Volume 5 — DISEASES OF THE NERVOUS SYSTEM. (continued 8)

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

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

⁶³ Op. cit.

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

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

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

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

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

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

⁶⁶ Op. cit.

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

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

⁶⁸ Textbook of Practical Medicine.

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

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

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

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

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

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

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

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

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

⁷¹ Op. cit.

⁷² Expression of Emotion, etc.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

⁷⁴ Op. cit.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

⁸⁰ L'Encéphale, June, 1882.

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

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

⁸¹ Diseases of Modern Life.

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

⁸² Op. cit.

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

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

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

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

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

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

⁸⁴ British Medical Journal, 1884, ii. 13.

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

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

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

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

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

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

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

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

⁸⁵ Op. cit.

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

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

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

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

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

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

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

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

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

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

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

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

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

⁸⁹ Brain, January, 1883.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

⁹⁵ Op. cit.

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

⁹⁶ Nice médicale.

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

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

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

⁹⁷ Lancet, 1859, ii. 619.

⁹⁸ Chicago Med. Journ. and Examiner, 1880.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

¹⁰¹ Brain, April, 1878.

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

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

¹⁰² Op. cit.

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

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

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

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

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

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

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

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

¹⁰⁴ Op. cit.

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

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

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

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

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