The history often throws great light upon the nature of the case. Disorder of the uterine function, often, very often, acts upon the imagination of the patient, leading her to pay attention to and exaggerate slight uneasy sensations. Long ailment with out material loss of flesh, proves that the sensations are not indicative of serious disease. The commencement of the present attack has not been ushered in by the usual accompaniments of an acute or febrile disorder ; in place of rigor or flushing, there has perhaps been a fainting fit, or an hysterical paroxysm, and the whole relation of symptoms betrays more or less of inconsist ency in their sequence and their supposed causes and effects.
At the time of examination the pulse may be either quiet or temporarily excited and quick, without heat or dryness of skin ; it is not hard or wiry, it is not firm, nor is it often full, but gene rally weak, and varying with the least excitement. If the face be flushed, it is out of proportion to the condition of the rest of the skin. The tongue may be evenly coated, with projecting red papillae; but there is no red edge, no thick brown streak in the centre, nor any patchy abrasion of epithelium; it is not dry, nor is there accompanying thirst. The urine is pale, limpid, and copious ; the bowels not altered from their usual state. There is no marked emaciation ; there is no pinching nor anxiety of fea tures; sometimes a marked readiness to tears, or alternation from smiles to frowns.
There is often alleged loss of power, in one or both legs, or in one arm. The best evidence of.the reality of this state is obtained by rather rough handling, which will always bring out resist ance; but it must be remembered that real loss of power is some times associated with spasm or reflex action, and to complete the evidence the limb should be placed in a constrained position, while the attention of the patient is strongly directed to some other organ ; if the mind be thoroughly preoccupied, it will be supported for a moment or two by voluntary effort.
On examining the region to which pain is referred, we very generally find extreme tenderness ; the slightest touch is repre sented as very painful, much more so than anything short of the most intense cutaneous inflammation could account for ; it is dif fused over a large surface, and is not local or limited ; and if the attention can be abstracted, very firm pressure is borne without apparent increase of suffering. Very good evidence of this fact may be obtained by varying the tactile manipulation with one hand and directing the patient's attention to that, while firm pres sure is made with the other, or by referring to the condition of the uterine or any other functions m which the patient feels espe cially interested. A distinction must be made between this mor
bid sensibility of hysteria and that which is felt in superficial rheumatism, or after muscular exertion. In such circumstances the tenderness which is really felt on a very slight touch, is re lieved by firm pressure; but to elicit this fact requires no abstrac tion of the patient's attention : where,as the hysterical tenderness here spoken of disappears and reappears without reference to the mode of examination, simply as the attention happens to be di rected to the spot.
La females the globus hystericus, or rising in the throat, or the occurrence of a regular hysterical paroxysm, often materially aids the diagnosis. But all the ordinary evidences of hysteria must not cause us to forget the possible coexistence of some severe ailment in such a constitution; and this so much the more that the very exaggeration of the symptoms may lead us to doubt the existence of actual disease in its early stage, because practical experience teaches us that it is not then necessarily associated with such symptoms. It is often a very nice point to determine what is due to imagination—perhaps associated with perverted volition—what is simply due to exaggeration, and what there is of real disease in the condition of the patient ; and this can only be done by carefully weighing the relation of disordered sensa tions, of perverted functions, knd of abnormal or normal physical aigns in each organ in succession.
As the more frequent forms of hysteria are mere simulations of disease, so a regular paroxysm is, after -- ellshion„a simulation of epilepsy, The limbs are tossed about with the same violence, but more of method may be detected in the hysterical, more of regularity in the epileptic convulsions. The patient in epilepsy bites his tongue severely, hurts or wounds himself in falling ; th.9 hysterical _female never seriouslyinjures herself, aral,s_cal ed lt2zthtsaier_gy of her movements dur irThe ar m. The expression or the tenures is often ri y istorted in epilepsy; is - . erall lacid in h-steri with a Ions movement o se .armaravarn _ )e epi rePtic fit ends in deep s uin er, t se ysterical paroxysm often in tears : in the one consciousness is slITTyle(1, in the other it is not_ ao, except when fainting occurs; but of this it is sometimes extremely dii4cult to feel quite certain.