104 Op. cit.
The method adopted in the cases supposed to be phthisis, but which proved to be hysterical, which has already been alluded to under the head of hysterical or nervous breathing, is worthy of note. The patients, it will be recalled, could not be induced to draw a long breath until the plan was adopted of having them count twenty without stopping, when the lungs expanded and the diagnosis was clear.
It is important to know whether or not children are of this hysterical tendency or are likely, sooner or later in life, to develop some forms of this disorder. In children as well as in adults the hysterical diathesis will be indicated by that peculiar mobility of the nervous system, which has been referred to under Etiology. It is chiefly by psychical manifestations that the determination will be made. These are often of mild degree and of irregular appearance. Undue emotionality under slight exciting cause, a tendency to simulation and to exaggeration of real conditions, inconsistency in likes and dislikes, and great sensibility to passing impressions, are among these indications. Children of hysterical diathesis are sometimes, although by no means always, precocious mentally, but not a few cases of apparent precocity are rather examples of an effort to attract attention, which is always present in individuals of this temperament.
It is also important, as urged by Allbutt,105 to make a distinction between hysterical patients and neurotic subjects, often incorrectly classed as hysterical. Many cases of genuine malady and suffering are contemptuously thrown aside as hysteric. Allbutt regards some of these neurotic patients as almost the best people in this wicked world. Although, however, this author's righteous wrath against the too frequent diagnosis of hysteria, hysterical pain, hysterical spine, etc. is entirely justifiable, he errs a little on the other side.
105 On Visceral Neuroses, being the Gulstonian Lectures on Neuralgia of the Stomach and Allied Disorders, delivered at Royal College of Physicians, March, 1884, by T. Clifford Allbutt, M.A., M.D. Cantab., F. R. S., Philada., 1884.
Hysteria and neurasthenia are often confounded, and, while both conditions may exist in the same case, just as certainly one may be present without the other. The points of differential diagnosis as given by Beard106 are sufficient for practical purposes. They are the following: In neurasthenia convulsions or paroxysms are absent; in hysteria they are among the most common features. In neurasthenia globus hystericus and anæsthesia of the epiglottis are absent, ovarian tenderness is not common, and attacks of anæsthesia are not frequent and have little permanency; in hysteria globus hystericus, anæsthesia of the epiglottis, ovarian tenderness, and attacks of general or local anæsthesia are all marked phenomena. The symptoms of neurasthenia are moderate, quiet, subdued, passive; those of hysteria are acute, intense, violent, positive. Neurasthenia may occur in well-balanced intellectual organizations; hysteria is usually associated with great emotional activity and unbalanced mental organization. Neurasthenia is common in males, although more common in females; hysteria is rare in males. Neurasthenia is always associated with physical debility; hysteria in the mental or psychical form occurs in those who are in perfect physical health. Neurasthenia never recovers suddenly, but always gradually and under the combined influences of hygiene and objective treatment; hysteria may recover suddenly and under purely emotional treatment.
106 Op. cit.
An affection termed general nervousness has been described by Mitchell. It does not seem to be strictly a neurasthenia, nor does it always occur in hysterical individuals. These cases are sometimes “more or less neurasthenic people, easily tired in brain or body; but others are merely tremulous, nervous folks, easily agitated, over-sensitive, emotional, and timid.” It is sometimes an inheritance; sometimes it results from the misuse of alcohol, tobacco, tea or coffee. Usually, it is developed slowly; occasionally, however, it arises in a moment. Thus, Mitchell mentions the case of a healthy girl who fell suddenly into a state of general nervousness owing to the fall of a house-wall. General nervousness is to be distinguished from hysteria, into which it sometimes merges, only by the absence of the mental perversions and the special motor, sensory, vaso-motor, and visceral disorders peculiar to the latter.
The differential diagnosis of hysteria and hypochondria, or what is better termed hypochondriacal melancholia, is often, apparently at least, somewhat difficult. Formerly, it was somewhat the fashion to regard hysteria in the male as hypochondria; but this view has nothing to support it. Hypochondria and hysteria, as neurasthenia and hysteria, are sometimes united in the same subject; one sometimes begets the other, but they have certain points of distinction. Hypochondria more frequently passes into real organic disease than does hysteria; it is more frequently associated with organic disease than is hysteria. Hypochondria is in the majority of cases a true insanity, while hysteria can only be regarded as such in the special instances which have been discussed. In hypochondria the individual's thoughts are centred upon some supposed disease until a true delusional condition is developed; this does not often occur in hysteria. Hypochondria is seen with as great a frequency in the male as in the female, while hysteria prevails much more largely in the female sex. In typical hypochondria more readily than in hysteria the patient may be led from one set of symptoms to another, the particulars of which he will detail in obedience to questions that are put to him, these symptoms not unusually partaking of the absurd and impossible. In hypochondria are absent those distinctive symptoms which in nearly all cases of hysteria appear in greater or less number, such as convulsions, paralysis, contracture, aphonia, hysterical joints, and the like. In hypochondria is present the groundless fear of disease without these outward manifestations of disease. The symptoms of hypochondria, as a rule, but not invariably, are less likely to change or abate than those of hysteria.