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 and {305} a 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
4 P.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
the {306} attending 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,[9] in 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.
[Footnote 9: This 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. {307} 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 AND COURSE.—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
often {308} elicit 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 end {309} the 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,[10] in 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.
[Footnote 10: _American Journal of the Medical Sciences_, 1879.]
[Illustration: FIG. 25.]
The figure is a representation of the opisthotonos of tetanus.[11] It
is the sketch of a soldier, struck with opisthotonos after having been
{310} wounded 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.
[Footnote 11: From Sir Charles Bell's _Anatomy 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.
Ruault[12] has 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 also {311} compressed 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.
[Footnote 12: _La France médicale_, vol. lxxxvi., p. 885.]
Thiery[13] of 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.
[Footnote 13: _Medical 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.