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 and {239}
turned 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 the {240} cases 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.
Mitchell[74] has 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.
[Footnote 74: _Op. 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 of {241} power 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-epilepsy[75] in 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.
[Footnote 75: _Journal of Nervous and Mental Disease_, vol. ix., No.
4, October, 1882.]
Mary Putnam Jacobi[76] has 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.
[Footnote 76: _Arch. 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.[77] I 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.
[Footnote 77: Quoted 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 times {242} before 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 Wood[78]
after 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.
[Footnote 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 the {243} manifestations of grave hysteria. An account
of an interesting case of this kind is given in a lecture by Wood,
reported by me in the _Philadelphia Medical Times_ for 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]
[Footnote 79: Charcot's lectures in _Le Progrès médical_ for 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.
{244} 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. Caraffi[80] reports 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.
[Footnote 80: _L'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.
Richardson[81] records 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.
[Footnote 81: _Diseases 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,
Richer[82] reports 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.
[Footnote 82: _Op. 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.[83] In this case the right ear twitched and
moved up and down. {245} 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.
[Footnote 83: _Philada. 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.