A system of practical medicine. By American authors. Vol. 5

by Unknown

HYSTERIA.

BY CHARLES K. MILLS, M.D.

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DEFINITION.—Hysteria is a functional disease of the cerebro-spinal axis, characterized either by special mental symptoms or by motor, sensory, vaso-motor, or visceral disorders related in varying degree to abnormal psychical conditions.

This, like all other definitions of hysteria, is imperfect. No absolutely satisfactory definition can well be given. It is not abnormal ideation, although this is so often prominent; it is not emotional exaltation, although this may be a striking element; it is not perversion of reflexes and of sensation, although these may be present. Some would make it a disease of the womb, others an affection of the ovaries; some regard it as of spinal, others as of cerebral origin; some hold it to be a disease of the nerves, others claim that it is a true psychosis; but none of these views can be sustained.

Sir James Paget¹ says of hysterical patients that they are as those who are color-blind. They say, “I cannot;” it looks like “I will not,” but it is “I cannot will.” Although, however, much of the nature of hysteria is made clear in this explanation, hysteria is not simply paralysis of the will. A true aboulomania or paralysis of the will occurs in non-hysterical patients, male and female, and of late years has been studied by alienists.

¹ “Clinical Lecture on the Nervous Mimicry of Organic Diseases,” Lancet for October, November, and December, 1873.

In many definitions the presence of a spasmodic seizure or paroxysm is made the central and essential feature; but, although convulsions so frequently occur, typical hysterical cases pass through the whole course of the disorder without suffering from spasm of any kind.

In a general neurosis a definition, well considered, should serve the purpose of controlling and guiding, to a large extent at least, the discussion of the subject.

The definition given asserts that hysteria is a functional disease. In the present state of knowledge this is the only ground that can be taken. It is claimed that in a strict sense no disease can be regarded as functional; but it is practically necessary to use such terms as functional in reference to affections in which disordered action without recognizable permanent alteration of structure is present. Temporary anatomical changes must sometimes be present in hysteria; organic disease may be a complication in special cases; post-mortem appearances may occasionally be found as accidents or coincidences; it is possible that structural alterations may result from hysteria; but no pathologist has as yet shown the existence of a special morbid anatomy underlying as a permanent basis the hysterical condition.

The mental, motor, sensory, and other phenomena of hysteria cannot be explained except by regarding the cerebro-spinal nervous system as the starting-point or active agency in their production.

The term vaso-motor is used in a broad sense to include not only peripheral vascular disturbances, but also cardiac, respiratory, secretory, and excretory affections of varying type. Some of these disorders are also visceral, but under visceral affections are also included such hysterical phenomena as abdominal phantom tumors, hysterical tympanites, and the like.

That all hysterical phenomena are related in varying degree to abnormal psychical conditions may perhaps, at first sight, be regarded as open to dispute and grave doubt. It is questionable whether in every case of hysteria the relation of the symptoms to psychical states could be easily demonstrated. I certainly do not look upon every hysterical patient as a case of insanity in the technical sense, but hold that a psychical element is or has been present, even when the manifestations of the disorder are pre-eminently physical. James Hendrie Lloyd,² in a valuable paper, has ably sustained this position, one which has been held by others, although seldom, if ever, so clearly defined as by this writer.

² “Hysteria: A Study in Psychology,” Journal of Nervous and Mental Disease, vol. x., No. 4, October, 1883.

The alleged uterine origin of hysteria has been entirely disregarded in the definition. This has been done intentionally. It is high time for the medical profession to throw off the thraldom of this ancient view. The truth is, as asserted by Chambers,³ that hysteria “has no more to do with the organs of reproduction than with any other of the female body; and it is no truer to say that women are hysterical because they have wombs, than that men are gouty because they have beards.”

³ Brit. Med. Journ., December 21, 1861, 651.

SYNONYMS.—Hysterics, Vapors. Many Latin and other synonyms have been used for hysteria: most of these have reference to the supposed uterine origin of the disease, as, for instance, Uteri adscensus, Asthma uteri, Vapores uterini, Passio hysterica, Strangulatio uterina seu Vulvæ. Some French synonyms are Maladie imaginaire, Entranglement, and Maux ou attaques de nerfs. Other French synonyms besides these have been used; most of them are translations from the Latin, having reference also to the uterine hypothesis. In our language it is rare to have any other single word used as a synonym for hysteria. Sir James Paget⁴ introduced the term neuromimesis, or nervous mimicry, and suggested that it be substituted for hysteria, and neuromimetic for hysterical. Neuromimesis is, however, not a true synonym. Many cases of hysteria are cases of neuromimesis, but they are not all of this character. Among the desperate attempts which have been made to originate a new name for hysteria one perhaps worthy of passing notice is that of Metcalfe Johnson,⁵ who proposes to substitute the term ganglionism, as giving a clue to the pathology of hysteria. His main idea is that hysteria exhibits a train of symptoms which are almost always referable to the sympathetic or ganglionic nervous system. This is another of those half truths which have misled so many. The term hysteria, from the Greek ὑστερα, the uterus, although attacked and belabored, has come to stay; it is folly to attempt to banish it.

⁴ Op. cit.

⁵ Med. Times and Gaz., 1872, ii. 612.

METHOD OF DISCUSSING THE SUBJECT.—It is hard to decide upon the best method of discussing the subject of hysteria. One difficulty is that connected with the question whether certain affections should be considered as independent disorders or under some subdivisions of the general topic of hysteria. Certain great phases of hysteria are represented by hystero-epilepsy, catalepsy, ecstasy, etc.; but it will best serve practical ends to treat of these in separate articles. They have distinctive clinical features, and are capable of special definition and discussion.

HISTORY AND LITERATURE.—To give a complete history of hysteria it would be necessary to traverse the story of medicine from the time of Hippocrates to the present. A complete bibliography would require an immense volume. Volume vi. of the Index Catalogue of the Library of the Surgeon-General's Office, United States Army, which has appeared during the present year (1885), contains a bibliography of nearly seventeen double-column pages, most of it in the finest type. The references are to 318 books and 914 journals. The number of books and articles cited as having appeared in different languages is as follows: Latin, 99; Greek, 2; German, 180; British, 177; American, 159; French, 449; Italian, 75; Spanish, 45; Swedish, 12; miscellaneous, 34. Even this wonderful list probably only represents a tithe of the works written on this subject. Those desirous of studying it from a bibliographical point of view can do so by consulting this great work.

Many as are the names and voluminous as is the literature, certain names and certain works are pre-eminent—Sydenham, Laycock, and Skey in England; Tissot, Briquet, Charcot, and Landouzy in France; Stahl, Frank, Eulenburg, and Jolly in Germany; and in America, Weir Mitchell. The greatest work on hysteria is the treatise of Briquet.⁶

⁶ Traité clinique et thérapeutique de l'Hystérie, par le Dr. P. Briquet, 1859.

Mitchell⁷ has organized into a scientific system a valuable method of treating hysteria, and has given to the world a series of studies of some types of the affection best or only seen in the United States.

⁷ Fat and Blood: An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria, and Clinical Lecture on Diseases of the Nervous System, especially in Women.

Among other American monographs on hysteria and allied subjects worthy of note are the contributions of Shaffer on The Hysterical Element in Orthopædic Surgery;⁸ Seguin's essay on Hysterical Symptoms in Organic Nervous Affections;⁹ Beard's volume on Nervous Exhaustion;¹⁰ the chapters on Hysterical Insanity, etc. in Hammond's text-books;¹¹ and the papers of G. L. Walton¹² on Hystero-epilepsy. Spitzka, Mann, Hughes, and Kiernan have made important contributions to the psychical aspects of the subject in various American medical journals.

⁸ The Hysterical Element in Orthopædic Surgery, by Newlin M. Shaffer, M.D., New York, 1880.

⁹ Archives of Neurology and Electrology, for May, 1875, and Opera Minora, p. 180.

¹⁰ A Practical Treatise on Nervous Exhaustion (Neurasthenia), by George M. Beard, A.M., M.D., New York, 1880.

¹¹ A Treatise on Diseases of the Nervous System, and A Treatise on Insanity in its Medical Relations.

¹² Brain, vol. v. p. 458, Jan., 1883; Journal of Nervous and Mental Disease, vol. xi. p. 425, July, 1884.

During the last five years I have published a number of articles and lectures on the subject of hysteria and hystero-epilepsy, some of which have been freely used in the preparation of this and the succeeding sections.¹³ My first paper on hystero-epilepsy, in the American Journal of the Medical Sciences, was written to strongly direct the attention of the American profession to the subject as studied in France. It was in large part a translation from the works of Charcot, Richer, and Bourneville, with, however, notes of some observed cases.

¹³ “Hystero-epilepsy,” American Journal of the Medical Sciences, October, 1881.
“Epileptoid Varieties of Hystero-epilepsy,” Journal of Nervous and Mental Diseases, October, 1882.
“Illustrations of Local Hysteria,” Polyclinic, vol. i., Nos. 3 and 4, September 15, October 15, 1883.
“Clinical Lecture on the Treatment of Hysterical Paralysis by Rest, Massage, and Electricity,” Med. and Surg. Reporter, vol. 1. p. 168, February 9, 1884.
“Clinical Lecture on the Differential Diagnosis of Organic from Hysterical Hemianæsthesia, etc.,” ibid. vol. 1. p. 233, 265, February 23, March 1, 1884.
“Clinical Lecture on Spinal Traumatisms and Pseudo-Traumatisms,” Polyclinic, vol. i. No. 9, March 15, 1884.
“A Case of Nymphomania, with Hystero-epilepsy, etc.,” Medical Times, vol. xv. p. 534, April 18, 1885.
“Hystero-epilepsy in the Male, etc.,” Medical Times, vol. xv. p. 648, May 30, 1885.
“Some Forms of Myelitis, their Diagnosis from each Other and from Hysterical Paraplegia,” Medical News, vol. xlvii., Nos. 7 and 8, August 15 and 22, 1885.
“Clinical Lecture on Acute Mania and Hysterical Mania,” Medical Times, vol. xvi. p. 153, November 28, 1885.

PATHOLOGY.—Strictly speaking, hysteria cannot be regarded as having a morbid anatomy. In an often-quoted case of Charcot's,¹⁴ an old hystero-epileptic woman, affected for ten years with hysterical contracture of all the limbs, sclerosis of the lateral columns was found after death. On several occasions this woman experienced temporary remissions of the contracture, but after a last seizure it became permanent. This is one of the few reported cases showing organic lesion; and this was doubtless secondary or a complication. In a typical case of hystero-epilepsy at the Philadelphia Hospital, a report of which was made by Dr. J. Guiteras,¹⁵ the patient, a young woman, died subsequently while in my wards. Autopsy and microscopical examination revealed an irregularly diffused sclerosis, chiefly occupying the parieto-occipital region of both cerebral hemispheres. Undoubtedly, as suggested by Charcot, in some of the grave forms of hysteria either the brain or spinal cord is the seat of temporary modification, which in time may give place to permanent material changes. Old cases of chronic hysteria in all probability may develop a secondary degeneration of the cerebro-spinal nerve-tracts, or even degeneration of the nerve-centres themselves may possibly sometimes occur. Two cases now and for a long time under observation further indicate the truth of this position. One, which has been reported both by H. C. Wood¹⁶ and myself,¹⁷ is a case of hysterical rhythmical chorea in a young woman. Although the hysterical nature of her original trouble cannot be doubted, she now has contractures of all the extremities, which seem to have an organic basis. The other patient is a woman who has reached middle life; she has several times temporarily recovered from what was diagnosticated as hysterical paraplegia, in one instance the recovery lasting for months. Now, after more than four years, she has not recovered from her last relapse. Contractures, chiefly in the form of flexure, have developed, and she has every appearance of organic trouble, probably sclerosis or secondary degeneration of the lateral columns.

¹⁴ Leçons sur les Maladies du Système nerveux.

¹⁵ Philadelphia Medical Times, 1878-79, ix. 224-227.

¹⁶ Ibid., vol. xi. p. 321, Feb. 26, 1881.

¹⁷ Ibid., vol. xii. p. 97, Nov. 19, 1881.

Briquet¹⁸ reviews the various hypotheses which have been held as to the pathological anatomy of hysteria, giving a valuable summary of the autopsies upon supposed hysterical cases up to the time of the publication of his treatise in 1859. About the sixteenth century, Rislau, Diemerbroeck, and Th. Bonet sought to establish a relation between lesions of the genital organs met with in the bodies of hysterical women and the affection from which they suffered. About 1620, Ch. Lepois believed that he had established the existence of certain alterations of the brain in cases of hysteria. Hochstetter and Willis toward the beginning of the present century arrived at similar conclusions. That researches into the state of the genital organs have chiefly occupied those investigating hysteria is shown by the writings of Pujol, Broussais, Lovyer-Villermay, and, above all, by those of Piorry, Landouzy, Schutzenberger, and Duchesne-Duparc. Georget, Brachet, Girard, Gendrin, Bouillaud, Forget, and Lelut, about the fourth or fifth decades of the present century, made numerous autopsies on those dying when hysterical phenomena were in full activity, and concluded that the genital organs of these individuals revealed nothing in particular. This, in brief, is also the conclusion of Briquet. Jeanne d'Albret, the mother of Henry IV., who was all her life subject to hysterical headache, had her brain examined after death, but absolutely nothing was found. Vesalius made an autopsy with equally negative results on a woman who died from strangulation in an hysterical attack. Royer-Collard also found nothing in an old hysteric. Briquet believed—and I fully accord with this view—that in some of the cases of Ch. Lepois, Hochstetter, and Willis diseases such as chronic meningitis were present with the hysteria. He concludes that anatomy does not show anything positive as to the seat or nature of hysteria, except the suspicion of a certain degree of congestion in various parts of the brain.

¹⁸ Op. cit.

While, however, hysteria may not have a morbid anatomy, it, like every other disease, has, in a correct sense, a pathology.

The ancients saw only the uterus when regarding hysteria. Hippocrates described the hysterical paroxysm and its accompanying disorders under the name of strangulation of the uterus. The ancients generally supposed that the disease originated in the ascent of the uterus to the diaphragm and throat. They believed that this accommodating organ could wander at will throughout the body, doing all manner of mischief. Hippocrates asserted that it was the origin of six hundred evils and innumerable calamities.

According to Sydenham,¹⁹ the disorders which are termed “hysterical in women and hypochondriac in men arise from irregular motions of the animal spirits, whence they are hurried with violence and too copiously to a particular part, occasioning convulsions and pain when they exert their force upon parts of delicate sensation, and destroying the functions of the respective organs which they enter into, and of those also whence they came; both being highly injured by this unequal distribution, which quite perverts the economy of nature.” Speaking of the strangulation of the womb, or fits of the mother, he says: “In this case the spirits, being copiously collected in the lower belly and rushing with violence to the fauces, occasion convulsions in all the parts through which they pass, puffing up the belly like a ball.”

¹⁹ The Entire Works of Dr. Thomas Sydenham, newly made English from the Originals, etc., by John Swan, M.D., London, 1763, pp. 416, 417.

After a time, the idea that the uterus was the exclusive seat of hysteria was in large measure supplanted by the view that the sexual organs in general were concerned in the production of hysterical phenomena. Romberg defined hysteria as a “reflex neurosis caused by genital irritation.” Woodbury²⁰ concludes as late as 1876 that only where the pathological source of hysterical symptoms resides in the uterus or ovaries, cases may, with some show of propriety, be termed hysterical; and where the uterus and organs associated with it in function are not in a morbid condition no symptoms can be correctly called hysterical.

²⁰ Medical and Surgical Reporter, December 2, 1876.

Bridges,²¹ another American writer, in a paper on the pathology of hysteria, says that hysteria does not occur most frequently in women with diseased wombs, but in those whose sexual systems, by pampering and other processes, are abnormally developed and sensitive. He makes the same point with reference to the male sex. Sometimes, however, besides the emotional state in the male, there is actual disease of the sexual organs, caused by abuse or over-indulgence. Uterine disease and hysteria are sometimes like results of one cause, and not respectively cause and effect: women are hysterical oftener than men because the uterine function in woman's physiology plays a more important part in the production of emotional diseases than any organ of the male sex.

²¹ Chicago Medical Examiner, 1872, xiii. 193-199.

The truth would seem simply to be, that, as the uterus and ovaries are the most important female organs, they are therefore a frequent source of reflex irritation in hysterical patients.

Seguin²² adopts with some reservation Brown-Séquard's hypothesis that cerebral lesions produce the symptoms which point out their existence, not by destroying organs of the brain, but by setting up irritations which arrest (inhibit) the functions of other parts of the encephalon. He says that he finds no difficulty in believing that the same symptom may exist as well without as with a brain lesion. “In typical hysteria the functions of parts of the encephalon included in the right hemisphere, or in physiological relation with it, are inhibited by a peripheral irritation starting from a diseased or disordered sexual apparatus or other part; and in case of organic cerebral disease the same inhibitory action is produced. In both kinds of cases we may have loss of rational control over the emotions, loss of voluntary power over one-half of the body, and loss of sensibility in the same part.”

²² “On Hysterical Symptoms in Organic Nervous Affections,” Archives of Electrology and Neurology, for May, 1875.

Simply as a matter of passing interest, the attempt of Dupuy²³ to frame a pathology of hysteria is worthy of attention. According to him, every local hysterical phenomenon is dependent upon an abnormal state of either lateral half of the upper part of the pons varolii. The centres of the pons, he holds, are perhaps merely passive in the process, only becoming organically implicated when various forms of permanent contractures and paralyses ensue.

²³ Medical Record, New York, 1876, ii. 251.

The pathology of hysteria must be considered with reference to the explanation of the exact condition of the cerebro-spinal axis during the existence of certain special grave phenomena of hysteria, such as hemianæsthesia, hemiplegia, paraplegia, and contractures.

What is the probable state of the nerve-centres and tracts during these hysterical manifestations? If, for example, in a case of hysterical hemianæsthesia it is admitted that the brain of the other side of the body is somehow implicated, although temporarily, what is the probable condition of this half of the brain? Is the cerebral change vascular or is it dynamic? If vascular, is the state one of vaso-motor spasm or one of paresis, or are there alternating conditions of spasm and paresis? Are true congestions or anaæmias present? If the condition is dynamic, what is its nature? Is it molecular? and if molecular in what does it consist? Is it possible to say absolutely what the pathological condition is in a disorder in which autopsies are obtained only by accident, and even when obtained the probabilities are that with fleeting life depart the changes that are sought to be determined?

Two hypotheses, the vaso-motor and the dynamic, chiefly hold sway. The vaso-motor, attractive because of its apparent simplicity, has been well set forth by Walton,²⁴ who contends that while it may not be competent to easily explain all hysterical symptoms, it will best explain some of the major manifestations of hysteria—for example, hemianæsthesia. Hemianæsthesia, he argues, may appear and disappear suddenly; it may be transferred from one side of the body to another in a few seconds; so blood-vessels can dilate as in a blush, or contract as in the pallor of fear, in an instant. In fainting the higher cerebral functions are suspended, presumably because of vaso-motor changes; therefore the sudden loss of function of one-half of the brain-centres, seen sometimes in hysterical hemiplegia and hemianæsthesia, may easily be imagined to be the result of an instantaneous and more or less complete contraction of cortical blood-vessels on that side. Neurotic patients have a peculiarly irritable vaso-motor nervous system. He records a case seen in consultation with H. W. Bradford. The patient had a right-sided hemianæsthesia, including the special senses, the sight in the left eye being almost wanting. The fundus of the right eye was normal; the left showed an extreme contractility of the retinal blood-vessels under ophthalmoscopic examination; these contracted to one-third their calibre, and the patient was unable to have the examination continued. The explanation offered is, that spasm of the blood-vessels on the surface of the left cerebral hemisphere had caused, by modification of the cortical cells, a right-sided hemianæsthesia, including the sight, and by reaching the meninges a left-sided spastic migraine, and by extending to the fundus of the left eye an intermittent retinal ischæmia.

²⁴ Journal of Nervous and Mental Disease, vol. xi., July, 1884, p. 424 et seq.

The vaso-motor hypothesis is held by Rosenthal,²⁵ who, however, wrongly gives the spinal cord the preponderating part in the production of the symptoms. According to this author, the anæsthesia and analgesia present in hysteria conform to the law as established by Voigt with regard to the distribution of the cutaneous nerves. The sensory nerves form at the periphery a sort of mosaic corresponding to an analogous arrangement in the spinal cord. “It is evident,” he says, “that the peripheral disorders in hysteria merely represent an exact reproduction of the central changes, and that the latter are situated, in great part, in the spinal cord.” He attributes a large part of the symptoms of hysteria to a congenital or acquired want of resistance of the vaso-motor nervous system. “Motor hysterical disorders are also due in the beginning to a simple functional hyperæmia, but in certain forms the chronic hyperæmia may lead to an inflammatory process which may terminate (as in Charcot's case) in secondary changes in the columns of the cord and nerve-roots.” When the brain is involved in hysteria, he holds that the most serious symptoms must be attributed to reflex spasms of the cerebral arteries and to the consequent cerebral anæmia.

²⁵ “A Clinical Treatise on Diseases of the Nervous System,” by M. Rosenthal, Vienna, translated by L. Putzel, M.D., vol. ii. Wood's Library, New York, 1879.

The dynamic pathology of hysteria is probably believed in by most physicians, and yet it is difficult to explain. Thus, Briquet²⁶ says that hysteria manifests itself by derangement of the nervous action, and what is called nervous influence is something like electricity. It is simply the result of undulations analogous to those which produce heat and light; in other words, it is a mode of movement. Wilks²⁷ compares some of the conditions found in hysteria to a watch not going; it may be thought to be seriously damaged in its internal machinery, yet on looking into it there is found a perfect instrument that only needs winding up. As regards the brain being for a time functionless, the possibility of this is admitted by all, as in sleep or after concussion. He mentions the case of a young girl who had been assaulted, and had complete paralysis of motion and sensation. The shock had suspended for a time the operations of her brain, and organic life only remained. We have only to suppose that half of the brain is in this way affected to account for all the phenomena of hemianæsthesia.

²⁶ Op. cit.

²⁷ Lectures on Diseases of the Nervous System, delivered at Guy's Hospital, by Samuel Wilks, M.D., F. R. S., Philada., 1883.

According to the dynamic view, the central nervous system is at fault in some way which cannot be demonstrated to the eye or by any of our present instruments of research. The changes are supposed to be molecular or protoplasmic, rather than vaso-motor or vascular.

As innervation and circulation go hand in hand or closely follow each other, my own view is that both vaso-motor and molecular changes, temporary in character, probably occur in the central nervous system in grave hysterical cases.

Whatever the temporary conditions are, it is evident, on the one hand, that they are not states of simple anæmia or congestion, and, on the other hand, that they are not inflammations or atrophies. Patients with hysterical manifestations of the gravest kind as a rule are free for a time from their harassing and distressing symptoms. This could not be if these symptoms were due to lesions of an organic nature. Sudden recoveries also could not be accounted for if the changes were organic.

Lloyd²⁸ contends that most hysterical symptoms, if not all, are due to abnormal states of consciousness. The development of this idea constitutes his argument for the recognition of the disease as a true psychosis. In the reflex action, not only of the lower spinal cord and ganglia of special sensation, but of the highest centres of the brain, he sees the explanation of many of the characteristics of hysteria. In other words, he finds that the sphere of the disease is more especially in the automatic action of the brain and cord.

²⁸ Op. cit.

Dercum and Parker²⁹ have published the results of a series of experiments on the artificial induction of convulsive seizures which bear upon this discussion of the pathology of hysteria. The experiments were performed by subjecting one or a group of muscles to a constant and precise effort, the attention being at the same time concentrated on some train of thought. The position most frequently adopted was the following: The subject being seated, the tips of the fingers of one or both hands were placed upon the surface of the table, so as to give merely a faint sense of contact—i.e. the fingers were not allowed to rest upon the table, but were held by a constant muscular effort barely in contact with it.

²⁹ Journal of Nervous and Mental Disease, vol. xi., October, 1884, pp. 579-588.

Tremors commenced in the hands; these became magnified into rapid, irregular movements which passed from one limb or part to another until the subject was thrown into strong general convulsions. Opisthotonos, emprosthotonos, and the most bizarre contortions were produced in various degrees. No disturbances of sensation were at any time present. Disturbances of respiration and phonation were often present in a severe seizure, and the circulatory apparatus was profoundly affected. A flow of tears, and occasionally profuse perspiration, were sometimes induced. After severe seizures large quantities of pale urine were passed. The reflexes were distinctly exaggerated. No unconsciousness was ever observed, but a progressive abeyance or paresis of the will. Nitrite of amyl seemed to arrest the convulsive seizures at once.

In attempting to explain these phenomena Dercum and Parker refer to the induction of Spencer as to the universality of the rhythm of motion. Through the whole nervous system of every healthy animal a constant rhythmical interchange of motion takes place. What might be called nervous equilibration results. In man the will modifies and controls the action of the nervous system; it assists in maintaining nervous equilibrium when it is threatened. The will being withdrawn from the nervo-muscular apparatus, and this being subjected to strain, a disturbance takes place. This same explanation may be applied to some of the convulsive and other phenomena of hysteria.

Comparing and analyzing the various views, it may be concluded with reference to the pathology of hysteria as follows:

(1) The anatomical changes in hysteria are temporary.

(2) These changes may be at any level of the cerebro-spinal axis, but most commonly and most extensively cerebral.

(3) They are both dynamic and vascular: the dynamic are of some undemonstrable molecular character; the vascular are either spastic or paretic, most frequently the former.

(4) The psychical element enters in that, either, on the one hand, violent mental stimuli which originate in the cerebral hemispheres are transmitted to vaso-motor conductors,³⁰ or, on the other hand, psychical passivity or torpor permits the undue activity of the lower nervous levels.

³⁰ Rosenthal.

ETIOLOGY.—Heredity has much to do with the development of hysteria. It is not that it is so frequently transmitted directly after its own kind, but this disorder in one generation generally indicates the existence of some ancestral nervous, mental, or diathetic affection.

Briquet³¹ has shown that of hysterical women who have daughters, more than half transmit the disease to one or several of these, and, again, that rather more than half of the daughters of the latter also become hysterical. Amann, according to Jolly,³² has stated that in 208 cases of hysteria he proved with certainty an hereditary tendency 165 times—that is, in 76 per cent. This is too big to be true.

³¹ Op. cit.

³² Ziemssen's Cyclopædia of the Practice of Medicine, vol. xiv., American translation.

Briquet has also made some careful investigations into the subject of the health of infants born of hysterical mothers. The investigations were based upon a study of 240 hysterical women, with whom he compared 240 other patients affected with such diseases as fever, phthisis, cancer, diseases of the heart, liver, and kidneys, but without any hysterical symptoms. In brief, the result of his investigations was that children born of hysterical mothers die more frequently and at a younger age than those who are born of mothers not hysterical.

The relation of hysteria to certain morbid constitutional states has long been recognized, particularly its connection with the tubercular diathesis. This has been shown by numerous observers, especially among the French. The most valuable recent contribution is that of Grasset,³³ who believes that a direct connection can be traced between the tubercular diathesis and hysteria. When the relations of hysteria to the scrofulous and tubercular diathesis are spoken of by him, it is not meant that hysterical subjects have tubercles in the lungs, but that these diatheses are found in various generations, and that among some subjects of the hereditary series the constitutional states manifest themselves as hysteria. It is not the evidences of hysteria with pulmonary and other tuberculous conditions that he is considering, but that hysteria may be, and often is, a manifestation of the tubercular diathesis. Two cases may present themselves: in one the neurosis is the only manifestation of the diathesis; in the other, it is continued in the same subject along with the other diathetic manifestations. In demonstration of his thesis he concludes with a series of most interesting cases, which he arranges into two groups. In the first, hysteria is the only manifestation of the tubercular diathesis; in the second, are simultaneous pulmonary and hysterical manifestations. In the first group he has arrayed eight personal observations and seventeen derived from various authors; in the second he has two personal and seventeen compiled observations.

³³ “The Relation of Hysteria with the Scrofulous and the Tubercular Diathesis,” by J. Grasset, Brain, Jan., April, and July, 1884.

Personal experience and observation go far to confirm the views of Grasset, although I recognize fully the strength of the objection of Brachat and Dubois and others that, phthisis being such a common complaint, it might be demonstrated by statistics that it was related to almost any disease. Not only hysteria, but other neuroses or psychoses, have a close connection with the tubercular diathesis.

Among the insane and idiotic and among epileptics phthisis is of frequent occurrence. At the Pennsylvania Training School for Feeble-minded Children the frequency of phthisis among the inmates of the institution is one of the most striking clinical facts. The insane of our asylums die of pulmonary troubles oftener almost than of any other disease. The fact that hysteria is met with in the robust and vigorous does not invalidate the position taken, for the robust and vigorous who are not hysterical are not infrequently found in the descendants of the tuberculous.

Laycock³⁴ believed that the gouty diathesis was particularly liable to give rise to the hysterical paroxysm or to irregular forms of hysteria. Gairdner, quoted by Handfield Jones,³⁵ supports this view.

³⁴ A Treatise on the Nervous Diseases of Women, by Thomas Laycock, M.D., London, 1840.

³⁵ Studies on Functional Nervous Disorders.

Gout in England plays a greater part in the production of nervous and other disorders than in this country, but even here its instrumentality is too often overlooked. In Philadelphia are many families, some of them of English origin, in which gout has occurred, sometimes of the regular type, but oftener of anomalous forms. Among the most striking examples of hysteria that have fallen under my observation, some have been in these families. In a few of them remedies directed to the lithæmic or gouty conditions in connection with other measures have been efficient. More frequently they have failed, for while a relation may exist between the neurotic disorder and the diathesis, it is not the diathesis, but the neurotic disorder, which we are called upon to treat.

That a certain mental constitution predisposes to hysteria cannot be doubted. Ribot³⁶ describes, chiefly from Huchard,³⁷ the hysterical constitution. It is a state in which volition is nearly always lacking. The prominent trait is mobility. The hysterical pass with increditable rapidity from joy to sadness, from laughter to tears; they are changeable, freakish, or capricious; they have fits of sobbing or outbursts of laughter. Ch. Richét compares them to children, who oftentimes can be made to laugh heartily while their cheeks are still wet with tears. Sydenham says of them that inconstancy is their most common trait: their sensibilities are aroused by the most trivial cause, while profounder emotions scarcely touch them. They are in a condition of moral ataxy, lacking equilibrium between the higher and lower faculties.

³⁶ Diseases of the Will.

³⁷ Axenfeld et Huchard, Traité des Neuroses, 2d ed., 1883, pp. 958-971.

As to sex, it is almost unnecessary to say that hysteria occurs with greater frequency among females than males; and yet it is all important to emphasize the fact that it is not exclusively a disease of the former sex. Some statistics on this subject have been collected. In Briquet's often-quoted 1000 cases of hysteria, 50 only occurred in men. I believe, however, that the proportion of hysterical men to hysterical women is greater than this. Instead of a ratio of 1 to 20, as these statistics would indicate, 1 to 15 would probably be nearer the truth. Statistics upon this subject are deceptive.

The occurrence of hysteria in the male was little discussed before the publication of Briquet's great work, but since that time it has received great attention from the medical profession. Charcot³⁸ in some recent lectures at Salpêtrière has called attention to this subject. From 1875 to 1885 he says that five doctoral theses have been written on hysteria in men. Batault has collected 218 and Klein 80 cases. The Index Catalogue contains 102 references to hysteria in the male.

³⁸ Le Progrès médical, 1885.

Hysteria in men may take on almost any form that it shows in women. It may occur in the strong, although more likely to be seen among the weak and effeminate. Even strong, vigorous workmen are susceptible, at times, to hysteria. According to Charcot, the duration of the affection differs somewhat in the two sexes. In male patients it lasts a long time and the symptoms are troublesome; in females the contrary is usually although not always the case. The occurrence of hysteria in the male sex has probably been overlooked through the tendency to class symptoms which would be regarded as hysterical in women as hypochondriacal in men.

One of the most typical half-purposive hysterical attacks that has ever come under my observation was in a literary man of some prominence. Hysterical syncope, contracture, hysterical breathing, hysterical hydrophobia, coccygodynia, hemiparesis, hemianæsthesia, and blindness are some other forms of hysteria in the male of which there are clinical records the result of personal observation. A remarkable case of hysterical motor ataxy was seen in a boy who was for some time a patient at the Philadelphia Polyclinic. Wilks³⁹ records several interesting cases of hysteria in boys. One simulated laryngismus stridulus, with paroxysmal suffocative attacks and barking. Another was a case of hysterical maniacal excitement; another was an example of malleation, or constant movement as in hammering; still others were instances of extreme hyperæsthesia, of anorexia, and of nervous dyspnœa. The same author also dwells on the hysterical perversion of the moral sense found in boys as in girls. He gives some instances clipped from English newspapers—attempts to poison, murder or attempts to murder, confessions false and true. Many instances could be added from our own sensational American sheets.

³⁹ Op. cit.

No age is free from a liability to hysteria. Its occurrence, however, at certain periods of life with great frequency is well known. The following table has been arranged from tables given by Briquet and Jolly, and shows that it is of most frequent occurrence between the ages of fifteen and thirty:

Age.	Landouzy.	Georget.	Beau.	Briquet.	Scanzoni.	Total.
0-10	4	1	—	66	—	71
10-15	48	5	6	98	4	161
15-20	105	7	7	140	13	272
20-25	80	4	3	71	64	289
25-30	40	3	—	24
30-35	38	—	—	9	78	149
35-40	15	—	—	9
40-45	7	1	—	1	44	65
45-50	8	—	1	3
50-55	4	—	—	3	11	25
55-60	4	—	1	2
60-80	2	—	—	—	3	5
	355	21	18	426	217	1037

Hysteria in the United States assumes almost every form, probably because we have here represented almost every race and nationality, either pure or mixed. While it cannot be clearly shown that certain races are much more prone to hysteria than others, the type of this disease is doubtless much influenced by racial and climatic conditions. Certain phases of the disease prevail in certain sections more than in others. Mitchell's⁴⁰ experience is that the persistent hystero-epilepsies, and the multiple and severe contractures which Charcot and others describe, are rare in this country among all classes, and especially uncommon in the lowest classes, among which Charcot seems to have found his worst and most interesting cases. He says that while his own clinic furnishes numerous cases of neural maladies, and while he has examples of every type of the milder form of hysteria, it is extremely uncommon to encounter the more severe and lasting forms of this disease. When Mitchell's Lectures were first published I was inclined to regard hystero-epilepsy of the grave type as of rare occurrence, and so stated in answer to a communication from him. Recently, as the result of a longer experience, I have become persuaded that some irregular forms are met with somewhat frequently in various sections of our country. It remains true, however, that in the Middle and Northern sections of the United States the graver hysterias of the convulsive type are not nearly as frequently observed as in the southern countries of Europe.

⁴⁰ Op. cit.

Dr. Guiteras, formerly physician to the Philadelphia Hospital, and Lecturer on Physical Diagnosis in the University of Pennsylvania, now in the United States marine hospital service, has for several years been on duty, most of the time, in Florida, the West Indies, and the Gulf of Mexico. In answer to an inquiry made by me, he writes: “Hysteria prevails with extraordinary frequency amongst the Cubans. It presents itself in the shape of excito-motory and mental phenomena, almost to the exclusion of all other manifestations. The motory anomalies comprise the whole range from mild hysterics to the gravest hystero-epilepsy. The latter is incomparably more frequent in Key West than in Philadelphia. The confirmed hystero-epileptics are few, but it is the rule for well-marked cases of hysteria to present occasionally, often only once in the course of the disease, hystero-epileptic seizures which may be of frightful intensity. By mental disorders I do not mean only the acute attacks of excitement and delirium which attend upon or take the place of convulsive attacks, but I mean also to include the chronic form of hysterical insanity, which is generally some variety of melancholia. These are the peculiarities of hysteria as seen by myself in the Latin race in the tropics. My experience teaches me that the Saxon race in the tropics shows the same peculiarities to a less extent.”

In the region referred to by Guiteras it will be remembered there is a mixed population composed largely of Spanish, French, and Portuguese. Climatic and other local influences may have something to do with the particular form which this disorder assumes in these tropical or semitropical districts, but race would seem to be the most important factor. In the section on Hystero-epilepsy I will speak of the irregular type of this disorder, which has fallen most frequently under my own observation.

Hysteria in the negro is of somewhat frequent occurrence, and is more likely to be of the demonstrative or convulsive than of a paralytic or negative form. Hysterical convulsions, particularly of the purposive kind, and hysterical mania, are often met with in the colored population of our large city hospitals and asylums.

The influence which climate exerts, like that of race, is rather on the type of hysteria than upon the disease itself. Hysteria is found in every climate, but in warm countries the disorder seems more likely to be mobile and dramatic than when found in the more temperate or colder zones.

Season and meteorological conditions have some influence on the production of hysterical attacks. It is well known that hysteria, chorea, and other allied nervous disorders are more likely to appear in the spring than at other seasons. This fact has been shown by various observers.

Hysteria may occur in any rank of life. It is not, as has been held by some, a disease of the luxurious classes. The American physician who has seen much of this disorder—and that means every physician of large practice—has met with hysterical cases in every walk of life. While this is true, however, hysteria of certain types is met with more frequently in certain social positions. Some of the remarks about race and climate apply also here. It is the type of the disorder, and its relative frequency among various classes, which are affected by social position. Young women of the richer classes, who have been coddled and pampered, whose wants and whose whims have been served without stint or opposition, often pass into hysterical conditions which do not have any special determining causative factor, or at least only such as are comparatively trivial. Occasionally, in them hystero-epilepsy, catalepsy, and the train of grave hysterical phenomena are observed. We are more likely, however, to have the minor and indefinite hysterical symptoms; or, if grave manifestations be present, they are most usually ataxia, paralysis, contractures, or aphonia, and not convulsive phenomena. Hysteria in our American cities is especially prevalent among certain classes of working-people, as among the operatives in manufacturing establishments. Dividing American society into the three classes of rich, middle, and poor, hysteria is most prevalent in the first and the last. It is, however, by no means absent in the middle class.

The absence of occupation on the one hand, and, on the other, the necessity of following work for which the individual is unfitted, particularly irritating lines of work, predispose to the occurrence of hysteria. It may be caused, therefore, either by no work, overwork, or irritating work. As to the special occupations, hysteria would seem to result most commonly in those positions where physical fatigue combines with undue mental irritation to harass and reduce the nervous system. In men it occurs often as the result of overwork conjoined with financial embarrassment. It is met with not infrequently among teachers, particularly those who are engaged in the straining and overstraining labor of preparing children for examinations. A good method of education is the best preventive; a bad method is one of the most fruitful causes of the affection. The injurious effect of American school or college life in the production of hysteria is undoubted, and should be thoroughly appreciated. Our educational processes act both as predisposing and exciting causes of this disorder. Both in our private and public educational institutions the conditions are frequently such as to lead to the production of hysteria or to confirm and intensify the hysterical temperament. In our large cities all physicians in considerable practice are called upon to treat hysterical girls and boys, the former more frequently, but the latter oftener than is commonly supposed. Hysteria in boys, indeed, does not always meet with recognition, from the fact that it is in boys. Cases of hysteria in girls under twelve years of age have come under my observation somewhat frequently. About or just succeeding examination-time these cases are largely multiplied. The hysteria under such circumstances may assume almost any phase; usually, however, we have not to deal in such patients with convulsive types of the disease.

Clarke⁴¹ has considered some of these questions in connection particularly with the physiological processes of menstruation, and its bearing upon the inability of girls to maintain equally with boys the stress of such competition.

⁴¹ Sex in Education, etc., by Edward H. Clarke, M.D., Boston, 1873.

The cramming processes which are resorted to in order to force children at fixed times from the lower to the higher grades of public schools, and more especially from grammar to normal or high schools, is a fruitful source of evil in this direction. It is not always so much hard study as it is the badly-arranged and too numerous subjects of study that make the strain. I have spoken of this in another connection as follows:⁴² “Our children are too largely in the hands of those educationalists to whom Clouston refers,⁴³ who go on the theory that there is an unlimited capacity in every individual brain for education to any extent and in any direction. Children varying in age and original capacity, in previous preparation, and in home-surroundings are forced into the same moulds and grooves. The slow must keep pace with the fleet, the frail with the sturdy, the children of toil and deprivation with the sons and daughters of wealth and luxury. A child is always liable to suffer from mental overwork when the effort is made to force its education beyond its receptive powers. Education is not individualized enough. The mind of the child is often confused by a multitude of ill-assorted studies. Recreation is neglected and unhealthy emulation is too much cultivated. In many communities admissions to various grades of public schools are regulated entirely by the averages obtained at examinations, instead of on the general record of the pupils in connection with proper but not too severe examinations. In consequence often, after the campaign of overwork and confusion called an examination, we see children developing serious disturbances of health or even organic disease—paroxysmal fever, loss of appetite, headache or neckache, disturbed sleep, temporary albuminuria, chorea, hysteria, and hystero-epilepsy.”

⁴² “Toner Lecture on Mental Overwork and Premature Disease among Public and Professional Men.” delivered March 19, 1884, Washington, Smithsonian Inst., January, 1885.

⁴³ Clinical Lectures on Mental Diseases.

The term students' hysteria has been applied to the neuromimetic disorders from which medical students frequently suffer during their attendance upon lectures. Some years since, when engaged in examining students upon the lectures upon the practice of medicine delivered by Professor DaCosta, I saw many illustrations of this affection, some of which were very amusing. In a paper on hysteria which received the prize at the Physical Society of Guy's Hospital, P. Horrocks⁴⁴ writes that during the fortnight following the death of the late Napoleon, Sir James Paget was consulted for stone in the bladder by no less than four gentlemen who had nothing the matter with them. “How many students,” says Horrocks, “are there, of one year's standing or more, who have not imagined and really became convinced that they were suffering from some disease, generally a fatal disease?” In such cases we have a combination of true psychical influence with overwork and the unhygienic surroundings for which our medical colleges are notorious.

⁴⁴ Med. and Surg. Reporter, vol. xxxvii., Nov. 24, 1877.

It has been my personal experience that comparatively few cases of hysteria occur among female medical students. Not long since a thesis was presented at graduation by a woman medical student⁴⁵ on the curative effects of professional training in neurasthenic and hysterical women. In this she shows that there are certain relations of mind over body which enable it to modify bodily conditions and ward off disease when other remedies appear almost powerless. She illustrates the therapeutic power of mental impressions and occupations by two cases in which a judicious and careful course of study acted to cure severe nervous and uterine troubles. One of these women, who had suffered with neurasthenia and general debility, severe nervous headaches, and other symptoms, was able during her last year at college to attend fifteen lectures a week, besides clinics, prepare for examination on five subjects, and was seldom troubled with even headache. She afterward was employed in hospital work, and could walk five miles a day without discomfort. That women medical students know when and how to take care of themselves during the menstrual period, and that they can, if they see fit, cease work or lighten their labors at that time, would partly account for their escaping from nervous break-down.

⁴⁵ “The Therapeutic Value of Mental Occupation,” by Hannah M. Thompson, M.D., Medical and Surgical Reporter, November, 1883.

That any form of irritation in a patient predisposed to hysteria may act as an exciting cause in this affection has led Laségue to apply the term peripheral hysteria to certain cases. One of his cases was a girl fourteen years old, who, having suffered for a few hours with her eyes because of some sand thrown into one of them by a playmate, awoke the next morning with a spasm of the eyelid on that side, which rendered it impossible for her to open that eye; and it remained closed during four months. He considered that the irritation produced by the sand was not the immediate cause of the spasm, but that its long duration was an hysterical phenomenon. The patient afterward became the subject of hysterical manifestations. In another complete hysterical aphonia came on after a slight bronchitis. Another, after an attack of indigestion, refused to touch either food or drink for twenty-four hours, and later was troubled with regurgitation from constriction of the pharynx or œsophagus which lasted for some weeks.

Anæmia and chlorosis are frequent exciting causes of hysteria in children, particularly in girls.

Disorders of menstruation play a prominent part as exciting causes of special hysterical manifestations. The period of the establishment of the menstrual function is one that is particularly fertile in the production of hysteria, much more so than acquired disorders of menstruation occurring later. Menorrhagia, dysmenorrhœa, and certain local utero-vaginal disorders may act upon those predisposed to hysteria as exciting causes. These conditions themselves are, on the other hand, sometimes caused by nervous, hysterical states in the individual.

With reference to the very common assertions that continence on the one hand, and sexual over-indulgence on the other, are the most prolific causes of hysteria, the true stand to take is that neither of these positions is philosophically correct; for, as Briquet has shown, nuns on the one hand and prostitutes on the other are frequent victims of this protean disorder.

As affirmed by Jolly, sexual over-irritation, particularly that induced by onanism, more frequently causes hysteria than sexual abstinence or deprivation.

The occurrence of hysteria and hysterical choreas among pregnant women has long been recognized. Scanzoni, quoted by Jolly,⁴⁶ states that of 217 patients whom he had treated, 165, or 76 per cent. had been puerperal, and that of the latter not less than 65 per cent. had borne children more than three times. Cases of grave hysteria or hystero-epilepsy have been aggravated by pregnancy and have led to premature labor.

⁴⁶ Op. cit.

Chrobak attacks the etiological problem of hysteria by referring its causation to movable kidneys! He observed 19 such patients in Vienna, 16 being in Oppolzer's clinic.⁴⁷ Three times no subjective symptoms accompanied the anomaly; eight times the trouble could be referred either to the dislocation of the kidneys or to disease of the same; and eight times the evidence of hysteria was unmistakable. Among the latter eight cases neither vaginal, uterine, nor ovarian conditions were recognized. He concludes that there is a direct nervous connection between the kidneys and the genital organs, and between both and hysteria.

⁴⁷ Medizinische-Chirurgische Rundschan, quoted by Boston Medical and Surgical Journal, 1870, lxxxiii. 430-432.

In brief, the truth is that frequent or severe local irritation in any part of the body in an individual of the hysterical diathesis may act as the exciting cause of an hysterical paroxysm or of special hysterical manifestations. Irritation or disease of the uterus or ovaries may result in hysteria, as may the bite of a dog, a tumor of the brain, a polypus in the nose, a phymosis, an irritated clitoris, a gastric ulcer, a stenosis of the larynx, a foreign body in the eye, a toe-nail ulcer, or a movable kidney.

Whatever tends to exhaust the nervous system will also cause hysteria, but only in those who have some inherited predisposition to the disorder. C. Handfield Jones⁴⁸ mentions heatstroke and severe physical labor as such causes. One of the sequelæ of heatstroke enumerated by Sir R. Martin, and quoted by Jones, is a distressing hysterical state of the nervous system, with an absence of self-control in laughing and crying, the paroxysm being followed by great prostration of nervous power.

⁴⁸ Op. cit.

The effect of imitation in the production of hysteria has been known in all ages. Most of the epidemics and endemics of nervous disorders which have from time to time prevailed in various parts of the world have either been hysterical in character or have had in them a large element of hysteria. While it is impossible in a practical work to devote much space to this branch of the subject, a discussion of hysteria in its etiological relations would be imperfect without some reference to these outbreaks. In ancient times, in the Middle Ages, and within comparatively recent periods extraordinary epidemics have occurred. No country within the range of medical observation has been entirely free from them. Communities civilized and semi-civilized, Christian and Mohammedan, Protestant and Catholic, have had a fair share of the visitations. Some of them constitute epochs in history, and, as Hecker,⁴⁹ their greatest historian, has remarked, their study affords a deep insight into the work of the human mind in certain states of society. “They are,” he says, “a portion of history, and will never return in the way in which they are recorded; but they expose a vulnerable part of man—the instinct of imitation—and are therefore very nearly connected with human life in the aggregate.”

⁴⁹ The Epidemics of the Middle Ages, from the German of J. F. C. Hecker, M.D., Professor at the Frederick William University at Berlin, etc., translated by B. G. Babington, M.D., F. R. S., etc.; 3d ed., London, 1859.

Some authors under hysteria, others under catalepsy, others under ecstasy, still others under chorea, have discussed these epidemics—a fact which serves to emphasize the truth that while these affections have points of difference, they have also an easily-traced bond of union. They are but variations of the same discordant tune. Briquet in an admirable manner sketches their history from the age of Pausanias and Plutarch to the time of Mesmer. Of American writers, James J. Levick⁵⁰ of Philadelphia has furnished one of the most valuable contributions to this subject.

⁵⁰ “An Historical Sketch of the Dance of St. Vitus, with Notices of some Kindred Disorders,” Med. and Surg. Reporter, vol. vii., Dec. 21 and 28, 1861, p. 276, and Jan. 4 and 11, 1862, p. 322.

In the year 1237 a hundred children or more were suddenly seized with the dancing mania at Erfurt; another outbreak occurred at Utrecht in 1278.

As early as the year 1374 large assemblages of men and women were seen at Aix-la-Chapelle affected with a “dancing mania.” They formed circles and danced for hours in wild delirium. Attacks of insensibility, of convulsions, and of ecstasy occurred. The disease spread from Germany to the Netherlands. In a few months it broke out in Cologne, and about the same time at Metz. “Peasants,” we are told, “left their ploughs, mechanics their workshops, housewives their domestic duties, to join the wild revelry, and this rich commercial city became the scene of the most ruinous disorder.”

The festival of St. John the Baptist was one celebrated in strange wild ways in these early days. Fanatical rites, often cruel and senseless, were performed on these occasions. Hecker supposes that the wild revels of St. John's Day in 1374 may have had something to do with the outbreak of the frightful dancing mania soon after this celebration. It at least brought to a crisis a malady which had been long impending.

The Flagellants afford another illustration of an early religio-nervous craze. Self-flagellation was indulged in for generations before the fourteenth century, but it then became epidemic. A brotherhood of Flagellants was formed; they marched in processions carrying scourges, with which they violently lashed and scourged themselves. As late as 1843, Flagellant processions, but without the whips and scourging, were continued in Lisbon on Good Friday.

Strasburg was visited by the dancing plague in 1418. Those afflicted were conducted to the chapel of St. Vitus, where priests attempted to relieve them by religious ceremonies. The name St. Vitus's dance, still so common as a synonym for chorea, has come down to us because of the alleged wonderful doings of this saint in behalf of those affected during some of the dancing epidemics. Both Hecker and Madden⁵¹ give interesting details of the personal history of St. Vitus, who was a Sicilian, born in the time of Diocletian, and even in childhood is said to have worked great miracles, and was delivered from many sufferings and torments. He died about the year 303. His body was moved to Apulia, afterward to St. Denys in France, and still later to the abbey of Corvey in Saxony. A legend was invented that St. Vitus, just before he bent his neck to the sword, prayed to God that he might protect from the dancing mania all those who should solemnize the day of his commemoration and fast upon its eve.

⁵¹ Phantasmata; or, Illusions and Fanaticisms, etc., by R. R. Madden, F. R. S., London, 1857.

Another strange disorder called tarantismus derived its name from the fact that it was supposed to be caused by the bite of the tarantula, a ground-spider common in Apulia, Italy. According to Hecker, the word tarantula is the same as terrantola, a name given by the Italians to a poisonous lizard of extraordinary endowments. The fear of the insect was so general that its bite was much oftener imagined than actually received. The disorder was probably in existence long before the fifteenth century, although the first account of it, that of Nicholas Perotti, refers to its occurrence in this century. Many symptoms followed the bite or supposed bite: the individuals became melancholy, stupefied, lost their senses, and, above all, were irresistibly impelled to dance until exhausted and almost lifeless. It was believed that the results of the bite could be cured, or at least much benefited, by dancing to a certain kind of music. Tarantism was at its height in the seventeenth century. To this day, in some parts of Italy, dances called tarantellas are performed with intricate figures to marked time.

Abyssinia was visited by a dancing mania called the tigretier, which, according to Hecker, resembled the original mania of the St. John dancers. It exhibited a similar ecstasy. Those affected with it were cured by dancing to the music of trumpeters, drummers, fifers, etc.

Levick says that the dancing mania of the fifteenth century is still kept in popular remembrance in some places by an annual festival, especially at Echtermarch, a small town in Luxembourg, where a jumping procession occurs annually on Whit Tuesday. In the year 1812, 12,678 dancers were in the procession.

The Anabaptists, a religious sect of the sixteenth century, exhibited many of the wild and grotesque phenomena of hysteria or hystero-epilepsy.

The French Calvinists or Camisards, who appeared near the close of the seventeenth century, were also the subjects of ecstasy and of peculiar fits of trembling. These trembleurs experienced convulsive shocks in the head, the shoulders, the legs, and the arms, and were sometimes thrown violently down.

About 1731 and later great crowds frequented the tomb of Deacon François de Paris, an advocate of the doctrines of Jansenius. It was reported that miracles were performed at his tomb: the sick were brought there, and often were seized with convulsions and pains, through which they were healed. The subjects of these attacks are sometimes spoken of as the Jansenist Convulsionnaires. The tomb was in the cemetery of St. Médard, and hence those who visited the place were also termed the Convulsionnaires of St. Médard. This disorder increased, multiplied, and disseminated, lasting with more or less intensity for fifty-nine years. Great immorality prevailed in the secret meetings of the believers.

Hecker gives some remarkable instances of the effect of sympathy or imitation exhibited on a smaller scale than in the epidemics of the Middle Ages. One is of a series of cases of fits in a Lancashire factory, the first one brought on by a girl putting a mouse into the bosom of another. In Charité Hospital in Berlin in 1801 a patient fell into strong convulsions, and immediately afterward six other patients were affected in the same way; by degrees eight more were attacked. At Redruth, England, a man cried out in a chapel, “What shall I do to be saved?” Others followed his example, and shortly after suffered most excruciating bodily pain. The occurrence soon became public; hundreds came, and many of them were affected in the same way. The affection spread from town to town. Four thousand people were said in a short time to be affected with this malady, which included convulsions.

Hecker in the edition of his work referred to has also a treatise on child pilgrimages.⁵² These pilgrimages, like the dancing mania, occurred in the Middle Ages. The greatest was the boy crusade in the year 1212. The passion to repossess the Holy Land then had its grip on Catholic Europe. The first impulse to the child pilgrimages was given by a shepherd-boy, who had revelations and ecstatic seizures, and held himself to be an ambassador of the Lord. Soon thirty thousand souls came to partake of his revelations; new child-prophets and miracle-workers arose; the children of rich and poor flocked together from all quarters; parents were unable to restrain them, and some even began to urge them. A host of boys, armed and unarmed, assembled at Vendôme, and started for Jerusalem with a boy-prophet at their head. They got to Marseilles, and embarked on seven large ships. Two ships were wrecked, and not a soul was saved. The other five ships reached Bougia and Alexandria, and the young crusaders were all sold as slaves to the Saracens. In Germany child-prophets arose, especially in the Rhine countries and far eastward. An army of them gathered together, crossed the Alps, and reached Genoa. They were soon scattered; many perished; many were retained as servants in foreign lands; some reached Rome. A second child's pilgrimage occurred twenty-five years later. It was confined to the city of Erfurt. One thousand children wandered, dancing and leaping, to Armstadt, and were brought back in carts. Another child's pilgrimage from Halle, in Suabia, to Mount St. Michel in Normandy, occurred in 1458.

⁵² Translated by Robert H. Cooke, M. R. C. S.

In the convent of Yvertet in the territory of Liège, in 1550, the inmates were seized with a leaping and jumping malady. The disorder began with a single individual, and was soon propagated.

Sometimes the convulsive disorders of early days, especially those occurring in convents, were associated with the strange delusion that the subjects of them were changed into lower animals. Various names have been given to disorders of this kind, such as lycanthropia or wolf madness, zoomania or animal madness, etc. Burton in the Anatomy of Melancholy gives an interesting summary of these disorders, which are also discussed by Levick.

In 1760 a religious sect known as the Jumpers prevailed in Great Britain. They were affected with religious frenzy, and jumped continuously for hours. Other jumping epidemics have appeared at different times, both in Great Britain and in this country.

The New England witchcraft episode is of historical interest in connection with this subject of epidemic hysteria. This excitement occurred during the latter part of the seventeenth century. Adults and children were its subjects. The Rev. Cotton Mather records many cases, some of which illustrate almost every phase of hysteria. Individuals who were seized with attacks, which would now be regarded as hysterical or hystero-epileptic, were supposed to have become possessed through the machinations of others. Those who were supposed to be possessed were tried, condemned, and executed in great numbers. Many accused themselves of converse with the devil. The epidemic spread with such rapidity, and so many were executed, that finally the good sense of the people came to the rescue.

The nervous epidemics, nearly all religious, which have occurred in this country have usually been during the pioneer periods, and have therefore appeared at different eras as one part of the country after another has been developed. Kentucky, Tennessee, Virginia, and neighboring States were visited time and again. Even to-day we occasionally hear of outbreaks of this kind in remote or primitive localities, whether it be in the far South-west or in the woods of Maine.

David W. Yandell⁵³ has published a valuable paper on “Epidemic Convulsions,” the larger part of the materials of which were collected by his father for a medical history of Kentucky. From this it would appear the convulsions were first noticed in the revivals from 1735 to 1742. Many instances are related of fainting, falling, trance, numbness, outcries, and spasms. The epidemic of Kentucky spread widely, reappeared for years, and involved a district from Ohio to the mountains of Tennessee, and even to the old settlements in the Carolinas. Wonderful displays took place at the camp-meetings. At one of these, where twenty thousand people were present, sobs, shrieks, and shouts were heard; sudden spasms seized upon scores and dashed them to the ground. Preachers went around in ecstasy, singing, shouting, and shaking hands. Sometimes a little boy or girl would be seen passionately exhorting the multitude, reminding one of the part taken by the children in the epidemics of the Middle Ages. A sense of pins and needles was complained of by many; others felt a numbness and lost all control of their muscles. Some subjects were cataleptic; others were overcome with general convulsions.

⁵³ Brain, vol. iv., Oct., 1881, p. 339 et seq.

The term jerks was properly applied to one of the forms of convulsion. Sometimes the jerking affected a single limb or part. The Rev. Richard McNemar has given a graphic description of this jerking exercise in a History of the Kentucky Revival. The head would fly backward and forward or from side to side; the subject was dashed to the ground, or would bounce from place to place like a football, or hop around with head, limbs, and trunk twitching and jolting in every direction. Curiously, few were hurt. Interesting descriptions of the jerks can be found in various American autobiographical and historical religious works. In such books as the Autobiography of Peter Cartwright, a Western Methodist, for instance, striking accounts of some of the phases of these epidemics are to be found. Lorenzo Dow in his Journal, published in Philadelphia in 1815, has also recorded them.

Hysterical laughter was a grotesque manifestation often witnessed. The holy laugh began to be a part of religious worship. Dancing, barking, and otherwise acting like dogs, were still other manifestations. It is remarkable that, according to Yandell, no instance is recorded in which permanent insanity resulted from these terrible excitements.

The absurd and extraordinary exhibitions witnessed among the Shakers belong to the same category, and have been well described by Hammond and others.

In a History of the Revival in Ireland in 1859, by the Rev. William Gibson, instances of excitement that fairly rivalled those which occurred in our Western States are given. Cases of ecstasy are described.

The religious sect known as the Salvation Army, which has in very recent years excited so much attention, curiosity, and comment both in America and England, has much in common with the Jumpers, the Jerkers, and the Convulsionnaires. The frenzied excitement at their meetings, with their tambourine-playing, dancing, shouting, and improvising are simply the same phases of religio-hysterical disorder, modified by differences in the age and environment.

In 1878, in the district of Tolmezo, Italy, an epidemic of hysteria which recalls the epidemics of the Middle Ages occurred. It has been described by M. Léon Colin.⁵⁴ It was reported to the prefect of Undine that for three months some forty females living in the commune of Verzeguis had been attacked by religious mania. “From the report it appears that the first was in the person of a woman named Marguerite Vidusson, who had been the subject of simple hysteria for about eight years. In January, 1878, she began to suffer from convulsive attacks, accompanied by cries and lamentations. She was regarded as the subject of demoniacal possession, and on the first Sunday in May was publicly exorcised. Her affection, however, increased in severity; the attacks were more frequent and more intense, and were especially provoked by the sound of the church-bells and by the sight of priests. Seven months later three other hysterical girls became subject to convulsive and clamorous attacks. Here, again, an attempt was made to get rid of the supposed demon. A solemn mass was said in the presence of the sufferers, but was followed only by a fresh outbreak. At the time of the visit of the delegates eighteen were suffering, aged from sixteen to twenty-six years, except three, whose ages were respectively forty-five, fifty-five, and sixty-three years. Similar symptoms had also appeared in a young soldier on leave in the village.” During the attacks the patients talked of the demon which possessed them, stated the date on which they were seized by it, and the names of the persons who were possessed before them. Some boasted of being prophetesses and clairvoyants and of having the gift of tongues. In all, the sound of church-bells caused attacks, and religious ceremonies appeared not only to aggravate the disease in the sufferers, but also to cause its extension to those not previously attacked. M. Colin points out that the soil is particularly favorable for the development of an epidemic of this nature. The people of Verzeguis are backward in education and most superstitious. Functional nervous diseases are common among them. The inhabitants of the village are largely cut off from intercourse with the adjacent country in consequence of comparative inaccessibility and the frequent interruption of communications by storms and floods. Craniometric observations on twelve of the inhabitants seemed to show that the brachycephalic form of skull predominated, and that the development of the cranium was slightly below the average. The epidemic proved extremely obstinate.

⁵⁴ Annales d'Hygiène, quoted in Lancet, Oct. 16, 1880.

In Norway and New Caledonia similar hysterical outbreaks have been observed in recent times.

An endemic of hysteria from imitation occurred in Philadelphia in 1880. Some of the cases fell under my own observation. A brief account of them is given by Mitchell in his Lectures. The outbreak occurred in a Church Home for Children, to which Dr. S. S. Stryker was physician. The Home contained ninety-five girls and six boys; all of them were well nourished and in good condition. The epidemic began by a girl having slight convulsive twitchings of the extremities, with a little numbness. Attacks returned daily; respiration became loud and crowing. She soon had all the phenomena of convulsive hysteria. Many of her comrades began to imitate her bark. Soon another girl of ten was attacked with harsh, gasping breathing, with crowing, speechlessness, clutching at her throat, and the whole series of phenomena exhibited by the first girl attacked. Nine or ten others were affected in like manner, and many of the remaining children had similar symptoms in a slight degree. At first convulsions occurred irregularly; after a while they appeared every evening; later, both morning and evening. The presence of visitors would excite them. Many interesting hysterical phases occurred among the children. One night some of them took to walking about on their hands and knees; others described visions. The girls often spoke of being surrounded by wild beasts, and one child would adopt the fiction which another related in her hearing. The cases were scattered about in different hospitals, and made good recoveries in from one to two months.

The Jumpers or Jumping Frenchmen of Maine and Northern New Hampshire were described by Beard in 1880.⁵⁵ They presented nervous phenomena in some phases allied to hysteria. In June, 1880, Beard visited Moosehead Lake and experimented with some of them. Whatever order was given them was at once obeyed. One of the Jumpers, who was sitting in a chair with a knife in his hand, was told to throw it, and he threw it quickly so that it struck in a beam opposite; at the same time he repeated the order to throw it with a cry of alarm. They were tried with Latin and Greek quotations, and repeated or echoed the sound as it came to them. They could not help repeating any word or sound that came from the person that ordered them. Any sudden or unexpected noise, as the report of a gun, the slamming of a door, etc., would cause them to exhibit some phenomena. It was dangerous to startle them where they could injure themselves, or if they had an axe, knife, or other weapon in their hands. Since the time of Beard's observation accounts of their doings have now and then found their way into newspapers. One recent account tells of one of these peculiar people jumping from a raft into the Penobscot River on an order to jump.

⁵⁵ Journal of Nervous and Mental Diseases, vol. vii., 1880, p. 487.

Hammond⁵⁶ has described under the name Miryachit an affection which seems to be essentially the same disorder as that of which the Jumpers are the victims. He quotes from a report of a journey from the Pacific Ocean through Asia to Europe by Lieutenant B. H. Buckingham and Ensigns Geo. C. Foulk and Walter McLean of the United States Navy, an account of this disease. The party made their first observations on this affection while on the Ussuri River in Siberia. The captain of the general staff approached the steward of the boat suddenly, and without any apparent reason or remark clapped his hand before his face; instantly the steward clapped his hand in the same manner, put on an angry look, and passed on. When the captain slapped the paddle-box suddenly, the steward instantly gave it a similar thump. Some of the passengers imitated pigs grunting or called out absurd names, etc.; the poor steward would be compelled to echo them all. The United States naval officers were informed that the affection was not uncommon in Siberia, and that it was commonest about Yakutsk, where the winter cold is extreme. Both sexes were subject to it, but men much less than women. It was known to Russians by the name of Miryachit.

⁵⁶ New York Med. Journ., Feb. 16, 1884.

In both these classes of cases a suggestion of some kind was required, and then the act took place independently of the will. “There is another analogous condition known by the Germans as Schlaftrunkenheit, and to English and American neurologists as somnolentia or sleep-drunkenness. In this state an individual on being suddenly awakened commits some incongruous act of violence, ofttimes a murder. Sometimes this appears to be a dream, but in others no such cause could be discovered.” Curious instances are mentioned by Hammond of this disorder.

The phenomena of automatism at command in hypnotized subjects have much similarity to the phenomena of these affections, and the same explanation to a certain extent will answer for both.

Paget⁵⁷ has ably discussed the subject of neuromimesis in general, and Mitchell⁵⁸ devotes two lectures to its consideration. As already stated when discussing the synonyms of hysteria, the mistake must not be made of supposing all cases of hysteria to be instances of neuromimesis; but, as Mitchell remarks, the hysterical state, however produced, is a fruitful source of mimicry of disease in its every form, from the mildest of pains up to the most complete and carefully-devised frauds. “Its sensitiveness and mobility, its timidity and emotionalness, its greed of attention, of sympathy, and of power in all shapes, supply both motive and help, so that while we must be careful not to see mimicry in every hysteric symptom, we must in people of this temperament be more than usually watchful for this form of trouble, and at least reasonably suspicious of every peculiar or unusual phenomenon.”

⁵⁷ Op. cit.

⁵⁸ Op. cit.

SYMPTOMATOLOGY.—At the outset of the discussion of the symptomatology of hysteria, hysterical cases should be divided into four classes—viz. (1) Cases in which the symptoms are involuntary; (2) cases in which the symptoms are artificially induced and become involuntary; (3) cases in which the symptoms are acted or simulated, but in which the patient, because of impaired mental power, is irresistibly impelled to their performance; (4) cases in which the symptoms are purely acts of deception which are under the control of the patient.

Keeping in mind these different classes, we will always be able to link to the phenomena of hysteria the psychical element which is present in all genuine cases of this disorder. To comprehend the existence of the psychical element in the first class, in which the manifestations are absolutely involuntary, may offer difficulties. In these cases, at a period more or less recent or remote, psychical stimuli may have acted to produce the hysterical phenomena, and, once produced, these have been repeated and intensified by habit, and continue independently both of volition and consciousness. The experiments of Dercum and Parker show how hysterical symptoms may be artificially induced and may get beyond the patient's control. The difference between induced and simulated manifestations must always be clearly borne in mind. To induce a set of phenomena a certain mechanism must be set in action, and this, through rational, explicable processes, leads to certain results. The psychical element enters here both positively and negatively—positively, in the determination to produce a certain train of events; negatively, in the condition of mental concentration or abstraction which is a part of the procedure. In the third class of cases acting or simulation is dependent upon the irresistible inclinations of the patient. This may seem to some an uncertain and even dangerous ground to take. I am convinced, however, after observing many hysterical cases, that acts clearly purposive, so far as the particular performance is concerned, are sometimes the result of a general unstable mental condition. Some at least of these patients are as irresistibly impelled to swallow blood and vomit, to scream and gesticulate, etc., as is the monomaniac to commit arson, to ravish, or to kill. In the fourth class, the cases of pure, unmitigated, uncontrollable deception, the psychical element is very evident, although some may question whether such cases should be ranged under the banner of hysteria, where it is both convenient and customary to place them.

The symptoms of hysteria may develop in any order or after any fashion. The graver hysterical phenomena, such as convulsions, paralysis, and anæsthesia, often seem to come on suddenly, but usually this suddenness of onset is apparent rather than real. Minor hysterical symptoms, such as general nervous irritability, pains, aches, and discomforts, and mental peculiarities, have usually been present for a long time. These minor evidences of the hysterical constitution are sometimes the only phenomena ever presented.

Todd⁵⁹ has described an expression of countenance which he designates as the facies hysterica. The characteristics of this expression are a remarkable depth and prominent fulness, with more or less thickness, of the upper lip, and a peculiar drooping of the upper eyelids. It would be absurd to assert that all hysterical patients presented this cast of countenance, but an appearance which approaches closely to this description is presented in a fair percentage of cases. It has seemed to me that male hysterics were more likely to have this peculiar facies than hysterical females.

⁵⁹ Reynolds's System of Medicine, vol. ii. p. 656.

The psychical peculiarities or mental disorders of hysteria form a large and important part of its phenomena. We have to deal not only with peculiar and diverse psychical manifestations, but to one form of mental disorder it is clinically convenient and correct to apply the designation hysterical insanity.

In the mildest cases of ordinary hysteria conditions of mental irritability and mobility are sometimes the only striking features. “Patients,” says Jolly,⁶⁰ “are timid, easily overcome by any unexpected occurrence, sentimental, and sensitive. Every trifle annoys and upsets them; and there is this peculiarity—that a more recent stimulus may often effect a diversion in an exactly opposite direction.”

⁶⁰ Op. cit.

As bearing upon the question of the mental state in hysteria, the confessions obtained by Mitchell from several patients are of great interest. One patient, who had learned to notice and dwell upon any little symptom, vomited daily and aroused much sympathy. She took little or no food. Spasms came on, and she confessed that every new symptom caused new anxiety, and that somehow she rather liked it all. She gradually lost all her symptoms except vomiting, and overcame this by desperate efforts. Another patient confessed to having played a game upon her doctor for a long time by pretending she took no food. She would get out of bed at night, but remain there all day; she filled up a vessel with water to make others believe she passed large quantities of urine, etc. Another patient, a girl of nineteen, who came on a litter from a Western State, after a time regained her feet. In her confession she stated that what she lacked was courage. She believed that she would have overcome her difficulties if any one had told her that nothing was the matter. “In looking back over the year with the light of the present,” she says, “I can only say that I believe that there was really nothing the matter with me; only it seemed to me as if there was, and because of these sensations I carried on a sort of starvation process physical and mental.”

The older and some of the more recent classifications of insanity recognize hysterical insanity as a distinct form of mental disease. Morel and Skae, however, in their etiological classifications, and Hammond, Spitzka, Mann, and Clouston in their recently-published works, give it a “local habitation and a name.” Krafft-Ebing not only recognizes hysterical insanity as a distinct form of mental disease, but, after the German fashion, subdivides it quite minutely, as follows: First, transitory forms: a. with fright; b. hystero-epileptic deliria; c. ecstatic visionary forms; d. moria-like conditions. Second, chronic forms: a. hystero-melancholia; b. hystero-mania; c. degenerative states with hysterical basis.

Spitzka⁶¹ speaks of chronic hysterical insanity as an intensification of the hysterical character, to which “a silly mendacity is frequently added, and develops pari passu with advancing deterioration.” At the State Hospital for the Insane at Norristown and at the department for the insane of the Philadelphia Hospital cases of chronic hysterical insanity have come under my observation. Hammond under hysterical mania includes several different and somewhat distinct mental disorders.

⁶¹ Insanity, its Classification, Diagnosis, and Treatment, by E. C. Spitzka, M.D., New York, 1883.

With regard to the occurrence of hysterical manifestations amongst patients suffering from some well-recognized non-hysterical forms of insanity, a tour through any large asylum will afford abundant evidence. Cases of tremor closely simulating cerebro-spinal sclerosis have been observed frequently among the insane. Paralysis, contracture, hysterical joints, hysterical neuralgias, convulsions, and cataleptoid phenomena are among other hysterical manifestations which have fallen under personal observation among the insane of various classes.

A remarkable case of hysterical motor paralysis was observed at the State Hospital for the Insane at Norristown. This patient was an intelligent single woman about thirty-five years of age, of good family, well educated; she had been a teacher and writer, and became insane through family and business troubles. When only eight years of age she was paralyzed for two years and a half, and had had at times during her life, before becoming insane, attacks of partial or complete unconsciousness. Prior to coming under observation she had been an inmate of an English private asylum. She was sick on shipboard coming to this country, and on her arrival was in a state of delirium and insomnia, with attacks of loss of sight. Four months later she developed mania with suicidal inclinations. Just before the development of this maniacal condition her lower limbs became comparatively helpless, and soon after she entirely lost their use. I found her in this condition, and examination showed no change in knee-jerk, electrical reactions, nutrition, nor genito-urinary conditions, which led me to diagnosticate the absence of any organic spinal trouble. The case was pronounced one of hysterical paralysis, and it was prophesied that she would eventually completely recover, probably suddenly. For one year her paralysis remained, her mental condition varying very greatly during this time—sometimes in a lethargic state; sometimes with variable delusions and delirium; occasionally violent and destructive, again peaceable and pleasant; sometimes requiring strong anodynes and hypnotics. Fourteen months after her paralytic condition began, one day she suddenly threw away her crutches and ran up and down the corridor of the hospital. From that time she walked without difficulty, although her mental condition did not entirely clear.

I wish to impress the fact that because hysterical manifestations occur in a case of insanity it should not necessarily be diagnosticated as one of hysterical insanity. Monomania, melancholia, mania, paretic dementia, epileptic insanity, and other forms of mental disorder may at times have an hysterical tinge or hysterical episodes.

The whole question of hysterical insanity is one of great difficulty. The psychical element is probably at the root of all cases of hysteria, but this does not justify us, as I have already stated, in declaring that all cases of hysteria are insane. In practical professional life we must make practical distinctions. In the matter before us distinctions are necessary to be made for legal as well as medical purposes. It might be right and proper to place a case of hysterical insanity in a hospital or asylum under restraint, but no one would dare to claim that every case of hysteria should be so treated.

Hysterical insanity may be conveniently subdivided into an acute and chronic form.

Acute hysterical insanity or hysterical mania is a disorder usually, in part at least, purposive, and characterized by great emotional excitement, which shows itself in violent speech and movement, and often also in deception, simulation, and dramatic behavior. The phenomena indicated by this definition may constitute the entire case, or, in addition, the patient may have, at intervals or in alternation, various other phases of grave hysteria, such as hystero-epileptic seizures or attacks of catalepsy, trance, or ecstasy.

In chronic hysterical insanity we have a persisting abnormal mental condition, which may show itself in many ways, but chiefly as follows: (1) A form in which occur frequent repetitions, over a series of years, of the phenomena of acute hysterical insanity, such as hysterical mania, hystero-epilepsy, catalepsy, etc.; (2) a form in which sensational deceptions—sometimes undoubtedly self-deceptions—are practised.

In a case of chronic hysterical insanity you may have both of these forms commingling in varying degree, as in the following case: G—— is a seamstress, twenty-one years of age. Although young in years, she is an old hospital rounder: she has at various times been in almost all the hospitals of the city. She has been treated for such alleged serious affections as fractured ribs, hemorrhages from the lungs, stomach, and vagina, gastric ulcer, epilepsy, apoplexy, paralysis, anæsthesia of various localities, amenorrhœa, dysmenorrhœa, and fever with marvellous variations of temperature. She has become the bane and terror of every one connected with her treatment and care-taking. She has developed violent attacks of mania, with contortions and convulsions, on the streets and in churches. Sums of money have been collected for her at times by those who have become interested in her as bystanders at the time of an attack or have heard of her case from others. She has made several pseudo-attempts at suicide. Recently an empty chloroform-liniment bottle tumbled from her bed at a propitious moment, she at the same time complaining of pain and symptoms of poisoning. She has refused to partake of food, and has been discovered obtaining it surreptitiously. Her large and prolonged experience with doctors and hospitals has so posted her with reference to the symptomatology of certain nervous affections that she is able at will to get up a fair counterfeit of a large variety of grave nervous disorders.

One of her recent attacks of hysteria was preceded by a series of hysterical phenomena, such as vomiting, hemorrhage, aphonia, ovaralgia, headache, and simulation of fever. She began by crying and moaning, which was kept up for many hours. She fell out of bed, apparently insensible. Replaced in bed, she passed into a state closely simulating true acute maniacal delirium. She shrieked, cried, shouted, and moaned, threw her arms and legs about violently, and contorted her entire body, snapping and striking at the nurses and physicians in attendance. At times she would call those about her by strange names, as if unconscious of the true nature of her surroundings. Attacks of this kind were kept up for a considerable period, and after an interval of rest were repeated again and again.

Many of the extraordinary facts which fill the columns of the sensational newspapers are the results of the vagaries of patients suffering from the second of the forms of chronic hysterical insanity. “When,” says Wilks,⁶² “you see a paragraph headed ‘Extraordinary Occurrence,’ and you read how every night loud rapping is heard in some part of the house, how the rooms are being constantly set on fire, or how all the sheets in the house are torn by rats, you may be quite sure that there is a young girl on the premises.” It is unnecessary to add that said girl is of the hysterical genus.

⁶² Op. cit.

A story comes from an inland town, for instance, of a respectable family consisting, besides the parents, of three daughters and six sons, one of whom died of pneumonia. Since his death the family had been startled by exciting and remarkable events in the house—a clatter of stones on the kitchen floor, the doors and windows being closed; shoes suddenly ascending to the ceiling and then falling to the floor, etc. Search revealed nothing to explain the affair. As throwing light upon this matter, a visitor, who confessed his inability to explain the occurrences, nevertheless referred to one of the daughters as looking like a medium.

Charcot and Bourneville give frequent instances of extraordinary self-deceptions or delusions among hysterical patients. The story of an English lady of rank, who reported that she was assaulted by ruffians who attacked her in her own grounds and attempted to stab her, the weapons being turned by her corsets, is probably an example of this tendency. Investigation made by the police force threw grave doubts upon the story.

Many of the manifestations classed as hysterical by medical writers are simply downright frauds. The nature of others is doubtful. The erratic secretion of urine, for example, has frequently engaged the attention of writers on nervous diseases, and has awakened much controversy. American hysterics are certainly fastidious about this matter, as I have not yet met, in a considerable experience, with a single example of paruria erratica. Charcot⁶³ refers sarcastically to an American physician who in 1828 gravely reported the case of a woman passing half a gallon of urinous fluid through the ear in twenty-four hours, at the same time spirting out a similar fluid by the navel. He also alludes to the case of Josephine Roulier, who about 1810 attained great notoriety in France, but was discovered by Boyer to be a fraud. This patient vomited matter containing urea, and shortly after came a flow of urine from the navel, the ears, the eyes, the nipples, and finally an evacuation of fecal matters from the mouth.

⁶³ Op. cit.

Hemorrhages from eyes, ears, nostrils, gums, stomach, bowels, etc. have often been observed among the hysterical; these cases sometimes being fraudulent and sometimes genuine. In the Philadelphia Hospital in 1883 was a patient suffering from grave hysteria, vomiting of blood being a prominent symptom. Although close watch was kept, several days elapsed before it was discovered that she used a hair-pin to abrade the mucous membrane of her nose, swallowed the blood, which passed into the throat, and then vomited it.

Sir Thomas Watson tells of a young woman who made a hospital surgeon believe that she had stone in the bladder; and Fagge, of a patient who had been supposed to have hydatid in the liver, and who produced a piece of the stomach of a rabbit or some other small animal, which piece she declared she had vomited. A few hours later she again sent for her medical man to remove from her vagina another fragment of the same substance.

A case is reported by Lopez⁶⁴ of spiders discharged from the eye of an hysterical patient. He regarded the case as one of hysterical monomania. Fragments of a dismembered spider were undoubtedly from time to time removed from the eye of the patient. Lopez believed that at first the fragments may have got into the eye accidentally, but that afterward the patient, under the influence of a morbid condition, introduced them from day to day. The total number of spiders removed in fragments was between forty and fifty. Silvy⁶⁵ relates a case in which a large number of pins and needles made their exit from a patient. Other needle cases are given, and also examples of insects and larvæ discharged from the human body. In one case worms crawled out of the nose, ears, and other natural openings; in another worms were found in active motion under the conjunctiva; in a third a beetle was discharged from the bladder, and several beetles were vomited by a boy.

⁶⁴ American Journal of Medical Sciences, Philadelphia, 1843, N. S., 74-81.

⁶⁵ Mémoires de la Société médicale, Anné 5, p. 181.

Jolly⁶⁶ records in a foot-note a case published in 1858, by I. Ch. Leitz of Pesth, of a young girl from whose eyes fruit-pips sprang, from whose ears and navel feces escaped, and from whose anus and genitals fleshy shreds came away, while worms with black eyes were vomited. He further tells of a woman from whose genitals four-and-twenty living and dead frogs passed, some of these, indeed, with cords of attachment. The birth of the frogs was witnessed and believed in by several physicians!

⁶⁶ Op. cit.

Hardaway⁶⁷ reports a curious case with simulated eruptions. The woman appeared to be in fear of syphilis contracted by washing the clothes of a diseased infant. She had blebs irregularly distributed upon the fingers and arm of the left side; these, the doctor concluded, had been caused by the application of vitriol. He reports another case in which a woman had an eruption on her left arm, and the sores, instead of getting better under treatment, got worse. On one visit he found needle-scratches on the old sore. Nitric acid, according to Hardaway, is a favorite substance for the production of such eruptions. The best diagnostic test is that the blister is linear, while in pemphigus it is circular, unlike that which would be produced by a running fluid. Hysterical women have irritated their breasts with cantharides. Niemeyer⁶⁸ mentions a woman at Krutsenberg's clinic who irritated her arm in such a way that amputation became necessary, and after that she irritated the stump until a second amputation had to be performed.

⁶⁷ St. Louis Courier of Medicine, 1884, xi. 352.

⁶⁸ Textbook of Practical Medicine.

Nymphomania is a form of mental disorder which sometimes occurs among the hysterical; or it would perhaps be more correct to say that nymphomania and grave hysterical affections are sometimes associated in the same case. It is a condition in which is present extreme abnormal excitement of the sexual passion—a genesic, organic feeling rather than an affection associated with the sentiment of love. Hammond treats of it under the head of acute mania, and considers cases of nymphomania as special varieties of this disease. Undoubtedly, this is the correct way of looking at the subject in many cases. In man the corresponding mental and nervous condition often leads to the commission of rape and murder. In woman the affection is most likely to show itself with certain collateral hysterical or hysteroidal conditions, as spasms, hystero-epilepsy, and catalepsy, or with screaming, crying, and other violent hysterical outbreaks. Sometimes there is a tendency to impulsive acts, but this does not usually go so far as to lead to actual violence.

Nymphomaniacs may be intelligent and educated, and if so they usually resist their abnormal passions better than the ignorant. A number of nymphomaniacs have been under treatment at the Philadelphia Hospital. One case was an epileptic and also hysterical girl. She had true epileptic seizures, and at other times had attacks of a hysteroidal character. She would make indecent proposals to almost any one, and would masturbate and expose herself openly. She also had occasional maniacal attacks. She died in the insane department of the hospital.

Nymphomania and what alienists call erotomania are sometimes not differentiated in practice and in books. They are, however, really different conditions. Erotomania and nymphomania may be associated in the same case, but it is more likely that erotomania will not be present in a case of nymphomania. Erotomania may exist as a special symptom or it may be one of the evidences of monomania. It is found in both men and women. Patients with this condition may have no sexual feeling whatever. The individual has some real or imaginary person to love. It is rather the emotion of love which is affected, not the sexual appetite. It is shown by watching or following the footsteps of the individual, by writing letters, and by seeking interviews. In the history of Guiteau an incident of this kind is mentioned by Beard.⁶⁹ He followed a lady in New York whom he supposed to be the daughter of a millionaire—followed her, watched her house and carriage, and wrote letters to her. Out West he showed the same sort of attentions to another lady. He went to the house, but was kicked out. Many of the great singers have been followed in this way.

⁶⁹ Journal of Nervous and Mental Disease, vol. ix., No. 1, January, 1882.

Some time ago I examined a man condemned to be hanged and within twenty-four hours of his death. He was an erotomaniac, whatever else he may have been. In the shadow of the gallows he told of a lady in the town who had visited him and was in love with him, and how all the women in the neighborhood were in love with him. He had various pictures of females cut from circus-posters in his cell. Erotomania is not generally found associated with hysteria.

Convulsions or general spasms are among the most prominent of hysterical manifestations. Under such names as hysterical fits, paroxysms, attacks, seizures, etc. they are described by all authors. Their presence has sometimes been regarded as necessary in order that the diagnosis of hysteria might be made; but this, as I have already indicated, is an erroneous view.

Under hysterical attacks various conditions besides general convulsions are discussed by writers on hysteria; for instance, syncope, epileptiform convulsions, catalepsy, ecstasy, somnambulism, coma, lethargy, and delirium. According to the plan adopted in the present volume, catalepsy, ecstasy, somnambulism, etc. will be considered in other articles, and therefore my remarks at this point will be limited to hysterical general convulsions.

These convulsions differ widely as to severity, duration, frequency, motor excitement, and states of volition and consciousness. Efforts have been made to classify them. Carter⁷⁰ describes three forms as primary, secondary, and tertiary. In the primary form the attack is involuntary and the product of violent emotion; in the secondary it is reproduced by the association of ideas; and in the tertiary it is deliberately shammed by the patient. Lloyd⁷¹ divides them into voluntary and involuntary forms, and discusses the subject as follows: “The voluntary or purposive convulsions are such as emanate from the conscious mind itself. Here are the simulated or foolish fits into which women sometimes throw themselves for the purpose of exciting sympathy or making a scene. I am convinced that a large number of hysteric fits are of this class: these are the patients who are cured by the mention of a hot iron to the back or the exhibition of an emetic. The involuntary forms of convulsion are more important. They happen in more sensible persons, and some of them are probably akin to starts, gestures, and other forcible or violent expressions of passions or states of the mind. A person wrings the hands, beats the breast, stamps upon the floor in an agony of grief and apprehension, and if terror is added he trembles violently. It is no great stretch of the imagination to suppose that great fear, anger, or some kindred passion, acting upon the sensitive nervous organization of a delicate woman or child, should throw them into a convulsion. This, in fact, we know happens. Darwin⁷² believes that in certain excited states of the brain so much nerve-force is liberated that muscular action is almost inevitable. He instances the lashing of a cat's tail as she watches her prey and the vibrations of the serpent's tail when excited; also the case of an Australian native, who, being terrified, threw his arms wildly over his head for no apparent purpose. The excito-motor reflexes of the cord may possibly take on true convulsive activity if released from the control of the will, which, as already said, is apt to be weak or in abeyance to this disease. Increased temperature is stated by Rosenthal to be always present in the great fits of epilepsy and tetanus, but absent in those of hysteria.”

⁷⁰ On the Pathology and Treatment of Hysteria, London, 1853.

⁷¹ Op. cit.

⁷² Expression of Emotion, etc.

This subdivision of hysterical convulsions into voluntary and involuntary, or purposive and non-purposive, is a good practical arrangement; but the four groups into which I have divided all hysterical symptoms—namely, the purely involuntary, the induced involuntary, the impelled, and the purely voluntary—include or cover these two classes, and allow of explanation of special cases of convulsion which cannot be regarded as either purely shammed or as entirely, and from the first, independent of the will.

Absolutely involuntary attacks with unconsciousness constitute what are commonly called hystero-epileptic seizures, and will be described under Hystero-epilepsy.

The voluntary, impelled, or induced hysterical fit may be ushered in in various ways—sometimes with and sometimes without warning, sometimes with wild laughter or with weeping and sobbing. The patient's body or some part of it is then usually thrown into violent commotion or convulsion; the head, trunk, and limbs are tossed in various directions. Frequently the arms are not in unison with each other or with the legs. Screaming, shouting, sobbing, and laughing may occur during the course of the convulsive movement; sometimes, however, the patient utters not a word, but has a gasping, noisy breathing. She may talk in a mumbling, incoherent manner even during the height of the attack. She is tragic in attitude or it may be pathetic. The face is contorted on the one hand, or it may be strangely placid on the other. Quivering, spasmodic movements of the eyelids are often seen; but the eyes are not fixed and turned upward with dilated pupils, as in epilepsy. The patient does not usually hurt herself in these purposive attacks. She may or may not appear to be unconscious. She does not bite her tongue, nor does she foam, as does the true epileptic, although she may spit and sputter in a way which looks somewhat like the foaming of epilepsy. She comes out of the fit often with evident signs of exhaustion and a tendency to sleep, but does not sink into the deep stupor of the post-paroxysmal epileptic state. The paroxysm may last a few or many minutes. Large quantities of colorless urine are usually passed when it is concluded.

Hysterical paralysis, so far as extent and distribution are concerned, may be of various forms, as (1) hysterical paralysis of the four extremities; (2) hysterical hemiplegia; (3) hysterical monoplegia; (4) hysterical alternating paralysis; (5) hysterical paraplegia; (6) hysterical paralysis of special organs or parts, as of the vocal cords, the œsophagus and pharynx, the diaphragm, the bowels, and the bladder. Russell Reynolds⁷³ has described certain cases closely allied to, if not identical with, some forms of hysterical paralysis under the head of paralysis dependent upon idea. These patients have a fixed belief that they are paralyzed. The only point of separation of such cases from hysterical paralysis is the absence of other hysterical manifestations. Perhaps it would be better to regard the condition either simply as hysterical paralysis or as a true psychosis—an aboulomania or paralysis of the will. Such cases often last for many years.

⁷³ Brit. Med. Journ., 1869, pp. 378, 483.

Among the 430 hysterical cases of Briquet, only 120 were attacked with paralysis. In 370 cases of Landouzy were 40 cases of paralysis.

Briquet reports 6 cases in which paralysis attacked the principal muscles of the body and of the four extremities; 46 cases of paralysis of the left side of the body, and 14 of the right; 5 of the upper limbs only; 7 of the left upper limb, and 2 of the right; 18 of the left lower limb, and 4 of the right; 2 of the feet and hands only; 6 of the face; 3 of the larynx; and 2 of the diaphragm. Landouzy gathered from several authors the following results: General paralysis in 3 cases; hemiplegia in 14; 8 cases of paralysis of the left side; in other cases the side affected not indicated; and 9 cases of paraplegia.

Hysterical paralyses, no matter what the type, may come on in various ways—suddenly, gradually, from moral causes or emotional excitement, or from purely physical causes, as over-fatigue. They may have almost any duration, from hours or days to months or years, or even to a lifetime. They are frequently accompanied by convulsive or emotional seizures. They may be of any degree of severity, from the merest suspicion of paresis to the most profound loss of power. Hysterically paralyzed muscles retain their electro-contractility. Limbs which have become atrophied from disuse may show a temporary lessening of response, but this is quantitative and soon disappears. In rare cases, owing probably to the condition of the skin, the response to electricity is not obtained until the current has been applied for several minutes to the muscles.

Hysterical hemiplegia and monoplegia may simulate almost any type of organic paralysis. The paralysis is usually in a case of hemiplegia, confined to the arm and leg, the face being slightly, if at all, implicated. Hysterical paralysis, limited to the muscles supplied by the facial nerve, is very rare. According to Rosenthal, it sometimes coexists with paralysis of the limbs of the same side, and is usually accompanied by anæsthesia of the skin and special senses. In a few rare cases, according to Mitchell, the neck is affected.

Several cases of hysterical double ptosis have come under my observation. The condition is usually one of paresis rather than paralysis. Cases of unilateral ptosis hysterical in character have also been reported. Alternating squints are sometimes hysterical, but they are usually of spasmodic rather than of paralytic origin.

Hysterical hemi-palsy is more frequent on the left than in the right side. In Mitchell's cases the proportion was four left to one right. The figures of Briquet have been given. It is usually, but not always, accompanied by diminished or abolished sensibility, both muscular and cutaneous. Electro-sensibility especially is markedly lessened in most cases.

When hemiplegia is of the alternating variety, the arm on one side and the leg on the other, or, what is rare in paralysis of organic causation, both upper extremities and one lower, or both lower and one upper, may be affected. Alternating hemiplegia of the organic type is usually a paralysis in which one side of the face and the leg and arm of the opposite side are involved.

Hysterical paraplegia is one of the most important forms of hysterical paralysis, and is sometimes the most difficult of diagnosis. It occurs usually, but not exclusively, in women. It comes on, particularly in young women, between puberty and the climacteric period, commonly between the twentieth and thirtieth years. Such a patient is found in bed almost helpless, possibly able to move from side to side, but even by the strongest efforts seemingly incapable of flexing or extending the leg or thigh or of performing any general movements of the foot. The feet are probably in the equino-varus position—extended and turned inward. Certain negative features are present. The muscles do not waste to any appreciable extent, as they would in organic paralysis. Testing the knee-jerk, it is found retained, possibly even exaggerated. The electrical current causes the muscles to contract almost as well as under normal conditions; if a difference is present, it is quantitative and not qualitative in character. Paralysis of the bowels and bladder is not usually found, although it is but fair to state that this appears not to be the conclusion arrived at by some other observers.

Paralysis or paresis of the vocal cords, with resulting aphonia, is a common hysterical affection. Hysterical aphonia is also due to other conditions—for instance, to an ataxia or want of co-ordinating power in the muscles concerned in phonation; or to spasm, real or imaginary, in the same parts. Hysterical paralysis of the vocal cords is almost invariably bilateral; viewed with the laryngoscope, the cords are seen not to come together well, if at all. One may be more active than the other; but a distinct one-sided paralysis of this region nine times out of ten indicates that the case is not hysterical.

The following case is of interest, not only because of the aphonia, but because also of the loss of the power of whispering. The patient, a young lady of hysterical tendencies, while walking with a friend stumbled over a loose brick and fell. She got upon her feet, but a moment or two after either fainted or had a cataleptoid attack. Several hours later she lost her voice and the power of whispering. She said that she tried to talk, but could not form the words. This condition had continued for ten months in spite of treatment by various physicians. She carried a pencil and a tablet, by means of which she communicated with her friends. She had also suffered with pains in the head, spinal hyperæsthesia; and occasional attacks of spasm. Laryngoscopic examinations showed bilateral paresis of the vocal muscles, without atrophy. The tongue and lips could be moved normally. She was assured that she could be cured. Faradic applications with a laryngeal electrode were made daily; tonics were given; and the patient was instructed at once to try to pronounce the letters of the alphabet. In less than a week she was able to whisper letters, and in a few days later words. In three weeks voice and speech were restored. Just as this patient was recovering another came to be treated for loss of voice. She was markedly aphonic, but could whisper without difficulty. She was told, to encourage her, that she need not be worried about her loss of voice, as another patient, who had lost not only her voice, but the ability to whisper, had recovered. The patient returned next day unable to whisper a syllable. She made, however, a speedy recovery. Under the name apsithyria, or inability to whisper, several cases of this kind have been reported by Cohen.

Hysterical paralyses of the pharynx and of the œsophagus have been reported, but are certainly of extreme rarity. Hysterical dysphagia is much more frequently due to spasm or a sensation of constriction.

Paralysis of the diaphragm in hysteria has been described by Duchenne and Briquet. I have had one case under observation. The abdomen is drawn inward instead of being pushed outward in the act of inspiration in organic paralysis of the diaphragm; this condition is simulated, but not completely or very closely, in the hysterical cases. In some of the cases of nervous breathing, which will be referred to hereafter, the symptoms are rather of a spastic than of a paretic affection of the diaphragm.

Paralysis or paretic states of the stomach and intestines are not uncommon among the hysterical, and produce tympanites, one of the oldest symptoms of hysteria. Jolly asserts that this “sometimes attains such a degree that the patients can be kept afloat in a bath by means of the balloon-like distension of their bellies”! The loss of power in the walls of the stomach and bowels is sometimes a primary and sometimes a secondary condition. The abdominal phantom tumors of hysterical women sometimes result from these paralytic conditions. These abdominal tumors are among the most curious of the phenomena of local hysteria. At one time two such cases were in the women's nervous wards of the Philadelphia Hospital. Both patients had been hysterical for years. In the first the tumor occupied the middle portion of the abdomen, the greater portion of its bulk more to the right of the median line. It was firm and nearly spherical, and the patient complained of pain when it was handled. She was etherized, and while under ether, and during the time that she was vomiting from the effects of the anæsthetic, the tumor disappeared, never to return. The other patient had a similar tumor for three days, which disappeared after the etherization of the first case.

Mitchell⁷⁴ has recorded some interesting paretic and other hysterical disorders of the rectum and defecation. Great weakness, or even faintness, after each stool he has found not uncommon, and other more formidable disorders occur. A patient who had been told that her womb was retroverted and pressing upon her rectum, interfering with the descent and passage of the feces, was troubled with hypersensitiveness of the lower bowel. This condition Mitchell designated as the excitable rectum. Patients in whom it is present apparently have diarrhœa; certainly they have many movements daily. Single stools, however, are small, and may be quite natural or they may seem constipated. The smallest accumulation of fecal matter in the rectum excites to defecation. One case had small scybalous passages every half hour. The forms of hysterical paresis or paralysis or pseudo-paralysis of the rectum observed by Mitchell were due—(1) to a sensory paralysis of the rectum; (2) to a loss of power in the rectal muscular walls; (3) a want of co-ordination in the various muscles used in defecation; (4) to a combination of two or of all of these factors. In rare cases the extrusive muscles act, but the anal opening declines to respond.

⁷⁴ Op. cit.

Hysterical locomotor ataxia, or hysterical motor ataxia, is an affection less common than hysterical palsy, but by no means rare. Various and diverse affections of motion are classed as hysterical ataxia by different authors. Mitchell speaks of two forms independent of those associated with vertigo. The first, that described by Briquet and Laségue, seems to depend upon a loss of sensation in both skin and muscles; the second often coexists with paralysis or paresis, and is an affection in which the patient has or may have full feeling, and is able to use the limbs more or less freely while lying down. As soon as she leaves the recumbent position the ataxia is very evident. She falls first to one side and then to the other. She “seems to be unable to judge of the extent to which balance is lost, and also to determine or evolve the amount of power needed to overcome the effect.” Mitchell believes that this disorder is common in grave hysteria, and is likely to be confounded with one of the forms of hysterical alternating spasm, in which first the flexors and then the extensors contract, the antagonistic muscles not acting in unison, and very disorderly and eccentric movements being the result. I have reported a case of hystero-epilepsy⁷⁵ in which a spasmodic condition closely simulated hysterical ataxia. The patient had various grave hysterical symptoms, with epileptoid attacks. She became unable to walk, or could only walk a few steps with the greatest difficulty, although she could stand still quite well. On attempting to step either forward or backward, her head, hips, shoulders, and trunk would jerk spasmodically, and she would appear to give way at the knees. No true paralysis or ataxia seemed to be present, but locomotion was impossible, apparently because of irregular clonic spasms affecting various parts of her body.

⁷⁵ Journal of Nervous and Mental Disease, vol. ix., No. 4, October, 1882.

Mary Putnam Jacobi⁷⁶ has reported a case occurring in an Irish woman aged thirty-five years as one of hysterical locomotor ataxia. It is questionable whether this case was not rather one of posterior spinal sclerosis with associated hysterical symptoms. The existence of pain resembling fulgurating pains, and especially the absence of the patellar tendon reflex, would incline me to hesitate a long time before accepting the diagnosis of hysteria, particularly as it is known that organic locomotor ataxia often has a much-prolonged first stage, and that wonderful temporary improvements sometimes take place.

⁷⁶ Arch. of Medicine, New York, 1883, ix. 88-93.

Ataxic symptoms of a mild form are of frequent occurrence in hysteria. They are shown by slight impairments of gait and difficulty in performing with ease and precision many simple acts, as in dressing, writing, eating, etc.

Hughes Bennett and Müller of Gratz call attention to the fact that young women may exhibit all the signs of primary spastic paralysis, simulating sclerosis, and yet recover.⁷⁷ I have seen several of these cases of hysterical spasmodic paralysis, and have found the difficulties in diagnosis very great. These patients walk with a stiff spastic or pseudo-spastic gait, and as, whether hysterical or not, the knee-jerk is likely to be pronounced, their puzzling character can be appreciated.

⁷⁷ Quoted by Althaus: On Sclerosis of the Spinal Cord, by Julius Althaus, M.D., M. R. C. P., etc., New York, 1885, p. 330.

In one class of cases, which cannot well be placed anywhere except under hysteria, a sense or feeling of spasm exists, although none of the objective evidences of spasmodic tabes can be detected. Comparing these to those which Russell Reynolds describes as paralysis dependent upon idea, they might be regarded as cases of spasm dependent upon idea.

One case of this kind which was diagnosticated as lateral sclerosis by several physicians recovered after a varying treatment continued for several years, the remedy which did him the most good being the actual cautery applied superficially along the spine. The patient described his condition as one of “spasmodic paralysis of all the muscles of the body.” If sitting down, he could not at once get up and walk or run, but would have to use a strong effort of his will, stretching his limbs several times before getting on his feet. Movements once started could be continued without much difficulty. When his hands were closed he would be unable, at times, to open them except by a very strong effort of the will. If one was opened and the other shut, he could manipulate the latter with the former. He sometimes complained of a sensation as of a steam-engine pumping in his back and shaking his whole body. He would sometimes be in a condition of stupor or pseudo-stupor, when he had a feeling as if he was under the influence of some poison. The spasms or jumpings in the back he thought sometimes caused emissions without erections. He compared the feeling in his back to that of having a nerve stretched like a piece of india-rubber. The excitement of mind would then cause the nerve to contract and throb. This description shows that the symptoms were purely subjective. Examination of the muscles of the legs and arms did not reveal, as in true spastic paralysis, conditions of rigidity. The limbs would sometimes be stiff when first handled, volition unconsciously acting to keep them in fixed positions; but they would soon relax. The knee-jerk, although well retained, was not markedly exaggerated, as in spastic paralysis, nor was ankle clonus present. The patient did not get progressively worse, but his condition vacillated, and eventually he recovered. A friend of the patient, living in the same neighborhood and going to the same church, was affected with true lateral sclerosis. It is worth considering how far in an individual of nervous or hysterical temperament observation of an organic case could have influenced the production of certain subjective symptoms, simulating spasmodic tabes.

Certain special forms of chorea are particularly liable to occur in the course of cases of hysteria. The most common type of the chorea of childhood, if not strictly speaking hysterical, is frequently associated with a hysteroid state, and is best treated by the same measures that would be calculated to build up and restore an hysterical patient. The following conclusions, arrived at by Wood⁷⁸ after a clinical and physiological study of the subject of chorea, show that certain forms of chorea may be hysterical or imitated by hysteria:

1st. Choreic movements may be the result of organic brain disease.

2d. Choreic movements exactly simulating those of organic brain disease may occur without any appreciable disease of the nerve-centres.

3d. General choreic movements, as well as the bizarre forms of electric and rhythmical chorea, may occur without any organic disease of the nervous system.

⁷⁸ “Chorea: a Study in Clinical Pathology,” by H. C. Wood, M.D., LL.D., Therapeutic Gazette, 3d Series, vol. i., No. 5, May 15, 1885.

To these propositions may be added a fourth—viz. Choreic movements may be the result of a peripheral irritation, or, in other words, may be reflex.

Hysterical rhythmical chorea is a form of chorea in which involuntary movements are systematized into a certain order, so as to produce in the parts of the body which are affected determinate movements which always repeat themselves with the same characters. The movements are strikingly analogous to the rhythmical movements, as those of salutation, which often occur in the second period of the hystero-epileptic attack. Rhythmical chorea should undoubtedly be arranged among the manifestations of grave hysteria. An account of an interesting case of this kind is given in a lecture by Wood, reported by me in the Philadelphia Medical Times for Feb. 26, 1881.

As Charcot has shown, rhythmic chorea is usually of hysterical origin, although it may exist without any of the phenomena which usually characterize hysteria. In these cases the movements imitated are according to a certain plan; thus, they may be certain expressive movements, as some particular form of dancing or the so-called saltatory chorea. They may be, again, certain professional or trained actions, such as movements of hammering, of rowing, or of weaving. Charcot speaks of a young Polish girl in whom movements of hammering of the left arm lasted from one to two hours, and occurred many times in a day for seven years. He has also given an account of another case, a patient with various grave hysterical manifestations, who would have a pain and beating sensation in the epigastrium, accompanied by a feeling of numbness. The right upper extremity would then begin to move; this would soon be followed by the left, and then by the lower extremities; then would follow a succession of varied action, complex in character, but in which rhythm and time and correct imitation of certain intentional and rational movements could readily be recognized. The attacks could be artificially induced in this patient by pulling the right arm or by striking on the patellar tendons with a hammer. During the whole of the attack the patient was conscious. In another patient rhythmical agitations of the arm, the movement of wielding a hammer, were produced in the first stage; then followed tonic spasms and twisting of the head and arms, suggesting a partial epilepsy; finally, rhythmical movements of the head to the right and left took place, the patient at the same time chanting or wailing.⁷⁹

⁷⁹ Charcot's lectures in Le Progrès médical for 1885.

In the following case an hysterical jumping chorea was probably associated with some real organic condition or was due to malarial infection. The patient was a middle-aged man. During the war he received a slight shell wound in the back part of the right thigh, and from that time suffered more or less with numbness and some weakness of the right leg. He was of an active nervous temperament. About three months before coming under observation he had without warning a peculiar attack which, in his own words, came on as if shocks of electricity were passed through his head, back, limbs, and other parts of the body. In this attack, which lasted for fully an hour, he jumped two or three feet in the air repeatedly; his arms, legs, and even his head and eyes, shook violently. He was entirely conscious throughout, but said nothing except to ask for relief. His wife, who was present, stated that at first he was pale, and afterward, during the attack, he became almost turgid under the eyes. Attacks appeared to come at intervals of seven and fourteen days for a time, so that his family physician surmised that there might be some malarial trouble, and prescribed for him accordingly. They soon, however, became irregular in character, and did not occur at periodical intervals. After the attacks he would lie down and go to sleep; he did not, however, pass into the condition of stupor that is observed after a grave epileptic seizure. His sleep seemed to be simply that of an exhausted nervous system.

Hysterical tremor is of various forms and of frequent occurrence: a single limb, both upper or both lower extremities, or the entire body may be affected. In a case of hystero-epilepsy, which will be reported in the next article, the patient had a marked tremor of the left arm, forearm, and hand, which was constant, but worse before her attacks; it remained for many months, and then disappeared entirely. Caraffi⁸⁰ reports the case of an hysterical girl of eighteen, anæsthetic on the right side and subject to convulsive attacks, who fell on the right knee and developed an arthritis. At the Hôpital Beaujon service of Lefort and Blum she presented herself with the above symptoms, aphonia, and an uncontrollable tremor of the right lower extremity, and trophic disturbances of the same. Immobilization of the limb was tried without benefit, and Blum then stretched the sciatic, with complete relief of the tremor and of the troubles of sensibility and of nutrition.

⁸⁰ L'Encéphale, June, 1882.

Hysterical contracture, like hysterical paralysis, may assume a variety of forms: it may be hemiplegic, monoplegic, paraplegic, alternating, or local, as of the ocular muscles, the facial or neck muscles; laryngeal, pharyngeal, or œsophageal; of the fingers or of the toes.

Richardson⁸¹ records the case of a young lady who saw in India a religious devotee with his leg flexed upon his body and fastened there. In a few hours she was found with her leg in a similar position, and this contracture remained until after she had been taken to London; then it disappeared as suddenly as it came. Conscious purpose could not have maintained the leg in such a position for an hour.

⁸¹ Diseases of Modern Life.

Some of the most remarkable cases of hysterical contracture are those chiefly studied by the French, which originate before or after convulsive seizures. Among the hystero-epileptics at Salpêtrière, Richer⁸² reports many varieties of contracture: one with hemianæsthesia and varying pain in the right side had permanent contracture with tremulousness of the lower extremities; another, with hemianæsthesia, pain, and frequent attacks of demoniacal delirium and paresis, had momentary contractures of the upper and lower extremities on the right side. In two other cases the contractures were of the hemiplegic form, while three others were paraplegic. In still other cases the contracture was monoplegic. Besides hemiplegic, monoplegic, and paraplegic contractures, I have seen illustrations of a number of local forms—among others, several remarkable cases of hysterical contractures of the wrist and hand and of the feet and toes, and one of hysterical torticollis. Hysterical contracture in any of its forms may occur as an isolated symptom or series of symptoms unconnected with the grave hysterical attack.

⁸² Op. cit.

Many forms of hysterical local spasms occur. Hysterical strabismus from spasm of the ocular muscles has been observed. Several cases have come under observation in which hysterical blepharospasm was present. In these cases, when the lids are forced open, the eyes disappeared in an extraordinary manner, usually being drawn downward and toward the internal canthus. Hysterical facial spasm occurs, and is usually clonic. One of the most remarkable hysterical local spasmodic affections which has come under personal observation was reported by me in a paper on chorea.⁸³ In this case the right ear twitched and moved up and down. The movement of the ear was peculiar; it continued nearly all the time, even when the patient's attention was not directed toward the part. The act seemed to be partially under the control of the will, as by a strong effort the left ear could be moved very slowly in the same up-and-down direction. The nostrils and upper lip were affected with twitching, and slight choreic movements were present in the entire right side of the body. The patient's general condition improved under treatment, but when last seen the local affection persisted, although it was not so severe.

⁸³ Philada. Med. Times, March 27, 1875.

Spasm of the pharynx, larynx, and œsophagus have been separated by several authors. In hysterical laughter spasmodic contraction of the laryngeal muscles occurs. Spasm of the glottis occurs in rare cases, according to Rosenthal, from the reflex effect of hyperæsthesia of the laryngeal mucous membrane, from irritation of the recurrent laryngeal nerve. Death from asphyxia has occurred in consequence of this form of spasm of the glottis.

Hysterical dysphagia, which is usually spasmodic, is sometimes a dangerous, and always an annoying, affection. An unmarried lady, forty years old, with a neurotic family history, a maternal uncle and aunt having been insane, at intervals since puberty had had various hysterical manifestations. After a severe winter, during which she had suffered more or less with rheumatism, she became depressed with reference to her spiritual condition: she had, in fact, a form of mild religious melancholia. After this had lasted for weeks she began to experience difficulty in swallowing. She would rise from the table suddenly, alarmed and gasping, and exclaiming that she could not swallow and was choking. She got so bad that she could not take anything but liquid food, and not nearly enough of this. She believed that her throat was gradually closing, and of course suspected cancer. She was assured that if any local obstruction existed it could be removed with one application of a probang. Cancer was also confidently excluded, and she was given iron, valerian, and quinine, and in a few days an instrument was passed down her throat. She as told that she would have no more difficulty. Tonics and full feeding were continued, and in less than a week she swallowed without any difficulty.

Of the so-called hysterical asthma or hysterical breathing I have seen several examples. A curious form of hysterical breathing, at least partly spasmodic, recently came to the Philadelphia Polyclinic—a young man twenty-one years of age, who confessed that he had been guilty of excessive masturbation for five or six years. He had been a moderate drinker and was the victim of an old hip disease. According to his story, this abuse had never appeared to have impaired his health until about one month before applying for treatment, when he began to have attacks of peculiar breathing. He would have a series of rapid, forced expirations which lasted for a period of from one to two or three minutes. He would then stop for a moment; then again the shallow breathing with forced expirations would ensue. He said that he breathed in this way because he thought he was going to die, and did so to keep alive. When he stopped he felt cold. He thought his belly did not go outward as it should in the act of breathing. During the time that the symptoms had been present he had had several frightful attacks of excitement, in one of which he ran breathing in the manner described to a drug-store from one to two blocks away, jumping, gesticulating, and calling for remedies. He had an anxious expression of the face, a look of excitement and worriment. His pulse was 110 and weak. Respirations during these attacks ranged from 38 to 50.

Coates,⁸⁴ speaking of hysterical or nervous breathing, gives the details of five cases. Four of these had been supposed to be suffering from phthisis; the fifth was apparently a case of hypertrophy of the heart. The breathing was quick and shallow. The patients could not be induced to draw long breaths until the expedient was adopted of having them count twenty without taking breath. During this the lungs expanded perfectly, air entering freely into every part. Coughing, and even blood-spitting of a venous character, were present. They might perhaps be classed as cases of hysterical or simulated phthisis.

⁸⁴ British Medical Journal, 1884, ii. 13.

Vaginismus, or spasm of the vagina, may with propriety be regarded as hysterical in some but not in all cases. Spasmodic contracture of the sphincters of the bladder and anus is also mentioned by Rosenthal. Goose-flesh, according to the same author, is a frequent phenomenon in the hysterical, and is due to spasmodic contraction of the muscular fibres contained within the skin.

The sensorial affections of hysteria can be classified according either to character or location. According to the character of the sensory disturbance a good practical arrangement is into cases of (1) Anæsthesia; (2) paræsthesia; (3) hyperæsthesia; (4) neuralgias and localized pains,—although one of these classes may sometimes be difficult to separate from another, or a doubt may arise as to whether or not a special symptom should be placed under one or another head. In hysterical anæsthesia sensation is decreased or abolished; in paræsthesia it is faulty or perverted; in hyperæsthesia it is increased over a more or less extensive surface; in neuralgia, pain is confined to certain nerve-trunks. The localized pains are neuralgic or mimetic, and are found in special localities, as in joints and in the breast.

Anæsthesia is one of the most frequent of hysterical phenomena, but is not, as stated by some authorities, present in all cases of genuine hysteria.

In 400 hysterical cases Briquet found 240 positive examples of anæsthesia. In this statement, however, he does not include cases of insensibility of the conjunctiva of the left eye or those cases in which anæsthesia lasted but a few hours after an attack. It is safe to say that anæsthesia of some sort is present in from 60 to 75 per cent. of all cases of well-marked hysteria. Analgesia, or insensibility to pain, is present frequently when loss or diminution of sensibility to touch, pressure, heat and cold, etc., is not observed.

Hysterical anæsthesia, may be of various forms, according to the parts of the body affected, as general anæsthesia; hemianæsthesia; anæsthesia of the lower half of the body; anæsthesia of one limb or one side of the face; anæsthesia of mucous membranes; anæsthesia of muscles, bones, and joints; anæsthesia of the viscera.

General anæsthesia is extremely rare. No example of it has ever fallen under my observation, but by Briquet and others a few cases have been reported.

Hemianæsthesia has in recent years received much attention from neurologists. In hystero-epilepsy it is the rule to find it present, but it is also observed in cases without spasms. In hemianæsthesia the loss of sensation exists in one lateral half of the body. Parts are insensible to various methods of stimulation—to impressions of touch, pain, temperature, and weight. Sometimes the mucous membranes of the side affected are involved. The sight, hearing, taste, and smell are commonly impaired if not lost.

Much attention has been paid to the study of hemianæsthesia by French physicians. Charcot⁸⁵ has an admirable historical summary and clinical description of the condition, leaving little for others to add. Piorry, Macario, Gendrin, Szokalsky, and Briquet are referred to by him. Briquet found it present in 93 cases out of 400. It is of much more frequent occurrence on the left side. According to Briquet, 70 cases were affected on the left side to 20 on the right.

⁸⁵ Op. cit.

Next to hemianæsthesia, anæsthesia of the lower half of the body is most common in hysterical cases. While hemianæsthesia often presents itself conjoined with hystero-epileptic symptoms, anæsthesia of the lower half of the body may be present as frequently without as with convulsive manifestations. Anæsthesia of one limb or of one side of the face is almost as rare as general anæsthesia, but does occur.

Anæsthesia of mucous membrane is an old observation. It may affect mucous membranes everywhere—of the nose, pharynx, larynx, vagina, urethra, the bladder, rectum, etc. Many of the peculiar and apparently inexplicable hysterical symptoms are due to the presence of this anæsthesia—such symptoms, for instance, as want of inclination to evacuate the bowels or the bladder, absence of sexual desire, absence of sensibility when applications are made to the throat, etc. Loss of sensibility in muscles, bones, joints, and viscera may be present, but is of course frequently overlooked from want of minute investigation. In hemianæsthesia the viscera of the anæsthetic side are sometimes hyperæsthetic. Thus the ovary, as has been especially shown by Charcot, may be very painful on pressure when the abdominal wall is perfectly insensible.

A striking characteristic of hysteroid sensory disorders of the anæsthetic variety is the suddenness with which they come and go. A complete transference of anæsthesia from one side of the body to another may occur in a few seconds, either without special interference or under the use of metals or electricity.

The term achromatopsia is due to Galezowski. Hysterical achromatopsia is a condition in which there is a failure to appreciate colors. In Daltonism, or true color-blindness, one color may be taken for another; in achromatopsia the notion of color may be completely lost. These colors are found by the patient to disappear in a regular order, and return in a reverse order as the patient recovers. Some remarkable cases of this kind have been reported as occurring among French hysterics. A few examples of the same affection have been reported in America. Sometimes the patient has lost perception of one or several colors. When only one color is lost, it is usually the violet; if two, the violet and green; then in regular succession follow the colors of the spectrum.

Hysterical blindness and achromatopsia have been well studied by Charcot and Richer and others of the French school. Special articles on hysterical or simulated affections of the eye have also been published by Schweigger,⁸⁶ Harlan,⁸⁷ and others.

⁸⁶ “On Simulated Amaurosis,” by C. Schweigger, Prof. at the University of Berlin, New York Medical Journal, Feb., 1866.

⁸⁷ “Simulated Amaurosis,” by George C. Harlan, M.D., American Journal of Medical Sciences, October, 1873; “Hysterical Affections of the Eye,” Transactions of the College of Physicians of Philadelphia, 3d Series, vol. ii., 1876.

In several cases of hystero-epilepsy under my care both amblyopia and achromatopsia were present. In one of these cases the patient was unable to read print of any size or to distinguish any colors, although she could tell that objects were being moved before the eyes. An ophthalmoscopic examination showed a normal fundus. Each eye was tested for near vision. It was found that she could read quite well with the right eye, and not at all with the left. While reading at about sixteen inches a convex glass of three inches focus was placed in front of the right eye, but she still continued to read fluently.

C. H. Thomas of Philadelphia has given me the particulars of a case of a woman about thirty-eight years old, both of whose eyes were, to all appearances, absolutely blind. The attack came on suddenly, the apparent cause seeming to be worry over a sick child. Ophthalmoscopic and other examinations of the eye showed nothing. She had no perception of light. She could look without winking at a blinding reflection of a whitewashed fence. In six weeks under a mere tentative treatment she got absolutely well. S. D. Risley of Philadelphia,⁸⁸ in a discussion at the Philadelphia Neurological Society, held that the feeble innervation of the hysterical patient was liable to diminish the range of accommodation and power of convergence, rendering the comfortable use of the eye impossible; and also that the feeble or deranged circulation in the hysterical individual might set up a group of symptoms in the eye presenting many of the characteristics of serious disease; which, however, were not simulated, but were, in fact, a relative glaucoma. While there was no absolute increase of intraocular tension, the normal tension of the eyeball was sufficient to interrupt the entrance of the feeble blood-stream into the eyes, and thus was set up the same group of symptoms as were present in actual increase of tension—viz. inadequate blood-supply to the retina, contracted field of vision, impaired central perception, diminished range of accommodation, and inability to use the eyes, particularly at a near point.

⁸⁸ The Polyclinic, vol. ii., No. 8, Feb. 15, 1885, p. 124.

Very few observations in cases of hysteria have been made with the ophthalmoscope, and probably little is to be learned in this way. In one of Charcot's patients, however, Galezowski saw an infiltration and capillary reddening of the disc with fusiform dilatations of the artery.

What might be termed hysterical dilatation of the pupil is sometimes observed. In the case reported by Harlan, to be hereafter detailed, the patient, a young girl who had a train of hysterical symptoms, began to complain of blindness or imperfect vision in the right eye, the pupil of which was found to be dilated. No proof could be obtained of the use of any mydriatic. The pupil remained dilated when exposed to a bright light. The dilatation came and went at intervals, and finally disappeared under the applications of a wooden magnet. W. Chester Roy has acquainted me with the facts of the case of a man who could at will alternately contract and dilate his pupils. This case would seem to lend color to the idea that the hysterical girl may have had voluntary control of the pupillary movements. In her case, however, only one pupil was involved. F. X. Dercum has given me the particulars of a case of rhythmical dilatation of the irides in a case of confirmed masturbation with hysterical symptoms.

Hysterical deafness has been observed and studied. Walton,⁸⁹ at Charcot's suggestion, has published the results of the examination at La Salpêtrière of 13 patients affected with hemianæsthesia with reference to anæsthesia of hearing. He divides hemianæsthetic patients into three classes: (1) Those with complete anæsthesia of one side, the other side remaining normal; (2) those having incomplete anæsthesia on one side, the other remaining normal; (3) those with anæsthesia more or less complete on both sides. In the first class anæsthesia of hearing extended to the deep parts of the ear; the membrane of the drum could be touched without eliciting any acknowledgment of sensation and without the least reflex movement. He also showed that the anæsthesia extended to the middle ear by the fact that insufflation by Politzer's air-douche produced no sensation in the ear of the affected side. In this class neither the watch, voice, nor tuning-fork was heard. In the second class, with incomplete anæsthesia on one side, the lost sensibility corresponded, as a rule, with that of the body in general. A common form was analgesia with thermoanæsthesia and diminution of the tactile sensibility. In the third class completeness of the anæsthesia is rarely the same on both sides, a common form being complete hemianæsthesia on one side and analgesia on the other.

⁸⁹ Brain, January, 1883.

A noticeable feature in all the cases under consideration was the uniformity with which the deafness for conveyance by the bone exceeded that for sounds conveyed by the ear. Walton says: “This is probably due to the fact that the vibrations conveyed to the ear by the air are better adapted for the irritation of the peripheral auditory apparatus than those conveyed by the bone. When, then, the receptive power of the auditory centres is lessened, as is probably the case in hysterical patients, the hearing for sounds conveyed by the bones disappears before that for sounds conveyed by the ear. This enfeeblement of the auditive centres in hysteria is quite analogous to that in old age, in which, as is well known, the perception for sounds conveyed by the bone disappears before that for sounds conveyed by the air, the former being sometimes completely lost before the age of sixty.” His principal conclusions are as follows: (1) The sensibility of the deep parts of the ear, including the tympanum and middle ear, disappears in hysterical hemianæsthesia with that of other parts of the body, and in the same degree. (2) The degree of deafness corresponds with that of the general anæsthesia, being complete when the latter is complete, and incomplete when the latter is incomplete. (3) When loss of hearing is incomplete, the deafness for sounds conveyed by the bone exceeds that for sounds conveyed by air. (4) When the transfer is made, the hearing, as well as the general sensibility of the deep parts of the ear, improves on one side (allowance being made for accidental lesions in the ear itself) in exactly the same degree in which it disappears on the other.

The following case has been kindly furnished to me by Charles S. Turnbull, the patient having in the first instance come to Philadelphia to consult his father, Laurence Turnbull: The patient was a young lady from New Jersey, eighteen years old. Her general health was good, although at times she had a pale and anxious look. She had never had any unusual sickness. Soon after the death of her mother, for whom she grieved very much, she began to grow deaf, and was for a time treated by her family physician. When she first came to Philadelphia she was absolutely deaf, but the most careful examination failed to discover a cause for the deafness in any affection of the external or middle ear. A current from ten cells of a galvanic battery was painful, but elicited no sound. She declared that she could not hear a musical box held close to the side of her head. In communicating with her, everything had to be written. A faradic current was used daily to her ears. Suddenly one morning, after a powerful current had been applied, her hearing returned, but before she came back for treatment the next day it had again left. The electrical treatment was continued: each day the hearing stayed longer and longer, and finally returned in full force and remained good.

By hysterical paræsthesia is meant that form of perverted sensation which is not distinctly depressed on the one hand or markedly increased on the other. Under this head would come such conditions as numbness, formications, prickling and tingling sensation, the sensation of a ball in the throat or globus hystericus, etc. These forms of perverted sensation are quite common among the hysterical.

Hyperæsthesia may present itself in almost any locality, its areas of distribution corresponding very well to those which have been given for anæsthesia. Hyperæsthesia of the special senses is of especially frequent occurrence. Great sensitiveness to sounds and to bright lights or to particular colors is commonly observed. What might be termed hysterical tinnitus aurium is met with occasionally.

Perversions of the senses of smell and taste are among the rarer phenomena in the sensory sphere in hysteria. These may be of three kinds: the senses may be completely obtunded; they may be hyperacute; or they may show peculiar perversions. To some individuals of the hysterical temperament certain smells are almost unendurable, and these may be odors which to others are particularly pleasant. In like manner, certain articles of food or drink may be the source of great discomfort or absolute suffering. It is one of the oldest of observations that hysterical and morbid cravings for disagreeable or disgusting substances sometimes exist.

In one group of hysterias the presence of pain is the predominating feature. Some of the situations in which hysterical pains are most frequently felt are the head, the pericardial or left inframammary region, over the stomach and spleen, the left iliac region, the region of the kidneys, the sacrum, the hip, the spine, the larynx and pharynx, one or both mammæ, or over the liver and the joints. Of these locations, omitting the consideration of headache, the most common seats of hysterical pain are the spine, the breasts and inframammary region, the left iliac or ovarian region, the sacrum or coccyx, and the joints.

Charles Fayette Taylor, in a brochure on sensation and pain,⁹⁰ has given a philosophical explanation of such pain, drawing largely from Carpenter, Bain, Spencer, and others. The pith of the matter is that many of our sensations are centrally initiated, the memory of previous objective sensations. “Pain is different from ordinary sensations, in that it requires an abnormal condition for its production, and that it cannot be produced without that abnormal condition. Hence it is impossible to remember pain, because the apparatus does not exist for causing such a sensation as pain after the fact or when it is to be remembered. Memory is a repetition, in the nerve-centre, of energy which was first caused by the sensory impulse from without. But centrally initiated sensations may be mistaken, in consciousness, for pains depending wholly on a certain intensity of excitability in the cerebral mass.”

⁹⁰ Sensation and Pain, by Charles Fayette Taylor, M.D.—a lecture delivered before the New York Academy of Sciences, March 21, 1881.

A large percentage of all cases of hysteria complain more or less of spinal irritation. Spinal periostitis, spinal caries, and perhaps some cases of spinal meningitis, are organic diseases which may give rise to tenderness on pressure along the spine; but the majority of cases of spinal irritation are found among neurasthenic or hysterical patients. So much has already been written about spinal irritation that much time need not be spent on the subject, were it not that even yet many practitioners are inclined to regard cases as organic spinal trouble because of the presence of great spinal tenderness, whereas this symptom is almost diagnostic of the absence of real spinal disease.

Painful diseases of the joints, especially in women, are not infrequently hysterical or neuromimetic. Many such cases have been reported. Taylor states, as the results of much carefully-guarded experience, that hundreds of lame people are walking about perfectly who do not know that they ought to limp, and that a much larger number are either limping and walking on crutches, or not walking at all, who have no affection whatever causing lameness.

Paget—and his experience accords with that of others—makes the hip and knee, among the joints, the most frequent seats of nervous mimicry as well as of real disease. According to him, mimicries in other joints are almost too rare for counting; and yet in my first case of this kind the pain was located in the shoulder. This case made a lasting impression. The patient was a young lady of nervous temperament, who came complaining of severe and continuous pain in the left shoulder. No history of injury was given. The pain was said to be rheumatic. Handling the arm and pressure round the joint caused extreme pain. No heat, no redness, no swelling were discoverable. The patient left me and went to a magnetic doctor, who entirely dispelled the disorder on her first visit by gently stroking the arm and shoulder. Another patient had been accidentally struck in the knee. No swelling, heat, or other signs of inflammation followed the accident, and did not afterward appear; but at intervals, for several years, she complained of severe pain in and around this joint. She would be for days, or it might be for weeks, without speaking of the pain; and then again she would complain almost incessantly, and would sometimes limp. These periods always corresponded with times of mental and physical depression, and the pain was evidently neuromimetic or hysterical.

The affection which has come down to us from ancient times under the name of clavus hystericus is an acute boring pain confined to a small point at the top of the head, and is sometimes described as resembling the pain which would be produced by driving a nail into the head; hence the term, from clavus, a nail. It may last for hours, days, or even weeks. Instead of clavus hystericus, hemicrania, occipital headache, or nape-aches may be present. On the whole, aches and pains of the head in hysterical cases are more likely to be localized to some point or area than to be general. Hysterical patients, however, not infrequently complain of constricting, contracting, or compressing sensations in the head.

In hysterical women the pulse is apt to be rapid, even sometimes twenty, thirty, to fifty pulsations to the minute above normal. The heart in these patients is irritable and prone to beat rapidly. One of Mitchell's cases is worthy of brief detail: A neurasthenic, hysterical woman, thirty-eight years old, when lying down had a heart-beat never less than 130 per minute. Exertion added twenty or thirty pulsations. Despite this irritability, however, the rhythm was good. Ovarian pressure and pressure along the spine would suddenly increase the heart-beats. Her temperature ranged from 95° in the morning to 100° or 101.5° F. in the evening, although she had no pulmonary or visceral trouble.

The high temperatures which have been observed in many cases of hysteria have been due to some form of shrewd fraud; but Briand⁹¹ maintains with Gubler, Rigel, Dieulafoy, and others that the term hysterical fever is correct, and he describes three forms of the fever: (1) The slow continued fever of Briquet, characterized sometimes by simple acceleration of the pulse, without elevation of temperature; sometimes by a temperature rise, either with or without phenomena or accompanied by headache, thirst, and other symptoms; (2) a shorter form, always the result of a more or less active disturbance of the nervous system by terror, fear, chagrin, and like causes; (3) a form with intermittent febrile phenomena. Examples of the different forms are given. Debove⁹² supports the view of the entity of the hysterical fever, citing cases—one a woman twenty-four years old who had, at intervals, marked fever, the temperature sometimes reaching 102¹/5° to 104° F. Malaria and tuberculosis were excluded. Sulphate of quinia had no influence upon her attacks, but antipyrine reduced the temperature and her general condition improved. Debove has observed the temperature to rise from 1° to 2° F. by mere suggestion when the patient was in a somnambulistic state.

⁹¹ Gazette hébdomadaire, quoted in Med. News, Dec. 1, 1883.

⁹² Ibid., quoted in Med. News, April 4, 1885.

On the other hand, it has been claimed that a true hysterical fever never occurs or is extremely rare. Admitting this view, several explanations may be given of the rise of temperature observed. It may be due to intercurrent affections, as typhoid or intermittent fever, or some local inflammatory disorder. It may be secondary fever, the result of muscular effort or some similar cause. Lastly, and most probably, it may be due to ingenious fraud, as to friction of the bulb, pressure, or tapping with the finger, dipping the instrument into hot water, connivance with the nurse, etc. Du Castel⁹³ has reported a trick of this kind. An hysterical girl, convalescent from an attack of sore throat, displayed remarkable alternations of temperature. One day the thermometer reached 163.4° F.! By carefully watching the patient it was found she had learned the trick of lightly tapping the end of the thermometer, which caused the mercury to ascend as far as she wished. In the case of chronic hysterical insanity of which the details have been given the temperature in the axilla on several occasions reached 102°, 103°, and even 105° F.

⁹³ Revue de Thérapeutique méd.-chir., No. xi., 1884.

Extreme states of pallor or blushing, sometimes in the extremities and at others in the face, are mentioned by Mitchell as among the vaso-motor disturbances of hysteria. Rosenthal gives a most interesting observation with reference to vaso-motor conditions in hysteria: the patient, a girl twenty-three years old, had epileptiform attacks, which were preceded by a subjective sensation of cold and discoloration of the hands and tips of the fingers. The hands became very pale, the tips of the fingers and nails of a deep blue; the patient experienced a disagreeable sensation of cold in the hands, and their temperature sank more than 3°, while the pulse dropped from 72 to 65 or 66. After the attack the temperature rose 2° higher than the normal condition; the fingers and nails became very red, and were the seat of an abundant perspiration; the pulse increased to 84 or 88. Other interesting symptoms were present.

Mitchell⁹⁴ has put on record three cases of hysteria in which was present unilateral increase in bulk at or near the menstrual period, and also at other seasons after emotional excitement. He does not give any opinion as to its nature, but believes that it is not a mere increase of areolar serum, and that it does not appear to resemble the vasal paralysis in which the leg throbs and exhibits a rise in temperature and tint. He is unable also to identify it with any form of lymph œdema which it resembles, for in this disorder there is more obvious œdema, and it is also quite permanent. Whatever the cause of the swelling, he believes that it is under the influence of the nervous system, and that it varies with the causes which produce analgesia or spasm. I have seen swelling of this kind in several cases, and have probably overlooked it in others. In one of my reported cases of hystero-epilepsy it was a very marked symptom, coming and going, increasing and diminishing, with other symptoms.

⁹⁴ American Journal of the Medical Sciences, New Series, vol. lxxxviii., July, 1884, p. 94.

Buzzard calls attention to the fact that in many cases belonging to the class of hysteria the epidermis, which has arrived at extraordinary thickness, apparently from disuse of the limbs, offers great resistance to the passage of electric currents. Under these circumstances a more than usual amount of care in thoroughly soaking and rubbing the skin, as well as in selecting the motor points, is necessary to avoid fallacies. Absence of reflex from the sole of the foot, according to the same authority, is a very constant symptom in hysterical paraplegia.

Some wasting does not negative the idea of hysteria, but this wasting a not associated with changing the electrical reaction.

Disturbance of the secretion of the urine is among the most frequent of the minor hysterical troubles, and has often been noted by writers upon this subject since a very early date. Sydenham⁹⁵ says that of the “symptoms accompanying this disease, the most peculiar and general one is the making great quantities of urine as clear as rock-water, which upon diligent inquiry I find to be the distinguishing sign of those disorders which we call hypochondriac in men and hysteric in women. And I have sometimes observed in men that soon after having made urine of an amber color, being suddenly seized with some disturbance of mind, they made a large quantity of clear water, with a continued violent stream, and remained indisposed till the urine came to its former color, when the fit went off.” This symptom shows itself as strikingly in the hysteria of the present day as in the age of Sydenham.

⁹⁵ Op. cit.

A complete anuria or ischuria is one of the older observations in hysteria. Laycock, Charcot, and many others have written at length on this subject. Finch⁹⁶ has published a curious case of complete anuria. The patient had various hysterical symptoms, including paroxysms with unconsciousness, contracture, also vomiting. Micturition and defecation were entirely suspended (?) from Dec. 24, 1877, to Feb. 22d of the following year. During a period of fifty-eight days paroxysms were frequent; but on using the catheter the bladder was always found empty. The probability of hysterical fraud is very great in this case. A few case of hysterical retention of the urine in men have been reported.

⁹⁶ Nice médicale.

Increase of the uterine and vaginal secretions is mentioned by Jolly as sometimes attributable to nervous influences in cases of hysteria. He mentions the case of a woman suffering from hysterical symptoms at the change of life whose disposition was decidedly depressed; though at times lively, particularly erotic. In this case simultaneously with tympanites appeared a thin, clear fluor albus. Local treatment with quiet had no decided effect, but it disappeared with the tympanites when the patient was excited by the visit of a sister who overwhelmed her with reproaches.

Hysterical vomiting of food sometimes persists for weeks; strangely enough, the patients usually appear to suffer little in consequence. Chambers believes that the articles swallowed do not all get into the stomach. The phenomena of rejection in these cases are similar to those of an œsophageal stricture; some of the matter swallowed is really retained, and therefore the patient will not starve as soon as might be supposed.

Two cases of simulated pregnancy by hysterical women have come under my observation. Cases are reported also in which hysteria simulated closely the process of natural labor, as one for instance, by Hodges.⁹⁷ A woman said to be in the fifth month of pregnancy engaged him to attend her at term. Four months afterward he was sent for, the patient having severe pains, supposing herself to be in labor. On examination, however, a tumor present turned out to be the bladder distended and prolapsed. Sparks⁹⁸ reports the case of a young married woman who had the symptoms of the third stage of labor, the case being purely hysterical.

⁹⁷ Lancet, 1859, ii. 619.

⁹⁸ Chicago Med. Journ. and Examiner, 1880.

Walker⁹⁹ reports a group of hysterical symptoms closely simulating the prodromes of puerperal eclampsia. The patient, a married woman only eighteen years old, when pregnant six months lifted a tub of water, rupturing the membranes. In the eighth month, after she had remained in bed three days, she began to complain of severe headache; soon she said she was blind; the pupils of the eye were neither dilated nor contracted, and responded sluggishly to light. Ophthalmoscopic examination gave negative results, but she did not flinch from the light of the mirror. Temperature, pulse, and respiration were about normal. The urine contained no albumen. She recovered her sight in twelve hours, and had no continuing trouble.

⁹⁹ Arch. of Medicine, New York, 1883, x. 85-88.

Paget mentions cases of phantom tumor occurring in the calf, thigh, and breast. These phantoms shift from one place to another, or disappear when the muscles are relaxed by anæsthetics or otherwise. The nervous mimicry of aneurisms (of Paget) are what Laycock and others treat of as pulsations. They are most frequent in the carotid artery and abdominal aorta. Of imitations of cancer it need only be said that the average hysterical female suspects every lump in the breast and elsewhere to be a cancer.

Mitchell mentions certain peculiar symptoms quite common among hysterical women, but which also occur, but more rarely, among men. When falling asleep these patients have something like an aura rising from the feet and going up toward the head. One patient had an aura which passed upward from his feet, and when it had reached his head he felt what he described as an explosion. Another had a sensation as though something was about to happen, but no distinct ascending aura. If he roused himself in time, he could by turning over release himself from the sensation and break the chain of morbid events. At the close of the attack he had a noise in his head—something like the sound of a bell which had been struck once. Other patients when going to sleep have constant sounds, faint usually and rarely loud and without a feeling of terror. Most of the patients were women worn out or tired out and hysterical.

Sometimes hysterical women awake with numbness and tingling, which rapidly passes away or yields to a little surface friction. Some persons who have in a measure recovered from hemiplegia of organic origin are liable to awake out of sleep with a numbness and lessening of power on the side once palsied. Palpitation of the heart, vertigo, and a certain fear of a respiratory character are among the milder forms of trouble which Mitchell mentions as haunting the sleep of nervous or hysterical women.

Under hysteria some of the affections, more common among men than women, known as railway brain, railway spine, etc., may be classified. These disorders might be termed traumatic hysteria. The amount of money that has been paid out by corporations, beneficial societies or individuals because of suits or threatened suits for damages in cases of railway or other accidents is something almost incredible. At least two classes of cases, besides those of recognizable gross lesion, are to be found in the ranks of those claiming such damages. These are first the bogus cases or malingerers, and secondly cases of nervous mimicry. An hysterical individual who has been in a railway collision, or has been the victim of an accident for which somebody else may possibly be made responsible, may deliberately practise fraud, or he may consciously or unconsciously imitate or exaggerate real symptoms of serious import. Sometimes there may be in the same case a mingling of real and of simulated or of neuromimetic disorders. As long as a claim of damages in this class of cases exists, great care should be taken in making a diagnosis. The neuromimetic cases, however, do occur, particularly in the hysterical and neurasthenic, without any reference to litigation.

A lady fell off her chair backward. She was not rendered unconscious, but became nervous, and began to have considerable pain and soreness in the sacral region and about the right sacro-iliac juncture. She had no palsy, nor spasm, nor anæsthesia, nor paræsthesia, and had no difficulty in her bladder, but nevertheless was helpless in bed for many weeks, supposing herself unable to stand. She recovered promptly, under treatment with electricity, as soon as a favorable prognosis was given in a very positive manner.

A man fell on the ice and struck his back, but was able to go on with his usual occupation, although complaining of his limbs. Two months afterward, while recovering from typhoid fever, he fell from a chair, and was unable to raise himself, and found that he had lost control of his legs and arms. During the attack he was not unconscious. He was bed-ridden for two months, but did not lose control of his bladder and bowels. He was put on his feet by a little treatment and much encouragement.

A woman was badly pushed about while riding in a street-car by the car being thrown off the track. She miscarried in about six weeks, flooding a good deal after injury to the time of miscarriage. Later, spinal symptoms began. She had extensive pain and tenderness at the lower end of the spine. She sometimes fainted. Examination revealed general spinal tenderness, much more marked in the sacro-coccygeal region. She was pale, anæmic, and neurasthenic. She brought suit against the railway company for damages, which were very properly awarded, as the miscarriage, hemorrhage, and consequent anæmia were without doubt the result of an accident for which she was in no wise responsible. Some organic spinal-cord disease, however, was supposed to exist, the chief foundation for this view being the extreme spinal tenderness, which was hysterical.

Finally, some hysterical cases present a succession of local hysterical phenomena following each other more or less rapidly. One symptom seems to take possession of the patient for the time being, but when relieved or cured of this, suddenly a new manifestation occurs. A new figure appears upon the scene, or perhaps I might better say a new actor treads the boards. Even in these cases, however, it would be difficult to say that the phenomena are really simulated. They are rather induced, and get partly beyond the patient's will.

A remarkable case of this kind is well known at the Philadelphia Polyclinic and College for Graduates in Medicine. She is sometimes facetiously spoken of as the “Polyclinic Case,” because she has done duty at almost every clinical service connected with the institution. The case has been reported several times: the fullest report is that given by Harlan.¹⁰⁰ The patient was taken sick in September with sore throat, and was confined to the house for about two weeks. She was attended by S. Solis Cohen. There was difficulty in swallowing, and some regurgitation of food. At the same time she had weakness of sight in the right eye. Later, huskiness of voice came on, and soon complete aphonia. Her voice recovered, and she then had what appeared to be pleuro-pneumonia. During the attack her arms became partially paralyzed. She complained of numbness down her legs and in her feet.

¹⁰⁰ Transactions of the Amer. Ophthalmological Soc., 20th annual meeting, 1884, 649.

Before these symptoms had disappeared twitchings of the muscles of the face set in, most marked on the right side. The face improved, but in two days she had complete spasmodic torticollis of the left side. One pole of a magnet was placed in front of the ear, and the other along the face; and under this treatment in a week the spasm ceased entirely.

In a short time she complained of various troubles of vision and a fixed dilatation of the pupil. Homonymous diplopia appeared. Reading power of the right eye was soon lost. The pupil was slightly dilated, and reacted imperfectly to light. She had distressing blepharospasm on the right side and slight twitchings on the left. Two months later a central scotoma appeared, and eventually her right eye became entirely blind except to light. The pupil was widely dilated and fixed, and the spasm became more violent and extended to the face and neck. The sight was tested by Harlan by placing a weak convex lens in front of the blind eye, and one too strong to read through in front of the sound eye, when it was found that she read without any difficulty. The use of the magnet was continued by Cohen. Blepharospasm and dilatation of the pupil improved. She, however, had an attack of conjunctivitis in the left eye, and again got worse in all her eye symptoms. A perfect imitation of the magnet was made of wood with iron tips. Under this imitation magnet the pupil recovered its size and twitching of the face and eyelids ceased.

The next campaign was precipitated by a fall. She claimed that she had dislocated her elbow-joint; she was treated for dislocation by a physician, and discharged with an arm stiff at the elbow. A wooden magnet was applied to the arm, the spasm relaxed, and the dislocation disappeared.

This ends Harlan's report of the case, and I had thought that this patient's Iliad of woes was also ended; but I have just been informed by J. Solis Cohen and his brother that she has again come under their care. The latter was sent for, and found the patient seemingly choking to death. The right chest was fixed; there was marked dyspnœa; respiration 76 per minute; her expectoration was profuse; she had hyperresonance of the apex, and loud mucous râles were heard. At last accounts she was again recovering.

This patient's train of symptoms began with what appeared to be diphtheria. The fact that she had some real regurgitation would seem to be strong evidence that she had some form of throat paralysis following diphtheria. She was of neurotic temperament. From the age of seven until ten years she had had fits of some kind about every four weeks. Because of her sore throat and subsequent real or seeming paralytic condition she came to the Polyclinic, where she was an object of interest and considerable attention, having been talked about and lectured upon to the classes in attendance. Whether her first symptoms were or were not hysterical, those which succeeded were demonstrably of this character. Frequently some real disease is the starting-point of a train of hysterical disorders.

DURATION AND COURSE.—Hysteria is pre-eminently a chronic disease; in the majority of cases it lasts at least for years. Its symptoms may be prolonged in various ways. Sometimes one grave hysterical disorder, as hysterical paralysis, persists for years. In other cases one set of symptoms will be supplanted by others, and these by still others, and so on until the whole round of hysterical phenomena appears in succession.

Deceptive remissions in hysterical symptoms often mislead the unwary practitioner. Cures are sometimes claimed where simply a change in the character of the phenomena has taken place. Without doubt, some cases of hysteria are curable; equally, without doubt, many cases are not permanently cured. It is a disease in which it is unsafe to claim a conquest too soon. In uncomplicated cases of hysteria the disorder often abates slowly but surely as age advances. As a rule, the longevity of hysterical patients is not much affected by the disorder.

COMPLICATIONS.—We should not treat a nervous case occurring in a woman or a man as hysterical simply because it is obscure and mysterious. Unless, after the most careful examination, we are able by exclusion or by the presence of certain positive symptoms to arrive at the diagnosis of hysteria, it is far better to withhold an opinion or to continue probing for organic disease. I can recall five cases in which the diagnosis of hysteria was made, and in which death resulted in a short time. One of these was a case of uræmia with convulsions, two were cases of acute mania, another proved to be a brain abscess, and the fifth a brain tumor. Hughes Bennett¹⁰¹ has reported a case of cerebral tumor with symptoms simulating hysteria in which the diagnosis of the true nature of the disease was not made out during life. The patient was a young lady of sixteen at the time of her death. Her family history was decidedly neurotic. She was precocious both mentally and physically, was mischievous and destructive, sentimental and romantic; she had abnormal sexual passions. She had a sudden attack of total blindness, with equally sudden recovery of sight some ten days afterward. Sudden loss of sight occurred a second time, and deafness with restoration of hearing, loss of power in her lower limbs, and total blindness, deafness, and paraplegia. Severe constant headaches were absent, as were also ptosis, diplopia, facial or lingual paralysis, convulsions with unconsciousness, vomiting, wasting, and abnormal ophthalmoscopic appearances. She had attacks of laughing, crying, and throwing herself about. Her appearance and character were eminently suggestive of hysteria. The patient died, and on post-mortem examination a tumor about the size and shape of a hen's egg was found in the medullary substance of the middle lobe of the right hemisphere.

¹⁰¹ Brain, April, 1878.

The association of hysteria with real and very severe spinal traumatism partially misled me in the case of a middle-aged man who had been injured in a runaway accident, and who sustained a fracture of one of the upper dorsal vertebræ, probably of the spines or posterior arch. This was followed by paralysis, atrophy of the muscles, contractures, changed reactions, bladder symptoms, bed-sores, and anæsthesia. The upper extremities were also affected. Marked mental changes were present, the man being almost insanely hysterical. The diagnosis was fracture, followed by compression myelitis, with descending motor and ascending sensory degeneration. An unfavorable prognosis was given. He left the hospital and went to another, and finally went home, where he was treated with a faradic battery. He gradually improved, and is now on his feet, although not well. In this case there was organic disease and also much hysteria.

Seguin¹⁰² holds that (1) many hysterical symptoms may occur in diseases of the spinal cord and brain; (2) in diseases of the spinal cord these diseases appear merely as a matter of coincidence; (3) in cases of cerebral disease the hysterical symptoms have a deeper significance, being in relation to the hemisphere injured. He collects, as illustrative of the propositions that hysterical symptoms will present themselves in persons suffering from organic disease of the nervous system, the following cases of organic spinal disease: One case of left hemiplegia with paresis of the right limbs, which proved after death to be extensive central myelitis, with formation of cavities in the cord; two cases of posterior spinal sclerosis, two of disseminated sclerosis, and one of sclerosis of the lateral column. In some of these cases the organic disease was wholly overlooked. Sixteen cases of organic disease of the brain accompanied by marked hysterical manifestations are also given: 9 of left hemiplegia; 2 of right hemiplegia with aphasia; 1 of left alternating with right hemiplegia; 1 of hemichorea with paresis; 1 of double hemiplegia; and 2 of general paresis. It is remarkable and of interest, in connection with other unilateral phenomena of hysteria, that emotional symptoms were present in 14 cases of left hemiplegia and in only 2 of right.

¹⁰² Op. cit.

Among the important conclusions of this paper are the following: “1. In typical hysteria the emotional symptoms are the most prominent, and according to many authors the most characteristic. In all the cases of cerebral disease related there were undue emotional manifestations or emotional movements not duly controlled. 2. In typical hysteria many of the objective phenomena are almost always shown on the left side of the body, and we may consequently feel sure that in these cases the right hemisphere is disordered. In nearly all of the above sixteen cases the right hemisphere was the seat of organic disease, and the symptoms were on the left side of the body.”

The possibility of the occurrence of hysteria in the course of acute diseases, particularly fevers, is often overlooked. Its occurrence sometimes misleads the doctor with reference to prognosis. Such manifestations are particularly apt to occur in emotional children. A young girl suffering from a moderately severe attack of follicular tonsillitis, with high fever, suddenly awoke during the night and passed into an hysterical convulsion which greatly alarmed her parents. Her fingers, hands, and arms twitched and worked convulsively. She had fits of laughing and shouting, and was for a short time in a state of ecstasy or trance. Once before this she had had a similar but slighter seizure, during the course of an ephemeral fever.

Among other complications of hysteria which have been noted by different observers are apoplexy, disease of the spleen, mania-a-potu, heart disease, and spinal caries, and among affections alluded to by competent observers as simulated by hysteria are secondary syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina pectoris, and cardiac dyspnœa.

DIAGNOSIS.—Buzzard¹⁰³ significantly remarks that you cannot cure a case of hysteria as long as you have any serious doubt about its nature; and, on the other hand, if you are able to be quite sure on this point, and are prepared to act with sufficient energy, there are few cases that will not yield to treatment. The importance of a correct diagnosis is a trite topic, but in no affection is it of more consequence than in hysteria, that disorder which, although itself curable, may, as has been abundantly shown, imitate the most incurable and fatal of diseases.

¹⁰³ Clinical Lectures on Diseases of the Nervous System, by Thomas Buzzard, M.D., Philada., 1882.

A few remarks with reference to the methods of examining hysterical patients will be here in place. Success on the part of the physician will often depend upon his quickness of perception and ability to seize passing symptoms. It is often extremely difficult to determine whether hysterical patients are or are not shamming or how far they are shamming. The shrewdness and watchfulness which such patients sometimes exercise in resisting the physician's attempts to arrive at a diagnosis should be borne in mind. A consistent method of procedure, one which never betrays any lack of confidence, should be adopted. “Trifles light as air” will sometimes decide, a single expression or a trivial sign clinching the diagnosis. On the other hand, the most elaborate and painstaking investigation will be frequently required.

The physician should carefully guard against making a diagnosis according to preconceived views. On the whole, the general practitioner is more likely to err on the side of diagnosticating organic disease where it does not exist; the specialist in too quickly assigning hysteria where organic disease is present, or in failing to determine the association of hysteria and organic disease in the same case.

Special expedients may sometimes be resorted to in the course of an examination. Not a few hysterical symptoms require for their continuance that the patient's mind shall be centred on the manifestations. If, therefore, the attention can, without arousing suspicions, be directed to something else during the examination, the disappearance of the particular hysterical symptom may clear away all obscurity. In a case reported by Seguin,¹⁰⁴ in which staggering was a prominent symptom, the patient was placed in the middle of the room and directed to look at the ceiling to see if he could make out certain fine marks; he stood perfectly well without any unsteadiness. In the case of a boy eleven years old whose chief symptoms were hysterical paralysis with contracture of the lower extremities, great hyperæsthesia of the feet, and a tremor involving both the upper and lower extremities, and sometimes the head, I directed him, as if to bring out some point, to hold one arm above his head and at the same time fix his attention on the foot of the opposite side. The tremor in the upper extremities, which had been most marked, entirely disappeared. This experiment was varied, the result being the same.

¹⁰⁴ Op. cit.

The method adopted in the cases supposed to be phthisis, but which proved to be hysterical, which has already been alluded to under the head of hysterical or nervous breathing, is worthy of note. The patients, it will be recalled, could not be induced to draw a long breath until the plan was adopted of having them count twenty without stopping, when the lungs expanded and the diagnosis was clear.

It is important to know whether or not children are of this hysterical tendency or are likely, sooner or later in life, to develop some forms of this disorder. In children as well as in adults the hysterical diathesis will be indicated by that peculiar mobility of the nervous system, which has been referred to under Etiology. It is chiefly by psychical manifestations that the determination will be made. These are often of mild degree and of irregular appearance. Undue emotionality under slight exciting cause, a tendency to simulation and to exaggeration of real conditions, inconsistency in likes and dislikes, and great sensibility to passing impressions, are among these indications. Children of hysterical diathesis are sometimes, although by no means always, precocious mentally, but not a few cases of apparent precocity are rather examples of an effort to attract attention, which is always present in individuals of this temperament.

It is also important, as urged by Allbutt,¹⁰⁵ to make a distinction between hysterical patients and neurotic subjects, often incorrectly classed as hysterical. Many cases of genuine malady and suffering are contemptuously thrown aside as hysteric. Allbutt regards some of these neurotic patients as almost the best people in this wicked world. Although, however, this author's righteous wrath against the too frequent diagnosis of hysteria, hysterical pain, hysterical spine, etc. is entirely justifiable, he errs a little on the other side.

¹⁰⁵ On Visceral Neuroses, being the Gulstonian Lectures on Neuralgia of the Stomach and Allied Disorders, delivered at Royal College of Physicians, March, 1884, by T. Clifford Allbutt, M.A., M.D. Cantab., F. R. S., Philada., 1884.

Hysteria and neurasthenia are often confounded, and, while both conditions may exist in the same case, just as certainly one may be present without the other. The points of differential diagnosis as given by Beard¹⁰⁶ are sufficient for practical purposes. They are the following: In neurasthenia convulsions or paroxysms are absent; in hysteria they are among the most common features. In neurasthenia globus hystericus and anæsthesia of the epiglottis are absent, ovarian tenderness is not common, and attacks of anæsthesia are not frequent and have little permanency; in hysteria globus hystericus, anæsthesia of the epiglottis, ovarian tenderness, and attacks of general or local anæsthesia are all marked phenomena. The symptoms of neurasthenia are moderate, quiet, subdued, passive; those of hysteria are acute, intense, violent, positive. Neurasthenia may occur in well-balanced intellectual organizations; hysteria is usually associated with great emotional activity and unbalanced mental organization. Neurasthenia is common in males, although more common in females; hysteria is rare in males. Neurasthenia is always associated with physical debility; hysteria in the mental or psychical form occurs in those who are in perfect physical health. Neurasthenia never recovers suddenly, but always gradually and under the combined influences of hygiene and objective treatment; hysteria may recover suddenly and under purely emotional treatment.

¹⁰⁶ Op. cit.

An affection termed general nervousness has been described by Mitchell. It does not seem to be strictly a neurasthenia, nor does it always occur in hysterical individuals. These cases are sometimes “more or less neurasthenic people, easily tired in brain or body; but others are merely tremulous, nervous folks, easily agitated, over-sensitive, emotional, and timid.” It is sometimes an inheritance; sometimes it results from the misuse of alcohol, tobacco, tea or coffee. Usually, it is developed slowly; occasionally, however, it arises in a moment. Thus, Mitchell mentions the case of a healthy girl who fell suddenly into a state of general nervousness owing to the fall of a house-wall. General nervousness is to be distinguished from hysteria, into which it sometimes merges, only by the absence of the mental perversions and the special motor, sensory, vaso-motor, and visceral disorders peculiar to the latter.

The differential diagnosis of hysteria and hypochondria, or what is better termed hypochondriacal melancholia, is often, apparently at least, somewhat difficult. Formerly, it was somewhat the fashion to regard hysteria in the male as hypochondria; but this view has nothing to support it. Hypochondria and hysteria, as neurasthenia and hysteria, are sometimes united in the same subject; one sometimes begets the other, but they have certain points of distinction. Hypochondria more frequently passes into real organic disease than does hysteria; it is more frequently associated with organic disease than is hysteria. Hypochondria is in the majority of cases a true insanity, while hysteria can only be regarded as such in the special instances which have been discussed. In hypochondria the individual's thoughts are centred upon some supposed disease until a true delusional condition is developed; this does not often occur in hysteria. Hypochondria is seen with as great a frequency in the male as in the female, while hysteria prevails much more largely in the female sex. In typical hypochondria more readily than in hysteria the patient may be led from one set of symptoms to another, the particulars of which he will detail in obedience to questions that are put to him, these symptoms not unusually partaking of the absurd and impossible. In hypochondria are absent those distinctive symptoms which in nearly all cases of hysteria appear in greater or less number, such as convulsions, paralysis, contracture, aphonia, hysterical joints, and the like. In hypochondria is present the groundless fear of disease without these outward manifestations of disease. The symptoms of hypochondria, as a rule, but not invariably, are less likely to change or abate than those of hysteria.

It is often of moment to be able to distinguish between two such well-marked affections as common acute mania and hysterical mania. In acute mania the disorder usually comes on gradually; in hysterical mania the outbreak of excitement is generally sudden, although prodromic manifestations are sometimes present. This point of difference is not one to be absolutely depended upon. In acute mania incoherence and delusions or delusional states are genuine phenomena; in hysterical mania delusional conditions, often of an hallucinatory character, may be present, but they are likely to be of a peculiar character. Frequently, for instance, such patients see, or say that they see, rats, toads, spiders, and strange beasts. These delusions have the appearance of being affected in many cases; very often they are fantastical, and sometimes at least they are spurious or simulated. In hysterical mania such phenomena as obstinate mutism, aphonia, pseudo-coma, ecstasy, catalepsy, and trance often occur, but they are usually absent in the history of cases of acute mania. In acute mania under the influence of excitement or delusion the patients may take their own lives: they may starve or kill themselves violently; in hysterical mania suicide will be threatened or apparently attempted, but the attempts are not genuine as a rule; they are rather acts of deception. In acute mania the patients often become much reduced and emaciated; in hysterical mania in general, considering the amount of mental and motor excitement through which the individuals pass, their nutrition remains good. In acute mania sleeplessness is common, persistent, and depressing; in hysterical mania usually a fair amount of sleep will be obtained in twenty-four hours. In many cases of hysterical mania the patients have their worst attacks early in the morning after a good night's rest. Acute mania under judicious treatment and management may gradually recover; sometimes, however, it ends fatally: this is especially likely to occur if the physician supposes the case to be simply hysterical and acts accordingly. Hysterical mania seldom has a serious termination unless through accident or complication.

In order to make the diagnosis of purposive hysterical attacks watchfulness on the part of the physician will often suffice. Such patients can frequently be detected slyly watching the physician or others. Threats or the actual use of harsh measures will sometimes serve for diagnostic ends, although the greatest care should be exercised in using such methods in order that injustice be not done.

In uræmia, as in true epilepsy, the convulsion is marked and the condition of unconsciousness is usually profound. An examination of the urine for albumen, and the presence of symptoms, such as dropsical effusion, which point to disorder of the kidneys, will also assist.

Hysterical paralysis in the form of monoplegia or hemiplegia must sometimes be distinguished from such organic conditions as cerebral hemorrhage, embolism or thrombosis, tumor, abscess, or meningitis (cerebral syphilis).

When the question is between hysteria and paralysis from coarse brain disease, as hemorrhage, embolism, etc., the history is of great importance. The hysterical case usually has had previous special hysterical manifestations. The palsy may be the last of several attacks, the patient having entirely recovered from other attacks. In an organic case, if previously attacked, the patient has usually made an incomplete recovery; the history is of a succession of attacks, each of which leaves the patient worse. In cerebral syphilis it happens sometimes that coming and going paralyses occur; but the improvement in these cases is generally directly traceable to specific treatment. Partial recoveries take place in embolism, thrombosis, hemorrhage, etc. when the lesion has been of a limited character, but the improvement is scarcely ever sufficient to enable the patient to be classed as recovered. The exciting cause of hysterical and organic cases of paralysis is different. While in hysterical paralysis sudden fright, anxiety, anger, or great emotion is frequently the exciting cause, such psychical cause is most commonly not to be traced as the factor immediately concerned in the production of the organic paralysis. In the organic paralysis an apoplectic or apoplectiform attack of a peculiar kind has usually occurred. In cerebral hemorrhage or embolism the patient suddenly loses consciousness, and certain peculiar pulse, temperature, and respiration phenomena occur. The patient usually remains in a state of complete unconsciousness for a greater or less period. In hysteria the conditions are different. A state of pseudo-coma may sometimes be present, but the temperature, pulse, and respiration will not be affected as in the organic case.

Hysterical monoplegia or hemiplegia, as a rule, is not as complete as that of organic origin, and is nearly always accompanied by some loss of sensation. The face usually escapes entirely. In organic palsy the face is generally less severely and less permanently affected than the limbs, but paresis is commonly present in some degree. Hysterical palsies are more likely to occur upon the left than upon the right side. Embolism is well known to occur most frequently in the left middle cerebral artery, thus giving the palsies upon the right. In hemorrhage and thrombosis the tendency is perhaps almost equal for the two sides. Some of these and other points of distinction between organic and hysterical palsies have been given incidentally under Symptomatology.

In organic hemiplegia aphasia is more likely to occur than in hysterical cases; and acute bed-sores and wasting of the limbs, with contractures, are conditions frequently present as distressing sequelæ. Such is not the rule in hysterical cases, for while there may be wasting of the limbs from disuse and hysterical contractures, bed-sores are seldom present, and the wasting and contractures do not appear so insidiously, nor progressively advance to painful permanent conditions, as in the organic cases. Mitchell mentions the fact that in palsies from nerve wounds feeling is apt to come back first, motion last; while in the hysterical the gain in the power of motion may go on to full recovery, while the sense of feeling remains as it was at the beginning of treatment. This point of course would help only in cases where both sensory and motor loss are present.

The examination of an hysterically palsied limb, if conducted with care, may often bring out the suppressed power of the patient. Practising the duplicated, active Swedish movements on such a limb will sometimes coax resistance from the patient. As already stated, electro-contractility is retained in hysterical cases.

The disorders from which it may be necessary to diagnosticate hysterical paraplegia are spinal congestion, subacute generalized myelitis of the anterior horns (chronic atrophic spinal paralysis of Duchenne), diffused myelitis, acute ascending paralysis, spinal hemorrhage, spinal tumor, posterior spinal sclerosis or locomotor ataxy, lateral sclerosis or spasmodic tabes, multiple cerebro-spinal sclerosis, and spinal caries.

In spinal congestion the patients come with a history that after exposure they have lost the use of their lower limbs, and sometimes of the upper. Heaviness and pain in the back are complained of, and also more or less pain from lying on the back. Numbness in the legs and other disturbances of sensation are also present. The paralysis may be almost altogether complete. Such patients exhibit evidences of the involvement of the whole cord, but not a complete destructive involvement. A colored woman, age unknown, had been in her ordinary health until Nov. 24, 1884. At this time, while washing, she noticed swelling of the feet, which soon became painful, and finally associated with loss of power. She had also a girdling sensation about the abdomen and pain in the back. She was admitted to the hospital one week later, at which time there was retention of the urine and feces. She had some soreness and tenderness of the epigastrium. She complained of dyspnœa, which was apparently independent of any pulmonary trouble. It was necessary to use the catheter for one week, by which time control of the bladder had been regained. The bowels were regulated by purgatives. She was given large doses of ergot and bromide and iodide of potassium, and slowly improved, and after a time was able to get out of bed and walk with the aid of a chair. An examination at the time showed that the girdling pain had disappeared. There was distinct loss of sensation. Testing the farado-contractility, it was found that in the right leg the flexors only responded to the slowly-interrupted current, while in the left both flexors and extensors responded to the interrupted current. In both limbs with the galvanic current the flexors responded to twenty cells, while the extensors responded to fifty cells. She gradually improved, and was able to leave after having been in the hospital three months.

The diagnosis of subacute myelitis of the anterior horns from hysterical paraplegia is often of vital importance. “A young woman,” says Bennett,¹⁰⁷ “suddenly or gradually becomes paralyzed in the lower extremities. This may in a few days, weeks, or months become complete or may remain partial. There is no loss of sensation, no muscular rigidity, no cerebral disturbances, nor any general affection of the bladder or rectum. The patient's general health may be robust or it may be delicate. She may be of emotional and hysterical temperament, or, on the contrary, of a calm and well-balanced disposition. At first there is no muscular wasting, but as the disease becomes chronic the limbs may or may not diminish in size. The entire extremity may be affected or only certain groups of muscles. Finally, the disease may partially or entirely recover, or remain almost unchanged for years.” This is a fair general picture of either disease.

¹⁰⁷ Lancet, vol. ii. p. 842, November, 1882.

Two facts are often overlooked in this connection: first, that poliomyelitis is just as liable to occur in the hysterical as in the other class; and, secondly, that the symptoms of hysterical paraplegia and poliomyelitis may go hand in hand.

The history is different in the two affections. Frequent attacks of paralysis in connection with hysterical symptoms are very suggestive, although not always positive. In poliomyelitis the disease may come on with diarrhœa and fever; often it comes on with vomiting and pain. The patellar reflex is retained, often exaggerated, and rarely lost, in hysteria, while it is usually lost in poliomyelitis. Electro-muscular contractility is often normal in hysterical paralysis, although it is sometimes slightly diminished quantitatively to both faradism and galvanism: the various muscles of one limb respond about equally to electricity: there are no reactions of degeneration in hysterical paralysis as in poliomyelitis. In poliomyelitis reactions of degeneration are one of the most striking features. The cutaneous plantar reflex is impaired in hysterical paraplegia; bed-sores are usually absent, as are also acute trophic eschars and the nail-markings present both in generalized subacute myelitis and diffused myelitis. True muscular atrophy is also wanting in hysterical paraplegia, although the limbs may be lean and wasted from the original thinness of the patient or from disuse. The temperature of the limbs is usually good. There is no blueness nor redness of the limbs, nor are the bowels or bladder uncomfortably affected.

Buzzard¹⁰⁸ gives two diagrams (Figs. 16 and 17), which I have reproduced. They are drawn from photographs. They show two pairs of feet, which have a certain superficial resemblance. In each the inner border is drawn up into the position of a not severe varus. They are the feet of two young women who were in the hospital at the same time. A (Fig. 16), really a case of acute myelitis, had been treated as a case of hysteria; and B (Fig. 17), really a case of hysteria, came in as a paralytic. In these cases the results of examination into the state of the electrical response and of the patellar-tendon reflex was sufficient to make a diagnosis clear. In the organic case the electrical reactions were abnormal and the patellar-tendon reflex was abolished. These conditions were not present in the hysterical case.

FIG. 16.

FIG. 17.

¹⁰⁸ Clin. Lectures on Diseases of the Nervous System, London, 1882.

The diagnosis of hysterical paraplegia from diffused myelitis is governed practically by the same rules which serve in subacute myelitis of the anterior horns, with some additional points. In diffused myelitis, in addition to the motor, trophic, vaso-motor, electrical, and reflex disorders of myelitis of the anterior horns, affections of sensibility from involvement of the sensory regions of the cord will also be present. Anæsthesia and paræsthesia will be present.

Acute ascending paralysis, the so-called Landry's paralysis, particularly when it runs a variable course, might be mistaken sometimes for hysterical paralysis. In one instance I saw a fatal case of Landry's paralysis which had been supposed to be hysterical until a few hours before death. In Landry's paralysis, however, the swiftly ascending character of the disorder is usually so well marked as to lead easily to the diagnosis. In Landry's paralysis the loss of power begins first in the legs, but soon becomes more pronounced, and passes to the arms, and in the worst cases swallowing and respiration become affected.

Spinal hemorrhage and spinal tumors, giving rise to paralysis, may be mistaken for hysterical paralysis, partly because of the contractures. Reactions of degenerations are usually features of this form of organic paralysis. The contractures of hysterical paralysis can be promptly relieved by deep, strong pressure along supplying nerve-trunks; this cannot be accomplished in the organic cases. Severe localized pains in the limbs, sometimes radiating from the spinal column, are present in the organic cases. Pain may be complained of by the hysterical patient, but close examination will show that it is not of the same character, either as regards severity or duration.

Hysterical locomotor ataxy is usually readily distinguished from posterior spinal sclerosis, although the phenomena are apparently more marked and more peculiar than those exhibited as the result of organic changes. Hysterical ataxic patients often show an extraordinary inability to balance their movements, this want of co-ordinating power being observed even in the neck and trunk, as well as the limbs. In hysterical cases a certain amount of palsy, often of an irregular type, is more likely to be associated with the ataxia than in the structural cases. The knee-jerk, so commonly absent in true posterior spinal sclerosis that its absence has come to be regarded as almost a pathognomonic symptom of this affection, in hysterical motor ataxy is present and exaggerated. In hysterical locomotor ataxy other well-marked symptoms of general hysteria, such as hysterical convulsions, aphonia, etc., are present.

In the diagnosis of spastic spinal paralysis from hysterical paraplegia great difficulties will sometimes arise. A complete history of the case is of the utmost importance in coming to a conclusion. If the case be hysterical, usually some account of decided hysterical manifestation, such as aphonia, sudden loss and return of sight, hysterical seizures, etc., can be had. Althaus holds that a dynamometer which he has had constructed for measuring the force of the lower extremities will, at least in a certain number of cases, enable us to distinguish between the functional and spinal form of spastic paralysis. In the former, although the patient may be unable to walk, the dynamometer often exhibits a considerable degree of muscular power; while in the latter, more especially where the disease is somewhat advanced, the index of the instrument will only indicate 20° or 30° in place of 140° or 160°, and occasionally will make no excursion at all.

The diagnosis of multiple cerebro-spinal sclerosis from hysteria occasionally offers some difficulties. Jolly goes so far as to say that it can only with certainty be diagnosticated in some cases in its later stages and by the final issue—cases in which the paralytic phenomena frequently alter their position, in which paroxysmal exacerbations and as sudden ameliorations take place, and convulsive attacks and disturbances of consciousness of a like complicated nature as in hysteria are met with. Disorders of deglutition and articulation, also characteristic of multiple cerebro-spinal sclerosis, are now and again observed in the hysterical. Recently, through the kindness of J. Solis Cohen, I saw at the German Hospital in Philadelphia a patient about whom there was for a time some doubt as to whether the peculiar tremor from which he suffered was hysterical or sclerotic. At rest and unobserved, he was usually quiet, but as soon as attention was directed to him the tremor would begin, at first in the limbs, but soon also in the head and trunk. If while under observation he attempted any movement with his hands or feet, the tremor would become violent, and if the effort was persisted in it would become convulsive in character. The effort to take a glass of water threw him into such violent spasms as to cause the water to be splashed in all directions. The fact that this patient was a quiet, phlegmatic man of middle age, that his troubles had come on slowly and had progressively increased, that tremor of the head and trunk was present, that cramps or tonic spasms of the limbs came and went, indicated the existence of disseminated sclerosis. The knee-jerk was much exaggerated, taps upon the patellar tendon causing decided movement; when continued, the leg would be thrown into violent spasm.

Spondylitis, or caries of the vertebræ, is sometimes difficult to distinguish from hysterical paraplegia or hysterical paraplegia from it, or both may be present in the same case. Likewise, painful paraplegia from cancer or sarcoma of the vertebræ may offer some difficulties. A woman aged forty-four when two years old had a fall, which was followed by disease of the spine, and has resulted in the characteristic deformity of Pott's disease. She was apparently well, able to do ordinary work, until about five years before she came under observation, when her legs began to feel heavy and numb, and with this were some pain and slight loss of power. These symptoms increased, and in three months were followed by a total loss of power in the lower extremity. She was admitted to the hospital, and for about three years was unable to move the legs. She went round the wards in a wheeled chair. The diagnosis was made of spondylitis, curvature, and paralysis and sensory disorders depending on compression myelitis, and it was supposed she was beyond the reach of remedies. One day one of the resident physicians gave her a simple digestant or carminative, soon after which she got up and walked, and has been walking ever since. She attributes her cure entirely to this medicine.

What is the lesson to be learned from this case? It is, in the first place, not to consider a patient doomed until you have made a careful examination. There can be much incurvation of the spine without sufficient compression to cause complete paralysis. In this patient organic disease was associated with an hysterical or neuromimetic condition. This woman had disease of the vertebræ, the active symptoms of which had subsided. The vertebral column had assumed a certain shape, and the cord had adjusted itself to this new position, yet for a long time she was considered incurable from the fact that the conjunction of a real and a mimetic disorder was overlooked.

Another patient aged twenty-seven had whooping cough, which lasted six weeks, and was followed by severe pain in the back. For this she consulted various physicians, being treated for Pott's disease and spinal irritation. She, however, continued to grow worse, and every jar and twist gave severe pain. At this time she had lost much flesh, had pain in her back and elsewhere, and was subject to numerous and violent spasms. When first seen by the physician who consulted me she was complaining of pains in her legs, hips, and left shoulder, which she considered rheumatic, and with pain in the abdomen. Examination of the back with the patient on her side showed a slight prominence over the position of the first or second lumbar vertebra. The spot was painful on pressure, and had been so ever since the attack of whooping cough three years before. A tap on the sole of either foot made her complain of severe pain in the back. The same result followed pressure on the head. The patient was unable to stand or walk, but occasionally sat up for a short time, although suffering all the time. There was no muscular rigidity. The limbs and body were quite thin, but, so far as could be detected, she had no loss of motor or sensory power. At times, when the pains were worse, the arms would be flexed involuntarily, and she stated that once the spine was drawn back and a little sideways. The pain in the hips was augmented by pressure. During the application of a plaster bandage she had a sort of fit and fainted, and the application was suspended. She soon recovered consciousness, but refused to allow the completion of the dressing. I diagnosticated the affection as largely hysterical, and a few months later received word that the patient was on her feet and well.

Kemper¹⁰⁹ relates the case of a lady who eventually died of sarcoma of the vertebræ, the specimens having been examined by J. H. C. Simes of Philadelphia and myself. She was supposed at first and for some time to be a case of hysteria with spinal irritation. In the case of a distinguished naval officer, who died of malignant vertebral disease after great suffering a short time since, this same mistake was made during the early stages of the disease: his case was pronounced to be one of neurasthenia, hysteria, etc. before its true nature was finally discovered. The absence of muscular rigidity in the back and extremities is the strongest point against vertebral disease in these cases.

¹⁰⁹ Journal of Nervous and Mental Diseases, vol. xii., No. 1, January, 1885.

In hysterical hemianæsthesia, ovarian hyperæsthesia, hystero-epileptic seizures, ischuria, and other well-known hysterical symptoms have usually been observed. The anæsthesia in hysterical cases is most commonly on the left side of the body, but it may happen to be so located in an organic case, so that this point is only one of slight value.

Some older observers, as Briquet, who is quoted and criticised by Charcot, believed that hemianæsthesia from encephalic lesions differed from hysterical hemianæsthesia by the fact that in the former case the skin of the face did not participate in the insensibility, or that when it existed it never occupied the same side as the insensibility of the limbs. Recently-reported cases have disproved the accuracy of this supposed diagnostic mark. In his lectures, delivered ten years ago, Charcot observed that up to that period anæsthesia of general sensibility alone appeared to have been observed as a consecutive on an alteration of the cerebral hemispheres, so that obtunding of the special senses would remain as a distinctive characteristic of hysterical hemianæsthesia. He, however, expected that cases of cerebral organic origin would be reported of complete hemianæsthesia, with derangements of the special senses, such as is presented in hysteria. His anticipations have been fulfilled. In the nervous wards of the Philadelphia Hospital is now a typical case of organic hemianæsthesia in which the special senses are partially involved.

Paralysis and contractures, if present, are apt to be accompanied in cases of organic hemianæsthesia, after time has elapsed, by marked nutritive changes, by wasting of muscle, and even of skin and bone. This is not the case in hysteria.

The subsequent history of these two conditions is different. The hysterical patient will often recover and relapse, or under proper treatment may entirely recover; while all the treatment that can be given in a case of organic hemianæsthesia will produce no decided improvement, for there is a lesion in the brain which will remain for ever. Hemianopsia, so far as I know, has not been observed in hysterical hemianæsthesia.

In the monograph of Shaffer, with reference to both true and false knee-joint affections certain conclusions are drawn which I will give somewhat condensed:

Chronic synovitis produces very few if any subjective symptoms; hysterical imitation presents a long train of both subjective and objective symptoms and signs, the former in excess. Chronic ostitis may be diagnosticated if muscular spasm cannot be overcome by persistent effort; when the spasm does not vary night nor day; when it is not affected by the ordinary doses of opium or chloral; when reaction of the muscles to the faradic current is much reduced; when a local and uniform rise of temperature over the affected articulation is present; when purely involuntary neural symptoms, such as muscular spasm, pain, and a cry of distress, are present. Hysterical knee-joint is present, according to this author, when the muscular rigidity or contracture is variable, and can be overcome by mildly persistent efforts while the patient's mind is diverted, or which yields to natural sleep, or which wholly disappears under the usual doses of opium or chloral; when the faradic response is normal; when rise of temperature is absent or a reduced temperature is present over the joint; when variable and inconstant, emotional, and semi-voluntary manifestations are present.

To recognize the neuromimesis of hip disease Shaffer gives the following points: The limp is variable and suggests fatigue; it is much better after rest; it almost invariably follows the pain. Pain of a hyperæsthetic character is usually the first symptom, and it is found most generally in the immediate region of the joint. “In place of an apprehensive state in response to the tests applied will be found a series of symptoms which are erratic and inconstant. A condition of muscular rigidity often exists, but, unlike a true muscular spasm, it can in most cases be overcome in the manner before stated. A very perceptible degree of atrophy may exist—such, however, as would arise from inertia only. A normal electrical contractility exists in all the muscles of the thigh.”

In the neuromimesis of chronic spondylitis or hysterical spine the pain is generally superficial, and is almost always located over or near the spinous processes; it is sometimes transient, and frequently changes its location from time to time; a normal degree of mobility of the spinal column under properly directed manipulation is preserved; the nocturnal cry and apprehensive expression of Pott's disease are wanting.

With reference to the hysterical lateral curvature, Shaffer, quoting Paget, says “ether or chloroform will help. You can straighten the mimic contracture when the muscles cannot act; you cannot so straighten a real curvature.”

In the diagnosis of local hysterical affections one point emphasized by Skey is well worthy of consideration; and that is that local forms of hysteria are often not seen because they are not looked for. “If,” says he, “you will so focus your mental vision and endeavor to distinguish the minute texture of your cases, and look into and not at them, you will acknowledge the truth of the description, and you will adopt a sound principle of treatment that meets disease face to face with a direct instead of an oblique force.” According to Paget, the means for diagnosis in these cases to be sought—(1) in what may be regarded as the predisposition, the general condition of the nervous system, on which, as in a predisposing constitution, the nervous mimicry of disease is founded; (2) in the events by which, as by exciting causes, the mimicry may be evoked and localized; (3) in the local symptoms in each case.

Local symptoms as a means of diagnosis can sometimes be made use of in general hysteria. A case may present symptoms of either the gravest form of organic nervous disease or the gravest form of hysteria, and be for a time in doubt, when suddenly some special local manifestation appears which cannot be other than hysterical, and which clinches the diagnosis. In a case with profound anæsthesia, with paraplegia and marked contractures, with recurring spasms of frightful character, the sudden appearance of aphonia and apsithyria at once cleared all remaining doubt. Herbert Page mentions the case of a man who suffered from marked paraplegia and extreme emotional disturbance after a railway collision, who, nine months after the accident, had an attack of aphonia brought on suddenly by hearing of the death of a friend. He eventually recovered.

To detect hysterical or simulated blindness the methods described by Harlan are those adopted in my own practice. When the blindness is in both eyes, optical tests cannot be applied. Harlan suggests etherization.¹¹⁰ In a case of deception, conscious or unconscious, he says, “as the effect of the anæsthetic passed off the patient would probably recover the power of vision before his consciousness was sufficiently restored to enable him to resume the deception.” Hutchinson cured a case of deaf-dumbness by means of etherization. For simulated monocular blindness Graefe's prism-test may be used: “If a prism held before the eye in which sight is admitted causes double vision, or when its axis is held horizontally a corrective squint, vision with both eyes is rendered certain.” It should be borne in mind that the failure to produce double images is not positive proof of monocular blindness, for it is possible that the person may see with either eye separately, but not enjoy binocular vision, as in a case of squint, however slight. Instead of using a prism while the patient is reading with both eyes at an ordinary distance, say of fourteen or sixteen inches, on some pretext slip a glass of high focus in front of the eye said to be sound. If the reading is continued without change, of course the amaurosis is not real. Other tests have been recommended, but these can usually be made available.

¹¹⁰ Loc. cit.

The diagnosis of hysterical, simulated, or mimetic deafness is more difficult than that of blindness. When the deafness is bilateral, the difficulty is greater than when unilateral. The method by etherization just referred to might be tried. Politzer in his work on diseases of the ear¹¹¹ makes the following suggestions: Whether the patient can be wakened out of sleep by a moderately loud call seems to be the surest experiment. But, as in total deafness motor reflexes may be elicited by the concussion of loud sounds, care must be taken not to go too near the person concerned and not to call too loudly. The practical objection to this procedure in civil practice would seem to be that we are not often about when our patients are asleep. In unilateral deafness L. Müller's method is to use two tubes, through which words are spoken in both ears at the same time. When unilateral deafness is really present the patient will only repeat what has been spoken in the healthy ear, while when there is simulation he becomes confused, and will repeat the words spoken into the seemingly deaf ear also. To avoid mistakes in using this method, a low voice must be employed.

¹¹¹ A Textbook of the Diseases of the Ear and Adjacent Organs, by Adam Politzer, translated and edited by James Patterson Cassells, M.D., M. R. C. S. Eng., Philada., 1883.

Mistakes in diagnosis where hysteria is in question are frequently due to that association with it of serious organic disease of the nervous system of which I have already spoken at length under Complications. This is a fact which has not been overlooked by authors and teachers, but one on which sufficient stress has not yet been laid, and one which is not always kept in mind by the practitioner. Bramwell says: “Cases are every now and again met with in which serious organic disease (myelitis and poliomyelitis, anterior, acute, for example) is said to be hysterical. Mistakes of this description are often due to the fact that serious organic disease is frequently associated with the general symptoms and signs of hysteria; it is, in fact, essential to remember that all cases of paraplegia occurring in hysterical patients are not necessarily functional—i.e. hysterical; the presence of hysteria or a history of hysterical fits is only corroborative evidence, and the (positive) diagnosis of hysterical paraplegia should never be given unless the observer has, after the most careful examination, failed to detect the signs and symptoms of organic disease.”

PROGNOSIS.—Hysteria may terminate (1) in permanent recovery; (2) in temporary recovery, with a tendency to relapse or to the establishment of hysterical symptoms of a different character; (3) in some other affection, as insanity, phthisis, or possibly sclerosis; (4) in death, but the death in such cases is usually not the direct result of hysteria, but of some accident. Death from intercurrent disorders may take place in hysteria. It is altogether doubtful, however, whether the affection which has been described as acute fatal hysteria should be placed in the hysterical category. In the cases reported the symptom-picture would in almost every instance seem to indicate the probability of the hysteria having been simply a complication of other disorders, such as epilepsy, eclampsia, and acute mania.

As a rule, hysterical patients will not starve themselves. They may refuse to take food in the presence of others, or may say they will not eat at all; but they will in some cases at the same time get food on the sly or hire their nurses or attendants to procure it for them. In treating such cases a little watchfulness will soon enable the physician to determine what is best to be done. By discovering them in the act of taking food future deception can sometimes be prevented. Hysterical patients do sometimes, however, persistently refuse food. These cases may starve to death if let alone; and it is important that the physician should promptly resort to some form of forcible feeding before the nutrition of the patient has reached too low an ebb. I have seen at least two cases of hysteria or hysterical insanity in which patients were practically allowed to starve themselves to death, but an occurrence of this kind is very rare. Feeding by means of a stomach-tube, or, what is still better, by a nasal tube, as is now so frequently practised among the insane, should be employed. Nourishment should be administered systematically in any way possible until the patient is willing to take food in the ordinary way. In purposive cases some methods of forcible feeding may prove of decided advantage. Its unpleasantness will sometimes cause swallowing power to be regained.

Wunderlich¹¹² has recorded the case of a servant-girl, aged nineteen, who, after a succession of epileptiform fits, fell into a collapse and died in two days. Other cases have been recorded by Meyer. Fagge also speaks of the more chronic forms of hysteria proving fatal by marasmus. He refers to two cases reported by Wilks, both of which were diagnosticated as hysterical, and both of which died. Sir William Gull describes a complaint which he terms anorexia nervosa vel hysterica. It is attended with extreme wasting; pulse, respiration, and temperature are low. The patients were usually between the ages of sixteen and twenty-three: some died; others recovered under full feeding and great care. In many of the reported fatal cases careful inquiry must be made as to this question of hysteria being simply a complication.

¹¹² Quoted in The Principles and Practice of Medicine, by the late Charles Hilton Fagge, M.D., F. R. C. P., etc., vol. i. 1886, p. 736.

Are not hysterical attacks sometimes fatal? With reference to one of my cases this view was urged by the physician in attendance. Gowers¹¹³ on this point says: “As a rule to which exceptions are infinitely rare, hysterical attacks, however severe and alarming in aspect, are devoid of danger. The attacks of laryngeal spasm present the greatest apparent risk to life.” He refers to the paroxysms of dyspnœa presented by a hemiplegic girl as really alarming in appearance, even to those familiar with them. He refers also to a case of Raynaud's¹¹⁴ in which the laryngeal and pharyngeal spasm coexisted with trismus, and the patient died in a terrible paroxysm of dyspnœa. The patient presented various other hysterical manifestations, and a precisely similar attack had occurred previously and passed away, but she had in the interval become addicted to the hypodermic injection of morphia, and Raynaud suggested that it might have been the effect of this on the nerve-centres that caused the fatal termination. Such cases have been described in France as the hydrophobic form of hysteria.

¹¹³ Epilepsy and Other Chronic Convulsive Diseases, by W. R. Gowers, M.D., London. 1881.

¹¹⁴ L'Union médical, March 15, 1881.

Patients may die in hysterical as in epileptic attacks from causes not directly connected with the disease. One of these sources of danger mentioned by Gowers is the tendency to fall on the face sometimes met with in the post-epileptic state. He records an example of death from this cause. He also details a case of running hysteria or hystero-epilepsy, in which, after a series of fits lasting about four hours, the child died, possibly from some intercurrent accident.

TREATMENT.—Grasset,¹¹⁵ speaking of the treatment of hysteria, says that means of treating the paroxysm, of removing the anæsthesia, of combating single symptoms, are perhaps to be found in abundance, but the groundwork of the disease, the neurosis or morbid state, is not attacked. Here he indicates a new and fruitful path. In his own summing up, however, he can only say that the hysterical diathesis offers fundamental grounds for the exhibition of arsenic, silver, chloride of gold, and mineral waters!

¹¹⁵ Brain, January, 1884.

No doubt can exist that the prophylactic and hygienic treatment of hysteria is of paramount importance. To education—using the term education in a broad sense—before and above all, the most important place must be given. It is sometimes better to remove children from their home surroundings. Hysterical mothers develop hysterical children through association and imitation. I can scarcely, however, agree with Dujardin-Beaumetz that it is always a good plan to place a girl in a boarding-school far from the city. It depends on the school. A well-regulated institution may be a great blessing in this direction; one badly-managed may become a hotbed of hysteria.

Recently I made some investigations into the working of the public-school system of Philadelphia, particularly with reference to the question of overwork and sanitation.¹¹⁶ I had special opportunities during the investigations to study the influences of different methods of education, owing to the fact that the public-school system of Philadelphia is just now in a transition period. This system is in a state of hopeful confusion—hopeful, because I believe that out of its present condition will come eventually a great boon to Philadelphia. At one end of the system, in the primary and the secondary schools, a graded method of instruction has been introduced. The grammar and the high schools are working on an ungraded or differently graded method. I found still prevailing, particularly in certain of the grammar schools for girls, although not to the same extent as a few years since, methods of cramming and stuffing calculated above all to produce hysteria and allied disorders in those predisposed to them.

¹¹⁶ The results of these investigations were given in a lecture which was delivered in the Girls' Normal School of Philadelphia before the Teachers' Institute of Philadelphia, Dec. 11, 1885.

Education should be so arranged as to develop the brain by a natural process—not from within outward; not from the centre to the periphery; not from above downward; but as the nervous system itself develops in its evolution from a lower to a higher order of animals, from the simple to the more complex and more elaborate. Any system of education is wrong, and is calculated to weaken and worry an impressionable nervous system, which attempts to overturn or change this order of the progress of a true development of the brain. To develop the nervous system as it should be developed—slowly, naturally, and evenly—it must also be fed, rested, and properly exercised.

In those primary schools in which the graded method was best carried out this process of helping natural development was pursued, and the result was seen in contented faces, healthy bodies, and cheerful workers. In future the result will be found in less chorea, hysteria, and insanity.

To prevent the development of hysteria, parents and physicians should direct every effort. The family physician who discovers a child to be neurotic, and who from his knowledge of parents, ancestors, and collateral relatives knows that a predisposition to hysteria or some other neurosis is likely to be present, should exercise all the moral influence which he possesses to have a healthy, robust training provided. It is not within the scope of an article of this kind to describe in great detail in what such education should consist. Reynolds is correct when he says that “self-control should be developed, the bodily health should be most carefully regarded, and some motive or purpose should be supplied which may give force, persistence, unity, and success to the endeavors of the patient.” In children who have a tendency to the development of hysteria the inclinations should not always or altogether be regarded in choosing a method or pursuing a plan of education. It is not always to what such a child takes that its mind should be constantly directed; but, on the contrary, it is often well to educate it away from its inclination. “The worst thing that can be done is that which makes the patient know and feel that she is thought to be peculiar. Sometimes such treatment is gratifying to her, and she likes it—it is easy and it seems kind to give it—but it is radically wrong.”

In providing for the bodily health of hysterical children it should be seen that exercise should be taken regularly and in the open air, but over-fatigue should be avoided; that ample and pleasant recreation should be provided; that study should be systematic and disciplinary, but at the same time varied and interesting, and subservient to some useful purpose; that the various functions of secretion, excretion, menstruation should be regulated.

The importance of sufficient sleep to children who are predisposed to hysteria or any other form of nervous or mental disorder can scarcely be over-estimated. The following, according to J. Crichton Browne,¹¹⁷ is the average duration of sleep required at different ages: 4 years of age, 12 hours; 7 years of age, 11 hours; 9 years of age, 10½ hours; 14 years of age, 10 hours; 17 years of age, 9½ hours; 21 years of age, 9 hours; 28 years of age, 8 hours. To carefully provide that children shall obtain this amount of sleep will do much to strengthen the nervous system and subdue or eradicate hysterical tendencies. Gymnastics, horseback riding, walking, swimming, and similar exercises all have their advantages in preventing hysterical tendencies.

¹¹⁷ Education and the Nervous System, reprinted from The Book of Health by permission of Messrs. Cassell & Co., Limited.

Herz¹¹⁸ has some instructive and useful recommendations with reference to the treatment of hysteria in children. It is first and most important to rehabilitate the weakened organism, and especially the central nervous system, by various dietetic, hygienic, and medicinal measures. It is important next to tranquillize physical and mental excitement. This can sometimes be done by disregard of the affection, by neglect, or by removal or threatened removal of the child from its surroundings. Such treatment should of course be employed with great discretion. Anæmia and chlorosis, often present in the youthful victims of hysteria, should be thoroughly treated. Care should be taken to learn whether children of either sex practise masturbation, which, Jacobi and others insist, frequently plays an important part in the production of hysteria. Proper measures should be taken to prevent this practice. The genital organs should receive examination and treatment if this is deemed at all necessary. On the other hand, care should be taken not to direct the attention of children unnecessarily to those organs when they are entirely innocent of such habits. Painting the vagina twice daily with a 10 per cent. solution of hydrochlorate cocaine has been found useful in subduing the hyper-irritation of the sexual organs in girls accustomed to practise masturbation. Herz, with Henoch, prefers the hydrate of chloral to all other medicines, although he regards morphine as almost equally valuable, in the treatment of hysteria in children. Personally, I prefer the bromides to either morphia or chloral. Small doses of iron and arsenic continued systematically for a long period will be found useful. Politzer of Vienna regards the hydrobromate and bihydrobromate of iron as two valuable preparations in the hysteria of children, and exhibits them in doses of four to seven grains three to four times daily.

¹¹⁸ Wien. Med. Wochen., No. 46, Nov. 14, 1885.

Hysteria once developed, it is the moral treatment which often really cures. The basis of this method of cure is to rouse the will. It is essential to establish faith in the mind of the patient. She must be made to feel not only that she can be helped, but that she will be. Every legitimate means also should be taken to impress the patient with the idea that her case is fully understood. If malingering or partial malingering enters into the problem, the patient will then feel that she has been detected, and will conclude that she had better get out of her dilemma as gracefully as possible. Where simulation does not enter faith is an important nerve-stimulant and tonic; it unchains the will.

Many physicians have extraordinary ideas about hysteria, and because of these adopt remarkable and sometimes outrageous methods of treatment. They find a woman with hysterical symptoms, and forthwith conclude she is nothing but a fraud. They are much inclined to assert their opinions, not infrequently to the patient herself, and, if not directly to her, in her hearing to other patients or to friends, relatives, nurses, or physicians. They threaten, denounce, and punish—the latter especially in hospitals. In general practice their course is modified usually by the wholesome restraint which the financial and other extra-hospital relations of patient and physician enforce.

Although hysterical patients often do simulate and are guilty of fraud, it should never be forgotten that some hysterical manifestations may be for the time being beyond the control of patients. Even for some of the frauds which are practised the individuals are scarcely responsible, because of the weakness of their moral nature and their lack of will-power. Moral treatment in the form of reckless harshness becomes immoral treatment. The liability to mistake in diagnosis, and the frequent association of organic disease with hysterical symptoms, should make the physician careful and conservative. It is also of the highest importance often that the doctor should not show his hand. The fact that an occasional cure, which is usually temporary, is effected by denunciation, and even cruelty, is not a good argument against the stand taken here.

Harsh measures should only be adopted after due consideration and by a well-digested method. A good plan sometimes is, after carefully examining the patient, to place her on some simple, medicinal, and perhaps electrical treatment, taking care quietly to prophesy a speedy cure. If this does not work, in a few days other severe or more positive measures may be used, perhaps blistering or strong electrical currents. Later, but in rare cases only, after giving the patient a chance to arouse herself by letting her know what she may expect, painful electrical currents, the hot iron, the cold bath, or similar measures may be used. Such treatment, however, should never be used as a punishment.

The method of cure by neglect can sometimes be resorted to with advantage. The ever-practical Wilks mentions the case of a school-teacher with hemianalgesia, hemianæsthesia, and an array of other hysterical symptoms who had gone through all manner of treatment, and at the end of seven months was no better. The doctor simply left her alone. He ordered her no drugs, and regularly passed by her bed. In three weeks he found her sitting up. She talked a little and had some feeling in her right side. She was now encouraged, and made rapid progress to recovery. Neglect had aroused her dormant powers. It must be said that a treatment of this kind can be carried out with far more prospects of success in a general hospital than in a private institution or at the home of a patient. It is a method of treatment which may fail or succeed according to the tact and intelligence of the physician.

I cannot overlook here the consideration of the subject of the so-called faith cure and mind cure. One difference between the faith cure as claimed and practised by its advocates, and by those who uphold it from a scientific standpoint, is simply that the latter do not refer the results obtained to any supernatural or spiritual agency. I would not advise the establishment of prayer-meetings for the relief of hysteria, but would suggest that the power of faith be exercised to its fullest extent in a legitimate way.

A young lady is sick, and for two years is seen by all the leading doctors in London; a clergyman is asked in and prays over her, and she gets up and walks. The doctors all join in and say the case was one of hysteria—that there was nothing the matter with her. Then, says Wilks, “Why was the girl subjected to local treatment and doses of physic for years? Why did not the doctors do what the parson did?”

Tuke¹¹⁹ devotes a chapter to psychotherapeutics, which every physician who is called upon to treat hysteria should read. He attempts to reduce the therapeutic use of mental influence to a practical, working basis. I will formulate from Tuke and my own experience certain propositions as to the employment of psychological measures: (1) It is often important and always justifiable to inspire confidence and hope in hysterical patients by promising cures when it is possible to achieve cures. (2) A physician may sometimes properly avail himself of his influence over the emotions of the patient in the treatment of hysterical patients, but always with great caution and discretion. (3) Every effort should be made to excite hysterical patients to exert the will. (4) In some hysterical cases it is advisable to systematically direct the attention to a particular region of the body, arousing at the same time the expectation of a certain result. (5) Combined mental and physical procedures may sometimes be employed. (6) Hypnotism may be used in a very few cases.

¹¹⁹ Influence of the Mind upon the Body.

The importance of employing mental impression is thoroughly exemplified, if nothing else is accomplished, by a study of such a craze as the so-called mind cure. Not a few people of supposed sense and cultivation have pinned their faith to this latest Boston hobby. A glance at the published writings of the apostles of the mind cure will show at once to the critical mind that all in it of value is dependent upon the effects of mental impression upon certain peculiar natures, some of them being of a kind which afford us not a few of our cases of hysteria. W. F. Evans has published several works upon the subject. From one of these¹²⁰ I have sought, but not altogether successfully, to obtain some ideas as to the basis of the mind-cure treatment. It is claimed that the object is to construct a theoretical and practical system of phrenopathy, or mental cure, on the basis of the idealistic philosophy of Berkeley, Fichte, Schelling, and Hegel. The fundamental doctrine of those who believe in the mental cure is, that to think and to exist are one and the same, and that every disease is a translation into a bodily expression of a fixed idea of mind. If by any therapeutic device the morbid idea can be removed, the cure of the malady is assured. When the patient is passive, and consequently impressible, he is made to fix his thoughts with expectant attention upon the effect to be produced. The physician thinks to the same effect, wills it, and believes and imagines that it is being done; the mental action to the patient, sympathizing with that of the physician, is precipitated upon the body, and becomes a silent, transforming, sanitive energy. It must be, says Evans, “a malady more than ordinarily obstinate that is neither relieved nor cured by it.”

¹²⁰ The Divine Law of Cure.

Hysteria cannot be cured by drugs alone, and yet a practitioner of medicine would find it extremely difficult to manage some cases without using drugs. Drugs themselves, used properly, may have a moral or mental as well as a physical influence. Among those which have been most used from before the days of Sydenham to the present time, chiefly for their supposed or real antispasmodic virtues, are galbanum, asafœtida, valerian, castor and musk, opium, and hyoscyamus. The value of asafœtida, valerian, castor, and musk is chiefly of a temporary character. If these drugs are used at all, they should be used in full doses frequently repeated. Sumbul, a drug of the same class comparatively little used, is with me a favorite. It can be used in the form of tincture or fluid extract, from twenty minims to half a drachm of the latter or one to two drachms of the former. It certainly has in many cases a remarkably calmative effect.

Opium and its preparations, so strongly recommended by some, and especially the Germans, should not be used except in rare cases. Occasionally in a case with sleeplessness or great excitement it may be absolutely indispensable to resort to it in combination with some other hypnotic or sedative. The danger, however, in other cases of forming the opium habit should not be overlooked. According to Dujardin-Beaumetz, it is mainly useful in the asthenic forms of hysteria.

Of all drugs, the metallic tonics are to be preferred in the continuous treatment of hysteria. Iron, although not called for in a large percentage of cases, will sometimes prove of great service in the weak and anæmic hysterics. Chalybeates are first among the drugs mentioned by Sydenham. Steel was his favorite. The subcarbonate or reduced iron, or the tincture of the chloride, is to be preferred to the more fanciful and elegant preparations with which the drug-market is now flooded. Dialyzed iron and the mallate of iron, however, are known to be reliable preparations, and can be resorted to with advantage. They should be given in large doses. Zinc salts, particularly the oxide, phosphide, and valerianate; the nitrate or oxide of silver, the ammonio-sulphate of copper, ferri-ferrocyanide or Prussian blue,—all have a certain amount of real value in giving tone to the nervous system in hysterical cases.

To Niemeyer we owe the use of chloride of sodium and gold in the treatment of hysteria. He refers to the fact that Martini of Biberach regarded this article as an efficient remedy against the various diseases of the womb and ovaries. He believed that the improvement effected upon Martini's patient was probably due to the fact that this, like other metallic remedies, was an active nervine. He prescribed the chloride of gold and sodium in the form of a pill in the dose of one-eighth of a grain. Of these pills he at first ordered one to be taken an hour after dinner, and another an hour after supper. Later, he ordered two to be taken at these hours, and gradually the dose was increased up to eight pills daily. I frequently use this salt after the method of Niemeyer.

The treatment of hysteria which Mitchell has done so much to make popular, that by seclusion, rest, massage, and electricity, is of value in a large number of cases of grave hysteria; but the proper selection of cases for this treatment is all important. Playfair¹²¹ says correctly that if this method of treatment is indiscriminately employed, failure and disappointment are certain to result. The most satisfactory results are to be had in the thoroughly broken-down and bed-ridden cases. “The worse the case is,” he says, “the more easy and certain is the cure; and the only disappointments I have had have been in dubious, half-and-half cases.”

¹²¹ The Systematic Treatment of Nerve-Prostration and Hysteria, by W. S. Playfair, M.D., F. R. C. P., 1883.

Mitchell¹²² gives a succinct, practical description of the process of massage: “An hour,” he says, “is chosen midway between two meals, and, the patient lying in bed, the manipulator starts at the feet, and gently but firmly pinches up the skin, rolling it lightly between his fingers, and going carefully over the whole foot; then the toes are bent and moved about in every direction; and next, with the thumbs and fingers, the little muscles of the foot are kneaded and pinched more largely, and the interosseous groups worked at with the finger-tips between the bones. At last the whole tissues of the foot are seized with both hands and somewhat firmly rolled about. Next, the ankles are dealt with in the same fashion, all the crevices between the articulating bones being sought out and kneaded, while the joint is put in every possible position. The leg is next treated—first by surface pinching and then by deeper grasping of the areolar tissue, and last by industrious and deeper pinching of the large muscular masses, which for this purpose are put in a position of the utmost relaxation. The grasp of the muscles is momentary, and for the large muscles of the calf and thigh both hands act, the one contracting as the other loosens its grip. In treating the firm muscles in front of the leg the fingers are made to roll the muscles under the cushions of the finger-tips. At brief intervals the manipulator seizes the limb in both hands and lightly runs the grasp upward, so as to favor the flow of venous blood-currents, and then returns to the kneading of the muscles. The same process is carried on in every part of the body, and especial care is given to the muscles of the loins and spine, while usually the face is not touched. The belly is first treated by pinching the skin, then by deeply grasping and rolling the muscular walls in the hands, and at last the whole belly is kneaded with the heel of the hand in a succession of rapid, deep movements, passing around in the direction of the colon.”

¹²² “Fat and Blood,” etc.

Massage should often be combined with the Swedish movement cure. In the movement cure one object is to call out the suppressed will of the patient. This is very applicable to cases of hysteria. The cure of cases of this kind is often delayed by using massage alone, which is absolutely passive. These movements are sometimes spoken of as active and passive, or as single and duplicated. Active movements are those more or less under the control of the individual making or taking part in them, and they are performed under the advice or direction, and sometimes with the assistance, of another. They proceed from within; they are willed. Passive movements come from without; they are performed on the patient and independently of her will. She is subjected to pushings and pullings, to flexions and extensions, to swingings and rotations, which she can neither help nor hinder. The same movement may be active or passive according to circumstances. A person's biceps may be exercised through the will, against the will, or with reference to the will.

A single movement is one in which only a single individual is engaged; speaking medically, single movements are those executed by the patient under the direction of the physician or attendant; they are, of course, active. Duplicated active movements require more than one for their performance. In these the element of resistance plays an important part. The operator with carefully-considered exertion performs a movement which the patient is enjoined to resist, or the latter undertakes a certain motion or series of motions which the former, with measured force, resists. Still, tact and experience are here of great value, in order that both direct effort and resistance should be carefully regulated and properly modified to suit all the requirements of the case. By changing the position of the patient or the manner of operating on her from time to time any muscles or groups of muscles may be brought into play. It is wonderful with what ease even some of the smallest muscles can be exercised by an expert manipulator.

The duplicated active movements are those which should be most frequently performed or attempted in connection with massage in hysterical patients. The very substance of this treatment is to call out that which is wanting in hysteria—will-power. It is a coaxing, insinuating treatment, and one which will enable the operator to gain control of the patient in spite of herself. As the patient exerts her power the operator should yield and allow the part to be moved.

Much of the value of massage and Swedish movements, in hysteria as in other disorders, is self-evident. Acceleration of circulation, increase of temperature, direct and reflex stimulation of nervous and muscular action, the promotion of absorption by pressure,—these and other results are readily understood. “The mode in which these gymnastic proceedings exert an influence,” says Erb,¹²³ “consists, no doubt, in occasioning frequently-repeated voluntary excitations of the nerves and muscles, so that the act of conduction to the muscles is gradually rendered more facile, and ultimately the nutrition of the nerves and muscles is augmented.”

¹²³ Ziemssen's Cyclopædia.

The objects to be attained by the use of electricity are nearly the same as from massage and duplicated active movements: in the first place, to improve the circulation and the condition of the muscles; and in the second place, to make the patient use the muscles. The faradic battery should be employed in these cases, and the patient should be in a relaxed condition, preferably in bed. A method of electrical treatment introduced some years ago by Beard and Rockwell is known as general faradization. This is sometimes used in the office of the physician. In this method the patient is placed in a chair with his feet on a large plate covered with chamois-skin; the operator then takes hold of the patient's hand and the other electrode is passed over the muscles of the neck, back, trunk, and extremities.

When the patient is in bed, as in the regular rest treatment, this method has to be modified, and then the best treatment is by direct muscular faradization. Two sponge electrodes are employed. The sponges are moistened, so that the current may pass through the skin and reach the muscles. Both electrodes are taken in one hand, the handle of one, pointing backward, being between the first and second fingers, while the handle of the other is between the third and fourth fingers. In this way the distance between the points of application can be readily altered. The current is then applied to the muscles everywhere, beginning with those of the feet. Muscles should be relaxed before passing the current through them. The whole body can be gone over in this way in the course of half an hour.

The hydropathic treatment of hysteria is one that has much in it to be commended. Jolly approves the systematic external application of cold water; Chambers advocates the daily morning use of shower-baths, holding that the bracing up of the mind to the shock of a cold shower-bath is a capital exercise for the weak will-power of the hysterical individual, and some admirable results have been reported by Charcot in inveterate neurasthenics and hysterics. Hydrotherapeutic treatment, continued perseveringly for a long time, says Rosenthal, “diminishes the extreme impressionability of hysterical patients, strengthens them, and increases their power of resistance to irritating influences, stimulates the organic functions, combats the anæmia, calms the abnormal irritability of the peripheral nervous system, and by diminishing the morbid increase of reflex power relieves the violence of the spasmodic symptoms. Even chronic forms which are combined with severe paroxysms of convulsions are susceptible of recovery under this plan of treatment.”

The hydrotherapeutic treatment may be contrasted with the treatment by seclusion, rest, massage, and electricity. Undoubtedly, one class of hysterical patients is greatly benefited by the latter method systematically carried out; these have already been described. In other cases, however, this method of treatment is useless; in some of them it has a tendency to prolong or aggravate the hysterical disorder, while in the same cases a well-managed hydrotherapeutic treatment will answer admirably. This is applicable in hysterical patients who eat and drink well, who, as a rule, preserve a good appearance, but whose mind and muscles are equally flabby and out of tone, and need to be stirred up both physically and mentally.

Dujardin-Beaumetz recommends prolonged warm baths of from one to two hours' duration, and believes that the therapeutic virtues of these baths are augmented by infusions of valerian.

In order to obtain satisfactory results from hydrotherapy, as well as from massage, electricity, etc., it is best to remove patients from their family surroundings. Good sanitariums near our large American cities where hydrotherapy and other special methods of treatment can be carried out are sadly needed. Hydrotherapeutic treatment is much more efficacious when conducted at a well-regulated institution, for several reasons. Measures troublesome in themselves are here carried out as a matter of daily routine. Numerous patients permit of the employment of competent attendants. The change is often of great benefit. The close personal supervision which hysterical patients are likely to have in a hydrotherapeutic establishment is also to be taken into consideration. Better modes of living, proper forms of exercise, regulated diet, etc. also enter; but still, a fair share of the good which results can be attributed to the water treatment.

While, however, it is better to remove hysterical patients, for hydrotherapeutic as well as for other treatment, from their family surroundings, and to place them in some well-regulated establishment, it is not by any means impossible to carry out such treatment in private practice, particularly in a house supplied with a bath-room. Many of our hydrotherapeutic institutions are in the hands of charlatans or of individuals who are not practically well fitted for their work. Not infrequently, however, good results are obtained even under these circumstances. Much more can be done in this direction with modest buildings and appliances than is generally supposed. It is not necessary to have numerous apartments: three or four rooms in a well-appointed house, if the arrangements for carrying out the hydrotherapeutic treatment are of a proper kind, will suffice for a large amount of good work. In almost any house provided with bath-rooms with hot and cold water some useful hydrotherapy may be attempted. The spinal douche or pour can be used by placing the patient in a sitz- or ordinary hip-bath and pouring the water from a spout or hose held at a certain height, the distance being regulated according to the patient's condition. Again, the patient sitting in a tub, water can be poured upon her, beginning at first with a high temperature and gradually lowering it. The shower-bath may also be used. An extemporaneous shower-bath can be provided by an ordinary watering-pot. Whole, three-quarters, or half baths at different temperatures can be given. One method of carrying out the wet pack is very simple. A comforter is spread upon the bed; next to this is placed a woollen blanket, and over the blanket a wet linen sheet, upon which the patient rests, with the head on a low pillow. The wet sheet, blanket, and comforter are then wrapped closely about the patient, bottles of hot water being placed at the feet. The cold drip-sheet method is another easily used. It consists in placing about the patient, while sitting up or standing, a sheet wet with cold water, and then vigorously rubbing her through the sheet.

Baths to the head may be used in some cases; cool head-baths are most frequently applied. One method of using these baths is to have the patient lie in such a position that the head projects a little beyond the edge of the bed and over a basin or receptacle of some kind. Water of a suitable temperature is then poured gently or squeezed out of a sponge over the head. For some forms of insomnia or some of the disorders of sleep in hysteria this treatment is a valuable auxiliary to other measures.

For the hysterical spine cold compresses may be used along the spine. On the other hand, hot fomentations may be found of benefit in some cases. Where hydrotherapeutic measures are employed attention should be paid to the condition of the circulation, particularly in the extremities. If the feet or hands are cold, hot applications or frictions should be used.

For certain of the vaso-motor disorders of hysteria, such as cold or hot feet, flushings, etc., local hydrotherapeusis will be of service. In hysterical contractures local stimulation by the douche method or by the steam bath may be tried. For the excitable rectum cold enemata in small quantities, so as not to be expelled, will be found to be very efficacious. For spasmodic attacks, whether purposive or involuntary, the use of the wet pack or the plunge-bath will sometimes be found of good service. In neuralgias and other painful local disorders of hysteria, frictions, fomentations, Turkish or Russian baths, and the wet pack are often very beneficial.

When hysteria is complicated, as it very often is, with disorders of the liver and stomach, hydrotherapeutic measures will be of added efficacy. When it is associated with genito-urinary disorders, even though the latter are not regarded as the cause of the former, special beneficial effects, both local and general, can be obtained from hydrotherapeutic measures. Locally, sitz-baths, hip-baths, douche-baths, hot and cold injections, and foot-baths may act as revulsives, astringents, or local tonics, while at the same time they are measures which tend to strengthen the system as a whole.

Sea-bathing is often of the greatest value, although it is sometimes difficult to induce hysterical patients, who are willing enough to go to the seashore, to resort to surf-bathing. Few measures are better calculated to bring up the tone of the nervous system of an hysterical or neurasthenic patient than well-directed sea-bathing. Where sea-bathing cannot be employed sea-water may be used indoors. Sea-water establishments, where baths at various temperatures may be had, are now to be found at all the best seaside resorts. In a few cases the internal use of large quantities of either hot or cold water, or of the ferruginous mineral waters, may be associated with the external treatment.

The climatic treatment of hysteria has received little or no attention; undoubtedly, much could be said in this connection. In a great country like ours a climate suited to the requirements of almost every form of disease can be had. The climate of those regions, either of the seaboard or inland, particularly well suited to cases of lung trouble, will often be useless, and sometimes harmful, to neurotic patients. For a certain class of hysterical patients a sojourn at the seashore, if not too protracted, will prove of great value. On the whole, for most hysterical patients of the neurasthenic type the best plan is to go first to the seashore for a few weeks, and then resort to an inland hilly or mountainous country, but not at too great an elevation. I have known the climate of some of the high altitudes of Colorado to be of positive injury by depressing the nervous system. Resorts like Capon Springs in West Virginia, out of the reach of steam and worry, with prevailing south-west winds, are desirable places.

The treatment of hysteria by the method of metallotherapy is worthy of some consideration. It is a method by no means new. It was known and practised by the ancients with rings and amulets. Popularized at the beginning of the present century by certain travelling charlatans, it was later, for a time, wholly ignored. In recent years it has been received with considerable attention. One Burq for many years practised metallotherapy in Paris disregarded or scouted by the profession, but claiming many remarkable cures. Finally, Charcot was induced to give him an opportunity of demonstrating the truth or falsity of his claims at Salpêtrière.¹²⁴ Cases of grave hysteria were submitted to the treatment, and in certain instances with striking results.

¹²⁴ Lancet, Jan. 19, 1878.

After having determined by a series of experiments the particular metal to which the patient is sensitive, bits of metal may be applied to the surface of the body in various places; this constitutes external metallotherapy. Or the metal, in the form of powder (as reduced iron) or an oxide or some other salt, may be administered; this is internal metallotherapy. That certain definite effects may be produced by the application of metals to the surface of the body is unquestionable. Some of the results which have followed their employment are the removal of anæsthesia and analgesia, relief of hysterical paralysis, improvement in the circulation, removal of achromatopsia, relief of contracture.

Many investigations in Germany, England, France, and this country have demonstrated that the same or similar effects can be produced by the application of other non-metallic substances, such as discs of wood, minerals, mustard plasters, etc. Hammond, among others, has shown this. How the results are obtained is still a matter of dispute. On the one hand, it is claimed, principally by the French observers, that the cures are due to the metals themselves, either by virtue of some intrinsic power or through some electrical currents generated by their application. On the other hand, it is asserted, particularly by the English observers, that the phenomena are best explained on the doctrine of the influence of the mind on the body; in other words, by the principle of expectant attention. Some at least of the effects are to be explained on the latter hypothesis, but it is likely that the monotonous impressions made upon the peripheral sense-organs by different substances applied locally may act reflexly on the brain.

Seguin¹²⁵ reports a case of convulsion and hemianæsthesia in an adult male cured by metallotherapy; the metal used was gold. Two ordinary twenty-dollar gold pieces were placed in the patient's hands, and afterward on his forearm, cheek, and tongue. Nothing else was suggested or done to him; sensibility returned, and the staggering and other symptoms disappeared. The patient left the hospital claiming to be perfectly well. The same author reports several other successful cases of metallotherapy, all of them reactions to gold. One was a girl sixteen years old with analgesia.

¹²⁵ Arch. of Medicine, New York, 1882.

Not a few cases are now on record of the cure of hysterical contracture and other forms of local hysterical disorders by the application of a magnet. Charcot and Vigouroux cured one case of hysterical contracture of the left arm by repeated applications of the magnet to the right or healthy arm. Debove by prolonged application of magnets relieved hemianæsthesia and hemiplegias—not only the hysterical varieties, but also, it is said, when dependent upon such conditions as alcoholism, plumbism, and even cerebral lesions. Maggiorani of Rome studied the physiological action of the magnet and laid down the first rules for its therapeutic use. In the case of powerful magnets we have more room for believing that an actual, tangible force is at work in producing the results than in the case of simple metals.

The question has been sometimes asked whether hypnotism can be used with success in the treatment of hysteria. Richer reports a few cures of hysteria through this agency. Braid has put on record between sixty and seventy cases which he claims to have cured by the same means. This list undoubtedly includes some hysterical cases—of paralysis, anæsthesia, aphonia, blindness and deafness, spinal irritation, etc. Both on theoretical grounds and from experience, however, I believe that the practice of hypnotization may be productive of harm in some cases of hysteria, and should be resorted to only in rare cases of mental or motor excitement.

By some, special measures during the hysterical fit are regarded as unnecessary. Jolly, for instance, says that we must merely take care that the patients do not sustain injury in consequence of their convulsive movements, and that respiration is not impeded by their clothing. Rothrock¹²⁶ reports several cases of hysterical paroxysms relieved by the application of either snow or ice to the neck. The applications were made by stroking up and down either side of the neck along the line of the sterno-cleido-mastoid muscles. He believed that the most probable explanation of the results obtained was the shock received from the cold substance, but that supplemental to this there may have been supplied through the pneumogastric nerve a besoin de respirer. This measure and the use of the cold spinal douche are both to be recommended.

¹²⁶ Philada. Med. Times, 1872-73, iii. 67.

Emetics are sometimes valuable. Miles¹²⁷ reports several cases of severe hysterical seizure in which tobacco was promptly efficient in controlling the affection. He used the vinum tabaci in doses of one drachm every half hour or hour until the system was relaxed and nausea induced, the effects usually being produced after taking three or four doses. Fifteen grains of sulphate of zinc may be used in adult cases. James Allen for a case of hysterical coma successfully used a hypodermic injection of one-tenth of a grain of apomorphia. Recently, at the Philadelphia Hospital this remedy has been successfully employed in two cases, one of hysterical coma and the other of hysterical mania. Inhalations of nitrite of amyl are often of surprising efficiency. This and other measures referred to under [HYSTERO-EPILEPSY] are also applicable in the treatment of any form of hysterical spasm.

¹²⁷ Clinical Med. Reporter, 1871, iv. 25-27.

For hysterical convulsions occurring during pregnancy an enema of asafœtida, camphor, the yolk of an egg, and water, such as has been recommended by Braun of Vienna, will often be found promptly efficacious.

Fagge¹²⁸ mentions a procedure which he had often seen adopted by Stocker—namely, pressure upon the arteries and other structures on each side of the neck.

¹²⁸ British Medical Journal, March 27, 1880.

For hysterical paralysis faradism and galvanism hold the chief place. Metallic-brush electricity should be used in the treatment of anæsthesia.

Whenever, in local hysteria, particularly of the paralytic, ataxic, or spasmodic form, it is possible to coax or compel an organ or part to perform its usual function long unperformed or improperly performed, treatment should be largely directed to this end. Thus, as Mitchell has shown, in some cases of aphonia, especially in those in which loss of voice is due to the disassociation of the various organs needed in phonation, by teaching the patient to speak with a very full chest an involuntary success in driving air through the larynx may sometimes be secured. Once compel a patient by firm but gentle means to swallow, and œsophageal paralysis begins to vanish.

Mitchell makes some interesting remarks upon the treatment of the peculiar disorders of sleep, which he describes and to which I have referred. When the symptoms are directly traceable to tobacco, he believes that strychnia and alcohol are the most available remedies, but gives a warning against the too liberal use of the latter. A treatment which was suggested to him by a clever woman who suffered from these peculiar attacks consists in keeping in mind the need of breaking the attack by motion and by an effort of the will. As soon as the attack threatens the patient should resolutely turn over, sit up, or jump out of bed, and move about, or in some such way overcome the impending disorder. Drugs are of little direct use. Small doses of chloral or morphia used until the habit is broken may answer, but general improvement in health, proper exercise, good food, and natural sleep are much more efficient.

Fagge says that he has seen more benefit in hysterical contracture from straightening the affected joints under chloroform, and placing the limb upon a splint, than from any other plan of treatment. Hammond¹²⁹ (at a meeting of the New York Neurological Society, Nov. 6, 1876) reports a case of supposed hysterical contracture in the form of wry neck, in which he divided one sterno-cleido-mastoid muscle; immediately the corresponding muscle of the other side became affected; he cut this; then contraction of other muscles took place, which he kept on cutting. The case was given up, and got well spontaneously about two years later. Huchard¹³⁰ entirely relieved an hysterical contracture of the forearm by the application of an elastic bandage.

¹²⁹ Philadelphia Medical Times, vol. vii., Nov. 25, 1876.

¹³⁰ Revue de Thérapeutique, quoted in Med. Times, vol. xiii., June 16, 1883.

A lady with violent hysterical cough was chloroformed by Risel of Messeberg¹³¹ for fourteen days at every access of the cough, and another for eight days. In both the symptoms were conquered. Nitrite of amyl is useful in similar cases.

¹³¹ Allg. Med. Centralzeitung, Oct. 9, 1878.

Graily Hewitt¹³² reports a case of hysterical vomiting of ten months' duration, caused by displacement of the uterus, and cured by reposition of that organ. The same authority, in a paper read to the London Congress, advanced the opinion that the exciting cause of attacks of hysteria and hystero-epilepsy was a distortion of the uterus produced by a flexion of the organ upon itself, either forward or backward. He believed the attacks were the result of reflex irritation. He recited eighteen cases, all of which were relieved. Flechsig¹³³ favors the gynæcological treatment of hysteria, including castration or oöphorectomy. He reports three cases with good results. His article favors the idea that any morbid condition of the genital organs present ought to be remedied before treating the hysterical symptoms. Zeuner,¹³⁴ on the other hand, refers to a number of cases in which gynæcological treatment gave either entirely negative results or was productive of positive injury to hysterical patients. He quotes Perreti,¹³⁵ physician to an asylum for the insane, who gives the details of a number of cases in which gynæcological examinations or treatment were directly productive of injury. He mentions a case of a female patient who had delusions and hallucinations of a sexual type in which the physician was the central figure. He reports cases in which proper constitutional treatment, without gynæcological interferences, led to a full recovery. Playfair, also quoted by Zeuner, states that he has often known the condition of hysterical patients to be aggravated by injudicious gynæcological interference. Oöphorectomy will be more fully discussed under HYSTERO-EPILEPSY.

¹³² Med. Press and Circ., June 2, 1880.

¹³³ Neurol., 7 Abt., 1885, Nos. 19, 20.

¹³⁴ Journ. American Med. Ass., Chicago, 1883, i. 523-525.

¹³⁵ Berliner klinische Wochenschrift, No. 10.