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Accountability and Educational Improvement

Melanie C.M. Ehren Editor

Methods and
Modalities of
Effective School
Inspections
Accountability and Educational Improvement

Series editors
Melanie C.M. Ehren, UCL Institute of Education, London, UK
Katharina Maag Merki, Institut für Erziehungswissenschaft, University of Zurich,
Switzerland
More information about this series at http://www.springer.com/series/13537
Melanie C.M. Ehren
Editor

Methods and Modalities

of Effective School
Inspections
Editor
Melanie C.M. Ehren
UCL Institute of Education
University College London
London, UK

Accountability and Educational Improvement

ISBN 978-3-319-31001-5 ISBN 978-3-319-31003-9 (eBook)
DOI 10.1007/978-3-319-31003-9

Library of Congress Control Number: 2016934206

© Springer International Publishing Switzerland 2016

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
Contents

1 Introducing School Inspections ............................................................... 1

Melanie C.M. Ehren
1.1 Introduction ........................................................................................ 1
1.2 Defining School Inspections .............................................................. 2
1.2.1 Frequency of Visits: Cyclical Versus Proportionate
Models ................................................................................. 4
1.2.2 Consequences of School Inspections: Sanctions
Versus No Sanctions ............................................................ 6
1.2.3 Reporting: Inspection Systems with/Without
Public Reporting .................................................................. 7
1.3 Inspections in the Broader Context of Monitoring ............................ 8
1.4 Goals and Functions of School Inspections ....................................... 10
1.4.1 Control ................................................................................. 11
1.4.2 Improvement ........................................................................ 11
1.4.3 Liaison ................................................................................. 12
1.4.4 Conflicting Goals and Functions of School
Inspections ........................................................................... 13
1.5 Structure of the Book ......................................................................... 14
References ................................................................................................... 15

Part I Understanding School Inspection Frameworks

2 The Evidence Base for School Inspection Frameworks ........................ 19
Jaap Scheerens and Melanie C.M. Ehren
2.1 Introduction........................................................................................ 19
2.1.1 Control of Input, Rules and Regulations ............................. 20
2.1.2 Evaluation and Support of Educational Processes ............... 20
2.1.3 Evaluation of School Output................................................ 21
2.2 Fit for Purpose: School Effectiveness Modelling
and Three School Inspection Functions ............................................. 24

v
vi Contents

2.3 Identification of Effectiveness Enhancing School Conditions;

Consensus Among Reviews............................................................... 27
2.3.1 Less Consistency of Effect Sizes in Quantitative
Research Syntheses .............................................................. 28
2.4 A Closer Look at the Meaning of the Key Factors
in Educational Effectiveness .............................................................. 31
2.4.1 Achievement Orientation ..................................................... 31
2.4.2 Educational Leadership ....................................................... 31
2.4.3 Staff Cooperation, Cohesion and Consensus ....................... 32
2.4.4 Curriculum Quality and Opportunity to Learn .................... 32
2.4.5 School Climate..................................................................... 32
2.4.6 Evaluation and Monitoring .................................................. 33
2.4.7 Parental Involvement ........................................................... 33
2.4.8 Classroom Climate............................................................... 33
2.4.9 Effective Learning Time ...................................................... 34
2.4.10 Structured Teaching ............................................................. 34
2.4.11 Constructivist Teaching and Independent Learning ............ 34
2.4.12 Differentiation ...................................................................... 35
2.5 The Multi-facetted Nature of School Effectiveness
Enhancing Variables .......................................................................... 35
2.6 Analysing Inspection Frameworks .................................................... 36
References ................................................................................................... 45
3 Validation of Inspection Frameworks and Methods .............................. 47
Melanie C.M. Ehren and Marcus Pietsch
3.1 Introduction........................................................................................ 47
3.2 Validity in the Context of School Inspections ................................... 49
3.3 Interpretation/Use Argument ............................................................. 50
3.4 Sources of Validity Evidence ............................................................. 53
3.4.1 Validity Evidence Based on Test Content ............................ 53
3.4.2 Validity Evidence Based on Relations
to Other Variables ................................................................ 55
3.4.3 Validity Evidence Based on Internal Structure .................... 56
3.4.4 Validity Evidence Based on Response Processes ................ 58
3.4.5 Validity Evidence Based on Consequences of Testing ........ 61
3.5 Challenges and Tensions in Inspection Frameworks,
Methods and Processes ...................................................................... 62
References ................................................................................................... 64

Part II The Current Evidence Base of School Inspection Research

4 School Inspections and School Improvement; the Current
Evidence Base ............................................................................................ 69
Melanie C.M. Ehren
4.1 Introduction........................................................................................ 69
4.2 Effects of School Inspections ............................................................ 71
Contents vii

4.2.1 Reflection on School Quality and Intentions to Improve .... 72

4.2.2 School Improvement ............................................................ 74
4.2.3 Improvement of Self-Evaluation.......................................... 76
4.2.4 Improved Student Achievement........................................... 78
4.2.5 No Effect .............................................................................. 79
4.3 Effects of School Inspections in Low and Middle
Income Countries ............................................................................... 80
References ................................................................................................... 82
5 Side Effects of School Inspection; Motivations and Contexts
for Strategic Responses............................................................................. 87
Melanie C.M. Ehren, Karen Jones, and Jane Perryman
5.1 Introduction........................................................................................ 88
5.2 Categories and Types of Unintended Consequences
of School Inspection .......................................................................... 88
5.2.1 Intended Strategic Behaviour............................................... 89
5.2.2 Unintended Strategic Behaviour .......................................... 90
5.2.3 Other Unintended Consequences ......................................... 91
5.2.4 Unintended Consequences of High Stakes Testing ............. 93
5.3 An Example from England ................................................................ 96
5.3.1 Fabricating the Stage ........................................................... 99
5.3.2 Playing the Game ................................................................. 100
5.3.3 Resistance and Cynicism ..................................................... 100
5.4 Explaining Unintended Consequences .............................................. 102
References ................................................................................................... 106
6 Mechanisms and Contexts of Effective Inspections ............................... 111
Melanie C.M. Ehren
6.1 Introduction........................................................................................ 111
6.2 Setting Expectations .......................................................................... 112
6.2.1 Coercive Isomorphism ......................................................... 114
6.2.2 Mimetic Isomorphism .......................................................... 116
6.2.3 Normative Pressures ............................................................ 118
6.2.4 Conditions of Isomorphic Change ....................................... 120
6.3 Inspection Feedback .......................................................................... 122
6.3.1 Evidence of Impact of Inspection Feedback ........................ 123
6.3.2 Conditions of Effective Feedback ........................................ 124
6.4 Capacity Building .............................................................................. 127
6.4.1 School Self-Evaluation ........................................................ 127
6.4.2 Professional Development ................................................... 128
6.5 Stakeholder Involvement ................................................................... 130
6.5.1 Voice .................................................................................... 131
6.5.2 Choice .................................................................................. 131
6.5.3 Exit ....................................................................................... 132
6.6 Logic of Change ................................................................................ 133
References ................................................................................................... 134
viii Contents

Part III Conclusion

7 Emerging Models of School Inspections; Shifting Roles
and Responsibilities .................................................................................. 143
Melanie C.M. Ehren
7.1 Introduction: Changing Landscapes .................................................. 143
7.1.1 England ................................................................................ 146
7.1.2 The Netherlands ................................................................... 147
7.1.3 Northern Ireland................................................................... 148
7.1.4 Dysfunctional Networks and Accountability Concerns....... 148
7.2 Evaluating Network Effectiveness ..................................................... 150
7.2.1 Structural Contingency of Networks ................................... 151
7.2.2 Relational Contingency of Networks ................................... 152
7.3 Inspections of/in Education Networks ............................................... 155
7.3.1 Evaluation Methodology...................................................... 155
7.3.2 Valuing and Judging ............................................................ 158
7.3.3 Use ....................................................................................... 162
7.4 Conclusion: Changing Roles and Responsibilities ............................ 164
References ................................................................................................... 167

Annexes ............................................................................................................ 171

Annex A ....................................................................................................... 171
Annex B ....................................................................................................... 174
Contributors

Melanie C.M. Ehren Reader in Educational Accountability and Improvement,

UCL Institute of Education, University College London, London, UK
Karen Jones CEM, Rowan House, Mountjoy Centre, Durham University,
Durham, UK
Jane Perryman UCL Institute of Education, University College London,
London, UK
Marcus Pietsch Institut für Bildungswissenschaft, Leuphana Universität Lüneburg,
Lüneburg, Germany
Jaap Scheerens Faculteit der Gedragswetenschappen (GW) Afdeling OMD,
Universiteit Twente, Enschede, The Netherlands

ix
Chapter 1
Introducing School Inspections

Melanie C.M. Ehren

Abstract This chapter introduces the fundamental principles and concepts of

school inspections. School inspections will be defined and distinguished from other
types of evaluation, such as quality monitoring, internal evaluations and audit. The
chapter will also present examples of different inspection practices across Europe
and explain how these have evolved over the last decades, while the goals and func-
tions of school inspections to control and support schools have remained relatively
stable. Many Inspectorates of Education try to meet both goals when inspecting
schools and the last section of the chapter will discuss potential conflicts that may
arise from combining both goals.

1.1 Introduction

Over the years there have been many changes in inspection systems which are often
the result of intense debates in the media and between politicians. Some of these
debates have resulted in an expansion of inspections when a country for example
performs poorly on international league tables such as PISA. In Germany many of
the Bundeslander implemented inspection systems in response to the so called
‘PISA shock’ in 2001. Equally many inspection systems have seen their budgets cut
in a period of economic recession or when the media reports of excessive account-
ability and administrative burden on schools.
Despite these recent budget cuts in many countries, inspections are here to stay
and have become important elements of education and accountability systems, par-
ticularly in Europe. They have an important role in providing information about the
quality of schools, particularly on wider, less easily measured goals such as school
culture and climate, safety and well-being and effective pedagogy. Their aggregated
inspection assessments of individual schools allow governments to take stock of the

M.C.M. Ehren (*)

Reader in Educational Accountability and Improvement,
UCL Institute of Education, University College London,
20 Bedford Way, London WC1H 0AL, UK
e-mail: m.ehren@ucl.ac.uk

© Springer International Publishing Switzerland 2016 1

M.C.M. Ehren (ed.), Methods and Modalities of Effective School Inspections,
Accountability and Educational Improvement,
DOI 10.1007/978-3-319-31003-9_1
2 M.C.M. Ehren

performance of the entire education system, beyond a summary of test scores in a

small number of subjects. Other advantages are, according to Barber (2004) that an
inspection system is able to provide rapid feedback and can comment on teachers’
reactions to national policies. Inspections can examine whether or not new policy is
beginning to affect the quality of teaching and can assess the extent of implementa-
tion of national policy. Inspection also has the potential, according to Barber (2004)
to enforce the implementation of such, as well as explaining (changes in) the perfor-
mance of education systems.
As the key for improving performance lies in the quality of classroom teaching,
school inspections are by nature well positioned to look at what works best in think-
ing about effective pedagogy and are also well placed to disseminate such effective
practice. During their visits of schools, as well as in follow-up activities in failing
schools, school inspectors can use a much more refined approach to address school
failure than the approaches we would find in monitoring and accountability systems
that only make use of test data and other quantitative performance indicators.
Despite this very favourable story about school inspections, there are also many
caveats to be told. The anxiety of teachers and head teachers when being observed,
the potential unreliability of such lesson observations, the large amounts of public
money to inspect schools, and the potential to stifle innovation are just a couple of
reasons to remain both critical and curious about the actual impact of inspections.
This criticality and curiosity is the main motivation for this book about school
inspections. Before we will discuss current school inspection frameworks and pro-
vide an overview of the present evidence base, this first chapter will define inspec-
tions and provide examples from across Europe on goals and functions of inspection
systems, as well as the major defining characteristics of such systems.

1.2 Defining School Inspections

Eddy Spicer et al. (2014) describe how inspection systems were originally intro-
duced in a number of European countries in the nineteenth century (e.g. HMI, now
OFSTED, UK, dates back to 1834) and have become complex and intricate sys-
tems, using different terminologies and playing different roles. The word ‘school
inspections’ has different meanings in different countries and many systems also
use other words to point to essentially the same exercise.
De Grauwe (2007a) for example describes how in African countries, the term
‘supervision’ is often used to cover all those services whose main function it is to
inspect, control, evaluate and/or advice, assist and support school heads and teach-
ers. External supervision in Africa particularly includes the work of inspectors,
advisors, counsellors, coordinators and facilitators located outside the school, at
local, regional or central levels, whereas the term ‘supervision’ is in most Western
countries understood as the field managers of schools who are typically internal to
the school and responsible for the daily functioning and operation of the school
(often including the line management of school staff).
1 Introducing School Inspections 3

During an OECD country review in Luxembourg in 2012 (Shewbridge et al.

2012) I also came across school inspectors who were primarily responsible for the
management of a number of schools and did not have school evaluation at the core
of their role. These school inspectors were appointed by the Ministry of Education
to act as an intermediary between the school and the Ministry. As fundamental
schools in Luxembourg have no school principal, they were essentially the hierar-
chical superior of the teachers in the schools in their district and had to combine
administrative tasks (e.g. making sure that schools abide to official regulations,
coordinating actions of the school committee presidents, etc.) with their evaluative
tasks of all the schools in their district. In addition they were also responsible for
ensuring that legislation, decrees and directives are executed in schools and educa-
tional reforms are implemented. In reality the daily management of the functioning
of their schools (e.g. counselling teachers in pedagogical matters and mediate
between teachers and parents in case of serious problems with students or serious
complaints from parents) took up most of their work, and school evaluation was not
a recurrent or widespread practice.
School inspection practices can also be found under the term of ‘quality reviews’.
A number of states and districts in the United States have recently introduced such
reviews to complement the federal test-based accountability system with additional
measures of educational practices (Ehren and Hatch 2013). An example is the
New York City Department of Education, which has developed ‘quality reviews’ to
complement the New York State test that is used to measure student performance
and student progress in schools. Ehren and Hatch (2013) describe how these quality
reviews include school visits by external reviewers who assess educational prac-
tices using a common rubric. The quality review process was implemented to com-
municate and reinforce a set of behaviours and practices that were expected to drive
improvements in student achievement, presenting schools with different, timelier
data about their instructional approaches and management systems. The reviews
aimed to support schools in their continuous improvement efforts and intended to
focus their responses and align their improvement efforts, curricula, assessment,
and instruction to the tested standards.
Other examples from the U.S. show how such external monitoring visits are
often explicitly linked to test-based accountability when reviews are used to moni-
tor schools that are failing to meet high stakes test targets. The review visits aim to
support and motivate schools to improve their outcomes on the high stakes test and
reviewers often focus on the school staff’s use of student achievement data in cogni-
tive subjects (particularly mathematics, reading and writing) to inform and improve
teaching and learning in the school. Such strong connection of school inspection
practices to student achievement tests can also be found in other countries, although
in somewhat different modes. England and the Netherlands for example use student
achievement data in their data collection before and during inspection visits to eval-
uate the school’s performance, or to target schools for (proportionate) inspection
visits.
In this book the practice of school inspections we follow Eddy Spicer, Ehren
et al.’s (2014) and De Grauwe’s (2007a) definition of school inspections as:
4 M.C.M. Ehren

the “external evaluations of schools, undertaken by officials outside the school with a man-
date from a national/local authority. Regular visits to schools are an essential part of school
inspections to collect information about the quality of the school, check compliance to
legislation and/or evaluate the quality of students’ work (e.g. through observations, inter-
views and document analysis).” (see Eddy Spicer et al. 2014, p.5). Common characteristics
of all school inspectors are, according to De Grauwe (2007a) that their explicit role is to
control and/or support, that they are located outside the school, and that regular visits of
schools are an essential part of their mandate.

The school level evaluative dimension forms an important part of school inspec-
tors’ roles, which means that inspections have at their core an element of judgment,
using a framework that allows for some level of comparison between schools. These
frameworks include standards on school quality, or indicators to check compliance
to legislation and judgments are generally presented in inspection reports with a
description of the school’s functioning on each of the standards or in summary
scores and league tables on websites of Inspectorates of Education. A judgment can
include an aggregate score for the school (e.g. as failing or well performing), but
may also include an overview of strengths and weaknesses. These judgments would
typically also have consequences for schools/school staff, which may be punitive
when financial sanctions are imposed or in the form of additional support for
schools/head teachers. Consequences can also include rewards when high perform-
ing schools receive bonuses or prizes for their performance.
In a recent comparative EU-study we summarized current practices of
Inspectorates of Education in six countries on these indicators. This summary of the
frequency of visits, the consequences of school inspections and their reporting of
inspection results provides an overview of the major elements of school inspection
systems in Europe, and the differences and commonalities between these systems in
2010.1 Similar summaries can also be found in the ‘blue book’ of the European
Association of Inspectorates of Education (SICI; the Standing International
Conference on Inspectorates of Education, see: http://www.sici-inspectorates.eu/)
and in the recent OECD report on ‘Synergies for Learning’ (2013).

1.2.1 Frequency of Visits: Cyclical Versus

Proportionate Models

As Ehren et al. (2013) describe, Inspectorates of Education differ in the frequency

of inspection visits to schools where some Inspectorates schedule regular visits and
cyclical inspections of all schools, while other Inspectorates of Education use a
more proportionate or risk-based model.
In proportionate risk-based inspection models, the frequency of inspections
depends on an analysis of documents and/or student achievement results (including
self-evaluation documentation) that the school submits to the Inspectorate of

1
The summary in Sects. 1.2.1, 1.2.2, and 1.2.3 was adapted from Ehren et al. 2013, p. 7–10.
1 Introducing School Inspections 5

Education. These documents and student achievement results are analysed for
potential risks of failing quality and visits are scheduled of schools where insuffi-
ciencies are expected. In such a model, schools with high risk of potentially failing
quality are scheduled for inspection visits, and failing schools are monitored more
frequently compared to schools showing no risks, allowing Inspectorates of
Education to make efficient use of their available resources and inspection
capacity.
The Inspectorates of Education in The Netherlands and England have a rela-
tively long tradition of implementing such a differentiated schedule of visits in
addition to cyclical visits. The Netherlands, for example, uses early warning analy-
ses to schedule inspection visits in potentially failing schools, while each school
also receives at least one inspection visit every 4 years in which specific areas of
concern or national targets are evaluated. Similarly, The English Inspectorate of
Education Ofsted conducts regular inspection visits to all schools, while 40 % of
schools graded as satisfactory, and all schools graded as inadequate, receive further
monitoring inspections. In Sweden, regular supervision includes basic inspection
visits to all schools once every 4–5 years, while schools that are evaluated as weak
receive more elaborate ‘widened’ school inspections. The selection of schools for
‘widened inspections’ is based on grades and results on national tests, observations
made in previous inspections, complaints and questionnaire responses from stu-
dents, parents and teachers.
The Irish, Czech and Styrian Inspectorates of Education originally carried out
whole school evaluations of all schools. However, recent policy changes in Ireland
have seen the introduction of ‘incidental inspections’. Unannounced and truncated
in terms of what they examine, there is a suggestion that this new category may be
used to assist weak schools, although it is not clear if re-inspection will be part of
this process. In Styria and the Czech Republic, the original schedule of full cyclical
inspections proved too ambitious, and changes have been made to downscale the
schedule of regular visits in Styria. School inspectors will use additional criteria and
strategies for selecting which schools to inspect, such as, for example, choosing
schools with young/new head teachers. In the Czech Republic, the number of school
inspectors and inspection days per visit will be decreased when small schools are
inspected or when the preparation phase included extensive information.
The increase in more proportionate inspection methods can be explained by the
collective school self-evaluation capacity of each country, local evaluative infra-
structures and support (SE guidelines, data warehouses, etc.), and also the length of
time that each inspectorate has been in existence. England and the Netherlands for
example have an infrastructure to support the administration and analysis of national
standardized student achievement tests and to support school self-evaluation and
reporting which is needed to initiate and implement risk-based and system-wide
inspections. For those countries that have not undergone a full round of country-
wide inspections and/or have limited access to system-wide school performance
assessment data, inspectorates tend to use cyclical inspections where schools are
regularly evaluated against one common standardized framework and
methodology.
6 M.C.M. Ehren

Ultimately most systems however seem to move towards a more targeted

approach for a variety of reasons.
Systems that have gone through a process of cyclical, school-wide inspections
have however seen a tendency to move towards targeted risk-based inspections for
a variety of reasons. As Van Bruggen (2010) explains the movement towards pro-
portionate inspections is justified by governments as a more cost-efficient model as
it allows them to target their resources to potentially weak schools. The increasing
scale and professionalism of some schools allow for risk-based inspections when
Inspectorates of Education can use results of self-evaluations to target inspection
visits and potential areas for improvement. According to Ehren and Honingh (2011),
risk-based models are often also called for to reduce administrative burden on
schools and give the high-performing schools more freedom to monitor and improve
their own quality.
Several authors have however criticized such motivations and have questioned
the rationale of risk-based inspection models.
However, concerns relating to the move from cyclical to targeted risk-based
inspections have also been expressed. Ehren and Honingh (2011) for example
explain how most of the risk-based models used by Inspectorates of Education have
student test scores at their core in deciding on potential risks on a broader range of
indicators of school quality. This focus on achievements contrasts, according to
these authors, with one of the basic ideas of risk analyses to offer warnings, and
provide information about potential shortcomings, instability and direct causes of
failures. Low student achievement results are treated as a warning sign for declining
performance, while they are the result of potentially failing educational processes.
Others (e.g. Leithwood et al. 2010) have also frequently emphasized how what hap-
pens in schools only accounts for 20 % of the variation in students’ achievement,
while the context in which schools operate and students socio-economic back-
grounds are important factors to explain student achievement results. Such concerns
are increasingly recognized and have led, in the Netherlands, to a reinstatement of
regular cycles of school inspections of all schools in the country.

1.2.2 Consequences of School Inspections: Sanctions

Versus No Sanctions

Inspection systems also differ in their consequences for failing schools. Schools
that are evaluated as ‘failing’ may receive additional support, but also often face
punitive consequences, such as sanctions or interventions (van Bruggen 2010).
Sanctions may include naming of the school on the internet (as a result of the pub-
lication of inspection findings) or re-structuring, merging of schools, reconstitution
or even closure. School inspectors may intervene in such schools by means of the
increased monitoring of specific improvement plans which the schools are required
to implement to address their weaknesses or failures. Consequences of school
inspections can also include rewards for high performing schools, financial bonuses
1 Introducing School Inspections 7

or the possibility of taking over another school or developing new and more autono-
mous schools (e.g. in England).
Examples of potential consequences are from Sweden where the Swedish
Inspectorate may withdraw the license and funding of independent schools and may
temporarily close down public schools. Most Inspectorates of Education are how-
ever not in a position to sanction schools directly. In the Netherlands, England and
the Czech Republic, Inspectorates of Education may advise the Minister of
Education to impose sanctions on failing schools (e.g. to remove the school from
the Register of Educational Facilities, or to impose administrative or financial sanc-
tions), but cannot enact those sanctions themselves.
Inspectorates of Education also often intervene in schools that are judged to be
failing. Ofsted (in 2010), for example, categorized schools as being in ‘special mea-
sures’ if the school is evaluated as inadequate and does not have the capacity to
improve; or it gives a school ‘a notice to improve’ when it is performing below
expectations. Schools in ‘special measures’ were required to work with the local
authority, and if no improvement followed, they were under threat of closure by the
Secretary of State. In the Netherlands, schools are monitored intensively when they
are not performing at the required standard. School boards are expected to develop
an improvement plan in which they address the weaknesses that have been identi-
fied in the inspection visit. The Dutch Inspectorate monitors the implementation of
this plan. In Sweden, struggling schools are given a certain amount of time to amend
identified shortcomings, and the implementation of improvements is inspected at a
follow-up visit. In Styria and Ireland, all schools had (in 2010) to develop an
improvement plan, even if they are not considered to be failing. This plan serves as
a target agreement between the principal and the inspector, and school inspectors
check on the implementation of these targets after 1 or 2 years. However, there are
no consequences in place for schools that fail to implement these targets. In the
Czech Republic, failing schools are monitored more frequently and are obliged to
implement corrections that have been identified by the Inspectorate.
Inspectorates of Education that use sanctions seem to work on the assumption
that schools will be more determined to learn and improve and to conform to inspec-
tion standards and react on inspection feedback if they have something to lose when
failing. Low stakes systems on the other hand assume that ‘insight’ of schools
(Böttger-Beer and Koch 2008, 254) into the goals and developmental options pre-
sented by inspections is an essential impulse for improvement and that ‘trust’ within
the school and with its constituencies is a core resource of improvement (Bryk and
Schneider 2002; Elstad et al. 2012).

1.2.3 Reporting: Inspection Systems with/Without Public

Reporting

A third element of inspection systems is about their reporting of inspection findings

to schools and the general public. Many Inspectorates, such as those in the
Netherlands, England, Sweden and Ireland publish inspection reports on the
8 M.C.M. Ehren

internet in which the functioning of individual schools according to the inspection

standards is described and areas of improvement are identified. The Netherlands
also publish (in addition to reports on individual schools) lists of failing schools and
summaries of the inspection assessments of all schools. Such reports are not pub-
licly available in Austria and the Czech Republic. In Austria, head teachers have the
duty to “demonstrably inform school partners” (parents, students and teachers) and
the school maintaining body (mostly communities) about the inspection results.
Inspectors do not usually check whether or not the inspection report was on the
agenda of a parent–teacher meeting, however they would do so if the problems
persisted or parents complained. In the Czech Republic, reports of thematic school
inspections (e.g. summarizing annual results of all the schools) are available, but
reports of individual schools are not publicised.

1.3 Inspections in the Broader Context of Monitoring

School inspections are often only one component, albeit an important one, of a more
general accountability and monitoring system that includes other devices such as
national testing and examination systems; the establishment of a national curricu-
lum framework; the system of teacher pre-service and in-service training etc. It is
through a combination of all these mechanisms that governments at national,
regional or local levels can influence what is going on in schools and make sure that
standards of quality are being kept within their education systems. From a policy
point of view, a discussion about school inspections cannot take place in isolation,
but must rather be situated within the perspective of improving the education quality
monitoring system as a whole. Such a holistic perspective is crucial, according to
De Grauwe (2007c) in ensuring that the different mechanisms of evaluation, moni-
toring and inspection of schools form a coherent entity that is explicitly directed at
improving pedagogical practices in the classroom. Coherence across education sys-
tems is important, according to Looney (2011) as the cost, in terms of money, time
and lost opportunities, is potentially enormous if systems are not well aligned.
Education and inspection systems that have different aims and include different
reforms and evaluation frameworks may create a thick web of overlapping, path-
dependent, layered relationships that pose inconsistent and conflicting demands on
schools. Ehren and Hatch (2013) for example describe how such misalignment may
occur when education systems are decentralized and newer accountability arrange-
ments on the local level (e.g. city or district) are added to centralized demands
already in place (e.g. at the national or state level). An example they give refers to
the United States where the national accountability requirements of the No Child
Left Behind (NCLB) Act of 2001 have been added on to many local state systems,
resulting in mixed messages regarding the performance of schools (Linn 2005). In
some of these cases, such as in New York City where schools face both a system
based on NCLB and a city system that uses a school grading system, schools may
fare well under one accountability system but poorly under the other (Pallas and
Jennings 2009).
1 Introducing School Inspections 9

Conflicts may also be created when traditional accountability systems, particu-

larly those that focus on ensuring compliance with rules and procedures, are com-
plemented with newer measures of student performance. Additionally, conflicts can
arise when schools face accountability demands from different authorities, such as
national and local governments. Under conditions where goals of education reforms,
and monitoring and inspection systems are in conflict, or are unclear or ambiguous,
schools may respond defensively or may seek out the most expedient or obviously
acceptable position, preventing them from learning and trying out new solutions.
A holistic perspective to ensure alignment in monitoring systems and practices
requires a careful analysis of both what exists in terms of evaluating practices and
available data in the system (e.g. availability of national standardized student
achievement tests), the capacity of school staff and other stakeholders to evaluate
school quality (e.g. evaluation literacy and expertise of school staff to engage in
rigorous evaluations), as well as the values and developmental objectives a country
would like to promote when implementing monitoring systems. Relevant questions
to ask are about the aspects of school quality a country wishes to promote or improve
(e.g. achievement in maths or literacy, or twenty-first century skills), the relative
importance to be given to external evaluation and inspections versus internal,
school-based evaluation. What will be the distribution of roles between the two?
What is the relative emphasis to be placed on control and support activities? What
type of school-based evaluation will be adopted? What will be the respective roles
played by the principal, the teachers, the parents and the local community represen-
tatives? To what extent will standardized testing and examinations be introduced?
How will the results be used for quality monitoring purposes?
The answers to these questions are not simply technical, but each of them cor-
responds to a theoretical if not ideological position on who is in charge of the evalu-
ation of school quality, and what such evaluations should address and assess.
Inspection systems have traditionally been designed as an element of a broader
monitoring system intended to evaluate schools on behalf of the education adminis-
tration. Their focus was often on school inputs and safeguarding the legitimate use
of public resources. The last two decades have however also seen Inspectorates of
Education develop frameworks to evaluate instructional processes, while the expan-
sion of national standardized student achievement tests have allowed them to assess
school results. Furthermore, the introduction of the internet and the wide accessibil-
ity of inspection reports have allowed other actors, such as teachers, parents and the
general public to use inspection reports and assessments in their monitoring of
schools, shifting the dominant role of central government in monitoring of schools
to more local levels.
These shifts have often been part of conscious attempts to reform and improve
education systems, aiming to devolve responsibilities of control and support to
actors at the school-site level (principals, teachers, community members or even
students) and increasingly relying on internal mechanisms of quality assurance,
self-evaluations and peer reviews. These practices are supposed to complement if
not, in certain radical cases, to replace external inspection and monitoring services.
In many countries the position of Inspectorates of Education within the education
10 M.C.M. Ehren

and monitoring system and the types of inspection methods, frameworks and report-
ing they use has changed steadily over the years.
An OECD report from 1995 on school evaluation practices in seven different
member countries – England, France, Germany, New Zealand, Spain, Sweden and
the United States – for example showed how many countries were undergoing radi-
cal reforms of their school systems and overhauling or restructuring accountability
mechanisms such as inspection. Reform programmes often included a stronger
voice for the user, more choice and competition and devolution of management
responsibility to schools. Increased autonomy for individual schools often went
hand in hand with the setting of targets and objectives, and some system of inspect-
ing or monitoring to check how far they have been reached.
The more recent OECD report on ‘synergies for better learning; an International
Perspective on evaluation and assessment’ (2013) shows how such policies are still
dominant in 2013 but have sparked an increasing focus on a need to maximise the
benefits of external school evaluation activities, and minimising the potential bur-
den of these activities on schools. The report suggests that there is more emphasis
placed on outcomes and impact, coupled with robust self-evaluation and a reduced,
more proportionate approach to external supervision in the 28 OECD countries that
were part of the review. These shifts are, according to the OECD, fundamentally
linked to a concern to make more effective use of the resources available for exter-
nal evaluation and particularly school inspections.
Despite these changes there seems to be a remarkable consistency in the underly-
ing goals of school inspections. De Grauwe (2007a, p. 709) for example writes that
in Africa, there is a striking lack of fundamental change in the mission and organisa-
tion of supervision services, since their creation in the nineteenth century. Even the
end of colonisation did not lead to a redefining of school inspections in these coun-
tries, according to the De Grauwe. Similarly, the OECD in 2013 reports of two
major purposes of school evaluation: development and accountability, which can be
found in varying degrees across a large number of countries. The underlying pur-
pose of an inspection system only seem to change, according to De Grauwe (2007a),
during grave political crises or revolutions, such as the end of the apartheid regime
in South Africa. The next session will take a closer look at these two types of goals
and potential conflicts that may arise when inspection systems try to combine the
two goals.

1.4 Goals and Functions of School Inspections

Many inspection systems distinguish between control and accountability versus

development and improvement goals of inspections, where control and accountabil-
ity is primarily about checking schools’ compliance to legislation and improvement
often involves a wider evaluation of the schools’ functioning and interventions to
support their functioning and build their capacity to improve (Donaldson 2013).
1 Introducing School Inspections 11

1.4.1 Control

The control function relates, according to De Grauwe (2007b) to the original mean-
ing of the word ‘inspection’ and is at the heart of compliance monitoring. In many
countries, control is considered to be the essential function of school inspectors and
focuses on checking statutory requirements, regulations and duties. According to
De Grauwe (2007d) and the OECD (2013), control and school accountability typi-
cally includes information on how the school complies with national standards and
regulations, but can also cover pedagogical as well as administrative inputs and
processes, such as control of human resource inputs (number of teachers, teacher-
student ratios), as well as material inputs. Inspections of material inputs is often a
core task of school inspections in developing countries where the school infrastruc-
ture has deteriorated so much that inspection of material inputs is taking precedence
over inspection of human inputs.

1.4.2 Improvement

Quality improvement has only become an important goal of school inspections

since the 1990s. Rosenkvist (2010) describes how broad reforms to the system of
schooling instituted in many countries saw accountability used as a means of qual-
ity improvement and decision making around resources, bringing increased focus to
accountability as a mechanism for not only defining standards and monitoring indi-
viduals, schools and school systems against those standards, but also as a lever for
efficient resource allocation, positive change and capacity building within each
organisation and across the system of education as a whole.
Improvement and support for school development typically includes an evalua-
tion of the quality of the school, identifying strengths and areas for school develop-
ment with the aim to improve teaching and learning within schools, to close
achievement gaps between schools and to enhance the performance of all students.
This would, according to the OECD (2013) necessitate a robust evaluation of the
processes and strategies associated with student learning to identify the areas the
school needs to prove, while also assessing the school’s capacity to implement such
improvements. The inspection feedback to the school on strengths and weaknesses
and suggestions on how to improve these weaknesses play an important role in
building such capacity and ensuring that schools improve student learning.
Support often takes the form of advice to teachers and headteachers during
inspection visits, but some countries also put into place other arrangements such as
individual tutoring, demonstration of lessons, in-service training programmes and
organisation of peer learning. Many inspectorates of Education also publish and
actively disseminate examples of good practice to support school improvement.
Improvement of schools is nowadays the primary mandate of almost all
Inspectorates of Education, but how they promote such improvement and the type
12 M.C.M. Ehren

of improvement they support differs substantially across systems as can be seen

from Ehren et al.’s (2013) summary of the main aims Inspectorates of Education in
six European countries set out to achieve in 2010:
• The Irish Inspectorate for example identifies very broad objectives, such as con-
tributing to self-evaluation, to school development and to the improvement of
the education system.
• The Swedish Inspectorate of Education aims to ensure the right of all students to
a good education in a safe environment. It expects to improve inspected schools
and to contribute to the improvement of the whole education system.
• The goal of the Styrian school inspections in Austria is also very broadly
described as supporting schools to constantly improve their quality and to pro-
mote the educational effectiveness and quality of the individual school, to ensure
legal and administrative compliance and equivalence and comparability of vari-
ous educational provisions within the system.
• The expected effects of the Dutch Inspectorate are more specifically described as
improvement of schools towards good education, where the standards in the
inspection framework are used to detail ‘good education’.
• Ofsted (the English Inspectorate of Education) emphasizes promoting improve-
ment of schools as well as ensuring services are user-focused and provide value
for money. School inspections should also encourage improvement of the educa-
tion system as a whole.

1.4.3 Liaison

Control and support and regular school visits often inform a third ‘liaison’ function
of Inspectorates of Education, according to De Grauwe (2007a). In this function,
Inspectorates of Education act as a liaison agent between the top of the education
system (where norms and rules are set) and the schools (where education is shaped
and takes place). Inspectors act as go-between agents in having a task to inform
schools of decisions taken by the centre, and to inform the centre of the realities at
school level. The annual and thematic reports, published by many Inspectorates of
Education, are a clear example of the liaison role of inspections. These reports pro-
vide a summary of aggregated school inspection assessments, sometimes on spe-
cific policy relevant themes, and allow national governments to monitor the
performance of the education system and adjust their policy to improve system
performance.
The liaison role of Inspectorates of Education can also include establishing good
linkages with other services involved in quality development of schools such as
pre- and in-service teacher training, curriculum development, preparation of
national tests and examination and identifying and spreading new ideas and good
practices between schools. This role becomes increasingly important when school
1 Introducing School Inspections 13

systems are decentralized and accountability shifts from vertical top down
approaches to more decentralized structures. Chapter 7 of this book will present
examples of the roles Inspectorates of Education may fulfil in such devolved
systems.

1.4.4 Conflicting Goals and Functions of School Inspections

Many Inspectorates of Education are tasked with achieving all three goals. Gaertner
et al. (2014) for example describe how school inspections may not only be used for
the purpose of traditional school accountability and control, but also for the purpose
of school development and gaining knowledge within a complex network of educa-
tional discourse. Particularly the combination of control and improvement may lead
to tensions as described by De Grauwe (2007b, p. 10). This is, according to De
Grauwe (2007a), not a recent issue; since the inception of the first inspectors, school
inspectors have been asked to control and to assist. Many studies saw this tension as
a fundamental weakness, and it remains an unresolved point in many countries from
different regions of the world.
This conflict of roles is particularly a concern in countries were both tasks are
carried out by the same person. School inspectors in these countries often feel that
a combination of both tasks hampers their professionalism in providing objective,
valid and reliable assessments of the quality of schools and/or teachers as they are
(in subsequent visits) inspecting the results (and quality of) their own advice to the
schools. Similar conflicts arise when designing inspection frameworks that need to
cater for both functions. As De Grauwe (2007a) explains, inspection frameworks
used to control schools and hold them accountable require standardized procedures
to evaluate and control schools in a transparent and comparable manner, while a
development and support function requires tailor-made services and frameworks to
support school-specific improvement.
The widespread trend towards more democracy and the call for more participa-
tion and for greater school autonomy has, according to De Grauwe (2007a) increased
the criticism of the combination of the controlling and support function, which goes
against the spirit of initiative expected of autonomous schools and teachers.
Autonomous schools are expected to shape their teaching and school organisational
practices to fit local context and needs and require and demand specific inspection
and support services which fit this specific context.
Various countries aim to solve some of these tensions by separating the control
and support function and tasking specific staff in charge of support such as peda-
gogical advisors or resource persons. A sharp focus on control in school inspections
has in many countries however also led to a deterioration in relationships between
school inspectors and teachers and headteachers/principals which would lead one to
argue against such a split in roles.
14 M.C.M. Ehren

1.5 Structure of the Book

The remainder of this book aims to provide an overview of what we know so far
about effective school inspections. The book is organized in three parts: Part I
‘understanding school inspection frameworks’, Part II ‘the current evidence base of
school inspections’ and Part III ‘Conclusion’.
Part I comprises Chaps. 2 and 3 in which we use school effectiveness research
and research on validity of assessments to conceptualize school inspection frame-
works and understand the features of ‘high quality’ inspection frameworks.
Chapter 2 takes a close look at inspection systems that aim to improve school qual-
ity, using the school effectiveness research to understand how inspection frame-
works and standards can measure and evaluate different aspects of quality. The
school effectiveness research has often been used to validate inspection frameworks
and protocols. The third chapter will therefore explain how Kane’s (2013) notion of
an ‘interpretation/use’ argument and the five sources of evidence described in the
Standards for Educational and Psychological Testing (AERA and NCME, 2014)
can be used to validate inspection systems. Chapter 3 will also present examples of
validation research of different inspection systems to explain what a validation
exercise may include. The presented validity framework provides a theoretical syn-
thesis that can serve as a valuable foundation for the elaboration of robust inspec-
tion frameworks for Inspectorates wanting to improve their frameworks, or countries
which aim to develop such frameworks.
In Part II we will present the current empirical base of what we know about
effectiveness of school inspections. In three chapters we will present the findings
from a systematic literature review on both positive effects of school inspections
(e.g. school improvement and improved student achievement, Chap. 4), as well as
unintended consequences (e.g. narrowing teaching approaches, gaming inspec-
tions, Chap. 5). As several countries have contrasting models and experiences of
impact of inspections, we will also discuss the mechanisms of change from school
inspections in Chap. 6, which will allow us to understand how and under which
conditions, school inspections cause improvement or strategic responses. The
three chapters provide a coherent and comprehensive overview of inspection sys-
tems in many different national systems, but also of many different models and
traditions of school inspection. The mechanisms of change in Chap. 6 allow us to
understand how school inspections can improve the effectiveness of schools, but
can equally also have detrimental effects to the quality of teaching and learning in
schools.
Part III, Chap. 7 of this book, will then discuss some of the changes in the roles
and responsibilities that have emerged over the last couple of years and present
some newer models of school inspections which have emerged over the last few
years. We will focus on one trend, the shift of inspections from single schools to
networks, offering a view of possible futures of school inspection through a broad-
ened focus on network structures and implications for the system of education.
1 Introducing School Inspections 15

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d06ae4af5954. Accessed 20 Oct 2014.
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 Part I
Understanding School Inspection
Frameworks
Chapter 2
The Evidence Base for School Inspection
Frameworks

Jaap Scheerens and Melanie C.M. Ehren

Abstract This chapter describes how Inspectorates of Education operationalize

different inspection goals (control, improvement, and liaison) in their inspection
indicator frameworks. The chapter provides an overview and examples of the indi-
cators used across a number of countries and how these are incorporated in inspec-
tion frameworks to evaluate and assess schools with the purpose of control,
improvement and liaison. We elaborate on potential inspection frameworks to
inspect and assess the processes and results of schooling (which includes making
expert judgements and –value added- models to evaluate school output), and discuss
their value and adequateness in the light of recent school effectiveness research.
Evaluating the value and adequateness of inspection frameworks and measures is an
important condition of valid inspections; a topic we will talk about in more detail in
the Chap. 3.

2.1 Introduction

In Chap. 1 we discussed different functions and purposes of school inspections,

which included the control, support and liaison with teachers, schools and the edu-
cation system. In this chapter we will discuss the types of standards in inspection
frameworks that would correspond to each of the three functions and suggest how
the school effectiveness research can inform such frameworks.

J. Scheerens
Faculteit der Gedragswetenschappen (GW) Afdeling OMD, Universiteit Twente,
Postbus 217, 7500 AE Enschede, The Netherlands
e-mail: j.scheerens@utwente.nl
M.C.M. Ehren (*)
Reader in Educational Accountability and Improvement,
UCL Institute of Education, University College London,
20 Bedford Way, London WC1H 0AL, UK
e-mail: m.ehren@ucl.ac.uk

© Springer International Publishing Switzerland 2016 19

M.C.M. Ehren (ed.), Methods and Modalities of Effective School Inspections,
Accountability and Educational Improvement,
DOI 10.1007/978-3-319-31003-9_2
20 J. Scheerens and M.C.M. Ehren

2.1.1 Control of Input, Rules and Regulations

De Grauwe (2007) and Eddy Spicer et al. (2014) describe how inspection systems
can emphasize school inputs, such as the number of text books per pupil, teacher
qualifications, number of pupils per class, etc. Such systems are particularly about
controlling compliance as its first goal is to make sure that schools comply with
predetermined norms fixed by law and administrative rules and regulations, such as
the availability and use of procedures, policies and protocols concerning for exam-
ple, admission policies or safety regulations and increasingly the satisfactory com-
pletion of school self-evaluation documents. Examples are the Swedish Inspectorate
of Education checking the extent to which schools provide equal access to educa-
tion for all students, and the Dutch and Irish Inspectorate of Education checking
whether schools schedule and offer a minimum number of lesson hours (Ehren et al.
2013). According to De Grauwe (2007), this type of control is the oldest bureau-
cratic type of monitoring: checking that rules and regulations are respected. The
classic inspectorate system combined with several forms of administrative self-
reporting by schools (filling out forms) is the main device on which this type of
control relies.

2.1.2 Evaluation and Support of Educational Processes

Inspectorates of Education who aim to support and monitor school improvement

will focus on the evaluation of educational processes in the school, as well as the
school’s output. Educational processes include the quality of the teaching in the
school, the classroom-level interactions amongst teacher-students-curriculum and
the ‘administrative’ organizing processes of the school. These processes have
become an increasingly more important part of inspection frameworks as there is a
general consensus that process variables are more important than input variables in
explaining differences in school quality, and information about school quality is
needed to improve the quality of schools. This is particularly the case in high income
countries where there is little variation in school inputs (see Hanushek 1986).
An overview of Van Bruggen (2010) for example shows how 18 European
Inspectorates of Education have indicators and criteria on ‘the organisation and
management in the school’, and ‘the teaching and learning’ in their frameworks to
ensure a national perspective on quality education and to evaluate schools against a
common set of criteria representing a national perspective on quality education.
Many of these frameworks are inspired by school effectiveness research according
to Ehren et al. (2013). Ehren et al.’s (2013) comparative study of inspection frame-
works in six European countries indicates a strong focus on educational processes
such as opportunity to learn and learning time, achievement orientation, clear and
Another random document with
no related content on Scribd:
Hysterical contracture, like hysterical paralysis, may assume a
variety of forms: it may be hemiplegic, monoplegic, paraplegic,
alternating, or local, as of the ocular muscles, the facial or neck
muscles; laryngeal, pharyngeal, or œsophageal; of the fingers or of
the toes.

Richardson81 records the case of a young lady who saw in India a

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

Some of the most remarkable cases of hysterical contracture are

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

Many forms of hysterical local spasms occur. Hysterical strabismus

from spasm of the ocular muscles has been observed. Several
cases have come under observation in which hysterical
blepharospasm was present. In these cases, when the lids are
forced open, the eyes disappeared in an extraordinary manner,
usually being drawn downward and toward the internal canthus.
Hysterical facial spasm occurs, and is usually clonic. One of the
most remarkable hysterical local spasmodic affections which has
come under personal observation was reported by me in a paper on
chorea.83 In this case the right ear twitched and moved up and down.
The movement of the ear was peculiar; it continued nearly all the
time, even when the patient's attention was not directed toward the
part. The act seemed to be partially under the control of the will, as
by a strong effort the left ear could be moved very slowly in the same
up-and-down direction. The nostrils and upper lip were affected with
twitching, and slight choreic movements were present in the entire
right side of the body. The patient's general condition improved
under treatment, but when last seen the local affection persisted,
although it was not so severe.
83 Philada. Med. Times, March 27, 1875.

Spasm of the pharynx, larynx, and œsophagus have been separated

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

Hysterical dysphagia, which is usually spasmodic, is sometimes a

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

Of the so-called hysterical asthma or hysterical breathing I have

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

Coates,84 speaking of hysterical or nervous breathing, gives the

details of five cases. Four of these had been supposed to be
suffering from phthisis; the fifth was apparently a case of hypertrophy
of the heart. The breathing was quick and shallow. The patients
could not be induced to draw long breaths until the expedient was
adopted of having them count twenty without taking breath. During
this the lungs expanded perfectly, air entering freely into every part.
Coughing, and even blood-spitting of a venous character, were
present. They might perhaps be classed as cases of hysterical or
simulated phthisis.
84 British Medical Journal, 1884, ii. 13.

Vaginismus, or spasm of the vagina, may with propriety be regarded

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

The sensorial affections of hysteria can be classified according either

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

Anæsthesia is one of the most frequent of hysterical phenomena, but

is not, as stated by some authorities, present in all cases of genuine
hysteria.

In 400 hysterical cases Briquet found 240 positive examples of

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

Hysterical anæsthesia, may be of various forms, according to the

parts of the body affected, as general anæsthesia; hemianæsthesia;
anæsthesia of the lower half of the body; anæsthesia of one limb or
one side of the face; anæsthesia of mucous membranes;
anæsthesia of muscles, bones, and joints; anæsthesia of the
viscera.

General anæsthesia is extremely rare. No example of it has ever

fallen under my observation, but by Briquet and others a few cases
have been reported.

Hemianæsthesia has in recent years received much attention from

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

Much attention has been paid to the study of hemianæsthesia by

French physicians. Charcot85 has an admirable historical summary
and clinical description of the condition, leaving little for others to
add. Piorry, Macario, Gendrin, Szokalsky, and Briquet are referred to
by him. Briquet found it present in 93 cases out of 400. It is of much
more frequent occurrence on the left side. According to Briquet, 70
cases were affected on the left side to 20 on the right.
85 Op. cit.
Next to hemianæsthesia, anæsthesia of the lower half of the body is
most common in hysterical cases. While hemianæsthesia often
presents itself conjoined with hystero-epileptic symptoms,
anæsthesia of the lower half of the body may be present as
frequently without as with convulsive manifestations. Anæsthesia of
one limb or of one side of the face is almost as rare as general
anæsthesia, but does occur.

Anæsthesia of mucous membrane is an old observation. It may

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

A striking characteristic of hysteroid sensory disorders of the

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

The term achromatopsia is due to Galezowski. Hysterical

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

Hysterical blindness and achromatopsia have been well studied by

Charcot and Richer and others of the French school. Special articles
on hysterical or simulated affections of the eye have also been
published by Schweigger,86 Harlan,87 and others.
86 “On Simulated Amaurosis,” by C. Schweigger, Prof. at the University of Berlin, New
York Medical Journal, Feb., 1866.

87 “Simulated Amaurosis,” by George C. Harlan, M.D., American Journal of Medical

Sciences, October, 1873; “Hysterical Affections of the Eye,” Transactions of the
College of Physicians of Philadelphia, 3d Series, vol. ii., 1876.

In several cases of hystero-epilepsy under my care both amblyopia

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

C. H. Thomas of Philadelphia has given me the particulars of a case

of a woman about thirty-eight years old, both of whose eyes were, to
all appearances, absolutely blind. The attack came on suddenly, the
apparent cause seeming to be worry over a sick child.
Ophthalmoscopic and other examinations of the eye showed
nothing. She had no perception of light. She could look without
winking at a blinding reflection of a whitewashed fence. In six weeks
under a mere tentative treatment she got absolutely well. S. D.
Risley of Philadelphia,88 in a discussion at the Philadelphia
Neurological Society, held that the feeble innervation of the
hysterical patient was liable to diminish the range of accommodation
and power of convergence, rendering the comfortable use of the eye
impossible; and also that the feeble or deranged circulation in the
hysterical individual might set up a group of symptoms in the eye
presenting many of the characteristics of serious disease; which,
however, were not simulated, but were, in fact, a relative glaucoma.
While there was no absolute increase of intraocular tension, the
normal tension of the eyeball was sufficient to interrupt the entrance
of the feeble blood-stream into the eyes, and thus was set up the
same group of symptoms as were present in actual increase of
tension—viz. inadequate blood-supply to the retina, contracted field
of vision, impaired central perception, diminished range of
accommodation, and inability to use the eyes, particularly at a near
point.
88 The Polyclinic, vol. ii., No. 8, Feb. 15, 1885, p. 124.

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

What might be termed hysterical dilatation of the pupil is sometimes

observed. In the case reported by Harlan, to be hereafter detailed,
the patient, a young girl who had a train of hysterical symptoms,
began to complain of blindness or imperfect vision in the right eye,
the pupil of which was found to be dilated. No proof could be
obtained of the use of any mydriatic. The pupil remained dilated
when exposed to a bright light. The dilatation came and went at
intervals, and finally disappeared under the applications of a wooden
magnet. W. Chester Roy has acquainted me with the facts of the
case of a man who could at will alternately contract and dilate his
pupils. This case would seem to lend color to the idea that the
hysterical girl may have had voluntary control of the pupillary
movements. In her case, however, only one pupil was involved. F. X.
Dercum has given me the particulars of a case of rhythmical
dilatation of the irides in a case of confirmed masturbation with
hysterical symptoms.
Hysterical deafness has been observed and studied. Walton,89 at
Charcot's suggestion, has published the results of the examination at
La Salpêtrière of 13 patients affected with hemianæsthesia with
reference to anæsthesia of hearing. He divides hemianæsthetic
patients into three classes: (1) Those with complete anæsthesia of
one side, the other side remaining normal; (2) those having
incomplete anæsthesia on one side, the other remaining normal; (3)
those with anæsthesia more or less complete on both sides. In the
first class anæsthesia of hearing extended to the deep parts of the
ear; the membrane of the drum could be touched without eliciting
any acknowledgment of sensation and without the least reflex
movement. He also showed that the anæsthesia extended to the
middle ear by the fact that insufflation by Politzer's air-douche
produced no sensation in the ear of the affected side. In this class
neither the watch, voice, nor tuning-fork was heard. In the second
class, with incomplete anæsthesia on one side, the lost sensibility
corresponded, as a rule, with that of the body in general. A common
form was analgesia with thermoanæsthesia and diminution of the
tactile sensibility. In the third class completeness of the anæsthesia
is rarely the same on both sides, a common form being complete
hemianæsthesia on one side and analgesia on the other.
89 Brain, January, 1883.

A noticeable feature in all the cases under consideration was the

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

The following case has been kindly furnished to me by Charles S.

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

By hysterical paræsthesia is meant that form of perverted sensation

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

Hyperæsthesia may present itself in almost any locality, its areas of

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

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

In one group of hysterias the presence of pain is the predominating

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

Charles Fayette Taylor, in a brochure on sensation and pain,90 has

given a philosophical explanation of such pain, drawing largely from
Carpenter, Bain, Spencer, and others. The pith of the matter is that
many of our sensations are centrally initiated, the memory of
previous objective sensations. “Pain is different from ordinary
sensations, in that it requires an abnormal condition for its
production, and that it cannot be produced without that abnormal
condition. Hence it is impossible to remember pain, because the
apparatus does not exist for causing such a sensation as pain after
the fact or when it is to be remembered. Memory is a repetition, in
the nerve-centre, of energy which was first caused by the sensory
impulse from without. But centrally initiated sensations may be
mistaken, in consciousness, for pains depending wholly on a certain
intensity of excitability in the cerebral mass.”
90 Sensation and Pain, by Charles Fayette Taylor, M.D.—a lecture delivered before
the New York Academy of Sciences, March 21, 1881.

A large percentage of all cases of hysteria complain more or less of

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

Painful diseases of the joints, especially in women, are not

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

Paget—and his experience accords with that of others—makes the

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

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

In hysterical women the pulse is apt to be rapid, even sometimes

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

The high temperatures which have been observed in many cases of

hysteria have been due to some form of shrewd fraud; but Briand91
maintains with Gubler, Rigel, Dieulafoy, and others that the term
hysterical fever is correct, and he describes three forms of the fever:
(1) The slow continued fever of Briquet, characterized sometimes by
simple acceleration of the pulse, without elevation of temperature;
sometimes by a temperature rise, either with or without phenomena
or accompanied by headache, thirst, and other symptoms; (2) a
shorter form, always the result of a more or less active disturbance
of the nervous system by terror, fear, chagrin, and like causes; (3) a
form with intermittent febrile phenomena. Examples of the different
forms are given. Debove92 supports the view of the entity of the
hysterical fever, citing cases—one a woman twenty-four years old
who had, at intervals, marked fever, the temperature sometimes
reaching 1021/5° to 104° F. Malaria and tuberculosis were excluded.
Sulphate of quinia had no influence upon her attacks, but antipyrine
reduced the temperature and her general condition improved.
Debove has observed the temperature to rise from 1° to 2° F. by
mere suggestion when the patient was in a somnambulistic state.
91 Gazette hébdomadaire, quoted in Med. News, Dec. 1, 1883.

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

On the other hand, it has been claimed that a true hysterical fever
never occurs or is extremely rare. Admitting this view, several
explanations may be given of the rise of temperature observed. It
may be due to intercurrent affections, as typhoid or intermittent fever,
or some local inflammatory disorder. It may be secondary fever, the
result of muscular effort or some similar cause. Lastly, and most
probably, it may be due to ingenious fraud, as to friction of the bulb,
pressure, or tapping with the finger, dipping the instrument into hot
water, connivance with the nurse, etc. Du Castel93 has reported a
trick of this kind. An hysterical girl, convalescent from an attack of
sore throat, displayed remarkable alternations of temperature. One
day the thermometer reached 163.4° F.! By carefully watching the
patient it was found she had learned the trick of lightly tapping the
end of the thermometer, which caused the mercury to ascend as far
as she wished. In the case of chronic hysterical insanity of which the
details have been given the temperature in the axilla on several
occasions reached 102°, 103°, and even 105° F.
93 Revue de Thérapeutique méd.-chir., No. xi., 1884.

Extreme states of pallor or blushing, sometimes in the extremities

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

Mitchell94 has put on record three cases of hysteria in which was

present unilateral increase in bulk at or near the menstrual period,
and also at other seasons after emotional excitement. He does not
give any opinion as to its nature, but believes that it is not a mere
increase of areolar serum, and that it does not appear to resemble
the vasal paralysis in which the leg throbs and exhibits a rise in
temperature and tint. He is unable also to identify it with any form of
lymph œdema which it resembles, for in this disorder there is more
obvious œdema, and it is also quite permanent. Whatever the cause
of the swelling, he believes that it is under the influence of the
nervous system, and that it varies with the causes which produce
analgesia or spasm. I have seen swelling of this kind in several
cases, and have probably overlooked it in others. In one of my
reported cases of hystero-epilepsy it was a very marked symptom,
coming and going, increasing and diminishing, with other symptoms.
94 American Journal of the Medical Sciences, New Series, vol. lxxxviii., July, 1884, p.
94.

Buzzard calls attention to the fact that in many cases belonging to

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

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

Disturbance of the secretion of the urine is among the most frequent

of the minor hysterical troubles, and has often been noted by writers
upon this subject since a very early date. Sydenham95 says that of
the “symptoms accompanying this disease, the most peculiar and
general one is the making great quantities of urine as clear as rock-
water, which upon diligent inquiry I find to be the distinguishing sign
of those disorders which we call hypochondriac in men and hysteric
in women. And I have sometimes observed in men that soon after
having made urine of an amber color, being suddenly seized with
some disturbance of mind, they made a large quantity of clear water,
with a continued violent stream, and remained indisposed till the
urine came to its former color, when the fit went off.” This symptom
shows itself as strikingly in the hysteria of the present day as in the
age of Sydenham.
95 Op. cit.
A complete anuria or ischuria is one of the older observations in
hysteria. Laycock, Charcot, and many others have written at length
on this subject. Finch96 has published a curious case of complete
anuria. The patient had various hysterical symptoms, including
paroxysms with unconsciousness, contracture, also vomiting.
Micturition and defecation were entirely suspended (?) from Dec. 24,
1877, to Feb. 22d of the following year. During a period of fifty-eight
days paroxysms were frequent; but on using the catheter the bladder
was always found empty. The probability of hysterical fraud is very
great in this case. A few case of hysterical retention of the urine in
men have been reported.
96 Nice médicale.

Increase of the uterine and vaginal secretions is mentioned by Jolly

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

Hysterical vomiting of food sometimes persists for weeks; strangely

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

Two cases of simulated pregnancy by hysterical women have come

under my observation. Cases are reported also in which hysteria
simulated closely the process of natural labor, as one for instance,
by Hodges.97 A woman said to be in the fifth month of pregnancy
engaged him to attend her at term. Four months afterward he was
sent for, the patient having severe pains, supposing herself to be in
labor. On examination, however, a tumor present turned out to be the
bladder distended and prolapsed. Sparks98 reports the case of a
young married woman who had the symptoms of the third stage of
labor, the case being purely hysterical.
97 Lancet, 1859, ii. 619.

98 Chicago Med. Journ. and Examiner, 1880.

Walker99 reports a group of hysterical symptoms closely simulating

the prodromes of puerperal eclampsia. The patient, a married
woman only eighteen years old, when pregnant six months lifted a
tub of water, rupturing the membranes. In the eighth month, after she
had remained in bed three days, she began to complain of severe
headache; soon she said she was blind; the pupils of the eye were
neither dilated nor contracted, and responded sluggishly to light.
Ophthalmoscopic examination gave negative results, but she did not
flinch from the light of the mirror. Temperature, pulse, and respiration
were about normal. The urine contained no albumen. She recovered
her sight in twelve hours, and had no continuing trouble.
99 Arch. of Medicine, New York, 1883, x. 85-88.

Paget mentions cases of phantom tumor occurring in the calf, thigh,

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

Mitchell mentions certain peculiar symptoms quite common among

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

Sometimes hysterical women awake with numbness and tingling,

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

Under hysteria some of the affections, more common among men

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

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

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

A woman was badly pushed about while riding in a street-car by the

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

Finally, some hysterical cases present a succession of local

hysterical phenomena following each other more or less rapidly. One
symptom seems to take possession of the patient for the time being,