Chorea Gravidarum and Hysteria
Recurring, permanent, localized spasms of facial or other groups of muscles, which are often called chorea, are tics,—convulsive tic, painful tic, accessorius spasm, and so on. Chorea is also characterized by various recurrent spasmodic movements, but the origin of the disease is commonly an infectious endocarditis, rheumatism, tonsillitis, or the like disease. This is Chorea Minor, St. Vitus's Dance, or Infectious Chorea. There is also a common chorea, which is not from an infection but from some nervous irritation, usually eye-strain, and disappears with the removal of the irritation. The chorea of pregnancy is often an infectious chorea, and then it is an extremely dangerous condition: the mortality in some collections of toxic cases is as high as 22 per cent. We meet, too, in pregnancy hysterical chorea, and a form which is partly hysterical and partly infectious in origin.
Primigravidae are more susceptible to infectious chorea in pregnancy than multigravidae. If a woman has not had true rheumatism she very rarely gets chorea after the first gestation. Rheumatism in the patient or in her immediate ancestors, epilepsy, fright and other emotions, and anemia are predisposing causes. The patients are all very neurotic; and if they had chorea in childhood, the condition is likely to recur in pregnancy.
Mild cases may be cured without damage to the woman or fetus, but many cases go on to abortion and death in coma and fever. Some severe cases result in a mania which may last for months; again, there is paralysis and delirium. The earlier in pregnancy the attack, the greater the danger to the fetus.
It is very important to differentiate infectious chorea from hysterical chorea—the latter may or may not be dangerous; chorea always is dangerous. In hysterical chorea the movements are sudden, isolated, and sometimes rhythmical, especially in the fingers; there are zones of anesthesia, and the perversity of the hysteric soon manifests itself. The movements in hysteria are never so intense as to exhaust the patient. In true chorea the movements are irregular, spasmodic, and increased by motion and voluntary effort, especially if the effort is sustained; they exhaust the patient.
Maniacal chorea differs from the mania of the puerperium from other causes: in maniacal chorea the woman is not so sullen, and is more garrulous than the patient with puerperal mania. The prognosis is better in maniacal chorea as to recovery of reason. Sometimes, however, the mania of puerperal chorea persists for months, or it may become even permanent.
If the fetus is viable and the choreic woman, with a clear toxic chorea, shows signs of exhaustion from the spasms and insomnia, or if her mania is becoming fixed and her delusions are dangerous (such women are likely to kill the infant), or if she has endocarditis, the uterus should be emptied, as a rule. If, however, the symptoms show a recession on treatment, the uterus should not be emptied. Albrecht[137] reported a case of chorea cured by an injection of serum from a normal pregnant woman. Each case must be judged by its own characteristics. The last sacraments should be given as soon as the symptoms grow grave.
Hysteria in a woman, even when mild, may grow serious in pregnancy when it takes the form of melancholia; but it is dangerous when it passes into maniacal excitement. In mania there may be exhaustion from a refusal to take food, and in labor maniacal hysteria may wreak grave injury on both mother and child. Hysterical women should be treated before pregnancy; indeed, the process of avoiding hysteria should have begun in the patient's grandparents.
The term hysteria has been handed down from the days when physicians thought there was a connection between uterine disorders and the set of nervous symptoms grouped about the title hysteria. It is now etymologically meaningless—men also grow hysterical. Briquet found 11 male to 204 female hysterics, and later statistics increase the number of males.
The disease is not readily definable. The patient is usually a young emotional woman, oftenest between fifteen and twenty years of age. She commonly has anesthetic spots on her body, concentric limitations of the fields of vision and reversals in the color fields, hysterogenetic zones, or tender points, which when pressed appear to inhibit the hysterical fit. The symptoms enumerated here are not, however, found in every case of hysteria, and it is difficult at times to diagnose the case. There is a popular notion that hysteria is a disease of malingerers, but it is as real as typhoid fever or a broken leg, and a much greater affliction than either of these conditions. Malingering is only a symptom of the disease.
The conditions that bring about hysteria are hysteria in a parent, or insanity, alcoholism, or some similar neurotic taint in an ancestor. Immediate causes are acute depressive emotions, shocks from danger, sudden grief, severe revulsions of feeling, as from disappointment in love or abandonment by a husband; and, secondly, cumulative emotional disturbance, as from worry, poverty, ill treatment, unhappy marriage, or religious revivals. Certain diseased conditions, as anemia, chronic intoxications, pelvic trouble, start it into activity when it is latent. It is also communicated by imitation and it may become epidemic.
After the great plague, the Black Death, in the fourteenth century, there were very remarkable epidemics of imitative hysteria in Germany and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state. These dances spread over Holland and Belgium and extended to Cologne and Metz. The "Dancing Plague" broke out again, in 1418, at Strasburg and in Belgium and along the lower Rhine. In 1237 there was a similar outbreak among children at Erfurt and many died from exhaustion. The tarantism in Italy from the fifteenth to the eighteenth century is another example of epidemic hysteria. There were epidemics of hysteria in Tennessee, Kentucky, and a part of Virginia, which began in 1800 and recurred for a number of years. These outbreaks started in revivals and camp meetings. The majority of the cases were in youths from fifteen to twenty-five years of age, but the hysteria was observed in persons from six to sixty years old. The muscles affected were those of the neck, trunk, and arms, and the convulsions were so strong that the patients were thrown to the ground and often leaped about like a live fish tossed out of the water on a bank.
Convulsions, tremors, paralyses of various forms and degrees are common in hysteria. In major hysteria the patient falls into a convulsion gently. There is checked breathing, up to apparent danger of suffocation. Then follows a furious convulsion, even with a bloody froth at the mouth, but there is a trace of wilfulness or purpose in the movements. Next may come a stage of opisthotonos, in which the body is bent back in a rigid arch until the patient rests on her head and heels only, like a wrestler; and this is followed by relaxation and a recurrence of the contortions. An ecstatic phase succeeds this at times, the so-called crucifix position, with outbursts of various emotions, and a final regaining of the normal state. Any of these stages, however, may constitute the entire fit. Some major hysterics can simulate demoniacal possession with extraordinary ingenuity. In minor hysteria there is commonly a sensation of a rising ball in the throat—the globus hystericus. There may be uncontrollable laughter or weeping, and muscular rigidity is frequent. The patient, especially if she is a child, may mimic dogs and other animals. The snarling, biting, and barking of false rabies are hysterical; such symptoms do not occur at all in real hydrophobia.
There are innumerable physical symptoms of the disease, but the mental phases have most to do with the treatment. The hysterical person is characterized by an overmastering desire to be an object of sympathy, interest, admiration, rather than by a tendency to baser instincts. The will is weak, the emotions explosive, the patient is impulsive and lacking in self-control. She readily goes from absurd laughter into floods of tears. She simulates pains and other symptoms of disease, and she is always a liar, no matter what her state in life, from nurse-girl to nun.
Acquired hysteria may be cured, but the congenital form is virtually hopeless; yet even with this latter kind much can be done by patient training. Such a girl or boy must be reared carefully and with a firm hand. A marked congenital hysteric should not marry. Marriage makes them worse, and they beget other hysterics. When a hysterical girl gets one of her fits the chief obstacle to cure is sympathetic visits from relatives and friends. If a patient in the vapors is taken from school and wept over, she will never come down to earth again. The girl who faints at the communion-rail regularly is always a hysteric, and the cure for her is a bucket of cold water in the sacristy, or a threat to turn her over to the police. You will find these fainters with a perfect pulse despite the faint. But there are other cases in which rough treatment is harmful, and the only method is patient tact. Such persons are objects of great pity and should be dealt with as one would deal with any deficient mind.