The whole question of hysterical insanity is one of great difficulty. The psychical element is probably at the root of all cases of hysteria, but this does not justify us, as I have already stated, in declaring that all cases of hysteria are insane. In practical professional life we must make practical distinctions. In the matter before us distinctions are necessary to be made for legal as well as medical purposes. It might be right and proper to place a case of hysterical insanity in a hospital or asylum under restraint, but no one would dare to claim that every case of hysteria should be so treated.
Hysterical insanity may be conveniently subdivided into an acute and chronic form.
Acute hysterical insanity or hysterical mania is a disorder usually, in part at least, purposive, and characterized by great emotional excitement, which shows itself in violent speech and movement, and often also in deception, simulation, and dramatic behavior. The phenomena indicated by this definition may constitute the entire case, or, in addition, the patient may have, at intervals or in alternation, various other phases of grave hysteria, such as hystero-epileptic seizures or attacks of catalepsy, trance, or ecstasy.
In chronic hysterical insanity we have a persisting abnormal mental condition, which may show itself in many ways, but chiefly as follows: (1) A form in which occur frequent repetitions, over a series of years, of the phenomena of acute hysterical insanity, such as hysterical mania, hystero-epilepsy, catalepsy, etc.; (2) a form in which sensational deceptions—sometimes undoubtedly self-deceptions—are practised.
In a case of chronic hysterical insanity you may have both of these forms commingling in varying degree, as in the following case: G—— is a seamstress, twenty-one years of age. Although young in years, she is an old hospital rounder: she has at various times been in almost all the hospitals of the city. She has been treated for such alleged serious affections as fractured ribs, hemorrhages from the lungs, stomach, and vagina, gastric ulcer, epilepsy, apoplexy, paralysis, anæsthesia of various localities, amenorrhœa, dysmenorrhœa, and fever with marvellous variations of temperature. She has become the bane and terror of every one connected with her treatment and care-taking. She has developed violent attacks of mania, with contortions and convulsions, on the streets and in churches. Sums of money have been collected for her at times by those who have become interested in her as bystanders at the time of an attack or have heard of her case from others. She has made several pseudo-attempts at suicide. Recently an empty chloroform-liniment bottle tumbled from her bed at a propitious moment, she at the same time complaining of pain and symptoms of poisoning. She has refused to partake of food, and has been discovered obtaining it surreptitiously. Her large and prolonged experience with doctors and hospitals has so posted her with reference to the symptomatology of certain nervous affections that she is able at will to get up a fair counterfeit of a large variety of grave nervous disorders.
One of her recent attacks of hysteria was preceded by a series of hysterical phenomena, such as vomiting, hemorrhage, aphonia, ovaralgia, headache, and simulation of fever. She began by crying and moaning, which was kept up for many hours. She fell out of bed, apparentlyinsensible. Replaced in bed, she passed into a state closely simulating true acute maniacal delirium. She shrieked, cried, shouted, and moaned, threw her arms and legs about violently, and contorted her entire body, snapping and striking at the nurses and physicians in attendance. At times she would call those about her by strange names, as if unconscious of the true nature of her surroundings. Attacks of this kind were kept up for a considerable period, and after an interval of rest were repeated again and again.
Many of the extraordinary facts which fill the columns of the sensational newspapers are the results of the vagaries of patients suffering from the second of the forms of chronic hysterical insanity. “When,” says Wilks,62“you see a paragraph headed ‘Extraordinary Occurrence,’ and you read how every night loud rapping is heard in some part of the house, how the rooms are being constantly set on fire, or how all the sheets in the house are torn by rats, you may be quite sure that there is a young girl on the premises.” It is unnecessary to add that said girl is of the hysterical genus.
62Op. cit.
A story comes from an inland town, for instance, of a respectable family consisting, besides the parents, of three daughters and six sons, one of whom died of pneumonia. Since his death the family had been startled by exciting and remarkable events in the house—a clatter of stones on the kitchen floor, the doors and windows being closed; shoes suddenly ascending to the ceiling and then falling to the floor, etc. Search revealed nothing to explain the affair. As throwing light upon this matter, a visitor, who confessed his inability to explain the occurrences, nevertheless referred to one of the daughters as looking like a medium.
Charcot and Bourneville give frequent instances of extraordinary self-deceptions or delusions among hysterical patients. The story of an English lady of rank, who reported that she was assaulted by ruffians who attacked her in her own grounds and attempted to stab her, the weapons being turned by her corsets, is probably an example of this tendency. Investigation made by the police force threw grave doubts upon the story.
Many of the manifestations classed as hysterical by medical writers are simply downright frauds. The nature of others is doubtful. The erratic secretion of urine, for example, has frequently engaged the attention of writers on nervous diseases, and has awakened much controversy. American hysterics are certainly fastidious about this matter, as I have not yet met, in a considerable experience, with a single example of paruria erratica. Charcot63refers sarcastically to an American physician who in 1828 gravely reported the case of a woman passing half a gallon of urinous fluid through the ear in twenty-four hours, at the same time spirting out a similar fluid by the navel. He also alludes to the case of Josephine Roulier, who about 1810 attained great notoriety in France, but was discovered by Boyer to be a fraud. This patient vomited matter containing urea, and shortly after came a flow of urine from the navel, the ears, the eyes, the nipples, and finally an evacuation of fecal matters from the mouth.
63Op. cit.
Hemorrhages from eyes, ears, nostrils, gums, stomach, bowels, etc.have often been observed among the hysterical; these cases sometimes being fraudulent and sometimes genuine. In the Philadelphia Hospital in 1883 was a patient suffering from grave hysteria, vomiting of blood being a prominent symptom. Although close watch was kept, several days elapsed before it was discovered that she used a hair-pin to abrade the mucous membrane of her nose, swallowed the blood, which passed into the throat, and then vomited it.
Sir Thomas Watson tells of a young woman who made a hospital surgeon believe that she had stone in the bladder; and Fagge, of a patient who had been supposed to have hydatid in the liver, and who produced a piece of the stomach of a rabbit or some other small animal, which piece she declared she had vomited. A few hours later she again sent for her medical man to remove from her vagina another fragment of the same substance.
A case is reported by Lopez64of spiders discharged from the eye of an hysterical patient. He regarded the case as one of hysterical monomania. Fragments of a dismembered spider were undoubtedly from time to time removed from the eye of the patient. Lopez believed that at first the fragments may have got into the eye accidentally, but that afterward the patient, under the influence of a morbid condition, introduced them from day to day. The total number of spiders removed in fragments was between forty and fifty. Silvy65relates a case in which a large number of pins and needles made their exit from a patient. Other needle cases are given, and also examples of insects and larvæ discharged from the human body. In one case worms crawled out of the nose, ears, and other natural openings; in another worms were found in active motion under the conjunctiva; in a third a beetle was discharged from the bladder, and several beetles were vomited by a boy.
64American Journal of Medical Sciences, Philadelphia, 1843, N. S., 74-81.
65Mémoires de la Société médicale, Anné 5, p. 181.
Jolly66records in a foot-note a case published in 1858, by I. Ch. Leitz of Pesth, of a young girl from whose eyes fruit-pips sprang, from whose ears and navel feces escaped, and from whose anus and genitals fleshy shreds came away, while worms with black eyes were vomited. He further tells of a woman from whose genitals four-and-twenty living and dead frogs passed, some of these, indeed, with cords of attachment. The birth of the frogs was witnessed and believed in by several physicians!
66Op. cit.
Hardaway67reports a curious case with simulated eruptions. The woman appeared to be in fear of syphilis contracted by washing the clothes of a diseased infant. She had blebs irregularly distributed upon the fingers and arm of the left side; these, the doctor concluded, had been caused by the application of vitriol. He reports another case in which a woman had an eruption on her left arm, and the sores, instead of getting better under treatment, got worse. On one visit he found needle-scratches on the old sore. Nitric acid, according to Hardaway, is a favorite substance for the production of such eruptions. The best diagnostic test is that the blister is linear, while in pemphigus it is circular, unlike that which would be produced by a running fluid. Hysterical women have irritated their breasts with cantharides. Niemeyer68mentions a woman at Krutsenberg's clinic who irritated her arm in such a way that amputation becamenecessary, and after that she irritated the stump until a second amputation had to be performed.
67St. Louis Courier of Medicine, 1884, xi. 352.
68Textbook of Practical Medicine.
Nymphomania is a form of mental disorder which sometimes occurs among the hysterical; or it would perhaps be more correct to say that nymphomania and grave hysterical affections are sometimes associated in the same case. It is a condition in which is present extreme abnormal excitement of the sexual passion—a genesic, organic feeling rather than an affection associated with the sentiment of love. Hammond treats of it under the head of acute mania, and considers cases of nymphomania as special varieties of this disease. Undoubtedly, this is the correct way of looking at the subject in many cases. In man the corresponding mental and nervous condition often leads to the commission of rape and murder. In woman the affection is most likely to show itself with certain collateral hysterical or hysteroidal conditions, as spasms, hystero-epilepsy, and catalepsy, or with screaming, crying, and other violent hysterical outbreaks. Sometimes there is a tendency to impulsive acts, but this does not usually go so far as to lead to actual violence.
Nymphomaniacs may be intelligent and educated, and if so they usually resist their abnormal passions better than the ignorant. A number of nymphomaniacs have been under treatment at the Philadelphia Hospital. One case was an epileptic and also hysterical girl. She had true epileptic seizures, and at other times had attacks of a hysteroidal character. She would make indecent proposals to almost any one, and would masturbate and expose herself openly. She also had occasional maniacal attacks. She died in the insane department of the hospital.
Nymphomania and what alienists call erotomania are sometimes not differentiated in practice and in books. They are, however, really different conditions. Erotomania and nymphomania may be associated in the same case, but it is more likely that erotomania will not be present in a case of nymphomania. Erotomania may exist as a special symptom or it may be one of the evidences of monomania. It is found in both men and women. Patients with this condition may have no sexual feeling whatever. The individual has some real or imaginary person to love. It is rather the emotion of love which is affected, not the sexual appetite. It is shown by watching or following the footsteps of the individual, by writing letters, and by seeking interviews. In the history of Guiteau an incident of this kind is mentioned by Beard.69He followed a lady in New York whom he supposed to be the daughter of a millionaire—followed her, watched her house and carriage, and wrote letters to her. Out West he showed the same sort of attentions to another lady. He went to the house, but was kicked out. Many of the great singers have been followed in this way.
69Journal of Nervous and Mental Disease, vol. ix., No. 1, January, 1882.
Some time ago I examined a man condemned to be hanged and within twenty-four hours of his death. He was an erotomaniac, whatever else he may have been. In the shadow of the gallows he told of a lady in the town who had visited him and was in love with him, and how all the women in the neighborhood were in love with him. He had various pictures of females cut from circus-posters in his cell. Erotomania is not generally found associated with hysteria.
Convulsions or general spasms are among the most prominent ofhysterical manifestations. Under such names as hysterical fits, paroxysms, attacks, seizures, etc. they are described by all authors. Their presence has sometimes been regarded as necessary in order that the diagnosis of hysteria might be made; but this, as I have already indicated, is an erroneous view.
Under hysterical attacks various conditions besides general convulsions are discussed by writers on hysteria; for instance, syncope, epileptiform convulsions, catalepsy, ecstasy, somnambulism, coma, lethargy, and delirium. According to the plan adopted in the present volume, catalepsy, ecstasy, somnambulism, etc. will be considered in other articles, and therefore my remarks at this point will be limited to hysterical general convulsions.
These convulsions differ widely as to severity, duration, frequency, motor excitement, and states of volition and consciousness. Efforts have been made to classify them. Carter70describes three forms as primary, secondary, and tertiary. In the primary form the attack is involuntary and the product of violent emotion; in the secondary it is reproduced by the association of ideas; and in the tertiary it is deliberately shammed by the patient. Lloyd71divides them into voluntary and involuntary forms, and discusses the subject as follows: “The voluntary or purposive convulsions are such as emanate from the conscious mind itself. Here are the simulated or foolish fits into which women sometimes throw themselves for the purpose of exciting sympathy or making a scene. I am convinced that a large number of hysteric fits are of this class: these are the patients who are cured by the mention of a hot iron to the back or the exhibition of an emetic. The involuntary forms of convulsion are more important. They happen in more sensible persons, and some of them are probably akin to starts, gestures, and other forcible or violent expressions of passions or states of the mind. A person wrings the hands, beats the breast, stamps upon the floor in an agony of grief and apprehension, and if terror is added he trembles violently. It is no great stretch of the imagination to suppose that great fear, anger, or some kindred passion, acting upon the sensitive nervous organization of a delicate woman or child, should throw them into a convulsion. This, in fact, we know happens. Darwin72believes that in certain excited states of the brain so much nerve-force is liberated that muscular action is almost inevitable. He instances the lashing of a cat's tail as she watches her prey and the vibrations of the serpent's tail when excited; also the case of an Australian native, who, being terrified, threw his arms wildly over his head for no apparent purpose. The excito-motor reflexes of the cord may possibly take on true convulsive activity if released from the control of the will, which, as already said, is apt to be weak or in abeyance to this disease. Increased temperature is stated by Rosenthal to be always present in the great fits of epilepsy and tetanus, but absent in those of hysteria.”
70On the Pathology and Treatment of Hysteria, London, 1853.
71Op. cit.
72Expression of Emotion, etc.
This subdivision of hysterical convulsions into voluntary and involuntary, or purposive and non-purposive, is a good practical arrangement; but the four groups into which I have divided all hysterical symptoms—namely, the purely involuntary, the induced involuntary, the impelled,and the purely voluntary—include or cover these two classes, and allow of explanation of special cases of convulsion which cannot be regarded as either purely shammed or as entirely, and from the first, independent of the will.
Absolutely involuntary attacks with unconsciousness constitute what are commonly called hystero-epileptic seizures, and will be described under Hystero-epilepsy.
The voluntary, impelled, or induced hysterical fit may be ushered in in various ways—sometimes with and sometimes without warning, sometimes with wild laughter or with weeping and sobbing. The patient's body or some part of it is then usually thrown into violent commotion or convulsion; the head, trunk, and limbs are tossed in various directions. Frequently the arms are not in unison with each other or with the legs. Screaming, shouting, sobbing, and laughing may occur during the course of the convulsive movement; sometimes, however, the patient utters not a word, but has a gasping, noisy breathing. She may talk in a mumbling, incoherent manner even during the height of the attack. She is tragic in attitude or it may be pathetic. The face is contorted on the one hand, or it may be strangely placid on the other. Quivering, spasmodic movements of the eyelids are often seen; but the eyes are not fixed and turned upward with dilated pupils, as in epilepsy. The patient does not usually hurt herself in these purposive attacks. She may or may not appear to be unconscious. She does not bite her tongue, nor does she foam, as does the true epileptic, although she may spit and sputter in a way which looks somewhat like the foaming of epilepsy. She comes out of the fit often with evident signs of exhaustion and a tendency to sleep, but does not sink into the deep stupor of the post-paroxysmal epileptic state. The paroxysm may last a few or many minutes. Large quantities of colorless urine are usually passed when it is concluded.
Hysterical paralysis, so far as extent and distribution are concerned, may be of various forms, as (1) hysterical paralysis of the four extremities; (2) hysterical hemiplegia; (3) hysterical monoplegia; (4) hysterical alternating paralysis; (5) hysterical paraplegia; (6) hysterical paralysis of special organs or parts, as of the vocal cords, the œsophagus and pharynx, the diaphragm, the bowels, and the bladder. Russell Reynolds73has described certain cases closely allied to, if not identical with, some forms of hysterical paralysis under the head of paralysis dependent upon idea. These patients have a fixed belief that they are paralyzed. The only point of separation of such cases from hysterical paralysis is the absence of other hysterical manifestations. Perhaps it would be better to regard the condition either simply as hysterical paralysis or as a true psychosis—an aboulomania or paralysis of the will. Such cases often last for many years.
73Brit. Med. Journ., 1869, pp. 378, 483.
Among the 430 hysterical cases of Briquet, only 120 were attacked with paralysis. In 370 cases of Landouzy were 40 cases of paralysis.
Briquet reports 6 cases in which paralysis attacked the principal muscles of the body and of the four extremities; 46 cases of paralysis of the left side of the body, and 14 of the right; 5 of the upper limbs only; 7 of the left upper limb, and 2 of the right; 18 of the left lower limb,and 4 of the right; 2 of the feet and hands only; 6 of the face; 3 of the larynx; and 2 of the diaphragm. Landouzy gathered from several authors the following results: General paralysis in 3 cases; hemiplegia in 14; 8 cases of paralysis of the left side; in other cases the side affected not indicated; and 9 cases of paraplegia.
Hysterical paralyses, no matter what the type, may come on in various ways—suddenly, gradually, from moral causes or emotional excitement, or from purely physical causes, as over-fatigue. They may have almost any duration, from hours or days to months or years, or even to a lifetime. They are frequently accompanied by convulsive or emotional seizures. They may be of any degree of severity, from the merest suspicion of paresis to the most profound loss of power. Hysterically paralyzed muscles retain their electro-contractility. Limbs which have become atrophied from disuse may show a temporary lessening of response, but this is quantitative and soon disappears. In rare cases, owing probably to the condition of the skin, the response to electricity is not obtained until the current has been applied for several minutes to the muscles.
Hysterical hemiplegia and monoplegia may simulate almost any type of organic paralysis. The paralysis is usually in a case of hemiplegia, confined to the arm and leg, the face being slightly, if at all, implicated. Hysterical paralysis, limited to the muscles supplied by the facial nerve, is very rare. According to Rosenthal, it sometimes coexists with paralysis of the limbs of the same side, and is usually accompanied by anæsthesia of the skin and special senses. In a few rare cases, according to Mitchell, the neck is affected.
Several cases of hysterical double ptosis have come under my observation. The condition is usually one of paresis rather than paralysis. Cases of unilateral ptosis hysterical in character have also been reported. Alternating squints are sometimes hysterical, but they are usually of spasmodic rather than of paralytic origin.
Hysterical hemi-palsy is more frequent on the left than in the right side. In Mitchell's cases the proportion was four left to one right. The figures of Briquet have been given. It is usually, but not always, accompanied by diminished or abolished sensibility, both muscular and cutaneous. Electro-sensibility especially is markedly lessened in most cases.
When hemiplegia is of the alternating variety, the arm on one side and the leg on the other, or, what is rare in paralysis of organic causation, both upper extremities and one lower, or both lower and one upper, may be affected. Alternating hemiplegia of the organic type is usually a paralysis in which one side of the face and the leg and arm of the opposite side are involved.
Hysterical paraplegia is one of the most important forms of hysterical paralysis, and is sometimes the most difficult of diagnosis. It occurs usually, but not exclusively, in women. It comes on, particularly in young women, between puberty and the climacteric period, commonly between the twentieth and thirtieth years. Such a patient is found in bed almost helpless, possibly able to move from side to side, but even by the strongest efforts seemingly incapable of flexing or extending the leg or thigh or of performing any general movements of the foot. The feet are probably in the equino-varus position—extended andturned inward. Certain negative features are present. The muscles do not waste to any appreciable extent, as they would in organic paralysis. Testing the knee-jerk, it is found retained, possibly even exaggerated. The electrical current causes the muscles to contract almost as well as under normal conditions; if a difference is present, it is quantitative and not qualitative in character. Paralysis of the bowels and bladder is not usually found, although it is but fair to state that this appears not to be the conclusion arrived at by some other observers.
Paralysis or paresis of the vocal cords, with resulting aphonia, is a common hysterical affection. Hysterical aphonia is also due to other conditions—for instance, to an ataxia or want of co-ordinating power in the muscles concerned in phonation; or to spasm, real or imaginary, in the same parts. Hysterical paralysis of the vocal cords is almost invariably bilateral; viewed with the laryngoscope, the cords are seen not to come together well, if at all. One may be more active than the other; but a distinct one-sided paralysis of this region nine times out of ten indicates that the case is not hysterical.
The following case is of interest, not only because of the aphonia, but because also of the loss of the power of whispering. The patient, a young lady of hysterical tendencies, while walking with a friend stumbled over a loose brick and fell. She got upon her feet, but a moment or two after either fainted or had a cataleptoid attack. Several hours later she lost her voice and the power of whispering. She said that she tried to talk, but could not form the words. This condition had continued for ten months in spite of treatment by various physicians. She carried a pencil and a tablet, by means of which she communicated with her friends. She had also suffered with pains in the head, spinal hyperæsthesia; and occasional attacks of spasm. Laryngoscopic examinations showed bilateral paresis of the vocal muscles, without atrophy. The tongue and lips could be moved normally. She was assured that she could be cured. Faradic applications with a laryngeal electrode were made daily; tonics were given; and the patient was instructed at once to try to pronounce the letters of the alphabet. In less than a week she was able to whisper letters, and in a few days later words. In three weeks voice and speech were restored. Just as this patient was recovering another came to be treated for loss of voice. She was markedly aphonic, but could whisper without difficulty. She was told, to encourage her, that she need not be worried about her loss of voice, as another patient, who had lost not only her voice, but the ability to whisper, had recovered. The patient returned next day unable to whisper a syllable. She made, however, a speedy recovery. Under the name apsithyria, or inability to whisper, several cases of this kind have been reported by Cohen.
Hysterical paralyses of the pharynx and of the œsophagus have been reported, but are certainly of extreme rarity. Hysterical dysphagia is much more frequently due to spasm or a sensation of constriction.
Paralysis of the diaphragm in hysteria has been described by Duchenne and Briquet. I have had one case under observation. The abdomen is drawn inward instead of being pushed outward in the act of inspiration in organic paralysis of the diaphragm; this condition is simulated, but not completely or very closely, in the hysterical cases. In some of thecases of nervous breathing, which will be referred to hereafter, the symptoms are rather of a spastic than of a paretic affection of the diaphragm.
Paralysis or paretic states of the stomach and intestines are not uncommon among the hysterical, and produce tympanites, one of the oldest symptoms of hysteria. Jolly asserts that this “sometimes attains such a degree that the patients can be kept afloat in a bath by means of the balloon-like distension of their bellies”! The loss of power in the walls of the stomach and bowels is sometimes a primary and sometimes a secondary condition. The abdominal phantom tumors of hysterical women sometimes result from these paralytic conditions. These abdominal tumors are among the most curious of the phenomena of local hysteria. At one time two such cases were in the women's nervous wards of the Philadelphia Hospital. Both patients had been hysterical for years. In the first the tumor occupied the middle portion of the abdomen, the greater portion of its bulk more to the right of the median line. It was firm and nearly spherical, and the patient complained of pain when it was handled. She was etherized, and while under ether, and during the time that she was vomiting from the effects of the anæsthetic, the tumor disappeared, never to return. The other patient had a similar tumor for three days, which disappeared after the etherization of the first case.
Mitchell74has recorded some interesting paretic and other hysterical disorders of the rectum and defecation. Great weakness, or even faintness, after each stool he has found not uncommon, and other more formidable disorders occur. A patient who had been told that her womb was retroverted and pressing upon her rectum, interfering with the descent and passage of the feces, was troubled with hypersensitiveness of the lower bowel. This condition Mitchell designated as the excitable rectum. Patients in whom it is present apparently have diarrhœa; certainly they have many movements daily. Single stools, however, are small, and may be quite natural or they may seem constipated. The smallest accumulation of fecal matter in the rectum excites to defecation. One case had small scybalous passages every half hour. The forms of hysterical paresis or paralysis or pseudo-paralysis of the rectum observed by Mitchell were due—(1) to a sensory paralysis of the rectum; (2) to a loss of power in the rectal muscular walls; (3) a want of co-ordination in the various muscles used in defecation; (4) to a combination of two or of all of these factors. In rare cases the extrusive muscles act, but the anal opening declines to respond.
74Op. cit.
Hysterical locomotor ataxia, or hysterical motor ataxia, is an affection less common than hysterical palsy, but by no means rare. Various and diverse affections of motion are classed as hysterical ataxia by different authors. Mitchell speaks of two forms independent of those associated with vertigo. The first, that described by Briquet and Laségue, seems to depend upon a loss of sensation in both skin and muscles; the second often coexists with paralysis or paresis, and is an affection in which the patient has or may have full feeling, and is able to use the limbs more or less freely while lying down. As soon as she leaves the recumbent position the ataxia is very evident. She falls first to one side and then to the other. She “seems to be unable to judge of the extent to which balance is lost, and also to determine or evolve the amount ofpower needed to overcome the effect.” Mitchell believes that this disorder is common in grave hysteria, and is likely to be confounded with one of the forms of hysterical alternating spasm, in which first the flexors and then the extensors contract, the antagonistic muscles not acting in unison, and very disorderly and eccentric movements being the result. I have reported a case of hystero-epilepsy75in which a spasmodic condition closely simulated hysterical ataxia. The patient had various grave hysterical symptoms, with epileptoid attacks. She became unable to walk, or could only walk a few steps with the greatest difficulty, although she could stand still quite well. On attempting to step either forward or backward, her head, hips, shoulders, and trunk would jerk spasmodically, and she would appear to give way at the knees. No true paralysis or ataxia seemed to be present, but locomotion was impossible, apparently because of irregular clonic spasms affecting various parts of her body.
75Journal of Nervous and Mental Disease, vol. ix., No. 4, October, 1882.
Mary Putnam Jacobi76has reported a case occurring in an Irish woman aged thirty-five years as one of hysterical locomotor ataxia. It is questionable whether this case was not rather one of posterior spinal sclerosis with associated hysterical symptoms. The existence of pain resembling fulgurating pains, and especially the absence of the patellar tendon reflex, would incline me to hesitate a long time before accepting the diagnosis of hysteria, particularly as it is known that organic locomotor ataxia often has a much-prolonged first stage, and that wonderful temporary improvements sometimes take place.
76Arch. of Medicine, New York, 1883, ix. 88-93.
Ataxic symptoms of a mild form are of frequent occurrence in hysteria. They are shown by slight impairments of gait and difficulty in performing with ease and precision many simple acts, as in dressing, writing, eating, etc.
Hughes Bennett and Müller of Gratz call attention to the fact that young women may exhibit all the signs of primary spastic paralysis, simulating sclerosis, and yet recover.77I have seen several of these cases of hysterical spasmodic paralysis, and have found the difficulties in diagnosis very great. These patients walk with a stiff spastic or pseudo-spastic gait, and as, whether hysterical or not, the knee-jerk is likely to be pronounced, their puzzling character can be appreciated.
77Quoted by Althaus:On Sclerosis of the Spinal Cord, by Julius Althaus, M.D., M. R. C. P., etc., New York, 1885, p. 330.
In one class of cases, which cannot well be placed anywhere except under hysteria, a sense or feeling of spasm exists, although none of the objective evidences of spasmodic tabes can be detected. Comparing these to those which Russell Reynolds describes as paralysis dependent upon idea, they might be regarded as cases of spasm dependent upon idea.
One case of this kind which was diagnosticated as lateral sclerosis by several physicians recovered after a varying treatment continued for several years, the remedy which did him the most good being the actual cautery applied superficially along the spine. The patient described his condition as one of “spasmodic paralysis of all the muscles of the body.” If sitting down, he could not at once get up and walk or run, but would have to use a strong effort of his will, stretching his limbs several timesbefore getting on his feet. Movements once started could be continued without much difficulty. When his hands were closed he would be unable, at times, to open them except by a very strong effort of the will. If one was opened and the other shut, he could manipulate the latter with the former. He sometimes complained of a sensation as of a steam-engine pumping in his back and shaking his whole body. He would sometimes be in a condition of stupor or pseudo-stupor, when he had a feeling as if he was under the influence of some poison. The spasms or jumpings in the back he thought sometimes caused emissions without erections. He compared the feeling in his back to that of having a nerve stretched like a piece of india-rubber. The excitement of mind would then cause the nerve to contract and throb. This description shows that the symptoms were purely subjective. Examination of the muscles of the legs and arms did not reveal, as in true spastic paralysis, conditions of rigidity. The limbs would sometimes be stiff when first handled, volition unconsciously acting to keep them in fixed positions; but they would soon relax. The knee-jerk, although well retained, was not markedly exaggerated, as in spastic paralysis, nor was ankle clonus present. The patient did not get progressively worse, but his condition vacillated, and eventually he recovered. A friend of the patient, living in the same neighborhood and going to the same church, was affected with true lateral sclerosis. It is worth considering how far in an individual of nervous or hysterical temperament observation of an organic case could have influenced the production of certain subjective symptoms, simulating spasmodic tabes.
Certain special forms of chorea are particularly liable to occur in the course of cases of hysteria. The most common type of the chorea of childhood, if not strictly speaking hysterical, is frequently associated with a hysteroid state, and is best treated by the same measures that would be calculated to build up and restore an hysterical patient. The following conclusions, arrived at by Wood78after a clinical and physiological study of the subject of chorea, show that certain forms of chorea may be hysterical or imitated by hysteria:
1st. Choreic movements may be the result of organic brain disease.
2d. Choreic movements exactly simulating those of organic brain disease may occur without any appreciable disease of the nerve-centres.
3d. General choreic movements, as well as the bizarre forms of electric and rhythmical chorea, may occur without any organic disease of the nervous system.
78“Chorea: a Study in Clinical Pathology,” by H. C. Wood, M.D., LL.D.,Therapeutic Gazette, 3d Series, vol. i., No. 5, May 15, 1885.
To these propositions may be added a fourth—viz. Choreic movements may be the result of a peripheral irritation, or, in other words, may be reflex.
Hysterical rhythmical chorea is a form of chorea in which involuntary movements are systematized into a certain order, so as to produce in the parts of the body which are affected determinate movements which always repeat themselves with the same characters. The movements are strikingly analogous to the rhythmical movements, as those of salutation, which often occur in the second period of the hystero-epileptic attack. Rhythmical chorea should undoubtedly be arranged among themanifestations of grave hysteria. An account of an interesting case of this kind is given in a lecture by Wood, reported by me in thePhiladelphia Medical Timesfor Feb. 26, 1881.
As Charcot has shown, rhythmic chorea is usually of hysterical origin, although it may exist without any of the phenomena which usually characterize hysteria. In these cases the movements imitated are according to a certain plan; thus, they may be certain expressive movements, as some particular form of dancing or the so-called saltatory chorea. They may be, again, certain professional or trained actions, such as movements of hammering, of rowing, or of weaving. Charcot speaks of a young Polish girl in whom movements of hammering of the left arm lasted from one to two hours, and occurred many times in a day for seven years. He has also given an account of another case, a patient with various grave hysterical manifestations, who would have a pain and beating sensation in the epigastrium, accompanied by a feeling of numbness. The right upper extremity would then begin to move; this would soon be followed by the left, and then by the lower extremities; then would follow a succession of varied action, complex in character, but in which rhythm and time and correct imitation of certain intentional and rational movements could readily be recognized. The attacks could be artificially induced in this patient by pulling the right arm or by striking on the patellar tendons with a hammer. During the whole of the attack the patient was conscious. In another patient rhythmical agitations of the arm, the movement of wielding a hammer, were produced in the first stage; then followed tonic spasms and twisting of the head and arms, suggesting a partial epilepsy; finally, rhythmical movements of the head to the right and left took place, the patient at the same time chanting or wailing.79
79Charcot's lectures inLe Progrès médicalfor 1885.
In the following case an hysterical jumping chorea was probably associated with some real organic condition or was due to malarial infection. The patient was a middle-aged man. During the war he received a slight shell wound in the back part of the right thigh, and from that time suffered more or less with numbness and some weakness of the right leg. He was of an active nervous temperament. About three months before coming under observation he had without warning a peculiar attack which, in his own words, came on as if shocks of electricity were passed through his head, back, limbs, and other parts of the body. In this attack, which lasted for fully an hour, he jumped two or three feet in the air repeatedly; his arms, legs, and even his head and eyes, shook violently. He was entirely conscious throughout, but said nothing except to ask for relief. His wife, who was present, stated that at first he was pale, and afterward, during the attack, he became almost turgid under the eyes. Attacks appeared to come at intervals of seven and fourteen days for a time, so that his family physician surmised that there might be some malarial trouble, and prescribed for him accordingly. They soon, however, became irregular in character, and did not occur at periodical intervals. After the attacks he would lie down and go to sleep; he did not, however, pass into the condition of stupor that is observed after a grave epileptic seizure. His sleep seemed to be simply that of an exhausted nervous system.
Hysterical tremor is of various forms and of frequent occurrence: a single limb, both upper or both lower extremities, or the entire body may be affected. In a case of hystero-epilepsy, which will be reported in the next article, the patient had a marked tremor of the left arm, forearm, and hand, which was constant, but worse before her attacks; it remained for many months, and then disappeared entirely. Caraffi80reports the case of an hysterical girl of eighteen, anæsthetic on the right side and subject to convulsive attacks, who fell on the right knee and developed an arthritis. At the Hôpital Beaujon service of Lefort and Blum she presented herself with the above symptoms, aphonia, and an uncontrollable tremor of the right lower extremity, and trophic disturbances of the same. Immobilization of the limb was tried without benefit, and Blum then stretched the sciatic, with complete relief of the tremor and of the troubles of sensibility and of nutrition.
80L'Encéphale, June, 1882.
Hysterical contracture, like hysterical paralysis, may assume a variety of forms: it may be hemiplegic, monoplegic, paraplegic, alternating, or local, as of the ocular muscles, the facial or neck muscles; laryngeal, pharyngeal, or œsophageal; of the fingers or of the toes.
Richardson81records the case of a young lady who saw in India a religious devotee with his leg flexed upon his body and fastened there. In a few hours she was found with her leg in a similar position, and this contracture remained until after she had been taken to London; then it disappeared as suddenly as it came. Conscious purpose could not have maintained the leg in such a position for an hour.
81Diseases of Modern Life.
Some of the most remarkable cases of hysterical contracture are those chiefly studied by the French, which originate before or after convulsive seizures. Among the hystero-epileptics at Salpêtrière, Richer82reports many varieties of contracture: one with hemianæsthesia and varying pain in the right side had permanent contracture with tremulousness of the lower extremities; another, with hemianæsthesia, pain, and frequent attacks of demoniacal delirium and paresis, had momentary contractures of the upper and lower extremities on the right side. In two other cases the contractures were of the hemiplegic form, while three others were paraplegic. In still other cases the contracture was monoplegic. Besides hemiplegic, monoplegic, and paraplegic contractures, I have seen illustrations of a number of local forms—among others, several remarkable cases of hysterical contractures of the wrist and hand and of the feet and toes, and one of hysterical torticollis. Hysterical contracture in any of its forms may occur as an isolated symptom or series of symptoms unconnected with the grave hysterical attack.
82Op. cit.
Many forms of hysterical local spasms occur. Hysterical strabismus from spasm of the ocular muscles has been observed. Several cases have come under observation in which hysterical blepharospasm was present. In these cases, when the lids are forced open, the eyes disappeared in an extraordinary manner, usually being drawn downward and toward the internal canthus. Hysterical facial spasm occurs, and is usually clonic. One of the most remarkable hysterical local spasmodic affections which has come under personal observation was reported by me in a paper on chorea.83In this case the right ear twitched and moved up and down.The movement of the ear was peculiar; it continued nearly all the time, even when the patient's attention was not directed toward the part. The act seemed to be partially under the control of the will, as by a strong effort the left ear could be moved very slowly in the same up-and-down direction. The nostrils and upper lip were affected with twitching, and slight choreic movements were present in the entire right side of the body. The patient's general condition improved under treatment, but when last seen the local affection persisted, although it was not so severe.
83Philada. Med. Times, March 27, 1875.
Spasm of the pharynx, larynx, and œsophagus have been separated by several authors. In hysterical laughter spasmodic contraction of the laryngeal muscles occurs. Spasm of the glottis occurs in rare cases, according to Rosenthal, from the reflex effect of hyperæsthesia of the laryngeal mucous membrane, from irritation of the recurrent laryngeal nerve. Death from asphyxia has occurred in consequence of this form of spasm of the glottis.
Hysterical dysphagia, which is usually spasmodic, is sometimes a dangerous, and always an annoying, affection. An unmarried lady, forty years old, with a neurotic family history, a maternal uncle and aunt having been insane, at intervals since puberty had had various hysterical manifestations. After a severe winter, during which she had suffered more or less with rheumatism, she became depressed with reference to her spiritual condition: she had, in fact, a form of mild religious melancholia. After this had lasted for weeks she began to experience difficulty in swallowing. She would rise from the table suddenly, alarmed and gasping, and exclaiming that she could not swallow and was choking. She got so bad that she could not take anything but liquid food, and not nearly enough of this. She believed that her throat was gradually closing, and of course suspected cancer. She was assured that if any local obstruction existed it could be removed with one application of a probang. Cancer was also confidently excluded, and she was given iron, valerian, and quinine, and in a few days an instrument was passed down her throat. She as told that she would have no more difficulty. Tonics and full feeding were continued, and in less than a week she swallowed without any difficulty.
Of the so-called hysterical asthma or hysterical breathing I have seen several examples. A curious form of hysterical breathing, at least partly spasmodic, recently came to the Philadelphia Polyclinic—a young man twenty-one years of age, who confessed that he had been guilty of excessive masturbation for five or six years. He had been a moderate drinker and was the victim of an old hip disease. According to his story, this abuse had never appeared to have impaired his health until about one month before applying for treatment, when he began to have attacks of peculiar breathing. He would have a series of rapid, forced expirations which lasted for a period of from one to two or three minutes. He would then stop for a moment; then again the shallow breathing with forced expirations would ensue. He said that he breathed in this way because he thought he was going to die, and did so to keep alive. When he stopped he felt cold. He thought his belly did not go outward as it should in the act of breathing. During the time that the symptoms had been present he had had several frightful attacks of excitement, in one of which he ran breathing in the manner described to adrug-store from one to two blocks away, jumping, gesticulating, and calling for remedies. He had an anxious expression of the face, a look of excitement and worriment. His pulse was 110 and weak. Respirations during these attacks ranged from 38 to 50.
Coates,84speaking of hysterical or nervous breathing, gives the details of five cases. Four of these had been supposed to be suffering from phthisis; the fifth was apparently a case of hypertrophy of the heart. The breathing was quick and shallow. The patients could not be induced to draw long breaths until the expedient was adopted of having them count twenty without taking breath. During this the lungs expanded perfectly, air entering freely into every part. Coughing, and even blood-spitting of a venous character, were present. They might perhaps be classed as cases of hysterical or simulated phthisis.
84British Medical Journal, 1884, ii. 13.
Vaginismus, or spasm of the vagina, may with propriety be regarded as hysterical in some but not in all cases. Spasmodic contracture of the sphincters of the bladder and anus is also mentioned by Rosenthal. Goose-flesh, according to the same author, is a frequent phenomenon in the hysterical, and is due to spasmodic contraction of the muscular fibres contained within the skin.
The sensorial affections of hysteria can be classified according either to character or location. According to the character of the sensory disturbance a good practical arrangement is into cases of (1) Anæsthesia; (2) paræsthesia; (3) hyperæsthesia; (4) neuralgias and localized pains,—although one of these classes may sometimes be difficult to separate from another, or a doubt may arise as to whether or not a special symptom should be placed under one or another head. In hysterical anæsthesia sensation is decreased or abolished; in paræsthesia it is faulty or perverted; in hyperæsthesia it is increased over a more or less extensive surface; in neuralgia, pain is confined to certain nerve-trunks. The localized pains are neuralgic or mimetic, and are found in special localities, as in joints and in the breast.
Anæsthesia is one of the most frequent of hysterical phenomena, but is not, as stated by some authorities, present in all cases of genuine hysteria.
In 400 hysterical cases Briquet found 240 positive examples of anæsthesia. In this statement, however, he does not include cases of insensibility of the conjunctiva of the left eye or those cases in which anæsthesia lasted but a few hours after an attack. It is safe to say that anæsthesia of some sort is present in from 60 to 75 per cent. of all cases of well-marked hysteria. Analgesia, or insensibility to pain, is present frequently when loss or diminution of sensibility to touch, pressure, heat and cold, etc., is not observed.
Hysterical anæsthesia, may be of various forms, according to the parts of the body affected, as general anæsthesia; hemianæsthesia; anæsthesia of the lower half of the body; anæsthesia of one limb or one side of the face; anæsthesia of mucous membranes; anæsthesia of muscles, bones, and joints; anæsthesia of the viscera.
General anæsthesia is extremely rare. No example of it has ever fallen under my observation, but by Briquet and others a few cases have been reported.