Chapter XII: Front Matter (12)

Chronic endarteritis, arterio-sclerosis, atheroma of the cerebral arteries may be so diffused as to simulate general paralysis, especially in drunkards and syphilitics, but the symptoms do not advance in the manner characteristic of that disease.

Multiple cerebro-spinal sclerosis of the descending form may be confounded with general paralysis while the symptoms are obscure and consist in change of character, when, indeed, organic disease can only be suspected to be present.

Lead has been known to attack the central nervous system in such a way as to produce an intellectual apathy and muscular weakness somewhat resembling the early stage of the demented form of general paralysis, but without its ataxic symptoms and its regular progress. The presence of lead in the urine, and the marked improvement from the use of {199} iodide of potassium, tonics, and electricity, are sufficient to establish the diagnosis.

Chronic and persistent alcoholism is always attended with some mental impairment, which may so resemble the dementia of general paralysis, with marked moral perversion, mental exaltation, grand delusions, muscular tremor, ataxic symptoms, and impaired muscular power, as to make the diagnosis doubtful for several months, until removal of the cause (alcohol) in the course of time causes the symptoms to so abate as to make the real character of the disease evident.

I have once seen chronic interstitial nephritis without its usual prominent symptoms and with mild uræmic convulsions mistaken for general paralysis.

A tumor of the brain, if not attended with the common symptom of vomiting, may be the cause of convulsions and headache resembling those often seen in general paralysis. Optic neuritis or atrophy is usual in cerebral tumor, but rare in a stage of general paralysis so early that the diagnosis might be doubtful.

Hemorrhagic pachymeningitis also now and then simulates an obscure case of general paralysis in the early stage, but a few weeks at most settle any doubts in the matter.

Although diffuse cerebral syphilis is more apt to be associated with distinctly localized symptoms than the demented form of general paralysis, and although it is characterized by a mental apathy and physical torpor which follow a more regular course with more definite symptoms, resulting in a slow decay, yet there may be doubtful cases in which the differential diagnosis is impossible, and in which antisyphilitic treatment does not throw any light on the subject. Syphilitic new growths, endarteritis, and meningitis may so far improve from the use of mercury or the iodide of potassium as to end in an apparent cure, but in those cases the symptoms are not so marked as to make an exact diagnosis always possible. A distinct syphilitic cachexia is presumptive evidence of syphilitic encephalitis when there is doubt whether the syphilis is the cause or the diathesis.

Profound melancholia is not so often as varying gloom or moderate despondency a symptom of general paralysis. When it is such, there are developed in time the other marks of that disease, and it will only be necessary to hold the diagnosis in reserve for their appearance. The melancholia masks the dementia unless it is very carefully sought for, and the tremor may be as marked in melancholia as in the early stage of general paralysis, but more universal.

Acute mania is not uncommonly mistaken for general paralysis, when, as often happens, the delusions are as expansive and the tremor as great in the mania as in general paralysis; and it may be several months before the differential diagnosis can be made with certainty. In the presence of a high degree of maniacal excitement, with great emotional agitation and muscular tremor, it is difficult to establish the fact of the existence or not of dementia in doubtful cases until it is well developed. Acute mania has been known to constitute the prodromal period of general paralysis for a number of years.

Primary mental deterioration cannot be always differentiated from general paralysis of the demented type in its early stage. After the {200} age of sixty the probabilities are in favor of primary mental deterioration in doubtful cases, but general paralysis occurs—seldom, to be sure—up to the age of sixty-five.

Early senile dementia may simulate general paralysis of the subacute form, but has not its clinical history. General paralysis of the quiet, insidious type and primary mental deterioration have been called premature senility. The three diseased conditions have certain points of similarity, and the pathological processes involved in them do not differ sufficiently to authorize the assumption that they are not closely related, if not simply variations, due to age and other causes, in one morbid process.

Finally, the mental impairment caused by the prolonged use of bromide of potassium and hydrate of chloral has been mistaken for general paralysis, until a critical examination unmistakably showed the presence of the well-known symptoms of those drugs.

In examining the patient it is especially important to avoid leading questions, as in general paralysis and in those conditions which simulate its early stage the mind is in a condition to readily fall into the train of thought suggested to it. The fact should be kept in mind, too, that the symptoms in early general paralysis are so variable as to be sometimes quite evident, and at other times not to be got at with certainty at all or only after long and patient examination; that they sometimes quite disappear under the influence of complete mental and bodily rest; and that in all stages, until near the end, such complete remissions may occur as to make the diagnosis, independent of the history of the case, difficult if not impossible.

A gentleman once committed an offence characteristic of general paralysis in marrying a pretty servant-girl while temporarily away from his home. His wife, daughters, and friends saw that the act was so contrary to his natural character that he was placed in an insane asylum and kept there several weeks under observation for an opinion as to his responsibility. He appeared so well in the absolute quiet and rest that he was declared sane, tried, and sentenced to the State prison, where he showed his marked mental impairment as soon as he was set to work. He could not concentrate his mind sufficiently for the simplest labor, and a couple of years later he was sent to the insane asylum to die, a complete mental and physical wreck, in the late stage of general paralysis.

PROGNOSIS.—The very few reported cures in so common a disease as general paralysis, and the circumstances under which they have been reported, lead to the suspicion that there was an error in diagnosis or that the mistake was made of supposing a remission to be a cure, as has often happened. The course of the disease is more rapid in men than women, and in young persons than in the older. From the galloping cases of a couple of months to those slowly advancing, with long remissions, over twenty years, the average, including the prodromal period, is probably not far from five (perhaps six) years. Collected from asylum statistics, it is given as from two to three years. When I am sure of the diagnosis, I generally say that the patient may die within twenty-four hours (of paralysis of the heart, from suffocation by an accident in an epileptic attack, from choking, from cerebral hemorrhage or effusion, or suddenly with cerebral symptoms of which the autopsy gives no {201} satisfactory explanation), within a short time of intercurrent disease, especially diarrhœa or pneumonia, or that he may live several years, as he probably will, and possibly have a remission, during which he may lead for a while somewhat the same kind of life as other people.

Persons presenting symptoms which can in no way be positively distinguished from those at the beginning of the prodromal period of general paralysis recover, but not many come under the physician's care so early. We are not yet in a position to say whether they were suffering from a mild, transient illness or from what would otherwise have become serious organic disease.

TREATMENT.—Life may be prolonged in general paralysis, and usually is prolonged, by the use of such measures as contribute to the patient's comfort, and which in a general way have already been considered under the head of treatment of mental disease on a previous page.

In my experience, stimulating tonics, wine, and even coffee, increase the morbid cerebral energy of the early stage of the disease, but are sometimes of use later. Cod-liver oil and the hypophosphites do better, and many of the disagreeable symptoms of the period of loss of control over the involuntary muscles are relieved by strychnia. Ergot and the judicious use of the bromides abate the cerebral congestion. Gastro-intestinal disorders, when not controlled by attention to diet, require the usual treatment.

Iodide of potassium in the large or small dose, and mercury, I have never found to benefit those cases of general paralysis with a previous history of syphilis. On the contrary, they have proved debilitating and harmful.

When furious excitement is not relieved by prolonged warm baths, with cool applications to the head if possible, and quiet, chloral is of use, and sometimes opium and its preparations.

Frequently-repeated violent convulsions, the epileptic state, are usually at once mitigated by chloral given by the rectum; the inhalation of nitrite of amyl is reported also to have been of use.

There are few cases in which I find that morphine does not quiet restlessness, calm delusions, abate distressing hallucinations, and make the patient generally more comfortable; and I give it freely, seldom more than twice a day, often almost daily, for two or three years. In this way it can be used in quite moderate doses. Coca also relieves symptoms.

Rest and quiet are most important in all stages of the disease. This can be best accomplished in a quiet private house in the country, which can be made a virtual hospital, and next in a private asylum. But such care is beyond the reach of the vast majority of the insane, to whom the public asylum becomes a necessity. Wherever they are, an orderly life is best for them, with as little irritating interference with their ways or control of them as is possible.

If the results of treatment are in the highest degree unsatisfactory, and consist chiefly in meeting symptoms as they come up, without hope of permanent recovery, it is not impossible that when we can put the patient under treatment at the very beginning of his disease, as we can now do in pulmonary consumption, the prognosis in the former disease may change as much for the better as it has changed in the latter.

A general paralytic is at any time liable to congestive or maniacal {202} attacks of short duration, and so is always, potentially, a dangerous person. In the prodromal period the risk is small; in all stages there will, in the majority of cases, be some warning; but in the developed disease the only safe way is to have some responsible person near at hand, both to prevent the patient from doing harm to others and to save him from injuring himself, whether by intent or through not knowing better than to wander off or fall into all sorts of accidents. In many conditions several should be readily available, or else the security of an asylum must be sought.

In the treatment of general paralysis by society the same rule should obtain as in all forms of insanity—that distinct mental disease is presumptive proof of irresponsibility, or at least of limited responsibility; that a diseased mind means lessened intellectual power throughout and diminished ability to choose the right and avoid the wrong; that there are changes in circulation or nutrition, or some unknown condition in the brain, especially in general paralysis, by virtue of which the mental state and power of self-control vary from time to time, and as a result of which a person seeming responsible one day may have been quite irresponsible some previous day.

INSANITY FROM GROSS LESIONS OF THE BRAIN (tumors, new growths of all kinds, exostoses, spicules or portions of depressed bone, embolisms, hemorrhages, wounds, injuries, cysticerci, etc.) is attended with the usual indications of those conditions which may determine diffuse disorders of the brain, giving rise to any of the symptoms of the various psycho-neuroses and cerebro-psychoses. The lowered mental and moral tone after cerebral hemorrhages is a matter of common observation, and after one an individual is rarely observed to be fully himself again.

The PROGNOSIS is very unfavorable. Although there are rare cases of improvement, the tendency is toward profound dementia.

CEREBRAL SYPHILITIC INSANITY comes either under the head of the insanity last described or belongs to the slowly-advancing dementia with final paralysis already referred to under the head of Diagnosis in General Paralysis, and called by some authorities on mental disease pseudo-paralytic dementia from syphilis.

Antisyphilitic treatment is of value in the first class of cases, and although most of the recoveries end in relapses and incurability, the prolonged use of iodide of potassium seems sometimes to effect a permanent cure. It is claimed that similar treatment is followed by the same result in the cases of dementia with paresis, but the weight of authority, and certainly my own experience, are against that statement.

CHRONIC ALCOHOLIC INSANITY depends upon the vascular and other changes due to abuse of alcohol so long continued that the pathological condition has become organic and incurable. It is commonly associated with delusions of suspicion or persecution. It may be a purely moral insanity, with gross beliefs rather than distinctly insane delusions, and it rarely fails to be at least that when the persistent excessive drinking is kept up until the age of beginning dissolution of the brain. It then gives rise to all sorts of embarrassing complications in regard to property, family relations, and wills. Chronic alcoholic insanity may take the form of mild dementia, by virtue of which the patient cannot control himself, but can be easily kept within bounds of reasonable conduct by various degrees of restraint, from the constant presence of a responsible {203} person to the seclusion of an asylum. In well-marked cases this dementia is associated with muscular weakness, tremor, and exhilaration to such an extent as to simulate general paralysis. It is then called by some—especially French—writers pseudo-paralytic dementia from alcohol.

The condition is susceptible of improvement by removal of the cause, alcohol, and by a carefully-regulated life, hydropathic treatment, etc., but complete recoveries cannot be expected.

SECONDARY DELUSIONAL INSANITY is slowly developed from various mental diseases, incurable or uncured, where the progress to marked dementia is slow, by the persistence of delusions in those forms of insanity characterized by delusions. It is chronic and incurable. In melancholia and mania the mental depression and the exaltation and motor excitement disappear to a great extent, and there are left a slowly-advancing dementia, confusion, and expanding delusions, with apathy or with agitation, for which the asylum is the only safe place unless physical weakness makes the patient harmless. It is either a terminal state in which many forms of insanity end, or a stage through which they pass to terminal dementia. It depends upon incurable, and therefore organic, changes in the brain, like all incurable insanity, although those changes are not yet determined exactly. It might be a question whether chronic delusional insanity properly belongs under the head of Organic Mental Diseases, and a similar criticism may be made regarding terminal dementia. But in this paper no definite classification of insanity is attempted, because our knowledge of the subject is still so indefinite, although the several mental diseases are grouped in a certain order for convenience to the reader and the writer; and this order of course approximately follows natural lines.

TERMINAL DEMENTIA is the end to which most of the insanity not resulting in recovery finally comes. The features marking the disease in its early stages for the most part disappear, leaving all the functions of the mind impaired in all degrees up to total extinction—the whole character on a lower plane. It is the disease which to so great an extent crowds the wards of insane asylums and almshouses with the (1) agitated or (2) apathetic chronic insane, the worst of whom are mental and physical wrecks, squatting on floors, uttering an unintelligible jargon, noisy, filthy, without intelligence for the simplest natural wants. Their chief function, under the prevalent methods of construction and management of lunatic hospitals in most places, is to blight with a certain feeling of hopelessness many of the curable insane who are obliged to go for rest and quiet to institutions where the overwhelming majority of the inmates are manifestly and painfully incurable.

French writers include a great part of chronic delusional insanity (secondary confusional insanity, Wahnsinn, secundäre Verrücktheit) and terminal dementia (Blödsinn) under one head, démence; and with much reason, as it is not always possible to differentiate between the two.

The proper TREATMENT of the incurable, demented insane should provide not only that they be not at large, where they annoy the strong and the well, but also that they shall not disturb the insane who are acutely ill and in need of treatment suited to sick people, and whose chances of recovery at best are none too favorable. Experiments, now quite numerous, have shown that the lives and occupations of many of them may be {204} made not entirely unlike those to which they were reared, and that nearly all may be suitably provided for without the expensive hospitals and appliances necessary for the proper treatment of acute mental disease.

A comparison of countries in which there is and is not a comprehensive system of State supervision of the insane by a competent board seems to me to reveal so unquestionably the fact that such a system alone provides the proper protection for the insane, and the needed variety and uniformly high standard of excellence in the provisions for their treatment, that I hope to see the medical profession using its vast influence upon public opinion to secure it.

If we meet in the wards of our insane asylums hopeless mental and physical wrecks, if we find there the extremity of human wretchedness, the supreme control of all that is evil or vile in our nature, the worst antitypes of all the virtues, so, on the other hand, nowhere else do we see such struggles for the mastery of the better impulses, such efforts against such odds to hold back the mind in an unequal fight. Nowhere else, too, are developed finer sympathy, more beautiful unselfishness, more generous charity, or more heroic resignation where no hope in life remains but for death.

The State has taken charge of these most unfortunate people, shutting up behind the same locked doors and barred windows people of all social grades, often mingling together in one presence the so-called criminal insane, insane criminals, idiots, imbeciles, epileptics, paralytics, the chronic insane, and the demented, with patients suffering from acute mental disease. Some of them are unconscious of their condition, many are better off than ever before, but others are painfully alive to their situation and surroundings, fully aware of the gravity of their illness, keenly sensitive to the distressing sights and associations, disturbed by the noises, and discouraged by the many chances of becoming like the worst incurables around them. The State cannot evade the responsibility of seeing that their confinement is made the least rigorous, wretched, and injurious possible.

{205}

HYSTERIA.

BY CHARLES K. MILLS, M.D.

DEFINITION.—Hysteria is a functional disease of the cerebro-spinal axis, characterized either by special mental symptoms or by motor, sensory, vaso-motor, or visceral disorders related in varying degree to abnormal psychical conditions.

This, like all other definitions of hysteria, is imperfect. No absolutely satisfactory definition can well be given. It is not abnormal ideation, although this is so often prominent; it is not emotional exaltation, although this may be a striking element; it is not perversion of reflexes and of sensation, although these may be present. Some would make it a disease of the womb, others an affection of the ovaries; some regard it as of spinal, others as of cerebral origin; some hold it to be a disease of the nerves, others claim that it is a true psychosis; but none of these views can be sustained.

Sir James Paget[1] says of hysterical patients that they are as those who are color-blind. They say, “I cannot;” it looks like “I will not,” but it is “I cannot will.” Although, however, much of the nature of hysteria is made clear in this explanation, hysteria is not simply paralysis of the will. A true aboulomania or paralysis of the will occurs in non-hysterical patients, male and female, and of late years has been studied by alienists.

[Footnote 1: “Clinical Lecture on the Nervous Mimicry of Organic Diseases,” _Lancet_ for October, November, and December, 1873.]

In many definitions the presence of a spasmodic seizure or paroxysm is made the central and essential feature; but, although convulsions so frequently occur, typical hysterical cases pass through the whole course of the disorder without suffering from spasm of any kind.

In a general neurosis a definition, well considered, should serve the purpose of controlling and guiding, to a large extent at least, the discussion of the subject.

The definition given asserts that hysteria is a functional disease. In the present state of knowledge this is the only ground that can be taken. It is claimed that in a strict sense no disease can be regarded as functional; but it is practically necessary to use such terms as functional in reference to affections in which disordered action without recognizable permanent alteration of structure is present. Temporary anatomical changes must sometimes be present in hysteria; organic disease may be a complication in special cases; post-mortem appearances may {206} occasionally be found as accidents or coincidences; it is possible that structural alterations may result from hysteria; but no pathologist has as yet shown the existence of a special morbid anatomy underlying as a permanent basis the hysterical condition.

The mental, motor, sensory, and other phenomena of hysteria cannot be explained except by regarding the cerebro-spinal nervous system as the starting-point or active agency in their production.

The term vaso-motor is used in a broad sense to include not only peripheral vascular disturbances, but also cardiac, respiratory, secretory, and excretory affections of varying type. Some of these disorders are also visceral, but under visceral affections are also included such hysterical phenomena as abdominal phantom tumors, hysterical tympanites, and the like.

That all hysterical phenomena are related in varying degree to abnormal psychical conditions may perhaps, at first sight, be regarded as open to dispute and grave doubt. It is questionable whether in every case of hysteria the relation of the symptoms to psychical states could be easily demonstrated. I certainly do not look upon every hysterical patient as a case of insanity in the technical sense, but hold that a psychical element is or has been present, even when the manifestations of the disorder are pre-eminently physical. James Hendrie Lloyd,[2] in a valuable paper, has ably sustained this position, one which has been held by others, although seldom, if ever, so clearly defined as by this writer.

[Footnote 2: “Hysteria: A Study in Psychology,” _Journal of Nervous and Mental Disease_, vol. x., No. 4, October, 1883.]

The alleged uterine origin of hysteria has been entirely disregarded in the definition. This has been done intentionally. It is high time for the medical profession to throw off the thraldom of this ancient view. The truth is, as asserted by Chambers,[3] that hysteria “has no more to do with the organs of reproduction than with any other of the female body; and it is no truer to say that women are hysterical because they have wombs, than that men are gouty because they have beards.”

[Footnote 3: _Brit. Med. Journ._, December 21, 1861, 651.]

SYNONYMS.—Hysterics, Vapors. Many Latin and other synonyms have been used for hysteria: most of these have reference to the supposed uterine origin of the disease, as, for instance, Uteri adscensus, Asthma uteri, Vapores uterini, Passio hysterica, Strangulatio uterina seu Vulvæ. Some French synonyms are Maladie imaginaire, Entranglement, and Maux ou attaques de nerfs. Other French synonyms besides these have been used; most of them are translations from the Latin, having reference also to the uterine hypothesis. In our language it is rare to have any other single word used as a synonym for hysteria. Sir James Paget[4] introduced the term neuromimesis, or nervous mimicry, and suggested that it be substituted for hysteria, and neuromimetic for hysterical. Neuromimesis is, however, not a true synonym. Many cases of hysteria are cases of neuromimesis, but they are not all of this character. Among the desperate attempts which have been made to originate a new name for hysteria one perhaps worthy of passing notice is that of Metcalfe Johnson,[5] who proposes to substitute the term ganglionism, as giving a clue to the pathology of hysteria. His main idea is that {207} hysteria exhibits a train of symptoms which are almost always referable to the sympathetic or ganglionic nervous system. This is another of those half truths which have misled so many. The term hysteria, from the Greek ὑστερα, the uterus, although attacked and belabored, has come to stay; it is folly to attempt to banish it.

[Footnote 4: _Op. cit._]

[Footnote 5: _Med. Times and Gaz._, 1872, ii. 612.]

METHOD OF DISCUSSING THE SUBJECT.—It is hard to decide upon the best method of discussing the subject of hysteria. One difficulty is that connected with the question whether certain affections should be considered as independent disorders or under some subdivisions of the general topic of hysteria. Certain great phases of hysteria are represented by hystero-epilepsy, catalepsy, ecstasy, etc.; but it will best serve practical ends to treat of these in separate articles. They have distinctive clinical features, and are capable of special definition and discussion.

HISTORY AND LITERATURE.—To give a complete history of hysteria it would be necessary to traverse the story of medicine from the time of Hippocrates to the present. A complete bibliography would require an immense volume. Volume vi. of the _Index Catalogue of the Library of the Surgeon-General's Office, United States Army_, which has appeared during the present year (1885), contains a bibliography of nearly seventeen double-column pages, most of it in the finest type. The references are to 318 books and 914 journals. The number of books and articles cited as having appeared in different languages is as follows: Latin, 99; Greek, 2; German, 180; British, 177; American, 159; French, 449; Italian, 75; Spanish, 45; Swedish, 12; miscellaneous, 34. Even this wonderful list probably only represents a tithe of the works written on this subject. Those desirous of studying it from a bibliographical point of view can do so by consulting this great work.

Many as are the names and voluminous as is the literature, certain names and certain works are pre-eminent—Sydenham, Laycock, and Skey in England; Tissot, Briquet, Charcot, and Landouzy in France; Stahl, Frank, Eulenburg, and Jolly in Germany; and in America, Weir Mitchell. The greatest work on hysteria is the treatise of Briquet.[6]

[Footnote 6: _Traité clinique et thérapeutique de l'Hystérie_, par le Dr. P. Briquet, 1859.]

Mitchell[7] has organized into a scientific system a valuable method of treating hysteria, and has given to the world a series of studies of some types of the affection best or only seen in the United States.

[Footnote 7: _Fat and Blood: An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria_, and _Clinical Lecture on Diseases of the Nervous System, especially in Women_.]

Among other American monographs on hysteria and allied subjects worthy of note are the contributions of Shaffer on _The Hysterical Element in Orthopædic Surgery_;[8] Seguin's essay on _Hysterical Symptoms in Organic Nervous Affections_;[9] Beard's volume on _Nervous Exhaustion_;[10] the chapters on _Hysterical Insanity, etc._ in Hammond's text-books;[11] and the papers of G. L. Walton[12] on _Hystero-epilepsy_. Spitzka, Mann, Hughes, and {208} Kiernan have made important contributions to the psychical aspects of the subject in various American medical journals.

[Footnote 8: _The Hysterical Element in Orthopædic Surgery_, by Newlin M. Shaffer, M.D., New York, 1880.]

[Footnote 9: _Archives of Neurology and Electrology_, for May, 1875, and _Opera Minora_, p. 180.]

[Footnote 10: _A Practical Treatise on Nervous Exhaustion (Neurasthenia)_, by George M. Beard, A.M., M.D., New York, 1880.]

[Footnote 11: _A Treatise on Diseases of the Nervous System_, and _A Treatise on Insanity in its Medical Relations_.]

[Footnote 12: _Brain_, vol. v. p. 458, Jan., 1883; _Journal of Nervous and Mental Disease_, vol. xi. p. 425, July, 1884.]

During the last five years I have published a number of articles and lectures on the subject of hysteria and hystero-epilepsy, some of which have been freely used in the preparation of this and the succeeding sections.[13] My first paper on hystero-epilepsy, in the _American Journal of the Medical Sciences_, was written to strongly direct the attention of the American profession to the subject as studied in France. It was in large part a translation from the works of Charcot, Richer, and Bourneville, with, however, notes of some observed cases.

[Footnote 13: “Hystero-epilepsy,” _American Journal of the Medical Sciences_, October, 1881.

“Epileptoid Varieties of Hystero-epilepsy,” _Journal of Nervous and Mental Diseases_, October, 1882.

“Illustrations of Local Hysteria,” _Polyclinic_, vol. i., Nos. 3 and 4, September 15, October 15, 1883.

“Clinical Lecture on the Treatment of Hysterical Paralysis by Rest, Massage, and Electricity,” _Med. and Surg. Reporter_, vol. 1. p. 168, February 9, 1884.

“Clinical Lecture on the Differential Diagnosis of Organic from Hysterical Hemianæsthesia, etc.,” _ibid._ vol. 1. p. 233, 265, February 23, March 1, 1884.

“Clinical Lecture on Spinal Traumatisms and Pseudo-Traumatisms,” _Polyclinic_, vol. i. No. 9, March 15, 1884.

“A Case of Nymphomania, with Hystero-epilepsy, etc.,” _Medical Times_, vol. xv. p. 534, April 18, 1885.

“Hystero-epilepsy in the Male, etc.,” _Medical Times_, vol. xv. p. 648, May 30, 1885.

“Some Forms of Myelitis, their Diagnosis from each Other and from Hysterical Paraplegia,” _Medical News_, vol. xlvii., Nos. 7 and 8, August 15 and 22, 1885.

“Clinical Lecture on Acute Mania and Hysterical Mania,” _Medical Times_, vol. xvi. p. 153, November 28, 1885.]

PATHOLOGY.—Strictly speaking, hysteria cannot be regarded as having a morbid anatomy. In an often-quoted case of Charcot's,[14] an old hystero-epileptic woman, affected for ten years with hysterical contracture of all the limbs, sclerosis of the lateral columns was found after death. On several occasions this woman experienced temporary remissions of the contracture, but after a last seizure it became permanent. This is one of the few reported cases showing organic lesion; and this was doubtless secondary or a complication. In a typical case of hystero-epilepsy at the Philadelphia Hospital, a report of which was made by Dr. J. Guiteras,[15] the patient, a young woman, died subsequently while in my wards. Autopsy and microscopical examination revealed an irregularly diffused sclerosis, chiefly occupying the parieto-occipital region of both cerebral hemispheres. Undoubtedly, as suggested by Charcot, in some of the grave forms of hysteria either the brain or spinal cord is the seat of temporary modification, which in time may give place to permanent material changes. Old cases of chronic hysteria in all probability may develop a secondary degeneration of the cerebro-spinal nerve-tracts, or even degeneration of the nerve-centres themselves may possibly sometimes occur. Two cases now and for a long time under observation further indicate the truth of this position. One, which has been reported both by H. C. Wood[16] and myself,[17] is a case of hysterical rhythmical chorea in a young woman. Although the hysterical nature of her original trouble cannot be doubted, she now has contractures of all the extremities, which seem to have an organic basis. The other patient is a woman who has {209} reached middle life; she has several times temporarily recovered from what was diagnosticated as hysterical paraplegia, in one instance the recovery lasting for months. Now, after more than four years, she has not recovered from her last relapse. Contractures, chiefly in the form of flexure, have developed, and she has every appearance of organic trouble, probably sclerosis or secondary degeneration of the lateral columns.

[Footnote 14: _Leçons sur les Maladies du Système nerveux_.]

[Footnote 15: _Philadelphia Medical Times_, 1878-79, ix. 224-227.]

[Footnote 16: _Ibid._, vol. xi. p. 321, Feb. 26, 1881.]

[Footnote 17: _Ibid._, vol. xii. p. 97, Nov. 19, 1881.]

Briquet[18] reviews the various hypotheses which have been held as to the pathological anatomy of hysteria, giving a valuable summary of the autopsies upon supposed hysterical cases up to the time of the publication of his treatise in 1859. About the sixteenth century, Rislau, Diemerbroeck, and Th. Bonet sought to establish a relation between lesions of the genital organs met with in the bodies of hysterical women and the affection from which they suffered. About 1620, Ch. Lepois believed that he had established the existence of certain alterations of the brain in cases of hysteria. Hochstetter and Willis toward the beginning of the present century arrived at similar conclusions. That researches into the state of the genital organs have chiefly occupied those investigating hysteria is shown by the writings of Pujol, Broussais, Lovyer-Villermay, and, above all, by those of Piorry, Landouzy, Schutzenberger, and Duchesne-Duparc. Georget, Brachet, Girard, Gendrin, Bouillaud, Forget, and Lelut, about the fourth or fifth decades of the present century, made numerous autopsies on those dying when hysterical phenomena were in full activity, and concluded that the genital organs of these individuals revealed nothing in particular. This, in brief, is also the conclusion of Briquet. Jeanne d'Albret, the mother of Henry IV., who was all her life subject to hysterical headache, had her brain examined after death, but absolutely nothing was found. Vesalius made an autopsy with equally negative results on a woman who died from strangulation in an hysterical attack. Royer-Collard also found nothing in an old hysteric. Briquet believed—and I fully accord with this view—that in some of the cases of Ch. Lepois, Hochstetter, and Willis diseases such as chronic meningitis were present with the hysteria. He concludes that anatomy does not show anything positive as to the seat or nature of hysteria, except the suspicion of a certain degree of congestion in various parts of the brain.

[Footnote 18: _Op. cit._]

While, however, hysteria may not have a morbid anatomy, it, like every other disease, has, in a correct sense, a pathology.

The ancients saw only the uterus when regarding hysteria. Hippocrates described the hysterical paroxysm and its accompanying disorders under the name of strangulation of the uterus. The ancients generally supposed that the disease originated in the ascent of the uterus to the diaphragm and throat. They believed that this accommodating organ could wander at will throughout the body, doing all manner of mischief. Hippocrates asserted that it was the origin of six hundred evils and innumerable calamities.

According to Sydenham,[19] the disorders which are termed “hysterical in women and hypochondriac in men arise from irregular motions of the animal spirits, whence they are hurried with violence and too copiously to a particular part, occasioning convulsions and pain when they exert {210} their force upon parts of delicate sensation, and destroying the functions of the respective organs which they enter into, and of those also whence they came; both being highly injured by this unequal distribution, which quite perverts the economy of nature.” Speaking of the strangulation of the womb, or fits of the mother, he says: “In this case the spirits, being copiously collected in the lower belly and rushing with violence to the fauces, occasion convulsions in all the parts through which they pass, puffing up the belly like a ball.”

[Footnote 19: _The Entire Works of Dr. Thomas Sydenham, newly made English from the Originals, etc._, by John Swan, M.D., London, 1763, pp. 416, 417.]

After a time, the idea that the uterus was the exclusive seat of hysteria was in large measure supplanted by the view that the sexual organs in general were concerned in the production of hysterical phenomena. Romberg defined hysteria as a “reflex neurosis caused by genital irritation.” Woodbury[20] concludes as late as 1876 that only where the pathological source of hysterical symptoms resides in the uterus or ovaries, cases may, with some show of propriety, be termed hysterical; and where the uterus and organs associated with it in function are not in a morbid condition no symptoms can be correctly called hysterical.

[Footnote 20: _Medical and Surgical Reporter_, December 2, 1876.]

Bridges,[21] another American writer, in a paper on the pathology of hysteria, says that hysteria does not occur most frequently in women with diseased wombs, but in those whose sexual systems, by pampering and other processes, are abnormally developed and sensitive. He makes the same point with reference to the male sex. Sometimes, however, besides the emotional state in the male, there is actual disease of the sexual organs, caused by abuse or over-indulgence. Uterine disease and hysteria are sometimes like results of one cause, and not respectively cause and effect: women are hysterical oftener than men because the uterine function in woman's physiology plays a more important part in the production of emotional diseases than any organ of the male sex.

[Footnote 21: _Chicago Medical Examiner_, 1872, xiii. 193-199.]

The truth would seem simply to be, that, as the uterus and ovaries are the most important female organs, they are therefore a frequent source of reflex irritation in hysterical patients.

Seguin[22] adopts with some reservation Brown-Séquard's hypothesis that cerebral lesions produce the symptoms which point out their existence, not by destroying organs of the brain, but by setting up irritations which arrest (inhibit) the functions of other parts of the encephalon. He says that he finds no difficulty in believing that the same symptom may exist as well without as with a brain lesion. “In typical hysteria the functions of parts of the encephalon included in the right hemisphere, or in physiological relation with it, are inhibited by a peripheral irritation starting from a diseased or disordered sexual apparatus or other part; and in case of organic cerebral disease the same inhibitory action is produced. In both kinds of cases we may have loss of rational control over the emotions, loss of voluntary power over one-half of the body, and loss of sensibility in the same part.”

[Footnote 22: “On Hysterical Symptoms in Organic Nervous Affections,” _Archives of Electrology and Neurology_, for May, 1875.]

Simply as a matter of passing interest, the attempt of Dupuy[23] to frame a pathology of hysteria is worthy of attention. According to him, every {211} local hysterical phenomenon is dependent upon an abnormal state of either lateral half of the upper part of the pons varolii. The centres of the pons, he holds, are perhaps merely passive in the process, only becoming organically implicated when various forms of permanent contractures and paralyses ensue.

[Footnote 23: _Medical Record_, New York, 1876, ii. 251.]

The pathology of hysteria must be considered with reference to the explanation of the exact condition of the cerebro-spinal axis during the existence of certain special grave phenomena of hysteria, such as hemianæsthesia, hemiplegia, paraplegia, and contractures.

What is the probable state of the nerve-centres and tracts during these hysterical manifestations? If, for example, in a case of hysterical hemianæsthesia it is admitted that the brain of the other side of the body is somehow implicated, although temporarily, what is the probable condition of this half of the brain? Is the cerebral change vascular or is it dynamic? If vascular, is the state one of vaso-motor spasm or one of paresis, or are there alternating conditions of spasm and paresis? Are true congestions or anaæmias present? If the condition is dynamic, what is its nature? Is it molecular? and if molecular in what does it consist? Is it possible to say absolutely what the pathological condition is in a disorder in which autopsies are obtained only by accident, and even when obtained the probabilities are that with fleeting life depart the changes that are sought to be determined?

Two hypotheses, the vaso-motor and the dynamic, chiefly hold sway. The vaso-motor, attractive because of its apparent simplicity, has been well set forth by Walton,[24] who contends that while it may not be competent to easily explain all hysterical symptoms, it will best explain some of the major manifestations of hysteria—for example, hemianæsthesia. Hemianæsthesia, he argues, may appear and disappear suddenly; it may be transferred from one side of the body to another in a few seconds; so blood-vessels can dilate as in a blush, or contract as in the pallor of fear, in an instant. In fainting the higher cerebral functions are suspended, presumably because of vaso-motor changes; therefore the sudden loss of function of one-half of the brain-centres, seen sometimes in hysterical hemiplegia and hemianæsthesia, may easily be imagined to be the result of an instantaneous and more or less complete contraction of cortical blood-vessels on that side. Neurotic patients have a peculiarly irritable vaso-motor nervous system. He records a case seen in consultation with H. W. Bradford. The patient had a right-sided hemianæsthesia, including the special senses, the sight in the left eye being almost wanting. The fundus of the right eye was normal; the left showed an extreme contractility of the retinal blood-vessels under ophthalmoscopic examination; these contracted to one-third their calibre, and the patient was unable to have the examination continued. The explanation offered is, that spasm of the blood-vessels on the surface of the left cerebral hemisphere had caused, by modification of the cortical cells, a right-sided hemianæsthesia, including the sight, and by reaching the meninges a left-sided spastic migraine, and by extending to the fundus of the left eye an intermittent retinal ischæmia.

[Footnote 24: _Journal of Nervous and Mental Disease_, vol. xi., July, 1884, p. 424 _et seq._]

The vaso-motor hypothesis is held by Rosenthal,[25] who, however, wrongly {212} gives the spinal cord the preponderating part in the production of the symptoms. According to this author, the anæsthesia and analgesia present in hysteria conform to the law as established by Voigt with regard to the distribution of the cutaneous nerves. The sensory nerves form at the periphery a sort of mosaic corresponding to an analogous arrangement in the spinal cord. “It is evident,” he says, “that the peripheral disorders in hysteria merely represent an exact reproduction of the central changes, and that the latter are situated, in great part, in the spinal cord.” He attributes a large part of the symptoms of hysteria to a congenital or acquired want of resistance of the vaso-motor nervous system. “Motor hysterical disorders are also due in the beginning to a simple functional hyperæmia, but in certain forms the chronic hyperæmia may lead to an inflammatory process which may terminate (as in Charcot's case) in secondary changes in the columns of the cord and nerve-roots.” When the brain is involved in hysteria, he holds that the most serious symptoms must be attributed to reflex spasms of the cerebral arteries and to the consequent cerebral anæmia.

[Footnote 25: “A Clinical Treatise on Diseases of the Nervous System,” by M. Rosenthal, Vienna, translated by L. Putzel, M.D., vol. ii. _Wood's Library_, New York, 1879.]

The dynamic pathology of hysteria is probably believed in by most physicians, and yet it is difficult to explain. Thus, Briquet[26] says that hysteria manifests itself by derangement of the nervous action, and what is called nervous influence is something like electricity. It is simply the result of undulations analogous to those which produce heat and light; in other words, it is a mode of movement. Wilks[27] compares some of the conditions found in hysteria to a watch not going; it may be thought to be seriously damaged in its internal machinery, yet on looking into it there is found a perfect instrument that only needs winding up. As regards the brain being for a time functionless, the possibility of this is admitted by all, as in sleep or after concussion. He mentions the case of a young girl who had been assaulted, and had complete paralysis of motion and sensation. The shock had suspended for a time the operations of her brain, and organic life only remained. We have only to suppose that half of the brain is in this way affected to account for all the phenomena of hemianæsthesia.

[Footnote 26: _Op. cit._]

[Footnote 27: _Lectures on Diseases of the Nervous System_, delivered at Guy's Hospital, by Samuel Wilks, M.D., F. R. S., Philada., 1883.]

According to the dynamic view, the central nervous system is at fault in some way which cannot be demonstrated to the eye or by any of our present instruments of research. The changes are supposed to be molecular or protoplasmic, rather than vaso-motor or vascular.

As innervation and circulation go hand in hand or closely follow each other, my own view is that both vaso-motor and molecular changes, temporary in character, probably occur in the central nervous system in grave hysterical cases.

Whatever the temporary conditions are, it is evident, on the one hand, that they are not states of simple anæmia or congestion, and, on the other hand, that they are not inflammations or atrophies. Patients with hysterical manifestations of the gravest kind as a rule are free for a time from their harassing and distressing symptoms. This could not be if these symptoms were due to lesions of an organic nature. Sudden recoveries also could not be accounted for if the changes were organic.

{213} Lloyd[28] contends that most hysterical symptoms, if not all, are due to abnormal states of consciousness. The development of this idea constitutes his argument for the recognition of the disease as a true psychosis. In the reflex action, not only of the lower spinal cord and ganglia of special sensation, but of the highest centres of the brain, he sees the explanation of many of the characteristics of hysteria. In other words, he finds that the sphere of the disease is more especially in the automatic action of the brain and cord.

[Footnote 28: _Op. cit._]

Dercum and Parker[29] have published the results of a series of experiments on the artificial induction of convulsive seizures which bear upon this discussion of the pathology of hysteria. The experiments were performed by subjecting one or a group of muscles to a constant and precise effort, the attention being at the same time concentrated on some train of thought. The position most frequently adopted was the following: The subject being seated, the tips of the fingers of one or both hands were placed upon the surface of the table, so as to give merely a faint sense of contact—_i.e._ the fingers were not allowed to rest upon the table, but were held by a constant muscular effort barely in contact with it.

[Footnote 29: _Journal of Nervous and Mental Disease_, vol. xi., October, 1884, pp. 579-588.]

Tremors commenced in the hands; these became magnified into rapid, irregular movements which passed from one limb or part to another until the subject was thrown into strong general convulsions. Opisthotonos, emprosthotonos, and the most bizarre contortions were produced in various degrees. No disturbances of sensation were at any time present. Disturbances of respiration and phonation were often present in a severe seizure, and the circulatory apparatus was profoundly affected. A flow of tears, and occasionally profuse perspiration, were sometimes induced. After severe seizures large quantities of pale urine were passed. The reflexes were distinctly exaggerated. No unconsciousness was ever observed, but a progressive abeyance or paresis of the will. Nitrite of amyl seemed to arrest the convulsive seizures at once.

In attempting to explain these phenomena Dercum and Parker refer to the induction of Spencer as to the universality of the rhythm of motion. Through the whole nervous system of every healthy animal a constant rhythmical interchange of motion takes place. What might be called nervous equilibration results. In man the will modifies and controls the action of the nervous system; it assists in maintaining nervous equilibrium when it is threatened. The will being withdrawn from the nervo-muscular apparatus, and this being subjected to strain, a disturbance takes place. This same explanation may be applied to some of the convulsive and other phenomena of hysteria.

Comparing and analyzing the various views, it may be concluded with reference to the pathology of hysteria as follows:

(1) The anatomical changes in hysteria are temporary.

(2) These changes may be at any level of the cerebro-spinal axis, but most commonly and most extensively cerebral.

(3) They are both dynamic and vascular: the dynamic are of some undemonstrable molecular character; the vascular are either spastic or paretic, most frequently the former.

(4) The psychical element enters in that, either, on the one hand, violent mental stimuli which originate in the cerebral hemispheres are {214} transmitted to vaso-motor conductors,[30] or, on the other hand, psychical passivity or torpor permits the undue activity of the lower nervous levels.

[Footnote 30: Rosenthal.]

ETIOLOGY.—Heredity has much to do with the development of hysteria. It is not that it is so frequently transmitted directly after its own kind, but this disorder in one generation generally indicates the existence of some ancestral nervous, mental, or diathetic affection.

Briquet[31] has shown that of hysterical women who have daughters, more than half transmit the disease to one or several of these, and, again, that rather more than half of the daughters of the latter also become hysterical. Amann, according to Jolly,[32] has stated that in 208 cases of hysteria he proved with certainty an hereditary tendency 165 times—that is, in 76 per cent. This is too big to be true.

[Footnote 31: _Op. cit._]

[Footnote 32: _Ziemssen's Cyclopædia of the Practice of Medicine_, vol. xiv., American translation.]

Briquet has also made some careful investigations into the subject of the health of infants born of hysterical mothers. The investigations were based upon a study of 240 hysterical women, with whom he compared 240 other patients affected with such diseases as fever, phthisis, cancer, diseases of the heart, liver, and kidneys, but without any hysterical symptoms. In brief, the result of his investigations was that children born of hysterical mothers die more frequently and at a younger age than those who are born of mothers not hysterical.

The relation of hysteria to certain morbid constitutional states has long been recognized, particularly its connection with the tubercular diathesis. This has been shown by numerous observers, especially among the French. The most valuable recent contribution is that of Grasset,[33] who believes that a direct connection can be traced between the tubercular diathesis and hysteria. When the relations of hysteria to the scrofulous and tubercular diathesis are spoken of by him, it is not meant that hysterical subjects have tubercles in the lungs, but that these diatheses are found in various generations, and that among some subjects of the hereditary series the constitutional states manifest themselves as hysteria. It is not the evidences of hysteria with pulmonary and other tuberculous conditions that he is considering, but that hysteria may be, and often is, a manifestation of the tubercular diathesis. Two cases may present themselves: in one the neurosis is the only manifestation of the diathesis; in the other, it is continued in the same subject along with the other diathetic manifestations. In demonstration of his thesis he concludes with a series of most interesting cases, which he arranges into two groups. In the first, hysteria is the only manifestation of the tubercular diathesis; in the second, are simultaneous pulmonary and hysterical manifestations. In the first group he has arrayed eight personal observations and seventeen derived from various authors; in the second he has two personal and seventeen compiled observations.

[Footnote 33: “The Relation of Hysteria with the Scrofulous and the Tubercular Diathesis,” by J. Grasset, _Brain_, Jan., April, and July, 1884.]

Personal experience and observation go far to confirm the views of Grasset, although I recognize fully the strength of the objection of Brachat and Dubois and others that, phthisis being such a common complaint, it might be demonstrated by statistics that it was related to {215} almost any disease. Not only hysteria, but other neuroses or psychoses, have a close connection with the tubercular diathesis.

Among the insane and idiotic and among epileptics phthisis is of frequent occurrence. At the Pennsylvania Training School for Feeble-minded Children the frequency of phthisis among the inmates of the institution is one of the most striking clinical facts. The insane of our asylums die of pulmonary troubles oftener almost than of any other disease. The fact that hysteria is met with in the robust and vigorous does not invalidate the position taken, for the robust and vigorous who are not hysterical are not infrequently found in the descendants of the tuberculous.

Laycock[34] believed that the gouty diathesis was particularly liable to give rise to the hysterical paroxysm or to irregular forms of hysteria. Gairdner, quoted by Handfield Jones,[35] supports this view.

[Footnote 34: _A Treatise on the Nervous Diseases of Women_, by Thomas Laycock, M.D., London, 1840.]

[Footnote 35: _Studies on Functional Nervous Disorders_.]