The nearest affinities of chronic pyæmia are with rheumatism, through gonorrhoeal or urethral rheumatism;1 with simple or single abscess-formation after fever; with hectic fever; yet, with very rare exceptions, the diagnosis from all these is, in practice, clear.

The prognosis in chronic pyæmia may, usually, be very favourable; especially when there are long intervals between the successive local manifestations of disease, and no evidence of serious pulmonary affection. The slower the pulse and breathing, and the less the sweating, the greater are, in general, the probabilities of

recovery.

The usual treatment of chronic pyæmia may be with good food, patient nursing, a moderate use of stimulants and tonics, and an abundance of fresh air. The value of this last condition was strikingly shown in Case V. The influence of the liquor potassæ in Case IV. deserves consideration. Its curative power seemed clearly proved; and I suspect that a part of its reputation for causing the absorption of tumours is due to its influence on morbid deposits imitating tumours, such as existed in that case.

1 Mr. Barwell in his work on 'Diseases of the Joints,' p. 101, maintains a similar opinion.-[Ed.]

172

NERVOUS MIMICRY.

LECTURE I.

A GROUP of cases of great practical importance is distinguished by this fact that a nervous disorder produces an imitation or mimicry of organic local disease. In some of these cases the mimicry occurs without any substantial disease whatever; in others it gives features of extreme severity to a disease which, in a normal condition of the nervous system, would be trivial or unfelt.

Much has been written on this subject-much that is good; but, if I may judge from the difficulties still often found in discriminating between the real and the mimic in diseases, there is need of writing more.

Cases of this kind are commonly included under the name Hysteria; but in many of them none of the distinctive signs of hysteria are ever observed, and from all of them it is desirable that this name should be abolished. For it is absurdly derived, and, being often used as a term of reproach, is worse than absurd. To call a patient hysterical is taken by many people as meaning that she is silly, or shamming, or could get well if she pleased; and no doubt there are patients of whom some of these things may be fairly said; but in many more,

hysteria, especially in the form of an unwilling imitation. of organic disease, is a serious affection, making life useless and unhappy and not rarely shortening it.

At any rate, let us, if we can, discard the name of hysteria from surgery. If it is to be retained at all, it may be for the cases of patients with hysterical convulsions and sense of suffocation, with the abdominal flatulence, the nervous urinary secretion, and those other associated signs of nervous disorder which are not imitations of other diseases, and are not themselves imitated. These are characteristic enough to deserve a distinct name, and hysteria will serve, at least as well as hypochondriasis and melancholy do for what they signify. But the characters of nervous mimicry are also distinct enough to make a separate group with another name. In English we may speak of nervous mimicry; in untranslated Greek, of neuromimesis. To patients and their friends the maladies may be said to be due to extreme nervous sensibility; or, if they also prefer Greek, we may call them hyperesthetic or hyperneurotic ;anything but hysterical.

The chief practical interest of these cases is in the diagnosis between them and the organic diseases imitated in them; and as it is only in clinical study, and on clinical grounds, that they can be grouped, so I shall keep to a clinical view of them, and shall speak of their pathology only as subservient to their diagnosis. I am the more content to do this because, in Dr. Russell Reynolds's essay on Hysteria in his 'System of Medicine,' and in Dr. Anstie's lectures on it in 'The Lancet,' you may easily find the whole subject recently and

accurately taught. Indeed, if it were not that I may treat the surgical part of the subject more fully than they, I should not have seen room or occasion to lecture on it at all.

Now, there is scarcely a local organic disease of invisible structures which may not be mimicked by nervous disorder. You hear of hysteric cough and hysteric aphonia, of hysteric dyspepsia and paralysis, of hysteric joints and spines; and there is scarcely any of these disorders in which the mimicry of real diseases is not, sometimes, so close as to make the diagnosis very difficult.

The means for diagnosis are to be sought-(1) in what may be regarded as the predisposition-the general condition of the nervous system on which, as on a predisposing constitution, the nervous mimicry of disease is founded; (2) in the events by which, as by exciting causes, the mimicry may be evoked or localised; (3) in the local symptoms of each case. And I shall speak of these things in this order; though it is the wrong order for the actual study of a case. In every clinical study, the examination of the present disease should precede that of its probable causes; though for lectures and reading the reverse order is usually the better.

First, then, as to the general condition of the nervous system which disposes to mimicry of local disease. In all well-marked instances there is some prominence and apparent excess of nervous action, leading to the general expression of the patient's being nervous or of nervous constitution. Neuromimesis cannot be found in all persons alike, or in any person at all times. It may be

regarded as a localised manifestation of a certain constitution; localised, that is, in the same meaning as we have when we speak of the local manifestation of gout or of syphilis, or of any other morbid constitution which we regard as something general or diffused, though distinct witness of it may be in only one or more parts. And the nervous constitution, like others, is inherited in different degrees of completeness or intensity; and may, like others, become less or more complete or intense according to the conditions in which it has to live.

As to what is, verily, the peculiarity of the nervous constitution, I believe we have nothing fit to be called knowledge. It is even hard to give fit names to what we may suppose it to be. We may speak of the nervous centres as being too alert, or too highly charged with nerve-force; too swift in mutual influence; or too delicately adjusted, or defectively balanced. But expressions such as these, or others that I see used, may be misguiding. It is better for us to study the nervous constitution in clinical facts; and the life of almost any patient with very marked nervous mimicry will supply materials for the study. I have, indeed, seen a few in whom I could find no other nervous error than the present mimicry of some disease. But in the great majority there is either history or present evidence of a characteristic nervous constitution, such as may serve towards diagnosis. Some have been, or are even now, truly hysterical subject to fits of irrepressible laughing, crying, or sobbing, or to convulsions of various hysteric kinds. But you will find nervous mimicry in very many who have never been hysterical. In some the sensibility