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LIBRARY OF CONGRESS. 
 
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 UNiTED STATES OF AMERICA. 
 
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HYSTERIA 
 
 AND ALLIED CONDITIONS 
 
 PRESTON 
 
HYSTERIA 
 
 CERTAIN ALLIED CONDITIONS 
 
 THEIR NATURE AND TREATMENT, WITH SPECIAL REF- 
 ERENCE TO THE APPLICATION OF THE REST CURE, 
 MASSAGE, ELECTROTHERAPY, HYPNOTISM, ETC. 
 
 GEORGE J. PRESTON, M.D. 
 
 PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM, COLLEGE OF PHYSICIANS AND SURGEONS, 
 
 BALTIMORE ; VISITING PHYSICIAN TO THE CITY HOSPITAL ; CONSULTING NEUROLOGIST 
 
 TO BAY VIEW ASYLUM, THE HEBREW HOSPITAL, THE CHURCH HOME AND 
 
 INFIRMARY, ETC.; MEMBER OF THE MEDICAL AND CHIRURGICAL FACULTY 
 
 OF MARYLAND, THE AMERICAN NEUROLOGICAL ASSOCIATION, ETC. 
 
 
 Ullustratefc 
 
 PHILADELPHIA 
 
 P. BLAKISTON, SON & CO. 
 
 IOI2 WALNUT STREET 
 1897 
 
 e^> 
 
Copyright, 1897, by P. Li.akiston, Son & Co. 
 
 Press of Wm. F. Fell & Co., 
 
 1220-24 Sansom St., 
 
 philadelphia. 
 
PREFACE. 
 
 At this day, when the fecundity of the medical 
 press is so great, it behooves an author to offer a 
 reason, an excuse, or an apology for bringing forth 
 a new book. In regard to this volume there are 
 two reasons that may, perhaps, be deemed suffi- 
 ciently weighty to warrant its appearance. The 
 first of these reasons is too obvious to require 
 elaboration ; namely, the importance of the subject. 
 Every day in his rounds the physician meets with 
 some phase of hysteria. Sometimes the diagnosis 
 can be made at the threshold of the door, but at 
 other times it is difficult in the extreme — a common 
 disease, often a puzzling disease, always difficult to 
 manage. 
 
 The second reason is that, while there exists an 
 immense amount of literature on hysteria, there is 
 no recent book in English on the subject. Of 
 course, it is treated of in works on general medicine, 
 but rarely with the minuteness that the importance 
 of the subject warrants. 
 
 The object of this little volume is to present the 
 symptomatology and differential diagnosis of hys- 
 teria in as concise a manner as possible, and to in- 
 dicate the various therapeutic measures that have 
 
iv PREFACE. 
 
 been found useful in the treatment of this disorder. 
 The general practitioner, for whom this book is 
 especially intended, not only wants to know to what 
 class of cases the rest cure, massage, electricity, 
 etc., are applicable, but also how these important 
 therapeutic measures are to be carried out. Hence 
 the sections on these and other modes of treatment 
 are prepared with some attention to detail. A few 
 conditions are discussed which, strictly speaking, do 
 not belong to hysteria, but are very closely allied to 
 this neurosis. 
 
 It was intended at first to illustrate certain phases 
 of hysteria by original photographs, but these were 
 found to be much inferior to, and far less typical 
 than, the beautiful drawings of Richer which have 
 been used. The diagrams have been taken some 
 from the works of Gilles de la Tourette, others from 
 Charcot. 
 
 A large amount of literature on the subject of 
 hysteria has been reviewed and references given to 
 the most important publications 
 
 The author will be more than satisfied if this little 
 volume will contribute its mite toward furthering 
 the work of that most important of all physicians, 
 the general practitioner. 
 
 8ig Charles Street, N. 
 
CONTENTS. 
 
 Chap. Page 
 
 I. Historical, 9 
 
 II. The Nature of Hysteria ; Etiology and Path- 
 ology, 29 
 
 III. Symptomatology, 56 
 
 IV. Disturbances of Motion: Tremor, Contracture, 
 
 Paralysis, 96 
 
 V. Convulsive Attacks : Major and Minor At- 
 tacks. — Hystero-Epilepsy, 122 
 
 VI. The Mental Condition in Hysteria, 141 
 
 VII. Visceral and Vasomotor Disturbances, 172 
 
 VIII. Differential Diagnosis, 204 
 
 IX. Treatment, 221 
 
 X. Electrotherapy. — Hydrotherapy. — Massage, . .245 
 
 XI. The Rest Cure. — Hypnotism. — Surgical Inter- 
 ference in the Treatment of Hysteria, . . . 264 
 
 INDEX, 295 
 
LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 i. Disseminated Anesthesia (anterior and posterior views), . 67 
 
 2. Glove and Stocking Form of Anesthesia (anterior and 
 
 posterior views). 68 
 
 3. Hemianesthesia, 69 
 
 4. Normal Visual Field, 80 
 
 5. Moderate Concentric Contraction of the Visual Field, 
 
 with Reversal of the Red and Blue Lines, 81 
 
 6. Hysterogenic Zones (anterior view), 92 
 
 7. Hysterogenic Zones (posterior view), , 93 
 
 8 "\ 
 
 ) Forms of Contracture of Hand and Wrist (after 
 
 9 " t Richer), . 103 
 
 11. Contracture of the Lower Extremity (after Richer), . ,105 
 
 12. Hysterical Contracture of the Foot : Equinovarus Type 
 
 (after Richer), 106 
 
 13. Contracture of Foot without Contracture of the Toes 
 
 (after Richer), 106 
 
 FULL PAGE PLATES. 
 
 THE CONVULSIVE ATTACK {after Richer). 
 
 Plate I. First or Epileptoid Period, 124 
 
 Tonic Spasm. 
 Plate II. Second Period or Period of Contortions, . . .132 
 
 Fig. 1. Movements of Wide Range. 
 
 Fig. 2. Hysterical Opisthotonos. 
 Plate III. Third Period or Period of Passionate Attitudes, 138 
 
 Fig. 1. The Phase of Sadness. 
 
 Fig. 2. The Phase of Toy or Exhilaration. 
 
HYSTERIA : 
 
 ITS NATURE AND TREATMENT. 
 
 CHAPTER I. 
 HISTORICAL. 
 
 The opinions and observations of men living at 
 different periods of the world's history concerning 
 some one subject form an interesting and often 
 useful part of the study of such subject. There is 
 much to be gained by thus following out the evo- 
 lution of some general principle. At first sight it 
 would seem a useless and empty labor to gather 
 up the historical fragments of some scientific truth, 
 since science has experienced such frequent and 
 violent cataclysms, shaking her very foundations 
 and changing completely the points of view. Yet 
 even in science this retrospection is not without its 
 uses. Our grasp of a subject is apt to be more 
 comprehensive and the expression of our opinion 
 less dogmatic if we have followed its history through 
 the various phases of its development. Of all the 
 branches of science, medicine has perhaps suffered 
 the most sudden arid startling changes. The dis- 
 covery of some new principle is revolutionary, and 
 many of the observations made under the influence 
 
 2 9 
 
io HYSTERIA: ITS NATURE AND TREATMENT. 
 
 of the old principles are rendered valueless. In 
 spite of this fact, however, the study of the history 
 of medicine is eminently suggestive, and conse- 
 quently of great value. 
 
 A goodly volume would be required to do any- 
 thing like justice to the history and literature of 
 hysteria, and the sketch here given embraces only 
 the barest outlines. If we consider the nature and 
 frequency of hysteria, and the varied and striking 
 phenomena which characterize it, we are not sur- 
 prised to find it mentioned in the earliest medical 
 writings. Hippocrates describes the affection in his 
 ' k De Yirmnibus," and makes allusions to it in his 
 " Prognostics." Sydenham * quotes a letter from 
 Democritus to Hippocrates relative to hysteria. 
 Aretaeus,f whose date is uncertain, but who prob- 
 ably lived in the latter part of the second century, 
 while holding very remarkable views as to the 
 etiology of hysteria, describes many of its character- 
 istic symptoms. Celsus (" De Vulvae Morbo ") and 
 Galen (" De Locis Affectis ") both give brief accounts 
 of the disorder. 
 
 Throughout the centuries preceding the middle 
 ages we find no additions to the literature of hyste- 
 ria. The science of medicine was at a low ebb, and 
 the teachings of Galen prevailed with little change 
 for many centuries. With the middle ages came a 
 curious and interesting manifestation of hysteria. 
 
 "* Rush's translation. 
 
 f " De Causis et Signis Morborum. 
 
HISTORICAL. ii 
 
 Previous to this time hysteria appeared only in its 
 simpler forms, but during the middle ages, and, in 
 fact, coming down to our own time, occurred out- 
 breaks of what may be regarded as epidemic hys- 
 teria. That these phenomena were not at the time 
 regarded as hysterical manifestations is quite certain. 
 The denseness of the superstition of the time and the 
 unbridled power of priestcraft must be taken as the 
 explanation both of the curious hysterical or psychic 
 phenomena, and also of the failure in great part of 
 the physicians of the day to recognize them as such. 
 Many of these epidemics of hysteria were closely 
 related to the religious notions at that time prevalent, 
 either as to cause or cure, and it must be borne in 
 mind that religious superstition was the most intense 
 passion of the time of which we are speaking. 
 Among the earliest of these hysterical epidemics was 
 that curious and fantastic dancing mania known as 
 the dance of Saint John. 
 
 The following description is taken from Hecker's * 
 interesting work : "In 1334 were seen in France and 
 Germany bands of men and women marching hand 
 in hand in the streets, dancing furiously until they 
 fell prostrate. They appeared entirely insensible to 
 their surroundings, shrieking out the names of saints 
 and leaping high in the air. The fits often re- 
 sembled epilepsy, the subjects of them falling sense- 
 less, foaming at the mouth, and exhibiting grimaces 
 and contortions of the body. A prominent symptom 
 
 * " The Epidemics of the Middle Ages." Tr. Babington, 1835. 
 
12 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 was a marked condition of tympany, the abdomen 
 being often enormously distended. If in any way 
 this tympany could be relieved the fits generally 
 came to an end. Many of the dancers wore belts 
 into which sticks were stuck, which were twisted to 
 produce compression, or some sympathetic friend 
 would kick the affected person violently in the 
 abdomen. This latter practice, as the old chron- 
 iclers relate, caused the custom of wearing sharp- 
 pointed shoes, then in vogue, to be abandoned. 
 Red colors so infuriated the dancers that in some 
 towns the wearing of red garments was prohibited 
 by law. The populace all turned out to witness these 
 processions of dancers, who were supposed to be 
 possessed of demons." 
 
 These epidemics spread with fearful rapidity, whole 
 towns or cities becoming affected. The origin of the 
 name, and perhaps of the dance itself, grew out of 
 the orgies held upon Saint John's Day, and toward 
 the close of these epidemics, that is after several 
 years, these scenes took place only at or near the 
 occurrence of this festival. In 141 8 Strasburg was 
 visited by a dancing mania, known as the dance 
 of Saint Vitus, from the fact that those affected found 
 relief and cure at the shrine of this saint. Some- 
 what similar to the dancing manias mentioned above 
 was the dance of Saint Guy. Some time before the 
 occurrence of the epidemics which have been spoken 
 of, in the year 1237, at Erfurt, a violent dancing mania 
 seized the children of the town, many of whom are 
 reported to have died from its effects, and others to 
 
HISTORICAL. 13 
 
 have had a tremor to the end of their lives. Para- 
 celsus describes these epidemics, stating that in some 
 persons it took the form of immoderate and uncon- 
 trollable laughter, while in others it manifested itself 
 in running, dancing, and other movements. In most 
 of the epidemics the dancers were greatly affected 
 by music, and the magistrates were accustomed to 
 hire musicians to play for them, and also robust per- 
 sons to dance with them until they were utterly ex- 
 hausted and fell to the ground. Another epidemic 
 which spread through Italy at this same epoch was 
 the Tarentism. The cause of this epidemic was pop- 
 ularly supposed to be the bite of the tarantula, a spe- 
 cies of spider. Baglivi* gives a minute account of 
 the effects supposed to be produced by the bite of 
 this insect. It is somewhat significant that in speak- 
 ing of the persons who inhabited the region where 
 this species of spider is found, Baglivi describes them 
 as "irascible, impatient, and subject to insomnia," to- 
 gether with other symptoms of nervous instability. 
 Hecker (loc. cit.) } in describing the symptoms of 
 Tarentism, gives a fairly recognizable picture of hys- 
 teria. These persons, he says, were melancholy at 
 times, again laughing, and often maniacal. They 
 passed large quantities of pale urine, and were 
 affected with loss of voice, blindness, and vertigo. 
 The theory upon which this dance was founded was 
 that the poison of the spider was eliminated through 
 the pores of the skin, and hence some active ex- 
 
 * "Opera Omnia." Ed. 1788. 
 
14 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ercise was necessary to promote the free action of 
 the perspiration. Music had a very soothing effect 
 upon these persons, and the notes of some of the 
 tunes are still extant. A dance similar to the Tar- 
 entism, called the Tigretier, is said to have been prac- 
 tised in Abyssinia from early times.* Throughout 
 the middle ages, and, in fact, coming down to mod- 
 ern times, were to be seen epidemics of hysteria 
 which differed more or less in their minute details, 
 but conformed to the general type of hysterical dis- 
 orders. These epidemics sometimes took the form of 
 catalepsy or trance ; sometimes the form of more or 
 less perfectly developed hystero-epilepsy. Again, 
 the prominent symptoms were mental, associated 
 with hallucinations and delusions. The most nota- 
 ble of these epidemics occurred in, or took their ori- 
 gin from, the convents. Youth, seclusion from the 
 ordinary avocations of life, and the dominance of 
 strong religious beliefs, amounting at this era to 
 rank superstition, furnished the most favorable con- 
 ditions possible for the growth and development of 
 hysteria. 
 
 A few examples will illustrate the form of hysteria 
 which flourished in the convents of Europe during 
 this period. In 1609, to quote Richet,*)* — to whose 
 work the reader is referred for a most interesting 
 and complete account of these epidemics, — there 
 occurred a demoniac possession among the nuns of 
 
 * Nathaniel Pearce, " Life and Adventures." 
 
 f " Etudes Cliniques sur La Grande Hysterie ou Hystero-Epilepsie," 
 Paris, 1885. 
 
HISTORICAL. 15 
 
 St. Ursula at Aix. Some of the symptoms were 
 " hallucinations, impulsive movements, a horror of 
 the confessional, suicidal tendencies," etc. The usual 
 form of the delusion was that of demoniac possession. 
 The nuns declared that Satan entered into their 
 chambers, commanding them to commit sinful and 
 shameful actions and forbidding confessional. At 
 Loudun, in 1632, was enacted a drama of hysteria 
 terrible in its denouement. The Sister Superior de- 
 clared that she had been visited at night in her cham- 
 ber by the phantom of a priest of the village, Urbain 
 Grandier by name. During the first visits this demon 
 in human shape hinted at certain revelations of relig- 
 ious secrets and religious mysteries which his power 
 would reveal. Upon subsequent visits the demon 
 made unholy propositions to the sister, declared his 
 love for her, and overpowered her with caresses. 
 
 Very soon, one after another of the nuns of this 
 convent declared that they in like manner were 
 nightly visited by the apparition of Urbain Grandier, 
 and described in the most glowing and shameful 
 terms the amorous expressions and lascivious actions 
 of the priest. The contagion spread to the women 
 of the village, who testified at the trial that Grandier 
 had made improper proposals to them during con- 
 fessional. An immense amount of testimony was 
 taken at this trial, the nature of which might have 
 put Rabelais to the blush. The unfortunate priest, 
 concerning whom there had never before been a 
 breath of reproach, w T as condemned to death and 
 executed. 
 
16 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 The demoniac possession of Louviers in 1642 re- 
 sembled in most respects that of Loudun. The 
 unfortunate victims of this epidemic of hysteria had 
 hallucinations of all the senses; they had visions of 
 lighted torches, balls of fire, fantastic animals, or 
 imaginary personages. Sounds of blasphemies or 
 lascivious words and horrible suggestions rung in 
 their ears. These subjective symptoms were often 
 accompanied by convulsions, contractures, loss of 
 consciousness, and the like. These young persons 
 were for the most part girls of the best families, well 
 educated and consecrated to a religious life. 
 
 In the year 1491 was seen a curious epidemic of 
 hysteria in a convent at Cambrai. The nuns were 
 horribly tormented by demons ; those thus affected 
 ran about the fields like dogs, threw themselves in 
 the air in imitation of birds, climbed trees like cats, 
 and hung from the branches. They made all kinds 
 of queer sounds, mostly in imitation of the cries of 
 animals. They also professed the power of divina- 
 tion. The persons in authority, both temporal and 
 spiritual, were in the habit of questioning these 
 afflicted persons, and by certain exorcisms extorted 
 confessions from them, which confessions were be- 
 lieved to be the veritable words of the Evil One. In 
 the epidemic just spoken of the devil, in the form of 
 one of the afflicted nuns, confessed that he had 
 obtained admission into the convent by the aid of one 
 of the sisters who had submitted to his embraces in 
 the cloisters. The demons were exorcised by send- 
 ing the names of the persons possessed to Rome, 
 
HISTORICAL. 17 
 
 where they were read out at mass by the Pope him- 
 self. 
 
 Throughout the latter part of the fifteenth and 
 early part of the sixteenth centuries occurred curious 
 epidemics of demon worship. These took various 
 forms and showed themselves, now as epidemics, 
 now in isolated cases. The general features, either 
 in the case of the epidemic or isolated form, were 
 substantially the same. There was supposed to be 
 a compact with the devil, formed in some mysteri- 
 ous way, and this compact required implicit obedi- 
 ence to the Satanic will. Many horrible instances 
 of infant murder and anthropophagism are related 
 by the old chroniclers. The civil authorities, stimu- 
 lated by the priests, were eager in hunting out these 
 demoniacs and putting them to death. 
 
 It is a very suggestive fact that sexual perversion 
 played a prominent part in these demoniac posses- 
 sions. Women declared under oath that they had 
 visited the midnight orgies of the demons and witches 
 and had been violated by demons. They described 
 in disgusting detail and with shocking minuteness 
 the sexual organs of the devil and his peculiar modes 
 of cohabitation. One of the old writers naively 
 remarks that fortunately this intercourse was never 
 fruitful. In 1550 the nuns of the convent of Uvertet 
 were seized with epidemic hysteria. The attacks 
 began with hallucinations of various kinds. Thev 
 declared that they were awakened by feeling them- 
 selves being drawn out of bed by the feet, and when 
 they reached the floor the most violent convulsions 
 
18 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 would come on, so violent that the persons about 
 them had great difficulty in restraining them ; pale 
 urine was voided in enormous quantities. One very 
 curious hallucination which characterized this epi- 
 demic was the sensation of being tickled on the soles 
 of the feet, and this caused immoderate and uncon- 
 trollable laughter. A very harmless lady living in 
 the neighborhood was, for no reason, supposed to be 
 in league with the devil and the cause of this posses- 
 sion. The torture was applied to her, resulting, as 
 it often did, in death. This epidemic lasted about 
 three years, and it is curious to note that at the time 
 of the subsidence of the epidemic, or, rather, imme- 
 diately before its subsidence, it was thought best to 
 refuse the public admission to the convent. It was 
 the custom for large numbers of persons to go to the 
 convent to witness the supposed manifestations of 
 the devil, and the power of religion in overcoming the 
 Evil One. Just as soon as the public were excluded 
 the epidemic came to an abrupt conclusion. It is 
 also curious to note that this coincidence attracted 
 no attention, not even from the medical men, so 
 absolute was the power of religious dogmas, so dense 
 was the superstition of that period. 
 
 The nuns of St. Brigette were attacked with a 
 similar affection ; they imitated the cries of animals, 
 and were frequently seized with a constriction of the 
 throat, so severe as to prevent their taking food. 
 The first one of the inmates of the convent to be 
 affected was a young girl who took the veil on ac- 
 count of an unfortunate love affair. This epidemic 
 
HISTORICAL. 19 
 
 lasted ten years. The epidemic which took posses- 
 sion of the nuns of Kintorp, near Strasburg, was at 
 first attributed to epilepsy. The persons affected 
 fell to the £round, lost consciousness, bit and tore 
 their clothing. As soon as one was seized it was a 
 signal for the rest who were in the same apartment. 
 They complained of a burning sensation in the soles 
 of the feet, likening it to contact with boiling water. 
 Here, as elsewhere, innocent persons were accused 
 of being in league with the devil and causing the 
 attacks. The cook of the convent and her mother 
 were convicted and burned at the stake. The epi- 
 demic of the nuns of the convent of Nazareth at 
 Cologne, in 1560, was notable for the prominent 
 part played by sexual hallucinations, the nuns de- 
 claring that the demons came into their beds at night. 
 At Amsterdam, in 1566, there appeared an epidemic 
 of hysteria, similar to the epidemics that have been 
 described, in an orphan asylum, the inmates being 
 mostly boys. This epidemic was characterized by 
 convulsive seizures, vomiting of foreign substances, 
 such as nails, needles, bits of thread, wool, etc. 
 There was noted in this epidemic a feature which 
 was very common in the later epidemics, namely, 
 the use of apparently unknown languages. Boys, 
 who were not supposed to be acquainted with any 
 other language than their own, spoke Latin or Greek 
 with apparent fluency. This was the first epidemic 
 of this kind among males, all the others before al- 
 luded to being confined to the opposite sex. In the 
 province of Lorraine, in the space of fifteen years, 
 
20 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 Remy, who was the public prosecutor, caused to be 
 put to death no less than 900 persons accused of 
 being devil worshipers. 
 
 To show that epidemic hysteria was not confined 
 to Southern nations, the epidemic of Elfdalem, in 
 Sweden, may be mentioned. Bekker, quoted by Cal- 
 meil,* describes this epidemic, which did not differ 
 materially from those of France and Italy, except so 
 far as the imagination of the North lacks the tropi- 
 cal luxuriance of the South. The details of the epi- 
 demic of Sweden necessarily differed somewhat from 
 that of the Southern races, since the surroundings, 
 the religion, and, above all, the mythology or super- 
 stition of the people, differs so greatly. The tribunal 
 which was appointed by the king of Sweden to take 
 action upon this supposed demoniac possession, con- 
 demned to death more than 80 persons and punished 
 more lightly a large number of others. This was very 
 heroic treatment, but in this particular instance was 
 effective. In many other instances, perhaps we 
 may say generally, rigorous persecution rather aug- 
 mented than caused any abatement in the hysterical 
 fury. 
 
 The practice of flagellation, f which began as a re- 
 ligious observance and can be traced to very early 
 times, became, in the middle ages, a veritable hys- 
 terical epidemic. In 1260, through the influence of 
 a monk named Rainer, an epidemic of flagellation 
 
 *"De la Folic" 
 
 f " Encyl. Brittan.," vol. IX. 
 
HISTORICAL. 21 
 
 spread through Italy, and thence through a large 
 part of Europe. Vast crowds of men, women, and 
 children, from every rank of society, marched 
 through the country, furiously lashing themselves 
 with leathern thongs. Pilgrimages were started, 
 every village or city visited contributing its quota. 
 So furious were these epidemics that edicts, both 
 secular and religious, were issued against them. 
 Many of the Crusades, especially the Children's Cru- 
 sade, might, without doing violence to our subject, 
 be ranked as hysterical manifestations. Certain it is 
 that hysteria played a very prominent part in these 
 uncontrollable relioious movements. 
 
 The hysterical phenomenon of stigmatization, or 
 the appearance of wounds in the hands, feet, and side, 
 resembling more or less closely the description given 
 in the Scriptures of the wounds of Christ, have been 
 made the subject of careful study, both from a scien- 
 tific as well as from a theological standpoint. Cases 
 of stigmatization are frequent, both in early and late 
 literature. A very interesting review of this subject, 
 by the Rev. Richard Wheatley,* traces the phenom- 
 enon from its earliest authentic instances down to 
 modern times. Among the first stigmatists was St. 
 Francis d'Assisi, in Italy, in 1224. This saint prayed 
 that he might be allowed to suffer crucifixion like 
 Christ, and immediately after one of his fervent 
 prayers his feet, hands, and side showed the charac- 
 teristic bleeding wounds. Christine de Stumbele, 
 
 * Popular Science Monthly, vol. XXXIII. 
 
22 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 in 1242, Veronica Giulani, in 1727, Catherin Em- 
 merich, in 181 1, Pal ma d' Oria, in 1 87 1, are among 
 the notable examples. One of the latest cases, and 
 one that was carefully observed, is that of Louise 
 Lateau, in Belgium. This case attracted great at- 
 tention, and has been so often described that it is 
 too well known to make any reference to it. The 
 cases mentioned are only the most notable ones, 
 since the religious records show more than 100. 
 While a few of these cases were evidences of pur- 
 pura hemorrhagica, or some similar affection, the 
 great majority were the grossest forms of deception, 
 encouraged often by overzealous priests, and ac- 
 cepted by a people sunk in crass superstition. 
 
 The vampirism of Poland and Hungary, in 1740, 
 was a wide-spread hallucination that certain specters 
 came at night and sucked the blood. This supersti- 
 tion is, of course, very ancient, and can be found in 
 the folk-lore of almost all peoples, but in the two 
 countries mentioned, and at the time alluded to, the 
 superstition amounted almost to an epidemic of 
 hysteria. 
 
 In the history of our own country we would not 
 expect to find records of wide-spread epidemics of 
 hysteria. At the time of the first settlement of 
 America the progress of civilization had materially 
 lessened this form of hysteria ; superstition was not 
 as rank, the power and influence of religion not as 
 undisputed. Added to this, the country was very 
 sparsely settled for so many decades, thus allowing 
 little social intercourse, and the character of the 
 
HISTORICAL. 23 
 
 early settlers, together with their active mode of life, 
 was by no means that which favored the develop- 
 ment of epidemic hysteria. Although the epidemfc 
 form of hysteria was not often seen, the minds of 
 the people were imbued with a belief in the miracu- 
 lous, and this took the form of a demoniac posses- 
 sion, or, in other words, witchcraft. That many of 
 the unfortunate persons burnt as witches were en- 
 tirely innocent of any belief in witchcraft is certain, 
 but a large number of the accused not only believed 
 in the diabolic possession, the compact with the 
 devil, the power to cast spells and to foretell the 
 future, in short, to act as the special agent of His 
 Satanic Majesty, but they sealed their belief with 
 their blood. These persons were unquestionably 
 hysterics ; the convulsions, the hallucinations, the 
 well-known anesthetic condition of their bodies, all 
 these recorded facts point unmistakably to hysteria. 
 In regard to this latter symptom, the test for witches, 
 or, as they were called on the continent of Europe 
 during the middle ages, persons possessed of the 
 devil, was made by blindfolding the accused one 
 and with a needle ascertaining whether there were 
 any spots on the body where the skin could be 
 pierced without causing any evidence of sensation ; 
 this, by the way, being a very commonly resorted to 
 test for hysteria to-day. Dr. Andrew D. White, 
 in his " New Chapters in the Warfare of Science," 
 says in regard to the witchcraft and like hysterical 
 phenomena of puritan New England : 
 
 "The life of the early colonists in New England 
 
24 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 was such as to give rapid growth to the germs of 
 the doctrine of possession brought from the mother 
 country. Surrounded by the dark pine forests, hav- 
 ing as their neiehbors Indians, who were more than 
 suspected of being children of Satan, harassed by 
 wild beasts apparently sent by the powers of evil to 
 torment the elect, with no varied literature to while 
 away the long winter evenings, with few amusements 
 save neighborhood- quarrels, dwelling intently on 
 every text of Scripture which supported their gloomy 
 theology, and adopting its most literal interpretation, 
 it is not strange that ideas regarding the darker side 
 of nature were rapidly developed." 
 
 More closely akin to epidemic hysteria, in fact a 
 distinct phase of it, were the orgies enacted at the 
 religious revivals of Kentucky and Tennessee in the 
 early part of this century. Dr. Felix Robertson * 
 gives a very interesting account of one of these 
 early "revivals" in Tennessee in the year 1803. 
 The ecstatic state, or as we would undoubtedly call 
 it now hysterical state, into which so many persons 
 passed, was regarded as- a favorable visitation of the 
 Deity, as a special gift of the Spirit. The ages of 
 those affected varied from six to sixty, but by far the 
 greater number affected were young women. The 
 paroxysm continued for an hour or more, and con- 
 sisted of violent trembling and shaking, accompanied 
 with loud groans and cries. At other times there 
 would be "jerks," — sudden inclinations of the head 
 
 * Phila. Med. and Phys. Journal, vol. II, 1805. 
 
HISTORICAL. 25 
 
 continuing for a quarter of an hour or longer. 
 Sometimes the affected person would leap high in 
 the air or run violently and aimlessly until exhausted. 
 Other symptoms were dancing, singing, labored res- 
 piration, lethargy, etc. Anesthesia was very gen- 
 erally present and excited much comment. Yandell * 
 gives a graphic account of similar epidemics in Ken- 
 tucky about the same period. 
 
 At one meeting it was computed that no less than 
 3000 persons fell to the ground in convulsions. A 
 quotation from Dr. Davidson shows how wide-spread 
 the epidemic was, resembling in this respect some of 
 those of the middle ages. The same author paints 
 in striking language the impressive scenes enacted 
 at these early and primitive religious gatherings: 
 " The glare of the camp fires falling on a dense 
 assemblage of heads simultaneously bowed in prayer, 
 hundreds of candles suspended from the trees, the 
 solemn chanting of hymns, the impassioned exhor- 
 tations, the sobs, shrieks, or shouts, the sudden 
 spasms which seized upon scores and dashed them 
 to the ground, all conspired .not only to invest the 
 scene with terrific interest, but to work up to the 
 highest pitch of excitement the feelings of all pres- 
 ent." Granade, a celebrated exhorter, says that at 
 one of his meetings "the people fell as if slain by a 
 mighty weapon, and lay in such piles and heaps that 
 it was feared they would suffocate, and that in the 
 woods." Catalepsy, convulsions, mimicry of ani- 
 
 * " Brain," vol. IV. 
 
26 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 mals, a peculiar laugh, called the " holy laugh," were 
 some of the most notable symptoms. 
 
 Epidemics of hysteria have often been observed 
 among the North American Indians, the most strik- 
 ing examples, perhaps, being the "ghost dance," 
 the " Messiah dance," etc., which have been described 
 in some of the late magazines. 
 
 Hysteria plays a very important part in the " camp 
 meetings " and "revivals " of the negroes. A former 
 student of mine, Dr. S. W. Welch, of Alabama, has 
 kindly given me some instances that have fallen 
 under his observation, of hysteria in the negro. 
 The " camp meetings " usually lasted for two weeks 
 or longer, being terminated by the commencement 
 of the cotton picking. Besides the usual shouting, 
 dancing, singing, and such-like performances, there 
 appeared an epidemic of catalepsy, or, as the ne- 
 groes called it, " trance." 
 
 After recovering from this " trance " wonderful 
 accounts were given of the things seen and heard. 
 One example will sufficiently illustrate the vividness 
 of the negro imagination. A negro girl about six- 
 teen years of age, after awakening from a "trance," 
 told Dr. Welch that she had walked a two-inch plank 
 over the abyss of hell. Below she saw the blue 
 flames, and the "Old Boy" piling fuel around the 
 sinners' heads. Conspicuous among these latter was 
 the figure of a gentleman of the community, who had 
 recently died, and who was noted for his profanity 
 and cruelty to the negroes. She made a safe escape, 
 although the devil reached after her and was so 
 
HISTORICAL. 
 
 27 
 
 close that she could see his Ion or claws. She then 
 found herself in a golden street, and in the distance 
 saw God sitting upon a white throne, with Jesus on 
 His right hand and " Old Miss Jesus " on His left. 
 Upon being interrogated as to what " Miss Jesus " 
 looked like, she replied that " Miss Jesus " had long 
 white hair like "Old Miss" (a saintly old lady who 
 had formerly owned the girl). 
 
 It is very interesting to compare such accounts as 
 this with the hysterical visions of the middle ages. 
 
 Apart from these wild outbursts of epidemic hys- 
 teria of which we have been speaking — -this accentu- 
 ation of the hysterical state — we find frequent and 
 important mention in the literature of the ages past 
 of the milder forms of the malady. We find certain 
 diseases, such, for example, as blindness, deafness, 
 paralysis, and the like, cured by the laying on of 
 bands of the Irishman, Greatrakes, or by a pilgrim- 
 age to a famous shrine, such as the tomb of Francois, 
 the " diacre Paris." The kind's touch and the won- 
 derful cures wrought by it, not only of the king's 
 evil, but of diverse diseases, all of which bear a 
 close resemblance to hysterical symptoms, show us 
 how common such conditions were. The method 
 employed, and the instantaneousness of the cure, 
 according to the old chronicles, fully warrant us in 
 regard in o- these so-called diseases as evidences of 
 hysteria. 
 
 This brief historical retrospect shows us that from 
 the earliest times of which we have any authentic 
 records, physicians have been familiar with the main 
 
28 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 phenomena of hysteria, however fantastic may have 
 been their ideas respecting its cause. Again, we ob- 
 serve the causative influence of great passions, such 
 as religious superstition, fear, licentiousness, and the 
 like. The contagiousness of hysteria and its mimi- 
 cry are well illustrated by the epidemics of the middle 
 ages, and also by the later epidemics to which refer- 
 ence has been made. While the more violent mani- 
 festations of hysteria, such as the dancing manias, 
 have hardly survived to the present day, we are 
 forced to the conclusion that the malady in its other 
 forms has increased rather than diminished. To 
 prove this it would only be necessary to bring our 
 historical sketch down to the present time and include 
 modern spiritualism, faith cure, mind cure, nervous 
 prostration, often falsely so-called, much of what is 
 designated neurasthenia or hypochondria, together 
 with those multiform hysterical symptoms which are 
 embraced under the comprehensive term, nervous- 
 ness. 
 
CHAPTER II. 
 
 THE NATURE OF HYSTERIA; ETIOLOGY 
 AND PATHOLOGY. 
 
 In considering the nature of a subject like hysteria, 
 which cannot be said to have anything but a mere 
 hypothetical pathology, it is well to consider care- 
 fully the etiology, hoping thus to get some light on 
 the subject. With a clear notion of the etiology of 
 hysteria we are in a better position, of course, to 
 look for pathological lesions, and in this way narrow 
 down our researches. The first question in the 
 etiology of hysteria is the influence of sex as a pre- 
 disposing cause. With the ancients, holding the 
 Hippocratic or Galenic theories, this was no ques- 
 tion, since from their definition hysteria could be 
 present only in the female. The late General 
 Butler is said to have used this argument with ereat 
 effect in the trial of a certain case in which it was 
 alleged that his client was hysterical. " Does not 
 the word hysteria mean womb? " he asked of the 
 medical witness who had testified as to the hysteria 
 of his client. Of course the doctor had to admit 
 that it did. " Well," said Butler, " I had this man 
 carefullv examined before coming- into court, and he 
 has no womb." During the middle ages we find 
 epidemics of hysteria affecting males as well as 
 
 females, but the hysterical nature of the epidemic 
 
 29 
 
30 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 was overlooked, or, rather, the religious superstition 
 of the times regarded these epidemics as veritable 
 possessions of the devil. One of the earliest writers 
 to recognize the fact that hysteria could occur in the 
 male was Sydenham.* " Few women," he says, 
 " excepting such as work hard and fare badly, are 
 quite free from every species of this disorder, and 
 several men also, who lead sedentary lives and study 
 hard, are affected with the same." Briquet f rather 
 underestimates the frequency with which hysteria is 
 met with in men when he puts the proportion as i 
 to 20. Much depends upon the comprehensiveness 
 of the term "hysteria," but if we include certain 
 mental manifestations of hysteria, the disproportion 
 between the two sexes will not be found to be as 
 great as that stated above. The faulty conception 
 of the nature of hysteria led the older writers to 
 call this condition, when met with in the male, hypo- 
 chondria, and this error has vitiated statistics ever 
 since. The two states are similar and often exist 
 coincidentally, but fundamentally they are distinct. 
 No statistics are necessary to prove the fact that 
 hysteria is most frequently seen near puberty; that 
 is, between the ages of fifteen and twenty, though 
 no age is exempt. It may be occasionally observed 
 in quite young children, though one is sometimes 
 inclined to doubt the accuracy of the diagnosis of 
 infantile hysteria. While not, perhaps, very common, 
 
 * Rush's translation. 
 
 | " Traite Clinique et Therapeutique de l'Hysterie," Paris, 1859, 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 31 
 
 it is not rare to find marked hysteria in the aged. 
 Hippocrates and Galen were inclined to the belief 
 that hysteria was more common after puberty because 
 the womb became lighter, and Aretaeus * explained 
 the fact of the rarity of hysteria in old women by 
 stating that in old age the womb was bound down 
 and therefore could not travel through the body, 
 this being, as we shall see, the Hippocratic idea of 
 the causation of the affection. 
 >^-In connection with the question of age, the influ- 
 ence of climate and race must be considered, since 
 these latter factors are important in determining the 
 period of puberty and the rapidity of mental de- 
 velopment. While hysteria is common in cold coun- 
 tries, Russia, Lapland, etc., its most congenial soil is 
 the warm latitudes. The emotional nature, the im- 
 pressionability, the intensity of the passions, the 
 demonstrativeness, the responsiveness of the South- 
 ern peoples comprise a temperament much more 
 suited to the development of hysteria than the un- 
 demonstrative, stolid, sluggish inhabitant of Arctic 
 regions. To what extent this difference is climatic, 
 and to what extent racial, is hard to decide, for we 
 cannot say just how great has been the influence of 
 the warmth and brightness upon the race character, 
 i^ er tain forms of hysteria are very common among 
 the^fcgroes. Largely endowed with superstition, 
 their hysterical manifestations are closely related to 
 their religious extravagances. Afifegro camp meet- 
 
 * Translated by Reynolds. London, 1837. 
 
32 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ing in a locality where the restraining influences and 
 the imitation of a higher civilization have not deeply 
 penetrated, will furnish material f©r a description of 
 many of the phases of hysteria.' I have not met 
 with paralysis of motion or sensation, or long con- 
 tinued contractures as frequently among thel/egroes 
 as in the white race. But convulsive seizures, and 
 more or less completely developed major attacks 
 are very common, as are paresthesia and mental 
 hysteria. I am inclined to believe that hysteria is 
 more frequent in this race to-day than it was dur- 
 ing the slavery period. The occurrence of hysteria 
 among the Indians has been referred to. In the 
 evolution of a race from barbarism to civilization 
 there is, of course, a corresponding change in the 
 nature of the mental derangements. The wilder fea- 
 tures of the contagious hysteria of the uncivilized 
 become less and less frequent, and in their place are 
 seen the less obtrusive forms, particularly the purely 
 mental form.^ 1 ^ 
 
 The subject of the influence of race upon the de- 
 velopment of hysteria is a very wide one, and its 
 proper place can be assigned to it only when we have 
 at our command more accurate and exhaustive sta- 
 tistics than are at present available. 
 
 The question of heredity plays an important role 
 as a causative factor in hysteria, as it does in all the 
 neuroses. Briquet's oft-quoted statistics are not 
 necessary to convince any one who has been an ob- 
 server of hysterical families of the truth of this state- 
 ment. As in the case of other neuroses, the here- 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 33 
 
 dity need not of necessity be direct, that is, a trans- 
 mission of hysteria itself from parent to child, but 
 most frequently is indirect, in that the antecedent of 
 hysteria may be any form of neurosis or mental dis- 
 ease. The inheritance of that indescribable some- 
 thing which we call a neurotic temperament, an 
 unstable, badly organized, or imperfectly developed 
 nervous system, while of uncertain definition, is a 
 most potent factor in the subsequent life-history of 
 the unfortunate legatee. While noting the impor- 
 tance of heredity, we should be careful not to as- 
 cribe to it evil results which really come from bad 
 environment. This latter point will be considered 
 under the effects of education. 
 
 Some authors have claimed that certain diatheses 
 were favorable to the development of hysteria. Gras- 
 set has laid especial stress upon the tubercular dia- 
 thesis in its relation to hysteria, claiming that it exerts 
 a distinct influence in the production of the neurosis. 
 Rheumatism and gout have also been assigned a 
 certain place in the general predisposition toward 
 hysteria. Any slow or long continued disease must 
 necessarily exhaust the nerve centers, for the mental 
 effect of severe disease, the fear of death and the 
 anxiety consequent upon it, play their part, as well 
 as the nutritive changes which are the direct results 
 of the pathological processes. Further than this 
 there has never seemed to me to be any predispos- 
 ing effects traceable to any disease, though the com- 
 bined effects referred to above may be noted after 
 or during the course of most serious illnesses. 
 
34 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 The association of hysteria with organic cord or 
 brain disease, is very often seen, and it is a difficult 
 matter to ascertain the exact causal relation which 
 exists between them. 
 
 The mistake is often made of attributing to hered- 
 ity the effects, good or bad, of education and en- 
 vironment. Educational influences in the produc- 
 tion of hysteria appear at both ends of the scale. 
 Defective or imperfect education does not dislodge 
 superstition, which, as we have seen, is very favorable 
 to the development of hysteria. More than this, 
 certain systems of education, while not exactly de- 
 fective, are certainly very unwise, cultivating to too 
 great a degree the emotional side of the child's na- 
 ture ; developing the dramatic, the pathetic, the senti- 
 mental, or the sensational. There are undoubtedly 
 many dull minds that are quickened by this method, 
 but there are many more stimulated to the point 
 where the normal exhibition of the emotions stops 
 and hysteria begins. As Tissot puts it, "If your 
 daughter reads novels at fifteen she will have hysteria 
 at twenty." While we can safely say that an imperfect 
 education predisposes to hysteria, it is no less true 
 that a too rigorous attention to books, with little 
 or no diversion, in like manner, though to a much less 
 degree, has the same tendency. The forcing sys- 
 tem in vogue at some of our schools often adds hys- 
 teria to the list of accomplishments. While "all work 
 and no play makes Jack a dull boy," it is also very apt 
 to make Jack an hysterical boy, and the same system 
 is even worse for Jack's sister. There are few uni- 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 35 
 
 versities that do not show in their faculties fairly typ- 
 ical examples of hysteria, the result of hard study and 
 too one-sided a mode of life. 
 
 Hardly separable from educational influences are 
 the impressions of environment. The mode of 
 thought and expression, the affections, emotions, 
 sentiments of the child are greatly dependent upon 
 the parent or teacher. The every-day life of the 
 child, its general management, its associates, all 
 have a distinct bearing upon its emotional nature, 
 and consequently upon the tendency for or against 
 hysteria. 
 
 In addition to the predisposinginfluence of improper 
 emotional environment in the formative period of 
 life, there is the effect of emotion as a direct exciting 
 cause. Far too little attention has been paid to this 
 most important factor. The conviction has been 
 growing upon me for years that in nearly every 
 case of hysteria there is some distinct emotional 
 cause recognized by the patient. In young girls it is 
 some love affair that has not " run smooth ; " a real 
 or fancied slight by the mother, uncongenial rela- 
 tives, ungratified ambitions, and the like. In older 
 women the causes are generally more grave. In 
 most instances the reply to the question as to 
 whether or not the hysterical condition was brought 
 about by trouble will be in the affirmative. The 
 variety of emotional causes is infinite ; a husband 
 who is not kind or who is a drunkard, grief from 
 the loss of children, uncongenial marriages, worry 
 induced by straitened circumstances, the res an- 
 
 
36 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 gusta domi, long-continued anxiety about the health 
 of some member of the family, these are some of 
 the many causes that are so often responsible for 
 the hysterical attack. Some one of these conditions 
 appearing suddenly and in an intense form induces 
 an acute attack of hysteria, or, again, when long 
 continued but of less intensity, strongly predisposes 
 to hysteria. The importance of bringing out clearly 
 these emotional etiological factors becomes very 
 apparent in the treatment of the case. It is impos- 
 sible to treat a case of hysteria successfully unless 
 there is perfect confidence between doctor and 
 patient, and the latter will feel, and rightly so, that 
 the physician does not clearly understand her case 
 if he is not aware of what she thinks is responsible 
 for the disease. 
 
 In regard to social conditions, hysteria is certainly 
 more common among the higher classes of society. 
 It is met with, of course, in every walk of life, but 
 the luxurious and wealthy classes, young persons 
 who have been raised in luxury and too often in 
 idleness, who have never been called upon to face 
 the hardships of life, who have never accustomed 
 themselves to self-denial, who have abundant time 
 and opportunity to cultivate the emotional and sensu- 
 ous, to indulge the sentimental side of life, whose 
 life purpose is too often an indefinite and self-indul- 
 gent idea of pleasure, the jeunesse doree of so- 
 ciety, these are the most frequent victims of hys- 
 teria. It is not the graver, but the milder forms of 
 the disease that we most often see in this class 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 37 
 
 of society ; particularly the purely mental forms. 
 The next most frequently affected grade of society 
 is the very lowest stratum, id les extremes se touch- 
 ent. In this class we find in like manner a life 
 given over to enjoyment, without fixed purpose ; free 
 rein given to " passions of the baser sort," not 
 feeling the necessity of self-control because they 
 have to a pitiably small degree any sense of pro- 
 priety or decency. Between these extremes we see 
 hysteria most often in persons who lead a seden- 
 tary life, to which is added severe mental labor, 
 care, anxiety, responsibility, monotony, and the like. 
 Consequently, we see hysteria frequently among 
 literary workers, teachers, clerks, etc. 
 
 Undue excitement and public notice or publicity 
 will account for the prevalence of hysteria among 
 members of the dramatic profession, musicians, and 
 even public speakers. 
 
 It is a very difficult matter to assign a proper place 
 to reflex irritation as a factor in the production of 
 hysteria. That reflex irritation does aggravate or 
 even originate hysteria in persons already predis- 
 posed to it is certain. The question, and it is one of 
 great importance, is whether long-continued irrita- 
 tion does not induce a certain condition in the nerve 
 centers, either higher or lower, even in persons not 
 predisposed to hysteria, which eventually induces the 
 disease. We are familiar with the profound func- 
 tional alterations produced in the central nervous sys- 
 tem by some very trivial peripheral irritation, showing 
 a wonderful disproportion between cause and effect. 
 
38 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 Familiar examples are the convulsions of infancy 
 from gastro-intestinal irritation, epileptiform seizures 
 dependent upon a tight prepuce or eye strain, and 
 the like. If we can have such wide-spread discharge 
 of nerve force from such apparently slight causes, it 
 is reasonable to suppose that some peripheral irrita- 
 tion acting for a long time eventually establishes an 
 instability of centers, higher or lower. Of course the 
 whole peripheral nervous system must be included 
 as presenting possible sources of irritation. Un- 
 doubtedly the part of the peripheral nervous system 
 which, from a priori reasoning, we should expect to 
 be most responsible is that supplying the reproductive 
 organs. The external genital organs are richly sup- 
 plied with sensory nerves, and, as has been recently 
 shown, the ovary also has a very rich nerve plexus, 
 a point formerly denied. Moreover, there is no 
 other reflex so frequently, so easily, and so power- 
 fully stimulated by purely psychic influences. Be- 
 sides this, there is a certain curiosity, often morbid, 
 but perhaps always present to some degree, attached 
 to the mysterious subject of generation, and conse- 
 quently to the organs which subserve this function. 
 It is not to be wondered at then that during certain 
 critical periods when the reproductive functions play 
 a prominent part, as puberty, the climacteric, preg- 
 nancy, or even at the ordinary menstrual periods, 
 the reflex disturbances originating from these organs 
 are pronounced. Yet it is doubtful whether in the 
 normal healthy subject this reflex ever passes the 
 physiological limit, as it so often does in the hys- 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 39 
 
 terical subject. It is even difficult to say to what 
 extent actual disease of the reproductive organs is a 
 factor in the production of hysteria. It is necessary 
 to discount most carefully the psychic influence pro- 
 duced by disease or supposed disease of these organs. 
 The very fact of the monthly period, and the 
 greater or less inconvenience attending menstruation, 
 acts as a constant suggestion, and the undue promi- 
 nence that has been given to minor and unimportant 
 uterine disorders during the last decad, has made 
 it an easy and natural thing for women to refer half 
 their ills to some fancied derangement of the repro- 
 ductive organs. That continued disease or irritation 
 of the reproductive organs may predispose to hys- 
 teria is undoubtedly true, but in the vast majority of 
 cases the hysterical subject refers the central disturb- 
 ance to that part of the periphery which is most 
 closely related to the higher centers. The impulses 
 travel back along - the most familiar and most fre- 
 quented paths. There exists, then, no actual rela- 
 tionship between hysteria and disease of the repro- 
 ductive organs. The hysterical woman refers to the 
 reproductive organs as the origin of her malady 
 simply because she must refer to some cause, and 
 these organs are constantly suggestive. The fre- 
 quency with which hysteria is seen at certain critical 
 periods when the reproductive organs are under- 
 going important changes — puberty and the meno- 
 pause — is to be explained rather on the ground 
 of the general disturbance of the nervous system 
 than by any reflex irritation. We see at these 
 
40 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 periods a tendency to the development, not only of 
 other mental diseases, but also of other maladies 
 having- no connection with the nervous system. Not 
 only is the nervous system perturbed by these im- 
 portant crises, but the whole body is more or less 
 affected by them. 
 
 While we should be very careful in accepting any 
 subjective symptoms in hysterical patients, we should 
 be doubly careful when these symptoms are referred 
 to the reproductive organs, for not only is it rare to 
 find these organs seriously diseased in hysteria, but 
 a simple examination will often fix a suggestion 
 which may be difficult to dislodge. 
 
 The ancients, as is well-known, had very pro- 
 nounced views on the subject of the relationship ex- 
 isting between the uterus and hysteria, regarding 
 this organ as the fans et origo of the disease. Not 
 only was disease of the reproductive organs sup- 
 posed to cause hysteria, but there was a wide-spread 
 belief among the older authors that continence was 
 an important and frequent cause. 
 
 Among other sources of peripheral irritation may 
 be mentioned disorders of the gastro-intestinal 
 tract. It is often a matter of difficulty to say to 
 what extent this may be cause, and to what extent 
 effect. The hysterical individual is very generally 
 inclined to be capricious in the matter of food, and 
 is very commonly more or less dyspeptic. As we 
 see melancholia caused sometimes by impacted feces, 
 it is not improbable that long-continued digestive 
 disturbances may, to some extent, act as a predis- 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 41 
 
 posing cause of hysteria. Cullen especially, of the 
 older writers, lays stress on gastro-intestinal disor- 
 ders in their relation to hysteria. 
 
 Having thus considered briefly the etiology of 
 hysteria, we are in a better position to draw certain 
 conclusions regarding its probable nature. As has 
 been noted in the historical sketch of hysteria, the 
 literature upon this subject is enormous, and the 
 views held concerning the nature of the disease very 
 various. The older writers seemed to enjoy elucidat- 
 ing (as they thought) the mystery of the nature of 
 hysteria, and in every generation almost, from the 
 earliest times, some physician or philosopher seemed 
 to feel himself called upon to expound his particular 
 theory. Hippocrates * clearly enunciated the theory 
 that hysteria was due to the movements of the uterus. 
 This organ was supposed to be freely movable, and 
 under certain conditions would rush upward, pushing 
 the thoracic viscera into the throat and causing the 
 sensation of choking. The hysterical symptoms af- 
 fecting other parts of the body were in like manner 
 explained on the theory of the wandering of the 
 uterus. 
 
 Briquet gives the following quotation from Plato, 
 which illustrates very well the ideas of the ancients 
 regarding the uterus : " The womb is an animal that 
 ardently desires to beget children. When it remains 
 sterile long after puberty it can scarcely tolerate this 
 condition ; it becomes indignant, runs here and 
 
 * " Complete Works." Adams. 
 
42 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 there through the body, arresting respiration, throw- 
 ing the body into extreme dangers, and occasioning 
 diverse diseases, until desire and love, uniting man 
 and woman, cause to grow a f r u it as on a tree, sow- 
 ing- in the womb, as in a field, invisible animals, 
 nourishing them after the separation, developing 
 them and giving birth to them, and in this manner 
 completing the generation of animals. Thus are 
 formed women and all females." Democritus, in a 
 letter to Hippocrates, says : " The womb is the origin 
 of 600 evils and innumerable calamities." 
 
 Aretaeus, who lived probably in the second cen- 
 tury, held the same ideas of the wandering of the 
 womb that had been announced by Hippocrates. 
 He states that if the womb were suddenly carried up- 
 ward there would occur a choking as in epilepsy, but 
 without spasms, the limbs moving irregularly, with 
 loss of speech and impairment or loss of sensation. 
 He explained the more frequent occurrence of hys- 
 teria in the young by the assumed fact that in old 
 women the womb became more tightly bound down, 
 and hence was not as free to wander at will through 
 the body. Celsus made no improvement upon the 
 views of Hippocrates, calling the disease passio 
 hysterica. Galen made the important announce- 
 ment that the uterus was stationary and had no 
 power of locomotion, thus upsetting the Hippocratic 
 theory. He thought that the menstrual blood be- 
 came dammed up in the uterus and underwent, at 
 times, putrefactive changes. Galen, or at least the 
 Galenic school, believed in a female seminal fluid, 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 43 
 
 and imagined that the retention of this fluid in the 
 uterus was a potent cause of hysteria. A modifica- 
 tion of this view was that there was an excessive 
 discharge of this fluid. Aetius accepted this theory 
 with the modification that malignant vapors started 
 from the uterus, which view was also held by Paulus 
 /Eginita. xAJexander de Tralles went back to the 
 Hippocratic theory of the wandering of the uterus. 
 Avicenna, who represents the Arabian school of 
 medicine, adopted the theories of Galen upon this 
 as upon most subjects. Forestius was such a warm 
 advocate of the theory of the retention of the female 
 seminal fluid that he advocated coitus as a means of 
 cure whenever this remedy was allowable, and when 
 not he advised the attending physician to anoint 
 his finger with an ointment of musk and bring on an 
 orgasm. To his credit be it said, that he recom- 
 mended that this procedure had better be carried out 
 by women. The views announced first by Hippoc- 
 rates, and more or less modified by Galen and others, 
 prevailed in the main down to the time of Charles 
 Lepois, 1620. This author denied the dependence 
 of hysteria upon the uterus, and described cases of 
 the disease occurring in men. He believed that the 
 seat of hysteria was in the brain, and drew an analogy 
 between it and epilepsy. Van Helmont (1650) re- 
 turned to the theory of Galen, and this theory, with 
 its "humoral" modifications, was more or less 
 closely adhered to by such men as Primrose (1650), 
 Sylvius (1660), Etmiiller (1660), Purcell (1707), 
 Pitcairne (1701), Schact (1747), and many others of 
 
44 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 this period. Hochstetter, in 1660, tried to prove 
 that hysteria was a convulsive malady starting from 
 the brain, and we find Thomas Willis (1660) ad- 
 vocating this same view. Highmore, in 1661, 
 agreed in the main points with this theory, but would 
 not admit the brain as the seat of the disease, holding 
 that hysteria was a disease of the whole system. 
 Sydenham, who gives an excellent description of 
 the symptoms of hysteria, believed that the animal 
 spirits rushed upward and affected the nervous sys- 
 tem generally. 
 
 Morgagni believed in the uterus as the starting- 
 point of hysteria. He held that an irritating in- 
 fluence originated in this organ and was carried 
 thence by the nerves to the brain. He gives a 
 very interesting account of autopsies made by 
 him in which he searched diligently for some defi- 
 nite pathological lesion. He found in some of his 
 cases what he considered diseased conditions of 
 the reproductive organs, and this led him to fix upon 
 the reproductive organs as the seat, or at least the 
 starting-point, of the disease. Cullen drew especial 
 attention to the relationship existing between hys- 
 teria and disorders of the gastro-intestinal tract. He 
 regarded hysteria as an affection of the reproductive 
 system, and makes the rather startling statement that 
 the cause of the disease is " a mobility of the system, 
 depending generally upon a plethoric state." 
 
 Lisfranc gives the following summary, which he has 
 modified from Brachet : " Many of the earlier authors 
 believed with Hippocrates in the aberrations of the 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 45 
 
 uterus. A large number supposed the proximate 
 cause of the disease to be the retention or putrefaction 
 of the semen or menstrual blood and the distribution 
 of malignant vapors over the body. More modern 
 authors still, continued to regard the uterus as the 
 seat of the disease, but supposed no other pathological 
 alteration in its condition than some modification 
 of its special nervous system, which reacted upon the 
 general nervous system. Somewhat later it was be- 
 lieved that hysteria was a general nervous affection 
 with no more precise seat than the nerves. Hysteria 
 has been located in the uterus (Hippocrates, Galen), 
 the general nervous system (Pomme, Boerhaave, 
 Sydenham), the brain (Willis, Georget), in the inferior 
 portion of the spinal cord (Amard), in the stomach 
 (Purcell, Vogel), in the lungs and heart (Highmore), 
 in the vena porta (Stahl), and so on almost ad in- 
 finitum!' 
 
 As representing modern views on the nature of 
 hysteria, the following quotation from Mills' admir- 
 able article on hysteria, in Pepper's " System of Medi- 
 cine," is given. This is a combination and modifica- 
 tion of the most important theories held to-day re- 
 garding the etiology of the affection. Mills says : 
 " Comparing and analyzing the different views, it may 
 be concluded, with reference to the pathology of hys- 
 teria, as follows : (i) The anatomical changes in hys- 
 teria are temporary.. (2) These changes may be at 
 any level of the cerebrospinal axis, but are most com- 
 monly and most extensively cerebral. (3) They are 
 both dynamic and vascular ; the dynamic are of some 
 
46 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 undemonstrable molecular character ; the vascular 
 are either spastic or paretic, most frequently the 
 former. (4) The psychic element enters in that, 
 either on the one hand, violent mental stimuli, which 
 originate in the cerebral hemispheres, are transmitted 
 to vasomotor conductors ; or, on the other hand, 
 psychic passivity or torpor permits the undue activity 
 of the lower nervous levels." 
 
 The citations eiven above show how various have 
 been the views held throughout the centuries regard- 
 ing the nature of hysteria. Some of these theories 
 are absurd, many fanciful, all without any underlying 
 basis of fact. And yet they are not without their 
 uses, for by picking out a bit here and a bit there 
 that may appeal to our individual reason, we may be 
 enabled to build up a theory that at least has the ad- 
 vantage of affording a certain amount of personal 
 satisfaction and explaining or harmonizing the phe- 
 nomena of the singular condition which we call hys- 
 teria. An unassorted mass of facts is a very difficult 
 thing to handle practically, so that, in this case at 
 least, an imperfect working theory is better than no 
 theory at all. In our studies of the nervous system 
 we are familiar with the division of the whole system 
 into certain levels. One level stops at the cord in- 
 cluding the peripheral system ; another reaches to the 
 basal ganglia; a third includes the brain cortex. This 
 mode of dividing the nervous system is, of course, 
 arbitrary and does not follow developmental lines. 
 A given sensorimotor reflex may stop at the cord, 
 may extend to the basal ganglia, or may pass to the 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 47 
 
 cortex. Now, it is highly probable that this highest 
 level, the cortex of the brain, is itself divisible. There 
 exists a center which presides over the more mechan- 
 ical working of the part which it represents, and we 
 are coming to believe that all parts of the body are 
 thus represented in the cortex. This might be 
 denominated the subconscious cortical center. Upon 
 its integrity depends the proper performance of 
 the function of the part over which it presides. 
 The spinal cord in all the higher animals acts as the 
 aeent for the transmission and conversion of the im- 
 pulses to and from this center. Beyond this sub- 
 conscious center must be a conscious, volitional cen- 
 ter, perhaps comprising one great center of volition, 
 perhaps subdivided, each subdivision presiding over 
 its own peculiar subconscious center. A movement 
 of the limbs may be the result of a simple sensori- 
 motor reflex reaching only the subconscious center, 
 or it may be the result of a descending stimulus 
 which starts directly from the center of volition. If 
 the lower center be destroyed the mechanism is 
 broken, and consequently the higher center is power- 
 less to accomplish its purpose, though there may be 
 present a consciousness of a violent effort to accom- 
 plish this purpose. This is well illustrated in the 
 attempts made to move a paralyzed limb, or, a more 
 common example, the efforts to overcome the effects 
 of a momentary pressure paralysis, as the sleep paral- 
 ysis. In this latter case, to take a concrete example, 
 we awaken at night after having lain upon the arm 
 and attempt to move it. We are thoroughly con- 
 
48 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 scious of using some powerful effort to move the arm, 
 but are utterly unable to do so until the compressed 
 nerve resumes its function. In the same manner an 
 individual with the arm center destroyed can go 
 through a mental process of voluntary movement of 
 the paralyzed part, which is certainly not a mere 
 muscle memory. 
 
 It is the function of these higher centers not only 
 to stimulate and set in action the lower or subcon- 
 scious centers, but also to inhibit, to diminish, or 
 even entirely suspend their action. 
 
 While this mechanism is more easily understood 
 in regard to motion, it is probably no less true, 
 though somewhat less comprehensible, in the do- 
 main of sensation. We can, under the vigorous 
 command of the higher centers, touch a heated sub- 
 stance without great discomfort, which, if accident- 
 ally brought in contact with the skin, would occasion 
 sharp pain and elicit a very vigorous reflex. Or we 
 can insert a pin into some not very sensitive part 
 without any great pain, while an unexpected prick 
 in the same region would be severely felt. On the 
 other hand, the higher centers acting upon the 
 lower may so greatly intensify sensation that a slight 
 touch will often excite all the semblance of pain. In 
 the same manner the centers presiding over the 
 vasomotor and visceral systems are acted upon by 
 the higher centers, which, ordinarily, do not inter- 
 fere with what might be called the routine work. 
 The sexual organs may be stimulated by central in- 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 49 
 
 fluence, for example, or vomiting may result from the 
 idea that the food taken was poisonous or disgusting. 
 
 It remains now to apply the above physiological 
 reasoning, which, in part at least, is generally ac- 
 cepted, to the phenomena of hysteria. 
 
 Taking as examples the two most characteristic 
 and frequent symptoms of hysteria, disturbances of 
 motion, including spasmodic conditions, contract- 
 ures, and paralyses, and disturbances of sensation, 
 including hyperesthesia, paresthesia, and anesthesia, 
 we are enabled to decide without difficulty what 
 portion of the nervous system is responsible for 
 their occurrence. If we test a case of hysterical paral- 
 ysis by all the means known to us, we cannot evoke 
 any symptoms suggestive of organic lesion. The 
 reflexes are not altered to any extent, or at least 
 not constantly so, the electric reaction is normal, nu- 
 trition unimpaired. There exists only the impossi- 
 bility of performing voluntary movements. The 
 lower centers show no sign of disease, and we turn 
 to the higher. As we know, the striking character- 
 istic of these cases is that recovery, when it takes 
 place, is often instantaneous ; the house takes 
 fire, the physician or attendant speaks in a harsh 
 manner, a pretended operation under an anesthetic 
 is gone through with, in short, some strong mental 
 shock or suggestion will, in an instant, dissipate all 
 the paralytic symptoms. If the lower levels were 
 affected, if the cord or peripheral nerves were in- 
 volved, this result could not, of course, take place. 
 We are forced, then, to the conclusion that the 
 
 5 
 
 1 
 
50 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 higher centers are at fault. For some reason, not 
 as yet plain to us, the higher centers are unable to 
 act upon the lower, under ordinary stimuli. When, 
 however, the stimulus to the higher centers is very 
 strong, as the instances above show, these centers 
 are aroused to a degree of activity which allows 
 them to emit a stimulus of sufficient force to excite 
 the lower centers to action. 
 
 In attempting to explain this clinical fact, we are 
 hampered by our want of knowledge of the connec- 
 tion which exists between the higher and lower 
 centers, and also by the as yet imperfect ideas con- 
 cerning the intimate structure of the nerve cell. 
 The higher centers could be prevented from acting 
 upon the lower either by a break in the connection 
 supposed to exist between the two, or by a condition 
 of the cells composing the higher centers. As to 
 the first point, we know too little of the manner in 
 which the different groups of nerve cells in the 
 brain are connected to reason upon the nature of 
 such connection. It may be that there is a distinct 
 set of fibers which subserve this function, or that 
 certain wave currents, transmitted independently of 
 distinct fibers, bring the different centers into com- 
 munication. As the question now stands, the most 
 probable interpretation of the clinical facts of hys- 
 teria is that the nerve cells are themselves affected, 
 and are not able to send to the lower centers a 
 stimulus of sufficient strength to excite these centers 
 to action. It is, of course, much more rational to 
 suppose that there exists in hysteria a functional 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 51 
 
 derangement, a temporary suspension of function 
 in the active cell rather than in the almost passive 
 fiber. The elaborate and valuable experiments of 
 C. H. Hodo-e* on the working nerve cell are most 
 suggestive in this connection. This observer has 
 shown that if the posterior nerve root be stimulated, 
 or if an animal be kept working in a treadmill, the 
 ganglion cells become vacuolated, use up their proto- 
 plasm, and that this protoplasm is renewed if the 
 cells be allowed time for recuperation. Extending 
 this reasoning, then, to the higher centers, we can 
 conceive the cells in this region gradually becom- 
 ing exhausted by a long-continued expenditure of 
 energy. The rest is never quite long enough to 
 repair the ravages of the work. According to our 
 theory, it is the higher centers that are involved in 
 hysteria, the centers that preside over volition and 
 the intellectual processes. The lower centers are 
 all in good order and fit for work, but the necessary 
 voluntary impulse is wanting. 
 
 Now the causes that are the most potent factors 
 in the production of hysteria — such causes as bad 
 environment, faulty training, in which the emotions 
 are too largely drawn upon, excitement, grief, worry, 
 emotional shock, and the like — furnish exactly the 
 conditions that a priori we w T ould expect to be re- 
 sponsible in' exhausting the nervous energy, using up 
 the protoplasm of the cells composing the higher 
 centers. These cells at length become exhausted to 
 
 * Journal of MoJ-phology, 1 892. 
 
52 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 such a degree that an ordinary stimulus cannot 
 arouse their activity, and they in turn cannot excite 
 the lower centers. When, however, the stimulus to 
 the higher centers is very intense or sudden, the 
 cells of these centers use up some of what might be 
 called their reserve or residual protoplasm, and a 
 stimulus of sufficient force to arouse the lower cen- 
 ters is liberated. 
 
 This same line of reasoning will, with almost equal 
 force, apply to the various symptoms of hysteria, 
 either somatic or mental. It is necessary to bear in 
 mind that in addition to the voluntary stimulus of 
 which we have been speaking, the higher centers also 
 exert a very important inhibitory influence, and that 
 when either of these impulses are for a long time ab- 
 sent, the lower centers, lacking this normal and neces- 
 sary stimulus, are apt to undergo certain changes of a 
 more or less temporary character ; in fact, Charcot 
 has supposed that distinct organic changes may re- 
 sult from lona-continued functional derangement. 
 Regarding the higher centers in their recipient 
 capacity, our theory would still seem to hold good. 
 In hysterical anesthesia, or other disturbances of sen- 
 sibility, the conducting paths are almost certainly 
 normal, the fault being in the percipient centers. 
 The distribution of the sensory disturbance, not con- 
 forming to the nerve supply, its sudden onset and as 
 sudden disappearance, together with entire absence 
 of symptoms pointing to any actual lesion in nerve 
 or cord, confirms this view. We are thus led to 
 conclude that hysteria is an affection of the higher 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 53 
 
 brain centers, perhaps an actual though temporary 
 loss of protoplasm. As a consequence of the in- 
 volvement of these higher centers, voluntary move- 
 ments are interfered with, sometimes evidenced by 
 irregular or convulsive movements ; at other times, 
 or perhaps at the same time, the percipient or recip- 
 ient function of these same centers is involved, and 
 the result is disturbance of sensation, either an exces- 
 sive sensibility or anesthesia. Studying the mental 
 phenomena of hysteria in the light of this theory, 
 we see that the irregular mental action, the instability, 
 emotional disturbance, the entire want of self-con- 
 trol, the profound changes that are so apparent in 
 the character of the individual, all point to a more 
 or less serious involvement of the higher brain 
 centers. 
 
 It is, then, to these higher centers that we must 
 look for the pathological changes in hysteria, and it 
 is not going too far to predict that when our technic 
 becomes more perfect than it is now, we shall be able 
 to detect changes in the protoplasm of the brain 
 cells which will clear up much of the mystery that 
 attaches to mental disturbance, whether of a tempo- 
 rary or permanent nature. The modern conception 
 of the neuron has suggested an explanation of the 
 phenomena observed in certain mental states, par- 
 ticularly hysteria. It had been suggested from time 
 to time that the neuron possessed a certain power 
 of movement. This was later demonstrated by 
 Wiedersheim * in the case of certain of the lower 
 
 * Anatomischer Anzeiger, 1 890. 
 
54 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 orders, and the theory has thus received a partial 
 confirmation. Of course, in the neurons of the 
 brain cortex the only movement supposable is a 
 contraction of the cell processes. This would, of 
 course, cause a break in the path of conduction. 
 Ramon y' Cahal * supposes the neuroglia cells to 
 be endowed with contractility, or at least to possess 
 the power of contracting their processes, and this he 
 thinks acts as a sort of insulator between the nerve 
 cells. Which ever of these hypotheses be correct, 
 or, more properly, if either one of them prove by 
 later experimentation to be tenable, a very plausible 
 theory is afforded upon which to explain many of 
 the phenomena seen in hysteria. Dercum, j* in a 
 careful review of this subject, says : " Let us take the 
 simple example of an hysterical paralysis, and see 
 how easily it is explained. The neurons of a certain 
 area of the cortex, for instance, retract the terminal 
 branches of the neuraxons to such an extent that the 
 latter are no longer in contact, or sufficiently near 
 to the neurons in the spinal cord which supply the 
 muscles of the paralyzed part. It explains also the 
 marvelous fact that an hysterical paralysis may at one 
 time be so real, so genuine, as to be indistinguishable 
 from a grossly organic paralysis, and yet the next 
 moment, upon a suggestion, may absolutely disap- 
 pear. This shifting of symptoms in hysteria, this 
 sudden disappearance of paralysis or anesthesia, can 
 
 * " Les Nouvelles Idees sur la Structure du Systeme Nerveux." 
 ^Jour. of New. and Ment. Dis., August, 1896. 
 
THE NATURE, ETIOLOGY, AND PATHOLOGY. 55 
 
 be explained by the view here advanced as it can by 
 no other. When the power is suddenly re-estab- 
 lished in a hysterically palsied limb, it simply means 
 that the terminal branches of the cortical neuraxon, 
 previously retracted, are again extended so as to 
 re-establish the proper relations with the spinal 
 neurons." 
 
 Of course, in a disease like hysteria opportunity 
 is rarely ever afforded for the study of the parts 
 supposed to be involved, and hence our deductions 
 must of necessity contain more of metaphysical 
 reasoning and more of pure theory than befits an 
 exact science. In the very name "hysteria" we are 
 obliged to make a concession, for whatever we may 
 or may not know about hysteria, this much is certain 
 — that it has no causative dependence upon the 
 uterus. The name, however, has become so fixed 
 by immemorial usage that we can hardly hope ever 
 to supplant it by some more fitting appellation. 
 
CHAPTER III. 
 
 SYMPTOMATOLOGY. 
 
 In considering the symptomatology of hysteria 
 there necessarily arises an embarrassment, due to 
 the comprehensiveness of the subject. The bound- 
 ary lines marking the limits of what is loosely termed 
 hysteria never have been, and from the nature of the 
 subject never can be, very sharply drawn. Accord- 
 ing to the ideas advanced in the last chapter, the 
 pathology of hysteria consists in some alteration in 
 the cells composing the higher centers, and our 
 knowledge of the domain and limits of these centers 
 is as yet undefined and hazy. We cannot clearly 
 define what we mean by volition, since it is com- 
 posed of many elements. We know, however, that 
 in hysteria the fault lies in the center or centers 
 which weigh and decide upon the considerations 
 determining choice. In hysteria, the scale of the 
 balance has been destroyed, and the relative value 
 of impulses cannot be ascertained. So far as is 
 known the impulses travel into the centers with 
 their accustomed speed and ease, but the centers 
 are incapable of putting the proper valuation upon 
 them. The terminal apparatus of the sensory 
 nerves, and the nerve fibers themselves, are in nor- 
 mal condition, but the information they convey to 
 the higher centers is either not interpreted at all or 
 
 56 
 
SYMPTOMATOLOGY. 57 
 
 misinterpreted. It is necessary to bear in mind that 
 this condition of loss of protoplasm, of lowered nu- 
 trition, which has been supposed to lie at the root of 
 the pathology of hysteria, involves the idea of irreg- 
 ular and incoordinate action, as well as inhibition. 
 Immediately preceding loss of action, or sometimes 
 accompanying it, is a condition of irritative action ; 
 consequently we would expect a priori to find irregu- 
 lar and excessive action in hysterical conditions as 
 well as loss of action ; the same causes that are 
 operative in producing paralysis will, in advance, 
 occasion convulsive movements or contractures. 
 The involvement of the cells composing the higher 
 centers, the using up of their protoplasm, in all 
 probability takes place in the irregular manner so 
 often seen in chronic diseases of the gray matter of 
 the spinal cord. Applying this method of reasoning 
 to the functions of the higher centers, it is seen at 
 once that in hysteria there may be present all grades 
 of under- or over-action. Certain emotions may be 
 greatly intensified, while others may be inhibited ; the 
 imagination, the feelings, the will, all the higher 
 functions are involved, now in a condition of irrita- 
 tion, acting too strongly, feverishly, irregularly, now 
 inhibited, not acting up to the normal standard. In 
 the same way the sensory impulses, the afferent 
 impulses generally, do not evoke the proper reflexes, 
 now eliciting a too strong response, now failing to 
 elicit any. Similarly the sum of the sensuous im- 
 pulses is not sufficiently powerful to excite the 
 centers presiding over what we know collectively as 
 
58 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 volition, and the result is loss, more or less complete, 
 of intentional movements. Again, from the idea of 
 the pathology of hysteria advanced above, there 
 may exist all degrees of involvement of the cells ; 
 the protoplasm may be slightly affected, greatly ex- 
 hausted, entirely used up. Consequently there may 
 exist all grades of symptoms belonging to the same 
 class, the class itself being determined by the par- 
 ticular group of cells invaded. 
 
 It is necessary to speak with great reserve about 
 the lighter phases of hysteria, since in functional 
 diseases generally a very ill-defined and shifting 
 line divides the normal from the abnormal. Having- 
 only a theoretical pathology to guide us, we cannot 
 lay down any hard and fast rule and say, "here the 
 physiological stops and the pathological begins." 
 Even if hysteria be conceived to be dependent upon 
 an actual loss of the protoplasm of the cells compos- 
 ing the higher centers, too little is known as yet about 
 the nature of this protoplasm to make its increase 
 or decrease a basis of classification. As a matter 
 of convenience, the term "hysteria," or " hysterical 
 temperament," has been applied to a class of cases 
 the only symptom of which is a general instability 
 or want of co-ordination of the nervous system. A 
 given stimulus cannot be counted upon to provoke 
 what might be called the normal or mean reflex. At 
 one time the reflex called forth is out of all propor- 
 tion greater than the stimulus would warrant ; again, 
 it falls far below what would be expected. Particu- 
 larly is this true of the mental states ; the emotions 
 
SYMPTOMATOLOGY. 59 
 
 are unusually vivid and easily provoked, fits of uncon- 
 trollable laughter succeed or are followed by equally 
 uncontrollable outbursts of grief. The affections 
 are often perverted ; likes and dislikes are very vio- 
 lent and irrational. The whole being seems too 
 delicately poised, or rather inaccurately poised, a 
 hair now turning the scale violently, and now a 
 weighty matter leaving it undisturbed. The proper 
 relation between cause and effect is not perceived. 
 Purely somatic symptoms are few ; an irregular 
 vasomotor control, now overstimulation of the 
 center, now inhibition ; sensations of heat and cold, 
 flush and pallor rapidly succeeding each other. 
 The appetite is irregular, at one time ravenous, again 
 entirely wanting, always capricious. Sexual disturb- 
 ances may be present, and probably are present 
 more often and to a higher degree than is admitted. 
 The sexual instinct may be excessive, deficient, or 
 perverted, the latter being especially common. Sleep 
 is irregular, restless, and broken by horrible dreams' 
 Such, in brief, are some of the symptoms of the 
 lighter forms of hysteria, or, more properly, of the 
 hysterical temperament. These symptoms appear 
 at, and are seen almost exclusively at or just prior to, 
 puberty, and doubtless are very closely connected 
 with the development of the sexual functions. This 
 lighter form of hysteria is the form that is recog- 
 nized popularly, and it is perhaps unfortunate that 
 this is so, since it is often hard to convince the laity 
 of the hysterical nature of certain graver symptoms 
 
6o HYSTERIA: ITS NATURE AND TREATMENT. 
 
 when these lighter symptoms, which have for so 
 long been regarded as cardinal, are absent. 
 
 That this variety of hysteria is very common goes 
 without saying, the point to be decided being to 
 what extent it is to be regarded as a developmental 
 phenomenon. The same set of symptoms, though 
 far less pronounced, may be observed in old age, 
 and it is extremely probable that both conditions 
 owe their existence to a certain malnutrition of the 
 cells composing the higher centers. In the vast 
 majority of cases this light variety of hysteria never 
 progresses beyond the lines here laid down, and the 
 symptoms, while presenting more or less variation, 
 in the main correspond to those described above. 
 Undoubtedly these lighter forms of hysteria, or if it 
 seems preferable to designate the condition merely 
 as the hysterical temperament, prepare the ground 
 for the more serious phases of the malady. Bad 
 environment, faulty modes of life, injudicious educa- 
 tion, and the like, will, of course, exert far more 
 influence, in a direction favoring the development of 
 grave hysteria, upon those cases in which the hys- 
 terical temperament already exists than where this 
 temperament is not pronounced. Hence it is at once 
 apparent that these lighter forms of hysteria should 
 be carefully studied in order to avert the threatened 
 danger. 
 
 Instead of following the French school, and divid- 
 ing our subject into normal or interparoxysmal hys- 
 teria and grand hystena, it is considered in its 
 
SYMPTOMATOLOGY. 61 
 
 entirety. Conceiving the disease to be etiologically 
 dependent upon some involvement of the cells com- 
 posing the higher brain centers, it follows that the 
 symptoms would present wide variations both as to 
 kind and degree. Added to this it is quite probable 
 that environment, education, suggestion, or racial 
 influences induce important modifications. 
 
 It is clearly impossible, then, to describe a typical 
 case of hysteria as we would describe a typical case 
 of typhoid fever. The most striking characteristic of 
 the affection which we are discussing is its infinite 
 variety. The symptomatology of hysteria includes 
 the functions of the whole body. Again, we never 
 know what symptoms to expect from an hysterical 
 subject. It may be that an individual case continues 
 for a very long time to exhibit only one or two of 
 the characteristic phenomena of the disease, anes- 
 thesia or paralysis ; or the whole train of symptoms, 
 somatic and mental, may be present. Hence it fol- 
 lows that the study of the symptomatology of hys- 
 teria must be a study of individual symptoms, con- 
 stantly bearing in mind the fact that in any given 
 case any or all symptoms may present themselves. 
 
 The headings under which this part of our sub- 
 ject will be considered are as follows : 
 
 i. Disturbances of sensation — anesthesia, pares- 
 thesia, hyperesthesia, affecting both general sensi- 
 bility and also the special senses. 
 
 2. Disturbances of motion — paralysis, contracture, 
 tremor, convulsive seizures. 
 
 3. Vasomotor, visceral, and nutritive disturbances. 
 
62 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 4. Mental symptoms. 
 
 5. Miscellaneous symptoms that do not belong 
 to any of the foregoing classes. 
 
 Anesthesia. — Of the multiform symptoms of hys- 
 teria, the most characteristic and most constant is 
 anesthesia. As has been noted in an earlier chap- 
 ter, this symptom stands forth prominently in the 
 epidemics of the middle ages. We read of the 
 kicks and blows inflicted upon the apparently in- 
 sensitive bodies of those affected with the dancing 
 plague, and in all probability anesthesia played a 
 part in the phenomenon of flagellation. Anesthesia 
 was recognized as an incontestable sign of demoniac 
 possession, and was resorted to as a test in the 
 detection of persons supposed to be possessed by 
 evil spirits. There were persons whose profession 
 it was to detect those in league with the devil. 
 When some unfortunate was accused of being pos- 
 sessed, the magistrate would order an examination, 
 which consisted in blindfolding the suspected per- 
 son, stripping off the clothes, and pricking the skin 
 with a needle to see if any spots of anesthesia could 
 be found. This examination was intrusted to the 
 " witch finder," or to a surgeon, and when spots of 
 anesthesia were detected they were regarded as 
 marks of the Evil One, and no other proof was 
 needed for conviction. The unfortunate Urbain 
 Grandier, whose sad case has already been referred 
 to, was subjected to this test, and was declared to 
 have " marks " or anesthetic spots on his body, a 
 declaration that was probably false, since it was 
 
SYMPTOMATOLOGY. 63 
 
 averred by many that they heard his exclamations 
 of pain when the surgeon who made the examina- 
 tion pierced his skin with the lancet. 
 
 The acceptance of this test as a proof of demoniac 
 possession caused such a large number of persons 
 to be put to death that, in 1603, it was forbidden by 
 the Parliament of Paris. 
 
 In spite of the frequency and the striking nature 
 of this symptom, anesthesia, it was not until near 
 the middle of the present century that it was clearly 
 recognized and studied as one of the most charac- 
 teristic phenomena of hysteria. The credit of this 
 recognition belongs, according to Briquet,* to Piorry, 
 who pointed it out in 1843 \ somewhat later a care- 
 ful study of hysterical anesthesia was made by Gen- 
 drin in France f and SzokalskyJ in Germany. 
 
 In speaking of sensation generally, it is important 
 to bear in mind that it is made up of several com- 
 ponent parts. Thus, we have tactile sense, pain 
 sense, temperature sense, muscular sense, with, per- 
 haps, some others less distinctly marked off. 
 
 Hysterical anesthesia may involve all these vari- 
 eties of sensation or only certain of them ; thus, a pa- 
 tient may be absolutely insensible to any kind of 
 stimulus, or may perceive tactile, without perceiving 
 painful, sensations ; again, these last two may be 
 normal, and temperature or muscular sense inter- 
 fered with. Sensation is involved, in hysteria, in 
 
 * Op. cit. | Bull, de VAcad. de Med., 1845. 
 
 % " Von der Anesthesie," etc., Vierteljahr. f. die prak. Heilkn. 
 
64 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 widely different degrees ; there may be absolute 
 loss, great impairment, or only slight blunting of the 
 acuity of perception. It is important to bear this in 
 mind,, since it is highly probable that many cases of 
 slight involvement of sensation pass unrecognized. 
 The methods of testing sensation require no spe- 
 cial description ; the finger is the best instrument for 
 testing tactile sensibility, since the amount of press- 
 ure used can best be regulated in this manner. It 
 is often necessary to use some form of esthesiom- 
 eter in testing tactile perceptions, the principle de- 
 pending upon the fact that the legs of the instru- 
 ment must be separated a certain distance in order 
 that the two points shall be perceived as two and 
 not as one. A fairly accurate table of measure- 
 ments has been worked out ; thus, the two points 
 can be distinguished by the tip of the tongue when 
 the distance between them is 1.5 mm. (^ of an inch) ; 
 finger tips, 2 to 3 mm. ; tip of nose, 6 mm.; forehead, 
 22 mm.; forearm, lower leg, and back of foot, 40 
 mm.; back, 60 mm.; upper arm and thigh, 75 mm. 
 It is necessary, of course, that the points of the in- 
 strument be blunt. For testing pain sense a needle 
 is used, and for temperature sense two test-tubes, 
 one filled with hot, the other with cold, water. Mus- 
 cular sense is tested by requiring the person exam- 
 ined to touch different parts of the body, and by 
 placing one limb in a certain position and having 
 the subject describe the position and imitate it with 
 the corresponding limb. Pressure sense is tested 
 by different weights, all having the same bulk, as 
 
SYMPTOMATOLOGY. 65 
 
 cartridges filled with shot, or balls with graduated 
 weights in them. It is of interest, also, to examine 
 the sensibility to the galvanic and faradic currents, 
 since it often happens that tactile and pain sense 
 may be entirely lost, while electric sensibility is more 
 acute than normal. Of course in all these experi- 
 ments the subject tested must be blindfolded. 
 
 The frequency with which anesthesia in some form 
 occurs in hysterical subjects is assuredly very great, 
 thouo-h American and English observers would 
 hardly indorse the statement made by Gendrin,* who 
 says : " In every case of hysteria, without exception, 
 from the beginning to the termination of the malady, 
 there exists a condition of anesthesia, general or 
 partial." Briquet states that in 240 cases there was 
 not one in whom there was not some decree of 
 anesthesia. 
 
 According to most observers, the left side is in- 
 volved twice as often as the right. Of the various 
 forms of anesthesia, the most frequent is analgesia, 
 or loss of pain sense. In these cases tactile sensi- 
 bility remains perfect, and the patient feels the 
 touch of the needle but experiences no pain. Next 
 in order of frequency is loss of common tactile 
 sensibility ; temperature sense is not infrequently 
 disturbed or lost. Loss of muscular and articular 
 sense has frequently been noted (Charcot,-}" Pitres,J 
 Lasegue§), but occurs more rarely than disturb- 
 
 * Loc. cit. -j- "Ouvres Completes." 
 
 \ " Des Anesthesies Hysteriques," 1887. 
 
 \ "Anesthesie et Ataxie Hysterique." Arch. Gs)i. de Med., 1864. 
 
66 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ances of the other varieties of sensation. Dana * 
 says, in regard to the disorders of cutaneous sensi- 
 bility, that pain sense is oftenest affected, then tem- 
 perature sense, then tactile sensibility, and that 
 muscular sense and articular sensibility are rarely 
 involved. 
 
 The distribution of cutaneous anesthesia in hys- 
 teria is very variable, complete or total anesthesia 
 being quite rare. Briquet f has recorded but four 
 cases out of 240. Gilles de la Tourette J has re- 
 ported several cases in which the anesthesia in- 
 volved the whole body, and other observers have 
 recorded a few instances of this wide-spread disturb- 
 ance of sensation. I have reported elsewhere a 
 case of total hysterical anesthesia in a male subject. § 
 Most frequently hysterical anesthesia appears in 
 patches — disseminated anesthesia. Sometimes these 
 areas are symmetrically disposed, but more fre- 
 quently they are scattered irregularly over the body, 
 having no definite shape and varying greatly in 
 size. Occasionally one finds a single spot of anes- 
 thesia of small size, and it is to be noted that this 
 variety of anesthesia is usually very intractable. In 
 a case under treatment at present there is an 
 anesthetic patch, not as large as the palm of the hand, 
 on the outer aspect of the left thigh, which has 
 persisted for more than a year. Not infrequently 
 part of one or more limbs may be involved, the 
 
 * Am. Jour. Med. Set., 1 890. f Loc.cit. 
 
 \ " Traite Clinique et Therapeutique de L' Hysteric" 
 I " Trans. Amer. Neurolog. Assoc.," 1895. 
 
SYMPTOMATOLOGY. 
 
 07 
 
 anesthesia taking the shape of a stocking or long 
 glove. An arm and leg on the same side may be 
 affected, or an arm on one side and the leg of the 
 opposite side. 
 
 Fig. 
 
 -Disseminated Anesthesia. 
 
 The most characteristic variety of hysterical anes- 
 thesia is hemianesthesia, and this form is seen nearly 
 as often as all the other varieties taken together. 
 Hysterical hemianesthesia divides the body into two 
 
68 
 
 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 equal parts by a vertical plane passing through the 
 middle line, one-half being normal, the other anes- 
 thetic. 
 
 The dividing line is drawn with the utmost accur- 
 
 Fig. 2. — Glove and Stocking Form of Anesthesia. 
 
 acy ; the body is exactly bisected vertically, and the 
 anesthetic and normal parts are sharply separated, 
 with no tendency to shade into one another. It will 
 
SYMPTOMATOLOGY. 
 
 69 
 
 be noted that the classification here employed differs 
 somewhat from that generally used, in that only two 
 varieties of anesthesia are recognized — the dissemi- 
 nated, including that variety of anesthesia which 
 
 Fig. 
 
 -Hemianesthesia. 
 
 occurs in irregular patches, as well as the glove and 
 stocking type, and hemianesthesia. If the former 
 of these varieties be subdivided into several groups, 
 then the hemianesthetic form is much the more 
 
70 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 common, but if only two varieties are recognized then 
 the irregular form is oftener seen than distinct hemi- 
 anesthesia. 
 
 Total anesthesia is, as has been said, a compara- 
 tively rare form, and no separate class need be 
 made for it. Not infrequently cases are met with 
 in which there is a distinct obtunding of sensation 
 over the whole body. This diminution of sensation 
 is not sufficiently marked to speak of it as anes- 
 thesia, and it is the appreciation of painful impres- 
 sions that is blunted rather than any disturbance of 
 tactile sense. 
 
 It rarely, if ever, happens that hysterical anesthesia 
 is sharply limited to the upper or lower half of the 
 body. Occasionally in hysterical paraplegia, as Char- 
 cot has pointed out, the lower limbs are anesthetic, 
 but even this is rare. 
 
 A study of the various forms of hysterical anesthe- 
 sia shows at a glance that there is no tendency for the 
 affection to follow the course of the peripheral nerves. 
 In seeking for analogies between hysterical and or- 
 ganic anesthesia it will be seen that irregular or dis- 
 seminated anesthesia of hysterical origin corresponds 
 to anesthesia due to cortical disease, while the second 
 variety, in which one-half of the body is involved, re- 
 sembles very closely organic hemianesthesia due to 
 a lesion of the capsule. In fact, it is sometimes diffi- 
 cult to determine, without invoking the aid of other 
 symptoms, whether hemianesthesia is organic or func- 
 tional. The skin over the anesthetic area presents 
 no peculiarities to the eye, except certain rather rare 
 
SYMPTOMATOLOGY. 71 
 
 vasomotor changes that will be noticed in another 
 chapter. The surface temperature is frequently a 
 little lower than that of the corresponding normal 
 part, and it is true, as was claimed in the epidemics 
 of St. Medard, that blood is not as easily drawn from 
 the affected as from the normal surface. Charcot 
 and Grisolle have both noted the difficulty experi- 
 enced in drawing blood by means of leeches from 
 anesthetic areas. The reflexes on the anesthetic 
 side are somewhat altered, the skin reflexes being 
 in great part abolished and the deep reflexes some- 
 times diminished, sometimes rather more active than 
 normal. The observation of Rosenbach, that the 
 abdominal reflex is lost in certain cases of intracranial 
 lesion and always preserved in hysterical conditions, 
 has not been confirmed. 
 
 The anesthesia of hysteria is by no means confined 
 to the skin ; in marked cases the deeper structures, 
 muscle and bone, are also involved. Very often the 
 abdominal viscera show marked analgesia, and can 
 be compressed and manipulated in a manner not pos- 
 sible under ordinary circumstances. Anesthesia of 
 the mucous membranes is very common. The conclu- 
 sions of Lichtwitz,* who has made a careful study of 
 this part of the subject, are as follows : (i) Anesthesia 
 of the mucous membranes usually follows the nature 
 and degree of the cutaneous anesthesia. (2) Total 
 hemianesthesia of the mucous membranes is exceed- 
 ingly rare. (3) The buccal mucous membrane gener- 
 
 * " Les Aneesthesies Hysteriques des Muqueuses," 1887. 
 
72 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ally shows incomplete anesthesia. (4) The mucous 
 membrane of the nose is never totally hemianesthetic. 
 (5) Anesthesia of the epiglottis is not a constant nor 
 pathognomonic symptom of hysteria. In regard to 
 hysterical anesthesia of the larnyx, Thaon * says : 
 "Anesthesia (hysterical) may occupy the entire larynx 
 and be absolute ; usually it is bilateral and not con- 
 fined to the distribution of any special nerve." 
 Often this condition is associated with paralysis of 
 the vocal cords. Anesthesia of the mucous mem- 
 brane about the anus is very rarely met with ; some- 
 what more common is anesthesia, or at least anal- 
 gesia, of the mucous membrane lining the urethra and 
 vagina. It is very common to find sensory disturb- 
 ances associated with some of the motor symptoms 
 of hysteria, such as paralysis, contracture, or convul- 
 sive movements. 
 
 The onset of hysterical anesthesia, like most of the 
 other symptoms of the disease, is apt to be sudden, 
 and is noted especially after paroxysmal seizures, 
 convulsions, paralysis, contractures, and the like. 
 Anesthesia, however, is mostdistinctly an interparox- 
 ysmal symptom, and is certainly the most constant and 
 pathognomonic of the so-called stigmata. It is inter- 
 esting to note that a wide-spread anesthesia may exist 
 for a long time without the subject being aware of 
 it. In a case seen a few years ago a complete hemi- 
 anesthesia had existed, probably, for several years, 
 entirely unrecognized by the patient. 
 
 * " L' Hysteric et le Larynx," 1881. 
 
SYMPTOMATOLOGY. 73 
 
 The danger of confounding cutaneous anesthesia 
 of hysterical nature with anesthesia due to some 
 organic lesion is not great. 
 
 It is true that hemianesthesia due to a lesion in the 
 capsule may resemble almost exactly a similar condi- 
 tion of hysterical nature, except that in the organic 
 form there is usually seen a facial paralysis along 
 with hemiplegia, and, perhaps, hemianopia ; cases 
 have been reported, however, of hemianesthesia of 
 capsular origin corresponding almost perfectly to 
 hysterical hemianesthesia. Syringomyelia often pre- 
 sents wide-spread and irregular areas of anesthesia, 
 but the other symptoms of this affection, particularly 
 the very marked trophic symptoms, are not likely to 
 be confounded with functional anesthesia. In certain 
 toxic anesthesias, due to alcohol, lead, arsenic, and a 
 few other poisons, very marked anesthesia may exist, 
 but in these conditions there exists a distinct neuritis 
 which can be readily recognized. 
 
 Special Senses. — The sense of touch has al- 
 ready been considered when speaking of the vari- 
 ous forms of anesthesia; of the remaining special 
 senses there are two that we should expect to be in- 
 volved along with anesthesia of the mucous mem- 
 branes, namely, taste and smell. In accordance with 
 the views expressed as to the central nature of 
 hysteria, disturbances of the special senses occur 
 without any involvement of the sense organs. In 
 the case of taste and smell, however, the association 
 between general and special sensation is very close. 
 The sense of smell is a very feeble sense in the human 
 7 
 
74 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 subject, and, as Foster* says, "the psychic devel- 
 opment of simple olfactory sensations is extremely 
 scanty." Moreover, as Lichtwitz has shown, the 
 nasal mucous membrane is far less apt to be affected 
 with tactile anesthesia than mucous surfaces else- 
 where. The sense of smell in hysterical subjects has 
 never been carefully examined. The author just 
 quoted states that loss of smell generally coincides 
 with the loss of tactile sense in the nasal mucous 
 membrane. He noted both unilateral and bilat- 
 eral loss of smell ; total, as well as loss of perception 
 of certain odors only. Briquet states that loss of 
 smell is generally unilateral, corresponding to the 
 loss of general sensation. Dana -f has found smell 
 lost only in cases of hemianesthesia. In one of my 
 own cases, a case of total anesthesia in the male, 
 there was entire loss of the sense of smell, which 
 symptom persisted for several months. The forego- 
 ing remarks apply in the main to the sense of taste. 
 Loss of the sense of taste is probably always asso- 
 ciated with more or less loss or impairment of smell, 
 and with a corresponding loss of tactile sensibility 
 over the tonoue and mucous membrane of the mouth. 
 Lichtwitz has noted that it frequently happens that 
 the sense of taste is lost over part of the tongue 
 only, while the whole of the mucous membrane is 
 anesthetic. No very well authenticated case of loss 
 of taste without loss of general sensibility has been 
 recorded. 
 
 *" Text-book of Physiology." f Loc. at. 
 
SYMPTOMATOLOGY. 75 
 
 Taste in hysterical subjects is often perverted, so 
 that disagreeable, or even repugnant, substances are 
 frequently eaten with apparent relish. In regard 
 to the loss or impairment of these two senses in 
 hysteria, it must not be forgotten that both these 
 special senses are subject to great individual varia- 
 tion. In the case of my own mentioned above 
 there was absolute loss of taste. The patient was 
 utterly unable to distinguish between the most 
 diverse substances. As he began to improve he 
 complained of his coffee being too sweet, and of his 
 food being too highly seasoned. Gilles de la Tour- 
 ette thinks that loss of both smell and taste are 
 not uncommon. Hysterical deafness would seem to 
 be more common than loss of smell or taste. In 
 most if not all cases of hysterical deafness there is 
 anesthesia of the meatus auditorius externus, and 
 often of the outer surface of the tympanum, this 
 anesthesia being a part of the general tactile dis- 
 turbance. Testing such patients with the tuning- 
 fork shows that the deafness is central ; aerial con- 
 duction is much better than conduction through the 
 bones of the head. They will hear the tuning-fork 
 when it is placed on the forehead or upon the teeth 
 only on the unaffected side, or, if both sides are in- 
 volved, they will hear better if the tuning-fork be 
 held close to the ear than if it be placed in contact with 
 the teeth. Again, Dana* has made the interesting 
 observation that deafness to low notes is rare, thus 
 
 * Loc. cil. 
 
76 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 furnishing an analogue to the limitation of the visual 
 field. Hysterical deafness may be either unilateral 
 or bilateral, and, in degree, complete or partial. 
 Walton,* from a study of cases at the Salpetriere, 
 concludes that (i) " the sensibility of the deep parts of 
 the ear, including the tympanum and middle ear, 
 disappears in hysterical hemianesthesia with that of 
 other parts of the body and in the same degree. 
 (2) The degree of deafness corresponds with that 
 of the general anesthesia, being complete when the 
 latter is complete, and incomplete when the latter is 
 incomplete." 
 
 Vision. — One of the most constant symptoms 
 of the interparoxysmal stage of hysteria is dis- 
 turbance of vision. Dana says: "The most con- 
 stant form of sensory anesthesia is limitation of 
 the visual field." Visual disturbance in hysteria 
 may take several forms. There may be total loss 
 of sight — hysterical amaurosis. This is certainly 
 a rare affection ; cases have been mentioned by 
 Briquet,f Charcot,^ Harlan, § Gilles de la Tour- 
 ette, I J Pitres,** Parinaud,-j-j- and others. See also an 
 interesting paper on this subject by Booth. %\ The 
 affection is more often unilateral, though there may 
 be total blindness in both eyes. Quite frequently 
 it comes on immediately after a convulsive attack. 
 The duration is usually short, though in Harlan's 
 
 * " Brain," vol. V, 1882. f Op. cit. % Op. cit. 
 
 I Med. News, Phila., 1890. || Op. cit. ** Op. cit. 
 
 ff Arch, de Neurol., Paris, 1889. \% " Trans. Amer. Neurolog. Assoc," 
 1895. 
 
SYMPTOM ATOLOCxY. 77 
 
 case it lasted for several years. It is often possible 
 to demonstrate the central nature of hysterical amau- 
 rosis in a very simple way, either by using different 
 colored glasses, so chosen that the combination of 
 colors made shows the perception of both colors, or 
 by employing the stereopticon in the case of mon- 
 ocular amaurosis. It is sometimes difficult to de- 
 cide whether we have a case of hysteria or merely 
 one of malingering to deal with. Of course the 
 presence of other hysterical stigmata aids the diag- 
 nosis, and while the eye defects will by no means 
 always exactly correspond upon repeated examina- 
 tions, still they are far more consistent than in the 
 malingerer. As has been noted, the most char- 
 acteristic form of visual defect in hysteria is limita- 
 tion of the visual field. The normal field for white 
 light is concentrically constricted until only central 
 vision remains. Visual acuity, as a rule, remains 
 good, though there may be varying degrees of 
 amblyopia. No changes have been perceived by 
 the use of the ophthalmoscope. As was noted 
 above, there is usually present anesthesia of the 
 cornea. The restriction of the visual field is bi- 
 lateral, though the two eyes may be affected in dif- 
 ferent degrees. This has given rise to the question 
 as to whether we ever have what might be called 
 hysterical hemianopia. The weight of evidence is 
 clearly against the occurrence of this form of eye 
 defect in hysteria. Briquet* and Galezowskif have 
 
 * Loc. cit. f " Prog. Med.," 1878. 
 
78 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 reported cases of so-called hysterical hemianopia, 
 though perhaps the most credible cases are one by 
 Lloyd * and another by Mitchell and De Schweinitz.-j- 
 If the condition does exist, it is certainly extremely 
 rare. Knies and Leber J endeavor to explain these 
 unilateral disturbances of vision in hysteria by com- 
 pression of the optic nerve at the foramen, due to 
 vascular dilatation. This would seem rather a fanci- 
 ful explanation, and would put the eye disturbances 
 outside the pale of pure hysterical phenomena, since 
 practically all the other symptoms of hysteria can be 
 satisfactorily explained on the theory of a central 
 disturbance. 
 
 As has been noted above, the visual field in hys- 
 terical amblyopia is restricted, and this limitation is 
 concentric and regular, thus differentiating it pretty 
 clearly from organic limitation of the field. The 
 field of vision on the side of the hemianesthesia is 
 usually much more markedly restricted than on the 
 other side, and, as Landesberg has shown, the re- 
 striction varies with different attacks, although the 
 violence of the attack seems to bear no definite 
 relation to the extent of the visual disturbance. 
 Fere, on the other hand, is inclined to believe that it 
 is rather the inaccuracy of the perimetric examina- 
 tions that causes the variations that are so frequently 
 observed. As we have seen, the restriction of the 
 visual fields varies from a scarcely appreciable limi- 
 
 *" Text-book of Nervous Diseases," Dercum. 
 
 f Jour, of A T erv. and Men t. Dis., 1 894. 
 
 I " Handbuch der Augenheilkunde," Band V. 
 
SYMPTOMATOLOGY. 79 
 
 tation up to complete amaurosis. The examination 
 must be carefully made with a perimeter, and it is 
 necessary to bear in mind that the eye becomes 
 rapidly fatigued, especially in hysterical subjects, and 
 consequently the results may be vitiated by too long 
 sittings. Besides the limitation of the visual fields 
 
 o 
 
 to white light there exist at the same time decided 
 disturbances of the color fields. There may be total 
 loss of color perception, achromatopsia, or only dis- 
 turbance of the relative position and extent of the dif- 
 ferent color fields. The first of these conditions, acro- 
 matopsia, is not common, at least in this country. 
 When it exists all objects appear of a uniform gray 
 or sepia color. The second variety of color disturb- 
 ance is very frequently met with in hysteria. This 
 consists of a perversion of the normal color fields, 
 or of a reversal of the fields. In the normal eye the 
 fields for colors are not co-extensive. Thus, the 
 largest field is for white light; then come blue, red, 
 and preen. The smallest field is that for violet. In 
 hysteria these relations are altered. In some cases 
 there is a simple restriction of the color fields, in 
 their normal order, but nearly always there is a re- 
 versal of the fields. Thus, the most frequent change 
 is between the red and blue. Instead of blue oc- 
 cupying the largest field, as it does normally, its 
 place is taken by red. Parinaud, commenting upon 
 the fact that in hysteria the largest color field is that 
 for red, says that perhaps the well-known predilec- 
 tion of hysterics for red may be thus explained. 
 From a careful analysis of a large number of hys- 
 
8o 
 
 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 terical visual defects, Mitchell and De Schweinitz* 
 draw the following conclusions: (i) Achromatop- 
 sia is not present in the American cases. (2) Re- 
 versal in the normal sequence of the colors, so that 
 red is the largest field, is usually present when there 
 is anesthesia, but disturbance of color sense is not 
 
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 Jk-*^ - 
 
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 140% 
 
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 Fig. 4. — Normal Visual Field. The unshaded portion of the diagram 
 
 shows form field. Line blue field ; line + + + + red field ; line 
 
 — I 1 V green field. 
 
 necessarily associated with anesthesia. (3) The 
 green field is, relatively at least, more and more 
 often contracted than any other. (4) The violence 
 of the hysterical manifestation bears no relation to 
 the disturbance of the color sense. (5) The most 
 
 'Jour, of Nervous and Mental Dis. , 1894. 
 
SYMPTOMATOLOGY. 
 
 « 
 
82 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 frequent changes in the visual fields are : (a). Sim- 
 ple contraction for color but not for form ; (b) con- 
 traction of fields for both ; (c) partial or complete 
 reversal of normal sequence in size of color fields, 
 the red being most commonly the largest ; (d) loss 
 of parts of the visual field, as in the form of a hemi- 
 anopia, or greater contraction of the field on one side 
 than on the other, the greater contraction usually 
 being found on the same side with the anesthesia. 
 
 A symptom that is sometimes observed in hysteria 
 is polyopia. Generally, only two or three images of 
 an object will be seen, but occasionally more. Ul- 
 rich* mentions a case in which six images were per- 
 ceived. When there are two images, the false one 
 is outside ; when there are three, the two false 
 images are on either side of the true. According 
 to Pansier -j- the images are not always on the 
 same level, and sometimes one seems nearer the 
 eye than another. Concerning the nature of hyster- 
 ical polyopia the same author concludes that, while 
 muscular defects have an important bearing in the 
 production of the visual disturbance, it must be ad- 
 mitted that it is in part cerebral. There are some 
 facts that cannot be explained by hysterical involve- 
 ment of the eye muscles. 
 
 It is always necessary to bear in mind the extreme 
 susceptibility of hysterical subjects to suggestion. 
 The commonly observed visual hallucinations are, in 
 
 * Monatshl. f. Augenheilk., 1882. 
 
 f " Les Manifestations Occulaires," Paris, 1892. 
 
SYMPTOMATOLOGY. 83 
 
 all probability, due to suggestion, as are, perhaps, 
 the conditions sometimes observed of megalopsia or 
 micropsia. 
 
 The various affections of the eye muscles seen in 
 hysteria will be described in another place. 
 
 Visual disturbances occurring in hysteria have 
 long been recognized. Omitting vague references 
 to hysterical blindness in the early medical writings, 
 we find distinct reference to hysterical visual disturb- 
 ances in the writings of Charles Lepois in 1618, 
 and later by Pomme, Hocken, Szokalski, and others. 
 The great value and significance of this symptom 
 was not appreciated until the appearance of the 
 papers of Charcot, Galezowski, Parinaud, and Fere. 
 The subject has been very carefully studied in this 
 country by Mitchell and De Schweinitz. 
 
 Paresthesia and Hyperesthesia. — Not as con- 
 stant or as characteristic as anesthesia, but still 
 occurring commonly during the course of hysteria, 
 are certain perverted or abnormally active manifes- 
 tations of sensation. Just as we see the motor dis- 
 turbances varying from convulsion to paralysis, so 
 sensation may be greatly heightened, or entirely lost. 
 Paresthesias of all kinds are met with in hysteria. 
 Undoubtedly these may sometimes have the value 
 of hallucinations or illusions, with an organic basis. 
 Slight nutritive disturbances may alter the skin, and 
 thus furnish a foundation for the sensory phenomena. 
 Or there may be a slight neuritis present, such as is 
 not infrequently seen affecting the hands or feet of 
 elderly people. As a rule, however, the paresthe- 
 
84 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 sias of hysteria, like the other phenomena of the dis- 
 ease, are of central origin and not dependent upon 
 any structural alteration in the sense organ. Very 
 often these perverted sensations take the form of 
 flashes of heat or cold, either local or general. 
 Again, and this is one of the most familiar of the 
 hysterical paresthesias, there is present the sensation 
 of insects crawling over the skin, or a feeling as of 
 a snake or lizard under the skin. One of the most 
 common forms of perverted sensation is that of 
 numbness, and this is often accompanied by, or alter- 
 nates with, sensations of pricking, tingling, burning, 
 and the like. This sensation of numbness in hys- 
 teria is purely subjective, and must not be con- 
 founded with light grades of anesthesia. It is impos- 
 sible to classify these perverted sensations, since the 
 cause is central, and there is no limit to their extent 
 except the imagination and vocabulary of the sub- 
 ject. In my own experience the paresthesias of 
 hysteria do not follow any fixed rule either as to 
 location or extent. Sometimes the disturbance is 
 confined more or less to one side, but usually the 
 distribution is irregular. Negroes seem particularly 
 prone to these disturbances of sensation. 
 
 After studying hysterical anesthesia, and observ- 
 ing how distinct, regular, and well marked are its 
 areas of distribution, one is rather surprised to find 
 that hyperesthesia and, as was just mentioned, par- 
 esthesia by no means follow the same lines. Gen- 
 eral hyperesthesia of the skin of the whole body is 
 not common, at least in any marked degree. It is 
 
SYMPTOMATOLOGY. 85 
 
 by no means unusual to hear hysterical patients 
 complain of " tenderness " over the entire body, but 
 distinct general hyperesthesia is comparatively rare. 
 The same may be said of a one-sided hyperesthesia, 
 corresponding to the commonly observed hemi- 
 anesthesia. Such cases have been recorded by 
 Briquet, Gilles de la Tourette, and others, but they 
 certainly occur but rarely. Disseminated hyper- 
 esthesia is the most common variety ; islets or 
 patches, exquisitely sensitive, sometimes occupying 
 a considerable area, oftener of small extent, are to 
 be seen in a large number of hysterical subjects. 
 These hyperesthetic patches may occur side by side 
 with areas of anesthesia. One of the characteristic 
 features of hysterical hyperesthesia is that while a 
 light touch excites lively pain, firm, hard pressure is 
 not painful. This, however, is not an invariable 
 rule. It will be noticed that in this connection no 
 distinction is drawn between hyperesthesia and 
 hyperalgesia. This hyperesthesia is not confined 
 to the skin, but is quite frequently observed in 
 deeper structures. The mucous membranes, vagina, 
 urinary passages, rectum, mouth, or throat, may 
 be the seat of an exquisite hypersensibility. The 
 vagina and urinary passages are most commonly 
 affected in this way, giving rise to the well-known 
 symptoms of vaginismus and painful micturition. 
 Cases have been reported in which it became very 
 difficult to take food in the ordinary way, owing to 
 the extreme sensitiveness of the mucous membrane 
 of the mouth, throat, or esophagus. Reference has 
 
86 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 already been made to the hypersensitiveness of the 
 organs of special sense other than the skin, giving 
 rise to curious disturbances in vision, hearing, smell, 
 and taste. It is thus seen that only in a very gen- 
 eral way does hysterical hyperesthesia correspond 
 to the opposite condition — anesthesia. 
 
 Belonging to the same general category of hyper- 
 esthesias are the very common painful affections 
 met with in hysteria. Hysterical pains may be 
 superficial, corresponding roughly to the distribution 
 of certain nerves, or they may be deep and ap- 
 parently associated with, or at least referred to, the 
 brain, spinal cord, articulations, or thoracic or ab- 
 dominal viscera. To the first category belong the 
 various forms of hysterical neuralgia. Of course, it 
 is difficult to speak with any degree of certainty 
 about hysterical neuralgia. Pain along the course 
 of a nerve, or at its point of emergence from a canal, 
 is still of too obscure a nature to admit of the dis- 
 tinction being sharply drawn between what is and 
 what is not hysterical. Headache, of various kinds, 
 is quite common among hysterical subjects, and so 
 far as we can judge is often a purely hysterical 
 symptom. The most characteristic of these head 
 pains, though among the rarest of them, is the clavus 
 hystericus, so graphically described by Sydenham. 
 The seat of this pain is usually the vertex, and it 
 is generally limited to a very small area. The 
 intensity of the suffering and the concentration to 
 one spot, suggested to the older writers, often so 
 happy in their similies, the idea of a nail being driven 
 
SYMPTOMATOLOGY. 87 
 
 into the skull. The duration of clavus hystericus is 
 variable, lasting from a few hours to several days. 
 Hysterical head pains of this nature have given rise 
 to the expression " pseudomeningitis," which will be 
 considered further on. Trifacial neuralgia, pain in the 
 temple or eyes, a sort of migraine, hysterical tooth- 
 ache, — this latter having been described by Syden- 
 ham, — are some of the more important varieties of 
 face pains that are common in hysterical subjects. 
 Pain is often felt in the throat, associated with the 
 well-known globus hystericus, or with aphonia. The 
 most common form of hysterical pain occurring in 
 the trunk is intercostal neuralgia. This pain does not 
 follow strictly the distribution of the intercostal nerves, 
 but is very often complained of over the region of 
 the heart, and is commonly associated with palpita- 
 tion or a sensation of movement of the heart. Pain 
 in the region of the heart will sometimes, in hysteri- 
 cal subjects, more or less closely simulate angina 
 pectoris. The suffering is intense, the pain radiates 
 through the chest and down the arms and is attended 
 with many of the mental symptoms of the organic 
 disease. The condition of the heart, the age of the 
 patient, the provoking causes, and the fact that the 
 hysterical affection generally occurs with great fre- 
 quency, indicate the correct diagnosis in most cases. 
 Pain in the mammary gland — " hysterical breast " 
 — has long been known, though its hysterical nature 
 was not at first generally recognized. An excellent 
 description of it is given by Brodie. The affection 
 is nearly always unilateral, and the pain, which is 
 
88 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 intense, is situated in the mammary gland, but may 
 radiate down the arm. There can be no doubt of 
 the fact that now and then cases of undoubted 
 hysterical nature are seen in which there is slight 
 tumefaction and even redness of the skin. The 
 mammary gland is one of the marked hysterogenic 
 zones, and irritation of the skin, as by light rubbing 
 or manipulating the gland, will often bring on con- 
 vulsive paroxysms. 
 
 Probably the frequent occurrence of cancer in this 
 region has done much to determine, through sugges- 
 tion, the seat of this hysterical manifestation. The 
 recognition of the hysterical breast is important, 
 since it has happened that amputation has been re- 
 sorted to on the supposition that some grave organic 
 disease existed. 
 
 The fact that has been mentioned — namely, that 
 distinct tumefaction has not infrequently been ob- 
 served in cases the nature of which was perfectly 
 clear — makes the differential diagnosis not always 
 easy. As a rule, other marked hysterical symptoms 
 exist : rubbing of the breast induces a paroxysm of 
 a hysterical nature, and, finally, a cure can nearly 
 always be brought about by a psychic form of treat- 
 ment. 
 
 Another very common seat of hysterical pain, 
 either spontaneous or provoked by pressure, is the 
 vertebral column. As a rule, the nape of the neck, 
 the region so frequently complained of in neuras- 
 thenia, is not involved, or at least is not so much in 
 evidence as the rest of the vertebral region. The 
 
SYMPTOMATOLOGY. 89 
 
 pain may exist as a more or less continuous dull 
 aching, or may appear only when pressure is made 
 over the spine. These cases may sometimes be 
 mistaken for Pott's disease ; in fact, the French 
 school recognizes a pseudo-Pott's disease. Brodie * 
 long ago called attention to the resemblance between 
 the early stages of spinal caries and its hysterical 
 imitation. Careful examination, watchful and intel- 
 ligent observation, and proper treatment will rarely 
 fail to clear up the nature of the case. More com- 
 mon than the foregoing symptom is what is called 
 hysterical arthralgia. Brodie recognized the im- 
 portance of this affection, or rather the close resem- 
 blance which often exists between hysterical and 
 structural joint disease, and has left a number of 
 valuable observations on the subject. He says : 
 " There is a class of cases of no infrequent occur- 
 rence in which the patient suffers considerable dis- 
 tress in consequence of pain referred to some of the 
 larger articulations. The disease appears to depend 
 on a morbid condition of the nerves, and may be 
 regarded as a local hysterical affection. At first 
 there is pain, referred to the hip or knee or some 
 other joint, without any evident tumefaction ; the 
 pain soon becomes very severe, and by degrees a 
 puffy swelling takes place ; the swelling is diffuse 
 and in most instances trifling. There is always 
 exceeding tenderness, connected with which we may 
 observe this remarkable circumstance : that gentle 
 
 * " Diseases of the Joints." 
 
90 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 touching or pinching the integument, in such a way 
 that the pressure cannot affect the deeper seated 
 parts, will often be productive of much more pain than 
 the handling of the limb in a more rude and careless 
 manner." 
 
 As a rule, only one joint is involved, and the joints 
 most usually affected are the knee and hip. Char- 
 cot states that of 70 cases of hysterical arthralgia 
 the knee was the seat of the affection in 38 in- 
 stances, the hip in 18, the wrist in 8, the shoulder 
 in 4, and the ankle in 2. There is generally a 
 zone of hyperesthesia about the affected joint. Of 
 course, careful examination under an anesthetic 
 will often, though by no means always, clear up the 
 case. It is in this class of cases that traumatism 
 plays such an important part, and a great proportion 
 of such cases are attributed to accidents which are 
 nearly always trivial. 
 
 There is a variety of hysterical hyperesthesia, 
 constant and characteristic, about which so much has 
 been said and written that it may be called a classic 
 symptom of hysteria — ovarian tenderness. It has 
 long been recognized that tenderness over the belly 
 was characteristic of hysteria. This symptom fig- 
 ures largely in the accounts that have come down to 
 us of the violent epidemics of hysteria of the middle 
 ages. This tenderness was vaguely located in the 
 lower part of the abdomen, and it was reserved for 
 Charcot to show that the pain was deep-seated, and 
 either in the ovary itself or its nerve-plexuses. This 
 fact — the location of the pain in the ovary and not 
 
SYMPTOMATOLOGY. 91 
 
 in the abdomen generally — has been amply con- 
 firmed by years of observation since its first an 
 nouncement. Many cases of displaced ovary in 
 hysterical subjects have proved that the tenderness 
 is in, and not around, the gland. Of course, this 
 applies to normal, and not to diseased, ovaries — a 
 fact that has not been fully appreciated, since many 
 ovaries are annually removed because of the hys- 
 terical pain located in them. Sometimes in males 
 there are tender spots corresponding to the situa- 
 tion of the ovaries in the female. In a case of hys- 
 teria in a man, recently under my care, these tender 
 zones were very well marked. In certain cases of 
 hysteria in the male the testicles seem to be abnor- 
 mally sensitive to pressure, and not infrequently 
 the seat of pain or disagreeable sensations. The 
 mammary glands often present painful areas, and 
 there are two distinct painful spots, one just 
 above, the other below, the gland. These circum- 
 scribed areas of hyperesthesia are known as hys- 
 terogenic zones. The most constant and charac- 
 teristic are the ovarian, the mammary, the supra- 
 and infra-mammary, and the spinal. Many other 
 zones have been described — about the head, throat, 
 scapulae, intercostal region, limbs, mucous mem- 
 branes, etc. ; but the ones mentioned above are the 
 most important. The significance of these hystero- 
 genic zones, as first described by Charcot, is that 
 light pressure or rubbing at these spots induces 
 some hysterical paroxysm, sometimes slight, again 
 severe, depending upon the nature of the special 
 
92 
 
 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 case. After the induction of the hysterical par- 
 oxysm, forcible and long-continued pressure will in 
 
 Fig. 6. — Hysterogenic Zones [anterior). 
 
 many cases cut short the paroxysm. It is interest- 
 ing in this connection to recall the curious proced- 
 
SYMPTOMATOLOGY. 
 
 93 
 
 ures, mentioned in chapter i, which were prevalent 
 in the epidemics of the middle ages : such as tying 
 
 Fig. 7. — Hysterogenic Zones [posterior). 
 
 a cord tightly around the waist and twisting a 
 stick which was thrust into it until the paroxysm 
 
94 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ceased ; and a similar treatment — that of striking or 
 kicking the abdomen of a person seized with a fit. 
 
 The following cases will illustrate the phenomena 
 of hysterogenic zones : A negro girl was brought into 
 the City Hospital with grand hysteria. She lay on 
 the floor in the " crucifix attitude," perfectly still and 
 rigid, until the ovarian or inframammary regions 
 were pressed upon, when a convulsive seizure would 
 come on. In this case deep pressure did not entirely 
 succeed in breaking up the attack. Another girl in 
 hysterical lethargy could only be awakened by deep 
 pressure over the ovary. A young married woman 
 was thrown into an attack of grand hysteria by rub- 
 bing the spinal region, and the attack was cut short 
 by continuous forcible pressure in the same region. 
 In none of these cases had similar procedures ever 
 been resorted to, so that there could have been no 
 element of suggestion. Sometimes one of these 
 zones, sometimes another, will be found most sensi- 
 tive; and, on the other hand, patients profoundly 
 hysterical may exhibit no hysterogenic areas. In some 
 subjects there occur pains or disagreeable sensations 
 in one or more of these zones, preceding an attack, 
 thus simulating the epileptic aura. 
 
 This brief description of the disturbances of sen- 
 sation met with in hysteria — namely: anesthesia, 
 paresthesia, and hyperesthesia — show T s us that the first, 
 or anesthesia, is the most common, and follows a more 
 regular course of distribution than the other two 
 varieties. Paresthesia is not very well defined, and 
 is often not to be differentiated from anesthesia on 
 
SYMPTOMATOLOGY. 95 
 
 the one hand and hyperesthesia on the other. Hy- 
 peresthesia, while not as characteristic a stigma as 
 anesthesia, is very generally present in hysteria, and 
 has associated with it that very peculiar and little 
 understood phenomenon of hysterogenesis. 
 
 The three illustrative cases mentioned above — 
 and many more could be cited from the writer's ex- 
 perience — are valuable in confirming the fact of 
 hysterogenesis as originally enunciated by Charcot, 
 since none of these subjects could possibly have 
 known the meaning of the pressure upon certain 
 spots. I refer to this especially because the pheno- 
 menon of hysterogenesis has been doubted, and it 
 has been alleged that the phenomena were the result 
 merely of suggestion. 
 
CHAPTER IV. 
 
 DISTURBANCES OF MOTION: TREMOR, 
 CONTRACTURE, PARALYSIS. 
 
 In studying the sensory disturbances of hysteria, 
 a very formidable difficulty presents itself in the fact 
 that the symptoms are purely subjective. The 
 patient declares that sensation is perverted or lost, 
 and the statement must be accepted, since there are 
 no means of proving or disproving such a statement 
 absolutely. There are no associate symptoms, such 
 as are present in anesthesia from cord or nerve 
 lesion. This same difficulty exists, and is on the 
 whole more pronounced, in dealing with hysterical 
 disturbances of motion. In organic paralysis the 
 associate symptoms, such as loss or exaggeration 
 of the reflexes, muscular atrophy, alterations in 
 the response to the electric currents, and so forth, 
 tell the story for diseases of the cord ; and if to these 
 symptoms we add the sensory disturbances and 
 pain following the course of the diseased nerves, the 
 history of the case, the form of the paralysis, the 
 eye symptoms in brain disease, the picture of some 
 organic lesion is fairly distinct. In hysterical motor 
 disturbances, on the other hand, there is only the 
 bald statement of the patient. No symptoms pre- 
 sent themselves to confirm the patient's statement 
 
 that paralysis exists — the motor disturbance by no 
 
 9 6 
 
DISTURBANCES OF MOTION. 97 
 
 means always conforms to any organic lesion — and 
 the appearance of the affected parts stands as con- 
 tradictory evidence against the patient's word. And 
 vet a careful study of such cases will always, or 
 ought always, convince the physician of the truth of 
 what the hysterical subject says in regard to these 
 symptoms. The limb cannot be moved, the con- 
 tracture cannot be overcome under any ordinary 
 stimulus. Let this stimulus, however, be abnormally 
 strong — some sudden and intense emotion — and the 
 hysterical paralytic becomes as active as ever. In 
 other words, the motor apparatus is unimpaired, 
 but the power to put this mechanism into action is 
 wan tin P". 
 
 All these facts are in harmony with the theory 
 advanced in another chapter ; namely, that the lower 
 centers are not involved, or only slightly involved, 
 in hysteria, while the higher centers, or centers of 
 volition, are at fault. An explanation of the fact 
 that these higher centers can be aroused by a stim- 
 ulus of great intensity is offered in the assumption 
 that the protoplasm of the cells composing these 
 centers has been expended in great part, and hence 
 it requires a very strong stimulus to excite what 
 might be called the residual or reserve protoplasm. 
 
 Disturbances of motion naturally fall into four 
 categories: (i) Tremor. (2) Contracture. (3) 
 Paralysis. (4) Convulsion. It would, perhaps, be 
 more in accordance with physiological teaching if 
 the arrangement placed tremor and convulsion in 
 one class, and contracture and paralysis in another. 
 9 
 
98 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 Slight disturbance of the motor apparatus, or over- 
 use of it, occasions tremor ; sometimes due to a 
 central lesion, sometimes to muscular fatigue. If 
 the irritation be carried further, convulsive move- 
 ments result, with perhaps more or less contracture 
 remaining, and the final stage is paralysis. For pur- 
 poses of convenience the arrangement given above 
 will be followed, except that the convulsive attack 
 will be described in a special section. 
 
 Tremor. — A symptom that has not attracted 
 much attention, but one that is usually present in 
 hysteria, is tremor. It is one of the stigmata of the 
 interparoxysmal state. It may involve the whole 
 body, or be confined to one side — the hemiplegic 
 form — or even show itself in but a single limb. The 
 movements are of slight range, and vary in fre- 
 quency from four to ten oscillations per second. 
 Modifying the classification of Charcot and Dutil, 
 there are two distinct varieties of hysterical tremor : 
 ( i ) Tremor persisting during repose and very slightly 
 affected by voluntary movements. The oscillations 
 are sometimes comparatively slow, three to five per 
 second, or more rapid, eight to nine. (2) Tremor 
 which may or may not be present during repose, but 
 which is greatly exaggerated by voluntary move- 
 ments. The number of oscillations in this form of 
 tremor range from five to seven per second. The 
 first variety may be compared to, and indeed often 
 closely resemble, the tremor of exophthalmic goiter, 
 alcoholism, mercurial or senile tremor ; the second 
 variety simulates the intention tremor of multiple 
 

 DISTURBANCES OF MOTION: TREMOR. 99 
 
 sclerosis. Tremor is not as constant or as charac- 
 teristic a symptom as anesthesia, but is present in 
 some degree in most cases. It would seem to be 
 especially common in men and children. Usually 
 its mode of onset is sudden, especially following 
 same traumatism or shock. Perret* relates the case 
 of a girl, aged eleven, in whom the tremor began 
 suddenly after a fright. The whole body was in- 
 volved, and the severity of the tremor was such that 
 it interfered with the use of the hands. Gilles de la 
 Tourettef mentions several cases in which the hand- 
 writing was greatly altered by hysterical tremor. 
 It is probable that all the cases of distinct rhythmic 
 chorea should be included under the head of hys- 
 terical tremor. While hysterical tremor is usually 
 associated with other stigmata of the disease, it is 
 certainly quite often seen in mild cases of hysteria, 
 particularly mental hysteria where the somatic stig- 
 mata are absent or very slightly marked. The 
 duration of hysterical tremor, like most of the inter- 
 paroxysmal symptoms of hysteria, is very variable. 
 Some cases last but a few months, while others will 
 extend over years. The tremor becomes most 
 marked after an attack, and pressure upon the hys- 
 terogenic zones will generally intensify the move- 
 ments. The relation between hysterical tremor and 
 certain metallic tremors has attracted attention. In 
 some instances it would seem that such poisons as 
 lead and mercury predispose to hysteria, and that 
 
 * Lyon Med. , Sept. ,1891. f Op. cit. 
 
ioo HYSTERIA: ITS NATURE AND TREATMENT. 
 
 the tremor seen in these cases was not due to the 
 metallic poison but was hysterical in nature. 
 
 Contracture. — Contracture is a more pronounced 
 and characteristic symptom of hysteria than the one 
 just described, tremor, though much less common 
 than anesthesia. The older writers, such as Briquet,* 
 Brodie,*j" and Duchenne, J while noting the existence 
 of contracture, described very few cases. Charcot § 
 and his pupils have carefully studied the whole ques- 
 tion, and have added greatly to the clinical picture. 
 Charcot, especially, calls attention to what he calls 
 the contracture diathesis. This curious neuromus- 
 cular state does not manifest its presence by any 
 objective sign, as Richer || points out, and the person 
 affected has free use of the muscles. The contrac- 
 ture is provoked by massage of the muscles, blows 
 on the tendons, sudden flexion of the limbs, faradiza- 
 tion of muscle or nerve, and other stimuli. The 
 tendon reflexes are usually considerably heightened, 
 and electrocontractility is modified. This modifica- 
 tion, as was first shown by Richer, consists, for the 
 main part, in a tendency of the current to spread ; 
 that is, to cause contractions of other groups of 
 muscles than the one directly excited by the current. 
 The contracture diathesis resembles the hypnotic 
 state in many of its features, and it is probable that 
 many of the phenomena observed are due entirely 
 to suggestion. Contracture is most frequently ob- 
 
 * Op. cit. f Op. cit. \ " De P Electrisation Localisee." 
 
 | Op. cit. || " Paralysies et Contractures Hysterique," Paris, 1892. 
 
DISTURBANCES OF MOTION: CONTRACTURE. 101 
 
 served after a convulsive attack, though it is a com- 
 mon interparoxysmal symptom. When not directly 
 preceded by an attack of grand hysteria it can usu- 
 ally be traced to some exciting cause, such as trau- 
 matism, neuralgic pain, fright, and the like. The 
 tendency of contracture to follow very trivial injuries 
 makes it worthy of careful consideration. While 
 occasionally contracture may develop gradually, fol- 
 lowing amyosthenia, paralysis, or spasmodic seizures, 
 as a rule its appearance is sudden. An hysterical 
 patient has had a convulsive seizure, and upon 
 regaining- consciousness contractures of one or more 
 limbs are seen. The grand attack passes like a tor- 
 nado, and leaves ereater Q r less destruction in its 
 wake, now paralysis, now contracture ; changing the 
 nature or degree of the interparoxysmal symptoms, 
 or adding new ones. 
 
 It is to be noted that the contractures attributed 
 to traumatism rarely follow any grave injury. A 
 slight cut or burn, a blow causing no apparent in- 
 jury, a fall, are some of the common causes. Con- 
 tracture is very liable to follow an injury attended 
 with emotional circumstances, especially if there is 
 an added suggestion. In traumatic cases the seat 
 of the injury determines, in a general way, the ex- 
 tent and location of the contracture. Contracture 
 may affect only part of a muscle bundle, giving rise 
 to what Weir Mitchell calls a muscular tumor, or 
 it may involve wide-spread groups of muscles. 
 Again, while usually attacking voluntary muscles, 
 it is not uncommon to see involuntary muscles 
 
102 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 affected, as, for example, the contracture of the in- 
 testines. A convenient classification of hysterical 
 contracture is that given by Axenfeld and Huchard.* 
 With some modifications it is as follows: (i) Con- 
 tracture following the monoplegic type, in which a 
 single limb is involved. (2) The paraplegic type, 
 in which both lower limbs are affected, either simul- 
 taneously or one after the other. (3) The hemi- 
 plegic type. (4) The crossed form, the leg on one 
 side and the arm on the other. (5) The rare gen- 
 eral form, in which all four extremities are involved. 
 (6) The periarticular form, in which the muscles 
 about the joints are affected. (7) The irregular 
 form, under which might be classed certain partial 
 contractures, such as torticollis, and the facial mus- 
 cles, and also involuntary muscles. In the mono- 
 plegic form the leg is the most frequent seat of the 
 affection, according to the French school. Gowers f 
 thinks that the arm is affected oftener than the 
 leg. In contracture of the upper extremity the 
 fingers are strongly flexed on the palm. They may 
 be flexed at the metacarpophalangeal joints and 
 extended at the phalangeal. The wrist is usually 
 strongly flexed, and the forearm is flexed upon the 
 arm, and either pronated or supinated. Sometimes 
 the hand alone is involved, or even one finger. 
 The following case illustrates the monoplegic type 
 in the upper extremity : An intelligent sailor had a 
 
 * " Traite des Nevroses. " 
 
 f •' Diseases of the Nervous System.' 
 
DISTURBANCES OF MOTION: CONTRACTURE. 103 
 
 fall on board ship, and shortly after came under my 
 care at the City Hospital. A most careful examina- 
 tion failed to reveal any injury whatever about the 
 shoulder or arm. Immediately after the fall the 
 arm was contractured, and when admitted into the 
 
 Fig. 8. Fig. 9. Fig. 10. 
 
 Forms of Contracture of Hand and Wrist. — [After Richer.) 
 
 hospital he was entirely unable to use it. His 
 fingers were strongly flexed, at both metacarpo- 
 phalangeal and phalangeal articulations ; the wrist 
 was flexed on the forearm and the latter strongly 
 
104 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 flexed on the arm. If great force were used, the 
 contracture would change its form, but could not be 
 overcome. The usual position of the arm was 
 flexion of the forearm on the arm, pronation of the 
 forearm, and adduction of the arm. When a forci- 
 ble attempt was made to overcome the contracture 
 the position of the parts changed ; the forearm sud- 
 denly became strongly supinated, the wrist ex- 
 tended, and the arm abducted. 
 
 In contracture of the lower extremity the leg is 
 forcibly extended. Charcot,* in describing a typical 
 case, says : " The left lower limb is in a state of exten- 
 sion ; the thigh is strongly extended and also the leg ; 
 the foot shows marked equinovarus. All the adduc- 
 tor muscles of the thigh are rigid, all the joints fixed, 
 and the limb as a whole is like a bar of iron." He 
 regards this as the characteristic position, and con- 
 siders flexion of the lower limb as exceptional. 
 Other writers seem also to regard the occurrence of 
 flexion of the leg as rare. The following case is an 
 instance of flexion of the lower extremity : Mary Y., 
 aged thirty-five, profoundly hysterical for years. She 
 exhibited, during the time she was under my obser- 
 vation, nearly every recorded stigma of hysteria, from 
 anesthesia to ischuria. The left leg was strongly 
 flexed on the thigh and the thigh upon the abdomen. 
 This contracture had lasted for a year at least, and 
 probably somewhat longer. The whole of the leg, 
 and in fact the entire left side, was anesthetic. The 
 
 * Loc. cit. 
 
DISTURBANCES OF MOTION : CONTRACTURE. 
 
 105 
 
 contracture was readily cured by suggestive treat- 
 ment. 
 
 The hemiplegic form of contracture involves the 
 arm and leg of the same side, the arm being usually 
 flexed and the leg extended. 
 The left side is more often af- 
 fected than the right. Usually, 
 both extremities are involved 
 simultaneously, though the con- 
 tracture may attack first one 
 and then the other. As this 
 form of contracture not infre- 
 quently follows hysterical par- 
 alysis, it is necessary to dis- 
 tinguish between hysterical and 
 organic contraction. This is, as 
 a rule, not difficult, since the 
 contraction of secondary de- 
 generation is very gradual in 
 its onset. Other points of dif- 
 ference will be noted in the 
 chapter on Differential Diag- 
 nosis. 
 
 In the paraplegic form of hys- 
 terical contracture the legs are 
 both extended and adducted. It 
 appears after a convulsive attack, or follows paralysis 
 of the lower extremities. Rare cases are reported of 
 contracture of all four extremities, but this is generally 
 a transient condition, in which first one then the other 
 side is involved. The periarticular form of con- 
 
 Fig. 11. — Contracture of 
 the Lower Extremity. 
 —{After Richer) 
 
io6 
 
 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 tracture may simulate very closely some of the vari- 
 eties of talipes, especially equinovarus, and, as has 
 been pointed out elsewhere, contracture of the mus- 
 cles about the hip-joint has not infrequently been 
 mistaken for coxalgia. Besides the varieties of con- 
 
 Fig. 12. — Hysterical Contracture of 
 the Foot : Equinovarus Type. — [After 
 Richer S 
 
 Fig. 13. — Contracture of 
 Foot without Con- 
 tracture of the Toes. 
 — {After Richer.) 
 
 tracture mentioned above, involving the muscles of 
 the trunk and extremities, it is not uncommon to see 
 contractures of the facial and ocular muscles, of the 
 laryngeal muscles, of the esophagus, vulva, stomach, 
 
DISTURBANCES OF MOTION: CONTRACTURE. 107 
 
 intestines, etc. Contracture of the facial muscles, 
 simulating facial paralysis, not infrequently occurs 
 after a convulsive attack. Contracture of the mus- 
 cles of the lower jaw, giving rise to hysterical teta- 
 nus, is not rare. The following cases* are illustra- 
 tive : A negress, under my care at the City Hospital, 
 with marked hysterical stigmata, showed, after each 
 convulsive attack, rigid contracture of the temporal 
 and masseter muscles, lasting for several hours. 
 No other muscles of the body were affected with 
 contracture, and there was no paralysis. 
 
 In another case, also a negress, the hysterical at- 
 tack came on after a slight traumatism. After the 
 convulsive seizure the jaws remained so tightly 
 clenched that it became impossible to feed her. She 
 was cured by suggestion. 
 
 A more persistent case was that of a young white 
 woman, with general hysterical symptoms and his- 
 tory, but presenting no stigmata other than con- 
 tracture of the muscles of the jaw. This condition, 
 which had lasted for a week, and which prevented 
 her from taking any but liquid food, w T as readily 
 cured by suggestion. Contracture also affects the 
 muscles of the eye, and while the cases are not per- 
 haps very frequent, still enough authentic and care- 
 fully observed instances have been reported to show 
 that the muscles of accommodation may be involved, 
 causing, as Galezowski, Parinaud, Borel, and others 
 have pointed out, a true hysterical myopia or hyper- 
 
 * Jour. Amer. Med. Assoc, Jan., 1 894. 
 
108 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 opia. In like manner the muscles moving the eye- 
 ball may be the seat of hysterical spasm or con- 
 tracture, causing strabismus, diplopia, and other 
 muscular defects. More common still rs hysterical 
 blepharospasm, which may be unilateral or bilateral, 
 and ptosis is also met with. Hysterical contracture, 
 as has been noted, does not spare involuntary mus- 
 cle. It is most probable that the classic symptom, 
 globus hystericus, is, in part at least, a contracture. 
 Some patients describe this peculiar phenomenon as 
 a ball which begins in the region of the stomach and 
 rapidly ascends to the throat. When it has reached 
 the throat it remains a greater or less length of time 
 in that position. Rarely, the ball seems to descend. 
 Sometimes there is the sensation of a very small 
 body in the throat, and again merely a sense of con- 
 striction. While, perhaps, a large part of this phe- 
 nomenon is purely psychic, and belongs to the cate- 
 gory of sensory disturbances, it is probable that there 
 is present more or less contracture of muscle fiber. 
 From this symptom probably came the old idea 
 (chap, i) that in hysterical attacks the uterus slipped 
 from its moorings and wandered to the throat. 
 
 Contractures of the stomach and intestines have 
 been mentioned. Contracture of the bladder, with 
 retention of the urine, is not uncommon. In hysteri- 
 cal vaginismus there is muscular contraction as well 
 as hyperesthesia. Contracture of the muscles of 
 the abdomen and intestines gives rise to the well- 
 known " phantom tumors." Contracture, or rather 
 spasm, of the diaphragm sometimes occurs, as in 
 
DISTURBANCES OF MOTION: CONTRACTURE. 109 
 
 the case of a young man apparently healthy who 
 presented himself at my clinic With this symptom. 
 Every one or two minutes there would be a violent 
 contraction of the diaphragm, interfering somewhat 
 with respiration ; the case was speedily cured by 
 suggestion. Hysterical spasm of the larynx is some- 
 times seen, both inspiratory and expiratory, occasion- 
 ing cough or modification of the voice, and interfer- 
 ing more or less with respiration. In addition to 
 this, the common form of contracture, Richer calls 
 attention to another variety in which there is severe 
 pain at the seat of contracture. While, of course, 
 any muscles may be involved in hysterical contrac- 
 ture, the varieties given above are the ones com- 
 monly seen. 
 
 Hysterical contracture, as has been noted, almost 
 always comes on suddenly, and generally follows a 
 convulsive seizure or traumatism. The muscles are 
 very rigid, and it is generally impossible to overcome 
 the contracture by force, though often the form of 
 the contracture may be altered. The reflexes are 
 not greatly changed, though there is a tendency to 
 exaggeration. Charcot has called attention to the 
 fact that in some cases of contracture of the leg, 
 ankle clonus may be obtained. The electric reaction 
 is slightly altered, as was shown in speaking of the 
 contracture diathesis. An important fact to be noted 
 is that in hysterical contracture, however long the 
 time that the limb may have been flexed or extended, 
 it rarely happens that any change takes place in the 
 joint. 
 
no HYSTERIA: ITS NATURE AND TREATMENT. 
 
 In one of the cases mentioned above, the left leg 
 had been flexed at the knee, and the thigh at the hip- 
 joint, for a year or longer. The sister of the patient, 
 a very intelligent woman, told me that during that 
 time she had never seen the limb extended, though 
 she had observed it carefully both day and night. 
 Under partial hypnotic suggestion the limb was 
 straightened out, and the movements of the joints 
 were perfect. On the other hand, in a case in which 
 hysterical contracture was suspected, chloroform 
 anesthesia failed to produce relaxation, and a diag- 
 nosis of non-hysterical contracture was made, which 
 was confirmed by an operation upon the diseased 
 joint. The slighter forms of contracture relax dur- 
 ing sleep, though it will be seen, from the case related 
 above, that the more severe cases retain the contrac- 
 ture continuously. The administration of chloroform 
 or ether is practically a perfect test, since it rarely, 
 if ever, happens that complete relaxation does not 
 follow profound narcosis. Nutrition is not greatly 
 affected, though in long-continued cases there may 
 be slight general atrophy from disuse. This, how- 
 ever, is never as marked as the atrophy which fol- 
 lows the disuse of a limb subsequent to fracture. 
 Perhaps, in certain rare cases, some degeneration 
 may take place involving the cord, and Charcot has 
 put on record an instance of this. In the case 
 referred to, a hysterical contracture, which at first 
 was intermittent, finally became permanent, and an 
 autopsy revealed a sclerosis of the lateral columns 
 of the cord. It must be admitted that the notion 
 
DISTURBANCES OF MOTION : PARALYSIS. ill 
 
 of degeneration following hysterical contracture is 
 based very largely upon this single case. It is diffi- 
 cult to determine whether there is loss of strength 
 in the contractured muscles, but it would seem that 
 this is generally the case. The association, as we 
 have seen, is very close between contracture and 
 paralysis, one often following the other. Certain it 
 is that there nearly always exists an anesthesia, 
 which may involve the entire side or only the con- 
 tractured muscles. This can nearly always be dem- 
 onstrated, even in cases of very limited contracture 
 — as, for example, blepharospasm — and constitutes 
 a valuable diagnostic sign. 
 
 The duration of hysterical contracture cannot be 
 fixed; it may last days, months, or years. It may 
 be continuous, or complete remissions may occur. 
 The disappearance of hysterical contracture, like its 
 onset, is usually sudden. It may cease without 
 obvious cause, or be cut short by suggestive treat- 
 ment, hypnotic or non-hypnotic, by the faradic cur- 
 rent, or some sudden, intense emotion. 
 
 Hysterical Paralysis. — Loss of power, or loss 
 of control over the muscles, is a very common 
 symptom of hysteria, and has been recognized since 
 the days of Hippocrates, in whose writings can be 
 found a very clear description of this symptom. 
 Sydenham, Pomme, Brodie, Laycock, and in fact all 
 the early writers on hysteria, have described hysteri- 
 cal paralysis. In a paper by John Wilson, pub- 
 lished in the " Medico-Chirurgical Transactions," of 
 London, for the year 1838, there is an excellent 
 
H2 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 description of some of the varieties of hysterical 
 paralysis, and, what is interesting, an outline of'treat- 
 ment by seclusion, rest, etc. Briquet met with some 
 form of paralysis 120 times in his 433 cases, and 
 Landouzy found it 40 times in 370 cases. My own 
 experience leads me to think that it is much less 
 frequently seen in this country than some of the 
 other stigmata. The onset of paralysis may be 
 gradual, being preceded by a certain amount of 
 muscular weakness or incoordination ; or it may be 
 sudden, as in the case of hysterical hemiplegia. 
 The paralysis may be entirely an interparoxysmal 
 symptom, or, as most frequently happens, may 
 appear immediately after a convulsive attack. In 
 common with other symptoms, it may take the place 
 of some other stigma, occurring on the disappear- 
 ance of anesthesia, contracture, or the like. Many 
 instances are related of the appearance of paralysis 
 after some sudden emotion. Akin to this is the 
 paralysis which follows some insignificant injury — 
 traumatic hysteria. It is not uncommon to see cer- 
 tain mild forms of hysterical paralysis after the 
 subsidence of some acute affection ; such, for ex- 
 ample, as typhoid fever. It is possible that some of 
 the cases reported as post-febrile neuritis are in 
 reality hysterical in character. 
 
 The most important of the causes that seem to 
 bear upon the production of hysterical paralysis is 
 the convulsive attack ; as has been pointed out, 
 this is the highest manifestation of hysteria. It is 
 the acute attack, and nearly always leaves some 
 sequelae. 
 
DISTURBANCES OF MOTION : PARALYSIS. 113 
 
 Next in importance as an etiological factor is trau- 
 matism. It is often difficult to decide between true 
 hysterical paralysis and wilful deception, when trau- 
 matism has been the exciting cause and a damage 
 suit is in prospect. 
 
 Hysterical paralysis varies in degree from slight 
 impairment of strength to entire loss of power. It 
 is not uncommon to hear hysterical patients com- 
 plain of sudden weakness, generally, however, of 
 short duration. Sometimes the arm becomes help- 
 less, and anything held in the hand will be dropped ; 
 or, what is perhaps more common, the weakness at- 
 tacks the legs, and the patient falls or has to sit 
 down at once. This muscular weakness, to which 
 the name amyosthenia has been given, is usually 
 hemiplegic in form. When one limb only is involved, 
 all the muscles, both flexors and extensors, are 
 affected. The most certain way to test this loss of 
 power is by means of the dynamometer. Repeated 
 tests should be made, comparing the affected with 
 the sound side, and recording the results for future 
 reference. In order that the tests be accurate, the 
 patient should not be allowed to look at the index 
 while pressing the dynamometer. Passing on to the 
 more pronounced forms of motor disturbance, we see 
 all varieties of paralysis. The most common type is 
 the hemiplegic, and the attack, which usually pre- 
 cedes the onset of the paralysis, resembles in some 
 degree an ordinary apoplexy. It may come on sud- 
 denly or gradually, and with or without loss of con- 
 sciousness. Sometimes instead of an attack the 
 
U4 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 patient sinks into a profound sleep, and the paralysis 
 appears after awakening. The left side is more fre- 
 quently involved than the right. When the attack 
 comes on gradually one limb is first involved, and 
 after a greater or less length of time the other limb 
 becomes affected ; sometimes it is the lower limb 
 that suffers first, again the upper. The paralysis is 
 generally more marked in the lower than in the upper 
 extremity. When the paralysis is only of moderate 
 degree, and the patient able to walk, the paralyzed 
 foot is dragged and not swung outward in a half 
 circle as is seen in organic hemiplegia. As Rey- 
 nolds* remarks, the hysterical patient looks at the 
 observers when attempting to walk, and not at the 
 ground, as the true hemiplegic does. 
 
 The face is rarely ever involved in hysterical hemi- 
 plegia. Until very recently it was stated that this 
 was invariable, and a valuable diaenostic sign. 
 Thus Axenfeld and Huchard, Gowers, Dana, and 
 most authors state that the face is never affected, 
 and Charcot formerly held this same view. In the 
 last three or four years, however, several cases of 
 undoubted hysterical hemiplegia, accompanied by 
 facial paralysis, have been reported. Ballet f refers 
 to three cases noted by Chantmesse, and relates one 
 case of his own. It was formerly taught, especially 
 by Charcot, that what appeared to be facial paralysis 
 was in reality contracture, and that the movements 
 
 * " System of Medicine." 
 j- L ' Un ion Med. , 1890, 
 
DISTURBANCES OF MOTION: PARALYSIS. 115 
 
 of the apparently paralyzed side were impaired solely 
 by the strong contracture of the opposite side. It 
 must be admitted that while facial paralysis is a very 
 infrequent accompaniment of hysterical hemiplegia, 
 still it does sometimes occur. 
 
 While, as has been said, hysterical paralysis may 
 be absolute, this is far from common. Usually the 
 loss of power is only partial, and the patient will 
 be able to drag the limb or slightly raise the arm. 
 The deep reflexes are normal or slightly exaggerated, 
 and sometimes, though rarely, ankle clonus can be 
 obtained. The superficial reflexes are often lost, 
 since hysterical hemiplegia is so often associated 
 with an anesthesia of the same side. The electrical 
 reactions are practically unaltered. A negative sign 
 of value, and one that was noted when speaking of 
 contracture, is the entire absence of any nutritive 
 changes even in long-continued cases of hysterical 
 hemiplegia. The skin is natural and the muscles 
 preserve their plumpness. To this rule there may 
 be rare exceptions, as will be seen in another 
 chapter. 
 
 Associated with hysterical paralysis are to be found 
 many of the other stigmata of the disease, hyper- 
 esthesia, pain, anesthesia, contracture, and the like ; 
 anesthesia is nearly always present, and generally 
 corresponds to the paralysis ; for example, if only 
 one limb is paralyzed, the anesthesis is usually lim- 
 ited to the part involved. This is, of course, not an 
 absolute rule, since the anesthesia may be dis- 
 seminated. 
 
n6 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 Next in frequency to the hemiplegic is the para- 
 plegic form of paralysis. Gowers believes that this 
 latter variety is the most common, and my own ex- 
 perience leads me to the same conclusion. The most 
 characteristic form of hysterical paraplegia is the 
 sudden giving way of the limbs noted above. The 
 duration of the paralysis in this case is, as a rule, 
 short, and there is only moderate loss of power. In 
 a more advanced degree there may be absolute loss 
 of motion in the lower extremities. The reflexes 
 are, as in the hemiplegic form, normal or exagger- 
 ated, and this being associated with anesthesia in the 
 great majority of cases furnishes a valuable diagnos- 
 tic point between hysterical and organic paraplegia. 
 The electrical reactions are unchanged, and nutrition 
 is very slightly, if at all, affected. The most common 
 cause of hysterical paraplegia is traumatism, and the 
 rapid transit street railways are daily furnishing ex- 
 amples of this form of hysteria. As will be seen in 
 another chapter, the nature of the paralysis, and the 
 fact that the accompanying anesthesia does not cor- 
 respond with the supposed cord injury, generally 
 makes the diagnosis clear. 
 
 Monoplegias are very common, affecting an entire 
 limb, or only certain groups of muscles. Monople- 
 gia, like paraplegia, is very often traumatic, and is 
 generally accompanied by anesthesia. 
 
 Quadriplegia, or paralysis of all four extremities, 
 is not common, though a number of such cases have 
 been reported. 
 
 Hysterical aphonia, due to paralysis of the vocal 
 
DISTURBANCES OF MOTION: PARALYSIS. 117 
 
 cords, is quite common. It is necessary to distin- 
 guish between this and hysterical mutism, a very 
 different condition. Often some emotional cause is 
 responsible for the onset of the paralysis, or again 
 it sometimes seems to be excited by a slight cold, or 
 an unimportant throat affection. The vocal cords 
 are widely separated by paralysis of the adductor 
 muscles. While this is the rule, it occasionally hap- 
 pens that the abductors are involved. In both cases 
 the paralysis is, as a rule, bilateral. In the case of 
 an elderly man referred to me there was paralysis 
 of only one adductor muscle. As there were very 
 few other stigmata present, the case was for a time 
 puzzling, until subsequent developments showed the 
 nature of the affection. 
 
 The mucous membrane of the larynx shows 
 nothing abnormal. There always exists more or 
 less anesthesia ; this may amount to only a trifling 
 lowering of sensibility, or there may be total anes- 
 thesia. When I was a student at the Salpetriere 
 this was generally regarded as a valuable symptom of 
 hysteria, and anesthesia of the mucous membrane 
 was found to be present in nearly all cases of hys- 
 teria. My experience with hysteria in this country 
 has not shown this symptom to be nearly as common 
 as in the French cases. Patients affected with hys- 
 terical aphonia can generally use low notes, and 
 often are able to sing. The duration of hysterical 
 aphonia is uncertain ; in one of my cases it lasted 
 for two or three years, and Gowers mentions a case 
 which continued, with occasional brief intermissions, 
 
n8 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 for ten years. The paralysis generally disappears 
 as suddenly as it comes on. This sudden onset and 
 equally sudden subsidence of symptoms are points 
 of such great value in the differential diagnosis of 
 hysteria, that it cannot too often be referred to. 
 
 In addition to paralysis of the muscles of the 
 larynx, we sometimes meet with paralysis of the 
 pharynx and esophagus interfering with deglutition. 
 There is a sense of constriction, and food taken 
 lodges midway down the esophagus, sometimes in- 
 terfering with respiration. There is at present under 
 my care a young negro girl who, for a year or more, 
 has not been able to swallow any solid food, or at 
 least anything but the very smallest particles. She 
 breaks up her bread into minute crumbs, and any 
 attempt to swallow large particles produces regur- 
 gitation. Careful examination has failed to reveal 
 any lesion of the esophagus, and a large esopha- 
 geal bougie passes without difficulty. These cases, 
 while at first sight alarming, never cause any serious 
 disturbance. The enormous distention of the stom- 
 ach and intestine with gas, so common in the course 
 of hysteria, is not easy to explain. Some writers 
 claim that it is produced by swallowing large quan- 
 tities of air. It would sometimes seem to be the re- 
 sult of contracture, and sometimes of distinct paraly- 
 sis of the muscle of the intestine. It is clear that 
 it is not caused by decomposition of food material 
 in the stomach or intestines. This symptom was a 
 marked feature in some of the epidemics of hysteria 
 that were seen in the middle ages (see chap. i). 
 
DISTURBANCES OF MOTION: PARALYSIS. 119 
 
 Joly* makes the rather remarkable statement 
 that in some instances this inflation was so great 
 that the patients would float in water. In some 
 cases of enormous distention respiration may be in- 
 terfered with. Paralysis of the bladder is not un- 
 common, and a few cases of paralysis of the dia- 
 phragm have been reported. 
 
 While contracture of the various muscular struc- 
 tures of the eye is very common, paralysis is so rare 
 that it can almost be disregarded. Pansier,-)- in a 
 careful review of all the literature, has been able to 
 collect only a few cases, and some of them doubtful, 
 of hysterical paralysis of either extrinsic or intrinsic 
 muscles. A few instances of hysterical paralysis 
 of the third and sixth nerves have been recorded. 
 Ophthalmoplegia would seem to be met with occa- 
 sionally, as are cases of paralysis of the muscles of 
 accommodation, and paralysis of the iris. 
 
 We are unable to explain why it is that, while con- 
 tracture of the muscles of the eye and sensory dis- 
 turbances of vision are among" the common manifes- 
 tations of hysteria, paralysis should be so rare as to 
 raise the question whether it really exists. 
 
 Besides the conditions discussed above of muscu- 
 lar weakness or paralysis, there is very often present 
 in hysterical subjects a certain amount of muscular 
 incoordination. Reynolds says the voluntary move- 
 ments are sluggish,- irrational movements are in ex- 
 
 *Ziemssen's Cyclopedia, 
 f Op. cit. 
 
120 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 cess, and emotional movements are exaggerated. 
 There seems to be a loss of control over the mus- 
 cles, sometimes wide in extent, again confined to 
 certain groups of muscles only. In some cases, 
 though certainly not in all, this may be due to loss 
 of muscular sense. Among the various forms of 
 muscular incoordination seen in hysteria there is a 
 symptom complex which has been dignified by the 
 French school with the name astasia-abasia. This 
 condition, seen most frequently in children, consists 
 of an inability to maintain the erect position, with, 
 sometimes, tremor or choreiform movements. When 
 the patient lies down the legs possess their normal 
 strength, but as soon as an attempt to stand or walk 
 is made, the patient falls, or walks in a most gro- 
 tesque, irregular manner. Rigidity is sometimes 
 present in these cases. The reflexes are unaltered, 
 and there is no disturbance in the electric reactions, 
 nor is the nutrition of the parts interfered with. 
 The termination is either in a sudden cure, or in 
 a change to some other hysterical phenomenon. 
 Looked at as a whole, hysterical paralysis occurs, 
 with few exceptions, along with other distinct hys- 
 terical stigmata. Its onset is sudden, and frequently 
 traceable to some emotional cause, or determined by 
 a trauma or other suggestion. The distribution of 
 the paralysis is not in accord with a spinal or peri- 
 pheral lesion, now involving one-half of the body, 
 now part of a limb, causing hemiplegia, paraplegia, 
 monoplegia, or quadriplegia. The paralysis is rarely, 
 if ever, complete. It is very generally attended with 
 
DISTURBANCES OF MOTION : PARALYSIS. 121 
 
 anesthesia ; the reflexes are practically unaltered, 
 nutrition unimpaired, electric reactions unchanged. 
 In other words, the symptoms point almost with cer- 
 tainty to the cortical centers for their origin. The 
 course of the paralysis, like all other symptoms of 
 hysteria, is extremely irregular and uncertain, now 
 lasting for a few days, again being prolonged for 
 months or even years. 
 
CHAPTER V. 
 
 CONVULSIVE ATTACKS: MAJOR AND MINOR 
 ATTACKS.— HYSTERO-EPILEPSY. 
 
 Among the multiform symptoms of hysteria, the 
 one which, take it all in all, is most characteristic is 
 the convulsive seizure. As has been pointed out in 
 a previous chapter (chap, i), the hysteria of the middle 
 ages seemed especially prone to manifest itself by 
 convulsive movements. Among uncivilized, or semi- 
 civilized, peoples, recognizing no reason for con- 
 straint, emotions at once find outward expression. 
 Fear, anger, love, reverence, are all visibly depicted 
 on the countenance, and graphically represented by 
 gestures. The epidemics of the middle ages, refer- 
 red to above, were characterized by wild, grotesque, 
 lascivious, devotional, and other gesticulations. 
 Among the negroes of the Southern States of 
 America convulsive attacks are more common than 
 among the whites, and are seen oftener than other 
 stigmata. With civilization comes the cultivation of 
 a conventional restraint, the development of a cer- 
 tain center which in the savage state was rudimen- 
 tary. If this supposed center becomes functionally 
 impaired, then, there being no check, no control, the 
 natural impulse to express emotion of any kind by 
 bodily movement obtains. According as the function 
 of these centers is impaired or totally abolished, will 
 
CONVULSIVE ATTACKS. 123 
 
 there be now a mere increase of the natural tendency 
 to express emotion by gesticulation, now a wild, in- 
 coherent, grotesque exaggeration of these gestures. 
 The first of these states is recognized by, and familiar 
 to, the laity. The popular idea of hysteria is derived 
 from the observation of these well-known pheno- 
 mena, and hysteria without them is not understood. 
 After some sudden emotion, either pleasurable or 
 the reverse, an exciting dance, some unexpected 
 stroke of good fortune, a sudden fright, the receipt 
 of unwelcome news, the hysterical girl bursts into an 
 uncontrollable fit of laughter, which generally alter- 
 nates with weeping. She throws her arms about, 
 pulls down her hair, throws herself on the floor, 
 sings, makes grimaces, embraces the bystanders, or 
 expresses fear or distrust of them. Quickly the 
 various emotional phases succeed one another, joy, 
 fear, anger, remorse, accompanied by the gestures 
 appropriate to each state. 
 
 After a period varying from minutes to hours, the 
 storm is followed by a calm, the period of excitement 
 is succeeded by one of depression. During this mild 
 paroxysm there may be apparent hallucinations, 
 generally visual. The identity of the persons about 
 the patient is not infrequently confused, and while 
 consciousness is disturbed it is not lost. Sometimes 
 the attacks are largely mental with few physical 
 manifestations, but as a rule there is present more 
 or less movement. Generally this is confined to 
 gesticulation expressive of some emotion, folding the 
 hands in supplication, doubling the fist in anger, 
 
124 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 wringing the hands in despair, and the like. There 
 is usually present some muscular rigidity, a mere 
 premonition of what is to follow in the severe attacks. 
 It is to be noted that in these mild attacks the indi- 
 viduality of the patient modifies to a greater or less 
 degree the symptoms. This is to be expected when 
 we observe that consciousness is not entirely lost in 
 these ligrht attacks. In this form the movements of 
 the limbs are in large part voluntary. If the patient 
 is lying on her back on the bed or floor, she will 
 kick her feet violently, and throw her arms about 
 in a distinctly purposive manner. Quite often she 
 will seize some one standing near. Efforts at for- 
 cible restraint will markedly increase the violence 
 of the movements. As a rule, there is no disturbance 
 of the circulation or respiration. The pulse is not 
 increased more than the active exertion would war- 
 rant, and if there is no great amount of exertion 
 it remains quite normal. The respiration is normal, 
 except in certain cases of " hysterical rapid respira- 
 tion." In these cases respiration becomes very quick 
 and shallow. The face is neither pale nor congested. 
 There is a peculiar and rather characteristic quiver 
 of the eyelids when the eyes are closed, and this 
 sign is of considerable diagnostic value. The pupils 
 show no constant or characteristic change. As has 
 been said, this minor attack may last from some min- 
 utes only, to several hours, and at the close of the at- 
 tack the patient may be a little depressed, or in some 
 cases appear quite normal. There are no very distinct 
 prodromes preceding the attack, which, as has been 
 
Plate 
 
CONVULSIVE ATTACKS. 125 
 
 noted, can usually be traced to some distinct, though 
 often trivial, exciting cause. The symptoms of the 
 minor attack vary greatly both in their form and in- 
 tensity, which makes it all but impossible to give a 
 description that will apply to all cases. 
 
 The "grand attack," or hystero-epilepsy, as it has 
 been unfortunately termed, the form that has been 
 rendered classic by Charcot's pen and Richer's pen- 
 cil, would seem to be of far less frequent occurrence 
 in this country than in France, and the same maybe 
 said of England (Gowers). The grand attack in 
 this country occurs in persons who, as a rule, pre- 
 sent stigmata in the interparoxysmal period. There 
 are often slight prodromal symptoms for several 
 days, such as nervousness, headache, malaise, and 
 other indefinite symptoms. It would seem that, like 
 the minor attack, there is nearly always some ascer- 
 tainable exciting cause. Often this cause is not dis- 
 tinctly an emotional one. A slight and unimportant 
 injury, some minor ailment causing perhaps a little 
 pain, and the like, are quite as often responsible for 
 the outburst as some emotional shock. The patient 
 falls, occasionally emitting a cry, which, however, is 
 not like the epileptic cry, but is a scream or a num- 
 ber of rapidly- repeated exclamations. As a rule, 
 the patient rather sinks down than falls, and there is 
 rarely any injury done in the fall, though this rule is 
 not absolute, and should not be relied on for diagno- 
 sis as much as. is done, since hysterical subjects will 
 occasionally hurt themselves. 
 
 Consciousness is lost, the face is usually somewhat 
 
126 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 congested, or it may be pale, pulse and respiration 
 normal. At first there is a period of tonic rigidity, 
 lasting for several minutes and succeeded by irregu- 
 lar clonic movements. The clonic convulsions bear 
 only a very slight resemblance to the clonic move- 
 ments of epilepsy. The range is much wider, and 
 they appear far more purposive. In this country 
 there is no separation between the clonic convul- 
 sions and the period of "grand movements " of the 
 French school. Not infrequently the " grand move- 
 ments " come on at once, immediately succeeding the 
 tonic period. The whole body is thrown violently 
 from side to side, the arms and legs are thrown about 
 with great force, and the head rolled rapidly. There 
 is generally decided opisthotonos ; sometimes the 
 body is curved laterally. The tonic and clonic periods 
 alternate, and pressure upon an hysterogenic zone 
 may convert one phase into another. For example, 
 a negro woman was brought into the City Hospital 
 totally unconscious, her whole body in a condition of 
 rigidity ; pressure upon the ovarian region threw 
 her into clonic convulsions, which lasted for some 
 minutes, and then the tonic stage came on again. 
 The tongue is not bitten, and there is no frothing at 
 the mouth. As in the minor variety, there is no 
 disturbance of the pulse or respiration, and the tem- 
 perature remains normal. The eyes are sometimes 
 wide open, at other times closed, and when closed 
 show the characteristic tremor of the lids that has 
 been mentioned. The pupils are normal as a rule, 
 but may be dilated. Generally the eyes are turned 
 
CONVULSIVE ATTACKS. 127 
 
 up, but they may stare straight in front. The attack 
 closes by a display of emotion. The patient will 
 cry or laugh, pour forth a tirade of abuse upon the 
 physician or some member of the family, talk inco- 
 herently, become very affectionate, and possibly show 
 mild hallucinations, generally visual. Usually sev- 
 eral hours elapse before the mental equilibrium is 
 entirely regained. 
 
 In the major attack consciousness is completely 
 lost. I have satisfied myself upon this point by 
 many observations upon patients brought into the 
 hospital. These cases, generally mistaken for epi- 
 lepsy, after going through the various symptoms 
 detailed above, will regain consciousness and look 
 about them with the wildest amazement depicted on 
 their countenance. They will be at an utter loss to 
 account for themselves, and are frequently greatly 
 humiliated at finding themselves in the accident ward 
 of a hospital. This point is dwelt upon, because, as 
 will be seen, attempts at treatment too often proceed 
 upon the theory that the patient is entirely conscious 
 of what is going on around her. During the greater 
 part of the major attack there is entire loss of cuta- 
 neous sensibility. A pin may be thrust through the 
 skin without the patient being aware of it, and the 
 conjunctiva is insensitive. This is the major attack 
 as we see it in this country, though it by no means 
 follows with any constancy the very general symp- 
 toms indicated above. Sometimes the whole attack 
 is tonic, the patient lying in the " crucifix attitude " 
 of the French school, with both arms stretched out 
 
128 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 at right angles from the body, the feet together, the 
 eyes open and staring vacantly into space. Again, 
 the only characteristic attitude is opisthotonos, which 
 will be maintained through most of the attack. 
 Other cases show few of these characteristic poses, 
 but dash themselves violently about, now starting to 
 their feet, now throwing themselves on the bed or 
 floor. The inappropriateness of the term hystero- 
 epilepsy, as applied to the form of hysteria seen in this 
 country, will be apparent from the foregoing descrip- 
 tion. There is, of course, a rough general resemb- 
 lance — loss of consciousness with tonic and clonic 
 convulsions — but the whole course and nature of the 
 attack differs in so many essential particulars from the 
 grand mal of epilepsy that with any reasonable care 
 the two conditions ought never to be confounded. 
 Of course, there are cases in which the resemblance 
 between epilepsy and hysteria is closer than the symp- 
 toms of the latter affection detailed above would 
 seem to imply, but these are the exceptions and not 
 the rule. A comparison between the two conditions 
 will be given in the chapter on Differential Diagnosis. 
 It will be seen that the minor and major attacks 
 differ only in degree, with often no sharp line divid- 
 ing them. In France, the major attack, or grande 
 hysterie, is not only a very much more common 
 affection, but it presents a far more sharply defined 
 and constant symptomatology. I occasionally see 
 cases of major hysteria in this country as well marked 
 and as characteristic as any I ever saw in the Sal- 
 petriere, but these cases are the exception and not 
 the rule. 
 
CONVULSIVE ATTACKS. 129 
 
 Charcot's great work consisted in separating epi- 
 lepsy from hysteria, and presenting us with a picture 
 which has become classic, of the latter affection in its 
 highest development. Grand hysteria has been di- 
 vided by the school of Charcot into four distinct pe- 
 riods, stages, or phases : (i) The epileptoid. (2) 
 The period of grand movements. (3) The period 
 of emotional attitudes. (4) The period of delirium. 
 
 The prodromes of an attack may extend over 
 several days. The patient generally shows some 
 distinct mental disturbance. She becomes very irri- 
 table and peevish, is easily provoked to anger by 
 trivial causes, gives way to all kinds of emotional 
 outbursts. At times she may be boisterous, laugh- 
 ing, singing, crying ; again she remains obstinately 
 mute. She is unjustly suspicious and jealous; is 
 apt to neglect her person, often dressing in some 
 bizarre fashion. At times there are hallucinations, 
 chiefly visual, occasionally affecting the other senses. 
 In addition to these mental symptoms there are often 
 distinct somatic prodromata. If the subject have no 
 interparoxysmal stigmata, or if these are slight, they 
 become prominent and well marked at this time. 
 Anesthesia and hyperesthesia are very generally 
 present ; the various motor symptoms appear : pa- 
 ralysis, contracture, tremor, and the like. The appe- 
 tite is lost, or very capricious ; the globus hystericus 
 nearly always present ; the abdomen frequently dis- 
 tended with flatus. Still nearer the onset of the at- 
 tack may appear certain of the characteristic pains 
 that have been studied in another chapter, clavus, 
 
130 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 epigastric or ovarian distress, throbbing sensa- 
 tions about the head, and the like, which have some- 
 what the value of aurse. These rather indefinite 
 symptoms usher in the attack, or at all events usually 
 closely precede it. The first period is the epileptoid, 
 and it is from this symptom complex that the term 
 hystero-epilepsy has arisen. The attack comes on 
 sometimes rather gradually, more often suddenly. 
 The face becomes pale, the eyes staring, and the 
 patient falls to the ground. The fall is rarely as 
 sudden or as violent as in true epilepsy. In most 
 cases the patient rather sinks to the floor than falls, 
 and it is rare that any injury is occasioned by the 
 fall. This is due to the fact that consciousness is 
 lost more gradually, and the loss is never as complete 
 as in epilepsy. There is not heard the characteristic 
 " epileptic cry," though there may be some sound — 
 sighing, groaning, or exclamation. The whole body 
 is now in a state of rigidity — the tonic phase. The 
 head is bent back, with, as Richer especially notes, 
 marked distention of the throat ; the arms are ab- 
 ducted, the fingers clenched on the palm of the 
 hand, the le^s and feet extended. There is a ten- 
 dency to opisthotonos, and sometimes this condition 
 is well marked at this stage. The eyes are gener- 
 ally closed, and the pupils, according to Fere, become 
 dilated during the clonic phase. There is, in most 
 cases, absolute loss of consciousness by the time the 
 tonic phase is well developed. The mouth is some- 
 times partly open, at other times tightly closed, with 
 clenched teeth, and there may be some frothing. 
 
 
CONVULSIVE ATTACKS. 131 
 
 The face becomes somewhat congested, and there is, 
 perhaps, a slight disturbance of respiration. 
 
 During this period there are tonic movements of 
 the limbs, flexion and extension, and movements of 
 the trunk. Soon the whole body becomes fixed and 
 immobile, assuming some particular position, dorsal 
 decubitus, opisthotonos, or the crucifix attitude. 
 
 Immediately succeeding the tonic phase comes the 
 clonic period of the epileptoid stage. The move- 
 ments are short and quick, though they have not 
 the shock-like character of the clonic convulsions of 
 true epilepsy. The range of the movements is wider 
 than in epilepsy, and they appear somewhat more 
 purposive. The body, limbs, and head take part in 
 these convulsive movements. Respiration becomes 
 somewhat rapid and noisy, and there are movements 
 of deglutition. 
 
 The duration of the epileptoid period, or rather 
 of the two phases which compose it, is somewhat 
 variable, usually occupying from one to five minutes. 
 This stormy period is immediately followed by the 
 calm of complete muscular relaxation. The subject 
 lies motionless, except perhaps a trembling of the 
 eyelids. In some cases there is not complete relaxa- 
 tion, but contractures more or less pronounced per- 
 sist. The duration of this period of relaxation is 
 uncertain, generally lasting for a few minutes, and 
 then the second phase, or the period of grand move- 
 ments, is ushered in. This second stage has been 
 variously designated as the period of grand move- 
 ments, the stage of contortions, or, as Charcot has 
 
132 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 happily termed it, the period of clownism. Follow- 
 ing the calm that has succeeded the epileptoid move- 
 ments, comes the most typical form of the grand 
 movements, the phenomenon of opisthotonos, or, as 
 the French school term it, the "arc de cercle." The 
 body rests upon the back of the head and the heels, 
 forming a veritable arch. The muscles of the abdo- 
 men are so rigid that a delicate woman can sustain 
 the weight of a man sitting upon her, a demonstra- 
 tion that all old students of the Salpetriere will recall. 
 In this country, my experience has led me to coincide 
 with the French school in designating this as by far 
 the most common of the forms taken in this second 
 period. In the majority of the American cases we 
 do not have this absolute opisthotonos, but merely an 
 approach to it. Often there is a combination be- 
 tween opisthotonos and pleurothotonos, the body 
 being curved backward and to one side. After a 
 few minutes the opisthotonos gives place to certain 
 fairly constant and characteristic movements. Of 
 these, perhaps the most common is a rapid flexion 
 of the upper part of the body ; the head is thrown 
 rapidly forward, nearly striking the knees, and then 
 violently back upon the pillow. Quite as common 
 in this country is the violent throwing of the whole 
 body from side to side. Again, the body may remain 
 quiet and the legs be rapidly carried to the vertical 
 position and then brought violently down upon the 
 bed. These movements of the limbs are usually 
 bilateral, but occasionally only one side is involved. 
 Sometimes the whole body is raised, resting only on 
 
Plaie II. 
 
 Fig. i. 
 
 Fig. II. 
 The Convulsive Attack — Second period or period of contorsions. 
 
 Fig. 1.— Movements of wide range. 
 Fig. 2. — Hystencai Opisthotonos. 
 
 (After R.cher.) 
 

 
CONVULSIVE ATTACKS. 133 
 
 the shoulders, so that the feet may almost touch the 
 head. These are among the most characteristic of 
 the movements seen in this stage, though often the 
 contortions are irregular, and do not conform to any 
 type. In this phase, we see no movements that are 
 in any degree purposive. Every action seems inco- 
 ordinate, violent, meaningless. The face generally 
 presents a contorted appearance, though the conges- 
 tion which was observed in the first stage has dis- 
 appeared. In like manner respiration has come back 
 to the normal, or nearly so. The duration of this 
 second phase is from five to fifteen minutes. As has 
 been noted, what corresponds to this stage in Amer- 
 ica, is characterized by far more irregular move- 
 ments, and as a rule lasts longer. 
 
 The third period is that of passionate attitudes. 
 Here we have the most perfect expression of the 
 rapidly varying mental states by gesticulation. Just 
 as we see in certain conditions of alcoholic intoxica- 
 tion, or during the administration of an anesthetic, 
 a period in which gesture largely takes the place of 
 language, so in this stage of the major attack, when 
 certain of the higher centers of the cortex are in- 
 capable of performing perfectly their function, the 
 lower cortical centers apparently try to make up the 
 defect. Thus, in this period, when consciousness does 
 not rise quite to the dignity of language, the emotions, 
 under no control, are expressed by gestures. Then, 
 again, the higher centers are beginning, in this stage, 
 to thaw out, as it were, and their action is irregular, 
 uneven, and incoordinate. There is hardly any limit 
 
134 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 to the phenomena of this third stage, since every 
 emotion that passes over the disturbed brain is 
 represented by its appropriate gesture. One of 
 the most characteristic poses is that known as 
 the "crucifix attitude." This has been described 
 elsewhere. I have satisfied myself that this is not 
 the product of suggestion. In two cases seen re- 
 cently, both mulatto girls, this attitude was exactly 
 as described by the French school, and the subjects 
 had never seen other hysterical patients and could 
 have had no possible suggestion made to them. 
 From the outward expression, we are forced to 
 conclude that during this period the patients are 
 subject to various hallucinations. They will point 
 to objects in the room, or possibly appear to be 
 listening to sounds or voices. They are in a sort 
 of dream, which rapidly changes the scene from 
 grave to gay, from a picture of horror to one of 
 delight. The religious beliefs or superstitions often 
 enter largely into the dreams, and are portrayed 
 by various imitations of religious ceremonies. The 
 representation of the various emotional states is 
 wonderfully vivid and varied. Fear, anger, menace, 
 remorse, sensuousness, and the like, are presented 
 with a faithfulness and reality that should be the 
 envy of an actor. 
 
 It is clearly impossible to resolve these various 
 gestures into any category, or to fix any definite 
 period for their duration, as Richer attempts to do. 
 For example, he says that the crucifix attitude lasts 
 twenty-three seconds ; the attitude of defense, four- 
 
CONVULSIVE ATTACKS. 135 
 
 teen ; of menace, eighteen ; of appeal, ten ; of luci- 
 bricity, fourteen ; of ecstacy, twenty-four ; of dread 
 of animals, especially rats, twenty-two ; of listening 
 to military music, nineteen ; of scorn, thirteen ; and 
 of lamentation, twenty-three. It is obvious that 
 while this classification might serve for the Quartier 
 Latin, it would not be generally applicable. As has 
 been said before, we cannot accept in toto the Sal- 
 petriere description of hysteria. 
 
 As will be seen in another chapter, the analogy 
 between hysteria and hypnotism, or certain hypnotic 
 states, is wonderfully close, and the principle of sug- 
 gestion is a factor that must not be neglected. Per- 
 sonal experience in the Salpetriere taught me years 
 ago that suggestion plays a not unimportant part in 
 the symptomatology of the hysteria as described by 
 certain pupils of that school. Certain it is that as 
 we see hysteria in this country, this third stage is 
 never the elaborate and distinct set of symptoms, 
 with their regular succession and definite duration 
 as certain writers describe. With us this stagfe is 
 distinctly emotional and dramatic. Anger, fear, af- 
 fection, and so forth, are given outward expression 
 by gestures, but they follow no regular order and 
 have no definite duration. For example, the case 
 of a woman, aged about thirty, who in this third stage 
 wept, expressed great affection for the physician, 
 whom she had never seen before, with fear of the 
 other persons in the room, and a great aversion to 
 her husband. This represents the average third 
 stage in the majority of cases this side the Atlantic. 
 
136 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 During this stage the subject may sing or dance, or 
 put herself in various suggestive attitudes, and usu- 
 ally gives utterance to expressions in harmony with 
 the other mental states. Often a very modest girl 
 will declare her love for the physician or some by- 
 stander, in terms that she would never employ in 
 her normal condition, or she may shower epithets 
 not usually employed in polite society upon her 
 dearest friends. Thus it is seen that this stage is 
 essentially the stage of dramatic representation of 
 certain emotional conditions. In the preceding 
 phase the movements were in no sense purposive ; 
 in this third period the gestures represent, with 
 wonderful accuracy, the phantasmagoria of the dis- 
 turbed brain. 
 
 The fourth period is called the stage of delirium. 
 As Richer says, the third phase of the major attack 
 is the period of acting ; the fourth stage that of 
 speech. Consciousness shows in the third stage a 
 dim returning-, and lang-ua^e beine confined to ex- 
 clamations, or at most to fragmentary sentences, is 
 inadequate to express the emotions, and gestures 
 are called to its aid. In the fourth stage conscious- 
 ness asserts itself more and more, and speech no 
 longer requires the assistance of gestures. Anes- 
 thesia has in large part disappeared in the fourth 
 stage, and the subject is to some degree conscious 
 of the surroundings, though not perfectly so. Hence 
 illusions and hallucinations are common. As has been 
 noted, these are associated in the main with vision, 
 though the other senses may be involved. Long 
 
CONVULSIVE ATTACKS. 137 
 
 confessions of past experiences are related, gar- 
 nished with fanciful details. In the third stage 
 hallucinations are probably present, but can be ex- 
 pressed only by gestures, while in the fourth, as has 
 been said, gesture gives way to speech. A fear of 
 animals has been described as a prominent feature 
 of the mental state, and the hallucinations often take 
 this form. In this stage the motor sequelae of the 
 grand attack begin to make their appearance, espe- 
 cially contracture. The stage of delirium may be 
 indefinitely prolonged, as will be seen when speak- 
 ing of the mental condition of hysteria (chap. vi). 
 
 In grand hysteria, as described by many writers of 
 the French school, the first stage or phase presents 
 practically complete loss of consciousness, and the 
 motor manifestations are utterly incoordinate and 
 entirely outside the control or even influence of the 
 higher centers. In the second stage these move- 
 ments become somewhat more purposive, though 
 still incoordinate ; in the third stage the muscular 
 movements are clearly attempts to illustrate or 
 emphasize a mental state that cannot be expressed 
 in articulate speech, while in the fourth stage speech 
 has returned but the higher centers are not yet able 
 to control its wild exuberance. 
 
 In this country, as has already been said, and also 
 in England, it is unusual to see these perfect attacks 
 of grand hysteria as described by French writers. 
 In most of our cases, however, it is possible to dis- 
 cern the reflex of this elaborate description. Charcot 
 and his pupils describe a form of hysteria as they 
 
138 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 see it : a disease peculiarly liable to be impressed 
 with the characteristic life of the Boulevards in gen- 
 eral and the Latin Quarter in particular, and yet we 
 must frequently be surprised at the appearance of 
 these phenomena that seem to be " suggested symp- 
 toms." In my own experience I have often been 
 struck with the similarity between the cases of 
 hysteria in negroes who, of course, have never been 
 in any possible manner under the influence of sug- 
 gestion, and the so-called " show cases " at the Sal- 
 petriere. It has seemed to me that the genius of 
 Charcot has given us a typical picture, with all the 
 minutest details, and that while hysteria in this 
 country falls short in many respects of his descrip- 
 tion, still the type is there, and the differences can be 
 accounted for by the diversity in race, climate, edu- 
 cation, mode of life, and all the circumstances that 
 go to make up the " environment." 
 
 According to Richer, whose description has in the 
 main been followed in the foregoing chapter, the epi- 
 leptoid period lasts from one to three minutes, sepa- 
 rated by a moment of calm from the second period, 
 which is of about the same duration as the first. 
 The third period, less sharply divided from the 
 second than is the second from the first, lasts from 
 five to fifteen minutes, the three stages occupying 
 something like half an hour. The fourth period, 
 that of delirium, is rather more indefinite, both in 
 its character and duration, than the other three, since 
 it is hard to fix a limit to the time when normal 
 intellection appears and terminates the scene. 
 
^ 
 
 Plate III. 
 
 Fig. I. 
 
 Fig. II. 
 The Convulsive Attack — Third period or period of passionate attitudes. 
 
 Fig. 1. — The Phase of Sadness. 
 
 Fig. 2.— The Phase of Exhilaration. 
 
CONVULSIVE ATTACKS. 139 
 
 There is no regularity in the recurrence of the 
 attacks of grand hysteria — in some cases attacks 
 are separated by long intervals, months or years ; 
 again, they may be of daily occurrence. As has 
 been noted elsewhere, the exciting causes are 
 many and various, and after the condition has once 
 been established, causes the most trivial may pro- 
 voke an attack. It would seem, from a careful 
 review of the literature on the subject, that attacks 
 of grand hysteria are rather more liable to appear 
 near the menstrual period in this country than in 
 France. It is difficult to say just what relationship 
 may exist between painful menstruation and attacks 
 of hysteria, but there can be no doubt of their 
 association. Attacks of grand hysteria may succeed 
 one another rapidly, leaving only some hours' interval 
 for repose and nourishment. This succession of 
 attacks may continue for weeks or even a month, 
 and yet the general health is very slightly impaired 
 provided nourishment be kept up. These cases 
 resemble in many respects the status epilepticus, but 
 differ, as will be seen, in many important particulars. 
 There are cases of hysterical attacks that are not 
 unlike petit mal ; several such have come under my 
 notice in which there was apparently a momentary 
 loss of consciousness. Close investigation has in 
 most instances satisfied me that there is not absolute 
 loss of consciousness, and the association with other 
 stigmata has decided the question. Still there are 
 cases in which it is extremely difficult to draw the 
 differential line between petit mal and hysteria. 
 
140 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 Thus it is seen that all the types of epilepsy are 
 represented in the convulsive attack of hysteria* 
 grand mal, petit mal, status epilepticus, and irregular 
 forms. We should bear in mind, however, that this 
 is not an instance of the mimicry of hysteria, but 
 only of the fact that both hysteria and epilepsy are 
 but symptoms of some disturbance of the motor 
 cortex, the cause underlying this disturbance being 
 entirely and radically different in the two cases. The 
 fact must not be overlooked, that in rare instances 
 hysteria and epilepsy may present themselves in 
 the same patient, and cases have been reported in 
 which it would seem that the attack itself combined 
 some of the symptoms of both affections. 
 
 It will be obvious from the description here'- given 
 of the grand attack, that it is the highest manifesta- 
 tion of hysteria — consciousness abolished, sensation 
 lost, motion violently disturbed and incoordinate. 
 Preceding the attack the somatic and mental stig- 
 mata of the disease are intensified, and as sequelae 
 we see contractures and paralyses. The great 
 variation in the symptoms, both as regards form 
 and intensity, is to be noted. Going back to the 
 theory as to the nature of hysteria, advanced in a 
 previous chapter, namely, that the disease is depend- 
 ent upon protoplasmic alteration in the cells com- 
 posing certain of the higher cerebral centers, it will 
 be seen that of necessity we should expect the 
 symptoms to correspond to the extent and degree 
 of these chancres. 
 
CHAPTER VI. 
 THE MENTAL CONDITION IN HYSTERIA. 
 
 While it is not easy to present a satisfactory 
 picture of the somatic stigmata of hysteria, it is far 
 more difficult to describe the mental symptoms. As 
 Charcot says, " Hysteria is a psychic disorder par 
 excellence!' According to the views advanced in 
 another chapter, hysteria is a disease of the higher 
 centers of the brain, and consequently we would 
 expect to find the mental symptoms prominent. 
 Again, from the nature of the case, it is ah but 
 impossible to classify these symptoms, or to de- 
 scribe a typical case. The whole essence of hys- 
 teria centers in the disordered function of certain 
 areas of the cerebral cortex, and a description of 
 the mental state seen in hysteria would include a 
 psychological analysis of tl;e hysterical mind. In 
 this analysis it would be absolutely necessary to 
 include the hereditary influences, the environment, 
 and all the moral, intellectual, and emotional forces 
 bearing upon the individual case. Again, to make 
 the picture complete, we would have to go over 
 much of the ground already covered, and show 
 how the somatic stigmata have resulted from the 
 disordered higher centers. It has seemed to me 
 
 that the modern French school has erred somewhat 
 
 141 
 
142 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 in the treatment of this part of the subject. On the 
 one hand they have drawn a rather too pronounced 
 picture of certain of the more grave symptoms, and 
 on the other they have hardly presented an ade- 
 quate description of the slighter, interparoxysmal 
 symptoms. In this country the former set of symp- 
 toms, characterized by hallucinations, loss of memory, 
 double personality, and the like, are comparatively 
 rare, while we have to deal every day with the 
 psychic manifestations of the hysterical tempera- 
 ment. Again, with us it would seem to be far 
 more common than it is in Europe, to have a blend- 
 ing of hysteria and hypochondria. Many cases of 
 so-called neurasthenia are really made up of the 
 symptoms of hysteria plus symptoms of hypochon- 
 dria. 
 
 The mental condition accompanying the hysterical 
 temperament in the interparoxysmal state is so well 
 known that it hardly merits any special description. 
 There is a certain condition of mind that we have 
 come to recognize, and have termed it, appropriately 
 or not, "hysterical." This mental state is seen as 
 an interparoxysmal symptom. Indeed, it cannot 
 properly be called a symptom at all, but is merely, 
 to use an artist's phrase, the "atmosphere" of the 
 picture. In a paper* published several years ago, 
 some of the characteristics of the mental condition 
 in hysteria were described. It would seem, and this 
 is a point that has not been clearly brought out, that 
 
 * Preston, New York Medical Journal, 1 889. 
 
THE MENTAL CONDITION IN HYSTERIA. 143 
 
 we may have well-marked mental symptoms of hys- 
 teria unaccompanied by any of the various well- 
 known somatic stigmata, such as convulsions, par- 
 alysis, anesthesia, hyperesthesia, and the like. In 
 this country especially, hysteria seems to manifest 
 itself by mental symptoms. The intellectual state 
 is characterized by instability, motility, capricious- 
 ness. As Sydenham * so well says, " what is most 
 consistent is their inconsistency." The subjects of 
 mild forms of mental hysteria are inclined to be 
 irritable ; they change rapidly from one state to 
 another ; are, to quote Richer, -j- " like children, in 
 whom one may provoke laughter while their cheeks 
 are still wet with tears." There is often present a 
 decided exaltation of the intellectual faculties. Such 
 a person may at times be a brilliant conversationalist 
 — versatile, witty, and gracious for a time — some 
 unimportant event, some meaningless remark, may 
 bring on a torrent of tears or provoke a fit of un- 
 controllable anger. The mental reflexes are, so to 
 speak, all heightened, and stimuli brought in from 
 without, or originating in the imagination, overrun 
 their natural boundaries, and excite more centers 
 than they should, and to too high a degree. Some 
 trivial and unimportant cause will often provoke a 
 powerful exhibition of emotion, nor can we predict 
 which particular emotion will be called forth. Given 
 a certain stimulus, .as, for example, the relation of a 
 
 * Op. at 
 
 I " La Grande Hysteric 
 
144 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 piece of bad news ; it is impossible to foresee whether 
 the hysterical patient will weep or laugh, will be ex- 
 alted or depressed. 
 
 Most of the events in the every-day life of these 
 individuals take upon themselves a sentimental cast, 
 and questions of the most matter-of-fact nature are 
 invested with a halo of romance. The whole intel- 
 lectual life, like a kaleidoscope, is changed by the 
 slightest movement, and the changes rapidly succeed 
 one another. Such individuals are, as a rule, in- 
 capable of long-continued application, and as a con- 
 sequence of this are rarely able to complete any 
 serious undertaking. The spirit of contradiction is 
 very strong with them, and they seem to take great 
 delight in denying to-day what they affirmed yester- 
 day. They will oppose, contradict, and set them- 
 selves directly against the wishes of those who are 
 dearest to them, and seem to experience a certain 
 gloomy pleasure in thus torturing themselves by 
 distressing their friends. One ever-present trait, 
 serving as a mainspring for many of their actions, 
 is an overweening egotism and a morbid desire for 
 notoriety. 
 
 Hypochondria, with often a tinge of melan- 
 choly, is frequently present, especially in children. 
 Such characteristics as vanity, love of notoriety, 
 inconsistency, simulation, and the like, has led some 
 writer to make the very ungallant remark, that 
 in the slighter mental phases of hysteria are to be 
 seen in an exaggerated form merely certain feminine 
 traits. Most of these symptoms, in a mild degree, 
 
^rw 
 
 THE MENTAL CONDITION IN HYSTERIA. 145 
 
 might be considered physiological rather than patho- 
 logical, and characteristic of puberty. Yet, when 
 they become pronounced, they point clearly to a dis- 
 tinct, though slight, disturbance of the equilibrium 
 of the higher centers. 
 
 The duration of this stage is very uncertain ; 
 sometimes it appears at the menstrual period only, 
 and lasts but a few days ; aorain, it may continue 
 for weeks or months. 
 
 These slight though somewhat characteristic men- 
 tal manifestations of hysteria are usually seen at or 
 near puberty, between the years of twelve and six- 
 teen, though it is no uncommon thing to see the 
 same, or at least very similar, symptoms occurring 
 late in life, and in both sexes. As has been said, it 
 is hardly appropriate to designate the symptoms 
 described above as hysteria, yet they have for so 
 long a time been so regarded, at least popularly, 
 that it is impossible to place them in any other cate- 
 gory. Passing on to more marked phases of hys- 
 teria, in which the interparoxysmal stigmata are 
 pronounced, certain distinct mental symptoms are 
 seen which are common to a large class. The 
 distinct, clearly-defined mental phenomena — what 
 might be called the mental stigmata — appear just 
 before, during, or immediately after an attack. In 
 other words, they are closely related to, and in a 
 sense may be said to form part of, the attack. In 
 the first case the mental symptoms are to be re- 
 garded as prodromes of the attack. The whole 
 mental state of the patient undergoes a marked 
 13 
 
146 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 change ; she becomes irritable, morose, easily ex- 
 cited. The emotional nature of the patient becomes 
 prominent, and the slightest stimulus provokes an 
 outburst. So characteristic are these mental symp- 
 toms, that they foretell, with certainty almost, the 
 onset of a paroxysm. 
 
 Occasionally, as Charcot has pointed out, the 
 mental disturbance may take the place of the 
 convulsive seizure, corresponding to the psychic 
 equivalent in epilepsy. The sleep, for some 
 time preceding the attack, is apt to be restless, 
 and nightmares and nocturnal hallucinations are 
 present. These dreams, or, as they may sometimes 
 be called, hallucinations, frequently make such a 
 profound impression that the subject of them may 
 be under their dominion for days afterward. Many 
 of the " possessions " of the middle ages were char- 
 acterized by nocturnal phenomena, producing such 
 profound impressions on the mental condition that 
 innocent persons were accused of frightful crimes, 
 and many of them were put to death on the evi- 
 dence given by hysterical girls, as in the case of 
 Urbain Grandier (chap. 1). 
 
 Suggestion, coming either from without or within, 
 plays a prominent part in mental hysteria. As has 
 been noted before, the various phenomena of hys- 
 teria present a most striking analogy to the phases 
 of hypnotism. Everywhere is to be seen the power- 
 ful influence of suggestion, and this is no less true 
 of the mental than of the somatic stigmata. There 
 is some defect in the co-ordination and regulation of 
 
^* 
 
 THE MENTAL CONDITION IN HYSTERIA. 147 
 
 the psychic processes. What we loosely call the 
 will-power is at fault, is in abeyance, and the emo- 
 tions are at the mercy of any passing suggestion. 
 Just as in the hypnotic state, wherein any suggestion 
 from the hypnotizer is accepted as real and acted 
 upon by the hypnotized, so in hysteria the emotions 
 may be aroused by some suggestive external cir- 
 cumstance, or may even be excited by the uncon- 
 trolled and active imagination of the subject. The 
 mental features during the attack have been de- 
 scribed under the head of the stage of emotional 
 attitudes. Following the attack is the stage of 
 delirium, of uncertain duration and variable inten- 
 sity. In some cases, this stage of delirium dom- 
 inates the attack to such an extent that it obscures 
 the other symptoms, and constitutes the so-called 
 hysterical mania which will be again referred to. 
 Disturbance, weakening or entire loss of volition, 
 is perhaps the most characteristic feature of the 
 mental state of hysteria and is described under the 
 name abulia. As it has been aptly put, the hysterical 
 patient says, "I cannot;" it looks like "I will not," 
 but it really is "I cannot will." 
 
 This weakening of the will-power may attain such 
 a high degree that the subject becomes almost an 
 automaton, depending for every action upon some 
 suggestion. There is a general disinclination to 
 exertion, unless the suggestive stimulus be con- 
 stantly applied. _ Often there is a decided tinge of 
 melancholy present. No phrase is oftener upon the 
 lips of the hysterical subject than " I cannot." Even 
 
148 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 when there is no paralysis present, the hysteric pro- 
 fesses to be utterly unable to make any physical 
 exertion. She will say that it is entirely impossible 
 for her to get out of bed, or to walk across the 
 room. She will readily acknowledge the import- 
 ance of exertion, and will admit that it is necessary 
 to do a certain thing, but declares that it is utterly 
 impossible. After a time it becomes difficult, and 
 finally impossible, for the hysterical patient to fix the 
 attention, and the intellectual faculties lie helpless. 
 
 One of my patients, a more than ordinarily intelli- 
 gent woman, spends her time bemoaning the fact 
 that she cannot read or sew. Her eyesight is per- 
 fect, yet for years she has not been able to occupy 
 herself, because she says it is impossible for her to 
 keep her eyes fixed on a book or on her needle- 
 work. Repeated assurances from a skilled oculist 
 have been given her that she could use her eyes, but 
 to no avail. If the apathy into which the hysterical 
 patient often sinks as a result of loss of control over 
 will be broken by a sufficiently strong stimulus, then 
 the emotions thus rudely awakened sweep along 
 with uncontrollable force. Moreover, this stimulus 
 need not be actually intense, but the weakened will- 
 power allows some very trivial and unimportant 
 event to become invested with imaginary signifi- 
 cance. Such persons will say constantly, "I know I 
 should not be disturbed by such a thing, but I am 
 utterly unable to control myself/' Janet* speaks of 
 
 * " Etat Mental des Hysteriques." 
 
THE MENTAL CONDITION IN HYSTERIA. 149 
 
 the " abulia" of sleep. It would seem that some 
 hysterical individuals cannot sufficiently "let go 
 themselves " to go to sleep. 
 
 As was noted in a previous chapter, the theory of 
 the disturbance of the centers presiding over voli- 
 tion would seem to furnish the best working theory 
 by which to explain the various phenomena of hys- 
 teria. With volition abolished, man becomes a mere 
 machine ; every action is a reflex. With volition 
 weakened, with the center performing its function 
 imperfectly, there is established a condition of inco- 
 ordination. Centripetal impulses convey informa- 
 tion which may be more or less perfectly inter- 
 preted, but with volition impaired the responses to 
 these impulses are either too feeble or too strong, 
 never showing the normal relation. In like manner 
 intrinsic stimuli are immeasurably distorted. After 
 a process of correct reasoning the hysterical subject 
 may come to the conclusion that a certain line of 
 action is to be pursued, but this becomes utterly 
 impossible because of the impaired volition. When 
 this phase of mental hysteria is long continued it 
 sometimes happens that there is a very marked 
 weakening of the intellectual faculties generally. 
 
 Janet,* in his exhaustive treatise on the mental 
 condition in hysteria, dwells at some length upon 
 the loss of memory. This is present in varying 
 degrees, and may relate to remote or recent events. 
 Of course the inability to fix the attention closely 
 
 * Op. cit. 
 
150 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 would explain the loss of memory for events that 
 have transpired during the hysterical period, but it 
 would seem that the recollection of early events is 
 often very imperfect. Some authors have claimed 
 that the misstatements and inaccuracies so common 
 in hysterical subjects can be explained by loss or 
 impairment of memory. While this may be true in 
 some instances, it certainly will not explain all cases. 
 
 After an attack, the recollection of what has taken 
 place is usually vague and uncertain, though there 
 is rarely the complete blank, such as is seen after 
 an epileptic seizure. The patient will generally 
 remember certain events in the early part of the 
 attack, and in some cases will be able to recall a 
 good deal of what has happened through the whole 
 period. 
 
 In very pronounced cases of hysteria there may 
 be seen a sort of fixed idea, or, as Janet calls it, a 
 "subconscious fixed idea." As a rule, these fixed 
 ideas have a distinct melancholic tinge, or hypo- 
 chondriacal character, and it is at times difficult to 
 decide whether they really belong to hysteria or to 
 pure mental disease. These fixed ideas show them- 
 selves particularly during an attack, and sometimes 
 apparently have their origin in the dreams and 
 nightmares already alluded to. 
 
 During the attack, or sometimes in the interpar- 
 oxysmal period, there may be, in hysterical women, 
 an evident desire to attract the opposite sex, but it 
 is doubtful whether there is actually much sexual 
 excitement. Most authors agree that there is a 
 
THE MENTAL CONDITION IN HYSTERIA. 151 
 
 diminution, rather than an increase, of sexual de- 
 sire. 
 
 The many curious instances of double personality, 
 or double life, that are reported show certain distinct 
 hysterical stigmata, and a large proportion of them 
 belong in the category of mental hysteria. These 
 cases will be alluded to again. 
 
 In addition to the mental changes mentioned 
 above, there are other mental disturbances that pre- 
 sent more marked symptoms. These cases belong 
 in the debatable ground, and it is often impossible 
 to say to what extent they are hysterical. The 
 most characteristic form that these graver manifes- 
 tations of mental hysteria assume is what has been 
 called hysterical mania. As a rule, the condition is 
 a continuation of the stag-e of delirium which con- 
 eludes the attack. The maniacal attack may, how- 
 ever, appear with few or none of the symptoms of 
 the convulsive seizure, and in this case is to be 
 regarded as the psychic equivalent. Pitres,* in de- 
 scribing hysterical mania, says : " Hysterical mania 
 does not differ from simple mania or epileptic mania 
 except in its etiology. It occurs in old hysterics or 
 those predisposed to hysteria, and generally follows 
 some profound emotion, particularly fear. It is seen 
 much oftener in women than in men, and in some 
 cases it has a tendency to recur regularly at the 
 monthly epochs." Tomlinson,-j- in reporting six cases 
 of hysterical mania, says : "I would define hysterical 
 
 * Op. cit. -\Jonr. of Nerv. and Ment. Dis., vol. xvi, 1891. 
 
152 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 mania as a form of mental disturbance, character- 
 ized by mental exaltation, sometimes varied by 
 depression, varying degrees of violence, irrational 
 conversation, with or without hallucinations, and 
 without delusions ; accompanied by exaggerated 
 conduct, the actions of the patient being purposive 
 and suggested, and governed by the surroundings." 
 Sometimes the mental depression is so marked that 
 the case closely resembles one of acute melancholia. 
 The question, of course, to be decided in all this 
 class of cases is, whether we are dealing with hys- 
 teria pure and simple, or whether there is a pure 
 insanity, painted, as Mitchell so well puts it, upon 
 a hysterical background. It is no uncommon thing 
 to find the somatic stigmata of hysteria well marked 
 in the insane, and in like manner hysterical mental 
 symptoms are often intricately blended with symp- 
 toms of pure insanity. There can be no doubt, 
 however, that there are cases, perhaps not very 
 numerous, but distinct in their symptomatology, 
 which resemble closely some of the forms of insanity 
 proper, especially mania and melancholia, but which, 
 from their origin, course, and termination, must be 
 regarded as distinctly hysterical. From what has 
 been said in regard to the milder mental changes, it 
 will be seen that an intensification of these symp- 
 toms will produce a picture similar in many respects 
 to certain forms of insanity. While official recog- 
 nition, so to speak, has hardly been accorded hys- 
 terical insanity, still in nearly every asylum there 
 are cases that are so classified. The duration of this 
 
THE MENTAL CONDITION IN HYSTERIA. 153 
 
 mental disturbance varies from a few minutes — as 
 the maniacal delirium immediately succeeding the 
 crave attack — to several months, or even longer. 
 x\s has been noted, there is often a tendency for the 
 attacks to recur, especially near the menstrual period, 
 or as the result of some profound emotion. 
 
 The following case, which was under my care for 
 several years, will illustrate some of the features of 
 hysterical insanity. Miss X, aged eighteen, of 
 healthy parentage, with an exceptionally good per- 
 sonal history, had a somewhat complicated love 
 affair, which seemed to be the starting-point of the 
 hysterical symptoms. Her mother described her as 
 a very tractable and obedient child, and very affec- 
 tionate in her disposition. It would seem that she 
 had been somewhat overindulged as a child. The 
 hysterical symptoms manifested themselves by a 
 change in disposition ; she became wilful, disobe- 
 dient, irritable, and unmanageable. She would say 
 outrageous things, and seemed to delight in shock- 
 ing the sensibilities of those about her. There was 
 never any evidence of delusions or hallucinations. 
 She was sent to a hospital, where she was regarded 
 as hysterical and " devilish." She ran away from 
 the institution, and after remaining at home for a 
 time became very troublesome on account of her 
 many freaks. 
 
 Upon examination there were no somatic stig- 
 mata, except marked ovarian tenderness, which 
 could not be accounted for, as there was no disease 
 of these organs. She was very obstinate, utterly 
 14 
 
154 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 refusing to do what was required of her. At 
 times she was very agreeable and entertaining ; 
 again, sulky and fretful. Her emotions were very 
 easily aroused, and she professed to take great 
 interest in the Catholic religion, thou eh she was a 
 
 <_> ' o 
 
 member of another church. While in the hospital 
 she pretended to take poison, and she confessed to 
 me that she used to take great delight in terrifying 
 her mother, by showing her a bottle of laudanum 
 and telling her that she had swallowed the whole of 
 it, when in reality she had only taken a few drops, in 
 order, as she said, to cause her breath to smell of 
 the drug and thus deepen the impression that she 
 had seriously attempted suicide. On one occasion 
 she turned on the gas in her room and was nearly 
 suffocated, but she confessed that she had no inten- 
 tion of committing suicide, her purpose being to put 
 herself slightly under the influence of the gas, and 
 then turn it off and enjoy the sensation thus pro- 
 duced. She, however, inhaled more than she had 
 intended, and as she went to turn it off she fell, and 
 but for the fact that she was discovered she would 
 undoubtedly have been suffocated. This would have 
 been regarded as a suicide of an hysteric, when, 
 from her own confession, nothine was further from 
 her thoughts. 
 
 In her case there seemed to be some sexual ex- 
 citement, and she probably masturbated. By strict 
 isolation, firm discipline, and suggestive treatment 
 she was entirely cured in a few weeks. After her 
 recovery she told me that all the time she felt that 
 
THE MENTAL CONDITION IN HYSTERIA. 155 
 
 she was doing wrong, and was greatly distressing 
 her mother, of whom she was very fond, but that 
 she was utterly unable to resist the temptation to 
 create a sensation. Some months after this she was 
 married, and about the time of her confinement she 
 fell into somewhat the same condition as that which 
 has been described, only more pronounced. She 
 continued to grow worse, and a well-known alienist 
 pronounced her case one of chronic mania. She 
 remained in this condition for some months before I 
 saw her. When she again came under my care she 
 was in a bad condition physically, anemic, somewhat 
 emaciated, with furred tongue and obstinate consti- 
 pation. She was obstinately mute, refused food, and 
 had to be fed with a tube for several weeks. 
 
 In two or three weeks she began to eat, but 
 remained mute for more than two months. She 
 understood all that was said, and would occasionally 
 laugh at some remark made in her presence. She 
 was sent to an asylum in the country, and in a few 
 months recovered perfectly. She never, in the 
 whole course of her disease, had any delusions or 
 hallucinations, and after her recovery could describe 
 very clearly the events of the months of illness. 
 Several times during the course of her disease she 
 became very much excited, and if she became angry 
 would strike the nurse, but apparently never tried 
 to do any great injury. At one asylum she several 
 times tore up the bed-clothes and broke the furni- 
 ture, because she was not permitted to have her 
 own way. 
 
156 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 This case is related at some length because it 
 illustrates the difficulty often experienced in making 
 a clear diagnosis in cases of mental hysteria. There 
 was no evidence, in this case, to show that there was 
 anything but hysteria, and yet many forms of pure 
 insanity were suggested. 
 
 It frequently happens that degeneracy is con- 
 founded with hysteria, and, as a matter of fact, it is 
 often not an easy thing to draw the line between 
 the two conditions, for the reason that after pro- 
 longed mental hysteria there may be seen some 
 degeneration. There is a set of mental phenomena 
 which, when slight, are very difficult of classification ; 
 such as the fear of soiling the hands, doubt as to 
 whether some accustomed duty has been properly 
 performed, etc. A patient of mine had to give up 
 his place as reporter on a newspaper, because he 
 was in constant dread of making mistakes in his 
 copy, and resigned a Government position of trust 
 because he feared he would commit some grave 
 error in his accounts. Another patient tried for 
 more than a year to force himself to get on a 
 railroad train. His business called him often to 
 another city, and it was nearly two years before 
 he was able to travel. He would often purchase 
 his ticket and pass through the gate, and then turn 
 back. He had no fear of accident, but, as he said, 
 he could not get on the train. These symptoms 
 are very often associated with hysteria, but in like 
 manner they are perhaps more frequently signs of 
 
THE MENTAL CONDITION IN HYSTERIA. 157 
 
 degeneracy. In this connection Kirchhoff* remarks : 
 " The basis of hysterical insanity is a degeneration, 
 and can be regarded as a mental invalidism which 
 imparts to the symptoms of the psychosis their 
 direction." While, as has been said, signs of 
 degeneracy appear after severe and long-continued 
 mental hysteria, this is the exception and not the 
 rule, and one is often surprised to find so few- 
 mental changes after protracted hysteria of an 
 aggravated type. 
 
 As to the prognosis of hysterical mental disease, 
 Kirchhoff f takes rather a grave view ; he says : 
 "The course of all the mental disorders which are 
 associated with hysteria may be extremely variable. 
 If the mental disturbance occurs in paroxysms, the 
 chances of recovery of the individual are favorable, 
 although relapses and new attacks are probable. 
 On the whole, the prognosis of the mental disorders 
 of hysteria is unfavorable, despite the probability 
 of the subsidence of the individual attack." This 
 prognosis is certainly unnecessarily grave ; hys- 
 terical mental disorders tend to recover in most 
 instances if they are uncomplicated. It must be 
 borne in mind, however, that a very considerable 
 number of the cases which are regarded as hysteri- 
 cal insanity are complicated with neurasthenia or 
 hypochondria, and a large proportion have a bad 
 hereditary history. 
 
 * " Handbook of Insanity." 
 f Op. at. 
 
158 HYSTERIA: ITS NATURE AND TREATMENT 
 
 The question as to whether hysterics ever commit 
 suicide must be answered in the affirmative. There 
 is certainly no disposition on the part of hysterical 
 individuals to take their own lives ; nothing is more 
 frequently on their lips than the expressed desire to 
 kill themselves, and yet suicide, as a result of hys- 
 teria, is exceedingly rare. Legrand du Saulle* thinks 
 the tendency to suicide is common enough, but it is 
 rarely carried out. He calls attention to the fact 
 that in true insanity there is always a definite motive 
 for the suicide — persecution, fear of ruin, etc. — while 
 the attempted suicide of hysterics seems to lack any 
 distinct motive. The hysteric generally announces 
 publicly her intentions, and the apparent attempts 
 are made with ostentation. 
 
 Gilles de la Tourettef mentions cases of actual 
 suicide in hysterical subjects, carried out with as 
 much secrecy and forethought as would have been 
 used in true insanity. I have seen one case, that of 
 a man of middle age, who was both hysterical and 
 hypochondriacal, who shot himself through the head. 
 He had never talked of suicide, and the preparations 
 were carefully made, nor was there any publicity 
 attending the act itself. It must be borne in mind 
 that the hysteric may carry the love of notoriety too 
 far, and succeed in an attempt that was not intended 
 to be successful, as in the case related above of 
 Miss X. 
 
 * " Les Hysteriques, " Paris, 
 | Op. cit. 
 
THE MENTAL CONDITION IN HYSTERIA. 159 
 
 Lethargy, Narcolepsy. — Closely allied to the 
 various mental phenomena observed in hysteria are 
 certain curious modifications of consciousness, of 
 which, perhaps, the most striking is hysterical leth- 
 argy. This condition has been recognized from a 
 very early period, Araetius having called attention 
 to it. It is also described in the writings of Galen. 
 Accounts of the affection, with illustrative cases, are 
 to be found in the works of Ambrose Pare, Syden- 
 ham, Charles Lepois, and many other of the older 
 authors. Of course, among the ancients there was 
 a certain mystery attached to these cases of pro- 
 longed sleep, and consequently their accounts have 
 to be received with some allowance. The strange- 
 ness of this symptom naturally excites public notice, 
 and the daily papers are constantly writing up some 
 " wonderful case " with wonderful inaccuracy. 
 
 Hysterical lethargy usually comes on suddenly. 
 The subject may be pursuing some ordinary avoca- 
 tion, when suddenly she falls into a profound sleep. 
 Doubtless the origin of some of the fairy tales of 
 sleeping princesses are founded upon cases of hys- 
 terical lethargy. So sudden is the onset in some 
 instances that apoplexy is suggested. Again, and 
 perhaps more frequently, the attack is preceded by 
 certain prodromal symptoms, malaise, nervousness, 
 hallucinations, mental changes, and the like. The 
 duration of the attacks is extremely variable; in 
 many instances there is only a momentary loss of 
 consciousness, resembling a fainting fit or an attack 
 of petit mal. Again, the sleep may last for days or 
 
160 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 even for months. The subject appears simply to be 
 in a profound sleep ; the face has a natural appear- 
 ance, though at times it may be slightly congested. 
 The muscles generally show a certain amount of 
 rigidity or intermittent contractions. The eyes are 
 closed, and, as Charcot has pointed out, there is a 
 constant slight quivering of the eyelids. The pupils 
 show no marked or constant change, being some- 
 times dilated, sometimes contracted. The pulse 
 maintains its normal frequency, and respiration is 
 regular and quiet. An important diagnostic symp- 
 tom is the temperature, which is never raised. 
 
 In a case seen in consultation not long since, 
 the diagnosis of hysterical lethargy had been made, 
 partly from the appearance of the patient, and 
 partly because the woman had formerly had attacks 
 of hysterical lethargy. The thermometer showed 
 marked rise of temperature, and a diagnosis of 
 apoplexy was made and afterward confirmed. Anes- 
 thesia is usually present. In two of my cases there 
 was total loss of tactile and pain sense. Gilles de 
 la Tourette and Cathelineau * have shown that there 
 is marked loss of weight and diminution of all the 
 elements of the urine in spite of regular and abund- 
 ant feeding. The duration of many cases is so great 
 that it is necessary to feed them, and this can readily 
 be done, since as the reflexes are not entirely 
 abolished, food placed on the back of the tongue 
 will be swallowed. The duration of the attacks, as 
 
 * " Progres Med.," 1 890. 
 
THE MENTAL CONDITION IN HYSTERIA. 161 
 
 has been said, is variable. Gairdner* relates the 
 history of a case in which the sleep continued with- 
 out interruption for more than five months, and 
 Pfendlerf reports one lasting over eighteen months. 
 Dana,J in an interesting paper on this subject, has 
 collected a number of cases of variable duration. 
 
 Cases have been reported by Semelaigne and 
 Janet § of apparent hysterical lethargy terminating 
 fatally. The attack may terminate by the patient 
 simply waking up, or, what is more common, by a 
 convulsive seizure. In many instances it is possible 
 to arouse the patient by pressing upon the hystero- 
 genic zones. In the case of Katie B., pressure 
 on the ovarian zone produced slight convulsive at- 
 tacks, but did not arouse her completely. The elec- 
 tric stimulation was then tried, and it was found that 
 a very mild current, either galvanic or faradic, would 
 instantly arouse her. One electrode was placed at 
 some indifferent point, and the other, the negative, 
 was placed upon a hysterogenic zone. She seemed 
 to experience great pain, though her skin was entirely 
 anesthetic, and the current strength was only a few 
 milliamperes. " Parmentier|| has described a form of 
 hysterical sleep which he calls narcolepsy. In this 
 condition the subjects are possessed with an uncon- 
 trollable desire to sleep. They will fall asleep on all 
 occasions, like the fat boy in " Pickwick." It is hardly 
 necessary to include these cases in another category, 
 
 * Lancet, 1888. t" Thesis >" Paris > ^33- 
 
 X " Trans. Med. Soc, New York," 1884. 
 
 \ " Arch. Gen. de Med.," 1891. II Loc. cit. 
 
162 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 since they are apparently similar in most respects to 
 the cases of short duration mentioned above. 
 
 In all the cases of lethargy that have been studied 
 with care and fully reported, are to be seen many of 
 the stigmata of hysteria. It is quite probable that in 
 many instances the sleep merely takes the place of 
 an attack. Nothing is more common in hysteria 
 than for one symptom to assume an intensity that 
 completely obscures all the others. Yet in hysteri- 
 cal lethargy can be seen reflexes of most of the 
 features of an attack. There is a certain amount of 
 muscular disturbance always present — rigidity or 
 convulsive movements — and anesthesia is marked, 
 together with great modification of the mental state. 
 This latter symptom is so much more marked than 
 the other stigmata that this affection belongs properly 
 under the head of mental symptoms. 
 
 Catalepsy, Ecstacy, etc. — It is not unusual to 
 find, during some period of the major attack of hys- 
 teria, a certain peculiar modification of the muscles, 
 which is denominated cataleptoid, or the state of cata- 
 lepsy. Generally this manifestation is seen in the 
 third stage, or that of emotional attitudes. The 
 limbs can be placed in any position, and remain thus 
 fixed until the muscles become physiologically fa- 
 tigued. While at the beginning of the attack there 
 may be some slight rigidity of the muscles, this very 
 soon gives way to a condition of wax-like flexibility 
 (flexibilitas cerea). These symptoms, as has been 
 noted, form a part of the attack, and are not to be 
 regarded as constituting a distinct condition. Cases 
 
THE MENTAL CONDITION IN HYSTERIA. 163 
 
 are met with, however, in which the ordinary symp- 
 toms of hysteria are so insignificant, or are so ob- 
 scured by the peculiar muscular phenomena, that 
 they are regarded as constituting a distinct class, and 
 are described under the term catalepsy. Catalepsy 
 was made much of by the older writers, and even 
 comparatively modern authors describe it as a dis- 
 tinct affection (Rosenthal). 
 
 The folio wine citation from Boerhaave,* which is 
 quoted in many of the older books, shows in what 
 a serious light catalepsy was formerly regarded. 
 ''Catalepsy," says Boerhaave, "is a dream in which 
 the patient becomes of a sudden void of feeling, and 
 retains that same position and action of all parts of 
 his body which it was in when the disease seized him 
 first. This doth happen so seldom that there is 
 hardly one physician in ten who in fifty years' prac- 
 tice shall happen to see it. Galen, in fifty years' prac- 
 tice, saw it but once. It seldom changes into other 
 diseases, yet it has sometimes been succeeded by the 
 falling sickness, convulsions, and foolishness, but 
 most times ends in death." 
 
 There can be no doubt of the fact that the isolated 
 cases of catalepsy are distinctly hysterical in nature, 
 and often, as has been noted, take the place of the 
 convulsive seizures. 
 
 There would seem to exist in many hysterical per- 
 sons a sort of cataleptoid tendency at times other 
 than during the grand attack. The abulia, or loss 
 
 * "Aphorisms," London, 1735. 
 
1 64 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 of will-power, which is the fundamental condition 
 underlying the hysterical state, makes more or less 
 of an automaton of the subject. Suggestions are 
 easily accepted and readily acted upon, and this fact 
 would in large part explain the phenomenon of cata- 
 lepsy. This condition is not, however, peculiar to 
 hysteria, since it is seen in certain forms of insanity, 
 notably the katatonia of Kaulbaum, and some forms 
 of simple melancholia. Again, the cataleptoid state 
 is one of the distinct phases of hypnotism. Evi- 
 dently we have to deal with some disturbance of the 
 normal relation which exists between the higher and 
 the lower, or motor centers ; the subject is not able 
 of his own will to set the motor mechanism in 
 operation. 
 
 It is clear that catalepsy should no longer be re- 
 garded as a distinct affection, but rather as a symp- 
 tom-complex, related to several abnormal mental 
 states. 
 
 Another phase of mental hysteria which is de- 
 scribed as a distinct affection in the older books is 
 ecstacy. Enough has been said in chapter i to 
 show that this condition was one of the most char- 
 acteristic manifestations of hysteria in early times. 
 Very generally, as has been shown, the ecstatic state 
 was the outcome of religious superstition, and simi- 
 lar conditions are sometimes seen in modern times 
 among ignorant and superstitious people. 
 
 Ecstacy constitutes one of the phenomena of the 
 third stage of the major attack, and is described under 
 that section. It is brought about most probably by 
 
THE MENTAL CONDITION IN HYSTERIA. 165 
 
 hallucinations of the special senses, which are in 
 great part forgotten after the subject recovers. 
 
 Closely related to mental hysteria is that curious 
 phenomenon known as somnambulism, or sleep 
 walking. While, of course, somnambulism cannot 
 be strictly regarded as belonging to hysteria, yet 
 some of the symptoms observed in this latter condi- 
 tion are clearly hysterical in nature. Again, there 
 can be no doubt of the fact that somnambulism oc- 
 curs, for the most part, if not wholly, in hysterical 
 subjects. Somnambulism is seen in children and 
 young adults, rarely in elderly persons. The night- 
 mares and night terrors of childhood may be re- 
 garded as modifications of the condition which, in 
 its fully developed state, is spoken of as somnambu- 
 lism. One of my patients, a lad of ten, will awake with 
 a scream, jump out of bed, and run into another 
 room where his parents are — all the while entirely 
 unconscious, or at least profoundly asleep. 
 
 Pritchard * says that somnambulism was known to 
 Hippocrates and Galen. He describes somnambu- 
 lism as " a manifestation of the nervous system, 
 characterized by a suspension, more or less complete, 
 of external feeling, while the imagination is active." 
 Bertrand -j- says: " Somnambulism constitutes really a 
 new life, returning at unequal intervals, connected 
 together by a new species of memory." 
 
 The attacks are apt to come on about the same 
 hour each time, usually after midnight, and can often 
 
 *" Cyclop, of Pract. Med.," 1845. f " Traite du Somnambulisme." 
 
166 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 be traced to some indiscretion in eating or some un- 
 usual excitement. The subject will get up, often 
 dressing carefully, and with the eyes either open or 
 shut, generally the former, will perform a series of 
 acts as naturally as when awake. 
 
 Popular descriptions of somnambulism have dwelt 
 rather too strongly on the tendency of somnambu- 
 lists to walk on the roofs of houses or other danger- 
 ous places. As a rule, they go through some accus- 
 tomed routine — a student gets his books, a farmer 
 goes to the stable and feeds his horses, etc. General 
 sensibility is abolished, or at least is greatly ob- 
 tunded, since somnambulists will often hurt them- 
 selves without awakening or showing any evidence 
 of feeling. 
 
 The special senses — vision certainly and perhaps 
 the others — are more or less active. It is probable, 
 however, that the special senses are under the domi- 
 nation of an autosuggestion or dream. Take, 
 as illustrative of this point, the curious case re- 
 lated by Muratori,* of a student who was accus- 
 tomed to get -up and dress himself, get his books 
 together, and spend some hours translating Latin. 
 On one occasion some friends came into his room 
 and found him thus occupied. They brought a lamp 
 and then blew out the candle which was on the stu- 
 dent's table. Immediately he ceased his work, 
 groped about the room, with difficulty found his way 
 to the kitchen, relit his candle, and resumed his occu- 
 
 * Quoted by Pritchard, loc. cit. 
 
THE MENTAL CONDITION IN HYSTERIA. 167 
 
 pation. In this instance the subject seemed blind to 
 all light except his own candle. 
 
 Guinon* cites a case of a young' man whose field 
 of yision seemed restricted to the paper upon which 
 he was writing. It would seem that in some instances 
 there is a decided psychic excitation, persons being 
 able to do mental work in a state of somnambulism 
 that was impossible for them in their waking 
 moments. 
 
 On this point Sir William Hamilton t says: "In 
 this remarkable state (somnambulism) the various 
 mental faculties are usually in a higher degree of 
 power than in the natural. The patient has recol- 
 lections of what was wholly forgotten. The imagi- 
 nation . . . and the faculty of reasoning are in 
 general exalted. It is also true that there is, or at 
 least seems to be, an exaltation of muscular sense or 
 muscular co-ordination, since some subjects will per- 
 form with ease feats that they could by no means 
 accomplish so well when in the waking state. The 
 mental state of somnambulism differs from that in 
 ordinary dreams, in that in the former there is never 
 any recollection remaining of what has passed. In 
 some mysterious way memory links together the 
 somnambulistic periods, the subject when awake 
 having absolutely no recollection of what has oc- 
 curred during the sleep-walking period, though re- 
 membering in one attack what has passed in a former 
 one." 
 
 * Progres Med. ,1891. j " Metaphysics. 
 
1 68 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 Many interesting cases illustrating this point are 
 to be found in the literature on the subject. Guinon * 
 relates the case of one of his patients who in one 
 attack wrote a dozen pages of manuscript, and in 
 another attack, three days later, began, without 
 hesitation and without referring- to the rest of the 
 manuscript, with page 13, also writing the last word 
 of page 12. In ordinary dreams there is a slightly 
 similar revival of memory. As a rule, the somnam- 
 bulist does not vary his performance, but repeats 
 the same actions in the same sequence in each 
 attack. Space will not permit the relation of any 
 of the amusing stories of somnambulism with which 
 literature, both scientific and popular, abounds. 
 
 The following case, which has been for some years 
 under my care, presents some curious features : 
 Mr. I., a well-known clergyman of a markedly hys- 
 terical temperament, began, about fifteen years ago, 
 to have somnambulistic attacks. The attack usually 
 comes on after midnight, and begins by loud talking. 
 He will often pray as if he were in his pulpit. After 
 a few minutes he gets out of bed, walks around the 
 room, and invariably looks for the chamber vessel. 
 If he succeeds in finding it he passes a large quan- 
 tity of pale urine, wanders about for a few minutes, 
 and goes back to bed. When he cannot find the 
 vessel he will urinate in any convenient receptacle. 
 His eyes are staring open and his face has a very 
 vacant expression. He will converse with persons 
 
 * Loc. cit. 
 
THE MENTAL CONDITION IN HYSTERIA. 169 
 
 in the room in a reasonably intelligent manner. He 
 rarely goes out of his room, though on a few 
 occasions he has done so. The next morning there 
 is not the slightest recollection of what has passed. 
 If no one has seen him, the only way he is aware of 
 having had an attack is that the room is sometimes 
 disordered in an effort to find some place to urinate. 
 On one occasion he dropped a pitcher and cut him- 
 self, and was not aware of the injury until the next 
 mornine- The attacks seem to bear some relation 
 to indiscretions in diet or to overwork. On one 
 occasion he took 60 grains of bromid of potash at 
 bedtime by mistake, and had an attack shortly after 
 midnight — which would have some weight in ex- 
 cluding the possible epileptic nature of the attacks. 
 He is not in any manner unconscious during the 
 attack, but can recognize persons he knows, and 
 will often ask them to get something for him ; but 
 it is very difficult to arouse him, or, rather, to restore 
 him to his normal mental state. This peculiar con- 
 dition lasts usually about half an hour, and the 
 attacks come on at irregular intervals, sometimes two 
 in a week, or, again, months will elapse between them. 
 A condition in many respects similar to somnam- 
 bulism, except that it takes place during the day and 
 is more prolonged, has been termed by Charcot 
 vigilambulism, in contradistinction to noctambulism, 
 as he designated the condition we have called som- 
 nambulism. In these cases of vigilambulism there is 
 a veritable double life, the threads of each being 
 taken up where they were broken off. 
 15 
 
170 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 Vigilambulism may last months or even years, the 
 subject returning to the normal mental state with no 
 recollection of the period of abnormal life. Many 
 illustrative instances of this double life could be 
 mentioned from both medical and lay sources. The 
 most carefully studied and most accurately reported 
 case is the classic history of Felida X., so graphically 
 described by Azam.* This patient, an hysterical girl, 
 would pass into what Azam calls the "second state," 
 in which, while her mental faculties were apparently 
 perfectly preserved, still her whole character was 
 entirely changed. The duration of the abnormal 
 state increased from hours to days, weeks, and 
 months, until she passed most of her life in this 
 " second state." She had not the slightest recollec- 
 tion while in one state of what had happened while 
 in the other, but her memory was perfect in each 
 separate condition, and she would apparently take 
 up one life just at the point she had left it perhaps 
 months before. The medico-legal aspect of these 
 cases is important, since without doubt acts may be 
 performed by such persons for which they could 
 hardly be held responsible, and, moreover, this con- 
 dition may subject persons to the criminal acts of 
 others. In the case of Felida X., the girl was 
 seduced while in the " second state." 
 
 It is not true, of course, that every sleep-walker is 
 markedly hysterical, but there can be no doubt of 
 the fact that the great majority of them are. Again 
 
 * " Hypnotisme et Double Conscience." 
 
THE MENTAL CONDITION IN HYSTERIA. 171 
 
 in some instances where we would hesitate to pro- 
 nounce the subject distinctly hysterical there is a 
 marked neurotic history. In a certain proportion 
 of cases the somnambulistic attack is really a part 
 of, or rather a modification of, the major hysterical 
 seizure. In fact, the somnambulistic attack may be 
 ushered in by a typical hysterical convulsion. In 
 studying the phenomena of natural somnambulism, 
 one cannot fail to be struck with the close analogy 
 which exists between it and the provoked somnam- 
 bulism of hypnotism. Charcot long ago pointed out 
 the relationship which exists between hysteria and 
 hypnotism, — a fact that has been abundantly borne 
 out by subsequent observations, — and natural som- 
 nambulism would almost seem to be the connecting 
 link between the two conditions. 
 
CHAPTER VII. 
 
 VISCERAL AND VASOMOTOR DISTURB- 
 ANCES. 
 
 Digestive disorders of various kinds are fre- 
 quently met with in hysteria. The older writers 
 laid great stress on this symptom, and Cullen made 
 it the basis of a theory of the etiology of hysteria. 
 Hysterical subjects nearly always have symptoms 
 referable to the stomach. Generally these symptoms 
 are vague, corresponding in a manner to the gastric 
 paresthesia of neurasthenia. Sensations of fullness 
 and distention, of emptiness, of "sinking," of move- 
 ment, of indistinct pain, and the like, are complained 
 of. As a rule, these subjective sensations are not 
 attended by any distinct disturbances of the func- 
 tions of the stomach. They constitute, except the 
 well-defined cases of neurasthenia, the so-called 
 " nervous dyspepsia," another example of a euphe- 
 mistic synonym for hysteria. 
 
 But apart from these vague general subjective 
 
 symptoms referred to the gastro-intestinal tract, 
 
 there are certain distinct and well-marked objective 
 
 symptoms. One of these conditions — referred to 
 
 in another chapter — is contracture of the esophagus. 
 
 Sometimes the spasm is clonic in nature, involving 
 
 only, or chiefly, the pharyngeal muscles, but more 
 
 frequently its main seat is in the esophagus. The 
 
 172 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 173 
 
 contracture takes place at different parts of the tube 
 in different subjects, and Gilles de la Tourette * has 
 sueeested that in some cases there exists a hystero- 
 genie zone in the esophageal mucous membrane. In 
 some subjects liquid, in others only solid, food in- 
 duces the contracture. As a result of the contrac- 
 ture, whether it be in the pharynx or esophagus, the 
 food is rejected before it reaches the stomach, occa- 
 sionally lodging for a few moments, but it is generally 
 returned almost immediately after the attempt to 
 swallow. A young negro girl who was under my 
 care for some time was unable to swallow any solid 
 food, or at least only minute particles. As soon as 
 the food passed the pharynx, it seemed to be arrested 
 and was at once regurgitated. She lived for months 
 on liquid food, with bread broken into minute 
 crumbs mixed with her milk or soup. A careful ex- 
 amination with the sound showed no organic stric- 
 ture, and after lasting for nearly a year the condition 
 disappeared. The duration of spasm or contracture 
 of the esophagus is uncertain, lasting weeks, months, 
 or even years. Often it vanishes suddenly after 
 some strong emotion or as the result of suggestive 
 treatment. Cases of death from inanition, — due to 
 hysterical contracture of the esophagus, — have been 
 reported (Briquet) .f Contracture may affect the 
 stomach and vomiting result, the food being re- 
 jected almost immediately after reaching the stom- 
 ach. There is no nausea, and no great amount of 
 
 * Op. cit. | Op. cit. 
 
174 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 pain or discomfort attending the vomiting. Appar- 
 ently as soon as the food touches the mucous mem- 
 brane of the stomach a single- contraction takes 
 place, the contents of the stomach is expelled, and 
 the organ resumes its natural condition. When food 
 is introduced by means of a tube, as soon as the 
 latter is withdrawn, a simple painless contraction 
 takes place and the food is rejected without having 
 been acted upon by the gastric juice. 
 
 Hysterical vomiting resembles, in many respects 
 the vomiting observed in cerebral disease, but it 
 must be borne in mind that in the former case there 
 are always present some of the many stigmata of 
 the disease, though, as will be noted, these stigmata 
 are often ill defined. In vomiting of cerebral origin 
 it is practically always possible to make out some 
 diagnostic symptoms of intracranial pressure, or 
 some grave blood changes. Gilles de la Tourette 
 and Cathelineau * have brought out the interesting 
 fact that in hysterical vomiting it rarely happens that 
 all the food taken by the mouth or introduced by 
 the stomach-tube is rejected, thus accounting for the 
 fact that in some instances hysterical vomiting is not 
 attended with as much emaciation as would be ex- 
 pected. In many cases, however, — in fact in all cases 
 when the vomiting continues over any considerable 
 period, — emaciation becomes profound, and cases of 
 death have been reported with autopsies showing no 
 lesions whatever ; as, for example, the case reported 
 
 *" La Nutrition dans L'Hysterie." 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 175 
 
 by Robinson.* Of course, instances of death from 
 hysteria or any of its complications are always 
 regarded with suspicion, and justly so, yet the case 
 above alluded to, and a few other similar ones, would 
 seem to leave no doubt of the fact that fatal results 
 have followed long-continued vomiting of purely 
 hysterical origin. It has been suggested that some- 
 times atonic vomiting and dilatation may be due to 
 paralysis of the muscular coats of the stomach, the 
 paralysis, of course, being of hysterical origin. 
 
 In addition to the vomiting of food, hematemesis 
 is occasionally observed in hysterical subjects. The 
 quantity of blood vomited is usually small, though 
 cases have been reported of large hemorrhages, 
 which were considered of hysterical origin ; as, for 
 instance, the case of Bouloumie,f in which as much 
 as a liter of blood was vomited. Sometimes the 
 blood is mixed with the food, but oftener it is ex- 
 pelled as pure blood of a bright red color, or only 
 slightly mixed with mucus. The blood may show 
 signs, occasionally, of having undergone partial 
 digestion, appearing in brownish clots. The hemate- 
 mesis may occur at irregular intervals and often 
 extends over many months' duration. Undoubtedly 
 most of the cases of so-called vicarious menstrua- 
 tion are really instances of hysterical hematemesis. 
 
 There is at present under my care a young girl 
 with many well-marked stigmata of hysteria, such as 
 hysterogenic zones and hemianesthesia, who has at 
 
 * Lancet, 1893. -j- Union med., 1880. 
 
176 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 times typical attacks of hysterical vomiting. The 
 vomitine is at times so severe and loner continued 
 that it is necessary to feed her by the rectum. At 
 intervals she has hematemesis, this symptom usually 
 occurring near the menstrual period. She will men- 
 struate for several days, vomiting small quantities of 
 bright red blood at the same time, and the hemate- 
 mesis will continue for several days after the men- 
 strual period has passed. She also has attacks of 
 hematemesis in the intervals between her menstrual 
 periods ; her stomach has been very carefully ex- 
 amined, and no evidence of any digestive disturb- 
 ance can be detected. This patient has a brother 
 who gives a history of similar attacks of vomiting of 
 blood. It is almost certain, as has been said above, 
 that the hemorrhages that are observed from various 
 mucous surfaces, and which are spoken of as in- 
 stances of vicarious menstruation, are in reality vaso- 
 motor hysterical manifestations. The association of 
 this symptom with the menstrual epoch is in accord 
 with the frequently observed exacerbations of hys- 
 terical symptoms at this time. While hysterical vom- 
 iting of blood is nearly always seen in women, cases 
 have been reported in men. 
 
 Gilles de la Tourette has suggested — and the 
 suggestion is worthy of careful consideration — the 
 possibility of confounding hysterical hematemesis 
 with gastric ulcer. He examined a number of cases 
 diagnosed as gastric ulcer in the Paris hospitals, 
 and found a large percentage of hysterical subjects 
 among them. The fact that gastric ulcer is most 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 177 
 
 frequently seen in young females, and that very 
 often there are few local symptoms, emphasizes 
 the necessity of excluding hysteria. Again, it not 
 infrequently happens that there may be areas 
 of hyperesthesia in the region of the stomach 
 of patients presenting the symptom of hysterical 
 hematemesis, so that the resemblance between the 
 two affections may be very close. 
 
 A very common gastric disturbance met with in 
 hysteria is hysterical anorexia, or anorexia nervosa. 
 In the forms of hysterical vomiting described above, 
 there, comes a time when the patient is unwilling to 
 take food for fear of disturbing the stomach, and 
 when some obstruction, as contracture of the esoph- 
 agus, exists, the difficulty in swallowing is so great 
 that the subject would rather go without food than 
 experience the discomfort of attempting to force it 
 through the constricted passage. This is not, how- 
 ever, what is meant by hysterical anorexia. In this 
 latter condition there exists no reason why food 
 should not be swallowed and digested. The patient 
 simply says that it is impossible to eat. This symp- 
 tom was first described by Lasegue * and Sir William 
 Gull,*)- and since their observations many cases have 
 been reported. There is no evidence of any distinct 
 fixed idea, such as we see in the insane ; or, at all 
 events, hysterical subjects rarely assign any cause 
 for their refusal to take food. 
 
 Occasionally, perhaps, they may express a desire 
 
 * Arch. Gen. de Med., 1873. \ Brit. Med. Jour., 1873. 
 
 16 
 
178 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 to reduce their weight, but this is rare. As a rule, 
 they begin by refusing certain articles of food, or 
 confine themselves to one. Sometimes this is 
 accompanied by a desire for things that are unfit 
 for food — the well-known conditions of pica and 
 malacia of the older writers. Sometimes gradually, 
 sometimes suddenly, the patient refuses food almost 
 entirely. Of course, there are many cases that 
 should not be included in this category, — cases of 
 wilful deception, in which the patient publicly refuses 
 food and consumes large quantities in secret. In 
 cases, however, about which there can be no doubt, 
 it is astounding how lon^ the anorexia and the con- 
 sequent starvation may go on without producing 
 emaciation. Often the subject will seem unusually 
 active and vigorous, while seemingly taking a very 
 insufficient amount of nourishment. After a time, 
 if the condition be pronounced, emaciation begins 
 to show itself. The patient becomes anemic, loses 
 flesh steadily, the skin becomes dry, and in a num- 
 ber of perfectly authentic cases death has resulted. 
 The idea, which was long prevalent, that in hysteri- 
 cal vomiting and hysterical anorexia nutrition is not 
 impaired has been clearly exploded by the careful 
 observations of Gilles de la Tourette * and Cathe- 
 lineau.f These authors noted the exact amounts of 
 food taken by patients affected with one of the con- 
 ditions described above, and in the case of vomiting 
 noted the amounts of food rejected ; and by weighing 
 
 * Loc. cit. -j- Loc. cit. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 179 
 
 the patients daily showed that in hysteria, as in any 
 other condition, it is necessary to eat to live. 
 
 The fallacy in the older observations, as these 
 authors have pointed out, lay in the fact that while 
 the hysterical patient apparently vomited everything 
 that was put into the stomach, in reality enough 
 food was retained to maintain life. There would 
 seem to be no doubt of the fact, however, that the 
 hysterical subject can keep up the nutrition of the 
 body on rather less food than a normal individual. 
 As a rule, there rarely exist any other well-marked 
 stigmata during the course of the anorexia, or, as 
 Lasegue says, "the other symptoms are suspended." 
 The duration of hysterical anorexia is very variable, 
 lasting weeks or months. 
 
 One of the most marked cases that has come 
 under my observation was that of a young girl 
 about nineteen years of age who, for no ascertain- 
 able reason, gradually refused to take food. For 
 weeks she led a very active life, walking, playing 
 tennis, etc., with no apparent ill-effects. She then 
 began to lose flesh, until she became a mere skele- 
 ton, having emaciated almost to the physiological 
 limit. A careful examination revealed no cause for 
 the emaciation, and a diagnosis of hysterical anorexia 
 was made. A little judicious neglect of the patient, 
 with an active out-door life, rapidly brought about a 
 cure. In a case seen recently, a girl of nineteen 
 had lost more than 40 pounds. She would assign 
 no cause for her refusal to eat, saying simply that 
 she did not care for food. Her color was good, but 
 
180 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 she was extremely weak and unable to make any ex- 
 ertion. In neither of these cases, which were both 
 undoubted instances of hysterical anorexia, were 
 there any well-marked somatic stigmata of hysteria. 
 
 Sollier and Parmentier,* after a number of careful 
 observations, conclude that in hysterical anorexia 
 there is no important modification in the character of 
 the gastric juice. 
 
 It is doubtful, as has been said, whether hystero- 
 genic zones, or patches of anesthesia, exist, or at any 
 rate are prominent factors in the gastro-intestinal 
 disturbances described above. We are then forced 
 to the conclusion that these peculiar, and fortunately 
 rather rare, manifestations of hysteria are central 
 and not peripheral, and are to be classed rather with 
 the mental than the somatic stigmata. And yet this 
 explanation is not altogether satisfactory, since, as 
 has been noted, it is not often possible to bring out 
 anything approaching a fixed idea dominating the 
 digestive system. We can merely refer the gastric 
 disorders observed in hysteria to some disturbance 
 in that part of the cortex representing the gastro- 
 intestinal tract. In the present state of our knowl- 
 edge, it is impossible to say to what extent these dis- 
 turbances are to be regarded as trophic manifesta- 
 tions. 
 
 Intestinal disorders are not infrequent in hysteria ,; 
 there may be a watery diarrhea — the so-called ner- 
 vous diarrhea — or obstinate constipation may exist. 
 
 * Congres de Lyon. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 181 
 
 These conditions have no distinctive features, and are 
 only recognizable by the absence of any apparent 
 cause, together with the association of other hysteri- 
 cal symptoms. It is possible that in some cases the 
 constipation, which is often of long duration and 
 very hard to overcome, may be a part of the gen- 
 eral paralytic phenomena. The cause of the diar- 
 rhea is by some observers regarded as an excessive 
 peristalsis, by others as due to certain indefinite 
 trophic lesions in the intestinal mucous membrane. 
 By far the most interesting and characteristic affec- 
 tion of the intestine met with in hysteria is the 
 enormous distention of the bowel with gas. In many 
 hysterical subjects there are sensations of distention 
 without any distinct increase in size, but now and 
 then cases are seen in which the abdomen becomes 
 enormously enlarged. Joly * reports a case in which 
 the collection of gas was so great that the patient 
 was enabled to float in water. 
 
 There is unquestionably an important mental ele- 
 ment relating to the etiology of hysterical tympanites, 
 for in many cases there is either the strong desire to 
 become pregnant, or the stronger emotion of fear 
 lest this condition be present. In a case now under 
 observation, the patient, a young girl with a moder- 
 ate degree of abdominal distention, believed herself 
 to have become pregnant from masturbation. Usu- 
 ally, however, the fear is not so groundless as in this 
 case. In some cases there is the history of a trau- 
 
 * " Ziems. Encyc." 
 
182 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 matism, received under emotional circumstances. 
 Perhaps the most frequent cause of hysterical tym- 
 panites at the present day is the dread of abdominal 
 tumor. The distention of the abdomen is usually 
 general and regular, occasionally limited to one side, 
 or even more sharply defined. In most cases there 
 is no pain complained of, though occasionally there 
 is the most intense hyperesthesia. Respiration is 
 sometimes interfered with by the distended intes- 
 tines pushing up the diaphragm and encroaching on 
 the thoracic cavity. 
 
 In the cases of simple distention where there is no 
 pain, there is often a close resemblance to pregnancy. 
 Literature abounds in instances of this nature, and 
 most obstetricians can recall amusing cases of false 
 pregnancy. The cases in which there is hyperes- 
 thesia suggest chronic peritonitis, and those present- 
 ing localized swellings, tumor. As a matter of fact, 
 such cases have been wrongly diagnosed and even 
 operated on (Simpson, Potain). Of course, it is 
 always possible to settle the diagnosis by the admin- 
 istration of an anesthetic, when the phantom tumor 
 or the false pregnancy resolves itself to reappear 
 after the effects of the anesthetic are recovered from. 
 
 Various theories have been advanced to account 
 for the origin of the gas in hysterical tympanites, 
 but as yet there is no very satisfactory explanation. 
 It has been suggested that it may be the result of 
 the fermentation of food, but this is not borne out 
 by the studies of the digestion in these cases. Nor 
 is it probable that the gas is simply swallowed. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 183 
 
 More fanciful still is the theory that gas is liberated 
 from the blood into the intestine. The most prob- 
 able solution of the question is that the intestinal 
 wall changes greatly in diameter, and the contained 
 gases become rarified. In some instances large 
 quantities of gas are emitted, either by the mouth or 
 the anus, and it may be drawn off by means of a 
 rectal tube. This gas, as a rule, is nearly without 
 odor. Some of these cases present the troublesome 
 and distressing symptom of borborygmus, which is 
 often so excessive and uncontrollable that social 
 intercourse becomes impossible. 
 
 Cases of hysterical tympanites have been reported 
 that resembled very closely intestinal obstruction, 
 the symptoms being great distention of the abdo- 
 men, pain, and even fecal vomiting. In a case 
 reported by Briquet, a solution of litmus injected 
 into the bowel was in a very short time vomited. 
 This case was watched most closely, and solutions 
 of various substances not to be found in the hospital 
 wards were injected, all of which were returned by 
 the mouth. The course of the gastro-intestinal 
 manifestations of hysteria is variable ; now appearing 
 as an isolated symptom, lasting a few days or weeks 
 and disappearing, or, again, continuing for months. 
 There is a marked tendency for these conditions to 
 reappear at irregular intervals, and, as a rule, they 
 are very resistant to treatment. 
 
 Affections of the Genito-Urinary Apparatus. 
 — In the description of the grand attack, and also in 
 connection with many of the interparoxysmal symp- 
 
1 84 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 toms of hysteria, mention has been made of polyuria. 
 This symptom has been noted from the earliest 
 times, and is to be regarded as one of the classic 
 observations in the symptomatology of hysteria. 
 The ordinary convulsive seizure very frequently ter- 
 minates by a copious discharge of pale urine of low 
 specific gravity. In addition to this transient poly- 
 uria it would seem that occasionally hysterical sub- 
 jects present this symptom for months or even years 
 (Gilles de la Tourette).* Axenfeldt and Huchard 
 say : " Hysterical polyuria is either transitory or 
 permanent. In the first instance, it is a phenomenon 
 frequently observed consecutive to some paroxysmal 
 seizure, and consists in the emission of a large 
 quantity of pale urine. The second variety is much 
 more rare, persists a greater or less length of time, and 
 is often unassociated with paroxysmal symptoms." 
 
 The pathology of polyuria in general is as yet so 
 obscure that we should hesitate to associate perma- 
 nent polyuria in a causative way with hysteria. 
 Cases have also been reported, especially by the 
 older writers (Laycock) of hysterical hematuria. In 
 some instances, where this latter symptom was asso- 
 ciated with great pain, the kidney has been excised, 
 and no stone being found, the diagnosis of hysteria 
 was arrived at. The possible sources of error in 
 such a diagnosis are apparent. 
 
 A very striking symptom which is occasionally 
 observed in hysterical subjects is suppression, partial 
 
 * Op. at. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 185 
 
 or complete, of the urine. Laycock, in his essay on 
 "Hysteria," published in 1840, declares that the 
 mild form of hysterical ischuria is of no uncommon 
 occurrence. In discussing the graver form, he re- 
 ports a number of cases, some from his own obser- 
 vation, but in the main gathered from old sources, 
 in which the length of the suppression of the secre- 
 tion is utterly incredible. 
 
 Still more incredible are the cases which Laycock 
 has collected of what might be called vicarious urina- 
 tion. He gravely reports instances, ostensibly worthy 
 of credence, of urine passing in considerable quan- 
 tities from the umbilicus (case xn, in which, after 
 three days of complete suppression of urine, two 
 quarts "gushed from the umbilicus"), from the anus 
 (case xv), from the mammae and skin (case 
 xxvn), from the ears, eyes, and so on. The most 
 astounding case of this marvelous collection is taken 
 from the American Journal of the Medical Sciences, 
 1827, concerning which the reporter, Dr. Arnold, 
 says : " Urine next flowed from the left ear, left eye, 
 afterward was discharged from the stomach. 
 The urine next flowed from the nipple of the right 
 breast, afterward from the left, next from the navel, 
 and finally nature, wearied in her irregularities, made 
 her last effort, which completed the phenomena 
 of the case, and established a discharge of urine 
 from the nose." These cases are referred to some- 
 what at length to show the difficulty in separating 
 the spurious from the genuine in the symptomatol- 
 ogy of hysteria. As will be seen, there is a grain of 
 
i86 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 truth present in all this mass of absurd nonsense, 
 since unquestionably there is in these cases of ischu- 
 ria a certain vicarious urination. 
 
 Charcot,* after going carefully and critically over 
 all the reputable cases of hysterical suppression of 
 urine, showed conclusively that the condition, while 
 rare, really exists. In one case most carefully ob- 
 served and hedged about with every precaution to 
 prevent fraud, the suppression of urine was almost 
 complete for weeks together. At the end of the 
 period there would occur a temporary polyuria, last- 
 ing a day or two, followed by another long period 
 of suppression. In this case, together with several 
 others studied by Charcot, the catheter was fre- 
 quently used, demonstrating the fact that the urine 
 was not passed into the bladder. In these cases 
 there was frequent vomiting, and the material ex- 
 pelled from the stomach showed urea present in de- 
 cided amounts. 
 
 When the amount of urine became very small the 
 vomitings would increase, and vice versa. In some 
 cases the other emunctories come to the aid of the 
 kidneys, and there exists profuse diarrhea, excessive 
 salivation, or, as in the case reported by Weir Mit- 
 chell, a very copious sweat. In these various ways 
 the actual amount of urea removed is considerable. 
 In a case of hysteria showing nearly all the recog- 
 nized stigmata of the disease, that was under my 
 care several years ago, the daily quantity of urine for 
 
 * Op. cit. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 187 
 
 months at a time would range from y 2 of an ounce 
 to an ounce. An examination of it showed nothing 
 abnormal except a relative increase of urea com- 
 pounds. In this case there was at times vomiting, 
 always very profuse sweating, and the breath had a 
 distinctly urinous odor. 
 
 Thus these instances of partial suppression of 
 urine — oliguria or ischuria — can generally be ex- 
 plained by the fact that the other systems are called 
 upon to supplement the work of the kidney, and 
 consequently uremic symptoms do not appear. The 
 cases of hysterical anuria, or total suppression, con- 
 tinuing any length of time, must be received with 
 great reserve. The peculiar tolerance of the hys- 
 terical subject, illustrated by the cases of long fasting 
 previously alluded to, may permit of a certain tempor- 
 ary suppression of urine, but unquestionably the sys- 
 tem will not be able to endure this state of affairs long 
 before symptoms of uremic poisoning begin to show 
 themselves. 
 
 The bladder is occasionally involved in hysterical 
 subjects, the mucous membrane showing, now, anes- 
 thesia or, again, hyperesthesia. This has been alluded 
 to in another chapter. It is probable that some 
 of the cases of " irritable bladder " are in reality 
 instances of hyperesthesia, of a purely hysterical 
 nature, of the vesical mucous membrane. Hysteri- 
 cal retention and incontinence are met with but have 
 no characteristic features. 
 
 Organs of Generation. — It is interesting, in view 
 of the derivation of the name hysteria, to see how 
 
1 88 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 rarely the reproductive organs are the seat of dis- 
 tinct hysterical manifestations. The older writers 
 dwelt largely upon the participation of these organs, 
 both in the etiology and the symptomatology of 
 hysteria. When we come, however, to study in a 
 scientific manner the stigmata of the disease, we 
 find very few constant symptoms relating to the 
 reproductive system. As has been noted, ovarian 
 tenderness is a characteristic phenomenon, but there 
 are other hysterogenic zones that are nearly, if not 
 quite, as constant. Again, it is quite common to 
 find marked tenderness over the corresponding 
 regions in the male. The uterus is rarely involved, 
 and the vaginal mucous membrane is not more 
 frequently the seat of anesthesia or hyperesthesia 
 than some other mucous membranes. The testicular 
 tenderness spoken of by some authors is hardly 
 characteristic enough to be placed in the category 
 of hysterical stigmata. The point that has been 
 raised, that in hysterical women there is an exces- 
 sive discharge of mucus from the vagina, has not 
 been borne out by observation. Again, while it has 
 been shown that in hysteria it is not unusual to find 
 certain disturbances in the sexual instincts, it is clear 
 that these disturbances are central rather than per- 
 ipheral. 
 
 The reason why hysterical women refer so many 
 of their ills to the organs of generation is because 
 the hysterical mind is peculiarly open to suggestion, 
 and the reproductive system, with its mysteries of 
 menstruation and pregnancy, furnishes a most fruit- 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 189 
 
 ful field for suggestion. It is to be hoped that the 
 clearer knowledge of the nature of hysteria will 
 restrain the operative fury with which the past 
 decad has become so familiar, and that the ovaries 
 will no longer be removed to cure a disease which 
 is resident in the higher cerebral centers. 
 
 Disturbances of Respiration. — It is very com- 
 mon to observe attacks of rapid respiration of mod- 
 erate intensity occurring alone, or associated with 
 other hysterical phenomena. Occasionally, however, 
 this symptom becomes so pronounced as to consti- 
 tute a veritable attack of what might be called 
 " hysterical asthma." Charcot * has recorded a case 
 in which the respirations numbered 180 a minute. 
 In this case there was no evidence of cyanosis, and 
 the pulse-rate was not disturbed. Weir Mitchell f 
 relates a number of cases of hysterical rapid breath- 
 ing, the respirations ranging from 60 to 150 a minute. 
 The breathing in these cases was costal in type, 
 superficial and without effort, and the pulse was not 
 accelerated. 
 
 The older writers, as Briquet, t described cases 
 in which there were great dyspnea, abundant rales, 
 cough, and profuse expectoration. As a rule, these 
 attacks of hysterical rapid breathing come on in 
 paroxysms and last several hours, terminating often 
 in a convulsion or some other hysterical manifesta- 
 tion, such as contracture or paralysis. Hysterical 
 hemoptysis is a symptom occasionally observed, and 
 
 * Op. cit., tome II. f Am. Jour. Med. Sci., 1893. % Loc. cit. 
 
190 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 is probably a part of the general vasomotor disturb- 
 ance so common in hysteria. It is most frequently 
 associated with a paroxysm of coughing, but may 
 occur independently. The amount of blood lost is 
 sometimes considerable, and the attacks may be re- 
 peated at intervals. The main interest in this symp- 
 tom is the diagnosis between this hysterical vaso- 
 motor affection and a beginning pulmonary tubercu- 
 losis. The older writers (Pomme) laid great stress 
 upon this phenomenon, and probably confounded it 
 with early tuberculosis. To-day, of course, such a 
 mistake should be impossible. The hysterical cough 
 has long been recognized, and ever since Sydenham's 
 description of it has found a place in all treatises on 
 hysteria. It is characterized by its hard, dry, parox- 
 ysmal nature. It occurs in distinct attacks, of which 
 as many as 30 or 40 may appear in a day. The 
 paroxysm may last only a few minutes or may be 
 prolonged for hours. A very diagnostic point is that 
 these attacks never occur during sleep. Notwith- 
 standing the frequency and often violence of the 
 attacks, the patient is not, as a rule, exhausted by 
 them ; and, as in hysterical rapid breathing, there is 
 rarely any cyanosis. 
 
 Hysterical expiratory spasm often mimics, in a 
 curious way, the cries of animals. Examples of this 
 are recorded in the account of the various early 
 epidemics of hysteria (chap. 1). A case of this sort 
 was recently under my care. A man of about 
 thirty years of age, with no very marked hysterical 
 stigmata, and apparently free from any distinct 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 191 
 
 mental disease, would, at intervals of five to fifteen 
 minutes, sine a line or two in a high falsetto voice, 
 
 o o 
 
 terminating in a dozen or more sharp, shrill barks, 
 not unlike the cry of an angry terrier. This con- 
 dition had lasted for several months when I first saw 
 him. Inspiratory spasm presents a large number of 
 varieties. Among them may be mentioned hiccough, 
 sobbing, sighing, yawning, and the like. Hysterical 
 hiccough was apparently very common in the epi- 
 demics of the middle ao-es, but does not seem to 
 
 o ' 
 
 have been noted often in modern literature. It 
 comes on in paroxysms, and lasts for days, or even 
 months, with little or no interruption. One case of 
 hysterical hiccough that I saw in a young girl lasted 
 for about a week and was cured by hypnotic sugges- 
 tion. In a case of hysterical yawning, Charcot found 
 that eight paroxysms occurred a minute, or 480 an 
 hour. Hysterical sneezing is quite a common affec- 
 tion, occurring in distinct paroxysms and generally 
 provoked by some emotional cause. 
 
 Affections of the Voice. — Hysterical aphonia, 
 or loss of voice, — inability to speak in a loud tone, — is 
 a very common hysterical manifestation, and has 
 long been observed. Conversation is carried on in 
 a low whisper, sometimes so low as to be almost 
 inaudible. 
 
 It is a well-known fact that many subjects of hys- 
 terical aphonia, in whom the voice has sunk to a 
 faint whisper, can sing as usual. Hysterical aphonia 
 is occasionally accompanied by spasm or paralysis of 
 the laryngeal muscles, but, as a rule, nothing can be 
 
192 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 made out from laryngoscopic examination. Prob- 
 ably in- most cases there exists a certain amount 
 of anesthesia of the laryngeal mucous membrane. 
 Generally the duration of hysterical aphonia is short, 
 but cases have been reported extending over months 
 and years. In one of my cases the condition lasted 
 many months. The voice was almost inaudible, 
 and it was necessary to put the ear close to the pa- 
 tient's mouth to hear what was said, and even then 
 many words were lost. This patient recovered rap- 
 idly under suggestion and the use of a strong fara- 
 dic current applied to the larynx. Hysterical apho- 
 nia must not be confounded with the much rarer 
 condition of hysterical aphasia which has been seen 
 in cases of hysterical hemiplegia. 
 
 In this connection might be mentioned another 
 variety of speech disturbance — hysterical mutism. 
 There are, practically, only three conditions in which 
 absolute loss of speech, or rather absolute mutism, 
 occurs ; namely, hysteria, certain distinct mental af- 
 fections in which there exist delusions respecting 
 speech, such as melancholia and some forms of para- 
 noia, and, thirdly, cases of simulation. 
 
 In hysterical mutism there is never any evidence 
 of the presence of a delusion, the patient apparently 
 being simply unable to utter any sound. The lips 
 will sometimes move but no sound will be produced. 
 The onset of the affection is sudden and generally 
 follows some emotional excitement. There rarely 
 exists any paralysis of the tongue, lips, or laryngeal 
 muscles. A case sent to me a few years ago was 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 193 
 
 that of a man of thirty-five years of age who had 
 been entirely mute for several weeks. Upon being 
 asked to talk he made grimaces, but was apparently 
 unable to utter a sound, and carried a tablet upon which 
 he wrote answers to all questions. He was taken to 
 the electrical room, and in as suggestive a manner 
 as possible a strong faradic current was suddenly 
 applied to his larynx. The result was a scream, 
 after which he began to talk. These cases some- 
 times last for years, and recovery generally takes 
 place suddenly, as in the case related above. 
 
 Cardiac and Vasomotor Symptoms. — It is 
 rather to be wondered at that the heart is not more 
 frequently involved in hysteria than would seem to 
 be the case, since this organ is so readily affected by 
 disturbances of the higher centers. Perhaps in most 
 cases of hysteria there is more or less cardiac dis- 
 turbance, but it rarely becomes a prominent symp- 
 tom. The most common symptom referable to the 
 heart that is met with in hysteria is an unduly rapid 
 pulsation. During the convulsive seizure this is 
 most marked, and is often out of proportion to the 
 physical exertion. The heart is easily excited in 
 many hysterical subjects, and a very trivial cause 
 may bring on an attack of hysterical tachycardia. 
 
 An interesting illustration of this is seen in the 
 report of a case by Dr. O'Donnovan.* A woman 
 who had many hysterical stigmata, was subject to 
 attacks of tachycardia, in which the heart would 
 
 * Maryland Med. Jour., 1 889. 
 17 
 
i 9 4 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 beat as many as 192 times a minute. These attacks 
 lasted several hours, when the normal rate of pulsa- 
 tion, 72, would be established. There was appar- 
 ently always some emotional cause as the starting- 
 point of the attacks, though the patient was not 
 aware of any unusual sensations about her heart and 
 seemed in no way incommoded by the condition. A 
 careful physical examination of the heart in this case 
 showed it to be perfectly normal. Whittaker calls 
 attention to the fact that many substances, such as 
 tea, coffee, tobacco, or alcohol, taken even in modera- 
 tion, will greatly and unduly excite the hysterical 
 heart. 
 
 The other extreme, a slow heart, is rarely seen in 
 hysteria, except in the state of lethargy already 
 alluded to. Palpitation is met with but is not espe- 
 cially frequent. The curious attacks of pseudo- or 
 hysterical angina, in which there is great pain com- 
 plained of in the region of the heart, and irregular 
 pains in the extremities of the same side, have 
 already been mentioned. 
 
 Far more common than cardiac symptoms are the 
 marked disturbances of the vasomotor system. In 
 a mild degree these disturbances consist of sudden 
 flushings of the face or upper part of the body, 
 together with subjective sensations of heat or cold. 
 These symptoms are usually fugacious, a patch of 
 redness appearing suddenly, lasting but a few 
 minutes, and disappearing. Sometimes there is an 
 alternation of vasomotor paralysis and constriction, 
 the appearance of the skin changing from red to 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 195 
 
 white. A condition which has often been noted is 
 the so-called "autographism." In certain hysterical 
 subjects a mark made with the finger-nail or the point 
 of a pencil brings out a wide scarlet band which may 
 persist for hours. This phenomenon played a con- 
 spicuous part in the epidemics of hysteria seen in the 
 middle ages. 
 
 Mesnet* has recorded a very marked case of this 
 condition, in which the line or word traced simply 
 with the finger lasted for many hours. Occasionally 
 the opposite condition of vasoconstriction has been 
 noted, sometimes giving a distinct local asphyxia. 
 The cold extremities, so often complained of by 
 hysterical patients, are probably examples of vaso- 
 constriction. Certain skin eruptions would seem to 
 be sometimes associated in a casual way with hys- 
 teria. Gilles de la Tourettef considers pemphigus 
 to be the most characteristic of the cutaneous affec- 
 tions allied with hysteria. The vesicular eruption of 
 herpes seems in some manner to be related to hys- 
 teria, and the same may be said of some of the forms 
 of eczema. 
 
 Weir Mitchell J has reported the case of a girl 
 who, in addition to hysterical rapid breathing and 
 other marked stigmata, had a peculiar eruption on 
 her leg. Duhring, commenting on this case, de- 
 scribes the lesion as a crust made up of epithelium, 
 and places it in the.category of trophic manifestations, 
 due to some general disturbance of the central ner- 
 
 * Gaz. des Hop., 1889. f Loc. at. j Loc. cit. 
 
196 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 vous system. More striking still are the cases of 
 hysterical gangrene, of which a large number have 
 now been reported (Kaposi, Hebra, Neumann, and 
 others). This affection is seen in young females, 
 and begins as a painful spot on the skin about the 
 size of a dollar. In a few hours the skin over the 
 painful area becomes gangrenous, and after a couple 
 of weeks the slough separates, leaving a character- 
 istic hypertrophied cicatrix. These ulcers recur at 
 irregular intervals for months or years. 
 
 Hysterical Edema. — A vasomotor phenomenon, 
 which was in all probability recognized by Syden- 
 ham, but which has only been studied carefully since 
 the observations of Charcot in 1889, is hysterical 
 edema. This rare affection develops rather sud- 
 denly in young persons, in whom, as a rule, there 
 are other hysterical stigmata. Usually only one 
 side is involved, though the disease may attack both 
 lower extremities. There may be no sensory dis- 
 turbances, but it is generally the case that a certain 
 degree of anesthesia is present, and sometimes 
 ♦hyperesthesia. The skin presents either a dead 
 white color, the white edema, or may be reddish or 
 bluish in tint, blue edema. The parts affected are 
 firm to the touch, and there is rarely any pitting on 
 pressure. The increase in the size of the limb or 
 other part involved is often very considerable. The 
 edema is sometimes associated with paralysis, as 
 in the interesting case related by Weir Mitchell.* 
 
 * Am. Jour. Med. Sci., 1884. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 197 
 
 Several cases of this nature were reported by 
 Mitchell under the title of "unilateral swelling," 
 and antedate the observations of Charcot. It was 
 noted by Mitchell that in his cases the swelling was 
 most marked near the menstrual period, or after 
 some emotional excitement. The skin showed no 
 change in color or temperature. 
 
 McCosh * reports the case of a woman in whom, 
 after attacks of hysterical convulsions, a blue edema 
 involved the breast, arm, and forearm of one side. 
 The skin was of a bluish tint, cold, and hyperesthetic. 
 Later the case developed what would seem to have 
 been hysterical gangrene or ulceration. A further 
 study of this case was made by Shaw, -j- I have 
 notes of one case of hysterical edema occurring in 
 a lad of fifteen. Both leo-s were involved from the 
 knees down, the edema being firm, not pitting on 
 pressure, and the skin dead white. The boy stated 
 that he was subject to these attacks and that his 
 mother also had them at times. The duration of 
 hysterical edema is variable, but usually lasts for 
 some months. 
 
 Excessive sweating, associated with distinct hyster- 
 ical symptoms, was noted by Sydenham. This 
 sweating may be either local or general, and is 
 sometimes preceded by a cold stage, as in the case 
 related by Sorbets.J In rare instances there may 
 occur a veritable . sweating of blood — hemidrosis. 
 
 Annals of Surgery, 1893. f Brooklyn Med. Jonr., 1893. 
 
 % Gaz. des Hop., 1889. 
 
198 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 While many of the cases occurring in the epidemics 
 of the middle ages were rank deceptions, made easy 
 by the religious superstition of the period, still there 
 can be no doubt of the fact that the phenomenon of 
 hemidrosis does really take place, since every pre- 
 caution to prevent fraud has been exercised. The 
 condition is seen only in hysterical subjects, and 
 certainly belongs to the vasomotor disturbances of 
 this disease. 
 
 Up to very recent times it was claimed that mus- 
 cular atrophy never occurred in hysteria, and when 
 it was present was an absolute proof of some organic 
 affection, or at least did not in any way connect itself 
 with hysteria. The recent observations of the French 
 school have proven indubitably that a slight degree 
 of muscular atrophy not very infrequently occurs in 
 hysteria. As a rule, the atrophy takes place in a 
 paralyzed or contractured limb, the paralysis or con- 
 tracture being, of course, of hysterical origin, and 
 involves the muscles, not by individual groups but 
 generally. Babinski * sums up the characteristic 
 features of hysterical muscular atrophy as follows : 
 " (1) The atrophy differs in degree in different cases, 
 but may be very well marked. (2) There are no 
 fibrillar contractions. (3) The idiomuscular excita- 
 bility is normal. (4) The electrocontractility may 
 be diminished, but there is no distinct reaction of 
 degeneration. (5) The atrophy often develops with 
 great rapidity, and its disappearance is equally 
 
 * Arch, de Neurol., 1886. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 199 
 
 sudden." Sometimes there are sensations of ting- 
 ling or even pain over the affected limb. 
 
 In general it will be noted that the trophic manifes- 
 tations of hysteria are very slight, so indistinct in 
 fact that they have received but a tardy and qualified 
 recognition. It is certain, however, that trophic dis- 
 turbances do occur in hysteria, and are related in a 
 casual manner to the neurosis. The great difficulty, 
 of course, is in excluding all other causes which 
 might affect nutrition, and as we now know these 
 causes are many and diverse. 
 
 Even in cases that go to autopsy there may still 
 remain a doubt as to whether some lesion has not 
 been overlooked, as in the case of extreme muscular 
 atrophy reported by Hirt* occurring in a young girl 
 who was a pupil in a school where there was an epi- 
 demic of hysteria. The autopsy in this case re- 
 vealed nothing, and the diagnosis was made, as it 
 were, "in default." Our knowledge of the interrela- 
 tion existing between the higher and lower centers 
 is still uncertain, and until this uncertainty is resolved 
 it is manifestly impossible to say what effect a gen- 
 eral disturbance of the nutrition of the cells consti- 
 tuting the higher centers may have upon the nutri- 
 tion of the cells of the lower centers, and conse- 
 quently upon the tissues which look to these lower 
 centers for the stimulus necessary to keep up a 
 healthy action. 
 
 Hysterical Fever. — A subject of great interest 
 
 * Deutsche Med. IVoch., 1 894. 
 
200 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 which might be considered in this connection is hys- 
 terical pyrexia. In considering this subject there 
 are two questions that naturally arise. First, is it 
 possible to have any considerable rise of tempera- 
 ture, which is due solely to some disturbance in the 
 heat-regulating apparatus ? and second, are the 
 recorded clinical observations free from error ? have 
 all other possible causes which might be opera- 
 tive in inducing fever been rigorously excluded ? 
 Without going into the physiological discussion of 
 the subject, the first question, namely, whether the 
 bodily temperature may be raised by disturbances 
 of the higher centers, may be answered in the 
 affirmative. Passing to the clinical consideration of 
 the subject we find, among the older writers (Pomme, 
 Sydenham, Whytt), descriptions of hysterical fever, 
 but it is doubtful whether these observations should 
 be received as exact, since the etiology of fever was 
 far from clear at that day, and certain causes which 
 are now well known to be active in the production 
 of fever were not recognized and consequently not 
 excluded. 
 
 Recent literature on hysteria contains frequent 
 reference to hysterical pyrexia, and the condition 
 would perhaps obtain still further recognition if 
 clinical observation were more frequently directed 
 to this symptom. One is rather surprised to find, 
 in looking through Richer's classic work, how rarely 
 the thermometer was used. Briquet* frequently 
 
 Op. cit. 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 201 
 
 refers to cases of hysterical pyrexia and considered 
 it a not infrequent symptom. Gilles de la Tourette * 
 states, on the other hand, that the condition has 
 never been seen at the Salpetriere. One of the 
 most exhaustive papers on the subject is that of 
 Sarbo, of Budapesth. -f His conclusions are as fol- 
 lows : (1) There is a genuine hysterical fever which 
 may be (a) continuous and (b) paroxysmal. (2) 
 Hysterical fever is a functional fever. (3) It occurs 
 either in simple hysteria or in hystero-epilepsy. 
 In the elaboration of these conclusions, the author 
 describes first a form of pseudohysterical fever, in 
 which are present tachycardia, vasomotor disturb- 
 ances, headache, thirst, and other symptoms of fever, 
 with no actual rise of temperature; and second, true 
 fever, which may present itself as a continued or as 
 an intermittent, irregular, or paroxysmal symptom. 
 
 There was recently under my care a very good 
 example of the first type : a young woman of a 
 marked hysterical temperament, without any very 
 decided stigmata, presenting all the phenomena of 
 fever without any actual rise of temperature. The 
 pulse ranged from 120 to 160, respiration was rapid, 
 skin dry, face rather flushed. The organs of circu- 
 lation and respiration, as in fact all the organs of 
 the body, were apparently perfectly normal. This 
 condition continued a week or more, with no rise of 
 temperature, and then disappeared. The continued 
 fever may be mild or severe ; it has no settled type ; 
 
 cit. f Arch, fur Psychiat., Band XXIII, 2. 
 
 18 
 
202 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 it may appear and disappear suddenly. Differences 
 in the temperature of the two sides of the body 
 are often observed, and there may be morning 
 and evening variations. The fever may follow, but 
 is independent of convulsive attacks. Pucci* con- 
 cludes: (i) That there is a true hysterical fever. 
 (2) It generally follows other hysterical symptoms, 
 yet it may be the first symptom of hysteria. (3) It 
 always accompanies other symptoms of hysteria, 
 which may become aggravated during the period of 
 the highest temperature. (4) It may assume the 
 quotidian or tertian intermittent type, or the remit- 
 tent or subcontinuous type. (5) It is accompanied 
 by the ordinary symptoms of fever, and may rise to 
 a high degree, and during the apyrexia the tempera- 
 ture may fall to 95 ° F. (6) The fever may undergo 
 notable interruptions of days or months. (7) Nu- 
 trition remains good, but the mental condition may 
 be disturbed. (8) The fever is refractory to anti- 
 thermic remedies. Debovef calls attention to the 
 irregularity of the fever, its long duration and in- 
 tensity, and the fact that there is no evening exacer- 
 bation. This author states that he has been able to 
 raise the temperature 2.7 F. by hypnotic suggestion. 
 Bressler J calls attention to the irregularity of the 
 fever, both as regards duration and intensity. Many 
 more authorities might be cited, but enough have 
 been given to prove conclusively the existence of 
 
 * Gazetta degli Ospitali, No. 91. 
 
 | Gaz. Hebdom., Feb., 1885 ; May, 1886. % Med. Ret 
 
VISCERAL AND VASOMOTOR DISTURBANCES. 203 
 
 hysterical pyrexia. It may be said, in passing, that 
 there have appeared recently reports of several 
 cases of extreme hyperexia which were supposed to 
 be of hysterical origin. One of these at least (the 
 Omaha case), and probably all of them, were palpa- 
 ble frauds. 
 
 It is to be noted, that during the progress of hys- 
 terical pyrexia there is comparatively little disturb- 
 ance of nutrition, and the urine, while showing a 
 slight decrease in solid constituents, is not altered to 
 anything like the degree observable in fevers due to 
 a distinct cause. A point of some practical value, 
 which has not been dwelt upon by the various writers 
 on this subject, is that in cases of fever from various 
 causes, hysteria may incidentally occur and change 
 the type and intensity of the disease. This, of course, 
 would apply only to the very first period of the 
 pyrexia. It has already been mentioned that a rise 
 of temperature has been obtained by hypnotic sug- 
 gestion. In one experiment upon an hysterical 
 woman, I was able to raise the temperature one 
 degree F. by non-hypnotic suggestion. It is not to 
 be wondered at that in hysterical persons fearing or 
 expecting some fever, puerperal or malarial for ex- 
 ample, autosuggestion acts upon the thermic centers. 
 There can be no doubt of the fact that hysterical 
 pyrexia is' very rare, but it is certain that the condi- 
 tion exists. 
 
CHAPTER VIII. 
 DIFFERENTIAL DIAGNOSIS. 
 
 It may be stated, without fear of contradiction, 
 that the diagnosis of hysteria is very often difficult, 
 and should never be made without careful considera- 
 tion. The recognition of hysterical symptoms is so 
 easy and plain that even a layman does not hesitate 
 to pronounce upon them, but this is far removed 
 from a true diagnosis. The question should always 
 arise, is hysteria responsible for all the symptoms ? 
 or, as Weir Mitchell has so graphically put it," Are 
 the symptoms merely painted upon an hysterical 
 background ?" 
 
 A quarter of a century ago hysteria was not so 
 generally recognized as now, or at least the charac- 
 teristic stigmata were not as familiar as they have 
 since become, and the most common mistake was to 
 regard these stigmata as evidences of grave organic 
 lesions of the central nervous system. To-day it is 
 quite as common a mistake to hasten to the diagno- 
 sis of hysteria after meeting some familiar and classic 
 symptom. Take, as an illustration, a case recently 
 under my care in the City Hospital : a woman with 
 hemianesthesia very well marked, besides other stig- 
 mata, which were cured by suggestive treatment, 
 but with well-marked kidney disease, as the autopsy 
 
 showed. In this case there was a very puzzling 
 
 204 
 
DIFFERENTIAL DIAGNOSIS. 205 
 
 symptom ; this was obstinate vomiting without any 
 gastric disease. The question — and it was an ex- 
 tremely difficult one — was, whether to attribute the 
 vomiting to hysteria or to the kidney disease which 
 at first was not well marked. 
 
 Multiform in its symptomatology, and wonderful 
 in its mimicry, hysteria must yet be regarded as a 
 distinct entity, attended by constant and characteris- 
 tic manifestations. Hence it becomes necessary to 
 separate it clearly from certain neuroses with which 
 it is sometimes confounded. In the first place, the 
 old fallacy, which has wrought such great injustice 
 to the victims of hysteria, namely, that all hysterics 
 were necessarily impostors, is now happily banished. 
 Traces of it linger, however, in regions remote from 
 the light of the newer science. It may be safely 
 said, that no physician who has taken the time and 
 trouble to intelligently study a single case of well- 
 marked hysteria has ever come away from such in- 
 vestigation without being convinced that hysteria is 
 a reality. Imitative as the disease is itself, it can 
 rarely be successfully feigned. The true hysteric is 
 far more apt to be mistaken for a malingerer than is 
 the impostor to be confounded with the victim of 
 this peculiar malady. 
 
 Owing to a faulty conception of the nature of 
 hysteria and an imperfect acquaintance with its 
 complex symptomatology, the error is often made 
 of using the terms hysteria and neurasthenia syn- 
 onymously. There is no need here to do more 
 than call attention to the fact that the well-marked 
 
206 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 stigmata of hysteria are practically entirely wanting 
 in neurasthenia. This latter term is used rather 
 loosely to indicate a general condition of want of 
 tone, debility, exhaustion of the central nervous 
 system. It has no very well-marked stigmata, such 
 as anesthesia, contracture, paralysis, and the whole 
 character and course of the disease, together with 
 its mode of onset, differ widely from hysteria. Con- 
 trast, for example, the clear-cut motor or sensory 
 manifestations in hysteria with the very general 
 muscular fatigue and the indefinite and shifting sub- 
 jective sensations of neurasthenia. The two diseases 
 are probably related, both in their etiology and 
 pathology, and unquestionably sometimes blended. 
 When this happens, it is not very difficult to pick out 
 the symptoms peculiar to each affection. Another 
 condition with which it is common to confound hys- 
 teria is hypochondria. There is far less excuse for 
 mistaking this affection for hysteria than for confus- 
 ing hysteria and neurasthenia. The older writers 
 are probably responsible for the confusion, since they 
 were accustomed to regard hypochondria as a sort 
 of male hysteria. Their conception of hysteria, as 
 implied in its name, did not allow them to assign it 
 to the male, and hence the term hypochondria had to 
 do duty for both diseases. 
 
 Hypochondria being distinctly a mental disease 
 with peculiar delusions and no true stigmata, differs, 
 of course, widely from hysteria and should never be 
 confounded with it. As in the case of neurasthenia, 
 it may sometimes be combined with hysteria, making, 
 
DIFFERENTIAL DIAGNOSIS. 207 
 
 by the way, an extremely intractable disease. There 
 is a certain condition, seen both in men and women, 
 that has never received any name and is generally 
 alluded to as "general nervousness." It partakes 
 slightly of the nature of the three conditions just 
 mentioned — sometimes the symptoms of one, some- 
 times of the other, predominating. The mental 
 condition is rather hypochondriacal, and the somatic 
 stigmata are inconstant, now showing the general 
 hyperesthetic phenomena of neurasthenia, again 
 recalling hysteria by the zonal distribution of the 
 points of tenderness or impaired sensation. This 
 hybrid affection is by no means uncommon ; its 
 course is extremely chronic, and the efforts at treat- 
 ment are often very ineffectual. One often sees a 
 condition among women of the higher walks of life 
 which is wrongly called hysterical. This condition 
 is characterized by a general inertia, usually mental 
 but sometimes physical, yet without the distinguish- 
 ing features of neurasthenia. The subjects declare 
 that they have lost interest in their daily amuse- 
 ments, and they greatly enjoy being on the sick-list. 
 They are not malingerers exactly, but are simply 
 victims of ennui. Sometimes through inheritance, 
 but more often as the result of a purposeless life, 
 there has come to them a weakened volition and a 
 certain state in which suggestion is all too readily 
 accepted and acted upon. Their emotional natures 
 are often in an exalted state, their likes and dislikes 
 greatly intensified, and their views of life tinged 
 with pessimism. This condition, which is, of course, 
 
208 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 a very general one and not to be classified or even 
 described with any accuracy, is mentioned here 
 because it is very commonly spoken of as hysterical. 
 Bearing in mind the characteristic features of hys- 
 teria, it will be seen that this and similar states are 
 not to be included under the name hysteria. They 
 bear, of course, some general similitude to certain 
 of the milder mental manifestations of hysteria but 
 lack the important stigmata. 
 
 It may be said that the diagnosis of hysteria 
 should never be made with certainty without the 
 presence of some of the well-known somatic stig- 
 mata, such as anesthesia, hyperesthesia, paralysis, 
 contracture, special sense disturbances, and the like. 
 One may suspect the approach of the disease from 
 certain indistinct mental states, but there can be no 
 certainty before the advent of some of the charac- 
 teristic objective symptoms. While the wealth and 
 variety of the symptoms of hysteria constitute an 
 aid to its diagnosis, as Lloyd has said, it is no less 
 true that the disease may be monosymptomatic, and 
 it is in this latter case that the differentiation between 
 it and some disease of widely different nature must 
 be made. Nor does this apply only to diseases of 
 the nervous system, — paralyses, anesthesias, and the 
 like, — but to many general acute and chronic com- 
 plaints. Consequently, it is a rule from which there 
 should be no deviation, that a diagnosis of hysteria 
 should never be made until after a careful, compet- 
 ent, and thorough physical examination. A sup- 
 posed hysterical head pain may be due to brain 
 
DIFFERENTIAL DIAGNOSIS. 209 
 
 tumor, or what was regarded as an abdominal hys- 
 terogenic zone may in reality prove to be a serious 
 disease of some of the viscera of this cavity. 
 
 In the foregoing pages the endeavor has been 
 made to point out, as clearly and concisely as possi- 
 ble, the salient features of the various symptoms of 
 hysteria, without attempting in each instance to 
 indicate the differential diagnosis. At the risk of a 
 certain amount of repetition, it is purposed now to 
 take up, seriatim, the more important stigmata of 
 hysteria, and briefly separate them from the condi- 
 tions they most resemble. 
 
 Anesthesia. — The diagnosis of the wide-spread 
 disturbances of sensation — hemianesthesia or, the 
 much rarer, total anesthesia — is not difficult, since 
 this form of sensory involvement occurs practically 
 only in hysteria. Of course, it is possible to have a 
 hemianesthesia of cerebral origin, due to lesion in 
 the capsule, and such cases have been reported 
 (Charcot). The same author has also called atten- 
 tion to the fact that hysterical hemianesthesia and 
 hemianesthesia of cerebral origin often perfectly 
 correspond. Of course, there are practically always 
 certain accompanying symptoms peculiar to each 
 condition. For example : in favor of hysteria would 
 be the age of the patient, the mode of onset, the 
 exact limitation to one side of the body, the very 
 common involvement of the special senses, the zones 
 of hyperesthesia which are nearly always present, 
 and the course of the case. In hemianesthesia of 
 cerebral origin the anesthesia is hardly so regular ; 
 
210 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 there are irregular motor symptoms which do not 
 correspond with the hysterical paralyses ; the special 
 senses are rarely involved, and the onset and course 
 of the case differ widely from the functional disease. 
 General anesthesia of cerebral origin, which, as stated 
 above, is conceivable, need not be considered. The 
 wide-spread anesthesia of peripheral neuritis, and 
 the sensory disturbances of syringomyelia and other 
 cord lesions, with their irregular distribution of anes- 
 thesia, altered reflexes, and marked trophic disturb- 
 ances, can never be confounded with hysteria. 
 
 Hysterical anesthesia involving one limb, or scat- 
 tered in patches over the body, may resemble a 
 limited neuritis or a cord lesion, but here again the 
 marked symptoms of these latter diseases are too 
 characteristic to be overlooked. Toxic neuritis, — 
 poisoning from lead, arsenic, alcohol, and the like, 
 — is to be borne in mind, since in these conditions 
 the anesthesia is often wide-spread, and in two of 
 the affections, notably, — arsenical and alcoholic poi- 
 soning — hysterical symptoms are curiously frequent. 
 It should not be forgotten that in many mental dis- 
 eases there may be distinct anesthesia. Of the 
 special senses, the only one in which disturbances 
 likely to be confounded with other conditions occur, 
 is vision. 
 
 Hysterical amblyopia presents one symptom which 
 is almost pathognomonic ; namely, anesthesia of the 
 conjunctiva and often of the cornea as well. This 
 symptom is of great value, since amblyopia from 
 other causes — as, for example, toxic amblyopia — 
 
DIFFERENTIAL DIAGNOSIS. 211 
 
 may come on almost as suddenly as the hysterical 
 form. It is extremely unusual to have hysterical am- 
 blyopia without a corresponding anesthesia of the skin 
 of the same side. The restriction of the visual field 
 in hysteria is regular and concentric, with a reversal 
 of the color fields, as has been pointed out in detail, 
 and there is rarely any impairment of visual acuity. 
 There can be no doubt, as Charcot has shown, that 
 it is possible to have amblyopia, with restriction of 
 the visual fields, from a lesion in the internal capsule. 
 Disturbances of the visual fields accompanying cord 
 lesions, such as multiple sclerosis, syringomyelia, or 
 locomotor ataxia, need merely to be mentioned, since 
 although they resemble somewhat the similar con- 
 dition seen in hysteria, there is nearly always distinct 
 alteration of the optic nerve or retina. Involvement 
 of the eye muscles in hysteria is so uncommon that, 
 with one exception, the subject need not be men- 
 tioned in this place. The exception to the rule is 
 hysterical blepharospasm, due to a contracture affect- 
 ing the orbicularis. The accompanying anesthesia, 
 together with the fact that there is nearly always 
 paralysis or contracture of muscles elsewhere, usually 
 makes the diagnosis clear. When the hysterical 
 nature of this condition is merely suspected and 
 cannot be distinctly made out, some suggestive 
 treatment should be employed. It may be said, that 
 a number of cases of hysterical blepharospasm have 
 been operated on under a mistaken idea, of course, 
 of their nature. 
 
 Hyperesthesia. — When there is present a gen- 
 
212 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 eral hyperesthesia, or where there are large areas 
 of the cutaneous surface involved, the diagnosis 
 presents no special difficulty. One may, perhaps, 
 sometimes think of polyneuritis or spinal meningitis, 
 but the resemblance of these latter to hysteria is 
 never very close. The localized hyperesthesias are 
 sometimes strongly suggestive of organic disease. 
 The pseudomeningitis of the French school is often 
 singularly like the genuine disease, and, as Chant- 
 messe * says, " Only the knowledge of the antece- 
 dents of the subject, the existence of disturbances 
 of sensation that can be referred to hysteria, the 
 temperature which does not rise above normal, per- 
 mit us to suspect the neurosis, and warn us to 
 reserve our diagnosis." A case of this nature re- 
 cently under my care, was so puzzling that I was 
 entirely unable to make up my mind as to whether 
 the symptoms were due to hysteria alone or to 
 organic disease complicated by hysteria. The re- 
 covery of the patient without any trace of paralysis 
 pointed to the former supposition. 
 
 Hysterical arthritic affections often simulate very 
 closely organic disease. Since the recent careful 
 study of infantile hysteria, it has been shown that 
 Pott's disease, in its early stages, is closely mimicked 
 by hysteria. The differential points are that in hys- 
 teria there is no actual deformity of the vertebral 
 column, no evidence of cord involvement, and the 
 pain is generally greater upon light friction upon the 
 
 Thesis," Paris, 1884. 
 
DIFFERENTIAL DIAGNOSIS. 213 
 
 skin than from deep pressure over the spines of the 
 vertebrae. Hysterical coxalgia, in like manner, pre- 
 sents a superficial rather than a deep hyperesthesia. 
 There is a triangular area of hyperesthesia, with the 
 apex about the pubis and the base over the sacrum. 
 The gait is an exaggeration of the gait of the 
 organic affection, though in many instances it closely 
 resembles it. The employment of an anesthetic 
 gives rather negative results, though, as Charcot* 
 has pointed out, the contracture reappears before the 
 hyperesthesia, reversing the order of the reappear- 
 ance of the symptoms after narcosis in the organic 
 affection. An acute observation of Brodie'sf is 
 that the nocturnal crisis of pain, which awakens the 
 patient and which is such a familiar and distressing 
 symptom in the genuine coxalgia, is not observed in 
 the hysterical form. In the case of the other joints, 
 as the knee or elbow, there is the same geometrical 
 arrangement of the superficial hyperesthesia, with 
 usually absence of heat and redness. There may 
 be actual swelling, or the contracture of the muscles 
 may closely simulate it. In general, whatever joint 
 be involved, it constitutes a veritable hysterogenic 
 zone, and light friction upon the skin covering it 
 will produce a modified hysterical paroxysm. A 
 very slight degree of muscular atrophy may some- 
 times attend the hysterical arthralgias, but not com- 
 parable to what is seen in the organic cases. 
 
 The hysterical breast, described by many of the 
 
 * Op. at. I Op. at. 
 
2i 4 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 older writers (Willis, Pomme, Astley Cooper), must 
 be differentiated from organic inflammatory condi- 
 tions by the general absence of heat and redness, 
 though sometimes there is a bluish tint of the skin 
 in the hysterical cases. It often resembles tumor, 
 and not infrequently has been operated on as such. 
 In doubtful cases, it is impossible to do more than 
 suspect, from the general appearance of the case, its 
 nature, and watch the course of the supposed tumor 
 or inflammation and the effects of suggestive treat- 
 ment. 
 
 Motor Disturbances. — Hysterical tremor may 
 be present during repose, or develop only on in- 
 tentional movements. It exists under two forms, as 
 has been pointed out, the slow and rapid types. In 
 general, hysterical tremor must be differentiated 
 from toxic tremors, and tremors due to some brain 
 or cord lesion. The resemblance between hysterical 
 tremor and the toxic tremors caused by lead, mer- 
 cury, alcohol, and some other substances, is often very 
 close, and this likeness is heightened by the frequent 
 existence of anesthesia in the latter affections. The 
 anesthesia, however, in the toxic tremors follows in 
 general the course of the peripheral nerves, and 
 rarely has the geometric distribution that is seen to 
 be so characteristic of hysterical anesthesia. Again, 
 in the tremors due to metallic or other poisoning, the 
 reflexes are greatly altered, the electrocontractility 
 is, as a rule, abolished, and muscular atrophy is more 
 or less pronounced. The tremors associated with 
 organic lesion of the cord or brain, multiple sclero- 
 
DIFFERENTIAL DIAGNOSIS. 215 
 
 sis, paralysis agitans, or post-hemiplegic conditions^ 
 together with choreiform affections, while some- 
 times more or less closely resembling hysterical 
 tremors, present, usually, pathognomonic symptoms, 
 and the only question to be decided is, as to whether 
 hysteria exists along with the organic disease. 
 
 Hysterical contracture may, as has been pointed 
 out, be general, the diathesis of contracture, or may 
 affect one or more limbs. The former condition 
 could only be confounded with Thomsen's disease 
 or tetany. The resemblance is not close enough to 
 the former rare disease to deserve notice, and in 
 the case of the latter the peculiar form of the con- 
 tracture is almost pathognomonic. It is also not at 
 all certain that hysteria does not play a part in the 
 etiology of tetany. Contracture of the extremities, 
 one or more, may resemble contracture from injury 
 to the peripheral nerves, injury to the structures of 
 the joint, or contracture following brain or cord 
 disease. In general, the diagnostic points of hys- 
 terical contracture are the suddenness of the onset, 
 the accompanying anesthesia, the very slightly 
 altered reflexes, the absence of marked muscular 
 atrophy, the sudden changing of form upon using 
 force to overcome the contracture, the disappearance 
 of the contracture after the application of the Es- 
 march bandage, or upon the administration of an 
 anesthetic. 
 
 It is a curious fact that an hysterical contracture 
 very rarely shows, under narcosis, any fixation of 
 the joint. Old contractures of many months' or 
 
216 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 even years' duration, are perfectly relaxed by an 
 anesthetic, and this is an important diagnostic point. 
 Cases of hysterical contracture have been reported 
 in which there was some fixation of the joint, but 
 such cases are exceptional and always suggest the 
 possibility of the hysteria having been grafted upon 
 an injury. 
 
 Hysterical paralysis of the monoplegic, hemi- 
 plegic, paraplegic, or quadruplegic type differs very 
 markedly from organic paralysis, and presents the 
 following characteristic features : the mode of onset, 
 the peculiar forms of anesthesia, unaltered reflexes, 
 electrocontractility and nutrition, absence of the 
 girdle sensation in the paraplegic form, with no 
 involvement of bladder or rectum : in the hemiplegic 
 form the facial muscles are not involved, or at least 
 this accident is extremely rare ; the leg is more par- 
 alyzed than the arm, and the gait in walking is drag- 
 ging and does not show the outward rotation of the 
 leg which is so characteristic of organic hemiplegia. 
 The course of the paralysis differs in that the symp- 
 toms of hysterical paralysis suddenly reach their 
 maximum, while in many forms of organic paralysis, 
 as in peripheral and spinal cord lesions, a consider- 
 able period elapses before the maximum is attained. 
 Again, the contracture in the hysterical variety 
 comes on at once, thus differing from a paralysis of 
 cerebral origin. It is by no means easy to tabulate 
 the points of diagnostic differentiation which exist 
 between hysterical and other convulsive seizures. 
 As has been shown, there are many grades of what 
 
DIFFERENTIAL DIAGNOSIS. 
 
 217 
 
 may be called hysterical convulsions. The typical 
 grand attack, or major hysteria, has, practically, to 
 be differentiated but from one condition ; namely, the 
 grand mat of epilepsy. 
 
 A comparison between the two conditions shows 
 the following salient points of differentiation : 
 
 HYSTERIA. 
 
 1. Often some exciting cause for 
 the attack, such as grief, anger, emo- 
 tional excitement. 
 
 2. An aura, consisting of globus 
 hystericus, subjective sensations, etc., 
 is common. 
 
 3. The attack occurs during the 
 day. 
 
 4. Loss of consciousness is gradual 
 and not always complete. 
 
 5. The patient is rarely hurt in 
 falling, but rather sinks down than 
 falls, and does not bite the tongue or 
 pass urine or feces involuntarily. 
 
 6. The range of the clonic move- 
 ments is wide. 
 
 7. The return to perfect conscious- 
 ness is rapid after the conclusion of 
 the attack. 
 
 8. There is no alteration of tem- 
 perature. 
 
 9. The duration of the attack is 
 half an hour or longer. 
 
 10. The urinary solids are de- 
 creased. 
 
 EPILEPSY. 
 1. Usually no exciting cause. 
 
 2. The aura is different in char- 
 acter and not so common. 
 
 3. The attacks occur very fre- 
 quently at night. 
 
 4. Loss of consciousness is always 
 sudden and complete. 
 
 5. The patient is very often in- 
 jured by the fall ; bites the tongue 
 and often passes urine and eces n- 
 voluntarily 
 
 6. The range of the clonic move- 
 ments is of slight extent. 
 
 7. The attack is very generally fol- 
 lowed by a heavy sleep or some mental 
 disturbance. 
 
 8. Not infrequently there is a dis- 
 tinct rise of temperature. 
 
 9. The duration of the attack is 
 never more than five to ten minutes. 
 
 10. The urinary solids are in- 
 creased. 
 
 As a matter of practice, the physician has very 
 often to make his diagnosis from a description of the 
 attack, and not from personal observation of it, and 
 the points to be inquired into specially are the hys- 
 terical antecedent symptoms, the exciting cause, the 
 
218 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 duration of the attack, the passage of urine during 
 the paroxysm, the biting of the tongue, and the 
 nature of the movements. 
 
 As a rule, fairly clear answers may be expected to 
 these questions. The fact that the hysterical patient 
 usually requires an audience is a valuable, though 
 not an absolute, diagnostic point. 
 
 The irregular, abortive, or incomplete hysterical 
 convulsive attacks may sometimes be mistaken for 
 uremia, brain lesions, the delirium of fever, or pois- 
 oning from certain substances. There is never any 
 real difficulty in the differential diagnosis between 
 hysteria and the conditions just mentioned, for the 
 hysterical element, especially the psychic manifesta- 
 tions, soon becomes evident, and the symptoms of 
 the various affections mentioned should be apparent 
 after careful examination. There is a phase of the 
 hysterical attack that may resemble petit mal rather 
 closely, and this condition has not been sufficiently 
 insisted upon. The patient will describe a certain 
 momentary loss of consciousness with or without sub- 
 jective sensations of tingling, numbness, or tightness 
 across the chest. Vertigo is often one of the symptoms 
 of this minor attack. The diagnosis is to be made 
 from the fact that there is no absolute loss of con- 
 sciousness, no change in the countenance, and the 
 minor hysterical attack is usually associated with 
 certain unmistakable psychic manifestations either 
 preceding or following the attack. Enough, per- 
 haps, has been said in another chapter in regard 
 to the mental condition in hysteria to differentiate 
 
DIFFERENTIAL DIAGNOSIS. 219 
 
 it from insanity. The peculiar and characteristic 
 emotional disturbances, the states of exaltation and 
 depression rapidly following each other, the tendency 
 to exaggeration, the absence of any distinct delu- 
 sions, the attendant somatic stigmata, — all these 
 manifestations present a picture that is sufficiently 
 clear. It is true, however, that now and then cases 
 are seen that can with difficulty be distinguished 
 from acute mania, and others from acute melancholia. 
 Such cases should be studied with great care and 
 watched for a considerable time, since the commit- 
 ment of such patients to an asylum as insane often 
 has a very bad effect. 
 
 The visceral and vasomotor manifestations of 
 hysteria are of importance, and are often con- 
 founded with organic disease. Disturbances of the 
 circulatory, respiratory, and digestive systems often 
 closely simulate organic affections, but can be differ- 
 entiated, practically with ease, by the negative re- 
 sults of a careful physical examination, taken to- 
 gether with the presence of hysterical stigmata 
 affecting other parts of the body. 
 
 Attention has been called to the fact that hysteri- 
 cal affections of the various viscera are attended 
 only by subjective sensations, and the presence of 
 distinct physical signs of disease is proof positive 
 that the' condition is not merely hysterical. In re- 
 gard to the stomach, for instance, it has already been 
 pointed out that hysterical vomiting is unattended 
 by any distinct digestive changes, and in hysterical 
 ischuria the urine obtained shows no abnormal in- 
 gredient. 
 
220 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 In general, it may be said that the diagnosis of 
 hysteria rests upon negative, no less than positive, 
 symptoms. We must be certain that the symptoms 
 complained of cannot be due to any recognized le- 
 sion, and to this must be added the characteristic 
 stigmata of the neurosis. Finally, the whole life- 
 history of the individual must be viewed ; the hered- 
 ity, the environment, the education, the mode of life, 
 and the emotional causes that might be responsible 
 as exciting causes. It will thus be seen that the ex- 
 amination of a case of hysteria carries the observer 
 over a very wide field, and demands thorough, pains- 
 taking, and conscientious work if a certain diagnosis 
 is to be arrived at. 
 
CHAPTER IX. 
 TREATMENT. 
 
 In considering hysteria, whether from the stand- 
 point of diagnosis or of treatment, the fundamental 
 idea is that the disease has its seat in the higher 
 centers of the brain, and that the bodily manifesta- 
 tions — anesthesia, hyperesthesia, contractures, par- 
 alysis, and like symptoms — depend for their exist- 
 ence upon the imperfect working of these higher 
 centers. Again, it is evident that heredity plays a 
 very important part in the etiology of hysteria, as it 
 does in so many mental affections. This heredity 
 may be direct or indirect, for the hysterical parent 
 may transmit hysteria to the offspring, or may hand 
 down only a neurotic taint, a predisposition to this 
 or other nervous disease. Hence it will be seen, 
 that the prevention of hysteria in persons who are 
 predisposed to it should claim the careful considera- 
 tion of the physician. 
 
 It is often difficult to assign the relative import- 
 ance to heredity and environment, and this is par- 
 ticularly true in the case of hysteria. We know, as 
 has just been said, that heredity is an extremely 
 important factor i.n the etiology of hysteria, but per- 
 haps due importance has not been assigned to the 
 influence of environment. The daughter of an hys- 
 terical mother starts in life, it is true, with a nervous 
 
222 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 system which by inheritance is predisposed to hys- 
 teria, but it is to be doubted whether this factor is 
 any more important than the constant association 
 with the hysterical parent. Environment, with all 
 that the term implies, acts upon the hysterical mind 
 through suggestion, and it has been shown that 
 suggestion runs through all the symptomatology of 
 hysteria. It is the strongest bond which connects 
 the two closely related conditions — hysteria and the 
 hypnotic state. Thus the child of an hysterical 
 mother is a constant witness of the emotional out- 
 bursts and hysterical crises, and these displays must, 
 of necessity, influence its developing mind. In no 
 way are children bound to their parents more closely 
 than through their emotions. A weeping mother 
 will soon have her little ones around her in tears, 
 although they may be totally ignorant of the cause 
 of the maternal grief. The unwholesome emotional 
 atmosphere, the sudden change from tragedy to 
 comedy, the sensationalism, the sentimentality of 
 the hysterical household, are certainly equally as 
 responsible, if, indeed, not more responsible, for the 
 development of hysteria than pure heredity. 
 
 These and like considerations furnish an indica- 
 tion for the prophylactic treatment of hysteria. It is 
 very evident that hysterical environment must be 
 avoided, and this is doubly true when in addition 
 there is a distinctly neurotic taint. Unfortunately, 
 the physician is, in the vast majority of cases, utterly 
 unable to carry out this prophylaxis. He may per- 
 form the disagreeable duty of advising that the 
 
TREATMENT. 223 
 
 children be kept as much as possible out of the 
 society of the hysterical mother, but generally such 
 advice is worse than futile. 
 
 Much may be accomplished in the way of prophy- 
 laxis by the judicious education of body and mind. 
 Children with a neurotic taint should be taken in 
 hand early, and great care should be exercised as to 
 their physical development. The love of outdoor 
 life should be strenuously inculcated, and every in- 
 ducement to outdoor exercise offered. A love for 
 nature, or fondness for some outdoor sport, has 
 saved many a child that was almost predestined to 
 hysteria. A great deal depends upon the systematic 
 training of this class of children. Their education 
 should be in competent hands, and it should be 
 supervised by some one conversant with the child's 
 disposition. The school hours should not be long, 
 but the child should be kept occupied while in school. 
 Contests for prizes should, so far as possible, be 
 discouraged. As the child grows older, the reading 
 should be carefully directed, and sensational litera- 
 ture forbidden. There is much truth, even if there 
 is a little exaggeration, in what Tissot says : " If 
 your daughter reads novels at fifteen she will have 
 hysteria at twenty." The development of the sexual 
 life is a period especially to be watched, and children 
 should unquestionably have these matters explained to 
 them as soon as they are old enough to understand. 
 The morbid curiosity surrounding this physiological 
 question should be early replaced by a clear under- 
 standing of the principles of reproduction. It should 
 
224 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 be the great effort of those directing the education of 
 the class of children of which we have been speak- 
 ing, to avoid all emotionalism and sentimentalism ; 
 to inculcate healthy views of life ; to suppress the 
 tendency to excess in matters social or religious ; 
 and to implant the principles of sound morality. 
 Space does not permit any further elaboration of 
 the details of this prophylactic treatment. Its im- 
 portance cannot be exaggerated, since if it be suc- 
 cessfully carried out the life of the individual is 
 unspeakably benefited. The vigorous outdoor life 
 of the English has developed a race in which there 
 is very little hysteria, while the more artificial, ex- 
 citable life on the Continent has had the opposite 
 effect. 
 
 The treatment of hysteria falls naturally under 
 two heads : first, the treatment of the general hys- 
 terical state, and second, the treatment of certain 
 special symptoms. It should be stated, at the very 
 outset, that a sine qua non of the successful treat- 
 ment of hysteria is the treatment of each individual 
 case. Few general rules can be laid down, or if 
 such rules are dogmatically stated, the exceptions 
 are very numerous. The physician must first calcu- 
 late the personal equation of the patient. The edu- 
 cation, mode of life, family history, tastes, disposi- 
 tion, special likes and dislikes, must all be noted. 
 Unless the physician gains, to some degree at least, 
 the confidence of the patient, commands her respect, 
 comes to possess a certain influence over her, and 
 convinces her that he understands her particular 
 
TREATMENT. 225 
 
 case, no treatment will avail. Again, it should be 
 clearly understood that the physician's authority is 
 absolute. I have seen many failures in the treat- 
 ment of hysteria, due to the fact that above the 
 doctor stood a father or mother as the high court of 
 appeal. It is always well to have the matter form- 
 ally settled before undertaking the case. One great 
 reason why the treatment of hysteria is so much 
 more successful in institutions than at home is, 
 because in a hospital or sanatorium absolute obedi- 
 ence to the rules is insisted upon. 
 
 The daily life of the patient should be arranged 
 for her; for example, it is well to write out a sched- 
 ule upon which is set down the hour of rising, the 
 time and character of the meals, the periods for rest 
 and exercise, and like details. The establishment 
 of regular habits, that are carried out with martial 
 exactness, is the first step in the treatment. It is 
 well to inquire minutely into the daily routine of the 
 patient's life, and impress her with the importance of 
 the various measures instituted. 
 
 The hysterical subject has, as a rule, an excellent 
 memory about everything that closely concerns her- 
 self, and she is disappointed if the physician does 
 not seem to keep the run of her particular case. 
 The treatment is both direct and indirect ; direct in 
 that it aims to remove the cause and thus cure the 
 disease, and indirect in that it attempts to relieve 
 certain symptoms that complicate the disease, though 
 they do not in any sense form a part of it. The 
 central idea in the treatment of hysteria may be ex- 
 
226 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 pressed by the word " suggestion." Again and 
 again in the preceding chapters has it been shown 
 that hysteria and hypnotism are related, and this re- 
 lationship indicates the line of treatment. The men- 
 tal condition of the hysterical subject is a reflex of 
 that of the hypnotized subject, and suggestion finds 
 a ready acceptance. We have to do with a mental, 
 not a bodily, disease, and according to the views ad- 
 vanced in chapter n, the part of the brain involved 
 is that in which are situated the higher centers. The 
 treatment, then, must be mental, — we must veritably 
 " minister to a mind diseased." Therefore, the 
 ordering of the patient's life — the directing the man- 
 ner in which the day must be spent — makes a strong 
 suggestion, first, of the authority of the physician, 
 and second, of the importance of the disease. A 
 mistake that is too apt to be made is to consider 
 hysteria too lightly, to insist to the patient that it is 
 trivial — a mere nothing. The patient knows only 
 too well that there is something the matter, some- 
 thing beyond her control, and is irritated by being 
 told that she must exercise more will-power. All 
 treatment, whether it be drug or hygienic measure, 
 should be made impressive — should be tipped, as it 
 were, with suggestion. The regulation of the diet 
 is a very important thing, and it is not sufficient to 
 simply tell the patient to eat more. As a rule, hys- 
 terical patients eat irregularly, spasmodically, now 
 too much, now too little, and their taste is apt to be 
 perverted In the milder cases, all that is necessary 
 is to see that the three meals are ample. Meat 
 
TREATMENT. 227 
 
 should form an important part of the dietary, with 
 eggs, milk, and simple vegetables. Sweets are to 
 be avoided, and the dessert should consist of fruit. 
 It is best to interdict alcohol, except in particular in- 
 stances, and then the malt liquors are preferable to 
 spirit or wine. In more severe cases it becomes 
 necessary to give nourishment more frequently, and 
 in all cases, even the milder ones that have just been 
 considered, it is often well to have the patient take 
 something light, — a glass of milk and a slice of 
 bread and butter, — between meals and before bed- 
 time. The details of the diet and the mode of ad- 
 ministering food in the severe cases will be described 
 under The Rest Cure, in another chapter. 
 
 After having properly regulated the diet and in- 
 creased the amount of nutritious food in the manner 
 suggested, the next thing is to strike the balance 
 between rest and exercise, and this is often a diffi- 
 cult matter to arrange. Here the individual equation 
 comes in, and must determine, to a great extent, 
 how far exercise should be pushed. In some cases 
 exercise seems at first to aggravate the symptoms, 
 especially the pain, and hence must be taken very 
 gradually. There can be no question as to the great 
 benefit to be derived from proper exercise. Syden- 
 ham recognized the value of exercise in the treatment 
 of hysteria, and strongly recommended horseback 
 riding. The great difficulty is to get the patient 
 interested in some outdoor exercise, for without 
 interest it becomes drudgery, and " there is no profit 
 where no pleasure's taken." Here the ingenuity of 
 
228 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 the physician is often sorely taxed, for the hysterical 
 subject has to be pushed along. Walking should be 
 prescribed in. definite quantity; as, for example, in- 
 struct the patient to take a brisk walk of half an 
 hour, morning and afternoon, or twice or thrice that 
 much if necessary. I have adopted a plan that 
 works well. I am accustomed to say to my pa- 
 tients, where, of course, I know the distances, walk 
 to such and such a place and back. Or I direct 
 them to ride to a certain point and walk back. 
 I have found that they are much more willing to 
 do this than simply go out on their own account. 
 Horseback riding is excellent, and patients are apt 
 to become fond of it. The bicycle has come as a 
 boon to the victims of hysteria, and doubtless has 
 more cures justly attributed to it than any other 
 remedy of recent times. Its excellence consists in 
 the fact that it is a form of exercise that can be 
 easily regulated, is within the. reach of all, gives 
 a maximum amount of fresh air with a minimum 
 amount of exertion, is interesting in itself, and in 
 the treatment of hysteria has the special advantage 
 of occupying both mind and muscles. 
 
 Gymnasium exercise is to be recommended only 
 in cases where outdoor exercise is not possible. 
 Passive exercise is of very great benefit in the 
 severer cases, and will be specially considered in 
 another chapter. As a rule, it is not necessary to 
 employ massage when the patient can be induced 
 to take sufficient outdoor exercise, though in certain 
 
TREATMENT. 229 
 
 instances, particularly where there is contracture or 
 paralysis, it is very useful. 
 
 It is generally advisable to have a place in the 
 schedule for rest, half an hour before luncheon and 
 aeain half an hour before dinner. It is of extreme 
 importance that hysterical patients have long hours 
 in bed. Such patients are very often better at night 
 than through the day, and will insist upon sitting up 
 late. It is a good plan to require from nine to 
 twelve hours in bed, whether the patient can sleep 
 or not. It should be made plain to them that the 
 simple rest in bed is beneficial, and often they can 
 be educated to accustom themselves to this. 
 
 A question that is hard to settle, and one that 
 must be determined in each individual case, is the 
 occupation of the .patient. In many, if not most, of 
 the mild cases, it is far better to permit light work — 
 household duties, and the like — provided they are not 
 burdensome or distasteful. In some cases there is a 
 feverish anxiety to be doing something that has to 
 be restrained. 
 
 The old writers on hysteria laid great stress on 
 the influence of the sexual life on the course of the 
 disease. This view was a perfectly consistent one 
 at a time when the uterus was supposed to be the 
 fons et origo of the disease. It was claimed, how- 
 ever, long after . the decay of this theory, that a 
 life of continence was very productive of hysteria. 
 According to Briquet, the older writers " shuddered 
 with one accord over the lot of the poor widows 
 who, according to their notions, were the inevitable 
 
230 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 victims of hysteria." As has been said in a previous 
 chapter, this view is entirely erroneous. The hys- 
 terical subject is not erotic, — in fact it has been pretty 
 clearly shown that the sexual instinct is rather sub- 
 normal. The hysterical woman desires to attract 
 the attention of men, but the sexual act itself is 
 often repugnant to her. Kraft-Ebing * says that in 
 the hysterical the sexual instinct is often abnormally 
 great, though in another part of the book he calls 
 attention to the fact that absence of sexual feeling is 
 especially to be found among hysterical individuals. 
 The dictum of Hippocrates, quoted above, " nub at 
 ilia et morbum effugiet" is true, but in an entirely 
 different sense from that in which he intended it. 
 Provided the hysterical subject marries happily, her 
 life becomes filled with new objects. It has wider 
 purposes ; it absorbs her energies ; it takes her out 
 of herself; it develops and strengthens her charac- 
 ter ; it is the fulfilment of her mission in the world. 
 On the other hand, if her married life be not a happy 
 one, the disease is always aggravated, and this is 
 especially so when the union is unfruitful. Some of 
 the most intractable cases of hysteria that have ever 
 come under my notice have been in childless women. 
 Clearly, then, the " besom genitaux" has little or no 
 place in the etiology of hysteria. Masturbation and 
 sexual perversion, however, would seem, in my 
 experience at least, to be rather more common in 
 hysterical subjects than in those free from the dis- 
 
 *" Psychopathia Sexualis." 
 
TREATMENT. 231 
 
 ease. In these cases it is probable that the heredi- 
 tary degeneracy which has predisposed to hysteria 
 has brought in its train certain sexual abnormalities. 
 
 The social relations of the hysterical subject must 
 be determined in each individual case. In bad cases 
 it is necessary to resort to isolation, and in general, 
 as has been said, such patients do best away from 
 home. Of course, the ideal treatment of the aver- 
 age case of mild hysteria is travel. In this is com- 
 bined a certain amount of outdoor exercise, an 
 entire change of scene, a removal from the sur- 
 roundings that have perhaps contributed to the pro- 
 duction of the disease, and at the same time there 
 is excited an interest in new things and strange 
 people which relieves the self-concentration. Unfor- 
 tunately, this plan of treatment is of very limited 
 application, especially in this country, where the 
 distances are so great and the change of scene not 
 so abrupt as it is on the continent of Europe. The 
 "wilderness cure" of Weir Mitchell is often produc- 
 tive of excellent results. This is not very expensive, 
 requiring merely a tent and outfit, with a few com- 
 panions, and there are a great many places within 
 easy reach where a small party can spend a summer 
 in a most agreeable fashion. This plan is especially 
 to be recommended for the treatment of hysteria in 
 men. 
 
 From what has been said about the general man- 
 agement of hysteria, it will be seen that the treat- 
 ment in the main aims at the mental symptoms. 
 The regular routine, the multitude of little things to 
 
232 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 be done, the various commands to be obeyed, all 
 these things tend to gradually restore and build up 
 a weakened will-power. It is suggestive in the ex- 
 treme ; it says to the patient : " You must do this 
 or that " ; " These things that are being done, so 
 many and varied, are surely going to be beneficial." 
 In the more severe cases, to which the vigorous rest 
 cure is applied, the suggestion becomes much more 
 imperative — the darkened room, the strange faces, 
 the absolute isolation from home and friends, the 
 many details of treatment, all make a powerful im- 
 pression upon the hysterical mind. Again, the 
 treatment is mental, in that it surrounds the patient, 
 as far as possible, with new objects. It is impossible 
 to banish a disagreeable thought by a mere fiat of 
 the will, but the thing that is possible is to put an 
 agreeable thought in its place. Hence the exercise, 
 pleasant occupation, and the like. The treatment 
 of hysteria by hypnotic suggestion has never real- 
 ized the expectations that the early attempts in this 
 direction promised. Still, much may be done in 
 this direction, and the study of hypnotism has taught 
 us much in the line of suggestive treatment. This 
 subject will be further discussed in the section on 
 Hypnotism. 
 
 Running through the whole treatment of a case 
 of hysteria must be a general moral effect exerted 
 by the physician. This should not consist so much 
 of a general exhortation to exert a weakened will- 
 power, but should point out the general cause of 
 the disease, if such cause is apparent, its course, the 
 
TREATMENT. 233 
 
 mental elements entering into the case, and the pur- 
 pose of the treatment. The patient knows only too 
 well that her will-power is enfeebled and cannot be 
 made to respond to the demands made upon it, and 
 it should be the aim of the physician to make this 
 clear ; to show her that the trouble lies in this 
 weakened will-power ; and to impress upon her 
 mind the fact that the treatment instituted is in- 
 tended especially to invigorate this debilitated will. 
 In this way it is possible to gradually work up to 
 the point of stimulating the desire to recover, and 
 the necessity of supreme exertion. The hysterical 
 subjects need encouragement all the time, and they 
 can be told, without fear of exaggeration, that they 
 have a hard personal fight to make. Every positive 
 symptom of improvement should be seized upon by 
 the physician and made much of. The question is 
 often asked, where the case is being treated at 
 home, as to the extent to which sympathy should be 
 expressed to the patient by members of the house- 
 hold. The rule that ou^ht alwavs to be followed is 
 to command the patient not to speak of her symp- 
 toms to any one but the doctor, and to restrict the 
 family in their inquiries as to the patient's condition. 
 A strict insistence upon the observance of this pro- 
 cedure will often save a vast amount of annoyance, 
 and be of distinct benefit to the patient. 
 
 In addition to these general measures, there are 
 certain more special therapeutic agents that have been 
 found useful in the treatment of hysteria. Of these, 
 the one that occupies easily the first place is hydro- 
 
234 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 therapy. No other single agent has been as useful 
 in my hands as this. It is a good routine practice 
 to order the cold douche to the spine, or the alter- 
 nate warm and cold douche every morning. The 
 subject is such an important one, and the therapeutic 
 application of water has received so little attention 
 in this country, that it seemed well to devote a spe- 
 cial section to this subject. The same remarks 
 apply in great measure to the application of electric- 
 ity, which will also be considered more in detail. 
 Of the different currents, perhaps the static is the 
 most useful in the treatment of hysteria, though 
 both galvanic and faradic yield good results. The 
 utility of this agent is due in large part to its sug- 
 gestiveness, and the same may be said concerning 
 metallotherapy, which at one time was largely used 
 in the treatment of certain of the accidents of hys- 
 teria. 
 
 From what has been said concerning the nature 
 of hysteria, it is very evident that little can be ex- 
 pected from the action of drugs. There is this very 
 important fact to be borne in mind, however, that 
 drugs form an excellent basis and opportunity for 
 carrying out a general suggestive treatment. The 
 mind of man has for so many ages attached a vast deal 
 of importance to the use of medicines, and for this 
 reason we cannot afford to neglect this avenue to 
 the imagination. Hence in employing drugs in 
 hysteria they should be used with a view to the 
 mental impression produced, more than for their 
 absolute physiological action. The quacks of all 
 
TREATMENT. 235 
 
 ages have been quick to recognize this, and it is 
 unfortunate that they have exploited it to such a 
 disgusting degree, since it has, in a measure, deprived 
 the profession of a very useful aid — the imagination 
 of the patient. It should not be thought beneath 
 the dignity of the profession to utilize this means, 
 and in prescribing medicine for the hysterical patient 
 as strong a mental impression as possible should be 
 made. The physician should bear in mind the fact 
 that in hysteria he is endeavoring to treat the mental 
 and not the bodily condition, and should dwell upon 
 the power of the particular drug in calming the 
 nervous excitement, and the patient should be im- 
 pressed with the fact that the symptoms complained 
 of will be relieved. The effect may be heightened 
 by administering the medicine frequently and in 
 some particular manner. It is simply astonishing 
 how much can often be accomplished by careful 
 attention to these seemingly trivial and unimportant 
 details. Just as in the hypnotic state a teaspoonful 
 of water impregnated with suggestion will produce 
 emesis or intoxication, so in hysteria the suggestion 
 that is added to the medicine is the most important 
 ingredient. It is a significant fact, and strongly 
 confirmatory of the statement just made, that the 
 various drugs that have been, from time immemorial, 
 employed in the treatment of hysteria have all some 
 very striking and peculiar odor. For example, asa- 
 fetida, musk, valerian, sumbul, and so on. It is 
 more than probable that the effectiveness of these 
 remedies is in large part due to the pervading odor. 
 
236 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 Little need be said concerning the physiological 
 action of these drugs, since it is too uncertain and 
 feeble to require any special notice. Musk was 
 freely prescribed by the older writers, but it is very 
 rarely used at the present day. The dose is from 
 5 to 15 grains in mucilage. Asafetida is perhaps 
 the member of the group that has attained the high- 
 est reputation in the treatment of hysteria, and is 
 very largely prescribed, especially by the laity. The 
 most convenient method of administering it is the 
 officinal pill (three grains), of which two to four may 
 be given at a dose. The other preparations of 
 asafetida are rarely used in hysteria. (Mistura asa- 
 fcetida, dose, gj ; and the tincture, dose 5j). With 
 the profession, valerian has of late years largely 
 taken the place of asafetida. Perhaps the best pre 
 paration is the ammoniated tincture, dose 5j to 3iij, 
 and the fluid extract, dose 5j. A preparation that 
 has proved useful in my hands, and which has a high 
 suggestive value, is valerianate of ether, put up in 
 capsules. The patient shortly after swallowing one 
 or two of these becomes distinctly aware of having 
 taken medicine. Sumbul is another remedy of value, 
 given in the form of the tincture, dose 5j to 5iv, or in 
 pills of the solid extract. Camphor, monobromid 
 of camphor, hops, lactucarium, and many other 
 similar drugs have been prescribed, but are not as 
 useful as the valerianates and asafetida. Of course, 
 these various remedies have a slight sedative action, 
 but it is so slight as to be unimportant in any other 
 condition than hysteria. The bromids are very 
 
TREATMENT. 237 
 
 largely prescribed in hysteria, but their use is very 
 disappointing. Undoubtedly they have some effect 
 in quieting " nervousness," but in well-developed 
 hysteria they are of very little service. Of the vari- 
 ous preparations of bromid the bromid of ammonia 
 is the best to employ in hysteria. I have had some 
 success with moderate doses of sulphonal, 10 to 15 
 grains, three times daily. A distinct effect follows 
 the administration of this drug, and very often the 
 good result of administering sulphonal in such doses 
 is very apparent. Of course, it should not be pushed 
 to the point of producing somnolence. There are 
 three other druofs that are orven far too often in 
 hysteria: opium, chloral, and alcohol. The hysteri- 
 cal subject too frequently becomes addicted to the 
 use of one or other of these substances. It may be 
 taken as a safe general rule that no one of these 
 three remedies should ever be resorted to in pure 
 hysteria. Of course, there may be exceptions, but 
 these should be very few. Many other drugs might 
 be included in this category, but the principal ones 
 have been mentioned. Little need be said concern- 
 ing- the use of tonics, digestives, and the like. Iron 
 is often indicated, and when indicated should be 
 given freely in the form of Blaud's pills, Glide's 
 pepto-mangan, or the tincture of the chlorid. 
 When forced feeding is being employed, it is often 
 necessary to aid digestion by some of the pepsin 
 compounds. 
 
 While the plan of treatment laid down above ap- 
 plies to the general management of the disease, it 
 
238 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 might be well to call attention briefly to the treat- 
 ment of certain special symptoms. 
 
 The utility of suggestion in the treatment of 
 hysteria becomes most apparent when applied to 
 certain special symptoms, for here the suggestion 
 assumes a concrete form. 
 
 Anesthesia and Hyperesthesia. — In the treat- 
 ment of anesthesia, whatever be the variety, elec- 
 tricity is the most valuable agent that can be em- 
 ployed. While the static is, perhaps, the best form 
 of current to use, — on account, I believe, of its 
 greater suggestive value, — the other currents can be 
 made almost equally useful. A very good method, 
 and one within reach of the general practitioner, is 
 the use of the faradic current with the wire brush 
 electrode. One electrode, covered with sponge or 
 cotton, is held at some indifferent point, and the 
 brush is slowly passed over the anesthetic area. It 
 is well to gradually increase the strength of the 
 current. The sittings should be short, — from five to 
 ten minutes, — and daily. Friction of the skin with a 
 hair glove or other rough substance will often be 
 found beneficial, as will the use of the cold douche, 
 — a fine spray driven with force directed upon the 
 anesthetic region. On the Continent, apparently 
 some success has been attained by the application 
 of certain metals to the insensitive surfaces. The 
 subject of metallotherapy, as this procedure is 
 termed, will be discussed elsewhere. 
 
 It is quite possible that the value of the electric 
 current is something more than merely suggestive, 
 
TREATMENT. 239 
 
 since the vigorous stimulation of the peripheral 
 nerves may exert a directly beneficial action. Much 
 the same plan of treatment is to be followed in the 
 case of hyperesthesia and hysterical pains in gen- 
 eral, except that here the continuous galvanic cur- 
 rent seems to be more serviceable. Special sense 
 disturbances — amblyopia, deafness, involvement of 
 taste and smell — are to be treated with specialized 
 electrodes described in another section. In the case 
 of hysterical deafness, the patient should be made to 
 listen every day for a specified time to the ticking 
 of a watch or clock. Hysterical loss of voice is 
 very amenable to treatment by the faradic current. 
 One electrode is placed at some indifferent point 
 and the patient is held by assistants so that she 
 cannot run away, and the other electrode is either 
 introduced into the upper part of the larynx, or, 
 what in my hands has answered equally well, held 
 over the outside of the larynx. If this latter 
 method is pursued, after the electrodes are in place 
 a strong current is suddenly turned on, and in 
 nearly every case the patient will make some ex- 
 clamation. Usually, in hysterical mutism, after some 
 sound has been uttered, the patient can be encour- 
 aged to attempt to use the voice. 
 
 Paralysis. — Here, again, faradization or static 
 electricity produces excellent results. These cases 
 require close attention, and the physician should 
 carefully examine' the paralyzed parts every day, 
 making some test, with the dynamometer, for exam- 
 ple, as to the gain in strength. It should be borne in 
 
2 4 o HYSTERIA: ITS NATURE AND TREATMENT. 
 
 mind that in using the dynamometer with hysterical 
 patients it should be so arranged that they are not 
 able to see the index. In a case recently under my 
 care, the following method was employed : The 
 patient, a young girl, had complete paralysis of the 
 right leg, not being able to move the limb even in 
 bed. The first seance consisted in making her move 
 the toes alone. As soon as this was accomplished 
 the day's treatment was over. The next day the 
 foot was moved, first passively and then she was 
 made to move it herself. Then a task would be 
 set ; for example, she would be told that she was to 
 practise for one day outward rotation of the leg. 
 She was shown how to make the movements, and all 
 other motion of the le£ was forbidden. Later, the 
 foot was put to the floor, then some weight was borne 
 on it ; next, walking with the assistance of two per- 
 sons, until the patient was gradually taught to walk 
 alone. The treatment extended over several weeks, 
 but this particular case was a difficult one and of 
 some months' standing. This case is described 
 somewhat at length to illustrate the method of pro- 
 cedure. In addition to these daily exercises faradi- 
 zation should be practised, together with massage 
 and Swedish movements. 
 
 Hysterical contractures are often very intractable, 
 and frequently last for months or even years in spite 
 of the most careful treatment. The faradic current, 
 so useful in paralysis, does harm rather than good 
 in contracture, and the galvanic current should be 
 employed in preference, though even this very fre- 
 
TREATMENT. 241 
 
 quently fails to accomplish anything. Massage, in 
 like manner, is of little avail. There is no advantage 
 in attempting forcibly to straighten the limb that is 
 the seat of the contracture. Sometimes, by long- 
 continued gentle manipulation, the contracture can 
 be overcome. Perhaps the best way to deal with 
 these cases is to put the patient under chloroform, 
 reduce the contracture, and then place the limb upon 
 a splint so that the contracture cannot return. This 
 procedure has the advantage of allowing the physi- 
 cian to examine the joint carefully and thus to decide 
 upon the nature of the contracture, if it had not 
 previously been clearly made out. It is astonishing, 
 however, to see how quickly a contracture will re- 
 turn after having been for weeks held straight on a 
 splint. Counterirritants and the actual cautery — a 
 very favorite mode of treatment — are of compara- 
 tively little value in genuine hysterical contracture. 
 The cases that are cured by these means alone are 
 usually those in which there is an element of malin- 
 gering. In rare instances, perhaps, surgical inter- 
 ference becomes necessary, but it is only in those 
 unusual cases in which, after complete relaxation of 
 the muscles has been obtained through the adminis- 
 tration of an anesthetic, it is seen that there is actual 
 shortening of the tendons. Attention has already 
 been called to the fact that hysterical contracture 
 may exist for years without any change taking place 
 in the joint, though, as Charcot has shown, this may 
 happen. 
 
 Convulsive Seizures. — The treatment of the 
 21 
 
242 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 grand attack of hysteria, and the many modifications 
 of it which have been spoken of, is often a very 
 troublesome matter. In private practice, the alarm- 
 ing- appearance of the patient spreads terror and 
 confusion through the household, and no amount of 
 assurance on the part of the physician can convince 
 the friends and relatives that the condition is not 
 fraught with great peril. Then, too, the measures 
 employed will often provoke adverse criticism. I 
 remember, on one occasion, what abuse was heaped 
 upon me for hypnotizing a girl who was in the latter 
 stage of the grand attack. I was accused of trifling 
 with a case of very serious illness. In the City 
 Hospital, where we see many cases of paroxysmal 
 hysteria, there are certain routine measures em- 
 ployed, some of which, while perhaps rather vigor- 
 ous, are nevertheless effective. The first procedure 
 is to attempt to cut short the attack by pressure 
 upon the hysterogenic zones, and if this fails, an ice 
 suppository will often stop the milder attacks. If 
 this fails, t l of a grain of apomorphia is given hypo- 
 dermically, which in a short time produces emesis 
 and with it an end of the attack. For the worst 
 cases chloroform is resorted to. I have several 
 times succeeded in hypnotizing patients in this stage 
 and stopping the attack by suggestion. It is evident 
 that in private practice certain of these measures 
 cannot be employed. The first thing to be done, 
 as Gilles de la Tourette has insisted upon, is to 
 secure absolute quiet for the patient. It is best to 
 have a mattress put on the floor, so as to avoid the 
 
TREATMENT. 243 
 
 danger of the patient hurting herself in the violence 
 of the grand movements. Sometimes it is neces- 
 sary to employ a sheet tied over the bed, or some 
 improvised camisole. This is better than attempt- 
 ing to hold the patient. Ovarian compression should 
 be at once resorted to and in a considerable per cent, 
 of cases this will cut short the attack, or at least 
 bring on a period of calm. The custom of putting 
 on an ovarian compress, so much in vogue at the 
 Salpetriere, is rarely employed in this country. The 
 shock of cold water dashed in the face, or a few 
 whiffs of nitrate of amyl or chloroform, will often 
 have a happy effect. If these measures fail, the 
 chloroform should be pushed to narcosis, or emesis 
 induced by apomorphia. It is well to try hypnotism 
 in all cases, and when the state of lethargy is pro- 
 duced suggestion may be made, and the patient told 
 that she will be well when awakened, or, what is 
 perhaps better, she may be permitted to sleep for 
 several hours. By adopting this latter method, the 
 state of delirium, which is often troublesome, is 
 averted. Careful attention to the patient is neces- 
 sary at the close of the convulsive attack, for then it 
 is that certain accidents, such as paralysis or con- 
 tracture, are apt to make their appearance. Much 
 can be done by suggestion, even when it is not 
 possible to produce hypnotic lethargy. I have fre- 
 quently observed patients at or near the close of a 
 convulsive attack, in whom suggestion was nearly as 
 potent as it is in the hypnotic state, and the physi- 
 cian should always look out for this condition and 
 take advantage of it. 
 
244 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 It will be seen that in the management of the 
 general and special symptoms of hysteria, a great 
 deal depends upon the ingenuity of the physician. 
 As has been said above, he should assume the en- 
 tire control of the patient, and by a firm manner and 
 careful attention to the minutest details, can accomp- 
 lish much. It is a mistaken idea that hysterical 
 subjects can be frightened out of an attack by noise 
 and bluster, and threats of the hot iron. This 
 method will often succeed with malingerers and 
 pseudohysterics, but not in genuine hysteria. 
 
 In the foregoing pages, frequent reference has 
 been made to certain special procedures which are 
 employed in the treatment of hysteria. These 
 measures are of such importance that they must 
 now be considered more in detail. 
 
CHAPTER X. 
 
 ELECTROTHERAPY.— HYDROTHERAPY.— 
 MASSAGE. 
 
 We are still very far from a perfect understanding 
 of the effects of electricity upon the human body. 
 We know that nerve and muscle can be stimulated 
 by the electric current, but in what way this effect is 
 brought about is still obscure. Again, there can be 
 no doubt of the fact that in many cases the electric 
 current will relieve pain, but it is not definitely 
 known how this is accomplished. It may be due to 
 the stimulation of the peripheral nerves, and in an 
 indirect way, perhaps, a stimulation of the centers, 
 or, as has been suggested, the application of the 
 electric current to the surface of the body may 
 hasten or retard certain electrobiological changes in 
 the deeper structures. In making use of electricity 
 in the treatment of hysteria, it is not claimed that 
 this agent produces any distinct physiological effects, 
 or at least anything beyond the stimulation of the 
 skin and peripheral nerves, and the muscles. In- 
 directly the stimulation of large areas of the skin 
 produces certain distinct changes in the superficial 
 circulation, and in this way may influence the circu- 
 lation as a whole. Again, as has just been said, 
 vigorous stimulation of the peripheral nerves will un- 
 doubtedly be felt in the nerve centers ; and perhaps 
 
 2 45 
 
 dl 
 
246 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 this factor has been overlooked in applying electric- 
 ity to the treatment of hysteria. On the other hand, 
 if we consider the nature of hysteria, looking upon 
 it as an involvement of the higher brain centers, and 
 then consider that electricity has for so long been 
 invested, by the laity at least, with mysterious pow- 
 ers in the treatment of disease, we see in this agent 
 the thing par excellence with which to produce a pro- 
 found mental impression. While, as was stated 
 above, electricity may produce certain definite effects 
 upon the nervous system, there can be no doubt of 
 the fact that its great usefulness in the treatment of 
 hysteria depends upon the mental impression it 
 produces. 
 
 Electricity may be employed both in the general 
 treatment of the hysterical condition and also for the 
 treatment of certain special symptoms. In the gen- 
 eral treatment of the hysterical condition any of the 
 currents may be employed for the purpose of either 
 stimulating the cutaneous surface or the muscles. 
 A very good plan of administering the current for 
 these purposes is to have a large foot-plate covered 
 with a damp cloth, and make the patient place the 
 feet upon this while the cutaneous surface may be 
 gone over with a wire brush. In the same manner, if 
 it is desired to stimulate the muscles, a small sponge- 
 covered electrode should be used instead of the 
 brush. Almost any kind of faradic apparatus will do 
 for this treatment. In the same way, general stimu- 
 lation may be very easily accomplished by the static 
 current. It may be said in regard to this form of 
 
ELECTROTHERAPY. 247 
 
 electricity that it possesses, to a much higher degree 
 than do the other varieties, suggestive properties, 
 and consequently it has come to be employed very 
 largely in the treatment of hysteria. The galvanic 
 current may be employed in the general treatment 
 of hysteria, either by going over the skin and mus- 
 cles in much the manner described above, or by 
 limiting its application to the region of the spine. 
 Mild currents (five to ten Ma.) passed through the 
 head are sometimes distinctly beneficial in the treat- 
 ment of hysterical head pains. In treating hysterical 
 paralysis the affected muscles should be made to con- 
 tract vigorously, and for this purpose the faradic 
 current is the best. As has been said, electricity 
 does not seem to be of much benefit in the treat- 
 ment of contracture. Anesthesia is best treated by 
 the faradic current and the wire-brush electrode. 
 The continuous, or interrupted galvanic current, is 
 also useful. This current is to be preferred in the 
 treatment of painful affections. Prince * has ob- 
 served that it not infrequently happens that cases of 
 what seem to be hysterical neuralgias are, in reality, 
 instances of localized neuritis, complicating the hys- 
 teria. In such cases the galvanic current is of far 
 greater value than either of the other forms of elec- 
 tricity. The faradic current has been used to cut 
 short the convulsive attack, and the galvanic current 
 may be employed for the same purpose. One elec- 
 trode should be placed over the most distinct hystero- 
 
 * ' ' Jnternat. Syst. of Electrotherap. ' ' 
 
248 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 genie zone, and a strong- current used. In two cases 
 of hysterical lethargy I found this method eminently 
 satisfactory. It is not necessary to describe in detail 
 the many symptoms of hysteria that are often suc- 
 cessfully treated by electricity, nor the special modes 
 of applying the various currents. Enough has been 
 said to show that suggestion plays the most import- 
 ant role, and hence every effort should be made to 
 intensify this suggestive element, both in the appa- 
 ratus used and in the manner of its application. 
 
 The history of the use of the magnet in the treat- 
 ment of disease, especially hysteria, is extremely 
 interesting. It would seem that from very early 
 times the magnet had been employed as a thera- 
 peutic agent, and certain distinct effects were attrib- 
 uted to its use. Aetius employed it in convulsions, 
 and Paracelsus to prevent epilepsy. Gilbert (1600), 
 Etmuller, and most of the early writers, advocated 
 the use of the magnet in many nervous disorders. 
 Laennec * states that he obtained good results in 
 cases of spasms by applying the magnet to the skin. 
 For a long time the use of the magnet in medicine 
 was discontinued, when a few years ago it was re- 
 vived in France. Charcot")- employed it in the treat- 
 ment of hysterical contractures and anesthesia. 
 Axenfeld and Huchard,J in their "Traite des Nev- 
 roses," published in 1883, say as to the physiological 
 effects of the magnet, that it produces a feeling of 
 intoxication and vertigo, and that the various secre- 
 
 * " Traite de L'Auscult." -f- Op. cit. % Op. cit. 
 
ELECTROTHERAPY. 249 
 
 tions are modified. They describe the peculiar 
 phenomenon of "transfer," which consists in placing 
 a horse-shoe magnet in contact with, or even near, 
 the affected part. The result, as these authors de- 
 scribed it, was that the contracture or paralysis would 
 gradually pass to the opposite side. The magnet 
 was then moved to the side to which the disease had 
 gone, and soon the paralysis, contracture, or anes- 
 thesia would reappear in its former site. This proce- 
 dure, several times repeated, finally brought about a 
 cure. These writers consider the magnet very useful 
 in the treatment of many hysterical stigmata. Cita- 
 tions could be given down to a very recent date 
 from well-known writers, — as, for example, Richer,* 
 — gravely describing the remarkable effects produced 
 by the magnet. Less than ten years ago I saw the 
 magnet frequently used in the Paris hospitals. Con- 
 trast the citations that have been given with the fol- 
 lowing statement from two well-known electricians, 
 Edwin J. Houston and A. E. Kennelly : f " So far as 
 we know at the present time, it would appear that the 
 magnetic flux is absolutely without influence either 
 upon the human body or on any of its physiological 
 processes ; and that, consequently, if any therapeutic 
 effects -do attend the use of magnets, the cause 
 must be of a psychic rather than of a physiological 
 nature. .... When, for example, a person is 
 placed with his head between the poles of a powerful 
 
 *" Paralysies et Contractures Hysteriques,'" 1892. 
 f " Electricity in Electrotherapeutics." 
 
 .-* 
 
250 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 dynamo-electric machine from which the armature 
 has been removed, so that the flux passes directly 
 through the head, even prolonged exposure has 
 failed to produce any observed effects either on the 
 pulse or respiration, whether the magnetic flux was 
 intermittent or was steadily maintained. Or take the 
 case of a powerful electromagnet, made by wrap- 
 ping an iron cannon with a suitable magnetizing 
 coil, and producing a flux sufficiently great to cause 
 heavy iron bars or bolts to be sustained on the 
 person of a soldier standing before the gun. Under 
 these circumstances no sensations were experienced 
 by the soldier, other than those of pressure from the 
 attracted masses of iron." 
 
 The history of the employment of the magnet in 
 the treatment of hysteria is an excellent object-les- 
 son. Here is an agent employed and esteemed by 
 both ancient and modern physicians in the treat- 
 ment of this disease, and when the crucial test of 
 exact scientific experimentation is applied to it, it is 
 shown to have absolutely no action upon the human 
 body. It is going too far to say that although it has 
 no action on the healthy body it exerts some physio- 
 logical action on the hysterical subject. That it 
 does produce certain effects on hysterical subjects 
 we cannot doubt from the multitude of recorded 
 cases, but this action is purely psychic. There can 
 be no objection whatever to its use in the treatment 
 of hysteria, but the physician employing it should 
 recognize that its action is upon the mind and not 
 the body. 
 
ELECTROTHERAPY. 251 
 
 In the same category belongs the curious pro- 
 cedure known as metallotherapy, which was reduced 
 to a system by Burcq. Like the application of the 
 magnet, this was simply a revival of a very ancient 
 practice. Mention of the external application of 
 metals for the treatment of various diseases may be 
 found in the writings of Galen, Paracelsus, van 
 Helmont, and many of the old authors. The obser- 
 vations of Burcq * — published in 1853, and confirmed 
 by many eminent physicians, in France especially, — 
 were, in brief, that hysterical subjects had special 
 affinities for certain metals, and that these metals 
 produced certain marked results on anesthesia, par- 
 alysis, contracture, and other hysterical stigmata. 
 The method of application was to take discs of 
 various metals — gold, silver, copper, zinc, etc. — of 
 the size of a large coin, and apply one or more 
 of them to the affected parts by means of a band- 
 age. In from fifteen to twenty minutes certain 
 effects began to be observed ; if the metal had been 
 applied to an anesthetic area, a zone of normal 
 sensibility would make its appearance, and would 
 gradually extend until the whole of the anesthesia 
 had disappeared. After a certain time the anes- 
 thesia would return. There was noted also the 
 phenomenon of transfer : the anesthesia leaving the 
 part first affected and involving a corresponding part 
 on the opposite side of the body. In the same man- 
 ner, paralyses and contractures were cured by apply- 
 
 * " Mettallotherapie. " 
 
252 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 ing metals to the surface of the skin, and the same 
 treatment was used in hysterical involvement of the 
 special senses. This idea was pushed still further, 
 and what was called internal metallotherapy, — the 
 administration of metals in solution, and also baths 
 of the various solutions, — was largely resorted to in 
 the treatment of hysteria. Afterward it was dis- 
 covered that certain kinds of wood had a similar 
 action, and this procedure was spoken of as xylo- 
 therapy. The scientific explanation of metallo- 
 therapy was discussed by various learned societies, 
 and the theory that seems to have obtained the 
 most support was that the metal-plate set up an 
 electric current. It hardly seems credible, at this 
 day, that only a few years ago such an absurdity 
 should have received as much attention as did this 
 one, from so many able men. The literature on the 
 subject is enormous, and not confined to journal 
 articles, but numbers many large volumes. Of 
 course, the whole explanation of the good results 
 that were certainly obtained by this mode of treat- 
 ment is that it was merely a new and rather impres- 
 sive mode of utilizing the principle of suggestion. 
 The success which attended the use of the magnet 
 and metallotherapy emphasizes most strongly the 
 value of suggestion in the treatment of hysteria. 
 
 Hydrotherapy. — The use of water as a thera- 
 peutic agent dates back to the earliest authentic 
 records. In the writings of Hippocrates may be 
 seen specific directions concerning the diseases in 
 which water was supposed to be beneficial, and the 
 
HYDROTHERAPY. 253 
 
 mode in which it was to be employed. He directed 
 attention, especially, to the use of cold water in 
 fevers, and also showed that a brief application of 
 cold water to the skin had a marked revulsive action. 
 In the works of all the older writers water was given 
 a distinct place among the various therapeutic agents, 
 — Celsus, Araetius, Alexander of Tralles, Frederick 
 Hoffman, and so on. The past decad has wit- 
 nessed a remarkable revival of hydrotherapeutics, 
 after a long period of disuse. This is especially 
 true of this country, since upon the Continent of 
 Europe water has always been used therapeutically. 
 The very marked advantages obtained from the use 
 of water in the treatment of fevers, especially ty- 
 phoid, has emphasized its action, and it is to be 
 hoped that before long it will be employed in many 
 non-febrile affections, since the reduction of higfh 
 temperature is only one of the many ways in which 
 water may be used with advantage in the treatment 
 of disease. In general, it may be said that the prin- 
 ciple upon which hydrotherapy rests is the application 
 of heat and cold to the body, and water is used as the 
 vehicle, so to speak. In no other manner can heat 
 or cold be so evenly applied to the surface of the 
 body, or so exactly regulated. Again, by the appli- 
 cation of water we are enabled to emphasize the 
 contrast between heat and cold, and thus obtain a 
 revulsive effect which is often useful. The general 
 conclusions as to' the physiological action of water 
 may be expressed as follows : (i) As to the circula- 
 tion. There can be no doubt of the fact that by 
 
254 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 the use of water a greater activity can be imparted 
 to the circulation. The oxygenation of the blood 
 is markedly improved (Dujardin Beaumetz *) and 
 the hematopoietic organs are stimulated. More than 
 this, Thayer -f has shown that after the cold bath the 
 number of leucocytes is greatly increased. (2) It 
 would seem that by the use of water, especially its 
 revulsive action, the functions of the brain and cord 
 are stimulated. It is not certain just what the ex- 
 planation of this action is ; most probably the stimu- 
 lation of the central nervous system is brought about 
 both by the stimulation of the peripheral nerves, 
 and also by the change in the caliber of the super- 
 ficial blood-vessels. This latter action is one of 
 great value, for in this manner the circulation is 
 equalized and congestion in internal organs relieved. 
 (3) The action of water in depressing the tempera- 
 ture has been so fully discussed of late that it need 
 not be mentioned here. There can be no doubt, as 
 Baruch J says, that heat and cold act as powerful 
 reflexes to the central nervous system. 
 
 Water being used mainly to apply the principle of 
 heat and cold to the body, the first point to be ob- 
 served in its application is the range of temperature. 
 As Baruch § has said, there is a wide range in tem- 
 perature, the extremes being, for cold 40 F. and for 
 heat 1 io° F. Beni Barde || makes the rather conve- 
 nient classification for practical use as follows : 
 
 * Therap. Gazette, 1888. f Johns Hopkins Bullet., 1893. 
 
 % Med. Rec. y 1893. \ Loc. cit. || " Hydrotherapies' 
 
HYDROTHERAPY. 255 
 
 Water from 8° to 12 C. (46 to 53 F.), very cold. 
 
 12 to 16 C. (53 to 6o° F,), cold. 
 
 26 to 30 C. (78 to 86° F.), warm. 
 
 " above 4o°C. (104 F.), hot. 
 
 Following the same author, the effects of warmth 
 applied by means of water are: (i) A tendency to 
 slightly raise the temperature of the body. (2) An 
 increase in the frequency of the respirations. (3) 
 An acceleration of the circulation. (4) An increase 
 in muscular irritability when the water is moderately 
 warm. (5) A diminution of nervous irritability. 
 
 Moderate cold applied to the body (1) decreases 
 bodily temperature. (2) Decreases the frequency 
 of respirations, which become deeper. (3) De- 
 creases the frequency of the circulation. (4) Low- 
 ers muscular contractility. (5) By its impression on 
 the peripheral nerves it transmits a marked stimulus 
 to the central nervous system. 
 
 The general application of water to different dis- 
 eases cannot here be considered, since we are con- 
 cerned only with its use in the treatment of hysteria. 
 It may be said that the two effects of water that are 
 most valuable in the treatment of hysteria are : 
 (1) The stimulation of the peripheral nerves, and a 
 resulting stimulation of the central nervous system, 
 and (2) the revulsive action. Of course, the two 
 are closely related. The former action is utilized in 
 the treatment of anesthesia and hyperesthesia. In 
 the treatment of these conditions the water should 
 be thrown from a spray, with a pressure of 15 
 pounds or greater, and should have a temperature 
 
256 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 of from 50 to 6o° F. This spray should be passed 
 rapidly over the whole body, except the head, and 
 the seance should not last longer than half a minute 
 to a minute. This douche can be improvised by 
 attaching a rose spray to the faucet of the bath-tub. 
 For the routine treatment of the hysterical condi- 
 tion the alternate warm and cold douche is very 
 beneficial. This can be carried out at home by using 
 a piece of rubber-tubing attached to the bath-tub 
 faucet, by pouring from a pitcher alternately warm 
 and cold water, or by means of a large sponge. 
 , The warm water should be first applied, the tem- 
 perature being from 8o° to 85 F., followed imme- 
 diately by the cold water of 50 to 6o° F. This 
 alternate warm and cold douche is kept up for five 
 minutes, the water being applied only to the spinal 
 region. The patient then takes a vigorous rub with 
 a coarse towel. In some cases it is better to use 
 the douche or shower to the whole body, except the 
 head. As a rule, the hysterical patient does not 
 stand the cold plunge well, and the full warm bath 
 is not to be recommended. 
 
 The beneficial effects of hydrotherapy, both ex- 
 ternal and internal, are seen to most advantage at 
 special institutions, or at watering-places, where 
 both the bath and the water taken internally are 
 impregnated with some mineral. Of course, under 
 these circumstances, it is hard to say how far the 
 water alone is effective in bringing about the good 
 results that are apt to follow a certain residence at 
 some of these places. The change of scene, of 
 
MASSAGE. 257 
 
 surroundings, of people, all contribute a very im- 
 portant part in the cure. The use of the cold douche 
 or of the cold pack is often of great service in cut- 
 ting short the convulsive stage. Sea-bathing is, as 
 a rule, very beneficial in hysteria. It is always nec- 
 essary to caution the patient not to make too much 
 exertion in the surf, and not to stay in the water 
 more than fifteen or twenty minutes. 
 
 In general, it may be said that in addition to the 
 positive and demonstrable good effects obtained by 
 the scientific use of water, there is the mental im- 
 pression produced by this somewhat unusual mode 
 of treatment. 
 
 Massage. — It may be stated in general that mas- 
 sage is chiefly applicable to those cases of hysteria, 
 often complicated with neurasthenia, in which the 
 patient cannot or will not take outdoor exercise. 
 No form of massage, mechanical movements, or 
 gymnastic exercise can compare with exercise in the 
 fields and woods. In many cases first coming under 
 treatment there is such muscular weakness that no 
 sufficient amount of walking, bicycling, or riding can 
 be taken. Then, too, hysterical patients often have 
 a disinclination to any form of exercise that cannot 
 at first be overcome. Again, certain of the acci- 
 dents of hysteria — paralysis, contracture, and the 
 like — make voluntary exercise impossible. In such 
 cases massage must be employed ; and, by careful 
 attention to details, can be made to take, in great 
 measure, the part of voluntary exercise. 
 
 It is well to understand at the outset that massage 
 
258 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 must be performed only by some one who has 
 learned the art. Very often, unless the physician is 
 watchful, some incompetent attendant will be em- 
 ployed to give the patient what is mistaken for 
 massage — simple friction of the skin. This rubbing 
 is not without some value, but it is far removed from 
 scientific massage. 
 
 It would seem that massage has been practised 
 from the earliest times. According to Schreiber,* a 
 certain system of massage and medical gymnastics 
 was known and practised by the Hindus and 
 Chinese. Galen gives specific directions for the 
 method of employing the different sorts of massage, 
 and among the Greeks and Romans it held a high 
 place as a therapeutic measure. Perhaps the 
 man who gave the greatest impetus to mechano- 
 therapy was Ling,f who worked and wrote in the 
 early part of the present century. Ling's system 
 was chiefly a combination of active and passive 
 movements, without any distinct massage as we now 
 use this term. This latter addition was introduced 
 by the French school some twenty-five years ago. 
 Following Schreiber, the effects of massage and 
 mechanical movements may be divided into two 
 groups. Primary, or mechanical effects, such as the 
 removal of exudates, extravasations, and the like. 
 With this use of massage we are not now concerned. 
 The secondary effects of mechanical movements are 
 
 * " A Manual of Massage." 
 
 | " A Treatise on the General Principles of Gymnastics." 
 
MASSAGE. 259 
 
 brought about by "increasing the circulation, stimu- 
 lating the muscular and nervous systems, by setting 
 up molecular changes and producing consequent 
 changes in sensation, and by effecting alterations in 
 the processes of general nutrition" (Schreiber). 
 
 Bearing in mind the physiology of the flow of 
 venous blood and lymph, it will readily be seen how 
 greatly massage ought to aid these fluids in their 
 somewhat sluggish movements. The venous blood 
 and lymph in the smaller vessels depend largely on 
 muscular movements to assist their flow, and so, by 
 increasing the rate of flow of these fluids, and by 
 squeezing the lymph out of the lymph crevices, gen- 
 eral nutrition is improved and the muscular and 
 nervous systems indirectly stimulated. In addition 
 to this there can be no doubt that both muscle and 
 nerve are mechanically stimulated by the manipula- 
 tions. Weir Mitchell * has shown that massage 
 causes a slight, but unmistakable, rise of tempera- 
 ture, and J. K. Mitchell f has demonstrated that after 
 massage there is a very marked increase in the 
 number of the red corpuscles and also of the hema- 
 globin, and in some instances an increase of white 
 corpuscles. 
 
 Massage should be practised upon the bare skin, 
 though some writers advise the patient to be clothed 
 in a loose gymnasium suit. The use of vaselin or 
 oil is not to be recommended. The various methods 
 adopted cannot be described minutely. It may be 
 
 *" Fat and Blood." f Med. News, 1893. 
 
260 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 said, in general (following Schreiber), that there are 
 the following important movements: (i) Pressing 
 and kneading with the finger-tips or knuckles. (2) 
 Tapping with the hand, fist, or some mechanical 
 contrivance. (3) Pinching, which is performed by 
 picking up the muscle-bundles that can be grasped. 
 Weir Mitchell's * description of the mode of apply- 
 ing general massage is so clear and complete that 
 it must be quoted verbatim. He says : " An hour 
 is chosen midway between two meals, and, the 
 patient lying in bed, the manipulator starts at the 
 feet and gently but firmly pinches up the skin, roll- 
 ing it lightly between his fingers and going carefully 
 over the whole foot. Then the toes are bent and 
 moved about in every direction, and next with the 
 thumbs and fingers, the little muscles of the foot are 
 kneaded and pinched more largely, and the inter- 
 osseous groups worked at with the finger-tips be- 
 tween the bones. At last the whole tissues of the 
 foot are seized with both hands and somewhat firmly 
 rolled about. Next, the ankles are dealt with in like 
 fashion, all the crevices between the articulating 
 bones being sought out and kneaded, while the joint 
 is put in every possible position. The leg is next 
 treated, first, by surface pinching, and then by deeper 
 grasping of the areolar tissue, and last by industri- 
 ous and deeper pinching of the large muscular 
 masses, which for this purpose are put in a position 
 of the utmost relaxation. The grasp of the muscles 
 
 *Loc. cit. 
 
MASSAGE. 261 
 
 is momentary, and for the large muscles of the calf 
 and thigh both hands act, the one contracting as the 
 other loosens its grip. In treating the firm muscles 
 in front of the leg, the fingers are made to roll the 
 muscle under the cushions of the finger-tips. At 
 brief intervals the manipulator seizes the limb in 
 both hands and lightly runs the grasp upward, so as 
 to favor the flow of venous blood-currents, and then 
 returns to the kneading of the muscles. The same 
 process is carried on in every part of the body, and 
 especial care is given to the muscles of the loin and 
 spine, while usually the face is not touched. The 
 belly is first treated by pinching the skin, then by 
 deeply grasping and rolling the "muscular walls in 
 the hands, and at last the whole belly is kneaded 
 with the heel of the hand in a succession of rapid, 
 deep movements, passing around in the direction of 
 the colon. It depends very much on the strength, 
 endurance, and practice of the manipulator, how 
 much good is done by these manceuvers. At first, 
 or for a few sittings, they are to be very gentle, but 
 by degrees they may be made more rough, and if 
 the masseur be a good one, it is astonishing how 
 much strength may be used without hurting the 
 patient. The early treatments should last half an 
 hour and should be increased by degrees to one 
 hour, after which should follow an hour of absolute 
 repose." 
 
 Passive and active movements are sometimes use- 
 ful ; in the former, the subject makes no resistance, 
 while in the latter variety, the patient, by voluntar- 
 
262 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 ily contracting certain groups of muscles, antagonizes 
 the force employed by the operator and, as it were, 
 isolates certain muscle-bundles. This, which is the 
 " Swedish " method, is useful in improving the gen- 
 eral tone of the muscles, and is particularly adapted 
 to the treatment of paralyses and contractures. The 
 use of apparatus in the patient's room is often dis- 
 tinctly beneficial, and the best device is one of the 
 many forms of pulley machines. In employing any 
 form of exercise in the treatment of hysteria, it 
 must be remembered that the mind must share in 
 the exercise as well as the body. As Du Bois Ray- 
 mond* well says : "It is plain, therefore, that every 
 motion of our body depends not so much upon the 
 force of the contractions of the muscles, as upon 
 the harmony of their action. To execute any com- 
 plex act, as a leap, for instance, each muscle must 
 begin to contract at exactly the right moment, and 
 the force exerted by each, according to definite laws, 
 should increase, continue, and diminish again, in order 
 to effect the suitable position of the limbs, and to 
 propel, at the proper speed, the center of gravity of 
 the body in the desired direction. We have reason 
 to believe that, as a rule, the muscle promptly obeys 
 the nerve, and that its degree of contractility for 
 each movement is determined by the degree of irri- 
 tability of the nerve which obtained at the moment 
 just preceding. Since the nerves are merely organs 
 for the conduction of impulses originating in the 
 
 On Exercise,' : 
 
MASSAGE. 263 
 
 motor cells, it follows that the actual mechanism of 
 every complex motion must have its seat in the cen- 
 tral nervous system ; and that, consequently, prac- 
 tising exercises is nothing more than schooling 
 the central nervous system. All species of bodily 
 exercises, therefore, are not simply muscular gym- 
 nastics, but nerve gymnastics as well." The golden 
 rule to be observed in regard to exercise, whatever 
 be its form, is to stop short of actual fatigue. Often 
 the good effects of the exercise are more than coun- 
 terbalanced by the exhaustion following too pro- 
 longed exertion. From this it follows that, in pre- 
 scribing exercise, we cannot simply order a certain 
 amount, but must be guided by the effect upon the 
 individual patient. 
 
CHAPTER XL 
 
 THE REST CURE.— HYPNOTISM.— SURGICAL 
 
 INTERFERENCE IN THE TREATMENT 
 
 OF HYSTERIA. 
 
 Without giving specific references, which might be 
 quoted at great length, it may be said that the gen- 
 eral principles of the rest cure have been suggested 
 from early times. In many of the older writers we 
 find hints of isolation, of feeding, and of massage in 
 the treatment of hysteria and allied disorders. It 
 may be said that no great discovery has ever been 
 announced without precursors of this sort. The 
 genius of Weir Mitchell was required to collect, to 
 collate, to put in working order, and to make prac- 
 tical, the vague suggestions that had gone before. 
 To him, therefore, is due the credit of having given 
 to us this most valuable form of treatment. Next to 
 Weir Mitchell, Playfair * has done most to popular- 
 ize this rest cure treatment, and his name is often 
 associated with it. Playfair, however, says very can- 
 didly, in one of his papers : "I am anxious to bring 
 . . . under notice ... a method of dealing 
 with certain grave and most intractable forms of 
 nervous disorder familiar to all who see much of the 
 diseases of women, which I first became acquainted 
 with through the study of a remarkable and interest- 
 ing little work by Dr. Weir Mitchell, of Philadelphia. 
 
 * " Nerve Prostration and Hysteria," 1883. 
 264 
 
THE REST CURE. 265 
 
 In doing so I have no original contribution to medi- 
 cal science to make, — I have simply followed Dr. 
 Mitchell's directions." Not only has Dr. Mitchell 
 indicated to the profession the plan of treatment 
 best adapted to the cases of grave hysteria, but with 
 his graceful pen he has endeavored to inculcate in 
 the minds of the laity lessons which, if laid to heart, 
 would greatly diminish the victims^of this uncomfort- 
 able malady. It may be said, in general, that the 
 principles underlying the rest treatment are four: 
 (1) Isolation. (2) Rest. (3) Forced feeding. (4) 
 Passive exercise. Of the four, probably the most 
 important is isolation. Charcot* says: "I must 
 admit that if I had to assign the first place to any 
 specific treatment for hysteria, it would be to isola- 
 tion. I cannot too strongly insist upon the capital 
 importance that I attach to isolation in the treatment 
 of this disease, in which the psychic element plays so 
 predominant a role. For fifteen years I have recog- 
 nized the importance of this mode of treatment, and 
 my daily observations have but confirmed my opin- 
 ion. It is necessary to separate hysterical patients 
 from their parents, whose influence is particularly 
 pernicious." 
 
 An hysterical girl under Charcot's care, who had 
 been suffering from many stigmata of the disease, 
 particularly hysterical anorexia, once said to him : 
 "As long as papa and mama were with me I did 
 not think that my disease amounted to much, and, as 
 
 * Op. cit. 
 23 
 
266 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 I had no inclination to eat, I did not eat. As soon, 
 however, as I perceived that you were the master, I 
 became afraid, and in spite of my repugnance, I 
 tried to eat and soon was able to do so." Weir 
 Mitchell * says : " It is rare to find any of the class 
 of patients I have described (hysterics) so free from 
 the influence of their surroundings as to make it 
 easy to treat them in their own homes. It is need- 
 ful to disentangle them from the meshes of old 
 habits, and to remove them from the contact with 
 those who have been the willing slaves of their cap- 
 rices. I have often made the effort to treat them in 
 their own homes, and to isolate them there, but I 
 have rarely done so without promising myself that I 
 would not again complicate my treatment by any 
 such embarrassments." The two quotations given 
 above emphasize the extreme importance of complete 
 isolation in bad cases. The patient should not be 
 allowed to see any members of the family, nor any 
 of the numerous friends who especially delight in 
 visiting such invalids, and it is impossible to carry 
 this out rigidly if the patient remain at home. One 
 of the great advantages of strict isolation is, that the 
 patient is removed from the sights and sounds of the 
 home life, which in very many cases have become 
 well-nigh intolerable. At home it is practically im- 
 possible to keep the mind of the patient at perfect 
 rest. Every sound suggests a train of thoughts 
 which are in the main disagreeable, or at least break 
 
 * " Wear and Tear." 
 
THE REST CURE. 267 
 
 in upon the mental repose. Every jar in the domes- 
 tic machinery finds its response in the patient's ner- 
 vous system. It is impossible to keep such a patient in 
 ignorance of the daily routine of the household, and 
 the ringing of the door-bell may furnish material for 
 half a day's disagreeable thoughts. Just as we rig- 
 idly exclude the light from an inflamed eye, so must 
 we keep the irritable nervous system, the exhausted 
 nerve centers, free from every stimulus that is liable 
 to excite them. The pernicious influence of an hys- 
 terical or foolish mother will counteract the effects of 
 the most careful and conscientious work on the part 
 of the physician, and, as Mitchell says, " There is no 
 success until we have broken up the whole daily 
 drama of the sick-room, with its little selfishnesses, 
 and its craving for sympathy and indulgence." 
 
 From what has been said it is evident that the 
 patient must, in most instances, be sent away from 
 home, and it is often a difficult matter to decide 
 upon a suitable place. As a rule, it is better to 
 avoid large hospitals and sanatoriums where there is 
 what might be called a " hospital air," and to select 
 some smaller institution, or, what is quite as good, a 
 room in a quiet boarding-house. The room should 
 be of good size, airy, and simply furnished. In some 
 very bad cases it is well to keep the room slightly 
 darkened for a few days. I can recall a case seen 
 in consultation that had been under treatment for 
 several weeks in a bright room, and no improve- 
 ment was noticed until the room was made dark. 
 Later in the treatment it is well to have all the light 
 
268 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 and sunshine possible. The isolation should for a 
 time be absolute, which means that not only must 
 the family and friends be excluded, but no communi- 
 cation with the outside world must be maintained, 
 and no messages or letters brought to the room. 
 
 The next question is as to the nature of the rest. 
 In very bad cases this should for a time be absolute. 
 The patient should not be allowed to make any 
 movements whatever, and should be fed by the 
 nurse. In regard to this point, Mitchell says : " In 
 some instances I have not permitted the patient to 
 turn over in bed without aid, and this I have done 
 because sometimes I think no motion desirable, and 
 because, sometimes, the moral influence of absolute 
 repose is of use." This absolute rest should be 
 continued, in the aggravated cases, for two weeks or 
 even longer, and then a certain amount of diversion 
 may be allowed. This may be attained by permit- 
 ting the nurse to read to the patient, or she may be 
 allowed to read a little herself. It may be said, in 
 passing, that the physician should carefully select 
 the books to be read. 
 
 The feeding of the hysterical patient, especially 
 where the hysteria is complicated with neurasthenia, 
 as these bad cases very often are, is of extreme 
 importance. As a rule, the majority of the patients 
 have very little appetite, or their appetite is in some 
 way perverted. They desire to eat things that are 
 indigestible and non-nutritious. It is well to begin 
 with a strict milk diet — a glass of milk every two or 
 three hours for the first few days. Then the regi- 
 
THE REST CURE. 269 
 
 men can be gradually increased by the addition of 
 eggs and meat. In a short time the patient is able 
 to take a full diet, which should consist of a cup of 
 black coffee in the morning, upon awakening. In 
 an hour, breakfast, which should be generous, — oat- 
 meal, rare steak or chops, with bread and butter and 
 milk or coffee. In three hours, or between break- 
 fast and luncheon, a glass of milk with a biscuit ; 
 then dinner or luncheon, preferably the former, for 
 it is better for such patients to take the heavy meal in 
 the middle of the day. Dinner should be a stout 
 meal, — soup, meat, and vegetables, with some simple 
 dessert, to be followed by something light three 
 hours after, — milk or beef-tea. Then supper at the 
 close of the day, and milk again before bedtime. 
 Often in bad cases it is well to give milk in the 
 night. It is necessary to attend to the bowels and 
 give some simple aperient when needed, and some- 
 times some preparation of pepsin is beneficial after 
 meals. As a rule, no alcoholic drinks should be 
 allowed, except perhaps a sound beer or one of the 
 malt preparations. The only drugs that are required, 
 as a rule, are iron and some simple bitter. Of course, 
 the details of the dietetics must be determined in 
 each individual case and the bare outline is here 
 indicated. In the case of obese hysterics, Mitchell 
 has shown it to be an excellent plan to keep them on 
 a low diet until they have lost flesh decidedly, and 
 then to go to work' and put flesh on again according 
 to the methods that have been explained above. As 
 the forced feeding and rest are in a certain way 
 
270 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 incompatible, it is necessary to substitute something 
 for exercise, and this place is taken by massage. 
 After a few days of rest this is begun, very gradu- 
 ally at first, the sittings lasting not more than twenty 
 minutes or half an hour, and the length of the 
 seance is increased a little daily until the limit of an 
 hour is reached. At the same time, either on alter- 
 nate days or at different hours on the same day, 
 general faradization of the muscles is practised. 
 
 As has been said, each case must be treated indi- 
 vidually ; with some patients it is advisable to begin 
 voluntary exercise after a week or ten days, while 
 with others two or three weeks should intervene be- 
 fore permitting it. The voluntary exercise should 
 be commenced very gradually, the patient being first 
 allowed to perform her own toilet, then to sit up, 
 then to walk a prescribed distance. The value of 
 the enforced rest is very soon appreciable, and pa- 
 tients soon become accustomed to it. As Weir Mit- 
 chell * happily expresses it, "From a restless life of 
 irregular hours, and probably endless drugging, from 
 hurtful sympathy and overzealous care, the patient 
 passes to an atmosphere of quiet, to order and con- 
 trol, to the system and care of a thorough nurse, to 
 an absence of drugs and to a simple diet. The re- 
 sult is always at first, whatever it may be afterward, 
 a sense of relief, and a remarkable and often a quite 
 abrupt disappearance of many of the nervous symp- 
 toms. ... If the physician has the force of 
 
 * " Fat and Blood." 
 
THE REST CURE. 271 
 
 character required to secure the confidence and re- 
 spect of his patient, he has also much more in his 
 power, and should have the tact to seize the proper 
 occasions to direct the thoughts of his patient to the 
 lapse from duties to others, and to the selfishness 
 which a life of invalidism is apt to bring about. Such 
 moral medication belongs to the higher sphere of 
 the doctor's duties, and if he means to cure his pa- 
 tient permanently he cannot afford to neglect them." 
 The cold douche, or the alternate warm and cold 
 douche, should be administered as soon as the pa- 
 tient is able to stand it. This should be given in the 
 morning after the morning coffee. 
 
 It is hardly necessary to point out the suggestive- 
 ness of this mode of treatment, since it is so obvi- 
 ous. The isolation, the frequent feeding, the mas- 
 sage, and electricity, are all suggestive to a high 
 degree, and the success of this mode of treatment 
 is in no small part due to this suggestive element. 
 This rigid rest treatment is applicable only, or mainly, 
 to the bad cases, and especially where, in addition 
 to the hysteria, there is a certain amount of neuras- 
 thenia. It often happens, however, that we want to 
 apply the principles of the rest cure without carry- 
 ing out strictly all the details of the treatment. 
 Under these circumstances it is possible to obtain 
 fairly good results from a modified form of rest treat- 
 ment. The plan that I have adopted is to write out 
 for such patients exactly what is to be done, the hour 
 of rising, the times and character of the meals, the 
 mode of applying the douche, the restrictions in re- 
 
272 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 gard to rest and exercise, etc., and see that these 
 regulations are strictly carried out. It must be said, 
 however, that the results in this modified rest treat- 
 ment are often very disappointing, for, as Playfair 
 says : " The worse the case is the more easy and 
 certain is the cure." 
 
 Hypnotism. — Throughout the foregoing pages 
 constant reference has been made to hypnotism, and 
 the similarity between this condition and hysteria 
 noted. Again, in the discussion of the various 
 methods of treatment, attention has been repeatedly 
 called to the potency of suggestion in hysterical 
 conditions. It may be well, then, to consider the 
 subject of hypnotism somewhat in detail, since it 
 must cast much light not only on the nature of hys- 
 teria, but also afford valuable suggestions as to 
 treatment. In the following sketch, liberal use has 
 been made of a paper presented to the Medical and 
 Chirurgical Faculty of Maryland several years ago.* 
 In looking through the earliest literature on the 
 subject of hypnotism, after due allowance has been 
 made for the play of the modern imagination, it is 
 impossible to deny the fact that hypnotism was not 
 only recognized but practised in the earliest times 
 of which we have any record. The Chaldeans, who 
 are accounted among the earliest soothsayers by 
 Cicero, had three orders for the study of magic: 
 The exorcisers, the sages, and the star-gazers. It 
 was their custom to sleep in certain temples in order 
 
 *" Trans. Med. and Chir. Faculty of Maryland," 1889. 
 
HYPNOTISM. 273 
 
 to acquire their wonderful gift. The ancient Egyp- 
 tians were much given to the practice of magic, and 
 all through the Old Testament may be found con- 
 stant allusions to it. An old French writer, who 
 studied the Egyptian hieroglyphics with the view of 
 determining to what extent they practised magnet- 
 ism, says * : " Magnetism was daily practised in the 
 temples of Isis, of Osiris, and Serapis." He goes 
 on to say : " In these temples the priests treated the 
 sick and cured them, either by magnetic manipula- 
 tion, or by some other means producing somnam- 
 bulism." Celsus opposed the miracles of Christ on 
 the ground that the Egyptian charlatans, for a small 
 sum of money, would perform their wonders publicly, 
 such as casting out devils and curing diseases by 
 blowing in the face of the person afflicted. 
 
 Another Epicurean mentions the same thing, and 
 recalls the reproach that the pagans cast up to Christ 
 that the temples of the Egyptians had been plund- 
 ered and their secrets extracted. In the temples of 
 ^Esculapius, of which there were a great number in 
 Greece, it was the custom to have sleeping-rooms 
 where the patients who visited the shrines were ac- 
 customed to fall into a deep sleep. When in this 
 condition the course of their malady and the neces- 
 sary treatment was revealed to them. Aristides 
 mentions the fact that the dumb regained speech by 
 drinking the waters of the spring at Pergamus. 
 The Romans derived their knowledge of magic from 
 
 * " Annales du Magnetisme Animal," 
 24 
 
274 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 the Greeks, and in fact used to consult oracles else- 
 where than in their empire. One finds many pas- 
 sages in Latin writers clearly pointing to hypnotism ; 
 as, for example, this one from Plautus : " How if I 
 stroke him slowly with the uplifted hand so that he 
 sleep." As we approach the Christian era we see 
 undeniable evidences of hypnotism. Galen alludes 
 to it and refers to the writings of Hippocrates on 
 the same subject. During the middle ages the prac- 
 tice of hypnotism passed into the hands of the clergy, 
 and was very successfully employed by them. The 
 churches took the place of the ancient temples, and 
 we see the same practices indulged in. Persons 
 who were sick resorted to these churches or to the 
 tomb of some saint. One reads of paralyzed per- 
 sons suddenly falling into a deep sleep at these 
 shrines, and awaking to find themselves cured of 
 their infirmities. In spite of the gross superstition 
 of this dark age, the study of magnetism was slowly 
 advancing. Marcellus Ficinus, born at Florence in 
 1433, admitted that certain men were endowed with 
 a mysterious power which they could exercise, not 
 only over their own bodies, but also over the bodies of 
 others. Paracelsus, a little later, makes this candid 
 statement: "The imagination can occasion disease 
 and cure it. The confidence that one has in amulets 
 and charms is the secret of their virtue." " Magic," 
 says Lord Bacon, " is the power of the imagination 
 of one individual acting upon the body of another." 
 The term magnetism came into vogue in the six- 
 teenth century. The magnet had been used for the 
 
HYPNOTISM. 275 
 
 cure of disease very much earlier, for it is mentioned 
 by Pliny, Galen, and Avicenna, but the application 
 of this term to hypnotic phenomena is not to be 
 found before this time. The seventeenth century 
 produced many zealous advocates of hypnotism, or, 
 as it was then called, magnetism. Robert Flood, of 
 England, propounded a very elaborate theory which 
 supposed a universal magnetic fluid pervading all 
 matter, and somewhat later we find, in the writings 
 of Maxwell,* a Scotch physician, the whole of Mes- 
 mer's doctrine in embryo. Valentine Greatrakes, 
 an Irishman, was celebrated for his cures, and 
 Robert Boyle, President of the Royal Society, says 
 of him : " Many physicians, noblemen, clergymen, 
 etc., testify to the truth of Greatrakes' cures. The 
 chief diseases which he cures are blindness, deafness, 
 and paralysis. He lays his hands on the part affected, 
 and so moves the disease downward." The man 
 who gave the greatest impetus to the study of hyp- 
 notism, and whose name has been so long associated 
 with it, was Mesmer. About the middle of the 
 eighteenth century Mesmer began to promulgate his 
 doctrines. While he attracted great attention, his 
 methods were so clearly those of the charlatan that 
 he was regarded with great distrust by the medical 
 profession of Vienna, where he was operating, and 
 at length he was requested to put an end to his 
 nonsense. Justly discouraged by his reception in 
 Austria, he went, in 1778, to Paris. Circumstances 
 
 Medicina Magnetica. 
 
276 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 greatly favored him, for there still lingered in the 
 minds of the Parisians memories of Swedenborg, 
 and the impressions made by the miracles at the 
 tomb of the Diacre Paris were not yet obliterated. 
 
 All Paris was in an uproar over Mesmer, and he 
 made many converts in the ranks of the medical 
 profession. He adhered to the ancient idea that 
 magnetism was a fluid pervading all space and pos- 
 sessed of properties similar to those of a magnet, 
 and that by it the human body could be acted upon. 
 Nothing could exceed the ridiculous nonsense and 
 outrageous quackery of Mesmer's seances in Paris. 
 One need only read the descriptions of them to see 
 that he was the prince of charlatans. In a large 
 room carefully covered with mattresses, his patients 
 were accustomed to assemble. This room was dark- 
 ened, and all the light that was admitted passed 
 through stained windows. In the center of this 
 room was the baquet, a tub or box of wood, in which 
 were placed a number of bottles filled with what was 
 supposed to be magnetized water. The tub was 
 filled with water, into which were thrown iron filings, 
 pulverized glass, and sand. From the tub projected 
 pieces of iron wire, and the patients laid hold of 
 these and formed a circle around the baquet. The 
 ring of subjects was formed by grasping the wire 
 which projected from the baquet with one hand, 
 while the other hand clasped the hand of the person 
 next, the feet, legs, and thighs being closely in con- 
 tact with the corresponding parts of the adjoining 
 person. When the patients were in a suitable frame 
 
HYPNOTISM. 277 
 
 of mind, Mesmer, clad in gorgeous apparel, would 
 enter the hall, and with an iron wand touch the 
 parts of the body that were supposed to be the seat 
 of some disease. Very soon these seances became 
 notorious as the resort of hysterical men and women, 
 and some of the orgies that are described could 
 have been possible only in Paris and only at the time 
 mentioned. The French Academy investigated 
 Mesmer, and a bitter discussion waged for many 
 years on the subject of hypnotism. In 1841 James 
 Braid, of Manchester, England, began a very care- 
 ful examination into the condition known as animal 
 magnetism, and demonstrated the part played by 
 suggestion. Following Braid were : Grimes, in this 
 country ; Esdaile, of Calcutta ; Azam, of Bordeaux ; 
 Lassegue, and many others. In 1879 Charcot began 
 the study of hypnotism, and his genius put it upon 
 the most scientific basis it had as yet occupied. This 
 somewhat lengthy historical sketch is necessary in 
 order to understand fully the evolution of hypnotism. 
 When we come to consider the nature of hyp- 
 notism we are launched upon a sea of speculation. 
 Rumpf has proposed the theory that the hypnotic 
 state is brought about by certain undefined vascular 
 changes in the brain. Preyer supposes an oxidiza- 
 ble substance formed by the cells of the brain cortex 
 under certain conditions, and Brown-Sequard con- 
 siders that the explanation of hypnotism is to be 
 found in the phenomenon of inhibition. The ex- 
 planation of the hypnotic state — if it can be called 
 an explanation — which has always seemed most satis- 
 
278 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 factory to me, is the following : By certain proce- 
 dures, our attention, to use a loose term, carrying 
 with it volition, is riveted upon a certain object or 
 idea, thus leaving the other centers free. Every one 
 is familiar with this state of abstraction. When in- 
 tently occupied with some object or idea, one re- 
 sponds to external stimulation — as brushing a fly 
 from the face, for example — or may answer questions 
 rationally, although there is no actual consciousness, 
 or at least a very dim consciousness of these acts. 
 We withdraw, as it were, the will from its work of 
 general direction and supervision, and concentrate it 
 upon some single thing. One is made to look intently 
 at some bright object and told not to let the eyes or 
 mind wander from it. Soon the muscles of the eyes 
 become fatigued, the mind becomes filled with the idea 
 of sleep — suggested by the tired and closing eyes — 
 and volition being concerned with keeping the atten- 
 tion upon the bright object, cannot intervene to put 
 aside the strong suggestion of sleep. Just as in natural 
 sleep certain cells are active, as shown by the phe- 
 nomenon of dreaming, so in the hypnotic state, with 
 volition off duty, or, to speak more exactly, detailed 
 for special duty, suggestion enters the mind freely 
 and the unreal is received and acted upon as real. 
 We do not, of course, know whether or not there 
 are any physical changes taking place in the cells of 
 the higher centers of the cerebral cortex during this 
 peculiar psychic state. This much, however, we do 
 know : that hypnotism is a reality ; that it is some 
 peculiar modification of the mind which has been 
 
HYPNOTISM. 279 
 
 observed for centuries. The fact that no sufficient 
 explanation of this phenomenon can be given is no 
 proof of its unreality. 
 
 That some of the old superstition concerning 
 hypnotism still lingers is evident from the frequently- 
 asked question, whether the power to induce this 
 state is not a peculiar one and resident only in cer- 
 tain persons. As has been shown, the subject him- 
 self is really responsible for the condition, the hyp- 
 notizer merely aiding in the matter of suggestion. 
 The more imperative the suggestion or the com- 
 mand to sleep, the more likely are they to be received 
 and acted upon. The manner of the operator and 
 the amount of confidence he begets are important 
 factors, and some practice is necessary in the man- 
 ner of making suggestions. Beside this, there is no 
 more power to produce the hypnotic state in one 
 person than in another. When we turn our atten- 
 tion to the questions, what kind and what proportion 
 of persons are susceptible to the hypnotic influence, 
 opinion is considerably at variance. Charcot and 
 the Salpetriere school have always maintained that 
 true hypnotism is to be seen only in persons who in 
 some degree at least are hysterical. This view 
 follows naturally from the position taken by this 
 same school, that hypnotism and hysteria are closely 
 related states. Bernheim and the Nancy school, 
 on the other hand, claim that hypnotism can be more 
 readily induced in subjects free from hysteria, and 
 even go so far as to say that hysterical individuals 
 make poor subjects. The weight of evidence, it has 
 
280 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 always seemed to me, points decidedly toward the 
 former of these views ; namely, that, generally 
 speaking, true hypnotism is to be found almost ex- 
 clusively among the class having what is recognized 
 as an hysterical temperament. 
 
 As to the proportion of persons who can be hyp- 
 notized, the testimony of different observers varies 
 greatly, ranging from 15 per cent by Durand, to 95 
 per cent, by Bernheim. Of course, this depends 
 upon what is called " hypnotism." It is possible to 
 produce a condition of mild lethargy in almost any 
 one who will submit to a prolonged sitting, but this 
 condition can hardly be called, strictly speaking, 
 hypnotism. My own experience has been that not 
 more than 10 to 15 per cent, of persons in this 
 country can be hypnotized sufficiently to make sug- 
 gestion available as a therapeutic measure. 
 
 The methods of inducing hypnotism now in vogue 
 are very simple, and the fantastic paraphernalia and 
 elaborate system of "passes" of Mesmer and his 
 school, and which are still practised by the profes- 
 sional hypnotizer, have fallen into disuse among all 
 scientific workers. It is simply necessary to have a 
 quiet room, not too many inquisitive observers, and 
 the hearty co-operation of the subject, and any one 
 of the following methods may be pursued. Fixation, 
 either by holding some bright object close to the 
 subject's eyes, and in such a position that the mus- 
 cles of the eyes will be easily fatigued, or by the 
 operator requesting the subject to regard him 
 steadily, thus fixing the eyes by the gaze. Again, 
 
HYPNOTISM. 2S1 
 
 many subjects may be hypnotized by simply holding 
 the eyes closed and maintaining a slight pressure on 
 the globes. A method that I have pursued is to hold 
 the patient's hand, making all the time moderate 
 pressure on the wrist. Persons easily hypnotized 
 may be thrown into the hypnotic condition by listen- 
 ing to a watch or other monotonous sound. Many 
 instruments have been devised to use in inducing the 
 hypnotic state, but any one of the procedures men- 
 tioned above will accomplish the same result if the 
 operator sufficiently impresses his subject. The 
 operator should always explain to the subject what 
 is going to be done, and insist with confidence that 
 the predicted results will follow. It is generally 
 well to prepare the mind of the subject by telling 
 him that he must not resist the hypnotic influence, 
 but must unreservedly give himself into the opera- 
 tor's hands. I have always thought that the reason 
 why it is possible to hypnotize a very much larger 
 proportion of people in France than in this country 
 is that in France every one understands the mean- 
 ing of hypnotism, and when the attempt is made to 
 induce this state the subject is expecting the well- 
 known phenomena. With us, on the other hand, 
 few people believe in the genuineness of hypnotism, 
 and this skepticism is naturally a great and ofttimes 
 a fatal bar to success. The operator should always 
 make repeated suggestions to the subject that he is 
 going to sleep, and the more emphatically these sug- 
 gestions are made the greater is the likelihood of 
 success. As soon as the patient is seated and begins 
 
282 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 to gaze at the bright object held before his eyes, or 
 has his eyes closed by the operator, the suggestion 
 should be made that he is going to sleep. " You are 
 going to sleep ; " " Your eyes are getting heavy ; " 
 " You will soon be asleep." And then, as the eyes 
 close, " You are sound asleep ; You cannot open 
 your eyes ; they are tight shut." These and similar 
 suggestions should be continually made. Patients 
 who have been often hypnotized by the same opera- 
 tor need only be told, " You are asleep," and the 
 suggestion is at once received as a fact. The oftener 
 a patient is hypnotized by the same operator the 
 easier it becomes to induce the hypnotic state. 
 
 If, when attempting to produce hypnotic lethargy, 
 the patient begins to laugh and to regard the opera- 
 tion as a farce, there is no use in continuing the 
 attempt. Patients should be told that the induction 
 of hypnotism is a purely therapeutic measure, and 
 if they cannot regard it seriously there is no use in 
 undertaking the treatment. It may be well just here 
 to protest against the dilettanti experiments with 
 hypnotism. There can be no doubt that the induc- 
 tion of the hypnotic state has a certain tendency 
 to favor the occurrence of hysteria, and sometimes 
 even more grave mental disturbances. In some 
 countries — and it should be in all — laws have been 
 enacted preventing the employment of hypnotism 
 except by a physician for therapeutic purposes. 
 The professional hypnotizer, when his performances 
 are not fakes, as they very often are, is capable of 
 doing a great deal of harm to nervous and hysterical 
 
HYPNOTISM. 283 
 
 individuals, the very ones who flock to this sort of 
 exhibition. 
 
 Many different modes of classifying the various 
 stages of hypnotism have been proposed, but the 
 one given by Charcot is the most scientific, and 
 serves as a basis for all the others. He divides the 
 hypnotic state into three stages: (1) Catalepsy. 
 (2) Lethargy. (3) Somnambulism. Catalepsy is 
 induced by simple fixation of the eyes upon some 
 bright object, or in susceptible persons by a sudden 
 noise. One of the "performances" in the Salpe- 
 triere was the striking of a gong at some unex- 
 pected moment in one of the wards, upon which 
 all the susceptible subjects would be thrown into 
 the condition of catalepsy, and this sudden fixa- 
 tion of their position, no matter what they might 
 be doing, often produced very grotesque effects. 
 This cataleptic condition is characterized by a wax- 
 like immobility. The limbs will remain in any posi- 
 tion in which they are placed by the operator, until 
 physiological fatigue ensues. It is wonderful, and a 
 proof of the genuineness of the phenomenon, that 
 such subjects will keep the arms or legs extended 
 for twenty or thirty minutes, or even longer. The 
 eyes are wide open, and the expression perfectly 
 impassive. In this condition there is general cutan- 
 eous anesthesia. If the eyes of the subject who has 
 been thrown into the cataleptic state be closed for a 
 moment, the condition of lethargy is induced. In 
 this state the eyes are tight shut, the head sunk 
 upon the breast, and there is every indication of 
 
284 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 profound sleep. The limbs when raised drop back 
 as if paralyzed, and there exists complete cutaneous 
 anesthesia. In this condition one may observe the 
 phenomenon of muscular hyperexcitability. By 
 pressing on certain muscles, or on the motor nerves 
 controlling them, a strong contraction results, so 
 strong that it is impossible to overcome it by force. 
 If in this somnambulic state the eyes are opened, 
 the condition of catalepsy is re-established. 
 
 The other state, somnambulism, may be induced 
 independently by suggestion, or, according to the 
 Salpetriere school, may be brought on by making 
 slight friction on the top of the head. In this con- 
 dition all the senses are very greatly heightened, and 
 often the mental faculties share this excitement. In 
 this state the subject will perform all sorts of actions 
 at the suggestion of the operator, and this is the 
 phase that is utilized by the professional hypnotist to 
 make the subject go through the various stock paces 
 for the amusement of the audience. Such is the 
 classification of Charcot, which, as Culliere says, is 
 an ideal classification with many exceptions. Lie- 
 bault gives six stages, the earlier ones being different 
 degrees of somnolence. Bernheim follows Liebault 
 and adds three other stages, making nine in all. 
 These classifications are merely the three stages of 
 Charcot variously subdivided. The fact that Bern- 
 heim and his school include certain light somnolent 
 conditions under the head of hypnotism, explains 
 the very high per cent, of hypnotizable subjects that 
 this school claims to have obtained. 
 
HYPNOTISM. 285 
 
 Many observers unite in saying that it is impossi- 
 ble to draw any sharp distinction between the differ- 
 ent stages, and that the various phenomena which 
 have been mentioned occur without any regular 
 order. My own experience has been that the prim- 
 ary condition is lethargy, and that the other states 
 are merely suggestive phenomena. In a fairly large 
 number of experiments the first indication of the 
 hypnotic influence has almost invariably been a con- 
 dition of lethargy which varied greatly in intensity. 
 If this lethargy was deep, then it was possible to 
 make the patient pass into catalepsy by simply open- 
 ing the eyes. I have never been able to bring about 
 somnambulism by making friction upon the head, as 
 Charcot describes, and have been able to induce this 
 state only by suggestion. In fact, my experiments 
 have led me to the conclusion that the fundamental 
 principle underlying hypnotism is suggestion. In 
 employing any one of the methods above described, 
 it has always, in my experience, been necessary to 
 make some suggestion in order to bring on any of 
 the various hypnotic states. The suggestion that 
 most frequently succeeds is that of sleep, and when 
 this is effective then any of the other states may be 
 very easily induced by making the appropriate sug- 
 gestion. The state of lethargy is, of course, brought 
 on by suggestion, and catalepsy is simply a sugges- 
 tion made by moving the limbs. In like manner, 
 the patient may "be told to get up, or to perform 
 certain acts, thus virtually putting him into the state 
 of somnambulism. I have become satisfied that the 
 
286 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 friction of the head spoken of above as a means of 
 inducing somnambulism is not effective unless the 
 patient in some way connects this procedure with 
 movement. A very important point to be borne in 
 mind is that in France almost every patient that 
 enters one of the hospitals, certainly every Parisian, 
 is familiar to a greater or less degree with the vari- 
 ous procedures of hypnotism, and consequently is 
 prepared, as it were, for these well-known sugges- 
 tions. In this country, on the other hand, sugges- 
 tions must be made verbally and clearly before the 
 subject understands the purport of them. 
 
 Charcot has described several minor or inter- 
 mediate stages, among which may be mentioned a 
 very mild form of lethargy, and also a condition 
 which he calls the state of " charm " or " fascination," 
 the important feature of these two states being that 
 the subject remembers upon awakening all that has 
 passed, while in the other states mentioned above 
 the period of hypnosis is a perfect blank. It has 
 been shown that the hypnotized subject will accept 
 and act upon any suggestion that is made. More 
 than this, it is possible with certain subjects to make 
 what is known as a post-hypnotic suggestion. A 
 patient in a condition of hypnosis is told that at a 
 certain time he will do such and such things. When 
 the time arrives the act is performed without the 
 patient knowing why. For example : a subject is 
 told, " To-morrow you will go to a certain place and 
 perform some act." The subject is awakened and 
 knows nothing of this suggestion, but at the ap- 
 
HYPNOTISM. 287 
 
 pointed time he does what had been told him while 
 in the hypnotic state. This post-hypnotic sugges- 
 tion has been found to persist for weeks. A nice 
 medico-legal question has been raised ; namely, 
 whether it is not possible to have crimes committed 
 through the influence of this post-hypnotic sugges- 
 tion. As a matter of fact, this question has come 
 up in the courts both in this country and in France, 
 the accused claiming that he was the victim of hyp- 
 notic suggestion. It has always seemed to me 
 rather doubtful whether the hypnotic suggestion is 
 strong enough to make a man commit murder, — to 
 overcome the inherent repugnance to such an act. 
 Many States have passed laws forbidding the indis- 
 criminate use of hypnotism, believing that in it there 
 is the possibility of crime. 
 
 The question of the therapeutic value of hyp- 
 notism in the treatment of hysteria and allied 
 neuroses is still a moot one. There can be no doubt 
 of its great utility in the treatment of many of the 
 so-called accidents of hysteria — paralysis, contrac- 
 tures, mutism, convulsive attacks, and the like. 
 When the physician has succeeded in inducing 
 hypnosis he should, for some minutes, repeat the 
 suggestion that the paralysis or other symptom would 
 be gone when the patient would be awakened. 
 Again, in the convulsive attack, as has been shown, 
 it is often possible to induce hypnosis and the patient 
 may be allowed to sleep, or the suggestion may be 
 made that when awakened the convulsion will have 
 disappeared. Again, in the interparoxysmal period, 
 
288 HYSTERIA : ITS NATURE AND TREATMENT. 
 
 in the treatment of the general condition, suggestion 
 may be made that there will be no more seizures. 
 On the whole, it may be said that the use of hypno- 
 tism in the treatment of hysteria is discouraging. 
 In the first place, by no means all hysterical subjects 
 can be hypnotized. Then, of the number that can 
 be influenced, a considerable proportion can only 
 be slightly hypnotized, not sufficiently so to make 
 use of suggestion. Again, it is found that sugges- 
 tions made to hysterical subjects are often very 
 transient in their effects. The paralyzed arm in a 
 few moments eoes back to its original condition. 
 On the other hand, cases are met with now and then 
 that yield brilliant results after this mode of treat- 
 ment. The great value of hypnotism, however, and 
 the great service it has done to medicine is that 
 it has taught us how to make our treatment of the 
 hysterical subject suggestive. We have learned 
 how to make suggestions, and have been taught to 
 appreciate this mode of managing the hysterical 
 subject. The successful treatment of hysteria is a 
 suggestion, not now and then as in hypnotic state, 
 but continuous ; every element of the treatment is 
 directed toward this end. If, then, hypnotism has 
 done nothing but this it has amply repaid all the 
 time and study that has for so many years been given 
 to it. 
 
 Surgical Interference in the Treatment of 
 Hysteria. — It has been shown that in the accidents 
 of hysteria, such as paralysis and contracture, sur- 
 gical interference is entirely unwarrantable. It may 
 
SURGICAL INTERFERENCE. 289 
 
 happen, in rare instances, that there is actual short- 
 ening of the tendons in contracture requiring- tenot- 
 omy, but this is altogether exceptionable. Surgical 
 operations are rarely ever thought of after the diag- 
 nosis of hysteria is made in the case of the two con- 
 ditions mentioned above. Far different has been 
 the history of operations upon the organs of repro- 
 duction for the cure of hysteria. As has been shown, 
 the early authors attributed hysteria to the migrations 
 of the uterus, and had the operation of hysterectomy 
 been known or been possible at the time, it would, 
 no doubt, have been frequently resorted to. As it 
 was, the treatment of hysteria often had in view the 
 supposed disease of the genital organs. " Nubat 
 ilia etmorbum effugiet" said Hippocrates, and For- 
 estius gives minute directions for the " confricatio 
 vulva." These efforts at treatment were simply the 
 logical outcome of the ignorance respecting the 
 nature of the disease hysteria, and were excusable. 
 It is, however, almost incredible that in the light of 
 the nineteenth century surgeons should endeavor to 
 cure a disease which is admitted to be in the brain 
 by operating upon the organs of generation. And 
 still the " operating frenzy " is not spent. Just as in 
 the cases mentioned in another chapter, in which 
 perfectly healthy breasts have been removed for a 
 supposed disease which was really in the mind of 
 the patient, and as joints have been laid open and 
 muscles and tendons cut for hysterical contractures, 
 so innumerable healthy ovaries have been removed 
 for hysterical pain situated in. this region. Without 
 25 
 
 wmm 
 
2 9 o HYSTERIA: ITS NATURE AND TREATMENT. 
 
 perceiving it, the effort has been made to remove, by 
 the knife, an hysterogenic zone. It became obvious, 
 after a time, that the mere existence of pain in the 
 region of the ovary was not sufficient cause for 
 operation, so the endeavor was made to show some 
 evidence of disease — a minute cyst or some other 
 utterly trivial condition. 
 
 Most of us were familiar a few years ago with 
 this sort of "gynecological pathology." After a 
 time the view that the ovaries in hysteria were dis- 
 eased had to be abandoned. Then the position was 
 boldly assumed that the removal of the ovaries, 
 though healthy, was good practice in the treatment 
 of hysteria and other mental diseases. For a time 
 this dictum was vigorously promulgated, and the 
 attack upon the healthy ovary in the hysterical sub- 
 ject became notorious. In this country, where so 
 much attention has been paid to gynecology and so 
 little to hysteria, this most unwarrantable operation 
 has been resorted to with disgraceful frequency, and 
 if it were necessary, long lists of published cases, 
 operated on for the cure of some neurosis, could be 
 given. Most unfortunately a certain proportion of 
 these operations were successful in relieving the 
 hysterical symptoms for a time, but for a very dif- 
 ferent reason than the one assigned. As has con- 
 stantly been pointed out, the central idea in the treat- 
 ment of hysteria is suggestion, and our constant aim 
 is to make a strong mental impression. Take, now, 
 the hysterical woman : let her undergo this most 
 grave operation, knowing often a good deal of what 
 
SURGICAL INTERFERENCE. 291 
 
 removal of the ovaries implies, feeling that her life 
 is to undergo a marked change ; let her pass through 
 the impressive preparation for the operation, and 
 after the operation be kept in bed for several weeks 
 and well nourished. Could any more impressive 
 treatment be devised ! I have often heard gyne- 
 cologists gravely assert that the surgical procedure 
 alone was responsible for the success. It is well 
 known that the suggestive effects of the operation 
 have been successfully employed, the patient being 
 prepared, anesthetized, and bandaged up, no opera- 
 tion, or sometimes only a slight cut, having been 
 made. It is not the place here to discuss the mor- 
 tality of the operation for the removal of the ova- 
 ries, but one of the arguments that is sometimes 
 offered in support of this mode of treating hysteria 
 is, that the removal of the ovaries is perfectly safe. 
 It mav be said that the statistics from which the 
 mortality tables have been taken are generally those 
 of very skilful operators. If all the cases operated 
 upon by unskilful and ignorant men were included, 
 the mortality would show a far higher figure. The 
 fact that this unwarrantable operation was for a 
 number of years so strongly advocated by many 
 able men, spread the fame of it far and wide among 
 the laity, and a neurologist is asked in most of his 
 bad cases of hysteria whether it had not better be 
 resorted to. Again, the cases of complete and per- 
 manent cure are limited in number, and must be, 
 since the operation has simply for the time acted 
 upon the higher brain centers in a suggestive 
 
292 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 manner, but has not removed the cause of the 
 disease. 
 
 In the vast majority of cases the hysterical symp- 
 toms return, and often the ovarian pain comes back 
 in the place where the ovaries ought to be. I could 
 give many cases even from my own experience if 
 space permitted. I will refer to two only : one a case 
 that has already been mentioned as illustrating hys- 
 terical" lethargy. In addition to this symptom the 
 girl had anesthesia and very marked hysterogenic 
 zones. Ovariotomy was performed upon her, and 
 she was dismissed as cured. Some six months or a 
 year after I inquired of her mother as to her condi- 
 tion, and was told that she had suffered a relapse and 
 had been taken to a hospital, where she had been 
 entirely cured by electricity. The case has passed 
 from my observation, but doubtless the girl has been 
 cured in many different ways since. The other case 
 was a woman with certain irregular symptoms. She 
 had, however, well-marked hysterogenic zones. 
 While under my care I discovered a floating kidney. 
 She improved somewhat and left the hospital. I next 
 saw her in another institution and learned that she 
 had had her ovaries removed, but the hysterical 
 stigmata were still present. Subsequently another 
 surgeon opened her belly the second time and re- 
 moved the floating kidney. After all this, she told 
 me that she was about in the same condition as 
 before the operation. These are two cases taken 
 at random, but they illustrate the point. 
 
 Twenty years ago neuroses in women were sup 
 
SURGICAL INTERFERENCE. 293 
 
 posed to be due to a stenosis of the os uteri, and 
 instruments were devised to enlarge this passage. 
 After a time this operation fell into disuse and all 
 nervous women who had even the most minute tears 
 in the cervix were told that this was the source of 
 the trouble — the fans et origo of their nervousness. 
 Then came the day for trachelorrhaphy, which was 
 practised to an absurd degree. Again, the operation 
 of removal or cauterization of the clitoris was at 
 one time frequently resorted to as a cure for hysteria. 
 To-day these operations have sunk into well-merited 
 oblivion, except in cases where there is a distinct 
 indication for them. They are no longer performed 
 for the relief of the purely nervous symptoms. The 
 same history might be given of the use and abuse 
 of the pessary. In a previous chapter, the attempt 
 has been made to show why women are apt to refer 
 their ills to the reproductive organs. The mystery 
 attached to the organs of generation and the monthly 
 discomforts of menstruation make these organs the 
 source of suggestion. This explains the extreme 
 readiness of hysterical women to submit to opera- 
 tions. In hysterical and neurasthenic men it is 
 extremely common to hear complaints relative to 
 the sexual organs, and yet the operation of castra- 
 tion has never been in danger of becoming popular 
 among men. The other side of the question — for 
 there is another side — which must be considered is 
 to what extent actual disease of the reproductive 
 organs is responsible for hysteria. It is extremely 
 doubtful whether any form of ovarian or uterine 
 
294 
 
 HYSTERIA: ITS NATURE AND TREATMENT. 
 
 disease ever caused hysteria in a person not pre- 
 disposed to this or other neurosis. On the other 
 hand, there can be no doubt that ovarian and uterine 
 disease or displacement may act as reflex causes and 
 thus aggravate the existing hysteria or even bring 
 on an attack in individuals predisposed to it. It 
 goes without saying that such actual disease of the 
 organs of reproduction, or, in fact, any irritating 
 cause, should be especially looked after in hysterical 
 subjects. 
 
 The rule, then, that should be adopted is that 
 operations should not be performed on hysterical 
 women for the relief of the nervous symptoms un- 
 less some distinct disease of the reproductive organs 
 can be detected. 
 
INDEX 
 
 ABULIA, 149, 163 
 Achromatopsia, 79 
 Age, influence of, 30 
 Aged, hysteria in the, 31 
 Amblyopia, 78 
 Amyosthenia, 1 13 
 Anesthesia, 62 
 
 differential diagnosis of, "J^, 209 
 
 disseminated, 66 
 
 distribution of, 66 
 
 frequency of, 65 
 
 glove and stocking form of, 69 
 
 hemianesthesia, 67 
 
 of mucous membranes, 71 
 
 of special senses, 7 3 
 
 onset of, 72 
 
 reflexes in, 71 
 
 total, 66 
 
 treatment of, 238 
 
 visceral, 71 
 Angina pectoris, pseudo- 
 Anorexia nervosa, 177 
 Aphasia, 192 
 Aphonia, 116, 191 
 Apoplexy, 113 
 Arthralgia, 89 
 
 diagnosis of, 212 
 Astasia- abasia, 120 
 Atrophy, muscular, 198 
 Aura, 130 
 Autographism, 195 
 
 BLADDER, irritable, 187 
 Blepharospasm, 108 
 
 87 
 
 Breast, hysterical, 87 
 
 differential diagnosis of, 213 
 
 CARDIAC disturbances, 193 
 Catalepsy, 162 
 
 hypnotic, 283 
 Children, hysteria in, 30 
 Clavus hystericus, 86 
 Climate, influence of, 31 
 Contracture, 96 
 
 and traumatism, 101 
 atrophy in, no 
 classification of, 102 
 differential diagnosis of, 111,215 
 hemiplegic form of, 105 
 of eye muscles, 107 
 of facial muscles, 107 
 of involuntary muscles, 108 
 of lower extremity, 104 
 of upper extremity, 102 
 paraplegic form of, 105 
 periarticular form of, 105 
 treatment of, 240 
 Convulsive attacks, 122 
 
 consciousness in, 125 
 cry in, 125 
 
 differential diagnosis of, 217 
 duration of, 133, 138 
 major, or grand attack, 125, 
 
 129 
 minor, 123 
 
 prodromes of, 124, 125, 129 
 stages of, 129 
 
 295 
 
296 
 
 INDEX. 
 
 Cough, 190 
 Coxalgia, 89 
 
 FEEDING, forced, 268 
 Fever, hysterical, 199 
 Flagellation, 20 
 
 DEAFNESS, hysterical, 75 
 
 Death in hysteria, 173, 174 
 
 Degeneracy and hysteiia, 156 
 
 Delirium, 136 
 
 Demoniac possessions, 17 
 
 Diagnosis, differential, 204 
 
 from general nervousness, 
 
 207 
 from hypochondria, 206 
 from neurasthenia, 205 
 of anesthesia, 209 
 of arthritic affections, 212 
 of contracture, 215 
 of convulsive attacks, 216 
 of hyperesthesia, 211 
 of mental affections, 218 
 of motor disturbances, 214 
 of paralysis, 216 
 of visceral and vasomotor 
 disturbances, 219 
 
 Diarrhea, nervous, 180 
 
 Diatheses, influence of, 33 
 
 Diet, 268, 226 
 
 Digestive disturbances, 172 
 
 Dyspnea, 189 
 
 ECSTACY, 162, 164 
 Edema, hysterical, 196 
 Education, effects of, 34 
 Electrotherapeutics, 234, 245 
 Environment, effects of, 35, 222 
 Epidemics of hysteria, 11 
 Epilepsy and hysteria, 217 
 Esophagus, contracture of, 172 
 Etiology, 29 
 Exercise, 227 
 
 Eye, affections of muscles of, 107, 
 108 
 
 GAIT in hysterical paralysis, 1 14 
 Gangrene, hysterical, 196 
 Gastric ulcer and hysteria, 176 
 Generation, organs of, 187 
 Genito-urinary disorders, 183 
 Globus hystericus, 87, 108 
 Grand attach, 125, 129 
 Gynecological operations in hysteria, 
 290 
 
 HEADACHE, 86 
 
 Hematemesis, 175 
 Hemianesthesia, 67 
 Hemianopia, 82, 77 
 Hemidrosis, 197 
 Hemoptysis, 189 
 Heredity, influence of, 32, 221 
 Hiccough, 191 
 Historical, 9 
 Hydrotherapy, 233, 252 
 Hyperesthesia, 83 
 
 forms of, 85 
 
 of mucous membranes, 85 
 
 treatment of, 238 
 Hypnotism, 272 
 
 modes of inducing, 280 
 
 stages of, 283 
 
 therapeutic value of, 287 
 Hypochondria, 144, 206 
 Hysteria, the name, 55 
 
 and hypnotism, 135 
 
 lighter forms of, 59 
 Hysterical fever, suggestion in, 203 
 
 temperament, 58 
 Hystero-epilepsy, 122, 128, 217 
 Hysterogenesis, 95 
 Hysterogenic zones, 91 
 
INDEX. 
 
 297 
 
 INTERCOSTAL neuralgia, 87 
 Ischuria, 185 
 Isolation, 265 
 
 JOINTS, hysterical, 
 
 OLIGURIA, 187 
 
 Ophthalmoplegia, 1 19 
 Opisthotonos, 128 
 Ovarian compression, 243 
 
 pain, 90 
 Ovariotomy in hysteria, 290 
 
 LETHARGY, 159 
 
 hypnotic, 283 
 Loss of memory in hvsteria, 
 
 149 
 
 MAGNET, use of, 248 
 
 Mania, hysterical, 15 1 
 
 Marriage, effects of, 230 
 
 Massage, 257 
 
 application of, 260 
 physiology of, 259 
 
 Masturbation, 230 
 
 Megalopsia and micropsia, 83 
 
 Meningitis, pseudo-, 87, 212 
 
 Mental condition in hysteria, 141 
 
 Metallotherapy, 251 
 
 Micropsia, 83 
 
 Motor disturbances, 96 
 
 classification of, 97 
 differential diagnosis of, 214 
 treatment of, 239 
 
 Mucous membranes, involvement of, 
 71,85 
 
 NARCOLEPSY, 159 
 
 Negro, hysteria in the, 31, 32 
 Nervous dyspepsia, 172 
 Neuralgia, 86 
 
 Neurasthenia, hystero-, 20£ 
 Nutrition in hysteria, 178, 196, 
 199 
 
 26 
 
 PAIN, hysterical, 86 
 
 sense, 64 
 Palpitation, 194 
 Paralysis, ill 
 
 cause of, 1 12 
 
 differential diagnosis of, 216 
 
 hemiplegic type of, 1 13 
 
 monoplegic type of, 1 16 
 
 of eye muscles, 1 19 
 
 of facial muscles, 1 14 
 
 of pharynx and esophagus, 1 18 
 
 of vocal cords, 117 
 
 onset of, 112 
 
 paraplegic type of, 116 
 
 quadriplegic type of, 116 
 
 reflexes in, 1 15 
 
 tests for, 113 
 
 treatment of, 239 
 Paresthesia, 83 
 Pathology, 29 
 Peritonitis, pseudo-, 182 
 Personality, double, 170 
 Petit mal and hysteria, 218 
 Pica, 178 
 Polyopia, 82 
 Polyuria, 184 
 Pott's disease, pseudo- 
 Pregnancy, false, 182 
 Pressure sense, 64 
 Pseudo-meningitis, 87 
 Ptosis, 119 
 Pyrexia, hysterical, 199 
 
 RACE, influence of, 
 
 So 
 
INDEX. 
 
 Reflex irritation, 37, 38 
 
 Respiration, disturbances of, 189 
 
 Rest cure, the, 264 
 
 mode of applying the, 267 
 modified, the, 271 
 
 SEA-bathing, 257 
 
 Sensation, modes of testing, 64 
 
 acuity of, in different parts of 
 body, 64 
 Sex, influence of, 29 
 Sexual disturbances, 59 
 
 instinct in hysteria, 59, 229 
 Skin, affections of, 195 
 Sleep, disturbances of, 59, 149 
 Smell, sense of, 74 
 Sneezing, 191 
 
 Social conditions, effects of, 36, 37 
 Somnambulism, 165 
 
 hypnotic, 284 
 Spasm, expiratory, 190 
 
 inspiratory, 191 
 Special sense disturbances, treatment 
 
 of, 239 
 Stigmatization, 21, 22 
 Suicide in hysteria, 158 
 Suppression of urine, 186 
 Surgical interference in hysteria, 288 
 Sweating, 197 
 Symptomatology, 56 
 
 TACHYCARDIA, 193 
 
 Taste, sense of, 73 
 
 Theories as to the nature of hysteria, 
 
 Traumatism, influence of, 101, 112 
 
 Treatment, general, 221 
 
 medicinal, 236 
 
 of anesthesia, 238 
 
 of contracture, 240 
 
 of convulsive seizures, 241 
 
 of hyperesthesia, 238 
 
 of paralysis, 239 
 
 of special sense disturbances, 239 
 
 of special symptoms, 238 
 Tremor, 96 
 
 classification of, 98 
 
 differential diagnosis of, 214 
 
 duration of, 99 
 Trophic manifestations of hysteria, 
 
 196, 197, 198 
 Tympanitis, 181 
 
 VAGINISMUS, 85 
 
 Vampirism, 22 
 
 Vigilambulism, 169 
 
 Visceral disturbances, 172, 219 
 
 Visual affections, 77 
 
 fields, constriction of, 78 
 reversal of, color fields, 79 
 
 Voice, affections of, 191 
 
 Vomiting, hysterical, 173 
 
 WATER, use of, 254 
 
 mode of applying, 256 
 Watering-places, influence of, 256 
 Wilderness cure, 231 
 
 YAWNING, 191 
 
 ZONES, hysterogenic, 91 
 
Catalogue No. 8. March, 1897 
 
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MEDICAL BOOKS. 19 
 
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MEDICAL BOOKS. 21 
 
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22 SUBJECT CATALOGUE. 
 
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MEDICAL BOOKS. 23 
 
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Tyson's 
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 Text-Book of the Practice of Medi- 
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