It is often of moment to be able to distinguish between two such well-marked affections as common acute mania and hysterical mania. In acute mania the disorder usually comes on gradually; in hysterical mania the outbreak of excitement is generally sudden, although prodromic manifestations are sometimes present. This point of difference is not one to be absolutely depended upon. In acute mania incoherence and delusions or delusional states are genuine phenomena; in hysterical mania delusional conditions, often of an hallucinatory character, may be present, but they are likely to be of a peculiar character. Frequently, for instance, such patients see, or say that they see, rats, toads, spiders, and strange beasts. These delusions have the appearance of being affected in many cases; very often they are fantastical, and sometimes at least they are spurious or simulated. In hysterical mania such phenomena as obstinate mutism, aphonia, pseudo-coma, ecstasy, catalepsy, and trance often occur, but they are usually absent in the history of cases of acute mania. In acute mania under the influence of excitement or delusion the patients may take their own lives: they may starve or kill themselves violently; in hysterical mania suicide will be threatened or apparently attempted, but the attempts are not genuine as a rule; they are rather acts of deception. In acute mania the patients often become much reduced and emaciated; in hysterical mania in general, considering the amount of mental and motor excitement through which the individuals pass, their nutrition remains good. In acute mania sleeplessness is common, persistent, and depressing; in hysterical mania usually a fair amount of sleep will be obtained in twenty-four hours. In many cases of hysterical mania the patients have their worst attacks early in the morning after a good night's rest. Acute mania under judicious treatment and management may gradually recover; sometimes, however, it ends fatally: this is especially likely to occur if the physician supposes the case to be simply hysterical and acts accordingly. Hysterical mania seldom has a serious termination unless through accident or complication.
In order to make the diagnosis of purposive hysterical attacks watchfulness on the part of the physician will often suffice. Such patients can frequently be detected slyly watching the physician or others. Threats or the actual use of harsh measures will sometimes serve for diagnostic ends, although the greatest care should be exercised in using such methods in order that injustice be not done.
In uræmia, as in true epilepsy, the convulsion is marked and the condition of unconsciousness is usually profound. An examination of the urine for albumen, and the presence of symptoms, such as dropsical effusion, which point to disorder of the kidneys, will also assist.
Hysterical paralysis in the form of monoplegia or hemiplegia must sometimes be distinguished from such organic conditions as cerebral hemorrhage, embolism or thrombosis, tumor, abscess, or meningitis (cerebral syphilis).
When the question is between hysteria and paralysis from coarse brain disease, as hemorrhage, embolism, etc., the history is of great importance. The hysterical case usually has had previous special hysterical manifestations. The palsy may be the last of several attacks, the patient having entirely recovered from other attacks. In an organic case, if previously attacked, the patient has usually made an incomplete recovery; the history is of a succession of attacks, each of which leaves the patient worse. In cerebral syphilis it happens sometimes that coming and going paralyses occur; but the improvement in these cases is generally directly traceable to specific treatment. Partial recoveries take place in embolism, thrombosis, hemorrhage, etc. when the lesion has been of a limited character, but the improvement is scarcely ever sufficient to enable the patient to be classed as recovered. The exciting cause of hysterical and organic cases of paralysis is different. While in hysterical paralysis sudden fright, anxiety, anger, or great emotion is frequently the exciting cause, such psychical cause is most commonly not to be traced as the factor immediately concerned in the production of the organic paralysis. In the organic paralysis an apoplectic or apoplectiform attack of a peculiar kind has usually occurred. In cerebral hemorrhage or embolism the patient suddenly loses consciousness, and certain peculiar pulse, temperature, and respiration phenomena occur. The patient usually remains in a state of complete unconsciousness for a greater or less period. In hysteria the conditions are different. A state of pseudo-coma may sometimes be present, but the temperature, pulse, and respiration will not be affected as in the organic case.
Hysterical monoplegia or hemiplegia, as a rule, is not as complete as that of organic origin, and is nearly always accompanied by some loss of sensation. The face usually escapes entirely. In organic palsy the face is generally less severely and less permanently affected than the limbs, but paresis is commonly present in some degree. Hysterical palsies are more likely to occur upon the left than upon the right side. Embolism is well known to occur most frequently in the left middle cerebral artery, thus giving the palsies upon the right. In hemorrhage and thrombosis the tendency is perhaps almost equal for the two sides. Some of these and other points of distinction between organic and hysterical palsies have been given incidentally under Symptomatology.
In organic hemiplegia aphasia is more likely to occur than in hysterical cases; and acute bed-sores and wasting of the limbs, with contractures, are conditions frequently present as distressing sequelæ. Such is not the rule in hysterical cases, for while there may be wasting of the limbs from disuse and hysterical contractures, bed-sores are seldom present, and the wasting and contractures do not appear so insidiously, nor progressively advance to painful permanent conditions, as in the organic cases. Mitchell mentions the fact that in palsies from nerve wounds feeling is apt to come back first, motion last; while in the hysterical the gain in the power of motion may go on to full recovery, while the sense of feeling remains as it was at the beginning of treatment. This point of course would help only in cases where both sensory and motor loss are present.
The examination of an hysterically palsied limb, if conducted with care, may often bring out the suppressed power of the patient. Practising the duplicated, active Swedish movements on such a limb will sometimes coax resistance from the patient. As already stated, electro-contractility is retained in hysterical cases.
The disorders from which it may be necessary to diagnosticate hysterical paraplegia are spinal congestion, subacute generalized myelitis of the anterior horns (chronic atrophic spinal paralysis of Duchenne), diffused myelitis, acute ascending paralysis, spinal hemorrhage, spinal tumor, posterior spinal sclerosis or locomotor ataxy, lateral sclerosis or spasmodic tabes, multiple cerebro-spinal sclerosis, and spinal caries.
In spinal congestion the patients come with a history that after exposure they have lost the use of their lower limbs, and sometimes of the upper. Heaviness and pain in the back are complained of, and also more or less pain from lying on the back. Numbness in the legs and other disturbances of sensation are also present. The paralysis may be almost altogether complete. Such patients exhibit evidences of the involvement of the whole cord, but not a complete destructive involvement. A colored woman, age unknown, had been in her ordinary health until Nov. 24, 1884. At this time, while washing, she noticed swelling of the feet, which soon became painful, and finally associated with loss of power. She had also a girdling sensation about the abdomen and pain in the back. She was admitted to the hospital one week later, at which time there was retention of the urine and feces. She had some soreness and tenderness of the epigastrium. She complained of dyspnœa, which was apparently independent of any pulmonary trouble. It was necessary to use the catheter for one week, by which time control of the bladder had been regained. The bowels were regulated by purgatives. She was given large doses of ergot and bromide and iodide of potassium, and slowly improved, and after a time was able to get out of bed and walk with the aid of a chair. An examination at the time showed that the girdling pain had disappeared. There was distinct loss of sensation. Testing the farado-contractility, it was found that in the right leg the flexors only responded to the slowly-interrupted current, while in the left both flexors and extensors responded to the interrupted current. In both limbs with the galvanic current the flexors responded to twenty cells, while the extensors responded to fifty cells. She gradually improved, and was able to leave after having been in the hospital three months.