her. In the spring of that year a mimic paralysis agitans appeared on the scene, occurring with marked violence at the return of each menstrual period. In this state of hysteric oscillation, from the semblance of one disease to that of another, she came under my care. This was in the autumn of 1858. The chloroform bottle, the opiate, and the catheter were now indispensable to her. She was sallow, haggard in expression, nervous and emotional in the highest degree. She still menstruated with great regularity, and her trismus and inability to empty the bladder remained as bad as ever. The teeth of the upper jaw, from constant pressure on the corresponding teeth below, were worn down in a remarkable degree, and the masseter muscles on each side had undergone a degree of hypertrophy very significant of their constant exertion during so long a period. A careful examination into her case removed from it, with two exceptions, every trace of organic disease. The uterus was unhealthy. There was much congestion and some enlargement of the cervix, and from its posterior lip hung down a small polypus, half the length of the little finger. There was in addition an unhealthy bunch of inflamed piles. After removing the polypus, and by repeated applications of nitrate of silver, and once or twice of stronger escharotics, the cervix was got into a perfectly healthy state. During this time a great amelioration took place in her state of general health. We had agreed to put the chloroform and the opiate on the shelf, and the catheter was also locked up. I then removed the piles, some by excision and some by ligature; "and from this," writes the patient, "I rose up in about ten days more free from pain than I had been for years." She then went into the country, and in a few months gained so much in strength and flesh as to be a wonder to herself and others-chloroform, opium, and the catheter were all disused and nearly forgotten. It was certainly a triumph over the hysteria, but, as it proved, it was not of very long duration. The menstrual crisis was now approaching, and we were to have one more long struggle with this obstinate, often beaten, but unconquered foe. The monthly discharge beginning to occur irregularly, was at last attended on one occasion with much pain and discomfort and a feeling of bearing down, in fact, a state of physiological congestion without relief by the usual flux. The old irritation appeared to leap back into its accustomed seat, and in April, 1859, this poor lady presented herself again as bad as ever, and, I am sorry to add, the opium had resumed its accustomed place on her dressing-table. I once or twice applied two or three leeches to relieve the uterine congestion, and always with benefit to her other symptoms; but as it was obvious this could not be repeated constantly, it became desirable, if possible, to overcome the hysteric disorder in some other way. As there appeared to be some irritation in the canal of the urethra, relief was given to that by smearing the catheter with a little extract of belladonna. Hypodermic injections of morphia and other anodyne substances into the arm were then used, and invariably opened the mouth in a few minutes; occasionally also chloroform was given. In fact, the old routine was being gradually reopened, during the time I was awaiting the completion of one of Legendre and Morin's instruments for applying the electricity of induction, which Duchesne has called after the name of its discoverer, Faraday. Upon the application of this remedial agent (the only means as yet untried) my hopes of success were grounded, and, as the result showed, not without good cause. I resolved to overcome the spasin of the muscles closing the jaw by throwing into action those whose function it is to open it, and which, in comparison with the former, were feeble and ill-nourished. Also it was determined to arouse the muscular contractility of the bladder, weakened by long abeyance of its activity and by the distension of its walls from long retention of urine. As the patient had been saturated with nervine tonics of every description for many years, she was to take nothing but a little tincture of sumbul in camphor-water occasionally. The first application of the Faradising instrument to the depressors of the jaw was perfectly successful. The opposing muscles, oddly though it may sound, appeared taken by surprise, and yielded in a very few minutes with a sort of snap. I gave the patient a pretty strong dose of the electric current, and she was informed that it would continue to increase in its force every day until the mouth ceased to shut! Then with a moistened sponge on the conductors, the abdominal muscles were first acted upon. They were in a state of hysteric rigidity, and no doubt thus helped on the seeming paralysis of the bladder. On the right side there was much less contractility of these muscles-and, indeed, generally of the muscles of the body-than on the left, and this was developed in a striking manner by the varying tolerance of the electric current. There was also a most marked anæsthesia of the skin all over the right side of the body. By soldering on a small brass button of the size of a small pea to the end of a piece of brass wire, and then enclosing this in an elastic catheter, I manufactured an excellent instrument for carrying the electric current to the walls of the bladder itself without communicating it to the urethra, which would have been intolerably painful. By the moistened sponge conductor applied over the pubis, and by connecting the wire of the catheter with the other pole of the instrument, we succeeded in arousing the torpid muscular irritability of the bladder. This was the treatment on which I based my hopes of an ultimate victory over the bladder, and it proved in the end quite successful. At the same time, having removed the irritability of the urethra, I determined to overcome temporarily its contractility, by gently dilating it as in the removal of stone from the female bladder, and thus break the habit of retention of urine. This was effected under chloroform by Weiss's dilator, and excellent results ensued. In a short time an obvious improvement took place in the patient's general state, and in her increased muscular powers. The depressors of the jaw acquired strength and a fuller increase of volume, and there was a very marked increase in the muscular power of the bladder, so that at last on using the catheter it projected a forcible stream, instead of the urine coming away in a mere passive flow. Occasionally a parenthesis of hysteric spasm would occur in the muscles of the face or of the neck. One morning my patient came to me with a mimic torticollis, and another time with her face drawn to one side in the most grotesque fashion. In the manner of a very decided rebuke for such unreasonable conduct, she received on each of these occasions so strong a dose of the electric current as to put an end to the difficulty as if by magic! We were thus gradually dislodging this martyrizing disorder, by, at the same time, giving her the muscular power to vanquish it, and calling out the will to that end. Much patience and a most determined resolution to conquer-at first wholly on my part, but afterwards very decidedly on that of the sufferer-brought this strange case to its close. The last thing done for her was on Saturday, the 9th of June, 1860, and on Monday, 11th, she came, overflowing with gratitude, to announce herself set free from her disorder. It is now nearly two years since this lady was discharged cured of her hysteria, and from that time to the present not even the shadow of any of her former annoyances has fallen over her history. Considering the long duration of her disorder-more than thirty years-its extraordinary pertinacity and obstinate recurrence, we may fairly conclude two years' absolute immunity to represent a complete cure. And as the menstrual function is now closed, and a source of irritation thus removed, we may fairly hope that this lady, who was called by some of the eminent physicians who attended her the " Queen of Hysteria," has vacated her throne to some younger successor. ART. 43.-An Extraordinary Case of Chorea. By Dr. W. CANNIFF, Professor of Surgery, University of (British American Journal, November, 1862.) CASE.-Jane M., aged 23, a native of Limerick, has been married nearly three years. Three months after marriage had a miscarriage, which, according to her own and friends' account, took place without any obvious cause, unless it were general weakness. Three months thereafter had a second miscarriage, still without any assignable cause. Fully nine months after this she had a third miscarriage, or premature labour. It was on this occasion that she first came under my notice, having been called in haste. When I arrived I found a still-born child still attached, and the placenta in utero. The child had apparently been dead for some time, and was between six and seven months. The placenta soon came away, and she had a quick and perfect recovery. The patient and her friends assured me that her health had been invariably good, and that no cause of the death of the child was known. About four months after this the patient found herself again pregnant. Two months later she had a severe fright from seeing a scuffle between her husband and father. This affected her mind very much, causing great depression of spirits, and at times great terror. This continued for about six weeks, when symptoms of chorea presented themselves, at first in the fingers and hand of the left side, and afterwards on the whole of the same side of the body. I recommended the utmost gentleness and cheerfulness to be observed towards her, and put her on the citrate of iron and quinine; under this treatment she gradually improved, until at last the twitchings had almost ceased, when, without any particular cause, the whole of the right side became affected, rendering her unable to walk or help herself. The treatment heretofore pursued seemed to have no effect, and I was induced to try the citrate of iron and strychnia. She very soon began to improve, and, although her progress was slow, she in about three months was perfectly free from the disease. She continued quite well until she had gone her full period of pregnancy. But with the labour-pains the chorea returned in every part of the muscular system. The several stages of labour were passed through in a comparatively short time; but as the labour advanced, and the pains became more severe, the jactitations increased in frequency and power. To attend a woman in confinement who has St. Vitus's dance is anything but easy, while the attitudes, the grimaces, and contortions were absolutely ludicrous. The patient was heartily ashamed of herself, and tried fruitlessly to keep in "position." In spite of herself, and mother, and nurse, and doctor, she would be first on one side of the bed, then on the other; now up against the head-board, now down to the foot. I had no particular fears until the head began to press against the perineum, when I thought, notwithstanding support and actual pressure, the head would be thrust through the undilated tissue. At each pain the urine would be forced out in quick streams from the urethra, while the sphincter ani could be felt twitching most actively. The labour was fortunately completed without any evil results. The twitching at once began to cease, and within twelve hours had entirely disappeared: her recovery was good. The child, a fine boy, was healthy, and has continued so up to the present time, now nearly a year. The mother also remains in good health. ART. 44.-Acute Chorea treated with Whisky. (American Medical Times, August 2, 1862.) CASE. A girl, æt. 16, was admitted recently into the Bellevue Hospital, New York, with symptoms of aggravated chorea of four weeks' duration. The convulsive movements were so violent and incessant, that she had not slept for four or five nights previous to her admission. Dr. Clark having observed the sedative effects of whisky administered in intoxicating doses in some cases of idiopathic tetanus, determined to try the same remedy in this case. He directed that half an ounce of whisky should be given to the patient every half hour, until intoxication was produced, (if necessary,) and sleep followed. After the third dose the girl slept half an hour; after the fourth dose she slept three hours; and from this time she slept well with doses repeated at longer intervals, and subsequently with the use of tonics she improved rapidly. There were no symptoms of heart disease, and no history of previous rheumatism. ART. 45.-The Degree of Frequency of Diphtherial Paralysis. By Dr. HENRI ROGER, Physician to the Hôpital des Enfans Malades, Paris. (Archiv Gén. de Méd., Jan., 1862; and Edin. Med. Journal, June, 1862.) Without going beyond the facts already recorded, it might be said in a general way, that of all the paralyses secondary to acute affections, none is nearly so common as that which we see developed during the course of, or during the convalescence from, croup, and especially from pharyngeal diphtheria. M. Maingault, in a work on diphtherial paralysis, published in Paris in 1859, records ninety cases of the kind, which, indeed, are spread over several years, were partly collected by himself, but chiefly borrowed from various authors, and are, besides, selected cases. Since attention has been directed to this complication of diphtheria, the examples have become infinitely more numerous; but there is in this greatly increased proportion at once an appearance and a reality: the paralysis, no longer passing unperceived as formerly, appears to be more common, and no doubt really is so; for epidemics of diphtheria are certainly more frequent, more general, and perhaps more severe now than they were thirty years ago. This is the opinion of Professor Trousseau, who attributes the large number of cases of consecutive paralysis to this, "that for some years back, diphtheria has assumed that peculiar physiognomy which it did not formerly possess, and which characterizes the toxic form." (Clinique Médicale, tom. i., p. 380.) "During the last few years the medical journals have published more than one hundred and fifty cases of diphtherial paralysis, and, as Dr. See remarks, in certain epidemics, the third or the half of the patients have been the subjects of an affection of sensibility or motility.' M. Lemaire, of Pont-Audemer, treated in the course of a few months eighteen cases of pharyngeal diphtheria, of which six terminated fatally, and every one of the twelve patients who recovered suffered from a consecutive paralysis. 66 'On comparing the preceding statements of different observers, we only arrive, however, at a somewhat vague approximation to the real proportion of cases of paralysis consecutive to pseudo-membranous affections; and if we have a certain idea of the absolute frequency of this complication, we have no data for deciding as to its relative frequency: this proportion has not been numerically determined, and I propose to endeavour to establish it, and to bring more precision into this question of etiology by means of clinical and statistical researches. 66 In the first place, I shall quote from two documents having reference to hospitals with which I was not personally connected. 66 During the first half of 1859, four cases of general diphtherial paralysis presented themselves at the Hôtel Dieu in the wards of Professor Trousseau; in two of these cases the diphtheria had been treated outside, and the patients had been brought to the hospital on account of the paralysis; in the other two the paralysis occurred in the hospital consecutive to a diphtheria of which all the phases had been observed. During the same period the number of diphtherial affections treated in the wards of M. Trousseau amounted to twenty-two, distributed as follows:-croup, 12; pharyngeal diphtheria, 6; cutaneous diphtheria, 4. Here, then, comparing the two cases of paralysis which occurred in the hospital with the twentytwo cases of diphtheria treated, the consecutive paralysis would be in the proportion of 2 to 22, or one-eleventh; but if it be borne in mind that in the series of observations the paralysis only occurred after pharyngeal diphtheria, which was only met with six times, the frequency of paralysis after pharyngeal diphtheria becomes greatly augmented, amounting, in fact, to one-third. "In the course of the same year, 1859, M. Garnier collected at the Hôpital St. Eugénie, in the wards of Dr. Barthez, fifteen cases of diphtherial paralysis; of these fifteen cases, six were admitted into the hospital on account of paralysis consecutive to diphtheria, for which they had been treated at their own homes; in the other nine cases the whole course of the affection was observed, but M. Garnier does not specify (except in two cases of cutaneous diphtheria) to what form of pseudo-membranous affections the paralysis had succeeded. As M. Barthez received into his wards a hundred and forty-one children suffering from diphtherial affections, this gives a proportion of one case of paralysis to about fifteen of diphtheria in general. 66 It occurred to me that, in order to be able to form an accurate idea of the relative frequency of the affection, it was necessary to observe what happened in cases of croup or pharyngeal diphtheria, XXXVII. 6 |