SOME ETIOLOGICAL TYPES OF HYSTERIA. WILLIAM BROWNING, M.D. Read before the Medical Society of the County of Kings, Sept. 18, 1894. The great variety of symptoms and cases that at present are classed under hysteria renders the subject a difficult one to handle in a brief space. Whether we accept the teachings of the Charcot school or not, the disorder is so common that it interests every practitioner and is often enough a disturbing element in every field of special work. Perhaps no less diversified are the factors that one time with another make up its etiology. Malnutrition and exhaustion may in some form represent more nearly than anything else its physical basis, and yet these terms are very far from being synonymous with hysteria. While various specific diseases frequently have a causal relation, there is as yet, I believe, no germ recognized as pathognomonic of hysteria. The very nature of the trouble, involving as it often does, the mental status of the patient .and others surrounding, renders the quest for an etiology doubly uncertain. Now and then, by happy accident or long opportunity, we get some insight. In attempting to describe the causes it is well first to make some kind of a classification. That here used is simply one of convenience and can claim little absolute value, except as serving well for presentation of the points that I wish to offer. My division is :-(i) Congenital Predisposition, (2) Faulty Training, (3) Later Accidental Causation. In practice all three of course, in most cases, enter as com- ponents, though in variable degree. And yet sufficient simple cases can be found for illustration. The course of the disorder it- self is also distinguished by considerable differences for each class. I. Congenital Basis-A Constitutional Type. In this form we cannot often trace the cause beyond finding antecedents that warrant the expectation of a neurotic make-up. To work out the etiology fully would require a familiar knowledge of several generations. In general it is a close parallel to that of several other neuroses. But some characteristics of this type are worth noting. Here, once hysterical, always so. And yet the may not have a 2 decidedly hysterical mind, except in its deeper lines, and prefer- ably not to an exasperating degree. It is the wearying succession of hysterical manifestations, first in one, then in another part of the body. Physical marks or stigmata are common. This is the degenerative form par excellence, and tends rather to the develop- ment of some organic nervous disease than to any single lasting hysterical trouble. Case. (') A woman of middle life, whose pedigree and personal career for many years it is possible to give with exceptional ac- curacy. In the family all kinds of nervous disorders were rife. Not further removed than cousins and aunts, the list includes, angina pectoris, asthma, epilepsy and suicide, diabetes, and a fondness for intoxicants. A sister suffered from weak heart and died suddenly. Even this does not exhaust the bad history, though it certainly leaves little to desire in this regard. On the other hand, this lady received an admirable training from infancy up. A wise and gentle firmness guided her all the way. In accordance with this her more conscious desires and tastes and all her sentiments were of the best. So far as training could go she had a healthy dislike for all things morbid and could e. g. safely be trusted to care most uprightly for a child. Further, her life during its early and middle years was fairly free from sharp trials, though not an idle one. But back of all this was the constitutional tendency that could not be eradicated. Hysterical troubles in piquant variety followed one another with brief seasons of respite :-Globus, hysterical knee, asthma, spinal irritation, fainting spells and cardiac irreg- ularities, anorexia and diarrhoeas, chills, insomnia, vesical and again rectal irritability, hypersesthesias and anaesthesias galore, followed one another in endless succession, except for relatively free intervals. Every form of narcotic and intoxicant was used, and in turn given up when discovered and advised against; but only in due time to be succeeded by a new one. Of course, any little accident or upset was bound to bring its sequel in the shape of an outbreak. There was little, if any, maliciousness that so often wears out the medical attendant, for, in accordance with well-ingrained training his advice was followed closely-for the time at least. Nor did there ever develop any of the more lasting hysterical conditions. This case illustrates well the hereditary type pure and simple, (i) Two of the cases given in this paper occurred in the practices respectively of Dr. Delafour and of Dr. McCorkle, 3 a life of prolonged struggle against tendencies that are ineradica- ble, a healthy mind so far as acquirements and inclinations go, with an inherited physique continually asserting itself. Moral treatment here is uncalled for, or at most is but a sup- portive measure. Nor can any system of Weir-Mitchellism really cure these patients, though it may benefit and certainly tide over passing outbreaks. Symptomatic treatment of the particular manifestation in hand is usually in order. II. Faulty Rearing-The Mental Type. This amounts to a family trouble in the sense that for its devel- opment the individual alone does not suffice-two or more per- sons are requisite just as they are for a quarrel. It presents some peculiarities and almost covers the field once popularly accredited to this disease. Such patients show pre- eminently the mental characteristics of hysteria. They are the indulgent, self-willed, scheming class. Malingering to a greater or less degree, or more often the magnifying of trifles into monu- ments, becomes so natural that they no longer know the difference between that and reality. To suffer horribly from nothings, to practice deception, play on the feelings of those next to them and perchance fool or worry their physician, is the object of their lives. Pronounced neurotic stigmata (physical signs) are with them less common. Yet they easily simulate disease and this is the more danger- ous, just as the subject is less tractable than other people. Their mental perversity holds them right on in the downward way, and on occasion they may carry the matter without a waver to a fatal termination. For it is not such an unusual thing to see these persons with no real trouble, sink nearly to the point where life ceases, and when a false course is pursued they now and then pass on to death. Thus the form that at the start appeared to have the least basis in fact, of necessity tends to the worst end. As to what is meant by improper bringing-up, most of us un- derstand better than we can describe. The underlying principle is summed up in Solomon's "Spare the rod and spoil the child." Corporal punishment may not be necessary, but wise example and some instruction in purpose, self-control and regard for our fellows, is imperative. There is no lack here of parental affec- tion, or what we call sympathy, but a development of this to excess. All these hysterics have as a basis an inordinate craving for sympathy. This may have been inborn, but often is a matter 4 of over-culture. Certainly per contra self-control can be culti- vated to great purpose. Perhaps, theoretically, the Puritan cult is still the best, and cer- tainly whatever its drawbacks, its followers were well-spared this form of hysteria. But in this as in his other ways the physi- cian naturally prefers a more eclectic course than any arbitrary system, and believes thus in the long run to accomplish better things. So-called sympathy may assume many forms. One of the most deleterious is purely physical and may be worth mentioning in some detail, as it tends to the development of other neuroses as well as hysteria. It is the fondling or "pawing over" habit that some parents have with their children. When most devel- oped it may, as Dr. Shaw suggests to me, become a disease in itself-the seniors seeming to crave it also. The parent is ever holding, patting, rubbing, stroking, embracing and in all ways of touch petting the child, and this may be kept up until long after maturity. The outcome is an excessive development of the sen- sory sphere. It may of course play with the greatest force on the sexual side, though it is not that to which 1 refer, but to the erethism that amounts to a dominating sensory hunger, seeking satisfaction in any accessible way. Less often it leads to perver- sion in the way of an abnormal dislike for everything of the kind. Such family-habits are of course so private that but exception- ally does even the physician get a full insight or realize their im- port. The extent to which this is carried in some families is to me at least astounding. Any advisory suggestion in regard to it is but too easily considered a thrust at their unusually happy fam- ily-life. Of course the only successful treatment of this form of hys- teria is the moral, whether under the guise of a rest-cure, or if not too well established by breaking up the surroundings in which it is flourishing, or by whatever other immediate means. It is always a difficult matter and requires a maximum of tact and pa- tience. Case.-Young man of nineteen years. No neurosis known in the family. One brother died of phthisis. The father died when the boy was three years old, but left the family amply en- dowed with worldly means. He has a " devoted mother," of the kind that humors every whim and fancy and will go anywhere or do anything that a child can suggest. By the time he was ten 5 years old he became irregular in school work. He might keep along for some weeks or months, then feel it was too hard and be allowed to drop'out. For a time, a private tutor was provided. But the boy came to feel that continuous study was too much for him. In those days he complained some of headaches. He was never much of a hand to play with other boys, as he would soon feel tired and be allowed to give up. In contrast to this it has been noticed that summers when away in the country he was always active, well and free from complaints. But on returning to town his old status would soon come back. His more immediate troubles dated from the previous summer when he was hurried back to town by a slight irritation of the neck of the bladder. A mass of preputial smegma was removed, and for a few weeks all went well. Then for the purpose of bene- fiting his supposed poor health a trip to California was under- taken. There he was circumcised and an assumed stricture cut. He had never had gonorrhoea, and his physician here had previ- ously passed a No. 34 sound. So that it was simply a spasmodic stricture, if in fact anything. Of course he was better for a few weeks. Then he had an attack of so-called grip and his eyes began to trouble him. He describes an irregular waviness of vision before both eyes, called by him "jiggling," and this has continued off and on since. Eminent ophthalmic surgeons in various cities have carefully examined his eyes, but always with negative result. His' urethral trouble still returns fre- quently. It is usually relieved for the time by the passage of a sound. For this complaint he has been to specialists in several cities and often returns to his physician here. When this symp- tom sets in-so-called spells-he becomes almost deliriously frantic, gets wrought up to a high tension, passes large quantities of clear urine of low gravity (sometimes down to 1,004), and may talk of suicide. Of course those nearest to him consider his trouble alarmingly serious and are fully subservient. These attacks he says are brought on by worrying about himself. If his attention is gained to anything outside of himself they disap- pear. It is clear that on several occasions suggestion from med- ical men has brought on or increased his symptoms. Physically he is a strong, well-built, robust-looking chap. Careful and repeated examinations failed to discover much abnor- mal. A coated tongue, some pupillary hippus, a pulse easily and 6 rapidly varying twenty or more beats, and occasional twitching around one or the other eye was about all. General sensation good in all varieties. No tremor at first examination but this he had developed fairly for the next occasion. It is almost dignifying his condition to call it hysteria. Clearly it is attributable to his circumstances and pampering in every way. III.-Immediate or Late Causation-The more purely physical form of hysteria. Exhaustion of any kind may act as a cause ; the various tox- aemias, prolonged sickness, shocks mental or material, bad habits in eating, drinking and personal care, excesses, accidents, losses of blood, etc. These are cases where they may be single attacks and per- manent recovery. Or one after another may be brought on and chronic invalidism may result. Here neither the signs of a neu- rotic make-up nor a specially hysterical cast of mind are evident. The attack may at the moment seem severe, but it is a dissociated matter. It does not at first appear to be of an hysterical nature, but closer observation serves to decide its character,-or to bor- row a term, that it is an hysterical equivalent. Case.-Young woman, by profession a trained nurse. No nervous troubles acknowledged in her personal or family history. Has suffered some from rheumatism since scarlet fever six years ago. Last year according to good observers she had two attacks of appendicitis, recovering however without operation. Then followed an attack of perihepatitis. She is a bright, attractive, rather pale girl, of fair complexion and a bit restless. Evidently she fears that her case is serious, possibly a stroke. Yet neither to casual observation nor in the cognizance of the medical men who have known her longer, is there anything hysterical about her. Nor was there any apparent motive, such as we often find. She has always been an over- sleeper (nine to ten hours or more) and has been somewhat taxed by a recent case. The present trouble began ten days before I saw her and had already mended slightly. On waking one morning she found the left hand numb as though asleep. Despite simple efforts to relieve, it extended up the arm that day. At the same time she felt "terribly fatigued.'' By the next day she realized when any- thing came in contact with the left foot that it gave the same pe- culiar sensation. Soon the whole corresponding half of the head, 7 especially the left ear and half of tongue, including whole circum- ference of mouth, became involved. As she was dizzy when up, heavy-headed, and had a feeling of plunging forwards when going down stairs, she has since remained in bed. Has been blue and cold all over, the numb sensation increasing when the parts get warm. P. 84 and fairly good so long as she remains recumbent. Tongue much coated, comes out straight. Cold sense found impaired on dorsum of left hand, though only to the wrist. Sensation as of something between the fingers. Complains of a drawn tight feel- ing in left palm and fingers andon chest-wall outwards from apex- beat. Pain sense reduced generally on the left side. Wrist re- flexes on both sides increased in extent and force. Both knee- jerks are over-strong, at times even starting the arms to extend at the elbQWS. It may be worth noting that because of an old injury to the right hand she is partially left-handed. Grip r. 54, 1- 54- Right pupil said always to have been wider than left. Diplopia since present attack, but no single muscle proves to be affected. It is chiefly present in extreme lateral positions, either to right or left, when slight nystagmus appears. No sectoral defect of vision, though some contraction of field in each eye. No spinal tenderness. However honest her complaints they certainly were much colored by the knowledge that she had gained as a nurse, and to such an extent as to require close examination before coarser organic trouble could be excluded. The practical sum of the case is that the girl was not equal to the busy, trying life of a nurse. She was simply exhausted or tired out, and when this was helped by rest and restoratives the trouble promptly abated. In less than a month from the onset she was well and away on a vacation. In this form the forced-feeding and rest-cure work wonders, so-called moral discipline playing therapeutically an unimportant role. In conclusion, it may be well to repeat that the three types given really represent causes that usually combine in any partic- ular case. By giving them in this way, as separate entities, I have hoped best to summarize the etiology of hysteria.