nose.

hysterical trouble expressed by disorders of motility, either paralysis, tremor or spasm, are sometimes very difficult to diagA woman of middle age presented herself at the OutPatient Department of the New York Hospital, several months ago, suffering with a rather violent rythmical tremor of the head and both hands, and accompanied by no abnormality of sensation. This tremor was quite persistent, and was markedly increased in volitional efforts. When she carried her handkerchief to her face, the hand shook more violently as she neared the accomplishment of the act than it did in the beginning. When carefully examined by Dr. Kinnicutt, who was present at her first visit, and myself, there seemed to be a possibility that her disease was a multiple cerebro-spinal sclerosis. Her face bore the particularly anxious expression described by writers upon the subject, and she sat bent forward, her head in advance of her body. There was no festination when she attempted to walk, and, from the absence of other signs, I did not feel at all sure of my diagnosis, but felt confident that there was some organic disease. When she next came, a week later, she was exceedingly emotional, and her movements were the same as before; and to these symptoms was added that of subjective numbness of the fingers. I might mention that the tremor was so violent that her voice was affected, and she talked very much as a person would who was chilled through. At her third visit, her only symptom was the emotional excitement, the tremor having entirely disappeared, and she was perfectly quiet until I asked her some question regarding its cessation, when it it returned with redoubled violence, and on my questioning her closely, she became very indignant. A careful examination revealed some left sided ovarian hyperesthesia. She was, I afterwards learned, committed to an asylum for hysterical insanity. Strangely enough in this case there was atrophy of one optic nerve, and had I noticed this feature earlier, I should have been more ready in the begining to suspect sclerosis as a lesion.

Various forms of hysterical paralysis, especially of a paraplegic form, may simulate the organic varieties very closely. Miss. E. was a patient of this kind who during the existence of hysterical paraplegia presented urinary and rectal disorders, which, if taken into account with her other troubles, might lead a medical man who should see her for the first time to call her ailment something more serious than it really was. At this time her loss of

power was complete, and through disuse her limbs had become greatly atrophied; indeed there were contractures of the tendinis achillis of both legs, anaesthesia and analgesia, so that a pin might be thrust into the muscular tissue of the leg without producing pain.

For a period of a month there was not only incontinence of urine but involuntary stools as well. At the end of this time the functions of the bladder and rectum became perfectly normal. From the fact that the urine discharged was inoffensive, perfectly clear and quite copious, that there was no ammoniacal odor, and that the stools were watery; that ovarian hyperæsthesia existed, and that before this time a great variety of hysterical symptoms had been expresed, entirely did away with the chance of error in diagnosis.

3

In other cases the difficulty has been greater, for instance Webb reports a case of hysterical locomotor ataxia which defied successful investigation for some time. The patient was a woman aged 35 years, who had suffered from menstrual troubles for a long period, and with these there were pains of various kinds in the back and legs, with the constricting band and a certain amount of anesthesia. She had lost control of the bladder and rectum, and the urine contained some albumen. She could not stand and would fall if not supported, and when she walked her feet were thrown out, and there was marked inco-ordination of muscular movements. A year after the commencement of her trouble her fingers became stiff and powerless. When her mind was directed from her condition, her back pain would not be complained of, and she could bear quite decided pressure on the vertebral spines. Somewhat in doubt as to her condition, Dr. Da Costa was called in consultation, and pronounced the case one of hysteria and such a diagnosis was verified by the fact that but feeble contractions followed electric stimulation of the muscles, which is the case in some forms of old hysteria, while in locomotor ataxia there is marked elevated electric irritability. Great improvement immediately followed treatment, which was still more decided when the menses were re-established.

In a hysterical malingerer I have witnessed symptoms which were for a time very suggestive of locomotor ataxia; there was absolutely no atrophy of the optic nerve, however, and there was

3. Amer. Jour. of the Med. Sciences, 1876, p. 119,

an assumed loss of power when the patient's muscular strength was tested, and a week after the first examination the whole character of her gait was changed; it becoming a spurious paraplegiform walk instead of an ataxic effort.

Last Fall, in consultation with Dr. J. P. P. White, of New York, I saw a man who presented a remarkable collection of nervous symptoms. He had been rather unsuccessful in some business affairs in the West, and keenly felt his embarrassment. On the way from Chicago he was seized with convulsions of a violent kind, and remained unconscious for some hours. When I visited him at his hotel I found him surrounded by friends who were doing their best to keep him quiet, and the efforts of two strong male nurses were almost insufficient to confine him to the bed. He was a powerful, muscular young man of about thirtyfive, showing no evidence of exhaustion, nor disease of any kind. I found him in a condition of opisthotonos, the are being greater than I had ever witnessed it before. The head was buried in the pillow, his face was flushed and swollen, and he sweated profusely. His eyes were staring and uncovered by the lids, while the pupils were widely dilated. The convulsions, at first tonic, and shortly afterwards clonic, lasted about two minutes. and there was afterwards a period of relaxation. The slightest jar of the bed or attempt to arrange the bed clothing precipitated a fresh attack. He had been in this condition for nearly twentyfour hours before I saw him, and had neither eaten nor given any intelligible sign of consciousness, except once, when he called "father," although there was no external appearance of unconsciousness, but the patient rolled his eyes about occasionally, and his face bore an expression which suggested that he desired to communicate, but could not. The case was at first puzzling, and suggested the idea that it might be either tetanus or strychnia poisoning. These were disposed of by the absence of traumatism and endemic influences; by the fact that the temperature was not especially high; that there was no trismus; that his trouble had lasted too long for strychnia poisoning-but the most striking proof of all, in regard to the real nature of the case, was the fact that the convulsions disappeared almost as if by magic when it was said in his hearing that the doctor had pronounced his trouble hysteria, and when he was given a mixture of assafoetida. The supposed rarity of male hysteria in general, and of this kind

in particular, would, in such a case, be likely to throw one off his guard.

There are many other forms of trouble which might be alluded to, but I forbear to weary my readers with their recital. One case, however, is worthy of mention because it is extremely rare. I speak of hysterical chorea. Several cases have recently been recorded, one by Cordly Bradford.*

In this case, who was a girl nineteen years of age, there were extensive movements, but none of the facial muscles. There was tenderness of the left ovary, and pressure relieved the irregular movements to some degree. In such cases the chronic movement occurred with well pronounced hysterical symptoms. In a personal example the first manifestations were those of an ordinary chorea, and afterwards there were developed very decided convulsions and other hysteroid symptoms.

Fanny McC. is a cloakmaker nineteen years of age. After a day spent at a picnic, and attended by a great deal of excitement, she became "nervous,” irritable, and refused food. A day or two later she began to "twitch," and well marked chorea appeared; not only were her hands affected, but her mouth moved as well. This continued for several weeks; she was meanwhile treated by her family physician. At the end of this time she should have menstruated, but did not, and suffered greatly from pain. The nervous symptoms now underwent a decided change. She became almost maniacal, threatened suicide, and other violence, had hallucinations and disturbed the peace of the family most thoroughly. At the invitation of Dr. Stuyvesant Morris I went to see her, and found her rolling on the floor in a semi-nude condition, talking incoherently, and beating her head against the boards. Her whole body was agitated by exaggerated choreic movements, which were incessant. When I next saw her, her trouble had undergone a change, so far as the mental condition was concerned, but her movements were quite violent. She could talk, but her speech was interrupted and explosive. There was gradual improvement when her uterine condition was treated, and though emotional and excited, she is now much better. There was absolutely nothing in the beginning to indicate the real nature of her chorea, and until the development of her more pronounced symptoms it presented nothing which differed from an ordinary case of chorea.

4. Br. Med. Jour., Oct. 12, 1878.

The development of real organic disease after a continued hysterical condition is, I am sure, quite possible, and I do not fully believe in the frequency of sudden cures after some particular hysterical train of symptoms have lasted for years. From personal observation of one case in particular I have no doubt but that a degeneration of the lateral column has followed hysterical paralysis and contracture of a lower extremity. At first in this case there was an uncomplicated volitional paralysis, an ordinary hysterical paralysis, but disuse of limbs after years spent upon a couch have brought more serious trouble, such as rigidity at the ankle and knee-joint, and deformities overcome only with difficulty by passive motion and retraction of the heel, as well as a very decided tendon reflex, and other peculiar evidences commonly seen in spastic paralysis. As to convulsive affections of hysterical character, I think the literature of hystero-epilepsy furnishes us with enough examples of developed convulsions as a result of the primary trouble to prove the truth of what I suggest. These are but two varieties of confirmed disease, and doubtless there are many others.

In cur examination of suspected cases we must be governed by certain peculiar features of hysteria, some of which have been recently discovered. 1 will not go into the question of the diagnosis of special symptoms, for this would lead to an interminable. discussion, but I would call the reader's attention to the fact that in cases of this kind we rarely find any of the more pronounced symptoms of confirmed organic disease. As those which are absent I may allude to cranial nerve paralysis. I do not know of such a condition as hysterical ptosis, though diplopia is an oc casional, but very rare symptom, and like many others of the same order, is liable to be a hysterical manifestation. Amaurosis and amblyopia are frequently hysterical, but in neuritis of the optic nerve and its consequences-disk atrophy, choked disk, or other retinal changes-are never found in hysterical subjects, except in rare coincidences. Strabismus may be hysterical, but in connection with other cranial nerve troubles is indicative of serious organic disease. As to pain as a symptom we can say but little, for dysæsthesæ of various kinds are bewildering, and except for other evidences of disease, it can have alone but little significance. The pure hysterical sensory disturbances are notably the hyperæsthesæ, and deep pressure does not produco anything like the discomfort of light contact. Atrophy of mus