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must be individually considered in connection with each case. Under proper management hysteria is usually a manageable disease. Many cases get instant relief under certain mental and moral influences.

Prognosis in hysteria is clouded by the probability of recurrence under the action of inciting causes that otherwise might be trivial incidents. Many patients make substantial gain and consider themselves well, when an exhaustive examination discovers numerous persistent stigmata. These may be considered subjective recoveries. It is exceptional for well-developed cases of hysteria to regain absolute health. Children and youths make better recoveries than older subjects. Major hysteria after the age of forty presents very poor prospects of complete recession. Many of the accidents of hysteria and some of the stigmata are capable of instant disappearence, many of the disabling features are easily controlled and dissipated, but the fact remains that the curability of hysteria has been greatly overstated.

Diagnosis. The diagnosis of hysteria loses many difficulties if it is clearly distinguished from neurasthenia, emotional disturbances, and wilful deceit with which it has been commonly confounded. They have nothing to do with hysteria properly considered, but may complicate it. While hysteria is polymorphous, and may mimic all other maladies, in that very fact lies its detection. There is in it always an excessive or paradoxical element. No disease, when well developed, is so distinctly marked and stigmatized. The most reliable and consistent features in hysteria are the mental characteristics and the psychic stigmata. Next in frequency and importance are the sensory stigmata, among which the disturbance of the color-fields by contraction and inversion is common and well-nigh pathognomonic. Anesthesias in islets or geometrical outlines are practically demonstrative of hysteria. The movability or motility of anesthetic areas under various influences is found in hysteria alone. Among the motor stigmata the contracture diathesis and the ideational loss of power for systematized movements, as shown in astasia or agraphia, while strength is normal in other respects, declare the hysterical state.

nature.

Some hysterical accidents are diagnostic. The typical hysterical seizure should be mistaken for nothing else. In the partial and much more commonly encountered seizures, attacks of ecstasy, of sleep, and of somnambulation are very distinctive. A careful examination of the palsies and contractures, taken with the ordinarily associated and usually superimposed sensory stigmata, should disclose their hysterical The rhythmical spasms are the property of hysteria alone. The tremors must be deciphered from the context of hysterical manifestations and confirmed by the exclusion of organic processes. The same is true of the intestinal accidents. In the condition of the urine during and after paroxysmal manifestations we have a valuable index. Reduction in total solids, especially in urea and phosphates, with the inverted proportion of alkaline and earthy phosphates is, perhaps, only found in hysteria.

Once the suspicion of hysteria is entertained, a painstaking examination of the patient should confirm or banish it. The greatest danger

arises from failing to appreciate the limitations of hysteria and allowing its presence to interrupt careful search for organic disease of which it may be a secondary expression. Too often, when hysteria is recognized, the physician is content to attribute every symptom and complaint to the psychoneurosis. Hysterics may have phthisis, Bright's disease, cerebral hemorrhage, typhoid fever, and hip-disease, as well as other persons. In every hysterical case the individual must not be forgotten or actual disease overlooked.

Treatment. Recognizing in hysteria a mental disturbance principally, the treatment must be mainly psychic. This point of view may at once strengthen and weaken the physician. Unless he has a clear conception of the power of mental therapeutics, he is likely to look upon all measures as mere placebos and to lack faith in their value. Not confident himself, he fails to inspire confidence in the hysterical patient. The game is lost before it is begun. It is the self-confidence of the charlatan or the fanatical belief of the "Christian Scientist" that now sometimes succeeds when well-informed physicians fail. Expectant attention and hopeful anticipation have cured hysteria in all ages, and are potent measures to-day. Methods are usually successful in proportion as they are novel to the patient, strike the fancy, and stimulate the imagination. This serves in itself to distract the hysteric from the rut of his fixed ideas, and, if the assurance of help and cure is added and constantly repeated by suggestion, it tends to supplant the morbid condition. A great moral impression or a mental shock may terminate hysteria at once or may greatly aggravate it. Treatment may be considered (1) as general, applicable to all manifestations of the disease; and (2) special, regarding the manifestations of individual cases.

General Treatment. The first consideration is, if possible, to decipher the fixed idea that dominates the patient. This is easily done when the hysterical syndrome originates in some serious mental storm or personal experience. In other cases it can be inferred from the hysterical manifestations, and occasionally it is constantly expressed in some worry or apprehension. In many cases, however, it is a subconscious idea. It may have arisen even in a dream, or it may be so intangible that it never is fully formulated in the patient's consciousness. Sometimes, from motives of shame, or modesty, or morbid conscientiousness, it is studiously concealed.

When once the end of the tangled skein is in the physician's hands, his task is to modify or destroy the fixed idea, and thus remove the source of morbid mentalization. Too often family and friends support the patient's morbid view and exaggerate the gloomy prospects, adding fuel to the flames by anxious solicitude and thinly veiled or openly expressed fears. In the highly suggestible condition of hysteria their constant presence and their consciously or unconsciously reiterated depressing suggestions counteract all possible good at the hands of the physician. The very locality in which the disease has developed constitutes a forcible reminder of its present and prospective woes. Unless the surroundings, companions, and visitors

of a hysteric can be absolutely controlled, it is usually impossible to manage the patient. It is for this reason that isolation and separation from everything associated with the patient's morbid past is usually the first and most essential requirement of treatment. Under new circumstances the statements of the physician regarding the trivial nature of the dominant idea or his orders to dismiss it and his assurance of cure carry a weight and force that are not immediately destroyed by other more constant and less wholesome influences. The very fact of isolation is a profound influence that can readily be guided into a hopeful and helpful channel. A visit from an anxious mother or solicitous friend may, in a few minutes, destroy all advantage and recall the morbid past with added intensity. This plan of treatment can often be put in the form of the Weir Mitchell rest-cure, and requires the same conditions already indicated in the treatment of neurasthenia (p. 560). Mild cases, especially in the young, can sometimes be well managed by a long journey with a sensible and not too sympathetic companion, or by a protracted visit to friends or relatives properly informed of the attitude they should maintain toward the patient.

Hypnotism in its concentrated form is a dangerous measure and only of occasional service. In the hypnotic state the patient may readily disclose the hidden or subconscious idea, and it may at once be attacked and destroyed by countersuggestion. In the same way progressive improvement or immediate relief from the various conditions present in the patient may be suggested. Hypnotism may, however, precipitate a latent hysteria, and patients hypnotized for the removal of trivial hysterical symptoms have, in the hypnotic state or immediately after it, bloomed out in all the manifestations of major attacks or developed protracted paralyses and contractures. In other cases hysteria restrained by hypnotism has recurred with added force when the séances were discontinued, and Féré goes so far as to consider hypnotism but a transformation of hysteria. It should be held as a last resort.

It goes without saying that anemia and general states call for such remedies as are ordinarily beneficial, and local disease presents exactly the same indications as in non-hysterical patients.

Special Treatment. The convulsive attacks can frequently be stopped by a dash of cold water, by a sharp command, by pressure on hysterogenic zones, and, if other means fail, by inhalations of ether. Their repetition depends upon conditions which must be met by the general measures previously indicated. Paralyses and contractures are among the most permanent accidents when once established, and become actual stigmata. If taken early, they can usually be managed. Massage, electricity, and repeated assurances of their early cure and of their insignificant importance is usually sufficient if the friends, in the way already described, do not defeat these measures. After a long duration they may require the full isolation treatment. Contractures of years'

standing may be followed by fibrotendinous contractions only amenable to surgery. Anesthesias and hyperesthesias can be modified by a number of influences of the esthesiogenic sort. Faradic and Franklinic

electricity often act very readily to reduce and completely dissipate the field of disturbed sensation. Various objects, metallic, wooden, etc., active or inert magnets, have the same influence. It is all a matter of concentrating the fixed and hopefully expectant attention upon the parts. In the same way these measures are useful in the palsies and contractures. Spinal irritation, so called, when once well marked, usually requires the isolation and rest treatment, but sometimes the actual cautery or flying blisters, or other heroic and hence impressive. measures, succeed in removing the hypersensitiveness. Aphonia and mutism require treatment of a similar sort. A faradic electrode introduced into the larynx or pharyngeal cauterization has succeeded almost instantly in some cases, but lasting benefit usually follows persistent and repeated suggestion of steady improvement, coupled with various suggestive manipulations of the parts. Laryngeal spasm and hysterical cough or sneezing, or diaphragmatic spasms, generally can be interrupted by having the patient or a nurse forcibly pull on the protruded tongue. Laryngeal spasm in rare instances may require anesthesia or even tracheotomy, but, fortunately, apnea is commonly followed by relaxation of the spasm. Dysphagia from esophageal spasms is often relieved by passing the stomach-tube and demonstrating the permeability of the gullet. Vomiting is sometimes benefited by lavage of the stomach and the mechanical introduction of food, but assurance of improvement and suggestion must be added to all these measures.

Finally, it is the physician who is most sure of himself and of his diagnosis and has a distinct idea of the mental side of hysteria who best succeeds with general or special treatment.

CHAPTER VII.

EPILEPSY.

EPILEPSY has been the subject of medical description since the earliest times. It was known to the ancients as the sacred disease, morbus sacer. In colloquial English it is called the "falling sickness." Its most characteristic manifestation shows forth in the derivation of the name "epilepsy," which implies being seized upon. The seizing has been variously attributed to mythological deities, to the possession of devils, and to vapors and humors arising in the body. Focal epilepsy, or Jacksonian epilepsy, resulting from cerebral injury or disease, may be omitted from the present consideration. Epileptoid attacks arising from alcohol, lead, and uremia, and the eclampsia of parturients and children, have no necessary relation to the epilepsy now in question. Epilepsy can scarcely be considered a distinct disease. It is a syndrome of nervous and mental symptoms appearing under a variety of

pathological states. In many instances it is associated with morphological cellular changes in the cortex. In as many or more cases the anatomical basis still escapes detection. So commonly is epilepsy presented by neuropathic and psychopathic strains, and in those physically or mentally defective, that in itself it may be considered a presumptive indication of degeneracy.

Etiology. Heredity plays a very important part in the causation of epilepsy. Arthritis, syphilis, phthisis, inebriety, insanity, and neuroses are common in the antecedents. Epilepsy appears frequently in succeeding generations, and may descend directly from parents to children, but is more likely to be indirectly propagated by way of collateral branches. The heredity is more often by transformation from other neuropsychic disease. Thus, hysteria, epilepsy, and idiocy may follow in successive generations. Epilepsy among cousins is more frequent than among brothers and sisters, where, however, various neuropathic equivalents are frequently encountered. Consanguinity plays no part unless it brings together individuals of similar nervous or mental defect.

Very

Epilepsy may appear at any age, but it is distinctly uncommon for it to commence after the age of thirty. Epileptoid attacks after that age should always awaken a suspicion of gross organic brain disease. Syphilis is the usual cause of such seizures from thirty to forty-five; after forty-five we encounter the degenerations of senility, vascular changes and accidents. The very great majority of cases of epilepsy develop under twenty years of age, and the pubescent period, between twelve and seventeen, contains the greater proportion of them. frequently epilepsy begins in infancy. Convulsions during the first and second dentitions, incited by any febrile, septic, or toxic cause, may be followed by epileptic attacks at puberty. In some cases beginning as eclamptic attacks in infancy or early childhood, epilepsy follows, with more or less periodical attacks from that time. Some families present numerous deaths from infantile convulsions, and epilepsy sometimes develops in those who escape. Nocturnal enuresis, pavor nocturnus, and epilepsy may appear in the same case, apparently replacing one another. It is necessary to carefully exclude from this consideration that large number of cases in which cerebral injury is present or brain defect arising from intra-uterine, birth, or postnatal causes. Such instances usually present evidence of cerebral trouble in some form of palsy, and are considered in part III. The two sexes are about equally affected.

Inciting Causes. The alleged inciting causes of epilepsy, by their number and relative harmlessness in the majority of individuals, reinforce the presumption of a necessary predisposing defect, in the field of which they become active. The hereditary considerations, the usual evidence of degeneracy, and the common onset of the disease at developmental epochs all speak of a vicious organization unequal to the shocks of ordinary life and the demands of growth. In some cases, however, it is impossible to fix upon any predisposing state.

Toric agents, such as alcohol, lead, mercury, tobacco, chloroform, ether, morphin, cocain, etc., have been accused of inciting epilepsy.

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