Hemianæsthesia has in recent years received much attention from neurologists. In hystero-epilepsy it is the rule to find it present, but it is also observed in cases without spasms. In hemianæsthesia the loss of sensation exists in one lateral half of the body. Parts are insensible to various methods of stimulation—to impressions of touch, pain, temperature, and weight. Sometimes the mucous membranes of the side affected are involved. The sight, hearing, taste, and smell are commonly impaired if not lost.
Much attention has been paid to the study of hemianæsthesia by French physicians. Charcot85has an admirable historical summary and clinical description of the condition, leaving little for others to add. Piorry, Macario, Gendrin, Szokalsky, and Briquet are referred to by him. Briquet found it present in 93 cases out of 400. It is of much more frequent occurrence on the left side. According to Briquet, 70 cases were affected on the left side to 20 on the right.
85Op. cit.
Next to hemianæsthesia, anæsthesia of the lower half of the body is most common in hysterical cases. While hemianæsthesia often presents itself conjoined with hystero-epileptic symptoms, anæsthesia of the lower half of the body may be present as frequently without as with convulsive manifestations. Anæsthesia of one limb or of one side of the face is almost as rare as general anæsthesia, but does occur.
Anæsthesia of mucous membrane is an old observation. It may affect mucous membranes everywhere—of the nose, pharynx, larynx, vagina, urethra, the bladder, rectum, etc. Many of the peculiar and apparently inexplicable hysterical symptoms are due to the presence of this anæsthesia—such symptoms, for instance, as want of inclination to evacuate the bowels or the bladder, absence of sexual desire, absence of sensibility when applications are made to the throat, etc. Loss of sensibility in muscles, bones, joints, and viscera may be present, but is of course frequently overlooked from want of minute investigation. In hemianæsthesia the viscera of the anæsthetic side are sometimes hyperæsthetic. Thus the ovary, as has been especially shown by Charcot, may be very painful on pressure when the abdominal wall is perfectly insensible.
A striking characteristic of hysteroid sensory disorders of the anæsthetic variety is the suddenness with which they come and go. A complete transference of anæsthesia from one side of the body to another may occur in a few seconds, either without special interference or under the use of metals or electricity.
The term achromatopsia is due to Galezowski. Hysterical achromatopsia is a condition in which there is a failure to appreciate colors. In Daltonism, or true color-blindness, one color may be taken for another; in achromatopsia the notion of color may be completely lost. These colors are found by the patient to disappear in a regular order, and return in a reverse order as the patient recovers. Some remarkable cases of this kind have been reported as occurring among French hysterics. A few examples of the same affection have been reported in America. Sometimes the patient has lost perception of one or several colors. When only one color is lost, it is usually the violet; if two, the violet and green; then in regular succession follow the colors of the spectrum.
Hysterical blindness and achromatopsia have been well studied by Charcot and Richer and others of the French school. Special articles on hysterical or simulated affections of the eye have also been published by Schweigger,86Harlan,87and others.
86“On Simulated Amaurosis,” by C. Schweigger, Prof. at the University of Berlin,New York Medical Journal, Feb., 1866.
87“Simulated Amaurosis,” by George C. Harlan, M.D.,American Journal of Medical Sciences, October, 1873; “Hysterical Affections of the Eye,”Transactions of the College of Physicians of Philadelphia, 3d Series, vol. ii., 1876.
In several cases of hystero-epilepsy under my care both amblyopia and achromatopsia were present. In one of these cases the patient was unable to read print of any size or to distinguish any colors, although she could tell that objects were being moved before the eyes. An ophthalmoscopic examination showed a normal fundus. Each eye was tested for near vision. It was found that she could read quite well with the right eye, and not at all with the left. While reading at about sixteen inches a convex glass of three inches focus was placed in front of the right eye, but she still continued to read fluently.
C. H. Thomas of Philadelphia has given me the particulars of a case of a woman about thirty-eight years old, both of whose eyes were, to all appearances, absolutely blind. The attack came on suddenly, the apparent cause seeming to be worry over a sick child. Ophthalmoscopic and other examinations of the eye showed nothing. She had no perception of light. She could look without winking at a blinding reflection of a whitewashed fence. In six weeks under a mere tentative treatment she got absolutely well. S. D. Risley of Philadelphia,88in a discussion at the Philadelphia Neurological Society, held that the feeble innervation of the hysterical patient was liable to diminish the range of accommodation and power of convergence, rendering the comfortable use of the eye impossible; and also that the feeble or deranged circulation in the hysterical individual might set up a group of symptoms in the eye presenting many of the characteristics of serious disease; which, however, were not simulated, but were, in fact, a relative glaucoma. While there was no absolute increase of intraocular tension, the normal tension of the eyeball was sufficient to interrupt the entrance of the feeble blood-stream into the eyes, and thus was set up the same group of symptoms as were present in actual increase of tension—viz. inadequate blood-supply to the retina, contracted field of vision, impaired central perception, diminished range of accommodation, and inability to use the eyes, particularly at a near point.
88The Polyclinic, vol. ii., No. 8, Feb. 15, 1885, p. 124.
Very few observations in cases of hysteria have been made with the ophthalmoscope, and probably little is to be learned in this way. In one of Charcot's patients, however, Galezowski saw an infiltration and capillary reddening of the disc with fusiform dilatations of the artery.
What might be termed hysterical dilatation of the pupil is sometimes observed. In the case reported by Harlan, to be hereafter detailed, the patient, a young girl who had a train of hysterical symptoms, began to complain of blindness or imperfect vision in the right eye, the pupil of which was found to be dilated. No proof could be obtained of the use of any mydriatic. The pupil remained dilated when exposed to a bright light. The dilatation came and went at intervals, and finally disappeared underthe applications of a wooden magnet. W. Chester Roy has acquainted me with the facts of the case of a man who could at will alternately contract and dilate his pupils. This case would seem to lend color to the idea that the hysterical girl may have had voluntary control of the pupillary movements. In her case, however, only one pupil was involved. F. X. Dercum has given me the particulars of a case of rhythmical dilatation of the irides in a case of confirmed masturbation with hysterical symptoms.
Hysterical deafness has been observed and studied. Walton,89at Charcot's suggestion, has published the results of the examination at La Salpêtrière of 13 patients affected with hemianæsthesia with reference to anæsthesia of hearing. He divides hemianæsthetic patients into three classes: (1) Those with complete anæsthesia of one side, the other side remaining normal; (2) those having incomplete anæsthesia on one side, the other remaining normal; (3) those with anæsthesia more or less complete on both sides. In the first class anæsthesia of hearing extended to the deep parts of the ear; the membrane of the drum could be touched without eliciting any acknowledgment of sensation and without the least reflex movement. He also showed that the anæsthesia extended to the middle ear by the fact that insufflation by Politzer's air-douche produced no sensation in the ear of the affected side. In this class neither the watch, voice, nor tuning-fork was heard. In the second class, with incomplete anæsthesia on one side, the lost sensibility corresponded, as a rule, with that of the body in general. A common form was analgesia with thermoanæsthesia and diminution of the tactile sensibility. In the third class completeness of the anæsthesia is rarely the same on both sides, a common form being complete hemianæsthesia on one side and analgesia on the other.
89Brain, January, 1883.
A noticeable feature in all the cases under consideration was the uniformity with which the deafness for conveyance by the bone exceeded that for sounds conveyed by the ear. Walton says: “This is probably due to the fact that the vibrations conveyed to the ear by the air are better adapted for the irritation of the peripheral auditory apparatus than those conveyed by the bone. When, then, the receptive power of the auditory centres is lessened, as is probably the case in hysterical patients, the hearing for sounds conveyed by the bones disappears before that for sounds conveyed by the ear. This enfeeblement of the auditive centres in hysteria is quite analogous to that in old age, in which, as is well known, the perception for sounds conveyed by the bone disappears before that for sounds conveyed by the air, the former being sometimes completely lost before the age of sixty.” His principal conclusions are as follows: (1) The sensibility of the deep parts of the ear, including the tympanum and middle ear, disappears in hysterical hemianæsthesia with that of other parts of the body, and in the same degree. (2) The degree of deafness corresponds with that of the general anæsthesia, being complete when the latter is complete, and incomplete when the latter is incomplete. (3) When loss of hearing is incomplete, the deafness for sounds conveyed by the bone exceeds that for sounds conveyed by air. (4) When the transfer is made, the hearing, as well as the general sensibility of the deep parts of the ear, improves on one side (allowance being made for accidentallesions in the ear itself) in exactly the same degree in which it disappears on the other.
The following case has been kindly furnished to me by Charles S. Turnbull, the patient having in the first instance come to Philadelphia to consult his father, Laurence Turnbull: The patient was a young lady from New Jersey, eighteen years old. Her general health was good, although at times she had a pale and anxious look. She had never had any unusual sickness. Soon after the death of her mother, for whom she grieved very much, she began to grow deaf, and was for a time treated by her family physician. When she first came to Philadelphia she was absolutely deaf, but the most careful examination failed to discover a cause for the deafness in any affection of the external or middle ear. A current from ten cells of a galvanic battery was painful, but elicited no sound. She declared that she could not hear a musical box held close to the side of her head. In communicating with her, everything had to be written. A faradic current was used daily to her ears. Suddenly one morning, after a powerful current had been applied, her hearing returned, but before she came back for treatment the next day it had again left. The electrical treatment was continued: each day the hearing stayed longer and longer, and finally returned in full force and remained good.
By hysterical paræsthesia is meant that form of perverted sensation which is not distinctly depressed on the one hand or markedly increased on the other. Under this head would come such conditions as numbness, formications, prickling and tingling sensation, the sensation of a ball in the throat or globus hystericus, etc. These forms of perverted sensation are quite common among the hysterical.
Hyperæsthesia may present itself in almost any locality, its areas of distribution corresponding very well to those which have been given for anæsthesia. Hyperæsthesia of the special senses is of especially frequent occurrence. Great sensitiveness to sounds and to bright lights or to particular colors is commonly observed. What might be termed hysterical tinnitus aurium is met with occasionally.
Perversions of the senses of smell and taste are among the rarer phenomena in the sensory sphere in hysteria. These may be of three kinds: the senses may be completely obtunded; they may be hyperacute; or they may show peculiar perversions. To some individuals of the hysterical temperament certain smells are almost unendurable, and these may be odors which to others are particularly pleasant. In like manner, certain articles of food or drink may be the source of great discomfort or absolute suffering. It is one of the oldest of observations that hysterical and morbid cravings for disagreeable or disgusting substances sometimes exist.
In one group of hysterias the presence of pain is the predominating feature. Some of the situations in which hysterical pains are most frequently felt are the head, the pericardial or left inframammary region, over the stomach and spleen, the left iliac region, the region of the kidneys, the sacrum, the hip, the spine, the larynx and pharynx, one or both mammæ, or over the liver and the joints. Of these locations, omitting the consideration of headache, the most common seats of hysterical pain are the spine, the breasts and inframammary region, the left iliac or ovarian region, the sacrum or coccyx, and the joints.
Charles Fayette Taylor, in a brochure on sensation and pain,90has given a philosophical explanation of such pain, drawing largely from Carpenter, Bain, Spencer, and others. The pith of the matter is that many of our sensations are centrally initiated, the memory of previous objective sensations. “Pain is different from ordinary sensations, in that it requires an abnormal condition for its production, and that it cannot be produced without that abnormal condition. Hence it is impossible to remember pain, because the apparatus does not exist for causing such a sensation as pain after the fact or when it is to be remembered. Memory is a repetition, in the nerve-centre, of energy which was first caused by the sensory impulse from without. But centrally initiated sensations may be mistaken, in consciousness, for pains depending wholly on a certain intensity of excitability in the cerebral mass.”
90Sensation and Pain, by Charles Fayette Taylor, M.D.—a lecture delivered before the New York Academy of Sciences, March 21, 1881.
A large percentage of all cases of hysteria complain more or less of spinal irritation. Spinal periostitis, spinal caries, and perhaps some cases of spinal meningitis, are organic diseases which may give rise to tenderness on pressure along the spine; but the majority of cases of spinal irritation are found among neurasthenic or hysterical patients. So much has already been written about spinal irritation that much time need not be spent on the subject, were it not that even yet many practitioners are inclined to regard cases as organic spinal trouble because of the presence of great spinal tenderness, whereas this symptom is almost diagnostic of the absence of real spinal disease.
Painful diseases of the joints, especially in women, are not infrequently hysterical or neuromimetic. Many such cases have been reported. Taylor states, as the results of much carefully-guarded experience, that hundreds of lame people are walking about perfectly who do not know that they ought to limp, and that a much larger number are either limping and walking on crutches, or not walking at all, who have no affection whatever causing lameness.
Paget—and his experience accords with that of others—makes the hip and knee, among the joints, the most frequent seats of nervous mimicry as well as of real disease. According to him, mimicries in other joints are almost too rare for counting; and yet in my first case of this kind the pain was located in the shoulder. This case made a lasting impression. The patient was a young lady of nervous temperament, who came complaining of severe and continuous pain in the left shoulder. No history of injury was given. The pain was said to be rheumatic. Handling the arm and pressure round the joint caused extreme pain. No heat, no redness, no swelling were discoverable. The patient left me and went to a magnetic doctor, who entirely dispelled the disorder on her first visit by gently stroking the arm and shoulder. Another patient had been accidentally struck in the knee. No swelling, heat, or other signs of inflammation followed the accident, and did not afterward appear; but at intervals, for several years, she complained of severe pain in and around this joint. She would be for days, or it might be for weeks, without speaking of the pain; and then again she would complain almost incessantly, and would sometimes limp. These periodsalways corresponded with times of mental and physical depression, and the pain was evidently neuromimetic or hysterical.
The affection which has come down to us from ancient times under the name of clavus hystericus is an acute boring pain confined to a small point at the top of the head, and is sometimes described as resembling the pain which would be produced by driving a nail into the head; hence the term, fromclavus, a nail. It may last for hours, days, or even weeks. Instead of clavus hystericus, hemicrania, occipital headache, or nape-aches may be present. On the whole, aches and pains of the head in hysterical cases are more likely to be localized to some point or area than to be general. Hysterical patients, however, not infrequently complain of constricting, contracting, or compressing sensations in the head.
In hysterical women the pulse is apt to be rapid, even sometimes twenty, thirty, to fifty pulsations to the minute above normal. The heart in these patients is irritable and prone to beat rapidly. One of Mitchell's cases is worthy of brief detail: A neurasthenic, hysterical woman, thirty-eight years old, when lying down had a heart-beat never less than 130 per minute. Exertion added twenty or thirty pulsations. Despite this irritability, however, the rhythm was good. Ovarian pressure and pressure along the spine would suddenly increase the heart-beats. Her temperature ranged from 95° in the morning to 100° or 101.5° F. in the evening, although she had no pulmonary or visceral trouble.
The high temperatures which have been observed in many cases of hysteria have been due to some form of shrewd fraud; but Briand91maintains with Gubler, Rigel, Dieulafoy, and others that the term hysterical fever is correct, and he describes three forms of the fever: (1) The slow continued fever of Briquet, characterized sometimes by simple acceleration of the pulse, without elevation of temperature; sometimes by a temperature rise, either with or without phenomena or accompanied by headache, thirst, and other symptoms; (2) a shorter form, always the result of a more or less active disturbance of the nervous system by terror, fear, chagrin, and like causes; (3) a form with intermittent febrile phenomena. Examples of the different forms are given. Debove92supports the view of the entity of the hysterical fever, citing cases—one a woman twenty-four years old who had, at intervals, marked fever, the temperature sometimes reaching 1021/5° to 104° F. Malaria and tuberculosis were excluded. Sulphate of quinia had no influence upon her attacks, but antipyrine reduced the temperature and her general condition improved. Debove has observed the temperature to rise from 1° to 2° F. by mere suggestion when the patient was in a somnambulistic state.
91Gazette hébdomadaire, quoted inMed. News, Dec. 1, 1883.
92Ibid., quoted inMed. News, April 4, 1885.
On the other hand, it has been claimed that a true hysterical fever never occurs or is extremely rare. Admitting this view, several explanations may be given of the rise of temperature observed. It may be due to intercurrent affections, as typhoid or intermittent fever, or some local inflammatory disorder. It may be secondary fever, the result of muscular effort or some similar cause. Lastly, and most probably, it may be due to ingenious fraud, as to friction of the bulb, pressure, or tappingwith the finger, dipping the instrument into hot water, connivance with the nurse, etc. Du Castel93has reported a trick of this kind. An hysterical girl, convalescent from an attack of sore throat, displayed remarkable alternations of temperature. One day the thermometer reached 163.4° F.! By carefully watching the patient it was found she had learned the trick of lightly tapping the end of the thermometer, which caused the mercury to ascend as far as she wished. In the case of chronic hysterical insanity of which the details have been given the temperature in the axilla on several occasions reached 102°, 103°, and even 105° F.
93Revue de Thérapeutique méd.-chir., No. xi., 1884.
Extreme states of pallor or blushing, sometimes in the extremities and at others in the face, are mentioned by Mitchell as among the vaso-motor disturbances of hysteria. Rosenthal gives a most interesting observation with reference to vaso-motor conditions in hysteria: the patient, a girl twenty-three years old, had epileptiform attacks, which were preceded by a subjective sensation of cold and discoloration of the hands and tips of the fingers. The hands became very pale, the tips of the fingers and nails of a deep blue; the patient experienced a disagreeable sensation of cold in the hands, and their temperature sank more than 3°, while the pulse dropped from 72 to 65 or 66. After the attack the temperature rose 2° higher than the normal condition; the fingers and nails became very red, and were the seat of an abundant perspiration; the pulse increased to 84 or 88. Other interesting symptoms were present.
Mitchell94has put on record three cases of hysteria in which was present unilateral increase in bulk at or near the menstrual period, and also at other seasons after emotional excitement. He does not give any opinion as to its nature, but believes that it is not a mere increase of areolar serum, and that it does not appear to resemble the vasal paralysis in which the leg throbs and exhibits a rise in temperature and tint. He is unable also to identify it with any form of lymph œdema which it resembles, for in this disorder there is more obvious œdema, and it is also quite permanent. Whatever the cause of the swelling, he believes that it is under the influence of the nervous system, and that it varies with the causes which produce analgesia or spasm. I have seen swelling of this kind in several cases, and have probably overlooked it in others. In one of my reported cases of hystero-epilepsy it was a very marked symptom, coming and going, increasing and diminishing, with other symptoms.
94American Journal of the Medical Sciences, New Series, vol. lxxxviii., July, 1884, p. 94.
Buzzard calls attention to the fact that in many cases belonging to the class of hysteria the epidermis, which has arrived at extraordinary thickness, apparently from disuse of the limbs, offers great resistance to the passage of electric currents. Under these circumstances a more than usual amount of care in thoroughly soaking and rubbing the skin, as well as in selecting the motor points, is necessary to avoid fallacies. Absence of reflex from the sole of the foot, according to the same authority, is a very constant symptom in hysterical paraplegia.
Some wasting does not negative the idea of hysteria, but this wasting a not associated with changing the electrical reaction.
Disturbance of the secretion of the urine is among the most frequent of the minor hysterical troubles, and has often been noted by writers uponthis subject since a very early date. Sydenham95says that of the “symptoms accompanying this disease, the most peculiar and general one is the making great quantities of urine as clear as rock-water, which upon diligent inquiry I find to be the distinguishing sign of those disorders which we call hypochondriac in men and hysteric in women. And I have sometimes observed in men that soon after having made urine of an amber color, being suddenly seized with some disturbance of mind, they made a large quantity of clear water, with a continued violent stream, and remained indisposed till the urine came to its former color, when the fit went off.” This symptom shows itself as strikingly in the hysteria of the present day as in the age of Sydenham.
95Op. cit.
A complete anuria or ischuria is one of the older observations in hysteria. Laycock, Charcot, and many others have written at length on this subject. Finch96has published a curious case of complete anuria. The patient had various hysterical symptoms, including paroxysms with unconsciousness, contracture, also vomiting. Micturition and defecation were entirely suspended (?) from Dec. 24, 1877, to Feb. 22d of the following year. During a period of fifty-eight days paroxysms were frequent; but on using the catheter the bladder was always found empty. The probability of hysterical fraud is very great in this case. A few case of hysterical retention of the urine in men have been reported.
96Nice médicale.
Increase of the uterine and vaginal secretions is mentioned by Jolly as sometimes attributable to nervous influences in cases of hysteria. He mentions the case of a woman suffering from hysterical symptoms at the change of life whose disposition was decidedly depressed; though at times lively, particularly erotic. In this case simultaneously with tympanites appeared a thin, clear fluor albus. Local treatment with quiet had no decided effect, but it disappeared with the tympanites when the patient was excited by the visit of a sister who overwhelmed her with reproaches.
Hysterical vomiting of food sometimes persists for weeks; strangely enough, the patients usually appear to suffer little in consequence. Chambers believes that the articles swallowed do not all get into the stomach. The phenomena of rejection in these cases are similar to those of an œsophageal stricture; some of the matter swallowed is really retained, and therefore the patient will not starve as soon as might be supposed.
Two cases of simulated pregnancy by hysterical women have come under my observation. Cases are reported also in which hysteria simulated closely the process of natural labor, as one for instance, by Hodges.97A woman said to be in the fifth month of pregnancy engaged him to attend her at term. Four months afterward he was sent for, the patient having severe pains, supposing herself to be in labor. On examination, however, a tumor present turned out to be the bladder distended and prolapsed. Sparks98reports the case of a young married woman who had the symptoms of the third stage of labor, the case being purely hysterical.
97Lancet, 1859, ii. 619.
98Chicago Med. Journ. and Examiner, 1880.
Walker99reports a group of hysterical symptoms closely simulating the prodromes of puerperal eclampsia. The patient, a married woman onlyeighteen years old, when pregnant six months lifted a tub of water, rupturing the membranes. In the eighth month, after she had remained in bed three days, she began to complain of severe headache; soon she said she was blind; the pupils of the eye were neither dilated nor contracted, and responded sluggishly to light. Ophthalmoscopic examination gave negative results, but she did not flinch from the light of the mirror. Temperature, pulse, and respiration were about normal. The urine contained no albumen. She recovered her sight in twelve hours, and had no continuing trouble.
99Arch. of Medicine, New York, 1883, x. 85-88.
Paget mentions cases of phantom tumor occurring in the calf, thigh, and breast. These phantoms shift from one place to another, or disappear when the muscles are relaxed by anæsthetics or otherwise. The nervous mimicry of aneurisms (of Paget) are what Laycock and others treat of as pulsations. They are most frequent in the carotid artery and abdominal aorta. Of imitations of cancer it need only be said that the average hysterical female suspects every lump in the breast and elsewhere to be a cancer.
Mitchell mentions certain peculiar symptoms quite common among hysterical women, but which also occur, but more rarely, among men. When falling asleep these patients have something like an aura rising from the feet and going up toward the head. One patient had an aura which passed upward from his feet, and when it had reached his head he felt what he described as an explosion. Another had a sensation as though something was about to happen, but no distinct ascending aura. If he roused himself in time, he could by turning over release himself from the sensation and break the chain of morbid events. At the close of the attack he had a noise in his head—something like the sound of a bell which had been struck once. Other patients when going to sleep have constant sounds, faint usually and rarely loud and without a feeling of terror. Most of the patients were women worn out or tired out and hysterical.
Sometimes hysterical women awake with numbness and tingling, which rapidly passes away or yields to a little surface friction. Some persons who have in a measure recovered from hemiplegia of organic origin are liable to awake out of sleep with a numbness and lessening of power on the side once palsied. Palpitation of the heart, vertigo, and a certain fear of a respiratory character are among the milder forms of trouble which Mitchell mentions as haunting the sleep of nervous or hysterical women.
Under hysteria some of the affections, more common among men than women, known as railway brain, railway spine, etc., may be classified. These disorders might be termed traumatic hysteria. The amount of money that has been paid out by corporations, beneficial societies or individuals because of suits or threatened suits for damages in cases of railway or other accidents is something almost incredible. At least two classes of cases, besides those of recognizable gross lesion, are to be found in the ranks of those claiming such damages. These are first the bogus cases or malingerers, and secondly cases of nervous mimicry. An hysterical individual who has been in a railway collision, or has been the victim of an accident for which somebody else may possibly be made responsible, may deliberately practise fraud, or he mayconsciously or unconsciously imitate or exaggerate real symptoms of serious import. Sometimes there may be in the same case a mingling of real and of simulated or of neuromimetic disorders. As long as a claim of damages in this class of cases exists, great care should be taken in making a diagnosis. The neuromimetic cases, however, do occur, particularly in the hysterical and neurasthenic, without any reference to litigation.
A lady fell off her chair backward. She was not rendered unconscious, but became nervous, and began to have considerable pain and soreness in the sacral region and about the right sacro-iliac juncture. She had no palsy, nor spasm, nor anæsthesia, nor paræsthesia, and had no difficulty in her bladder, but nevertheless was helpless in bed for many weeks, supposing herself unable to stand. She recovered promptly, under treatment with electricity, as soon as a favorable prognosis was given in a very positive manner.
A man fell on the ice and struck his back, but was able to go on with his usual occupation, although complaining of his limbs. Two months afterward, while recovering from typhoid fever, he fell from a chair, and was unable to raise himself, and found that he had lost control of his legs and arms. During the attack he was not unconscious. He was bed-ridden for two months, but did not lose control of his bladder and bowels. He was put on his feet by a little treatment and much encouragement.
A woman was badly pushed about while riding in a street-car by the car being thrown off the track. She miscarried in about six weeks, flooding a good deal after injury to the time of miscarriage. Later, spinal symptoms began. She had extensive pain and tenderness at the lower end of the spine. She sometimes fainted. Examination revealed general spinal tenderness, much more marked in the sacro-coccygeal region. She was pale, anæmic, and neurasthenic. She brought suit against the railway company for damages, which were very properly awarded, as the miscarriage, hemorrhage, and consequent anæmia were without doubt the result of an accident for which she was in no wise responsible. Some organic spinal-cord disease, however, was supposed to exist, the chief foundation for this view being the extreme spinal tenderness, which was hysterical.
Finally, some hysterical cases present a succession of local hysterical phenomena following each other more or less rapidly. One symptom seems to take possession of the patient for the time being, but when relieved or cured of this, suddenly a new manifestation occurs. A new figure appears upon the scene, or perhaps I might better say a new actor treads the boards. Even in these cases, however, it would be difficult to say that the phenomena are really simulated. They are rather induced, and get partly beyond the patient's will.
A remarkable case of this kind is well known at the Philadelphia Polyclinic and College for Graduates in Medicine. She is sometimes facetiously spoken of as the “Polyclinic Case,” because she has done duty at almost every clinical service connected with the institution. The case has been reported several times: the fullest report is that given by Harlan.100The patient was taken sick in September with sore throat, and was confined to the house for about two weeks. She was attended by S. SolisCohen. There was difficulty in swallowing, and some regurgitation of food. At the same time she had weakness of sight in the right eye. Later, huskiness of voice came on, and soon complete aphonia. Her voice recovered, and she then had what appeared to be pleuro-pneumonia. During the attack her arms became partially paralyzed. She complained of numbness down her legs and in her feet.
100Transactions of the Amer. Ophthalmological Soc., 20th annual meeting, 1884, 649.
Before these symptoms had disappeared twitchings of the muscles of the face set in, most marked on the right side. The face improved, but in two days she had complete spasmodic torticollis of the left side. One pole of a magnet was placed in front of the ear, and the other along the face; and under this treatment in a week the spasm ceased entirely.
In a short time she complained of various troubles of vision and a fixed dilatation of the pupil. Homonymous diplopia appeared. Reading power of the right eye was soon lost. The pupil was slightly dilated, and reacted imperfectly to light. She had distressing blepharospasm on the right side and slight twitchings on the left. Two months later a central scotoma appeared, and eventually her right eye became entirely blind except to light. The pupil was widely dilated and fixed, and the spasm became more violent and extended to the face and neck. The sight was tested by Harlan by placing a weak convex lens in front of the blind eye, and one too strong to read through in front of the sound eye, when it was found that she read without any difficulty. The use of the magnet was continued by Cohen. Blepharospasm and dilatation of the pupil improved. She, however, had an attack of conjunctivitis in the left eye, and again got worse in all her eye symptoms. A perfect imitation of the magnet was made of wood with iron tips. Under this imitation magnet the pupil recovered its size and twitching of the face and eyelids ceased.
The next campaign was precipitated by a fall. She claimed that she had dislocated her elbow-joint; she was treated for dislocation by a physician, and discharged with an arm stiff at the elbow. A wooden magnet was applied to the arm, the spasm relaxed, and the dislocation disappeared.
This ends Harlan's report of the case, and I had thought that this patient's Iliad of woes was also ended; but I have just been informed by J. Solis Cohen and his brother that she has again come under their care. The latter was sent for, and found the patient seemingly choking to death. The right chest was fixed; there was marked dyspnœa; respiration 76 per minute; her expectoration was profuse; she had hyperresonance of the apex, and loud mucous râles were heard. At last accounts she was again recovering.
This patient's train of symptoms began with what appeared to be diphtheria. The fact that she had some real regurgitation would seem to be strong evidence that she had some form of throat paralysis following diphtheria. She was of neurotic temperament. From the age of seven until ten years she had had fits of some kind about every four weeks. Because of her sore throat and subsequent real or seeming paralytic condition she came to the Polyclinic, where she was an object of interest and considerable attention, having been talked about and lectured upon to the classes in attendance. Whether her first symptoms were or were not hysterical, those which succeeded were demonstrably of this character.Frequently some real disease is the starting-point of a train of hysterical disorders.
DURATION ANDCOURSE.—Hysteria is pre-eminently a chronic disease; in the majority of cases it lasts at least for years. Its symptoms may be prolonged in various ways. Sometimes one grave hysterical disorder, as hysterical paralysis, persists for years. In other cases one set of symptoms will be supplanted by others, and these by still others, and so on until the whole round of hysterical phenomena appears in succession.
Deceptive remissions in hysterical symptoms often mislead the unwary practitioner. Cures are sometimes claimed where simply a change in the character of the phenomena has taken place. Without doubt, some cases of hysteria are curable; equally, without doubt, many cases are not permanently cured. It is a disease in which it is unsafe to claim a conquest too soon. In uncomplicated cases of hysteria the disorder often abates slowly but surely as age advances. As a rule, the longevity of hysterical patients is not much affected by the disorder.
COMPLICATIONS.—We should not treat a nervous case occurring in a woman or a man as hysterical simply because it is obscure and mysterious. Unless, after the most careful examination, we are able by exclusion or by the presence of certain positive symptoms to arrive at the diagnosis of hysteria, it is far better to withhold an opinion or to continue probing for organic disease. I can recall five cases in which the diagnosis of hysteria was made, and in which death resulted in a short time. One of these was a case of uræmia with convulsions, two were cases of acute mania, another proved to be a brain abscess, and the fifth a brain tumor. Hughes Bennett101has reported a case of cerebral tumor with symptoms simulating hysteria in which the diagnosis of the true nature of the disease was not made out during life. The patient was a young lady of sixteen at the time of her death. Her family history was decidedly neurotic. She was precocious both mentally and physically, was mischievous and destructive, sentimental and romantic; she had abnormal sexual passions. She had a sudden attack of total blindness, with equally sudden recovery of sight some ten days afterward. Sudden loss of sight occurred a second time, and deafness with restoration of hearing, loss of power in her lower limbs, and total blindness, deafness, and paraplegia. Severe constant headaches were absent, as were also ptosis, diplopia, facial or lingual paralysis, convulsions with unconsciousness, vomiting, wasting, and abnormal ophthalmoscopic appearances. She had attacks of laughing, crying, and throwing herself about. Her appearance and character were eminently suggestive of hysteria. The patient died, and on post-mortem examination a tumor about the size and shape of a hen's egg was found in the medullary substance of the middle lobe of the right hemisphere.
101Brain, April, 1878.
The association of hysteria with real and very severe spinal traumatism partially misled me in the case of a middle-aged man who had been injured in a runaway accident, and who sustained a fracture of one of the upper dorsal vertebræ, probably of the spines or posterior arch. This was followed by paralysis, atrophy of the muscles, contractures, changed reactions, bladder symptoms, bed-sores, and anæsthesia. The upper extremities were also affected. Marked mental changes were present,the man being almost insanely hysterical. The diagnosis was fracture, followed by compression myelitis, with descending motor and ascending sensory degeneration. An unfavorable prognosis was given. He left the hospital and went to another, and finally went home, where he was treated with a faradic battery. He gradually improved, and is now on his feet, although not well. In this case there was organic disease and also much hysteria.
Seguin102holds that (1) many hysterical symptoms may occur in diseases of the spinal cord and brain; (2) in diseases of the spinal cord these diseases appear merely as a matter of coincidence; (3) in cases of cerebral disease the hysterical symptoms have a deeper significance, being in relation to the hemisphere injured. He collects, as illustrative of the propositions that hysterical symptoms will present themselves in persons suffering from organic disease of the nervous system, the following cases of organic spinal disease: One case of left hemiplegia with paresis of the right limbs, which proved after death to be extensive central myelitis, with formation of cavities in the cord; two cases of posterior spinal sclerosis, two of disseminated sclerosis, and one of sclerosis of the lateral column. In some of these cases the organic disease was wholly overlooked. Sixteen cases of organic disease of the brain accompanied by marked hysterical manifestations are also given: 9 of left hemiplegia; 2 of right hemiplegia with aphasia; 1 of left alternating with right hemiplegia; 1 of hemichorea with paresis; 1 of double hemiplegia; and 2 of general paresis. It is remarkable and of interest, in connection with other unilateral phenomena of hysteria, that emotional symptoms were present in 14 cases of left hemiplegia and in only 2 of right.
102Op. cit.
Among the important conclusions of this paper are the following: “1. In typical hysteria the emotional symptoms are the most prominent, and according to many authors the most characteristic. In all the cases of cerebral disease related there were undue emotional manifestations or emotional movements not duly controlled. 2. In typical hysteria many of the objective phenomena are almost always shown on the left side of the body, and we may consequently feel sure that in these cases the right hemisphere is disordered. In nearly all of the above sixteen cases the right hemisphere was the seat of organic disease, and the symptoms were on the left side of the body.”
The possibility of the occurrence of hysteria in the course of acute diseases, particularly fevers, is often overlooked. Its occurrence sometimes misleads the doctor with reference to prognosis. Such manifestations are particularly apt to occur in emotional children. A young girl suffering from a moderately severe attack of follicular tonsillitis, with high fever, suddenly awoke during the night and passed into an hysterical convulsion which greatly alarmed her parents. Her fingers, hands, and arms twitched and worked convulsively. She had fits of laughing and shouting, and was for a short time in a state of ecstasy or trance. Once before this she had had a similar but slighter seizure, during the course of an ephemeral fever.
Among other complications of hysteria which have been noted by different observers are apoplexy, disease of the spleen, mania-a-potu, heartdisease, and spinal caries, and among affections alluded to by competent observers as simulated by hysteria are secondary syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina pectoris, and cardiac dyspnœa.
DIAGNOSIS.—Buzzard103significantly remarks that you cannot cure a case of hysteria as long as you have any serious doubt about its nature; and, on the other hand, if you are able to be quite sure on this point, and are prepared to act with sufficient energy, there are few cases that will not yield to treatment. The importance of a correct diagnosis is a trite topic, but in no affection is it of more consequence than in hysteria, that disorder which, although itself curable, may, as has been abundantly shown, imitate the most incurable and fatal of diseases.
103Clinical Lectures on Diseases of the Nervous System, by Thomas Buzzard, M.D., Philada., 1882.
A few remarks with reference to the methods of examining hysterical patients will be here in place. Success on the part of the physician will often depend upon his quickness of perception and ability to seize passing symptoms. It is often extremely difficult to determine whether hysterical patients are or are not shamming or how far they are shamming. The shrewdness and watchfulness which such patients sometimes exercise in resisting the physician's attempts to arrive at a diagnosis should be borne in mind. A consistent method of procedure, one which never betrays any lack of confidence, should be adopted. “Trifles light as air” will sometimes decide, a single expression or a trivial sign clinching the diagnosis. On the other hand, the most elaborate and painstaking investigation will be frequently required.
The physician should carefully guard against making a diagnosis according to preconceived views. On the whole, the general practitioner is more likely to err on the side of diagnosticating organic disease where it does not exist; the specialist in too quickly assigning hysteria where organic disease is present, or in failing to determine the association of hysteria and organic disease in the same case.
Special expedients may sometimes be resorted to in the course of an examination. Not a few hysterical symptoms require for their continuance that the patient's mind shall be centred on the manifestations. If, therefore, the attention can, without arousing suspicions, be directed to something else during the examination, the disappearance of the particular hysterical symptom may clear away all obscurity. In a case reported by Seguin,104in which staggering was a prominent symptom, the patient was placed in the middle of the room and directed to look at the ceiling to see if he could make out certain fine marks; he stood perfectly well without any unsteadiness. In the case of a boy eleven years old whose chief symptoms were hysterical paralysis with contracture of the lower extremities, great hyperæsthesia of the feet, and a tremor involving both the upper and lower extremities, and sometimes the head, I directed him, as if to bring out some point, to hold one arm above his head and at the same time fix his attention on the foot of the opposite side. The tremor in the upper extremities, which had been most marked, entirely disappeared. This experiment was varied, the result being the same.
104Op. cit.
The method adopted in the cases supposed to be phthisis, but which proved to be hysterical, which has already been alluded to under thehead of hysterical or nervous breathing, is worthy of note. The patients, it will be recalled, could not be induced to draw a long breath until the plan was adopted of having them count twenty without stopping, when the lungs expanded and the diagnosis was clear.
It is important to know whether or not children are of this hysterical tendency or are likely, sooner or later in life, to develop some forms of this disorder. In children as well as in adults the hysterical diathesis will be indicated by that peculiar mobility of the nervous system, which has been referred to under Etiology. It is chiefly by psychical manifestations that the determination will be made. These are often of mild degree and of irregular appearance. Undue emotionality under slight exciting cause, a tendency to simulation and to exaggeration of real conditions, inconsistency in likes and dislikes, and great sensibility to passing impressions, are among these indications. Children of hysterical diathesis are sometimes, although by no means always, precocious mentally, but not a few cases of apparent precocity are rather examples of an effort to attract attention, which is always present in individuals of this temperament.
It is also important, as urged by Allbutt,105to make a distinction between hysterical patients and neurotic subjects, often incorrectly classed as hysterical. Many cases of genuine malady and suffering are contemptuously thrown aside as hysteric. Allbutt regards some of these neurotic patients as almost the best people in this wicked world. Although, however, this author's righteous wrath against the too frequent diagnosis of hysteria, hysterical pain, hysterical spine, etc. is entirely justifiable, he errs a little on the other side.
105On Visceral Neuroses, being the Gulstonian Lectures on Neuralgia of the Stomach and Allied Disorders, delivered at Royal College of Physicians, March, 1884, by T. Clifford Allbutt, M.A., M.D. Cantab., F. R. S., Philada., 1884.
Hysteria and neurasthenia are often confounded, and, while both conditions may exist in the same case, just as certainly one may be present without the other. The points of differential diagnosis as given by Beard106are sufficient for practical purposes. They are the following: In neurasthenia convulsions or paroxysms are absent; in hysteria they are among the most common features. In neurasthenia globus hystericus and anæsthesia of the epiglottis are absent, ovarian tenderness is not common, and attacks of anæsthesia are not frequent and have little permanency; in hysteria globus hystericus, anæsthesia of the epiglottis, ovarian tenderness, and attacks of general or local anæsthesia are all marked phenomena. The symptoms of neurasthenia are moderate, quiet, subdued, passive; those of hysteria are acute, intense, violent, positive. Neurasthenia may occur in well-balanced intellectual organizations; hysteria is usually associated with great emotional activity and unbalanced mental organization. Neurasthenia is common in males, although more common in females; hysteria is rare in males. Neurasthenia is always associated with physical debility; hysteria in the mental or psychical form occurs in those who are in perfect physical health. Neurasthenia never recovers suddenly, but always gradually and under the combined influences of hygiene and objective treatment; hysteria may recover suddenly and under purely emotional treatment.
106Op. cit.