A Consideration of the Pareesthetic 
Neurosis. 
HY 
JOSEPH COLLINS, M. D., 
NEW YORK, 
Instructor of Nervous Diseases in the New York Post-Graduate 
Medical School ; Neurologist to the Demilt Dispensary ; 
Physician to the Hospital for Nervous Diseases. 
Reprinted from the Bostoji Medical and Surgical Journal 
of September 14, 1893. 
BOSTON: 
DAMRELL & UPHAM, PUBLISHERS, 
No. 283 Washington Street. 
1893. S. J- PARKHILL & CO., PRINTERS 
BOSTON A CONSIDERATION OF THE PARESTHETIC 
NEUROSIS.1 
BY JOSEPH COLLINS, M.D., NEW YORK, 
Instructor of Nervous Diseases in the New York Post-Graduate 
Medical School; Neurologist to the Demilt Dispensary, etc. 
Some two years ago, while attending the meeting of 
the Southwest German Neurological Society at Baden- 
Baden, my attention was attracted to a paper read by 
Dr. Leopold Laquer, entitled, “ A Special Form of 
Paraesthesia of the Extremities.” I remembered that 
we had seen a number of such cases in the clinic at the 
Post-Graduate School, and determined on my return 
to make a study of them with a view to their classi- 
fication. 
The paper which I present to you this evening is 
based on an analysis of forty-three cases in which the 
symptom-complex, hereafter described, was the only 
evidence of illness. I have endeavored to exclude 
from these statistics other cases of acro-neuroses, 
which, while they present some of the symptoms of 
the following cases, have other individual symptoms 
more pronounced, such, for instance, as ignipedites, 
waking palsy, and the like. Before entering into a 
discussion of the details of the form of paraesthesia to 
which I wish to call your attention, I should like in 
the first place to give the clinical history of a single 
case that shows a typical picture of this most distress- 
ing disorder. 
Mrs. L., thirty-nine years old, is married and does 
house-work, including needle-work, washing and scrub- 
1 Read before the New York Neurological Society, June 6,1893. 2 
bing. She was born in Germany, and has a good 
family history. The patient is a stout, stroug, well- 
nourished-looking woman, and gives the following his- 
tory : About five years ago she began to complain 
of “ pins and needles ” sensations in both hands, 
the right worse than the left. This continued, off 
and on, for two years. She was then taken with 
a severe flooding, and since that time the sensations 
have been very much more troublesome. As a rule, 
they come on in the following way: She may go to 
bed quite well, with an entire absence of any sensa- 
tions in the hands, and about four o’clock next 
morning she is awakened with a dumb, sleeping sensa- 
tion, as if electricity was passing through them, or, as 
she expresses it, “ as if her hands had gone to sleep, 
only a hundred times worse.” These sensations per- 
sist after she arises ; and rubbing, using, moving or 
chafing the hands, as is often done to restore the cir- 
culation, gives no relief. The symptoms are somewhat 
ameliorated when she gets up and stands or walks 
about with the hands hanging by the sides. During 
the day, when she works about the house, the paraes- 
thesim are not present; but when she stops and takes 
up sewing or sits quietly or lies down, and particularly 
on the following night, the sensations are very severe. 
In this patient the paraesthesiae never occur in the 
feet. There are no objective symptoms. Her general 
health is good, appetite normal, bowels constipated, 
menstruation regular but excessive ; she has headaches 
occasionally, and gets tired much more easily than 
formerly. 
It will be seen that the clinical picture, in brief, is 
as follows: The sufferers from this affection are in 
fairly good health ; that is, were it not for the paraes- 
thesiae, they would not have occasion to consult a phy- 
sician. The paraesthesiae which they complain of are 3 
made up of gnawing, boring, “ pins and needles ” sen- 
sations in the extremities, particularly the upper, and 
involving the fingers, hands and forearms, often of 
both sides, but not infrequently of only one. These 
sensations are not limited to the distribution of any 
one particular nerve in the extremity, but spread over 
entire segments of a member, such as a hand or fore- 
arm, with equal intensity. There is rarely any pain 
in the sense in which that word is ordinarily used. 
Using the word pain as the antithesis of pleasure, this 
paraethesia furnishes a form of exquisite pain. While 
the paraethesiae lasts and in the interim between at- 
tacks, which is always a variable period, there are no 
fairly constant objective phenomena. Occasionally, 
the circulation of the extremities is evidently some- 
what sluggish. There is absolutely no tenderness on 
pressure over any of the nerves of the part, and no 
perceptible changes of a trophic, motional or degener- 
ative nature. The affection shows itself intermittently 
in paroxysms, and the period of the twenty-four hours 
when an attack is most likely to show itself is from 
four to six in the morning. The perverted' sensations 
at this time become so severe as to awaken the patients 
and put an end to farther rest. Another favorite 
time is a corresponding hour in the afternoon. As a 
rule, however, the attacks in the day-time have a very 
close relationship to the work that the patient has been 
doing. In one subject to this form of paraesthesia an 
attack can almost always be precipitated by doing 
sewing or any other needle-work and by washing or 
scrubbing. There is no loss of sensibility to any form 
of sensorial irritation, nor is there loss of muscular 
strength on testing with the dynamometer. The pa- 
tients complain, however, that the strength of their 
arms is more easily exhausted than formerly, and they 
cannot so easily sustain effort. In some cases the pa- 4 
tients will describe other subjective sensations ; but, 
in the main, they are as I have given them. 
In studying the etiology of this affection, I find that 
the average age of the patients is just above thirty- 
nine years. Of the 43 cases on which this paper is 
based, 35 were women, eight were men. The age 
ranged from twenty-three to fifty-nine. Of the 43 
cases, 26 were in the decade between thirty-five and 
forty-five years. Of the 35 women in the series, seven 
had suffered at some not very remote period either 
from metorrhagia or flooding.2 
I want to emphasize this point somewhat, as it 
seems to have an indirect bearing in the etiology. Of 
the 43 cases, six had suffered previously from rheu- 
matic or gouty pains, and of these three were males. 
In eight of the cases there was evidence of more or 
less anaemia. The most striking factor in the etiology, 
however, is the occupation. Of the 34 females, about 
55 per cent, did either washing or scrubbing, crochet- 
ing or needle-work of some kind. Of the males, one 
was a waiter and dish-washer in a restaurant, another 
was a carpet-stretcher. Of the females, five were 
nursing children, two were pregnant. The time of 
the year in which the paraesthesiae were most trouble- 
some does not seem to be pertinent, and changes in 
the weather have no effect except that these patients 
naturally become, after a time, anything but cheerful, 
and inclement weather adds to their gloom. Neither 
2 Of 183 cases selected from the literature, including our own cases, 
the following etiological hearings are seen : 
Number of females 151, males 32. Average age 40.7 years. 
Number of cases between 15 and 25 ... 19 
“ “ 25 “ 35 . . . 43 
“ “ “ 35 “ 45 . . . 58 
“ “ “ 45 “ 55 . . . 37 
“ “ “ 55 “ 65 . . . 23 
Over 65 2 
Of the 151 females in which the occupation was noted, 39 did scrub- 
bing and washing, 48 did needle-work, and 23 did house-work. In 
two cases only was direct heredity seen to be manifest. 5 
heredity nor neuroses, such as hysteria, neurasthenia, 
etc., can be associated with this form of paraesthesia. 
Schultze has recently stated 8 that the sudden expo- 
sure from heat to cold has a causative influence, but I 
have been unable to find it in my cases, nor have I 
been able to induce the paraesthesia artificially in this 
manner, as will be spoken of later. Regarding dis- 
turbances of digestion being at the bottom of the 
trouble, as has been positively stated by Saunby, I 
must say that the digestive functions were carefully 
studied in many of the more recent cases of this series, 
and rarely was any particular disturbance of it found. 
When alcohol is apparently a causative factor of the 
paraesthesia, it should, I believe, be classified under 
the toxic variety. What relation this form of paraes- 
thesia bears to autotoxaemia and the lithaemic constitu- 
tion is not so easily disposed of. Unquestionably, 
there exists in the minds of many physicians who have 
observed this neurosis some illy-defined ideas as to the 
relationship of lithaemia and this form of paraesthesia ; 
but I gravely doubt if there be any closer relationship 
between it and the lithaemic diathesis, than there is 
between lithaemia and the development of neurasthe- 
nia or some of the vaso motor neuroses. Lithaemia in 
itself is the result of deficient oxidation of proteid 
matters in the blood ; and as the manifestations of this 
form of paraesthesia is through the peripheral blood- 
vessels it is extremely plausible that the paraesthesia 
is not the result of the lithaemia but one of the factors 
on which the lithaemia itself is dependent. We are 
forced to this conclusion by the results of medication 
directed to the lithaemic state alone, which is very 
unsatisfactory. The other haematotoxic conditions of 
gout and rheumatism do not seem to have any causa- 
tive relationship. Bodily fatigue, over-exertion, poor 
3 Deutsche Zeitsch. f. Nervenh., 3d Vol. 6 
nourishment and ventilation, lactation, and in fact any- 
thing that lowers the vigor and health of the body, are 
powerful predisposing factors. The hands are the 
parts affected most frequently. In 43 cases both 
hands were affected alone in more than 50 per cent, 
of the cases; all four extremities in nine cases, and 
one extremity in ten cases. When the paraesthesise 
came in one extremity at a time, I do not mean to say 
that this one part was solely the one affected. The 
following case illustrates how the sensations would 
leave one hand and go to the other. 
Mrs. A., forty-one years old, American, married, 
and does house-work. Personal and family history 
good. She has never had a severe sickness except 
uterine inflammation and metrorrhagia after a miscar- 
riage. For the past four years she has been troubled 
with boring, heavy, “ pins and needles ” sensations in 
the hands, and less in the forearms. She never had 
the sensation in both hands at the same time, but fre- 
quently when it passes away from one hand it appears 
in the other. She noticed this trouble for the first 
time shortly after the miscarriage already mentioned. 
These tingling and dumb, sleeping sensations in her 
hand awaken her early in the morning, and rubbing, 
squeezing and using her hands does not seem to dissi- 
pate the sensations. The greatest relief is obtained by 
wrapping her hands in flannel and applying dry heat. 
The parsesthesim are slightly more troublesome in wet 
weather ; it never affects the lower extremities. If she 
washes to day the painful sensations to-morrow would 
be almost unbearable. She suffers considerably from 
headache. Before concluding what 1 have to say about 
the etiology of this form of paraesthesia, I wish to refer 
again to the possibility that metrorrhagia has more than 
a casual relationship in precipitating this affection and 
iu helping to keep it up after it occurs. Of the 34 7 
women in this series of cases no fewer than 12 gave 
a history of flooding at some time, before or during 
the tenancy of the paraesthesiae. I do not wish to 
be quoted as saying that flooding is the cause of this 
paraesthesia, but that it sometimes appears to be an 
etiological factor. The menopause I do not find to 
stand in close relationship, although the preponderance 
of cases is between thirty-five and forty-five years. 
These patients are not necessarily at the change of 
life, and as a matter of fact most of them are not. 
One of the most aggravating cases that we have had 
to treat at the clinic was that of a lady sixty years old 
who gave a typical history corresponding to the one 
above, except that the paraesthesiae affected all the 
extremities. This patient, notwithstanding her age, 
was menstruating regularly. Two cases (women) 
gave a history of excessive sexual intercourse, but 
with “ withdrawal ” on the part of their husbands. 
This had been practised for some years to avoid con- 
ception. It is admitted by gynaecologists that indul- 
gence in this practice is followed by a condition resem- 
bling sub-involution and metrorrhagia as a natural 
sequence. 
Taking these etiological factors into consideration, 
one is led to the question as to what the probable seat 
of the trouble may be. Nearly every one who has 
written on paraesthesiae has had something to say on 
this point, in which he differed from others. It 
seems to me that we can exclude any trouble in the 
central nervous system and spinal cord. It is scarcely 
necessary for me to enter into details for the basis of 
this statement. 
I am of the opinion that this form of paraesthesiae is 
due to defective innervation in the blood-vessels which 
causes a low degree of blood-pressure and lack of 
proper blood-supply to the terminal branches of the 8 
peripheral sensorial nerves. That is, the vascular 
changes may be secondary to central exhaustion. The 
perception of paraesthesiae is, of course, a central pro- 
cess. It is probable that frequently in the beginning 
this paraesthesia is set up in a predisposed neurotic 
subject, and as a result of the combined influence of 
central cortical over-stimulation (from the reception of 
the peripheral impressions) and the suffering of the pa- 
tient, acts upon ganglionic cells in certain areas of the 
cortex and produces exhaustion. This may be called 
a functional exhaustion similar to that produced and 
observed by Hodge. The causative factors of this form 
of paraesthesia are extremely chronic and remedial meas- 
ures when not associated with rest are rarely benefi- 
cial. While rest, mental and bodily, is frequently fol- 
lowed by great relief, I am therefore inclined to agree 
with Laquer that it may be an exhaustion neurosis. 
On a few of these patients I instituted some experi- 
ments for the purpose of corroborating the opinion 
that vascular changes may start anew the paraes- 
thesiae. If the patient whose history I have detailed 
at the beginning of this paper was made to hold both 
hands above the head, the paraesthesiae would set in 
with such intolerable severity after four minutes that 
she could not keep them in this position. If one hand 
was held above the head and the other by the side, the 
paraesthesiae would come on in the uplifted hand while 
the other hand would remain free. Putnam has no- 
ticed a similar condition in some of his patients. After 
the bands had been elevated for a few minutes and the 
paraesthesiae had appeared and they were then allowed 
to hang down they could be seen to become dusky in 
color and swollen-like, showing that there was more 
or less vascular congestion following a transient anae- 
mia. 
Another patient who had paraesthesiae in the hands 9 
alone, had her hands dipped in water of the ordinary 
temperature, and allowed to remain there for from 
five to ten minutes, with no resulting paraesthesiae. 
But if the hands were first dipped in very hot water 
and then in iced water the tingling sensations would 
come on after a few minutes. If the order was re- 
versed, that is putting one hand in the cold water first 
and the hot water afterwards, the paraesthesiae did not 
seem to occur. 
Another patient, a male, shoemaker, who suffered 
from paraesthesiae in all four extremities, was experi- 
mented on with Fleming’s Tincture of Aconite, a drug 
which in small doses is known to lower blood-pressure 
and produce a lessened amount of blood, particularly 
to the periphery of the body with a high degree of 
certainty. One drop of this tincture was given every 
fifteen minutes to this patient when he was free from 
the paraesthesiae, and almost invariably every time he 
was subjected to this treatment, by the time he had 
received the fourth dose the paraethesiae would occur. 
It was not, I believe, the tingling which is caused 
by the absorption of a considerable amount of aconite 
into the system for two reasons : first, the tingling 
that results from large doses of aconite occurs in all 
parts of the body in the order of their sensitiveness as 
determined by Weber ; and secondly, because in the 
same patient, veratrum viride, a drug which does not 
produce tingling, was followed in its administration by 
similar results to those obtained by aconite. Such ex- 
periments are in no way conclusive, but they are sug- 
gestive as to the probable conditions antecedent to the 
development of the paraesthesiae. The fact that the hour 
out of the twenty-four when these sensations come on 
with considerable certainty is in the early morning, a 
time when the ebb of life is at its lowest tide and the 
blood-pressure registering nearest the base line, is an- 10 
other bit of evidence in favor of the idea that the es- 
sential preceding condition in the development of the 
paraesthesise is a vascular one. That it occurs when 
the patient lies down as. for instance, in the day-time, 
and after use of the parts, as in working, scrubbing or 
needle-work, etc., is not inconsistent with this line of 
thought. 
I cannot agree with some writers on the subject 
who say “ we shall not have to look far for a solution 
of this difficulty. It is evident that we have faulty or 
imperfect actions in some of the more important tis- 
sues or structures of the economy, such as degenera- 
tive changes in the vessels, etc.” From a rather care- 
ful study of the vascular system in these patients with 
the aid of the sphygmograph I must say that it is but 
rarely that I have found any indications of arterial 
degeneration. 
Before saying a word in regard to the treatment 
which has been found most successful with these pa- 
tients I would like to suggest a classification of the 
paraesthesic ueurosis, and illustrate each of the divi- 
sions by citing a typical case. Of course, it will be 
understood that I rigidly exclude the neuralgias, neu- 
ritis, ignipedites, etc. The following classification is 
principally on an etiological basis: 
(1) Emotional. 
(2) Mental. 
(3) Neurasthenic. 
(4) Toxic. 
(5) Waking numbness. 
(6) The one under consideration which may be 
called an occupation paraesthesise, so often is it asso- 
ciated with a certain class of occupations. 
As an example of the first form, I cannot do better 
than to present the notes of a case reported bv Dr. 
Dana. A gentleman forty years old, a cotton-broker, 11 
suffered from almost constant sensations of numbness, 
prickling, etc., of the left arm and hand, extending up 
to the elbow. The symptoms annoyed him to the last 
degree. There was no anaesthesia or objective changes 
in the hand, and the patient wras in good general 
health. He was an excessive smoker, but interdicting 
this and subjecting him to various forms of treatment 
was followed by no benefit. Finally, after some 
months cotton went up and the affection gradually left 
him. 
As a type of the paraesthesiae depending upon a dis- 
ordered mental state the following case of galean- 
thropy or Katzensucht, as it is termed by the Germans, 
may be related. A young woman twenty-seven years 
old, who had inherited marked neurotic taint, her 
mother haviug died of cerebral softening at forty years 
old, one aunt of insanity at thirty-three years old, and 
one great-auut had epilepsy. The patient herself was 
always very nervous when a child. For a considera- 
ble time she had complained of inability to sleep well, 
and in the morning of most distressing sensations ; 
tingling, numb, pinching sensations in the hands and 
forearms, particularly the right, aud in the feet worse 
than in the hands. These sensations persisted most of 
the day, but disappeared toward evening. In addition 
to the paraesthesiae of the extremities she says there is 
an area about as large as the hand above her right 
buttock where the sensations also appear. After suf- 
fering from these paraesthesiae for some time she had a 
transient attack of the mania known as galeanthropy. 
The attack come on in the following way: After 
some very trying domestic infelicities she was left 
alone one day, and was sitting brewing her troubles, 
when she noticed that a picture of the “Father of his 
Country,” hanging on the wall on the opposite side of 
the room, suddenly begau to misbehave in a most re- 12 
markable manner. Then all the other pictures on the 
walls followed this illustrious example. This kept up 
for some time; and then she thought she was being 
transformed into a cat; and after that she acted like 
a cat, walked on all fours, spit and scratched when any 
one came near her, would not let them undress her or 
put her to bed, would eat only off the floor, tried to 
scramble up the bed-post and sides of the room like a 
cat, etc. She imagined she was consorting with other 
felines, and, in fact, gave quite a typical history of 
this form of alienation. After quite a protracted treat- 
ment this patient recovered from her mental affection, 
though she still has the paraesthesiae occasionally. 
The neurasthenic form is really quite common, and 
it is unnecessary to quote a very elaborate history. 
The following case seen in private practice may be 
taken as an example: 
X., a married lady of forty-four years, was bred a 
lady of leisure, but circumstances at present compel 
her to manoeuvre with a small amount of money in- 
vested in a business in order to make a living. As a 
result, she has developed quite a typical neurasthenic 
condition of the cerebral type. She has head-pressure 
and sensations, morbid fears and dread, loss of strength 
and ambition, and, added to this, paraesthesiae of the 
hands and feet, which are extremely distressing. When 
the neurasthenic symptoms have their good days, the 
paraethesiae are forgotten, and the reverse. 
The toxic forms of paraesthesiae, of which we see so 
many examples, are, I believe, mostly the indications 
of beginning multiple neuritis. Frequently, however, 
they do not go to extensive changes in the nerves and 
muscles, and we see the manifestations of toxicity only 
in the paraesthesiae. Many writers have spoken of this 
form of paraesthesiae, and it is not infrequently asso- 
ciated with malarial poisoning, moderate alcoholism, 13 
and the ingestion of other poisons. In the following 
case it resulted from excessive tea-drinking : 
C. B., female, fifty years old, native of England, 
married. Has had nine children. Has always drank 
a glass or two of beer a day, but drinks mostly tea, 
which is taken strong and often. She thinks seven or 
eight cups a day would be a low average. She says 
she keeps the tea on all the time, and frequently takes 
it in place of food. She reached the menopause about 
three years ago. For upwards of two years she has 
complained of burning, gnawing, prickling sensations 
in the feet and legs. Sometimes these sensations are 
really very painful. More recently she has felt simi- 
lar sensations in the arms from the elbows down, and 
in the face. All around her mouth she gets prickling 
“ pins and needles ” sensations; and her face gets a 
sort of numb, wooden feeling in it, so that she has to 
put up her hand to feel if her face is really there. 
The appetite is fairly good, bowels constipated, and 
she suffers considerably from frontal headache and 
gets low-spirited often. This patient, when tea and 
beer were entirely forbidden her, and she was put 
upon a nutritious diet with nux vomica and out-door 
exercise, improved steadily, so that now she is practi- 
cally well. 
Several other cases could be cited where the parass- 
thesiae have disappeared after a prolonged treatment 
with anti-malarials. 
Under the title of “Waking Numbness,” Dr. A. H. 
Smith has described four cases of a condition which 
would seem to be a form of paraesthesiae, to which is 
added more or less complete temporary abolition of 
motility. In a case presenting himself at the clinic, a 
barber thirty years old, of strong neuropathic predis- 
position, complained that when arising in the morn- 
ing his hands were powerless, feeling as if he “ had 14 
bowled tenpins too long the night before and had no 
strength in them,” and with this, tingling, numb sen- 
sations. He had been in the habit of taking a nap 
during the slack hours in the afternoon, but he was 
obliged to forego indulging himself in this direction, as 
the numb feelings were sure to come on after awak- 
ening. This mau improved under the use of galvan- 
ism, tonics, invigorating baths and out-door exercise, 
but he was lost sight of before he was completely well. 
Then there are the paraesthesiae that come with 
rheumatism, gout, arthritis, etc. ; but they should be 
included under the division of toxic paraesthesiae. We 
have had many good examples of the paraesthesiae re- 
sulting from a combination of rheumatism, bad nutri- 
tion and depravity. One young lady, a dancer in a 
well-known ballet extravaganza, complained of a con- 
dition very much resembling the history just detailed. 
She had less periodical and more continual impairment 
of strength than did the last patient. She was very 
anaemic, run down, badly nourished, kept late hours, 
used enormous amounts of cosmetics containing lead, 
and had previously suffered from rheumatism. Her 
improvement was very slow, on account of the fact 
that necessity compelled her to keep on with her occu- 
pation and the harmtul prerequisites which were inci- 
dent to her business. 
These illustrative cases of paraesthesiae have been 
detailed for the purpose of showing that the parsesthe- 
tic neurosis presents itself under several different 
forms ; and, with some license, they can be grouped 
as I have indicated. Recently, Schultze, of Bonn, has 
published an article dealing with the form of parms- 
thesiae that I have considered in the first part of this 
paper. He has given to it the title of “ Acro-parms- 
thesiae.” If I am right in my contention for the above 15 
classification, this term is not sufficiently definite to 
warrant admitting it to our nomenclature. Acro-paraes- 
thesiae simply means parsesthesiae of the extremities. 
You will admit that the forms of paraesthesiae that I 
have mentioned are of real occurrence, and could prob- 
ably duplicate the cases I have detailed by a large 
number of cases. 
Regarding the therapeutics of this special form of 
paraesthesiae I can only admit and concur in what all 
previous writers have stated, namely, that we have no 
specific remedy. In my experience, prolonged rest 
has been the most important beneficial agent, particu- 
larly when restorative treatment is added. 
I consider the administration of neurotics and de- 
pressants, such as antipyrin, phenacetin and the like, 
positively harmful. I have not found it necessary to 
treat specially and individually the digestive tract, for, 
as has before been stated, it is not customary to find it 
seriously at fault. Too much emphasis cannot be laid 
upon the point that everything which tends to exhaust 
these patients or in any way interfere with their vital- 
ity should be controverted. The use of the faradic 
current, in the shape of the faradic local bath, as re- 
commended by Laquer, seemed to be very beneficial 
in two cases that have been under continuous treat- 
ment during the past winter. In fact, I may say that 
one of these patients has apparently recovered under 
this treatment after she had acted upon the advice to 
wean her baby, which she had been nursing for a long 
time. The galvanic current has not given anything 
more than temporary relief. So far as treatment has 
been given with directness to combat any lithsemic 
diseases that have been supposed to exist, I must say 
candidly that I have seen no startling results. Some 
of these patients have been on spring water and min- 
eral acids without any beneficial results. 16 
The plan of treatment which is most beneficial is 
regulation of the diet (particularly by limitation of the 
nitrogeneous food-stuffs), quiet out-door life, change of 
occupations and habits, and the administration of re- 
storatives. 
A list of the literature bearing on this subject is 
herewith appended : 
Aulde. Medical Bulletin, p. 292, 1887. 
Berger. Brezlauer Artzl. Zeitsch., Nos. 7 and 8, 1879. 
Bernhardt. Neurolog. Centrallb., July 1, 1890. 
Chapman. Medical Times and Gazette, 1863. 
Cohen. Arch. General de Med., October, 1863, etc. 
Dana. New York Medical Record, p. 57, 1885. 
Dodge. Medical News, July 30, 1887. 
Haig. London Lancet, September 26, 1885. 
Hodge. American Journal of Comparative Medicine, 1891. 
Hanfield-Jones. Studies in Functional Nervous Dis., London. 
Laquer. Neurolog. Centrallb., p. 188, 1893. 
Mitchell. Lecture on Diseases of the Nervous System, Phila- 
delphia, 1885. 
Nothnagel. Deutsch. Archiv. f. klin. Med., ii, p. 173, 1886-7. 
Ormerod. St. Bartholomew Hospital Reports, 1883. 
Piotrowski. Przeglad lekarski Krakow, No. 35. 
Putnam. Archives Med., p. 147, 1880. 
Rosenbach. Centrallb. f. Nervenheilk. u. Psych., xiii, 1890. 
Saunby. London Lancet, September 5, 1885. 
Sinkler. Medical Times, p. 841, 1884. 
Smith. American Journal of Medical Sciences, p. 411, 1887. 
Southey. St. Bartholomew Hospital Reports, vol. xvi, p. 16. 
Sq-uire. London Lancet, December 4, 1886. 
Schultze. Deutsch. Zeitsch. f. Nervenheilk., vol. iii, 1893. Two Volumes yearly, beginning with the first Nos. in January and July. But 
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