reproduced. They are drawn from photographs. They show two pairs of
feet, which have a certain superficial resemblance. In each the inner
border is drawn up into the position of a not severe varus. They are
the feet of two young women who were in the hospital at the same time.
A (Fig. 16), really a case of acute myelitis, had been treated as a
case of hysteria; and B (Fig. 17), really a case of hysteria, came in
as a paralytic. In these cases the results of examination into the
state of the electrical response and of the patellar-tendon reflex was
sufficient to make a diagnosis clear. In the organic case the
electrical reactions were abnormal and the patellar-tendon reflex was
abolished. These conditions were not present in the hysterical case.
[Illustration: FIG. 16.]
[Illustration: FIG. 17.]
[Footnote 108: _Clin. Lectures on Diseases of the Nervous System_,
London, 1882.]
The diagnosis of hysterical paraplegia from diffused myelitis is
governed practically by the same rules which serve in subacute
myelitis of the anterior horns, with some additional points. In
diffused myelitis, in addition to the motor, trophic, vaso-motor,
electrical, and reflex disorders of myelitis of the anterior horns,
affections of sensibility from involvement of the sensory regions of
the cord will also be present. Anæsthesia and paræsthesia will be
present.
Acute ascending paralysis, the so-called Landry's paralysis,
particularly when it runs a variable course, might be mistaken
sometimes for hysterical paralysis. In one instance I saw a fatal case
of Landry's paralysis which had been supposed to be hysterical until a
few hours before death. In Landry's paralysis, however, the swiftly
ascending character of the disorder is usually so well marked as to
lead easily to the diagnosis. In Landry's paralysis the loss of power
begins first in the legs, but soon becomes more pronounced, and passes
to the arms, and in the worst cases swallowing and respiration become
affected.
Spinal hemorrhage and spinal tumors, giving rise to paralysis, may be
mistaken for hysterical paralysis, partly because of the contractures.
Reactions of degenerations are usually features of this form of
organic paralysis. The contractures of hysterical paralysis can be
promptly {267} relieved by deep, strong pressure along supplying
nerve-trunks; this cannot be accomplished in the organic cases. Severe
localized pains in the limbs, sometimes radiating from the spinal
column, are present in the organic cases. Pain may be complained of by
the hysterical patient, but close examination will show that it is not
of the same character, either as regards severity or duration.
Hysterical locomotor ataxy is usually readily distinguished from
posterior spinal sclerosis, although the phenomena are apparently more
marked and more peculiar than those exhibited as the result of organic
changes. Hysterical ataxic patients often show an extraordinary
inability to balance their movements, this want of co-ordinating power
being observed even in the neck and trunk, as well as the limbs. In
hysterical cases a certain amount of palsy, often of an irregular
type, is more likely to be associated with the ataxia than in the
structural cases. The knee-jerk, so commonly absent in true posterior
spinal sclerosis that its absence has come to be regarded as almost a
pathognomonic symptom of this affection, in hysterical motor ataxy is
present and exaggerated. In hysterical locomotor ataxy other
well-marked symptoms of general hysteria, such as hysterical
convulsions, aphonia, etc., are present.
In the diagnosis of spastic spinal paralysis from hysterical
paraplegia great difficulties will sometimes arise. A complete history
of the case is of the utmost importance in coming to a conclusion. If
the case be hysterical, usually some account of decided hysterical
manifestation, such as aphonia, sudden loss and return of sight,
hysterical seizures, etc., can be had. Althaus holds that a
dynamometer which he has had constructed for measuring the force of
the lower extremities will, at least in a certain number of cases,
enable us to distinguish between the functional and spinal form of
spastic paralysis. In the former, although the patient may be unable
to walk, the dynamometer often exhibits a considerable degree of
muscular power; while in the latter, more especially where the disease
is somewhat advanced, the index of the instrument will only indicate
20° or 30° in place of 140° or 160°, and occasionally will make no
excursion at all.
The diagnosis of multiple cerebro-spinal sclerosis from hysteria
occasionally offers some difficulties. Jolly goes so far as to say
that it can only with certainty be diagnosticated in some cases in its
later stages and by the final issue—cases in which the paralytic
phenomena frequently alter their position, in which paroxysmal
exacerbations and as sudden ameliorations take place, and convulsive
attacks and disturbances of consciousness of a like complicated nature
as in hysteria are met with. Disorders of deglutition and
articulation, also characteristic of multiple cerebro-spinal
sclerosis, are now and again observed in the hysterical. Recently,
through the kindness of J. Solis Cohen, I saw at the German Hospital
in Philadelphia a patient about whom there was for a time some doubt
as to whether the peculiar tremor from which he suffered was
hysterical or sclerotic. At rest and unobserved, he was usually quiet,
but as soon as attention was directed to him the tremor would begin,
at first in the limbs, but soon also in the head and trunk. If while
under observation he attempted any movement with his hands or feet,
the tremor would become violent, and if the effort was persisted in it
would become convulsive in character. The effort to take a glass of
water threw him into {268} such violent spasms as to cause the water
to be splashed in all directions. The fact that this patient was a
quiet, phlegmatic man of middle age, that his troubles had come on
slowly and had progressively increased, that tremor of the head and
trunk was present, that cramps or tonic spasms of the limbs came and
went, indicated the existence of disseminated sclerosis. The knee-jerk
was much exaggerated, taps upon the patellar tendon causing decided
movement; when continued, the leg would be thrown into violent spasm.
Spondylitis, or caries of the vertebræ, is sometimes difficult to
distinguish from hysterical paraplegia or hysterical paraplegia from
it, or both may be present in the same case. Likewise, painful
paraplegia from cancer or sarcoma of the vertebræ may offer some
difficulties. A woman aged forty-four when two years old had a fall,
which was followed by disease of the spine, and has resulted in the
characteristic deformity of Pott's disease. She was apparently well,
able to do ordinary work, until about five years before she came under
observation, when her legs began to feel heavy and numb, and with this
were some pain and slight loss of power. These symptoms increased, and
in three months were followed by a total loss of power in the lower
extremity. She was admitted to the hospital, and for about three years
was unable to move the legs. She went round the wards in a wheeled
chair. The diagnosis was made of spondylitis, curvature, and paralysis
and sensory disorders depending on compression myelitis, and it was
supposed she was beyond the reach of remedies. One day one of the
resident physicians gave her a simple digestant or carminative, soon
after which she got up and walked, and has been walking ever since.
She attributes her cure entirely to this medicine.
What is the lesson to be learned from this case? It is, in the first
place, not to consider a patient doomed until you have made a careful
examination. There can be much incurvation of the spine without
sufficient compression to cause complete paralysis. In this patient
organic disease was associated with an hysterical or neuromimetic
condition. This woman had disease of the vertebræ, the active symptoms
of which had subsided. The vertebral column had assumed a certain
shape, and the cord had adjusted itself to this new position, yet for
a long time she was considered incurable from the fact that the
conjunction of a real and a mimetic disorder was overlooked.
Another patient aged twenty-seven had whooping cough, which lasted six
weeks, and was followed by severe pain in the back. For this she
consulted various physicians, being treated for Pott's disease and
spinal irritation. She, however, continued to grow worse, and every
jar and twist gave severe pain. At this time she had lost much flesh,
had pain in her back and elsewhere, and was subject to numerous and
violent spasms. When first seen by the physician who consulted me she
was complaining of pains in her legs, hips, and left shoulder, which
she considered rheumatic, and with pain in the abdomen. Examination of
the back with the patient on her side showed a slight prominence over
the position of the first or second lumbar vertebra. The spot was
painful on pressure, and had been so ever since the attack of whooping
cough three years before. A tap on the sole of either foot made her
complain of severe pain in the back. The same result followed pressure
on the head. The {269} patient was unable to stand or walk, but
occasionally sat up for a short time, although suffering all the time.
There was no muscular rigidity. The limbs and body were quite thin,
but, so far as could be detected, she had no loss of motor or sensory
power. At times, when the pains were worse, the arms would be flexed
involuntarily, and she stated that once the spine was drawn back and a
little sideways. The pain in the hips was augmented by pressure.
During the application of a plaster bandage she had a sort of fit and
fainted, and the application was suspended. She soon recovered
consciousness, but refused to allow the completion of the dressing. I
diagnosticated the affection as largely hysterical, and a few months
later received word that the patient was on her feet and well.
Kemper[109] relates the case of a lady who eventually died of sarcoma
of the vertebræ, the specimens having been examined by J. H. C. Simes
of Philadelphia and myself. She was supposed at first and for some
time to be a case of hysteria with spinal irritation. In the case of a
distinguished naval officer, who died of malignant vertebral disease
after great suffering a short time since, this same mistake was made
during the early stages of the disease: his case was pronounced to be
one of neurasthenia, hysteria, etc. before its true nature was finally
discovered. The absence of muscular rigidity in the back and
extremities is the strongest point against vertebral disease in these
cases.
[Footnote 109: _Journal of Nervous and Mental Diseases_, vol. xii.,
No. 1, January, 1885.]
In hysterical hemianæsthesia, ovarian hyperæsthesia, hystero-epileptic
seizures, ischuria, and other well-known hysterical symptoms have
usually been observed. The anæsthesia in hysterical cases is most
commonly on the left side of the body, but it may happen to be so
located in an organic case, so that this point is only one of slight
value.
Some older observers, as Briquet, who is quoted and criticised by
Charcot, believed that hemianæsthesia from encephalic lesions differed
from hysterical hemianæsthesia by the fact that in the former case the
skin of the face did not participate in the insensibility, or that
when it existed it never occupied the same side as the insensibility
of the limbs. Recently-reported cases have disproved the accuracy of
this supposed diagnostic mark. In his lectures, delivered ten years
ago, Charcot observed that up to that period anæsthesia of general
sensibility alone appeared to have been observed as a consecutive on
an alteration of the cerebral hemispheres, so that obtunding of the
special senses would remain as a distinctive characteristic of
hysterical hemianæsthesia. He, however, expected that cases of
cerebral organic origin would be reported of complete hemianæsthesia,
with derangements of the special senses, such as is presented in
hysteria. His anticipations have been fulfilled. In the nervous wards
of the Philadelphia Hospital is now a typical case of organic
hemianæsthesia in which the special senses are partially involved.
Paralysis and contractures, if present, are apt to be accompanied in
cases of organic hemianæsthesia, after time has elapsed, by marked
nutritive changes, by wasting of muscle, and even of skin and bone.
This is not the case in hysteria.
The subsequent history of these two conditions is different. The
hysterical patient will often recover and relapse, or under proper
{270} treatment may entirely recover; while all the treatment that can
be given in a case of organic hemianæsthesia will produce no decided
improvement, for there is a lesion in the brain which will remain for
ever. Hemianopsia, so far as I know, has not been observed in
hysterical hemianæsthesia.
In the monograph of Shaffer, with reference to both true and false
knee-joint affections certain conclusions are drawn which I will give
somewhat condensed:
Chronic synovitis produces very few if any subjective symptoms;
hysterical imitation presents a long train of both subjective and
objective symptoms and signs, the former in excess. Chronic ostitis
may be diagnosticated if muscular spasm cannot be overcome by
persistent effort; when the spasm does not vary night nor day; when it
is not affected by the ordinary doses of opium or chloral; when
reaction of the muscles to the faradic current is much reduced; when a
local and uniform rise of temperature over the affected articulation
is present; when purely involuntary neural symptoms, such as muscular
spasm, pain, and a cry of distress, are present. Hysterical knee-joint
is present, according to this author, when the muscular rigidity or
contracture is variable, and can be overcome by mildly persistent
efforts while the patient's mind is diverted, or which yields to
natural sleep, or which wholly disappears under the usual doses of
opium or chloral; when the faradic response is normal; when rise of
temperature is absent or a reduced temperature is present over the
joint; when variable and inconstant, emotional, and semi-voluntary
manifestations are present.
To recognize the neuromimesis of hip disease Shaffer gives the
following points: The limp is variable and suggests fatigue; it is
much better after rest; it almost invariably follows the pain. Pain of
a hyperæsthetic character is usually the first symptom, and it is
found most generally in the immediate region of the joint. “In place
of an apprehensive state in response to the tests applied will be
found a series of symptoms which are erratic and inconstant. A
condition of muscular rigidity often exists, but, unlike a true
muscular spasm, it can in most cases be overcome in the manner before
stated. A very perceptible degree of atrophy may exist—such, however,
as would arise from inertia only. A normal electrical contractility
exists in all the muscles of the thigh.”
In the neuromimesis of chronic spondylitis or hysterical spine the
pain is generally superficial, and is almost always located over or
near the spinous processes; it is sometimes transient, and frequently
changes its location from time to time; a normal degree of mobility of
the spinal column under properly directed manipulation is preserved;
the nocturnal cry and apprehensive expression of Pott's disease are
wanting.
With reference to the hysterical lateral curvature, Shaffer, quoting
Paget, says “ether or chloroform will help. You can straighten the
mimic contracture when the muscles cannot act; you cannot so
straighten a real curvature.”
In the diagnosis of local hysterical affections one point emphasized
by Skey is well worthy of consideration; and that is that local forms
of hysteria are often not seen because they are not looked for. “If,”
says he, “you will so focus your mental vision and endeavor to
distinguish the minute texture of your cases, and look into and not at
them, you will {271} acknowledge the truth of the description, and you
will adopt a sound principle of treatment that meets disease face to
face with a direct instead of an oblique force.” According to Paget,
the means for diagnosis in these cases to be sought—(1) in what may be
regarded as the predisposition, the general condition of the nervous
system, on which, as in a predisposing constitution, the nervous
mimicry of disease is founded; (2) in the events by which, as by
exciting causes, the mimicry may be evoked and localized; (3) in the
local symptoms in each case.
Local symptoms as a means of diagnosis can sometimes be made use of in
general hysteria. A case may present symptoms of either the gravest
form of organic nervous disease or the gravest form of hysteria, and
be for a time in doubt, when suddenly some special local manifestation
appears which cannot be other than hysterical, and which clinches the
diagnosis. In a case with profound anæsthesia, with paraplegia and
marked contractures, with recurring spasms of frightful character, the
sudden appearance of aphonia and apsithyria at once cleared all
remaining doubt. Herbert Page mentions the case of a man who suffered
from marked paraplegia and extreme emotional disturbance after a
railway collision, who, nine months after the accident, had an attack
of aphonia brought on suddenly by hearing of the death of a friend. He
eventually recovered.
To detect hysterical or simulated blindness the methods described by
Harlan are those adopted in my own practice. When the blindness is in
both eyes, optical tests cannot be applied. Harlan suggests
etherization.[110] In a case of deception, conscious or unconscious,
he says, “as the effect of the anæsthetic passed off the patient would
probably recover the power of vision before his consciousness was
sufficiently restored to enable him to resume the deception.”
Hutchinson cured a case of deaf-dumbness by means of etherization. For
simulated monocular blindness Graefe's prism-test may be used: “If a
prism held before the eye in which sight is admitted causes double
vision, or when its axis is held horizontally a corrective squint,
vision with both eyes is rendered certain.” It should be borne in mind
that the failure to produce double images is not positive proof of
monocular blindness, for it is possible that the person may see with
either eye separately, but not enjoy binocular vision, as in a case of
squint, however slight. Instead of using a prism while the patient is
reading with both eyes at an ordinary distance, say of fourteen or
sixteen inches, on some pretext slip a glass of high focus in front of
the eye said to be sound. If the reading is continued without change,
of course the amaurosis is not real. Other tests have been
recommended, but these can usually be made available.
[Footnote 110: _Loc. cit._]
The diagnosis of hysterical, simulated, or mimetic deafness is more
difficult than that of blindness. When the deafness is bilateral, the
difficulty is greater than when unilateral. The method by etherization
just referred to might be tried. Politzer in his work on diseases of
the ear[111] makes the following suggestions: Whether the patient can
be wakened out of sleep by a moderately loud call seems to be the
surest experiment. But, as in total deafness motor reflexes may be
elicited by the concussion of loud sounds, {272} care must be taken
not to go too near the person concerned and not to call too loudly.
The practical objection to this procedure in civil practice would seem
to be that we are not often about when our patients are asleep. In
unilateral deafness L. Müller's method is to use two tubes, through
which words are spoken in both ears at the same time. When unilateral
deafness is really present the patient will only repeat what has been
spoken in the healthy ear, while when there is simulation he becomes
confused, and will repeat the words spoken into the seemingly deaf ear
also. To avoid mistakes in using this method, a low voice must be
employed.
[Footnote 111: _A Textbook of the Diseases of the Ear and Adjacent
Organs_, by Adam Politzer, translated and edited by James Patterson
Cassells, M.D., M. R. C. S. Eng., Philada., 1883.]
Mistakes in diagnosis where hysteria is in question are frequently due
to that association with it of serious organic disease of the nervous
system of which I have already spoken at length under Complications.
This is a fact which has not been overlooked by authors and teachers,
but one on which sufficient stress has not yet been laid, and one
which is not always kept in mind by the practitioner. Bramwell says:
“Cases are every now and again met with in which serious organic
disease (myelitis and poliomyelitis, anterior, acute, for example) is
said to be hysterical. Mistakes of this description are often due to
the fact that serious organic disease is frequently associated with
the general symptoms and signs of hysteria; it is, in fact, essential
to remember that all cases of paraplegia occurring in hysterical
patients are not necessarily functional—_i.e._ hysterical; the
presence of hysteria or a history of hysterical fits is only
corroborative evidence, and the (positive) diagnosis of hysterical
paraplegia should never be given unless the observer has, after the
most careful examination, failed to detect the signs and symptoms of
organic disease.”
PROGNOSIS.—Hysteria may terminate (1) in permanent recovery; (2) in
temporary recovery, with a tendency to relapse or to the establishment
of hysterical symptoms of a different character; (3) in some other
affection, as insanity, phthisis, or possibly sclerosis; (4) in death,
but the death in such cases is usually not the direct result of
hysteria, but of some accident. Death from intercurrent disorders may
take place in hysteria. It is altogether doubtful, however, whether
the affection which has been described as acute fatal hysteria should
be placed in the hysterical category. In the cases reported the
symptom-picture would in almost every instance seem to indicate the
probability of the hysteria having been simply a complication of other
disorders, such as epilepsy, eclampsia, and acute mania.
As a rule, hysterical patients will not starve themselves. They may
refuse to take food in the presence of others, or may say they will
not eat at all; but they will in some cases at the same time get food
on the sly or hire their nurses or attendants to procure it for them.
In treating such cases a little watchfulness will soon enable the
physician to determine what is best to be done. By discovering them in
the act of taking food future deception can sometimes be prevented.
Hysterical patients do sometimes, however, persistently refuse food.
These cases may starve to death if let alone; and it is important that
the physician should promptly resort to some form of forcible feeding
before the nutrition of the patient has reached too low an ebb. I have
seen at least two cases of hysteria or hysterical insanity in which
patients were practically allowed to starve themselves to death, but
an occurrence of {273} this kind is very rare. Feeding by means of a
stomach-tube, or, what is still better, by a nasal tube, as is now so
frequently practised among the insane, should be employed. Nourishment
should be administered systematically in any way possible until the
patient is willing to take food in the ordinary way. In purposive
cases some methods of forcible feeding may prove of decided advantage.
Its unpleasantness will sometimes cause swallowing power to be
regained.