Hysteria

Hysteria, a term applied to an affection which may manifest itself by a variety of symptoms, and which depends upon a disordered condition of the highest nervous centres. It is characterized by psychical peculiarities, while in addition there is often derangement of the functions subserved by the lower cerebral and spinal centres. Histological examination of the nervous system has failed to disclose associated structural alterations.

By the ancients and by modern physicians down to the time of Sydenham the symptoms of hysteria were supposed to be directly due to disturbances of the uterus (Gr. ὑστέρα, whence the name). This view is now universally recognized to be erroneous. The term “functional” is often used by English neurologists as synonymous with hysterical, a nomenclature which is tentatively advantageous since it is at least non-committal. P. J. Möbius has defined hysteria as “a state in which ideas control the body and produce morbid changes in its functions.” P. Janet, who has done much to popularize the psychical origin of the affection, holds that there is “a limitation of the field of consciousness” comparable to the contraction of the visual fields met with in the disease. The hysterical subject, according to this view, is incapable of taking into the field of consciousness all the impressions of which the normal individual is conscious. Strong momentary impressions are no longer controlled so efficiently because of the defective simultaneous impressions of previous memories. Hence the readiness with which the impulse of the moment is obeyed, the loss of emotional control and the increased susceptibility to external suggestion, which are so characteristic. A secondary subconscious mental state is engendered by the relegation of less prominent impressions to a lower sphere. The dual personality which is typically exemplified in somnambulism and in the hypnotic state is thus induced. The explanation of hysterical symptoms which are independent of the will, and of the existence of which the individual may be unaware, is to be found in a relative preponderance of this secondary subconscious state as compared with the primary conscious personality. An elaboration of this theory affords an explanation of hysterical symptoms dependent upon a “fixed idea.” The following definition of hysteria has recently been advanced by J. F. F. Babinski: “Hysteria is a psychical condition manifesting itself principally by signs that may be termed primary, and in an accessory sense others that we may call secondary. The characteristic of the primary signs is that they may be exactly reproduced in certain subjects by suggestion and dispelled by persuasion. The characteristic of the secondary signs is that they are closely related to the primary phenomena.”

The causes of hysteria may be divided into (a) the predisposing, such as hereditary predisposition to nervous disease, sex, age and national idiosyncrasy; and (b) the immediate, such as mental and physical exhaustion, fright and other emotional influences, pregnancy, the puerperal condition, diseases of the uterus and its appendages, and the depressing influence of injury or general disease. Perhaps, taken over all, hereditary predisposition to nerve-instability may be asserted as the most prolific cause. There is frequently direct inheritance, and cases of epilepsy and insanity or other form of nervous disease are rarely wanting when the family history is carefully enquired into. As regards age, the condition is apt to appear at the evolution periods of life—puberty, pregnancy and the climacteric—without any further assignable cause except that first spoken of. It is rare in young children, but very frequent in girls between the ages of fifteen and twenty-five, while it sometimes manifests itself in women at the menopause. It is much more common in the female than in the male—in the proportion of 20 to 1. Certain races are more liable to the disease than others; thus the Latin races are much more prone to hysteria than are those who come of a Teutonic stock, and in more aggravated and complex forms. In England it has been asserted that an undue proportion of cases occur among Jews. Occupation, or be it rather said want of occupation, is a prolific cause. This is noticeable more especially in the higher classes of society.

An hysterical attack may occur as an immediate sequel to an epileptic fit. If the patient suffers only from petit mal (see Epilepsy), unaccompanied by true epileptic fits, the significance of the hysterical seizure, which is really a post-epileptic phenomenon, may remain unrecognized.

It is convenient to group the very varied symptoms of hysteria into paroxysmal and chronic. The popular term “hysterics” is applied to an explosion of emotionalism, generally the result of mental excitement, on which convulsive fits may supervene. The characters of these vary, and may closely resemble epilepsy. The hysterical fit is generally preceded by an aura or warning. This sometimes takes the form of a sensation as of a lump in the throat (globus hystericus). The patient may fall, but very rarely is injured in so doing. The eyes are often tightly closed, the body and limbs become rigid, and the back may become so arched that the patient rests on her heels and head (opisthotonos). This stage is usually followed by violent struggling movements. There is no loss of consciousness. The attack may last for half-an-hour or even longer. Hysterical fits in their fully-developed form are rarely seen in England, though common in France. In the chronic condition we find an extraordinary complexity of symptoms, both physical and mental. The physical symptoms are extremely diverse. There may be a paralysis of one or more limbs associated with rigidity, which may persist for weeks, months or years. In some cases, the patient is unable to walk; in others there are peculiarities of the gait quite unlike anything met with in organic disease. Perversions of sensation are usually present; a common instance is the sensation of a nail being driven through the vertex of the head (clavus hystericus). The region of the spine is a very frequent seat of hysterical pain. Loss of sensation (anaesthesia), of which the patient may be unaware, is of common occurrence. Very often this sensory loss is limited exactly to one-half of the body, including the leg, arm and face on that side (hemianaesthesia). Sensation to touch, pain, heat and cold, and electrical stimuli may have completely disappeared in the anaesthetic region. In other cases, the anaesthesia is relative or it may be partial, certain forms of sensation remaining intact. Anaesthesia is almost always accompanied by an inability to recognize the exact position of the affected limb when the eyes are closed. When hemianaesthesia is present, sight, hearing, taste and smell are usually impaired on that side of the body. Often there is loss of voice (hysterical aphonia). It is to such cases of hysterical paralysis and sensory disturbance that the wonderful cures effected by quacks and charlatans may be referred. The mental symptoms have not the same tendency to pass away suddenly. They may be spoken of as inter-paroxysmal and paroxysmal. The chief characteristics of the former are extreme emotionalism combined with obstructiveness, a desire to be an object of interest and a constant craving for sympathy which is often procured at an immense sacrifice of personal comfort. Obstructiveness is the invariable symptom. Hysteria may pass into absolute insanity.

The treatment of hysteria demands great tact and firmness on the part of the physician. The affection is a definite entity and has to be clearly distinguished from malingering, with which it is so often erroneously regarded as synonymous. Drugs are of little value. The moral treatment is all-important. In severe cases, removal from home surroundings and isolation, either in a hospital ward or nursing home, are essential, in order that full benefit may be derived from psychotherapeutic measures.