The cough was of medium pitch, mild intensity, dry and sonorous, short and monotonous, neither rising nor falling in cadence. It seemed to me to be objectless or imitative, and reminded me of the stage cough which the susceptible old maid assumes to attract attention. It was certainly not suggestive of the cry of any animal, but was a cough, pure and simple, accompanied by the usual indicative muscular contractions. Her pulse was seventy-six, and her respirations twenty to the minute. At each fourth inspiration and before the commencement of the fifth, there were three distinct coughs. Without her knowledge, I discovered, with the aid of my watch, that the intervals of rest maintained an astonishing regularity, being either of eleven, twelve or thirteen seconds' duration; and registering my observations for half an hour, I found the average interval to be twelve seconds. From this it follows that she coughed fifteen times a minute, 900 times an hour, 21,600 times a day; but allowing eight hours for sleep, she actually coughed 14,400 times per day. A quick and deep inspiration would at any time cause cough, but curiously, always with the tertiary rhythm.

Notwithstanding the numerical magnitude of these explosive efforts, her only subjective signs were pains in the chest walls toward the close of the day, with a shorter interval between her usual attacks of headache.

I found her to be of medium height, with a well formed and well nourished body, of good color and sparkling eyes, and with no evidences of strumous or syphilitic origin. As I have said before, there were no genito-urinary disturbances; there was no pain on pressure over the ovaries or back, and I could find no nervous cutaneous disturbances, though she had subjective symptoms of anæsthesia, hyperæsthesia, formication, etc., limited, however, to the external surface. On several occasions, most careful examinations of her chest failed to discover any pathological state. Owing to her somewhat shallow inspirations, the vesicular murmur, over the whole chest, was not of the usual intensity, and was sometimes of a jerky and sobbing character. The inspiration preceding the cough expanded the chest more than the others, and the cough produced visible vibration of the chest walls. She was a peculiarly favorable subject for the purposes of laryngoscopy and rhin

oscopy, and bore the introduction of the mirror so well that I suspected some anæsthesia of the palate and pharynx; but, on examination with a laryngeal steel sound, it seemed to me that all the parts were of about normal sensibility; if there were any deviation, it was on the side of hyperæsthesia. I could easily see as far as the bifurcation of the trachea, but found nothing beyond a superficial congestion of the trachea, a condition to be expected after so much coughing. The tension, approximation and abduction of the vocal cords were normal; nor did they exhibit any twitching or fluttering movements. I induced a young lady friend, whose larynx was normal, to imitate the cough of my patient, and examined her larynx during the cough, but found no difference in the phenomena preceding and accompanying the cough efforts in her case and that of my patient.

Her uvula was not relaxed, the papillæ at the back of the tongue not enlarged, the naso-pharynx normal-in a word, neither by touch or sight, could I find any derangement of her respiratory tract. My friend, Dr. W. M. Whistler, the accomplished laryngologist, kindly examined her, also, and agreed with my observations.

Remembering the fruitless methods of treatment in the experience of others, to whom I shall refer farther on, I determined to be original, assuming hyperesthesia, though I could find none. I ordered her to inhale a spray of iced water and belladonna, to apply iced clothes about the neck, to keep an icebag on her head, and in addition I sprayed with ether from the sixth cervical vertebræ to the occiput. She also took ten grains of bromide of potassium with ten drops of tincture belladonna three times daily. This benumbing of the central and peripheral respiratory nerve tracts, though faithfully pursued for a fortnight, was without any beneficial effect. I bethought me then of a case mentioned in Graves' "Clinical Memoirs," where every known remedy had been tried in vain for a constant cough that afflicted a young lady, which was afterwards cured by an old woman, who gave the patient a remedy which expelled a tapeworm. But remedies administered for the purpose, convinced me that my patient was not suffering from any vermicular disease.

For the next two weeks, I applied the constant current, extra

and intra-laryngeal, gave her at the same time minute doses of opium, a capsicum gargle and an inhalation of the vapor of oil of sweet flag. But this stimulating plan, like the benumbing, was without result. I then tried the effects of physical exhaustion, ordering her to walk every day until quite tired out. At the end of three weeks, I saw her again, and found that she had reached ten miles a day. She related that on her return home, after these walks, that on lying down her cough would cease completely for an hour or longer, but that as soon as she was well rested that it would commence again. About this time she received an invitation to accompany some friends, for a sojourn at Dieppe, in the north of France. I advised her by all means to go, and she left London during the last week in August. I shortly afterward received a letter from her, in which she stated that she was completely cured; that on the morning after her arrival at Dieppe, she arose from bed, did not cough once, and had passed two days without coughing. She returned to London at the end of September, but, up to this date, I have not heard that she had any cough whatsoever since the day when it so suddenly ceased at Dieppe.

There can be no doubt that this remarkable case was an example of that group of symptoms which has been called "hysterical cough." Literature does not afford many descriptions of the disease, accurate enough to correspond with my case, though there are many loose references to curious laryngeal phenomena in hysterical women.

Sydenham, in his epistolary address to William Cole, speaking of hysteria, says, "that it sometimes affects the lungs, causing an almost perpetual dry cough, and though it does not shake the chest so violently as other coughs, yet the fits are more frequent; that this species of cough is very rare and chiefly affects women of a phlegmatic constitution."

In the first volume of the Medical Times and Gazette (London) for 1862, page 109, Dr. Peacock describes a typical case which was treated by inhalations of chloroform and the internal administration of gradually increased doses of chloride of zinc, without avail; and in the same journal for 1863, volume 2, page 116, Dr. Harley describes a case which lasted but eight days, during which, except during sleep, and on assuming the recumbent attitude,

the patient coughed seventy times a minute. He does not state whether the cough ceased suddenly or not, but states that it was cured (?) by a mixture containing valerianate of zinc, camphor and assafoetida, with cold douches to the back, and dry friction night and morning.

The only résumé and complete description of the disease that I have been able to find is by Professor Lasegue, of Paris,* who

says:

"Hysterical cough differs from the convulsive cough of children, as it is not accompanied by violent spasms, and therefore not followed by congestion, threats of asphyxia, and the divers accidents which result from thoracic convulsions. During the attack, so frequent are the concussions of cough, that it might almost be considered constant. If the cough stop, it is not from any cause which would cause one to stop, that proceeded from a chest affection. The intervals of repose return with remarkable regularity; like chorea, the cough stops absolutely during sleep; a diagnostic feature.

"There is a monotonous rhythm about the cough, such as one, two or three coughs after each inspiration, and the rhythm being once established, continues. There is no sputa, or occasionally, a very little; no dyspnoea during the interval; the respirations are somewhat less deep than usual, deep inspirations being avoided on account of their cough producing effect; there are no physical signs except those arising from repressing full inspirations; the vesicular murmur less intense, at some places indistinct, hardly heard at one moment and shortly afterward reappearing. The cough may be simple or compound. In its simple state it is like that which results from the inhalation of some irritating gas, such as chlorine; it is dry, sonorous, and continues indefinitely without modification of timbre; in its compound state it may be associated with hoarseness, aphonia, or vomiting. In some cases it takes a particular timbre, like that of a bird, for instance; it may be harsh, metallic, shrill, etc., etc. This is exceptional, and should not be confounded with the vocal troubles of hysteria, such as mewing, barking, etc.

* De la toux hysterique. Lasegue, Archives Génerales de Médecine. Mai., 1854; p. 513.

"The cough not only preserves its identity, but exhibits no tendency to transform itself into other forms of hysteria; there are very few examples of this. It is a chronic affection, lasting months and even years, and is uninfluenced by other pathological or physiological changes going on; it is unaffected by medication, its long continuance giving one a chance to try everything. Change of place has rapidly effected several cures. It may cease suddenly or slowly; it affects, exclusively, women and has never been noticed beyond the age of twenty-five. In some cases it was the first hysterical outbreak; in others, not; it does not belong to one more than another category of symptoms. It does not figure among the hysterical antecedents which have been observed where phthisis has supervened, and is never the insidious approach of that malady. Notwithstanding its persistence, it seldom has evil effects, except those of weakening, loss of appetite, impairment of the digestive functions, pallor, loss of flesh, pains in the thoracic walls, and it has never had a fatal termination. The clinical history of cases is remarkably alike."

M. Lasegue then gives the details of a number of cases. He also quotes one from Elliotson, where there was one cough with each expiration; one from Davies, in the London Medical Gazette of 1834, who says he has seen thirteen parallel cases, and who recommends change of air and scene as the only remedies; one from Trousseau, which continued thirteen months; one from Whytt, in a child eight years old, in which the recumbent position at once stopped the cough, which lasted a year, during which all kinds of medication were tried, but which suddenly stopped of itself; one from Lubert, in which the cough occurred every half minute, but was at once stopped by the recumbent attitude, and also when the patient played the guitar; at the opera she did not cough at all during the singing, but attracted attention by her coughing during the dialogue; after lasting sixteen months, unaffected by medication, it suddenly ceased one morning of itself; did not return for six months, when it occurred again and lasted six months, and again suddenly disappeared; one from Chonel, in which the cough began exactly at 2 p. m. and lasted until 7 p. m.; one from Dr. Synclair, which lasted four days, and came on after taking fifty drops of laudanum; and one from