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]

[Footnote 6: _Traité clinique et thérapeutique de l'Hystérie_, par le
Dr. P. Briquet, 1859.]

Mitchell[7] 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.

[Footnote 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. Walton[12] on
_Hystero-epilepsy_. Spitzka, Mann, Hughes, and {208} Kiernan have made
important contributions to the psychical aspects of the subject in
various American medical journals.

[Footnote 8: _The Hysterical Element in Orthopædic Surgery_, by Newlin
M. Shaffer, M.D., New York, 1880.]

[Footnote 9: _Archives of Neurology and Electrology_, for May, 1875,
and _Opera Minora_, p. 180.]

[Footnote 10: _A Practical Treatise on Nervous Exhaustion
(Neurasthenia)_, by George M. Beard, A.M., M.D., New York, 1880.]

[Footnote 11: _A Treatise on Diseases of the Nervous System_, and _A
Treatise on Insanity in its Medical Relations_.]

[Footnote 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.

[Footnote 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. Wood[16] 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 {209} 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.

[Footnote 14: _Leçons sur les Maladies du Système nerveux_.]

[Footnote 15: _Philadelphia Medical Times_, 1878-79, ix. 224-227.]

[Footnote 16: _Ibid._, vol. xi. p. 321, Feb. 26, 1881.]

[Footnote 17: _Ibid._, vol. xii. p. 97, Nov. 19, 1881.]

Briquet[18] 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.

[Footnote 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 {210} 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.”

[Footnote 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.” Woodbury[20] 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.

[Footnote 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.

[Footnote 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.

Seguin[22] 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.”

[Footnote 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 Dupuy[23] to
frame a pathology of hysteria is worthy of attention. According to
him, every {211} 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.

[Footnote 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.

[Footnote 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 {212} 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.

[Footnote 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, Briquet[26] 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. Wilks[27]
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.

[Footnote 26: _Op. cit._]

[Footnote 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.

{213} Lloyd[28] 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.

[Footnote 28: _Op. cit._]

Dercum and Parker[29] 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.

[Footnote 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
{214} transmitted to vaso-motor conductors,[30] or, on the other hand,
psychical passivity or torpor permits the undue activity of the lower
nervous levels.

[Footnote 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.

Briquet[31] 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.

[Footnote 31: _Op. cit._]

[Footnote 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.

[Footnote 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 {215} 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.

Laycock[34] 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.

[Footnote 34: _A Treatise on the Nervous Diseases of Women_, by Thomas
Laycock, M.D., London, 1840.]

[Footnote 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. Ribot[36] 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.

[Footnote 36: _Diseases of the Will_.]

[Footnote 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 {216} great attention from the medical profession.
Charcot[38] 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.

[Footnote 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. Wilks[39] 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.

[Footnote 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     |
  25-30      40        3       ...      24     |  64       289

  30-35      38       ...      ...       9     |
  35-40      15       ...      ...       9     |  78       149

  40-45       7        1       ...       1     |
  45-50       8       ...       1        3     |  44        65

  50-55       4       ...      ...       3     |
  55-60       4       ...       1        2     |  11        25

  60-80       2       ...      ...      ...        3         5
            355       21       18      426       217      1037

{217} 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's[40] 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.

[Footnote 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
{218} 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
{219} 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.

Clarke[41] 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.

[Footnote 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.”

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

[Footnote 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, {220}
some of which were very amusing. In a paper on hysteria which received
the prize at the Physical Society of Guy's Hospital, P. Horrocks[44]
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.

[Footnote 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 student[45] 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.

[Footnote 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
{221} 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.

[Footnote 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.

[Footnote 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 Jones[48] 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.

[Footnote 48: _Op. cit._]

{222} 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.”

[Footnote 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.
Levick[50] of Philadelphia has furnished one of the most valuable
contributions to this subject.

[Footnote 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.

{223} 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
Madden[51] 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.

[Footnote 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.

{224} 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 {225} 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.

[Footnote 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. Yandell[53] 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 {226} 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.

[Footnote 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 {227} 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.

[Footnote 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 {228} 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.

[Footnote 55: _Journal of Nervous and Mental Diseases_, vol. vii.,
1880, p. 487.]

Hammond[56] 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.

[Footnote 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.

Paget[57] has ably discussed the subject of neuromimesis in general,
and Mitchell[58] 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 {229} 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.”

[Footnote 57: _Op. cit._]

[Footnote 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 {230} time. These minor evidences of the hysterical
constitution are sometimes the only phenomena ever presented.

Todd[59] 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.

[Footnote 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.”

[Footnote 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; {231} _d_.
moria-like conditions. Second, chronic forms: _a_.
hystero-melancholia; _b_. hystero-mania; _c_. degenerative states with
hysterical basis.

Spitzka[61] 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.

[Footnote 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.

{232} 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 {233} 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.

[Footnote 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. Charcot[63] 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.

[Footnote 63: _Op. cit._]

Hemorrhages from eyes, ears, nostrils, gums, stomach, bowels, etc.
{234} 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 Lopez[64] 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. Silvy[65] 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.

[Footnote 64: _American Journal of Medical Sciences_, Philadelphia,
1843, N. S., 74-81.]

[Footnote 65: _Mémoires de la Société médicale_, Anné 5, p. 181.]

Jolly[66] 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!

[Footnote 66: _Op. cit._]

Hardaway[67] 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. Niemeyer[68] mentions a woman at
Krutsenberg's clinic who irritated her arm in such a way that
amputation became {235} necessary, and after that she irritated the
stump until a second amputation had to be performed.

[Footnote 67: _St. Louis Courier of Medicine_, 1884, xi. 352.]

[Footnote 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.

[Footnote 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 {236}
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. Carter[70] 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. Lloyd[71] 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. Darwin[72] 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.”

[Footnote 70: _On the Pathology and Treatment of Hysteria_, London,
1853.]

[Footnote 71: _Op. cit._]

[Footnote 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, {237} 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 Reynolds[73] 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.

[Footnote 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, {238} 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 {239}
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 {240} 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.

Mitchell[74] 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.

[Footnote 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 {241} 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-epilepsy[75] 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.

[Footnote 75: _Journal of Nervous and Mental Disease_, vol. ix., No.
4, October, 1882.]

Mary Putnam Jacobi[76] 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.

[Footnote 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.

[Footnote 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 {242} 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 Wood[78]
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.

[Footnote 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 {243} 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]

[Footnote 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