Seguin102 holds that (1) many hysterical symptoms may occur in diseases of the spinal cord and brain; (2) in diseases of the spinal cord these diseases appear merely as a matter of coincidence; (3) in cases of cerebral disease the hysterical symptoms have a deeper significance, being in relation to the hemisphere injured. He collects, as illustrative of the propositions that hysterical symptoms will present themselves in persons suffering from organic disease of the nervous system, the following cases of organic spinal disease: One case of left hemiplegia with paresis of the right limbs, which proved after death to be extensive central myelitis, with formation of cavities in the cord; two cases of posterior spinal sclerosis, two of disseminated sclerosis, and one of sclerosis of the lateral column. In some of these cases the organic disease was wholly overlooked. Sixteen cases of organic disease of the brain accompanied by marked hysterical manifestations are also given: 9 of left hemiplegia; 2 of right hemiplegia with aphasia; 1 of left alternating with right hemiplegia; 1 of hemichorea with paresis; 1 of double hemiplegia; and 2 of general paresis. It is remarkable and of interest, in connection with other unilateral phenomena of hysteria, that emotional symptoms were present in 14 cases of left hemiplegia and in only 2 of right.
102 Op. cit.
Among the important conclusions of this paper are the following: “1. In typical hysteria the emotional symptoms are the most prominent, and according to many authors the most characteristic. In all the cases of cerebral disease related there were undue emotional manifestations or emotional movements not duly controlled. 2. In typical hysteria many of the objective phenomena are almost always shown on the left side of the body, and we may consequently feel sure that in these cases the right hemisphere is disordered. In nearly all of the above sixteen cases the right hemisphere was the seat of organic disease, and the symptoms were on the left side of the body.”
The possibility of the occurrence of hysteria in the course of acute diseases, particularly fevers, is often overlooked. Its occurrence sometimes misleads the doctor with reference to prognosis. Such manifestations are particularly apt to occur in emotional children. A young girl suffering from a moderately severe attack of follicular tonsillitis, with high fever, suddenly awoke during the night and passed into an hysterical convulsion which greatly alarmed her parents. Her fingers, hands, and arms twitched and worked convulsively. She had fits of laughing and shouting, and was for a short time in a state of ecstasy or trance. Once before this she had had a similar but slighter seizure, during the course of an ephemeral fever.
Among other complications of hysteria which have been noted by different observers are apoplexy, disease of the spleen, mania-a-potu, heart disease, and spinal caries, and among affections alluded to by competent observers as simulated by hysteria are secondary syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina pectoris, and cardiac dyspnœa.
DIAGNOSIS.—Buzzard103 significantly remarks that you cannot cure a case of hysteria as long as you have any serious doubt about its nature; and, on the other hand, if you are able to be quite sure on this point, and are prepared to act with sufficient energy, there are few cases that will not yield to treatment. The importance of a correct diagnosis is a trite topic, but in no affection is it of more consequence than in hysteria, that disorder which, although itself curable, may, as has been abundantly shown, imitate the most incurable and fatal of diseases.
103 Clinical Lectures on Diseases of the Nervous System, by Thomas Buzzard, M.D., Philada., 1882.
A few remarks with reference to the methods of examining hysterical patients will be here in place. Success on the part of the physician will often depend upon his quickness of perception and ability to seize passing symptoms. It is often extremely difficult to determine whether hysterical patients are or are not shamming or how far they are shamming. The shrewdness and watchfulness which such patients sometimes exercise in resisting the physician's attempts to arrive at a diagnosis should be borne in mind. A consistent method of procedure, one which never betrays any lack of confidence, should be adopted. “Trifles light as air” will sometimes decide, a single expression or a trivial sign clinching the diagnosis. On the other hand, the most elaborate and painstaking investigation will be frequently required.
The physician should carefully guard against making a diagnosis according to preconceived views. On the whole, the general practitioner is more likely to err on the side of diagnosticating organic disease where it does not exist; the specialist in too quickly assigning hysteria where organic disease is present, or in failing to determine the association of hysteria and organic disease in the same case.
Special expedients may sometimes be resorted to in the course of an examination. Not a few hysterical symptoms require for their continuance that the patient's mind shall be centred on the manifestations. If, therefore, the attention can, without arousing suspicions, be directed to something else during the examination, the disappearance of the particular hysterical symptom may clear away all obscurity. In a case reported by Seguin,104 in which staggering was a prominent symptom, the patient was placed in the middle of the room and directed to look at the ceiling to see if he could make out certain fine marks; he stood perfectly well without any unsteadiness. In the case of a boy eleven years old whose chief symptoms were hysterical paralysis with contracture of the lower extremities, great hyperæsthesia of the feet, and a tremor involving both the upper and lower extremities, and sometimes the head, I directed him, as if to bring out some point, to hold one arm above his head and at the same time fix his attention on the foot of the opposite side. The tremor in the upper extremities, which had been most marked, entirely disappeared. This experiment was varied, the result being the same.