As a rule, hysterical patients will not starve themselves. They may refuse to take food in the presence of others, or may say they will not eat at all; but they will in some cases at the same time get food on the sly or hire their nurses or attendants to procure it for them. In treating such cases a little watchfulness will soon enable the physician to determine what is best to be done. By discovering them in the act of taking food future deception can sometimes be prevented. Hysterical patients do sometimes, however, persistently refuse food. These cases may starve to death if let alone; and it is important that the physician should promptly resort to some form of forcible feeding before the nutrition of the patient has reached too low an ebb. I have seen at least two cases of hysteria or hysterical insanity in which patients were practically allowed to starve themselves to death, but an occurrence of this kind is very rare. Feeding by means of a stomach-tube, or, what is still better, by a nasal tube, as is now so frequently practised among the insane, should be employed. Nourishment should be administered systematically in any way possible until the patient is willing to take food in the ordinary way. In purposive cases some methods of forcible feeding may prove of decided advantage. Its unpleasantness will sometimes cause swallowing power to be regained.
Wunderlich112 has recorded the case of a servant-girl, aged 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.
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. Gowers113 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's114 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.
113 Epilepsy and Other Chronic Convulsive Diseases, by W. R. Gowers, M.D., London. 1881.
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 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!
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.