there Avas no relief from  the  sensation of cold.   Accord-
ingly, I advised  local massage;  but after its use the parts 
  SUBJECTIVE FALSE SENSATIONS  OF COLD.  115

seemed colder than ever—that is to say, Avhen the actual
temperature of the parts Avent up %° to 1°  F. under  mas-
sage the  sensation to the patient Avas  as if the part had
become colder.   He  Avas under  the  impression  that gal-
vanic electricity locally Avas of  service, but exercise did
not improve his condition.  After many months' treatment,
during Avhich I saw him occasionally, he had gained largely
in general  health and freedom  from nervousness, and in
capacity to do his Avork with his usual energy; yet, not-
withstanding, there Avas  the same  constant sensation of
local cold.
   I think malaria  may be ruled  out as  a cause of his
trouble.   The most careful study shoAved no local ten-
derness, except as stated.   There Avas at times, after long
exertion, slight tingling of  the left foot.
   This case Avas one of real suffering; the ache of the
cold Avas  intense and  disqualifying.    In the light of
other cases I suspect this to have  been a neuritic con-
dition.  The increase of warmth from massage Avas felt
as  cold,  and this is interesting,  since he had a quite
normal appreciation of applied cold and heat.
   Case XL.  (Case 821  in Note-book.)  Subjective  sen-
sation of cold.—Mr.  C.  S.,  aged sixty-three years ;  glass
manufacturer.   Patient has  no bad  habits;  has never
had syphilis.  He has  been for many years an extremely
active  business  man, Aveighted Avith many responsibilities
and constantly afoot.  There  are no head-symptoms.  He
sleeps  well, has a good appetite, and  there are no gastro-
intestinal troubles.
   Five years ago he had some difficulty in passing Avater,
and, later on, a return of the same trouble, Avhich appeared
on examination to be due to an enlargement of the  pros-
tatic gland.  Within a feAV months he found that exercise
tired  him,  especially mounting stairs.   There is  noAV no 
116             NER VO US DISEASES.
cardiac lesion to account for the difficulty, and the arteries
are in unusually good order.   There is a distinct lack of
power in both legs, and, in Avalking, he does not use the left
foot as well as he should.   His station is good ; his SAvay,
standing with his eyes shut, is  antero-dextral, not exceed-
ing an inch in either direction.  The knee-jerk is normal,
three and one-half inches;  reinforcements  are  normal.
There is no clonus, and no perceptible loss of sensation in
the legs and arms, either as to touch, pain, or temperature.
There is no tingling or numbness.   The mixed urine of
the night and  morning contains two grains of sugar  to the
ounce, but no  albumin or casts.  None of these symptoms
were  such as  to alarm him or cause him to consult me.
He attributed  them all to overwork and to being too much
afoot.
   That which drove  him to seek my advice was a slowly
increasing and very  positive sensation of cold, from the
waist down to the  calves  of the legs, and limited to the
posterior half  of the body.  It Avas usually most severe on
the right side, but varies a great deal, sometimes being felt
more on  the  left.   The  sensation is described  as  being
equivalent to  that  Avhich would be experienced by sitting
long  on  ice.   It caused him to desire  to cover the parts
concerned with an excessiATe amount  of  clothing.   As the
cold  Avas  apparently lessened  by motion, he kept  afoot,
Avhen evidently his general condition demanded that he
should not.  He tells me that at times, after active mo-
tion,  he has some sense of numbness  down the back of the
right leg in the region affected  with the false sense of cold.
I could find no notable difference betAveen the temperature
of the tAvo sides of the body in the regions Avhere he suf-
fered, but, as both had more or less of the same trouble, it
Avas natural that the temperature should not differ greatly.
Normal surface-temperatures are  apt to vary in different
individuals, and to  a far greater extent than interior tern- 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  117

peratures.  There is no standard so exact as to enable per-
sons to compare Avith it surface-temperature of a case like
this ; undoubtedly, however, the temperature Avas not beloAv
normal.  The masseur Avho rubbed him insisted that at
times the buttocks were warmer than they usually are.
  My  patient improved rapidly  under tonic  treatment
and proper diet—in fact, the sugar disappeared entirely—
and he regained full  health after a feAV months  of care.
The unpleasant sensation of cold Avas the last symptom to
leave  him.   It is as Avell to say, in conclusion, that  my
patient Avas not a  nervous man, nor was he hypochondri-
acal.   He was rather  disposed to underrate than to over-
rate his symptoms.  The complaint he made of the sense
of cold was most positive ;  at times the sensation  was so
distinct that he could  hardly keep himself from believing
that some  cold application Avas being applied to the parts
in question.
  In  this  case there  Ayas no sensitiveness of the loAver
nerves, but a sharp bloAV on the sacrum with a rubber
hammer was felt in a dull, deep pain, someAvhat lasting,
and it seems possible that in this, as  in the other cases
of buttock-cold, there may be obscure commencements
of neuritic trouble  in the cauda equina.  The sensation
of coldness of the  buttocks is not excessively rare.  I
have seen it from time to time, and now that my atten-
tion has been directed to a possible cause,  I shall,  per-
haps,  be better able in future to relate the  symptom to
its probable parentage neuritis.
  Case XLI.  (Case 935 in Private Note-book.)  Subjective
sensation of cold  in the right foot, with  actual increase of
temperature in the parts.—J. C, male, aged  fifty-two years,
a native of Pennsylvania, by occupation  a  clerk.   Has
had perfect health.  Never had syphilis.   Stands on his
feet at work for seven hours a day.  Is married ;  has six 
118            NERVOUS DISEASES.
children, all Avell.   He lives in a country  which is  not
malarious,  a mountainous region 1000 feet aboA'e  the
sea.
  About five years ago Mr. C. found that  his right foot
became painfully cold after standing for a length of time.
Even when in a warm room he was inclined to dress that leg
warmly—often wore two pairs of socks  and an "arctic"
rubber shoe, heavily lined.  At this early period he found
that the parts affected  were  not cold to the touch,  and
Avere apt to be more flushed than the other foot.
  As the summer progressed (and this  has  been the case
nearly every summer  since) the foot  became better.  At
times all that summer it was tender, and was eased by his
sitting down.  In  the winter which  followed the impres-
sion that the  foot was cold was often  so intense that he
Avould  go from his work  and  remove the  covering from
the limb and ask some one to examine the foot to see if
it  were not frozen.  The  observer called upon Avas apt to
say that  it felt warm  to the  touch.  His general health
remained good.  He was able to do his  Avork, and  lived a
tranquil life until a few Aveeks ago, A\hen symptoms occurred
Avhich caused him to consult me.
  I found him a man of fairly robust appearance, of good
color, Avith no history of specific or malarial poison.   His
heart and  kidneys were healthy, and  there were no pecu-
liarities which I need mention except those concerned with
the foot.   About six weeks before he came to me—that is
to say, the end of January, 1887—the  foot became more
and  more troublesome, and he began to have also a ting-
ling sensation on the right side of the  head in the scalp,
and  also in the hand on the same side.  These symptoms
came on suddenly  one  day,  when  he  was  rising in  the
morning.   They have now passed aAvay.  The other head-
symptom of which  he  complains (and which he  insists he
did not have  before the symptoms just mentioned)  is a 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  H9

sensation of roaring in the head, accompanied Avith a throb-
bing in the vertex.  The dynamometer showed good results
for both hands.  His foot and its conditions are Avhat give
him most trouble, and it is for these that he consults me.
  Of the  present state of his symptoms  he gives me the
folloAving account: He is better in  summer than in Avinter,
although at  all seasons the foot becomes distressingly cold
when he has been standing on  it  for more than half  an
hour.  To sit eases it someAvhat;  to put it up on a chair
eases  it more ; lying in bed for  some time gives him the
greatest relief, as AAThen  he Avakes  in the morning the foot
seems to be warm.   An  upright position has an immediate
effect.  He  says, when  that  position  is assumed, the leg
seems to become cold to the knee.   There is absolutely no
difference in  the appearance of the tAvo limbs, whether he is
standing or is lying down.  The knee-jerk on both sides is
equal and normal, the other reflexes  good, as Avell as the
electric  reactions.  The sensory  appreciations of all kinds
are natural.   Both feet are  flatter than they should be, but
I could find no trace of tenderness in either.   The tem-
perature of the right foot was 1° F. higher than that of the
left foot.  On one occasion Seguin's surface-thermometer
(arbitrary) marked 6° difference of the right  as above the
left; and these peculiarities of temperature Avere the same
when the left foot Avas placed in the same physical condi-
tions as the right.  The sciatic nerves behind the knee Avere
quite tender.   I did not study the  temperature-sense, as it
was long ago, and I was not aAvake to the value of this as
a symptom.   Treatment proved of  little value.

  This case Avas, probably, also a neuritic affection.   In
some Avays  it resembles  the remarkable  cases  which
I  described as  erythromelalgia.   In them, however,
there Avere  pronounced vaso-motor disturbances, Avith
excessive pain.  Of late it has  been  pointed out that in 
120
NERVOUS DISEASES.
some cases of positive neuritis the capacity to be aware
of degrees of cold applied to the skin is present, Avhile
the like poAver to distinguish heat is lost,1  This symp-
tom existed in none of my cases ; but I may not have
too carefully looked for it,   I have observed it  in hys-
teria and seen the re\Terse condition, and also that heat
could cause pain when the  needle did  not.   But this
part of  symptomatology needs careful re-examination.
Meamvhile I may conclude that a sense of intense local
coldness should cause us to  suspect neuritis as a cause.
I  had last winter  a sad case of general neuritis in a
Avoman.   Exercise increased it  enormously, and Avhen
it became  worse in any part there was iu that nerve-
territory a painful sense of cold, Avith very often rise of
temperature and local enlargement of the veins, but no
notable incapacity to discriminate temperatures.
   I may add, as regards all  these cases, that mere vasal
states do not suffice to explain the false  sense of intense
local coldness.    If  they be  of local peripheral origin,
we must assume that the nerves are then constantly in
a  physical state such as is present Avhen true cold  is
applied.
   The condition of false sense of heat is to be met with,
as is well  knoAvn.   For  myself, I  haATe never yet felt
sure that there  are  distinct nerves for perceiving heat
or cold.    Another  theory is possible, as I have else-
Avhere stated in  regard to pain and touch.
   My next case of intensified capacity to feel cold stands
alone, but I am  sure it Avill  not do so \rery long.   I owe
it to the kindness of  Dr. Kinnicutt.   Exactly the  re-
verse state is to be seen  most often in the insane, but I

  1 George W. Jacoby : Journal of Mental and Nervous Disease, June, 1889. 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  121

reserve the cases of false sense of heat, local or general,
for another paper.   They offer greater difficulties.
  Case  XLII.—L.  P., Kansas, aged fifty-seven years,
lawyer.  AVhen  a youth, aged  seventeen, the patient suf-
fered from a  renal  complication  during  an  attack  of
scarlet fever.  Albumin has been found almost constantly
in his urine from that date, and casts very frequently.  He
has, nevertheless, enjoyed  good health, and  although his
urine still contains albumin, and hyaline and granular casts
are occasionally found, he is in  excellent condition, and
performs all his varied legal duties easily.   On careful ex-
amination there are no signs of cardiac or vascular changes.
The heart is not hypertrophied.    There is no  marked arte-
rial tension and no appreciable  change in the vessel-walls.
  For  the  past six or seven years he has been greatly an-
noyed by subjective sensations of cold.  These sensations
are general, but are particularly marked along the inner
aspect of the upper arm ;  they  are  greatly  increased by
mental application.   To relieve these sensations he Avears
at present  three suits of the heaviest woollen undercloth-
ing, three pairs of the  heaviest Avoollen socks, felt boots
made expressly for him  of  the heaviest material, over his
ordinary boots or shoes, and a flannel bandage around the
abdomen.   At night  he wears  two  of the above suits, a
flannel chest-protector, and the woollen socks.   He sleeps
under five  double blankets, on  a feather mattress Avith a
hair one underneath.  Moreover, he is obliged to keep the
night-temperature of  his  room  at 80°, and  after an un-
usually hard day at court at 90° or 95°.
  The  only change of  underclothing that  he  makes in
summer is  the doing aAvay with one  of  the three suits.
The  sensations of cold are  positively painful.   I have
made inquiry  as  to the truth of his statements concern-
ing  the amount  of clothing worn, and they are borne out
by my examinations.   The surface-temperature is normal,
                          11 
122
NER VO US DISEASES.
even when he complains most bitterly of  his  symptoms.
He has a highly sensitive and nervous organization, Avith
an active mind.  He is well-balanced, cheerful, and philo-
sophical about his sufferings.  He Avalks from  five to  six
miles daily Avithout fatigue—on the contrary, Avith benefit.
He is absolutely free from the ordinary symptoms of hys-
teria, and has no pain and no tenderness along the nerve-
tracts.
   This case  is calculated to make us reflect upon the
ordinary standards of heat and cold.   They vary with
individuals,  with social classes, and with periods of life,
as  the aged well know.   The present case is that of
a  man abnormally susceptible to cold.   Explanation
I  have none to offer.   It is interesting to be assured
that a man  may have tube-casts in his urine for forty
years  and yet  preserve a standard of  general health
and activity.
   Class  III.   Finally, I give a case of false sense of
cold in an hysterical Avoman.  Such cases must be rare.
The reversed  state I  have also seen in the hysterical
more than once.
   Case XLIII.  (Case 409 in Private Note-book.)—Miss
B., aged thirty-three years, Pennsylvania.  The patient in
this case Avas a young  Avoman in easy circumstances,  for
many years a victim to hysterical conditions, first acute and
aftenvard  chronic.    To  describe her case Avould be to
describe almost every form Avhich hysteria assumes.
   At seventeen she  began to be irregular as to her men-
strual  periods, and at last passed into a condition of hys-
terical  stupor, then into catalepsy, and later had for several
weeks  onsets of  hystero-epilepsy.  xVt last, coming out of
this condition, she suffered for  a long while from attacks
of rigidity, the left leg finally remaining at an  angle to
the trunk and  knee.  Next,  several months passed aAvay, 
  SUBJECTIVE FALSE SENSATIONS OF COLD.  123

during which she continued  subject to slight  hysterical
attacks, and  then by degrees improved so  as to be fairly
well.   She was an emotional and very intelligent woman,
fond of reading and devoted to music.  She  exercised but
little, however, and Avas, Avhen I  first saw her, again drift-
ing into a life of invalidism.
  About tAvo months before she came to me  she passed over
one menstrual time, and during the month  which folloAved
began to have a sense of cold on the left side of the body.
This condition arose quite gradually, and  became  at last
so violent as to compel  her to Avear, on that side, two  or
three times the amount of clothing required on the other.
This excessive increase of clothing made her so ridiculously
one-sided that she was ashamed to be seen  in public.  She
continued to dress in this peculiar fashion, rarely leaving
the house, and presented an appearance more easily imag-
ined than described.
  I first saAv her early in February,  1883.  She was  then
a Avoman of fair general appearance, Avith nothing notably
wrong  in any organ, and Avith all the secretions in good
order.  She had had no hysterical attack for  several months.
Menstruation was natural, almost without  pain at her last
period.  At this time, hoAvever, she complained of a diffi-
culty in swalloAving and of a sensation as of a band around
her throat.  The whole  left side  of the body  Avas still sub-
ject to the sensation of  cold to Avhich I have alluded, and
which  affected  also the  same  side of the  face, head, and
neck.  There Avas no loss of sensation to the touch on this
side—in fact, there Avere hyperassthetic spaces, one below
the left breast and one below  the floating ribs on the left.
This region of tenderness continued to the middle line and
down to  the pubes.  The special senses Avere normal, and
there Avas no change in the color-fields.
  In the discussion which folloAved Dr.  James J. Put-
nam said:   "In chronic spinal  disease and in chronic 
124
NERVOUS DISEASES.
neuritis I have seen the coldness to which Dr. Mitchell
refers. This was quite marked in one case which I shall
report in my paper.   This patient suffers from sensory
neuritis Avhich may possibly be due to lead.   The sensa-
tion of cold is present to an extreme degree.  In regard
to the sensation of cold in persons not presenting signs of
anaemic neuritis, I am not familiar with anything  like
Avhat  has been reported, though  I have seen cases in
which there were  sensations of  excessive heat, without
organic disease."
  Dr. C. K. Mills said: " I think that the sensation of
cold is a very important symptom of neuritis.   I have
seen it in one  case of acute neuritis of  the ulnar nerve
followed  by paralysis  of  the  muscles of  the  hand.
During the hottest summer weather the patient had to
Avear a great deal of extra wrapping on the arm.  Often
a sensation of extreme  heat  follows injury of the ner-
vous system, either  peripheral  or central.  I recollect
that after the attempted assassination  of Garfield  the
description that he is said to have given of the feelings
in his feet Avas that of extreme  burning.  I remember
having expressed  at that time the idea that the  spinal
cord was involved." 
CHAPTEP  VII.
MOTOR ATAXIA IN A CHILD OF THREE YEARS,  AVITH
  RETAINED  MUSCLE-REFLEXES;   PERNICIOUS  ANAE-
  MIA, AVITH LOCOMOTOR ATAXIA AND HYSTERIA.

  This child, Avhose parents kindly permit me to show
him to you, has a form of malady Avhich I saw for the
first time when I saw  him last week.   Here is a fine
little  man, Avell deA^eloped, exceedingly strong, and as
intelligent as  most children at his age.  He  is quite
unable to stand  alone.   Even to sit  alone  seems diffi-
cult.  No one Avill fail  to note that he is ataxic from
head  to  feet.   The following  notes of his condition at
the present time are compiled from the examination
record made by Dr. John K. Mitchell, and the very
clearly written statement of the father:

  Case XLIV.—P. Q., male, three years  and five months
of age.
  Family history.  The child's grandfather Avas addicted to
alcohol.   The parents are second cousins,  and much alike
in disposition  and general characteristics.  There is also
some tuberculous history in the ancestry.
  The child Avas  born normally  at term.  No instruments
Avere  used.  The  only  thing  attracting attention at the
time of birth was "something unusual"  about the little
one's ankles.   The physician said it Avas "all right," and
the babe  seemed othenvise healthy ; the child cried, kicked,
nursed from the breast, etc. Owing to mammary abscesses
the mother nursed the infant  no more than four Aveeks
                         11* 
126
NERVOUS DISEASES.
After that the child lived on non-sterilized coavs' milk, and
later on '' malted milk " and  other  artificial  foods  until
eight months of age, and Avith  sustained good health.
  At that time, however (eight months of age), the child
Avas taken on a railroad journey.  It is supposed that " sour
milk " Avas the cause of a severe attack of diarrhoea, which
resulted, a few days later, in Avhat the physician Avrites Avas
"spurious  hydrocephalus;  the temperature  103.5° F."
The child threw its  hands about, especially  toAvard the
head, and moaned a great deal.   It had also  "intolerance
of light" at this time.
  The physician gave a  cool bath  and a dose of brandy.
By the next day the patient is said to have recovered from
the serious symptoms, including the diarrhoea.
  After this attack of bowel-trouble digestion seemed  as
well performed  as  usual.  Two months  later (i. e., at ten
months of age) it Avas specially noticed that the child could
not sit  erect.   Nothing  had seemed  abnormal until noAV
other than  undue lassitude.  On examination, Dr. J.  S.
Hackney found that "there Avas an antero-posterior curva-
ture of  the  spine," the most prominent point being about
the mid-dorsal region.
  Accordingly a plaster jacket  Avas  applied.   This Avas
cut and removed as often as necessary.   There seemed  to
be some relief from this for the  now evidently Aveak back.
The jacket Avas Avorn for  six Aveeks.
  The little patient has  kept up a general good tone since
then, the back seeming to have become straight and quite
strong again;  nor has he had  any boAvel-complaint since
that in his first summer.
  The present condition seems to date from thirteen months
of age,  Avhen the child began to have an oscillatory move-
ment of the left eye and later of the right eye.  This  nys-
tagmus  was always  the  more noticeable in  the left eye.
At  this time, too, his health Avas good.   He seemed some- 
MOTOR ATAXIA.
127
Avhat nervous, but did not have any convulsive movements,
and never has had any such tendency.
  At fourteen months of age he had an attack of bronchitis.
In the second week of this  illness symptoms of  Avhat was
said to have been tuberculous meningitis made their appear-
ance.   Both bronchial and meningeal  sjrmptoms, however,
disappeared during the third week.  Since then  and until
now the child has enjoyed very good health, excepting for
extreme nervousness  during the illness stated.  He  now
became  easily startled and  scared.  This timidity has be-
come more apparent as he  grows older.  He is at present
unusually sensitive.   His father  says  the mental faculties
are normal or even precocious.
  The child did not move about if placed on the floor until
tAvo years old.  It has only been since January, 1894  (three
years and tAvo months old),  that he has begun to  pull him-
self up to a standing position Avith his  arms and the aid of
a chair, bed, etc.  Noav, when up, he can walk along the
side of the bed or balusters, holding  firmly  for support.
This  ability has  been acquired only Avithin the  past few
months.  Even when thus holding himself upon his feet he
seems in fear of falling.
  The patient has been extremely constipated until  about
a year ago.  Since then the boAvels have been reasonably
regular.  This change has probably been brought about by
the greater physical exertion of attempted movement.
  The  child is  rather pale;  the muscles are fair in  size,
but very flabby.  The head  is large, but symmetrical.  The
chest is large—indeed unusually full for a child.   He does
not crawl, but he can shuffle  about, seated;  he  can Avalk
about when supported, but with a marked ataxic gait and
Avith  feebleness.   He jerks the legs forward in  the effort
at locomotion.   The  erectores spinee  are weak.   The ab-
dominal muscles and thigh  muscles do  not  hold  the body
steadily upright on the legs.   He leans too far fonvard or 
128             NER VO US DISEASES.
back.  The tendency is more backAvard, hoAvever, Avhen he
is thus supported.  He cannot feed himself.
  Incoordination is marked in  the hands, but there is no
tremor.  He uses the left hand better than the right, and
possibly the left leg a little better than the right one.
  Nervous system.  Sensation is perfect everywhere.  Knee-
jerks and elboAV-jerks are normal and no ankle-clonus exists.
Muscle-jerks of the arms and legs give normal response on
stimulation with the percussion-hammer.  Electrical ex-
amination shows no  alteration to faradism or galvanism.
The child seems intelligent and alert, though timid  and
nervous.   No  signs of pain Avere elicited at any time dur-
ing the examinations.   He talks fairly, drawls his words
someAvhat, but  speaks freely.  The mouth and teeth are
normal.  There is no preputial adhesion, no incontinence
of urine, and this excretion is normal.
  Eyes (examined by Dr.  A. G. Thomson).  The '' pupils
react normally  to light and accommodation.   There is no
choked disc.   The nystagmus of both eyes and the con-
vergent squint  of the left  eye are, therefore, not due to
any refractive  error,"  but are incoordinate  movements,
such as are seen in other parts of the body.
  All other functions and organs are normal.

  It seems reasonably clear that the cause of this inter-
esting malady was not prenatal.   The child  remained
Avell until he had the too common experience of summer
diarrhoea, followed, as  Ave sec  so  often, by brief brain-
symptoms.  What  happened  then is not  uoav  clearly
known.  He is said to  have had " spurious  hydroceph-
alus," and was, according to the  note, very ill.   At or
after this time he could  not sit up as he had been able
to do.   At the thirteenth month nystagmus began, or
Avas first seen.   Then followed a  bronchitis and brain-
symptoms described as " tuberculous meningitis," and 
MOTOR ATAXIA.
129
from this too he got well, but was seen to be more and
more aAvkAvard as he grew older.
  I confess to some  puzzle in this case.   There are no
eye-ground signs.  There is no wasting.  There is no
palsy  of any nerve.  There is  unusual  poAver  from
croAvn to sole; there  is no sensory loss, and yet he can-
not stand at all Avithout some stay.   Aided by a finger
he can Avalk,  throwing his feet out, and  " clumping"
precisely like a true  spinal ataxic.   But no such case
in an adult had ever such a degree of disorder without
disturbed feeling, or  pain, or  anaesthesia,  or girdle-pain,
or pupillary  signs.  Here are none of  these.   Also,
the ataxia is in all the limbs, but is Avorse in the legs.
In the arms and  legs, to my surprise, I  found normal
tendon-jerks, so called, and also normal reinforcements
of these muscle-reflexes.  There is  nothing  spastic in
these.   Sometimes they  are  excessive,  probably  from
reinforcement due to emotion.  There is no clonus ; but
this is  rare in the child under any conditions.   If this
Avere  spinal  ataxia,  Avith added lateral sclerosis,  we
should have spastic reflex signals and the usual feeble-
ness apt to be seen in that disorder;  also the high ataxic
movement of the feet  seen in our case would be want-
ing.
   Tabes of all kinds is, as  a  rule, progressive.   The
lad before you continuously  improves in the use of his
limbs.    This is,  therefore,  neither tabes nor spastic
ataxia, nor is it the picture of hereditary ataxia; neither
has he pain-crises nor trophic changes, so that probably
the posterior nerve-roots and the gray spinal  centres are
to be excluded from a share  in this  disorder.
   It scorns to me possible that the double brain-diseases
he  is  said  to have  had, and Avhich left his power of 
130
NERVOUS DISEASES.
mind and of muscle unimpaired, may have fallen  on
the cerebellum  and  left it permanently injured in one
of its functions.   As against  this is the lad's gain in
steadiness; but even with most of the cerebellum gone
birds have after a year been able to fly.   The mechan-
isms of replacement of  function are not as yet clear to
us, although we are  often called  on to recognize  their
value.
   It is possible that the cerebellum may have suffered
over a large area of  the surface, and that this damage
may have been in part repaired, and a share of the
functional activities safe-guarded  and  replaced by the
other mechanisms Avhich contribute  to the integrity of
equilibration.
   I cannot say, however, that I am, even now, entirely
sure as to a cerebellar lesion being the true cause of the
ataxic state seen in this child; but  it cannot be spinal
unless the ataxia of childhood  should prove to be a very
different condition from  that of the adult—an ataxia
Avithout  sensory,  ocular,  or reflex symptoms.  If Ave
had any evidence of tumor of the cerebellum, we should
be aided in our diagnosis.   In it there may be preser-
vation of the knee-jerk,  but we have  here  no sign of
tumor.
   I confess, as  I study this case, to increasing difficulty
of decision; as one  looks at it, the case is to the eye a
typical spinal ataxia; examined more nearly,  much is
lacking to make the perfect picture  of  that disorder or
disease.   But almost as much is also wanting to assure
us of a cerebellar origin; and one should remember, I
repeat, that AATe have hardly any studies of spinal ataxia
in childhood.  I reported one years ago, Avhich came out 
MOTOR ATAXIA.
131
of Pott's disease, at the age of five, and was seen by
me in a woman of forty.   It had  progressed in leaps,
Avith long periods of pathological inactivity.
   When so thoughtful a man as Gowers admits that the
grouped symptoms seen in locomotor ataxia may be due
to disease either of the cord or of the peripheral nen^es,
one sees the  tangle  into which we have  gotten our
knowledge of the mechanism  of  harmonious muscle-
action, and its offspring, equilibration.
   As there  may be much loss of  motor poAver, much
impairment of motor centres and  nerves, Avithout cor-
responding loss of muscle-harmonies, we must, I think,
still look to disease of the nerves of muscular sensation,
their spinal  tracts, and their cerebellar connection, for
the varied seats of the inco5rdination of complex muscle-
acts.
   It is conceded that integrity  of the knee-jerk, or any
tendon-jerk  from a blow on the tendon,  implies Avhole-
ness of  the neural arc of conduction and response from
the centres concerned.  When there is distinct, typical
ataxia Avithout spastic states, and  with normal preser-
vation of  knee-jerk and ankle-jerk, it seems reasonable
to conclude that the cause of this ataxia must lie above
the region concerned  in the muscle-muscle-reactions.1
The law Avhich applies to knee-jerks and  all  tendon-
jerks explains in part the direct muscle-jerk from a blow.
For here, as  Morris LeAvis and I  have shown, this re-
sponse  is due  to tAvo  contributions, one  the intrinsic
muscular irritability,  and one the addition from the
cord.   The former continues  after nerve-section; the
latter is lost, but its loss is only to be proved by the fact
1 Contra-distinguished from skin-muscle-reflexes. 
132
NERVOUS DISEASES.
that you can then no longer reinforce  the direct muscle-
jerk by remote voluntary motion.
   Such is the case late in posterior sclerosis.  A blow
on the  muscle causes a jerk, but reinforcement is no
longer possible.   The  response  from tendon-jerk  is
only a finer, a  more  delicate, expression, and  a  larger
one, of the same phenomenon.   In  this boy neither
muscle-jerk nor tendon-jerk is gone, nor yet their rein-
forcement.
   The facts  as to all this  matter of  sensory  motor as
Avell as motor reinforcement in its varied forms, discov-
ered  by Lewis and myself,  remain as yet almost un-
noticed in the text-books, and  unused by clinical  in-
quirers.
   As regards this boy I conclude, then, that the cause
of his remarkable ataxic state must lie aboATe the seat of
response to the tendon-jerks, and does not interfere Avith
the track of reinforcement, Avhich  is easily obtainable.
   I must leave this case and its consideration without
further words.   I do not fully understand it,  and the
frank statement  that I do not may have  for you some
moral value.    Under training,  with constant  little
bribes to do this or  that  until he succeeds, the  lad is
steadily improving, and has continued  so to do  up to the
later date of  July, 1896.   E\ren ordinary ataxics may
improve by industrious efforts made with closed eyes,
and this  child has  in his  favor  a normal  mind and
entirely wholesome nutrition.
   An equally  interesting case for study  is a woman
now in  McCormick  ward.  Dr. Walker  will  read the
notes, which owe much of their  interest to Dr. Musser,
in whose charge she has been at the Presbyterian Hos-
pital; and to Dr. Pearce, who is responsible for the 
MOTOR ATAXIA.
133
blood-counts made for Dr. John K. Mitchell's paper on
the influence of massage on the blood-count.
   I shall  presently show you the case.   It  is another
illustration of  clinical difficulty in  decision.   Here
again we have an example of ataxia,  typical  and also
extreme, with, save for one notable exception, perfect
knee-jerks and elboAv-jerks and entire muscle-jerks from
a blow, and all  reinforcible:
  Case XLV.—E.  I.,  female, single, aged fifty years, Avas
admitted to the  Infirmary for Nervous Diseases, in my
service,  March 2, 1894.  She is intelligent, and gives the
following history as to  her illness, amplified  by the  obser-
vations  at the Presbyterian  Hospital  and by  our later
notes:
  Family history.  The woman is of a long-lived ancestry.
Her father and  mother are living and  Avell at eighty-two
and seventy-five years respectively.  Three sisters are all
healthy.  Two brothers have died of scarlet fever and dys-
entery, and one  sister in infancy.  There are no neuroses
or psychoses among her relatives, and the patient herself
had  an  uneventful childhood as regards maladies, passing
through mild forms of the usual diseases of youth.
  In 1887 she  suffered from  the  ordinary symptoms of
nervous exhaustion, had anorexia, and  felt  tired most of
the day.   These  symptoms ran the course of many of such
cases when ill cared for.  After an attack of influenza,
in 1889, she Avas almost bedridden  for  a year  from what
she says was "weakness " only.
  She was  about again for several  months, able to walk
Avith a  cane, but  could not  bear  much exertion. She
was especially weak in the spine and  had  considerable
pain across the  lumbar region.  The patient  also  states
that at  this time she always had  better use of the right
foot  than of the left—the latter Avas heavy and seemed to
"drag" in  walking.
                          12 
134
NEB VO US DISEASES.
  She  continued in this way Avith but little change in the
foregoing meagre symptomatology until July, 1890, when
she went to the Cooper Hospital, Camden,  remaining there
three months, Avith little or no improvement;  thence she
was  taken to  the  Presbyterian  Hospital, Philadelphia,
Avhere  she stayed in the wards one year.   There she Avas
in a highly neurotic condition, and had hysterical outbursts
of crying and laughing.  The sequelae  of these  climaxes
(Avhich occurred, as a rule, near the menstrual epochs) were
states of lethargy and  again of fear, in which temporary
hysterical delusions became prominent.   The sick women
about  her were often  much frightened by her peculiar,
wandering talk.  In  a few  days she Avas  apt to  regain
partial control,  and would censure  herself for acting so
foolishly—of which, however, she had only vague remem-
brances.  At  this time, too, she seemed able to Avalk only
with the assistance  of a nurse, and but for short distances.
Her upper extremities also were Aveak, and she was clumsy.
It was, therefore, with difficulty that she fed or assisted in
dressing herself. Under rest and tonics there Avas improve-
ment of the general health, and on leaving the hospital she
was able to walk a short distance with the aid of  a cane.
She Avas then at home from March to November, 181)2,
when she was readmitted to the Presbyterian Hospital,
where since then she has had a multiplicity of symptoms.
  Menstruation was normal up to  June,  1893.  In July
she  had a  severe  attack  of dysentery.   The convales-
cence was slow, and she was left very anaemic, the blood-
count  showing as low  as 581,000  red  cells on  August
1st of  that  year.   On September 1st  the  blood-count
showed 950,000  red  cells  with  macrocytes,  microcytes,
etc.  On  October  18th the  red cells  had  increased to
1,620,000.  The patient's  condition seemed  now  fairly
good.  Her color had  returned in a measure, so  that the
outlook seemed  more encouraging.  There was  no men- 
MOTOR ATAXIA.
135
strual flow between June and  October,  in  which latter
month she had a  slight  show,  which recurred again in
November, but never since.
  By January 1,1894, there was no material change, save
that in the last few days  she was decidedly more anaemic
again, and had headache,  dyspnoea, weakness, and palpita-
tion of the heart on the slightest attempt at exertion, with
oedema of the  ankles  coming  on late  in the afternoon.
There was no oedema of the face.  The skin  has become
of a lemon-yellow color and  the conjunctivae  of a  bluish
tint.  Her lips are almost colorless.
  The apex-beat of the heart  is in the  fifth interspace.
No thrill is felt. The shock of the second sound is readily
felt in the pulmonary area.  The area of cardiac dulness
is  normal. There  is a soft, hemic, systolic murmur, low
in pitch, transmitted into the axilla, accompanying but not
obliterating the first sound at  the apex.   There is also a
higher-pitched systolic murmur (probably hemic) heard in
the pulmonary area.
  The area of liver-dulness is slightly increased.  There is
one tender spot on palpation with the finger-tips to the
right of the median line tAvo inches, and another two and
a  half inches  above the umbilical line.   On January
16th the patient had severe pain in the region of this ten-
der spot, Avith  great pallor and increasing Aveakness, so much
so that duodenal ulceration and possibly hemorrhage were
thought of. Dr. Musser had the stools carefully examined.
No blood  Avas passed, however, and no parasite  could  be
found as a cause of  the  severe anaemia.   The haemoglobin
had at this time gone down to 15 per cent., while the red
blood-cells numbered 930,000.   There  were also poikilo-
cytes, macrocytes,  and  microcytes  in  abundance,  Avhile
macroscopically  a   drop of blood  looked  like  slightly
tinged muddy water.
  By February  22d  the patient's  skin  and  mucous 
136             NEB VO US DISEASES.
membranes had again brightened.  Her general condition
also  became  much  improved.  She was  decidedly less
nervous, and  sat  up a short time in a chair each  after-
noon, but  tired easily and could not walk.
  On admission to the Infirmary, March 2, 1894, the fol-
lowing  notes Avere  made  as to her  condition:  She  is
a brunette, fairly Avell nourished, weighing 129 pounds.
She  complains of  a  feeling of "numbness  and tingling "
in her hands and feet.   She says  if  she  undertakes  to
hold  anything in her hands she  must see it in  order
to feel sure that it is there.  She can feed herself, but her
hands are too clumsy to permit of her cutting her food. She
cannot dress her  hair.   She can button her night-dress,
but clumsily, and only as far up as she  can see the buttons.
These defective acts seem to be all due to awkAvardness
rather than to actual loss of tactile sense, which seems per-
fect  in the hands and fingers.  The disorder  is mainly a
motor ataxia.  There is no  subjective numbness or ting-
ling anywhere except in the hands and feet.  She does not
complain of headache. She has pain in the back after any
exertion, such as sitting up.  She can stand only by being
supported on either side;  she takes  a few steps  while being
thus  held, but the movements are markedly ataxic.  The
left  foot is pushed forward.  The  right one is thrown up
and  out in utter incoordination.
  In the sitting position, unsupported and Avith  eyes closed,
she does not  sway.
  Other than by the characteristic gait, ataxia of the loAver
extremities is shown  by an inability to bring  the heel  of
either foot in contact Avith the opposite instep.   Ataxia of
the upper extremities is shown even when lying by inability
to bring the fingers of the outstretched hand  to the nose
Avith  the  eyes closed.  The movements  of  the lower ex-
tremities are  less  incoordinate when she lies supine.
  The reflexes—plantar,  epigastric, and abdominal—are 
MOTOR ATAXIA.
137
normal.  The knee-jerks are also normal and reinforcible.
There is no clonus.   There is absence of the normal ankle-
jerks, as tested by tapping the tendo-Achillis, but they can
be elicited by reinforcement.  The elboAV-jerks are normal
and reinforcible.   The muscle-jerks are everywhere normal
and reinforcible.
  Sensibility.   She distinguishes Avith natural competence
the two points of the  aesthesiometer Avhen placed on the
fingers, and  points   out quite  accurately  the  fingers  so
touched.   There   seems  to   be  some  delay in  decision.
Tactile sensation  on the palmar and  dorsal  surfaces  of
both hands is  normal.   The thermal sense is perfect.   As
to the  weight  (or muscle-)  sense, on holding the palm of
the hand out (the patient being blindfolded) she  distin-
guishes a difference  betAveen the folloAving Aveights—i. e.,
'' the least observable difference " of Weber's law:' The right
palm  distinguishes  one ounce from  two ounces only; the
left palm tells one-quarter ounce from one-half ounce. Thus
there is a difference in  muscle-sense between the right and
left arms, and the perception  is not as acute as it should
be.  Numbness and tingling sensations are complained of
in the hands and feet.  No such paraesthesia exists in other
parts.  There is no  amesthesia or hyperaesthesia, but there
is varying analgesia to a deep pin-prick, as  follows:  The
left lower  extremity is analgesic  from the groin to  the

  i Weber used the method of "least observable differences" as applied to
sensations of pressure and the measurement of lines by the eye, but Pechner
expanded it and assumed that all just observable differences are equally
great; so that the law is sometimes  called " Fechner's law."  Expressed in
another way, the results depend on  (1) strength of stimuli; (2) degree of ex-
citability. If two is constant  and one is then  varied, it is found that if the
 stimulus be doubled, trebled, etc., the sensation only increases as the loga-
 rithm of the stimulus (e.  g., stimulus 10,100, and 1000 times, then sensation
increases 1, 2, and 3).  There is a lower limit of excitation liminal intensity and
an upper limit of excitation liminal intensity. Thus above this no appreciable
increase in sensation can be distinguished. This is called the " range of sen-
 sibility."  Thus, with 10 grammes in the hand, we have to add or remove 3.3
 grammes before a difference in sensation is perceptible.  In 100 grammes we
 would have to add or withdraw 33.3 grammes.
                             12* 
138             NERVOUS DISEASES.
metatarso-phalangeal joints, and the right upper extremity
from midway betAveen  the shoulder  and the elboAV to the
metacarpo-phalangeal joints.   The condition of analgesia
of the upper extremity is variable, hoAvever, as twenty-four
hours after the first examination sensation to pain seemed
almost as acute  as upon the  opposite side.  The right leg
and thigh are at  times partially analgesic to a pin-prick,
but the areas of defect vary greatly from day to day.
   Dr. Willits reports the muscular response  to faradism
everyAvhere normal.
   Drs. de Schweinitz and A.  Thomson made the following
eye-report:  '' Both discs gray, especially in  the deeper
layers.   Arteries too small, veins normal.  Pupils normal.
Color-fields (red and  blue) typically reversed.  Form-fields
contracted."
   The reaction-time of the different senses Avas next inves-
tigated.
   Mr.  Lightner Witmer kindly made examinations of this
woman for me at the Psychological Laboratory of the Uni-
versity of Pennsylvania, on March 27, 1894, from A\rhich
the folloAving is abstracted :
   First,  as regards the motor nervous  system, as recorded
on the chronoscope (an  instrument  for recording  the ra-
pidity  of a motion).  It was  found that to pass over a dis-
tance of  50 cm. it took the right hand  yWit °f a se°ond
(i. e., 224 cr).  In the left hand  ^jVo °^  a second Avas re-
quired to pass as quickly as  possible over the same dis-
tance.
   A second series of these  motor  impulse  experiments
(made  after all  the reaction-time experiments) Avas but
little  lengthened  as  compared to  the  first series, thus
pointing  to  the  absence  of  fatigue of  any considerable
amount.
   The  normal rate of movement,  from the experiments of
Professors Fullerton and Cattell, varies  betAveen  87 a to 
MOTOR ATAXIA.
139
 180 a for 50 cm., as recorded on the chronoscope.  The
 woman's movements were therefore slow.
   The reaction-time  to sound varied from 181<t to 343 <r,
 somewhat  longer than the  normal, Avhich ranges from
 120<rtol70ff.
   The reaction-time for light varied from 160 a to 350 a.
 The normal light-perception is from 160 c to 200 a.
   The reaction-time to electric  shock varied from 200 o to
 476 o-, a Arery marked retardation—and this, too, Avhile the
 muscle-response to faradism seemed normal.  Here is one
 of the enigmas appearing in this curious case.
   There  is thus a general tendency to sloAvness of percep-
 tion.  The receptive centres have at least become dulled.
   The patient's  general health is fair.   All organs seem
 normal, excepting that the  boAvels are a little torpid.  She
 has good control over the bladder, and analysis of the urine
 is negative.   Sleep is undisturbed,
   The color  has  returned markedly since January, 1894,
 the red blood-cells numbering 3,200,000 and not being
 altered in shape  or size.   The haemoglobin-estimation  is
 60 per cent.1

   The case as you hear it must strike you as peculiar.
 Reading this story backward, so to speak, the paresis,
 the anorexia, the type of  mental disorder, all  point  to
 hysteria.  Then we have added a dysentery, which leaves
 her with such anaemic conditions and accompaniments
as,  for a time, seem  to make the  diagnosis of added
 pernicious anaemia probable.   The history of the devel-
opment of the remarkable  ataxia is not complete, but
its presence is to-day her most obvious symptom. Note

  1 After the administration of pyrophosphate of iron in divided doses up to
95 grains in some 70 hours the blood-count showed increase of red blood-
corpuscles to 4,160,000, and of hemoglobin to 70 per cent. See Dr. John K.
Mitchell's paper on Blood-counts. 
140
NER VO US DISEASES.
also the facts of varying analgesia, the typical changes
in the color fields, the  equally  curious  alterations  in
these, and you have before you a case of hysteria with
the very unusual  additions of pernicious anaemia and
ataxia of  motion.
   As you see her walk, with the aid of two nurses, she
usually lifts the feet high, and throAVS them, so to speak,
in a disorderly Avay.   With shut eyes her  motions are
all Avorse, as you may perceive Avhen the ataxic hand-
movements are thus  studied.   You would  have no
doubt, at sight, of hers being a case of typical posterior
sclerosis, and still less doubt if you recall the  fact that
she cannot tell the difference as betAveen the weight  of
a penny and that of  a silver dollar.  The exact facts
are better related in  the  case-notes.  Apparently she
has more or less defect of  the sense of amount of mus-
cular exertion  put forth—loss of  muscle-sense.
   Naturally,  I look with suspicion on an hysterical
Avoman long in  hospital  Avards; but as to the facts
I  have stated  I do not think Ave were deceived.  I
shall presently return to this matter  of loss of muscle-
sense.
   Considering  the case  as ataxic, such as Ave  see here
at every clinic, you should be surprised to find,  as I
now show you, that we have normal  knee-jerks, elboAV-
jerks, and muscle jerks, and also normal reinforcements.
The responses  are not spastic,  and the limbs are not
like  those  of people Avith lateral  columnar disease and
" lead-pipe" passiVe  flexion.   There is no clonus;  I
can get no ankle-jerk by a bloAV on the tendo-Achillis,
or on the sole of the foot.  I can call out this  response
by motor  or sensory reinforcement.  But for this re-
markable exception I should have almost no indecision 
MOTOR ATAXIA.
141
as to how to characterize  this deeply interesting case.
Perhaps I should not give too much importance to the
partial loss of ankle-jerk, especially in a case so pro-
foundly  hysterical.   Is this  case, then, an hysterical
ataxia due to hysterical  loss of  muscle-sense?   That
this  should be, along Avith  preservation  of  muscle-
reflexes, and  with  no loss of  tactile sense, and only
variable cutaneous analgesia,  would be  interesting and
unusual, and, let me admit, a little puzzling.   Hysteria
confuses, but  does  not exclude organic spinal  mala-
dies, and the partial loss of the lowest muscle-reflex is
suspicious.  But there are no  other signals  of  poste-
rior  sclerosis: no pain, no reflex losses in the  ataxic
arms, no eye-signs.
   Briquet, Avhose pictures  of hysteria look to me a little
too viArid, described a form of ataxia due to  loss  of
both skin-sense  and muscle-sense.  He seems to think
that  the loss  of the latter is not to  be met with until
the former has become positive.   With this double loss
comes incapacity  to  effect  a motor purpose  without
seeing the acting member.  With view, he  says, the
muscular acts are  perfect.   This is not the case in our
patient;  nor do I think it ever  is in these cases pre-
cisely as he states it.  The  sight helps the true hysterical
ataxic, but does not enable her to attain ease and per-
fection in her acts.
   The interest of our o\vn case lies in the isolated loss
of pain-sense, Avithout corresponding absence of cuta-
neous tactile  sense.    I have often seen more or less
surface-anaesthesia  Avith   more or less or no loss of
muscle-sense.   The great defect of this latter seen in
our  present case, Avithout any notable tactile loss, is 
142             NERVOUS DISEASES.

more than merely uncommon.   Again, with the ataxia
and  failure to estimate differences in Aveights, we have
complete muscle-reflexes.

  Case XLVI.—In the same Avard is a girl of twenty-tAvo
years, who has the more common form of hysterical ataxia
which  I described many years  ago.   She is now nearly
Avell, but a month ago  her walk was a thing most interest-
ing to see.   She Avalked as a jointed doll  endoAved  with
life  might Avalk—a  succession  of  jerky, abruptly ended
movements, with  sway of head  and body back and front
or to right and  left.  For  a fuller account  I refer you
to my original delineation  of  this  singular form of dis-
order.
  The patient Avas put alone in a room, given very decided
faradic currents  to the muscles with the wire brush  on  a
dry skin, and daily full massage, with iron and arsenic.
  She has been  rapidly  improving.  At  first, to  aid her
steps, she  used the  device I described long ago as crutch-
canes : but  she can  now Avalk unaided; she has deserted
her bed; knits and sews, and seems a prosperous case.
  April 23, 1894.  Her station is  good with closed  eyes.
Sensation is now  normal in all  forms, and the obvious de-
lay in perception exists no longer.  She can Avalk clumsily
some tAventy feet unaided.
  Up  to May 20th  my records describe  increasing gain.
She Avalks a few steps unaided, but still prefers to help her-
self Avith the crutch-canes.   She Avas rarely in bed;  knitted,
seAved, and used scissors.
  At this time her station-sway Avith closed eyes Avas hardly
more than normal.
  Soon after  I left  my service, in early  June, the knee-
reflexes began to grow less and less responsive,  and the
blood-counts fell  to 1,600,000, the  haemoglobin to 20 per
cent. 
MOTOR  ATAXIA.
143
  September 1, 1894, she died.  I add  Dr. Burr's post-
mortem notes :
  "At post-mortem I found <piite marked emaciation.  Skin
lemon-yellow.   Subcutaneous fat small in amount, orange-
yelloAV in color.  Muscles very dark  red.  Blood liquid
throughout  the body.   Heart  normal in  size;  cavities
contain a little semifluid blood ; Avails, average thickness;
muscle  broAvnish ;  very slight,  old thickening  of mitral
valves.   Liver slightly fatty.  Lungs, kidneys, and spleen
shoAved nothing noteAVorthy.   No gastric atrophy.  Tibial
marrow currant-jelly color, broken-down, cancellated bone
tissue.  Many  nucleated red  corpuscles.  Cerebral mem-
branes and brain normal; spinal membranes normal.   On
cross-section of the spinal cord  the posterior  columns are
pearly gray.
   "Microscopical examination,  highest level of cervical cord.
Very marked degeneration  of the posterior columns, ex-
cept  a narroAV level along  the edge of the gray matter.
In the lateral columns in the region of the crossed pyram-
idal tracts,  but not confined  strictly to them and not in
contact with the posterior gray matter, is an area of much
slighter but still  quite  marked degeneration.   Running
round the periphery of the lateral columns and reaching
quite far forward is an irregular band of not very marked
degeneration.  The intensity of the lesion varies much.
It is patchy, greater here, less there.  The remainder of
the white matter and the gray matter normal.  Peripheral
nerve-roots  normal.   No meningitis.
   "Cervical swelling.  The same condition obtains.
   " Upper dorsal region.  The condition is the same, except
that  the band of  healthy tissue between  the  gray matter
and the posterior  columns is wider and there are quite a
number of  healthy fibres in  the  periphery of the latter.
Marked degeneration of  the  crossed pyramidal tracts.
Cerebellar tract fairly normal. 
144
NERVOUS DISEASES.
  "Loiver dorsal region.   The same.
  "Lumbar swelling.  Slight degeneration of the postero-
internal column ; very slight of postero-external.  A small
area of degeneration in the crossed pyramidal tract.
  "Histological examination. There is a very fine and very
dense network of connective tissue.  No increase of blood-
vessels and slight  thickening of their Avails.  There is no
histological difference between the lesion in the posterior
and  that in  the  lateral  columns.   Median and  sciatic
nerves normal."
  To sum up, here is a case of hysteria on which are
grafted later the typical symptoms of pernicious anae-
mia  with its ordinary deceitful rise and  fall of blood-
counts.   At an uncertain period Ave  have the further
addition of an aberrant type of locomotor ataxia due
to organic disease of  the cord.  The changes for the
better in the way  of motion and loss of analgesia were
due  to  an improvement in the  group  of hysterical
symptoms.
  I  shall rarely be able to sIioav you so interesting an
example of the combination of three distinct maladies,
nor of the diagnostic  confusion Avhich  grave hysteria
brings into the study  of organic  disease.   Looking
back, the case appears plain enough. 
CHAPTER  VIII.
 POST-HEMIPLEGIC PA IX;  PEE-HEMIPLEGIO  PAIX;
   POST-HEMIPLEGIC  DISEASE   OF  JOINTS;  POST-
   HEMIPLEGIC NODES.

  There is some danger  lest amid the attractive fas-
cinations of novel bacteriological study Ave  may lose
sight of the more every-day  need  for incessant clinical
watchfulness  as to the lesser symptomatic novelties
which are yet to be detected.  The case which I show
you  to-day may very  well illustrate my  meaning.
It is of considerable  interest on account of  the early
date at which joint-disorder folloAved an attack of hemi-
plegia.  I shall presently speak  to you further of its
nature and explanation.   It reminds me to ask your
attention  to pain as among  the occasional prodromes
and sequels of hemiplegia;  also to a somewhat  novel
matter—the nodes which occasionally appear as sequelae
of this paralysis.
  The late Prof. John K. Mitchell first called attention,
in 1831, to the production,  through spinal  injury and
sequent disease, of joint-lesions  often distinguishable
with difficulty from the lesions of rheumatism.  Alli-
son, in 1838, described joint-lesions  following  hemi-
plegia.  Drs. Morehouse, Keen, and  myself reported
numerous examples of joint-trouble caused by periph-
eral nerve-lesions, and since then I  and others have
added largely to the  literature which deals with nutri-
tive changes occasioned, early or late, by cerebral and
                         13 
146            NER VO US DISEASES.
spinal disease, and by the diseases or traumas of nerve-
trunks.
  It is iioav generally admitted that the joint-disorders
which  occasionally  follow hemiplegia from  cerebral
lesions owe their  origin  to a  descending degenerative
change  involving the motor tract and finally the cord.
If this  be so, Ave must also admit that these  changes
are in certain cases very rapid, as I have now seen
at least four cases,  all of right-sided cerebral lesion,
in which one  or more  joint-lesions  folloAved Avithin
four days.  Then there is, too, a small group  of cases
not alluded to  in the  books,  in which the sequence is
as follows:
   1.  Primarily, unilateral pain in muscular or fibrous
tissues and great soreness.
   2.  Tenderness of certain joints, slight swelling,  and
pain on only one side.  Repeated attacks strictly limited
to one side.
   3. Subsequent cerebral  clot and paralysis of the pain-
ful side.
   4.  Increase of joint-lesions on the palsied side alone,
and generally chronic unilateral joint-trouble.
   Another  type,  Avhich,  like  this, giA^es  us  occasion
enough to reflect, is this:
   1.  Long-continued, or occasional, muscular  aches on
one side  only, Avithout heart-disease or gout, and Avith
no joint-troubles.
   2.  After a year  or  two paralysis of the side thus
previously affected.
   3. Secondary joint-lesions on the same side, becoming
chronic.
   In a third class, which is somewhat rare, we have as
an  immediate  prodrome of hemiplegia acute  pain  in 
HEMIPLEGIC DISORDERS.          147
 the muscular masses,  so  as to be  taken  for  muscular
 rheumatism, but confined to the side which within forty-
 eight hours becomes hemiplegic.   The following  brief
 case-sketches may ansAver for illustrations:
   Case  XLVII.—C. S.,  aged fifty-tA\o years,  a house-
 keeper, in general good health and free  from  cardiac,
 renal,  or gouty  troubles,  Avas attacked  in 1880, in the
 early spring, with pain and soreness in the shoulder-muscles
 and in the thigh  of the right side.  The attack was sharp,
 but lasted only a week.   It Avas  repeated a month later,
 and again  and  again,  with more or  less   SAvelling and
 tenderness of the shoulder,  finger-joints, and knee on the
 right side only.   The last  tAvo attacks  were accompanied
 with headache and slight  vertigo.   The final  attack Avas
 limited to severe  ache in the arm  and leg, and after three
 days of great pain  there Avas sudden loss of power of the
 whole right  side, with loss of sensation.   This  last Avas
 brief; but the motor loss was  more grave,  and there Avas
 never entire recovery of motion in either leg or arm.   On
 the fifth day the  shoulder became SAVollen and tender, and
 a  week  later several  of  the finger-joints suffered in like
 manner and finally the  knee.   There  was  early and, at
 last, late rigidity  of the arm-muscles.  None of the joints
 got well.   All passed into  a  state of  subacute inflam-
 mation,  and death followed a second hemorrhage within
 eighteen months.

   In this case the joint-lesions Avere seen before and also
 after the cerebral lesion.

  Case XLVIIL—M., aged sixty-four years, a physician,
 was well  as  to heart,  kidneys, and arteries, which to ap-
pearance were unusually free from disease.   For two years
before his paralysis  he was  subject to nearly constant pain
in the muscles of  the right arm and leg ;  occasionally, but
rarely, he had slight pain in the right knee-  and shoulder- 
148
NERVOUS DISEASES.
joints ; none  in  the smaller  articulations.   Occasionally
the pain Avas  so severe in all of the right-side muscles of
limbs and trunk as to confine him  to his bed for a week.
There Avas never pain on the left side.
  In June, 1859, a \dolent bout  of pain, still only on the
right  side, was folloAved on the second day by sudden and
incomplete loss of  use of the  right leg and  arm, without
disturbance of consciousness or of  sensation.  Within the
next three years he had three attacks of hemiplegia, none
severe, but each of them preceded by a similar onset of
muscular pain and tenderness.   He finally died of pneu-
monia.

   I saw many years ago a middle-aged  Avoman, who was
seized, Avithout  known cause, with violent pain in the
right arm and leg.  There were no joint-lesions.   The
pain was agonizing.   Within thirty-six hours she  had
a quite complete attack of hemiplegia on the same side,
after  Avhich  the pain sloAvly  faded away and  never
returned.   She made a good recovery and died, years
after, of lung-disease.
   I could readily add to these  cases.   To  observe one-
sided pain or joint-lesions as prodromes or  remote ante-
cedents of  cerebral lesions is not exceedingly rare.  I
have  seen one such  case within  a year, and in it the
muscular pain, as  is not uncommon, sloAvly passed away
with the paralysis.
   It is, of course, easy to dismiss these as cases of the
coincidental occurrence of rheumatism and brain-lesions;
but this will hardly satisfy the modern clinical observer.
Certainly they  should suggest inquiry  as to whether or
not incipient brain-lesions, finally productive of paral-
ysis, may not, either directly or  through  an influence 
HEMIPLEOIC DISORDERS.         149
on  the  cord, occasion morbid phenomena simulating
rheumatic symptoms.
  It  is conceivable that the many cases I have seen
may,  one and  all, represent the  coincidental occur-
rence of unilateral  rheumatism Avith a  sequence of
hemiplegia.   But  there  is another explanation which
is possible, and for this reason I desire to call attention
aneAV to the antecedents and consequences  of certain
hemiplegias.   If, as I and others have seen, inflamed
joints may folloAV Avithin from one to four days upon
hemiplegias,  it seems  unlikely that  their  presence
can be  due  to  organic  spinal  changes, or to  these
alone, unless these changes be far more rapid than Ave
at present conceive them to be.  If they are due directly
to the immediate influence of the brain-lesion or to its
effects on the  yet  unaltered cord, then even the joint-
lesions,  which are more  remote in time, may haATe  a
like origin.  Really, it does not as yet seem to be quite
sure that the cord is always or alone responsible, or that
the  joint-troubles as Avell as the pain may not have
their primary origin in the cerebral centres.   And at
all  events Ave need careful study of the motor tracts in
cases of  early death from  cerebral disease.
  Another rare consequence of hemiplegia is the, as
yet, undescribed occurrence of nodes of the periosteum.
These still further  add to  the rheumatic  picture pre-
sented by certain palsied limbs.  I speak of these nodes
as being, so far, undescribed, for in  a Avide search  I
find no  mention of them, and they appear thus far to
have escaped the attention of clinical observers.
  I first saw them some  years ago iu  a Avorkman about
forty-five years old.   He was a plumber, but had no
                        13* 
150            NER VO US DISEASES.
evidence of lead-poisoning, which, in fact, is scarcely
ever  seen  in this class of mechanics.   The  patient
had  never  had any genital  malady, and was in good
health until  he had, after ovenvork in hot weather, an
attack of left hemiplegia.  Unconscious for a day, he
made a fair recovery,  except as to his .arm, in which
during tAvo or three months developed late rigidity and
joint-lesions.  The knee, Avhich is rarely affected, suf-
fered, although slightly.   In examining Avith care the
state of this man's joints I found, about three inches
above the ankle, an elongated,  very tender node about
an inch Avide, and at the insertion  of the deltoid a sec-
ond, still more prominent.  Interested in these  lesions,
I asked Dr. Maury, as an expert in  syphilis, to ex-
amine the case.   He came to the conclusion  that there
Avere no evidences of  this malady, Avhich, I may add,
the man positively denied having ever had.  A long
and  active course of treatment  Avith iodides  and mer-
cury failed to alter the nodes in the least degree, and I
came at last to the couclusion that, like the joint-lesions,
they were indirectly the offspring of the cerebral malady.
I have since then seen similar cases, but of these I have
no notes.
  The case  I iioav show you came  first under notice in
1891,  and is the earliest example of  joint-lesion fol-
lowing hemiplegia which I have  ever met  with.  It
also  shows  to this day the interesting nodes to which
I desire to call attention:
  Case XLIX.—G. W., aged fifty-eight years,  is  a manu-
facturer in  active business,  of good health and habits.
He indulges in moderation as to Avine and  tobacco.  He
has  never had  syphilis, and there is no obvious disease
of the heart or vessels, and  no renal  disorder.   He is 
HEMIPLEGIC DISORDERS.          151
subject at times, for a week or more, to deposits of urates in
the urine passed  at  night.   On  July 20, 1891, after  a
severe  mental and moral strain which necessarily  lasted
during four hours, he  went  to a  friend's  house  to rest.
As he  Avas  about to  lie down  he reeled  and fell.   The
left arm, on which he leaned against the  bed, Avas some-
what twisted, and possibly strained, as he fell.   He was
found  unconscious, and with complete  paralysis of the
left side.    In  twenty-four  hours he  was  conscious  of
his surroundings.  His  speech Avas  long affected, and the
tongue Avas  protruded  far to the left.  The  leg recov-
ered  fairly Avell,  but  Avhen  first seen  by me—November
10, 1891—the foot still  dragged  a little; the left arm Avas
helpless.
  The  day after the paralysis he felt pain in the shoulder
and down the outside of the arm.   From this date he had
increasing pain, SAvelling, and tenderness in this joint.  In
August the elbow became painful, and early in September
all the joints of  the left hand Avere inflamed.  There Avas
early rigidity, and, later, extreme rigidity, with violent con-
traction of the forearm-muscles,  so that the nails indented
the palm.  There  had been  little gain as to these symp-
toms, but the pain has become less severe.  At the deltoid
insertion  a node, three  inches by  one, of  irregular form
and quite prominent, could be  felt.  It was  plainly peri-
osteal  and  painful in  varying degrees.   On  the  ulna,
above the wrist, was a second node, and above it a smaller
one, both very distinct and also  tender.
  The  foot was somewhat contracted.  All the nails on the
palsied side  greAV very slowly for two months.  Sensation
was slightly  defective  as to touch only on the palmar faces
of the  first and second digits.
  The  tongue Avas protruded to the left,  and speech Avas
not quite perfect.
  When seen, in  May, 1892, there Avas less  pain, but all 
152
NER VO US DISEASES.
of the joints of the left arm Avere tender, sAvollen, and use-
less.
  The nodes are still to be felt, although they vary in size,
and are at times larger than now.

   This case is to me very interesting.  It is possible
that the shoulder-joint  may have been twisted in the
fall, and  that this accounts for the very early inflamma-
tion,. Avhich, later, may have owed its continuance to the
paralysis.  I have, however, seen one case  in Avhich the
joint-lesion came on within thirty-six hours, and other
cases in which it came on within four days.  Therefore,
it is possible that in the  present example the shoulder-
trouble may have  been the immediate offspring  of the
brain-lesion alone.
   The mechanism of the production of these very com-
mon incidents of hemiplegia is still a difficult question.
Perhaps  a careful study of the post-mortem chemical
state of the limbs may help us; but it should be made
immediately after death.   It is quite  possible that the
nutritive disturbances of a  palsied limb may evolve,
locally, products which give rise to these pseudo-rheu-
matic  appearances.   Peripheral nerve-lesions  clearly
alter  the skin-secretions, as I have elsewhere shown,
and they may as likely evolve within the limb chemical
products favorable to the evolution of joint-disease.  It
is not  enough to say that this is caused by altered nu-
trition.  The  nodes I describe are also one more addi-
tion to the points of clinical  resemblance betAveen a
palsied  and a  rheumatic limb, and, small as is their
 mportance, it is, I think, of value to note their occa-
sional presence.
   When acute  unilateral  pain immediately precedes 
HEMIPLEGIC DISORDERS.          153
hemiplegia of the same  side, such a  sequence should
lead us to  reconsider  the more doubtful  instances  in
Avhich pain and joint-lesions more remotely but more
continuously  antedate  the palsy.   I  have myself no
doubt that pain and many other sensations may be of
cortical and cerebral origin.1

 1 Note an interesting paper  on Brain-itch, by Dr. Bremer, of St. Louis.
Review of Insanity and Nervous Diseases, December, 1892. 
CHAPTER IX.
           THE TREATMENT  OF SCIATICA.

  I promised that these clinical lessons should some-
times consider for you such peculiar therapeutic methods
as are in use  within  our Avails.   Accordingly, I call
your attention to-day to certain points in the diagnosis
and treatment of sciatica.
  Under  this  name the books include true neuralgia,
without demonstrable organic  changes in the nerve, and
the graver pain Avhich is due, as a rule, to some grade
of neuritis.
  Let us admit that the first class is seen in practice in
all  degrees, has a  great variety of  parentage, and at
times many parents, or haply none that can be found.
  To men like you, advanced  students, clinically watch-
ful, it is needless to say that  the milder sciatic neural-
gias are sometimes of malarial, gouty, rheumatic, syph-
ilitic,  anaemic, or  other origin—mere functional dis-
orders like the typical fifth-nerve neuralgia.   Be this as
it may, I am  sure that sciatic pains, whatever be their
cause, are likely to become permanent and to pass into
distinct forms of  organic disease  of  the  sheaths, and,
at last, into neuritis, with degenerative  changes in the
nerve-tissue.   Too  often you can detect no  distinct
cause, or find that you must  fall back for explanation
on a general loAvering of tone, or on relatively slight
anaemia, or something as trivial  in appearance.  The
unusual causes, the distant reflex parentage,  like the 
           THE TREA TMENT OF SCI A TIC A.     155

luckily discovered decayed tooth of fifth-nerve neural-
gia,  are  rarely  called on  to  explain sciatica.   They
serve at best to keep us watchful and to make the text-
books less dull reading by introducing the pleasant un-
expectedness of  romance.
  I pause here to urge on you the fact that every human
being has a different standard of resistance to the effects
of anaemia, malaria,  or  any  of  the varied  forms  of
blood-defect or  mal-assimilation.   What does not de-
press one is serious for another.  Also, I ask you again
to remember that frequently  a  neuralgia  has  many
parents.   Ovenvork, overworry, or a hemorrhage may
cause anaemia,  and out  of this  may come functional
gastro-intestinal failures,  and these in turn may occasion
lithaemic disturbances, or make available for mischief
the effects of exposure or accident.
  Possibly, at times, old and long latent syphilis,  or
even  gout, is answerable.   Such a case meets with a
fall on the buttocks, and thus acquires, owing to the con-
stitutional poisoning of the patient, capacities to develop
an obstinate neuritis.  The type and severity depend
upon the hygienic surroundings and the past history.
An English writer declares that he has neATer seen caus-
algia such as A\re saAv from 1861 to 1864, nor have I so
seen it since, because  men worn out with marching,
soaked with malaria, and  exhausted by exposure and
diarrhoea,  are not now  the  subjects of wounds from
Minie-balls.
  For the unthoughtful there is only the final accident;
for the  man who  thinks there  is link  on link  of the
chain of  preparatory states, and it were easy to illus-
trate  them further.   This is, however, to be  only a
lesson of hints,  and I pass on. 
156            NER VO US DISEASES.
   Before considering  the ordinary sciaticas I pause to
 say  a Avord  as to sciatic pain of  Avhich the cause is
 organic and lies within the pelvis.  You cannot be too
 watchful as to this source of  trouble.  When you find
 extravagant  pain down the nerve be careful  Iioav you
 decide.   Sciatic neuritis  is a  very painful malady, but
 the  pain caused by the  squeeze  and inflammation  of
 rapid intra-pelvic carcinoma is a far more terrible thing,
 and the grade of pain may help  you in your decision.
 In any case of doubt  the rectal examination should  be
 thorough.
   Several times in my life I have seen the causal diag-
 nosis of a furious sciatica made on  the post-mortem
 table by the discovery of a saddle-like  growth astride
 of the  cords  of the parent plexus.  If the tumor  be
 small, palpation is useless  as a guide, and  the best of
 us may be baffled.  At times a large growth rewards
 our  search.   TAvice I  have seen accumulations of feces
 give rise to  irritative pressure:   one got  well; but
 one, which had been  treated  for  multiform malignant
 tumors,  Avas  so  regarded  up to  death  and  perished
 miserably.  The post-mortem section showed enormous
 fecal accumulations of such  hardness  as  caused one
 of the assistants to think they Avere masses of calculi.
 In this case the pain was in the right sciatic nerve.
  Benign tumors or groAvths of syphilitic  origin may
 act Avithin the pelvis to cause sciatic pain, as the folloAV-
 ing interesting case serves to  show:
  Case L.—L. B., aged forty years, a planter, states that
 sixteen years  ago he had a sore, then said to be syphilitic.
 He has had no secondaries of  which he Avas  ever  aware,
 but has all his life been subject to herpetic eruptions  on
the glans penis.  He  has been,  over and over, pronounced 
THE TREATMENT OF SCIATICA.      157
 free from  specific  disease.  In  August,  1891,  he began
 to  have vague aches in the occiput, the right  knee, and
 the thigh.   In September he had pain  in and  about  the
 sciatic  notch and  doAvn the leg.  These  aches  became
 worse, especially  below the knee, and at last almost  de-
 prived  him of the power  to  stand  or  Avalk.   At night,
 after twelve, his pain Avas so intense  that  morphia became
 essential.   His case on entry here Avas too easily  taken  for
 granted by me as an ordinary neuritis, and subjected to
 the usual treatment.   When this entirely failed I began
 to suspect that Ave Avere dealing with  sciatica of an unusual
 type.  In making the re-examination which this suspicion
 caused me to undertake I found at the middle of the right
 thigh a smooth swelling of the bone.   If, as seemed likely,
 this Avas a node and specific, it became clear that it was in
 no Avay competent to  cause  the pain; but it  Avas as  clear
 that there  might be Avithin the pelvis or at the notch a
 similar  growth, so placed as to compress and irritate the
 great sciatic.  One week of full treatment by iodides led
 to rapid lessening of the external node and to a SAvift ex-
 tinction of the pain.  My inference was  probably  correct.
 After a feAV weeks he Avas dismissed cured.

   It is also AArcll to remind you that childbed may cause
 sciatica.  I  kneAv many years  ago of one woman who
 ahvays  suffered  during three weeks  after labor  with
 double  sciatic pain, and at last, after a labor  in which
 there Avas  profuse flooding,  Avas afflicted Avith  a  left-
 sided sciatica for many months.   Some pain  in these
 nerves you will all hear about in childbeds, and I may
add that to strain at  stool may cause increase of suffer-
ing to a patient tormented by sciatica, and even to rheu-
matic people Avho are Avithout distinct neuritis.
  I am quite sure that some Avomen suffer more  than
do others in childbed from  this effect of pressure by the
                           14 
158
NERVOUS DISEASES.
descending head.   For this there may be a reason in
the form of the pelvc,  and possibly in the mode in
Avhich the presentation occurs.
  Of the terrible sciatica of alcohol I need say nothing
here,  and that lead or arsenic may cause sciatic neural-
gia of neuritic type is also to be remembered.
  Strange  as  it may  seem, one  may be misled for a
time as  to diagnosis by a subacute inflammation of the
hip-joint, with aches about the knee, slight wasting, and
stiffness.   As between this and the sciatic  pain Avhich
exists chiefly  in and  around the foramen of exit  and
has caused nutritive changes in the gluteal muscles, one
is at times troubled to decide.   At all events,  I  have
seen  surgeon  and physician err one way or another as
to these maladies.
   And  now as to  one or two matters connected with
sciatic pain, before we consider the treatment of sciatic
neuritis and  the  neuralgias  likely,  under conditions
adverse to  recovery, to  eventuate  in the more serious
malady.  I shall  presume  upon your full knoAvledge
of the  symptoms  of  sciatica.   The gait, the wasting,
the pain-points, and the hyperaesthesia or anaesthesia I
may pass over as  familiar.   But look iioav at the case
I shoAV you from  McCormick ward.   When this man
entered here he had violent pain at the sciatic notch on
carrying the  leg forward.  A case near by, noAv Avell,
had pain down the leg on putting the leg far back, and
at each  step as the leg on which  he stood reached its
extreme limit of backward position. The fonvard SAving
eased him.  A case seen last year fell as if shot when
he stood on the  lame leg, the pain  darting down  the
limb from the notch.   A few years ago I saw a still
worse example of this  form  of  pain.  In  this latter 
THE TREATMENT OF SCIATICA.       159
case, after long treatment, I found that very deep pres-
sure at or over the notch caused acute pain.  Finally,
Ave cut doAvn (I think it was Dr. Morton who operated)
and  found a small,  round,  hard,  fibrous  groAvth  just
over the  point  of exit of the  nerve.    Its removal
brought about a speedy recovery.  Extreme lift of the
leg  in  sciatica  nearly  ahvays gives increase of pain,
and some sciatica patients Avho have  suffered long care-
fully limit the length of their step so as not to make
any pull on the ner\Te.
  Walking exercise usually makes  the  pain of sciatic
neuritis worse.   The cause is, perhaps, not so simple as
it may seem to you.  Of course, it is natural to presume
—is, I  think, generally taken for  granted—that the
rhythmic tension of the muscles at the notch squeezes a
swollen nerve as Ave Avalk or stand,  and thus increases
the suffering.
  I have taken some pains to see how far this may be
true.   The result of a  brief study of  dissections made
for me by Dr. Addinell HeAvson, that I might investi-
gate the matter, proved of interest, especially  as the
anatomies did not make it entirely clear.
  The great sciatic emerges from its foramen Avith ample
space around it.  Then  it lies  in an irregular triangular
gutter between the tuber ischii and the great and lesser
trochanters.  This space is over-large and narroAvs or
widens as inversion or eversion of the foot and leg turns
the head of the bone imvard or outward.   Above, or
posteriorly, this deep gutter is covered by the gluteus
maximus.   At the lower edge of this muscle the deep
fascia turns under it and then is reflected doAvnward, so
as to roof over the loAver part of the sciatic gutter with
a dense covering,  which is attached to the ischial tuber- 
160
NERVOUS DISEASES.
osity,  and  to  a part  of the lesser trochanter.  This
fascia  thus forms  a strong  tentorium,  protecting  the
nerve more or less from external violence.   The pyri-
form muscle, Avhich overlies the nerve, is so situated
that it crosses Avhere the nerve, lying rather free in its
Fig. 2.
Divided body
   .°f  ■
 Pyn/omi s
  Muscle
Small
Sciatic
Nerve \
Anomalous high division ol great sciatic nerve, one branch passing througli
                     pyriformis muscle.

notch,  could,  eA7en  if  SAVollen,  Avith difficulty  suffer
from the action of this muscle.   In front of  the nerve
lie the quadratus and gemelli  and  the  tendon  of the
obturator.  When these muscles swell in such contrac-
tile effort as eA7erts the foot they may more or less press
upon the nerve,  but the  consentaneous  action  of the 
THE TREATMENT OF SCIATICA.       161
tightening mass of  the  gluteus must tend to enlarge
the cavity in front of it and make tense its roof, so that
unless immense swelling of the nerve be present or a
groAvth,  the  activity of  these muscles could  scarcely
cause pinching or pressure of moment.
  Dr. J. M. Taylor called my attention to the fact that
in 1600 sciatic nerves there  were  49  anomalies of a
nature to cause quite surely pain in a swollen  nerve
Avhen  the  pyriformis  acts.   In these anomalies  the
nerve divides so that one part goes  through the belly
of the muscle—as is well seen in Dr.  Taylor's sketch.
As a fact, eversion or immersion of the foot rarely gives
rise to  increase of  sciatic ache.  AVe must  look else-
Avhere for explanations.   It seems to me probable that
the forward  swing  of  the leg in Avalking may be  felt
because at its full limit it must repeatedly stretch  the
nerve  a little, and  very  little is needed to hurt  an
inflamed nerve.  Thus, going up stairs, Avhich stretches
the nerve far more, is painful.  Also, we should re-
member that the thigh-muscles, bound down by tense
fascia,  may in  action somewhat compress the track of
the nerve.
  Whether any of  the  exceptional cases of violent
anguish  referred to  the  notch on standing are due or
not to the anomalous peculiarity mentioned I cannot
say.
  Very rarely, it is the backward motion which causes
pain, and for this I can see no competent explanation.
  I suspect that very often the pain  increased or repro-
duced  by walking is due to  more   mysterious causes,
Avhich  are of  central origin and analogous to such as are
present in facial neuralgias when the patient cheAvs or
SAvallows, talks or laughs.   Then there seems to arise a
                         14* 
162
NERVOUS DISEASES.
sudden reinforcement of capacity to feel  pain on  the
part of the nerve-centres.   It is  also  quite  sure that
certain sciatic cases are  eased by exertion;  probably
these are not  cases of neuritis.
   I wish to say a few Avords as to the time of the ex-
acerbations of pain in sciatica. I have studied with some
care the hour of greatest pain in neuralgias, and I think
I may be secure in stating that for fifth-nerve neural-
gias it is likely to be before noon,  and for  sciatica after
4 p.m.  In many cases of the latter malady it is between
12 at night and 4 a.m. ; these  figures  are  the result of
an examination of something like a hundred neuralgias.
   Whilst this holds good for our oAvn climate, it may be
quite untrue  elsewhere,  as in the South or in England.
I  mention this  because abroad  the remarkable statistics
of my clinics, and the studies of Dr. Morris LeAvis and
of the author on chorea in relation  to seasons, have been
doubted, or declared  not to have been confirmed  by
European observers.   It Avould be odd enough if they
Avere,  as almost inevitably the relation  of pain or other
morbid  phenomenon to time of day or year may differ
in one continent from  another.  It is  the  comparative
results which become interesting.
   As  regards this question of  the time of pain-occur-
rence  there  are  A'aluable papers  by myselfl and  by
Captain Catlin,2 U. S. A., Avhich  exhibit, as concerns
a  remarkable  case  of  traumatic  neuralgia,  a curious

  1 Relation of Pains to AVeather, by S.  AVeir Mitchell, M.D.  American
Journal of the Medical Sciences, April, 1S77.
  - Relations of Pain to Weather, Studied during Eleven Years of a Case
of Traumatic Neuralgia, by Captain R. A. Catlin, U. S. A., with Notes by
S. AVeir Mitchell.  Transactions of the College of Physicians,  Philadelphia,
1883.
  Memoirs of the National Academy  of Sciences, 1892.  Final report by
Captain Catlin. 
          THE TREATMENT OF SCIATICA.      163

tendency to the increase of pain at set periods of the
day.
  Sciatic pain  tends to be worse at night.  The treat-
ment should, so  to speak, folloAV it  into this period;
and  this is avIiv I ha\Te  insisted  here  on  the time-
question.
  And  now let us pass on to the  treatment.   If  you
turn to  the text-books, as to this and other Avell-studied
diseases, you Avill find a bewildering list of drugs,  and
mechanical and  other treatment mentioned, with the
constant introduction of " So-and-so has been or may
be used;"  also, " G recommends this,  K that,  in  this
disorder."  Dropping all  this puzzling list of drugs,
and what not, I shall now tell you Avhat I usually do
here,  and  do in succession in  these cases, as  improve-
ment or failure makes desirable.   In prhrate practice
you  cannot ahvays do  at once as  you wish  to do, or
think really  best.  Except  as to  that which  money
brings—change of climate and the like—so far as mere
immediate  treatment  is concerned—the poor, in a hos-
pital like this, have sometimes a better chance than the
rich or highly placed, as certain  illustrious precedents
have proved.
  If  in the text-books  the list of drugs and counter-
irritants Avere followed by a clear statement of Avhat the
author  advised in mild or in grave cases, these books
Avould acquire a definite and individualized value.  One
may read all that GoAvers, or Gray, or Dana says, and,
if young in practice, rise Avithout the least distinct idea
as to just how these able  men  treat their oavu cases of
sciatica. You may rest  assured that they  are more
definite in  their practice than might  be inferred from
their  books.  The treatises on mere therapeutics are yet 
164
NERVOUS DISEASES.
worse.   In one is a list  of  forty agents which may be
used in sciatica.
   Let us say that Ave have to deal with a mild case, a first
attack.  The usual careful search through the organs
and secretions has been made.  Any obvious constitu-
tional  disorder is  provided for.  What next ?  As to
this, all are at one—rest in bed, constant and prolonged,
till recovery  is assured.  FeAV things are  as A'aluable
as  dry  cups,  if you use  them  thoroughly and  early.
Very effective is a double or even a triple row of cups
all around and over the notch and  doAvn the leg, along
the nerve-branches to the ankle.  There should be some
three dozen  cups simultaneously applied, and  they
should  remain on half an hour, but not be used so as
to  blister.   This measure  is repeated  the next day;
then tAvo days later, and this alone may ansAver.  Or,
if for any reason you caunot do this, put on mustard,
at least three  inches Avide, from notch to ankle;  or, at
least, to the knee.   Add a  little molasses to the  mus-
tard, and you  may then leave it on for hours; and this,
too, may ansAver.  Some of the elder doctors, like Pear-
son, kneAv the fact that very extensive  moderate counter-
irritation is often better than  limited and more severe
attacks on the skin by irritants.
   If these means fail, what is to be done  next'.'  As
to this  I hesitate no  longer, but go on at once to the
means  I noAV  employ in chronic  cases.  But, at the
beginning,  and perhaps later, until  you  can perma-
nently ease the ache,  it is  needful  sometimes to use
narcotics.   Cocaine is the best, in from one-fourth to
one-half grain hypodermatic  injections.   Plow rarely
Ave use narcotics here, even  in our worst cases of  sciat-
ica, the resident  physicians very Avell know.  If you 
           THE TREATMENT OF SCIATICA.       165

 prefer morphia, give one dose at about 8 or 9 p.m., and
 get rid of it soon.
   But  suppose the disease prove intractable?   Let us
 take the case in Avhich mild  irritants, rest in bed,  and
 constitutional  means  have failed; or  that of  the  old
 hospital guest Avho has  carried pain Avith him from
 ward to Avard this year or tAvo.
   Consider a moment the attitude and ways of a really
 severe case of neuritis, and let us see Avhat guides these
 obviously  offer.   The man lies in  bed with  the leg
 slightly bent at the knee  and hip.   If he wishes to
 turn, he keeps the limb rigid—splints it, let us say, by
 the use of his muscles, aids it with the stay of support-
 ing  hands.  In  the exacerbations, in the anguish of
 the night's increase of pain,  a touch, even slight  fric-
 tion of  the bedclothes, increases the  distress.    It was
 while watching such cases that it occurred to me to use a
 splint to keep the limb quiet.   If I could by this means
 forbid the use of muscles, I  should  thus far secure to
 the nerve  physiological rest, which, for many reasons,
 seemed  desirable.  If free motion gave pain, all motion
 might be  relatively hostile to recovery.   At a much
 later date I was struck with  the  familiar fact  that all
 contacts Avere  avoided in certain  cases and  that any
 sudden  touch,  even  that of the bedclothes, Avas able to
 increase the pain.  It seemed  to me, as I considered the
 matter,  that such  unequal, irregular  contacts might be
 hurtful, and that by a bandage I could secure the sur-
faces  from these,  and  thus still further iusure to  the
nerve functional  repose.   Finally, it Avas  possible that
the bandage  might, by gentle, firm,  general pressure,
lessen the amount of blood circulating in  the leg, and
thus relieve, just as one eases an aching finger by firmly 
166
NER VO US DISEASES.
grasping it.  My success seems to be a justification of
the reasoning; but  that is of little moment.  There is
much good treatment which we cannot explain.
  There are many  ways of  doing these two  things.
But whether you suspend the leg in a  splint, or use
Avire or moulded splints, the splint must  check  motion
at the hip and knee.  This is the essential  matter.  The
bandage must be of  thin, pure flannel, and reach from
foot to groin.  I have used rubber or elastic stockings,
and also combined use of  the splint with pressure by
plaster  or other splint dressings.   Practically here we
use for  all true sciaticas  a firm  flannel bandage from
foot to groin and  reapply it tAvice a day.  The leg is
slightly bent at the knee  and kept nearly straight at
the thigh, and  in this position secured to a light side-
splint from axilla to ankle  by a few turns  of a bandage.
Care is, of course,  taken  to  prevent  pressure  on  the
heel.  After a feAV days the  joint-angles are slightly
changed at each dressing.   Still later, as the pain fades,
the joints are mildly and  passively exercised  Avhenever
the bandages are renewed.  Usually three weeks must
pass before we can begin to abandon treatment; a much
longer  time may be needed for old cases.   Finally, Ave
take off the splint in the day, but leave the bandage on.
At night we replace the splint.   Later Ave give up the
splint, and, Avith the presence or absence of pain as our
sole guide, in like  manner we omit the  bandage, noAV
in the day, and finally at night, but not at all until
the patient has begun to move about, and perhaps not
then.
   Meanwhile with cod-liver oil, iron at need, good diet,
care as  to the bowels, never allowing a costive passage,
forbidding effort at stool (preventing it by hot enemas) 
THE TREATMENT OF SCIATICA.      167
—by these means, I repeat, Ave carry the man through.
When  the pain has  quite  gone we use mild massage
once a  day before replacing the bandages.   The process
must be careful, Avith avoidance of roughness.
  There  may be left, near the close of this treatment,
one or  more points of persistent pain,  not often severe.
These are best treated by counter-irritants, the best being
the light touch of  a A\hite-hot Paquelin button, or a
small blister.
  The  getting up of  a severe sciatic case is not unim-
portant.   Motion, the full use of  the  leg and buttock
muscles,  and the pressure of the hard edge of a chair,
or close stool, are likely to bring back pain.  Hence,
we  do  not allow a  man to sit at all the first week that
he  is up.  He must at first  stand, and then walk, but
always, whether he walk or stand, it must be with the
aid of  crutches.  He may be  upright, or lying  on a
bed, but not seated.   Electricity is rarely needed,  even
if there  has  been much wasting.   With exercise  and
massage, or Avithout the latter, the muscles  usually get
strong.
   I have said no word of  the use  of continuous cold  so
much  employed here before the  bandage and splint
combined were found to  triumph readily  over  most
cases.  It is still occasionally employed.   The method
I  have elsewhere detailed  at  length  in the  Interna-
tional  Lecture Series.  It gives us a  resource of  great
value  if  the less troublesome  plan should  happen  to
fail; and failure is rare unless the neuritis has gone up
the nerve into the sacral  plexus,  or unless the pain is
really  spinal in its origin.  My former published cases
involved the combined use of ice and splint-rest.  Those
I have shown you of late were treated chiefly with the 
168
NER VO US DISEASES.
tight bandage and long splint, to which you may add
ice-bags  at  need.   The rapid gain to be had in an old
case of sciatic pain  out of these  means—the flannel
bandage, splint-rest,  and ice—must be seen to be fitly
appreciated, and I may add that in  mild cases the tight
bandage  used alone is often of value.   I do not claim
for these simple means any such  certainty  as  seems
usually to be demanded from novel methods.   I find,
however, that I rarely fail, and that my colleagues, like
myself, are  using these means.  It is Avith me an old
treatment, for in 1872, in my book on Nerve  Injuries,
p. 72, I  used  these Avords:

   "When  the disease is really  subacute and the nerve
tender on pressure for  some  considerable part of its length,
I insist upon the most absolute rest. If it be the leg which
is attacked, the patient must go to bed and consent to wear
a  carved splint for several weeks.  If it  be  the arm, a
splint  ansAvers to put it in a state of repose, and Avithout
this it is  vain to employ other means.
   " Cold should be used over  the nerve-track by means of
Chapman's spine-bag,  or, better, by such as are noAV made
by the Davidson Rubber Company, Avhich are thinner than
those of English make.  The caoutchouc bag should be
inclosed in a case of thin flannel, and may then be kept in
situ by a splint and a bandage, if  a  splint be worn.  In
most  instances I  have used  them over nearly the Avhole
length of the main nerve, and haAre usually contented my-
self with  their  employment in the daytime.  In some cases,
however, I have had them reneAved twice in the night, and
this plan I believe to be the better of the two.  The  only
difficulty lies in the first, pain from cold, and is easily over-
come.  The relief  afforded is often  remarkable, and the
loss of the nerve in size, hardness,  and tenderness  most
gratifying." 
THE TREATMENT OF SCIATICA.       169
  The following briefly stated cases, for which I  am
indebted to Dr. J. M. Taylor, sufficiently illustrate my
practice.   Many more might ha\'e been added.

  Case LI.—J. M., aged thirty-six years, born in Ireland, a
carpenter, as a boy had some kind of bone-disease involving
the left tibia, with a purulent discharge. Eight years ago he
fell forty feet, hurting his left hip.  He drinks rather freely
of whiskey, smokes excessively, and denies venereal disease.
There was  no neuralgia in the leg until three years since,
when it began Avith a dull pain in the region of the sciatic
notch, and passed along the  outer aspect of  the thigh to
the knee.  The pain is now confined  to the course of the
left sciatic nerve; it is constant and worse at night; it is
increased  in the  act of sitting down, and on rising from
this position there is much less pain.
  Examination of the various organs proved negative.  A
scar was found on the left leg, at the junction of the upper
and  middle thirds of the tibia; there is another a little
posteriorly to this, and a third lower down; these resulted
from old  sores, Avhich finally  healed ten years ago.  The
pupils  react to accommodation and light;  knee-jerks and
elboAV-jerks, and plantar reflexes, etc.,  are normal.
  The measurements of the thigh, nine inches above patella,
were: R., 21 in.;  L., 18 in.
  The thigh, six  inches above the patella, measured : R.,
181 in.; L., 16 in.   The calf : R., 13 in.;  L., 13J  in.
  He responded  normally everyAvhere as to touch, tested
Avith the  aesthesiometer;  localization  was good;  urine
analysis Avas negative.
  The patient Avas admitted to the hospital  February 18,
1892, in  a state of extreme suffering.
   The treatment ordered was  absolute rest, good diet, milk
between  meals, iron and  quinine, flannel  bandage,  and
massage.   He  managed, with phenacetin, to do without
                           15 
170
NERVOUS DISEASES.
opiates, and on the fourth day of treatment he ceased to
feel acute pain.
  On March 3d no pain Avas complained of  and the splint
was removed ;  the limb Avas kept straight.
  On March 14th the weight of the body cautiously put
upon the left leg Avas followed by no pain.
  On March 30th the man Avas Avell able to move freely
Avithout pain ; no cautery or treatment other than the ban-
dage  and splint was needed, massage  having been aban-
doned early.   He had a slight relapse on  the 16th, owing
to his having  risen, incautiously and Avithout a crutch, to
assist a patient who had fallen.

   This Avas a clear case of sciatic  neuritis, with much
wasting.   Seen  after many  months  he  was still free
from pain.
   Case LII.  Double Sciatica.—K. P., a porter, aged fifty-
seven years, a German ;  married, has seven  children ; was
never ill until December, 1891, when he had Avhat he  de-
scribes as a bilious attack, which kept him abed three Aveeks.
He broke two ribs three years ago.  There Avas no evidence
of syphilis. In October, 1891, he had a rheumatic SAvelling
of the right ankle.  A little later the pain extended up
the line of the posterior  tibial  nerve, and generally along
that of the main  trunk.  It was worse upon exertion, and
was eased by recumbency.  Nevertheless, he Avent  on with
his rather heavy work until, after exposure to  Avet,  the
pain became far  worse and the knee someAvhat stiff.   At
times he could no longer walk, and had also aches in  the
back and in the left leg.
  In  August  he  had seArere cramps  in both legs  and
limped  increasingly.  Still, under dire pressure of need,
he continued to work.  Late in August he had solar  ex-
haustion, and  at  the Pennsylvania Hospital was  treated
by ice-rubbing.   This, he  thinks,  chilled  him severely. 
           THE TREATMENT OF SCIATICA.       171

The  next  day intense pain  arose in the  left leg,  greAV
Avorse, and he became able to work  only  intermittently.
The pain uoav (October 14th), on admission, is very seA-ere
over the right sciatic and in the thigh and  the calf of the
right  leg.  There  is, also, pain  on  pressure, but  none in
the sciatic notch or in the popliteal space.  In the left leg
pain is very marked  on pressure along the entire course of
the sciatic.  There is no  pain in the back.
  Measurements.  Thigh  : R., 18 in.; L., 16 in.  Calf:
R., 13£ in.; L.,  13  in.   Dynamometer: R. hand,  125;
L. hand, 125.
  The knee-jerks on  both sides are normal,  and there is no
clonus;  the elboAV-jerks on both sides are normal, and there
is no impairment of  muscle-jerks ; sensation is everyAvhere
good;  the heart,  lungs,  kidneys, etc.,   are  normal.  To
stand long occasioned pain in both legs, especially in the
thighs;  walking is difficult and painful.  In November,
1892, on taking charge,  I found this man in bed, having
had elsewhere many forms of treatment, all  unsuccessful.
He Avas ordered full diet, rest in bed, Avith flannel ban-
dages to both legs.   On  the  third  day he became nearly
free from pain.  Thereafter the usual changes as  to splint
and bandage Avere  made.   It seems needless  to repeat them.
  On December 2d  he  Avas alloAved to  Avalk a  little on
crutches,  but not to sit doAvn.   Two pain-points in the
upper thigh were lightly cauterized.   He Avas discharged
December 12, 1892,  apparently well.

   This appears to have  been a case of  true double sci-
atica, probably rheumatic.  I learn that  he is iioav (April
1st) Avell  and at  Avork.  The immediate effects of the
splint and bandage  were very gratifying.

  Case LIII.—G. C, aged sixty-five years, is a machinist;
he drinks and smokes  moderately; is  very rarely ill.
During the Avar he had " camp fever." He  denies venereal 
172
NERVOUS DISEASES.
history.  He is married; has had nine children, five are
living and four dead. Suddenly, six weeks ago, pain began
in the left  hip and leg; the left foot feels  asleep quite
constantly;  the pain groAvs worse  at night, on change of
weather, on rising from  a chair,  and  while walking or
going up steps.
  The man is pale and  thin and has the gait of  one in
much pain ; the left leg is held stiffly.  The left knee-jerk
is slightly in excess of the right.   Pressure over the  left
sciatic notch causes pain,  and also along the course of the
nerve.  He Avas admitted to the  hospital  March 5, 1892,
and  was ordered  absolute  rest in bed, flannel bandages,
straight  splint,  extra  diet, milk, iron, and cod-liver oil.
On March 10th the report  says that the pain  disappears
in the  daytime, but  at  night  is sufficiently  severe to
keep him awake.    On March  13th all  pain  has disap-
peared, except  a soreness over the external condyle of the
femur  and  external malleolus where it is  in  contact with
the splint.   He now sleeps well.   On March 18th all pain
is lost, even  upon  deep pressure.  On March 21st  the
splint  is removed  in the daytime, but the limb is to be
kept in extension  and  quiet.  The splint  Avas  applied at
night until  the 26th inst.   The bandage  was  constantly
used, and he Avalked Avith  crutches.   He  has  had slight
relapses,  necessitating the use of the splint for a day or
two.   On March   28, IS^o, he  Avas discharged Avell—a
rapid recovery.
  Case LIV.—P.  G.,  aged fifty years, had  the interest-
ing combination. of sciatica and erythromelalgia.   The
family history  was negative.   He Avas a married man
Avith six  children, all well.  In the army he had a  severe
attack of measles folloAved by dysentery, and later typhoid
fever ;  he Avas ill  fhre  months.    After the  war he  had
malarial  fever.   Seven years after the first attack of dys-
entery he had a second  attack Avhich  lasted five  years, 
THE TREATMENT OF SCIATICA.
during  Avhich  time he passed much  blood and  mucus ;
most of this time he continued at work and often voided
tAvelve stools daily.   During  the  last five  years the man
had been pretty well.   He had never had any special in-
jury, but  has not been very strong since the last attack of
dysentery.   He  worked as a lumberman for  five years,
being out in  all weathers.   In January, 1889, he began
to work in the coal-mines.   Since his  army-life he has
had some fleeting rheumatic  pains noAV and again.  The
present trouble began January, 1889,  Avhile at work in a
mine, Avith severe  shooting-pain  in the  right  arm  and
shoulder, noticed while  at rest, but disappearing  on mo-
tion.   This lasted  three weeks.  He sleeps habitually on
the right side and had need to keep the arm flexed.   One
month after this, pain began in the left hip, shooting doAvn
the course of the sciatic to the calf and ankle, and being
of greatest intensity from the knee to the ankle.   He Avas
then confined to bed four Aveeks; on  the slightest move-
ment the pain  was much increased ;  this  gradually les-
sened, but the man  Avas  unable to Avork  for five months.
He describes the pain,  when  it began, as a burning and
craAvling sensation  in the  right leg, as if the flesh was on
fire; this continued in both feet in very severe degree; he
could place his right foot on the floor, but not the left one,
on account of excessive pain.   After tAvo months' treatment
he had improved, but Avas unable to Avork for five months.
He was pretty well until January, 1892, at which time pain
of similar kind, but more severe, attacked  the back  and
left hip, seeming to Avarp the body to the left side.   Much
pain Avas  caused by any attempt  to straighten the body,
shooting down the left leg into the foot and toes.  He Avas
again confined to bed for four months.  He Avas in the
Jefferson  Hospital  in May,  1892, for  five Aveeks.  He
finally Avas Avell enough to go home, but could not Avalk,
and  on arriving the  pain greAV Avorse.  Since May, while
                          15* 
174
NERVOUS DISEASES.
standing with the left leg pendant, the blood seemed to
accumulate  in  the  foot and leg up to the knee and cause
intense pain.
  October 14, 1892.  The left leg is noticeably shrunken
and  flabby; there  is considerable pain on pressure over
the sciatic notch, with soreness over the calf-muscles, but
none in  the popliteal space ; there is no shortening of the
limb.  The  foot is red and hot Avhen hanging down.
  Measurements.  Thigh:  R.,  17  in.;  L., 15 in.   Calf:
R., 121 in>.  L., 11 in.
  There is slight clonus in the left leg, but  none in the
right;  the  knee-jerks on  both  sides are normal;  the
plantar  and skin  reflexes are normal;  there  is  slight
hyperesthesia  in the left leg below the knee;  the  heart,
lungs, etc., are normal; the bowels are inclined to be loose
and irregular;  the  appetite is fair ; the digestion poor.
  This  man, while in the standing position, declares him-
self  unable  to allow his heel to touch the ground, asserting
that  it  would  pain so increasingly  and  furiously as to
"drive  him Avild."  There is  also pain on pressure over
the  entire  sole of  the foot;  pressure caused an  intense
flushing of  the surface.
  The treatment ordered Avas absolute rest, flannel ban-
dages, the straight  splint; massage, except to the left leg ;
cod-liver oil, malt, extra food, iron, quinine, and strychnine.
   On October  26th the pain was  so intense that ice was
applied.  On  December 2d, the ATaso-niotor  difficulty not
lessening satisfactorily, the left leg and foot Avere elevated.
Internally,  sodium phosphate Avas ordered, forty grains in
hot  Avater, an  hour before meals, to relieve  the constant
catarrhal condition of the stomach.
   On December 19th the  man was very much improved in
respect  to the sciatic pain; he  gained in Aveight and vigor,
and he  Avas  alloAved to go home on the 20th, as he declined
to remain longer.  He still wore  the flannel bandage and 
THE TREATMENT OF SCIATICA.
used crutches.  The flushing of the  foot was not better;
the hyperaesthesia of the member was little altered.

   As usual  in  my sad  experience  of erythromelalgia,
nothing  did much  good for the foot, although heat,
cold, electricity, and massage were  used Avith care,  and
I give the case  as it left us, because of the great gain
in  the  sciatic  pain, which,  if  not  Avell,  Avas vastly
bettered by local rest and bandage.  The long elevation
of the leg and  foot seemed to make the nerve-tracks
more tender, a  result  Avhich  I have seen  before  and
since, nor did it help the vaso-motor complications.  I
presume this man to have  a quite distinct case of  ery-
thromelalgia, Avith sciatic and terminal neuritis.
   You may with reason ask Avhat T do if the treatment
by the  splint-rest  and bandage, or by splint-rest  and
ice, fail.   At first,  to clear my experimental therapeu-
tics from needless doubt, I used these means only in
cases which I Avas sure were  sciatic  neuritis, and  this
alone.    I  have elseAvhere  recorded  the  results.1  Of
late, and since I felt secure as to  my process.  I  and
others have used these means in cases of  more dubious
nature—in  double leg-pain, in those who  had certainly
troubles in the loAver cord.   In such examples of sciatic
pain of  central  origin there have  been many failures
to record—many cases in Avhich splint-rest did no good,
or little.   In the true sciatic cases Avhich finally defy
all medical means there  remains  for  consideration
nerve-stretching.   I have  seen it  fail Avhen  my  own
milder means succeeded.   I believe that Avhen surgical
nerve-stretching is  employed  we should at once folloAV
up its use by that of the roller and splint-rest.  Some
i International Lecture Series. 
176
NERVOUS DISEASES.
of the relapses which follow its successful use have, I
am sure, been  due to neglect of the precautions with
which in very case of neuritis I desire to surround my
patient.  In conclusion, I desire to add that I do not
look upon splint-rest and the bandage as certain to cure
all  sciaticas, but as  sure to relieve or cure most cases,
and as valuable adjuncts to whatever other  means be-
comes desirable. 
CHAPTER  X.
ERYTHROMELALGIA:  RED  NEURALGIA OF THE EX-
   TREMITIES; VASO-MOTOR  PARALYSIS OF THE EX-
   TREMITIES; TERMINAL NEURITIS.

   I think myself fortunate in being able to show you
this morning the two cases iioav before us.  One is a
typical example of  A^asal spasm in the arterioles of the
fingers, and is known as Raynaud's disease.  The other
is the remarkable  malady which I first described  in
1872, and  to which in 1878, at Professor Ashhurst's
suggestion, I gave the  name of erythromelalgia (redness,
extremity,  pain); " red neuralgia" some like to call it.
It is inconceivable that these two disorders should ever
haATe  been  confused, and  yet at least one able observer
speaks of erythromelalgia, dead fingers, local asphyxia,
local syncope, symmetrical gangrene, as all being simply
different types of Raynaud's disease.  I hardly imagine
anything clinically more  strange than  to  consider the
cases before us as one.  Examples of Raynaud's malady
are not rare; cases of  erythromelalgia are very uncom-
mon.
   Here before you are two people.   One is a pale, ner-
vous, excitable  woman, whose  condensed  history my
clinical aid will presently read.  We shall someAvhat
abbreviate, for the Avhole matter has become familiar,
and, except as to the mechanism of causation1 concern-
ing the clinical features, Ave  know all that we are likely
» Medical Record, N. Y., July, 1885. 
178             NER VO US DISEASES.
soon to know. I shoAV the case uoav only as a contrasted
clinical picture.
  Case LV.—C.  L.,  single,  aged thirty years, a  dress-
maker,  is an  intelligent woman.  She has  had no  grave
illness, but after a long strain and much work she  began
to have the well-knoAvn corpse-fingers.   These attacks be-
came severe  and more lasting, and by  and by passed at
times into the condition of local asphyxia, the fingers be-
coming livid  in tint.  Later, she had slight gangrenous loss
of all the finger-tips.   You see the scars on  the finger-tips,
now Avhite and cold.  This state may  come and go, or may
end in the livid condition, when the returning blood stays
in the part and becomes black.
  Observe noAV that when I prick the livid finger the blood
floAvs out black, and  does not redden by exposure.   It  is
clear that it is  locally  charged with  excess of carbon
dioxide,  but  has  no  other peculiarities.  Many of Ray-
naud's cases suffered much pain.  This woman, like  others
I have seen, has had but little.
  Case LVI.—Turn  noAV  to this man in the rolling-chair.
Thin, ruddy,  anxious-looking, he is in no wise hysterical,
and is both patient and intelligent.   His face bears the
signal-lines of pain.   Look at his foot, as it lies on the ex-
tended leaf of the chair.  There is nothing notable about it
except the scars of an old injury.  It is like the other foot
—neither red nor pale.  He says it aches continuously—a
dull, deep-burning ache.  Also, as you see, it  is tender to
deep pressure and less so  to lighter pressure, except as to
the outside and as to  the heel and fourth and  fifth toes.  I
ask him to rise.   He does this aided.   He positively will
not stand on  the foot.   He leans noAV on a chair.  Almost
at once three of the toes become of a bright, rosy tint; then,
beginning  in island-like spaces, a  deeper tint  covers a
large part of the  foot.   The arteries  throb.  The veins
stand out in  strong relief.   In a feAV minutes the vascular 
ER YTHROMELALGIA.
179
tumult lessens.  The arteries cease to throb.  The redness
becomes dusky or in places purplish—not  livid,  as in the
Avoman's case.  At once the dependency of  the foot brings
increase of pain, and this gets Avorse until he will  stand no
longer or falls fainting.
  In like degree the hyperesthesia, both of depth and sur-
face, is augmented.   Finally,  the touch of  a feather gives
pain, and deeper pressure sends darts of pain up the track
of the posterior tibial nerve.   At last the pain is unendur-
able and I must let him put the foot up again on a chair.
  It is interesting to observe  Iioav unstable everywhere is
his  surface-circulation ;  how flushes  come and go over the
legs and trunk, and how little the other foot changes color.

  Surely, no  tAvo  more   entirely  separate groups  of
symptoms could  be found : this cold, AA7hite  hand, with
its  pale  fingers, free  from  pain of any moment and
more or less anaesthetic, and  noAV  presently livid; this
hot, deep-red  foot,  so  painful that its torment brings          t^-~*
out the  sweat on the sufferer's brow.
  Before dismissing these cases, I  desire to say a feAV
Avords as to the contrasts  they offer.
  Lannois, whose book I mentioned, thus characterizes
local asphyxia, or symmetrical gangrene, and  erythro-
melalgia.   I have someAvhat altered his definitions:

    Local asphyxia (Raynaud).        Erythromelalgia (Weir Mitchell).
Sox: Four-fifths females.            In twenty-seven cases two were
                                women.
Begins with ischemia.              Little or no difference of color is seen
                                until the foot hangs down in up-
                                right posture, when it becomes
                                rose-red.
The affected parts become bloodless   The arteries throb, and the color be-
  and white.  In certain cases  there     comes dusky-red or violaceous in
  is  the deep, dusky congestion of a     tint.
  cyanosed  part,  with or without
  gangrene. 
180
NERVOUS DISEASES.
      Local asphyxia (Raynaud).        Erythromelalgia (Weir Mitchell).
 Pain may be absent or acute, and   Pain usually present;  worse when
   comes and goes; has no relation to    the part hangs down  or is pressed
   position.  May precede  local as-    upon.  In bad cases,  more or less
   phyxia.                        at all times.
 Unaffected by seasons. In many cases   AVorse in  summer and from heat.
   all the symptoms can be brought    Eased by cold.
   on by cold.
 Anaesthesia to touch.              Sensation of all kinds preserved.
 Analgesia.                      Hyperalgesia.
 Temperature much lowered and un-   Temperature greatly  above normal
   altered by posture.                 Dependency causes in some cases
                                increase of heat; in others lower-
                                ing of temperature.
 Gangrene local and  limited; likely   No gangrene; asymmetrical.
   to be symmetrical.
    Erythromelalgia,  then,  is a chronic disease  in Avhich
 a part or parts—usually one or more extremities—suffer
 Avith  pain, flushing,  and local  fever, made far worse if
 the parts hang doAvn.   There are mild cases Avhich do
 not progress, and which may come and go.  There are
 others Avhich exhibit all the symptoms to such  a degree
 as to  make the  disease one of terrible torment.
   In 1878, when  my second paper Avas published, I pre-
 dicted that the malady would soon be shown to be more
 common than  it  appeared then to   be—and  this has
 proved to be the case.   Lannois's treatise1 gives many
 cases, and of late the German observers have  delineated
 it with their usual care, and especially Gerhardt.   At
 the  time I Avrote  I should, if driven to be positive in
 statement, have inclined toAvard considering this malady
 as due to some form  of spinal disorder.   And this may
 yet  prove more or less true of some of the cases, or of
 some stage of the  cases.   But at present the  reason-
able explanations  incline  rather toward some  form of
1 Erythromelalgia, 1880, p. 71. 
ER YTHR 0 MELALGIA.
181
 that neAV clinical perplexity, peripheral neuritis.  Light
 is cast on the matter  by the later history  I have  just
 obtained of the case of Mr. K., whom I saw in 1876,
 and Avhose story it seems worth while to give here at
 length, before  returning  to  the discussion of causes.
 Here  is a brief resume from my paper of 1878:

 -  Case LYII.—G. K., single, clerk, lost his  right arm in
 Avar, 1862.   Army-life Avas too  exacting for  his strength,
 and in 1864 an  attack  of typhoid left him Avith impaired
 vision—relieved in 1872 by glasses.   Between these latter
 dates  the foot-trouble  began, with burning pain and red-
 ness, made much  Avorse  by exercise.   He  persisted in
 Avalking until he caused blisters, and these were the only
 nutrition-changes I have  eA'er  seen in  this  disease.  In
 1875, with some evidences of paresis in  leg and arm, the
 remaining hand  became red, tender, and painful.   The
 case was typical.   In  July,  1877, after  extremities of
 anguish, Mr. K. Avent to Elmira, Avhere  Dr. Morris  LeAvis
 saAv him for me and made notes.  There was little change
 as to the disease;  but  he  had become silent  and morose,
 and was unable to be  out of  bed.   From November to
 July of 1877 he had nine attacks of convulsions, or rather
 of general  rigidity.  He spoke sloAvly  and in Avhispers.
 Clearly he had become more or less hysterical.
  There was slight oedema from the Avaist doAvn.  Pressure
 on  the spine caused pain, and  the  extremities Ave re very
 tender everyAvhere.  The finger-ends Avere bluish and cold.
 The last tAvo  phalanges Avere smooth, red, and  shiny, re-
 minding one of certain cases of traumatic neuritis.  There
 was great pain in the feet, the worse for  heat and depend-
 ency.  Also, he complained of girdle-pain at the  waist.
Sensation in all  forms  Avas  normal as to motion ;  a fine
tremor  existed throughout upon effort.   There Avas very
quick  exhaustion,  but  no other  distinct  loss of power.
                          16 
182
NERVOUS DISEASES.
Temperature and electric tests Avere difficult and objected
to.   Faradic reaction in the  arm-muscles Avas normal.
The  same current in the leg-muscles caused no motion; a
stronger current  caused  general convulsive movement of
the limb.   There Avas no other obvious change.1

   To my surprise, I learned of late that this  unfortu-
nate gentleman Avas still aliATe.  One of our  staff, Dr.
Burr,  has visited him  at my desire, and  this  is  the
present history,  after at least twenty-three   years  of
varied  suffering:

   "  The patient's  condition  remained the same from the
time Dr. Mitchell last saAv him until 1883, during which
year the redness  in  the  feet sloAvly  disappeared and  the
pain grew less  severe and finally became a mere ache.
There  has never since been a  return of the color.  For
some years the legs and  abdomen ha\re felt numb, or, as
he expresses it, he is ' dead from the belly down.'  He has
never  had a bedsore.  He has lost  flesh  during the  last
part of five years, but at times increases a little in Aveight.
He  lies on the right side or back, with the eyes covered
by tAvo bandages.   Lying on the left  side causes pain in
the left shoulder.   The room is kept darkened.  He has
not  read for many years; not because ATision is bad, but
because doing so causes occipital ache and  nervous feelings
in the  head.   The Aroice is Avhispering, and so low that he
is heard with difficulty.   There is remarkable emaciation,
the  abdominal Avail almost falling against  the spine.  The
skin is  very pale, but the mucous membranes are of fairly
good color.
   "As  he lies in  bed the feet fall forward in  lax exten-
sion.  He can. flex and extend the toes, ankles, and knees,
and  adduct and abduct the thighs while the legs are sup-

  1 See American Journal of the Medical Sciences, July, 1878, for full report. 
ER YTHR OMELAL GIA.
183
 ported by the mattress, but  he cannot raise the legs from
 the bed.   He can move the left arm Aveakly in all direc-
 tions, but has not strength enough to grasp anything.   He
 cannot feed himself.   There is no more Avasting of  the legs
 than of the rest of the body.   Position does not now influ-
 ence  the color of the extremities. There is no oedema of the
 feet.   The skin-temperature is good to the touch.  There
 is no rigidity at the  ankle-joint, knee-joint, or thigh-joint,
 passive  motion being perfectly free.  No trophic joint-
 lesion is  present.   As to  sensation, he localizes touch  in
 the legs  and the arm perfectly.   Contact is often felt as
 pain, more so  in the legs than in  the arm.   There is no
 more pain on pressure  over a nerve  than over a muscle.
 There is no discoverable SAvelling of the nerve-trunks.
   "The  reflexes in  the legs are all  increased.   A slight
 touch on the soles, and at times, indeed, on  any  part  of
 the legs, Avill cause the member to be quickly and forcibly
 drawn  up, and  sometimes the  movement may extend  to
 the other leg.  The knee-jerk is quick, large, and  spastic.
 Clonus is present in both feet, and at times patellar clonus
 can be produced.  The left  elboAA'-jerk is present, but not
 very  marked.  The muscle-jerks are capricious.  Chin-jerk
 cannot  be obtained.
   " The bowels are moved once in eight or ten days, ahvays
 by strong purgative medicine or mechanically.  He never
 has a voluntary  stool.  He  cannot hold  Avater after the
 desire to micturate  comes on, but the  stream is good and
 there  is never dribbling.  Sexual desire and poAver are abol-
 ished.  Examination  of the abdominal and thoracic organs
 is  negative.  Sleep  is variable and often restless.  Violent
jerking of the legs is frequent  during slumber.  He noAV
 has no violent pain in the feet, but at times much severe
aching.  He can foretell a storm by increase in foot-pain
and shoulder-ache.    He complains much of queer, inde-
scribable feelings in the head. 
184
NERVOUS DISEASES.
  '' There is no difficulty in sAvallowing.  Appetite is vari-
able.  Mental condition  is good, but  all mental effort is
disliked.   I believe that at the present time an hysterical
element is added  to  his  organic disease.   His  manner,
voice, and head-symptoms point in this direction."
  On April 13, 1893, this patient  died in Washington,
and to my regret no cadaveric section was alloAved.

  Seen in the wisdom-yielding light of many years this
case seems to have been originally  a neuritis of  peculiar
type, resulting, as time went on,  in  the addition of
hysteria and of lasting spinal lesions to be discerned in
the clear language of  spastic conditions, excitable re-
flexes, clonus,  and girdle-pains.   Neither hysteria nor
the added spinal malady may be essential features of the
disease.   I have  seen  them in other cases,  not always
with the same manifestations as here. And, on the other
hand, I knoAV of erythromelalgias of milder type, which,
after tAventy-five  years,  have altered little, and  cer-
tainly have not become worse or added a single spinal
symptom.  The old age of a case may really be of more
analytic  value than  a  cadaveric section.   In K. the
neuritis clearly ceased to be a very active agency.   The
sequent spinal malady, probably at one  time  itself a
central and limited neuritis, remains, and, too, the hys-
teria is visible enough.   And now let us turn  aneAV to
the present case.   Mr. K.'s  case,  as I read it to-day,
might have  been better studied in 1876.   I did not
realize its importance.   I lay before you Dr.  Rhein's
notes of the present case, taken in  my Avard.  Dr. Burr
has also  giAren it his  careful attention.  It is so pure a
type of erythromelalgia that I consider it most desirable
to study  it Avith extreme minuteness. 
ER YTHR OMELAL GIA.
185
   Case La III.—T.  S., aged  tAventy-one years, a stone-
 cutter, applied  for treatment at  Dr. Goodman's clinic in
 February, 1893, on account of  pain in the right foot and
 difficulty in moving it.  Dr. Goodman, promptly recogniz-
 ing the neurotic element in the case, kindly transferred the
 patient to  my  care.  The family and personal history is
 negative.
   In February, 1892, the  patient, with several other men,
 was raising a stone weighing betAveen ten and  eleven hun-
 dredweight, Avhen the board supporting  it  broke and one
 end of the  stone  fell  three  feet and struck the patient's
 right  foot  just  in  front  of the  ankle-joint.   In  a feAV
 moments  the stone Avas removed.   The patient was uncon-
 scious for a little while.  After about an hour he again
 became unconscious and remained so for four hours.   The
 Avound Avas  superficial and bled very little.  The foot and
 leg, half-Avay  to  the  knee, SAvelled considerably.   The
 patient Avas kept at rest  for four days and hot water was
 applied to the leg.   Six Aveeks later a large SA\Telling  upon
 the sole was incised  for the relief of a supposed abscess.
 Little bleeding followed, and there Avas no  evidence of sup-
 puration.   Ever since the  injury there has been difficulty
 as to motion in the ankle, OAving  to pain.  He began to Avalk
 December 24, 1892.   The sAvelling did  not disappear en-
 tirely until tAvo months after the accident.   Walking caused
 sharp pain under  the internal malleolus and just in front
 of the ankle-joint.  In  damp Aveather there Avas pain in
 the right great toe.   The right  foot felt Avarmer to the
 patient than the left.  The effort to Avalk Avas soon given
 up  and the  horizontal position permanently  assumed as
the only one possible to be borne.
  There are at present five scars due to the injury on the
dorsal aspect of the foot.   One,  1 cm. by 1.4 cm. in size, is
situated 6 cm. internal to the median line of the foot and
9 cm. beloAV a line connecting the malleoli. The second,
                          16* 
18 6             NER VOUS DISEA SES.
about the  same size, is 7 cm.  to the inner side  of the
first.  In the median line and anterior to the first are three
smaller  scars each about 2 cm. in diameter.  They are  all
dark  purplish  and  hypersensitive  to pressure.   He  is
unable  to  stand up, or, rather, to sustain  any part of  his
weight on the right foot, except for a moment, by resting
on the heel alone.
  The whole of the  right  foot, as he  lies  at rest  supine,
the leg being  extended, is slightly redder in places  than
the left; but after a feAV minutes in this horizontal position
it is observed that, save for the  tint of the scars, the feet
are indistinguishable  in hue.  AVhen standing erect, Avith
the right foot  hanging down, the foot becomes flushed at
once; the  first and second toes assume a bright red, and
this extends, appearing here and there in islets of deepen-
ing color  until the Avhole foot is of a dark, dusky tint,
which becomes more pronounced the longer he is up.  The
upper limit of  redness  is marked by a dark-red band on
the ankle, If inches above the loAver border of the internal
malleolus.   It  encircles the limb,  except for an irregular
space on the outer aspect.
  The beginning of the flush in the pendent foot is marked
by increase in  the size of the veins and by a visible and
rapidly augmented  force  of  arterial  pulsations.   It is a
true vascular storm.   After a few minutes  the veins  re-
main  large, but the arterial throb lessens;  the  color  be-
comes more and more purplish, but even after a half-hour,
when the patient stood on crutches, Avas never of the smoky
tint seen in local asphyxia.   When again put at rest and
supine  all of  the vascular symptoms disappeared  quite
promptly.   The Avhole foot is over-sensitive in all  posi-
tions.  The hyperaesthetic areas differ according as the part
is level  or pendent.   It  is hypersensitive  to  a  needle-
prick, to heat and to cold, and to pressure. The diagrams
make clear the facts Avithout need of fuller verbal statement. 
 
 
ER YTHR OMELA LGIA.
187
  When lying on a level slight touches give no pain, but
the least increase of pressure hurts.   Pin-pricks cause ex-
treme pain ; all degrees of heat or warmth are over-appre-
ciated up to the knee.   The same degrees of heat and also
of cold  seem, as the case might be, hotter  or colder than
they appear to be when applied to the other leg.   This is
also far more  notable  when  the tests are made  in the
flushed areas.
  There is constant ache of  the  right foot, even when at
rest on  a level.  Motion, passive or active, makes it un-
endurable.  If upright, it grows far Avorse, and he at last
becomes faint.   AVhen erect the least touch is productive
of extreme pain.
  The outer side  of the foot, supplied by the external
saphena, is unaffected; and this is true of  the heel, Avhich 
188             NER VO US DISEASES.
is supplied by the plantar cutaneous branches of the pos-
terior tibial nerve.  The rest of the plantar surface, sup-
plied  by  the  internal and  external plantar nerves ; the
inner surface  and dorsum of the foot,  supplied by the in-
ternal  branch of the musculo-cutaneous nerve  and the
long or internal saphenous nerve;  the adjoining sides of
the great and second toes, supplied by branches from the
anterior tibial, which communicate Avith the internal branch
of the musculo-cutaneous nerve, are involved.   The area
of over-sensitiveness on the posterior leg and thigh is sup-
plied  by  the  small sciatic.  The light  shading shoAVS the
areas sensitive to light  pressure, Avhile the dark shading
shows the area sensitive to firm pressure.
  The draAving, for Avhich I owe my thanks to Dr. Taylor,
represents the color assumed when long dependent.
  Motion.  The  power  over extension and flexion  of the
foot is hard  to  study, because the pain inhibits motion.
At  rest there seems  to be power' to move the ankle and
toes.  Above  the knee the movements appear to be with
normal poAver.
  Dynamometer: hand, right, 158 ;  left, 155.
  There is marked  atrophy of the calf-muscles, chiefly
involving the anterior group.   The circumference  of the
right  calf 5  cm. below the tubercle of the  tibia is 27.6
cm.; of the left calf, 30.7 cm.   There is also some wasting
of the vastus externus and vastus interims, the circumfer-
ence of the right thigh a few inches  above the knee being
39.5 cm.,  Avhile that of the left thigh is 42 cm.
  The circumference  of the thigh  at the highest point  is,
on the right side, 51  cm.; on the left, 50 cm.
  There is, when at rest, a fine, rhythmical tremor involv-
ing the whole leg, and when circular pressure is made about
the calf-muscles it is increased.   When the leg is long ele-
vated above the  level of  the pelvis this tremor gradually
disappears.  Besides this there may be observed,  occasion- 
ERYTHROMELALGIA.             189
ally, clonic spasms  of the  flexors of the first, second, and
third toes, much increased as  to number  and force when
the foot hangs down.  There is  also seen a fibrillary tremor
of the calf-muscles, more especially posteriorly, and of the
posterior thigh-muscles.
   The foot was occasionally re-examined when pendent.
The pain varied, as did also the color.   The patient says it
is  always worse in bad weather.  Finally, the foot was ele-
vated on an inclined plane, forty degrees, for three weeks.
This rather lessened the pain, but made the whole posterior
tibial nerve very tender.   After  a  day or  two of rest at a
level this passed away;  nor has there been at other times
sensitiveness on  pressure of any nerve-trunk outside of the
area of flushing.
   When, at the  end of three Aveeks, the foot Avas permitted
to hang down, all of the symptoms at once returned in their
utmost severity.
   A day later a bandage  restricting the return of  venous
blood Avas put on at various levels to see if this would cause
the vascular storm seen in the pendent foot.  It did  not.
The right foot scarcely flushed more than, under like cir-
cumstances, does the normal member.
   Reflexes: Right knee-jerk, -f- -f-.  Spastic ; reinforcible
by M. and S.
   Left knee-jerk, normal.
   Ankle-clonus, right, six  or eight beats.
   Ankle-jerk, right, -j—\-.  Spastic.
   Ankle-jerk, left, normal; no clonus.
   The arm-reflexes are normal.
   Muscle-jerks : Right, below knee, excessive as compared
with left.
   All skin-reflexes are normal.
   Electric examination (made  by Dr.  Willits):
   Far.: Foot-extensors, }  in. coil, right leg ;  1 in. coil, left
leg.  Foot-flexors, :] in. coil, right leg ; 1 in. coil, left leg. 
190
NERVOUS DISEASES.
  Extensors (tibialis ant.) : Galv., K. cl. c, 4 milliamperes,
right leg; K. cl. c, 5 milliamperes, left leg.  Flexors : An.
cl. c, 5 milliamperes, right leg;  An. cl. c, 8 milliamperes,
left leg.
  There is, therefore, quantitative  increase  in  the leg-
muscles of  the affected side ;  no qualitative change.   Sen-
sation  to rapid  faradic current  is lessened on the affected
side.
  The  eyes were  examined  by Dr. de  ScliAveinitz,  who
found  vision, pupils,  fundus,  form- and color-fields all
normal.  The heart has a faint systolic  murmur  at the
apex.   The lungs are normal.
  Examination  of the surface-temperature of the legs gave
the following  results: mouth, 98.6°  F.  Legs flat in bed
—the thermometer on dorsum of foot, behind great and
second toe—right foot, 95° ;  left foot, 87.8°.  Legs hang-
ing over side  of  bed, after thirty minutes : right foot,  95° ;
left foot, 86.6°.
  Mouth, 101.8° (patient has slight pharyngitis).  The pa-
tient being flat in bed : right foot, 96.8° ;  left foot, 94.6°.
Legs hanging: right foot, 95.8° ; left foot, 92.6°.
  Repeated examinations Avere made. There Avere marked
variations of  temperature in both extremities.   Once  both
feet  were colder  than the thermometers would register, viz.,
86° F.  The  affected foot  was always the warmer.   The
temperature fell Avhen the feet were pendent.
  No record  of  treatment  is here added, as nothing did
good.  The man was wonderfully patient,  but  wore a  look
of suffering and  was absolutely free from hysteria.

  This story, as told in Dr. Rhein's notes, but  too  well
illustrates  the obstinacy of  grave cases  of erythromel-
algia, and  accords with a long and  miserable accumula-
tion  of therapeutic failures.   I never  saw a bad  case
get well.   A feAV milder examples have varied much, 
ER YTHR OMELA LGIA.
191
or even seemed to become well, or remained  slight
enough to be borne.   I know of one case, that of a
Avoman in middle age, in Avhich  the pain and  flush,
limited to the dorsum of the foot, come and go, seem-
ingly Avithout cause.   Nothing helps her, but rest in
bed is unavoidable.   The usual treatments have failed
in this present case, and I have no desire to repeat what
has proved ATalueless.
   Whatever may have been the originative  cause in
other cases, here there is a clear story of  Avound, of
the peculiar swelling so common after neural injury,
and  Avhich  has  over and over been  laid open  as an
abscess by men  not easily deceived.  Then there is the
gradual increase of tenderness far in excess of that seen
in ordinary inflammation.   I  am of opinion  that Ave
ha\re to deal Avith a neuritis of the foot caused by the
Avound.
   I  use the word  neuritis—nerve-end  neuritis—with
more or less of doubt. Some such distinct affection of the
smaller nerves does seem to me probable, but Avhether
it is  congestion, neuritis, or some other of the unde-
scribed changes in  the  lesser nerves or in the  ultimate
nerve-plates, we may not as yet decide Avith certainty.
I shall return later to this  question of neuritis.   We
are uoav concerned  Avith treatment.   I have confessed
to complete therapeutic defeat in all my previous cases.
It seemed to me that it Avould in this man's case be
reasonable to cut the nerves Avhich  are as to motion
unimportant, and to do this near  to the foot, and as to
the tAvo great plantar trunks, to stretch these.   I shall
ask  Prof. Keen therefore to exsect portions of the in-
ternal saphenous and musculo-cutaneous nerves and to
stretch, as I have said, the tAvo plantars.   These meas- 
192
NERVOUS DISEASES.
ures ought to destroy largely feeling on the dorsum and
the inside of the sole and dorsum, and by the stretching
of the terminal branches of the posterior  tibial much
lessen  the sensibility of the sole.  The anterior tibial,
if  one may trust the anatomies, has  a  small share in
the innervation of the  foot; but  the  inosculations and
interchange of nerve-fibres are such that I  may find, as
one  does in the  hand, that  a section  by  no means
strengthens one's esteem for the pictures and statements
of  the anatomist.   The step  I propose has not been
taken  before in this disorder,  but is a common enough
resort  in truncal neuritis.   My hope  is that the opera-
tions I  contemplate will  lessen  the  reflex influences
which cause the vascular congestion, and Avill  so di-
minish sensibility as to permit massage to be painlessly
employed.
   Dr. Keen operated on April 10th.  He exsected two and
one-half inches of the musculo-cutaneous  nerve and the
same length of tAvo branches of the internal  saphenous.
The two  end-branches (plantar) of the  posterior tibial
nerve  Avere stretched at the internal  malleolus  with  a
traction of  fifteen pounds thrice used.  The result next
day was remarkable.   There was almost immediate relief.
The foot  could be squeezed, pinched, or pricked without
pain.   Anaesthesia, as shown by the accompanying dia-
gram, Avas not  as extensive  as  we  were led to expect  it
might  be.  The day folloAving  operation the temperature
of the  feet Avas:  R., 95°  F.;  L.,  93.5°; mouth, 99.5°.
On the right,  clonus was still present  and the knee-jerk
was still excessive.   The wounds healed in a  few  days.
On the 4th of  May the patient began to Avalk on crutches.
Clonus  had then disappeared, and  the reflexes Avere no
longer  exaggerated.  There was still some flushing of the
foot Avhen pendent, but no pain or  hyperaesthesia.   AVhen 
ER YTHROMELALGIA.
193
discharged  May 6th, he could walk well, but was ordered
to continue to use crutches as a measure of precaution, and
had also a bandage applied daily.  Dr. Kyle reports  cul-
tures from blood and nerves obtained at the operation as
yielding purely negative results.1

                          Fig. 4.
   Sense of touch, heat, and
't \    cold lessened or lost.
  On May 12th S. reappeared at my clinic.  He Avas able
to walk a little, but refrained, at my request, from  much
use of the legs.  The flush is  lessened ; the arteries do not
throb.  He stands  and moves Avithout pain.   Above all,
the temperature of  the pendent  diseased  foot  is noAV less
than that of the left member.
  June 7th S.  is reported  Avell and walking easily without
crutches.   Six months later he was at his  work as a stone-
mason, and entirely free from pain.
   The  tendency of  recent  writers  seems  to be, as  I
have said, toward considering erythromelalgia as a neu-
ritis.  But suppose we accept this vieAV, and in the light

  1 The pieces of exsected nerve were hardened in Mueller's fluid for some
weeks, imbedded in celloidin, and stained with carmine. On microscopic
examination the musculo-cutaneous and  two branches of  the internal
saphenous were found to be absolutely  normal.
                            17 
194
NER VO US DISEASES.
of the tAvo cases I have given it seems more than prob-
able, it by no means sets the matter utterly at rest. Neu-
ritis is  becoming a sad puzzle.   AVe may have it with
paresis and little pain;  Ave may  have it without notable
paresis and Avith  horrible pain.   It exists with or Avith-
out myositis.   Again,  it  may give  rise  to  causalgia,
joint-troubles, and  alterations of nails  and  hair.   It
may fail to disturb nutrition or greatly to  alter local
heat; and  lastly, if erythromelalgia be  a neuritis,  it
may cause pain  and flushing, and  to these, iucreased
enormously by dependency of the part,  may add such
a  rise  of temperature as  is  rarely seen  in acute  local
inflammation.
   You see that to give a name to a  possible  cause does
not ahvays help us.   If each of these groups of symp-
toms  be due  to  neuritis, why do they so vary ?   We
may conclude that the nerves are subject,  like the
spine, to inflammations affecting only certain  systems;
but in the  nerves  the fibres of sense of motion  and
nutrition  and vasal  control are, as we think, scat-
tered through the parent nerve, whence  it seems  hard
to comprehend the possibility of isolated inflammation
of systems.   And  yet to this Ave seem  driven.   The
difference in effect  between neuritis of a trunk, of the
minuter nerves,  or  of the terminal plates has not as
yet been fully considered.  Certainly the constant, gen-
eral, deep, and surface tenderness  of erythromelalgia
looks to me much like a condition of diffused, Avhat I
might call terminal, neuritis, sure,  like  all nerve-end
maladies or influences, to  cause remote  reflex effects.
The exsected  nerves taken at a part of the nerve-trunk
within the flushed area show no signs of inflammation.
AVe  may, therefore, conclude that  erythromelalgia  is 
ER YTHROMELAL G1A.
195
uot, as some have thought, a truncal neuritis; but  this
very negative  fact,  taken with the  symptoms, makes
more probable  the explanation of  a nerve-end neuritis.
   Let us return to the phenomena  which follow let-
ting the foot hang  doAvn.  The  man  is  seated.   He
remarks that to make the foot very red he must stand.
At once  as  he rises the  tint gets a  brighter rose, and
goes on as before described.   This is really a vascular
storm, and soon the throbbing of the  vessels is less  vio-
lent, and the temperature falls a little or is stationary.
In most of these cases pendency causes first a rise  and
then later a fall of the mercurial column.  In this man,
as in some others, there is a fall, but less notable on the
diseased side.
   I think this may vary Avith  the age of the disease.
AVhat Ave see is more than a mere vaso-motor palsy.   If
it Avere only that, Ave could  with ease flush the  foot
when, the leg being horizontal, we tie a ligature below
the knee.  You have seen how very slightly then the
foot flushes.  The upright posture and the long  column
of blood seem needed to get a great effect.
   In this present case the muscles  are, as  to motion,
over-responsive to electricity, and, as to sensation, but
slightly responsive to the same agency. This is unusual.
Indeed, to see excess of response in disease is very rare.
Also, there is some Avasting in these over-irritable mus-
cles, and  this adds  to my surprise at their too ready
reply to the battery  in both forms.
   Moderate ankle-clonus is present and right knee-jerk
in great excess as a spastic  reflex.   Altogether  the
grouping of symptoms is  uncommon.
   The complex symptom-group here considered is not
easy to  interpret, especially in the  entire absence of 
196
NERVOUS DISEASES.
hysteria.  Ordinarily—apart from the erythromelalgia—
the signals in our present case  would point to a local
spinal and not extensive lesion,  and, remembering some
other histories of erythromelalgia, Ave are not unpre-
pared for this conclusion.  Even then the riddle is but
half-read.   Spastic states of spinal birth do  not yield
excessive electro-muscular excitations, or SAviftly fail
after nerve-stretching and sections.
   It is to be remembered that only the older cases pre-
sent these quasi-spinal symptoms in grave forms.  Allan
Sturges's case had wasting, Avith  only quantitative re-
duction of electric excitability.   Whether clonus and
spastic knee-jerk are ever only of peripheral neuritic
origin we do not know.    AATien I froze my oavu ulnar
nerve, repeating  Waller's  experiments, the  related
nerves and muscles acquired for a time a wild excess of
excitability to all mechanical impressions.   It is really
an open question.   The gradual loss of clonus after the
operation and the lessening of the  spastic quality of the
knee-jerk seem  to  me interesting  and rather difficult
to explain.
   The typical form, then, of erythromelalgia is prob-
ably a painful nerve-end neuritis  with or without  co-
existent inflammation of the parent stems.   Probably,
too, although the skin may be of normal tint when the
limb is at rest, the deeper tissues are ahvays too full of
blood, aud the temperature supra-normal.   Dependency
only exaggerates these conditions, except that as to tem-
perature  it does  not always do so. The abrupt lessening
and  final loss of pain, local fever, hyperesthesia, and
flushing under the influence of nerAre-section and stretch-
ing, make it seem likely that some of these symptoms
are reflex from excited or inflamed nerve-ends.   AVhen 
ER YTHR OMELALGIA.            197
they can no longer play mischievously on  the  centres
they  are in turn released  from certain of  the  morbid
additions which stand in the way of recovery.   I have
over and over tried to bring about the same results by
hypodermatic use of opium.   I have no record  of suc-
cess,  but I  see that a  recent case is said to have been
thus helped.
   I  have noticed  that  when  the  feet are pendent the
temperature in the sound foot falls.  This  result a little
surprised me.   I find no mention of it elsewhere, and
we shall at  once  study it Avith care; as a fact in thermal
physiology  it may be  of interest.
   In conclusion, I desire to add that I have seen cases
of red neuralgia in which the disorder occurred at any
part of the  surface in isolated skin-spaces.   I suspect,
too, that in another species there are end-inflamed nerves
in some of  the viscera and  iu  the  muscles.   I hope in
future to report a small group of such cases.
   I  add to these cases one in which the  operation for
relief of this  interesting disorder resulted in  gangrene
and death:

   Case LIX.—April 7,1894.  S. M. H, a physician, mar-
ried, aged forty-eight years ; a stout, square-built man, with
good coloring ; always Avell;  Avorked  hard in full practice.
The  first sign of  the present trouble occurred in August,
1893, during a holiday  in camp.  After considerable exer-
tion in carrying over a portage he felt severe burning in the
fourth toe of the  right foot; but within a day this passed
away, and no further trouble resulted until in November of
the same year he slipped and wrenched the same foot, after
which, in the course of a week, severe burning pains in the
sole set in.   These were not constant, but came and Avent,
growing worse by degrees. In the inteiwals of the hot pain
                         17* 
198
NER VO US DISEASES.
there Avas  much aching  in  the same territory.  When
the exacerbations of pain had been severe the ache some-
times extended up  the leg.   He  was able,  however, to
stand and use the leg a little in going  about  his Avork
until February 1, 1894, when he  found  that  standing
increased the pain so much that he Avas obliged  to give
up attempting to do any work on his feet.  He continued
to practise as far as he was able, spending much time at
rest  in a  supine position or with the  foot raised up at fre-
quent intervals.   By these aids he  succeeded in obtaining
temporary ease.
  At present the leg aches if long in  a dependent position.
The foot shows, even when at rest and the patient in bed,
more red and Avhite mottling  than is usual in  other  and
similar  examples of disease.  This varies somewhat.   At
the  date of examination it extends as described from the
tip of the little toe almost to the middle line of the  heel
behind, and is about one inch in width.  The inner side of
the  great  toe, along the  edge of the nail, has a faint red
blush, not nearly  so deep in  color,  and  from  about the
middle of  the calcaneum at the side of the heel fonvard
to the middle of the arch of the foot on  the  inner edge is
mottled  in the  same manner, but less darkly.  There is a
spot o\rer the  inner margin  of  the  metatarsophalangeal
articulation of the little  toe,  Avhich  is red and of about
half an inch in breadth.  In the middle of the  metatarso-
phalangeal articulation of the big toe is a similar, some-
what larger  spot,  not quite so darkly red.  Wherever this
reddish  mottling  is  present  is the seat  of pain, and the
same area is, at its worst,  exquisitely  hyperaesthetic to
touch, but someAvhat relieved by gently applied pressure.
Throughout  this  territory some spots are more sensitive
than others.  The hyperaesthesia is greatest OA^er the  area
described as  at  the base of the little toe on the  sole.   The
spot upon the base of the great toe on the sole is very sen- 
ER YTHR 0 MELALGIA.
199
sitive.   The tips of the four lesser toes—not the pulps, but
the extremities—are also very tender, but do not shoAv the
same amount of redness.   These characteristics are perhaps
better  illustrated by the diagram than by my description ;
generally the intensity of tenderness corresponds to the
degree of redness.  The line betAveen tenderness and ordi-
nary sensibility is not  very sharply defined.
  All  this description applies in a far less degree to the
foot when elevated.   Attacks  of unbearable pain  are
brought  on  by standing, by  dependent position of the
limb, by warmth, as a hot summer-day ; and at the same
time the  hyperesthesia  is increased.   Cold,  supine  posi-
tion, and  elevation  of  the leg all ameliorate the pain  and
the tenderness.  The condition of the weather as to storms
has little influence.  Passive motion gives no pain.
  The measurements  of  the  foot are  as follows :  Right
(affected  side), around metatarso-phalangeal  articulation
(largest point), 8| inches; around instep, 9  inches.  On
the left  corresponding  points,  respecthely,  8|  and  8f
inches—a slight  difference, the increase being upon the
bad foot.
  Standing for a moment or tAvo someAvhat relieves the
pain and tenderness,  but immediately a great increase  of
pain results.  After being thirty seconds upon his feet there
is a marked  change in the color on the edge of the foot,
especially on the little toe  and  the neighboring joint, the
Avhole  becoming a livid, deep, mottled red, almost purple  in
places.  Both sides of the instep SAveat a little after stand-
ing, and  there is then  greatly increased  hyperesthesia.
There  is iioav no marked throbbing of  the arteries in this
position or after it, and  the  red blush does  not seem  to
spread OA^er the foot much beyond the outlines of redness
seen Avhen the foot is at rest and elevated ;  it only becomes
far more marked.   Knee-jerk is excessive upon both sides,
more on the right.  There is no ankle-clonus  and no trace 
200             NER VO US DISEASES.

of tenderness of the nerves up the leg.  The dorsum of the
foot  does not share  in the redness or  tenderness  at  all.
The  diagrams and colored  print  sufficiently illustrate the
symptoms I have described.

                         Fig. 5.
               Outside of foot.
Degree of tenderness is represented by depth of shading.
  The patient Avas examined repeatedly and Avith the utmost
care by the author, by Dr. John K. Mitchell, and  by Dr.
Morris  LeAvis.  The  lungs Avere  normal;  the heart  and
vessels at the wrist and elseAvhere Avere  apparently  free
from disease.  The  arterial  tension  Avas  not in  excess. 
PLATE  II.
Foot hanging down for thirty minutes.   (J. M. Taylor.) 
 
ER YTHR OMELA L GIA.             201
 There Avas no  arcus  senilis, and  the morning urine  Avas
 normal.   That passed at bedtime shoAved a feAV  pus-cor-
 puscles—no casts—and once a faint trace of albumin with
 the superposition acid test.   The folloAving record of  sur-
 face-temperatures shows the results of examinations on tAvo
 consecutive days :
   April 7,1894.  Surface-thermometer placed over the  very red
 spot on sole of right foot near base of little toe.
    A. Leg held horizontal on couch 20 min.....312/5o q_
      Leg placed perpendicular (foot down) 10 min.   .   .  32VB° C.
                  Temperature rose.....4.0 c.
   The foot became much congested.
   Thermometer then placed over ball of great toe.
    B. Leg now horizontal for 20 min......35°  C.
      Leg placed perpendicular 10 min......3o3/10° C.
                  Temperature rose.....2/10° C.
   April 8,1894. Thermometer placed over dorsum of right foot.
    C. Horizontal 20 min.........34°  C.
      Then standing 10 min........343/5° C.
                 Temperature rose.....\° C.
   Comparison of left (unaffected foot) at same time and  place.
    D. Horizontal 20 min.........29° C
      Standing 10 min.'.........28° C.
                  Temperature fell.....1° C.
   The rise of temperature  here apparent in the foot
 Avhen hanging doAvn and  the patient upright on crutches
 is such as is  often seen early in cases of red neuralgia.
 The  contrast Avhere  the normal   left  foot loses  heat
 Avhen the  patient is  erect,  is significant of what, as I
 have shown elseAvhere, is to be expected.
   There seemed to me no doubt as to this case  being: a
typical example of erythromelalgia.   Nor could  I  see
why I should not recommend Avith confidence the oper-
ation Avhich in another had effected a radical cure. 
202
NERVOUS DISEASES.
   The patient was  suffering  as intensely as any such  case
 within my experience, and there seemed no reason to regard
 the operation as serious.
   Accordingly,  on  April 12,  1894,  Dr. T. G. Morton  oper-
 ated precisely as in the case just referred to.  The  ether
 was taken Avithout the least difficulty.   An incision was
 first made over the  ankle  and  the  musculo-cutaneous
 nerve picked up and excised for four inches.  Next the
 internal  saphenous was excised for five inches above the
 ankle; then  making an incision four inches  long  over
 the posterior tibial nerve  behind the  inner  malleolus,
 this nerve was stretched by passing the  curved  hook
 under  it  at  its point of  division  into the  tAvo plantars.
 A force  of tAventy-eight  pounds Avas  applied, as shoAvn
 by the  attached scales.   The incisions Avere closed  Avith
 continuous silk sutures, dressed  Avith sterilized gauze, and
 the patient put to bed with the foot  elevated.  He had
 considerable  pain  that  night  and  required  morphia.
 Stomach  remained very  irritable  for  some hours  after
 the  opsration,  and  the  patient  became  very nervous.
Four  days later he still continued  to be excessively  ner-
 vous and excitable, and had much pain  in  the limb and
 foot.  For this  reason it Avas impossible to test sensation
 accurately.   He could  feel a toAvel passed over the foot,
 however.   It became impossible to  keep the foot quiet on
 account of his extreme restlessness and complaint of pain
 in the foot.   Finally the dressings were removed and  cold
 applications Avere applied Avith some relief.
   On the  fourth day Dr. Morton  became uneasy at the
 absence of circulation in the toes.  I myself Avas out of the
 city, and the case Avas for a time altogether in the hands
 of the very skilled surgeon who had  operated. It was  noAV
becoming plain that the foot Avas threatened Avith gangrene.
 On the fifth day the patient's friends announced their in-
 tention  to take  him  away from the hospital.  This  was 
ER YTHB0MELALGIA.
203
done  despite  every  remonstrance.  Elsewhere,  a  Aveek
after, an amputation Avas  attempted, and was followed by
death upon the operating-table.

   I have been unable to obtain full details of the later
symptoms.   Circulation Avas arrested in the foot before
he left us, and when the amputation Avas effected there
is said to have been some necrotic disease around the
lips of Dr.  Morton's incisions.   I understand  that no
post-mortem section Avas alloAved, and  that permission
Avas obtained with  difficulty to  examine the lea"  after
its remoATal.
   I am indebted to  Dr. P. S. Hall for all that I finally
know of this unfortunate case.   At the second opera-
tion the  ether A\as taken Avithout any unusual trouble;
but suddenly at the close of the  operation the  patient
became  livid,  breathed  with difficulty,  and died, as
has been related.   In the popliteals a long, soft  clot
was found, the upper extremity of  Avhich shoAved signs
of rupture and detachment.   There was probably pul-
monary embolism.
  All the vessels of the amputated member shoAved  " thick-
ening of the middle coat " (i.e., the muscular Avails).  This
obtained  in  eAren the smallest arterioles in the sole of the
foot, Avhile in the larger A'essels here and there, in addition,
Avere calcareous deposits.
  Further histological study  will be necessary to complete
the case.  It is  to be remarked that Dr. Burr found no
change in the portion of excised  nen'e  removed by Dr.
Morton.
  This AAas a plain case of  erythromelalgia.  The ex-
amination of sections of smaller vessels made  by  Dr.
Hall  enabled me to  verify his statements.  Degenera-
tive changes limited to these  lesser vessels are rare, 
204
NEBVOUS DISEASES.
nor do  I  know how during life to detect them.   In
the absence of an autopsy the remoter causes of the
final disaster must remain unknown.   As to operative
relief, I think  that in the future I should stretch all the
nerves, and leave resection of their trunks to be resorted
to if the milder means gave no fortunate results. 
CHAPTER  XI.
  NOTES  OX SURFACE-TEMPERATURES AS AFFECTED
               BY POSTURE OF  LIMBS.

   I reminded you last Avinter of the  endless possibili-
ties open to mere observation in clinical medicine when
pointing out the peculiarities of local temperatures in a
case of erythromelalgia.
   To become sure as to general temperatures in a case
of disease is usually easy, requiring only ordinary care
and good thermometers; but to  get  surface-tempera-
tures accurately is a more difficult matter, demanding,
as it does, more time, far greater care, and instruments
that as yet are very unsatisfactory, either because they
are too sIoav in registering or too fragile.  I commonly
employ the coil-bulb thermometer, guarding the coil
Avith a cork, hollowed  so as to roof over the coil, and
perforated  to admit of the  passage of the stem.  The
instrument must remain long on the part.   It may be
kept in place  by a very thin caoutchouc  band, split so
as to be passed over the tube, and arranged so as to lie
lightly around the limb with just enough  pressure to
keep it in place.   Thus the contact is kept equally the
same, and  in  comparing  the tAvo members great care
must be taken accurately to repeat this and  other con-
ditions.  If the pressure be  too great, it is sure to affect
for a time the thin walls of the bulb, and  then, as the
instrument is lifted, the column instantly falls a little,
this amount representing rise from excess of  pressure.
The coil-bulbs are less subject to this source of error.
                         18 
206
NEBVOUS DISEASES.
  The study of skin-temperatures has been fairly Avell
made, but even yet may gain in accuracy and complete-
ness.  Moreover, there are some points  as to normal
temperatures rarely considered by neurologists in com-
paring the heat of  symmetrical regions.  Certain of
these  have come out clearly in the study made  during
the last year by me, and under my direction,  by the
staff  of  the  Infirmary,  notably Drs. F.  S. Pearce,
Taylor,  Burr,  and others.
  Minute  precautions  are essential in  dealing  with
minute  differences,  and in fact one may take  it as a
rule that the finer the instrument the finer must be the
human  instrument  using  it.   We still need  a  perfect
surface-thermometer.
  As the rise or fall in cases  of local neuritis may be
but slight, it is well to remember that normal differences
as betAveen right and left members are by no means un-
common.   If, for  illustration, in this healthy man at
rest and supine, we apply the surface-thermometer and
leave it at least ten minutes on the dorsum of the right
foot, it notes 35.6° C,  aud on  the left 35.2° C.   Here
is a fact of interest.  The two  feet are not always alike
in temperature.  At times the amount of difference
is 1° C.   Now let the  man  stand up,  and  with the
thermometers  in the same places they come  to mark
35.4° C. and 34.9° C. respectively. This is one example
taken at random.  Meanwhile  the mouth-temperature
has remained unaltered.  Certainly this is an interesting
fact;  it  may have escaped notice.
  Last spring, in a case of red neuralgia, we were meas-
uring the temperatures of the feet  in  bed, and when
hanging  over  the  edge, or Avhen dependent from  the
hips, the man  being on crutches.   In the acute stage 
       NO TES ON S UBFA CE- TEMPERA TUR ES.    207

of this disease dependency of limb is apt to cause a rise
of local  temperature; but in the case  in  question, and
perhaps  in all Avhen the disorder has lasted  long, there
is, under these circumstances, a fall  of temperature and
not a rise.
   The fall in this case led me to study anew the natural
thermal  conditions, and after personally learning  that
the normal foot  when dependent  is  likely to  fall in
temperature, I asked Drs. Taylor and  Burr to test the
matter.   They both found the observation to be correct
in themselves and in several of  our nurses.   I  then
asked  Dr. Pearce to make a series of  observations on
the foot and hand.  These have been made with  care
and skilfully varied.  To save space I give the figures
in tabular form.
 1
 2
 3
 4
 5i
 6
 7
 8
 9
10
111
Position of right leg.
Horizontal.	Standing
35.6°	35.4°
34.6	34.4
33.6	32. 8
31.4	30.0
34.4	34.0
34.8	33.2
35.0	35.0
35.6	34.2
34.2	33.2
33.6	31.8
33.6	31.0
Position of left leg.
Horizontal.! Standing.
35.5°	31.9°
34.6	34.6
33.6	32.4
31.6	30.2
35.4	33.4
34.0	33.2
35.8	35.6
35.8	35.0
34.6	32.2
34.0	32.4
34.2	30.4
No.
Time.



 p. M.

 P. M.

 A.M.

 A.M.

 P. M.

 A. M.

 Noon.

 P. M.

 A.M.

 P. M.

 P. M.
No.
Time.



 p. M.

 P. M.

 A.M.

 A.M.

 P. M.

 A. M.

 Noon.

 P. M.

 A.M.

 P. M.

 P. M.
 1 Experiments 5 and 11 were performed upon two old cases of erythromel-
algia of the left leg in men twenty-one and thirty-four years of age respec-
tively.  All others were upon healthy persons. 
208
NERVOUS DISEASES.
  In the preceding eleven experiments upon the dorsum
of both feet (at the  same time) the thermometers were
read in twenty minutes, as the subject lay supine; then
ten minutes later, the subject standing for the same
length 'of time.   The extremities Avere kept uncovered
and away from draughts.  The centigrade scale Avas
used.   The temperature of the room Avas 68° F.
  The same conditions obtained in the following experi-
ments upon the soles of the feet:
	Time.	Position of right leg.		Position of left leg.
No.		Hung over Horizontal edge of couch.		Hung over Horizontal.; edge of couch.
12	A.M.	31.6° 33.2°		34.0° 33.8°
13	P. M.	34.8	31.4	
14	P. M.	36.0	35.2	
15	A.M.	31.6 30. 6		32.0 31.0
16	A.M.	30. 8 30.4		29.0 | 29.0
  The same conditions, the patient lying supine contin-
uously:
	No.		Time.	Palm of left hand.		
				Horizontal couch.	on	Held up verti-cally.
25			P. M.	35.6°		35.4°
26			P. M.	34.6		34.2
27			P. M.	35.2		35.0
28			A.M.	35.6		35.4
29			A. M.	35.1		35.0
30		1	A.M. P. M.	I 34.4		34.0
 
      NOTES ON SURFACE-TEMPERATURES.   209

  The conclusions that may be formulated as to surface-
temperatures are as folloAvs :
  The temperature of  the dorsum and sole of the feet
is on an average from 1° C. to 1° C. less when standing
erect than Avhen lying horizontally.
  All things being equal, the morning surface-tempera-
ture is less than the evening surface-temperature on the
dorsum  or sole of  the feet.
  The mouth-temperature varies little as  between lying
down and standing; or, if  it  changes, there is a very
slight rise.
  The nearer the trunk the less do the surface-tempera-
tures vary in different portions of the body.
  The palms of the hands are the warmest parts of the
extremities; their surface becomes less Avarm as the ex-
tremity  is moved  from a resting horizontal position to
one of hanging doAvn loosely, and finally to being  held
up in a  vertical position.
  The foregoing  obtains whether the body lies supine
or is held erect.
  The two hands or the two feet vary somewhat in tem-
perature in the same person under apparent equality of
conditions.  At times the right  member  is Avarmer; at
others it is the left.
18* 
CHAPTER  XII.
  THREE CASES  OF REMARKABLE  SPINAL ANTERIOR
      CURA'ATURE  WITH MENTAL  ABERRATION.

   I show you  to-day two out of three cases of some-
 what unusual character.   The  third  member of the
 group I have not here.  You cannot fail to observe at
 once the attitude of this girl.  Let me ask your atten-
 tion to this singular case.  The curvature came and
 grew complete within a few months.  It is still remark-
 able,  and was far more so.   The Avhole spine was bent
 forward, the belly protruded, and the head carried back,
 to enable her to see objects on  a  line with the  eyes.
 There was no possibility of straightening her either by
 passive efforts at suspension or through volition, but
 these attempts gave rise to no pain.   The spine seemed
 to be rigid, and she could neither make it erect nor fully
 bend  to one side; the head also possessed small power
 of rotation or flexion, Avhile the neck-muscles were not
 rigid.   With the gain in her mental state these peculiar
 symptoms have  become notably less.
   This  description also applies nearly throughout to the
 man,  except that his  spinal difficulty was  altogether
 above the lumbar region.  The girl's case is, no doubt,
 largely  hysterical, and so also  is that of  the boy, Avho
had in an extreme degree the spinal peculiarity.
  The man's  condition  hardly justifies the label hys-
teria; nor did that of two others  alluded to later.
  Here, then, are  three people—a  boy, a girl, and
a man—all  more or less  insane, and  all  shoAvino- a 
SPINAL CUR1 rA TURE.
211
disorder of  the vertebral  column, which comes Avith
the mental state, and lessens as this gets better, and is
not due to appreciable organic  disease.
  How very strange are  the postures is shown in Dr.
Taylor's sketches.   In a large experience of all  forms
of mental disorder I have  never seen elsewhere any-
thing just like these in the pronounced character of the
curves and in the immobility Avhich they manifested.
  The boy's case is less distinct, but the resemblance to
the others suffices  to justify the grouping.   Perhaps
this collection of  symptoms may be accidental.   The
chance grouping together of symptoms in a trio of cases
may readily deceive one into  the  belief that  we have
before us an undescribed clinical type.   I have been
patiently reticent, and  have long withheld these three
cases from publication,  in the hope of seeing others like
them, Avhich might permit of a larger numerical com-
parison.  My patience has not  been rewarded Avith suc-
cess, and I  am  now tempted to call  attention to a
peculiar set  of symptoms,  Avith the hope  that  others
may contribute like cases to my meagre  list, so  that a
larger experience  may become possible.   I incline to
the belief that the cases I here  exhibit illustrate a novel
clinical group, Avhich  may  be non-hysterical  or  may
assume the hysterical type, and to which I hesitate as
yet to affix a label.
   I ought to say, also, that in the past I have met with
at least three patients who had this collection of  symp-
toms ; but of these I have no  notes, as they were  seen
long years ago, and only in consultation.
   The question is now  in this  form:  Is there a clinical
type, hysterical or not,  characterized by mental failure,
physical  weakness,  retinal changes(?),  and  rapidly 
212
NERVOUS DISEASES.
evolved spinal curvature, extreme in degree and other-
wise unusual in type, not due to organic vertebral dis-
ease?
  Case LX.—F. B., female, thirteen years  of  age, Avas
brought to my clinic April 4, 1890.  The family history
is negative.  The child Avas born at term.   The labor Avas
easy,  and instruments were not  used.  She Avas breast-
fed .   She began to walk at thirteen months, and to talk at
about the same time. She has never had any serious illness
except pneumonia, seven years ago.  She developed well,
mentally and physically, until about eleven months ago,
when her mother  noticed that she had fits  of  causeless
crying and  great  depression.  At times  she Avould con-
vulsively break out in attacks of  violent anger.   "While 
SPINAL CURVATURE.
213
previously she had ahvays been  number one in her school,
she soon lost all interest in study, fell to  the foot of the
class, and finally refused to go to school at all.   She sits
all day, careless and  unconcerned as to Avhat is  going  on
around her.   She will  haA'e nothing  to do Avith her old
school-friends, shows no affection for her parents or brothers
and sisters, and never speaks except in answer to a question,
save that sometimes she talks to herself, and, as if under
the influence of  an hallucination, will cry out, "What do
you want?" "Get out of here," etc.   She has largely lost
the sense of personal cleanliness and is dirty in her habits.
  Her general bearing is striking.   The abdomen is thrown
forward, the shoulders back, the  right one  being much
higher than  the left, Avhile the head is "throAvn fonvard,
the chin at times resting upon the chest.  The left thumb
is strongly flexed, the  forearm pronated, and the arm
rotated inwardly.  The entire  spine  bends stiffly, and it
appears impossible for  her to stand erect.  She stands, as
sIioavu in Fig. 8, on the heel of the right and the toe of the
left foot.   There is no  evidence of spinal bone-disease, no
angular cur\Tature, no pain on pressure, no  sensitiveness to
heat or to  cold.   While there is a  little general  muscular
Aveakness, there  is no true palsy, and except for slight pallor
she is Avell nourished.  There are  occasional slow, lateral
movements  of the head,  and the hands are sloAvly passed
over each other.   Whether these movements are purposive
or automatic cannot be determined.  The  fingers of both
hands can be passively  hyper-extended.
  Her expression is fatuous and idiotic.  She seems to take
no notice of  her surroundings,  and is absolutely without
interest in anything.   Her replies to questions are silly;
her speech sIoav  and somewhat thick.
  She sleeps Avell noAV, but formerly slept badly, and seemed
to fear the dark.  Menstruation has never appeared, though
she is quite Avell developed.  Her appetite is fair.  The 
214
NERVOUS DISEASES.
urine is normal.   The knee-jerk is slightly large, but not
spastic.   Sensation is normal.
  Dr.  de ScliAveinitz  examined her  eyes, and reports:
" Concomitant  convergent squint.  Xo  swelling of disc,
but  there is a diffuse  retinal haze, especially marked
above and below the discs.  Both eyes are hypermetropic."
Pig. 8.
   The patient was seen again  in  February, 1893.  Her
mental condition was even Avorse than before.  She never
spoke  except in a silly fashion, and  had to be attended to
like an infant.  She  still had outbursts of anger.   Physi-
cally she Avas in about the  same  condition as already de-
scribed, except that the protrusion  of  the abdomen and
the large anterior curvature of the lumbar and loAver dorsal
spine were less marked. 
SPINA L C UR VA T URE.
215
  September, 1893.  She has steadily but sloAvly improved
since the last date, with lessening curvature, but the  gain
in the physical aspects of the case far outstrips the gain in
the mental condition.  The eye-grounds are better.
  She continued to improve physically.  The  back lost its
curve,  the belly became  as  to form natural,  the  head
assumed a natural position, and  A'ery much more sloAvly
she recoA'ered her health of mind, and is iioav considered to
be as well as before the onset of this singular malady.
  Cask LXI.—L. W., male, twenty-five years old,  mar-
ried, a mill-hand, came to the clinic November 22, 1889.
  The family history is negative.  The patient  denies Arene-
real disease, and no evidence of it is discoverable.   He
has  used no  liquor and  tobacco  only moderately.   He
had always  been well until June, 1888, when his employer
discharged him on the ground of mental unfitness for Avork.
He complains of backache and  headache.  He says that
he  often  hears voices of invisible people talking  to  him,
but he cannot remember what they say.   He denies that
he ever gets despondent, and  is totally unconscious of  any
mental trouble.
  His general bearing is  precisely similar to that of the
first case described.  The head is kept flexed on the breast,
the eyes wide open, the dorsal curve and rigidity most  re-
markable ; nor  could  they be altered  by effort, voluntary
or  passive.   The  gait is shuffling and slow, and the right
foot is  much everted.  Station is good.  The knee-jerk
is large, but not spastic.   Sensation is normal.   There is
no  paralysis.
  His expression is dull and sleepy.  Mentally he is stupid.
He understands Avhat  is said to  him, and replies intelli-
gently, but  often his statements cannot be relied on.   He
will unwittingly falsify.   He has  lost all interest.   His
inability to Avork is evidently due to mental insufficiency,
and not to  the pain of Avhich he complains.   He is harm- 
216
NERVOUS DISEASES.
less and never  subject to fits of anger; and, on the other
hand, he is Avithout affection.  In other words, he is in a
condition of dementia.
  The abdominal  and thoracic organs are normal.   The
eyes Avere  examined  by Dr. de SchAveinitz, Avho reports
that there is a slight retinitis.
  He was seen  again some months  later, in the spring of
1890, and  had  improved sufficiently to do  odd jobs, but
was still unfit for continued Avork.   The spinal curve Avas
far less and the mobility nearly normal.   The eyes were
reported to be materially better.  He was far more cheer-
ful, and observed  Avith interest that he was much more
erect  and did not have  to tilt his  head back and lift his
lids to get  a full view of  the faces of people.  At this time
there Avas  a complete re-examination, which added nothing
to the simple statements  already made.  He  continuously
improved,  and  I was informed made a complete recovery.
  Case LXII.—L. R.,  male,  sixteen years of  age, was
sent by Dr. Pearce, of Steubenville, Ohio,  in  March, 1890.
The family history is negative.  The patient suffered no
injury at or near birth.  He has neArer had convulsions or
any other serious acute illness.  He has ahvays been very
retiring, seldom speaking unless spoken to, never mirthful,
averse to society, and not fond of amusement.  He attended
the public schools  for six or seven years, but Avas always
careless and indifferent  about  his  studies,  and as time
passed grew duller and duller.   About two years  ago his
comrades  annoyed  him  so much that he Avas  taken from
school, and for a while he Avas taught at home.  Finally,
hoAvever, all efforts at education  had to  be abandoned.
He still possesses  intelligence enough to read, but rarely
does so.   He understands perfectly all that is said to him,
but is morose and irritable.  He cries a great deal, and is
Avithout affection.   He is extremely disobedient and Avith-
out fear of punishment.  He protests that there is nothing 
SPINAL CURVATURE.            217
the matter Avith him ; says dramatically that he Avill live a
thousand years, and  that he Avants to be left  alone.  He
often gets  upon his hands and knees on  the floor, and,
turning his head in an objectless manner toAvard the ceil-
ing, remains  so  for a considerable time.  His usual posi-
tion is sitting with the thighs strongly flexed on the abdo-
men, the legs flexed on the thighs, the arms  clasped around
Fig. 9.
the legs, and the head down, with the chin resting upon the
knees.   This knotted position he maintains for hours.  At
times he suddenly  rises, hops, or runs around the room,
whining  the Avhile, always  going  to the left if he meets a
table or chair or other obstruction. He will stop suddenly,
jump up and doAvn many  times, frowning  and looking
horror-stricken, and  then walk away and  sit doAvn in his
                          10 
218
NER VO US DISEASES.
 accustomed attitude.  He objects much to being touched,
 saying  that it hurts him;  but deep pressure does not give
 so severe pain as a light touch.  His hyperesthesia is men-
 tal, not peripheral.  He is reluctant to talk to any one, or
 eATen to answer a question ; and Avhen he does so he repeats
 Avords, a clause, or even a sentence several times, so that
 frequently it is difficult to comprehend what he says.  He
 is, however, sometimes boisterous, and Avill sAvear  roundly
 and scold every one around him, and squirm and jump and
 throw himself about, and finally fall  to  the  ground ex-
 hausted, panting for breath, grasping  at his chest as if in
 deadly fear of suffocation.  He complains bitterly of new
 clothing, saying that it  is too tight and binds him.  He
 has great  trouble in dressing and undressing, but objects
 strongly to being assisted.  He will apparently forget what
 he is doing; will put  on a shirt and not remember that a
 coat should follow.  The same peculiarity  is shown in eat-
 ing.  It is no unusual  thing  for him to sit at the table for
 hours muttering to himself, and only now and then taking
 a mouthful of food.  So  bad is  this  that he  sometimes
 suffers from want of nourishment.  He goes to stool of his
 own accord, but may be found thus engaged  hours  after-
 Avard.   The character of his sleep A'aries much ;  sometimes
 it is quiet and restful, at others much broken.
  The illustration shoAVS Avell  the peculiarities of his usual
 position when standing.  The  legs are slightly flexed at the
 knees, the abdomen thrown  fonvard,  and the shoulders
 rounded.   There are increase in the normal antero-posterior
 spinal curvature  and slight left lateral  curvature.  There
 is no evidence of bone-disease.   He stands with the legs in
 partial flexion.  This bending  can be overcome by passive,
 but not by active motion, and the spine can by no means
be straightened.  The  skin is  yellowish and harsh.   The
knee-jerk is lessened, but distinctly reinforcible.  The tho-
racic and abdominal organs are normal. Careful watching 
SPINA L C UR VA TURE.
219
has failed to detect evidence of masturbation.   The eyes
appear to be normal.
  AVhen heard from, three years later, he had improved
considerably, the  change coming  on rather  suddenly in
March of  this year.  lie said one  day that he had been
out of school so long that he would  be behind the boys, and
asked for his books.  A teacher was obtained for him, and
he became obedient and cheerful  and desirous to study.
The gain has been happily continuous, and, as in the other
cases, the change  in carriage and  the  lessening of spinal
immobility have gone  on as the mental state has become
clearer.

   I  find it more  than merely difficult to discuss  these
three cases.   They seem to me to belong to one group;
but if in my ample experience I cau  recall but two or
three like them,  I think we  must concede them to  be
of extreme rarity.  Perhaps my report may lead,  as
usual, to the publication of other  examples of what I
am inclined to regard as a very distinct  clinical genus. 
CHAPTER  XIII.
 CONCERNING  THE  HISTORY  OF  THE DISCOVERY OF
   REFLEX OCULAR NEUROSES, AND  THE  EXTENT TO
   AVHICH THESE REFLEXES  OBTAIN.1

   As skilled ophthalmologists, you must be aAvare that
 you  touch the genbral practice of  medicine  at many
 points, and very often are most helpful; but sometimes,
 because  of being satisfied to think only of the  eye, may
 quite fail to be as helpful as you might be.
   Nowadays,  except for  obvious eye-trouble, you are
 most likely to be consulted as concerns headaches, and
 to be asked if they are in  this  or that case the offspring
 of disorders of the visual apparatus.   Very frequently
 the patient goes directly to you, so that you become his
 only  adviser, and it is as to  this form  of undivided
 responsibility that I shall have to speak before I close;
 for it is  here that you sometimes fail  to grasp the truth
 that he  who has properly corrected the  eye may have
 left undone that without Avhich  his work  loses much of
 its value.
  Before dealing with this and other more  practical
 matters,  I should like to call your attention to  the gen-
 eral  history of the  connection of  headaches and other
 neuroses with eye-strain.  I am the more interested in
doing this because I had a personal share in directing
 the attention of the medical public to this matter, and

 i An abstract of remarks before the Ophthalmologic Section of the College
of Physicians of Philadelphia, March 26,  1894. 
           REFLEX OCULAR NEUROSES.        221

also because it is my belief that Ave of this city Avere the
first to bring this relation into large  practical prom-
inence.
  I am under the impression that Dr. Ezra  Dyer and
Dr. J. Haskett Derby, of Boston, were the first Amer-
icans to bring us home from Germany modern vieAvs as
to corrections to be  accomplished in  disorders of the
optic apparatus.
  Dr.  Dyer  came here to live in 1862.  From  this
accomplished oculist I learned a great deal  in regard
to the treatment of the eyes, and it was through certain
cases throAvn into his hands by me that I came first to
apprehend more fully the mischief-making capacity of
imperfect eyes.
  I remember Avith great distinctness the earlier of the
many important cases I saAv with Dr.  Dyer.  Some of
them made a serious  impression upon  my mind.  One
was that of a young Avoman  whom I  had knoAvn for
many years to have exceedingly disordered eyes, and to
be unable to use them for more than a minute at a time
without pain.  She suffered a great deal from headache,
but although she had seen many physicians, neither they
nor I, nor Dr. Dyer (Avhom she consulted  as  to  her
eyes), had any suspicion  that the eyes  Avere almost the
sole factor in the product of pain.   The headaches were
entirely  occipital.   Dr.  Dyer  carefully glassed  this
young  Avoman,  merely to aid her vision, and  shortly
afterward, in some tAvo or three months, she told me
that her headaches had entirely disappeared, but that
they returned if from any cause  she  Avas Avithout  her
glasses for a few days.
  This fact struck me very forcibly. Shortly afterward
I met  in consultation the late Dr.  John F.  Meigs,
                         19* 
222
NERVOUS DISEASES.
concerning the case of a young Avidow Avho had suffered
for many years with extreme headache, pain doAvn the
spine, and also with what at that time I considered as
hysterical spasmodic retraction of the head.   After we
had talked the case over,  Dr. Meigs said to me that his
medical  resources were exhausted as to this case, and
that he  did not  know Avhat caused the headaches.   I
then asked if they might not possibly be due to Avhat
at that  time  I  was  beginning to call " eye-strain."
He said it Avas possible, but that he had never met with
or heard of such a thing.   I  got  his ready consent to
refer his  patient to  Dr. Dyer.  Careful  correction
promptly relieved these headaches.  The stiffened mus-
cles at the back of the neck relaxed, and four months
afterward this Avoman was in better health than she had
been since childhood.   These, and other cases, at last
opened  my mind to  a distinct conception  of the fre-
quency of  the relation between disorders of the appa-
ratus of the eyes and headache or other neuroses.
   As Dr. Dyer's practice enlarged, and as  physicians
began to have increasing confidence  in the modern
methods of correcting the eyes, I, too, learned still more
of these interesting difficulties.  I think the knoAvledge
that a headache  might be due to  ocular troubles was
becoming pretty well  diffused  among the more intelli-
gent of  the profession in Philadelphia, when, in the
Medical Reporter, in 1874, in Avriting  of headaches, I
described headaches from eye-strain, and gave several
cases at  length.   These  cases Avere  corrected by Dr.
Thomson.  The cases seen with Dyer occurred as early
as from  1862 to  1864; I cannot more surely set the
dates.   I then got the impression, which I still retain,
that hemicrania of the classic type,  although it may be 
           REFLEX OCULAR NEUROSES.       223

increased and made Avorse by ophthalmic defects, rarely
owes its existence to this alone, and that headaches of
eye-strain are usually of quite different type.
  I did not again  Avrite on the subject until 1876.   In
April of that year  I published a paper in the American
Journal of the Medical Sciences.  I  there stated the
folloAving conclusions, having learned that  not  only
headaches,  but  vertigo, nausea,  anaemia,  and  much
disturbance of the general health might be due to im-
perfect eyes.   At that time I  summed up my opinions
as follows :
  1. That  there are  many headaches Avhich are caused
by disorders of the refractive  or accommodative appa-
ratus of the eye.
  2. That in  some instances the brain-symptom is the
most  prominent, and  sometimes  the sole  prominent
symptom of the eye-troubles; so that Avhile there may
be no pain or sense of fatigue in the eye, the strain with
which  it is used may be  represented by  occipital  or
frontal headache only.
  3. That the long continuance of  eye-trouble may  be
the unsuspected source of insomnia, vertigo, nausea, and
general failure of health.
  4. That in many cases the  eye-trouble becomes sud-
denly mischievous, owing to some failure of the general
health, or to increased sensitiveness of brain from moral
or mental causes.
.  It may be  somewhat interesting to carry the history
of the subject beyond  this point.  The knoAvledge  of
which I speak is perhaps one of the most valuable con-
tributions to the relief of human suffering that has been
made during  the century.  It is impossible to give the
credit of this vast gain to any one man, and to say with 
224
NERVOUS DISEASES.
 truth that it Avas due to him alone.  Helmholtz, Don-
 ders, and von Graefe made this relief possible by their
 scientific Avork;  but neither  in  Europe nor here Avas
 there, so far as  I  know, in 1862, or much  later, any
 practical conception among either oculists or physicians
 as to the frequent poAver of bad eyes to create headache
 and  divers other  troubles.   Xo physician  then sent
 headache-cases to an ophthalmic surgeon, and my paper
 of April, 1876,  Avas, I think, the first contribution  of
 importance to  this  subject made from  the standpoint
 of  the general practitioner.
   In fact, one looks in vain for many  a day through
 the text-books on the eye, and the monographs on head-
 ache, for a statement of the imperative  need to  study
 the eyes in headache, vertigo, etc.  If here and there
 Ave find  a sagacious ophthalmologist speaking  of the
 distress  and pain which manifest  ocular trouble occa-
 sions, the general text-books are silent as to a practical
 hint, and the profession at large remains ignorant.
   Quite recently, in 1886, there appeared Ernest Clark's
 book on Eye-strain, and  here is  full confirmation  of
 Avhat I  state, and,  too, of Dr.  Clark's entire failure
 to make clear our  share in the  valuable  discovery I
 am discussing.   This author points out that fifty years
 ago  Tyrell, in speaking of asthenopia, very well de-
 scribed its poAver to cause headache, dyspepsia, vomiting,
 diplopia, vertigo,  and palpitation.   He even employed
 the term " eye-strain," its  first printed  use, I suspect,
 in connection with this  subject.
  I  find in Dr.  George Stevens's book on Functional
 Nervous  Diseases, published in 1887, information which
enables me to carry forward the history of this subject.
He says,  page 8:  " Xo general principle of sympathetic 
           REFLEX OCULAR NEUROSES.        225

or reflex irritation had,  however, been formulated, and
the first pri)ded announcement of the existence of such
a principle Avas made  by myself, in a paper presented
to the Albany Institute in the early part  of 1876 "
(On Some Results of  the Anomalous Refraction of the
Eyes).  It is difficult  to understand this claim.
   The paper to which Dr. Stevens alludes here as  pre-
sented to the Albany  Institute was read by title before
the Institute, May 30, 1876, and placed on file to be
presented thereafter;  but I do  not  find it anywhere
stated in the Transactions or Proceedings of the Albany
Institute that it was ever read or printed.
   Soon aftenvard a paper, by the same author,  Avas read
before the  Academy of  Medicine in  XeAV York, June
15th of the  same year (Refractive Lesions  and  Func-
tional Nervous Disorders).   This  paper  deals with
the question of chorea chiefly.   Dr. Stevens attributes
a very large proportion of  choreal cases to hyperme-
tropia.  As to this matter  I  shall  have more to say
before I close.
   In  the New York Medical Record, September, 1876,
there  is also a paper by Dr. Stevens upon the Rela-
tions  between the Anomalous  Refraction of the Eyes
and Certain Functional Diseases of the Nervous Sys-
tem, Avith a table shoAving the refractive condition of the
eyes in fifty-four cases of epileptic and insane  persons.
This paper deals with the fact that refractive errors are
common in cases of epilepsy and the like, and  with the
great  frequency with which refractive anomalies have
been found in connection Avith recurrent headache.  As
to this matter, too, we have the later papers of both Drs.
Stevens and Ranney, concerning Avhich I  shall  also
have a few words to say. 
226            NERVOUS DISEASES.
   I  find  later, in the New York Medical Journal for
June,  1877, a paper by  Dr.  Stevens (Light  in its
Relation to Disease), Avhich I  presume is the same as
one  presented to the Albany Institute December  19,
1876.  It deals chiefly Avith the question of heredity in
connection with faulty refraction of the eyes and other
matters.
   In looking over the  later history of this matter I
find  that certainly one of the earliest distinct papers on
the  subject of astigmatism as  causing headaches Avas
Avritten by Dr. William Thomson in 1879.1 After this,
papers began to multiply in the eighties; but long before
the  general medical  public had the least idea of this
valuable discovery, these two gentlemen (Drs. Thomson
and  Dyer) had obtained a clear and practical grasp of
the facts in question.
   So much for the history of this matter; it has become
an old story.
   Now, the every-day practitioner called  upon to treat
a neurosis, especially a headache, habitually refers  the
patient to an ophthalmologist, and does not knoAV Avhence
came this inestimable  lesson.   I can remember to have
heard it laughed at as utterly absurd.
   Before  leaving  the subject  I should like to say a
few Avords as to the more  recent claims made by Drs.
Stevens and Ranney.  Men Avho run into  extremes are
often those who in  the end teach proportioned Avisdom
to such as  knoAV  Avisely to profit  by  the excesses of
others.   This is going to  be  the case in regard to the
extreme  vieAvs enunciated by  these  two  gentlemen.
There  is in  them  an element  of  occasionally  useful
 i The literature before this must have been meagre indeed.  See American
Medical Library Catalogue. 
REFLEX OCULAR NEUROSES.        227
truth.   Where  they appear to me to have most dis_
tinctly  failed I ha\7e endeavored  to point out to the
best of my ability.
  At my clinic for two years or more  Dr. G. E. de
Schweinitz examined  Avith  the utmost care the eyes of
all  of the numerous choreic children who appeared at
the Infirmary  for Nervous Diseases.   The  cases ex-
tended  to one  hundred, and although many of  them
have been given  the  most careful  attention,  I do not
think that any notable good  in the Avay of cure of
chorea Avas obtained by correction of refractive or other
errors.  In the disorder I first described as " habit-
chorea" glasses have uoav  and then been  found to be
useful,  but  not often; nor  should Ave expect to find
anything else in regard to chorea proper.   It is largely
a disorder of seasons, in the  first place ; and, secondly, it
is a disease easy enough to  treat.  The great mass of
cases get well  without  much difficulty;  in  a  large
number of  instances  the  disease  is  self-limited, and
prospers, even if let alone; nor has  it the gravity Avhich
one would be led to expect from reading Dr.  Stevens's
early paper.  Dr.  de  Schweinitz Avill, I  am  sure, en-
tirely agree Avith the conclusions I have reached as being
his opinion and mine,  to the effect that Ave have gotten
no  good by correcting the  eyes in cases of chorea.   I
came to this  matter with a  perfectly free and unbiased
mind, but this  Avas the end.   Choreal children Avith
ocular defects got Avell under arsenic alone quite as soon
as others Avho  had no like  disorder of vision; or the
choreas  got well, and  the hypermetropia remained un-
altered and uncorrected.
  And  noAV as to epileptics I have met with no better
fortune.  As regards  this,  I have read Avith care the 
228
NERVOUS DISEASES.
conclusions of Stevens and Ranney, and wished I could
have  seen some of  the epileptic persons whom they so
successfully treated.   Those who have seen much of
epilepsy knoAV that in  some respects it is a very curious
disease.  If we take an obstinate epileptic case and put
it suddenly under new conditions, in a new place, with
altered diet and different surroundings, we occasionally
find marked  changes for the better, Avhich are usually
temporary. This is frequently the case at the Infirmary.
When an habitual epileptic is admitted for the purpose
of being watched, in order to determine the  quality of
the spasm, weeks and even months  may pass Avithout
the patient having an attack, Avhen before this they
occurred every day; and  this,  too, despite the discon-
tinuance of all drugs.  I know of cases of  men who had
such attacks  before entering the army, and who  under
the neAV surroundings were entirely freed from  them.
These are the things which make neurologists careful
in concluding for the value of  a  new agent in this sad
malady until the cure has  lasted a long  Avhile, and been
observed with  care.   Still, there are  cases found  in
Ranney's last  contribution (Eye Treatment of  Epi-
leptics.   New York Medical Journal, January 13, 20,
and 27, 1894) Avhich seem to have ended  in  cures.  I
can only say that Ave have  failed to obtain like results in
our own attempts to cure epilepsy by the  correction of
very obvious refractive errors or by cutting tendons.  I
neither  believe nor disbelieve.  When I can  see two or
three cases of  cure of uudoubted epilepsy by tendon-
clipping I shall Avant to recommence.   So far I have
had only disappointment, and  others here who began
to cut tendons Avith enthusiastic hope  have, like me,
got no good  for  their patients out of an  industriously 
REFLEX OCULAR NEUROSES.        229
acquired experience in this direction.  I  shall be but
too happy to drop the dubious mood in AAdiich I am as
to this Avhole matter.
   I believe, as regards tenotomy versus prisms, that these
surgeons have  taught us a lesson Avhich Ave  may Avith
moderation usefully employ.   I have called your atten-
tion to the matter because I am Avell assured that if, as
to tendon-cutting, the gentlemen Avhom I have so frankly
criticised have gone too far, you, I think, have not gone
far enough.
   I have tried  as to  this Avhole matter to be fair and
courteous, and yet to set the history right.  As concerns
too positive vicAvs of treatment, time alone  will entirely
settle these.
   And  now a word or tAvo as to your oAvn relations to
the disorders in Avhich Ave see ocular troubles, or as to
those in Avhich these are the cause of symptoms.
   I trust the day has gone when you will put on prisms,
or  cut the tendons of ataxic cases without perceiving
the spinal source of the defects; but a more lasting evil
arises out of the fact that sometimes you do not compre-
hend the fact I have long tried to teach, that eye-strains
lasting through  the years of development may make
permanent headaches Avhich no glass Avill do more than
partially relieve.
   Again, you often see people Avho OAve to ill health a
suddenly intensified capacity to feel an eye-strain.  You
glass them and expect  too much.   Neither you nor any
specialist can, or should, escape from a sense  of larger
responsibility ;  and if  you cannot  hold  your patient
Avhen you have corrected the eyes, it  is  imperative that
he  learn from you the fact that he needs more than
merely the best correction of the eyes.   A careful study
                         20 
* 230            NERVOUS DISEASES.
would often tell you that a man may have two or three
forms of headache, and that it Avere well to understand
that while your glasses may cure an occipital ache, for
instance, he may still continue to have neuralgic hemi-
cranial pain, or an occasional attack of gouty headache.
   I suspect that our own oculists are far in  advance of
the English and most Continental surgeons  in the care
which with  they correct defects in refraction.  I fancy
that they sometimes fail to get the best  possible results
because of difficulties due,  it may be, to personal pecu-
liarities in patients, or sometimes to the belief that slight
muscular defects may be  let  alone when the refraction
has been accurately corrected. 
CHAPTER  XIV.
    WRONG REFERENCE  OF SENSATIONS OF  PAIX.

  It occasionally happens that in  the large clinical
material seen at  the hospital Ave meet Avith cases that
are hardly capable of nosological classification, and yet
are not without their lessons.   Here, as an example, is
a case so unusual that  I  have rarely  seen one  like it or
even analogous to it.   It is a very simple story :

  Case LXIII.—T. M. Avas sent to  my clinic at the In-
firmary for Nervous Diseases by Dr. J. H. McKee, on De-
cember 7, 1894.   She Avas sixty-two  years of age, born in
Pennsylvania, and married.  Her mother died at the age
of ninety-fi\re, and her father at seventy-three from  " can-
cer."  Two sisters and three brothers are Avell.  One sister
died of" tuberculosis " and one brother of " spotted fever."
The Avoman has borne three sons;  two  are well, and one is
asthmatic.  She takes tAvo cups of strong tea and  two of
strong coffee daily, and beer moderately.   The menopause
occurred between  forty and forty-fhre  years of age.  She
has  had pneumonia twice, once at fifty-tAvo and again  at
fifty-seven years of age.
  On November 25, 1894, thirteen days ago, Avhile  black-
ing  a stove, she let a heavy stove-plate fall  on the right
foot, striking the toes.  The great toe and  the adjacent one
were injured, and Avere  discolored from the bruising.   A
line of blackish discoloration is still present under the nail
of the second toe.   But  there is  no swelling or redness,
though some pain still persists.
  Immediately on the reception of the  injury she felt acute 
232
NERVOUS DISEASES.
pain on the antero-internal aspect of the left leg (the unin-
jured side) at the junction of the upper and middle thirds.
This  pain extended downAvard into  the foot and upward
into the thigh.   It was of a burning character, fairly con-
stant, but Avorse at night.   At present the appetite is good
and improving, the tongue is clean, there is no vomiting,
but the woman has an occasional headache attended Avith
nausea.
   The heart's action is rhythmic, the sounds distinct.  The
vascular tension is moderately increased.  The radial and
temporal arteries are tortuous and resistant. There is slight
vertigo, no  dyspnoea,  and no swelling of the feet.   There
is an increased frequency of micturition,  both nocturnal
and diurnal.  The urine contains no albumin or sugar and
has a specific gravity  of  1022.
   The Avoman has lost flesh in the last tAvo weeks, because,
as she states, of the severity of the pain.  She has not had
chills, fever, or sweats,  She sleeps poorly; and  Avorse since
the accident.  Memory is good and hearing is fairly good ;
but the eyesight is poor, although improved  by glasses.
The station is a little unsteady.   The knee-jerks are active,
and sensation is  apparently normal.   There is no history
of traumatism of the left leg.  The left tibia is particularly
tender in the middle third, on the inner and outer margins.
The left leg is also more florid and the temperature slightly
higher.  There is no inflammatory or other deposit present.
An electric examination of the tibial group  of muscles
shows a slight quantitative decrease to the faradic current.
There is no galvanic change.
   On  December 21, 1894, the Avoman was better, under
the daily use of galvanism.  On January 8, 1895, constant
gain was reported.
   I have  personally gone over this case with  extreme
care,  and see no cause to disbelieve the statement made
by the patient.  She declares that,  having had a heavy 
   MISREFERENCE OF SENSATIONS OF PAIN.  233

weight fall on the right  foot, there was at once a pain
in the left shin so sharp as to distract her attention
from  the quite severe injury received by the opposite
member.   Also she declares that the referred pain has
now, for three Aveeks, survived that of the part hurt.
   This case,  unusual as it is, seems not to be  unique.
In fact, I came yesterday, in Sharkey on Epilepsy, upon
a case in AAdiich the pain caused  by an injection for gon-
orrhoea was felt as an acute pain on top of the head.  I
myself recall  two of  Avhich I have personal knoAvledge.
One was that of a man Avho, having a felon on the right
thumb, had,  until  it Avas relieved, severe pain  in the
opposite thumb.  The reference was  to both thumbs,
and not from a foot to  a non-symmetric part  of the
opposite limb.  In another case, in Avhich an omnibus-
windoAV Avas  let fall on a finger in Avhich Avas a felon,
there  Avas Avith  the  pain of the finger a lasting  and
very violent  pain  in the face and neck of  the other
side.
   I have also some remembrance of having many times
heard during the great Civil  War from men shot state-
ments as to their having felt the wound as pain in some
remote part of the body.   In the  notes of  that time
made  by Morehouse, Wr. W. Keen, or by me, I find,
in fact, interesting examples of the kind of referred pain
seen in this woman.
   One Avas the case of Captain now Admiral Stembel,
who, being shot through the right side of the neck, had
with reflex paralysis of the  left arm  also pain in that
unwounded member.  Other instances are as folloAvs:
   Case II. of Circular No. VI., 1864.  A shell-wound
of one leg (right)  at once gave rise to burning pain in
both feet and in the right arm and right pectoral region.
                         20* 
234
NERVOUS DISEASES.
  Case VI.  A wound of the testicle Avas referred to
the back, where alone was any pain felt.
  Case V.  A shell-wound of the outer side of the left
thigh with immediate reference of pain to the same area
on  both  thighs.   The  man  thought, indeed, that  he
was shot through both thighs.  Other of our cases ex-
hibited  similar phenomena of cross  or symmetric or
non-symmetric reference of  the pain of a wound.
  Case VI., in Hutchinson's series,  p.  313,  is one of
injury of  the median and ulnar nerves which gave rise
to pain in the opposite hand.   Pirogoff  has a report of
the same form  of cross-reference  from a wound.  Such
false reports as to the seat of  pain-cause are not rare as
regards the branches  of a single  nerve.   A familiar
example is seen or felt in the  widely referred pain from
an exposed dental nerve.
  Our present case does not stand alone.   Neverthe-
less, instances  of  unsymmetrical  cross-reference  are
rare enough to make it worth while to call  them to
your attention.
  One of my  older friends,  now dead, a  naturalist of -
great distinction, had on one leg a small mole.  If this
was roughly rubbed or pinched, he had at once a sharp
pain in  his chin.   More interesting are  the cases in
Avhich after a nerve-section, or late in a neuritis, there
is a reference centrad of touch at some lower point.   I
long ago described this  class of facts, and  not very
successfully  commented  upon  their cause.    In his
book on  Remote Consequences of Nerve Injuries John
K. Mitchell gives many illustrations of this form of
referred touch-sense.   He  has also  still more curious
cases  of  sensations referred peripherad or to a remote
region. 
   MISREFERENCE OF SENSATIONS OF PAIN.   235

  The unusualness of the present case lies in the con-
tinuance of pain in the remote region long  after the
seat of the originating cause had ceased to be painful.
  I do not think that Ave are as yet prepared to reason
upon some of these symptoms.  I refer the curious to
the book I have last mentioned.  One can, in a meas-
ure,  comprehend that a  violent stimulus to a sensory
nerve  may be SAvitched off  on to other nerve-tracts or
centres, as if it Avere the escape of an over-charge; but,
even if Ave  hazard such an hypothesis, it is still difficult
to explain the persistency of certain of these transferred
impressions,  for it is a laAv  of the receiving centres for
painful impressions that Avhen the cause of the pain
ceases to be active the feeling of being hurt ends.   But
in some of these  examples of false reference of pain
there must have been made  in a centre some more or less
permanent change that continuously represents the effect
to which any pain-making agency usually gives rise. 
CHAPTER  XV.
        PSEUDOCYESIS:  SPURIOUS PREGNANCY.

   I had hoped to sIioav you to-day a case Avhich is of
unusual interest and of the utmost rarity.   The patient
will,  I think, come hither sooner or later, because she
is convinced I am Avrong  as to her state, and because
she believes that Professor Hirst, whom I shall  ask to
see her, Avill agree with  her and  disagree with me.
Moreover, she is hysterical and inclined to exhibit her-
self.   I shall not wait  for her return, as  it may  never
happen, but take her  case as a text or an excuse for
dwelling on a subject of interest to both the obstetrician
aud the neurologist.
   I find it somewhat  hard to  fit  her  case and  others
like it with  a label.  If I call it simulation of  preg-
nancy, that would be  near to  a  satisfactory name; it
would not fully satisfy me.   As usual, I  should have
to qualify and  explain it.  Perhaps  it were well  to
leave the matter until  I have stated some illustrative
examples.   Before doing so I  shall give an outline of
the condition for which I claim your attention.
   A  woman, young, or it may be at  the climacteric,
eagerly desires a child,  or is horribly afraid of becom-
ing pregnant.  The menses  become slight in amount,
irregular, and at last cease or not.  Meanwhile the abdo-
men and breasts enlarge OAving to rapid  taking  on of
fat, and this is less visible  elseAvhere.   There comes
with this excess of fat the most profound conviction of 
SP URIO US PREGNANCY.           237
the fact of pregnancy.  By and by the child is felt, the
physician takes it for  granted, and  this goes on until
the  great diagnostician,  Time, corrects  the delusion.
Then the fat disappears Avith remarkable speed and the
reign of this  singular simulation  is at an end.   When
I describe one or two of these cases you will, I fancy,
agree with me that the  subject  is worth discussing.
   Perhaps the cases may be more frequent than I think
they are.  As a consultant I might rarely hear of them.
The general physician  and the obstetrician are more
liable to encounter them,  and yet they must be uncom-
mon.  Some years ago  I  asked Dr. Duer if he recalled
the two or three cases of this nature sent to him by me.
He said yes, aud that he  had also met Avith one or two
others.   Shortly after this  I was  consulted  by a lady
in regard to a Avoman of thirty years of age,  a nurse in
Avhom she Avas interested.    This person had  been mar-
ried some three years to a very old man possessed of a
considerable estate.  He died, leaving his Avife her legal
share and the rest to distant  cousins, unless the Avife
had a child. For tAvo months before he died the Avoman,
who was very anaemic, ceased to menstruate.   She  be-
came sure that she Avas pregnant,  and thereupon took
on flesh at a rate and in a Avay  which seemed to justify
her belief.   Her breasts  and  abdomen Avere the chief
seats of this overgrowth.   The menses did not return,
her pallor increased; the child was felt, and every prep-
aration  made  for deli\Tery.  At the eighth month  a
physician made an examiuation and assured her of  the
absence of pregnancy.   A second medical opinion con-
firmed the  first, and  the tenth month  found  her of
immense size and still positive as to her condition.  At
the twelfth month her menstrual Aoav returned, and  she 
238
NER VO US DISEASES.
became sure it Avas the early signal of labor.   When it
passed over, convinced of her error, she at once dropped
weight at the rate of half a pound a day despite every
effort to limit  the  rate of  this remarkable  loss.   At
the end of two months she had parted with fifty pounds
and was  on the whole less ansemic.   At this stage I
was consulted by letter, as the Avonian had become ex-
ceedingly hysterical.
   Another instance I saw when in general  practice.
A lady who had several children and suffered much in
her pregnancies, passed  five  years Avithout  becoming
impregnated.   Then she missed a period,  and had as
usual vomiting.  She made some Avild  efforts to end
her supposed pregnancy, and, failing, accepted her fate.
Meanwhile  she Amounted  up to the eighth  month, and
ate little.   Nevertheless she took on fat so as to  make
the abdomen aud breasts  immense  and to excite un-
usual attention.
   No physician examined her until the supposed  labor
began, Avhen, of course,  the truth came out.   She Avas
pleased not to  have another child, and in  her case, as
in all the others knoAvn to me, the fat  lessened as soon
as the mind was satisfied as to the non-existence of
pregnancy.   As I now recall the facts, this woman Avas
not more than  tAvo  months in getting rid of the excess
of adipose tissue.
   Dr.  Hirst tells me he  has met Avith cases of women
taking on fat with  cessation  of  the menses in Avhich
there was also a steady belief in the  existence of preg-
nancy.   He  has not so  followed  up these cases as to
know if in them the fat fell away with speed when once
the patient  Avas assured that no child existed Avithin
her.   My much regretted friend  Goodell's death  de- 
SPURIOUS PREGNANCY.          239
prived  me  of  the detailed account of at  least two
examples  having precisely  the sequence of symptoms
I have described.
  These women are in no sense of unsound mind, nor
is their  illusion to be classified Avith the obstinate belief
as to pregnancy held by some of the  insane.  These
latter persons may be virgins or not.  Sometimes the
idea has arisen  in connection Avith uterine  symptoms,
or else is the outcome of some exposure to the creation
of pregnancy and alarm at a possible but non-existent
pregnancy.   Many of these people hold to the notion
for years.  Dr. Hirst recalls to me the story of Dupuy-
tren, who, Avhen consulted  for such a case of eighteen
years' duration (the patient Avas of the belief that she
Avas going to have a son), advised the Avoman to swallow
a  private tutor.   It is said to  have  cured  the case,
which  I  much doubt.   I kneAV of  one instance  in
Avhich a physician etherized such a case,  and assured
the  Avoman he  had taken  aAvay a  dead  child.   This
answered for a Aveek, and then she confided to him her
regret that he had not taken aAvay the other, as noAV she
kneAV they were tAvins.
   The  delusion of pregnancy in the insane is  neither
created nor kept up of need by excess of flesh or failure
of  menstruation.   No  such food for fancy is needed.
These  cases defy the contradictions  of time and the
popular knoAvledge of physiology.  On the other hand,
the illusion of the patients I describe  is inevitably de-
stroyed by  time and adverse circumstance.
   I can find no mention anyAvhere in literature of cases
precisely like those  I  have described.  Perhaps I may
have overlooked them or they might be found on more
careful search.  Yet, after inquiry of men Avith the large 
240
NERVOUS DISEASES.
experience of Goodell, Duer, and Hirst, I am forced to
believe them exceptionally rare.
  A woman is emotionally eager to have or not to have
a child; one Avith the  unsatisfied craving for mother-
hood, or one who has been fearfully tormented  in her
pregnancies—these, I  think, are the classes  of Avomen
liable to this complex group of symptoms.  More  rareb-
it is a Avoman long childless, who someAvhat early and
suddenly ceases to flow, and, as is not rare at the climac-
teric, puts on flesh very rapidly.   The illusion of preg-
nancy is in such females a flattering one.
  The other cases are the more interesting.  The Avoman
has naturally and too constantly dAvelt with disappointed
hope or abiding fear on the loss or delay of the periodic
bleeding.  Then she becomes more gladly sure or more
alarmed, as the case may be, as she gains flesh and
especially abdominal fat.   Is this gain in flesh an acci-
dent of  nutrition which  combines, Avith lessened  or
absent menstruation, to  give and sustain her groAving
illusion as  to  pregnancy ?  Women,  as  I long ago
remarked in my book on Rest-treatment, are easier to
fatten than men; also in them  gain  or loss of adipose
tissue is more common than in the other sex, and less
significant as to health or of pathological disaster. The
point as  to which  I remain  in doubt  is as to whether
belief in the presence of the pregnant condition in any
Avay influences  the  really singular gain in  fat seen in
certain of these cases.  Whether it is, as I said, coinci-
dent and  assistant of belief, or Avhether it folIoAvs that
mental state, I do not know.  Some women thus de-
luded are, when once assured of pregnancy, likely to
be careful to exercise less than usual, and acquire, like
some pregnant women, excessive appetites.   Also it is 
             SP URIO US PREGNANCY.          241

quite sure that once they are convinced of their delusion
they lose flesh very speedily, and  this, too, may be in
a measure due to a return to normal habits.  Still there
remains for us the unsolved problem of how much the
mind has to do with the gain and loss of weight.  The
first of these cases I ever saAv Avas brought to my knoAvl-
edge in a singular way:  A Avoman had given  birth to
two female children.   Some years passed, and her desire
for a boy was ungratified.  Then she missed her Aoav
once, and had thrice after this, as was customary with
her when pregnant,  a  very small  but regular loss.
At the second month morning \Tomiting came on, and
this too Avas  usual.  Meamvhile  she greAV very fat,
and, as the groAvth Avas largely abdominal, she became
easily sure of her condition.  She  Avas not my patient,
but her husband consulted me as to his  OAvn  morning
sickness, Avhich came Avith the first occurrence of this
sign in his wife,  as  had  been  the case  tAvice in her
former  pregnancies.   I advised him to leave home,
and this proved  effectual.   I learned later  that the
Avoman continued to  gain flesh  and be sick eATery
morning until the seventh month.   Then menstrua-
tion returned, an examination  was made, and Avhen
sure that there Avas no possibility of her being pregnant
she began  to lose flesh, and Avithin a feAV months re-
gained her usual size.
   The sympathetic vomiting of the husband is  an inter-
esting  subject to Avhich  I  called attention some years
ago in  my lectures on nervous maladies.
21 
               CHAPTER  XVI.

            HYSTERICAL  CONTRACTURES.

  These clinical lessons are, in a measure, the offspring
of opportunity.  The Avards have, of late, giveu us cases
of contracture that have been so interesting and so sug-
gestive as to tempt me to  call attention  to  their diag-
nosis and especially to their treatment.   The subject is
in no sense  exhausted.
  We do not know what hysteria is.  So far, death has
destroyed in all cases what evidence life might  have
offered as to its existence  as an obvious thing capable
of visual demonstration; and still we are apt, sometimes
with too much confidence, to refer  back its  manifesta-
tions to this or that centre.   Thus, it has  been taken
for granted  that hysterical contracture is due to disorder
somewhere  present in such columns of the cord as are
usually diseased in cases of spastic paralysis.  The chief
basis on  which this opinion rests is  this:  Cases of  long-
continuing hysterical contracture have been seen to end
in sclerotic alterations of the  lateral columns of the
spinal cord.   The inference is that the precedent func-
tional states Avere also due to the  less visible hysterical
conditions  of  these  columns.1  Moreover, it has been
taken for granted that the state of  contracture is anal-
ogous to the condition we find  present in muscles ren-
dered over-responsive by lateral sclerosis.
1 Charcot: Soc. med. des Hdpitaux, vol. ii., 2d series, p. 24, 
HYSTERICAL CONTRACTURES.       243
  I am not at all secure that these inferences are safe,
or even that  contracture is of a certainty due to spinal
centres  at  all.   It is quite  possibly purely  local and
muscular as  to origin; and, indeed, there  are  reasons
Avhy it is extremely difficult to consider it as of spinal
birth, or in any way  analogous to the  state of excita-
bility seen  in disease  of the lateral columns.
  The history of contracture is briefly this:  Under an
influence,  such as emotion, or from causes unknown,
but usually  in a  frankly hysterical case,  a  group or
groups  of  muscles contract abruptly  or by degrees.
These spasms may imrolAre flexors or extensors, or both
at once.  They may affect one muscle or almost every
group in all four extremities, and also the truncal mus-
cles.  The condition  thus  developed may last for days
or years.   The muscles concerned are not over-respon-
sive to  bloAVS or to electricity.   The  skin-reflexes are
normal  or nearly so;  the knee-jerk and ankle-jerk may
not be in excess.   Clonus is absent, or, if present, inde-
cisive or brief, as we  see it in hysteria or in over-excit-
able, weak people.   The  prolonged  muscular  action
seems not to raise the  local temperature.   If you deeply
ansesthetize  the  patient,  the muscles relax, but not
always nor fully except early in the  case. An Esmarch
bandage commonly gives  rise  to complete  relaxation.
In sleep some early cases  relax;  others do  not.  Very
gentle effort  in  sleep to alter the  angle of the  limb may
succeed, but  the least abruptness  of pull  calls out a
spastic  response.  Othenvise the spasm is usually con-
stant, and efforts to overcome it forcibly give great pain.
Very often there is loss of normal power in such mus-
cles as  are,  and even in  such muscles of the affected
limb as are  not, in a state of spasm.  Usually there is 
244
NERVOUS DISEASES.
profound anaesthesia, confined to the disordered  limbs
or involving half the body.
   I have said that the spasm is chronic, and this  is the
rule; but I have seen cases in Avhich it came and  went,
or was seen only on alternate days.   Quite  often  the
flexors or extensors alone are contractured, but in  the
sad examples of general chronic spasm  both sets of
muscles are apt to suffer.
   A contracture may last for years, and go as abruptly
as it came—or, it is so said.  I have never seen this
happen, but  I cannot  doubt the  positive  statements
made by others.
   Under early reasonable treatment these spasms, if
locally limited to single groups of muscles, are apt to
get Avell.   My own efforts to cure them with discs of
metal, magnets, or by hypnotic suggestion have left me
with mere  histories  of  defeat.   And  yet under  other
treatments  I often see these cases get well early.   But
this is not true of  the more extensive contractures; in
fact, the more extensive  the region affected the more
difficult the early treatment.
   Xow let  us look at the  graver form, that of multiple
contracture.  A  patient far  gone  in the sad  drama of
hysteria has sloAvly, or abruptly, or after the part has
been paralyzed and become insensible, a contracture of
one limb, which gets worse.  In a week or two the other
limb suffers.   Still later the remaining extremities be-
come drawn  up,  and even the face, neck,  belly, and
thorax are involved.  There  are paralysis,  surface-
anaesthesia, and  intense  spasm.   Pain is  rare, unless
called out by pressure or motion.   Usually all the mus-
cles suffer,  but the attitude is commonly one of extreme
flexion,  either because  of the greater power of  the 
HYSTERICAL CONTRACTURES.       245
flexors, or that they are the more excited.  In some
cases the limbs  are  in  extreme spastic  extension, or
this  is the case as to the legs, and not as  to hands and
arms.   Very early  in  these  cases the muscle-muscle-
reflexes1 are  mechanically abolished or are pathologi-
cally interfered Avith; and later all reflexes may disap-
pear in the  disordered  parts, and even direct response
to a blow on the muscle be  lost.   There  is apt to be
diminished quantitative muscular response to  faradic
currents, and after years even galvanic responses may
be lessened.   The anaesthesia is of the surface, and is
finally profound.
  Sleep does  not relax these cases after they have existed
for some months.   Great but uniform  wasting  is seen.
The  muscles harden.   About the joints and between
the tendons a similar but far  greater leathern-like har-
dening is found.  Ether or chloroform no longer causes
relaxation;  nor  does  an Esmarch bandage, or even
section of the tendons,  give rise to relaxation as in the
local contracture.
  This is a different symptom-group.  If we ask our-
selves, What has happened ?  What is the cause ? we are
at once face to  face with a grave and interesting prob-
lem.    Without a history we  would be apt enough to
consider such a case as one of anterior poliomyelitis.  It
is but a sketch of that malady; it is not a true picture.
But  suppose this patient bedridden for a score of years.
I have seen  such cases, in which  the  cold, absolutely
anaesthetic limbs have lost all  reflexes, and in which the
shrunken  muscles refuse to  move under any form of
electric current, save here and there to powerful gal-

             1 By these are meant the knee-jerks, ;etc.
                         21* 
246
NERVOUS DISEASES.
vauic alternations.   The  picture of  an anterior spinal
malady seems then to be fairly complete.
   This sad condition belongs only to the multiple con-
tractures.  It is never found in the  single-limb spasm,
no matter hoAv lasting that may be.   I have seen con-
tracture of the extensors of one leg endure six years and
show no sign of the peculiar permanent hardening which
marks the second stage of some more generalized con-
tractures.  I recall one case in which for nine years the
left gastrocnemial group remained in violent contracture.
Then a section put an end to the spasm.   To my sur-
prise the muscle thus released from tension was soft and
had  not shrunk.   In both of these cases,  when under
ether, the relaxed  muscle behaved to electricity like a
normal muscle.
   All of this is unlike what happens in the contractures
affecting two or more extremities.   Here,  even in the
very early months,  the muscles  may begin to show a
brawn-like hardness, which is a constant condition aud
not to be altered  by anaesthetics.  The muscle, at first
spasmodically  shortened, becomes organically set and
stiffened.  There is still and ahvays more or less spasm,
or at least this may be the  case for years.   It is also
possible  that joint-lesions due  to long disuse and  to
subluxations  may have finally their share in adding to
this complex symptom-group the element of reflex mus-
cular contractions.
   You may have already inferred that I have  become
quite assured  that  there  are two forms of hysterical
contracture: one apt to be local and limited and not
followed by organic muscular changes; the other apt to
affect two or more limbs, and almost every muscle, even 
          HYSTERICAL CONTRACTURES.       247

of the trunk, and  prone to result in the muscular and
areolar tissue-changes already described.
  I think it curious that Avhile the early stage of gen-
eral contracture is most difficult of cure, Avhen the dis-
ease  has caused  organic  changes and  is in its second
stage it is far less hard to deal with.   Perhaps this may
be due in part to the disappearance of  active hysteria.
Indeed it is often true that iu certain old examples of
contracture the symptom, contracture, exists no longer,
and Ave have to deal only Avith the mischief  of organ-
ically shortened muscles, altered joints, and sclerematous
changes  in the intermuscular  spaces.  The hysteria is
lost Avith years; the spasm lessens or ceases; the conse-
quences  and additions remain.
   I  have said enough to enable you  to separate this
peculiar state from disease of the  lateral or from that
of the anterior gray columns of the cord.   If, however,
any other test be  needed, it is to be found in the ease
and speed with which under rubbing and faradic elec-
tricity these  wasted muscles recover  their characteristic
excitability.   With this return such  reflex  actions as
had been mechanically obliterated  again  become vis-
ible, but the skin-reflexes remain absent until the anaes-
thesia passes away.
   Richet divides contractures into painful and painless.
I never saw a case of constantly painful contracture in
America.  Some of these cases, however, become pain-
ful for a reason  not always present and Avhich only of
late has become clear to me.   In  general  the  painless
contracture  may be made painful  by quite moderate
efforts  to overcome  the  contraction;  and  in old cases,
such  as  I shall describe, the pain on  movement is in the 
248
NER VO US DISEASES.
joints and not in the muscles.  In  advanced  cases of
extreme contracture of the legs you meet now and then
with examples of agonizing pain, apt to be referred to
the feet and never  seen in the arm.   I had  long con-
sidered  this  symptom as of spinal  parentage.  Some
years ago, however, I was led in a seemingly hopeless
case to  suspect that the very great suffering present
might be due to the stretching of the sciatic  nerves at
the notch and to a  possible localized irritation or even
neuritis.   A number of tendons were cut and partial
extension effected.  Immediate relief followed and the
pain continuously lessened as  extension by instruments
became more complete.   Encouraged by this unlooked-
for success, the case was attacked Avith larger hope, and
in the end I  had  the pleasure of seeing a young and
intelligent woman restored to a life  of healthy useful-
ness.   I happen to-day to have  seen  this woman;  a
strong, Avell-nourished, and apparently vigorous person.
Looking back  to the gnarled, blind,  speechless patient
of years ago, it seems a quite incredible rescue.  Xoth-
ing except the rapid  cure in this  case shook my belief
that very material organic change in the cord had taken
place.   So far as  my OAvn knowledge goes, post-hys-
terical sclerosis of the cord occurs only in generalized
contracture, after ten or  twenty years of life in bed.
In one such case I saAv, after death, a moderate, irregu-
larly  scattered sclerosis of the anterior  columns and
gray matter.
   With such  a symptom-group before us as I  have
already described as existing in old cases of multiple
contracture, it  is almost  impossible  for the inexperi-
enced to disbelieve the presence  of more or less organic
fascial change  in the cord.   So difficult is it, indeed, 
HYSTERICAL CONTRACTURES.       249
that I  have often asked  myself, if it may not be that
organic lesions in hysterical people ha\re a less serious
hold on the tissues than  such as come in the ordinary
way, Avithout precedent hysteria. Either we must accept
some such conclusion, or else  believe that the group of
symptoms delineated may occur without having for their
parents organic material  lesions of central nerve-cell
and fibre.  I  trust I make clear how difficult is this
problem.
   It is  especially interesting to me  just now, because I
have in my care a young woman whose case is very like
that I  just noAV mentioned  as fortunate.   As our first
illustration of contracture and of many of the most  re-
markable incidents of hysteria, I shall have read to you
at length this strange story of  disease.   It is rare that
a record has been  kept Avith the care given to this one:
   Case LXIV.—E. M.  H, of Arkansas, is  a girl fifteen
years of age, Avhose parents are  in good  health, and who
has three  brothers and sisters alive and well. The mother
has had two miscarriages ; one child Avas born prematurely,
and one died of hydrocephalus at six  months.  A maternal
aunt Avas insane.
   The  patient  was born at term, without difficulty and
Avithout instruments, and proved to be a healthy and well-
formed  baby.   She was  breast-fed for six months; never
had convulsions, and, although  she had  scarlet fever, her
childhood Avas fairly healthy.
   She learned to Avalk and talk early and  well;  Avas, in
fact, a  bright, intellectual child.  Menstruation began at
twelve years, and ceased a year before the girl came under
observation.
   In 1890 the patient had epidemic influenza, without re-
markable consequences.  The present trouble began in that
year.  Late in March of 1890 she was running along  a wet 
250
NERVOUS DISEASES.
boardAvalk, when she slipped  at the end and fell, striking
the back of her neck on the  edge of the last board  She
had to be assisted to rise, and complained of headache for
several days.  About a Aveek  later she tripped in the grass
and fell, causing a green-stick fracture of the left radius.
As soon  as  the  nature of the accident was understood, a
plaster-cast was put on the arm, and soon afterward it was
observed that the hand had begun to "draAV up," and that
to extend it was extremely painful.  This gave rise to no
suspicion, but Avhen the cast was taken off it Avas found that
the arm and hand  Avere entirely paralyzed,  had no sensa-
tion, a very poor circulation, had shrunk  perceptibly, and
Avere blue and mottled.
  The spine Avas examined, and is said  to have been sensi-
tive in the upper cervical region.   The girl declared that
tapping it at this time made the knees  tremble and ache.
She Avas ordered to bed,  applications of  ice made to the
spine, and bromides and other medication employed.  In a
few days she became extremely nervous, flighty, and imag-
inative ; had to  have the room dark,  obliged everybody
to go about in slippers, and objected to the slightest noise.
  Her physician concluded the trouble to  be hysterical,
ordered the shutters opened, and suggested that her parents
insist upon an effort to move  the hand.   The child set her
own Avill to  Avork as soon as  she was assured that it was
possible, and in a few days Avas using  the limb tolerably
well, and was on her feet again, though Aveak.  The  hand
still remained partially flexed, and rather uncertain in its
movements for some time afterward.
  Late in June she was  taken to a farm  in the country,
Avhere she steadily regained her strength and flesh, playing
with other children, until the middle of July, when there
were four excessively hot days.  Athough she Avas  kept as
quiet as could be, on the fourth day the left arm  dropped
helpless and began to contract, and later to shrink, and 
HYSTERICAL CONTRACTURES.       251
became remarkably blue and mottled. Early next morning
she staggered into her mother's room, complaining of dizzi-
ness.   Her mother caught her in her arms, and from that
time she  has never stood erect upon her feet without aid.
She Avas put in bed, and had a fever in a few days,  Avith a
temperature of from 101° to 102°.  She  Avas extremely
excitable, and  had a variable tendency to fancy shapes and
sounds about  her.   Within a few days the temperature
became normal.  By and by she sat up and played, using
both hands and  arms  freely, and could  put  out  either
foot to draAV to her the playthings she dropped from her
hands.  Still she could not stand.   TAvice  she forgot, and
springing up to ansAver a call dropped instantly on the floor.
After Avaiting  for tAvo  Aveeks, thinking she would recover
the use of her  legs, her parents took her home to her oAvn
doctor.   There was at  this time an almost daily percep-
tible loss of poAver in the legs, and sensation also began to
go, which had not happened before.
   On October 1st, tAventy-four days after the last fall, the
child Avas Avithout sensation beloAV  the knees.  Her tem-
perature  averaged from time to time from 101° to 102°,
Avith a ATery rapid pulse, and a slight return of the excit-
able, flighty condition.  The former  treatment was repeated,
and again motion was  restored in ten days.   The hand at
this time measured three-quarters of an inch less in circum-
ference at the first joint than the  other, and  the skin  peeled
deeply from the ends of the fingers and  thumbs, so as in a
measure to suggest the  kind of change that is seen after an
attack of scarlet  fever.
   From this time on there Avas a  steady gain until Septem-
ber 6th, Avhen  one day  she lost her balance and fell back-
Avard off  her seat, striking the back of her neck, a little to
the right, at the base of the brain, on the sharp edge of a
sill—not  a door-sill, but a part of  the frame of the barn
where she had  been taken for her amusement.  The bloAV 
252
NER VO US DISEASES.
raised a large lump, and was really severe. She fell doubled
up betAveen the step and the Avail; and  the other children
pulled  her out rather violently, and she complained that
they hurt her back in so doing.  This was late in the fore-
noon.   She  ate no dinner that  day, and looked pale and
haggard, but said nothing about the matter.  Very soon
afterward it was  observed that there was no motion  in
either feet or legs, and that the latter had begun to draw
up ;  but the arms and hands were still untouched by this
disastrous trouble.
  By October 15th the knees Avere at a slightly acute angle,
and  still drawing up.  Any attempt  at extension caused
great pain.   The girl was  able to sit up,  but complained
that  her back Avas constantly tired.  Finally a rung Avas
sawed  out of  her low chair in order to  let the feet  draw
back under it.  On October 19th, while sitting busily cro-
cheting, her right hand  fell suddenly in her  lap, and a
minute later the left, and neither moved again for twenty-
seven months.  In less than a week both arms had draAvn
up to  a right-angle, the fingers and  wrist were bent  in
flexion upon the arms, and both arms and legs were totally
devoid of sensation.  After this the child  could not sit up
any more, pain in  the spine being constant at the loAver part,
chiefly in the dorso-lumbar region.   The sphincter muscles
of the  bladder and rectum were at this  time  sometimes  in
a relaxed condition and allowed everything to pass, and  at
other times violently contracted, so as to make  the discharge
of urine or feces for the time impossible.
  For days the little patient was an entirely helpless per-
son, except for the ability to move  her  head from side  to
side.  About November 11th chloroform was fully admin-
istered, but the tendons did not  relax, and it  required the
efforts of two physicians to extend the arms and legs, so  as
partially to straighten the  joints.  Xext day there Avas a
decided change for the worse.   Spasmodic contractions  of 
           HYSTERICAL CONTRACTURES.       253

the neck and  pectoral muscles set in.   The girl could not
SAvallow even liquids.  Food was then given by injections
for some days.   It required an hour for her to relieve her
bladder, and at this time the urine Avas heavily charged with
phosphatic deposits, so that in a pint they were one or two
inches deep.
  All sorts of things happened in the next feAV Aveeks. The
tongue Avas drawn to one side on occasions, so that the teeth
rubbed the skin off it.  The child became blind and nearly
entirely deaf. The pectoral muscles occasionally contracted
powerfully, so as to draw the arms across the chest, or the
chest into a deep concave,  making full  breathing impossi-
ble.  On  other occasions the head  Avas jerked violently
from side to side, even in sleep, and the girl would rise
from the pillow and move to and fro with a  pendulum-like
motion,  and  then  fall back,  still  asleep,  or  apparently
exhausted.
  There were  constant spasms of the  diaphragm, during
Avhich it seemed that the child would never  breathe again.
Her temperature during this  time varied from 95° to 101°,
sometimes making this extreme excursus Avithin two hours,
the pulse being then from 130 to 180, and respirations be-
yond the possibility of counting.   MeanAvhile emaciation
increased; sleep  became  almost impossible (even  with
copious doses  of codein), seldom lasting more than from
thirty to sixty minutes.  At this time  it was necessary to
tie her head  down  to give  her any rest at all.  Ice was
kept on the whole length of the spinal cord, an ice-cap
was placed on the  head, and in these measures the patient
seemed to find more relief than in anything else.   There
was a broad  red  band across her  forehead, very difficult
to describe, and deep streaks down both her cheeks, of an
intense red.    Her eyelids sometimes remained open for  •*
long periods,  and  at  others Avere shut for  hours, so that
she could not open them.   Again,  the eyes themselves
                           22 
254
NER VO US DISEASES.
would  move independently, sometimes one rolling upward
and the other doAvnward, or one outward and one inAvard,
producing a most extraordinary appearance.  " Every hour
for weeks," said her mother, " we expected to see her draw
her last breath ; nor were we alone in the belief that it was
impossible that she should come out of this condition and
live."  " I should have mentioned also," added her mother,
'' to  withhold  nothing of interest, that  she  passed  entire
days in a comatose condition, and others in a state that
could more aptly be described as a deep  sleep."
  During this  long period the girl was fed entirely by the
bowel,  and was rubbed with oil and brandy, the throat and
mouth being sprayed Avith Avater and glycerol every feAV
minutes.   On  December 16th came Avhat is  described  by
her parent as the crisis.   She had  alarming spasms of the
diaphragm, much longer than the  preceding ones.  Then
they suddenly  ceased, and did not return for three years.
There  was a slight relaxation  at this time  of all of the
contractions, and the patient was rather more comfortable.
In a few days afterward she began to swallow a little, but
at this time she was entirely blind ;  she had also no sense of
taste.  The  smallest amount of water  swallowed  caused
extreme pain, and  the slight effort of masticating or swal-
loAving food gave rise to profuse perspiration and indescrib-
able  weakness.
  It was characteristic of the  hysterical nature of the case
that  the  girl could sometimes be fed by means of spoons
Avhich  were of  some unusual form,  letting her feel the pat-
terns with her lips or tongue.   About this time she began
to take potassium iodide, increasing the dose as fast as the
stomach could bear it.
  On January 9,1891, she was able, with effort, to tell the
number of fingers held up close to her eyes,  and on Janu-
ary 16th could distinguish outlines and bright colors.
  On March 1st her sight became good  in the right eye; 
           HYSTERICAL CONTRACTURES.       255

it had  never, until very lately, returned fully to the left
eye.  She could see things less distinctly Avith the latter.
  Fearing the effect of heat upon her (as she manifestly
lost ground Avhen overheated ; her legs dreAV up more forci-
bly, and she lost flesh as the Avarm days came on), her
parents Avere advised to take  her to the mountains  for the
stimulus of a rarer atmosphere and the coolness of the high
altitude.  A  cot Avas made, Avhich Avas swung on solid rub-
ber rope  to save  jarring, and she Avas  carried up Roan
Mountain, 6394 feet high.  She  began at once to sleep
Avell, eat well, and move Avith ease.  At this time the hands
were  still twisted together at  the Avrists,  and  tightly
clenched.   She also had the embarrassing  symptom  of
violent protrusion of the rectal mucous  membrane, Avhich
Avould come  down suddenly in her sleep.  If it was not
pushed into  place at once,  it seemed to  be caught, and
then it became congested, and its  return was exceedingly
difficult.
   At  this time the legs  Avere still  contracted and motion-
less ;  both knees Avere subdislocated ; the left foot Avas laid
up over the right thigh, and the right foot on the left thigh.
Both feet Avere draAvn into a sharp curve, and the toes Avere
drawn under so tightly, and so close together, that it Avas
impossible to draAV a rag under or betAveen them.  Quan-
tities of iron and potassium iodide Avere given, with occa-
sional cessation of the treatment to let the  stomach  recover
its tone.
   The child's  parents remained on the mountain Avith her
from June 6th to October 16th, and  then  returned to her
native toAvn.   During these four months  she had gained
thirty-three  pounds in weight, having  weighed in  June
forty-five  pounds and  in October seventy-eight  pounds.
 On her return she instantly ceased gaining flesh, was  again
 attacked  by influenza, and Avas Avretchedly Aveak all winter ;
 she had to be watched closely, and  continually kept cool, 
256
NERVOUS DISEASES.
insisting upon  the  Avindows  being open  day and night,
although the thermometer was often at zero.  Her physi-
cian urged her  parents to  hasten aAvay early in the spring,
and  accordingly they started in April, waited a  month  at
the foot of Roan Mountain for the snow to melt, and moved
over the mountain to Glen Ayres, 4500 feet above the sea-
level, on the south slope.  As before, the girl began to pick
up at once.  Sensation, which had crept doAvn  from the
shoulders the previous summer nearly to the elboAVS, began
to be manifest below the elboAVS.
  In June, 1892, menstruation began.   The girl was then
twelve years and eight months  old.  There was no gen-
eral  disturbance  of the system at  this time, beyond slight
backache and headache, and no hysterical manifestation.
The menstruation continued with perfect regularity and  in
good quantity until  December, 1893, Avhen it ceased.
   There has never been  any unnatural discharge or any
complaint  of pain or uneasiness at the menstrual period,
except  that caused occasionally  by retention  of urine.
There was  a general access of strength and flesh during
the summer of  1892, and  in  September the family moved
again to the summit of  the mountain for the Avinter, fully
determined  to test the value of altitude in the child's case.
In  the  meanwhile,  unable to use her hands, the little one
learned to Avrite and draw beautifully with pen and pencil
in her mouth, holding them firmly on the right side between
her teeth, and moving the head.  She complained that the
other side  of her mouth Avas "left-handed."  She  con-
ducted  in this  astonishing manner a large correspondence
entirely by herself, except the  folding of the letters and
placing them  in  the  envelopes,  the  hands being  still
clenched and twisted as I have described.   Fig. 10 illus-
trates her  mode  of Avriting, and Fig. 11 the Avriting.   I
have since seen her Avrite and  draAV Avith the pencil or pen
held by the teeth as described. 
HYSTERICAL CONTRACTURES.

                Fig. 10.
257
E. M. H. writing with pen held in mouth.
             Fig.  11.






                       I-
With pen in teeth, 1892.
        22* 
258
NER VO US DISEASES.
  The Avinter  was extremely  severe  on the mountains.
During January it Avas impossible to keep the temperature
in the sitting-room up to 32°.  Most of the time it was from
20° to 30°.  For some weeks previously the girl had been
able to move her right thumb a little, and on January 13th
she  opened that hand and moved all the fingers, but could
not  separate the wrists, Avhich, if  I  have made the matter
clear, I should  have  described as being pressed violently
one against the other.
  January 15th, two  days later, she opened  the left hand
and moved all the fingers, and got  the hands apart.  In a
very few  days afterward  she was using them both  for
writing  and  knitting, somewhat awkwardly,  of  course.
Sensation  began to creep down below the elbows ; her flesh
increased  rapidly, her color became good, and there was
more warmth of  the  extremities.  Her legs were  still
motionless, subluxated at the  knees, and violently drawn,
as before described.
                        Fig. 12.





      f$L~ yW^i^  *>u^v ^CJa %JL.






             With pen in right hand, March 19,1893.

  In April she was taken  to  Professor Allen,  of  Indian-
apolis, who cut the tendons in the groins and under  the
knees.  The joints had  grown out  of shape, and the skin
under the knees  had contracted and hardened so much
 
HYSTERICAL CONTRACTURES.       259
after thirty-two months' flexion as to make full extension
dangerous.  A moderate amount of chloroform came near
proving fatal, and so the cords Avere cut in four operations,
wdiiskey being  given  beforehand.   Then extension-braces
were fitted to be Avorked Avith ratchets, and the patient Avas
brought back  to the  mountain-top.  She soon sat up  in
a Avheeled chair, rolling it Avith her own hands, and, in
fact, became a picture of rosy, plump girlhood.
  In August,  1893, she  began  moving her feet slightly,
and resolutely practised,  Avith the aid of her mother, until,
in October, she could move the sewing-machine treadle a
little.  She had to lift her  legs and feet Avith  her hands,
but could move her feet and toes.  There was still at this
time no sensation in  the legs below the groin, but it Avas
pretty good in the arms, and she could feel a needle almost
down to  the  knuckles of  both hands.  The knees had
been forcibly  extended  daily by the  use  of  instruments
until  the  angle Avas extremely  slight.  This  process Avas
very painful,  always giving rise to great distress in  the
lumbar vertebrae. Several attempts to stand with assistance
caused extreme torment in the same region.
   On September 30th the child Avas taken  in a buckboard
wagon several hundred yards, and again on October 29th.
   On November 2d she appeared languid; her back hurt
her more ; she  could not sit up, but preferred to lie still  all
day.  She was  carried doAvn stairs as usual  to  lie on a
couch, and the stretching  at that  time was omitted and
never resumed.   After this she did not sit up.   Tavo Aveeks
later there Avas a slight menstrual discharge;  her appetite
failed, and her strength gave Avay.   For the  first  time in
five months it Avas necessary to put  ice-bags on the back of
her neck.    In other words, she  had a very serious relapse.
   She could not be carried down stairs until May.  Her
parents had intended to move to Roan Station  for  the
winter, but did not think it advisable to disturb her. 
260
NERVOUS DISEASES.
  Violent palpitation of the heart came on;  the pulse Avas
160, hard and bounding; the temperature Avas only 97° ;
the respiration very rapid.  At this time the physicians
who saw the girl Avere again satisfied that it was impossible
that she could live much longer.
  On January 12, 1894, she had serious ulcerations of the
mouth and throat; her breathing became as rapid as from
90 to 160 per minute; her pulse quick, Aveak, and wiry.
The urine was exceedingly scanty and dark.   The legs be-
came again motionless ; the cords contracted at the knees ;
the hips  aud  the arms were still free, as they had  been
before, but increasingly numb.
  At this time  there came on  also a great difficulty in
speech.   Ice was now used on the head also, and again the
child desired to have all light and sound excluded.  On
January  20th she spoke once:  "Mamma," she  said, "it
hurts," and never afterward, up to the time of her falling
under my own care.   Nor, in  fact, did she  make  in  this
period an articulate sound, asleep  or awake.  The vocal
bands Avere relaxed at this time, and are said to have been
ulcerated.  The  legs Avere draAvn up almost to the body,
but  there never Avas as much contraction of the  thigh on
the pelvis as of the leg on the thigh.
  The girl could still express herself in Avriting Avith her
hands, but complained that they Avere weak and numb, and
she  feared, as she Avrote, that  they  Avere " going again."
On February 10th she had  violent contraction of  the ab-
dominal muscles following an enema;  convulsive shudder-
ings for a time ran over her body, and her hands and arms
in an hour were  completely paralyzed.
  From February 10th till March 3d she  had no discharge
from her  bowels.  On February 14th she had. great diffi-
culty in expiration ;  she would fill  her chest to the utmost
degree with  air,  and then remain half a minute Avithout
expelling it, and finally would drive it out in jerking whiffs,
her head moving violently to and fro as she did so. 
HYSTERICAL CONTRACTURES.       261
  At this time  there was  great  difficulty in  deglutition,
and  occasionally swallowing was  followed by violent con-
vulsive efforts, during which the  blood would fly forcibly
from  the nose and mouth.  Two hours  or more were re-
quired to swallow two or three ounces of milk, and nour-
ishment was mainly given by enemata.   At this time some
effort Avas made  to knead the abdomen, but every attempt
caused contractions of  the bowels so violent that the mus-
cles Avould spring into stiff cords, and remain thus for hours;
Avhile the urine  had to be drawn, and was brown and ex-
ceedingly oflensi\re, but without blood.
  On March 3d there Avas a temporary cessation  of con-
tractions, and the bowels Avere moved, and this  was the
last motion until March 29th.  During  all this time the
patient Avas  fed  chiefly by enema; nothing passed aAvay,
everything  being absorbed with astonishing ease.
  After February 10th all communication  Avas made  by
the eyelids ; the  child could no longer use her hands or her
speech, even in the faintest Avhisper; but Avhen she wished
to indicate anything she would wink several times.   Cards
were held up containing the alphabet, and when the  right
letter Avas reached  she would wink.
  On March  12th continuous convulsions of the head,
arms, bowels, jaws, and tongue set in.  All food and drink
were  given  by  the bowel  and  by  outward  application.
Again there Avas a deep crimson  flush all over the head,
and  it was  needful continuously to keep ice on the  neck
and  head.   The facial  and temporal arteries were of the
size of large  lead-pencils; all  were throbbing so violently
that their pulsation could be counted across the room.
  On March 22d  the convulsions were so violent as to re-
quire men to hold the child, and at this time it Avas observed
that the urine became of an extraordinary odor, described
to be like that of the cat.  On March 25th she was totally
deaf,  partially blind, and entirely speechless.   She could 
262
NERVOUS DISEASES.
not feel a needle anywhere in the body, except in the lips.
The skin was rough all over the body, and looked and felt
like sand paper, presenting an indescribable dry roughness.
At this time any attempt to comb  the hair Avas  followed
by bleeding from the scalp, and  the hair fell out in hand-
fuls.  Emaciation became extreme.   All of this time the
girl had an  exceeding sensitiveness as to heat, and the
breathing would  become terribly difficult if the Avindows
were closed, so that her family  were obliged to keep the
sash up and the transom over the door  open although they
were on the  top  of the mountain,  Avith the  thermometer
doAvn in the neighborhood  of zero. Her  nurses, as may
be imagined, suffered severely under this regime.
   On March  29th her convulsions  ceased.   On April 4th
she had discharges of green and yellow pus, in remarkable
quantities, from the ears and  nose, as  well as from  one or
two abscesses Avhich had to  be opened  in various parts of
the body ;  one on the side of the neck appeared to be very
serious.  Shortly after this her sight began to return, and
it was soon found that she Avas reading the motions  of her
attendant's lips, although stone-deaf, and  very  soon she
understood every  syllable, Avhen the light Avas good and
faces were turned squarely toward  her.   From this time
for months she continued to  improve  in this accomplish-
ment.   Her family learned  for her  use the deaf-and-dumb
alphabet, so that she  communicated with them either by
speaking with her own lips,  so that  her mother  read them,
or by looking at the lips of  those talking, or by seeing the
motion of her mother's fingers, when  her sight at  length
was better.  Following this there  was a  period of many
months during which  she was subject to curious and fre-
quent attacks of congestion  of the superficial veins all over
the body.  The Avhole body Avould sometimes become mot-
tled blue, as if a coarse blue veil Avere draAvn over it; the
lips  and eyelids  would grow almost black, and breathing 
HYSTERICAL CONTRACTURES.        263
become exceedingly difficult.  It Avas then necessary to give
stimulus quickly, and to sponge the body with cold and hot
water, and reneAV the hot-Avater bottles, and do quick work,
in order, as it seemed to her family, to save the child from
death.  A  little excitement,  or  a  too Avarm room, would
in a minute  bring on one of these remarkable  attacks.
The last attack of  this sort occurred in September.
   Early in May she began to chew a little; she could swal-
Ioav no solids, and  only from  one-eighth to one-fifth of the
fluids attempted ; the diet Avas still chiefly by enema.  On
May 2d Dr. Allen, Avho saw her, expressed his surprise that
she Avas still  alive, and  it did not seem possible then that
she could  live from hour to hour, although  she had been
really convalescing for  nearly a month.  She was  breath-
ing entirely Avith the diaphragm at this time; the  lungs
were congested and full of rales, and in the costal  region
quite motionless.
   From this time there were gradual gains, and it seems
useless to repeat the roll of extraordinary hysterical symp-
toms.  Early in June she began moving the fingers of the
left hand.  On June 13th she Avas able to " shake hands
all around," as she said, and could swallow a little solid
food, and nearly all liquids.  On June 19th she wrote her
name for  Dr. Allen and for her  mother, and respiration
began to be deeper and more comfortable, and she Avas more
cheerful and happy.   On September 13th she was moved
down to Roan Station, 2650 feet above sea-level.   On Sep-
tember 28th,  the third consecutive Avarm  day, the mercury
being at 80°, a violent inflammation of the eyeballs and eye-
lids and congestion of the entire face and  neck  came on,
and lasted until the  weather changed, a week later. At
this time the  child began to make her right hand hold the
Avork for her  left hand.   The left hand and arm were quite
free and vigorous, although there Avas no feeling as yet in
any part of them. 
264
NERVOUS DISEASES.
  Every warm day in October and November brought back
symptoms similar to those already described, hut the prompt
use of cold applications stopped the attacks.
  On November 26, 1894, four  years and  three months
after the second injury, and four years and nearly eight
months after the first injury on the boardwalk, and thirteen
months  after the last  relapse, the sight was good in the
right eye; dim in the  left eye.  The ear-drums were said
to be congested, but she distinguished many sounds through
a trumpet, if one spoke loudly.   Often she could not dis-
tinguish both syllables of a two-syllable Avord, not even her
own name.   After the  first  efforts  her  deafness  again
seemed  to increase.  At this time she heard rather better
on  cold days than on  warm  days.  High-pitched  voices
hurt her.
                         Fig. 13.
With pen in left hand, November, 1894.
  On examination of the ears no perforation of the drums
was  found,  in  spite of the  free discharge from the ears.
Inflation of the Eustachian tubes Avas attempted, but could
not be borne. No effort at articulation was possible. Com-
paratively little food could  be taken, but it was swallowed
more freely, and some food was still given by injection.
  Although there was a gradual gain in flesh and strength,
sensation returned late in both arms above the  elbows.
The right hand recovered its motion and  held the work so 
HYSTERICAL CONTRACTURES.       265
as to enable her to use the needle with her left hand; or
else she would hold the pen in the right hand for writing,
and guide  the less active part Avith the left hand, seizing
it at the wrist.
  The limbs remained  unchanged, the feet crossed  and
drawn.  The patient lay nearly all the time at this period
on the right side, and could not bear lying on the spine at
all.  There Avere a great many rales in the right lung, and
what was described as emphysema and congestion, but the
pulmonary condition Avas better than a month before.  The
temperature was usually half a degree above normal; the
pulse always a hundred  or more, and easily increased.  The
girl at this time could not bear a temperature of OATer 60°,
whether natural or artificial, and had to have plenty of air.
The stomach could not  hold  much food at a time;  efforts
to feed her produced contraction and  pain and a threat of
return of bad symptoms.  The bowels Avere only moved by
copious enemata ; the discharges Avere sIoav and difficult, by
reason of Aveakness.  A good deal of mucus passed, fre-
quently in large shreds.   The bladder Avas subject  to invol-
untary and frequent passages.  The child was aAvare Avhen
these would begin, and  could sometimes, though not often,
start them, but could not stop them.  The skin had become
natural in  texture and of a • good color.  There had  been
no bedsores recently; there  had  been one on the head in
March, but it had healed up very readily.   The right ear,
I  should say, had a large piece Avorn out of the rim—a
deep notch caused by the jerking of the head on the pillow
in February and March of the year before.  This  had long
since healed.  The spine was very tender; the child could
not bear to  have it touched; the muscles alongside of it
 were also very sensitive.
   The mother added  that at  this time the girl Avas fifteen
years  of age; that she had  grown  symmetrically  in the
main ; that if she ever  walked she would not be noticed as
                           23 
266
NERVOUS DISEASES.
under-developed anywhere.   The feet Avere rather small,
but not deformed; and the  hands, like the feet, were of
good shape. The child's mind Avas phenomenally clear and
keen, her  memory  inexhaustible, and her  patience very
great.  Her intelligence, as her mother said, Avas  almost
clairvoyant.
  In December, 1894, this  child was brought to  me: a
bright, exceedingly intelligent, very pretty girl,  less thin
about the  face than elseAvhere, and sufficiently developed
for her  time  of  life.   There  Avas  general  emaciation,
Avhich  was most  marked  in the right arm; her  Aveight
at this time Avas about sixty pounds.  There Avas great con-
traction of the legs upon the thighs, so that the heels  lay
up  against the buttocks,  and the feet Avere  crossed, one
ankle over the other.   The contraction of the thighs upon
the pelvis was not much beyond a right-angle.  The knees
Avere closely drawn together.  It Avas impossible forcibly
to straighten  the legs, even  after complete use of chloro-
form, and the joints Avere secondarily affected, the knees
partially luxated.  The skin of the limbs about the ankles
and knees Avas thickened, shining, and smooth, and behind
the knee was excessively hard and tough, as though there
was infiltration of the areolar tissues, it being difficult to
feel the tendons distinctly.   The temperature of  the  legs
Avas good  above the knees, but the feet were  exceedingly
cold, although there  was  nothing remarkable about  the
nutrition of the nails, either in the feet  or hands. The
cutaneous, muscular, and tendinous reflexes were all absent,
and pins could be stuck in anywhere below the hips Avith-
out evidence of pain.  Neither Avas there any thermal sense
beloAV the groin or in the right arm.
  Over and above the contraction in the  muscles there
appeared to be also a true paralysis of motion below  the
knee, as the child was incapable of making the  slightest
exhibition of  movement of the toes or ankles.  She could 
HYSTERICAL CONTRACTURES.       267
lift and hold both arms up from the  bed.   She could not
grasp anything Avith  either hand, but Avith a little  man-
agement and  support could  hold  a  book.  There Avas
incomplete loss of poAver in the upper limbs to localize a
touch or to detect extremes of heat and cold.  Pain was
here unfelt, and there Avas analgesia over the Avhole trunk.
The biceps tendon-jerk and the muscle-jerk of the exten-
sors of the hand were, hoAvever, present.   Respiration was
normal, about eighteen to the minute;  the heart lungs,
and bowels Avere natural;  there Avas no evidence of organic
disease in the abdomen or elsewhere  ; the urine Avas normal.
The sight Avas  good at this time;  the pupils Avere equal,
moderately dilated, and reacted Avell to light and in accom-
modation.
                         Fig. 14.
<U  hud*
9

       With pen in right hand, guided by left hand, March, 1895.

  The child  declared that she was absolutely deaf, and
made no  attempt to speak.   She read her mother's lips
with ease, and mine with  more difficulty, explaining  that
it was on account of the moustache Avhich hides the lips.
  Dr. Archibald G. Thomson examined the eyes and ears, 
(35
Fig. 15.
E. M. H.  Attitude before treatment. 
~IG. Ifi.
E. M. H.  Attitude afler fifteen days' treatment.
to
to
«5 
270
NER VO US DISEASES.
and reported as follows:  O. D.  The media are clear; the
pupil clear and reacting normally.   The disc is normal and
color good, with a small central cup.  The vessels and the
fundus are normal, 4-1, with astigmatism.   The fields for
form and color are normal.   0. S.  The same as the right,
except that the  astigmatism is a little higher.  The mus-
cular balance is  slight.   Exophoria  due to Aveakness of
internal rectus.  There is no perforation of the tympanic
membrane or other gross lesion of the ears.
  This child remained at rest in bed on  her side always.
To be on the back caused  lumbar  ache.  Before  attempt-
ing any more serious step I  endeavored to  see how much
movement I could get in the legs by the continuous use of
massage  and faradic electricity.  Very soon I found  that
there was a slight increase of sensation e\rery where;  that
the limbs Avere beginning again to groAV; that they could
be draAvn doAvn each day a little loAver; and that  the  tem-
perature of the feet increased.   After a few weeks of this
treatment we ceased  to gain any further power of passive
extension of the  limbs, and it became obvious to  me that,
however reluctantly, I must resort to surgical interference.
  Meanwhile  her deafness interested me greatly.  It be-
came rapidly well in a few weeks. Speech came back  with
nearly as great speed, so that Avithin two months  after she
fell into my hands  she could speak  perfectly well,  could
hear entirely Avell, could see as Avell  as ever, and was recov-
ering pretty rapidly the use of the left arm and more slowly
of the right.  She had made also the great gain in motion
and sensation  in the  lower limbs above the ankles.
  At this time I requested Dr. Keen to make section of
the tendons of the  leg, one at a time, and this Avas  done
Avith great difficulty  under profound etherization; partial
straightening  of the  leg  was  accomplished  then  with
weights and apparatus, but not with the  ratchet.  There
has been a gradual extension of  the left leg, and it seems 
HYSTERICAL CONTRACTURES.       271
likely that it will  continue to improve, although the pre-
vious history prepared me to see at any time some return
of hysterical phenomena.
  On April 26, 1895, the  left leg Avas so much better that
Dr. Keen thought it Avould be well to operate on the right
leg.  Sections of the tendons at the  knee Avere made, but
it Avas found that the head  of  the tibia  Avas so luxated
posteriorly as to render impossible  such extension as had
been effected on the opposite side.  After a time a suitable
apparatus may overcome this unfortunate mechanical diffi-
culty ;  but much will depend  on her endurance, and  the
gain to be  hoped for from massage  and  electric  stimula-
tion.
  Of the draAvings,  Fig. 15 represents the attitude of the
child Avhen she  first came under my  care; Fig. 16 the re-
sults obtained by massage and electricity and slight exten-
sion by weights, up to the date of operation ; and Fig. 10
the position in  which she placed herself Avhen using her
pencil  or pen with her  mouth.  I also add facsimiles of
parts of letters Avritten with her hands and with the mouth
(Figs.  11, 12, 13, 14).
  As  a  clinical lesson in hysteria, nothing could be
more instructiATe than this record.   I have little doubt
that early isolation and resolute treatment Avould have
saved  these years of distress.   Before  Ave pass on to
consider the gravest symptom—the  general contractures
—I desire to call your  attention to the  fact of the ab-
sence of changes in the fields for color and form—surely
an  amazing thing in a case with so much anaesthesia.
Unlike the case first spoken of, the wasted leg-muscles,
especially the flexors, can be stimulated  by faradic cur-
rents ; but the current  that  moves them  so  slightly is
one that I cannot  endure,  and that painfully cramps
any of my muscles  on which I test it. Electro-muscular 
272
NERVOUS DISEASES.
sensibility  is very  much lessened.   Those muscles  of
the limbs  that  are  made tense  by long contraction of
their  opponents  scarcely  stir  at all Avith the utmost
poAver of a battery, but when I relax  them someAvhat
by forcible extension of the limb the extensors thus re-
laxed move better under faradic excitation.   This cor-
responds Avith the observations  reported  long  ago by
Morris J. Lewis and myself to the effect that forcibly
stretched muscles not only move badly under electricity,
but also do not feel  it as keenly.
  Had not these muscles been once Aveakened by tendon-
section and their sequent elongation I should have begun
by cutting them.  I felt that to cut these tendons again
might result in  further  additions to their lengths and
that I should run great risk of seriously disabling their
strength.   XeArertheless I Avas forced to take this risk.
In a long experience with hysterical contracture I have
never before come face to face Avith this difficulty.   Of
course, there is always the after-resource of shortening
the tendons.
  Seeing Iioav great is the power Avith which the muscle
in a state of spasm contracts, I used  to  fear that its
retraction after  surgical  section of tendons would be
excessive.   It is not so.   Rather does the sudden ces-
sation  of tension appear to put the muscle at rest, as
though the resistance were one of the means of keeping
up the pull made by the muscle.   I have, in fact, lost
the fear I once had as to section of hysterical  muscles
or their tendons.
  In  the  case of Miss C, of which  I  have  already
spoken, there Avas extreme pain in the feet. In another
case, to be presently described, there  was a  like tor-
ment.  In the one just now related there has been little 
HYSTERICAL CONTRACTURES.       273
or none.    The  reason is  clear, I  think:  Avhile the
flexion  at  the  knee is in this  latter  case extreme, that
of the thigh on  the trunk is  not.   In Miss C.'s case
not only were  the knee-joints at the  utmost angle of
acuteness  possible, but  the knees touched  the chin, as
was nearly the  case in the man in Scott Ward, of whom
I shall  have more to say by-and-by.  Now flexion at
the knee  only  relaxes  the sciatic  nerve, but extreme
flexion of the thigh on the trunk keeps the nerve tightly
draAvn over the edge  of the  notch, and may Avell be—
indeed Avas, I am sure—the chief cause of pain in two
of the cases referred  to.  In  both, tendon-section and
even partial extension of the limb speedily put an end
to the pain in  question.  In my last case  the absence
of pain is, I think, due to the lack of extreme flexion
of the thigh on the trunk.
  There are other interesting features in this case  Avith
which I can deal but lightly.   One Avas the rare symp-
tom  hysterical deafness.  It  Avas complete; nor did
the most unexpected and  violent sounds enable me to
detect the  patient in  simulation.   With  the use  of
Malony's ear-tubes she soon began to hear a little, and
Avith  her  general gain the deafness  speedily departed.
I should not, above all, forget to say that  for the first
time in her history she was isolated from her relatives.
  January 14,  1896.  From May, 1895, the patient was
absent in the country until  September, and since then has
been in  the  care  of Dr. J. K. Mitchell.  Her Aveight has
increased seventeen pounds. She has lost the indescribable
look  of  Avatchfulness so familiar in these cases.  Her will-
poAver is better;  she "has new  interests, and insists hope-
fully on her poAver to get well.   Her condition was at this
time as  folloAvs: 
274
NERVOUS DISEASES.
  She sits  in  a  wheel-chair, Avhich she moves Avith  ease.
She is rosy and in good condition, and Aveighs 101 pounds.
Her hand-movements are perfect.  The legs are better than
ever, and every movement is possible, although some  mus-
cles move less well  than others.   The reflexes are all  pres-
ent and  the knee-jerk  and  ankle-jerk are  present; all
nerves transmit  currents normally Avith faradic or syne-
soidal currents;  the leg-muscles show slight  quantitative
lessening of response.   The legs are still  flexed on the
thighs, but the angle thus made is becoming  Avider.  The
feet still drop a little, but the toes have perfect flexion and
extension.  Sensation is nearly perfect in all its forms.  Red
blood-corpuscles, 4,200,000.  Haemoglobin, .90 +.  Urine
normal.  The  Roentgen rays gave  an encouraging picture
of improvement  in the partially luxated knee.
  On January 15th Prof.  Keen  stretched the legs under
ether, and Avith such good results that  in a week she was
able to stand on crutches, and unaided to walk a feAV steps.

  I think  Ave may noAV feel assured that, if no intercur-
rent accident occurs, this patient will regain such health
of mind and body as will repeat the extraordinary results
of the very similar case of  Miss  C, already alluded
to,  and more fully recorded  in my Lectures on the
Nervous Diseases of Women.
  I have thought it svcdl to give unusually ample notes
of this  later record of  hysteria.   Xo more instructive
lesson can  be given as to the need for hopeful, persever-
ing treatment in a case of Avhat did seem at first beyond
all human aid. 
              CHAPTER  XVII.

      hysterical,  contractures (Continued).

  I dismissed last Aveek a case of contracture in Avhich
the legs were in extension.  I read you the notes as an
interesting contrast to the flexor-spasms  just described.
I like also to speak of this case because it illustrates one
very rational Avay of dealing Avith a partially developed
hysteria, for really, despite a long history, it was unde-
veloped.  A year or so more at home Avould have given
us another bed-case.

  Case LXV.—Annie P., unmarried, white,  seventeen
years of age, Avas sent to me for treatment, and Avas admitted
to the  Infirmary NoArember 3, 1894.   The family history
Avas negative.   She had  four  brothers and five  sisters
Avho were living and Avell.   The patient Avas a small child
at birth, but  ahvays enjoyed good health.  She had the
ordinary diseases of childhood, and a mild typhoid fever
and attacks of influenza in 1890, 1891, and May, 1892.
After partial recovery from the last  attack she suddenly
began to suffer from pain in the right heel and the arch of
the foot, with a feeling as of  a " large stone in the shoe."
Hot Avater gave relief.  The  pain  returned, and was now
better and again worse.  The heel, and indeed the whole
foot, and later the calf and the outer side of the thigh,
became very sensitive to touch, and Avere also the seat  of
much spontaneous pain.  Later, pain appeared in the left
heel and spread similarly.
  About one year after  the first attack the  girl was sud-
denly seized Avith  acute and severe  pain  in the sacrum, 
276
NER VO US DISEASES.
which soon affected the whole spine.  Motion of  the arms
and legs, she said, made the pain worse.   She noAV took to
her bed  (May, 1893).  Soon afterward she became rigid,
with the arms spread  out laterally, the head retracted, and
the legs extended.  Pain was then severe in all the extrem-
ities, but not alone in  the shortened muscles.   It gradually
grew  less toward evening, but the rigidity continued.  The
patient  was never  unconscious.  During the summer  of
1893  she recovered  sufficiently to Avalk a  little, but she still
had great back-pain and frequent relapses.'
  In  October, 1893, after walking "too far," she was given
a hot bath.  When taken out she fainted and had "heart-
failure," and  frequent  trouble with her heart afterward.
She was almost constantly on a bed or sofa from that time,
and had  occasional attacks of  asthma  during  the year
before coming under  observation.  Menstruation, regular
and painless before  the present trouble, Avas still fairly reg-
ular, but the flow was very dark and offensive, though quite
free.  Otherwise  there  were no  signs of  disease of the
genito-urinary organs.  The appetite was  fair, considering
the very  long confinement.   Digestion  was  good.   The
bowels were costi\re.
  Examination showed a  slightly built, anaemic-looking
girl, weighing eighty-three pounds.   She was very much
emaciated, especially in the legs.  The groAvth of  hair was
unusual and excessive for her age and sex, all over the body
as well as on the head.  The skin was in good order, and
the nails smooth and well formed.  All touch anywhere on
the legs andjfeet was painful, especially on the inner aspects.
This sensitiveness varied from time to time.  A slight touch
Avas painful;  pressure excessively  so.  The nerve-trunks
seemed no more tender than the muscles.  Two points were
nowhere  distinguished as such on the feet at less than an
inch and a half, and at a slightly less distance on the legs.
The temperature-sense was normal.  The  abdomen Avas not 
           HYSTERICAL CONTRACTURES.        277

sensitive, and there Avere  no hysterogenic areas in the
ovarian regions, nor any typical disturbance of the color-
fields.
  The girl Avas Avithout pain in the arms.  There Avas ap-
parently a slight thickening about the spinous processes in
the lower dorsal region, and the processes were excessively
sensitive.  The Avhole spine and  the gutter on both  sides
for a distance of an inch and a half or two inches Avas very
tender, Avith areas of exquisite hypersensitiATeness  between
the shoulders, at the waist, and over the  Avhole  sacrum.
Firm pressure Avith  the palm of the hand over the sacrum
Avas less painful than  touch.  Use of the  arms, she said,
increased the spinal pain and tenderness.  The knee-jerk
was slightly increased, and easily reinforcible by motion,
sensation, and emotional excitement.  There was no clonus.
Elsewhere the muscular and all other reflexes were normal.
A presystolic murmur was heard  at  the base of  the heart
and along  the left side of the sternum, and faintly in the
axilla and  at  the  apex.   The pulse, which Avas soft  and
wanting in  fulness and  force, varied  from 100 to 120.
Respiration varied from  30 to 50.  The blood-count was
2,500,000 ; the color 75 per cent.

   It  is rare  to  see so great sensitiveness to touch as
Miss P.  exhibited,  and still more rare to find the mus-
cular tissue sensitive.   As to contracture, the condition
found Avas rare and curious.  The extensors and flexors
of  the lower limbs all  felt firm, but the result of  this
general contraction was rigid stiffening of both legs in
extension.   The feet were  less  remarkably  stiffened
than  the  legs.   The arms were no longer in a state of
contracture.  All  efforts to flex and, after flexion, to
extend the legs  met with that  continuous  yielding
resistance common in spastic states, and to which long
ago I gave the name  of " lead-pipe" symptom.
                           24 
278
NER VO US DISEASES.
  At my  second  visit I ordered the girl  to  walk,  and,
despite her disbelief in her poAver to obey, she Avas  able
Avith small help to get  up and take a dozen steps, during
which the heels did not touch the  floor.   Tavo years on
bed or couch made this exertion difficult.   Having  once
given her reason for hope, I put  her back in bed, and for
two weeks  forbade exercise,  while  massage, tonics,  and
good diet  were employed.  She gained rapidly in  flesh.
The corpuscular  blood-count  doubled after a  Aveek  of
massage j1  all the functions began to resume their orderly
action.  She was then alloAved as a favor to rise and walk,
and two weeks later Avas able to go  home in excellent
condition.

  In the  present case  I began by insisting that  this
bedridden  girl should  walk.   I showed her that she
could do  so, and promised  her that the  pains in the
back  and leg would leave as she greAv more and more
able to exercise.   Had  I failed as to my predictions I
should have doubly injured the case, but  when one has
had a long experience Avith  hysteria it is easy to select
the cases for abrupt exercise of authoritative influence.
There were  doubts and  tears,  but  she walked, as
ordered.
  There is much to dwell  upon in the several  cases I
have brought before you.   But now it is,  above all, the
prognosis and treatment to which I desire to call atten-
tion.   Charcot has said that very marked decrease  of
faradic contractility ought to make us suppose that the
spinal cord has been invaded, and that the existence of
a spinal organic  lesion of more or less gravity will be
placed almost beyond doubt, if, under the influence of

 1 See paper by John K, Mitchell on the Influence of Massage on the
Blood-count  American Journal of the Medical Sciences, 1894. 
HYSTERICAL CONTRACTURES.       279
deep sleep induced by chloroform, rigidity of the mem-
bers only gives  way slowly, or even  persists to any
marked extent, or if with this the faradic reactions are
greatly lessened.
  You  Avill  have seen that I do not altogether agree
Avith this great student of  disease, and  that I approach
these cases  in  a  far  more hopeful  mood  than I could
do  if I accepted the despair which his dictum would
bring.
  The treatment need hardly  be set  forth  in detail.
Above all, get your hysteric  patient  away  from her
audience.   A hospital-ward is  no place for her.  But
if you cannot deal with her elseAvhere,  treat the case as
commonplace or  trivial,  and  call  no  attention  to  it.
For the rest, all the toning means are of use, and there
are moral tonics not to be neglected,  but for Avhich a
prosperous hour must be chosen.
  It is Avell to say that the  more you can improve the
nutrition  of  joint, muscle, and nerve  by mechanical
and electric  tonics,  the better will  be your chances of
success when at  last section of  tendons  becomes de-
sirable.
  I have put  aside  a fiual case of  contracture in the
male because of  the doubts I long entertained as to its
origin.
  Case LN VI.—W. H. G., aged thirty-three years, an un-
married railroad-clerk, was  sent to me by Dr. W. S. Beebe,
of Kirkwood, N.  Y.   Dr. J. E. Talley has  made the fol-
lowing notes of his case: The man's  father is  living and
well.  His mother died of typhoid fever at fifty-seven years
of age.  He has one sister, in good health.   There are no
known family diseases worthy of record.  The patient him-
self had  the ordinary diseases of childhood,  excepting 
280
NER VO US DISEASES.
scarlet fever.  He had pneumonia at  nine  years of age.
He never  drank to excess, nor has he ever abused the
tobacco-habit.  He certainly has had no syphilis.
  The series of ailments that ended in ai hat you see began
with bronchitis in 1890.  His physician said that at the
time he Avas run down  from  overwork, and ordered him to
take a vacation.   He Avent away for two months  and re-
turned to his desk feeling much better.   After Avorking for
a month, he was on November 6,1890, "seized with chills,"
and had three in succession.  After this he was confined to
bed for fourteen weeks, suffering from what was described
as "nervous  prostration."   He is said to ha\Te also had
some bronchitis.  It was not until five months later (April,
1891) that he was  out of bed permanently, and  able to
walk  with  the aid  of  two canes.   He was unsteady on
closing his eyes and Avhen trying to stand or Avalk in the
dark.  At this time, he tells  us, the knee-jerk was  present,
and this is probable, as the patient is very intelligent and
has studied his symptoms assiduously.
  During 1891 he got much better, and walked Avithout a
cane,  except when going  a  long  distance.   He still  con-
tinued to cough more or less.
  In March, 1892, he felt Avell enough  to go  down to El
Paso, Texas, to take charge of an  office.   There he lost
his cough, gained in Aveight, and was doing very Avell until
August, 1893, when a "very dear" friend and fellow-worker
died of haemoptysis.  The shock of  this loss, coupled  with
extra Avork, seemed  to  be too much for him,  and again he
began to fail, and to become on the least occasion emotional
even to tears.
  From September 1,1893, he  had pains in his feet, which
continued  until December, 1893, Avhen he took a mustard
foot-bath for their  relief.  On the following morning he
aAVoke to find  his legs drawn up at the knees, just as  they
Avere Avhen he came to me for treatment on March 15,1894. 
           HYSTERICAL CONTRACTURES.       28l

The thighs were rigidly draAvn up so as to touch the abdo-
men.   There Avas also spastic adduction of both thighs and
of the legs and flexion of the feet.  The contractions con-
tinued to  become more complete and  more rigid.   As to
sensation at this time the man can tell us as to this nothing
of value.
  On admission to the Infirmary the contracted and sym-
metrically wasted state  of the loAver limbs described was
very apparent.  The  right foot was flexed firnjly against
the buttock, a forcible pull on the  foot being required to
separate the heel from the buttock.   The left foot and leg
were in the same  position, except that the heel could be
separated  from the buttock a distance of a foot and a half
by force.  The hamstring tendons on both sides were very
rigid, as Avere also the muscles of the thigh and leg on both
sides.  He could move the toes of both feet fairly Avell, but
flexion and extension at the ankles Aveie limited,  every
muscle being rigid.
  The patient said that the wasting of the limbs Avas really
not great, as he had ahvays been very thin.  The circum-
ference at the middle  of the right thigh Avas 35 cm., of the
left 35 i cm., at the middle of the legs on both sides 10 cm.
The whole body Avas extremely emaciated.  The  hands
shoAved notable Avasting of the interossei muscles and of the
thenar and hypothenar eminences.  There Avas no clubbing
of the fingers.  The  dynamometer registered  55 in either
hand.  The spinal column shoAved nothing abnormal.  There
Avere scars of previous cauterization.
  Sensation was everyAvhere normal until Ave examined the
feet.  In the left foot sensation as to touch, pain, and tem-
perature was absent on the Avhole dorsum, the anterior third
of the sole, and the heel.   The mid-region recognized touch.
On the right foot there Avas an absence of sensation on the
first, fourth, and fifth  toes; touch was felt in the third and
fourth toes on both surfaces ;  also on the dorsum and on
                          24* 
282            NERVOUS DISEASES.
the sole generally, except at the heel.  It Avas  nowhere
normal on either foot, but improved above the ankle until
at mid-leg it seemed perfect.
   These facts are interesting, because there is no account
of early loss of  feeling.   It  seems certain, however,
that this anaesthesia must have been an early symptom.
The overwhelming  pain appears to have turned atten-
tion from the merely negative sign,  loss of  tactile sen-
sation.
   Pain had been felt in the legs before contraction came
on, but was never severe, and  was taken to be  rheuma-
tism.  The pain which came after the contractions had
lasted fifteen days Avas more severe and of  a different
character.   It grew to be at last the absorbing feature
of the case.
   There  have  been no  bedsores or evidences of  grave
trophic disorder.  Co-ordination Avas good in the arms and
fingers.  Station and gait, of course, were not obtainable,
the man being bedridden, nervous, and very emotional.
   The knee-jerk was not obtainable, nor could we get ankle-
clonus or muscle-jerks in the legs.   The epigastric, abdom-
inal, and cremasteric reflexes appeared to be normal,  as
was also the elbow-jerk.   The man has never had inconti-
nence of urine.  He has had  no priapism ;  and, in fact,
very seldom has an erection.  He has had throughout per-
fect control over the rectum.
   Dr.  Archibald G. Thomson  reported  upon the  eyes:
'' The pupils are equal and dilated.  They react in accom-
modation,  but not to light.   The media  are  clear.   The
discs are a trifle grayish, the arteries small.   The fundus
is  pale.  The muscular  balance is  good.   There is no re-
versal or contraction of the  color-fields."
   With the man on his back the chest-expansion was Ik
inches.  The percussion-note was higher-pitched above the 
           HYSTERICAL CONTRACTURES.        283

right  than above the left clavicle, and a full inspiration
heightened the pitch on the right side and but very little
on the left.   The whole right side moved less than the left.
Respiration was a trifle  harsh at the left apex, and expira-
tion was here prolonged and more marked than inspiration,
but of about the same pitch as elseAvhere.  There Avas very
little change in vocal fremitus and resonance on the left
side, but on the right chest  anteriorly the \'oice was con-
veyed much more clearly than elseAvhere.   On full  inspira-
tion there Avere moist rhonchi at both  apices, more  marked
on  the right.  Posteriorly the  eleventh  rib on the left
shoAved a prominence, as if it had been broken.
  On  having the  patient sit up it Avas observed that the
left nipple Avas slightly higher than the right.   The right
chest moved more (§ inch) than  the left during respiration.
A musical murmur, systolic  in time, was heard at the end
of expiration over the base and  at  the apex of the heart.
The apex-beat Avas  found to be in the fourth interspace,
with the greatest impulse at the  sterno-costal junction.
   Staining the sputum for tubercle-bacilli Avas  negative;
uranalysis also Avas negative.  The temperatures were rarely
over the normal line.

   It was evident that the lung-condition had nothing
to do with the paralysis.   There was much difference
of opinion as to the cause of these very interesting con-
tractures.  The absence  of a more distinct previous
hysterical history led some of our staff to regard the
case as possibly one of spinal  hemorrhage.
   As to treatment I had no indecision.  The  great
flexion of the thigh on the  pelvis, as in Miss C.'s case,
kept  the sciatic nerve stretched at  the notch.   There
was but one remedy.  As to what more we should win
beside relief  from pain I could not anticipate. 
284
NERVOUS DISEASES.
  At my desire, on March 29,1894, Dr. W. W. Keen oper-
ated on the  right leg, dividing the thigh-muscles at their
attachments to the pelvis; also the inner and outer ham-
string tendons.  He could not bring the leg to a straight
position even then on account of the rigidity of the parts,
and  for fear of  tearing the contracted femoral vessels.
The  limb Avas dressed, and a double-inclined plane and ex-
tension-weights applied.   The extension-apparatus sloAvly
accomplished its purpose, but was somewhat  hampered by
the development of a small bedsore over the sacrum as a
result of the necessity of  keeping the man  constantly on
his back.  This soon healed, and  the limb was then more
actively extended each day by increasing the Aveights.
  As this extension at once eased and soon put an end to
pain in the foot of the leg on which Dr. Keen had oper-
ated, it was thought well to treat  the other limb in like
fashion.  This was done on June 19, 1894, Avith equally
good results.
  The surgical  treatment  closed with section of both gas-
trocnemial tendons on December 7,  1894.   The patient
has noAV no pain, and has gained from day to day and
month to month in the straightening of the limbs, in moral
courage, and in increasing freedom from nervousness.
  Except  for an  attack of diphtheria, which necessitated
removing the man to the  Municipal Hospital, where he
stayed from December, 1894, until  January  22, 1895, he
has been making constant improvement.  His present state
(February 4, 1895) is as follows :
  A faint systolic murmur is  heard  over  the apex of  the
heart and at the base.  No circulatory disturbance exists.
The  lungs have cleared up.  There is no cough or expec-
toration. The blood-count is 4,900,000.  The haemoglobin-
value of the  blood is 95 per cent., and the man looks ruddy.
There is an absence of the neurotic facies.  The muscles are
less wasted, but firm, and  respond well to the faradic cur- 
HYSTERICAL CONTRACTURES.
285
rent everywhere, even in the legs.  There are no tender
spots on the body  and there is  no evidence of  neuritis.
The man  controls his boAvels and urine normally.  There
is no priapism or other abnormality of the genital organs.
The Aveight to-day  is 101 \ pounds, being a gain of only
6] pounds since admission to the  wards.
  There is still general emaciation, but the thighs and legs
are someAvhat more wasted than  other parts of the body.
There  are to  be seen the  scars of the operations  on  the
thighs and legs.  There are no excoriations, no clubbing of
the nails, or other  evidences of trophic disturbance other
than those caused by lack of use  of the muscles.
  The right thigh  is in a straight line with  the abdomen
as the  patient  lies on his  back.   The leg can be extended
to an angle of 170° Avith the thigh.   The  right ankle is
perhaps a little extended, the toes being slightly flexed.
  The left thigh is also in a straight line with the abdomen,
as is the left leg with the thigh as the man lies passively on
the bed.   The ankle, foot, and toes are in good position.
  Both thighs can be freely flexed, adducted, and  circum-
ducted, and there, is the same  voluntary control  over the
knees,  legs, and ankles.  The toes are less freely movable.
The man walked five  feet with the assistance of the nurse
and a chair to-day.  The grasp is good and equal, and no
other motor palsy exists.
  The patient has taken tonics, cod-liver  oil, etc., and since
September 17, 1<S!)4, he has  had  massage and movements
with faradism daily to the affected limbs.
  Early in April Dr. William J.  Taylor divided the mus-
cles on the inner side of both feet.  This Avas needed  be-
cause of the swelling and  pain in the  feet when the man
was long afoot, and which seemed due to the cramped form
of these parts.
  On  May 11, 1895,  the man Avas Avalking a little on
crutches and improving.   After exercise  the  feet were 
286            NERVOUS DISEASES.
still more or less painful.  He has steadily groAvn better
up to this date (June, 1895).

  The case, as you have heard it, does not enable us to
be sure as to the immediate cause of the trouble.  G.
has been asthenic—neurasthenic, if you please;  he re-
covers, goes South, and, as a railway clerk, is overtaxed
and much worried.   For ten days he has aches in the
legs, and aAvakens at last with his legs draAvn up.
  Are these  hysterical  contractures?   At first they
could  be relaxed under ether.  Must Ave accept Char-
cot's dictum that this is a certain sign of their hysterical
origin?  There was probably some early loss of  sensa-
tion, but if, as has been suspected, these spasms were
due to a  hemorrhage within or on the cord, we  might
Avell have had this symptom.   I confess that there was
too little disturbance to alloAV me to entertain the latter
diagnostic theory.   Here is a man Avho sleeps Avell and
aAvakens with great and increasing  contractions, and
probably with more or  less anaesthesia.   In time the
reflexes fail or lessen;  the electric reactions are quanti-
tatively diminished, and the mechanical reactions lost.
All this  might come from a neurotic, functional spasm,
and it all reads like the progressive story of an hyster-
ical disorder.  It differs in no wise  from the cases of
Miss  C.  and  Miss H., except that there are no other
hysterical  signals  flying.   Also in this  (G.) case the
reflexes  have come back, the electric reactions  are all
better, and here and there Ave can call  out movement
by a blow Avith the hammer.   At present G.'s legs are
straight, or nearly so, and  the muscles are all improv-
ing.   AVhere and when these gains will end I  do not
know; but certainly so  far, in the  light of treatment, 
HYSTERICAL CONTRACTURES.       287
the case does not read like one of organic disease of
the cord, nor like any form of neuritis.
   My conclusion is that in this case Ave have hysterical
contractions in the adult male, a rare phenomenon, in
this country at least, where we have the nervous tem-
perament, but are not neurotic to the extent seen in the
Latin races.
   Fortunately, cases of general contracture  are rare.
But, whether general  or  local,  if  they have  proved
during  four or  five  months  amenable to  no medical
means, then I counsel the use of  the knife and the sec-
tion of tendons.   It is true that Charcot and  others
have described cases in which, after years, contractions
ceased abruptly and the limb was as before. The state-
ment should have had a long  appendix of  exceptions.
In cases of  moderate contracture, not drawing the part
to an extremely acute angle, sudden recovery may leave
the joints undamaged; but  in grave cases this never
can be the case  with  joints like the knee, which  is
always  the most  difficult articulation to deal with.  A
long, Adolent  contraction of the flexors partly luxates
the tibia backAvard, and results in joint-changes which,
after years of contraction, are incapable of cure.
   In these knee-cases,  perhaps in all articulations long
out of  place, there is probably soon or late more  or less
of that kind of inflammation Avhich is also seen in joints
too long on a splint.  If this be so, a part of the quan-
titative failures to respond to electricity may  be due to
the muscular wasting so commonly observed in connec-
tion with damaged joints.
   But, Avhatever the cause, I have seen hysterical con-
tractions in which, after section of tendons, the joints
were too much altered to admit of  useful  restoration. 
288
NER VO US DISEASES.
The leg, bent at an angle of 45°, is brought, by section
and the screw, to a much larger  angle, but cannot be
made straight enough for use.   There is motion within
limits, but with Aveak muscles and bent legs  the  effort
needed for  walking becomes excessive.   Under  these
circumstances there may arise a question as to the pro-
priety of  making  the leg straight by an operation that
will leave it rigid.   Above all, I Avish to impress upon
you finally that a long-contractured limb is not a limb
to confide to the rare relief  brought or not brought by
time.
   I desire  to call  attention to certain  hitherto un-
noticed clinical facts :
   1.  Two forms of hysterical  contracture exist.   One
concerns  single parts aud limited groups  of  muscles.
In this the contracture may last for years without the
addition of  organic changes in  muscles, joints, or inter-
stitial  tissues.  In this variety, or species, if you like,
of the genus contracture, sudden cessation  of the spasm
is possible, or more  probable than  in generalized con-
tractures.
   2.  Another form of contracture exists which attacks
in succession one limb after another, until  soon or late
all or nearly  all  the voluntary muscles of the limbs,
as well as those of the trunk, may become involved.
The cases of this group do not, in my experience, ever
get well abruptly.   In them the muscles, joints, and
areolar tissues undergo serious  organic changes.
   In the first or limited form the muscles and the  mus-
cular reflexes remain unaltered or are but little changed,
and  mechanical and electric responses continue to be
normal or nearly  so.  In  the second or  generalized
form the muscle-muscle-reflexes, such as knee-jerk, are 
          HYSTERICAL CONTRACTURES.       289

lost  or  mechanically interfered  with late  in  the dis-
order, and the electric responses are quantitatively les-
sened, and may, in time, be almost altogether lost.   It is
only in  this form, after years of life in bed, that Ave
may expect to see changes in the cord.   Whether these
are merely independent accidents, or are the  rare sec-
ondary  products of the hysterical condition or  of  the
organic changes this occasions in the peripheral neiwes
and muscles, we do not yet knoAV.
   In both forms we may  expect to find  loss in  the
sensory function of the  skin, and more surely  in  the
generalized contracture.
25 
CHAPTER  XVIII.
 ROTATORY MOVEMENTS  IN THE  FEEBLE-MINDED.

  Most people, when seated, find some vague relief in
change of attitude.   Even  when lying at rest in bed
we still feel this need; long-continuance in one position
seems to make it agreeable to alter it.
  In some persons an excess of  this tendency is shown
in  constant restlessness;  with  some,  and  especially
among children,  it  exists remarkably during  sleep.
Certain persons incline to repeat  one  movement, and
find, in so doing,  the comfort most of  us  obtain  from
any change of posture.   The frequent repetition of a
movement  may  end  in its  becoming  masterful,  and
finally the habit may gain almost despotic control.
  The young are, naturally, the most liable to become
the victims of  such tricks  of  habit.  If they are prop-
erly cared for as children, they soon unlearn these mor-
bid ways; or, if uncared for,  they may carry them into
adult life.
  The acts I refer to may be very simple movements,
but  sometimes they are  or come to  be  complicated
motions,  the origin  and continuance of which it is not
easy  to understand.  I knew a man who carried out of
childhood a curious  habitual action.   Always before
sitting down he walked once  around the chair.   If by
any chance he forgot to do so, he  must rise and  obey
the impulse.  He was ashamed of this habit, and would
loiter and move about to conceal the action, but always 
ROTATORY MOVEMENTS.          291
must  at last go  once  around the  chair.   Another
person, a woman,  sat down  only to rise,  and sit,
and so on, a dozen times before she could remain  at
ease.
  Somewhere on the boundary line between voluntary
and involuntary, or, rather, automatic acts, lie the move-
ments  seen  in the disorder I named habit-chorea or,
as others like to call it, habit-spasm.   In this a child
is subject to movements of  one or  another set of mus-
cles, and these are more or less capable of  control.  It
is a morbid  condition,  and usually curable.
  Whatever the source of any of these movements, it
is repetition which finally gives to  them the  power of
a habit.  At last to arrest such movement by force of
Avill  becomes  difficult.   A  vast sense of  relief  arises
when we yield  to  the tendency to repeat a  habitual
motion.  Increasing discomfort attends upon the refusal
to obey the habit-born impulse.  I have seen a  girl's
arm tied to  the waist by a mother  resolute to  break up
the habit of rubbing  the  top of her head; a violent
attack  of hysteria folloAved.
  In  some  cases the  smaller, simpler habit-acts are
more easy to overcome than are the larger  and compli-
cated movements, like the spinning habit.
  If the whole range of these semi-automatic or impul-
sive movements is to be  found  in  the  ranks of the
healthy, it  seems obvious  that  in  the mentally defec-
tive, a class indifferent to criticism and Avith  less will-
force at command,  we should  find them in their most
despotic forms.   Indeed,  in  the  young  of  imperfect
mind these  habit-acts  are apt very soon to become im-
perative.   I fancy they are often semi-imperative from 
292
NERVOUS DISEASES.
the start, and are the offspring of suggestion or inher-
ited instincts.
  Among the defective who are found at Elwyn1 are
numerous illustrations of  many varieties of  the forms
of movement of  which  I  have  briefly  spoken.  At
present I desire  to ask attention especially to the rare
cases  of  Dervish  movement, which I hesitate to de-
scribe as spasm without further knowledge of hoAV far
these acts were primarily irresistible or hoAV far they
have  become so  from frequent repetition.   It is con-
ceivable that in the slackly  governed organization of  a
defective  child these motor habits in Avhich a certain
pleasure is  found may arise and  dominate  far more
readily than in those of sound mind.
  The cases I  shall relate differ, and  each must  be
studied by itself.   I have  myself seen elsewhere two
cases  of  tendency  to  spin in  Avhich  the  children
were  in perfect  health  of  body  and  mind;   both
were  girls.   When, in  one  of these cases, the mother
realized that an ungovernable habit had been formed,
the child, then about ten  years old, was  brought to
me for advice.   At  first the girl had merely rotated
until  giddy,  as  many children like to do.  Finding
some  satisfaction  in  it,  she  took  to  rotating  when
alone, and at last became  remarkably expert.   She
confessed that she  liked  it, and  would  go where,
unnoticed, she  could spin  unseen.   By this time the
habit  had become so  despotic that when  kept  with
other and older people she would jump up of a sudden
and  spin furiously  until she was  forcibly stopped.
When long controlled  she  became  strangely restless,
and, if allowed a minute's  spin, seemed to be at once
      1 The Pennsylvania Institution for Feebleminded Children. 
              ROTA TOR Y MO VEMENTS.          293

comforted.   This child Avas easily cured by a long stay
in bed.   There Avere no evidences  of  hysteria, and it
Avas  most unlike the case of hysterical gyration which
I have elseAvhere related.
  Defective children or adults  avIio  rotate  evidently
derive a certain amount of enjoyment from their aston
ishing feats,  whether  the motion be  the imperative
result of  organic  disease or only a habit long undis-
turbed by disciplinary or other interference.   There is
also  added  the distinctive satisfaction obtained by the
Aveak-minded when  able to  attract observation or to
excite surprise.

  Case LXVII.—L. H, female, aged sixteen years, came
to the Pennsylvania  Training School for Feeble-minded
Children from the almshouse.  The maternal grandparents
were  intemperate.   The father Avas also a drunkard and
abused the  mother before conception  and  during preg-
nancy.  There are two  other children living, a  boy and a
girl—the latter is an inmate  of the  Elwyn School; a sister
died at eleven months in convulsions.
  The patient was born  at term ; labor Avas normal.  She
was nourished at the breast  three  months by the mother,
and  then, strange to  say, se\-en  months by the  maternal
grandmother.  She Avas a sickly baby, and had convulsions
from  the fifth until the eighth month of life, but has had
none since.
  In late childhood, but  exactly when is unknown, Dervish
spinning, as  described beloAV, appeared.
  She is now a small, pale-faced child.  No palsies, no atro-
phies.  Teeth  fair.  No signs of  septic  taint.  Heart and
luno-s normal.  All bodily functions are performed  nor-
mally.  She has not yet menstruated.  Her vocabulary is
small aud her speech is someAvhat indistinct.   She is active,
                         25* 
294
NERVOUS DISEASES.
noisy, and  heedless of  danger.   She is  also nervous and
restless.  She  is destructive and dangerous as to fire, and
is  apt to stray from the Home.   She attends the  school,
and  understands readily  what is  said to her and obeys

                         Fig. 17.
promptly, but her physical  and mental restlessness is so
great that she cannot improve much in school-work.
  The  station with eyes open or shut is good.   Knee-jerk
normal.  The pupils are equal and react to light and with 
ROTA TOR Y MO VEMENTS.           295
accommodation.  Sensation is normal, and  there are  no
physical deformities.   She has occasionally some involun-
tary twitchings of the face.
  The most interesting symptom in her case is the habit of
Dervish spinning.  Many times  daily  she  suddenly rises,
walks  to the middle of the  room, rests upon one heel
(usually the left one),  the  toes  being  raised, and then
rotates, usually to the left,Avith extreme rapidity, her dress
rising like the governor of a steam engine, as shown in Fig.
17 ;  her arms are either clasped upon the chest or Avidely
extended, and  her  right foot beats  the  floor  to keep up
the rotation.  While  spinning,  her place  on   the  floor
changes but little; there is almost no forward, backAvard,
or lateral progress.   The duration of the spinning  varies
from fifteen minutes to a half-hour.   There is usually no
acceleration  of  her normal  pulse (90) or of  respiration
(20).  While rotating, her eyes  remain closed.  There is
no evidence of vertigo.  She is able after a half-hour's spin
to walk away  on a perfectly straight  line.  There  is no
evidence that she is under the influence of any imperative
impulse, nor are the movements  forced.  It seems like a
natural act.  If in  good humor,  she  will spin  or cease to
spin at command ; if in bad humor,  she  will refuse to
obey either  request.   When asked why  she spins, she
answers (and her intelligence is  sufficiently to  be  relied
upon)  that she " likes  it;  it is  fun."  Her sister will, if
requested, go through the same movements, but does them
clumsily.
   When  seen  by  me after  thirty minutes' spinning  her
pulse  had risen  from 90 to  115, but the respiration  did
not  rise in like  proportion.  When asked to spin  to the
right she tries it, but is unable to do it Avith ease or as long
as she  is able to rotate to the left.  The motion is so in-
conceivably rapid  that two of us failed  to count the rate
of the spin. 
296
NER VO US DISEASES.
  Case LXVIII.—H.  F. was admitted to the Pennsyl-
vania Training School for Feeble-minded  Children  from
the almshouse  on May 30, 1877, Avhen  five years of age.
He was healthy when born, but at four  months of age he
fell twelve feet and had spasms from that time ; occasion-
ally they lasted for two weeks.   The mother was born in
Ireland; the father was a native of Philadelphia.  There
were  two healthy children,  younger than  the  one  here
spoken of.   Paternal grandfather Avas insane.
  The patient  was small of stature, light weight, and a
demi-microcephalic, an  epileptic, and a mute idiot.   He
had general convulsions three or four times a month.
  The boy is interesting or remarkable only for his automa-
tism,  which existed when he was admitted. At  all times
he was  subject  to odd motions of the hands, but periodi-
cally during the day  he Avould give an exhibition of the
habit, which has given him the name of " The Dervish."
This began Avith tapping his chin with his left hand, deli-
cately and rapidly, touching the fingers  of his left hand to
the wrist of the right, making  two or three salaams,  after
which he began to gyrate from  the left to the right.  The
right  heel acted as a pivot, and the rotation Avas kept up
by touches of the  left toe or heel to the floor.   The turns
varied from three to  seven, with intervals of a salaam or
two between every set of rotations,  and lasted for a long
while.   Fifteen minutes  or more Avere thus passed before
he  darted away toAvard a AvindoAV, where he remained a
feAV minutes in  a fixed  or dazed state,  from which  he
aroused to recommence his hand tricks,  perhaps liking to
stand on  a  broad belt of  sunlight, so as the better to dis-
play his hand, Avhich he watched Avith some appearance of
enjoyment.  He suffered from cataract of the right lens,
and possibly partial amaurosis of the left eye.
  A supplemental performance was to stand in one place 
ROTATORY MOVEMENTS.          297
and throw the head and shoulders  from side to side, de-
scribing with  the forearm two-thirds of a circle, Avith the
occiput set  back as far as the neck  would permit.  In
none of these  performances Avas it thought that conscious-
ness was abolished or suspended.
  He seldom lost his balance and could walk very straight
the moment he stopped spinning.   He  has been knoAvn to
make 2000 revolutions in an  hour.
  In 1886 he seemed to  be failing, and became too Aveak
to spin.  About this time he became almost blind—quite
so in one eye.   The only improvement noticed in the effort
to train him Avas that his habits Avere more  cleanly.  His
hearing was very acute.   He could distinguish voices in a
crowd Avhen there Avas a great deal of noise, and he would
respond Avhen  a familiar voice  called him by name.  His
head  was  inclined almost  constantly  to  the left.   He
seemed to have an idea of  self-preservation, though he
appeared oblivious of what Avas going on around him.  He
died in a spasm on October 14,1890.  The spasms were
ahvays unilateral, and  alternated,  first on the right, then
on the left side.
  Post-mortem   examination.   Body well nourished, skull
normal,  demi-microcephalic,  scalp  very  thick.  Dura
mater so  firmly adherent to  the skull-cap along superior
longitudinal sinus that the sinus was torn open on remov-
ing the bone.  Right hemisphere fairly well developed and
apparently healthy.  On the left side the  occipital lobe
was entirely destroyed, as was  also  the left anterior one
and part of  the superior parietal and supramarginal lobe ;
a thick-Availed cyst supplied their place.   The left tem-
poral  lobe Avas hard, white, and shrunken.  The remaining
portions of the hemisphere exhibited the atypical arrange-
ment of the convolutions often seen in brains Avhere devel-
opment has been interfered with very early in life.  Hemi- 
298
NERVOUS DISEASES.
opia must in this case have existed since the origin of  the
lesion.
  This case I never saw.   I am indebted for the notes
to Dr.  M.  W.  Barr, the  physician in  charge of  the
Elwyn Asylum.
  The  motions  were probably imperative, but even as
to so plain a case of organic disease it is difficult to feel
secure as to this point.   It is not stated that, like  the
last case, the eyes were kept shut while he rotated,  nor
is the  rate of  motion given.   It is said to  have been
very rapid.
  Case LXIX.—Male, aged thirty-two years.   This man
is a medium-grade imbecile.   His station  and gait  are
steady.   Knee-jerks,  pupillary  and  other  reflexes  are
present.   There  are no  sensory or motor  disturbances.
He is  robust and works continuously under  the guidance
of an  attendant.  There is no  deformity of head, spine,
or extremities.   The  thoracic and abdominal viscera pre-
sent no  symptoms or physical signs of disease.   Scars on
the chest and back are suggestive of syphilis, but there are
no distinct evidences of the condition.  The tongue is clean
and protrudes straight, and there are a few scars upon  this
organ, the result of  injury during previous  epileptic fits.
His sight and hearing are good  and he talks quite readily,
but  his answers to questions are somewhat incoherent  and
wandering.  He  seems of mild disposition, but is subject to
outbursts of temper, which may come on abruptly.   There
are no fixed hallucinations.
  When working or while eating  he  suddenly stands  up
and turns once  around slowly;  then he sits down or goes
about his occupation with an air of apparent mental relief.
He never turns  to the right, and the motion was not  re-
produced at suggestion. 
ROTATORY MOVEMENTS.          299
  This patient is intelligent enough to tell me that he
is unable to resist the  impulse to rise and turn around
as described.   When  asked to get up and turn he re-
fused to do so ;  but after a time, which was variable,
he leaped up of a sudden, turned once, or  even twice
(which  is rare),  and  then quietly resumed his work.
Occasionally while walking he executes the same single
rotatory motion,  and then moves on as before. 
 
INDEX.
PROF., operation by,  /RATLIN on relation of pain to
 A LLEN
A  258
Anaemia, pernicious, 133, 142
Anaesthesia, hysterical, 281
    psychic. 17
Anatomy of sciatic tract, 159  .
Anhalonium, symptoms of, 61
Anosmia. 19
Anxiety of prae-dormitium, 67
Arthritis in hemiplegia, 146
    in hysterical disease, 287
Ataxia, cerebellar cause of, 130
    Gowers on, 131
    hysterical, 142
         on awakening, NT
    motor, in a child, 125
    muscle sense in, 137
    pernicious anaemia and, 133
    retained reflexes in, 137
Aura, visual, 84
    with sensory shocks, 81
DAILLARGER  on  hallucina-
D  tions of prae-dormitium, 60,
    61
Ball, Dr. M. V., 32
Barr, case by, 298
Bennett on sensory auras, 83
Blindness, hysterical, 253
    psychic, 15
Blood-letting in melancholia, 47
Briquet on hysterical ataxia, 141
Bromide  causing  homicidal im-
  pulses, 63
Burr, case by, 182
    on local temperature-changes
      from position, 207
    post-mortem notes by, 143
\J  weather, 162
Childbed causing sciatica, 157
Chorea, eye-examination in, 227
    hysterical, 94
    in sleep, 85, 86, 87
    of habit, 96
    on waking, 87, 89
Clark on eye-strain, 224
Cold-sensations,  cases of,   115—
      117
    causes of,  111
    classification of. 107
    from neuritis, 120
         of cauda,117
    hysterical, 122
    in buttocks, 112, 113
    intensified capacity  to feel,
      121
    Mills on,  124  _
    of central origin, 108,  111
    Putnam on, 123
    subjective, in peripheral neu-
       ritis,  112
    with elevation of tempera-
      ture,  113, 117
    with unchanged  tempera-
      ture,  112
Color-fields  in  hysterical  para-
      plegia, 35, 75
    normal, in hysteria, 270, 282
    reversal of, 106
Contracture, hysterical, 242, 275
    anaesthesia in, 261, 266
    cases, 249, 275, 279
    differing forms of, 246, 288
    ending  in sclerosis, 243
    multiple,  of hysteria, 244
    painful, 281
26 
302
INDEX.
Contracture, probably not spinal
      in origin, 243
    reflexes in, 245
    reflexes absent in,266
    resembling   poliomyelitis,
      246
    Richet on, 247
    symptomatology of, 243
    tenotomy for, 248, 284
Cooper, Sir Astley, 110
Cuba, seasonal  melancholia  in,
  43
Curvature, spinal, with insanity,
          210
         cases, 212, 215, 216
D
AY-NUMBNESS functional,
 Deafness, hysterical, 253
 Derby on e^e-strain, 221
 De Schweinitz,  eye-examination
       by, 20, 96, 138,  190, 214
     eyes in chorea, 227
     on sleep-ptosis, 77, 78
 Diaphragm,  spasm  of,  in  hys-
   teria, 253
 Dyer on eye-strain, 221
 Dysaesthesia on waking, 70
 Dyschromatopsia, hysterical,  75,
       106
     in hysterical palsies, 36
     J.   K.   Mitchell  and   de
       Schweinitz on, 36


   EPILEPTICS, eyes of, 227
     Erythromelalgia, 177
         blood-pressure in, 195
         cases of,  178,  181, 185,
           197
         compared   with  Ray-
           naud's disease, 179
         incurability of, 190
         morphia in, 197
         surface-temperature   in,
           197
         with  gangrene of foot,
           197
         with  sciatica, 172
Examination,  post-mortem,   of
  spinning case, 297
Eye-strain as cause of headaches,
  220
Eyes in chorea, 227
    in epilepsy, 227

  FAILURE, respiratory, in sleep,
    91
Feeble-minded,  rotatory  move-
  ments in, 290
Fere,  cases by, 73, 75
Foot-fidgets, 86


pERIIARDT on erythromelal-
U  gia, fso
Glycosuria in melancholia, 51
Gowers on ataxia, 131

   HABIT-CHOREA, 96
    diet in,  98
    eyes in, 227
    treatment of, 98
Hall,   Dr. P.  S.,  post-mortem
  notes by, 203
Hallucinations of prae-dormitium,
  62
Headaches and eye-strain, 220
Heat-sense, loss of, 266
Hemianopsia, hysterical, 20
Hemiplegia, arthritis in, 146, 150
    nocturnal, 68
    node in, 150, 151
    nodes following. 145,149
    pain as a prodrome of, 143
         as a sequel of, 143
    subjective coldness in, 111
Hewson  on  anatomy of  sciatic
  tract, 159
Hip-disease  simulating sciatica,
  158
Hurd on recurrent melancholia,
  42
Hyperaesthesia. hysterical, 276
Hypnotism in melancholia, 34
Hysteria, anaesthesia in, 281
    ataxia of, 87. 142
    contracture in, 242, 279
        multiple in, 244
    dyschromatopsia  in, 35, 75,
      106
    eyes in, 35, 75, 106, 270, 282 
INDEX.                       303
Hysteria, myoclonus in, 99
    sclerosis following, 248
    sensations of cold in, 122
    with locomotor ataxia, 133

IMPULSE, homicidal, due to
I          bromides, 63
         in  melancholia, 46
Insanity, relation of  prae-dormi
  tium to, 59
Insomnia from eye-strain, 223


 JACKSON,  Professor Samuel,
v      on recurrent melancholia,
       55
    on   respiratory  failure  in
      sleep, 91
Joints,  post-hemiplegic disease
  of, 148, 150


   KEEN  and Morehouse on pain-
       misreference,  233
    operation by, 192, 270, 284
Kinnicutt, case by, 120
Knee-jerk, in ataxia, 131
    in sclerosis, 132
    reinforcement of, 132
Krafft-Ebing, melancholic  hyp-
  notized by, 34

   LANNOIS on  erythromelalgia,
     179
Leg-pain in sleep, 79

   MELANCHOLIA,  abrupt  re-
      covery in, 26, 37
    bloodletting in, 48
    caused by dream, 50
    during digestion, 51
    effect of menstruation on,  44
    heredity in,  28
    inter-menstrual, 47
         case of, 44
    irregular recurrent, 53
    menstrual, 44, 46
    of post-dormitium, 49
    predisposing causes, 27
    recurrent seasonal, 32
Melancholia, recurrent  seasonal,
      cases of,  32, 36. 37, 39, 40
    related to sleep, 49
    removal of ovaries  in, 45
    sensory delusions during post-
      dormitium, 49
    tends to recur, 31
    treated by hypnotism, 34
    with erotic impulses, 45
    with glycosuria, 51
    with homicidal impulse,  46
Melancholies, marriage  of, 29
Mills on cold-sensations, 124
Mind-blindness, 15
Misreference of pain,  231
Mitchell, J. K., and de Schweinitz
  on dyschromatopsia, 36
Mitchell, J. K., on misreference
      of pain, 234
    joint-lesions from spinal in-
      juries,  145
Morton, operation by, 159, 202
Movement-rate in ataxia, 138
Movements, imperative, 291
    rotatory, 290
    spinning, 292,  293, 296
Myoclonus, multiple,  99, 100
Muscle, pyriform,  share of, in
      producing sciatica,  160
    -sense in ataxia, 137
VAUSEA from eye-strain, 223
i-A   Neuritis as a cause of  ery-
          thromelalgia, 181,194,
          196
        changes of thermal sense
          in,120
        cold-sensations in,  112,
          117, 120
        sciatic, 155
        terminal, 194
Neuroses, ocular,  220
Nodes following hemiplegia, 145,
  149, 151
Numbness, hysterical, 73


  OCULAR neuroses, 220
     Olfaction, loss of, 19
Ormerod on numbness, 72 
304
INDEX.
  PAIN and weather, Catlin on,162
    as a prodrome of hemiplegia,
      145,147
Pain as a  sequel of hemiplegia,
      147
    misreferred, 231
        cases, 231, 233, 234
Paralysis from irritation, 76
    hysterical, 266
Paraplegia, hysterical, 35
Paresis, nocturnal, 68, 72, 75
Pearce on local temperatures, 207
Pershing, case by, 15
Pinel on  seasonal  melancholia,
  42
Post-dormitium, 59
    relation of, to insanity, 59
    sensory delusions in melan-
      cholia, 49
Prae-dormitium, Baillarger on, 60
    hallucinations in, 62
    olfactory disturbance in, 62
    relation of, to insanity, 59
    sensory shocks in, 83
    terrors in, 65
Pregnancy, delusion  of, in the
      insane, 239
    spurious, 236
Prentiss  on physiological  effects
  of anhalomum, 61
Pseudocyesis, 236
    cases, 236, 237, 238, 239, 241
    causation of,  239
    Hirst on, 238
    sympathetic vomiting of hus-
      band in, 241
    vomiting in,  238
Ptosis of sleep, 77
Putnam on cold-sensations, 123
   RANNEY, on eye-treatment of
       epilepsy, 228
Raynaud's disease, case of, 178
         compared with erythro-
           melalgia, 177, 179
Reactions, faradic, in hysterical
  paralysis, 278, 279  _
Reaction-time in ataxia, 138, 139
Reflex ocular neuroses, 220
Reflexes retained in ataxia, 128
Reinforcement of knee-jerk, 132
Richet on contractures, 247
Rigidity, hysterical, on awaking,
  90
Rotation, imperative, 298
Rotatory movements, 290
        cases of, 293, 296, 297
SAUNDBY on  sleep-numbness,
s
Schule, on recurrent melancholia,
  43
Sciatica, 154
    and erythromelalgia, 172
    cases of, 169, 170, 171
    childbed, 157
    diagnosis of, 154
    double, 170
    from   fecal  accumulations,
       156
    from pelvic growth, 156
    from pressure  during deliv-
       ery,  156
    from tumor, 159
    hours of exacerbation, 161
    influence of position on, 158
    of central origin, 175
    pyriform muscle's  share in,
    .  160
    simulated by hip-joint  dis-
       ease,  158
    treatment of, 164
         bandage, 166
         blisters, 167
         cautery, 167
         cocaine, 165
         dry cups, 165
         ice, 167
         massage, 167
         morphine, 165
         nerve stretching, 175
         splint-rest, 165
Sciatic nerve, anatomy of, 159
Sclerosis, knee-jerk in, 132
    post-hysterical, 248
Sensory shocks, 80
Sharkey on  misreference of pain,
  232
Shocks, auditory, 81
         and sensory, 81 
INDEX.
305
Shocks, olfactory, 81, 83
    sensory, 80, 81
        in daytime, 83
    visual, 81
Sinkler on numbness, 72
Sleep disorders, 58
    -jerks, 85
    -numbness, 68
        in neuritis, 71
        with pain, 71
    -pain, 79
    -ptosis, 77, 78
    respiratory failure in, 91
    -shocks 80, 82
        double auras in, 84
        prae-dormitium, 80
        olfactory, 83
             aura in,84
        visual aura in, 84
Smith,  Dr Andrew H., on sleep-
   numbness, 68
Spasm, tonic, on waking, 89, 90
Stevens on refractive lesions, 225
Surface-temperatures,  205, 207
Starr, case by, 37
Syphilis,  sciatica due to, 156
Tenotomv for  hysterical contrac-
      ture, 272
    in ocular neuroses, 229
Thermometer for surface-temper-
  atures, 205
Thermometry  of  erythromelal-
  gia, 201
Thomson on astigmatism causing
      headache, 226
    A. G., eye-examinations bv,
       L28, 267, 282
Tobacco  causing sleep-jerks, 86
            -shocks, 82
Tyrell on eye-strain, 224
UREA lessened in acute  melan-
  cholia, 56
\rASO-MOTOR paralysis of ex-
V   tremities, 177
Vertigo from eye-strain, 223
Vomiting, sympathetic, in hus-
  band, 241
Visual-fields in hysteria, 36, 75,
  106
TAYLOR, J  M., case  by,  169
 1         170
        on  anomalous   sciatic
           nerves, 159
    W. J., operation by, 285
Temperature, difference of, on two
      sides, 206
    influence of position on, 207
xyAKING-NUMBNESS, 70
 m      cases of, 72, 75
        following  nerve - freez-
          ing, 71
Waking tonic spasm, 89
Weather and pain, 162
Witmer on reaction-time, 138 
 
 
 
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CLINICAL MANUALS.  See Series of Clinical Manuals, page 14.
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COLEMAN (ALFRED).  A  MANUAL OF DENTAL  SURGERY
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CORNTL (V.).  SYPHILIS: ITS  MORBID  ANATOMY, DIAGNO-
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CULBRETH (DAVID M. R.).  MATERIA MEDICA AND PHAR-
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CULVER (E. M.) AND HAYDEN (J.R.).  MANUAL OF VENE-
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DALTON (JOHN C).  A TREATISE ON HUMAN PHYSIOLOGY.
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----DOCTRINES OF THE CIRCULATION OF THE BLOOD. In
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DAVENPORT  (F. H.).   DISEASES OF WOMEN.   A  Manual  of
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DAVIS' (EDWARD P.).  A  TREATISE ON OBSTETRICS.  FOR
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DAVIS (F. H.).  LECTURES ON CLINICAL MEDICINE.  Second
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DE LA BECHE'S GEOLOGICAL OBSERVER.   In one large octavo
    volume of 700 pages,  with 300 engravings.  Cloth, $4.
DENNIS  FREDERIC S.) AND  BILLINGS (JOHN S.). A SYS-
    TEM OF  SURGERY.  In  contributions  by  American  Authors.
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DERCUM  (FRANCIS  X.,  EDITOR).    A  TEXT-BOOK ON
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    plates.  Cloth. sti.Od  ; leather, S7.00.  (Net.)  Just ready.
DE SCHWEINITZ (GEORGE  E.).  THE TOXIC  AMBLYOPIAS.
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    Very handsome  octavo, 240 pages, 46 engravings, and 9 full-page
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DRAPER (JOHN C).  MEDICAL PHYSICS.   A Text-book for Stu-
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DRUITT (ROBERT).  THE PRINCIPLES  AND  PRACTICE  OF
    MODERN SURGERY.  A new American, from the  twelfth London
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    volume of 965 pages, with 373 engravings.  Cloth, $4 ; leather, $5.
DUANE  ALEXANDER).   THE  STUDENT'S  DICTIONARY  OF
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DUNCAN (J. MATTHEWS).  CLINICAL  LECTURES  ON THE
    DISEASES OF WOMEN.  Delivered in St. Bartholomew's Hospital.
    In  one octavo volume of 175 pages.  Cloth, $1.50.
DUNGLISON (ROBLEY).  A DICTIONARY OF  MEDICAL SCI-
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 EDIsat(ARTHUR W.).  DISEASES  OF  WOMEN.  A Manual  for
     Students and Practitioners.  In one handsome 8vo. volume of 576 pages,
     with 148  engravings.  Cloth, r3; leather, $4. 
6            Lea Brothers & Co.'s Publications.
ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY.
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    From the eighth and revised English edition.   In one octavo volume
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EMMET  (THOMAS  ADDIS).   THE PRINCIPLES AND PRAC-
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ERICHSEN  (JOHN E.).   THE  SCIENCE AND  ART  OF SUR-
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ESSIG (CHARLES J.).  PROSTHETIC DENTISTRY.  Just ready.
    See American Text-Books of Dentistry, page 2.

FARQUHARSON (ROBERT).  A GUIDE TO THERAPEUTICS.
    Fourth American  from  fourth English edition, revised by Frank
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FEELD (GEORGE P.).  A MANUAL  OF DISEASES OF THE
    EAR.  Fourth edition.  In one octavo volume of 391 pages, with 73
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FLINT (AUSTIN). A  TREATISE  ON THE  PRINCIPLES AND
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    by Frederick P. Henry, M D.  In one large 8vo. volume of 1143
    pages, with engravings.  Cloth, $5.00; leather,  $6.00.

----A MANUAL OF  AUSCULTATION AND PERCUSSION; of
    the Physical Diagnosis of Diseases of the Lungs and Heart, and of
    Thoracic Aneurism.  Fifth edition, revised by James  C. Wilson, M. D.
    In one handsome 12mo.  volume of 274 pages, with  12  engravings.

----A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS AND
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----A PRACTICAL  TREATISE ON  THE  PHYSICAL EXPLO-
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-----MEDICAL ESSAYS.  In one 12mo. vol. of 210 pages. Cloth, $1.38.

-----ON  PHTHISIS : ITS  MORBID ANATOMY, ETIOLOGY, ETC.
    A  Series of Clinical  Lectures.   In one  8vo. volume  of  442 pages.
    Cloth, $3.50.

FOLSOM  (C. F.).  AN  ABSTRACT  OF STATUTES  OF U. S.
    ON CUSTODY  OF THE INSANE.  In one  8vo. vol. of 108 pages.
    Cloth, $1.50. Also bound with Clouston  on Insanity.

FOSTER  (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New
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    leather, $5.50.

FOTHERGDLL (J. MILNER).   THE PRACTITIONER'S HAND-
    BOOK  OF TREATMENT.  Third edition.  In one handsome octavo
    volume of 664 pages.  Cloth, $3.75; leather, $4.75.

FOWNES (GEORGE).  A MANUAL OF ELEMENTARY CHEM-
    ISTRY (INORGANIC AND ORGANIC).  Twelfth  edition. Em-
    bodying Watts' Physical and  Inorganic  Chemistry.  In one royal
    12mo. volume of 1061 pages, with 168 engravings, and  1 colored
    plate.   Cloth, $2.75; leather, $3.25. 
Publications.             7
FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY.
    In one handsome octavo volume of 677 pages, with 51 engravings and
    2 plates.  Cloth, $3.75 ;  leather, $4.75.
FULLER  (EUGENE).    DISORDERS  OF  THE SEXUAL  OR-
    GANS  IN  THE  MALE.  In one very handsome octavo volume of
    238 pages, with 25  engravings  and 8 full-page plates.   Cloth, $2.
    Just ready.
FULLER (HENRY).  ON DISEASES OF THE LUNGS AND AIR
    PASSAGES.  Their Pathology,  Physical Diagnosis, Symptoms and
    Treatment.  From  second English edition. In one 8vo. volume of 475
    pages.  Cloth, $3.50.
GANT (FREDERICK JAMES). THE STUDENT'S SURGERY.  A
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GD3BES  (HENEAGE).  PRACTICAL PATHOLOGY AND MOR-
    BID HISTOLOGY.   In one very handsome octavo volume of 314
    pages, with 60 illustrations, mostly photographic.  Cloth, $2.75.
GD3NEY  (V. P.). ORTHOPEDIC SURGERY.  For the use of Practi-
    tioners and Students.  In one Svo. vol. profusely illus.  Preparing.
GOULD (A. PEARCE).   SURGICAL  DIAGNOSIS.  In one 12mo.
    vol. of 5S9 pages.  Cloth, $2.  See Student's Series of Manuals, p. 14.
GRAY (HENRY).  ANATOMY,  DESCRIPTIVE AND SURGICAL.
    New and thoroughly revised American edition, muih enlarged in text,
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    of 1239 pages, with 772 large and elaborate engravings on wood. Price
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GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND
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GREEN (T. HENRY).  AN  INTRODUCTION  TO  PATHOLOGY
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    224 engravings and a colored plate.  Cloth, $2.75.
GREENE (WILLIAM  H.).  A  MANUAL OF MEDICAL  CHEM-
    ISTRY.  For the Use of Students.  Based upon Bowman's Medical
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GROSS (SAMUEL DA  A PRACTICAL TREATISE ON THE DIS-
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HABERSHON (S.  0.\   ON THE DISEASES OF THE ABDOMEN,
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    In one octavo volume of 554 pages, with 11 engravings.  Cloth, $3.50.
HAMILTON (ALLAN MCLANE).  NERVOUS DISEASES, THEIR
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HAMILTON (FRANK  H.). A PRACTICAL TREATISE ON FRAC-
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HARDAWAY (W. A.).  MANUAL OF SKIN  DISEASES.  In one
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8             Lea  Brothers & Co.'s Publications.
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----A HANDBOOK OF ANATOMY AND PHYSIOLOGY.  In one
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HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES.
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    Student's Series of Manuals,  p. 14.
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HILL (BERICELEY).  SYPHILIS AND  LOCAL   CONTAGIOUS
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HILLIER  (THOMAS).   A  HANDBOOK OF  SKIN DISEASES.
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HODGE (HUGH L.).  ON DISEASES  PECULIAR TO WOMEN,
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HOFFMANN ^FREDERICK) AND POAVER (FREDERICK B.).
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HOLI>EN  (LUTHER).  LANDMARKS, MEDICAL  AND  SURGI-
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HUDSON  (A.). LECTURES  ON THE STUDY OF FEVER. In one
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HUTCHINSON JONATHAN). SYPHILIS. In one pocket-size 12mo.
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JONES  iC. HANDFD3LD).   CLINICAL  OBSERVATIONS  ON
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JULER  HENRY. A  HANDBOOK  OF OPHTHALMIC SCIENCE
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KING (A. F. A.).   A MANUAL OF OBSTETRICS.   Sixth edition.
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KIRK (EDWARD C). OPERATIVE DENTISTRY.  Shortly.  See
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KLEIN (E.).   ELEMENTS  OF- HISTOLOGY. Fourth  edition.  In
    one pocket-size 12mo. volume of  376 pages,  with 194 engravings.
    Cloth, $1.75.  See Student's  Series of Manuals,  p. 14.
LANDIS (HENRY  G.). THE MANAGEMENT OF LABOR. In one
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LA ROCHE (R.).'  YELLOW FEVER.  In two 8vo. volumes of  1468
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LAWSON (GEORGE).  INJURIES  OF  THE EYE, ORBIT AND
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10
Lea Brothers & Co.'s Publications.
LEA (HENRY C).  A HISTORY OF AURICULAR CONFESSION
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LEE (HENRY) ON SYPHILIS.  In one 8vo. volume  of 246 pages.
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LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY.
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LEISHMAN (WLLLIAM).  A SYSTEM OF MIDWIFERY. Includ-
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LOOMIS  (ALFRED  L.)  AND THOMPSON  (W. GILMAN),
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LUCAS (CLEMENT). DISEASES OF THE URETHRA. Preparing.
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LUDLOW (J. L.).   A  MANUAL  OF EXAMINATIONS UPON
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LUFF (ARTHUR P.).  MANUAL OF CHEMISTRY, for  the use of
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LYMAN (HENRY M.).  THE PRACTICE  OF MEDICINE. In one
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LYONS (ROBERT  D.).  A TREATISE ON FEVER.   In one octavo
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MANUALS.   See Student's Quiz Series, p. 14,  Student's Series of Manu-
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MORRIS (HENRY;.   SURGICAL DISEASES OF THE KIDNEY.
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MULLER (J.).   PRINCIPLES OF PHYSICS AND METEOROL-
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NATIONAL DISPENSATORY. See StiUi, Maisch & Caspari, p. 14.
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OWEN   (EDMUND).  SURGICAL DISEASES  OF CHILDREN.
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PEPPER'S SYSTEM OF MEDICINE.  See p. 2.
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12           Lea Bkothers &  Co.'s Publications.
PLAYFAIR (AV. S.).   A  TREATISE ON  THE SCIENCE  AND
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---- THE SYSTEMATIC TREATMENT OF  NERVE PROSTRA-
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POLITZER (ADAM i. A TEXT-BOOK OF THE DISEASES OF THE
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QUIZ SERIES.  See Student's Quiz Series, p. 14.
RALFE  .CHARLES  H.).  CLINICAL   CHEMISTRY.  In  one
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REICHERT (EDWARD T.).  A TEXT-BOOK ON PHYSIOLOGY.
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-----A COURSE OF PRACTICAL HISTOLOGY.   New edition, re-
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16
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WOHLERS OUTLINES  OF ORGANIC CHEMISTRY.  Translated
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YEAR-BOOK OF TREATMENT FOR 1896. A Critical  Review for
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