Limited space will not permit me fur ther to discuss the paroxysmal stage of hysteria, although I have left many in teresting points untouched.
Some points in the diagnosis of hys terical convulsions:— 1. The immediate cause of the con vulsion is often some mental shock or physical exhaustion.
. 2. The patient sinks rather than falls to the floor, and rarely injures herself in sinking.
3. Pupils equal and rarely normal in size and respond to light. It must be borne in mind that strong and continued muscular movements will cause the pu pils to dilate and will prevent their re sponding quickly to light.
Attention called to the absence of the pupil-reflex in attacks of hysteria. Ob servations were made in the clinic of Professor Krafft-Ebing, who confirmed the diagnosis and the fact of the absent reflex. The latter was also confirmed by the ophthalmologist Bernheim. The ob servations were made by having the lids held apart, the eye being illuminated by a hand-lamp and the cornea protected by salt solution. Thus the eyes could be observed for many minutes. The pupils were wide open and motionless for as much as twenty seconds. J. P. Karplus (Wiener med. Woe11., No. 52, '90.
4. The color of the face remains prac tically normal. There may be a slight venous congestion of the face if the breathing ceases several seconds beyond the interval observed in health. This is in marked contrast to the changes ob served in the color of the face in severe cases of epileptic convulsions.
5. The tongue is not bitten, unless it is injured in the fall; but this is rare. There is rarely blood and froth oozing from the mouth, and the clothes are not soiled by the discharge of faeces or urine.
6. Consciousness in some cases seems to be fairly preserved, usually it is blunted, and probably is never as pro foundly lost as in case of epilepsy.
7. The muscular movements are psy chical in character, i.e., they seem often to be purposive in their nature, and lack much of that pure reflex act observed in epilepsy. In hysteria rhythm or fre quency of the movements is maintained, but the force varies; in epilepsy the fre quency lessens, but the force of the mus cular contraction is kept up until the convulsive movements cease.
8. The hysterical convulsion is usu ally much longer than the epileptic. They may last from ten or fifteen min utes to an hour or more.
9. Pressure over a sensitive ovary or other "hysterogenic zones" will some times arrest the convulsion.
10. Co-ordinated and exaggerated muscular movements, apart from the rhythmical clonic convulsive movements, especially marked if restraint is at tempted, form a large part of the convul sion.
Differential Diagnosis.—At the end of each heading, sensory symptoms, the spe cial sense-organs, motor symptoms, and paroxysmal symptoms, or hysterical con vulsions, will be found a summary of the principal diagnostic points of each group of phenomena. It is unnecessary to re peat them here.
In the vast majority of instances the diagnosis of hysteria is comparatively easy if one is familiar with all the ear marks of the disease. Much precision and certainty is lost to that physician who regards hysteria as a protean dis ease, without certain constant and char acteristic symptoms. While it is true that on superficial observation the symp toms of hysteria at times may appear to mimic those of nearly every organic lesion of the nervous system, viscera, and joints, yet, by a careful study of it, espe cially of the stigmata, their onset, course, and duration, it will be discovered that hysteria is a definite and distinct disease with its own laws and clean-cut symp toms, and that the mimicry is but so in appearance. It must never be lost sight of that hysteria and organic disease may be associated. The two diseases may exist in the same person at the same time. Indeed, in one who is strongly predis posed to hysteria the development of or ganic disease will give rise to hysteria. In such cases it is important to bear in mind that the pronounced and more ob trusive symptoms of hysteria may, and frequently do, overshadow, if they do not entirely obscure, the indistinct symptoms of organic disease. A failure to recog nize this fact is, I am quite confident, to blame for many mistakes, and not a few blunders that I have encountered in the practice of some excellent physicians.
The first duty of the physician on meeting with a case that seems to be hys terical in character is to determine, if possible, by repeated, thorough, and sys tematic examinations whether or not there is any organic lesion present. The presence of a multitude of symptoms, all pointing to hysteria, are not sufficient to rest a diagnosis upon, if there is one symptom that positively indicates an or ganic lesion.