A Neurologic Assessment of The Salem Witch Trials

Author’s note: As a part-time Salem resident for the past 8 years, I have become fascinated with its history, especially as relates to the Salem witch trials, and what could have caused the strange behavior witnessed in the initial accused—Elizabeth “Betty” Parris (age 9), Abigail Williams (age 11), Elizabeth Hubbard (age 18), Mercy Lewis (age 17), and Mary Wolcott (age 17)—all of whom began having unexplained seizures in January of 1692 after they were identified as being possessed. Medical or neurologic disorders likely caused the unusual behavior of these individuals, which set into motion a chain of events that eventually resulted in the execution (mostly by hanging) of 25 innocent individuals.

Throughout the year, but especially just after Labor Day and through Thanksgiving, >2 million tourists descend upon Salem, Massachusetts, a city of just under 48,000 people located ~22 miles north of Boston. Salem—a city rich with history—has become synonymous with Halloween, has been the subject of several blockbuster movies, and is notorious as the locale of a dark event in American history: the Salem witch trials.¹

1692 Salem

At the time of the events that took place in 1692, Salem Town (now encompassing Salem and Peabody) was a settlement of ~1400 people. Steeped in Puritan values, Salem Town was patriarchal and hierarchical and tended toward misogyny. If a woman stepped out of her traditional, prescribed place, she was often locked up or chastised (for example, this was the time period depicted in Nathaniel Hawthorne’s novel, The Scarlet Letter).

The affluent town was a major merchant center for goods passing to and from the colonies to England.² An annex portion, called Salem Village (now Danvers and Middleton), was a settlement of ~550 people, mainly poor farmers who did not want to be part of Salem Town, politically or ecclesiastically.³

The people of Salem Village had a strong fear of the devil; fear and suspicion in general were prevalent in both Salem Town and annex due to a recent smallpox epidemic and constant threats of attack by indigenous people.² During this time, witch prosecutions in Europe were starting to wind down, and King Charles II had just revoked the Massachusetts charter. This in turn led to a somewhat anarchic society in Massachusetts in which ministers could easily accuse individuals of witchcraft and magistrates were eager to prosecute coupled with a dysfunctional court system in which judges were known to consider speculative evidence (Fig. 1).⁴

Before the Trials: Symptoms and Rumors

In January of 1692, the daughter (Elizabeth Parris, age 9) and niece (Abigail Williams, age 11) of the reverend Samuel Parris, minister of the Salem church, suddenly began experiencing strange and frightening symptoms, which included seizures, screaming out in pain, holding their heads, twisting and contorting their bodies, and barking like dogs. Both girls had low-grade fevers and were often found hiding under furniture.^5,6 Also living in their house was a married slave, Tituba, who was thought to be from Barbados.

Before the symptoms began, the girls would often go into the woods and practice oomancy, a popular method of fortune telling during that time, in which the shape of an egg white as it floated in a glass of water was believed to resemble a shape or symbol depicting aspects of the individual’s future.^3,6 It is unknown whether Tituba played any role in teaching the girls about supranatural ideas or fortune telling; however, there are no official records indicating that she did so.³

Shortly thereafter, other girls and young women, including Elizabeth Hubbard (age 18), Mercy Lewis (age 17), and Mary Wolcott (age 17), also began having unexplained seizures. All the girls and young women had been orphaned and were marginalized in their society.^5,6

By mid-February, after prayers and medicine provided no relief, a local physician, Dr William Griggs (with whom Elizabeth Hubbard lived), diagnosed the odd behavior as the result of “bewitchment” (ie, having been placed under a spell).

As word of the illness spread throughout Salem Village, Salem Town, and Essex County, others begin to experience other paranormal symptoms, including seeing disembodied spirits and feeling as if being stabbed or choked. Individuals began naming neighbors, acquaintances, and strangers as witches. As fear continued to spread, people who were not obvious suspects were also accused, in many cases driven by old family feuds and rumors.⁵

Accusations and Trials

Tituba was one of the first to be accused (by Abigail Williams and Elizabeth Parris). In an effort to save herself, Tituba confessed to being a witch and named 2 other women—Sarah Good and Sarah Osborne—as her accomplices.^2-5 Tituba’s confession further fueled the mass panic and set into motion the famous witch trials, which occurred from February of 1692 through May of 1693, in which >200 people were accused (including 4-year-old Dorothy Good); 30 were convicted; 19 died by hanging; 1 man, Giles Cory (whose wife Martha was also accused and hanged), who refused to admit he was a witch, was pressed to death; and 5 others died in jail.^2-5

The first to be tried and found guilty was Bridget Bishop of Salem Town.⁵ She was hanged on June 10, 1692, at Procter’s Ledge, which is about a 10-minute walk from downtown Salem. Eighteen others would follow (Fig. 2). The trials ended in May of 1693, after the wife of the then-governor of Massachusetts, William Phipps, was accused of witchcraft. Phipps ordered that a new court be established, and that “spectral” evidence be omitted from trials. Soon after that time, he pardoned all of those who had been accused of witchcraft.^2,3

Neurologic Explanations for the Symptoms

Political and religious components played a role in fueling the Salem witch trials; however, the causes of the symptoms leading to the mass panic are less well-explained. Several plausible neurologic explanations exist for the symptoms exhibited by people throughout Salem Village, Salem Town, and Essex County.

Ergot Poisoning

Almost all neurologists are familiar with ergots, which have long been used in the field to treat headaches; however, few have seen individuals with ergot poisoning, which, in current times, would most likely result from medication overdose or overuse. Ergot poisoning symptoms resemble those associated with disorders such as serotonin syndrome or lysergic acid diethylamide (LSD) use. Reports of ergot poisoning date from 600 BC, continuing into the Middle Ages, including the St Anthony’s fire epidemic.⁷ Ergot poisoning has been linked to the consumption of grains (usually rye) or animals contaminated with the fungus Claviceps purpurea, which contains ergot alkaloid derivatives of tryptophan.⁸

Two related syndromes have been described: ergotismus convulsivus, characterized by paranoia, hallucinations, twitches, and spasms; and erototismus gangraenosus, which causes loss of peripheral sensation and edema.⁹ Could the girls and young women of Salem have had the convulsive type? A number of the symptoms they experienced are consistent with this diagnosis, and the conditions for the development of ergot poisoning were in place in 1691 (ie, a severe winter and damp spring, which would have affected the rye consumed in early 1692).⁵ In addition, there are some theories that suggest that the girls and young women involved were at an age where their immune symptoms may not have been fully developed, leaving them susceptible to fungal poisoning.⁸

However, had ergot poisoning been the culprit, one would expect more individuals in the same household or Salem Village, Salem Town, and the remainder of Essex County to have been affected. Furthermore, it is unlikely that Dr Griggs would have missed the diagnosis of ergot poisoning, because previous outbreaks, such as the St Anthony’s fire epidemic,⁷ would have brought enough awareness to the syndrome to become what would best be termed “general medical knowledge.”

Infectious and Other Forms of Encephalitis

In young individuals who present with headaches, seizure-like activity, and neuropsychiatric symptoms (ie, trouble with speech, hallucinations, disorientation, personality changes), a diagnosis of encephalitis (infectious or noninfectious) must always be considered. However, as outlined in the following, encephalitis would be a highly unlikely cause of the symptoms experienced in Salem in 1692.

Noninfectious Encephalitis. Noninfectious types of encephalitis include acute disseminated encephalomyelitis (ADEM) and anti-NMDA receptor encephalitis. ADEM usually affects young children, and occurs after a bacterial or viral infection, childhood rash, immunization, or, in rare cases, smallpox. Symptoms usually occur after a latent period of days to weeks. Initial symptoms can include fever, stiff neck, headaches, nausea, and vomiting, and progress to confusion and depression of consciousness.¹⁰ None of the girls or young women experienced these types of symptoms, and there was no reported previous illness or rash (or, considering their unavailability in the 1700s, vaccinations); therefore, ADEM is highly unlikely.

Anti-NMDA receptor encephalitis usually presents over a period of 4 weeks, with a high prevalence for female individuals and people aged <18 years. Initial symptoms often include psychiatric disturbances, seizures, confusion, and memory loss.¹¹ People often initially develop bizarre or disturbing behavior and mood changes. Hallucinations may occur, as well as the development of strange beliefs and agitation. After a period of 1 to 2 weeks, individuals will develop movement disorders, autonomic symptoms, and loss of awareness. These symptoms coincide with those experienced by the girls and young women of Salem. However, the incidence of the disorder is ~1.5 per million, the disease is not spread from human to human, and no large outbreaks have been reported.¹¹ There was no method to test for NMDA-R antibodies in the 1690s; however, because of the number of individuals experiencing symptoms, anti-NMDA encephalitis is an unlikely cause.¹¹

Infectious Encephalitis. Possible infectious etiologies include viral (eg, herpes simplex virus [HSV], varicella-zoster virus [VZV], influenza, enterovirus, measles, mumps, rubella), tick-borne (eg, Lyme disease), bacterial (eg, meningococcal, pneumococcal), fungal (eg, histoplasma, cryptococcus), and parasitic (eg, toxoplasmosis).

Measles, mumps, rubella, and pneumococcal or meningococcal meningitis can be removed from the differential: there were no reported outbreaks at the time, they all have an above-average mortality rate, and most individuals will have permanent sequela if they survive.^12-14 None of the girls or young women died of their illness, and all of them returned to their baseline health status.

Toxoplasmosis, histoplasmosis, and cryptococcus are also unlikely, because they tend to occur in immunocompromised individuals.^15,16 Immunocompetent people who contract toxoplasmosis usually experience mild symptoms,15 unlike those experienced by the individuals in Salem and the surrounding communities.

Enterovirus can cause encephalitis in ~3% of cases. Some of the symptoms overlap with those experienced by the girls and young women of Salem (eg, headache, myoclonus, altered sensorium); however, the neurologic symptoms associated with enterovirus are those associated with the brainstem (eg, oculomotor, bulbar).¹⁷

Given the onset of symptoms in January, the possibility of influenza-associated encephalitis should be considered. This viral syndrome usually affects very young children; however, mid-childhood and adult cases have been reported. The symptoms usually have a rapidly progressive course, including disturbances in consciousness, disorientation, and seizures, within a few days after the onset of typical influenza symptoms (eg, fever, respiratory symptoms).¹⁸ The disease has a high mortality rate, especially in young children. Influenza-related encephalitis cannot be completely ruled out as a cause, but there were no reports of an influenza outbreak, and the people with symptoms recovered quickly.

Two possibilities remain under consideration: the herpesviruses and central nervous system Lyme disease.

Herpesviruses. Herpesviruses are a common cause of encephalitis, and HSV1, HSV2, or VZV infection can lead to neurologic complications. It is unlikely that VZV played a role in the current scenario, because none of the individuals were reported to have had a rash, which would be typical for chickenpox or shingles which were often confused with smallpox in colonial America.

HSV encephalitis (HSVE) is one of the most common causes of encephalitis. HSV1 is by far the most common cause of HSVE (causing ~90% of cases) and has a bimodal age distribution (age <20 or >50 years). People with HSE usually initially develop fever, headache, and nausea, followed by acute or subacute onset of lethargy, confusion, and delirium, as well as psychiatric symptoms, like those seen in the girls and young women of Salem.¹⁹ However, the mortality rate of untreated HSVE is >70%, which makes it an unlikely etiology, being that none of the affected individuals died.¹⁹

Central nervous system Lyme disease. Lyme disease can present with neurologic symptoms in its chronic form, is highly endemic to New England, and has been around for >5000 years. Lyme disease is one of most common bacterial neurologic infections. Typical symptoms include painful meningoradiculitis, peripheral motor paresis, and lymphocytic meningitis (Bannworth triad). Just over 3% of individuals with Lyme disease will meet the criteria for encephalitis, with a yearly prevalence of ~1 in 1 million. Encephalitic symptoms can include personality changes, confusion, unconsciousness, hemiparesis, ataxia, dysarthria, and seizures, which usually occur in conjunction with meningoradicular symptoms.²⁰ Given the rarity of the disorder and lack of cranial nerve and radicular symptoms, it is highly unlikely that Lyme disease played a role in the illness seen in Salem before the witch trials.

Functional Neurologic Disorders

Functional neurologic disorders (FNDs) result from disruption of brain networks. Symptoms include seizure-like episodes, movement disorders, cognitive issues, dizziness, stuttering or trouble speaking, visual disturbances, hearing and vision issues, hallucinations, slowness, and fatigue.²¹ Subsets of FND include functional neurologic symptom disorder, functional movement disorder, and functional seizures.²¹ FND was initially recognized in the 18th century, with the synonymous term “conversion disorder” used until 2013, when FND was added to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.²¹ Because the diagnosis did not exist in 1692, and given the influence of religion and superstition at the time, it would not be unusual to attribute the young women’s symptoms, which are almost pathognomonic for a FND, to satanic or paganistic beliefs.

Although FNDs are the second most common reason for neurologic consultation (encompassing 10% to 15% of neurologic visits),and given that they are likely underdiagnosed, the prevalence in the general population is 12 per 100,000²¹; therefore, how Salem Town and Salem Village, with a population of <2000 people, could have had so many cases is unclear. However, there have been descriptions of mass panic throughout history, including the dancing plague of 1518 (in which 400 people in France danced in the street until they dropped),²² the writing tremor epidemic of 1892 (in which young women developed uncontrolled shaking, amnesia, and altered consciousness when attempting to write),²³ the Tanganyika laughing epidemic of 1962 (in which >1000 East African school girls were unable to stop laughing),²⁴ and others.

More recently, in October of 2012, 14 teenage girls and 1 teenage boy at a junior/senior high school in Le Roy, NY, developed facial tics, twitching, and garbled speech. The symptoms were initially attributed to toxic waste exposure and then a possible streptococcus outbreak. However, after testing produced negative results, it was hypothesized that the symptoms could be due to a conversion disorder spread or triggered by interactions on social media. When the amount of time spent on social media by these teenagers was reduced, almost all the individuals experienced a resolution of their symptoms.²⁵

The TikTok Tics. During the COVID-19 pandemic, tic‐related and Tourette syndrome–related videos began gaining popularity on the video-sharing application TikTok, especially among teenage girls. Shortly thereafter, several individuals (overwhelmingly teenage girls) began to develop atypical tics, mainly arm movements (as opposed to the predominant facial movement seen in Tourette syndrome), which were severe and disabling, and often resulted in self-injury; vocal tics were also present to a lesser extent.^26-28

The TikTok tics shared many similarities with functional (or psychogenic) tics. One of the largest studies on this phenomenon, by Olvera et al,²⁶ reported demographic characteristics commonly seen in FND: a disproportionate number of participants were transgender or nonbinary, were on the autism spectrum, had attention-deficit/hyperactivity disorder, or had trauma in their past; several also had a history of tics.

The TikTok tics and Salem witch trials both followed widespread disease outbreaks (the COVID-19 pandemic and a smallpox epidemic, respectively), in which young people were isolated, and anxiety ran high due to a lack of treatment. Several of the affected girls and young women in 1692 Salem, similar to those reported by Olvera et al,²⁶ were also on the fringes of society and had experienced life trauma.

Given the current prevalence of attention-deficit/hyperactivity disorder (just over 11% of individuals age 5 to 17 years) and autism (1 in 36 children), it is likely that at least 1 of the girls or young women in 17th-century Salem could have had one of these disorders.^29,30 There was no social media in 1692; however, the affected girls and young women lived “within a stone’s throw” of each other, and spent a good amount of time together. Once the symptoms started, the girls were not separated, escalating the situtaion.³¹

The strange behaviors seen in the girls and young women of Salem Village, the tics observed in teenagers with TikTok tics, and the symptoms reported by high-school students in LeRoy, NY,²⁸ resolved in all cases within weeks, and the individuals returned to their baseline health status.

Conclusion

The Salem witch trials mark a dark period in our country’s history, during which 25 innocent people were put to death. A memorial to the victims of the trials features granite benches bearing the names and execution details of the victims and a stone threshold inscribed with truncated quotes from the accused (Fig. 3). A combination of political, religious, social, and medical factors intertwined to trigger mass panic, spurred on by the symptoms of 5 young women who likely had an FND according to the authors’ assessment.