1 UV Li LIVi N^i •i ,**' ui^clioijal Nervous Disorders Id won) en cGjillicuddy JfcGi UBRABYOF CONGRESS. •._ Copyright No, Sheli , .//^._/_ UNITED STATES OF AMERICA. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN WOMEN BY T. J. MCGILLICUDDY, A.M.,M.D. Consulting Physician to the Italian Hospital, X. Y; Surgeon-in-charge of the New York Mother's Home Maternity Hospital ; Surgeon-in-charge of the Metropolitan Dispensary and Hospital for Women and Children ; Fellow of the Neio York Academy of Medicine ; Member of the American Medical Association ; Member of the International Medical Congress, Berlin, 1691, etc, etc. ILLUSTRATED BY FORTY-FIVE WOOD ENGRAVINGS AND TWO CHROMO-LITHOGRAPHIC PLATES NEW YORK \-\%\l> r l WILLIAM WOOD AND COMPANY 1896 $ ^ -£-> Copyright by WILLIAM WOOD & COMPANY, 1896. PREFx\CE The attention of the profession has been confined of late years too exclusively to surgical gynaecology and to dis- eases with marked pathological changes. Great strides have been made in the development of these branches of medical science. They have had many able exponents. Less has been written on medical gynaecology, although a subject equally deserving of research and one which will abundantly reward the scientific investigator. There are many important nervous disorders in women without de- terminable anatomical changes in either the brain or spinal cord. Although there is no interesting anatomico-patho- logical history to be detailed in such cases, they are so com- mon, and cause so much suffering, that we must give them the share of attention they deserve. They are not usually found in hospitals but are seen fre- quently in private practice, and very often in the upper strata of society. The observations which follow have no claim to completeness on the subject. It is only intended to draw the attention to a class of affections which is frequently seen, and not so minutely described as the im- portant organic diseases and surgical affections. In the consideration of the functional derangements of the nervous system in women, it should be remembered that many uterine and digestive disorders are simply a small part of a constitutional condition which requires IV PREFACE. treatment, leaving the uterine or other ailment to disap- pear of itself when the general health becomes restored. The diagnosis of functional disease should be carefully made, for even in chronic organic cases many important organic changes take place without the accompanying physical signs, and to determine the question whether an ailment is functional or organic will at times completely mystify the most competent and astute physician. It is hoped that this contribution will be of interest and some practical advantage to the general practitioner, from whose standpoint it is written, and of value to future ex- plorers in this interesting department of medical work. 776 Madison Avenue, New York. CONTENTS. CHAPTER I. PAGE The Reflex Neuroses, 1 CHAPTER II. The Cerebral Neuroses, or Psychoses, 27 CHAPTER III. Spinal Reflex Neuroses, 34 CHAPTER IV. Cardiac Reflex Neuroses, 42 CHAPTER V. Vascular Neuroses, 47 CHAPTER VI. Pharyngeal and Laryngeal Reflex Neuroses, . . .81 CHAPTER VII. Bronchial Reflex Neuroses, 85 CHAPTER VIII. Gastric Reflex Neuroses, 89 CHAPTER IX. Intestinal Reflex Neuroses, 98 CHAPTER X. The Renal Reflex Neuroses, 106 CHAPTER XI. The Vesical Reflex Neuroses, 108 VI CONTENTS. CHAPTER XII. PAGE The Reflex Genital or Hystero- Neuroses. . . .112 CHAPTER XIII. The Glandular Reflex Neuroses, 118 CHAPTER XIV. Ophthalmic Reflex Neuroses, 128 CHAPTER XV. The Aural Reflex Neuroses, 137 CHAPTER XVI. Lingual Reflex Neuroses, 140 CHAPTER XVII. The Articular Reflex Neuroses, 144 CHAPTER XVIII. The Dermal Reflex Neuroses or Dermatoses, . . . 149 CHAPTER XIX. Hysteria, . .157 CHAPTER XX. Hystero- Epilepsy, 183 CHAPTER XXI. Hemicrania— Migraine, ....... 243 CHAPTER XXII. Therapeutics, 251 FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN WOMEN, CHAPTER I. THE REFLEX NEUROSES. Every woman suffers more or less, and many almost constantly, from functional derangements of some of the organic structures of the body. We are frequently con- sulted by those who, although suffering from no gross pathological condition, nevertheless require our aid for the great discomforts, both physical and mental, which these various functional disturbances entail, and we should make every effort to afford them consolation and relief. Many of these simple deviations from the normal are really precursors of conditions of a most serious nature. There is every reason to investigate carefully these minor ailments, because of their great frequency and the impor- tant bearing they have upon our success as practitioners. It is often claimed that many physicians are too scienti- fic and not sufficiently practical in their treatment of pa- tients. This is a matter we should guard against, because the physician's duty is first and foremost that of healing and not altogether that of solving scientific problems. No scientific physician is pleased when he finds he has lost » FUNCTIONAL NERVOUS DISORDERS. some of his patients because they have been discontented and annoyed at his lack of interest and sympathy for their minor functional disturbances, and that an arrant impostor has them in charge, because, by his tact and knowledge of human nature, he has readily relieved their imaginary or trifling ailments. Old ladies and lay persons generally are often loud in their praises of these irregular practitioners simply because they have given at- tention to these minor difficulties. Among the more important of these lesser derange- ments are the reflex neuroses, which will be considered from the standpoint of the general practitioner or gynae- cologist. There are many who seem to consider them insignificant, and some even appear to doubt their actual existence. The reflex neuroses are, of course, symptoms, but yet are more than simple symptoms as they are frequently pro- ductive of more distress than the organic disease from which they take their origin. Neurosis is a generic term for conditions of hyperes- thesia or disturbance of the nervous system which simu- late disease in an organ that is healthy, or without evident lesion of any of its parts. They may be general or local. Every general practitioner should be well acquainted with them, and every specialist also. The latter must first have the knowledge of the general practitioner, otherwise many mistakes will certainly be made in the diagnosis and treat- ment of chronic ailments. For example, if the confiding and unsuspecting patient with a run-down constitution — the result of anxiety, bad air, and a worse diet — with a headache and some abdominal or uterine symptoms, strays into the office of an enthusiast in ocular tenotomy, he will probably want to relieve her distress by dividing the rec- THE REFLEX XEUROSES. 3 tus muscle for eye-strain. If, however, as is more likely, she applies to a surgical gynaecologist of a certain class, a symptomatic uterine catarrh, an inoffending laceration, or a harmless, retiring cystic ovary will be pounced upon by this enlightened specialist, and receive most vigorous treat- ment; and if he does not always sterilize carefully his in- struments he usually succeeds in sterilizing the patient. Or perhaps her destiny may lead her into the office of a digestive specialist, who, of course, diagnoses stomach trou- ble as the cause of all her ills, and proceeds to lower sev- eral feet of rubber hose into her surprised stomach, and treat that organ to a wholesome bath. If our specialism be allowed to run into exclusivism, very shortly the only safe man for a patient to consult will be the old-fashioned general practitioner with all his faults and deficiencies. The benefits of specialism are many and most important, but there are also some dangers to be avoided. The neuroses of women should be studied carefully from both an anatomical and physiological standpoint. There is indeed much yet to be learned and plainly stated; The nervous system must be studied by the general practi- tioner as well as by the specialist, otherwise he is shut out from a true knowledge of disease. The important bear- ing of nutrition upon all ailments must be carefully con- sidered before a practical common -sense solution of the many difficult problems which present themselves can be reached. That many nervous disorders are caused reflexly, there can be no doubt. There is much difference of opinion in regard to the causation of the various neuroses, but many cases are recorded illustrating the fact that peripheral irritation is a very decided factor in their production. Irritation may be set up in any part of the body, and may 4 FUNCTIONAL NERVOUS DISORDERS. result in a reflex disorder in a distant organ. Some of the sources of irritation which may be noted, are : In the Digestive Organs — Indigestion. a. Stomach — Gastric catarrh, ulcer. b. Intestines — Para sites, ulcers, intestinal catarrh. f Haemorrhoids. c. Rectum-^ ™ cers ; | Ihread worms. (_ Pruritus ani. In the Genitourinary Organs— Inflammations. Internal- — a. Kidneys — Calculus. I Catarrhal states. ^ . ( Inflammations. c. Ovaries — i M ,.-, ,, ( Morbid growths. d Uterus— i Tnflammation s- ( Morbid growths. External — a. Vulva — Pruritus, herpes. b. Clitoris — Adhesions. ( Inflammation. In the Respiratory Organs — -j Irritation (catarrhal) . ( New growths. In the Eyes— -i Eye strain - ( Errors of refraction and accommodation. IN the JiARS j Impacted cerumen. The foregoing is by no means a complete summary of the causative factors which operate in the production of reflex disturbances, yet they are fair examples of what we should look for when searching for some peripheral irrita- tion to assist us in the diagnosis and treatment of disease. Although severe local disease may exist in an organ with but little reflex disturbance, still, usually many re- flex nervous disorders depend on slight peripheral irrita- THE REFLEX NEUROSES. tions ; and these reflex irritations, if they are not the abso- lute and complete causes of the nervous phenomena, are certainly exciting causes in those individuals who have a predisposing temperament. No one has more thoroughly investigated the reflex hystero-neuroses than Dr. George J. Engelmann, of St. Louis, whose contributions on this subject are extremely valuable. Both the sympathetic and the spinal systems are involved, and a condition of anaemia or lowered vital- ity is the most important causative agent in producing the hypersensitiveness of the nervous system. This weak- ness is the most prominent factor in the disorder. The study of the subject is of the greatest importance in the diagnosis of disease — for instance, asthma, which one may be led to consider a local pulmonary or cardiac disease, is often of reflex origin, either from the uterus, gastrointes- tinal tract, or from localized growths in the posterior nares. The spasmodic croup and convulsions in children are good examples of reflex nervous action. Reflex or nervous diarrhoea is often seen in horses and other animals. It is also very common as an intestinal neurosis in the human subject, and is a result of distur- bances of the sympathetic system through mental influ- ences. The condition is analogous to that where the sound of running water causes a reflex stimulation of the renal glands, thus assisting urination. Strong mental impressions stimulate both the vesical and rectal nerves of the young soldier when going into battle for the first time, while the uterine nerves in the young female emigrant produce amenorrhoea from the ex- citement incident to leaving home and coming to a for- eign country. The diarrhoea of scared soldiers and of nervous horses is of similar origin, and the emission of 6 FUNCTIONAL NERVOUS DISORDERS. the malodorous fluid of the Mephiticus americanus when pursued or frightened may be explained in the same way. The differential diagnosis between a severe reflex head- ache depending upon uterine or digestive disease, such as pelvic cellulitis or indigestion with constipation, and be- ginning exophthalmic goitre, where a rapid pulse and swollen thyroid are among the earliest manifestations, is often exceedingly difficult, as the mere fact of entering a physician's office for examination will often produce in nervous young women a great amount of excitability. This may give rise not only to a rapid pulse, but also produce a globus hystericus — itself possibly a temporary congestion of the thyroid. Many of these reflex condi- tions are certainly common and are yet not always appre- ciated at their true value. They should be carefully stud- ied in order that the differentiation between functional and organic or structural disease in an organ may be readily determined. They are of interest not only to the gynae- cologist, on account of their frequency in women, but to the aurist, the oculist, the dermatologist, the neurologist, and the surgeon. In this class of cases, although the uterus is a great factor in their production, the stomach and intes- tines play fully as important, if not a greater part. They may be divided according to the following classification. The neuroses of the nervous system. The neuroses of the circulatory system. The neuroses of the digestive system. The neuroses of the respiratory system. The neuroses of the genito-urinary system. The neuroses of the glandular system. The neuroses of the cutaneous system. The spinal and cerebral centres are not only implicated in these disorders, but the ganglionic and vasomotor THE REFLEX XEUROSES. 7 nerves probably even more so. This is readily seen in the flushes, perspirations, or blanching of the surface of the body. The cardiac and solar plexuses are without doubt of great importance in these ganglionic disturbances. The reflex neuroses are not to be confounded with symp- toms from local mechanical pressure — mere local inflam- matory neuralgia. They may, however, cause severe pain. Every one is familiar with the common reflex neu- roses — e.g., those of pregnancy — but it is with the less common, but no less interesting varieties that we are concerned at present. They are important on account of their misleading qualities, and are of great practical im- port in the daily routine of medical practice. These are the symptoms which connect general with special medicine, and without a knowledge of them the practitioner no longer remains a scientific physician, but gradually drifting into exclusivism, becomes little more than a skilled mechanic, and under his care the wrong organ will often receive the benefit of the medica- tion. Comparatively little has been written upon this subject. Fordyce Barker was well aware of its importance, and wrote a work dealing with some of the hystero-psychoses, entitled " Uterine Disease, an Exciting Cause of Insan- ity." Hodge and Tilt have recorded many cases. Hegar has studied them, and has shown also their importance in gynaecology. The alienist Esquirol has pointed out their connection with insanity. Dr. Engelmann has given them special study in an elaborate article in the Gynaecological Transactions for 1887, and Dr. H. J. Boldt has described the " Cardiac Neuroses in Connection with Ovarian and Uterine Disease" in an interesting article in the American Journal of Obstetrics for August, 1886. A number of 8 FUNCTIONAL NERVOUS DISORDERS. other writers have also enlarged upon this interesting subject. The frequency of hystero-neuroses may be judged when Dr. Engelmann states that he has observed in private practice, in the ten years since writing his first paper in 1877, over a thousand cases of menstrual hystero neuroses of the stomach alone. The intimate connection, reflexly, between the uterine and digestive organs is often manifested by gastralgia in cases of retroversion, the cure of the retroversion causing the immediate and permanent disappearance of the pain in most cases. Cases of violent vomiting occurring during the act of coition have been noted. Here, in this true re- flex neurosis there is generally an excessive secretion of hydrochloric acid. A case of this kind has been recently reported in the Medical Record by Dr. M. Gross. The digestive disorders are frequent causes reflexly of genital weakness, although anaemia may also be present. No part of the body should be regarded as an indepen- dent tissue, as each one holds the closest relations with the rest of the system and is always influenced by morbid conditions in the other parts. Digestive and uterine disorders at the menopause fre- quently manifest themselves by reflex disturbances of sensation in the lower extremities. One of the curious symptoms of such disturbance is diminished sensibility and a feeling as if the patient were walking over feather beds, or large puff balls, and sinking at every step. Cramps of the muscles of the calf of the leg are also of common occurrence in these disorders. These cramps are, in my opinion, of vasomotor origin, and when attacking the toes or calves, are similar in many respects to migraine. It is not alone a muscular cramp, the circulation being prin- THE REFLEX NEUROSIS. 9 cipally disturbed. There is much between the two that is analogous. Almost every gynaecological surgeon, who has given the matter any attention, has seen reflex neuroses dependent upon lacerated cervix. The scar tissue probably includes nerve filaments, and so keeps up a persistent irritation. It is not the specialist but the general practitioner who is most liable to discover the various reflex neuroses and give them their proper weight and treatment. No attempt whatever has been made to go into the sub- ject exhaustively. It is simply desired to speak of symp- toms and conditions which are commonly met with, espe- cially in women patients, and to consider some of the disorders which lie in that comparatively unknown region between gynaecological surgery and general medicine. It is to be regretted that many gynaecologists, in the treat- ment of diseases of women, never permit their range of vis- ion to extend beyond the pelvis. This is more particularly so in the case of the younger physicians who become spe- cialists immediate!}" upon graduating, and who have never bad the advantages to be derived from a general practice. Neuroses of ophthalmic nature require careful investi- gation of the digestive function, the kidneys, and the uterus. A regulation of the diet, or some gynaecological treatment, is often all that is required. Many cases of apparent gastric disease have been treated for years by medication directed to the stomach, when an endometritis was the principal causative factor in the production of the symptoms. And vice versa many a leucorrhcea has been treated locally by douches and astringents when chronic dyspepsia and hepatic congestion were responsible for its continuance. Through the ramifications of the spinal and ganglionic nerves irritation in one part of the body 10 FUNCTIONAL NERVOUS DISORDERS. shows itself in distant organs. Thus, cerebral irritations may expend their force in gastric distress, and again, most of the headaches from which patients suffer are the result of disturbances within the abdominal and pelvic cav- ities. By a series of plates illustrating this subject it is hoped to exhibit in a graphic manner certain pathological facts, and still further to establish certain connections and functions of the ganglionic system in order that some ob- scurities in the physiology of the nervous system may pos- sibly be removed. A thorough knowledge of these reflex symptoms is ex- tremely important, as it helps to broaden the domain of medical treatment, and careful study of the subject will increase the usefulness of both specialist and general prac- titioner, and tend to promote more harmonious relations between the different branches of medical science. The methods of treatment of the old-fashioned general practi- tioner are much more to be commended in the treatment of uterine disease than are those of some of the up-to-date gynaecologists, who think it their bounden duty to make a digital and visual examination of every patient, married or single, who enters their offices, regardless of the fact that the uterine symptoms are simply the results of over- work, bad hygiene, and poor diet, the rectification of which would cause them speedily to disappear, or of local con- ditions alone. It is really criminal to make a physical uterine examination of a young unmarried woman unless such a course is unmistakably indicated. The great ma- jority of these cases do not call for any such procedure. In the married it is entirely different, and examinations may be made much more freely. I have seen violent attacks of apnoea produced by uter- ine disease, and many of the cerebral neuroses are the re- THE KEFLEX LEUKOSES. 11 suits of irritations springing up in the gastro-intestinal tract. Much of the irritability, bad temper, and moral perversion takes its origin in the abdominal cavity. The differential diagnosis between a reflex neurosis and a local inflammatory condition is often difficult, and many times the two are combined. When the neurosis is present the symptoms are out of proportion to the local pathological changes. We find lesions and pathological conditions existing in various parts of the body which, increasing in severity, increase correspondingly the severity of the neu- rosis, and treatment directed to these pathological states decreases the neurosis or causes its disappearance, while local remedies applied directly to the seat of the neurosis are productive of no benefit. Some of the neuroses are very persistent. Cases of hemiansesthesia, hemiplegia, and paraplegia lasting for years have frequently been seen. I am led to believe that in the reflex neuroses there is undoubtedly local congestion dependent on the irritation. In the globus hystericus in many instances this con- gestion can be determined by placing the finger, during its existence, on the front of the throat just below the lar- ynx, where it will be found very tender to the slightest pressure. The digestive and genital organs of women are so inti- mately connected by their nervous and vascular relations that to treat them separately, and yet successfully, is im- possible, therefore it is readily seen how important it is for every gynaecologist to be thoroughly familiar with the digestive disorders. As I have already said in an article, the uterus, tubes, and ovaries are often treated as if they were in no way connected with each other ; so it is with the digestive tract. Its connection with the genital 12 FUNCTIONAL NERVOUS DISORDERS. organs is so extremely intimate that neither of them should be treated without a careful investigation of the other, lying as they do in the same cavity, with the same vascular and nerve supply. The skin, digestive and nervous systems are very inti- mately connected. Dermatoses, where the eruption covers the nose and upper part of the cheeks in butterfly form, are very common in the country districts where large quanti- ties of indigestible fried foods are eaten. The dermatoses of reflex origin are very numerous. The laryngologist and rhinologist also should give special attention to these disorders. Dr. S. C, a personal friend, tells me that every month or two, when suffering from an attack of aggravated indi- gestion, he also has regularly a severe pharyngeal and ton- sillar inflammation accompanying it. This, however, might be due to an extension of the disease by continuity along the oesophagus. Yet it is probably of reflex origin. Dr. L., after a continued indulgence in strong coffee, is always attacked with severe congestion of the nasal mucous membrane, and coryza, which in this case is nothing more than a reflex neurosis. These reflex symp- toms have been to a great extent ignored by the profession as a whole. The ancient Eomans recognized the conges- tion and enlargement of the thyroid as a result of uterine irritation. Probably the most common of all the neuroses is the well-known morning sickness of pregnancy; migraine, and other types of headache dependent on gastric and liver disturbances are also good examples of the reflex neuroses. It is not supposed that grave diseases, such as epilepsy, chronic mania, and other organic diseases of the nervous THE REFLEX NEUROSES. 13 system, are dependent upon slight peripheral irritations, but it is certain that many important and decided func- tional disorders are. On the other hand, it may be said that there is not the slightest doubt that there have been many errors in ascribing conditions depending upon a general blood state, the result of mal-assimilation or auto- infection, to some slight peripheral disturbance. Some physicians are inclined to repudiate entirely the reflex theory of functional disorders, and this seems to have been quite fashionable of late. The study of the reflex neu- roses is nothing more than a study of the sj'mptoms of disease which manifest themselves in distant portions of the body. A perfect classification of the reflex neuroses of individ- ual organs is at present impossible, but for clinical pur- poses we may include the following among the more com- mon forms : 1. Cerebral. 10. Kenal. 2. Spinal. 11. Vesical. 3. Cardiac. 12. Genital. 4. Vascular. 13. Glandular. 5. Pharyngeal. 14. Ophthalmic. 6. Laryngeal. 15. Aural. 7. Bronchial. 16. Lingual. 8. Gastric. 17. Articular. 9. Intestinal. 18. Dermal. Many of these are combined, as in the cerebro-spinal and gastro-intestinal. And two or more may exist at the same time, as gastric and dermal, cardiac and respiratory, vascular and glandular. In his article "A Clinical Study of Neuralgias," in the New York Medical Journal, July 30th, 1887, Dr. Dana 14 FUNCTIONAL NERVOUS DISORDERS. says in speaking of The Origin of " Reflex" or Transferred Neuralgias and Pain: " No point connected with the clinical history of neural- gias is of more interest than that of their so-called ' reflex ' origin. The production of migraine has been attributed, as we have seen, to the stomach and liver, to the eye, the tonsils, and the nose. Digital, plantar, cardiac, intercos- tal, and, in fact, all the neuralgias have been attributed to extrinsic causes. So much has appeared in literature re- garding the effects of such remote irritation that the im- portance of this influence has perhaps become exaggerated. At the same time the subject is one deserving of further and persistent study until its present many obscurities are removed. " In this study it is to be remembered that the term re- flex used here is not technically a correct one. An irrita- tion in the stomach may cause a pain which is felt in the forehead. The impulse, starting in the stomach nerves, is conveyed to the cortex of the brain, and this is felt as a sensation excited by the trigeminal nerve. It is a trans- ferred sensation, not a reflex one. since the impulse is afferent only, and the outward reference of the pain is purely psj^chical. "Reflex pains are, therefore, really 'transferred pains,' as a rule. In some cases it may be, however, that irrita- tions provoke reflex vasomotor changes in remote parts, and the ansemia or congestion thus produced causes pain. There may be, therefore, 'indirectly produced reflex pains.' The term reflex pain is so widely used that I can- not attempt to discard it. I use it, however, with the ex- planation here given. . . . "Irritations from the stomach cause reflexly a larger variety of pains. It is not possible to decide always THE REFLEX NEUROSES. 15 whether these pains are reflex, or are due to vaso-motor disturbances or the circulation of morbid products in the blood as in cases of fermentative dyspepsia, and of consti- pation associated with dyspepsia. " We all know that the simple ingestion of a glass of ice- water will cause a sharp frontal or temporal pain. Lau- der Brunton finds that constipation and presumable intes- tinal irritation cause a diffuse frontal headache over the whole brow. When there is no constipation and the con- dition is one of gastric irritation the pain is either just above the eyes, or more rarely in the occiput (when it will be relieved by acids) , or just at the roots of the hair (when it will be relieved by alkalies). . . . " The scapular or shoulder pains in dyspepsia, and the pains felt between the scapulae, due to the involvement of the posterior branches of the second to the sixth intercos- tal nerves, are common phenomena familiar to all. " Gastric irritations must have a certain severity to be felt as pain in the stomach or epigastrium, and in these cases there is doubtless, as a rule, some muscular spasm of the stomach walls. "The milder irritations produced by gas, undigested food, excess of acid, etc., seem to be reflected most often upon the upper intercostal nerves or the cardiac nerves, vagal or sympathetic. The headaches in gastric irrita- tion so often involve some toxic element that we cannot speak of their origin with much positiveness. " The stomach and intestines are probably the most fre- quent cause of transferred pains; after this I would place the uterus and its appendages, and next the eye or heart. Lange considers that the heart ranks second. " In kidney disease neuralgic pains may be felt in the lumbar region, radiating forward to the lower abdomen 16 FUNCTIONAL NERVOUS DISORDERS, and genitals— in other words, a lumbo-abdominal neural- gia is produced. In a case of renal colic I have observed the pain to be repeatedly centred about the anterior supe- rior crest of the ilium. "Pains started up by the gall-bladder are felt in the right side of the thorax and right arm, while it is one of the aphorisms of medicine that disorders of the liver may cause pain in the right shoulder. Bilious headaches cured by a dose of calomel I have observed to be located sometimes in the vertex and occiput. " In abscess of the spleen there is a pain felt in the left shoulder (Grotonelli, Wardell). " Lange says (loc. cit.) that in uterine troubles the re- flex pains occur oftenest in the form of arthralgias. I have had a patient suffering with painful spasms of the bladder who had intense pain in the palms of the hands every time she had a bladder spasm {Medical Record, July 25th, 1885) ; another patient, while pregnant, suf- fered from digital neuralgia, and in a third case reported by myself, a patient of Dr. Nilsen's, suffering from ova- rian prolapse, had severe and continuous neuralgic pains in the wrist. Studies of the cause of reflex pains in the feet show that they may be referred in almost all cases to irritation of the genito-urinary tract, and occur more often in the male {Medical Record, July 25th, 1885). The pains of uterine disorder, when reflected down, appear rarely to go below the knee; in other words, they affect the lower branches of the lumbar plexus, and not the sacral nerves. " It has been stated that pain in the heels may be caused by ovarian abscess. In my experience, such pains are due to lithsemic and neurasthenic conditions, and will be relieved by remedies addressed to such states. It may be THE REFLEX NEUROSES. 17 said in general, then, that pelvic irritations are felt most frequently in the upper and short branches of the lumbar plexus, next perhaps in the intercostal nerves and upper cervical nerves, then in the trigeminus, and last in the hands and feet. " Lesions in the lung itself cause reflex pains in the form of intercostal neuralgia. Slight pulmonary conges- tions, such as occur at the very onset of phthisis, may cause intercostal neuralgia, and Anstie speaks of the value of these pains as warnings of the approach of phthisical disease. Apart from these neuralgias, the lung is very rarely an excitant of reflex pains, perhaps because its nerve supply is small, aside from the sensory fibres of the vagus. Further study, however, may show that lung irritation may cause some of the painful affections of the larynx, tongue, or throat. " The question now arises whether, with these various facts before us, any general statements can be made with regard to the production of transferred pains. If we study them in connection with the anatomical arrange- ments of the cerebro-spinal and so-called sympathetic sys- tem, it is possible that the diffusion and transference of pain, though in 'a mighty maze,' will not appear entirely without a plan. " The cerebro-spinal nerves are sent out from their cen- tres in divisions or companies of seven, and each company acts together and serves a common definite physiological purpose. These divisions are : "1. The oculo-motor nerves, the trifacial, and the sev- enth — which supply motion and feeling to the face and anterior scalp. The remaining cranial nerves supply in- ternal parts. " 2. The four upper cervical nerves forming the cervical 18 FUNCTIONAL NERVOUS DISORDERS. plexus. This leash of nerves supplies motion and sensa- tion to the neck and occiput, and controls the movements of the cephalic extremity. It is in close connection with the trifacial, both at its origin and periphery, both di- rectly and via the sympathetic. It is subjected to much the same disturbances, and may be looked upon as physio- logically almost a part of the first set — i.e., of the com- mon sensori-motor cranial nerves. " 3. The third leash of nerves is composed of the last four cervical and first dorsal. They form the brachial plexus, and furnish motion and sensation to the upper ex- tremities. "4. The fourth set includes the dorsal nerves from the second to the sixth. This supplies the chest wall, includ- ing the pleura, and with the sympathetic the lungs beneath . " 5. The fifth set consists of the lower seventh to elev- enth intercostals, which supply motion and sensation to the abdominal walls, to the lower dorsal muscles, and the skin over them. " 6. The sixth set consists of the first four lumbar nerves with part of the twelfth dorsal, which is really a lumbar nerve. This supplies motion and sensation to, in general words, the hip girdle — i.e., the muscles (erector spinae, etc.) of the loins, those of the anterior, inner, and outer portion of the thigh, and the skin over these regions, extending down to the upper half of the buttock and to the groin, scrotum, and labia. It is the lumbar plexus which furnishes most of this supply. "7. The seventh and last set consists of the sacral nerves, whose anterior branches (those of the first four, with the lumbo-sacral cord) form the sacral plexus. This supplies the external genitals of the male, the clitoris and THE EEFLEX NEUROSES. 19 Area I. Area II. Area III. Area IV. Area V. Strands of cerebrospinal nerves. Trigeminus, facial, etc. Upper 4 cervi- cal. Lower 4 cervi- cal and 1st dorsal. Upper 6 dorsal. Lower 6 dorsal except last. Area VI.; 12th dorsal, 4 i lumbar. Area VII. 5th lumbar and 5 sacral. Distribution. Face and its orifices, anterior scalp. Occipital region, neck. Upper extremities. Thoracic wall Abdominal wall, up- per lumbar, upper lateral thigh sur- face. Lumbar region, up- per gluteal, ante- rior and inner thigh and knee. Lower gluteal, pos- terior thigh, leg. Associated ganglia of sympathetic. 4 cerebral. 1st cervical. 2d and 3d cervi- cal, 1st dorsal. 1st to 6th dorsal. 5th to 12th dor- sal. 1st to 4th lum- bar. 1st to 5th sacral Main distribution. Head. Head (slightly to heart) . Heart. Lungs. Abdominal viscera, testes, ovary, fundus uteri via renal plexus. Pelvic organs. To pelvic organs, the sympathetic supply being small. Figs. 1 and 2.— Diagram showing the distribution of the seven cerebro-spinal strands of nerves, and the location of transferred pains and neuralgia. (After Dana.) 20 FUNCTIONAL NERVOUS DISORDERS. part of the vagina, the perineum and external sphincter and the lower buttocks, and the posterior part of the thigh and leg, except its inner side. In a general way we may state that the lower portion gives motion and sensation to the legs and posterior thigh (the sciatic) ; the upper portion to the genitals and the gluteal, perineal, and anal region (superior gluteal, small sciatic, pudic). 1 u Now each of these seven sets of nerves is in intimate connection by two branches with the sympathetic ganglia, and through these with the viscera of the different cavities. The accompanying diagram shows better than any descrip- tion what this relation is. " I. The first two leashes of nerves are connected most intimately with the four cerebral sympathetic ganglia (ophthalmic, otic, submaxillary, spheno-palatine) and with the upper cervical ganglion. " We can understand how irritations in the cranial cav- ity may be reflected almost indifferently upon the trigemi- nal or upper cervical nerves. " II. The third leash of nerves to the upper extremity is connected with the three cervical and first intercostal gan- glia, all of which go to make up the cardiac nerves. " Hence irritations of the heart are reflected so often in the shoulder and. down the arm. " III. The first six nerves of the thoracic wall are con- nected with the corresponding sympathetic ganglia which supply the lung tissue, and this anatomical fact may ex- plain why in slight pulmonary congestions pain may be re- ferred to the intercostal nerves. 1 The sides of the body and both upper and lower extremities, ex- cept a portion of the legs, are supplied by lateral branches of the spinal nerves; the back, from occiput to iliac crest, by dorsal branches. THE REFLEX NEUROSES. 21 " IV. The fifth leash of nerves, fifth to the eleventh in- tercostal, is connected with the sympathetic ganglia, which supply nerves to the abdominal viscera via the splanchnic nerves. The great splanchnic supplies all the abdominal Fig. 3.— Chart Showing the Different Levels of the Cerebro-spinal and Sympathetic Nerve-supply. Cerebro-spinal nerves represented on the right side ; sympathetic nerves on the left side. (After Dana.) viscera, including the visceral serous membranes, except the kidneys. These are more largely supplied by the small splanchnic which arises from the eleventh and twelfth thoracic ganglia. The renal plexus in turn sends branches 22 FUNCTIONAL NERVOUS DISORDERS. to the spermatic cord, testes, ovary, and fundus uteri, so that those parts of the pelvic organs are especially con- nected with the lower dorsal nerves ; hence irritations of ovary, testes, cord, part of the uterus and kidneys, are often reflected as pains in the region of the kidneys and in the groins. It is, perhaps, over this arc that the low-down one-sided pains so often felt over the ninth to twelfth ribs originate. "V. The lumbar strand of nerves is connected with the lumbar ganglia and via the aortic plexus with the descend- ing colon, sigmoid flexure, and upper part of the rectum ; through the hypogastric plexus with the pelvic organs which it joins the sacral nerves and ganglia in supplying. "VI. The genital organs (vagina, cervix uteri, penis, prostate), except the testes and ovaries, are in close con- nection with the sacral strand of nerves (the seventh) ; the other pelvic viscera are more abundantly supplied by the lumbar and lower dorsal strands. Hence we find sciaticas and podalgia, and reflex pains throughout the lower ex- tremity in urethral irritations, rarely in irritations of the testes, ovary, or higher parts of the pelvis. These latter cause more often lumbo-abdominal neuralgias. " In attempting to explain the reflex pains from the vis- cera, I am led to the belief that the pneumogastric nerve must be left out of account as a direct factor. The mass of the sympathetic nerves to the sensitive thoracic, ab- dominal, and pelvic viscera, are made up of white, medul- lated nerves that come directly from the cord. These nerves carry sensory fibres, and their excitation is painful (Ludwig, O. Nasse). " Whether it be the heart, stomach, or uterus, therefore, irritations that excite pain more probably pass up to the brain via the spinal nerves, their posterior roots, and the THE REFLEX XEUR0SES. 23 spinal cord. Having, however, to travel through two or three sets of ganglia, it is easy to understand how they may become diffused, and travel up paths belonging to another strand of nerves, and so be referred by the mind to a place remote from their origin. " I have taken the liberty of quoting very extensively from Dr. Dana's article on account of its great value in the elucidation of the subject. Sometimes transferred pains are of organic origin and due to the effects of pressure. This is illustrated in the following case reported by Dr. John Hilton : " Within the last three months I was requested to see a young lady from the country on account of some painful symptoms she had in her right hand, especially in the little finger and the ring finger. Associated with these symp- toms there was the suspicion of an aneurism of the right subclavian artery. I will not trouble you with all the particulars of this case, but only those which bear upon the suggestions before us. The patient had a slight, hard swelling upon the first rib, which her mother thought had resulted from a fracture that occurred in her childhood, she being now about nineteen years of age. The swelling had lifted up the subclavian artery very much, and gave it the appearance of unusual pulsation, and upon close ex- amination a sort of aneurismal bruit could be heard, ap- parently the result of some enlargement encroaching upon the subclavian artery. There was really no aneurism. This was a case in point, where something had occurred to the first rib, possibly a fracture (of that I have my doubts, still it might have been so), which led to the pres- sure upon this ulnar nerve, and had caused the loss of sen- sation in the little and the adjoining finger, the loss of tem- perature in those two fingers especially, and very constant pain in them. These are, as far as I can see, conditions of a case, which might ultimately terminate in gangrene of the fingers. In the case of this young lady, we have only 24 FUNCTIONAL NERVOUS DISORDERS, the evidence of deterioration having gone so far as to diminish both the size and the temperature of the fingers, and to produce considerable pain in them. What has been the issue of the case I do not know. It was, before I saw it, invested with a great degree of anxiety, on the part of both the patient and her friends, for they had received the impression that she had a subclavian aneurism, which would require a very serious, and no doubt to her mind a very dangerous, operation." The following case, also reported by Hilton, shows the effect of transferred irritations in modifying the nutrition of a part : " Gray Hair on the Temple Depending on a Decayed Molar Tooth in the Lower Jaw on the Same Side. — A person was brought to me by a surgeon suffering very great pain on the left side of his face. He was much ex- posed to the weather, and suffered a great deal in conse- quence. He had taken many things to cure the neuralgia, as it was termed. I observed that he wore a wig, and I asked him the reason. He said, 'Curiously enough, the hair on my left temple has all turned gray. I did not like to have black hair on one side and gray on the other, so I had my head shaved, and wear a wig. ' Upon examining his mouth, I found he had a decayed and painful molar tooth on the left side of the lower jaw — supplied by the third division of the fifth nerve. The patch of gray hair appeared to me to be the effect of the nervous association of the auriculotemporal branch of this third division of the fifth nerve with the decayed tooth in the lower jaw. When this second molar tooth in the lower jaw was ex- tracted the neuralgic pain very nearly ceased. I have not seen the patient since, and cannot say whether the hair has recovered its color. All I can say is, it was stated to me, that during the time he was suffering extreme pain on the left side the hair over the temporal region became nearly white: a difference in color suggesting to myself some structural deterioration, and to the patient the pro- priety of having his head shaved and wearing a wig." THE REFLEX NEUROSES. 25 The curious effect that fright and pain or neuralgia in a distant part has in causing the hair to turn gray sud- denly has been exemplified lately in my practice. Ten days ago I was asked to see Mrs. K., a lady of sixty-five years who had been knocked down by a cable car. The only injury she received besides a very great fright and a severe bruising was a painful injury to the back of the left hand. The daily dressing of the hand was performed by my assistant, who, like many other recent hospital and dis- pensary graduates, was not at all tender or sympathetic in his manipulation; moreover, the solution of bichloride of mercury and the mixture of ether and iodoform applied was an additional source of pain. The family and the friends of the patient state emphatically that before the accident she did not have a gray hair in her head. Now the vertex and frontal region is quite gray, the black and gray lying peculiarly in streaks. On the left side, the same side as the injured hand, the hair is very much grayer and covers a much larger surface, extending down on the side of the head much farther toward the neck. The hair on the back of the head and neck is very black. It has always been heretofore a subject of interest and re- mark to the family and friends that although sixty-five years old, Mrs. K. was entirely without any gray hairs. Another case with which I am acquainted is that of a young man whose wife was drowned in a freshet, where she was found among a lot of bushes. Her appearance was so terrible and the sight gave the husband such a shock that the hair of part of one side of his head and the eyebrow and corresponding half of his mus- tache turned perfectly white. These sudden modifica- tions of nutrition of a part are difficult to explain, espe- cially so when we consider the hair simply as an appen- 26 FUNCTIONAL NERVOUS DISORDERS. dage to the body. Cases of sudden fright turning all the hair white in a single night are often reported. Mr. R. S., when a young man, was shipwrecked and floated in the ocean for forty-eight hours lashed to a plank. When found his hair had turned very white as a, result of the mental agony which he had undergone. CHAPTER II. THE CEREBRAL NEUROSES OR PSYCHOSES. There are peculiarities of the mind well known to every observer, which are often dependent upon morbid con- ditions of the abdominal and pelvic viscera. Of these the lighter and more common forms are : Mental depression, loss of memory, excessive irritability, wakefulness, or, on the other hand, intense lethargy and drowsiness during the daytime; morbid fears, such as of death, disaster, or insanity; hypnotism, trance, catalepsy, somnambu- lism, neurasthenia or nervous exhaustion, anaesthesias, globus hystericus, cardiac palpitations, joint neuroses or joint pains, amenorrhcea, enuresis, dyspepsia, and diar- rhoea coming on from bad news or "hard times." Under this head will come all the hysterical symptoms dependent upon the emotions, such as hysterical aphonia, hysterical apncea, hysterical laryngismus, hysterical suffocation and strangulation. The more severe types are melancholia, mania, and convulsions. It is not to be expected that we have included all the cerebral neuroses, but we will simply touch upon the more prominent and those most frequently met with. The question in my mind is, how to differentiate hysteria, which is generally dependent upon anaemia, from the neuroses. The cerebral neuroses often occur in neurotics from the mind being directed to a particular part ; this is seen in patients who are familiarly known as " womb cranks, " who imagine they have uterine disease, and are sometimes 28 FUNCTIONAL NERVOUS DISORDERS. readily cured by almost any simple manipulation of the uterus. Many of these women have been cured by having a uterus "tipped into place" when it was never out of its normal position, while in others, local measures of any kind will not avail for the cure of the mental disorder. The influence of the digestive and sexual organs upon the mental functions is well known to all physicians, yet in the practical treatment this knowledge is not always used to advantage. A young woman of exceedingly happy disposition becomes despondent and discouraged, with a completely changed disposition. From being kind and agreeable she becomes offensive, peevish, and insulting. This mental state is the result of an exacerbation of diges- tive or uterine disease, and is in reality a reflex hystero- or gastric psychosis. In some cases it is so severe as to cause fixed delusions ; even in the milder forms these psychoses result in much domestic unhappiness. The psycho-neuroses such as melancholia, mania, and hysterical insanity, which are not in any way connected with organic disease of the cerebrum, are often benefited by operations and treatment directed to other organs of the body. Interesting cases in confirmation of this have been recorded by Dr. Fordyce Barker and other authorities. Very much can be done in the way of improving these functional disorders by the method of expectant attention. If the patients are thoroughly convinced that the physician is curing them, many of them readily get well under almost any form of treatment, but there can be no doubt, as every gynaecologist is well aware, that many neuroses of a severe character depend upon uterine and ovarian lesions which must receive attention. In puerperal mania and melan- cholia nothing favors the return of the mental faculties to the normal so much as the restoration to health of THE CEREBRAL NEUROSES OR PSYCHOSES. 29 the pelvic viscera. Uterine involution will often start im- provement. A common time for cerebral neuroses or psychoses to ori- ginate is the first few weeks of married life. I have seen the worst cases of hysterical apncea dependent on a cica- trized lacerated cervix. Severe migraine resulting from ovarian inflammation or from indigestion is a most com- mon occurrence. The following case is instructive in this connection : Migraine, Hemiplegia, and Chorea, Dependent upon Uterine Irritation. — Mrs. Alice C, set. 18j r ears; menses came on first profusely when she was 13, lasting for four or five days. During her sixteenth year they became very scanty, lasting two days. This condition continued for about six months when severe pain of short duration started in the left ovarian region. Then, from overwork and worry followed by a mild attack of diphtheria, her present condition was developed. She suffered severely from chorea and was also very hysterical. The hemiplegia came on gradually six weeks after the attack of diphtheria, and involved the face and upper and lower extremity of the left side. The attack of hemiplegia lasted for three months. She was treated by medication and actual cautery applied to the back. The treatment helped the chorea but had no effect on the hemiplegia. There were no changes at this time in the menses, which were still scanty and painful. At the end of three months she took a short sea voyage (as far as Portland, Me.), which caused a complete disappearance of hemiplegia and chorea. About a month afterward, after a thirty-mile ride and a severe disappointment in a love affair, she had a slight return of the hemiplegia. Two months later, on her return to the city during the hot weather, she had a severe attack of right hemiplegia. She at present complains of occipital and temporal headaches. There is also severe pain in the cardiac region. Has had nasal hemorrhages at time of 30 FUNCTIONAL NERVOUS DISORDERS. menses for several months and at other irregular periods. For the last few days she has suffered from nausea and morning vomiting ; is now pregnant. The hemiplegia continues on the right side ; its seat was formerly the left. She is excessively nervous ; her tongue seems to be thick and her speech is imperfect. Any se- vere annoyance will cause a fit of hysteria. Suffers also with migraine on the left side accompanying the morning vomiting. The functional character of the hemiplegia in the pre- ceding case is shown not only by its transference from the left to the right side, but also in a degree by its occur- ring at an early age, organic hemiplegia or paraplegia occurring usually at an advanced age or at the time of degenerative changes in the blood-vessels. Like chorea, functional hemiplegia is found during periods of develop- ment. Functional Paralyses. — There are many points of simi- larity in functional and organic palsies; it is, however, often easy to differentiate between the two. The functional variety is generally connected with the menstrual period and exaggerated by it, its intensity varying from time to time. These paralyses sometimes disappear suddenly, although as a rule the return to the normal condition is gradual. In speaking of functional and hysterical paralyses we should carefully differentiate between the two, calling only those hysterical in which the emotions play a part. The term hysteria ought to be confined to cases where distinc- tive hysterical symptoms are present, as there are many functional cases without apparent hysteria. In these cases, if we begin by rectifying the general health, the mind will of itself return to the normal state. If the intelligence and will power of the patient are enlisted in the treatment and THE CEREBRAL NEUROSES OR PSYCHOSES. 31 she uses them to help herself, the recovery is much more rapid. Muscular power is greatly diminished in hysterical cases. This is most pronounced in the extremities, espe- cially on the left side. When facial palsy is present it is generally on the side Fig. 4.— Hysterical Paralysis. Fig. 5.— Hysterical Contractur Fig. 6.— Crutch Paralysis. Fig. 7— Crutch Paralysis. From a Patient Falling Asleep with Axilla Resting on the Back of a Chair. of the involved limbs. Aphonia, due to palsies of the laryngeal muscles, is quite common, and the muscles of the pharynx and oesophagus have also been noted bv 32 FUNCTIONAL NERVOUS DISORDERS. many observers as having been affected with hysterical paralysis. In the common forms of this disorder one limb, one side, or both lower extremities are involved. The attacks usually come on after severe mental excitement or a hystero-epi- leptic seizure. The paralysis may be partial or complete, and is usually accompanied by anaesthesia. Vesical paralysis is very frequently present in cases of hemiplegia and paraplegia, but rectal paralysis is much less common. Anaemic or functional paralysis depends upon qualitative changes in the blood and is often the result of severe dis- eases. The red blood corpuscles are diminished and the watery elements increased, with the result of affecting the motor functions of the nerve centres. Functional or anaemic paralysis has been seen after such exhausting diseases as typhoid fever, chronic diarrhoea or dysentery, bowel and uterine hemorrhages, chlorosis, dia- betes, scurvy, and malaria. Even in intestinal indigestion there is excessive weakness of the lower extremities accom- panied by cramps and pain. The paraplegia in these cases is due to a lack of arterial blood in the spinal cord. We should be careful to differentiate between functional and organic paralyses, such as come on from the arterial changes in syphilis or from embolism. The digestive tract and genito-urinary organs are generally the exciting factors, when diseased, of the functional or reflex paralysis. The irritation arising in these organs causes a contraction of the blood-vessels of the spinal cord which may lead eventually to an atrophy of the parts involved. Excessive irritation of the sensory fibres causes an arrest of the functions of the motor nerve centres. On careful exami- nation many of the so-called reflex or functional paralyses THE CEREBRAL XEUROSES OR PSYCHOSES. 33 will be found due to pathological changes in the spinal cord. Eeheverria reports a case of ulceration of the cervix uteri, in which the application of a weak galvanic current, one electrode upon the symphysis pubis and the other upon the uterine cervix, produced violent pain and trembling in the legs, with paralysis for fourteen hours. Rosenthal reports a case of a girl, aged twenty-three, who suffered for three weeks from paresis of the legs coming on with pains and cramps in the abdomen. He found a needle deeply embedded in the vagina, and after its re- moval the paresis disappeared rapidly. In Nonat's case, loss of consciousness with paraplegia came on as the result of cauterization of the uterine cervix. Landry reports a case in which the paralysis disap- peared after the restoration of the deflected uterus to its normal position. The most common cause of functional paraplegia is irri- tation of the genital organs by masturbation or excessive venery. When from excessive coition, the paralysis comes on very suddenly. 3 CHAPTER III. SPINAL REFLEX NEUROSES. Changes in the uterus and digestive tract manifest them- selves by irritations throughout the whole of the spinal column, and in fact throughout the entire nervous system, and by the spinal and cerebral nerves all portions of the body respond to these changes. Many of the symptoms arising are readily noted by the laity : pains in the wrists, ankles, and fingers are often called wind pains, resulting as they sometimes do from irritations in the digestive tract when flatulence is present. Spinal irritation and spinal pains are quite character- istic of uterine disease, and the backache of weak diges- tion is a very common symptom. For a good example of spinal neurosis the case of Miss M. N., page 233, may be cited. Sympathetic pains occurring on the surface of the body, and having connection with affections of internal organs, are of great interest, as by them we can appreciate and locate organic changes and derangements of function of the internal portions of the body. The pain which occurs between the shoulders or over the inferior angles of the scapula is perhaps the most frequent of these " sympathetic" pains which we meet, and must be connected with the distribution of some of the spinal nerves, because there are no other structures which could give expression to the pain, and no other nerves occupy this position except the fourth, fifth, and sixth dorsal nerves, 34 SPINAL REFLEX NEUROSES. 35 which are distributed over the interscapular space and the inferior angles of the scapulae. Hilton says : If we trace the great splanchnic nerve from within the thorax downward, and find it connected at its abdominal end with the solar plexus, thence trace its dis- tribution to the stomach, duodenum, liver, and pancreas; and if we follow the other or upper end of the same great splanchnic upward to the fourth, fifth, and sixth dorsal nerves, which give peripheral sensitive filaments to the in- teguments, over the angles of the scapulae, to the interscapu- lar spaces and the adjoining skin, one can well imagine that these nerves carrying the influence upward and backward may explain the occurrence of the pains sometimes expe- rienced in those external parts associated, with abdominal visceral disturbance. The pain which persons experience in disease of these viscera may be explained by the relative position of the great splanchnic nerve, communciating, on the one hand, with the solar plexus, and then with these digestive organs, and, on the other, distributing its branches to the fourth, fifth, and sixth dorsal nerves. In disease of the lower cervical, the dorsal, and the lumbar regions of the vertebral column the pain is usually expressed on both sides symmetrically. When the dis- ease lies between the occiput and the atlas, or between the first and second cervical vertebrae, this is not the case. In all cases of symmetrical pain the cause is central, or double, both sides being alike in a diseased condition. For instance, the positions of the sixth and seventh dorsal nerves are here indicated, as they are distributed to the skin just over the pit of the stomach. If pain be felt at that part alike on both sides of the median line, these nerves become the only possible expression of that cause, for there is no other structure there situated which could 36 FUNCTIONAL NERVOUS DISORDERS. manifest the pain. Then, tracing the nerves producing these surface pains backward to the posterior median line, and noting accurately the healthy or unhealthy condition of the various structures near which these intercostal nerves would pass — such as the ribs, pleurse, aorta, oesophagus, and other structures in the poste- rior mediastinum — we arrive at the vertebra and spinal cord, and in that way, by the law of exclu- sion, we arrive at the diseased spine as the real cause of the pains experienced at the pit of the stom- ach (see Fig. 8). In children bellyache is often the most prominent symptom in pleurisy or pneumonia. The at- tendant often concentrates his attention entirely upon the viscera under the upper half of the ab- dominal walls. This treatment is entirely misplaced, and blistering or poulticing the chest is the This is also an instance where the same nerves which supply the muscles supply likewise the skin over the muscles, and where the local manifestations are remote from the real cause of the symptoms. The Griffin brothers, of Limerick, in their exhaustive and valuable work entitled " Observations on the Functional Affections of the Spinal Cord and Ganglionic Nerves, in which their Identity with Sympathetic, Nervous, and Simulated Disease is Illustrated," published sixty years ago in London, draw the following conclusions : " 1st. That tenderness at one or more points of the spine Fig. 8.— Side View of Chest, Showing the Course of the Sixth and Seventh Dorsal Nerves. (Hilton.) method to be pursued. SPIRAL KEFLEX NEUROSES. 37 is an attendant on almost all hysterical complaints, on numerous cases of functional disorder when the hysteric disposition is not so obvious, and in many nervous or neu- ralgic affections. " 2d. That many of the symptoms of these affections evidently depend upon a peculiar state of certain nerves, probably at their origin, may be reproduced at any moment by pressure, and are often relieved by remedies applied there. " 3d. That, in all cases of tenderness of the cervical and upper dorsal spine, there was nausea, or vomiting, or pain of the stomach, or affections of the upper extremities; but no pain of the abdomen, dysuria, ischuria, hysteralgia, or affections of the lower extremities. " 4th. That, in all cases of dorsal tenderness, pains affect- ing the abdomen, bladder, uterus, testes, or lower extrem- ities, were usual symptoms; while nausea, vomiting, or affections of the upper extremities were never complained of. " 5th. That nausea and vomiting appeared to have more relation to tenderness of the cervical spine, pain of the stom- ach to tenderness of dorsal; but that, when there was sore- ness of both, nausea or vomiting was still more frequent, and pain of the stomach scarcely ever absent. " 6th. That when several points or a great extent of the spinal column are painful and tender on pressure, local remedies are generally less effectual, and there is a strong disposition to transference of the disordered action from one organ to another ; the pain or tenderness in all such cases of transference shifting its place to a corresponding part of the spinal column, leaving the original point free, or with a very diminished degree of tenderness. " 7th . That spinal tenderness is seldom or never met with 38 FUNCTIONAL NERVOUS DISORDERS. in cases of pure inflammation, except when these accident- ally occur in persons previously suffering from irritation of the cord ; and that, when appearances of inflammation present themselves in any organ, accompanied by a corre- sponding spinal tenderness, they cannot commonly be re- moved by the remedies applicable to inflammatory cases, and are often rendered worse by them. " 8th. That there does not appear to be a complaint to which the human frame is liable, whether inflammatory or otherwise, which may not be occasionally imitated in dis- turbed states of the cord; and hence that this disturbed state is one vast source of those complaints called hysterical or nervous. "9th. That those functional disorders connected with spinal tenderness are very often attended by some disturb- ance of the functions of the uterus, but that they are by no means always so, since they occur in those who are regular in this respect ; in girls long before the menstrual period of life, in women after it has passed, and, lastly, in men of nervous susceptible habits, and in boys. " 10th. That in fact they are not necessarily dependent upon any one organ ; since they are found indifferently coexisting with disturbance of the digestive organs solely, or the uterus solely, or of the circulatory or respiratory system. " 11th. That from the cases detailed we have reason to suppose spinal tenderness may arise from uterine disorders, from dyspepsia, from worms in the alimentary passages, from affections of the liver, from mental emotions, from the poison of typhus, from marsh miasmata, from erysip- elatous, rheumatic, and eruptive fevers, and from the irri- tation arising from local injury. " 12th. That it is almost invariably found in connection SPINAL KEFLEX LEUKOSES. 39 with gastric or abdominal tenderness, in fever ; and this tenderness is probably like the soreness of the scalp, pains in the limbs, etc., dependent on a morbid state of the cord. " 13th. That, whether in fever or in other complaints, it is met with in the situation of the eighth or ninth dorsal vertebra much more frequently than at any other part of the spine. " 14th. That affections attended by spinal tenderness are seldom fatal ; that, even in those cases of intense irritation of the cord under which patients suffer extremely from pain for years, the event is generally favorable. " 15th. That they frequently, as well as hysteria, occur with all the appearances of a primary affection of the nervous system. " 1 6th . That affections are occasionally met with present- ing all the marks of the hysteric character, and perfectly resembling cases described as those of spinal irritation, but unattended by spinal tenderness or any other direct indi- cation of a morbid state of the cord." In one form of spinal irritation the hypersesthetic or hypersemic type predominates ; this is especially frequent in women. One of the first signs of the disease is weakness and weariness of the back and limbs. There is pain in the back, which is intermittent at first but afterward becomes very severe and constant ; it is usually located in the neck or between the scapulae; it occurs less commonly lower down. The spinal column is extremely sensitive to pres- sure, the pain is increased by exertion, by sitting erect or by bending of the body; from the irritated spine the pain radiates in .all directions according to that portion of the column which is affected. When the upper portion is in- volved, there is headache, insomnia, vertigo, nausea and vomiting, dyspnoea, palpitation of the heart, irritation of 40 FUNCTIONAL NERVOUS DISORDERS. the diaphragm causing hiccough, heaviness, and soreness of the upper extremities. When it is the lower portion which is involved the abdomen, uterus, and bladder are affected by spasms and neuralgias; the lower extremities are often weak and cold. These neuralgias and motor disturbances are often of a migratory character. Along with the head- ache there is mental weakness; the patient quickly tires of intellectual effort. It is a chronic ailment lasting many weeks or months, the patient alternately improving and relapsing. Among the causes of this disorder are excessive stimu- lation of the emotions, over-excitement of the sexual organs, overwork and mental exhaustion, late retiring followed by early rising, anaemia, hydrsemia, and bad digestion resulting from bad air and unhygienic living. It is rather an obscure affection and difficult of diagnosis, distinguished from inflammatory affections of the cord by the non-ap- pearance of permanent anaesthesias and- paralyses, and by the absence of the sensation of a cord -like constriction around the abdomen, and of severe spasms and contrac- tures. There is no elevation of temperature and no marked muscular atrophy in this disorder. The treatment consists in improving the quality of the blood, giving easily digested nutritious food after correct- ing digestive disorders, and the administration of strych- nine, quinine, and iron in moderate doses. The hygienic surroundings should be looked to. Coun- try life with horseback or bicycle riding, should be recom- mended, but the exercise should not be carried to the point of severe fatigue. Hydrotherapeutic measures may be employed with advantage. Hot applications to the dor- sal spine are often of value. The foregoing methods of treatment should be used with caution, and measures, SPINAL REFLEX NEUROSES. 41 particularly of a severe nature, should be tentatively employed. In the anaemic type of spinal irritation, weakness and exhaustion are the predominant symptoms ; pain is also present but is not severe or persistent. The patients tire very readily : after slight physical exertion, a short walk, ascending a single flight of stairs, standing for a short length of time, they are compelled to retire to bed. Sleep is unnatural and disturbed, and they generally feel as ex- hausted and prostrate on rising as they did on retiring. They are frequently hypochondriacal and suffer from a dread of fatal maladies such as paralysis, heart disease, consumption, etc., often having their hearts and lungs examined by physicians. Digestion in these patients is generally weak, and they usually suffer with cold hands and feet. This neurasthenic condition may last for many years and may sometimes even degenerate into organic disease of the spinal cord. Among the more common causes of this disorder is excessive irritation of the sexual organs, excessive insomnia, great mental exertion, and bad dietetic habits. The treatment should consist of forced feeding, rest, change of scene, abstention from sexual excitement and mental exertion. The food should be nitrogenous and easy of digestion. A stimulant of porter, ale, beer, or light wine should be taken with the food, and tonic drugs such as nux vomica, cinchona, and iron employed. Sea-bathing in great moderation is often of much benefit, as is the ap- plication of static electricity. The patients with these neu- roses are usually the daughters of wealthy neurotics who have exhausted their vitality in the struggle for money. CHAPTER IV. CARDIAC REFLEX NEUROSES. Stimuli arising from diseased states of the gastrointes- tinal or uterine organs are fully as powerful as the emo- tions in causing cardiac disturbance, and for this reason the cardiac neuroses are frequently dependent not only upon diseased conditions in the cranial, but also in the thoracic and abdominal, cavities. Among the cardiac neuroses are: (1) palpitations; (2) tachycardia; (3) bradycardia; (4) intermittent and irregu- lar heart action ; and (5) angina pectoris. Cardiac reflex neuroses are quite common; they take their origin not only in uterine and gastro-intestinal dis- turbance, and are frequently dependent upon an excitation of the emotions, but may result from severe cutaneous im- pressions. The intimate connection of the sympathetic nerves gives ample opportunity for the development of functional disorders of the heart. The most severe and important of these neuroses is pseudo-angina pectoris, not only on account of its frequency but from its close simu- lation of the true disease. In the functional form of the disorder there is no organic lesion present; the pain is of the same type and follows the same direction as in the true form of the disease, running down the left shoulder through the arm and hand. The attacks are not constant and there is frequent soreness over the region of the heart. In weak and hysterical women with this affection, the least exertion starts up an attack of palpitation with vertigo as 42 CAEDIAC REFLEX NEUROSES. 43, a result. Sometimes this continues for quite a time, with pain in the region of the heart, and breathing also gives more or less pain. Numbness in the arm and hand is very- frequent and neuralgic pains in the arm are often present. The palpitations are generally relieved by a few moderate doses of tincture of strophanthus. Women approaching the menopause are more liable to the disorder than at other periods, although it is common in dyspeptic girls. In the milder forms of the disease the attacks may last but a few seconds, the patient experiencing first a sharp pain similar to a "stitch" in the cardiac region. Simultaneous with these there is a sensation as if of suffocation. The patient finds it impossible to breathe. This continues and the pain in the heart becomes extremely severe. The left arm and hand twitch and seem to straighten out and become rigid. This entire process may only occupy a few seconds. The patient thinks while it lasts that death is imminent. During the attack the proper treatment is the hypodermic injection of either morphine with atropine, or ether, pref- erably the former. The use of each depends upon the pulse — a strong pulse indicating morphine while a weak one calls for ether. The cardiac neuroses dependent upon pelvic or digestive disorder have not hitherto received in medical treatises the amount of attention which their importance and frequency call for. In the treatment of the abdominal or pelvic dis- order upon which they depend, not only local but consti- tutional treatment is usually necessary. It is found that in some of these cases the emotions or sudden mental excitement will bring on severe attacks of flatulence when the patient has hitherto been quite free from it-. It often seems to be of a neurotic origin, and it is a debated question where the gas comes from. The 44 FUNCTIONAL NERVOUS DISORDERS. flatulence is said to arise quite independently of fermen- tation. Some patients have a great deal more vitality than others; two individuals may apparently have the same amount of strength, but, as it has been aptly put, one has much better "timber" than the other, and consequently greater vital resistance to disease. The difference between the two manifests itself nowhere more completely than in the heart muscle, one withstanding all sorts of mental strain, physical hardships, and disease, without apparent ill results, and the other very readily collapsing under simply depressing influences. The pulse, respiration, and general aspect may, to our crude methods of observation, be appar- ently the same in both cases, yet one is on the verge of col- lapse. Many patients have a presentiment of impending dissolution. This is the result of the failure of vital forces manifesting itself to the individual by some curious mental process. I have seen a case of this kind in which the pre- sentiment was verified, the woman dying of concealed accidental hemorrhage. The same feeling occurs in severe cases of haemoptysis and hsematemesis. Dr. George W. Jacoby, in the New York Medical Journal for April 8th, 1893, states that in probably more than one-half of the persons suffering with motor disorder of the heart no anatomical lesion is discoverable ; he con- siders the subject one of great practical interest and divides the motor neuroses into the intermittent, irregular, those that are abnormally slow (bradycardia) and those that are abnormally frequent (tachycardia). In arhythmical forms of the disorder he states that the cause ought to be sought in some disorder of the digestive tract, and that it is ex- plicable by reflex through the vagus, and that a general neurasthenia is often present. CARDIAC REFLEX NEUROSES. 45 Alcohol and tobacco are well-known factors in the pro- duction of these disorders. In bradycardia the digestive tract is credited with being the disturbing factor ; in tachy- cardia (which is not at all the same as palpitation) , the heart beat is perfectly regular but very rapid. It generally takes place in neurasthenic patients, as shown by the marked disorder of the urinary discharge, this sometimes being very excessive and at other times exceedingly scanty. Mental influences and digestive disturbances are placed as prominent factors in its production. In his valu- able article Dr. Jacoby states that he is quite convinced that the neuroses are often the precursors of organic dis- ease. He says : " So long as the equilibrium of the ner- vous system can be re-established after functional disorder, so long as repair out-balances waste, so long can we speak of functional disorder ; as soon, however, as waste is in ex- cess of repair, so soon do we have lesion, and with it organic disease. So in all these cases of motor neuroses of the heart, what to-day we may look upon as a pure neurosis may remain so for a period of time and then get well, or may develop into organic disease. Their prognosis, there- fore, is not to be estimated from the cardiac symptoms alone." This is my experience also in the motor neuroses of the heart and the cases of pseudo-angina pectoris which I have treated. We never know when they may show themselves as symptoms of organic lesions. The cardiac reflex neuroses are evidences in very many cases of a weakened heart muscle, and in some patients, especially those who are far advanced in years, there is a possibility of their being snuffed out at any time, the post-mortem showing probably nothing more than a slight enlargement with some minor degenerative changes in the heart muscle, no valvular lesions being present. 46 FUNCTIONAL NERVOUS DISORDERS. The heart disorder is simply a part of the general arte- rial change, which includes all portions of the body and shows itself especially in the kidneys. Mrs. B., set. 26, is a thin, anaemic blonde, now con- valescing from her first confinement. On the fourth day after delivery I first saw this patient in consultation. Her pulse at this time was but 38 and regular; there was no sign of any disorder of the valves or of the heart muscle. Her appetite is fair, and the only discoverable troubles are a slight gastric irritation and pain and tenderness, not of a very marked character, in the region of the right ovary. She tells me that before becoming pregnant she suffered for a considerable time from leucorrhoea. On the eighth day after her delivery the pulse rose to 66 and after slight exer- tion was 72 for a short while, but fell again to 66. Mrs. B. K., 43 years of age, an anaemic blonde, has had seven children. During every pregnancy she has had frequent attacks of cardiac palpitation, has also suffered with heartburn and a considerable amount of flatulence. Attacks of nervousness and fear were also present, and the sight of water or (in winter) of the windows covered with frost, would induce an attack of this kind. In the middle of her last pregnancy an attack of la grippe caused a great increase in the number of these manifestations. The cardiac palpitations at this time persisted without inter- mission for four da} 7 s and nights (tachycardia). The attacks of nervousness and fear come on generally at night, but sometimes in the afternoon, with intense redness of the face. She is compelled to jump up and move around, as she cannot remain quiet while they are present. When the uterus is in the unimpregnated state she does not suffer from any of these disorders. This would point to a causal relationship between them, and would tend to show their reflex character. CHAPTER V. VASCULAR NEUROSES. The vascular neuroses are the vasomotor or those of the peripheral circulation. They may be general or local, ex- ternal or internal — external, as in a morbid blush, or in- ternal, as in a globus hystericus. Vasomotor neuroses are exceedingly complex phenomena, the causes and results of which are often difficult of eluci- dation. In giving them consideration one should remem- ber accurately the anatomy and physiology of the parts involved in their production. Among the more marked of the general vascular neu- roses is the hysterical or nervous fever mentioned below, usually resulting from some uterine or digestive difficulty. General nervous chills are also a vasomotor disorder de- pendent upon some local irritation, either cerebral, ab- dominal, or pelvic. Febrile conditions dependent on uterine disease are very common at the menopause; they often simulate malarial fevers, but are not benefited by quinine. Treatment directed to the uterine trouble often gives relief. In some cases they have their origin in ab- normalities of the menstrual flow. Among the local vascular neuroses we find flushes, morbid blushing, extreme redness of the nose and malar prominences, burnings of the palms of the hands, soles of the feet, top of the head, side of the chest, erythematous 47 48 FUNCTIONAL NERVOUS DISORDERS. eruptions, hemorrhages, sweats — sometimes unilateral or confined to the hands and feet — coldness of the extremities, dryness of the body. I have seen a number of cases of morbid flushing or blushing in my practice, and a few of them I have con- sidered of sufficient importance to justify me in taking- notes of them. In looking up the subject in medical lit- erature I could find but comparatively little bearing upon it. Dr. Harry Campbell, of London, published a rather extensive monograph upon this subject in August, 1890, and to it I am indebted for much information. The ganglionic system through the vasomotor nerves which control the circulation, and through which it trans- mits irritations in the same way as the cerebro-spinal system, is the important factor in these neuroses. Pallor and flushings show the contraction or dilatation of the vessels through this influence. That the mind is a great factor in many of these states, or that they are really psy- choses, is shown by the condition of excessive or morbid blushing. Sometimes the irritation reflected is general, as in con- ditions of neurotic fever or when nervous chills occur. It is said that in some cases of neurotic fever the temperature has even risen to over 110° F. Mental and nervous ex- citement will frequently run the temperature up to 104°, and this temperature will subside quickly without any treatment other than the removal of the original cause of excitement. Besides being reflected generally, it is some- times reflected locally or partially, as in cases of palsy of the extremities or of the face; or sometimes the disturb- ance is more marked, as is seen in cases of flushings of the abdomen. Morbid flushing at the menopause is very frequent as a VASCULAR REFLEX NEUROSES. 49 result of genital disease, but in very many cases I am con- vinced chronic gastro-intestinal catarrh is a still more im- portant factor in lowering the tone of the nervous system. In these cases the gastro-intestinal canal needs treatment more often than the uterus. In cases of morbid flushing salivation is frequently present. This is, of course, a glandular neurosis, and it shows the interdependence and identity of the different forms. It must not be con- founded with salivation from the too free administration of mercurials. The latter maybe due to the teeth contain- ing many fillings of cheap mercurial amalgam instead of gold or silver. Dentists claim that this is a not uncom- mon cause of mercurial salivation, and it should always be borne in mind when this symptom is observed. A flushed and congested face with a red and swollen nose is a frequent gastro-intestinal vascular neurosis or dermatosis. The so- called " chronic erysipelas " of the face is a vascular der- matosis and comes under the head of dermal neuroses. Excessive perspirations are glandular neuroses, but they are of vasomotor origin. It is very difficult to separate and classify these neuroses, as they are so commonly found associated in the same patient, and they are also so in- timately interconnected. The red nose and flushed cheeks due to reflex vasomotor disorder are a source of great mortification and mental dis- tress to those so affected. It is a most disagreeable afflic- tion, especially to women. It has been generally consid- ered by the ignorant as a sign of alcoholic indulgence : more often it is due to gluttony and gastro-intestinal dis- ease from overfeeding and high living. Particularly in small provincial towns many persons have been condemned as secret drinkers when they were simply suffering from a gastro-intestinal catarrh, secondary possibly to a post- 50 FUNCTIONAL NERVOUS DISORDERS. nasal catarrh, which was unfortunately manifested in a disordered state of the vasomotor nerves of the face. Bad cooking and general unhygienic living are the usual causes of this condition in women. As an instance of the way the ignorant look at it, I may quote a remark in this con- nection which I overheard a rough fellow make : " If they don't drink they should take in their sign." That the ignorance is not all confined to the poorer classes is shown by the dietaries of those in higher life. Extreme cold- ness of the extremities is a very common vascular neu- rosis due to abdominal or pelvic disease, and indigestion is fully as frequent a factor in its causation as uterine congestions. There are also patients who suffer from extreme pallor of the face whenever excitement causes the heart to beat furiously. Some of these local vascular neuroses become chronic and exist as dermatoses, like acne rosacea and chronic urticaria. Upon the disappearance of the local disease these reflex disorders cease to exist. The flushed appearance is, in many of these cases, due to a vasomotor paralysis. Some of these patients will frequently have the upper portion of the body in a constant flush, while the feet will be cold as ice. Insomnia is here often present, sometimes of such a severe type as to lead to mild forms of mental aberration. Vasomotor paralysis, causing burn- ing sensations at the vertex and occiput, is a very common symptom of uterine or ovarian disease. Coldness of the extremities is not only present in disorders of the uterus and anemic conditions, but is a common symptom of other abdominal difficulties, such as indigestion and "bilious- ness." Very many patients with indigestion have numb- ness and coldness of the left side of the body, which is often very marked, the heel and the tips of the toes and fingers VASCULAR EEFLEX NEUROSES. 51 on the left side being sometimes excessively cold. Even the novelists note the vasomotor changes dependent upon mental disturbances when they speak of a heroine's face blanching and of her " shivering and becoming cold with nervous excitement." In hemicrania and similar vasomotor neuroses the arteries may undergo spasmodic constriction, thus shutting off the blood supply and rendering the parts pale and anaemic ; or there may be dilatation of the vessels with hyperaemia of the part. Sometimes these conditions alternate : there is constriction followed by dilatation, and a consequent blanching followed by a suffusion of the part affected. These cold sensations and hot flushes of the skin are most commonly seen at the menopause when uterine or digestive disease is present, but may occur at any time. Either of these two conditions continuing for a considerable space of time results in marked nutritive disturbance of the parts involved. In the anaemic type the parts are pale and an- esthesia is present. In the hyperaemic type there is warmth and redness of the part with some slight hyperesthesia; the glands involved are stimulated and there is increased secretion. Profuse perspiration may, however, take place in this disorder without any other symptoms being appar- ent to the observer. Irritations of the plexuses and fila- ments of the sympathetic and cerebro-spinal systems from disease in the abdominal or pelvic cavities start up many vasomotor disturbances in distant parts of the body. The numbness with tingling present in the left arm in attacks of angina pectoris is a good example of a reflex vasomotor neurosis. Vasomotor neuroses of this spasmodic variety may also depend, upon ovarian irritation. If the causa- tive lesion is central, as in a case of endometritis, we maj" find both the lower extremities affected by a change in the 52 FUNCTIONAL NERVOUS DISORDERS. vascular supply and in the sensation of the parts, frequently causing reflex paraplegia. Mrs. T., set. 76, has had attacks of angina pectoris. Her left arm is considerably weaker than the right and at times is painful, particularly in the centre of the palm and the front of the elbow joint, with numbness and tingling of the fingers; the arm is cold, but its nutri- tion does not seem to be impaired. Only by the most care- ful examination can the pulsation be detected in the radial artery at the left wrist, and it is impossible to count it ; the pulse in the right radial is very strong. When she was very much younger, she says, her physician never noted any special difference between the pulsations of the two radials, or, if he did, which is more likely, he never spoke of it. She had suffered since girlhood with cardiac weakness. In some patients this condition of spasmodic contraction of the blood-vessels is temporary when depend- ent upon abdominal or pelvic disease, and disappears readily on removal of the causative lesion, the pulse in both arms, and probably in both feet, in many cases be- coming equal in strength. Morbid flushing, as a vasomotor disturbance, is due often- times to want of tone in the surface vessels, which thus causes either great pallor or flushing of the part. It is this w T ant of tone also in the deeper vessels which probably causes the congestive and ansemic types of neuralgic head- aches, and there are, I believe, undoubtedly extreme states of pallor or flushing of the cerebral tissue, the same as we frequently see on the surface of the skin. Areas of pallor in the brain may give rise to symptoms like ansemic roar- ing, snappings, whistlings, etc. These patients frequently have anaemia of all the extremities, suffering intensely from cold hands and feet. There can be no doubt that the intracranial blood pressure is to a degree under the control VASCULAR REFLEX NEUROSES. 53 of the sympathetic nervous system, the same as the blood supply in other parts of the body. In considering the sympathetic system and its connections we need simply outline the circulatory apparatus, as in this department it manifests its greatest changes. Excessive emotion, shown by morbid blushing, is due in many cases to a weakened condition of the sympathetic nerves and to anaemia result- ing from fatigue, insufficient sleep, and exhaustion. Morbid blushing, although not, strictly speaking, a serious disorder, is, to say the least, extremely disagreeable to the victim. It is simply the manifestation of a weakness in the nervous system. It is not the symptom of blushing which needs treatment, but the general condition which is at the basis of the disorder. Probably the most prominent exciting cause is self-consciousness, either by introspection or by the attention being drawn to the external portions of the body while under examination by others. If a modest individual of extremely nervous tem- perament is in company with a number of persons, and imagines that the people around her are regarding her critically and are entertaining rather a disparaging opinion of her, she is very liable to manifest her abnormal self- consciousness by blushing, or even by becoming embar- rassed in her conversation, and stammering. Shy and nervous persons blush readily when attention or remarks are directed to their personal appearance. Women are said to suffer more frequently than men from this disorder ; but there are many men whose nervous system is disor- dered, either congenitally or by exhausting mental or physical work, who are much given to blushing and other manifestations of nervous weakness. The young blush much more pronouncedly than those who are older, not only on account of the texture of the skin being more deli- 54 FUNCTIONAL NERVOUS DISORDERS. cate and healthful, but from inexperience and on account of their condition of hypersensitiveness not having as yet been blunted by continued contact with the world. Blush- ing is generally confined to the face, on account of its ex- treme vascularity, and therefore, having a greater supply of vasomotor nerves, emotional disturbances manifest them- selves more prominently in that part, the face being the portion of the body most exposed to view and upon which most attention is concentrated in looking for recognition, or in studying character or discerning beauty or homeli- ness. The self-attention thus given the face makes it abnormally sensitive and the vessels extremely prone to dilate, with blushing as a result. It is said, among nations where other parts of the body are exposed to view, that blushing is by no means confined to the face, but is much more widely diffused. Many people blush more readily before strangers than before acquaintances, though sometimes the opposite is the case. In some individuals the blushing takes place at regular hours, and with many it is so severe that it actually prevents them from going into society. Blushing rarely, if ever, occurs in solitude or in darkness ; it occurs only when observation is directed toward the personal appear- ance, and then results from embarrassment and self-con- sciousness. Anything which lowers the tone of the ner- vous system tends to the development of functional nervous disorders, of which excessive self-consciousness is a type. Many cultivated and scientific men are prone to blush in- ordinately from humility and diffidence, having a low opinion of their own ability, while the ignorant egotist is never known to blush. That colored people blush has been proven by scars on the face changing color under condi- tions which would induce blushing in those who are white. VASCULAR REFLEX NEUROSES. 55 Blondes exhibit a tendency to blushing, when the skin is healthy, much more vividly than do brunettes with sallow skins, although it is quite probable that dark-haired ladies blush with fully as great frequency as those who are light. It is more common in those of delicate nervous organiza- tions, while those of coarse natures are very little affected by it. In attacks of excessive self-attention, where there is a difficulty in concentrating the thoughts, the one idea be- comes unduly prominent and morbid blushing results. Some people blush on the slightest occasion. A case is- noted of a telephone clerk who blushes even when convers- ing through the telephone. Some men cannot go into shops where there are women without blushing intensely. Many clerks are victims of blushing, and, as a result, suffer much mental distress while serving customers. Teachers blush before their pupils, and men before their wives. Lovers blush frequently and painfully in the presence of their future partners. Lawyers are about the only class to whom this annoying affection is unknown. A grizzled old sea- captain, who passed many years in command of passenger ships crossing the Atlantic, invariably became much em- barrassed and blushed hotly when addressed by young and handsome lady passengers. Blushing is much more fre- quent in old men than in old women. Predisposition to blushing, like other peculiarities in individuals, is frequently inherited. Darwin calls atten- tion to a case of inherited blushing which came under the observation of Sir James Paget. While conversing with a young girl "a big splash appeared, first on one cheek, and then other splashes variously scattered over her face and neck. He subsequently asked the mother whether her daughter always blushed in this peculiar way, and was 56 FUNCTIONAL NERVOUS DISORDERS. answered, 'Yes; she takes after me.' Sir James Paget then perceived that by asking this question he had caused the mother to blush, and she exhibited the same peculiarity as her daughter." Many of these inordinate blushers are timid and melan- cholic, sometimes to a degree bordering upon a mild form of mental aberration. They seek solitude and are exces- sively sensitive about people they meet, who they may fancy are criticising their personal appearance. For this reason they are so shy that they dislike meeting friends or strangers in the street. Many of the victims of this dis- order, if relating an incident or anecdote, will often lose the thread of the story by their concern as to what their auditors may be thinking of them. The best cure for this condition of excessive self-con- sciousness is a constant and free intermingling with others in the work of life. Solitude is a great factor in the pro- duction of self-consciousness. Poverty and worriment are also elements in the causation of excessive shyness. The preventive treatment of this condition should be begun in childhood, by sending the children to large public schools where they will be allowed a considerable amount of freedom from restraint and come in contact with a coarser and rougher element. This will tend to make them bolder and more self-reliant. Children who seem to be afflicted with shyness and inherit a morbidly sensitive nervous disposition, should at a very early age be instructed in elocution and encouraged, or in fact compelled, to fre- quently give recitations before their classmates. It is also well to have them taught music and singing, the exhi- bition of which accomplishments before friends or class- mates will materially tend to remove the predisposition to shyness when present. It is said that many coquettes have VASCULAR KEFLEX NEUROSES. 57 the power of voluntary blushing. This is likely to be true in some instances, as the smaller blood-vessels of the face may probably be influenced through the nervous system to a certain extent. Blushing often depends on certain emo- tional influences. When these influences are but slight the blushing may be extremely evanescent; when the emotional changes are very marked the blushing may be very intense. Blushing is the external manifestation of the internal emotional perturbation, and its extent is gen- erally in proportion thereto. Some women, instead of blushing when suffering these distressing emotional dis- turbances, become absolutely pale. The blush may be preceded by very little disturbance, or it may be ush- ered in by a warm glow over the whole body. In severe cases the mental confusion is very marked, the heart throbs violently, there is a sensation of suffocation, and the breath becomes short. There is a peculiar sensation at the epi- gastrium, often followed by the condition of globus hys- tericus or constriction of the throat. Palpitation of the heart is a very common condition immediately preceding the act of blushing. Many blush- ers experience a feeling of dread as part of the emotional state. The dread, breathlessness, speechlessness, and glo- bus hystericus are all depressing emotions, and are often accompaniments, in a greater or less degree, of the actual blush. When the blushing is of a severe type there is always mental confusion present. In a large number of cases the individual completely loses the power of thought for the time being. The mind is completely paralyzed, and, in popular language, she is "covered with confusion," or, in slang parlance, "rattled." There is an instinctive desire for self -concealment. The blusher either averts the head 58 FUNCTIONAL NERVOUS DISORDERS. or looks downward. The expression, " I wished I could have sunk through the floor," which we have heard used, aptly expresses the mental condition of the patient at this time. The overworked cultured classes have, as a rule, more self -consciousness than the uneducated, but they have more power to restrain its manifestations. They very rarely meet your gaze directly, and while conversing habitually look at some adjacent object, merely bestowing occasional side glances on the person with whom they are conversing. It is almost impossible to compel any of the lower animals to look one in the face and eyes even for a very short space of time. Especially is this the case with the dog, whose head you cannot possibly hold still for a few seconds while looking into his eyes. In some cases of very violent blushing the face becomes bathed in perspiration. In some women it is so severe that it is followed by a well-marked rash which not only covers the face, chest, and neck, but may extend to the hands. The blush is often followed by pallor of the face ; this is due to constriction of the blood-vessels — a reaction following their dilatation. Morbid blushing occurs most frequently in women exhausted by anxiety, the eating of improperly cooked foods, bad air, and overwork. The blood of these patients is usually anaemic. When a person has once suffered from this disorder he is liable to have subsequent attacks, as the nervous system is highly im- pressionable, and the condition once well developed is apt to be perpetuated by slight influences, such as dis- ordered digestion. Irritations arising in the digestive organs are probably the chief causes of the nervous depression which accom- panies these conditions. The impure blood resulting from the bad digestion produces most deleterious influences on VASCULAR REFLEX XEUROSES. 59 the nervous system, thus starting up a great variety of functional disturbances, of which morbid blushing is a good type. Many of these tendencies to weakness of the digestive and nervous system are inherited. An impor- tant factor, therefore, in the treatment of these conditions is the enrichment and purification of the blood by dietetic and hygienic means. As already stated, education is a great factor in the treatment of hereditary nervous weak- nesses, and this educational treatment should be begun at a very early age, when the first demonstrations of excessive shyness, which is part of the nervous weakness, are noticed. Otherwise it is liable to increase in severity until it be- comes an actual disease. Skilful care and treatment will do much toward remov- ing this condition of weakness. Habits of solitude and self -communing should be discouraged and the child should be forced to mingle freely with other children, which has a very wholesome influence and tends greatly to the modifica- tion of any peculiarities of disposition. In the adult the treatment is more difficult. Everything which contributes to elevate the tone of the nervous system should be adopted. Nothing is more important in these cases than the im- provement of the general nutrition. These neurotics, without exception, suffer from anaemia. Therefore the diet and regimen require special supervision. Rest, mental and physical, with proper hygienic surroundings and forced scientific feeding, will probably cure the majority of cases. In some of the severer types massage, tonic baths, and electricity are indicated. Many of these cases begin with dyspepsia, resulting often from post-nasal catarrh. The social instincts should be cultivated and every possible effort made to enjoy life. In this state the nervous centres are exhausted and must be built up 60 FUNCTIONAL NERVOUS DISORDERS. again by th-e enriched blood. Change of climate to a higher altitude is often useful in these cases as a stimulant to digestion and nutrition. It is in this way that advan- tage is derived from a trip to the Adirondack region or the Rangeley Lakes in Maine. Out-of-door exercise, as in the treatment of all functional nervous disorders, is of the greatest utility. It has a most favorable influence on the general health. Wind and sun, having a tanning influ- ence on the skin, which will render the blushing less re- markable, should be courted as much as possible when taking outdoor exercise. During attacks of blushing relief is often obtained by lying down ; they then gradually dis- appear under the influence of rest. An irrational method of living, by which there is no regularity in respect of food, exercise, and rest, is the cause of most of the weak- ness of the nervous system in these individuals. This is more particularly true among the poorer classes. The women, looking after the wants of the household, see that the other members of the family get food, but neglect to supply themselves in a proper manner ; they thus soon be- come victims of digestive disorders and drift into chronic invalidism. Fried meats, pastry and pickles, strong tea, coffee, and wines, are all agents in retarding the digestion and impoverishing the blood. Morbid blushing is often caused by bad digestion. The irritative action of wines or other alcoholic drinks on the mucous membrane of the stomach reflexly causes flushing of the face. Cold bathing is preventive and also exercises a curative influence on this state; but as in many cases the cold bath is injurious and cannot be tolerated, the patient should be gradually trained to resist its depressing influence. The bath should be first given tepid and the temperature grad- ually lowered in each succeeding bath. The immersion \ MCGillicuddy.-Plare I \ h. o Q < O CO CO CO CO CO < q: < Q_ C£ o o o CO § VASCULAR REFLEX NEUROSES. 61 should be of very short duration, and should be imme- diately followed by vigorous friction with a coarse towel or a flesh-brush or bath-glove, and finally the application of the warm bare hand until the entire surface of the body glows. Hot baths are often ver} 7 beneficial to ner- vous patients and are best taken before retiring. Electricity is of considerable advantage in these cases of nervousness ; mild galvanism should be applied daily for a short time only. If the face is heated and reddened by sitting in close proximity to the fire or by bathing it in very hot water, it will give immunity from blushing for a very considerable time. Many drugs are of great advantage in this disorder, notably iron, quinine, camphor, and turpentine. Stimu- lants are very disadvantageous and should be avoided as much a possible. Vasomotor Disorder. Abdominal Flushing. — Mrs. A. E. (see plate), 40 years of age; seven years married, but never pregnant. She has been ailing ever since her mar- riage. Before this she worked hard at monthly nursing. For several years past she has suffered from constant pain in the lumbar region posteriorly. Frequently suffers from severe pain and a sensation of burning in the vertex, neces- sitating the use of local applications for relief. Feels con- stantly fatigued and is compelled to lie down frequently. Has " no ambition or appetite. " For years past she has not taken any breakfast, with the exception of three or four cups of strong coffee. During menstruation nothing is retained on the stomach except the coffee. Now menstru- ates every two weeks, and during these periods the ab- domen becomes swelled and assumes a dark or bluish-red color and feels very hard; at the same time the lower extremities are " just like death, cold and clammy." There is also severe abdominal pain and the face is exceptionally 62 FUNCTIONAL NERVOUS DISORDERS. red and hot. She feels feverish and thirsty, and has " fever sores" about the nose and mouth. There is also inconti- nence of urine, and the urine is scanty by day but excessive by night. During menstruation the bowels do not move, even after enemata. The tongue is coated with a whitish- brown fur. During her menses she is compelled to remain in bed, and during her last period was delirious and tore her hair out in handfuls. Vasomotor paresis of the lower extremities sometimes takes place in the nervous and hysterical, in which the legs become extremely hard and engorged almost to burst- ing. This also occurs at times in the hands or face. In speaking of a case of this type where the abdomen was the seat of the disorder, Dr. Weir Mitchell says : " The last case of hysterical vasomotor manifestations which I shall quote was so amazing that if I had not had the good for- tune to see it over and over, and to show it once to my friend Dr. William V. Keating, I might reasonably have hesitated to tax the credulity of my hearers. " Some twenty years ago I attended a young married woman whose life was embittered by losses of property and by the ill treatment of her husband, who finally deserted her. For a long period she exhibited, at times, hysteric disorders in the form of spasms, rigors, hemipalsies, and at last, for a month or two, moderate maniacal excitement. With favoring circumstances she at last got well, and re- moving to the West was lost sight of until about ten years ago, when I was called to see her at a hotel in Philadel- phia. At this time my patient was 35 years old, was irregular as to her monthly flow, and had, as I found, a womb tilted forward but not diseased, and no ovarian tenderness, or, at least, no tenderness of belly which was not the same everywhere. She was rather pale and very thin, and had a relaxed pendent abdomen marked by the scars of four pregnancies. I could find no disease of heart, VASCULAR KEFLEX NEUROSES. 63 lungs, or kidney. She gave me this brief history : After some years of ease and comfort she had been led to risk her property in a wild speculation which ruined her, and now she was keeping a boarding-house in New York and was doing well, or likely to do well, except for the strange malady for which she came to consult me. After her new misfortunes she had some hysterical troubles, but these ceased to annoy her, and she began to observe that at or about the time of her menstrual flow, and afterward at any time, she was liable to have an enlargement of the belly, which did not seem to her to be due to wind, as with that form of swelling her previous experience had made her but too fully acquainted. The trouble became by degrees worse, and at last was so extreme as to cause certain un- pleasant feelings and to subject her to suspicions of being pregnant. " The swelling was certainly caused at times by emotion. It began at any time, rarely at night. Within a few hours the belly, in place of being flaccid and pendent, was swollen enormously. She looked, in fact, as a woman, thin as she was, would have looked at the eighth month of pregnancy. Other attacks were less severe, but alwa}'S they lasted for some hours before she could stand up, and it was usually a week before she was well. "When I saw her an attack was at its worst. The woman's pulse was about 165 and was a mere thread, at times imperceptible. Her face and limbs were white and cold. The abdomen was tense and red and could be felt to throb distinctly, while all over it the vessels, veins, and arteries were visibly enlarged. On listening over the belly I could hear a humming noise, a slight thrill. The chest itself was not quite so pale as the neck or face, but the breath was difficult and rapid. It was clear that, owing to palsy of all the abdominal vessels, all the avail- able blood of the body of a too bloodless woman was for a time in this cavity and its walls. If while in this state she sat up she instantly fainted, and it was difficult even to lift her head because of the symptoms thus caused. She 64 FUNCTIONAL NERVOUS DISORDERS. herself complained of the tension of the belly and of the distressing pulsation within it. " The day after, the abdomen was certainly a third less, and it was then seen by Dr. Keating, who, like myself, could give no other explanation of the. condition seen than the one I have just mentioned. After a week the belly became nearly as flat as usual and I then ceased to see my patient. I learned from her some years later that by slow degrees she had become well of this singular malady." A former United States Senator from Rhode Island was noted as exhibiting a peculiar phase of morbid blushing during his forensic efforts : his face seemed to be divided into thirds ; the centre of the face from forehead to chin would become extremely red, while his ears and the sides of his cheeks would exhibit the opposite condition of ex- treme pallor. Morbid Flushing — Vasomotor Disorder after Hemi- plegia — Diabetes — Dietetic Treatment — Becovery. — Mrs. K. (see plate, Fig. 6), 68 years of age. About twelve years ago she had an attack of hemiplegia on the right side. She can see but very little with the right eye. Whenever she takes a small quantity of tea it sends the blood to one side of the face, accompanied by a tingling sensation; coffee has no such effect. This also occurs when she is excited and when busily engaged in mental work. This she has learned to look upon as a warning to desist from excitement or mental strain. She is often kept awake at night from nervousness excited by the burning and tin- gling. The patient is very stout and suffers from the fat form of diabetes. Under dietetic treatment, both liquid and solid, the sugar has disappeared from her urine and she is now in fair health. Functional Vasomotor Disorder — Unilateral Flush- ing. — M. F. (see plate, Fig. 4) , aged 20, single. Seen Janu- ary 1st, 1892. Strong, tall blonde. Unilateral flushing of right side of face. It came on first three months ago, M?GiUicuddy.-Plahe II Fig.l / Fig. 2 fw^^ ( J 1 Fig. 3 Fie. 4 Fi^-5 ,#:!* ■m *#■ Fig- 6 CASES OF MORBID BLUSHING. VASCULAR REFLEX NEUROSES. 65 eight days before menstrual period, and was coincident with an attack of leucorrhoea. Has also occurred from three to eight days before menstrual period. Her face is pale at first, but gradually gets red until most of right side is extremely so, the left side remaining pale. The redness disappears as the menstrual flow comes on. Nervous Unilateral Flushings and Indigestion. — Mrs. A. Z. (see plate, Fig. 5), 27 years of age, has had two children. She is extremely nervous, especially after a hearty meal. When digestion is slow, as it usually is, it is generally accompanied by palpitation of the heart. She had malaria when in the country five years ago. She was well up to that time. Her indigestion is accompanied by flatulence and eructations, but these are not very severe. Two weeks ago she was seized with a very severe head- ache. This was similar to those she had had at every menstrual period for the past five years. Occasionally a period is not accompanied by this headache, but if so the headache is much worse at the next period. They are migrainous in character and are generally located in the right temple. At times she suffers from severe gastralgia, which is most noticeable when a storm is approaching. For the past two weeks the scalp has been exquisitely tender and the hair has come out freely in combing it. At present her headaches are mostly occipital. She is frequently troubled with unilateral flushings of the face (left side), accompanied by dizziness and vertigo. The vasomotor neuroses are such complex phenomena that a correct appreciation of the vasomotor nerves and their physiological action, as well as the anatomy and physiology of the arteries with which they are connected, is essential to their proper understanding. Dr. Charles N. Smith, in an article on " Vasomotor Neu- roses of Pelvic Origin" in the American Journal of Obstetrics, November, 1890, says that "arteries over one one-hundredth of an inch in diameter have walls com- 66 FUNCTIONAL NERVOUS DISORDERS. posed of an internal, middle, and external coat. The in- ternal coat is of the same structure throughout the whole arterial system, irrespective of the size of the vessel. It is thin, elastic, and identical in structure with the endocar- dium. The external coat, of white, inelastic fibrous tissue, varies but little in structure in the three sizes of arteries. The structure of the middle coat, however, is found to vary considerably with the size of the vessel. In the arteries of largest size the middle coat is formed almost exclusively of yellow elastic tissue, with but few muscular fibres. This middle coat gives to these largest vessels great elas- ticity; but, owing to the absence of muscular fibres, they possess little or no contractility. In the medium-sized arteries the yellow elastic tissue gradually disappears, its place being taken by muscular fibre. In the arteries of smallest size no yellow elastic tissue whatever is found, it having been entirely replaced by muscular fibre. In arteries less than one one-hundredth of an inch in diameter the inelastic external coat disappears, leaving but two coats in the vessel wall — the internal, and an external formed entirely of muscular tissue. " It will be seen, then, that the principal difference between the three sizes of arteries lies in the middle coat, and that, while the largest arteries have practically no muscular fibres, these fibres increase in number as the arteries diminish in size, until they alone form the whole of this coat. This muscular tissue is of the unstriped or involuntary variety, arranged in circular fibres surround- ing the vessel, with a few fibres arranged in a longitudinal manner. The presence of these circular muscular fibres gives to the arteries of medium and smallest size great contractility — a power not possessed by the largest- sized arteries. By relaxation of these fibres the arteries are VASCULAE REFLEX NEUROSES. 67 dilated to their widest extent, allowing a correspondingly- increased amount of blood to pass through them. By con- traction of the fibres the lumen of the arteries can be so narrowed that but a limited amount of blood can circulate through them. " The contraction and dilatation of these muscular fibres are regulated by nerve ganglia and fibres known as the vasomotor ganglia and nerves. In the arteries of largest size, there being no muscular tissue, we find no nerve fibres distributed to their walls, although the nerves follow them in their course. The arteries of medium and smallest size, however, receive an abundant nervous supply, the nerves passing to the circular muscular fibres. " The vasomotor fibres and ganglia in the arterial walls receive their stimulation through non-medullated nerve fibres coming to them from the sympathetic nervous gan- glia. Phj'siological experiments have proven that these fibres are not derived from the sympathetic ganglia, but are communicating fibres from the cerebro-spinal system. These fibres are of two kinds, each capable of conveying a distinct impulse. One conveys a motor impulse to the vasomotor ganglia, resulting in a contraction of the arterial walls, while the other conveys an impulse which inhibits the action of the vasomotor ganglia and allows the arterial walls to relax. The former are known as the vaso-con- strictor, and the latter as the vaso-dilator, nerves. " Under normal conditions the vasomotor nerves maintain the arteries in a condition of partial contraction or tone. They regulate the amount of blood to a part by causing a contraction or dilatation of the vessels, according as the part requires a diminished or an increased amount of blood. In this action the vaso-dilator nerves are the most active. " The centre presiding over these nerves is in the medulla, 68 FUNCTIONAL NERVOUS DISORDERS. in the floor of the fourth ventricle. This centre, in turn, receives stimulating and inhibitory impulses from the cortex. The medullary centre is reinforced by centres situated in the spinal cord and in the sympathetic ganglia. " Contraction of the arterial walls can result from but one cause, that being a motor impulse sent to the vasomotor ganglia over a vaso-constrictor nerve. Dilatation of an artery, however, can result from two causes, namely, a failure on the part of a vaso-constrictor nerve to convey its normal impulse, allowing the artery to become dilated by blood pressure, or from a vaso-dilator impulse inhibiting the action of the vasomotor ganglia, while the vaso-con- strictor impulse is present but rendered inoperative. Vaso-constrictor impulses are constant, while vaso-dilator impulses are intermittent. " In addition to these centrifugal constrictor and dilator fibres, which emerge from the spinal cord by the anterior or motor nerve roots, there are other fibres, entering the cord by the posterior roots, which convey centripetal in- fluences to the spinal vasomotor centres. The sensory im- pulses so carried to the centres provoke reflex motor action resulting in either contraction or dilatation of the arteries at the periphery. Sensory impulses, resulting in reflex motor action, may also reach the vasomotor reflex centres through the sensory nerves of the cerebro-spinal system. "In vasomotor neuroses either one of two conditions may occur. There may be a spasm of the arteries, owing to an excessive vaso-constrictor impulse, and resulting in a greater or less diminution in the blood supply to the part supplied by the constricted arteries; or there may be a relaxation of the vessels, allowing an increased blood supply to the parts. This arterial dilatation may be active or passive. In active dilatation the vaso-constrictor nerve VASCULAR REFLEX NEUROSES. 69 still conducts its normal stimulus to the vasomotor ganglia, but its effect on the ganglia is overbalanced by the inhibi- tory action of the vaso-dilator nerve. In passive dilatation the vaso-constrictor nerve fails to convey its stimulus to the ganglia, either from disease of the centres or of the nerve itself, which allows the arteries to be dilated by blood pressure. This last condition is one of vaso-constrictor paralysis. In addition to these two conditions of spasm and of relaxation, there may be an alternation of excessive constrictor and dilator influences, resulting at one time in spasm and diminished blood flow, and at another in dila- tation and excessive blood flow. " Prolonged spasm of the arteries gives rise to marked local symptoms and is soon followed by decided nutritive changes. The parts supplied by the contracted arteries are pale, cold, and numb. The skin is shrunken and wrinkled. Slight tingling sensations are felt. Anaesthe- sia may be present to a greater or less extent. Gradually the nutrition of the part becomes defective, and atrophy with impairment of function follows. Nutrition may suf- fer to so great an extent as to produce ulceration or gan- grene. " The effects produced by prolonged dilatation can be di- vided into primary and secondary. The primary effects are a red or mottled appearance of the skin, associated with increased temperature, both subjective and objective, increased secretion by the part, slight hyperesthesia, and rapid increase in nutritive changes. These primary con- ditions are later followed by secondary changes, owing to the sluggish circulation through the widely dilated vessels. The hot, red surface becomes cold, blue, cedematous, and clammy, although the subjective heat remains. Nutrition suffers and function becomes impaired. In the mixed or 70 FUNCTIONAL NERVOUS DISORDERS. alternating form, heat and cold follow one another in rapid succession. The part is alternately flushed and pallid, and at times bathed in profuse perspiration. " Turning our attention to the pelvic organs, it is seen that the uterus, tubes, and ovaries are richly supplied with nerves, both from the sympathetic and cerebro-spinal sys- tems, while important nerve trunks and plexuses ramify freely in the cellular tissue surrounding them. When we consider the injuries and diseases to which these important organs and the surrounding tissues are subject, we can scarcely fail to realize how seriously they must at times involve the nerves here distributed. As is well known, injury to, or irritation of, the pelvic nerve trunks and fila- ments is often followed by reflex disturbances in distant parts of the body. Irritation of pelvic nerves carrying im- pulses to the vasomotor centres is followed by vasomotor disturbances, not only in the pelvis, but also in distant parts as well." Dr. Smith relates the following cases which demonstrate how active the injuries and diseases of the female pelvic organs are in causing reflex vasomotor neuroses. "Case I. — Mrs. A., married, age 28, consulted me in 1888. Previous to the birth of her first and only child, in 1883, her health had been of the best. Labor was tedious and terminated by forceps. Two weeks after confinement she was attacked by pelvic peritonitis, confining her to bed for six weeks and to the house about three months. Grad- ually strength and health returned, and her usual light household duties were resumed, although she was never free from leucorrhoea, backache, and slight intermittent pelvic pain. About one year after confinement her right arm began to show signs of increasing weakness. There was a subjective feeling of coldness in the arm -and band, and on exposure to cold this feeling was so intensified as VASCULAR REFLEX NEUROSES. 71 to become exceedingly painful. Numbness and tingling sensations were often present. Gradually tbese symptoms grew more intense, until the arm became nearly useless. For two years she was treated for muscular rheumatism, but of course with no benefit. At the time of her first visit to me the arm was pale and cold and the skin shrunken. Measurements over the middle of the biceps showed the arm to be one and one-fourth inches less in cir- cumference than the left. Weakness was so marked that it was impossible to raise the arm to the head and retain it there long enough to do up the hair. Not even a light weight, as a glass of water, could be safely carried in the right hand. The arm was habitually carried flexed at the elbow and drawn across the body, as if in a sling. Severe attacks of numbness were frequent. Repeated careful trials failed to detect even the slightest pulsation in the radial artery at the wrist. After my failures to find radial pulsation the patient informed me that within the past year two other physicians had also failed to find pulsation. Pulse in left radial strong and natural. Patient is positive that she formerly had pulsation in right radial. " Examination of the pelvic organs disclosed a bilateral laceration of cervix extending high up to cervico-vaginal junction. A large amount of cicatricial material was present. The cervix was slightly eroded. A slight chronic general endometrits was present. " Recognizing the case to be one of vasomotor neurosis of the spasmodic variety, and believing that it was of reflex origin from pelvic disease, I advised immediate treatment for the endometritis, to be followed, as soon as practicable, by repair of the lacerated cervix. This was readily con- sented to, and as soon as the endometritis was sufficiently relieved I successfully repaired the cervix. Within two months after the operation the arm began to show signs of improvement, and within six months a fairly strong pulse was discernible in the radial. The coldness, pallor, and numbness disappeared, strength fully returned, and to- day, two years after operation, the right arm has as great 72 FUNCTIONAL NERVOUS DISORDERS. a circumference at all points as the left. No difference can be detected in the strength of the pulse in the two arms. " Case II.— Mrs. B., age 40, consulted me in 1887 for the relief of growing weakness in both legs, associated with numbness, tingling sensations, coldness, and pallor of the surface. The sensation of coldness was extremely annoy- ing, obliging her to sit with feet and legs near the fire nearly all of the time, even in warm weather. The legs were so weak that she required assistance in ascending or descending a flight of stairs, and could not, on a level sur- face, walk a greater distance than two short blocks. These troubles had been present for about two years, and had gradually increased in severity. She has been confined four times, the last being a miscarriage, at the sixth month, in 1882. Examination showed a single deep laceration of the posterior lip of the cervix, with the formation of con- siderable cicatricial tissue. Firm pressure in angle of laceration caused slight pain and tingling in legs. A slight cervical endometritis and erosion were present. Diagnosis : Vasomotor neurosis, spasmodic variety, of re- flex uterine origin. The endometritis was relieved by treatment, and the laceration then closed by operation. " No marked change in the condition of the legs was apparent for nearly six months, when improvement com- menced and progressed gradually to complete relief of con- strictor symptoms in legs within eighteen months after operation. The legs are now strong, enabling her to per- form her usual household duties, to ascend and descend stairs unaided, and to walk long distances without especial fatigue. "Case III. — Mrs. C, age 30, confined but once, that in 1883, consulted me in 1888. She was suffering from chronic catarrhal salpingitis and chronic general endome- tritis. The symptoms of salpingitis and endometritis dated back about three years. For the past six months she had been greatly annoyed by rapid alternation of hot and cold sensations extending over the whole body, but especially VASCULAR REFLEX NEUROSES. 73 marked on the abdomen, head, and shoulders. During the hot flushes the skin became intensely congested and was bathed in profuse perspiration. This condition was soon followed by coldness and pallor of the same parts. These conditions were identical with those often observed at the menopause. Menstruation, however, was regular, and is so still. " This was plainly a case of vasomotor neurosis of the mixed or alternating variety. That it was of pelvic origin is clearly proven by the fact that as the salpingitis and en- dometritis improved under treatment the vasomotor symp- toms disappeared. She has now been entirely free from these vascular disturbances for about one year." " The striking similarity between the neurosal symptoms presented in the last case and those observed at the meno- pause, naturally leads one to consider whether or not the climacteric hot flushes and their attendant conditions are not results of a vasomotor neurosis. I am very decidedly of the belief, and in that belief I hold but that of many others, that the hot flushes, the sudden alternations of heat and cold, of blush and pallor, and the local and general sweatings, occurring at the menopause, are the results of a vasomotor neurosis of the mixed or alternating variety, and generally of pelvic origin. That these disturbances are of the vascular system needs no demonstration. That they are of pelvic origin is shown by the report of Case III., where the relief of the pelvic trouble was followed by disappearance of vascular symptoms identical with those occurring at the menopause. Further, following artificial production of the menopause by removal of the tubes and ovaries, we frequently see the same vascular disturbances as occurred in Case III. and as occur at the menopause. In these cases of operation the forced cessation of function of the pelvic organs, and the changes which take place in 74 FUNCTIONAL NERVOUS DISORDERS. the structures remaining after operation, are sufficient to produce the neurosis. " At the menopause the generative organs undergo con- siderable change of an atrophic nature, and their function is abolished. The changes in the organs are surely suffi- cient to set up reflex nervous derangements resulting in vascular disturbance. Of course it is within the realm of possibilities for these vascular disturbances to be of a ner- vous origin, independent of the changes in the pelvic organs; but, in my opinion, such an origin is rare as compared with the frequency of a pelvic origin. " That the vasomotor neuroses of the menopause may be aggravated or caused by pre-existing pelvic disease is un- doubtedly true. It is equally true that, as severe neu- roses occur at this time in women whose pelvic organs are not only healthy but have been all through life, they show that the climacteric changes are in themselves sufficient to produce these peculiar disturbances. I have made re- peated local examinations in a number of such cases, and failed to find any abnormal conditions of the pelvic viscera. It is possible that in some of these cases the vascular dis- turbances were occasioned by disease or derangements out- side of the pelvis. Careful questioning and examination of the patients, however, failed to show such disease or derangement in other parts of the body. The fact that these vasomotor disturbances subside after the climacteric changes are complete, argues very strongly in favor of a pelvic origin." On the other hand, however, there may be cases of vaso- motor neuroses of the menopause which are not directly of pelvic origin, but owe their existence to the unbalanced condition of the nervous system. W. J. Conklin, M.D., in a paper on "Some Neuroses of the Menopause," read VASCULAR KEFLEX NEUROSES. 75 before the American Association of Obstetricians and Gynaecologists in 1889, says: "The cases are not few in which the neurotic affections exist independently of all complicating disorders of the sexual or other organs of the body, the peculiar nervous instability of the menopause being alone responsible for the symptoms. Perhaps it may not be amiss, in an. association where every disease is. viewed through gynaecological spectacles, to suggest that in some cases the pelvic symptoms themselves are caused by, not the cause of, the nervous disorders. The vicious circle begins in the nerve centres, not in the pelvic viscera. To ignore this fact and consider the latter alone is to wholly misinterpret the neurosis." The Pulse. In nervous and hysterical women the pulse is something which especially claims our attention. In very many we find it rapid — an increase of from twenty to forty beats above the normal, even in cases where the patient is not exercising. At the New York Mother Home Maternity Hospital, I have noted at a single visit that one patient would have a pulse of 52 to the minute, and in the patient beside her the pulse would range from 100 to 120. In neither of these patients would there be any form of pathological disturb- ance, except some slight perturbation of the nervous system resulting from the strain of the labor. Miss E. B., ;et. 20, has just recovered from a severe attack of chlorosis by the use of pil. Blaud cum gentian. Since early childhood has been subject to fainting spells ; would tumble over in the middle of a meal, and after being sprinkled with cold water would get up and finish it with good appetite. Lately it has been noticed that during the 76 FUNCTIONAL NERVOUS DISORDERS. fainting attacks, which are always preceded by dizziness and an intensely sick stomach, there is, at times, redness (amounting to a bright flush) of the face, while in other attacks there is marked pallor. The extremities are " cold as ice." The attacks are always preceded by heart palpi- tation ; heart sounds are normal ; digestion is weak. Whenever chicken salad is taken, a fainting attack is cer- tain to come on after a short time. Vasal Weakness in the Left Side. — Mrs. M. J. P., set. 32, weight 224 pounds, of medium height. Has been ail- ing for seven or eight years, but has been worse for a year past. Has no appetite. Distress after meals. Feels com- fortable only when her stomach is empty ; has " blue fits" and crying spells; sleepless nights or horrid dreams; suf- fers with numbness of the left side, and the left leg, from the calf down, is swollen and extremely puffy. She often wakes up in the middle of the night with a sensation of great weight and numbness in the left arm, and frequent- ly feels with the right hand to see if the left hand is there (night palsy, nocturnal hemiplegia) . Has a great deal of pain in the left side on walking; great flatulence of ner- vous origin after eating. This disturbance of the left side I have noted in several cases to be more common than on the right. It seems to be due to interference of the ganglia of the sympathetic of the left side, and also to the presence of the heart on that side, as decidedly a great deal of the stomach trouble occurs at the greater curvature ; this is the seat in almost all cases of the greatest amount of pain. Some patients also com- plain of pain over the region of the pylorus. In Mrs. P. 's case any surprise or shock, such as disagreeable news or sudden loud noise, would instantly cause an attack of purg- ing and vomiting, and this would even follow trivial things that would be unnoticed by a person in a fair condition of physical health. VASCULAR REFLEX NEUROSES. 77 At the time she came under my notice she had been vomiting blood regularly for three months (vicarious men- struation) . She became very enthusiastic over the treat- ment, and said that from the first she began to improve, and after a few visits called herself well. The treatment consisted of the usual restriction of diet and tonic regimen. Vasal Weakness and CEdema Preceding Each Men- strual Period. — Miss M. S., set. 20, rather active temper- ament but not strong ; has the appearance of the scrof- ulous diathesis. Three or four months ago, one morning preceding her menstruation, the left hand was ice-cold, felt very heavy, and the whole arm ached. The next two mornings the same annoying condition returned. In the evening, usually about two days before the menses appear, the left foot and leg become much swollen, accompanied by warmth and a burning sensation. This remains until the menses appear; her face also swells at the same time so much as to be very noticeable. I have seen her face much distorted on these occasions by oedema around the eyes and at the base of the nose. This is a condition of vasal weakness or temporary functional vasal paresis, and is not very uncommon. Menses regular, last two days and a half ; extremely painful. She feels so exhausted as to imagine that a stroke from a feather would annihilate her. Angeio-neurotic oedema is one of the rare vasomotor neuroses. In this disorder some disturbance of the vaso- motor system is the principal factor in its causation, but the cerebro-spinal system is also implicated. It has been said that the cedematous swelling is due to paralysis of the sympathetic, but this alone is not sufficient for the swelling of the parts. There must be also present an active irrita- tion of some kind. In addition to this the lymphatics, veins, and arterioles are concerned in its production. It '78 FUNCTIONAL NERVOUS DISORDERS. is usually supposed to be a non -inflammatory affection lo- cated in the connective tissue beneath the skin or mucous membrane. The cedematous swelling is often quite pale, while in other cases it is of a dark-red color. It does not readily pit on pressure and is usually without pain. It generally comes on rather suddenly with some sensation of tension in the part ; its duration is indefinite, lasting from a few hours to several days or even weeks. Dr. Joseph Collins, in his extensive study of the disease, says that, as a rule, it does not show itself in more than two or three localities at a single visit, and commonly only in one. Sometimes its disappearance in one part is followed by its appearance in another at a considerable distance. It may appear upon the extremities, face, or abdomen; less frequently upon the larynx, genitals, and stomach. It may occur in these situations more often than is generally believed, on account of the difficulty of diagnosis. Its occurrence in any part predisposes to its return in the same situation. It is not so well understood, on account of its rarity, as are some of the more common cedemas, e.g., the so-called menstrual cedemas. The larynx would seem to be a favorite spot for its development, on account of its being so much exposed to the influence of a cold or a vitiated atmosphere. It is said to arise more commonly in parts which have been the seat of an injury or of an inflamma- tion such as erysipelas. It may be produced by a sudden cooling of the body such as occurs in passing from a heated room into the cold air without being sufficiently protected by extra clothing. This was noted in one of my cases, that of a gentleman who left a heated ball-room and rode a considerable distance in a cold horse-car with the extra protection of only a light spring overcoat. The attack in this case was limited to the larynx, and was of so severe a character that tracheotomy was required. In another VASCULAR EEFLEX NEUROSES. 79 of my cases the gastro-intestinal tract seemed to be the seat of the irritation, which caused the affection to mani- fest itself reflexly in the back of the hand. There was excessive mental and bodily exhaustion in both these pa- tients, and in all my cases there was mal-digestion. The disease in the larynx, has been often mistaken for a syphi- litic manifestation in cases in which the system was per- fectly free from that disease. This reflex dermatosis has been variously termed giant urticaria or urticaria tuberosa, periodic swelling, acute idiopathic oedema, acute non-inflammatory oedema, acute circumscribed oedema, Australian blight, and angeio-neu- rotic oedema. This disease is said by some to occur more frequently in males than females, although other authori- ties state that the proportion of the sexes attacked is the same. It is said to be more common in cold weather and in parts of the body most exposed to the cold — the hands, face, anct larynx. Cases have been reported as having originated from grief and anxiety. Starr mentions a case of this sort. Dr. Collins, after an extended and critical investigation of this subject in The American Journal of the Medical Sciences for December, 1892, arrives at the following con- clusions : " 1. That there exists a variety of oedema attended by such striking characteristics of its own that we are justi- fied in referring its origin to the nervous system. " 2. The seat of the manifestation of the lesion is prob- ably in those vessels and lymphatics which pass through the corium to the subdermal tissues. "3. It is probable that although the lesions or the irri- tants on which the disease is dependent may attack other parts of the system yet the result directly appears through the sympathetic system 80 FUNCTIONAL NERVOUS DISORDERS. "4. Evidence concerning the bearing of trophic influ- ences in the production of the disease cannot be produced, but when trophic changes do occur they are more plausibly attributed to the changes brought about by the oft recur- ring oedema, per se, than to influences exerted through the nervous system as true tropho-neuroses. "5. It is quite possible to believe that in the future its causation may be attributed and shown to be dependent upon products manufactured and ordinarily disposed of within the system, but which, acted on by sinister influ- ences either inherited or acquired, result in the temporary disturbance of the vasomotor system, which is manifested in various parts of the body, depending, as does the analogous condition of the distribution of blushing and flushing, upon structural peculiarities either central or peripheral, or upon inherent predilections. " 6. This condition has a close relationship to the many oedemas spoken of, and also a family relation with many of the arthropathies as yet not well understood, but known to be directly caused through the agency of the nervous system. "7. It must be admitted from clinical evidence that the affection in question has a family relation with other vaso- motor neuroses such as exophthalmic goitre and urticaria." It should be remembered that oedema may be produced artificially by the tying of a ligature tightly around the arm, wrist, or ankle. In a case of an hysterical woman who suffered from oedema of the hand every morning on rising, no cause co aid be detected by her physicians until it was discovered that she was in the habit of placing a tight ligature upon her wrist at night and removing it before their arrival in the morning. CHAPTER VI. PHARYNGEAL AND LARYNGEAL REFLEX NEUROSES. Pharyngitis and laryngitis of reflex origin are of quite frequent occurrence. They are often dependent upon stom- ach derangement. Diseased pelvic viscera are also com- monly recognized as the cause of their production. Irrita- tions of the end organs of the nerves, in either the digestive or reproductive organs, start up disturbances in the respi- ratory tract, through the intimate connection of the sym- pathetic nervous system and the vagus, which closely simulate disease of strictly local origin. I am quite convinced that the reflex origin of these dis- orders is but rarely recognized by many practitioners. This would seem to explain their extreme chronicity under long-continued local treatment of the throat. They yield promptly, however, to the treatment of the causative dis- order in the digestive or reproductive organs. The side of the throat or tonsil which is involved usually corre- sponds to the side of the abdominal or pelvic cavity where the disease is most intense. Less often the entire throat is affected. Many of these attacks precede the menstrual flow, and they are quite common in young girls. The symptoms usually complained of are soreness extending down the sides of the throat, and pain of an aching char- acter in the tonsils and pillars of the fauces. Sometimes the parts appear congested, at other times there are no local signs of disease. 6 81 82 FUNCTIONAL NERVOUS DISORDERS. Laryngeal neuroses frequently accompany menstrual disturbances, and stomach cough is a well-recognized pathological condition dependent upon chronic stomach disorder. It is of a spasmodic hacking character with no local manifestations in the larynx except a slight redness when the attacks are severe and frequent. Many of these coughs are dependent upon endometritis and dysmenor- rhcea. The most severe reflex cough I ever heard was in a young girl approaching puberty, and was wholly due to uterine disease. During the paroxysms, which were of a loud, dry, and barking character, the patient had to be held by two men to prevent her precipitating herself upon the floor. Laryngismus stridulus, a common affection in weakly children, is usually dependent upon gastric disorder. In this condition the alimentary mucous membrane should receive careful attention. Small doses of "gray powder" should first be administered, followed by large doses of strong tonics, such as citrate of iron and quinine. Great attention should be given to the diet and hygiene of the patient. Angeio-neurotic oedema is of reflex origin. It is usually dependent on digestive disorder, and a common location for it is the larynx. A common symptom complained of by patients suffer- ing from digestive disorder, is a peculiar sensation as if from the irritation of a hair lying upon one side of the phar}-nx. Others with gastric disorder have a similar sensation on the roof of the mouth. Chronic rhinitis and pharyngitis are reflex neuroses dependent upon imperfect digestion and excretion. The two are almost always present in the same patient. The PHARYNGEAL AND LARYNGEAL REFLEX NEUROSES. 83 treatment which is most efficacious is brisk purgation fol- lowed by a proper diet and regimen. In a "Note on Codeine," in the Lancet, Dr. James Braithwaite, of Leeds, says: "Codeine seems to have a special action upon the nerves of the larynx ; hence it re- lieves a tickling cough better than any ordinary form of opium. One-half of a grain may be given half an hour before bedtime. It was in my own case that I first began to use codeine. For more than twenty years, usually once every winter, I have been seized with a spasmodic cough just before going to sleep, which becomes so severe that I am compelled to get up and sit by the fire. After an hour or two I return to bed and am free from the cough till the next winter. In other respects I enjoj" good health. Many years ago I found that one-half grain of codeine, taken about two hours before bedtime, absolutely stops the attack and leaves no unpleasant effect the next morning. In cases of vomiting from almost any cause, one-quarter- grain doses of codeine usually answer exceedingly well. In the milder forms of diarrhoea one-half to one grain of the drug usually answers most satisfactorily, and there are no unpleasant after-effects." Dr. C. Henri Leonard, in a paper in the Journal of the American Medical Association, 1892, discusses the ques- tion of the female voice in sexual disease, and cites numer- ous cases in which uterine and ovarian disease have re- sulted in an impairment of the voice. In one case, from a high mezzo the range was reduced to a contralto, and in other cases the masculine tones were creeping in. At the time of menstruation it is claimed to be a common occurrence for singers to find changes in the purity of tone or range of voice. The reason for this is found in the intimate connection of the nerves supplying 84 FUNCTIONAL NERVOUS DISORDERS. the vocal organs (spinal accessory) and the uterus through the medium of the solar plexus. Taking into considera- tion the fact that from the lowest to the highest note the vocal cords vibrate from five hundred and seventy-two to sixteen hundred and six times a second in soprano singers, and that there are about a hundred muscles which must be brought into co-ordination to produce perfect phonation, it is not surprising that some slight reflex trouble will have the result of causing changes in the voice. In confirmation of his ideas Dr. Leonard cites the case of a patient of Dr. Severs, of Fort Wayne, who from reflex influences had not spoken above a whisper for two years. In this case cure resulted from treatment of a rectal trouble. The following case is another illustration : Miss S. L, aged 50, had hysterical spasm of the oesoph- agus, making it very difficult to swallow solid food. The passage of a bristle probang, which was allowed to remain in the throat for a short time, removed the spasm. CHAPTER VII. BRONCHIAL REFLEX NEUROSES. These usually take their origin in a manner similar to the foregoing, from lesions in the genitals, or in the diges- tive tract. Asthmatic attacks of great violence often de- pend upon nasal polypi or congestions of the mucous mem- brane of the posterior nares. Cases have been reported of nervous asthma dependent upon uterine retroflexion. Bronchial hystero-neuroses of pregnancy are of common occurrence. Bronchial and cardiac neuroses are often combined. Cheyne-Stokes' respiration has been noticed as a neurosis dependent upon pelvic disease. Lacerations of the cervix set up stomach symptoms by stimulation of the cceliac axis, and disordered action of the heart and difficult breath- ing rnay be caused by extension of the irritation along the pneumogastric. After the operation for lacerated cervix these usually disappear. Galvanism, by its action on the uterine nerves, sometimes permanently checks the dyspnoea and heart palpitation. The importance in these cases of carefully regulated diet and hygienic exercises cannot be overestimated. Hiccough may be termed a respiratory neurosis, as it consists of sudden contractions of the respiratory muscles, particularly the diaphragm. The starting-point of irrita- tion is usually in the digestive tract, although it may be in the uterus. Sometimes this is a very severe ailment, and 85 86 FUNCTIONAL NERVOUS DISORDERS. may produce death from loss of sleep and exhaustion. Among the occasional causes of hiccough are swallowing the saliva while smoking, or the taking of solid food im- mediately afterward. Renal and biliary calculi have been ascribed as causes of hiccough. It is quite common in patients who have been drinking alcoholic liquors to excess. Hiccough may be cured by holding the breath as long as possible, or by taking several sips of water without draw- ing a breath, which amounts to the same thing. If this should fail, a teaspoonful of ether in a little camphor water will often arrest it. This is, of course, when the hiccough is due to gastric disturbance. The cause of the disorder should always be ascertained and removed. Yawning is clearly a neurosis, but a trivial one. It is commonly dependent upon indigestion or pregnancy. It is generally supposed to be always due to drowsiness, and to result from a lessening of the nervous energy of the body. It might be deemed a very simple affair, but it is extremely common and rather interesting to the practi- tioner in that it seems to be communicable ; when in an assemblage one person is seen to yawn, others follow the action, or yawn at the same time. They seem to imitate each other involuntarily. Yawning is probably "catch- ing" upon the same principle that squint and stammering are, but it is not so disagreeable. It is quite possible that the unimpregnated uterus may be implicated in the pro- duction of yawning. Yawning from nervous exhaustion and fatigue is of centric origin; it is really a cerebro- spinal neurosis. Sneezing. — Sternutation is usually a trivial disorder, and is, in a manner, similar to hiccough. It is a convul- sive motion of the muscles of expiration resulting from BR0XCHIAE REFLEX NEUROSES. 87 nasal irritation, by which the air is driven with a loud and hissing sound through the nasal passages. It is often found present as a neurosis in whooping-cough and diges- tive disorders, and especially when intestinal parasites are present, more particularly thread worms w T hich irritate the rectum. Any rectal irritation, such as that resulting from hem- orrhoids, constipation, or pruritus, will cause reflexly not only sneezing but intense irritation, with swelling of the tip and alse of the nose. This is particularly noted in chil- dren, and is a well-known sign of the presence of worms. Severe attacks of sneezing sometimes result from disorders of menstruation. There are many patients with weakened digestive organs who have attacks of sneezing on the slightest exposure of the body to cold ; in these cases there is often set up a vasomotor paralysis of the nasal mucous membrane, with a very profuse watery secretion, often sufficient to thoroughly soak a handkerchief in a very short time. Treatment for these cases is usually of a tonic nature — Fowler's solution, quinine, strychnine, and iron, with a careful rearrangement of the diet, both liquid and solid. The act of sneezing can be stopped immedi- ately by pressure with the finger across the upper lip, thus shutting off the blood supply to the nose and reducing the congestion of the mucous membrane. Bronchial Hystero- Neurosis of Pregnancy. — Mrs. S., aged 37, very stout and flabb}'. Third pregnancy. Is troubled with a severe cough coming on at conception, lasting through the whole of pregnancy and disappearing after delivery. This has occurred in three successive preg- nancies. At other times she is entirely free from bronchial irritation. 88 FUNCTIONAL NERVOUS DISORDERS. The increased activity and growth of the uterus during pregnancy whenever any pathological conditions are pres- ent, are responsible for the frequent occurrence of neuroses, and these are looked upon not only by the laity but by the profession as evidences of impregnation. CHAPTER VIII. GASTRIC REFLEX NEUROSES. These are exceedingly common. All the symptoms of indigestion may depend upon morbid changes in other organs, and disappear when the causative disorder is re- moved by local treatment. Many cases of apparent gas- tritis depend upon morbid changes in the reproductive organs. The most common of these neuroses is the well- known nausea and vomiting of pregnancy, which is some- times so severe as to cause death. Among the less important neuroses of the stomach is the tympanitic distention, the belching and vomiting, which accompany menstrual congestion. Faintness, boulimia, and anorexia are frequently the result of uterine and ovarian congestion. It is said that the vomiting of pregnancy is simply a physiological neurosis, but I am convinced that the physiological changes which take place in the uterus daring pregnancy would not cause this reflex disturbance if the uterus and its adnexse were perfectly healthy, which among civilized women is rarely the] case. I have noticed that among women who have apparently healthy reproductive organs the vomiting in the early months of pregnancy is but slight and of trivial import- ance. Many cases of chronic gastric catarrh are asso- ciated with endometritis, but whether it is a reflex neuro- sis or not is doubtful; at any rate, the irritation set up by the endometritis would not be beneficial to the gastric 89 90 FUNCTIONAL NERVOUS DISORDERS. secretions. In cases where the endometritis has been re- lieved by curetting and other local treatment, the stomach symptoms have disappeared. In studying the gastro-hystero-neuroses we must give due attention to the function of the portal circulation and remember the morbid changes which take place from obstructions to its normal flow. In these cases stomachic remedies like pepsin, nux vomica, and bismuth are of no value in removing the distressing stomach symptoms until the pelvic disorder is relieved by appropriate treatment. Small fibroids and polypi of the endometrium are also pro- ductive of symptoms which simulate chronic gastric dis- ease. Induration of the cervix and stenosis of the cervical canal start up vomiting and many other forms of ner- vous disturbance, such as hysterical trismus, globus hyster- icus, and even catalepsy. Gaseous distention of the stomach coming on as a neurosis of the menstrual period may be so severe as to be accompanied by vomiting and pain. A very large proportion of all gynecological patients suffer from this neurosis. It usually comes on for a few days before the menstrual flow, and is sympto- matic of the uterine congestion which precedes the flow. Many of these cases are treated as attacks of indigestion, or as a mild form of gastritis. The epigastric region is usually tense, tympanitic, and sensitive to pressure. There is more or less backache, and with the dysmenor- rhcea there are usually cramps, pain in the stomach, and congestive headache. In some cases the epigastric swelling may be very marked and extremely painful. This usually occurs when there is sudden suppression of menstruation from exposure to cold or getting the feet wet. These gas- tro-hystero-neuroses are dependent upon pathological condi* GASTRIC REFLEX NEUROSES. 91 tions of the uterus, and are often present in school girls who have morbid appetites, with cravings for pickles and chalk. These cravings are not the result of chlorosis alone, as is often supposed, but in many cases are depend- ent upon morbid irritations resulting from puberty and uterine catarrh. In many of these young girls a ravenous appetite accompanies the menstrual congestion, and is a result of a morbid stimulus taking its origin in a diseased uterus. In other patients there is complete anorexia dur- ing the menstrual period, and all these symptoms disap- pear only upon relief of the uterine disease. Quite as fre- quently the uterine symptoms are indications of gastric or hepatic disturbance, and very many cases of uterine catarrh and endometritis are dependent upon hepatic obstruction. A very common reflex from gastric disorder is frontal headache ; in fact, the great majority of headaches are re- flex, and a large number of them are consequent upon gastric or hepatic disturbance, and vice versa. Neuroses of the stomach are very frequent results of functional dis- turbance from disease in other organs. Fleisher has noted a diminution of the secretion of hydrochloric acid during menstruation, and Dr. M. Gross reports the case of a neurasthenic patient who was attacked after almost every coitus with nausea and gastralgic pains, sometimes asso- ciated with vomiting. The vomited matters always con- tained an excess of free hydrochloric acid. He also men- tions the fact that there is a condition of the gastric juice known as anachlorhydria, or nervous anacidity, found in neurasthenic and hysterical patients in whom no organic disease of the stomach is present. The great importance of the relations existing between the gastric juice and the diseases of other organs of the body must be recognized. 92 FUNCTIONAL NERVOUS DISORDERS. He states that there is scarcely an internal disorder in which the gastric digestion is not largely implicated and connected more or less intimately with functional disturb- ances. Dr. Gross, in his article "On the Connection be- tween Affections of the Stomach and Diseases of Other Organs" (New York Medical Journal, May 4th, 1895), says : " A full comprehension of the morbid processes in the stomach, of the morbid symptoms of disturbed gastric digestion, cannot be obtained without considering the re- lations between the stomach and the diseases of the other organs of the body; for every affection of the stomach is reflected back on the other organs, and inversely every disease of the organs reacts upon the stomach." He speaks chiefly of the circulatory disturbances which lead to con- gestions, and their sequelae in diseases of the heart, the lungs, and the liver. As a matter of special importance he points out that in a number of cases symptoms of dys- pepsia precede the first signs of phthisis, and considers the dyspeptic troubles as the result of venous hyperemia and congestion coming on from the disturbed pulmonary circu- lation. The digestive complaints are to my mind more often the causative factors in the production of pulmonary disease than its results. Of the various neuroses associated with uterine disease, particularly retroflexion and the neuroses dependent upon it, the gastric neurosis is probably the most frequent. Often, however, we may observe the persistence of the gastric neurosis in spite of the cure of the retroflexion. Quite recently, indeed, clinical investigators have devoted increased attention to the digestive disturbances which are not due to an organic disease of the digestive appa- ratus, but are based upon certain conditions of irritation or atony of the nervous system. Every gynecologist will ad- GASTRIC REFLEX NEUROSES. 93: mit that women suffering for a long time with sexual dis- eases complain chiefly of associated gastric disturbances of a widely varying nature. In such cases we have to deal with dyspeptic disturbances without organic altera- tions of the digestive apparatus, in which the diseases of the uterus and its adnexa give rise to centripetal irritation of the nervous system, and these in a reflex way act upon the digestion. Thus, we often meet with gastralgias of the most violent kind with the onset of menstruation. In these cases there may be increased or continuous acid se- cretion, which ceases after the flow. The persistence of the gastric neuroses after the cure of the uterine disease is due (see Engelmann) to a persistence of the irritation in the nerve terminals. Gastric Neuroses of Pregnancy. — Gastric neuroses de- pendent upon pregnancy are exceedingly common. Mrs. Van H., aged 42, suffers from severe pain in the epigastrium, running up to the pharynx, where it mani- fests itself as a globus hystericus. This comes on during pregnancy, and is dependent upon it, and so marked is this relation that she says " it comes on at the very mo- ment of conception." She can eat only a little steak and very light food during the day; if she eats more she suffers much from nausea. She also suffers from soreness in the epigastric region. The tongue is perfectly clean, and there are no symptoms of gastric catarrh. If she drinks much liquid, it immediately excites vomiting. These conditions in her case always disappear immedi- ately after delivery. Mrs. McC, aged 58, gastro-enteric catarrh and psy- choses. Has always been fairly well, but has suffered from a sensation of fulness before having had quite enough to eat. Shortly after eating she eructates immense quan- tities of gas. Her teeth are in very poor condition. Is not emaciated. Is extremely nervous, and without the 94 FUNCTIONAL NERVOUS DISORDERS. slightest provocation often gives way to tears. When I was first called to see her she was suffering from an attack of severe cramps and colic with extreme distention of the bowels. Sleep is generally undisturbed. While out walk- ing she worries continually about her home, and desires to return almost immediately. Her daughter, a young lady of eighteen, is also extremely nervous and suffers in a similar manner. In one of her attacks, after fasting a long time, she became delirious and was insane for some weeks. During this time her stomach was so weak and sensitive that it would not contain even a toasted cracker. The diet these two have been living on the past summer has consisted of fried meats, fruits, and watermelons. Hysteric Suffocation as a Gastric Reflex Neurosis. • — Miss Katie A., aged 30, single, has shortness of breath. Menses are rather scanty. At times she has pains with them which extend into the thighs. Slight leucorrhoea. During attacks of hysterical suffocation she feels like sob- bing. Has no cough. Lungs and heart are normal. She drinks four cups of coffee in the morning and two cups of tea during the day. This is a case of hysteric suffocation resulting from excessive use of coffee. Melancholia a Gastric Reflex Neurosis. — Mrs. S., aged 32. Ever since her brother's death, which occurred about six months ago, she has been extremely low-spirited, but has been complaining off and on for some years past. For the last two or three months suicide has always been in her thoughts. She is almost always in tears; her di- gestive organs are much disordered. She has abnormal appetites and cravings, and all the food which is ferment- able sours almost immediately after it has been taken. Is always very constipated. She has not left her house for weeks at a time. For the past two months has not been outside of the house, and, although physically able to do so, cannot be prevailed upon to take exercise. A car- riage was brought around to the door on several occasions, GASTRIC EEFLEX NEUROSES. 95 and her husband and friends insisted on her going for a ride to see if it would break up the monotony and depres- sion from which she suffered. She immediately went to bed and remained there, and persistently refused to go. After treatment of her digestive organs her condition im- proved. She was induced to go shopping and on short visits, and finally, after careful dieting, she recovered completely. A good example of a gastric uterine reflex is to be found in rapid manual or instrumental dilatation of the cervix, which will some times start most violent reflex vomiting lasting for hours. I have in mind a patient who had the cervix dilated for the purpose of curettage of the en- dometrium. The result of the instrumental stretching of the part was to set up a violent vomiting lasting for more than twenty-four hours. The following case shows the relation between digestive and nervous disorders : Mrs. J. T. H., aged 31; nullipara, married six years. This patient has always had headaches, and these have been of one of two distinct types — one nervous and the other migrainous. The former is situated at the vertex, occurs most intensely at the menstrual epoch, but is also present at other times. The sensation was that of "a splitting pain of the head," and at times it has made her delirious. She also has occipital headache, and this is re- lieved by hot water-bags or by other forms of hot appli- cations to the occiput. The second type, or migrainous headache, has been so extremely severe that she has been compelled to go to bed as soon as the attack began. The pain is confined to a spot not larger than a half-dollar. Nausea comes on with or, as is often the case, precedes the headache. During these attacks a numbness starts in various parts of the extremi- ties, with complete loss of sensation; as the patient ex- 96 FUNCTIONAL NERVOUS DISORDERS. presses it, "a cold, tingling numbness." Sensation only is abolished; motion is perfect. At these times she is much distressed by crawling sensations in the lower ex- tremities. I find that many other women experience simi- lar disagreeable sensations. Ever since she was a young girl she has lived in hotels, and has indulged in all sorts of sweets and pastries, and has at the present time an intense craving for candies and fruits. She says constipation has existed ever since she was born. The menstrual function is regular, but is scanty and painful. She has occasional attacks of anuria, and suffers from a pure uterine neuralgia, which is inde- pendent of menstruation. Her tongue is heavily coated. She is growing fat, and feels fairly strong. She has been eating everything she craves — all sorts of French cookery, preserves, cakes, etc. At times she has a craving for common potato starch and has used it by the five-pound box, eating it by the handful. Several of her lady friends have also done this. She chews a great deal of unground coffee. This case is typical of disordered conditions of the diges- tive organs, and secondarily of disorder of the uterine func- tions, the result of bad hygienic and dietetic habits. To correct this condition, attention must be given to the psychical condition of the patient. I gave this lady the following prescription : Inf. calumbee, § ss. Tinct. cinchonas co. , 3 ij. Sodii phosphat., 3 iij. Aq. menthse pip. , § ij. One teaspoonf ul in a glass of hot water, half hour before meals. I also carefully regulated her diet. She returned in about one week much improved as regards the headache, and her digestion was also decidedly better. These morbid cravings are quite common. I have seen GASTRIC REFLEX NEUROSES. 97 two young girls who consumed daily one to two ounces of ordinary table salt. In the New York Magdalen Asylum it is very common for the inmates to chew tea leaves, and very strong coffee is frequently taken by them for its stim- ulant effect when they cannot obtain alcoholic beverages. These patients are not chlorotic, and hence these cases are of more than usual interest. It is evident from this case that there is an intimate connection between the dis- ordered condition of the digestive organs and that of the pelvic organs, and indirectly of the nervous system, as shown by the headaches from which she suffered. I am thoroughly convinced that more attention should be given to the digestive functions by gynecologists generally, and that in a large proportion of cases the uterine functions are of but secondary importance. CHAPTER IX. INTESTINAL REFLEX NEUROSES. Looseness of the bowels and flatulence are common as intestinal hystero-neuroses. Among young girls diarrhoea immediately preceding the menstrual period has been noted in a number of cases. There is, as a rule increased intes- tinal action with hypersecretion of the intestinal glands, following sexual connection, due to the excitement of the vasomotor nerves resulting from the genital stimulation. In others there are symptoms of vesical weakness and functional disturbance of the bladder. In some cases there is diarrhoea preceding the flow, constipation during its continuance, and diarrhoea for a day or two following its cessation, and then costiveness during the remainder of the intermenstrual period, and this regular succession of events occurs at every catamenial epoch. Vice versa, intestinal and rectal disease with much mucous discharge have a weakening effect on the sexual powers, and impo- tence and barrenness are often reflex neuroses dependent upon intestinal disease. Intestinal indigestion, constipa- tion, impaction of the colon and chronic diarrhoea manifest their presence frequently by reflex occipital headache. A loaded colon is a great factor in producing reflex nervous symptoms. When it is emptied, however, by a brisk cathartic, relief immediately follows, the reflex symptoms disappearing. Many of the dermatoses are the results of faecal impaction. Chloasmic spots may be the result of the INTESTINAL REFLEX NEUROSES. 99 absorption of faecal material and its attempted excretion by the skin, or it may be a pure reflex. The improvement in the appearance of these patients under colonic flushings and hepatic stimulation is usually well marked. Scybalse, by pressure or irritation of the ganglionic nerves, frequently set up a severe gastralgia. Enteralgia or colic, the result of hysteria or severe mental excitement, which is probably a neuralgia of the mesenteric plexus, is an affection principally of the sym- pathetic system. The following case of cerebro-abdominal neurosis was related to me by Dr. M. Gross: The patient, a young woman, aged 23, was apparently in a fair condition of health. A few hours after witness- ing an accident to a friend she was attacked by a violent constant pain in the bowels, which exhibited marked ex- acerbations ; it seemed to be located in the small intestine as its origin in the uterus, stomach, and large intestine, was readily excluded. Menstruation was perfectly normal, the pain preceding its advent and continuing after it had disappeared ; the stomach was not sensitive and the loca- tion of the borborygmi did not involve the large intestine. There was no abdominal distention ; the pain was located in the region of the navel and gave the impression of com- ing entirely from the small intestine and radiating toward the back. She obtained slight relief only in a stooped, sitting posture. She had been treated by some lady phy- sicians with opiates in large doses, without any effect ex- cept to make her sleepless and miserable. The neurotic origin of the distress being determined, Dr. Gross put her upon large doses of the bromides with nearly immediate good result, the pain being relieved in a short time. Attacks of pain of this kind are allied to the attacks of 100 FUNCTIONAL NERVOUS DISORDERS. diarrhoea and vomiting which come on from depressing mental excitement. Why the pain is located at this point and not in the uterine or cardiac nerves, is an interesting question ; it may be because this, at the particular time of the attack, was the weakest part, or the digestion may have been arrested at this portion of the digestive tract during the excitement. During digestion, there is of course a physiological congestion of the active part. Intestinal Reflex Neuroses — Nervous Diarrhoea. — Miss Florence M., aged 42, is of an exceedingly nervous temperament. Says she suffers constantly, except when she takes boiled milk, from a watery painless diarrhoea. When a child she says vegetable food of almost any de- scription gave her diarrhoea. Ever since, she has lived principally upon boiled milk. Is extremely voluble; is very introspective, noting the most trifling variations in her condition with great care, and in fact thinks about little else. She is a woman of good education, and when a young girl of twenty and for some years after was a writer of short stories for magazines. While engaged at this work the blood would leave her extremities, which became extremely cold, and would collect in the head and face. At this time the head and neck would perspire very freely. After completing her work she was always taken with diarrhoea, which became so severe that her parents stopped her literary work. She thought that the air of Chicago, her home, did not agree with her, as diarrhoea persisted while she remained there. At one time she lived from May to October on a large steamer which made long trips on the great lakes, and at this time she was comparatively free from the diarrhoea. Drugs seem never to have been of benefit. While I have been conversing with her, her face is flushed and she calls attention to the extreme coldness of her hands and feet. She says that she could outline with a pencil, and she shows with her finger, the areas of severe cold over the ovarian region, which feel "as if there were lumps of ice there." Fig. 9. INTESTINAL KEFLEX NEUROSES. 101 Fig. 9.— Intestinal Reflex Neurosis. Vasomotor Disorder. 102 FUNCTIONAL NERVOUS DISORDERS. Nervous Diarrhoea. — Miss M., aged 28. When ner- vous from any cause, such as a severe reprimand from her father, or when anxious because of his intoxication, or the illness of her mother, who is a chronic nervous in- valid, she is always taken with a sudden and severe diar- rhoea. This condition frequently lasts for days. Bad news of any kind will bring on such an attack. Nervous Diarrhoea and Morbid Flushings.— Miss A. M., aged 33. Seen January 27th, 1890. During the past summer she has suffered from malarial symptoms, chills and fever, and sweatings. Had an attack about one year ago. Now, whenever she gets ready to go out, she has an attack of diarrhoea. There is no flatulence, but simply diarrhceal evacuations occur. Recently the attacks have come on the first three nights of each week. They are ac- companied by cramps; her face becomes excessively red, especially the nose, and she can scarcely see because of a mist which comes before her eyes. This is an evidence of a vasomotor flushing of the face and head. She has also some pain in the left ovarian region. At times there is a frequent desire to urinate, and both urination and diar- rhoea are increased at the menstrual period. She has monorrhagia lasting seven or eight days. These morbid flushings cause her considerable annoyance. A few days ago while she was in a hairdresser's chair, there was a very severe attack of morbid flushing accom- panied by heat and perspiration (see Plate II., Fig. 6). This was so noticeable that the hairdresser proceeded to fan her. She has had severe intestinal cramps, and be- lieving these to be due to a lack of the natural intestinal secretions and to fermentation, I prescribed Fowler's solu- tion, which gave complete relief. For the nervous phe- nomena the following simple prescription was ordered : ]$ Potassii bromidi, Sodii bromidi, aa § ss. Syrupi, § iv. Sig. One teaspoonful every three hours. The effect of the bromides was to stop the menorrhagia, INTESTINAL REFLEX NEUROSES. 103 and her menstruation now lasts only four days. For the malarial complications which were thought to be possibly a powerful causative factor, five grains of quinine were given three times a day. This, she says, acted as a brisk cathartic. This result I have noted before in other patients of a nervous type. The preceding case is one of morbid flushing; in fact, it was for this that she principally consulted me, although the nervous diarrhoea was also quite troublesome. The following, by Dr. John Hilton, is a good example of transferred symptoms. The irritation from an anal ulcer is transferred probably through the medium of the spinal cord or through the sympathetic to other organs in the ad- jacent parts. Case of Anal Ulcer Producing Retention of Urine and Symptoms of Pregnancy. — "The case is that of a young lady, aged about 22, whom I saw some years ago with the late Dr. Golding Bird. She was an excellent dancer, good company in a drawing-room, and thought to be a very agreeable and attractive person. Gradually she receded from that position in society, lying down a good deal on the sofa, suffering much pain, always un- comfortable, occasionally quitting the room, whether in society or at home among her own relations. It was noticed that she had occasional sickness, menstruation was not regular, the abdomen was decidedly increasing in size. She became very fond of lying in bed instead of going to balls and dances — in fact, she said she could not dance or enjoy society at all — and was very uncomfortable. A. surgeon was consulted, who, perceiving the patient's changed character, and finding the lower part of the abdomen decidedly large and prominent, mentioned a suspicion of pregnancy to her mother. Her mother, who was personally acquainted with the late Dr. Golding^ Bird, took her to him. He examined her carefully. 104 FUNCTIONAL NERVOUS DISORDERS. and said: "She is not in the family way, depend upon it; I think the symptoms arise from piles, or something wrong in the rectum." It was under these circumstan- ces that I was requested to examine her. I found her suffering from piles and prolapsed rectum, retention of urine nearly complete, enlarged abdomen, sickness, loss of appetite, constant pain at the lower part of the stomach, bowels constipated, frequent loss of blood from the rectum, and extreme pain during and after defecation. Her ill- ness commenced, many weeks before I saw her, with great pain in passing a motion, and all her urgent symptoms resulted from the original anal ulcer. This was the order of events: The nerves of the anus and neck of bladder being derived from the same trunk nerve — the pudic — the nerve irritation extended from the anal ulcer to the mus- cles of the neck of the bladder and urethra. This caused them to contract, and produced difficulty in making water, and subsequently the retention of urine. The protracted distention of the bladder caused pressure upon the rectum, interfering with the return of blood from near the anus, and this, added to the straining of the patient to relieve herself, caused distention of the rectal veins and partial prolapse of the rectum. Hence arose all the other symp- toms to which I have adverted. " I passed a probe between the projecting folds of the rectum, and soon made out where the ulceration existed. I removed a portion of an external pile, and then obtained a clear view of it, situated just within the anus, full half an inch wide, and more than three-quarters of an inch in length; muscular fibre formed its base. I divided the sphincter muscle through the centre of the ulcerations, and nearly the whole of the painful symptoms quickly sub- sided, and the patient was soon well and as happy and gay as ever. I have seen the lady several times since, and she has remained perfectly well." Miss H., aged 30, has an enlarged retroverted uterus with much tenderness and prolapse when evacuating the bowels and at menstrual periods. The pain was so severe INTESTINAL REFLEX NEUROSES. 105 that Alexander's operation of shortening the round liga- ments was proposed by a well-known New York gynecolo- gist. This condition was accompanied by a severe form of chronic indigestion, and the patient was extremely anaemic and worried. She went to the country for the summer, and returned in the fall in perfect health, not having taken in the mean time any medicine or submitted to any operation. This case exemplifies the fact that many cases of uterine disease are dependent on, or aggra- vated by, the disturbance of the digestive organs. This is undoubtedly true of dysmenorrhcea. If we succeed in strengthening the patient and curing the indigestion, the pains at menstruation disappear. CHAPTER X. THE RENAL REFLEX NEUROSES. Cases of marked variations in the secretion of urine may be reflex or symptomatic. Psychological changes are great factors in modifying the secretion of the kidneys, the emotions affecting the renal secretions even more strongly than they do those of the bowels. The urine secreted under the influence of nervous excitement is copious and limpid. Sudden changes of temperature by reflex stimulation cause marked renal irritability and increased micturition. The hypersecretion of any gland is simply the result of in- creased nerve stimulation, and mental excitement follow- ing stimulation of the emotions is a common cause, not only in man but in animals, of an increase in the secre- tion of urine. Neuralgic pains are not so common in the kidneys as in other organs of the body, but when they do occur they are sometimes very severe and of an aching character.. Anything which tends to enfeeble the vital powers pro- duces a marked modification of the urinary flow. In very many of these cases of renal functional disorder there is a large amount of urea excreted, and the urine is of a very high specific gravity. In patients with nervous prostra- tion the urine is often very pale in color. In the cases in which there is an excess of urea discharged there is also a tendency to the deposit of oxalate-of-lime crystals. These may be present in great numbers and of large size. The}r 106 THE EEXAL EEFLEX NEUROSES. 107 are evidence of debility, and indicate morbid nervous in- fluences. The increased secretion of the watery elements of the urine following upon an hysterical attack is a com- mon occurrence in the practice of all physicians. The Duchess of C. is a very corpulent, neurotic patient, all of whose family were consumptive. She possesses the peculiarly thin, silky hair which accompanies that state, and is of a marked scrofulous diathesis. Although an elderly woman, she has a remarkably delicate pink and white complexion. She suffers a great deal from nervous dyspepsia accompanied by frequent gaseous eructations. She has had attacks of pseudo-angina pectoris. Her men- tal condition exercises a most remarkable influence over the renal secretion. While suffering from nervous excite- ment lasting two days and following an accident to her carriage, she urinated about every ten minutes during that time, and passed a very large quantity of pale urine. She claims that while riding either in a carriage or in the cars anuria exists; she never feels the slightest desire to urinate even though the journey should last for two or three days, although when at home she urinates fre- quently. While in attendance at the deathbed of her daughter she had an attack of polyuria and claims to have passed within a few hours more than three gallons. This statement, however, may be taken cam grano salts, as a great many of these patients have a tendency to " elabo- rate," and possibly she exaggerated a little. But there is no doubt that she passed a very considerable quantity. (Some of the recent authors have called attention to the fact that the granular kidney is frequently of nervous origin. See Medical Record, November 24th, 1894.) CHAPTER XI. THE VESICAL REFLEX NEUROSES. These are common in women, but the literature is not Very extensive. The most common cause is some diges- tive, uterine, or rectal disease affecting the bladder reflexly through the sympathetic. Lesions of the cervix are com- mon sources of irritation, as are thread-worms, anal fis- sure, hemorrhoids, constipation, sudden change of tem- perature, mental disturbances, and the irritations of the female urethra from too acid urine, the result of bad digestion or a urethral caruncle. No one has written more lucidly on this subject than Dr. Alexander J. C. Skene. Among the functional disturbances of the bladder are frequent urination, painful urination, incontinence of urine, difficult urination, pain after urination, and reten- tion of urine. Emotional disturbances are prominent fac- tors in functional derangements of the bladder; fear and fright are among the most common of these which influ- ence discharge. Frequent urination, and the sudden evac- uation of the urine with modifications of its character, are common results from disturbances of the nervous system. In nervous and hysterical conditions the urine may be limpid, acid, and very excessive (polyuria). "Nervous re- tention of urine (ischuria) is also very common. Difficult and painful urination are likewise conditions frequently met with as neuroses. Incontinence of urine in children 108 THE VESICAL REFLEX NEUROSES. 109 is often dependent upon digestive disorder, and disappears immediately on its correction. Many derangements of the bladder are said to result from malaria. This can be explained, not only by the malarial poison affecting the bladder and urethra through the nervous system, but probably by a mechanical agency at work in addition to the nervous cause of the disease. The congestion of the liver which is present in malaria interferes with the portal circulation and thus causes a congestion of the bladder. Removal of the hepatic ob- struction causes a ready disappearance of the disorder. It is claimed that the much-maligned ovaries are respon- sible for many of the neurotic disturbances of the bladder. Ovarian irritation is undoubtedly a frequent factor in the production of excessive urination and also of scanty urina- tion and dysuria. A feeling of pressure and uneasiness is often present; the pain in the bladder is usually con- fined to the neck, and is generally most severe during the act of micturition. In these cases a careful examina- tion of the urine fails to find any deviation from the nor- mal standard. The bladder itself is not sensitive, and the condition is readily determined to be a pure neurosis de- pendent upon the inflammation and disturbance in the ovary. Treatment directed to the inflamed ovary usually causes a disappearance of the bladder symptoms. It is difficult to differentiate between renal and vesical neuroses on account of the intimate connection of the parts. In the treatment of the reflex neuroses of the bladder tonics should be administered and a careful regimen en- joined. Among the drugs found useful are mix vomica, iron, quinine, and the vegetable bitters. The digestive organs should receive special attention, and the slightest deviation from their normal condition should be at once 110 FUNCTIONAL NERVOUS DISORDERS. corrected. The diet should be simple and nourishing, and all indigestible articles carefully excluded. Pleasant com- pany should be sought after, especially at meal-times, and cheerfulness should be cultivated. Strong tea and coffee, wines, condiments, and all other articles which are inhibi- tory of digestion should be strictly avoided. Diluents and soothing decoctions should be given by the mouth. The mild alkalo-saline waters, such as Highland water, and preparations of uva ursi, triticum repens, scoparium, and acacia are useful for removing irritation. Local applica- tions of laudanum, belladonna, chloral, and morphine may be used with advantage either as suppositories or in- jections per rectum. Bladder injections containing a small quantity of morphine are also useful in removing the sensitiveness of the mucous membrane. Enuresis is a common and troublesome affection of childhood, often difficult to manage. It is most common in nervous children suffering with digestive disorders. It is undoubtedly in many cases a neurosis resulting from reflex irritation. The various causes of this disorder are obscure. The most valuable remedies are those which are tonic in their action, such as iron and strychnine. Tinc- ture of belladonna is recommended in five-drop doses. The whole subject of reflex bladder troubles is a vexed question, and these disorders are often difficult of diagno- sis. A most thorough investigation to discover the cause of the trouble should be made before any course of treat- ment is attempted. My friend, Dr. R., gives me the details of the following case: Mrs. H. had been married for about four months, and the marriage had never been properly consummated owing THE VESICAL REFLEX NEUROSES. Ill to the fact that the approach of her husband had always resulted in a sudden and uncontrollable emptying of her bladder, a real incontinence of urine. It had never oc- curred before she was married, and never at any other time than on attempting to perform the marital act. No matter how often or how infrequently the attempts were made, the result was always the same. The consequence was that the husband was thoroughly disgusted and unable to accomplish the act. Strychnine, belladonna, and can- nabis indica were tried without any benefit. Cauteriza- tion of the neck of the bladder, however, was followed by marked improvement. CHAPTER XII. THE REFLEX GENITAL OR HYSTERO-NEUROSES. Many of the hystero-neuroses are very severe in their manifestation. They most commonly occur at the men- strual period. Genito-urinary disturbances are reflected to any part of the body, but more frequently to the hypo- gastrium, the vertex, and the occiput. Pains are also fre- quent in the lumbar region, knees, ankles, and wrists; also in the neck below the occiput. The terminals of the cere- brospinal nerves are frequently implicated. When hystero-neuroses are constant, they are usually increased in severity by menstruation, or by anything which causes uterine congestion, such as colds or over- exertion. Sometimes, however, the menstrual discharge decreases their severity. The pains in the small of the back follow the distribution of the nerves around to the hypogastric region, and the pain is usually more marked on the diseased side. It is sometimes localized between the shoulder-blades. I had a patient in whom the pains of labor were all reflected to the head. She was also a victim of hystero-epilepsy. Another patient had them all in the thighs — this latter is a rather common condition. The pains of the hypogastric neuroses are superficial, and are diffused along the terminal nerves; while the pain from local inflammatory conditions is deep-seated, and due to direct mechanical pressure. The pain in the occiput and back of the neck is com- 112 THE HYSTERO-NEUROSES. 113 monly described by the patient as being " like two drawn cords in the nape of the neck." In the vertex the pain is commonly of a pressing or burning character, and an eruption or dermatosis some- times results. A very common hystero-neurosis is the quiverings and shakings in the abdomen, of which a large number of patients complain. Superficial pains in the toes, soles of the feet, and heels are often said to result from ovarian and uterine, as well as from gastric disease. They usually occur on the same side as that of the affected tube or ovary, and in gastric disease, if the left side be painful, then the greater cur- vature of the stomach is the probable seat of the inflamma- tion. If the toes and fingers of the right side are affected, then without doubt a duodenitis is the cause, the irritation being at the pyloric orifice of the stomach. This is due probably to the distribution of the sympathetic nervous system. Coccygodynia is sometimes a hystero-neurosis. Narcolepsy, Trance, Lethargy, Hallucinations, Ante- cedent to the Establishment of the Menstrual Function {a Hystero- Neurosis) . — Edna S., aged 12, still in short dresses, is in good condition physically ; suffers with head- ache, mostly frontal, more frequent in the afternoon ; is a thoughtful, energetic, bright, cheerful child, with an ex- ceedingly acute memory. She has the face of a girl of sixteen. Appetite good; bowels regular; is not ansemic, and has a plentiful supply of fresh air. Her mother died of phthisis when the child was five years old; her father is very frail and delicate. On returning from school, for some time past, she has always been dizzy and drowsy and wishes to go to bed immediately, instead of, as heretofore, playing with her dolls and enjoying herself. After a 114 FUNCTIONAL NERVOUS DISORDERS. quarrel or an attack of fretting, she has hysterical hallu- cinations of vision, every object seeming of double size. Every object that comes in contact with her body, such as a sheet, seems to be extremely heavy. When in a nervous state after crying, she has the feeling that the lips, tongue, and hands are swollen to a great size, although no swelling is visible. She usually retires between 8 and 9 p.m. In the morning when awakened and called to get up, she hears but cannot move; her mind is awake but she has no power of motion ; her eyelids are closed and she has to be vigorously shaken every morning. She is not lazy or tired, but she cannot move a muscle when in this state. She will hear commands and orders, but is unable to obey them, and lies like a log. If left alone, she will remain in this condition for from twelve to fifteen hours. At times there is a sensation of constriction, as of a band around the head. Her father has suffered from attacks of trance. He has lain in a cataleptoid state, heard and knew his friends by their voices, but has been unable to move — mind awake, but body asleep. When sensation is returning, in the case of the child, a peculiar prickling, as of needles, is felt in an increased de- gree. After coming out of an attack she often has to slap her hands to aid the return of sensation. Under treatment by tonics and a nutritious diet this patient has very much improved. I wish to refer here to a pathological condition which I have observed, and which has not yet (to my knowledge) been noted save by a very few medical authors. I refer to recurrent sexual orgasms in women. In the following cases they existed as a reflex from ovarian irritation : Mrs. S., aged 22, veryansemic; has had two children, no miscarriages; last pregnancy four months ago; did not nurse the baby, and it died from marasmus. Has been weak and nervous for the last five years. Has had within THE HYSTER0-XEUR0SES. 115 a short time four attacks of sexual orgasm, with consider- able discharge. Bowels constipated. Has pain in the left ovarian region. Miss C. H., aged 27, pale, large, strongly built. Has an orgasm three or four times some days. Uterus tender on examination. Has a burning sensation in left ovarian region. Mrs. A. R., aged 36, widow. Married twelve years; widow for nine years; three children. Menses first at 14; they recur every two or three weeks, duration five to eight days, flow profuse. Has some aching pain twenty- four hours before the flow and continuing through the first day. Leucorrhcea, slight but continuous. With the bear- ing-down pains has an orgasm. Does not masturbate or have connection ; very sensitive about the internal genitals. Urinates every fifteen or twenty minutes. Bowels regular. Has lacerated cervix. Rosenthal, of Vienna, says: " I had under my care a young hysterical female who performed peculiar suction movements during her parox- ysms, during sleep, and in a condition of semi-conscious- ness. One day, as her consciousness was returning, I dis- covered a mucous fluid upon the external genitals, al- though the genital organs were normal. After having often observed a similar occurrence, I decided to warn the patient that she was concealing secrets from me which would undoubtedly result to her detriment. She then con- fessed that she secretly read light novels at night, that she then had erotic dreams, and, that upon waking, she felt exhausted and worn out. The hysterical paroxysms de- veloped after this condition of excitement had lasted several months. A trip to the country and hydrothera- peutic measures caused the disappearance of the pollutions, and the hysterical seizures yielded soon afterward. In another case, a patient, during profound sleep, saw her 116 FUNCTIONAL NERVOUS DISORDERS. dead mother appear before her, and begged her pardon for concealing the fact that she had a mucous discharge from the genitals after voluptuous dreams, blaming the obscene books loaned by a friend as the cause of the discharge and of the hysterical paroxysms. This flux, caused by erotic excitement of the nervous system, is produced by the glands of Bartholin and by the acinous glands surround- ing the meatus urinarius." As a rule these involuntary orgasms occur at night and result from masturbation, erotic thoughts, and over-ex- citement of the genital organs by stimulating food and drinks, diseases of the rectum, hemorrhoids, habitual constipation, and worms; diseases of the bladder, inflam- mation and calculi, irritation of the urethra and glans clitoridis. These orgasms weaken the nervous system and lower the vital energies, thus affecting nutrition. When long continued they cause melancholia and mental weak- ness. In the treatment of these conditions, as in that of all the reflex neuroses, we should endeavor to remove the cause. When they are due to constipation or hemorrhoids, these should be relieved by attention to the liver and digestive tract. If worms are present, we should give injections of the cold-water infusions of quassia, or very weak solutions of carbolic acid, corrosive sublimate or vinegar, the latter being preferable on account of its less poisonous action. It is also very important when these parasites are present to abstain for a time from the use of sweets and fresh milk, and to add much salt to the diet. These patients should sleep on a hard mattress, lying upon the side and with merely a light covering. The dorsal decubitus tends to stimulation of the genital organs. Among the drugs which may be administered are qui- THE HYSTER0-NEUR0SES. 11? nine and iron for their tonic effect, and Fowler's solution, belladonna, camphor, lupulin, and bromide of potassium. From these good results may be expected. Great benefit is also derived from cold sponging of the body. Electric- ity is also useful, but its application, should not be too severe or prolonged. CHAPTER XIII. THE GLANDULAR REFLEX NEUROSES. Probably the most important glands which we have to consider in this connection are the breasts. All irrita- tions in the pelvic organs manifest themselves to a greater or less degree by changes in the mammary glands. The most common reflexes are swelling, engorgement, and pain. These glands are intimately connected with the other sexual organs, and the functional activity of both is absolutely interdependent as they are but different parts of one apparatus — the sexual. Sensations of tenderness in the mamma are not infre- quent manifestations in young women at their menstrual periods, and at the beginning of pregnancy. Again, at the period of the " climacteric " sensations of similar nat- ure may occur and they may accompany various diseased conditions of the pelvic organs. The subjects usually affected are women of a highly sensitive disposition or those with hysterical tendencies. The tenderness may be very slight, or there may be actual and severe pain. Sometimes so excessive is the tenderness that the slight- est touch cannot be endured. When this is the case it is. termed mastodynia. Many patients afflicted with mas- todynia are thoroughly convinced that they are suffering from cancer or some other serious ailment. Tonic treat- ment, with local sedatives and dietetic regulation, are often the only remedial measures necessary. 118 THE GLANDULAR KEFLEX NEUROSES. 119 Uterine or ovarian pain resulting from inflammation is frequently accompanied by a reflex pain in the breast, and disturbances of the uterine condition, either by menstrua- tion or conception, are usually followed by congestion of the mammary glands. In some cases of dysmenor- rhcea the breasts become exceedingly tense and painful. The pain is of a lancinating character, penetrating to the shoulder blades, and is present during the entire menstrual period, but disappears upon the cessation of the flow. In other cases the shooting pains in the breast and the sore- ness of the nipples precede the appearance of the menstrual discharge, and pass away entirely with its disappearance. Changes in the other glands, accompanying pathological conditions of the digestive organs, are much more common than is generally supposed and have not to any very great extent been brought to the attention of the medical pro- fession. Thyroid enlargement is often a well-known reflex, de- pending upon activity of the genital organs in the female. This was well known by the ancients, who considered en- largement of the neck as an evidence of consummation of marriage or of the occurrence of pregnancy. It was cus- tomary to measure the neck with a fillet before and after the first night of the married state. I am inclined to think that the globus hystericus is nothing more nor less than a neurosis dependent upon the physiological conges- tion of the thyroid. Hypersecretion of the salivary glands is frequently known to accompany menstruation, and is one of the first signs of pregnancy. It is sometimes very severe and annoying in the early months, and does not entirely pass away until delivery. There is an intimate connection be- tween the parotid glands and the reproductive organs. 120 FUNCTIONAL NERVOUS DISORDERS. Cases have been reported where a diseased ovary has caused reflexly the suppression of the secretion of the parotid gland on the same side. Parotiditis sometimes causes a painful oophoritis. This is undoubtedly due to sympathetic transference, such as takes place in the testes of the male. Severe inflammation of the parotid has taken place in cases of ovariotomy. Several instances of this kind have been reported by Drs. Emmet, Mann, Reamy, and others. Hepatic neuroses are frequently dependent upon emo- tional disturbances. This fact is well known to non-medi- cal writers, for the novelists speak of the sallow counte- nance presented by the hero or villain after he has passed a sleepless night, torn by conflicting emotions. The emo- tional jaundice is here probably the result of disturbances of the vasomotor system. Many of the glandular neuroses have been considered under other headings, such as intestinal, renal, etc. Excessive perspiration of the hands and feet, as a reflex symptom from digestive disorder, is very common. The feet in these patients, being encased in shoes which pre- vent evaporation, often present the white and wrinkled appearance seen when the skin has been soaked for a long period in a strong solution of soda. Many persons with weakened digestive organs and con- stipation have a strong odor in the urine, due to intestinal decomposition of sulphur compounds and the pronounced appearance of indican in the excretion. It is probably the same decomposition that produces the malodorous perspi- ration in the axilla, and which is often much more exces- sive on the right side. Its greater frequency there is probably due to the presence of the liver and the empty- ing of the portal s} T stem on that side. In some of these THE GLANDULAR KEFLEX NEUROSES. 121 subjects the left axilla may be entirely free from odor. This odor is of a much stronger kind- in the negro race, and also in people with very pronounced red hair. Some young women of the latter type suffer much from this pecularit}". In the ball-room, when they become heated from dancing and are perspiring profusely, it requires the whole effect of the very powerful and pungent perfumes which they use to disguise this disagreeable odor. Hyperhidrosis — Ephidrosis. — The following case lately came under my notice, but circumstances prevented me from making more than a superficial examination : Mr. H., a young man, a blond, 25 years of age, much addicted to the use of alcohol, exhibits a curious phase of this condition. On the warmest days, and after vio- lent exercise, he will exhibit no signs of perspiration on his head, face, or neck, but from the second joints to the extremities of the fingers of each hand a copious perspira- tion will be present. So profuse is it that he can by shak- ing his hand sprinkle the perspiration around in large drops. This peculiar condition may be the result of some morbid process in the liver, such as diabetes. The glandular organs of the body are markedly influ- enced by the vasomotor irritations arising in the sympa- thetic. The glycogenic function of the liver and excretion by the kidneys are under the control of the sympathetic. The cervical sympathetic, as well as its distribution in the thorax may, when irritated and disturbed, cause uni- lateral hypersecretion of sweat. Cases have been reported of unilateral hyperhidrosis the result of Basedow's disease or diabetes. Here there is myosis on the affected side, redness of the skin, and elevation of temperature. In one of these cases galvanization of the cervical sympathetic caused profuse sweating upon the corresponding part of the face and head, while in another case a result exactly 122 FUNCTIONAL NERVOUS DISORDERS. opposite was obtained. Fraenkel, in his Inaugural Dis- sertation, Breslau, 1874, reports the case of a patient with cardiac and thyroid hypertrophy, accompanied by attacks of dyspnoea and hyperhidrosis of the left half of the face. On autopsy the left cervical sympathetic was found covered with rounded nodules as large as grains of sand, blackish -brown in color. On microscopic examina- tion they were found to consist of varicose vascular dila- tations with a formation of fusiform cells in their walls, The ganglion cells were strongly pigmented and filled with dark cells. Seguin, in the American Journal of the Medical Sci- ences, October, 1872, reported a case of a male patient, aged fifty years, who came under his notice. This man had exhibited for a number of years a unilateral hyperhidrosis in which, while the left side was profusely bathed in per- spiration, the right remained entirely dry. The patient died of exhaustion, and the autopsy revealed large cancer- ous masses in the abdominal cavity affecting principally the mesenteric glands. Another deposit of carcinomatous tissue as large as a small orange was found behind the left clavicle, external to the sterno-mastoid muscle. On the right side the cervical sympathetic was found to be adherent to the sheaths of the pneumogastric nerve and the vessels. The superior ganglion and adjacent parts were much injected. These conditions are certainly of much interest. In some cases mechanical compression of the sympathetic nerve is readily determined, while in others the condition is quite probably of reflex origin, from disturbance in the thoracic, abdominal, or pelvic cavities. Hemidrosis — Unilateral Hyperhidrosis. — This is not a very unusual condition. In two cases which recently THE GLANDULAK KEFLEX NEUROSES. 123 came under my observation the left side was affected. One was a lady of about thirty, of strong frame, but suf- fering at this time from a severe chronic bronchitis, worse on the left side. The explanation of the hemidrosis in this case would seem to be that the ganglia of the sympathetic in the region of the left lung were excited, and the fibres Fig. 10. —Hemidrosis. also of the sympathetic controlling the secretion of sweat were stimulated by a local sepsis ; or, the pressure of the enlarged bronchial glands caused the stimulation, and took this means (unilateral sweating) of ridding the body of the poison. Half of the face, head, and body were bathed in a profuse perspiration, the hair on that side being very 124 FUNCTIONAL NERVOUS DISORDERS. wet, while the opposite side of the face, head, and body was perfectly dry. In the other case the cause of the func- tional aberration was not determined, the patient being apparently in robust health. She passed from my observa- tion before the obscure cause of the disorder could be ascertained. The pathology of this symptom is obscure. It is well known that severance of the sympathetic in horses causes a profuse unilateral perspiration. A case is reported of paroxysms of angina pectoris with ■hyperhidrosis of the left side. On post-mortem examina- tion the ganglia of the left sympathetic showed a patho- logical condition of the blood-vessels, which were dilated and varicose, while the nerve tissue on the right side was perfectly normal. In this case, Ebstein claimed that the hyperhidrosis resulted from a temporary or permanent compression of the nerve elements of the sympathetic with resulting paralysis. Rockwell reports a case which indi- cates an involvement of the vasomotor and oculo-pupillary fibres of the sympathetic. Patient, a male, set. 65, was extremely feeble, and suffering from digestive disorders. There was profuse unilateral hyperhidrosis involving the right side of the body, and the right leg and foot to a less extent, while the left side was at all times abnormally dry, the median line, both front and back, sharply defining the two conditions. There was persistent congestion of the conjunctivae. The right ear was redder and hotter than the left. There was considerable myosis, suggestive of paralysis of the oculo- pupillary as well as sympathetic vasomotor fibres. The hyperhidrosis lessened under the galvanic and faradic currents. Localized perspiration is much more common than THE GLANDULAR REFLEX NEUROSES. 125 general perspiration. In some cases it is confined to the hands and feet alone; in others the axillse, sca]p, and peri- neum are the only parts affected. I have at present under my observation a brother and sister, both of whom sweat excessively from the hands and feet. In the case of the young man, who is about eighteen, the feet are the most affected. They are constantly soaked with perspiration, and have the peculiar wrinkled appearance presented by the hands of a washerwoman who has been all day engaged at her avocation. In these two cases, as with most patients suffering from this disorder, both diet and hygiene are improper. A strong solution of chromic acid, as a local application, was of benefit to both of these patients. Hartmann mentions the case of a woman who during pregnancy perspired only from the right side of the body, and Sir Erasmus Wilson speaks of a young lady under his care whose hands drip with perspiration, the palms filling with the secretion, under the influence of a slight ner- vous excitement. He also mentions the case of a man with severe gastric disorder who called on him one morning with " rills" of perspiration running down one side of his face and forehead, the other side being perfectly dry. An eminent actor told him the following anecdote of himself. When a young man he had one night been playing in a tragedy in which he had become violently heated, and had scarcely had time to cool when he had been obliged to go on the stage again in a character which required that he should make up as an old man of eighty. In the course of the play he had been struck by the great amount of attention of which he was the recipient, especial- ly from those in the audience who were nearest to the stage. Concluding that it was the excellence of his acting which was attracting such attention, he felt flattered and exerted 126 FUNCTIONAL NERVOUS DISORDERS. himself to the utmost. He was thoroughly puzzled, how- ever, at the sensation which he seemed to be creating, and at the bursts of laughter in the wrong places which greeted him. Upon retiring to his dressing-room he found that it was not alone the excellence of his acting which had so excited his audience, but the droll appearance of his face, one-half of which had been washed clear of its painted wrinkles by a partial perspiration and displayed the youth- ful features of a young man of twenty, while the other half exhibited the careworn lines and wrinkles of eighty. On his chest the perspiratory side was reversed, the side corresponding to the perspiring side of the face being perfectly dry, and the other side bathed in a profuse sweat. At a later period the perspiratory action ceased over the entire body. Cutaneous hemidrosis may be considered as a neurosis referable to the cutaneous system. I prefer not to class it as a dermatosis. Bromidrosis. — My friend, Dr. Peter Murray, has given me the particulars of the following case of bromidrosis : Miss G., aged 18 years, suffered for a considerable time with excessive and most fetid perspiration of the feet, and so copious was the secretion that as she walked across the floor a "swashing" sound was heard at every step, her shoes being literally full of water. The special point of interest is the immediate success of the treatment insti- tuted. The feet were bathed in hot water, and afterward liberally powdered with a mixture of equal parts of sali- cylic acid and borax. This caused considerable irritation for two days. Extract of witch-hazel was also used after the hot water with the result of completely curing the dis- order. The patient was seen a year afterward, and had had no relapse. Dr. Murray also mentioned the case of a gentleman THE GLANDULAR EEFLEX NEUROSES. 127 with whom he is acquainted who claims never to have perspired. Upon the hottest days his face gets intensely red and shiny, and appears as if about to burst, but re- mains perfectly dry. The patient's age is sixty-five, and he is of a thin, spare habit. I remember some years since having seen a lady of about fifty years who suffered in a precisely similar man- ner, never perspiring even in the hottest weather or after severe muscular exertion; she had some eczema of the upper extremities, and was almost bald. The suppression of the sweat secretion was productive of considerable ex- haustion and much distress. A saturated solution of bichromate of potash, applied twice a day, is said to be a sure cure for bromidrosis. It was of advantage in all the cases in which I have used it. In the German army dilute chromic acid is said to be almost exclusively employed for excessive sweating of the feet. I have also prescribed chromic acid with much success for patients who suffer from this disorder and who engage in avocations requiring the handling of polished steel in- struments. On account of its acid character the perspira- tion is most destructive to the polish on such instruments. CHAPTER XIV. THE OPHTHALMIC REFLEX NEUROSES. Many ophthalmic symptoms are dependent not only upon ovarian and uterine affections but are common manifestations of digestive disorder. They are indepen- dent of any structural change in the eye. Among the more common reflex neuroses of the eye are : asthenopia, amblyopia, hysterical amaurosis, menstrual amaurosis, gravidarum amaurosis, retinal hyperesthesia, retinal anaesthesia, photophobia, dimness of vision, mouches volantes, disturbances of accommodation, hysterical stra- bismus, hemeralopia (night blindness), nj^ctalopia (day blindness), mydriasis, and myosis. It is not at all uncommon for patients afflicted with chronic abdominal and pelvic disease to be troubled with asthenopia and dimness of vision, yet in the mind of the average practitioner the interdependence or reflex charac - ter of these conditions is by no means well established. Cases of transitory amaurosis or amblyopia resulting regu- larly from a menstrual reflex, have been reported, and these have disappeared completely under uterine treat- ment. In some cases the ophthalmic symptoms are cere- bral neuroses or psychoses, being of hysterical origin. In many patients undoubtedly the weakness of the eyes is dependent upon the general systemic weakness arising from chronic digestive disorder, and a good course of tonic, dietetic, and hygienic treatment would invigorate the sys- 128 THE OPHTHALMIC KEFLEX NEUROSES. 129 tern sufficiently to cause them to disappear; yet in some instances they are true reflex neuroses. In a patient under my care there is not only impairment of vision but there is a limitation of the visual field. If she endeavors to read, or gazes steadily at any fixed object for a time, dark, wavy lines seem to intervene. There is no structural dis- ease of the eye present; the patient is' neurasthenic, and suffers from chronic gastric catarrh, cardiac weakness, and incipient renal disease. Disturbances of vision are quite common as menstrual neuroses where pelvic inflammation is present, the greater involvement being in that eye corresponding to the side where the inflammation is the more intense. Retinal hyperesthesia and anaesthesia are not only cere- bral neuroses but are common results of pelvic inflamma- tion. They also result from indigestion following the use of coarse vegetable food. Ptosis may result from the irri- tation reflected from hepatic and gastric disease. Lacera- tion of the cervix is responsible for some of the reflex ophthalmic neuroses. It is claimed that photophobia may also result as a reflex from endometritis and cellulitis. Puerperal amaurosis resulting from eclampsia might be classed as a cerebral neurosis depending, as it probably does, on uremic poisoning of the cerebral centres. This functional disorder must not be confounded with retinitis albuminurica, from which it is entirely distinct. Asthenopia is sometimes a cerebral neurosis dependent on a lack of mental energy; the patient has lost confi- dence in his power of using his eyes. Psychological treatment is here, of course, indicated. Many cases are on record of hysterical amblyopia and amaurosis and a great variety of means have been adopted for the sudden cure of these cerebral neuroses. Persons 9 130 FUNCTIONAL NERVOUS DISORDERS. with weak eyes should not read, write, or do any fine sewing on an empty stomach. A neurasthenic patient of mine who suffered greatly from a blurring of vision and the appearance of wavy lines in the atmosphere was always vastly relieved for a time by partaking of a full meal. Under careful treatment directed to the digestive organs, this reflex neurosis entirely disappeared. In mydriasis the dilatation of the pupil is usually con- fined to one eye, and the vision is much disturbed. Sometimes it is of organic origin, as a result of certain forms of brain disease, such as hydrocephalus, apoplexy at the base, concussion, etc. It is frequently intermit- tent, especially when caused by entozoa. It often sub- sides spontaneously or upon removal of the causative disease. The condition of myosis may result from irritation of the oculomotor nerve, which in turn may depend upon obstinate constipation or spinal paralysis. It is often an obscure affection. Photophobia is in some cases a violent ophthalmic re- flex resulting from uterine disease. Haziness and dim- ness of vision are frequently present at the same time. In cases of chronic cellulitis mouches volantes are supposed by very many physicians to be reflex neuroses dependent on renal disease, but they are also frequently present in cases of endometritis and pelvic cellulitis. The oculo-pupillary disorders arising from compression of the cervical or upper portions of the dorsal cord gener- ally appear as a paralytic myosis, and a spasmodic mydri- asis. These symptoms may alternate. In some cases both eyes are affected ; in others only one. The cervical sympathetic is very rarely the seat of trau- matic lesions, and hitherto but few cases have been re- THE OPHTHALMIC KEFLEX NEUROSES. 131 ported. During the American Civil War, Mitchell, More- house, and Keen had under observation a soldier who had been shot behind the lower jaw on the right side, at the anterior border of the sterno-mastoid muscle. The bullet made its exit on the left side, below and about an inch from the angle of the lower jaw. The wound healed in six weeks. When examined in the tenth week there was marked myosis (especially when the eye was shaded) of the right pupil. There were also myopia, slight ptosis, conjunctival redness, and frontal pains on the same side. Several times an unusual redness of the left side of the face was seen after exertion. While in a state of repose the temperature was found normal in the mouth and both ears. The foregoing symptoms are similar to those which are observed as resulting after experimental section of the sympathetic in animals. Kaempf (Ges. d. Wien. Aerzte, March 8th, 1872) re- ported the case of a soldier who was wounded in the cervical region, and presented right paralytic myosis from injury to the right sympathetic. Galvanization was frequently tried without any result. When the cervical region of the cord or the brachial plexus is wounded disturbances in the cervical sympathetic may also arise. Hutchinson has observed unilateral myosis, narrowing of the palpe- bral fissure, and elevation of the temperature on the corre- sponding side of the head. In addition to this, Seelig- muller (Berliner klinische Wochenschrift, 1870 and 1872) reports a case with emaciation and atrophy of the cheek on the same side as the injury. Rosenthal also re- ports a case of injury to the cervical cord with persistent slowness of the pulse and very marked dilatation of the left pupil. Observations upon fractures of the cervical vertebrae 132 FUNCTIONAL NERVOUS DISORDERS. have been published by Rendu, in which other symptoms of irritation accompanied the unilateral mydriasis. In luxations of the vertebrse, however, myosis was observed, with symptoms of paralysis, as was also found by Rosen- thal to be the case in two patients suffering from caries of the odontoid process. In certain forms of ataxia, and in progressive muscular atrophy, a considerable amount of contraction of the pupil on the affected side is generally observed. Periodical attacks of sciatica are liable to occur in these cases, often with hyperesthesia of the skin. During these attacks spasmodic mydriasis sometimes ap- pears upon the side affected. Here I desire to mention the great satisfaction with which I have read the volume en- titled "Uterus and Eye, a Treatise upon the Functions and Diseases of the Female Sexual Organs in their Patho- genic Influence on the Organ of Vision," by Dr. Salo Cohn. This work gives the whole subject in systematical classification, and is so much more to be appreciated as it pays close attention to a domain that has up to the present time never been thoroughly cleared. It is therefore at once theoretically interesting and practically important not only to the ophthalmologist and gynecologist but also to the general practitioner, who may learn to cure func- tional diseases of the eye by treatment of the genital organs. This work again shows how important it is that even in devoting ourselves to one special we ought to remain in close connection with general medicine. The author has also classified the normal and pathological functions of the female sexual organs and has on a physi- ological base shown the way upon which the pathogenic influence reaches the brain and eye. The conditions of puberty and the climacteric which are not at all clear in the minds of the ordinary practitioner THE OPHTHALMIC REFLEX NEUROSES. 133 have received a thorough elucidation and are classified with regard to their pathological features into the chapters on menstrual anomalies. When looking over this work we are surprised to see how intensely normal menstrua- tion as well as pregnancy and parturition may influence all parts of the visual apparatus from the lids up to its centres. The puerperium and lactation play also an im- portant role in producing affections of the eye of some- times a grave character. Finally, the question how loss of blood affects the organ of vision has received exhaustive attention. The whole work, that brings two distant parts of the body in close connection, a connection which is formed by the nervous system, verifies to a great extent the theories and facts that I have laid down in this book, which is in a measure a supplement to the before-men- tioned work and proves by many cases the truth of his premises. Like the author mentioned I also distinguish between the general morbid condition of the body that may pathologically interfere with the normal functions of an organ and the pathological condition of a part of the body that may cause disturbances in a distant organ. The author gives precisely his standpoint referring to the gen- eral distinction between reflex and hysteric action of a nerve. He thinks that such a distinction does not exist at all and that we have to deal with only one kind of irri- tation. This reflex action we recognize as such if we find out its origin, but are we permitted to call the irritation hysteric because we do not find the cause? We know very well that sometimes the original affection, as the author mentions, may have disappeared. The original wound may have healed, but the nervous irritation, sensible or insensible to the patient, may persist and continue, for a time at least, 134 FUNCTIOtfAKtfERVOUS DISORDERS. to produce its evil effects upon the distant part of the body. I may add, according to my experience, that this is the cause for so many disorders, especially in the female, that are generally and falsely classified as hysterical dis- orders. The electric current may still influence the bell through the medium of the wire even after we have re- moved the pressure from the button. This shows again that we are approaching the time when the word hysteria will perhaps be entirely stricken out of medical termi- nology. In every case where we find a trace that leads us to a morbid point, we have certainly not the right to speak of hysterical irritations. In all these cases we have to use the term reflex; at the present time we have to limit at least the term hysteria to those conditions where mental emotions apparently play the prominent part with- out any other visible or, to our imperfect methods, detect- able cause. The acceptance of this statement by the profes- sion will tend to still further clear up an obscure part in the disturbances of the nervous system. If we are aware that the so-called hysteric condition is sometimes a grave affec- tion we shall in the first instance try to find out the causa- tive point, and even if we do not succeed we have no right to shrug our shoulders at such an unhappy patient and declare all her suffering as pure and simple imagination. "The evil is," as Dr. Cohn in his work correctly remarks, " by no means imaginary but really exists, and the patients generally suffer severely under caprices of their ailment which they try in vain to master by 'an energetic will.' " I am fully convinced that I am not the only one who on the occasion of a post-mortem found out the pathologic origin of the death of a patient who for many a year was treated for hysteria, and I remember a case belonging to this group where even a large aneurism of the abdominal THE OPHTHALMIC KEFLEX NEUROSES. 135 aorta escaped the examining eyes of the physicians as cause for the symptoms that went to make the diagnosis "hysteria." It is interesting also that some affections of the eye have been called hysterical. Those that come under observa- tion in connection with the functions of the female genital organs or in connection with dysmenorrhceic troubles, according to Dr. Cohn, do not form a separate category, but belong rather to that group of cases in which a func- tional disturbance of the eye is induced by reflex action from a local genital affection. Can we, for instance, con- sider the contraction of the visual field as a support for the diagnosis of hysteria, if we hear from the author men- tioned that this same contraction is brought about by the menstrual process and is found in a series of other disor- ders? Are we justified in treating patients with " hysteric" symptoms in a careless and contemptuous manner, if we read in the same book that after long duration of such an " hysterical" affection of the eye, where the fundus at first did not present any perceptible change, hyperaemia of the papilla may set in at a time when there is no attack, and lastly may bring on organic alterations in the optic nerve? Functional Mydriasis. — Miss E.,-aged 25, a neuras- thenic, is considerably annoyed by intermittent mydriasis of the right eye, the pupil undergoing excessive dilata- tion, while the iris in the left eye remains in a state of inaction. This is caused hj a spasmodic action of the dilator pupillae, resulting from irritation of the sympa- thetic or the cerebro-spinal nerves communicating with it. It is of an ephemeral character, and may be a reflex from either nasal disorder or some irritation in the abdominal or pelvic cavity. It may be of the nature of chorea. Many persons, in a nervous or slightly weakened state, have a certain amount of twitching of the upper lid, due 136 FUNCTIONAL NERVOUS DISORDERS. to reflex irritation. Helminthiasis is often represented as a cause of ephemeral mydriasis. In Miss E.'s case weakness of the digestive organs is probably the foundation of the disorder. Eggs in any form always bring on a severe attack of indigestion, ac- companied by a migrainous headache. The application of strong solutions of nitrate of silver to the post-nasal region was followed by a marked improvement in the digestive symptom. Disagreeable disturbances of accommodation frequently occur as reflexes in neurasthenic, dyspeptic persons. CHAPTER XV. THE AURAL REFLEX NEUROSES. The aural reflex neuroses are probably not of great im- portance, still they are of sufficient moment to be given a place. The following are good examples : Aural Reflex Neuroses ivith Vasomotor Disorder. — Mrs. McN., aged 68. This patient's stomach has always been weak, and she now has marked anaemia from chronic gastro- intestinal catarrh. For the last three months she has had a burning neuralgia on the vertex, which radiates all over the head. Accompanying this are whistlings and noises in the ear which are extremely annoying. For the last two days the sensation has been like the snapping of parlor matches. She starts up in the night talking in her sleep. She is costive and the appetite is extreme!}' poor. Some slight improvement occurred under dietetic treat- ment. Aural Reflex Neuroses, Vasomotor Disturbance; Anaemic Roaring. — Miss S., aged 29, suffers every day from a roaring noise in the head which is so loud that she imagines that people sitting in the same room can hear it. She is very anaemic, and it takes but little to make her faint. She is exceedingly pale except over the malar prominences, and suffers from a very severe menorrhagia which is so profuse as to often cause faintness. She has pain on locomotion, and there is also pain in the back and in the left side. The roaring in her head ceases when her head is lowered, and she generally sleeps without a pillow, but her sleep is restless. She has an excellent appetite. There is severe leucorrhoea. On examination, I find the 137 138 FUNCTIONAL NERVOUS DISORDERS. neck of the uterus is occluded by a large mucous polypus. This was removed, and the patient gradually recovered her health. Unilateral Ancemic Roaring. — Mrs. C. H. C. , aged 39, is far advanced in phthisis. She is excessively anae- mic; her expectoration is viscid and exceedingly copi- ous. She experiences the most distress from an intermit- tent sensation of loud roaring in the right ear and the whole of the right side of the head. She complains more of this and is more anxious for its relief than for that of any other symptom. It is quite evident to my mind that the inflammatory disorder of the left lung is the source of this trouble and that the irritation is transmitted through the decussation of nerve fibres in the spinal column (de- cussatio pyramidum) to the right side of the head in the floor of the fourth ventricle. The auditory nerve, through which in this case the irritation is manifested, takes its origin in the floor of the fourth ventricle. Pathology here demonstrates what microscopical anatomy teaches. Care- ful examination of the ear showed no local disorder present. Under a superficial examination of this case the practi- tioner would be apt to consider it a purely local disorder, and direct his treatment to the ear, giving no attention whatever to the chest and abdominal cavity, which should always be interrogated when obscure aural symptoms are present. A common reflex from the auditory nerve is the sensa- tion which is popularly known as " setting the teeth on edge," and arises from harsh and scratching noises; the effect being generally more pronounced on the person who causes the sounds, perhaps on account of the irritation being transmitted in a measure also through the spinal column. These sensations are intensified in those who are ansemic and sensitive. THE AURAL REFLEX NEUROSES. 139' In some cases of ansemia, from insufficient or improper diet, along with mental worry, the patients suffer attacks, of a peculiar nature. Immediately following a slight sen- sation of fear or depression there is a hyperesthesia of all the special senses. If the patient is walking in the streets, the sound of her own and others' footsteps is most distressing ; people seem to rush by her with great vio- lence, or, if they remain behind, she fears they are about to pounce upon her ; their movements seem to be distress- ingly energetic and extremely rapid. If riding in a horse- car or other vehicle, the sensation of a very rapid and dan- gerous pace is experienced when the horses are merely going at a slow trot. It is all hallucination, but reasoning and knowledge of its incorrectness do not remove it. The tongue also is in a state of extreme sensitiveness. Distant and insignificant sounds are fancied to be in the immedi- ate vicinity of the patient, and of deafening volume; and even the vision seems to be somewhat sharpened. These manifestations are unaccompanied by any sensation of pain. CHAPTER XVI. LINGUAL REFLEX NEUROSES. Cases of lingual neuralgia, without any objective signs of inflammatory action being present in the tongue, are often very severe and obstinate. Of the reflex and neural- gic character of this disorder there can be no doubt. Local applications, as a rule, afford no relief. It is some- times remarkably persistent, lasting in some cases for years. It is more common in women than in men. One of my patients who has suffered with this disorder never ex- perienced an attack unless -she visited a certain fashionable watering-place, when within twenty-four hours an attack always came on with great severity. Her teeth are good and well cared for, and there is no sign of local disease of the tongue. It is natural in color and normal in size, without any indentation of its edges. The tongue is peculiarly susceptible to nervous influences of either an organic or functional character. This is seen in the uni- lateral coating occurring in cases of hemiplegia resulting from cerebral hemorrhage, while the stammering in cases of mental fatigue is probably due in a degree to a lack of nervous strength in the organ. The neuralgia is most common in neurasthenic and melancholic patients with imperfect digestion. Some women suffer from it only during pregnancy. In some cases the patients experience great difficulty in articulation, and the taking of any food except in a liquid form is impossible, owing to the severe pain experienced. 140 LIXGUAL KEELEX XEUR0SES. Ill Burning sensations in the tongue are not uncommon re- flex sensations in women. They are often of hysterical origin, and care must be taken to differentiate them from similar sensations accompanying inflammatory conditions. In the superficial forms of glossitis the tongue is dry, glazed, exceedingly red and tender with an accompanying burning sensation. When the inflammation is deeply seated there is often much swelling. In the treatment, a tonic regimen should be carried out, and Fowler's solution in five-drop doses given three times daily combined with quinine five grains. Iodide of potas- sium may also be given in small doses. In some cases Dono- van's solution may be of value, or pills of the carbonate of iron and gentian, freshly made. Blaud's pills, as ordinarily sold in the drug stores, like the quinine pills, are often so insoluble that they are of little use. Dr. John Hilton, in his work on "Rest and Pain," men- tions the following cases, which are interesting in this con- nection : Furred Tongue on One Side, Depending on Disease ivithin the Cranium. — " The first time I had an oppor- tunity of clearing up such a case as this occurred in 1843. On December 17th, 1843, 1 examined, with Mr. Blenkarne, a surgeon in the city, the body of one of his patients, who had died with disease of the brain and spine. She had suffered from intense pain on the left side of the head. She had also, during her life, a tongue furred on the left, and scarcely at all on the right side. It became, therefore, an important point to clear up what was the probable cause of that condition of the tongue. We made a post-mortem examination and found, as was anticipated, a diseased spine. Then, upon very careful examination of the head, on turning up the dura mater from the anterior part of the petrous portion of the left temporal bone, for the especial 142 FUNCTIONAL NERVOUS DISORDERS. purpose, we exposed the Gasserian ganglion, or the gang- lion of the fifth nerve. We there found what might be called a scrofulous deposit upon the convex edge of this ganglion, involving the second division, of the fifth nerve more than the third, but still involving all more or less. Here, then, appeared to us to be the probable explanation of the tongue furred on its left side. This observation was made in 1843; the disease was near the ganglion of the fifth nerve, and on the same side as the furred tongue. If I should not mention the fact again, it will be clearly Fig. 11.— Sketch of a tongue furred only on the left side, resulting from a de- cayed and painful second molar tooth in the upper jaw of the same side of the head. understood that the diseased condition of the tooth, or of the fifth nerve, was always found on the same side as the furred tongue, and that the fur was confined to the an- terior two-thirds of the upper surface of the tongue, over the distribution of the lingual gustatory nerve — a portion of the third division of the fifth." Furred Tongue on One Side Caused by a Decayed Tooth on the Same Side.— " The sketch (Fig. 11) is of a tongue furred on one side, and comparatively clean on the other. This furred condition of the tongue is frequently associated with a diseased condition of the second and third divisions of the fifth nerve. It is, in fact, a func- tional and structural deterioration depending upon ner- vous influence. LINGUAL REFLEX LEUKOSES. 143 " Recently, a lady, whom I have known for some years, consulted me regarding some matters not of importance, and I, perhaps not for any very precise purpose, said, 'Let me look at your tongue. ' She put out her tongue, and it was furred on one side. I said, 'You have a bad tooth,' and she thought it was exceedingly clever on my part. 'Yes,' she replied, 'and I am going to Mr. Bell to have it taken out. ' She went and had it extracted ; I saw her a fortnight afterward, and all the fur had subsided. This was a second molar tooth in the upper jaw of the same side as the furred tongue." I have also seen the side of the tongue coated from tip to base from toothache, while the centre and other side were quite normal in color. 10 CHAPTER XVII. THE ARTICULAR REFLEX NEUROSES. Pain in the hip, knee, ankle, shoulder, elbow, and wrist is often a transferred pain or of reflex origin.* Many cases of hysterical joint are undoubtedly true neuroses, but they are very puzzling symptoms, and require careful investiga- tion and treatment of both the digestive and reproductive organs before they become manageable. Pain in the knee is commonly associated with uterine disease. An anky- losis of the knee-joint, or a lameness, may be either a psychosis or a gastric or uterine reflex. A laceration of the cervix, accompanied by a local inflammation upon one side of the uterus, has been known to produce pain and stiffness in the knee of the same side. Pain and tender- ness at the hip-joint, simulating hip disease, may result from uterine disorder, thus showing its reflex nature. Pains in the wrist and ankle have been spoken of as of ovarian origin. They usually exist upon the same side as the affected ovary- * A most learned clergyman, whom I am treating, tells me that when a youth at the "hobbledehoy" age he was exceedingly shy, and whenever called upon to present himself prominently to the gaze of others, he was immediately seized with an intense weakness in the knees. This was so severe on one occasion as to cause him to fall flat upon the floor. He was also the victim of morbid blush- ing. 14-4 THE ARTICULAR REFLEX NEUROSES. 145 Stiffness of the joints of the lower extremities has been noted as an accompaniment of menstruation in cases of pelvic inflammation, coming on shortly before the cata- menial flow, increasing with its height and disappearing with its cessation. Dr. John Hilton gives the following explanation of hysterical pain in hip or knee joint : " The sacral ganglia and the lower lumbar ganglia of the sympathetic nerve are connected with the great sciatic nerve, and partly also with the obturator nerve. These same ganglia are connected likewise with the nerves pro- ceeding through the broad ligament to the uterus and to the ovaries. I think we have here, then, an explanation of the frequent occurrence of what we call hysterical hip- joint or hysterical knee-joint. If the nerves in the ovaries or the uterus be in a state of irritation, that irritation can be conducted to these sacral nerves or to the obturator, and then, in accordance with the generally received law of distribution of nervous influence, irritation or pain may be manifested at the other peripheral or articular end of the same nerve. Hence it may be expressed within the knee- joint, on the inner side of the knee-joint, or it may be within the hip-joint, because the hip-joint as well as that of the knee receives its nerves from these various sources. The posterior part of the hip-joint, you will remember, has nerves coming to it from the sacral plexus. The sacral plexus receives some filaments from the sacral ganglia ; so do the uterine and ovarian nerves ; and it is quite possible, nay, I think is very likely, that the irritation commenc- ing in the ovaries or the uterus might be conveyed to some of the filaments derived from the same ganglia in the sacrum, and irritation in the hip-joint be thus produced. You will observe that the two nerves, which are so dis- 10 146 FUNCTIONAL NERVOUS DISORDERS. tributed as to be capable of producing the pain in the joints, are the great sciatic and the obturator; and I be- lieve this is a probable explanation of the fact that of all the joints in the human body affected hysterically as we Fi3. 12.— a, Spinal cord. 6, Spinal nerves going to the posterior part of the body- behind the vertebral column, c, A visceral artery accompanied by branches of the sympathetic nerve, d, Common spinal nerve, composed of motor and sensory filaments, e, Portion of intestine (uterus or ovary) receiving minute filaments from the spinal nerves and sympathetic nerve. /, Ganglia of sympa- thetic nerve, united to each other by longitudinal filaments, and receiving branches from, as well as giving off branches to, a common spinal, motor, and sensory nerve. The arrows indicate the directions which any intestinal, uterine, or ovarian irritation might pursue centrifugally, either directly backward to the skin in that region, or along a spinal nerve to its muscular, articular, or cutaneous destination. term it, none are so frequently involved as those of the hip and the knee. Sir J. Paget, to whose lot it has fallen to see more of these cases than to any other surgeon, save perhaps the late Sir B. Brodie, speaks as follows in his * Clinical Lectures and Essays,' edited by Howard Marsh, p. 197 : ' Among all the joints, the hip and the knee, which are the most frequent seats of real disease, are THE ARTICULAR REFLEX NEUROSES. 147 equally so of the mimicry — a fact not easy to account for. It may be due to mental association, perhaps unconsciously, or to a mingled inheritance — for instance, to an inheri- tance of nervous constitution and of relative weakness in the joint or joints most weak in progenitors.' By tracing these two nerves, I think we may find a probable interpre- tation of that frequency. I have here constructed a dia- gram intended to represent what I have been alluding to. Suppose this (/) to represent the three ganglia of the sym- pathetic ; we have then a spinal nerve (d) attached to the spinal cord, and taking its onward course to the muscles and the skin. We know that these spinal nerves commu- nicate with the ganglia, and so, by the sympathetic branches travelling along the arteries (c) , reach the intes- tine (e), uterus, and ovaries. Let us assume, then, that a patient may have irritation from any cause in the intes- tine, in the uterus or ovaries, or in the broad ligaments. On this map we may trace the course of that intestinal, uterine, or ovarian irritation through the ganglia, through the spinal nerve and spinal marrow, thence to be reflected to any part of the peripheral or articular distribution of that same spinal nerve. This condition, I apprehend, is sometimes very clearly recognized in the case of the in- testines. Who is there that has not felt griping pains in the interior of the intestines from some morbid agent lying there, or from drastic purgatives traversing the gut, ac- companied by pains or cramps in the leg, and pains in the loins? — conveyed in the latter instance by the filaments of spinal nerves, which pass to the posterior part of the body or the lumbar region. And is it not a common occurrence in cases of uterine and ovarian irritations for the patients to complain of pain in the joints, but particularly over the posterior part of the sacrum? The ovarian and uterine 148 FUNCTIONAL NERVOUS DISORDERS. nerves traverse the ganglia of the sympathetic, and so reach the spinal nerves. Hence the morbid influence con- veyed by the posterior branches of the spinal nerves to the skin over the lumbar and sacral regions explains the lum- bar and sacral pains experienced by such patients." CHAPTER XVIII. THE DERMAL REFLEX NEUROSES OR DERMATOSES. A very definite relation exists between the skin and the internal organs. In cases where a derangement of the stomach, liver, kidney, or uterus coexists with a skin dis- ease, the removal of the internal disorder frequently causes the disappearance of the cutaneous affection. This results from the intimate functional interdependence of the vari- ous parts. In the treatment of all skin disorders special attention should be given to what physiology teaches — that is, the intimate connection between the functions of the skin, liver, and kidneys. " Imperfect digestion and in- efficient renal elimination are the causes of one-half of all skin diseases, and this is particularly noted in gouty and rheumatic subjects. The connection between dermatoses of the face (such as acne and chronic redness) and uterine and digestive de- rangements is noted by all practitioners. Many of the dermatoses are merely symptoms of general diseases whose chief seat is the internal organs. Such affections are said to be often the results of faecal impac- tion. Among the reflex neuroses of the skin are : 1st. Hyperesthesia. 2d. Anaesthesia. 3d. Perverted sensibility. Under the heading of neurotic disease of the skin may 149 150 FUNCTIONAL NERVOUS DISORDERS. be classed pruritus, prurigo, urticaria, herpes, acne ro- sacea, lichen. Pruritus as a reflex neurosis is frequently dependent upon gastro-intestinal and genito-urinary disturbances. Rich, stimulating, and indigestible diet, intestinal para- sites, and many digestive and uterine derangements are among the common causes of this disorder. The itching may be general or local ; in digestive disorders it is usu- ally the extremities which are most affected, although the entire surface of the body may be involved. Among the varieties of its local manifestations are: Pruritus ani, pruritus vulvae, pruritus urethrse, pruritus nasi. Prurigo as a reflex dermatosis is common in advanced life. The itching is of a peculiar, burning, tingling char- acter, aggravated by friction. It may be partial or gen- eral, and is most common on the back, the outside of the limbs, and in the region of the anus and genital organs. The most common causes of this affection are improper diet and unhygienic living. Prurigo of the anus and vulva undoubtedly depends upon obstruction of the portal circulation from congestion of the liver. It is commonly present in persons of intemperate habits, and is frequently very severe and recurrent during the menopause. Eruptions which appear at puberty have been known to come again at the menopause, while in the mean time the patient has been free from any similar affection. Some writers on diseases of the skin have recognized the reflex nature of some of the dermatoses, but they simply consider them part of the general morbid condition. Many of the digestive and sexual changes in women are accom- panied by disorders of the skin. It is common to see women affected with uterine or digestive disorder suffer- ing at the same time from eczema facialis, acne, or urticaria, THE REFLEX DERMATOSES. 151 which does not subside under the ordinary forms of treat- ment, and only disappears on removal of the uterine or digestive disorder. Reflex dermatoses dependent upon the menstrual disturbance manifest themselves some- times by a small red surface on the side of the nose, cheek, chin, or other portions of the surface of the body. These patches may be erythematous, or sometimes pustular in their nature. Others are diffuse inflammatory eruptions, and are called by some physicians chronic recurrent erysip- elas (the erysipele catameniel of the French writers). There is, however, nothing erysipelatous about the eruption. Ecchymoses and hemorrhagic spots have been noted by writers as recurring regularly at the menstrual period.. The causative connection between catarrhal conditions of the uterine or digestive organs and these cutaneous erup- tions is readily distinguished. A case is on record of a young woman whose first appearance of menstruation was accompanied by hemorrhagic perspirations which recurred regularly at each menstrual period until she be- came pregnant, when the perspirations ceased, never to return. Symptomatic chloasmata are always dependent upon some internal disorder. Chloasma uterinum generally appears as a brownish discoloration on the abdomen, fore- head, or cheeks. Sometimes it is so pronounced that the patient appears as if wearing a mask. This affection may present a very dark hue, even black, or the discoloration may be so light in color as to be scarcely noticeable. Cutaneous discolorations of this type are common in patients with digestive disorders and in those suffering from cancerous affections. Reflex dermatoses as a rule receive but slight attention from the gynecologist. Sudden changes of the complexion 152 FUNCTIONAL NERVOUS DISORDERS. of a most marked character are readily recognized by even the laity as a result of the correction of digestive disease, or as following a beneficial operation upon the uterus or its appendages. The sallow countenance present in liver derangements may be a true neurosis. It generally yields readily to the treatment of the causative hepatic disorder. In some cases of pregnancy the pigmentation does not extend beyond the linea alba and the areola of the breasts, while in a great number of others the face is as strongly marked. Among the common dermatoses of puberty are acne and seborrhcea. Acne is more often functional than organic. It occurs usually about the establishment of puberty, and is dependent upon physiological changes that have a patho- logical accompaniment; it is also commonly induced by digestive derangements, and exists as a dermatic reflex in patients who indulge freely in alcohol, and in those with some forms of dyspepsia. Uterine disease is sometimes productive of acne in its severest form. Seborrhcea is sometimes dependent upon disorders of digestion alone, while at other times pathological condi- tions of the genital apparatus are its causative agents. Attention to regimen, laxatives, and local uterine treat- ment rarely fail in causing its speedy removal. The beautiful complexions of girls with perfect digestive apparatus are most commonly seen in the youthful peasant emigrants from Great Britain and Ireland arriving on our shores. This is not alone the result of good nutrition and healthy blood, but is a proof that no uterine or diges- tive derangement exists to cause neurotic disturbances in the appearance of the skin. In some forms of uterine disease the abdomen may turn almost black, while in others it is mottled or grayish in THE KEFLEX DERMATOSES. 153 appearance. This pigmentation disappears when proper treatment is instituted. Acne rosacea in a severe form is a very common com- plaint with farmers' wives who live upon a bad diet, con- sisting of fried meats and an abundance of indigestible pastry. Herpes of the pudenda has been noted in cases of metritis, and is here undoubtedly a reflex nervous symptom. In patients suffering from dysmenorrhcea, tumefactions about the size of a small walnut frequently appear in vari- ous parts of the body as reflex manifestations. In some of these patients at the menstrual period the breasts become intensely painful, and there is often numbness and tingling of the fingers. Mrs. P. (Fig. 13), aged 42, has been subsisting for a con- siderable time upon indigestible, badly cooked carbohy- drate food. She is quite weak and unable to do any phys- ical labor without resting frequently. Every afternoon she is obliged from exhaustion to lie down for a number of hours. She is mentally depressed, and suffers much from fermentative dyspepsia, flatulence being an exceedingly annoying symptom. Her chest is covered by patches of chloasma, circular in form, and varying in size from that of a pea to an orange; the color is brown. Under treat- ment directed to her liver and rectifying her diet, these dis- colorations rapidly disappeared. She was given a drachm of sodium phosphate in hot water, three times daily, an hour before food. A Menstrual Dermato- Neurosis. — Fig. 14 illustrates a case of menstrual dermato-neurosis of the face which came under the care of Dr. George M. Edebohls, and was reported by him (Transactions of the New York Obstet- rical Society, November 15th, 1892). Between the ages of fifteen and nineteen this patient suffered from dysmen- orrhcea and an eruption on the right side of the face, as seen in the illustration. There was an interval of eight 154 FUNCTIONAL NERVOUS DISORDERS. months when she was about eighteen, during which neither the eruption nor the dysmenorrhoea appeared. Dr. Ede- bohls treated her on December 22d, 1891, for endometritis Fig. 13. and catarrhal salpingitis, by dilatation of the cervix, curettage, and gauze-drainage of the uterus. The result was the complete disappearance of the dysmenorrhoea and eruption for the space of three months. They reappeared again, and three months later he found, on examination, THE KEFLEX DERMATOSES. 155 small cystomata of both ovaries, which had not been present before. On June 28th, 1892, he performed double ovariotomy and ventro-fixation of the uterus. Two poly- cysts, one of the left ovary, ten centimetres in diameter, and one of the right, six centimetres in diameter, were re- moved. Since the operation, six months ago, the patient Fig. 14. has not menstruated or suffered any pelvic pain. The eruption of the face, however, has returned regularly every month, and is rather more pronounced than formerly. On one occasion it extended around to the left side of the face. The future developments will demonstrate whether the phenomenon is to be regarded as a molimen menstruate. Treatment. — The curative measures must be first di- rected to the correction of the mode of living and general 156 FUNCTIONAL NERVOUS DISORDERS. hygiene, when these are found to be improper. The diet should be nourishing but not too stimulating, and the use of all alcoholic beverages should be strictly forbidden. Alkaline baths should be taken, and the strictest cleanli- ness enforced. With regard to internal treatment, the dilute hydro- chloric acid before meals will be found very beneficial, as will also strychnine. Arsenic may be often used with ad- vantage in the form of either Fowler's or Donovan's solu- tion. The bowels should be carefully regulated. The local measures, for the purpose of allaying the itching when present, may be the application of lotions or salves. A wash of liquor plumbi subacetatis with a little opium may be employed, or one containing bichloride of mercury or, better still, a strong emulsion of kretol (this is especially useful in pruritus ani) . Ointments, made on the same prin- ciples, or containing belladonna, camphor, or opium, may also be used, and are often of service when the lotions fail to give relief. CHAPTER XIX. HYSTERIA. Among the imitations of organic disease which, in one or another of its many forms, we are liable at any time to meet in our practice, is hysteria. Any or every part of the body may, under the influence of the nervous system, be its seat ; in my opinion it has not received the careful attention which it deserves, although much has been writ- ten upon the subject. There are many physicians engaged in active practice who give it scarcely a passing thought. The mind of the average practitioner is taken up with the pathological changes going on in the body. Congestion, inflammation, and their results attract all his attention, and he almost altogether ignores functional disturbances. Hysteria is an objectionable name, as the brain rather than the uterus is the organ involved. To find a suitable substitute, however, is extremely difficult; common usage has given the name hysteria to certain forms of nervous irritation, and we therefore accept it. Many cases of spinal tenderness, which is a simple func- tional disorder, a reflex from digestive or other abdominal disturbance, have been supposed to be local or other in- flammatory diseases, and have been treated by confinement to bed, blisters, and other local remedies, when no disease was present in the part under observation. Contractures of the hand or foot, of supposed organic origin, have often been met with, when hysteria was alone 157 158 FUNCTIONAL NERVOUS DISORDERS. the cause of their production. A very large number of the diseases in women of all classes is of hysterical origin. This explains the marvellous results obtained from the many and various methods of treatment in vogue; at present electricity is the general cure-all, and a short time hence some other medical fad will probably be the fashion. Simulated or unconsciously feigned disease might be said to be the rule, while inflammatory disease is the exception. Hysteria may usually be traced to some constitutional weakness or to exhaustion of mind or body with some ac- companying marked mental emotion. Anything which powerfully excites the intellectual sphere, such as severe mental shock, excessive stimulation and indulgence of the imagination and emotions, tends to the development of hysteria. Hysteria occurs frequently in epidemics, of which med- ical history gives several examples. Life in dreary mo- notonous surroundings, such as prisons or isolated farms, results in the production of much hysteria and insanity. From the never-changing gloom, the lack of social inter- course, and the ceaseless repetition of a daily routine, these surroundings are as destructive to mental as to physical health. The hysterical are as a rule anaemic, nervous people, who are fretful, emotional, and quick-tempered. It is not alone the emaciated ansemics who suffer from the disease, but fat women with hydrsemia are its frequent victims. Impaired digestion, the result of defective hy- giene and bad cookery, is a primary cause of anaemia, and the basis of most of the cases under consideration. The seeds of hysteria exist in the great majority of women : whether it develops, or how it develops, depends upon the individual peculiarities of each case. Hereditary taint plays a very considerable part in the development of HYSTERIA. 159 this disorder, mothers in very many instances transmit- ting such weaknesses to their daughters. When there is insanity in a family, it also predisposes the female mem- bers to hysteria, as will also any nervous disease in the mother. Age is a predisposing cause, by far the largest propor- tion of cases occurring from the accession to the cessation of menstrual life, at both of which periods its attacks are much more severe than at any other time. Precocious de- velopment of the intellect in children, and allowing them to mix too much in the society of their elders, taking them to theatrical representations, balls, parties, etc., thus un- duly stimulating and exciting their nervous systems at an early period, exaggerate their sensibility and make their constitutions fertile soil for the development and growth of the seeds of hysterical disorder. Climate plays no inconsiderable part in the development of hysteria, which, according to many writers, is most common in extreme northern and southern latitudes, and especially in those countries where women menstruate at a very early age. In large cities hysteria is much more common than in the country. Sedentary occupations, improper diet, impure air, lack of sufficient bodily exercise, constant brooding over relig- ious subjects, and any other circumstances which tend to lower the tone of the nervous system, may be ranked among the exciting causes of hysteria. Irritations of the genital apparatus, especially a perver- sion of the sexual functions, are also fruitful sources of this disorder. The victims of sexual perverts, either male or female, often suffer from very severe attacks of hys- teria. Hysteria is most common in young women and girls, 160 FUNCTIONAL NERVOUS DISORDERS. but is not by any means confined to them, as we find it in women of forty or fifty, and rarely in young men and boys. In all of these patients the health is in a poor condition ; the circulation is weak, the tone of the nervous system is lowered and. unstrung, and a great variety of morbid sen- sations are present. The blood being impoverished, the brain suffers from anaemia, and irresolution and weakness take the place of self-confidence and mental strength. These patients are nervous and excitable and are liable to sudden disturbances of the emotions without apparent cause. Much of the illness prevalent is factitious ; people who are not compelled to work hard for a living having time to indulge their morbid fancies. Many of the poor have no time to consider their sensations, but must work on ac- tively in spite of weariness and fatigue. Much supposed muscular weakness or weariness is in reality mental. The hunter, tired after a long and unsuccessful chase, sud- denly discovers game in the distance; fatigue and ex- haustion immediately vanish, and miles are again covered by him with pleasure and a sensation of lightness, the mind having overcome the body. The view held by Dr. Bristowe with respect to hysteria and other functional nervous diseases and their mutual relationship was that there are many functional diseases of the nervous system, among which may be included many forms of insanity, the different classes of epilepsy, chorea, migraine, neuralgia, and hysteria. All of these are characterized by groups of symptoms referable to ex- citement, depression, or aberration of the nervous func- tions, and mainly those of the nervous centres. They are severally distinguished clinically by the association of definite groups of symptoms, determined either by the HYSTERIA. 161 particular part of the nervous system affected, by the spe- cial kind of affection which takes place therein, or by the order and mutual relation of events. They are regarded as specific diseases, because experience teaches us that such groups of symptoms are so commonly observed under particular conditions as to show that specific causes must underlie them and determine their occurrence. But the causes of the affections are for the most part closely related to one another, if not identical; the individual symptoms, which by their modes of aggregation constitute the sev- eral diseases as we know them are common in a greater or less degree to all of them. Many cases occur in which it is difficult, if not impossible, to determine satisfactorily in which category they should be placed, and indeed there is no substantial line of demarcation between the diseases. Dr. Bristowe further holds that hysteria represents an unstable condition of the nervous functions, that is inde- pendent of any organic change in the nervous system, in which, at one time or another, one or more of its part may be temporarily affected in one of various ways. There is, as a rule, little difficulty in diagnosis, owing partly to the conditions under which the symptoms of the disease arise, partly to the emotional state which is usu- ally present, and partly to peculiarities in the symptoms themselves. Among the sensory disturbances which occur in hys- teria are anaesthesia, hyperaesthesia, and neuralgia. Sometimes the disturbance is local, at other times quite general. The anaesthesia is most frequent on the left side, and may be coincident with analgesia. Hemianaesthesia, occurring with contracture, is frequently connected with one-sided ovarian pain. The anaesthesia is usually con- fined to the integument, but when it is very profound, the 11 162 FUNCTIONAL NERVOUS DISORDERS. muscular tissue and mucous membranes become involved, thus causing loss of taste and smell. Hearing and sight may also become deficient when there is anaesthesia of the retina. Hyperesthesia may be limited to the skin of the hands and feet or the scalp; it may also occur in patches over the front of the chest and abdomen. Hypersesthesia of the joints is noted under the head of joint neuroses. These pains in the joints are sometimes accompanied by oedema and swelling of the tissues, thus simulating rheumatic in- flammation. When the special senses are involved, the eye is extremely sensitive to light and hearing is markedly exaggerated, so that the slightest sound, such as the rus- tling of a newspaper is greatly magnified, the patient im- agining that the paper is being violentl} 7 torn to pieces. The ticking of a clock may be extremely annoying from its apparent loudness, and even the ticking of a watch may be distressing. Patients with hypersesthesia of the sense of hearing are much annoyed by the fact of a person walking behind them; the footfall seems to them to be very noisy, and they imagine that they are being pursued and that the person following them is about to rush upon them with great force. This condition of nervousness is apt to be produced by the excessive use of hot baths and improper feeding. Hysterical neuralgias which are accompanied by other signs of hysteria undergo rapid modifications as regards their severity and location. After much excitement, or after convulsions, these neuralgias may occur along the course of certain nerves, most frequently in the temporal, frontal, occipital, or auricular regions. Hemicrania of the left side is a very common occurrence in hysteria. Neuralgias may also be met with in other situations. HYSTERIA. 163 Enteralgia and cardialgia are frequently observed, but the most usual seat of pain in these cases is the ovaries. The ovary may, or may not, be enlarged. It is claimed by Charcot that pressure over the region of the ovary will moderate and often stop the convulsion of hystero-epi- lepsy. I have found, however, that pressure increases the severity of the convulsion, and has an effect similar to pressure of the ovary itself, which, as Charcot has stated, is often sufficient to induce the hystero-epileptic attack. A case quoted in the " Iconographie de la Salpetriere" has seemed to me of sufficient interest to be given somewhat in detail. "In November, 1887, Gilles de la Tourette found a young hysterical girl in a ward of the Salpetriere. Among the other symptoms of her nervous affection she had a spasmodic contraction of the upper and lower lid of the left eye. She first came for treatment on the 22d of September. Her father had a rheumatic diathesis, her mother died of heart disease, and her sister suffers from hysteria. She herself had measles in childhood, and at seven years of age Sydenham's chorea appeared and lasted five years. At fifteen years she first menstruated. On July 1st, 1887, she caught cold, had a sore throat, and felt a stiffness in her neck. The next morning she was speech- less and could not swallow. At the end of a week the throat was better, but her voice had not returned, and in addition she had pain in her knee, and markedly in the right hip. During this trouble she had also had three or four convulsive attacks. La Tourette found that by pres- sing upon the eyeballs she was easily put into a light hypnotic sleep. In this condition she was able to speak and was entirely free from suffering ; in a more profound sleep the same results were obtained. As the result of one of her attacks in the month of November, the left eye re- mained closed and the patient fancied that the lid was more tightly held down as time went on. She had never 164 FUNCTIONAL NERVOUS DISORDERS. seen any one suffering from blepharospasm. Her condi- tion on the 27th of November is as follows : " She is still voiceless, suffers pain in the left hip, and her left eye is still affected. She can feel cold and the prick of a pin and can recognize touch all over the right side of the body, with diminution in sensitiveness in the right hand extending four fingers' breadth above the wrist. The left side is less sensitive to touch and cold than the right. There is a zone of analgesia and anaesthesia ex- tending the whole length of the left arm. As to the left leg it is a little less sensitive than the right. The left half of the scalp is anaesthetic; pressure upon the left ovary produces a spasm. Hearing is less acute on the left side; the left eye is amaurotic, there is nothing abnor mal in the fundus, and the pupil reacts to light. In the right eye the visual field is narrowed (-§-§-) , but there is no dyschromatopsy. Upon applying Esmarch's band to the wrist the hand becomes flexed ; if suddenly stretched, the arms remain in extension. No amount of personal effort avails to open the left eye, and quite a resistance is perceptible upon forcible lifting of the lid. Touching the cornea causes lacrymation, but no feeling of pain. Hyp- notic suggestion was begun upon the 27th of November, and about the first of December the patient's voice returns and her eyelid opens, but the eye is still very weak. After a few hours' interval sight is completely lost in that eye ; hypnotic suggestions are made every morning. "The hysterical attacks continued until June, 1888, but in December of that same year when she left the hospital she was not entirely cured." Richer has noticed a number of cases similar to the one described. The blepharospasm is at times clonic, and again tonic in nature; a third variety is called pseudo- paralytic. Amaurosis, complete or incomplete, always exists in hysterical blepharospasm. In almost all cases of hysteria there is present an exaggeration of motor excita- HYSTERIA. 165 bility which varies in degree from quick, precipitate move- ments to contractions of a single muscle or an entire group, and in some cases it may even pass into convul- sions. Strabismus (convergent or divergent), with spasms of the optic muscles, and spasmodic twitchings and con- tractions of the muscles of the face are manifestations which we find in hysterical patients in the region of the head. Hysterical aphonia in emotional young girls is at times associated with hysterical squint. The French writers have especially noted the narrowing of the palpebral fis- sure (hysterical blepharospasm) , with contraction or twitch- ing of the muscles of the same side of the face accompany- ing the condition ; hysterical anorexia, vomiting and even convulsions may also be present. The same side of the body is usually the seat of complete ausesthesia; not only feeling but taste and smell are deficient, and the percep- tion of color in the corresponding eye is imperfect or abol- ished. The ovarian region, however, is sensitive to pres- sure. General chorea, similar to chorea gravidarum, is also in some cases an additional source of distress. Occasionally the hemianesthesia is replaced by h3 T per- aesthesia, or there is, while the patient is under treatment, a partial or temporary transference of the condition to the other side. In the sterno-cleido-mastoid, the trapezius, and other muscles of the neck, also in the larynx, pharynx, and oesophagus, spasm is often developed in a rapid and severe manner. Sometimes the muscles of deglutition are inter- fered with, causing severe sensations of choking. Hysterical dyspnoea has been known to be so severe that tracheotomy has had to be resorted to in order to afford relief. This functional affection of the larynx is of an 166 FUNCTIONAL NERVOUS DISORDERS. asthmatic character, and comes on suddenly without rise of temperature; it is often accompanied by cough. Among the common forms of hysterical manifestations in the region of the neck and chest are hysterical laughter, shouting, weeping, yawning, cough, and asthma. In the abdominal region the hysterical phenomena ob- served are borborygmus, hiccough, hysterical eructations, regurgitation of food, vomiting, and spasmodic affections of the genito-urinary apparatus. The attitude and walk in hysterical hemiplegia is de- scribed by Gilles de la Tourette as follows : " After taking a few steps the patient whose left side is supposed to be affected rests his body on his right foot, which is thrown a little forward. All tonicity has left the muscles of the left leg, and they are partly atrophied ; the leg acts accord- ing to the laws of weight and with the thigh forms an obtuse angle, strongly limiting the movement of the knee ligaments. The left foot is placed in the equino-varus po- sition, the heel turned outward, and the point resting on the floor on the dorsal side of the first three toes. It is perfectly inert, and when the patient is walking is dragged after the other foot, all progress being confined to the right side." Todd in his clinical lectures says : " I particularly wish to call your attention to the special character of the movement of the paralyzed leg when the patient walks ; in my opinion, it is characteristic of the hysterical affection. If you watch a person suffering from an ordinary hemi- plegia, the result of a cerebral organic lesion, you will no- tice that in walking he has a peculiar way of carrying the paralyzed limb : the healthy side of the trunk is first car- ried forward and supports the weight of the body; then by a movement of circumduction the paralyzed limb is HYSTERIA. 167 swung forward, causing the foot to describe the arc of a circle. The hysterical patient, on the contrary, drags the affected leg as if it were an inanimate object ; there is no movement of circumduction, and no effort is made to lift the foot, which simply drags upon the floor." This absolute paralysis of the limb is characteristic of hysteria, and its presence will be of great assistance in reaching a diagnosis, should the hysterical stigmata be absent. In speaking of hysterical contractures Dr. S. Weir Mit- chell says : " We do not know what hysteria is. So far death has destroyed whatever evidence life might have offered as to its existence as an obvious thing capable of visual demonstration, and still we are apt sometimes with too much confidence to refer back its demonstration to this or that centre. Thus it has been taken for granted that hysterical contracture is due to disorder somewhere pres- ent in such columns of the cord as are usually diseased in spastic paralysis. The chief basis upon which this opinion rests is this : Cases of long-continued contracture have been seen to end in sclerotic alteration of the lateral col- umns of the spinal cord. The inference is that the pre- cedent functional states were also due to the less visible hysterical conditions of the columns. (Soc. rued, des Hopitaux, Vol. CXI., 2d series, p. 24, Charcot.) More- over, it has been taken for granted that the state of con- tracture is analogous to the condition we find present in muscles rendered overresponsive by lateral sclerosis. I am not at all sure that these inferences are safe, or even that contracture is of a certainty due to spinal centres at all. It is quite possibly purely local and muscular as to origin, and indeed there are reasons why it is extremely difficult to consider it as of spinal birth, or in any way 168 FUNCTIONAL NERVOUS DISORDERS. analogous to the state of excitability seen in disease of the lateral columns. I have become quite assured that there are two forms of hysterical contracture — one apt to be local and limited, and not followed by organic muscular changes ; the other apt to affect two or more limbs, and almost every muscle, even of the trunk, and prone to result in the mus- cular and areolar tissue changes already described. I think it curious that while the earlier stage of general con- tracture is most difficult to cure, when the disease has caused organic changes and is in its second stage it is far less hard to deal with. Perhaps this may be due in part to the disappearance of active hysteria. Indeed it is often true that in certain old examples of contracture, the symp- tom contracture exists no longer, and we have to deal alone with the mischief of originally shortened muscles, altered joints, and sclerematous changes in the intermus- cular space. The hysteria is lost with years ; the spasm lessens or ceases; the consequences and additions remain." The causation of this affection is to a degree frequently emotional. It comes on sometimes abruptly, and its dura- tion may be short, or for the rest of the patient's life. It may affect all or several muscles, and all the extremities may be involved, as represented in Fig. 16. Sometimes the spasm is continuous, again it is intermittent. Local ansesthesia is present, as a rule; under ansesthestics, and sometimes during sleep in the early simpler cases, there is relaxation. After the muscles shorten or harden, there is of course no relaxation. General contractures are rare. In the treatment of this condition gradual extension by instrumental means may be employed, such as extension braces with ratchets, or an apparatus with weights. It is extremely important that the Weir Mitchell method of isolation should be resorted to early in these cases. HYSTERIA. 169 A careful ophthalmoscopic examination should be made, in order to assist in excluding organic disease. Hysteri- cal contractures are what we term functional, as no or- ganic changes are found in the spinal column as causa- tive factors. Under treatment by massage, hydro- or elec- tro-therapy, and curative exercise as practised in a Zander Fig. 15.— Reflex or " Hysterical " Contraction Due to Gastric Irritation. institute, the affected parts often rapidly regain their former condition. In some cases tendons will have to be cut. Hysterical contractures of the sphincters of the vagina, bladder, and anus are quite common. Contractures of the extremities (see Figs. 16 to 21) often appear after emotional excitement or convulsions. Tremblings are also common, particularly of the upper extremities; sometimes the lower extremities are also involved. When respiration is inter- fered with, there may be severe manifestations of dyspnoea, 170 FUNCTIONAL NERVOUS DISORDERS. ' and attacks of asthma and asphyxia in lungs that are nor- mal are common reflex hysterical symptoms. Anorexia or bulimia is also commonly present. Epigastric pulsa- tion, tympanitic distention, constipation, belching, and obstinate vomiting are often seen in these patients. Men- struation is often disordered ; it may be suppressed, scanty, or irregular. When there is retention of urine from anaesthesia of the vesical mucous membrane in paralysis of the bladder, careful catheterization must be employed for a consider- able length of time; suppression of the urinary flow (anu- ria) or morbidly diminished urinary secretion (oliguria) is often noted. The following cases I quote from the " Iconographie de la Salpetriere, " as I consider them of value in the descrip- tion of hysterical manifestations : " Paul Richer calls attention to a case of hysterical con- tracture of the right leg which deserves mention because of the unusual position of the limb, and because of its re- sistance to all treatment, including hydrotherapy and mag- netism . " The patient, seen in February, 1882, was a young girl of fifteen years, with no other history than that of an im- petiginous eczema of the face and hands during childhood (being covered with an eruption until the age of seven;, and frequently occurring attacks of ophthalmia. There was no history of nervous antecedents in the family. " Four years previously, at the age of eleven, during a railway journey, she claims to have gone to sleep in a twisted position, or she may have taken cold. The follow- ing day intense pain was felt in the right hip, which seems to have persisted for several days. Before she left her bed a stiffness of her right leg was noticed, and a few days later the right arm was affected in the same way. The position of the arm was that of flexion, the fingers HYSTERIA. 171 bent inward, the hand bent upon the forearm, and the forearm upon the arm in inward rotation and adduction in such a manner that it was placed transversely behind the back. " The lower limb was in a position of extension, the thigh extended upon the leg and pelvis, the foot in extension. Eighteen months later the condition gradually improved, and in a few weeks showed no trace of stiffness. The leg, however, remained in a state of contracture, so that the patient was unable to sit down ; she was obliged to eat in a standing posture, and in walking trod upon the heel, the toes being elevated. Any effort to lower the toes or to flex the leg upon the thigh increased the rigidity of the muscles. The right leg was by measurement found to be 4.5 cm. smaller than the left, the right thigh 1.5 cm. smaller than the other. During sleep the contracture en- tirely disappeared, but returned at once upon waking, and even when sleep was light or disturbed. Dr. Sayre, of New York, endeavored to overcome the condition by forced flexion ; a plaster dressing was tried, but as soon as it was removed the contracture reappeared. The ma- nipulations and dressings caused intense pain." A case under Delprat's charge in Amsterdam is inter- esting. "A young girl of seventeen, previously strong, and with no personal history of neurosis, but belonging to a very nervous family, came in February, 1891, for treat- ment for her face, which was affected with bilateral con- tracture. The trouble dated from the previous August, when it started with toothache of the left upper incisors. After a month's duration of the pain, the patient noticed that the left side of her face was at times subject to con- tractures. These were at first temporary, lasting from one-half hour to three hours and a half, and occurred sev- eral times in the twenty-four hours. After a month's duration they spread to the right side of the face. A de- 172 FUNCTIONAL NERVOUS DISORDERS. cayed incisor was taken out, but the face remained in the same condition. " The patient is anaemic, too tall for her age, thin, and has a laughing, bizarre expression. The labial commis- sure is elevated on the right side, and lowered on the left, the nasal groove being more marked on the right side. At first sight one is forcibly reminded of facial hemi- plegia. The right eye looks smaller than the left, which is due to a slight contraction of the right palpebral orbi- cularis. Upon a careful examination it is seen that the contraction is also quite evident on the left side. In breathing the cheek is not flabby as if inert, the air escap- ing more easily on the right side. In opening the mouth, the opening is larger on the right side than on the left ; the tongue is protruded without deviation, and is freely movable. When the left side is covered, the expression on the other appears to be that of a laughing disdain. The expression of the left side is sad and dull. If the mouth be energetically rubbed, the contraction disappears and the expression becomes normal. After a few seconds of rest, a twitching begins in the levator labii superioris alseque nasi, and in the zygomaticus major of the right side. After each tremor the degree of contraction in- creases until it becomes fixed. At the same time contrac- tions are seen in the levator menti of the left side, and the chin is somewhat elevated. The left labial commissure is a trifle lowered, the upper lip becomes stiff, the ala nasi is depressed, and the lower lip protrudes slightly beyond the upper. All this happens in about two minutes' time. Even in sleep the contracture persists. The decayed teeth seem to have been the cause of the trouble in this case. The patient is highly hysterical ; she has a hemi-farado- cutaneous anaesthesia on the left side (face, arm, and leg). Upon the left side she feels the electric brush only when it is applied with more force than on the right. " In the treatment of this patient suggestion was used without hypnotic sleep. Her willingness to aid in the treatment was of great assistance. Suggestion was con- HYSTERIA. 173 tinued for about eight weeks, and four months later there was an apparently perfect cure." Paul Richer thus describes the diathesis of hysterical contracture: "The victim of this trouble presents no objective sign; he preserves freedom of movement, the manifestations of his trouble being always brought about by the manipulations of the physician or by some chance occurrence. This condition of the neuro-muscular sys- tem partakes of paralysis in that it usually coincides with a weakness of motility, and of contracture in that the slightest excitement will bring it on or cause it to dis- appear. This diathesis is found outside of hysteria. It has been called ' latent contracture.' Its principal points are: "1. Exaggeration of the tendon reflexes. This is con- stant but variable in degree. " 2. Epileptoid tremblings. This may occur, but very rarely. " 3. The muscles react to electricity, but in a modified degree. " A. When the interruptions of the electrical current are rapid, the muscles are tetanized as in health, but in hys- teria the muscles acted upon are not the only ones con- tracted. " B. If the interruptions are slow, the muscular twitch- ings are at first slow and distinct, but finally become continuous. " C. There are certain irregularities in the muscular twitchings : " a. Myographic readings show a lengthening of the de- scending curve. " b. At times a single electric shock will bring on a per- 174 FUNCTIONAL NERVOUS DISORDERS. manent contraction, in which case the descending curve is incomplete, and the muscle remains in a state of contrac- ture. " c. As a rule several shocks are needed to give this per- manent contracture. " 4. Contractures are brought on by : " Deep muscular massage. "A succession of raps upon the tendon. " Stretching and flexion of the limbs. " Injury to a nerve. " Application of a vibrating tuning-fork. " Faradization of the muscles or nerves. " Magnetism. " Superficial excitement of the skin by light pressure. " Suggestion while the patient is awake. " These various methods are not of equal efficacy." Sollier and Malapert speak in the following manner of voluntary contraction in a hysterical patient : " Contraction, whether organic or the result of experi- mentation, may be defined as a pathological state of the muscle characterized by an. involuntary and continuous rigidity. A man thirty-five 3 7 ears old, an acrobat by pro- fession, has suffered a slight muscular rupture of one of the adductors of the thigh. His father was not of a ner- vous temperament; the mother suffered from migraine and an aunt was somnambulistic. The patient himself has met with several professional accidents ; at the age of sixteen he was operated upon for a tuberculous testicle. " His health is good, although he is a heavy drinker and suffers from alcoholic tremors ; strange to say, he has but little strength in his arms. The peculiarity which he possesses is that he can at will induce a contracted con- dition of certain muscles. He stretches his arm horizon- HYSTERIA. 175 tally, the anterior surface turned upward with his five fingers in apposition at the tips. While he watches his arm with great attention, the flexors forcibly contract, and are followed by the supinator, brachialis anticus, and finally the posterior muscles. The forearm meanwhile is affected with increasingly severe spasmodic twitchings. Then suddenly the hand is placed in forced pronation, and then it and the forearm are placed in forced extension. The arm drops alongside of the body at an angle of 20° ; the whole proceeding has taken from ten to fifteen seconds. In the condition described the muscles of the hand and those of the forearm are absolutely contracted, the contrac- tion diminishing from the distal extremity to the origin of the limb. The extended fingers cannot be closed. The wrist can be moved a little, the elbow a trifle more freely, and the shoulder still more readily. The flexors of the fingers are hard and contracted, but less so than the exten- sors. This state of contraction may last for more than an hour, and can be brought on at will, the patient feeling no cramps at all. He can act upon the abdominal muscles in the same way. He first contracts the recti abdominis, and as the thorax enlarges the intestines seem displaced upward. The abdomen is then suddenly depressed and the whole intestinal mass is pushed upward, all the organs being displaced. It is possible for the patient to walk, talk, eat and drink in this condition, which lasts from ten to fif- teen minutes. In putting an end to this performance he proceeds slowly, the whole mass sinking gradually into position. "This man is a typical hysteric. His pharynx has no sensibility, as is proved by the power he possesses of swallowing glass; at times he has a globus in the region of the right floating ribs. He is deaf in the left ear 176 FUNCTIONAL NERVOUS DISORDERS. and slightly so in the right. His sense of taste is much impaired." In hysteria both circulatory and respiratory symptoms or disorders are common. Pulsations of the abdominal aorta, which, owing to a stiffness of the abdominal walls from local inflammatory states are readily transmitted to the palpating hand, are often in these cases mistaken for aneurism. Tachycardia, or rather palpitation and irregular beating of the heart, are also common, the rate of beating sometimes going as high as two hundred in the minute. " In severe attacks of hysteria, swelling of the neck is of frequent occurrence, but it is seldom seen as a permanent symptom between the paroxysms. Richer has seen one case at the Salpetriere. It is the result of blood stasis, itself the result of respiratory and muscular spasm. The stopping of respiration stops the call for venous blood to the thorax which is produced by every respiratory move- ment; the contracted muscles compress the veins of the neck as they enter the chest and more or less interfere with the flow of blood. As the neck enlarges the tissues become congested, the superficial veins enlarge and bulge out under the skin ; this congestion spreads to the face, the lips, the eyes, etc. These phenomena are at times so striking that they give a special character to hysteria." Emile Boix gives a case of blue hysterical oedema : " The patient is a man of thirty-five years. There is a history of neuralgia in some members of the family. The patient was troubled with incontinence of urine up to the age of fourteen years. He has had three attacks of rheu- matism, and has twice had facial erysipelas. There is no history of specific trouble. In August, 1888, he had pain- ful cramps in the right hand, especially when attempting to grasp any object ; then the hand became cold, pale, and HYSTERIA. 177 numb, so that he was unable to use it. On the fourth morning after the onset of the attack, the hand was enor- mously swollen. He then entered the hospital, and pre- sented the following symptoms : His right arm was par- alyzed, the hand cedematous, cold, and bluish in color, stiff, with absolute absence of feeling in the fingers. The pharynx was also anaesthetic ; the eyes were normal and there was no other perceptible trouble. " The patient was put under the influence of chloroform, and the hand turned pinkish in hue; its temperature was higher than that of the left hand. It remained quite stiff, which was doubtless due to the rheumatic trouble, as there were fibrous bands present; sensibility returned and the paralysis and oedema disappeared, all within the twenty- four hours. " On January 1st, 1890, the man returned to the hospital, again complaining of the swelling in his hand ; the thumb was also involved, as well as half of the forearm. In March the oedema had disappeared, only to reappear in August. In December of the same year the condition of the patient is as follows. He is a tall, fair man, with blue eyes; his hair is scrupulously parted and his moustache curled ; his voice is altered ; in short he has the character- istic appearance of an hysteric. The muscular develop- ment is only medium ; his right hand only is affected, the arm seems paralyzed, the patellar reflex is normal. On his right side he is insensible to touch, and the sensibility to heat and cold is much diminished; the pharynx is still anaesthetic, this anaesthesia being shared by one half of the tongue, the right nostril, conjunctiva, and ear. Taste, smell, and sight are affected upon the right side. The hand, especially upon the dorsal aspect, is swollen, almost to bursting; its color is still blue. The oedema is not affected by position, and, although it pits on pressure, the swelling immediately returns. The hand is absolutely insensible; it remains in a flexed position, and when an attempt is made to move the fingers the muscles of the forearm are affected as in spinal epilepsy. At times there 12 178 FUNCTIONAL NERVOUS DISORDERS. is a rhythmic tremulousness of the hand. There is exces- sive perspiration of the right axilla. " Three facts are worthy of ©special notice in this case. " 1. The coloration of the hand was changeable, passing from a violaceous blue to a whitish tinge, as in the case of oedema due to a cardio-renal lesion. " 2. Although the oedema felt hard, the fact that it would pit upon pressure made it probable that it was elastic oedema. "3. The temperature of the hand was found to vary in its different parts, the variation at times being as much as 16.4°. " The suggestion that the effect of hypnotism should be tried appears to have alarmed the patient, and to have caused his disappearance. He was evidently averse to having the condition cured, as it obtained support for him in the hospitals." Wallet gives this description of hysterical anorexia. " This is found only in young girls, usually between the ages of twelve and fifteen. When present, it is usually the only symptom of hysteria. Its persistence and the rate at which it increases unless promptly and energeti- cally treated would lead one to believe that it was due to a nervous degeneration. " It is of indefinite duration, and when weakly indulgent parents do nothing to overcome the obstinacy of the patient, as sometimes happens, death is the result. The weakened condition of the patient makes her an easy victim to disease, more especially tuberculosis. To quote a case in point : "Miss B., seventeen years of age, was brought to the Auteuil Hydrotherapeutic Institute in a terribly emaci- ated condition. All the bones were plainly visible, the muscles were easily felt, the skin was dull and lifeless, cold and clammy. Her eyes were sunken, lips swollen, HYSTERIA. ' 179 tongue coated, and breath foul. The skin of the legs was blotched in appearance; there was slight oedema of the feet and ankles, which pitted on pressure. The patient was very constipated, and her menstruation had ceased. The visual field was slightly diminished. She was very fond of walking, and this exercise was allowed her on the condition that she would consent to take her food. As no improvement followed, long walks were forbidden, and she was not allowed to go beyond the boundaries of the garden; even this limited amount of exercise had to be stopped, the patient confined to her room, and finally to her bed. She still contrived to get more exercise than was good for her, as she had the fixed notion that repose would fatten her, and she thought that her looks were im- proved by extreme thinness. After six weeks' treatment menstruation reappeared, and her weight increased from 27 to 34 kilos." Hysterical fever, as the result of nervous excitement, usually begins with a chill which is followed by the fever- ish symptoms; these are usually confined to the face and head. The patients easily become delirious, and may have tremor or convulsions; the mouth is dry and the appetite impaired. The temperature rises, and the pulse increases from normal to 100 or 120 a minute. Under the head of vascular secretory neuroses may be placed hysterical salivation. It is not common, but has occasionally occurred. Hysterical psychoses manifest themselves in the lighter forms by excitability and great sensitiveness to matters of minor moment; by sudden changes from sadness to gayety, or by attacks of sullenness and obstinacy. In the more pronounced forms, melancholia or mania may de- velop. Brissaut and Souques report the following case of delir- ium of hysteria. 180 FUNCTIONAL NEBVOUS DISOEDEES. "A young girl, 9 years of age, of nervous origin, fell upon her right hip, and as a consequence had pain, swell- ing, and redness of the parts. The swelling subsided, but left in its place a psychical hyperesthesia which lasted for ten years. It showed itself in various ways, such as vomitings, swelling of the abdomen, and attacks of un- consciousness. " Through a mistake in diagnosis she was at first treated for coxalgia, then for abscess with peritonitis, and was on the point of being treated by laparotomy. It was really a case of hysterical simulation, probably induced by the questioning, explorations, and treatment of the ph} T sician. " At the age of thirteen, injudicious friends began to tease her about getting fat, and thus she became impressed with the desire to become thin. Her method of attaining this end was to eat as little as possible and to vomit all that she did eat. For some time her wish to grow thin was somewhat latent, although a fixed idea, but at the age of sixteen the teasing became too much for her to bear, and she absolutely refused food. She became alarmingly emaciated, and was several times at the point of death. In an ecstatic religious state she sought help at Lourdes, and the first time apparently received benefit; the second time, however, the pilgrimage did her no good, and this fact threw her into a state of despondency, as she imagined that she must have fallen from grace, probably because of unconfessed sins. This despondency changed into a fixed mania. Under treatment she gained thirty kilos in weight in three months' time. This sudden regaining of fat is seen only in hysterical patients." In somnambulism of hysterical origin, as in the ordinary type of somnambulism, the supervision of the mind over the organs of special sense is for the time being sus- pended. Some consciousness is present, but it is not usually of sufficient intensity to leave much if any impression on the mind when the patient is awakened. There is generally present in hysteria more or less intense HYSTERIA. 181 inclination to sleep, which may go on to lethargy, a con- dition which may last several days. This has been de- scribed as transient catalepsy. Several kinds of spas- modic manifestations most usually precede the state of somnolence. The pulse becomes small and intermittent ; the breathing is slow and in some cases scarcely to be detected. The skin is dry and cold ; the bladder loses the power to evacuate its contents, rendering necessary the use of the catheter. The bowels also lose their power to act, and may remain in this condition for weeks. The most powerful stimulation is needed to arouse the patient from this state for even a short time. At the termination of hysterical convulsions there is a somewhat similar condition of somnolence, but the fact that it is of short duration, and is followed by alleviation of the patient's symptoms, will serve to distinguish it from the state here described. The most unusual and severe form into which this hysterical somnolence may pass is the condition known as hysterical trance. The patient sees and hears, either per- fectly or in part, what is going on around her, but is un- able to move or to call out. There is a condition known as disease mimicry. We all remember our mothers' early warning that " mocking is catching." From automatic conditions this is a natural tendency. Mimicry of normal and abnormal conditions exists, an example being the suffering of sympathetic labor pains upon the part of husbands present during the parturi- tion of their wives, or their sufferings from the morning sickness of pregnancy. Francis Bacon speaks of this morning vomiting, and Dr. Weir Mitchell reports such a case. The treatment of hysteria may be divided into (1) psychical, (2) separation of the patient from her friends 182 FUNCTIONAL NERVOUS DISORDERS. and usual surroundings, with such other moral treatment as may be deemed proper, and (3) medical treatment. In the last-named, the effort must be to combat the anaemia present by tonics and a large amount of meat in the diet. Massage and electrical baths with the static and inter- rupted current are also useful adjuncts. The moral treat- ment consists mainly in removing the patient from the pernicious influence of relatives and friends who, although meaning well, do harm. Functional diseases of the nervous system are in the great majority of cases due to malassimilation, as is the case with the organic diseases. In both acute and chronic cases the results obtained by treatment will depend upon the care which we bestow upon the digestive organs. In the physiological cure of disease the state of the digestive organs is the all-important factor; medicines may assist, but it is quite as probable that they often retard recovery* CHAPTER XX. HYSTERO-EPILEPSY. Hysteroepilepsy, according to Charcot and Richer, is only hysteria in the highest degree, and not hysteria com- plicated with other neuroses. Although hysteria in the male is not an extremely rare occurrence, still it is so fre- quent among females that it might be said to be the char- acteristic disease of that sex. I have seen one case of hystero-epilepsy in a lad, which came on from a fall and a great fright; and there are many physicians who have seen cases where the male patient imagines, or learns for the first time, that he has some fatal disease, or where, after some great physical or moral shock, he becomes as hysterical as a woman. In hystero-epilepsy there is the hysterically nervous con- stitution combined with the depressing effects of anaemia, prolonged anxiety, mental shock or excitement, and the stimulus of uterine and ovarian disturbance starting up the hysteric aura. In about all the functional diseases of the nervous system of women, the general condition is the same — the co-ordination and harmony of the cerebro-spinal and ganglionic nervous systems are sadly out of tune. It matters not what pulls the patient down, whether it is an exhausting menorrhagia or great mental anxiety, the re- sult is the same, and manifests itself often in these ex- plosions of weakness. 183 184 FUNCTIONAL NERVOUS DISORDERS. The hystero-epileptic attack according to Richer is di- vided into four distinct periods : 1. The epileptoid period. 2. The period of contortions and great movements. 3. The period of emotional attitudes. 4. The period of delirium. The epileptoid period has a tonic phase, a clonic phase, and a phase of resolution. Loss of consciousness was com- plete during the entire epileptoid period in the following cases, as is the rule, and all the attacks were more or less complete. In speaking of the rarity of this disease, which Fig. 16. —First or Epileptoid Period. makes its study more interesting, Dr. S. Weir Mitchell writes " that in my experience, and it has been very great, these terrible cases are rare in America in any class of life, and most uncommon in the lower classes, among which Charcot seems to have found his worst and most interesting cases. In this disorder there is, I suspect, some difference between this country and Europe. " Dr. Charles K. Mills says that hystero-epilepsy of im- perfectly developed or irregular type is a not uncommon affection in this country, but the disease in its regular HYSTERO-EPILEPST. 185 type is comparatively rare. Dr. Allan McLane Hamilton Teports two cases. Hart and Barbour state that it is rare in Great Britain. They have seen one case in which it was present in a modified form. Many physicians whom I have met, both in Paris and New York, seem to believe that hystero-epilepsy is a Parisian disease, and rarely, if ever, met with elsewhere. 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P CO a pH © S 8 Id +3 o 03 _E P U o 02 P © o 8 § q=! 9 +3 , CP o © .as CO C? ^ t> s? 8 OS 8 QQ ■+3 DC P © 'O © r^ +j Fh 43 -si -■a o p © s 3D 43 . © co S 8 c p © s 03 © a c 43 o.a s^o S ° o3 U >> ►» PhCO Q Q J , © 1 •2 o *03 p © © co +3 !h 03 43 •+3 >> 03 8a cS pP e3 pH © *03 © pP ©" 43 CO 43 o p>» .2 © pP s p '© T3 ■4^ 03 g OQpQ si pp 43 03 83 P "C co © o Ph-*3 qq- £$ P © ft O pp P CO j™ P O P CO O 43 co "fH 43 0> s CO > c S3 U co h3 o O k> vi > 68 JS 1 03 o: _ P P P Ti O o O CO s M M pO -H P P co- o o3 co pew 73 ^5 .P CP s P P eS CO ... O 03 03 t-V* § § -S2 p-i > Mg © © p«M £ fc < S> CSJ CO seen it was of a stertorous character. The skin is of a. pale and death-like hue; the pulse is usually feeble and frequently accelerated. This condition is not very rare when disease of the brain is present, and it often coexists with insanity. It is cer- tainly a curious and interesting affection, and, being of a rather marvellous type, is a subject of great interest to non-medical readers. The daily newspapers frequently publish cases of cata- lepsy or trance; the result of reading the articles is to excite a dread of being buried alive, and is thus the cause of considerable mental suffering among weak-minded peo- ple. As undoubted cases of this horrible occurrence are upon record, it is essential that the condition should re- ceive from the physician the study and investigation which it deserves. The following case of trance was described to me by a patient, an exceedingly intelligent woman and a close observer, who was an eye-witness of the occurrence. Case I. — Mrs. K. L. is 48 years old, and extremely ner- vous; she has had one child. Her husband, a sea captain, causes her a great deal of worry on account of his vicious behavior. Her affection for him is very great, but he does HYSTERO-EPILEPSY. ■ 225 not return it. She is tall and rather emaciated, has dark hair and gray eyes, and a sallow complexion. For the past five years, she has been having so-called "fainting-fits." These come on suddenly, and she usually comes out of them in from half an hour to an hour. On one occasion, exhausted from the exertion of ironing a dress for her daughter of 12 years, she fell into one of these fits, and remained without motion from 7 p.m. until 10 p.m. the next night — near twenty-seven hours. She was cold and seemed to be perfectly lifeless. Those in attendance ap- plied a hand mirror to her mouth to see if there was any respiration to deposit moisture upon it, but there seemed to be none. After this incomplete test the neighbors pro- nounced her dead and proceeded to make her shroud. Dr. John Osborne was called, and said that she was liv- ing. He requested to be called again if there were any change in her condition. During these twenty-seven hours, Mrs. L. says that she was conscious of every word that was spoken, and of course heard the remarks about her supposed death. She said her only hope was that when her child returned from the entertainment to which she had gone, she would in her fright throw herself upon her neck and awaken her. She was unable to see, but hearing was normal. Attempts were made to administer food, but she could not swallow. She claims to have been entirely conscious the whole time, and must have endured agonies of mental torture. A pricking sensation in the lower limbs ushered in a gradual return to a waking state. The attack was followed by shivering. She said that she was quite convinced that they would bury her alive. She thought that the attack had some connection with the menopause. She lived for fifteen years after this incident. In cases of apparent death in the state of catalepsy, every effort should be made to resuscitate the patient by means of galvanism, transfusion, etc. ; and in many cases where death seems to have occurred beyond a doubt our efforts will be crowned with success. Decomposition is 15 226 FUNCTIONAL NERVOUS DISORDERS. the only positive, irrefutable evidence of death. The vital spark may be latent, only needing the application of fara- dism or galvanism, or both, to fan it again into activity. There is no doubt whatever that many persons have been buried alive in a state of catalepsy who might have been 'i restored to life, had the proper means been taken for their reanimation. In my opinion, the efforts to resuscitate the apparently dead in this condition should end only with the appear- ance of evidences of commencing decomposition. Attacks of trance frequently alternate with attacks of hystero-epilepsy. They are undoubtedly dependent upon some form of vasomotor disturbance in the cerebral circu- lation. In these cases, the pulse in the beginning of the attack is extremely rapid and irregular; afterward it becomes less frequent and more feeble, dropping down to 40, and finally being quite imperceptible at the wrist. In some cases even the heart cannot be heard to beat with- out careful auscultation with the stethoscope. Under such conditions a person might easily be buried alive. In the cases under discussion, neither respiration nor circulation is perceptible, the patient frequently lying in this con- dition for hours or even days. The onset of catalepsy is very rarely sudden ; there are usually some premonitory symptoms, e.g., headache, in- somnia, nervous irritability or excitement, illusions, and sometimes convulsions of a mild character. At the time of the seizure the entire muscular s} T stem is affected with a sudden rigidity. Cases are rare in which only certain limbs are affected. The muscles for a time are fixed, and the limbs can be neither flexed nor extended, the patient remaining in the exact position she was in at the time of the attack. The eyes are often directed upward, having HYSTERO-EPILEPSY. 22? a wild, staring expression. Sometimes the lids are closed, but usually they remain open. After a period of fixed rigidity, the muscles assume the condition known as " waxen flexibility" ; the limbs or fingers can be placed in any, even the most abnormal, position, and will remain as placed for a considerable length of time. A patient can even be stood upright on his feet, and with the very slight- est support will retain that position. The patient upon recovery has no recollection of what has occurred during the attack, and in some severe cases anaesthesia and analgesia are present ; in others, however, the patient retains sensibility to a certain extent, but reflex movement is absent; the nostrils or the soles of the feet may be tickled without eliciting any manifestations of sensation. In some cases the conjunctiva may retain its sensibility. The functions of the bladder and bowels are performed slowly; a piece of food introduced into the pharynx is usually swallowed without difficulty. In some cases, after the power of voluntary motion has been recov- ered, the " waxen flexibility" of the limbs may still persist. Some patients while in the cataleptic state have a per- fect consciousness of everything that is transpiring around them; others have a partial and indistinct idea of what is happening; while others again are totally oblivious to their surroundings and their loss of consciousness is com- plete. The recovery from one of these attacks is always sudden ; the patient starts up with a yawn or a sigh, as if from a deep sleep. The paroxysms, as a rule, at first occur without any regularity. After the initial attacks the patients are usu- ally in good health, but after the occurrence of many and severe seizures they suffer for some time from hysterical symptoms, headache, vertigo, and general prostration. 228 FUNCTIONAL NERVOUS DISORDERS. The causes of catalepsy are very seldom local, but affect the entire system. Nervous, hysterical women are the most common subjects. Violent emotions, mental excite- ment, impaired diges- tion, disordered menstru- ation, nervous exhaus- tion, and similar causes are the exciting factors of this condition. The seizures are most common in young adults, about the beginning of the period of active uterine life, or in those more advanced in life who have uterine disease. Dr. Gooch relates the following case, which is a good example of the disorder : The patient was a woman, the victim of melancholi a. Shortly after parturition she was seized with the cataleptic attack, and presented the following appearan- ces: She was lying in bed motionless and apparent- ly senseless. It was Fig. 26.— Catalepsy in Melancholia. Patient keeps this position for half an hour with- out moving. thought the pupils of her eyes were dilated, and some apprehensions were entertained of effusion on the brain j but on examining them closely it was found they read- HYSTERO-EPILEPST. 229 ily contracted when the light fell upon them. Her eyes were open, but there was no rising of the chest, no movement of the nostril, no appearance of respiration. The only signs of life were warmth and a pulse which was 120, and weak. Her fseces and urine had been voided in bed. In attempting to rouse her from this senseless state the trunk of the body was lifted up and placed so far back as to form an obtuse angle with the lower extremities, and in this posture, with nothing to support her, she continued sitting for many minutes. One arm was now raised, and then the other, and in the posture they were placed they remained. It was a curious sight to see her sitting up staring lifelessly, her arms outstretched, yet without any visible signs of animation. She was very thin and pallid, and looked like a corpse that had been propped up and stiffened in that attitude. She was now taken out of bed and placed upright, and attempts were made to rouse her by calling loudly in her ears, but in vain ; she stood up, indeed, but as inanimate as a statue. The slightest push put her off her balance, and she made no exertion to regain it, and would have fallen had she not been caught. She went into this state three times ; the first lasted fourteen hours, the second twelve hours, and the third nine hours, with waking intervals of three days after the first fit, and of one day after the second; after this time the disease assumed the ordinary form of melancholia. The case of M. C, which follows, shows the effect of malarial fever, together with exhausting uterine disease, in the production of the lethargic or trance state. Exces- sive leucorrhoea in frail, delicate women is not only pro- ductive of profound nervous disturbances and physical exhaustion, but, in a great number of young women, is the principal causative factor in the production of phthisis. The leucorrhoea in these cases is usually secondary to the maldigestion, although sometimes it precedes it. The case especially shows the well-known value of Fowler's 230 FUNCTIONAL NERVOUS DISORDERS. solution as a tonic in these conditions of exhaustion of the nervous system. Case II.— Lethargy, Trance, Recurrent Orgasm De- pendent upon Oophoritis, Endocervicitis, and Leucor- rhcea. — Miss M. C, teacher, age about 26, is frail and very delicate. A few months previous to her first menses, which commenced at 14, this patient had her first attack, during which she could neither speak nor move, but was perfectly conscious. In 1873, she had a severe attack of chills and fever and has since suffered more or less from malaria. She has always been a heavy sleeper, and al- though she has done all she could to combat her drowsi- ness, it would overcome her, no matter what position she would take. She has slept standing, sitting, and kneeling ; her head during this time would seem of a ton weight. In 1879 she became very nervous, and for two or three months she slept from twelve to fourteen hours each day, and even then she still felt drowsy, but her head was much relieved. Part of the time she had a feeling as if an iron band were tightly pressing the crown of the head. Leu- corrhcea then commenced, and has continued more or less ever since. In the summer of 1886 she was very weak, and afternoons while resting, and oftentimes before going to sleep at night, she would have the following sensations: At first she would lose all power of feeling in the hands and feet, until gradually the whole body became numb; at the same time she had the hallucination that she was as- suming immense proportions, each tooth seeming to ex- pand, and she could feel the nerve of each separate one throbbing. Very often at this stage she would jump up in great fright, her heart beating violently and the whole body trembling; at others, after a while she would fall into a heavy sleep. At other times on awakening she was conscious of all that happened around her, but was utterly unable to move or speak. She has recognized persons entering the room, heard what they said, and has done her utmost to let them know she was awake, but could not HYSTERO-EPILEPSY. 231 move a voluntary muscle of her body. She has, at such times, tried to move a finger or a toe or an eyelid, but could not succeed. She has sometimes been an hour trying to rouse herself out of this state, and when at last she suc- ceeded, the efforts made would leave her very much ex- hausted and bring on a severe palpitation of the heart. She had these attacks very often during the summer and autumn of 1886, but was not seriously ill until December, when I first saw her. She was then very feeble, but under treatment improved greatly. In April, 1887, she began to have recurrent orgasms, which occurred regularly ten days after menstruation, continuing daily for a week. These lasted until July, and caused a return of the cata- leptoid state. On examination, the uterus was found ten- der and eroded, with tenderness and enlargement of both ovaries. She was given phosphorus pills, Fowler's solu- tion in large doses, and fly blisters were applied over the ovarian region. Electricity (faradic current) increased the number of orgasms. Fowler's solution produced great improvement, and she now enjoys good health. Case III. — Trance or Cataleptoid State; Ovarian Hypercesthesia, Cervix Eroded, Dysmenorrhcea, Leu- corrhcea. — Miss A. B., age 23, has severe headaches which come on before the menses ; very severe pain in the left ovarian region comes on with the menstral flow. She has leucorrhcea, and on examination the pelvic peritoneal plane is found to be very sensitive ; the cervix is eroded. She is at times very hysterical. She has had an attack of severe pain in the epigastrium during which she w r as cataleptoid; this persisted for a considerable time. Under treatment by curative exercise, hydrotherapy, and massage she made a good recovery. Excessive fright is a common cause of severe functional nervous disease, as is also a lack of judicious restraint upon the emotions. Jealousy, as in the following case, is 232 FUNCTIONAL NERVOUS DISORDERS. a common cause of hysterical manifestations in those who are the victims of defective hygiene. Case IV. — Hystero- Catalepsy ; Trance, Ovarian Hypercesthesia, Menorrhagia. — Miss L. L., age 18. Her father is dead, her mother a drunkard and quarrel- some. January 10th, 1888. Her first attack was six months ago from a fright, some one having placed a " stuffed man" in her bed. This attack lasted three hours and was followed by slighter attacks. A month ago she had another severe attack, has been very nervous, and is jealous of her lover. She has had a severe cold. At 2 P.M. to-day, she went off into a "sort of faint"; there were no twitchings nor convulsions. When I saw her, her pupils were contracted to pinhead size. She has general cutaneous anaesthesia, responding but slightly to severe tests. Pulse is jerky and irregular, limbs in a cataleptoid state, skin cold, and she looks like death. January 11th, her condition was unchanged. Suddenly she gives a jerk, throws both arms backward and extends them, and goes into an ecstatic condition. During the attack she has very marked internal strabismus and is cataleptoid. Later I learned that the bowels have been constipated for five days, and that she has pain in the back of the head and precordial region. She has had dysmenorrhcea ever since the function of menstruation was established. During the last month she has men- struated twice and very profusely. There is ovarian hyperesthesia. Mistakes in diagnosis are of course frequent, but the error made in the following case should serve to put us all upon our guard against classifying simple functional reflex disorders as cases of profound local disease. The case also shows what has been noted in other instances, that not only a condition of anaemia but one of supposed cerebral hyperemia may precede the cataleptoid state. A sensa- HYSTERO-EPILEPST. 233 tion as of hammering at the vertex, joined to excessive redness of the face, has been noted in many patients suffer- ing from various functional nervous disorders. Case V. — Trance of Cataleptoid State j Spinal Irri- tation, Globus Hystericus, Endometritis, Leucorrhcea, Retroflexion, Menstruation Never Regular. — Miss M. KT., single, age 26, menstruated first at 20; at 17 she had a discharge of thick, yellowish leucorrhoea, which continued a year and six months; she was kept in bed thirteen months by a physician (for supposed suppurating spinal disease discharging by the vagina). The spine is tender from the middle dorsal region to the coccyx, this tender- ness having been very marked at the time when the physi- cian ordered her to keep to her bed. At the time when the menses were appearing, she had an attack of vicarious hemorrhage from the stomach. Menstruation is never regular. She has pain in the temples and neuralgic head- ache; the skin is sensitive. There is a bright flush on both malar bones, and the least excitement gives her a momentary but intense blush. The tongue is coated white; pulse 100, strong and full; stomach swollen. She has pain in the left ovarian region, extending to the back. Since the age of 18 she has had attacks in which she was sleepless and frightened at night. The attacks came, both when asleep and awake, with a sensation of compression in the brain, the face being at this time very red, and were followed by a creeping sensation beginning at the toes and fingers and going to the head ; then ensued a cata- leptoid state. She could moan but could do nothing else — could stir neither hands nor feet. To-day, May 20th, 1889, the globus hystericus " is one minute in the throat, and the next back again to the left ovarian region." She has cold and clammy feet and hands. Appetite is poor, and she is easily nauseated. On examination I find endometritis and retroflexion. Agonizing and unbearable pain, not only in the ovarian but in the epigastric region, is a very common, if not the :; : i . N JTIOXAL 8TERV0US sob most frequent, exciting cause ;: both hystero- epilepsy and [ : the catalej toid state. Case VI. — Tn / Cataleptoid State; Ovarian srcesthes \ . . :. Palpitations, LaceraU n\i\ Granulations. — Mrs. L. is a widow, age 30, Her attack .: hystero-eataleptoid state comes on from agoniz- ing pain in the ovarian region before menstruation : she is constantly nauseated, and is very nervous. The a: lasts but a tew minutes: she rinds it impossible to move or speak, "is oold as ice," and sweats profusely. It is sometimes followed by extreme prostration. She has mi- graine. Examination reveals laceration of the cervix on the left side, with granulations. Case VII. — Airs. K.j 33 years of age. is a nullipara, al- though married for a number of years. December 10th, IS! C she complained of feeling very badly: her head was sore from neuralgia, she had no appetite, her stomach was distended, and her tongue was heavily coated. I just succeeded in relieving her of a tapeworm in the fol- lowing manner: I prescribed a mixture containing . hm of kretol to four ounces of water, of which she took a dessertspoonful every two hours. This was fol- lowed by a large dose of castor oil. and within an hour the worm was brought away complete. Before this she had been suffering much with " bloating" of the belly and s in the legs, and had had grinding of the teeth at night. The excessive evacuations produced by the castor oil made her feel very weak, and while sleeping the trance or cataleptoid state came on. She heard the letter carrier : ing the door bell, but could not get up to answer it. She knew where she was and tried very hard to move, but found it impossible. There was " no dream about it" : it - simply that she was powerless to move. When she finally came out of this state, her feet "felt as heavy as lead." and she could not be induced to lie down again for tear of a return of the attack. HYSTERO-EPILEPSY. 235 In her case, the condition of the digestive organs and the anaemia present, together with the excessive drain upon her system from the energetic action of the oil, were sufficient to induce this cataleptoid attack. The following case illustrates a mild form of trance or the cataleptoid state, or an allied condition. Case VIII. — Mary G., 27 years of age. The disease began with great mental worry. She is now extremely nervous. She has had three attacks in which her legs " gave way" ; she becomes suddenly weak and numb all over the body. These attacks do not last very long ; they are not the same as attacks of syncope, but consist of a sudden numbness or powerlessness. At the present mo- ment, although her appetite is fair and her color good, her feet and hands are numb, and she frequently experiences creeping sensations in the extremities. The attacks come on with a severe nervous chill, and are followed by hys- terical trembling. Under dietetic and medical treatment she recovered. The following case of cataleptoid state illustrates the intimate connection between the digestive and nervous systems, and the dependence of nervous manifestations upon malassimilation, these conditions resulting from overwork and bad food. Case IX. — Agnes G., an anaemic young girl, suffers severely with frontal headaches, which come on three days before menstruation. The face during this time feels cold, and there is a sensation of coldness on the vertex as if it had been " wet with cold water:" I frequently find that the headaches of anaemia are also present immediately before menstruation. In this case there were also severe cramps of anaemic dysmenorrhcea coming on immediately after the appearance of the flow. The pain is most severe in the left ovarian region and in 236 FUNCTIONAL NERVOUS DISORDERS. the back ; her feet " are never warm." On vaginal exami- nation I find considerable leucorrhcea present, and the peritoneal plane is considerably inflamed and quite sensi- tive. She consults me principally for severe attacks of gastric pain, during which she completely loses control of herself, and can neither speak nor move. This state lasts for the space of twenty minutes or more. After a time she gradually recovers both motion and sensation. Her digestion is markedly embarrassed, as the result of over- work and a bad selection of food. She takes strong tea in large amounts. Ecstasy. Ecstasy is a state of the system in which the mind is apparently absorbed by some dominant idea, the patients being at the time totally insensible to their surroundings. The condition is somewhat similar to that of catalepsy, and is by many authors considered to be identical with trance, of which it is probably a form. It is frequently present after a hystero-epileptic attack. The visual hallucina- tions which often occur are the most remarkable features of this condition. The mind is active and the visions are remembered after the attacks are over. In cataleps}^, however, there is usually total oblivion during the attack. At this time the pulse remains normal. Attacks are often epidemic during periods of religious excitement, when they usually take the simpler forms of the maladj\, They are quite common at negro revivals and among the primi- tive Methodists. The "convulsionnaires" were a set of religious ecstatics existing before the French revolution. The Dervishes in Egypt, and the Jumpers of eastern Maine and New York, are also specimens of this class of religious contortionists, who suffer from a mild form of mania. The disease is communicable by imitation, espe- HYSTERO-EPILEPSY. 237 cially among the ignorant. "Mocking is catching," not only among children but among adults, and especially is this so when the disease is epidemic and its manifestations assume the more noisy and ridiculous forms. This was seen in the spasmodic epidemics of the Middle Ages. The dancing-mania lasted for a period of one hundred and fifty years in Germany. Many of these ecstatic cranks pretend to find in the Bible examples to justify their capers. Among the exciting causes of ecstasy, emotional dis- turbances, especially of a perverted religious character, are the most prominent. Severe and prompt measures should be used to suppress these epidemics. At one time, in the Infirmary for Chil- dren and Young Girls, I had an epidemic of chorea in which about a dozen children were affected. Isolation, with but little other treatment except Fowler's solu- tion, was sufficient to cause its almost immediate disap- pearance. Somnambulism. Somnambulism is frequently present in cases of hystero- epilepsy as a part of the attack, following the more pro- found disturbances. It seems to be a very mild form of delirium or cerebral irritation. The mildest type consists simply of talking during sleep, but in the more severe forms the patient leaves the bed and walks about, and if the cerebral excitement be still more marked he even goes into the street and walks long distances. It is quite com- mon in nervous and excitable children who are fed freely upon indigestible food. Adults who are subject to it are usually such as are suffering from profound mental anx- iety, or who are engaged in exhausting mental occupation. Upon awaking in the morning there may sometimes be 238 FUNCTIONAL NERVOUS DISORDERS. a faint recollection of what has occurred, as the disease is really only a very pronounced form of dreaming of which movement forms a part. A good description of a typical case is given by Shakespeare in his portrayal of Lady Macbeth. In the treatment special attention should be given to diet and the condition of the digestive organs. The men- tal state previous to retiring should be calm. Precautions should be taken to have the windows of the somnambu- list's room so fixed that he cannot walk or fall out of them, as many have received serious harm in this manner. Cerebral excitement resulting from excess of the emo- tions, or from intellectual exertion, are causative factors in this disease, and should be avoided. Overloading and embarrassing the digestive organs with an excess of greasy and improperly prepared food tends to disturbance of the cerebral circulation by causing hyperemia, with somnam- bulism as a result. In some young patients somnambu- lism tends to become a habit. It is well to sleep with the head well raised. Only light meals of easily digested food should be taken several hours before retiring, and fully an hour before a glass of hot water should be drunk to re- move gastro-intestinal irritations and act as a sedative to the digestive tract. When the hot water is taken immedi- ately before retiring it acts as a stimulant to the circula- tion and induces cerebral hypersemia. There are some patients who require a little food, such as a cracker or a piece of toast and a small glass of milk very shortly be- fore retiring, and who cannot sleep without it. When such patients are subject to somnambulism, the greatest care should be exercised that only the smallest amount of food is taken, as indigestion predisposes to cerebral con- gestion, which is already present in these cases. HYSTERO-EPILEPSY. 239 One method of arresting the attack of somnambulism is to place a slab of marble, a piece of sheet-iron, zinc, oil- cloth, or any such cold body beside the bed, in such a position that the sleepwalker must first step upon it. As a rule, he will go no further ; the cold thrill sent through him will partially awaken him, and he will return to bed. Insomnia. Cerebral hyperemia is the most common factor in the production of wakefulness. An excited or active state of the brain, with an increased amount of blood in its tissues, are the conditions usually present. The removal of the irritation and hyperemia is therefore essential before sleep can be procured. After great mental strain or great phys- ical effort, insomnia usually follows, due probably in these cases to hyperaemia of the brain as a result of weakened heart action. Where there is an exhaustion of the vaso- motor nerves, there is a deficient tone in the cerebral ves- sels, and a passive hyperaemia results. Cerebral anaemia is, as a rule, present when the patient is drowsy, although in diseased states wakefulness may be produced by it. Insomnia should in many cases be looked upon as a neurosis dependent upon disease of the liver and other organs. Patients suffering from severe malarial fever seldom sleep well, and in these cases the h} T pnotic action of quinine is marked, in addition to its other valuable properties. In conditions of exhausted nerve force with insomnia, the stimulation arising from a full meal often causes the patient to become drowsy and sink into a sound sleep. The irritation of an empty stom- ach and the consequent cerebral hyperaemia cause much wakefulness. It is a custom with many persons to take a 240 FUNCTIONAL NERVOUS DISORDERS. sandwich and a glass of light beer before retiring, and in fact anything which stimulates the solar plexus of the sympathetic in these cases has a soporific action. I do not, however, consider this to be a good practice, as digestion is always markedly slower and more feeble dur- ing sleep. The drinking of coffee and tea, even in mode- ration, will sometimes, especially in those unaccustomed to their use, prevent sleep. Wines, especially those diffi- cult of digestion, when taken in moderate amount, may produce wakefulness, but copious libations would probably produce the opposite effect. Monotonous sounds or the reading of uninteresting books have a soporific influence, as has the counting of numbers in a chanting manner. The monk's prescription of " telling the beads" is a good method of inducing sleep, or one may gaze fixedly at some object upon the ceiling. Winking for the space of one or two minutes has been recommended among a variety of other measures. Opium in moderate doses is a useful drug, but it should be carefully handled for fear of caus- ing the opium habit. It should not be given by hypoder- mic injection except for the relief of very acute pain. Hyoscyamus, the bromides, belladonna, and in some cases cannabis indica, and alcoholic beverages are useful. Chorea. Chorea Minor. — Chorea, or the disease commonly known as St. Vitus' dance, is a functional nervous affec- tion which usually occurs in childhood, is quite often met with in young women, and is found sometimes dur- ing pregnancy. Rarely also it may manifest itself at the menopause. From the period of the second dentition until about the age of nine years, both sexes seem to be HYSTEKO-EPILEPST. 241 'equally liable, but after that age, according to Sir Thomas Watson, females are more prone to the disease than males, in the proportion of about five to two. This disorder is characterized by defects of voluntary co-ordination, by clonic spasmodic movements of the vol- untary muscles, and by a certain degree of weakness, more or less appoaching to paralysis, in the affected parts. The movements usually subside during sleep. They are some- times unilateral, the left being the side most frequently affected. This variety is called hemichorea. The pa- tients are usually anaemic, the mind is weakened, and there is much irritability of temper. Anaesthesia is some- times present. As the disease is a neurosis, there are no characteristic anatomical changes to be found in fatal cases. Its causation depends upon anaemia, the result of defective diet and hygiene. The exciting cause may be a fright, or any violent disturbance of the emotions. It is in children often associated with rheumatism. Many remedies have been employed for the relief of this condition. I have had the best success with Fowler's solu- tion in large doses. In an epidemic of this disorder which occurred at the Infirmary for Children and Young Girls, every case recovered under its administration combined with isolation to obviate the mental contagion. It is lauded by many as a specific for the disease. Strychnine, iron, and opium have also been used with much benefit, as have also the oxide of zinc, valerian, camphor, and asa- fcetida. Chloroform and ether given internally are said by some to be of advantage on account of their antispas- modic action. I have had no experience with them. Careful alimentation is of the greatest importance. Dr. Hermann Nebel, in his classic monograph, "The Mechanical Treatment of Chorea, A Historico-Critical 16 242 FUNCTIONAL NERVOUS DISORDERS. Study," translated by Dr. L. Wischnewetzky, has com-* pletely covered the subject and given the best means of treatment for this affection. Chorea Major. — The term chorea has been made to include almost all forms of involuntary movements in which distinct spasm or a pronounced tremor does not exist — salaam convulsions, moving the head back and forth in a half -rotary manner, bowing, bobbing, and oscil- lating movements. In its severe type it is a very grave disorder and most distressing to witness, the patient cease- lessly tossing herself in all directions and being kept in bed only by means of straps. Headache, delirium, and even coma are often present. The digestive organs are always more or less involved, as indicated by anorexia, gastralgia, or vomiting. Chorea major has often assumed an epidemic character. In 1418 an epidemic broke out in Strasburg which took the form of uncontrollable dancing, leaping, and scream- ing. Sometimes the epidemics are of a decidedly hyster- ical type, characterized by fits of laughter, dancing, crying, screaming and howling, associated with mental delusions, and with eructations. The disease has been common in France, Germany, and Italy. In England and America we have the Jumpers and Shakers, victims of religious enthusiasm. Many strange paroxysms have accompanied the disorder in France and Scotland. The body has been distorted into every conceivable shape, and wild dancing and leaping have been kept up to the point of absolute exhaustion. CHAPTER XXI. HEMICRANIA— MIGRAINE. This extremely common vasomotor neurosis is, in women, usually excited by certain reflex disturbances. In some attacks there is contraction of the arterioles on the affected side, with consequent anaemia, as shown by pallid face, shrunken eye, and dilated pupil. At other times the opposite condition of the circulation prevails; there is dilatation of the vessels, with a flushed face, in- jected conjunctivae, and contracted pupils. Prof. Charles L. Dana says that this form of neuralgia occurs more often in women than men, in the proportion of three to one ; the attacks are most frequent in winter and least so in the spring. In America the characteristic form is the angeio-spastic type ; but migraine may occur with but little vascular change, and there are nervous or sick-head- aches which stand halfway between typical migraine and ordinary rheumatic or gastric headaches. In most of his cases migraine was found to be hereditary, or at least a family disease, alternating sometimes with other neuroses, especiahy asthma and other neuralgias. Only two of his cases seemed to be due to asthenia and refractive errors of the eye, and he was not able to convince himself of any peculiar nasal or pharyngeal irritations. He adds that the idea that migraine is a disease of the sympathetic system is one of the old medical superstitions which, with the old idea of the sympathetic system, ought to be done away with entirely. Indeed it hardly deserves to be dis- 243 244 FUNCTIONAL NERVOUS DISORDERS. cussed with seriousness. Migraine is a general neurosis like epilepsy, showing itself in nervous discharges mainly in the area of the fifth. Symptomatically, therefore, it is to be spoken of as a form of trigeminal neuralgia whose manifestations are strikingly associated with vascular and secretory, and sometimes motor, visual, and auditory disturbances. In speaking of the determination of reflex pains with regard to the eye, he says they are produced by asthenopia, of which there are four types — 'refractive, accommodative, muscular, and neurasthenic. " It appears to be established that refractive asthenopia in one eye may give rise to migraine. The view that nearly all migraines are .due to refractive errors or to imperfection in the muscular ap- paratus of the eye is certainly, in my experience, incor- rect. It is well to remember that, while eye troubles may cause neuralgia, so, on the other hand, neuralgias of the fifth may cause eye troubles — such as blepharospasm, mydriasis, myosis, and asthenopia (Faucheron, Bee. d'Ophthal., March, 1881). Occasionally eye irritation causes occipital or fronto-occipital pain, but this does not seem to be the rule. Iritis may cause pain felt over one- half of the cranium, like a migraine." Mallendorf (Virch. Arch., January, 1868) states that in his opinion migraine is due to a lack of energy in the vasomotor nerves of one of the carotid arteries, with sec- ondary relaxation of the vessel and increased flow of blood to the brain. Hypersensitiveness of the senses, with hyperesthesia of the scalp, nausea, and sometimes vomit- ing, are the secondary symptoms. Dimness of vision is sometimes present. Mallendorf quotes as proof of his theory the fact that the pain is entirely stopped by com- pressing the carotid on the side affected, and that when HEMICRANIA — MIGRAINE. 245 the compression is removed the pain returns; also that compression of the carotid on the non-affected side in- creases the pain. The subjects in whom we chiefly meet with migraine are women, who from hysteria or ansemia have developed a morbid excitability. It is not unfrequently accompanied by vomiting and is a most distressing affection. Owing to the changes which take place at the menopause, migraine usually disappears at this period. For the treatment of migraine a variety of agents have been used — bromide of potassium in large doses, valerian- ate of caffeine, quinine, Fowler's solution, etc. When anaemia or chlorosis is present, the preparations of iron may be administered with advantage. Outdoor exercise and pure air are most valuable adjuncts. Extract of ergot has also been recommended, and in certain forms, where vascular spasm is present, the inhalation of nitrite of amyl is of service. I do not believe, however, that the administration of any drug is alone capable of effecting any permanent benefit in these cases. Much more satisfactory results can be obtained by properly regulated outdoor exercise, curative gymnastics, pure air, baths, especially sea bathing, to- gether with a properly ordered diet and manual treatment. I append a few cases of migraine. In all of them it will be seen that uterine disease played the chief role as an etiological factor. Mrs. B. L., age 47, has six children and has had two miscarriages. She has migraine, always on the third day of menstruation, and night blindness. There is pain in the hypogastrium, and also, during menstruation, in the back and shoulder. She does not have leucorrhcea. Miss C, age 25, has had migraine and headaches for 246 FUNCTIONAL NERVOUS DISORDERS. five or six years; they have been more frequent the last six months. Menstruation lasts over a week, and the flow is excessive. She has a thick, yellowish leucorrhcea ; pulse is weak, appetite poor. She works hard sewing on fura with a machine. Mrs. M., age 45, lacerated cervix, endometritis. Mrs. L., age 30, endometritis. Miss O. C, age 38, endometritis, left ovarian pain. Mrs. Cr., age 20, endometritis after abortion. Mrs. V., age 23, endometritis. Mrs. B., age 23, endometritis, lacerated cervix. Mrs. T., age 43, menopause. Mrs. B., age 24, endometritis and perimetritis, leucor- rhcea. Miss C, age 25, menorrhagia, leucorrhcea. Mrs. B. L., age 47, dysmenorrhoea, occurs on third day; also has night blindness. Miss N. B., age 24, dysmenorrhoea, inflammation of left ovary. The following case is of interest because of the alterna- tion of two opposite states. Miss B., age 26, while living in the country always enjoyed perfect health. Since coming to New York, two years ago, she has suffered at irregular periods, at first about once in two weeks, now usually once and sometimes twice a week, from severe attacks of migraine. In the intervals between the attacks there is not the slightest pain or dis- turbance. There are some slight prodormal symptoms, such as soreness of the body and weariness. She awakes in the morning suffering with the pain, which manifests its greatest intensity in or just above the eye. There is no tenderness of the cervical ganglia of the sympathetic. Nausea always accompanies the attacks, which usually last from six to twelve hours. They are at times of the congestive and at others of the anaemic type. When of the former, the side of the face is intensely flushed; when of the latter, there is extreme pallor of the parts HEMICBAOTA — MIGRAINE. 247 affected. She has an intense craving for sour articles of food, and takes large amounts of strong coffee. A care- fully regulated diet caused immediate relief, which con- tinued so long as L he patient adhered strictly to the prescribed dietary and hygienic regimen. Migraine might be termed a cramp in the head. It is somewhat similar to angina pectoris, in which there is often a cramp of the left arm, with coldness, numbness, and anaesthesia. I have a patient who has a similar cramp in the third and fourth toes of the right foot ; it is a reflex from intes- tinal indigestion. Headache. This is the most common of all nervous symptoms de- pendent upon indigestion. The indigestion is usually sec- ondary and occurs in the liver without any apparent symptom except weakness and some anaemia. Worry and anxiety are factors in its production, by primarily inter- fering with the digestion. Hypoxemic Headache. — In this affection, which is often toxic, as in cases of malaria, the congestion is constant, and may last for weeks if no remedial measures are taken. The greater the congestion the more intense the pain. Its seat is most frequently the vertex and through the temples. In many cases there is considerable fever. The vaso- motor conditions in the brain are undoubtedly similar to those observed in the face. There we may have cerebral flushes, morbid flushing, or on the contrary pallor, due to increase or diminution of the blood supply. All of these phenomena are dependent upon vasomotor changes. Treatment of Headache. — Quinine may be given as a tonic, and with iron is useful in relieving this condition. 248 FUNCTIONAL NERVOUS DISORDERS. Tincture of mix vomica, in ten-minim doses, is also a very efficacious remedy in removing the indigestion and conse- quent headache. In the hypersemic form of headache, digitaline granules, in doses of one-sixtieth of a grain, twice daily, are often of use. Bathing the head with alco- hol or RaspaiPs "Eau Sedatif" gives at times marked relief. Bromo-caffeine is a preparation that relieves tem- porarily many cases of true migraine. It often seems to act like magic, but the effect produced is not lasting. In bilious headache, dilute nitro-muriatic acid, five to ten minims in water, or a dose of the phosphate of soda will often give relief. Congestive Headache. — Mrs. S., a widow, age 42, has for a week past had constant and severe headache, worse at night, due to the worry and care of a large boarding- house. The pain affects the entire head, more especially the top and back. The urine has a specific gravity of 1.014, is of light color, and is normal in quantity; it contains neither albumin nor phosphates. The patient is languid, weak, and intensely drowsy, and usually has a great thirst, due to chronic gastric catarrh. The headaches are in this case of gastric and hepatic origin, and are frequently the result of financial worry. Under a lessening of the mental strain, and with happier surroundings, her condition has markedly improved. Migraine, Congestive Type, Due to Chronic Intersti- tial Nephritis. — Mrs. M., age 55, stout, has slight asthma. Examination of the urine shows albumin. She is careful in her diet. She caught a severe cold, which manifested itself principally by an attack of severe mi- graine that was relieved only by the persistent use of large hypodermic injections of morphine. It lasted about three days. She had a similar attack before, which lasted so long that the diagnosis of the attending physician was "inflammation of the meninges of the brain." HEMIC RANI A — MIGRAINE. 249 Migraine and Asthmatic Bronchitis Dependent upon Indigestion, — Miss S. V., age 40, has asthmatic bron- chitis of long standing. Many of her relations have died of phthisis. She is now suffering from severe migraine in right temple, which frequently recurs. That it is of a congestive type is indicated by the throbbing and enlarge- ment of the carotid artery, and from attacks of hemor- rhage on the same side of the nose. For a year past she has been living entirely upon vegetable food, of which she has been taking excessive quantities. She has an especial craving for fresh bread. She dislikes meat. A simple dietary was prescribed, consisting of broiled minced beef, stale bread, hot water, etc., as well as a tonic regimen, and she states that from the very first she began to im- prove and to develop an appetite for meat. She now likes it very much, and considers it a great luxury. Breathing has become easier and the asthma has entirely disap- peared. Her voice, which was almost entirely lost, has returned. She was supposed by her friends to be a case of chronic phthisis, but she is now, after three days' treat- ment, vastly improved in health, and considers herself quite well. Hemicrania, Dependent upon Maldigestion and upon Irritation from the Left Ovary. — Miss J. W., age 28, is a blonde, unmarried, well educated and refined, with much strength of character ; she has every comfort. When I first saw her, in October, 1887, she was suffering from hemi- crania. The pain, which was of a very severe character, was localized in a small spot on the right side of the head near the vertex. The attack was usually so severe as to cause fainting; she complained of excruciating pain in the left ovary, and felt as if she might lose her reason. Octo- ber 26th, 1890, while suffering, she took twenty-five grains of bromide of potassium, which, she thought, started the pain in the left ovary, and this was followed by a sense of suffocation, a globus hystericus, and a hystero-epileptic attack. When I saw her she was rigid and seemed uncon- scious ; she was surrounded by her friends, who were much 250 FUNCTIONAL NERVOUS DISORDERS. alarmed, thinking that perhaps she had poisoned herself with the medicine. She seemed unable to speak, but after taking a teaspoonful or two of brandy and water she became completely conscious, but could not open her fin- gers, which were tightly closed. After a little time the contractions relaxed and her hands opened. She com- plained of creeping sensations all over her body, and would continually clasp and unclasp her fingers. She had the usual symptoms of migraine, a tendency to which she had inherited from her mother. Miss W. is especially liable to have these attacks in the early spring, and when for any length of time she has been confined to the house with- out fresh air. They are also brought on by overwork. She has no post-nasal catarrh nor eye trouble as causative factors. Bromide of caffeine in large doses gave a temporary relief. A short sea voyage to a southern port was recom- mended, and was productive of marked benefit by greatly improving her general health. Migrainous Headache as a Gastric Neurosis. — Mrs. D., age 38, has had two children. Whenever there is an acid condition of the stomach she suffers from most severe migrainous headaches, alternately in either temple. She has also severe pains over the greater curvature of the stomach. There is a great amount of flatulence and much intestinal colic. While pregnant she is unable to eat meat or other solid food in the morning ; she takes merely coffee, and during the day consumes a good deal of tea. She takes only two meals daily, one at 11 a.m., and the other at 6 p.m. She has a craving for salt meats, for vegetables, especially potatoes, and for fruit. Under a change of diet there was a marked alleviation of her symptoms. In many of these cases there is a tendency toward chronic nephritis. CHAPTER XXII. THERAPEUTICS. "In other cases special treatment remains ineffectual, until by generally strengthening treatment the vital energies have increased and the process of recuperation, latent in the organism, is again aroused to life. " — Gustaf Zander. In the treatment of these neurasthenic conditions the most important factor to be considered is vitality, or re- sistance to disease; it should be carefully studied and every effort made to sustain and augment it. Often by inspection alone the skilful physician can determine quite accurately the vital resistance of the patient. Some indi- viduals are of "good timber," while others can only be compared to punk. The first seem to have an invincible power of resistance to the effects of starvation, accident, or disease, while the second will succumb to the most trilling ailment or casualty. Many thin and apparently delicate persons easily resist deleterious influences, and if affected quickly recover; while some stout, and to all appearances strong individuals, can, under the same conditions, barely exist, so weak is their vital resistance. Those of the first class are endowed at birth with this force of constitution, while the portion of the others is inherited weakness. Fear, as is well known, is a great factor in the produc- tion of disease; it depresses the force of the system, thus weakening the vital resistance. It causes cold sweats, diarrhoea, excessive urination, disordered perspiration, 251 252 FUNCTIONAL NERVOUS DISORDERS. palpitation of the heart, and jaundice. By this depressing action upon the vital functions, it favors the onset of the disease and increases its malignity when present. This is commonly seen in epidemics, such as cholera, typhus fever, or small-pox, fear causing the disease in many who would otherwise escape. The passions of the mind and soul have as important a place as factors in the production of disease as the septic poisons and the various morbific bacteria, and they are of special importance in these hysterical, neurotic affections. When a woman is in the full vigor of health, all her functions are properly regulated and are always the same. The heart beat is slow, full, and strong ; the respiration is natural and unembarrassed; the nervous system is per- fectly in accord with the rest of the body. When, how- ever, weakness supervenes, all sorts of aberrations in in- finite variety occur. As much of the disease from which nervous women suffer is of bacteriological origin, the pre- vention of catarrhal states of the digestive, respiratory, or genital tracts by internal or tissue asepsis (as I term it) is of vast importance. The value of prophylaxis should be more appreciated than it is in our daily practical work. I do not under- estimate the importance of symptomatic treatment as our routine practice demands it, but we should not, as we are prone to do, confine ourselves to dealing exclusively with symptoms which in most cases arise from the basic malady. Our conception of disease must be broader. By considering the basic malady, we are better prepared to meet the demands of modern prophylaxis. The physician will have to deal with the pathological tendency to non- bacteriological affections, such as retarded growth, anse- mia, cardiac weakness, contracted chest, catarrhal con- THERAPEUTICS. 253 ditions, etc. , as well as affections of microbic origin, with which I intend to deal briefly. In these days hereditary predisposition is no longer regarded from a fatalistic standpoint, a knowledge of hygiene and prophylaxis giv- ing us the means to counteract it ; the highest art of the physician lies in applying this knowledge to individual needs, preventing overexertion, strengthening weakened organs, and restoring tone to the system. Internal sterilization presents many difficulties not en- countered by the surgeon, whose treatment can be local- ized. Internal or tissue asepsis is a complicated matter, and in the majority of cases we have to adopt a systema- tic constitutional treatment. Measures which vitalize the organs, promote circulation, metabolism, and tissue change, and so contribute to the building up of the whole system, will have to be adopted, and will consist of a proper die- tary, curative exercise, internal and external hydrotherapy, electro-therapy, change of climate, or appropriate drugs, according to the indications. I believe that medicines are more effective in a patient whose vitality has been in- creased than in one whose vitality is low. The internal use of water is to my mind a valuable means of restoring tone. (See my article upon the subject in the Medical Record for November, 1895.) Dr. Otto Leichtenstern ('''Handbook of General Therapeutics," Ziemssen, Vol. IV., New York, 1885) says that the effects of abundant water drinking are in close connection with the quantity and temperature of the water taken in. The effect of the drinking of cold water is a lowering of the bodily temper- ature, and if the stomach is empty it leaves it very quickly. The water absorbed through the mucous membrane of the stomach and intestines is in large part taken up by the veins, notably the vena portce, as well as by the lymphat- 254 FUNCTIONAL NERVOUS DISORDERS. ics. There is no diminution of the specific gravity of the blood, as has been shown by the experiments of Magendie, Nasse, Denis and Leichtenstern, nor is any increase of water observed after copious water drinking. This is due to the fact that as soon as the water is absorbed from the stomach and intestines it begins to be excreted in the urine. Thus a large amount of water can pass through the body in a short time without causing any demonstrable increase of the amount of water in the blood. The water distrib- utes itself not only to the blood current but also to the fluids of the tissues in all parts of the body. Leichten- stern says that we have in copious water drinking, a means of subjecting the whole system to a powerful wash- ing out, and a consequence of this is the temporary in- creased excretion of certain products of the tissue changes. He says that although, so far as he knows, " no thorough experiments, not open to exception,' have as yet been made on the action of copious water drinking in conversion of tissue, yet experiments up to the present time warrant the following conclusion: . . . The greater amount of diuresis after drinking large quantities of water pro- duces a quantitative increase of the excretion of urea, of chloride of sodium, of phosphoric and of sulphuric acids." It has also been shown that the amount of uric acid is diminished by copious water drinking. Investiga- tors have found an increase in urea, and the increase of salts in the urine has been proved by the experiments of half a dozen different observers. Without doubt the in- creased quantity of water which permeates the tissues favors the decomposition of the waste albumin, and thus augments the excretion of urea ; there may be also a more rapid removal of the urea already formed, but the major- ity of authors believes the increased conversion of the albu- THERAPEUTICS. 255 minates to be the main factor. New and thorough experi- ments upon this subject may be desirable, but for my part, I do not consider them to be necessary. Leichtenstern still further says : " Unquestionably, numberless cures owe more of their efficacy, in diseases, to the diuretic and washing- out effect of the water drunk in increased quantity than to the salts and gases dissolved in it. We make the most extensive use of this washing-out power of water in thera- peutics. Copious water drinking, may, under proper cir- cumstances, be used efficaciously in many cases : when it is the object to bring exudations to absorption, to wash out accumulated particles of bile from the blood and from the tissues, to increase the secretion of bile and the press- ure of the secreted bile; when it is the object to remove certain poisons which have got into the system, or to wash out blocked up urinary tubuli. In all these cases where large quantities of water are employed, simple water (I include here distilled water with any addition to make it palatable) is to be preferred to mineral waters or to solu- tions of salts. And as water in large quantities is better borne by the stomach taken warm than cold, the use of the former is preferable, and besides that it is more rapidly diffused." " It is known that other excretions besides that of urine are influenced by copious water drinking. Leh- man observed in the horse an increased secretion of the parotid, the specific gravity of which at the same time became lighter; and Weinman witnessed a considerable increase in the pancreatic secretion of the animal experi- mented upon, after a large supply of water. Bidder, Schmidt, Nasse, Arnold, found the secretion of bile in- creased after copious draughts of water, the specific grav- ity of bile diminished, and the amount of solid matter excreted through it increased. 256 FUNCTIONAL NERVOUS DISORDERS. " Copious Water Drinking Increases the Sensible and Insensible Transpiration of the Skin, in Health and in Many Diseases. This has been proved by innumerable experiments which have been made by Ferber, Mosler, Weyrich, and repeated in Niemeyer's clinic." Where a small quantity of chloride of sodium is con- tained in the water, as at salt springs, the secretion of the gastric, juice, which is strongly antiseptic, is stimulated and increased; the formation of peptone is also favored, and reflexly the salt excites the peristaltic action of the stomach and intestines, and thus furthers the removal of any stagnating contents which would otherwise remain for a longer time in the digestive canal. Salt has also a slight diuretic action. With a slight increase of the supply of chloride of sodium, there is an increased excretion of nitro- gen through the urine. Yoit says that this action of chlo- ride of sodium is caused by its increasing the celerity of diffusion of the current of fluids through the tissues, so that larger amounts of the circulating albumin are exposed to the breaking-up powers of the cells. The practitioners at Bath, England, according to Leichtenstern "make the fullest use of this important physiological fact, and of its explanation, in expounding the curative effects of the salt waters, as well as in laying down indications for their use. The salt waters, they say, 'powerfully excite the conver- sion of tissue' ; hence their favorable operation in 'general plethora,' 'in over-nutrition,' in obesity, etc. " While the salt waters promote the circulation of the fluids also through pathological products, plastic and other formations, they loosen their structure, carry away their albuminates, and favor their combustion ; along with this, fat is formed in the pathological products, which now can easily be absorbed. On this is based the theory of the THERAPEUTICS. 257 curative effects of salt water in scrofulosis, with its many exudations and hyperplasias of the glands; on this rests the theoretical indication for the use of these waters in the most varied exudations of different organs, especially in chronic infarction of the uterus, in chronic exudations of the pelvis, in peri- and para-metritis, etc. . . . " Voit announces as a further property of salt, that it influences the solubility and the diffusibility of albuminous matters. On these no doubt correct conclusions of the physiologist, balneotherapists ground the important thera- peutic effects of the salt waters. To use their modes of expression, salt waters 'stimulate and heighten the plastic activity of the organism, facilitate the formation of cells, increase the number of blood corpuscles, lower the amount of water and of albumin of the blood,' and as these waters, as we said above, at the same time increase the combustion of albuminates, they should possess the remarkable property of regenerating the whole organism, of purifying it of its injurious dross, and of renewing its youth. The problem of Medea would thus be solved in tho simplest way, by salt waters. Diruf pointed out as a fact 'which could not be sufficiently proclaimed,' in a therapeutical point of view, that a 'moderately increased supply of chloride of sodium is able, under certain conditions, to induce, along with the accelerated conversion of nitrogenous tissues, an excess of formative over removing action in the system, and in other cases to reverse the process.' Certainly a very convenient if not a very clear theory for explaining the efficacy of salt waters in the most different forms of disease, a fact which cannot be empirically gainsaid. " Chloride of sodium is said to increase 'the secretion of various mucous surfaces,' and especially that of the organs of respiration. It is said to act as an 'anticatarrhal.' as a 17 258 FUNCTIONAL NERVOUS DISORDERS. 'solvent of mucus' to 'regulate the nutritive condition of the affected mucous membrane,' etc. Hence the recom- mendation of these waters in catarrh of the respiratory organs; the lion's share of the empirically proved efficacy of these waters, in such affections, is no doubt to be as- cribed to their warmth." Anything which destroys the micro-organisms that are detrimental to the bodily health is an antiseptic ; therefore dietetic treatment in its broadest sense, which includes curative exercise, hydrotherapy, etc., as well as the scien- tific selection and preparation of food, is antiseptic, as it enhances the vitality and bodily resistance to disease bac- teria, by increasing the germicidal power of the blood. As many nervous women are tuberculous, or are from their anaemic condition in danger of contracting tuber- culosis, a few words upon its prophylaxis will not be out of place. Up to about twelve years ago the treatment of tubercu- losis was entirely empirical. In 1882 Robert Koch, of Berlin, for the first time proved beyond a doubt that this disease was caused by bacilli which, on account of their peculiar behavior toward strong acid, could be positively diagnosed in every case of tuberculosis. All subsequent experiments have shown that Koch's statements were per- fectly correct, and to-day we can say that there is no tuberculosis without the presence of these characteristic tubercle bacilli. It is true that at the commencement of the affection it is not always easy to find the bacilli, but careful examination of the sputa at different times will invariably show their presence in a greater or less degree. Tuberculosis' may start very slowly and gradually; so much so that, physically, no characteristic symptoms of the disease may be found, but examination of the sputa THERAPEUTICS. 259 will already, at this early period, demonstrate the presence of the bacilli. In every case of cough which has lasted for some time the physician should invariably make it the rule to examine the sputum, whether he suspects tuber- culosis or not. If this is done, and only then, can we ex- pect better results from our treatment than we have heretofore achieved. In a large number of cases bacilli may be found in the s^>uta long before there are any well-marked physical signs, so that their detection will afford the first clew to the pa- tient's malady. Even at the present day some physicians claim that there are cases of phthisis without the presence of tubercle bacilli. The trouble with them will, however, simply lie in the meaning of the word "phthisis," as some will call a chronic catarrhal pneumonia fibroid phthisis. That this is not tuberculosis need hardly be mentioned. Another mistake which is often made is to call tubercle bacilli the sole cause of tuberculous infection, since tubercu- losis will never affect people with good constitutions, but only those with poor, broken-down constitutions. People with good constitutions may continually inhale the bacilli without any bad effects whatever. The human body may be in a condition that is termed health, and still pathogenic bacteria may be present; these are kept in abeyance by the defensive action of the blood -serum and leucocytes. It is this repressive power of the blood that keeps them from propagating and doing injury to the economy. Bacteria often seem to be destroyed by phagocytosis. There is an antibacterial property in the tissues, fluids, and secretions of the body, and these are natural defences against the growth of micro-organisms. The contact of germs does not lead to infection unless the material is 260 FUNCTIONAL NERVOUS DISORDERS. present to favor their development. One of these causes is a poor or broken-down constitution. When this is present any existing bacteria will multiply and thrive. Another cause is the presence of the products of fermentation, in- flammatory exudates, and diminished blood-supply. If the constitution is improved, and the pabulum upon which the bacteria thrive removed or its formation stopped, their development is hindered or entirely checked, and thus the severer forms of inflammation are obviated. A plant can- not grow upon a rock or thrive upon barren soil, and so it is with all forms of life, even the minute organisms. The substances upon the surfaces of wounds which cause the development of micro-organisms and thus produce infec- tion, are readily removed by the most important and chief means for all sterilization; that is, the mechanical purifi- cation by washing and cleansing with water. Why should not the substances in the interior of the organism, which are the pabulum for bacterial development, also be removed, at least to a great extent, through the channels of the body which terminate directly in the emunctory organs? It is quite possible that the sewerage system of the tissues, when properly stimulated in the work of elimi- nation, will carry along in its circulation much of the material which causes infection, and thus produce what might be termed an internal sterilization or asepsis. Many seem to think that, after a germ has once entered the body, it cannot be removed until it is thoroughly digested; but why should not cleanliness, applied to the internal organs whenever possible, aid in the elimination of the micro-organisms? If we cleanse the oral cavit} r daily, we may just as well go farther and cleanse the stomach, intes- tines, and the tissues. Tubercle and other bacilli usually enter the organism by the canals and ducts which commu- THERAPEUTICS. 261 nicate with the outside of the body. The alimentary canal in many cases is the primary means of entrance. The infec- tion then extends by following various routes. The bacilli are carried along the lymphatic channels into the tissues or lymphatic glands. These glands appear to have the power of arresting the infection, for a time at least, before it finally passes into the blood, and this would seem to be the critical period in the treatment. Pure or sterilized granite or trap-rock waters taken hot in sufficient quanti- ties and at proper times, combined with systematic mus- cular exercise, hot baths, and massage, will certainly help to cleanse out the tissues of the bod3 T . We ma}' furthermore take advantage of the bactericidal properties of the blood serum. This protective property of nature is best enhanced by enriching the blood by the various means within our power, one of the most important of which is scientific dieting. The ordinary diet of indi- viduals is often extremely bad, the place of wholesome food being taken by sweets and stimulants, such as sugar, pas- try, tea, coffee, and alcoholic drinks, so that not infre- quently patients will grow weak and the constitution will suffer simply on account of the deprivation of proper nourishment. The plan of treatment, which I have already described in the New York Medical Journal for October, 1894:, consists in giving at rather frequent intervals a consi oper- able quantity of carefully roasted or broiled beef or mut- ton, raw eggs, stale bread, butter, sterilized milk, and vegetables. After a few days of treatment the meat should not be less in amount than a pound a day, and the quantity of bread and vegetables should be, if possible, somewhat larger. When there is a disgust for the meat diet the stomach needs special treatment, for a short time 202 VV NATIONAL NERVOUS DISORDERS. only, by the addition of a digestant, such as dilute hydro- chloric acid and hot water to remove irritations. Tuberculosis is the great destroyer, as it is the most frequent of all fatal diseases; and malnutrition and de- fective elimination, which will sooner or later break down the constitution, are at its foundation. It is estimated that in the United States nearly five hundred individuals die of this disease every twenty-four hours. Its extreme prevalence and destructiveness have urged physicians in all countries to make strenuous efforts for its prevention and extermination. It has been mentioned in this work a number of times that constitution is one of the most important points in the development of tuberculosis. It may be well to show how the constitution of the patient can easily be deter- mined under the microscope. Not only may this be done by the colorless blood corpuscles, but also by the inflam- matory pus corpuscles which we will invariably find pres- ent in every sputum in which there is an inflammation of any kind whatever. These views were first announced by Carl Heitzmann in 1879, and have since been corroborated by a number of independent observers both here and abroad. They are the following: The amount of living matter within a limited bulk of a corpuscle varies greatly in different in- dividuals. It is obvious that what is called a healthy or vigorous constitution is based upon a large amount of liv- ing matter in the body, the new growth of which in morbid processes is very lively; while a phthisical or so- called scrofulous diathesis must be caused by a relatively small amount of living matter, the new growth of which is scanty in morbid processes. In other words, a corpuscle will exhibit coarse granulation, or it will be almost homo- THERAPEUTICS. 263 geneous-looking, under the microscope, owing to the large amount of living matter in strong individuals of good constitution; while a corpuscle taken from a person with a weak or tuberculous constitution will be pale and finely granular, as but little living matter is present in it. In a given case, therefore, the more numerous the coarsely granular pus corpuscles or colorless blood corpuscles pres- ent, the better the constitution; and, on the other hand, the more abundant the finely granular ones, the worse the constitution; and when the corpuscles become broken up and disintegrated we can say that death is not far distant. As long, then, as we find the coarsely granular, homogene- ous corpuscles predominating, so long there will be no danger of the individual contracting tuberculosis; and when upon examination we find that the corpuscles do not contain a sufficient amount of living matter, that is, they have become more or less finely granular, we should at once resort to all possible means to increase the living matter, as otherwise tuberculosis may set in at any time. Klebs, in the Journal of the American Medical Asso- ciation for October 12th, 1895, says, in speaking of anti- phthisin in tuberculous affections of children : " It would certainly be unreasonable to demand that this remedy, which has a specific germicidal effect upon the tubercle bacillus only, shall also remove and cause the cure of pathologic changes which result remotely from the primary cause, and, more unreasonable still, that the rem- edy shall also favorably influence and cure complications which, like infection with other pathogenic germs, have no relation to tuberculosis at all, more than that they may be associated in the same patient. " In all such cases it is necessary to remove the compli- cations by other treatment, either before or in conjunction 264 FUNCTIONAL NERVOUS DISORDERS. with the application of the specific remedy ; but the final results are determined by the importance and curability of such attending pathologic processes. " We see, thus, that the use of a specific germicidal rem- edy can only be fully effective when the disease is still uncomplicated by secondary degenerations, and is free from complications which, unfortunately, are present in most cases of tuberculous disease as they come under our notice; there are, however, not a few cases of purely tuberculous affections in an early stage in which the results of specific medication are highly satisfactory. . . . For these, as in all other therapeutic efforts, the only unavoid- able condition is that the organism itself shall still have the power to use and appropriate the introduced curative substance; for under no circumstances can we otherwise conceive the cure of disease than that the living organism must, itself, take an active part in its removal." In closing his paper he says : " Finally, I wish to point out that, in all tuberculous affections, the same as in many other severe and serious diseases, their treatment in hos- pitals or special institutions offers great advantages over that of private practice." The means of improving the general constitution have already been partly stated above, but I wish to dwell espe- cially upon the good results obtained from regular syste- matic physical exercise. The medical profession has always deemed physical education a hygienic measure of the greatest importance. The well-known Dr. Gustaf Zander says: "Experience having shown that regular muscular exercises, gradually made more strenuous, not only develop and strengthen the muscles, but promote the removal of pathological changes in the tissues, give tone to the nervous system, and vitalize THERAPEUTICS. 265 the circulation of the blood and lymph and the activity of many organs, it is natural that such exercises should be included among therapeutic agents. For this purpose there was, however, requisite the power to execute these exercises according to physiological laws, and to modify their action, like that of any other therapeutic agent, ac- cording to the needs of each individual case." Therefore those persons who take up physical culture without a com- petent medical instructor may do themselves serious in- jury, or at least obtain no special benefit from it, by attempting methods unsuited to their physical condition, or neglecting to carry out a practical system in a proper manner. Physical exercise at home soon becomes a mat- ter of drudgery to the weak and poorly developed, who especially require it. As the interest is lost, it is neglected or carried out in a desultory manner, and thus the beneficial results are not obtained. Under a competent medical in- structor there is, along with sustained interest, a rapid and harmonious development of those portions of the body which most need it. Hysterical women and" neurasthenic patients of both sexes especially, and also children, should not be allowed to take this exercise at home, as they per- form it without system, overdoing it one day and entirely neglecting it the next. Very judicious passive exercise should begin the treatment, which should be gradually in- creased; at the same time they are under control, which strengthens their will power, and they have to obey instead of ordering others about. The indications and contraindications for muscular exer- cise should be carefully determined. Exercise does not do everything; sometimes rest and drugs are needed. Ther- apeutics always belong to the physician, and not to the layman. The massage following the bath is something 266 FUNCTIONAL NERVOUS DISORDERS. difficult, and with many impossible, to obtain at home, and it should not be in the hands of laymen. In anaemic, nervous women with bad carriage, to overcome the de- formity of round shoulders, the muscles of the back and abdomen must be systematically exercised and strength- ened. The flattening of the chest, which is the result of the shoulders falling forward, tends to the production of lung disease, by interfering with their complete expansion. To overcome this deformity, the patient should stand with head erect, with the abdomen drawn back and chest pro- jecting, and then forcibly draw the shoulders back as far as possible, as if to make the shoulder-blades meet. This should be performed from ten to fifty times daily ; in fact, at frequent intervals during the day, whether exercising or not. All shoulder braces are useless for this purpose. For broadening the chest, assume the erect posture. The movement should be as follows: Starting with the hands in front of the hips, force them by a lateral and backward movement as high above and behind the head as possible. 'A modification of this movement, which is easier and more graceful, consists in starting with the arms extended behind the back, and letting them go up alternately as far as possible, while keeping the elbows perfectly rigid. All these exercises are best performed with light dumbbells, from two to five pounds in weight. This last movement is of especial advantage in drawing upward and outward the sides of the chest, thus increas- ing its capacity. Another beneficial exercise for deepening the chest and straightening the shoulders, is to stand with arms project- ing straight forward, elbows perfectly stiff. Let the arms go straight backward as far as they will, on a level with the shoulders. Meanwhile, the erect posture must be THERAPEUTICS. 267 maintained — head erect, chest projecting, and chin drawn in. This is a splendid exercise for increasing the lung capacity. These movements should be repeated until the particular muscles involved become fatigued, when the instructor will change them and bring into use another set of muscles, and so on. The respiration should be full and free, and the air perfectly pure. A system of this kind, carried out in a scientific manner, strengthens not only the muscles, but all the vital functions, and is adapted not only to adults, but to children as well. Respiration and digestion are improved with the increase of vitality, and the elimination of the waste of the body is greatly en- hanced. By specific exercises the chest cavity is broad- ened and deepened, and the chest expansion and manner of breathing greatly improved and permanently benefited. Not only the lungs, but the brain and nervous system are powerfully influenced by systematic bodily exercise. The brain will accomplish only imperfect results if the body is not in a state of health. Everywhere we see the lack of physical exercise; men, women, and children Avith narrow chests, pale, emaciated faces, and a general look of exhaustion are met daily. If extreme leanness is not present, obesity produces ugliness of the human form. A comely, erect, well-formed body is much less common. Judicious systematic muscular ex- ercise and a proper dietary give vigor, activity, and cour-. age, both mental and physical. The supply of oxygen is greatly increased by deep, full inhalations in the open air, thus increasing the lung capac- ity, purifying the blood, and strengthening the nervous system. The temperature of the body is equalized as a result of ttie muscular exercise and the eliminative sys- tem stimulated to increased activity, while digestion and 268 FUNCTIONAL NERVOUS DISORDERS. assimilation are brought to their highest point of effi- ciency. I desire to refer at this point to Dr. Wischnewetzky, who first established a complete median ico-therapeutic Zander institute in this country, and directed it for five years, but at present has no connection with the institu- tion. He says in " Contributions to Mechanico-Therapeu- tics and Orthopaedics," Vol. I., No. 2: " By affording a basis for the scientific medical application and discussion of mechanico-therapeutics, Dr. Zander has placed the sub- ject above the level of a peculiarly Swedish method, and has enriched the science of medicine. Hence, although Dr. Zander is a Swedish physician, his method can no more be called Swedish than pathological anatomy, which has been so effectively promoted in Germany, is German, or antiseptic surgery English, because Joseph Lister was born in England. . . . " The physician has here forced the mechanical progress of our age into the service of medicine for the solution of problems of an anatomical nature. He enables us to exer- cise any given group of muscles strictly in accordance with the laws of physiology ; to exclude any other group at will ; to determine which groups are called into action, and to what extent in every movement made. "By subjecting to localization, measurement, and con- trol a therapeutic agent which, for want of these qualifica- tions, was not susceptible of rigid scrutiny, Dr. Zander has created the basis for the use of mechanical treatment as an agent capable of fulfilling all the conditions imposed by the most exigent scientific criticism. " The importance of systematically organized muscular exercise is no longer a subject of debate. The question always open for the conscientious physician is : ' How THERAPEUTICS. 209 shall such treatment be administered without risk of harm and with all the benefit which is in many cases obtainable from it?'" Alimentation and Hygiene. Correct alimentation in nervous derangements is most important. To secure healthy, rich blood, proper food and good digestion are necessary. In many patients suf- fering from functional nervous disorders there may be a depraved appetite present, and in other cases the appetite may be entirely absent, so that the amount of nourishment obtained by these patients, if they are left to follow their own inclinations, will be very small, although they may partake of large quantities of indigestible and unwholesome food. Indigestion is a common causative factor in the produc- tion of functional nervous disorders. Those who are en- gaged in intellectual work, such as journalists, lawyers, physicians, and other professional men who lead seden- tary lives, are most likely to have functional disorders as a result of indigestion. But indigestion is most common in nervous women. Conditions of high pressure and men- tal strain, such as striving for financial and social success, cause the overtaxed and exhausted stomach to rebel. Worry and anxiety cause a condition of mental depres- sion : the patient is distrustful of herself and of the future, and, neglecting exercise, mopes at home without enlivening distraction, the result being an impaired digestion and a lowered state of the nervous system. These women, as a result of their imperfect digestion, are almost always irri- table and find difficulty in exercising sufficient self-control to make life pleasant to themselves and their friends. In many of these cases of indigestion and nervousness there is a condition of extreme lethargy, while in others the 270 FUNCTIONAL NERVOUS DISORDERS. opposite condition of sleeplessness is frequently present. Women of this class, as a rule, when they are in this con- dition eat a sufficiency of easily digested food, but the catarrhal state of the mucous membrane of the stomach and intestines interferes with its absorption. It not only causes interference with absorption, but in many cases it causes decomposition and promotes the development of poisonous products. These, when absorbed into the sys- tem, irritate and depress the patient and bring on the ner- vous manifestations. So weak, languid, and easily fatigued do the patients become, that they are unable to take the exercise necessary to rid the system of its waste- ash through the emunctories of the body. The excretion of perspiration is insufficient in amount, and there is usu- ally chronic constipation interrupted by intercurrent at- tacks of diarrhoea. It is well known that some headaches are dependent upon constipation, and that they are often relieved by cathartic medication. Irritation of the vasomotor nerves of the head from disturbances of the stomach or intestines is a common condition. Constipation causes reflexly a sensation of congestion, and the frontal congestive head- ache is the result of the indigestion and constipation, act- ing reflexly or by direct absorption in the intestines. In health there is a blessed unconsciousness of the very exist- ence of a stomach, but let dyspepsia be present and the patient can think of little else. A perfect digestion gives great energy; the blood circulates normally through the brain and the nervous system, work, mental or physical, is a pleasure, and life seems well worth living. But the dyspeptic knows nothing of the joys of existence. A shattered nervous system is all that occupies her time and thoughts, and by this constant introspection are brought THERAPEUTICS. 271 about the various conditions of neurasthenia, hysteria, and other complaints which we have been studying. The importance of dietetic treatment will thus be evident. It is essential that a definite plan be pursued, and there are some important points which we must ever keep in mind. We must procure an effective elimination of all the waste products of the body. First, we must prepare the diges- tive tract and the tissues of the body to receive and as- similate the nutriment, and then we must select the most nutritious food and so prepare it that it will be readily assimilated. We must remember f to treat the whole sys- tem, which is in a pathological condition. The most rational method of securing elimination through all the channels of the body is by stimulating the activity of all the emunctories by the ingestion of a large quantity of hot water, and by hot sponge baths, followed by a vigorous rubbing of the skin. This plan of treatment, to be effec- tive, must be systematically carried out, and both physician and patient must steadfastly avoid that complete depend- ence on drugs which converts the wisest method of treat- ment into blind empiricism. The causation of a disease should be carefully studied, and then by treating the diathesis the consequent disease can be prevented or removed. Most of these diseases depend for their propagation upon defects of nutrition. These being removed, the disorder often disappears. We must remove the cause, otherwise the disease will persist in spite of all treatment, and to do this a perfectly clear diagnosis is necessary. It is the bringing up of the vital- ity of the patient that leads to recovery, as a lowering of the vitality is the first factor in producing disease. Whenever there is vital energy there is resistance to dis- ease. It is a well-known fact that Nature has the power 272 FUNCTIONAL NERVOUS DISORDERS. to cure in most cases if we give her the materials to work with, and at the same time stimulate the activity of the emunctories sufficiently to remove the poisonous waste. The diet for neurotic patients must be a scientific one, based on a knowledge of what the different kinds of food do for the organism. We must provide, first, for the oxidation and elimination of waste products, and, secondly, for scientific alimenation with readily absorbed and easily assimilated nutritive materials of the highest grade. There are many factors necessary for the successful treat- ment of the neuroses — rest, mental and physical, pure dry air, gentle exercise in the sunshine — all are important; but these are as nothing if the nutrition does not receive proper attention. A knowledge of dietetics is far more essential to success than a knowledge of drugs in the treat- ment of either acute or chronic disease. A careful study of the physiology of digestion and assimilation and of the composition and value of the different foods clearly shows us the means by which we are to construct a diet of the greatest utility to our patients. It would seem as if here- tofore there had been a great lack of definite knowledge as to the construction of diet lists. The usual fault is that there is too great a variety for each meal, and much of it is comparative!} 7 difficult of digestion. The best argu- ment in favor of the more enlightened dietetic treatment of a disease is to be found in the clinical results. We now know, through a study of physiological chemistry, what foods are of high and what of low nutritive value; what ones are easily digested and assimilated ; what re- quire special gland elaboration before their nutritive ele- ments can be utilized; what foods readily ferment, and what are the causes of this abnormal change. Of especial value are the proteid or tissue-building foods, THERAPEUTICS. 273 and the one which stands at the head of the list, because of its utility in these cases, is beef. It is difficult to show the importance of the selection of a correct amount of the different classes of food. If a certain class is taken in excess there is imperfect assimilation, and disease slowly but surely results. I have known fatal diabetes to result from excessive indulgence in raisins. Oatmeal mush, fer- menting in the intestines, is a common factor in the pro- duction of nephritis. A vegetable diet contains an injuri- ous amount of the carbohydrates and too little of the proteid element, which in this combination is difficult of digestion. That a meat diet, with a moderate proportion of carbohydrates, is the best food for neurotics lias been fre- quently demonstrated clinically. Milk has not so great a food value as meat because of its greater difficulty of diges- tion, its proneness to ferment because of the sugar it con- tains, its lack of reparative material — not four per cent, of proteids — and the great danger of its being impure. Milk may fatten and keep the patient plump, but fat persons sometimes have tuberculosis and are frequently neurotic, and much of the fat we see is unhealthful. It is, neverthe- less, of great value as a nutrient. Bearing in mind the best proportions of the three classes of proximate principles — viz., that the amount of proteids taken should exceed the amount of starchy food and fat — ■ it is proper to consider how these proportions can be ob- tained in a most nutritive and assimilable form, so that while the nutrition is brought to the highest point, elimi- nation may not be hindered. In the beginning of the treatment the patient should eat nothing sweet, sour, or fried, and starchy and farinaceous foods should be entirely prohibited, with the exception of a small quantity of stale bread or boiled rice, until the digestive and lymph chan- 18 274 FUNCTIONAL NERVOUS DISORDERS. nels are entirely free from the irritating products of fer- mentation. In functional nervous disorders there is usually a feeble digestion and frequently a low-grade catarrhal and inflammatory state of the digestive tract. The internal administration of hot water will tend fo re- move this condition and restore the parts to their normal state. It is not so much that large quantities of food should be taken, but that it should be thoroughly assimi- lated. The meat should be lean, juicy beef from the cen- tre of the round ; and, after all the fat and fibre have been removed, it should be cut into small pieces and passed twice through a perfectly clean meat chopper; or it may be scraped from the fibrous tissue with a knife or meat scraper, or chopped on the block by the butcher. This minute subdivision by grinding or chopping makes it most digestible. The majority of patients have bad teeth, which frequently infect the food. If the meat is not thoroughly masticated, the stomach certainly cannot prepare it for absorption. It should be kept sterile by handling it with perfectly clean hands and by cleansing with boiling water every implement it touches. The pulp should now be pressed very gently into cakes from one-half to three- fourths of an inch in thickness. If they are made too thick, they will be difficult to cook, and they should not be pressed too firmly together, as this renders them less digestible and less palatable. The cakes should then be carefully broiled over a clear coal fire, or over one free from smoke and blaze, and they should be turned fre- quently to retain the juice. If desirable, they can be sea- soned with a little salt, pepper, or butter. Another method of cooking the beef pulp is to gently simmer it with a small quantity of water upon the back of the stove for about twentv minutes; it should not be THERAPEUTICS. 275 allowed to boil, as this coagulates the albumin, turning it to a gray color, and makes it difficult of digestion. This dish is commonly known as Scotch collops. With this meat diet a small quantity of dry, stale bread, two days old, should be taken. It should not exceed in bulk the amount of meat taken. Beef tea of the right kind, prop- erly made, or liquid peptonoids, may be given for a short time. After a time some vegetables can be carefully added in small quantity, a mealy potato, or, as before mentioned, a little boiled rice, hominy or farina, sago or tapioca gruel; but our main dependence must be upon the beef. When there is a strong craving for more variety, the dietary may be extended by cautiously adding a soft-boiled egg, a nicely broiled tender steak, lamb, mutton, turkey, game or chicken, French peas or string beans. The succulent vegetables, celery, lettuce, dandelion, cauliflower, and spin- ach, are sometimes useful, as they assist in overcoming the constipation that is frequently present. Idiosyncrasy must be considered. There are whole families who cannot taste milk in any form. I have a patient, a young man of twenty, who can never taste tomatoes — even the odor of sliced tomatoes being sufficient to make him sick. There are other things also, such as asparagus and cauliflower, which it is im- possible for him to eat, and like many others, he cannot eat Lima beans or yellow beans. Articles having a de- cided odor are exceedingly distasteful to him. He has never eaten butter and cannot take it in any form, either fresh or salt, without it causing excessive nausea. These neuroses, as they may be termed, of the gustatory nerve are often really psychoses and are exceedingly common. Manv of our ordinarv articles of diet are taken as the re- 276 FUNCTIONAL NERVOUS DISORDERS. suit of an acquired taste. This is particularly the case with tomatoes, Lima beans, oyster plant, parsnips, carrots, and turnips. Many persons cannot eat batter on bread, even when extremely hungry, without being nauseated. Again, some individuals never eat salt, while others take inordinate quantities. In these cases there is always digestive derangement and generally decomposition of starchy, saccharine, and fatty articles of diet. In the foregoing regimen these have been excluded to a great extent. If constipation be present, a little Turkish rhu- barb, or, better still, a small glass of senna tea, with an aromatic such as fennel to obviate griping, or a teaspoon - ful of table salt in a glass or two of cold water, may be taken on going to bed or on rising. Bad cooking and in- digestible food, like cheese, pastry, baked beans, corn, lobsters, clams, pork, greasy macaroni, sausage, cabbage, pickles, porridge or mush, hard-boiled eggs, salads, veal, doughnuts, nuts, raisins, raw onions, cucumbers, fruits, and impure milk should be carefully avoided. To this may be added strong tea and coffee, especially the latter. As regards liquids, the patient may be allowed to drink a cup of properly prepared, thick, home-made beef tea, or the expressed juice of beef every two or three hours, if very weak; otherwise only at meals. Peptonized milk, or milk and Highland water, or cocoa, or very weak tea, may also be taken for a change, but without sugar. The patient should have a table to himself or eat alone ; otherwise there will be a temptation to indulge in articles not permitted. When the appetite increases very much, four meals may be taken daily, if needed, but at regular hours, the last one not to be later than seven o'clock. It is not well for the physician to be too strict in regard to diet, nor prejudiced against certain foods, as individuals THERAPEUTICS. 277 vary. The meals should be simple, and confined to a few articles, the fewer the better. Elimination of the diseased products is of extreme im- portance in all acute and chronic diseases. When the vitiated matter is removed by elimination the disease can- not be so severe, as then there is an internal asepsis which prevents bacillary development. The eliminating organs should be stimulated, and hot water is the blandest and most efficacious means of accomplishing it through the kidneys. A glass or two of hot water should be taken an hour or two before meals, and half an hour before retiring, and enough fluid, preferably water, with the meals to assist digestion and absorption. It would be well if hot- water shops were as common in this country as in China ; they would to a degree be a substitute for the liquor stores, and would accomplish the same purpose in removing in- ternal cravings and stimulating the patron without intox- icating him. After elimination the next important step is to build up, when possible, the diseased and broken-down tissues. This is accomplished by stimulating the manufacture of pure, fresh blood. In neurotics, there being an excess of waste, we must be careful to get the proper quantities and proportions of pro- teid and carbohydrate foods, and have the waste products completely oxidized. When fresh meat is taken there is an increase in the red corpuscles — the oxygen carriers — but there is a limit to the quantity of food that can be oxi- dized. Ordinarily, we take too much carbohydrate food, and our meats (proteids) are, except in the largest cities and among the more intelligent, usually improperly cooked — most generally fried. It is the taking of excessive quantities of indigestible and stimulating foods that causes 278 FUNCTIONAL NERVOUS DISORDERS. disease. To maintain the highest standard of health, more of meat than of vegetable food should be taken. Carnivorous or meat-eating animals seldom have con- sumption, while it is quite common in the herbivorous or vegetable-eating animals. The greater " vitality" or activ- ity of the former as compared with the latter is worthy of note. The fallacies of a purely vegetable diet are most com- monly demonstrated by the bedside of the patient. Such a diet requires a greater amount of oxygen and more ex- tensive elaboration by the glandular structures of the body, and results in an excess of waste, which must be excreted. I have seen nephritis developed by the excessive indulgence in cereal and fried foods. Milk, although almost univer- sally recommended, is not a good exclusive diet for a con- sumptive. It is all right for small children and babies, who simply require to be kept warm with fattening food. Experience has taught me that a meat diet is far prefer- able for adults. It is a concentrated and most nutritious food, and withal is easy of digestion. In Japan there are scarcely any cows, yet the people are in good health. In treating neurotics we should give attention to both the liver and the lungs. We should restore the biliary secretion to a healthy standard, both as to quality and quantity. From our standpoint the liver is the most im- portant organ, for by its defective elaboration of food pro- ducts nutrition is impaired, and anaemia and disease result. Overfeeding and improper feeding tend to imperfect elabo- ration and elimination by giving the liver and kidneys too much work to perform. I do not discard milk in cases of neurasthenia and other functional diseases, but I think too much reliance has been placed upon it alone as a reconstructive tissue food. There THERAPEUTICS. 279 are many who say they cannot take milk, but the stomach can be trained to receive it and in a short time to relish it. A very small quantity should be given at first. It should be remembered, however, that milk has been shown to contain a number of parasites and bacteria. In these diseases the increased digestion of nitrogenous food is our sheet anchor, and when this is inadequate there is no arresting the progress of these maladies. Even in cases in which the lungs are involved the progress of the disease can be permanently arrested, if too much tissue has not been destroyed. While nothing gives such good results as dietetic treatment, aided by medicines, a careful preparation of the digestive tract and its appendages should not be omitted. This not only removes catarrhal and inflammatory states, but gives tone and strength to the muscular and nervous systems, stops diarrhoea, nausea, and fever, restores the appetite, and increases and enriches the blood supply. Such treatment, when combined with proper climate and other hygienic and medicinal remedial measures, brings back health and vigor to many an appar- ently hopeless neurasthenic. The following rules should not be regarded as infallible and absolute guides, but serve as important hints, the application of which the attending physician will point out: (1) Be careful to eat enough, but not too much. It is said that the majority of persons eat too much. I am sure there are a vast number who eat too little. Use great care as to the quality and kind of food taken. (2) Do not eat too rapidly or drink too much liquid during the meal, as this tends to imperfect mastication and to bolting the food. (3) Do not take a great variety at each meal, but con- 280 FUNCTIONAL NERVOUS DISORDERS. tent yourself with a few articles of the simplest and most nutritious kind, such as stale white bread, boiled rice, hominy, or farina; fresh beef, mutton, or lamb; fresh fish, oysters, mealy baked or boiled potatoes, celery, cauli- flower, spinach, lettuce, tomatoes. (4) Do not use strong tea, coffee, or stimulants unless specially permitted. Eat nothing sweet, sour, or fried. Meats should be fresh and of the best qualit}\ They are best broiled rare, and should be eaten hot. Beef and mut- ton, if not broiled or roasted, should be stewed until very tender. Eggs should be poached or soft boiled. Corn bread, as a rule, is made too sweet, otherwise it is very wholesome. No saleratus biscuits, hot or cold, or pancakes, except on rare occasions, should be taken. Rice, hominy, farina, cracked wheat, and cornmeal can be used. Occasionally, after the patient becomes somewhat stronger, strained oatmeal gruel can be taken. It is best cooked in a water bath; that is, a vessel for the purpose set in a pot of boiling water. This prevents it from burn- ing. It should cook for several hours. It can be used with milk or cream. For drinking purposes nothing equals good, pure soft water, from a granite or trap-rock region. If the stomach is tender, it is an excellent plan to sip slowly a glass of hot water half an hour before meals or during the meal, with a little milk added to give it color. Cacao is digestible and strengthening. Skim milk is also useful, and is best taken hot. As it is difficult for the patient to remember lengthy verbal statements, especially when also the exact dosage and manner of taking the drugs prescribed must not be forgotten and is always considered by them of the greatest importance, any of the following articles of diet or the THERAPEUTICS. 281 rules which are necessary in the treatment of the case can be underlined or pen-marked at the side of a prepared list : MEATS. Beef. Mutton. Lamb. Chicken. Turkey. Duck. Game. Beef tea (thick) . Mutton broth (thick) . Chicken broth (thick). Liver. Eggs (poached or soft-boiled). Oysters. Fresh fish. Butter. Buttermilk. Thick milk. Sweet milk. Kumyss. Soups. Milk puddings. Custard. White wheat bread (stale) . Brownbread. Roasted bread. Toast. Corn bread. Crackers. Rice. Hominy. VEGETABLES, Potatoes (white). Potatoes (sweet). Peas (tender). Beans (white). Beans (Lima). Spinach. Celery. Cauliflower (boiled). Cabbage tops (tender) . Lettuce. Farina. Cracked wheat. Cornmeal mush. Macaroni. Cornstarch pudding. Germea. Arrowroot. FRUIT. Tomatoes. Onions. Bananas. Melons. Peaches. Grapes. Prunes. Apples (baked or stewed) , Oranges. DRINKS, Cacao. Chocolate. Caramel coffee. Lemonade. Whey. Chicken broth. Beef tea. Mineral waters. The food question recurs three times every day and is an important one. There are many nervous patients who 282 FUNCTIONAL NERVOUS DISORDERS. do not take enough food, fearing that it will not be digested and cause distress from pain and flatulence. Some of these patients have a great many dislikes, which thus cur- tail the variety of food greatly, so much so that it is com- mon to find them in a state of partial inanition. Often- times they are quite hysterical on this point. Much of the food they prefer is indigestible or made so by improper cooking. Gradually the dietary of these patients should be enlarged, especially the fresh meat portion of it, until sufficient is taken to supply the actual needs of the body. As a rule, stimulants of all kinds should be forbidden. In certain cases it is desirable that four or even five meals should be taken daily, but these should not be large, as the patient might thus overeat. The following is a sam- ple of what might be taken : Breakfast^ 8 to 9. Hominy, rice, farina, or arrowroot, with rich milk or cream; two or three small chops, with a slice or two of bread and butter; a glass of water, hot or cold, after the meal. About eleven or twelve o'clock a cup of beef tea or a glass of milk and a cracker can be taken, if the patient is hungry. Luncheon, 1 to 2. Fresh meat or fish, either roast, broiled, or boiled. Beef, mutton, or lamb; mashed or well-baked potatoes; some green vegetables, such as let- tuce, celery, cauliflower, or tomatoes ; finally a plain milk pudding, with a cup of weak tea, cacao, or milk. Supper. Fresh fish, soft-boiled eggs, chicken, or turkey, bread and butter; a glass of cold or hot water containing a little milk. On retiring a cup of beef tea, cacao, or chocolate, agree- ably prepared, may be taken if desired. If wines are desired, a small glass of claret or Burgundy may be taken THERAPEUTICS. 283 at luncheon. As a rule, patients do better without alco- holic stimulants. When there is a condition of great nerve exhaustion, placing the patient away from friends and relatives in a properly conducted sanatorium is of marked benefit. On entering, a very careful physical examination should be made and recorded. This should include the patient's weight and dynamometer strength of the impor- tant muscles. The Weir Mitchell plan of treatment is often of great benefit to these patients. About four ounces of milk should be given every two hours while the patient is awake, but they should not be awakened to take it, the quantity should be gradually increased until at least two quarts are taken daily. If it disagrees and makes the pa- tient "bilious," a little salt or some lime water should be added to it, after diluting it with boiling water. After a few days plain nutritious foods can gradually be added, until a full diet supplements the milk taken. After a time the superalimentation can be gradually reduced and open- air physical curative exercise indulged in to a great ex- tent. All dietetic, general, tonic, or other treatment is useless unless there is a plentiful supply of pure air. Pure air is a great stimulant to the appetite and digestion by reason of the oxygen which it" contains. The rooms occupied by the sick person should therefore be carefully ventilated, without producing draughts, and in cold weather should be filled with a genial warmth. The patient should be out of doors as much as possible when the weather is not too severe. Oxygen should be forced, so to speak, into the lungs by an atomizer attached to an air compressor. It is the sine qua non in all nervous and lung diseases. It can 284 FUNCTIONAL NERVOUS DISORDERS. also be used in the form of pyrozone, or peroxide of hydro- gen, properly diluted for inhalation or the spray. Gentle and systematized exercise, without fatigue, has a very beneficial effect upon nutrition by stimulating the action of the heart, accelerating the circulation, and in- creasing the respiration. It thus increases the oxidation of waste products and leaves room for the assimilation of nutriment. For the weak, a daily carriage ride is bene- ficial, and for those who cannot afford this the street cars can be utilized. Boat rides on bays, lakes, or rivers, and sea voyages are also often very beneficial; but the invalid must be well wrapped up. For those who are able, walking in moderation is a very useful form of exercise. Voluntary exercise is best given in the form of scientific gymnastics under a competent medical instructor, and it should be carried to the point of moderate fatigue of the muscles used, but no farther. The arms and chest muscles are especially to be exer- cised, and this is accomplished by light dumbbells. If the patient is extremely weak, passive exercise by Swedish movements or massage may be given. For con- stipation and indigestion local abdominal massage should be employed. In certain institutions, sanatoriums, and schools of phys- ical culture passive exercise is given in a perfected man- ner. Properly performed, it is of great value to nervous invalids. The rubbing, pressing, and shampooing which the muscles get strengthens them without calling for any nerve expenditure. The skin is nourished, hardened, and strengthened by the same process. Under it, combined with the muscular exercise and the shower, the obese lose fat and the lean grow plump from a new development of THERAPEUTICS. 285 healthy muscular tissue. It would seem to be as neces- sary to groom the human animal as it is the horse. The result is about the same; both thrive under it. Not every nurse or operator can give passive exercise in a proper manner. It requires a special knowledge and training. As a remedial measure it is adapted to many disorders of the nervous system. The best time for its application is immediately after the showerbath, aud it may be given in some cases twice a day. After the body has been well dried the frictions with the hand or bath glove should be systematically given to all parts of the body. The muscles and parts that are weak and require it should be especially worked under the fingers, and all dampness and coldness removed by the stimulating healthy effect of the frictions upon the circulation. Many other motions are used, such as kneading and tapotement or percussions, and the nutri- tion of the body is much improved as a consequence. A good time for the exercise is early in the morning before breakfast, or three or four hours after a meal. After the exercise the patient should rest for at least an hour if possible. The curative exercise and massage ought to take from thirty to ninety minutes, according to the condition of the patient. The skin should assist in the work of elimination and protection. Cool or cold sponge baths, according to the vitality of the patient, have a most salutary effect. A fine shower is preferable to the sponge or dip. Its duration should be exceedingly brief, and after it the skin should be rubbed dry with coarse towels. Assisted by the patient herself, the bath should be taken in a room of mild tem- perature. Followed by massage, the cool bath is one of the greatest nerve and brain tonics known. A hot sponge 286 FUNCTIONAL NERVOUS DISORDERS. bath, with a little kretol added, should be taken at night, and the body should be vigorously rubbed afterward. If there is a tendency to "catching cold," the body may be well rubbed with some nutritive oil. In order to sleep, the mind should be kept from exciting occupation, especially toward evening. The room should be well ventilated and the bed comfortable. The evening meal should be light and simple, and no food should be taken as a rule immediately before retiring. Care should also be taken to avoid stimulants. An abundance of un- disturbed sleep is of vital importance to nervous invalids. They should retire promptly at ten o'clock, if not before. The importance of improving the nutrition of the neurotic is acknowledged by all physicians. By careful attention to the foregoing method the quality of the blood and the general nutrition of the body are greatly improved. Mal- nutrition in all degrees is found among the nervous, and especially those suffering from neuralgia. The rational treatment for such cases is to fill the blood-vessels with blood rich in nutritive materials to feed the impoverished nerves, as starvation is at the foundation of most of the nervous ills. Most of the cases result from anxiety, im- proper diet, and deficient sleep. It is not so much work as worry that does the damage. Forced feeding, as a sequence to muscular exercise in a pure atmosphere, and mental as well as physical rest are what is needed. When this is properly carried out the patients, as a rule, rapidly recover. It is a simple means of treatment, yet a success- ful one. In severe cases isolation, change of scene, and electro-therapy may be required. Outdoor exercise is very beneficial to all nervous invalids. Flannel garments, of a thickness suitable to the season, should be worn. It would be difficult to get them too THERAPEUTICS. "28? thick for our severe winters. In cold weather the stock- ings should be of wool. Corpulence. — Neurasthenic patients who suffer from corpulence may experience much benefit by excluding for a short time from their diet all fatty foods, or those that are converted into fat, such as sugar aud farinaceous foods, bread, potatoes, beets, parsnips, carrots, turnips, rice, hominy, beans, peas, and substituting spinach, cel- ery, tomatoes, lettuce, cauliflower, greens, cabbage free from stems, buttermilk, skimmed milk, oysters, eggs and meat, except pork or veal. All vegetables grown under- ground should be avoided. A lean-meat diet is essential in this affection, but it must be properly prepared, otherwise the patient will soon get disgusted and abandon it. Properly prepared, and jn proper quantities, it can readily be taken for a long period with a relish. The modes of preparing and cooking meat which have already been given may be used in the case of corpulency, and the following additional recipes will be found advan- tageous. Methods of Cooking the Ground Meat. — Scotch col- lops: Put one pound of chopped or ground beef in a stew-pan and add enough cold water to cover the meat; add an onion cut up fine and a little salt and black pepper. Simmer carefully on the back of the range (it must not be allowed to boil) ; add a little sauce free from red pepper shortly before serving, and garnish with small, thin pieces of roasted bread, not too crisp or hard. The following is another way of cooking the chopped meat, is very pleasant for a change, and when so pre- pared it is easily digested : Take one pound and a half of chopped or ground beef, 288 FUNCTIONAL NERVOUS DISORDERS. one pint of good meat soup, free from fat ; simmer care- fully over a gentle fire until well cooked. It must not boil, as this coagulates the albumin, interfering with its digestibility and its value as nourishment. This is more palatable than the beef cakes, even when they are soaked in meat soup before broiling. A nice dish for a change is to take some stock and a little boiled milk, and add one-third the quantity of bread crumbs to the chopped beef, mixing well together and mak- ing into soft cakes about three-quarters of an inch thick. Brush over them, beaten white of egg and broil carefully over a clear coal fire. Still another way is to broil the meat slightly, pass it through the meat chopper, and then mix it with good meat soup free from grease and simmer carefully until cooked over a gentle fire, being careful not to let it boil. This is very nourishing. Frequent bathing, especially Turkish baths, accompa- nied by vigorous massage, walking, exercise, or bicycle riding, must be taken. Cold water and kretol baths of short duration have a delightfully stimulating effect upon the skin. Large quantities of fresh air should be inhaled to oxidize the excess of fat, which the hot water then eliminates. With the above is combined the medical treatment, con- sisting of the chlorate and iodide of potassium as oxidi- zers, and such other remedies as are indicated and usually prescribed. The physician should make such modifications in the diet as the condition of the patient requires. Much of the food eaten not being digested, it undergoes fermentation, evolving yeast, carbonic acid gas, vinegar, or alcohol. Instead of nourishing the body, a catarrhal THEKAPEUTICS. 289 state of the digestive organs is the result of this fermenta- tion, and a diseased condition of the tissues of the body supervenes. In perfect health the normal amount of adipose tissue should not exceed five per cent of the total weight of the body. Obesity is due usually to defective oxidation of the excess of food taken, and of the waste of the body gener- ally. It is a disease process resulting from eating to ex- cess of all kinds of food, and especially those that form fat. Excessive use of alcoholic beverages and lack of ex- ercise in the open air are also great factors in its produc- tion. It is simply the outcome of wrong physical habits, and especially improper alimentation. The difficulty of breathing, the great enlargement of the body, and interfer- ence with easy movements are the principal symptoms which attract the attention in this condition. The cure of this disease is safe and rather simple by a rigid adherence to a proper dietary. In a comparatively short time, as a result of the treatment, the digestive or- gans are restored to a healthy state. In a very extensive experience during the last ten years with this plan of treatment, I have seen that, when honestly carried out as advised, it has usually been successful, and has never been productive of anything but good to the patient, as it is based upon scientific principles. Special feeding is here indicated by the condition of the system, and acts as a means of cure in this disease, which has, as a rule, resulted from unhealthy feeding. The hot water should be carefully taken as advised, as it is a most important part of this method of treatment. The action of hot water in the stomach and intestines has already been fully discussed. It should be quite hot, but still of a comfortable temperature — anywhere between 110° 19 290 FUNCTIONAL NERVOUS DISORDERS. * and 130° F. — and not simply warm, as warm water nau- seates. It may be slightly disagreeable to take at first, but one soon gets accustomed to it. A pinch of salt or a few drops of lemon juice may be added if desired. Many physicians advise almost complete abstention from liquids, but it seems to me that this is a dangerous procedure and liable, from the non -elimination of the poisonous waste of the body, to cause arterial and renal disease. When digestion and assimilation are much interfered with, as in this disease, the diet of ground or chopped beef is indicated, it being very easy of digestion and as- similation. It is rapidly absorbed and enriches the blood, which is always in this disease deficient in the oxygen carriers (the red blood corpuscles). Carefully broiled, ten- der steak is nearly as useful as the ground beef, but it should be well masticated. Although it is not a fattening diet, it is very strengthening, making the weak happier and more comfortable as a result of their renewed health. This is a hard diet, and a great deal of self-denial and perseverance will be necessary. It is best to eat alone and yet be in the room with company. Thus the temptation to indulge in forbidden articles of food is avoided. If there is a feeling of weakness or insomnia at night, drink a little beef tea, or have a sandwich or cracker at hand. In beginning the treatment the patient ma3 T feel a trifle weaker in body for a day or two, owing to the absence of the products of fermentation, alcohol, etc., but this is nat- ural and to be expected. The patient should at first keep quiet, and he will rapidly grow strong and his mind will feel stronger and clearer. There will immediately begin a shrinkage in weight as the diseased fat disappears. Out- of-door exercise should be taken — walking, bathing, dumb- bell exercise for ten minutes, three times daily, three hours THERAPEUTICS. 291 after meals. As a rule all stimulants are forbidden, ex- cept as specially ordered by the physician. Obesity is simply a disease, and must be treated as such. The fat accumulates because it is not oxidized. Alcohol, taken as a beverage and generated in the intes- tine by fermentation of starchy food, interferes to a marked extent with oxidization. The following bill of fare will be found to be an excel- lent one in these cases : Breakfast. Four to five ounces of chopped beef, chicken, mutton, or game, or broiled white fish. One large cup of weak tea, without milk or sugar. Dinner. Five or six ounces of any white fish except herring or eels ; any kind of poultry or game; any meat except pork or veal; a biscuit or a slice of stale bread; a tablespoonful of liquid peptonoids in water. Supper. Three or four ounces of chopped beef, chicken, and two small slices of stale bread. A pint of hot spring water should be sipped at intervals every two hours. As a laxative, when needed, a wine- glassful of senna tea, with a little fennel added, may be taken. Assimilation. — By the term assimilation is meant the phenomena of the incorporation of food taken by living beings into their own tissues. This, in other words, is a storing up of products to be used in the development of energy, with the resultant formation of waste products. The latter are thrown off by the excretory organs, i.e., the bowels, kidneys, lungs, and skin. Of the substances used as food, water is the most im- portant. The processes of digestion, absorption, and tissue metabolism cannot go on without it. One can survive upon it longer than upon any other single alimentary prin- 292 FUNCTIONAL NERVOUS DISORDERS. ciple; it is not only food, but a digestive agent as well> and constitutes from fifty-eight to seventy per cent, (ac- cording to different authorities) of the body weight. The various substances destined for excretion require water for their solution, especially so in the urine. The water for drinking is usually obtained from springs, although river waters, which are less pure, are frequently used for this purpose. Granite-rock water (of which the Highland water is a good example) constitute the best class of po- table waters; next come the trap-rock waters. The spar- kling lime-rock waters, like Apollinaris, are also palatable and pleasant to use, but not quite so digestible as the former. A good drinking-water should not be too hard ; it should be colorless and without odor. When there is the slightest suspicion in regard to its purity, it should be thoroughly tested to see that it is free from organic matter in a state of decomposition, as many of our most fatal dis- eases, such as typhoid fever, cholera, and dysentery come to us through the water supply. Milk, or some of its preparations, while a complete food for infants, is not suit- able alone for adult life, as it contains relatively more fat and sugar than necessary proteids. Boiling tke milk coagulates the albumin, making it insoluble and difficult of digestion. Cow's milk is richer in proteids and poorer in sugar than human milk ; its curd is more dense and much more difficult of digestion. It is much influenced by the food given to the cattle; carrots, turnips and parsnips changing not only the odor, but the color and flavor also. Fragrant grasses modify the taste of milk and butter. This is seen in the superiority of June butter. Milk is frequently the means of communicating infectious dis- eases, such as scarlet fever and measles. Steaming the milk by raising the temperature to scalding, but not to THERAPEUTICS. 293 "the boiling-point, is useful in destroying impurities which may be present, and thus sterilizing it. Beef and other proteid foods increase the amount and richness of human milk ; the fats present in the milk are not obtained from fats ingested, but from a splitting up of the proteid molecules. A pure, fresh meat diet gives milk containing a large amount of fat ; the milk sugar and ca- sein are also derived in the same way from the proteid food taken. Animal Food. — Besides the muscle substance, all beef contains more or less fat ; the red color is due to the haemo- globin present in the meat substance; the salts are potash and phosphoric-acid compounds. Magnesium phosphate and calcium phosphate are also present in smaller amount. The amount of fat present varies according to the con- dition of the animal, and is given differently by different authorities. In the substance of the meat itself, after the re- moval of visible fat, there is said to be about eleven per cent, in the ox, and three per cent, in the sheep and in the fowl, about two per cent, of fat still remaining. Beef contains four times the amount of proteids as milk. In Great Britain and America beef leads all other meats as a staple. Roast beef is the form it takes in England, while in the United States fried steak is the most common form in which we find it. The latter, I need scarcely say, is extremely indigestible. Contrary to the general opinion, rare beef is not nearly so beneficial as that which has been properly cooked. Cooking is really a partial digestion, as it softens the fibre and makes it easy of maceration in the stomach. Warm foods of all kinds are more digestible than cold ones, and this is a fact to be remembered when the diges- tion is weak. Steaks should be broiled by a quick yet gentle heat ; all beef should be thoroughly masticated, and 294 FUNCTIONAL NERVOUS DISORDERS. not eaten in too large amount at any one time. Improper mastication may result from defective teeth, but more often the pernicious habit of bolting food is the cause of the weakened digestion. An occasional glance at some work upon table etiquette may assist in overcoming this habit. Roast beef is very wholesome; the outer or first cut is less digestible than the inner slices. Mutton is digestible, but not so nourishing as beef, and is very whole- some when roasted. Boiled, with caper sauce, and served with fresh, well-cooked vegetables, it is digested by very weak stomachs, and is nourishing. The preparation of meat is the essential thing to be con- sidered; in roasting it must not be burned, and in boiling it should not be cooked to pieces. All boiled meats should be allowed to stand in their own liquor for some time after the boiling has ceased, to reabsorb the juices; otherwise they will be dry. Veal is not often digestible, although often tender. It must be carefully cooked. Pork should be selected with great care ; it must not be dark nor very red, but of a delicate pink color, with very white fat. Salted meats should be only mildly salted and not old, as the process of salting toughens them. Simmer the meat gently, as furious boiling is not of advantage. In spite of the reputation which bread has obtained as the staff of life, meat is certainly more nutritious and strengthening. Vegetable Foods. — The cereals are the most important of the vegetable foods ; they contain not only starch, pro- teids, and salts, but about fifteen to twenty per cent, of water. The nitrogenous element is most abundant on the exterior of the grain, but coarse foods, containing much bran, are indigestible. The finely ground flours or meals are the preparations most suitable to digestion ; some of the cellulose or external envelope, however, may be di- THERAPEUTICS. 295 gested. The more fat a vegetable food contains, the more difficult is it of digestion. Vegetable proteids are useful, but they are not so easily digested and elaborated as the animal proteids. There is also more waste from vegetable than from animal food. The farinaceous substances are largely composed of starch, while the leguminous seeds, such as peas, beans, and lentils, contain much proteid matter, and are largely used in the form of soup by the poorer classes. Potatoes contain principally water and starch, about two per cent of soluble albumin, a small amount of pot- ash and of chloride of sodium. There are also present in the cellular tissue phosphoric, malic, and hydrochloric acids. Green vegetables and fruits are chiefly of value for the salts they contain; they are therefore of use in scurvy and allied conditions. They fill an important place in the treatment of functional diseases in women. Food Accessories. — Alcohol, taken regularly in large doses, has a profound effect upon the nervous system, affecting all the mental and bodily faculties; by its direct action upon the digestive organs it causes catarrh and inflammation. Up to a certain extent, the alcohol taken into the system is readily oxidized. It often acts as a substitute for food which may be insufficient in amount, but it interferes markedly with oxidization. Small doses excite and large doses paralyze the nervous system. Its stimulating action is always followed by a corresponding depression. In small doses it gives a feeling of warmth, but even moderate doses lower the temperature of the body. Brandy more than whiskey hampers salivary diges- tion, although some claim that it promotes it by causing an increased flow of saliva. All wines have a strong re- tarding effect upon salivary digestion ; claret, sherry, port, 296 FUNCTIONAL NERVOUS DISORDERS. and hock even in so small a proportion as one per cent have a marked inhibitory effect. This is probably due to the acidity of these wines. Digestion is interfered with by malt liquors, according to their acidity. We have spoken before of water, and would merely observe in this place that although, as above demonstrated, wines have an inhibitory effect upon salivary digestion, this can be materially lessened by the addition of water containing the alkaline carbonates. Alcoholic beverages should be given with the greatest reserve to neurasthenics or nervous persons. As a rule, it is better not to prescribe them at all, unless in combination with the bitter tonics. Tea exercises a most decidedly inhibitory effect upon salivary digestion, undoubtedly on account of the tannin contained in it ; when used at all by persons whose diges- tive powers are in any way impaired, it should be made extremely weak and be partaken of sparingly. About five grains of the bicarbonate of soda in the teapot will remove the restraining action which it has upon the salivary digestion. Coffee, in this respect, is far less harmful than tea, and the same may be said of cacao. The latter is popularly supposed to favor digestion much more than tea or coffee, probably because it is used in a much weaker state than either of the other beverages; it is commonly used in about a two-per-cent infusion, whereas tea and coffee are used in about a five and seven per cent infusion respectively. Sugar and common salt, although exercising a very considerable influence upon peptic digestion, seem neither to favor nor to retard the salivary digestion. Salt, being to a certain degree a condiment, excites the secretion of the saliva. Sugar is very fermentable. THERAPEUTICS. 297 Gastric digestion being of greater extent than salivary, it is important to note the effect upon it of many food accessories. The effect of ardent spirits, such as brandy, whiskey, and gin, depends upon the amount of alcohol they contain ; the greater the amount the more do they embarrass digestion. In the proportions commonly used at meals they have no appreciable action of the kind, neither are they in any way beneficial. If they be taken at all, they should invariably be diluted and drunk in small amount, as large amounts markedly impede digestion. Wines and beers have a much more inhibitory influence upon gastric digestion. Very small quantities of cham- pagne have a slightly accelerating effect, due probably to the stimulation of its effervescent qualities, while claret, sherry, and port, more especially sherry, have a markedly retarding action. The same may be said of malt liquors. When taken in large quantities, they very decidedly re- tard the digestion of bread and other starchy articles of food. Tea, coffee, and cacao in strong infusions have a powerful retarding influence on gastric digestion, but when taken in weak infusions, as cacao is usually made, the effect is slight. The retardation is especially noticed with starchy foods. Table or small beer, as used in England, or very light lager beer, such as the two-per-cent. beer, taken while in its effervescent state, has probably no deferent effect on gastric digestion, or none worth mentioning. The influence of these food accessories upon pancreatic digestion is much less marked than upon the gastric or the peptic. Medicinal Treatment. Reconstructive Remedies. — Many drugs are employed with good results in the treatment of nervous disorders. 298 FUNCTIONAL NERVOUS DISORDERS. Coffee, and its alkaloid caffeine, are especially useful as a domestic remedy for slight migrainous headaches which come on after meals, and is a common and extremely valu- able remedy for functional headaches. Cafe noir is sup- posed to be efficacious in hastening digestion, but in many nervous dyspeptic persons its use is detrimental. In ner- vous asthma coffee and caffein are often very useful when administered in strong doses. The reflex vomiting of pregnancy is often checked by the use of alcoholic drinks, as whiskey or brandy, and these stimulants in small doses will sometimes be found useful in the class of cases under consideration in this work. Generous wines in small quantities act as a reparative food, and, as they restrain the waste of nervous tissue, they will be found most use- ful agents. They are to be used only where unmistak- ably indicated, as there is always some danger of inducing the alcoholic habit. They by no means take the place of the natural food of the body, although their use, it is sup- posed, may sometimes tide the patient over a critical period. Among the best tonics for neurotic individuals are the cinchona preparations, more especially in those cases which have a malarial element, characterized by a perio- dicity or intermittency of the symptoms. As bitter tonics and appetizers they are of advantage to stimulate the digestive powers, thus assisting nutrition and strengthen- ing the entire system. One of the best of these prepara- tions is the sulphate of quinine; in small doses it acts as a good heart stimulant, and is preferable to digitalis in cardiac disorders. In large sedative doses it is dangerous in this class of cases. In certain reflex nervous asthmas, reflex coughs and dyspnoeas, however, large doses may be administered with advantage. The cinchona preparations THERAPEUTICS. 299 (more especially the sulphate of quinine) act most bene- ficially and quickly in neuralgias of malarial origin. It will be found advantageous to combine the quinine with opiates if the pain be very persistent and severe. Mi- graine is benefited in most cases by a combination of quinine and digitalis. In functional and catarrhal affections of the stomach and intestines, an infusion of calumba is very useful in restoring the digestion to its normal condition. A bitter tonic, disagreeable to take, but sometimes of value, is quassia; it often very quickly relieves vertigo of stomachic origin. Another extremely bitter tonic is gentian; it is often valuable in stimulating the digestion in functional nervous disorders, and usually succeeds in removing the debility which is at the root of these ailments. The com- pound tincture of gentian is an excellent product, and can be combined with the cinchona preparations, which are the best of all this class. These should be taken in small quantities and at regular intervals; they all increase the force of assimilation and thus act as strong nerve tonics. Condurango, which has been in bad odor from its hav- ing been recommended as a specific for cancer, is said to be a good stomachic and appetizer. I have seen admi- rable results from its use, in increasing the appetite and the digestive powers, when its fluid extract has been com- bined with the tincture of nux vomica. However, Lauder Brunton claims that it is physiologically inert {Journal of Anatomy and Physiology, April, 1876). Arsenic in the form of Fowler's solution is a good tonic to the nervous system ; through its beneficial action on the digestive function it gives tone and strength to all the organs, thus increasing the vital resistance. It should be used with great caution, in view of its poisonous properties. 300 FUNCTIONAL NERVOUS DISORDERS. Where there is no inflammation of the digestive organs, a good bitter tonic, with the addition of a little capsicum, is all that will be required in the way of medicine, but a generous supply of nutritious food should be given. When severe nasal or gastric catarrh is present, this must be first removed before any efforts are made toward the enrich- ment of the blood. Astringent tonics, hot water, substan- tial meat foods, so prepared as to be easy of digestion, are here indicated. City life in large centres is incompatible with the best hygienic conditions; a few weeks in the country or at the seaside speedily bring a restoration of the vital forces in these disorders, Inhabitants of large and busy cities, who live constantly at high pressure, re- quire a more sustaining diet than the residents of small towns or those who live in the country. City life tends directly to the development of the neuroses by its enervat- ing action upon the system. Generous wines, with quinia, are highly recommended, but a scientific dietary and the maintenance of proper hygienic conditions are more important elements in the treatment. In melancholia and the psychoses, tonics are especially indicated. Wines and cordials; pure air and pure water; proteid and carbohydrate food in proper proportions, along with drugs which stimulate digestion; and mental as well as physical rest, will do much toward reanimating and restoring these patients. In cases in which chlorosis is present we find the follow- ing train of symptoms : Marked exaltation or depression of spirits; emaciation, at times slight, at others well de- fined; paleness, often with a greenish tinge of the skin and mucous membranes; pearly appearance of the sclerotic; pufflness, most marked in the face; development of ca- THERAPEUTICS. 301 cbexia; coldness of bands and lower extremities; full, soft and accelerated pulse; elevation of temperature; thirst; dryness of cuticle ; hysteria, melancholia; muscular debil- ity and a condition of general nervousness; irregular respirations; irregular neuralgic pains; spinal sensitive- ness ; palpitations ; a dry, barking cough ; dyspepsia, pyro- sis, a depraved appetite. Vomiting may be present and constipation is a frequent accompaniment, although, after the disease has existed for a considerable time, diarrhoea may be present. Irregular and excessive flushing of the face, an anaemic bruit at the base of the heart, and a venous hum in the neck may also be observed. In these cases the menstrual function is always affected, and may be entirely absent ; on the other hand, menorrhagia may exist. Menstruation may be painful, irregular, scanty, or of abnormal color ; leucorrhcea is very often present. The above is a brief resume of the symptoms of chloro- sis, a condition which is very frequently present in the class of diseases under consideration. The administra- tion of the various preparations of iron will usually give great relief. In many cases of chlorosis the disease is not recognized by the physician, because, as is often the case, the disturbances of menstruation, the dyspeptic symp- toms, and the nervous manifestations appear either sepa- rately or together before the peculiar pallid appearance of the skin has reached the point which proclaims the disease even to an inexperienced eye. In the treatment of chloro- sis, iron, arsenic, and strychnine are invaluable, and may be given according to the following prescription : 3 Strych. sulph., gr. ^. Acid, arsenios., gr. -£$. Ferri reduct., gr. i. M. 302 FUNCTIONAL NERVOUS DISORDERS. This in tablet form is an excellent preparation for chlorotic girls and neurasthenic patients generally. Iron should be administered at meals, as these are the periods when the gastric fluid contains the greatest amount of acid. In cases in which pyrosis or " water brash" is present, the iron should be administered between meals. When one preparation of iron has been used without ob- taining a satisfactory result, another should be tried. The treatment should be continued without intermission dur- ing the menstrual periods, and should not be discontinued until the disappearance of the chlorosis ; then there should be an intermission for about a month, when the treatment should be again taken up for three or four weeks. The following is a good combination : T$ Mass. Blaud, . . . . . . gr. v. Hydrarg. bichlor. , . . . . gr. g^. Strych. sulph., gr. ^. Acid, arsenios., gr. ^. M. One of these tablets should be taken after each meal. As a recurrence of the chlorosis is always possible, the iron treatment should be continued for some time, gradually increasing the intervals between the administrations and gradually decreasing the periods during which the iron is exhibited. In the treatment of nervous symptoms, due consideration must be given to the patient's constitution and temperament. In full-blooded and vigorous women, when anything approaching hysterical convulsions pre- sents itself, the administration of iron is likely to be pro- ductive of more harm than good ; while in other patients who are debilitated from loss of blood or other cause the nervous symptoms will very generally disappear with rapidity under the treatment by ferruginous preparations. THERAPEUTICS. 303 In neuralgia, which is a very common symptom in chlo- rotic patients, and which in such cases changes its seat with remarkable rapidity, iron will usually prove of great benefit. This type of neuralgia is often very difficult to recognize. In cases of facial neuralgia, local applications should be combined with the internal administration of iron, and may consist of belladonna or chloroform ; some- times hypodermic injections of morphine may be given. In functional nervous disorders, while placing a due amount of reliance upon drugs, other agents must not be overlooked. The importance of a proper diet, strictly adhered to, cold or tepid baths, and a suitable form and amount of bodily exercise cannot be overestimated. With regard to bodily exercise, we may remark that while in some cases it is a valuable adjunct to the treatment, in others, in which neither iron nor any other medicinal agent will be of advantage, properly directed systematic exercises alone will effect a cure. Antispasmodic Agents. — Among the antispasmodic agents which are useful in the treatment of the nervous dis- orders of women, valerian occupies a very prominent posi- tion. In simulated disease in hysterical subjects, its value in large doses can scarcely be exaggerated. In cases in which vertigo is present, its administration is always indicated. Asafcetida may be prescribed in all cases in which vale- rian is suitable, but it possesses the disadvantages of an ex- ceedingly disagreeable odor and taste and a liability to cause purging, which make it a less desirable agent than valerian. In violent hysteria, and when constipation and hysterical colic exist, asafcetida has been found to be use- ful. It will give better results than valerian in nervous disorders of the digestive and respiratory tract. Camphor has been extensively used in almost all neu- 304 FUNCTIONAL NERVOUS DISORDERS. rotic disorders. It is, however, more useful in the nervous symptoms accompanying fevers than in true neuroses. It has been highly extolled in the treatment of mania. Its greatest value is perhaps as an anaphrodisiac. Ether is both a stimulant and an antispasmodic, but its effect is transient. A few drops administered when pre- monitions of an hysterical fit are noticed, will usually abort the attack. In spasmodic and nervous affections unaccompanied by inflammation, it is very valuable. In spasmodic colic, nervous palpitations and headache, and during the paroxysms of spasmodic asthma, it will be found very useful, as it will, in fact, for many nervous symptoms arising in the course of almost any disease. Hoffman's anodyne is a good form in which to adminis- ter ether. For mental emotion or hysteria this gives prompt relief. It is of great temporary value in angina pectoris and in spasmodic asthma, but full doses must be given to produce the desired effect. In hysterical sick- headaches half -drachm doses should be given, or, combined with the ammoniated tincture of valerian, two-drachm doses every twenty or thirty minutes. All abdominal irritations, such as colic or diarrhoea, causing spasmodic contractions of the arteries of the lower extremities, which especially in children are often accompanied by a rush of blood to the head, are relieved by a few drops of Hoff- man's anodyne. When there is a deficient supply of blood to the lower extremities, spasm of the muscles, as in- dicated by painful cramps and flexion of the toes upon the soles of the feet, shows reflex irritation. Hysterical women are often victims of rumbling and gurgling in the bowels, and suffer from excessively cold feet, the result of arterial spasm from abdominal irritation. Two teaspoonfuls of Hoffman's anodyne is an efficient remedy. THERAPEUTICS. 305 Oxide of zinc has been used in almost all neurotic affec- tions, and some authorities claim to have seen great benefit accrue from its use, especially in epilepsy. Taking all the evidence for and against it, however, its value is very questionable. The same remarks apply to the acetate and lactate of zinc. The oxalate and nitrate of cerium have been used in neuroses by Sir James Simpson, who affirmed that he had a great measure of success with them, especially in the vomiting of pregnancy. Reflex vomiting of cerebral origin, the vomiting of pregnancy, and seasickness are benefited by treatment with the bromides. In seasickness the dose used need not be large, but it should be accompanied by a goblet or two of very hot water. Used in this way they are very suc- cessful agents, but the hot water is the more important. Palpitation of the heart is benefited by them, when not de- pendent upon anaemia or gastric catarrh; but when due to either of these two conditions, rectification of the gastric disorders and the consequent enrichment of the blood are of primary importance. In insomnia, the hypnotic action of the bromides is well marked. They are often prescribed with benefit in alcoholic delirium, but the elimination of the poison by drinking hot water and the assimilation of nutritious food are of vastly more importance in the treat- ment. Where there is much anaemia the bromides are harmful, as they are especially liable to set up gastric catarrh if not properly administered. In melancholia and hypochondriasis they may sometimes be used with benefit, while again, in the same conditions, their exhibition may be harmful. Migraine of the congestive type is often markedly benefited by the use of the bromides, especially of the effervescent preparations. In the vascular neuroses 20 306 FUNCTIONAL NERVOUS DISORDERS. they often give marked relief; in morbid blushings and flushings occurring at the menopause, or whenever the local circulation is disturbed, the bromides are indicated. In the respiratory neuroses, reflex coughs of abdominal or pelvic origin, false croup, and reflex asthma, full doses usually give prompt relief. In ovarian neuralgia, and irritation, accompanied by menorrhagia or other functional disorder of the uterus, the exhibition of the bromides fre- quently removes these distressing conditions. Narcotics. — Opiates have been much used in the class of diseases under consideration, for the purpose of allaying spasm, relieving pain, and counteracting the insomnia which is often present. They appear to be of most use in cases of insanity, ecstasy, melancholia, and religious mania, but their unpleasant after-effects and the disagreeable dreams produced by their use, together with the danger of causing the opium habit, are facts which must receive due consideration from the physician and make him cautious in prescribing these agents. In hysteria, opium combined with an antispasmodic, such as valerian or asafcetida, is often most valuable. When great pain is present, such patients are very toler- ant of opium, and a larger dose than the usual one must be administered. The local application of opiate lotions is also helpful, and should not be neglected. Sometimes in chorea, moderately large doses of opium are productive of very great benefit. In neuralgias it was formerly the custom to use opium internally and to apply it externally to the affected part, but since hypodermic injections of morphine have come into general use, they have quite superseded the other forms of treatment. When the neuralgia is facial the application of a strong solution of sulphate of morphine to THERAPEUTICS. 307 the gums and buccal surfaces of the cheek on the affected side will often prove most efficient. In these cases qui- nine should always be administered internally, as it will in great measure assist to retard the return of the neural- gia. In tic doloureux, which is an extremely obstinate affection, large doses of opium have always given more re- lief than any other method of treatment. In neuralgia, especially of the facial type, the internal administration of belladonna has been most favorably spoken of. It should be given in frequently repeated doses, to be reduced as the pain becomes less. Its use should be continued until all traces of the neuralgic pain have disappeared. In many cases it will be expedient to administer fairly large doses of the sulphate of quinine to prevent the return of the attack. The local application of belladonna has been followed by very satisfactory results in cases in which the affected nerve is superficial. In se- vere cases the part should first be blistered, and the bella- donna applied after the removal of the epidermis. After the disappearance of the pain, quinine should be adminis- tered. In the nervous colic which frequently occurs in hot weather and in tropical climates, belladonna has proved of signal service. Some practitioners claim that this drug has given gratifying results in cases of insanity, but other authorities assert that they have never seen any benefit from its use; wherefore it would seem that its value in these cases is not fully established. Belladonna is a powerful stimulant and tonic to the sympathetic nerve centres, especially those which have supervision over the involuntary muscular fibres. It is of the greatest value in functional disorders of such organs as contain these fibres, as for instance the alimentary canal from the phar- ynx to the anus, the genito-urinary passages, the heart, 308 FUNCTIONAL NERVOUS DISORDERS. and the whole arterial system. In nervous women with globus hystericus there is spasm or paralysis of the oesophagus. This is usually relieved, by belladonna. In hysterical gastrodynia it is sometimes of much benefit. In chronic constipation resulting from uterine or ovarian irritation, it alone often corrects this condition. In reflex asthma one-fifteenth of a grain of atropine, injected hypo- dermically low in the nape of the neck, often affords prompt relief. The constipation of nervous women and hypochondriacs has been successfully treated by small doses of belladonna, which will often effect the desired result when powerful purgatives have failed. In these cases the best period for its administration is at bedtime. It may be added that abdominal massage properly given is in these cases a specific. In gastralgia and enteralgia belladonna has also been found useful. Where there is a tendency to constipation it may be given at mealtimes or at bedtime. In the uterine pains of neuralgic character occurring in chlorotic subjects, belladonna is a most useful agent. It may be used either in the form of a rectal or a vaginal injection ; if the former, about fifteen minims of the tinc- ture should be injected with a little water ; if the latter, a strong decoction should be employed, say about one ounce to three pints, and repeated twice or thrice daily. In the vomiting of pregnancy, the extract of belladonna, made into a thin paste by means of water, and applied with friction over the hypogastric region, has been found to be remarkably successful. After the friction a compress of wet lint, covered with gutta-percha tissue, or oiled silk, should be applied. Belladonna has also been successfully used for the same purpose in the form of applications to the cervix. In the salivation occurring in some neurotic THERAPEUTICS. 309 patients, small doses of the sulphate of atropine have been used with good results. In spasmodic asthma, smoking the dried leaves of belladonna has given relief, often when all other agents have failed. If the patient has an insur- mountable objection to smoking, the drug may be adminis- tered internally, but, although some relief may be obtained in this manner, the results are by no means as satisfactory as those produced by the smoking. Dr. William M. Leszynsky, in a paper upon the use of atropine in the treatment of localized muscular spasm, read by him before the New York Neurological Society in Feb- ruary, 1891, says (and his remarks show the value of the drug in cases in which the spasm is of functional origin) : "In March, 1884, I reported a case of clonic torticollis successfully treated by the subcutaneous administration of the sulphate of atropine. The following is a brief synopsis of the case: Female, 21 years of age; unmarried; clonico- tonic spasm affecting the right sterno-cleido-mastoid mus- cle, of nearly two months' duration. "The initial dose was one-eightieth of a grain, which was daily increased in amount until, on the twentieth day, she was receiving nearly one-sixth of a grain (the maxi- mum dose), which was continued in the same quantity daily for four days, when recovery supervened. " No decided improvement was manifested until the in- jection of nearly one-sixth of a grain. All other treat- ment was deemed auxiliary to the atropine. In the discussion which followed, it was claimed that, as a num- ber of other remedies (galvanism, bromides) were used in conjunction with the atropine, it would be difficult to determine which effected the cure. From the close obser- vation of this case, I felt confident, and so expressed my- self at the time, that the recovery could be attributed to 310 FUNCTIONAL NERVOUS DISORDERS. the effect of the atropine. Subsequently the long- wi shed- for opportunity presented itself, which enabled me to test the efficacy of the drug in a similar form of spasm, un- trammelled by the objectionable association of other reme- dies. I therefore take pleasure in submitting the history of the following case for your consideration and criticism : "Charles C, born in the United States, 37 years of age and a painter by occupation, presented himself for treat- ment June 2d, 1888. Three years previous, muscular spasm began on the right side of the neck, arising six weeks after an abscess had been opened at the angle of the jaw on the right side. The force of the spasm is increased by mastication and closure of the jaw, and it is more active upon mental excitement. He is frequently aroused from sleep by the severity of the paroxysm. " There is no complaint of pain, but only of numbness in the right lower lip. His occupation frequently brought him in contact with lead, but he never suffered from colic or paralysis. There is no history indicative of trauma or syphilitic infection. Formerly, alcoholic excesses. The bowels are constipated, but his appetite is good. " He was treated hj means of medicines and electricity for four months without relief. " He is a fairly nourished man of average height. There is well-pronounced clonico-tonic spasm affecting the right platysma, forcibly drawing downward the fascia about the chin and the lower angle of the mouth. " The clonic character of the spasm preponderates, and is almost constant. The muscle is hypertrophied to nearly four times its normal size, and its outline is distinct and well defined. There is an area of complete anaesthesia one centimetre and a half by three centimetres at the vermilion border of the lower lip, near the angle of the mouth on the right side, which extends inward over the mucous mem- brane and over the alveolar process in the lower jaw. " The mechanical irritability of the facial muscles is well THERAPEUTICS. 311 marked. The jaw jerk is demonstrable. There is no apparent caries of the teeth. There is no abnormality evi- dent in other portions of the body. " Treatment. — A cantharides plaster was placed over the affected muscle. "June 9th. — One week has elapsed since treatment was begun, but there is no improvement in the spasm. The mechanical irritability of the facial muscles has diminished. He sleeps better. Injected y^-g- of a grain of sulphate of atropine into the platysma. "lOth.-Gr. Tfo. "11th. — Sleeps well, and the spasm is less frequent. Gr. Tiro- "12th. — Vertigo was complained of half an hour after the injection. He says he is very much better. The ex- aggerated mechanical irritability of the facial muscles has markedly decreased. There is also some abatement in the frequency of the spasm, which was formerly produced or aggravated by closing the jaw or turning the head to the left. "These movements can now be accomplished with im- punity. Sensation is returning in the ansesthestic area. Only one slight spasm occurred to-day. The tonic char- acter of the spasm has entirely subsided. Gave gr. -^ . "13th.— Gr. Jq- " 14th. — Spasm is induced by pressure over the alveolar process in the right inferior maxilla, in the locality of the second bicuspid tooth (which has been lost). Atropine, " 15th.— Gr. eV "16th. — No spasm since last note. Only slight vertigo after last dose. Gr. -^. "19th. — Has been receiving daily injections of gr. -^ without producing toxic symptoms. Injected gr. -£%. " 21st. — He did not call yesterday. No spasm since last note. Gr. -fa. "23d. — No attack. Says he is well. Gr. ^g. " 26th. — No injection since last note. Spasm has not re- 312 FUNCTIONAL NERVOUS DISORDERS. turned. The most energetic effort fails to produce any spasmodic action in the platysma. Administration of atropine discontinued. "August 18th. — Reports to-day that he has remained free from spasm. " The successful treatment in this case extended over the brief period of two weeks, and was restricted to the daily administration of atropine. " The solution used was — 1$ Atropinee sulph., gr. i. Aq. destil. , § i. M. " One minim of this solution represents -$fa of a grain of atropine. My method has been to give four minims (gr. T |o) at the first injection, and to be on the alert for consti- tutional effects. Upon discovering that there is no idio- syncrasy in regard to the drug, it is administered once daily, and the quantity gradually increased from day to day until the desired effect is produced or intolerance is established. " The production of severe constitutional symptoms is not an essential feature in this plan of treatment. "One of the experimental physiological efforts of the drug, when given in sufficient quantity, is to paralyze the motor nerves, first affecting their trunk. " I am not prepared to say whether the atropine relieves the spasm through its constitutional action and its ulti- mate paralytic effect upon the motor nerve trunk, or by its immediate local action. " It seems to me, however, that, by injecting the fluid directly into the substance of the muscle, it is not so rapidly absorbed, and thus has ample opportunity to act locally upon the intra-muscular nerve elements. There ap- THERAPEUTICS. 313 pears to be no ground for the assumption that the atropine possesses an elective affinity for the hyperkinetic area after its absorption into the general circulation. This remedial measure deserves a fair trial in analogous cases before resorting to surgical procedures, such as nerve stretching or tenotomy, the results of which are not always encourag- ing. " The improvement in the following case of facial spasm seems worthy of note : "On the 29th of May, 1888, I was consulted by M. M., a widow, 50 years of age, who stated that for nearly a year the left upper eyelid has been tremulous. Facial spasm developed four months ago. It is worse in wet weather and upon mental excitement. The cause of the spasm is unknown. She has suffered from occasional ver- tical cephalalgia during the last two years. Climacteric three years ago. She received galvanic treatment for six months without any perceptible change. There is con- stant tremor in the lower segment of the orbicularis palpe- brarum, also frequent clonic spasm affecting all of the left facial muscles. There are no teeth in the left upper or lower jaw. They were lost during pregnancy. No ten- derness over the alveolar processes. No spinal tenderness. The pupils are small, but react normally both to light and in accommodation. Hypermetropia, 2 D. No fundus lesion. " She was kept under observation until June 9th, when she received the first injection of y^-g- of a grain of atro- pine. The needle was introduced deeply into the tissues of the face, near the exit of the facial nerve at the stylo- mastoid foramen. "June 10th. — The spasm is a little more frequent, but weaker. Gave injection of five minims. " 11th. — Face was flushed for nearly two hours after the injection. There is decided improvement. Til v. "12th. — Flushing of the face and dryness of the mouth 314 FUNCTIONAL NERVOUS DISORDERS. and throat all of yesterdaj 7 afternoon. She says she is much better, and the improvement is evident. TT|,vi. "13th.— mvij. "14th. — Doing well. TUviij. (gr. ^). "15th.— mix. " 16th. — tt[x. Spasm in orbicularis palpebrarum is quite noticeable, but feeble. " 19th. — Has had daily injection since last note. Much improved. The only symptoms following the injection are flushing and headache, which subside in a few hours. " Since beginning the use of atropine I have never wit- nessed a well-marked facial spasm. The orbicularis pal- pebrarum is mostly affected, but not so much as formerly. Tremor has taken the place of the spasm in the other mus- cles, mxij. (gr. 4V). " 23d. — Daily injection since last note. " 30th. — She says she has an occasional spasm, as before, but neither so severe nor so frequent. TT[xv. "October 13th. — She reports to-day having discontinued treatment, and states that thus far the improvement has been permanent. " It is well known that, in this peculiar and obstinate affection with an obscure pathology, remissions occasion- ally occur independently of treatment. " The improvement, however, in this case was sufficiently encouraging to commend this method of treatment for further trial." Stramonium, which is very similar in its action to bella- donna, may be used in the same class of cases. When one fails, the other should always be tried, as many cases may be relieved by the one and not at all benefited by the other. In insanity and chorea, and especially in cases of mono- mania with hallucinations, stramonium has been highly THERAPEUTICS. 315 extolled, but it is in spasmodic asthma that its value is most apparent. The powdered leaves should be smoked in the form of cigarettes, or in a pipe, mixed with equal parts of dried sage leaves. Inhalations of the drug are used but are much less reliable. In neuralgias the internal admin- istration of the tincture of stramonium has been found to be of great service. It should be given in small doses — four or five minims repeated every three or four hours. Plasters made of stramonium have also been used in the treatment of neuralgias, especially those of the scalp, and have many advocates, but it is only in transient and superficial neuralgias that they can be of any benefit. Hyoscyamus is a very valuable drug, with properties similar to those of belladonna and stramonium. It is most useful as a sedative in nervous disorders, and is of great value when given internally in the treatment of neural- gias. It may also be locally applied in cases in which the affection is transient and superficial. In hysteria its use has greatly benefited the patient, more especially when convulsions have occurred. Cannabis indica, or hashish, is a drug which deserves to be employed in functional diseases more often than is the case. It may be given when there is no acute inflam- mation present. In migrainous headaches it is a remedy of great value and also in neuralgia. Its principal effect is to ward off the attack rather than to stop it when pres- ent. I have a very favorable opinion of it as a preventive agent under these conditions. It is an excellent substitute for opium, causing none of the evil effects of the latter. In treating migrainous headache we should not forget that gastric irritation is usually the cause of the pain, and that relief of the stomach disorder usually causes a disappearance of the headache. Cannabis indica is of 316 FUNCTIONAL NERVOUS DISORDERS. value in some cases of hysteria, and may also be used sometimes for the relief of dysmenorrhea. The following combination is highly recommended by Dr. Henry J. Kenyon as a nerve tonic in chronic neural- gic headaches and other neuralgias : Zinc phosphide, . ' . gr. &• Ext. cannabis ind. , gr. i- Ext. nux vom., gr. h Sodium arseniate, gr. &■ Quinine sulph. , • gr- *. Ext. aconite root, . g r - Ttr One tablet should be taken at 10 a.m. and at 4 and 9 p.m. and the number increased by one tablet every week until four are taken three times daily; they should be taken steadily for three or four months. They act as an altera- tive to diseased nerves. Lobelia is an excellent agent in nervous asthma, and frequently gives much relief to patients who have received no benefit from the administration of either belladonna or stramonium. It is best given in the form of the tincture, in doses of from ten to twenty-five drops, three or four times a day. Aconite is a product of special value in neuralgias and nervous headaches ; it is also very useful in amenorrhea dependent upon the existence of a condition of spasm in the uterus. Three minims of the tincture should be given thrice daily. The following combination in tablet form has been found useful in acute attacks of tic douloureux : 1$ Aconite amorph. , gr- *fo- Aatifebrin, .... gr. ij. Quin. mur. , gr. i. Arsen. chlorophos., gr- T¥0- Strych. mur., gr. 7 h>- Almost the only class of nervous diseases in which THERAPEUTICS. 317 chloral has been used with any great measure of success is acute mania. In this condition it will quiet agitation and induce sleep. In melancholia and several other con- ditions its action is so depressing as to contraindicate its use. In asthma and in insomnia it may produce temporary benefit. Equal parts of chloral and camphor triturated together form a clear liquid, which, when painted over the surface at the seat of pain, is of great value in neuralgia. For the relief of nervous headaches the following for- mula has been found excellent : R Acetanilid, gr. iij. Camph. monobrom. , . ... gr. ij. Caffein cit. , gr. i. This is best used in tablet form, and may be repeated every two hours as needed. When much flatulence is present it is well to give as an antifermentative two grains of the salicylate of soda, combined with charcoal, ginger, and aromatics. This is useful when taken in tablet form an hour or two after meals, with a plentiful supply of water. Electro-Therapeutics. This branch of medical science is at present making such forward strides, is undergoing such rapid changes, and is of so great importance in the treatment of the diseases which we have been considering, that the reader is referred to special works upon the subject. Few agents are more useful in nervous disorders than electricity, but the limitations of this work do not permit of the extensive consideration of the topic which it deserves, while to treat it cursorily might be misleading and would certainly be unsatisfactory. 318 FUNCTIONAL NERVOUS DISORDERS. Dilatation for Stenosis and Flexion of the Uterus. In many neurasthenic and hysterical women, this proce- dure may be necessary. Frequently nervous disorders are dependent upon chronic endometritis, obstructive dysmen- orrhoea, and sterility, and to remove the inflammation and the obstructions to menstruation and insemination, it is often necessary to dilate and straighten the uterine canal. The stenosis is very frequently at the internal os, and is caused by flexion of the neck on the body. This condition is the result of pelvic inflammation, subinvolu- tion, or hypertrophy, which forces down the uterus and the cervix against the posterior vaginal wall, thus deflect- ing the cervix while in a softened condition upward on the body, or flattening the end of it to a button-shape. It deforms the external os, causing it to become a mere slit. Schroeder * says : " Stenosis of the cervix may be con- genital or acquired. The congenital form sometimes in- volves the whole cervical canal, and is very frequent at the external os, which is much contracted ; seldom at the internal os. In the normal uterus (with the small cervix and the small external os of the undeveloped uterus we are not concerned at present) the vaginal portion is sometimes very long, hard, and gristly, and projects unusually pointed and conical into the vagina. On the point is the external os, so small as sometimes scarcely to be perceived, and in the speculum it is difficult to discover the small opening, and then often only by a drop of mucus protruding from it. Frequently the anterior lip projects and overlaps the * Karl Schroeder: " Krankheiten der weiblichen Geschlechtsor- gane," BerliD, 1881. THERAPEUTICS. 319 posterior, so that the os is hidden as by a vaive." These are conditions of defective development. In the majority of cases of stenosis the obstruction is at the internal os, and is the result of anteflexion. Od passing the sound in these cases, it meets with an obstruction which is quite sensitive, due, probably, to inflammatory hyperaesthesia or irritability from flexion compression of the nerves at the angle. This obstruction may exist and there may still be no dysmenorrhcea. The internal os is occluded by inflam- matory swelling before dysmenorrhcea manifests itself from this cause, although sterility is the common result. Duncan * recommends as very successful in dysmenor- rhcea spasmodica mechanical treatment by dilatation with bougies ; the point he insists on is the stretching or dis- tention of the internal os, using in some cases as high as No. 12 or 13, corresponding to male bougies, but with a different curve. Sir James Simpson, of Edinburgh, maintained that stenosis of the internal os produces dysmenorrhcea and sterility, and devised a metrotome for cutting the constric- tion. There is no doubt that flexions are a very great cause of sterility, not only by mechanical obstruction, but also by producing secondarily strongly alkaline uterine and cervi- cal catarrhs, which destroy the vitality of the sperma- tozoa. Miiller f states that " conception may be rendered difficult by a flexion of the uterus. This pathological condition in the majority of cases implicates the narrowed portion of * J. Matthews Duncan: "Clinical Lectures on the Diseases of Women," 1882. •f P. Miiller: "Cyclopaedia of Obstetrics and Gynaecology," Vol. xi., pp. SQetseq., 1887, article "Sterility." 320 FUNCTIONAL NERVOUS DISORDERS. the uterine body; viz., where normally the uterine walls are in simple apposition they become firmly compressed, thus producing a stenosis of the uterine canal." The sharper, more acute the angle of flexion, the more certain the sterility; and, if the cervical canal is plugged with thick, tenacious mucus, there is no doubt of its being an absolute cause of that condition. Flexions of the uterus cause many reflex symptoms— vertigo, headache, neuras- thenia, nausea and vomiting, and very many other hys- tero-neuroses. These are only relieved by dilatation and Fig. 27. Fig. 28. proper intra-uterine and extra-uterine treatment. Flex- ions and endometritis are very often the exciting and direct cause of hystero-epilepsy — a fact which I have demonstrated by several cases in my own private practice. A number of different forms of uterine dilators have been devised, but about all of them — like Sims', Ellinger's, and Palmers' — diverge laterally, and dilate the cervical canal at the internal os in a direction where there is very frequently no constriction. The advantages of this form of instrument over the ordinary lateral dilators is best shown by an article by Dr. Graily Hewitt, in the Annals THERAPEUTICS. 321 of Gynaecology of 1888, from which the above two illus- trations are taken. They represent a well-marked case of acute anteflexion, and demonstrate of themselves the correctness of dilating the internal os and cervical canal in Fig. 30. an antero-posterior direction. He says, referring to Fig. 27 : " The uterine cervical canal is here hardly visible at the centre and upper part of the cervix, owing to the closeness of apposition of the anterior and pos- terior walls, which closeness is due, as is manifest, to the presence of the flexion. In Fig. 28 is shown another illustration of the same uterus, but the cervical canal on one side (the right) is opened out by traction of two threads. ... It is thus made evident that the cervical canal is not by any means de- stroyed. The interesting fact becomes evident that the 21 Fig. 81. 322 FUNCTIONAL NERVOUS DISORDERS. canal is unusually widened from side to side at the same time that it is so narrowed from before backward that it is hardly visible when the canal is in its untouched, flexed state. In this particular case the part of the uterine canal most affected by the flexion is just below the internal os. The bending of the uterus produces a curvature of the canal, which operates particularly on the canal for about three-quarters of an inch. In this space the canal is ex- cessively wide from side to side, but excessively narrow from before backward, and it is manifest that the lateral wideninng, as well as the antero-posterior compression and narrowing, result from the shape of the uterus. The in- ference also follows that exaggeration of the degree of the bending of the uterus would have the effect of increasing the compression of the uterine canal. It is not easy, look- ing at this specimen, to avoid the conclusion that the es- cape of menstrual fluid and menstrual debris from the uterus must have been very difficult so long as the uterus remained flexed to its present degree." The accompanying drawings demonstrate the result of flexion in a simple rubber tube : Fig. 29 represents a side view, showing the compression in the direction of the arrows, while Fig. 30 is a front view, showing the lateral widening. The lateral dilators cannot be made to dilate the cervical canal in its antero-posterior or conjugate diame- ter with any sort of satisfaction, and lateral flexions are extremely rare. The instrument devised has handles which are most convenient to manipulate, with the regis- tering guide well out of the way of the fingers, and is graduated in inches and in centimetres, so that one can exactly determine the amount of dilatation and keep a record of it if desired. The intra-uterine portion of the blades is but two inches in length, as that is all that is THERAPEUTICS. 323 necessaiy. The danger of injuring the fundus uteri is thus avoided. It gives the greatest dilatation at the inter- nal os, where it is most needed. Of the lateral dilators, I think Sims' is the best. As to what constitutes stenosis. Peaslee * says : " In the imparous woman the narrow- est point of the cervical canal — viz., the internal os — is, when opened by passage of the menstrual fluid, an ellipse whose conjugate and transverse diameters average, re- spectively, one-sixth and one-eighth of an inch, its area corresponding very nearly with that of a circle one-seventh of an inch in diameter. The external os, also elliptical when moderately dilated, has diameters averaging one- fourth and one-sixth of an inch. It thus has an area ex- actly twice that of the internal os, and equaling that of a circle one-fifth of an inch in diameter. In the parous woman the size of the external os varies within quite ex- tensive limits, since it is exposed to so many of the acci- dents of parturition, while the internal os is more nearly uniform." He finds, as a rule, the lowest average diame- ter in parous women who are neither sterile nor have dysmenorrhcea to be about one-fifth of an inch, or a little less, at the inner os, presenting nearly twice the area, of that of the imparous woman ; the external os, as a rule, to be about one-fourth of an inch in diameter. He believes that in the treatment of dysmenorrhcea and stenotic steril- ity these dimensions will be found sufficient in many cases : Imparous. — The internal os equals a circle one-seventh of an inch in diameter; the external os equals a circle one-fifth of an inch in diameter. * E. R. Peaslee : Transactions of the New York Academy ot Medicine, 1876, p. 428 et seq. 324 FUNCTIONAL NERVOUS DISORDERS. Parous. — The internal os equals a circle one-fifth of an inch in diameter ; the external os equals a circle one-fourth of an inch in diameter. The performance of trachelotomy is now comparatively rare. There are many cases of conoidal cervix and ante- flexion in which Sims' sagittal incision may be performed, but it is better to try the milder and safer method of dila- tation first. Coe * says : " That the incision of the cervix for steno- sis is not an entirely harmless procedure is evident ana- tomically as well as clinically. The proximity of the peritoneum and the rich network of veins which lies in the muscular coat of the uterus renders the danger of peri- tonitis and septic absorption no imaginary one. The in- dications are clearly to make the incision as limited in length and depth as possible, and to practise rigid anti- sepsis." Bilateral incision is obsolete as an operation ex- cept in cases of conical cervix and pinhole os, and then simply as preliminary to dilatation. In the treatment of these cases we frequently find the uterus tender, with an almost imperforate cervical canal, swollen and occluded by tenacious mucus. It is necessary to have the uterus and adnexa prepared for the operation of dilatation by the usual treatment for removing inflam- matory condition, i.e., hot- water injections, astringent and detergent applications, boroglyceride, boric acid, tam- pons, etc. (Boroglyceride, an excellent preparation, was first introduced into this country from England by the late celebrated J. Marion Sims, where it was first used by a Mr. Balfe for preserving game.) On the table or cabi- net at the operator's side there should be, besides instru- * H. C. Coe: "American System of Gynaecology," vol. i., p. 151. THERAPEUTICS. 325 ments, solutions of carbolic acid, bichloride, etc., a small porcelain, china, or glass dish containing cotton tampons soaked with boroglyceride and glycerin, and others dry. If they are not ready prepared, it causes considerable delay while the patient is on the table, which is unpleasant. After cleansing the cervix and vagina by mopping them with wet absorbent cotton, a double tenaculum is hooked into the anterior lip of the uterus, and it is drawn down- ward gently. With a hypodermic syringe, to which a silver intra-uterine pipe is attached, about thirty minims of a four-per-cent. solution of cocaine are injected into the uterine cavity, and the external os is plugged for a few moments with absorbent cotton. This gives great relief, particularly in acute and subacute endometritis with pelvic pain. After a few moments the dilator can be inserted and the canal dilated. In some cases it is necessary to pass conical cervical bougies before the dilator can be used. Of the usual forms, Peaslee's are inflexible, being of steel, and Hanks' are of hard rubber; two sets have been made, one of block tin and the other of copper, which are flexible, and can be moulded without trouble to the curves of the uterine canal. They are to precede the dilator when the canal is too small for its introduction. The block-tin sounds can also be used as obturators for in- serting the tracheal cannula. Ordinarily, half an inch is as far as dilatation should be carried. The patient should be in the Sims position. The operation can be done in many cases at the physician's office, but the uteri of some women have a habit of getting up a severe inflammation on very slight provocation, so it is safer to do the operation at the patient's home, and then with all antiseptic precau- tions. The instruments are to be washed in hot soap water to remove adherent mucus, and then in clean water, dried, 326 FUNCTIONAL NERVOUS DISORDERS. and passed through the flame of a spirit lamp, thus destroy- ing all germs, which boiling water does also. It does not discolor the instruments or "give them the blues," and they are finally placed in a three-per-cent. carbolic-acid Fig. 32. solution. In rare cases, when an in- cision is required at the internal os on account of the fibrous band or induration at the compressed angle of flexion, I have had a knife made with a metallic handle flexible below the blade, yet strong enough to resist any ordinary pressure for cut- ting-purposes. It is one-eighth of an inch broad at the base and one-sixteenth near the point, with a rounded point and back. A Sims or Emmet intra-uterine knife can be used, but they are much more expen- sive. After the blades of the dilator have been sterilized by passing them through the spirit flame, they are well greased and introduced. The handles are pressed gently and slowly, until the guide shows that half an inch, or a little over a centimetre, separates the blades. After cleansing the uterine cavity with an antiseptic, the intra-uterine stem is inserted and allowed to remain, the patient drawing it away by the silk thread if it causes any irritation. The stem (Fig. 32) has been modified by giving it a retaining- Fig. 33. THERAPEUTICS. 327 swell, which adapts itself to the normal shape of the cervi- cal canal between the external and internal os and pre- vents it from slipping out if the proper size has been used. The principle involved in the intra-uterine stem is the same as in Dr. O'Dwyer's tubes for stenosis of the larynx, from which the idea of the retaining-swell and the perforation for the thread for its withdrawal was copied. The special Fig. 34.— Stenosis Case. forceps (Fig. 33) for introducing the stem holds it very firmly during its insertion. Messrs. Tiemann & Co. have put the instruments in, a case (Fig. 34), which also contains a rather heavy uterine probe to determine the direction of the canal. One is led to believe that the treatment of the fore- going conditions by dilatation is both rational and scien- tific. It is of course applicable to chronic cases only, and is a delicate procedure, requiring skill and good judgment. Cold. Cold acts on the vasomotor system as a neurotic irri- tant. As a tonic it produces a shock which, if not too great, is always followed by a reaction. This exercises 328 FUNCTIONAL NERVOUS DISORDERS. the system, and thus tends to improve the nutrition and strengthen the body, or the part to which it is applied. It is a tonic in cases of weak circulation and feebleness of mus- cular power. It strengthens the heart and the arteries. It improves the digestion. During a cold bath, be it dip, shower, or sponge, great care should be taken that the patient does not become exhausted by its too long continu- ance. Five minutes is a sufficient length of time for any one. Reaction should be favored by massage and the use of the flesh brush. In migraine with dilation of the temporal artery and congestion of one eye, in cerebral congestion from sun- stroke, strong coffee, or tea, and in nasal hemorrhage great relief is often obtained by cold applications to the nape of the neck. Cold acts as a styptic by lessening the calibre of the arteries through its irritant effect upon the vasomotor nerves. By its irritation of the afferent nerves it causes not only a variation in the calibre of the vessels of the surface of the part to which it is applied, but also in all the arteries directly beneath that part. When the organs of the body are in pairs and perfectly symmetrical, as is the case with the eyes, cheeks, ears, hands, and feet (the kidneys, testicles, and lungs are not), any variation in the calibre of the vessels of one will cause a like variation in the calibre of the vessels of the other. Variations also in the calibre of the vessels of certain parts of the body are attended by corresponding changes in the arteries of certain other parts. These associations have been deter- mined empirically ; thus, the interdependence of the con- dition of the circulation of the feet, the abdominal and pelvic organs, and the pharynx, as well as that in the nape of the neck with the arteries of the brain and face, is well known. Dr. William M. Thomson, of New York, has in THERAPEUTICS. 329 his lectures noted the laws of the vasomotor s} T stem, and their response to the action of cold. An ice bag or ether spray applied to the epigastrium stops haematemesis. Holding a piece of ice in one hand will check bleeding in the other. A cold footbath will arrest metrorrhagia, as will also ice rubbed against the inner aspect of the thighs and across the abdomen. In post-partum hemorrhage the cold should be applied by means of the ether spray, for the sudden and intense impression which it makes causes effectual uterine contraction without chilling the patient. When the ether is not available, ice water may be poured from a moderate height, but this is rarely, if ever, necessary. Slapping the thighs and abdomen with cloths or towels wrung out in ice water is more convenient and in every way better. 330 FUNCTIONAL NERVOUS DISORDERS. Literature. Anderson, T. : British Medical Journal, February 8, 18T9. Baruch, Simon : Uses of Water in Modern Medicine. Detroit, 1892. Bastian, H. Charlton : Paralysis. New York, 1886. Bastian, H. Charlton : Brain as an Organ of the Mind. New York, 1880. Bastian, H. Charlton: Various Forms of Hysterical or Functional Paralysis. London, 1893. Bauduy, Jerome K. : Diseases of the Nervous System. Philadel- phia, 1892. Beard and Rockwell • Sexual Neurasthenia. New York, 1894. Beard and Rockwell : Medical and Surgical Electricity. New York, 1871. Beard, G. M. : Nervous Exhaustion. New York, 1880. Boldt, H. J. : Cardiac Neuroses. American Journal of Obstet- rics, August, 1886. Reflex Vaso- Motor Neurosis (Blue (Edema). Ibid., February, 1886. Bosworth, F. H. : The Relation of Vaso-Motor Disturbances to Diseases of the Upper Air-Tract. New York Medical Journal, November 23, 1895. Bourneville et Reynard : Iconographie Photograph i que de la Sal- petriere. Paris, 1878. Bourneville et D'Olier: Recherches sur l'Epilepsie, l'Hysterie, et l'ldiotie. Progres Medical, 1881. Bramwell, Byrom : The Diseases of the Spinal Cord. Edin- burgh, 1882. Briquet : Traite Clinique et Therapeutique de l'Hysterie. Paris* 1859. Bristowe, John Syer : Diseases of the Nervous System. London, 1888. Brodie, Sir Benjamin C. : Local Nervous Affections. London, 1837. Brown, Ralph: Neurasthenia. London, 1894. Brown-Sequard, C. E. : Lectures on the Diagnosis and Treatment of Functional Nervous Affections. New York, 1868. Brown-Sequard, C. E. : Lecons sur les Nerfs Vaso-Moteurs. Paris, 1892. Carpenter, William B. : Mental Physiology. London, 1874. Carter, Robert Brudenell : Hysteria. London, 1853. Chapman, John : Neuralgia. London, 1893. Charcot, J. M. : Lecons sur le Systeme Nerveux. Paris, 1873 and 1884. LITERATURE. 331 Charcot, J. M. : Clinique des Maladies du Systeme Nerveux. Paris, 1873. Clevenger, S. V. : Spinal Concussion. Philadelphia, 1889. Clouston, I. S. : The Neuroses of Development. London, 1891. Collins, Joseph : Angeio-Neurotic (Edema. American Journal of the Medical Sciences, December, 1892. New York Medical Record, April, 1892. Conklin, W. J. : Some Neuroses of the Menopause. Transactions of the American Association of Obstetricians and Gynaecologists, 1889. Cowles, Edward: Neurasthenia. Boston, 1891. Dana, Charles L. : New York Medical Journal, July, 1887. Dana, Charles L. : Text-Book of Nervous Diseases. New York, 1892. Davey, James George: The Ganglionic Nervous System. Lon- don, 1858. De la Tourette, Gilles. Traite Clinique et Therapeutique de l'Hysterie. Paris, 1895. Dubois, Frederic : Hypochondrie et Hysteric Paris, 1837. Edebohls, G. M. : New York Journal of Gynaecology and Obstet- rics, January, 1893. Emmet, Thomas Addis : Principles and Practice of Gynaecology. Philadelphia, 1884. Emminghaus, H. : AllgemeinePsychopathologie. Leipsic, 1878. Engelmann, George J. : Gynaecological Transactions, 1877 and 1887. Etheridge, James H. : Medical Gynecology. American Journal of the Medical Sciences, January, 1892. Eulenburg, Albert : Lehrbuch der Nervenkrankheiten. Berlin, 1878. Evans, W. F. : Mental Medicine. Boston, 1895. Goodell, W. : Lessons in Gynaecology, Lesson XXX. Philadel- phia, 1880. Gowers, W. R. : Diseases of the Nervous System, vol. ii. Lon- don, 1888. Grasset, J. : Maladies du Systeme Nerveux. Paris, 1886. Gray, Landon Carter : Nervous and Mental Diseases. Philadel- phia, 1893. Gross, Morris : New York Medical Journal, May 4, 1895. Hamilton, Allan McLane : Nervous Diseases, their Description and Treatment. Philadelphia, 1878. Hammond, William A. : A Treatise on Diseases of the Nervous System. New York, 1881. Hammond, William A. : Spiritualism and Allied Causes and Conditions of Nervous Derangements. New York, 1876. Hart and Barbour : Manual of Gynaecology. New York, 1883. 332 FUNCTIONAL NERVOUS DISORDERS. Hartshorne, Henry: Reynolds' System of Medicine, vol. i., 1880. Heiberg, J. : Atlas of the Cutaneous Nerve Supply. London, 1888. Herter, Christian K. : The Diagnosis of Diseases of the Nervous System. New York, 1892. Hilton, John : Rest and Pain. New York, 1879. Horsley, Victor : The Structure and Functions of the Brain and Spinal Cord. Philadelphia, 1894. Jauch, P. L. : Automatisme Psychologique. Paris, 1894. Jolly, F. : Ziemssen's Cyclopaedia of Medicine. New York, 1877. Jones, C. Handfield. Studies in Nervous Functional Disorders. London, 1870. Krafft-Ebing, R. von : Lehrbuch des Psychiatric Stuttgart, 1883. Krafft-Ebing, R.von (Chaddock, C. G. , translator): Psychopathia Sexualis. Philadelphia, 1892. Laycock, Thomas : Nervous Diseases of Women. London, 1840. Lee, Charles Carroll : The Relation of Peripheral Irritation to Diseases of the Womb and its Appendages. Annals of Gynaecology and Paediatry, June, 1890. Leszynsky, William M. : New York Medical Journal, March, 1891. Lloyd, James Henry : Hysteria (Nervous Diseases by American Authors). Philadelphia, 1895. Mann, Edward C. : Manual of Psychological Medicine and Allied Diseases. Philadelphia, 1883. Maudsly, Henry : Pathology of the Mind. New York, 1880. McGillicuddy : New York Medical Journal, August 1888. McGillicuddy : New York Medical Journal, November, 1893. McGillicuddy : Dietetic and Hygienic Gazette, January, 1895. McGillicuddy : Transactions of the New York State Medical Asso- ciation, vol. vii., 1890. McGillicuddy : New York Medical Record, October, 1894. McGillicuddy : New York Medical Record, November, 1895. Mills, Chas. K. : Hystero- Epilepsy. American Journal of Medical Sciences, October, 1881 ; and System of Medicine, Pepper, 1886. Mitchell, J. K. : Massage. Medical News, 1893. Mitchell, J. K, and de Schweinitz, G. E. : A Further Study of Hysterical Cases and their Field of Vision. Journal of Nervous and Mental Disease, New York, 1894. Mitchell, J. K. : Notes on the Effects of Massage on the Blood Current. Transactions of the College of Physicians, Philadelphia, 1893. Mitchell, J. K. : The Effect of Massage on the Number and Hae- moglobin Value of the Red Blood Cells. American Journal of the Medical Sciences, Philadelphia, 1894. LITERATURE. 333 Mitchell, S. Weir : Wear and Tear of the Nervous System. Philadelphia, 1887. Mitchell, S. Weir : Fat aud Blood, and How to Make Them. Philadelphia, 1888. Mitchell, S. Weir: Lectures on the Diseases of the Nervous System, Especially in Women. Philadelphia, 1885. Mitchell, S. Weir: Hysterical Rapid Respiration, with Cases. American Journal of the Medical Sciences, Philadelphia, March, 1893. Nebel, Hermann : The Mechanical Treatment of Chorea. Con- tribution to Mechanico- Therapeutics and Orthopaedics, vol. i., No. 3. Osier. William : On Chorea. Philadelphia, 1894. Peterson, F. : Hydrotherapy in the Treatment of Nervous and Mental Diseases. American Journal of the Medical Sciences, Phila- delphia, 1893. Playfair, W. S. : The Systematic Treatment of Nerve Prostration and Hysteria. London, 1883. Putzel, L. : Common Forms of Nervous Diseases. New York, 1880. Richer, Paul : Etudes Cliniques sur la Grande Hysterie ou Hys- tero-Epilepsie. Paris, 1885. Roose, Robson : Nerve Prostration. London, 1888. Rosenthal, M. : Clinical Treatise on the Diseases of the Nervous System. London, 1881. Ross, James: Diseases of the Nervous System. New York, 1883. Sachs, B. : Nervous Diseases of Children. New York, 1895. Seguin, Edward C. : Opera Minora. New York, 1884. Smith, Charles N: Vaso-Motor Neuroses of Pelvic Origin. American Journal of Obstetrics, vol. xxiii., No. 11, 1890. Starr, M. Allen : Familiar Forms of Nervous Disease. New York, 1891. Stevens, G. F. : Functional Nervous Disorders. New York, 1887. Sturges, O. : Medical Examiner. London, 1876. Todd, Robert B. : Lectures on Paralysis. Philadelphia, 1855. Tilt, Edward John : The Change of Life. New York, 1882. Tuke. Daniel Hack : Influence of the Mind upon the Body. Philadelphia, 1884. Van de Warker, Ely : American Journal of the Medical Sciences. November, 1892. Webber, Samuel G. : Treatise on Nervous Diseases. New York, 1885. Wischnewetzky, L. i Contribution to Mechanico-Therapeutics and Orthopaedics, vol. i., No. 2. Wood, H. C. : Nervous Diseases and their Diagnosis. Phila- delphia, 1887. 334 FUNCTIONAL NERVOUS DISORDERS. Zander, Gustaf : The Mechanico-Therapeutic Institute. Contri- bution to Mechanico-Therapeutics and Orthopaedics, vol. i, No. 1. Zander, Gustaf : Mechanico-Therapeutics and Orthopaedics by- Means of Apparatus. Contribution to Mechanico-Therapeutics and Orthopaedics, vol. i., No. 2. Ziemssen, H. von : Cyclopaedia of the Practice of Medicine. New York, 1877. PREFATORY NOTE TO THE APPENDIX. The study of a subject is simplified and made more interesting when the verbal descriptions are supplemented by illustrative charts, plates, or dia- grams. Such devices assist in clearing up any obscurities in the text and are often of value in medicine in obtaining a correct diagnosis. The author has devised the following series of charts with the hope that they will serve a good purpose in illustrating some points in a rather obscure yet important branch of medical science. CHART I. • Hysterical Aphonia Apncea Dysphagia " Laryngismus " Strangulation " Suffocation Globus Hystericu Hemiplegias Contractu! Paraplegias Contractures : Mental Depression, Loss of Memory, Excessive Irri- tability, Wakefulness, In- I tense Lethargy, Day I Drowsiness or Narcolep- sy, Morbid Fears, Hyp- notism, Trance, Catalep- sy, Somnambulism, Neurasthenia. Anaesthe- sias, Hystero-Epilepsy or Hysteria Major, Melan- cholia, Mania Joint Neuroses CEREBRAL REFLEX NEUROSES CHART II. Hyperchlorhydria (A Primary Neu- rosis in Melan- cholia and Hvsteria) Dyspepsia I Diarrhoea \ (From Mental Emotion) Amenorrhea (Due to severe Mental Disturbances) Anachlorhydria (A Reflex in the Hys terical and the Neurasthenic) Intermittency Irrepularity Palpitation Bracliyciirdia :) Tachycardia U; v Enuresis I Polyuria (Reflexes from Men- tal Excitement) CEREBRAL REFLEX NEUROSES-Continued CHART III. SPINAL REFLEX TENDERNESS ARISES USUALLY FROM IRRITATION IN THE DIGESTIVE TRACT— FROM MENTAL EMOTIONS; POISONS OF VARIOUS FEVERS-FROM UTERINE DISORDERS. Cervieo-occipital pain (In Uterine Disease) f Reflex tenderness of Cer. vical and Upper Dorsal I Spine frequently accom- panies Gastralgia, Nausea, Vomiting, and Stomach Disease of different types— Ulcus and Hypersecretion of Hydrochloric Acid — Pain is between the Shoulder Blades— The Upper Extrem- ities may also be affected— This may be from direct Ir- ritation of the Cceliac Gan- glia of the Sympathetic Pains and Inflammatory conditions of the Lower Abdomen, Bladder, Genital Organs , and Lower Extrem- ities cause Reflex Spinal Tenderness in this region- Lower Dorsal and Lumbar — Most common in Uterine Affections— Endometritis SPINAL REFLEX NEUROSES 341 CHART IV. Ringing, Paroxysmal Cough ■_ (Dependent on Pregnancy) \ Asthma (From Uterine Retroflexion) Singultus ) Hiccough J (Fr»m Irritation in Digestive Tract) ./ Bronchial Irritation (Due to Chronic Gastrie Catarrh) •- 1 Unilateral Perspiration * Cheyne-Stokes Respiration (From Pelvic Disease) BRONCHIAL REFLEX NEUROSES CHART V. Stomachal Vertigo Asthenopia ) ) 'inmess of Vision Ttosis ) (Reflex from Digestive and Uterine disorder ) Angeio-spastic Mi- graine, a com- mon Gastric Neu- rosis—}! i g r a i n e and Toe Cramps, frequent an d i nt er- ehangeable symp- toms re suit in from indigestion Hay Fevei Reflex from Gastric Diseafe Dysmenorrhcea (Reflex from Chronic Gastric Catarrh) Fingers Anaesthetic or Neuralgii- (So-called "wind pains") Gastric Headache— Frontal ^ Giant Urticaria, or Anpreio- • neurotic CEdema of Larynx ( and Dorsum of the Hand (Due to Chronic Indigestion) Asthma (Reflex from Gastric causes) Angina Pectoris and Pseudo-An- gina, with Left- Arm Cramps A naesthesia Neuralgia t Palpitation (From Gastric Irri- tation)— Angeio-spastic Cramps in the Can , Leg Ache Gas iro-intestinal { Neuroses— Com- i mon in Cholera, | Diabetes, etc. I Sharp pains in the I calf (Frequently due to Indigestion from strong coffee) GASTRIC REFLEX NEUROSES 345 CHART VI. Headaches {. Uterine Origin ) Swelling of Face, Arm, and >• \- Hand ) ■ (A Mensti*ual Neu rosis) Ovarian Hyper- esthesia, caus- ing Hyftero- epilepsy— If Inflammation is severe the pain is in- cr eas e d by pressure Diminution of ] secretion of ! Hydrochloric | Acid J (Reflex from Men- struation— E. Fleischer) Tingling of the Fingers and Swelling of the y jg Ball of the Thumb (A menstrual Neu- rosis) Excessive Secre- ) tion of Hydro- - chloric Acid ( ^ Reflex after Coitus— M. Gross) Pain in Heel (Reflex from Ovarian Disease) ( Pharyngeal ■< Congestion, ( Change of Voice (Witn Puberty) Neuralgia, Uterine (Common in Pregnancy) f Asthma, ] Uterine j y I Dyspnoea, ! » I Uterine [ g Cough, * [ Uterine J Quiverings o f Abdomen, Gas- tric Flatulence, Pyrosis, Acidity, Dyspepsia(Uter- ine), Epigastric SwellingorTym- panitic Disten- tion, ^ausea and Vomiting (con- stant), of Men- struation and Pregnancy, Faint ness, An- orexia, Bulimia. Belching (ac- companying Menstrual Con- gestion, Morbid Appetites or . Cravings) ■-. Wrist Pains (From Ovarian Disease) Hystero- Neuioses of the Joints Hip Knee Ankle ( Contractures of ( the Toes (Accompanying the earlier Men- strual periods) HYSTERO-NEUROSES 347 CHART VII. Salivation, or Hypersecretion (Reflex from Menstruation, and Early Symptom of Pregnancy) Thyroid Enlargement (From Uterine Irritation) Mammary Swellings (Keflex from Ovarian or Utei ine Disease) Mastodynia. or Neuralgia Mam- I ma? (Menstrual) ( Congestion of Mammary Glands (Keflex from Menstruation, | or Concept ion) J Hypersecretion of Gas- 1 trie Juice, and Hyper- - chlorhydria ) A Sensory Neurosis, Gland- ular— (Ewald) Hepatic Congestion and Jaundice (Reflex from Disturbed Emotions) Gall-Ftone Colic causes Reflex Temporary Hypochlorhydria ( Suppression of Secretion of / Parotid Gland (Due to reflex from Diseased Ovary, and Parotiditis c.i uses re- flexly, through Sympathetic, a painful oophoritis) ( Seborrhea and Axillary Per- ( spiration (Reflex from Indigestion) Renri Calculi (Cause Hvperchlorhydria R.fiexly) ( Excessive Perspiration of Hands "( and Feet (Reflex from Digestive Disorder) Many of the Glandular Neuroses have been classified unuer other headings, such as Dermal, In- testinal, Renal, etc. GLANDULAR REFLEX NEUROSES CHART VIII. Retinal Hyperesthesia Anaesthesia (Common in Indiges- tion from Coarse Vegetable Food) Asthenopia (From Chronic Gastric Catarrh) Ptosis (Due to Liver Disorder) Mydriasis (Intestinal Parasites) Myosis (Constipation) ) Mouches Volantes (From Endome- tritis and Pelvic Cellulitis) Also a Renal Reflex (?) Hemeralopia (Night blindness) Nyctalopia (Day-blind ness (Menstrual Neuroses ;') Amaurosis (Menstrual) Amblyopia " ( Amaurosis (Hysterical) ( '" (Puerperal) ( Strabismus (Hys- ( tericai) (Due also to Worms) ( Disturbances of I Accommodation (Due to Indigestion) Dimness of Vision (From Abdominal and Pelvic Disease) Photophobia (From Uterine Disease) REFLEX OPHTHALMIC NEUROSES 351 CHART IX. Anaemic roarings (Keflex from Uter- ine Polypoid growths) Neuralgia of ) Aural Serves J (Reflex from Preg- nancy) f Cracklings, ! whistlings, loud ] explosions like I pistol-shots (Reflex from Uter- ine or Gastroin- testinal Disorder) ( Puffing, like •s that of a start- ( ing locomotive (Reflex from Ova- rian Disease, com- mon as an Aura in Hystero- epilepsy) REFLEX AURAL NEUROSES 353 CHART X. Chloasma a n d 1 Sallow Com- ^ plexion ) (Due to Faecal Im- paction) Pruritus Nasi (Due to rectal Ir- ritation, from Worms or Haem- orrhoids; Chronic Redness (Due to Uterine and Digestive Derangements) Hyperesthesia ) Anaesthesia > Perverted Sensibility ) (Due to Genito-Urinarj or Gastro-Intestinal Disturbances) BS5 }*— » HaBmorrhagic Perspira- , tions occurring at J Menses Urticaria Hives Nettlerash \ (From Ingestion of Shellfish and other Indigestible Foods) f Erythema Uteri- ! mini ] Chloasma Uteri- L nuin fAcne Rosacea, with Nasal Red- ness, Eruptions (Due to Gastric Disease) ! Pigmentation of Areola (Reflex from Preg- ■3 f Pruritus (From Diges- s- ', tive Disorder) % \ Flushes ) From Di- u Perspirations - gestive O (.Seborrhoea ) or Uter- ine Disorder Abdominal Chlo- asmata or the Brownish Discol- oration of Preg. nancy Herj>es of Pudenda (Due to Metritis) ( Prurigo of Anus ( and Vulva (Due to Obstruction of Portal Circula- tion from Conges tion of Liver) Severest at Meno- pause REFLEX DERMATIC NEUROSES 355 INDEX Abdomen almost black, 152 Abdominal flushing, 61 Accommodation, disturbances of, 128 Achromatopsia, 197 Acne rosacea, 150, 152, 153 Aconite in neuralgias and nervous headaches, 316 Affections of microbic origin, 253 of the spinal cord, 36 Alexander's operation, 105 Alimentation and hygiene, 269 Alkaline baths, 156 Amaurosis, complete or incomplete, 164 gravidarum, 128 hysterical, 128, 159 transitory, 128 Amblyopia, 128, 197 hysterical, 129 transitory, 128 Amenorrhoea, 27 aconite in, 316 Ansemia, 5, 139, 157, 252 Anaemic headaches. 235 Anaemic roaring, 137 unilateral, 138, Anaesthesia. 27. 197 Analgesia, 196 Angeio-neurotic oedema, 77, 82 Angina pectoris, 52, 124 Animal food, 293 Anorexia at menses, 89, 91 Anorexia, description of 178 hysterical, 178 Antispasmodic agents, 303 Anuria, 96 Aortic plexus, 22 Aphonia, hysterical, 27, 31, 165 Apncea, hysterical, 27, 29 reflex, 10 Apoplexia, 130 Arnold, 255 Arsenic, 156, 299 Arthralgias in uterine disease, 16 Arthropathies, 80 Articular reflex neuroses, 144 Artificial production of the meno- pause, 73 Asafcetida, 303 Assimilation, 291 imperfect, 273 Asthenopia, 128, 129 Asthma, 5, 306, 316 hysterical, 166 spasmodic, 309 Ataxia, forms of, 132 Atrophy of cheek, 131 progressive muscular, 132 Atropine in localized muscular spasm, 309 in reflex asthma, 308 in salivation, 308 Auditory nerve, 138 Aura hysterica, 194 Aural reflex neuroses, 137 symptoms and abdominal cav- ity, 138 symptoms and chest disease. 138 Australian blight, 79 Autoinfection a cause of symptoms, 137 Bacon, 181 Bacteria, 259 Bacterial development, 260 357 358 INDEX. Bactericidal properties of blood serum, 261 Bacteriological origin of disease, 252 Barker, 7 Basic malady, 252 Bath, practitioners at, 256 Belching and vomiting accompany- ing menstrual congestion, 89 Belladonna, 307 in globus hystericus, 308 Bichromate of potassium in bromi- drosis, 127 Bidder, 255 Bladder, 4 functional disturbance, 98 neurotic disturbance, 108 treatment, 109 Blepharospasm, hysterical, 164, 165 Blue hysterical oedema, 176 Blurring of vision, 130, 188 Boix, 176 Boldt on cardiac neuroses, 7 Borborygmus, hysterical, 166, 194 Boulimia. 89 Braithwaite on codeine, 83 Briquet, 189, 194 Brissaut, 179 Bristowe on hysteria, 159, 160 Broad conception of disease, 252 Brodie, 146 Broken-down constitutions, 259 Bromides, 305 Bronchial and cardiac neuroses often combined, 85 Bronchial hystero-neurosis, 87 Bronchial reflex neuroses, 85 causes of, 85 Brunton on condurango, 299 Burning sensations of tongue, 141 hysterical origin of, 141 Cafe noir, 298 Caffeine, 298 Calculus, 4 Calumba, 299 Camphor, 303, 317 Cannabis indica, 315 Cardiac disease, 5 irritations, 27 neuroses in connection with ovarian and uterine disease, 7 Cardiac palpitation, 27, 194 Cardiac reflex neuroses, 42 dependent on digestive disorder, 43 Cardiac weakness, 252 Cardialgia, 163 Catalepsy, 27, 90, 215. 221, 222 in melancholia, 223 table, 223 transient, 181 Cataleptoid state, 114, 221, 222 Catarrh, symptomatic uterine, 3 Catarrhal states, 4, 252, 279 Causative factors in reflex disturb- ances, 4 Cerebral anaemia, 239 excitement, 238 hypersemia, 239 irritations, 10 neuroses, 10, 27 Cerebro-abdominal neuroses, 99 Cerebro-spinal nerves, 17 Cerumen, impacted, 4 Cervical induration, 90 spine, 37 sympathetic, 130 tenderness, 37 Charcot, 163, 184, 187, 190, 192, 197 Change of climate, 60 Cheyne-Stokes' respiration, 85 Chloasma, 98, 153 uterinum, 151 Chloasmata, symptomatic, 150, 151 Chlorosis, 90, 300 Choking, hysterical, 165 Chorea, general, 29, 165, 306, 314 major, 242 minor, 240 Chromic acid in hyperhidrosis, 127 Cinchona preparations, 298 Cleanliness, internal, 260 Climacteric changes, 74 Coccygodynia, 113 Cohn on uterus and eye, 132 Cold, 327 Coldness of extremities, extreme, 50 Colic, 99 Collins on angeio-neuroticcedema,78 Colonic flushings, 99 Condurango, 299 Congestion in globus hystericus, 11 INDEX. 359 Constipation, 15, 108, 270, 308 during intermenstrual period, 98 during menstruation, 98 Constitution, run down, 2 Contracted chest, 252 Contractures, 159, 196 causes of, 174 general, 168 treatment, 168 Convulsions with dysmenorrhea, 220 " Convulsionaires," 236 Copious water drinking, 254 Corpulence, 287 Cough, hysterical, 166 Cramp in the head, 247 Cramps, muscular, 8 Cranial cavity, irritations in, 20 Dana, 243 Debility, evidences of, 107 Delirium of hysteria, 179 Delusions, fixed, 27 Denis, 254 Deprat, 171 Dermal reflex neuroses or derma- toses, 149 Dermatologist, 6 Dermato-neurosis, menstrual, 153 treatment, 155 Dermatoses, 12, 50, 98 acne rosacea, 153 chronic urticaria, 150 reflex, 79 Diabetes, vasomotor disorder in, 64 Diagnosis of disease, 5 Diaphragm, irritation of, 40 Diarrhoea after menstrual period, 98 preceding menstrual period, 98 reflex or nervous, 5, 27, 100 Diet of neurotic patients, 272 Dietetic treatment, 271 Digestive disease, 6 disorder, a common symptom of, 82 disorders at menopause, 8 disturbances in cardiac neu- roses, 45 organs, 4 Dilatation of uterine cervix, for stenosis, 318 Dimness of vision, 128 Diruf. 257 Disease mimicry, 147, 181 Diseases, organic, of nervous sys- tem, 12 Disturbances of vision, 129 Donovan's solution, 156 Drowsiness during the daytime, 27 Dubois (d 1 Amiens), 189 Duncan, 319 Dyschromatopsia, 197 Dysmenorrhea, 119, 153, 231 Dyspepsia. 33 Dyspnoea, 39, 85, 165 Dysuria, 37, 109 Ears, 4 Ebstein on unilateral hyperhidrosis, 124 Ecchymoses, 151 Echeverria, 33 Ecstasy, 216, 236 Eczema facialis, 150 Edebohls on menstrual dermato- neurosis, 153 Electrotherapy, 253, 317 Elimination of diseased products, 277 Ellinger, 320 Emmet, 326 Endocervicitis, 230 Endometritis, 233 a causative factor, 9, 71, 89, 90, 154 hepatic obstruction in, 91 Engelmann, 5, 93, 186 Enteralgia, 99, 163 Enuresis, 27, 110 Epigastric swelling, 90 Ephidrosis, 121 Epilepsy, 12 Errors of refraction and accommo- dation, 4 Eructations, hysterical. 166 Eruptions at puberty, 150 at the menopause, 150 of the face, 155 Erysipelas, "chronic,"' 49 Ether, 304 Excessive perspirations, 49 Exclusivism in medical practice, 7 360 INDEX. Excretion of urea, 254 Exophthalmic goitre, 680 Expectant attention, 27 External hydrotherapy, 253 Eye strain, 3, 4 Faintness, 89 False croup, 306 Fatalistic standpoint, 253 Faucheron, 244 Fear, a factor in disease, 251 Ferber, 256 Fermentation products, 260 Fever, hysterical, 179 Flatulence, 98, 153, 317 Flushing, unilateral, 64, 65 Food accessories, 295 Fowler's solution, 156, 299 Fraenkel on dyspnoea and hyperhi- drosis, 122 Fried meats, 153, 273 Functional disease, 6, 182 paralysis, 30 Gaube on hysterogenic zones, 199 General nledicine, 9 practitioner, 2, 3, 10, Genital and digestive organs inti- mately connected, 11 reflex neuroses, 112 weakness, anaemia present, 8 Genito-urinary organs, 4 disturbance, 112 Gilles de la Tourette, 163 Glandular reflex neuroses, 118 Globus hystericus, 6, 11, 27, 90, 119 Glossitis, superficial forms, 141 Glycogenic functions of the liver, 121 Griffin Brothers, 36 Gross on anachlorhydria, 91, 92 on cerebro-abdominal neurosis, 99 Gynecologist, 6, 151 surgical, 3 Gynecologist's range of vision, 9 knowledge of digestive disor- ders, 11 Galvanism, 85 Gamgee, 201 Ganglionic nerves, irritation trans- mitted through, 9 nerves observations on, 36 system, 48 Gaseous eructations, 107 Gasserian ganglion, 142 Gastralgia at menstruation, 93, 212 in cases of retroversion, 8 Gastric catarrh, 5 disturbance, frontal headache in, 91 disturbance, uterine symptoms of, 91 irritation, 15 neuroses of pregnancy, 93 neuroses, persistence of, 93 Gastric reflex indigestion, 89 Gastric reflex neuroses, 89 common, 89 Gastrodynia, hysterical, 308 Gastro-enteric catarrh, 93 Gastro-hystero-neuroses, 90 Gastro-intestinal catarrh, results of, 49 tract, irritations in, 11 Haemorrhoids, 4, 108 Hallucinations, 113, 139 Hamilton, 185 Hanks, 325 Hart, Ernest, 201 Hart and Barbour, 185 Hartmahn, unilateral hyperhidro- sis, 125 Haut mal, 220 Haziness of vision, 130 Headache, 247 bilious, 16 congestive reflex, 6, 10, 12, 247 hypersemic, 247 migrainous, 95, 315 occipital, 95 Heaviness and soreness of upper ex- tremities, 40 Heitzmann, 262 Hemiplegia, hysterical, 166 Hemidrosis, 122 Hemeralopia (night blindness), 128 Hemianesthesia, 11, 165 Hemicrania, 13, 243 ansemic type, 51 a vasomotor neurosis, 51 from ovarian irritation, 51 INDEX. 361 Hemicrania, hyperaemic type, 51 Hemorrhagic spots, 151 perspirations, 151 Hepatic stimulation, 99 obstruction, 109 Hereditary nervous weakness, 59 diet and regimen in, 59 educational treatment in, 59 massage in, 59 predisposition, 253 Herpes, 150 Hiccough a respiratory neurosis, 85 causes of, 86 hysterical, 166 treatment, 86 Highest art of the physician, 253 Hilton on hysterical pain, 145 Hodge, 7 Hoffman's anodyne, 304 Hot applications to spine, 40 baths, 261 flushes, 73 Hutchinson on unilateral myosis, 131 Hydraemia, treatment of, 40 Hydrocephalus, 130 Hydrotherapy, 40, 115. 167 Hygiene, 253 Hygienic exercises, 85 Hyperesthesia, 165, 197 of all the special senses, 139 Hyperhidrosis, unilateral, 121 Hypersecretion of salivary glands. 119 Hypersensitiveness of nervous sys- tem, 5 Hypnotism, 27, 187 Hypochondriacal patients, 41 Hypogastric neuroses, 112 plexus, 22 Hysteria, 157 age, 159 anaemia in, 158 anaesthesia, 161 characteristics, 160 climate, 159 contracture, 161 diagnosis, 161 due to constitutional weakness, 158 hemianaesthesia, 161 Hysteria, hemicrania, 162 hereditary taint, 158 hyperaesthesia, 162 impaired digestion 158 insanity, 159 major, 190 morbid fancies, 159 neuralgias, 162 occurs in epidemics, 153 sedentary occupations, 159 sensory disturbance, 161 treatment, 181 Hysteric suffocation, 94 Hysterical aura, 197, 198 contractures, 173 convulsions, 167, 169, 181 fever. 179 gastrodynia, 308 joint, 144 psychoses, 179 salivation, 179 somnambulism, 180 somnolence, 181 stigmata, 167 strabismus. 123 trance, 181 trismus, 90 vasomotor manifestation, 62 yawnings, 194 Hystero- catalepsy, 216 Hystero-epilepsy, 183 according to Charcot and Ri- cher, 133 attacks of catalepsy, 190 attacks of lethargy, 190 attacks of somnambulism, 190 contortions, 203 demoniacal attack, 203 disorders of circulation, 194 disorders of digestive function, 193 disorders of motility, 196 disorders of respiration, 194 disorders of secretion. 194 disorders of sensation. 196 dysmenorrhea a common cause of, 217 emotional attitudes, 203 exalted emotions. 191 hallucinations. 191 hemianaesthesia, 196 362 IKDEX. Hystero-epilipsy, opisthotonic posi- tion, 218 period of delirium, 213 prodromic period, 190 sorrowful hallucinations, 207, 208 tables of, 205, 206 with combined crises, 189 with distinct crises, 189 Hystero-epileptic attack, 184 Hysterogenetic zones, 199 Hystero-neuroses, 8, 112 ophthalmic, 216 Iconographie de la Salpetriere, 163 Idiopathic oedema, 79 Idiosyncrasy, 275 Impaction of colon, 98 Incipient renal disease, 129 Indigestion, 4, 6, 50 Induration of cervix, 90 Inflammatory exudates, 260 Insanity, 159, 314 hysterical, 28 Insomnia, 39, 270, 286 Insufficient or improper diet, 139 Internal hydrotherapy, 253, 260 or tissue asepsis, 253, 260 sterilization, 253, 260 Intestinal catarrh, 4 glands, hypersecretion of, 98 Introspection, constant, 270 Irritability, excessive, 27 Irritations, peripheral, 3 of cord, 22 of ovary, 22 Iron, 302 Isolation, 237 Joint ankylosis, 144 neuroses, 27 pains, 27, 144 stiffness, 144 weakness, 144, 147 Joints and ganglia of sympathetic, 148 and ovarian irritations, 147 and spinal nerves, 148 and uterus, 147 Kaempf on cervical sympathetic, 131 Keating, 62 Keen on cervical sympathetic, 131 Kidneys, 4 granular, 107 irritability, 106 neuralgic pains, 106 secretion, 106 under control of sympathetic, 121 Klebs, 263 Koch, 258 Kretol, emulsion of, 156 Lacerated cervix, 3, 234 cervix, reflex neuroses depend- ent on, 9, 144 Lactation and affections of the eye, 133 Lameness, a psychosis, 144 Laryngeal reflex neuroses, 81 Laryngismus, hysterical, 27 stridulus, 82 Laryngitis of reflex origin, 81 Laryngologist, 12 La Tourette. 163 Laughter, hysterical, 166 Lee, 185 Lehman, 255 Leichtenstern, 253, 254 Leonard on female voice in sexual disease, 83 Lesions in lung a cause of reflex pain, 17 Leszynsky, 309 Lethargy, 113, 221 complicated by contractions or by cataleptoid state, 221 intense, 27 simple, 221 with apparent death, 221 Lichen, 150 Liebreich, 201 Lingual neuralgia, 140 local applications in, 140 Lithsemic conditions, 16 Liver, affections of, 38 Lobelia in nervous asthma. 316 Louyer Villermay, 189 Lumbar ganglia, 22 plexus, 17 Lumbo-abdominal neuralgias, 22 INDEX. 363 Malapert, 174. Malassimilation, 13, 235 Mallendorf, 241 Mammary glands, 118 changes in, 118 pain, 118, 153 swelling, 118 Mania, 27 chronic, 12 Marsh, 116 Massage, 169, 182, 261, 288 Mastodynia, remedial measures in, 118 Mechanical purification, 260 Medicinal treatment, 297 Melancholia, 27, 94, 229, 300, 305 Memory, loss of, 27 Menopause, 43, 45 vasomotor neuroses of, 74 Menorrhagia, 232 Menstrual congestion, morbid appe- tite at, 91 hystero-neuroses, 8 Menstruation, 83 gastric changes during, 91 oedema preceding, 77 sudden suppression of, 90 vicarious, 77 Mental depression, 27, 139, 211 disturbances, vasomotor change in, 50 influences in cardiac neuroses, 45 Metabolism, 253 Micro-organisms, 259 Migraine, 12, 29, 234, 243, 328 congestive type, 305 production of, 14 treatment of, 245 Mills, 184, 186 Mitchell, 62, 130, 167, 168, 181, 184, 283 on cervical sympathetic, 130 on hysteria, 167 on hysterical contractures, 167 on treatment, 283 Morbid appetites, cravings, 91, 96 fears, 27 flushing at menopause, 48, 306 flushing a vasomotor paralysis, 50 Morbid flushing, chronic gastroin- testinal catarrh in, 49 flushing, inherited, 55 flushing or blushing, 48 flushing, salivation in, 49 flushing, treatment, 61 growths, 4 Morehouse, 131 Molimen menstruate, 155 Motor disturbances, migratory, 40 Mouches volantes, 128, 130 Midler, 319 Murray, on anidrosis, 127 on bromidrosis, 126 on hyperhidrosis, 126 Murray's treatment, 126 Muscular exercises, 264 Mydriasis, 128, 130 ephemeral, 136 functional, 135 Myosis, 121, 128, 130, 132 Narcolepsy, 113 Narcotics, 306 Nasse, 254 Xausea, 95 and vomiting, 39 Nebel, 241 Nervous disorders, 3 exhaustion, 27 prostration, 41, 106 system, disturbance of, 2 Neuralgia, inflammatory local, 7 Neuralgias, 306 cardiac, 14 digital, 16 during pregnancy, 140 intercostal, 14 in the heel and wrist, 16 lingual, 140 migratory, 40 transferred or reflex, 14 Neurasthenia, 27 anachlorhydria in, 91 Neurasthenic conditions, 16 patients, 45 Neurologist, 6 Neuroses, classification, 13 combined, 13 common, 13 definition, 2 364 INDEX. Neuroses, general or local, 2 of menstrual period, 90 reflex, 1, 2 Niemeyer, 256 Night blindness (hemeralopia), 128 Non-bacteriological affections, 252 New growths. 4 Nyctalopia (day blindness), 128 Obesity, 289 Ocular tenotomy, enthusiast in, 2 Oculist, 6 Oculo-pupillary disorders, 130 O'Dwyer, 327 (Edema, acute idiopathic, 79 angeio-neurotic, 77 circumscribed, 79 indefinite duration, 78 lympathics in, 77 non-inflammatory, 79 veins in, 77 (Edema, hysterical, 80 varieties, 80 Oophorectomy for hystero-epilepsy, 186 Oophoritis, 230 Ophthalmic reflex neuroses, 128 symptoms, 128 Opiates, 306 Opium and valerian, 306 Organic or structural disease, 6 Orgasms, 116 treatment, 116 Out-of-door exercise, 60 Ovarian hyperesthesia, 210 irritation, 114 neuralgia, 306 pain, 119 Ovary, cystic, 3 Overexertion, 253 Oxalate-of-lime crystals in urine, 106 Paget, 146 Pain at the hip joint, 144 frontal or temporal, 14 gall bladder, 16 in abscess of spleen, 16 in the knee, 144 in the wrist or ankle, 144 kidney, 15 occipital, 15 Pain, scapular or shoulder, 15 transferred, 15, 17 Pallor of face, extreme, 50 Palmer, 320, Palpitation of the heart, 39 Palsy, facial, 31 Pancreatic digestion, 297 Paralysis, ansemic, 31, 32 complete, 31 crutch, 31 functional, 30 hysterical, 30 organic, 32 partial, 31 vesical, 31 Paraplegia, 11, 31, 32 Parasites in milk, 279 Parotid glands and reproductive organs, 119 Parotiditis and oophoritis, 120 Passions of the mind, 252 Peas lee, 323 Pelvic cellulitis, 6 irritations, 17 Period of delirum, 213 Periodic swelling, 79 Peripheral irritation, 3 Perspirations, excessive, of hands and feet, 120 localized, 124 malodorous, 120 Phagocytosis. 259 Pharyngeal inflammation, 12 reflex neuroses, 81 Pharyngitis, chronic, from imper- fect digestion, 82 of reflex origin, 81 Photophobia, 130 Phthisis, 259 intercostal neuralgia in, 17 Physical exercise, 265 Physicians, practical, 1 scientific, 1 Pigmentation, 153 Pneumogastric nerve, 22 Podalgias, 22 Polyuria, 107, 108 Portal circulation, 90 Post-nasal catarrh, 50 Practitioner, general, 2 Pregnancy and visual apparatus, 133 INDEX. 305 Preparation of meat, 274 Prophylaxis, 252, 253 modern, 252 Proteids, 273 Prurigo, 150 Pruritus, 150 ani, 3 Pseudo-angina pectoris, 42, 45, 107 treatment of, 43 Psychological treatment, 129 Psychoses or cerebral neuroses, 27, 28, 300 Ptosis a reflex from gastric or hepat- ic disease, 129 Puerperal amaurosis, 129 mania, 28 melancholia, 28 Puerperium and eye affections, 133 Pulmonary disease, 5 Pulse, 75 Quinine sulphate, 299 Reconstructive remedies, 297 Rectum, 4 Reflex asthma, 306 conditions, 6 coughs, 306 disturbance, 4 Reflex dermatoses dependent on menstrual disturbance, 151 hystero-neuroses, 5 pains are transferred pains, 14 pains from viscera, 22 vasomotor changes, 14 Reflex neuroses, 1 congestion in, 11 differential diagnosis, 11 symptoms in, 10 Renal reflex neuroses, 106 hypersecretion, 106 irritability, 106 nervous prostration in, 106 secretions, 106 Rendu on unilateral mydriasis, 132 Retinal anaesthesia, 128 hyperesthesia, 128 Retroflexion, 233 Rhinitis, chronic, 82 Rhinologist, 12 Richer, 164, 170, 173, 176, 190, 196 Rockwell on unilateral hyperhidro- sis, 124 Rosenthal on unilateral mydriasis, 131, 132 Routine practice, 252 Salivation, 308 Salpetriere, 176 Sandras, 189' Sayre, 171 Schmidt, 255 Schroeder, 318 Sciatica, 22, 132 Scientific physicians, 1 problems, 1 Scrofulous diathesis, 107 Seasickness, treatment of, 305 Seborrhoea, 152 Seeligmuller on atrophy of cheek, 131 Sensation, reflex, disturbances of, in lower extremities, 8 Seguin on unilateral hyperhidrosis> 122 Sexual apparatus, 118 orgasms, recurrent, 114 Shouting, hysterical, 166 Simulated disease, 36 Simulation of disease, 2 Simpson, 305, 319 Sims, 320, 323 Sneezing, reflex, 86 Solar plexus, 35 Sollier, 174 Somnambulism, 270 hysterical, 180, 211, 215 Souques, 179 Spasm, hysterical, 165, 168 muscular, 15 of bladder, 16 of larynx, 165 of oesophagus, 165 of pharynx, 165, 194 of sterno-cleido-mastoid, 165 of trapezius, 165 Special feeding, 289 treatment, 251 Specialist, 2, 3 Spinal irritation, 34, 38, 233 anoemic form, 41 hypenemic form, 39 366 INDEX. Spinal irritation, treatment, 41 inflammation, 38 pains, 34 reflex neuroses, 34 system, 5 tenderness, 37, 157 Splanchnic nerve, 35 Spurious peritonitis, 187, 197 Squint, hysterical, 165 Stammering, 140 Stenosis case, 327 Strabismus, hysterical, 128, 165 Strengthening treatment, 251 Suffocation, hysterical, 27, 94 Surgeon, 6 Sydenham's chorea, 163 Sympathetic ganglia, 20, 21 pains, 34 system, 5 Sympathy for minor ailments, 2 Symptomatic chloasmata, 150, 151 treatment, 252 Symptoms, abdominal, 2 uterine, 2 Systematic constitutional treat- ment, 253 Tachycardia, 176 Therapeutics, 251 Thomson, 328 Thread-worms, 4 Thyroid, swollen, 6, 119 Tilt, 7 Tissot, 189 Todd on hysterical hemiplegia, 166 Trance, 27, 113, 221, et seq. table, 223 Trismus, hysterical, 90 Tropho-neuroses, 80 Tubercle bacillus, 259 Tuberculosis, 258 Tumefaction, 153 Turner, 201 Tympanites, 90, 194 Unhygienic living, 50 Unilateral sweating, 123 Urination, difficult, 108 effect of fear or fright on, 106 frequent, 108 incontinence, 108 Urination, pain after, 108 painful, 108 retention, 108 Urine, hyperacid, 108 nervous, 194 pale, 107 Urticaria, 80, 150 giant, 79 tuberosa, 79 Uterine disease, 152 a cause of insanity, 7 gastric neurosis most fre- quent in, 92 disorders at menopause, 8 examination of unmarried, 10 involution, 29 neuralgia, 96, 308 neuroses, 92 pain, 119 Uterus and eye, 132 growth and activity of, during pregnancy a cause of reflex neuroses, 88 Vascular reflex neuroses, 47 burnings of the palms, 47 burnings of the side of the chest, 48 burnings of the soles of the feet, 47 burnings of the top of the head, 47 coldness of extremities, 48 erythematous eruptions, 48 external or internal, 47 flushes, 47 flushing of malar prominences, 47 general or local, 47 general or nervous chills, 47 hemorrhages, 48 of puerperal circulation, 47 sweats, 48 Vasomotor disorder, functional, 64, 101 ganglia, €>S nerves, 65, 66, 67, 68 neuroses of pelvic origin, 65 spasmodic varieties, 70, 72, 73 paresis of lower extremities, 62 INDEX. 367 Vegetable diet, 278 . foods, 294 Yertigo, 39 Vesical reflex neuroses, 108 causes of, 108 varieties, 108 Virchow, 201 Vitality, 253 lowered, 5 in patients, 44 Voice, changes in, at the time of menstruation, 83 Voit, 256 Voluntary blushing, 57 Vomiting, reflex, 305, 308 nausea and, 39 violent, 8, 95 Wakefulness, 27 Wallet, 178 Water, internal use of, 253 Watson, 241 Weeping, hysterical, 94, 166 Weyrich, 256 Wilson, on hyperhidrosis, 125 Wines, generous, 298. 300 Woman, functional derangements, 1 physical discomforts, 1 Women, neuroses of, 3 Worry and anxiety, 269 Yawning, a trivial neurosis, 86 causes of, 86 hysterical, 166 Zander, 251, 264, 268 Ziemssen, 253 ' ^H *. U*■