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LECTURES

DISEASES OF THE NERVOUS SYSTEM,

ESPECIALLY IN WOMEN.

BY

S. WEIR MITCHELL, M.D.

'5

MEMBER OP THE NATIONAL ACADEMY OF SCIENCES; PHYSICIAN TO THE ORTHOP-(EDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE

NERVOUS SYSTEM ;

VICE-PRESIDENT OP THE PHILADELPHIA COLLEGE OF PHYSICIANS;

MEMBER OP THE NEW YORK ACADEMY OF MEDICINE J

HONORARY CORRESPONDING MEMBER OP THE BRITISH MEDICAL ASSOCIATION ;

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY;

FOREIGN ASSOCIATE OP THE ROYAL MEDICAL SOCIETY OF NORWAY;

AUTHOR OF A TREATISE ON INJURIES OF NERVES, ETC. ETC.

SECOND EmTION", KEYISED AND ENLARGED,

WITH FIVE PLATES.

PHILADELPHIA:

LEA BROTHERS & CO. 1885.

Entered according to the Act of Congress, in the year 1885, by

LEA BROTHERS & CO., in the Office of the Librarian of Congress. All rights reserved.

DORNAN, PRINTER

DEDICATED TO

J. HUGHLINGS-JACKSON, M.D., F.R.S.

WITH WARM PERSONAL REGARD,

IN GRATEFUL ACKNOWLEDGMENT

HIS SERVICES TO

THE SCIENCE OF MEDICINE.

PREFACE TO SECOND EDITION.

The book has been long out of print, but only of late have I found time to prepare a second edition.

I have altered considerably some of the early lectures, and have added others on the difficulties of diagnosis in hysterical diseases of joints, on the relations of hysteria to organic disease of the spine, and on hysterical disorders of the rectum.

PREFACE TO FIRST EDITION.

The lectures which compose this volume deal chiefly with some of the rarer maladies, or forms of maladies, of women. Many of them are original studies of well-known diseases, and others deal with subjects which have been hitherto slighted in medical literature or which are almost un- known to it.

I desire to express my thanks for very valuable aid to my colleague Dr. Whaeton Sinkler, to Professor Horatio C. Wood, to Dr. Louis Starr, and especially to Dr. Morris J. Lewis.

CONTENTS.

LECTUEE I.

THE PARALYSES OE HYSTERIA.

PAGE

Paraplegia — Hemiplegia — Bilateral hemiplegia . . .13

LECTUEE II.

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS.

Briquet's hysterical ataxia — New forms of hysterical ataxia — Forms of paresis ......... 39

LECTUEE III.

MIMICRY OE DISEASE.

Causes of mimicry — The hysterical state — General nervous- ness— General failure of health — Psychic peculiarities — Natural mental and moral conditions favoring mimicry of disease — Imitative vomiting — Imitative palsj' — Mimicry of pain — Imitative epilepsy — Imitative meningitis — Epidemic of rhythmic chorea ........ 55

LECTUEE IV.

MIMICRY OF DISEASE,

Hysteria in childhood — Simulated vomiting — Simulation of hip-joint disease — Autobiographical confessions . . .81

X CONTENTS.

LECTUEE Y.

PASE

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN.

Rotatory spasms — Functional spasms — Strychnic spasms — Spasms on change of position — Local spasms simulating tumors — In the pectoral muscles — In the walls of the ab- domen— In the gastrocnemius — Hysterical athetosis. . 96

LECTURE VI.

TREMOR.

Hysterical tremor — Nervous tremor with organic disease of the spine — Alcoholic tremor in nervous women . . .114

LECTURE VII.

CHRONIC SPASMS.

Chronic spasm with simulation of local injury of ulnar nerve — Chronic spasm of leg — Contracture of leg muscles — — Treatment of hysterical contractions — Section of tendons — Simulated contractions — Simulation of contractions and of disease of ulnar nerve — Chronic spasmodic ptosis . . 123

LECTURE VIII.

CHOREA OF CHILDHOOD.

The relations of the chorea of childhood — To season — To climate — To locality — To race — Forms of chorea . . 137

LECTURE IX.

HABIT CHOREA.

Definition— Cases of habit chorea— Relatlo to chorea of childhood — Treatment 1-^6

' CONTENTS. XI

LECTUKE X.

PAGE

DISORDERS OF SLEEP IN NERVOUS OR HYSTERICAL PERSONS.

Sensory shocks — Emotional shocks — Irregular motor dis- charges— Nocturnal functional hemiplegia — Respiratory failures in sleep ......... 163

LECTURE XI.

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERTOUS OR

HYSTERICAL.

Pulse in hysteria — Agitation of heart followed by apparent death — Eccentricities of pulse in the hysterical — Palpita- tion of heart with flushing of face — Palpitation of heart with pallor of face — Surface ischsemia — Vaso-motor par- alysis in the limbs or the face — Extreme vaso-motor paralysis of the whole vascular system of the abdominal cavity — Respiratory peculiarities of hysteria — Case of rapid respiration in man from wound ...... 184

LECTURE XIL

HYSTERICAL APHONIA.

Paralysis of laryngeal muscles — Failure of coordination in the various organs which combine to produce speech . . 208

LECTURE XIII.

HYSTERICAL JOINTS.

Typical case — Hysterical knee with plastic infiltration of con- nective tissues outside of the capsule 218

Xll CONTENTS.

LECTURE XIV.

PAGE

HYSTERIA AND ORGANIC DISEASE OF THE SPINE.

Old cases of hysteria — Unusual case with spinal disease . 227

LECTURE XY.

GASTRO-INTESTINAL DISORDERS OF HYSTERIA.

Comparative rarity of hystero-epilepsies in America — Difficulty of feeding hysterical women — Troubles as to mastication — Eorms of dysphagia — Hysterical anorexia — Hysterical vomiting — Hysterical fasting .... 238

LECTURE XYI.

THE RECTUM AND DEFECATION IN HYSTERIA.

Irritable rectum — The paretic rectum — Anaesthesia of rectum — Incoordination in defecation — Painful rectum — Anal spasm . .... . . . . . • • 252

LECTURE XVII.

THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS- TION AND' HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC- TRICITY AND FULL FEEDING.

Character of cases needing this treatment — Seclusion — Nurses — Uterine disease — Ovarian disorders — Seclusion — Rest — Massage — Electricity — Mode of feeding . . .265

DISEASES

OF THB

NERVOUS SYSTEM,

ESPECIALLY IN WOMEN.

LECTURE I.

THE PARALYSES OF HYSTERIA.

The case to which I drew your attention at mj last clinic is here again, a girl, rather wanting in the signs of sexual ripeness, although sixteen years old. You will recall the fact that she lost the use of the right arm hecause of having been alarmed. The scare brought on what every woman knows as an attack of hysterics — our ancestors called it the vapors. The girl cried and laughed by turns, and then had a slight fit, on coming out of which she could no longer lift her right arm, or rather she could lift it but a few inches. On finding this to be the case, she grew much concerned, and by and by could not lift it at all, the idea that it could not be raised helping, as is apt to be the case, to make the trouble worse. There seems to have been no deceit, but perhaps the first feebleness may have been slight, and the power of her belief in her want of force

14 DISEASES OF THE NERVOUS SYSTEM.

great, and this is rather the more likely since, as you saw, I raised the arm and said, " Now you can keep it up," which she did. You see that it seems again palsied. A new order restores it, and she lifts it without much effort, having won a belief in my being able to aid her. I send her away with a lightly uttered word or two as to the use of the hot iron, if she again loses power. The warning may answer, or may not. We had a case very like this two years ago. I believe it got well.

We see here among the ill-fed, needy, and wor- ried, a good many cases of hysterical loss of power, and I meet a yet larger number among women of the upper classes, in whom the disease is caused by unhappy love affairs, losses of money, and the daily fret and wearisomeness of lives which, passing out of maidenhood, lack those distinct occupations and aims which, in the lives of men, are like the steady- ing influence of the fly-wheel in an engine.

A yet more common cause of hysterical disorder is to be met with among the young persons who frequent the colleges for women. Every year brings me a fair contingent of patients from these schools; and I have asked myself over and over why it is that these places produce so much disease which ought to be avoidable. As our society is constituted, it is clear that women must have opened to them the higher grades of instruction ; and yet something must clearly be done to avoid the penalties which hard study, class competitions, and the emotional stimulus women bring to their work, are apt to produce.

PAEALYSES OF HYSTEEIA. 15

Something might be done by a careful medical examination of the fitness of girls entering colleges. Their power to work during and just after men- struation should be inquired into, and their early months of college work should be carefully watched. Above all, their eyes ought to be examined, because numerous women become ill from the strain of brain- work done with imperfect vision. Moreover, these inspections should be repeated at reasonable intervals.

Let me admit in passing that, at Yassar and some other schools, the machinery and organization for the care of the physical and mental health of students exists ; but it does not seem to work satisfactorily. The reason is only too clear. The general sense — shall I say the prejudices — of such groups of women is opposed to conceding the belief held by physi- cians that there are in the physiological life of women disqualifications for continuous labor of mind. Public sentiment is in women's colleges against this belief, and acts as a constant goad for women at times unfit to use their brains. If ever the horrible system of coeducation of the sexes becomes more general, this difficulty will, of course, be mischiev- ously emphasized by the modest dislike of the weaker girls to exhibit, at intervals, signs of failure, or to excuse themselves from tasks which they cannot competently pursue alongside of the male, who is not weighted by the occasional need to plead any form of recurrent disability.

It is my present wish to speak of some of the many kinds of hysterical paralysis, and to dwell far more freely on methods of treatment than upon

16 DISEASES OF THE NEKVOUS SYSTEM.

minute details in the natural history of these dis- orders. I do this chiefly because as regards treat- ment I hold very positive opinions, and because these opinions have, I believe, been amply justified by happy results, some of which are familiar enough to those who have followed my practice.

The group of instances of lessened power which I shall here discuss will include the usual forms of hysteric paraplegia and hemiplegia, and that which I shall call double hemiplegia. I shall not attempt to cover the whole range of hystero-palsies, but seek chiefly so to define a certain number as to allow me to speak of their treatment. I shall also describe four forms of seeming loss of power, only one of which is essentially hysterical in nature, and not found elsewhere with the same features. I allude to hysterical motor ataxia.

The others are palsy from the rule of an idea, general paresis, and consciously mimicked palsy.

All three of these may be and are seen outside of hysteria, but they find in it a fertile soil, and are none the easier to treat when they are masking in this disguise.

One of the chief troubles in clearly knowing and in dealino; with all of these forms of disease is due to the fact that in most cases, and to some extent, they may exist in union. The case of palsy may be partly real, partly pure weakness, partly loss of power from want of belief in being able to move; or conscious mimicry may be added to palsy or to the forbidding influence of a regnant idea, or to the true hysteric palsy may be joined ataxy of motion. For such vex-

PARALYSES OF HYSTERIA. 17

ing marriages of disorders, and for their offspring of doubt, we must be ready and watchful. They make the true limits of hysteric lack of power hard to de- fine, hard to treat, full of surprises, and unfailing in interest and variety. Take this for an instance : You have a case of extreme hysteric paresis to treat. As a rule, it is readily cured. You predict a clear and happy future. As time wears on the mere weakness is gone, the limbs are plump again, the cheek red, and then you may find, if you have not been careful, as I have found, that hidden in the mere weakness there is a distinct amount of motor palsy — a mild, one-sided loss of power — a true hysteric palsy, and not at all easy to cure. I shall pick for you, out of my note-books, cases of each of the forms of disease I have just spoken of, and shall try to make plain to you how I treat them. There were once no cases so much dreaded by me. There are now none to which I go with so much pleasure, I am sure that I treat them to-day with a success I could not once have gained, and I think that what success I have had has been due to more exact ideas as to what is needed, and that unflinching purpose and action which grow out of distinct views.

Let us take first a case of paraplegia — less common than hemiplegia and more difficult to relieve. The example I shall quote for you is the more interesting because of its having ended in death.

Mrs. C, set. 36, a strong woman, and in all ways well, lost by sudden death a child and her husband. Thus having cast on her the care of a large estate, loaded with many burdens, she began to show excess

2*

18 DISEASES OF THE NERVOUS SYSTEM.

of anxiety as to her affairs, and from being sweet of temper became abrupt and full of unreasonable doubt as to her advisers. The worry brought with it speedy loss of blood globules, and as she was a woman who flowed very freely each month, all these causes together began to tell. This is the kind of thing we see much of in medicine. The books say this, that, or the other causes hysteria. In practice it is usual to find two or three causes — acting to assist one another. This woman was quite ready for an outbreak of some form of nerve trouble, when of a sudden she met the final blow in the form of a telegram. The news it bore was neither good nor ill, but by evil luck the writing looked like that of her dead husband, and she began to laugh with that strange want of appropriateness in emotional expres- sion so common in the nervous. Awaking next day her legs seemed heavy, which caused her great alarm. At once, as she told me, the fear of palsy arose in her mind, and haunted her the more as, day by day, the feebleness grew worse. She was in Germany when taken ill, and seems to have been looked upon as suffering from an organic malady, for she was treated with nitrate of silver and the hot iron. Then as she failed to get relief anywhere, she was sent from one spa to another with a skill which as yet we are fortunately far from being able to reach.

St. Moritz, Schwalbach, Vichy, Loueche, and springs of less note, had each their turn, after the European fashion, until, in despair, she was carried back to America, where I saw her often and until the close of her life.

PAEALYSES OF HYSTERIA. 19

This was what I found : A woman of 36, height 5 feet 2 inches, weight 170 lbs., flabby, and thin- blooded, with healthy heart, lungs, and kidneys. On the left side of the vagina was felt a tumor about the size of a walnut. It was very tender, and firm pres- sure on it gave rise to nausea and distress down the left leg. I had no doubt that this growth w^as a dis- placed ovary, but despite this change of place, the left iliac fossa, both the skin and the parts reached by deeper pressure, was tender to touch. Was it ovarian tenderness ? Hardly, in this case. I have been told by Dr. Goodell that he has seen this same sensitiveness in other instances where the ovary had been displaced, and probably too much has been and is made of this symptom. The tenderness in Mrs. C.'s case was isolated, as is not unusual, and all about it up to the waist and down to the feet the bod}^ was without sense of touch or pain, or of heat and cold. In tracing this defect upwards it was found to cover the left breast, but this was so to-day, and then to- morrow it was less, the upper limit ranging from the navel to the left armpit.

Motor power was failing when I first saw her, but this had been the case before, and had been followed by a change for the better.

The plan pursued in treating the case was one to which I groped my way a few years ago. My patient was very thin-blooded, and yet very fat. Such cases, for some reason not clear to me, are more hard to redden than are those of thin people in like states of blood. But if you can safely cause these persons to lose flesh, as they are helped to remake it, you may

20 DISEASES OF THE NERVOUS SYSTEM.

sometimes redden them with ease, and to raise the number of blood globules to the normal is usually to lift a woman above that low level of health, which is one, at least, of the factors of hysteria.

Mrs. C. was, when first seen by me, sitting up most of the day, and sewing, writing, and the like, when not too nervous. I put her in bed, and employing as a diet milk alone, mixed with a little rice-water or barley-water, I began to lessen the amount given, until, using less than a quart a day, her weight fell off at the rate of about a quarter to a half pound a day. When she showed signs of weakness I added beef soup to the diet for a day or two, and thus in one month brought down her weight some twenty- four pounds. This could not with safety have been so quickly done had not the patient have been kept in bed. Then the milk was by degrees increased. Raw beef and vegetables were added, malt extract was used before meals, a little red wine or champagne was allowed, and iron was given freely, the feeding being frequent. When I made the increase in diet I began to arouse sensation by the use of the wire brush and induction currents.

E'ow in common palsies, or in those from nerve wounds, feeling is apt to come back first, motion last; but in hysteric palsies, as I think, the gain in active motion may go on, and even reach a useful amount while yet the lack of feeling rests as it was when the treatment began. Just this change took place in Mrs. C. : She grew brighter, and more happy, gained in color and flesh, and began to move her legs. In a month after she reached full diet she

PAKALYSES OF HYSTEEIA. 21

could walk with some trouble, and about this time the sense of touch showed signs of betterment, but the power to feel pain was unchanged, and, in fact, was never complete in the left leg.

I^ext began a plan of steady, urgent calls upon her for increase of the use of her limbs, so that before long she was able to walk out of doors. At this point I fear there was a mistake made in the treatment. Thinking the battle won I pushed her too hard, and one day after walking much further than usual she felt an excess of fatigue. Returning home she gave out of a sudden, and the morning after was again hardly able to stir either leg. I may pause here to repeat as to this matter a warning I have often given. It is to urge on you the utmost care as to allowing a hysterical patient on the way to health — I mean, of course, one who has lost power — to do more each day than fulfil the ordered task of that day. Most cases of hystero-palsies are easily tired, and it is almost sure to be the case that they cannot make a long effort without showing the effect in some way; moreover the mental results of extreme tire are to be feared, because any positive, real sensation is apt to become the peg, so to speak, on which the patient may hang the complement of a larger and less real sensation.

More slowly this time Mrs. C. got back some con- trol over her movements, but at a certain point the gain ceased, and we made no further progress, nor did this surprise me. Hysterical paraplegia is, as I have said, more hard to cure than any other hys- terical trouble except, perhaps, multiple contractures,

22 DISEASES OF THE NEEVOUS SYSTEM.

and I felt that I had done well to win what I had won.

About six months later this lady died after a brief illness, which seemed to me more like a sudden and complete palsy of the pneumogastric nerves than anything else. 'No examination post mortem w^as allowed. I have seen three deaths in hysteria; all were abrupt, and two were due to acute congestion of the kidneys.

The following case resulted more happily : The patient, a woman get. 18 years, had been in good health. Her paraplegia w^as caused by seeing her father seriously injured by a fall from a horse. She became feeble, ceased to eat sufficiently, and in a week was unable to lift hand or foot. She was brought to me six months later, and was then a rosy girl of eighteen, not wasted, but presenting a singular flabbiness of the muscular masses. The loss of power in the legs and feet was so complete that, except in the left foot, no motion could be seen. The hands were so feeble as to be useless, although all the fingers could be moved. Even the neck was too weak to sustain the head. I had never seen the loss of power in hysteria so complete. That of sensation was not less so. The face was on both sides defective in power to feel pain or touch, or change of tem- perature, yet smell, taste, and hearing were as in health. I expected to observe some notable func- tional disturbance in the eyes, and therefore asked Dr. Wm. Thomson to see her. The most elaborate examination by this expert ophthalmologist failed to show the existence of even the slightest defect of

PARALYSES OF HYSTERIA. 23

color-sense, or, in fact, anything except hyperme- tropic astigmatism. Below the face there was no ability to feel pain. The sense of touch was lessened in acuteness, but not lost. The power to localize an impression was impaired, and the sense of tempera- tures lost. I should have said that beneath the skin there was some feeling. On applying to the nipple the bare metal poles of the secondary current of an induction coil — a severe test — no signal of pain ap- peared ; but, when two needles were carried through the skin, and a strong current passed between them, some pain was felt. Over the dorsal and cervical spine — that is, from the third cervical to the tenth dorsal spine — was a space about an inch wide in which pin-pricks could be readily felt. Elsewhere the needles used caused no more expression of pain than if the woman's flesh had been a pincushion, and no bleeding followed their use. As there w^as constant regurgitation of strongly acidulated food after each of the large meals she took, she was placed on the exclusive use of milk containing two grains of bi- carbonate of soda to the ounce. This, with massage and electricity, and such training as I shall describe at another place, triumphed after two months, and she became able to eat, sleep, and walk, much as others do. l^evertheless, the analgesia remained nearly the same in the legs as at first, although it disappeared above the waist almost entirely. The sense of touch was not more improved than that of pain, and this was as stated when she had become well enough to walk two miles. She seems uncon- scious of this continued defect, and my previous

24 DISEASES OF THE NERVOUS SYSTEM.

experience teaches me to hope that by degrees the analgesia will disappear. In fact, the most useful lesson we can draw from this and other like cases is the fact that full volitional control may return while the sense of touch or of pain remains greatly im- paired. Once set the patient usefully afoot, and we shall do well to cease to call attention to the con- tinuance of the sensory failure. Secure to such cases a quiet, unemotional life, and with the renewal of healthy nutritive functions, the sensory failures will in turn cease to exist.^

Of that more common type, the palsies of one side of the body, you have seen a number. In this country, at least, they are more frequent than the paraplegias; less hard to cure, but quite lasting enough to make you cautious as to what you predict about their future. Where they occur in the feeble and thin-blooded, who have by degrees grown emo- tional, tearful, and weak of will, you may have more hope of helping them than if they are met with in robust people of non -emotional type, in whom the usual emotional elements which go to build up this temper of mind are wanting, or are small in amount. The former offer through the relief of their nutritive defects chances of obvious nature ; the latter are apt to be bright or even able women, who enlist their mental forces in behalf of their symptoms, and treat the hated charge of being hysterical with utter scorn.^

^ Six months after the above notes were written, I learn that the patient whose case I have described above is perfectly well.

^ I ought, perhaps, to add that these women are usually mobile and excitable by nature, prone to laughter more than tears, so that

PAEALYSES OF HYSTEKIA. 25

I cannot leave this subject of hemipalsies of hys- teria without a few words as to the ordinary type of this disorder. I shall, therefore, sketch for you somewhat briefly the chief symptoms of hemiplegia of hysterical origin.

This disease may come on slowly, and during the varied course of a case of hysteria, or it may arise abruptly — in an instant, even — in women known or not suspected to be hysterical, owing to some pro- found emotion or to an accident, such as a fall or a wound. It is often of such insidious development that its presence, when mild, is a thing rather to be found by looking for it than of such a nature as to be forced upon the attention of the observer. It is excessively rare to see it as complete as we see a hemiplegia of organic origin. J^early always — I might venture to say always — it is associated with some loss or disturbance of sensation. More often this latter symptom is the dominant one, and the lack of power merely amounts to a paresis or incom- plete palsy.

Unlike the hemipalsy of cerebral and organic cause, hysterical half-palsies involve more or less all of one side of the body, excepting the face ; but in a few rare cases the neck is distinctly affected, while usually when the case is incomplete, it is the leg which suffers most, both as to sensation and motion.

Apart from the fact that the face escapes, there are other symptoms which differentiate these losses

it is hardly exact to say they are not emotional. Their form of too ready emotional disturbance lies merely in an unusual direction for the victims of hysteria.

3

26 DISEASES OF THE NERVOUS SYSTEM.

of power from those which are due to clots or emboli, and a knowledge of which enables us to diagnosticate the case with sufficient ease, as arising from hysteria. As to locality, in Briquet's cases there were 70 on the left to 20 on the right; in my own note-books, I find the pi'oportion as 4 left to 1 right. The amount of loss of power is often quite definite, but in other cases it varies in degree, and from day to day, within wider ranges than we see in palsies of organic birth.

It is exceedingly rare to see unilateral loss of power in hysteria without distinct defects of feeling.

Sensation is disturbed, lessened, or lost either throughout the one-half of the body or in varying amounts over this space, and in the face, as a rule, less than elsewhere. In rare cases, the sensibility improves very near the middle line of the body. In some instances no feeling exists; more often sense of touch and power to localize sensations remains with profound analgesia, and often also with lack of power to tell heat from cold. In bad cases, espe- cially if very feeble, the vision is subject to blurring, or the eye on the affected side undergoes the curi- ous loss of color-sense described by Galezowsky; although in the milder cases, and in some grave ones, this is assuredly not a constant symptom. Deafness is much more rare, but has been seen twice within a year in this clinic by Dr. Sinkler.

Charcot and Dr. Buzzard both state that the patel- lar tendon reflex is exaggerated on the side of the palsy, and the latter that the ankle clonus may at times be met with. In the last three cases I have seen of hysterical hemipalsy the patellar tendon reflex

PARALYSES OF HYSTERIA. 27

was increased on the affected side. In two others it was notably lessened, as was the case in the girl present at my last clinic, in whom it was only possible to be sure that this symptom existed at all by grasp- ing the muscles with one hand while the blow was struck. In another case the flexors responded and not the extensors ; and in yet another, with an exag- gerated reflex, there was also a sharp contraction of the adductors on both sides.

In a case now under my care there is slight con- tracture of the calf muscles, and the heel is thus drawn up. The attempt to evolve ankle clonus is successful, but in a few seconds the extensor muscles of the thigh jerk or twitch, and next the foot of the sound side exhibits a beautiful example of ankle clonus.

A good deal has been said as to ovarian tender- ness in hysterical hemianeesthesia and in the yet graver hysteric states. I put less stress on it than is done by the school of Salpetriere. Often in hemi- palsies of the kind we are now discussing there is tenderness over a region which has by a sort of un- questioning agreement been called ovarian, and which begins at the groin, and is of variable extent. Some- times there is no such sensitiveness, or else possibly it extends above the navel, or it is felt only on deep pressure, and in another case only upon pinching of the skin. Then again, it may exist when one or both ovaries are gone ; so that while we must admit this sesthogenetic region as common in hysteria, we must not too readily feel sure that its sensitiveness is related directly to the little ovary beneath it.

28 DISEASES OF THE NERVOUS SYSTEM.

It has been shown of late that defects of the spe- cial senses, once looked upon as peculiar to hysterical hemiplegia, are to be met with also in palsies of organic cause. I have elsewhere in this volume spoken of ischsemia of the skin as being found in other than hysteric analgesia. Within a few months^ I have called attention to yet another resem- blance between palsies of organic and of functional birth; and have shown that in hysterical hemiplegia we may meet with unilateral swelling analogous to that seen in like palsies due to clots or emboli. The oedema of organic brain disease w^hen present at all is pretty constant ; that of hysteria varies enor- mously, and is influenced by menstruation, exercise, and emotional disturbances. It may be slight, or may surpass by far any like disorder to be met with in hemiplegia due to clot or embolus. There is also something peculiar about the swelling. In places it is clearly oedematous ; but in others no pit can be made by pressure, or else the most prolonged pres- sure is needed to produce this sign of oedema.

In the early stages of hysterical palsies the elec- trical reactions are normal; but after a time changes occur in a certain proportion of cases. These are rarely such as indicate those degenerative changes which force upon us the inference that the spinal cord has undergone some destructive change. More commonly long-contracted limbs, suflfering from the atrophy of disuse, present merely a relative lessening in response to maximal electrical excitations. Some-

^ Am. JoLirn. Med. Sci., July, 1884. Unilateral Swelling of Hysterical Hemiplegia,

PAEALYSES OF HYSTERIA. 29

times we meet with eccentric phenomena which demand further study. Thus, as is well known, it is common to find the healthy response of muscles to electricity delayed a little, or to see it increase after the current has been used a few moments. I^ow, in some hysterical cases, the only peculiarity is an enormous increase in the length of this period. I saw this well illustrated some time ago in a chronic case of horrible rhythmic spasms of the arms, with palsy of sense and motion in the legs. Dr. Yarrow, the attending physician, studied with me the electric state, which was curious. When with slow or rapid breaking of circuit (induced currents) we tested the leg muscles, the currents, although unbearable by us, caused no motion until the}^ had been steadily applied for from two to three minutes to any one muscle.

There are, therefore, numerous points of likeness between palsies of organic cause and those due to hysteria. ]^evertheless, the differential diagnosis is rarely difi&cult, and I may add that while I see many mistakes made, owing to confounding hysteric para- plegias with those of organic cause, I rarely see such confusion as regards hysteric hemiplegia.

The following case, now in the Infirmary, may serve as a fair type of this form of paralysis : Miss L., a fine, large, ruddy woman of 26 years of age, owes her hemipalsy to the shock of a fall from affluence to the need to support herself by giving lessons in music. Then a succession of deaths fell upon her household; and at last, one day, while engaged in teaching, she fell asleep, as it were, abruptly, at about

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30 DISEASES OF THE NERVOUS SYSTEM.

9 A. M. She was aroused enough to be taken to bed, and there remained thirteen hours, in what seemed to be profound slumber. After this unusual trouble she grew more and more hysterical, and at last came under my care. Her organs are, in general, healthy; but she has this curious peculiarity, of which she seems quite unaware. The pulse varies from 80 to 95; but the respiration, without seeming to be hur- ried or distressed, is never less than 40, and is often 60 to the minute.

She has considerable loss of power, with incom- plete analgesia, defect of thermal sense, and preserva- tion of touch. The face is scarcely affected at all, and the senses of sight, smell, and taste are intact. There is no ovarian tenderness on either side, and the analgesia varies daily, almost hourly, as to extent, place, and amount. A mustard plaster or blister, or, more remarkably, freezing by rhigolene, will often restore feeling over a large space for a few hours or for days; but invariably the next menstrual flow un- does whatever good may have been done. I tried the '' metal cure" in this, as I have tried it over and over in other and worse cases ; but, although from it, or from glass, cork, wood, or what not, I have obtained many times a slight local change in feeling, I have never seen this complete, and have never once wit- nessed the phenomenon of transfer of the analgesia or ansesthesia to the opposite side — a phenomenon which seems to be undeniably frequent in the hands of as admirable an observer as Charcot. I ought to add that my colleague, Dr. Sinkler, has not been in

PARALYSES OF HYSTERIA. 31

this matter more fortunate than I, although he has, I believe, studied several cases from this point of view. The patient I have mentioned has many other hys- terical troubles, and, being quite rosy and stout, will be a difficult case to deal with. It is interesting to learn that until this girl came here neither she nor her medical attendants were aware that she had any loss of feeling.

The temperature of the left, the affected leg, is normal, or the same as the other, and pin-pricks fail to bleed at any part of the limb where there is lessened feeling. The tendon reflex of the patella is remarkably exaggerated on the palsied side, but there is no ankle clonus. Under use of good diet and tonics this girl is gaining color and weight, while by a succession of irritants, chiefly the wire- brush and induction currents, the sensation has been more and more successfully restored, so that the last menstrual flow, which commonly leaves her much w^orse, has been less disastrous than usual.

I shall not trouble you further with details of this the most common type of hysteric hemiplegia, but pass on to one of the forms not well described as yet, and which I shall, in advance, venture to call double hemiplegia. This, as we shall presently see, is not merely another name for paraplegia.

Miss B., a sturdy, handsome girl, set. 16 years, had a series of ills, one on another, from time to time. The first sign of trouble was twitches of the eyelids, and tears on reading ; then there was a pause of two years. The next disturbance was a noisy and obstinate hiccup, during which both iliac fosspe be-

32 DISEASES OF THE NERVOUS SYSTEM.

came tender, and a single hypodermic use of morphia was followed by convulsions. Il^ext came hysteric loss of desire for food, nausea, pains in the left arm and leg, and spasm of the vessels in the left leg, so that it became white and cold. Up to this time she still walked out; but in the summer of 1878 the use of galvanism is said to have been followed by sick stomach and loss of power to stand. In the autumn she got rid of immense masses of hard feces, when all the symptoms improved for a time. The next winter was passed in bed, vomiting a good deal; eating little; the bowels very hard to move; the urine passed every hour. About this time, also, she began to shun light, and came at last to living, with covered eyes, in a darkened room. When I saw this young lady I was struck with the thorough type of the emotional hysteric person she showed ; nor from the usual weak will to the usual love of sym- pathy was there any tint wanting to the picture. I watched her for a few daj^s without ordering treat- ment, until I learned all I could of herself, her his- tory, her home-life, her pursuits, her ambitions, and her mental powers. Then a talk with a watchful nurse helped me further, and I saw clearly that I had to do not with a clever woman who may be won over, and who is flattered by the tribute paid to her mind when you insist that to cure her she must be made to understand and agree with you, but with a child who, to be made well, had to be calmly and firml}' ruled, and held day b}^ day to rigid account. She was at once shut up, with a good nurse, and kept at rest in bed, not being allowed to use her hands

PARALYSES OF HYSTERIA. 33

even to feed herself. As she had been able to knit and sew, and be read to, and to receive many visits, the sense of the irksomeness of the treatment soon made her eager to do anything I wished. Then began a system of bribes. She was told that if she could learn to bear the light she would be able to be read to, but that the nurse could not be allowed to strain her eyes. It would have been easy to open the windows and say you must bear the light, but if she herself gained this point of vantage, it would have the great value of being a self-conquest. In a few days I found the sunlight bright in her room. Then she was asked to overcome the habit of regur- gitating her food. One or two scoldings, some show of disgust, and the promise that she should soon feed herself if she obeyed my wishes, helped us through with this. There were relapses; but as I found she hated milk I felt forced to put her back on the milk diet we began with whenever she threw up a meal, so that before long we heard no more of the vomit- ing; meanwhile the steady feeding and the use of massage, and local muscle treatment by electricity, began to show in a gain of flesh and color and firm- ness of muscle. She was now very weary of this unending quiet, and the time for education of the motor powers seemed to have come. Her loss of motion on the left side was very marked, and there was complete want of power to feel pain or to tell heat from cold; yet I could not make out any loss of vision or of color-sense. The touch was not per- fect, but she knew fairly well where she was touched, although she could not be tickled.

34 DISEASES OF THE NERVOUS SYSTEM.

As regards the pain-sense, there was one very curious point to which I have already alluded. As the needle came within an inch or two of the middle line of the body, both at the back and front, it was felt, and the better felt the nearer it came to this line ; nor do I recall having met with this fact in any case of palsy from organic cause. The right side of the body was palsied in a less degree, and only as to motion, the leg far more than the arm. The same was the case on the left side as regards all the forms in which the functions were deficient. ]^ow as this case grew better the right side became entirely well first, leaving the left hemiplegia as before, so that I have reason to speak of the whole loss as being due to a double hemiplegia. In other cases I have seen a general loss of sense and motion, and observed entire relief on the right side, leaving only a hemiplegia of the left.

My patient had some wasting of the left leg, and less good electro-muscular reaction on the left, but no pain on that side from any form of current. The tendon reflex below^ the knee-pan was good on the right, and also on the left ; but, what was new to me, the jerk was sometimes due to the extensors, and sometimes due to the flexors, the extensors in the latter case not seeming to move at all. Here was another of the oddities of this most strange disorder.

As is usual, she moved her limbs best while in bed ; and showed, when I came to let her sit up, or stand, the loss of balancing power which is seen in all grave hysteric palsies, and is, indeed, almost a sure sign of the parentage of the disease.

PARALYSES OF HYSTERIA. 35

I have often asked you to note another point which this case showed very welL You ask the patient to raise the leg; it is lifted an inch. You insist on effort; it is lifted higher; or, if a great effort be made, the motion consists of a series of lifts and pauses.

The reliefs of distinct hystero-palsies are said to be often abrupt. Under emotion or return of the menstrual flow, or on an order from some one, the patient gets well. I must say that in hystero-hemi- plegia and paraplegia, with loss of feeling, I have not been so happy as to see these delightful cures. In hysteria with mere paresis, in the palsies from belief, or from a ruling idea, I have seen such results many times. Neither do I believe that all hysteria is after a time within control of the sick person; nor that she can in all instances run away in case of a fire, according to a popular belief In fact, I have now in my care a lady who was so tested by chance, and who utterly failed to do more than fall down in her effort to escape from a house on fire.

In fact, profound emotions may work either way for good or for ill, and no human sagacity will suf- fice to enable us to predict results. The evil is quite as likely to be prominent as the good, and at all events you may rest assured that emotions are some- w^hat unmanageable and unreliable as therapeutic agents.

I have felt the need to say this, even if too briefly, because I must add that the cures of these cases are to be made by a slow, steady, hopeful training of the will powers through every-day effort, which needs

36 DISEASES OF THE NERVOUS SYSTEM.

some caution not to err in the way of excess. A little nervousness is a bad sign, and it is well each day to attempt a very little — no matter how little if only we succeed, and can make the patient see it. I shall in another place be more precise as to the means used. Enough to say of this case that it went on slowly gaining ground, and was under my care a year before the patient could walk well enough on crutches to go home with a cheerful future. It was not a brilliant case, and it taxed nurse and doctor to the uttermost — a case urged and scolded, and teased and bribed, and decoyed along the road to health; but this is what it means to treat hysteria. There is no short cut; no royal road.

Let us take another case. It was as much like the last as it could well be. The patient, Miss C. P., set. 18 years, the child of wealthy parents, came to me last year from Indiana. The motor losses were very remarkable, and, as in the last case, it was the left side which suffered most. She was unable to lift the left leg, or flex or extend the foot, so that below the knee there was motion in the toes alone. The left arm preserved all movements, but all alike were feeble. The right side was more symmetrically dis- ordered, so that almost every muscle of the leg and arm was partially paralyzed. Sensation was lost for pain on the left side, save as to the belly and breast, where it seemed to be good, while in the face and neck it was lessened. Sense of temperature was more absolutely lost over the whole side than is com- mon; and touch, not quite lost anywhere, was dis- turbed or lessened in irregular spaces. On the right

PAKALYSES OF HYSTERIA. 37

side sense of pain was lessened in the arm and lost in the leg, while touch and the thernaal sense were well preserved. There was one matter in which this case differed from the last one, and this changed my whole manner of dealing with the malady. My new patient was a clear-headed, well-educated girl, who had once had a vigorous will. She was described to me as unselfish, thoughtful, and intelligent, and as a woman only brought down to a state of hysteria by long illness and the want of helpful advice at the right moment. She was emotional and ashamed of her tears, and honestly hated the whole matter of sickness. You will see such hysterical women. You will see others whose minds are like the back of a piece of needle-work with a bafi[ling absence of pat- tern— women with a low, whining, bleating voice that is by itself a tell-tale of the kind of will-less ataxia which seems to cripple the mind no less than the body. These are the hard cases to relieve. But to return to my more favorable case. I tried to make her see how m.uch the defects of body have to do with those of mind, and therefore the need to begin by building up the body anew. When, after a time, the limbs began to round, and color to come back to her pallid cheek, I set her to thinking how far the early troubles might have been within her control. I assured her that, although she could not now overcome at once the results due to habitual failure of self-control, repeated efforts would surely end in success. She was told that it was like the case of a bad temper, easy to hold in check at first, but if long unheld at last uncontrollable. It is not

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38 DISEASES OF THE NERVOUS SYSTEM.

hard to open this point of view to a clever woman. You urge this idea from day to day; you ask her to try your way. She says she has done so, and then 3^ou point out that with ill-health success was out of the question, while with rising health it might be easy. At last you get her to promise to fight every desire to cry, or twitch, or grow excited.

Above all, you teach her the priceless lesson for a woman of the value of moods, of the ease with which she can get herself into a state of dangerous tension, of the necessity of learning, not how to bear a thing, but how to approach the idea of bearing it in a state of calm. It is a long sermon, but I can only give these few pregnant texts. It is always apt to win with a woman of intelligence, and the fools are to be dealt with by other moral drugs than these, or the honest pill must be gilded with timely flattery or such better motives as ma}^ help it to find the woman's conscience, if that is to be stirred at all.

By and by, as one symptom after another gave way before her eftbrts, she became more and more sure that I must be right as to all ; and I have seen few cases gain ground with equal speed. I^everthe- less a whole year was needed to make her well able to take up afresh her full round of social and house- hold duties. In fact, even with the best of self-help from the patient, the cure of any one of these cases is a long and arduous course of education.

HYSTERICAL MOTOR ATAXIA. 39

LECTURE II.

HYSTEKICAL MOTOK ATAXIA— HYSTEKICAL PAEESIS.

The form of disorder to which I shall next direct your attention in connection with hysteria is the motor ataxia of this disease. It is necessary here to be extremely precise, because, as you will see if you read Briquet's admirable study of hysteria, he also describes a form of hysterical motor ataxia.

Ataxia, as you well know, means merely disorder or irregularity, and when therefore we speak of loco- motor ataxia we mean only disordered movement, and not of necessity enfeebled movement. The cause of the disorder or incoordination thus introduced into motor functions may vary.

In hysteria, so far as I know, there are two forms of motor ataxia independent of those associated with vertigo. That described by Briquet and Lasegue seems to depend upon a loss of sensation in both skin and muscles. In Lasegue's case the girl was only able, the eyes being closed, to move the limbs which were still sensible, but was totally unable to move the anaesthetized parts, or to know where they were when moved by another person. While see- ing, she could walk readily and even without looking

40 DISEASES OF THE NERVOUS SYSTEM.

at her feet.^ In other and similar cases there is merely a lack of coordination in complex motor acts.

There is, however, another and a very interesting form of hysterical motor ataxia, as yet undescribed, which is, I fancy, rather rare in its most perfect type, and which may without due care be taken, as was posterior sclerosis of the cord long taken, for some kind of paralysis.

The trouble I am about to speak of I find to be in some of its degrees very common in hysteria — to coexist with many hysteric palsies or paretic states, and sometimes, though rarely, to be the prominent malady, with almost no loss of voluntary power.

The hysterical ataxic patient of this class, and I shall consider first the nearly pure case, has full feel- ing, or may have it, and is quite well able to use the limbs more or less freely while lying down. When she begins to sit up or kneel or stand, the lack of coordinate muscular movements becomes at once visible.

Instantly the patient begins to fall to one side, a voluntary effort to redress the disturbed balance results in' a partial fall to the other side, or back or forward, as may chance. The patient seeyns to be unable to judge of the extent to which the balance is lost, and also to determine or evolve the amount of

1 There may be in this something of habit. In the few cases of spinal locomotor ataxia which I have seen in women I have been struck with the way in which, as their garments habitually hide the feet, they managed to dispense with the guiding sight of these parts.

HYSTERICAL MOTOR ATAXIA. 41

power needed to overcome the defect. The abrupt- ness of these efforts at redressing the loss of equi- librium appears to show an absence of defect of the usual antagonistic activity of opponent muscles. I am inclined to suggest as a reasonable theory that perhaps a large share of this difficulty may be due to a slowness in volitional acts by reason of which the mandate reaches the muscle loo late to be of ready service. This is by no means unlikely, for in some hystero-palsies I have measured and proved the re- tardation of nerve-conduction. Slowness in learning the need to move a muscle and slowness in moving it would give rise to just such incoordinate action as these cases exhibit. The lack of orderly movement is chiefly in the neck and trunk, and is made worse, like all disorder of motion, by excluding the guiding influence of vision.

This very interesting form of incoordination in muscular acts is limited for the most part to the more complex movements. It is seen little or least in single limb motions, better in sitting or kneeling, better still in standing, and best of all in walking. It is not due to weakness because it exists in cases strong enough to sit, stand, and walk firmly, if only power were needed to the efficient accomplishment of these acts. Also, while you may find it with general or local lack of surface feeling, it is not due to this, because anaesthesia of the skin alone is, in the hys- terical at least, incompetent to cause ataxia of motion. In the confusion and odd grouping of symptoms in hysteria, the trouble I have described is apt to be overlooked or attributed to coincident conditions.

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42 DISEASES OF THE NERVOUS SYSTEM.

It is, therefore, fortunate to find now and then cases in which this form of motor disorder occurs almost alone, so that we have a chance of studying it without being embarrassed by other symptoms.

I believe that this ataxic state is common in grave hysteria, and is to be found often enough in milder cases. I think also that some of the cases which are attributed too promptly to muscular anaesthesia will be found to be free from that defect, and to be due to other causes than those to which Briquet has at- tributed them. Perhaps it may be that conscience of locality will prove a differentiating test, since it is said to be lost in the hysterical ataxia of Briquet, and is certainly not always lost in the form I have here delineated.

I do not think one could readily confound this ataxia of movement with anything else, unless it be with one of the rarest of the forms of hysterical spasm. The following case is an apt illustration of this latter disease which might, perhaps, be well de- scribed as alternating spasms, the action of the flexors calling the extensors instantly into movement, and these in turn summoning the flexors into like activity. These semi-spasmodic motions were the more curious in the last case I saw, because of the general and pro- found paresis which made every volitional effort ex- cessively difficult. I may add that there was also a contraction of the right leg and a left hemi-ansesthesia with fair conscience of the place of a touch.

The patient, when seated and held up, or even when the head alone was unsustained, showed the following symptoms : The head or body was pulled

HYSTERICAL MOTOR ATAXIA. 43

to one side. At the limit of this motion, or before that was reached, it was violently jerked over by the opponent muscles, as if their stretching were the sig- nal for an explosive act of power. At once, or in a moment, the other muscles acted in like fashion, and so the head or trunk was thrown about in a strange and disorderly manner so long as the patient remained upright. The same type of movement extended to the legs and arms. These acts were certainly of volitional birth, but they were, so to speak, convul- sive renderings of natural acts, and were sometimes very violent.

I may add that, notwithstanding the complexity of symptoms, with such a loss of memory as necessi- tated an entire reeducation, this girl became entirely well.

In place of giving you types of motor ataxia with palsy I shall prefer to choose one now in my care, and which has the least share of palsy for the largest share of incoordination of the muscles.

Miss B., set. 20, Kentucky, of healthy, living parents, in August, 1876, while going home from the Centennial Exhibition, caught a slight cold, out of which came complete loss of voice for seventeen months. In its return it came and went abruptly, and was well to-day and gone to-morrow. In Sep- tember, 1871, at the Hot Springs, Arkansas, after a good deal of worry, she is said to have had headache and dizziness, after which of a sudden she lost speech, and became unconscious, with her jaws firmly locked. The legs and arms were seized with spasms, and when they became better had nearly lost touch-sense,

44 DISEASES OF THE NERVOUS SYSTEM.

and did not feel pin-pricks. This attack ended in weakness and fever, with cold feet and loss of power to swallow even saliva. After three weeks she re- gained speech, and then again relapsed. She was said to have had a typhoid fever, which does not seem likely.

About the fifth week she was found to have lost power in the legs. The loss is described as having been nearly entire; but by March, 1879, she had re- gained a good deal of motion. Since then she has been at a standstill.

In October, I saw Miss B. in bed, a dark-skinned, rosy-looking girl, without the least turn to tears or undue emotion. I should only have said that her manner was quick and excitable. She certainly had none of the usual furtive look, and small deceitful- nesses of some hysterical girls. E^either was there any loss of tendon (patellar) reflex, and the senses of pain, of touch, and of heat were perfect.

While in bed, Miss B. moved all her limbs some- what slowly, but with a great deal of power; the lift of the leg was done in jerks, as by distinct orders of will, but she showed none of the tremor and twitching of face and tearful look so common in hysteric girls called on for an unusual effort. When held up on her knees, she swayed to and fro, always falling if not assisted. When somewhat later she could stand up, the motor disorder showed still better. From head to foot every muscle used to preserve the upright posture gave Vs'slj momently, and was braced again by distinct acts of will. The rocking motion so caused was curious to see. A

HYSTERICAL MOTOR ATAXIA. 45

slight push was sure to upset her, as if she was un- able to provide in time enough of power to resist the shock and restore the disturbed balance. If I warned her of the coming shock, she did far better. The touch of a hand greatly aided her, and the closing of her eyes made things worse. I^or did Miss B., when standing, appear to have the least idea of her balance being in danger until the sway of her figure became extreme, when she caught her- self up, and with an effort regained her erect position only to fall to the other side. There seemed to be a lack of appreciation of the failing balance, and a slowness in redressing it when lost or in peril. When added to this we have complete loss of feeling — when skin, bone, joint, and muscle share alike in this respect — we have, of course, a still more com- plete and a different form of want of power to pre- serve the upright posture ; but this is said to be the character of the trouble spoken of by Briquet and others, and I wished to make it clear that there were causes of motor ataxy which did not of need involve any lack of tactile sense.

In Miss B.'s case, little was needed beyond train- ing the weak and inapt muscles, because she ate and digested well, slept soundly, and was free from pain.

My first step was to point out to her that, after she had made an effort which seemed extreme, another forth-putting of will would add to the previous result. This seems a simple thing to make clear ; but, if you can convince your patient of the fact, it is of great service, because then you go on to point out further that, perliaps, by a series of trained and aided efforts,

46 DISEASES OF THE NERVOUS SYSTEM.

there may be won, bit by bit, a full power of motion. To lodge this idea in a woman's mind is at once to widen the horizon of hope. How much you gain by it depends a little on whether your patient is clever and wants to get well, or is silly and prefers the role of hysteria; but, after all, the whole mode of treat- ment rests on a study of character, or of character and hysteria, and a moral diagnosis is the first step to take.

With Miss B., at a standstill for months — bright, clever, longing for active life — the idea was as a wholesome ferment. The nurse now began to train her while in bed to move the legs, one at a time, very slowly, but in larger and larger movements, with intervals between of a minute or more.

An order is given to lift the leg ; if it be too weak, a finger beneath the ankle aids it, but no attempt must be let to fail utterly; as she gets on, the orders are to be obeyed more quickly. It is easy to sketch out for one's self what such a system should be in its details. After it has gone far enough, the patient is seated in bed with some support to her spine, and is trained to move the head freely. When, in Miss B.'s case, she was put on the edge of the bed seated, the motor ataxia began to show, so that it took some time to overcome this trouble. The next step used with me to be a lesson in walking, but of late I find it better to teach the girl to creep, which is an easy and natural mode of training for the walk. The patient has pads tied over her knees, and, lying flat on her face on the floor, without skirts, has around her a folded sheet. At an order, she tries to rise,

HYSTERICAL MOTOR ATAXIA. 47

helped by the lift of the sheet-belt held b}^ the nurse. When she is able to do this, and can gather her legs and arms so as to make herself a quadruped, she is taught to balance herself, every effort being assisted, when needing help, by the nurse standing above her. The progress to creeping is easy; then comes the lesson of kneeling and pushing a chair ; and, last, that of standing in a corner or by a chair. You see that, following nature's lessons with docile mind, we have treated the woman as nature treats an infant. For aid in walking we have three devices : the ex- pensive wheel crutch, which can be easily imitated by a clever carpenter, being merely a framework with rollers so arranged that it includes crutch sup- ports. E'ext, if need be, I use a device which may be common, for all I know, but which I have not seen elsewhere. It is a pair of crutches with a stout half-hoop of metal between and in front of the two. This gives a solid support, and, in ataxic cases, is very useful as giving a sense of security, and, there- fore, of confidence. This crutch-frame is soon re- placed by a pair of supports, the bases of which are about seven or eight inches long and two broad. They may be made like the lower half of a crutch, or have two columns of a support set in the base, or may be a single cane with broad base ; the top in any case should have a double curve so as to lie easily in the line of the natual slope of the palm when resting on such a support. A rubber footing gives a little elasticity and a good hold on any form of flooring. With such a broad base of support, it is quite pleasant to find how soon the patient learns

48 DISEASES OF THE NERVOUS SYSTEM.

with its aid to balance herself. A third form of support, which I devised two or three years ago, is of use in hj^steric or in any form of hemiplegia. If the left arm be too feeble to aid the left leg by grasping a crutch, I resort to the following arrange- ment. On the lame side a crutch, having above an unusually deep hollow to receive the armpit, is fastened to the arm by two straps or by a glove riveted to the hand-piece of the crutch, so as that the hand, once slipped into it, is pretty firmly held. From the crutch a double metal bar curves forward and towards the sound side, and ends in a handle which is grasped by the sound hand and carried for- ward by it. I have found these supports most useful in many forms of weakness. In making them, or having them made, pray remember that they should be made light ; most crutches are too heavy.

With regard to Miss B., I may add that she got well in two months, so as to walk unhelped anywhere, and that she is now free from pain and nervousness.

Before leaving the subject of hysteric motor ataxy, I wish to add yet a single illustrative case in order to show that ataxy, connected with hemiplegia, may affect a single limb. Such cases approach in char- acter the choreoid troubles which accompany or follow certain cases of hemiplegia from organic dis- ease of the brain, and afford yet another of the shadowy resemblances which link the various forms of hysterical disorders to their analogues of more definite parentage. Miss C, set. 30, grew up in luxury and ease, subject to what she somewhat in- definitely described as spells of prostration with

HYSTERICAL MOTOR ATAXIA. 49

nervousness. At the age of twenty, a sudden death in her family caused a sharp convulsive attack, fol- lowed by a brief period of insanity, lasting in all three weeks. Three years later, her family fell into almost absolute want, and she began to work hard in the effort at self-support, and then gradually failed in health, suffering at intervals from a variety of hysterical symptoms. These resulted abruptly in incomplete left hemi-ansesthesia, with great loss of power in the leg, and lessened power in the hand and arm.

With this report of her case, she came to me some months ago. Except a very slight retro-flexion, there was no uterine trouble. E^either ovary was sensitive, but the spine in all its length, and the left side of the chest and the upper part of the belly, were very tender — more to touch than deep pressure. All other organs were healthy.

The hemi-ansesthesia as to touch and pain was notable in the parts below the waist, and was incom- plete in irregular areas, which shifted daily. Pin- pricks did not bleed in the leg.

The hand and arm had good sense of touch every- where, but lessened pain-sense chiefly on the radial aspect of the arm. The leg was almost motionless. The arm and hand could be used with nearly natural force, but were stricken with remarkable ataxy of movement without the least sign of spasm. The utmost concentration of will failed to direct the hand so as to enable it to grasp or manipulate an object once held. The limb would waver to and fro, and at last descend on the object with an effort which

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60 DISEASES OF THE NERVOUS SYSTEM.

usually carried the hand far to left or right. A certain abrupt jerkiness characterized every motion, and the failure of directive power was singularly illustrated at the piano, where the one incoordinate member contrasted with the unusually skilful touch of the other. As so often happens in the post- paralytic chorea of cerebral lesions, the palsy was inversely as the ataxic difficulty, and consisted rather in lack of persistent energy than in want of initiatory power.

By slow degrees this ataxy of movement passed away, and, w^iat was most curious, it lessened with the increase in want of power, while this also has in turn disappeared, leaving as yet some dyssesthesia, but no notable want of strength.

There yet remains to us hysteric paresis. Among the many disorders which hysteria affords, certain ones come clearly out at times from the tangle of named or nameless symptoms, and enable us to speak of them under some distinct name. It is a comfort, amidst so much that is confusing, to find these groupings of symptoms ; and, in diseases of vague boundaries like neurasthenia and hysteria, a good deal of this useful sort of secondary classifica- tion is possible.

The history of hysteria is sometimes one of years, and in certain cases, either at the outset or after more or less of the strange drama of this disease has been played, the patient falls into a state of inertness of mind and body, which I am forced, for lack of a better name, to call hysteric paresis.

You might, I presume, feel free to give to these

HYSTEKICAL MOTOR ATAXIA. 51

cases another label than the one I have given. They are, however, over and above all else, pareses — examples of intense feebleness, free from any accom- panying defect of sensation ; but it is paresis in hys- terical women, and if you forget this fact, you may be sure that you will have but little success in the treatment.

This disorder may be seen in union with other signs which are more or less clearly hysterical; but sometimes we find it almost pure from these dis- guises, as in the case of Miss L., from IsTew Jersey, now in the Infirmary. A person of languid nature, not strong in mind or body, she began some years ago to be emotional, to have loss of appetite, weak- ness, tender spine, vertex headaches, abdominal tenderness, and rare convulsions. By and by she took to bed, and with more and more complaint of her back, and soon of soreness everywhere, ate less and less, gave no care to her bowels, and at last be- came feeble, sallow, wasted to the limit of wasting, and content to lie still most of the time, using mind and body as little as she could. From this state I rescued her and made her well, and now she is here again far worse than ever, unable to lift a limb or to turn over. She is twenty-two years old, and has not menstruated in six months. She is five feet five inches, and may weigh about eighty-eight pounds. Her skin is rough, dry, unpliant, yellowish, and seems to be firmly glued to the bones and muscles beneath it. Her morning temperature does not ex- ceed 97.5° F. ; her heart beats 90 to 120, and is quick and feeble. The other organs seem healthy, and the

52 DISEASES OF THE NERVOUS SYSTEM.

secretions normal. She cries at times, but not mucli. Her face, marked with acne, is set, inert, wooden, as if she could not smile. The lids droop, the mouth hangs a little open, the voice is so feeble that it is hard to know what she says. The spine is very tender, and to touch it causes a gush of tears ; but the left iliac fossa and the chest muscles are also tender, and compression of any of these hyperses- thetic spaces causes nausea and vertigo. Her dislike to make any effort was great, but it was also clear that the power to move was not lost. There w^as not during movement the jerky action of hystero- palsies, but an extreme and evident difficulty in motion, and a sudden failure to prolong it; observe also that sensation was unimpaired.

I was very much struck in this case with the ease with which these patients become feverish. The least overexertion was competent to cause a distinct rise in temperature and pulse ; but, for some reason not yet clear to me, these changes required some hours to produce them.

All the battery of toning influences was turned on this woman, and she is now gaining ground apace. She is fed often and in small amount, had for a time rectal feeding also — and the mechanical tonics, mas- sage and electricity. As usual in all such cases, we wait until the flesh is coming back, the color bright- ens, and the muscles grow firmer under our mechan- ical stimulations, before we call upon her to exert herself. Then, in this order, with passive motion — motion aided hy a nurse, motion resisted by a nurse, active motion, unhelped — we shall train her back to

HYSTERICAL MOTOR ATAXIA. 53

a state of health. We shall cure her surely, but whether or not she will remain well I cannot say. It will depend on what kind of influences surround her, on what she is when well.

I have given here a short sketch of a state of paresis, in which with some anaemia or without a very marked condition of lack of blood all the func- tions are enfeebled, and this is most notable in those which involve muscular exertion of any kind. If there be also any pain, such as that of spinal irrita- tion made worse by motion, the patient is even more apt to be sluggish, and is not slow to avail herself of this and of every excuse to keep as quiet as possible. The real and singular want of power, as measured by the dynamometer, the difficulty in beginning as well as in continuing a motion, seems to set this apart from cases of mere neurasthenia, while the general wasting and appearance of malnutrition serve yet more deeply to mark the distinction. The disorder I have described so briefly is one of those which adds many recruits to that large class which some one has called ^' bed cases," and which are above all things distinguished by their desire to remain at rest.

I shall elsewhere give in sufficient detail what I over and over allude to in these lectures — my views as to how best to treat those difficult combinations of hysteria with defective nutrition which are often too much for the best of us, and to those pages, and to what I have written previously in other places, I must now refer you. I have some belief in the occa- sional value of induction-currents in hystero-palsies, but, as to the direct good to be had out of the drugs

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54 DISEASES OF THE NERVOUS SYSTEM.

on which men once relied in the treatment of this disease, I have said nothing, because, except to con- demn, I had nothing to say, and because I believe that the numberless remedies for hysteria to be found in the books will be swept by another generation into the limbo provided for drugs with decayed reputa- tions ; but in thus expressing myself I do not mean to say that no drugs have an indirect value. What you have to do is to rectify with care positive uterine troubles, to treat defects of nutrition, to relieve the anaemia so apt to exist in hysteria, to see that every function is well cared for, and last, not least, to learn what need there is to alter the moral surroundings of your patient, and then with kind and patient care, and an unbending will, to bring about the changes she may seem to require.

MIMICRY OF DISEASE. o5

LECTURE III.

MIMICKY OF DISEASE.

You will recall the fact that the case I show you to-day is one of three which have presented them- selves at this clinic within one week. Each of these by chance illustrates a different form of disorder, and each of the three is a distinct example of one of the various groups of causes which evolve a simulation of disease. The literature of this subject is widely scattered, and consists chiefly of isolated cases to be found in the journals. The best essays on the surgi- cal aspect of simulated disorders are the admirable lectures of Paget,^ Skey's^ little volume, and an able paper by Dr. Shaffer,^ of New York, on hysterical dis- ease of joints. Except Russell Reynolds's^ admirable paper on diseases due to fixed ideas or emotions, I know of no medical essay of much merit on this sub- j ect. I regret that the able physician I have j ust named has not further treated of these forms of disorder; no one was better fitted to do so. It is, in truth, to be de- sired that the whole subject should be handled afresh by some as competent observer. It would be easy for

1 Paget, Sir J., Clinical Lectures and Essays.

2 Skey, E. C, Lectures on Hysteria.

3 The Hysterical Element in Orthopaedic Surgery. * See Brit. Med. Journ., 1869, pp. 378 and 483.

66 DISEASES OF THE NERVOUS SYSTEM.

me to make up for you an interesting history of these troubles from the experience of others, but I think that I shall be more pleasantly instructive if I deal only, or most largely, with cases coming within the range of my own knowledge, and especially if I make use of some of the curious self-analyses which patients who have recovered have placed at my dis- posal. Both for what they betray and what they conceal these histories are valuable, and especially so when they come from women of educated intel- ligence.

The elements out of which these disorders arise are deeply human, and exist in all of us in varying amount, while many of the determining and con- ditioning factors come from accidental, or, at least, external agencies. As a rule, the means at work to produce mimicked disease are in the books made to seem too simple.

I have not time to do here as I might wish, and to go into the full psychology of this subject, and must content myself, therefore, with an outline which shall mark out for you the chief causes which supply the foundations for simulated diseases, and those which build on this, and those w^hich strengthen and guard the morbid structure.

First of all comes the hysterical state, fertile parent of evil. However produced, it is a fruitful source of mimicry of disease, in its every form, from the mild- est of dreamed pains up to the most complete and carefully devised frauds Its sensitiveness and mo- bility, its timidity and emotionalness, its greed of attention, of sympathy, and of power in all shapes,

MIMICKY OF DISEASE. 57

supply both motive and help, so that while we must be careful not to see mimicry in every hysteric symp- tom, we must, in people of this temperament, be more than usually watchful for this form of trouble, and at least reasonably suspicious of every peculiar or unusual phenomenon.

What it is convenient to call the nervous tempera- ment, or that state which may be acquired, and which I like to describe as general nervousness, is a fertile field for simulated maladies, because in it, as in hys- teria, the qualities which we all possess are apt to take on a morbid development, and to get out of the limits of rational control.

Of the individual share taken by each of these causes I shall by and by speak. Before, however, I pass .on to lesser premises, I would like to digress in order to say a few words in explanation of what I mean hy general nervousness. You will find this term used over and over in these lectures, and also in the annual statement of diseases treated at the Infirmary for diseases of the nervous system. I used to try to classify these cases under other heads, but came at last to see that there is a state which is best labelled thus, and that after eliminating all the cases which can be otherwise classed, a small residuum is left to which no other name applies. Some of them are more or less neurasthenic people, easily tired in brain or body ; but others without this, or with this peculiarity but slightly developed, are merely tremu- lous, nervous folks, easily agitated, over-sensitive, emotional, and timid. This state falls on man or woman or child, and is not hysteria. It is with some

58 DISEASES OF THE NEEVOUS SYSTEM.

people a morbid birth-gift, with some an inheritance, and in its worst shapes it is made or acquired by misuse of alcohol or tobacco, or tea or coffee. IsTaturallv you may think that such a state must be slowly created, and usually it is; but also it is true that a very permanent state of general nervousness may be evolved by the accident of a moment, when precedent conditions favor it. In a lecture on general nervousness in the male, I mentioned examples of this kind, and last week we saw at my clinic a case in which a moment of intense terror, owing to the fall of a house wall, caused in a healthy girl a state of general nervousness, alike serious and lasting. However acquired, the condition I have outlined highly favors the mimicry of disease.

Another good growing ground for simulation is in a mere lowering of the general tone of health from ansemia, or any cause whatsoever. You know that out of failing health comes, often enough, nerv- ousness or hysteria, but even when these states do not arise, mere lowering of the standard helps, in many susceptible people, to awaken doubts, sus- picions, and terrors, which need little hint or help from without to enable the victim to construct a morbid edifice of non-existent disease.

If, then, you should ask me whether for the creation of mimicked disorders we need the aid of lowered health, of hysteria, or of general nervous- ness, I should answer that while such states are usually the responsible parents, a small proportion of examples arise in persons who, being in absolute health, owe the troubles in question to their possess-

MIMICRY OF DISEASE. 59

ing some natural or inherited combination of physical peculiarities, which becomes a competent mischief- maker when aided by external accident. The people who, from any cause, simulate disease are, I think, apt to be naturally distinguished by certain peculiari- ties. They are generally over-sensitive, pain hurts them more than others, and is a more important matter in life. Perhaps they really feel pain more, and, at all events, they complain of it more. As a rule, they are timid, fearful, and watchful, nursing for evil, any chance word incautiously dropped, and, therefore, prone to dwell on physicians' opinions, to deduce exaggerated possibilities of trouble, and in obedience to the least prediction of ill to consent or hasten to take extreme precautions.

Then, again, you are aware that everyone has some capacity for mentally influencing or disturbing functions of the body which usually are not under the control of volition. A few well people have this in a marked manner, and in some hysteric or nerv- ous states this power becomes enormously increased and widened in range. I do not mean that these people acquire the power to wdll intestinal trouble, for instance, but that they certainly may gain ability somehow to disturb the bowel functions by thinking of them. There are many stories in regard to this ; but let the average man endeavor by any mental process to cause diarrhoea, and he will, I think, find it no easy task. It seems incredible that a woman can learn to vomit at will ; but this is common; and, also, happily she can be taught to suppress this

60 DISEASES OF THE NERVOUS SYSTEM.

vomiting by volitional effort when the will is aided by a potent motive.

Books like Dr. Tuke's are full of stories illustrative of such facts, and I myself have seen a large number. It is clear, then, that we can sometimes acquire such control over functions supposed to be outside of volitional rule, and that this is made easier in certain temperaments and in states of hysteria, feebleness, or nervousness.

The disturbances thus brought about lie usually in the heart or vessels, or in the gastro-intestinal tract, and are caused or aided by expectant attention or dread, or by morbid watchfulness with a knowl- edge of symptoms.

It has been said by Hunter, as quoted by Tuke, that, if a number of men surrounding a table on which they have placed each a hand, will fix their attention on the member, some of them at least will soon feel in the part a peculiar sensation. I have tried this in vain, and I have also tried without result to cause my heart to beat quicker by merely attending to its action, yet I am myself of a rather nervous temperament. It is curious to find John Hunter avowing the ease with which he could in this manner create symptoms, and then to find Sir James Paget declaring himself utterly unable to pro- duce mimicry of disease by any amount of attentive effort. The difference among healthy men in this respect must, however, be immense. Of this I had once a curious illustration. When a very young man, five of us made a series of what are called by the homcBopathists provings of certain medicines,

MIMICRY OF DISEASE. 61

each man being ignorant of the drug taken ; three of the live had a great variety of symptoms, but the other two had none. It is well to add that the symptoms corresponded neither among the observers nor to those set down in the homoeopathic manuals. My friend, Professor Tj'son, will recall an amusing example of the effects of expectation in a patient of ours. The iirst day he saw her, in order to use electricity, she chanced to have at the time, as she always had under excitement, a loose stool. This took place also at his next visit; and thereafter he never made a call at a set time w^ithout causing sharp purgation. When he came unlooked for, then the whole trouble left her. It brought to my mind the case of an English physiologist, who happened to have diarrhcea when about to give his first lecture. The embarrassment and annoyance were great, and so impressed him that for a year he never lec- tured without having just beforehand a loose stool. The sufferer chanced to relate these facts to a well- known physician, then a very young man; being himself also a biologist, he unluckily felt interest enough in this matter to recall it when soon after about to appear for the first time before an audience. The excitement attendant on a novel situation, with a knowledge of how it had affected another, caused it to have a like effect on him, and for a long time he was always thus anno^^ed when about to lecture. I have given these as illustrations of increase of action under mental disturbances and expectation or dread. They could readily be multiplied. In the two cases named, anxiety caused the repetition of a

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62 DISEASES OF THE NERVOUS SYSTEM.

flow which was at first accidental, or, at all events, not born of emotion alone. In like fashion arise and continue certain of the forms of cardiac and vasal nervous disturbances. First there is some sudden and unusual influence disturbing the circulation ; then, upon occurrence of lesser but like causes, a similar trouble arises, until a morbid habit is fully formed.

There exists in all of us, feebler in age and more potent in childhood, a tendency to automatic and unconscious imitation which is the parent of a good deal of the mimicry of disease. It may exist in sim- ple forms, or be emphasized by love, anxiety, fear, or even by disgust.

I have said it vs^as potent in the young, and it is in them responsible for a good many of the peculiarities and resemblances usually set down to inheritance ; but it is also to be seen at times in their elders. Some months ago, I was showing to a physician a very singular case of unilateral grimace. As I turned from my patient, I noticed that the doctor was repeating with his own features the morbid action before him. I said, ''Do you know that you were imitating this lad's grimace ? " "I know now," he said, " but I must have done it without conscious imitation." Perhaps no better or more illustrative example of the natural tendency could be given. This was pure automatic imitation.

The tendency to cough, when forced for a long time to listen to a cough, is an instance where ten- dency to imitation is made powerful by sympathy or

MIMICRY OF DISEASE. 63

aftectioii. It may account for some, at least, of the false wbooping-coughs we meet with.

A more amusing example is one which I have seen several times, but which seems to have escaped mention in print. It is the occurrence of vomiting in the husband of a pregnant woman. The story of one of these unlucky sympathizers is worth telling :

He was rather noted as an unfaithful mate and a man of altogether loose ways. After Rye years of marriage, his wife becoming pregnant — an event much desired — he seemed to reform, and was very much in her society. Her vomiting, which was extremely severe, at last affected him in like manner, every day or two, to his utter disgust. Her second pregnancy gave rise to a return of his malady. I believe that she ceased to be sick with her third child — certainly with her fourth — but, so soon as on each occasion he became aware of her state, his vomiting came on, and lasted for a month or two; indeed, I think, in one case much longer.

The character of his disorder at length became known to his friends, and he was so mercilessly chaffed that it was at last almost dangerous to men- tion the matter. I have seen other cases — his was the worst — but I was told of one in ^ew York, last week, and the victim was a physician.

I may have overlooked something in my search through the books for mention of these curious facts. Prof Groodell reminds me of what Francis Bacon says (Cent. x. Para. 986) : " There is an opinion abroad — whether idle or no I cannot say — that loving 9.nd kind husbands have a sense of their wives breed-

64 DISEASES OF THE NEEVOUS SYSTEM.

ing child, by some accident in their own bodies." Did he mean vomiting, or some more mysterious diagnostic warning? In the Lancet there is brief mention incidentally of a husband as having been sick at stomach during his wife's pregnancy.

There could be no better examples than these somewhat ludicrous instances of the influence of automatic imitative tendencies. In the case just mentioned, the habit became so strong that emesis was reexcited by a mere knowledge of the fact that there existed in the woman the state out of which previously had grown the original trouble.

Instances of graver disease evoked in like fashion have been given by Reynolds and Anstie, and always it is found that fear, or the sight or the remembrance of suffering in others, has been an eflicient means of aiding the imitative tendency. In this manner trou- blesome paresis, simulative of palsy seen in a relative, has been produced. The condition thus acquired is not a true palsy, and does not give us the full roll of symptoms seen in the real case ; but it is something more than a mere voluntary imitation, because there is often a distinct incapacity for movement. The dif- ficulty as to the amount of true pain felt in such of these cases as mimic that symptom, I shall more than once have occasion to speak of; and it follows us everywhere in our efforts to appreciate fairly the ex- tent of nerve irritation. It must bear to true pain, perhaps, some such mysterious relation as the paresis of these cases bears to true paralysis.

I saw last winter a young lady of highly nervous and timorous organization, who was long under my

MIMICRY OF DISEASE. 66

care, and at length fully recovered. While in bed an indiscreet attendant told her of the horrible agony she had witnessed in a case of facial neuralgia, which began daily about 11 a. m. A day or two later my patient began to have pain in the same locality and at the same hour every morning. She was one of those women in whom you could cause pain any- where by pressure on the spine, and a few suggestive and directing remarks; and no more was needed than the frequent mention of the torment of another, and the remembrance that she herself had already had what was called ovarian neuralgia. For some days she really seemed to have an intense facial pain. It wore away after I ceased to pay any attention to it.

There is a state of mind and body, not rare in well- developed hysteria, in which there exists a so mon- strous development of this strange power to create disorder by thinking of it, that even a slight hint, as it were, will suffice to evoke a novel symptom. In this disease, indeed, we find women, and men too, passing into a mental state in which they are really much hke people in dreams. Their power to reason on the phenomena of the senses leaves them, and what they conceive to be the case takes the place of that which is. These are they who are hurt by light, or believe^they are; who cannot bear noise, or think they cannot ; who feel vibrations as pain ; who live muffled lives in dark rooms, and believe they cannot walk, or even lift a hand, or move the head. Such cases are looked upon as simulations of disease by

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66 DISEASES OF THE NERVOUS SYSTEM.

some writers, and are, I am sure, prone to pass into that evil stage of hysteria.

This tenclenc}^ is, of course, to be met with, to some extent, in all grave hysteric cases ; but it is also, as I have said, the ruling feature of a few. If you cause such hysteric women as these to believe that you can cure them, you enlist on your side their own troops, for as you can create symptoms, so can you also create absence of sj^mptoms. There is in all this something like the so-called magnetizing of which we used to hear and see so much. Under a fixed belief people were made unable to move, or could not close the eyes, or could not open them, or were made to seem to have a pain by touching a point on the body. The patients I speak of are all very subject to like delu- sions. You put a finger firmly on the spine, and ask if the patient have now a pain in the left breast? She says no. You repeat. At last she says, ^' Yes — Oh, it hurts me I" Now, is this pure sham, or is it not? Does the presence of the set belief create pain ? Is it like the pain of dreams, which seems real enough while we are in the state of dreaming ? I have tlaought over all this a great deal. When we put a finger on the eye unopened for days, and say "ISTow you can open it," and this is done; or when we arrest motion by an order, we see a plain phys- ical result which must have behind it a ganglionic change out of which it grows; and so it seems to me that, looking at the pain evoked by ideas or beliefs in the light we get from the motor phenomena, so evolved, we are hardly wise to stamp these pains as non-existent.

MIMICRY OF DISEASE. 67

At the same time that I put forward this doubt as to the justice of the common view, I am far from thinking that the hysteric girl of the class I am now discussing suffers as sharply as she seems to do; the emotions are no more under control than in a dream, and no pains are little, no burdens light.

I have now in my care Miss C. from Milw^aukee. When I first saw her she was in bed, which she quit but rarely and with diificulty. The room was kept dark, and she wore blue glasses over the closed eyes, and outside of all a bandage. She used cotton in her ears, and her nurse and parents crept about in list slippers. She had in all ten pillows, large and small, as supports around her, and was, as a young hysterical girl once told me, " crowded with symp- toms."

The character of this girl had always been that of a person thoughtful of and for herself, and not free from esteem for her own mental powers, so that she had been able and also very willing hy degrees to rule a meek household with that reckless despotism the throne of which is very often the couch of an invalid.

This case seemed to me one in which set beliefs, easily gotten and well nursed, had attained a power which gave rise to pain and over-sensitiveness and more or less inhibited movement. I began to deal with it by learning all I could from the girl herself to add to what I already knew of her mind, her morals, her habits, tastes, friends, education, and home life. Then the talk was allowed to settle on her eyes, and at last on the uses of light, and the fact

68 DISEASES OF THE NERVOUS SYSTEM.

that its excess hurts even the healthy, but does not injure them. When at last she grew interested, and with herself for a text that was easy, I said, that per- haps a woman of strong character might learn to bear the light after long disuse of her eyes; that such a one could not get well readily in the dark, and that although the light would pain her, it most surely could not cause disease. I then left her, with the idea that she could in a few days conquer her rebel eyes, and that it was absurd for a woman of intellect to let one organ disorder the whole body. The next day I found her with open eyes and sun- light in the room. One by one the ideas on which the case was built were thus artfully removed, and she is now after but a few days of treatment far on the road to health.

These victories are less easy with older women ; but even then the mode of dealing with them is as much a question of the basis of character as of any- thing else. Sometimes we only need to dispel one symptom to overcome all; sometimes the return to health and healthy ideas exacts a long and tiresome struggle. Sometimes it is safe to assure the patient at the outset that she has but to believe and exert herself in order to walk.

In this infirmary I saw, a few years ago, an abrupt success obtained in this latter way in a woman, fifteen years in bed, who was made able to walk well in three weeks, and I could easily add, were it needed, the details of many other and less striking cases.

I had meant to say something here of that form of hysteria in which the patient deliberately acts a part

MIMICRY OF DISEASE. 69

and with more or less cunning deceives those about her. I have seen a goodly number of these cases, but among them I have found quite rare the attempt to simulate palsy. It is easy enough to learn when a woman is pretending to pass calculi or vomit snake- bones, but to know if her loss of power be real, or if she be suffering from an inhibitory idea or belief is more difficult. I may say , however, that purely simu- lated palsies in hysterical girls, lack the qualities of hystero-palsies, are too complete, and show no loss of feeling. The best cases I can recall were in very young girls, and were present with much mental dis- turbance, and after a long role of hysteric symptoms had been played with success.

One of the cases I lately showed you was a curious and most instructive illustration of imitation where distress and terror at witnessing disease in a sister were the efficient factors.

Mary C, aged nine, had frequent, sudden, and severe attacks of epilepsy. After they had lasted two years, the mother brought her to my clinic, and with her a lad aged eleven. He was a puny, feeble, pallid boy, easily alarmed, and so nervous that he could hardly answer my questions. It seemed that nearly six months before I saw him, he ran a nail into his foot, and, about the time the wound healed, had something like a hysterical attack, which seems to have impressed him with the idea that he was afflicted in the same manner as his sister. Soon after this he had what the mother called a spasm, whenever the girl was attacked, and still later when he heard she had a convulsion, or at times without

70 DISEASES OF THE NERVOUS SYSTEM.

this suggestive cause. His attacks began with tremor. He was said then to become insensible and to shake all over violently. There was no tongue biting, and no coma following the attack, and no facial spasm. After becoming satisfied of the psychical origin of his disorder, I ordered him a cold douche whenever attacked, and directed that he should have the hot iron applied to his neck if the attacks did not cease in a month. At the same time the sister's fits were controlled by bromides, so that he ceased to have before him the constant incitement to attacks. With- out further treatment, the boy's fits, if I may so call them, promptly disappeared, not all at once, but by degrees, and he is now well. That in this case the fits of the boy were imitative is clear enough — that without the model before him they would not have arisen is plain.

We need not ask a cause for simpler forms of imi- tation, as seen in normal functional acts, as when the micturition of one in a herd of cattle awakens the idea among the rest and leads all of them to follow^ the example. The imitative tendency is a useful part of our developing powers, but here in cases like that of this boy, where there are other children, he alone imitates. Does the terror he only as a timid nervous lad feels, intensify his imitative faculty, and what motive is there for yielding to such a tendency? It may be that there is a certain pleasure in giving way to instinctive imitative propensities, and moreover we must all have observed how some sick children enjoy the important role of being ill, of being cod- dled and attended to, and this is especially noticeable

MIMICRY OF DISEASE. 71

in large families, or in asylums, where usually no one child receives in health undue attention. Such aids as these there are, no doubt, to cases of mimicry, while sometimes the patient's surroundings are to be blamed, as fastening the disorder or even as giving such information about symptoms as is consciously or not applied to the perfecting of them, the actor re- ceiving as it were, from a too sympathetic audience, hints which enable him the better to sustain his part.

Some of you saw but lately the case which sug- gests these remarks. Here, again, the actor was a lad. The following details of his case I owe to his physician. Dr. Benjamin Smith, of Falsington, in this State :

0. F., set. 9, had at school a slight chill, and in the evening thereafter headache and fever; he was well next day, but w^as said to have had headache the day following. At this date the doctor found him sufier- ing from great tenderness at several points of the spinal column. He could not recall having hurt his back, but a few days later declared that he then re- membered having fallen so as to strike the back, and that the pain was severe ; also, that, on the same day, he had fallen so as to hurt his head. Both falls were said to have taken place on December 25th.

As soon as the tender spine and headache were known to exist, the lad was kept at home and anxi- ously cared for, while the pain in the head increased and extended at last to the spine. At this date a remarkable dilatation of the pupils was observed, and, the pains increasing, he would lie in bed and rub his head for relief, or have it rubbed. Mean-

72 DISEASES OF THE NERVOUS SYSTEM.

while Ms pulse was not above 80, and did not rise with the presumed increase of pain ; nor did he lose appetite.

About the fourteenth day the headache was said to be at its worst, pains arose all over the body, and the muscles of the neck began to be complained of as sore and stiff, while nausea and pretty violent vomiting added to the alarm which his case excited, being set down, despite Dr. Smith's ojDinion, as an attack of cerebro- spinal meningitis. At this time, after the vomiting ceased, there was a sudden cessa- tion of all the symptoms; but in a few days more his troubles returned, and with dreadful complaint of head and backaches, with universal soreness and utter inability to walk, he was at last brought to me for an opinion and for treatment. His case had then lasted five weeks, and was supposed by some phy- sicians and by his relatives to be of a dangerous gravity.

When I saw this lad he was lying in bed, some- what flushed, but not in a bad condition ; his pulse was 85 ; his breathing 20 ; his temperature normal. His eyes w^ere bright, and I was struck, as Dr. Smith had beeii, by the widely dilated pupil. He was con- stantly declaring that his head hurt him ; and it was, as I observed, very notably retracted, the muscles of the neck being stiff* and tender. Any effort to flex the head gave rise to tears, remonstrances, and urgent cries of pain. The scalp was everywhere tender and the w^hole of the erector spinse muscles were also sore, so that the least tap or touch upon them caused him to cry. His legs were gathered up close to his body,

MIMICRY OF DISEASE. 73

and, besides some loudly expressed annoyance when exposed to a bright light, he complained bitterly of the vibrations caused by carriages passing or of the steps of his nurses when they moved across the room.

If, however, he were interested in anything, I found that I could flex the head or touch the spine without causing pain until his attention was recalled to the act. This — with the absence of fever, the calm pulse, the fair appetite, and a certain watchful and furtive expression — led me to believe that he was more or less consciously mimicking disease. As soon as I felt secure in my opinion, I lifted the lad out of bed, and, with severity, ordered him to stand up ; he hesitated a moment, and then dropped the flexed limbs under him, lifted his head at a second order, and, as I released him, walked to his bed — a feat which he had been supposed to be utterly unable to do. After this there w^as no trouble ; he was kept out of bed, and, with a rough rubbing daily and a little urging, was able to play in the garden in three days, and to go home in a w^eek. His pains, stiff" neck, and tender spine were never heard of after the first day in the hospital. I was careful to have him kept on a farm away from his home for some months. There has been no relapse.

This case excited great attention, and was the centre of the too affectionate regards of many rela- tives. The lad became early aware that he was believed to be in grave danger. His head and spinal pains were attributed to meningitis, and the symp- toms discussed in his hearing. Only thus can we account for his curious condition, when, in the face

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74 DISEASES OF THE NERVOUS SYSTEM.

of opposition founded on his presumably serious state, Dr. Smith brought him to me.

I saw, some years ago, a like case in the person of a young woman who had nursed two cases of cerebro- spinal meningitis. Her imitation was admirable, and for some days took in both her own physician and myself

Careful use of the thermometer, and a rigorous study of symptoms, can alone enable us to avoid such traps as these. The}^ illustrate what may occur in nervous people, under the influence of depressing agencies, and when surrounded by too great sym- pathy, and by ail the information needed to enable them to act a part.

The lessons which such cases teach us are obvious enough. The need for care in discussing symptoms before nervous women or children, the necessity of early apprehension of the true state of things in simulated disease, and the wisdom of acting deci- sively when once we are sure of our ground, are all of them points on which it is hardly needful that I should dwell.

In October, 1880, I was asked by Dr. Stryker to see in consultation a number of cases at the Church Home for Children, and, as these present the most amazing illustration of mimicked disease I have ever seen, I shall describe them as being the best possible illustration of nearly every point on which I have dwelt. The home is a handsome, wholesome asylum for children, and is situated a few miles from Philadelphia. It contained about 95 girls and but 6 boys. Both the sick and well, when I saw them,

MIMICRY OF DISEASE. 76

were amply nourished, and healthy-looking; nor was it possible to find in their home or in their habits any influences which could be credited with giving birth to neurotic tendencies. The diet was good, the hours regular, the play and out-door life sufficient; neither was there in the education given, nor in the religious training, anything with which it was pos- sible to find fault from a medical point of view.

Dr. Stryker gives me in substance the following account : Margaret Trimble, set. 12, a rosy and sturdy brunette, in admirable health, is one of a neurotic breed, there being in the immediate family two cases of infantile palsy. On September 4th, in the dormi- tory, when in bed at night, she began to have with- out known cause, unless it might have been a trifling indigestion, slight convulsive twitches of the arms and legs, with a little numbness of the extremities. This was a matter of a half hour, and she got up well next day. There were no further attacks until the 11th, and thenceforwards they returned daily. At first she was well in the intervals, and slept and went about like the other girls. Her respiration during the attacks was harsh and noisy, and she made at each inspiration a loud crowing noise, much like the breathing in croup. The attacks, rare at first, soon became frequent, and lasted from fifteen minutes to three hours; attention from others inevitably brought them on, even when she was seated and laughing or chatting with her companions. She would then slip down, to the floor, and hands, feet, and body would be seized with uncontrollable convulsive motions, so that it was impossible to keep upon her person clothes

76 DISEASES OF THE NERVOUS SYSTEM.

or bed-covering. During an attack she lay on her back, or rolled from side to side, while both arms and legs thrashed the floor with quick and hard blows. The body was lifted from moment to mo- ment, and thrown down again wdth violence, in a fashion strange to see. Meanwhile, her face was contorted with swiftly changing grimaces, and the tongue thrust out and drawn in, while her head was thumping hard on the floor. Sleep w^as apt to fol- low a fit; and there was at times, and later in the case, a good deal of choreoid difliculty in moving, or in handling objects ; at times the crowing existed alone, and at times the legs became feeble, and she stumbled and fell about.

This child was sent to the Hospital of the Univer- sity of Pennsylvania, where she remained two months, under the care of my friend. Professor Horatio Wood. Dr. Musser, the Registrar, sends me his notes, from which I add the following par- ticulars :

The muscles of the face, neck, eye, and tongue were at this time unaffected by the spasms. While seated she swayed backwards and forwards in clonic spasms. When lying down, her spasms were much as I have described them. There w^as lack of co- ordination in all arm and hand movements, but no anaesthesia anywhere. There was tonic spasm of the adductors of the thighs, and in a slight degree of the flexors of the forearms. All movement ceased in sleep. There was no lesion of the eye-ground. The urine was normal. There was a slight systolic roughening at the apex of the heart. The usual

MIMICKY OF DISEASE. 77

remedies for chorea having failed, the actual cautery was twice used on the spine, but with no better for- tune. Etherization on a full stomach caused vomit- ing for twenty-four hours, and a permanent relief of all the symptoms. Under careful and systematic training of the muscles, with much urging, and a good deal of scolding, she made finally a complete recovery.

This girl's case was seen by many of her comrades, and not only excited their amusement and curiosity, but led some of them to imitate her " bark," so that they were reproved by the matron for their tricks.

On September 8th, Dr. Stryker being in the home, Kate Mchols, a wholesome looking girl of 10, was brought to him in the nursery, in what seemed at first to be a sharp attack of false croup. She was breathing hard, gasping, crowing, speechless, and wildly clutching at her throat. Her possible rela- tion to the first case was not then understood, and she was treated as if for croup. The trouble per- sisted all day, and was noted as made worse by noise, or any excitement, and to be by and by associated with slight convulsive jerkings of the limbs. Mean- while, the pulse was rapid, but there was no fever. The following night all of these troubles passed away in a sound sleep, from which she awakened crowing and barking; and after a day of increasing nervous agitation, exploded in a convulsion, identical in character with that of case I^o. 1. The attacks thereafter increased in violence, but all of her func- tions were well performed. She ate, drank, and passed urine and feces as usual; and when free from

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78 DISEASES OF THE NEKVOUS SYSTEM.

convulsions was merry and pleasant, until the ap- proach of a nurse with medicine, or the visit of a manager to the Infirmary, started her oft' anew. From the outset she began to lose power in the limbs. When held up, she would start fairly, but instantly the legs became convulsed, the feet tripped one over the other, and she fell in a fit on the floor.

The girl was also treated at the University Hos- pital much as was the last case ; the cautery was of little use, but the effect produced by ether on her comrade had a decidedly good moral influence, and seemed to have a good deal to do with her recovery.

Case 3. — On September 9th, Sallie Speer was seized with the same form of respiratory spasm, but with the crowing noise there was a continuous chattering of the teeth, like that of a bad ague chill. On the 10th the usual convulsions came on, she having ample preparation from seeing those of the other children. In a few days all of her symptoms passed away, and she returned to the school-room, for a week, when the same disorders reappeared, and she was once more placed in the nursery.

Case 4. — Florence Pierce, set. 12, had about the 11th like attacks; but, besides the usual convul- sions, she had remarkable mydriasis in the intervals. While yet able to walk, she had singular attacks of festination ; and if going towards her bed, would run furiously and be thrown headlong across it, and on to the floor beyond. Generally she crawled about on her hands and knees, with her head swaying about as if it was held up with difliculty.

Case 5. — Miriam Drinkhouse, set. 11, was depressed

MIMICRY OF DISEASE. 79

on account of having been placed in a lower class than her comrades, owing to her inability to keep up w^ith them in their studies, l^ext day she was unable to stand, and her first fit followed on October 13th.

Case 6. — Fannie Clark, set. 12, was taken ill with respiratory spasms, and the same convulsions about October 13th. She had, also, remarkable coldness of feet and hands, which was not observed in the others.

Florence Mack, get. 8, Sarah IsTolen, set. 12, Florence Mulligan, ^t. 10, Bella Burk, set. 11, Mary Mitchell, set. 12, were all taken about the 12th to the 15th of October. Their symptoms were much the same as those above described. There were also a number of other cases, some slight and some severe. Owing to want of space, all the first cases were placed in the two adjoining rooms of the infirmary. Here they were seen by one another, and also more or less by such girls as were engaged in the housework. Other cases were soon added, and at last there were at least ten cases in the apartments mentioned. The results of this companionship may be easily imag- ined. At first the convulsions were irregular as to time, but after awhile they took place only in the evening, and later still in the morning and the evening ; although at any time a visit such as mine, or that of Dr. Stryker, or of a lady manager, was sufiicient to start the attacks. Then one girl would begin to bark or twitch, then a second and a third, until, on bed or floor, or seated, ten or twelve chil- dren were wheezing, barking, grunting, crowing, or in violent convulsions ; while the bewildered nurses

80 DISEASES OF THE NERVOUS SYSTEM.

ran from one to another, presenting a scene quite astonishing to witness.

During a few clajs there were many interesting variations in this singular malady. On one occasion, all of the children in the sick ward got out of hed at night, and took to walking ahout on their hands and knees; at other times, some of them, speaking in their sleep, described their visions. One saw black men; another, whose mother had been recently pregnant, spoke of herself as having had a child, and mentioned the luxuries she considered desirable for a person so situated. More commonly the girls were scared, or said they were, by wild beasts ; and one child would adopt the vision which another re- lated within her hearing. After consultation, all of the cases were scattered about among different hos- pitals,^ where, as a rule, they made prompt recoveries under somewhat various treatments. The cases lasted from one month to three.

1 The Jefferson College, the Presbyterian, and the Episcopal Hospitals. I am indebted to Dr. Starr for full notes of several of the cases.

MIMICKY OF DISEASE. 81

LECTURE IV.

MIMICKY OF DISEASE.

The cases with which I have illustrated this sub- ject of mimicry of disease have been, so far, some- what simple and uncomplicated; nor could they have readily or long deceived any watchful physician who had had any experience of neurotic maladies. There are, however, more complicated cases to be met with, and some of these are remote from those so far de- scribed, in that the symptoms were not imitated from models ready at hand, or wholly learned from gab- bling nurses or relatives.

They exhibit also the curious progress from simu- lation, not consciously imitative, to conscious unre- sisted simulation, and at last dissimulation. I shall relate here two admirable instances of these inter- esting combinations of mimicry passing into well- sustained fraud.

A good many years ago I saw, one evening, a girl, aged 13 years, who had never had any of the mala- dies of childhood excepting measles. When her new troubles began she was not as yet menstruating, nor did she show any notable signs of womanly develop- ment.

In January, 1866, when skating, her right instep became chafed severely, and for this she was kept at

82 DISEASES OF THE NERVOUS SYSTEM.

rest for two or three weeks, but received very little care from her mother, and, in fact, needed but little. One day an attack of indigestion ended in vomiting, which was very violent, and v/hich brought about her all the sympathy her elder relatives could give. From this time her appetite failed, and the vomiting recurred at intervals. Long after, she told me that she could have vomited less, but that everybody was kind when she was so sick. Here, at least, was a distinct failure to resist, and probably a desire to aid, in producing sickness of stomach. The vomiting grew more frequent in the spring, and after a fort- night of fever, which she is said to have had in June, 1866, all food was thrown up, and the bowels v^ere opened only once in ten days, or even less often. These conditions persisted through 1866, with little change, the child rejecting everything, and growing at last sallow, and desperately wasted. The skin became sensitive to touch, so that no water could be used for fear of causing convulsions, and most of the time she was shaken by violent hiccough.

The vomiting, at first accidental, was thus at last aided and cherished for a purpose, until, as often hap- pens, the morbid act became habitual and despotic. But in a nervous system such as this child's no such habit could persist without giving rise to other symp- toms as grave, while these in turn w^ould be nursed and developed to win and keep up the sympathy, attention, and importance, w^hich are among the un- natural moral appetites, of a nature once started upon this disastrous road so strewn with multiple disor- ders. When such persons get well, their lips are so

MIMICRY OF DISEASE. 83

surely sealed by shame and self-disgust, as to make it difficult to verify by frank confession the suspicions which arose in the minds of bystanders, or to trace the fatal steps by which the victim descends, from the state in which she welcomes a symptom, to the degradation of creating symptoms. My patient, when first seen by me, had been abandoned, as in a dying state, by two homoeopathic physicians, who had left for her use a prescription of rather ample doses of morphia.

The picture which this child presented when first I saw her was not readily to be forgotten. She was lying on her back, staring upwards, with glassy eyes set deep in dark rings, which faded into a sallow leathery skin, drawn tense over projecting bones. Her mouth was wide open, the jaw dropped, and the whole cavity literally lined with thrush (muguet).^ The skin of the body was dry, and splotched with islets of dusky red, and the bedclothes were kept ofi:* of the sensitive surface by a shelter of half hoops. As I stood and looked at this singular spectacle, ap- parently that of a dying child, she groaned at brief intervals, and also coughed a good deal, at such times expressing pain in her face, but usually lying quite still, with a look of merely the most profound melan- choly. A careful study enabled me to find no organic disease. Her urine was so scanty that she often passed but two ounces a day ; but this was not albu- minous; the belly was very tender to touch, although,

1 The coating of oidium albicans was the most remarkable I have ever seen.

84 DISEASES OF THE NERVOUS SYSTEM.

if I distracted her attention, neither touch nor pres- sure caused any sign of pain; attention was needful to enable her to feel these pains, but as it may be said that attention is for all pain a reinforcing element, too much stress must not be laid on this point. I noticed, however, that this w^retched, wilted, starved creature followed my motions with attentive eyes, although she never turned her head.

I asked for milk, and put within her lips a table- spoonful, for which she closed her mouth; a moment passed, and with a gulp she threw it up. I repeated the dose, keeping a finger on the larynx. Again she threw up, or seemed to; for, as the larynx did not make the usual upward movement which accom- panies the act of deglutition, it was clear that she had not swallowed at all. I watched this neat little fraud several times. Usually she swallowed a part of each mouthful, and, holding the rest in her mouth, suddenly cast it out with a very fair imitation of the convulsive act of emesis. When quite sure of having correctly observed her, I abruptly charged her with the deceit. At first she denied in a faint voice, and saying she couldn't help it, began to cry. A little sternness enable me to get down her a full glass of milk. I then cleared the room of all her friends, threw aw^ay the hoops, and sat down by her side. She was evidently conquered and alarmed, which I did not wish her to be. I therefore took her hand quietly, and told her that she could get w^ell ; that milk was needful ; that, if thrown up, it would be given again, and that I meant to feed her whether she liked it or not.

MIMICRY OF DISEASE. 85

The after-care, which owed its success largely to the care of Dr. Wm. W. Keen, was arduous enough. The belly — and, indeed, the whole skin — was rubbed twice a day with sweet oil ; milk was given freely and often, and the bowels rid of their packed con- tents by the use of frequent enemata. I found the spine exquisitely tender, but, as is often the case, this was much helped by ice-bags (dry cold). Meanwhile the thrush faded under the use of washes of sulphite of soda. The patient's head was elevated a little day by day, and the diet was increased and varied. The bowels proved so obstinate that nothing but croton oil moved them, and the trouble of swallow- ing persisted for some time, although lessened when- ever her attention could be called away from the act of deglutition. Incessant attention to the muscular ap- paratus of the throat had made the use of these parts difficult, and swallowing having ceased to be auto- matic, was reembarrassed by every new concentra- tion upon it of an act of will. When she received milk in her mouth it always rested there for some time; if, however, the head was thrown back, and at the same time the larynx pushed up by a hand, this sort of hint usually proved successful, and the move- ment of deglutition was completed. By degrees this trouble passed away, and she gained in strength so as to sit up, and after awhile to stand.

The use of induction-currents to the disused mus- cles was a further help, and, with the gain in power, came back easier movements of bowels and bladder, and a more wholesome moral tone. Within six

86 DISEASES OF THE NERVOUS SYSTEM.

weeks the girl was able to call at my house, and she is now, I believe, the healthy mother of a family.

I could never extract from this child, "when well, anything beyond the statement that she ^' just could not help it;" and if I pressed her further, she said she was sorry, and took refuge in tears.

A^bout two years ago I saw, with Dr. Finn, a case quite as remarkable. The girl, aged thirteen years, living in Ohio, after an attack of ague, began to limp a little one day, and said she had a pain in the right knee. A physician examined it, and told her parents quite truly that there was no cause for alarm, ad- vising at the same time exercise, and a let-alone treatment. This w^ould have answered well, and have saved much trouble, had not some one per- suaded her mother to ask advice of the travelling agent of a surgical institute, who diagnosed hip-joint disease, put on a temporary splint, and arranged to cure the child at the institute. From this time, when the little public opinion about the girl pronounced for a grave malady, she grew speedily worse, and under the influence of the discussions as to the hip- joint disease and its symptoms, she began to act out as fully as possible the pathological drama so fool- ishly taught her. The pain increased, and the leg contracted at the knee and hip. At the institute things grew^ worse, and very soon there was double hip disease, and local applications, and splints, many and wonderful. But when one of these curious cases is well engaged in this career of simulation, there comes a time when, either because the first trouble no longer excites sympathy, or for more complex

MIMICRY OF DISEASE. 87

reasons, these forms of disease become progressive and invasive. In our little patient, the contractions of the thigh remaining, the arms, especially the left, became flexed, the feet being in full extension. At this time hysterical spasms came on ; the eyelids closed, and remained shut; and, most strange of all, she was unable to eat before 9 o'clock p. m. In this state the child was first seen by Dr, Finn, who re- moved her to quiet lodgings, where soon afterwards I saw her, and heard this exasperating history of folly and quackery. As I first saw her, she lay on the bed, her back to the light — a queer little shrivelled creature, tawny of tint, and the skin covered with bran-like scales, washing being a rare ceremony. Legs and arms were drawn up so as almost to hide the thin, ancient-looking and cunning little visage, which seemed so blind with its closed but quivering lids, and yet so unnaturally astute in its intentness of attention when her own case was mentioned or discussed.

Her right hip was red and swollen, and the thumbs of both hands had been so long and tightly con- tracted as to have caused the palms to ulcerate, while the whole skin was sensitive to such a degree that the bedclothes were not allowed to touch her, and she uttered a muffled cry of dismay and seeming terror at every approach ; her voice was reduced to a faint whisper, and she was said to be totally blind.

The treatment in this case was of easy enough application in a child. A single nurse was left in charge. The legs were violently straightened and their owner invited to set them in order, so as to

88 DISEASES OF THE NEEVOUS SYSTEM.

avoid in future this abrupt and painful treatment. We were told as usual that she never could eat until nine p. m., and wonder was expressed that, having her eyes shut, she was able to know what o'clock it was. The clock on the mantle was an obvious aid, and at all events, when set forward two hours, the nine o'clock meal was asked for at seven. The gain in this case was steady and easy enough. I lost sight of the child after she left us to return home, but at the time of her departure she was nearly well, and, I learn, has entirely recovered.

I have often thought that, if I could induce older patients who had been affected more or less like these children to relate to me their histories with sufficient frankness, I should obtain a larger insight into the motives which prompt them to cultivate or to create symptoms. As interesting additions to this rare branch of medical autobiography the three letters which I subjoin must suffice :

"The period of my life about which you ask me, I can only look back upon with a sort of disgust which makes it unpleasant for me to speak about ; it is only the hope that some one else may be helped by it w^hich makes me willing to speak of it at all. I was brought up by an invalid aunt, and I often think of what you once said to me, that the women who indulge their own nervous systems are those who most indulge children. My aunt taught me very early to notice and dwell upon any little symptom I happened to have, and, when I was fourteen, I un- luckily hurt my knee. For this I was kept in bed two weeks, and, when I wanted to get up, I was told

MIMICRY OF DISEASE. 89

to keep quiet. Under this enforced rest my appetite failed, and I began to have nausea. My first vomit- ing created a sensation in the household, which I think, as I recall it, I enjoyed as making me im- portant. Very soon I got to vomiting every day; there was none of the nausea which I had at first, and which I have since been familiar with as a part of sea-sickness. It gave me no annoyance to cast up my food, and was, indeed, rather a relief. From this time I was surrounded with sympathy and doctors. A few months later my aunt died and I was left in charge of an uncle and aunt, and became one of a large circle of children, among whom I got very little of the care which had before this encompassed me. I remember well that I resented the change, and, finding that if I took little food I excited alarm, I began to yield to the tendency to excite distress and anxiety by taking little or no food at times, I sup- pose this abstinence gave rise to the nervousness, and finally to the spasms which came on at this time, at least I can give no further explanation; I only know that every new symptom caused new anxiety, and that I somehow liked it all. After a while a new doctor was called in, and under his rule, which was very stern, I got better, and was able to leave home and go to the seashore, where, under new in- fluences and interests, I lost all my symptoms except the vomiting, which seemed to me uncontrollable. I lost this only by resolute efibrts; in fact, by efforts so desperate that often, when food rose in my mouth, I swallowed it again. I do not think I should ever have so tried if I had not overheard a person in whom

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90 DISEASES OF THE NERVOUS SYSTEM.

I had a great interest express himself as having heard with disgust of mj habit. Tlien, as you know, I learned from you that the habit could be broken; I succeeded, as you know, and am married and have a little girl, and I can promise you that she at least wdll never be allowed to go through what I have done."

I presume that this partial self-analysis is as near to a full and truthful statement of the motives which urge to mimetic fraud as we are likely to get. I have been told by one woman that she was as irre- sponsible as one in a dream; while more usually you are told simply " I do not know why I did it; I could not have meant to deceive any one." My next ex- tract from these confessions is in some sense honest enough, and, as I said before, is curious, both as to what it reveals and what it hides. The writer is long since dead, and I am therefore at liberty to use her letter with such precautions as make identification impossible.

I had seen my patient in the morning and received this letter in the evening. For several weeks she had been under my care with these conditions, a good rosy color, fair weight, and regular functions ; but at times enormous losses of urine and intense spinal irritability, which forbade her to stand or to walk a step. For her food she ate a chop at breakfast, and no other food the rest of the day. You must not understand me to say that I accepted all these state- ments, but merely as briefly sketching what seemed to be her state. This very pretty invalid was a charm- ing and witty, and most accomplished person. After

MIMICKY OF DISEASE. 91

her husband's death, she had taken to her couch, and, despite aches and ailments, was in her becoming sick outfit the centre of an attractive circle, which gladly gathered about the couch, on which she was carried from room to room. I hardly know under what circumstances she developed the full range of her powers. The irritable spine came first, and as one doctor after another was consulted other symptoms were added to her repertory.

She had been some little, while under my care, when I saw two things which confirmed my well- grounded suspicions as to the nature of her case ; she slept alone, disliking the constant presence of a nurse ; but she rarely failed to ring for her attendant twice every night.

The last morning I saw her, I had occasion to look at her feet, and noticed that her soles were dotted with black marks ; coupling this with the fact that she had complained of her wood fire as having smoked, I concluded that she had been afoot in the night, and that the dark marks came from "blacks" on the floor, the result of a defective fire draught. A moment later, observing some crumbs on her bolster, I asked her to sit up that I might examine her spine. As she rose, I threw aside her pillow, and saw under it two oranges, several slices of bread, and a banana. To my amazement she said cooly, " Well, now I am caught; I thought you would do it soon or late." My rather sharp remonstrances seemed only to amuse her, and that evening I re- ceived the 1 etter, a part of which I print.

" Before this reaches you I shall have made ar-

92 DISEASES OF THE NERVOUS SYSTEM.

rangements to leave. The game I have played on you I have played on others, and in my restricted life I have found it very amusing. You must not blame my maid, as I paid the woman who cleaned the room to bring me food. I found that doctors got tired of my sore back, and that they ceased to feel interest in me, a thing I never did like, so I began to com- plain of queer symptoms; and as this often aroused new interest, I went on experimenting until I hit on the starvation idea, which has done very well. Of course I got up at nights, and walked a good deal too, but how you knew it I would like to know. As to the urine, I used to fill up the vessel with water. I hope you will not tell my doctor at home, you would take away a good deal that is pleasant, and spoil an interesting case, too.''

These are the only cases of this form of moral obliquity in which I have ever been able to get a free confession. They expose, I fancy, to some ex- tent, the motives which underlie the duplicity of such women.

The last of these statements is more recent, and I have permission to print it. It is in some ways more valuable than the others; the belief this woman at last reached as to the want of foundation for her presumed physical disabilities, and her continued conviction that the pains were as distinct as any pain, must, I think, be received with respect. I am sure that she has done her best to analyze her symp- toms truthfully.

She came to me on a couch, or litter, from a Western State, a o^irl of 19, not wasted, and of good

MIMICRY OF DISEASE. 93

tints. She was said to be unable to walk, motion hurt her; and her eyes were carefully guarded from light by a double bandage. She was kindly but firmly treated, and was able in a few days to bear sunlight, and to go downstairs. When once she had been made sure that all this could be done without death, I allowed her to go forward more slowly, with such help from tonics, good diet, etc., as I could give. She very often talked to me about the cause for her disorder, and out of my inquiries and interest in her case came the self-analysis I append. It needs no commentary.

" I suppose, in all cases of nervous affections, one's natural temperament and constitution play an im- portant part; and, doubtless, with me, a tempera- ment rather emotional, sensitive, and occasionally morbid, had something to do with making possible the state I was in when I went to see Dr. Mitchell, in December, 1879.

" The immediate cause for the headaches, which began a year before that time and never left me after it, seemed to be a few weeks of mental and social strain. I had for two years before that time suffered from a weak back, had felt constantly tired, spent much of my time on the bed, and taken but little exercise. But in the fall of 1878 I felt much better and undertook study and class recitation, and became much interested in some evening literary and social clubs. For a few weeks I went every day to the utmost limit of my strength, and was then suddenly prostrated with severe headache and excessive weari- ness.

94 DISEASES OF THE NERVOUS SYSTEM.

" I, of course, tried quiet and rest immediately, and after a while grew better, but had a return of headache and weariness whenever I tried exerting myself much again. There is no question that what I lacked then was courage. If some one could have told me that there was nothing of consequence the matter, I am sure I should have overcome the diffi- culty and very soon have gained endurance by exer- tion ; but, instead, I became afraid to do things for fear of bringing suffering; and, as month after month passed, I could do less and less. I cannot now understand why I could not have seen — why I could not realize that the less I did the less I could do ; but I was blind, and so was everyone else. I thought it was some strange, mysterious disease that was taking away my strength. By summer, a few minutes' conversation or the walk of a block would make the pain in my head agonizing, and every sound became unendurable. My eyes, too, shared in my good-for-nothing state.

" In the fall, the pain went into my back and limbs, and sent me to bed with the strange infatua- tion that I could not move without injury, as I cer- tainly could not without pain. I had laid in one position with closed eyes for eight weeks, before going to Dr. Mitchell, in a state of supposed help- lessness. One thing I want to say in extenuation of myself, and that is, that the pain was real, not fancied. Whatever its cause, or however easily it might have been averted, it was genuine suffering at the time. I was scarcely ever hysterical, either,

MIMICRY OF DISEASE. 95

in the usual sense of the term, for, at least, I realized the necessity of self-control.

^' In looking back over that year with the light of the present, I can only say that I believe there wixs> nothing really the matter with me, only it seemed as if there was ; and, because of those sensations, I carried on a sort of starvation process, physical and mental. Why that process should have brought me into such a condition, I must leave with some one wiser than I to unriddle."

96 DISEASES OF THE NERVOUS SYSTEM.

LECTURE V.

UNUSUAL FOKMS OP SPASMODIC AFFECTIONS IN

WOMEN.

You will find, if you come to have much experi- ence in the cases of hysterical women, that in some instances the disorder arises in general convulsions following upon a state of acquired nervous instability, and then runs on into a great variety of symptoms — palsies, hyperaesthesias and anaesthesias and con- tractions— to end, at last, in years of bed-ridden invalidism, or, much more rarely, in spinal sclerosis. A single case will thus give jou, in disorderly and unexpected succession, every scene of what 1 have ventured elsewhere to call the drama of hysteria.

At the risk of repeating an old story,! have sought, in one of these lessons, to relate some of these his- tories, chiefly that I might illustrate afresh the termination in sclerosis, and partly to show what might be done to rescue certain of what seem to be the most hopeless of these exasperating cases.

Apart from these, however, we see two forms of hysterical disorder, in which the primary signs are either slight and aborted, or remain so inconspicuous as to give but little aid in the early diagnosis. One of these is marked by mental derangements, and is usually treated as simply a causeless insanity until

SPASMODIC AFFECTIONS IN WOMEN. 97

some outbreak of the commoner forms of hysteric signs reveals the true condition. I mention it here only to complete my rather rude and partial classifi- cation. The other is characterized by the extraordi- nary variety and strangeness of the convulsive dis- orders, which, for years, and from time to time, afflict the patient ; all other symptoms being present rarely, or in feebly repi^esented forms. I propose to relate and discuss for you some of the most unusual of these cases.

In 1871, I was consulted by an intelligent unmar- ried lady, Miss L. P., set. 26, from Mississippi, for a condition of system which was probably due to cer- tain emotional disturbances following a violent onset of cholera morbus. The attack was repeated a few days later. The day after, she had intense, burning pain between the shoulders and down the whole length of the spine. This symptom lasted long, and with it, for a month, during which she kept her bed, there were brief periods of febrile activity. She is said to have had no severe headache, and no uterine or urinary symptoms. On first rising she found that her legs were feeble, and this paresis was best marked on the left side.

When first seen by me these symptoms remained unchanged. The weakness of the left side was com- plained of both in the arm and leg, and as affecting the eye. She needed a supporting arm when walk- ing, but did as well in the darkness as in the light, and stood fairly well with shut eyes. The left sole was slightly less sensitive than the right. Above this there was no dyssesthesia. There was also no

9

98 DISEASES OF THE NERVOUS SYSTEM.

analgesia, and heat and cold were well distinguished. There was, at times, a sense of extreme weight on the chest. The burning pain in the spine was un- equally distributed. It was worse at the 5th and 6th dorsal vertebrae, and was increased at night and by fatigue. The temporary application of ice made it worse, and this increased sufiering was felt for some time afterwards. Elsewhere she had no fixed suffer- ing, but complained of darting neuralgic pains almost at any point of the body. There was no womb trouble of moment. On the left side there was a large area of variable iliac tenderness, not great, and sometimes absent. It was less on deep pressure than on slight touch. The eye-grounds were normal, but she was said to have at times double vision, if very tired.

This case, as I recall it, puzzled me greatly, and was finally treated as of organic cerebro-spinal origin ; and this idea was strengthened by the fact that at times there was distinct rigidness of the erector spinse muscles. She came under my care first in the autumn of 1872, and gradually improved. The back was several times cauterized early in Jan- uary, 1873, and great gain followed. Somewhat later a slight and singular tottering of gait was seen ; but, on the whole, the progress was good and steady ; so that, by the end of January, 1874, she could walk with ease a quarter of a mile on level ground. In February, 1874, Miss P. made the mistake of leaving home, and subjecting herself to what was, for her, excessive fatigue and much social excitement. Then, as always since, fatigue brought on more or less nervousness, and the singular forms of spasms which

SPASMODIC AFFECTIONS IN WOMEN. 99

have proved so enduring an annoyance. At the close of a day of unusual fatigue, on rising from her chair to cross the rooni, she suddenly staggered back, and then rotated violently several times. These fits re- turned over and over, and resulted within a week in fresh dorsal pain, extreme lassitude, and a curious inability to keep her balance. Meanwhile, the rota- tions were usually, but not always, to the left. The loss of equilibrium was great. On rising she would pitch forward, and then sideways, and then turn swiftly. The pitching was really convulsive, and not due to lack of balancing power, and there was no subjective sense of giddiness. She came to see me soon after, and was much worse for the journey. During ten days of quiet here the rotatory spasms gave place to violent and nearly constant spasmodic jerking of the head backwards or forwards, to right or to left. As this also departed she had a new onset of what she called "twists," and thenceforward turned only to the left. These spasms were amazing things to see — suddenly, while crossing the room, she would rotate furiously to the left, about three to six times. The turn was very rapid, and seemed to begin with the spine. Then the head followed, and, as she said, it seemed hard for the legs to keep up with the back.

At other times an irresistible power seemed to drag her up on to her tiptoes, where she would re- main a moment, as it were, fixed. At this time she could walk, or even run, backwards, but a forward naovement was beset with difficulties. She would be, as it were, hurled forward, and then rotate, or

100 DISEASES OF THE NERVOUS SYSTEM.

the effort to move in a forward direction would end in a rapid retrogressive stagger, followed by rotation to left. There was no vertigo except as a result of the spinning. In June she went home, and from this period she had a succession of slow gains with sudden relapses. If leading a very quiet life, she sometimes passed six months without spasms. Worry, fatigue, excitement, were all sure to bring them on. At times there was no warning, but usually pain in the feebler leg, nervousness, and irritability were premonitory of an attack. Then she M^ould of a sudden find one leg oddly twisted around the other, or would be drawn up on to her toes, or forced to walk on her heels, or would pitch hither and thither, not from weakness, but from alternating unilateral spasms. At these times her will seemed to be absolutely suspended. "It is," she says, " as if some other will-power had me in possession. I struggle against it in vain."^

The first point to notice in this case is its generic re- lation to the class of functional spasms of Duchenne; those in which spastic movements are associated with or follow some form of normal muscular action. Such spasms do not arise during repose, and in this sense chorea is at first, and in some cases throughout, as I have elsewhere observed, a form of functional spasm. ^ Perhaps I shall, in a measure, clear your minds as to the nature of what I mean by functional spasms if I recall to you the influence of strychnia in

1 For analogous cases see Eussell Kejmolds's System of Medicine, art. Chorea.

2 Am. Journ. Med. Sci., October, 1876.

SPASMODIC AFFECTIONS IN WOMEN. 101

large doses — such as you have seen given here many times. You will remember that in certain spinal maladies, such as those of syphilitic birth, it is my habit first to give iodides in heavy doses, and then to suspend these for a time, and to give strychnia up to the limit of physiological endurance, that is to say, until I cause an approach to spasms. When, for ex- ample, you give hypodermically the one-fifth to the one-eighth of a grain daily — the patient will have little or no annoyance if you are careful to insist that he remain at absolute rest in bed for two hours after each injection. If there be any tendency to spastic twitchings of the muscles, the will is com- petent to control them, unless, and this is the point I would make, the patient attempts to exercise. Should he do this, the eftbrt results at once in irregu- lar movements of an incoordinate character, and in slight or more grave spasms of the muscles em- ployed. While at rest there is no obvious trouble, but voluntary movement occasions spasms, which are the offspring of the poison. They are, in a word, functional spasms, and would not be seen at all, with limited use of strychnia, were it not for the efforts at voluntary action.

The second consideration to which it is worth while to call attention was the great variety of the forms assumed by Miss L. P.^s attacks, and the tem- porary limitation of the disorder to partial groups of muscles. These facts alone would, I think, entitle us to suspect hysteria as a cause; and, when we learn that no attacks ever took place in the street, and that pleasant surroundings lessened the likelihood of the

102 DISEASES OF THE NEKVOUS SYSTEM.

occurrence of the spasms, while all depressing and enfeebling agencies were apt to bring them on, no further doubt should exist as to the parentage of the disorder. Muscular action perfect in health loses in force and in sureness, and in steadiness, as any one falls away from the highest standard of physical con- dition, and when there is in the ganglia some cause tending towards irregularity in any shape, it also is apt to rise into gravity just in proportion to the failure in physical status. Add to this emotional disturb- ances, which in certain natures are prone to express themselves in some form of irregular muscular acts, and we have all the needed factors for producing such convulsions in persons at all capable of evolving them.

I consider that the treatment, which I need not here describe, utterly failed. I never succeeded in raising my patient's health to such a level as to put her above the possibility of these curious attacks. I, perhaps, ought rather to say that I never could keep her at that level. The least blow to health was with her a knock-down, and recovery was slow. Prac- tically speaking, the woman who habitually has hysterical spasms has something wrong with her general health. She is anaemic, or has lost general tone, and cannot get up, so to speak, or there is that remarkable state of easy tire which is called nervous exhaustion, but which were often better called nerv- ous exhaustibility, and which is, perhaps, due to some form of defective nutrition of the nerve cen- tres. Always there is some such cause behind the spasms. If we can relieve it we cure the convul-

SPASMODIC AFFECTIONS IN WOMEN. 103

sions, or rather make the soil fatal to their growth. I do not think this is always possible. There are some ansemias which resist all treatment. There are some mysterious forms of nutritive failure which are never made well.

I have seen recently a case which somewhat re- sembles Miss L. P.'s. Miss C, a native of Maryland, set. 21, was sent, when 17 years old, to a school in which boys and girls were educated together. Just before leaving home she had two slight attacks of "stiffness" when rising from the sitting posture. While at school she never menstruated, although previously regular. E^ext came a light attack of diphtheria, and still her general health seems not to have been obviously damaged; but the ''contrac- tions" grew more frequent until at last one day, in class, she was unable to speak, owing to trismus which came on as she rose to recite. She went home after this event, and in a few weeks her men- strual flow returned; nevertheless the spasms con- tinued, and this despite a gradual rise in health, and a nature free from melancholy, and prone to seek and find healthy enjoyment in outdoor life. A fur- ther gain followed a residence of some weeks in the West, but still the attacks continued ; nor did it seem that almost perfect health secured immunity.

At present, in 1880, this young woman looks in admirable condition; nor is there, on careful study of her case, any evidence of organic disease or func- tional disorder. While seated she never has any symptom of spasm; but many^times in each day, when rising from a seated or recumbent posture, she

104 DISEASES OF THE NERVOUS SYSTEM.

is seized with attacks which I have now seen her exhibit many times.

On rising she is seized with spasms of the legs, neck, face, and arms and hands. These vary end- lessly, and are not often exactly alike in any two attacks. Usually the phenomena are these, and in this order :

Just as she begins to move, after rising from a chair, she has —

1. A stiffening of the muscles of the legs, and chiefly of those of the thighs. This causes a certain constraint in her first steps, but does not prevent them.

Having moved a few steps, she has —

2. A consentaneous spasm of the neck (twist to left and downward pull) of the body ; also to left, of the lower part of the face, either to left or right, or stiffness from bilateral spasm of face. The left arm is sometimes in violent flexion from fingers to shoul- der, or the arm is extended and the hand fiexed. There is the same variety as to the movements of the right arm. When I last saw a fit, the right arm and hand were thrown out in rigid extension, the left being as perfectly in flexion.

3. 'No matter what posture was assumed, she was, so to speak, fixed in it for perhaps ten to fifteen seconds. The spasm came on, and rather slowly culminated in some one odd posture, and there and then the woman became, as it. were, a statue for the moments that followed.

4. These spasms were painless, and disappeared in an instant.

SPASMODIC AFFECTIONS IN WOMEN. 105

5. They caused no confusion, or vertigo, or any other ill feeling, nor any sleepiness. She went on at once to do whatever she had meant, such as to walk or to dance.

At times the attacks are frequent, at others rare, and absence from home and change of scene and climate seem to lessen the number of fits.

6. These spasms are often, but not always, pre- ceded by a condition which is sometimes chronic, at others comes only as an immediate warning of attack ; at all events, its presence is a sure sign that the attacks will come on readily and be more than commonly hard to prevent. This precedent state consists in a slight general tingling which varies in amount, and is apt to be accompanied by a sense of stiffness in the muscles of the legs. These are rather evidences of a chronic and slight condition of spasm than of anything which it is worth while to call an aura.

If, on rising, she stands still a moment and pre- pares herself to walk by some indescribable mental act, which is not a mere resolve, because here the will is quite powerless, she can prevent an attack. To rise quickly and walk at once, or to turn abruptly just after beginning to walk, are apt to cause fits.

The relationship of such attacks of functional spasm as these is as near to chorea as to epilepsy, for the state of which she speaks as favoring and pre- ceding a fit cannot for reasons already given be looked upon as an aura, and we know of no epi- lepsies in which the functional and orderly act of a muscle or muscles gives rise in some way to the

106 DISEASES OF THE NERVOUS SYSTEM.

irregular and disorderly discharge of nerve force which constitutes a spasm. But in grave chorea, this is precisely what does occur, the forms of spasm having of course in that disorder, as in functional spasms, differentiating peculiarities. I gave this woman bromide of lithium, chiefly to see if the bromides would control or lessen the fits. The attacks were not lessened by this agent.

After this failure I was at a loss how to deal with the case. There are spasms which are so nearly a part of the normal muscle acts or so tied up with them as to be as hard to change by medicine as the orderly sequence of any common muscular action, nor is the task of reform more easy when years of repetition have made deep the easy ruts of habit. I could only insist that she must live so careful a life as never to rise without being on guard. Then also, since violent exertion distinctly lessened her ten- dency to spasms, I advised an abundance of exercise. The results of this advice were good, and the case rapidly prospered when she took to hard housework, which happened to interest her very greatly.

The next case which I desire to add to this group of spasmodic disorders, is, like the last two, remark- able for the great variety of distorting forms assumed in turn. Some of you may recall the patient, a poor unmarried seamstress, aged forty-three, tall, thin, and with a face constantly and deeply flushed; a pulse of 90 to 100, and, so flir as I could discover, no organic disease. When nearing the age of forty she began to have retarded menstrual flow, but neither then nor when seen by me a year later, was

SPASMODIC AFFECTIONS IN WOMEN. 107

there any uterine trouble. In June, 1878, after some family annoyances, she had a severe rigor, ending in trismus which came on abruptly, and repeated itself thereafter with like suddenness, and at inconvenient seasons, usually while she was eating. In August it was replaced by dysphagia. She acquired, as a consequence of this condition, a deadly fear of the abortive efforts to swallow, and would chew for many minutes before making an attempt at degluti- tion. In the autumn this too passed away, and in October she first consulted me at my clinic for a " lump " on the chest. I was about to refer her to one of our surgeons when her remark that it went and came interested me, and I carefully examined it. To my surprise the growth was in or on the left great pectoral above the breast. It was an oval flattened swelling with quite abrupt edges. If I carried the arm out so as to make the muscle tense, in a few minutes the tumor disappeared gradually, and I perceived that it was a phantom tumor with which I had to deal. I was familiar enough with these as seen in or on the belly, but I now saw only my second case of this phenomenon in anj^ other muscular mass. The " tumor" was hard and dense, and the temperature over it was a half degree above that of the neighboring parts. Hard rubbing gradu- ally dispersed it, but it formed again in a few hours, and I may add was always tender.

I next found to my great interest that all of the pectoral on this side was in a state of curious irrita- bility, and this you will recognize as only an increase of a normal quality. When, for example, I strike a

108 DISEASES OF THE NEKYOUS SYSTEM.

healthy muscle with a finger-tip, or better, a pointed caoutchouc percussion-hammer, such as that which we use to test tendon reflexes — two facts are observ- able. First, the whole length of the muscular fibre struck contracts, or a large part of the whole length. Then, as it relaxes, a little hard prominence forms in the muscle at the part struck, and remains for a few seconds until it gradually disappears.^ In this woman's case, the secondary local contraction was larger than is usual, and lasted for at least a half hour or more. A few weeks later, she came to the hospital to stay, and now the pectoral tumor had gone, and the belly presented the usual appearance of a phantom tumor. All of its muscles were violently contracted, so as to look like a rounded growth. It was painfully tender and the percussion note was dull. It, however, presented one peculiarity I had never seen in any other such case. Several times a day the whole contraction passed away, but the least handling of the belly brought it all back, or this took place without any interference. The woman was during all this time in a state of amazing nervousness, and w^as seized with universal tremor whenever any one came near to her bed. Her pulse rose at times to 130, and the temperature fluctuated daily and irregularly from 97° F. to 105° F. We got her well enough to walk about and to leave the

1 I described these phenomena very many years ago in the Trans, of the Phila. Acad. Nat. Sci., not then being aware that Weber had called attention to them. They are best seen in the pectorals of thin people.

SPASMODIC AFFECTIONS IN WOMEN. 109

hospital, but the abdominal contraction still existed or did so after a year had passed away.

I have seen a similar false tumor in the calf of a highly hysterical lady. It was relieved in a week or two by the daily use of massage.

I shall complete this group of cases by a very singular one, which I saw last year. M. B., female, set. 59, a worn-out school-teacher, always feeble and lacking blood, but otherwise well, had a slight sprain of the knee, which forced her to remain at rest. Very soon she perceived a rhythmical spasm of the middle of the muscular masses of the calf of the left leg. The muscle gathered into a hard painful swell- ing about five inches below the popliteal space. The contraction, which was two by three and one-half inches in size, was sudden and horribly painful, and the region attacked was always sore, but was most so during the spasm. This lasted a few seconds, but the space affected was at all times hot and a little hard. The spasms were singularly regular, about twenty-five to thirty a minute, but there were often long periods of one to five hours during which no spasm existed. She had been treated in various ways without relief, but I was finally enabled to help her by rest in bed, the use of a splint, and careful feeding and iron, but the local trouble was not entirely cured until I had used several injections of atropine, which were thrown into the muscle, a plan which was, I think, first employed by Drs. Morehouse, Keen, and myself, in the Hospital for N^ervous Diseases during our civil war.

To complete the group of unusual forms of spasm

10

110 DISEASES OF THE NERVOUS SYSTEM.

in women, I shall only add a case or two of hysterical athetosis. Since Dr. Hammond first described this interesting member of the family of choreoid spasms, I have seen two cases in which the athetoic spasms were simulated in hysteric women. One of these I saw but once, as it did not return to my clinic ; the other was a private patient, and was long under ob- servation.

L. C, 8et. 25, from Canada, a stout, ruddy, unmar- ried woman, was probably overworked at puberty in acquiring accomplishments which she can no longer use. At 14 she had diphtheria, but no sequent palsy. The hysterical aspects of her case are represented by tendency to tears, by rare hystero-epilepsy, by fits of hysteric coma, by great nervousness, distress at loud sounds and bright lights, and by general abdominal tenderness. Over and above these it is to be re- marked that she has a certain general feebleness, not at all suggested by her look of health, nor is she ever very steady in her motions, and is liable to a fine tremor, which subsides only after she has been for some time at perfect rest. Also there is a slight but distinct and very slow oscillation of her eyes, so that this group of symptoms suggests sclerosis. Other- wise she is well, and it may suffice to say so without going into negative details as to sensation, motion, reflexes, and the functions in general.

Possibly this is an hysterical woman with an or- ganic malady, but to which cause shall we refer the athetoic spasms, which I shall now describe ? When for relief the hands lie closely locked on her lap, save for tremor, little movement is to be seen, but

SPASMODIC AFFECTIONS IN WOMEN. Ill

when released, and especially during excitement or attention to them, both hands, the left being the worse, exhibit the most singular motions. The fingers extended, or in extension and flexed on the palm, move to and fro, coming together or sepa- rating, or crossing the line of the thumb. These motions are slow, and of a perfectly disorderly char- acter, but they never cease except in sleep and during efforts at any manual work, when they are always replaced by the slight tremulousness already alluded to. In Dr. Hammond's case, at least in the one given as a type, the movements continued during sleep, and also they were powerful, and there was some pain in the limbs concerned, but none of this applied to my patient. The motions could be easily controlled by another's hand, the resistance being but slight, while also there was no pain. When, however, my patient grew excited or emotional, the movements became rapid, and during her menstrual periods, which were natural, this was also the case. There was no spasm in the feet. The history of these movements is that thej arose out of a succes- sion of hystero-epileptic fits, Vv'ith intervals of stupor, or of stupor with rigidity. At the close of these attacks, although she was in other respects well, the fingers were noticed to be strangely affected, and the disorder thus begun grew slowly worse.

The only question is as to the origin of these spasms. Is it an athetosis proper, or an hysterical imitation of athetosis, or merely athetosis grown, as one might say, on an hysterical soil, and modified by its place of growth ? Despite the fact that the

112 DISEASES OF THE NEKVOUS SYSTEM.

athetosis arose directly out of hysterical disorder, I incline to the latter view, especially as in many par- ticulars the case otherwise conforms sufficiently to Dr. Hammond's admirable account. I ought to add, however, that in cases more clearly and purely hysterical, athetoic movements are sometimes met with.

In my second case, that of an unmarried woman, Miss J., set. 40, there were slight mental disorder, sensory delusions, left hemiansesthesia, an hysterical temperament, and slight ovarian tenderness (left). Rapid relief of the mental trouble was obtained under treatment, with slow improvement and final cure of the anaesthesia, large gain in flesh and blood, and entire recovery from the hysterical symptoms in general. During the early months of the case there were at intervals attacks of athetoic spasms. Usually these came and went without appreciable cause. At other times emotion, especially terror from her sensory dreams, seemed able to occasion them. They lasted from five minutes to hours, were not violent, conformed absolutely to the type cases, were bilate- ral, but ceased in sleep, existed only in the hands, and several times ceased when Miss J.'s attention was diverted.

The character of these motions diflfered somewhat from the utter irregularity of Hammond's disease. I should say they differed unless her attention was called to them, in which case no semblance of order in the spasms could be seen. When unwatched by the patient, the motions consisted in constant slight to and fro and lateral movements of all the fingers,

SPASMODIC AFFECTIONS IN WOMEN. 113

but at brief intervals. A large range of motion would affect first the thumb, and then in turn all of the fingers in succession from the forefinger to the little finger.

As this woman improved in general condition the finger spasms slowly passed away, and have now, I believe, been absent for at least a year. Whatever doubt there may be as to the hysterical origin of the former case, none can exist as to the last one, so that we may, I think, rank hysterical athetosis among the forms of clonic spasms seen in this peculiar disorder.

10*

114 DISEASES OF THE NERVOUS SYSTEM.

LECTURE VI.

TEEMOE.

In accordance with the plan I have followed here of treating at one time of groups of symptoms, at another of single symptoms, I shall ask your atten- tion to some of the minor forms of motor disorder found among nervous or hysterical women.

The subjects I shall choose are Tremor, or tremu- lousness, and certain Spasms, usually local, which are not within the range of hystero-epileptic states, but coexist with perfect consciousness.

You have seen here over and over the tremor of tobacco, of alcohol, of lead, of old age, and also the forms of tremor which are yet more active, such as are met with in shaking palsy and sclerosis. Besides being thus an expression of weakness, as in old age, or fatigue, or the feebleness of convalescence, or of organic disease, or toxic states, tremor is a sign in many people of transient emotion, of fear, of excite- ment, of anger, or of grief, almost as natural a motor expression in some mobile natures as the facial fea- ture spasm, laughter or crying, is of uncontrolled mirth or grief. Tremor like these, too, is capable, under certain circumstances, of passing over the line of healthy functional manifestation and becoming a symptom of disorder and lack of emotional control. Here we are to consider it as a symptom found often

TREMOR. 115

among the nervous, a symptom which may be local or general, temporary or enduring, and may, in a few cases, be so much the most prominent feature of a case as almost to constitute a disorder deserving of being itself labelled as a disease.

If the organic tremors, the offspring for the most part of coarse textural changes, be clearly spinal, it is interesting to ask if the representative tremor of hysteria be in like manner of functional spinal birth, a question more easy to ask than to answer; but seeing the volitional control which many nervous patients possess, as regards the symptom tremor, it seems probable that, in extreme cases, the cerebral ganglia lose those inhibitory qualities which are usually active in the healthy. That, however, this symptom may be of mere emotional origin, or de- rived from pathological changes, becomes important in diagnosis where it sometimes chances that a spinal malady is painted on a background of hysteria, or that hysterical additions arise in emotional patients to disturb our belief that we have had to do with a malady purely organic. These mixtures of symp- toms are, as you will readily admit, when you have seen many such cases, as bewildering as charades. Some of you may recall the case of Miss M., aged 25, a fat and ruddy person, who suffered first from over- study, combined with some mental worry. At the age of fourteen she had diphtheria, but no sequent paralysis, and came to me a few years ago, at this clinic, a person looking as little like having organic disease as any you are apt to see. About three years before I saw her she had had an unfortunate love

116 DISEASES OF THE NERVOUS SYSTEM.

affair, which had ended in a high degree of general nervousness, a form of trouble which we have very frequently had occasion to bring before you, and the symptoms of which, I trust, are now familiar to you. It came on rather abruptly, as these things some- times do, resulting in a tendency to tremor, which was excited by the slightest emotion, or the least ex- citement or worry, and was always worse at the time of her periods. We have also intercalated, in her case, a brief history of occasional hysterical spasm, with spinal and ovarian tenderness. It seems prob- able that on top of this came a condition of organic disease of the spine, which is not as yet fully de- veloped, but which will in all probability end in a general sclerosis, of the character which we call disseminated. She has now some slight difficulty in walking, vague pains through the limbs, some numbness of the feet and hands, and slight diffi- culty of speech, a certain drawling of her words, quite characteristic of the condition in question; she has, too, occasional vertigo, and the disk of her left eye is, I think, suspiciously white, while I find, upon careful examination, that the vision of that eye is not nearly so good as on the other side. The peripheral appreciation of colors is distinctly impaired, so that there seems to be only too much reason to fear that the optic nerves are suffering from atrophic change. The tremor she has at present may have been origi- nally, and probably was, purely hysterical, since it came and went, and was more or less within control of the will. It has now all the characteristics of a tremor from organic cause. She cannot thread a

TREMOR. 117

needle at all, or eat easily, or carry a full glass to the mouth without violent agitation; while the hands are for the most part quiet when at rest. Looking at the whole of the peculiarities of this case, it seems to me extremely probable that it has passed quietly, and without the suspicion of her physician, into a state of organic disease of the spine.

You are, of course, aware that there are two forms of tremor in connection with spinal troubles; I may coarsely state their peculiarities as follows : One is constant while the limb is at rest, and is lessened by motion; and the other is less when the limb is at rest, and is made very much worse by voluntary motion. The tremor of nervousness, and that which is seen in hysteria, may be always constant except in sleep, or may come and go irregularly, without ap- parent cause, but will always be liable, like some of the spinal tremors, to remarkable increase under ex- citement or expectation, or the sense of being watched. It is usually a tremor of variable extent, so to speak, the range of disturbance, w^hat I may call the width, being greater than that of most organic tremors, at least at their beginning, while under the influence of emotion, or without known cause, it may pass into a condition of local or general convulsions, the range of motion increasing like the lengthening oscillations of a pendulum. In one respect, however, it distinctly differs from the tremors of organic origin, which are never notably controllable by the will; whereas, in people merely nervous, or hysterically nervous, it is nearly always possible greatly to limit, and some- times for a time altogether to efface the tremor by a

118 DISEASES OF THE NERVOUS SYSTEM.

sturdy effort on the part of the patient. The form of tremor of which I am now speaking, may be con- fined to one limb, or may be so general, that almost every part of the body may be agitated by it, and in these latter cases, if the muscles of the face suffer also, they are apt to exhibit larger movements, rather than the finer tremors which affect the limbs. I re- member only too well the case of a lady, from one of our neighboring counties, which bafiled us com- pletely, a year or two ago in this hospital. She was a woman, aged 82, thin, not anaemic, in fact, rather ruddy. The disease began about four years before she came to me, and was a general nervousness and neurasthenia, caused by a long spell of nursing two of her family through fatal maladies. At the close of this effort, which is always one of the greatest strains that can be put upon a woman, she broke down with hyperpesthetic conditions of the senses, with tender spine, with great fatigue on the least exertion, and with a general failure of her nutritive functions. I do not remember when the tremor began, which was so marked a feature of her case, but I think it was a year from the time of the first outbreak of her symptoms. When alone in her room, and thinking herself unobserved, she was usually quiet, except for a twitching movement of the face, but when anybody entered, and especially when I myself approached, she was seized at once with a universal tremor and with extreme general nervousness, so that speech became inhibited, and deglutition was palsied for a time.

For some months, at least, the movements were of

TREMOR. 119

this character, and only after a time grew what I may call larger. This was also the history of each onset of shaking. The motion rose from tremulousness through large tremor visible to the eye everywhere, into a tremor which had in it a certain character of violence, and was varied with occasional slight jerks of the limbs, and accompanied with perpetual agitation of every muscle of the face, so that she presented an appearance not less singular than dis- tressing. This may pass as a good case, in fact, as a rather remarkable case of general tremor, but you will understand that this symptom in less marked degree is very often to be found as an expression of all nervousness, and even of weakness as in conva- lescence or in old age, while but few old hysterical cases escape without more or less exhibition of it.

Localized tremors, I mean such as are absolutely confined to one part, are somewhat more rare, nor do I remember to have had the opportunity of ex- hibiting to you here a single illustration of this class. I have now under my care, however, a very interest- ing woman, who has in both limbs below the knee a condition of tremor, which is about as fair an exam- ple of what I mean as anything that I have recently seen. In her it was caused by a long strain of nurs- ing followed by a disastrous railway accident, in which though she herself was not injured, one of her parents was killed. It was her general condition for which she came to me, and the tremor is to be regarded as only one symptom. I was told that some time ago, she was the subject of general tremor. She seems to have now a condition of mind not very

120 DISEASES OF THE NERVOUS SYSTEM.

rare among highly nervous women, and which with- out much straining of language I might effectually describe as mental tremor. A moment of mental indecision seems to trouble her in regard to every- thing upon which decision is necessary, she revokes her opinion, again decides, and so, but with far more uncertainty of mind than is shown in her speech, comes at last to a conclusion. Her general condition is exasperated by hysterical anorexia, by some dys- phagia, and by perpetual and distressing tendencies to micturition, and by violent flushing of the face. Under the influence of tonics, and careful treatment, she utterly failed to improve, but since I have placed her alone, in the care of a nurse before unknown to her, and steadily fed her every two hours, with also the daily use of massage, she has so rapidly im- proved, that now there remains very little of these conditions excepting the tremor of which I have spoken, but not fully described. While her hands are perfectly steady her feet are most of the time, or were most of the time, in a state of tremor caused by incessant minute activity on the part of the flexors and extensors of the feet, while there is also a good deal of trembling of the leg and thigh. It has less- ened from above downwards. However quiet her limbs, my visit is sure to set them going. She has been taught since she came here to restrain these movements by act of will, at flrst for a minute, and now for an hour at a time. Aided by the gain in general health, this training of the will has proved efficient, and there is at present hardly any tremor in the right leg, while that of the left is fast disap-

TREMOR. 121

pearing. A well- applied bandage in some way helps her, perhaps, as she says, by keeping her so reminded of the limb as to be able to dominate it.

A year has elapsed since I wrote the last sentence, and she is now entirely well.

What else need be said of nervous or hysterical trembling has been already spoken of in connection with my remarks on the subject of general nervous- ness, to which it is so apt to be related. What I most desire here is that you should never confuse it, as you may easily do, with other tremors, but I must have said enough to warn you on that subject.

Alcoholic tremors can only concern us in their diagnostic relationships, and it will suffice if I say, that as to this tremulousness, and as to other neural symptoms, you should be constantly alive to the rare, the very rare possibility that your patient may owe some of them to the secret abuse of stimulants. I say the rare possibility, because in a long and large practice among women of the best social class, and the one presumed by some people to be prone to this vice, I have seen but five or six cases of alco- holic drunkenness. I well recall a sad case which was brought to me some hundred miles on a couch, on account of a shocking state of universal tremor, with attacks of prolonged stupor and rarer hystero- epileptic attacks. The woman had been " diagnosed at," as she told me, by many doctors, and took a ma- licious pleasure in showing me a number of opinions. The tremor was incessant and large, but did not become worse for my visit, although it was at times, I thought, purposely exaggerated, the patient being

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122 DISEASES OF THE NERVOUS SYSTEM.

distinctly pleased at the importance of the role she was playing. I confess, that I too should have been deceived as to this case, had it not been for a practice which you will do well to acquire, a practice now become with me a deeply confirmed and increas- ingly active habit of noticing in a room, not only the patient but everything else. Missing a bottle of cologne from its usual place, where I was apt to make use at times of its contents, I said, ''Where is your cologne?" " My maid upset it," she answered; " she upset it on the table yesterday; she is very awkward, and did the same thing last week." My eyes natu- rally turned to the table, which was of antique ma- hogany, varnished. Now, I had observed that when cologne falls on varnish it permanently whitens it, but this table was clean of spots. I repeated my question, and when the same positive answer came, I was suddenly sure that she was drinking cologne, and this proved to be the case. We wrung from her and her maid a sad tale of the fraud and strata- gems by which she had been able to indulge in this singular habit undetected for years.

CHRONIC SPASMS. 123

LECTURE VII.

CHRONIC SPASMS.

Chronic spasms persistent through months, or even through years of waking life, are rare enough among women, but exceptionally rare among even the most nervous men. The only cases I recall in these arose from nerve wounds. In my book on Injuries to ISTerves I quoted but one case, which I had myself seen. I saw others which had suffered from violent spasm as an immediate consequence of a ball- wound, and where, however, the spasm lasted but a few hours ; but was in one case so great that the nails of the spastically shut hand cut the palm deeply.

You see, therefore, how uncommon is the condition of true chronic spasm, and why, therefore, it pos- sesses so much interest.

The chronic spasms of women with h^^steria are, perhaps, among the most obstinately unmanageable of all the graver symptoms of this disorder. They are said at times, by the books, to make sudden re- coveries. My own experience as to this is the same as in hystero-palsies. I do not see abrupt recoveries — why, I cannot say — perhaps because the cases which reach me are always old ones, much treated. At all events, you must have seen enough here to

124 DISEASES OF THE NERVOUS SYSTEM.

know that we earn our triumphs, as a rule, by intel- ligent and patient care.

These chronic spasms may affect almost any part. You are apt to see the jaw locked; I have seen it kept rigidly open. I have seen the head bent on to the breast, and so held for months. The false tumors of the belly are local spasms of muscles ; such a case I saw last year, with Dr. Sinkler, who must well remember how the immense tremulousness told us what was the constitutional cause of trouble before the woman could uncover her supposed tumor.

Sometimes you will see these very local contrac- tions in a part of other muscles. I once saw two large, permanent tumors in the calf of the leg. They were merely contractions of muscle, and not of the whole, but of a part, and, like some of the abdominal contractions, were very tender. They came very near to being removed by a surgeon — who, too often, made his diagnosis with the knife.

I have, however, made mention of some of these cases in a former lecture, and need not dwell here on this especial form of the trouble in question.

Permanent spasms, then, may affect almost any muscle of the body, and be so violent and lasting as to excite our amazement that, through many years, in some cases, a few groups of ganglionic cells should be competent to evolve such enormous amounts of force. I recall from my notes one case, which was, I think, a very interesting illustration of these affections, and which is also worth mentioning to you, on account of the success of the treatment, and because of the various therapeutical experiments,

CHKONIC SPASMS. 125

for experiments they must largely be in the treat- ment of this disease, which were made by others or by myself. This young lady, Miss C, from Mary- land, was brought to me a few years ago, as some of my assistants may remember, with violent spasm of all the anterior muscles of the right thigh and leg, the foot, however, being extended. The rigidity of the limb was something extraordinary — it stood out, when erect, at absolutely a right angle to the body, and no pressure that I dared to use w^as competent to depress it notably without causing extreme pain, and soreness of the stretched muscles. When the hand was placed upon the anterior muscles of the thigh they could be felt to be in a state of tremor, as though not all of the muscular fibres were acting at once. Probably, owing to the long-continued action of the muscles, the limb was never entirely relaxed in sleep, nor during the many months she was at the hospital was it ever seen to be in any other position than at a right angle, or at an angle of 45° with the line of the erect body. A multitude of therapeutic experiments ending always in failure, and the abandonment of the case, had been made by several ph^^sicians; nevertheless, I undertook the treatment with a certain amount of hope, such, in fact, as I always have, when an hysterical case is taken away from her own home and social sur- roundings, and subjected to new and revolutionary influences.

I began the study of her case by placing her seated at the foot of the bed propped up with pillows, and then suspended from her ankle an increasing amount

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126 DISEASES OF THE NERVOUS SYSTEM.

of weight, to learn whether I could by degrees de- press the limb, and thus wear out the muscles. I have, however, seen her carry a weight of fifty pounds for three hours, and she was but a frail girl, without the limb falling more than a few inches. Under ether the limb relaxed, but there always remained a certain amount of rigidity, owing, I presume, to what I may call the setting of the too long-contracted muscle.

Long before the ether left her, the spasm returned, and, therefore, I was quite sure that it was not one of those forms of mimic spasms of which I have pre- sented to you some curious examples. I next made an effort to wear out the spasm by the use of induc- tion-currents, using two batteries, but although I employed such a power of the batteries as could not readily be sustained by any but an hysterical woman, I did not succeed in my efforts, and she remained much as before. The use of galvanism to the spine, no matter what might be the direction of the cur- rent, also failed. She was finally cured by very much gentler treatment, which consisted in the use, twice a day, of the fullest hypodermic injections of atropia she could bear thrown directly into the rigid muscles. As soon as the atropia began to show its power in a certain amount of relaxation of the limb, I also had the limb manipulated, having it moved in different directions, upwards, downwards, and sideways. Under this treatment she steadily improved, and finally left the hospital able to walk on crutches, with the limb nearly straight under her, but still unable to employ it in walking. By this time she

CHRONIC SPASMS. 127

had obtained a certain amount of volitional control over its action, and in a few months became entirely well. There are cases, however, in which steady extension of the flexed limb, or steady flexion of the extended limb by apparatus will succeed in overcoming this rigidity. Of this I have seen an excellent example in the case of Miss "W., also from Maryland, who came to me with the diagnosis of general sclerosis, but who really presented one of the most extraordinary illustrations of hysterical symptoms which I have met with in years. She had at one and the same time some general palsy, a profound loss of power of the left leg, anaesthesia, and chronic hysterical spasm of the right leg, with violent alternate spasms and extensions of the head, together with a quite marked amount of mental hebetude, somewhat rare in such forms of hysteria. To make her case still more difiicult, I may add, that she was fat and rosy, in perfect condition, men- struating with ease and regularity, and apparently suflfering from no organic trouble whatsoever. I say to add to the difficulty, because I always feel more hopeful of a case of hysteria when it occurs in the person of a woman lean, wasted, and ansemic. You have then, of course, the chance when building up a constitution, to aid your moral treatment by all of the profound alterations which you may bring about during the process of fattening, and fllling with good blood an exhausted system. In her case I succeeded in extending the limb by the use of a screw^ appa- ratus, and a stirrup fastened to the extended foot, and attached to the apparatus below the knee. Per-

128 DISEASES OF THE NERVOUS SYSTEM.

haps the anaesthesia of the limh may have aided me in this matter, but, as I have said above, it is not often that you succeed by these means, and in using them you may expose your patient to a second dis- order in the form of general convulsions, or local spasms in parts remote from that first affected.

I saw an example of this in the case of a lady whom I went to Massachusetts to see, some years ago, and who sufi:ered from atrocious chronic spasm of the left arm, so that it was always painfully flexed. There was no anaesthesia of the limb, and every effort to make it straight gave rise, if persisted in, to general convulsions, which finally caused, as 3^ou may imagine, the total cessation of all efforts in that direction.

The treatment of these forms of spasm must usually consist in the treatment of the general condition, and of what that is, I have already fully spoken, in speak- ing of the general subject of the course of hysteria.

I said in 1881, when these lectures were first printed, that section of tendons in hysterical con- tractions of muscles was uuadvisable. I have now, after two years, to modify this statement. During this interval I have thrice seen section of the tendo Achillis prove valuable.

In another instance, where, in despair, I cut several tendons, the contractions returned with vio- lence ; but in all of these cases the first and interest- ing effect was sudden arrest of the spasm.

The cases which did well were all of them young women whom I had succeeded in lifting to a higher level of health, and in whom, as a consequence, all

CHRONIC SPASMS. 129

the hysterical symptoms had faded away, excepting this single obstinate spasm of the calf muscles. The relation of one case may suffice:

Miss L., set. 15, who had passed through many forms of hysteria, and at last grown sound enough to resume her usual studies, returned after. two years, remarkably well, with the one exception of a con- stant spasm of the calf muscles. When she left me two years before, I had hoped that with improving health this last relic of hysteria would pass away. I was surprised to find that it was as bad as ever, and that she was absolutely without any other hysterical symptom. The spasm was most violent and always was worse for any efifort to flex the foot, or from prolonged walking. It certainly seemed that, as splints and atropine and all else had failed, we were justified in using the knife, yet I could not but fear that after section of its tendon the muscle might continue in a state of spasm. Dr. Sydney Roberts, who shared my doubts, divided the tendon, the patient being under ether ; but the retreat of the released muscle was not extreme nor spastic, and to my pleasure, when the tendon reunited, there was no return of spasm, the power of the muscle was normal, and I had learned a useful lesson. Certainly in this case the tension kept up by the tendon was a condi- tion of the existence of spasm. There has been up to this time — a year having passed by — no return of the trouble, nor of any other hysterical phenomena.

When, then, you meet with chronic spasm in the hysterical, deal first with all the possible causes of the constitutional state; and only when you have

130 DISEASES OF THE NERVOUS SYSTEM.

succeeded in relieving this can you hope to see the spasms get better by any of the local means I have mentioned.

Spasms such as these, are not often purposely mimicked, but occasionally you will meet with an illustration in this form of that unconscious simula- tion of disease, if I may be allowed such a phrase, of which I have already so frequently spoken. In this disorder there occasionally arises a chance for the success of those abrupt impressions upon a patient which so amazes alike the sufferer and her friends. I recollect, as an illustration, the example of a very charming young girl from Rhode Island. When I first saw her she was lying on the bed, with her knees drawn up, her feet not extended as is usual, but flexed. I was told that when she awoke ill the morning, they were straight, but were almost immediately drawn up into the state in which I saw them. After going over her whole system and not discovering evidences of organic disease, I finally made up my mind that it was a case for one of those bold experiments which sometimes succeed when more timid action fails. After inducing her mother to leave the room, I suddenlv straightened one of the girl's legs. I met with no difiiculty until I had partially attained my object, and this proved to me with certainty, that it was a willed spasm with which we had to deal, and not one controlled by volition. I then said to her, '' I have straightened one of your limbs, straighten the other for me." She said, "I cannot, but perhaps you can." I straightened it with but little difficulty. I then said, " Sit up on

CHRONIC SPASMS. 131

the side of the bed." She replied that she had not sat up for years, but I finally got her seated with much trouble, and then, picking up a gay cravat, and tying it around her neck, I said, laughing, "iTow you are all dressed for a walk, how amusing it would be to meet your mother at the door." To my sur- prise she yielded, seeming to enter into the fun of the idea, and with a staggering gait (such as you would expect from one long confined to bed) she advanced with me to the door, where she met her astonished parent who was just coming into the room. She never went back to bed again perma- nently, and in a few weeks afterwards was able to ride on horseback.

You now and then meet with cases in which the whole range of hysterical phenomena leap into mis- chievous life owing to some most trivial wound or other hurt, but it also chances at times that a real and grave injury of a nerve may give you an almost indistinguishable mixture of nutritive and other dis- orders the usual result of nerve wounds, and also of hysteric symptoms such as may perfectly well arise without traumatic cause. It becomes then almost impossible to say of a given symptom, such as chronic spasm, which may be the child of either parent, whether it be hysteric or due to the nerve lesion, and yet as concerns treatment, it may be of the utmost moment to reach such a decision. The follovv^ing case is a remarkable illustration of my meaning.

I saw last year, wdth Dr. Morton, P. L., set. 26, a maid-servant, who had, a year ago, a fall in which

132 DISEASES OF THE NERVOUS SYSTEM.

she bruised her left side. Being of a nervous and impressible nature, it was not surprising that she was seized at once with left unilateral numbness and slight loss of power. These symptoms faded away in a few daj^s as one of the minor injuries due to her fall rose into mischievous prominence. In falling, she struck her left elbow so as to cause pain down the arm, but not in the ultimate distribution of the ulnar nerve. Five days after the accident the pain grew w^orse, and a general hypersesthesia spread over the ulnar side and middle of the arm. At the same time the lingers began to ilex more and more, until at last all the finger-tips and the thumb came into contact in the position assumed when with all of the fingers w^e hold some small object. The hand was held in extreme and constant flexion chiefly by spasm of the palmaris longus, the tendon of which was rigid and prominent. The least eftbrt at passive motion of the parts caused intense pain, and the hypersesthesia was so great that a touch on any part of the fingers, except the thumb and forefinger, and on nearly the whole forearm seemed to occasion the utmost distress.

This case, I confefes, somewhat puzzled me. I^erve wounds of themselves give rise in either sex to hys- terical states, so that, except for my knowledge of the previous temperament, this condition was of little diagnostic aid. The hyperaesthesia was ex- treme. It is so in many nerve wounds or contusions, but, at least early in the case, it does not pass out of the distribution of the nerve presumably affected. lu this case it did not seem to have any accurate

CHRONIC SPASMS. 133

anatomical site, that is, it was partly in the ulnar, and irregularly there, and in a portion of the median and musculo-spiral territories ; while there was none of the tactile loss which inevitably accompanies nerve lesions, there being agonizing pain, and yet lack of accurate sense of touch. Besides this, in the present case, the lingers were cold ; there were no joint lesions, nor any causalgia or nutritive changes in the skin or nails. When, too, I pressed on an indifferent point — such as the olecranon process — and led her to believe that I was compressing a nerve, she described her increase of pain as terrible. Either, then, this was a case of slight nervous lesion exasperated by the hysterical temperament, or else it was not a nerve hurt of any gravity, and all of the symptoms had arisen in consequence of a trivial hurt, just as a pin-prick may be the starting-point of the most extreme and enduring hysterical phe- nomena. It would, I think, be difficult to find a better illustration of the difficulties in reaching a distinct diagnosis in such cases, and yet a diagnosis is here, if in any case, most desirable, because, if the case be purely due to contusion of the ulnar nerve, the question of operative interference is certain to arise should the symptoms continue long. This woman was put under the daily use of galvanism to the arm and hand. Each application was followed by relaxation of the contracted parts and by a lessen- ing of the hypersesthesia. When the poles were applied without making circuit, the same results followed, and I have now not the faintest doubt that

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134 DISEASES OF THE NERVOUS SYSTEM.

the phenomena were from the beginning to the end of purely hysterical parentage.

There is a form of spasm which is sometimes mis- taken for paralysis, and is to be met with, as far as I know, only among women; that is to say, in a large experience I have never encountered a case among men; it is what I might call spasmodic ptosis. It is to be distinguished from that violent closure of the eye which is found with or without some disorder of the fifth nerve, by the fact that it is simply a quiet shutting of the lid, and a resistance on attempting to lift it up with the fingers, and an absolute incapacity for a time to raise it by the will. If this were a paralytic feebleness, there would, of course, be no difficulty in pushing up the eyelid with the finger, but, as I have just stated, this cannot be done without the exertion of a good deal of force. I fancy that, even among women, this condition is rare, as I do not remember seeing more than three or four instances. I mention them as curiosities and as cases which you may occasionally see. There is also a paralytic ptosis which is common among women, and which I hope you will not confound with the malady with which we are now dealing. The last example I have seen of spastic ptosis was in the person of a lady, who came from the interior of Pennsylvania, and who has since died of cancer of the stomach. She was a