dangerous, and always an annoying, affection. An unmarried lady, forty
years old, with a neurotic family history, a maternal uncle and aunt
having been insane, at intervals since puberty had had various
hysterical manifestations. After a severe winter, during which she had
suffered more or less with rheumatism, she became depressed with
reference to her spiritual condition: she had, in fact, a form of mild
religious melancholia. After this had lasted for weeks she began to
experience difficulty in swallowing. She would rise from the table
suddenly, alarmed and gasping, and exclaiming that she could not
swallow and was choking. She got so bad that she could not take
anything but liquid food, and not nearly enough of this. She believed
that her throat was gradually closing, and of course suspected cancer.
She was assured that if any local obstruction existed it could be
removed with one application of a probang. Cancer was also confidently
excluded, and she was given iron, valerian, and quinine, and in a few
days an instrument was passed down her throat. She as told that she
would have no more difficulty. Tonics and full feeding were continued,
and in less than a week she swallowed without any difficulty.
Of the so-called hysterical asthma or hysterical breathing I have seen
several examples. A curious form of hysterical breathing, at least
partly spasmodic, recently came to the Philadelphia Polyclinic—a young
man twenty-one years of age, who confessed that he had been guilty of
excessive masturbation for five or six years. He had been a moderate
drinker and was the victim of an old hip disease. According to his
story, this abuse had never appeared to have impaired his health until
about one month before applying for treatment, when he began to have
attacks of peculiar breathing. He would have a series of rapid, forced
expirations which lasted for a period of from one to two or three
minutes. He would then stop for a moment; then again the shallow
breathing with forced expirations would ensue. He said that he
breathed in this way because he thought he was going to die, and did
so to keep alive. When he stopped he felt cold. He thought his belly
did not go outward as it should in the act of breathing. During the
time that the symptoms had been present he had had several frightful
attacks of excitement, in one of which he ran breathing in the manner
described to a {246} drug-store from one to two blocks away, jumping,
gesticulating, and calling for remedies. He had an anxious expression
of the face, a look of excitement and worriment. His pulse was 110 and
weak. Respirations during these attacks ranged from 38 to 50.
Coates,[84] speaking of hysterical or nervous breathing, gives the
details of five cases. Four of these had been supposed to be suffering
from phthisis; the fifth was apparently a case of hypertrophy of the
heart. The breathing was quick and shallow. The patients could not be
induced to draw long breaths until the expedient was adopted of having
them count twenty without taking breath. During this the lungs
expanded perfectly, air entering freely into every part. Coughing, and
even blood-spitting of a venous character, were present. They might
perhaps be classed as cases of hysterical or simulated phthisis.
[Footnote 84: _British Medical Journal_, 1884, ii. 13.]
Vaginismus, or spasm of the vagina, may with propriety be regarded as
hysterical in some but not in all cases. Spasmodic contracture of the
sphincters of the bladder and anus is also mentioned by Rosenthal.
Goose-flesh, according to the same author, is a frequent phenomenon in
the hysterical, and is due to spasmodic contraction of the muscular
fibres contained within the skin.
The sensorial affections of hysteria can be classified according
either to character or location. According to the character of the
sensory disturbance a good practical arrangement is into cases of (1)
Anæsthesia; (2) paræsthesia; (3) hyperæsthesia; (4) neuralgias and
localized pains,—although one of these classes may sometimes be
difficult to separate from another, or a doubt may arise as to whether
or not a special symptom should be placed under one or another head.
In hysterical anæsthesia sensation is decreased or abolished; in
paræsthesia it is faulty or perverted; in hyperæsthesia it is
increased over a more or less extensive surface; in neuralgia, pain is
confined to certain nerve-trunks. The localized pains are neuralgic or
mimetic, and are found in special localities, as in joints and in the
breast.
Anæsthesia is one of the most frequent of hysterical phenomena, but is
not, as stated by some authorities, present in all cases of genuine
hysteria.
In 400 hysterical cases Briquet found 240 positive examples of
anæsthesia. In this statement, however, he does not include cases of
insensibility of the conjunctiva of the left eye or those cases in
which anæsthesia lasted but a few hours after an attack. It is safe to
say that anæsthesia of some sort is present in from 60 to 75 per cent.
of all cases of well-marked hysteria. Analgesia, or insensibility to
pain, is present frequently when loss or diminution of sensibility to
touch, pressure, heat and cold, etc., is not observed.
Hysterical anæsthesia, may be of various forms, according to the parts
of the body affected, as general anæsthesia; hemianæsthesia;
anæsthesia of the lower half of the body; anæsthesia of one limb or
one side of the face; anæsthesia of mucous membranes; anæsthesia of
muscles, bones, and joints; anæsthesia of the viscera.
General anæsthesia is extremely rare. No example of it has ever fallen
under my observation, but by Briquet and others a few cases have been
reported.
{247} 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. Charcot[85] has 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.
[Footnote 85: _Op. 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.
{248} 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,[86] Harlan,[87] and others.
[Footnote 86: “On Simulated Amaurosis,” by C. Schweigger, Prof. at the
University of Berlin, _New York Medical Journal_, Feb., 1866.]
[Footnote 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,[88]
in 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.
[Footnote 88: _The 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 under {249} the 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,[89] at
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.
[Footnote 89: _Brain_, 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 accidental {250} lesions 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.
{251} Charles Fayette Taylor, in a brochure on sensation and pain,[90]
has 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.”
[Footnote 90: _Sensation 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
periods {252} always 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, from _clavus_, 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.