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_.]
Gout in England plays a greater part in the production of nervous and
other disorders than in this country, but even here its
instrumentality is too often overlooked. In Philadelphia are many
families, some of them of English origin, in which gout has occurred,
sometimes of the regular type, but oftener of anomalous forms. Among
the most striking examples of hysteria that have fallen under my
observation, some have been in these families. In a few of them
remedies directed to the lithæmic or gouty conditions in connection
with other measures have been efficient. More frequently they have
failed, for while a relation may exist between the neurotic disorder
and the diathesis, it is not the diathesis, but the neurotic disorder,
which we are called upon to treat.
That a certain mental constitution predisposes to hysteria cannot be
doubted. Ribot[36] describes, chiefly from Huchard,[37] the hysterical
constitution. It is a state in which volition is nearly always
lacking. The prominent trait is mobility. The hysterical pass with
increditable rapidity from joy to sadness, from laughter to tears;
they are changeable, freakish, or capricious; they have fits of
sobbing or outbursts of laughter. Ch. Richét compares them to
children, who oftentimes can be made to laugh heartily while their
cheeks are still wet with tears. Sydenham says of them that
inconstancy is their most common trait: their sensibilities are
aroused by the most trivial cause, while profounder emotions scarcely
touch them. They are in a condition of moral ataxy, lacking
equilibrium between the higher and lower faculties.
[Footnote 36: _Diseases of the Will_.]
[Footnote 37: Axenfeld et Huchard, _Traité des Neuroses_, 2d ed.,
1883, pp. 958-971.]
As to sex, it is almost unnecessary to say that hysteria occurs with
greater frequency among females than males; and yet it is all
important to emphasize the fact that it is not exclusively a disease
of the former sex. Some statistics on this subject have been
collected. In Briquet's often-quoted 1000 cases of hysteria, 50 only
occurred in men. I believe, however, that the proportion of hysterical
men to hysterical women is greater than this. Instead of a ratio of 1
to 20, as these statistics would indicate, 1 to 15 would probably be
nearer the truth. Statistics upon this subject are deceptive.
The occurrence of hysteria in the male was little discussed before the
publication of Briquet's great work, but since that time it has
received {216} great attention from the medical profession.
Charcot[38] in some recent lectures at Salpêtrière has called
attention to this subject. From 1875 to 1885 he says that five
doctoral theses have been written on hysteria in men. Batault has
collected 218 and Klein 80 cases. The _Index Catalogue_ contains 102
references to hysteria in the male.
[Footnote 38: _Le Progrès médical_, 1885.]
Hysteria in men may take on almost any form that it shows in women. It
may occur in the strong, although more likely to be seen among the
weak and effeminate. Even strong, vigorous workmen are susceptible, at
times, to hysteria. According to Charcot, the duration of the
affection differs somewhat in the two sexes. In male patients it lasts
a long time and the symptoms are troublesome; in females the contrary
is usually although not always the case. The occurrence of hysteria in
the male sex has probably been overlooked through the tendency to
class symptoms which would be regarded as hysterical in women as
hypochondriacal in men.
One of the most typical half-purposive hysterical attacks that has
ever come under my observation was in a literary man of some
prominence. Hysterical syncope, contracture, hysterical breathing,
hysterical hydrophobia, coccygodynia, hemiparesis, hemianæsthesia, and
blindness are some other forms of hysteria in the male of which there
are clinical records the result of personal observation. A remarkable
case of hysterical motor ataxy was seen in a boy who was for some time
a patient at the Philadelphia Polyclinic. Wilks[39] records several
interesting cases of hysteria in boys. One simulated laryngismus
stridulus, with paroxysmal suffocative attacks and barking. Another
was a case of hysterical maniacal excitement; another was an example
of malleation, or constant movement as in hammering; still others were
instances of extreme hyperæsthesia, of anorexia, and of nervous
dyspnœa. The same author also dwells on the hysterical perversion of
the moral sense found in boys as in girls. He gives some instances
clipped from English newspapers—attempts to poison, murder or attempts
to murder, confessions false and true. Many instances could be added
from our own sensational American sheets.
[Footnote 39: _Op. cit._]
No age is free from a liability to hysteria. Its occurrence, however,
at certain periods of life with great frequency is well known. The
following table has been arranged from tables given by Briquet and
Jolly, and shows that it is of most frequent occurrence between the
ages of fifteen and thirty:
Age. Landouzy. Georget. Beau. Briquet. Scanzoni. Total.
0-10 4 1 ... 66 ... 71
10-15 48 5 6 98 4 161
15-20 105 7 7 140 13 272
20-25 80 4 3 71 |
25-30 40 3 ... 24 | 64 289
30-35 38 ... ... 9 |
35-40 15 ... ... 9 | 78 149
40-45 7 1 ... 1 |
45-50 8 ... 1 3 | 44 65
50-55 4 ... ... 3 |
55-60 4 ... 1 2 | 11 25
60-80 2 ... ... ... 3 5
355 21 18 426 217 1037
{217} Hysteria in the United States assumes almost every form,
probably because we have here represented almost every race and
nationality, either pure or mixed. While it cannot be clearly shown
that certain races are much more prone to hysteria than others, the
type of this disease is doubtless much influenced by racial and
climatic conditions. Certain phases of the disease prevail in certain
sections more than in others. Mitchell's[40] experience is that the
persistent hystero-epilepsies, and the multiple and severe
contractures which Charcot and others describe, are rare in this
country among all classes, and especially uncommon in the lowest
classes, among which Charcot seems to have found his worst and most
interesting cases. He says that while his own clinic furnishes
numerous cases of neural maladies, and while he has examples of every
type of the milder form of hysteria, it is extremely uncommon to
encounter the more severe and lasting forms of this disease. When
Mitchell's _Lectures_ were first published I was inclined to regard
hystero-epilepsy of the grave type as of rare occurrence, and so
stated in answer to a communication from him. Recently, as the result
of a longer experience, I have become persuaded that some irregular
forms are met with somewhat frequently in various sections of our
country. It remains true, however, that in the Middle and Northern
sections of the United States the graver hysterias of the convulsive
type are not nearly as frequently observed as in the southern
countries of Europe.
[Footnote 40: _Op. cit._]