progressed without notable failure or improvement for some months. Indeed, he gained a little strength, ate pretty well, and spent his time quite comfortably in the open air. He lived in an elegantly appointed country hotel, half a dozen miles from my office. I visited the house every two or three days, but never detected any intimation of impending involvement of my young friend's brain. About the middle of April I was sent for to visit D- When I arrived the landlady called me aside and stated that she was distressed to say it -Mr. D had been intoxicated for twenty-four hours or more. She wished me "to straighten him up." I found him sitting upon the veranda, as I approached he failed to recognize me. I spoke and extended my hand. He arose, held out his hand, mumbled something and at once staggered back into his chair. He presented every appearance of acute alcoholism face congested, half-silly, half-stupid expression, eyes bright and a trifle watery, muscles relaxed so that he half-reclined in his chair. To all my questions he replied "Yes," with a silly sort of laugh. He would respond to suggestions, would sit, stand, swallow, etc., as requested. At times he would even reply, for a moment, to some question, with apparent correctness, and then, perhaps before his answer was complete, would relapse into the semi-conscious state. At no time would he acknowledge pain, nor did he, at any time, complain of headache. He endeavored to walk and to undress himself, but his muscles seemed too limp. He seemed to lack both co-ordinating and muscular power. The good landlady attended him the more devotedly because she had misjudged his condition. For several days he remained in about the same state. The excretory functions were performed when he was so requested. Food and medicine were also taken when suggested. Finally his condition became worse; semi-coma and coma successively developed. Catheterization became necessary. There was no fever; heart and kidneys normal; respiration became slower and deeper than before; pupils normal; face became paler. There was no action of the voluntary muscles for some days, yet no tendency toward bed-sores. This condition persisted for five or six days, when improvement began. In twenty-four hours the patient was, apparently, as well as before the attack, except for profound prostration. During my absence from the house, Mr. D gave explicit directions regarding his business affairs and the disposal. of his effects. Some hours after, he quietly died. He remained conscious to almost the end.

CASE III. Charles M, aged twenty-eight, of Lamar, Mo. Mother, two brothers, sister, and aunts had consumption. Martin developed the well-known symptoms of the disease, and was advised to remove to Southern California. After arriving here his history was uneventful; the disease pursued its ordinary course, although its progress was slow. The patient was a laborer, had wife and children to support, consequently could not care for himself as he ought to have done. After watching his case for some two years, I was called to his bedside on September 8, 1888. I found him wildly delirious. The combined efforts of several men were required to restrain him. My first thought was "a drunk," notwithstanding I knew him to be a total abstainer. Investigation soon convinced me that his system contained no alcohol. His wife stated that except a severe headache, he seemed in his usual health until he began to act crazy," when she sent for me. The patient exhibited the wildest mania. He struggled, fought, bit, raved, cursed violently and obscenely. He had been a consistent Christian. No other symptoms could be elicited. The terror and distress with which he inspired his family and friends allowed no time for examination. To prevent injury to himself and others I had him strapped to a comfortable. cot, then administered hypodermics of morphia sulph.; two quarter-grain doses were required. Three or four

hours sleep followed. When he awoke he was calmer but still delirious, and at intervals required restraint. During the ensuing twenty-four hours the mania very gradually disappeared and semi-stupor supervened. The patient would swallow nourishment placed between his lips; would attempt to answer questions, but his replies were absolutely incoherent. At the first observation his temperature was 1042° F., but within forty-eight hours became almost normal without the administration of antipyretics. Bowels and bladder were incontinent for two days. No involuntary motor symptoms were apparent. The stupid stage gradually disappeared after five or six days. As he regained consciousness the only symptom complained of was headache, which he could not localize and which gradually ceased as he grew more rational. No memory of his condition remained. The case was void of further symptoms; recovery was rapid. The lung trouble was in abeyance for a few weeks. M- returned to work and for two months was able to earn full wages. In December he died from phthisis pulmonalis, without return of cerebral symptoms.

CASE IV. First examined July 16, 1889. Referred to me by Professor Ingals. Mrs. W, of Chicago, aged twenty-seven, married four and one-half years; miscarriage two years ago at three months. Now has a baby three months old. Always delicate but never really sick until two years ago. When about eleven years old underwent a surgical operation upon her foot, for what was termed tuberculosis of one of the bones. No tubercular taint in her family. Husband healthy. Had, at one time, some slight uterine trouble readily cured by local treatment. Following miscarriage had cough and diarrhoea. Tubercle bacilli demonstrated in sputa and stools. Emaciation began at about the eighth month of last pregnancy. Slight hæmoptysis during labor, in which she was attended by Professor Jaggard, who performed episiotomy and a primary operation for laceration. Has never recovered strength since birth of child. Menses recurred about six weeks ago; at present quite weak. Postnasal catarrh. Throat dry, and at times painful; hoarseness; vocal cords relaxed. Slight arytenoidal swelling. Pretty constant, loose, painless cough; at times becoming paroxysmal and accompanied by vomiting. Expectoration profuse, thick, greenish yellow. Pulse, 120; temperature, 1021⁄2° F.; respiration, 19; expansion, 26 to 28. Cavity in the left apex. Subcrepitant râles pretty much all over remaining part of left lung. On right side dulness around and below nipple, with loud, moist râles all over front and back. Appetite fairly good. No gastric pain. Tongue clean. Diarrhoea. Stools changeable, profuse, mushy. Four to twenty per day. Normal weight 124 pounds; at present 97. Profuse night-sweats from time to time.

was

To transcribe my notes of this case would be tedious, as the patient remained under my constant treatment for two years. I will at once detail (and that rapidly) the cerebral symptoms that ensued after some months. The first point noticed was headache. The whole head was involved, but the severest pain was occipital, extending forward toward the eyes. This pain became exceedingly intense. The lady was very courageous, but was many times forced to cry and scream on account of the violence of the pain. It resembled the pain accompanying tumor of the brain. Owing to this pain Mrs. Wobliged to take to her bed, thus avoiding light, noise, and motion. Finally mental symptoms began to develop. A little flightiness became noticeable. Hallucinations developed, such as visions of rats, bugs, etc., on the wall and bed. Gradually torpor of mind became apparent, marked by slow and stupid replies to questions. Twitching of muscles appeared, followed after a few days by violent convulsions. No paralytic symptoms at any time. As the motor disturbance subsided the patient became calmer, evidently had less headache, but failed to recognize husband, sister, or nurse. She

imagined herself in another city, in short, exhibited the classical symptoms of an attack of insanity. This latter condition, after continuing some two weeks longer, finally wore away, leaving the patient apparently none the worse for her experience, beyond the natural prostration. The pulmonary and intestinal symptoms had already improved to a marked degree prior to the appearance of the headache. During the attack just detailed this improvement steadily continued and no relapse followed. At no time during the attack was fever manifest. Incontinence of urine and fæces occurred a few times. Liquid food was administered daily. Respiration was slow and regular.

When Mrs. W left Banning, some eighteen months subsequently, she was in excellent condition. No diarrhoea; weight, 120 pounds; very little cough; scarcely any expectoration; plenty of strength. To all appearance a strong, hearty woman. The cavity had contracted; except for a few râles the physical signs had disappeared. A letter from her husband, a few months ago, assured me that her improvement had continued, and that she was enjoying excellent health. I consider this case remarkable. I have had other patients who suffered from combined pulmonary, with cavities, and intestinal tuberculosis make good recoveries. No other one, however, in which these conditions existed, plus cerebral tuberculosis, has made such marked improvement. The five or six years of continued good health indicate the possibility of a final cure. This patient had all the advantages that love, wealth, and intelligence could bring to bear upon her

case.

CASE V. One evening about 10 P.M. the proprietor of the Bryant House called me to examine a stranger. The patient, a man about forty years of age, came to the hotel, having arrived on the west-bound overland train. The man sat on a chair in the office until supper-time, about four hours. As he paid no attention to the announcement of the meal, Mr. W— asked if he wished supper, the man looked at him but made no reply. Mr.

W

then touched him on the shoulder and invited him to the supper-room, the man arose without speaking and followed. Mr. W- placed him at the table and was obliged to attend to other business. The waitress could not induce him to give an order. She supposed him intoxicated and brought him a meal of her own selection. The man ate, then remained in his chair until the waitress requested him to leave, at the same time taking hold of his chair. He arose and left the room without speaking. He returned to the office and took a chair. Later, Mr. W— asked him if he desired a room-no answer. Realizing that something was wrong Mr. W— sent for me. An examination made it evident the patient was suffering from pulmonary phthisis. I could not induce him to speak, or to reply by a sign. He had a stupid, half-dazed, half-inquiring expression; was free from fever; contracted his brows as if his head pained; presented no motor symptoms. The man had arrived without baggage; had probably left it on the train. The hotel register and a pen were offered him. He took the pen and wrote. The result was an unintelligible scrawl. There was nothing on his person that offered a clew to his name or residence. Mr. W, the landlord, kindly cared. for the patient that night and took him next morning to the county hospital at San Bernardino. months after I endeavored to trace the case. while politics had reorganized the hospital staff and my inquiries were fruitless. Beyond question this case was one of cerebral tuberculosis.

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CASE VI. First examined December 10, 1890. Referred to me by Dr. Arndt, of San Diego. William H. B, of Ypsilanti, Mich. Tall, spare, blonde, aged thirty-three teacher. Father, aged fifty-three; and mother, aged forty-three, died of phthisis. Health always excellent until the summer of 1889, when he took no vacation, worked at the Agricultural College all

He

summer and entered upon his fall work worn out. In October he took cold, coughed, fainted in class-room; had some throat trouble; spat blood occasionally. In July, 1890, came to Southern California. First went to a small place in the mountains where he improved; but, wishing more contact with civilization, went to the coast, where he soon began to fail. Passing over the record of symptoms, which was but ordinary, I copy from my book the following data: Weight reduced from 163 to 1361⁄2 pounds. Pulse, 120; temperature, 102° F.; respiration, 24; expansion, 31 to 331⁄2 inches. Larynx much congested; both arytenoids swollen and infiltrated, almost obliterating the space between. The patient complained much of laryngeal pain, but there was no ulceration. Right side of chest much flattened. Extensive cavity in right lung. The posterior portion of this lung was utilized for respiratory purposes, while the lateral portions were infiltrated. On the left side existed marked dulness at apex, and persistent moist râles audible all over front and back. Under proper care this patient gained perceptibly during the ensuing three months. Appetite and weight increased, cough and expectoration diminished, fever subsided, strength improved, physical signs were modified. However, about midnight of March 21st, I was called to his room; the noise he had made having awakened a neighbor. I found him in a peculiar dazed condition, sitting half clad upon the bed. The heart was beating 140 times per minute; temperature,normal; respiration, 14. His replies to questions were very slow, one or two minutes intervening between question and reply. Some of his answers were à propos and apparently rational, others bore no relation to the question. would laugh in a silly manner and say he did not know what ailed him. Pain in the head, which he could not locate, seemed a prominent symptom. He seemed conscious of his surroundings and of his condition, but his remarks were erratic and disconnected. Next morning he came to my office in his usual condition. He wished to know what ailed him the preceding night, his memory of the events being clouded. The only symptom remaining was a dull, diffused headache. During the following month the patient was very despondent-contrary to his habit-and gradually lost bodily vigor. Yet the pulmonary symptoms improved. About 2 A.M. on April 18th, I was again called, to find him in a condition precisely similar to that of March 2ist, except that he had fever, temperature 1032° F., and his mental hebetude was more profound. He would answer questions if urged, but his replies were mal à propos. The silly laugh, the vacant stare, the stupidity were peculiar. He had entire control over his voluntary muscles. There was no muscular twitching, but, at times, considerable restlessness. He would eat, if requested, or evacuate bowels and bladder; but did not seem to think of such things unless suggested to him. The fever subsided in a day or two, but the mental state remained. He looked like one in a dream, yet conscious when spoken to, or like a somnambulist. These symptoms continued, with gradually decreasing intensity, for two weeks. His mind became entirely clear and no trace of cerebral disease remained after three or four weeks. Mr. B-returned to Michigan, where he consulted Professor Shurly, to whom I had referred him. I am ignorant of his further history until his death, late in the summer of 1892. I think he remained under the care of his brother, a prominent Michigan physician.

CASE VII.- First examined January 28, 1893. Charles W. G., of Tacoma, student, aged twentytwo. Family history free from tuberculosis. Good health until February 1892, when he had la grippe. Was ordered to Southern California and sent to me. Present symptoms: Pain in larynx after talking. Cough, worse in morning and after exercise, but little at night, dry or loose, painful to throat. Expectoration scanty, freest in the morning, white, frothy, or yel

low, at present bloody. Has had several hemorrhages during past fortnight. Some chest pain at bases of lungs, occasionally higher on left side. Sleeps on back or right side. Appetite good, but cannot use milk or fats. No flatulence, no abdominal pain. Gastric condition good just now, although he reports history of irritable stomach ever since illness began. Bowels regular until he commenced taking tannic and gallic acids to relieve hæmoptysis. Kidneys normal, no venereal; night-sweats have disappeared. Strength very limited. Normal weight, 135 pounds; present weight, 119. Extremities cold. Very nervous. Respiration, 36; pulse, 112, and weak; temperature, 1002° F. Hyperæmia of nasal mucosa, deviation of septum, hypertrophy of middle turbinated. Pharynx congested; follicular disease of posterior wall. Laryngeal mucosa red and swollen, presenting sodden appearance. Vocal bands approximate and are pearly. Arytenoids infiltrated, pyramidal. Right lung normal except slight retraction of apex. Left lung hepatized, some little air entering the infra-axillary, supra-scapular, and infraclavicular regions. No cavities, but evidences of beginning softening. The pulmonary condition was probably the result of an unresolved pneumonia-tubercular infection having taken place later.

From the date of my examination the patient continued to improve until February 21st. On the 22d Mr. G. sent for me. He complained of nausea, pain in epigastrium, and headache. February 23d, patient reported a sleepless night, very severe frontal headache, inability to retain food, heavily coated tongue. Absence of abdominal tenderness, fever, etc., excluded gastritis. Indigestion of nervous origin seemed to explain the symptoms. The patient's mind was sluggish, his answers slow and hesitating-a condition I attributed to pain, loss of sleep, and lack of food. On February 24th the temperature was normal; pulse, 60, full and strong; abdominal pain moderate; no food retained; constipated stool; headache more general and severe; pupils dilated; mental state unchanged; very restless; complained of transitory numbness of left side. The possibility of tubercular deposit in the brain began to be considered. To reproduce the daily record would be tedious. From this time forward the manifestations of cerebral disease became more marked. The pulse continued slow-54 to 68-full and strong, until a few hours before death, when it became rapid and weak. Abdominal pain and nausea gradually subsided, so that, in a few days patient could take any easily digested food. Bowels remained constipated. Headache continued constant, always more severe in frontal region. Mental symptoms became more prominent by almost imperceptible degrees. At first merely slowness of cerebration, then confusion of ideas and statements, finally a dull, stupid state, gradually increasing into coma. The numbness was referred to one, then the other, and finally both sides-always transitory. Toward the end pupils became contracted. The restlessness developed into twitching of muscles, more marked on the left side. At times he was a trifle difficult to control. There was retention of urine for a few days, necessitating use of catheter. From the first the respiration was affected, the rate having fallen from over 30 to 16 or 18. The immediate cause of death seemed to have been inhibition of the respiratory functions. Death occurred March 5th, the thirteenth day.

CASE VIII.-March 16, 1895. In response to a telegram I arrived at Indio at 2 A.M., and found my patient unconscious. The gentleman's sister stated that Mr. John A. D, of San Francisco, aged twentyseven, had suffered more or less for three years from some lung affection. That a few months before he had experienced an acute attack which confined him to bed for many days. Subsequently his physician had ordered him to Indio, where he arrived two weeks prior to my visit. Mr. D had apparently improved, and on March 15th was unusually bright and cheerful.

9

He ate a hearty dinner, but in a couple of hours felt some nausea, soon followed by vomiting. During the afternoon he complained of headache. After taking some light refreshment he retired to bed about 6 P.M., still complaining of headache and languor. About P.M. the sister, who occupied an adjoining room, heard moans, and upon running to her brother's bed found him unconscious. Miss D spoke of his cough, expectoration, loss of weight, fever, occasional nightsweats, etc., but could not give exact information regarding any of his symptoms. Evidently it was a case of tuberculosis. I found him lying on the right side, the right arm and hand were cold, perhaps from interference with the circulation. He would lie quietly, as if asleep, for about an hour, or until disturbed. Then for some twenty minutes became restless, tossing his left arm, flexing and extending the lower extremities, moaning, etc. He could swallow liquid placed on his tongue. The pupils were widely dilated. Respiration, 48. Pulse ranged from 80, at 2 A.M., to 140 just before death about 7 A.M. Temperature slightly above normal. The symptoms of this case are necessarily meagre, as Mr. D— never regained consciousness; but they are sufficient to determine the diagnosis.

I have no doubt that many slight degrees of tubercular deposit in the brain remain latent-so far as symptoms are concerned-and that many other cases exhibit so few indications that we overlook their exist

Perhaps the diagnosis is unimportant-so little can be done for relief. Nevertheless, it is interesting to reflect upon the ubiquity of tubercle.

HYSTERICAL AMBLYOPIA AND AMAURO· SIS. REPORT OF FIVE CASES TREATED BY HYPNOTISM. 1

By J. ARTHUR BOOTH, M.D.,

CONSULTING NEUROLOGIST TO THE FRENCH HOSPITAL, NEW YORK CITY.

WE may define hysteria to consist of such a condition of the general nervous system, original or acquired, as renders it capable of simulating most local diseases; of complicating them in their progress, and modifying them in their usual phenomena. The number of derangements and diseases which hysteria is capable of simulating is well known; but defective vision is one of the less familiar forms, and so I take the opportunity to direct your attention to this subject; at the same time reporting a few cases, which may prove of some interest.

This special form of functional trouble, not due to alcohol or tobacco, is, by no means, a common one; this is especially true in regard to the cases of amaurosis; those of amblyopia and narrowing of the fields of vision being more frequently met with.

The onset of the disturbance is usually sudden, and generally follows some shock, either mental or physical. In attempting to examine the eye there is a spasmodic contraction of the orbicularis muscle which is increased on exposure to a bright light, at the same time causing a sense of anxiety, profuse lachrymation, and a spasmodic closure of the lid of the eye. The globe itself does not present anything abnormal, except that in a certain number of cases one may find some anesthesia of the cornea. (This was a marked symptom in one of my cases, Case IV.) The pupils are equal and react readily and normally. The media, lens, vessels, and fundus are normal, so that the local examination does not lead to any knowledge of the pathological nature of the other symptoms which one learns from the patient. Question the patient, and she complains of defective vision, pain either ocular or supra-orbital, and great sensibility to light. There may be absolute loss 1 Read before the American Neurological Association, Boston, June 5, 1895.

of sight, generally in one eye, or only amblyopia and a reduction of the field of vision to a small area around the fixation point. Besides the above we find the local and general symptoms of hysteria, viz. : a circumscribed pain over the brow, a globular sensation in the throat, excitability and irritability of the nervous system, palpitation of the heart, a tendency to laugh and cry without cause, irregular, painful, or absent menstruation. The following cases were referred to me by Dr. David Webster, and well illustrate the above objective and subjective symptoms.

CASE I. Amblyopia and Contraction of the Fields of Vision. Vision Restored in Twelve Séances.-Kate Teighteen years of age, was seen for the first time on June 12, 1894, when the following history was obtained: She had always been nervous, but otherwise had had no trouble until the appearance of menstruation, two years ago; then, during the first year she suffered much pain each month. For the past year menstruation has come on at irregular intervals, and has now been absent for two months. Within the last six months the patient has become very depressed and emotional, and she has also had two convulsive seizures of a hysterical

L.E

eral health good up to eighteen months ago; then after some business troubles and excesses, he became depressed, nervous, and could not sleep. Six months ago he noticed that he was having periods of temporary blindness, these only lasting for a second or two. Three months later his vision became blurred, and this condition has remained up to the present time. He has never had any diplopia. Within the last month there has been more or less frontal and occipital headache, and lately he has become very emotional. Sometimes he gets confused and cannot remember dates, otherwise his memory is good. The urine has been examined several times and always found to be normal. At one time he had herpes preputialis, and being told that it was due to a syphilitic infection, thought all his symptoms were caused by this disease.

Examination.-Stands well with eyes closed. Kneejerks high but equal. Grasp of hands as shown by the dynamometer: R. 44-40; L. 40-39. Tongue straight; speech normal. Pupils equal, of medium size, and active. The ocular muscles thoroughly tested with prisms, do not show any degree of paresis. The optic nerves and retinal vessels appear perfectly normal.

R.E.

90°

10 20 30 40 50 60 70 800°

nature. One month ago a brother committed suicide, and it was shortly after this that she first noticed failure of vision; at times becoming entirely blind; this latter condition only lasting a few seconds. Examination does not reveal any organic lesion of the nervous system. Any attempt to examine the eyes causes a spasmodic closure of the lids. Both pupils are moderately dilated and react normally. The vision of the right eye is, and of the left eye 8. Both fields of vision are very much contracted, as is shown in Fig. 1.

The fundus, media, and vessels are normal, nothing being found to account for the condition present. Two attempts to hypnotize the patient failed, but on the third trial she passed into a deep sleep, and suggestions referable to the conditions present were made. After seven séances, the fields were again measured and a marked improvement was found, the degree being shown in Fig. 2.

The treatment by suggestion was continued until August 15th, when the patient was discharged with perfectly normal fields and vision fully restored.

CASE II. Amblyopia. Contraction of the Visual Fields. Improvement after Six Séances. March 29, 1895. Charles T, aged twenty-eight, single; clerk. Gen

Both visual fields are very much contracted. (See Fig. 3.)

There is no loss of color perception. The left side, including the cornea, is slightly anesthetic, and he now states that he occasionally has a temporary feeling of weakness in the leg and arm of this side. Examina

tion does not reveal the slightest loss of power: all the muscles are firm and react normally to both the faradic and galvanic currents. He was hypnotized without any difficulty, and the proper suggestions were then made. This method of treatment was continued for two weeks, resulting in a complete disappearance of many of the symptoms complained of. The visual fields were again measured, and though some improvement was shown, still there remained a certain amount of contraction. (Fig. 4.)

On April 12th he stated he had been having more or less pain in his abdomen for several days, and that this morning he had passed some white objects at stool. Upon examining these, they were found to be a number of the links of tænia solium. A mixture of castoroil and felix mas was ordered, with directions as to diet, etc.; which resulted in the passing of two worms, many yards in length, including the heads. Three days later his eye symptoms had all disappeared, the visual fields