nineteen, who, after a succession of epileptiform fits, fell into a
collapse and died in two days. Other cases have been recorded by
Meyer. Fagge also speaks of the more chronic forms of hysteria proving
fatal by marasmus. He refers to two cases reported by Wilks, both of
which were diagnosticated as hysterical, and both of which died. Sir
William Gull describes a complaint which he terms anorexia nervosa vel
hysterica. It is attended with extreme wasting; pulse, respiration,
and temperature are low. The patients were usually between the ages of
sixteen and twenty-three: some died; others recovered under full
feeding and great care. In many of the reported fatal cases careful
inquiry must be made as to this question of hysteria being simply a
complication.
[Footnote 112: Quoted in _The Principles and Practice of Medicine_, by
the late Charles Hilton Fagge, M.D., F. R. C. P., etc., vol. i. 1886,
p. 736.]
Are not hysterical attacks sometimes fatal? With reference to one of
my cases this view was urged by the physician in attendance.
Gowers[113] on this point says: “As a rule to which exceptions are
infinitely rare, hysterical attacks, however severe and alarming in
aspect, are devoid of danger. The attacks of laryngeal spasm present
the greatest apparent risk to life.” He refers to the paroxysms of
dyspnœa presented by a hemiplegic girl as really alarming in
appearance, even to those familiar with them. He refers also to a case
of Raynaud's[114] in which the laryngeal and pharyngeal spasm
coexisted with trismus, and the patient died in a terrible paroxysm of
dyspnœa. The patient presented various other hysterical
manifestations, and a precisely similar attack had occurred previously
and passed away, but she had in the interval become addicted to the
hypodermic injection of morphia, and Raynaud suggested that it might
have been the effect of this on the nerve-centres that caused the
fatal termination. Such cases have been described in France as the
hydrophobic form of hysteria.
[Footnote 113: _Epilepsy and Other Chronic Convulsive Diseases_, by
W. R. Gowers, M.D., London. 1881.]
[Footnote 114: _L'Union médical_, March 15, 1881.]
Patients may die in hysterical as in epileptic attacks from causes not
directly connected with the disease. One of these sources of danger
mentioned by Gowers is the tendency to fall on the face sometimes met
with in the post-epileptic state. He records an example of death from
this cause. He also details a case of running hysteria or
hystero-epilepsy, in which, after a series of fits lasting about four
hours, the child died, possibly from some intercurrent accident.
TREATMENT.—Grasset,[115] speaking of the treatment of hysteria, says
that means of treating the paroxysm, of removing the anæsthesia, of
combating single symptoms, are perhaps to be found in abundance, but
the groundwork of the disease, the neurosis or morbid state, is not
attacked. Here he indicates a new and fruitful path. In his own {274}
summing up, however, he can only say that the hysterical diathesis
offers fundamental grounds for the exhibition of arsenic, silver,
chloride of gold, and mineral waters!
[Footnote 115: _Brain_, January, 1884.]
No doubt can exist that the prophylactic and hygienic treatment of
hysteria is of paramount importance. To education—using the term
education in a broad sense—before and above all, the most important
place must be given. It is sometimes better to remove children from
their home surroundings. Hysterical mothers develop hysterical
children through association and imitation. I can scarcely, however,
agree with Dujardin-Beaumetz that it is always a good plan to place a
girl in a boarding-school far from the city. It depends on the school.
A well-regulated institution may be a great blessing in this
direction; one badly-managed may become a hotbed of hysteria.
Recently I made some investigations into the working of the
public-school system of Philadelphia, particularly with reference to
the question of overwork and sanitation.[116] I had special
opportunities during the investigations to study the influences of
different methods of education, owing to the fact that the
public-school system of Philadelphia is just now in a transition
period. This system is in a state of hopeful confusion—hopeful,
because I believe that out of its present condition will come
eventually a great boon to Philadelphia. At one end of the system, in
the primary and the secondary schools, a graded method of instruction
has been introduced. The grammar and the high schools are working on
an ungraded or differently graded method. I found still prevailing,
particularly in certain of the grammar schools for girls, although not
to the same extent as a few years since, methods of cramming and
stuffing calculated above all to produce hysteria and allied disorders
in those predisposed to them.
[Footnote 116: The results of these investigations were given in a
lecture which was delivered in the Girls' Normal School of
Philadelphia before the Teachers' Institute of Philadelphia, Dec. 11,
1885.]
Education should be so arranged as to develop the brain by a natural
process—not from within outward; not from the centre to the periphery;
not from above downward; but as the nervous system itself develops in
its evolution from a lower to a higher order of animals, from the
simple to the more complex and more elaborate. Any system of education
is wrong, and is calculated to weaken and worry an impressionable
nervous system, which attempts to overturn or change this order of the
progress of a true development of the brain. To develop the nervous
system as it should be developed—slowly, naturally, and evenly—it must
also be fed, rested, and properly exercised.
In those primary schools in which the graded method was best carried
out this process of helping natural development was pursued, and the
result was seen in contented faces, healthy bodies, and cheerful
workers. In future the result will be found in less chorea, hysteria,
and insanity.
To prevent the development of hysteria, parents and physicians should
direct every effort. The family physician who discovers a child to be
neurotic, and who from his knowledge of parents, ancestors, and
collateral relatives knows that a predisposition to hysteria or some
other neurosis is likely to be present, should exercise all the moral
influence which he possesses to have a healthy, robust training
provided. It is not within the {275} scope of an article of this kind
to describe in great detail in what such education should consist.
Reynolds is correct when he says that “self-control should be
developed, the bodily health should be most carefully regarded, and
some motive or purpose should be supplied which may give force,
persistence, unity, and success to the endeavors of the patient.” In
children who have a tendency to the development of hysteria the
inclinations should not always or altogether be regarded in choosing a
method or pursuing a plan of education. It is not always to what such
a child takes that its mind should be constantly directed; but, on the
contrary, it is often well to educate it away from its inclination.
“The worst thing that can be done is that which makes the patient know
and feel that she is thought to be peculiar. Sometimes such treatment
is gratifying to her, and she likes it—it is easy and it seems kind to
give it—but it is radically wrong.”
In providing for the bodily health of hysterical children it should be
seen that exercise should be taken regularly and in the open air, but
over-fatigue should be avoided; that ample and pleasant recreation
should be provided; that study should be systematic and disciplinary,
but at the same time varied and interesting, and subservient to some
useful purpose; that the various functions of secretion, excretion,
menstruation should be regulated.
The importance of sufficient sleep to children who are predisposed to
hysteria or any other form of nervous or mental disorder can scarcely
be over-estimated. The following, according to J. Crichton
Browne,[117] is the average duration of sleep required at different
ages: 4 years of age, 12 hours; 7 years of age, 11 hours; 9 years of
age, 10½ hours; 14 years of age, 10 hours; 17 years of age, 9½ hours;
21 years of age, 9 hours; 28 years of age, 8 hours. To carefully
provide that children shall obtain this amount of sleep will do much
to strengthen the nervous system and subdue or eradicate hysterical
tendencies. Gymnastics, horseback riding, walking, swimming, and
similar exercises all have their advantages in preventing hysterical
tendencies.
[Footnote 117: _Education and the Nervous System_, reprinted from _The
Book of Health_ by permission of Messrs. Cassell & Co., Limited.]
Herz[118] has some instructive and useful recommendations with
reference to the treatment of hysteria in children. It is first and
most important to rehabilitate the weakened organism, and especially
the central nervous system, by various dietetic, hygienic, and
medicinal measures. It is important next to tranquillize physical and
mental excitement. This can sometimes be done by disregard of the
affection, by neglect, or by removal or threatened removal of the
child from its surroundings. Such treatment should of course be
employed with great discretion. Anæmia and chlorosis, often present in
the youthful victims of hysteria, should be thoroughly treated. Care
should be taken to learn whether children of either sex practise
masturbation, which, Jacobi and others insist, frequently plays an
important part in the production of hysteria. Proper measures should
be taken to prevent this practice. The genital organs should receive
examination and treatment if this is deemed at all necessary. On the
other hand, care should be taken not to direct the attention of
children unnecessarily to those organs when they are entirely innocent
{276} of such habits. Painting the vagina twice daily with a 10 per
cent. solution of hydrochlorate cocaine has been found useful in
subduing the hyper-irritation of the sexual organs in girls accustomed
to practise masturbation. Herz, with Henoch, prefers the hydrate of
chloral to all other medicines, although he regards morphine as almost
equally valuable, in the treatment of hysteria in children.
Personally, I prefer the bromides to either morphia or chloral. Small
doses of iron and arsenic continued systematically for a long period
will be found useful. Politzer of Vienna regards the hydrobromate and
bihydrobromate of iron as two valuable preparations in the hysteria of
children, and exhibits them in doses of four to seven grains three to
four times daily.
[Footnote 118: _Wien. Med. Wochen._, No. 46, Nov. 14, 1885.]
Hysteria once developed, it is the moral treatment which often really
cures. The basis of this method of cure is to rouse the will. It is
essential to establish faith in the mind of the patient. She must be
made to feel not only that she can be helped, but that she will be.
Every legitimate means also should be taken to impress the patient
with the idea that her case is fully understood. If malingering or
partial malingering enters into the problem, the patient will then
feel that she has been detected, and will conclude that she had better
get out of her dilemma as gracefully as possible. Where simulation
does not enter faith is an important nerve-stimulant and tonic; it
unchains the will.
Many physicians have extraordinary ideas about hysteria, and because
of these adopt remarkable and sometimes outrageous methods of
treatment. They find a woman with hysterical symptoms, and forthwith
conclude she is nothing but a fraud. They are much inclined to assert
their opinions, not infrequently to the patient herself, and, if not
directly to her, in her hearing to other patients or to friends,
relatives, nurses, or physicians. They threaten, denounce, and
punish—the latter especially in hospitals. In general practice their
course is modified usually by the wholesome restraint which the
financial and other extra-hospital relations of patient and physician
enforce.
Although hysterical patients often do simulate and are guilty of
fraud, it should never be forgotten that some hysterical
manifestations may be for the time being beyond the control of
patients. Even for some of the frauds which are practised the
individuals are scarcely responsible, because of the weakness of their
moral nature and their lack of will-power. Moral treatment in the form
of reckless harshness becomes immoral treatment. The liability to
mistake in diagnosis, and the frequent association of organic disease
with hysterical symptoms, should make the physician careful and
conservative. It is also of the highest importance often that the
doctor should not show his hand. The fact that an occasional cure,
which is usually temporary, is effected by denunciation, and even
cruelty, is not a good argument against the stand taken here.
Harsh measures should only be adopted after due consideration and by a
well-digested method. A good plan sometimes is, after carefully
examining the patient, to place her on some simple, medicinal, and
perhaps electrical treatment, taking care quietly to prophesy a speedy
cure. If this does not work, in a few days other severe or more
positive measures may be used, perhaps blistering or strong electrical
currents. Later, but in rare cases only, after giving the patient a
chance to arouse {277} herself by letting her know what she may
expect, painful electrical currents, the hot iron, the cold bath, or
similar measures may be used. Such treatment, however, should never be
used as a punishment.
The method of cure by neglect can sometimes be resorted to with
advantage. The ever-practical Wilks mentions the case of a
school-teacher with hemianalgesia, hemianæsthesia, and an array of
other hysterical symptoms who had gone through all manner of
treatment, and at the end of seven months was no better. The doctor
simply left her alone. He ordered her no drugs, and regularly passed
by her bed. In three weeks he found her sitting up. She talked a
little and had some feeling in her right side. She was now encouraged,
and made rapid progress to recovery. Neglect had aroused her dormant
powers. It must be said that a treatment of this kind can be carried
out with far more prospects of success in a general hospital than in a
private institution or at the home of a patient. It is a method of
treatment which may fail or succeed according to the tact and
intelligence of the physician.
I cannot overlook here the consideration of the subject of the
so-called faith cure and mind cure. One difference between the faith
cure as claimed and practised by its advocates, and by those who
uphold it from a scientific standpoint, is simply that the latter do
not refer the results obtained to any supernatural or spiritual
agency. I would not advise the establishment of prayer-meetings for
the relief of hysteria, but would suggest that the power of faith be
exercised to its fullest extent in a legitimate way.
A young lady is sick, and for two years is seen by all the leading
doctors in London; a clergyman is asked in and prays over her, and she
gets up and walks. The doctors all join in and say the case was one of
hysteria—that there was nothing the matter with her. Then, says Wilks,
“Why was the girl subjected to local treatment and doses of physic for
years? Why did not the doctors do what the parson did?”
Tuke[119] devotes a chapter to psychotherapeutics, which every
physician who is called upon to treat hysteria should read. He
attempts to reduce the therapeutic use of mental influence to a
practical, working basis. I will formulate from Tuke and my own
experience certain propositions as to the employment of psychological
measures: (1) It is often important and always justifiable to inspire
confidence and hope in hysterical patients by promising cures when it
is possible to achieve cures. (2) A physician may sometimes properly
avail himself of his influence over the emotions of the patient in the
treatment of hysterical patients, but always with great caution and
discretion. (3) Every effort should be made to excite hysterical
patients to exert the will. (4) In some hysterical cases it is
advisable to systematically direct the attention to a particular
region of the body, arousing at the same time the expectation of a
certain result. (5) Combined mental and physical procedures may
sometimes be employed. (6) Hypnotism may be used in a very few cases.
[Footnote 119: _Influence of the Mind upon the Body_.]
The importance of employing mental impression is thoroughly
exemplified, if nothing else is accomplished, by a study of such a
craze as the so-called mind cure. Not a few people of supposed sense
and cultivation have pinned their faith to this latest Boston hobby. A
glance at the published writings of the apostles of the mind cure will
show at once to the {278} critical mind that all in it of value is
dependent upon the effects of mental impression upon certain peculiar
natures, some of them being of a kind which afford us not a few of our
cases of hysteria. W. F. Evans has published several works upon the
subject. From one of these[120] I have sought, but not altogether
successfully, to obtain some ideas as to the basis of the mind-cure
treatment. It is claimed that the object is to construct a theoretical
and practical system of phrenopathy, or mental cure, on the basis of
the idealistic philosophy of Berkeley, Fichte, Schelling, and Hegel.
The fundamental doctrine of those who believe in the mental cure is,
that to think and to exist are one and the same, and that every
disease is a translation into a bodily expression of a fixed idea of
mind. If by any therapeutic device the morbid idea can be removed, the
cure of the malady is assured. When the patient is passive, and
consequently impressible, he is made to fix his thoughts with
expectant attention upon the effect to be produced. The physician
thinks to the same effect, wills it, and believes and imagines that it
is being done; the mental action _to_ the patient, sympathizing with
that of the physician, is precipitated upon the body, and becomes a
silent, transforming, sanitive energy. It must be, says Evans, “a
malady more than ordinarily obstinate that is neither relieved nor
cured by it.”
[Footnote 120: _The Divine Law of Cure_.]
Hysteria cannot be cured by drugs alone, and yet a practitioner of
medicine would find it extremely difficult to manage some cases
without using drugs. Drugs themselves, used properly, may have a moral
or mental as well as a physical influence. Among those which have been
most used from before the days of Sydenham to the present time,
chiefly for their supposed or real antispasmodic virtues, are
galbanum, asafœtida, valerian, castor and musk, opium, and hyoscyamus.
The value of asafœtida, valerian, castor, and musk is chiefly of a
temporary character. If these drugs are used at all, they should be
used in full doses frequently repeated. Sumbul, a drug of the same
class comparatively little used, is with me a favorite. It can be used
in the form of tincture or fluid extract, from twenty minims to half a
drachm of the latter or one to two drachms of the former. It certainly
has in many cases a remarkably calmative effect.
Opium and its preparations, so strongly recommended by some, and
especially the Germans, should not be used except in rare cases.
Occasionally in a case with sleeplessness or great excitement it may
be absolutely indispensable to resort to it in combination with some
other hypnotic or sedative. The danger, however, in other cases of
forming the opium habit should not be overlooked. According to
Dujardin-Beaumetz, it is mainly useful in the asthenic forms of
hysteria.
Of all drugs, the metallic tonics are to be preferred in the
continuous treatment of hysteria. Iron, although not called for in a
large percentage of cases, will sometimes prove of great service in
the weak and anæmic hysterics. Chalybeates are first among the drugs
mentioned by Sydenham. Steel was his favorite. The subcarbonate or
reduced iron, or the tincture of the chloride, is to be preferred to
the more fanciful and elegant preparations with which the drug-market
is now flooded. Dialyzed iron and the mallate of iron, however, are
known to be reliable preparations, and can be resorted to with
advantage. They should be given in large doses. Zinc salts,
particularly the oxide, phosphide, and {279} valerianate; the nitrate
or oxide of silver, the ammonio-sulphate of copper, ferri-ferrocyanide
or Prussian blue,—all have a certain amount of real value in giving
tone to the nervous system in hysterical cases.
To Niemeyer we owe the use of chloride of sodium and gold in the
treatment of hysteria. He refers to the fact that Martini of Biberach
regarded this article as an efficient remedy against the various
diseases of the womb and ovaries. He believed that the improvement
effected upon Martini's patient was probably due to the fact that
this, like other metallic remedies, was an active nervine. He
prescribed the chloride of gold and sodium in the form of a pill in
the dose of one-eighth of a grain. Of these pills he at first ordered
one to be taken an hour after dinner, and another an hour after
supper. Later, he ordered two to be taken at these hours, and
gradually the dose was increased up to eight pills daily. I frequently
use this salt after the method of Niemeyer.
The treatment of hysteria which Mitchell has done so much to make
popular, that by seclusion, rest, massage, and electricity, is of
value in a large number of cases of grave hysteria; but the proper
selection of cases for this treatment is all important. Playfair[121]
says correctly that if this method of treatment is indiscriminately
employed, failure and disappointment are certain to result. The most
satisfactory results are to be had in the thoroughly broken-down and
bed-ridden cases. “The worse the case is,” he says, “the more easy and
certain is the cure; and the only disappointments I have had have been
in dubious, half-and-half cases.”
[Footnote 121: _The Systematic Treatment of Nerve-Prostration and
Hysteria_, by W. S. Playfair, M.D., F. R. C. P., 1883.]
Mitchell[122] gives a succinct, practical description of the process
of massage: “An hour,” he says, “is chosen midway between two meals,
and, the patient lying in bed, the manipulator starts at the feet, and
gently but firmly pinches up the skin, rolling it lightly between his
fingers, and going carefully over the whole foot; then the toes are
bent and moved about in every direction; and next, with the thumbs and
fingers, the little muscles of the foot are kneaded and pinched more
largely, and the interosseous groups worked at with the finger-tips
between the bones. At last the whole tissues of the foot are seized
with both hands and somewhat firmly rolled about. Next, the ankles are
dealt with in the same fashion, all the crevices between the
articulating bones being sought out and kneaded, while the joint is
put in every possible position. The leg is next treated—first by
surface pinching and then by deeper grasping of the areolar tissue,
and last by industrious and deeper pinching of the large muscular
masses, which for this purpose are put in a position of the utmost
relaxation. The grasp of the muscles is momentary, and for the large
muscles of the calf and thigh both hands act, the one contracting as
the other loosens its grip. In treating the firm muscles in front of
the leg the fingers are made to roll the muscles under the cushions of
the finger-tips. At brief intervals the manipulator seizes the limb in
both hands and lightly runs the grasp upward, so as to favor the flow
of venous blood-currents, and then returns to the kneading of the
muscles. The same process is carried on in every part of the body, and
especial care is given to the muscles of the loins and spine, while
usually the face {280} is not touched. The belly is first treated by
pinching the skin, then by deeply grasping and rolling the muscular
walls in the hands, and at last the whole belly is kneaded with the
heel of the hand in a succession of rapid, deep movements, passing
around in the direction of the colon.”
[Footnote 122: “Fat and Blood,” etc.]