HISTORICAL NEUROLOGY
Mitchell’s case of “pendulum spasms” Psychogenic movement disorder considered as male hysteria
Douglas J. Lanska, MD, MS, MSPH
Correspondence to Dr. Lanska: [email protected]
ABSTRACT
Background: In the late 19th century, a man with a psychogenic movement disorder was evaluated by many of the Philadelphia neurologists associated with Silas Weir Mitchell. In 1885, prior to the development of movie cameras or projectors, the patient was photographed by pioneering photographer Eadweard Muybridge, in collaboration with neurologist Francis Dercum, using arrays of sequentially triggered single-image cameras. The photographic sequences are among the first motion picture sequences of patients with neurologic disorders.
Methods: Examination of extant primary source documents concerning this patient, including published writings and photographic sequences by Muybridge and Dercum, the original clinical descriptions, Mitchell’s documentation of the patient’s later clinical course, and results of the autopsy.
Results: Mitchell and his colleagues concluded that this was a “case of undoubted hysteria” in a man. Support for this contention includes the following: protracted course, spanning decades with temporary remissions; inconsistent character of the movement and features incongruous with typical “organic” tremors; complex, bizarre movements that are difficult to classify; increase in movements with attention; alteration in frequency of the movements with movement of the opposite arm; ability to trigger or temporarily stop the movements with unusual or nonphysiologic interventions; involvement of the opposite arm in a synchronous abnormal movement later in the course; remission with hypnotic suggestion; absence of other neurologic signs; and normal brain autopsy. Conclusion: The clinical history, serial examinations, photographic documentation, and autopsy results support Mitchell’s contention that this was a case of male hysteria, or, in modern terminology, a psychogenic movement disorder. Neurology® 2015;84:424–429
Supplemental data at Neurology.org
Hysteria had long served as a misogynistic, medicalized judgment of the behavior of women, but it came to renewed prominence as a medical disorder in the late 19th century, particularly with the work of Jean-Martin Charcot, Silas Weir Mitchell, and Sigmund Freud1–11 (see table e-1 on the Neurology® Web site at Neurology.org for years of birth and death of individuals referred to in this article). Charles Lepois, Thomas Willis, and Thomas Sydenham had argued in the 17th century that both men and women were susceptible to nervous disorders, and even that female hysteria was analogous to male hypochondriasis, but throughout the 19th century hysteria was commonly considered almost exclusively as a disorder of women.4,5 Charcot, Mitchell, and other late-19th-century neurologists promoted an organic paradigm to explain hysteria, approaching it as a neurophysiologic disorder with a putative underlying organic pathology that had so far eluded detection.1–11 By 1875, Mitchell7 had formulated the key components of his eponymous “rest cure” for neurasthenia and hysteria—a combination of “seclusion, certain forms of diet, rest in bed, massage (or manipulation), and electricity”8(p33)—that was employed particularly with women.6–11 The loosely formulated rationale for this approach was to provide stimulating and restorative treatments that would allow repletion of exhausted neural energy stores in affected women. This treatment became the standard treatment of hysteria for several decades, From the Neurology Service, Veterans Affairs Medical Center, Great Lakes VA Healthcare System, Tomah, WI. Portions of this work were presented previously in scientific and educational sessions at annual meetings of the American Academy of Neurology on April 1, 2003; April 28, 2004; April 10, 2005; April 12, 2011; and April 23, 2012. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the author, if any, are provided at the end of the article.
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ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
serving at least to move common practice away from medicating affected individuals with bromides and opiates. Discounting the former gynecologic theories in favor of a neurophysiologic or neuropathologic formulation opened the conceptual possibility that both men and women could be affected by the disorder, and indeed beginning in the latter half of the 19th century Pierre Briquet (1859) and later Charcot (from 1878 to 1893) championed the idea that men could also be affected.2,4,5 Even into the early 20th century, though, no neurophysiologic or neuropathologic basis of neurasthenia or hysteria was substantiated, although some neurologists (Charcot and Mitchell included) argued that the changes were simply too subtle for existing methods to detect. In 1876, Silas Weir Mitchell12 reported a man with a complex psychogenic movement disorder, using in part observations of his clinical assistant Wharton Sinkler. The patient was considered then as a rare case of hysteria in a man and was eventually studied by many Philadelphia neurologists associated with Mitchell, including Francis Dercum, Morris Lewis, John Kearsley Mitchell, and John Madison Taylor.13–17 He was one of the first medical subjects ever to be filmed with a motion picture apparatus and these images and meticulous clinical descriptions are extant.15–20 In 1904, with William Spiller, Mitchell13,14 provided further clinical details and results of autopsy. Because of the long time under observation and the lack of confounding intercurrent medical illness, the case was considered especially important in the quest for an organic locus for hysteria, and also served to reinforce Charcot’s view that hysteria was not restricted to women. CASE HISTORY Robert Connolly (R.C.), a 33-yearold watch-case maker, presented to Mitchell in 1876. In 1874, R.C. had developed intermittent leg weakness with walking, and was forced to stop “to regain power” after which the right leg would “drag for a time.”12(p329) In January 1875, he developed an intermittent, fine left-hand tremor, “only visible when the left arm was flexed,”13(p626) which soon developed peculiar characteristics: with slight movements of other limbs, or with talking or eating, the left arm moved in a pendular fashion.
[The movements] so much resembled the steady, rapid movement of a pendulum that I spoke of it at once to my assistants as a case of what might be called, descriptively, pendulum spasms. In fact, its rhythmic regularity was astonishing [157160/minute].It was as accurate as the heart in its motion.12(p329)
Certain factors modified the movements: emotional excitement and electrical stimulation increased the force, and voluntary movements of other limbs increased the frequency. If the patient stood up, the left arm struck the thigh with markedly greater force, and if he then raised his right arm, the frequency increased to 200/min until the arm was lowered. The movements ceased during sleep, but upon wakening his fingers “began to twitch.moving as do those of a violin player.”12(p329) The movements could also be temporarily halted by certain maneuvers, but such efforts caused intense headache. When the movements temporarily ceased, left arm motor function was normal, except for the hand “which itself never ceased to twitch.”13(p627) Attempts passively to fully extend his partially flexed fingers, caused increased pain in the occiput.If he seized the left hand by the right, and flexing the left arm, held it, the left hand for a moment seemed to struggle with increasing violence; he tottered, his face became convulsed; there was horrible pain in the back of the head. Then as he gently released the left arm, save for a slight tremor or twitching of the unquiet fingers, it remained at rest, and might not move in violent spasm for an hour or more, and was sometimes nearly still for twelve hours.When standing, if he wished to check the pendulum spasm, he threw the left leg back so as to trip the toe; the arm then fell in to the right as it moved and he brought the leg forward, catching the arm against the thigh. Then there was a general convulsive movement of the entire body and the limb came to rest. When the arm was hanging at his side it began to move if he walked a few steps, or if he lifted the right arm, in which at times, especially after sudden arrest of the spasm, I noticed some large tremor.13(pp627–628)
In October 1876, the “pendulum spasms” were replaced by intermittent complex rotatory limb movements: “The extended left hand and arm described a circle at the rate of 140 a minute or more.”13(p628) In 1885, Mitchell released R.C. to Dercum to be photographed by English-American photographer Eadweard Muybridge (although in 1904, Mitchell misremembered the year as 1888).13–17 Muybridge had been recruited by the University of Pennsylvania to expand his pioneering motion picture efforts with sequentially triggered single-image cameras.17 Dercum Neurology 84
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collaborated with Muybridge to photograph neurologic patients from the University Hospital neurology clinic and the Philadelphia Hospital wards. According to extant correspondence, Dercum was responsible for the idea of applying Muybridge’s technique to record disorders of movement.17 Muybridge’s 11-volume Animal Locomotion (1887) included 592 separate images on 22 plates of 20 subjects with neurologic
Figure 1
disorders.17–20 Two plates, with 5 separate motion sequences totaling 56 individual photographic images, were taken of R.C. (figure 1). Dercum considered R.C. a case of “functional spasm (local chorea)”12(p330) with similarities to suggestion-induced pseudoseizures.16,21 Dercum noted that R.C. held his arm semi-flexed with hand and fingers “markedly contracted and in constant vibration.”16(p332) With walking, the flexion
Motion picture sequences of Mitchell’s case of “pendulum spasms”
Motion picture sequences of R.C.’s psychogenic movement disorder taken by pioneering photographer Eadweard Muybridge using sequentially triggered single-image cameras in 1885. Rows 1–4 are from Muybridge’s Plate 556, and rows 5–7 are from Plate 557, selected by Muybridge from 6 multi-image negatives taken of R.C. on June 24, 1885. Although the patient’s abnormal movements ceased in a supine position, they were triggered by volitionally raising his head (rows 1–2) or by Dercum eliciting a knee jerk with a karate chop to the patellar tendon (rows 3–4). Rows 5–7 show 3 separate sequences of R.C.’s abnormal movements while standing. Row 5 shows the movements precipitated by walking, row 6 shows the subsequent exacerbation and change in character of the movements to large rotary motions if R.C. attempted to raise his arms at the shoulder, and row 7 shows the change to oscillatory movements if instead of raising the arms at the shoulder he flexed at the elbows. The images are from Muybridge’s Complete Human and Animal Locomotion (1887). Public domain. Courtesy of the Boston Public library. 426
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posture changed to a rapid rotary arm motion at 2–3 Hz, but increasing “wonderfully in extent”16(p333) with attempted arm abduction (figure 1).16 Ultimately, identical synchronous movements developed in the opposite arm: “There is certainly here a curious association of movement.”16(pp333–334) R.C. could trigger or relieve the movements with unusual interventions: all abnormal movements ceased while supine, but were triggered with volitionally raising the head, or if the examiner struck the right patellar tendon or tried to elicit ankle clonus (which was absent) (figures 1 and 2).13–16 Sharply tapping the leg muscles, including the quadriceps, did not elicit the movements.13 If Mr. C..lies down with his back and head flat upon the ground, all vibration of the hand ceases. It becomes perfectly quiet, and he can execute with it the most exact and delicate voluntary movements. If, however, he now attempts to raise the head, violent tremor at once appears in the hand.This tremor is so violent that the feet and head are affected. It is remarkable that raising of the head is the only [volitional] movement that provokes the tremor. Raising the right hand or either foot has no effect. Similarly, [abnormal movements can be].violently excited by striking the patellar tendon.or by attempting to elicit ankle clonus. It is also a remarkable fact that the tremor so excited.cannot be quieted unless Mr. C. arises completely from the ground and lies down anew.16(pp334–335)
Numerous treatments proved unsuccessful. Beginning in 1897, however, R.C. was hypnotized by Taylor and later by Mitchell, with temporary resolution of all abnormal movements and return to normal
Figure 2
function and productive employment. Taylor had been Mitchell’s personal assistant at the Infirmary for Nervous Diseases (1882–1896),22 and was experienced with hypnotism.23 Despite obvious clinical improvement, R.C. refused further hypnotism. As Mitchell recounted: He saw many doctors and haunted clinics, and was variously treated with no good result. In December, 1897, I asked Dr. J.M. Taylor to hypnotize Mr. C. and use suggestion.As usual, Mr. C. took a freshly hopeful interest in the new treatment, and kept a penciled, irregular record of the sittings and their results. For a long while it was impossible to induce the hypnotic state, but as Dr. Taylor writes me, after thirty sittings, of a half hour each, partial effects were attained. During these many sittings Mr. C. never passed into deep sleep.Mr. C’s notes state that after the seventh sitting he wrote a letter with his left hand and without tremor. On the twenty-third sitting the pendulum movements, previously very active, ceased for a few hours. This effect was obtained thereafter only at intervals during daily hypnotization. In January the sittings were more successful, and on the fifteenth sitting in that month all spasms ceased. He was able to take a place as assistant in the Jefferson College library, and for three months continued well, efficient and much liked for gentleness and amiability. Then something took place which excited him disagreeably.The spasms returned in both forms. While he was in bed, Dr. Taylor visited him, and was able to so influence him by an order that he could rise and walk about the room without spasmodic actions. It is interesting that after this he declined to be aided again by hypnotic means,
Superimposed tracings made by Dercum from photographic images of the patient’s psychogenic movement disorder
Superimposed tracings made by Dercum of R.C.’s movements from separate frames of the individual motion sequences.4 These superimposed tracings show the range and overall character of R.C.’s movements. The top leftmost image corresponds to rows 1–2 of figure 1, whereas the bottom leftmost image corresponds to rows 3–4 (note the representation of Dercum’s hand used to elicit a knee jerk with a karate chop), and from left to right the remaining images correspond to rows 5–7, respectively. The images are from Dercum’s chapter, “A study of some normal and abnormal movements photographed by Muybridge,” in Animal Locomotion: The Muybridge Work at the University of Pennsylvania: The Method and the Result (1888). Public domain. Courtesy of Google Books. Neurology 84
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declaring to Dr. Taylor that the hand of the Lord was upon him, and that he felt he should bear his trouble with a serene mind to the end of his days.Once, however, he allowed me to hypnotize him, with good results, which were not lasting, but after this would have no more of it nor give a reason except that it was disagreeable. Probably he missed the attention his case excited, for now again he began to appear at the clinics, but was unwilling to take any form of treatment. It is needless to say that every other means of treatment had been sedulously employed, and that excepting hypnotic suggestion, all had failed.13(pp631–632)
After 1898, R.C.’s overall neurologic condition was better, but his movements never resolved: In these later years there was no change of movement, but he was certainly stronger, and when in the country walked five or six miles daily. The pendulum movement was not often observed, and the weakness of the legs never returned. The rotation action persisted.until his death.13(p631)
In July 1903, R.C. developed congestive heart failure, and subsequently died that November, after which an autopsy was performed by Augustus Eschner, Alfred Allen, and Allen Smith, with the assistance of Spiller, “to whom was confided the study of the nerve organs”13(p632): Whether through hysterical interests and the vanity of being thought unusual, or because I had been able to serve him in various ways, he volunteered to leave me his body. Within a few hours after his death I made free to use this privilege. There had been meanwhile no intercurrent malady, nothing to disturb such pathologic states as hysteria might offer. The death was sudden. The conditions seemed to be ideally perfect. This unusual chance was fully utilized.13(pp625–626)
Meticulous gross and microscopic examination of the CNS revealed no pathologic abnormalities.13 Remarkable, indeed, were the involuntary movements.in this case, persisting through so long a period, and it may at first thought seem strange to those who have not paid much attention to the pathology of the nervous system, that no lesions have been found to explain them, and yet we could hardly expect spasms that could be held in check for sometime by hypnotism to be dependent on organic changes in the nervous system.13(p633)
After almost 3 decades of observation and a negative autopsy, Mitchell and Spiller13 concluded that R.C. had hysteria:
characteristic.The conclusion justifies us in stating that with our present methods the most typical hysteria lasting for years, presents no sign of representative organic lesion. This is, however, the wisdom of to-day; that of to-morrow may be based on other and more refined methods and be very different.13(pp637–638) DISCUSSION The clinical history, serial examinations, photographic documentation, and autopsy results support Mitchell’s contention that this was a “case of undoubted hysteria”13(p638) in a man, or, in modern terminology, a psychogenic movement disorder: absence of other neurologic signs, despite careful evaluations by multiple skilled neurologists over 3 decades; protracted course with normal function during temporary remissions; complex, bizarre movements that are difficult to classify; inconsistent character of movements and other features incongruous with typical “organic” tremors (including bizarre precipitating and relieving factors); increase in movements with attention; alteration of movement frequency with movements of the opposite arm; involvement of the opposite arm in a synchronous abnormal movement; ability to trigger or temporarily stop the abnormal movements with unusual nonphysiologic interventions; inexplicable features (e.g., profound occipital pain with passive finger extension); features suggestive of la belle indifference; temporary remission with hypnotic suggestion; normal limb function when movements remitted; and normal brain autopsy.24–28 The diagnostic certainty for psychogenic movement disorder can be considered as “documented” according to the 1988 Fahn-Williams classification scheme (symptoms relieved by suggestion, psychotherapy, or placebo, or symptoms absent when surreptitiously observed).27 As with R.C., treatment of hyperkinetic psychogenic movement disorders remains difficult: such disorders often persist and cause considerable disability.24,27–30 Although R.C. was considered an ideal case in which to seek a neuropathologic substrate for hysteria, this hope was ultimately frustrated. Even though Mitchell, like Charcot, held out hope that an organic basis for hysteria would ultimately be identified with new methodologies,3–5,14 it was not long after this that etiologic theories of hysteria moved from a neuropathologic to a psychopathologic basis, particularly with the influence of Sigmund Freud and the rise of private practice psychiatry.4,5 AUTHOR CONTRIBUTIONS Dr. Lanska was responsible for all aspects of this study.
No one would hesitate to label [this as] hysteria. The psychical picture is complete. The mental peculiarities, the motor phenomena, the vesical [bladder] symptoms, the 1 form of therapeutic success are all 428
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STUDY FUNDING D. Lanska is supported by the Department of Veterans Affairs and has also received the following support: American Academy of Neurology,
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Minneapolis, MN, funding for travel (oral history interviews); MedLink Neurology, editorial responsibilities and authorship; Encyclopedia of the Neurological Sciences, editorial responsibilities and authorship; State Farm Insurance Co., consultation fee for review of a personal injury claim; International Society for the History of the Neurosciences, partial funding for travel (invited lecture); and I.M. Sechenov First Moscow State Medical University, Moscow, Russia, funding for travel (invited lectures).
14.
DISCLOSURE
16.
15.
The author reports no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
Received June 19, 2014. Accepted in final form October 1, 2014. REFERENCES 1. Charcot J-M. Clinical Lectures on Diseases of the Nervous System: Delivered at the Infirmary of La Salpêtriere by Professor J.M. Charcot. Volume III. Translated by Thomas Savill. London: The New Sydenham Society; 1889:77. 2. Goetz CG. Charcot: The Clinician: The Tuesday Lessons: Excerpts From Nine Case Presentations on General Neurology Delivered at the Salpêtriere Hospital in 1887–88. New York: Raven Press; 1987:116–117. 3. Goetz CG, Bonduelle M, Gelfand T. Charcot: Constructing Neurology. New York: Oxford University Press; 1995: 206–207. 4. Micale MS. Charcot and the idea of hysteria in the male: gender, mental science, and medical diagnosis in late nineteenth-century France. Med Hist 1990;34:363–411. 5. Micale MS. Hysterical Men: The Hidden History of Male Nervous Illness. Cambridge, MA: Harvard University Press; 2008. 6. Lanska DJ. Characteristics and lasting contributions of 19th-century American neurologists. J Hist Neurosci 2001;10:202–216. 7. Mitchell SW. Rest in nervous disease: its use and abuse. In: Seguin EC, ed. A Series of American Clinical Lectures. New York: G.P. Putnam’s Sons; 1875:83–102. 8. Mitchell SW. Fat and Blood, and How to Make Them. Philadelphia: Lippincott; 1877. 9. Mitchell SW. The treatment of obstinate cases of nervous exhaustion and hysteria by seclusion, rest, massage, electricity, and full feeding. In: Mitchell SW. Lectures on Diseases of the Nervous System: Especially in Women, 2nd edition. Churchill, UK: K & A; 1885:265–283. 10. Mitchell SW. The evolution of the rest treatment. J Nerv Ment Dis 1904;31:368–373. 11. Mitchell SW. The treatment by rest, seclusion, etc., in relation to psychotherapy. JAMA 1908;50:2033–2037. 12. Mitchell SW. On functional spasms. Am J Med Sci 1876; 22:321–333. 13. Mitchell SW, Spiller WG. A case of uncomplicated hysteria in the male, lasting thirty years, with post-mortem examination. J Nerv Ment Dis 1904;31:625–638.
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Mitchell SW, Spiller WG. A case of uncomplicated hysteria in the male, lasting thirty years, with postmortem examination. Trans Assoc Am Physicians 1904; 19:433–435. Dercum FX. The walk and some of its phases in disease: together with other studies based on the Muybridge investigation. Trans Coll Phys Phil 1888;10:308–338. Dercum FX. A study of some normal and abnormal movements photographed by Muybridge. In: Animal Locomotion. The Muybridge Work at the University of Pennsylvania: The Method and the Result. Philadelphia: J.B. Lippincott; 1888:103–133. Lanska DJ. The Dercum-Muybridge collaboration for sequential photography of neurologic disorders. Neurology 2013;81:1550–1554. Muybridge E. Animal Locomotion: An Electrophotographic Investigation of Consecutive Phases of Animal Movements, 1872–1885, Vol. VIII. Philadelphia: University of Pennsylvania; 1887. Muybridge E. Abnormal movements, males & females (nude & semi-nude): vol. 8. In: Muybridge’s Complete Human and Animal Locomotion: All 781 Plates From the 1887 Animal Locomotion, Vol. II. New York: Dover Publications; 1979:1081–1139. Muybridge E. Animal Locomotion: An Electrophotographic Investigation of Consecutive Phases of Animal Movements: Prospectus and Catalogue of Plates. Philadelphia: J.B. Lippincott; 1887. Dercum FX, Parker AJ. On the artificial induction of convulsive seizures. J Nerv Ment Dis 1884;11:579–588. Lanska DJ. John Madison Taylor (1855–1931) and the first reflex hammer. J Child Neurol 1990;5:38–39. Taylor JM. Hypnotism. JAMA 1899;32:487. Deuschl G, Köster B, Lücking CH, Scheidt C. Diagnostic and pathophysiological aspects of psychogenic tremors. Mov Disord 1998;13:294–302. Fahn S, Williams D. Psychogenic dystonia. Adv Neurol 1988;50:431–455. Jankovic J, Vuong KD, Thomas M. Psychogenic tremor: long-term outcome. CNS Spectr 2006;11:501–508. Koller W, Lang A, Vetere-Overfield B, et al. Psychogenic tremors. Neurology 1989;39:1094–1099. Monday K, Jankovic J. Psychogenic myoclonus. Neurology 1993;43:349–352. Feinstein A, Stergiopoulos V, Fine J, Lang AE. Psychiatric outcome in patients with a psychogenic movement disorder: a prospective study. Neuropsychiatry Neuropsychol Behav Neurol 2001;14:169–176. McKeon A, Ahlskog JE, Bower JH, Josephs KA, Matsumoto JY. Psychogenic tremor: long-term prognosis in patients with electrophysiologically-confirmed disease. Mov Disord 2009;24:72–76.
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Mitchell's case of ''pendulum spasms'': Psychogenic movement disorder considered as male hysteria Douglas J. Lanska Neurology 2015;84;424-429 DOI 10.1212/WNL.0000000000001192 This information is current as of January 26, 2015 Updated Information & Services
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Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
Mitchell’s case of “pendulum spasms” Psychogenic movement disorder considered as male hysteria
Douglas J. Lanska, MD, MS, MSPH
Correspondence to Dr. Lanska: [email protected]
ABSTRACT
Background: In the late 19th century, a man with a psychogenic movement disorder was evaluated by many of the Philadelphia neurologists associated with Silas Weir Mitchell. In 1885, prior to the development of movie cameras or projectors, the patient was photographed by pioneering photographer Eadweard Muybridge, in collaboration with neurologist Francis Dercum, using arrays of sequentially triggered single-image cameras. The photographic sequences are among the first motion picture sequences of patients with neurologic disorders.
Methods: Examination of extant primary source documents concerning this patient, including published writings and photographic sequences by Muybridge and Dercum, the original clinical descriptions, Mitchell’s documentation of the patient’s later clinical course, and results of the autopsy.
Results: Mitchell and his colleagues concluded that this was a “case of undoubted hysteria” in a man. Support for this contention includes the following: protracted course, spanning decades with temporary remissions; inconsistent character of the movement and features incongruous with typical “organic” tremors; complex, bizarre movements that are difficult to classify; increase in movements with attention; alteration in frequency of the movements with movement of the opposite arm; ability to trigger or temporarily stop the movements with unusual or nonphysiologic interventions; involvement of the opposite arm in a synchronous abnormal movement later in the course; remission with hypnotic suggestion; absence of other neurologic signs; and normal brain autopsy. Conclusion: The clinical history, serial examinations, photographic documentation, and autopsy results support Mitchell’s contention that this was a case of male hysteria, or, in modern terminology, a psychogenic movement disorder. Neurology® 2015;84:424–429
Supplemental data at Neurology.org
Hysteria had long served as a misogynistic, medicalized judgment of the behavior of women, but it came to renewed prominence as a medical disorder in the late 19th century, particularly with the work of Jean-Martin Charcot, Silas Weir Mitchell, and Sigmund Freud1–11 (see table e-1 on the Neurology® Web site at Neurology.org for years of birth and death of individuals referred to in this article). Charles Lepois, Thomas Willis, and Thomas Sydenham had argued in the 17th century that both men and women were susceptible to nervous disorders, and even that female hysteria was analogous to male hypochondriasis, but throughout the 19th century hysteria was commonly considered almost exclusively as a disorder of women.4,5 Charcot, Mitchell, and other late-19th-century neurologists promoted an organic paradigm to explain hysteria, approaching it as a neurophysiologic disorder with a putative underlying organic pathology that had so far eluded detection.1–11 By 1875, Mitchell7 had formulated the key components of his eponymous “rest cure” for neurasthenia and hysteria—a combination of “seclusion, certain forms of diet, rest in bed, massage (or manipulation), and electricity”8(p33)—that was employed particularly with women.6–11 The loosely formulated rationale for this approach was to provide stimulating and restorative treatments that would allow repletion of exhausted neural energy stores in affected women. This treatment became the standard treatment of hysteria for several decades, From the Neurology Service, Veterans Affairs Medical Center, Great Lakes VA Healthcare System, Tomah, WI. Portions of this work were presented previously in scientific and educational sessions at annual meetings of the American Academy of Neurology on April 1, 2003; April 28, 2004; April 10, 2005; April 12, 2011; and April 23, 2012. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the author, if any, are provided at the end of the article.
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ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
serving at least to move common practice away from medicating affected individuals with bromides and opiates. Discounting the former gynecologic theories in favor of a neurophysiologic or neuropathologic formulation opened the conceptual possibility that both men and women could be affected by the disorder, and indeed beginning in the latter half of the 19th century Pierre Briquet (1859) and later Charcot (from 1878 to 1893) championed the idea that men could also be affected.2,4,5 Even into the early 20th century, though, no neurophysiologic or neuropathologic basis of neurasthenia or hysteria was substantiated, although some neurologists (Charcot and Mitchell included) argued that the changes were simply too subtle for existing methods to detect. In 1876, Silas Weir Mitchell12 reported a man with a complex psychogenic movement disorder, using in part observations of his clinical assistant Wharton Sinkler. The patient was considered then as a rare case of hysteria in a man and was eventually studied by many Philadelphia neurologists associated with Mitchell, including Francis Dercum, Morris Lewis, John Kearsley Mitchell, and John Madison Taylor.13–17 He was one of the first medical subjects ever to be filmed with a motion picture apparatus and these images and meticulous clinical descriptions are extant.15–20 In 1904, with William Spiller, Mitchell13,14 provided further clinical details and results of autopsy. Because of the long time under observation and the lack of confounding intercurrent medical illness, the case was considered especially important in the quest for an organic locus for hysteria, and also served to reinforce Charcot’s view that hysteria was not restricted to women. CASE HISTORY Robert Connolly (R.C.), a 33-yearold watch-case maker, presented to Mitchell in 1876. In 1874, R.C. had developed intermittent leg weakness with walking, and was forced to stop “to regain power” after which the right leg would “drag for a time.”12(p329) In January 1875, he developed an intermittent, fine left-hand tremor, “only visible when the left arm was flexed,”13(p626) which soon developed peculiar characteristics: with slight movements of other limbs, or with talking or eating, the left arm moved in a pendular fashion.
[The movements] so much resembled the steady, rapid movement of a pendulum that I spoke of it at once to my assistants as a case of what might be called, descriptively, pendulum spasms. In fact, its rhythmic regularity was astonishing [157160/minute].It was as accurate as the heart in its motion.12(p329)
Certain factors modified the movements: emotional excitement and electrical stimulation increased the force, and voluntary movements of other limbs increased the frequency. If the patient stood up, the left arm struck the thigh with markedly greater force, and if he then raised his right arm, the frequency increased to 200/min until the arm was lowered. The movements ceased during sleep, but upon wakening his fingers “began to twitch.moving as do those of a violin player.”12(p329) The movements could also be temporarily halted by certain maneuvers, but such efforts caused intense headache. When the movements temporarily ceased, left arm motor function was normal, except for the hand “which itself never ceased to twitch.”13(p627) Attempts passively to fully extend his partially flexed fingers, caused increased pain in the occiput.If he seized the left hand by the right, and flexing the left arm, held it, the left hand for a moment seemed to struggle with increasing violence; he tottered, his face became convulsed; there was horrible pain in the back of the head. Then as he gently released the left arm, save for a slight tremor or twitching of the unquiet fingers, it remained at rest, and might not move in violent spasm for an hour or more, and was sometimes nearly still for twelve hours.When standing, if he wished to check the pendulum spasm, he threw the left leg back so as to trip the toe; the arm then fell in to the right as it moved and he brought the leg forward, catching the arm against the thigh. Then there was a general convulsive movement of the entire body and the limb came to rest. When the arm was hanging at his side it began to move if he walked a few steps, or if he lifted the right arm, in which at times, especially after sudden arrest of the spasm, I noticed some large tremor.13(pp627–628)
In October 1876, the “pendulum spasms” were replaced by intermittent complex rotatory limb movements: “The extended left hand and arm described a circle at the rate of 140 a minute or more.”13(p628) In 1885, Mitchell released R.C. to Dercum to be photographed by English-American photographer Eadweard Muybridge (although in 1904, Mitchell misremembered the year as 1888).13–17 Muybridge had been recruited by the University of Pennsylvania to expand his pioneering motion picture efforts with sequentially triggered single-image cameras.17 Dercum Neurology 84
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collaborated with Muybridge to photograph neurologic patients from the University Hospital neurology clinic and the Philadelphia Hospital wards. According to extant correspondence, Dercum was responsible for the idea of applying Muybridge’s technique to record disorders of movement.17 Muybridge’s 11-volume Animal Locomotion (1887) included 592 separate images on 22 plates of 20 subjects with neurologic
Figure 1
disorders.17–20 Two plates, with 5 separate motion sequences totaling 56 individual photographic images, were taken of R.C. (figure 1). Dercum considered R.C. a case of “functional spasm (local chorea)”12(p330) with similarities to suggestion-induced pseudoseizures.16,21 Dercum noted that R.C. held his arm semi-flexed with hand and fingers “markedly contracted and in constant vibration.”16(p332) With walking, the flexion
Motion picture sequences of Mitchell’s case of “pendulum spasms”
Motion picture sequences of R.C.’s psychogenic movement disorder taken by pioneering photographer Eadweard Muybridge using sequentially triggered single-image cameras in 1885. Rows 1–4 are from Muybridge’s Plate 556, and rows 5–7 are from Plate 557, selected by Muybridge from 6 multi-image negatives taken of R.C. on June 24, 1885. Although the patient’s abnormal movements ceased in a supine position, they were triggered by volitionally raising his head (rows 1–2) or by Dercum eliciting a knee jerk with a karate chop to the patellar tendon (rows 3–4). Rows 5–7 show 3 separate sequences of R.C.’s abnormal movements while standing. Row 5 shows the movements precipitated by walking, row 6 shows the subsequent exacerbation and change in character of the movements to large rotary motions if R.C. attempted to raise his arms at the shoulder, and row 7 shows the change to oscillatory movements if instead of raising the arms at the shoulder he flexed at the elbows. The images are from Muybridge’s Complete Human and Animal Locomotion (1887). Public domain. Courtesy of the Boston Public library. 426
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posture changed to a rapid rotary arm motion at 2–3 Hz, but increasing “wonderfully in extent”16(p333) with attempted arm abduction (figure 1).16 Ultimately, identical synchronous movements developed in the opposite arm: “There is certainly here a curious association of movement.”16(pp333–334) R.C. could trigger or relieve the movements with unusual interventions: all abnormal movements ceased while supine, but were triggered with volitionally raising the head, or if the examiner struck the right patellar tendon or tried to elicit ankle clonus (which was absent) (figures 1 and 2).13–16 Sharply tapping the leg muscles, including the quadriceps, did not elicit the movements.13 If Mr. C..lies down with his back and head flat upon the ground, all vibration of the hand ceases. It becomes perfectly quiet, and he can execute with it the most exact and delicate voluntary movements. If, however, he now attempts to raise the head, violent tremor at once appears in the hand.This tremor is so violent that the feet and head are affected. It is remarkable that raising of the head is the only [volitional] movement that provokes the tremor. Raising the right hand or either foot has no effect. Similarly, [abnormal movements can be].violently excited by striking the patellar tendon.or by attempting to elicit ankle clonus. It is also a remarkable fact that the tremor so excited.cannot be quieted unless Mr. C. arises completely from the ground and lies down anew.16(pp334–335)
Numerous treatments proved unsuccessful. Beginning in 1897, however, R.C. was hypnotized by Taylor and later by Mitchell, with temporary resolution of all abnormal movements and return to normal
Figure 2
function and productive employment. Taylor had been Mitchell’s personal assistant at the Infirmary for Nervous Diseases (1882–1896),22 and was experienced with hypnotism.23 Despite obvious clinical improvement, R.C. refused further hypnotism. As Mitchell recounted: He saw many doctors and haunted clinics, and was variously treated with no good result. In December, 1897, I asked Dr. J.M. Taylor to hypnotize Mr. C. and use suggestion.As usual, Mr. C. took a freshly hopeful interest in the new treatment, and kept a penciled, irregular record of the sittings and their results. For a long while it was impossible to induce the hypnotic state, but as Dr. Taylor writes me, after thirty sittings, of a half hour each, partial effects were attained. During these many sittings Mr. C. never passed into deep sleep.Mr. C’s notes state that after the seventh sitting he wrote a letter with his left hand and without tremor. On the twenty-third sitting the pendulum movements, previously very active, ceased for a few hours. This effect was obtained thereafter only at intervals during daily hypnotization. In January the sittings were more successful, and on the fifteenth sitting in that month all spasms ceased. He was able to take a place as assistant in the Jefferson College library, and for three months continued well, efficient and much liked for gentleness and amiability. Then something took place which excited him disagreeably.The spasms returned in both forms. While he was in bed, Dr. Taylor visited him, and was able to so influence him by an order that he could rise and walk about the room without spasmodic actions. It is interesting that after this he declined to be aided again by hypnotic means,
Superimposed tracings made by Dercum from photographic images of the patient’s psychogenic movement disorder
Superimposed tracings made by Dercum of R.C.’s movements from separate frames of the individual motion sequences.4 These superimposed tracings show the range and overall character of R.C.’s movements. The top leftmost image corresponds to rows 1–2 of figure 1, whereas the bottom leftmost image corresponds to rows 3–4 (note the representation of Dercum’s hand used to elicit a knee jerk with a karate chop), and from left to right the remaining images correspond to rows 5–7, respectively. The images are from Dercum’s chapter, “A study of some normal and abnormal movements photographed by Muybridge,” in Animal Locomotion: The Muybridge Work at the University of Pennsylvania: The Method and the Result (1888). Public domain. Courtesy of Google Books. Neurology 84
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declaring to Dr. Taylor that the hand of the Lord was upon him, and that he felt he should bear his trouble with a serene mind to the end of his days.Once, however, he allowed me to hypnotize him, with good results, which were not lasting, but after this would have no more of it nor give a reason except that it was disagreeable. Probably he missed the attention his case excited, for now again he began to appear at the clinics, but was unwilling to take any form of treatment. It is needless to say that every other means of treatment had been sedulously employed, and that excepting hypnotic suggestion, all had failed.13(pp631–632)
After 1898, R.C.’s overall neurologic condition was better, but his movements never resolved: In these later years there was no change of movement, but he was certainly stronger, and when in the country walked five or six miles daily. The pendulum movement was not often observed, and the weakness of the legs never returned. The rotation action persisted.until his death.13(p631)
In July 1903, R.C. developed congestive heart failure, and subsequently died that November, after which an autopsy was performed by Augustus Eschner, Alfred Allen, and Allen Smith, with the assistance of Spiller, “to whom was confided the study of the nerve organs”13(p632): Whether through hysterical interests and the vanity of being thought unusual, or because I had been able to serve him in various ways, he volunteered to leave me his body. Within a few hours after his death I made free to use this privilege. There had been meanwhile no intercurrent malady, nothing to disturb such pathologic states as hysteria might offer. The death was sudden. The conditions seemed to be ideally perfect. This unusual chance was fully utilized.13(pp625–626)
Meticulous gross and microscopic examination of the CNS revealed no pathologic abnormalities.13 Remarkable, indeed, were the involuntary movements.in this case, persisting through so long a period, and it may at first thought seem strange to those who have not paid much attention to the pathology of the nervous system, that no lesions have been found to explain them, and yet we could hardly expect spasms that could be held in check for sometime by hypnotism to be dependent on organic changes in the nervous system.13(p633)
After almost 3 decades of observation and a negative autopsy, Mitchell and Spiller13 concluded that R.C. had hysteria:
characteristic.The conclusion justifies us in stating that with our present methods the most typical hysteria lasting for years, presents no sign of representative organic lesion. This is, however, the wisdom of to-day; that of to-morrow may be based on other and more refined methods and be very different.13(pp637–638) DISCUSSION The clinical history, serial examinations, photographic documentation, and autopsy results support Mitchell’s contention that this was a “case of undoubted hysteria”13(p638) in a man, or, in modern terminology, a psychogenic movement disorder: absence of other neurologic signs, despite careful evaluations by multiple skilled neurologists over 3 decades; protracted course with normal function during temporary remissions; complex, bizarre movements that are difficult to classify; inconsistent character of movements and other features incongruous with typical “organic” tremors (including bizarre precipitating and relieving factors); increase in movements with attention; alteration of movement frequency with movements of the opposite arm; involvement of the opposite arm in a synchronous abnormal movement; ability to trigger or temporarily stop the abnormal movements with unusual nonphysiologic interventions; inexplicable features (e.g., profound occipital pain with passive finger extension); features suggestive of la belle indifference; temporary remission with hypnotic suggestion; normal limb function when movements remitted; and normal brain autopsy.24–28 The diagnostic certainty for psychogenic movement disorder can be considered as “documented” according to the 1988 Fahn-Williams classification scheme (symptoms relieved by suggestion, psychotherapy, or placebo, or symptoms absent when surreptitiously observed).27 As with R.C., treatment of hyperkinetic psychogenic movement disorders remains difficult: such disorders often persist and cause considerable disability.24,27–30 Although R.C. was considered an ideal case in which to seek a neuropathologic substrate for hysteria, this hope was ultimately frustrated. Even though Mitchell, like Charcot, held out hope that an organic basis for hysteria would ultimately be identified with new methodologies,3–5,14 it was not long after this that etiologic theories of hysteria moved from a neuropathologic to a psychopathologic basis, particularly with the influence of Sigmund Freud and the rise of private practice psychiatry.4,5 AUTHOR CONTRIBUTIONS Dr. Lanska was responsible for all aspects of this study.
No one would hesitate to label [this as] hysteria. The psychical picture is complete. The mental peculiarities, the motor phenomena, the vesical [bladder] symptoms, the 1 form of therapeutic success are all 428
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STUDY FUNDING D. Lanska is supported by the Department of Veterans Affairs and has also received the following support: American Academy of Neurology,
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Minneapolis, MN, funding for travel (oral history interviews); MedLink Neurology, editorial responsibilities and authorship; Encyclopedia of the Neurological Sciences, editorial responsibilities and authorship; State Farm Insurance Co., consultation fee for review of a personal injury claim; International Society for the History of the Neurosciences, partial funding for travel (invited lecture); and I.M. Sechenov First Moscow State Medical University, Moscow, Russia, funding for travel (invited lectures).
14.
DISCLOSURE
16.
15.
The author reports no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
Received June 19, 2014. Accepted in final form October 1, 2014. REFERENCES 1. Charcot J-M. Clinical Lectures on Diseases of the Nervous System: Delivered at the Infirmary of La Salpêtriere by Professor J.M. Charcot. Volume III. Translated by Thomas Savill. London: The New Sydenham Society; 1889:77. 2. Goetz CG. Charcot: The Clinician: The Tuesday Lessons: Excerpts From Nine Case Presentations on General Neurology Delivered at the Salpêtriere Hospital in 1887–88. New York: Raven Press; 1987:116–117. 3. Goetz CG, Bonduelle M, Gelfand T. Charcot: Constructing Neurology. New York: Oxford University Press; 1995: 206–207. 4. Micale MS. Charcot and the idea of hysteria in the male: gender, mental science, and medical diagnosis in late nineteenth-century France. Med Hist 1990;34:363–411. 5. Micale MS. Hysterical Men: The Hidden History of Male Nervous Illness. Cambridge, MA: Harvard University Press; 2008. 6. Lanska DJ. Characteristics and lasting contributions of 19th-century American neurologists. J Hist Neurosci 2001;10:202–216. 7. Mitchell SW. Rest in nervous disease: its use and abuse. In: Seguin EC, ed. A Series of American Clinical Lectures. New York: G.P. Putnam’s Sons; 1875:83–102. 8. Mitchell SW. Fat and Blood, and How to Make Them. Philadelphia: Lippincott; 1877. 9. Mitchell SW. The treatment of obstinate cases of nervous exhaustion and hysteria by seclusion, rest, massage, electricity, and full feeding. In: Mitchell SW. Lectures on Diseases of the Nervous System: Especially in Women, 2nd edition. Churchill, UK: K & A; 1885:265–283. 10. Mitchell SW. The evolution of the rest treatment. J Nerv Ment Dis 1904;31:368–373. 11. Mitchell SW. The treatment by rest, seclusion, etc., in relation to psychotherapy. JAMA 1908;50:2033–2037. 12. Mitchell SW. On functional spasms. Am J Med Sci 1876; 22:321–333. 13. Mitchell SW, Spiller WG. A case of uncomplicated hysteria in the male, lasting thirty years, with post-mortem examination. J Nerv Ment Dis 1904;31:625–638.
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