more difficulty, explaining that it was on account of the moustache which hides the lip.

Dr. Archibald G. Thomson examined the eyes and ears, and reported as follows: O. D. The media are clear; the pupil clear and reacting normally. The disc is normal and color good, with a small central cup. The vessels and the fundus are normal, 4-1, with astigmatism. The fields for form and color are normal. O.S. The same as the right, except that the astigmatism is a little higher. The muscular balance is slight. Exophoria due to weakness of internal rectus. There is no perforation of the tympanic membrane or other gross lesion of the

ears.

This child remained at rest in bed on her side always. To be on the back caused lumbar ache. Before attempting any more serious step I endeavored to see how much movement I could get in the legs by the continuous use of massage and faradic electricity. Very soon I found that there was a slight increase of sensation everywhere; that the limbs were beginning again to grow; that they could be drawn down each day a little lower, and

Meanwhile her deafness interested me greatly. It became rapidly well in a few weeks. Speech came back with nearly as great speed, so that within two months after she fell into my hands she could speak perfectly well, could hear entirely well, could see as well as ever, and was recovering pretty rapidly the use of the left arm and more slowly the right. She had made also great gain in motion and sensation in the lower limbs above the ankles.

At this time I requested Dr. Keen to make sections of the tendons of the leg, one at a time, and this was done with great difficulty under profound etherization; partial straightening of the leg was accomplished then, with weights and apparatus, but not with the ratchet. There has been a gradual exten. sion of the left leg, and it seems likely that it will continue to improve, although the previous history prepared me to see at any time some return of hysterical phenomena.

On April 26, 1895, the left leg was so much better that Dr. Keen thought it would be well to operate on the right leg. Sections of the tendons at the knee were made, but it was found that the head of the tibia was so luxated posteriorly as to render impossible such extension as had been effected on the opposite side. After a time a suitable apparatus may overcome this unfortunate mechanical difficulty, but much will depend on her endurance, and the gain to be hoped for from massage and electric stimulation.

Of the drawings, Fig. 6 represents the attitude of the child when she first came under my care; Fig. 7 the results obtained by massage and electricity and slight extension by weights, up to the date of operation; and Fig. 1 the position in which she placed herself when using her pencil or pen with her mouth. I also add fac-similes of parts of letters, written with her hands and with the mouth. (Figs.

2, 3, 4, 5.)

As a clinical lesson in hysteria, nothing could be more instructive than this record. I have little doubt that early isolation and resolute treatment would have saved these years of distress. Before we pass on to consider the gravest system-the general contractures-I desire to call your attention to the fact of the absence of changes in the fields for color and form-surely an amazing thing in a case with so much anesthesia. Unlike the case first spoken of, the wasted leg-muscles, especially the flexors, can be stimulated by faradic currents; but the current that moves them so slightly is one that I cannot endure, and that painfully cramps any of my muscles on which I test it. Electro-muscular sensibility and irritability are very much lower. Those muscles of the limbs that are made tense by long contraction of their opponents scarcely stir at all with the utmost power of a battery, but when I relax them somewhat by forcible extension of the limb the relaxed extensors move better under

observations reported long ago by Morris J. Lewis and myself to the effect that forcibly stretched muscles not only move badly under electricity, but also do not feel it so keenly. Had not these muscles been once shortened by tendon-section and their sequent elongation I should have begun by cutting them. I felt that again to cut these tendons would result in further additions to their lengths and that I should run great risk of seriously disabling their strength. Nevertheless I shall be forced, soon or late, to take this risk. In a long experience with hysterical contracture I have never before come face to face with this difficulty. Of course, there is always the after-resource of shortening the tendons.

Seeing how great is the power with which the muscle in a state of spasm contracts, I used to fear that its retraction after surgical section of tendons would be excessive. It is not so. Rather does the sudden cessation of tension appear to put the muscle at rest, as though the resistance were one of the means of keeping up the pull made by the muscle. I have, in fact, lost the fear I once had as to section of hysterical muscles or their tendons.

In the case of Miss C.,' of which I have already

spoken, there was extreme pain in the feet. In another case, to be presently described, there was a like torment. In the one just now related there has been little or none. The reason is, I think, this: While the flexion at the knee is in this latter extreme, that of the thigh on the trunk is not. In Miss C.'s case not only were the knee-joints at the utmost angle of acuteness possible, but the knees touched the chin, as was nearly the case in the man in Scott Ward, of whom I shall have more to say byand-by. Now flexion at the knee only relaxes the

sciatic nerve, but extreme flexion of the thigh on the trunk keeps the nerve tightly drawn over the edge of the notch, and may well be—indeed was, I am sure the chief cause of pain in two of the cases referred to. In both, tendon-section and even partial extension of the limb speedily put an end to the pain in question. In my last case, the absence of pain is, I think, due to the lack of extreme flexion of the thigh on the trunk.

There are other interesting features in this case with which I can deal but lightly. One was the rare symptom, deafness. It was complete; nor did the most unexpected and violent sounds enable me to With Malony's detect the patient in simulation. ear-tubes she began to hear a little, and with her general gain the deafness speedily departed. I should not, above all, forget to say that for the first time in her history she was isolated from her relatives. (To be concluded.)

1 Lectures on Nervous Diseases, p. 227.

THE PUPIL IN HEALTH AND IN EPILEPSY. BY WENDELL REBER, M.D.,

OF POTTSVILLE, pa.

PUPILLARY inequality, technically termed anisocoria, is a sign that has been little studied in the healthy subject. In treating of pathologic conditions frequent reference is made to it, but as to its frequency in health, facilitating comparative study, there is practically nothing said of it in the textbooks, and but few pages devoted to it in the literature. A comprehensive treatment of the "Pupillary Reaction" by Haddaeus' and a second paper by Iwanow' comprise the main contributions to this topic in the last ten years.

The matter of inequality of the pupils in its relation to epilepsy has in recent years been brought forward by several observers. In the Journal of Nervous and Mental Disease for 1893 Browning, of Brooklyn, discusses at some length the frequency of anisocoria in the interparoxysmal periods of epilepsy, and refers to the existence of this sign in its latent form. This, I believe, is the first mention of "latent pupillary inequality." In opening the subject this writer states that "the condition of pupillary inequality is not very rare, even in persons of average health; that no great importance attaches to it in any class of troubles, but as an objective sign it is worthy of further study." After recording statistics he observes further: "As to the proportion of anisocoria in non-epileptics, or as to what proportion of the above cases may be due to local anomalies of the eye itself, we have no figures for comparison."

It will be the purpose of this paper first to direct attention to the percentage of anisocoria-manifest and latent-occurring in persons of average health, and then to consider pupillary inequality as seen by myself among a number of epileptics at the State Hospital for the Insane at Norristown, Pa., during my residence as interne at that institution.

Of anisocoria in health there is little to be found anywhere, as I have said. De Schweinitz' makes mention of it only in a foot-note, in which he briefly records the finding of Iwanow." The latter investigator made his observations on 134 healthy young recruits, and found an equal width of pupil in but 12 of them. The right pupil was larger in 49, the

1 Haddaeus: Berliner klinische Wochenschrift, 1886, Nos. 17 and 18.

2 Iwanow: Arch. of Ophthal., vol. xvi, p. 464. On the reaction of the healthy pupil.

3 Manifest inequality refers to the occurrence of unequal pupillary areas under full monocular exposure to diffuse daylight.

Latent inequality occurs when the pupils are equal under full monocular exposure to diffuse daylight, but differ in size when in a passive condition in a darkened room, the pupil being illuminated by a feeble light from the ophthalmoscopic mirror as in ordinary ophthalmoscopy. ♦ Text-book, p. 264. Op. cit.

5

left in 73. The face was asymmetric in 131, the left half being larger in 99, the right half in 32. Iwanow believes that "an unequal width of pupil does not always have a pathologic significance."

Fuchs,' after explaining the consensual reaction to light and the connection existing between the oculomotor nuclei of both sides, producing simultaneity of action, concludes that "inequality of the pupils is always pathologic." To my mind, having myself found in 50 selected healthy cases slight unequal width of pupils 7 times, it seems safe to assume that our Viennese author refers to an inequality both manifest and gross.

From my case-records I have tabulated the pupillary conditions in 50 cases presenting vision of or better, most of which applied for relief from slight refractive anomalies. The list includes both sexes. It embraces work that antedates my interest in latent anisocoria, and will serve therefore only in studying manifest pupillary conditions.

The

dimensions noted in each of the records mentioned have reference to the condition of the iris when

unaffected by the associated acts of convergence and accommodation, as it is my practice when observing the pupil to have the patient survey a distant object. In this series of cases taken from both sexes there were found five anisocorics, a proportion of 10 per cent.

During last summer, through the kindness of the United States recruiting officer at this point (Pottsville), it was my privilege to examine the eyes of a great number of applicants for enlistment in the army. From these I have tabulated 50 cases, with the view of ascertaining the percentage of anisocoria-both varieties-existing in healthy subjects. By examining males only any conflicting findings that might be the result of special feminine characteristics were avoided. All of these applicants were fine examples of physical manhood and well-being, presented normal eyes, and had vision of or better. The following course was pursued in each case :

1. Subjects were chosen whose eyes were free from tissue-changes in all the media and tunics.

2. The complicating influence of convergence and accommodation was excluded by proper measures. 3. The observation for manifest pupillary inequality was conducted under full indirect solar illumination (diffuse daylight).

4. That for latent anisocoria was made with illumination from the ophthalmoscopic mirror as in ordinary ophthalmoscopy, using a three-fifths-inch flame on an argand burner, this amount of light at a distance of one foot being just sufficient to carry on examination in a well-darkened room.'

1 Text-book, p. 261.

2 It was understood that even more exact results, had it been desired, could have been obtained by estimating each time the