THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES CLINICAL LESSONS T^ERVOUS DISEASES BY S. WEIR MITCHELL, M.D., LL.D. Edin. MEMBER OF THE NATIONAL ACADEMY OF SCIENCES ; HONORARY FELLOW OF THE ROYAL MEDICO-CHIRURGICAL SOCIETY OF LONDON LEA BROTHERS & CO. PHILADELPHIA AND NEW YOEK 1897 Entered according to the Act of Congress, in the year 1897, by LEA BEOTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. DORNAN TRINTKR. lOO PREFACE I TAKE this opportunity to thank my clinical aids, Drs. John Madison Taylor, C. W. Burr, Guy Hinsdale, John K. Mitchell, John H. Rhein, F. S. Pearce, A. A. Eschner, and F. W. Talley for the careful personal study given to the cases in this little book and for whatever consequent value they may have. I am also indehied to Dr. John Madison Taylor for the representations of erythromelalgia and for the other illustrative drawings. S. AY. M. erT5[v98 CONTENTS CHAPTER I. PAGE Hysteria: Psychic Anresthesia for Touch ; Psychic Anosmia; Psychic Blindness . . . . . . . .13 CHAPTER II. Recurrent Melancholia: Seasonal Melancholia; Melancholia arising out of Menstruation ; Inter-menstrual Melan- cholia ; Melancholia arising out of Dreams or Originating in the Post-dormitium ; Melancholia during Digestion . 25 CHAPTER III. Irregularly Recurrent Melancholia with Short Intervals and not in Apparent Relation to Function .... 53 CHAPTER IV. Some Disorders of Sleep ....... 58 CHAPTER V. Choreoid Movements in an Adult Male, probahly of Hysteri- cal Origin ; Unusual Hysterical Movements in a Child ; Hysterical Myoclonus 94 CHAPTER VI. Subjective False Sensations of Cold 107 VI CONTENTS. CHAPTER Vir. PAGE Motor Ataxia in a Child of Three Years, with Retained Muscle-reflexes ; Pernicious Anaemia, with Locomotor Ataxia and Hysteria . . . . . . .125 CHAPTER VIII. Post-hemiplegic Pain ; Prse-hemiplegic pain ; Post-hemiplegic Disease of Joints ; Post-hemiplegic Xodes . . . 145 CHAPTER IX. The Treatment of Sciatica . . . . .154 CHAPTER X. Erythromelalgia: Red Xeuralgia of the Extremities ; Vaso- motor Paralysis of the Extremities; Terminal Xeuritis . 177 CHAPTER XI. Xotes on Surface-temperatures as Affected by Posture of Limbs 205 CHAPTER XII. Three Cases of Remarkable Spinal Anterior Curvature with Mental Aberration . . . . . .210 CHAPTER XIII. Concerning the History of the Discovery of Reflex Ocular Neuroses, and the Extent to which these Reflexes Obtain 220 CHAPTER XIV. Wrong Reference of Sensations of Pain . . . . .231 CONTENTS. yii CHAPTER XV. PAGE Pseiictocyesis ; Spurious Pregnancy ... . . 236 CHAPTEE XVI. Hysterical Contractures . . 242 CHAPTER XVII. Hysterical Contractures [Continued) • • . . 275 CHAPTER XVIII. Rotatory Movements in the Feeble-minded .... 290 ERRATUM Page 53, in chapter heading, /o/- '' mehincholia with long inter- vals," read " melancholia with short intervals." CLINICAL LESSONS ON NERVOUS DISEASES. CHAPTER I. HYSTEEIA: PSYCHIC ANESTHESIA FOR TOUCH; PSYCHIC ANOSMIA; PSYCHIC BLINDNESS. In beginning this record of the lessons given at my clinic I may mention that this service is here carried on by the visiting physicians Avith the aid of the junior staff. Notwithstanding the small size of the hospital, the ward and oat-services have given the material for such activity of clinical study as few larger hospitals can show. The work thus done includes Morris Lewis's well- known examination with me of the Seasonal Relations of Chorea; a like essay on the Summer Prevalence of the Palsies of Childhood, by Sinkler; Osier's work on the Spastic Palsies; Eshner's excellent essay on Tremors; J. K. MitchelPs volume on Remote Con- sequences of ^NTerve Lesions ; Hinsdale on Station in Health and Disease, and many papers, by the author and others, too numerous for more than allusive men- 2 1 4 NER VO US DISEA SES. tion. Still more valuable is it that here have been proved the availability of the so-called rest-treatment in open wards, and the possibility of thus giving to the poor what is commonly believed to be attainable only by the richer classes. I feel glad to say, indeed, that while the papers named, and a host of others, illustrate the careful scien- tific use made of our wards and laboratory, we do not forget that the first object of our wards is the cure of disease/ Certain of these lessons, therefore, will not deal alone with the many singular cases which are likely to come before us, but also with therapeutic methods in use here before they were thought possible in hospitals, or that, as I think, are better applied and better known within these walls than outside of them. The first case I ask you to look at to-day is from Scott Ward. Watch her as she enters. Her self-con- scious, fixed facies will, or should, strike you. Xute her ways. At one moment she seems blind ; at the next, she moves with swift ease. Her case is full of these oppositions. I read it, and all of it, now, before her, as she is exceedingly intelligent, and will set us right if we err. Dr. Pershing, of Denver, has greatly helped us as to the early history, and saw with clearness of medical judgment into the true nature of this un- usually instructive case, which, owing to its changeful features, has greatly puzzled me. I have now reached conclusions which carry my comprehension of it up to a point beyond which the case itself does not suffici- ently yield clinical material for a further advance. I In the report for 1895 is a list of papers produced by the statf and assist- 3.nts. HYSTERIA. 15 Case I. — B. L., a woman, aged forty-two years, mar- ried, applied for treatment October, 1892, complaining of blindness. Family history. Her mother's father was paralyzed. One of her mother's brothers had hydrocephalus, and was epileptic and blind for a year and a half before his death from typhoid fever when twenty-seven years old. Her father died of pulmonary tuberculosis. One sister died of some spinal disease, said to have been caused by a fall three and a half years previously. Personal history. The patient has two living healthy children ; two others died. She has had five abortions. She does not use alcohol. There is no evidence of syphilis. Nor has she had any serious illness except typhoid fever at the age of fourteen years. For many years the woman has been greatly troubled by family matters, and especially in consequence of a child's death. The present disorder began in 1887. Soon after a mis- carriage she found that it was becoming difficult for her to recognize large objects, while small ones could be seen easily. In reading she was compelled at last to spell each word, because she could see only one letter at a time. She was fitted with glasses, but no relief followed their use. As time passed, vision grew worse. As the form-fields nar- rowed she recognized persons, not by their faces, but by their clothing and general bearing. She could see a small piece of silk or a pin upon the floor, but could not recog- nize large objects. During the second year she lost, to a great degree, the power of recognizing colors. She could walk perfectly well, and avoided obstacles. During the third year she could still see small objects, but could not tell whether or not a house was completely built, or distinguish a man from a horse. In the fourth year she began to strike against objects in walking, and everything appeared dark. She 1 6 NEB VO US DISEASES. could distinguish between night and day, and even between a bright and a dim light. In December, 1891, she was examined and treated by Dr. Pershing, who has kindly furnished me the follow- ing additional notes: "She is sent to me as being per- fectly blind. Lately she has lost command of words and finds it difficult to carry on a conversation, because words do not come to her mind, and are not understood when heard, though she can readily repeat them after another person. Recently something was said about a dust-pan and brush. She repeated the words, but had no idea what they meant until she handled the objects, when the idea came back. She complains of inability to perform the simplest arithmetical operations (but this is inconstant), and also to recognize by touch familiar objects of dress, such as a belt. She consulted Dr. Starr and Dr. Roosa, of Xew York, in November, 1890. She could not name colors for Dr. Roosa, but a few days later sorted w^orsteds correctly for Dr. Charles H. Thomas, of Phila- delj^hia. " Status proesens. She recognizes the difference between light and darkness. She cannot count fingers or the win- dows in the room. The pupils are equal and each reacts to light falling only on the other eye. The ophthalmo- scopic appearances are normal. An interrupted galvanic current of one milliampere applied to either side of either eyeball gives a distinct subjective flash. The examination of the other special senses, in all their forms, general sen- sibility, motion, and the reflexes, shows nothing abnormal. She is not led, and in going out of a room finds the door- knob without feeling for it, though not always. She im- proved under treatment by massage, electricity, iron, quinine, and strychnine, and moral means. Just before leaving the hospital she told me that she had thought she was totally blind, l)ut she knew now that she could not HYSTERIA. 1 7 possibly have been so, because she was in the habit of doing many things for which sight was absokitely neces- sary. This statement was volunteered as the result of her OAvn reflection. After careful study of the case I was cer- tain it was hysterical." (The accompanying diagrams show the fields of vision taken by Dr. Pershing.) The improvement in her condition that took place while in Dr. Pershing's care soon disappeared under the stress of family trouble. Present state (October, 1892). The face, when at rest, is vacant and expressionless. The Avoman moves about the room with apparent ease, and rarely stumbles against an object. While her gait is not that of a blind person, it also is not that of one with normal vision. When any object is put before her eyes she says she cannot tell what it is. On being told to cross the room and sj^eak to a gen- tleman standing there, she goes in the proper direction, but is greatly surprised to find, on hearing the supposed man speak, that it is a woman. When a watch is given her and she is asked to tell what it is by touch, she fails. If, how- ever, it is put near enough to her ear for her to hear the ticking, she names it immediately. She fails to recognize a clothes-brush by touch, but when she hears me use it, says : "It is what you brush clothes with — a clothes-brush." The same is true of a nail-brush, except that she calls it a hair-brush. She cannot at first recognize a key by touch, but, on being told that it has to do with a door, says, rather doubtingly, "It is a door — door-knob," and then quickly corrects herself, saying, " No, it is a door- key." She fails entirely to recognize a knife by touch. On being given a pencil she calls it a penknife, and adds, "It is Avhat you write Avith," and does not seem to be aAA^are of her error. At one examination she was entirely unable to tell coins or cA^en to recognize that they Avere metal, but the next day she recognized a fiAX-cent piece 2^ HYSTERIA. 19 after considerable difficalty, and then quickly told quar- ters, halves, and dollars. She could not, however, distin- guish between a one-cent and a five-cent piece. A pen- holder, with pen attached, she calls a pen. A plate she names properly, but calls a tumbler first a plate, then a bowl, and finally a tumbler. A pin, a needle, a book, a pair of scissors, and a piece of paper she knows instantly by touch, but sometimes not at all. She says that a ball put in her hand is round, when asked its shape, and recog- nizes a piece of cardboard cut in the form of a circle. She calls a triangular card three-cornered, but all rectangular cards are to her square. An oval she sometimes calls square, sometimes round. After being told several times what an object put in her hands is, she remembers it and answers correctly several days later. The sense of contact is perfect. There is no anaesthesia. She immediately responds when touched, and can tell the point of a pin from the head, always answering properly '' dull " or " sharp." She cannot, however, localize sensa- tion, so as to name the fingers, but can put a finger cor- rectly on the place touched. The pain-sense is normal. The temperature-sense is normal. If salt or sugar be put upon the tongue, she names the former and says the latter is sweet like candy or sugar, and taste seems to be correct as to even more delicate flavors. Given benzine, cologne, alcohol, and oil of tur- pentine to smell she says she recognizes them as different, but cannot name them. She says they are unlike. She can write her initials and the first part of her surname fairly well, the latter part being a scrawl. She cannot, however, write any isolated letters except o and c. She describes the latter as o with a piece cut out. If her hand be guided in making letters, she still fails to recognize them. She cannot even write the letters of her name unless she begins at the beginning. 20 ^ER VO US DISEASES. What may be called spontaneous speech — I mean the speech of ordinary conversation — is at the present time normal, though she claims that formerly she misused words. For example, though she may not be able to name an object when given to her, yet if she wants it she will use the proper word in asking for it. Notwithstanding her claim that she has forgotten how to spell, she spells short words correctly. She also solves simple arith- metical 2:)roblems. She is nervous, depressed, and at times lachrymose. Dr. de Schweinitz has examined her eyes and reports as follows : " There is divergent squint in the right eye. The pupils are large, reacting slowly to light ; the right very sluggishly. The discs are grayish-red. The veins are full ; the arteries are small — the smaller in the right eye. There is lack of fixation, but the patient sees light in all direc- tions. The right eye open (the left closed) perceives ob- jects to the left of the median line and sometimes in the middle, but not to the right. The left eye open (the right closed) perceives objects to the left and in the median line, but not to the right. There is partial right lateral hemianopsia. Given cards to sort, she matches blue ones correctly, but confuses red and green and all others. It was impossible to take the color-fields." Remarks. A few preparatory words may make easier for you my after-explanations. AVe associate with known objects their possession of certain qualities of dimension, form, texture, color, etc. These objects are mentally classified- and labelled — a pencil, a box, a hat, and so on. AVhen we see or handle one of these objects, and find by sight or touch that it possesses a group of qualities, we must determine on the label, after swift comparison with the collected complex memories of things already seen or handled, or both. HYSTERIA. 21 It will help us to look at this problem in the most simple form. When we examine by sight or touch a familiar object, a single hint, as it were, may suffice, as the tick which suggests a watch. If the object be very novel, the examination as to the determinative proper- ties and their associations and degrees may be long and difficult. We store away these acquisitions for compari- son in certain cerebral centres, visual or tactile, or both. As regards olfaction, the questions the examinative sense, so to speak, can ask and answer are limited. Usually, as concerns the non-pungent odors, one single quality is perceived, and from it the individual reasons by comparison Avith past memories of scents, and de- clares the label lie is accustomed to assign to the odor in question. This is very simple, compared to the com- plexity of the properties by which visual and tactile recognitions are made. In persons who are ^' mind-blind/^ as Muuk called it, '^ the thing put before them is seen, but suggests no corresponding psychical idea.'^ Now what is here meant by being seen is one of two things, or both together. The thing seen may be present to the man as an image is to a mirror, for the mirror has no memory, and cannot compare the present with the past; or else it is meant that beside this the object so seen may present recognized qualities, but that the patient has no power to place these for comparison with those of other periods. In neither case can he label the object or say what use it has, although he may occasionally do this latter, even when he cannot name it. The object may be seen, its qualities compared with older memories, its nature or use be thus known, and yet the power to label it with the vocal sign we call a word be lost. 22 ^ER VO US DISEA SES. These sets of conditions are all seen in this case at times. Tluis, I blindfold the woman, and offer to her nose vinegar, cologne, asafoetida, valerian. She says they are different; does not take one for another. In other words, she does not say all alike are odors with- out difference; but a clear perception of the single quality so felt as different in each cannot be lodged in relation to former knowledge for comparison. Hence it has no distinctiveness and cannot be labelled. It is interesting to study this simple case, and then that of sight. Here the partial general blindness and the added hemianoptic imperfection complicate mat- ters, and these conditions vary from day to day. You will remember, also, that all color-sense is dead, except as to blue, and that the form-field is much con- tracted. Still, at times she can see the hands of a watch — not, however, so as to tell the hour. At her best moments she may appreciate qualities sufficiently to say that one thing is larger than another, but not so as to say that this is round or square. At these times she is able to distinguish one person from another, but never to label them until they speak. In her worse ocular states she cannot distinguish any form of qualitative difference. You will remember that Dr. Pershing de- scribes her as having been at one time word-deaf, as now she is word-blind. This trouble is better known and more often seen than the yet more curious form of defect as regards touch. Remember that she can tell heat, cold, touch, pain in all degrees. Occasionally she spontaneously describes a test-object; more often she does not, and yet is able, as the stated inquiries show, to answer cor- rectly all the queries competent to describe an object. HYSTERIA. 23 Very often the final question, What is it? she cannot answer; or else, and rarely, says what it is for, but not its name. At other times she cannot reply as to the qualities as told by touch alone, or tell scissors from a corkscrew, a book from a watch; and yet tact is per- fect. This corresponds to mind-blindness. She is mind-touchless. There is psychic anaesthesia as to touch; or, to be more accurate, either this is true, or else she has lost the power of mentally comparing new sensations with the stored memories of those long acquired. I have not spoken of the localities involved in this triple loss. Concerning these our knowledge is still in- complete, and cases of hysterical representation of these singular symptoms are least of all suitable to help us. And certainly this patient is an hysterical illustration of mental incapacities to use the information won through smell, sight, and touch; and, as I am sure such cases are very rare, I have thought it worth while to state for you the reflections which this one has brought to my mind. Dr. Pershing had reached a like conclu- sion early in the case. Of course, these cases all have alexia and agraphia. It has been suggested that the various memorial incapacities, such as the total loss of knowledge of localities or of individuals, maybe limited forms of mind-blindness, as if one room in the many man- sions of memory were suddenly walled up. These are, I think, yet more complex conditions of psychic dis- order, and only a part of them may fairly be referred to the form of mental trouble which this case exhibits in so many varieties. Finally, we need a better term than mind-blind, and a good Avord for the corresponding condition in which touch and smell are involved. 24 ^""EB VO US DISEASES. It has seemed to me that all of these curious states of consciousness as to objects seen or felt may be repre- sented in the changing psychic development of a child — objects seen in early life are first represented as on a mirror; later, their qualities are defined; and, lastly, they are labelled. Dr. Pershing writes to me of the later history as follows : March 9, 1896. The woman with mind-blindness gradu- ally grew worse after her return from Philadelphia. While walking one evening with her mother, who is very deaf, they were both struck by a cable car, but apparently not seriously injured. When I saw Mrs. S. a few weeks after this accident she could not talk rationally on any subject, but kept talking in a senseless, bewildered way, the words being distinctly uttered with occasionally a pause, as though the word did not appear in memory. " Water-closet" was repeated with especial frequency, without any logical or grammatical connection with other words. The intellect was evidently much impaired, and she had to be constantly attended. The pupils Avere widely dilated, and one eye, the left, I think, turned out. The pupils did not contract in a bright hght. The ophthalmoscope showed nothing abnormal. In the summer of 1894 she came as an insane patient to the County Hospital, in my service ; but I was away at the time, and Dr. Eskridge, who had charge of my patients, had her taken to St. Luke's as a private patient. That ended my connection with the case, but I know that she remained demented and was at times noisy. She died in the autumn of 1894. CHAPTEE II. RECURRENT MELANCHOLIA: SEASONAL MELANCHO- LIA; MELANCHOLIA ARISING OUT OF MENSTRUA- TION; INTER-MENSTRUAL MELANCHOLIA; MELAN- CHOLIA ARISING OUT OF DREAMS OR ORIGINATING IN THE POST-DORMITIUM; MELANCHOLIA DURING DIGESTION. I HAVE long had in mind to speak to you of certain forms of the mental disorder we call melancholia, and of which at this clinic we see so many examples. It sometimes offers for our consideration peculiarities of origin which have not received the attention they should have had. As usual in these lessons, which are informal, and not meant to cover the whole medical history of the subject, I shall limit myself to speak of so much of the matter in hand as shall appear to me desirable to dwell upon. Assuredly, the treatment of mental disorders is one of the least satisfactory of the varied problems with which we have to deal. About nothing do we knoAV less than of the true pathology and ultimate cause of the dis- orders which we group under the name of insanity. Indeed, we are as yet uncertain as to where Avithin the skull is the nerve-matter with which we think or imagine. The abruptly occurring accidents to, or diseases of, joint, muscle, or nerve, we can measurably comprehend; but when we come to deal with disorders of the brain we are at once face to face with certain unanswered questions. 26 ^"^'ER VO US DISEASES. While most disorders of the mind are apt to origin- ate gradually, and often take a long while to become formidable, at other times these troubles spring up sud- denly; and this is more frequently the case with all the forms of methodically recurrent disease of the mind. I do not mean to say that sudden outbursts of mania or melancholia, such as, according to the German writers and others, are more prone to occur in recurrent exam- ples of these disorders, are very common ; but only that they are to be met with, and that when we do see them they still further emphasize the difficulty of explaining that which happens within the brain at the time of occurrence of such outbreaks. A strong emotion, a dream as I shall show, or some as inexplicable cause, may occasion forms of temporary or lasting mental dis- order, for which we have as yet no reasonable explana- tion. The largeness of the psychical and the smallness of the observable co-attendant pathological physical conditions never cease to amaze the thoughtful. Usually these and all forms of such morbid psychoses get well slowly; but sometimes recovery even in chronic cases is as abrupt as may have been the origin, and then one asks in vain what could have been the nature of the morbid factors which, acting suddenly or slowly, are efficient for years, and perhaps cease to have dis- ordering competency in a night or a day. Such cases are, indeed, rare, as I have said; but they do exist, and may be met with at times in some of the recurrent melancholias to which presently I desire more especially to call attention. The individuals who constitute mankind have what one might call a par of cheerfulness. It varies, of course; is subject to the vici.earance and as to function normal. She came of a family in which there was and had been much in- sanity, more eccentricity, and some persons of great ability. At the age mentioned Miss K. became, in June, without known cause, furiously maniacal. Within a month this became less and less, and she remained in a state of deep dejection, speechless and motionless, often with a positive rain of tears. As time wore on it was seen that two days before, during, and after the menstrual flow Miss K. was increasingly brighter. After seven months this was so remarkably persistent that at the time of relief she read and wrote letters, talked and heard talk with pleasure, and went back voluntarily to her piano, singing and playing with taste and charm. The second year found this lady free from mental dis- 48 ^^ER VO US DISEASES. order, except for eight days midway between her monthly flows. At this time she was silent, or even speechless, tearful, and full of gloom. Now and then she would write an answer to questions, but considered it wicked to speak. The approach of the menstrual terra brought a rapid increase of good spirits, and during the flow and later she was thought to be natural by those who knew her best. At this season she declared that the time of melancholia was never so distinct in her memory as it might have been expected to be. She forgot its details, and seemed to suffer very little from the recollection of what she had gone through. This is a merciful and not a rare feature of many forms of mental disorder. The impression they leave on the memory has the evanescent quality of the mind's record of a dream. When this case had lasted in this state for two years I saw her in consultation with the late Professor Charles D. Meigs. He Avas strongly of opinion that she should be bled in the interval, and accordingly she was bled some twenty ounces about ten days after the flow ceased, and was also put permanently on a diet chiefly vegetable. After the first bleeding the sequent depression in the middle of the month was less, and after four successive bleedings, which were done much closer to the time of the expected attack, it became insignificant. I then sent her on a long ocean voyage, during which her convalescence became complete. She died fourteen years after, from an acute intestinal malady, but had never any return of inter-menstrual or other disorder of the mind. I ought to state that long before the lancet was used a great variety of treatment had been resorted to, and that nothing had been left undone which I could devise to break up these attacks. I am reminded by this case of three occasions on w^hich suicidal failures, causing immense loss of blood, resulted MELANCHOLIA. 49 in rapid relief in melancholias of the gravest types. I have seen another within a very few days of this writing. I leave these facts, which I have not time here to discuss, to the ingenious interpretation of others. I pass, in this brief summary, to the cases of melancholia which seemed to have some relation to sleep or its phe- nomena. In the year 1895 I read to the Association of Physicians and Pathologists a paper on the Disor- ders of Sleep. I then classified the mental phenomena arising out of dreams, or out of what I called the prce- or the post-dormitlum. At this time I drew atten- tion to Baillarger as the only author who had realized the importance of this period, the post-dormitium, in connection with insanity. The gteat value of these facts, and of those I added, has even yet failed to attract further contributive illustrations. The cases I reported were chiefly of hallucinations of the senses. Since then I have seen a number of instances in which the post-dormitium was haunted by sensory delusions of painful character, followed by an hour or two of really deep melancholia in a waking state. It is familiar knowledge that melancholias are worst on awaking, but instances of this brief melancholia either preceded or not by sensory post-dormitial hallucinations are more rare. A single case will suffice: Case XII. — C. J., clergyman, of Connecticut, aged sixty-five years, had, twenty years before, a long and severe spell of simple melancholia. At this later date, in the early spring, he began to have, befoVe he was fully awake, delusions as to voices reproaching him. With these were visions of droll or horrible faces. When he became fully conscious these left him, upon opening his eyes, but for awhile i*eturned if he again closed them. 5 50 NER VO US DISEASES. A few miuiites later the sounds and visions left him en- tirely, but for two hours he was the victim of a melan- cholia so deep as to be once or twice almost overwhelm- ingly suicidal. About 11 a.m. this all passed away, and he became so well as to be able to attend competently to important duties during the rest of the day. These phe- nomena lasted for years at intervals, and finally ended in senile dementia of the passive type. I have also seen remarkable instances of temporary but really profound melancholias which were the out- come of dreams. I recall two such cases. It may answer to relate one. The borderland of unsoundness of mind is sometimes subject to a great increase in the number of dreams, and these may be so constantly horrible or terrifying as to be a w^arniug of the coming mental disaster, as has been more than once pointed out, especially by Baillarger. It is, however, uncommon to find the dream resulting in an attack of agitative or simple melancholia. Abnormal fear, irrational anxiety, may come of it, but not often distinct melancholia. Case XIII. — Mr. L., aged thirty years, an engineer, consulted me on account of nocturnal attacks. Except that he had frequent ophthalmic megrim, he was in good health and free from evil hereditations. After a period of great commercial anxiety he had one night a dream of falling from the trestle of a bridge. He awoke sweating and in a state of wild agitation. He said that he rose, lit up the room, and began to walk about. His affairs seemed to him hopelessly involved ; he figured himself as weak, incapable, and untrustworthy. Life seemed unendurable. He cried like a child, and at last drank a tumbler of brandy and fell asleep. This torment came again at in- tervals of weeks or months, and later ^ on became frequent. MELANCHOLIA. 51 The dreams varied, but the results were the same. A summer in the woods brought relief, and an ocean voyage finally rid him of this disorder, I shall close this too condensed statement of certain of the unusual ways in which melancholias arise with a single example of its production during digestion^ in a case of intermittent glycosuria: Case XIV. — H. R., aged about forty years, a scholar of uncommon ability, consulted me for a condition then and since unknown to my experience. He had been for years a dyspeptic, suffering much with a sense of weight at the epigastrium, with wind and excess'of acid. Within a few months the dinner at 7 p.m. was followed by the usual distress, but later, about 9 p.m., by deep dejection, indif- ference to life, desire to be alone, tears, and what he called "fragments of delusions," easily disposed of by the reason, but apt to return. This condition passed away about 12 at night, and he usually slept well. These attacks became of daily occurrence and were more or again less severe. It was soon found that he had sugar in his urine ; that the quantity was least on rising from sleep in the morning ; that it increased after meals, and was largest about two or three hours after dinner, the time at which his melancholia arose and deepened. A long course of skimmed-milk diet was of great service, and later, by eating a carefully chosen diet six times daily, he did very well, escaping for a long period both the glycosuria and the mental disorder, which appeared in the evenings and seemed to be related to a rise in the amount of excreted sugar. He died of double pneumonia some years later. I recall no other case of melancholia clearly related to digestive troubles, or to glycosuria; nor do I think that ordinary cases of the mental disease suffer more after 52 ^ER VO US DISEASES. meals. The early morning hours are, as all alienists know, the time of greatest misery ; the chosen hours for suicidal thoughts or efforts. When this sequence is reversed and the evening is the time of gloom we have, as a rule, to deal merely with the dejection met with in some neurasthenics or hypochoudriacs, or witli an hysterical simulation of melancholia. CHAPTER III. IRREGULARLY RECURRENT MELANCHOLIA WITH LONG INTERVALS AND NOT IN APPARENT RELATION TO FUNCTION. Perhaps there is no more reason to be surprised at melancholias which recur after a day or days of sanity, than as to those which return after months or years. In cases like that quoted at tlie close of the last lesson the regular repetition of melancholia in connection with the time of digestion tempts the reason with pos- sibilities of explanation; but in the cases to which I now refer, and shall illustrate with a striking example, no form of explanation as yet seems available. ]N"ever- theless, it is in the careful study of such melancholias and their sequent intervals of soundness of mind that we are offered the best chance of discovering the agen- cies which can so quickly develop a mental disorder. The following case sought advice while I was writing this paper. It is an example of recnrrent melancholia of brief duration, returning every two or three days, and lasting four hours to twenty hours: Case XV. — C. E., retired merchant, aged sixty-five years, married. The father was healthy, and died aged eighty- eight years; mother healthy, died aged eighty-four years. Three sisters are alive and well. Three brothers died aged respectively seventy-five, seventy-four, and thirty-eight years ; one nephew had melancholia with delusions. Had had typhoid fever in 1870 — no sequelae ; habits 5- 54 ^^^ VO US DISEASES. good ; uo syphilis. For fifteen years has been liable to feel depressed when his business became troublesome, or in commercial crises. His general health is unusually good. The heart and arteries are far better than is common at his age. He is clear of head, competent in business, sleeps well. His appetite is good ; his bowels regular. Is liable to occasional indigestion, with non- acid eructations. He has normal reflexes ; his station is perfect. The urine shows no albumin or sugar. The morning urine, on standing, presents a small deposit of free uric acid and urates. The attacks I shall describe have no relation to the meal-times. When away from home they are fewer in number, but except as to this he knows of nothing which affects the number or severity of the spells. About five years ago Mr. E. began to have brief attacks of mild melancholia. They came at irregular intervals — weeks apart. A year later their frequency and intensity increased, until ever since they have continuously recurred two or three times a week. The longest interval is five days. They may repeat themselves every day, on two to four successive days, or return upon alternate days with regularity. The seasons do not affect their number, nor does the time of day. He may awaken in an attack ; he may have one at evening, and lose it in the sleep, w^iich it does not seem to make less sound. He can neither avoid these spells nor lessen their force or shorten them. From the time he first feels the attack or sense of dejection to its climax about half an hour elapses. It passes away even more abruptly at times, but commonly is an hour in leaving him, dating the time from a sense of distinct relief to full possession of his natural cheerfulness. While thus afflicted he is melancholy, irritable, turns over and over in mind every possible source of annoyance, even conjuring up the worries of others with which to MELANCHOLIA. 55 perplex himself. At these times he must be alone ; will see no one ; contemplates suicide, but has made no suicidal attempt and does not believe he ever will. This dejection he describes as profound, and says that hope seems dead, affection valueless, and life a torment. He has no delu- sions of sense ; then there is a feeling of relief, and, as de- scribed, the ''cloud passes," and he is, as usual, gay, happy, and equal to any sport or work. To illustrate this singular case, I give his own record of twenty-two successive days in midwinter: twelve were free from attacks; on three he had brief, mild spells. He had six sharp attacks, and one of great severity both as to length and excess of melancholy. Prof. Samuel Jackson described a case not purely or very distinctly melancholia, which recurred alternate weeks with sane intervals, and ended in dementia. I can find nowhere, however, a melancholia which repeats the phenomena of the case I have given. This gentleman returned January 12, 1897, to permit of study of his days of melancholia as compared with the normal intervals. Unluckily, but as is usual with him when aAvay from home, he had fewer attacks — in fact but two in the fortnight of his stay. Study of his secretions by Dr. Pearce began by an examination Avhich gave the following results : He was feeling well ; pulse 72 and respiration 18 ; temperature, 98.5° ; blood-count, 4200,000 ; hemoglobin, 90, at 11 p.m. The urine for twenty-four hours was over the normal, as he weighs 140 pounds ; amount, forty-five to fifty-five ounces ; specific gravity, 1020. No abnormal constitu- ents except amorphous phosphates were thrown down after the urine stood a few hours. At this time he looked well and ruddy, and was, as usual, gay and cheerful. 56 NER VO US DISEASES. Ou January 20tli he had an attack : notes taken at 10 to 11 P.M. He had been, as he said, ' ' fine " until late this after- noon, when he began to feel badly. Did not wish to speak to anybody or exert himself. Noticed nervous cough and accumulation of sticky mucus in throat and feeling of depression about the " brain" and of pressure over sternum. Did not care to go to "opera" on account of this " cloud " settling over him. Went to bed and slept, but awoke in two hours in a dreamy state with feeling of despair and discouragement, the "cloud" or haze gradu- ally falling over him until the mental depression was almost unbearable, and he was afraid he would be an "imbecile." Unnatural dread of the little preparation to go home. Could not, through any effort, throAV off the feeling. When seen at 10.30 p.m. the eyes were dull and red, the pupils equal and resj^ionded sluggishly but equally ; station good ; knee-jerks normal ; respirations regular, 18 per minute ; pulse full, compressible, 72 per minute ; tongue clean and moist ; temperature subnormal, 97.6° F. January 21st, reports attack as passing off while Ave were talking together at 11 p.m. Slept well; awoke at 7 a.m. Feels "fine." Says he could do business to-day better than usual, being clear and competent. Four ounces of urine were saved during the attack. During the day of onset the quantity of urine fell to thirty- three ounces. In another minor attack it was in excess — fifty-five ounces. While in mental health he passed ratlier less urea than is usual ; in both the attacks it was materially lessened. The percentage of uric acid was decidedly increased in the more severe attacks, but not in the milder. Indican was certainly present in larger amount in the urine of the MELANCHOLIA. 57 melancholias than in that passed while free from depres- sion, when only a trace was detected. I complete this notable case with a table of the days of melancholia noted during 1896: In January there were nine bad days ; February, six ; March, ten ; April, thirteen ; May, eight ; June not given, but said to be a bad month ; July, ten ; August, five ; September, three ; October, nine ; November, five ; De- cember, eight. Evidently the spring and summer months, up to August, were the worst. Unfortunately, this gentleman was called away before he gave us any further opportunity to study his case, and it were unwise to draw conclusions from these im- perfect chemical analyses. CHAPTER IV. SOME DISORDERS OF SLEEP. When dealing with organs or functions the physi- ology of which we, in a measure at least, comprehend, it becomes easy and pleasant to discuss their alterations from health; but as regards sleep we know little. The wildest theories have been entertained concerning it; and, after all, we are simply driven to believ^e that it is a state of the nerve-cells — and why not of the nerves ? — in which they become functionally actionless in a variable degree. Whether this be true also of the other cell-structures of the body we do not know; and sleep may be a universal function, as would seem reasonable to those who believe that plants sleep. It is sure, also, that the sleeping brain contains less blood, or that it circulates less, than the brain awake, and this is the limit of what we know. The disorders of sleep are many. I have found my- self driven to choose among them, and I shall limit myself to a less known group, to some members of which I was the first to call attention. In 1876^ I described several of the morbid states of sleep, and again Avrote of them more freely in 1878.^ In 1882, in my lectures on Xervous Disorders of Women, I dwelt at greater length on the symptoms in question, as well as on others which have been much 1 Philadelphia Medical Reporter, 1876. - Virginia Medical Journal, 1878. SOME DISORDERS OF SLEEP. 59 discussed of late in the journals ^vitliout notable addi- tions of value. In making choice of how I shall treat of sleep-troubles I have been influenced somewhat by the fact that certain of these it has been my fortune to see and to study more than I have the better known phenomena of dreams, somnambulism, and the like. The approach to the unconsciousness of slumber, and.^ too, the return from it to the world of volition, may be medically considered as part of sleep, and, as I shall show, these periods are often disturbed by certain very interesting symptoms. As we are falling asleep the senses go off guard in orderly and well-known succession — this interval I de- sire to label the prce-dormltium. When we begin to awaken, and the drowsied sentinels resume their posts, there is again a changeful time, during which the mind gradually regains possession of its powers — this interval I may call, in like fashion, the post-dormitium. The Relation of the Prse-dormitium to Insanity. In the borderland of coming slumber, when we are not yet overwhelmed by its full power, the steadying contradictions of the external world are, in a measure, by degrees cut off, whilst the will still holds a slowly lessenino^ rule. It has Ions: been known to alienists that the prse-dormitium is apt to be invaded by hallucina- tions in those who are becoming disturbed in mind. Every student of himself knows, too, what a fairy coun- try for visions is this intermediate state. Since, in the sound, it is the time for castle-building, it seems nat- ural that, in the disordered, it should serve to foster dangerous hallucinations, and that, in rare instances, these should be limited to the period in question. Bail- 60 ^^ER VO US DISEASES. larger is the only author who has studied with any care the relation of the pr?e-dormitiuin to insanity. Of this he says: '*The organs of sense ceasing to transmit to us exterior impressions, the control of our ideas escapes us, and what- ever rises appears, as it were, spontaneous ; at times vague or confused, fantastic forms succeed one another, and we have of it all but a half-consciousness. At times more distinct forms appear, and we are present, as it were, at a strange spectacle in which we take no active share, but which leaves distinct traces on the mind. Any exterior intervening impression causes these visions to vanish. A sudden noise, or touch, or light awakens fully the senses, recalls attention, and these phantoms are effaced."^ The period now in question is of great psychological interest; nor have the laws which control it been studied enough. In childhood it is certainly the time of easily attained visions, and in the imaginative this is especially the case. As years go on the power to fill this magic interval with what we will to see grows less, and in later years is materially impaired or is altogether lost. I have been at some pains to learn to what extent the capacity to call up, control, and dismiss visions exists in the prae-dormitium. The ability to project visually at will on the screen of consciousness greatly varies with the individual. Generally in youth it is possible soon after closing the eyes for sleep to evoke visions. Some children can control these visions. They see what they will. This was at one time the case with me. Others may will in vain. They see nothing or only the crude stuff of dreams, or else something they did 1 Baillarger : Aunales Med. Psych., vols. v. and vi. S03IE DISORDERS OF SLEEP. 61 not seek to summon. Few can hold these phantoms. They come, they go, change and vary under mysterious influences, uncontrollable by the will. Such is apt to be the case later in life for all who continue to be able to possess the power. This is hardly the place to go much further into the physiology of the prse-dormitium. I speak of it only because it is the threshold of sleep and full of interest to the alienist, and, indeed, to the neurologist. Even this brief study of its peculiarities reminds one of the prolonged condition into which we are brought by the action of moderate doses of such drugs as mescal — Anheloiiium Lewinii. The original study of this drug by Professor Prentiss and a later examination by the author^ have made clear the remarkable resemblance of mescal intoxication to the natural period I have called the prge-dormitium. I speak here with assurauce only as to myself, for, as I have said, we as yet need a full study of the psychology of the states which precede and follow slumber. In a long series of interesting cases Baillarger shows that certain persons, otherwise still sound, are liable to have, between waking and sleep, hallucinations which long precede the outbreak of insanity. He describes instances of such hallucinations of sight and hearing as lasting from one to three years, and ending in grave mental disease. These were usually voices or visions, fading when the eyes were opened, as occurs with mes- cal visions. In one case there Avas something like the sense of a blow on the head, and then on the bed, but nothing comparable in this direction to the phenomena British Medical Journal, Dec. 5, 6 62 NER VO US DISEASES. of sensory shocks to which I shall presently call your attention. I have myself seen illustrations of the facts men- tioned, and I speak of them here because this is ground we rarely go over in our examinations of patients. It may possibly be found that valuable prognostic indica- tions as to insanity are to be gained by examination of the prse-dormitium. Before passing on to other matters I may say that generally, as I have known them, these prodromes of insanity were connected with eye or ear alone. In but one case was olfaction concerned. I will content myself with a sketch of it: Case XVI. — Mrs. C, aged forty years, of a neurotic family, all liable to neuralgic headaches. One brother died of ataxia. Convulsions in infancy were common to all five brothers and sisters, none ending in epilepsy. Mrs. C, who was well except as to headaches, had a fall which injured her nose. The shock resulted in persistent headaches, without other cerebral trouble save complete loss of smell. Two years later she had, but only on going to sleep, a sense of horrible odors, which were fecal or animal and most intense. This lasted several months, and then were added sounds of voices, which were at first vague, but at last accusative, and soon were heard in the day. The case ended in melancholia with delirium of persecu- tion, during which the trouble as to smell passed away. Case XVII. — A. C, a clever lad, of exceptionally able and normal descent, became insane at eleven years of age, and was long maniacal and often homicidal. For some months before this outbreak — which was acute — he was troubled by seeing animals on his bed before he fell asleep. Opening his eyes routed them at once. The condition SOME DISORDERS OF SLEEP. 63 seemed to have none of the peculiarities of the night- terrors of childhood. I am tempted to add the brief notes of another lad's case, in which the same period was a time of singular disorder of mind. It is, of course, known to many of you that the bromides may in some persons (and notably in the young) occasion, like mercaptan, profound melan- choly or maniacal tendencies, which in several instances in my experience have been homicidal, or at least madly destructive. Case XVIII. — The lad in question, an epileptic, aged eleven years, was said to become homicidal from bromides. I was skeptical enough to test the matter. About the seventh day of using full doses of lithium bromide the trouble showed itself in the prjesomnic time as visions of himself killing other children. They annoyed him greatly, so that he strove to keep awake ; but at last, tired of the unnatural effort, would fall asleep, with too brief an interval to allow of his being disturbed again. After several nights of like distress the homicidal tendency broke out in abrupt and dangerous violence during the daytime. There are epileptic cases in which inhibition of fits causes homicidal explosions which cease when the fit comes on, and do not recur for a time, whether bro- mides are continuously used or not. In this lad's case the fits did not lessen the tendencies to destroy or injure others. These lasted as long as the bromides w^ere given. I think Echeverria mentions like cases. ^ There exists also, I may say, a group of cases (not in the books) in which the borderland of sleep is haunted 1 Also the author. See On Exceptional ElFeets of Bromides. Transactions of Association of American Physicians and Pathologists, May, 1896. University Medical Magazine, June, 1896. 64 ^^'^-B VO US BISEASES. by hallucinations for weeks or years without their end- ing of necessity in mental disease; but it is quite im- possible for me here at this time to dwell on these interesting cases, of which I have seen a few, and but a few. In no respect do they differ from the like cases reported by Baillarger in which insanity resulted, save in the fact that it did not. Voices were heard or dis- tressing visions seen during the prse-dormitium, and at no other period. AVith time and due care these vis- ions faded away. Tw^o of the half-dozen I recall were hysterical women; two were men in busy affairs; and one, the worst, a Avoman of thirty-seven years, was, I think, preserved from insanity by the loss of her ovaries. Tlie corresponding time, which comes after sleep and before full wakefulness, is also said by Baillarger to be troubled in some by hallucinations, but of this I have no experience;^ nor does he speak of it as common. Tuke also has reported cases. There is yet another and stranger mental condition experienced, though rarely, in the prse-dormitium. This is a suddenly acquired and sometimes persistent sensa- tion of fear or terror without any sensory hallucination. For our emotional states we have usually a cause, or at least think we have; but what I now describe is an emotion without known parentage. Children may exhibit this continuous fear after the scare of a dream, like the echo of an emotion the cause of which is over. Sometimes in adults this lasting sense of alarm is the product of a dream. The victim awakens and continues even for hours to feel the fear to which his dream gave 1 See, however, as to this, my own later experience— chapter on Recurrent Melancholia— in this present volume. SOME DISORDERS OF SLEEP. 65 rise. He is wide awake; lights the lamp; reads, or tries to; but is still fear-haunted, reason as he may. The patient who is liable to this fear may also be sub- ject to attacks of pure fear without a dream-cause, and arising in the time between waking and slumber. He has then no dream. Of a sudden, whilst half-awake, the man is afraid. It is pure fear, such as the insane have at times. I append a case from my first paper. Both forms of the trouble here mentioned wTre felt. The case is given as stated by the sufferer, a scholarly, much overworked man, with no obvious habits, hereditations, or disorders to explain his condition. He says: Case XIX — "About the year 1871, being then fifty-five years old and in sound health, I was troubled with what I understand to be ' night- terrors,' but unlike any I have been able to hear of. Upon retiring I could generally tell whether or not I should have this trouble during the night. These premonitions were : a difficulty in breathing, not being able to draw a f idl breath, owing, as it seemed to me, to some obstruction in the lungs ; intense nervousness ; turning from side to side. ' ' I would fall asleep and have vivid dreams, and almost always upon the same subject, the purport of which was, that after long absence from home I returned and found that some one dear to me had become idiotic. "The most painful attack of this kind occurred in 1872. That night I dreamed that after a long absence I returned, and, upon approaching the city, I saw upon a steamboat my aunt. She had become crazy in my absence and was under the charge of keepers. As I neared the boat to speak to her she leaped overboard and was drowned, and her body, with a fearful idiotic leer upon her face, floated past me so close that I could touch it. I awoke with a sudden start, trembling from head to foot ; and, although 6- 66 NER VO US DISEASES. in a moment I realized that it was but a dream, yet the feeling of terror, instead of leaving me, rather increased. I was obliged to rise, light the gas, and leave the room and remain for several hours in an adjoining one. I then re- turned to bed and slept until morning ; but the next even- ing, when it came time to retire, the recollections of the past night were so vivid, and the intensity of the mental suffering so clearly before my mind, that I could not force myself to retire. ^ly reason told me that this Avas a foolish feeling, and that I ought to conquer it ; but after a severe struggle reason gave place to this undefinable feeling of terror. That night, and for several nights after- ward, although I was not addicted to drinking, I drank strong liquor until my senses were clouded, and this I did intentionally, otherwise I could not have retired. '* Daring the daytime, when thinking over this fearful attack, I concluded that if it were given me to choose be- tween passing one such night and being deaf, blind, or lame for life, I should choose the latter ; nay, I felt that even death itself would be preferable to such another night. I have never since experienced such intense suffering, but have passed through it many times in lighter forms. "This fall (1875) it took a different turn. Upon re- tiring I was unable to keep my eyes closed, because the moment I closed them a feeling akin to fright would cause me to open them. "This was like, but incomparably less than, the dream- evolved terror. Nevertheless, it was bad enough. It did not come if, sitting up, I closed my eyes ; but to lie down and close them was often enough ; or, if the emotion did not then arise, it seemed to burst upon me just as I was conscious that sleep was near. These attacks were the Avorst. I was afraid — and of nothing. No reasoning helped me. As I am by nature, despite my professional life, hardy and courageous, I was rather ashamed of being SOME DISORDERS OF SLEEP. 67 fearful of nothing, knowing that in battle I had had no more fear than others, and none that disturbed me. ''After tossing endlessly for hours I would at last sleep for an hour or more with the sense of sleeping ill. If 1 had a bad bout, I sometimes awakened with my mind not clear and feeling as if I needed effort to steady it." Despite these alarming symptoms this gentleman got well after a summer in camp in Maine. Others have described to me this state of fear in the prae-dormitial condition. Says one: Case XX. — ''I have had, like others, nightmare; but this comes over me while I am quite conscious, and of this I am sure. Whilst yet capable of mental analysis and just pleasantly drowsing, I simply and abruptly realize that I am afraid. I feel it coming. I am not paralyzed, as by nightmares ; I can move. If I fully sit up, it is over ; but if I delay to do so, and it catches me, it stays on for a minute or two after I am completely awake and master of myself. I sometimes lie still with open eyes and seek to know why I fear, or reason it over, but nothing relieves me. The fear goes by degrees, but if at once I he down again and close my eyes it comes back." Another mental state, somewhat akin to this last (for fear and anxiety are near akin), also occupies the prae- dormitium. It is always an associate of bad sleep or of insomnia, and consists in a series of unreasonable fears and anxieties. I will let a sufferer tell his story as he wrote it for me. Case XXI. — This sufferer was fifty years old, of ner- vous temperament, a man of restless intelligence, anxious always, successful past the common, free from disease, en- dowed with a perfect stomach, and habitually insomnic. He called three hours a good sleep, and for years lived on 68 NERVOUS DISEASES. this and an afternoon nap of an hour. Now and then his restlessness got worse, and was the insomnia of over-vigilant and excited centres, which furnished a succession of anx- ieties, each in turn capable of inhibiting sleep. He says : " This trouble haunts the time close to sleep. I lie down ; am easy, and assured of sleep. Suddenly, I think, is the gas turned off properly ? I get up and look ; re- turn to bed ; get up again, and so on. At last I become anxious as to my son, aged six. Is he safe in bed ? Will he fall out ? My wife goes to see, reassures me, and then I go myself, and go a dozen times. Next, it is the fur- nace, or the locks, or fear of fire, until, worn out, I am surprised by sleep. It seems as if this thing waits for me at the gates of sleep, and I can understand that just then one's fancies may run wild. But once awake, the thing goes on until I am ashamed of the demands made upon my wife, and, too, of my own folly. I know of others who have the same trouble, but never in the day season." Sleep-numbness. Nocturnal Paresis or Paralysis. As sleep-numbness, this disorder has become familiar since I described it in February, 1876, and later more fully in my book in 1882. Since then, Dr. Andrew H. Smith, in this country, and Dr. Saundby, in England, have written of it anew; the former as an undescribed neurosis, and the latter without full knowledge of what had already been written. Dr. Saundby thinks I ap- pear to have recognized this condition, but is of the opinion that the name I gave — nocturnal hemiplegia — in view of the occasional association of temporary loss of powder, is not very appropriate. In fact, I de- scribed pronounced cases chiefly, and their duration had nothing to do with the nomenclature. In general, functional day-numbness (as I and others have described it), whether neurotic, anaemic, gouty. SOME DISORDERS OF SLEEP. gg diabetic, atonic, or asthenic, is apt enough to repeat itself at night in sleep. Bat there are people who never hav^e day-numbness, and who are, nevertheless, liable to awaken with this interesting; neurosis. Definitions of it do not admit of sharp boundaries. It may be local, transient, a slight numb feeling, a faint tingling of the fingers, of a leg, or of one side ; or else it may be intense, and present us with paresis and real defects of the touch- and pain-sense. In another case it may show itself, though rarely, as an alarming mono- plegia, or as a distinct hemiplegia, lasting but a few moments, or growing worse during hours. Again, it may involve the whole body, but is then apt to be less severe than are the hemi- or monoplegic forms. I have seen several of them in one person; at this time slight numbness, and at that hemiplegia, alarmingly positive, with marked loss of power and with lessened sensibility. For Dr. Andrew A. Smith, waking-numbness is a parsesthesia at the exit from sleep, and " in this,^' he says, ^^ there is nothing added, and nothing taken away.'^ But these subjective states, which to-day are mere tingling or formication, may to-morrow deepen into the semblance of hemiplegia, with distinct loss of sensation. It is only a question of degree. The neur- asthenic, the hysterical, the tobacco-poisoned, the gouty, the dyspeptic, are liable to awaken with numbness, tingling, dyssesthesia of a part, or of both hands, or of a side. It goes off in a few minutes. More rarely there is a distinct weakness of an arm or side, with dys- aesthesia, very rarely with complete loss of feeling. And so it is that we may have various degrees of dis- turbance from faint tingling to profound temporary dyssesthesia, and defects of power from paresis up to 70 ^ER VO US DISEASES. a brief simulation of paralysis. Were the worst of these simulations to last, they would be grave enough, and, in fact, it does sometimes happen that such states as I describe may ev^en deepen in intensity after the patient is fully awake. In some patients they recur night after night, attack both hands or both sides on successive nights, or occur at intervals for years. I may add that I have sometimes seen this symptom in men apparently vigorous, and that it also occurs, now and then, in those who have multiple cerebral aneurisms or endarteritis. I have seen it, too, over and over, in convalescent hemiplegics. They awaken with the palsy worse, a functional condition being for a time added to that which had an organic cause, or the sound side suffers, to their great alarm. I give a physician's story of his attack: " Excessive work, with double abuse of tobacco (smok- ing and chewing), had caused day-numbness, which troubled the ulnar territories most. One morning I awakened with transient numbness of the whole left hand, with no true loss of touch. A week later I had, on awakening, dyssesthesia, with pricking of the whole right side, including face and tongue. I arose, found leg and arm weak, examined sen- sation in the finger-tips and recognized the fact that with scissor-points applied to the finger-cushions I could not be sure of them as two at one-third of an inch separation. T was about to send for a physician, when the sense of ting- ling becoming worse in the extremities, the dysiesthesia grew less, and in two hours I was as well as ever." It is of interest that he soon after saw a case of waking-numbness in a tobacco-using patient, wdiom he confidently reassured, stating his own case. In fact. SOME DISORDERS OF SLEEP. 71 however, the patient owed his numbness to unrecognized diabetes, and it ended in gangrene. The history of numbness in all its grades points to a central origin, but that it may arise otherwise is also clear. In some cases of neuritis I have seen night- numbness as a first, a transient, and a repeated symp- tom preceding the pain by several days. Some years ago, whilst writing my book on Nerve Lesions, I froze my right ulnar nerve at the elbow with alcohol at 0° F. For ten days afterward I had more or less discomfort, and at times acute pain, but espe- cially, on several occasions, a positive numbness of the ulnar territory with which I awakened. It passed off with friction in an hour, but was much worse than the occasional day-numbness which my somewhat rash ex- periment created. Yet, for a time, it was purely a waking symptom and faded swiftly. The more pro- found examples of hemiansesthesia with paresis as post- somnic states are, I think, most apt to involve the right hemisphere. I recall no instance of aphasic accompa- niments in the rarer left brain disturbances. In their varieties these symptoms probably represent functional irritations or inhibitions of quite various parts of the brain ; unlike their hysteric related states, they are felt in the face as well as below it, and are clinically of kin to the functional anaesthesias and pareses of certain migraines. In some cases, notably in hysteria, waking-numbness is associated with pain in the parts affected, or there are also parsesthetic expressions, as sense of constriction, of elongation, or of enlargement of limbs, etc. At times the sensation resembles the furious formication of aconite-poisoning. 72 ^^R VO US DISEASES. In Dr. Ormerod's paper^ on numbness (which is the best of the English essays) he speaks of the pain suffered by some of his cases^ and as to this he is quite correct. In fact, there are those who awake with pain in arm or leg, or both, so intense as to make the accompanying numbness seem of little moment. Pain as an accompa- niment is also mentioned by Sinkler, but not as being severe; whereas it is in some instances of waking- numbness very great. I add two or three cases. The first, again that of a physician, I give as he wrote it. He says: " The preparative causes of my present state were excess in tobacco and a practice Avhich left me no rest. Then came a domestic calamity, and I broke down with distress in the occiput and an amount of suddenly developed physical feebleness which annoyed me. I could not walk up three flights of stairs without resting. My heart be- came rapid — 90 to 100 ; my temperature 97.4°, and at night 98°. I ^Yas struck, too, with the weakness of my bladder, the urine merely falling as it emerged. All this was in December. In February I began to have night- numbness, and woidd wake in the night with all four limbs numb. The worse attacks were those at waking in the morning late. Early in the night the symptoms were less notable, or else affected one limb only, or one side. At times it was mere tingling ; at others, positive lessening of sensibility to touch and pain. When this was the case the limbs were for a time paretic ; on one occasion so much so that I fell on getting out of bed. The trouble has never lasted more than thirty minutes, and usually went off with great tingling, as of a limb asleep, as is said. After March I began at times to have numbness in daytime, but rarely so intense as to disturb feeling. The tingling 1 SI. Bartholomew's Hospital Reports, 1S«3. SOME BISOBDERS OF SLEEP. 73 occasionally affected my whole surface, and was apt to begin around the mouth." In this case the symptoms were neurasthenic, and absolutely no other cause could be assigned for them. Recovery was complete. The next cases are from Dr. Fere/ and are certainly hysterical and of great interest. Case XXII. — ''Mrs. V. came to consult me, for the first time, at the Saltpetriere on January 12, 1885. She was accompanied by her mother, who was over sixty years of age, but still very agile, and looked much younger than she really was. The mother had a painful ovarian spot with slight anaesthesia on the left side. Although the menses had ceased nine years previously, she had been subject to migraine, with attacks of melancholia, and occasionally convulsive fits. The father, who had been a drunkard and profligate, had quitted the house twenty years before, and no one knew what had become of him. A brother of the father had died iu prison while under- going confinement for swindling. Mrs. V. had two sisters born after her. The one had died of convulsions connected with teething at the age of eighteen months ; the other died of convulsions when only six months old. " Mrs. V. had been a precocious child both physically and mentally. She had Avalked and spoken at a very early age, and had learned very rapidly at school. She has never had convulsions nor tic, but from the age of six has suf- fered from frequent migraine, followed by vomiting, and during her whole life her sleep has been troubled by noc- turnal terrors and nightmare. Menses began when she was twelve. At the age of seventeen she had attacks of chorea in consequence of worry. This lasted three months, and chiefly affected the left side. At nineteen she was mar- ried, and had her first child, a boy, when twenty-three. 1 Brain, October, 1889. 7 74 NEB VO US DISEASES. This child died of convulsions on the eighth day. In the following year she was delivered of a child stillborn. During her pregnancy she had anorexia and vomiting, which ceased spontaneously in the fourth month. "Since her chorea Mrs. V. has always enjoyed good health, and has had no distinctive nervous outbreaks until about three years ago. At the time her husband died she suffered severe pecuniary loss. This induced insomnia, followed by loss of appetite and emaciation. By hard work her health became pretty good. About two months ago she had a very abundant metrorrhagia. A few days after this mishap she began to feel constrictive pains in the head, extending over the whole of the cranium, but pre- dominating in the postero-inferior region, which appeared, moreover, to be the seat of a constant pressure. From time to time she heard a cracking noise in the back part of the neck, Avhich resounded in the occipital region of the skull. At nightfall she was seized by painful fancies, of ruin for her mother and her daughter, of illness for all her friends ; at the same time she was a prey to unusual pusillanimity and indecision. Her sleep was disturbed by dreadful nightmares. She was widely awake toward six in the morning, but was incapable of making any move- ment. She suffered from distention of the bladder, but could not even think of getting up. Her limbs seemed numb to her, and as if wrapped in cotton. She appeared to know the position of her extremities only, and it seemed to her as if the greater part of each limb was wanting, and her hands and feet had been brought up close to her body. The sensation is analogous to that experienced by amputated persons, who say they feel only the extremity of the absent limb. She could make no movement what- ever. "When daylight was admitted a sensation of numb- ness and pricking gradually appeared in the extremities of the fingers and toes. These sensations, occasionally very SOME DISORDERS OF SLEEP. 75 painful, preceded the return of ability to move. About eight o'clock the patient could get out of bed, maintain herself in a standing position, and make movements of the arms. The complicated movements of the fingers, how- ever, remained almost impossible. She was thus incapable of fastening her clothes or of taking up a pin. When she had moved her arms and had been rubbed a little her fin- gers became more supple. From the time she awoke until the nearly complete restoration of movement took in gen- eral about three hours. One day, when left in a dark room until about ten o'clock, she was found in the same helpless condition. Movements of the head and neck and of articulation were not affected. On examination no modification of the external aspect of the limbs could be determined. She suffered pain in the region of the left ovary and had slight anaesthesia on the same side. The contraction of the field of vision was tolerably extensive, and the patient was insensible to violet rays in the left eye. The iris of the left eye was of a deeper brown and the pupil not so large as on the other side. Under the influence of bitters, iron, bromide of potassium, and hydrotherapy combined with static electricity all these symptoms dis- appeared in the space of three weeks, with the exception of pain over the ovary and the hemiansesthesia. This case was, of course, distinctly hysterical." Case XXIII. — Mrs. P. She complained of sudden shocks in the head which awoke her abruptly. These occurred by night four or five times. Finally came other troubles which raised her inquietude to a climax. When her sleep became broken, toward four or five o'clock in the morning, she found that she could not move any of her limbs. This general helplessness did not last very long, for after a few minutes of effort she recovered power of movement in her right hand and foot, but for the limbs on the left side prolonged friction was necessary. This paresis was accom- 76 NER VO US DISEASES. panied chiefly ou the left side by a sensation of painful numbness and pricking. The hand especially was cold, and the fingers appeared to diminish in volume, the riugs hanging quite loosely. This helplessness, which at first persisted only a few minutes, was in a month's time prolonged for an hour or more. The patient could not raise herself out of bed until some one had rubbed her energetically. Even then she would remain for many hours incapable of making any delicate movements or even of simply fastening her dress. When the paralysis was at its maximum the patient declared that she was no longer conscious of the existence of her own body ; that she was, to use her own words, a pur esprit. Under the influence of cold douches repeated twice a day at regular hours and a tonic treatment of iron, nux vomica, and arsenic, with bromide of potassium given every evening in moderate doses — one to three grammes — her condition rapidly improved. The paralytic numb- ness on waking diminished at once in duration and then in intensity. At the end of fifteen days it had almost completely vanished. The sensations of shocks in the head, which had caused the patient to awake, disappeared in turn. The anorexia and pains resisted longer ; at the end of six weeks the pain in the tendo-Achillis still per- sisted, but in time it too disappeared. It is verv clear that a vast rano;e of disease or dis- order seems capable of causing night-palsy in its variety of degree. As concerns the cause^ there is much differ- ence of opinion; some look upon it as due to rare somnic conditions of the vessels of the brain, wdiile others, like Fere/ attribute it to a deficiency of physiological excitation — ^^ paralysis from irritation. ^^ 1 Brain, October, 1889. S03fE DISORDERS OF SLEEP. 77 Reflex it surely is at times, and purely local or periph- eral but rarely. It is needless to discuss treatment. It means any- thing from the treatment of neurosis to that of gout, neurasthenia, habits, renal insufficiency, diabetes, and what not. Sleep-ptosis. Another form of annoyance to which I have time to give but a passing notice is the ptosis of sleep. Of this I nowhere find mention. The pa- tient awakens with palsied lips; lifted, they fall. In some instances it lasts a few minutes or longer, or else before the disorder repairs itself sleep returns, and in the morning the patient has it anew, or awakens with- out it. I append two cases which came under the care of Dr. de Schweinitz: Case XXIV. — One was that of a woman, aged sixty-five years, as I understand in good health and not hysterical. There was some irritation of the lids and slight general con- junctivitis, also there was a slowly ripening double cataract. As the vision was still fairly good she read much, and if she used her eyes freely in the evening was sure to experience the following trouble : waking in the night, she found that her eyes could not be opened by the will. After they were forcibly opened they remained controllable by volition until after sleeping again, when the same phenomena recurred. The notes are not complete, and although she describes the ptosis as spastic, it seems to me to have been only a night-palsy of temporary duration. A somewhat similar case was observed at my clinic a few weeks ago, and I have seen a number of them. 78 NER VO US DISEASES. Case XXV. — J. C, aged twenty-nine years, a widow, was in absolute health after a childless marriage of four years. Soon after her husband's death she began to suffer with sexual dreams, and later with these and hemianses- thesia of decisive type without loss of power. A year from the beginning of her widowhood she awakened thrice in one night with paralysis of the lids. There were no eye- troubles, but the lids as she awakened could not be lifted at will. When raised by a finger they fell flaccid, and only by degrees, in an hour, recovered tone. This trouble, unknown to the day, continued for many months, and, indeed, disappeared only when this and all other symptoms were promptly dispersed by a second marriage. lu another case the ptosis was like the emotional spastic ptosis of hysteria we see in waking hours, and well know^n to neurologists: Case XXYI. — A woman, aged sixty-seven years, in good general health, but full of notions ; for fourteen years she has been the subject of stubborn retinal asthenopia ; the eye-grounds are, however, healthy ; there is a considerable degree of hypermetropia and astigmatism, together with in- sufiiciency of the internal straight muscles. Each night, for a long time, usually between twelve and two, she has been awakened over and over by a feeling that her eyes have closed spasmodically. She arises, forces them open with difficulty, and bathes them, ' ' because the lids feel as if they were sticky and would glue fast." The phenomena repeat themselves, but never by day. This case proved, I believe, very obstinate, and is only notable because it is of nocturnal origin alone. Sleep-pain. I add a feW' Avords as to what is, for rarity, a medical curiosity. I find in my note-book some half-dozen cases of pain in the legs, never known SOME DISORDERS OF SLEEP. 79 to the day, and needing sleep as a conditioning factor. Whenever I have spoken of this obscure disorder to a patient he is apt, if intelligent, to say : ' ' No, not pain; it is distress.'^ It occurs in middle life, or later, and, without previous disease, comes on slowly. In one case it followed typhoid fever. The cases are alike. A man is well in the day; walks, works, does as do others. Some time after he falls asleep he is awakened by aching in the legs, from the sole half-way to the knees. There is but one remedy — motion. He rises, walks for ten minutes, is eased, goes to sleep, and in an hour or two awakens to feel the distress and repeat the relieving exercise. There is no unusual heat or cold; nor any abnormal appearance. The matter is unpleasantly simple, and there is no clue to a cause. The case I now quote from my note-book I saw two years ago. It is typical of a rare condition. Case XXVII. — J. C, aged fifty-eight years, farmer, Kentucky ; married, two healthy children ; himself of sound breed. Has worked hard and has never known a serious illness. Xo malaria. In October, 1886, consulted me. I found him a man weighing 180 pounds ; height six feet, vigorous, Avith soft arteries ; heart beating 76 and per- fect. He has no piles, hernia, or varicose veins. Eats well ; is in all ways moderate and regular ; does not smoke and does not chew tobacco. All the reflexes are normal ; the heart and arterial tension healthy. Xo organ is diseased ; can work all day ; no tenderness in nerve-tracts. About four years ago he began to Avake now and then with distress in the legs. During the next year this got worse, and now is a source of extreme suffering and of disabihty, because of the loss of sleep it causes. Within an hour after bedtime he awakens in Avhat he calls tor- 80 NER VO US DISEASES. meut. From the knee to the toe his legs ache, without throb or sharp pain. He rises, walks until weary, goes to bed, sleeps, and wakes to the same pain or distress. Again walks, and so on, until day brings relief. At the Infirmary we learned that in the attacks the legs remain normal as to temperature, reflexes, and elec- trical conditions, as well as to sensation. No remedies were of the least use, except morphine, and I advised its steady use in despair as to other means. Sensory Shocks. Another phenomenon of sleep, or its borders, and also in the sensory sphere, I described long ago as sensory shock or discharge.^ This is a more rare, but also a more interesting disorder, than numb- ness. Except my own paper and a small book by a homoeopathic practitioner,^ I know of no literature on the subject beyond a few lines of remark on my paper in an essay of Hughliugs Jacksou's. Nevertheless, the subject is still of interest. All the disturbing phenomena of sleep at some time represent themselves, more or less well, in our waking hours ; but sensory shocks are, of all disorders of sleep, the most rare in daytime. In the pn^-dormitium while sensation is fading, but never on waking from sleep, the patient has in his head a sudden and violent sensation, and the forms it assumes may be classified thus: 1. In the sphere of general sensation. He feels as if struck, or as if he had a shock like that which a sudden arrest of motion causes ; or it is a feeling of i^ending. 1 Virginia Medical Journal, op. cit. Lectures on Nervous Diseases, op. cit. 2 In Dr. W. S. Searle's book he described sleep-shocks as a neurosis, hitherto unmentioned in medicine, and was evidently unaware that I had already and fully delineated its peculiarities. SOME DISORDERS OF SLEEP. 81 or as of a bolt driven through the head. These are the most comiQOii. 2. Auditory. A loud noise, like that of a pistolshot or of the crash of broken glass, or as of a bell, or a wire sharply twanged. 3. Visual. A flash of light. 4. Olfactory. Sudden sense of an odor. 5. I doubtfully add what I call emotional discharges. These are always mere abrupt sensations of fear, some- times preceding the sensory shock, and sometimes fol- lowing. What happens is usually this: A man going to sleep, but still quite conscious, and able to observe, feels sud- denly a shock in the head. It seems mechanical, as of a blow, or noise, or else of both ; and, also, there may be added a flash of light, vivid or like the soft summer lightning along an evening horizon. The intensity of these phenomena may be appalling, and even those who are used to them greatly dread their return. The first experience is sometimes most alarming. In many cases there is an aura. A physician, who came to me on account of these attacks, first called my attention to this. While waiting for sleep he became aware of an indescribable something w^iicli rose from the feet and hands, and, taking eight or ten seconds to reach the head, ended in a sound like the crash of glass houses breaking in a hail-storm, witli a vivid flash of yellow light, leaving him for a moment dazed, but able at once to rise, or to think. Such is the usual account given of this aura. It never varies, save that it may rise only from the belly. All sufferers, or nearly all, who have an aura, say they can stop the attack by turning over, or sitting up, 82 NER VO US DISEASES. or even by opening the eyes. A friend^ who had this trouble owing to tobacco, says : Case XXVIII. — "The shocks were of two kinds; one as if I received in the brain a thump, and one as if a pistol- shot occurred in the head. I had for a long while no idea that the pleasant mistress, Xicotia, was disturbing my in- ternal economy. At last, before learning this, I got used to these abnormal things, and would lie still and feel what you call the aura. By the way, it is not at all like an air, but like the surging upward of something more positive. When it gets to the neck I am gone ; the explosion occurs. Below that I can avert the wretched thing, either by rising or rolling over, for it never comes except I be on my right side. IS'o mental effort suffices to check it." I have notes of two males wdio suffer only if on the right side, but I have not always made inquiry as to this point. The aura is said at times to be like a tingling, or else is described as an upward surge of indescribable nature, and at times rises only from the epigastrium. Often there is none. Once felt in any case, it usually con- tinues in some form to precede all future attacks. There is another form of Avarning, Avhich patients only succeed in describing as a state of brain which foretells the shock. I have heard this called a hum- ming, or buzzing, within the head. Hysterical women are often quite unable to stop the shocks, or else the aura is too swift to be a timely warn- ing. It is rare to find any grave result. A few people become vertiginous, but not severely, x^t first, alarm causes emotional scare and a quickened heart, and in some few, even when repetition has lessened the terror of the shocks, they cause a more prolonged palpitation SOME DISORDERS OF SLEEP. 83 of the heart. In a few minutes, when sleep is again near, comes another shock, or there are a number of slight attacks, as of a bell, or a guitar-string twanged, and by degrees fading away ; visual discharges less commonly recur in this manner. I have over and over met with cases of sensory shock in the daytime, but only in the hysterical. In some few people they occur during sleep, and awaken the patient, but their habitual time is in the prse-dormitium. All of these curious outbreaks represent, as a rule, the ^^ coarse stuff ^' of sensory product, or something near it. There is sense of shock alone, or this in succession with noise or light, or both. The noise is more rarely comparable as to a note of music, or as to a bell, or a string vibrating. And so also of the optic explosion. There is light, violet or pale yellow. Xo visions appear; no voice calls. It is ^^ primary sensory stuff,^' and no more. In the one case connected with smell the patient had an epigastric aura, and smelt bananas. She had anosmia. These singular symptoms are found in some neuras- thenics, in hysteria, and most often in men as a result of overuse of tobacco-smoking. I first knew of it in my own case, during an attack of neurasthenia, many years ago, and soon learned that it was immediately due to my segar. I can assure you that one's first acquaint- ance with it is most terrifying. Bromides and strych- nine control it, as I have elsewhere stated. I pointed out years ago the interesting resemblance of these innocent attacks to epilepsy, and Hughlings Jackson has also noted the fact. Bennett,^ in a paper 1 Lancet, April, 1889. 84 ^"ER VO US DISEASES. on the Sensory Auras of Epilepsy, describes cases in which the signal-aura consisted simply of crude sen- sation, such as tingling or pain, which he calls sensory epilepsy. These are sensory cortex centre explosions, with consciousness and without spasm. Xext to touch-aura in epilepsy comes most often optic aura — sense of light, or definite color with form. In the prse-dormitium explosions the visual phenomena are still more crude than in these ; but in epilepsy audi- tory auras are rare, and gustatory and olfactory auras still more uncommou. The patient who has a special sensory aura feels as if j? truck a sharp blow, or per- ceives a noise in the head, or sees red fire, or a flash of light, and has no fit. Or else he has a sub- jective taste, or, like a physician I know, smells human ordure for half an hour, and may or may not fail to have the usual sequent spasms. These epilep- sies are very like such prsesomnic shocks as give us in their completest form a sense of tingling, which, rising, ends in a more abrupt sensory discharge, as of a sensation of shock, light, or sound, or these variously combined, as does also occur in epilepsy sometimes, as I have seen. Agaiu, too, in the subjects of sleep-shocks are found those who have in the prsesomnic state condi- tions of terror or daze, which are brief, and represent like phenomena in the intellectual or emotional sphere, such as are the dazed or dreaming states of some epilep- tics. And, curiously enough, this, too, may in our illus- trative shocks be preceded by a sensory aura of one or two senses — double auras. In epilepsy with auras we may have, first, an aura — i.e., a sensory discharge, usually simple tingling — and then a sense of flash or sound, or of light and sound SOME DISORDERS OF SLEEP. 85 together; the centres being, one may notice, in juxta- position.^ In prsesomnic discharges the discharge is simple, or preceded by tingling — true aura — vague epigastric sen- sations. The analogy to epilepsy is closer when, as often occurs, an uncontrollable jerk or flop of the whole body ends the attack. With motor centres patholog- ically over-excited, or capable of being morbidly over- charged, widespread epileptic motor phenomena may follow the sensory discharges, and in early cases of sen- sory explosions hysterical convulsions of mild type may result, and thus bring us still more near to the sequen- tial chain of epileptic conditions. On the other hand, epilepsy is not a disorder which haunts the praesomnic time. However close the apparent analogy, there must be a wide difference between it and these sensory explo- sions. Lastly, there is a form, which I have seen but twice, in which we have an aura — a flash, shock, or sound — and a sense of pain darting down the cervical spine and then along both arms to the finger-ends. Sleep-jerks. Chorea. In the motor sphere are certain disorders which trouble the sleep, or praesomnic state, in hysteria and neurasthenia, and which are only distinguished from phenomena found in health by their excesses. We all have had the common experience of a sudden jerk of the body as we were falling asleep. This, in certain cases, is exaggerated as to degree and number, and may occur also during sleep. I have seen many cases in which, scores of times in each night, the sleeper was awakened by a violent movement of every muscle at once. In others the jerks are of arms 1 Angular gyrus and superior tempor o-sphenoidal convolution. 8 86 ^V^^ VO US DISEASES. or legs only. Probably, what are known as ^^foot fidgets/' which oblige the sufferer to move in order to get rid of an ever-recurring sense of unease, are, too, of like parentage, and are to be seen in all degrees of intensity. I was lately consulted by a Western banker, aged forty six years, to appearance well. xS o organ was diseased. He had passed successfully through a time of great financial trouble, and in its midst his wife fell ill. After slie recovered he began to be a poor sleeper, and exhibited in turn a variety of sleep-troubles. He had mild forms of shock — i.e., light and noise. Dis- use of tobacco aided these and improved his sleep; but, somewhat later, he began to have jerking in sleep. An arm, or the leg, or the body was violently moved, so as to w^ake him up, and this, he declared, took place count- less times in the night. Still later he lay awake with uneasiness in the legs. He moved about and got a little relief. If he lay still, he had to move again. These motor discharges at times assume, through their frequency and severity, sach importance as to affect health by the destruction of sleep w^iich they occasion. An instance is given in my book of a woman weighing two hundred pounds, who spent her nights in a series of motor explosions so vigorous as at times to break the bed-slats. She has told me that she believes herself to have had as many as a hundred in a night ; the whole body moving violently in sleep with a jerk like the leaps of a dying fish. A different form of unease is seen in children who nevertheless seem to be well. Their sleep remains un- broken, but they roll over, twist, turn, wriggle, and continue to do so for hours. Possibly they are dream- ing, but of this there is often no evidence, and they are SOME DISORDERS OF SLEEP. 87 not affected in health by this extraordinary restlessness, which may remain as the habit of a year or more. I have over and over watched these little ones in a sleep which permitted them to roll over and bend the body and move the limbs, until it seemed scarcely possible that they could remain through it all in a state of slumber. A little pause might follow and then another period of nearly constant movement. In adults such extremity of restlessness is very un- common, and means more than in childhood. Of the hysterical sleepers much might be said, but in them this form of activity during sleep is seen at times. In the singular ataxia of hysteria, which I described a few years ago, the early stages of the disorder are apt to exhibit on waking an ataxic condition, which becomes increasingly worse, and at last continues through the waking hours. More commonly the ataxia comes on by degrees, and only in the day. Lastly, in relation to the motor sphere are the rare examples of chorea seen only for a time on waking from sleep, of which elsewhere I find no mention. As re- gards this, I may remark that some early ataxics and some neurasthenics are apt to be unsure of their move- ments for a little while after waking. Case XXIX. — A. B., female, aged fourteen years, men- struating regularly ; somewhat anaemic, but in other re- spects healthy. Last spring, in the mouth of March, she Avas attacked by a singular form of chorea. She had this trouble at no time except in sleep and on waking from sleep ; on either occasion it occurred in attacks which did not last very long. Her mother, w^ho frequently watched her in the night, said that three or four times in each night she became restless, 88 NERVOUS DISEASES. ' kicked off the covers, and began to move her hands, slowly flexing or extending them until at last, the arms also moving, a general choreal movement ensued, which, at the same time, affected the legs, arms, and body, but never the face. The attack affected her almost always when she awoke from slee^), during the time she was suf- fering from this disorder. In the warm summer weather it disappeared. It has returned again recently. She has been under my care for some time, so that I have had an opportunity of seeing that she is a person in j^erfect health, with no organic disease about her on which I can lay a finger. The attacks in the night are very rare, but she scarcely passes a morning without waking in this choreal condition. The spasm lasts from a half to three-quarters of an hour, and by degrees fades away. She apparently has no control over her movements, and in this respect they differ from ordinary choreas, except of the worst kind. This special manifestation of chorea must be ex- tremely rare. In the experience of many years (in which I have seen a multitude of cases) I recall but three or four of this character. It is mostly confined to sleep or to the awakening state, not apparently ex- isting during the day. I have no hesitation, how-ever, in classing it as chorea, because it readily yields to the treatment which is given to choreal cases, and because, in one instance, it occurred in a child who had had two previous attacks of chorea. This instance is, perhaps, worth relating: Case XXX. — C. J., a clever little boy of about twelve years — ^not very strong nor very active-minded ; never rheu- matic ; heart normal ; not very fond of outdoor sports, and somewhat anaemic — was attacked one spring with chorea, from which after two months he recovered. The following SOME DISORDERS OF SLEEP. §9 spring he was attacked again ; this attack lasted seven weeks, after which he again got Avell. The next spring it was replaced by the peculiar form of post-somnic chorea of which I have spoken. He had absolutely no chorea during the day. He usually woke up about half -past seven in the morning with choreoid movements of the hands ; both sides were alike affected. They were not in character like those of the girl mentioned above, and were more distinctly under control. For half an hour, however, he could not pick up anything without dropping it. What struck me with him, also, was that the face was not con- cerned in any way, nor did it affect either leg. Sensation did not appear to be affected, and he was relieved by the ordinary arsenical treatment and cold douches. Tonic Spasm is another rare trouble born of slum- ber, and lasting after it. I quote the only cases my note-books afford: Case XXXI. — Mr. J. C, aged forty-five years, merchant, had syphilis and distinct secondaries at the age of twenty- three years. Was well at the time of the malady about to be mentioned — that is, he had no perceptible organic trouble. About four years ago he began in the early mornings to wake up with rigidity of the legs. This was so extreme that it was impossible for him to bend the ankles or knees, or to elevate the knees at all. If they were lifted by an- other with difficulty, they fell slowly in extension. It was truly, therefore, a distinct tonic spasm. If at that time he had excess or defects of knee-jerk, I cannot learn. This state continued to show itself for over two years, occurring at intervals ; sometimes taking place every morn- ing for a week, then lapsing for a month, but never exist- ing at other times than when he came out of sleep. If he woke up in the night, he occasionally had this same coudi- 8* 90 NER VO US DISEASES. tion, but this was far more rare. It was commonly a mornincr affliction, and lasted for a few minutes or at most an hour. After a certain length of time the symptoms disap- peared, but, owing to a bout of drinking, they renewed themselves. Again he got well, and a period of two years elapsed without further trouble. He then began to have vertigo, followed by difficulty in controlling his water, and this was followed by incoordination and the entire range of ataxic troubles to which he is now a victim. 1 quote another case as a still more remarkable example of rigidity developed in sleep and continuing for a time after Avaking: Case XXXII. — The patient was a man in good circum- stances, aged forty-five years. He was in the habit occasion- ally of awakening in the middle of the night with rigidity of the legs. The limbs were violently extended, the feet being so completely flexed as to be straight with the line of the legs. It was almost impossible to lift the legs without lifting the whole trunk, so tightly were the muscles con- tracted and so rigid was the whole mass, including the intra-pelvic group. This did not seem to be due to any- thing in the way of specific disease nor to bad habits. The man had no disease to which I could relate it, except that he had been for many years a dweller in the lower part of the city, and had had attacks of ague year after year, and one very severe attack of remittent fever. Be- yond this there was nothing, and these symptoms had long since disappeared ; neither spleen nor liver was en- larged, nor, at the time of the rigidity, was he suffering from any malarial difficulties. The kidneys, heart, and lungs were alike sound, and to tliis day I remain puzzled as to the causation of this very peculiar mahidy. I saw SOME DISORDERS OF SLEEP. 91 him several times, because he used frequently to ring me up in the night in order that I might witness this affec- tion, which was painful from the intensity of the contrac- tion of the muscles. I have heard him scream from what he described as " positive agony." Indeed, nothing re- lieved it except full hypodermatics of morphia, under which slowly, within a couple of hours, the muscles would relax, but always after an attack would remain extremely sore for days together. He finally ceased to suffer. I have seen a disorder of the same kind^ or some- thing similar, in hysterical women ; but even among them it is very rare, and it is not necessary for me to go into details. The state is merely an hysterical curi- osity. I mention it to complete the list of peculiar cases which I select from my note-books. Respiratory Failure in Sleep. I conclude this study of the disorders of sleep by calling attention to one of very great interest. I believe that it was first described by the late Professor Samuel Jackson, but I have been unable to find his paper, which is not in the catalogue of the Army Medical Library. I recall, however, hearing him speak of cases in his lec- tures.^ Where, for some reason, the respiratory centres are diseased or disordered, a man may possess enough gan- glionic energy to carry on breathing well, while the waking will can still supplement the automatic activity of the lower centres. But in sleep, these being not quite competent, and volition off guard, there ensues a gradual failure of respiration, and the man awakens 1 Since this paper was first published others Lave called attention to this symptom in sclerosis. 92 NER VO US DISEASES. with a sense of impending suffocation. This is not to be confounded with the hysterical sleep-symptom of sense of suffocation, which is probably closer to the phenomenon of nightmare, and is followed by or associated with fear, and is soon lost on awakening. In the cases I refer to the symptom is sometimes a signal of dangerous meaning. I have met with it in extreme neurasthenia, but in worse forms in locomotor ataxia in its paralytic stage. I have never seen it in labio-glossal lingual paralysis, where it should seem likely to occur. In ataxia it may be due to sudden incompetence of the laryngeal muscles, Avhich are liable, late in ataxia, to become paralyzed. Usually, however, it appears to be a failure of the chest and diaphragmatic movements. Case XXXIII. — Mr, C, aged fifty-six years, had pos- terior sclerosis, but gave no evidence iu the day of respira- tory incompetence, although he was distinctly far iu the paral}i;ic state. When in deep sleep he began to breathe less and less deeply, and at last, for a few seconds, not to breathe at all. At this moment he moved, twitched, and at last awakened Avith evidences of commencing apnoea in the color of the lips, tongue, and nails. When awake a few voluntary efforts to respire relieved him. These attacks became at last so frequent and perilous that a nurse sat by his bed and awakened him as soon as he began to breathe less and less deeply. As time went on the trouble increased, and whenever he fell asleep respiration ceased abruptly. He was finally worn out with loss of slee}), and died suddenly in one of these onsets of respiratory failure. No post-mortem could be obtained. • I have seen two other cases, but none so remarkable as that I have briefly related. But on the morning SOME DISORDFAIS OF SLEEP. 93 after I wrote these lines I saw a case in an ataxic not yet in the paralytic stage. Just at the moment of fall- ing asleep he feels a sense of suffocation, fails to respire, and, in great alarm, sits up. These attacks probably differ somewhat from those of sleep. The type differs from that of the ordinary Cheyne- Stokes respiration, being merely a gradual failure to inhale — a less and less deep inspiration, but no sequence of rapid breaths ending in dyspnoea. CHAPTER V. CHOREOII) MOVEMENTS IX AX ADULT MALE, PROB- ABLY OF HYSTERICAL ORIGIX; UXUSUAL HYS- terical movemexts ix a child; hysterical :myocloxus. Case XXXIY. — D. F., a white male, aged thirty-seven years, applied for treatment December, 1894, on account of spasmodic to-and-fro movements of the head. The family history is negative, and the previous health has been gen- erally good. He had typhoid fever when ten years old, and again Avhen eighteen. He has been married fourteen years, and has had three children, of whom one died of dysentery. Syphilis is denied, and there is no evidence of it. His habits were good, and he did not use tobacco excessively. About three months before coming to the Infirmary he had been much worried about moving his place of business to some other part of the country. He could reach no de- cision, grew nervous, slept little, became dyspeptic and very melancholy. After about two weeks spasmodic movements of the head suddenly appeared. Present state. Every few moments the head is forcibly jerked backward by the trapezii muscles. AVhen lying in bed the spasm is much less frequent. It is increased in frequency during examination, and for a time ceases en- tirely if the attention be strongly directed to any object. For example, while looking at a thermometer bulb the patient was quiet for five minutes. During sleep there are no movements whatever. While in the hospital he devel- oped general choreiform movements. HYSTERICAL MOVEMENTS. 95 He is fairly well nourished. His expression is markedly melancholic. Intelligence is good, but he is profoundly apathetic. He declares that he sleeps very little. His appetite is poor and he suffers much from gaseous eructa- tions after eating. The thoracic and abdominal organs are normal, the station good, and the gait normal. The urine is normal. Prof, de Schweinitz examined his eyes, and reported slight hypermetropic astigmatism with in- sufficiency of the interni. The patient was put at absolute rest in bed, given gel- semium, bromide, and chloral, and, later, hypodermatic injections of distilled Avater. These had a very happy effect upon his insomnia, and, indeed, caused he declared drowsiness the following day. After about eight weeks' stay in the hospital he was discharged greatly improved, but still having occasional clonic spasms of the trapezii. There were no sensory changes. The man was emotional and given to tears. Soon after admission he began to have at times, after exercise, great emotion, or any excitement, curious movements of one limb or of the trunk. Thus the arm would be extended forcibly, and again and again for a half-hour, or the leg, or both legs, with intervals of twelve to fourteen seconds ; or the whole trunk, as he lay, flopped fish-like until wearied. The head-movements were likely to cease when any other form of spasm was present, but were, on the whole, the most common. They were generally either to-and-fro motions or backward jerks, seemingly due more to the trapezii than to the other posterior neck-muscles. Over all of these movements he had temporary volitional control. When he thus restrained them he said that the sense of discomfort became by degrees really unendurable, and he had to ''let go." Eemarks. The resemblance, clinically, to the cases of habit-chorea or habit-spasm, as Gowers likes to 96 ^^ER VO US DISEASES. describe the disorder I first called attention to some years ago, is very striking. The lad I shall show you to-day is another illustration of a genus of cases which has several related species, and such variety as individuality may occasion. As in this case, so also in that of the boy, hysteria is the potent agent in their production. Case XXXV. — B. F., a male, aged ten years, applied for treatment in December, 1892, complaining of invol- untary movements of the head. His father had had fits in childhood, and one cousin has had habit-chorea. One brother died in convulsions when seven months old. The patient had diphtheria when two years old, scarlet fever three years ago, and measles last year. He has always been nervous. The mother states that he is the smallest boy in his class and has always stood at the head in his studies. She thinks that overstudy in preparing for ex- aminations may have been the cause of his illness. The present trouble began about two weeks before application for treatment. There is constant wagging of the head from side to side, shrugging of the shoulders, and winking. The patient is a bright, well-made lad, with excellent muscular develop- ment. The station is good with the eyes closed. The knee-jerks are capricious. Clonus is absent. The cremas- teric reflex is present. The abdominal reflexes are absent. The elbow-jerk is present. The muscle-jerks in the arms are very marked. There are no palsies. Si:)eech and sensation are normal. His physical health is good, and examination reveals no disease of the abdominal or tho- racic organs. The foreskin is very long, but there are no adhesions. There is no genital irritation nor any bad habit. Prof, de Schweinitz examined his eyes and reports: " R. E , V. — 15/xxx. Round disc, temjioral edges clear ; HYSTERICAL MOVEMENTS. 97 nasal and upper and lower margins hidden by grayish in- filtration ; much white tissue around central vessels. Veins full, arteries normal. L. E., V. = 15/xv (partly). Similar condition of disc, but blurring of disc less marked. Slight concomitant convergent squint. Eyes Avander in under cover. Hypermetropia = 1.5 D. Slight astigma- tism. Diagnosis : hemi^neuritis with hypermetropic astig- matism, and slight convergent squint." The case was diagnosticated as habit-chorea, treatment given, and the boy told to return in a week. Two weeks later he came back showing marked changes in the symp- toms. Every few minutes the head is jerked violently and suddenly to the right or left. Previously the motions had been slow and gentle. An arm is very forcibly ex- tended once, or the legs are flexed and extended once. Similar movements elevate or depress the shoulders. These movements are independent of each other ; that is to say, at any given moment any part may be involved, though oftentimes the legs move synchronously. The movements are shock-like, sudden, rapid, and violent. They appear almost as if willed. During sleep they cease entirely. Emotional excitement increases them markedly. Volun- tary motion of arm or leg decreases them for the time being in the member used, but has no effect upon the rest of the body. While lying down they are less severe than when up. There are no sensory failures. He was given Fow- ler's solution in increasing doses and ordered to be kept at rest. After a few days the movements suddenly ceased, but were immediately followed by attacks of violent, barking, spasmodic cough, so severe as to alarm his parents. When next seen at the Infirmary he would every few minutes make a short, quick, explosive, grunting noise. When told to breathe deeply the cough stopped entirely. Atten- tion produced by having him fix his eyes upon a bright 9 98 NER VO US DISEASES, object had the same effect. Slight general choreiform movements were also present. Complete cure followed his admission to the Infirmary and subjection to the hos- pital discipline in bed for a few weeks. Remarks. This case, as you see, looks like wdiat I venture to call acute habit-chorea. The same powder of control exists for a time as in the man. The uneasi- ness under self-control is present. The abrupt cessation of other movements when the barking or grunting comes on is sometimes seen in habit-chorea; but in that dis- order there are usually frequent repetitions, never vio- lent, of the part disturbed. This lasts for days or longer, and on ceasing may be replaced by like movements else- where. These children may or may not be hysterical, but the hysteria of childhood often fails to give you a complete picture of that disorder. The grunting is not like the cough of hysterical ^vomen, and is probably only an incidental product of one of the forms of semi- spasmodic movement. At times it is due to sudden abdominal muscular contractions. Clinically and prac- tically all this is interesting. Of this you may be sure, that w^hen adults are afflicted w^ith these forms of tem- porarily controllable semi-spasmodic motions, you w^ill find them hard to get well. All the emotionalness of such temperaments as incline to motor disorder is in- creased by their presence. These people get self-w^atch- ful, depressed, and wdll-less. Children are easier to cure, no matter how grave the malady, or how distinct the hysteria. Ahvays wMth them developmental change assists, if you know how to use your opportunities. Isolate them, if possible. Insist on mild diet — as of milk or vegetables, or these combined. Keep them at rest, and by-and-by offer little bribes to restrain the HYSTERICAL MOVEMENTS. 99 movements. The slight cases of habit-spasm may be enduring, and the more severe cases get well, like this good little fellow. There are cases which do not, and which develop into the disastrous states of mind and body I have delineated in my Lectures on Nervous Diseases. These failures are commonly due to the folly of parents. There is no worse enemy of a nervous child than a nervous mother. The peculiar violence of spontaneous action in the lad's spasmodic movements recalled to my mind a man who, many years ago, was my patient. He was subject — and for periods of a week or two — to a disorder of which, being a quiet bank-clerk, he was much ashamed. After a few days of general uneasiness, which made him restless and inclined to excessive exertion, he began to have spasmodic actions — like this boy's — a sense of profound unease for a few minutes, ending in a single motion of abrupt violence. A leg was thrown upAvard or back; an arm, w^ith the fist clenched, struck out once with a look of purpose about the act which was contradicted by the fact that he had over and over hurt his hand by driving it against some obstacle. Once or twice he had hurt others. At times he would warn me or another of the coming risk. No cause for this peculiar state was ever found ; nor do I know what became of the man. Some of you may recall the interesting case seen here last year, in a Hebrew in middle life, who presented a striking illustration of multiple myoclonus. I reported it with other as curious spastic cases to the Neurolog- ical Association. I now recall it to state that the man has become well and walks about like others. I saw once, some years ago, a similar case, and it too was hysterical and in a Hebrew. 100 NEB VO US DISEASES. And now I am able to read you the notes of a case of multiple myoclonus, clearly hysterical, a ad in a gen- tleman whom I lately saw in consultation in a distant State. As I have so lately discussed the possibility of these spasms originating in the cord, I shall not need to repeat my remarks. Case XXXVI. — C. B., aged thirty-five years. Family history. Some of the remote ancestors were rather eccentric or peculiar in certain directions. His paternal uncle died, aged forty-five years, of acute cerebral disease, said to have been encephalitis. One cousin, a son of this uncle, has had incoordination of all the extremities, cho- reic movements of the face accompanying voluntary move- ments only, and indistinctness of speech, which were first noted in infancy, but were not thought to have been con- genital. The mother's labor was normal, no instruments having been used. The child was somewhat backward in develoji- nient ; the anterior fontanelle seems to have remained open unusually long. There were decided indistinctness and difficulty in speech, which only disappeared after some years. At school the boy was rather slow and seemed disinclined to learn. He was always a little jDCCuliar ; he had very strong opinions on various subjects which could not be readily influenced, and were different from those natural to his companions. For some years before his present attack (six years ago) he had been considered rather odd by neighbors. When about seven years old he was thrown out of a light wagon and the wheel passed over his head. No evidence of fracture of the skull was detected and he seemed well in a few days. When fifteen or sixteen years old, and while studying rather hard at school, he began to have severe frontal, bilateral head- HYSTERICAL MOVEMENTS. 101 aches, which at first came after study only, but gradually persisted, although the study was given up, and after a time came in the mornings without apparent cause, lasting some hours, apparently often connected with the condition of the weather, being Avorse when there was a cold, piercing, or bracing wind. From this time the headaches have per- sisted, at first coming principally in the spring, while he was free from them during the rest of the year ; later, occurring at any season, and gradually growing more fre- quent and more troublesome, so that, finally, he gave up his home in the city and lived entirely in the country. Study was found to be impossible. Change of climate made his sufferings worse. The patient led an out-of-door life, superintending and working on his farm until his present trouble began. He was an unusually large, strong, and muscularly well-developed man. The present trouble began six years ago, some time after a moral shock in which the emotions were much involved. He was attacked with unusually severe headaches, general lassitude, and inability to work, so that he let his farm for a time and came to live with his parents, who had a large estate in the neighborhood. While with them he was one day, when driving, attacked, without apparent cause, with a fit of coughing, which lasted some minutes and Avas of a convulsive character and so violent as to be alarming. After this similar attacks of coughing came on almost daily, and seemed to be aggravated or provoked by driving. A few days later he began to have attacks of violent, involuntary movements (clonic spasms) affecting the extremities, being at first often unilateral, sometimes on one side and sometimes on the other. The lower ex- tremities were more affected, on the whole, than the upper. The earlier attacks of spasms occurred only on rising in the morning. After a few weeks the coughing-spells were largely replaced by hiccoughs, and it was found that the 9* 102 NER VO US DISEASES. headaches, the cough, the hiccoughs, and the motor spasms were more or less interchangeable. Since this time the general features of the affection have remained unaltered. The motor spasms have gradually become more frequent, for some years occurring daily at stated hours (periodic), with frequent intervening attacks, and now several times every day. The motor attacks consist of very violent, more or less regular movements of the extremities, especially the lower, when violent stamping or up-and-down movements follow each other with great rapidity ; in the upper ex- tremities there are regular, coarse movements of the entire extremities. These attacks come on, especially at the regular times, without apparent cause, but are also pro- duced at any time by a sudden, unexpected touch or by any touch with which emotion is connected. They are also produced by movement (both seusori-motor and moto-motor spasms). The paroxysms of cough disappeared after some months to a considerable extent, w^hile the hiccoughs lasted only a few weeks, the place of both being apparently taken by the larger spasms of the limbs. During the last three years there have been many attacks of retching and vomiting (or regurgitation), without nausea, and, for the last two years, attacks of violent and forcible shouting. For a year past some loss of strength has been noticed and an increase in the ease with which the spasms are caused, especially by walking, so that they now largely preclude any attempt at exercise, as he states that he is liable to have his legs drawn from under him violently and suddenly, so that he falls to the ground. If walking be persisted in, in spite of the spasms, the headache be- comes unbearable. Of late, the trunk has also been in- vaded by the spasms, the body being frequently bent to one side, usually the left ; and clonic spasms in the trunk- muscles sometimes last for hours and even days (once HYSTERICAL MOVEMENTS. 103 apparently without remission for four clays, but the patient was not seen while asleep), causing great soreness and ten- derness in these muscles. There is noAV much dizziness, which began first six months ago, and now causes an additional difiiculty in walking. He has taken food irregularly for years ; of late, not more than one meal of solids a day, and that usually at 11 p.m., and the rest of the time weak coffee or milk when wished for. The bowels are regular; the urine negative. The face is now usually pale, but becomes turgid and congested during attacks, partly from the violence of the motion. The intellect is unimpaired (broadly speaking). Sleep has been good. Remarks. This gentleman, unlike our former case, is in easy circumstances. It were better he Avere not, as he is able to control his own surroundings and to isolate himself as he pleases. The limitations to which the position, age, and circumstances of the case subject our therapeutics must be clear to you. When I first examined this most expressively hysterical case I found my patient up, and after a partial examination, with increasing signs of fear and nervousness, he went to bed. There I completed a long, but, of necessity, im- perfect study. He was a rather well-built, well-colored man, with no organic troubles. As I went on to make the ordinary search as to sensation, reflexes, etc., all being normal, he became all the time more and more convulsed. If I touched a leg, it passed at once into violent convulsion, and this at times involved all four limbs, and was so terrible that I thought the bed would be broken. When he tried to walk, and always then if emotionally disturbed, he ^vould begin to stamp in a strange way and with swiftly increasing force, and this 104 NEB VO US DISEASES. spastic state, reaching the trunk, seemed then to draw him down, so that he fell or contrived to get back to the bed. I was obliged at last to cut short my exam- ination, but not before, with the aid of his physician, I was able to reach very distinct conclusions. Cases of violent hysteria in the male are not common, at least in America. Only once in my life have I seen a male exhibit all the acts in the long drama of hysteria precisely as we so often see them in the female. I now add the opinion given in the case of Mr. C. B. A careful consideration of the symptoms brings me to three conclusions: 1. That the form of the convulsive attacks brings this disorder closer to the clinical delineations of myo- clonus than to those of any other group of symptoms. He is liable to have violent stamping, or worse, from standing — i. e. , sole-pressure causes it. Also, when cog- nizant of it, a mere touch anywhere brings on clonic spasms of the legs, or of the arms under like circum- stances. Voluntary motion may, as in other cases, give rise to like spasms — I. e, the spasms as to cause may be sensori-motor or moto-motor. 2. Evidently attention increases the severity of sen- sori-motor manifestations. 3. For various reasons, this myoclonus seems to me hysterical. The transfers, the interchangeableness of spasms, headache, regurgitation, hiccough, and vocal symptoms, all point this way. So do the type of lar- yngeal phenomena and the characteristic regurgitation without nausea; and that the first spasms followed a grave emotional disturbance assists us to a like conclu- sion. The original injury may have been coutributive, HYSTERICAL MOVEMENTS. 105 but there is not in the skull any distinct local evidence of organic lesion. If it all be at last hysteria, or due to the injury but in its outcome hysteric, one might look to find sensory changes; bnt close examination of the skin is impossi- ble, and without ether I could not see the eye-grounds as I wished to do. It would be worth while once to do this under ether. Probably the spasms have their birth in the cord. They seem to me in quality and history functional, and I ought to add that, when off guard — a rare thing — the touch of my hand does not occasion spasm, nor does his own touch of himself, unless, having been asked if it be so capable, he with pre-attention touches himself. Probably he is incurable, but this does not imply the certainty of his not losing the spasm. If he were a lad, I should take him away, and with isolation, massage, and electricity treat him, and have hope. Now, I do not advise it. I should like to see hypnotism used. I would assuredly use arsenic for a year. I would not let him live wholly alone or unvisited by friends, as he now wishes. Hypodermatic use of arsenic is to be considered. I have little doubt that the injury may have been the ultimate cause of headache, and that he has had more or less of chronic meningitis. If he could have a good study of the eyes by an expert, I should feel better satisfied, as the eyes may, with slight ocular defects, be competent to trouble a defective brain. Also, the color- fields might prove very interesting. I gather enough in various ways to make me think that Mr. C. B. was never a perfectly normal person in earlier youth. When, to a person of such neurotic 106 NER VO US DISEASES. type, come accident, emotions, etc. , then the worst and the more unusual results are to be apprehended. Yet a word before I close the lesson of the day. I have used the label hysteria again and again. It is, and as yet mast be, a word of somewhat loose employ- ment. I am not sure that it is just to apply it here, because with spastic or other symptoms the patient is merely emotional; but certainly we, by common con- sent, do this, especially in the unusual forms of spasm and in cases in which clearly emotion was the parent of spasms. When we have areas of anaesthesia we use the term in question with lessened doubt. If, too, we find these, and Avith them optical anaesthesia for colors or especially reversals of the color-fields, our doubts are further lessened. But, after all, it is the grouped condi- tions which fully justify such clinical labels. Dr, J. K. Mitchell and Prof, de Schweinitz have shown how much our American experience as to the eye-symptoms of hysteria may vary from that of the French observers. CHAPTER VI. I DESIRE to draw attention to a single symptom which has not, hitherto, received sufficient notice; it is not of extreme rarity. The cases I sliall report are characterized by the facts that the patient complains of local or general cold- ness, and that, as a rule, the parts involved have no abnormal temperature, or have one the reverse of that complained of. No doubt there are in medical litera- ture many such records, but they must be buried in cases which, being reported under other titles, are diffi- cult to find. In the catalogue of the Army Medical Library there is no heading which covers this symptom. The meagre material which I possess could, with time, have been made larger, as I find that almost every phy- sician has met with cases of the kind I am about to recount. I liave enougli, however, to enable me to make a rough division of my cases into at least three classes: Class I. has a central cause, and must be of great rarity. Class II. is frequently due to neuritis, and is not very uncommon. It contains cases which lack the remain- ing qualities of neuritis, and may or may not be due to local inflammatory nerve-states. Class III. is inexplicable or hysterical, and the phe- nomena are commonly unilateral, as in the first class. 1 Transactions of the Association of American Physicians and Pathologists, 1895. 108 NEB VO US DISEASES. As these cases have not occurred to me in such com- petent numbers as to enable me to generalize largely, I shall relate them with what comment each suggests. Class I. In this class I have but a single case, but it is so remarkable that I am glad to present it for con- sideration. Case XXXVII. — Sir P. Broke was seriously wounded in the head in the fight between the " Chesapeake" and the "Shannon," in 1813. He received a severe sabre- wound on the head while boarding the " Chesapeake." Of the later consequences of this Avound I find no very distinct account in the loosely Avritten and tedious biog- raphy of the patient. * On August 8, 1820, Sir P. Broke had a fall from his horse, which he described as follows : " I was stunned by the fall, but it was only for a moment, for I was certainly dragged only a few yards ; and I chiefly remember, as my first perception after the fall, that I was lying on my back and looking upAvard at my foot in the stirrup. I certainly got up unconscious of injury and walked about a quarter of a mile to my mother's house, whence I had just departed. I remember nothing of this walk, and my recollection recommences with my sitting down quietly in the room and telling her I had had a fall. I began in a few minutes to have some sense of stupor, as from a blow on my head, and, having gone upstairs to wash the dirt off my head, I then dis- covered that my head was scratched in several places and bleeding. The stupor became more oppressive, and I sent for a surgeon, who bled me in the left arm, taking away ten or twelve ounces of blood. This might be about an hour and a half after the accident. The stupor increased considerably ; I was persuaded to go upstairs again and go to bed. This I clearly remember, and that while pull- ing my clothes off a violent retching and vomiting came SUBJECTIVE FALSE SENSATIONS OF COLD. 109 on, and then my memory again failed me for several hours ; but on the following morning I was perfectly clear again and had some good sleep. I felt the usual soreness in the head from such contusions, but had no hurt in any part of the body nor any uneasiness in my stomach, and my appetite was unimpaired. I felt weak, but unconscious of any material injury beyond the bruises I had received. "The usual treatment in such cases was resorted to to prevent inflammation, and successfully, though my bodily powers were thereby, of course, considerably weakened. The first symptoms that I remember of any affection of the nerves were my perceiving, in the afternoon of the day fol- lowing the accident, a sense of extreme cold in my leg and foot and left hand, so that I could not sleep in com- fort without a worsted glove and worsted stocking ; and in the course of the next day I discovered that the whole of the left side was strangely affected, the sense of cold ap- pearing to lie internally upon the coating of the bones of the arm, thigh, and leg ; and that, though the flesh exter- nally was warm to the touch and generally in a state of perspiration, and though the skin appeared perfectly fresh and smooth, without any sign of withering or contraction, yet that skin over the whole left side of my person was affected with a singular numbness to the touch. "After a time it became necessary to consult Sir Astley Cooper, who wrote to Dr. Lynn in the following language : " ' I have heard from Sir P. Broke a minute detail of his feelings and an accurate history of his case. The situa- tion appears to be as follows : On the left side of the head the sabre-cut has depressed the bone and compressed the brain ; and as the edges of the fracture, which are displaced, have long since united to the skull, all expectation of any change in that part must be abandoned, and the diminished nervous energy of the right side, consequent upon this in- jury, will continue without variation. 10 110 NEE VO US DISEASES. " 'Not so in the right side. There the mischief has been an extravasation of blood upon the brain or its mem- branes, and from decussation of nerves from the brain to the body the left side is suffering from diminished tempera- ture or power of resisting its changes, and from altered sensations. The heart is subject to occasional alteration in its functions from diminished nervous excitability, and hence the pain felt in its region and the sense of strangu- lation under which Sir P. Broke occasionally labors. The stomach is also occasionally suffering from its sympathy w^ith the brain, and hence those attacks which drinking warm water alleviates. Congestion in the brain from changes in position and from over-exertion of mind tends to a sudden increase of all the symptoms ; but this is tem- porary only. The probability is that the blood will gradu- ally absorb if Sir Philip's general health be supported and he avoids too much mental excitement and he preserves his body from humid circulation.' " Nothing is said further either by Sir A. Cooper or the biographer of Sir Philip in regard to the very interesting symptoms described ; but in Guthrie's Military Surgery, where first I lit on the case, that author thus describes it : "Admiral Sir P. Broke received a cut with a sword on boarding the * Chesapeake,' on the left side of the back of the head, which went through his skull, render- ing the brain visible ; the wound healed in six months. After temporary paralysis of the right side he recovered, with a loss of power and a disordered sensation in the sec- ond, third, and little fingers of the right hand, aggravated by cold weather and by mental anxiety. " Seven years afterward he fell from his horse and suf- fered from concussion of the brain, which added to his former sensations by rendering the left half of his whole person incapable of resisting cold or of evolving heat. In a still atmosphere abroad, at 68° F., he said, ' the left side SUBJECTIVE FALSE SENSATIONS OF COLD. H] requires four coatings of stout flannel, which are augmented as the thermometer descends every two degrees and a half, to prevent a painful sense of cold ; so that when it stands at freezing-point the quantity of clothing of the affected side becomes extremely burdensome. When exposed to a breeze, or in moving against the air, one or even two oil- skin coverings are necessary, in addition, to prevent a sen- sation of j)iercing cold driving through the whole frame.' Moderate horse exercise and generous diet improved the general health ; the warm bath caused a distressing effect ; the shower-bath, cold or tepid, increased the paralytic affec- tion. Frictions with remedies of all kinds increased it also, and so did sponging with vinegar and water, as well as any violent, stimulating, quick excitement or earnest attention to any particular subject. The Admiral died unrelieved, twenty-six years after the receipt of the injury, of disease of the bladder." Owing to the rather vague statements of the surgeons and the biographer, we can only infer that iho; fall may have given rise to a rupture of a vessel, supra- or sub- meningeal hemorrhage, slight motor loss, and irritative disturbance of sensory regions, causing numbness of the opposite side and false sense of cold. Occasionally, in hemiplegia, coldness is a symptom mentioned by the patient, but not much complained of. I recall no case like this one, but I have distinct remem- brances of at least two instances of probable clots involv- ing the internal capsule and optic thalamus, causing lack of muscular sense and numbness on the left side. In both unilateral sense of cold was felt, although there was no fall of temperature. In one of them the anaes- thesia w^as notable, so that pin-pricks were not felt and did not bleed. Both were adult males. In cases of hemiplegia it is desirable to know not 112 NER VO US DISEASES. only the actual temperatures of the two sides, but also how w^ell cold and heat are distinguished on both sides: and, lastly, if there be abnormal subjective sensation of either cold or heat on the palsied side; and, too, the date of this symptom relatively to the attack — because, clearly enough, even in a cerebral paralysis, the later comino; on of false feelings of cold or heat in the ex- tremities may be due to peripheral neuritis. Class II. Local sensations of cold loithout lowered local temperatures. The three cases which follow are none of them as full as is now desirable, because the notes were made as mere memoranda for use in the conduct of the cases, and before I began to feel a larger interest in the symp- tom. All three were affected in the lower half of the body — two of them especially in the buttock, which is a not rare seat of the symptom in question. Case XXXVIII. (Case 281 in Xote-book.) Local sen- sation of cold in the buttocks. — J. P., single ; aged fifty-three years ; Connecticut. The patient was a man of fortune, and had gone through a variety of excesses, chiefly sexual. He had had gonorrhoea, but never syphiHs. There had been attacks of pain in the legs, arms, and back, and these had been in a measure relieved by various means before he came under my care. He also had a variety of vague gastric symptoms, which grew out of the hypochondriacal state. He had had tingling of both legs and feet, some loss of power in the right arm, tenderness upon pressure along many nerve-tracks, and a difiiculty of using his brain for prolonged mental exertion, which I believe to have been of small moment. The one symptom on account of which I have mentioned this case was the constant complaint of coldness. SUBJECTIVE FALSE SENSATIONS OF COLD. II3 When seen by me he was ruddy, in good flesh, and had no organic disease of any of the viscera. The nerve-tracks above the waist were not sensitive, and he had long been free from neuritic symptoms of the arms. The two sciatic nerves were slightly tender from the exit- points to the knee. The electrical tests gave normal re- sults. The statioD-sway was antero-dextral, and good ; knee- jerk, right seven inches, left one inch, but sensory reinforce- ments added to the knee-jerk three inches or more right and left. Motor reinforcements added about two inches right and left. Superficial reflexes were normal. Sexual power somewhat lessened. Excessive exercise increased the ten- derness and also exaggerated the sense of coldness. This symptom began to be felt before he complained of distinct pain in any region, and his aches w^ere so much better that it was merely the coldness w^hich brought him to me. This was positive and most distressing. It affected both but- tocks and the upper half of the back of both thighs, and was as intense as if he were seated on ice. Occasionally the calves suffered. I saw him but once, and I do not know how the case resulted. The parts complained of were warm to the touch, but I took no note of the actual local temperatures. Case XXXIX. (Case 840 in Xote-book.) Subjective sen- sation of cold ill buttocks with actual elevation of temperature. — J. P. C. , coal dealer ; aged fifty-two years. No syphilis or gonorrhoea ; much on his feet ; uses neither tobacco nor alcohol. Married, has tAvo children. Family healthy and long-lived. The patient lives in a somewhat malarious portion of New Jersey, but has not, himself, been subjected to positive ague. About eighteen months ago, having been more than usually afoot and somewhat worried by business annoy- ances, he began to have a painful sensation of cold in the left gluteal region, and down the back of the thigh 10* 1 1 4 NEB VO US DISEA SES. nearly to the knee. There was nothing of the kind in the other leg. This trouble increased gradually until it be- came so positive that he was in constant discomfort. It has varied very little up to the present time, and, although better in summer, is yet distinctly felt through the warmest weather. Heat at all times makes him feel comfortable, and the greatest amount of relief is obtained by standing with his back to a hot fire. As soon as he leaves the fire, however, the sensation of cold returns with all its vigor, and, in fact, rarely leaves him. There is no perceptible pain in the parts affected. His station is good ; his knee- jerk is normal, three and one-half inches, and capable of ready reinforcement, both sensory and motor. The ankle- jerk is present and reinforcible ; there is no clonus. Super- ficial reflexes exist in integrity. Electrical reaction of the limbs normal ; water and bowel mechanism perfect ; but he thinks that since this trouble began his sexual power has lessened. Digestion is good, appetite fair. All secretions normal. His eyes are exceptionally good, since he is not yet obliged to wear glasses. An actual examination of the temperature shows the left buttock to be distinctly warmer than the right ; it was found to be J° to ^° F. higher than on the right side. The exit-point of the left sciatic was at times tender. He declares himself to be not as strong as he was. He is somewhat paler, and has lost from four to five pounds of flesh. Always in the morning, on rising, he is nervous — as he says, a " little trembly." There seemed to be no indications, except to look after the manifest failure of his general health. Quinine and arsenic had already failed, and long hohdays in the mountains proved valueless. Iron was given in moderate doses, as well as strychnine and cod-liver oil. Within a week or two he began to gain in health. His weight improved, but there w^as no relief from the sensation of cold. Accord- ingly, I advised local miussage ; l)ut after its use the parts SUBJECTIVE FALSE SENSATIONS OF COLD. 115 seemed colder than ever — that is to say, when the actual temperature of the parts went up ^° to 1° F. under mas- sage the sensation to the patient was as if the part had become colder. He was under the impression that gal- vanic electricity locally was of service, but exercise did not improve his condition. After many months' treatment, during which I saw him occasionally, he had gained largely in general health and freedom from nervousness, and in capacity to do his work with his usual energy ; yet, not- withstanding, there was the same constant sensation of local cold. I think malaria may be ruled out as a cause of his trouble. The most careful study showed uo local ten- derness, except as stated. There was at times, after long exertion, slight tingling of the left foot. This case was one of real suffering; the ache of the cold was intense and disqualifying. In the light of other cases I suspect this to have been a neuritic con- dition. The increase of warmth from massage was felt as cold, and this is interesting, since he had a quite normal appreciation of applied cold and heat. Case XL. (Case 821 in Note-book.) Subjective sen- sation of cold. — Mr. C. S., aged sixty-three years ; glass manufacturer. Patient has no bad habits ; has never had syphilis. He has been for many years an extremely active business man, weighted with many responsibilities and constantly afoot. There are no head-symptoms. He sleeps well, has a good appetite, and there are no gastro- intestinal troubles. Five years ago he had some difficulty in passing water, and, later on, a return of the same trouble, which appeared on examination to be due to an enlargement of the pros- tatic gland. Within a few months he found that exercise tired him, especially mounting stairs. There is now no 116 NEB VO US DISEASES. cardiac lesion to account for the difficulty, and the arteries are in unusually good order. There is a distinct lack of power in both legs, and, in walking, he does not use the left foot as well as he should. His station is good ; his sway, standing with his eyes shut, is antero-dextral, not exceed- ing an inch in either direction. The knee-jerk is normal, three and one-half inches ; reinforcements are normal. There is no clonus, and no perceptible loss of sensation in the legs and arms, either as to touch, pain, or temperature. There is no tingling or numbness. The mixed urine of the night and morning contains two grains of sugar to the ounce, but no albumin or casts. None of these symptoms were such as to alarm him or cause him to consult me. He attributed them all to overwork and to being too much afoot. That which drove him to seek my advice was a slowly increasing and very positive sensation of cold, from the Avaist down to the calves of the legs, and limited to the posterior half of the body. It was usually most severe on the right side, but varies a great deal, sometimes being felt more on the left. The sensation is described as being equivalent to that which would be experienced by sitting long on ice. It caused him to desire to cover the parts concerned with an excessive amount of clothing. As the cold was apparently lessened by motion, he kept afoot, when evidently his general condition demanded that he should not. He tells me that at times, after active mo- tion, he has some sense of numbness down the back of the right leg in the region affected with the false sense of cold. I could find no notable difference between the temperature of the two sides of the body in the regions Avhere he suf- fered, but, as both had more or less of the same trouble, it was natural that the temperature should not differ greatly. Normal surface-temperatures are apt to vary in different individuals, and to a far greater extent than interior tem- SUBJECTIVE FALSE SENSATIONS OF COLD. 117 peratures. There is no standard so exact as to enable per- sons to compare with it surface-temperature of a case like this ; undoubtedly, however, the temperature was not below normal. The masseur who rubbed him insisted that at times the buttocks were warmer than they usually are. My patient improved rapidly under tonic treatment and proper diet — in fact, the sugar disappeared entirely — and he regained full health after a few months of care. The unpleasant sensation of cold was the last symptom to leave him. It is as well to say, in conclusion, that my patient was not a nervous man, nor was he hypochondri- acal. He was rather disposed to underrate than to over- rate his symptoms. The complaint he made of the sense of cold was most positive ; at times the sensation was so distinct that he could hardly keep himself from believing that some cold application was being applied to the parts in question. In this case there was do sensitiveness of the lower nerveSj but a sharp blow on the sacrum with a rubber hammer was felt in a dull, deep pain, somewhat lasting, and it seems possible that in this, as in the other cases of buttock-cold, there may be obscure commencements of neuritic trouble in the cauda equina. The sensation of coldness of the buttocks is not excessively rare. I have seen it from time to time, and now that my atten- tion has been directed to a possible cause, I shall, per- haps, be better able in future to relate the symptom to its probable parentage neuritis. Case XLI. (Case 935 in Private Note-book.) Subjective sensation of cold in the right foot, ivith actual increase of temperature in the parts. — J. C, male, aged fifty-two years, a native of Pennsylvania, by occupation a clerk. Has had perfect health. Never had syphilis. Stands on his feet at work for seven hours a day. Is married ; has six 118 NERVOUS DISEASES. children, all well. He lives in a coimtiy which is not malarious, a mouutainous region 1000 feet above the sea. About five years ago Mr. C. found that his right foot became painfully cold after standing for a length of time. Even when in a warm room he was inclined to dress that leg warmly — often wore two pairs of socks and an "arctic" rubber shoe, heavily lined. At this early period he found that the parts affected were not cold to the touch, and were apt to be more flushed than the other foot. As the summer progressed (and this has been the case nearly every summer since) the foot became better. At times all that summer it was tender, and Avas eased by his sitting doAvn. In the winter which followed the impres- sion that the foot was cold was often so intense that he would go from his work and remove the covering from the limb and ask some one to examine the foot to see if it were not frozen. The observer called upon was apt to say that it felt warm to the touch. His general health remained good. He was able to do his work, and lived a tranquil life until a few weeks ago, when symptoms occurred which caused him to consult me. I found him a man of fairly robust appearance, of good color, with no history of specific or malarial poison. His heart and kidneys were healthy, and there were no pecu- liarities which I need mention except those concerned with the foot. About six weeks before he came to me — that is to say, the end of January, 1887 — the foot became more and more troublesome, and he began to have also a ting- ling sensation on the right side of the head in the scalp, and also in the hand on the same side. These symptoms came on suddenly one day, Avhen he was rising in the morning. They have now passed away. The other head- symptom of which he complains (and which he insists he did not have before the symptoms just mentioned) is a SUBJECTIVE FALSE SENSATIONS OF COLD. II9 sensation of roaring in the head, accompanied with a throb- bing in the vertex. The dynamometer showed good results for both hands. His foot and its conditions are what give him most trouble, and it is for these that he consults me. Of the present state of his symptoms he gives me the following account : He is better in summer than in winter, although at all seasons the foot becomes distressingly cold when he has been standing on it for more than half an hour. To sit eases it somewhat ; to put it u^ on a chair eases it more ; lying in bed for some time gives him the greatest relief, as when he wakes in the morning the foot seems to be warm. An upright position has an immediate effect. He says, when that position is assumed, the hg seems to become cold to the knee. There is absolutely no difference in the appearance of the two limbs, whether he is standing or is lying down. The knee-jerk on both sides is equal and normal, the other reflexes good, as w^ell as the electric reactions. The sensory appreciations of all kinds are natural. Both feet are flatter than they should be, but I could find no trace of tenderness in either. The tem- perature of the right foot was 1° F. higher than that of the left foot. On one occasion Seguin's surface-thermometer (arbitrary) marked 6° difference of the right as above the left; and these peculiarities of temperature were the same when the left foot was placed in the same physical condi- tions as the right. The sciatic nerves behind the knee were quite tender. I did not study the temperature-sense, as it was long ago, and I was not awake to the value of this as a symptom. Treatment proved of little value. This case was, probably, also a neuritic affection. In some ways it resembles the remarkable cases which I described as erythromelalgia. In them, however, there v/ere pronounced vaso-motor disturbances, with excessive pain. Of late it has been pointed out that in 1 20 ^ER VO US DISEASES. some cases of positive neuritis the capacity to be aware of degrees of cold applied to the skin is present, while the like power to distinguish heat is lost.^ This symp- tom existed in none of my cases ; but I may not have too carefully looked for it. I have observed it in hys- teria and seen the reverse condition, and also that heat could cause pain when the needle did not. But this part of symptomatology needs careful re-examination. Meanwhile I may conclude that a sense of intense local coldness should cause us to suspect neuritis as a cause. I had last winter a sad case of general neuritis in a Avoman. Exercise increased it enormously, and when it became Avorse in any part there was iu that nerve- territory a painful sense of cold, with very often rise of temperature and local enlargement of the veins, but no notable incapacity to discriminate temperatures. I may add, as regards all these cases, that mere vasal states do not suffice to explain the false sense of intense local coldness. If they be of local peripheral origin, we must assume that the nerves are then constantly in a physical state such as is present when true cold is applied. The condition of false sense of heat is to be met with, as is well known. For myself, I have never yet felt sure that there are distinct nerves for perceiving heat or cold. Another theory is possible, as I have else- where stated in regard to pain and touch. My next case of intensified capacity to feel cold stands alone, but I am sure it will not do so very long. I owe it to the kindness of Dr. Kinnicutt. Exactly the re- verse state is to be seen most often in the insane, but I 1 George W. Jacoby : Journal of Mental and Nervous Disease, June, 1889. SUBJECTIVE FALSE SENSATIONS OF COLD. 121 reserve the cases of false sense of heat, local or general, for another paper. They offer greater difficnlties. Case XLII. — L. P., Kansas, aged fifty-seven years, lawyer. When a youth, aged seventeen, the patient suf- fered from a renal complication during an attack of scarlet fever. Albumin has been found almost constantly in his urine from that date, and casts very frequently. He has, nevertheless, enjoyed good health, and although his urine still contains albumin, and hyaline and granular casts are occasionally found, he is in excellent condition, and performs all his varied legal duties easily. On careful ex- amination there are no signs of cardiac or vascular changes. The heart is not hypertrophied. There is no marked arte- rial tension and no appreciable change in the vessel-walls. For the past six or seven years he has been greatly an- noyed by subjective sensations of cold. These sensations are general, but are particularly marked along the inner aspect of the upper arm ; they are greatly increased by mental application. To relieve these sensations he wears at present three suits of the heaviest woollen undercloth- ing, three pairs of the heaviest woollen socks, felt boots made expressly for him of the heaviest material, over his ordinary boots or shoes, and a flannel bandage around the abdomen. At night he wears two of the above suits, a flannel chest-protector, and the Avoollen socks. He sleeps under five double blankets, on a feather mattress with a hair one underneath. Moreover, he is obliged to keep the night-temperature of his room at 80°, and after an un- usually hard day at court at 90° or 95°. The only change of underclothing that he makes in summer is the doing away wdth one of the three suits. The sensations of cold are positively painful. I have made inquiry as to the truth of his statements concern- ing the amount of clothing worn, and they are borne out by my examinations. The surface- temperature is normal, 11 1 22 NER VO US DISEASES. even when he complains most bitterly of his symptoms. He has a highly sensitive and nervons organization, with an active mind. He is well-balanced, cheerful, and philo- sophical about his sufferings. He walks from five to six miles daily without fatigue — on the contrary, with benefit. He is absolutely free from the ordinary symptoms of hys- teria, and has no pain and no tenderness along the nerve- tracts. This case is calculated to make us reflect upon the ordinary standards of heat and cold. They vary with individuals, with social classes, and with periods of life, as the aged Avell know. The present case is that of a man abnormally susceptible to cold. Explanation I have none to offer. It is interesting to be assured that a man may have tube-casts in his urine for forty years and yet preserve a standard of general health and activity. Class III. Finally, I give a case of false sense of cold in an hysterical woman. Such cases must be rare. The reversed state I have also seen in the hysterical more than once. Case XLIII. (Case 409 in Private Xote-book.)— Miss B., aged thirty-three years, Pennsylvania. The patient in this case was a young woman in easy circumstances, for many years a victim to hysterical conditions, first acute and afterward chronic. To describe her case would be to describe almost every form which hysteria assumes. At seventeen she began to be irregular as to her men- strual periods, and at last passed into a condition of hys- terical stupor, then into catalepsy, and later had for several weeks onsets of hystero-epilepsy. At last, coming out of this condition, she suffered for a long while from attacks of rigidity, the left leg finally remaining at an angle to the trunk and knee. Next, several months passed away, SUBJECTIVE FALSE SENSATIONS OF COLD. 123 during which she continued subject to slight hysterical attacks, and then by degrees improved so as to be fairly well. She was an emotional and very intelligent woman, fond of reading and devoted to music. She exercised but little, however, and was, when I first saw her, again drift- ing into a life of invalidism. About two months before she came to me she passed over one menstrual time, and during the month which followed began to have a sense of cold on the left side of the body. This condition arose quite gradually, and became at last so violent as to compel her to wear, on that side, two or three times the amount of clothing required on the other. This excessive increase of clothing made her so ridiculously one-sided that she was ashamed to be seen in public. She continued to dress in this peculiar fashion, rarely leaving the house, and presented an appearance more easily imag- ined than described. I first saw her early in February, 1883. She was then a woman of fair general appearance, Avith nothing notably wrong in any organ, and with all the secretions in good order. She had had no hysterical attack for several months. Menstruation was natural, almost without pain at her last period. iVt this time, however, she complained of a diffi- culty in swallowing and of a sensation as of a band around her throat. The whole left side of the body was still sub- ject to the sensation of cold to which I have alluded, and which affected also the same side of the face, head, and neck. There was no loss of sensation to the touch on this side — in fact, there were hyperiesthetic spaces, one below the left breast and one below the floating ribs on the left. This region of tenderness continued to the middle line and down to the pubes. The special senses were normal, and there Avas no change in the color-fields. In the discussion which followed Dr. James J. Put- nam said: ^^ In chronic spinal disease and in chronic 124 ^'EB VO US DISEASES. neuritis I have seen the coldness to which Dr. Mitchell refers. This was quite marked in one case which I shall report in my paper. This patient suffers from sensory neuritis which may possibly be due to lead. The sensa- tion of cold is present to an extreme degree. In regard to the sensation of cold in persons not presenting signs of anaemic neuritis, I am not familiar with anything like what has been reported, though I have seen cases in which there w^ere sensations of excessive heat, without organic disease.' ' Dr. C. K. Mills said: '' I think that the sensation of cold is a very important symptom of neuritis. I have seen it in one case of acute neuritis of the ulnar nerve followed by paralysis of the muscles of the hand. During the hottest summer weather the patient had to wear a great deal of extra wrapping on the arm. Often a sensation of extreme heat follows injury of the ner- vous system, either peripheral or central. I recollect that after the attempted assassination of Garfield the description that he is said to have given of the feelings in his feet was that of extreme burning. I remember having expressed at that time the idea that the spinal cord was involved.'^ CHAPTER VII. RETAINED MUSCLE-EEFLEXES; PERNICIOUS ANAE- MIA, WITH LOCOMOTOR ATAXIA AND HYSTERIA. This child, whose parents kindly permit me to shoAV him to you, has a form of malady which I saw for the first time when I saw him last week. Here is a fine little man, well developed, exceedingly strong, and as intelligent as most children at his age. He is quite unable to stand alone. Even to sit alone seems diffi- cult. No one will fail to note that he is ataxic from head to feet. The following notes of his condition at the present time are compiled from the examination record made by Dr. John K. INIitchell, and the very clearly written statement of the father: Case XLIV. — P. Q., male, three years and five months of age. Family history. The child's grandfather was addicted to alcohol. The parents are second cousins, and much alike in disposition and general characteristics. There is also some tuberculous history in the ancestry. The child was born normally at term. No instruments were used. The only thing attracting attention at the time of birth was "something unusual" about the Httle one's ankles. The physician said it was "all right," and the babe seemed otherwise healthy ; the child cried, kicked, nursed from the breast, etc. Owing to mammary abscesses the mother nursed the infant no more than four weeks 11* 126 NERVOUS DISEASES. After that the chikl lived on uon-sterilized cows' milk, and later on "malted milk" and other artificial foods until eight months of age, and with sustained good health. At that time, however (eight months of age), the child was taken on a railroad journey. It is supposed that " sour milk " was the cause of a severe attack of diarrhoea, which resulted, a few days later, in what the physician writes was "spurious hydrocephalus; the temperature 103.5° F." The chikl threw its hands about, especially toward the head, and moaned a great deal. It had also "intolerance of light " at this time. The physician gave a cool bath and a dose of brandy. By the next day the patient is said to have recovered from the serious symptoms, including the diarrhoea. After this attack of bowel-trouble digestion seemed as well i^erformed as usual. Two months later (/. e., at ten mouths of age) it Avas specially noticed that the child could not sit erect. Nothing had seemed abnormal until now other than undue lassitude. On examination. Dr. J. S. Hackney found that ' ' there was an antero-posterior curva- ture of the spine," the most prominent point being about the mid-dorsal region. Accordingly a plaster jacket was applied. This was cut and removed as often as necessary. There seemed to be some relief from this for the now evidently weak back. The jacket was worn for six weeks. The little patient has kept up a general good tone since then, the back seeming to have become straight and quite strong again ; nor has he had any bowel-complaint since that in his first summer. The present condition seems to date from thirteen months of age, when the child began to have an oscillatory move- ment of the left eye and later of the right eye. This nys- tagmus was always the more noticeable in the left eye. At this time, too, his health was good. He seemed some- MOTOR ATAXIA. 127 what nervous, but did not have any convulsive movements, and never has had any such tendency. At fourteen months of age he had an attack of bronchitis. In the second week of this illness symptoms of what was said to have been tuberculous meningitis made their appear- ance. Both bronchial and meningeal symptoms, however, disappeared during the third week. Since then and until now the child has enjoyed very good health, excepting for extreme nervousness during the illness stated. He now became easily startled and scared. This timidity has be- come more apparent as he grows older. He is at present unusually sensitive. His father says the mental faculties are normal or even precocious. The child did not move about if placed on the floor until two years old. It has only been since January, 1894 (three years and two mouths old), that he has begun to pull him- self up to a standing position with his arms and the aid of a chair, bed, etc. Now, when up, he can walk along the side of the bed or balusters, holding firmly for support. This ability has been acquired only within the past few months. Even when thus holding himself upon his feet he seems in fear of falling. The patient has been extremely constipated until about a year ago. Since then the bowels have been reasonably regular. This change has probably been brought about by the greater physical exertion of attempted movement. The child is rather pale ; the muscles are fair in size, but very flabby. The head is large, but symmetrical. The chest is large — indeed unusually full for a child. He does not crawl, but he can shuffle about, seated ; he can walk about when supported, but with a marked ataxic gait and with feebleness. He jerks the legs forward in the effort at locomotion. The erectores spinas are weak. The ab- dominal muscles and thigh muscles do not hold the body steadily upright on the legs. He leans too far forward or 128 ^EE VO US DISEASES. back. The tendency is more backward, however, when he is thus supported. He cannot feed himself. Incoordination is marked in the hands, but there is no tremor. He uses the left hand better than the right, and possibly the left leg a little better than the right one. Nervous system. Sensation is perfect everywhere. Knee- jerks and elbow-jerks are normal and no ankle-clonus exists. Muscle-jerks of the arms and legs give normal response on stimulation with the percussion-hammer. Electrical ex- amination shows no alteration to faradism or galvanism. The child seems intelligent and alert, though timid and nervous. No signs of pain were elicited at any time dur- ing the examinations. He talks fairly, drawls his words somewhat, but speaks freely. The mouth and teeth are normal. There is no preputial adhesion, no incontinence of urine, and this excretion is normal. Eyes (examined by Dr. A. G. Thomson). The ' ' puj^ils react normally to light and accommodation. There is no choked disc. The nystagmus of both eyes and the con- vergent squint of the left eye are, therefore, not due to any refractive error," but are incoordinate movements, such as are seen in other parts of the body. All other functions and organs are normal. It seems reasonably clear that the cause of tliis inter- esting malady was not prenatal. The child remained well until he had the too common experience of summer diarrhoea, follow^ed, as we see so often, by brief brain- symptoms. What happened then is not now^ clearly known. He is said to have had " spurious hydroceph- alus/' and was, according to the note, very ill. At or after this time he could not sit up as he had been able to do. At the thirteenth month nystagmus began, or was first seen. Then followed a bronchitis and brain- symptoms described as '' tuberculous meningitis," and MOTOR ATAXIA. 129 from this too he got well, but was seen to be more and more awkward as he grew older. I confess to some puzzle in this case. There are no eye-ground signs. There is no wasting. There is no palsy of any nerve. There is unusual power from crown to sole; there is no sensory loss, and yet he can- not stand at all without some stay. Aided by a finger he can walk, throwing his feet out, and ^^ clumping" precisely like a true spinal ataxic. But no such case in an adult had ever such a degree of disorder without disturbed feeling, or pain, or anaesthesia, or girdle-pain, or pu2)illary signs. Here are none of these. Also, the ataxia is in all the limbs, but is worse in the legs. In the arms and legs, to my surprise, I found normal tendon-jerks, so called, and also normal reinforcements of these muscle-reflexes. There is nothing spastic in these. Sometimes they are excessive, probably from reinforcement due to emotion. There is no clonus ; but this is rare in the child under any conditions. If this were spinal ataxia, with added lateral sclerosis, we should have spastic reflex signals and the usual feeble- ness apt to be seen in that disorder; also the high ataxic movement of the feet seen in our case would be want- ing. Tabes of all kinds is, as a rule, progressive. The lad before you continuously improves in the use of his limbs. This is, therefore, neither tabes nor spastic ataxia, nor is it the picture of hereditary ataxia; neither has he pain-crises nor trophic changes, so that probably the posterior nerve-roots and the gray spinal centres are to be excluded from a share in this disorder. It vseems to me possible that the double brain-diseases he is said to have had, and which left his power of 1 30 NER VO US DISEA SES. mind and of mnscle nnimpaired, may have fallen on the cerebellum and left it permanently injured in one of its functions. As against this is the lad's gain in steadiness; but even with most of the cerebellum gone birds have after a year been able to fly. The mechan- isms of replacement of function are not as yet clear to us, although we are often called on to recognize their value. It is possible that the cerebellum may have suffered over a large area of the surface, and that this damage may have been in part repaired, and a share of the functional activities safe-guarded and replaced by the other mechanisms which contribute to the integrity of equilibration. I cannot say, however, that I am, even now, entirely sure as to a cerebellar lesion being the true cause of the ataxic state seen in this child; but it cannot be spinal unless the ataxia of childhood should prove to be a very different condition from that of the adult — an ataxia without sensory, ocular, or reflex symptoms. If we had any evidence of tumor of the cerebellum, we should be aided in our diagnosis. In it there may be preser- vation of the knee-jerk, but we have here no sign of tumor. I confess, as I study this case, to increasing difficulty of decision; as one looks at it, the case is to the eye a typical spinal ataxia ; examined more nearly, much is lacking to make the perfect picture of that disorder or disease. But almost as much is also wanting to assure us of a cerebellar origin; and one should remember, I repeat, that we have hardly any studies of spinal ataxia in childhood. I reported one years ago, which came out MOTOR ATAXIA. 131 of Pott's disease, at the age of five, and was seen by me in a woman of forty. It had progressed in leaps, with long periods of pathological inactivity. When so thoughtful a man as Gowers admits that the grouped symptoms seen in locomotor ataxia may be due to disease either of the cord or of the peripheral nerves, one sees the tano^le into which we have gotten our knowledge of the mechanism of harmonious muscle- action, and its offspring, equilibration. As there may be much loss of motor power, much impairment of motor centres aud nerves, without cor- responding loss of muscle-harmonies, we must, I think, still look to disease of the nerves of muscular sensation, their spinal tracts, and their cerebellar connection, for the varied seats of the incoordination of complex muscle- acts. It is conceded that integrity of the knee-jerk, or any tendon-jerk from a blow on the tendon, implies Avhole- ness of the neural arc of conduction and response from the centres concerned. When there is distinct, typical ataxia without spastic states, and with normal preser- vation of knee-jerk and ankle-jerk, it seems reasonable to conclude that the cause of this ataxia must lie above the region concerned in the muscle-muscle-reactions. ^ The law which applies to knee-jerks and all tendon- jerks explains in part the direct muscle- jerk from a blow. For here, as Morris Lewis and I have shown, this re- sponse is due to two contributions, one the intrinsic muscular irritability, and one the addition from the cord. The former continues after nerve-section; the latter is lost, but its loss is only to be proved by the fact 1 Contra-distinguished from skin-muscle-reflexes. 1 32 NER VO US DISEASES. that you can then no longer reinforce the direct muscle- jerk by remote voluntary motion. Such is the case late in posterior sclerosis. A blow on the muscle causes a jerk, but reinforcement is no longer possible. The response from tendon-jerk is ouly a finer, a more delicate, expression, and a larger one, of the same phenomenon. In this boy neither muscle-jerk nor tendon-jerk is gone, nor yet their rein- forcement. The facts as to all this matter of sensory motor as well as motor reinforcement in its varied forms, discov- ered by Lewis and myself, remain as yet almost un- noticed in the text-books, and nnnsed by clinical in- quirers. As regards this boy I conclude, then, that the cause of his remarkable ataxic state must lie above the seat of response to the tendon-jerks, and does not interfere with the track of reinforcement, which is easily obtainable. I must leave this case and its consideration without further words. I do not fully understand it, and the frank statement that I do not may have for you some moral value. Under training, with constant little bribes to do this or that until he succeeds, the lad is steadily improving, and has continued so to do up to the later date of July, 1896. Even ordinary ataxics may improve by industrious efforts made with closed eyes, and this child has in his favor a normal mind and entirely wholesome nutrition. An equally interesting case for study is a woman now in McCormick ward. Dr. Walker will read the notes, which owe much of their interest to Dr. Musser, in whose charge she has been at the Presbyterian Hos- pital; and to Dr. Pearce, who is responsible for the MOTOR ATAXIA. 133 blood-counts made for Dr. John K. Mitchell's pa2:>er on the influence of massage on the blood-count. I shall presently show you the case. It is another illustration of clinical difficulty in decision. Here again we have an example of ataxia, typical and also extreme, with, save for one notable exception, perfect knee-jerks and elbow-jerks and entire muscle-jerks from a blow, and all reinf orcible : Case XLV. — E. I., female, single, aged fifty years, was admitted to the Infirmary for Nervous Diseases, in my service, March 2, 1894. She is intelligent, and gives the following history as to her illness, amplified by the obser- vations at the Presbyterian Hospital and by our later notes : Family history. The woman is of a long-lived ancestry. Her father and mother are living and well at eighty-two and seventy-five years respectively. Three sisters are all healthy. Two brothers have died of scarlet fever and dys- entery, and one sister in infancy. There are no neuroses or psychoses among her relatives, and the patient herself had an uneventful childhood as regards maladies, passing through mild forms of the usual diseases of youth. In 1887 she suffered from the ordinary symptoms of nervous exhaustion, had anorexia, and felt tired most of the day. These symptoms ran the course of many of such cases when ill cared for. After an attack of influenza, in 1889, she was almost bedridden for a year from what she says was " weakness " only. She was about again for several months, able to walk with a cane, but could not bear much exertion. She was especially weak in the spine and had considerable pain across the lumbar region. The patient also states that at this time she always had better use of the right fo6t than of the left — the latter was heavy and seemed to ''drag" in walking. 12 134 NER VO US DISEASES. She coutiuued iu this way with but little change in the foregoing meagre symptomatology until July, 1890, when she went to the Cooper Hospital, Camden, remaining there three months, with little or no improvement ; thence she was taken to the Presbyterian Hosj^ital, Philadelphia, where she stayed in the wards one year. There she was in a highly neurotic condition, and had hysterical outbursts of crying and laughing. The sequelae of these climaxes (which occurred, as a rule, near the menstrual epochs) were states of lethargy and again of fear, in which temporary hysterical delusions became prominent. The sick women about her were often much frightened by her pecuhar, wandering talk. In a few days she was apt to regain partial control, and would censure herself for acting so foolishly — of which, however, she had only vague remem- brances. At this time, too, she seemed able to walk only with the assistance of a nurse, and but for short distances. Her upper extremities also were weak, and she was clumsy. It was, therefore, with difficulty that she fed or assisted in dressing herself. Under rest and tonics there was improve- ment of the general health, and on leaving the hospital she was able to walk a short distance with the aid of a cane. She was then at home from March to November, 1892, when she was readmitted to the Presbyterian Hospital, where since then she has had a multiplicity of symptoms. Menstruation Avas normal up to June, 1893. In July she had a severe attack of dysentery. The convales- cence was slow, and she was left very anaemic, the blood- count showing as low as 581,000 red cells on August 1st of that year. On September 1st the blood-count showed 950,000 red cells with macrocytes, microcytes, etc. On October 18th the red cells had increased to 1,620,000. The patient's condition seemed noAV fairly good. Her color had returned in a measure, so that the outlook seemed more encouraging. There was no men- MOTOR ATAXIA. 135 strual flow between June and October, in which latter month she had a slight show, which recurred again in November, but never since. By January 1, 1894, there was do material change, save that in the last few days she was decidedly more anaemic again, and had headache, dyspnoea, weakness, and palpita- tion of the heart on the slightest attempt at exertion, with oedema of the ankles coming on late in the afternoon. There was no oedema of the face. The skin has become of a lemon-yellow color and the conjunctivae of a bluish tint. Her lips are almost colorless. The apex-beat of the heart is in the fifth interspace. No thrill is felt. The shock of the second sound is readily felt in the pulmonary area. The area of cardiac dulness is normal. There is a soft, hemic, systolic murmur, low in pitch, transmitted into the axilla, accompanying but not obliterating the first sound at the apex. There is also a higher-pitched systolic murmur (probably hemic) heard in the pulmonary area. The area of liver-dulness is slightly increased. There is one tender spot on palpation with the finger-tips to the right of the median line two inches, and another two and a half inches above the umbilical line. On January 16th the patient had severe pain in the region of this ten- der spot, with great pallor and increasing weakness, so much so that duodenal ulceration and possibly hemorrhage were thought of. Dr. Musser had the stools carefully examined. No blood was passed, however, and no parasite could be found as a cause of the severe anaemia. The haemoglobin had at this time gone down to 15 per cent., while the red blood-cells numbered 930,000. There were also poikilo- cytes, macrocytes, and microcytes in abundance, while macroscopically a drop of blood looked like slightly tinged muddy water. By February 22d the patient's skin and mucous 136 NERVOUS DISEASES. membranes had again brightened. Her general condition also became much improved. She was decidedly less nervous, and sat up a short time in a chair each after- noon, but tired easily and could not walk. On admission to the Infirmary, March 2, 1894, the fol- lowing notes were made as to her condition : She is a brunette, fairly Avell nourished, weighing 129 pounds. She complains of a feeling of "numbness and tingling " in her hands and feet. She says if she undertakes to hold anything in her hands she must see it in order to feel sure that it is there. She can feed herself, but her hands are too clumsy to permit of her cutting her food. She cannot dress her hair. She can button her night-dress, but clumsily, and only as far up as she can see the buttons. These defective acts seem to be all due to awkwardness rather than to actual loss of tactile sense, which seems per- fect in the hands and fingers. The disorder is mainly a motor ataxia. There is no subjective numbness or ting- ling anywhere except in the hands and feet. She does not complain of headache. She has pain in the back after any exertion, such as sitting up. She can stand 07ily by being supported on either side ; she takes a few steps while being thus held, but the movements are markedly ataxic. The left foot is pushed forward. The right one is thrown up and out in utter incoordination. In the sitting position, unsuj^ported and with eyes closed, she does not sway. Other than by the characteristic gait, ataxia of the lower extremities is shown by an inability to bring the heel of either foot in contact with the opposite instep. Ataxia of the upper extremities is shown even when lying by inability to bring the fingers of the outstretched hand to the nose with the eyes closed. The movements of the lower ex- tremities are less incoordinate when she lies supine. The reflexes — plantar, epigastric, and abdominal — are MOTOR ATAXIA, I37 normal. The knee-jerks are also normal and relnforcible. There is no clonus. There is absence of the normal ankle- jerks, as tested by tapping the tendo-Achillis, but they can be elicited by reinforcement. The elbow-jerks are normal and reinforcible. The muscle-jerks are everywhere normal and reinforcible. Sensibility. She distinguishes with natural competence the two points of the gesthesiometer Avhen placed on the fingers, and points out quite accurately the fingers so touched. There seems to be some delay in decision. Tactile sensation on the palmar and dorsal surfaces of both hands is normal. The thermal sense is perfect. As to the weight (or muscle) sense, on holding the palm of the hand out (the patient being blindfolded) she distin- guishes a difference between the following weights — i. e., ' ' the least observable difference " of Weber's law :' The right palm distinguishes one ounce from two ounces only ; the left palm tells one-quarter ounce from one-half ounce. Thus there is a difference in muscle-sense between the right and left arms, and the perception is not as acute as it should be. Numbness and tingling sensations are complained of in the hands and feet. No such parsesthesia exists in other parts. There is no anaesthesia or hypersesthesia, but there is varying analgesia to a deep pin-prick, as follows : The left lower extremity is analgesic from the groin to the 1 Weber used the method of " least observable differences " as applied to sensations of pressure and the measurement of lines by the eye, but Fechner expanded it and assumed that all just observable differences are equally great; so that the law is sometimes called " Fechner's law." Expressed in another way, the results depend on (1) strength of stimuli ; (2) degree of ex- citability. If two is constant and one is then varied, it is found that if the stimulus be doubled, trebled, etc., the sensation only increases as the loga- rithm of the stimulus (e. g., stimulus 10, 100, and 1000 times, then sensation increases 1, 2, and 3). There is a lower limit of excitation liminal intensity and an upper limit of excitation liminal intensity. Thus above this no appreciable increase in sensation can be distinguished. This is called the " range of sen- sibility." Thus, with 10 grammes in the hand, we have to add or remove 3.3 grammes before a difference in sensation is perceptible. In 100 grammes we would have to add or withdraw 33.3 grammes. 12- 1 38 ^^^ yO us DISEASES. metatarso-phalangeal joints, and the right upper extremity from midway between the shoulder and the elbow to the metacarpo-phalangeal joints. The condition of analgesia of the upper extremity is variable, however, as twenty-four hours after the first examination sensation to pain seemed almost as acute as upon the opposite side. The right leg and thigh are at times partially analgesic to a pin-prick, but the areas of defect vary greatly from day to day. Dr. Willits reports the muscular response to faradism everywhere normal. Drs. de Schweinitz and A. Thomson made the following eye-report : ' ' Both discs gray, especially in the deej^er layers. Arteries too small, veins normal. Pupils normal. Color-fields (red and blue) typically reversed. Form-fields contracted." The reaction-time of the different senses was next inves- tigated. Mr. Lightner Witmer kindly made examinations of this woman for me at the Psychological Laboratory of the Uni- versity of Pennsylvania, on jMarch 27, 1894, from which the following is abstracted : First, as regards the motor nervous system, as recorded on the chronoscope (an instrument for recording the ra- pidity of a motion). It was found that to pass over a dis- tance of 50 cm. it took the right hand yV^^ ^^ ^ second (?'. e,, 224 (t). In the left hand y^Fo ^^ ^ second was re- quired to pass as quickly as possible over the same dis- tance. A second series of these motor impulse experiments (made after all the reaction-time experiments) was but little lengthened as compared to the first series, thus pointing to the absence of fatigue of any considerable amount. The normal rate of movemeut, from the experiments of Professors Fullerton and Cattell, varies l)etween 87 o to MOTOR ATAXIA. 139 180 (T for 50 cm., as recorded on the chronoscope. The woman's movements were therefore slow. The reaction-time to sound varied from ISla to .343 a, somewhat longer than the normal, which ranges from 120 a to 170^. The reaction-time for light varied from 160 (^ to 350 a. The normal light-perception is from 160 o- to 200 ff. The reaction-time to electric shock varied from 200 hat you see began Tvith bronchitis in 1890. His physician said that at the time he T^as run down from overwork, and ordered him to take a vacation. He went away for two months and re- turned to his desk feeling much better. After w^orking for a month, he was on November 6, 1890, "seized with chills," and had three in succession. After this he was confined to bed for fourteen weeks, suffering from Avhat w^as described as "nervous prostration." He is said to have also had some bronchitis. It was not until five months later (April, 1891) that he was out of bed permanently, and able to walk with the aid of two canes. He was unsteady on closing his eyes and when trying to stand or walk in the dark. At this time, he tells us, the knee-jerk was present, and this is probable, as the patient is very intelligent and has studied his symptoms assiduously. During 1891 he got much better, and walked without a cane, except when going a long distance. He still con- tinued to cough more or less. In March, 1892, he felt w^ell enough to go down to El Paso, Texas, to take charge of an office. There he lost his cough, gained in weight, and was doing very well until August, 1893, when a "very dear" friend and fellow-w^orker died of hiemoptysis. The shock of this loss, coupled w^ith extra work, seemed to be too much for him, and again he besran to fail, and to become on the least occasion emotional even to tears. From September 1, 1893, he had pains in his feet, which continued until December, 1893, when he took a mustard foot-bath for their relief. On the following morning he awoke to find his legs drawn up at the knees, just as they were w^hen he came to me for treatment on March 15, 1894. Hysterical contractures. 281 The thighs were rigidly drawn up so as to touch the abdo- men. There was also spastic adduction of both thighs and of the legs and flexion of the feet. The contractions con- tinued to become more complete and more rigid. As to sensation at this time the man can tell us as to this nothing of value. On admission to the Infi^rmary the contracted and sym- metrically wasted state of the lower limbs described was very apparent. The right foot was flexed firmly against the buttock, a forcible pull on the foot being required to separate the heel from the buttock. The left foot and leg were in the same position, except that the heel could be separated from the buttock a distance of a foot and a half by force. The hamstring tendons on both sides were very rigid, as were also the muscles of the thigh and leg on both sides. He could move the toes of both feet fairly well, but flexion and extension at the ankles were limited, every muscle being rigid. The patient said that the wasting of the limbs was really not great, as he had always been very thin. The circum- ference at the middle of the right thigh was 35 cm., of the left 35 i cm., at the middle of the legs on both sides 10 cm. The whole body was extremely emaciated. The hands showed notable wasting of the interossei muscles and of the thenar and hypothenar eminences. There was no clubbing of the fingers. The dynamometer registered oo in either hand. The spinal column showed nothing abnormal. There were scars of previous cauterization. Sensation was everywhere normal until we examined the feet. In the left foot sensation as to touch, pain, and tem- perature was absent on the whole dorsum, the anterior third of the sole, and the heel. The mid-region recognized touch. On the right foot there was an absence of sensation on the first, fourth, and fifth toes ; touch was felt in the third and fourth toes on both surfaces ; also on the dorsum and on 24^ 282 NER VO US DISEASES. the sole generally, except at the heel. It was nowhere normal on either foot, but improved above the ankle until at mid-leg it seemed perfect. These facts are interesting, because there is no account of early loss of feeling. It seems certain, however, that this anaesthesia must have been an early symptom. The overwhelming pain appears to have turned atten- tion from the merely negative sign, loss of tactile sen- sation. Pain had been felt in the legs before contraction came on, but was never severe, and was taken to be rheuma- tism. The pain which came after the contractions had lasted fifteen days w^as more severe and of a different character. It grew to be at last the absorbing feature of the case. There have been no bedsores or evidences of grave trophic disorder. Co-ordination was good in the arms and fingers. Station and gait, of course, were not obtainable, the man being bedridden, nervous, and very emotional. The knee-jerk was not obtainable, nor could Ave get ankle- clonus or muscle-jerks in the legs. The epigastric, abdom- inal, and cremasteric reflexes appeared to be normal, as was also the elbow-jerk. The man has never had inconti- nence of urine. He has had no priapism ; and, in fact, very seldom has an erection. He has had throughout per- fect control over the rectum. Dr. Archibald G. Thomson reported upon the eyes : " The pupils are equal and dilated. They react in accom- modation, but not to light. The media are clear. The discs are a trifle grayish, the arteries small. The fundus is pale. The muscular balance is good. There is no re- versal or contraction of the color-fields." With the man on his back the chest-expansion was Ik inches. The percussion-note was higher-pitched above the HYSTERICAL CONTRACTURES. 283 right than above the left clavicle, and a full inspiration heightened the pitch on the right side and but very little on the left. The whole right side mov^ed less than the left. Respiration was a trifle harsh at the left apex, and expira- tion was here prolonged and more marked than inspiration, but of about the same pitch as elsewhere. There was very little change in vocal fremitus and resonance on the left side, but on the right chest anteriorly the voice was con- veyed much more clearly than elsewhere. On full inspira- tion there were moist rhonchi at both apices, more marked on the right. Posteriorly the eleventh rib on the left showed a prominence, as if it had been broken. On having the patient sit np it was observed that the left nipple was slightly higher than the right. The right chest moved more (2" inch) than the left during respiration. A musical murmur, systolic in time, was heard at the end of expiration over the base and at the apex of the heart. The apex-beat was found to be in the fourth interspace, with the greatest impulse at the sterno-costal junction. Staining the sputum for tubercle-bacilli was negative ; nranalysis also was negative. The temperatures w^ere rarely over the normal line. It was evident that the lung-condition had nothing to do with the paralysis. There was much difference of opinion as to the cause of these very interesting con- tractures. The absence of a more distinct previous hysterical history led some of our staff to regard the case as possibly one of spinal hemorrhage. As to treatment I had no indecision. The great flexion of the thigh on the pelvis, as in Miss C.'s case, kept the sciatic nerve stretched at the notch. There was but one remedy. As to what more we should win beside relief from pain I could not anticipate. 284 NER VO US DISEASES. At my desire, on March 29, 1894, Dr. W. W. Keen oper- ated on the right leg, dividing the thigh-muscles at their attachments to the pelvis ; also the inner and outer ham- string tendons. He could not bring the leg to a straight position even then on account of the rigidity of the parts, and for fear of tearing the contracted femoral vessels. The limb was dressed, and a double-inclined plane and ex- tension-weights applied. The extension-apparatus slowly accomplished its purpose, but was somewhat hampered by the development of a small bedsore over the sacrum as a result of the necessity of keeping the man constantly on his back. This soon healed, and the limb was then more actively extended each day by increasing the weights. As this extension at once eased and soon put an end to pain in the foot of the leg on which Dr. Keen had oper- ated, it was thought well to treat the other limb in like fashion. This was done on June 19, 1894, with equally good results. The surgical treatment closed with section of both gas- trocnemial tendons on December 7, 1894. The patient has now no pain, and has gained from day to day and month to month in the straightening of the limbs, in moral courage, and in increasing freedom from nervousness. Except for an attack of diphtheria, which necessitated removing the man to the Municipal Hospital, where he stayed from December, 1894, until January 22, 1895, he has been making constant improvement. His present state (February 4, 1895) is as follows : A faint systolic murmur is heard over the apex of the heart and at the base. Xo circulatory disturbance exists. The lungs have cleared up. There is no cough or expec- toration. The blood-count is 4,900,000. The hsemoglobin- value of the blood is 95 per cent., and the man looks ruddy. There is an absence of the neurotic facies. The muscles are less wasted, but firm, and respond well to the faradic cur- HYSTERICAL CONTRACTURES. 285 rent everywhere, even in the legs. There are no tender spots on the body and there is no evidence of neuritis. The man controls his bowels and urine normally. There is no priapism or other abnormality of the genital organs. The weight to-day is 101 i pounds, being a gain of only 6f pounds since admission to the wards. There is still general emaciation, but the thighs and legs are somewhat more wasted than other parts of the body. There are to be seen the scars of the operations on the thighs and legs. There are no excoriations, no clubbing of the nails, or other evidences of trophic disturbance other than those caused by lack of use of the muscles. The right thigh is in a straight line with the abdomen as the patient lies on his back. The leg can be extended to an angle of 170° with the thigh. The right ankle is perhaps a little extended, the toes being slightly flexed. The left thigh is also in a straight line with the abdomen, as is the left leg with the thigh as the man lies passively on the bed. The ankle, foot, and toes are in good position. Both thighs can be freely flexed, adducted, and circum- ducted, and there is the same voluntary control over the knees, legs, and ankles. The toes are less freely movable. The man walked five feet with the assistance of the nurse and a chair to-day. The grasp is good and equal, and no other motor palsy exists. The patient has taken tonics, cod-liver oil, etc., and since September 17, 1894, he has had massage and movements with faradism daily to the affected limbs. Early in April Dr. William J. Taylor divided the mus- cles on the inner side of both feet. This was needed be- cause of the swelling and pain in the feet when the man was long afoot, and which seemed due to the cramped form of these parts. On May 11, 1895, the man was walking a little on crutches and improving. After exercise the feet were 286 ^EB VO US DISEASES. still more or less painful. He has steadily grown better up to this date (June, 1895). The case, as you have heard it, does not enable us to be sure as to the immediate cause of the trouble. G. has been asthenic — neurasthenic, if you please; he re- covers, goes South, and, as a railway clerk, is overtaxed and much worried. For ten days he has aches in the legs, and awakens at last with his legs drawn up. Are these hysterical contractures? At first they could be relaxed under ether. Must we accept Char- cot's dictum that this is a certain sign of their hysterical origin ? There was probably some early loss of sensa- tion, but if, as has been suspected, these spasms w^ere due to a hemorrhage within or on the cord, we might well have had this symptom. I confess that there was too little disturbance to allow me to entertain the latter diagnostic theory. Here is a man wdio sleeps well and awakens with great and increasing contractions, and probably with more or less anaesthesia. In time the reflexes fail or lessen; the electric reactions are quanti- tatively diminished, and the mechanical reactions lost. All this might come from a neurotic, functional spasm, and it all reads like the progressive story of an hyster- ical disorder. It differs in no w^ise from the cases of Miss C. and Miss H., except that there are no other hysterical signals flying. Also in this (G.) case the reflexes have come back, the electric reactions are all better, and here and there we can call out movement by a blow with the hammer. At present G.'s legs are straight, or nearly so, and the muscles are all improv^- ing. Where and when these gains will end I do not know; but certainly so far, in the light of treatment. HYSTERICAL CONTRACTURES. 287 the case does not read like one of orgauic disease of the cord, nor like any form of neuritis. My conclusion is that in this case we have hysterical contractions in the adult male, a rare phenomenon, in this country at least, where we have the nervous tem- perament, but are not neurotic to the extent seen in the Latin races. Fortunately, cases of general contracture are rare. But, whether general or local, if they have proved during four or five months amenable to no medical means, then I counsel the use of the knife and the sec- tion of tendons. It is true that Charcot and others have described cases in which, after years, contractions ceased abruptly and the limb was as before. The state- ment should have had a long appendix of exceptions. In cases of moderate contracture, not drawing the part to an extremely acute angle, sudden recovery may leave the joints undamaged ; but in grave cases this never can be the case with joints like the knee, which is always the most difficult articulation to deal with. A long, violent contraction of the flexors partly luxates the tibia backward, and results in joint-changes which, after years of contraction, are incapable of cure. In these knee-cases, perhaps in all articulations long out of place, there is probably soon or late more or less of that kind of inflammation which is also seen in joints too long on a splint. If this be so, a part of the quan- titative failures to respond to electricity may be due to the muscular wasting so commonly observed in connec- tion with damaged joints. But, whatever the cause, I have seen hysterical con- tractions in which, after section of tendons, the joints were too much altered to admit of useful restoration. 288 NER VO US DISEASES. The leg, bent at an angle of 45°, is brought, by section and the screw, to a much larger angle, but cannot be made straight enough for use. There is motion within limits, but with weak muscles and beut legs the effort needed for walking becomes excessive. Under these circumstances there may arise a question as to the pro- priety of making the leg straight by an operation that will leave it rigid. Above all, I wish to impress upon you finally that a long-contractured limb is not a limb to confide to the rare relief brought or not brought by time. I desire to call attention to certain hitherto un- noticed clinical facts : 1. Two forms of hysterical contracture exist. One concerns single parts and limited groups of muscles. In this the contracture may last for years w^ithout the addition of organic changes in muscles, joints, or inter- stitial tissues. In this variety, or species, if you like, of the genus contracture, sudden cessation of the spasm is possible, or more probable than in generalized con- tractures. 2. Another form of contracture exists which attacks in succession one limb after another, until soon or late all or nearly all the voluntary muscles of the limbs, as well as those of the trunk, may become involved. The cases of this group do not, in my experience, ever get well abruptly. In them the muscles, joints, and areolar tissues undergo serious organic changes. In the first or limited form the muscles and the mus- cular reflexes remain unaltered or are but little changed, and mechanical and electric responses continue to be normal or nearly so. In the second or generalized form the muscle-muscle-reflexes, such as knee-jerk, are HYSTERICAL CONTRACTURES. 289 lost or mechanically interfered with late in the dis- order, and the electric responses are quantitatively les- sened, and may, in time, be almost altogether lost. It is only in this form, after years of life in bed, that we may expect to see changes in the cord. Whether these are merely independent accidents, or are the rare sec- ondary products of the hysterical condition or of the organic changes this occasions in the peripheral nerves and muscles, we do not yet know. In both forms we may expect to find loss in the sensory function of the skin, and more surely in the generalized contracture. 25 CHAPTEK XVIII. ROTATORY MOVEMENTS IN THE FEEBLE-MINDED. Most people, when seated, find some vague relief in change of attitude. Evea when lying at rest in bed we still feel this need; long-continuance in one position seems to make it agreeable to alter it. In some persons an excess of this tendency is shown in constant restlessness; with some, and especially among children, it exists remarkably during sleep. Certain persons incline to repeat one movement, and find, in so doing, the comfort most of us obtain from any change of posture. The frequent repetition of a movement may end in its becoming masterful, and finally the habit may gain almost despotic control. The young are, naturally, the most liable to become the victims of such tricks of habit. If they are prop- erly cared for as children, they soon unlearn these mor- bid ways; or, if uncared for, they may carry them into adult life. The acts I refer to may be very simple movements, but sometimes they are or come to be complicated motions, the origin and continuance of which it is not easy to understand. I knew a man who carried out of childhood a curious habitual action. Always before sitting down he walked once around the chair. If by any chance he forgot to do so, he must rise and obey the impulse. He was ashamed of this habit, and would loiter and move about to conceal the action, but always ROTATOR Y MO VEMENTS. 291 must at last go once around the chair. Another person, a woman, sat down only to rise, and sit, and so on, a dozen times before she could remain at ease. Somewhere on the boundary line between voluntary and involuntary, or, rather, automatic acts, lie the move- ments seen in the disorder I named habit-chorea or, as others like to call it, habit-spasm. In this a child is subject to movements of one or another set of mus- cles, and these are more or less capable of control. It is a morbid condition, and usually curable. Whatever the source of any of these movements, it is repetition which finally gives to them the power of a habit. At last to arrest such movement by force of will becomes difficult. A vast sense of relief arises when we yield to the tendency to repeat a habitual motion. Increasing discomfort attends upon the refusal to obey the habit-born impulse. I have seen a girl's arm tied to the waist by a mother resolute to break up the habit of rubbing the top of her head; a violent attack of hysteria followed. ::: In some cases the smaller, simpler habit-acts are more easy to overcome than are the larger and compli- cated movements, like the spinning habit. If the whole range of these semi-automatic or impul- sive movements is to be found in the ranks of the healthy, it seems obvious that in the mentally defec- tive, a class indifferent to criticism and with less will- force at command, we should find them in their most despotic forms. Indeed, in the young of imperfect mind these habit-acts are apt very soon to become im- perative. I fancy they are often semi-imperative from 292 NEB VO US DISEASES. the start, and are the offspring of suggestion or inher- ited instincts. Among the defective who are found at Elwyn^ are numerous illustrations of many varieties of the forms of movement of which I have briefly spoken. At present I desire to ask attention especially to the rare cases of Dervish movement, which I hesitate to de- scribe as spasm without further knowledge of how far these acts were primarily irresistible or how far they have become so from frequent repetition. It is con- ceivable that in the slackly governed organization of a defective child these motor habits in which a certain pleasure is found may arise and dominate far more readily than in those of sound mind. The cases I shall relate differ, and each must be studied by itself. I have myself seen elsewhere two cases of tendency to spin in which the children were in perfect health of body and mind; both were girls. When, in one of these cases, the mother realized that an ungovernable habit had been formed, the child, then about ten years old, was brought to me for advice. At first the girl had merely rotated until giddy, as many children like to do. Finding some satisfaction in it, she took to rotating when alone, and at last became remarkably expert. She confessed that she liked it, and would go where, unnoticed, she could spin unseen. By this time the habit had become so despotic that when kept with other and older people she would jump up of a sudden and spin furiously until she was forcibly stopped. When long controlled she became strangely restless, and, if allowed a minute's spin, seemed to be at once 1 The Pennsylvania Institution for Feeble-minded Children. ROTA TOR Y MO VEMENTS. 293 comforted. This child was easily cured by a long stay ia bed. There were no evidences of hysteria, and it was most unlike the case of hysterical gyration which I have elsewhere related. Defective children or adults who rotate evidently derive a certain amount of enjoyment from their aston- ishing feats, whether the motion be the imperative result of organic disease or only a habit long undis- turbed by disciplinary or other interference. There is also added the distinctive satisfaction obtained by the weak-minded when able to attract observation or to excite surprise. Case LXVII. — L, H., female, aged sixteen years, came to the Pennsylvania Training School for Feeble-minded Children from the almshouse. The maternal grandparents were intemperate. The father was also a drunkard and abused the mother before conception and during preg- nancy. There are two other children living, a boy and a girl — the latter is an inmate of the Elwyn School ; a sister died at eleven months in convulsions. The patient was born at term ; labor was normal. She was nourished at the breast three months by the mother, and then, strange to say, seven months by the maternal grandmother. She was a sickly baby, and had convulsions from the fifth until the eighth month of life, but has had none since. In late childhood, but exactly when is unknown, Dervish spinning, as described below, appeared. She is now a small, pale-faced child. No palsies, no atro- phies. Teeth fair. No signs of septic taint. Heart and lungs normal. All bodily functions are performed nor- mally. She has not yet menstruated. Her vocabulary is small and her speech is somewhat indistinct. She is active, 25* 294 NEE VO US DISEASES. noisy, and heedless of danger. She is also nervous and restless. She is destructive and dangerous as to fire, and is apt to stray from the Home. She attends the school, and understands readily what is said to her and obeys Fig. 17. promptly, but her physical and mental restlessness is so great that she cannot improve much in school-work. The station with eyes open or shut is good. Knee-jerk normal. The pupils are equal and react to light and Avith ROTA TOR Y MO VEMENTS. 295 accommodation. Sensation is normal, and there are no physical deformities. She has occasionally some involun- tary twitchings of the face. The most interesting symptom in her case is the habit of Dervish spinning. Many times daily she suddenly rises, walks to the middle of the room, rests upon one heel (usually the left one), the toes being raised, and then rotates, usually to the left,with extreme rapidity, her dress rising like the governor of a steam engine, as shown in Fig. 17 ; her arms are either clasped upon the chest or widely extended, and her right foot beats the floor to keep up the rotation. While spinning, her place on the floor changes but little ; there is almost no forward, backward, or lateral progress. The duration of the spinning varies from fifteen minutes to a half-hour. There is usually no acceleration of her normal pulse (90) or of respiration (20). While rotating, her eyes remain closed. There is no evidence of vertigo. She is able after a half-hour's spin to walk away on a perfectly straight line. There is no evidence that she is under the influence of any imperative impulse, nor are the movements forced. It seems like a natural act. If in good humor, she will spin or cease to spin at command ; if in bad humor, she will refuse to obey either request. When asked why she spins, she answers (and her intelligence is sufficiently to be relied upon) that she " likes it; it is fun." Her sister will, if requested, go through the same movements, but does them clumsily. When seen by me after thirty minutes' spinning her pulse had risen from 90 to 115, but the respiration did not rise in like proportion. When asked to spin to the right she tries it, but is unable to do it with ease or as long as she is able to rotate to the left. The motion is so in- conceivably rapid that two of us failed to count the rate of the spin. 296 NERVOUS DISEASES. Case LXVIII.— H. F. was admitted to the Pennsyl- vania Training School for Feeble-minded Children from the almshouse on May 30, 1877, when five years of age. He was healthy when born, but at four months of age he fell twelve feet and had spasms from that time ; occasion- ally they lasted for two weeks. Tiie mother was born in Ireland ; the father was a native of Philadelphia. There were two healthy children, younger than the one here spoken of. Paternal grandfather was insane. The patient was small of stature, light weight, and a demi-microcephalic, an epileptic, and a mute idiot. He had general convulsions three or four times a month. The boy is interesting or remarkable only for his automa- tism, which existed when he was admitted. At all times he was subject to odd motions of the hands, but periodi- cally during the day he would give an exhibition of the habit, which has given him the name of " The Dervish." This began with tapping his chin with his left hand, deli- cately and rapidly, touching the fingers of his left hand to the wrist of the right, making two or three salaams, after which he began to gyrate from the left to the right. The right heel acted as a pivot, and the rotation was kept up by touches of the left toe or heel to the floor. The turns varied from three to seven, with intervals of a salaam or two between every set of rotations, and lasted for a long while. Fifteen minutes or more were thus passed before he darted away toward a window, where he remained a few minutes in a fixed or dazed state, from which he aroused to recommence his hand tricks, perhaps liking to stand on a broad belt of sunlight, so as the better to dis- play his hand, which he watched with some appearance of enjoyment. He suffered from cataract of the right lens, and possibly partial amaurosis of the left eye. A supplemental performance was to stand in one place ROTA TOR Y 310 VEMENTS. 297 and throw the head and shoulders from side to side, de- scribing with the forearm two-thirds of a circle, with the occiput set back as far as the neck would permit. In none of these performances was it thought that conscious- ness was abolished or suspended. He seldom lost his balance and could walk very straight the moment he stopped spinning. He has been known to make 2000 revolutions in an hour. In 1886 he seemed to be failing, and became too weak to spin. About this time he became almost blind — quite so in one eye. The only improvement noticed in the effort to train him was that his habits were more cleanly. His hearing was very acute. He could distinguish voices in a crowd when there was a great deal of noise, and he would respond when a familiar voice called him by name. His head was inclined almost constantly to the left. He seemed to have an idea of self-preservation, though he appeared oblivious of what was going on around him. He died in a spasm on October 14, 1890. The spasms were always unilateral, and alternated, first on the right, then on the left side. Post-mortem examination. Body well nourished, skull normal, demi-microcephalic, scalp very thick. Dura mater so firmly adherent to the skull-cap along superior longitudinal sinus that the sinus was torn open on remov- ing the bone. Right hemisphere fairly well developed and apparently healthy. On the left side the occipital lobe was entirely destroyed, as w^as also the left anterior one and part of the superior parietal and supramarginal lobe ; a thick-walled cyst supplied their place. The left tem- poral lobe was hard, white, and shrunken. The remaining portions of the hemisphere exhibited the atypical arrange- ment of the convolutions often seen in brains where devel- opment has been interfered with very early in life. Hemi- 298 ^'ER VO us DISEASES. opia must in this case have existed since the origin of the lesion. This case I never saw. I am indebted for the notes to Dr. ^I. AY. Barr, the physician in charge of the Elwyn Asylum. The motions were probably imperative, but even as to so plain a case of organic disease it is difficult to feel secure as to this point. It is not stated that, like the last case, the eyes were kept shut while he rotated, nor is the rate of motion given. It is said to have been very rapid. Case LXIX. — Male, aged thirty-two years. This man is a medium-grade imbecile. His station and gait are steady. Knee-jerks, pupillary and other reflexes are present. There are no sensory or motor disturbances. He is robust and works continuously under the guidance of an attendant. There is no deformity of head, spine, or extremities. The thoracic and abdominal viscera pre- sent no symptoms or physical signs of disease. Scars on the chest and back are suggestive of syphilis, but there are no distinct evidences of the condition. The tongue is clean and protrudes straight, and there are a few scars upon this organ, the result of injury during previous epileptic fits. His sight and hearing are good and he talks quite readily, but his answers to questions are somewhat incoherent and wandering. He seems of mild disposition, but is subject to outbursts of temper, which may come on abruptly. There are no fixed hallucinations. When working or while eating he suddenly stands up and turns once around slowly ; then he sits down or goes about his occupation with an air of apparent mental relief. He never turns to the right, and the motion was not re- produced at suggestion. ROTA TOR Y MO YEMEN TS. 299 This patient is intelligent enough to tell me that he is unable to resist the impulse to rise and turn around as described. When asked to get up and turn he re- fused to do so ; but after a time, which was variable, he leaped up of a sudden, turned once, or even twice (which is rare), and then quietly resumed his work. Occasionally while walking he executes the same single rotatory motion, and then moves on as before. INDEX ALLEN, PROF., operation bv 258 Anaemia, pernicious, 133, 142 Anpesthesia, hysterical, 281 psychic. 17 Anatomy of sciatic tract, 159 Anhaloninm, symptoms of, 61 ' Anosmia, 19 Anxiety of prse-dormitium, 67 Arthritis in hemiplegia, 146 in hysterical disease, 287 Ataxia, cerebellar cause of, 130 Gowers on, 131 hysterical, 142 on awakening, 87 motor, in a child, 125 muscle sense in, 137 pernicious anaemia and, 133 retained reflexes in, 137 Aura, visual, 84 with sensory shocks, 81 BAILLARGER on hallucina- tions of pree-dormitium, 60, 61 Ball, Dr. M. V., 32 Barr, case by, 298 Bennett on sensory auras, 83 Blindness, hysterical, 253 psychic, 15 Blood-letting in melancholia, 47 Briquet on hysterical ataxia, 141 Bromide causing homicidal im- pulses, 63 Burr, case by, 182 on local temperature-changes from position, 207 post-mortem notes by, 143 /RATLIN on relation of pain to \J weather, 162 Childbed causing sciatica, 157 Chorea, eye-examination in, 227 hysterical, 94 in sleep, 85, 86, 87 of habit, 96 on waking, 87, 89 Clark on eye-strain, 224 ■ Cold -sensations, cases of, 115- 117 causes of, 111 classification of. 107 from neuritis, 120 of Cauda, 117 hysterical, 122 in buttocks, 112, 113 intensified capacity to feel, 121 Mills on, 124 of central origin, 108, 111 Putnam on, 123 subjective, in peripheral neu- ritis, 112 with elevation of tempera- ture, 113, 117 with unchanged tempera- ture, 112 Color-fields in hysterical para- plegia, 35, 75 normal, in hysteria, 270, 282 reversal of, 106 Contracture, hysterical, 242, 275 anaesthesia in, 261, 266 cases, 249, 275, 279 ^ diflfering forms of, 246, 2S8 ending in sclerosis, 243 multiple, of hysteria, 244 painful, 281 26 302 IXDEX. Contracture, probably not spinal in origin, 248 reflexes in, 245 reflexes absent in, 266 resembling poliomyelitis, 246 Richet on, 247 symptomatolog}' of, 243 tenotomy for, 24S, 284 Cooper, Sir Astley, 110 Cuba, seasonal melancholia in, 43 Curvature, spinal, with insanity, 210 cases, 212 215, 216 DAY-NUMBNESS functional. 68 Deafness, hysterical, 253 Derby on e^ve-strain, 221 De Schweinitz, eve-examination by, 20, 96, 138, 190, 214 eyes in chorea, 227 on sleep-ptosis, 77, 78 Diaphragm, spasm of, in hys- teria, 253 Dyer on eye-strain, 221 Dysaesthesia on waking, 70 Dyschromatopsia, hysterical, 75, 106 in hysterical palsies, 36 J. K. Mitchell and de Schweinitz on, 36 EPILEPTICS, eyes of, 227 Erythromelaigia, 177 blood-pressure in, 195 cases of, 178, 181, 185, 197 compared with Ray- naud's disease, 179 incurability of, 190 morphia in, 197 surface-temperature in, 197 with gangrene of foot, 197 with sciatica, 172 Examination, post-mortem, of spinning case, 297 Eve-strain as cause of headaches, '220 Eyes in chorea, 227 in epilepsy, 227 FAILURE, respiratory, in sleep, 91 Feeble-minded, rotatory move- ments in, 290 Fere, cases by, 73, 75 Foot-fidgets, 86 GERHARDT on erythromelai- gia, 180 Glycosuria in melancholia, 51 Gowers on ataxia, 131 HABIT-CHOREA, 96 diet in, 98 eyes in, 227 treatment of, 98 Hall, Dr. P. S., post-mortem notes by, 203 Hallucinations of prpe-dormitium, 62 Headaches and eye-strain, 220 Heat-sense, loss of, 2')6 Hemianopsia, hysterical, 20 Hemiplegia, arthritis in, 146, 150 nocturnal, 68 node in, 150, 151 nodes following. 145, 149 pain as a prodrome of, 143 as a sequel of, 143 subjective coldness in, 111 Hewson on anatomy of sciatic tract, 159 Hip-disease simulating sciatica, 158 Hurd on recurrent melancholia, 42 Hyperaesthesia. hysterical, 276 Hypnotism in melancholia, 34 Hysteria, anaesthesia in, 281 ataxia of, 87. 142 contracture in, 242, 279 multiple in, 244 dyschromatopsia in, 35, 75, '106 eyes in, 35, 75, 106, 270, 282 INDEX. 303 Hysteria, myoclonus in, 99 sclerosis following, 248 sensations of cold in, 122 with locomotor ataxia, 133 IMPULSE, homicidal, due to 1 bromides, 63 in melancholia, 46 Insanity, relation of pra?-dormi tium to, 59 Insomnia from eve-strain, 223 J ACKSOX, Professor Samuel, on recurrent melancholia, on respiratory failure in sleep, 91 Joints, post-hemiplegic disease of, 148, 150 KEEN and Morehouse on pain- misreference, 233 operation by, 192, 270, 284 Kinnicutt, case by, 120 Knee-jerk, in ataxia, 131 in sclerosis, 132 reinforcement of, 132 Krafft-Ebing, melancholic hyp- notized by, 34 LANNOIS on erythromelalgia, 179 Leg -pain in sleep, 79 MELANCHOLIA, abrupt re- covery in, 26, 37 bloodletting in, 48 caused by dream, 50 during digestion, 51 effect of menstruation on, 44 heredity in, 28 inter-menstrual, 47 case of, 44 irregular recurrent, 53 menstrual, 44, AQ of post-dormitium, 49 predisposing causes, 27 recurrent seasonal, 32 Melancholia, recurrent seasonal, cases of, 32, 36. 37, 39, 40 related to sleep, 49 removal of ovaries in, 45 sensory delusions during post- dormitium, 49 tends to recur, 31 treated by hypnotism, 34 with erotic impulses, 45 with glycosuria, 51 with homicidal impulse; 46 Melancholies, marriage of, 29 Mills on cold-sensations, 124 Mind-blindness, 15 Misreference of pain, 231 Mitchell, J. K., and de Sclnveinitz on dyschromatopsia, 36 Mitchell, J. K.. on misreference of pain, 234 joint-lesions from spinal in- juries, 145 Morton, operation by, 159, 202 Movement-rate in ataxia, 138 Movements, imperative, 291 rotatorv, 290 spinning, 292, 293, 296 Myoclonus, multiple, 99, 100 Muscle, pyriform, share of, in producing 5-ciatica, 160 -sense in ataxia, 137 ^AUSEA from eye-strain, 223 xi Neuritis as a cause of ery- thromelalgia, 181, 194, 196 changes of tnermal sense in, 120 cold-sensations in, 112, 117, 120 sciatic, 155 terminal, 194 Neuroses, ocular, 220 Nodes following hemiplegia, 145, 149, 151 Numbness, hysterical, 73 OCULAK neuroses, 220 Olfaction, loss of, 19 Ormerod on numbness, 72 304 INDEX. PAIN and weather, Catlin on, 162 as a prodrome of hemiplegia, 145,147 Pain as a sequel of hemiplegia, 147 misreferred, 231 cases, 231, 233, 234 Paralysis from irritation, 76 hysterical, 266 Paraplegia, hysterical, 35 Paresis, nocturnal, 68, 72, 75 Pearce on local temperatures, 207 Pershing, case by, 15 Pinel on seasonal melancholia, 42 Post-dormitium, 59 relation of, to insanity, 59 sensory delusions in melan- cholia, 49 Prse-dormitium, Baillarger on, 60 hallucinations in, 62 olfactory disturbance in, 62 relation of, to insanity, 59 sensory shocks in, 83 terrors in, 6o Pregnancy, delusion of, in the insane, 239 spurious, 236 Prentiss on physiological effects of anhalonium, 61 Pseudocvesis, 236 cases, 236, 237, 238, 239, 241 causation of, 239 Hirst on, 238 sympathetic vomiting of hus- band in, 241 vomiting in, 238 Ptosis of sleep, 77 Putnam on cold-sensations, 123 RANNEY, on eye-treatment of epilepsy, 228 Raynaud's disease, case of, 178 compared with erythro- ; melalgia, 177, 179 I Reactions, faradic, in hysterical paralysis, 278, 279 ' | Reaction-time in ataxia, 138, 139 Reflex ocular neuroses, 220 I Reflexes retained in ataxia, 128 \ Reinforcement of knee-jerk, 132 Richet on contractiires, 247 Rigidity, hysterical, on a\vaking, 90 Rotation, imperative, 298 Rotatory movements, 290 cases of, 293, 296, 297 SAUNDBY on sleep-numbness, 68 Schiile, on recurrent melancholia, 43 Sciatica, 154 and erythromelalgia, 172 cases of, 169, 170, 171 childbed, 157 diagnosis of, 154 double, 170 from fecal accumulations, 156 from pelvic growth, 156 from pressure during deliv- ery, 156 from tumor, 159 hours of exacerbation, 161 influence of position on, 158 of central origin, 175 pyriform muscle's share in, *160 simulated by hip-joint dis- ease, 158 treatment of, 164 bandage, 166 blisters, 167 cautery, 167 cocaine, 165 dry cups, 165 ice, 167 massage, 167 morphine. 165 nerve stretching, 175 splint-rest, 165 Sciatic nerve, anatomy of, 159 Sclerosis, knee-jerk in, 132 post-hysterical, 248 Sensory shocks, 80 Sharkey on misreference of pain, 232 " Shocks, auditory, 81 and sensory, 81 INDEX. 305 Shocks, olfactory, 81, 83 sensory, 80, 81 in daytime, 83 visual, 81 Sinkler on numbness, 72 Sleep disorders, 58 -jerks, 85 -numbness, 68 in neuritis, 71 with pain, 71 -pain, 79 -ptosis, 77, 78 respiratory failure in, 91 -shocks 80, 82 double auras in, 84 prne-dormitium, 80 olfactory, 83 aura in, 84 visual aura in, 84 Smith, I)r Andrew H., on sleep- numbness, 68 Spasm, tonic, on waking, 89, 90 Stevens on refractive lesions, 225 Surface-temperatures, 205, 207 Starr, case by, 37 Syphilis, sciatica due to, 156 Tenotomy for hysterical contrac- ture, 272 in ocular neuroses, 229 Thermometer for surface-temper- atures, 205 Thermometry of erythromelal- gia, 201 Thomson on astigmatism causing headache, 226 A. G., eye-examinations by, 128, 267, 282 Tobacco causing sleep-jerks, 86 -shocks, 82 Tyrell on eye-strain, 224 UREA lessened in acute melan- cholia, 56 yASO-MOTOR paralysis of ex- T tremities, 177 Vertigo from eye-strain, 223 Vomiting, sympathetic, in hus- band, 241 Visual-fields in hysteria, 36, 75, 106 TIAYLOR, J M., case by, 169 1 170 on anomalous sciatic nerve^ 159 W. J., operation by, 285 Temperature, difference of, on two sides, 206 influence of position on, 207 WAKING-NUMBNESS, 70 cases of, 72, 75 following nerve - freez- ing, 71 Waking tonic spasm, 89 Weather and pain, 162 Witmer on reaction-time, 138 Catalogue of Books PUBLISHED BY Lea Brothers & Company, 706, 708 & 710 Sansom St., Philadelphia. Ill Fifth Avenue (Corner 18th Street), New York. The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. 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