(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.

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 furnished 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 "very 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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in April, 1907. She was seized with a violent screaming fit when she learned she was to be taken to the hospital, and the attempt to remove her had to be abandoned. A second attempt a few days later was successful. At the hospital she was visited by her sister from time to time, who reported that she would "become hysterical, crying very loud and hard."

The patient came under our care at the hospital, December 1, 1907, and the following notes were made of her condition. She lies on the sofa in careless fashion. Her dress is very untidy. She actively resents the physician's conversation with her and will make no reply to questions, or else a fretful, irritable one. When ordered to get up she will do so in a wilful, irritable manner and betake herself to a distant part of the ward. She lies about in this indifferent manner apparently taking no interest in anything, and apparently holding a strong resentment for all persons of the male

She treats the hospital sister very much better. In fact the sister reports that she can converse with the patient very readily and that her conversation is quite sensible, and that she behaves well. Lately (March, 1908) the patient is asking to go home, and she has from time to time promised to behave more civilly toward the physicians. But she forgets this promise when she sees any of them.

A point which has not been previously mentioned should be noted here, namely, that the patient submitted to a gynecological examination several months ago. She was naturally reserved and modest and this was a great ordeal for her. We mention this as it may explain the strong antipathy for the male sex which the patient holds.

The patient is visited by one or the other of her two sisters every two or three weeks. These sisters report that the patient talks to them very freely; and she asks for the latest news and gossip regarding her friends. She manifests a distinct interest in the wearing apparel of her sisters and sometimes asks that a hat be taken off for her inspection; or she will turn up a skirt to examine the embroidery, etc. When her sisters urge her to be more neat in her attire and upbraid her for her carelessness in dress, she replies that she cannot take any interest as long as she is in "a place like this." She protests much against the horror of the asylum and the crazy actions of some of the patients there; but at