On Masturbation and Hysteria in 
Young Children. 
REMARKS BEFORE THE MEDICAL JOURNAL ASSOCIATION OP N, Y., 
IN NOVEMBER, 1875. 
BY 
A. JACOBI, M.D., 
Clinical Professor of Diseases of Children. College of Physicians and Surgeons. N. Y. 
Tteprinted from the American Journal of Obstetrics and. Diseases of 
Women and Children, Fol. VIIJ., No. IV., February, and 
Vot. IX., No. 11., June, 1876. 
NEW Y 0 BTK; 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1876. ON 
MASTURBATION AND “HYSTERIA” 
IN YOUNG CHILDREN. 
BY' 
A. JACOBI, M.D., 
Clinical Professor of Diseases of Children, College of Physicians and Surgeons, N. Y. 
REMARKS BEFORE THE MEDICAL JOURNAL ASSOCIATION OF N. Y., 
IN NOVEMBER, 1875. 
Reprinted from the ‘c American Journal of Obstetrics and Diseases of Women 
and Children ” for February and June, 1876. 
NEW YORK 
WM. WOOD & CO., 27 GREAT JONES STREET. 
1876. SUBMITTED 
AND 
DEDICATED 
TO THE 
MEMBERS OF THE SECTION POE DISEASES OF CHILDREN 
OF THE 
GESELLSCHAFT DEUTSCHER NATURFORSCHER UND H3R/,TE ” 
OF 
INSBRUCK, 1869, 
AND OF 
HAMBURG, 1876. ON MASTURBATION AND “HYSTERIA” IN YOUNG CHILDREN. 
REMARKS BEFORE THE MEDICAL JOURNAL ASSOCIATION OP N. Y., IN 
NOVEMBER, 1875. 
A. JACOBI, M.D., 
Clinical Professor of Diseases of Children, College of Physicians and Surgeons, N. Y. 
Greater accuracy of observation, and increasing knowledge 
of a large number of physiological facts have, of late years, 
had a peculiar influence on the current pathological views con- 
cerning the nervous system. More than ever, local and cir- 
cumscribed causes have been sought for, and found, for 
distant or general nervous symptoms; and the tendency to 
localize disease—the great achievement in modern diagnostics 
—has, in my opinion, contributed much to develop the dispo- 
sition on the part of medical men, to overlook general causes 
over an actual or alleged local anomaly. lam afraid that in 
many cases the charm of positiveness has given rise to serious 
mistakes. For instance, I believe that the doctrine of reflex 
spasms and particularly that of reflex paralysis will be greatly 
reduced in influence when the cases will be more thoroughly 
studied. This class of cases has been recruited principally from 
nerve affections connected with diseases of the genito-urinary 
organs. A number of years ago the cases of “ reflex paralysis ” 
depending on a disease of the kidneys were quite numerous 
indeed. Since they were carefully studied on the post mortem 
table, it grew evident that the consecutive nervous symptoms 
resulted from the direct contiguous transmission of the morbid 
process along the nerves upwards until it reached the spinal 
cord. 
Thus the diagnosis of reflex paralysis had to be changed 
into that of an ascending neuritis and myelitis. As the medical 
mind cannot be satisfied until all the links between cause and 
effect are clearly seen, we ought to take exception to the readi- 
ness with which nervous symptoms are apparently explained. 
If there is in this connection any subject in regard to which I still Jacobi : On Masturbation and 
2 
—in spite of the vigorous and sagacious efforts of such observers 
as Drs. L, A. Sayre and F. N. Otis—hesitate to fully accept their 
views, it is the frequency of (neuralgic, spastic and) paralytic 
symptoms depending upon phimosis.1 But lately (.Medical 
Record, Oct. 16th, 1875), Dr. J. H, Hunt related such a “ case 
of partial paralysis from reflex action caused by adherent pre- 
puce,” in which, I must admit, I do not find, upon close obser- 
vation, the proof of the postulation set forth in the title of the 
paper. The patient was a boy of six years, with a peculiar stag- 
gering walk, who seemed unable to properly control the lower 
extremities, and therefore was subject to frequent falls. He 
was nervous, and exhibited a twitching of the muscles of the 
face and extremities. His penis was found erected. He 
started and screamed in his sleep. The tongue, in the attempt 
of protruding, rolled about in the mouth. Articulation and 
intellect were below the average, in fact the boy was consid- 
ered “ idiotic ” in the neighborhood. After circumcision, im- 
provement took place rapidly. 
The case yields but a few points. The boy’s intellect wras 
below the average, so that people thought him “ idiotic.” Be- 
sides, the child suffered from St. Yitus’ dance, in which all the 
voluntary muscles participated, according to the above history. 
If there is any sickness, where a child of six years can make 
the impression of stupidity or idiocy, it is chorea minor, with 
its utter want of control over locomotion or articulation, and 
its emotional aberrations. Thus nothing, perhaps, remains ex- 
cept a case of protracted chorea, which “ improved rapidly 
after circumcision.” I ought not to go into a further criticism 
of the case, but I must say that no attempt has been made to 
explain the chorea by its habitual causes, and not even a state- 
ment is made of the condition of the heart, or of the spine, or 
concerning the previous occurrence, or non-occurrence, of acute 
articular rheumatism, or of the habit of masturbation so easily 
contracted when the phimosis is marked enough to prove an 
annoyance and irritation, and frequently given up when the 
source of constant irritation has been removed. 
1 C. Mauriac (Hude sur les neuralgies symptomatiqu.es de I’orchi-epididy- 
mite blennorrhagique, Paris, 1870) claims—but admits no more—that “no 
less than four per cent, have reflex neuralgia, spinal, lumbo-abdominal, inter- 
costal, sciatic, crural or visceral.” “Hysteria” in Young Children. 
3 
It is this habit of masturbation in the infant and child, to 
which I here desire to draw attention. To what extent it is 
practised in more advanced years, and how it interferes with a 
robust physical, mental and moral development of adolescence, 
is but too well known to both the physician and the pedagogue. 
But it has often appeared to me that its frequent occurrence in 
the quite young is by no means fully appreciated. There are 
some cases in which the diagnosis can be made from the condi- 
tion of the parts when suspicion has been aroused. Tumefac- 
tion of prepuce and glans penis, and redness and oedematous 
appearance of the former, swelling of the labia majora, redness 
of the introitus vaginae, moisture of the labia and vagina from 
over-secretion of the glands of Bartholin and the muciparous 
glands surrounding the urethra, are sometimes conclusive, when 
orgastic excitement has been observed. But these cases are by 
no means very frequent. Accidental or morbid swelling of the 
parts, and over-secretion from other causes may obscure the 
diagnosis. The majority of diagnoses can be made from care- 
ful observation of the child on the part of its attendants. A 
girl of three years was sent by a medical friend, because of a 
peculiar form of slight convulsive affections which were reported 
by the mother to have lasted a considerable time. These attacks 
would come in irregular intervals, frequently when the child 
was playing upon the floor or crouched upon a chair. Red- 
ness in the face and slight twitching about the eyes, with a 
deep sigh now and then, were all the symptoms enumerated. 
The child was well built, pale, the face was a little bloated. 
There was no history of a single violent eclamptic attack, or of 
any previous disease, or of premature teething and ossification 
of the cranial sutures and fontanelles, no history of epilepsy in 
the family, no effect of vermifuges and sedatives which had 
been administered. But for a long time the baby had lost her 
former spirits, was not noisy, but rather peevish and listless, 
alternately. A few questions and answers sufficed to convince 
me of the presence of masturbation in the little girl. She never 
had an attack of any kind when asleep. She never had one 
when walking about, or when playing and tossing about. She 
always had them when sitting down. She was very apt to 
keep her thighs closely joined, or to cross her legs. She 
moved and rubbed her limbs violently, got purple in the face, Jacobi ; On Masturbation and 
4 
began to perspire, to twitch about her eyes, which often looked 
excited, and lean back exhausted, sighing, or breathing hur- 
riedly. To insure the diagnosis, the temperature of the rectum 
was taken and found normal; the urine examined, and no 
albumen found. Such cases are by no means rare. A number 
of them have been observed by me, which exhibited the same 
symptoms to a greater or lesser degree. Local changes of the 
parts are sometimes absent, although the habit be of long dura- 
tion, The consequences, however, as far as general health is con- 
cerned are (csetcris paribus) the same. Amongst the prominent 
symptoms, beside the general expression of anaemia, and 
bloatedness, I ought to mention the change of temper. hTot 
infrequently have I been puzzled about the presence of either 
masturbation or general anaemia from other causes, or premoni- 
tory symptoms of meningitis. The children are quiet, morose, 
fretful, peevish, sleep restlessly, or sometimes too soundly; 
appetite variable; bowels often constipated; pulse some- 
times a little accelerated, frequently slow, and not rarely ir- 
regular ; expression of headache round their brows; skin 
sometimes very dry, flabby, and lifeless, sometimes inclined to 
perspiration, sometimes shining with accumulated sebum. In 
children of from six to eight years I have now and then met 
with comedones, as in the adolescent, in whom they are a fre- 
quent accompaniment of masturbation. 
A little boy of my acquaintance had frequently been noticed 
suddenly to leave his toys, walk through the room dreamily, 
sit down under the chandelier, stare upwards and commence a 
kneading exercise—by means of his two little lists—directed 
against his privates, which his nurse thought very cunning, 
indeed. The symptoms were described as about the same as 
those reported of the little girl mentioned above. In his case 
the penis had frequently been found erected, and continued to 
have that tendency until his vesical catarrh and frequent 
micturition were relieved. 
The causes of masturbation, no matter whether considered as 
an acquired habit or a disease, are very various indeed. I have 
positive knowledge of cases in which the habit was contracted 
by the treatment of infants, both male and female, at the hands 
of nurses or servants. The pleasurable sensation experienced 
by the victim, on the genital organs being gently tickled and “ Hysteria ■” in Young Children. 
excited, and when unruly, their greater manageableness resulting 
therefrom, caused a morbid desire leading to onanism in its 
most violent form. Protracted gentle rubbing, or beating of the 
gluteeal regions in infants, as also in later years (6 to 10), of rid- 
ing on horseback, I have seen followed by erection of the penis 
and orgastic excitement. Pressure of the parts and high tem- 
perature are injurious. Thus act feather-beds and soft furni 
ture; thus also warm and heavy first pantaloons, the delight of 
the boy and pride of the mother. They may prove hurtful from 
more than one cause. Not only are the parts kept too hot and are 
sometimes compressed, but the frequent micturition of the child 
necessitates the frequent and protracted handling of the penis. 
The young child is but clumsy and the reverse of adroit. It 
takes him time to disentangle the organ. Frequently in the 
streets and gardens have I seen sympathizing little friends, mostly 
of the other sex, and then somewhat older, or servants, busy 
with rendering the required aid in the emission of the urine. 
The good habit of washing young children in cold water is not 
always unattended with a certain degree of danger. There are 
some which are unduly excited by it at bedtime. In adults I 
have frequently observed, that, while cold washing of the whole 
body—genital organs included—would be attended with good 
results in the morning, it—or the cold shower-baths—just 
before going to bed would lead to excitement and nocturnal 
emissions. This observation has induced me to pay some atten- 
tion to the possible ill effect of the same dietetic treatment, in 
the evening, in the cases of such children who were known as, 
or suspected of, being addicted to the morbid habit. Local irri- 
tation of the genito-urinary organs is amongst the most common 
causes of masturbation. Most of their morbid processes have 
amongst their principal symptoms peripheral hyperesthesia, or 
pain in the glans penis, which, like many neuralgic affections, 
are partly relieved by handling or pressing, and thereby con- 
stitute the possibility of contracting a habit. Nor are affec- 
tions in those organs rare. One of the first affections of the 
newly born is an anomaly of the kidney. The uric infarctus 
of the first few weeks is a fertile source of gravel or stone, both 
in the kidneys or bladder, and of nephritis. In fact the large 
majority of vesical calculi—not at all rare in the young—were 
renal first, and descended with, or without, accompanying symp- Jacobi : On Masturbation and 
6 
Toms from the renal pelvis. In six out of forty necropsies of 
children under a year, made in a certain period in the same pub- 
lic institution, I found renal calculi. Although this figure can- 
not by far be taken as anything like a true proportion, it proves, 
nevertheless, that stone in children quite young is not rare at all. 
Besides, the experience of specialists has always proven that the 
histories of vesical calculi date in many cases far back into 
early childhood. Nor is gravel by any means very rare. 
Many of the hard screaming spells of babies, so willingly attri- 
buted to flatulency, naughtiness, or “ teething,” find on close 
examination their easy explanation in the condition of the 
urine. Catarrh of the bladder is a very frequent affection ; 
even a number of cases of incontinence of urine take their 
origin from that condition of the mucous membrane, with its 
subsequent effect upon the nerve distributions. Sometimes it 
is itself the progenitor of a ureteric or renal catarrh; more fre- 
quently, particularly in girls, it is the effect of a catarrh of the 
external parts. Bor leucorrhcea—from a number of causes—is 
a very frequent affection. In the very young, the presence of 
hardened vernix in the vagina and cervix, in the somewhat 
older, of decomposed urine, or foreign bodies, or exposure, or an 
accidental abrasion, result in a catarrh of the vagina, with all 
its harmful privileges upon the condition of neighboring 
mucous membranes and nerves. Generally, long duration 
makes it a disagreeable and uncomfortable affection, both in it- 
self and its possible consequences. Urethral catarrh in the young 
male is rare, but balanitis and balanoposthitis are very frequent, 
and ready causes of irritation. Their sources are both evident 
and numerous. The prepuce is long and frequently narrow. 
It need not even be very long, but still its lower blade and the 
surface of the glans penis are apt to be moist with fresh or 
ammoniacal urine. When it is narrow, the facilities for that 
discomfort are the greater; when it is very much so, the 
prepuce will often be pouched out during the emission of the 
urine, and micturition be effected drop by drop. The sebaceous 
follicles of the inside of the prepuce are very large—as they are 
all over the embryo and very young infant—and smegma very 
copious indeed. Thus its decomposition and the formation of 
irritating: fat-acids are but the matter of a short time. If I 
add to all this the sometimes irregular attachment of the pre- “Hysteria” in Young Children. 
7 
puce to the glans, with the formation of local pouches for 
smegma or urine, the number of possible or probable injuries 
appears large enough, without my believing in the alleged occur- 
rence of severe nerve disorders depending on the sole presence 
of the embryonic or infant phimosis or epithelial conglutination 
of glans penis and prepuce. 
The intimate correlation of the branches of the pudendal 
plexus (n, hsemorrhoidalis med. and inf. for bladder, vagina, 
muse, levator and sphincter ani ext. and int.; and n. pudendus 
for the pelvic cavity, with n. perinsealis for perinseum and mm. 
transversi penis, bulbo-cavernos, sph. ani. ext., scrotum, labia 
majora and vestibulum vaginee—and n. penis dorsalis for penis 
and clitoris) explains why abnormal conditions of the lower por- 
tion of the intestinal tract are amongst the frequent causes of 
genito-urinary irritation. The frequency of this connection is 
well known to those who have to deal with affections of the 
rectum or prostata in the adult. In the child the intestinal 
irritation is mostly of two kinds, consisting either in the pres- 
ence of worms (often ascaris, more frequently oxyuris), or con- 
stipation, the frequent cause of seminal emissions in the pre- 
disposed adult. In regard to the effect of constipation, it mat- 
ters not whether it be produced by incompatible food, or 
rhachitical insufficiency of the muscular layer, or by the inflec- 
tions of the (in the embryo and young infant) normally 
elongated and curved colon descendens. In all of these cases the 
effect upon the neighboring organs, particularly the nerves, is 
the same, and irritation of the glans penis can sometimes be 
explained by no better cause; for fissure of the anus, although 
not impossible, and sometimes met with, is rare. 
The conditions of the urine, with its constant and direct effect 
upon the nerves of the urinary organs, ought not to be lost sight 
of in this connection; of the effect of stone, gravel, and 
mucus I spoke above. The changes taking place in conse- 
quence of improper food or medicines are no less important. 
Large quantities of meat, eggs, spice, salt, beer, are injurious, 
Cantharides and other irritants ought to be avoided or carefully 
handled. Alkaline salts are by no means indifferent. Most of 
them irritate the kidneys, some dangerously so in certain cases. 
Nitrate and chlorate of potassa and soda belong to that class, 
emphatically. Fatal cases of overdoses of the chlorates do not Jacobi ; On Masturbation and 
8 
appear in the latest text-books on materia meclica and thera- 
peutics, nor have I met with any in the journals. While, then, 
postponing the elaborate communication of such cases as not 
belonging here, I shall but say that they exist. Congestion of 
the kidneys with over-secretion I have observed frequently, ne- 
phritis with fatal termination once, and am cognizant of more 
cases. I believe lam justified, perhaps, in my impression, that 
the frequency with which kidney diseases in children have 
come to my knowledge during the last ten years may have its 
source in the indiscriminate use of the chlorates—amongst the 
public—for catarrhal and diphtheritic affections of the pharynx. 
To sum up, I should say that all causes resulting in direct or 
indirect irritation of the nerves of the genito-urinary organs 
are apt to give rise to masturbation in the young. It is under- 
stood that I do not speak of the large class of cases occurring 
amongst school children and the inmates of institutions. From 
many of them the same tale is told of the prevalence of the 
dangerous habit amongst the children. 
The treatment of infants and children affected with the mor- 
bid tendency is indicated by its causes. No uniformity exists 
in either. The nurse requires watching as well as the baby. 
Excessive phimosis, circumcision. Balanitis and balanoposthitis, 
cleanliness and astringents. Stones and gravel, mostly alkaline 
salts, the majority being uric in the beginning. Yesical catarrh, 
alkalies, tannin, cubebs, hyoscyamus, injections according to 
circumstances. Constipation, its appropriate treatment, dietetic, 
antirachitical, roborant, laxative (injections). Worms, anthel- 
mintics. The acquired nervous derangement, bromide of ammo- 
nium or potassium. Anstie administers the bromide of potassium 
rather in “ fierce activity of mind and body” than in the effects 
of masturbation. My observations as to its beneficial effects 
are more favorable, however. Lupulin and camphor have 
proved very serviceable in my hands, Regulations as to feed- 
ing are self-evident after I have given a list of substances which 
prove injurious. Regular bathing and constant occupation 
under careful supervision are urgent requisites. The children 
must not be permitted to sit on the floor too long. When the 
symptoms of an attack exhibit themselves, take them up, and 
occupy their body and mind. Force is often required. They 
must not remain in bed after waking up ; in some cases I had “Hysteria ” in Young Children. 
9 
them taken up from their sleep every morning, and kept them 
awake all day, so as to secure sound and uninterrupted sleep 
all night. Infibnlation, as advised by Celsus, might be re- 
placed by an artificial sore of the surface of the penis. At all 
events, there are many cases which exert to the utmost both 
the watchfulness of the attendants and the ingenuity of the 
medical adviser. 
Important amongst the therapeutical indications are those 
referring to the general influences produced upon the whole 
nervous system by the constant irritation of a large number of 
peripheric nerves. The symptoms of irritation are soothed 
and relieved by the above-mentioned sedatives; those of mas- 
turbation, and exhaustion resulting therefrom, by a general 
roborant treatment and nerve tonics, amongst which I place 
strychnia foremost, iron and arsenic next. The affections in 
which they are principally indicated, are neuroses, either of the 
nerve centres, such as epilepsy and chorea magna, or of a peri- 
pheric nerve, or a number of nerves, or nerve complexes. The 
form in which peripheric nerves are generally affected, is 
that of hypenesthesia or neuralgia, terms which are not used as 
identical, because medical men have agreed to employ the 
latter, where the sensations are changed for a longer term, 
or where a positive lesion can be detected in the nerve itself. 
Neuralgias are seldom treated of amongst the nervous dis- 
eases of infants and children, although the inherited element 
in the etiology of neuralgia, amongst adults, is acknowledged 
to be very powerful, indeed. Thus Anstie found twenty-four 
ont of a hundred cases of neuralgia depending upon hered- 
itary transmission. A number of causes resulting in neu- 
ralgias, it is true, are not found at the age of which I am here 
treating. Thus a number of lesions belonging to advanced age, 
such as atrophy, tumefaction, hypersemic condition of the neu- 
roglion, visible dilatation and elongation of the blood-vessels, cica- 
trices and indurations, tumors; the abuse of alcohol, of changing 
climates, of various traumatic and mechanical influences, are 
out of the question. Nor are the causes so much emphasized 
by Anstie, such as an excess in religious training, and compul- 
sory employment of the mind with transcendental subjects, to 
be accused of interfering with the healthy development of the 
nerve-tissue of early childhood. But there are a large number 10 
Jacobi : On Masturbation and 
of young children, in whom a neuropathic disposition is well 
marked. Hereditary influences, acquired diseases of the hones 
so much more frequent in the young than in the old, and even 
irritation and exhaustion by masturbation, play an important 
part. If close observers, such as Yalleix or Eulenbnrg, have 
but a small percentage of neuralgias amongst the young, it is 
because the class of patients they had to deal with were not 
of the mixed character yielding accurate and complete sta- 
tistics. For cases of neuralgias are by no means rare; par- 
ticularly hemicrania and spinal irritation are frequently met 
with. 
Hemicrania is by no means rare. In girls and boys, partic- 
ularly the former, I have often observed it. The variety 
which has been called angioparalytic, and depends upon, or is 
complicated with, enlargement of blood-vessels, may not be 
frequent. In fact I have seen but very few cases under ten 
years, in which that symptom required, and was benefited by, 
generous administration of ergot. But the angiospastic variety, 
with contracted blood-vessels, pale face, and generally neurotic 
appearance, is really frequent. It results from a number of 
causes. It is one of those forms of nerve trouble which is 
inherited perhaps as frequently as any other. Neurotic 
mothers, both thin and fat, are liable to transmit it to their 
young daughters. Congenital chlorosis, consisting in anomalous 
smallness of the arterial blood-vessels, is a frequent cause. 
Observation through many years of a permanent practice 
has yielded many cases, in which I followed children from 
early childhood to adult age. Their congenital condition re- 
sulted in nervousness and trigeminal neuralgia in the child, 
and chlorosis and “hysteria” in the young woman, with a bad 
prognosis until the climacteric years will put a partial end to 
the consecutive symptoms. Some cases were the result of 
anaemia and masturbation, some depended upon malaria, or 
slow convalescence from acute diseases, or protracted intestinal 
catarrh. But the worst and earliest cases I have seen re- 
sulted from masturbation. The children, both male and female, 
look anaemic, some thin, some bloated, are fretful, and change- 
able. 
The attack of trigeminal (mostly supraorbital) neuralgia 
was sometimes unilateral, sometimes bilateral, and could last “Hysteria ” in Young Children. 
11 
for days, and amount to such agony in some instances, that the 
suspicion of cerebral disease was aroused. In a few cases the 
suppression of masturbation was the principal promoter of re- 
covery, In others medicinal treatment proved effective, where 
the bad habit had resulted in a thorough lowering of the sub- 
stance and function of the nerves. Iron administered for a long 
period, together with a roborant diet, belladonna in frequent 
and small doses, nitrite of amyl (inhaled during the attacks, as 
in the spastic hemicrania of adults; not internally, where I have 
found it absolutely inert) and protracted application of a mild 
galvanic current will prove successful. I should not leave this 
subject, however, without mentioning the effect of strychnia in 
speedily restoring the impaired nerve power, provided the doses 
are not too small, and the mode of administration the appro- 
priate one. A child of five years ought not to take less than -prth 
part of a grain in the course of a day, of either the sulphate or 
nitrate. Larger doses are frequently not only tolerated, but 
required. The best mode of its administration, however, is not 
by the mouth, but subcutaneous. A single daily dose of a twen- 
tieth part of a grain of the sulphate of strychnia in water will 
fully suffice. 
Its beneficial effect upon the nerve-centres explains, its 
power over the other form of neurosis not infrequently found 
in children—“ spinal irritation,” a term which for thirty years 
had an ontological existence in our vocabulary. After it had 
been given a bona-fide place amongst elementary ailments, 
modern medicine has ceased to look upon it as a unit. There 
are cases in which it is found to be due to a simple irradi- 
ation from cardialgia, others in which it depends on con- 
tagious and miasmatic diseases, typhoid and intermittent 
fevers; or on dyscrasic conditions, such as tuberculosis or 
scurvy ; or on deficient sanguification, from anaemia, hydraemia, 
for smallness of arteries; or on venous obstruction superin- 
duced by diseases of the lungs, heart, or abdomen, or on 
congestion of the spinal cord and surroundings depending 
upon improper innervation; or on anaemia of the spinal 
cord; or on a neuralgia of the skin, or muscle, or bones, 
or meninges. It is evident, from the long list of causes, that 
the cases of “ spinal irritation ” must be more frequent in the 
adult than in the young. But in these, this form of neuralgia 12 
Jacobi : On Masturbation and 
is by no means rare. Every cause tending to lower the status 
of the sensitive nerves of skin, muscle, spinous processes, or 
spinal meninges, will result in permanent hypersesthesia, or 
local neuralgia. Where the presence of other causes of ex- 
haustion in the child—such as enumerated above—can be ex- 
cluded, the suspicion that the incompetency and faulty function 
of the sensitive nerves are due to masturbation, will frequently 
be well founded. 
Neuroses of the joints have come under my observation a 
number of times in children of from five to twelve years, 
particularly in girls. I allude to the affection first described 
in Brodie’s second edition, 1822, since by Stromeyer, in 1844, 
and by Esmarch. The majority of cases have been observed 
about the knee-joint, but the ankle-joint and the hip-joint are by 
no means free therefrom. The internal condyle of the os femoris, 
the styloid processus of the ulna, and the vertebral column, are 
also pet places. The same affection, however, has been observed 
in the sciatic, obturator, crural, peroneal, saphenous and tibial 
nerves, in the cervical, lumbar, hypogastric and sacral plexuses, 
also in many peripheric nerve branches distributed about the 
integuments, joints, periosteum and bones. In both of the lat- 
ter, according to Luschka, sensitive nerves are very numerous 
indeed ; thus they ought not to be lost sight of in the attempt at 
localizing the diagnosis. 
o o 
A girl of eleven years, a patient of the German Dispensary 
some twelve years ago, applied to the surgical department for 
coxalgia. The pain was intense, the relative posture of the 
parts that of coxitis in the second stage, no change during day 
or night. The knocking of the knee against the hip-joint, said 
to he painless in “hysterical” coxalgia of the adult, was painful; 
thus the diagnosis was uncertain for weeks. A striking feature 
in the case, however, was the fact that the child was not 
emaciated, and no fever could be detected. Anaesthesia was 
required to solve the problem. Under chloroform the spas- 
modic contraction relaxed, no crepitation was felt, mobility com- 
plete. A general roborant treatment, with an occasional seda- 
tive, and compulsory exercise, restored the patient gradually, 
after months of patient treatment, and a year’s useless suffer- 
ing. 
A little girl, nine years old, small and delicate for her age, u Hysteria ” in Young Children. 
13 
but never subject to any form of serious disease, has for half a 
year suffered from intense pain, occasionally of the knee-joints, 
more frequently of the ankle-joints, but mostly of the tarsus 
and metatarsus. The attacks were mostly of short duration, 
and but rarely brought to my notice until lately, when I was re- 
quested to attend to her rheumatism. She had complained for 
days from severe pain about both ankle-joints, and the metatar- 
sus. Conversation and play moderated her complaint consid- 
erably ; the thermometer did not rise above the normal standard 
in the rectum, slight pressure resulted in expressions of severe 
pain, continued pressure appeared rather to relieve than to in- 
crease the sensitiveness. Again, the diagnosis of a neurosis 
appeared more indicated than that of a rheumatic affection ; 
again compulsory exercise, roborant treatment, both general and 
local, were resorted to, with success. 
A similar case was that of a girl of fourteen years, who 
after a long walk up and down hill, through ice and snow, was 
taken with severe pain about the left hip-joint, which soon 
incapacitated her for the use of the left lower extremity. Her 
case appeared particularly difficult. She had been a sufferer 
from early childhood. From her third year she suffered from 
osteitis, resulting finally in cicatrices of the malar and superior 
maxillary bones of the left side, disfiguring her orbit; of the 
right radius, and the left os femoris below the trochanter. She 
was eleven years before she was permitted to walk. Since 
that time she throve, grew strong and hearty, and regularly 
menstruated before she completed her thirteenth year. In that 
respect she was never irregular afterwards. When the above 
symptoms of pain and immobility showed themselves, the diag- 
nosis of coxitis, or pericoxitis, was made. Accordingly she was 
treated, principally, by rest, and her severe pain somewhat 
relieved, sometimes, by subcutaneous injections of morphia. 
In the course of time a variety of treatments were resorted to, 
every one without success. In this condition she had remained 
for a year and eight months, when I saw her. She was in the 
same bed in which she had been a year and a half before, was 
in constant pain, bore no touching about the hip-joint, or the 
anterior aspect of the thigh, from the ramus horizontal is 
downwards to the extent of three inches, tolerated no moving, 
was hardly ever relieved for any length of time by subcuta- 14 
Jacobi : On Masturbation and 
neons injections of morphia, showed no swelling of the trochan- 
teric region, but a slight but well-marked elevation of the cen- 
tral portion of the ram ns horizontalis ossis pnbis, which was 
also met with on pressing the linger down into the pelvic 
cavity, and a few indies down the femur, in the median line. 
Some explorative punctures, in different depths, revealed 
nothing. The diagnosis appeared positive enough, in my 
mind; an osteitis of very slow progress explained all the 
symptoms. The absence of fever conld be explained by 
the very slowness of the whole process. Still, it appeared 
somewhat peculiar that the general condition of the patient, 
then sixteen years old, was far from unsatisfactory. Her 
generalhealth, in fact, was good, and she was fleshy and 
rosv. 
In connection with the case I may be permitted to state that 
the patient had been seen by a number of prominent medical 
men. She lived in a German University town. The professor 
of theory and practice, a gentleman of world-wide fame, 
agreed with me in the diagnosis of an osteitis. The professor 
of surgery, and a Kew York friend who left an enviable 
surgical reputation and practice in Yew York City to enjoy a 
scientific “ otium cum dignitate” in Europe, pronounced in 
favor of a neurosis. Between the two opposite diagnoses the 
patient had the questionable benefit of doubt and wavering 
treatment. ISo change took place while she was under my 
observation; but I had scarcely returned home, when other 
symptoms developed, which turned the scale in favor of my 
surgical friends, such as tenesmus, irritation of the bladder, 
of irregular severity, duration, and alternation. Henceforth 
her recovery was a matter of time, endurance and patience. 
Internal remedies, external remedies, electricity, were exhaust- 
ed. Compulsory exercise restored her. When she was to be 
removed from her place of sickness, she had to be carried on a 
stretcher for many miles to get to a railroad depot, reached her 
home hundreds of miles away, under excruciating pains, was 
compelled finally to sit, to stand, to walk, to take exercise; and 
improved gradually, but so slowly, that when, a year after- 
wards, she was sent to a foreign country for an entire change, 
she still walked with pain, limped, and got exhausted for many 
a long, weary mouth. “Hysteria ” in Young Children. 
15 
A girl of about eight years,1 was under my treatment for 
a neuralgia of the right ulnar nerve, without fever or spinal 
complication. After some time a moderate swelling of the 
subcutaneous issue of the carpus, and in the neighborhood of 
the shoulder-joint, was added to her difficulties. They dis- 
appeared, only to be replaced by a very severe pain of the toes 
of her right foot. Her sufferings were intense for a long 
o o o 
time; they appeared to be mitigated, when an oedematous 
swelling of her right foot made its appearance. A protracted 
tonic and galvanic treatment was required to restore her. 
Another girl of five years was presented for acute rheuma- 
tism of the right shoulder-joint, which was said to have lasted 
several weeks, and to be very painful. There was excessive 
sensitiveness to the slightest touch, and some swelling. But it 
struck me that, since the commencement of the attack, neither 
the heart nor another joint were affected, that there was no 
fever, that deep pressure produced no more pain than super- 
ficial touch; that the pain extended as well over the thoracicus 
longus as the shoulder and upper arm; and finally, that the 
swelling was not exactly in the shoulder-joint, but above; 
nearer to, and to the rear of, the acromial end of the scapula. 
Thus my diagnosis was secured. I had to deal with a neuralgia 
of the cervical plexus, and not with “rheumatism.” 
In the same lecture from which I have just quoted, I alluded 
to the case of a boy of eight years, who had contracted a slight 
mitral incompetency while suffering from chorea, years 
previously. A year and a half ago he was attacked with 
rheumatism of both wrists, knees and ankle joints. A number 
of joints of the foot also took part in the process. There was 
moderate fever and distinct swelling of wrists, knees, and 
ankles. After some weeks his fever was gone, and the swelling 
very moderate indeed. Still, his complaints grew no less. He 
was taken with sudden attacks of excessive pain, which gave' 
rise to screams and yells commencing about dark and continuing 
all night; was very sensitive, even in day-time, to the slightest 
touch, and exhibited such a disproportion between his objective 
and subjective symptoms that my suspicion was directed to 
IA. Jacobi, “ Acute Rheumatism in Infancy and Childhood,” p. 38. A series 
of American Clinical Lectures, edited by E. 0. oeguin, M.D., Yol. 1., No. 
ii. p. 53* 16 
Jacobi : On Masturbation and 
other quarters than before. Then I recollected, that in periods 
of great mental anxiety, his father, many years ago, suffered 
from very severe and well-pronounced attacks of “hysterical” 
convulsions, and that his mother, a refined, intellectual, and 
neurotic woman, while subject to chronic oophoritis, had been 
disturbed by neuroses of both peripheric (mostly neuralgic) 
and cerebral character. My young patient had no more fever 
for some time, there was hardly any articular swelling left; he 
was quite comfortable at certain times, screamed fearfully 
—without tears—on the slightest touch on certain points, and 
became quiet, often, under protracted and deep pressure, 
particularly when his attention was diverted. The pain was 
not confined to the points most sensitive in sciatica, in fact 
there was no pain about the leg, joint, or the sciatic notch. A 
number of cutaneous branches of the crural nerves were 
affected, as also the ramifications spreading to the synovial 
membrane. At the same time, neither heart nor spinal cord 
participated in the process. If the original inflammation of the 
joint had anything to do with it, it had but been the source of 
irritation (in this case, perhaps, by a contiguous neuritic pro- 
cess ?) in the sensitive nerves of both synovial membranes and 
skin. When, in accordance with the diagnosis of neurosis 
(neuralgia only, no vaso-motor complication being present) the 
treatment was changed to iron, galvanism, roborant diet, and 
warm bathing, the condition improved. But it took several 
months’ absence from the city, and persistent exercise in a more 
genial climate, before recovery was complete. 
The pxeumogastkic neeve is frequently the seat of both irrita- 
tive and paralytic neuroses in the adult. Of these, aphonia, so 
common in the “hysteria” of advanced years, I have never seen 
in the child. But the “ hysterical ” cough has often become a 
subject of observation. The first case I remember to have 
noticed sixteen years ago in dispensary practice. The patient 
was a boy of six years. A loud, hoarse, abrupt cough announced 
his entrance into the building; the absence of any change upon 
the mucous membrane of both the pharynx and larynx pointed to 
a neurotic origin of the affection. He never coughed in his 
sleep, but incessantly during the day, with but very short inter- 
missions., Frequently his shoulders and the muscles of his face 
would participate in the convulsive process, with twitchings “Hysteria ” in Young Children. 
17 
and contortions. He had suffered for two months, and two 
more months of permanent treatment with arsenic and atropia 
—the galvanic current forming no part in my therapeutical 
resources at that early time—were required before a gradual 
improvement took place. Some years ago I observed the same 
neurotic cough in two children of the same family, one a boy 
of six, the other one of four years. It was most developed in 
the former. First, I was inclined to accuse the hypersemic con- 
dition of the pharynx as the cause of the cough, the more so as 
the tonsils were congenitally enlarged, and had repeatedly been 
the seat of catarrhal and erysipelatous inflammation. But a 
successful local treatment of these affections had but a partial 
effect upon the cough. Protracted attacks would follow each 
other, and were but little influenced by sedative and roborant 
treatment. Hot before the child was detected as being given to 
excessive masturbation, and the habit finally suppressed, did the 
treatment directed against the neurosis prove effective. In 
the younger patient masturbation was not detected; his cough, 
however, was less pronounced and obstinate. Evidently 
nervous irritability and imitation had a great deal to do with 
the affection in his case. It has struck me as singular, in my 
experience, that the large majority of these pnenmogastric 
neuroses took place in' male children, while the same affection 
when found in adolescent or adult age, was mostly found in the 
female. 
Paralytic and paretic conditions of simply neurotic charac- 
ter are not very frequent in the young. The large majority 
of cases require the searching for a local, mostly central, 
origin. Still, neurotic paralysis will occur. A girl of nine 
years, coming home from school some afternoon, fell in front of 
her residence with an attack of general clonic convulsions. She 
was carried up stairs, the convulsion subsided, and a local para- 
lysis took its place. Hearly the whole of the right motor 
oculi was paralyzed, the muse, obliquus superior alone being 
intact. Ptosis was complete, the right eye deviated outwards, 
the pupil was somewhat dilated, but responded to the light 
slowly. On the left side the rectus interims muscle was intact, 
and the pupillar branch was a little affected. The tongue de- 
viated to the right. In this condition the child remained for 
weeks, until she gradually improved. After having been con- 
-2 18 
Jacobi : On Masturbation and 
sidered well for some time, another attack of general convul- 
sions took place, and was again followed by the same symp- 
toms, A number of weeks afterward she was presented to me 
with the above symptoms, exhibiting in addition the expres- 
sion of general anaemia, and complaining of occasional head- 
aches, After convincing myself of the absence of a central 
cause, and excluding everything except a merely functional 
disturbance, I promised to relieve her at once in such a manner 
that she was firmly impressed with the certainty of success. 
I pressed my thumb firmly upon her supraorbital nerve, and 
commanded her to open her eye. Her ptosis was instantly 
removed. She remained well for several weeks, when again 
she exhibited the same symptoms (this time without previous 
convulsions), and was relieved in the same manner. Mean- 
while, a general roborant treatment was resorted to, with the 
final result of a favorable report concerning her permanent 
condition. 
Another form of paralysis, of evidently neurotic character, 
resembles very much the spinal paralysis of the young, the so- 
called essential or infantile paralysis. It is apt to appear quite 
suddenly, and although not differing much from the latter in its 
symptoms, is more promising in its termination. It appears to 
result from a change in circulation of the spinal cord only; 
and such cases as have been observed, appear to point to the 
anterior horns as the principal seat of the affection. For sen- 
sation is generally less affected than motion. Hor is the effect 
of the affection so great as in myelitis or meningo-myelitis. 
For neither rectum nor bladder are affected as in general de- 
generative processes of the nerve centre, or in affections of the 
posterior horns only. Such affections bear a great similarity to 
what is known to take place sometimes after dysentery, typhoid 
fever, variola, or other serious infectious diseases. Subsequent 
paralyses have been claimed to be “ functional,” because, fre- 
quently, a number of symptoms which would result from uni- 
versal disease of the spinal cord, are absent, with what 
justice, is hardly our province here to go into. Still we can 
point to the fact that, with the same reason, essential paralysis 
might be claimed as functional. In fact, so we did, before 
we knew better ; the name of “ dental paralysis ” given to the 
“ essential,” speaks volumes for medical naivete. A very few “Hysteria ” in Young Children. 
19 
cases of paraplegia in the adult, depending upon blood-vessel 
dilatation only, have been reported in the journals in the 
course of the last few years. They all refer to adults. Two 
cases, which first drew my attention to this class of paralysis, 
also occurred in adults. One was a young man of twenty odd 
years, who came with a recently and suddenly developed para- 
plegia to the German Hospital. His upper extremities were 
normal, his lower extremities heavy, paretic. Walking was 
almost impossible, the patient not being able to raise his feet 
from the ground. Sensation was but little affected, the sphinc- 
ters active. Masturbation was freely admitted. JSTo previous 
disease accused. Temperature was slightly raised, pressure 
on the lumbar portions of vertebral column but little painful. 
In his case I excluded a deep lesion of the spinal cord, and 
thought I ought to trace the affection to a momentary change 
in the circulation of the spinal cord or the meninges, anteri- 
orly. In regard to that, it would make no difference in the 
facts (but perhaps in the indications for treatment) whether 
the cause of the dilatation of blood-vessels is sought in a para- 
lysis of sympathetic fibres; or whether, as Goltz has it, the dila- 
tation takes place through the action of spinal, vessel-dilating 
nerves, which come from the spinal cord and can be called 
into action by reflex, from other centripetal fibres. According 
to the diagnosis, galvanism and ergotin were freely used. The 
effect was remarkable, inasmuch as improvement took place 
soon, and recovery within a few months. 
A second case was in the same hospital for some time when 
the other was admitted. The patient had been paralyzed some 
months before he was admitted. He had been in the ward 
before his condition was recognized as similar to the other 
patient, who came in with the affection recently started. The 
same treatment was resorted to, with marked benefit, though 
slower result. 
The following is a case of neurosis, with its centre about the 
lower portion of the spinal column, in which the symptoms of 
both paresis and increased irritability were well-marked and 
coexisting. The former predominated, however. I look upon 
it as a case of vaso-motor neurosis (paralysis) with blood-vessel 
dilatation, the frequent changes being due to the very fact that 
the affection of the sympathetic nerve did not produce an 20 
Jacobi : On Masturbation and 
anatomic lesion, but a change in the haemostatic and nutritive 
conditions. In point of fact, neuroses of the vaso-motor nerves 
are frequent in the young. It is hut just that it should be so ; 
for the physiological and pathological action of the sympa- 
thetic nervous system ought to go hand in hand with their 
early development. In embryonic life, the cells of the sympa- 
thetic nervous system develop prior to those of the cerebro- 
spinal system. Those enclosed in the nerve centres are earlier 
than those in the outlying organs. Those in the spinal 
cord precede those in the cerebrum. Those in the anterior 
horns are earlier than those in the other parts of the cord. 
In other words, the centres for circulation (and motion) pre- 
cede the development of other centres. Let us add to these 
statements the fact that the nervous system is heavier, more 
extensive in proportion to the weight of the whole body, 
and the physiological necessity of greater irritability and 
nervous vulnerability in the young requires no further illustra- 
tion. 
Mary L. M. was lOf years old in February, 1874, when her 
mother wrote as follows : “ She began complaining some three 
or four years ago of stomach-ache, which at first we treated 
with home remedies, thinking it of little importance. When the 
pain increased, so as to torture her constantly, Dr. M. treated 
her a long time, but without success; and, at his advice, Dr. C. 
used electricity (electro-magnetism), very successfully. For 
about six or eight months she was quite well. Then the old 
difficulty returned, in the form of nausea, from which she has 
suffered almost constantly for a year and a half at least. Dur- 
ing this time various remedies were used; she was removed 
from school, her diet and bowels were carefully watched. 
During the summer months, (1872) she was always in the coun- 
try ; and, last winter, (1872-1873), she was also sent off for a 
change. Electricity was again used, then galvanism, but un- 
successfully. In the middle of August, (1873) while in the 
country, she wras taken with typhoid fever. During the fever 
she had no nausea; but as she convalesced it returned. Still, 
after some time, say for two or three weeks, she was apparently 
well. She was out again in mild weather during December, 
(1873) and January, (1874), taking exercise on a velocipede. 
Some over-fatigue caused its return, and some ten days ago she “Hysteria ” in Young Children. 
21 
was, in the night, taken with a general convulsion. Since then 
she has kept her bed, being constantly nauseated and very 
weak.” 
In February, 1871,1 saw her. Her “weakness” was almost 
complete paraplegia. In fact, she had not left her bed for a 
fortnight, and her condition was not appreciated at all. She 
could move her whole extremities with a sudden swing, by an 
effort of her trunk, but neither the muscles of the thighs nor 
legs responded to the will, if will she had. There was some 
slight movement, however, of the toes. Eeflex motility was 
but inconsiderable. Sensibility was not always disturbed. 
Sometimes both extremities, sometimes one, were hypersesthe- 
tic; sometimes only certain, not always the same, territories. 
How and then anaesthesia set in, but never over a large surface. 
Such anaesthetic surfaces, sometimes the size of a hand, some- 
times larger or smaller, felt cold to the touch, and were fre- 
quently pale. Hot always, however, would coldness of the 
surface and anaesthesia correspond. Sometimes, side by side 
with the cold or pale surface there was a circumscribed red spot, 
of the size of some square inches, to that of the hand, or larger, 
thoroughly hyperaemic. Such hyperaemia could, besides, be eas- 
ily produced by gentle friction. When so produced, it would 
remain six or eight minutes, and gradually disappear. Fre- 
quently the whole limbs were bathed in perspiration, alternating 
with dry coolness. The perspiring surfaces felt usually cold, 
not always with a change in the natural color. Pressure over 
the limbs resulted in but moderate pain. Pressure over the 
spinous processes was but little painful, somewhat more so 
about half an inch each side of the median line, about the lower 
dorsal and upper lumbar vertebrae. Even this symptom, how- 
ever, was not constant. There was moderate constipation, never 
a difficulty in emptying her bladder, the urine pale, some- 
times copious and limpid. Temperature always normal, with 
the exception of the times of excessive perspiration, when it 
would fall below the normal. Other morbid symptoms were but 
rare. There was an occasional slight cough. The internal viscera 
were all in a normal condition. The child looked pale but not 
emaciate, was cheerful though whimsical, and appeared to 
enjoy her rest and the trouble she gave her attendants to a 
moderate degree. Jacobi; On Masturbation and 
Of diagnostic importance were tire small number of tangible 
changes in proportion to the large number of symptoms, fre- 
quent alternations amongst the latter, the trifling and but occa- 
sional pain near the median vertebral line, the intact condition 
of the sphincter, and the absence of temperature elevations. 
The latter is particularly important. Changes in temperature 
are, in diseases of the nerve centres, mostly not in proportion 
to the dignity of the case. Destructive processes may run their 
full course without much fever. Therefore, the most careful 
observation is required to secure a differential diagnosis. And 
still, in many cases, the height of temperature, a difference of 
one or two degrees, is the only diagnostic sign between an “ or- 
ganic ” (inflammatory, nutritive) and a functional or peripheric 
disease. Many a time have I secured a diagnosis by repeated 
measurements only, having no other guide. For obtaining 
correctness, the rectum alone, with its uniform temperature (at 
least in children, foecal accumulations in the adult rectum per- 
mitting of possible mistakes) yields a positive result, which, as 
the difference to be found is probably but trifling in figure, 
though important in meaning, is urgently needed. For that 
reason I always measure the temperatures in the rectum, in 
questionable diseases of the nerve centres. Many a case of 
encephalitis or myelitis owed its diagnosis to the persistent eleva- 
tion of perhaps one-half to one or two degrees. 
Thus I fastened my diagnosis on a changed circulation rather 
than a nutritive alteration in the spinal cord, and took all of 
the symptoms for the result of a vaso-motor neurosis, on which 
partly temporary, partly obstinate dilatation of the blood-ves- 
sels were thought to be dependent. In consequence, the only 
treatment consisted, with trifling additions of occasional stimu- 
lants and nervina, in the administration of ergot, and the use of 
the galvanic, either ascending and descending spinal, or the 
peripheric current. Improvement began soon after the com- 
mencement of this course of treatment; it progressed steadily 
for months, until the child wTas out of bed and about. She was 
afterwards, without any further medical treatment, taken to 
Europe, and reports of a complete recovery were soon sent. She 
has been well since. 
A boy of fourteen years was seen by me, two years ago, 
with Dr. Arcularius. His upper extremities were in a normal “Hysteria ” in Young Children. 
23 
condition, his lower ones paretic, and moved with a swing by 
an effort of his trunk, but he could stand when supported, both 
with open and closed eyes. His skin felt dry, was slightly 
anaesthetic, no neuralgia anywhere. His urine was normal, 
contained no albumen. His sphincters were active. No pain 
on pressure over his vertebral column. No increase of tempera- 
ture. The history yielded a report of many years of assiduous 
masturbation. The diagnosis was the same as above, and a 
similar treatment adopted. Of the result I am not informed, 
as I did not see the patient afterwards, and the attending 
physician has since died. 
A case of G raves’ (BasedowT’s) disease has lately been pub- 
lished by Fr. Chvostek (Oester. Jahrb.f. Pddiatrik, vi. 1875, p. 
51.) It occurred in a girl of twelve years. This affection is 
but rare in children. Beside his own, Chvostek collected only 
four additional cases, one of Trousseau in a boy of fourteen, 
Solbrig in one of eight, Rosenberg in a girl of seven, Dusch in 
a child of between the third and fourth year. Thus, I have 
every reason to feel very much satisfied at having seen three 
cases in children myself. 
Mary S., Bolton, Lake George, came under my observation 
in the summer of 1871, during my residence in the neighbor- 
hood of that village. She was then ten years old, and had 
suffered from her symptoms “ for years.” She was of average 
size, well developed, pale, intellectual; a good scholar, a poor 
eater. Now and then her face or her feet would swell. The 
functions of her rectum and bladder were normal. She com- 
plained of great weakness, could not walk without an effort, 
the heart would beat violently, and dyspnoea set in on slight 
exertion. The dulness over her heart was too extensive by 
one half, the shock perceptible to both hand and eye from the 
third to the sixth intercostal spaces. A loud systolic murmur 
was audible all over the chest, covering the diastole. It was 
of ecpial strength over mitral and aortic regions, and extended 
into the carotids. The radial pulse was feebler than normal. 
There was no history of any disease except malaria ; no rheu- 
matism. No swelling of the neck, no affection of the eye was 
noticed at that one visit she paid me ; at all events, it must 
have been very slight, if it was present at all. Lungs were 
normal; nor could anything abnormal be discovered in her 24 
Jacobi : On Masturbation and 
abdominal viscera. Under the circumstances my diagnosis was 
that of a genera] chronic endocarditis, and the prognosis a 
very grave one. For a long time, during the following autumn 
and winter, she took iron and digitaline, and followed such 
dietetic rules as I saw fit to give. She called upon me again 
the day I left that part of the country, in the early part of 
September, 1875. To my astonishment she was better to all 
appearances in her general health than the previous year. She 
could walk better, and her appetite had improved. The local 
symptoms were the same everywhere. The size of the heart 
was perhaps a little less ; the murmur as loud and extensive as 
last year. Besides, I noticed at once a slight protrusion and 
immobility of her eyeballs, a staring look, and somewhat 
swelled lower eyelids, and a considerable goitre. The diag- 
nosis was changed into that of Graves5 disease, and the prog- 
nosis corrected accordingly. Three months she took tinct. 
ferri and digitalis, regularly, and when in January, 1876, I 
received her news, they were favorable. 
Dr. Moller, of West 37th street, introduced to me a little 
patient of nine years, Louisa W., whom he had attended for 
several months, about six months ago. When presented to me 
she was greatly improved already. Still she was anaemic, and 
of small stature; smart, and a good scholar. The contractions 
of her heart were both visible and palpable over three inter- 
costal spaces, the pulsations of both carotids unusually distinct. 
The systolic murmur was strong, and audible over the whole 
chest, both anteriorly and posteriorly. Her eyes did not pro- 
trude. The thyroid gland was slightly swollen on the left 
side; very much so, and protruding, on the right. It was not 
the first time, however, that I noticed a unilateral swelling of 
the thyroid gland in Graves5 disease. She had steadily im- 
proved under the use of iron and digitaline (gr. l-10th daily) 
and quinia, and roborant diet, and thus the treatment was 
continued. When I saw her four months afterwards, her 
general appearance was about normal—still the child was 
small—her eyes did not protrude, her goitre was not visible to 
the left of the median line, and less marked than formerly, on 
the right; her heart5s action was less impetuous, and the 
murmur less loud and less extensive. Of her complete 
recovery I entertained no doubt. “Hysteria'1'1 in Young Children. 
25 
The third case is an exact counterpart of the one just men- 
tioned. She was a patient of the clinic, and its records con- 
tain the few notes which were taken at her two visits. She 
was nine years, of average size, not remarkably anaemic. Heart 
loud and impetuous, systolic murmurs very strong and exten- 
sive, eyes not protruding, the right lobe of the thyroid consider- 
ably, the left hut slightly swelled. Nothing was known about 
a previous disease, nor was any discoverable at the time of our 
examination. A similar treatment was resorted to, with 
what effect we had no means to ascertain since. 
The neurotic origin of many skin diseases is established 
beyond doubt. Amongst them we count herpes zoster and 
urticaria. To the same class belongs pemphigus, in its rare 
acute form, with its hundreds of vesicles or bullae filled .with a 
thin alkaline fluid and surrounded by a red circle. Ido not here 
allude to that form which is frequently seen upon the surface 
of the new-born; viz., a few bullae spread over the whole body, 
and then of an innocent character; or on the palms of the hands 
or the soles of the feet, and then mostly of syphilitic origin. I 
allude only to that form, the existence of which is doubted by 
such an experienced observer as Hebra, who asserts never to 
have seen a case amongst a million of patients. 
More than a year ago I was called to see a patient of Dr. 
Chabert’s, in Hoboken. The little girl, four years old, was 
taken sick with a moderate fever, and exhibited a general 
redness of the whole surface the next day. On the third day 
the redness appeared in circumscribed territories, which were 
elevated, leaving between them portions of the skin of a more 
normal character. Although no symptoms belonging to the 
respiratory organs made their appearance, measles were sus- 
pected. On the fourth day a large number of the elevated 
territories exhibited a serous effusion raising the epidermis, the 
vesicles ranging between the sizes of a pin’s head and that of a 
coffee bean. Accordingly, the diagnosis was changed into 
that of pemphigus. On the next day, the number of small 
vesicles was very limited, every one of them increased in size, 
and a number of them broke, either spontaneously, or in con- 
sequence of moving or scratching. On the evening of the sixth 
day I saw the child. She then had a temperature (rectal) of 
103°, a pulse of 160, and a proportionate numberof respirations Jacobi : On Masturbation and 
(44 to 46). She was on her back, moaning, delirious, wrapped in 
cotton, not an inch of the surface was normal. The epidermis 
was partly lost, in consequence of the effusions underneath, 
which were very copious, and the thrown-off integumeuts were 
washed or scratched off. In some places a number of bullse 
were still intact, thus on the scalp ; on others, square inches of 
surface were entirely denuded of epidermis; even hands and 
feet were raw and sore. Hot before the following day did the 
sufferings of the child terminate with her death. 
I could not but consider the sudden outbreaks of this pe- 
culiar form of dermatitis as the result of a neurosis. Was it 
a sudden attack, brought on by some poisonous influence, 
malaria, diphtheria, variola ? There was neither a history of 
any of them in the child, nor in the immediate neighborhood. 
Was it but the final attack of a neurotic disposition in the 
patient, which had exhibited kin, but apparently unlike 
outbreaks before % I learned, on questioning, that the patient, 
now four years old, had suffered from extensive urticaria, 
which had tortured the little sufferer from birth. More than 
half the days of all her life she had been afflicted with this 
scourge. Ho dietetic care, no medical treatment had ever 
relieved or benefited her. Other sickness she never had, how- 
ever. Urticaria, and frequent perspiration, such was the his- 
tory of the infant and child, until she finally succumbed under 
the violent outbreak of the neurosis, which, while formerly 
confining its efforts to the production of local dermatitis of the 
lower strata, wound up with extensive superficial effusion. 
Where did it take its origin ? There was a younger baby, two 
years old, in the family. He had “ hives,” but by no means 
so much, or so often, as the girl. The mother was free. The 
father was a sufferer from urticaria, almost constantly, for the 
last 1-| years, and found no relief. A younger brother of his 
had been affected with frequent and severe attacks of urticaria 
all his life. 
A similar case, not so severe, because not fatal, has come to 
my notice, through the kindness of Hr. Assenheimer. The 
little girl is in her third year, had her first outbreak of acute 
pemphigus before she was a year old. The eruption was mostly 
spread over back, chest and abdomen, also over the thighs. 
Frequently, large portions of the surface were denuded of its “Hysteria” in Young Children. 
27 
epidermis, the effusion being so copious, that the epidermis was 
washed off before scabs could form. When I saw her, the 
affection had lasted several months. Looking upon it as a vaso- 
motor neurosis, with dilatation of the blood-vessels and consecu- 
tive effusion, I advised—beside general attendance to the health 
of the child—the constant administration of quinine and ergotin. 
This treatment was followed bj a speedy success, blot only 
did the bulke dry up rapidly, but their reappearance ceased, 
and the patient did well for some time. After the treatment 
had been discontinued, a return took place. A few weeks ago 
I have again seen the patient, covered with pemphigus, less 
violent and extensive, but still with its old character and local 
severity. 
The following is a case in which the neurotic symptoms 
were less localized: 
Alice K. (patient of Dr. Guleke’s), thirteen years old, not 
menstruated, was a bright and vigorous child, ambitious and 
studious. On the fourth of January, 1876, after a good night, 
she was taken with nausea and delirium, and two hours after- 
wards with general and bilateral convulsions, and loss of con- 
sciousness. During the attack the pupils were equal, somewhat 
dilated, but little responding to light. The tongue was bitten. 
In short intervals the convulsions returned for three or four 
hours, when finally they ceased, after the free inhalation of 
chloroform and the administration of turpentine injections. 
Soon after the convulsions, the urine contained albumen in 
small quantities; it disappeared next day, never to return. 
Temperature 102. Pulse not very frequent, could be estima- 
ted only during the attack. On the evening of the same day 
consciousness was somewhat restored. Pulse and temperature 
as above. On the next day the temperature remained the 
same; pulse became slower, sank gradually to 60, and was 
once observed to be but 48. Some (3d to sth) Cervical verte- 
brae became painful, after a while, on pressure. The child 
grew irritable, insisted on getting out of bed, to school, to the 
piano. Application of ice to the head, and the administration of 
chloral hydrate with bromide of potassium brought some re- 
lief. Temperature in rectum sank to 100°, and remained abso- 
lutely normal after a short time. Bromide of potassium was 
ordered, but irregularly taken. About the end of February 28 
Jacobi : On Masturbation and 
vomiting set in, not preceded by nausea or retching. Sleep 
was not good. The child grew more and more pale and irrita- 
ble, disobedient, unmanageable, obstinate, with frequent local 
flushes about the face. Such was the condition in the middle 
of March, when I saw her. The slight elevation of tempera- 
ture in the beginning, the vomiting, and perhaps also the slow, 
(not irregular) pulse at a certain period of the affection gave 
ns the impression that possibly the process was one of irrita- 
tion of the brain, perhaps produced by the presence of a 
tumor. The administration of bromide and iodide of potas- 
sium was advised. Three weeks afterwards the report was 
tolerably favorable. No new brain symptoms had developed. 
Pulse about 80, regular. Respiration normal. No sighing. 
No more vomiting. Temperature normal, with a difference 
between morning and evening of three-fifths of a degree. 
The emotional disturbances the same, perhaps worse. The 
child irritable, peevish, disobedient, with occasional unex- 
plained or unprovoked circumscribed flushes about face and 
forehead. The sphincters acted normally through the wdiole 
time. I allow that the case admits of doubts concerning the 
diagnosis. But the principal reason for the diagnosis of a 
functional disturbance is certainly present, viz,, the absence of 
symptoms necessitating the diagnosis of an anatomical lesion. 
Besides, the functional anomalies attending a general neurosis 
are so manifold and various, that I believe the case is not very 
doubtful. The very slight increase in temperature, in the be- 
ginning of the whole process, may be the accidental result 
only of a complication; or it may, like the slight albuminuria, 
depend on the circulatory stagnation attending and following 
the convulsion. If lam not greatly mistaken, the case is one 
of bona fide “ hysteria.” Morever, momentaneous increases in 
temperature may be found when circulation is disturbed. Local 
hyperaemia from a neurotic cause will raise the temperature. 
Even chronic nutritive diseases of originally the same character 
will admit changes of heat. Thus even in a few cases of uni- 
lateral hypertrophy (mostly described by Friedberg, Trelat, 
and Monod) an increase of from half a degree to two degrees 
has been observed from time to time. 
After all, then, the neurotic impressibility known by the gen- 
eral term of “ hysteria,” which is still considered by many as “Hysteria ” in Young Children. 
29 
an attribute of the adolescent or adult female, is not confined 
to either the adult or the female. It is true that, in regard to 
the male sex, the term of hypochondriasis is preferred to that 
of hysteria, in those cases in which we have to deal with certain 
general, either moral or emotional, disturbances; but the 
recognized forms of “ hysteria,” such as laughing and crying 
spells, and convulsions, under the ordinary circumstances be- 
lieved to form or cause, and usher in, hysterical attacks, are by 
no means unheard of amongst men. I have above alluded to 
the case of a gentleman, about thirty years old, who was always of 
a rather nervous temperament. While under constant mental 
strain, brought on by a chronic ailment of his eyes, which he was 
told would necessitate the removal of one of his eyes, he suffered 
from very frequent and intense hysterical convulsions, which re- 
turned for years, until the operation was performed ; and after' 
the moral shock attending the prospect of the operation and 
the operation itself was overcome, his attacks became more and 
more rare. Another male patient of mine, fifty-four years old, 
has frequent attacks of “nervousness,” trembling, weakness 
about the “ stomach,” globus, and dizziness, which are always 
followed by the frequent and copious elimination of a limpid 
urine, for hours. The disease is more frequent in females, it 
is true. In them it has long been attributed—as its name 
shows—to some affection of the sexual organs. But it is an ac- 
knowledged fact, that it does not result from their acute affec- 
tions, which ought to be expected to work more serious changes 
than chronic ones. On the other hand, many a case of “ hyste- 
ria” is certainly not complicated with a demonstrable disease of 
the genital organs. In thirty-four cases of “ hysteria” reported by 
Bernutz, nineteen were free of such complications ; and finally, 
such cases as have been reported by Grisolle, and Castiaux, 
{Gaz. hdp. 1853,1873,) prove that “ hysteria ” occurred with en- 
tire absence of both uterus and ovaries; not to speak of 
Charcot’s case, in which a sclerosis of the lateral columns of the 
spinal cord formed the only etiological element. 
Statistical reports prove further, that “ hysteria ” is found be- 
fore either adolesence or adult age. Briquet states that twenty 
per cent, of his cases occurred in “ children; ” Amann collected 
sixteen of from eight to fifteen years in a total of two hundred 
and sixty-eight; Althaus, seventy-one out of eight hundred and 30 
Jacobi : On Masturbation and 
twenty below ten; Landouzy, forty-eight from tire tenth to the 
fifteenth year, ont of three hundred and fifty-one; Scanzoni, 
ont of two hundred and seventeen, four below ten, and thir- 
teen between ten and fifteen. 
If the preceding statements prove anything, they demonstrate 
that the symptoms of “ hysteria ”—no matter whether they be- 
long to motor or sensitive, sensorial or vaso-motor nerves— 
are found in all ages. This does not mean, however, that child- 
ren will exhibit, as a rule, a number or all of the disturbances 
met with in the adult, or female, at the same time. In the ma- 
jority of cases the neurosis is but local or circumscribed; but, 
when closely studied, of the well-known neurotic character. 
Now, if my readers should, after perusing these pages, come to 
the conclusion that the term of “hysteria” is an improper one, 
I shall be far from dissatisfied. It is but just that our nomen- 
clature should gradually get rid of a number of terms which 
have but a clinical meaning of moderate convenience, and that 
we should substitute in their places anatomical and physiologi- 
cal diagnoses. 
APPENDIX. 
The following case of masturbation in an infant was com- 
municated to me by J. B. A,, M.D. 
April Ist, 1876. 
De. A. Jacobi. 
My Dear Doctor:—l have delayed writing, that 1 might 
give you the result of treatment in the case of our little one, 
and also the history of the case, as promised. This 1 inclose, 
and hope it may prove of interest. The case is virtually ended, 
as she has not had a complete attack since we saw you, and 
adopted the measures suggested. Occasionally, while being 
held, she stiffens the limbs, but a separation of the thighs at 
once puts a stop to it all. She seems perfectly well, is eating 
and sleeping well, has gained in strength, and flesh, and color, 
and Ido not see how she could be better. The constipation is 
entirely overcome by the change in diet. There is no evidence 
of any trouble with the kidneys or bladder. For a few weeks “Hysteria ” in Young Children. 
31 
we gave the cod-oil emulsion with the hypophosphites, but now 
she is not taking anything. I am very truly yours, 
J. B. A. 
CASE. 
During the first nine months the child was perfectly healthy, 
and did not suffer from any of the ailments common to in- 
fancy. At this age teething commenced. It was not accom- 
panied by pain or any constitutional disturbance, and has not 
been during: the cutting; of the nine teeth she now has at four- 
teen months. The first indications of nervous trouble were 
noticed about this time. They were very slight and occurred 
while the child was lying in its mother’s lap. She suddenly 
became pale, had a peculiar dazed expression, and her atten- 
tion could not readily be attracted. On being raised up and 
moved, she immediately became natural in looks and action. 
This was repeated a few times only, when the attacks changed 
in character. In addition to the appearance of the counte- 
nance already described, there was much muscular rigidity; 
the arms became quite stiff and strongly resisted being flexed, 
and the hands were clenched and the little fists firmly pressed 
into the iliac region on either side. At the same time the legs 
were strongly extended at right angles to the body, and there 
was a strong contraction of the abdominal muscles, and a 
straining as if at stool. If the child was held against one’s 
breast she made strong pressure with the knees, and up and 
down movements of the body. After a short period, a mo- 
ment or two, the respirations were quickened to a rapid pant- 
ing, and perspiration started freely from the head and stood 
in drops about the mouth. The attacks often terminated in 
sleep. There was at no time any spasmodic or convulsive 
movement, or unconsciousness, or mental disturbance beyond 
an apparent abstraction. 
The attacks came on irregularly; at times with intervals of 
some days, and, again, they were repeated many times a day, 
for several days in succession, and sometimes for two or three 
hours with but slight intermission. They never came on dur- 
ing sleep, but usually when the child was sitting on the lap, 
and occasionally when on the bed or floor. If she was placed 
on the floor early in the attack, and amused with her play- 32 
Jacobi: On Masturbation, etc., in Children. 
things, it would frequently be broken up; if, however, she was 
held till it was fully developed, and then put down, she would 
lie upon her side, and the attack would progress as described. 
During the whole period she suffered much from constipa- 
tion and from successive attacks of bronchitis, which reduced 
her flesh and strength. For some weeks the bowels were moved 
only by injections or medicines. During this period, the ner- 
vous attacks were more frequent and severe. The condition 
of the child attracted the attention of all who saw her while 
suffering thus ; and, of course, each one had a theory concerning 
the nature and cause of the attacks. By some they wrere at- 
tributed to the state of the bowels, but by far the greater 
number to the presence of worms. To exclude the possibility 
of this theory, santonin was given, without, however, pro- 
ducing any result. Some physicians considered the attacks of 
serious import, and urged the use of the bromides, and, though 
none expressed the opinion that they were of an epileptiform 
character, the inference was plainly to be deduced. 
On watching the child closely, the conviction was forced 
upon my own mind that the power of habit was a strong ele- 
ment in the case, and I entertained the belief that, by im- 
proving the general health, and correcting the tendency to 
constipation, recovery would ensue. To this end she was 
given cod-oil emulsion and laxatives.1 
It was at this time, and when the child was thirteen months 
old, that you saw her. Upon the adoption of your advice there 
was a wonderful change. The mother fully carried out your 
suggestions to separate the thighs, to remove the hands, and 
to amuse and attract the attention of the child. The habit 
was to be broken up at all hazards. Care and watchfulness 
have been crowned with complete success, and there is now 
scarcely a tendency toward the habit perceptible. A change 
of diet, in substituting for milk, a variety of food and of fruit, 
has corrected the condition of the bowels, and cod-oil emul- 
sion, with the hypophosphites, aided by proper hygienic care, 
has improved the general health, and the child is now in 
good flesh and strength, well and happy. 
1 At the time of the infant’s visit in New York, there was also a marked 
amount of mucus in the urine. If it continued, the administration of al- 
kalies was recommended.