S. Weir (Silas Weir) Mitchell.

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^v.



V






Boston Medical Library
in the Francis A. Countway
Library of Medicine -Boston



LECTURES



ON



DISEASES OF THE NERVOUS SYSTEM,



ESPECIALLY IN WOMEN.



BT



S. WBIE MITCHELL, M.D



V



MEMBER OP THE XATIOXAL ACADEMY OP SCIEXCES ;
PHYSICIAN TO THE ORTHOPEDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE

NERVOTTS SYSTEM ;

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ;

MEMBER OF THE NEW YORK ACADEMY OF MEDICINE ;

ASSOCIATE FELLOW OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES OF BOSTON!

HONORARY MEMBER OF THE STATE MEDICAL SOCIETIES OF NEW YORK,

NEW JERSEY, AND MARYLAND ;

HONORARY CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIATION ;

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY ;

HONORARY MEMBER OF THE ST. ANDREW'S MEDICAL GRADUATES' ASSOCIATION ;

FOREIGN ASSOCIATE OF THE ROYAL MEDICAL SOCIETY OF NORWAY ;

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



WITH FIVE PLATES.




PHILADELPHIA:

HENRY C. LEA'S SON & CO.

1881.




Entered according to Act of Congress, in the year 1881, by

HENRY C. LEA'S SON & CO.,
in the Office of the Librarian of Congress. All rights reserved.



COLLINS , PRINTER.



DEDICATED TO



J. HUGHLINGS-JACKSON, M.D., F.KS.,



WITH WARM PERSONAL REGARD,



IN GKATEFUL ACKNOWLEDGMENT



HIS SERVICES TO



THE SCIENCE OF MEDICINE.



1*



Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons and Harvard Medical School



http://www.archive.org/details/lecturesondiseas00mitc2



PEEFACE.



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

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



CONTENTS.



LECTURE I.

THE PARALYSES OF HYSTERIA.

PAGE

Paraplegia — Hemiplegia — Bilateral hemiplegia — Electric re-
actions in hysterical palsies — Treatment . . . .13

LECTURE II.

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS.

Briquet's hysterical ataxia — N'ew forms of hysterical ataxia —
Forms of paresis ........ 34

LECTURE III.

MIMICRY OF DISEASE.

Causes of mimicry — The hysterical state — General nervousness
— General failure of health — Psychic peculiarities — Natural
mental and moral conditions favoring mimicry of disease —
Imitative vomiting — Imitative palsy — Mimicry of pain —
Imitative epilepsy — Imitative meningitis — Epidemic of
rhythmic chorea ........ 50

LECTURE IV.

MIMICRY OF DISEASE.

Hysteria in childhood — Simulated vomiting — Simulation of
hip-joint disease — Autobiographical confessions . . 75



CONTENTS.



LECTURE V.

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN.

PAGE

Kotatory spasms — Functional spasms — Stryclmic spasms —
Spasms on change of position — Local spasms simulating
tumors — In the pectoral muscles — In the walls of the
abdomen — In the gastrocnemius — Hysterical athetosis . 89

LECTURE yi.

TREMOR — CHRONIC SPASMS.

Hysterical tremor — I^ervous tremor with organic disease of
the spine — Alcoholic tremor in nervous women — Chronic
spasm with simulation of local injury of ulnar nerve — Chronic
spasm of leg — Contracture of leg muscles — Chronic spasmo-
dic ptosis . . . . . . . - .106

LECTURE Yll.

CHOREA OF CHILDHOOD.

The relations of the chorea of childhood — To season — To
climate — To locality — To race — Forms of chorea . .127

LECTURE VIII.

HABIT CHOREA.

Definition — Cases of habit chorea — Relation to chorea of
childhood — Treatment . . . . . . .146



CONTENTS. XI

LECTURE IX.

DISORDERS OF SLEEP IN NERVOUS OR HYSTERICAL PERSONS.

PAGE

Sensory shocks — Emotional shocks^ — Irregular motor dis-
charges — Nocturnal functional hemiplegia — Respiratory
failures in sleep . . . . . . . .153

LECTURE X.

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERVOUS

OR HYSTERICAL.

Pulse in hysteria — Agitation of heart followed by apparent
death — Eccentricities of pulse in the hysterical — Palpitation
of heart -with flushing of face — Palpitation of heart with
pallor of face — Surface ischsemia — Yaso-motor paralysis
in the limbs or the face — Extreme vaso-motor paralysis
of the whole vascular system of the abdominal cavity —
Respiratory peculiarities of hysteria . . . . 1 74

LECTURE XL

HYSTERICAL APHONIA.

Paralysis of laryngeal muscles — Failure of coordination in the
various organs which combine to produce speech . .191

LECTURE XII.

GASTRO-INTESTINAL DISORDERS OF HYSTERIA.

Comparative rarity of hystero-epilepsies in America — Diffi-
culty of feeding hysterical women — Troubles as to masti-
cation — Forms of dysphagia — Hysterical anorexia — Hys-
terical vomiting — Hysterical fasting — Defecation in hys-
teria 201



xil CONTENTS.

LECTURE XITI.

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

PAGE

Character of cases needing this treatment — Sechision —
Nurses — Uterine disease — Ovarian disorders — Seclusion —
Rest — Massage — Electricity — Mode of feeding . .217



For Description of Plates, with Eemarks, see
pages 127 to 145.



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DISEASES



OF THE



NERYOUS SYSTEM,

ESPECIALLY IN WOMEN.



LECTURE I.

THE PARALYSES OF HYSTERIA.

The case to wliicli I drew your attention at my
last clinic is here again, a girl, rather wanting in the
signs of sexual ripeness, although sixteen years old.
You will recall the fact that she lost the use of the
right arm because of having been alarmed. The
scare brought on what every woman knows as an
attack of hysterics — our ancestors called it the vapors.
The girl cried and laughed by turns, and then had a
slight fit, on comino; out of which she could no lono^er
lift her right arm, or rather she could lift it but a
few inches. On finding this to be the case, she grew
much concerned, and by and by could not lift it at
all, the idea that it could not be raised helping, as is
apt to be the case, to make the trouble worse. There
seems to have been no deceit, but perhaps the first
feebleness may have been slight, and the power of
her belief in her want of force great, and this is
2



14 DISEASES OF THE NERVOUS SYSTEM.

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

We see here among the ill-fed, needy, and worried,
a good many cases of hysterical loss of power, and I
meet a yet larger number among women of the upper
classes, where the disease is caused by u.nhappy love
affairs, losses of money, and the daily fret and weari-
someness of lives which, passing out of maidenhood,
lack those distinct purposes and aims which, in the
lives of men, are like the steadying influence of the
fly-wheel in an engine.

It is my present wish to speak of some of the many
kinds of hysterical paralysis, and to dwell far more
freely on methods of treatment than upon minute
details in the natural history of these disorders. I
do this chiefly because as regards treatment I hold
very positive opinions, and because these opinions
have, I believe, been amply justified by happy re-
sults, some of which are familiar enough to those
who have followed my practice.

The group of instances of lessened power which I
shall here discuss will include the usual forms of hys-
teric paraplegia and hemiplegia, and that which I
shall call double hemiplegia. I shall not attempt to



PARALYSES OF HYSTERIA. 15

cover the whole range of hystero-palsies, but seek
chiefly so to define a certain number as to allow me
to speak of their treatment. I shall also describe
four forms of seeming loss of power, only one of
which is essentially hysterical in nature, and not
found elsewhere with the same features. I allude to
hysterical motor ataxia.

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

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

One of the chief troubles in clearly knowing and
in dealing with all of these forms of disease is due to
the fact that in most cases, and to some extent, they
may exist in union. The case of palsy may be partly
real, partly pure weakness, partly loss of power from
want of belief in being able to move ; or conscious
mimicry may be added to palsy or to the forbidding-
influence of a regnant idea, or to the true hysteric
palsy may be joined ataxy of motion. For such vex-
ing marriages of disorders, and for their offspring of
doubt, we must be ready and watchful. They make
the true limits of hysteric lack of power hard to de-
fine, hard to treat, full of surprises, and unfailing in
interest and variety. Take this for an instance : You
have a case of extreme hysteric paresis to treat. As
a rule, it is readily cured. You predict a clear and
happy future. As time wears on the mere weakness
is gone, the limbs are plump again, the cheek red, and
then you may find, if you have not been careful, as I



16 DISEASES OF THE NEKVOUS SYSTEM.

have found, that hidden iu the mere weakness there is
a distinct amount of motor palsy — a mild, one-sided,
loss of power — a true hysteric palsy, and not at all
easy to cure. I shall pick for you, out of my note-
books, cases of each of the forms of disease I have
just spoken of, and shall try to make plain to you
how I treat them. There were once no cases so much
dreaded by me. There are now none to which I go
with so much pleasure. I am sure that I treat them
to-day with a success I could not once have gained,
and I think that what success I have had has been
due to more exact ideas as to what is needed, and
that unflinching purpose and action which grow out
of distinct views.

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

Mrs. C, set. 36, a strong woman, and in all ways
well, lost by sudden death a child and her husband.
Thus having cast on her the care of a large estate,
loaded with many burdens, she began to show excess
of anxiety as to her affairs, and from being SAveet of
temper became abrupt and full of unreasonable doubt
as to her advisers. The worry brought with it speedy
loss of blood globules, and as she was a woman who
flowed very fully each month, all these causes together
began to tell. This is the kind of thing we see much
of in medicine. The books say this, that, or the other
causes hysteria. In practice it is usual to find two or
three causes — acting to assist one another. This
woman was quite ready for an outbreak of some form



PARALYSES OF HYSTERIA. 17

of nerve trouble, when of a sudden she met the final
blow in the form of a telegram. The news it bore
was neither good nor ill, but by evil luck tbe writing
looked like that of her dead husband, and she began
to laugh with that strange want of appropriateness
in emotional expression so common in the nervous.
Awaking next day her legs seemed heavy, which
caused her great alarm. At once, as she told me, the
fear of palsy arose in her mind, and haunted her the
more as, day by day, the feebleness grew worse. She
was in Germany when taken ill, and seems to have
been looked upon as sufiering from an organic mal-
ady, for she was treated with nitrate of silver and
the hot iron. Then as she failed to get relief any-
where, she was sent from one spa to another with a
skill Avhich as yet we are fortunately far from being
able to reach.

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

This was what I found: A woman of 35, height 5
feet 2 inches, weight 170 lbs., flabby, and thin blooded,
with healthy heart, lungs, and kidneys. On the left
side of the vagina was felt a tumor about the size of
a walnut. It was very tender, and firm pressure on it
gave rise to nausea and distress down the left leg. I
had no doubt that this growth was a displaced ovary,
but, despite this change of place, the left iliac fossa,
both the skin and the parts reached by deeper pres-
sure, was tender to touch. Was it ovarian tender-

2*



18 DISEASES OF THE NERVOUS SYSTEM.

ness? Hardly, in this case. I have been told by Dr.
Goodell that he has seen this same sensitiveness in
other instances where the ovary had been displaced,
and probably too much has been and is made of this
sj^raptom. The tenderness in Mrs. G.'s case was iso-
lated, as is not unusual, and all about it up to the
waist and down to the feet the body was without
sense of touch or pain, or of heat and cold. In
tracing this defect upwards it was found to cover the
left breast, but this was so to-day, and then to-morrow
it was less, the upper limit ranging from the navel to
the left armpit.

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

The plan pursued in treating the case was one to
which I groped my way a few years ago. My patient
was very thin blooded, and yet very fat. Such cases
for some reason not clear to me are more hard to
,^ redden than are those of thin people in like states of
blood. But if you can safely cause these persons to
lose flesh, as they are helped to remake it, you may
sometimes redden them with ease, and to raise the
number of blood globules to the normal is usually to
lift a woman above that low level of health, which
is one, at least, of the- factors of hysteria.

Mrs. C. was, when first seen by me, sitting up most
of the day, and sewing, writing, and the like, when not
too nervous. I put her in bed, and employing as a diet
milk alone, mixed with a little rice-water or barlev-
water, I began to lessen the amount given, until,
using less than a quart a day, her weight fell oft' at



PARALYSES OF HYSTERIA. 19

the rate of about a quarter to half a pound a day.
When she showed signs of weakness I added beef
soup to the diet for a day or two, and thus in one
month brought down her weight some twenty-four
pounds. This could not with safety be so quickly
done unless the patient were kept inert and supine.
Then the milk was by degrees increased. Raw beef
and vegetables Avere added, malt extract was used
before meals, a little red wine or champagne was
allowed, and iron was given freely, the feeding being
frequent. When I made the increase in diet I began
to arouse sensation by the use of the wire brush and
induction currents.

Now in common palsies, or in those from nerve
wounds, feeling is apt to come back first, motion last;
but in hj^steric palsies, as I think, the gain in active
motion may go on, and even reach a useful amount
while yet the lack of feeling rests as it was Avhen
the treatment began. Just this change took place
in Mrs. C. : She grew brighter, and more happy,
gained in color and flesh, and began to move her legs.
In a month after she reached full diet she could walk
with some trouble, and about this time the sense of
touch showed signs of betterment, but the power to
feel pain was unchanged, and, in fact, Avas never com-
plete in the left leg.

Kext began a plan of steady, urgent calls upon her
for increase of the use of her limbs, so that before
long she was able to walk out of doors. At this point
I fear there was a mistake nmde in the treatment.
Thinking the battle won I pushed her too hard, and
one day after walking much further than usual she



20 DISEASES OF THE NERVOUS SYSTEM.

felt an excess of fatigue. Eeturning home she gave out
of a sudden, and the morning after was again hardly
able to stir either leg. I may pause here to repeat
as to this matter a warning I have often given. It is
to urge on you the utmost care as to allowing a hys-
terical patient on the way to health — I mean, of
course, one who has lost power — to do more each day
than fulfil the ordered task of that day. Most cases
of hystero-palsies are easily tired, and it is almost
sure to be the case that they cannot make a long
effort without showing the effect in some way ; more-
over the mental results of extreme tire are to be
feared, because any positive, real sensation is apt to
become the peg, so to speak, on which the patient
may hang the complement of a larger and less real
sensation.

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

About six months later this lady died after a brief
illness, which seemed to me more like a sudden and
complete palsy of the pneumogastric nerves than any-
thing else. 'No examination post mortem was allowed.
I have known three deaths in hysteria ; all were ab-
rupt, and two were due to acute congestion of the
kidneys.

Of that more common type, the palsies of one side
of the body, you have seen a number. They are



PARALYSES OF HYSTERIA. 21

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

I cannot leave this subject of hemipalsies of hys-
teria without a few words as to the ordinary type of
this disorder. 1 shall therefore sketch for you some-
Avhat briefly the chief symptoms of hemiplegia of
hysterical origin.

This disease may come on slowly, and during the
varied course of a case of hj^steria, or it may arise
abruptly, in an instant even, in women known or not
suspected to be hysterical, owing to some profound
emotion or to an accident, such as a fall or a wound.
It is often of such insidious development that its
presence, when mild, is a thing rather to be found by

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


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