LECTURES 
 
 ON 
 
 DISEASES OF THE NERVOUS SYSTEM, 
 ESPECIALLY IN WOMEN. 
 
LECTURES 
 
 DISEASES OF THE NERVOUS SYSTEM, 
 
 ESPECIALLY IN WOMEN. 
 
 S.' WEIR MITCHELL, M.D., 
 
 MEMBER OF THE NATIONAL ACADEMY OF SCIENCES J 
 
 PHYSICIAN TO THE ORTHOPEDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE 
 
 NERVOUS SYSTEM ; 
 
 FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; 
 
 MEMBER OF THE NEW YORK ACADEMY OF MEDICINE J 
 
 ASSOCIATE FELLOW OF THE AMERICAN ACAHEMY OF ARTS AND SCIENCES OF BOSTON 
 
 HONORARY MEMBER OF THE STATE MEDICAL SOCIETIES OF NEW YORK, 
 
 NEW JERSEY, AND MARYLAND; 
 
 HONORARY CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIATION ; 
 
 HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY J 
 
 HONORARY MEMBER OF THE ST. ANDREW'S MEDICAL GRADUATES' ASSOCIATION J 
 
 FOREIGN ASSOCIATE OF THE ROYAL MEDICAL SOCIETY OF NORWAY ; 
 
 AUTHOR OF A TREATISE ON INJURIES OF NERVES, ETC. ETC. 
 
 v~ 
 
 WITH FIVE PLATES 
 
 n? 
 
 vc 
 
 
 B1 \ 
 
 
 PHILADELPHIA: 
 HENRY C. LEA'S SON & CO 
 
 1881. 
 
J*' 
 
 Entered according to Act of Congress, in the year 1881, by 
 
 HENRY C. LEA'S SON & CO., 
 
 in the Office of the Librarian of Congress. All rights reserved. 
 
 
 \'fr 
 
 f 
 
 
 COLLINS, PRINTER. 
 
DEDICATED TO 
 
 J. HUGHLINGS-JACKSON, M.D., F.R.S., 
 
 WITH WARM PERSONAL REGARD, 
 
 IN GRATEFUL ACKNOWLEDGMENT 
 
 HIS SERVICES TO 
 
 THE SCIENCE OF MEDICINE. 
 
 1* 
 
PREFACE. 
 
 The lectures which compose this volume deal 
 chiefly with some of the rarer maladies, or forms 
 of maladies, of women. Many of them are original 
 studies of well-known diseases, and others deal with 
 subjects which have been hitherto slighted in medical 
 literature or which are almost unknown to it. 
 
 I desire to express my thanks for very valuable 
 aid to my colleague Dr. "Whartox Sinkler, to 
 Professor Horatio C. Wood, to Dr. Louis Starr, 
 and especially to Dr. Morris J. Lewis. 
 
CONTENTS. 
 
 LECTURE I. 
 
 THE PARALYSES OF HYSTERIA. 
 
 PAGE 
 
 Paraplegia — Hemiplegia — Bilateral hemiplegia — Electric re- 
 actions in hysterical palsies — Treatment . . . .13 
 
 LECTURE II. 
 
 HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS. 
 
 Briquet's hysterical ataxia — New forms of hysterical ataxia — 
 Forms of paresis ........ 34 
 
 LECTUKE III. 
 
 MIMICRY OF DISEASE. 
 
 Causes of mimicry — The hysterical state — General nervousness 
 — General failure of health — Psychic peculiarities — Natural 
 mental and moral conditions favoring mimicry of disease — 
 Imitative vomiting — Imitative palsy — Mimicry of pain — 
 Imitative epilepsy — Imitative meningitis — Epidemic of 
 rhythmic chorea . . . . . . . .50 
 
 LECTURE IY. 
 
 MIMICRY OF DISEASE. 
 
 Hysteria in childhood — Simulated vomiting — Simulation of 
 hip-joint disease — Autobiographical confessions . .75 
 
CONTENTS, 
 
 LECTURE V. 
 
 UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN. 
 
 PAGE 
 
 Rotatory spasms — Functional spasms — Strychnic spasms — 
 Spasms on change of position — Local spasms simulating 
 tumors — In the pectoral muscles — In the walls of the 
 abdomen — In the gastrocnemius — Hysterical athetosis . 89 
 
 LECTURE VI. 
 
 TREMOR — CHRONIC SPASMS. 
 
 Hysterical tremor — Nervous tremor with organic disease of 
 the spine — Alcoholic tremor in nervous women — Chronic 
 spasm with simulation of local injury of ulnar nerve — Chronic 
 spasm of leg — Contracture of leg muscles — Chronic spasmo- 
 dic ptosis . ... . . . . . .106 
 
 LECTURE VII. 
 
 CHOREA OF CHILDHOOD. 
 
 The relations of the chorea of childhood — To season — To 
 climate — To locality — To race — Forms of chorea . .127 
 
 LECTURE VIII. 
 
 HABIT CHOREA. 
 
 Definition — Cases of habit chorea — Relation to chorea of 
 childhood — Treatment . . . . . . .146 
 
CONTENTS. XI 
 
 LECTURE IX. 
 
 DISORDERS OF SLKEP IN .NERVOUS OR HYSTERICAL PERSONS. 
 
 PAGE 
 
 Sensory shocks — Emotional shocks — Irregular motor dis- 
 charges — Nocturnal functional hemiplegia — Respiratory- 
 failures in sleep . . . . . . . .153 
 
 LECTURE X. 
 
 VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERVOUS 
 OR HYSTERICAL. 
 
 Pulse in hysteria — Agitation of heart followed by apparent 
 death — Eccentricities of pulse in the hysterical — Palpitation 
 of heart with Hushing of face — Palpitation of heart with 
 pallor of face — Surface ischemia — Vaso-motor paralysis 
 in the limbs or the face — Extreme vaso-motor paralysis 
 of the whole vascular system of the abdominal cavity — 
 Respiratory peculiarities of hysteria . . . . 1 74 
 
 LECTURE XL 
 
 HYSTERICAL APHONIA. 
 
 Paralysis of laryngeal muscles — Failure of coordination in the 
 various organs which combine to produce speech . .191 
 
 LECTURE XII. 
 
 GASTRO-INTESTLNAL DISORDERS OF HYSTERIA. 
 
 Comparative rarity of hystero-epilepsies in America — Diffi- 
 culty of feeding hysterical women — Troubles as to masti- 
 cation — Forms of dysphagia — Hysterical anorexia — Hys- 
 terical vomiting — Hysterical fasting — Defecation in hys- 
 teria 201 
 
Xll CONTENTS. 
 
 LECTURE XIII. 
 
 THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS- 
 TION AND HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC- 
 TRICITY, AND FULL FEEDING. 
 
 PAGE 
 
 Character of cases needing this treatment — Seclusion — 
 Nurses — Uterine disease — Ovarian disorders — Seclusion — 
 Rest — Massage — Electricity — Mode of feeding . .217 
 
 For Description of Plates, with. Remarks, see 
 pages 127 to 145. 
 

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DISEASES 
 
 OF THE 
 
 NERTOTJS SYSTEM, 
 
 ESPECIALLY IN WOMEN. 
 
 LECTURE I. 
 
 THE PARALYSES OF HYSTERIA. 
 
 The case to which I drew jour attention at my 
 last clinic is here again, a girl, rather wanting in the 
 signs of sexual ripeness, although sixteen years old. 
 You will recall the fact that she lost the use of the 
 right arm because of having been alarmed. The 
 scare brought on what every woman knows as an 
 attack of hj^sterics — our ancestors called it the vapors. 
 The girl cried and laughed by turns, and then had a 
 slight fit, on coming out of which she could no longer 
 lift her right arm, or rather she could lift it but a 
 few inches. On finding this to be the case, she grew 
 much concerned, and by and by could not lift it at 
 all, the idea that it could not be raised helping, as is 
 apt to be the case, to make the trouble worse. There 
 seems to have been no deceit, but perhaps the first 
 feebleness may have been slight, and the power of 
 her belief in her want of force great, and this is 
 
14 DISEASES OF THE NERVOUS SYSTEM. 
 
 rather the more likely since, as you saw, I raised the 
 arm and said, "Now you can keep it up," which she 
 did. You see that it seems again palsied. A new 
 order restores it, and she lifts it without much effort, 
 having won a belief in my being able to aid her. I 
 send her away with a lightly uttered word or two as 
 to the use of the hot iron, if she again loses power. 
 The warning may answer or may not. "We had a 
 case very like this two years ago. I believe it got 
 well. 
 
 We see here among the ill -fed, needy, and worried, 
 a good many cases of hysterical loss of power, and I 
 meet a yet larger number among women of the upper 
 classes, where the disease is caused by unhappy love 
 affairs, losses of money, and the daily fret and weari- 
 someness of lives which, passing out of maidenhood, 
 lack those distinct purposes and aims which, in the 
 lives of men, are like the steadying influence of the 
 fly-wheel in an engine. 
 
 It is my present wish to speak of some of the many 
 kinds of hysterical paralysis, and to dwell far more 
 freely on methods of treatment than upon minute 
 details in the natural history of these disorders. I 
 do this chiefly because as regards treatment I hold 
 very positive opinions, and because these opinions 
 have, I believe, been amply justified by happy re- 
 sults, some of which are familiar enough to those 
 who have followed my practice. 
 
 The group of instances of lessened power which I 
 shall here discuss will include the usual forms of hys- 
 teric paraplegia and hemiplegia, and that which I 
 shall call double hemiplegia. I shall not attempt to 
 
PARALYSES OF HYSTERIA. 15 
 
 cover the whole range of hystero-palsies, but seek 
 chiefly so to define a certain number as to allow me 
 to speak of their treatment. I shall also describe 
 four forms of seeming loss of power, only one of 
 which is essentially- hysterical in nature, and not 
 found elsewhere with the same features. I allude to 
 hysterical motor ataxia. 
 
 The others are palsy from the rule of an idea, gen- 
 eral paresis, and consciously mimicked palsy. 
 
 All three of these may be and are seen outside of 
 hysteria, but they find in it a fertile soil, and are none 
 the easier to treat when they are masking in this 
 disguise. 
 
 One of the chief troubles in clearly knowing and 
 in dealing with all of these forms of disease is due to 
 the fact that in most cases, and to some extent, they 
 may exist in union. The case of palsy may be partly 
 real, partly pure weakness, partly loss of power from 
 want of belief in being able to move ; or conscious 
 mimicry may be added to palsy or to the forbidding 
 influence of a regnant idea, or to the true hysteric 
 palsy may be joined ataxy of motion. For such vex- 
 ing marriages of disorders, and for their offspring of 
 doubt, we must be ready and watchful. They make 
 the true limits of hysteric lack of power hard to de- 
 fine, hard to treat, full of surprises, and unfailing in 
 interest and variety. Take this for an instance : You 
 have a case of extreme hysteric paresis to treat. As 
 a rule, it is readily cured. You predict a clear and 
 happy future. As time wears on the mere weakness 
 is gone, the limbs are plump again, the cheek red, and 
 then you may find, if you have not been careful, as I 
 
16 DISEASES OF THE NERVOUS SYSTEM. 
 
 have found, that hidden in the mere weakness there is 
 a distinct amount of motor palsy — a mild, one-sided, 
 loss of power — a true hysteric palsy, and not at all 
 easy to cure. I shall pick for you, out of my note- 
 books, cases of each of the forms of disease I have 
 just spoken of, and shall try to make plain to you 
 how I treat them. There were once no cases so much 
 dreaded by me. There are now none to which I go 
 with so much pleasure. I am sure that I treat them 
 to-day with a success I could not once have gained, 
 and I think that what success I have had has been 
 due to more exact ideas as to what is needed, and 
 that unflinching purpose and action which grow out 
 of distinct views. 
 
 Let us take first a case of paraplegia — less common 
 than hemiplegia and more difficult to relieve. The 
 example I shall quote for you is the more interesting 
 because of its having ended in death. 
 
 Mrs. C, ddt. 36, a strong woman, and in all ways 
 well, lost by sudden death a child and her husband. 
 Thus having cast on her the care of a large estate, 
 loaded with many burdens, she began to show excess 
 of anxiety as to her affairs, and from being sweet of 
 temper became abrupt and full of unreasonable doubt 
 as to her advisers. The worry brought with it speedy 
 loss of blood globules, and as she was a woman who 
 flowed very fully each month, all these causes together 
 began to tell. This is the kind of thing we see much 
 of in medicine. The books say this, that, or the other 
 causes hysteria. In practice it is usual to find two or 
 three causes — acting to assist one another. This 
 woman was quite ready for an outbreak of some form 
 
PARALYSES OF HYSTERIA. 17 
 
 of nerve trouble, when of a sadden she met the final 
 blow in the form of a telegram. The news it bore 
 was neither good nor ill, but by evil luck the writing 
 looked like that of her dead, husband, and she began 
 to laugh with that strange want of appropriateness 
 in emotional expression so common in the nervous. 
 Awaking next day her legs seemed heavy, which 
 caused her great alarm. At once, as she told me, the 
 fear of palsy arose in her mind, and haunted her the 
 more as, day by day, the feebleness grew worse. She 
 was in Germany when taken ill, and seems to have 
 been looked upon as suffering from an organic mal- 
 ady, for she was treated with nitrate of silver and 
 the hot iron. Then as she failed to get relief any- 
 where, she was sent from one spa to another with a 
 skill which as yet we are fortunately far from being 
 able to reach. 
 
 St. Moritz, Schwalbach, Vichy, Loueche, and 
 springs of lesser note, had each their turn, after the 
 European fashion, until, in despair, she was carried 
 back to America, where I saw her often and until 
 the close of her life. 
 
 This was what I found : A woman of 35, height 5 
 feet 2 inches, weight 170 lbs., flabby, and thin blooded, 
 with healthy heart, lungs, and kidneys. On the left 
 side of the vagina was felt a tumor about the size of 
 a walnut. It was very tender, and firm pressure on it 
 gave rise to nausea and distress down the left leg. I 
 had no doubt that this growth was a displaced ovary, 
 but, despite this change of place, the left iliac fossa, 
 both the skin and the parts reached by deeper pres- 
 sure, was tender to touch. Was it ovarian tender- 
 
 2* 
 
18 DISEASES OF THE NERVOUS SYSTEM. 
 
 ness ? Hardly, in this case. I have been told by Dr. 
 Groodell that he has seen this same sensitiveness in 
 other instances where the ovary had been displaced, 
 and probably too much has been and is made of this 
 symptom. The tenderness in Mrs. G.'s case was iso- 
 lated, as is not unusual, and all about it up to the 
 waist and down to the feet the body was without 
 sense of touch or pain, or of heat and cold. In 
 tracing this defect upwards it was found to cover the 
 left breast, but this was so to-day, and then to-morrow 
 it was less, the upper limit ranging from the navel to 
 the left armpit. 
 
 Motor power was failing when I first saw her, but 
 this had been the case before, and had been followed 
 by a change for the better. 
 
 The plan pursued in treating the case was one to 
 which I groped my w r ay a few years ago. My patient 
 was very thin blooded, and yet very fat. Such cases 
 for some reason not clear to me are more hard to 
 redden than are those of thin people in like states of 
 blood. But if you can safely cause these persons to 
 lose flesh, as they are helped to remake it, you may 
 sometimes redden them with ease, and to raise the 
 number of blood globules to the normal is usually to 
 lift a woman above that low level of health, which 
 is one, at least, of the factors of hysteria. 
 
 Mrs. C. was, when first seen b}^ me, sitting up most 
 of the day, and sewing, writing, and the like, when not 
 too nervous. I put her in bed, and employing as a diet 
 milk alone, mixed with a little rice-water or barley- 
 water, I began to lessen the amount given, until, 
 using less than a quart a day, her weight fell off at 
 
PARALYSES OF HYSTERIA. 19 
 
 the rate of about a quarter to half a pound a day. 
 When she showed signs of weakness I added beef 
 soup to the diet for a day or two, and thus in one 
 month brought down her weight some twenty-four 
 pounds. This could not with safety be so quickly 
 done unless the patient were kept inert and supine. 
 Then the milk w r as by degrees increased. Raw beef 
 and vegetables were added, malt extract was used 
 before meals, a little red wine or champagne was 
 allowed, and iron was given freely, the feeding being- 
 frequent. When I made the increase in diet I began 
 to arouse sensation by the use of the wire brush and 
 induction currents. 
 
 Now in common palsies, or in those from nerve 
 wounds, feeling is apt to come back first, motion last; 
 but in hysteric palsies, as I think, the gain in active 
 motion may go on, and even reach a useful amount 
 while yet the lack of feeling rests as it was when 
 the treatment began. Just this change took place 
 in Mrs. C. : She grew brighter, and more happy, 
 gained in color and flesh, and began to move her legs. 
 In a month after she reached full diet she could walk 
 with some trouble, and about this time the sense of 
 touch showed signs of betterment, but the power to 
 feel pain was unchanged, and, in fact, was never com- 
 plete in the left leg. 
 
 Next began a plan of steady, urgent calls upon her 
 for increase of the use of her limbs, so that before 
 long she was able to walk out of doors. At this point 
 I fear there was a mistake made in the treatment. 
 Thinking the battle won I pushed her too hard, and 
 one day after walking much further than usual she 
 
20 DISEASES OF THE NERVOUS SYSTEM. 
 
 felt an excess of fatigue. Returning home she gave out 
 of a sudden, and the morning after was again hardly 
 able to stir either leg. I may pause here to repeat 
 as to this matter a warning I have often given. It is 
 to urge on you the utmost care as to allowing a hys- 
 terical patient on the way to health — I mean, of 
 course, one who has lost power — to do more each day 
 than fulfil the ordered task of that day. Most cases 
 of hystero-paisies are easily tired, and it is almost 
 sure to be the case that they cannot make a long 
 effort without showing the effect in some way ; more- 
 over the mental results of extreme tire are to be 
 feared, because any positive, real sensation is apt to 
 become the peg, so to speak, on which the patient 
 may hang the complement of a larger and less real 
 sensation. 
 
 More slowly this time Mrs. C. got back some con- 
 trol over her movements, but at a certain point the 
 gain ceased, and we made no further progress, nor 
 did this surprise me. Hysterical paraplegia is, as I 
 have said, more hard to cure than any other hysterical 
 trouble except, perhaps, multiple contractures, and I 
 felt that I had done well to win what I had won. 
 
 About six months later this lady died after a brief 
 illness, which seemed to me more like a sudden and 
 complete palsj^ of the pneumogastric nerves than any- 
 thing else. No examination post mortem was allowed. 
 I have known three deaths in hysteria ; all were ab- 
 rupt, and two were due to acute congestion of the 
 kidneys. 
 
 Of that more common type, the palsies of one side 
 of the body, you have seen a number. They are 
 
PARALYSES OF HYSTERIA. 21 
 
 more frequent than paraplegias; less hard to cure, 
 but quite lasting enough to make you cautious as to 
 what you predict about their future. Where they 
 occur in the feeble and thin-blooded, who have by 
 degrees grown emotional, tearful, and weak of will, 
 you may have more hope of helping them than if 
 they are met with in robust people of non-emotional 
 type, in whom the usual emotional elements which go 
 to build up this temper of mind are wanting, or are 
 small in amount. The former offer through the re- 
 lief of their nutritive defects chances of obvious 
 nature; the latter are apt to be bright or even able 
 women, who enlist their mental forces in behalf of 
 their symptoms, and treat the hated charge of being 
 hysterical with utter scorn. 1 
 
 I cannot leave this subject of hemipalsies of hys- 
 teria without a few words as to the ordinary type of 
 this disorder. 1 shall therefore sketch for you some- 
 what briefly the chief symptoms of hemiplegia of 
 hysterical origin. 
 
 This disease may come on slowly, and during the 
 varied course of a case of hysteria, or it may arise 
 abruptly, in an instant even, in women known or not 
 suspected to be hysterical, owing to some profound 
 emotion or to an accident, such as a fall or a wound. 
 It is often of such insidious development that its 
 presence, when mild, is a thing rather to be found by 
 
 1 I ought, perhaps, to add that these women are usually mohile 
 and excitahle hy nature, prone to laughter more than tears, so that 
 it is hardly exact to say they are not emotional. Their form of too 
 ready emotional disturbance lies merely in an unusual direction 
 for the victims of hysteria. 
 
23 DISEASES OF THE NERVOUS SYSTEM. 
 
 looking for it than of such a nature as to be forced 
 upon the attention of the observer. It is excessively 
 rare to see it as complete as we see a hemiplegia of 
 organic origin. Nearly always, I might venture to 
 say always, it is associated with some loss or distur- 
 bance of sensation. More often this latter symptom 
 is the dominant one, and the lack of power merely 
 amounts to a paresis or incomplete palsy. 
 
 Unlike the hemipalsy of cerebral and organic cause, 
 hysterical half-palsies involve more or less all of one 
 side of the body, excepting the face ; but in a few 
 rare cases the neck is distinctly affected, while usu- 
 ally when the case is incomplete, it is the leg which 
 suffers most, both as to sensation and motion. 
 
 Apart from the fact that the face escapes there are 
 other symptoms which differentiate these losses of 
 power from those which are due to clots or emboli, 
 and a knowledge of which enables us to diagnose the 
 case with sufficient ease, as arising from hysteria. As 
 to locality, in Briquet's cases there were 70 on the left 
 to 20 on the right; in my own note-books, I find the 
 proportion as 4 left to 1 right. The amount of loss 
 of power is often quite definite, but in other cases it 
 varies in degree within wider ranges than we see in 
 palsies of organic birth. 
 
 Sensation is disturbed, lessened, or lost either 
 throughout the one half of the body or in varying 
 amounts over this space, and in the face as a rule less 
 than elsewhere. In rare cases, the sensibility improves 
 very near the middle line of the body. In some in- 
 stances no feeling exists ; more often sense of touch and 
 power to localize sensations remains with profound 
 
PARALYSES OF HYSTERIA. 23 
 
 analgesia, and often also with lack of power to tell 
 heat from cold. In bad cases the eye loses its keen- 
 ness of perception, and the color sense is blunted 
 while smell and taste alike suffer. 
 
 The ovarian region on one side is apt bat not cer- 
 tain to be tender, either on the surface or upon deep 
 pressure. Charcot and Dr. Buzzard both state that 
 the patellar tendon reflex is exaggerated on the side 
 of the palsy, and the latter that the ankle clonus may 
 at times be met with. In the last three cases I have 
 seen of hysterical hemipalsy the patellar tendon re- 
 flex was increased on the affected side. In two others 
 it was notably lessened, as was the case in the girl 
 present at my last clinic, where it was only possible 
 to be sure that this sjnuptom existed at all by grasp- 
 ing the muscles with one hand while the blow was 
 struck. In another case the flexors responded and 
 not the extensors ; and in yet another, with an exag- 
 gerated reflex, there was also a sharp contraction of 
 the adductors on both sides. 
 
 These symptoms, with the history, should make 
 the diagnosis an easy one, and I may add that while I 
 see many mistakes made, owing to confounding hys- 
 teric paraplegias with those of organic cause, I rarely 
 see such confusion as regards hysteric hemiplegia. 
 
 The following case, now in the Infirmary, may 
 serve as a fair type of this form of paralysis. Miss L., 
 a fine, large, ruddy woman of 26 years of age, owes her 
 hemipalsy to the shock of a fall from affluence to the 
 need to support herself by giving lessons in music. 
 Then a succession of deaths fell upon her household, 
 and at last one day, while teaching, she fell asleep, as 
 
24 DISEASES OF THE NERVOUS SYSTEM. 
 
 it were abruptly, at about 7 A. M. She was aroused 
 enough to be taken to bed, and there remained in 
 what seemed to be profound slumber, thirteen hours. 
 After this unusual trouble she grew more and more 
 hysterical, and at last came under my care. Her 
 organs are, in general, healthy; but she has this 
 curious peculiarity, of which she seems quite un- 
 aware. The pulse varies from 80 to 95, but the 
 respiration, without seeming to be hurried or dis- 
 tressed, is never less than 40, and is often 60 to the 
 minute. 
 
 She has considerable loss of power, with incom- 
 plete analgesia, defect of thermal sense, and preserva- 
 tion of touch. The face is scarcely affected at all, 
 and the senses of sight, smell, and taste are intact. 
 What is curious is, that there is no ovarian tender- 
 ness on either side, and that the analgesia varies 
 daily, almost hourly, as to extent, place, and amount. 
 A mustard plaster or blister, or, more remarkably, a 
 rhigolene freezing, will often restore feeling over a 
 large space for a few hours or for days; but inva- 
 riably the next menstrual flow undoes whatever 
 good may have been done. I tried the " metal cure" 
 in this, as I have tried it over and over in other and 
 worse cases; but although from it, or from glass, 
 cork, wood, or what not, I have obtained many times 
 a slight local change in feeling, I have never seen 
 this complete, and have never once witnessed the 
 phenomenon of transfer of the analgesia or anaesthesia 
 to the opposite side — a phenomenon which seems to 
 be undeniably frequent in the hands of as admirable 
 an observer as Charcot. I ought to add that my col- 
 
PARALYSES OF HYSTERIA. 25 
 
 league, Dr. Sinkler, has not been in this matter more 
 fortunate than I, although lie lias, I believe, studied 
 several cases from this point of view. The patient I 
 have mentioned lias many other hysterical troubles, 
 and being quite rosy and stout, will be a difficult case 
 to deal with. It is interesting to learn that until this 
 girl came here neither she nor her medical attendants 
 were aware that she had any loss of feeling. 
 
 The temperature of the left, the affected leg, is nor- 
 mal, or the same as the other, and pin-pricks fail to 
 bleed at any part of the limb where there is lessened 
 feeling. The tendon reflex of the patella is remark- 
 ably exaggerated on the palsied side, but there is no 
 ankle clonus. Under use of good diet and tonics this 
 girl is gaining color and weight, while by a succession 
 of irritants, chiefly the wire-brush and induction cur- 
 rents, the sensation has been more and more success- 
 fully restored, so that the last menstrual flow has 
 been less disastrous than usual. 
 
 I shall not trouble you further with details of this 
 the most common type of hysteric hemiplegia, but 
 pass on to one of the forms not well described as yet, 
 and which I shall, in advance, venture to call double 
 hemiplegia. This, as we shall presently see, is not 
 merely another name for paraplegia. 
 
 Miss B., a sturdy, handsome girl, set. 16 years, had 
 a series of ills one on another from time to time. 
 The first sign of trouble was twitches of the ej^elids, 
 and tears on reading ; then there was a pause of two 
 years. The next disturbance was a noisy and obsti- 
 nate hiccup, during which both iliac fossae became 
 tender, and a single hypodermic use of morphia Avas 
 3 
 
26 DISEASES OF THE NERVOUS SYSTEM. 
 
 followed by convulsions. Next came hysteric loss of 
 desire for food, nausea, pains in the left arm and leg, 
 and spasm of the vessels in the left leg, so that it be- 
 came white and cold. Up to this time she still walked 
 out; but in the summer of 1878 the use of galvanism 
 is said to have been followed by sick stomach and loss 
 of power to stand. In the autumn she got rid of im- 
 mense masses of hard feces, when all the symptoms 
 improved for a time. The next winter was passed in 
 bed, vomiting a good deal; eating little; the bowels 
 very hard to move; the urine passed every hour. 
 About this time also she began to shun light, and 
 came at last to living, with covered eyes, in a dark- 
 ened room. When I saw this young lady I was 
 struck with the thorough type of the emotional hys- 
 teric person she showed ; nor from the usual weak 
 will to the usual love of sj^mpathy was there any tint 
 wanting to the picture. I watched her for a few 
 days without ordering treatment until I learned all I 
 could of herself, her history, her home-life, her pur- 
 suits, her ambitions, and her mental powers. Then 
 a talk with a watchful nurse helped me further,- and 
 I saw clearly that I had to do not with a clever 
 woman who may be won over, and who is flattered 
 by the tribute paid to her mind when you insist that 
 to cure her she must be made to understand and 
 agree with you, but with a child who to be made well 
 had to be calmly and firmly ruled, and held day by 
 day to rigid account. She was at once shut up, with 
 a good nurse, and kept at rest in bed, not being 
 allowed to use her hands even to feed herself. As 
 she had been able to knit and sew, and be read to, 
 
PARALYSES OF HYSTERIA. 27 
 
 and to receive many visits, the sense of the irksome- 
 Bess of the treatment soon made her eager to do any- 
 thing I wished. Then began a system of bribes. 
 She was told that if she could learn to bear the light 
 she would be able to be read to, but that the nurse 
 could not be allowed to strain her eyes. It would 
 have been easy to open the windows and say jou 
 must bear the light, but if she herself gained this 
 point of vantage, it would have the great value of 
 being a self-conquest. In a few days I found the 
 sunlight bright in her room. Then she was asked to 
 overcome the habit of regurgitating her food. One 
 or two scoldings, some show of disgust, and the pro- 
 mise that she should soon feed herself if she obeyed 
 my wishes, helped us through with this. There were 
 relapses; but as I found she hated milk I felt forced 
 to put her back on the milk diet we began with when- 
 ever she threw up a meal, so that before long we 
 heard no more of the vomiting; meanwhile the steady 
 feeding and the use of massage, and local muscle treat- 
 ment by electricity, began to show in a gain of flesh 
 and color and firmness of muscle. She was now very 
 weary of this unending quiet, and the time for educa- 
 tion of the motor powers seemed to have come. Her 
 loss of motion on the left side was very marked, and 
 there was complete want of power to feel pain or to 
 tell heat from cold ; yet I could not make out any 
 loss of vision or of color-sense. The touch was not 
 perfect, but she knew fairly well where she was 
 touched, although she could not be tickled. 
 
 As regards the pain sense there was one very curious 
 point to which I have already alluded. As the needle 
 
28 DISEASES OF THE NERVOUS SYSTEM. 
 
 came within an inch or two of the middle line of the 
 body it was felt, and the better felt the nearer it came 
 to this line; nor do I recall having met with this 
 fact in any case of palsy from organic canse. The 
 right side of the body was palsied in a less degree, 
 and only as to motion, the leg far more than the 
 arm. The same was the case on the left side as 
 regards all the forms in which the functions were 
 deficient. Now as this case grew better the right 
 side became entirely well first, leaving the left hemi- 
 plegia as before, so that I have reason to speak of 
 the whole loss as being due to a double hemiplegia. 
 In other cases I have seen a general loss of sense and 
 motion, and observed entire relief on the right side, 
 leaving only a hemiplegia of the left. 
 
 My patient had some wasting of the left leg, and 
 less good electro-muscular reaction on the left, but 
 no pain on that side from any form of current. The 
 tendon reflex below the knee-pan was good on the 
 right; and also on the left; but what was new to me 
 the jerk was sometimes due to the extensors, and 
 sometimes due to the flexors, the extensors in the 
 latter case not seeming to move at all. Here was 
 another of the oddities of this most strange disorder. 
 
 As is usual she moved her limbs best while in bed, 
 and showed, when I came to let her sit up, or stand, 
 the loss of balancing power, which is seen in all 
 grave hysteric palsies, and is, indeed, almost a sure 
 sign of the parentage of the disease. 
 
 I have often asked you to note another point which 
 this case showed very well. You ask the patient to 
 raise the leg. It is lifted an inch ; you insist on 
 
PARALYSES OF HYSTERIA. 29 
 
 effort, it is lifted higher; or if a great effort be made 
 the motion consists of a series of lifts and pauses. 
 
 The reliefs of distinct hystero- palsies are said to be 
 often abrupt. Under emotion or return of the men- 
 strual flow, or on an order from some one, the patient 
 gets well. I must say that in hystero-hemiplegia 
 and paraplegia, with loss of feeling, I have not been 
 so happy as to see these delightful cures. In hysteria 
 with mere paresis, in the palsies from belief, or from 
 a ruling idea, I have seen such results many times. 
 Neither do I believe that all hysteria is after a time 
 within control of the sick person ; nor that she can 
 in all instances run away in case of a fire, according 
 to a popular medical belief. In fact I have now in 
 my care a lady who was so tested by chance, and 
 who utterly failed to do more than fall down in her 
 effort to escape from a house on fire. 
 
 In fact profound emotions may work either way 
 for good or for ill, and no human sagacity will suf- 
 fice to enable us to predict results. The evil is quite 
 as likely to be prominent as the good, and at all 
 events you may rest assured that emotions are some- 
 what unmanageable and unreliable as therapeutic 
 agents. 
 
 I have felt the need to say this, even if too briefly, 
 because I must add that the cures of these cases are 
 to be made by a slow, steady, hopeful training of the 
 will powers through every-day effort, which needs 
 some caution not to err in the way of excess. A 
 little nervousness is a bad sign, and it is well each 
 day to attempt a very little — no matter how little if 
 only we succeed, and can make the patient see it. I 
 
 3* 
 
30 DISEASES OF THE NERVOUS SYSTEM. 
 
 shall in another place be more precise as to the means 
 used. Enough to say of this case that it went on 
 slowly gaining ground, and was under my care a year 
 before the patient could walk well enough on crutches 
 to go home with a cheerful future. It was not a 
 brilliant case, and it taxed nurse and doctor to the 
 uttermost — a case urged and scolded, and teased and 
 bribed, and decoyed along the road to health ; but 
 this is what it means to treat hysteria. There is no 
 short cut ; no royal road. 
 
 Let us take another case. It was as much like the 
 last as it could well be. The patient, Miss C. P., set. 
 18 years, the child of wealthy parents, came to me 
 last year from Indiana. The motor losses were very 
 remarkable, and, as in the last case, it was the left 
 side which suffered most. She was unable to lift the 
 left leg, or flex or extend the foot, so that below the 
 knee there was motion in the toes alone. The left 
 arm preserved all movements, but all alike were fee- 
 ble. The right side was more symmetrically disor- 
 dered, so that almost every muscle of the leg and arm 
 was partially paralyzed. Sensation was lost for pain 
 on the left side, save as to the belly and breast, where 
 it seemed to be good, while in the face and neck it 
 was lessened. Sense of temperature was more abso- 
 lutely lost over the whole side than is common ; and 
 touch, not quite lost anywhere, was disturbed or les- 
 sened in irregular spaces. On the right side sense of 
 pain was lessened in the arm and lost in the leg, while 
 touch and the thermal sense were well preserved. 
 There was one matter in which this case differed from 
 the last one, and this changed my whole manner of 
 
PARALYSES OF HYSTERIA. 81 
 
 dealing with the malady. My new patient was a 
 clear-headed, well educated girl, who once had had a 
 vigorous will. She was described to me as unselfish, 
 thoughtful, and intelligent, and as a woman only 
 brought down to a state of hysteria by long illness 
 and the want of helpful advice at the right moment. 
 She was emotional and ashamed of her tears, and 
 honestly hated the whole matter of sickness. You 
 will see such hysterical women. You will see others 
 whose minds are like the back of a piece of needle- 
 work with a baffling absence of pattern — women 
 with a low, whining, bleating voice that is by itself 
 a tell-tale of the kind of will-less ataxia which seems 
 to cripple the mind no less than the body. These 
 are the hard cases to relieve. But to return to my 
 more favorable case. I tried to make her see how 
 much the defects of body have to do with those of 
 mind, and therefore the need to begin by building up 
 the body anew. When, after a time, the limbs began 
 to round, and color to come back to her pallid cheek, 
 I set her to thinking how far the early troubles might 
 have been within her control. I assured her that, 
 although she could not now overcome at once the 
 results due to habitual failure of self-control, repeated 
 efforts would surely end in success. She was told 
 that it was like the case of a bad temper, easy to hold 
 in check at first, but if long nnheld at last uncontrol- 
 lable. It is not hard to open this point of view to a 
 clever woman. You urge this idea from day to day ; 
 you ask her to try your way. She says she has done 
 so, and then you point out that with ill health success 
 was out of the question, while with rising health it 
 
32 DISEASES OF THE NERVOUS SYSTEM. 
 
 might be easy. At last you get her to promise to 
 fight every desire to cry, or twitch, or grow excited. 
 
 Above all, you teach her the priceless lesson for a 
 "woman of the value of moods, of the ease with which 
 she can get herself into a state of dangerous tension, 
 of the necessity of learning, not how to bear a thing, 
 but how to approach the idea of bearing it in a state 
 of calm. It is a long sermon, but I can only give 
 these few pregnant texts. It is always apt to win 
 with a woman of intelligence, and the fools are to be 
 dealt with by other moral drugs than these, or the 
 honest pill must be gilded with timely flattery or 
 such better motives as may help it to find the 
 woman's conscience, if that is to be stirred at all. 
 
 By and by, as one symptom after another gave 
 way before her efforts, she became more and more 
 sure that I must be right as to all ; and I have seen 
 few cases gain ground with equal speed. Neverthe- 
 less a whole year was needed to make her well able 
 to take up afresh her full round of social and house- 
 hold duties. In fact, even with the best of self-help 
 from the patient, the cure of any one of these cases 
 is a long and arduous course of education. 
 
 Before leaving the subject of hysteric palsies I 
 would say a few words as to the electric reactions. 
 In most cases, and early in nearly all, the muscle 
 reactions are normal ; but after a time, and in most 
 old cases, these are less good than in health ; nor do 
 limbs long palsied fail to shrink somewhat, while 
 marked wasting is rare. When there is loss of 
 motion and of feeling, Duchenne's axiom is correct ; 
 that is, we have then normal electric reaction of 
 
PARALYSES OF HYSTERIA. 33 
 
 muscles and absence of all sensation of pain from the 
 most severe currents. In some early cases I have 
 seen a state of things not elsewhere spoken of. I 
 saw it last week in a chronic case of horrible 
 rhythmic spasms of the arms, with palsy of sense and 
 motion in the legs. Dr. Yarrow, the attending phy- 
 sician, studied with me the electric state, which was 
 curious. When with slow or rapid breaking of cir- 
 cuit (induced currents) we tested the leg muscles, the 
 poles, even with currents unbearable by us, caused 
 no motion until they had been steadily applied for 
 from two to three minutes over any one muscle ; but 
 the reaction of nerve and muscle, one pole on each, 
 Avas somewhat more rapid, although still very slow. 
 What we saw was in reality but an exaggeration of 
 the delay in arousing muscles which we see in health 
 and in other forms of disease than hysteria. 
 
34 DISEASES OF THE NERVOUS SYSTEM. 
 
 LECTURE II. 
 
 HYSTERICAL MOTOR ATAXIA— HYSTERICAL 
 PARESIS. 
 
 The form of disorder to which I shall first direct 
 your attention in connection with the false palsies of 
 hysteria is the motor ataxia of this disease. It is 
 necessary here to be extremely precise, because, as 
 you will see if you read Briquet's admirable study of 
 hysteria, he also describes a form of hysterical motor 
 ataxia. 
 
 Ataxia, as you well know, means merely disorder 
 or irregularity, and when therefore we speak of loco- 
 motor ataxia we mean only disordered movement, 
 and not of necessity enfeebled movement. The cause 
 of the disorder or incoordination thus introduced into 
 motor functions may vary. 
 
 In hysteria, so far as I know, there are two forms 
 of motor ataxia independent of those associated with 
 vertigo. That described by Briquet and Lasegue 
 seems to depend upon a loss of sensation in both skin 
 and muscles. In Lasegue's case the girl was only 
 able, the eyes being closed, to move the limbs which 
 were still sensible, but was totally unable to move 
 the anaesthetized parts or to know where they were 
 when moved by another person. While seeing, she 
 could walk readily and even without looking at her 
 
HYSTERICAL iMOTOR ATAXIA. 35 
 
 feet. 1 In other and similar cases there is merely a 
 lack of coordination in complex motor acts. 
 
 There is, however, another and a very interesting 
 form of hysterical motor ataxia which is, I fancy, 
 rather rare in its most perfect type, and which may 
 without due care be taken, as Duchenne's disease was 
 long taken, for some kind of paralysis. 
 
 The trouble I am about to speak of I find to be in 
 some of its degrees very common in hysteria — to co- 
 exist with many hysteric palsies or paretic states, and 
 sometimes, though rarely, to be the prominent malady, 
 with almost no loss of voluntary power. 
 
 The hysterical ataxic patient of this class, and I 
 shall consider first the nearly pure case, has full feel- 
 ing, or may have it, and is quite well able to use the 
 limbs more or less freely while lying down. When 
 she begins to sit up or kneel or stand, the lack of 
 coordinate muscular movements becomes at once 
 visible. 
 
 Instantly the patient begins to fall to one side, a 
 voluntary effort to redress the disturbed balance 
 results in a partial fall to the other side or back or 
 forward, as may chance. The patient seems to be 
 "unable to judge of the extent to which the balance is 
 lost, and also to determine or evolve the amount of 
 power needed to overcome the defect. The abruptness 
 of these efforts at redressing the loss of equilibrium 
 
 1 There may be in this something of habit. In the few cases of 
 Duchenne's disease which I have seen in women I have been 
 struck with the way in which, as their garments habitually hide 
 the feet, they managed to dispense with the guiding sight of these 
 parts. 
 
36 DISEASES OF THE NERVOUS SYSTEM. 
 
 appears to show an absence or defect of the usual 
 antagonistic activity of opponent muscles. I am 
 inclined to suggest as a reasonable theory that per- 
 haps a large share of this difficulty may be due to a 
 slowness in volitional acts by reason of which the 
 mandate reaches the muscle too late to be of ready 
 service. This is by no means unlikely, for in some 
 hystero-palsies I have measured and proved the re- 
 tardation of nerve conduction. Slowness in learning 
 the need to move a muscle and slowness in moving 
 it would give rise to just such incoordinate action as 
 these cases exhibit. The lack of orderly movement 
 is chiefly in the neck and trunk, and is made worse, 
 like all disorder of motion, by excluding the guiding 
 influence of vision. 
 
 This very interesting form of incoordination in 
 muscular acts is limited for the most part to the more 
 complex movements. It is seen little or least in 
 single limb motions, better in sitting or kneeling, 
 better still in standing, and best of all in walking. 
 It is not due to weakness because it exists in cases 
 strong enough to sit, stand, and walk firmly, if only 
 power were needed to the efficient accomplishment of 
 these acts. Also, while you may find it with general 
 or local lack of surface feeling, it is not due to this, 
 because anaesthesia of the skin is, in the hysterical at 
 least, incompetent to cause ataxia of motion. In the 
 confusion and odd grouping of symptoms in hysteria, 
 the trouble I have described is apt to be overlooked 
 or attributed to coincident conditions. It is, there- 
 fore, fortunate to find uoav and then cases in which 
 this form of motor disorder occurs almost alone, so 
 
HYSTERICAL MOTOR ATAXIA. 37 
 
 that we have a chance of studying it without being 
 embarrassed by other symptoms. 
 
 I believe that this ataxic state is common in grave 
 hysteria, and is to be found often enough in milder 
 cases. I think also that some of the cases which are 
 attributed too promptly to muscular anaesthesia will 
 be found to be free from that defect, and to be due to 
 other causes than those to which Briquet has attri- 
 buted them. Perhaps it may be that conscience of 
 locality will prove a differentiating test, since it is 
 said to be lost in the hysterical ataxia of Briquet, 
 and is certainly not lost in the form I have here 
 delineated. 
 
 I do not think one could readily confound this 
 ataxia of movement with anything else unless it be 
 with one of the rarest of the forms of hysterical 
 spasm. The following case is an apt illustration of 
 this latter disease which might perhaps be well de- 
 scribed as alternating spasms, the action of the flexors 
 calling the extensors instantly into movement, and 
 these in turn summoning the flexors into like activity. 
 These semi-spasmodic motions were the more curious 
 in the last case I saw because of the general and pro- 
 found paresis which made every volitional effort ex- 
 cessively difficult. I may add that there was also a 
 contraction of the right leg and a left hemi-anaesthesia 
 with conscience of place. 
 
 The patient, when seated and held up, or even 
 when the head alone was unsustained, showed the 
 following symptoms: The head or body was pulled 
 to one side. At the limit of this motion, or before 
 that was reached, it was violently jerked over by the 
 
38 DISEASES OF THE NERVOUS SYSTEM. 
 
 opponent muscles, as if their stretching were the sig- 
 nal for an explosive act of power. At once or in a 
 moment the other muscles acted in like fashion, and 
 so the head or trunk was thrown about in a straDge 
 and disorderly manner so long as the patient remained 
 upright. The same type of movement extended to 
 the legs and arms. These acts were certainly of 
 volitional birth, but they were, so to speak, convul- 
 sive renderings of natural acts, and were sometimes 
 very violent. 
 
 I may add that, notwithstanding the complexity of 
 symptoms, with such a loss of memory as necessitated 
 an entire re-education, this girl became entirely well. 
 
 In place of giving you types of motor ataxia with 
 palsy I shall prefer to choose one now in my care, and 
 which has the least share of palsy for the largest 
 share of incoordination of the muscles. 
 
 Miss B., set. 20, Kentucky, of healthy, living 
 parents, in August, 1876, while going home from the 
 Centennial Exhibition, caught a slight cold, out of 
 which came complete loss of voice for seventeen 
 months. In its return it came and went abruptly, 
 and was well to-day and gone to-morrow. In Sep- 
 tember, 1871, at the Hot Springs, Arkansas, after a 
 good deal of worry, she is said to have had head- 
 ache and dizziness, after which of a sudden she lost 
 speech, and became unconscious, with her jaws firmly 
 locked. The legs and arms were seized with spasms, 
 and when they became better had nearly lost touch- 
 sense, and did not feel pin pricks. This attack ended 
 in weakness and fever, with cold feet and loss of power 
 to swallow even saliva. After three weeks she re- 
 
HYSTERICAL MOTOR ATAXIA. SU 
 
 gained speech, and then again relapsed. She was said 
 to have had a typhoid fever, which does not seem 
 likely. 
 
 About the fifth week she was found to have lost 
 power in the legs. The loss is described as having 
 been nearly entire, but by March, 1879, she had re- 
 gained a good deal of motion. Since then she has 
 been at a standstill. 
 
 In October I saw Miss B. in bed, a dark-skinned, 
 rosy-looking girl, without the least turn to tears or 
 undue emotion. I should only have said that her 
 manner was quick and excitable. She certainly had 
 none of the usual furtive look, and small deceitful- 
 nesses of some hysterical girls. Neither was there 
 any loss of tendon (patellar) reflex, and the senses of 
 pain, of touch, and of heat were perfect. 
 
 While in bed Miss B. moved all her limbs somewhat 
 slow'fy, but with a great deal of power ; the lift of 
 the leg was done in jerks, as by distinct orders of will, 
 but she showed none of the tremor and twitching of 
 face and tearful look so common in hysteric girls 
 called on for an unusual effort. When held up on 
 her knees, she swayed to and fro, always falling if 
 not assisted. When somewhat later she could stand 
 up, the motor disorder showed still better. From 
 head to foot every muscle used to preserve the upright 
 posture gave way momently, and was braced again 
 by distinct acts of will. The rocking motion so 
 caused was curious to see. A slight push was sure 
 to upset her, as if she was unable to provide in time 
 enough of power to resist the shock and restore the 
 disturbed balance. If I warned her of the comingr 
 
40 DISEASES OF THE NERVOUS SYSTEM. 
 
 shock, she did far better. The touch of a hand 
 greatly aided her, and the closing of her eyes made 
 things worse. Nor did Miss B., when standing, ap- 
 pear to have the least idea of her balance being in 
 danger until the sway of her figure became extreme, 
 when she caught herself up, and with an effort re- 
 gained her erect position only to fall to the other side. 
 There seemed to be a lack of appreciation of the fail- 
 ing balance, and a slowness in redressing it when lost 
 or in peril. When added to this we have complete 
 loss of feeling, when skin, bone, joint, and muscle 
 share alike in this respect, we have, of course, a still 
 more complete and a different form of want of power 
 to preserve the upright posture, but this is the cha- 
 racter of the trouble spoken of by Briquet and others, 
 and I wished to make it clear that there were causes 
 of motor ataxy which did not of need involve any 
 lack of tactile sense. 
 
 In Miss B.'s case little was needed beyond training 
 the weak and inapt muscles, because she ate and 
 digested well, slept soundly, and was free from pain. 
 
 My first step was to point out to her that, after she 
 had made an effort which seemed extreme, another 
 forth-putting of will would add to the previous result. 
 This seems a simple thing to make clear; but, if you 
 can convince your patient of the fact, it is of great 
 service, because then you go on to point out further 
 that, perhaps, by a series of trained and aided efforts, 
 there may be won, bit by bit, a full power of motion. 
 To lodge this idea in a woman's mind is at once to 
 widen the horizon of hope. How much you gain by 
 it depends a little on whether your patient is clever 
 
HYSTERICAL MOTOR ATAXIA. 41 
 
 and wants to get well, or is silly and prefers the role 
 of hysteria ; but, after all, the whole mode of treat- 
 ment rests on a study of character, or of character 
 and hysteria, and a moral diagnosis is the first step 
 to take. 
 
 With Miss B., at a standstill for months — bright, 
 clever, longing; for active life — the idea was as a whole- 
 some ferment. The nurse now began to train her 
 while in bed to move the legs, one at a time, very 
 slowly, but in larger and larger movements, with 
 intervals between of a minute or more. 
 
 An order is given to lift the leg ; if it be too weak, 
 a finger beneath the ankle aids it, but no attempt 
 must be let to fail utterly; as she gets on, the orders 
 are to be obeyed more quickly. It is easy to sketch 
 out for one's self what such a system should be in its 
 details. After it has gone far enough, the patient is 
 seated in bed with some support to her spine, and is 
 trained to move the head freely. When, in Miss B.'s 
 case, she was put on the edge of the bed seated, the 
 motor ataxia began to show, so that it took some 
 time to overcome this trouble. The next step used 
 with me to be a lesson in walking, but of late I 
 find it better to teach the girl to creep, which is an 
 easy and natural mode of training for the walk. The 
 patient has pads tied over her knees, and, lying flat 
 on her face on the floor, without skirts, has around 
 her a folded sheet. At an order, she tries to rise, 
 helped by the lift of the sheet-belt held by the nurse. 
 When she is able to do this, and can gather her legs 
 and arms so as to make herself a quadruped, she is 
 taught to balance herself, every effort being assisted, 
 
 4* 
 
42 DISEASES OF THE NERVOUS SYSTEM. 
 
 when needing help, by the nurse standing above her. 
 The progress to creeping is easy ; then comes the 
 lesson of kneeling and pushing a chair ; and last that 
 of standing in a corner or by a chair. You see that, 
 following nature's lessons with docile mind, we have 
 treated the woman as nature treats an infant. For 
 aid in walking we have three devices : the expensive 
 wheel crutch, which can be easily imitated by a clever 
 carpenter, being merely a framework with rollers so 
 arranged that it includes crutch supports. Next, if 
 need be, I use a device which may be common, for 
 all I know, but which I have not seen elsewhere. It 
 is a pair of crutches with a stout half-hoop of metal 
 between and in front of the two. This gives a solid 
 support, and, in ataxic cases, is very useful as giving 
 a sense of security, and therefore of confidence. 
 This crutch-frame is soon replaced by a pair of sup- 
 ports, the bases of which are about seven or eight 
 inches long and two broad. They may be made like 
 the lower half of a crutch, or have two columns of 
 a support set in the base, or may be a single cane with 
 broad base ; the top in any case should have a double 
 curve so as to lie easily in the line of the natural slope 
 of the palm when resting on such a support. A rubber 
 footing gives a little elasticity and a good hold on 
 any form of flooring. With such a broad base of 
 support, it is quite pleasant to find how soon the 
 patient learns with its aid to balance herself. A 
 third form of support which I devised two or three 
 years ago is of use in hysteric or in any form of 
 hemiplegia. If the left arm be too feeble to aid the 
 left leg by grasping a crutch, I resort to the following 
 
HYSTERICAL MOTOR ATAXIA. f 43 
 
 arrangement. On the lame side a crutch, having 
 above an unusually deep hollow to receive the armpit, 
 is fastened to the arm by two straps or by a glove 
 riveted to the hand-piece of the crutch, so as that the 
 hand once slipped into it is pretty firmly held. From 
 the crutch a double metal bar curves forward and 
 towards the sound side, and ends in a handle which 
 is grasped by the sound hand and carried forward by 
 it. I have found these supports most useful in many 
 forms of weakness. In making them or having them 
 made, pray remember that they should be made 
 light ; most crutches are too heavy. 
 
 With regard to Miss B., I may add that she got 
 well in two months so as to walk unhelped anywhere, 
 and that she is now free from pain and nervousness. 
 
 Before leaving the subject of hysteric motor 
 ataxy, I wish to add yet a single illustrative case in 
 order to show that ataxy, connected with hemiplegia, 
 may affect a single limb. Such cases approach in 
 character the choreoid troubles which accompany or 
 follow certain cases of hemiplegia from organic dis- 
 ease of the brain, and afford yet another of the 
 shadowy resemblances which link the various forms 
 of hysterical disorders to their analogues of more 
 definite parentage. Miss C, set. 30, grew up in luxury 
 and ease, subject to what she somewhat indefinitely 
 described as spells of prostration with nervousness. 
 At the age of twenty a sudden death in her family 
 caused a sharp convulsive attack, followed by a brief 
 period of insanity, lasting in all three weeks. Three 
 years later her family fell into almost absolute want, 
 and she began to work hard in the effort at self sup- 
 
4i DISEASES OF THE NERVOUS SYSTEM. 
 
 port, and then gradually failed in health, suffering at 
 intervals from a variety of hysterical symptoms. 
 These resulted abruptly in incomplete left herni- 
 anassthesia, with great loss of power in the leg and 
 lessened power in the hand and arm. 
 
 With this report of her case she came to me some 
 months ago. Except a very slight retro-flexion, 
 there was no uterine trouble. Neither ovary was 
 sensitive, but the spine in all its length, and the left 
 side of the chest and the upper part of the belly were 
 very tender — more to touch than deep pressure. All 
 other organs were healthy. 
 
 The hemi-ana3sthesia as to touch and pain was 
 notable in the parts below the waist, and was incom- 
 plete in irregular areas, which shifted daily. Pin 
 pricks did not bleed in the leg. 
 
 The hand and arm had good sense of touch every- 
 where, but lessened pain sense chiefly on the radial 
 aspect of the arm. The leg was almost motionless. 
 The arm and hand could be used with nearly natural 
 force, but were stricken with remarkable ataxy of 
 movement without the least sign of spasm. The 
 utmost concentration of will failed to direct the hand 
 so as to enable it to grasp or manipulate an object 
 once held. The limb would waver to and fro, and at 
 last descend on the object with an effort which usu- 
 ally carried the hand far to left or right. A certain 
 abrupt jerkiness characterized every motion, and the 
 failure of directive power was singularly illustrated 
 at the piano, where the one incoordinate member con- 
 trasted with the unusually skilful touch of {he other. 
 As so often happens in the post-paralytic chorea of 
 
HYSTERICAL MOTOR ATAXIA. 45 
 
 cerebral lesions, the palsy was inversely as the ataxic 
 difficulty, and consisted rather in lack of persistent 
 energy than in want of initiatory power. 
 
 By slow degrees this ataxy of movement passed 
 away, and what was most curious it lessened with the 
 increase in want of power, while this also has in turn 
 disappeared, leaving as yet some dysesthesia, but no 
 notable want of strength. 
 
 There yet remains to us hysteric paresis. Among 
 the many disorders which hysteria affords, certain 
 ones come clearly out at times from the tangle of 
 named or nameless symptoms, and enable us to speak 
 of them under some distinct name. It is a comfort, 
 amidst so much that is confusing, to find these group- 
 ings of symptoms, and, in diseases of vague bounda- 
 ries like neurasthenia and hysteria, a good deal of this 
 useful sort of secondary classification is possible. 
 
 The history of hysteria is sometimes one of years, 
 and in certain cases, either at the outset or after more 
 or less of the strange drama of this disease has been 
 played, the patient falls into a state of inertness of 
 mind and body, which I am forced for lack of a better 
 name to call hysteric paresis. 
 
 You might, I presume, feel free to give to these 
 cases another label than the one I have given. They 
 are, however, over and above all else paresis — pure 
 intense feebleness; but it is paresis in hysterical 
 women, and if you forget this fact, when it exists, 
 you may be sure that you Avill have but little success 
 in the treatment. 
 
 This disorder may be seen in union with other 
 signs which are more or less clearly hysterical ; but 
 
46 DISEASES OF THE NERVOUS SYSTEM. 
 
 sometimes we find it almost pure from these disguises, 
 as in the case of Miss L., from New Jersey, now in 
 the Infirmary. A person of languid nature, not strong 
 in mind or body, she began some years ago to be emo- 
 tional, to have loss of appetite, weakness, tender spine, 
 vertex headaches, and abdominal tenderness and rare 
 convulsions. By and by she took to bed, and with 
 more and more complaint of her back, and soon of 
 soreness everywhere, ate less and less, gave no care 
 to her bowels, and at last became feeble, sallow, wasted 
 to the limit of wasting, and content to lie still most 
 of the time, using mind and body as little as she 
 could. From this state I rescued her and made her 
 well, and now she is here again far worse than ever, 
 unable to lift a limb or to turn over. She is twenty - 
 two years old, and has not menstruated in six months. 
 She is five feet five inches, and may weigh about 
 eighty -eight pounds. Her skin is rough, dry, un- 
 pliant, yellowish, and seems to be firmly glued to the 
 bones and muscles beneath it. Her morning tempe- 
 rature does not exceed 97.5° F. ; her heart beats 90 to 
 120, and is quick and feeble. The other organs seem 
 healthy, and the secretions normal. She cries at 
 times, but not much. Her face, marked with acne, is 
 set, inert, wooden, as if she could not smile. The lids 
 droop, the mouth hangs a little open, the voice is so 
 feeble that it is hard to know what she says. The 
 spine is very tender, and to touch it causes a gush of 
 tears; but the left iliac fossa and the chest muscles 
 are also tender, and compression of any of these 
 hyperaesthetic spaces causes nausea and vertigo. Her 
 dislike to make any effort was great, but it was clear 
 
HYSTERICAL MOTOR ATAXIA. 47 
 
 that no motion was lost, although all were wonder- 
 fully feeble. There was not during movement the 
 jerky action of hystero-palsies, but an extreme and 
 evident difficulty in motion, and a sudden failure to 
 prolong it. 
 
 I was very much struck in. this case with the ease 
 with which these patients become feverish. The 
 least over-exertion was competent to cause a distinct 
 rise in temperature and pulse ; but, for some reason 
 not yet clear to me, these changes required some 
 hours to produce them. 
 
 All the battery of toning influences was turned on 
 this woman, and she is now gaining ground apace. 
 She is fed often and in small amount, had for a time 
 rectal feeding also — and the mechanical tonics, mas- 
 sage, and electricity. As usual in all such cases, we 
 wait until the flesh is coming back, the color bright- 
 ens, and the muscles grow firmer under our mechani- 
 cal stimulations before we call upon her to exert her- 
 self. Then, in this order, with passive motion — 
 motion aided by a nurse, motion resisted by a nurse, 
 active motion, unhelped — we shall train her back to 
 a state of health. We shall cure her surely, but 
 Avhether or not she will remain well I cannot say. 
 It will depend on what kind of influences surround 
 her, on what she is when well. 
 
 I have given here a short sketch of a state of 
 paresis, in which with some anaemia or without a 
 very marked condition of lack of blood all the func- 
 tions are enfeebled, and this is most notable in those 
 Avhich involve muscular exertion of any kind. If 
 there be also any pain, such as that of spinal irritation 
 
48 DISEASES OF THE NERVOUS SYSTEM. 
 
 made worse by motion, the patient is even more apt 
 to be sluggish, and is not slow to avail herself of this 
 and of every excuse to keep as quiet as possible. 
 The real and singular want of power, as measured by 
 the dynamometer, the difficulty in beginning as well 
 as in continuing a motion, seems to set this apart 
 from cases of mere neurasthenia, while the general 
 wasting and appearance of mal-nutrition serve yet 
 more deeply to mark the distinction. The disorder 
 I have described so briefly is one of those which adds 
 many recruits to that large class which some one has 
 called "bed cases," and which are above all things 
 distinguished by their desire to remain at rest. 
 
 I shall elsewhere give in sufficient detail what I 
 over and over allude to in these lectures — my views as 
 to how best to treat those difficult combinations of 
 hysteria with defective nutrition which are often too 
 much for the best of us, and to those pages, and to what 
 I have written previously in other places, I must now 
 refer you. I have some belief in the occasional value 
 of induction-currents in hystero-palsies,. but, as to the 
 direct good to be had out of the drugs on which men 
 once relied in the treatment of this disease, I have 
 said nothing, because, except to condemn, I had 
 nothing to say, and because I believe that the num- 
 berless remedies for hysteria to be found in the books 
 will be swept by another generation into the limbo 
 provided for drugs with decayed reputations ; but in 
 thus expressing myself I do not mean to say that no 
 drugs have an indirect value. What you have to do 
 is to rectify with care positive uterine troubles, to 
 treat defects of nutrition, to relieve the anaemia so 
 
HYSTERICAL MOTOR ATAXIA. 49 
 
 apt to exist in hysteria, to see that every function is 
 well cared for, and last, not least, to learn what need 
 there is to alter the moral surroundings of your 
 patient, and then with kind and patient care, and an 
 unbending will, to bring about the changes she may 
 seem to require. 
 
50 DISEASES OF THE NERVOUS SYSTEM, 
 
 LECTURE III. 
 
 MIMICRY OF DISEASE. 
 
 You will recall the fact that the case I show you 
 to-day is one of three which have presented them- 
 selves at this clinic within one week. Each of these 
 by chance illustrates a different form of disorder, and 
 each of the three is a distinct example of one of the 
 various groups of causes which evolve a simulation 
 of disease. The literature of this subject is widely 
 scattered, and consists chiefly of isolated cases to be 
 found in the journals. The best essays on the surgi- 
 cal aspect of simulated disorders are the admirable 
 lectures of Paget, Skey's little volume, and an able 
 paper by Dr. Schaffer, of New York, on hysterical 
 disease of joints. Except Eussell Eeynolds's paper on 
 diseases due to fixed ideas or emotions, I know of no 
 medical essay of much merit on this subject. It is 
 to be desired that the whole subject should be handled 
 afresh by some competent physician. It would be 
 easy for me to make up for you an interesting history 
 of these troubles from the experience of others, but 
 I think that I shall be more pleasantly instructive if 
 I deal only, or most largely, with cases coming within 
 the range of my own knowledge, and especially if I 
 make use of some of the curious self-analyses which 
 patients who have recovered have placed at my dis- 
 
MIMICRY OF DISEASE. 51 
 
 posal. Both for what they betray and what they con- 
 ceal these histories are valuable, and especially so 
 when they come from women of educated intelligence. 
 
 The elements out of which these disorders arise are 
 deeply human, and exist in all of us in varying amount, 
 while many of the determining and conditioning fac- 
 tors come from accidental, or, at least, external agen- 
 cies. As a rule, the means at work to produce 
 mimicked disease are in the books made to seem too 
 simple. 
 
 I have not time to do here as I might wish, and to 
 go into the full psychology of this subject, and must 
 content myself, therefore, with an outline which shall 
 mark out for you the chief causes which supply the 
 foundations for simulated diseases, and those which 
 build on this, and those which strengthen and guard 
 the morbid structure. 
 
 First of all comes the hysterical state, fertile parent 
 of evil. However produced, it is a fruitful source of 
 mimicry of disease, in its every form, from the mild- 
 est of dreamed pains up to the most complete and 
 carefully devised frauds. Its sensitiveness and mo- 
 bility, its timidity and emotionalness, its greed of 
 attention, of sympathy, and of power in all shapes 
 supply both motive and help, so that while we must 
 be careful not to see mimicry in every hysteric symp- 
 tom, we must, in people of this temperament, be more 
 than usually watchful for this form of trouble, and at 
 least reasonably suspicious of every peculiar or unu- 
 sual phenomenon. 
 
 TThat it is convenient to call the nervous tempera- 
 ment, or that state which may be acquired, and which 
 
52 DISEASES OF THE NERVOUS SYSTEM. 
 
 I like to describe as general nervousness, is a fertile 
 field for simulated maladies, because in it, as in hys- 
 teria, the qualities which we all possess are apt to take 
 on a morbid development, and to get out of the limits 
 of rational control. 
 
 Of the individual share taken by each of these 
 causes I shall by and by speak. Before, however, I 
 pass on to lesser premises, I would like to digress in 
 order to say a few words in explanation of what I 
 mean by general nervousness. You will find this 
 term used over and over in these lectures, and also in 
 the annual statement of diseases treated at the In- 
 firmary for diseases of the nervous system. I used 
 to try to classify these cases under other heads, but 
 came at last to see' that there is a state which is best 
 labelled thus, and that after eliminating all the cases 
 which can be otherwise classed, a small residuum is 
 left to which no other name applies. Some of them 
 are more or less neurasthenic people, easily tired in 
 brain or body ; but others without this, or with this 
 peculiarity but slightly developed, are merely tremu- 
 lous nervous folks, easily agitated, over-sensitive, 
 emotional, and timid. This state falls on man or 
 woman or child, and is not hysteria. It is with some 
 people a morbid birth-gift, with some an inheritance, 
 and in its worst shapes it is made or acquired by mis- 
 use of alcohol or tobacco, or tea or coffee. Naturally 
 you may think that such a state must be slowly cre- 
 ated, and usually it is ; but also it is true that a very 
 permanent state of general nervousness may be 
 evolved by the accident of a moment, when prece- 
 dent conditions favor it. In a lecture on general 
 
MIMICRY OF DISEASE. 53 
 
 nervousness in the male, I mentioned examples of 
 this kind, and last week we saw at my clinic a case 
 in which a moment of intense terror, owing to the 
 fall of a house wall, caused in a healthy girl a state 
 of general nervousness, alike serious and lastiner. 
 However acquired, the condition I have outlined 
 highly favors the mimicry of disease. 
 
 Another good growing ground for simulation is in 
 a mere lowering of the general tone of health from 
 anaemia, or any cause whatsoever. You know that 
 out of failing health comes, often enough, nervous- 
 ness or hysteria, but even when these states do not 
 arise, mere lowering of the standard helps, in many 
 susceptible people, to awaken doubts, suspicions, and 
 terrors, which need little hint or help from without to 
 enable the victim to construct a morbid edifice of 
 non-existent disease. 
 
 If, then, you should ask me whether for the crea- 
 tion of mimicked disorders we need the aid of low- 
 ered health, of hysteria, or of general nervousness, I 
 should answer that while such states are usually the 
 responsible parents, a small proportion of examples 
 arise in persons who being in absolute health owe 
 the troubles in question to their possessing some 
 natural or inherited combination of physical peculiari- 
 ties, which becomes a competent mischief maker when 
 aided by external accident. The people who, from 
 any cause, simulate disease are, I think, apt to be natu- 
 rally distinguished by certain peculiarities. They are 
 generally over-sensitive, pain hurts them more than 
 others, and is a more important matter in life. Per- 
 haps they really feel pain more, and, at all events, 
 
54 DISEASES OF THE NERVOUS SYSTEM. 
 
 they complain of it more. As a rule, they are timid, 
 fearful, and watchful, nursing for evil, any chance 
 word incautiously dropped, and, therefore, prone to 
 dwell on physicians' opinions, to deduce exaggerated 
 possibilities of trouble, and in obedience to the least 
 prediction of ill to consent or hasten to take extreme 
 precautions. 
 
 Then, again, you are aware that every one has some 
 capacitjr for mentally influencing or disturbing func- 
 tions of the body which usually are not under the 
 control of volition. A few well people have this in 
 a marked manner, and in some hysteric or nervous 
 states this power becomes enormously increased and 
 widened in range. I do not mean that these people ac- 
 quire the power to will intestinal trouble, for instance, 
 but that they certainly may gain ability to somehow 
 disturb the bowel functions by thinking of them. 
 There are many stories in regard to this ; but let the 
 average man endeavor by any mental process to cause 
 diarrhoea, and he will, I think, find it no easy task. 
 It seems incredible that a woman can learn to vomit 
 at will; but this is common; and, also, happily she 
 can be taught to suppress this vomiting by volitional 
 effort when the will is aided by a potent motive. 
 
 Books like Dr. Tuke's are full of stories illustrative 
 of such facts, and I myself have seen a large number. 
 It is clear, then, that we can sometimes acquire such 
 control over functions supposed to be outside of 
 volitional rule, and that this is made easier in certain 
 temperaments and in states of hysteria, feebleness, or 
 nervousness. 
 
 The disturbances thus brought about lie usually in 
 
MIMICRY OF DISEASE. 55 
 
 the heart or vessels, or in the gastrointestinal track, 
 and are caused or aided by expectant attention or 
 dread, or by morbid watch fulness with a knowledge 
 of symptoms. 
 
 It has been said by Hunter, as quoted by Tuke, 
 that, if a number of men surrounding a table on 
 which they have placed each a hand will fix their 
 attention on the member, some of them at least will 
 soon feel in the part a peculiar sensation. I have 
 tried this in vain, and I have also tried without re- 
 sult to cause my heart to beat quicker by merely 
 attending to its action, yet I am myself of a rather 
 nervous temperament. It is curious to find John 
 Hunter avowing the ease with which he could in 
 this manner create symptoms, and then to find Sir 
 James Paget declaring himself utterly unable to pro- 
 duce mimicry of disease by any amount of attentive 
 effort. The difference among healthy men in this 
 respect must, however, be immense. Of this I had 
 once a curious illustration. When a very young 
 man, five of us made a series of what are called by 
 the homceopathists provings of certain medicines, 
 each man being ignorant of the drug taken ; three of 
 the five had a great variety of symptoms, but the 
 other two had none. It is well to add that the 
 symptoms corresponded neither among the observers 
 nor to those set down in the homoeopathic manuals. 
 My friend, Professor Tyson, will recall an amusing 
 example of the effects of expectation in a patient of 
 ours. The first day he saw her, in order to use 
 electricity, she chanced to have at the time, as she 
 always had under excitement, a loose stool. This 
 
5Q DISEASES OF THE NERVOUS SYSTEM. 
 
 took place also at his next visit ; and thereafter he 
 never made a call at a set time without causing sharp 
 purgation. When he came nnlooked for, then the 
 whole trouble left her. It brought to my mind the 
 case of a well-known English physiologist, who hap- 
 pened to have diarrhoea when about to give his first 
 lecture. The embarrassment and annoyance were 
 great, and so impressed him that for a year he never 
 lectured without having just beforehand a loose stool. 
 The sufferer chanced to relate these facts to a well- 
 known physician, then a very young man; being 
 himself also a biologist, he unluckily felt interest 
 enough in this matter to recall it when soon after 
 about to appear for the first time before an audience. 
 The excitement attendant on a novel situation, with 
 a knowledge of how it had affected another, caused it 
 to have a like effect on him, and for a long time he 
 was always thus annoyed when about to lecture. 
 
 I have given these as illustrations of increase of 
 action under mental disturbances and expectation or 
 dread. They could readily be multiplied. In the 
 two cases named, anxiety caused the repetition of a 
 flow which was at first accidental, or, at all events, 
 not-born of emotion alone. In like fashion arise and 
 continue certain of the forms of cardiac and vasal 
 nervous disturbances. First there is some sadden and 
 unusual influence disturbing the circulation, then, 
 upon occurrence of lesser but like causes, a similar 
 trouble arises, until a morbid habit is fully formed. 
 
 There exists in all of us, feebler in age and more 
 potent in childhood, a tendency to automatic and 
 unconscious imitation which is the parent of a good 
 
MIMICRY OF DISEASE. 67 
 
 deal of the mimicry of disease. It may exist in sim- 
 ple forms, or be accented by love, anxiety, fear, or 
 even disgust. 
 
 I have said it was potent in the young, and it is in 
 them responsible for a good many of the peculiarities 
 and resemblances usually set down to inheritance ; 
 but it is also to be seen at times in their elders. 
 Some months ago I was showing to a physician a 
 very singular case of unilateral grimace. As I 
 turned from my patient, I noticed that the doctor 
 was repeating with his own features the morbid 
 action before him. I said, "Do you know that you 
 were imitating this lad's grimace?" "I know now," 
 he said, "but I must have clone it without conscious 
 imitation." Perhaps no better or more illustrative 
 example of the natural tendency could be given. 
 This was pure automatic imitation. 
 
 The tendency to cough, when forced for a long 
 time to listen to a cough, is an instance where ten- 
 dency to imitation is made powerful by sympathy or 
 affection. It may account for some at least of the 
 false whooping- coughs we meet with. 
 
 A far more amusing example is one which I have 
 seen several times, but which seems to have escaped 
 mention in print. It is the occurrence of vomiting in 
 the husband of a pregnant woman. The story of one 
 of these unlucky sympathizers is worth telling : — 
 
 He was rather noted as an unfaithful mate and a 
 man of altogether loose ways. After five years of 
 marriage, his wife becoming pregnant — an event much 
 desired — he seemed to reform, and was very much in 
 her society. Her vomiting, which was extremely 
 
58 DISEASES OF THE NERVOUS SYSTEM. 
 
 severe, at last affected him, every day or two, to his 
 utter disgust. Her second pregnancy gave rise to a 
 return of his malady. I believe that she ceased to 
 be sick with her third child — certainly with her 
 fourth — but, so soon as on each occasion he became 
 aware of her state, his vomiting came on, and lasted 
 for a month or two ; indeed, I think, in one case much 
 longer. 
 
 The character of his disorder at length became 
 known to his friends, and he was so mercilessly 
 chaffed that it was at last almost dangerous to men- 
 tion the matter. I have seen other cases — his was 
 the worst — but I was told of one in New York last 
 week, and the victim was a physician. 
 
 I may have overlooked something in my search 
 through the books for mention of these curious facts. 
 Prof. Groodell reminds me of what Francis Bacon 
 says (Cent. x. Para. 986): "There is an opinion 
 abroad — whether idle or no I cannot say — that loving 
 and kind husbands have a sense of their wives breed- 
 ing child, by some accident in their own bodies." 
 Did he mean vomiting, or some more mysterious 
 diagnostic warning? In the Lancet there is brief 
 mention incidentally of a husband as having been 
 sick at stomach during his wife's pregnancy. 
 
 There could be no better examples than these 
 somewhat ludicrous instances of the influence of au- 
 tomatic imitative tendencies. In the case just men- 
 tioned, the habit became so strong that emesis was 
 re-excited by a mere knowledge of the fact that there 
 existed in the woman the state out of which pre- 
 viously had grown the original trouble. 
 
MIMICRY OF DISEASE. 59 
 
 Instances of graver disease evoked in like fashion 
 have been given by Reynolds and Anstie, and always 
 it is found that fear, or the sight or the remembrance 
 of suffering in others, has been an efficient means of 
 aiding the imitative tendency. In this manner trou- 
 blesome paresis, simulative of palsy seen in a relative, 
 has been produced. The condition thus acquired is 
 not a true palsy, and does not give us the full roll of 
 symptoms seen in the real case; but it is something 
 more than a mere voluntary imitation, because there 
 is often a distinct incapacity for movement. The dif- 
 ficulty as to the amount of true pain felt in such of 
 these cases as mimic that symptom, I shall more than 
 once have occasion to speak of; and it follows us 
 everywhere in our efforts to fairly appreciate the ex- 
 tent of nerve irritation. It must bear to true pain 
 perhaps some such mysterious relation as the paresis 
 of these cases bears to true paralysis. 
 
 I saw last winter a young lady of highly nervous 
 and timorous organization, who was long under my 
 care, and at length fullv recovered. While in bed an 
 indiscreet attendant tolcl her of the horrible agony 
 she had witnessed in a case of facial neuralgia, which 
 began daily about 11 A. M. A day or two later my 
 patient began to have pain in the same locality and 
 at the same hour every morning. She was one of 
 those women in whom you could cause pain any- 
 where by pressure on the spine, and a few suggestive 
 and directing remarks ; and no more was needed than 
 the frequent mention of the torment of another, and 
 the remembrance that she herself had already had 
 what was called ovarian neuralgia. For some days 
 
60 DISEASES OF THE NERVOUS SYSTEM. 
 
 she really seemed to have an intense facial pain. It 
 wore away after I ceased to pay any attention to it. 
 
 There is a state of mind and body, not rare in well- 
 developed hysteria, in which there exists a so mon- 
 strous development of this strange power to create 
 disorder by thinking of it, that even a slight hint, as 
 it were, will suffice to evoke a novel symptom. In 
 this disease, indeed, we find women, and men too, 
 passing into a mental state in which they are really 
 much like people in dreams. Their power to reason 
 on the phenomena of the senses leaves them, and what 
 they conceive to be the case takes the place of that 
 which is. These are they who are hurt by light, or 
 believe they are ; who cannot bear noise, or think 
 they cannot; who feel vibrations as pain; who live 
 muffled lives in dark rooms, and believe they cannot 
 walk, or even lift a hand, or move the head. Such 
 cases are looked upon as simulations of disease by 
 some writers, and are, I am sure, prone to pass into 
 that evil stage of hysteria ; but there are others I also 
 know who live lives of odd inhibition — slaves to the 
 tyrant ideas which they themselves create. 
 
 This, of course, is to be met with, to some extent, 
 in all grave hysteric cases ; but it is also, as I have 
 said, the ruling feature of a few. If you cause such 
 hysteric women as these to believe that you can cure 
 them, you enlist on your side their own troops, for as 
 you can create symptoms, so can you also create ab- 
 sence of symptoms. There is in all this something 
 like the so-called magnetizing of which we used to 
 hear and see so much. Under a fixed belief people 
 were made unable to move, or could not close the 
 
MIMICRY OF DISEASE. 61 
 
 eyes, or could not open them, or were made to seem 
 to have a pain by touching a point on the body. The 
 patients I speak of are all very subject to like delu- 
 sions. You put a finger firmly on the spine, and ask 
 if the patient have now a pain in the left breast? 
 She says no. You persist. At last she says, "Yes — 
 Oh, it hurts me!" Now, is this pure sham, or is it 
 not ? Does the presence of the set belief create pain ? 
 Is it like the pain of dreams, which seems real enough 
 while we are in the state of dreaming? I have 
 thought over all this a great deal. When we put a 
 finger on the eye unopened for days, and say " Now 
 you can open it," and this is done ; or when we arrest 
 motion by an order, we see a plain physical result 
 which must have behind it a ganglionic change out of 
 which it grows ; and so it seems to me that, looking 
 at the pain evoked by ideas or beliefs in the light 
 we get from the motor phenomena, so evolved, we are 
 hardly wise to stamp these pains as non-existent. 
 
 At the same time that I put forward this doubt as 
 to the justice of the common view, I am far from 
 thinking that the hysteric girl of the class I am now 
 discussing suffers as sharply as she seems to do ; the 
 emotions are no more under control than in a dream, 
 and no pains are little, no burdens light. 
 
 I have now in my care Miss C. from Milwaukee. 
 When I first saw her she was in bed, which she quit 
 but rarely and with difficulty. The room was kept 
 dark, and she wore blue glasses over the closed eyes, 
 and outside of all a bandage. She used cotton in her 
 ears, and her nurse and parents crept about in list 
 slippers. She had in all ten pillows, large and small, 
 6 
 
62 DISEASES OF THE NERVOUS SYSTEM. 
 
 as supports around her, and was, as a young hysteri- 
 cal girl once told me, " crowded with symptoms." 
 
 The character of this girl had always been that of a 
 person thoughtful of and for herself, and not free from 
 esteem for her own mental powers, so that she had 
 been able and also very willing by degrees to rule 
 a meek household with that reckless despotism the 
 throne of which is very often the couch of an invalid. 
 
 This case seemed to me one in which set beliefs, 
 easily gotten and well nursed, had attained a power 
 which gave rise to pain and over-sensitiveness and 
 more or less inhibited movement. I began -to deal 
 with it by learning all I could from the girl herself 
 to add to what I already knew of her mind, her morals, 
 her habits, tastes, friends, education, and home life. 
 Then the talk was left to settle on her eyes, and at 
 last on the uses of light, and the fact that its excess 
 hurts even the healthy, but does not injure them. 
 When at last she grew interested, and with herself 
 for a text that was easy, I said, that perhaps a woman 
 of strong character might learn to bear the light after 
 long disuse of her eyes ; that such a one could not get 
 well readily in the dark, and that although the light 
 would pain her, it most surely could not cause dis- 
 ease. I then left her, with the idea that she could in 
 a few days conquer her rebel eyes, and that it was 
 absurd for a woman of intellect to let one organ dis- 
 order the whole body. The next day I found her 
 with open eyes and sunlight in the room. One by one 
 the ideas on which the case was built were thus art- 
 fully removed, and she is now after but a few days of 
 treatment far on the road to health. 
 
MIMICRY OF DISEASE. 63 
 
 These victories are less easy with older women ; 
 but even then the mode of dealing with them is as 
 much a question of the basis of character as of any- 
 thing else. Sometimes we only need to dispel one 
 symptom to overcome all ; sometimes the return to 
 health and healthy ideas exacts a long and tiresome 
 struggle. Sometimes it is safe to assure the patient 
 at the outset that she has but to believe and exert 
 herself in order to walk. 
 
 In this innrmar}^, I saw a few years ago, an abrupt 
 success obtained in this latter way in a woman, fifteen 
 years in bed, who was made able to walk well in three 
 weeks, and I could easily add, were it needed, the 
 details of many other and less striking cases. 
 
 I had meant to say something here of that form of 
 hysteria in which the patient deliberately acts a part 
 and with more or less cunning deceives those about 
 her. I have seen a goodly number of these cases, but 
 among them I have found quite rare the attempt to 
 simulate palsy. It is easy enough to learn when a 
 woman is pretending to pass calculi or vomit snake- 
 bones, but to know if her loss of power be real, or if 
 she be suffering from an inhibitory idea or belief is 
 more difficult. I may say, however, that purely simu- 
 lated palsies in hysterical girls, lack the qualities of 
 hystero-palsies, are too complete, and show no loss of 
 feeling. The best cases I can recall were in very 
 young girls, and were present with much mental dis- 
 turbance, and after a long role of hysteric symptoms 
 had been played with success. 
 
 One of the cases I lately showed you was a curious 
 and most instructive illustration of imitation where 
 
64 DISEASES OP THE NERVOUS SYSTEM. 
 
 distress and terror at witnessing disease in a sister 
 were the efficient factors. 
 
 Mary C, aged nine, had frequent, sudden, and 
 severe attacks of epilepsy. After they had lasted 
 two years, the mother brought her to my clinic, and 
 with her a lad aged eleven. He was a puny, fee- 
 ble, pallid boy, easily alarmed, and so nervous that 
 he could hardly answer my questions. It seemed 
 that nearly six months before I saw him, he ran a 
 nail into his foot, and, about the time the wound 
 healed, had something like an hysterical attack, which 
 seems to have impressed him with the idea that he 
 was afflicted in the same manner as his sister. Soon 
 after this he had what the mother called a spasm, 
 whenever the girl was attacked, and still later when 
 he heard she had a convulsion, or at times without 
 this suggestive cause. His attacks began with tremor. 
 He was said then to become insensible and to shake 
 all over violently. There was no tongue biting, and 
 no coma following the attack, and no facial spasm. 
 After becoming satisfied of the psychical origin of his 
 disorder, I ordered him a cold douche whenever at- 
 tacked, and directed that he should have the hot iron 
 applied to his neck if the attacks did not cease in a 
 month. At the same time the sister's fits were con- 
 trolled by bromides, so that he ceased to have before 
 him the constant incitement to attacks. Without 
 further treatment, the boy's fits, if I may so call them, 
 promptly disappeared, not all at once, but by degrees, 
 and he is now well. That in this case the fits of /the 
 boy were imitative is clear enough — that withont the 
 model before him they would not have arisen is plain. 
 
MIMICRY OF DISEASE. 65 
 
 We need not ask a cause for simpler forms of imi- 
 tation, as seen in normal functional acts, as when the 
 micturition of one in a herd of cattle awakens the 
 idea among the rest and leads all of them to follow 
 the example. The imitative tendency is a useful part 
 of our developing powers, but here in cases like that 
 of this boy, where there are other children, he alone 
 imitates. Does the terror he only as a timid nervous 
 lad feels, intensify his imitative faculty, and what 
 motive is there for yielding to such a tendency ? It 
 may be that there is a certain pleasure in giving way 
 to instinctive imitative propensities, and moreover we 
 must all have observed how some sick children enjoy 
 the important role of being ill, of being coddled and 
 attended to, and this is especially noticeable in large 
 families, or in asylums, where usually no one child 
 receives in health undue attention. Such aids as 
 these there are, no doubt, to cases of mimicry, while 
 sometimes the patient's surroundings are to be blamed, 
 as fastening the disorder or even as giving such infor- 
 mation about symptoms as is consciously or not ap- 
 plied to the perfecting of them, the actor receiving as 
 it were, from a too sympathetic audience, hints which 
 enable him the better to sustain his part. 
 
 Some of you saw but lately the case which sug- 
 gests these remarks. Here, again, the actor was a lad. 
 The following details of his case I owe to his physician, 
 Dr. Benjamin Smith, of Falsington, in this State: — 
 
 0. F., ast. 9, had at school a slight chill, and in the 
 evening thereafter headache and fever ; he was well 
 next day, but was said to have had headache the day 
 
 6* 
 
66 DISEASES OF THE NERVOUS SYSTEM. 
 
 following. At this date the doctor found him suffering 
 from great tenderness at several points of the spinal 
 column. He could not recall having hurt his back, 
 but a few days later declared that he then remem- 
 bered having fallen so as to strike the back, and that 
 the pain was severe ; also, that, on the same day, he 
 had fallen so as to hurt his head. Both falls were 
 said to have taken place on December 25th. 
 
 As soon as the tender spine and headache were 
 known to exist, the lad was kept at home and anx- 
 iously cared for, while the pain in the head increased 
 and extended at last to the spine. At this date a 
 remarkable dilatation of the pupils was observed, 
 and, the pains increasing, he would lie in bed and rub 
 his head for relief, or have it rubbed. Meanwhile 
 his pulse was not above 80, and did not rise with the 
 presumed increase of pain ; nor did he lose appetite. 
 
 About the fourteenth day the headache was said 
 to be at its worst, pains arose all over the body, and 
 the muscles of the neck began to be complained of 
 as sore and stiff, while nausea and pretty violent 
 vomiting added to the alarm which his case excited, 
 being set down, despite Dr. Smith's opinion, as an 
 attack of cerebro-spinal meningitis. At this time, 
 after the vomiting ceased, there was a sudden cessa- 
 tion of all the symptoms; but in a few days more his 
 troubles returned, and with dreadful complaint of 
 head- and back-aches, with universal soreness and 
 utter inability to walk, he was at last brought to me 
 for an opinion and for treatment. His case had then 
 lasted five weeks, and was supposed by some phy- 
 
MIMICRY OF DISEASE. 67 
 
 sicians and by his relatives to be of a dangerous 
 gravity. 
 
 When I saw this lad he was lying in bed, some- 
 what flushed, but not in a bad condition ; his pulse was 
 85 ; his breathing 20 ; his temperature normal. His 
 eyes were bright, and I was struck, as Dr. Smith had 
 been, by the widely drlated pupil. He was constantly 
 declaring that his head hurt him, and it was, as I 
 observed, very notably retracted, the muscles of the 
 neck being stiff and tender. Any effort to flex the 
 head gave rise to tears, remonstrances, and urgent 
 cries of pain. The scalp was everywhere tender and 
 the whole of the erector spinas masses were also sore, 
 so that the least tap or touch upon them caused him 
 to cry. His legs were gathered up close to his body, 
 and, besides some loudly expressed annoyance when 
 exposed to a bright light, he complained bitterly of 
 the vibrations caused by carriages passing or of the 
 steps of his nurses when they moved across the room. 
 
 If, however, he were interested in anything, I 
 found that I could flex the head or touch the spine 
 without causing pain until his attention was recalled 
 to the act. This — with the absence of fever, the 
 calm pulse, the fair appetite, and a certain watchful 
 and furtive expression — led me to believe that he 
 was more or less consciously mimicking disease. As 
 soon as I felt secure in my opinion, I lifted the lad 
 out of bed, and, with severity, ordered him to stand 
 up ; he hesitated a moment, and then dropped the 
 flexed limbs under him, lifted his head at a second 
 order, and, as I released him, walked to his bed — a 
 feat which he had been supposed to be utterly unable 
 
68 DISEASES OF THE NERVOUS SYSTEM. 
 
 to do. After this there was no trouble; he was kept 
 out of bed, and, with a rough rubbing daily and a 
 little urging, was able to play in the garden in three 
 days and to go home in a week. His pains, stiff 
 neck, and tender spine were never heard of after the 
 first day in the hospital. I was careful to have him 
 kept on a farm away from his home for some months. 
 There has been no relapse. 
 
 This case excited great attention, and was the centre 
 of the too affectionate regards of many relatives. The 
 lad became early aware that he was believed to be in 
 grave danger. His head and spinal pains were attri- 
 buted to meningitis and the symptoms discussed in 
 his hearing. Only thus can we account for his curious 
 condition, when, in the face of opposition founded on 
 his presumably serious state, Dr. Smith brought him 
 to me. 
 
 I saw some years ago a like case in the person of a 
 young woman who had nursed two cases of cerebro- 
 spinal meningitis. Her imitation was admirable and 
 for some days took in both her own physician and 
 myself. 
 
 Careful use of the thermometer and a rigorous 
 study of symptoms can alone enable us to avoid such 
 traps as these. They illustrate what may occur in 
 nervous people, under the influence of depressing 
 agencies and when surrounded by too great sympathy 
 and by all the information needed to enable them to 
 act a part. 
 
 The lessons which such cases teach us are obvious 
 enough. The need for care in discussing symptoms 
 before nervous women or children, the necessity of 
 
MIMICRY OF DISEASE. 69 
 
 early apprehension of the true state of things in 
 simulated disease, and the wisdom of acting decisively 
 when once we are sure of our ground, are all of them 
 points on which it is hardly needful that I should 
 dwell. 
 
 On my return from Europe in October, 1880, I was 
 asked by Dr. Stryker to see in consultation a number 
 of cases at the Church Home for Children, and, 
 as these present the most amazing illustration of 
 mimicked disease I have ever seen, I shall describe 
 them as being the best possible illustration of nearly 
 every point on which I have dwelt. The home is a 
 handsome, wholesome asylum for children, and is 
 situated a few miles from Philadelphia. It contained 
 about 95 girls and but 6 boys. Both the sick and 
 well when I saw them were amply-nourished, and 
 healthy-looking ; nor was it possible to find in their 
 home or in their habits any influences which could be 
 credited with giving birth to neurotic tendencies. The 
 diet w r as good, the hours regular, the play and out- 
 door life sufficient ; neither was there in the education 
 given, nor in the religious training, anything with 
 which it was possible to find fault from a medical 
 point of view. 
 
 Dr. Stryker gives me in substance the following 
 account: Margaret Trimble, aet. 12, a rosy and sturdy 
 brunette, in admirable health, is one of a neurotic 
 breed, there being in the immediate family two cases 
 of infantile palsy. On September -1th, in the dormi- 
 tory, when in bed at night, she began to have without 
 known cause, unless it might have been a trifling indi- 
 gestion, slight convulsive twitches of the arms and 
 
TO DISEASES OF THE NERVOUS SYSTEM. 
 
 legs, with a little numbness of the extremities. This 
 was a matter of a half hour, and she got up well next 
 day. There were no further attacks until the 11th, 
 and thenceforwards they returned daily. At first she 
 was well in the intervals, and slept and went about 
 like the other girls. Her respiration during the 
 attacks was harsh and noisy, and she made at each 
 inspiration a loud crowing noise, much like the breath- 
 ing in croup. The attacks, rare at first, soon became 
 frequent, and lasted from fifteen minutes to three 
 hours; attention from others inevitably brought them 
 on, even when she was seated and laughing or chat- 
 ting with her companions. She would then slip down 
 to the floor, and hands, feet, and body would be seized 
 with uncontrollable convulsive motions, so that it was 
 impossible to keep upon her person clothes or bed 
 covering. During an attack she lay on her back, or 
 rolled from side to side, while both arms and legs 
 thrashed the floor with quick and hard blows. The 
 body was lifted from moment to moment, and thrown 
 down again with violence, in a fashion strange to see. 
 Meanwhile, her face was contorted with swiftly chang- 
 ing grimaces, and the tongue thrust out and drawn in, 
 while her head was thumping hard on the floor. 
 Sleep was apt to follow a fit, and there was at times, 
 and later in the case, a good deal of choreoid difficulty 
 in moving, or in handling objects; at times the crow- 
 ing existed alone, and at times the legs became feeble, 
 and she stumbled and fell about. 
 
 This child was sent to the Hospital of the Univer- 
 sity of Pennsylvania, where she remained two months, 
 under the care of mv friend, Professor Horatio Wood. 
 
MIMICRY OF DISEASE. 71 
 
 Dr. Musser, the Registrar, sends me his notes, from 
 which I add the following particulars: — ■ 
 
 The muscles of the face, neck, eye, and tongue were 
 at this time unaffected by the spasms. "While seated 
 she swayed backwards and forwards in clonic spasms. 
 When lying down, her spasms were much as I have 
 described them. There was lack of coordination in 
 all arm and hand movements, but no anesthesia any- 
 where. There was tonic spasm of the adductors of the 
 thighs, and in a slight degree of the flexors of the fore- 
 arms. All movement ceased in sleep. There was no 
 lesion of the eye ground. The urine was normal. 
 There was a slight systolic roughening at the apex of 
 the heart. The usual remedies for chorea having failed, 
 the actual cautery was twice used on the spine, but 
 with no better fortune. Etherization on a full stom- 
 ach caused vomiting for twenty-four hours, and a 
 permanent relief of all the symptoms. Under careful 
 and systematic training of the muscles, with much 
 urging, and a good deal of scolding, she made finally 
 a complete recovery. 
 
 This girl's case was seen by many of her comrades, 
 and not only excited their amusement and curiosity, 
 but led some of them to imitate her "bark," so that 
 they were reproved by the matron for their tricks. 
 
 On September 8th, Dr. Stryker being in the home, 
 Kate Nichols, a wholesome looking girl of 10, was 
 brought to him in the nursery, in what seemed at 
 first to be a sharp attack of false croup. She was 
 breathing hard, gasping, crowing, speechless, and 
 wildly clutching at her throat. Her possible relation 
 to the first case was not then understood, and she was 
 
72 DISEASES OF THE NERVOUS SYSTEM. 
 
 treated as if for croup. The trouble persisted all day, 
 and was noted as made worse by noise, or any ex- 
 citement, and to be by and by associated with slight 
 convulsive jerkings of the limbs. Meanwhile, the 
 pulse was rapid, but there was no fever. The follow- 
 ing night all of these troubles passed away in a sound 
 sleep, from which she awakened crowing and barking; 
 and after a day of increasing nervous agitation, ex- 
 ploded in a convulsion, identical in character with that 
 of case ISo. 1. The attacks thereafter increased in 
 violence, but all of her functions were well performed. 
 She ate, drank, and passed urine and feces as usual, 
 and when free from convulsions was merry and pleas- 
 ant, until the approach of a nurse with medicine, or 
 the visit of a manager to the Infirmary, started her 
 off anew. From the outset she began to lose power 
 in the limbs. When held up she would start fairly, 
 but instantly the legs became convulsed, the feet 
 tripped one over the other, and she fell in a fit on the 
 floor. 
 
 The girl was also treated at the University much 
 as the last case ; the cautery was of little use, but the 
 effect produced by ether on her comrade had a de- 
 cidedty good moral influence, and seemed to have a 
 good deal to do with her recovery. 
 
 Case 3. — On September 9th, Sallie Speer was seized 
 w^ith the same form of respiratory spasm, but with 
 the crowing noise there was a continuous chattering 
 of the teeth, like that of a bad ague chill. On the 
 10th the usual convulsions came on, she having 
 ample preparation from seeing those of the other 
 children. In a few days all of her symptoms passed 
 
MIMICRY OF DISEASE. 73 
 
 awaj, and she returned to the school-room, for a week, 
 when the same disorders reappeared, and she was once 
 more placed in the nursery. 
 
 Case 4. — Florence Pierce, aet. 12, had about the 
 11th like attacks, but, besides the usual convulsions, 
 she had remarkable mydriasis in the intervals. While 
 yet able to walk she had singular attacks of festina- 
 tion, and if going towards her bed would run furiously 
 and be thrown headlong across it, and on to the floor 
 beyond. Generally she crawled about on her hands 
 and knees, with her head swaying about as if it was 
 held up with difficulty. 
 
 Case 5. — Miriam Drinkhouse, aet. 11, was depressed 
 on account of having been placed in a lower class than 
 her comrades, owing to her inability to keep up with 
 them in their studies. Next day she was unable to 
 stand, and her first fit followed on October 13th. 
 
 Case 6.— Fannie Clark, aet. 12, was taken ill with 
 respiratory spasms, and the same convulsions about 
 October 13th. She had also remarkable coldness of 
 feet and hands, which was not observed in the others. 
 
 Florence Mack, aet. 8, Sarah Nolen, aet. 12, Florence 
 Mulligan, aet. 10, Bella Burk, aet, 11, Mary Mitchell, 
 aet. 12, were all taken about the 12th to the loth of 
 October. Their symptoms were much the same as 
 those above described. There were also a number 
 of other cases, some slight and some severe. Owing 
 to want of space all the first cases were placed in the 
 two adjoining rooms of the infirmary. Here they 
 were seen by one another, and also more or less by 
 such girls as were engaged in the housework. Other 
 cases were soon added, and at last there were at 
 7 
 
74 DISEASES OF THE NERVOUS SYSTEM. 
 
 least ten cases in the apartments mentioned. The 
 results of this companionship may be easily imag- 
 ined; at first the convulsions were irregular as to 
 time, but after awhile they took place only in the 
 evening, and later still in the morning and the even- 
 ing; although at any time a visit such as mine, or that 
 of Dr. Stn r ker, or of a lady manager was sufficient 
 to start the attacks. Then one girl would begin to 
 bark or twitch, then a second and a third, until on 
 bed or floor, or seated, ten or twelve children were 
 wheezing, barking, grunting, crowing, or in violent 
 convulsions ; while the bewildered nurses ran from 
 one to another, presenting a scene quite astonishing 
 to witness. 
 
 During a few days there were many interesting 
 variations in this singular maladv. On one occasion, 
 all of the children in the sick ward got out of bed at 
 night, and took to walking about on their hands and 
 knees ; at other times some of them described in 
 soliloquy dreams, one saw black men, another, whose 
 mother had been recently pregnant, described herself 
 as having had a child, and mentioned the luxuries she 
 considered desirable for a person so situated. More 
 commonly the girls were scared, or said they were, by 
 wild beasts, and one child would adopt the vision 
 which another related within her hearing. After con- 
 sultation all of the cases were scattered about among 
 different hospitals, 1 where, as a rule, they made prompt 
 recoveries, under somewhat various treatments. The 
 cases lasted from one month to three. 
 
 1 The Jefferson College, the Presbyterian, and the Episcopal 
 Hospitals. I am indebted to Dr. Starr for full notes of several of 
 the cases. 
 
MIMICRY OF DISEASE. 75 
 
 LECTURE IV. 
 
 MIMICRY OF DISEASE. 
 
 The cases with which I have illustrated this sub- 
 ject of mimicry of disease have been, so far, some- 
 what simple and uncomplicated; nor could they have 
 readily or long deceived any watchful physician who 
 had had any experience of neurotic maladies. There 
 are, however, more complicated cases to be met with, 
 and some of these are remote from those so far de- 
 scribed, in that the symptoms were not imitated from 
 models ready at hand, or wholly learned from gabbling 
 nurses or relatives. 
 
 They exhibit also the curious progress from simu- 
 lation, not consciously imitative to conscious unre- 
 sisted simulation, and at last dissimulation. I shall 
 relate here two admirable instances of these inter- 
 esting combinations of mimicry passing into well- 
 sustained fraud. 
 
 A good many years ago I saw, one evening, a girl, 
 aged 13 years, who had never had any of the maladies 
 of childhood excepting measles. When her new trou- 
 bles began she was not as yet menstruating, nor did 
 she show any notable signs of womanly development. 
 
 In January, 1866, when skating, her right instep 
 became chafed severely, and for this she was kept at 
 rest for two or three weeks, but received very little 
 
76 DISEASES OF THE NERVOUS SYSTEM. 
 
 care from her mother, and, in fact, needed but little. 
 One day an attack of indigestion ended in vomiting, 
 which was very violent, and which brought about her 
 all the sympathy her elder relatives could give. From 
 this time her appetite failed, and the vomiting re- 
 curred at intervals. Long after, she told me that she 
 could have vomited less, but that everybody was kind 
 when she was so sick. Here, at least, was a distinct 
 failure to resist, and probably a desire to aid, in pro- 
 ducing sickness of stomach. The vomiting grew more 
 frequent in the spring, and after a fortnight of fever, 
 which she is said to have had in June, 1866, all food 
 was thrown up, and the bowels were opened only 
 once in ten days, or even less often. These conditions 
 persisted through 1866, with little change, the child 
 rejecting everything, and growing at last sallow, and 
 desperately wasted. The skin became sensitive to 
 touch, so that no water could be used for fear of caus- 
 ing convulsions, and most of the time she was shaken 
 by violent hiccough. 
 
 The vomiting, at first accidental, was thus at last 
 aided and cherished for a purpose, until, as often hap- 
 pens, the morbid act became habitual and despotic. 
 But in a nervous system such as this child's no such 
 habit could persist without giving rise to other symp- 
 toms as grave, while these in turn would be nursed 
 and developed to win and keep up the sympathy, 
 attention, and importance, which are among the un- 
 natural moral appetites, of a nature once started upon 
 this disastrous road so strewn with multiple dis- 
 orders. When such persons get well, their lips are 
 so surely sealed by shame and self-disgust, as to make 
 
MIMICRY OF DISEASE. 77 
 
 it difficult to verify by frank confession the suspicions 
 which arose in the minds of bystanders, or to trace 
 the fatal steps by which the victim descends, from the 
 state in which she welcomes a symptom, to the degra- 
 dation of creating symptoms. My patient, when first 
 seen by me, had been abandoned, as in a dying state, 
 by two homoeopathic physicians, who had left for her 
 use a prescription of rather ample doses of morphia. 
 The picture which this child presented when first 
 I saw her was not readily to be forgotten. She was 
 lying on her back, staring upwards, with glassy eyes 
 set deep in dark rings, which faded into a sallow lea- 
 thery skin, drawn tense over projecting bones. Her 
 mouth was wide open, the jaw dropped, and the whole 
 cavity literally lined with thrash (muguet). 1 The 
 skin of the body was dry, and splotched with islets of 
 dusky red, and the bedclothes were kept off' of the 
 sensitive surface by a shelter of half-hoops. As I stood 
 and looked at this singular spectacle, apparently that of 
 a dying child, she groaned at brief intervals, and also 
 coughed a good deal, at such times expressing pain in 
 her face, but usually lying quite still, with a look of 
 merely the most profound melancholy. A careful 
 study enabled me to find no organic disease. Her 
 urine was so scanty that she often passed but two 
 ounces a day ; but this was not albuminous ; the belly 
 was very tender to touch, although, if I distracted her 
 attention, neither touch nor pressure caused any sign 
 of pain; attention was needful to enable her to feel 
 these pains, but as it may be said that attention is for 
 
 1 The coating of oidium albicans was the most remarkable I have 
 ever seen. 
 
 7* 
 
78 DISEASES OF THE NERVOUS SYSTEM. 
 
 all pain a reinforcing element, too much stress must 
 not be laid on this point. I noticed, however, that 
 this wretched, wilted, starved creature followed my 
 motions with attentive eyes, although she never turned 
 her head. 
 
 I asked for milk, and put within her lips a table- 
 spoonful, for which she closed her mouth ; a moment 
 passed, and with a gulp she threw it up. I repeated 
 the dose, keeping a finger on the larynx. Again she 
 threw up, or seemed to; for, as the larynx did not 
 make the usual upward movement which accompanies 
 the act of deglutition, it was clear that she had not 
 swallowed at all. I watched this neat little fraud 
 several times. Usually she swallowed a part of each 
 mouthful, and, holding the rest in her mouth, sud- 
 denly cast it out with a very fair imitation of the 
 convulsive act of emesis. When quite sure of having 
 correctly observed her, I abruptly charged her with 
 the deceit. At first she denied in a faint voice, 
 and saying she couldn't help it, began to cry. A 
 little sternness enabled me to get down her a full 
 glass of milk. I then cleared the room of all her 
 friends, threw away the hoops, and sat down by her 
 side. She Avas evidently conquered and alarmed, 
 which I did not wish her to be. I therefore took 
 her hand quietly, and told her that she could get 
 well ; that milk was needful ; that, if thrown up, it 
 would be given again, and that I meant to feed her 
 whether she liked it or not. 
 
 The after-care, which owed its success largely to 
 the care of Dr. Wm. W. Keen, was arduous enough. 
 The belly — and, indeed, ihe whole skin — was rubbed 
 
MIMICRY OF DISEASE. 79 
 
 twice a day with sweet oil; milk was given freely 
 ami often, and the bowels rid of their packed con- 
 tents by the use of frequent enemata. I found the 
 spine exquisitely tender, but, as is often the case, this 
 was much helped by ice-bags (dry cold). Meanwhile 
 the thrush faded under the use of washes of sulphite 
 of soda. The patient's head was elevated a little day 
 by day, and the diet was increased and varied. The 
 bowels proved so obstinate that nothing but croton 
 oil moved them, and the trouble of swallowing per- 
 sisted for some time, although lessened whenever her 
 attention could be called away from the act of deglu- 
 tition. Incessant attention to the muscular apparatus 
 of the throat had made the use of these parts diffi- 
 cult, and swallowing having ceased to be automatic, 
 was re-embarrassed by every new concentration upon 
 it of an act of will. When she received milk in her 
 mouth it always rested there for some time ; if, how- 
 ever, the head was thrown back, and at the same time 
 the larynx pushed up by a hand, this sort of hint 
 usually proved successful, and the movement of de- 
 glutition was completed. By degrees this trouble 
 passed away, and she gained in strength so as to sit 
 up, and after awhile to stand. 
 
 The use of induction currents to the disused mus- 
 cles w^as a further help, and, with the gain in power, 
 came back easier movements of bowels and bladder, 
 and a more wholesome moral tone. Within six weeks 
 the girl was able to call at my house, and she is now, 
 I believe, the healthy mother of a family. 
 
 I could never extract from this child, when well, 
 anything beyond the statement that she "just could 
 
80 DISEASES OF THE NERVOUS SYSTEM. 
 
 not help it;" and if I pressed her further, she said 
 she was sorry, and took refuge in tears. 
 
 About two years ago I saw, with Dr. Finn, a case 
 quite as remarkable. The girl, aged thirteen years, 
 living in Ohio, after an attack of ague, began to limp 
 a little one day, and said she had a pain in the right 
 knee. A physician examined it, and told her parents 
 quite trnly that there was no cause for alarm, ad- 
 vising at the same time exercise, and a let-alone 
 treatment. This would have answered well, and 
 have saved much trouble, had not some one per- 
 suaded her mother to ask advice of the travelling- 
 agent of a surgical institute, who diagnosed hip-joint 
 disease, put on a temporary splint, and arranged to 
 cure the child at the institute. From this time, when 
 the little public opinion about the girl pronounced 
 for a grave malady, she grew speedily worse, and 
 under the influence of the discussions as to the hip- 
 joint disease and its symptoms, she began to act out 
 as fully as possible the pathological drama so foolishly 
 taught her. The pain increased, and the leg con- 
 tracted at the knee and hip. At the institute things 
 grew worse, and very soon there was double hip dis- 
 ease, and local applications, and splints, many and 
 wonderful. But when one of these curious cases is 
 well engaged in this career of simulation, there comes 
 a time when, either because the first trouble no longer 
 excites sympathy, or for more complex reasons, these 
 forms of disease become progressive and invasive. 
 In our little patient, the contractions of the thigh re- 
 maining, the arms, especially the left, became flexed, 
 the feet being in full extension. At this time hyster- 
 
MIMICRY OF DISEASE. 81 
 
 ical spasms came on ; the eyelids elosed, and remained 
 shut ; and, most strange of all, she was unable to 
 eat before 9 o'clock P. M. In this state the child 
 was first seen by Dr. Finn, who removed her to quiet 
 lodgings, where soon afterwards I saw her, and heard 
 this exasperating history of folly and quackery. As 
 I first saw her, she la}' on the bed, her back to the 
 light — a queer little shrivelled creature, tawny of 
 tint, and the skin covered with bran-like scales, wash- 
 ing being a rare ceremony. Legs and arms were 
 drawn up so as almost to hide the thin, ancient-look- 
 ing and cunning little visage, which seemed so blind 
 with its closed but quivering lids, and yet so unnatu- 
 rally astute in its intentness of attention when her 
 own case was mentioned or discussed. 
 
 Her right hip was red and swollen, and the thumbs 
 of both hands had been so long and tightly contracted 
 as to have caused the palms to ulcerate, while the 
 whole skin was sensitive to such a degree that the 
 bedclothes were not allowed to touch her, and she 
 uttered a muffled cry of dismay and seeming terror 
 at every approach ; her voice was reduced to a faint 
 whisper, and she was said to be totally blind. 
 
 The treatment in this case was of easy enough 
 application in a child. A single nurse was left in 
 charge. The legs were violently straightened and 
 their owner invited to set them in order, so as to 
 avoid in future this abrupt and painful treatment. 
 "We were told as usual that she never could eat until 
 nine P. M., and wonder was expressed that, having 
 her eyes shut, she was able to know what o'clock it 
 was. The clock on the mantel was an obvious aid, 
 
82 DISEASES OF THE NERVOUS SYSTEM. 
 
 and at all events, when set forward two hours, the 
 nine o'clock meal was asked for at seven. The gain 
 in this case was steady and easy enough. I lost sight 
 of the child after she left us to return home, but at 
 the time of her departure she was nearly well, and, 
 I learn, has entirely recovered. 
 
 I have often thought that, if I could induce older 
 patients who had been affected more or less like these 
 children to relate to me their histories with sufficient 
 frankness, I should obtain a larger insight into the 
 motives which prompt them to cultivate or to create 
 symptoms. As interesting additions to this rare 
 branch of medical autobiography the three letters 
 which I subjoin must suffice : — ■ 
 
 II The period of my life about which you ask me, 
 I can only look back upon with a sort of disgust 
 which makes it unpleasant for me to speak about ; it 
 is only the hope that some one else may be helped 
 by it which makes me willing to speak of it at all. I 
 was brought up by an invalid aunt, and I often think 
 of what you once said to me, that the women who 
 indulge their own nervous systems are those who 
 most indulge children. My aunt taught me very 
 early to notice and dwell upon any little symptom I 
 happened to have, and, when I was fourteen, I un- 
 luckily hurt my knee. For this I was kept in bed 
 two weeks, and, when I wanted to get up, I was told 
 to keep quiet. Under this enforced rest my appetite 
 failed, and I began to have nausea. My first vomit- 
 ing: created a sensation in the household, which I 
 think, as I recall it, I enjoyed as making me impor- 
 tant. Yery soon I got to vomiting every day ; there 
 
MIMICRY OF DISEASE. 83 
 
 was none of the nausea which I had at first, and 
 which I have since been familiar with as a part of 
 sea-sickness. It gave me no annoyance to cast up 
 my food, and was indeed rather a relief. From this 
 time I was surrounded with sympathy and doctors. 
 A few months later my aunt died and I was left in 
 charge of an uncle and aunt, and became one of a 
 large circle of children, among whom I got very little 
 of the care which had before this encompassed me. 
 I remember well that I resented the change, and, 
 finding that if I took little food I excited alarm. I 
 began to yield to the tendency to excite distress and 
 anxiety by taking little or no food at times. I sup- 
 pose this abstinence gave rise to the nervousness, 
 and finally to the spasms which came on at this time, 
 at least I can give no further explanation ; I only 
 know that every new symptom caused new anxiety, 
 and that I somehow liked it all. After a while a new 
 doctor was called in, and under his rule, which was 
 very stern, I got better, and was able to leave home 
 and go to the seashore, where, under new influences 
 and interests, I lost all of my symptoms except the 
 vomiting, which seemed to me uncontrollable. I lost 
 this only by resolute efforts; in fact, by efforts so 
 desperate that often, when food rose in my mouth, I 
 swallowed it again. I do not think I should ever 
 have so tried if I had not overheard a person in w r hom 
 I had a great interest express himself as having heard 
 with disgust of my habit. Then, as you know, I 
 learned from you that the habit could be broken ; I 
 succeeded, as you know, and am married and have a 
 little girl, and I can promise you that she at least 
 
84 DISEASES OF THE NERVOUS SYSTEM. 
 
 will never be allowed to go through what I have 
 done." 
 
 I presume that this partial self-analysis is as near 
 to a full and truthful statement of the motives which 
 urge to mimetic fraud as we are likely to get. I 
 have been told by one woman that she was as irre- 
 sponsible as one in a dream ; while more usually you 
 are told simply "I do not know why I did it ; I could 
 not have meant to deceive any one." My next extract 
 from these confessions is in some sense honest enough, 
 and, as I said before, is curious, both as to what it 
 reveals and what it hides. The writer is long since 
 dead, and I am therefore at liberty to use her letter 
 with such precautions as make identification im- 
 possible. 
 
 I had seen my patient in the morning and received 
 this letter in the evening. For several weeks she had 
 been under my care with these conditions, a good rosy 
 color, fair weight, and regular functions ; but at times 
 enormous losses of urine and intense spinal irritability, 
 which forbade her to stand or to walk a step. For her 
 food she ate a chop at breakfast, and no other food 
 the rest of the day. You must not understand me to 
 say that I accepted all these statements, but merely as 
 briefly sketching what seemed to be her state. This 
 very pretty invalid was a charming and witty, and 
 most accomplished person. After her husband's 
 death, she had taken to her couch, and, despite aches 
 and ailments, was .in her becoming sick outfit the cen- 
 tre of an attractive circle, which gladly gathered about 
 the couch, on which she was carried from room to 
 room. I hardly know under what circumstances she 
 
MIMICRY OF DISEASE. 85 
 
 developed the full range of her powers. The irri- 
 table spine came first, and as one doctor after another 
 was consulted other symptoms were added to her 
 repertory. 
 
 She had been some little while under my care 
 when I saw two things which confirmed m} r well- 
 grounded suspicions as to the nature of her case; she 
 slept alone, disliking the constant presence of a nurse ; 
 but she rarely failed to ring for her attendant twice 
 every night. 
 
 The last mornino- I saw her I had occasion to look 
 
 o 
 
 at her feet, and noticed that her soles were dotted 
 with black marks; coupling this with the fact that 
 she had complained of her wood fire as having smoked, 
 I concluded that she had been afoot in the night, and 
 that the dark marks came from " blacks" on the floor, 
 the result of a defective fire draught. A moment later, 
 observing some crumbs on her bolster, I asked her to 
 sit up that I might examine her spine. As she rose, I 
 threw aside her pillow, and saw under it two oranges, 
 several slices of bread, and a banana. To my amaze- 
 ment she said coolly, "Well, now I am caught: I 
 thought you would do it soon or late." My rather 
 sharp remonstrances seemed only to amuse her, and 
 that evening I received the letter, a part of which I 
 print. 
 
 "Before this reaches you I shall have made arrange- 
 ments to leave. The game I have played on you I 
 have played on others, and in my restricted life I 
 have found it very amusing. You must not blame 
 my maid, as I paid the woman who cleaned the room 
 to bring me food. I found that doctors got tired of 
 8 
 
00 DISEASES OF THE NERVOUS SYSTEM. 
 
 my sore back, and that they ceased to feel interest in 
 me, a thing I never did like, so I began to complain 
 of queer symptoms, and as this often aroused new 
 interest, I went on experimenting until I hit on the 
 starvatiou idea, which has done very well ; of course 
 
 1 got up at nights and walked a good deal too, but 
 how you knew it I would like to know. As to the 
 urine, I used to fill up the vessel with water. I hope 
 you will not tell my doctor at home, you would take 
 away a good deal that is pleasant, and spoil an inter- 
 esting case too." 
 
 These are the only cases of this form of moral 
 obliquity, in which I have ever been able to get a 
 free confession. They expose, I fancy, to some ex- 
 tent, the motives which underlie the duplicity of 
 such Avomen. 
 
 The last of these statements is more recent, and I 
 have permission to print it. It is in some ways more 
 valuable than the others ; the belief this woman at 
 last reached as to the want of foundation for her pre- 
 sumed physical disabilities, and her continued con- 
 viction that the pains were as distinct as any pain, 
 must, I think, be received with respect. I am sure 
 that she has done her best to analyze her symptoms 
 truthfully. 
 
 She came to me on a couch, or litter, from a "West- 
 ern State, a girl of 19, not wasted, and of good tints. 
 She was said to be unable to walk, motion hurt her ; 
 and her eyes were carefully guarded from light by a 
 double bandage. She was kindly but firmly treated, 
 and was able in a few days to bear sunlight, and to 
 go downstairs. When once she had been made sure 
 
MIMICRY OF DISEASE. 87 
 
 that all this could be clone without death, I allowed 
 her to go forward more slowly, with such help from 
 tonics, good diet, etc., as I could give. She very often 
 talked to me about the cause for her disorder, and out 
 of my inquiries and interest in her case came the self- 
 analysis I append. It needs no commentary. 
 
 "I suppose, in all cases of nervous affections, one's 
 natural temperament and constitution play an impor- 
 tant part, and, doubtless, with me, a temperament 
 rather emotional, sensitive, and occasionally morbid, 
 had something to do with making possible the state 
 I was in when I went to see Dr. Mitchell, in Decem- 
 ber, 1879. 
 
 "The immediate cause for the headaches, which 
 began a year before that time and never left me after 
 it. seemed to be a few weeks of mental and social 
 strain. I had for two years before that time suffered 
 from a weak back, had felt constantly tired, spent 
 much of my time on the bed, and taken but little 
 exercise. But in the fall of 1878 I felt much better 
 and undertook study and class recitation, and became 
 much interested in some evening literary and social 
 clubs. For a few weeks I went every day to the 
 utmost limit of my strength, and was then suddenly 
 prostrated with severe headache and excessive weari- 
 ness. 
 
 "I, of course, tried quiet and rest immediately, and 
 after a while grew better, but had a return of head- 
 ache and weariness whenever I tried exerting myself 
 much again. There is no question that what I lacked 
 then was courage. If some one could have told me 
 that there w r as nothing of consequence the matter, I 
 am sure I should have overcome the difficulty and 
 
88 DISEASES OF THE NERVOUS SYSTEM. 
 
 very soon have gained endurance by exertion ; but, 
 instead, I became afraid to do things for fear of bring- 
 ing suffering, and, as month after month passed, I 
 could do less and less. I cannot now understand why 
 I could not have seen, why I could not realize that 
 the less I did the less I could do ; but I was blind, 
 and so was every one else. I thought it was some 
 strange, mysterious disease that was taking away my 
 strength. By summer, a few minutes' conversation 
 or the walk of a block would make the pain in my 
 head agonizing, and every sound became unendurable. 
 My eyes, too, shared in my good-for-nothing state. 
 
 "In the fall, the pain went into my back and limbs 
 and sent me to bed with the strange infatuation that 
 I could not move without injury, as 1 certainly could 
 not without pain. I had lain in one position with 
 closed eyes for eight weeks, before going to Dr. 
 Mitchell, in a state of supposed helplessness. One 
 thing I want to say in extenuation of myself, and 
 that is that the pain was real, not fancied. Whatever 
 its cause or however easily it might have been 
 averted, it was genuine suffering at the time. I was 
 scarcely ever hysterical either in the usual sense of 
 the term, for, at least, I realized the necessity of self- 
 control. 
 
 "In looking back over that year with the light of 
 the present, I can only say that I believe there was 
 nothing really the matter with me, only it seemed as 
 if there was, and, because of those sensations, I carried 
 on a sort of starvation process, physical and mental. 
 Why that process should have brought me into such 
 a condition, I must leave with some one wiser than I 
 to unriddle." 
 
SPASMODIC AFFECTIONS IN WOMEN. 89 
 
 LECTURE V. 
 
 UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN 
 WOMEN. 
 
 You will find, if you come to "have much experi- 
 ence in the cases of hysterical women, that in some 
 instances the disorder arises in general convulsions 
 following upon a state of acquired nervous instability, 
 and then runs on into a great variety of symptoms — 
 palsies, hyperesthesias, and anaesthesias, and contrac- 
 tions — to end, at last, in years of bed-ridden invalid- 
 ism, or, much more rarely, in spinal sclerosis. A 
 single case will thus give you, in disorderly and un- 
 expected succession, every scene of what I have ven- 
 tured elsewhere to call the drama of hysteria. 
 
 At the risk of repeating an old story, I have sought, 
 in one of these lessons, to relate some of these histo- 
 ries, chiefly that I might illustrate afresh the termi- 
 nation in sclerosis, and partly to show what might be 
 done to rescue certain of what seem to be the most 
 hopeless of these exasperating cases. 
 
 Apart from these, however, we see two forms of 
 hysterical disorder, in which the primarv signs are 
 either slight and aborted, or remain so inconspicuous 
 as to give but little aid in the early diagnosis. One 
 of these is marked by mental derangements, and is 
 usually treated as simply a causeless insanity until 
 
90 DISEASES OF THE NERVOUS SYSTEM. 
 
 some outbreak of the commoner forms of hysteric 
 signs reveals the true condition. I mention it here 
 only to complete my rather rude and partial classifi- 
 cation. The other is characterized by the extraordi- 
 nary variety and strangeness of the convulsive disor- 
 ders, which, for years, and from time to time, afflict 
 the patient ; all other symptoms being present rarely, 
 or in feebly-represented forms. I propose to relate 
 and discuss for you some of the most unusual of these 
 cases. 
 
 In 1871 I was consulted by an intelligent unmar- 
 ried lady, Miss L. P., ast. 26, from Mississippi, for a 
 condition of system which was probably due to cer- 
 tain emotional disturbances following a violent onset 
 of cholera morbus. The attack was repeated a few 
 days later. The day after, she had intense burning 
 pain between the shoulders and down the whole length 
 of the spine. This symptom lasted long, and with it, 
 for a month, during which she kept her bed, there 
 were brief periods of febrile activity. She is said to 
 have had no severe headache, and no uterine or uri- 
 nary symptoms. On first rising she found that her 
 legs were feeble, and this paresis was best marked on 
 the left side. 
 
 When first seen by me these symptoms remained 
 unchanged. The weakness of the left side was com- 
 plained of both in the arm and leg, and as affecting the 
 eye. She needed a supporting arm when walking, but 
 did as well in the darkness as in the light, and stood 
 fairly well with shut eyes. The left sole was slightly 
 less sensitive than the right. Above this there was 
 no dysesthesia. There was also no analgesia, and 
 
SPASMODIC AFFECTIONS IN WOMEN. 91 
 
 heat and cold were well distinguished. There was, at 
 times, a sense of extreme weight on the chest. The 
 burning pain in the spine was unequally distributed. 
 It was worse at the 5th and 6th dorsal vertebrae, and 
 was increased at night and by fatigue. The temporary 
 application of ice made it worse, and this increased suf- 
 ering was felt for some time afterwards. Elsewhere she 
 had no fixed suffering, but complained of darting neu- 
 ralgic pains almost at any point of the body. There 
 was no womb trouble of moment. On the left side there 
 was a large area of variable iliac tenderness, not great, 
 and sometimes absent. It was less on deep pressure 
 than on slight touch. The eye-grounds were normal, 
 but she was said to have at times double vision, if 
 very tired. 
 
 This case, as I recall it, puzzled me greatly, and 
 was finally treated as of organic cerebro-spinal 
 origin ; and this idea was strengthened by the fact 
 that at times there was distinct rigidness of the erec- 
 tor spinoe muscles. She came under my care first in 
 the autumn of 1872, and gradually improved. The 
 back was several times cauterized early in January, 
 
 1873, and great gain followed. Somewhat later a slight 
 and singular tottering of gait was seen ; but, on the 
 whole, the progress was good and steady ; so that, by 
 the end of January, 1874, she could walk with ease a 
 quarter of a mile on level ground. In February, 
 
 1874, Miss P. made the mistake of leaving home, 
 and subjecting herself to what was, for her, excessive 
 fatigue and much social excitement. Then, as always 
 since, fatigue brought on more or less nervousness, 
 and the singular forms of spasms which have proved 
 
92 DISEASES OF THE NERVOUS SYSTEM. 
 
 so enduring an annoyance. At the close of a day of 
 unusual fatigue, on rising from her chair to cross the 
 room, she suddenly staggered back, and then rotated 
 violently several times. These fits returned over and 
 over, and resulted within a week in fresh dorsal pain, 
 extreme lassitude, and a curious inability to keep her 
 balance. Meanwhile, the rotations were usually, but 
 not always, to the left. The loss of equilibrium was 
 great. On rising she would pitch forward, and then 
 sideways, and then turn swiftly. The pitching was 
 really convulsive, and not due to lack of balancing 
 power, and there was no subjective sense of giddiness. 
 She came to see me soon after, and was much worse for 
 the journey. During ten days of quiet here the rotatory 
 spasms gave place to violent and nearly constant spas- 
 modic jerking of the head backwards or forwards, to 
 right or to left. As this also departed she had a new 
 onset of what she called " twists," and thenceforward 
 turned only to the left. These spasms were amazing 
 things to see — suddenlv, while crossing the room, she 
 would rotate furiously to the left — about three to six 
 times. The turn was very rapid, and seemed to begin 
 with the spine. Then the head followed, and, as she said, 
 it seemed hard for the legs to keep up with the back. 
 At other times an irresistible power seemed to drag 
 her up on to her tiptoes, where she would remain a 
 moment, as it were, fixed. At this time she could 
 walk, or even run backwards, but a forward move- 
 ment was beset with difficulties. She would be, as it 
 were, hurled forward, and then rotate, or the effort to 
 move in a forward direction would end in a rapid 
 retrogressive stagger, followed by rotation to left. 
 
SPASMODIC AFFECTIONS IN WOMEN. 93 
 
 There was no vertigo execpt as a result of the spin- 
 ning. In June she went home, and from this period 
 she had a succession of slow gains with sudden re- 
 lapses. If leading a very quiet life, she sometimes 
 passed six months without spasms. Worry, fatigue, 
 excitement were all sure to bring them on. At times 
 there was no warning, but usually pain in the feebler 
 leg, nervousness and irritability were premonitory of 
 an attack. Then she would of a sudden find one leg- 
 oddly twisted around the other, or wonld be drawn 
 up on to her toes, or forced to walk on her heels, or 
 would pitch hither and thither, not from weakness, 
 but from alternating unilateral spasms. At these times 
 her will seemed to be absolutely suspended. "It is," 
 she says, "as if some other will power had me in 
 possession. I struo-o-le against it in vain." 1 
 
 x CO o 
 
 The first point to notiee in this case is its generic 
 relation to the class of functional spasms of Duchenne ; 
 those in which spastic movements are associated with 
 or follow some form of normal muscular action. 
 Such spasms do not arise during repose, and in this 
 sense chorea is at first, and in some cases throughout, 
 as I have elsewhere observed, a form of functional 
 spasm. 2 Perhaps I shall, in a measure, clear your 
 minds as to the nature of what I mean by functional 
 spasms if I recall to you the influence of strychnia in 
 large doses — such as you have seen given here many 
 times. You will remember that in certain spinal 
 
 1 For analogous cases see Russell Reynolds's System of Medicine, 
 art. Chorea. 
 
 2 Am. Journ. Med. Sci., October, 1876. 
 
94 DISEASES OF THE NERVOUS SYSTEM. 
 
 maladies, such as those of syphilitic birth, it is my 
 habit first to give iodides in heavy doses, and then to 
 suspend these for a time, and to give strychnia up to 
 the limit of physiological endurance, that is to say, 
 until I cause an approach to spasms. When, for ex- 
 ample, you give hypodermically the one- fifth to the 
 one-eighth of a grain daily — the patient will have 
 little or no annoyance if you are careful to insist 
 that he remain at absolute rest in bed for two hours 
 after each injection. If there be any tendency to 
 spastic twitchings of the muscles, the will is compe- 
 tent to control them, unless, and this is the point I 
 would make, the patient attempts to exercise. Should 
 he do this, the effort results at once in irregular move- 
 ments of an incoordinate character, and in slight or 
 more grave spasms of the muscles employed. While 
 at rest there is no obvious trouble, but voluntary 
 movement occasions spasms, which are the offspring 
 of the poison. They are, in a word, functional 
 spasms, and would not be seen at all, with limited use 
 of strychnia, were it not for the efforts at voluntary 
 action. 
 
 The second consideration to which it is worth while 
 to call attention was the great variety of the forms 
 assumed by Miss L. P.'s attacks, and the temporary 
 limitation of the disorder to partial groups of muscles. 
 This alone would, I think, entitle us to suspect hys- 
 teria as a cause ; and, when we learn that no attacks 
 ever took place in the street, and that pleasant sur- 
 roundings lessened the likelihood of the occurrence 
 of the spasms, while all depressing and enfeebling 
 agencies were apt to bring them on, no further 
 
SPASMODIC AFFECTIONS IN WOMEN. 95 
 
 doubt should exist as to the parentage of the disorder. 
 Muscular action perfect in health loses in force and in 
 sureness, and in steadiness, as any one falls away from 
 the highest standard of physical condition, and when 
 there is in the ganglia some cause tending towards 
 irregularity in any shape, it also is apt to rise into 
 gravity just in proportion to the failure in physical 
 status. Add to this emotional disturbances, which in 
 certain natures are prone to express themselves in 
 some form of irregular muscular acts, and we have 
 all the needed factors for producing such convulsions 
 in persons at all capable of evolving them. 
 
 I consider that the treatment, which I need not here 
 consider, utterly failed. I never succeeded in raising 
 my patient's health to such a level as to put her above 
 the possibility of these curious attacks. I, perhaps, 
 ought rather to say that I never could keep her at 
 that level. The least blow to health was with her 
 a knock down, and recovery was slow. Practically 
 speaking, the woman who habitually has hysterical 
 spasms has something wrong with her general health. 
 She is anaemic, or has lost general tone, and cannot 
 get up, so to speak, or there is that remarkable state 
 of easy tire Avhich is called nervous exhaustion, but 
 which were often better called nervous exhaustibility, 
 and which is, perhaps, due to some form of defective 
 nutrition of the nerve centres. Always there is some 
 such cause behind the spasms. If we can relieve it 
 we cure the convulsions, or rather make the soil fatal 
 to their growth. I do not think this is always pos- 
 sible. There are some anaemias which resist all treat- 
 
96 DISEASES OP THE NERVOUS SYSTEM. 
 
 ment. There are some mysterious forms of nutritive 
 failure which are never made well. 
 
 I have seen recently a case which somewhat re- 
 sembles Miss L. P.'s. Miss C, a native of Maryland, 
 jet. 21, was sent, when 17 years old, to a school in 
 which boys and girls were educated together. Just 
 before leaving home she had two slight attacks of 
 "stiffness" when rising from the sitting posture. 
 While at school she never menstruated, although 
 previously regular. Next came a light attack of 
 diphtheria, and still her general health seems not to 
 have been obviously damaged ; but the "contractions" 
 grew more frequent until at last one day, in class, she 
 was unable to speak, owing to trismus which came 
 on as she rose to recite. She went home after this 
 event, and in a few weeks her menstrual flow re- 
 turned; nevertheless the spasms continued, and this 
 despite a gradual rise in health, and a nature free 
 from melancholy, and prone to seek and find healthy 
 enjoyment in outdoor life. A further gain followed 
 a residence of some weeks in the West, but still the 
 attacks continued ; nor did it seem that almost per- 
 fect health secured immunity. 
 
 At present, in 1880, this young woman looks in ad- 
 mirable condition ; nor is there, on careful study of her 
 case, any evidence of organic disease or functional dis- 
 order. While seated she never has any symptom of 
 spasm ; but many times in each day, when rising from 
 a seated or recumbent posture, she is seized with at- 
 tacks which I have now seen her exhibit many times. 
 
 On rising she is seized with spasms of the legs, 
 neck, face, and arms and hands. These vary end- 
 
SPASMODIC AFFECTIONS IN WOMEN. 9T 
 
 lessly, and are not often exactly alike in any two 
 attacks. Usually the phenomena are these, and in 
 this order : — 
 
 Just as she begins to move, after rising from a 
 chair, she has — 
 
 1. A stiffening of the muscles of the legs and 
 chiefly of those of the thighs. This causes a certain 
 constraint in her first steps, but does not prevent 
 them. 
 
 Having moved a few steps she has — 
 
 2. A consentaneous spasm of the neck (twist to left 
 and downward pull), of the bodj^ also to left, of the 
 lower part of the face, either to left or right, or stiff- 
 ness from bilateral spasm of face. The left arm is 
 sometimes in violent flexion from fingers to shoul- 
 der, or the arm is extended and the hand flexed. 
 There is the same variety as to the movements of the 
 right arm. When I last saw a fit the right arm and 
 hand were thrown out in rigid extension, the left 
 being as perfectly in flexion. 
 
 3. No matter what posture was assumed, she was, 
 so to speak, fixed in it for perhaps ten to fifteen sec- 
 onds. The spasm came on, and rather slowly culmi- 
 nated in some one odd posture, and there and then 
 the woman became, as it were, a statue for the 
 moments that followed. 
 
 4. These spasms were painless, and disappeared in 
 an instant. 
 
 5. They caused no confusion, or vertigo, or any 
 other ill feeling, nor any sleepiness. She went on at 
 once to do whatever she had meant, such as to walk 
 or to dance. 
 
98 DISEASES OF THE NERVOUS SYSTEM. 
 
 At times the attacks are frequent, at others rare, 
 and absence from home and change of scene and cli- 
 mate seem to lessen the number of fits. 
 
 6. These spasms are often but not always preceded 
 by a condition Avhich is sometimes chronic, at others 
 comes only as an immediate warning of attack; at 
 all events its presence is a sure sign that the attacks 
 will come on readily and be more than commonly 
 hard to prevent. This precedent state consists in a 
 slight general tingling which varies in amount, and 
 is apt to be accompanied by a sense of stiffness in 
 the muscles of the legs. These are rather evidences 
 of a chronic and slight condition of spasm than of any- 
 thing which it is worth while to call an aura. 
 
 If, on rising, she stands still a moment and prepares 
 herself to walk by some indescribable mental act, which 
 is not a mere resolve because here the will is quite 
 powerless, she can prevent an attack. To rise quickly 
 and walk at once, or to turn abruptly just after begin- 
 ning to walk are apt to cause fits. 
 
 The relationship of such attacks of functional 
 spasm as these is as near to chorea as to epilepsy, for 
 the state of which she speaks as favoring and preceding 
 a tit cannot for reasons already given be looked upon 
 as an aura, and we know of no epilepsies in which the 
 functional and orderly act of a muscle or muscles 
 gives rise in some way to the irregular and disorderly 
 discharge of nerve force which constitutes a spasm. 
 But in grave chorea, this is precisely what does occur, 
 the forms of spasm having of course in that disorder, 
 as in functional spasms, differentiating peculiarities. 
 I gave this woman bromide of lithium chiefly to see 
 
SPASMODIC AFFECTIONS IN WOMEN. 99 
 
 if the bromides would control or lessen the fits. The 
 attacks were not lessened by this agent. 
 
 After this failure I was at a loss how to deal with 
 the case. There are spasms which are so nearly a part 
 of the normal muscle acts or so tied up with them as 
 to be as hard to change by medicine as the orderly 
 sequence of any common muscular action, nor is the 
 task of reform more easy when years of repetition 
 have made deep the easy ruts of habit. I could only 
 insist that she must live so careful a life as never to 
 rise without being on guard. Then also, since violent 
 exertion distinctly lessened her tendency to spasms, I 
 advised an abundance of exercise. The results of this 
 advice were good, and the case rapidly prospered 
 when she took to hard housework, which happened to 
 interest her very greatly. 
 
 The next case which I desire to add to this group 
 of spasmodic disorders, is, like the last two, remark- 
 able for the great variety of distorting forms assumed 
 in turn. Some of you may recall the patient, a poor 
 unmarried seamstress, aged forty- three, tall, thin, and 
 with a face constantly and deeply flushed ; a pulse of 
 90 to 100, and, so far as I could discover, no organic 
 disease. When nearing the age of forty she began to 
 have retarded menstrual flow, but neither then nor 
 when seen by me a year later, was there any uterine 
 trouble. In June, 1878, after some family annoyances, 
 she had a severe rigor, ending in trismus which came 
 on abruptly, and repeated itself thereafter with like 
 suddenness, and at inconvenient seasons, usually while 
 she was eating. In August it was replaced by dys- 
 phagia. She acquired, as a consequence of this 
 
100 DISEASES OF THE NERVOUS SYSTEM. 
 
 condition, a deadly fear of the abortive efforts to 
 swallow, and would chew for many minutes before 
 making an attempt at deglutition. In the autumn 
 this too passed away, and in October she first con- 
 sulted me at ray clinic for a " lump" on the chest. I 
 was about to refer her to one of our surgeons when 
 her remark that it went and came interested me, and 
 I carefully examined it. . To my surprise the growth 
 was in or on the left great pectoral above the breast. 
 It was an oval flattened swelling with quite abrupt 
 edges. If I carried the arm out so as to make the 
 muscle tense, in a few minutes the tumor disappeared 
 gradually, and I perceived that it was a phantom 
 tumor with which I had to deal. I was familiar 
 enough with these as seen in or on the belly, but I 
 now saw only my second case of this phenomenon in 
 any other muscular mass. The "tumor" was hard 
 and dense, and the temperature over it was a half 
 degree above that of the neighboring parts. Hard 
 rubbing gradually dispersed it, but it formed again in 
 a few hours, and I may add was always tender. 
 
 I next found to my great interest that all of the 
 pectoral on this side was in a state of curious irrita- 
 bility, and this you will recognize as only an increase 
 of a normal quality. When, for example, I strike a 
 healthy muscle with a finger tip, or better, a pointed 
 caoutchouc percussion-hammer, such as that which we 
 use to test tendon reflexes — two facts are observable. 
 First, the whole length of the muscular fibre struck 
 contracts, or a large part of the whole length. Then, 
 as it relaxes, a little hard prominence forms in the 
 muscle at the part struck, and remains for a few sec- 
 
SPASMODIC AFFECTIONS IN WOMEN. 101 
 
 onds until it gradually disappears. 1 In this woman's 
 case, the secondary local contraction was larger than is 
 usual, and lasted for at least a half hour or more. A 
 few weeks later, she came to the hospital to stay, and 
 now the pectoral tumor had gone, and the belly pre- 
 sented the usual appearance of a phantom tumor. All 
 of its muscles were violently contracted, so as to look 
 like a rounded growth. It was painfully tender and the 
 percussion note was dull. It, however, presented one 
 peculiarity I had never seen in any other such. case. 
 Several times a day the whole contraction passed away, 
 but the least handling of the belly brought it all back, or 
 this took place without any interference. The woman 
 was during all this time in a state of amazing nervous- 
 ness, and was seized with universal tremor whenever 
 any one came near to her bed. Her pulse rose at times 
 to 130, and the temperature fluctuated daily and 
 irregularly from 97° F. to 105° F. We got her well 
 enough to walk about and to leave the hospital, but 
 the abdominal contraction still existed or did so after a 
 year had passed away. 
 
 I have seen a similar false tumor in the calf of a 
 highly hysterical lady. It was relieved in a week or 
 two by the daily use of massage. 
 
 I shall complete this group of cases by a very singu- 
 lar one, which I saw last year. M. B., female, set. 59, 
 a worn-out school teacher, always feeble and lacking- 
 blood, but otherwise well, had a slight sprain of the 
 
 1 I described these phenomena many years ago in the Trans, of 
 the Phila. Acad. Nat. Sci., not then being aware that Weber had 
 called attention to them. They are best seen in the pectorals of 
 thin people. 
 
 9* 
 
102 DISEASES OF THE NERVOUS SYSTEM. 
 
 knee, which forced her to remain at rest. Very soon 
 she perceived a rhythmical spasm of the middle of the 
 muscular masses of the calf of the left leg. The mus- 
 cle gathered into a hard painful swelling about five 
 inches below the popliteal space. The contraction, 
 which was two by three and one-half inches in size, was 
 sudden and horribly painful, and the region attacked 
 was always sore, but was most so during the spasm. 
 This lasted a few seconds, but the space affected was 
 at all times hot and a little hard. The spasms were 
 singularly regular, about twenty-five to thirty a 
 minute, but there were often long periods of one to 
 five hours during which no spasm existed. She had 
 been treated in various ways without relief, but I was 
 finally enabled to help her by rest in bed, the use of 
 a splint, and careful feeding and iron, but the local 
 trouble was not entirely cured until I had used seve- 
 ral injections of atropine, which were thrown into the 
 muscle, a plan which was, I think, first employed by 
 Drs. Morehouse, Keen, and myself in the Hospital for 
 Nervous Diseases durino- our civil war. 
 
 To complete the group of unusual forms of spasm 
 in women, I shall only add a case or two of hysterical 
 athetosis. Since Dr. Hammond first described this 
 interesting member of the family of choreoid spasms, 
 I have seen two cases in which the athetoic spasms 
 were simulated in hysteric women. One of these I 
 saw but once, as it did not return to my clinic ; the 
 other was a private patient, and was long under ob- 
 servation. 
 
 L. C, ast. 25, from Canada, a stout ruddy unmarried 
 woman, was probably overworked at puberty in ac- 
 
SPASMODIC AFFECTIONS IN WOMEN. 103 
 
 quiring accomplishments which she can no longer use. 
 At 14 she had diphtheria, but no sequent palsy. The 
 hysterical aspects of her case are represented by ten- 
 dency to tears, by rare hystero-epilepsy, by fits of hyste- 
 ric coma, by great nervousness, distress at loud sounds 
 and bright lights, and by general abdominal tenderness. 
 Over and above these it is to be remarked that she 
 has a certain general feebleness, not at all suggested by 
 her look of health, nor is she ever very steady in her 
 motions, and is liable to a fine tremor, which subsides 
 only after she has been for some time at perfect rest. 
 Also there is a slight but distinct and very slow os- 
 cillation of her eyes, so that this group of symptoms 
 suggests sclerosis. Otherwise she is well, and it may 
 suffice to say so without going into negative details as 
 to sensation, motion, reflexes, and the functions in 
 general. 
 
 Possibly this is an hysterical woman with an organic 
 malady, but to which cause shall we refer the athetoic 
 spasms, which I shall now describe? When for relief 
 the hands lie closely locked on her lap, save for a fine 
 tremor little movement is to be seen, but when re- 
 leased, and especially during excitement or attention 
 to them, both hands, the left being the worse, exhibit 
 the most singular motions. The fingers extended, or 
 in extension and flexed on the palm, move to and fro, 
 coming together or separating, or crossing the line of 
 the thumb. These motions are slow, and of a per- 
 fectly disorderly character, but they never cease 
 except in sleep and during efforts at any manual 
 work, when they are always replaced by the slight 
 tremulousness alreadv alluded to. In Dr. Ham- 
 
104 DISEASES OF THE NERVOUS SYSTEM. 
 
 mond's cases, at least in the one given as a type, the 
 movements continued during sleep, and also they 
 were powerful, and there was some pain in the limbs 
 concerned, but none of this applied to my patient. 
 The motions could be easily controlled by another's 
 hand, the resistance being but slight, while also there 
 was no pain. When, however, my patient grew ex- 
 cited or emotional, the movements became rapid, and 
 during her menstrual periods, which were natural, this 
 was also the case. There was no spasm in the feet. The 
 history of these movements is that they arose out of 
 a succession of hystero-epileptic fits, with intervals of 
 stupor, or of stupor with rigidity. At the close of 
 these attacks, although she was in other respects well, 
 the fingers were noticed to be strangely affected, and 
 the disorder thus begun grew slowly worse. 
 
 The only question is as to the origin of these spasms. 
 Is it an athetosis proper, or an hysterical imitation of 
 athetosis, or merely athetosis grown, as one might 
 say, on an hysterical soil, and modified by its place of 
 growth ? Despite the fact that the athetosis arose 
 directly out of hysterical disorder, I incline to the 
 latter view, especially as in many particulars the case 
 otherwise conforms sufficiently to Dr. Hammond's 
 admirable account. I ought to add, however, that in 
 cases more clearly and purely hysterical, athetoic 
 movements are sometimes met with. 
 
 In my second case, that of an unmarried woman. 
 Miss J., set. 40, there were slight mental disorder, 
 sensory delusions, left hemianesthesia, an hysterical 
 temperament, and slight ovarian tenderness (left). 
 Eapid relief of the mental trouble was obtained under 
 
SPASMODIC AFFECTIONS IN WOMEN. 105 
 
 treatment, with slow improvement and final cure of 
 the anaesthesia, large gain in flesh and blood, and 
 entire recovery from the hysterical symptoms in 
 general. During the early months of the case there 
 were at intervals attacks of athetoic spasms. Usually 
 these came and went without appreeiable cause. 
 At other times emotion, especially terror from her 
 sensory dreams, seemed able to occasion them. They 
 lasted from five minutes to hours, were not violent, 
 conformed absolutely to the type cases, were bilateral, 
 but ceased in sleep, existed only in the hands, and 
 several times ceased when Miss J. was exposed to 
 some diverting cause. 
 
 The character of these motions differed somewhat 
 from the utter irregularity of Hammond's disease. I 
 should say they differed unless her attention was 
 called to them, in which case no semblance of order 
 in the spasms could be seen. When un watched by 
 the patient, the motions consisted in constant slight to 
 and fro and lateral movements of all the fingers, but 
 at brief intervals. A larger range of motion would 
 affect first the thumb, and then in turn all of the fin- 
 gers in succession from the forefinger to the little 
 finger. 
 
 As this woman improved in general condition the 
 finger spasms slowly passed away, and have now, I 
 believe, been absent for at least a year. Whatever 
 doubt there may be as to the hysterical origin of the 
 former case, none can exist as to the last one, so that 
 we may, I think, rank hysterical athetosis among the 
 forms of clonic spasms seen in this peculiar disorder. 
 
106 DISEASES OF THE NERVOUS SYSTEM 
 
 LECTURE VI. 
 
 TREMOK— CHROXIC SPASMS. 
 
 In" accordance with the plan I have followed here 
 of treating at one time of groups of symptoms, at 
 another of single S} r mptoms, I shall ask your atten- 
 tion to some of the minor forms of motor disorder 
 found among nervous or hysterical women. 
 
 The subjects I shall choose are Tremor, or tremu- 
 lousness, and certain Spasms, usually local, which are 
 not within the range of hystero-epileptic states, but 
 coexist with perfect consciousness. 
 
 You have seen here over and over the tremor of 
 tobacco, of stimulus, of lead, of old age, and also the 
 forms of tremor which are yet more active, such as 
 are met with in shaking palsy and sclerosis. Besides 
 being thus an expression of weakness, as in old age, 
 or fatigue, or the feebleness of convalescence, or of or- 
 ganic disease, or toxic states, tremor is a sign in many 
 people of transient emotion, of fear, of excitement, 
 of anger, or of grief, almost as natural a motor ex- 
 pression in some mobile natures as the facial feature 
 spasm, laughter or crying, is of uncontrolled mirth or 
 grief. Tremor like these, too, is capable, under cer- 
 tain circumstances, of passing over the line of healthy 
 functional manifestation and becoming a symptom of 
 disorder and lack of emotional control. Here we are 
 
TREMOR — CHRONIC SPASMS. 107 
 
 to consider it as a symptom found often among the 
 nervous, a symptom which may be local or general, 
 temporary or enduring, and may, in a few cases, be so 
 much the most prominent feature of a case as almost 
 in itself to constitute a disorder deserving of being 
 itself labelled as a disease. 
 
 If the organic tremors, the offspring for the most 
 part of coarse textural changes, be clearly spinal, it is 
 interesting to ask if the representative tremor of hys- 
 teria be in like manner of functional spinal birth, a 
 question more easy to ask than to answer; but seeing 
 the volitional control which many nervous patients 
 possess, as regards the symptom tremor, it seems 
 probable that, in extreme cases, the cerebral ganglia 
 lose those inhibitory qualities which are usually active 
 in the healthy. That, however, this symptom may 
 be of mere emotional origin, or derived from patho- 
 logical changes, becomes important in diagnosis where 
 it sometimes chances that a spinal malady is painted 
 on a background of hysteria, or that hysterical 
 additions arise in emotional patients to disturb our 
 belief that Ave have had to do with a malady purely 
 organic. These mixtures of symptoms are, as you will 
 readily admit, when you have seen many such cases, 
 as bewildering as charades. Some of you may recall 
 the case of Miss M., aged 25, a fat and ruddy person, 
 who suffered first from overstudy, combined with 
 some mental worry. At the age of fourteen she had 
 diphtheria, but no sequent paralysis, and came to me 
 a few years ago, at this clinic, a person looking as. 
 little like having organic disease as any you are apt 
 to see. About three years before I saw her she had 
 
108 DISEASES OF THE NERVOUS SYSTEM. 
 
 had an unfortunate love affair, which had ended in a 
 high degree of general nervousness, a form of trouble 
 which we have very frequently had occasion to bring 
 before you, and the symptoms of which, I trust, are now 
 familiar to you. It came on rather abruptly, as these 
 things sometimes do, resulting in a tendency to tre- 
 mor, which was excited by the slightest emotion, or 
 the least excitement or worry, and was always worse 
 at the time of her periods. We have also interca- 
 lated, in her case, a brief history of occasional hys- 
 terical spasm, with spinal and ovarian tenderness. It 
 seems probable that on top of this came a condition 
 of organic disease of the spine, which is not as yet 
 fully developed, but which will in all probability end 
 in a general sclerosis, of the character which we call 
 disseminated. She has now some slight difficulty in 
 walking, vague pains through the limbs, some numb- 
 ness of the feet and hands, and slight difficulty of 
 speech, a certain drawling, prolongation of her words, 
 quite characteristic of the condition in question ; she 
 has, too, occasional vertigo, and the disk of her left 
 eye is, I think, suspiciously white, while I find, upon 
 careful examination, that the vision of that eye is not 
 nearly so good as on the other side. The peripheral 
 appreciation of colors is distinctly impaired, so that 
 there seems to be only too much reason to fear that 
 the optic nerves are suffering from atrophic change. 
 The tremor she has at present may have been origi- 
 nally, and probably was, purely hysterical, since it 
 .came and went, and was more or less within control 
 of the will. It has now all the characteristics of a 
 tremor from organic cause. She cannot thread a 
 
TREMOR — CHRONIC SPASMS. 109 
 
 needle at all, or eat easily, or carry a full glass to the 
 mouth without violent agitation; while the hands are 
 for the most part quiet when at rest. Looking at the 
 whole of the pecularities of this case, it seems to me 
 extremely probable that it has passed quietly, and 
 without the suspicion of her physician, into a state of 
 organic disease of the spine. 
 
 You are of course aware that there are two forms 
 of tremor in connection with spinal troubles; I may 
 coarsely state their peculiarities as follows : One" is 
 constant while the limb is at rest, and is lessened by 
 motion ; and the other is less when the limb is at rest, 
 and is made very much worse by voluntary motion. 
 The tremor of nervousness, and that which is seen in 
 hysteria, may be always constant except in sleep, or 
 may come and go irregularly, without apparent cause, 
 but will always be liable, like some of the spinal tre- 
 mors, to remarkable increase under excitement or ex- 
 pectation, or the sense of being watched. It is usually 
 a tremor of variable extent, so to speak, the range of 
 disturbance, what I may call the width, being greater 
 than that of most organic tremors, at least at their 
 beginning, while under the influence of emotion, or 
 without known cause, it may pass into a condition of 
 local or general convulsions, the range of motion in- 
 creasing like the lengthening oscillations of a pendu- 
 lum, In one respect, however, it distinctly differs 
 from the tremors of organic origin, which are never 
 notably controllable by the will ; whereas, in people 
 merely nervous, or hysterically nervous, it is nearly 
 always possible greatly to limit, and sometimes for a 
 time to altogether efface the tremor by a sturdy effort 
 
 10 
 
110 DISEASES OF THE NERVOUS SYSTEM. 
 
 on the part of the patient. The form of tremor of 
 which I am now speaking, may be confined to one 
 limb, or may be so general, that almost every part of 
 the body may be agitated by it, and in these latter 
 cases, if the muscles of the face suffer also, they are 
 apt to exhibit larger movements, rather than the finer 
 tremors which affect the limbs. I remember only too 
 well the case of a lady, from one of our neighboring 
 counties, which baffled us completely, a year or two 
 ago in this hospital. She was a woman, aged 32, thin, 
 not anaemic, in fact, rather ruddy. The disease be- 
 gan about four years before she came to me, and was a 
 general nervousness and neurasthenia, caused by a 
 long spell of nursing two of her family through fatal 
 maladies. At the close of this effort, which is always 
 one of the greatest strains that can be put upon a 
 woman, she broke down with hyperaesthetic conditions 
 of the senses, with tender spine, with great fatigue on 
 the least exertion, and with a general failure of her 
 nutritive functions. I do not remember when the 
 tremor began, which was so marked a feature of her 
 case, but I think it was a year from the time of 
 the first outbreak of her symptoms. When alone in 
 her room, and thinking herself unobserved, she was 
 usually quiet, except for a twitching movement of the 
 face, but when anybody entered and especially when 
 I myself approached she was seized at once with a uni- 
 versal tremor and with extreme general nervousness, 
 so that speech became inhibited, and deglutition was 
 palsied for a time. 
 
 For some months, at least, the movements were of 
 this character, and only after a time grew, what I may 
 
TREMOR — CHRONIC SPASMS. Ill 
 
 call larger. This was also the history of each onset 
 of shaking. The motion rose from trenmlousness 
 through large tremor visible to the eve everywhere, 
 into a tremor which had in it a certain character of 
 violence, and was varied with occasional slight jerks 
 of the limbs, and accompanied with perpetual agita- 
 tion of every muscle of the face, so that she presented 
 an appearance not less singular than distressing. 
 This may pass as a good case, in fact, as a rather 
 remarkable case of general tremor, but you will 
 understand that this symptom in less marked degree 
 is very often to be found as an expression of all ner- 
 vousness, and even of weakness as in convalescence 
 or in old age, while but few old hysterical cases 
 escape without more or less exhibition of it. 
 
 Localized tremors, I mean such as are absolutely 
 confined to one part, are somewhat more rare, nor do 
 I remember to have had the opportunity of exhibit- 
 ing to you here a single illustration of this class. I 
 have now under my care, however, a very interesting 
 woman, who has in both limbs below the knee a con- 
 dition of tremor, which is about as fair an example of 
 what I mean as anything that I have recently seen. 
 In her it was caused by a long strain of nursing followed 
 by a disastrous railway accident, in which though she 
 herself was not injured, one of her parents was killed. 
 It was her general condition for which she came to me, 
 and the tremor is to be regarded as only one symp- 
 tom. I was told that some time ago, she was the sub- 
 ject of general tremor. She seems to have now a con- 
 dition of mind not very rare among highly nervous 
 women, and which without much straining of language 
 
112 DISEASES OF THE NERVOUS SYSTEM. 
 
 I might effectually describe as mental tremor. A mo- 
 ment of mental indecision seems to trouble her in re- 
 gard to everything upon which decision is necessary, 
 she revokes her opinion, again decides, and so, but 
 with far more uncertainty of mind than is shown in 
 her speech, comes at last to a conclusion. Her gene- 
 ral condition is exasperated by hysterical anorexia, by 
 some dysphagia, and by perpetual and distressing ten- 
 dencies to micturition, and by violent flushing of the 
 face. Under the influence of tonics, and careful treat- 
 ment, she utterly failed to improve, but since I have 
 placed her alone, in the care of a a nurse before un- 
 known to her, and steadily fed her every two hours, 
 with also the daily use of massage, she has so rapidly 
 improved, that now there remains very little of. these 
 conditions excepting the tremor of which I have spoken, 
 but not fully described. While her hands are perfectly 
 steady her feet are most of the time, or were most of 
 the time, in a state of tremor caused by incessant 
 minute activity on the part of the flexors and exten- 
 sors of the feet, while there is also a good deal of 
 trembling of the leg and thigh. It has lessened from 
 above downwards. However quiet her limbs, my 
 visit is sure to set them going. She has been taught 
 since she came here to restrain these movements by act 
 of will, at first for a minute, and now for an hour at a 
 time. Aided by the gain in general health, this train- 
 ing of the will has proved efficient, and there is at 
 present hardly any tremor in the right leg, while that 
 of the left is fast disappearing. A well-applied band- 
 age in some way helps her, perhaps as she says by 
 
TREMOR — CHRONIC SPASMS. 113 
 
 keeping her so reminded of the limb as to be able 
 to dominate it. 
 
 A year has elapsed since I wrote the last sentence, 
 and she is now entirely well. 
 
 What else need be said of nervous or hysterical 
 trembling has been already spoken of in conneetion 
 with my remarks on the subject of general nervous- 
 ness, to which it is so apt to be related. What I most 
 desire here is that you should never confuse it, as you 
 may easily do, with other tremors, but I must have 
 said enough to warn you on that subject. 
 
 Alcoholic tremors can only concern us in their 
 diagnostic relationships, and it will suffice if I say, 
 that as to this tremulousness, or other neural symp- 
 toms, you should be constantly alive to the rare, the 
 very rare possibility that your patient may owe 
 some of them to the secret abuse of stimulants. I 
 say the rare possibility, because in a long and large 
 practice among women of the best social class, and 
 the one presumed by some people to be prone to 
 this vice, I have seen but five or six cases of alco- 
 holic drunkenness. I well recall a sad case which 
 was brought to me some hundred miles on a couch, 
 on account of a shocking state of universal tremor, 
 with attacks of prolonged stupor and rarer hys- 
 tero-epileptic attacks. The woman had been "diag- 
 nosed at," as she told me, by many doctors, and 
 took a malicious pleasure in showing me a number of 
 opinions. The tremor was incessant and large, but 
 did not become worse for my visit, although it was 
 at times, I thought, purposely exaggerated, the patient 
 being distinctly pleased at the importance of the role 
 
 10* 
 
114 DISEASES OF THE NERVOUS SYSTEM. 
 
 she was playing. I confess, that I too should have been 
 deceived as to this case, had it not been for a practice 
 which yon will do well to acquire, a practice now 
 become with me a deeply confirmed and increasingly 
 active habit of noticing in a room, not only the patient 
 but everything else. Missing a bottle of cologne from 
 its usual place, where I was apt to make use at 
 times of its contents, I said, " Where is your cologne?" 
 "My maid upset it," she answered ; " she upset it on 
 the table yesterday ; she is very awkward, and did 
 the same thing last week." My eyes naturally 
 turned to the table, which was of antique mahogany, 
 varnished. Now, I had observed that when cologne 
 falls on varnish it permanently whitens it, but this 
 table was clean of spots. I repeated my question, and 
 when the same positive answer came, I was suddenly 
 sure that she was drinking cologne, and this proved 
 to be the case. We wrung from her and her maid a 
 sacl tale of the fraud and stratagems by which she had 
 been able to indulge in this singular habit undetected 
 for years. 
 
 Chronic spasms persistent through months, or even 
 through years of waking life, are rare enough among 
 women, but exceptionally rare among even the most 
 nervous men. The only cases I recall in these arose 
 from nerve- wounds. In my book on Injuries to 
 Nerves I quoted but one case, which I had myself 
 seen. I saw others which had suffered from violent 
 spasm as an immediate consequence of a ball- wound, 
 and where, however, the spasm lasted but a few 
 hours ; but was in one case so great that the nails of 
 the spastically shut hand cut the:palm deeply. 
 
TREMOR — CHRONIC SPASMS. 115 
 
 You see, therefore, how uncommon is the condition 
 of true chronic spasm, and why, therefore, it possesses 
 so much interest. 
 
 The chronic spasms of women with hysteria are, per- 
 haps, among the most obstinately unmanageable of all 
 the graver symptoms of this disorder. They are said 
 at times, by the books, to make sudden recoveries. 
 My own experience as to this is the same as in hys- 
 tero-palsies. I do not see abrupt recoveries — why, I 
 cannot say — perhaps because the cases which reach 
 me are always old ones, much treated. At all events, 
 you must have seen enough here to know that we 
 earn our triumphs, as a rule, by intelligent and pa- 
 tient care. 
 
 These chronic spasms may affect almost any part. 
 You are apt to see the jaw locked ; I have seen it kept 
 rigidly open. I have seen the head bent on to the 
 breast, and so held for months. The false tumors of 
 the belly are local spasms of muscles; such a case I saw 
 last year, with Dr. Sinkler, who must well remember 
 how the immense tremulousness told us both what 
 was the constitutional cause of trouble before the 
 woman could uncover her supposed tumor. 
 
 Sometimes you will see these very local contrac- 
 tions in a part of other muscles. I once saw two good 
 large, permanent tumors in the calf of the leg. They 
 were merely contractions of muscle, and not of the 
 whole, but of a part, and, like some of the abdomi- 
 nal contractions, were very tender. They came very 
 near to being removed by a surgeon — -av1io, too often, 
 made his diagnosis with the knife. 
 
 I have, however, made mention of some of these 
 
116 DISEASES OF THE NEKVOUS SYSTEM. 
 
 cases in a former lecture, and need not dwell here on 
 this especial form of the trouble in question. 
 
 Permanent spasms, then, may affect almost any 
 muscle of the body, and be so violent and lasting as 
 to excite our amazement that, through many years, 
 in some cases, a few groups of ganglionic cells should 
 be competent to evolve such enormous amounts of 
 force. I recall from my notes one case, which was, 
 I think, a very interesting illustration of these affec- 
 tions, and which is also worth mentioning to you, on 
 account of the success of the treatment, and because 
 of the various therapeutical experiments, for experi- 
 ments they must largely be in the treatment of this 
 disease, which were made by others or by myself. 
 This young lady, Miss C, from Maryland, was brought 
 to me a few years ago, as some of my assistants may 
 remember, with violent spasm of all the anterior mus- 
 cles of the right thigh and leg, the foot, however, being- 
 extended. The rigidity of the limb was something 
 extraordinary, it stood out, when erect, at absolutely 
 a right angle to the body, and no pressure that I dared 
 to use was competent to depress it notably without 
 causing extreme pain, and soreness of the stretched 
 muscles. When the hand was placed upon the ante- 
 rior muscles of the thigh they could be felt to be in 
 a state of tremor, as though not all of the muscular 
 fibres were acting at once. Probably, owing to the 
 long-continued action of the muscles, the limb was 
 never entirely relaxed in sleep, nor during the many 
 months she was at the hospital was it ever seen to be 
 in any other position than at a right angle, or at an 
 angle of 45° with the line of the erect body. A mul- 
 
TREMOR — CHRONIC SPASMS. 117 
 
 titude of therapeutic experiments ending always in 
 failure, and the abandonment of the case had been 
 made by several physicians; nevertheless, I under- 
 took the treatment with a certain amount of hope, 
 such, in fact, as I always have, when an hysterical case 
 is taken away from her own home and social surround- 
 ings, and subjected to new and revolutionary influences. 
 
 I began the study of her case by placing her seated 
 at the foot of the bed propped up with pillows, and 
 then suspended from her ankle an increasing amount 
 of weight, to learn whether I could by degrees depress 
 the limb, and thus wear out the muscles. I have, 
 however, seen her carry a weight of fifty pounds for 
 three hours, and she was but a frail girl, without the 
 limb falling more than a few inches. Under ether 
 the limb relaxed, but there always remained a certain 
 amount of rigidity, owing, I presume, to what I may 
 call the setting of the too long-contracted muscle. 
 
 Long before the ether left her, the spasm returned, 
 and, therefore, I was quite sure that it was not one of 
 those forms of mimic spasms of which I have presented 
 to you some curious examples. I next made an effort 
 to wear out the spasm by the use of induction currents, 
 using two batteries, but although I employed such a 
 power of the batteries as could not readily be sustained 
 by any but an hysterical woman, I did not succeed in my 
 efforts, and she remained much as before. The use of 
 galvanism to the spine, no matter what might be the 
 direction of the current, also failed. She was finally 
 cured by very much gentler treatment, which con- 
 sisted in the use, twice a day, of the fullest hypo- 
 dermic injections of atropia she could bear thrown 
 
118 DISEASES OF THE NERVOUS SYSTEM. 
 
 directly into the rigid muscles. As soon as the 
 atropia began to show its power in a certain amount 
 of relaxation of the limb, I also had the limb manipu- 
 lated, having it moved in different directions, upwards, 
 downwards, and sideways. Under this treatment she 
 steadily improved, and finally left the hospital able to 
 walk on crutches, with the limb nearly straight under 
 her, but still unable to employ it in walking. By this 
 time she had obtained a certain amount of volitional 
 control over its action, and in a few months became 
 entirely well. There are cases, however, in which 
 steady extension of the flexed limb, or steady flexion 
 of the extended limb by apparatus will succeed in over- 
 coming this rigidity. Of this I have seen an excellent 
 example in the case of Miss TV\, also from Maryland, 
 who came to me with the diagnosis of general sclero- 
 sis, but who really presented one of the most extraor- 
 dinary illustrations of hysterical symptoms which I 
 have met with in years. She had at one and the same 
 time some general palsy, a profound loss of power of 
 the left leg, anaesthesia, and chronic hysterical spasm 
 of the right leg, with violent alternate spasms and 
 extensions of the head, together with a quite marked 
 amount of mental hebetude, somewhat rare in such 
 forms of hysteria. To make her case still more diffi- 
 cult, I may add, that she was fat and rosy, in perfect 
 condition, menstruating with ease and regularity, and 
 apparently suffering from no organic trouble whatso- 
 ever. I say to add to the difficulty, because I always 
 feel more hopeful of a case of hysteria when it occurs 
 in the person of a woman lean, wasted, and anaemic. 
 You have then, of course, the chance when building 
 
TREMOR — CHRONIC SPASMS. 119 
 
 up a constitution, to aid your moral treatment by all 
 of the profound alterations which you may bring 
 about during the process of fattening, and tilling with 
 good blood an exhausted system. In her case I suc- 
 ceeded in extending the limb by the use of a screw 
 apparatus, and a stirrup fastened to the extended foot, 
 and attached to the apparatus below the knee. Per- 
 haps the anaesthesia of the limb may have aided me 
 in this matter, but, as I have said above, it is not often 
 that you succeed by these means, and in using them 
 you may expose your patient to a second disorder in 
 the form of general convulsions, or local spasms in 
 parts remote from that first affected. 
 
 I saw an example of this in the case of a lady whom 
 I went to Massachusetts to see, some years ago, and 
 who suffered from atrocious chronic spasm of the left 
 arm, so that it was always painfully flexed. There 
 was no anaesthesia of the limb, and every effort to 
 make it straight gave rise, if persisted in, to general 
 convulsions, which finally caused, as you may imagine, 
 the total cessation of all efforts in that direction. 
 
 The treatment of these forms of spasm must con- 
 sist in the treatment of the ereneral condition, and of 
 what that is, I have already fully spoken, in speaking 
 of the general subject of the course of hysteria. 
 
 I have seen tendons cut for these cases, an opera- 
 tion to which surgeons are rather too prone in my 
 opinion. I cannot remember a case which was re- 
 lieved by such an operation, while the use of atropia 
 hypodermically, and of the slower but gentler method 
 of manipulation, and in a few cases of extension by 
 instruments, will in a certain number, assuredly not 
 
120 DISEASES OF THE NERVOUS SYSTEM. 
 
 in all, bring about a permanent cure. Spasms such 
 as these, are not often mimicked, but occasionally 
 you will meet with an illustration in this form of 
 that unconscious simulation of disease, if I may be 
 allowed such a phrase, of which I have already so 
 frequently spoken. In this, and in the mimicked pal- 
 sies which are yet more rare, there occasionally arises 
 the chance for those abrupt impressions upon a patient 
 which so amaze alike the sufferer and her friends. 
 I recollect, as an illustration, the example of a very 
 charming young girl from Ehode Island. When I 
 first saw her she was lying on the bed, with her 
 knees drawn up, her feet not extended as is usual, but 
 flexed. I was told that when she awoke in the morn- 
 ing, they were straight, but were almost immediately 
 drawn up into the state in which I saw them. After 
 going over her whole system and not discovering evi- 
 dences of organic disease, I finally made up my mind 
 that it was a case for one of those bold experiments 
 which sometimes succeed when more timid action 
 fails. After inducing her mother to leave the room, 
 I suddenly straightened one of her legs. I met with 
 no difficulty until I had partially attained my ob- 
 ject, and this proved to me with certainty, that it 
 was a willed spasm with which we had to deal, and 
 not one controllable by volition. I then said to her, 
 " I have straightened one of your limbs, straighten 
 the other for me." She said, " I cannot, but perhaps 
 you can." I straightened it with but little difficulty. 
 I then said, "Sit up on the side of the bed." She replied 
 that she had not sat up for years, but I finally got 
 her seated with much trouble, and then, picking up a 
 
TREMOR — CHRONIC SPASMS. 121 
 
 gay cravat, and tying it around her neck, I said, laugh- 
 ing, "Now you are all dressed for a walk, how amus- 
 ing it would be to meet your mother at the door." To 
 my surprise she yielded, seeming to enter into the fun of 
 the idea, and with a staggering gait (such as you would 
 expect from one long confined to bed) she advanced 
 with me to the door, where she met her astonished 
 parent who was just coming into the room. She 
 never went back to bed again permanently, and in a 
 few weeks afterwards was able to ride on horseback. 
 
 You now and then meet with cases in which the 
 whole range of hysterical phenomena leap into mis- 
 chievous life owing to some most trivial wound or 
 other hurt, but it also chances at times that a real 
 and grave injury of a nerve may give you an 
 almost indistinguishable mixture of nutritive and 
 other disorders the usual result of nerve wounds, and 
 also of hysteric symptoms such as may perfectly well 
 arise without traumatic cause. It becomes then al- 
 most impossible to say of a given symptom, such as 
 chronic spasm, which may be the child of either parent, 
 whether it be hysteric or due to the nerve lesion, and 
 yet as concerns treatment, it may be of the utmost 
 moment to reach such a decision. The following case 
 is a remarkable illustration of my meaning. 
 
 I saw last year, with Dr. Morton, P. L., set. 26, a 
 maid-servant, who had, a year ago, a fall in which 
 she bruised her left side. Being of a nervous and 
 impressible nature, it was not surprising that she 
 was seized at once with left unilateral numbness 
 and slight loss of power. These symptoms faded 
 away in a few days as one of the minor injuries due 
 11 
 
122 DISEASES OF THE NERVOUS SYSTEM. 
 
 to her fall rose into mischievous prominence. In 
 falling, she struck her left elbow so as to cause pain 
 down the arm, but not in the ultimate distribution of 
 the ulnar nerve. Five days after the accident the 
 pain grew worse, and a general hyperesthesia spread 
 over the ulnar side and middle of the arm. At the 
 same time the ringers began to flex more and more, 
 until at last all the finger-tips and the thumb came 
 into contact in the position assumed when with all of 
 the fingers we hold some small object. The hand was 
 held in extreme and constant flexion chiefly by spasm 
 of the palmaris longus, the tendon of which was rigid 
 and prominent. The least effort at passive motion of 
 the parts caused intense pain, and the hyperesthesia 
 was so great that a touch on any part of the fingers, 
 except the thumb and forefinger, and on nearly the 
 whole forearm seemed to occasion the utmost distress. 
 This case, I confess, somewhat puzzled me. Nerve 
 wounds of themselves give rise in either sex to hys- 
 terical states, so that, except for my knowledge of the 
 previous temperament, this condition was of little 
 diagnostic aid. The hyperesthesia was extreme. It 
 is so in many nerve wounds or contusions, but, at 
 least early in the case, it does not pass out of the dis- 
 tribution of the nerve presumably affected. In this 
 case it did not seem to have anv accurate anatomical 
 site, that is, it was partly in the ulnar, and irregularly 
 there, and in a portion of the median and musculo- 
 spiral territories ; while there was none of the tactile 
 loss which inevitably accompanies nerve lesions, there 
 being agonizing pain, and yet lack of accurate sense 
 
TREMOR — CHRONIC SPASMS. 123 
 
 of touch. Besides this, in the present case, the fingers 
 were cold ; there were no joint lesions, nor any caus- 
 algia or nutritive changes in the skin or nails. When, 
 too, I pressed on an indifferent point — such as the 
 olecranon process — and led her to believe that I was 
 compressing a nerve, she described her increase of 
 pain as terrible. Either, then, this was a case of slight 
 nervous lesion exasperated by the hysterical tempera- 
 ment, or else it was not a nerve hurt of any gravity, 
 and all of the symptoms had arisen in consequence 
 of a trivial hurt, just as a pin-prick may be the start- 
 ing-point of the most extreme and enduring hysterical 
 phenomena. It would, I think, be difficult to find a 
 better illustration of the difficulties in reaching a dis- 
 tinct diagnosis in such cases, and yet a diagnosis is 
 here, if in any case, most desirable, because, if the 
 case be purely due to contusion of the ulnar nerve, 
 the question of operative interference is certain to 
 arise should the symptoms continue long. This 
 woman was put under the daily use of galvanism to 
 the arm and hand. Each application was followed by 
 relaxation of the contracted parts and by a lessening 
 of the hyperesthesia. When the poles were applied 
 without making circuit, the same results followed, and 
 I have now not the faintest doubt that the phenomena 
 were from the beginning to the end of purely hysteri- 
 cal parentage. 
 
 There is a form of spasm which is sometimes mis- 
 taken for paralysis, and is to be met with, as far as I 
 know, only among women ; that is to say, in a large 
 experience I have never encountered a case among 
 
124 DISEASES OF THE NERVOUS SYSTEM. 
 
 men ; it is what I might call spasmodic ptosis. It is 
 to be distinguished from that violent closure of the 
 eye which is found with or without some disorder 
 of the fifth nerve, by the fact that it is simply a 
 quiet shutting of the lid, and a resistance on attempt- 
 ing to lift it up with the fingers, and an absolute 
 incapacity for a time to raise it by the will. If 
 this were a paralytic feebleness, there would, of 
 course, be no difficulty in pushing up the eyelid with 
 the finger, but, as I have just stated, this cannot be 
 done without the exertion of a good deal of force. 
 I fancy that, even among women, this condition is 
 rare, as I do not remember seeing more than three or 
 four instances. I mention them as curiosities and as 
 cases which you may occasionally see. There is also 
 a paralytic ptosis which is common among women, 
 and which I hope you will not confound with the 
 malady with which we are now dealing. The last 
 example I have seen of spastic ptosis was in the per- 
 son of a lady, who came from the interior of Pennsyl- 
 vania, and who has since died of cancer of the stomach. 
 She was a person easily tired, emotional, and low- 
 spirited at the same time. She suffered also from 
 nasal catarrh, and had, like most of these cases, no 
 photophobia. During the winter previous to her visit 
 to me she began to have, without known cause, a 
 closure of the lids. They would remain closed for 
 several hours at a time, and then would open with 
 probably as little cause as they closed. I saw her 
 twice before I obtained an opportunity to see this 
 symptom. She then seemed to be unable to raise the 
 eyelid, and I could not lift it without a considerable 
 
TREMOR — CHRONIC SPASMS. 125 
 
 amount of effort. I treated her for a long time, and 
 in various ways, and she had at different times tried 
 galvanism and electrieity and many other forms of 
 treatment. Section of the supraorbital nerve had 
 been proposed to her by an enterprising surgeon, but 
 she got well apparently unaided by physicians, and 
 died, as I have said, four years afterwards of malig- 
 nant disease. Another case was in a woman of great 
 intelligence and remarkable accomplishments who had, 
 I think, injured her brain by excessive devotion to 
 study. She had no disease of the eye proper, nor any 
 organic malady, nor could I say that she was a notably 
 nervous woman. She had, however, been from child- 
 hood a shy person, subject to blush too easily, and at 
 times excessively embarrassed by the presence of 
 strangers. The trouble of her eyes came on for the first 
 time at a watering-place. When going to dinner, and 
 sitting down, she observed that a great number of per- 
 sons were looking at her as a last arrival- she mentioned 
 the fact to her husband, and was almost immediately 
 attacked by a violent closure of the eye, and was 
 obliged to be led in this condition from the table. 
 "When this had happened once, you may well imagine 
 that every repetition of the original eause brought 
 back a return of the disorder, until at last it was quite 
 impossible for her to go to table in the room with 
 other people. You will see that in this case emotion, 
 and, after the establishment of the symptom, the des- 
 potic control of an unpleasant memory were competent 
 to create and then to continue this grave inconvenience. 
 I succeeded in inducing her, however, to make an effort 
 to go to dinner, without regard to what happened, and 
 
 11* 
 
126 DISEASES OF THE NERVOUS SYSTEM. 
 
 to face the slight unpleasantness and the talk which 
 her appearance might create. Her courage was final- 
 ly rewarded by a cure, which was perfected, so to 
 speak, by a long absence in Europe, and constant ex- 
 posure to the very difficulties which had given rise to 
 her first attacks. 
 
CHOREA OF CHILDHOOD. 127 
 
 LECTURE VII. 
 
 CHOREA OF CHILDHOOD. 
 
 Some years ago I was struck with the rarity of the 
 true chorea of childhood among negroes, of whom a 
 fair proportion applied for aid at my clinic. In the 
 hope of securing more full information as to this 
 question, I asked my friend, the late Professor Henry, 
 of the Smithsonian Institution, to distribute in the 
 Southern States a circular, asking the following ques- 
 tions : — 
 
 1. As to the frequency of chorea in white children. 
 
 2. As to its relative prevalence in localities. 
 
 3. As to its relative frequency in black children of 
 pure breed. 
 
 4. As to its frequency in mulattoes. 
 
 5. As to the season of greatest frequency of attacks. 
 This circular was sent, for the most part, to the 
 
 meteorological and other observers, who were corre- 
 spondents of the Smithsonian, and through them to 
 their friends. It reached thus a very intelligent class, 
 and fell into the hands of secretaries of State and 
 county medical societies, who were at much pains to 
 give me the collective experience of large numbers of 
 practitioners. 
 
 Had all, or nearly all, of my circulars been an- 
 swered, I could have quite fairly mapped out the 
 
128 DISEASES OF THE NERVOUS SYSTEM. 
 
 relative prevalency of chorea as to States. As it was, 
 my replies gave me the experience of two hundred 
 and ten physicians scattered through the towns and 
 rural districts of the South and Southwest. The in- 
 formation thus obtained is very interesting, and, how- 
 ever incomplete it may be, is too curious to be laid 
 aside. In the hope, therefore, that it may awaken 
 ampler and more exact research, I have ventured to 
 analyze it. No one can feel more fully than I how 
 much it lacks of being perfect as evidence, or how 
 largely it is open to criticism on account of the fal- 
 lacies, which are apt to pervade information thus 
 obtained. 
 
 The points with which I shall deal will be: — 
 
 The relation of the chorea of childhood — ■ 
 
 To season and meteorological conditions. 
 
 To climate. 
 
 To locality, town or country. 
 
 To race. 
 
 Forms of chorea. 
 
 Relation to season. — It became clear, many years 
 ago, to every one who followed my clinics, that as the 
 cold of winter faded away, and the changeful weather 
 of March and April prevailed, cases of chorea became 
 frequent. This continued to be the case until, with 
 the warmer season, the number fell away, remaining 
 then at about the same ratio through the autumn and 
 winter months. 
 
 These facts were so striking that at my desire Dr. 
 Gerhard collated all the available cases from the note- 
 books of the Infirmary for Nervous Diseases, in order 
 to arrive at an accurate determination of this point in 
 
CHOREA OF CHILDHOOD. 129 
 
 the natural history of the disease. Soon after, Dr. 
 Mills published a like summary of cases from the 
 clinic books of the University of Pennsylvania; and 
 within a few days Dr. Morris Lewis has kindly 
 brought together all of our own cases which have 
 presented themselves since the date of Dr. Gerhard's 
 paper, with additions from my private note-books. 
 This experience thus covers all classes of society. 
 
 Dr. Gerhard found that my clinic and note-books of 
 private cases gave for the time of attacks of sixty- 
 eight cases of chorea, thirty-nine in the spring 
 months, ten in the summer, seven in the autumn, 
 and twelve in the winter. This result was sufficiently 
 striking, but was incomplete, because the months of 
 attacks were not indicated. The subject seemed to 
 me to promise interest enough to repay a more exact 
 study, and for this purpose an effort has been made 
 to relate the attack to months instead of seasons, and 
 to examine into the conditions of weather which are 
 to be found in periods of the greatest and least fre- 
 quency of chorea. For the intelligent study here 
 made of this difficult subject I am largely indebted 
 to the skilful industry of Dr. Morris J. Lewis. 
 
 A few years ago no such study would have been 
 possible, but, the resources of the Weather Bureau 
 having been put at my disposal, I have found no ob- 
 stacle, save in the changes of the method of nota- 
 tion in its tables which have been made from time to 
 time. 
 
130 DISEASES OF THE NERVOUS SYSTEM. 
 
 EXPLANATION OF TABLE I. 
 
 Line 1. Interpreted by using column of figures to 80 ; is 
 intended to represent the mean relative humidity, i. e., 
 the mean per cent., and not the mean actual amount, of 
 the moisture which could be held in solution at the mean 
 temperature of each month ; the amount representing com- 
 plete saturation being indicated as 100, — the mean for the 
 month being obtained from the daily mean relative hu- 
 midity. 
 
 Line 2. Interpreted by using the column of figures 29.70 to 
 30.30; is intended to represent the mean barometric read- 
 ings for each month. 
 
 Line 3. Interpreted by using the column of figures to 80 ; is 
 intended to represent the mean thermometric readings for 
 each month. (Fahrenheit scale.) 
 
 Line 4. Interpreted by using the column of figures to 80 ; is 
 intended to represent the actual rainfall or melted snow in 
 inches for each month. 
 
 Line 5. Interpreted by using column of figures to 80 ; is 
 intended to represent the months of 'onset of 170 separate 
 attacks of chorea. 
 
 Line 6. Interpreted by using column of figures 10 to 20; is 
 intended to represent the mean daily range of tempera- 
 ture for each month. This is obtained by subtracting the 
 mean of the minimum temperatures, of each month, from 
 the mean of the maximum temperatures of the same, and 
 is an indication of the variableness of the different months. 
 
 EXPLANATION OF TABLE II. 
 
 This table is merely a mean of the five years 1876-80, and is 
 interpreted in the same manner as Table I. 
 
CHOREA OF CHILDHOOD. 131 
 
 EXPLANATION OF TABLE III. 
 
 Line 1. Is intended to represent the actual number of days on 
 which rain or snow fell in the diiFerent months of the 
 years 1876-80. 
 
 Line 2. Is intended to represent the actual number of cloudy 
 days during the same period, — the cloudy days being deter- 
 mined by the following rule : "In determining whether a 
 day is clear, fair, or cloudy, its character will be deter- 
 mined by taking the sum of the entire number of fourths 
 of clouds, observed at 7 A. M., 2 P.M., and 9 P. M. A 
 clear day will be one in which the sum of observed fourths 
 is 3, or less than 3 ; a fair day, one in which the sum is 
 from 4 to 8 inclusive ; and a cloudy day, one in which the 
 sum is from 9 to 12 inclusive." 
 
 Line 3. As in Table II. ; is intended to represent the months of 
 onset of 170 separate attacks of cliorea. 
 
 EXPLANATION OF TABLE IV. 
 
 Line 1. Is intended to represent the number of storm centres 
 
 passing within 750 miles of Philadelphia during the years 
 
 1878-80. 
 Line 2. Is intended to represent the number of storm centres 
 
 passing within 400 miles of Philadelphia (1878-80). 
 Line 3. Is intended to represent the months of onset of 87 
 
 separate attacks of chorea (1878-80). 
 
132 DISEASES OF THE NERVOUS SYSTEM. 
 
 Remarks and conclusions. — In drawing conclusions 
 from these tables, it must be remembered that, while 
 the meteorological portion is complete as far as carried 
 out, the number of attacks of chorea represented is 
 by no means the complete number occurring in Phila- 
 delphia during the five years under consideration, but 
 is merely a list of as many separate attacks as could 
 be collected, where the month and year of onset were 
 known without doubt. 
 
 In glancing at Table II. it is seen that the chorea 
 line (5) suddenly rises to a very high point in March, 
 this month having 35 attacks, or 20.58 per cent, of 
 the whole number; the line then falls suddenly in 
 April, then rises slightly during the summer, to fall 
 again and reach its minimum in October, viz. : 6 
 attacks, or 3.52 per cent. ; after this a very slight rise 
 occurs. In comparing this line with the line of mean 
 temperature alone (line 3) nothing especial is seen, 
 the same temperature in the autumn, as in the spring, 
 not being accompanied by an increase of the disease ; 
 nor is much light thrown on the subject in comparing 
 it with either the line of the mean relative humidity 
 (line 1), or with that of the mean barometer (line 2), 
 except that there appears to be an increase of chorea 
 with a fall in the mean relative humidity and baro- 
 metric tracings, and vice versa. This can also be seen 
 in Table I., but not as plainly as in Table II. 
 
 It has been stated that the disease is most preva- 
 lent during moist, cold weather ; but this assertion 
 does not appear to be sustained by Table II., where 
 it is seen by comparing the lines 1 and 3 that January, 
 February, and December have a much lower mean 
 
CHOREA OF CHILDHOOD. 133 
 
 temperature, and a much higher mean relative humid- 
 ity than March, and yet these months have but a small 
 proportion of attacks. 
 
 Nothing of any apparent importance can be gleaned 
 by comparing the mean daily range of temperature 
 (line 6) with the chorea line. 
 
 In comparing the amount of rainfall and melted 
 snow per month (line 4, Table II.), with the chorea 
 line, there appears to be a slight coincidence, the lines 
 rising and falling together except in May and June, 
 although the amount of rainfall is not proportionate 
 to the number of attacks. In looking at Table III., 
 it is seen that the line representing the actual number 
 of cloudy days (line 2) bears a much closer resem- 
 blance to the chorea line than does that of the actual 
 amount of rain and snow (line 4, Table II.). In July 
 and August there appears to be a discrepancy between 
 the two, but in other respects the resemblance is 
 marked ; the maximum attacks of chorea, occurring 
 in March, coinciding exactly with the greatest number 
 of cloudy days, and the minimum, in October, coin- 
 ciding with the minimum number of the latter. The 
 increase in the number of cloudy days in November 
 does not have a proportionate number of attacks of 
 chorea, although a slight rise is perceptible. 
 
 Allowance must be made here for the method of 
 computing the cloudy days, as the rule previously 
 stated is not without its objections ; for by this it may 
 rain, or there may be a thunderstorm on a clear or fair 
 day. The line representing the number of days upon 
 which rain or snow fell (line 1, Table III.) also resem- 
 12 
 
134 DISEASES OF THE NERVOUS SYSTEM. 
 
 bles, in some respects, the chorea line. This point will 
 be referred to further on, after a study of Table IV. 
 
 Line 1 of this table represents the number of storm 
 centres that have passed within a circle, whose radius 
 is 750 miles, drawn round Philadelphia as a centre, 
 during 1878-80, inclusive. The two previous years 
 were omitted, as the storm records were not available. 
 It was originally intended to construct a table show- 
 ing the number of storm centres that passed within 
 circles of varying radii ; but as it was seen that the 
 resemblance between the storm and chorea lines in- 
 creased as the circles increased in size until the largest 
 with 750 miles radius was reached, it was concluded 
 to simplify the table by only tracing the lines that 
 represent the number of storm centres passing within 
 the circles of 750 and 400 miles radii respectively ; 
 the latter line (2, Table IY.) being inserted to corro- 
 borate the statement just made. 
 
 The reason of the resemblances between some of the 
 lines in Tables II. and III. now becomes more appa- 
 rent, as they may be considered as component parts of 
 a storm, or as some of the factors of a storm, so that 
 a partial resemblance between them might reasonably 
 be expected. A conclusion which it seems justifiable to 
 draw from the foregoing study is, that no single factor 
 of a storm explains satisfactorily the rise and fall of 
 the chorea line, but it is where these are taken collec- 
 tively, as in the storm line, that the greatest resem- 
 blance is seen. 
 
 It is worthy of note here that the chorea line of 
 Table IY. resembles, in all its important features, the 
 chorea line of Table III., although there are 83 fewer 
 
CHOREA OF CHILDHOOD. 135 
 
 attacks included in it, so that it is reasonable to sup- 
 pose, if a larger number of attacks could be collected, 
 the resulting line would resemble those depicted in 
 the tables. 
 
 It appears that the area over which a storm has its 
 influence is strikingly alike in chorea and in neural- 
 gia, as proved by my former studies in the case of 
 Captain Catlin. 1 
 
 It will be seen with what extreme caution we have 
 ventured to draw conclusions from the elaborate 
 study here made. It is at all events valuable as a 
 step in a good direction. 
 
 The facts which come out here so clearly as to the 
 time of choreal attacks and their relation to storm 
 states would seem to indicate the further need for a 
 yet more refined and careful study of other points. 
 It were most desirable in future to set apart the cases 
 of chorea from fright and to study alone those cases in 
 which rheumatism accompanied or preceded this dis- 
 ease, while it would be also most interesting to learn 
 how far the curve of acute inflammatory rheumatism 
 would compare with that of choreal frequency. 
 
 It is of course probable that other factors than 
 conditions of weather may have a share in multiply- 
 ing attacks. One of these is certainty the influence 
 of mental labor. I know of many, cases which get 
 well when they cease to study, and relapse at every 
 new effort to do school work. With us the public 
 schools have their most important examination in 
 June, when promotions are made and class rank deter- 
 
 1 Am. Journ. Med. Sci., April, 1877. Relation of Pain to Weather. 
 
136 DISEASES OF THE NERVOUS SYSTEM. 
 
 mined. The pressure on the children is often con- 
 siderable, and may have its share in the rise of the 
 chorea line in early summer. 
 
 It is interesting, as we pass from this subject, to 
 pause a moment in order to contrast with chorea, an- 
 other neural malady as regards their meteorological 
 factors. 
 
 Some time ago my colleague, Dr. Wharton Sinkler, 
 showed that the paralysis of childhood is most com- 
 mon in hot weather. He has now, at my request, 
 made out the curves of relative monthly frequency 
 of this disease as seen at our clinics since 1872, and 
 has added the curve of temperature. (See Table V.) 
 
 The gradual rise to a maximum in August suggests 
 disastrous preparation by the weather of July, our 
 month of greatest heat; and the minimum reached in 
 winter is certainly a fact which no previous theory of 
 this disease could have prepared us to suspect or an- 
 ticipate. 
 
 Recurrence of Chorea. — The tendency of chorea to 
 recur is mentioned by several authors, and especially 
 by See. He speaks in one case of six, and in another 
 of seven returns; and, what is most interesting, he 
 fixes on the autumn as the time of relapses, as well 
 as of the initial outbreaks, and thinks that each suc- 
 cessive attack is apt to be lighter than the last, which 
 has certainly not held good in my own experience. 
 The French authors who mention any time for occur- 
 rence or recurrence of this malady all follow See's 
 statement. According to him, the six autumn and 
 winter months furnish three-fifths of all the choreas. 
 This he attributes to the joint action of cold and 
 
CHOREA OF CHILDHOOD. 137 
 
 moisture, which seem to him the most important 
 factors, but which, as our tables show, does certainly 
 not hold good as regards this country and latitude. 
 
 Dr. Gerhard's paper mentioned the facts observed 
 in this direction at my clinic, and in my private prac- 
 tice. Out of 80 cases, 25 bad been attacked before. 
 Of the 25 cases, 14 had thus had chorea three times; 
 8 had had it twice; and 3 had experienced it four 
 times. Of the 25, nineteen recurred in the spring. 
 
 My later experience has given me cases of chorea 
 which have recurred in a yet more remarkable man- 
 ner. One young girl had chorea for four years either 
 in March or April; then once in February; and then 
 for two years in May. In another case the disease 
 broke out in a lad aet. twelve, and recurred every 
 spring for three years. In a third case, the disease 
 began in a girl of seven, and missing one }^ear per- 
 sisted until she was thirteen, when it ceased to appear. 
 The attacks began usually in March or April. 
 
 I never knew a case to recur thus pertinaciously 
 in the autumn, although sometimes, in this latitude, 
 vernal attacks get well in summer, and recur in au- 
 tumn. The same holds good of winter chorea. If 
 cured, there is a positive tendency to break out in 
 the spring. 
 
 Dr. Morris J. Lewis's table of my own clinics gives 
 this result as to repetitions of attacks: 126 cases, 
 representing 185 attacks. 
 
 Sinee I have been well aware of these facts, I have 
 been accustomed to warn parents of the tendency of 
 chorea to recur, and have always given careful in- 
 struction as to the general treatment of the child in 
 
 12* 
 
138 DISEASES OF THE NERVOUS SYSTEM. 
 
 winter, and have always given arsenic as the spring 
 began. I have in this way broken up, in many cases, 
 the habit of vernal recurrence of chorea. 
 
 How far such facts hold good of other latitudes than 
 this I cannot yet say; but I gather from many of the 
 letters of answer I received from our warmer States, 
 that the onsets of this disease are probably more com- 
 mon in winter than with us. I have no accurate 
 numbers wherewith to settle the question. It would 
 be very interesting to know what law of occurrence 
 and recurrence chorea follows in Great Britain. 
 
 Relations of Chorea to Climate. Locality. — After I 
 had determined the factor which I have here illus- 
 trated, I became somewhat interested in the question 
 of climate as related to this disease, and was soon 
 struck with the slight information on this subject to 
 be found in the books. Yon Ziemssen says that 
 Hirsch has now authoritatively contradicted Kufz's 
 statement of the rarity of this disease in the warm 
 zones both in black and white. Its relative frequency 
 is hard to judge of, because there is little or no death- 
 rate, and because cases are sometimes noted as deaths 
 from chorea, when they were due to other maladies. 
 Hence the only evidence is the statement of physi- 
 cians in active practice. 
 
 If I consider this, I should conclude from the 
 answers to my questions, that warmth does not nu- 
 merically lessen it, as in fact my tables show. It 
 appears to exist in all of the larger cities all over 
 our Southern States, and also quite freely in Cuba. 
 Dr. Finley, of Havana, and Drs. Landetta and De Cas- 
 tro, formerly of that city, report it as common enough, 
 
CHOREA OF CHILDHOOD. 139 
 
 especially among girls at the approach of puberty. I 
 hear like accounts from Lisbon and from the great 
 cities of South America. In a few cases Southern 
 physicians write me that it is rare even in large towns, 
 but when they add the number of cases they have 
 seen, it is usually clear that they have met with quite 
 as much of this disease as it is common to encounter 
 at the North. The facts already pointed out, which 
 show clearly enough that chorea is seen most in the 
 spring and early summer, might very well prepare 
 ns to find least of it in such localities as the Ber- 
 mudas, where the temperatures vary so little through- 
 out the year ; but as to this I have no information. 
 
 There is another factor in the case, and an impor- 
 tant one. It comes clearly out in the answers I re- 
 ceived. Chorea is a disorder engendered in some way 
 by the evil influences which are found wherever men 
 live crowded together in masses. It is essentially a 
 disease of cities. The larger cities, both in the north 
 and south, furnish it, as I should judge, in much the 
 same proportion. There is less in the smaller places, 
 and in country practice, north and sonth, it is an ex- 
 ceptionally rare disease. Physicians who have been 
 twenty to forty years in rural practice, sometimes 
 cannot recall a case, and yet, as we know, rare cases 
 are usually the best remembered. Among one hun- 
 dred letters, were twenty representing — and it is no 
 bad way to put it — over three hundred years of prac- 
 tice by men who have never seen a case of chorea. 
 
 I should at least have expected to find, that, in 
 highly malarious countries, where, as we know, the 
 endemic influence tells severely on the health of all 
 
110 DISEASES OF THE NERVOUS SYSTEM. 
 
 ages, this lowering cause would be competent to do 
 what some combination of atmospheric causes en- 
 ables the spring and summer months to do — awaken 
 chorea, There is, however, no evidence to favor the 
 view that chorea can have a malarial origin, except 
 that it arises in spring with as much certainty as ague. 
 But there is also some direct evidence to show that 
 there may even be something hostile in malaria to 
 chorea — a point which I make with considerable 
 doubt. It would seem, however, that, in localities 
 where malarious plains are bounded by wholesome 
 hills, — as a most excellent observer, Dr. Ellis, of 
 Elkton, declared, and some other physicians also, — the 
 chorea which they met with arose on the hills, and 
 not on the plains. To this I should add, that, in cer- 
 tain of the most malarious regions of the South, 
 chorea is a nearly unknown malady. 
 
 It would naturally follow upon what I have said, 
 that the disease itself would be found to increase nu- 
 merically in cities in direct proportion to their growth. 
 Of the increase of a rarely mortal disorder we can, 
 however, have no just conception, and the deaths 
 reported as due to chorea must, as I have said, be 
 regarded with a certain amount of suspicion, and this 
 remark will especially apply to years long past when 
 there was far less accuracy of discrimination as to the 
 causes of death from neural maladies. 
 
 The slightest study of the vital statistics of our own 
 cities will show how just is this criticism. In Chicago 
 from 1851 until 1866 there is no report of a death by 
 chorea at any age Then in 1866 there is one, a girl 
 of 15 years, and then none to 1869, where my statis- 
 
CHOREA OF CHILDHOOD. 141 
 
 tics fail me. The population had meanwhile increased 
 from 38,000 to 252,000. 
 
 In Philadelphia, between 1807 and 1881, chorea is 
 given as the cause of death in 64 persons, of whom 38 
 are said to have been under 20 years, and 26 over 
 that period of life. In this list are many over fifty 
 and many under two years, so that there were prob- 
 ably in these two sets a fair proportion of imperfect 
 diagnoses. 
 
 Race. — Although aware of the insufficiency of the 
 material on my hands to answer thoroughly this ques- 
 tion, I have felt unwilling not to use the letters which 
 so many gentlemen have been at great pains to write 
 me. I have, however, hesitated the more because 
 the tentative opinion on this question which I reached 
 quite early, has been criticized by very able southern 
 physicians as not in accordance with the facts they 
 themselves had observed. 
 
 Let me admit, to begin, that in these letters there 
 may be many errors; that rare cases may be for- 
 gotten ; that the negro often fails to call on a doctor 
 for even serious maladies ; and, granting these sources 
 of distrust of my statistics, I do not see how we can 
 fail to conclude as I have done, not that the negro is 
 insusceptible of having chorea, but that in the black 
 race it is far more rare than in the white. 
 
 Of sixty physicians who replied at length — some 
 lived in cities or towns, some in the country — twenty- 
 seven speak of chorea as rare in the white ; all of the 
 rest give the number, or an approach to the number, 
 of white cases they can recall. One has seen an epi- 
 demic outbreak of chorea. Of these sixty, forty-nine 
 
142 DISEASES OF THE NERVOUS SYSTEM. 
 
 have never seen chorea in the black ; the rest who 
 write speak of it as rare, or mention having seen single 
 cases. I should add that many of the examples spoken 
 of were women, but exactly of what ages is rarely 
 stated. 
 
 Even this curious correspondence of view does 
 not, however, impress me so much as the character 
 of the writers of some of the letters and the extent 
 of inquiry which they have made. It may be well 
 worth while to analyze portions of this evidence. 
 
 Dr. B. De Landetta says, as regards Cuba, and two 
 others indorse his opinion: "I have never seen 
 chorea in the negro, which is strange, because it is 
 rather frequent in Cuba among white girls at puberty, 
 and because rheumatism is common in the negro." 
 Dr. Ch. Finley, of Havana, thinks chorea rare among 
 whites; but, despite his appeal to the Havanese 
 Academy of Medicine and the publication of the 
 questions in its journal, but one case of chorea in 
 the black could be heard of. 
 
 Among the letters are several from physicians who 
 had been large owners of slaves, and had also had 
 extensive plantation practice. One, Dr. Ashe, of 
 Alabama, having seen in all seven white cases, never 
 saw a case in the negro. 
 
 Dr. Benj. Lee writes that in a year of service in 
 the Hospital of the Home for Colored Children, New 
 York, he saw a case of chorea in a mulatto girl set. 15 
 end fatally, but has never seen it in the pure black. 
 Dr. Kolloek writes me from Cheraw, S. C, that he 
 has seen in twenty five years of large practice some 
 twelve cases in the white and two in the negro of 
 
CHOREA OF CHILDHOOD. 143 
 
 pure breed. Three physicians write me from Louis- 
 burg, N. C, that one of them in thirty-six years of 
 practice recalls six or seven cases and one death in 
 whites. Two others have seen a few white cases, and 
 none of the three any black cases. Prof. J. L. Cabell 
 recalls but five cases in the white, and has seen none 
 in the black. Prof. Bemiss, of New Orleans, has seen 
 cases both in white and black, and does not feel sure 
 as to this question. Dr. Ellis, of Elkton, Md., a most 
 competent observer, has obtained, by careful inquiry, 
 knowledge of thirty cases in the white in ten years, 
 and of two in black or colored children. Dr. Michel, 
 Montgomery, Ala., writes me that no one of the thirty 
 members of their County Society ever saw a case in 
 the pure negro. The disease is seen in whites. The 
 secretary of the Medical Society of Columbia, S. C, 
 from correspondence in the State and from the debate 
 on this subject in the society, was unable to discover 
 a case of chorea in the negro. 
 
 Dr. Peyre Porcher, having put this question to thir- 
 teen members of the Charleston, S. C, Medical Society, 
 received for answer that the disease is not common 
 among whites, and that no one of the number had 
 seen a case in the negro, and to this, Prof. E. Geddings 
 adds testimony to the same effect. Dr. Laurance, of 
 Hot Springs, Ark., says chorea is found very rarely 
 among negroes, more often among mulattoes, but is 
 not a common disease where he has lived in the South. 
 The general evidence in Yirginia is very much to this 
 effect, but in Eichmond it is clearly. less infrequent, 
 both iu white and black or colored, than elsewhere in 
 the State. 
 
144 DISEASES OF THE NERVOUS SYSTEM. 
 
 On the other hand, many physicians in Virginia 
 state that it is as common in one race as in the other, 
 and Dr. Landon Edwards, of Eichmond, after a careful 
 inquiry, reached the conclusion that the negro has no 
 immunity. 
 
 It seems to me, however, that as the matter stands, 
 the weight of evidence is in favor of the opinion that 
 the black is less liable to chorea than is the white. 
 
 Varieties of Chorea. — I pointed out some years ago, 
 that there exist at least three groups or species in the 
 genus chorea of childhood. The significance of the 
 distinctions is not as yet clear to me, but I am in- 
 clined to think that they may indicate a differentia- 
 tion in the anatomical sites of the central disturbances 
 which give rise to this disorder. As they are not yet 
 adopted in the books or confirmed by the researches 
 of others, I shall venture here to restate briefly my 
 views so as sufficiently to illustrate the peculiarities I 
 have seen. 
 
 Group First. — The common type; awkwardness and 
 incoordination of voluntary movement, followed soon 
 or late by automatic or unwilled clonic spasms of 
 various parts. 
 
 Group Second. — The disease never gets beyond the 
 first stage of incoordination. Just as in some scle- 
 roses of the cord there is no tremor save during voli- 
 tional acts, so here the irregular motions only occur 
 during willed actions. 
 
 Group Third is, I think, the most unusual type, 
 but I see occasional cases every spring. In this 
 there are constant automatic, irregular, clonic spasms 
 usually of the hands, but during volitional acts these 
 
CHOREA OF CHILDHOOD. 145 
 
 entirely vanish, and the most complicated acts are 
 well performed and without obvious incoordination. 
 In other cases voluntary motion merely lessens the 
 spasmodic activity, but does not abolish it. It is 
 necessary to illustrate only this third group. 
 
 T. C, set. 14, female, applied at my clinic in May, 
 1879. She was a florid healthy looking descendant 
 of healthy people, but had one brother who was epilep- 
 tic. In March, 1878, she was attacked rather sud- 
 denly with clonic spasms of both hands. These parts 
 were in incessant movement during- the waking; hours, 
 and until she attempted some acts of volition. Then, 
 and during the movement in question, they were en- 
 tirely free from all appearance of incoordination. She 
 could write, sew, lift a glass of water, or do any other 
 act involving complex motion without the least tre- 
 mor, but in a moment after it was done, the fingers 
 would again resume their spasmodic activity. 
 
 I have seen a number of these cases. They are 
 distinctly choreal, and yield to such treatment as is of 
 value in that disease, but they differ plainly enough 
 from the ordinary type of chorea. 
 
 13 
 
146 DISEASES OF THE NERVOUS SYSTEM. 
 
 LECTURE VIII. 
 
 HABIT CHOREA. 
 
 I have over and over in my clinics called attention 
 to a disorder of childhood which is the source of some 
 anxiety and more annoyance both to parents and 
 physicians. This trouble I venture here to label 
 Habit Chorea, and for reasons which, I think, are 
 good and which will appear in full as we consider the 
 cases. 
 
 Over and over some anxious mother will ask you 
 to notice her child on account of some little trick or 
 gesture in which the child indulges. Then you will 
 see that it is winking rapidly, or pursing up the 
 mouth or drawing it to one side, or, perhaps, that the 
 brow is lifted at intervals or a shoulder shrugged, or 
 some forward movement of the jaw or head is re- 
 peated over and over at varying intervals. 
 
 These acts occur usually in children of either sex, 
 but I think most often in girls from 7 to 14 years of 
 age. In many cases the single grimace or motion is 
 repeated for months and then disappears, and, if this 
 were all, I should hardly think it worth while to label 
 so trivial a disturbance of -health ; but in other cases 
 the first habit is lost by and by, and another takes its 
 place, so that the variety and obstinacy of the habits 
 become troublesome and even cause alarm ; or, worse 
 
HABIT CHOREA. 147 
 
 still, the little patient lias a large repertory of these 
 performances, and will execute a remarkable variety 
 in one day. Usually, in such instances, there is some 
 one motion which is more violent or more frequent 
 than the others. 
 
 If you examine with care the history of these little 
 patieuts }^ou often find that there has been some 
 fall from the plane of health, and you will at once 
 wish to know wherein the child's life and work and 
 play are not what they should be. Sometimes find- 
 ing nothing to blame, you will recall the fact that, 
 in the process of growth, children undergo cyclical 
 changes which are not permanent, and which in turn 
 may bring or take away tendencies to neurosal dis- 
 orders, so that you must not always expect to be able 
 to detect the causes of such disease. 
 
 If you analyze more closely the character of the 
 symptoms we are studying, you will find quite enough 
 to repay attention. You will observe, first, that atten- 
 tion to the child increases the trouble, and that any 
 little failure in health has a like influence. Then, if 
 you see many such cases, you will observe that these 
 children are sometimes irritable or excitable, or ex- 
 hibit clearly enough a condition of nervousness, being- 
 more emotional than is natural ; while, in a few 
 instances, they lapse into well-pronounced chorea of 
 the ordinary type. In fact, this disorder has a cer- 
 tain kinship to the latter affection. If you ask an 
 intelligent child, who is thus diseased, why it makes 
 the grimaces, or repeats, at intervals, some odd move- 
 ment, you will learn that, while the patient is able, 
 in most instances, to restrain itself and control the 
 
148 DISEASES OF THE NERVOUS SYSTEM. 
 
 exhibition of motor disorder, tins restraining power 
 becomes increasingly difficult the longer such effort 
 lasts, and that a certain malaise or discomfort results ; 
 while to give way and let the morbid impulse have 
 full sway is attended with a sense of comfort and 
 relief. 
 
 Such is, in brief, a'll that I know about this small 
 malady; although you will, perhaps, comprehend it 
 better if I relate cases and point out, by illustrations, 
 the fact that its treatment should be very much that 
 which is needed in full-fledged chorea ; another argu- 
 ment, if a slight one, in favor of the relationship of 
 the two disorders. 
 
 During the present month of November I saw M. 
 C. Gr., oet. 13, girl. Never a robust child, at the age 
 of six she became, without known cause, nervous, 
 restless, and irritable ; and was, for awhile, a bad 
 and uneasy sleeper. About this time she began to 
 have a slight hacking cough, which came and went; 
 was made worse by an attack of scarlet fever, and 
 still exists at times. It sounded like a cough which 
 was forced and voluntary. At nine or ten years, the 
 cough almost passed away, and was succeeded by a 
 sort of snuffling, during which she made the usual 
 grimace, always on the left side, and precisely such 
 a movement as accompanies snuffling. Whenever 
 she makes this contortion she pushes her cheek up 
 with the left hand. For a long while the cough and 
 the snuffling act continued, the one or the other being 
 prominent for a time. She was scolded and bribed 
 into making great efforts to stop these morbid acts, 
 and more or less succeeded. The next summer she 
 
ITABIT CHOREA. 149 
 
 was taken to Saratoga, and the cough and snuffles 
 abated, but a new symptom arose. The mouth would 
 be opened wide, and as it closed both eyes shut, and 
 remained closed for a moment, or else this took place 
 without any opening of the mouth. 
 
 When I saw the child, all of these odd movements 
 were in full activity, but usually one of the three was 
 more frequent than the others. There was at this 
 time a good deal of dyspepsia, sluggish appetite, and 
 pain in the back low clown, probably indicative of 
 the coming on of her menstrual flows, the approach 
 of which was rendered probable by a rapid develop- 
 ment of her bust and pelvis. She had had no worms, 
 and no organic or functional disturbances other than 
 those I have mentioned. As she is just now, for the 
 first time, under treatment, I can say nothing as yet 
 of its success. Careful and good diet, light gymnas- 
 tics, no school, gentle aperients, and full doses of ar- 
 senic constitute such therapeutics as seemed to me 
 reasonable. I ought to add, that she does not seem 
 in any degree mortified at her own peculiarities, and 
 this will be met by some effort to make the matter 
 appear to her as rather disgraceful, and not to be 
 mentioned — something, in fact, to be ashamed of. I 
 shall be much surprised if this combination of physi- 
 cal and moral treatment fails us. 
 
 The next case I shall relate is quite as good a type. 
 This was a lad, aged fourteen, who was taken from 
 school a few months before on account of twitching 
 and nervousness. He had become also irritable and 
 capricious, and the grimaces, for which chiefly he was 
 brought to me, had increased, and had, indeed, been 
 
 13* 
 
150 DISEASES OF THE NERVOUS SYSTEM. 
 
 increasing from the previous April, and until he gave 
 up school late in July. It is in fact usually safe in 
 such cases as this, and in all choreal troubles, to pre- 
 dict either a return or an increase of the symptoms in 
 the spring. 
 
 In this lad the twitches began with snapping of the 
 eyes, and this came and went, but was never quite 
 lost, but merely lessened when some new symptom 
 arose. The second form of trouble consisted in a 
 curious rolling of the head, difficult to describe. This 
 was bad enough, but quite suddenly within a few 
 days the face became more quiet, and there arose a 
 disorder of the abdominal muscles which Avere 
 abruptly contracted at intervals. Over this and over 
 all of these motions my patient had a good deal of 
 control. If he set himself to hold it in check, this 
 was possible so long as he steadily attended to the 
 task, but while it was easy to repress it for fifteen 
 minutes it was difficult after half an hour, and increas- 
 ingly more and more hard, until by and by some 
 slight lack of attention enabled the act to recur, or 
 else the sense of discomfort and strain involved in 
 these resolute acts of will power became unendurable, 
 and the lad abandoned the effort. After a month or 
 two of these movements, the respiration was broken 
 every few minutes by a sudden long drawn abrupt 
 inspiratory act. Still later the head w r as affected, 
 or rather the neck, with a little short negative shake. 
 The abdominal and respiratory disorder gave way at 
 last to shrugging of one shoulder, and then to this 
 with a queer upward pull of the whole side. The 
 worst attack lasted but a few weeks, and was a sort of 
 
HABIT CHOREA. 151 
 
 straightening up of the body. These varying condi- 
 tions endured for several years. At one time the 
 boy seemed well, then spring time or any little malady, 
 especially indigestion, or much study and in-door life 
 seemed to reproduce the troubles in some shape new 
 or old. It was a slight grimace to-day, and in a 
 week or two it was a sudden action of the muscles of 
 the back or a shrug or a spasm of the muscles of the 
 belly. In no case did the hands or feet suffer, and 
 always the disorderly act was distinctly controllable 
 by will ; this repression was unpleasant, and some 
 relief was found in allowing the muscles to have their 
 
 way. 
 
 As the patient's eyes were plainly imperfect, Dr. 
 Noyes, of New York, was so kind as to send me a 
 statement to the effect that the lad had, in the right 
 eye a slight mixed astigmatism, and in the left a 
 slight compound hypermetropic astigmatism. These 
 errors were really trifling in amount. Toe eye mus- 
 cles showed some weakness. The eye grounds were 
 healthy. 
 
 I had a long bout of treatment with this lad, whose 
 docility and good sense lent me every help. 
 
 He took at first a good deal of valerianate of zinc, 
 and had cold douches to the spine, and also arsenic 
 internally. Meanwhile he was taken from school and 
 set free in Yirginia on the sea-coast to ride, swim, 
 shoot, and fish. Notwithstanding these wholesome 
 aids, we got no further in the way of relief until we 
 began to use hypodermic injections of arsenic. For 
 this Fowler's solution without the lavender was used 
 thrice a week, iu doses rising from two drops to twelve, 
 
152 DISEASES OF THE NERVOUS SYSTEM. 
 
 and as this heroic medication was followed by rapid 
 subsidence of the symptoms, it was continued for 
 nearly three months. A sea-voyage and residence 
 at an English school completed his cure, and then 
 we had also the favoring influence of approaching 
 puberty. 
 
 These cases, and I might readily add others, suffi- 
 ciently illustrate the varieties and the peculiarities of 
 the disorder to which, for reasons which must now be 
 plain enough, I have with some hesitation given the 
 name of Habit Chorea. The last case also defines suf- 
 ficiently well what the treatment ought to be. 
 
DISORDERS OF SLEEP. 153 
 
 LECTURE IX. 
 
 DISORDERS OF SLEEP IN NERVOUS OR 
 HYSTERICAL PERSONS. 
 
 The man before us is a feeble anaemic creature, 
 who complains that he has become nervous, an ill 
 sleeper, and has lost weight. He is a coffin maker, 
 and looks as if he were artistically fitted for some 
 such ghastly labor. He has no organic malady, and 
 I only speak of him at all because one symptom of 
 his case is of sufficient interest to serve as a text. 
 
 He tells his story well, perhaps more dramatically 
 than I can, but with less brevity than I need just now. 
 When falling asleep he is conscious of something in- 
 definable, not describable, rising from his feet and 
 going up to the head. Usually he can move and thus 
 check the progress of the disorder ; sometimes he can- 
 not and then the attack results in a sense of some- 
 thing like a blow struck on his head. At first it 
 created terror, now he has become used to it, and is 
 no longer alarmed, although the expectation of it is 
 unpleasant, and apt to keep him awake. 
 
 This is a mild form of a very curious symptom — -I 
 can hardly call it more — which is quite common 
 among hysterical women, more rare among men, and 
 which exists in a variety of forms, and is in such 
 persons at times a difficult symptom to deal with, and 
 
154 DISEASES OF THE NERVOUS SYSTEM. 
 
 in certain cases the parent of a great deal of mischief. 
 In 1875, I published a brief paper 1 on some of the 
 disorders of sleep, in which I described these phe- 
 nomena as follows : — ■ 
 
 'The trouble I shall describe is rarely found alone, 
 but makes a part of one of those groups of neurosal 
 symptoms which have no place in the books, and 
 which are apt to vary largely. 
 
 1 M. A., a prominent physician from the Northern 
 States, after a season of greatly excessive labor, be- 
 came rapidly anasmic and weak, and developed the 
 following symptoms : tingling, numbness, and heat of 
 the extremities — now here, now there — on the chest, 
 face, or scalp. At times, after much fatigue, islands 
 of vasal paresis, seen as slightly raised purple blotches 
 on the feet, are observed, and frequent waking up at 
 night, with numbness of either arm ; feeble sleep, a 
 dull, occipital pain, which made him wish to hold the 
 part ; singing in the head, referred now to the occiput, 
 now to the ears, but an inconstant symptom. He 
 was at last driven to consult me by the following 
 symptoms, which caused him the utmost alarm. 
 
 ' When just falling asleep, he became conscious of 
 something like an aura passing up from his feet. 
 When it reached his head, he felt what he described 
 as an explosion. It was so violent and so loud, that 
 for a time, he could not satisfy himself that he was 
 not hurt. The sensation was that of a pistol shot, or 
 as of a bursting of something, followed by a momen- 
 tary sense of deadly fear. This sense of an aura is, as 
 Brown -Sequard wisely says, not confined to epilepsy.' 
 
 1 Virginia Med. Monthly, Feb. 1876. 
 
DISORDERS OF SLEEP. 155 
 
 I have now in my care, a very accomplished gen- 
 tleman, whose case is in almost every respect like that 
 just sketched, except that the numbness is never uni- 
 versal. The victim (Mr. V.) is, in this instance, a 
 slight sensitive scholar, not overworked, but too 
 steadily worked, which may amount to the same 
 thing. In him, the numbness of the finger-ends came 
 on abruptly, but as in the other case, there is no true 
 loss of tactile sense, and possibly, nay probably, the 
 feeling belongs to some condition of the lesser blood- 
 vessels of the part, and only secondarily to the nerves. 
 
 He feels, as he is falling asleep, a sense of something 
 about to happen, but no distinct ascending aura. If 
 he arouses himself in time, for which at the moment 
 he clearly comprehends the need, he can by turning 
 over relieve himself and break the chain of morbid 
 events. He can even watch, as it were, the coming 
 of the shock, and in some way know the moment be- 
 yond which he must not wait. The first patient de- 
 scribed as suffering in like fashion has also remarked 
 on this peculiarity. Mr. V. has rarely the sense of a 
 pistol-shot or a blow on the head. "I have,'' he says, 
 11 at the close of the attack, a noise in my head, which 
 is sometimes like the sound of a bell, which has been 
 struck once, and I have in my case listened as to a 
 bell, to the vibration coming and going at rhythmical 
 intervals, or else I hear a loud noise, which is most 
 like that of a guitar string, rudely struck, and which 
 breaks with a twang." The result is always, how- 
 ever, a sense of dread, but not such a death terror as 
 has Mr. A. 
 
 I have been told by other persons, that they were 
 
156 DISEASES OF THE NERVOUS SYSTEM. 
 
 liable, when going to sleep, to have sudden sounds, 
 faint usually, and rarely loud, but without feeling of 
 terror. 
 
 Since writing this account I have seen a large 
 number of persons who suffer in like fashion from 
 some one of the various forms. The most of the 
 cases are women worn out, or tired out, and hysteri- 
 cal, whether strong and well nourished or not. In 
 sturdy men it is rare, unless they be excessive users 
 of tobacco. 
 
 The disorder in question I never saw in a man, ex- 
 cept in the border land between waking and sleeping. 
 He may have the aura and then the subjective sensory 
 phenomenon, or the latter may come without warn- 
 ing ; but in hysteric females these attacks may arise 
 either at the moment of going to sleep, or during the 
 day at any time, and while fully awake. At times 
 they are slow in the march of their symptoms, and 
 may be checked by the patient if, what is rare, she have 
 enough of resolution ; but very often the aura rises 
 fast, too fast to allow of action or of emotion, or else 
 just slowly enough to give time for a sense of fear, the 
 full development of which requires a certain amount 
 of time. 
 
 The warning by an aura is common in women thus 
 attacked, and consists either in an indefinite sense of 
 something rising towards the brain from the feet or 
 hands, or both, or else it is a distinct tingling. 
 
 In a smaller number of cases the only warning 
 is an impending sensation of pure terror, which 
 increases until the sensory shock occurs. But as 
 regards all forms of the aura, or warning sensation, it 
 
DISORDERS OF SLEEP. 157 
 
 is found tli at, as a rule, the intensity of the emotion 
 weakens with repetition. 
 
 The aura is totally lost in the phenomena which 
 follow. These may be classified as follows: — 
 
 1. In the sphere of general sensation: sense of a 
 blow, of shock on or in the head, of rending or 
 bursting. 
 
 2. In the auditory sphere : loud noise like an ex- 
 plosion. 
 
 3. In the visual sphere : flash of light. 
 
 4. In the olfactory sphere : sense of odor. 
 
 5. A combination of two or more of these sensory 
 manifestations. 
 
 6. More or less abrupt and general motion, the 
 ordinary outcome of any violent and sudden sensa- 
 tion. 
 
 It will repay us to analyze somewhat more minutely 
 the pecularities of these interesting attacks, since I 
 have usually found that they are not only sources of 
 alarm to patients, but of doubt and puzzle to their 
 medical attendants. 
 
 In the first group the final symptom is referred to 
 the head, and is a feeling of a blow, violent or light, 
 struck on the skull ; or it is a feeling so terrible as 
 to be described as something like an explosion, or a 
 pistol shot, or more vaguely as a shock, something 
 undefinable and terrifying. 
 
 The auditory forms are described in their varieties 
 as a noise, an explosion, the sound of a bell, a booming 
 sound — that of a guitar-string rudely struck. 
 
 The visual form is simply a flash of light, with or 
 without sense of noise. 
 14 
 
158 DISEASES OF THE NERVOUS SYSTEM. 
 
 The single case of an olfactory form of sensation 
 will be more fully described hereafter. 
 
 The affections of general sensation may exist with 
 auditory symptoms or not, since, when it is possible 
 to get a patient to evolve, out of the terror and con- 
 fusion of such attacks, an analysis, they usually men- 
 tion some disturbance of audition as going with the 
 sense of a blow. 
 
 In rare cases the patient is left with a momentary 
 vertigo ; more often the start which announces the 
 sensory symptom ends the attack, so far as its imme- 
 diate phenomena are concerned. Not so, however, its 
 results in the emotional sphere. In some persons it. 
 gives rise to great alarm, even after many repetitions 
 of attacks, and in these and others is apt to leave the 
 victim shaken and hysterical, or to be the first of a 
 series of hysterical symptoms, the end or exact future 
 of which no man can predict. 
 
 I would like now to illustrate some of these inte- 
 resting symptoms by cases, always asking you to re- 
 member that in this lesson, as in some others, I am 
 picking out a single symptom for study, and that it is 
 not always the main feature of the case. 
 
 The following case is told so well in the language 
 of the sufferer that I prefer to leave her account al- 
 most unaltered. It is one of a few rare examples in 
 which the shocks occurred at times while awake as 
 well as during the state of sleep. A series of severe 
 mental and physical strains, and a slight sunstroke 
 left my patient, a woman, now over fifty, anaemic 
 and reduced to the weight of seventy-six pounds, 
 her height being five feet three inches. Her eyes 
 
DISORDERS OF SLEEP. 159 
 
 and ears were healthy, her womb normal. There was 
 no trouble of any internal organ, but there was a loud 
 soft haemic murmur at the right side of the base of the 
 heart. Her sleep was good as a rule, but was easily 
 disturbed and insecure. She writes thus : " Some years 
 ago, when thirty -nine years old, after a long bout at 
 nursing, sustained by quinine and stimulants, I began 
 to fail in health, and then first became subject, whether 
 asleep or awake, to a sensation, which I can only de- 
 scribe as a wave going through my head and threaten- 
 ing as it seemed to me an unconsciousness which 
 never came. If in bed, I would start up, and if riding 
 or walking would clutch at some near object for fear 
 of falling, yet I cannot remember to have felt unstable. 
 The following summer, after slight heat-stroke, and a 
 new exposure to severe fatigue of body and mind, 
 I experienced, once only, a sensation like the explo- 
 sion of a pistol in my head. I hardly know how other- 
 wise to describe it. A few months later, I began to 
 have what I have always since called my shocks. A 
 peculiar something, which for want of a better name 
 I call electricity, starts from my head, chest, stomach, 
 or bowels, and seems to pervade me in a flash, then 
 comes the sense of shock in the head and an uncon- 
 trollable shriek. At first, it never came unless mv 
 eyes were shut, but for one week when I was most 
 highly nervous and sleepless, it would come if I 
 was startled by any sudden sound, and then I found 
 that for a short period I could cause it by touching 
 a spot over my stomach. 
 
 " Of late, these shocks are not always preceded by 
 any length of warning, and are in the head alone. 
 
160 DISEASES OF THE NERVOUS SYSTEM. 
 
 They come mostly as I am going to sleep, and by 
 straining my eyes to keep them open, I can some- 
 times prevent the shocks altogether. I should say, 
 that there is often some queer sense of chilliness 
 in my head for an hour before the shocks, which 
 is in a general way a warning of what may come. 
 I do not like to so restrain them when the ten- 
 dency is strong, as I then have one or two during 
 the night while asleep, when they are very frightful 
 to me. In some cases there will be a succession of 
 weak shocks, and at last a strong one, when I shriek. 
 After absence from home and freedom from cares, I 
 have been exempt from these shocks for weeks or 
 months." 
 
 This unhappy case I mention first, because of its 
 obstinacy. I have rarely seen the shocks thus per- 
 sistent, and I am sure that they will disappear when- 
 ever this woman becomes vigorous. Neither is the 
 case quite typical, like one I have lately seen, and 
 which readily got well. It is valuable because the 
 shocks were so much the most prominent symptom. 
 
 Early this winter, Mrs. L., of Massachusetts, aet. 45, 
 a ruddy, hale looking woman, five feet four, weight 156 
 pounds, came to me with this simple story: She was 
 well until her husband met a year ago with disasters in 
 business. Her anxiety about him, and the worry 
 attendant upon the management of a household with 
 suddenly lessened means, were made worse by the 
 grave illness of her only child. She became nervous 
 under these influences, and began to suffer from sounds 
 which commonly cause no annoyance. Then her sleep 
 got to be imperfect, and she had a series of hysterical 
 
DISORDERS OF SLEEP. 161 
 
 attacks — the usual spasms — trismus, rigidity, hysteric 
 coma, and the like, with a slight but distinct and 
 general lessening of acuity of the sense of pain and 
 of touch. Finally these phenomena passed away, and 
 about this time she became subject to the shocks I 
 have spoken of. These occurred either at the moment 
 of going to sleep, and while quite conscious, or in the 
 day-time, and when wide awake. 
 
 The aura began in both feet, and ascended rapidly 
 to the head, sometimes being felt also in the hands 
 and arms. It was described as an air, and at times as 
 a faint tingling. It ended in a sudden sense of a loud 
 report, which caused her to seize her head with both 
 hands, and left her in a state of alarm and feebleness, 
 and with a brief but tumultuous throbbing of the 
 heart. The attacks took place irregularly, once a week 
 at first, and later at much longer intervals. Their 
 effect was disastrous, because they gave rise to dis- 
 tressing nervousness, and sometimes to prolonged hys- 
 terical conditions, in which all her usual hyperaesthetic 
 states were remarkably accentuated. 
 
 While she was under my care I saw a lady from 
 New York who was a sufferer from a variety of nervous 
 symptoms, dependent in part on a split cervix uteri and 
 a lacerated perineum. These were surgically relieved 
 through operative means by Prof. Goodell, but the 
 after-treatment of the hysterical conditions, hyperes- 
 thesia, sleeplessness, and intense general nervousness 
 was a slow process. The use of ether during the 
 operation, which I have learned somewhat to dread in 
 grave hysteria, seemed to be the immediate parent for 
 
 14* 
 
162 DISEASES OF THE NERVOUS SYSTEM. 
 
 a time of an increase in all her old symptoms, and of 
 some new ones, among which were the shocks. 
 
 The attacks came at any time except in sleep, and 
 were similar to those of Mrs. L., but less severe. 
 There was no aura, unless we can so call a feeling of 
 impending peril, which lasted a few seconds, and 
 ended in a sensation of a blow on the head. The 
 attacks ceased after a month, and have never returned. 
 
 The next case I have to relate was more curious. 
 A girl, set. 18, was placed in mj care some years ago 
 suffering from a slight unilateral hysterical paralysis, 
 with well-marked anaesthesia. She was far less ner- 
 vous than the woman I have described, and, in fact, 
 it is, I think, not rare to find that women with distinct 
 hystero-palsies are, if we omit ovarian tenderness, 
 fairly free from the various hyperesthesia which 
 constitute one of the groups of hysteric symptoms. 
 She had, however, attacks when going to sleep, in 
 which she became conscious of a something which 
 seemed to ascend from the feet to the head. If she 
 could rouse herself, or turn over, the attack termi- 
 nated, and usually did not recur that night. It some- 
 times happened, however, that she was not able to 
 act in time, or was clearly conscious that she could 
 not, in which case there was a wild flash of vivid 
 red light, and she was at once seized with distressing 
 nervousness, and sometimes with tremor. I do not 
 remember that the attacks ever took place when 
 awake, while it is as certain that they never occurred 
 during sleep. 
 
 The next illustration of the double sensory discharge 
 giving rise to subjective feelings of sound and light is 
 
DISORDERS OF SLEEP. 163 
 
 valuable, because the account is given to me by the 
 sufferer, a medical officer of the United States Army, R. 
 M. O'R, ret. 35, married, parents living, both of gouty 
 diathesis. He is, and always has been, strictly tem- 
 perate in all respects. Smokes in moderation. When 
 twelve years old, had a sharp attack of intercostal 
 rheumatism. In 1868 contracted malarial fever, from 
 which he has suffered more or less ever since. In 
 1867 received a trifling gunshot wound of right thigh. 
 In 1875 had concussion of the brain, and some injury 
 to back, resulting from a fall. Was confined to bed 
 for a week or ten days, and walked with difficulty for 
 some time after. Was troubled with vertigo for over 
 a year. Has had no other sicknesses nor injuries. 
 
 In June last, while sitting lost consciousness; did 
 not fall. On recovering, saw objects surrounded by 
 a halo; walked home with some difficulty, and went 
 to bed ; slept none that night, but occasionally dozed, 
 and was awakened by a sensation of falling, or by a 
 sudden noise, or by voices calling. Eemained in this 
 condition for about two days ; could arouse himself, 
 but as soon as the effort relaxed, dozed, and had the 
 feelings described. This condition gradually wore 
 off, leaving vertigo, appreciable muscular weakness 
 (especially of the lower extremities), a sense of con- 
 striction around the head, wakefulness, and want of 
 appetite. 
 
 Late in June came to Philadelphia ; consulted Dr. 
 Alison, who observed that one pupil was somewhat 
 dilated. Subsequent ophthalmoscopic examination 
 by Dr. Thomson showed nothing abnormal. 
 
 Early in August went to Oswego, and has passed 
 
164 DISEASES OF THE NERVOUS SYSTEM. 
 
 the time there and thereabout until a week ago. 
 Within the past month has had two or three severe 
 headaches, with pain, over the left temple. These have 
 followed fatigue or excitement. 
 
 At present he can walk but a short distance with- 
 out growing very tired, then comes vertigo, seemingly 
 confined to the posterior portion of the head, and a 
 condition of nervous exhaustion, lasting some time. 
 The same effects ensue upon mental strain of any 
 kind. He sleeps fairly well. The feeling of constric- 
 tion around the head is constant. Appetite variable, 
 but never very good; bowels inclined to be costive; 
 temper irritable; want of capacity to think a subject 
 out, or to decide any question ; has lost weight. No 
 organic trouble of heart, lungs, or kidneys. 
 
 Since June last he has had several shocks, of an 
 explosive character, which appeared to be within the 
 cranium. They came at irregular intervals, and 
 without assignable cause. They have always occurred 
 just as he was falling asleep, and have been preceded 
 by no abnormal sensations. He is awakened by what 
 seems to be a loud explosion in his head, accompanied 
 by a flash of white and blinding light. There is no 
 pain with it, and except an acceleration of the pulse 
 there are no sequeke. The noise thus heard is de- 
 scribed as a rather low note, accompanied with a feel- 
 ing as if the head was sundered by the explosion. 
 The attacks come and go, but are always so dreaded 
 as to make him dread the going to sleep. 
 
 I have notes of a jet more singular case, which I 
 hesitate a little, and perhaps without due cause, to class 
 with these. 
 
DISORDERS OF SLEEP. 165 
 
 A woman, set. 40, and in good health, was hurt 
 during the tumult which followed the explosion of 
 the boiler of a steamboat. She was thrown against 
 the rail of the boat, striking her nose violently, and 
 then fell into the water, whence she was rescued 
 insensible. For several weeks she was very ill, and 
 recovering became the victim of acute hysteria, which 
 in a year passed away, leaving her feeble and emo- 
 tional. Her sense of smell w r as entirely lost from the 
 time of her accident, and except that she had at times 
 a subjective and very annoying impression of the 
 presence of an odor of brown soap, she had had 
 absolutely no appreciation of odors. 
 
 When I saw her two years after her accident she 
 had, at long intervals, these symptoms. At any time, 
 awake or asleep, she became aware of something like 
 a touch moving over her, usually about the epigas- 
 trium. After a few moments she experienced a sense 
 of shock in the head, usually at the back of the head, 
 and with it a remarkably distinct sense of a strong 
 odor, like that of bananas. It persisted for, as she 
 thought, a minute or more, and then slowly faded 
 away. 
 
 I have seen a number of these cases of sensory 
 shock, and I suspect that, when inquired into, we shall 
 find them less rare than might be supposed. The 
 instances I have related cover most of the varieties I 
 have seen, and it only remains to say a few words as 
 to their clinical relationships, diagnosis, and treat- 
 ment. 
 
 The clinical relationships of these attacks are to 
 epileptic fits, and to those well-known, and, I may 
 
166 DISEASES OF THE NERVOUS SYSTEM 
 
 say, normal phenomena of a sudden movement of the 
 body at the moment of going to sleep, or even at 
 other times, to which I shall presently refer again. 
 
 The analysis of the shock attacks is simple. The 
 basis is hysterical excitability, or a hyperesthesia 
 from tobacco, or overwork with worry. The at- 
 tack itself is preceded in many cases by an aura of 
 some kind, which is the first sensory expression of 
 the coming disturbance. The aura is a phenomenon 
 of general sensation. Then follows a more or less 
 violent discharge from a centre of general sensation, 
 as of a blow or shock ; or from auditory centres, a noise 
 as of a bell, a guitar-twang, or an explosion ; or from 
 visual centres, a flash of light; or, perhaps, two centres 
 act at once ; and there may be no aura, as in many 
 epilepsies. 
 
 The fact that these attacks do in some people take 
 place in the waking state, removes them from dream 
 phenomena, and from the domain of nightmares and 
 of night-terrors ; one form of which occurs in the inter- 
 val between sleep and waking, and presents some 
 analogies to these attacks of sense-shock. 
 
 In this form of night-terror, which is seen rarely, 
 but has often enough been described to me, the 
 sufferer is perfectly conscious of the coming on of a 
 nameless dread. Something precedes it in the way 
 of a warning. He can, by an act of will, escape it by 
 motion, or he may watch its onset. "When it cul- 
 minates it is merely a state of insensate dread or 
 terror, without a felt cause, dreamed or other. This 
 seems to me, in the mental or mere emotional sphere, 
 to be closely akin to the sensory shocks. 
 
 As to diagnosis I do not see how these attacks can 
 
DISORDERS OF SLEEP. 1G7 
 
 well be confused with anything else, unless with the 
 minor epilepsy, from which it ought to be easily 
 enough distinguished. 
 
 As to treatment there is not much to say, but what 
 there is to say is important and interesting. 
 
 As we are dealing chiefly with the nervous mala- 
 dies of women, the cases in which sensory shocks are 
 caused by tobacco and excess of brain- work do not 
 so immediately concern us here. I may, however, 
 be permitted to say that in all symptoms directly 
 traceable to tobacco there are two remedies available 
 while the habit is being broken, strychnia and alco- 
 holic stimulus. It should be needless to say that the 
 man who orders the latter ought to have some secu- 
 rity that his patient will not construe his orders too 
 liberally. But this is a matter for a doctor's con- 
 science ; and, at least, he may feel secure that a little 
 whiskey at bedtime will correct the evil results of 
 over-use of tobacco, and may be left off as soon as 
 the tobacco is much lessened. As to strychnia no 
 warning is needed ; and Dr. Landon B. Edwards has 
 pointed out, and with reason, that it is the tonic most 
 useful in the feebleness which comes of abuse of 
 tobacco — that pleasant wife and fatal mistress. 
 
 As to cases of sensory shock in women, the real 
 remedy lies in treatment of the conditions out of which 
 it grows. Of these, I have already said enough, but 
 there is one matter as to which, in the nervous mala- 
 dies of women, it is hardly possible to say enough. 
 
 Perhaps I had better introduce what I wish to say 
 in this direction by a brief extract of a letter from a 
 woman who has suffered gravely from the shocks I 
 
168 DISEASES OF THE NERVOUS SYSTEM. 
 
 have described. She sa}^s : " I suffer, as you are well 
 aware, from these shocks in the time between sleep 
 and wakefulness, and also in the day-time, though 
 rarely then. It did not seem to me at first possible 
 that I could in any way control these attacks or 
 save myself from their results. I found, however, 
 that, as I had warning enough, I really could do so. 
 So I set myself every night to be resolute to turn 
 over or sit up if I had a warning ; and every day I 
 said to myself, if I have the warning to-day, I will 
 not yield, but jump up and run about. To my sur- 
 prise, I found that by following out this determina- 
 tion with resoluteness I could break up most of the 
 attacks." 
 
 The treatment hinted at in this letter from a clever 
 woman is really valuable. It consists in instructing 
 the patient before going to sleep, and every day, to 
 keep in mind the need to break the attack by motion 
 and by an effort of will. 
 
 I do not know of any drug which is directly useful 
 in such cases of sensory shock as seem too grave to 
 await in patience the influence of general tonics. 
 The bromides are, in competent doses — such doses as 
 make deeper sleep than common — dangerous to nutri- 
 tion or at least hurtful enough to be avoided if pos- 
 sible ; and in the small doses, in which they do good 
 in hysteria, are, as regards this particular symp- 
 tom, valueless. Small doses of chloral or morphia, 
 used until the habit be broken, answer well ; but still 
 better is a general improvement in health, and then, 
 if the attacks persist, such exercise as will insure 
 natural fatigue deep enough to make it impossible to 
 avoid sleep. 
 
DISORDERS OF SLEEP. 169 
 
 In the same paper on sleep to which I have already 
 alluded occurs some brief account of the motor dis- 
 charges which are so familiar to us all as taking place 
 just at the moment of deepening sleep. 
 
 What I pointed out then, and what I wish to recall 
 attention to here, is that this normal symptom, if I 
 may be allowed so to call it, does sometimes rise into 
 the mischievous position of being the dominant diffi- 
 culty in a case on account of its interference with 
 sleep. 
 
 The symptom in question — while it rarely takes 
 place except in the interval between waking and 
 sleep, and never between sleep and waking — may 
 also arise during sleep itself, and cause abrupt dis- 
 turbance. I have seen it very troublesome in. grow- 
 ing lads and in some overworked men; but it is rare 
 to find it so strikingly developed as in the case of a 
 woman who consulted me to-day. This unfortunate 
 person was forty-three, the mother of several children, 
 and of late irregular in her menstruation. I was 
 struck with the fact that her color was good, but that 
 she was curiously thin and very haggard. She is 
 well as to her digestion, but has too much wind, and 
 finds eating hard work ; otherwise she is well in the 
 day-time, and can read, sew, walk, or drive, as pleases 
 her. Once or twice she has had long crying spells, 
 without other cause than a sense of the wretchedness 
 of her condition. When bedtime comes she goes 
 with fear and reluctance to encounter sleep and the 
 discomfort it brings to her. Just as she begins to 
 lose herself, an arm, a leg, or the whole body sud- 
 denly moves with violence. As she awakens, her 
 15 
 
170 DISEASES OF THE NERVOUS SYSTEM. 
 
 hands a ad feet, or either alone, twitch for a few 
 moments. Then she settles herself to sleep anew, 
 only to repeat the same process, until at last she sits 
 up, crying hysterically, or, worn out, falls into a 
 slumber seemingly too sudden and profound to allow 
 of the phenomena I have described. Her daughter, 
 who came with her, described these nights of suffer- 
 ing as truly pitiable, and told me that nothing had as 
 yet seemed to afford the least relief. 
 
 Of late, Mrs. K. J. has been apt to wake up later 
 in the night with unilateral tingling, of Avhich I shall 
 presently speak more fully. 
 
 You must of course consider this as an unusual 
 case ; but it is just unusual cases which are apt to 
 puzzle young physicians; and to be able in such cases 
 as these to recognize the close kinship between an 
 almost natural phenomenon and its excessive develop- 
 ment into an annoying disorder, is not only comforting 
 to the patient but useful to the physician. 
 
 A good many hysterical women exhibit this symp- 
 tom ; and in a few it becomes troublesome, either by 
 its repetitions, as in Mrs. E.'s case, or, what is less com- 
 mon, from its severity. A quite ludicrous example 
 of the latter I saw a few years ago. The patient was 
 one of those stout, ruddy women, with good ovaries, 
 and uterus where it should be, and yet hysterical to an 
 exasperating degree. She weighed over 200 pounds, 
 and was unhappily subject to what she called "fish- 
 flaps," which were really remarkable, because her 
 body would be thrown up from the bed so high, and 
 descend with such violence owing to her weight, that 
 it was not rare to find the slats of the bed giving 
 
DISORDERS OF SLEEP. 171 
 
 way. She grew better as her hysteria lessened, but 
 is, I believe, still subject at times to these unpleasant 
 and undesired gymnastic symptoms. 
 
 There is yet another and a very interesting sleep 
 symptom seen at times in Duchenne's disease, and 
 in a variety of degrees in some feeble and anasmic 
 persons ; but far more common among women than 
 among men. I ventured some years ago, in speaking 
 of it, to call it "night palsy," or "nocturnal hemiple- 
 gia." Since seeing more examples I perceive that 
 brachial monoplegia is its most common expression. 
 
 This curious symptom assumes one of two forms — ■ 
 the one common, the other rare. In the more usual 
 cases the sleeper awakens with numbness, or rather 
 tingling and numbness, of one arm, a leg alone, which 
 is infrequent, or the whole side, including the face, 
 and even the tongue, which is now and then attacked 
 alone. The disorder may be mere tingling, or actual 
 loss, or rather lessening of tactile sensation ; but in 
 any case it rapidly fades away, or yields to a little 
 friction. At first, while it is in the arm alone, the 
 patient refers it to lying on the part ; but this be- 
 comes an impossible explanation of the hemiplegic 
 examples. 
 
 As I have seen in a month three cases of this 
 rather interesting condition, it cannot be very rare. 
 It is significant, perhaps, that some persons who have 
 gotten pretty well of a hemiplegia of organic cause 
 are liable to awaken out of sleep with numbness and 
 lessened power of the side once palsied. It is remark- 
 able that in the case of Mrs. E. J., of which I just now 
 spoke, this same curious functional hemiplegia would 
 
172 DISEASES OF THE NERVOUS SYSTEM. 
 
 at times occur on the same nights when she suffered 
 from motor discharges. 
 
 The less common form of night palsy is, perhaps, 
 also the more serious, but may be like the usual 
 examples, but an expression of hysteria or of the 
 exhaustion felt by an ill-nourished brain during the 
 long fast of the sleeping hours. In it the patient 
 exhibits a far more distinct loss of unilateral power, 
 which, however, lasts for an hour or more after 
 awaking, and may even become worse for a time in 
 place of at once improving. 
 
 I recall very well the case of Mrs. C. L., set. 27, 
 who, after profound blood losses in confinement, 
 nursed, with success, through several excessive men- 
 strual periods. She then had an attack of nocturnal 
 hemiplegia, which became more grave during some 
 hours, and yielded easily to faradic stimulation, iron, 
 and good diet. She had after this several light 
 attacks, and twice well-marked brachial diplegia, 
 which lasted but a few hours. I should add, that 
 there was no renal trouble, and that she made a 
 perfect recovery. 
 
 Among other milder forms of trouble, which at 
 times haunt the sleep of nervous or hysterical females, 
 are palpitation of the heart, vertigo, and a certain 
 failure of the respiratory centres, which is met with 
 also in grave shape in some cases of Duchenne's dis- 
 ease, or in any very feeble people, and is, of course, not 
 confined to women. 
 
 In locomotor ataxia, towards its paralytic stage, 
 this symptom is but an expression of a defect in the 
 medulla oblongata, and has twice in my knowledge 
 
DISORDERS OF SLEEP. 173 
 
 finally resulted in sudden death during sleep. In 
 feeble and hysterical people it means simply a tem- 
 porary failure of function, owing to imperfect nutri- 
 tion. 
 
 The centre remains competent so long as the will 
 is free, during the waking hours, to assist the auto- 
 matic activity of the ganglia, but when sleep leaves 
 the regular succession of respiratory acts to the 
 unaided powers of defective nerve-cells, there some- 
 times comes a moment of temporary incompetence, 
 and the patient wakes up gasping and alarmed. 
 
 The best remedy for these troubles is to be found 
 in the general treatment, of which I have already 
 said enough, and in great care to supply nourishment 
 at bedtime, and if needful to repeat its use during 
 the night. Of course I take it for granted that every 
 care shall have been given to the state of the stomach 
 and bowels ; and I may add, finally, that some patients 
 suffer less, or not at all, if lying on one side or the 
 other, or on the back, the position of success being 
 purely a matter of experiment. 
 
 15* 
 
174 DISEASES OF THE NERVOUS SYSTEM. 
 
 LECTURE X. 
 
 VASO-MOTOR AND RESPIRATORY DISORDERS IN 
 THE NERVOUS OR HYSTERICAL. 
 
 I have over and over called attention in my clinics 
 to some of the many and curious vaso-motor disturb- 
 ances which we see in so great variety among nervous 
 women. From the heart to the capillaries we are 
 liable to meet with conditions of disorder, which are 
 sometimes almost as lasting as if they owed their 
 parentage to obvious and coarse structural lesions. 
 This indeed is a familiar fact which I have had ample 
 opportunity to verify both in my clinic and in my pri- 
 vate practice. No matter what be the form of gene- 
 ral nervousness or the variety of hysterical illustra- 
 tion, the nervous supply of the heart or vessels, or 
 both, almost never escapes from bearing some part 
 of the mischief, and only too often, after everything 
 else is well and the patient is afoot and able to live as 
 pleases her, she will still be reminded by something 
 in connection with the blood supply and its channels, 
 that they are almost the last to regain the vigor and 
 steadiness of health. 
 
 The first point to which I wish to ask your atten- 
 tion is the pulse. In the mass of hysterical women, 
 and especially in those we see here who are apt to be 
 feeble, and easily tired as well as liable to tears and to 
 
VASO-MOTOR DISORDERS. 175 
 
 more distinct expressions of the hysteric temperament, 
 the pulse is apt to be permanently rapid, that is for 
 months or years it may remain 20, 30, 50 pulsations 
 to the minute above the normal number. You may 
 see this in a woman who is supine in bed, and who 
 for the time presents no startling evidence of general 
 disorder. I shall have presently to illustrate this fact 
 by cases. 
 
 But besides the speed of the heart movement these 
 cases present also two other phenomena ; their hearts 
 are irritable and prone to beat rapidly owing to causes 
 which are powerless to affect the less excitable organ 
 of the healthy. Then also with this cause of being 
 set going beyond their common rate these hearts 
 are apt to become irregular, and to seem to tumble 
 about in an alarming manner. The careful study 
 of these well-known peculiarities will very well 
 repay us. Therefore, before going further we will 
 linger a little upon the questions connected with 
 the pulse rate and rhythm of nervous or hysteric 
 Avomen. 
 
 Out of half a dozen good cases I take two or three 
 to enable me to illustrate these points. After that I 
 shall point out some of the eccentric pulse symptoms, 
 and then say a few words as to the mode of dealing 
 with the irritable heart of the nervous, either when it 
 is but a symptom, or when it rises into such promi- 
 nence as to be the dominant mischief. 
 
 There was last -year in the Infirmary for Nervous 
 Diseases, a lady from Yirginia, who presented in a 
 typical form the cardiac states which I expect to find 
 in neurasthenic women, and especially in such as are 
 
176 DISEASES OF THE NERVOUS SYSTEM. 
 
 both feeble and hysterical. She was 38 years old, 
 married but childless, and had been for some years 
 subject to hysterical attacks, which passing away left 
 her at last so feeble that she was unable to walk up 
 stairs without great exhaustion. She was five feet 
 one, weighed one hundred pounds, and was anaemic 
 and sallow. Her uterine functions were fairly good, 
 and she suffered no pain and had no distinct uterine 
 disease although both ovarian regions were tender, 
 and pressure upon them caused nausea and vertigo, 
 as well as other phenomena to which I shall presently 
 refer. Her digestion was good if she ate but little at 
 a time and was not tired or excited. 
 
 Her heart when she was lying down was never 
 under 180 beats per minute. Any exertion raised it 
 20 to 30 pulsations. The least excitement did the 
 same, but despite this irritability the rhythm was al- 
 ways good, and I should add there was no affection of 
 the eyes or the thyroid gland. Pressure on the ovarian 
 region gave rise to sudden increase in the number of 
 heart beats, but pressure on the spine almost anywhere 
 had a like influence. She had tried absolute rest for 
 a week or two at a time, and had taken a large amount 
 of tonics and of digitalis. Her temperature was curi- 
 ous, being in the mornings 97-97.5°, and in the late 
 evening, 9 to 10 P. M., 100-101.5°, although there 
 was no pulmonary or other visceral trouble. The 
 evening pulse was usually a few beats under that of 
 the morning. 
 
 Electricity (induced current, slow interruptions) 
 used as a muscular exerciser, and also massage, ex- 
 cited her greatly, causing tremor, tearfulness, and a 
 
VASO-MOTOR DISORDERS. 177 
 
 rapid increase in the pulse. Withal, the heart was 
 perfectly healthy as to its valves and its size. 
 
 I began her treatment by using various forms of 
 digitalis, but although she took enormous dosesl never 
 succeeded in making any impression on the heart and 
 usually this drug seriously disturbed digestion. I found 
 that frequent small feeding with rest somewhat aided 
 her, but although she was thus made more comfort- 
 able there was no substantial gain, until in despair I 
 resorted to Carell's skimmed-milk treatment. After 
 three weeks of this I was able to repeat the use of 
 massage which I had been forced to abandon. From 
 this time the improvement in flesh, color, and self-con- 
 trol was notable. When she was able to walk about 
 after two months of rest, the heart had fallen to 95° and 
 was far less excitable, and her temperature ha'd be- 
 come normal. It required, however, many months of 
 care to make her circulation quite natural, but within 
 six months she became fat (one hundred and thirty 
 pounds), and was able to complete her cure by a sum- 
 mer in the mountains. 
 
 This was, of course, an extreme case of cardiac 
 nervousness, but it is no unfair type, and I need add 
 little to the description. Sometimes the tumultuous 
 action of the hysterical heart is the most distressing 
 and most upsetting of all the many symptoms of this 
 disorder, so very fertile in symptoms. We all know 
 how unpleasant and appalling even is the sense of 
 sudden and great irregular palpitation, and in the ner- 
 vous and hysteric this impression loses nothing of its 
 terror. You will meet with such women — women 
 whose hearts seem to become wildly irregular on the 
 
178 DISEASES OF THE NERVOUS SYSTEM. 
 
 least provocation, or on none. Digestion in these 
 women causes it, and here I cannot too earnestly insist 
 that digestion, like some other functional acts, gives 
 rise to symptoms which are not of necessity proofs 
 that the function in question is imperfect or diseased. 
 Ordinarily, if we have palpitation of a healthy heart 
 during digestion, that means often enough that our 
 patient is dyspeptic, but not so in nervous and hysteri- 
 cal women. Digestion naturally quickens the pulse, 
 and in these people the normal quickening passes into 
 palpitation. That I am correct as to this is shown in 
 the same women more rarely by the varied disturb- 
 ances which follow the most perfect performance of 
 other normal functional acts as simple as micturition 
 or defecation. I have seen patients in whom bowel 
 movement always produced irregular heart action, 
 and I have now a lady under my care who has, soon 
 after passing water, slight chilliness, twitching of the 
 face, and extreme palpitation of the heart. Yet, the 
 act of urination is, in this case, painless, and, in fact, 
 absolutely natural. You may regard all of this as 
 of trifling: moment, but I have seen cases like these 
 treated with many drugs, and in a case similar to the 
 last one I have known a surgeon resort to dilatation 
 of the urethra. Bear in mind, therefore, that some- 
 times in nervous people the activity of a normal func- 
 tion is competent to cause distress or awaken symp- 
 toms. 
 
 The violence and singularity of the pulse-signs in 
 true hysteria are beyond expression strange. 
 
 I saw, very many years ago, a handsome girl, of 
 twenty, from Cincinnati, who had spells of apparent 
 
VASO-MOTOR DISORDERS. 179 
 
 death, if I may use such a term. One of these I had 
 the good fortune to see, and indeed to cause, for hav- 
 ing been warned by no one that, to speak before her 
 of certain things, was apt to cause the trouble, I 
 unluckily began to discuss with her the subject of a 
 personal peculiarity, from which I had been told she 
 suffered. 
 
 It seemed that certain odors would, in her, bring 
 on hysterical attacks. You may recall a case here, 
 last week, of an aphonic girl, in whom musk would 
 do this. Now my patient had, at last, become very 
 sensitive as to this as to other matters, and no one 
 near her ventured to talk about odors ; since then it 
 seemed that the young lady was liable to suffer, as if 
 from the odors themselves. Of late the hystero -epi- 
 lepsy had given place to the "Death spells," as her 
 friends called them, and it was one of these I pro- 
 voked. She said to me, "I am going to have an 
 attack ; feel my pulse. In a few minutes I shall be 
 dead." Her pulse, which just before was about 100, 
 was now racing, and quite countless; while the 
 irregularity and violence of the heart's action seemed 
 to me inconceivable. With the interest of an hys- 
 terical woman in her own performances, she said to 
 me, "Now watch it; you will be amazed." This cer- 
 tainly was the case. Within a few minutes the pulse 
 began to fall in number, and, as well as I can recall 
 it, in some fifteen minutes was beating only 40. Then 
 a beat would drop out here and there; the pulse 
 meanwhile growing feebler, until at last I could nei- 
 ther feel it, nor yet hear the heart. In this state of 
 seeming death, white, still, without breathing or per- 
 
180 DISEASES OF THE NERVOUS SYSTEM. 
 
 ceptible circulation, this girl lay for from two to four 
 days. In this time there were spells of a few minutes, 
 during which the heart beat again furiously and 
 irregularly, as was also the case when she revived. 
 
 Of course, emotion of any kind is, in such women, 
 able to disturb the heart-rhythm and its number; 
 and while such persons are subjected to the contacts 
 of daily life, it is, therefore, hard to relieve them. 
 
 The oddities of hysterical cases are perceptible 
 enough in the way in which the heart -action seems, 
 at times, to disobey all apparent laws, and baffle all 
 predictive skill. I have seen such persons, whose 
 hearts beat slower when they rose, and faster when 
 they were lying down. I have now a patient, whose 
 heart is quiet enough while she is supine, but to lie on 
 either side causes palpitation and increased rapidity 
 of pulse. 
 
 There are now in the Infirmary two cases of great 
 general nervousness with hysterical histories. Nei- 
 ther has organic disease. The one has an average 
 morning pulse of 100, and a night pulse of 75. The 
 other nearly reverses these numbers, but I have been 
 utterly unable to find a precise cause for these pecu- 
 liarities. 
 
 Apart from cardiac troubles, or in relation with 
 them, are certain vaso-motor disturbances which give 
 rise to very distressing, or, at least, to annoying 
 troubles in this class of sufferers. 
 
 Every hysterical woman is liable to a certain want 
 of tone in the surface-vessels which gives rise to a 
 group of disorders, owing to which we meet with 
 extreme states of pallor or of flushing which in some 
 
VASO-MOTOR DISORDERS. 181 
 
 cases affect the extremities and in others are most 
 visible in the face. This want of steadiness in the 
 vessels of the skin belongs to some extent, and natu- 
 rally, to others than the class I speak of, and is seen 
 very well in certain healthy women of fair com- 
 plexion, and is also common in persons who are 
 liable to the congestive type of neuralgic headaches. 
 Watch one of these women, and, if they have this 
 peculiarity in a high degree, it will come out under 
 the excitement and embarrassment of clinical ques- 
 tioning. You will then see the face flush, and the 
 flush by degrees break up into spots of red which 
 move slowly and have bounding margins of pale- 
 ness; and all this will be best seen on the neck 
 and cheeks and below the ears. At the same time 
 the hands and feet /may become cold, and, at all 
 events, you will find that almost incurably cold feet 
 are the constant annoyance of these patients; and 
 sometimes the cold feet are pale ; and sometimes, in 
 graver hysterical cases with palsy or sensory defects, 
 they may be purplish ; and both appearances indicate, 
 as you know, defects of blood-supply, and both lead 
 to like results. 
 
 Another and very remarkable indication of the ac- 
 quired sensitiveness of the surface-vessels in cases of 
 the hemiplegia of hysteria is the well-known fact that 
 any moderate traumatic injury to the skin-vessels gives 
 rise to their instant contraction, so that slight wounds 
 which usually bleed do not do so in them. I have seen 
 this state of things in hysterical girls who were not suf- 
 fering from analgesia, but in most cases it is found 
 over a half of the body affected by some loss or lack 
 16 
 
182 DISEASES OF THE NERVOUS SYSTEM. 
 
 of feeling of some kind. As the feeling improves, the 
 needle wound bleeds, and whatever aids the one con- 
 dition helps the other, so that, when from the use of 
 metals the phenomenon of transference of the anaes- 
 thesia to the opposite limb occurs, it is at once found 
 that needle wounds cease to bleed on the side attacked 
 and bleed on that deserted by the disease. As I said 
 in a former lecture, I have myself been unfortunate 
 in never yet having been able to see the phenomenon 
 of transfer. I have several times seen metals laid on 
 the anaesthetic parts give rise to some partial return 
 of feeling and of bleeding from needle-pricks, but I 
 have seen caoutchouc and wood and even sponge do 
 the same ; and the effect of a blister and of the rhigo- 
 lene spray can be seen in a patient now in the wards. 
 I may add that dry cups and mustard have also given 
 me the same results. There may be indeed some 
 unsuspected relation between loss of sensation and the 
 bloodlessness of slight wounds, for in one, at least, of 
 those remarkable cases of total surface anaesthesia to 
 all forms of sensory impression, in a case of profound 
 melancholia, although the loss of feeling extended to 
 the face and mouth, and was certainly not hysterical, 
 the surface was made to bleed with the most extreme 
 difficulty. The same phenomenon of failure of pin 
 pricks to bleed has been recently observed by me in 
 a man with he mi- anaesthesia of cerebral and organic 
 cause. It seems likely that cutaneous ischaemia is to 
 be added to the list of symptoms which Charcot has 
 pointed out as common to hysteric hemi-palsies, with 
 loss of pain-sense, and the hemi-anaesthesia of more 
 definite cause. Since I was led to suspect that there 
 
VASO-MOTOR DISORDERS. 183 
 
 is some link of relation between anaesthesia and sur- 
 face failure to bleed, I have been on the lookout for 
 a case of nerve section in which to test the matter. 
 Two days ago, Dr. E. J. Levis cut the sciatic and 
 crural nerves in a man who has a deep and incurable 
 ulcer of the left leg. This operation deprived him 
 of all sense below the middle calf, and I was enabled, 
 with Dr. Levis's permission, to examine, the case in 
 his ward at the Pennsylvania Hospital. 
 
 All forms of sensation were extinct in the foot. 
 Using a very large needle, I left it in place some 
 time, or turned it about freely, but was unable to 
 cause a single drop of blood to flow from these re- 
 peated wounds. As I withdrew the needle, a small, 
 snow-white ring, slightly raised, formed around the ori- 
 fice, and seemed to be due to contraction of the neigh- 
 boring skin muscles. This most interesting observa- 
 tion confirmed for me what already I had seen some 
 years ago in other and less extensive nerve sections. 
 I had, however, continued to doubt the correctness of 
 the former observations, which were made in cases 
 of division of ulnar or median trunks. It certainly 
 seems as though the loss or lessening of sensation 
 were associated with the taking off from the skin 
 vessels of some inhibitory influence, so as to leave 
 them to contract with violence under the influence of 
 any irritating cause. All explanations may admit of 
 question, but as to the fact to be explained, I think 
 there can be no further doubt. I hope that I have 
 here said enough to direct attention anew to this in- 
 teresting phenomenon. 
 
 Temporary flushing or pallor of face is very apt to 
 
184: DISEASES OF THE NERVOUS SYSTEM. 
 
 accompany sudden and irregular heart action, and to 
 become and remain a distressing symptom. Why, 
 with a perturbed heart, this woman should have a 
 deadly paleness, and that a profound flush of face, I 
 cannot say, but both sets of conditions are familiar to 
 me. Now, as in such females the heart becomes 
 agitated, and the face red or white on the least pro- 
 vocation, or on the mere expectation of it, you can 
 readily see what an annoyance it may become. 
 
 I saw last year a bright, intelligent New England 
 girl, who, with much general nervousness, had also a 
 heart far too rapid, but besides its speed, if she met 
 a friend suddenly, or went into a drawing room, or 
 was even spoken to unexpectedly, her heart became 
 irregular, and her face very pale. You may readily 
 imagine to how much misconception such a disorder 
 might give rise. The longer it lasted the worse it 
 became, and one pleasure or one duty after another 
 was given up in turn, because of the shame to which 
 every mildest emotion subjected her. After long 
 treatment she became well as to most of her ailments, 
 but had been a year in seeming health before her cir- 
 culation re- acquired the proper tone, and she could 
 again face, without fear, all the trials of social life. 
 
 Flushing with tumultuous heart action is more 
 common, and is, I should say, more like an exaggera- 
 tion of a common functional event of health. Still, 
 Avhen it occurs habitually on the least emotion, it 
 is, like any such symptom, a source of most bitter 
 annoyance. 
 
 Unilateral, or strictly local flushing, is, I suspect, a 
 very rare affection, either in hysteria or elsewhere, 
 
VASO-MOTOR DISORDERS. 185 
 
 but, of course, the best examples are to be found in 
 hysteria. 
 
 Last year I was consulted by a lady, both of whose 
 legs were as red as blood in excess could make them, 
 and this state came on after many months of varied 
 hysteric troubles. Excepting an imperfect paraplegia 
 these had all passed away for the most part, but when- 
 ever she sat up, her legs filled with blood and looked 
 as if they might burst. Unlike cases of erythro- 
 melalgia there was no pain, and when the limbs were 
 elevated they slowly got back their color. Pin pricks 
 bled easily, and there was no loss of feeling. I 
 watched this singular condition for some weeks, every 
 effort failing to relieve it, and finally, I may add, when 
 it was let alone, and only the constitutional state was 
 looked after, the local paralysis of vessels gradually 
 got well. 
 
 I have over and over seen this vasal paresis in the 
 hands of these women, and one distressing case of in- 
 tense and permanent redness of the face, which took 
 at first a unilateral form, and then attacked the entire 
 face in spells. These began at any time, but chiefly 
 in the morning hours. A spot of color came any- 
 where on the face, went and came, and at last others 
 appeared. These coalesced after a time, and the color 
 darkening the face, scalp, ears, and upper neck seemed 
 like those of a heavy drinker. There was no pain, 
 or only a sense of uncomfortable fulness and heat. 
 The eye-ground did not seem to share so fully in the 
 vascular fulness, but the depths of the ears did. Be- 
 lief was obtained by a spray of cool water, which did 
 b3st at a temperature of 50° to 60° F. If let alone 
 
 16* 
 
186 DISEASES OF THE NERVOUS SYSTEM. 
 
 the redness passed away slowly within three hours. 
 At first, and at times afterwards, the heart's action 
 was disturbed a little. I should add that very pro- 
 longed use of digitaline seemed, with care of the 
 general health, to do the most towards the complete 
 relief of this unhappy patient. 
 
 The last case of hysterical vaso- motor manifesta- 
 tions which I shall quote was so amazing that if I had 
 not had the good fortune to see it over and over, and 
 to show it once to my friend Dr. William V. Keating, 
 I might reasonably have hesitated to tax the credu- 
 lity of my hearers. 
 
 Some twenty years ago I attended a young married 
 woman, whose life was embittered by losses of pro- 
 perty, and by the ill-treatment of her husband, who 
 finally deserted her. For a long period she exhibited 
 at times hysteric disorders in the forms of spasms, 
 rigors, hemi-palsies, and at last for a month or two 
 moderate maniacal excitement. With favoring cir- 
 cumstances she at last got well, and removing to the 
 west, was lost sight of until about ten years ago, 
 when I was called to see her at a hotel in Phila- 
 delphia. At this time my patient was 35 years old, 
 was irregular as to her monthly flow, and had, as I 
 found, a womb tilted forward but not diseased, and no 
 ovarian tenderness, or at least no teuderness of belly 
 which was not the same everywhere. She was rather 
 pale, and very thin, and had a relaxed pendent belly 
 marked bj^ the scars of four pregnancies. I could 
 find no disease of heart, lungs, or kidney. She gave 
 me this brief history : After some years of ease and 
 comfort, she had been led to risk her property in 
 
VASO-MOTOR DISORDERS. 187 
 
 a wild speculation which ruined her, and now she 
 was keeping a boarding house in New York, and was 
 doing well, or likely to do well, except for the strange 
 malady on account of which she came to consult me. 
 After her new misfortunes she had some hysterical 
 troubles, but these ceased to annoy her, and she began 
 to observe that at or about the time of her menstrual 
 flow, and afterwards at any time, she was liable to have 
 an enlargement of the belly, which did not seem to 
 her to be due to wind, as with that form of swelling 
 her previous experience had made her but too fully 
 acquainted. The trouble became by degrees worse, 
 and at last was so extreme as to cause certain unpleas- 
 ant feelings, and to subject her to suspicions of being 
 pregnant. 
 
 The swelling was certainly caused at times by emo- 
 tion. It began at any time, rarely at night. Within 
 a few hours the belly, in place of being flaccid and 
 pendent, was swollen enormously. She looked, in fact, 
 as a woman, thin as she was, would have looked at 
 the eighth month of pregnancy. Other attacks were 
 less severe, but always they lasted for some hours be- 
 fore she could stand up, and it was usually a week 
 before she was well. 
 
 When I saw her an attack was at its worst. The 
 woman's pulse was about 165, and was a mere thread 
 at times imperceptible. Her face and limbs were 
 white and cold. The abdomen was tense and red, 
 and could be felt to throb distinctly, while all over it 
 the vessels, veins, and arteries were visibly enlarged. 
 On listening over the belly I could hear a humming 
 noise, a slight thrill. The chest itself was not quite 
 
188 DISEASES OF THE NERVOUS SYSTEM. 
 
 so pale as the neck or face, but the breath was diffi- 
 cult and rapid. It was clear that owing to palsy of 
 all the abdominal vessels, all the available blood of 
 the body of a too bloodless woman was for a time in 
 this cavity and its walls. If while in this state she 
 sat up she instantly fainted, and it was difficult even 
 to lift her head, because of the symptoms thus caused. 
 She herself complained of the tension of the belly, 
 and of the distressing pulsation within it. 
 
 The day after the abdomen was certainly a third 
 less, and it was then seen by Dr. Keating, who, like 
 myself, could give no other explanation of the con- 
 dition seen, than the one I have just mentioned. 
 After a week the belly became nearly as flat as usual, 
 and I then ceased to see my patient. I learned from 
 her some years later that by slow degrees she had 
 become well of this singular malady. 
 
 Yet a few words before I abandon this subject as 
 to the irregularities of breathing in the hysterical. 
 These may accompany cardiac disturbances, which 
 is rare, or may exist alone, without elevation or 
 altered rhythm of pulse. In other forms of disease, 
 as you well know, when the breathing becomes rapid, 
 the pulse also proportionally increases in number; 
 and it is uncommon to see excitement of heart from 
 fever or inflammation without a like rise in the rate 
 of respiration ; but hysteria breaks all laws, except its 
 own rules of eccentricity. 
 
 I have seen a woman -with a respiratory rate of 
 10, and a pulse of 100 ; another, with a pulse of 30, 
 and a normal speed of breathing. 
 
 There is now in this hospital a case of hemi-anses- 
 
VASO-MOTOR DISORDERS. 189 
 
 thesia and hemiplegia, getting well after two years 
 in bed. When she began to walk abont, two months 
 ago, her pulse was 60 to 70 ; her respiration 15 to 
 18. My assistant soon after observed that the rate 
 of breathing was increasing, and, without calling 
 attention to it, we began to keep daily notes of it, 
 and of the heart and temperature. 
 
 The average pulse, early in November, was 75-85 in 
 the morning and evening respectively. Eespiration 
 16-17. 
 
 At the close of December the pulse had slowly risen 
 to an average, for the two daily observations, of 94.1, 
 with, nearly always, a rather faster pulse in the 
 mornings ; but, meanwhile, the breathing rose to a 
 daily average of 49.4. 
 
 Some of the numbers are remarkable. I give in 
 a brief column one week, for comparison with 
 healthy states : — 
 
 
 
 Pulse. 
 
 Respiration. 
 
 Fulse. 
 
 Respiration, 
 
 
 
 Morning. 
 
 Morning. 
 
 Evening. 
 
 Evening. 
 
 
 
 10 A. M. 
 
 10 A. M. 
 
 10 P.M. 
 
 10 P. M. 
 
 Dec. 
 
 22. 
 
 102 
 
 50 
 
 91 
 
 48 
 
 it 
 
 23. 
 
 100 
 
 52 
 
 99 
 
 53 
 
 t< 
 
 24. 
 
 98 
 
 57 
 
 100 
 
 62 
 
 t( 
 
 25. 
 
 90 
 
 55 
 
 87 
 
 47 
 
 << 
 
 26. 
 
 95 
 
 37 
 
 85 
 
 39 
 
 (( 
 
 27. 
 
 98 
 
 55 
 
 88 
 
 44 
 
 (( 
 
 28. 
 
 93 
 
 49 
 
 88 
 
 89 
 
 Mean 99.3 50.7 91.1 47.2 
 
 The respiration was singularly tranquil, despite its 
 rapidity, and there was not the slightest appearance 
 of effort. Digitalis, given in half-ounces of the infu- 
 sion, seemed to have no effect on the pulse after some 
 
190 DISEASES OF THE NERVOUS SYSTEM. 
 
 days, but so disturbed the stomach that I was forced 
 to give it up. The thirtieth of a grain of sulphate of 
 morphia brought down the breathing one-fourth, and 
 the one-twentieth of a grain had a still more percepti- 
 ble effect, so that the average fell for the last week to 
 28.1, while the pulse held an average of 81.2. A 
 single full dose of opium, given to relieve pain, 
 brought the respiratory rate from 58 to 17 within 
 a few hours ; the pulse falling at the same time from 
 88 to 73. 
 
 This is a remarkable example of a rather unusual, 
 but sometimes overlooked hysterical symptom. In 
 a doubtful case it alone would decide the diagnosis ; 
 for a like condition, outside of hysteria, is a clinical 
 curiosity. The most remarkable illustration, not hys- 
 terical, is that reported by Dr. J. H. Brinton and my- 
 self. A man, after receiving a ball through his right 
 lung, continued for years to breathe at the rate of 100 
 to 130 to the minute ; his pulse being 85 to 90. 
 
 I said that this abnormal rate might alone decide 
 your belief in its hysterical cause ; nor is this a 
 mere theoretical idea. A few years ago I was one 
 of three physicians called to see a lady, long ill with 
 a variety of ailments. She had passed into a state of 
 stupor, from which, for two days, it had been impos- 
 sible to arouse her. I observed that while her pulse 
 was about 90, her breathing was almost impercepti- 
 ble ; on careful count, however, it proved to be 96 in 
 the minute, from which I was sure that the case would 
 prove, in the end, to be hysterical; an opinion justi- 
 fied within a few hours by the repeated occurrence of 
 very violent hystero-epilepsy. 
 
HYSTERICAL APHONIA. 19 L 
 
 LECTURE XL 
 
 HYSTERICAL APHONIA. 
 
 The patient before us to-day is a very notable illus- 
 tration of the pranks which may be played by hys- 
 teria. I read you her history, and as you hear it I 
 think you will see that almost at any time a resolute 
 man, whom she trusted and who understood her dis- 
 order, could have saved her and her family from long 
 years of suffering. Her case will enable me to point 
 out to you, as I have done very often before, that the 
 natural history of many of the forms of hysteria is 
 still an open study. One reason for that is I pre- 
 sume the disgust with which the general practitioner 
 encounters this malady. It is hysteria, and with that 
 seems to end all need for observation of details and 
 varieties of symptoms, such as more manageable dis- 
 orders obtain. 
 
 Mrs. E., a3t. 31, from New Jersey, was brought up 
 among people of narrow means and larger wants. A 
 rather frail constitution and nervous parents doubly 
 prepared her for the ills which were, perhaps, only 
 hastened by an attack of ague, followed by pneumo- 
 nia, in September, 1870. Soon after recovery a day 
 of fatigue and some worries ended in hysterics, with 
 retention of urine. A more violent fit followed an 
 attempt to do some rather hard work. From this 
 time the Pandora's box of hysteric ills was opened, 
 
192 DISEASES OF THE NERVOUS SYSTEM. 
 
 and they came almost without limit. Remaining in 
 bed, fit followed fit, until, when a little better, she 
 chanced to smell musk, upon which she fell into a 
 state of stupor, and was thought to be dying. Then 
 the voice fell to a whisper, and so came and went for 
 five years, and at last failed so utterly that for the 
 last five years she has uttered no sound. Meanwhile 
 she stayed in bed till 1872, and had, in succession, 
 general paresis, right arm and hand paralyzed, enor- 
 mous swelling of hand so as to resemble an abscess, 
 and a variety of hyperesthesias ; on one occasion a blow 
 on the hand caused retraction of the head, followed 
 abruptly by recovery of previously lost power. Soon 
 afterwards there were in succession repeated attacks 
 of hemiplegia, renewed hysterics, paralysis of left 
 leg, and swelling of foot, with exquisite hyperesthe- 
 sia of the whole skin. In September, 1872, a slight 
 effort brought on palsy of the left arm, so that 
 she had finally loss of power in both hands, with 
 loss of voice. This was followed by anuria, and then 
 by complete absence of saliva, so that for a time the 
 mouth was absolutely dry. Meanwhile speechless, 
 and with paralysis of all her limbs, she could only 
 call any one by seizing the handle of a small bell 
 in her teeth and shaking the head. After a year 
 and a half the use of induction currents seemed to 
 have a good effect, and she was soon able to use her 
 hands, and to walk. At this time and for seven years 
 the right hand swelled enormously before each men- 
 strual flow, and at the close of the week the skin 
 came off in large patches. In 1876, she had violent 
 retro-spasms of the head and motor ataxia of the legs. 
 
HYSTERICAL APHONIA. 193 
 
 In 1877, she had hysterical convulsions, photophobia, 
 a variety of pains, glossitis, with great swelling of 
 the tongue, long attacks of coma, hysterical vomiting, 
 and two weeks of nearly complete fasting, and spas- 
 modic ptosis. 
 
 You will, I think, agree with me that a more 
 miserable catalogue of ills could hardly be made out. 
 Within a year the more active troubles have faded 
 away, and we have before us only a weak, pale, 
 sensitive woman, with complete loss of voice. 
 
 You will remember that this woman was at my last 
 clinic, and that I told her she could probably learn to 
 speak. Two days later she wrote to me that, for the 
 first time in ten years, she had made a sound, and 
 this is all, but in the mean while I asked her to come 
 to my house, and there I studied her case yet more 
 carefully; ai}d now to-day she comes back, and I shall 
 test the value of the theory I have formed as to her 
 case. But, before I do this, let me say a few words 
 as to the types of aphonia and dysphonia connected 
 with hysteria. You will find in Cohen's excellent 
 book, and in Ziemssen, very good accounts of this 
 group of disorders, but I think it will admit of further 
 study, and I, therefore, venture here to tell you about 
 it -some things which are not found in the text-books. 
 
 Hysterical loss of voice is apt to come on in long 
 cases of hysteria without apparent cause. The voice 
 goes and comes, is hoarse or feeble, and at last be- 
 comes reduced to a whisper, or is lost altogether for 
 weeks or years. Then the patient has to write what 
 she would have talked ; and if, as in this girl's case, 
 her arms be palsied for a time, only manual signs re- 
 17 
 
194 DISEASES OF THE NERVOUS SYSTEM. 
 
 main until the people around her learn to read those 
 labial signs with which communication at length be- 
 comes so easy as to take away desire to make the 
 painful effort at audible speech. 
 
 In a few cases emotion causes abrupt loss of speech 
 power. Cohen relates such a case ; I have seen 
 several. Nor when we remember that it is through 
 the voice-muscles that we express so many of our 
 emotions, can we wonder that it is in the larynx that 
 we feel the choking spasm of grief, or that here, also, 
 intense sense of pathos, or almost any deep feeling, 
 asserts its power by some act of muscular spasm ; or 
 that in nervous people yet graver emotional shocks 
 result in the palsy of the organs through which we 
 are prone to express emotion. 
 
 There are, as I have seen them clinically, at least 
 three forms of hysteric conditions which disturb vo- 
 cal utterance, and these three forms are sometimes all 
 seen in one case, or may exist distinct. We have, 
 first, bilateral palsy of the adductors of the vocal 
 cords; second, disassociation of the various organs 
 needed in phonation; third, habitual spasm, or sense 
 of spasm, during use of the larynx in speech. 
 
 The first, or bilateral loss or lack of power in the 
 crico-arytenoid muscles, is the common type of hys- 
 terical aphonia, and is usually found with loss of 
 power in some of the other muscles of the larynx. 
 If, in a case of hysteria, you have loss of voice, or 
 suddenly the patient becomes a whisperer, you may 
 be pretty sure that you have to deal with this form 
 of trouble. Even if there has been a cold and sore 
 throat, with cough, you may safely conclude that the 
 
HYSTERICAL APHONIA. 195 
 
 slight local inflammation did not cause the aphonia, 
 but acted as what I may call a hint to the hysterical 
 condition. This caution is, I may add, the more 
 needed because an outbreak of this form of trouble 
 is often caused by catarrh; but this is the kind of 
 thing we see every day in hysteria. The catarrh 
 passes into hysteric paresis. A diarrhoea from over- 
 eating becomes an hysterical diarrhoea; an attack of 
 true emesis from indigestion is the parent of hysteri- 
 cal regurgitation, and this may last for years. 
 
 Bilateral hysteric -p&lsy of the vocal cords may be 
 extreme or slight, but where it is marked you will 
 see, with the laryngoscope, that the cords do not 
 come well together when the patient makes vowel 
 sounds. One cord may come nearer the middle line 
 than the other, but neither does its duty. This is an 
 easy examination commonly, because, as a rule, hys- 
 terical people are not at all disturbed or gagged by 
 the mirror ; but this is not always so, and the patient 
 we see to-day has a quite sensitive throat. If you 
 find a distinct unilateral glottic palsy, you have, 
 probably, a non-hysterical paralysis — at least I have 
 never seen a monoplegic state of larynx which was 
 hysterical. You would naturally suppose that apho- 
 nia and dysphagia would often be found together, 
 but this is rare, very rare, although I can recall cases 
 where the two disorders alternated. 
 
 The loss of voice in hysteric aphonia has some odd 
 peculiarities, or rather exceptions : the patient cannot 
 speak, or can only whisper with mouth or larynx so 
 faintly as to be scarcely heard with the aid of the ear- 
 trumpet ; yet she may be able to sing well, as happened 
 
196 DISEASES OF THE NERVOUS SYSTEM. 
 
 in one of Cohen's cases ; or, as chanced in that of a lady 
 whom we saw together, she may be able to speak aloud 
 in her sleep, and then only. On these occasions the 
 unwonted sound of her own voice would awaken her, 
 and the disappointment which followed the next wak- 
 ing effort at speech was most distressing, and the 
 emotion thus occasioned gave rise, like all emotion in 
 such cases, to an even greater loss of what mere 
 whispering power was left. 
 
 Many examples of these disorders are seen in pretty 
 strong, stout, and even ruddy women, and when met 
 with in such persons are, like all the hysterical phe- 
 nomena of the nearly healthy, especially unmanage- 
 able. When hysteric aphonia is found in feeble and 
 easily-tired women, the effort to speak or cough with 
 an open larynx, or with weak chest muscles, gives rise 
 to a good deal of soreness, and emphasizes that sense of 
 painful fatigue about the pectoral region of which this 
 class of invalids is so apt to complain. The victim of 
 this disease is very often able to speak low, the voice 
 breaking at times. Other and extreme cases lose the 
 power to whisper with the larynx, and can still whis- 
 per with the mouth ; and others, again, are unable to 
 utter the faintest sound, or to laugh or cough so as to 
 be heard at all. It must be obvious to you that, in the 
 worst cases, we have here a dual condition, a paralysis 
 which, though without coarse organic cause, may be 
 lasting, and a disassociation of the motor activities of 
 the respiratory, laryngeal, and buccal and oral mus- 
 cles — parts which, by physiological construction and 
 long habit, unite to produce voice. The two troubles 
 are often seen together in variable degrees ; or the 
 
HYSTERICAL APHONIA. 197 
 
 incoordination may exist alone, there being still 
 power to close the larynx. 
 
 We should then have the second and less well-known 
 form of aphonia, and this it is well to study with care. 
 The present case is a perfect example. If, while using 
 the throat mirror, I ask her to sound the broad A, the 
 vocal cords come together, but do not vibrate, because 
 she is unable to use synchronously the respiratory 
 muscles to drive air through the narrowed orifice. 
 Of course there is no laryngeal whisper. In some of 
 these cases, as I have seen, the patient can whistle more 
 or less well, because for this act only the mouth and an 
 expiratory effort are needed ; but there are others who 
 cannot execute even this simple act of coordination, 
 and these persons would seem, therefore, to have also 
 lost power to use vocally the lesser bellows — the mouth 
 — in connection with the tongue and lips, so that in 
 this case buccal whispering would also be lost, and the 
 patient would then have what Cohen calls apsithuria, 
 and be absolutely whisperless. I will defer speaking 
 of the third form of dysphonia until we consider the 
 case before us. This young woman has good power 
 over the laryngeal muscles. I ask her to speak ; she 
 makes a great effort, but, as I found in my last ex- 
 amination, I cannot hear her even with an ear-trumpet. 
 She has neither with larynx nor mouth capacity to 
 whisper. She can whistle feebly, but whistling is 
 not a feminine accomplishment, or she might do bet- 
 ter. You observe that, when trying to speak, she 
 makes extreme movements of the lips, and this is 
 done to enable her friends to read this language of 
 oral signs which she thus renders clear or emphatic. 
 
 17* 
 
198 DISEASES OF THE NERVOUS SYSTEM. 
 
 What I have here said well enough describes this 
 curious condition, which seems not to have been very 
 clearly recognized as being sometimes a state apart 
 from paralytic conditions. I can give no explana- 
 tion of the immediate causes of these singular inco- 
 ordinations. Let us now test their presence. It has 
 occurred to me that, if I could teach her how once 
 more to use with success these disunited activities, 
 she might regain her voice. On thinking how I 
 could best bring this about, it seemed to me that, if 
 I could teach her to speak only with a very full 
 chest, I might secure an involuntary success in driv- 
 ing air through the larynx. I shall ask her to fill 
 her lungs several times, and, when very full, to keep 
 her mouth wide open, and, as she sounds or tries to 
 sound the broad A, to breathe out violently. I aid 
 her by myself performing the act. To her surprise, 
 for the first time in ten years, she makes a clear, 
 audible sound. Then, always insisting on each single 
 letter being made with very full chest, we go over 
 the vowels, and then try the labials, and at last words. 
 As she leaves me she says, " Thank you." I insist 
 that she shall not speak save with a full chest; that she 
 must never use oral signs alone ; and that she must 
 be silent except during the lessons her sister will now 
 give her thrice a day. 
 
 If this had been a case of glottic palsy, I should 
 think her sudden cure was due to the emotions caused 
 by her novel treatment, as Cohen has seen, and I also, 
 the mere use of the throat mirror restore voice; but at 
 her first visit here we got no result from this or from 
 Oliver's method of manipulating the larynx, so that 
 
HYSTERICAL APHONIA. 199 
 
 I itself shall believe that the result was due to my 
 teaching unused organs the easiest way to regain their 
 habitual function. 
 
 Under the use of tonics, rest, and full feeding, with 
 vocal lessons, aud a continued order not to speak at 
 other times, she has continuously improved. Whe- 
 ther or not she will relapse depends a good deal on 
 her surroundings. Such cases are only too prone to 
 fall back. 
 
 Hysterical spasm of the larynx is a phrase which 
 I almost hesitate to use, since I cannot be absolutely 
 sure that the disorder I shall describe is really due to 
 this cause. There are few of us who, at some time 
 of our lives, have not known the sensation of chok- 
 ing in the- throat from emotion. It is a brief and 
 unpleasant matter, and for well people a rare one, but 
 among highly-nervous people, or hysterical women, 
 there is a rare form of this trouble, or something 
 allied to it, which gives rise to temporary loss or in- 
 hibition of voice. At first from emotion, worries, or 
 without known cause, there is felt in or about the 
 larynx a sense of momentary strangling and pain. If 
 the person is speaking, the voice breaks, and she re- 
 mains speechless, or the voice becomes shrill and then 
 breaks. At every effort there is pain, distress referred 
 to the larynx, and squeaky, broken tones. There is 
 also a sense of constriction, and sometimes the oesopha- 
 gus seems to share in the annoyance, and an upward 
 gulping effort follows or accompanies the laryngeal 
 disturbance. I have seen this group of symptoms 
 become so frequent in one case, that at length the girl 
 refused to speak at all. It was apt in this case to fol- 
 
200 DrSEASES OF THE NERVOUS SYSTEM. 
 
 low meals, and these were seasons of real suffering, 
 because of the intense dysphagia, which caused her 
 to chew every morsel for many minutes before ven- 
 turing upon the task of deglutition. The meal be- 
 came, therefore, a severe strain upon an already feeble 
 constitution, and this seemed to have something to do 
 with the more ready causation of the laryngeal dis- 
 order at these special seasons. A long course of milk 
 and soup diet, inhalations of nitrite of amyl, and gal- 
 vanization of the larynx finally relieved greatly these 
 troubles, but there was no entire cure until a year 
 later I succeeded in materially improving her gene- 
 ral condition. 
 
 We have, then, laryngeal palsies usually with, 
 sometimes without, incoordination of the chest, dia- 
 phragm, and mouth; pure incoordination without 
 paralysis ; and, lastly, a disease which seems to be a 
 temporary spasm of the vocal muscles of the larynx, 
 caused by effort at speech, in other words, afunctional 
 spasm. 
 
GASTRO-INTESTINAL DISORDERS. 201 
 
 LECTURE III. 
 
 GASTRO-INTESTINAL DISORDERS OF HYSTERIA. 
 
 I have said in these lectures very little as to the 
 gravest of hysterical symptoms — the persistent hys- 
 tero-epilepsies, and the multiple and severe contrac- 
 tions which Charcot and others describe. I have said 
 little because, in my experience, and it has been very 
 great, these terrible cases are rare in America in any 
 class of life, and most uncommon in the lower classes, 
 among which Charcot seems to have found his worst 
 and most interesting cases. In this disorder, as in 
 chorea and many other diseases, there is, I suspect, 
 some difference between this country and Europe. 
 
 My own clinic furnishes yearly hundreds of cases 
 of neural maladies, but while I often see examples of 
 every type of the milder forms of hysteria, it is ex- 
 tremely uncommon to encounter the more severe and 
 lasting forms of the disease. 
 
 My friend, Dr. C. K. Mills, who has charge of the 
 extensive out-wards for incurables at the Philadel- 
 phia Hospital, writes me that his experience is simi- 
 lar to mine. He says : " My wards contain some 
 cases of hysteria of long duration, but they are not 
 numerous. As the result of some experience, both 
 in and out of hospitals, I have come to the conclusion 
 
 X 1 
 
202 DISEASES OF THE NERVOUS SYSTEM. 
 
 that cases of grave hysteria, such as the hystero-epi- 
 lepsies of Charcot, are rare in this city and country. 
 Spasmodic disorders, associated with hysteria, do not 
 seem to me to be as frequent here as abroad. Hys- 
 terical palsies are more often met with. Neuralgia, 
 spinal irritation, ovarian hyperesthesia, and special 
 forms of mental and moral perversion are, in my ex- 
 perience,, the more usual forms of American hysteria." 
 It is impossible to acquire as to a matter like this 
 precise statistical information, but from what I know 
 of the experience of other physicians in New York, 
 Boston, Baltimore, and Chicago, there is every reason 
 to believe that it does not differ from the views enter- 
 tained by Dr. Mills and myself. The causes of this 
 difference in the symptom-products of a disease so 
 common, and which finds in all lands and all female 
 human nature enough conditions favorable to its 
 growth, would be a somewhat interesting inquiry, but 
 one for which I must confess there is yet wanting 
 satisfactory material. 
 
 I have given in the final lesson of this volume 
 some general directions as to the treatment of extreme 
 cases of malnutrition and lrysteria. I would like to 
 make here some remarks as to the especial difficulties 
 which meet us in connection with the stomach and 
 bowels of hysterical women. No matter whether we 
 treat them, as is preferable, by exercise and baths 
 and fresh air and tonics, or are driven in despair to 
 the more unnatural treatment by seclusion and rest, 
 we have still in all cases, to feed them, and in all to 
 see that the bowels are kept reasonably open. The 
 lighter cases of hysteria which come afoot to my 
 
GASTRO-INTESTINAL DISORDERS. 203 
 
 clinic can give yon no idea of the gigantic, almost 
 grotesque proportions which symptoms may assume 
 in the graver cases of hysteria, but in each and all it 
 is nearly always some trick of the stomach or gastro- 
 intestinal tract which soon or late baffles or perplexes 
 us. In one case you have an apparent inability to 
 chew; food rests in the mouth until helplessly removed 
 by a nurse or is half passively let fall out by the 
 patient. I have such a case now. I had to begin by 
 admitting an interest in her failures and advising her 
 to move the jaw with the hands, which she did do for 
 a while until the power or the belief in the power to 
 chew came back. Next comes the oesophagus with 
 its troubles — at times a spasm, at times a paralytic 
 state, more rarely a pharyngeal anaesthesia — but in 
 each case attention to the act of swallowing helps to 
 embarrass it. 
 
 You will be well off if you escape this exasper- 
 ating disorder in your early hysterical cases. It is 
 most enduring, and difficult of relief. I think it curi- 
 ous that in my experience this trouble is rare in old 
 hysteric cases. There are symptoms which are rela- 
 tively common early in cases, others which are seen 
 later, and are apt to last. Dysphagia one sees often 
 in cases which are afoot. 
 
 If Ave fail of this annoyance, we may have to meet 
 certain gastric disorders. One is loss of appetite, 
 anorexia ; the other is vomiting. Of this latter symp- 
 tom I have already said something in a former lec- 
 ture. What I now refer to is the simple regurgitation 
 which we meet with in these cases. There is no 
 nausea — certainly after a while none, — but the food 
 
204 DISEASES OF THE NERVOUS SYSTEM. 
 
 is returned to the outer air with a gulp, and often 
 with remarkable and painless ease. 
 
 You may think this sounds like a rather mild 
 malady ; but in reality it is one of the symptoms 
 which, while it may haunt any stage of hysteria, is 
 of all symptoms except multiple contractions the most 
 enduring. I can now recall five cases of hysteria 
 lasting from fifteen to twenty^five years. All are 
 bed-ridden ; and while four have contractions, three 
 are in the habit of vomiting every meal ; and have 
 done this for years. One has actually grown stout 
 under this ; but she is an opium-eater, and rest with 
 opium greatly aids the storing up of unwholesome 
 fat. The others are at least not wasted, and you ask 
 yourself in vain how they live upon the small amount 
 they seem to retain. In reality there is apt to be 
 some deception as to this. Nearly always these 
 women assure you that they throw up all of each 
 meal ; but they are apt to go through with the matter 
 alone or unseen, and no one takes the trouble to learn 
 how much is realty retained. I did take this trouble 
 once, in a case of which by and by I shall say more, 
 and learned that about one-third to one-half of the 
 meal remained. In an hysterical girl at absolute rest 
 this might very well answer to nourish her amply. 
 
 I put aside for the time the symptom loss of appe- 
 tite, because of all of the embarrassments we meet with, 
 this is the worst. To call this loss of appetite, ano- 
 rexia, but feebly characterizes this sympton. It is 
 rather an annihilation of appetite, a lack so complete 
 that it seems in some cases impossible ever to eat 
 again. Out of it grows an indisposition to eat at all, 
 
GASTRO-INTESTINAL DISORDERS. 205 
 
 an antagonism to food, which results at last and in its 
 worse forms in spasms on the approach of food, and 
 thus in turn to some of those remarkable cases of 
 survival for long periods without food, which you need 
 not confound with the more or less successful efforts 
 to deceive by the pretence of fasting. You will have 
 constantly to deal with the various grades of this dis- 
 order, if you are called upon to treat hysteria. When 
 it is merely anorexia, you may disregard it as you 
 would the anorexia of fever, no matter how extreme 
 it may be, and indeed the more so because it is ex- 
 treme. There are some useful hints which you may 
 keep in mind for these contingencies. Fluids can be 
 taken when solids are inhibited by the disgust they 
 cause, but, as regards solids themselves, if they be 
 finely divided or put in a fluid as mincemeat in soup or 
 rice in milk, they are sometimes taken well whilst if 
 alone they would be rejected. I may also add that if 
 the patient be in bed you will often be able to give 
 solids, if the nurse herself feeds the patient, since then 
 you get rid of at least one volitional act, and the 
 added chance for deliberation, and consequent disgust 
 which it affords. 
 
 Sometimes this symptom exists only at the men- 
 strual period, or is then greatly intensified, and, as at 
 this time the consequences due to loss of blood are in 
 feeble women made worse by failure to eat, one of the 
 most valuable lessons you can teach such women is the 
 absolute need to eat, or, at least, to drink nutritive food, 
 whether it be agreeable or not. The graver cases of 
 self- starvation which arise out of the superlative degree 
 of hysterical indifference to food are far more serious. 
 18 
 
206 DISEASES OF THE NERVOUS SYSTEM. 
 
 They result, as I have said, in the patient taking no 
 food, and sometimes before such cases the utmost 
 skill and the largest experience are simply impotent. 
 Few of these cases exist without there being a certain 
 amount of doubt as to whether or not these long fasts 
 are really fasts, yet, as regards some of them, there 
 can, I think, be no doubt ; but in no real case has 
 the duration of the fast reached that affirmed to have 
 existed in examples like that of Louise Lateau. 
 
 I have seen several instances of extreme fasting, 
 and I propose now to call your attention to two of 
 them which possess a peculiar interest. The first 
 one I studied with extreme care and with every 
 possible advantage ; the second came to me long- 
 after the time of fasting had passed, and although a 
 woman to all appearances hopelessly hysterical, com- 
 pletely recovered. Her fast was observed by phy- 
 sicians as competent as Charcot and Brown-Sequard, 
 and of it I have a very good history : — ■ 
 
 Miss L. C, set. now 38 years, had in her 18th year 
 an unhappy love affair, and soon afterwards a fall in 
 which she struck her back. Within a few weeks 
 intense spinal irritation set in, for which braces and 
 corsets were used, and, these failing, rest in bed was 
 prescribed. The latter remedy was a fatal one, and 
 she has never since left the bed to which a physician's 
 orders sent her. It were tedious and useless to dwell 
 on the wild variety of symptoms which followed, as 
 we are dealing now with only one of them. Hys- 
 terical paralyses, anaesthesias, ischuria, anuria, poly- 
 uria, hjrpersesthesias of skin, eyes, and ears, succeeded 
 one another singly or in perplexing groups. A year 
 
GASTRO-INTESTINAL DISORDERS. 207 
 
 or more before I first saw her, contractions of the two 
 legs and feet began, and went on from bad to worse; 
 while both legs to the waist were insensible to pain 
 and changing temperatures, but still appreciated the 
 position of a touch quite fairly well. The body was 
 excessively wasted, the skin dry and sallow, and 
 covered with bran-like scales of epithelium. About 
 the sixth year of her disorder she began to have a 
 constipation so obstinate that neither drugs nor 
 mechanical aid was of the slightest use, and from this 
 time for years the bowels were moved but once a 
 month, at which time there were violent attacks of 
 hystero-epilepsy. At or near the time when this 
 difficulty developed itself fully, she ceased to pass 
 water more than once a day. With the help of care- 
 ful nurses, I was able to study this curious symptom 
 which in her assumed an unusual form. During 
 thirty-nine days her urine reached a daily average of 
 three ounces. The specific gravity was 1040 to 1060. 
 It was dark, and clouded with urates and crystals of 
 oxalates and uric acid. The pulse rose to 120; the re- 
 spirations to 60 or 70 ; and in place of the usual vomit- 
 ing, which Charcot has studied so admirably and which 
 he has shown to be vicarious and charged with urea, 
 profuse sweats broke out, and left the skin covered 
 with a white film in which I found large quantities of 
 urea. Then the scene changed, and about the thirty- 
 ninth day the sweats ceased, violent vomiting with 
 nausea followed, and she began to drink vast quan- 
 tities of water, which seemed to be absorbed with 
 great speed, since the vomiting which took place at 
 intervals was merely of a thick, slimy mucus. At the 
 
208 DISEASES OF THE NERVOUS SYSTEM. 
 
 same time the anuria ceased, and, from passing some 
 days no urine at all, she poured forth large amounts 
 of limpid water, sp. gr. 1005 to 1012. 
 
 The fluid thus secreted averaged, for ten days, five 
 to ten quarts ; but the amount swallowed was equal 
 or more in amount. By degrees this symptom faded 
 away, and she drank less and less, and ate almost 
 nothing ; until, at the close of another month, the 
 urine growing smaller in amount, she ceased to vomit, 
 except when urged to take food. Her condition was 
 then as follows : She passed six to ten ounces of urine 
 daily, and drank, by the teaspoon, about twelve to 
 fourteen ounces of water. She took no food at all for 
 ten days, and then ate a few teaspoonfuls of milk, 
 which always caused vomiting. From this time 
 twenty days passed, during which she took no food, 
 but had fifty to eighty drops of laudanum daily, Avhich 
 she never vomited. Her eyes remained closed, the 
 least vibration or light caused agonizing cries, and 
 every one expected to see her die at any moment. 
 Efforts at rectal feeding or inunction of oils gave rise 
 to horrible spasms, and in this condition day after 
 day went by. The watch over her was rigid and 
 faithful, and every effort even to give a teaspoonful 
 of fluid was carefully noted. I am as sure as I can 
 be of anything that in one month and five days she 
 never took in all more than twenty-four ounces of 
 milk, and the amount of water I have mentioned. 
 Whether this almost incredible abstinence was aided 
 by the large quantity of opium taken is, at least, dif- 
 ficult to say. There were, during the time in question, 
 a large number of hysterical spasms, but, with this 
 
GASTR0-1NTESTINAL DISORDERS. 209 
 
 exception, the patient lay almost motionless. Now, 
 as yet, we quite lack material for the determination 
 of the nutritive needs of a body at absolute rest ; so 
 that it is hard to decide how much is needed for the 
 mere sustenance of necessary function. I have seen 
 a woman, weighing one hundred pounds, remain at 
 rest in bed, and lose no weight in ten days on a diet 
 of one pint of good milk daily. 
 
 Certainly my patient lost weight. At the close of 
 her fast, when she began to take and retain milk in 
 small portions, she was wasted almost to the last 
 degree, and this has never failed to happen in such 
 experiences as I have had of true fasting. This 
 woman had in all three periods of abstinence, but the 
 one I have described was by far the longest. The 
 contractions have of late years become more and more 
 extreme, and, as they have increased, the anaesthesia 
 has become less, while the electro-muscular excita- 
 bilitv of the le^-muscles has lessened. I have little 
 doubt that the lateral columns of the cord are now in 
 a state of advanced sclerosis. 
 
 The second case of fasting was also one of extreme 
 interest, because abstinence was one of a series of 
 most interesting phenomena, covering some years ; 
 and resulting, finally, in a complete restoration to 
 health. 
 
 Miss L., of Connecticut, aet. now 28 years, went 
 abroad after having suffered a long and severe strain 
 on her emotions and sympathies ; a strain which did 
 not lessen, but from which she fled in despair. The 
 results were broken sleep, great, though suppressed 
 nervousness, but no notable functional disturbances. 
 
 18* 
 
210 DISEASES OF THE NERVOUS SYSTEM. 
 
 To keep down this sensation of nervous excitement 
 she was accustomed to walk for hours, returning home 
 with increasing pain and tenderness of the spine, the 
 back of the head, and the scalp in general. The symp- 
 toms were thought grave, and were at last treated by a 
 long blister over the spine. On removal of the blister 
 there was a furious outbreak of weeping, general con- 
 vulsions, and incessant local spasms of the extremities, 
 which nothing checked or lessened. These conditions 
 lasted during February and March, and were made 
 worse by a large crop of carbuncular boils, which 
 formed on the part where the blister had been placed. 
 About this time, despite the sagacious care of excellent 
 physicians, she began to eat less and less, and at last 
 early in April, ceased to eat at all. Exaggerated hic- 
 cough set in, furious convulsions arose at every effort 
 to feed her, and these symptoms repeated themselves 
 six or seven times a day, sometimes without any ap- 
 parent cause. Rectal feeding was given up, because it 
 also gave rise to spasms, and there seemed nothing to do 
 but to wait. For twenty-seven days neither liquid nor 
 solid was swallowed. The tongue and lips became black 
 and dry, and cracked ; the lips were thin and crusted 
 like the teeth with sordes and blood ; the breath 
 foul ; the eye sunken ; respiration quick and labored ; 
 the pulse 120 to 130 ; and speech whispered and dif- 
 ficult. Meanwhile, all convulsive acts ceased, and 
 her mind seemed at times quite clear and capable. 
 Twice her physicians were called in to see her die; 
 but the stupor, which seemed almost as deep as death, 
 also, in its turn, passed away. 
 
 I am unable to give details as to the state of the 
 
GASTRO-INTESTINAL DISORDERS. 211 
 
 secretions during all of this long fast. The bowels 
 were, I think, moved once, and the urine ceased to be 
 secreted after the eighteenth day. 
 
 There was some difference of sentiment in the con- 
 sultation brought about by this grave condition, one 
 great authority advising inaction until nature asked 
 for food, which he thought would happen. Another 
 physician who was then consulted saw in her case an 
 example of starvation which, having reached the 
 limits of great peril, demanded forced feeding by the 
 stomach tube. I am positively informed that of this 
 counsel, which it was resolved to follow, the patient 
 knew nothing. However, at this critical moment she 
 motioned to her physician, and in a whisper said she 
 could now take food. Then came two weeks of care- 
 ful spoon-feeding, with constant threats of repeating 
 the old troubles when, suddenly, a general tremor set 
 in, and the motion growing larger, became twitching, 
 and so by a crescendo movement went on into violent 
 convulsive acts, until despite the care of those about 
 her she was thrown by a series of spasms from the 
 bed^to the floor, where she lay, muffled with shawls, 
 cloaks, and pillows to save her from bruising herself, 
 until at length chloroform brought quiet. The sum- 
 mer wore away with a variety of symptoms, such as 
 partial palsies, aphonia, and mental depression. The 
 next autumn she was removed to Liverpool, and there 
 during the winter she had variable degrees of ano- 
 rexia, and the usual miserable variety of hysterical 
 disorders. Treatment was varied enough, but always 
 unavailing, because no treatment could ignore food, 
 and that was kept at the minimum on which exist- 
 
212 DISEASES OF THE NERVOUS SYSTEM. 
 
 ence is possible. Early in the next September the 
 girl mustered courage to cross the Atlantic, and ar- 
 rived in New York, suffering with a loud, incessant 
 cough, which brought up strange quantities of glairy 
 mucus. Emaciated to the last degree, with evening 
 fever and morning chills, she seemed on the verge 
 of death, when almost suddenly the cough ceased, and 
 the starvation symptoms reappeared, but not in so 
 disastrous a shape as had marked their appearance 
 in Paris. After a partially successful treatment at 
 the hands of her physician in New York, circum- 
 stances removed her from his care. Again the sto- 
 mach tube was advised and declined by the family, 
 and again days passed without food, while the convul- 
 sions, the wasting, the black tongue, the breath, 
 which Brown-Sequard had described as an odor like 
 that of altered fusel oil, and the shrunken belly all pro- 
 mised a new period of three weeks' fasting. It proved, 
 however, less complete than before, and she gradually 
 rallied. From this time she remained in bed for 
 nine months, eating little and irregularly, a wretched 
 invalid, not very thin, but not fat, with occasional 
 spasms, great nervousness, distressed by light, by 
 sounds, by any company which was not quite agree- 
 able, forever alarming her friends by threatenings of 
 a repetition of her former troubles. I somewhat re- 
 luctantly took charge of this lady early in the follow- 
 ing spring. The most absolute seclusion and the use 
 of skimmed-milk diet, aided by massage, slowly 
 triumphed over her disorder, and by and by she re- 
 gained control over her too emotional tendencies. 
 The details of this treatment I have elsewhere dwelt 
 
GASTRO-INTESTINAL DISORDERS. 213 
 
 upon. It triumphed in this case so completely as to 
 have restored my patient to absolute health, and to 
 social duties and engagements which, had seemed to 
 her hopelessly lost. 
 
 The same obstinacy of symptoms which attends such 
 happily rare cases as these is also occasionally met 
 with in regard to the function of defecation. 
 
 You will find among hysterical and also among 
 merely feeble people several forms of difficulty asso- 
 ciated with this function. One which is not uncom- 
 mon is a feeling of great weakness after every opera- 
 tion. This sometimes goes so far that the patient will 
 show clearly enough, in the pallor and the hastened 
 heart, how real is the sudden enfeeblement thus pro- 
 duced. In still less common cases the patient faints 
 after the stool is passed, and is especially apt to do so 
 if the evacuation be loose and therefore sudden. I 
 know of one man in quite fair health who is never 
 without a sense of faintness at and after a passage, 
 while a stool at all watery is sure to cause him to faint. 
 
 Naturally enough such phenomena are frequent in 
 the class of cases we are uoav considering — so that it 
 is sometimes needful to give a little stimulus before 
 the evacuation occurs, and also to insist on the use of 
 a bed-pan. If you can thus break up a morbid habit, 
 or at least make this occurrence of faintness unlikely 
 for awhile, the gradual return to full health, which, 
 meanwhile, you are in other ways promoting, will 
 take care of the future. 
 
 A far more formidable symptom is the indisposition 
 of some hysteric women to make any effort towards 
 evacuating the bowels. They will tell you that it 
 
214 DISEASES OF THE NERVOUS SYSTEM. 
 
 gives them intense pain, and that they cannot exert 
 themselves, or else they will make, or seem to make, 
 efforts which result only in failure. At last you 
 begin to find that medicine does not act, and is met 
 with resistance. It does this or it does that. It gives 
 acute pain, or it disturbs digestion; you try other 
 aperients, and always there is some objection, while 
 you begin to observe that, for some reason, the 
 doses needed are large. If, now, you make a rectal 
 examination, you may chance to find the lower bowel 
 full of feces, or else absolutely empty, as far as j^our 
 powers of local examination enable you to reach. 
 Either there is a palsy of the bowel somewhere, or, 
 what is practically the same thing, there is a tem- 
 porary inhibition of its natural movements. Day 
 after day goes by in vain use of enemata and drugs. 
 You will recall my mention, in one of these lectures, 
 of the case of an hysterical girl thus affected, and also 
 what I have said in the present lesson as to the case 
 of the patient first described. In her, monthly evacu- 
 tion of the bowels has continued, and is now the habit 
 of years. I recall another case in which, after pro- 
 longed treatment, I advised that the bowels should 
 be left to regulate themselves. Three weeks went 
 by without an operation, and, when it came, child- 
 birth could hardly have been worse. On another 
 occasion five weeks elapsed, and then, what is natu- 
 rally not rare in such cases, diarrhoea folloAved the 
 constipation ; so that for months there was this alter- 
 nation — diarrhoea, tenesmus, intense straining, num- 
 berless efforts clailv, and then, in a day, all movement 
 arrested, and absence of stools for weeks. 
 
GASTROINTESTINAL DISORDERS. 215 
 
 If it happens to you, in an evil hour, to have one 
 of these cases to treat, with the additional need to 
 treat also the difficulties with which some tender 
 mother surrounds such a case, you are much to be 
 pitied. I recall such an example, which I saw in 
 consultation some years ago. It begau with a spot 
 of abdominal tenderness over the spleen. Pressure 
 on this caused nausea and vertigo. Then we had 
 convulsions, hysterics, coma, enormous polyuria, and, 
 at last, among other things, constipation. The phy- 
 sician in charge gave me this list of the drugs given 
 in four days — night and morning, on each day, an 
 ounce of castor oil ; at mid day and bedtime one drop 
 of croton oil ; three drops had been used in one day. 
 The more drugs she took the more she demanded, 
 and yet it was impossible to see that the doses given 
 caused pain. Meanwhile, for the nurse and mother 
 the arrangement for each evacuation was the event 
 of the day. A long stomach-tube was carried six or 
 seven inches up the bowel, and a half pint of olive oil 
 injected ; then followed one quart to three of flaxseed 
 tea. During the use of the enema one person was oc- 
 cupied in compressing the anal opening so as to pre- 
 vent the escape of fluid. This help was made neces- 
 sary on account of the great relaxation of the sphinc- 
 ter, into w r hich a thumb could be passed without any 
 resistance which could be felt to arise from a muscu- 
 lar act. Meanwhile, the patient, while insisting on 
 the use of more water, was shrieking with pain. The 
 whole affair took two to four hours, and the patient 
 was, I thought, the least exhausted of those concerned. 
 Sometimes, their efforts gave rise to a stool; some 
 
216 DISEASES OF THE NERVOUS SYSTEM. 
 
 times, there was none for a week ; and, sometimes, 
 under the wild entreaties of the patient, these trying 
 scenes were repeated in the night, nurse and mother 
 being aroused to assist. I endeavored to get this girl 
 out of the control of her family, but I did not suc- 
 ceed ; and I believe that her hysteria is now firmly 
 established. 
 
TREATMENT BY SECLUSION, REST, ETC. 217 
 
 LECTURE XIII. 
 
 THE TREATMENT OF OBSTINATE CASES OF 
 NERVOUS EXHAUSTION AND HYSTERIA BY 
 SECLUSION, REST, MASSAGE, ELECTRICITY, 
 AND FULL FEEDING. 
 
 The lessons I have here gathered together would 
 be incomplete, were I not to add some more detailed 
 statement of my views as to the general treatment of 
 the conditions out of which arise the varied phe- 
 nomena of hysteria. Nothing, I think, can be more 
 melancholy than an honest survey of the amount of 
 good done in hysteria by the host of drugs which go 
 to form the so-called therapeutics of this disease. 
 In disorders where time is valuable we may find a 
 happy resource in the famous class of antispasmodics, 
 but as a rule they are swiftly disappearing from the 
 apothecary's prescription files, and the physician of 
 our day who is called upon to treat hysteria, or general 
 nervousness or neurasthenia, wisely contents himself 
 with a careful estimate of causes, and an effort to deal 
 with these by patient treatment. 
 
 Perhaps no cases are more common in general 
 practice, none more annoying, and none more dreaded 
 than those of hysteria, in its infinite number of forms 
 and its infinite variety of masquerade. The lighter 
 troubles, the spasms, rigors, nervousness, and curi- 
 ous mental states, which haunt the times of sexual 
 19 
 
218 DISEASES OF THE NERVOUS SYSTEM. 
 
 changes in a woman's life, and especially her pas- 
 sage into womanhood, are more or less easily dealt 
 with. A careful study of the girl's character, of her 
 home surroundings, of the incidents of social life, 
 which come with the development of possible passion, 
 will be the best guide to treatment, and with the 
 obvious indications given us by distinct physical ail- 
 ments, local or general, constitute oar chief resources. 
 
 But besides these every-day manifestations of hys- 
 teria, we meet in practice with a growing class of 
 disorders in which change of social circumstances, 
 love affairs, disappointments, and what the French call 
 vies manquees, combine with physical accidents to 
 create invalids, who unite neurasthenic states with a 
 bewildering list of hysterical phenomena. These 
 are the " bed cases," the broken-down and exhausted 
 women, the pests of many households, who constitute 
 the despair of physicians, and who furnish those an- 
 noying examples of despotic selfishness, which wreck 
 the constitutions of nurses and devoted relatives, and 
 in unconscious or half-conscious self-indulgence de- 
 stroy the comfort of every one about them. 
 
 These are the cases of chronic hysterical invalidism 
 w r hich are so difficult to deal with. There must be 
 in every country thousands of these unhappy people. 
 They weary doctor after doctor, go hopelessly through 
 the various cures, and at last end in therapeutic 
 inactivity, or find a refuge in homoeopathy, which 
 promises a pill for every symptom, and leaves them 
 at last where it found them. 
 
 It is among such cases that we meet with the 
 strange and interesting disorders of which I have 
 
TREATMENT BY SECLUSION, REST, ETC. 219 
 
 narrated so many in these lessons, — disorders which 
 are to be met, not by mere symptomatic therapeutics, 
 but by a full and clear comprehension of underlying 
 causes, and by such treatment of these, whether they 
 be moral or physical, as shall destroy the soil in which 
 hysteric phenomena flourish. 
 
 You will infer from these few introductory sen- 
 tences that I look upon most cases of confirmed hys- 
 teria as finally dependent on physical states or defects 
 which may first have been directly or indirectly due 
 to moral causes, or to these in conjunction with vari- 
 ously-produced constitutional conditions. Anaemia 
 gives rise to lessened power of self-control, this to 
 emotional disturbances, and these, in tarn, to loss 
 of appetite, out of which, if the surroundings be 
 favorable, come graver nutritive disorder and endless 
 invalidism. This is a fair sketch of an every-day 
 occurrence. It would be waste of time to dilate on 
 matters so familiar. 
 
 In grouping cases of hysteria — and remember 
 that I speak now of the old and complicated and 
 exasperating forms of this disorder — there is one 
 reservation which I shall have to make, and but one. 
 It refers to the small group of women in whom Ave 
 witness obstinate hysteria associated with a nearly 
 perfect state of physical health. As I recall these 
 cases they have usually been women in middle life, 
 and in easy circumstances. I know to-day of a dozen 
 or so of such people who are able to walk about and 
 to do much as they please ; women in good condition, 
 fat and ruddy, w r ith sound organs and good appetites, 
 but ever complaining of pains and aches, and liable 
 
220 DISEASES OF THE NERVOUS SYSTEM. 
 
 on the least emotional disturbance to exhibit a quaint 
 variety of hysterical phenomena. For these women 
 there is usually no cure, and you will treat them in 
 vain. 
 
 We have, then, the hysterical women who are yet 
 well enough to be able to correct the causes of their 
 disease by exercise and fresh air ; and in this class we 
 find abundantly the cases of hysterical joints, and all 
 the range of mild hysteric and mimetic symptoms. 
 Once make sure that you have such people to deal 
 with, and common-sense hygiene, enforced by a reso- 
 lute will, and, when you have their confidence, some 
 earnestly given moral advice, will be the most they 
 will require. Let us put these aside, and we arrive 
 at the classes with an allusion to which I began this 
 lesson. They are the old and habitually bed-ridden, or 
 couch-loving invalids, who are to-day, as they have 
 long been, the despair of the best of us. What shall 
 we do with them ? 
 
 For practical purposes we may divide them coarsely 
 into two sets — first, the nervous and hysterical woman, 
 who is at the same time fat, but, as a rule, anaemic. The 
 class is not a large one, nor is its anasmia very pro- 
 found. As a rule, there is a look about the fatness 
 of these women which is anything but reassuring. 
 They are more or less feeble, not large feeders, and 
 prone to suffer from excessive tire upon dispropor- 
 tionate exertion. I have elsewhere discussed 1 at length 
 the probability of there being chemical differences 
 between the fat of these and of more healthy people. 
 
 1 Fat and Blood. J. B. Lippincott & Co., 1877. 
 
TREATMENT BY SECLUSION, REST, ETC. 221 
 
 There is muscle and muscle, fat and fat, and it is now 
 become more and more sure that these mysterious 
 variations in the quality of tissues, however little we 
 may know of their chemistry, are such important fac- 
 tors in health that we cannot at all afford to disregard 
 them. I say all this, because, when you meet with 
 women who are at once very stout, and not too nota- 
 bly anemic, you may be disposed to regard them too 
 lightly as free from suspicion of any such grave nutri- 
 tive disorders as may seem to offer reasonable expla- 
 nation of their nervous symptoms. Those who are 
 very plainly pallid and flabby, fat and feeble, will, I 
 may here say, offer, like the rest of their class, a 
 problem not always very easy to solve. We shall, 
 by and by, consider how they are to be dealt with. 
 
 There remains, in the second place, the larger class 
 of nervous, and exhausted, and hysterical women who 
 are, as a rule, weak, pallid, flabby, disfigured by acne 5 
 or at least with rough and coarse skins ; poor eaters ; 
 digesting ill ; incapable of exercise, and suffering from 
 the cold extremities which lack of this, with thin 
 blood, occasions. They lie in bed, or on sofas, hope- 
 less and helpless, and exhibit every conceivable va- 
 riety of hysteria, 
 
 It has been for some years my custom, when in 
 these women every other plan has failed, to deal with 
 them by a certain combination of therapeutic means 
 which has now been securely tested by time and hun- 
 dreds of successes. It has stood the criticism and 
 won the approval of many competent physicians, who 
 have found in it a resource where all else had failed. 
 
 19* 
 
222 DISEASES OP THE NERVOUS SYSTEM. 
 
 As it is now seven years since I first published 1 a 
 formal statement of this method, it seems to me that 
 the time has come when I should say in what respect 
 my opinions have been altered or confirmed, and what 
 changes I would desire to suggest. I shall, therefore, 
 give here a condensed statement of the treatment in 
 question, and referring to my former publications for 
 minute details, shall criticize it in the light of what, 
 without want of modest statement, I may venture to 
 call an enormous experience. 
 
 The treatment to which in these pages I so many 
 times refer, consists in an effort to lift the health of 
 patients to a higher plane by the use of seclusion, 
 which cuts off excitement and foolish sympathy; by 
 rest, so complete as to exclude all causes of tire; by 
 massage, which substitutes passive exercise for exer- 
 tion ; and hy electrical muscular excitation, which 
 acts in a somewhat similar manner to massage, and with 
 it by depriving rest in bed of its essential evils, leaves 
 only its good. These means enable us to over-feed 
 our patients, and to enable them to digest with ease 
 large amounts of food. 
 
 I have here put first the idea of seclusion. That 
 means separation from indulgent friends and sympa- 
 thetic relatives. It is a change in the interest of 
 every one concerned, because a chronic invalid is a 
 slow poison in a household of loving people. It 
 means, too, the breaking up of old habits; and it 
 means, usually, a change of diet and personal sur- 
 
 1 Rest in the Treatment of Disease. Seguin series of Lectures. 
 Appleton & Co., New York. Fat and Blood, 1877. 
 
TREATMENT BY SECLUSION, REST, ETC. 223 
 
 rou ridings, because seclusion is not often to be at- 
 tained at home. For nervous or hysterical people it 
 must be absolute; for merely feeble people, who re- 
 tain the power of self-control, and who are to be put 
 at rest, it admits of every degree of liberality. We 
 should remember, however, that even if a woman be 
 only a tired and weak invalid, and not a very nervous 
 one, she must, owing to the necessities of the treat- 
 ment, see daily the masseuse, the electrician, the 
 nurse, and the physician, so that to admit other 
 visitors is to make a needless call upon her growing 
 strength, which in these cases is sorely taxed by con- 
 versation. I do not say that seclusion is impossible 
 in the home of the invalid, for I have obtained it with 
 success many times, when my nurse was a thoroughly 
 good one ; but the other plan of securing it by a 
 change of dwelling is better and far easier. Seclusion, 
 of course, has for its objects the cutting off of many 
 hurtful influences; but, above all, it means the power 
 of separating the invalid from some willing slave, a 
 mother or a sister, whose serfdom, as usual, degrades 
 and destroys the despot, while it ruins the slave. Like 
 all rules, this latter one of isolation from habitual per- 
 sonal relations, has its exceptions. I have had cases 
 nursed successfully by a mother or a sister, but I 
 never wish to make the experiment, because it inevi- 
 tably makes heavier the doctor's task, and because it 
 is nearly always an experiment. Get your patient 
 alone with a good nurse, with some woman who is 
 trained, intelligent, young, and clever enough to read 
 aloud, and with culture enough to make her an agree- 
 able companion. Ten years ago there were no such 
 
224 DISEASES OF THE NERVOUS SYSTEM. 
 
 nurses; to-day there are enough of them; but in 
 choosing a nurse, remember that if she has no tact, 
 or has a short temper, or is clumsy, or un-neat, you 
 may have your case spoiled, or be forced to change 
 the nurse midway in your treatment; but, at all 
 events, never hesitate about this. If the patient and 
 nurse do not agree, make a change, and, if need be, 
 another. I cannot enough emphasize this matter of 
 the nurse. Put yourself in the place of an intelligent 
 lady shut up for two months with a coarse woman, 
 whose talk and whose habits disgust, and doubly dis- 
 gust, because the victim is emotional and sensitive 
 by nature and by habit, and you will realize the need 
 for care in your choice of an attendant. Mere technical 
 training will not answer, and I have seen an utterly 
 untrained woman, of good brains and tact, win suc- 
 cesses which are sometimes denied to the best edu- 
 cated nurses who lacked those ever-needed moral 
 qualities which no training and no length of expe- 
 rience will give to some women. 
 
 And now, having your patient isolated and the 
 nurse in charge, certain grave questions arise. We 
 will presume that the case has been found to be suit- 
 able, and that the patient has come within your own 
 control — whether at her home or elsewhere — that her 
 case is new to you, and that you have decided to use 
 rest. The first question you will have to settle is as 
 to whether it be wise when using this treatment to 
 correct all womb troubles at once, or to wait, or to 
 neglect them altogether ? I am guided as to these 
 matters by the following rules : In the case of mar- 
 ried women, I make or cause to be made a thorough 
 
TREATMENT BY SECLUSTON, REST, ETC. 225 
 
 examination to begin with. If there be only conges- 
 tive states and their consequences, I trust to the 
 general treatment for cure. If there be marked dis- 
 placements or excessive menstruation I like to correct 
 the one and have the uterus well searched for possible 
 causes of the other. Should there be grave fissures 
 of the neck of the womb or perineal rupture I prefer 
 to have these relieved at once if the patient be in a 
 moderately good state, but if the case be one of ex- 
 treme feebleness I prefer to delay all surgical inter- 
 vention until the improved conditions which follow 
 my treatment offer a better chance of successful 
 mechanical interference. If the patient be a virgin, 
 and there seems little reason to suspect misplace- 
 ments, I trust again to the general treatment. If, 
 moreover, there be plain evidence of misplacement, 
 and the patient be of that temperament which makes 
 vaginal examinations disastrous shocks to the nervous 
 system, I wait patiently the result of the rest and its 
 aids. Then at the close of two months I like to make 
 an effort at local relief, in the hope that with a rein- 
 forced nutritive life my patient may bear the strain. 
 Dr. Goodell will remember cases, seen with me, in 
 which the patient, having retroversion, decided to 
 undergo no mechanical treatment, and has seemingly 
 become and remained well, under rest, etc., despite 
 the uterine trouble. 
 
 Misplaced ovaries cause in my experience a great 
 deal of trouble, but both Prof. Goodell and I have seen 
 a number of cases in which this annoying complica- 
 tion righted itself spontaneously during treatment by 
 rest. In one of these cases, the misplacement was so 
 
226 DISEASES OF THE NERVOUS SYSTEM. 
 
 extreme and the symptoms caused by it so grave that 
 the propriety of double ovariotomy was more than 
 once discussed. We were pleasurably surprised as the 
 treatment progressed to find a gradual slipping up- 
 wards of the ovaries until at last they regained their 
 usual place. This change accompanied a remarkable 
 gain in vigor and in flesh. I have never yet been 
 able to make clear to myself precisely why under 
 these circumstances the ovaries should be drawn up, 
 but Prof. Goodell's opinion in a matter of this kind 
 must be far better than mine, and as he thinks there 
 is a competent physical explanation, I give his re- 
 marks in full : " The ovaries should be daily re- 
 placed by atmospheric pressure, the knee-breast pos- 
 ture, and the result is that they finally go up to stay 
 up. Under the influence of the general gain in 
 health, and the local handling of the masseuse, the 
 organs cease to be congested. Then the increased 
 deposit of fat in the abdominal walls, in the omental 
 apron, and around the viscera, to say nothing of the 
 needful fat-padding in all the pelvic nooks and cran- 
 nies, increases the retentive power of the abdomen." 1 
 
 " By its gravity the now fat-laden and overhang- 
 ing wall of the abdomen tends to draw toward itself, 
 that is to say upward, the movable AYall of the pelvis. 
 The behavior is like that of a half- filled India-rubber 
 ball, in which bulging at one portion causes a corre- 
 sponding cupping at another." 
 
 You are now ready to put your patient at rest in 
 bed, and you will not, I trust, despise any details which 
 
 1 Lesons on Gynaecology, Groodell, p. 116. 
 
TREATMENT BY SECLUSION, REST, ETC. 227 
 
 will make rest endurable and useful. You cannot 
 always get, but you can desire to get, sunshine, an 
 open fireplace, a well-made bed, and a lounge for 
 change. 
 
 Rest means with me a good deal more than merely 
 saying " Go to bed and stay there." It means care 
 that letters bring no worrying news, that they are 
 brief and of such kind as a nurse may read aloud. It 
 means absence of all possible nse of brain and body. 
 It means neither reading nor writing;, at least for a 
 time, with exceptions in cases where, as is rare, there 
 is no asthenopia. If the nurse can read to the patient, 
 and reading be borne without fatigue, let it be used at 
 first for only a few minutes at a time. If this wearies, 
 then let the nurse try to cull the bits of interesting 
 news from the papers, and as she glances over the 
 columns talk this to the patient in place of formally 
 reading aloud. Why this tires less than reading I do 
 not know, but that it does so I am sure. If you are 
 disposed to smile because I say let the nurse feed the 
 patient, you will not, if, lying supine, you make the 
 experiment of using your own hands in this act of 
 feeding. Or even if seated in bed you do this, you 
 will find that the effort is singularly tiresome. I be- 
 lieve I have done something to make rest fashion- 
 able among physicians as an essential in the treat- 
 ment of spinal maladies, and both in them and in 
 the treatment of neurasthenia and hysteria it is well 
 that you clearly comprehend what it is that I mean 
 by rest. Your trouble will be always that the pa- 
 tient will desire to lie on a sofa, or to make some 
 such compromise, but in bad cases, and it is only of 
 
228 DISEASES OF THE NERVOUS SYSTEM. 
 
 these I speak, all this is but mere trifling, and you had 
 better, on the whole, make an error in the direction 
 of a too absolute rest. 
 
 The moral uses of enforced rest are readily esti- 
 mated. From a restless life of irregular hours, from 
 hurtful sympathy and over-zealous care, the patient 
 passes into an atmosphere of quiet, of orderly control, 
 and under the care of a thorough nurse. The result 
 is always at first, whatever it may be afterwards, a 
 sense of relief, and a remarkable and often a quite 
 abrupt disappearance of many of the nervous symp- 
 toms which had previously harassed the patient. 
 With this first sense of ease comes the precious chance 
 of the doctor for moral medication. He can now point 
 out that, however hard it was with failing powers to 
 control emotion and suppress nervousness, it is easy 
 to do all this when the physical condition is improv- 
 ing. This doctrine will be aided and enforced by the 
 nurse if a good one, and your patient will be con- 
 stantly reminded that she is getting better physically, 
 and is expected to accomplish more and more in the 
 way of self-restraint. If she fails you praise the 
 effort. If she succeeds you applaud the success. You 
 are her whole audience, and this with an hysterical girl 
 gives you great power. Why rest is of therapeutic 
 value I have elsewhere more fully shown. It is of 
 more use here to urge that, like all medication, it has 
 its evil side, and that it is to the other parts of this 
 system we must look for the means of overcoming and 
 counteracting them. Ordinarily prolonged rest en- 
 feebles circulation, weakens digestion, lessens appetite, 
 and constipates the bowels. The active muscles are 
 
TREATMENT BY SECLUSION, REST, ETC. 229 
 
 every one of them pumps, which subject the local 
 blood circuits to sudden flushing, and the heart in a 
 person at rest loses twenty beats a minute, and thus 
 adds to the passive mischief. Moreover, the liver and 
 the double abdominal circulation, and the moving 
 bowels cease to have the constant stimulation which 
 they get when we are afoot, and so in many ways 
 damage is done. Rest, then, is, or may be, hurtful. 
 We turn to massage and electricity for aid in correct- 
 ing this. Massage, or kneading of the muscles, has 
 been long used in Europe and the East. It is the 
 "shampooing" of the oriental, the "lammi lammi" of 
 the Sandwich Islander. I do not know that it has been 
 used except by me as a systematic daily mechanical 
 tonic. For details of just how it ought to be done, 
 and with what caution, and how long and what are 
 the immediate physiological effects, I must again refer 
 to my book, on Fat and Blood. Used daily, half an 
 hour to an hour, it is a pleasant and refreshing process, 
 and even when, as does happen, it seems at first to 
 tire, all of this result, soon or late, passes away. 
 
 It substitutes exercise for exertion, and does nearly 
 all that a moderate amount of active muscular motion 
 can do in the way of warming the limbs, increasing 
 the blood-flow, stimulating the local circulations, and 
 reddening the skin. It may, and should, at last, be a 
 pretty violent influence, and, by and by, may be used 
 in such a way as to jog the intestines like the invalu- 
 able shaking given by a rough trotting horse. To be 
 thoroughly done it needs a trained masseuse, but any 
 clever person, who is strong enough, may easily 
 learn to do it; and it enables one daily to rub into 
 20 
 
230 DISEASES OF THE NERVOUS SYSTEM. 
 
 the skin a large amount of some nourishing oil, like 
 that of the olive or the cocoanut. I never could see 
 why a tonic so valuable as this should be left to assist 
 the triumphs of the charlatan ; and I feel that, in 
 making it of easy use, I have clone that which, in 
 many ways, is valuable to the surgeon and the phy- 
 sician. You will meet with some difficulty in having 
 the back kneaded when there is spinal irritation, but 
 as to this you must be relentless ; and the masseuse, 
 by degrees approaching the sore spots, will in time 
 come to treat them as thoroughly as any other part, 
 and with the sure result of, by and by, lessening and 
 destroying the local sensitiveness. In like manner 
 the hyperesthesias of other regions may be dealt 
 with, and, above all, that which is sometimes a truly 
 ovarian, and sometimes merely an abdominal surface 
 sensitiveness, may, with time and cautious patience, 
 be relieved or cured. 
 
 Massage is, in these cases, absolutely essential : elec- 
 tricity is very desirable ; but we can, in many cases, 
 do without it. 
 
 It involves the daily use of induction currents (slow 
 interruptions) to almost every muscle which can be 
 reached ; the object being to throw each muscle into 
 decided contraction. Finally, a mild current with 
 rapid breaks of current is made to pass from the neck 
 to the feet for fifteen minutes. That it is, thus used, 
 a powerful tonic I have not the faintest doubt, and I 
 commonly use it with massage, except where the need 
 to save expense is of moment. 
 
 These means are employed to prevent rest from 
 being hurtful, and to enable us to fatten and redden 
 
TREATMENT BY SECLUSION, REST, ETC. 231 
 
 the patient by a methodical system of over-feeding, 
 with the use of proper tonics. I have already said that 
 there is some trouble in treating fat and anaemic wo- 
 men. You may cure them by ordinary means, but it is 
 easiest and safest to do so by putting them at rest, and 
 under-feeding with milk, so as, at first, materially to 
 reduce the flesh, after which the patient may be sub- 
 jected to the usual treatment by massage and the 
 other means I have detailed. It is easy, with perfect 
 security, to lessen the fat rapidly, if only the patient 
 be kept in bed ; otherwise, as we have too well known, 
 it is a dangerous and difficult thing to effect. I may 
 add that if there is much, or a very obstinate dyspep- 
 sia, it is well to begin the treatment of any case by 
 Card's milk treatment. It is astonishing how this 
 simplifies matters, and how under milk, massage, and 
 rest the whole train of nervous ills melts away in a 
 few days ; and how we are able to dispense with 
 chloral and morphia, or habitual use of other drugs. 
 Indeed I may add that I should be sorry, now-a-daj^s, 
 to treat any old case of the opium habit without these 
 invaluable aids. 1 
 
 In fact, if I have the least doubt, I never fail to 
 begin in any case of treatment by rest, with milk as 
 the sole diet ; while, of course, there are also many 
 cases where it is used only as an adjuvant, and I 
 simply feed the patient in the ordinary manner. By 
 some such plan the patient has the diet gradually 
 increased, until it is common to see her take three 
 meals as well as two quarts of milk, six to nine ounces 
 
 1 Am. Jour. Med. Sci., Oct. 1866. 
 
232 DISEASES OF THE NERVOUS SYSTEM. 
 
 of Hoff's fluid malt, and a variable amount of raw 
 soup between meals and at bedtime. 
 
 Iron in large doses, alcohol rarely, and cod-liver oil, 
 by the mouth or rectum, when well borne, are to be 
 added as indicated. 
 
 The result of two months of such treatment, in 
 pale, bloodless, meagre, and nervous women, must be 
 seen to be believed or duly appreciated. You have 
 seen it here often enough to fully understand me. 
 Each and all of the means described are to be slowly 
 and by degrees laid aside, and then you have as care- 
 fully to get your patient up and afoot. Of late I 
 have been in the habit of preparing for this by allow- 
 ing the nurse or masseuse to exercise the patient, 
 while in bed, with a series of slowly- executed Swed- 
 ish gymnastics, which are continued in a modified 
 form, when the patient gets up. If this be well and 
 pleasantly managed, it is both agreeable to the patient 
 and a valuable means of training the muscles. 
 
 The final results of all this treatment when it suc- 
 ceeds are to reasonably increase the bulk of the body, 
 to improve the moral and physical tone, and to cure 
 the anasmia. These changes are obvious in some de- 
 gree early in the case, the flesh shows first in the face, 
 and the gain in blood in the pink of the finger-nail, 
 which I am apt to watch and note. I have been many 
 times asked if these amendments or cures are per- 
 manent, and I believe I am now, after a careful re- 
 view of some hundreds of cases, fully able to say that 
 they are quite as lasting as the cures of any nutritive 
 defects obtained in more ordinary ways. It is a plan 
 never to be used where exercise, outdoor life, tonics, 
 
TREATMENT BY SECLUSION, REST, ETC. 233 
 
 or change have not been thoroughly tested ; but where 
 these have failed it leaves us with a novel resource 
 without which no case of broken constitution, nerv- 
 ousness, or old hysteria should be left to hopeless 
 invalidism, and to a life in bed, or on a lounge. I 
 never use it if I can do without it ; but in well-chosen 
 cases I use it, with a confidence which has become 
 alike courageous and habitual. 
 
 20* 
 
INDEX 
 
 ABDOMEN, chronic spasm of 
 walls of, 115 
 Abdominal muscles, spasm of, 
 
 101, 115 
 Alternatinghysterical spasms, 37 
 Analgesia, transfer of, in hemi- 
 plegia, 24 
 Ankle clonus in hysteric hemi- 
 plegia, 23 
 Anorexia, hysterical, 205 
 Anstie on mimicry of disease, 59 
 Aphonia, Cohen on, 193 
 
 from incoordination, 196 
 hysterical, 191 
 forms of, 194 
 treatment of, 198 
 Apsithuria, 197 
 Ashe on chorea in negro, 142 
 Athetosis, hysterical, 102 
 
 simulated, 102 
 Atropia in chronic spasms, 117 
 Aura in sensory shock, 154 
 
 BEMISS on chorea in negro, 
 143 
 Briquet and Lasegue on hysteri- 
 cal motor ataxia, 34, 37 
 on hysteric hemiplegia, 22 
 Buzzard on hysterical hemi- 
 plegia, 23 
 
 CABELL on chorea in negro, 
 142 
 Calf, chronic spasms of, 11 5 
 Card's milk cure, 231 
 Cases — 
 
 alternating spasms, 37 
 
 Cases — 
 
 cerehro-spinal meningitis, 
 
 simulated, 68 
 double hemiplegia, 25, 30 
 habit chorea, 148, 149 
 hysterical anorexia, 206, 
 209 
 aphonia, 191 
 hemiplegia, 23 
 motor ataxia, 38 
 
 with hemiplegia, 43 
 paralysis, 13 
 paraplegia, 16 
 paresis, 46 
 spasms, 91, 99 
 imagined disease, 61 
 imitated epilepsy, 64 
 mimicked disease, 69, 71, 
 
 72, 73 
 neuralgia from imagination, 
 
 59 
 nocturnal hemiplegia, 171, 
 
 172 
 ptosis, spasmodic, 124 
 sensory shock, 153, 158, 
 160, 161, 162, 163, 164, 
 167, 169 
 simulated athetosis, 102, 104 
 disease, 65, 75, 80, 82, 
 84 
 spasms, chronic, 118 
 
 simulated, 120 
 on rising, 96 
 tremor, alcoholic, 113 
 hysteric, 107 
 localized, 111 
 neryous, 110 
 Charcot on hysterical hemi- 
 plegia. 23 
 
236 
 
 INDEX 
 
 140 
 
 Chorea, deaths from, in Phila- 
 delphia, 141 
 Ellis on, 140 
 explanation of tables of, 130, 
 
 131 
 Finley on, 138, 142 
 Gerhard on, 128, 129 
 Hirsch on, 138 
 in cities, 139 
 in country, 139 
 in Lisbon, 139 
 in negro, 142 
 
 Ashe on, 142 
 
 Beniiss on, 143 
 
 Cabell on, 142 
 
 Edwards on, 144 
 
 Geddings on, 143 
 
 Kollock on, 142 
 
 Lee on, 142 
 
 Michel on, 143 
 
 Porch er on, 143 
 in southern latitudes, 139 
 Landetta and Decastro on, 
 
 138, 142 
 Lewis on, 129 
 occurrence of, 136 
 of childhood, 127 
 relation of, to barometer, 
 213 
 
 to climate, 138 
 
 to mean relative hu- 
 midity, 132 
 
 to mental labor, 135 
 
 to moisture with cold, 
 132 
 
 to race, 141 
 
 to rain-fall, 133 
 
 to season, 128 
 
 to storms, 134 
 
 to temperature, 132 
 Rufz on, 138 
 
 season of maximum of at- 
 tacks of, 132 
 See on recurrence of, 136 
 varieties of, 145 
 Von Ziemssen on, 138 
 Cohen on aphonia, 193 
 
 | Color sense in hysteric hemi- 
 plegia, 23 
 Crutches for motor ataxia, 42, 43 
 
 DEFECATION in hysteria, 213 
 Disturbance of sensation in 
 hysteric hemiplegia, 22 
 Double hemiplegia, hysterical, 25 
 Duchenne on hystero-palsies, 32 
 Dysphagia, hysterical, 202 
 
 EDWARDS on chorea in negro, 
 144 
 Electricity, faradic, 230 
 Electric reactions in hystero- 
 palsies, 32 
 Ellis on chorea, 140 
 Exhaustion, nervous, treatment 
 of, 217 
 
 FAT, excessive, treatment of, 
 231 
 Finley on chorea, 138, 142 
 Flushing, unilateral, in hysteria, 
 
 184 
 Forms of crutches for motor 
 ataxia, 42, 43 
 
 GASTROCNEMIUS, spasm of, 
 101, 102, 115 
 Geddings on chorea in negro, 143 
 Gerhard on chorea, 128, 129, 137 
 Goodell on displaced ovaries, 
 
 225, 226 
 Gymnastics, Swedish, 232 
 
 HABIT chorea, 146 
 symptoms of, 147 
 treatment of, 149 
 Hammond, Dr. Wm. A., 102 
 Hemiplegia, hysterical, 20 
 ankle clonus in, 23 
 Briquet on, 22 
 Buzzard on, 23 
 Charcot on, 23 
 
INDEX 
 
 237 
 
 Hemiplegin, hysterical — 
 color sense in, 23 
 disturbance of sensation 
 
 in, 22 
 ovarian tenderness, 23 
 patellar reflex in, 23 
 peculiarities of, 22 
 nocturnal, 171 
 Hirscli on chorea, 138 
 Hysteria, defecation in, 213 
 forms of, 219 
 gastro-intestinal disorders 
 
 of, 201 
 irregularities of pulse in, 178 
 Mills on, 201 
 paralyses of, 13 
 paresis of vessels in, 184 
 pulse in, 175, 178 
 respiration in, 188, 189 
 treatment of, 217 
 vasal disorders in, 181, 184, 
 
 185, 186 
 with defective nutrition, 48 
 Hysterical spasms, 91 
 
 alternating, 37 
 Hys tero-epilepsies, rarity of, in 
 
 America, 201 
 Hvstero-palsies, sudden cures 
 of, 29 
 
 "IMAGINED diseases, 61 
 1 Imitated paresis, 59 
 Ischremia, cutaneous, 182 
 
 in hysterical paralysis, 
 181 
 
 K 
 
 EEN, Dr. W. W., 102 
 
 Kollock on chorea, 142 
 
 IACK of coordination in hys- 
 J terical motor ataxia, 35, 36 
 Landetta and Decastro on chorea, 
 
 138, 142 
 Larynx, hysterical spasm of, 199 
 Lee on chorea in negro, 142 
 Levis, nerve section, 183 
 
 Lewis on chorea, 129, 137 
 Lisbon, chorea in, 139 
 
 MALARIA, relation of, to 
 chorea, 140 
 Massage, uses of, 229, 230 
 "Metal cure" in hysterical 
 
 hemiplegia, 24 
 Michel on chorea in negro, 143 
 Milk, treatment by, 231 
 Mills on hysteria, 201 
 Mimicked disease at Church 
 
 Home, epidemic of, 69 
 Mimicked disease, causes of, 51 
 automatic imitation, 57 
 general nervousness, 52 
 hysteria, 53 
 lowered health, 53 
 mental influence, 54 
 nervous temperament, 
 
 52 
 physical peculiarities, 
 
 53 
 sympathy, 57 
 Mimicry of disease, 50, 75 
 Morehouse, Dr. George R., 102 
 Motor ataxia, hysterical, 34, 38 
 
 two forms of, 34 
 Mustard- plaster in hysterical 
 hemiplegia, 24 
 
 NEGRO, chorea in, 142 
 Nervousness, general, 52 
 Niedit-teiTors, 166 
 
 OVARIES, displacement of, 
 225, 226 
 tenderness in region of, in 
 paraplegia, 18 
 
 PAGET on mimicry of disease, 
 50 
 Paralyses of hysteria, 13 
 Paralysis, infantile, relation to 
 temperature of, 136 
 Sinkler on, 136 
 
238 
 
 INDEX. 
 
 Paraplegia, hysterical, 16 
 Paresis, hysterical, 45 
 
 of vessels in hysteria, 1 84 
 Pectoralis major, spasm of, 100 
 Philadelphia, deaths from 
 
 chorea in, 141 
 Porcher on chorea in negro, 143 
 Ptosis, spasmodic, 123 
 Pulse in hysteria, 175, 178 
 
 RAGE, relations of, to chorea, 
 141 
 Respiration, failure of, in sleep, 
 172 
 in hysteria, 188, 189 
 rapid, 190 
 
 treatment of failure of, 173 
 Respiratory disorders, 174 
 Rest, treatment hy, 227 
 Reynolds on mimicry of disease, 
 
 50, 59 
 Rhigolene freezing in hysterical 
 
 hemiplegia, 24 
 Rufz on chorea, 138 
 
 S CHAFFER on mimicry of dis- 
 ease, 50 
 Seclusion in hysteria, 222 
 See on chorea, 136 
 Sensation in middle line in 
 
 double hemiplegia, 28 
 Shock, auditory, 157 
 olfactory, 157 
 
 sensory, clinical relations 
 of, 166 
 treatment of, 168 
 visual, 157 
 Simulated disease, patients' de- 
 scriptions of, 82, 85, 87 
 treatment of, 78, 81 
 Skey on mimicry of disease, 50 
 Sleep, disorders of, 153 
 Spasmodic affections, unusual 
 
 forms of, 90 
 Spasms, chronic, 114 
 
 atropia in, 117 
 duration of, 116 
 from nerve injuries, 114 
 mimicked, 122 
 
 Spasms, chronic — 
 
 of abdomen, 115 
 of calf of leg, 115 
 of hysteria, 115 
 of leg and thigh, 116 
 power of, 117 
 simulated, 120 
 traumatic, 121 
 treatment of, 1 19 
 functional, resemble chorea, 
 
 98 
 hysterical, 91 
 
 alternating, 37 
 local (see Tumors, phan- 
 tom), 
 rotatory, 92 
 Strychnia, necessity for rest 
 when using, 94 
 
 TENDERNESS, ovarian, in 
 paraplegia, 18 
 Tendon reflex, patellar, in hys- 
 teric hemiplegia, 23 
 Treatment of double hemiplegia, 
 29 
 of hysteria with defective 
 nutrition, 48 
 Tremor, alcoholic, 113 
 forms of, 106 
 hysteric, 106 
 _ nervous (see Nervousness, 
 general), 52 
 organic, forms of, 109 
 Tumors, phantom, of abdomen, 
 
 101, 115 
 
 of gastrocnemius, 101, 
 
 102, 115 
 
 of great pectoral muscle, 
 100 
 
 UTERUS, treatment of, in hys- 
 teria, 225 
 
 VASO-MOTOR disorders, 174 
 cold feet in, 181 
 of skin in hysteria, 184 
 Vomiting, hysterical, 203 
 Von Ziemssen on chorea, 138 
 
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