the attack or series of attacks, the spasms continuing sometimes from
one to four or five hours. The order of events was not always the
same, and yet a general similarity could usually be seen in the
successive stages of the phenomena. I will try to give an outline of
the different stages and phases as observed on an occasion when the
seizures were severe.
[Illustration: FIG. 18.]
After lying down, the first noticeable manifestation was a twitching
of {295} the eyelids and of the muscles of the forehead and mouth. Her
head was next moved from side to side, and she looked around vaguely.
Respiration became irregular. In a few moments a convulsive tremor
passed down her body and limbs. Her arms were now carried outward
slightly from the body, the hands being partly clenched. The lower
extremities were straightened, the left foot and leg being carried
over the right (Fig. 18). Her limbs were rigid. Her mouth was closed,
the teeth being ground together. Consciousness was lost, and
respiration seemed to stop.
[Illustration: FIG. 19.]
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. A
{296} few seconds later she became quiet but rigid, in the position
shown in Fig. 19, corresponding to the position of crucifixion of the
French writers.
[Illustration: FIG. 20.]
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.
[Illustration: FIG. 21.]
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.
{297} 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,
{298} 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.
[Illustration: FIG. 22. 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).]
[Illustration: FIG. 23. 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. They {299} are 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 their
{300} phenomena 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. Muscular {301} tetanization 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 in {302} order, 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.
[Illustration: FIG. 24.]
A beautiful illustration of one of the positions assumed by a
hystero-epileptic is shown in Fig. 24 from Allan McLane Hamilton's
treatise on _Nervous 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 to {303} frightful 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]
[Footnote 8: Published in _Journal 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. She {304} had 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.