diseases of the spinal cord and brain; (2) in diseases of the spinal
cord these diseases appear merely as a matter of coincidence; (3) in
cases of cerebral disease the hysterical symptoms have a deeper
significance, being in relation to the hemisphere injured. He
collects, as illustrative of the propositions that hysterical symptoms
will present themselves in persons suffering from organic disease of
the nervous system, the following cases of organic spinal disease: One
case of left hemiplegia with paresis of the right limbs, which proved
after death to be extensive central myelitis, with formation of
cavities in the cord; two cases of posterior spinal sclerosis, two of
disseminated sclerosis, and one of sclerosis of the lateral column. In
some of these cases the organic disease was wholly overlooked. Sixteen
cases of organic disease of the brain accompanied by marked hysterical
manifestations are also given: 9 of left hemiplegia; 2 of right
hemiplegia with aphasia; 1 of left alternating with right hemiplegia;
1 of hemichorea with paresis; 1 of double hemiplegia; and 2 of general
paresis. It is remarkable and of interest, in connection with other
unilateral phenomena of hysteria, that emotional symptoms were present
in 14 cases of left hemiplegia and in only 2 of right.
[Footnote 102: _Op. cit._]
Among the important conclusions of this paper are the following: “1.
In typical hysteria the emotional symptoms are the most prominent, and
according to many authors the most characteristic. In all the cases of
cerebral disease related there were undue emotional manifestations or
emotional movements not duly controlled. 2. In typical hysteria many
of the objective phenomena are almost always shown on the left side of
the body, and we may consequently feel sure that in these cases the
right hemisphere is disordered. In nearly all of the above sixteen
cases the right hemisphere was the seat of organic disease, and the
symptoms were on the left side of the body.”
The possibility of the occurrence of hysteria in the course of acute
diseases, particularly fevers, is often overlooked. Its occurrence
sometimes misleads the doctor with reference to prognosis. Such
manifestations are particularly apt to occur in emotional children. A
young girl suffering from a moderately severe attack of follicular
tonsillitis, with high fever, suddenly awoke during the night and
passed into an hysterical convulsion which greatly alarmed her
parents. Her fingers, hands, and arms twitched and worked
convulsively. She had fits of laughing and shouting, and was for a
short time in a state of ecstasy or trance. Once before this she had
had a similar but slighter seizure, during the course of an ephemeral
fever.
Among other complications of hysteria which have been noted by
different observers are apoplexy, disease of the spleen, mania-a-potu,
heart {260} disease, and spinal caries, and among affections alluded
to by competent observers as simulated by hysteria are secondary
syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina
pectoris, and cardiac dyspnœa.
DIAGNOSIS.—Buzzard[103] significantly remarks that you cannot cure a
case of hysteria as long as you have any serious doubt about its
nature; and, on the other hand, if you are able to be quite sure on
this point, and are prepared to act with sufficient energy, there are
few cases that will not yield to treatment. The importance of a
correct diagnosis is a trite topic, but in no affection is it of more
consequence than in hysteria, that disorder which, although itself
curable, may, as has been abundantly shown, imitate the most incurable
and fatal of diseases.
[Footnote 103: _Clinical Lectures on Diseases of the Nervous System_,
by Thomas Buzzard, M.D., Philada., 1882.]
A few remarks with reference to the methods of examining hysterical
patients will be here in place. Success on the part of the physician
will often depend upon his quickness of perception and ability to
seize passing symptoms. It is often extremely difficult to determine
whether hysterical patients are or are not shamming or how far they
are shamming. The shrewdness and watchfulness which such patients
sometimes exercise in resisting the physician's attempts to arrive at
a diagnosis should be borne in mind. A consistent method of procedure,
one which never betrays any lack of confidence, should be adopted.
“Trifles light as air” will sometimes decide, a single expression or a
trivial sign clinching the diagnosis. On the other hand, the most
elaborate and painstaking investigation will be frequently required.
The physician should carefully guard against making a diagnosis
according to preconceived views. On the whole, the general
practitioner is more likely to err on the side of diagnosticating
organic disease where it does not exist; the specialist in too quickly
assigning hysteria where organic disease is present, or in failing to
determine the association of hysteria and organic disease in the same
case.
Special expedients may sometimes be resorted to in the course of an
examination. Not a few hysterical symptoms require for their
continuance that the patient's mind shall be centred on the
manifestations. If, therefore, the attention can, without arousing
suspicions, be directed to something else during the examination, the
disappearance of the particular hysterical symptom may clear away all
obscurity. In a case reported by Seguin,[104] in which staggering was
a prominent symptom, the patient was placed in the middle of the room
and directed to look at the ceiling to see if he could make out
certain fine marks; he stood perfectly well without any unsteadiness.
In the case of a boy eleven years old whose chief symptoms were
hysterical paralysis with contracture of the lower extremities, great
hyperæsthesia of the feet, and a tremor involving both the upper and
lower extremities, and sometimes the head, I directed him, as if to
bring out some point, to hold one arm above his head and at the same
time fix his attention on the foot of the opposite side. The tremor in
the upper extremities, which had been most marked, entirely
disappeared. This experiment was varied, the result being the same.
[Footnote 104: _Op. cit._]
The method adopted in the cases supposed to be phthisis, but which
proved to be hysterical, which has already been alluded to under the
{261} head of hysterical or nervous breathing, is worthy of note. The
patients, it will be recalled, could not be induced to draw a long
breath until the plan was adopted of having them count twenty without
stopping, when the lungs expanded and the diagnosis was clear.
It is important to know whether or not children are of this hysterical
tendency or are likely, sooner or later in life, to develop some forms
of this disorder. In children as well as in adults the hysterical
diathesis will be indicated by that peculiar mobility of the nervous
system, which has been referred to under Etiology. It is chiefly by
psychical manifestations that the determination will be made. These
are often of mild degree and of irregular appearance. Undue
emotionality under slight exciting cause, a tendency to simulation and
to exaggeration of real conditions, inconsistency in likes and
dislikes, and great sensibility to passing impressions, are among
these indications. Children of hysterical diathesis are sometimes,
although by no means always, precocious mentally, but not a few cases
of apparent precocity are rather examples of an effort to attract
attention, which is always present in individuals of this temperament.
It is also important, as urged by Allbutt,[105] to make a distinction
between hysterical patients and neurotic subjects, often incorrectly
classed as hysterical. Many cases of genuine malady and suffering are
contemptuously thrown aside as hysteric. Allbutt regards some of these
neurotic patients as almost the best people in this wicked world.
Although, however, this author's righteous wrath against the too
frequent diagnosis of hysteria, hysterical pain, hysterical spine,
etc. is entirely justifiable, he errs a little on the other side.
[Footnote 105: _On Visceral Neuroses, being the Gulstonian Lectures on
Neuralgia of the Stomach and Allied Disorders_, delivered at Royal
College of Physicians, March, 1884, by T. Clifford Allbutt, M.A., M.D.
Cantab., F. R. S., Philada., 1884.]
Hysteria and neurasthenia are often confounded, and, while both
conditions may exist in the same case, just as certainly one may be
present without the other. The points of differential diagnosis as
given by Beard[106] are sufficient for practical purposes. They are
the following: In neurasthenia convulsions or paroxysms are absent; in
hysteria they are among the most common features. In neurasthenia
globus hystericus and anæsthesia of the epiglottis are absent, ovarian
tenderness is not common, and attacks of anæsthesia are not frequent
and have little permanency; in hysteria globus hystericus, anæsthesia
of the epiglottis, ovarian tenderness, and attacks of general or local
anæsthesia are all marked phenomena. The symptoms of neurasthenia are
moderate, quiet, subdued, passive; those of hysteria are acute,
intense, violent, positive. Neurasthenia may occur in well-balanced
intellectual organizations; hysteria is usually associated with great
emotional activity and unbalanced mental organization. Neurasthenia is
common in males, although more common in females; hysteria is rare in
males. Neurasthenia is always associated with physical debility;
hysteria in the mental or psychical form occurs in those who are in
perfect physical health. Neurasthenia never recovers suddenly, but
always gradually and under the combined influences of hygiene and
objective treatment; hysteria may recover suddenly and under purely
emotional treatment.
[Footnote 106: _Op. cit._]
{262} An affection termed general nervousness has been described by
Mitchell. It does not seem to be strictly a neurasthenia, nor does it
always occur in hysterical individuals. These cases are sometimes
“more or less neurasthenic people, easily tired in brain or body; but
others are merely tremulous, nervous folks, easily agitated,
over-sensitive, emotional, and timid.” It is sometimes an inheritance;
sometimes it results from the misuse of alcohol, tobacco, tea or
coffee. Usually, it is developed slowly; occasionally, however, it
arises in a moment. Thus, Mitchell mentions the case of a healthy girl
who fell suddenly into a state of general nervousness owing to the
fall of a house-wall. General nervousness is to be distinguished from
hysteria, into which it sometimes merges, only by the absence of the
mental perversions and the special motor, sensory, vaso-motor, and
visceral disorders peculiar to the latter.
The differential diagnosis of hysteria and hypochondria, or what is
better termed hypochondriacal melancholia, is often, apparently at
least, somewhat difficult. Formerly, it was somewhat the fashion to
regard hysteria in the male as hypochondria; but this view has nothing
to support it. Hypochondria and hysteria, as neurasthenia and
hysteria, are sometimes united in the same subject; one sometimes
begets the other, but they have certain points of distinction.
Hypochondria more frequently passes into real organic disease than
does hysteria; it is more frequently associated with organic disease
than is hysteria. Hypochondria is in the majority of cases a true
insanity, while hysteria can only be regarded as such in the special
instances which have been discussed. In hypochondria the individual's
thoughts are centred upon some supposed disease until a true
delusional condition is developed; this does not often occur in
hysteria. Hypochondria is seen with as great a frequency in the male
as in the female, while hysteria prevails much more largely in the
female sex. In typical hypochondria more readily than in hysteria the
patient may be led from one set of symptoms to another, the
particulars of which he will detail in obedience to questions that are
put to him, these symptoms not unusually partaking of the absurd and
impossible. In hypochondria are absent those distinctive symptoms
which in nearly all cases of hysteria appear in greater or less
number, such as convulsions, paralysis, contracture, aphonia,
hysterical joints, and the like. In hypochondria is present the
groundless fear of disease without these outward manifestations of
disease. The symptoms of hypochondria, as a rule, but not invariably,
are less likely to change or abate than those of hysteria.
It is often of moment to be able to distinguish between two such
well-marked affections as common acute mania and hysterical mania. In
acute mania the disorder usually comes on gradually; in hysterical
mania the outbreak of excitement is generally sudden, although
prodromic manifestations are sometimes present. This point of
difference is not one to be absolutely depended upon. In acute mania
incoherence and delusions or delusional states are genuine phenomena;
in hysterical mania delusional conditions, often of an hallucinatory
character, may be present, but they are likely to be of a peculiar
character. Frequently, for instance, such patients see, or say that
they see, rats, toads, spiders, and strange beasts. These delusions
have the appearance of being affected in many cases; very often they
are fantastical, and sometimes at least they are spurious or
simulated. In hysterical mania such {263} phenomena as obstinate
mutism, aphonia, pseudo-coma, ecstasy, catalepsy, and trance often
occur, but they are usually absent in the history of cases of acute
mania. In acute mania under the influence of excitement or delusion
the patients may take their own lives: they may starve or kill
themselves violently; in hysterical mania suicide will be threatened
or apparently attempted, but the attempts are not genuine as a rule;
they are rather acts of deception. In acute mania the patients often
become much reduced and emaciated; in hysterical mania in general,
considering the amount of mental and motor excitement through which
the individuals pass, their nutrition remains good. In acute mania
sleeplessness is common, persistent, and depressing; in hysterical
mania usually a fair amount of sleep will be obtained in twenty-four
hours. In many cases of hysterical mania the patients have their worst
attacks early in the morning after a good night's rest. Acute mania
under judicious treatment and management may gradually recover;
sometimes, however, it ends fatally: this is especially likely to
occur if the physician supposes the case to be simply hysterical and
acts accordingly. Hysterical mania seldom has a serious termination
unless through accident or complication.
In order to make the diagnosis of purposive hysterical attacks
watchfulness on the part of the physician will often suffice. Such
patients can frequently be detected slyly watching the physician or
others. Threats or the actual use of harsh measures will sometimes
serve for diagnostic ends, although the greatest care should be
exercised in using such methods in order that injustice be not done.
In uræmia, as in true epilepsy, the convulsion is marked and the
condition of unconsciousness is usually profound. An examination of
the urine for albumen, and the presence of symptoms, such as dropsical
effusion, which point to disorder of the kidneys, will also assist.
Hysterical paralysis in the form of monoplegia or hemiplegia must
sometimes be distinguished from such organic conditions as cerebral
hemorrhage, embolism or thrombosis, tumor, abscess, or meningitis
(cerebral syphilis).
When the question is between hysteria and paralysis from coarse brain
disease, as hemorrhage, embolism, etc., the history is of great
importance. The hysterical case usually has had previous special
hysterical manifestations. The palsy may be the last of several
attacks, the patient having entirely recovered from other attacks. In
an organic case, if previously attacked, the patient has usually made
an incomplete recovery; the history is of a succession of attacks,
each of which leaves the patient worse. In cerebral syphilis it
happens sometimes that coming and going paralyses occur; but the
improvement in these cases is generally directly traceable to specific
treatment. Partial recoveries take place in embolism, thrombosis,
hemorrhage, etc. when the lesion has been of a limited character, but
the improvement is scarcely ever sufficient to enable the patient to
be classed as recovered. The exciting cause of hysterical and organic
cases of paralysis is different. While in hysterical paralysis sudden
fright, anxiety, anger, or great emotion is frequently the exciting
cause, such psychical cause is most commonly not to be traced as the
factor immediately concerned in the production of the organic
paralysis. In the organic paralysis an apoplectic or apoplectiform
attack of a peculiar kind has usually occurred. In cerebral hemorrhage
or embolism the {264} patient suddenly loses consciousness, and
certain peculiar pulse, temperature, and respiration phenomena occur.
The patient usually remains in a state of complete unconsciousness for
a greater or less period. In hysteria the conditions are different. A
state of pseudo-coma may sometimes be present, but the temperature,
pulse, and respiration will not be affected as in the organic case.
Hysterical monoplegia or hemiplegia, as a rule, is not as complete as
that of organic origin, and is nearly always accompanied by some loss
of sensation. The face usually escapes entirely. In organic palsy the
face is generally less severely and less permanently affected than the
limbs, but paresis is commonly present in some degree. Hysterical
palsies are more likely to occur upon the left than upon the right
side. Embolism is well known to occur most frequently in the left
middle cerebral artery, thus giving the palsies upon the right. In
hemorrhage and thrombosis the tendency is perhaps almost equal for the
two sides. Some of these and other points of distinction between
organic and hysterical palsies have been given incidentally under
Symptomatology.
In organic hemiplegia aphasia is more likely to occur than in
hysterical cases; and acute bed-sores and wasting of the limbs, with
contractures, are conditions frequently present as distressing
sequelæ. Such is not the rule in hysterical cases, for while there may
be wasting of the limbs from disuse and hysterical contractures,
bed-sores are seldom present, and the wasting and contractures do not
appear so insidiously, nor progressively advance to painful permanent
conditions, as in the organic cases. Mitchell mentions the fact that
in palsies from nerve wounds feeling is apt to come back first, motion
last; while in the hysterical the gain in the power of motion may go
on to full recovery, while the sense of feeling remains as it was at
the beginning of treatment. This point of course would help only in
cases where both sensory and motor loss are present.
The examination of an hysterically palsied limb, if conducted with
care, may often bring out the suppressed power of the patient.
Practising the duplicated, active Swedish movements on such a limb
will sometimes coax resistance from the patient. As already stated,
electro-contractility is retained in hysterical cases.
The disorders from which it may be necessary to diagnosticate
hysterical paraplegia are spinal congestion, subacute generalized
myelitis of the anterior horns (chronic atrophic spinal paralysis of
Duchenne), diffused myelitis, acute ascending paralysis, spinal
hemorrhage, spinal tumor, posterior spinal sclerosis or locomotor
ataxy, lateral sclerosis or spasmodic tabes, multiple cerebro-spinal
sclerosis, and spinal caries.
In spinal congestion the patients come with a history that after
exposure they have lost the use of their lower limbs, and sometimes of
the upper. Heaviness and pain in the back are complained of, and also
more or less pain from lying on the back. Numbness in the legs and
other disturbances of sensation are also present. The paralysis may be
almost altogether complete. Such patients exhibit evidences of the
involvement of the whole cord, but not a complete destructive
involvement. A colored woman, age unknown, had been in her ordinary
health until Nov. 24, 1884. At this time, while washing, she noticed
swelling of the feet, which soon became painful, and finally
associated with loss of power. She had also a girdling sensation about
the abdomen and pain in the back. She was {265} admitted to the
hospital one week later, at which time there was retention of the
urine and feces. She had some soreness and tenderness of the
epigastrium. She complained of dyspnœa, which was apparently
independent of any pulmonary trouble. It was necessary to use the
catheter for one week, by which time control of the bladder had been
regained. The bowels were regulated by purgatives. She was given large
doses of ergot and bromide and iodide of potassium, and slowly
improved, and after a time was able to get out of bed and walk with
the aid of a chair. An examination at the time showed that the
girdling pain had disappeared. There was distinct loss of sensation.
Testing the farado-contractility, it was found that in the right leg
the flexors only responded to the slowly-interrupted current, while in
the left both flexors and extensors responded to the interrupted
current. In both limbs with the galvanic current the flexors responded
to twenty cells, while the extensors responded to fifty cells. She
gradually improved, and was able to leave after having been in the
hospital three months.
The diagnosis of subacute myelitis of the anterior horns from
hysterical paraplegia is often of vital importance. “A young woman,”
says Bennett,[107] “suddenly or gradually becomes paralyzed in the
lower extremities. This may in a few days, weeks, or months become
complete or may remain partial. There is no loss of sensation, no
muscular rigidity, no cerebral disturbances, nor any general affection
of the bladder or rectum. The patient's general health may be robust
or it may be delicate. She may be of emotional and hysterical
temperament, or, on the contrary, of a calm and well-balanced
disposition. At first there is no muscular wasting, but as the disease
becomes chronic the limbs may or may not diminish in size. The entire
extremity may be affected or only certain groups of muscles. Finally,
the disease may partially or entirely recover, or remain almost
unchanged for years.” This is a fair general picture of either
disease.
[Footnote 107: _Lancet_, vol. ii. p. 842, November, 1882.]
Two facts are often overlooked in this connection: first, that
poliomyelitis is just as liable to occur in the hysterical as in the
other class; and, secondly, that the symptoms of hysterical paraplegia
and poliomyelitis may go hand in hand.
The history is different in the two affections. Frequent attacks of
paralysis in connection with hysterical symptoms are very suggestive,
although not always positive. In poliomyelitis the disease may come on
with diarrhœa and fever; often it comes on with vomiting and pain. The
patellar reflex is retained, often exaggerated, and rarely lost, in
hysteria, while it is usually lost in poliomyelitis. Electro-muscular
contractility is often normal in hysterical paralysis, although it is
sometimes slightly diminished quantitatively to both faradism and
galvanism: the various muscles of one limb respond about equally to
electricity: there are no reactions of degeneration in hysterical
paralysis as in poliomyelitis. In poliomyelitis reactions of
degeneration are one of the most striking features. The cutaneous
plantar reflex is impaired in hysterical paraplegia; bed-sores are
usually absent, as are also acute trophic eschars and the
nail-markings present both in generalized subacute myelitis and
diffused myelitis. True muscular atrophy is also wanting in hysterical
paraplegia, although the limbs may be lean and wasted from the
original {266} thinness of the patient or from disuse. The temperature
of the limbs is usually good. There is no blueness nor redness of the
limbs, nor are the bowels or bladder uncomfortably affected.