months' duration, caused by displacement of the uterus, and cured by
reposition of that organ. The same authority, in a paper read to the
London Congress, advanced the opinion that the exciting cause of
attacks of hysteria and hystero-epilepsy was a distortion of the
uterus produced by a flexion of the organ upon itself, either forward
or backward. He believed the attacks were the result of reflex
irritation. He recited {287} eighteen cases, all of which were
relieved. Flechsig[133] favors the gynæcological treatment of
hysteria, including castration or oöphorectomy. He reports three cases
with good results. His article favors the idea that any morbid
condition of the genital organs present ought to be remedied before
treating the hysterical symptoms. Zeuner,[134] on the other hand,
refers to a number of cases in which gynæcological treatment gave
either entirely negative results or was productive of positive injury
to hysterical patients. He quotes Perreti,[135] physician to an asylum
for the insane, who gives the details of a number of cases in which
gynæcological examinations or treatment were directly productive of
injury. He mentions a case of a female patient who had delusions and
hallucinations of a sexual type in which the physician was the central
figure. He reports cases in which proper constitutional treatment,
without gynæcological interferences, led to a full recovery. Playfair,
also quoted by Zeuner, states that he has often known the condition of
hysterical patients to be aggravated by injudicious gynæcological
interference. Oöphorectomy will be more fully discussed under
HYSTERO-EPILEPSY.
[Footnote 132: _Med. Press and Circ._, June 2, 1880.]
[Footnote 133: _Neurol._, 7 Abt., 1885, Nos. 19, 20.]
[Footnote 134: _Journ. American Med. Ass._, Chicago, 1883, i.
523-525.]
[Footnote 135: _Berliner klinische Wochenschrift_, No. 10.]
{288}
HYSTERO-EPILEPSY.
BY CHARLES K. MILLS, M.D.
DEFINITION.—Hystero-epilepsy is a form of grave hysteria characterized
by involuntary seizures in which the phenomena of hysteria and
epilepsy are commingled, and by the presence in unusual number and
severity, between the paroxysms, of symptoms of profound and extensive
nervous disturbance, such as paralysis, contracture, hemianæsthesia,
hyperæsthesia, and peculiar psychical disorders.
SYNONYMS.—Hystero-epilepsy has long been known under various names, as
Epileptiform hysteria, by Loyer-Villermay and Tissot; as Hysteria with
mixed attacks, by Briquet; as Hysteria major or Grave hysteria, by
Charcot. The term hystero-epilepsy has been used with various
significations, and often without due consideration, and for these
reasons some authorities advise that it should not be used at all.
Gowers,[1] for instance, refers to epileptic hysteria, hysterical
epilepsy, and hystero-epilepsy as hybrid terms which tend rather to
hinder than to advance the study of the nature of these convulsive
attacks and their relations to other forms of hysteria. He holds that
it is a clear advantage to discard them as far as possible, and
suggests the use of the term hysteroid, as proposed by W. W. Roberts,
or that of co-ordinate convulsions, as describing accurately the
character of the attack. These suggested terms do not strike me as
improvements upon those which he wishes the profession to avoid. The
word hysteroid, while good enough in its way, is certainly
objectionable on the ground of indefiniteness. Co-ordinate is
proposed, because the convulsive movements are of a quasi-purposive
appearance; that is, they are so grouped as to resemble phenomena
which may be controlled by the will. This meaning of co-ordinate,
however, as applied to the disorder in question, would not be easily
grasped by the average physician. When it is impossible to name a
disease from the standpoint of its pathological anatomy, the next best
plan is to use a clinical term which in a plain common-sense manner
gives a fair idea of the main phenomena of the affection.
Hystero-epilepsy, if it means anything, means simply a disorder in
which the phenomena of both hysteria and epilepsy are to some degree
exhibited. Certainly, this is what is seen in the cases known as
hystero-epileptic. In forming the compound the hysterical element is,
very properly, expressed first, the disease being a hysteria with
epileptic {289} or epileptoid manifestations, rather than an epilepsy
with hysterical or hysteroid manifestations. A study of the definition
of hystero-epilepsy which has been given will show that it is intended
to restrict the application of the term in the present article to
cases with involuntary or non-purposive attacks, the voluntary or
purposive having been considered in the last article.
[Footnote 1: _Epilepsy and other Chronic Convulsive Diseases: their
Causes, Symptoms, and Treatment_, by W. R. Gowers, M.D., F. R. C. P.,
etc., London, 1881.]
HISTORY.—The greatest impulse to the study of hystero-epilepsy in
recent years has been given by the brilliant labors of Charcot and his
pupils and assistants in his famous service at La Salpêtrière. In his
lectures on diseases of the nervous system[2] (edited by Bourneville),
and in various publications in _Le Progrès médical_ and other
journals, Charcot has reinvestigated hysteria major with great
thoroughness, and has thrown new light upon many points before in
obscurity. He deserves immense credit also for the work which he has
stimulated others to do. Bourneville, well known as the editor of some
of Charcot's most valuable works, has published, alone or with others,
several valuable monographs upon hysteria and epilepsy.[3] The most
valuable work on hystero-epilepsy, however, because the most elaborate
and comprehensive, is the treatise of Richer.[4] Richer was for a time
interne in the Salpêtrière Hospital, and with Regnard pursued his
investigations under the superintendence and direction of Charcot. His
book is a volume of more than seven hundred pages, containing a vast
amount of information and profusely illustrated, in large part by
original sketches by the author. Charcot himself has written for it a
commendatory preface.
[Footnote 2: _Leçons sur les Maladies du Système nerveux_. A portion
of these lectures have been translated by G. Sigerson, M.D., and
published by the New Sydenham Society of London, and reprinted in 1878
and 1879 in _Medical News_.]
[Footnote 3: Bourneville, _Recherches clinique et therapeutique sur
l'Épilepsie et l'Hystérie_, 1876; Bourneville et Voulet, _De la
Contracture hystérique-permanente_, 1872; Bourneville et Regnard,
_Iconographie photographique de la Salpêtrière_. I have made special
use of the second volume of the last of these works.]
[Footnote 4: _Études cliniques sur l'Hystero-épilepsie, ou Grande
Hystérie_, par le Dr. Paul Richer, Paris, 1881.]
No article on hystero-epilepsy can be written without frequent use of
this work of Richer, and also of the numerous contributions of
Charcot. To them we are indebted for new ways of looking at this
disease, as well as for an almost inexhaustible array of facts and
illustrations of the diverse phases of this disorder.
While the curious, grotesque, or outrageous manifestations now known
as hystero-epileptic have been discussed with more or less minuteness
by authors from the time of Sydenham to the present, usually, and more
especially in all countries but France, these manifestations have been
studied as isolated phenomena. Charcot and Richer, however, present a
comprehensive view of hysteria as a disease of a certain typical form,
but often manifesting itself in an imperfect or irregular manner. This
regular type is characterized particularly by a frequently- or
infrequently-recurring grave attack, which is divided into distinct
periods, and these periods into phases.
This regular type of grave hysteria once understood, a place of
advantage is gained from which to study the disease in its imperfect,
irregular, and abortive forms. Whatever its pathology may be, such
striking symptoms as loss of consciousness with spasm, hallucinations,
and {290} illusions show at least temporary disturbance of the
integrity of the cerebrum.
Hystero-epilepsy of imperfectly developed or irregular type is a not
uncommon affection in this country, but the disease in its regular
type is comparatively rare.
VARIETIES.—Hysteria and epilepsy, so far as seizures are concerned,
may show themselves in two ways in the same patient; but I believe
that it is best that the term hystero-epilepsy should be restricted in
its application, as Charcot, Bourneville, and Richer have advised, to
the disorder in which hysterical and epileptic symptoms are commingled
in the same attack—what is spoken of by the French as hystero-epilepsy
with combined crises. The other method of combination is in the
affection known as hystero-epilepsy with separate crises, in which the
same patient is the victim of two distinct diseases, hysteria and
epilepsy, the symptoms of which appear independently of each other.
The fact that hysteria is at times associated with true epilepsy is
often overlooked. A patient who is known to have had pure hysterical
seizures of the grave type has also a genuine paroxysm of epilepsy,
and thus the medical attendant is deceived. I will dismiss the
consideration of hystero-epilepsy with separate crises with a few
paragraphs at this place, devoting the rest of the article to the
disorder with combined crises.
The coexistence of hysteria and epilepsy, with distinct manifestations
of the two neuroses, has been most thoroughly considered by
D'Olier.[5] Beau in 1836, and Esquirol in 1838, first showed this
coexistence. Landouzy in 1846 first made use of the name
hystero-epilepsy with separate crises.
[Footnote 5: Memoir which obtained the Esquirol prize in 1881, by M.
D'Olier, interne of the hospitals of Paris, on “Hystero-Epilepsy with
Distinct Crises, considered in the Two Sexes, and particularly in
Man,” translated and abstracted by E. M. Nelson, M.D., in the
_Alienist and Neurologist_, April, 1882.]
In France the distinct existence of hysteria and epilepsy in the same
individual is not, according to D'Olier, a very exceptional fact. Beau
has reported it 20 times in 276 cases. The different modes of
coexistence have been summed up by Charcot as follows: “1, Hysteria
supervening in a subject already epileptic; 2, epilepsy supervening in
a subject previously hysterical; 3, convulsive hysteria coexisting
with epileptic vertigo; 4, epilepsy developing upon non-convulsive
hysteria (contracture, anæsthesia).”
The following case, now in the Philadelphia Hospital, illustrates the
first of these modes of combination: S——, aged thirty-nine, female, a
Swede, came to this country in 1869. She said that her mother had fits
of some kind. The patient had her first fit when she was four years
old. Her menses did not come on until she was nineteen. With the
appearance of her periods she had fainting-spells off and on for two
years, and in these spells she would fall to the ground. After two
years she improved somewhat, but still would have an occasional
seizure like petit mal. Four years ago she had a severe fit, in which
she bit her tongue. This was a paroxysm of true epilepsy. It was
witnessed by the chief nurse in the hospital, a competent observer.
Since then she has had attacks of some kind every month or oftener.
She rarely had a true epileptic seizure. Often, however, she had
hysterical and {291} hystero-epileptic attacks. These paroxysms have
been witnessed by myself and by the resident physician and nurse.
Rarely they were epileptic, frequently they were hysterical. Mental
excitement will often induce an hysterical spasm.
PATHOLOGY.—Holding that hystero-epilepsy is a form of grave hysteria,
the remarks which have been made in the last article on the probable
nature of severe convulsive attacks will be applicable here. In
hystero-epilepsy with the typical grave attack we have the highest
expression of that disturbance of cerebro-spinal equilibrium which
constitutes the pathology of hysteria.
ETIOLOGY.—It will also be unnecessary to go at length into the
discussion of the predisposing and exciting causes of
hystero-epilepsy. In general, its predisposing causes are those of
hysteria of any form. Certain causes or conditions, however,
predispose to certain types or forms of hysteria. The Latin races are
more inclined to the hystero-epileptic form of hysteria than are the
natives of more temperate or colder climates. Bearing upon this point,
I have already quoted the letter of Guiteras with reference to
hysteria and hystero-epilepsy in Cuba and semi-tropical America. Forms
of religion which cultivate to an extreme degree the emotional or the
sentimental side of human nature tend to produce hystero-epilepsy.
With reference to sex it may be said that hystero-epilepsy prevails to
a greater extent among females than males, even proportionately to a
larger degree than some of the other marked phases of hysteria. It
does, however, occur in men and boys, although rarely. Richer records,
from the practice of Charcot, a case in a lad of twelve years. Several
cases have fallen under my own care.
Ten years since I saw a case of hystero-epilepsy, which in some
respects closely simulated tetanus, in a youth nineteen years old. He
was well until seventeen years of age, when he slightly wrenched his
back. Shortly afterward he felt some pain between the shoulders. From
that time, at irregular intervals, generally of a few days only, he
was subject to attacks of dull pain, which seemed to run up the spine
to the head. About two months after this injury he first had a
spasmodic attack. A spasm would come on while he was quietly sitting
or working. The body assumed the backward-arched position. As his
father described the case, there was always space enough under his
back for a baby to crawl through. Generally, he would have more than
one seizure on a given occasion. He would sometimes have as many as
six or seven in one hour. On coming to, he would stare and mutter and
work his mouth and lips, at the same time pointing around with his
hands and fingers in a wild way. Sometimes he would sleep for several
hours afterward if not disturbed, but his sleep was not of a
stertorous character. He said that he could feel the attacks coming
on; his body felt as if it was stretching, his head going back. He
thought he was not conscious during the whole of the attacks, but
between the spasms he could take medicine when directed. When first
examined he had decided tenderness on pressure over the second, third,
and fourth dorsal vertebræ. Pressure in this region would sometimes
bring on a convulsive paroxysm. When first seen he had been for three
months having seizures every two or three weeks. He was under
observation for several months, during which time he was treated with
faradization to the spine, the hot spinal douche, tonics, and
bromides, and made a complete recovery.
{292} W. Page McIntosh[6] has reported several cases of
hystero-epilepsy in the male, one of which is doubly interesting
because it was in a negro. This patient was twenty-one years old,
stout, and previously in good health. He complained of intense pain in
the stomach, and soon passed into a violent convulsion. To show the
importance of diagnosis in these cases, it is interesting to note that
the doctor first thought of strychnia-poisoning, then of acute
indigestion, next of tetanus. Soon, however, he decided that he had a
case of hysteria. The patient had other convulsions on the day
following the first attack. The seizures were evidently
hystero-epileptic or hysterical. He was not unconscious, and believed
that on a recent previous evening he had been conjured by an old
negress. The spell was to work in three days, which it did. The doctor
counter-spelled him with a hypodermatic syringe, after which he
promptly recovered. McIntosh reports another case in a man forty years
old and the father of six children, who was laboring under strong
mental excitement because of the sufferings of a dangerously ill
child. His whole form was convulsed, and his body underwent a variety
of peculiar contortions. He had had similar attacks before, and had
subsequent recurrences.
[Footnote 6: _Med. News_, vol. xlviii., No. 1, Jan. 2, 1886, pp. 5-8.]
The following case was observed in the Philadelphia Hospital:
W. F. ——, aged twenty-eight years, married, has one child. His
seizures began seven years ago, when he had an attack while playing a
game of pool. At this time he had, according to his account, a sudden
feeling of giddiness or vertigo in which he fell over and had a spasm,
during which he thinks he was unconscious. After the seizure he
suffered from headache, but had no disposition to sleep.
From that time until the present he has been subject to these spells,
though the paroxysms are very irregular in frequency. Sometimes he
will have several attacks in a day; again, he will be free from them
for days, and perhaps for two or three weeks, but never for more than
a month at a time. They have come on him while walking in the street,
and on several occasions he has been taken to different hospitals. He
was admitted to the Philadelphia Hospital four times. On his first
admission he only remained over night; on his second and third he
remained for two or three weeks. On the last admission he remained
four weeks, and had spasms every day and night after admission. He
had, by actual count, from five to six hundred after he went in; and
in one evening, from seven P.M. to midnight, he had no less than
thirty-eight. These seizures, which were witnessed by myself and two
resident physicians, differed but little from each other, although at
times some were more violent than others. They began with a forced
inspiration; then the patient straightened himself out and breathed in
a stertorous or pseudo-stertorous manner. The pulse in that stage
became slow, and at times was as low as 48 per minute. The temperature
was normal or subnormal. The arched position was sometimes taken, but
the opisthotonos was not marked. The paroxysm ceased by an apparent
forced expiration, and the breathing then became normal; the patient
remained in a somewhat dazed condition, which was only momentary.
During the attack the patient said that he was unconscious of his
surroundings. In the interval between the attacks he suffered from
headache and from pain {293} over the region of the stomach. He also
had tenderness on pressure over the lumbar vertebræ. He never bit his
tongue.
Age has some influence in the development of hystero-epilepsy. It is
of most common occurrence at the period of pubescence; it is rare in
old age, but occurs with comparative frequency in middle life; or,
rather, it should be said that middle-aged hystero-epileptics are not
uncommonly met with, individuals who have for many years been subject
to the attacks. In young children, girls or boys, it is certainly
rare.
With reference to the exciting causes of hystero-epilepsy, it will
only be necessary to say that of those which have already been
enumerated in the general discussion of the etiology of hysteria, a
few, such as domestic troubles, abnormal sexual excitement, and
painful menstruation, are likely to induce the paroxysm, but fright,
excitement, anxiety, sudden joy, and other psychical disturbances are
the most frequent of the exciting causes of the seizures. A threat or
a blow has been known to precipitate an attack. The use or abuse of
alcohol is sometimes an exciting cause. Reflex irritation, such as
that from intestinal worms, and digestive disorders sometimes produces
hystero-epileptic attacks in children.
SYMPTOMATOLOGY.—In considering the symptoms of hystero-epilepsy the
subject must be approached from several points of view. In the first
place, the disorder can be divided (1) into the regular or typical
grave attack; and (2) into the irregular attacks. These irregular
seizures can be greatly subdivided, but their discussion will be
confined to those types which have been most observed in this country,
although I do not think that any variety of hystero-epilepsy is
distinctively American; and this is what might be supposed from the
largeness of our country and the different nationalities of which it
is composed.
I have seen but few cases of hystero-epilepsy of the regular type. One
of these was first described at some length in the _American Journal
of Medical Sciences_ for October, 1881. I will here give the case,
with illustrations, somewhat condensed from the accounts as first
published.[7]
[Footnote 7: For the opportunity of studying and treating this case I
was under obligations to Charles S. Turnbull and J. Solis Cohen, the
patient having been for several months under their care at the German
Hospital of Philadelphia. Carefully prepared notes of the case were
furnished to me by H. S. Bissey and H. W. Norton, resident physicians
at the hospital. I was also under great obligations to my friend J. M.
Taylor for a series of sketches of the positions assumed by the
patient at different stages of the attack.]
R——, æt. 21, single, was first admitted to the German Hospital Nov.
13, 1879. Between her ninth and twelfth years she had had several
attacks of chorea. During childhood she was often troubled with
nightmare and unpleasant dreams; she often felt while asleep as if she
were held down by hands. She was frequently beaten about the head and
body. Her menses did not appear until she was nearly eighteen. Before
and at her first menstrual epoch she suffered severe pain and cramp.
During the first year of her menstruation, while at Atlantic City, the
flow appeared in the morning, and she went in bathing the same
afternoon. She stayed in the water two hours, was thoroughly chilled,
and the discharge stopped. Ever since that time she had only
menstruated one day at each period, and the flow had been scanty and
attended with pain. When about eighteen she kept company with a man
for five months, and after having put much confidence in him learned
that he had a wife and two children. This episode caused her much
worriment. She positively {294} denied seduction. She became much
depressed. September 2, 1879, she was seized in a street-car with a
fainting fit. On coming to, she found her left arm was affected with
an unremitting tremor. Seven weeks later she was admitted to the
German Hospital. She had severe spasmodic attacks, and the diagnosis
of hysteria was made. She remained in the hospital about four weeks.
On leaving she again went into service. She was readmitted June 9,
1880, in an unconscious or semi-conscious condition. She had been on a
picnic, and while swinging was taken with an attack of spasm and
unconsciousness. During two hours after admission she had a series of
convulsions. After this she had similar attacks two or three times a
week, or even oftener.
I first saw her about the middle of January, 1881. She had an
hysterical face, but was possessed of considerable intelligence, and
when questioned talked freely about herself. The most prominent
physical symptom that could be discovered was a large tremor,
affecting the left arm, forearm, and hand. This was constant, and had
been present since her admission to the hospital. The left half of her
body was incompletely anæsthetic, the anæsthesia being especially
marked in the left forearm. Ovarian hyperæsthesia could not at this
time be made out. She was, however, hyperæsthetic over the occipital
portion of the scalp and the cervico-dorsal region of the spine.
Pressure or manipulation of these regions would in a few moments bring
on an attack of spasm. The attacks, however, usually occurred without
any apparent exciting cause.
For a period of from six to twelve hours before an attack she usually
felt dull, melancholy, and strange in the head. Frequently she had
noises like escaping steam in her ears, but more in the right ear than
in the left. She complained of cardiac palpitations. She usually had
pain in the small of her back. Her limbs felt weak and tired. Just as
the attack was coming on her eyes became heavy and misty, her head
felt as if it was sinking backward, and if not supported she would
fall in the same direction.