A SERIES OF CASES OF PARESTHESIA, MAINLY OF THE HANDS, OF PERIODICAL RECUR- RENCE, AND POSSIBLY OF VASO-MOTOR ORIGIN BY JAMES J. PUTNAM, M.D. LECTURER ON DISEASES OF THE NERVOUS SYSTEM, MEDICAL SCHOOL, HAR- VARD UNIVERSITY [Reprinted from the Archvies of Medicine, October, r8So] NEW YORK G. P. PUTNAM'S SONS 182 Fifth Avenue r88o A SERIES OF CASES OF PARESTHESIA, MAINLY OF THE HANDS, OF PERIODICAL RECURRENCE, AND POSSIBLY OF VASO-MOTOR ORIGIN * WITHIN the past few years there has come to niy notice, mainly at the Out-Patient Department of the Massachusetts General Hospital, a large number of cases such as I do not remember to have seen described any- where in detail, though they are often the subject of brief reference. While differing from each other in minor re- spects, these cases agree in presenting as a common symp- tom a disturbance of the subjective sensibility of the skin, giving rise to what is known popularly as numbness, recur- ring periodically, coming on especially at night or very early in the morning, and affecting one or both hands, either alone or in company with the arms, the legs, or rarely the whole body. This numbness was very often excessively intense, so as to amount to real pain in itself, and sometimes also it was associated with pain of a more or less typical neuralgic character, especially in the arms. Occasionally the numbness was associated also with a sort of rigidity of the fingers involving some loss of power, and sometimes a change of color of the skin of the nature of paleness or red- *Read before the American Neurological Association, in June, 1880. Reprinted from the Archives of Medicine, Vol. iv, No. 2. October, 1880. 2 JAMES J. PUTNAM. ness. In some cases, simply letting the arm hang out of bed or shaking it about for some moments would drive the numbness away; in others, this could only be done by pro- longed rubbing and use of the hands in ordinary em- ployments. Under this latter influence it rarely failed to yield temporarily. Most of the patients were women in middle life, and many of them were debilitated or anaemic. On the other hand, a few well-marked cases were in strong, healthy men, one of them being a gentleman-farmer, a vig- orous man living a temperate out-of-door life. In the course of this brief sketch, the criticism will, no doubt, have arisen in the minds of some of my readers that these cases ought not to be made into a nosological group by themselves, a large part of them belonging in the same general class with the neuralgias, and others with the vaso- motor affections, fully described by Raynaud, Vulpian and others, under the name of local asphyxia of the fingers. As a matter of fact, all the symptoms which I have mentioned are met with not unfrequently in cases of well-marked neuralgia, as well as in those of the vascular spasms of the fingers alluded to. To me, however, one interesting feature of my cases lies in the fact, that while resembling both these affections, as well as another to be mentioned later, they differ from them in well-defined respects, and thus help us to split these groups of symptoms up into their constituent parts, from which the clinical necessity of giving names, which must often be inadequate, is apt to distract our attention. Thus,, the term, neuralgia, has practically usurped for the 'one symptom, pain, the field which scientifically belongs, with almost equal rights, to the trophic and vaso-motor and other symptoms with which the pain is usually accompanied; and it is very instructive to study this analogous series of cases in which the symptoms of so-called numbness, usually PARESTHESIA OF THE HANDS. 3 of little account, is brought into the foreground. The same might be said with regard to the affection characterized by vascular spasm of the fingers, between which and one divis- ion at least of the neuralgias, the cases to be reported per- haps form a transitional group. The neuralgias to which I refer are those in which the pain is supposed to be * due to vascular spasm in the peripheral distribution of the affected nerves, depriving the nerve terminations of their arterial blood supply. Such is believed to be the origin of the intense pain of lead colic, and, perhaps, of other visceral neuralgias and of migraine, and to it is probably due, in part, the numb, aching pain from exposure of the hands and feet to cold. The pain in the later stages of frost-bites is, no doubt, due on the other hand to congestion of the nerve filaments, and the chances are that this influence, too, plays a part in the cases before us. Dr. Weir Mitchell* has dedicated a lecture to the symptom, numbness, which covers a good deal of the ground here traversed; but the literature of the subject is otherwise scanty. Most important for our present dis- cussion are the papers by Raynaud (De 1'asphyxie lo- cale. These de Paris, 1862; and art., Gangrene sym^trique, in the Nouveau Diet, de Med. et de Chir. Prat.); and Vulpian, (Lecons sur l'appareil vaso-moteur, Paris, 1875.) I will first sketch the history of one or two illustrative examples, taken nearly at random from my case-book, and then give a brief analysis of the whole number which I have seen. Case i.-A married woman, 50 years of age, always strong and well. As a young girl, used to have neuralgia in the face ; never since. For the past four weeks she has suffered from intense sense of numbness of one or both hands, from wrists down. It is present to a greater or less degree nearly all the time, but is worse * Phila. Med. & Surg. Reporter, Dec. 2, 1876. 4 JAMES J. PUTNAM. at night, especially from about 3 a. m. till daylight, and also when, after doing housework, she sits down to sew. At such times she finds, after a few minutes, that she can scarcely hold a needle ; the numbness, subjective and objective, is so intense, especially on the palmar surfaces of the thumb and fingers. This sensation is often associated with pretty severe pain, felt mostly in the back of the hands ; but not with change of color of the hands or with swell- ing. All the time of her visit to the M. G. H. the numbness was only present in the thumb, and the sensibility to the aesthesiometer was not impaired. The treatment (cannabis indica) has been used too short a time to justify conclusions as to its efficiency. Case 2.-Single woman, 20 years of age. Anaemia. Numb- ness of entire left hand, except thumb ; of 3 years' duration, often associated with paleness of fingers ; skin of hands hard and dry. (A condition similar to this is described by Raynaud, as present in a few of his cases, and is said to have disappeared with the per- manent disappearance of the local asphyxia.) Case 3.-Married woman, 24 years of age. Moderate degree of anaemia and debility. Numbness and prickling of entire right hand and arm, associated with deep-seated aching; worst at night and early in the morning ; increased also by putting hand in hot water, and by lying down even in the daytime; relieved by let- ing hand hang down or by rubbing. Hands said to be sometimes warm, sometimes as cold as lumps of ice, and of bluish color ; but numbness not worse during either one of these stages than during the other. Finger tips often turn white, especially when hand is used. Tingling easily excited by pressure over various parts of arms, including nerve trunks. Strychnia, phosphorus, galvanism, used successively (the galvanism three times a week for 2 to 3 weeks) without marked results, though the last, applied from spinal cord to brachial plexus, gives sometimes temporary, and possibly, at last, slight permanent relief. When the numbness is severe the fingers feel stiff and helpless. Case 4.-Married woman, 40 years of age. Marked anaemia and debility. Numbness of hands, sometimes very intense, and associated with sense of powerlessness of fingers, coming on early in the morning. It has been recurring for 21 years, though much less severe when she has lain in bed for some months at a time, as she has done occasionally from sheer prostration. Case 5.-Married woman, 37 years of age. Good health : now in fifth month of pregnancy. For past two months she has suf- fered from intense sense of prickling in both hands and arms below PARESTHESIA OF THE HANDS. 5 elbow, especially in right; worse at night or at 2 to 3 o'clock in the morning, though rarely entirely absent; sometimes associated with aching of hands. During a previous pregnancy she was simi- larly troubled for about one week. These symptoms are made worse by hard work, and by bad weather. The sensibility of the finger tips of both hands is greatly diminished at times. Fingers are generally warmer than normal, and feel better when cool, though contact with cold water increases the symptoms. The fingers never become pale, but sometimes red, hot, and throbbing, and in the morning they sometimes tremble and are powerless, so that she can with difficulty extend them. Potassium bromide at night gives some relief. Ice was applied to back of neck for twenty minutes on three successive nights without avail. There was finally gradual improvement under constant use of potassium bromide in very large doses, though for a time the symptoms became worse. Case 6.-Married woman, 24 years old. For many years she has been troubled with sense of prickling, numbness, and weak- ness in hands, to such a degree that she sometimes drops what she is holding. It is at its worst early in the morning, though it does not wake her up. Symptoms are increased by contact of hand with hot water ; relieved by cold. Patient reports that her mother was troubled with these same symptoms during pregnancy with patient herself, to such a degree that she could scarcely use her arms. Patient herself was not worse during a pregnancy four years ago. Case 7.-Single woman, 22 years of age. Health always good, except that she has backache at times. Lives in the country, and does easy work. For past year she has suffered from numbness and tingling, sometimes quite intense, in left hand, especially finger-tips ; worse at night, but felt also in the daytime when she lies down or sits down to do fine work. Some relief from' letting hand hang out of bed and from rubbing. Usually the sensation is that of prickling, but at times there is intense pain, as if fingers were swollen and tightly compressed. They are, however, not swollen. When symptoms are present, hand feels cold and moist, but does not change color. Great and permanent improvement and final cure under use of phosphorus (gr. t. d.). To these cases I will add but one more, to show that neither the male sex nor vigorous persons are entirely ex- empt from this affection. 6 JAMES J. PUTNAM. Case 8.-Patient is a man, 40 years old, and lives an out-of- door, temperate life, in charge of his own farm in the country. Smokes, and drinks tea and coffee, but moderately, and for a long time took neither of the two last-mentioned to see if symptoms would be relieved, which they were not. He is free from other symptoms than those now under consideration, except that he has noticed that his legs " go to sleep " unusually early (that is, when in constrained position). He has been annoyed for several years by numbness of one or both hands, especially left, coming on at about six in the morning, and passing away when he gets up or lets the hands hang out of bed. This condition is worse in win- ter than in summer. It is not associated with any change in the appearance of the hands. Much relief while taking pills contain- ing strychnine. Of good cases, answering pretty nearly to the descriptions given above, I have notes of 31,* besides several neural- gias, in which numbness was a marked though not the most prominent symptom, and of two cases of local asphy'xia. I am not prepared to say, however, that none of these 31 would by others be called cases of neuralgia, nor to deny, on the other hand, that they may be found capable of further subdivisions. Numbness is an indefinite term, and may at times have been used simply to describe a dull aching neuralgic pain without marked perversions of sub- jective sensibility, such as prickling, formication, sense of heat and cold, etc. To the majority this criticism would not, however, apply. Of these 31 patients, 28 were women, three men. Of the women, 21 were married and three single. Of four, no record is made in regard to this point. Almost all the patients were in middle life. Thus there were : None below 20 years 12 between 20 and 30 13 " 30 " 40 6 " 40 " 50 6 over 50 * Since this paper was first prepared, I have seen a number of new cases. PARESTHESIA OF THE HANDS. 7 Ten of the cases were noted as being in poor health; five in good health. Tea and tobacco were a possible cause in one rather anomalous case in a male patient; pregnancy in two or three cases, and in one reported to me by another patient. Cases of recognized organic disease of the nerve centres were, it need hardly be said, excluded. The symp- toms were confined to one side of the body (hand, or hand and arm, or hand and leg) in fifteen cases; in fifteen others they involved both sides. In one case the whole body was thus invaded. In the large majority of cases one hand was worse than the other, however, and, as a rule, certain fingers were more severely affected than the rest; oftenest those supplied by the median nerve, though not necessarily all of these at one time. With regard to the duration of these symptoms, they might be said to have been chronic in almost every case ; always lasting for weeks, usually for months or years. Of interesting accessory symptoms coldness and pallor of the fingers is especially worthy of mention. This is noted in but two or three cases, and in them it recurred periodically with the numbness. A larger number of patients said their hands felt full and swollen ; actual swelling was, however, objectively confirmed by myself in only one or two cases. I rarely saw the patients, however, when the symptoms were at their height. In two cases the skin of the palm of the hand was thick and dry, indicating a change which may have been due to the patient's occupation, though no suffi- cient cause of this kind could be traced : it is worthy of note in connection with a similar change which occurred in some of Raynaud's patients. Several of the women spoke strongly of the effect of water-sometimes cold, sometimes hot-in either aggravating their symptoms or in causing an indescribably unpleasant sensation.; cold weather, also, al- most always increased the symptoms, and they were worse 8 JAMES J. PUTNAM. in winter than in summer, In three, a similar exacerbation followed leaning upon the arms in scrubbing floors or at other work, and others complained that the arm ~or leg "went to sleep " with unaccustomed readiness when placed in constrained positions. This same increased liability to " go to sleep," affecting the legs of patients with chronic myelitis, has been commented on by several writers and has struck me most forcibly on several occasions. The differential clinical diagnosis has to deal mainly with neuralgia, by which is meant the typical neuralgia, such as is generally believed to be of central origin, with vascular spasm of the fingers, the "local asphyxia" of Raynaud, and with neuritis. From neuralgia, the affection before us is distinguished by the following facts : i. Both sides of the body are so often affected at once (in one half of my cases). 2. The course of the affection is so chronic, lasting often without remission for months and years, and yet not neces- sarily associated with depressed health, and not increasing in violence as time goes on. 3. The sense of "numbness " or prickling is so strongly marked in proportion to the pain. 4. The pain, when present, is usually of a dull aching character, and often apparently rather an intensification of the "numbness " than acute pain of any familiar kind. 5. Even when the pain is severe it rarely involves the whole of the distribution of the brachial plexus, or is con- fined to the distribution of any one nerve, often involving only the hands. 6. A high degree of local anaesthesia is often present. Though these signs would have to exclude a typical central neuralgia they might not exclude all neuralgias of peripheral origin, nor should we expect such to be the case. PARESTHESIA OF THE HANDS. 9 Neuritis, unless of a very low type, is excluded by the absence of muscular wasting, or of notable trophic changes in the skin and its appendages. In one case (Wilson) the arm was said to swell frequently and remained almost constantly warmer than the other. This was not, however, a typical case fide infra). From the local asphyxia of Raynaud, this affection is dis- tinguished by the following facts : i. The change of color indicative of vascular spasm is much less prominent than in the local asphyxia, while the " numbness" is more so. In many cases no change of color was present, even when the pain was intense. 2. By its more distinctly marked periodicity, the exacer- bations being almost invariably in the night, especially toward morning, whereas, as a rule, the local asphyxia is brought on by exposure of the skin to cold or cool air. Still, a type of the local asphyxia in which the symptoms recur regularly and spontaneously, is recognized by Ray- naud ; and, as in them, certain fingers, and always the same ones, are usually the first victims. On the other hand there are several points of relation- ship between the affection described by Raynaud and the one now before us. The pain in both is of much the same character. It is thus described by the French writer: "A depressing sense of numbness and tingling is first felt, and this is followed by sensations of burning and stinging, which pressure intensifies. At the same time the tactile sense of the skin may be so much impaired that it is difficult for the fingers to retain small objects in their grasp." During the period of reaction, while the small vessels are dilating, the parts are said to be the seat of sensations of intense distress like that caused by frost-bites. Similar descriptions were very often given by my pa- 10 JAMES J. PUTNAM. tients, though it was, perhaps, more common for them to speak of " aching " pains, and, as has been said, these are sometimes sharp and darting, and may occupy the whole arm, as indeed is true also of the cases described by Ray- naud. In both diseases the symptoms are worse in winter than in summer; in cold and stormy than in warm weather. Raynaud says: " It is not uncommon to find a woman complaining of this premonitory numbness off and on dur- ing two or three years, the symptoms passing away with the coming of summer and returning with the winter, and ending eventually in symmetrical gangrene." None of my cases have terminated in this way to my knowledge, though I have histories of some of them ex- tending over many years. On the other hand two pa- tients, if not more, have distinctly spoken of the disap- pearance of the symptoms during summer. In both af- fections, women, usually debilitated but sometimes in per- fect health, are by far more often attacked than men, .and the middle years of life (20-30-40) show the largest num- ber of cases. In neither affection can any special diathesis (rheumatic, gouty, etc.) be assumed as a cause, nor, in my cases at least, had the patients been especially subject to neural- gias. On the whole, especially when we reflect that in some of my cases also there was a marked change of color of the affected parts, it will seem that the resemblances between these two affections are quite striking enough to suggest the possibility of a relationship. In view of this fact I venture to suggest as a possible cause for the symptoms in the typical cases of the affec- tion here described, alterations of the blood-supply of the smaller branches or terminal filaments of the sensitive nerves supplying the affected districts, occurring, as a rule, 11 PARESTHESIA OF THE HANDS. independently of any notable changes in the general cu- taneous circulation of the part. I am well aware of the difficulties in the way of establish- ing this opinion, and of the impropriety of asserting it dog- matically. So far as the evidence to be drawn simply from the character of the prominent symptom itself is concerned, " numbness " is of course to be met with as a result of the excitation of any part of the sensitive tract, from the cortex cerebri to the peripheral expansion of the cutaneous nerves. The distribution of the symptom is a better guide to the localization of the disturbance. Thus, the fact that, in our cases, both hands are usually involved, renders a cerebral lesion improbable, and similarly, the non-coincidence of the area over which the symptom is felt with the distribution of any one nerve, renders it some- what improbable, though certainly not impossible, that the lesion is one affecting the principal nerve trunks of the bra- chial plexus. The cervical enlargement of the spinal cord might be the part primarily concerned, but in our entire ignorance of the arrangement of the nuclei of the sensitive nerves in the cord, it would be impossible to assert such a view with confidence. In favor of the suggestion which I have advanced-pur- posely in a somewhat vague form-are : The analogy of these cases, with the local asphyxia of Raynaud (in some of the cases there was definite change of color in the skin), and the fact that this theory would reasonably explain the phenom- ena under consideration, inasmuch as it has been established beyond much doubt (Waller, Mitchell, Reynaud, Vulpian, Richet, etc.) that alterations of the circulation in nerve trunks, whether of the nature of anaemia or hyperaemia, may give rise to the whole range of paraesthesiae, and to pain. Finally, whether the hypothesis is correct or not, or 12 JAMES J. PUTNAM. whether it is valid for a certain number of cases and not for the rest, it is one which may fairly demand investigation. If it should prove tenable, the numbness in these cases would be analogous to the pain in the so-called neuralgias of vaso-motor origin, such as lead colic and migraine. To accept it we should have to admit that the vessels of circulation in the nerve branches have a regulatory appa- ratus more or less independent of that for the vessels of the overlying skin. I know of no data for establishing this assumption except, possibly, the fact that the hand, or other part, may feel very cold, although the surface is abun- dantly supplied with arterial blood.* On the other hand, the autonomous conditions of the cir- culation in the muscles and viscera furnish sufficient analogy for such a state of things. Perhaps a stronger argument against the hypothesis is the fact that those symptoms of numbness, etc., may occur not only confined to a definite part, like the hand, but spread over a large and ill-defined region, as the legs in Berger's cases {vide infra), or even the whole body. It is hard to say just what significance is to be attributed to this fact. If the question be put as to the ultimate cause of the vaso-motor spasm, I should refer to the discussion of this question by Raynaud and Vulpian, apropos of the local as- phyxia, the former holding that it is due to an abnormal state of the spinal vaso-motor centres, the latter pointing out that the action of the local muscular mechanism may likewise play its part. In the foregoing descriptions of my cases, one or two special symptoms were mentioned which deserve a mo- ment's attention. Thus certain patients were quoted as saying that to plunge the hands into hot or cold water caused very unpleasant sensations. This, or a kindred phe- nomenon, the increased sensitiveness to pressure met with *p, Runge. Arch, fur Klin. Med., 1870. PARESTHESIA OF THE HANDS. 13 in the local asphyxia, is explained by Richet under the supposition that the peripheral nerves are made more excit- able by the loss or diminution of their blood-supply. In order that this phenomenon may be present the hyperaes- thetic portion of the nerve need not be its periphery, but might be at any part of its course or at its centre (y. Eulen- burg, Leitungsneuralgie); and indeed this same increased sensitiveness to hot and cold water is occasionally seen in cases of meningitis, as from Pott's disease. Still it is by no means a common event, and must be rarely seen in true neuralgia even of a severe type, and I look on it as proba- bly a real sign of local irritation of the nerve filaments in the hand itself, in the cases now before us. Why is it that night and early morning are so regularly the time for these morbid phenomena to make their appear- ance ? It can hardly be alone because, his business done, and the house quiet, the patient is at liberty to think of his discomforts, for the pain often wakes him from a sound sleep, during which his sufferings had presumably been for- gotten. It is at this same hour, 3 or 4 A.M., that epileptic attacks are so apt to occur, and that death reaps his largest harvest. The exacerbations of pain of some forms of neu- ralgia, and especially that of neuritis, are also apt to occur at this time, as is well known, and this consideration, taken together with the fact that in at least one of my cases (yide infra, John Wilson), there were distinct signs of neuritis of a very low type, furnishes additional evidence that the char- acteristic lesion is one of the peripheral nerves and not of the nerve centres. With regard to the treatment of these cases, I have had too little opportunity to test the different modes carefully to make a statistical statement of any real significance, and I can only offer my experience as of suggestive value. I have used galvanism, phosphorus, strychnia, bromide of 14 JAMES J. PUTNAM. potassium, cannabis indica, nitrite of amyl, and a few other remedies. One of the male cases, of years' standing, im- proved quite remarkably while taking strychnine, which had been preceded by phosphorus, and in several others, phosphorus certainly seemed to be of great efficacy,- greater than any of the other drugs. Nitrite of amyl I should like to try further before speak- ing of it. Galvanism was tried faithfully in a number of cases, the current being passed along the arm in various fashions, but though it seemed to help from time to time, I was not im- pressed in its favor on the whole. Raynaud has reported recently several cases in which he obtained excellent and permanent results from galvanism of the upper part of the spinal cord daily, for a number of weeks, and I should be encouraged thereby to try again. Unfortunately, an Out- Patient Department is not the best place in the world for making careful therapeutic investigations. It is not to be supposed that, with the description of the affection which has formed the subject of this paper, I re- gard all the cases or groups in which " numbness " or " paraesthesia " is the most prominent symptom, to be dis- posed of. One or two cases are in fact included in my list, which perhaps deserve to be classified separately, where this symptom instead of recurring periodically remained constantly present, whether seated in the hands,-or rather fingers,-or in the feet and legs. One case of this kind I will refer to, as I have learned some new points in his history within the past few days. John Wilson, a middle aged man of temperate habits and good health, a currier by trade, and obliged, in working, to bear with force against a wooden scraper held in both hands, has suffered for the past fifteen years from a sense of " numbness " and prick- ling in the left hand and arm below elbow. This sensation rarely, if ever, leaves him entirely, night or day,. PARESTHESIA OF THE HANDS. 15 but is intensified by cold weather and by hard work, and is very bad at night, often waking him up from a sound sleep. When in its mildest form, it is felt only in the fingers ; when worse, in the hand, and finally in the arm, as stated ; but it is at no time confined to the distribution of any single nerve. At times the feeling is so intense that it amounts to severe pain, but this is of an aching character, and is distinctly recognized as being only an intensifica- tion of the paraesthesia, not something apart from this. It is de- scribed as being like that felt when one's leg is severely "asleep," or something like the benumbing pain of cold. The hand does not change color. A moderate degree of the prickling is not in- compatible with (apparently) perfect tactile sensibility, but when it is severe the sensibility is said to be much impaired. The mus- cular power of the arm is as good as ever when it is not " numb," but then the fingers and arm feel stiff and helpless. Shaking the arm in the air gives relief for a while. At times he thinks the arm swells, and at one visit to my office the left arm was distinctly warmer than the right, even though, as it was Sunday, the numb- ness was not at the time severe. Dr. S. L. Abbot has related to me a similar case, in which the arm felt sore on pressure. In that case, salicylic acid in doses of grs. x, seemed to give great relief. One would be led by the history of these cases to sus- pect neuritis or pressure on the nerve trunks, perhaps, in the former, by the muscles themselves, as sometimes hap- pens, but this would seem to be excluded by the fact that the distribution of the sensation is not coextensive with that of any one nerve, and that it is felt as well at night as during use of the limb. Still, I do not regard the case as typical of the group of which I have been mainly speaking. The nerves of certain persons, even in perfect health, seem to be more susceptible to the effect of pressure than others, and more under certain circumstances than under others. Thus I have noticed with myself that the pressure of a heavy coat or of the strap of a knapsack, while it is liable to make both arms " go to sleep," affects the left arm far sooner than the right, and certain fingers (the forefinger 16 JAMES J. PUTNAM. and thumb) before any of the others, and that this happens much more readily on a hot, oppressive, than on a cool, day. An analogous group of cases to those reported in this pa- per (based on six observations) has recently been described by Dr. O. Berger of Breslau (Breslauer Aertzl. Zeitschr., 1879, Nos. 7 and 8), and given in abstract in the Centralblatt fur Nervenheilkun.de, etc., 1879, No. 12, by Mobius. The main symptom is described as attacks of intense paroxysmal and very unpleasant, though not sharply painful, paraes- thesia (formication, prickling, " numbness," burning) of the legs. These attacks occurred after protracted sitting or standing, not after walking. The sensation either began to be felt in the neighborhood of the hip-joint and spread to the foot, or vice versa. In some cases the arms were in- volved, and very often one arm and one leg were preemi- nently or exclusively attacked. The disturbance of sensi- bility was always associated with a sense of great muscular helplessness, interfering with voluntary motion. Each at- tack was of but a few moments' duration, but they recurred at short intervals. The aggregate duration of the affection was chronic up to nine years, as in mXny cases, and the gen- eral health of the patients was usually good. Of the six patients, four were men, two women; all were in middle life, and of the well-to-do classes of society. Berger believes the affections to be of spinal origin, and found nothing, except arsenic, of value in the treatment, and that only as a palliative. No argument will be necessary to show the analogy between these cases and mine, though it would be premature to claim that the pathology of both must be the same, or even that it is identical in the whole number of my own cases. Taking all together, it will be seen that there are several, perhaps quite a number of more or less distinct types, and that in one form or another they are far from rare. ARCHIVES OF MEDICINE FOR 1880. A BI-MONTHLY JOURNAL. Edited by Dr. E. C. Seguin, in conjunction with Thomas A. McBride, M.D., Lecturer on Symptomatology in the College of Physicians and Surgeons, New York, in charge of general medi- cine ; Matthew D. Mann, M.D., of Hartford, Ct., Clinical Lecturer in Gynecology in the Medical Department of Yale College, in charge of Obstetrics, and Diseases of Women and Chil- dren ; and Lewis A. Stimson, M.D., Professor of Pathological Anatomy in the Medical Depart- ment of the University of New York, in charge of Surgery. The Archives of Medicine will continue to be published every two months. Each number is handsomely printed in large octavo form on heavy paper, and the articles are liberally illustrated whenever their subjects render this desirable. The Archives will riot be a neutral or impersonal journal. The views of its Editorial staff upon topics of current interest and upon books will be expressed without favor or enmity, over the writers''initials or full names. Prior to entering upon the second year of the Archives existence, the Editor does not desire to make any loud promises of things to be done, but prefers simply to point to what has appeared in its columns, and to call the attention of the profession to the list of physicians who have ex- pressed their intention to be collaborators. Among Original Articles published in the first five numbers of the Archives, we may cite the following as possessed of general interest. Supplementary Rectal Alimentation by Dr. A. H. Smith ; The Self-limitation of Phthisis by Dr. Austin Flint, Sr. ; Fibroids of the Uterus by Dr. T. G. Thomas ; Phthisis Pulmonalis by Dr. J. R. Leaming ; The Pathological Anatomy of Tetanus by Dr. R. W. Amidon ; A Contribu- tion to the Study of Cancer of the Rectum by Dr. L. A. Stimson ; The Use of the Actual Cautery in Medicine by the Editor ; Diarrhoea, Entero-colitis and Cholera Infantum by Dr. J. L. Teed ; Psycho-physiological Training of an Idiotic Hand by Dr. Edward Seguin ; and Mr. Delafield's series of Lessons upon Electricity. The five Editorial Articles have treated of the following subjects : The Present Aspect of the Question of Tetanoid Paraplegia by the Editor; The Utility of the Sphygmograph in Medicine by Dr. Thomas A. McBride ; Obstetrics in Siam by Dr. Sam'l R. House ; Ulceration of the Cervix Uteri by Dr. Matthew D. Mann ; Lunacy Reform, Historical Considerations by the Editor. In the Department for Original Observations twenty valuable cases have been recorded, several of which might have formed the basis of original articles. COLLABORATORS. London.-Drs. J. Hughlings Jackson, J. Burdon-Sanderson, and Sydney Ringer. Paris.-Profs. J. M. Charcot, J. Marey, and A. Oi.i.ivier. Germany.-Prof. Dr, W. Erb, of Heidelberg. Philadelphia.-Profs. D. Hayes Agnew, M.D., J. M. Da Costa, M.D., William Goodell, M.D., Roberts Bar- tholow, M.D., S. W. Gross, M.D., and Drs. Thos. G. Morton, E. O. Shakespeare, and J. C. Wilson. Boston.-Drs. James R. Chadwick, Charles P. Putnam, James J. Putnam, Samuel R. Webber. Baltimore.-Prof. E. T. Miles, M.D. Hartford, Conn.-Dr. Samuel B. St. John. Albany, N. Y.-Prof. Samuel B. Ward, M.D. NEW YORK CITY AND BROOKLYN : Prof. C. R. Agnew, M.D., Prof. Fordyce Barker, M.D., Prof. Francis Delafield, M.D., Prof. W. D. Draper, M.D., Prof. Austin Flint, Sr., M.D., Prof. William A. Hammond, M.D., prof. A. Jacobi, M.D., Prof. Mary Putnam Jacobi, M.D., Prof. E. G. Janeway, M.D., Prof. E. L. Keyes, M.D., Prof. Alfred L. Loomis, M.D., Prof. F, N. Otis, M.D., Prof. M. A. Pallen, M.D., Prof. Thos. R. Pooley, M.D., Prof. D. B. St J. Roosa, M:D„ Prof. H. B. Sands, M.D., Prof. A. J. C. Skene, M.D., Prof. R. W. Taylor, M.D., Prof. T. Gaillard Thomas, M.D., Prof. W. H. Van Buren, M.D,, Dr. R. W. Amidon, Dr. Wm. T. Bull, A. Floyd Delafield, A.B., Dr. H. J. Garrigues, Dr; V. P. Gibney, Dr. L..Carter Gray, Dr. E. Gruening, Dr. C. Heitzmann, Dr F. P. Kinnicutt, Dr. Jas. R. Leaming, Dr. C. C. Lee, Dr. P. F. Munde, Dr. J. C. Perry, Dr. N. M. Shaffer, Dr. J. C. Shaw, Dr. J Marion Sims, Dr. A. H. Smith, Dr. E. C. Spitzka, Dr. Clinton Wagner, Dr. Robert Watts, Dr. David Webster, Dr. R. F. Weir, and the Editorial Staff. Subscription, per year, $3 00. Price, per number, 60 cts. Specimen number sent on receipt of 25 cts. G. 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