BY A. MYERSON, M.D.
Clinical Director and Pathologist, Taunton State Hospital Taunton State
Hospital Papers, 1914-5
THE progress in our understanding of hysteria has come largely through the elaboration of the so-called mechanisms by which the symptoms arise. These mechanisms have been declared to reside or to have their origin in the subconsciousness or coconsciousness. The mechanisms range all the way from the conception of Janet that the personality is disintegrated owing to lowering of the psychical tension to that of Freud, who conceives all hysterical symptoms as a result of dissociation arising through conflicts between repressed sexual desires and experiences and the various censors organized by the social life. Without in any way intending to set up any other general mechanism or to enter into the controversy raging concerning the Freudian mechanism, which at present is the storm center, the writer reports a case in which the origin of the symptoms can be traced to a more simple and fairly familiar mechanism, one which, in its essence, is merely an intensification of a normal reaction of many women to marital difficulties. In other words, women frequently resort to measures which bring about an acute discomfort upon the part of their mate, through his pity, compassion and self-accusation. They resort to tears as their proverbial weapon for gaining their point. In this case the hysterical symptoms seem to have been the substitute for tears in a domestic battle.
Case History—Patient is a woman, aged thirty-eight, of American birth and ancestry. Family history is negative so far as mental disease is concerned, but there seems to have been a decadence of stock as manifested in the steady dropping of her family in the social scale. She is one of two children, there being a brother, who, from all accounts, is a fairly industrious, but poverty-stricken farmer. Her early childhood was spent in a small village in Massachusetts. She received but little education, largely because she had no desire to study and no aptitude for learning, although she is by no means feeble-minded. The menstrual periods started at fourteen, and have been without any noteworthy accompanying phenomena ever since. History is negative so far as other diseases are concerned. She worked as a domestic and in factories until she was married for the first time at the age of twenty. She had no children by this marriage. It is stated on good authority that she took preventive measures against conception and if pregnant induced abortion by drugs and mechanical measures. At the end of eight years there was a divorce. Just which one of the partners was at fault is impossible to state, but that there was more than mere incompatibility is evident by the reticence of all concerned. Shortly afterward, she married her present husband with whom she has lived for about nine years. He is a steady drinker, but is a good workman, has never been discharged, and, apparently, his drinking habits do not interfere with the main tenor of his life. He lives with the patient in a small house of which they occupy two garret rooms, meagerly furnished, though without evidence of dire poverty.
From her fifteenth year the patient has been subject to fainting spells. By all accounts they come on usually after quarrels, disagreements or disappointments. They are not accompanied by blanching, by clonic or tonic movements of any kind, they last for uncertain periods ranging from five minutes to an hour or more, and consciousness does not seem to be totally lost. In addition she has vomiting spells, these likewise occurring when balked in her desires. She is subject to headaches, usually on one half of the head, but frequently frontal. There is no regular period of occurrence of these headaches except that there is also some relation to quarrels, etc. On several occasions the patient has lost her voice for short periods ranging from a few minutes to several hours following particularly stormy domestic scenes.
On July 29 of this year she was suddenly paralyzed. That is to say, she was unable to move the right arm, the right leg, the right side of the face, and she lost the power of speech entirely; there was complete aphonia. This "stroke" was not accompanied by unconsciousness, but was preceded by severe headache and much nausea. During the three weeks that followed she remained in bed, recovering only the function of the arm. Her husband fed her by forcing open her mouth with a spoon. She did not lose control of the sphincters. As she manifested no other progress to recovery despite the administration of drugs, numerous-rubbings and liniments, the physician in charge called the writer into consultation.
Physical Examination Aug. 20—A well-developed, fairly well nourished woman, appearing to be about thirty-five years of age. Face wears an anxious expression and she shuns the examiner's direct gaze. Movements of the right hand and arm are now fairly free. There is no appreciable difficulty in any of its functions according to tests made for ataxia, strength, recognition of form, finer movements, etc., in fact, she uses this hand to write with, as she cannot talk at all. Such writing is free, unaccompanied by errors in spelling, there is no elision of syllables and no difficulty in finding the words desired. The face is symmetrical on the two sides. There is no evidence of paralysis of the facial muscles. In fact, the cranial nerves, by detailed examination, are intact, except in so far as respiration and speech are concerned. The right leg is held entirely spastic, the muscles on both sides of the joints, that is, flexors and extensors, being equally contracted. It is impossible to bend this leg at any joint except by the use of very great force. The reflexes everywhere are lively but are equal on the two sides, and none of the abnormal reflexes is present, including in this term Babinski, Gordon and Oppenheim.
Sensation—There is very markedly diminished reaction to pin prick all over the right side, including face, arm, chest, leg and tongue. In some places complete analgesia obtains. Reaction to touch is likewise diminished and recognition of heat and cold is impaired.
Speech—There is complete loss of the ability to make any sound, either voiced or whispered; that is to say, there is complete aphonia,— there is loss of all voice. The patient understands everything, however, and writes her answers to questions rapidly and correctly. She can read whatever is written, there is no difficulty in the recognition of objects, no evidence of any aphasia whatever.
The diagnosis—hysteria—can hardly be doubted. The history of headaches, fainting spells without marked impairment of consciousness, vomiting spells, hemianaesthesia, hemianalgesia, complete aphonia and an exaggerated paralysis, not only of the right leg, but of the ability to thrust out the tongue, while at the same time all other cranial functions were unimpaired together with the apparent health of the individual in every other respect, make up a syndrome hardly to pass unrecognized.