HYSTERIA, WHAT IT IS AND WHAT IT IS NOT.*

BY CHARLES K. MILLS, M. D.,

Professor of Neurology in the University of Pennsylvania; Neurologist to the Philadelphia General Hospital.

(From the Department of Neurology of the University of Pennsylvania.)

Hysteria, a favored topic with medical writers since the time. of the father of medicine, has again come to the front under the stimulating influence of Babinski, who has attracted the attention of the neurological world to this old subject, as Marie, a few years since, revived interest in aphasia. In the case both of aphasia and hysteria, views regarded as classical if not irrefragable have been attacked with skill and audacity. The profession of medicine owes much both to Marie and to Babinski, even if it is not prepared to give universal acquiescence to their views. Much that Babinski' has advanced should be received without demur. One thing of great value which has come out of his studies and writings has been the more exact delimitation of the definition of hysteria, even if the bounds set by him are not accepted in their entirety. He has done for hysteria what our distinguished American colleague, Dr. Dana, has accomplished for another nervous disorder so often discussed with hysteria and not infrequently combined with it in a clinical case, in his paper on "The Partial Passing of Neurasthenia." It might be said

* Read at the sixty-fifth annual meeting of the American MedicoPsychological Association, Atlantic City, N. J., June 1-4, 1909.

'Ma Conception de l'Hystérie et de l'Hypnotisme (Pithiatisme). Conference faite à la Société de l'Internat des Hopitaux de Paris, June 28, 1906.

Émotion, Suggestion et Hystérie. Extraits des comptes rendus de la Société de Neurologie de Paris, July 4, 1907.

Instabilité Hystérique (pithiatique) des membres et du tronc. Extraits des comptes rendus de la Société de Neurologie de Paris, March 5, 1908. Démembrement de l'Hystérie Traditionnelle, Pithiatisme, 1909.

also that Dana,' after the fashion of Babinski, and almost contemporaneously with the latter's first general presentation of his conception, has set limits to hysteria which are not very different from those of Babinski, although expressed in somewhat different

terms.

The tendency in the past has been to regard too many clinical phenomena as hysterical-to assign to hysteria every sort of nervous affection for which no other abiding place could be found. In a few respects Babinski has perhaps narrowed too much the conception of hysteria.

The definition of hysteria has been often essayed. Reference to a few of these definitions might here be made. In doing this I shall refrain from recalling any of my own efforts in this direction, as these with more experience have become more or less unsatisfactory. Starr, in his recently published work on "Nervous Diseases, Organic and Functional" (second edition, 1907), speaks of it as "a functional nervous condition characterized by a permanent mental state, which may be termed the hysterical temperament, and by sudden temporary attacks, of mental or emotional or physical kind." A definition like this, although necessarily imperfect, answers well enough for general descriptive purposes. The inclusion by Starr of the hysterical temperament as a permanent condition is important, as indicating that always underlying hysterical phenomena is a constitutional predisposition.

Dana, in his article on "The Limitation of the Term Hysteria," in his usual terse and thoughtful manner, has given a definition which appeals to those who have dealt practically with the disease when he says that hysteria "is a morbid mental condition in which ideas or emotional states seriously and unwittingly control the body and produce more or less permanent and objective morbid states." In this definition he introduces an etiological factor largely disregarded by Babinski, and insists with correctness on the possible greater or less permanence of the phenomena of the disease, in this respect also differing somewhat from the French neurologist.

"The Partial Passing of Neurasthenia." Boston Medical and Surgical Journal, March 31, 1904.

“The_Limitation of the Term Hysteria, with a Consideration of the Nature of Hysteria and Certain Allied Psychoses." Journal of Abnormal Psychology, February, 1907.

The etiological and therapeutic definition of Babinski is that now most attracting attention, but this, like all others, is far from being completely satisfactory. While it is impossible to state what the transient anatomical substrata of hysterical phenomena are, in every definition which deals with the supposed nature of hysteria, some consideration must be given to this matter, as well as to the question of inherited tendency. An affection which presents such definite symptoms and signs as those which are recognized universally as hysterical must have beneath it a change of some sort in the nervous system, even though this is of a more or less transitory character. The disease is functional in the sense that this change is not necessarily permanent, and healthy conditions can often, but by no means always, be readily restored; but disease it is, whatever its nature and however short or long its duration. What the change in the nervous system is, the most extensive observation and investigation have not enabled us to learn, but the same may be said of other so-called mental and nervous disorders which are everywhere appreciated as real diseases of melancholia, mania, the neuralgias and chorea, for instance. The speculations advanced like those of cortical vasomotor spasm, of toxemia, and of neuronal disseverance, are all open to the objection that they cannot be proved and are not on the basis of analogy truly explanatory of the phenomena.

Objections of another sort may be urged to the psychological definitions which discuss hysteria as a dissociation or disintegration of personality. This it probably is, but not much help is given to the student or the practitioner by such a definition unaccompanied by a consideration of both predisposing and exciting etiology, and of its generally recognized clinical phenomena. The disease is genuine, not simply imaginary or factitious, even if the conditions underlying it are not demonstrable by any known methods.

A partial error in the definitions of both Dana and Babinski is that sufficient emphasis is not laid upon the abortive or imperfectly developed forms of hysteria. These constitute a considerable percentage of the cases which should be really regarded as instances of hysteria, and no more reason exists for not recognizing them than for not believing in the abortive forms of other well-known diseases as, for instance, the formes frustes of ex

ophthalmic goiter. These cases of hysteria in which hypesthesia, sometimes of light grade, moderate or slight impairment of motor power, choreiform movements, tremor, and other well-known phenomena are present, are as truly instances of the disease, although of less severity, than those observed in the rare disease described by Dana, in which gravely marked and more permanent symptoms and signs can be demonstrated. The same constitution or temperament usually underlies them, and they present the same or similar stigmata, these differing only in their intensity. That they are amenable to treatment is not an argument against their genuineness.

The main advantage of Babinski's definition that hysteria is a nervous disorder induced by suggestion and cured by persuasion, is that it concentrates attention upon what the framer of the definition believes are its great causative and curative agencies. It leaves the fundamental nature of the disorder unexplained, while presuming, of course, its psychic pathology.

Babinski includes in his list of hysterical stigmata, that is, in his series of phenomena which are capable of being produced by pure suggestion and cured by persuasion, "convulsive attacks; somnambulism; delirium; paralysis; divers contractures; tremors; cloreiform movements, usually rhythmical; disturbances of phonation and respiration; disorders of sensibility shown in anesthesia and hyperesthesia; sensorial anomalies; and disturbances of the bladder."

Speaking of what should be excluded from the hysterical syndrome, he tells us, "Suggestion cannot abolish or exaggerate tendon reflexes or cause disturbance of the pupillary reflexes or the cutaneous reflexes; at most, suggestion can only render examination of these phenomena difficult, or place obstacles in the way which might mislead a novice, but which an experienced neurologist would overcome; suggestion cannot induce vasomotor, secretory or trophic disorders, and it cannot alone induce hemorrhage, anuria, albuminuria or fever."

Let us turn aside for a moment to say a word about terminology. All things considered, it is better to retain the word hysteria unless some term unequivocally expressive can be substituted, and even Babinski has failed in this respect. In order to enforce his views he has coined the new term pithiatism and its derivative

pithiatic from Greek words meaning "persuasion" and "curable." As he recognized, this new term refers to only one, although an important, feature of his definition. It does not indicate the idea of suggestion as a cause, although he regards suggestion as one of two factors of his definition. An earlier recommendation than that of Babinski, of a term to describe hysterical and hypnotic phenomena, was suggignoskism or suggestionism, but this term is as objectionable as pithiatism, and for a somewhat similar reason, namely, that it is not sufficiently descriptive.

Is it altogether philosophical to describe a disease by a term which is supposed to indicate the method of successfully treating it?

Objections might be offered to this therapeutic-test method in terminology as in diagnosis. Quinine in malaria, mercury in syphilis are remedial or curative agencies. Should one, therefore, define these diseases, not as affections with special pathogenesis and well-known clinical phenomena, but in terms which indicate that they yield to certain medicinal remedies? No one but Babinski and his immediate following will dispute that hysterical affections will not always yield to methods of persuasion or education, unless these are supplemented by other measures calculated to improve the general nutrition of the patient and to counterbalance inherited predisposition. What neurologist of large experience has not seen, especially in his private work, cases of grave hysteria which have resisted all suggestive and persuasive efforts until measures of a physical character have been used? It is true it has been said that the so-called rest treatment, with its seclusion, massage and electricity, is only a special method of applying suggestion and persuasion. Abundant experience, however, shows that massage and electricity, and other physical measures, do much more than merely stimulate the hope and imagination of the patient. They improve nutrition by aiding digestion, assimilation and elimination. That they improve the quality of the blood has been shown by actual investigation. In many cases of hysteria and hysteroneurasthenia, and especially the latter, the physical measures employed play a large part, and sometimes a part which is little if at all inferior to the psychotherapy exerted through the personality of the physician. Both the psychic and physical methods have their appropriate places and proportions in the treatment of hysteria.