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.