Masked: A Dark Romantic Suspense

(Club Exposure Book 5) Ivy Nelson

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 Masked

Club Exposure 5
Ivy Nelson
Contents

Copyright

NL Signup
Blood
A Note From The Author
1. Chapter 1
2. Chapter 2
3. Chapter 3
4. Chapter 4
5. Chapter 5

6. Chapter 6
7. Chapter 7
8. Chapter 8
9. Chapter 9
10. Chapter 10
11. Chapter 11
12. Chapter 12
13. Chapter 13
14. Chapter 14
15. Chapter 15

16. Chapter 16

17. Chapter 17
18. Chapter 18

19. Chapter 19
20. Chapter 20
21. Chapter 21
22. Chapter 22

23. Chapter 23
24. Chapter 24
25. Chapter 1
26. Chapter 2
About The Author
About the Author
15. Chapter 15

16. Chapter 16

17. Chapter 17
18. Chapter 18

19. Chapter 19
20. Chapter 20
21. Chapter 21
22. Chapter 22

23. Chapter 23
24. Chapter 24
25. Chapter 1
26. Chapter 2
About The Author
About the Author
Copyright © 2023 by Ivy Nelson

All rights reserved.

No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording,
or other electronic or mechanical methods, without the prior written permission of the publisher, except as permitted by U.S. copyright
law. For permission requests, contact ivynelsonbooks@gmail.com.

The story, all names, characters, and incidents portrayed in this production are fictitious. No identification with actual persons (living or
deceased), places, buildings, and products is intended or should be inferred.

Book Cover by Ivy Nelson

Illustrations by [Illustrator]

First edition 2023

Copyright © 2023 by Ivy Nelson

All rights reserved.

No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording,
or other electronic or mechanical methods, without the prior written permission of the publisher, except as permitted by U.S. copyright
law. For permission requests, contact ivynelsonbooks@gmail.com.

The story, all names, characters, and incidents portrayed in this production are fictitious. No identification with actual persons (living or
deceased), places, buildings, and products is intended or should be inferred.

Book Cover by Ivy Nelson

Illustrations by [Illustrator]

First edition 2023

For a free Novel, sign up for my newsletter at www.ivynelsonbooks.com/newsletter
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Blood
Blood
 A Note From The Author

asked contains depictions of BDSM. This book is the author’s interpretation of BDSM
M fantasies and is not intended to be an educational tool. BDSM is different for everyone, and
this is just one perspective. Everything in this book is fictitious and should be read as such. If you
choose to participate in BDSM, please remember consent above all else and please do educate
yourself with something that isn’t a work of fiction.
I hope you enjoy this creation.
Ivy Nelson
P.S. The following is a non-exhaustive list of potential tw/cw in this book. I hope it helps.

Warnings
Kidnapping; Knife play; degradation/humiliation play; spit play; dirty talk; Dom/sub dynamics;
impact play; discipline/punishment; honorifics; exhibitionism; bondage; contracts
 A Note From The Author

asked contains depictions of BDSM. This book is the author’s interpretation of BDSM
M fantasies and is not intended to be an educational tool. BDSM is different for everyone, and
this is just one perspective. Everything in this book is fictitious and should be read as such. If you
choose to participate in BDSM, please remember consent above all else and please do educate
yourself with something that isn’t a work of fiction.
I hope you enjoy this creation.
Ivy Nelson
P.S. The following is a non-exhaustive list of potential tw/cw in this book. I hope it helps.

Warnings
Kidnapping; Knife play; degradation/humiliation play; spit play; dirty talk; Dom/sub dynamics;
impact play; discipline/punishment; honorifics; exhibitionism; bondage; contracts
Chapter 1
Chapter 1
Five years ago

Reva
hat the hell is that noise? The annoying sound grew louder in Reva Calhoun’s ears, and she
W pulled the pillow over her head to muffle it. But sleep had already vanished, and the noise
became recognizable. A doorbell.
A very annoying doorbell.
She rolled over in the unfamiliar bed and nudged the man sleeping next to her. “Parker, wake up,”
she hissed when he batted her away.
How was he sleeping through this?
After several more nudges, she got him awake enough that he realized someone was at the door.
“Shit. What time is it?” he muttered as he rolled off the bed and pulled his sweatpants on.
Parker Jasper was her most recent partner, and the first she’d gone home with after a long string of
bad dates. But she didn’t know him that well, and tonight was her first time sleeping over.
“I’m coming, I’m coming,” Parker shouted as he headed into the hallway of the rather impressive
apartment. Apartments this size weren’t easy to come by in the heart of D.C.
Reva slipped out of bed and looked around for her jeans from the night before. She’d borrowed
one of Parker’s shirts before they went to sleep.
A police officer stood in the living room talking to Parker in hushed tones when she got to him. He
held up a hand for her to stop, so she stayed back. The police knocking on your door at midnight was
never a good sign.
“I’m not that close with my stepfather anymore, so I don’t know where he is. How did you know to
come looking for me?”
“You’re listed in his emergency contacts at his office.”
That seemed to surprise Parker, but he didn’t say as much.
“Why is it so important that you find Noah? Did he do something wrong?”
The officer shook his head. “We can’t give you any details, but it’s very important that we speak
with him. Do you have any ideas for how we might reach him?”
Parker dragged a hand down his face. “Christ. He’s odd about answering the door, so if you came
on strong, he would have just pretended he wasn’t home. Let me call him. I should have his
girlfriend’s number; I can try to call her too.”
 “That would be very helpful, Mr. Jasper. We’re sorry to interrupt your sleep.”
Parker squeezed her shoulder as he headed back to the bedroom for his phone. “Sorry about all
this, baby.”
Reva shook her head. “It’s fine. I hope everything is OK with your stepdad.”
he Parker grimaced. “It’s been a long time since I’ve thought of him that way. Him and my mother are
sedivorced.”
Reva bit her lip and looked down at his plain gray t-shirt, unsure what to say next.
“Noah, it’s Parker. Where are you? The police want to talk to you.”
,” A pause.
“Well, answer the door next time, they woke me and my girl up out of a dead sleep.”
Reva wasn’t sure she could be called his girl; they barely knew each other. But now didn’t seem
like the time to correct him.
Parker ended the call and headed back for the officer. “He says he’ll answer the door this time.”
of The officer cleared his throat and ran a hand through his hair. “I’m afraid we’re about to give him
some bad news, and it might be good to have a familiar face available when we’re done. You might
vefollow us if you want to be that person.”
Parker made a face that said the officer was ridiculous. “I’m sure he’s got someone he can call if
edit’s that bad. Or that girlfriend of his that’s entirely too young for him can comfort him.”
The officer shifted uncomfortably, and Reva got a sick feeling in her stomach. “We should go,
HeParker. I understand you’re not close, but the officer is right, having a familiar face when you get the
asworst news of your life is a comfort.”
She wished she’d had someone familiar to lean on the night her worst news came.
to Parker rolled his eyes but waved a hand. “Fine. Get dressed. I can drop you off at home on our way
back.”
She blinked. “I thought we were going to get breakfast.”
Then again, if Parker’s stepfather was about to be in crisis, her being at home might be for the best,
so she didn’t wait for him to respond. She just headed for the bedroom to search for the rest of her
akclothes.
Five minutes later, they were climbing into Parker’s BMW.
me “I can’t say I was prepared to introduce you to my family,” he said with a forced laugh. “Especially
hisnot to Noah. He’s… different.”
 Reva put a hand on his arm. “It’s fine. Something tells me he’s about to get some really awful
allnews.”
Parker gave a terse nod, and they spent the rest of the drive in silence. She wondered how badly
the marriage to his mother must have ended. Then again, if Noah still had Parker in his emergency
recontacts, it couldn’t have been that bad, right?
It took nearly forty-five minutes to get to their destination, and Reva was awestruck by the size of
the house they parked in front of. She knew Parker was well off just by the apartment he had and the
car he drove, but this house screamed filthy rich.
The police officer asked them to stay back while he knocked on the door. It took a full two minutes
before a man in his early to mid-forties answered the door. He wore dark denim pants and a black
msweater that stretched across his broad shoulders, and there was a look of irritation in his dark eyes.
“Can I help you, officer?”
His voice nearly made Reva gasp. It was deep but not booming. There was a comforting richness
mto it, and she wanted to hear him speak more.
ght “Mr. Jasper, may we come in?”
So, Parker shared a last name with his stepfather? Interesting.
if “I’d rather you didn’t. What’s going on?”
“Does Elise Bricker live here?”
o, Noah blinked, and a chill raced through Reva as the man realized what he was about to hear.
he “Where is she? What happened to Elise?” His voice was still powerful, but there was a tremor in
it that gave away the panic that was likely bubbling inside him.
“I’m afraid Ms. Bricker was found dead a few hours ago.”
ay Noah’s fists clenched, and Reva’s stomach lurched as she watched his world come undone.
“That’s impossible. She was on her way home from a business trip. I just got a message from her
two hours ago saying her plane was delayed.”
st, The officer straightened and held up a hand. “Are you sure about that? She was found dead in a
erfriend’s apartment several hours ago and we believe she was killed sometime between Friday
evening and Saturday morning. That message may have been from her killer.”
Something shifted in Noah, and he backed away. “Come in. I’ll get my phone.”
ly “Sir, we had to contact your stepson to find you, and we hope you don’t mind, but he followed us.”
Noah blinked in confusion and then his eyes landed on her. Reva locked eyes with him for several
seconds before he shook his head and jerked his gaze to Parker.
ul “You didn’t have to be here. But come in.”
“Noah, I’m so sorry,” Parker said, heading for the entrance. “We didn’t know what they were going
lyto tell you, and Reva insisted we come. I’m glad she did.” Parker smiled her way as they stepped
cythrough the door.
Noah looked pained for a moment, then he turned on his heel and disappeared further into the
ofhouse.
he “Come on,” Parker said, reaching for her hand. “The living room is this way.”
The officer followed them, and a few minutes later Noah returned with his phone.
es “We’ll get this back to you as soon as possible, Mr. Jasper. Can you tell us more about when you
cklast saw Elise?” The officer asked as he put the phone into an evidence bag.
Noah launched into a monotone recollection of his weekend. He’d worked late, and Elise asked if
she could go on a last-minute trip for a charity she fundraised for. He’d agreed but told her to be home
ssby tonight because they had things to do tomorrow.
Reva found it odd that it almost sounded like Elise had been asking for permission to go on a trip
and was given a curfew, like some teenager. But that wasn’t important. Someone was dead. Killed
gruesomely from the sounds of it.
Reva wasn’t sure how much longer she could handle sitting here listening to this conversation.
There were too many parallels to the conversation she had with police six years ago.
She leaned over and whispered in Parker’s ear. “Where’s the bathroom?”
in He nodded to the door. “Down the hall, past the kitchen. Want me to escort you?”
Reva shook her head. “No. Stay with him.”
In the bathroom, she splashed water on her face and tried to tamp down the emotion that felt lodged
in her throat. After several minutes, she stepped back into the hallway and willed herself to head
ertoward the living room. When she reached the entry to the impressive kitchen, she stopped. Maybe
everyone could use some coffee. How hard could it be to find the coffee maker?
a In the kitchen, the island was set with two plates and a bottle of wine was open on the counter.
ayHe’d been expecting her home and was going to feed her. Another wave of sadness washed over her,
and she turned toward the wall of cabinets to search for coffee supplies.
“You didn’t strike me as the type to snoop.” The deep voice made her jump, and she whirled with a
mug in her hand.
al “Sorry. Coffee seemed like it would help right now, so I was going to make it. But I don’t see the
coffee maker.”
 “Making yourself at home? You must really like my son.”
ng Reva shrugged. “I just met him a couple of weeks ago.”
ed “And yet, you were in his bed when the police arrived.”
This conversation was getting uncomfortable fast.
he “I’m sorry. I’ll just go back to the living room.”
For the first time, Noah smiled, and her heart twisted at the sight of it. It was a sad smile, but it
made him even more handsome, and she fought the urge to hug him.
“The coffee maker is here.” He reached around her and pressed a button on the wall. The
oucountertop split and a fancy machine rose.
“That thing looks like it cost more than my car,” she muttered as she stepped up to it and tried to
ifsort out how to turn it on.
me “Alexa, make a pot of coffee,” Noah said.
Then he turned and headed for the living room. Before he stepped into the hall, he said, “I like mine
ipwith cream, no sugar. Parker doesn’t drink it.”
ed Reva blinked and shook her head. What a strange interaction. But she was glad to have something
to do other than dwell on the sadness in the other room. Noah seemed unfazed, but grief would hit him
n.soon. There were little touches around the house that said he loved Elise.
A few minutes later, she carried a tray laden with coffee mugs and cream and sugar into the living
room and set it down.
“Jesus, Noah. You asked her to make coffee. Elise isn’t even in the ground yet.”
Reva picked up her own coffee and sat next to Parker again. “He caught me in the middle of doing
edit. He didn’t ask.”
ad Parker looked at her skeptically before casting a glare at his stepfather.
be Noah remained quiet throughout the entire strange exchange. It left her with even more questions
about this family. All of them incredibly rude to ask.
er. The officer had dozens of questions for Noah about where Elise had been and who she was with.
er,Some of the names that popped up surprised Reva. Bradley Givens was the son of a presidential
candidate. Carrie Davenport-Mercer was a fairly well-known investigative journalist. Just who was
h aNoah Jasper that he rubbed shoulders with these people?
When the officers left a half hour later, Parker stood to leave as well. “We should go get that
hebreakfast,” he said with a smile.
Food was the last thing Reva wanted right now, but she nodded and stood.
 “Stay. I’ll cook.”
Parker raised an eyebrow. “Do you even know how?”
Noah gave a sad smile. “Elise and I cooked together all the time. Breakfast is the easiest meal of
them all.”
Now Reva felt obligated to stay, so she sat back down on the couch and picked up her coffee. “That
itsounds nice, Mr. Jasper.”
“Noah. Call me Noah.”
he Reva nodded. “Can I help, Noah?”
Noah shook his head. “I’ll only be a few minutes.”
to “We didn’t have to stay.”
Reva touched Parker’s shoulder. “It’s important. Trust me.”
He didn’t seem convinced, but pulled out his phone and sat back against the couch and tucked an
nearm around her.
After several minutes, the silence became too much to cope with, so she jumped up. “I’m going to
nghelp anyway.”
m Parker gave a grunt of acknowledgement and kept scrolling his phone. In the kitchen, she found
Noah leaning against the island with his eyes closed.
ng An open carton of eggs sat out, and oil was smoking on the stove. She moved quickly and turned the
burner off as she moved the pan away from the hot coils.
“I said I didn’t need help,” he said gruffly.
ng “Trust me, you do. You’re going to want to hide from everyone over the next few weeks and you’re
probably the type that thinks it’s poor form to cry, but it’s not. Answer the phone when your friends
call to check on you and don’t turn down offers to make your life easier. Because someday soon
nsyou’re going to break, and when you do, it won’t be pretty. Right now, you’re probably pretty annoyed
with me because you don’t know me and that’s fine. But you should go talk to your son and I’ll finish
th.breakfast.”
al His knuckles were white as he gripped the marble counter behind him, and his eyes flashed with
asanger. But then his lips quirked up in a half smile.
“You’ve got spunk. I’ll give you that. That’s nothing but good for Parker. There’s a slab of ham in
hatthe fridge. If you’re going to be in here, you might as well help.”
She blew out a breath, thankful she hadn’t completely pissed him off, and opened the fridge. Along
with the ham, she grabbed mushrooms, a bell pepper, and an onion and set up a workstation on the
 opposite side of the island.
She slid him the onion and pulled a knife out of the block.
of “Trying to force me to cry?”
“So, he’s got a sense of humor. I’m willing to bet that’s one of the things she liked about you.”
hat He sliced the onion in half and put one piece aside. “No one has ever accused me of having a sense
of humor, Reva. Even when I’m not grieving, I’m an asshole.”
She cocked her head and studied him. “Probable. But you cared about her, and she saw something
in you.”
“Stop.” His voice was hard. “I can tell what you’re doing, and your one semester of psychology
101 is nothing up against my PhD.”
She raised an eyebrow. “Well, Dr. Jasper. I’m not sure what you think I’m doing, but I’m trying to
anbe the friendly face I wish I’d had on a night similar to this. Nothing more. But I’ll be sure to tell my
dissertation adviser that you don’t think I can hack it in the PhD program anymore.”
to For a split second, she thought he looked impressed, but he schooled his features and went back to
prepping the food.
nd “Psychology?”
She shook her head and pushed the diced mushrooms to the side so she could start on the ham. “I
hedid a double major in undergrad in psychology and political science. Now I’m in a dual track Masters
and PhD program where I’m studying public relations and human sexuality.”
Noah stopped chopping and leaned forward. “Now that is intriguing. What made you want to study
resuch an interesting combination?”
ds She blushed but didn’t look away from him. “That’s complicated. But ultimately, I have my eye on
onhelping improve sex education in this country. Whether that’s by working with a board of education,
edor working with a federal branch of government, I haven’t figured out yet. I could end up teaching at a
shuniversity and conducting research, or I can run a non-profit. It’s a niche field of study, for sure, but
it’s actually quite versatile.”
th “I’m impressed. If you ever need a contact at the ACSL, I’ve got a few.”
“They are an excellent organization. But we really don’t have to talk about me.”
in He cracked several eggs into a bowl and pulled out a whisk. “Talking about you keeps me from
thinking about her.”
ng “You’ve only known she was gone for a couple of hours.”
he “Which means I have a lifetime to mourn.”
 She frowned but slid the ham, bell peppers and mushrooms his way. “If you insist. What now?”
He motioned to the pantry behind her. “There should be some good bread in there. We’ll keep it
simple and have omelets with toast.”
“Can you talk to your toaster too?”
se He smirked. “I could. But my son might have me committed and his mother would try to come after
my money again.”
ng She winced, and he frowned, shaking his head. “Sorry. That was inappropriate. Parker and his
siblings are my adopted children, but Parker doesn’t think too highly of me anymore and his mother
gyoutright hates me.”
“I’m sorry to hear that. I would give anything to see my parents again so I can’t relate to Parker on
tothat, but I hope the two of you figure out how to be close again someday.”
my After that, they worked in silence, and soon they were in the living room eating with Parker who
wrinkled his nose at the mushrooms.
to “Sorry. That was me.”
“Noah knows how I hate them. He just didn’t correct you because he’s a dick.”
Reva frowned and tried to reassure him with a hand on his shoulder. That was a harsh thing to say
“Ito his grieving father. “We can get something else on the way back to my place.”
rs He shrugged and pushed his plate away. “I got a last-minute meeting with Monica Parrish, and I
should really try to get a bit of sleep beforehand, so I should get Reva home.”
dy Noah shoved his own plate away and stood. “Now who’s being a dick? I’ll walk you both out.”
Reva’s head was spinning from the speed at which things shifted between these two. What was
ontheir problem? But she stood and followed the two men to the front door where Parker shifted
n,awkwardly. “I’m sorry about Elise. I’ll have Mandy and Jacob check on you this week.”
ta Noah nodded and extended his hand for a firm shake before he turned to Reva and smiled. “It was
utlovely to meet you. Perhaps you can bring my son around more often.”
She opened her arms for a hug.
A mistake she shouldn’t have made.
The way his scent enveloped her had her pulse racing and her mind going places it had no business
mgoing.
“I can come sit with you if you need me to,” she heard herself saying against his chest.
Then he kissed the crown of her head and gently pushed her to the door. “Go. You don’t need to sit
with a sad old man. I’ll be fine.”
 Nothing about Noah made her think of him as an old man. If anything, he screamed sex and danger.
itShe had to get out of there before her thoughts got entirely too inappropriate for the circumstances.

er

his
er

on

ho

ay

dI

as
ed

as

ss

sit
 Nothing about Noah made her think of him as an old man. If anything, he screamed sex and danger.
She had to get out of there before her thoughts got entirely too inappropriate for the circumstances.
Chapter 2
Chapter 2
Five Years Ago

Noah
oah stared in the mirror and straightened his stark black tie. Black was his go-to color, so
N getting dressed today was no different from any other day.
Except it was.
The coroner released Elise’s body, and today was her funeral. It would be a closed casket service,
and friends had talked him out of seeing her body because of the gruesome nature of her death. She
wasn’t supposed to die before him. She was supposed to get bored and leave the way most women
with their arrangement did. But after two years, Elise had shown no signs of wanting to leave. They
loved each other in every way possible. That didn’t stop him from believing she would leave one
day. He just never expected it to be like this.
His phone buzzed on the dresser, and he picked it up.

Parker: Is it OK if I bring Reva to the funeral?

Noah’s relationship with his son was strained and had been since the divorce. Even though Parker
didn’t share his blood, he still thought of him as his son and even adopted the boy and his two siblings
after his birth father died tragically. The marriage to their mother, Melinda, had been a mistake. They
were about as different as two people can be. But he loved her kids as his own, and all three of them
still used his last name even though they weren’t as close as he would like. Mandy, the middle child,
would be getting married in a little less than a year. He was invited to the wedding, but so far, she
hadn’t asked him to walk her down the aisle. Noah wasn’t sure how he felt about that. He didn’t feel
entitled; it was her wedding after all. But he could picture himself in that role.
He read the text again and thought of Reva Calhoun. She’d been there the night the police told him
about Elise. Gorgeous but uncomfortable in her own skin even though she was brilliant and had a
spunky side. Not the kind of girl Patrick usually went for. But that might be good for him.

Noah: Bring her. I appreciate her being here the other night.

It was kind of her to want to come. Something told him Patrick wouldn’t have even attended the
funeral if his new girlfriend didn’t insist. But it meant he would have all three of his children in the
 same room with him for the first time in nearly a decade. He was grateful for that, despite the reason
for them coming together.
He clutched the locket Elise wore as a collar and tucked it in his pocket. “Miss you too much,
princess.” His voice cracked, and he hated the sound of it in the empty bedroom.
so On the front steps of his house, he waited for the car to be brought around. His phone rang, and he
scowled when he recognized the number.
“Noah. We could use you in Poland next week.”
e, “Seriously, Jared? I’m burying my girlfriend today, and you’re trying to call me into the field?”
he Jared cleared his throat and had the decency to sound remorseful. “You know we wouldn’t ask if it
enweren’t absolutely necessary. You’re the only one with the skill to negotiate with these people. The
eypresident himself is asking for the great Dr. Jasper to lend his profiling expertise.”
ne Fuck.
“Yeah. OK. Give me the rest of the weekend. I’ll get on a plane Monday.”
Getting back into the field might take his mind off the grief.
After he met Elise, Noah had taken a break from the field and spent most of his time working from
D.C. Occasionally, his work for the state department would still take him out of town, but he’d
limited his dangerous activities because he enjoyed coming home to Elise on her knees. They were
er
always pushing him to get back to full-time status, though.
gs
In the back of the limo, he thought about what he would say to her parents. They’d never been huge
ey
fans of Noah’s. Not that he blamed them. If Mandy brought home a man nearly twice her age, he
m
would look at him skeptically too. That made him a hypocrite, he knew that. But Elise was special.
d,
She was a ball of energy, but she wasn’t flighty. She could drink like a fish with her girlfriends, but
he
she never took it too far and always came home to him and his dominance. Maybe it’s because he
el
spoiled her. Spoiling her was his favorite pastime. After he’d completely defiled and used her in the
bedroom, he would shower her with whatever she wanted.
m
“We should bring you in through the back of the church, Dr. Jasper. The press is already pretty
a
heavy despite our best efforts.”
It didn’t surprise Noah that Elise’s funeral garnered media attention. The murder made the news
since it was one in a string of gruesome deaths. Plus, the son of a presidential candidate was wrapped
up in all of it and his girlfriend Darci had been kidnapped by the murderer. There was little he could
hedo about the press, since Darci would be at the funeral.
he
on His role at the state department was secret, and he wanted it to stay that way. So he didn’t hide
from the press, but he didn’t linger when they were around either.
h, Actively hiding meant they would seek him out and ask more questions than he was prepared to
answer.
he So he adjusted his tie and shook his head at his driver. “I’ll go in through the front. Let them see
me. That should satisfy them. I won’t be making a statement, though.”
The driver scowled but didn’t argue.
At the church, he kept his head down as he climbed the stairs and made his way inside. His
itexpression remained stoic, and he was careful to keep his eyes devoid of emotion.
he Inside was another story. The room was thick with emotion that nearly smothered him.
“Noah, I’m so sorry.” Darci Sanders wrapped her arms around him and cried against his chest. He
hugged her back and let her cry. Elise had a lot of friends who were hurting today. He needed to be
strong for them. If he wanted to, he could fall apart at home.
“It’s not your fault, Darci. I want you to hear me say that.”
m She lifted her head and wiped at her eyes. “Thanks, Noah. I can’t stop seeing her like that and I
’dmiss her so much.”
re “How are you? Have you seen a therapist?”
Elise was murdered in Darci’s apartment, and she’d walked in on the gruesome scene.
ge “Yeah. I’m seeing my regular therapist weekly for a little while.”
he “Good girl.” He kissed the top of her head before she walked away to join her boyfriend, Bradley.
al. Noah turned to find Parker and Reva standing behind him.
ut Parker offered his hand for a handshake, but Reva came at him with a hug.
he He was struck again by her beauty, and he hoped his son was treating her right.
he “Noah, I’m so sorry for your loss,” Reva said as she stepped away from Parker. “I didn’t know
Elise, but I know she meant a lot to you, and the crowd here today is a testament to how wonderful
ttyshe must have been.”
Noah smiled and put a hand on her shoulder. “Thank you, Reva. And thank you again for being
wsthere the night she died. It meant a lot to have you and Parker there.”
ed Parker moved closer and laced his fingers with Reva’s. “Mandy and Jacob are already inside. The
ldfuneral director put us on the front row with you. I hope that’s OK.”
Noah smiled. “I’d like nothing more.”
 de The service was as gut wrenching as Noah expected it to be, but he kept it together enough to say a
few words.
to At the cemetery, it was harder to keep himself together. Her friends, Darci, Carrie, and Olivia were
in tears the entire time, and Noah noticed Reva stayed misty-eyed as well. But she was observant, and
eeat one point during the service, she put a hand on his arm and leaned close.
“It’s OK not to cry until later.”
Noah grimaced and patted her hand. “Thanks.” Her words gave him the strength to get through the
Hisrest of the burial.
After the graveside service, those closest to Elise came back to Noah’s house for a small
reception. Playing host was the last thing he wanted to do, so he’d hired staff for the day and locked
Hehimself in his study after greeting everyone. Her parents were too grief stricken to attend and had
begone back to their house, but he promised to check on them often.
Two scotches in, the grief hit him like a ton of bricks in the form of anger, and he hurled his drink at
the wall. “God damn it,” he bellowed, unable to keep it inside any longer.
d I “Dad?” a voice from the hallway said.
Only Mandy called him Dad. Guilt flooded him when he realized she’d heard his outburst.
“I’m fine, sweetheart. Just leave me be.”
“Jacob and I have to leave. We just wanted to say goodbye.”
He swiped at the tears he didn’t realize had fallen and stood to unlock the door.
“Thanks for coming,” he said, pulling her into a hug.
“Of course. I’m so sorry she’s gone.”
In the entryway, he hugged Jacob and Mandy goodbye and told them to drive safe. Unable to face
the mess in his office, he headed for the kitchen, intent on getting a cup of coffee.
w He found Reva sitting at the island crying.
ul “Reva?”
She jumped and whipped her head around as she grabbed a napkin and dabbed at her eyes. “Oh
nggod. I’m sorry. Look at me being a mess over someone I never met.”
Noah smiled and slipped onto the barstool next to her. “She was pretty amazing, but I get the
heimpression the tears are for someone else.”
Reva cocked her head. “What makes you say that?”
“Just a sense I’m getting. Want to talk about it?”
“Today is about you.”
ya He put a hand over hers. “And I’ve had enough of people feeling sorry for me.”
She closed her eyes and fingered the handle of her mug for several seconds before she spoke. “My
reparents and older sister died in a horrible accident my junior year of high-school, seven years ago.”
nd Noah did the math. That made her no more than twenty-three now. Elise died at twenty-six.
At forty-two, most people thought he was too old for her, but they made it work.
“I’m so sorry, Reva. That’s a lot of loss in one night.”
he “Tell me about it. My entire world turned upside down. Sitting through the police talking to you the
other night, brought back a lot of memories I’d suppressed.”
all He squeezed her hand before pulling away. “Thank you for being here. I hope you’ll bring Parker
edaround more often. Of all my children, he’s the one who hates me the most.”
ad Reva frowned. “I don’t know him very well. We’ve only been going out a couple of weeks. But I
don’t think he hates you. I just think he doesn’t understand you.”
at Noah brows drew together in confusion. He wasn’t that difficult to understand.
“Still, I appreciate getting to see him more often, and I can’t thank you enough for insisting he
come.” He stood and pulled a card out of his pocket.
“This is my personal information. You don’t know me, but I can fix just about any problem you
might have. So, if you ever find yourself in trouble with no one else to call, reach out. I want to help.”
And he meant it. Parker would accuse him of hitting on her. But something about Reva just
screamed that she needed protecting.
As long as she was dating his son, he would do what he could to do just that.
She tucked the card in her pocket. “I should go find Parker.”
ce He watched her for the rest of the evening. She spent time at Parker’s side, but he usually spotted
her picking up someone’s trash or carrying empty dishes to the kitchen.
She looked at home in his house. He liked that. Hopefully, it meant he would see Parker more often.
When she disappeared from the living room and stayed gone for longer than usual, he went in search
Ohof her, worried she might be overwhelmed with emotion again.
Instead, he found her in the doorway of his study with a dustpan, cleaning up his mess.
he “I have a cleaning staff. You don’t have to do that.”
She jumped, then laughed. “You seem to have a habit of scaring me.”
“And you have a habit of being places you don’t belong.”
Her face turned red. “Sorry. I just need to stay busy.”
 He took the dustpan from her and bent to finish sweeping up the glass. “No need to apologize. I’m
Mysorry I made the mess to begin with. Pretty sure I scared my daughter with it.”
Awkward silence hung between them, and he cleared his throat. “I should take this to the kitchen.”
“I should go find Parker.”
Later, when everyone said goodbye, he hugged her for a little longer than he should have, but she
returned it and stepped back with no hint of awkwardness.
he “Just call if you need anything, Noah,” Parker said, before offering his own hug.
The house was empty, and he had a hard time sleeping. Living here without his Elise seemed
erimpossible. Getting back into the field might be for the best. Poland was a long way away and didn’t
hold the memories that this place held.
t I The next day, Noah stayed in his office and drank the pain of missing Elise away. By Monday, he’d
hardened his heart and was ready to get back to work.

he

ou
.”
ust

ed

n.
ch
 He took the dustpan from her and bent to finish sweeping up the glass. “No need to apologize. I’m
sorry I made the mess to begin with. Pretty sure I scared my daughter with it.”
Awkward silence hung between them, and he cleared his throat. “I should take this to the kitchen.”
“I should go find Parker.”
Later, when everyone said goodbye, he hugged her for a little longer than he should have, but she
returned it and stepped back with no hint of awkwardness.
“Just call if you need anything, Noah,” Parker said, before offering his own hug.
The house was empty, and he had a hard time sleeping. Living here without his Elise seemed
impossible. Getting back into the field might be for the best. Poland was a long way away and didn’t
hold the memories that this place held.
The next day, Noah stayed in his office and drank the pain of missing Elise away. By Monday, he’d
hardened his heart and was ready to get back to work.
Chapter 3
Chapter 3
Nine Months Later
eva
R “Reva!” Thank you so much for coming on such short notice.
Mandy Jasper pulled her into a hug, and Reva patted her back. “Of course. I’m so sorry about
Sarah and Jay.”
Tomorrow, Mandy would get married to her long-time boyfriend, Liam, and they were all in a
Château in the south of France for the big day. Except, one of the bridesmaids and groomsmen were
stuck in the United States because they didn’t realize their passports were expired.
“It’s fine. We’ll miss them, but these things happen. I’m just glad you were here to step in. And now
I’m glad I didn’t go for having all the bridesmaids in the same dress. The design team brought extra
dresses with them. Let’s go pick the one you like so the designer can get started on the alterations.”
Reva was so glad Mandy didn’t want her to go on some crazy shopping trip. She hated shopping
and avoided it. Even fancy shopping in France. Or maybe especially fancy shopping in France.
“So, how are things with you and my brother?” Mandy asked as they walked down a hall and up a
flight of stairs to get to the sewing room.
Talking about Parker with his family made her uncomfortable. She liked him, but she didn’t know
what kind of future they had. They had fun together, and he wasn’t a douchey guy. But did she see him
as her forever relationship? She didn’t know. So far, though, all the pro-con lists she liked to make
worked out in his favor.
“Good. We’re still getting to know each other.” It seemed like the safest response.
They entered the sewing room where four dresses were hung neatly on a rack. “Oh wow. These are
gorgeous.”
The dresses were probably worth more than her entire wardrobe. She’d learned that the Jasper
family had billions. But she didn’t care about the money. In fact, it made her uncomfortable. The fact
that attending this wedding would cost over four months of her bills and she could never afford it on
her own made coming awkward, but she was going to do her best to enjoy the adventure.
“Now. I hope you don’t mind, but you’ll be walking down the aisle with my dad. We asked him to
step in to fill the other groomsmen spot.”
Reva’s eyes grew wide. Why not Parker? And why wasn’t her dad walking her down the aisle.
“Monica and Parker are almost identical in height; I didn’t want to switch that up at the last minute.
And my dad needs a role in the wedding. I’m just not having anyone escort me down the aisle and I’m
 sure he’s hurt about that. This will be good for him. And also, he hates Monica, but I don’t have the
details on why, so I can’t cause drama by making them walk together. Planning a wedding is a lot,
Reva.”
She gave a little laugh at Mandy’s rapid-fire explanation despite the small bit of panic bubbling on
utthe inside. “Don’t worry about it, Mandy. It’s your wedding. I’ll walk with whoever you need me to.”
If she was honest, she was nervous about seeing Dr. Noah Jasper again. They hadn’t spoken since the
afuneral, but his voice often appeared in her dreams.
re “I really appreciate this. We considered not replacing Sarah and Jay, but Liam’s mom insists we
need to have a big wedding party for the pictures we release to the public. It’s a whole thing. You’re
wreally doing me a huge favor.”
ra The bride-to-be clapped her hands together, changing the subject. “So, which dress do you like?”
Reva studied the dresses for a few seconds before choosing the halter style neckline with a flowing
ngwaist. “This one. The others don’t seem like they would hang right on me.”
“Excellent. I loved that one when the designer brought it to me.”
a God, how much were they spending on this wedding? Something told her she didn’t want to see the
accounting. It would just depress her, given the fact that she was facing the prospect of losing funding
wfor her graduate program soon.
m “What’s your shoe size? I’ll get you a pair to match.”
ke “Seven.”
“Great. Let’s get Jasmine in here to get your measurements and then you can get out of here and find
Parker. I’m sure this was not how you planned to spend your day.”
re To be honest, she was planning to curl up in hers and Parker’s room—which was bigger than her
entire apartment back in D.C.—and read a book all day while he spent time with the other
ergroomsmen.
ct A gorgeous older woman came floating into the room with a tape measure around her neck and
onReva swore birds should have been following her. She looked familiar, but Reva had no idea why.
“Oh, goody. She picked one of my designs,” the woman said as she approached Reva and started
toturning her this way and that.
“It’s beautiful, Jasmine. Thank you so much. I’m so excited you were free to be here this week,”
Mandy gushed.
te. “Your mother was very insistent. And my Simon has been after me to take another vacation, so
mwe’re staying an extra week after the wedding. I should thank you, darling.”
he She turned to Reva and ordered her into the dress with such confidence that she didn’t hesitate. As
ot,she slipped it over her head, Jasmine whispered, “No offense to Sarah, but I’m rather glad her
passport was expired. You were simply made for one of my dresses.”
on It was a struggle to keep the smirk off her face as the fabric fell over her body. It was luxurious and
.”fit her just the way it was. But Jasmine threw the tape measure around her anyway and pulled on the
hefabric.
“We hardly need to alter this at all. It’s as if I made it for you. When I was designing it, I had a
wefeeling someone special would wear it. I just didn’t realize how special. My muse did though.”
re Was she serious?
“Jasmine is one of the best designers in the world. She designed for six people at the Oscars last
year. How lucky am I?” Mandy said, excitement in her eyes.
ng Reva didn’t care who made the dress she was wearing, but there was something about Jasmine that
she liked. And she had to agree that the dress was a near perfect fit as it was.
After the older woman poked and pulled on the dress for several minutes, she declared her
hemeasurements done and ordered her to take the dress off.
ng “You need some diamonds. I’ve got a few gorgeous pieces with me. You can try them in the
morning.”
“Oh, That’s unnecessary. I’m sure I’ve got something in my jewelry bag.”
“Nonsense. Enjoy the pampering, darling. I see in your eyes that it’s been a while.”
nd Reva frowned. What the hell was that supposed to mean? But she didn’t have time to think about it
because the woman gathered the dress she’d just taken off and floated out of the room again.
er “Wow, that was a lot,” Reva said as she stared after her, stunned.
er “Jasmine Darlington.” Mandy said in a dreamy voice. “I still can’t believe my mother tracked her
down. She’s so picky about who she works with. Now get out of here and enjoy the island. Rehearsal
ndisn’t for hours.”

ed

k,”
“Ms. Calhoun, how is your graduate program going?”
Reva sucked in a sharp breath and turned at the sound of Noah Jasper’s velvet voice. His smile
so
was breathtaking, but it didn’t quite reach his eyes. He looked tired. There was a hollowness about
him that hadn’t existed when he opened the door for the police all those months ago. Parker had
Ascalled him a few times, but to her knowledge he hadn’t visited. And she would not nag him about it.
erTheir relationship was too new for her to become the nagging girlfriend.
“Dr. Jasper, how good to see you again. It’s going well. Thank you. And how are you?” It didn’t
ndfeel right to give him the honest answer that her department was on the cusp of having to make some
heserious funding cuts.
“I’m surviving. My daughter tells me I’ll be escorting you tomorrow. I hope this means you’ll save
ame a dance at the reception.”
Dance with Noah Jasper? She could imagine herself tripping all over her own feet.
“I’ve never been a superb dancer. But I’ll think about it.”
ast Before he could say anything else, someone called for him and he put a hand on her shoulder.
“Excuse me. I’ll see you when rehearsal starts.”
hat She stared after him until Parker came and wrapped his arms around her from behind.
“Are you glad you came, babe?”
er She smiled at him and nodded. “Of course. Is it weird that I’m walking down the aisle with Noah
and not with you?” She learned not to refer to Noah as Parker’s dad. He definitely didn’t see him like
hethat. Not like the other two did. Though even Jacob called him Noah, he at least still seemed to like
the man that adopted him when his own father died.
Parker frowned. “Why would it be weird? It’s a wedding. You have to walk with the person you fit
the best with, or the photographers get weird, or the bride starts crying.”
it Reva laughed at his characterization of weddings. He thought she would fit best with his dad? Or
did he think Monica would look best with him? She had to admit she was kind of jealous that Monica
Parrish was walking with Parker. They’d met a few times, and she didn’t care for the woman. But she
erwas a friend of the family and important to some aspect of Parker’s work, so she didn’t say anything.
al A half hour later, rehearsal started, but Noah wasn’t there. Had something happened?
“Reva, can you walk by yourself tonight and just give my Dad the notes in the morning? He had to
take an important work call.”
Ever the agreeable one, Reva walked down the aisle by herself, pretending to be on the arm of the
handsome older Jasper. His looks were rugged, and she got the sense he’d seen some things in his line
of work—whatever that was, Parker wasn’t exactly clear on it—but he was still nice to stare at.
Halfway through the ceremony rehearsal, Noah slipped into his spot on the groom’s side of the
le
wedding party and Reva swore he winked at her when their eyes met.
ut
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 FIG. 57.

Diagram to represent the Mode of Action of Counter-irritants applied to

the Chest (Lauder Brunton). The irritation of the afferent nerves by the
blister on the chest wall gives rise to a vaso-constrictor reflex in the
vessels of the lung.

Since the vaso-motor nerves are connected almost exclusively with

the dorsal portion of the spinal cord, it is very natural to conclude that
the vaso-motor reflex centres are situated in this region; and the
hypothesis has been advanced by Jacubovitch, and strongly urged
by Gaskell,11 that the cells of the vesicular columns of Clarke, which
are peculiar to this region, are the seat of these reflex mechanisms.
This hypothesis gains some support from the pathology of syringo-
myelia. In this disease the gray matter surrounding the central canal
and the vesicular columns are destroyed. The characteristic
symptoms are vaso-motor and trophic disturbances, consisting of
changes in the vascular tone, changes of local temperature, and
various eruptions, in some cases going on to ulceration in the skin
and mucous membranes. It is, however, undecided whether the
vaso-motor centres of the cord are limited to the columns of Clarke,
or are situated in the gray matter surrounding the central canal, since
both these parts are destroyed in this disease.12 That they are not
located in the anterior or posterior gray cornua is determined by the
fact that diseases limited exclusively to these areas do not cause
vaso-motor disturbances. The situation of the various reflex centres
for the various parts of the body is at different levels of the cord, as
has been determined by the experiments already cited to establish
the level of origin of the vaso-motor nerves. The exact location of the
vaso-constrictor and vaso-dilator reflex centres for definite parts is
yet to be ascertained.
11 Loc. cit.
 12 See Fürstner, Arch. für Psych., xiv. 422.

Vaso-motor Tracts.—These reflex centres are connected with the

medulla by tracts which lie in the lateral columns of the spinal cord,13
although it is not determined in which part of these columns. It is not
possible as yet to separate the constrictors from the dilators in this
tract, nor to determine whether it transmits impulses in both
directions or only from above downward. Nor is the course of
associating fibres between reflex centres at different levels known. In
cases of transverse myelitis the control of the medulla is removed
from the vascular centres below the lesion, and the lack of vascular
tone seen in the paralyzed limbs, together with the susceptibility to
local irritation, is the result of this division of the vaso-motor tracts.
13 “Owsjanikow and Tschirijew,” Bull. de l'Acad. de St. Petersbourg, xviii. 18.

Medullary Centres.—It has been stated already that a general vaso-

motor centre with both constrictor and dilator powers is situated in
the medulla. This lies in two divisions on each side of the middle line,
in or just beneath the floor of the fourth ventricle, from the calamus
scriptorius up to the level of the sixth nerve-nucleus. Each division
governs the vascular tone of its own side of the body,14 and lesions
in its region in man produce unilateral vaso-motor symptoms.15 This
centre can be excited to reflex action by strong irritation locally or
through the blood, in which case a general constriction or dilatation
of the vessels of the entire body will ensue. It seems probable,
however, that the general centre in the medulla is made up of a
number of special centres, each of which governs a definite set of
organs. The vascular tone of the thoracic and abdominal viscera is
certainly regulated by a series of such centres. Brown-Séquard and
Schiff have produced hemorrhages in the lungs, pleura, stomach,
intestines, and kidneys at different times by destructive lesions of the
medulla, and the well-known experiments of Bernard, in which by
puncture of the medulla local hyperæmia of the liver or kidneys was
caused, producing glycosuria or polyuria, confirm this view. Lesions
of these parts in man produce similar effects. Charcot has shown
that in cerebral hemorrhage ecchymoses may be found in the
stomach, pleura, and endocardium, and that pneumonia is especially
frequent upon the paralyzed side. De Jonge16 has been able to
collect thirteen cases of diabetes mellitus in which a lesion of the
medulla (hemorrhage or tumor) was found after death; and Flatten17
has proven the existence of similar lesions in diabetes insipidus. The
connection of these centres with the liver and kidneys has been
traced elsewhere.18 The medulla contains a special centre for the
vaso-motor nerves of the abdomen, which are in the domain of the
splanchnic nerves. This centre is excited reflexly by impulses
reaching it through the depressor nerve of Cyon from the heart; so
that when that organ is overburdened it may be relieved by a fall of
arterial pressure produced by dilatation of the abdominal vessels.
Whether the connection of the medulla with the centres in the
semilunar ganglion which preside directly over these vessels is
made by way of the spinal cord or by way of the pneumogastric
nerve is still undetermined, though the researches of Gaskell favor
the former view. Gastric and intestinal disturbances are certainly
produced by nervous lesions in the medulla, but whether they are
due to vascular changes is uncertain. The vomiting of mucus and
blood, and the large watery evacuations which accompany mental
shock or anxiety, as well as the polyuria associated with mental
effort, have been ascribed to irritation of local centres in the medulla
governing the gastro-intestinal and urinary organs by impulses
received from the cortex above. The spleen is under the control of
vaso-motor centres, since section of the splenic branches of the
semilunar ganglia will produce a great enlargement of the organ, and
irritation of the cut end of these branches will produce contraction.19
The medulla also contains a vaso-dilator centre for the erectile
tissues of the genital organs, irritation of which by mental action or
local disease causes impulses to pass to the nervi erigentes by way
of the spinal cord, resulting in a flow of blood to the parts. Although a
centre has been thought to exist controlling the circulation in the
lungs, whose paralysis has been supposed to explain the occurrence
of sudden pulmonary œdema without other known cause, no definite
facts regarding it are known. That the action of the heart is under the
control of the medulla is a fact too well known to require more than a
mention. The physiology of the nervous control of the heart cannot
be discussed here.
14 Owsjanikow, Arbeiten aus d. Physiol. Instit. zu Leipzig, 1871.

15 M. A. Starr, “Sensory Tract in Central Nervous System,” Journ. Nerv. and Ment.
Dis., July, 1884, pp. 396-398.

16 Arch. f. Psych., xiii.

17 Ibid.

18 See Tyson, “Diabetes Mellitus,” Pepper's System of Medicine, Vol. I. p. 195; Edes,
“Diabetes Insipidus,” ibid., Vol. IV. p. 30.

19 Tarchanoff, Pflüger's Arch., viii. p. 97; Ross, Diseases of the Nervous System, vol.
i. p. 225.

While these medullary centres are certainly influenced by impulses

reaching them from the cerebral hemispheres, as is evident from the
vaso-motor symptoms produced by mental action—e.g. pallor from
fright, blushing, etc.—it is impossible to state in what portion of the
hemispheres in man the higher vaso-motor centres lie. Eulenburg
and Landois locate them in the motor area in animals.20 They are
certainly beyond control of the will, and are wholly reflex in their
action, a purely mental act in this case being the excitant of a purely
physical result.21
20 Arch. f. Path. Anat., Bd. lxviii. p. 245.

21 In addition to the articles already cited the reader is referred to Landois's

Physiology, to Duval's article, “Vaso-moteurs,” in the Dictionnaire de Médecine et de
Chirurgie, vol. xxxviii. (1885), for a summary of vaso-motor physiology, and to
Gerhardt's “Ueber Angio-neurosen,” Volkmann's Sammlung klin. Vorträge, No. 209.
Gaskell's researches, published in the Journal of Physiology, are the most recent and
satisfactory.
PATHOGENESIS.—From this review of the physiology of the vaso-motor
system it becomes evident that disturbances of vascular tone may
be produced by many different causes acting upon many various
parts. They may be due to local affections of the part in which the
symptoms are present, as in the case of erythema22 after burns or
frost-bite, or congestion of any organ after injury. They may be due
to affections of the vaso-motor nerves passing to the part affected,
as in the case of vascular changes due to peripheral nerve lesions.23
They may be due to affections of the sympathetic ganglia connected
with the part affected, as in the case of migraine,24 sudden flushing
of one ear, certain cases of polyuria,25 and Basedow's disease.26
They may be due to lesions in the spinal cord affecting the vaso-
motor centres27 or compressing the nerve-roots on their way to and
from the sympathetic ganglia,28 as is the case in the various forms of
myelitis and in Raynaud's disease or symmetrical gangrene, and in
meningitis, tumors of the cord, or Pott's disease. They may also be
caused by such conditions in the cord as cut off the vaso-motor
centres from the medullary centres, such as transverse myelitis from
compression or traumatism.29 They may be due to lesions of the
medulla oblongata,30 as is seen in some cases of polyuria and
glycosuria,31 and in cases of universal erythema32 following acute
fevers. They may be due to diseases of the cerebral hemispheres,
as is evident from the vaso-motor symptoms occurring in hemiplegia
and hysteria. Finally, they may be of a reflex origin, dependent upon
some obscure source of irritation in a part quite distant from the
region in which the symptoms appear.33
22 Vol. IV. p. 511.

23 Vol. V., “Neuritis.”

24 Vol. V., “Migraine.”

25 Vol. IV., “Polyuria.”

26 Vol. III. p. 761.

27 Vol. V., “Syringo-myelitis.”

 28 Vol. V., “Meningitis Spinalis.”

29 Vol. V., “Transverse Myelitis.”

30 Vol. V., “Medulla.”

31 Vol. I., “Diabetes Mellitus.”

32 Vol. IV. p. 512.

33 Vol. V. p. 205.

The DIAGNOSIS of the seat of the lesion in many cases of vaso-motor

neurosis may be made if the organ or the exact limitation of the area
affected be ascertained, and the history of the case, together with
the concurrent symptoms of other kinds, be considered. In some
cases no organic cause can be found, and in these a reflex cause
should be diligently searched for.

SYMPTOMS.—A vaso-motor affection may manifest itself either by a

spasm or a paralysis of the vessels. In angiospasm the part affected
becomes pale, and irritation no longer causes a vaso-motor reflex. It
looks shrunken, and if the skin over it is loose it may be thrown into
folds or shrivelled, presenting the appearance seen in the hands
after long immersion in hot water. The lack of blood in the part
arrests the processes of metabolism which are normally constant,
and if the condition continues this may result in such a disturbance of
nutrition that ulceration, or even gangrene, may ensue. The local
anæmia, combined with the cessation of metabolism, produces a fall
of temperature in the affected part, which is then more easily
affected by the temperature of the air than in a normal state, so that
exposure to cold is very liable to cause freezing. These conditions
necessarily produce an impairment of function, so that if the affection
is located in the extremities, as the fingers, they are soon rendered
useless. The term digiti mortui has been applied to this state. In the
surface of the body angiospasm causes cutis anserina, pallor,
numbness, tingling, slight anæsthesia, and analgesia. If it occurs in a
limb, the finer motions are imperfectly performed, and in time the
nutrition of the muscles may be so impaired as to produce atrophy
and paresis. It may even lead to gangrene. Nothnagel has
recorded34 five cases of sciatica in which the pain produced a reflex
spasm of the vessels of the leg, which, persisting, resulted in partial
paralysis, atrophy, lowering of temperature, pallor, and sensory
disturbances. Ross mentions35 the sudden appearance of
circumscribed patches on the hands and forearms of washerwomen,
in which there is a pallor, coldness, and partial anæsthesia. These
may be limited to the distribution of a single nerve, and may be
accompanied by trophic affections.
34 Arch. f. Psych., v.

35 Vol. I. p. 221.

Spasm of the veins may occur as well as of the arteries,36 or

independently of them. In the latter case the blood will not pass out
of the capillaries. The part will then be blue, swollen, œdematous,
and painful; the temperature will be lowered by increased radiation of
heat, and all the sensations and functions be impaired in greater or
less degree. If this continues, nutrition may suffer, and in the end
gangrene develop, which will take its course and lead to the throwing
off of the part. Grainger Stewart has described such a condition
occurring in both hands and feet.37 It may be likened to a severe
form of Raynaud's disease.
36 Weiss, “Symmetrische Gangrän,” Wiener Klinik, 1882.

37 Grainger Stewart, An Introduction to the Study of Nervous Diseases, p. 138.

Angio-paralysis is more frequent than angiospasm, and may be due

either to paralysis of the vaso-constrictors or to excitement of the
vaso-dilators. It shows itself by a bright-red or mottled appearance of
the skin, and increase of local temperature, and more rapid
processes of nutrition, together with an increase of secretion if the
part is a gland or a mucous membrane, and an increase of sweat if it
is the skin. In the latter case an increased sensitiveness to changes
of temperature, a subjective sensation of heat, and hyperæsthesia
and hyperalgesia may occur. The hyperæsthesia on the paralyzed
side which is present in hemiparaplegia spinalis is ascribed to the
vaso-motor paralysis. But these symptoms soon give place to others.
The dilatation of the vessels, which at first caused an increased flow
of blood to the part, produces a slowing of the blood-current in the
part, just as a river runs less rapidly where it becomes wider. The
slowing of the current in the skin allows of a more complete cooling
of the part as the radiation of heat and the evaporation of moisture
are increased, and the slowness of the renewal of blood impairs the
processes of nutrition, so that to the first stage of redness, heat, and
increased metabolism there ensues a stage of blueness, cold, and
defective nutrition, and the function of the part may be impaired. In
this stage it usually presents a mottled appearance, and may be
slightly swollen and œdematous, and the continued increase of
perspiration gives it a clammy coldness to the touch. In all of these
conditions severe pain, sometimes of a burning character, is a very
distressing symptom (causalgia). These conditions are seen in
peripheral nerve-lesions, and give rise to the appearances which
have been so admirably described by Weir Mitchell.38
38 Injuries of Nerves.

A peculiar combination of symptoms may be mentioned here, to

which Weir Mitchell has given the name of erythromelalgia.39 This
disease begins with tenderness and pain in the soles of the feet,
which are soon followed by a marked distension of the capillary
vessels. The congestion is attended by a sensation of burning pain
similar to that produced by a blister. The surface is at first of a dull
dusky-red color; later it appears purple. The redness is not uniformly
distributed over the sole, but occurs in patches of irregular shape,
being especially frequent over prominent parts exposed to pressure
and friction, and the attacks seem to be brought on by long standing
or walking. At first there is a rise of temperature in the affected
surface, the arteries pulsate visibly, the veins are swollen, and there
may be some œdema. Later, the foot is cold and pale. Sensations of
touch and temperature are normal, but the part is so extremely
tender that walking is impossible. There is no paralysis. One or both
feet may be affected, but the patches of redness are rarely
symmetrical. The hands are occasionally affected. The condition
may occur in paroxysms or may remain for some time. It resists all
known methods of treatment, although applications of cold relieve
the burning pain to some extent and the tenderness enforces rest.
39 Amer. Journ. of the Med. Sci., July, 1878.

With angio-paralysis may be classed the taches cérébrales of

Trousseau no longer considered diagnostic of meningitis, but
denoting a weakened condition of vaso-constrictor action in the local
ganglia of the vessel-wall which may occur upon local irritation of the
skin in any severe disease affecting the nutrition of the general
nervous system.

Actual rupture of the capillaries in the course of vaso-motor diseases

is rarely observed, although the stigmata appearing in hysterical and
cataleptic patients may be ascribed to this cause. In this connection
tabetic ecchymoses may be mentioned, which appear suddenly
without local injury, and resemble an ordinary bruise, running a
similar course. They occur only in the course of locomotor ataxia.40
40 Straus, Arch. de Neurologie, tome i. p. 536.

In addition to these forms of vaso-motor affections there is a

condition of instability of vascular tone which manifests itself by
sudden transient changes in the circulation of various organs. This is
a functional affection, usually due to malnutrition. It is seen in many
cases of neurasthenia and hysteria, and manifests itself by sudden
flushes or pallor, alternations of heat and cold, local sweating,
attacks of mental confusion, and inability to use any organ
continuously from disturbance of the power of the vaso-dilators to
maintain a condition of functional hyperæmia.41 Little is actually
known about the causes of this state of the vascular system,
although much has been written about it. (For a fuller description the
article on Neurasthenia may be consulted.)
41 Anjel, Arch. für Psychiatrie, xv. 618.
Many functional derangements of the internal viscera have been
ascribed to such vaso-motor instability with more or less probability,42
but hypothesis of this kind, however plausible, is evidently beyond
confirmation. It is especially in affections of this kind that causes of
reflex irritation are to be carefully sought. Cutaneous angio-
neuroses, such as have just been described, may affect any part of
the body. They usually appear suddenly, producing much discomfort
and an impairment of function in the part if it is an extremity. They
disappear as rapidly as they come. The duration of such attacks
varies from a few minutes to several days. They are very liable to
recur. If it is the vessels under the control of the cervical sympathetic
which are affected, the symptoms will be those of migraine or of
lesion of the ganglia.43 If it is the vessels in the extremities which are
involved, the condition of digiti mortui or erythromelalgia or
symmetrical gangrene44 may be produced.
42 Fox, The Influence of the Sympathetic System in Disease, London, 1885.

43 See p. 1263.

44 See p. 1257.

A singular epidemic occurred in France in 1828 and 1830 which was

termed acrodynia. Many persons were suddenly seized with vomiting
and purging, and soon after the onset the extremities became red or
mottled in blotches, swollen and œdematous, and hot, painful, and
tender. The attacks lasted from a few days to two months, and
during this time the skin became thick and hard, the muscles weak
and subject to spasms, and the general health was impaired.
Relapses occurred in many cases, but all finally recovered, and
hence the exact nature of the disease was not ascertained.

COURSE.—In any case of vaso-motor neurosis the course of the

disease and its termination will depend chiefly upon its cause. If the
cause is some permanent lesion of the nervous system, the
condition will remain, and in this case the termination will depend
upon the severity of the symptoms. Angiospasm may be so severe
as to lead to gangrene ana the separation of the part affected, or
may be so slight as to cause only subjective discomfort and a little
pallor. Angio-paralysis may lead to an extreme degree of congestion,
which is attended by heat and pain at first, later by paræsthesia and
coolness, with increased liability of the part to be affected by
changes in the surrounding air. This stage is succeeded by one of
less marked dilatation of the vessels and a spontaneous partial
recovery, although the more moderate symptoms may continue
indefinitely and seriously impair the function of the part. If the cause
is a temporary derangement of function in the vascular mechanism,
is reflex irritation which can be removed, or is a curable organic
disease, the symptoms will subside rapidly or gradually and perfect
recovery may follow. If the condition is one of irritability in the vaso-
motor centres, producing alternations of flashing or pallor, such as is
observed in nervous exhaustion, it may recur irregularly for a
considerable length of time until the causative condition can be
removed.

PROGNOSIS.—The prognosis must be determined in each case by a

consideration of the cause of the affection, of the nature of the
symptoms, of the severity of the disease, and of the possibility of
success in both symptomatic and causative treatment. In the angio-
paralytic cases an eventual spontaneous relief from much of the
discomfort may be promised, although the duration of the symptoms
cannot be predicted.

TREATMENT.—Treatment must be directed primarily to removing or

diminishing the severity of the cause. A review of the section on
Pathogenesis will indicate how wide a field this may include, and the
reader must be referred to the special articles which are alluded to in
that place for therapeutic measures. Special diligence is to be shown
in searching for a source of reflex irritation. When the cause cannot
be reached, and when the symptoms are of such severity as to
demand immediate attention, treatment may be directed to them.

In all conditions of vaso-motor disease it is important to shield the

part from external injury; for if the vessels are dilated they are liable
to rupture, and any abrasion of the surface may produce serious
inflammation and ulceration; and if the vessels are contracted any
injury will be repaired slowly and imperfectly on account of the
anæmia, and may even hasten the approach of gangrene.

Perfect rest, bandaging with cotton, and even the application of a

light splint to the extremities will be advisable in cases of
angiospasm. It is desirable to retain the animal heat, inasmuch as its
supply is deficient. In angio-paralysis rest in a somewhat elevated
position and applications of mild evaporating lotions are indicated in
the early stage; later, the limb may be bandaged. It is not advisable
to attempt by tight bandaging to counteract the effect of the vascular
paralysis, for the nutrition of the limb is liable to suffer and gangrene
may be induced.

Massage of a part affected with vaso-motor symptoms is of great

service, since the circulation can be increased in the veins, and thus
indirectly in the capillaries, and the nutrition of the part can thus be
favored. It is more efficacious in angio-paralysis than in angiospasm.
Too rough rubbing is of course to be avoided, lest the skin be injured.
All counter-irritation is to be strictly forbidden.

Electricity has been used with varying results. According to Erb,45

moderate faradic applications contract the vessels; strong faradic
applications, especially with the brush, dilate the vessels. The
galvanic current at first contracts the vessels, but this is followed by
a secondary dilatation, which will be greater and occur more rapidly
the stronger the current used.46 Cathodal closures contract the
vessels; the anodal continuous current dilates them widely. Stabile
continuous currents through a nerve dilate the vessels which the
nerve supplies. Inasmuch as vaso-constrictors and vaso-dilators
pass together in many nerves, and are found together in all parts, it
is impossible to apply electricity to either alone. In those cases,
therefore, in which it has been ascertained which set of vaso-motors
is affected, it is not always possible to produce a direct effect upon
that set by electrical treatment. Erb recommends, in conditions of
vaso-motor spasm a trial of the galvanic current, the cathode on an
indifferent point, the anode being applied over the vaso-motor
centres governing the part, and also over the area of the body which
is affected, and held there while a moderate continuous current is
passing, interruptions being avoided; or, the cathode being placed on
the neck, the anode may be applied to the nerves passing to the
affected part; or a strong continuous current may be sent through the
nerve, its direction being changed several times during a moderately
long application. Finally, the faradic brush applied to the part or a
strong faradic current sent through its nerve may relax the spasm. In
any case, all these methods should be tried before electrical
treatment is abandoned.
45 Electrothérapie, 562.

46 To this statement Lauder Brunton assents—Pharmacology, p. 250.

In vaso-motor paralysis other methods are used. The cathode is

placed on the part congested, and a weak galvanic current is
employed with frequent interruptions or even with changes of the
pole; or the cathode may be moved about upon the reddened skin
while a mild continuous current is passing. A very weak faradic
current with wet electrodes, or even a weak faradic current applied
with a brush, may be of service. Here, again, various methods may
be tried.

If the extremities are affected, it may be well to immerse them in a

basin of water which is connected with one pole of the battery, and
the current directed in the manner just described, according to the
case. It must be confessed that no definite results can be predicted
from the use of electricity in these cases, and much more experience
is needed before definite rules can be laid down. The records show
that in apparently similar cases opposite methods of application have
produced favorable effects, while in other cases all methods have
failed. Too much reliance should not be placed in electrical
treatment. Erythromelalgia is an obstinate affection, and
symptomatic treatment, directed chiefly to quieting the pain by opium
and allaying the sensation of burning by cool baths, must be resorted
to.
Internal remedies may be tried appropriate to the condition present.
In angiospasm nitrite of amyl inhaled, or nitro-glycerin 1/100 gr. t. i. d.,
may give considerable relief, although both of these drugs are to be
used with caution. Chloral hydrate is also of some service, and
where the patient is in pain and suffers from insomnia this may fulfil
several indications. In angio-paralysis ergot has been used with
advantage. Oxygen inhalations are of service. Chloride of potassium
may also be tried. It is evident, however, that such remedies, acting
as they do upon the general arterial system, are not to be depended
upon in the treatment of local conditions, since they have no
selective action upon the affected part. The majority of the drugs
known as sedatives and antispasmodics have been used in these
conditions, but the records of individual cases show that they are not
of much avail. Theoretical therapeutic measures based upon
experimentation on animals have been fully discussed by Lauder
Brunton,47 but practical experience has not yet been sufficiently
extensive to warrant any further statements.
47 Pharmacology, Therapeutics, and Materia Medica, pp. 229-360. Lea Bros., 1886.

Symmetrical Gangrene.

SYNONYMS.—Local asphyxia, Asphyxie locale, Raynaud's disease;

Symmetrische Gangrän.

DEFINITION.—Symmetrical gangrene is an affection of the nervous

system characterized by arterial or venous spasm appearing in
symmetrical parts of the body, especially in the phalanges of all the
extremities, which may result in trophic changes or in gangrene.
There are various stages in the disease, which have given rise to the
various names by which it is known. The stage of local syncope, in
which there occurs a moderate contraction of the arterioles and
consequent pallor of the part, may be followed by a stage of local
asphyxia, in which the complete contraction of the arterioles cuts off
entirely the supply of arterial blood, and the regurgitation of venous
blood produces cyanosis of the part; and this, if continued, may
result in the gangrene of the part, which is then thrown off. Instead of
a condition of local asphyxia, there may be a spasm of the smaller
veins, resulting in a local erythema, which may go on to capillary
stasis and then to gangrene. The spasm of the vessels may cease at
any stage as suddenly as it began; and if this occurs in the first or
second stage, no gangrene results.

HISTORY.—While isolated cases of this affection had been recorded

as curiosities during the past two centuries,48 the disease was first
studied with care by Raynaud in his Thèse de Paris in 1862. He
collected twenty-eight cases which had been described with
accuracy or had been personally observed in the hospitals of Paris,
and after a thorough analysis of the symptoms defined the disease
as “a neurosis characterized by an exaggeration of the excito-motor
power of the cord presiding over the vaso-motor nerves.” He called
particular attention to the condition of spasm in the vessels, and
proposed the name asphyxie locale to designate the peculiar
appearance of the parts affected. He also noticed the resulting
gangrene as a new variety of gangrene, not dependent upon
embolism or upon changes of an atheromatous nature in the coats of
the vessels.
48 Schrader, 1629; Hertius, 1685; Bouquet, 1808; Moulin, 1830; Racle, 1859—cited in
full by Weiss, “Symmetrische Gangrän,” Wiener Klinik, 1882.

The condition was at once recognized by others, and several cases

had been reported prior to 1873, when Raynaud published a more
complete article on the subject in the Dictionnaire de Médecine et de
Chirurgie under the title gangrene symmétrique; in 1874 he recorded
five new cases in the Archives générales de Médecine, vol. i. pp. 5
and 189.

The disease, having been thus established as a definite nervous

affection, began to be noticed in other countries than France; and
Billroth in Vienna,49 Weir Mitchell,50 Mills,51 A. McL. Hamilton,52 and J.
C. Warren53 in this country, and many other careful observers,
published cases, together with more or less complete articles upon
the disease. In 1882, Weiss produced a monograph54 upon the
subject containing references to all the cases which had appeared;
and this is still the most complete article to be found, although the
essay of R. Lauer55 and the discussion of the disease by the Berlin
Medical Society,56 as well as the short articles of Schulz57 and Lutz,58
deserve mention, for they contain additional observations of cases
and numerous facts not to be found elsewhere.
49 Wiener Med. Wochensch., 1878, No. 23.

50 Amer. Journ. of the Med. Sci., 1878, July.

51 Ibid., 1878, Oct.

52 N. Y. Med. Journ., 1874, Oct.

53 Boston Surg. and Med. Journ., 1879, No. 3.

54 Weiss, Wiener Klinik, 1882, “Symmetrische Gangrän;” also Zeitschrift für Prac.
Heilkunde, 1882.

55 Inaug. Dissert., Strasburg, 1884.

56 Zeitschrift für klin. Med., vi. p. 277, 1883.

57 Deut. Arch. f. klin. Med., xxxv. 183, 1884.

58 Bäyr. ärzt Intell. Blatt, 1884, xxxi. 24.

SYMPTOMS.—The disease begins suddenly in all cases, and the

constitutional symptoms are less prominent than the local ones. In
some cases there are noticed a certain degree of mental
disturbance, a condition of depression with a tendency to sigh and
cry without cause, disturbed sleep with unpleasant dreams,
irritability, and headache. A loss of appetite and disorders of
digestion may follow, and then the local symptoms appear. In other
cases, which seem to be the majority, the local condition develops
without any such premonitory disturbances of the nervous and
digestive systems, although these may ensue. The local symptoms
first noticed may be paræsthesiæ or pain in all the extremities,
usually limited to the tips of the fingers and the toes. These are
continuous and severe, and are immediately followed (and
occasionally preceded) by an appearance of ischæmia or of
cyanosis or of erythema, in the order of frequency named.

(1) The fingers may look pale and dead, presenting the appearance
of the so-called digiti mortui, and may be cold, painful, and
anæsthetic. If this condition is moderate in degree, a certain amount
of blood will continue to flow through the contracted arterioles, and
then it corresponds to the description given by Raynaud of syncope
locale. If it is extreme, the part may be wholly deprived of arterial
blood, and then a true local asphyxia is present. In this stage the
patients usually suffer considerably, although some do not complain
of pain until the next stage. The ischæmia is attended with an
impairment of sensation to touch, temperature, and pain, and finer
motions become clumsy on account of the subjective numbness and
actual anæsthesia. At the same time, the fingers look shrunken, the
skin being thrown into folds, as if the hand had been soaked in hot
water, or they may appear as if frozen, the skin being hard and
immovable.59 The secretion of perspiration may be increased, and
the fingers feel damp as well as cold, or it may be suspended. The
local temperature is lowered. If the part is cut, little or no blood will
flow. At this stage the arterial spasm may suddenly relax and the part
return gradually to its normal condition, the cessation of the
constriction of the arteries and the return of blood being usually
accompanied by burning pain, which may last for some hours. The
duration of such an attack may vary from a few moments to several
days. If it continues longer, this stage is usually succeeded by the
second stage, of cyanosis.
59 Finlayson, Medical Chronicle, 1885, No. 4.

(2) The stage of cyanosis results from one of two conditions: either
the arterial spasm is so complete that no blood passes into the part,
in which case venous blood from lack of vis a tergo or in response to
gravitation regurgitates into the capillaries, distending them and
producing a state of blueness; or a venous spasm occurs, preventing
the exit of blood from the part, which then becomes actively
congested, and the blood in the capillaries, from want of renewal,
soon becomes venous and produces the cyanotic appearance. The
stage of ischæmia may be so short that it is hardly noticed, so that
the patient's attention is first attracted by the swollen, blue, and
extremely painful condition. The skin may be stretched, the tissue
infiltrated with products of exudation, which can be pressed out, as
can also the venous blood, and the surface may itch as well as be
painful. Anæsthesia is rarely present in this stage, and there may
even be hyperæsthesia. The part is cool from the increased radiation
of heat and cessation of the processes of metabolism, the local
temperature being lowered. The small vessels on the surface will be
visibly injected, and capillary ecchymoses may rarely be seen. There
is less liability to difficulty in movement in this stage than in the
former one, as the sensations of the part are not benumbed, but if
present it is due to the swelling. This condition, like that in the former
stage, may cease suddenly, the recovery of the normal appearance
being, as a rule, slower than after a simple ischæmia. The duration
of this stage has varied from a few seconds to several days. It is
usually followed by gangrene.

(3) The condition of local erythema is described here because it may

lead to gangrene, and has therefore been considered by Weiss as
one of the early stages of the disease. As a rule, however, it is not
followed by the death of the part, and the affection in these cases is
probably one of erythromelalgia rather than of symmetrical
gangrene. Like the stage of ischæmia, the stage of erythema may
appear suddenly. The part presents a bright-red or a mottled
appearance—is hot and swollen, and painful. The vessels are visibly
injected, the local temperature is raised, the secretion of sweat may
or may not be increased, and the patient feels a burning sensation
rather than pain. Hyperæsthesia to touch and temperature and pain
is usually present, or the sensations are normal. The blood can be
pressed out, but returns immediately. In this condition of hyperæmia
slight injuries lead frequently to an inflammatory process, ulcers may
form in the pulps of the fingers or around the nails, and the eschars
may appear dark and even gangrenous; or an actual condition of
gangrene may appear in the tips of the fingers, the exact method of
its occurrence being a matter of dispute. The erythematous condition
is much more likely to be permanent than are the other stages of the
disease—another fact which has led to some hesitation in
considering it a true stage. This condition of erythema may be due to
a paralysis of the vaso-constrictors, the converse of the spasm
occurring in ischæmia. It has also been ascribed to an irritation of the
vaso-dilators; and this appears to be the more probable hypothesis.

(4) The stage of gangrene is always preceded by that of cyanosis,

and the death of the tissue is due to the arrest of nutrition
consequent upon a stasis of the blood. It is not necessary to invoke
the injury of trophic nerves to explain its appearance. In the tips of
the cyanotic fingers, on their palmar surface, beneath the epidermis,
a small blister appears, filled with a dark serous fluid or with pus or
blood. This soon ruptures, and a dark dry scab forms, beneath which
an ulceration may go on destroying the corium, but not penetrating
deeper. In the majority of cases the gangrene is limited to a small
area of the pulps of the fingers, and only involves the superficial
layers of the corium. The gangrenous spot is surrounded by a purple
margin. When the sphacelus has separated a scar remains which is
frequently insensitive. In other cases when the sphacelus is thrown
off it leaves a deep ulcer, which may look as if the lost tissue had
been cut out with a punch, and this gradually granulates and heals.
In still other cases the entire skin of the terminal phalanx may
become black and dry, presenting a true gangrenous appearance.
Then a line of demarcation is formed, usually at the junction of the
terminal with the middle phalanx; separation of the gangrenous part
occurs, and a stump is left covered with thin, glossy skin. This
extensive gangrene, involving an entire phalanx, is the exception
rather than the rule.

While the gangrenous process is in progress in the tip of the finger

the nails cease to grow, and may become bulbous and rigid; the
epidermis elsewhere may become dry and desquamate, and
ulceration around the root of the nail may take place. With the
completion of the stage of gangrene, which may last from one to five
weeks according to its extent, the local symptoms terminate.

It is the symmetrical distribution of the local symptoms just

enumerated which is the peculiar characteristic of the disease. The
fingers of both hands, the toes of both feet, symmetrically situated
spots upon the back, trunk, thighs, legs, forearms, and arms (in the
order of frequency named), are affected either singly or in
combination. In the majority of cases fingers and toes are affected
together, and a few spots are seen on the trunk. In many cases the
toes escape. In a large number of cases the face has been affected,
spots of cyanosis appearing on the nose or ears or lips. As a rule,
the stage of gangrene only ensues in the tips of the extremities, but
a few cases are recorded in which little areas of skin elsewhere have
passed through all the stages of the disease. Pigmentation occurs in
spots upon the body when the process does not go on to gangrene.

Among the rare symptoms which have occurred in some cases are
great impairment of temperature, pain, and electric sensations in the
affected extremities; swelling, pain, redness about, and effusion into,
the joints; considerable loss of motion in the muscles of the hands
and feet, with diminution of electric excitability, but no qualitative
change; and oculo-pupillary changes ascribed to an irritation of the
cervical sympathetic fibres at their origin in the spinal cord.

In addition to the constitutional symptoms mentioned, which may

usher in the disease and may continue during its course, there have
been observed temporary albuminuria, glycosuria, and hæmaturia.
Fever never occurs as a symptom of the disease, and if present
must be ascribed to some other condition. The special senses have
been affected in a few cases. In one case a spastic contraction of
the retinal arteries alternated with attacks of ischæmia in the
extremities.60 The intellect is usually unaffected, but Weiss observed
a case in which transient aphasia occurred, which he attributes to
local spasm in the arteries of the cortex. The patient could find words
only after long thought, and spoke slowly and with difficulty.
60 Raynaud, Arch. gén. de méd., 1874, p. 11; Galezowski examined the discs.