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lethargic state; sometimes with variable delusions and delirium;
occasionally violent and destructive, again peaceable and pleasant;
sometimes requiring strong anodynes and hypnotics. Fourteen
months after her paralytic condition began, one day she suddenly
threw away her crutches and ran up and down the corridor of the
hospital. From that time she walked without difficulty, although her
mental condition did not entirely clear.

I wish to impress the fact that because hysterical manifestations

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

The whole question of hysterical insanity is one of great difficulty.

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

Hysterical insanity may be conveniently subdivided into an acute and

chronic form.

Acute hysterical insanity or hysterical mania is a disorder usually, in

part at least, purposive, and characterized by great emotional
excitement, which shows itself in violent speech and movement, and
often also in deception, simulation, and dramatic behavior. The
phenomena indicated by this definition may constitute the entire
case, or, in addition, the patient may have, at intervals or in
alternation, various other phases of grave hysteria, such as hystero-
epileptic seizures or attacks of catalepsy, trance, or ecstasy.
In chronic hysterical insanity we have a persisting abnormal mental
condition, which may show itself in many ways, but chiefly as
follows: (1) A form in which occur frequent repetitions, over a series
of years, of the phenomena of acute hysterical insanity, such as
hysterical mania, hystero-epilepsy, catalepsy, etc.; (2) a form in
which sensational deceptions—sometimes undoubtedly self-
deceptions—are practised.

In a case of chronic hysterical insanity you may have both of these

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

One of her recent attacks of hysteria was preceded by a series of

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

Many of the extraordinary facts which fill the columns of the

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

A story comes from an inland town, for instance, of a respectable

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

Charcot and Bourneville give frequent instances of extraordinary

self-deceptions or delusions among hysterical patients. The story of
an English lady of rank, who reported that she was assaulted by
ruffians who attacked her in her own grounds and attempted to stab
her, the weapons being turned by her corsets, is probably an
example of this tendency. Investigation made by the police force
threw grave doubts upon the story.
Many of the manifestations classed as hysterical by medical writers
are simply downright frauds. The nature of others is doubtful. The
erratic secretion of urine, for example, has frequently engaged the
attention of writers on nervous diseases, and has awakened much
controversy. American hysterics are certainly fastidious about this
matter, as I have not yet met, in a considerable experience, with a
single example of paruria erratica. Charcot63 refers sarcastically to
an American physician who in 1828 gravely reported the case of a
woman passing half a gallon of urinous fluid through the ear in
twenty-four hours, at the same time spirting out a similar fluid by the
navel. He also alludes to the case of Josephine Roulier, who about
1810 attained great notoriety in France, but was discovered by Boyer
to be a fraud. This patient vomited matter containing urea, and
shortly after came a flow of urine from the navel, the ears, the eyes,
the nipples, and finally an evacuation of fecal matters from the
mouth.
63 Op. cit.

Hemorrhages from eyes, ears, nostrils, gums, stomach, bowels, etc.

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

Sir Thomas Watson tells of a young woman who made a hospital

surgeon believe that she had stone in the bladder; and Fagge, of a
patient who had been supposed to have hydatid in the liver, and who
produced a piece of the stomach of a rabbit or some other small
animal, which piece she declared she had vomited. A few hours later
she again sent for her medical man to remove from her vagina
another fragment of the same substance.
A case is reported by Lopez64 of spiders discharged from the eye of
an hysterical patient. He regarded the case as one of hysterical
monomania. Fragments of a dismembered spider were undoubtedly
from time to time removed from the eye of the patient. Lopez
believed that at first the fragments may have got into the eye
accidentally, but that afterward the patient, under the influence of a
morbid condition, introduced them from day to day. The total number
of spiders removed in fragments was between forty and fifty. Silvy65
relates a case in which a large number of pins and needles made
their exit from a patient. Other needle cases are given, and also
examples of insects and larvæ discharged from the human body. In
one case worms crawled out of the nose, ears, and other natural
openings; in another worms were found in active motion under the
conjunctiva; in a third a beetle was discharged from the bladder, and
several beetles were vomited by a boy.
64 American Journal of Medical Sciences, Philadelphia, 1843, N. S., 74-81.

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

Jolly66 records in a foot-note a case published in 1858, by I. Ch. Leitz

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

Hardaway67 reports a curious case with simulated eruptions. The

woman appeared to be in fear of syphilis contracted by washing the
clothes of a diseased infant. She had blebs irregularly distributed
upon the fingers and arm of the left side; these, the doctor
concluded, had been caused by the application of vitriol. He reports
another case in which a woman had an eruption on her left arm, and
the sores, instead of getting better under treatment, got worse. On
one visit he found needle-scratches on the old sore. Nitric acid,
according to Hardaway, is a favorite substance for the production of
such eruptions. The best diagnostic test is that the blister is linear,
while in pemphigus it is circular, unlike that which would be produced
by a running fluid. Hysterical women have irritated their breasts with
cantharides. Niemeyer68 mentions a woman at Krutsenberg's clinic
who irritated her arm in such a way that amputation became
necessary, and after that she irritated the stump until a second
amputation had to be performed.
67 St. Louis Courier of Medicine, 1884, xi. 352.

68 Textbook of Practical Medicine.

Nymphomania is a form of mental disorder which sometimes occurs

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

Nymphomaniacs may be intelligent and educated, and if so they

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

Nymphomania and what alienists call erotomania are sometimes not

differentiated in practice and in books. They are, however, really
different conditions. Erotomania and nymphomania may be
associated in the same case, but it is more likely that erotomania will
not be present in a case of nymphomania. Erotomania may exist as
a special symptom or it may be one of the evidences of monomania.
It is found in both men and women. Patients with this condition may
have no sexual feeling whatever. The individual has some real or
imaginary person to love. It is rather the emotion of love which is
affected, not the sexual appetite. It is shown by watching or following
the footsteps of the individual, by writing letters, and by seeking
interviews. In the history of Guiteau an incident of this kind is
mentioned by Beard.69 He followed a lady in New York whom he
supposed to be the daughter of a millionaire—followed her, watched
her house and carriage, and wrote letters to her. Out West he
showed the same sort of attentions to another lady. He went to the
house, but was kicked out. Many of the great singers have been
followed in this way.
69 Journal of Nervous and Mental Disease, vol. ix., No. 1, January, 1882.

Some time ago I examined a man condemned to be hanged and

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

Convulsions or general spasms are among the most prominent of

hysterical manifestations. Under such names as hysterical fits,
paroxysms, attacks, seizures, etc. they are described by all authors.
Their presence has sometimes been regarded as necessary in order
that the diagnosis of hysteria might be made; but this, as I have
already indicated, is an erroneous view.
Under hysterical attacks various conditions besides general
convulsions are discussed by writers on hysteria; for instance,
syncope, epileptiform convulsions, catalepsy, ecstasy,
somnambulism, coma, lethargy, and delirium. According to the plan
adopted in the present volume, catalepsy, ecstasy, somnambulism,
etc. will be considered in other articles, and therefore my remarks at
this point will be limited to hysterical general convulsions.

These convulsions differ widely as to severity, duration, frequency,

motor excitement, and states of volition and consciousness. Efforts
have been made to classify them. Carter70 describes three forms as
primary, secondary, and tertiary. In the primary form the attack is
involuntary and the product of violent emotion; in the secondary it is
reproduced by the association of ideas; and in the tertiary it is
deliberately shammed by the patient. Lloyd71 divides them into
voluntary and involuntary forms, and discusses the subject as
follows: “The voluntary or purposive convulsions are such as
emanate from the conscious mind itself. Here are the simulated or
foolish fits into which women sometimes throw themselves for the
purpose of exciting sympathy or making a scene. I am convinced
that a large number of hysteric fits are of this class: these are the
patients who are cured by the mention of a hot iron to the back or the
exhibition of an emetic. The involuntary forms of convulsion are more
important. They happen in more sensible persons, and some of them
are probably akin to starts, gestures, and other forcible or violent
expressions of passions or states of the mind. A person wrings the
hands, beats the breast, stamps upon the floor in an agony of grief
and apprehension, and if terror is added he trembles violently. It is
no great stretch of the imagination to suppose that great fear, anger,
or some kindred passion, acting upon the sensitive nervous
organization of a delicate woman or child, should throw them into a
convulsion. This, in fact, we know happens. Darwin72 believes that in
certain excited states of the brain so much nerve-force is liberated
that muscular action is almost inevitable. He instances the lashing of
a cat's tail as she watches her prey and the vibrations of the
serpent's tail when excited; also the case of an Australian native,
who, being terrified, threw his arms wildly over his head for no
apparent purpose. The excito-motor reflexes of the cord may
possibly take on true convulsive activity if released from the control
of the will, which, as already said, is apt to be weak or in abeyance
to this disease. Increased temperature is stated by Rosenthal to be
always present in the great fits of epilepsy and tetanus, but absent in
those of hysteria.”
70 On the Pathology and Treatment of Hysteria, London, 1853.

71 Op. cit.

72 Expression of Emotion, etc.

This subdivision of hysterical convulsions into voluntary and

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

Absolutely involuntary attacks with unconsciousness constitute what

are commonly called hystero-epileptic seizures, and will be
described under Hystero-epilepsy.

The voluntary, impelled, or induced hysterical fit may be ushered in

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

Hysterical paralysis, so far as extent and distribution are concerned,

may be of various forms, as (1) hysterical paralysis of the four
extremities; (2) hysterical hemiplegia; (3) hysterical monoplegia; (4)
hysterical alternating paralysis; (5) hysterical paraplegia; (6)
hysterical paralysis of special organs or parts, as of the vocal cords,
the œsophagus and pharynx, the diaphragm, the bowels, and the
bladder. Russell Reynolds73 has described certain cases closely
allied to, if not identical with, some forms of hysterical paralysis
under the head of paralysis dependent upon idea. These patients
have a fixed belief that they are paralyzed. The only point of
separation of such cases from hysterical paralysis is the absence of
other hysterical manifestations. Perhaps it would be better to regard
the condition either simply as hysterical paralysis or as a true
psychosis—an aboulomania or paralysis of the will. Such cases
often last for many years.
73 Brit. Med. Journ., 1869, pp. 378, 483.

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

Briquet reports 6 cases in which paralysis attacked the principal

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

Hysterical paralyses, no matter what the type, may come on in

various ways—suddenly, gradually, from moral causes or emotional
excitement, or from purely physical causes, as over-fatigue. They
may have almost any duration, from hours or days to months or
years, or even to a lifetime. They are frequently accompanied by
convulsive or emotional seizures. They may be of any degree of
severity, from the merest suspicion of paresis to the most profound
loss of power. Hysterically paralyzed muscles retain their electro-
contractility. Limbs which have become atrophied from disuse may
show a temporary lessening of response, but this is quantitative and
soon disappears. In rare cases, owing probably to the condition of
the skin, the response to electricity is not obtained until the current
has been applied for several minutes to the muscles.

Hysterical hemiplegia and monoplegia may simulate almost any type

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

Several cases of hysterical double ptosis have come under my

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

Hysterical hemi-palsy is more frequent on the left than in the right

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

When hemiplegia is of the alternating variety, the arm on one side

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

Hysterical paraplegia is one of the most important forms of hysterical

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

Paralysis or paresis of the vocal cords, with resulting aphonia, is a

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

The following case is of interest, not only because of the aphonia,

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

Hysterical paralyses of the pharynx and of the œsophagus have

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

Paralysis or paretic states of the stomach and intestines are not

uncommon among the hysterical, and produce tympanites, one of
the oldest symptoms of hysteria. Jolly asserts that this “sometimes
attains such a degree that the patients can be kept afloat in a bath
by means of the balloon-like distension of their bellies”! The loss of
power in the walls of the stomach and bowels is sometimes a
primary and sometimes a secondary condition. The abdominal
phantom tumors of hysterical women sometimes result from these
paralytic conditions. These abdominal tumors are among the most
curious of the phenomena of local hysteria. At one time two such
cases were in the women's nervous wards of the Philadelphia
Hospital. Both patients had been hysterical for years. In the first the
tumor occupied the middle portion of the abdomen, the greater
portion of its bulk more to the right of the median line. It was firm and
nearly spherical, and the patient complained of pain when it was
handled. She was etherized, and while under ether, and during the
time that she was vomiting from the effects of the anæsthetic, the
tumor disappeared, never to return. The other patient had a similar
tumor for three days, which disappeared after the etherization of the
first case.

Mitchell74 has recorded some interesting paretic and other hysterical

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

Hysterical locomotor ataxia, or hysterical motor ataxia, is an affection

less common than hysterical palsy, but by no means rare. Various
and diverse affections of motion are classed as hysterical ataxia by
different authors. Mitchell speaks of two forms independent of those
associated with vertigo. The first, that described by Briquet and
Laségue, seems to depend upon a loss of sensation in both skin and
muscles; the second often coexists with paralysis or paresis, and is
an affection in which the patient has or may have full feeling, and is
able to use the limbs more or less freely while lying down. As soon
as she leaves the recumbent position the ataxia is very evident. She
falls first to one side and then to the other. She “seems to be unable
to judge of the extent to which balance is lost, and also to determine
or evolve the amount of power needed to overcome the effect.”
Mitchell believes that this disorder is common in grave hysteria, and
is likely to be confounded with one of the forms of hysterical
alternating spasm, in which first the flexors and then the extensors
contract, the antagonistic muscles not acting in unison, and very
disorderly and eccentric movements being the result. I have reported
a case of hystero-epilepsy75 in which a spasmodic condition closely
simulated hysterical ataxia. The patient had various grave hysterical
symptoms, with epileptoid attacks. She became unable to walk, or
could only walk a few steps with the greatest difficulty, although she
could stand still quite well. On attempting to step either forward or
backward, her head, hips, shoulders, and trunk would jerk
spasmodically, and she would appear to give way at the knees. No
true paralysis or ataxia seemed to be present, but locomotion was
impossible, apparently because of irregular clonic spasms affecting
various parts of her body.
75 Journal of Nervous and Mental Disease, vol. ix., No. 4, October, 1882.

Mary Putnam Jacobi76 has reported a case occurring in an Irish

woman aged thirty-five years as one of hysterical locomotor ataxia. It
is questionable whether this case was not rather one of posterior
spinal sclerosis with associated hysterical symptoms. The existence
of pain resembling fulgurating pains, and especially the absence of
the patellar tendon reflex, would incline me to hesitate a long time
before accepting the diagnosis of hysteria, particularly as it is known
that organic locomotor ataxia often has a much-prolonged first stage,
and that wonderful temporary improvements sometimes take place.
76 Arch. of Medicine, New York, 1883, ix. 88-93.

Ataxic symptoms of a mild form are of frequent occurrence in

hysteria. They are shown by slight impairments of gait and difficulty
in performing with ease and precision many simple acts, as in
dressing, writing, eating, etc.

Hughes Bennett and Müller of Gratz call attention to the fact that
young women may exhibit all the signs of primary spastic paralysis,
simulating sclerosis, and yet recover.77 I have seen several of these
cases of hysterical spasmodic paralysis, and have found the
difficulties in diagnosis very great. These patients walk with a stiff
spastic or pseudo-spastic gait, and as, whether hysterical or not, the
knee-jerk is likely to be pronounced, their puzzling character can be
appreciated.
77 Quoted by Althaus: On Sclerosis of the Spinal Cord, by Julius Althaus, M.D., M. R.
C. P., etc., New York, 1885, p. 330.
In one class of cases, which cannot well be placed anywhere except
under hysteria, a sense or feeling of spasm exists, although none of
the objective evidences of spasmodic tabes can be detected.
Comparing these to those which Russell Reynolds describes as
paralysis dependent upon idea, they might be regarded as cases of
spasm dependent upon idea.

One case of this kind which was diagnosticated as lateral sclerosis

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

Certain special forms of chorea are particularly liable to occur in the

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

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

2d. Choreic movements exactly simulating those of organic brain

disease may occur without any appreciable disease of the nerve-
centres.

3d. General choreic movements, as well as the bizarre forms of

electric and rhythmical chorea, may occur without any organic
disease of the nervous system.
78 “Chorea: a Study in Clinical Pathology,” by H. C. Wood, M.D., LL.D., Therapeutic
Gazette, 3d Series, vol. i., No. 5, May 15, 1885.

To these propositions may be added a fourth—viz. Choreic

movements may be the result of a peripheral irritation, or, in other
words, may be reflex.

Hysterical rhythmical chorea is a form of chorea in which involuntary

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

As Charcot has shown, rhythmic chorea is usually of hysterical

origin, although it may exist without any of the phenomena which
usually characterize hysteria. In these cases the movements imitated
are according to a certain plan; thus, they may be certain expressive
movements, as some particular form of dancing or the so-called
saltatory chorea. They may be, again, certain professional or trained
actions, such as movements of hammering, of rowing, or of weaving.
Charcot speaks of a young Polish girl in whom movements of
hammering of the left arm lasted from one to two hours, and
occurred many times in a day for seven years. He has also given an
account of another case, a patient with various grave hysterical
manifestations, who would have a pain and beating sensation in the
epigastrium, accompanied by a feeling of numbness. The right upper
extremity would then begin to move; this would soon be followed by
the left, and then by the lower extremities; then would follow a
succession of varied action, complex in character, but in which
rhythm and time and correct imitation of certain intentional and
rational movements could readily be recognized. The attacks could
be artificially induced in this patient by pulling the right arm or by
striking on the patellar tendons with a hammer. During the whole of
the attack the patient was conscious. In another patient rhythmical
agitations of the arm, the movement of wielding a hammer, were
produced in the first stage; then followed tonic spasms and twisting
of the head and arms, suggesting a partial epilepsy; finally,
rhythmical movements of the head to the right and left took place,
the patient at the same time chanting or wailing.79
79 Charcot's lectures in Le Progrès médical for 1885.

In the following case an hysterical jumping chorea was probably

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

Hysterical tremor is of various forms and of frequent occurrence: a

single limb, both upper or both lower extremities, or the entire body
may be affected. In a case of hystero-epilepsy, which will be reported
in the next article, the patient had a marked tremor of the left arm,
forearm, and hand, which was constant, but worse before her
attacks; it remained for many months, and then disappeared entirely.
Caraffi80 reports the case of an hysterical girl of eighteen, anæsthetic
on the right side and subject to convulsive attacks, who fell on the
right knee and developed an arthritis. At the Hôpital Beaujon service
of Lefort and Blum she presented herself with the above symptoms,
aphonia, and an uncontrollable tremor of the right lower extremity,
and trophic disturbances of the same. Immobilization of the limb was
tried without benefit, and Blum then stretched the sciatic, with
complete relief of the tremor and of the troubles of sensibility and of
nutrition.
80 L'Encéphale, June, 1882.