GASES GALLED HYSTERICAL. READ BEFORE me Philadelphia Comity Medical Society, October 11th, 1876, BY K WOODBURY, M.D., OF PHILADELPHIA. / ° [Reprinted from the Philadelphia Medical and Surgical Reporter, Dec. 2d, 1876.] PHILADELPHIA: JAMES A. MOORE PRINTER, 1222 and 1224 SANSOM STREET. 1877. CASES CALI,ED HYSTERICAL HEAD BEFORE THE PHILADELPHIA COUNTY MEDICAL SOCIETY, At its Meeting1, Oct. lltli, 1870. I f BY FRA.NK WOODBURY. M.D. Gentlemen:—To any one familiar with current medical literature, who has noticed the frequent reports of cases called hysterical, it must be sufficiently evident that the word Hysteria is now used in more senses than one, and with uncertain signification. Among writers, some are found who carefully give the exact pathological condition of the uterus in each case of supposed hysteria; the conscience of others is satisfied if the patient possess a uterus, without a thought as to its condition ; while there is a third, and apparently increasing class, who use the term hysteria with the great- est freedom, applying it to cases where the uterus is absent, and connecting it with dis- orders of individual organs where there is no distinction of sex. Cases have thus come to be called hysterical which have no points what- ever in common, not even agreeing in the simple fact of possessing a uterus. It shall be the proposed province of this article, however, not to take up the entire sub- ject of hysteria for systematic discussion, but to consider, as briefly as possible, some of the leading clinical phenomena presented by cases called hysterical, and to attempt to discover in the tangled skein of evidence, here and there, a thread, which hereafter may serve as a clue to the elucidation of this obscure subject. Nothing need here be said of the importance of the topic, further than to recall the fact that hysteria has been the olium medicinoe from a pre-historic period, and that its pathology is still unsettled, although cases are of sufficiently frequent occurrence to make such a .consumma- tion eminently desirable. Since Sydenham has declared that hysteria constitutes one-half of the chronic diseases of women, and in the opinion of Bricquet it affects one-fourth part of the entire female sex, it may be not undesirable to stop for a moment to inquire what is meant by hysteria. The derivation of the word, from hystera, the womb, indicates that originally it was applied to designate a general disorder whose pathological cause resided in the uterus ; subsequently, it came into use in a less re- stricted sense, in connection with certain gen- eral symptoms, without intending special refer- ence to their causation. In this acceptation it is now generally employed to indicate a neu- rosis of undefined pathological relations, but presenting most diverse and striking symptoms. The confusion into which the pathology of hysteria has fallen is explained by the simple fact that the term has been applied to a group of symptoms which may occur in different diseases, and may complicate many morbid states. This accounts for the apparently ir- reconcilable views held by different authors. Bricquet, Charcot, and others, believe that hysterical symptoms are purely nervous, and are not in any way dependent upon the uterus ; but, on the other hand, the fact that the Galeno- Ilippocratic view (which considers the disease as essentially uterine), has still advocates, is evident from the published reports of cases. 2 That all ca*es called hysterical, however, can- not be uterine in their pathology, is evident from the following considerations: — First, hysteria is often declared to be present when no direct evidence is given of uterine dis- ease. Secondly, the term hysteria is applied with- out discrimination to cases where the uterus is entirely absent, both in the male sex and in the female (defectio uteri). Thirdly, serious organic disease of the uterus is rarely complicated by symptoms called hys- terical. Therefore, since hysteria may be present where the uterus is healthy, or entirely absent, and uterine disease may exist without hysteria, no constant relation of cause and effect can be claimed to exist between the uterus and symp- toms called hysterical, even where they mutually complicate each other ; for if they may exist independently of each other, they may co- exist independently of each other. From which it is clearly demonstrable that phenomena have been called hysterical which, properly speak- ing, were not hysterical in their origin. At the same time, it is freely conceded that uterine disorder may produce general ill-health and find expression in varied symptoms, as wit- ness the following extract from a recent article by Percy Boulton, on “ Metro cerebral Dis- ease : ”*— “ It is scarcely understood by the bulk of general practitioners, that in a reflex way this organ (the uterus) may be a source of many diseases, and that the irritation of ovulation is a frequent cause of epilepsy and insanity. The sickness of pregnancy is an acknowledged fact, but madness, except when puerperal, is rarely thought to be of uterine origin. “In turning over a few pages of my note- book,! am reminded of patients, many of whom had their symptoms treated often and long by the family doctor without any result, because the real cause was not recognized. Without attempting a complete list of such cases, 1 will name a lew of the reflex disorders I have met with :— “Cerebral: Periodic headaches, neuralgia, depression of spirits, hysteria, epilepsy, melan- choly, etc. “Pulmonic: Phthisis. “Cardiac: Irritation. “ Gastric : Dyspepsia, sickness, flatulence. “ Intestinal : Constipation, diarrhoea. “ Vesical: Enuresis, irritation. —to say nothing of the diseases of the uterus and ovaries.’’ • Truly a serious charge to bring against the uterus, and certainly enough burden for it to bear, without, in addition, saddling it with all the vagaries of so-called hysteria. Symptoms such as these might, however, and with some show of propriety, be called hysterical, as they are produced by uterine disease ; but the point that itis desired toemphasize is this: the term hysteria is incorrectly used in a vastly more comprehen- sive range of application, to describe symptoms that belong to widely different disorders. The incongruity of this indiscriminate application of the word is strikingly manifest when we read of hysteria in the male, where it becomes absurdly inappropriate. The inconsistency of this application of the word must have been even more evident to the original mind who was the first to use it in this connection than it appears to us, for continued use has now somewhat sanctioned the solecism ; but though, at present, it is shorn of some .of its strangeness, it certainly has lost nothing of its impropriety. The persistence of this word, in spite of such strong reasons for its discon- tinuance, must be due to the fact that it implies a peculiar shade of meaning, difficult to convey by any other expression. It has been a word without a synonym, convenient to apply to dis- eases whose nature was otherwise unknown. The question may here be pertinently asked, “ Is it true that there is a peculiar systemic affection for which nosology affords no moie ex- pressive name than hysteria?” In searching the records for an answer, it may, perhaps, he ascertained that this word has been used in a vague and indefinite manner in the place of an exact diagnosis; in other words, hysteria has been given as a definite diagnosis in cases where no real diagnosis has been made. No better authority could be quoted to decide this ques- tion than the published reports of cases them- selves, which, in this light, naturally separate into three groups :— Class i.—Cases called hysterical, in which it was subsequently ascertained that there was an error of diagnosis. Class ii.—Cases called hysterical, where there is room for the suspicion that a clearer insight into the nature of the disease, with due recog- *The Obstetrical Journal, for February, 187(1, American ed. 3 nition of the pathological processes involved, would have led to definite diagnosis. Class hi.—Cases thus correctly diagnosed by competent observers, but which, judging from analogy, would have been called hysterical by others of less skill or experience. Before entering into a discussion of the cases, it would, perhaps, be as well to anticipate a possible objection to this mode of considering the subject. It may be urged that hysteria is a functional disease, and not connected with any pathological lesion. Assuming this for the moment to be true, even then hysteria would not be the proper title of such an affection ; for if it be independent of any organic disease, it cannot be caused by uterine disorder, and there- fore cannot be hysterical. But this is not believed to be true. An organ in a strictly normal condition can neither be the seat of disorder itself, nor cause disease in any other organ, either by sympathy, irritation, or reflex action. What has been often called purely functional disorder, is, therefore, an expression of partial knowledge, and, like the doctrine of equivocal generation, instances will be the more rare in their occurrence, just in proportion with our advance in biological science. By this, however, it is not meant to imply that every departure from a state of health is accompanied by organic lesion ; the disorders of the circulating fluid have not as yet received sufficient consideration, and are believed to be a fruitful source of disorder of function. Dis- orders termed functional, therefore, may be due to blood disease, or to an unrecognized, perhaps temporary, pathological state of some organ. To return to our subject, it will scarcely be necessary to quote a series of cases to demon- strate the absence of uniformity in the use and understanding of the term hysteria. In the early part of this paper this has been already alluded to, and, moreover, it would be super- fluous to stop to prove what will not be denied. Without descending to detail, we will merely repeat what has been before said in this con- nection : There are, among medical writers, some who regard the uterus as the Jons et origo of the symptoms called hysterical; there are others who consider hysteria as simply a pre- rogative of the female* sex ; and finally, there is a third group, who defy etymology and apply the term to certain phenomena, either in an or- gan or in an individual, without reference to sex. Believing that it will be generally ucknowl- edged that the word Hysteria is used in connec- tion with different morbid states, we will pass to the consideration of cases in which it has been wrongly used. Class i.—Cases called hysterical, in which it was subsequently ascertained that there was an error of diagnosis. Although sufficiently numerous in practice, this class of cases rarely finds its way into the journals, unless there are other points of such importance in the case as to overcome the natural dislike of any one to publish his mis- takes. It is said that the great difficulty in the differential diagnosis of hysteria, so called, resides in its powers of simulation and mimicry. Cases are referred to, in the books, where the attendant was deceived, thinking, at first, that he had to do with a frank expression of some familiar disease, but afterward discovered that it was “only hysteria.” On the other hand, the many instances are not reported where obseure cases were pronounced hysterical merely be- cause their real nature was not recognized. The experience of any physician, whose prac- tice extends over a series of years, will doubt- less furnish instances of spinal curvature, caries, brain tumor, or softening, and other grave vis- ceral lesions, which, in their incipiency, were thought to be hysteria. Such cases are vastly more frequent in practice than in medical literature, for the reasons already indicated, but the following are cases in point: — Dr. It. M. West* records a “case of sudden apoplectiform seizure, terminating fatally in thirty-six hours, on the sixth day of lying-in,” in which the symptoms were at first attributed to hysteria, but in which the autopsy showed brain lesions. In connection with this case, the words of Dr. Eugene Dupuyf have a peculiar appropri- ateness. Observation and experiment permit him to state that, “ Very likely, hysterical phe- nomena are dependent upon the abnormal state of either lateral portion of the upper part of the pons varolii” (New York Medical Record). Another case of mistaken diagnosis is given by Dr. Fordyce Barker,X in which a case of puerperal embolism of the posterior tibial artery was regarded, at first, as due to hysteria, by a surgeon who was called in consultation. * Transactions of the Obstetrical Society of London, vol. ii, p 27ti; London, 1860. t Philadelphia Medical Times, vol. VI, p. 129. I “The Puerperal Diseases.” JS'evv York, 1874 p. 259. 4 In a case recently reported by Dr. F. P. Foster, it is stated that the symptoms “ seemed, at first, to point to pulmonary embolism, but they were soon found to be caused by hysteria.” The case, until the ninth day after confinement, was doing well; but while sitting up to use a vaginal injection, she experienced general pains, with a sense of distress and impending suffocation, but without true dyspnoea. The diagnosis of hysteria was based on the fact that the patient rapidly recovered, and that she and her mother had previously had attacks called hysterical. The interesting features of this last case will be the apology for continuing it in the company of the two preceding, where it was found,* although it is scarcely a case in which the diag- nosis is acknowledged by its author to be incor- rect. It is believed that there are some who, per- haps, would explain these symptoms upon an- other hypothesis than hysteria, as due to causes among which the alteration in the blood crasis, and vascular pressure, as well as the nervous exhaustion following overstrain, both incident upon the recent parturition, would figure promi- nently. Or the explanation of this, and indeed of many other cases called hysterical, may be suggested by the diagnosis in “ Two Cases of Pe- culiar Mental Trouble following the Puerperal State,” reported by Dr. Allan McLane Hamilton, in the American Supplement to the Obstetrical Journal, for July, 1876. The patients were uraemic during pregnancy, but without convul- sions or other grave symptoms. Subsequently they displayed morbid impulses, eccentric be- havior, and suicidal manifestations. This was not the insanity of lactation, because in both these cases the milk was suppressed. He says, to quote his own words, “ I have seen the same symptoms expressed, though in a less marked degree, in patients who were suffering from chronic nephritis, and where the puerperal state had nothing to do with the history.” This is important evidence, and it is believed that it suggests the secret source of symptoms that sometimes pass for hysteria until their true nature is discovered. From these we naturally pass to the consideration of— Class ii.—Cases called hysterical, where there is room for the suspicion that a clearer insight into the nature of the disease, with due recog- nition of the pathological processes involved, would have led to a definite diagnosis. In the first group of cases the hypothesis of hysteria was acknowledged to be incorrect. The only difference between them and these we are about considering lies in the accident of dis- covery ; in the latter the real character of the disease has failed to receive recognition. To this group the great majority of cases called hysterical, in all probability, really belong. Hysteria is a most convenient word to use, in place of a diagnosis, especially in nervous affec- tions, whose expressions are confessedly so diffi- cult of interpretation. For those who desire a royal road to the understanding of these disor- ders, we may well imagine we overhear some medical Rancho Panxa piously exclaiming, ‘‘Blessed be the man who invented Hysteria!” Medical literature offers many illustrations of the truth of the assertion that the word hys- teria has been frequently used in the place of a diagnosis. The authority of Sir B. C. Brodie is quoted, on the authority of Gross,* to establish the fact that there is such a thing in pathology as a hysterical joint, and this distinguished example has been diligently copied. Medical litera- ture now offers a large assortment of hysteri- cal affections of different parts of the body; a recent illustration of this is found in the Trans- actions of the College of Physicians of this city, for 1875, in an article by Ur. Harlan, on “ Hysterical Affections of the Eye.” To remove any uncertainty as to whether or not uterine disease is indicated by the title, it may be men- tioned that the paper contains notes of five cases, in four of which the age is given ; three of these are girls, aged respectively ten, eleven, and fourteen years; and the fourth is of the male sex, whose age is immaterial for pres- ent purposes. Hysteria thus affords an example of a word which, having swung loose from its original meaning, drifts at the mercy of wind and tide, from one shade of signification to another, accord- ing to the caprice or understanding of its tempo- rary employer. In confirmation of this, we point to the medical journals themselves, that con- stantly bring us reports of cases with hysterical joints, hysterical eyes, hysterical bladders, hys- terical catalepsy, convulsions, trismus, locomotor ataxia, paralysis, and so on through a nosology purely hysterical. Viewed in this light, the ob- servation of Celsus, Ex vulva quoque feminis • “System of Surgery,” Phila., 1872, 5th ed., vol. 1, p. 1097. * New Y ork Medical Record, p. 314 of current vol ume. 5 vehemens malum nascitur, certainly applies with peculiar force. From the preceding cases, where the word Hysteria is manifestly misused, we may turn to those instances in which emotional and nervous phenomena are displayed, and which are gen- erally regarded as typical cases of hysteria. The question may here be repeated, Is it true that there is a peculiar phase of systemic disease for which nosology affords no more definite title than hysteria? In what has been called the hysterical state, weakened will-power and morbidly exalted sensibility are important factors. In such cases, the higher faculties of the mind—the reason, the judgment, and the will—become subordinated to the passions and emotions, and in proportion to the extent of this disturbance of the natural balance of the mind will phe- nomena of delirious volition and disordered in- tellection manifest themselves, ranging in de- gree from merely eccentric behavior, with fits of laughing or crying, with restrainable morbid impulses, to attacks of acute mania, hypochon- driasis, or confirmed melancholy. This will include those curious cases of unconscious malingering, with temporary loss of speech, inability to walk, epileptiform convulsions and coma, which are considered characteristic of hysteria. Dr. Bennett,* in speaking of the morbid per- version of the f elings that takes place in some cases called hysterical, states positively that “ it is really a form of temporary insanity, the result of disease.” This statement, met with after commencing this paper, has forestalled one of its intended conclusions, that cerebral hysteria is a form of insanity, mild in char- acter at times, and having its paroxysms separated by lucid intervals, but differing in neither of these traits from other mild forms of insanity which are never called hysterical. In the cases just considered, there may or may not be co-existing disease of the intra- pelvic organs, but the symptoms themselves are plainly psychological. But even should the uterus be in an abnormal condition, it is evident that, in many cases called hysterical, there are just grounds for believing that both the uterine disorder and the general symptoms are independent expressions of a general dys- crasia. Impoverished blood causes, in one direction, dysmenorrhceal troubles and patholog- ical states of the uterus and ovaries ; in an- other, through disturbed capillary circulation, it leads to mal-nutrition of the nervous ganglia generally, with, it may be, local congestions or transudations in the vesicular neurine, thus producing temporary paralysis of motion and sensation or muscular contractions when oc- curring in the spinal cord; but in the cerebral hemispheres, giving rise to psychologi- cal phenomena. Certainly, nothing can be gained by calling such cases hysterical. There is yet another class of cases, in which the symptoms are traceable to a peculiar excita- tion of the great nerve centres, from a periph- eral source of irritation. The protean character of the phenomena, presented in different cases, is due to the particular point of election in the nervous system, which responds to the irrita- tion ; thus, if within the cerebrum, it would give rise to psychological disturbances; in the medulla or cerebellum, epilepsy or chorea may result; in the spinal cord, the kinesodic tract may cause paralysis, paresis, or muscular con- tracture ; of the sensory tract, there may follow the phenomena of exalted, depressed, or per- verted sensation, including neuralgia and anal- gesia ; and occurring in the ganglia of the great sympathetic, there may be disturbed secretory function, anorexia, and perhaps alteration in bodily temperature. In some cases it is probable that two or more of these centres of irritation may concur in the same patient. But to show the narrow boundary that divides such cases from organic lesion and pathological change, we may consider what might take place in a suppositious case. For the sake of illustration, let the dorsal region of the spinal cord be the seat of election for the explosion of a peripheral irritation, the source of which may be supposed in this case to reside in a diseased uterus. As long as there is only exaltation of function of this part of the nervous system, it is conceded that the case may be correctly considered as hysteria, and the symp- toms called hysterical. But very soon continued excitation produces local changes in the cord, expressed by congestion, anaemia, or degenera- tion of nerve cells; for continued exercise of function, without physiological intervals of rest, passes rapidly over the boundary line into the domain of pathology. Secondary changes may folio v, such as inflammation, softening, sclero- *On “Inflammation of the Uterus.'’ London, 1861. 4th edition, p. 477. 6 sis, atrophy of nerve cells with relative increase of cellular tissue, which, certainly, no one would think of calling hysterical if their path- ology were recognized; and this remark applies as forcibly to the other cases just referred to, of spinal congestion, anaemia, and atony of nerve cells, only their pathology is not so readily recognized. Nor is this likely to occur as long as the word hysteria is considered a satisfactory diagnosis for cases of paresis, paraplegia and altered sensation that clearly indicate an abnor- mal condition of a nervous centre. As regards convulsive hysteria, the position defended in this paper is the one taken by Dr. Bennett in his classical work before mentioned. He says, “ Convulsive hysteria is a disease of the spino-cerebral nervous system, which may exist independently of any uterine lesion, or of any evident connection with the uterus and its functions.” To this statement, from so high an authority, nothing need be added. Although cases of so-called hysteria in the male would naturally come within the limits of this class, it is believed that no consideration of them is needed further than the mere mention of their title. Class hi.—Cases correctly diagnosed by com- petent observers, but which, judging from analogy, would have been called hysterical by others of less skill or experience. Among these may be included cases which during life were considered hysterical, but post-mortem examination showed lesions of the nervous system. Dr. Dupuy, in the article already referred to, states that he has very often observed hysterical symptoms in cases of lesions of the pons varolii, both in male and female subjects, caused by most diverse diseases. Dr. Bonnemaison* states that the body of a hys- terical female was examined after death by Grisolle, who was able to demonstrate the con- genital absence of the uterus and part of the vagina. A similar case, without the autopsy, was re- ported by the writer in the Philadelphia Medi- cal Times.f The case being of more than pass- ing interest, we reproduce part o( the clinical history from the published report:— Case.—Miss Bertha D., 22 years of age, ad- mitted into Pennsylvania Hospital, August 14, 1873. “For more than seven years she had suffered from physical disturbances every four weeks, often being obliged to keep her bed at these periods, but never had any vaginal dis- charge. She frequently had epistaxis at these times, which greatly relieved the headache and pelvic distress. On one occasion the family physician ordered an application of leeches to her thighs and abdomen, from which she expe- rienced such relief that she subsequently ap- plied them several times of her own accord. She refused to permit a vaginal examination while at home, and her physician recommended a visit to America, thinking that a change of climate might encourage the establishment of the function.” After her admission into the hospital, “ in making a digital examination, an abnormal condition of the vagina was found The sur- rounding parts showed nothing unusual, but the vagina was a cul-de-sac, of scarcely an inch in depth.” Further examination with the patient under the influence of ether showed that “ no uterus or rudiment of one existed. With two fingers in the bowel, a fold of membrane or band of fibrous tissue could be felt running across the pelvis, high up, as if it were the broad ligament. There was nothing to represent the uterus, as there was not even a perceptible thickening of this membrane in the centre.” The point of special interest in the case, in the present connection, will now appear. “The patient remained under observation nearly seven weeks, during which she showed marked hysterical symptoms, losing conscious- ness on several occasions.” Without a physical examination this case would have been pronounced purely hysterical; with one, it is seen that the hysterical symptoms, in this case at least, must have had their origin in the nervous system, and not in the uterus, because there was no uterus. There are several other cases in point that might be introduced here, but the limits of the article forbid. We cannot refrain, however, from quoting, and somewhat in detail, a case that carries with it the conviction that in less skillful hands it would have been pronounced hysterical. It is reported by Professor J. S. Jewell,* as follows:— Case.—“Mrs. S., aged 41 years; married late in life, and the mother of one child, now four years old. IShe has a nervous tempera- ment, rather light complexion, light hair and blue eyes. She is quick and lively in move- ment, in motions and temper, and has come from a nervous but otherwise healthy family. * Archives Generates de Medecin, vol. xxv, C s., 1875, p. 66B. t “Case of Absent Uterus and S’agina, with Rudi- mentary Ovaries, (?) with Regularly-recurring Men- strual Molimen.” Philadelphia Medical Times, vol. v., p. 51. * “ Case of Morbidly Exulted Sensibility.” Fcrlesof American Clinical Uectures, edited by E. C. .Seguin, New York, 1870. Vol. 11, pp. 24, el seij. 7 Mrs. S., prior to seeking advice, had been for months watching with an invalid mother, who finally died of some form of lung disease. To the loss of sleep, irregularity in habits, and the physical and mental exhaustion incident to prolonged watching, she attributes her present bad health, at least in a great measure. But prior to this she had headache, irregular appe- tite, occasional constipation, and sometimes disturbed sleep. These symptoms she has had, at times, ever since the birth of her child. She menstruates somewhat irregularly, and at times has leucorrhoea, and some pain in the sacral region, in the small of the back and through the hips, all of which latter symptoms are aggravated at the recurrence of the men- strual period. There is no cough ; there is no fixed pain anywhere. There are no decided chills and fever, except at rare and irregular intervals. There is no paralysis, and, in fact, no evidence of any serious local disease any- where, not even in the pelvis. But one condi- tion is present in her case in a very high degree, viz., abnormally exalted nervous sensi- bility, and this is man fested in almost every form and sphere, whether in the physiological or psychological relations. She is, or seems to be, sensitive to almost every touch on the skin, but particularly over the spine, along many parts of which there is well-marked hyper algesia, rather than hyperaesthesia, while in other parts these two states appear to be com- bined. Though the skin has almost a normal temperature, yet she complains inordinately of cold impressions when they are made. There is very slight photophobia, and moderate use of the eyes, especially if the gaze i3 intent or fixed for a few minutes, gives rise to dizz'ness of the head, feelings of intra-cranial pressure, especially at the top of the head, pain in the occipital region, formication in the skin of the upper extremities and upper portion of the trunk, and sometimes of other parts of the body. Beside these phenomena, and others, vaso motor disturbances in the skin of the fingers, more especially of the palmar surface, appear; and palpitation of the heart, embar- rassed breathing, and feelings of nausea and faintness arise upon fixed use of the eyes. But the most careful examination I have been able to make does not show any defect in the vision as regards the capacity for adjustment, etc., which might account for the symptoms I have just related. “ ller hearing is acute, more so than natural. She has frequent ringing in the ears, and some- times other abnormal sounds, but they are not constant in kind nor duration. “ Our patient eannot rise up suddenly after sitting or lying, or stoop down, or, as she lies, sometimes, cannot turn in bed, so she will rest on one side, and thus disturb the equilibrium of the intra-cranial circulation ; nor can she apply herself mentally, without experiencing in all these cases confusion and vertigo. “ If she becomes exhausted, she can feel her heart beat, and the pulsations of the arteries in many parts of the body, even at the fingers’ tips. “ At times she can feel the peristaltic move- ments of the bowels with startling distinctness, or the presence of food in the stomach, or of fecal accumulations in the lower bowels if she become constipated ; or the presence of urine in the bladder, even when it is moderately dis- tended. A slight sound, if unexpected, and more particularly if unusual in character, gives her a most uncomfortable start, affecting momentarily the action of nearly the whole muscular system, and also for a time the action of the vascular system. In other words, reflex excitability of the nervous system is greatly exaggerated in her case. “ Site is just as morbidly excitable in her emotions, especially those of a depressing char- acter, as she is in respect to her mere physio- logical sensibilities. She is easily distressed and filled with anxiety by slight causes, whether arising out of her own condition or of her surroundings. She is especially alarmed at the various changes in her feelings that occur and vary almost hourly, unless her mind is pleasantly occupied with company, or in some other way. She is as weak in will power as she is in muscular power. Nervous weakness may show itself in either or both of these ways.” “ The pathological conditions underlying this will be found present in hundreds of others, which differ from it only in their extent and the grouping or peculiar character of their symptoms. If this be so, it is a matter of im- portance for us to have a correct knowledge, if we can obtain it, of the nature of the condi- tion of the nervous system itself, out of which these many-hued and morbid forms of sensi- bility spring.” In short, Professor Jewell concludes that in the nervous system of such patieuts there “ is a lesion of nutrition, which consists in a more or less serious loss of balance, as between waste and repair, and on the side of the former. “ The nervous centres become so unstable and responsive when in this impaired state, that the slightest centripetal impressions are capable of arousing reflexes, altogether dispro- portionate, in energy, duration, and extent, to their cause, as compared with the natural course of such things. ... It is rather customary in considering these cases of hyperaesthesia, hy- peralgesia, exalted reflex excitability, etc., to fix their organic seat in a vague way in the peripheral nerves or surface, but in my opinion this is a grave error. I do not say that the condition of the nerve fibres plays no part in these cases of morbidly exalted sensibility, but I am prepared to affirm that they have but little to do with it.” The diagnosis of this case is given by Pro- fessor Jewell as Exalted Morbid Sensibility, and it requires no comment. In drawing this paper to a close, it is believed 8 that the consideration of the subject warrants the following vii. Where this cause exists elsewhere than with the uterus, the symptoms are improperly termed hysterical. vm. As there is nothing in the symptoms themselves to indicate whether they are uterine, or not uterine, in their origin, the word Hysteria is of doubtful propriety, being in one case incorrectly applied, and in the other having nothing to commend' it that would counter- balance its positive disadvantage of imposing a definite pathological character upon a disease in advance of the diagnosis. ix. Medical nomenclature offers more precise expressions for the various uterine diseases than the word Hysteria, while its use to describe a pure neurosis is evidently incorrect. In all cases called hysterical, the diagnostician should not be misled by a name given to a group of symptoms, but should investigate their nature and source, and apply, in preference, a title that more clearly describes their pathological relations. x. The progress of pathology requires that the use of the word Hysteria should be very much restricted, if not finally discontinued. conclusions: i. What has been called Hysteria is not a disease, but a symptom of disease. ii. Where the pathological source of such symptom resides in the uterus or ovaries, cases may, with some show of propriety, be termed hysterical. hi. Where the uterus and organs associated with it in function are not in a morbid condi- tion, no symptoms can be correctly called hys- terical. iv. When the diagnosis of Hysteria is made, the burden of proof rests with the user of the term to show, first, that there is co existing uterine disorder, and, secondly, that it is the direct and sole cause of the pathological phe- nomena in question. v. Symptoms called hysterical may be due to reflex irritation of the great nerve centres. vi. The source of the irritation causing these reflex symptoms may reside in any other organ than the uterus.