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complex of hysteria ; but it is not so easy to believe, as I have already indicated, that a train of disturbances, sensory, motor, visual and visceral, can be elicited by a single examination. However these phenomena originate, by examination or by the unaided work of the mind of the one in whom the symptoms appear, even those who hold to the doctrine of suggestion as the active agent in the production of the phenomena are willing to admit their genuineness.

Litigants have their rights and injustice may be done by the too ready acceptance of the doctrine of purely mental or psychic causation in the production of hysteria. Two or three years since an opinion was rendered by the Supreme Court of the State of Pennsylvania which in effect held that damages cannot be recovered for injuries resulting from fright and not from actual physical harm. That fright alone may cause the most distressing result to health, or be even the chief cause of death, in some particular instance, might easily be substantiated by facts which have become historical. In most cases of fright, especially when this comes on in connection with an accident, this psychic phenomenon is itself associated with some serious physical condition and may be directly dependent upon physical cause. Fright assuredly may be an element in those cases in which, as the result of collision or sudden jar or fall, the individual so falls or is so projected as to be bruised or dazed, or otherwise evidently subjected to harm and distress. In these cases, and not improbably in all cases, the central nervous system, and especially certain portions of the brain, are temporarily the subject of important change from their usual normal state. While one may not be able to translate in exact explanatory terms such old and well-worn expressions as nervous shock and cerebral or cerebrospinal concussion, there can be no doubt that some physical perturbation actually occurs before or coincident with the psychic disorder, fright, or whatever else, alleged to be the chief agency in causation.

From the foregoing the following conclusions may be reached :

(1) Hysteria is a disease called functional, because its material pathology is not understood, although it has such pathology.

(2) It is a disease which has for its basis a constitutional condition spoken of with more or less accuracy as temperament, neuropathy or degeneracy.

(3) It is a disease which manifests itself by well-defined symptoms, motor, sensory, vasomotor, visceral and mental.

(4) Hysteria may be caused in a variety of ways, the chief of which is suggestion, although emotion, physical injury or disease and other causes may enter.

(5) Emotional phenomena are frequently present in hysteria.

(6) Hysteria is favorably influenced and sometimes cured by psychotherapy, but may require for its cure auxiliary measures, such as rest, drugs, food, massage, electricity, fresh air and change of scene.

(7) Hysteria is a psychoneurosis, not in a technical sense an insanity, and must be differentiated from psychasthenia and all the accepted forms of insanity.

(8) Hysteria must be differentiated from neurasthenia, although hysteria and neurasthenia are often combined in the same case.

(9) Hysteria is not simulation, although hysteria and simulation may be present in the same case.

THE DIFFERENTIAL DIAGNOSIS BETWEEN HYSTERICAL INSANITY AND DEMENTIA PRÆCOX; WITH REPORT OF AN ILLUSTRATIVE CASE OF

HYSTERICAL INSANITY.

BY THEODORE DILLER, M. D., Physician to the Psychopathic Department of St. Francis Hospital,

AND

GEORGE J. WRIGHT, M. D., Assistant Physician to the Psychopathic Department of St. Francis

Hospital, Pittsburgh.

a

In the January number of the Journal of Nervous and Mental Diseases we discussed at some length the subject of hysterical insanity and reported several illustrative cases. The diagnosis of hysterical insanity is one which is often attended with much difficulty and uncertainty; but we believe it to be one of real importance, and not merely one of academic interest; for, given a diagnosis of hysterical insanity, the prognosis and treatment are greatly influenced thereby. We pointed out that it is especially difficult to make a differential diagnosis between hysterical insanity and dementia præcox, since both of these affections occur with the greatest frequency at about the same period of life, i. e., in the adolescent period and present many characteristics in common.

Among the cases which we had prepared for incorporation in our previous paper is one which we are reporting in this present communication and which we omitted from that report because at that time the case, to our minds, only brought up questions as to the difficulties in differential diagnosis between dementia præcox and hysterical insanity without answering them. But the subsequent developments of the case have, to our minds, cleared up the diagnosis, and we now confidently look upon the case as one of hysterical insanity. The case illustrates pretty well a number of

* In the Journal of the American Medical Association for March 4, 1905, Dr. Diller had previously reported four cases of hysterical delirium. points which may arise in the differential diagnosis between hysterical insanity and dementia præcox and we, therefore, believe it is one worthy of record.

A single woman, aged 25 years, a school teacher, was admitted to St. Francis hospital, April 25, 1907. The patient's sister fur

. nished a long account of her previous illness, which is abridged as follows:

The patient had been in failing health since the spring of 1906. She was always tired and never refreshed by sleep. She had had a number of complaints during the spring of 1906, among them an ear trouble of some sort. At the close of the June school term she was very much run down and very nervous. She could not leave the city because of sickness and death in the family. She returned to her school in the fall; and after teaching two weeks she was compelled to give up.

She was under a physician's care until December. By January, 1907, she seemed much brighter and more active, and she went back to school, but against the protests of her sister. Two weeks later she was troubled with noises in her head. She was advised to stop school at once, but could not be persuaded to do so. She was troubled with “ biliousness” and constipation. Her bowels were very hard to move. She was very much exhausted in the morning. She was becoming irritable. She suffered severe pains in the head. She complained of dizzy spots" before the eyes. For a whole week she did not sleep. She drained the contents of a bottle containing a hypnotic solution without securing sleep. She became more irritable and started to cry about small matters. On February 24, 1907, she collapsed after taking an electric treatment. After this she was very weak; and for a time seemed in a sort of stupor or was constantly drowsy. She would seem very much brighter for a few days and then relapse. She continued to complain of pain in the head. She slept only two, three or four hours at night; but her sleep was very sound. She would awaken and jump from bed on account of terrible dreams, in which she was always sinking or falling. She would become “hysterical” and say things that were just imaginary, and burst out crying hard and loud.” At times she became very cross, irritable and fretful. · She commenced to worry for fear she would lose her position at school. When quiet she was in deep thought. “She would think, think continually about school and her ear.” At times she became very much depressed, “very low spirited and sad.The doctor examined the ear and found only slight catarrh. The patient now wished to sit by the window on extremely cold days. She wanted to take cold baths, and “ never could get air enough.” One thing she never lost interest in was clothes, new hats, etc. The physician advised her removal to the hospital

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