State Hospital for the Insane at Norristown. This patient was an
intelligent single woman about thirty-five years of age, of good
family, well educated; she had been a teacher and writer, and became
insane through family and business troubles. When only eight years of
age she was paralyzed for two years and a half, and had had at times
during her life, before becoming insane, attacks of partial or
complete unconsciousness. Prior to coming under observation she had
been an inmate of an English private asylum. She was sick on shipboard
coming to this country, and on her arrival was in a state of delirium
and insomnia, with attacks of loss of sight. Four months later she
developed mania with suicidal inclinations. Just before the
development of this maniacal condition her lower limbs became
comparatively helpless, and soon after she entirely lost their use. I
found her in this condition, and examination showed no change in
knee-jerk, electrical reactions, nutrition, nor genito-urinary
conditions, which led me to diagnosticate the absence of any organic
spinal trouble. The case was pronounced one of hysterical paralysis,
and it was prophesied that she would eventually completely recover,
probably suddenly. For one year her paralysis remained, her mental
condition varying very greatly during this time—sometimes in a
lethargic state; sometimes with variable delusions and delirium;
occasionally violent and destructive, again peaceable and pleasant;
sometimes requiring strong anodynes and hypnotics. Fourteen months
after her paralytic condition began, one day she suddenly threw away
her crutches and ran up and down the corridor of the hospital. From
that time she walked without difficulty, although her mental condition
did not entirely clear.
I wish to impress the fact that because hysterical manifestations
occur in a case of insanity it should not necessarily be
diagnosticated as one of hysterical insanity. Monomania, melancholia,
mania, paretic dementia, epileptic insanity, and other forms of mental
disorder may at times have an hysterical tinge or hysterical episodes.
{232} 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,
apparently {233} insensible. 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.
[Footnote 62: _Op. 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. Charcot[63] refers 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.
[Footnote 63: _Op. cit._]
Hemorrhages from eyes, ears, nostrils, gums, stomach, bowels, etc.
{234} 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 Lopez[64] of 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. Silvy[65] relates 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.
[Footnote 64: _American Journal of Medical Sciences_, Philadelphia,
1843, N. S., 74-81.]
[Footnote 65: _Mémoires de la Société médicale_, Anné 5, p. 181.]
Jolly[66] records 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!
[Footnote 66: _Op. cit._]
Hardaway[67] reports 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. Niemeyer[68] mentions a woman at
Krutsenberg's clinic who irritated her arm in such a way that
amputation became {235} necessary, and after that she irritated the
stump until a second amputation had to be performed.
[Footnote 67: _St. Louis Courier of Medicine_, 1884, xi. 352.]
[Footnote 68: _Textbook 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.[69]
He 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.
[Footnote 69: _Journal 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 of {236}
hysterical 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. Carter[70] describes 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. Lloyd[71] divides 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. Darwin[72] believes 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.”
[Footnote 70: _On the Pathology and Treatment of Hysteria_, London,
1853.]
[Footnote 71: _Op. cit._]
[Footnote 72: _Expression 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, {237} 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 Reynolds[73] has 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.
[Footnote 73: _Brit. 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, {238} 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.