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The cramming processes which are resorted to in order to force children at fixed times from the lower to the higher grades of public schools, and more especially from grammar to normal or high schools, is a fruitful source of evil in this direction. It is not always so much hard study as it is the badly-arranged and too numerous subjects of study that make the strain. I have spoken of this in another connection as follows:42 “Our children are too largely in the hands of those educationalists to whom Clouston refers,43 who go on the theory that there is an unlimited capacity in every individual brain for education to any extent and in any direction. Children varying in age and original capacity, in previous preparation, and in homesurroundings are forced into the same moulds and grooves. The slow must keep pace with the fleet, the frail with the sturdy, the children of toil and deprivation with the sons and daughters of wealth and luxury. A child is always liable to suffer from mental overwork when the effort is made to force its education beyond its receptive powers. Education is not individualized enough. The mind of the child is often confused by a multitude of ill-assorted studies.

Recreation is neglected and unhealthy emulation is too much cultivated. In many communities admissions to various grades of public schools are regulated entirely by the averages obtained at examinations, instead of on the general record of the pupils in connection with proper but not too severe examinations. In consequence often, after the campaign of overwork and confusion called an examination, we see children developing serious disturbances of health or even organic disease—paroxysmal fever, loss of appetite, headache or neckache, disturbed sleep, temporary albuminuria, chorea, hysteria, and hystero-epilepsy.”

42 “Toner Lecture on Mental Overwork and Premature Disease among Public and

Professional Men.” delivered March 19, 1884, Washington, Smithsonian Inst., January, 1885.

43 Clinical Lectures on Mental Diseases.

The term students' hysteria has been applied to the neuromimetic disorders from which medical students frequently suffer during their

attendance upon lectures. Some years since, when engaged in examining students upon the lectures upon the practice of medicine delivered by Professor DaCosta, I saw many illustrations of this affection, some of which were very amusing. In a paper on hysteria which received the prize at the Physical Society of Guy's Hospital, P. Horrocks44 writes that during the fortnight following the death of the late Napoleon, Sir James Paget was consulted for stone in the bladder by no less than four gentlemen who had nothing the matter with them. “How many students,” says Horrocks, “are there, of one year's standing or more, who have not imagined and really became convinced that they were suffering from some disease, generally a fatal disease?” In such cases we have a combination of true psychical influence with overwork and the unhygienic surroundings for which our medical colleges are notorious.

44 Med. and Surg. Reporter, vol. xxxvii., Nov. 24, 1877.

It has been my personal experience that comparatively few cases of hysteria occur among female medical students. Not long since a thesis was presented at graduation by a woman medical student45 on the curative effects of professional training in neurasthenic and hysterical women. In this she shows that there are certain relations of mind over body which enable it to modify bodily conditions and ward off disease when other remedies appear almost powerless.

She illustrates the therapeutic power of mental impressions and occupations by two cases in which a judicious and careful course of study acted to cure severe nervous and uterine troubles. One of these women, who had suffered with neurasthenia and general debility, severe nervous headaches, and other symptoms, was able during her last year at college to attend fifteen lectures a week, besides clinics, prepare for examination on five subjects, and was seldom troubled with even headache. She afterward was employed in hospital work, and could walk five miles a day without discomfort.

That women medical students know when and how to take care of themselves during the menstrual period, and that they can, if they see fit, cease work or lighten their labors at that time, would partly account for their escaping from nervous break-down.

45 “The Therapeutic Value of Mental Occupation,” by Hannah M. Thompson, M.D.,

Medical and Surgical Reporter, November, 1883.

That any form of irritation in a patient predisposed to hysteria may act as an exciting cause in this affection has led Laségue to apply the term peripheral hysteria to certain cases. One of his cases was a girl fourteen years old, who, having suffered for a few hours with her eyes because of some sand thrown into one of them by a playmate, awoke the next morning with a spasm of the eyelid on that side, which rendered it impossible for her to open that eye; and it remained closed during four months. He considered that the irritation produced by the sand was not the immediate cause of the spasm, but that its long duration was an hysterical phenomenon. The patient afterward became the subject of hysterical manifestations. In another complete hysterical aphonia came on after a slight bronchitis.

Another, after an attack of indigestion, refused to touch either food or drink for twenty-four hours, and later was troubled with regurgitation from constriction of the pharynx or œsophagus which lasted for some weeks.

Anæmia and chlorosis are frequent exciting causes of hysteria in children, particularly in girls.

Disorders of menstruation play a prominent part as exciting causes of special hysterical manifestations. The period of the establishment of the menstrual function is one that is particularly fertile in the production of hysteria, much more so than acquired disorders of menstruation occurring later. Menorrhagia, dysmenorrhœa, and certain local utero-vaginal disorders may act upon those predisposed to hysteria as exciting causes. These conditions themselves are, on the other hand, sometimes caused by nervous, hysterical states in the individual.

With reference to the very common assertions that continence on the one hand, and sexual over-indulgence on the other, are the most prolific causes of hysteria, the true stand to take is that neither of these positions is philosophically correct; for, as Briquet has shown,

nuns on the one hand and prostitutes on the other are frequent victims of this protean disorder.

As affirmed by Jolly, sexual over-irritation, particularly that induced by onanism, more frequently causes hysteria than sexual abstinence or deprivation.

The occurrence of hysteria and hysterical choreas among pregnant women has long been recognized. Scanzoni, quoted by Jolly,46 states that of 217 patients whom he had treated, 165, or 76 per cent. had been puerperal, and that of the latter not less than 65 per cent. had borne children more than three times. Cases of grave hysteria or hystero-epilepsy have been aggravated by pregnancy and have led to premature labor.

46 Op. cit.

Chrobak attacks the etiological problem of hysteria by referring its causation to movable kidneys! He observed 19 such patients in Vienna, 16 being in Oppolzer's clinic.47 Three times no subjective symptoms accompanied the anomaly; eight times the trouble could be referred either to the dislocation of the kidneys or to disease of the same; and eight times the evidence of hysteria was unmistakable. Among the latter eight cases neither vaginal, uterine, nor ovarian conditions were recognized. He concludes that there is a direct nervous connection between the kidneys and the genital organs, and between both and hysteria.

47 Medizinische-Chirurgische Rundschan, quoted by Boston Medical and Surgical

Journal, 1870, lxxxiii. 430-432.

In brief, the truth is that frequent or severe local irritation in any part of the body in an individual of the hysterical diathesis may act as the exciting cause of an hysterical paroxysm or of special hysterical manifestations. Irritation or disease of the uterus or ovaries may result in hysteria, as may the bite of a dog, a tumor of the brain, a polypus in the nose, a phymosis, an irritated clitoris, a gastric ulcer, a

stenosis of the larynx, a foreign body in the eye, a toe-nail ulcer, or a movable kidney.

Whatever tends to exhaust the nervous system will also cause hysteria, but only in those who have some inherited predisposition to the disorder. C. Handfield Jones48 mentions heatstroke and severe physical labor as such causes. One of the sequelæ of heatstroke enumerated by Sir R. Martin, and quoted by Jones, is a distressing hysterical state of the nervous system, with an absence of selfcontrol in laughing and crying, the paroxysm being followed by great prostration of nervous power.

48 Op. cit.

The effect of imitation in the production of hysteria has been known in all ages. Most of the epidemics and endemics of nervous disorders which have from time to time prevailed in various parts of the world have either been hysterical in character or have had in them a large element of hysteria. While it is impossible in a practical work to devote much space to this branch of the subject, a discussion of hysteria in its etiological relations would be imperfect without some reference to these outbreaks. In ancient times, in the Middle Ages, and within comparatively recent periods extraordinary epidemics have occurred. No country within the range of medical observation has been entirely free from them. Communities civilized and semi-civilized, Christian and Mohammedan, Protestant and Catholic, have had a fair share of the visitations. Some of them constitute epochs in history, and, as Hecker,49 their greatest historian, has remarked, their study affords a deep insight into the work of the human mind in certain states of society. “They are,” he says, “a portion of history, and will never return in the way in which they are recorded; but they expose a vulnerable part of man—the instinct of imitation—and are therefore very nearly connected with human life in the aggregate.”

49 The Epidemics of the Middle Ages, from the German of J. F. C. Hecker, M.D.,

Professor at the Frederick William University at Berlin, etc., translated by B. G. Babington, M.D., F. R. S., etc.; 3d ed., London, 1859.

Some authors under hysteria, others under catalepsy, others under ecstasy, still others under chorea, have discussed these epidemics— a fact which serves to emphasize the truth that while these affections have points of difference, they have also an easily-traced bond of union. They are but variations of the same discordant tune. Briquet in an admirable manner sketches their history from the age of Pausanias and Plutarch to the time of Mesmer. Of American writers, James J. Levick50 of Philadelphia has furnished one of the most valuable contributions to this subject.

50 “An Historical Sketch of the Dance of St. Vitus, with Notices of some Kindred

Disorders,” Med. and Surg. Reporter, vol. vii., Dec. 21 and 28, 1861, p. 276, and Jan. 4 and 11, 1862, p. 322.

In the year 1237 a hundred children or more were suddenly seized with the dancing mania at Erfurt; another outbreak occurred at Utrecht in 1278.

As early as the year 1374 large assemblages of men and women were seen at Aix-la-Chapelle affected with a “dancing mania.” They formed circles and danced for hours in wild delirium. Attacks of insensibility, of convulsions, and of ecstasy occurred. The disease spread from Germany to the Netherlands. In a few months it broke out in Cologne, and about the same time at Metz. “Peasants,” we are told, “left their ploughs, mechanics their workshops, housewives their domestic duties, to join the wild revelry, and this rich commercial city became the scene of the most ruinous disorder.”

The festival of St. John the Baptist was one celebrated in strange wild ways in these early days. Fanatical rites, often cruel and senseless, were performed on these occasions. Hecker supposes that the wild revels of St. John's Day in 1374 may have had something to do with the outbreak of the frightful dancing mania soon after this celebration. It at least brought to a crisis a malady which had been long impending.

The Flagellants afford another illustration of an early religio-nervous craze. Self-flagellation was indulged in for generations before the

fourteenth century, but it then became epidemic. A brotherhood of Flagellants was formed; they marched in processions carrying scourges, with which they violently lashed and scourged themselves.

As late as 1843, Flagellant processions, but without the whips and scourging, were continued in Lisbon on Good Friday.

Strasburg was visited by the dancing plague in 1418. Those afflicted were conducted to the chapel of St. Vitus, where priests attempted to relieve them by religious ceremonies. The name St. Vitus's dance, still so common as a synonym for chorea, has come down to us because of the alleged wonderful doings of this saint in behalf of those affected during some of the dancing epidemics. Both Hecker and Madden51 give interesting details of the personal history of St. Vitus, who was a Sicilian, born in the time of Diocletian, and even in childhood is said to have worked great miracles, and was delivered from many sufferings and torments. He died about the year 303. His body was moved to Apulia, afterward to St. Denys in France, and still later to the abbey of Corvey in Saxony. A legend was invented that St. Vitus, just before he bent his neck to the sword, prayed to God that he might protect from the dancing mania all those who should solemnize the day of his commemoration and fast upon its eve.

51 Phantasmata; or, Illusions and Fanaticisms, etc., by R. R. Madden, F. R. S.,

London, 1857.

Another strange disorder called tarantismus derived its name from the fact that it was supposed to be caused by the bite of the tarantula, a ground-spider common in Apulia, Italy. According to Hecker, the word tarantula is the same as terrantola, a name given by the Italians to a poisonous lizard of extraordinary endowments.

The fear of the insect was so general that its bite was much oftener imagined than actually received. The disorder was probably in existence long before the fifteenth century, although the first account of it, that of Nicholas Perotti, refers to its occurrence in this century.

Many symptoms followed the bite or supposed bite: the individuals became melancholy, stupefied, lost their senses, and, above all, were irresistibly impelled to dance until exhausted and almost

lifeless. It was believed that the results of the bite could be cured, or at least much benefited, by dancing to a certain kind of music.

Tarantism was at its height in the seventeenth century. To this day, in some parts of Italy, dances called tarantellas are performed with intricate figures to marked time.

Abyssinia was visited by a dancing mania called the tigretier, which, according to Hecker, resembled the original mania of the St. John dancers. It exhibited a similar ecstasy. Those affected with it were cured by dancing to the music of trumpeters, drummers, fifers, etc.

Levick says that the dancing mania of the fifteenth century is still kept in popular remembrance in some places by an annual festival, especially at Echtermarch, a small town in Luxembourg, where a jumping procession occurs annually on Whit Tuesday. In the year 1812, 12,678 dancers were in the procession.

The Anabaptists, a religious sect of the sixteenth century, exhibited many of the wild and grotesque phenomena of hysteria or hysteroepilepsy.

The French Calvinists or Camisards, who appeared near the close of the seventeenth century, were also the subjects of ecstasy and of peculiar fits of trembling. These trembleurs experienced convulsive shocks in the head, the shoulders, the legs, and the arms, and were sometimes thrown violently down.

About 1731 and later great crowds frequented the tomb of Deacon François de Paris, an advocate of the doctrines of Jansenius. It was reported that miracles were performed at his tomb: the sick were brought there, and often were seized with convulsions and pains, through which they were healed. The subjects of these attacks are sometimes spoken of as the Jansenist Convulsionnaires. The tomb was in the cemetery of St. Médard, and hence those who visited the place were also termed the Convulsionnaires of St. Médard. This disorder increased, multiplied, and disseminated, lasting with more or less intensity for fifty-nine years. Great immorality prevailed in the secret meetings of the believers.

Hecker gives some remarkable instances of the effect of sympathy or imitation exhibited on a smaller scale than in the epidemics of the Middle Ages. One is of a series of cases of fits in a Lancashire factory, the first one brought on by a girl putting a mouse into the bosom of another. In Charité Hospital in Berlin in 1801 a patient fell into strong convulsions, and immediately afterward six other patients were affected in the same way; by degrees eight more were attacked. At Redruth, England, a man cried out in a chapel, “What shall I do to be saved?” Others followed his example, and shortly after suffered most excruciating bodily pain. The occurrence soon became public; hundreds came, and many of them were affected in the same way. The affection spread from town to town. Four thousand people were said in a short time to be affected with this malady, which included convulsions.

Hecker in the edition of his work referred to has also a treatise on child pilgrimages.52 These pilgrimages, like the dancing mania, occurred in the Middle Ages. The greatest was the boy crusade in the year 1212. The passion to repossess the Holy Land then had its grip on Catholic Europe. The first impulse to the child pilgrimages was given by a shepherd-boy, who had revelations and ecstatic seizures, and held himself to be an ambassador of the Lord. Soon thirty thousand souls came to partake of his revelations; new childprophets and miracle-workers arose; the children of rich and poor flocked together from all quarters; parents were unable to restrain them, and some even began to urge them. A host of boys, armed and unarmed, assembled at Vendôme, and started for Jerusalem with a boy-prophet at their head. They got to Marseilles, and embarked on seven large ships. Two ships were wrecked, and not a soul was saved. The other five ships reached Bougia and Alexandria, and the young crusaders were all sold as slaves to the Saracens. In Germany child-prophets arose, especially in the Rhine countries and far eastward. An army of them gathered together, crossed the Alps, and reached Genoa. They were soon scattered; many perished; many were retained as servants in foreign lands; some reached Rome. A second child's pilgrimage occurred twentyfive years later. It was confined to the city of Erfurt. One thousand

children wandered, dancing and leaping, to Armstadt, and were brought back in carts. Another child's pilgrimage from Halle, in Suabia, to Mount St. Michel in Normandy, occurred in 1458.

52 Translated by Robert H. Cooke, M. R. C. S.

In the convent of Yvertet in the territory of Liège, in 1550, the inmates were seized with a leaping and jumping malady. The disorder began with a single individual, and was soon propagated.

Sometimes the convulsive disorders of early days, especially those occurring in convents, were associated with the strange delusion that the subjects of them were changed into lower animals. Various names have been given to disorders of this kind, such as lycanthropia or wolf madness, zoomania or animal madness, etc.

Burton in the Anatomy of Melancholy gives an interesting summary of these disorders, which are also discussed by Levick.

In 1760 a religious sect known as the Jumpers prevailed in Great Britain. They were affected with religious frenzy, and jumped continuously for hours. Other jumping epidemics have appeared at different times, both in Great Britain and in this country.

The New England witchcraft episode is of historical interest in connection with this subject of epidemic hysteria. This excitement occurred during the latter part of the seventeenth century. Adults and children were its subjects. The Rev. Cotton Mather records many cases, some of which illustrate almost every phase of hysteria.

Individuals who were seized with attacks, which would now be regarded as hysterical or hystero-epileptic, were supposed to have become possessed through the machinations of others. Those who were supposed to be possessed were tried, condemned, and executed in great numbers. Many accused themselves of converse with the devil. The epidemic spread with such rapidity, and so many were executed, that finally the good sense of the people came to the rescue.

The nervous epidemics, nearly all religious, which have occurred in this country have usually been during the pioneer periods, and have therefore appeared at different eras as one part of the country after another has been developed. Kentucky, Tennessee, Virginia, and neighboring States were visited time and again. Even to-day we occasionally hear of outbreaks of this kind in remote or primitive localities, whether it be in the far South-west or in the woods of Maine.

David W. Yandell53 has published a valuable paper on “Epidemic Convulsions,” the larger part of the materials of which were collected by his father for a medical history of Kentucky. From this it would appear the convulsions were first noticed in the revivals from 1735 to 1742. Many instances are related of fainting, falling, trance, numbness, outcries, and spasms. The epidemic of Kentucky spread widely, reappeared for years, and involved a district from Ohio to the mountains of Tennessee, and even to the old settlements in the Carolinas. Wonderful displays took place at the camp-meetings. At one of these, where twenty thousand people were present, sobs, shrieks, and shouts were heard; sudden spasms seized upon scores and dashed them to the ground. Preachers went around in ecstasy, singing, shouting, and shaking hands. Sometimes a little boy or girl would be seen passionately exhorting the multitude, reminding one of the part taken by the children in the epidemics of the Middle Ages.

A sense of pins and needles was complained of by many; others felt a numbness and lost all control of their muscles. Some subjects were cataleptic; others were overcome with general convulsions.

53 Brain, vol. iv., Oct., 1881, p. 339 et seq.

The term jerks was properly applied to one of the forms of convulsion. Sometimes the jerking affected a single limb or part. The Rev. Richard McNemar has given a graphic description of this jerking exercise in a History of the Kentucky Revival. The head would fly backward and forward or from side to side; the subject was dashed to the ground, or would bounce from place to place like a football, or hop around with head, limbs, and trunk twitching and

jolting in every direction. Curiously, few were hurt. Interesting descriptions of the jerks can be found in various American autobiographical and historical religious works. In such books as the Autobiography of Peter Cartwright, a Western Methodist, for instance, striking accounts of some of the phases of these epidemics are to be found. Lorenzo Dow in his Journal, published in Philadelphia in 1815, has also recorded them.

Hysterical laughter was a grotesque manifestation often witnessed.

The holy laugh began to be a part of religious worship. Dancing, barking, and otherwise acting like dogs, were still other manifestations. It is remarkable that, according to Yandell, no instance is recorded in which permanent insanity resulted from these terrible excitements.

The absurd and extraordinary exhibitions witnessed among the Shakers belong to the same category, and have been well described

by Hammond and others.

In a History of the Revival in Ireland in 1859, by the Rev. William Gibson, instances of excitement that fairly rivalled those which occurred in our Western States are given. Cases of ecstasy are described.

The religious sect known as the Salvation Army, which has in very recent years excited so much attention, curiosity, and comment both in America and England, has much in common with the Jumpers, the Jerkers, and the Convulsionnaires. The frenzied excitement at their meetings, with their tambourine-playing, dancing, shouting, and improvising are simply the same phases of religio-hysterical disorder, modified by differences in the age and environment.

In 1878, in the district of Tolmezo, Italy, an epidemic of hysteria which recalls the epidemics of the Middle Ages occurred. It has been described by M. Léon Colin.54 It was reported to the prefect of Undine that for three months some forty females living in the commune of Verzeguis had been attacked by religious mania. “From the report it appears that the first was in the person of a woman

named Marguerite Vidusson, who had been the subject of simple hysteria for about eight years. In January, 1878, she began to suffer from convulsive attacks, accompanied by cries and lamentations.

She was regarded as the subject of demoniacal possession, and on the first Sunday in May was publicly exorcised. Her affection, however, increased in severity; the attacks were more frequent and more intense, and were especially provoked by the sound of the church-bells and by the sight of priests. Seven months later three other hysterical girls became subject to convulsive and clamorous attacks. Here, again, an attempt was made to get rid of the supposed demon. A solemn mass was said in the presence of the sufferers, but was followed only by a fresh outbreak. At the time of the visit of the delegates eighteen were suffering, aged from sixteen to twenty-six years, except three, whose ages were respectively forty-five, fifty-five, and sixty-three years. Similar symptoms had also appeared in a young soldier on leave in the village.” During the attacks the patients talked of the demon which possessed them, stated the date on which they were seized by it, and the names of the persons who were possessed before them. Some boasted of being prophetesses and clairvoyants and of having the gift of tongues. In all, the sound of church-bells caused attacks, and religious ceremonies appeared not only to aggravate the disease in the sufferers, but also to cause its extension to those not previously attacked. M. Colin points out that the soil is particularly favorable for the development of an epidemic of this nature. The people of Verzeguis are backward in education and most superstitious.

Functional nervous diseases are common among them. The inhabitants of the village are largely cut off from intercourse with the adjacent country in consequence of comparative inaccessibility and the frequent interruption of communications by storms and floods.

Craniometric observations on twelve of the inhabitants seemed to show that the brachycephalic form of skull predominated, and that the development of the cranium was slightly below the average. The epidemic proved extremely obstinate.

54 Annales d'Hygiène, quoted in Lancet, Oct. 16, 1880.

In Norway and New Caledonia similar hysterical outbreaks have been observed in recent times.

An endemic of hysteria from imitation occurred in Philadelphia in 1880. Some of the cases fell under my own observation. A brief account of them is given by Mitchell in his Lectures. The outbreak occurred in a Church Home for Children, to which Dr. S. S. Stryker was physician. The Home contained ninety-five girls and six boys; all of them were well nourished and in good condition. The epidemic began by a girl having slight convulsive twitchings of the extremities, with a little numbness. Attacks returned daily; respiration became loud and crowing. She soon had all the phenomena of convulsive hysteria. Many of her comrades began to imitate her bark. Soon another girl of ten was attacked with harsh, gasping breathing, with crowing, speechlessness, clutching at her throat, and the whole series of phenomena exhibited by the first girl attacked. Nine or ten others were affected in like manner, and many of the remaining children had similar symptoms in a slight degree. At first convulsions occurred irregularly; after a while they appeared every evening; later, both morning and evening. The presence of visitors would excite them. Many interesting hysterical phases occurred among the children. One night some of them took to walking about on their hands and knees; others described visions. The girls often spoke of being surrounded by wild beasts, and one child would adopt the fiction which another related in her hearing. The cases were scattered about in different hospitals, and made good recoveries in from one to two months.

The Jumpers or Jumping Frenchmen of Maine and Northern New Hampshire were described by Beard in 1880.55 They presented nervous phenomena in some phases allied to hysteria. In June, 1880, Beard visited Moosehead Lake and experimented with some of them. Whatever order was given them was at once obeyed. One of the Jumpers, who was sitting in a chair with a knife in his hand, was told to throw it, and he threw it quickly so that it struck in a beam opposite; at the same time he repeated the order to throw it with a cry of alarm. They were tried with Latin and Greek quotations, and

repeated or echoed the sound as it came to them. They could not help repeating any word or sound that came from the person that ordered them. Any sudden or unexpected noise, as the report of a gun, the slamming of a door, etc., would cause them to exhibit some phenomena. It was dangerous to startle them where they could injure themselves, or if they had an axe, knife, or other weapon in their hands. Since the time of Beard's observation accounts of their doings have now and then found their way into newspapers. One recent account tells of one of these peculiar people jumping from a raft into the Penobscot River on an order to jump.

55 Journal of Nervous and Mental Diseases, vol. vii., 1880, p. 487.

Hammond56 has described under the name Miryachit an affection which seems to be essentially the same disorder as that of which the Jumpers are the victims. He quotes from a report of a journey from the Pacific Ocean through Asia to Europe by Lieutenant B. H. Buckingham and Ensigns Geo. C. Foulk and Walter McLean of the United States Navy, an account of this disease. The party made their first observations on this affection while on the Ussuri River in Siberia. The captain of the general staff approached the steward of the boat suddenly, and without any apparent reason or remark clapped his hand before his face; instantly the steward clapped his hand in the same manner, put on an angry look, and passed on.

When the captain slapped the paddle-box suddenly, the steward instantly gave it a similar thump. Some of the passengers imitated pigs grunting or called out absurd names, etc.; the poor steward would be compelled to echo them all. The United States naval officers were informed that the affection was not uncommon in Siberia, and that it was commonest about Yakutsk, where the winter cold is extreme. Both sexes were subject to it, but men much less than women. It was known to Russians by the name of Miryachit.

56 New York Med. Journ., Feb. 16, 1884.

In both these classes of cases a suggestion of some kind was required, and then the act took place independently of the will.

“There is another analogous condition known by the Germans as

Schlaftrunkenheit, and to English and American neurologists as somnolentia or sleep-drunkenness. In this state an individual on being suddenly awakened commits some incongruous act of violence, ofttimes a murder. Sometimes this appears to be a dream, but in others no such cause could be discovered.” Curious instances are mentioned by Hammond of this disorder.

The phenomena of automatism at command in hypnotized subjects have much similarity to the phenomena of these affections, and the same explanation to a certain extent will answer for both.

Paget57 has ably discussed the subject of neuromimesis in general, and Mitchell58 devotes two lectures to its consideration. As already stated when discussing the synonyms of hysteria, the mistake must not be made of supposing all cases of hysteria to be instances of neuromimesis; but, as Mitchell remarks, the hysterical state, however produced, is a fruitful source of mimicry of disease in its every form, from the mildest of pains up to the most complete and carefully-devised frauds. “Its sensitiveness and mobility, its timidity and emotionalness, its greed of attention, of sympathy, and of power in all shapes, supply both motive and help, so that while we must be careful not to see mimicry in every hysteric symptom, we must in people of this temperament be more than usually watchful for this form of trouble, and at least reasonably suspicious of every peculiar or unusual phenomenon.”

57 Op. cit.

58 Op. cit.

SYMPTOMATOLOGY.—At the outset of the discussion of the symptomatology of hysteria, hysterical cases should be divided into four classes—viz. (1) Cases in which the symptoms are involuntary; (2) cases in which the symptoms are artificially induced and become involuntary; (3) cases in which the symptoms are acted or simulated, but in which the patient, because of impaired mental power, is irresistibly impelled to their performance; (4) cases in which the

symptoms are purely acts of deception which are under the control of the patient.

Keeping in mind these different classes, we will always be able to link to the phenomena of hysteria the psychical element which is present in all genuine cases of this disorder. To comprehend the existence of the psychical element in the first class, in which the manifestations are absolutely involuntary, may offer difficulties. In these cases, at a period more or less recent or remote, psychical stimuli may have acted to produce the hysterical phenomena, and, once produced, these have been repeated and intensified by habit, and continue independently both of volition and consciousness. The experiments of Dercum and Parker show how hysterical symptoms may be artificially induced and may get beyond the patient's control.

The difference between induced and simulated manifestations must always be clearly borne in mind. To induce a set of phenomena a certain mechanism must be set in action, and this, through rational, explicable processes, leads to certain results. The psychical element enters here both positively and negatively—positively, in the determination to produce a certain train of events; negatively, in the condition of mental concentration or abstraction which is a part of the procedure. In the third class of cases acting or simulation is dependent upon the irresistible inclinations of the patient. This may seem to some an uncertain and even dangerous ground to take. I am convinced, however, after observing many hysterical cases, that acts clearly purposive, so far as the particular performance is concerned, are sometimes the result of a general unstable mental condition. Some at least of these patients are as irresistibly impelled to swallow blood and vomit, to scream and gesticulate, etc., as is the monomaniac to commit arson, to ravish, or to kill. In the fourth class, the cases of pure, unmitigated, uncontrollable deception, the psychical element is very evident, although some may question whether such cases should be ranged under the banner of hysteria, where it is both convenient and customary to place them.

The symptoms of hysteria may develop in any order or after any fashion. The graver hysterical phenomena, such as convulsions,

paralysis, and anæsthesia, often seem to come on suddenly, but usually this suddenness of onset is apparent rather than real. Minor hysterical symptoms, such as general nervous irritability, pains, aches, and discomforts, and mental peculiarities, have usually been present for a long time. These minor evidences of the hysterical constitution are sometimes the only phenomena ever presented.

Todd59 has described an expression of countenance which he designates as the facies hysterica. The characteristics of this expression are a remarkable depth and prominent fulness, with more or less thickness, of the upper lip, and a peculiar drooping of the upper eyelids. It would be absurd to assert that all hysterical patients presented this cast of countenance, but an appearance which approaches closely to this description is presented in a fair percentage of cases. It has seemed to me that male hysterics were more likely to have this peculiar facies than hysterical females.

59 Reynolds's System of Medicine, vol. ii. p. 656.

The psychical peculiarities or mental disorders of hysteria form a large and important part of its phenomena. We have to deal not only with peculiar and diverse psychical manifestations, but to one form of mental disorder it is clinically convenient and correct to apply the designation hysterical insanity.

In the mildest cases of ordinary hysteria conditions of mental irritability and mobility are sometimes the only striking features.

“Patients,” says Jolly,60 “are timid, easily overcome by any unexpected occurrence, sentimental, and sensitive. Every trifle annoys and upsets them; and there is this peculiarity—that a more recent stimulus may often effect a diversion in an exactly opposite direction.”

60 Op. cit.

As bearing upon the question of the mental state in hysteria, the confessions obtained by Mitchell from several patients are of great interest. One patient, who had learned to notice and dwell upon any

little symptom, vomited daily and aroused much sympathy. She took little or no food. Spasms came on, and she confessed that every new symptom caused new anxiety, and that somehow she rather liked it all. She gradually lost all her symptoms except vomiting, and overcame this by desperate efforts. Another patient confessed to having played a game upon her doctor for a long time by pretending she took no food. She would get out of bed at night, but remain there all day; she filled up a vessel with water to make others believe she passed large quantities of urine, etc. Another patient, a girl of nineteen, who came on a litter from a Western State, after a time regained her feet. In her confession she stated that what she lacked was courage. She believed that she would have overcome her difficulties if any one had told her that nothing was the matter. “In looking back over the year with the light of the present,” she says, “I can only say that I believe that there was really nothing the matter with me; only it seemed to me as if there was, and because of these sensations I carried on a sort of starvation process physical and mental.”

The older and some of the more recent classifications of insanity recognize hysterical insanity as a distinct form of mental disease.

Morel and Skae, however, in their etiological classifications, and Hammond, Spitzka, Mann, and Clouston in their recently-published works, give it a “local habitation and a name.” Krafft-Ebing not only recognizes hysterical insanity as a distinct form of mental disease, but, after the German fashion, subdivides it quite minutely, as follows: First, transitory forms: a. with fright; b. hystero-epileptic deliria; c. ecstatic visionary forms; d. moria-like conditions. Second, chronic forms: a. hystero-melancholia; b. hystero-mania; c. degenerative states with hysterical basis.

Spitzka61 speaks of chronic hysterical insanity as an intensification of the hysterical character, to which “a silly mendacity is frequently added, and develops pari passu with advancing deterioration.” At the State Hospital for the Insane at Norristown and at the department for the insane of the Philadelphia Hospital cases of chronic hysterical insanity have come under my observation. Hammond under

hysterical mania includes several different and somewhat distinct mental disorders.

61 Insanity, its Classification, Diagnosis, and Treatment, by E. C. Spitzka, M.D., New

York, 1883.

With regard to the occurrence of hysterical manifestations amongst patients suffering from some well-recognized non-hysterical forms of insanity, a tour through any large asylum will afford abundant evidence. Cases of tremor closely simulating cerebro-spinal sclerosis have been observed frequently among the insane.

Paralysis, contracture, hysterical joints, hysterical neuralgias, convulsions, and cataleptoid phenomena are among other hysterical manifestations which have fallen under personal observation among the insane of various classes.

A remarkable case of hysterical motor paralysis was observed at the State Hospital for the Insane at Norristown. This patient was an intelligent single woman about thirty-five years of age, of good family, well educated; she had been a teacher and writer, and became insane through family and business troubles. When only eight years of age she was paralyzed for two years and a half, and had had at times during her life, before becoming insane, attacks of partial or complete unconsciousness. Prior to coming under observation she had been an inmate of an English private asylum. She was sick on shipboard coming to this country, and on her arrival was in a state of delirium and insomnia, with attacks of loss of sight. Four months later she developed mania with suicidal inclinations. Just before the development of this maniacal condition her lower limbs became comparatively helpless, and soon after she entirely lost their use. I found her in this condition, and examination showed no change in knee-jerk, electrical reactions, nutrition, nor genito-urinary conditions, which led me to diagnosticate the absence of any organic spinal trouble. The case was pronounced one of hysterical paralysis, and it was prophesied that she would eventually completely recover, probably suddenly. For one year her paralysis remained, her mental condition varying very greatly during this time—sometimes in a