Other svmptoms characteristic of the disease are Chovostek's — a contraction
of the muscles caused by light tapping along the course of a nerve; Trousseau's
— the induction of spasm by pressure over the affected part, especially along
a nerve trunk or over a blood-vessel; Erb's — exaggerated electrical irritability,
especially to galvanism, and Hofmann's — the production of paraesthesia by
pressure over a sensory nerve. Difficult urination or inability to perform
this function may be observed. The reflexes are exaggerated.

The prognosis of the disease is good, recovery usually taking place in a
few days or more rarely after a month or two. Recurrences are common
especially in the winter and early spring.

Death may occur in cases due to severe gastric lesions or those due to-
removal of the parath}T:oid glands.

Treatment consists first in removal of the cause of the condition; any
digestive disorder should receive appropriate treatment and the same is true
of rickets. The spasm may be relieved by hot baths, an ice bag applied to
the spine or if necessary chloroform may be given by inhalation; frictions,
massage, passive movements and the electric current may be employed with
benefit and a properly hygienic mode of life should be prescribed.

Of drugs those which have a sedative action in spasmodic conditions should
be employed. The bromides, hydrated chloral and antip}Tine are the most
useful. In cases characterized by severe pain the h}-podermatic adminis-
tration of morphine may be necessary.

The extract of the th^Toid gland is said to relieve certain cases, even those



8l6 DISEASES OF THE NERVOUS SYSTEM.

in which parathyroid excision has not been performed. The beginning
dosage of this substance is 5 grains (0.33) three times a day.

Thyroid transplantation has been suggested.

In cases due to gastric dilatation, cure may result from one of the surgical
operations adapted to the treatment of this condition, or if this mode of treat-
ment is contraindicated or refused by the patient, frequent and thorough
lavage slccording to the methods laid down under the treatment of gastric
dilatation should prove beneficial.

HYSTERIA.

Definition. An abnormal condition of the nervous system characterized by
morbid changes in the functions of the body resulting from lack of mental
control over acts and emotions and by exaggeration of sensory impressions.

iEtiology. Heredity has a direct influence upon the causation of this
disease and even if true hysteric conditions have not occurred in the ancestry
there is often a family history of other nervous conditions, such as epilepsy,
insanity, mental degeneration, etc. Alcoholism and drug habits as well as
consanguineous marriage are factors in its production. While hysteria is
more common among females it is by no means seldom observed in males.
The age at which the disease is most frequently met is from that of puberty
to the thirtieth year. The Anglo-Saxon races are much less prone to the
disease than are the Latin races and it is particularly frequent among the
Hebrews. The hysterical temperament is likely to develop in pampered
individuals who have been accustomed to excessive sympathy and to make
much of every slight ailment.

Hysteria is more frequently observed in the poor and wealthy than among
the middle classes. It is predisposed to by poor, sordid and unhealthy sur-
roundings, by lack of proper nourishment and life under severe mental strain
or worry.

As exciting causes may be mentioned sudden mental or traumatic shock,
fear, joy, grief, business reversal, prolonged illness, sexual excess and mastur-
bation.

Pathology. Hysteria, being a purely functional disease, is characterized
by no recognizable morbid change in the nervous system.

Symptoms. These occur in number and variety equaled by no other
disease and comprise the symptoms of any of the other nervous affections.
In the earlier stages the hysterical patient is irritable, emotional or despon-
dent, magnifies every ill and is anxious for sympathy; he may give himself
over to mirth or may indulge in attacks of weeping without apparent reason.
His mentality may be more than usually active, although hysteria may occur
in the mentally deficient. The general health may be of the most robust.



HYSTERIA. 817

The hysteric convulsion may be preceded by manifestations such as those
described above or such prodromata as vertigo, neuralgic pains, localized
cutaneous anaesthesia or ovarian tenderness may be present. At times an
aura resembling that of the true epileptic convulsion may be observed; most
frequently this occurs as the globus hystericus, which is characterized by a
sensation of choking as if there were obstruction of the trachea or oesophagus.

The most marked type of the convulsion {hystero-epilepsy or hysteria major)
may be preceded by an aura, following which the patient may utter a cry,
falls apparently unconscious and exhibits a tonic spasm, this is followed by
the clonic stage and finally by relaxation and coma. The paroxysm is usually
rather longer than that of epilepsy. The second stage of the attack is termed
"clownism" by Charcot and is characterized by violent and exaggerated
muscular contortions, emotional display or cataleptic poses. In the third
period the patient assumes various attitudes expressive of ecstasy, happiness,
terror or erotism. The fourth period or that of return to consciousness is
characterized by delirious and hallucinatory manifestations in which the
patient seems to see visions, hear voices and may converse with imaginary
persons. These hallucinations may persist after the seizure is past.

In the minor form of conviilsive seizure the prodromata may be similar to
those described above; at the actual onset of the attack the patient falls, taking
good care not to get hiirt; the spasms consist of clonic muscular contractions
which may involve all four limbs and even the trunk. The contractions
are irregular and although the patient seems unconscious he gives the impres-
sion to the experienced observer that the condition is feigned. The convul-
sion passes in a few minutes or the patient may be aroused by the use of a
strong galvanic shock or by dashing a small amount of cold water in the face.
The seizure does not leave the patient in a somnolent or torpid state as does
that of epilepsy.

During the non-convulsive stage the hysterical patient may exhibit symp-
toms referable to almost any organ or tissue of the body; these may be divided
as follows:

Motor Symptoms. In addition to the convulsive movements of hysterical
paroxysms the patient may simulate various forms of paralysis such as hemi-
mono-, or paraplegia, tonic muscular spasms, contractures of the muscles
of the extremities or of the neck, disorders of coordination or tremors. The
paralysis is usually hemiplegic and more often on the left side, the face being
seldom affected. Limbs apparently useless for locomotion may be moved
while the patient lies in bed and if one leg is apparently paralyzed it is drag-
ged shufiflingly along while the other limb is taking ordinary steps, and is not
swung outward as in true hemiplegia. Ataxia may accompany the paralysis
which may be either spastic or flaccid. Vocal cord paralysis with loss of
voice is not rare and may be demonstrated by laryngoscopic examination
52



OI6 DISEASES OF THE NERVOUS SYSTEM.

which is particularly easy in hysterical patients, because of the anaesthesia
of the pharynx, one of the stigmata of hysteric conditions.

The reflexes may be exaggerated, and the so-called hysterical joint may be
observed. The latter is characterized by pain and swelling, of sudden onset,
usually affecting the knee or hip. Motion is interfered with and in conse-
quence muscular atrophy from disuse may ensue.

Contracture of the abdominal muscles may result in the so-called "phantom
tumor." This is most frequently seen in the umbilical region and at times
very accurately simulates a firm and solid growth. It is considered to be due
to a spasmodic contraction of the diaphragm, the recti abdominis being at
the same time relaxed, the vertebral column curved forward and the intestines
distended. Pseudocyesis or false pregnancy is a variety of this condition.
Such spurious tumors disappear if the patient is subjected to general anaes-
thesia.

Sensory Symptoms. Of these the most common are areas of cutaneous
hyperaesthesia, anaesthesia or paraesthesia, the latter consisting of sensations
of numbness or tingling, formication or of heat and cold. Symptoms refer-
able to the organs of special sense may occur such as mere lessened acuity
of sight or diminution of the visual field. Other disorders are total blindness
(never, however, hemianopsia) and loss of color sense. Deafness is not uncom-
mon and loss of the senses of smell and taste is by no means rare.

Vasomotor Symptoms. Paleness or blushing of the skin as well as localized
areas of coldness or heat may be present. (Edema has been observed. Haemop-
tyses and haematemesis may be alleged by the patient but in these cases the
blood as a rule comes from the gums and then only in small amount. Hyster-
ical haemorrhages into the skin have been reported but must be most unusual.

Such secretory disorders as excessive or diminished perspiration, diminu-
tion or increase of the saliva and lessened or increased urinary excretion are
frequently met, pol}airia especially so, the urine being profuse in quantity,
light in color and of low specific gravity. The urine in marked cases often
undergoes further change, the urates and phosphates being diminished and
the normal ratio (i to 3) of the earthy to the alkaline phosphates being changed
to I to 2 even i to i ; at the same time the urine is diminished in quantity.
This change is considered by the disciples of Charcot to be a differential
diagnostic point between convulsive hysteria and true epilepsy.

Digestive Symptoms. These are common and may consist of simple indi-
gestion, gastralgia, perversions of appetite or flatulence.

Vomiting is frequent and may be voluntarily induced and oesophageal
spasm resulting in dysphagia may occur. Constipation is frequent while
diarrhoea is seldom seen.

Respiratory symptoms consist of the hysterical cough which occurs parox-
ysmally, is harsh and is accompanied by little or no expectoration; of dyspnoea



HYSTERIA. 819

which may disappear upon diversion of the patient's attention, and obstinate
hiccough.

Cardiac symptoms such as arrhythmia, tachycardia or bradycardia and
attacks of syncope are not unusual.

Mental symptoms are prominent and variable. The patient is emotional,
easily worried and excitable; the temper is irritable and hallucinations are
frequent. True insanity may develop and rarely cataleptic trances have
been observed.

Hysterical fever has been reported as reaching a temperature of 105 to
110° F. (40.5-43.5° C.) or even higher. Such a rise of temperature occurs
irregularly and usually patients exhibiting this symptom are malingerers
and in some way manipulate the thermometer; close watching usually results
in their detection.

The prognosis in hysteria as regards life is good, fatal cases being rarely
if ever seen. As regards recovery the prognosis depends upon the type of the
disease in hand. Mild cases may recover within a few weeks, while others
may go on for a number of years exhibiting intermissions and variations of
the symptoms.

Treatment. Prophylaxis of the disease consists in combating all the
influences mentioned in the section on aetiology as likely to be predisposing
factors. Children, especially those of neurotic tendency or heredity should
be most carefully trained, they should be kept from association with hysterical
persons and should be subjected to a proper system of training and education,
self-control and denial being insisted upon, while over-indulgence and the
gratification of every whim should be discouraged.

In the treatment of hysteria much depends upon the personality of the
physician. He should be of firm character, insistent upon the proper fulfil-
ment of his orders and at the same time sympathetic within proper limits.
The milder hysterical manifestations seldom require much treatment other
than that directed at the cause of the condition; this, in the mild type as well
as in the more marked form of the disease, should be removed if possible.
The patient's general physical condition should be carefully supervised and
any abnormality corrected; at the same a regular and hygienic mode of life
should be insisted upon, with the proper diet, sufficient exercise and fresh
air, and particularly shoiild the patient be provided with some congenial
occupation in which he is able and willing to engage. Tonics, especially
arsenic and iron in moderate doses, are usually indicated. For the hyper-
irritability of the nervous system various sedatives may be prescribed such as
the bromides, including monobromated camphor, asafoetida, castoreum,
musk, chloroform, acetphenetidine, exalgine and the preparations of valerian.
Hydrated chloral and morphine if used at all should be employed with the
utmost caution.



820 DISEASES OF THE NERVOUS SYSTEM.

The pains should be treated by means of the thermo-cautery and the gal-
vanic current. Paralyses and cojitractures necessitate the employment of
massage, manipulation and forced movements in connection with the electric
current. Laryngeal paralyses may respond to electric treatment and anaes-
thesia to frequent applications of the faradic current. Paralyses and contrac-
tures of the limbs may persist despite anything that can be done. Hysterical
vomiting may necessitate the employment of Debove's method of forced
feeding (see p. 6i6).

The hysterical attack may be treated by sprinkling cold water in the patient's
face or by flicking the face with a wet napkin, the flesh may be pinched vigor-
ously, or it may be well, having seen that the patient is properly disposed of,
to leave her, allowing her to emerge from the seizure and find herself alone,
no one being present to offer sympathy. It has been suggested that pressure
upon the epigastric region or over the ovaries will cause a cessation of the
spasmodic manifestations. In spite of any rigidity of the abdominal parietes
the pressure, if continuous and energetic, will often prove effectual. In the
male pressure may be made over the same areas. A galvanic current of from
five to ten milliamperes, one pole at the front of the body and the opposite
behind, may be employed. Repeated sudden interruptious of the current
increase its ef&cacy. Another method of treatment, which has the advantage
of entire safety, consists in giving inhalations of amyl nitrite. This drug
rarely fails to stop the seizure and has an excellent mental effect upon the
patient, ^ther and ethyl bromide may also be administered by inhalation
but chloroform is hardly disagreeable enough to be of use. Capsules of aether
which explode in the stomach are sometimes effective.

In marked types of hysteria no treatment excels that first advocated by
Weir Mitchell. It is particularly indicated in those patients who are confined
to bed. It consists in placing the patient entirely under the care of a compe-
tent nurse and if possible removing her from association with her family and
sympathizing friends, and, while the treatment should be varied to meet the
exigencies of each case, its main details are as follows: The patient is kept
absolutely quiet in bed, is not allowed to read or, at first, even to feed herself.
Massage and electricity are employed for gradually lengthening periods, being
omitted, however, during the menstrual epoch. A slowly interrupted faradic
current is to be preferred to the galvanic. At first the diet is entirely of milk
either skimmed or diluted with lime, barley or carbonated water in propor-
tion of about 4 or 5 to i; 4 to 6 ounces (120.0 to 180.0) are given every
two hours, this quantity to be gradually increased in accordance with the
tolerance of the patient. If necessary the milk may be peptonized. After
from seven to ten days, the milk being continued, solid food is allowed at mid-
day. A chop or raw oysters with bread and butter or toast and a cup of cocoa
or coffee make an acceptable luncheon and after some days a breakfast con-



NEUEASTHENIA. 82 1

sisting of an egg and a roll or a few biscuit is added. The patient should
be given a sponge bath daily. In from four to six weeks the patient is allowed
to sit up, a few moments at first, but as time passes, for longer periods and still
later she is allowed to drive out and to take short walks. The latter are
lengthened little by little until the patient is able to take considerable amounts
of exercise without fatigue. The treatment should be carried out with the
utmost regard for system and regularity, a schedule being made for the day,
the hours for feeding, massage, electricity, exercise, rest, etc., being fixed.
It is important that the patient should be allowed to rest for an hour after
massage and the latter and electricity should never be given in close conjunc-
tion, an interval of two to four hours is not too great.

Most excellent results have followed this method of treatment particularly
in thin, poorly nourished individuals.

Hydrotherapeutic measures are often of service in hysterical conditions,
the nervous irritability responding particularly weU to hot and cold packs.
Hypnotism has been employed in the treatment of hysteria, especially in
France, but while remarkable results have in numerous cases been achieved,
most American writers unite in asserting that it should be used with the
utmost caution if at all.

NEURASTHENIA.

Synonyms. Nervous Exhaustion; Nervous Prostration; The American
Disease.

Definition. Neurasthenia is a functional disorder of the nervous system
characterized by exhaustion of both the mental and physical energies of the
patient.

.Etiology. The influence of heredity in this disease is well recognized,
neurasthenia often occurring in those whose parents have been of neurotic
or hysterical type or have lived the rapid, worrisome life that has become
too common during the past three decades. Neurasthenia is more common
in men than in women and results from over-work, attended with excessive
mental strain or worry, as well as from the abuse of alcohol and tobacco, and
the use of morphine. It occurs secondary to syphilis and the acute infec-
tious diseases, particularly influenza; it may be caused by sexual excesses
and perversions and by traumatism.

Pathology. No definite morbid change in the nervous system has been
recognized as characteristic of neurasthenia.

Symptoms. These in many cases are similar to those of hysteria of the
mild type but are varied, depending upon the organ or organs chiefly affected
by the state of nerve weakness. In the cardiac form there are rapid and
irregular heart action perceptible to the patient, and pain referred to the pre-



82 2 DISEASES OF THE NERVOUS SYSTEM.

cordium. In the gastric type there are epigastric pulsation and sensations
of distress after eating with borborygmi. Vaso-motor manifestations such as
sudden hot flushes or sweats may occur and the patient may suffer from
vertigo or attacks of syncope. In another type of the disease the symptoms
are referable chiefly to the nervous system and consist of muscular weakness,
often scP marked as to interfere with locomotion and the performance of ordi-
nary acts with the hands and fingers, hyperaesthesiae and parsesthesise and
disorders of the special senses. The mentality may be affected and the
patient suffers from low spirits, despondency or irritability of temper. Insom-
nia and mental confusion are not rare and the suicidal tendency may occur.

Sexual neurasthenia is not uncommon, the patient complaining of frequent
nocturnal emissions, a dread of impotence which may result in inability to
perform the sexual act and spermatorrhoea, the discharge of seminal fluid
often accompanying mictiirition or defaecation. In males suffering from this
type of the disease there are frequently pain and tenderness of the testicles;
ovarian tenderness and menstrual disorders are frequently associated with
neurasthenia in women.

Polyuria is frequently present, the urine being of light color and low specific
gravity, although cases in which the urine is diminished in quantity and dark
in color may be met. Puringemic conditions are not infrequent complica-
tions of neurasthenia and this fact should not be forgotten when treatment
is taken under consideration.

The prognosis is good in cases which are willing and financially able to
undergo the treatment necessary.

Treatment. Prophylaxis consists in the attempt to so train children of
neurotic inheritance and tendency that both the mental and physical forces
may be conserved and rendered as resistant as possible. Over-indulgence is
to be avoided and the child's food, school work, exercise and hours of sleep
shoifld be studiously regulated. Highly-strung and irritable children should
be managed with great tact, the nurse or teacher should never lose her own
temper while controlling the child and any excessive excitement or emotion
is best managed by giving a warm bath followed by a sponge off with cool
water. After this the child may be put to bed for a few hoiirs and will usually
go to sleep.

Prophylaxis in adults consists in the avoidance of excessive business worry
and the leading of a regular life, particular attention being paid to exercise
and sleep; frequent vacations may be advisable and it is often well, if the
patient can arrange it, for him to take these under conditions totally different
from those to which he is accustomed at home and away from sympathizing
friends and relatives. The diet of the neurasthenic shoifld be simple and
noiirishing and, if allowed at aU, tea, coffee, tobacco and alcohol should be
used in moderation.



NEURASTHENIA. 823

Just as in the treatment of hysteria the physician about to take in hand a
case of neurasthenia should seek to gain the implicit confidence of his patient.
Naturally the ability to accomplish this object depends to a great extent upon
the personality of the physician. The latter's visits, while regular, should not
be too frequent and should be made at definite intervals. Much discretion
should be used in responding to unnecessary calls from the patient. It is,
perhaps, better to have an understanding with the nurse in this regard and
to suggest that she use her discretion in transmitting such calls. The selection
of a nurse is an important item. She should be a vigorous and robust woman
and of a temperament as little nervous and emotional as possible.

The rest cure described in the section on the treatment of hysteria was first
devised for neurasthenic patients and in many cases, especially obstinate
and resistant ones in women or those complicated by drug habit, achieves
excellent results.

Hydrotherapy is an efficacious form of treatment and if about to employ
it the patient should be studied in order to ascertain whether his state is one
of nervous excitation or of depression. In the former case the patient may
not possess sufl&cient resistance to undergo a rigid course of bath treatment
but will need to be strengthened by means of a systematic rest and diet cure
before the hydrotherapeutic measures are admissible. In the ordinary type
of neurasthenia the preferable mode of hydrotherapeutic procedure is the
cold douche given but a short time and under considerable pressure. The
jet should be applied in turn to all parts of the body except the head. Very
excitable and emotional patients are benefited by the cold wet pack or half
bath, followed by vigorous friction and exercise in order to produce a satis-
factory reaction. If the cold douches impress the patient unfavorably the
Scotch douche may be substituted. The douches are usually given twice a
day, the patient being allowed to lie down for an hour or two after each.

Electric treatment is often useful in connection with hydrotherapeutic
procedures. Galvanism or Franklinization associated with the high frequency
current and general faradization may be employed. The Franklinic and
faradic currents and the actual cautery may be employed in localized pain.

Patients able to travel are often greatly benefited by a sea voyage or a
sojourn at one of the various spas where baths may be taken and mineral
waters drunk. The latter frequently have an excellent mental effect upon
the patient and the regular mode of life insisted upon at such resorts is bene-