A remarkable case of hysterical motor paralysis was observed at the State Hospital for the Insane at Norristown. This patient was an intelligent single woman about thirty-five years of age, of good family, well educated; she had been a teacher and writer, and became insane through family and business troubles. When only eight years of age she was paralyzed for two years and a half, and had had at times during her life, before becoming insane, attacks of partial or complete unconsciousness. Prior to coming under observation she had been an inmate of an English private asylum. She was sick on shipboard coming to this country, and on her arrival was in a state of delirium and insomnia, with attacks of loss of sight. Four months later she developed mania with suicidal inclinations. Just before the development of this maniacal condition her lower limbs became comparatively helpless, and soon after she entirely lost their use. I found her in this condition, and examination showed no change in knee-jerk, electrical reactions, nutrition, nor genito-urinary conditions, which led me to diagnosticate the absence of any organic spinal trouble. The case was pronounced one of hysterical paralysis, and it was prophesied that she would eventually completely recover, probably suddenly. For one year her paralysis remained, her mental condition varying very greatly during this time—sometimes in a lethargic state; sometimes with variable delusions and delirium; occasionally violent and destructive, again peaceable and pleasant; sometimes requiring strong anodynes and hypnotics. Fourteen months after her paralytic condition began, one day she suddenly threw away her crutches and ran up and down the corridor of the hospital. From that time she walked without difficulty, although her mental condition did not entirely clear.
I wish to impress the fact that because hysterical manifestations occur in a case of insanity it should not necessarily be diagnosticated as one of hysterical insanity. Monomania, melancholia, mania, paretic dementia, epileptic insanity, and other forms of mental disorder may at times have an hysterical tinge or hysterical episodes.
The whole question of hysterical insanity is one of great difficulty. The psychical element is probably at the root of all cases of hysteria, but this does not justify us, as I have already stated, in declaring that all cases of hysteria are insane. In practical professional life we must make practical distinctions. In the matter before us distinctions are necessary to be made for legal as well as medical purposes. It might be right and proper to place a case of hysterical insanity in a hospital or asylum under restraint, but no one would dare to claim that every case of hysteria should be so treated.
Hysterical insanity may be conveniently subdivided into an acute and chronic form.
Acute hysterical insanity or hysterical mania is a disorder usually, in part at least, purposive, and characterized by great emotional excitement, which shows itself in violent speech and movement, and often also in deception, simulation, and dramatic behavior. The phenomena indicated by this definition may constitute the entire case, or, in addition, the patient may have, at intervals or in alternation, various other phases of grave hysteria, such as hystero-epileptic seizures or attacks of catalepsy, trance, or ecstasy.
In chronic hysterical insanity we have a persisting abnormal mental condition, which may show itself in many ways, but chiefly as follows: (1) A form in which occur frequent repetitions, over a series of years, of the phenomena of acute hysterical insanity, such as hysterical mania, hystero-epilepsy, catalepsy, etc.; (2) a form in which sensational deceptions—sometimes undoubtedly self-deceptions—are practised.
In a case of chronic hysterical insanity you may have both of these forms commingling in varying degree, as in the following case: G—— is a seamstress, twenty-one years of age. Although young in years, she is an old hospital rounder: she has at various times been in almost all the hospitals of the city. She has been treated for such alleged serious affections as fractured ribs, hemorrhages from the lungs, stomach, and vagina, gastric ulcer, epilepsy, apoplexy, paralysis, anæsthesia of various localities, amenorrhœa, dysmenorrhœa, and fever with marvellous variations of temperature. She has become the bane and terror of every one connected with her treatment and care-taking. She has developed violent attacks of mania, with contortions and convulsions, on the streets and in churches. Sums of money have been collected for her at times by those who have become interested in her as bystanders at the time of an attack or have heard of her case from others. She has made several pseudo-attempts at suicide. Recently an empty chloroform-liniment bottle tumbled from her bed at a propitious moment, she at the same time complaining of pain and symptoms of poisoning. She has refused to partake of food, and has been discovered obtaining it surreptitiously. Her large and prolonged experience with doctors and hospitals has so posted her with reference to the symptomatology of certain nervous affections that she is able at will to get up a fair counterfeit of a large variety of grave nervous disorders.
One of her recent attacks of hysteria was preceded by a series of hysterical phenomena, such as vomiting, hemorrhage, aphonia, ovaralgia, headache, and simulation of fever. She began by crying and moaning, which was kept up for many hours. She fell out of bed, apparently insensible. Replaced in bed, she passed into a state closely simulating true acute maniacal delirium. She shrieked, cried, shouted, and moaned, threw her arms and legs about violently, and contorted her entire body, snapping and striking at the nurses and physicians in attendance. At times she would call those about her by strange names, as if unconscious of the true nature of her surroundings. Attacks of this kind were kept up for a considerable period, and after an interval of rest were repeated again and again.
Many of the extraordinary facts which fill the columns of the sensational newspapers are the results of the vagaries of patients suffering from the second of the forms of chronic hysterical insanity. “When,” says Wilks,62 “you see a paragraph headed ‘Extraordinary Occurrence,’ and you read how every night loud rapping is heard in some part of the house, how the rooms are being constantly set on fire, or how all the sheets in the house are torn by rats, you may be quite sure that there is a young girl on the premises.” It is unnecessary to add that said girl is of the hysterical genus.