FIG. 19.
Body position in hysterical seizure
A series of strong convulsive movements next ensued. Her entire body was tossed up and down and twisted violently from side to side. Sometimes she assumed a position of opisthotonos. Her whole body was then again lifted and hurled about by the violence of the movements. Afew seconds later she became quiet but rigid, in the position shown in Fig. 19, corresponding to the position of crucifixion of the French writers.
FIG. 20.
Body position in hysterical seizure
Soon she assumed the position represented by Fig. 20, and the convulsions were renewed with violence, the patient's limbs and body being frequently tossed about and the latter sometimes curved upward. After these movements had continued a brief period the patient became calm and partially relaxed; but the respite was not long. A series of still more remarkable movements began, chiefly hurling and lifting of the body. Eventually, and apparently as a climax to a succession of efforts directed to this end, she sprang into the position of extreme opisthotonos represented in Fig. 21. This sketch, by Taylor, is a very faithful view of her exact position. She remained thus arched upward for a minute, or even more. A series of springing and vibratory movements followed, the body frequently arching.
FIG. 21.
Body position in hysterical seizure
As the spasms left she sat up on her bed, and at first looked around with a bewildered expression. She turned her head a little to one side and seemed to gaze fixedly at some object. Her expression was slightly smiling. When spoken to she looked straight at the one addressing her, but without appearing to know what was said, and the next moment the former position and attitude were resumed. After a few minutes she lay down muttering incoherently, and in about a quarter of an hour fell asleep.
I have simply described one attack. Sometimes she would have several in succession, or the spasmodic manifestations would be repeated several times in a regular or an irregular manner. Strong pressure in the ovarian regions usually would not cut short the spasms. They could be stopped, however, by etherization or by active faradization of the limbs or trunk. She did not always conduct herself in the same manner in the period which succeeded the spasms. Sometimes, after getting into the sitting posture, instead of smiling, she would look enraged and speak a few words. The following expressions were noted on one occasion: “You know it! Yes, you do! Yes! yes!” Often she was heard to mutter for hours after the attack. Her lips would sometimes be seen to be moving without any words being heard. Sooner or later she would fall into sound sleep which would last several hours.
During the spasms she seemed to be entirely unconscious of her surroundings. To a looker-on her movements seemed sometimes to have the appearance of design, but I soon convinced myself that such was not the case. She was insensitive to painful or other impressions. Her expression was blank and unchanging. She said that the only thing that she remembered about the attacks was that she heard a strange, confused sound; this was most probably just as she was returning to consciousness.
Numerous remedies were tried without any apparent effect. These included sodium and potassium bromides, iron, zinc salts, physostigma, cimicifuga, camphor, ether, etc. A uterine examination was made, but nothing especially calling for local treatment was found. She was placed upon equal parts of tincture of valerian and tincture of iron in half-teaspoonful doses three times daily. Capsules of apiol were also ordered to be taken three times daily just before and during her menstrual period. Her menses became more profuse and continued longer. The attacks began to diminish in frequency, and became less severe. In March, not having had a seizure for several weeks, she left the hospital and again went into service. Six months elapsed and she had no attack. She reports occasionally at my office. She says that she feels entirely well. The tremor of the left upper extremity entirely disappeared. She continued to take valerian and iron for four months, but stopped the apiol after the second or third menstrual period.
With this case before us the phenomena of the disease can be more readily grasped. I will necessarily make free use of the labors of Richer in my description of symptoms.
Hystero-epileptic attacks usually, although not always, have distinct prodromes. These have been more thoroughly studied and reported by Richer than by any other author. They are classed by him under the four heads of psychical affections, including hallucinations, affections of the organic functions, motor affections, and affections of sensibility. The patient's condition is changing; she is listless, irritable, melancholy, despairing, slovenly. Sometimes she is noisy, sometimes mute. At times she is full of wild excitement. Hallucinations of sight sometimes come on at this period—most commonly visions of cats, rats, spiders, etc. These visions of animals, as first pointed out by Charcot, in passing before the patients run from the left to the right or from the right to the left, according as the hemianæsthesia is situated on the left or on the right. Hallucinations of hearing, as of music, threats, demands, whistling, trumpeting, etc., also occur, chiefly on the hemianæsthetic side. These hallucinations are worse at night. Sometimes at night the patients are the victims of imaginary amours. Want of appetite, perverted taste, nausea and vomiting, flatulence, tympanites, ptyalism, unusual flow of urine, feelings of oppression, hiccough, laughing, barking, loss of voice, palpitation of the heart, and flushings are among some of the many disorders of the organic functions which are sometimes present during the prodromal period. Loss of muscular power or a species of ataxia, peculiar limited spasmodic movements, contracture, first of one limb and then of another, may be observed. Charcot, Bourneville, Regnard, and Richer, all give admirable illustrations of different forms of contracture. In one case the right arm and wrist are flexed,and the hand held at the level of the shoulder with fingers extended. Anæsthesia—total, unilateral, or local, tactile, of pain, temperature, etc.—may also occur. Sometimes achromatopsia or color-blindness shows itself; sometimes deafness in one ear is present. Tenderness over the ovarian region is often an immediate precursor. To Charcot we owe the most careful study of these symptoms.
Among the most interesting prodromic affections of sensibility are the hysterogenic or hystero-epileptogenic zones. These have been well studied and described by Richer, from whose work Figs. 22 and 23 have been taken. Brown-Séquard has shown that animals rendered epileptic by lesions of the spinal cord, medulla oblongata, or nerves are sometimes attacked with convulsions spontaneously, but it is also possible to provoke these attacks by exciting a certain region of the skin which he designates as the epileptogenic zone. This zone, situated on the same side of the body as the nervous lesion, has its seat about the angle of the lower jaw, and extends toward the eye and the lateral region of the neck. The skin of this region is a little less sensitive than that of the opposite side, but touching it most lightly provokes epileptic convulsions. The simple act of breathing or blowing on it brings about the same result.
Something analogous to this epileptogenic zone has been noticed among hystero-epileptics, and has been pointed out by several writers. Richer gives the particulars of a number of cases. In one patient the hyperæsthetic zone was between the two shoulder-blades. Simply touching this region was sufficient to provoke an attack, and this was more easily done if near the time of a spontaneous seizure. After the grave attacks the excitability would seem to be exhausted, and pressure in the zone indicated would not cause any convulsive phenomena. A second case presented a similar condition. If touched over the dorsal spine between the shoulders, she felt a violent pain in the belly, then a sense of suffocation, which brought on at once loss of consciousness. In a third patient the hysterogenic zone was different. It was double. It was necessary to touch two symmetrical points situated to the outside and a little below the breasts in order to bring on the hystero-epileptic convulsions. Touching one of these points did not produce any result. Other cases are given in detail, but a glance at the two figures (22 and 23) will show some of the principal hysterogenic zones both for the anterior and posterior surfaces of the body. A zone of ovarian hyperæsthesia was common to all the patients. It did not differ essentially from the other hysterogenic zones. If the ovarian hyperæsthesia existed along with other hysterogenic points, the excitation of the ovarian region was always the most efficacious. The hysterogenic zones always occupy the same place in the same case. They are found on the trunk exclusively; they are more frequently in front than behind; in front they occupy lateral positions, and are often double and symmetrical; behind they are more often single and median; they exist more frequently to the left than to the right, and the unilateral zones have always been met with on the left side.
FIG. 22.
Anterior hysterogenic zones
Principal Hysterogenic Zones, anterior surface of the body:a,a′, supramammary zones;b, mammary zones;c,c′, infra-axillary zones;d,d′,e, inframammary zones;f,f′, costal zones;g,g′, iliac zones;h,h′, ovarian zones (after Richer).
FIG. 23.
Posterior hysterogenic zones
Principal Hysterogenic Zones, posterior surface of the body:a, superior dorsal zone;b, inferior dorsal zone;c, posterior lateral zone (after Richer).
The hysterogenic zones bear no constant relation to the hemianæsthesia. It is true that the ovarian pain is most often seated on the hemianæsthetic side, but sometimes it is present on the opposite side. Theyare not at all times equally excitable. They are more so when the convulsive attack is imminent.
Ovarian pressure gives rise to the spasmodic attacks: the same pressure arrests them. What is true of ovarian compression is equally true of all the hysterogenic zones. A light touch brings on the convulsions, which have scarcely commenced when they can be stopped by a new excitation of the same point.
As already stated, the attack of hystero-epilepsy, having fully begun, is divided by Richer into distinct periods. Although these are seldom seen in perfection, it is necessary to have some clear idea of theirphenomena in order to view the affection comprehensively. They were seen well developed in the case given. These periods are—(1) The epileptoid period; (2) the period of contortions and of great movements; (3) the period of emotional attitudes; (4) the period of delirium.
In the first or epileptoid period of the hystero-epileptoid attack, which receives its name from its resemblance to true epilepsy, various phases always reproduce themselves in the same order. Loss of consciousness and arrest of respiration, muscular tetanization in various positions, followed by clonic spasms, and, finally, muscular resolution, are the successive phenomena of this period, which usually lasts several minutes. Loss of consciousness is complete during this period. Musculartetanization shows itself in movements large and small, sometimes of the whole body. The trunk may become as stiff as a bar of iron; the face is sometimes cyanosed, puffed; froth even appears, which it is well to remember, as this is considered by some as absolutely diagnostic of epilepsy. Many positions may be assumed. The important significant features of the tonic phase of period are muscular tetanization with loss of consciousness and respiratory spasm. In the clonic phase movements at first rapid and short, later larger and more general, ensue, and are accompanied by whistling inspiration, jerking expiration, hiccoughs, noisy deglutition. The phase of muscular resolution comes on, in which the patient completely relaxes; sometimes a true stertor occurs. The epileptoid period usually lasts altogether several minutes, the first two phases usually occupying about one minute.
In the period of contortions and great movements wonderful attitudes and contortions are observed in one phase, and in another great movements. One of the attitudes particularly fashionable with hystero-epileptics is the arched position, in which the body is curved backward in the form of an arch so as to rest only on the head and feet. Sometimes the patient may rest on the belly or side, the remainder of the body preserving its curved position; the body may indeed assume almost any strange and seemingly impossible attitude. The so-called great movements are executed by the entire body or by a part of the body only; they are of great variety; sometimes they are movements of salutation; sometimes the semiflexed legs are projected upward, etc. Often the phase of great movements is marked at its beginning by a piercing cry; loss of consciousness is not the rule.
The period of emotional attitudes or statuesque positions is the most dramatic stage of a highly dramatic disease. Hallucinations ravish and transport the patient: sometimes they are gay, sometimes they are sad. The dramatic positions assumed are in consonance with the patient's hallucinations. The patient reproaches, opposes, supplicates, is angry, is furious; she assumes positions of supplication on her knees, becomes menacing, and even strikes. In the great works of Bourneville, of Regnard, and of Richer many cases are related at great length and with vivid details. Camera and pencil are frequently called in to assist the pen in presenting scenes which read as if drawn from an exciting drama or novel. Among the expressions and attitudes which they have succeeded in photographing are those illustrating emotions of menace, appeal, amorous supplication, erotism, ecstasy, mockery, beatitude.
After the period of the emotional attitude consciousness returns, but only in part, and for a time the patient remains a prey to a delirium whose character varies. This delirium may be concerned with subjects the most varied; it may be gay, sad, furious, religious, or obscene. It is mingled with hallucinations; voices are heard; sometimes are seen personages who are known; sometimes the scenes are purely imaginary. During this fourth period the patients will sometimes make the most astounding statements and accusations. They will wrongfully charge theft, abuse, etc. upon others; they believe in the reality of their hallucinations, and, what is more important, they will sometimes persist in this belief after the attack is over. The third and fourth periods are sometimes confounded. When the four periods described succeed each other inorder, they constitute a regular and complete attack of hystero-epilepsy.
By comparing the notes upon the case detailed with the description given of the typical hystero-epileptic attack, it will be seen that the different periods, and even the phases, can be made out with but little difficulty. After a few moments of convulsive movements and irregular breathing the patient was attacked with muscular tetanization, arrested respiration, and loss of consciousness. Tonic convulsions followed, and then immobilization in certain positions. Next came the clonic spasms and resolution. In the period of contortions the arched position is one more extreme than any represented by the illustrations of the French authors, although it is closely approximated by some of their illustrations. After this position of opisthotonos had been taken a succession of springing and lifting movements occurred, probably corresponding to the phase of great movements. The period of emotional attitudes was very clearly represented by the position assumed, the expression of countenance, and sometimes by the words uttered. Even the period of delirium was imperfectly represented by the mutterings of the patient, which were sometimes long continued after the attack.
FIG. 24.
Position of hysterical epilepsy
A beautiful illustration of one of the positions assumed by a hystero-epileptic is shown in Fig. 24 from Allan McLane Hamilton's treatise onNervous Diseases. The patient, æt. eighteen, represented in the figure had suffered from hystero-epileptic attacks since the beginning of the menstrual period. Usually, she had severe but distinct epileptic seizures, and afterward an hystero-epileptic paroxysm. The muscles of her back were rigidly contracted in opisthotonos. Her arms were drawn over her chest, and her forearms slightly flexed and crossing each other. Her thumbs were bent in and covered by her other fingers, which were rigidly flexed. Her toes were also flexed, and her right foot presented the appearance called by Charcot le pied bot hystérique, or hysterical club-foot.
As has already been stated, hystero-epilepsy of irregular, imperfect, or abortive type is most commonly observed in this country, or at least in the Middle States, of which my own knowledge and experience are greatest. As has been demonstrated by Richer and Charcot, the irregular type may be of any form, from a paroxysm with a scarcely detectible convulsive seizure and scarcely recognizable loss of consciousness up tofrightful attacks which from their terrible nature have been termed demoniacal, and in which occur the wildest phenomena of movement, frightful contortions and contractions, with grimaces and cries of fury and rage. Sometimes the movements show a violence beyond description. These frightful seizures are of extreme rarity in America. Sometimes attacks of ecstasy or attacks of delirium are the predominating or almost the only feature. The epileptoid attack, so far as my experience has gone, is the most prevalent variety of hystero-epilepsy. Epileptoid attacks are simply the result of the predominance and modification of the first or epileptoid period of the typical grave attack. Richer has described several varieties.
I have seen a number of cases of the epileptoid variety or other irregular forms. These cases have presented a few or many of the symptoms of grave hysteria, such as anæsthesia, analgesia, hyperæsthesia, blindness, aphonia, paralysis, contracture, etc., and have also had attacks of tonic and clonic spasm, with complete or partial loss of consciousness. The phenomena of the periods of contortions and great movements, of emotional attitudes, and of delirium have been, however, altogether or almost entirely absent. These epileptoid attacks have varied somewhat in different cases.
The following are the notes of three cases observed by me:8
8Published inJournal of Nervous and Mental Disease, vol. ix., No. 4, October, 1882.
M——, æt. twenty-seven, a widow, admitted to the Philadelphia Hospital February 4, 1882, was married thirteen years before, when only fourteen years of age, and remained in comparatively good health for four years after her marriage, during which time she had three children, all of whom died in early infancy. Four years after her marriage, while carriage-riding, she for the first time had a spasm. According to her story, the seizure was very severe; she lost consciousness, and passed from one spell into another for an hour or more. She had a second attack within two weeks, and since has had others at intervals of from one week to three or four months. Four years ago she passed into a condition of unconsciousness or lethargy in which she remained for three days. On coming out of this state she found that the left half of her body was paralyzed and that she was speechless. In two weeks she recovered her speech and the paralysis disappeared. On June 15, 1881, she gave birth to a male child. On the night of the 16th she became delirious, and on the 17th she again lost her speech and had a paralytic seizure, the paralysis now affecting both legs. She recovered her speech in a few days, but the paralysis remained. Her babe lived, and with her was admitted to the hospital. He had had seven attacks of spasm at intervals of about a month. The patient's mother was for a time insane, and had been an inmate of an insane asylum for some months since her first epileptiform attack.
She was carefully examined on the day of her admission. She was bright, shrewd, and observant. She gave an account of her case in detail, and said she was a puzzle to the doctors. Both legs were entirely helpless; the feet were contractured in abduction and extension, assuming the position of talipes equino-varus; the legs and thighs were strongly extended, the latter being drawn together firmly. The left upper extremity was distinctly weaker than the right, but all movements were retained. Shehad no grasping power in the left hand. She was completely anæsthetic and analgesic below the knees, and incompletely so over the entire left half of the body. Pain was elicited on pressure over the left ovary and over the lower dorsal and lumbo-sacral region of the spine. Both knee-jerks were exaggerated.
I lectured on this patient at my clinic at the hospital, stating that I believed the case to be one of hystero-epilepsy, and only needed to see an attack of spasm to confirm the diagnosis. Up to this time she had not had a seizure since admission. She had, however, been complaining for several days of peculiar sensations in the head and of severe headache. She had also been more irritable than usual, and said that she felt as if something was going to happen to her. The same afternoon, Dr. Rohrer, the resident physician in charge of the patient, was sent for, and found her in a semi-conscious state. She did not seem to know what was going on around her, but was not in a stupor. Her pulse was 114 to 120; respirations were 20 to 22, regular. The corneæ responded on being touched. Some twitching movements of the eyeballs and eyelids were noticed; the thumb and forefinger of the left hand also moved, as if rubbing something between them.
In a few moments an epileptoid paroxysm ensued. She became unconscious and rigid. The lower extremities were strongly extended in the equino-varus position already described. The arms were extended at her sides, the wrist being partly flexed and rotated outward, the hands clenched. Her face, at first pale, became deeply congested. Her trunk became rigid in a position of partial opisthotonos. Brief clonic spasms followed, then resolution, the whole seizure not lasting more than from two to three minutes. She lay for a minute or two unmindful of anything or anybody, and then sat up and looked around wildly. She dropped back again and began to mumble, as if she wished to speak, but could not. Paper and pencil were given to her, and she wrote that she was conscious, but could not speak. Her temperature, taken at this time, was 99.8° F.
Attacks similar to the one just described occurred at irregular intervals for two days. On their cessation she was speechless, and the permanent symptoms already detailed—the anæsthesia, paralysis, etc.—were deepened. During the attacks but little treatment was employed; hypodermic injections of morphia and potassium bromide by the mouth were, however, administered. After the attack the valerianate of iron by the mouth, faradization of the tongue, and galvanization of the legs below the knees with weak currents, were ordered. Her speech returned in a week. For about a month she showed no other signs of improvement; then she began to mend slowly, gradually using her limbs more and more. On May 11, 1882, she was discharged, and walked out of the hospital with her child in her arms, apparently perfectly well. During the last month of her stay no treatment was used but mild galvanization every other day.
Mrs. A——, æt. forty-five, was seen by me in consultation. For some months at her menstrual period she had been out of sorts. At times she had had hallucinations of sight. For several weeks she had been troubled more or less with a feeling of numbness and heaviness in the left arm and leg, particularly in the latter, and also with diffused pain in the head anda sensation of aching and dragging in the back of the neck. For three weeks, off and on, she had had diarrhœa, which had weakened her considerably. She awoke one morning feeling badly and yawning every few minutes. She passed into a condition of unconsciousness with attacks of spasm. I did not see her on this the first day of her severe illness, but obtained from the physician in attendance some particulars as to the character of her seizures. Evidently the condition was similar to that presented by the last case, that described by Richer as the epileptoid status, in which tonic and clonic spasm and resolution are repeated again and again. Attack after attack occurred for nine or ten hours, sometimes one immediately following another, sometimes an interval of several minutes or of half an hour or more intervening. Respiration was partially arrested. Tonic spasm predominated; the limbs became rigid in various positions; sometimes the neck and trunk were strongly bent backward, producing partial opisthotonos. While the body and limbs remained tetanized they were thrown into various positions (clonic phase of an epileptoid attack). Although she answered questions addressed to her by her physician between the spells, she did not recognize him until evening, after the spasms had ceased, and then was not aware that he had been in attendance during the day, although he had been with her almost constantly. Leeching and dry cupping to the back of the neck were employed, and potassium bromide and tincture of valerianate of ammonia were given.
Early on the morning of the next day she had another attack of unconsciousness and spasm, in which I had the opportunity of seeing her. The spasm amounted only to a slight general muscular tetanization. The whole attack lasted probably from half a minute to a minute. The following day, at about the same hour, another paroxysm occurred, having a distinct but brief tonic, followed by a clonic, phase, in which both the head and body were moved. The next day, also at nearly the same hour, she had an attack of unconsciousness or perverted consciousness without spasm. She had a similar seizure at 4P.M.For two days succeeding she had no attacks; then came a spell of unconsciousness. After this she had one or two slight attacks, at intervals of a few days, for about two weeks.
Between the attacks the condition of the patient was carefully investigated. On lifting her head suddenly she had strange sensations of sinking, and sometimes would partially lose consciousness. She complained greatly of pain in the head and along the spine. Her mental condition, so far as ability to talk, reason, etc. was concerned, was good, but any exertion in this direction easily fatigued her and rendered her restless. She had at times hallucinations of animals, which she thought she saw passing before her from left to right. The left upper and lower extremities showed marked loss of power. The paralysis of the left leg was quite positive, and a slight tendency to contracture at the knee was exhibited. She was for two weeks entirely unable to stand. The knee-jerks were well marked. Left unilateral sweating was several times observed.
A zone of tenderness was discovered in the occipital region and nape of the neck, and she had also left ovarian hyperæsthesia. Left hemianæsthesia was present, head, trunk, and limbs being affected. She complained of dimness of vision in the left eye, and examination by theattending physician and myself showed both amblyopia and achromatopsia, she was unable to read print of any size or to distinguish any colors with the left eye, although she could tell that objects were being moved before the eye. A distinguished ophthalmologist was called in consultation. An ophthalmoscopic examination showed a normal fundus. Each eye was tested for near vision. It was found that she could read quite well with the right eye, and not at all with the left. While reading at about sixteen inches a convex glass of three inches focus was placed in front of the right eye, but she still continued to read fluently. A few minutes later, however, on retesting, she could not read or distinguish colors with the left eye. Sometimes toward evening her feet would become slightly œdematous. Examination of the urine showed neither albumen nor sugar. The heart-sounds were normal.
Owing to the apparent periodicity of the attacks quinine in large doses was administered, and seemed to act beneficially. In addition, valerianate of zinc and iron, strychnia, and other nerve-tonics were used in her subsequent treatment. Applications of faradic electricity, both with the metallic brush and the moist sponges, were made every other day. She was persistently and strongly encouraged as to the certainty of her recovery. Her paralysis, anæsthesia, etc. gradually disappeared, and in little more than two months she was able to leave home and go to the country. She has since remained well, but is more easily fatigued than formerly, and does not feel as strong in the left side of her body as she did when in perfect health. At her menstrual period she becomes very nervous.
M——, æt. twenty-three, a well-educated young lady,9in the autumn of 1880 had nursed her mother faithfully through a serious illness. She became anæmic and nervous. Choreic twitchings and occasional slight spasms were the first symptoms that alarmed her family. The spasms came on apparently from any over-exertion. Gradually they became a little more severe in character. Under rest-treatment, with gentle massage, tonics, and steady feeding, in six weeks she greatly improved. A few weeks later, however, she again relapsed, and became worse than she had ever been. The spasms returned with greater force and frequency. She became unable to walk, or could only walk a few steps with the greatest difficulty, although she could stand still quite well. On attempting to step either forward or backward her head, shoulders, hips, and trunk would jerk spasmodically and she would appear to give way at the knees. No true paralysis or ataxia seemed to be present, but locomotion was impossible, apparently because of irregular clonic spasms affecting various parts of her body. Eventually she became extremely hypersæsthetic in various regions (hysterogenic zones), along the spine, beneath the breasts, in the ovarian area, etc. The slightest pressure or any applications of heat or cold, electricity, etc. would generally bring on an attack of spasm.
9This patient was for a long time under the professional care of George McClellan of Philadelphia, who has kindly furnished me with some notes. I shall simply give an outline sketch of the case, describing particularly her epileptoid attack. For several weeks, during the absence of McClellan from the city, she was attended by M. O'Hara, and with him I saw her frequently in consultation.
While trying to apply galvanism on one occasion she suddenly complained of nausea, and her expression changed, becoming somewhat fixed.Her face became flushed, her limbs and body rigid. The head and body were thrown backward to a moderate extent. Next, the shoulders were drawn upward, the head appearing to be sunk between them; the arms were found to be rigidly extended at her sides, the wrists partly flexed, and the fingers clenched; the legs also were spasmodically extended, the thighs drawn together, and the feet in the equino-varus or hysterical club-foot position. Phenomena like those described above as visceral spasm now were observed. The chest, and even the abdomen, were lifted up and down rapidly, and the respiration became quick, irregular, and apparently very difficult. Consciousness seemed to be impaired, but not absolutely lost. The symptoms just described took about one minute for their exhibition. Muscular relaxation now occurred, and an interval of calm, lasting about two minutes, followed, during which the patient spoke, answering one or two questions addressed to her. After the brief period of repose, however, another phase of the attack came on. In this the heaving movements of the body and what appeared to be intense respiratory spasms were the chief features. This portion of the attack endured scarcely a minute; the patient came to quickly, and was able to converse. In general, her attacks were of a similar character.
The drugs used included bromides, iodides, strychnia, chloride of sodium and gold, zinc salts, iron, etc. etc.; her condition vacillating, sometimes better, sometimes worse. She was finally placed in bed by McClellan, and an extension apparatus was employed, under which treatment, in a little more than one year from the time she was first attacked with spasm, she recovered.
The permanent or intervallary symptoms of hystero-epilepsy are in the main the phenomena which have been described when speaking of the prodromes of this affection. They are, indeed, the whole train of symptoms—the mental or psychical disorders, the motor, sensory, reflex, vaso-motor, and isolated phenomena—which have been described under special heads when considering the general symptomatology of hysteria. The full-fledged case of hystero-epilepsy is hysteria with a full array of special permanent hysterical manifestations, and the great paroxysm superadded. Certain phenomena are, however, more prominent and of much more frequent occurrence. Among these are paralysis or paresis, either of the unilateral or paraplegic variety; hemianæsthesia, including anæsthesia of all the senses; and contractures, particularly in the lower extremities.
DURATION ANDCOURSE.—The duration and course of hystero-epilepsy are very uncertain; most cases last many years. In a few instances the hystero-epileptic attacks are all from which the patient suffers; even in the cases of long duration the general health does not appear to become greatly impaired.
DIAGNOSIS.—To arrive at a correct diagnosis between hystero-epilepsy and epilepsy is sometimes very difficult. The fact that the patient is a male does not decide for epilepsy. In making this diagnosis close attention should be given to—1, The history and the causes of the disease; 2, the physical and mental condition of the patient; 3, above all, the phenomena of the spasmodic attacks.
In hystero-epilepsy a careful study of the history of the case will oftenelicit a moral cause. The patients rarely injure themselves seriously by falling, whereas in true epilepsy they often suffer from severe injuries. The mental and physical health of a person suffering from hystero-epilepsy differs widely from that of the true epileptic. In hystero-epilepsy the number of attacks has little or no apparent influence on the patient's mental or physical condition. Little or no deterioration of the mind occurs. The memory is not much impaired. Hystero-epileptics are usually well nourished and frequently of good physique. This is not the case in true epilepsy; the number of attacks has a decided effect on the patient's mental condition. The demented appearance of the old epileptic is well known, whereas in the hystero-epileptic nothing in physiognomy or carriage indicates that the patient has been suffering from any disease. It cannot be said that all epileptics have no mental power, but some deterioration of the mind usually occurs, and becomes well marked as the case progresses.
The paroxysms in epilepsy are very well marked, especially if it is epilepsy of the grave form. They are often ushered in with a scream. The patient suddenly falls, and at times is severely injured. The convulsion is generally violent, rapidly alternating from clonic to tonic spasm, without special phases or periods. Complete and profound loss of consciousness, with great distortion of face and eyes, is present. The tongue is frequently bitten. After the attack the patient passes into a deep stupor. In hystero-epilepsy usually the seizure does not begin with a scream or sudden fall, the convulsion has periods and phases, and the tongue is not bitten.
It is said that in hystero-epilepsy there is no loss of consciousness, but this is not strictly true. This point is the most difficult one for physicians to clear up in arriving at a diagnosis, as in many textbooks complete loss of consciousness is laid down as the strongest evidence of epilepsy. Loss of consciousness does occur in hystero-epilepsy, particularly in certain varieties. Richer says that the loss of consciousness is complete during the entire epileptoid period in a case of the regular type. To decide as to consciousness or unconsciousness is not as easy as might be supposed. Varying degrees of consciousness may be present. At times in hystero-epileptic attacks the patient may respond to some external influences and not to others. Consciousness is perverted or obtunded often, and it is hard to decide whether the patient is positively and entirely unconscious of her surroundings. In epilepsy the loss of consciousness is profound and easily determined. In regard to the distortion of the face and eyes, this sign is usually absent in hystero-epilepsy, as in the German Hospital case, in which the patient had a series of violent seizures lasting two hours, with marked opisthotonos, yet the facial expression remained calm and serene throughout.
In hystero-epilepsy the attacks are rarely single; usually they are repeated, constituting the hystero-epileptic status. They are more frequently repeated than in epilepsy, although it is of course well known that there is an epileptic status terrible in character. In a series of hystero-epileptic attacks usually the seizures come on in rapid succession, the interval being brief. These series are apt to last for hours or days. The attacks that compose a series in hystero-epilepsy vary in duration and in violence. At first they are of violent character; toward the endthe seizures may gain in extent, but they are likely to lose in intensity.
Charcot and Bourneville make a strong diagnostic point between hystero-epilepsy and true epilepsy of the fact that in epilepsy there is a peculiar rise of temperature during the convulsion, even to 104° F., whereas in hystero-epilepsy the temperature is nearly or quite normal.
Arrest of attacks by ovarian compression in females, and by nerve compression, nitrite of amyl, and the application of electric currents, can be brought about in hystero-epilepsy, and not in epilepsy. A study of the effect of bromides may assist in arriving at a diagnosis. The action of bromides, drugs which are often used in both affections, favors the opinion that the two diseases are distinct. Bromides, according to Charcot and Richer, so effective in epilepsy, are without effect in hystero-epilepsy. Dujardin-Beaumetz, however, on the other hand, declares that “who says hysteria says bromides,” and also that at the present time there is not an hysterical patient but has taken bromides, the bromide of potassium being most frequently used. The truth is, that bromides may be useful for temporary purposes, for certain phases and symptoms of the disease, but produce no radical permanent improvement in the disease hystero-epilepsy.
D. Webster Prentiss,10in reporting a case, gives some good points of distinction between real and hysterical tetanus, which is practically hystero-epilepsy. In his case, which was hysterical, the attack was ushered in by noise in the ears, deafness, and blindness, whereas in true tetanus and strychnia-poisoning the senses are preternaturally acute. There was unconsciousness during the paroxysm, which does not occur except just before death in the other affections. The eyes were closed during the spasms; they stare wildly open in the other diseases. The patient had long, uninterrupted sleep at night; in true tetanus no such relief comes until convalescence.
10American Journal of the Medical Sciences, 1879.
FIG. 25.
Opisthotonos of tetanus
The figure is a representation of the opisthotonos of tetanus.11It is the sketch of a soldier, struck with opisthotonos after having beenwounded in the head; and in connection with it I will briefly call attention to the points of differential diagnosis as given by Richer, and which have been confirmed by my own observations. In the opisthotonos of tetanus the contraction of the face and the peculiar grin are distinguishing points, and are well represented in Bell's sketch. In the hysterical arched position, while the jaws may be strongly forced together, the features are most often without expression. The contracture of the face and the distortion of the features will be met with more often in the other varieties of contortion. The curvature of the trunk differs but little in the two cases, but the abdominal depression observed in the sketch of Bell is far removed from the tympanitic appearance present in the majority of hystero-epileptics. In the tetanic cases the patient rests only on the heels, while in the hysterical cases the knees are slightly flexed, and the patients are usually supported on the bed by the soles of the feet.
11From Sir Charles Bell'sAnatomy and Physiology of Expression as connected with the Fine Arts.
Hystero-epileptics are often suspected of simulation. Richer refers to many facts which seem to throw out conclusively the idea of simulation. Among these are the results obtained by æsthesiogenic agents, the experiments in hypnotism, where many of the results produced could not be simulated. Some English authors—and among them notably the physiologist Carpenter—have endeavored to find the explanation of the results obtained by the æsthesiogenic agents in a special action of the moral on the physical nature which they designate expectant attention. While the reality of the action of expectant attention in certain cases will not be denied, it cannot be invoked to explain satisfactorily all the phenomena. The patients are not aware of the results sought; which, indeed, in some cases, are contrary to the expectations of the observer himself.
PROGNOSIS.—A few cases of hystero-epilepsy get well, either with or without treatment, in a short time. Some cases, which in addition to the grave attack have had in the intervals the other striking symptoms of major hysteria, such as hemianæsthesia and contractures, get well only after many months or years; some never recover, although, as a rule, they do not die from anything directly connected with the disease, but from some accident or more commonly from some intercurrent disorder. Cases supposed to be cured often relapse. The patient may be apparently well for months, or even years, when under some exciting cause the old disorder is again aroused. On the whole, the prognosis is more serious the longer the case has endured. Family history and environment have much to do with determining the prognosis.
TREATMENT.—In considering the treatment of hystero-epilepsy I will, in the main, confine my attention to a discussion of the methods of managing and treating the convulsive seizures. With reference to the numerous special phenomena of this disease, the directions given and the suggestions made in the general article on Hysteria will be equally applicable in this connection.
Ruault12has recently recommended compression of a superficial nerve-trunk in order to terminate an attack of hysteria or hystero-epilepsy. The face being always accessible, he prefers making pressure on the infraorbital nerves as they emerge from their foramina, but he has alsocompressed the ulnar nerve behind the inner condyle of the humerus. In a brief note to the Philadelphia Neurological Society, made Feb. 23, 1884, I called attention to the value of strong nerve-pressure for the relief of hysterical contracture, and can confirm from several successes Ruault's recommendation for the employment of the same measure to avert convulsive attacks.
12La France médicale, vol. lxxxvi., p. 885.
Thiery13of the Saint Pierre Hospital, Brussels, arrests paroxysms by what he calls torsion of the abdominal walls. He grasps in his hands the walls of the abdomen and imparts to them a certain kind of torsion, which he gradually increases. This treatment is practically the same as the deep ovarian pressure of Charcot. This compression of the ovary on the side of the seat of the lesion ordinarily will arrest immediately the convulsions. The patient is extended horizontally, and the physician plunges the closed fist into the iliac fossa, often using great force to overcome the muscular resistance. Poiner has invented an apparatus called a compressor of the ovaries, which can sometimes be used with advantage.
13Medical and Surgical Reporter, Oct. 7, 1876.
Nitrate of amyl is undoubtedly of value in averting grave hysterical attacks—convulsions, trance, ecstasy, pseudo-coma, mania, etc. It is frequently used with marked success. Its action was studied on a vast scale at La Salpêtrière. The convulsions usually stop almost immediately after one, two, or three inhalations. It is to be preferred to inhalations of chloroform or ether.
Nitro-glycerin can be used in the treatment of the hystero-epileptoid convulsions. Notes of a very interesting case of hystero-epilepsy in which this remedy was successfully employed have been furnished me by David D. Stewart of Philadelphia. The case was one of hystero-epilepsy with combined crises. Amyl nitrate on several occasions broke the convulsive attack, but the patient did not completely regain consciousness. Stewart was called in during an attack, and found that the patient had been unconscious for an hour and a quarter. He gave her hypodermically three minims of a 1 per cent. solution of nitro-glycerin, and another injection after an interval of about eight minutes. She became conscious within one minute after the second injection. After this she had two seizures, both of which occurred on the same day, and yielded with remarkable promptness to a few minims of nitro-glycerin given by the mouth. She was put on three minims three times a day of this drug, the dose being gradually increased. Sufficient time has not elapsed to report as to the effect of the drug given during the intervals.
Strong faradic currents, applied with metallic electrodes to the soles of the feet or to the spine, are occasionally efficacious. The galvanic current to the head has been extensively employed in the service of Charcot to arrest hysterical and hystero-epileptic attacks of the grave variety. One electrode is applied to the forehead, the other to any convenient place upon the body, as the leg, the ovarian region, or the spine. The current is applied continuously for several minutes, or voltaic alternations are made. This method has been used with success in a few instances, but should never be resorted to by a physician uncertain of his diagnosis or one practically unfamiliar with the powers and properties of the electrical current.