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 Briand[91]
maintains 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. Debove[92] supports 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
102-1/5° 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.
[Footnote 91: _Gazette hébdomadaire_, quoted in _Med. News_, Dec. 1,
1883.]
[Footnote 92: _Ibid._, quoted in _Med. 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 tapping {253} with the finger, dipping the
instrument into hot water, connivance with the nurse, etc.
Du Castel[93] has 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.
[Footnote 93: _Revue 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.
Mitchell[94] has 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.
[Footnote 94: _American 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
upon {254} this subject since a very early date. Sydenham[95] says
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.
[Footnote 95: _Op. 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. Finch[96] has 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.
[Footnote 96: _Nice 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.[97] A 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. Sparks[98] reports the case of a young
married woman who had the symptoms of the third stage of labor, the
case being purely hysterical.
[Footnote 97: _Lancet_, 1859, ii. 619.]
[Footnote 98: _Chicago Med. Journ. and Examiner_, 1880.]
Walker[99] reports a group of hysterical symptoms closely simulating
the prodromes of puerperal eclampsia. The patient, a married woman
only {255} eighteen 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.
[Footnote 99: _Arch. 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
may {256} consciously 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.[100] The patient was taken sick in September with
sore throat, and was confined to the house for about two weeks. She
was attended by S. Solis {257} Cohen. 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.
[Footnote 100: _Transactions 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. {258} Frequently some real disease is
the starting-point of a train of hysterical disorders.
DURATION AND COURSE.—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 Bennett[101] has 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.
[Footnote 101: _Brain_, 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, {259} 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.