Hysteria.

Definition.—A functional disturbance of the general nervous system in which there is "an abnormal susceptibility to external impressions, and a deficient power of the will to restrain its manifestations," and characterized by a multitude of symptoms that simulate many diseases.

Etiology.—Among the predisposing and exciting causes may be mentioned:

Sex.—About nine hundred and fifty cases out of every thousand occur in females.

Heredity.—A very large per cent of all oases of hysteria occur in families of neurotic tendencies, such as epilepsy, insanity, chorea, sick headache, neuralgias, and allied conditions.

Age.—Hysteria usually develops between the age of puberty and twenty-five, few cases occurring after the age of forty.

Psychical Influences.—In neuropathically inclined patients, fright, especially of a severe kind, like railroad accidents and fire, great shock, fear, love, jealousy, disappointments, anxiety, melancholy and remorse, are apt to be followed by hysteria.

Environments.—Girls reared in luxurious city homes, with but little responsibility, and who are petted, pampered, and reared amid excitement and dissipation, are far more subject to hysteria than those reared in the country, and who are taught to be useful and share some of the responsibilities of life.

Sexual derangements are found to underlie many cases of hysteria. Irregular menstruation, uterine displacements, ovarian irritation, ulceration of the cervix, an adherent clitoris, a vaginitis leucorrhea, and not infrequently masturbation, are found on examination.

Ranney believes eye-defects and muscular insufficiencies in the orbit attend nearly all hysterical patients.

Pathology.—Hysteria is a purely functional disturbance of the nervous system, no anatomical lesions being found in this disease.

Symptoms.—The clinical picture of hysteria embraces such a varied and complex list of symptoms that it will be impossible to name them all. For convenience of description the symptoms may be divided into mental, sensory, motor, and visceral.

Mental Condition.—One of the characteristic conditions of hysteria is a defect of the will and an excess of the emotions. These patients crave sympathy, and are peculiarly self-conscious. They readily give way to joy or grief, the effects of which, laughter and tears, are indulged in to excess. Uncontrollable laughing or crying for hours is sometimes witnessed. Such patients, when sick, make no effort to get well, preferring the sympathy of friends to convalescence, and not infrequently so skillfully magnifying their symptoms that they not Only succeed in deceiving their friends as to their true condition, but the physician as well. Sometimes they will produce artificial lesions by the application of irritants producing various eruptions, or, as in one case that came under my observation, the patient had produced red spots on the palms of the hands by the use of a red rose on her hat, and so skillfully did she hide her work and so persistently did she deny all knowledge of the cause, that her parents sent her to Seton Hospital for treatment.

Finding, however, that the physicians were not as gullible as her parents, and that the treatment suggested was not to her liking, she confessed to the part she had played in the deception. Some patients, with a perverted sense of delicacy, show concretions or bodies, and insist that they have passed the same from the bladder or rectum.

Sensory Symptoms.—Hyperesthesia may manifest itself simply by tenderness on pressure over sensitive points, or it may arise as spontaneous pain. While hyperesthetic spots may be found in any part of the body, they are rare on the extremities. A favorite location is the vortex, where the pain is frequently agonizing in character, and is known as clavus hystericus. Other favorite locations are over the sternum, under the mammae, over the ovaries, and along the spinal column. These sensitive spots or zones are known as "hysterogenic points." These painful points may involve the entire spinal column or only a single point, and a simple touch may cause exquisite pain. Abdominal hyperesthesia may resemble gastric ulcer, appendicitis, or peritonitis. The hysterical breast is recognized by the great tenderness, by constant variations in the swelling, and by "the recurrence of the symptoms at the usual period or after exceptional excitement or fatigue."

The special senses may be affected, as hyperesthesia of the eye or ear, or sight may be limited or even lost for certain colors, while the loss of the sense of taste, smell, or hearing is not infrequent, or the opposite condition, extreme sensitiveness to sound, taste, and smell may be present.

Anesthesia, or loss of sensation in a limb or entire side is known as hemianesthesia, and is quite significant as a diagnostic factor. "Sensation has sometimes been restored to a part by the local application of metal plates, especially iron, copper, zinc, or gold (metallo-therapy), and under these circumstances anesthesia may be found at the corresponding spot on the previous healthy opposite side of the body."

Motor Symptoms.—"Paralysis.—Hysterical aphonia is not uncommon; it results from paralysis of the adductors of the vocal cords. It is important to note that adductor paralysis, without abductor paralysis, is always a functional disorder. On the other hand, abductor paralysis, existing alone, is mostly due to organic disease, and very rarely the result of hysteria; it causes stridor and dyspnea, and may even in hysteria lead to dangerous asphyxia. Dysphagia may arise from functional paralysis of the pharyngeal muscles. Ptosis also occurs as a hysterical symptom; it may be single, or double. Paralysis of the limbs occurs in the form of paraplegia or hemiplegia, or all the limbs may be paralyzed together. The paralysis in these cases is often not complete, and if the patient makes an effort to move the limb in a particular direction, it may be seen that some antagonistic muscles contract. The patient may assert that she is unable to lift the arm, yet if it is raised by any one else she will often keep it supported or let it drop only half-way, showing that the muscles believed to be paralyzed have still a considerable amount of power. Also, if the attention is directed to other things the patient may unconsciously move the supposed useless limb. If one lower extremity is alone affected, on attempting to walk the patient drags the paralyzed limb behind her, making no effort to bring it forward, but only hopping along on the sound limb. The nutrition of the muscles and the electrical reactions are generally normal, but wasting of muscles is sometimes observed. Knee-jerks are generally normal, and there is no true continuous ankle-clonus, but there is often a clonus lasting only a few seconds, and in some cases the knee-jerks are excessive. In paraplegia the legs can often be moved in bed, but the patient is quite unable to stand, and there is never incontinence of urine or feces; in hemiplegia the leg is sometimes worse than the arm, and the face and tongue are always spared. Paralysis is sometimes, but not always, accompanied by anesthesia. In a rare form of hysteria, every attempt to move, or contract a muscle, is painful (akinesia algera). Another form of hysteria is a disorder called astasia-abasia, in which the patient can neither stand nor walk, though he can move the legs in bed, and there is neither incoordination nor sensory failure." (Taylor.)

Convulsive Seizures.—Following excitation of the emotions the patient becomes hysterical, laughs or cries, and complains of a ball in the throat (globus hystericus), which in turn is followed by convulsions. The muscular spasms are clonic and irregular. Gradually the attack subsides, with the passage of a large quantity of limpid urine. The convulsions sometimes simulate true epileptic attacks, though the tongue is not bitten. "The convulsive seizure is usually followed by emotional displays, by cataleptic poses, by opisthotonos or other distortions, and by attitudes and grimaces expressive of the deepest emotions." Following this, the patient may go into a trance, or hallucinations and delirium may follow.

Contractures and Spasms.—Tonic contractions may affect one side, hemiplegic in character, or from the waist down (paraplegic), or be confined to a single part (monoplegic), as in hysterical contraction of the jaw (trismus). Where one side is affected, the arm is generally flexed at the elbow, while the leg is rigidly extended. The contractions usually disappear during sleep; but in exaggerated cases, only the deepest chloroform narcosis is sufficient to produce relaxation.

Phantom tumors, simulating pregnancy, are sometimes seen, and are due to contraction of certain abdominal muscles and relaxation of the recti, permitting the inflation of the intestines with gas.

Clonic contractions are generally rhythmic in character, and known as "rhythmic chorea" ("hysterical chorea").

Visceral Symptoms.—Globus hystericus, the sensation of a ball rising in the throat, is often associated with spasm of the pharynx and esophagus, rendering deglutition difficult or impossible. Gastric disturbances are quite common, and furnish a variety of symptoms. In one the food is regurgitated soon after eating, there being little or no nausea; this may continue for months with but little emaciation; in another there will be hysterical anorexia, the patient persistently refusing food for days, and growing quite emaciated. In these cases, however, there is nearly always deception practiced, the patient eating clandestinely. Another will have a perverted or depraved appetite, eating undesirable and unwholesome food. In rare cases there is reversed peristalsis, the patient vomiting rectal enemas, or there is peristaltic unrest. While diarrhea may be present, constipation of a most persistent type is the rule, and it is not infrequent to find such patient going a week or ten days without stool.

Respiratory symptoms are quite frequent, the patient breathing from forty to one hundred per minute, without change in the frequency of the pulse or evidence of dyspnea. A dry, spasmodic, or barking cough is a not infrequent symptom.

Circulatory disturbances, such as the "irritable heart" and palpitation, are exceedingly common, while pallor, local flushings, and pseudo-angina occasionally are seen.

Urinary symptoms are nearly always present. After an attack of hysteria the urine is abundant, limpid, and of low specific gravity. Suppression, hysterical anuria, may last for several days, yet uremia fail to appear.

"Trance or lethargy is, like catalepsy, sometimes the result of hysteria, or of exhausting illness, or of hypnotism. The patient is in a peculiar condition resembling sleep, and may remain so for days or even weeks. The face is pale, the limbs relaxed and the eyelids resist efforts to open them. The pupils are moderately contracted or dilated, and react to light. The pulse is small, the heart-sounds are feeble or inaudible, and the breathing is extremely quiet, so that occasionally the patient has been thought to be dead. In prolonged cases there are remissions in which the patient may take food, relapsing again into stupor. Most cases recover. Double consciousness and somnambulism are other developments of hysteria." (Taylor.)

Diagnosis.—The family history should throw some light upon the case. Thus, if similar conditions have occurred in the family or near relatives, or they have had insanity, chorea, epilepsy, sick headache, or neurasthenia, and if the patient has been excitable from early childhood, and but little effort has been used to control excessive emotions,—if with such a history the various symptoms above noted be present, there can be but little doubt left as to the true condition.

Prognosis.—This is always favorable as to life, and nearly always as to a cure of the disease, though years may elapse before this is accomplished. Usually after the menopause, the disease disappears.

Treatment.—There is no class of patients that receive as little sympathy as the victims of hysteria, and an important part of the treatment is patience on the part of the attending physician. While they are not to be humored—in fact, the physician should exercise firmness with his patients—they should not be allowed to observe annoyance or disgust or disinterestedness on the part of the medical adviser. Confidence in the physician must not be shaken. Hypnotism or suggestion will prove more or less beneficial in nearly all cases. Where possible, the patient's environments should be changed and travel, with congenial company, often works wonders in the way of a cure. The patient's mind must be gotten away from self, and anything that will accomplish this will be beneficial. A visit of several weeks' duration will often answer the same purpose.

The excitement and dissipations of city life also tend to aggravate hysteria, and a change should be made from the city to the country, where quiet, fresh air, plenty of sunshine, a nourishing diet, and regular hours can be secured.

The exciting cause must be determined and removed before much benefit can be expected, and a most thorough examination should be made of the rectum, where pockets, papillae, fissures, ulcers, hemorrhoids, undue contraction of the sphincters, or redundant and prolapsed tissue may be found responsible for the lesion. The uterus, both body and cervix, the vagina, the perineum, the ovaries, and the urethra should be carefully inspected; for the cause of the trouble very often is found at these parts, a correction of which often gives instant and permanent relief.

In the way of medication the treatment will be symptomatic, meeting the various conditions as they arise. The remedies most frequently indicated are pulsatilla, passiflora, viburnum, gossypium, gelsemium, ammoniated tincture of valerian, scutellaria, cypripedium, and like remedies, which should be studied with reference to this condition.

The rest-cure will be highly beneficial in many cases, while faradic and static electricity is followed by good results. Sometimes the dread of unpleasant medication is sufficient to act as the restraining- cause, till a cure is effected. Thus one cure comes to my mind where my preceptor, with the old lobelia emetic, effected a cure. At the first call the emetic was given for its full effect, two hours or more being required in its administration. A second attack was treated in the same way, and the interval between attacks lengthened. At the third call, while getting ready the nauseating mixture, the patient, with a woe-be-gone disgusted look, said, "Doctor, don't you give nothing but pukes?" "Nothing else for your kind of sickness," said the doctor; "but I want to assure you that you will never have to take another, for this is the last attack you will ever have." The cure was complete. The dread of the emetic, together with the mental impression, "You will never have to take another," was sufficient to arrest the disease in this case.

In nervous children the treatment should be prophylactic. They should not be advanced too rapidly in their school-work, should be taught self-restraint, not allowed to have every whim gratified, should have but few cares during the stage of puberty, and all dissipations of city life carefully avoided till full maturity, and but few cases will occur.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.